Differential diagnosis and degree of involvement will vary from patient to patient« What work¶s for YOUR patient? .

One Step At A Time«   Stage 1: Flaccidity No voluntary or reflexive activity is present in either involved limb. first seen as resistance to passive stretch. Associated reactions cannot be elicited. Stage 2: The basic movement synergies or some of their components may be elicited reflexively as associated reactions. begins to develop . Minimal voluntary motion present. Spasticity.

. The basic movement synergies may be performed voluntarily. Stage 4: Movements which deviate from the basic synergies can be accomplished on a volitional basis. although full range of all components may be lacking.  Stage 3: Spasticity becomes more marked. Spasticity begins to decline.

Isolated muscle actions can be performed freely. Spasticity continues to decrease.   Stage 5: Basic synergies lose their dominance over volitional behavior and the patient becomes increasingly more adept at performing movement combinations which differ greatly from the synergies. Stage 7: Restoration of normal motor function . Stage 6: Spasticity is essentially absent.

. However. etc.And Then Comes the But«  Recovery may be arrested at any stage depending on severity of insult. loud noises. sneezing. recovery may proceed so rapidly that certain stages may not be observable  Associated reactions. may still appear under stress conditions such as sudden fright. anxiety. particularly the basic movement synergies. etc. in cases of slight damage. degree of sensory involvement.  A stage in the recovery process is never skipped.


1960-70s) 1960- ‡ Motor Relearning Program for Stroke (1980s) ‡ Contemporary Task-Oriented Approach Task(1990s) . 1940s)  Movement Theory Approach (Brunnstrom.Different Approaches Muscle Re-education Approach (1920s) ReNeurodevelopmental Approaches (1940-70s) (1940 Sensorimotor Approach (Rood. 1950s)  NDT Approach (Bobath.

³But TONY !? Which one do I use?´ .

Muscle Re-education Approach ‡ Ultimate Goal = Development of coordinated movement patterns. Training begins with learning the control of individual muscles on a cognitive level .

tendon tapping.Rood·s Sensorimotor Approach ‡ Involves superficial cutaneous stimulation using stroking. icing. or muscle stimulation with vibration. and joint compression to evoke voluntary contraction or inhibition of proximal muscles . brushing.

‡ Patients are taught to use and voluntarily control the motor patterns available to them at a particular point during their recovery process ‡ Enhances specific synergies through use of cutaneous/proprioceptive stimuli. and central facilitation. hoping that synergistic activation of muscle would. with training. She encouraged flexor and extensor synergies during early recovery. .Brunnstrom¶s Approach ‡ Emphasised the synergistic patterns of movement that develop during recovery from hemiplegia. transition into voluntary activation.

FLEXION Shoulder Girdle Shoulder Elbow Forearm EXTENSION Elevation and/or Depression & Retraction Protraction Abduction & *Adduction. External rotation Internal rotation *Flexion Supination Extension *Pronation .

Internal rotation *Extension * Knee Ankle Foot DF PF Inversion Inversion . Abduction. *Adduction. External rotation Flexion * EXTENSION Extension.FLEXION Hip *Flexion.

‡Tonic Neck Reflexes ‡Tonic Labryinthine Reflex ‡Tonic Lumbar Reflex  Homolateral Limb Synkinesis .

ASSOCIATED REACTIONS  UE:   Flex of uninvolved = Flex of involved Ext of uninvolved = Ext of involved Flex of uninvolved = Ext of involved Ext of uninvolved = Flx of involved Flex = Flex Ext = Ext  LE:    INVOLVED:   .


unresponsive muscles. they reinforce abnormally increased tonic reflexes (spasticity) . voluntary reactions and subsequent normal movement patterns *Suppress abnormal muscle patterns before normal patterns are introduced«* Mass synergies avoided because although they may strengthen weak.Bobath·s Neurodevelopmental Technique Approach (NDT) ‡ GOAL ± Normalize tone by inhibiting spasticity ± Inhibit primitive patterns of movement ± Facilitate autonomic.

palms down towards supination with fingers open .RIP ± Reflex Inhibiting Posture ‡ In Sitting« ± Symmetry with head in midline ‡ Trunk in midline ± Pelvis in neutral position » Hips in line with knees (90 degrees ± break ext tone) » Balls of feet under knees » UE relaxes with elbows at 90 deg of flex but not fully ext. hands on knees.

Knott and Voss¶ PNF Approach Proprioceptive Neuromuscular Stimulation Uses spiral and diagonal components of movement rather than traditional movements in cardinal planes of motion GOAL ± Facilitating movement patterns that will have more functional relevance than the traditional technique of strengthening individual group muscles ± Relies on quick stretching and manual resistance of muscle activation of the limbs in functional directions. .

 Static Balance  Rhythmic Stabilization  Dynamic Stabilization  Available ROM for Standing .

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