Approaches to Therapeutic Exercise and Activity for Neurological and Developmental Conditions

(Bobath and Brunnstrom Approaches)

PT 154: Therapeutic Exercise III Ms. Mary Grace M. Jordan, PTRP 23 November 2009

Learning Objectives
At the end of the lecture, the students should be able to: Discuss the theoretical basis of the neurodevelopmental approaches Discuss the concepts and principles underlying the Bobath approach Discuss the concepts and principles underlying the Brunnstrom approach

Sensorimotor Approaches
Bobath approach Brunnstroms movement therapy Rood approach Proprioceptive neuromuscular facilitation

Theoretical basis
Neurodevelopmental model Reflex theory Hierarchical theory Systems approach

Neurodevelopmental Model
motor control and its production refers to two systems of output: the open loop (voluntary control ) and the closed loop (postural control) mechanisms

(Keshner, , 1981)

Open-loop system
commands sequences of movement that are centrally stored in the nervous system and that serve the functions of mobility in the production of isolated joint and limb motions

(Keshner, , 1981)

Closed-loop system
Dependent upon afferent feedback for the elicitation of its automatic movements that serve as the principle motility or stability of the organism prerequisite for the development of normal movement behaviors arise from patterns of coordination

Reflex Theory
The basic unit of motor control are reflexes
Reflexes purposeful movement Damage to the CNS results to re-emergence of and inability to control the reflexes

Hierarchical Theory
Motor control is hierarchically arranged
CNS structures involved with movement can be grouped into HIGHER, MIDDLE, and LOWER levels Higher centers regulate and control the middle and lower centers Damage to the CNS results to disruption of the normal coordinated function of these levels

Systems approach
suggests that the CNS does not operate in a strictly descending manner no higher levels with which to control the operation of the lower levels there is a mutable relationship between the various levels so that each level will alternate between command and subordinate roles in relation to the other levels.
(Keshner, , 1981)

Bobath Approach
Concepts and Principles

History
Developed by Dr. Karel Bobath, a neuropsychiatrist, and Mrs. Berta Bobath, a physical therapist 1943 while working with children with cerebral palsy

Original theoretical framework

Based on the works of Jackson, Sherrington, and Magnus
who described nervous system as HIERARCHICAL in nature

Model
Higher brain centers exerted control over lower-level centers Eg. The cerebral cortex control supercedes that of the brainstem

Original theoretical framework

Hypothesis
A neurologic insult will lead to a release of

the lower-level centers from higher-level center inhibitory control, resulting in stereotypical postures, primitive movement patterns and predominant reflex activity

Adult hemiplegia..
Treatment approach was later on expanded to include the rehabilitation of adults with motor problems, particularly CVA Main problem: the abnormal coordination of movement patterns combined with abnormal postural tonus (Bernstein, 1967) Secondary problem: muscle strength and muscle activity

Bobath concept
Is a living concept, it is not static
It has undergone changes in its theoretical base to accommodate developments in the fields of neurophysiology, biomechanics, and typical development

Holistic approach
It involves the whole patient, his sensory, perceptual and adaptive behaviour, and motor problems

Traditional View
Principles of treatment
Normalize muscle tone Inhibit primitive reflexes Facilitate normal postural reactions Treatment should be developmental

Techniques
Handling Weight bearing over the affected limb Utilize positions that allow use of the affected limbs Avoidance of sensory input that affect muscle tone

Previously
The control of movement was thought to be dependent on the normal postural reflex mechanism
E.g. utilizing righting reactions and equilibrium reactions in association with normal postural tone

Systems Theory

Reconstruction of the NDT approach

Hierarchical Theory

Premise
Different parts of the CNS influence one another Nervous system is capable of initiating, anticipating, and controlling movements
feedforward and feedback mechanisms

CNS has the ability to shape and/or renew itself in response to practiced activities: neuroplasticity

Evidence on neuroplasticity
(Fisher, BE and Sullivan, KJ, 2001) Neuroplasticity can occur on the lesioned side of the cerebral cortex following CVA when provided appropriate practice in using involved side Rehabilitation strategies should promote recovery rather than compensation Techniques should incorporate the following:
Active participation in motor skill learning Specific skills training and strengthening directed to the involved limbs Intense, task-specific practice that optimizes the sensorimotor experience

Basic premises
Sensations of movements are learned, not movements per se Basic postural and movement patterns are learned that are later elaborated on to become functional skills

Problems in the adult patient with stroke

Abnormal tone Loss of postural control Abnormal coordination Abnormal functional performance

Goals
Decrease the influence of spasticity and abnormal coordination Improve control of the involved trunk, arm and leg Retain normal, functional patterns of movement in the adult stroke patient

Principles of treatment: Adult hemiplegia

Treatment should avoid movements and activities that increase muscle tone or produce abnormal reflex patterns in the involved side
Treatment should be directed toward the development of normal patterns of posture and movement (movement patterns are not based on the developmental sequence but on patterns important for function)

Principles of treatment: Adult hemiplegia

The hemiplegic side should be incorporated into all treatment activities to reestablish symmetry and increased functional use Treatment should produce a change in the quality of movement and functional performance of the involved side

Principles of treatment: Adult hemiplegia

Individualize functional outcomes Emphasize motor control Increase active use of the involved side Provide practice to improve motor performance that lead to motor learning Teach 24-hour management to increase retention and carryover Use an interdisciplinary approach to intervention

Stages of hemiplegia and the Bobath Approach

Initial Flaccid Stage
tx focus on positioning and movement in bed to avoid the typical postural patterns of hemiplegia

Stage of Spasticity
tx is a continuation of the previous stage with the goal of breaking down the total patterns by developing control of the intermediate joints

Stages of hemiplegia and the Bobath Approach

Stage of Relative Recovery
tx aims at improving the quality of gait and the use of the affected hand

Principles of treatment: children with cerebral palsy

Treat the child as a whole Basis for intervention is normal movement and their interrelationships Treatment incorporates facilitation and inhibition using key points of control
abnormal tone is always inhibited normal responses, once elicited, are always repeated

What are key points of control (KPC)?

Parts of the body where the therapist can most effectively control and change patterns of posture and movement in other body parts
Proximal: spine, sternum, shoulder/scapula, pelvis/hip Distal: jaw, elbow, wrist, knee, base of the thumb, ankle, big toe Head may be a proximal or distal KPC

use KPC that allow full pattern to be broken during handling

Facilitation-Inhibition
Facilitation
is a mean by which movement is made easy, made possible, and made necessary

Inhibition
involves decreasing the use of pathological movements and the effects of tonal dysfunctions on movement

Facilitation and inhibition may be used simultaneouly and may be applied throughout the session

What is handling?
Manner of controlling the patient through tone influencing patterns

Normal patterns of activity used to modify abnormal patterns of posture and movement o Total TIPs: whole body is controlled in a reversal of the abnormal pattern o Partial TIPs: some body parts remain free to move TIPs are utilized via KPCs

Law of Shunting
at any moment during the movement or a postural change, the CNS mirrors or reflects faithfully, the state of the body musculature Therefore, it is the body musculature which guides and directs the CNS Thus, tone inhibiting patterns are used to give the CNS the sensation of normal movements

Principles of treatment: children with cerebral palsy

Child must be active during treatment to achieve functional goals
Voluntary control of normal responses is encouraged

Treatment and evaluation are ongoing Treatment if functionally-oriented

Principles of treatment: children with cerebral palsy

NDT is appropriate for persons with sensorimotor dysfunction regardless of age and cognition

Non-professionals can be an active participant in treatment

Treatment methods
Modify sensory input through handling, positioning reflex inhibiting postures and use of key points of control Facilitate automatic reactions Normal movement patterns are integrated into developing nervous system

OLD THEORY
Hierarchical brain organization (Reflex model)

NEW THEORY
Systems Model

Normal postural reflex mechanism as the Postural control is learned together with basis of normal movement the skill; feedback and feedforward mechanisms needed for efficient movement control
Static postures and positions used for treatment Progressing the client through normal developmental milestones Development of control proceeds in a cephalocaudal direction Work on components of motions which the child will then apply to function Client is an active participant in the session Developmental milestones serve as guidelines but should not be strictly adhered to Control of movement develops in proximal to distal or distal to proximal directions Client must work on functional tasks to learn the skill

Evidence

The Effectiveness of the Bobath Concept in Stroke Rehabilitation

Boudewijn, K. et al. (2009) Stroke. 2009;40:e89. 16 studies involving 813 patients with stroke were included for further analysis. There was no evidence of superiority of Bobath on sensorimotor control of upper and lower limb, dexterity, mobility, activities of daily living, health-related quality of life, and cost-effectiveness. Only limited evidence was found for balance control in favor of Bobath.

Brunnstroms Movement Therapy

Concepts and Principles

History
Developed by Signe Brunnstrom, a physical therapist from Sweden Theoretical foundations:
Sherrington Magnus Jackson Twitchell

Premise
When

the CNS is injured, as in CVA, an individual goes through an evolution in reverse Movement becomes primitive, reflexive, and automatic

Changes

in tone and the presence of reflexes are considered part of the normal process of recovery

Principles of treatment
Facilitate

the patients progress throughout the recovery stages of postural and attitudinal reflexes to increase and decrease tone of muscles of skin over the muscle produces contraction facilitates contraction

Use

Stimulation

Resistance

Basic limb synergies

Mass movement patterns in response to stimulus or voluntary effort or both
Gross flexor movement (flexor synergy) Gross extensor movement (extensor synergy) Combination of the strongest components of the synergies (mixed synergy)

Appear during the early spastic period of recovery

Important! (Limb Synergies)

Muscles are neurophysiologically linked and cannot act alone or perform all of their functions If one muscle in the synergy is activated, each muscle in the synergy responds partially or completely Patient CANNOT perform isolated movements when bound by these synergies

Basic limb synergies: UE

Scapula:

Flexor Shoulder: Synergy

Elbow: Forearm:

retraction and/or elevation abduction and ext rotation flexion supination

Scapula:

Extensor Synergy

Shoulder: Elbow: Forearm:

protraction and /or depression adduction and int rotation extension pronation

Basic limb synergies: UE

Hip:

Flexor Synergy Knee:

Ankle: Toe:

flexion, abduction, and ext rotation flexion dorsiflexion extension

Hip:

Extensor Synergy

Knee: Ankle: Toe:

extension, adduction, and int rotation extension plantarflexion flexion

Mixed synergy: UE
Flexor
Strongest elbow flexion

Extensor
shoulder adduction internal rotation

Next strongest Weakest shoulder abduction external rotation

forearm pronation
elbow flexion

Mixed synergy: LE
Flexor
Strongest hip flexion

Extensor
hip adduction knee extension ankle plantarflexion ankle inversion

Weakest

hip abduction external rotation

hip extension hip int rotation toe flexion

The Typical Hemiplegic Posture

HEAD Lateral y flexed toward the affected side

UPPER LIMB

TRUNK LOWER LIMB

Scapula depressed, retracted Shoulder adducted, IR Elbow flexed Forearm pronated Wrist flexed, ulnarly deviated Fingers - flexed Lateraly flexed toward the affected side
Pelvis posteriorly elevated, retracted Hip IR, adducted, extended Knee extended Ankle plantarflexed, inverted, supinated Toes - flexed

Attitudinal and postural reflexes

Tonic Neck Reflexes
Symmetric TNR
stimulus
Neck flexion

response
Upper extremity flexion Lower extremity extension

Neck extension

Upper extremity extension Lower extremity flexion

Asymmetric TNR
stimulus response

Neck lateral rotation

Jaw side: upper extremity extension lower extremity flexion Skull side: upper extremity flexion lower extremity extension

 Tonic Labyrinthine Reflexes

stimulus supine prone response Limbs tend to move in extension Limbs tend to move in flexion

Tonic Lumbar Reflex

stimulus response Trunk rotation (R) Increased flexor tone (R) UE and (L) LE Increased extensor tone (L) UE and (R) LE Trunk rotation (L) Increased flexor tone (L) UE and (R) LE Increased extensor tone (R) UE and (L) LE

Associated reactions
Investigation by Walshe (1923)
Associated reactions are released postural reactions deprived of voluntary control

Investigation by Simons (1923)

Position of the head has a marked influence on the outcome of the associated rections Limb reactions evoked closely resemble tonic neck reflexes

Observations by Brunnstrom (1951,1952)

UE: movements employed elicited the same reactions in the affected limb LE: movements employed elicited opposite reactions in the affected limb

Associated reactions
Observations by Brunnstrom (1951, 1952)
may be evoked in a limb that is essentially flaccid, although latent spasticity may be present may occur in the affected limb under a variety of condition: in the presence of spasticity, when a degree of voluntary control has been achieved, and after spasticity has subsided may be present years after the onset of hemiplegia

Associated Reactions
Observations by Brunnstrom (1951,1952)
repeated stimuli may be required to evoke a response tension in the muscles of the affected limb decrease rapidly after cessation of stimulus that evoked the associate directions attitudinal reflexes influence the outcome of associated reactions

Associated reactions
Homolateral Limb Synkinesis
The response of one extremity to stimulus will elicit the same response in its ipsilateral extremity

Raimistes Phenomenon
Resisted abduction or adduction of the sound limb evokes a similar response in the affected limb

Associated reactions
Yawning
Flexor synergy is elicited during initiation of yawn

Coughing and Sneezing

Evoke sudden muscular contractions of short duration

Hand reactions
Steps to restoration of hand function (Twitchell, 1951)
1. Tendon reflexes return and become hyperactive 2. Spasticity develops; resistance to passive motion is felt 3. Voluntary finger flexion occurs, if facilitated by proprioceptive stimuli

Hand reactions
4. Proprioceptive traction response can be elicited
Aka proximal traction response Stretch of flexors of one of the joints of the upper limb facilitates a contraction of the flexor muscles of other joints of the same limb thus producing total limb shortening

5. Control of hand without proprioceptive stimuli begins

Hand reactions
6. Grasp is reinforced by tactile stimulus on the palm of the hand; spasticity declines 7. True grasp reflex can be elicited; spasticity further declines

Elicited by disctally moving deep pressure over certain areas of the palm and digits
Catching phase: weak contraction of flexors and adductors upon stimulus Holding phase: proceeds when traction is done on muscles activated in the catching phase

Other hand reactions

Instinctive Grasp Reaction
Stationary contact with the palm of the hand results to closure of the hand

Instinctive Avoiding Reaction

With the arm elevated in a forward-upward direction, the fingers and thumb hyperextend; stroking the palm in a distal direction exaggerates the posture

Soques Finger Phenomenon

Elevation of the hemiplegic arm beyond the horizontal results to estension and abduction of the fingers

Recovery stages in hemiplegia

STAGE CHARACTERISTICS

Stage 1 Period of flaccidity

Neither reflex nor voluntary movements are present

Stage 2 Basic limb synergies may appear as associated reactions

Spasticity begins mostly evident in strong components (flexor synergy appear prior to extensor synergy) Minimal voluntary movement responses may be present
Stage 3 Patient starts to gain voluntary control over movement

synergies Spasticity reaches its peak Semi-voluntary stage as individual is able to initiate movement but unable to control it

STAGE

CHARACTERISTICS

Stage 4

Some movement combinations outside the path of basic limb synergy patterns are mastered Spasticity begins to decline
More difficult combinations are mastered Spasticity continues to decline Individual joint movement becomes possible Coordination approaches normalcy Spasticity disappears: individual is more capable of full movement patterns Normal motor functions are restored

Stage 5 Stage 6

Stage 7

Treatment Principles
1. Treatment progress developmentally 2. When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation and or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement

Treatment Principles
3. Resistance (proprioceptive stimulus) promotes a spread of impulses to produce a patterned response while tactile stimulation facilitates only the muscle related to the stimulated area

Treatment Principles
4. When voluntary effort produces or contribute to a response, patient is asked to hold the contraction (isometric). If successful, an eccentric (contracted lengthening) is performed and finally a concentric (shortening) contraction is done.

Treatment Principles
5. Facilitation is reduced or dropped out as quickly as the patient shows evidence of volitional control. 6. No primitive reflexes, including associated reactions, are used beyond Stage 3. 7. Correct movement once elicited is repeated

Reference
Bandong, A. (2008). Approaches to therapeutic exercise: Concepts, principles, and strategies. Power point lecture presentation in PT 154. Bobath B (1990). Adult hemiplegia: Evaluation and treatment (3rd ed). Oxford, Heinemann Medical Books. Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore, McGraw-Hill Inc. Sawner K & LaVigne J (1992). Brunnstroms Movement Therapy in hemiplegia: A Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.