Brunnstrom Approach to Physical Therapy

BRUNNSTROM Approach Dr. Fatma Said Zidan Lecturer of Physical Therapy for neuromuscular disorder &its surgery, BUC  BRUNNSTROM TECHNIQUE Basic principles:  Brunnstrom developed a technique for maximizing recovery following stroke based on specific...

BRUNNSTROM Approach Dr. Fatma Said Zidan Lecturer of Physical Therapy for neuromuscular disorder &its surgery, BUC  BRUNNSTROM TECHNIQUE Basic principles:  Brunnstrom developed a technique for maximizing recovery following stroke based on specific observations.  This approach encourages the development of flexor and extensor synergies during early recovery, with the intention that synergic activation of muscles, with training, will considered as a transition into voluntary activation of movements.  The parallel is drawn in this approach between recovery from stroke and normal development, i.e. reflex to voluntary; gross to fine movement and proximal to distal control.  Based on the observations of recovery following stroke, this approach use:  Associated reactions, tonic neck reflexes, primitive reflexes to initiate mass flexion or extension movements of upper and lower limb muscle groups.  The development of basic synergies to facilitate movement. The use of such characteristics is considered to be of a temporary nature which, together with sensory stimulation, verbal and manual support, needs to be withdrawn in order for voluntary control to develop.  Facilitation of the recovery process to take place in developmental stages. These stages have only to be achieved and not perfected before attempts at the next stage may begin. Assessment Methods  1- Tonic reflexes  2-Associated reactions  3. Sensory evaluation: - Joint sense - Touch sensation - Sole sensation  4. Assessment of basic limb synergies  5. Stages of motor recovery  6- Speed test  1. Primitive reflexes: ATNR (asymmetrical tonic neck reflex) STNR (symmetrical tonic neck reflex)  Tonic labyrinthine supine reflex Tonic labyrinthine prone reflex Positive supporting reaction  Negative supporting reaction : ( Release of +ve supporting reaction)  Tonic lumbar reflex: Stimulus: rotation of the trunk (to the right for example) Response: flexion of the right upper limb, extension of the right lower limb, flexion of the left lower limb, extension of the left upper limb.  Tonic Thumb Reflex: When the affected upper extremity is elevated above the horizontal with forearm supination, thumb extension is facilitated (pronation is facilitatory to finger extension). Also thumb extension and abduction can be facilitated by scratching on the radial aspect of forearm, above 1st web space and common extensor origin. 2.Associated reactions: U.L Mirroring reaction Souques’ Phenomenon Raimiste’s Phenomenon Homolateral Limb Synkineses Inter-limb Synkineses Associated reactions in the upper extremity Associated reactions in the lower extremity Soques’ Phenomenon Ramiste’s phenomenon 3. Sensory evaluation:  - Joint sense: With the patient seated and is blindfolded; the affected upper limb is supported by the examiner and moved to different positions asking the patient to perform identical position with the unaffected extremity.  - Touch sensation: The palmer aspect of the finger tips are touched with a rubber end of a pencil and the patient is asked to determine without looking which fingertip is touched.  - Sole sensation: the patient, without looking, is asked to determine if an object is touching and pressing against his sole of the foot or not and where. 4. Assessment of basic limb synergies  The strongest component of Flexor synergy: elbow flexion whiles the weakest component: shoulder abduction and external rotation.  The strongest components of Extensor synergy: adduction (pectoralis major) and pronation while the weakest component: elbow extension.  The strongest component of Flexor synergy: hip flexion while the weakest component: hip abduction, external rotation.  The strongest components of Extensor synergy: Hip adduction and Knee: extension whiles the weakest component: hip internal rotation. 5. Stages of motor recovery: 6- Speed test Speed test can be used to assess spasticity during anyone of the recovery stages, provided that the patient has sufficient active ROM.  Treatment principles of Brunnstrom approach: 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. The responses of the patient from such facilitation combine with the patient's voluntary effort to produces semi voluntary movement.  When voluntary effort appears:  - The patient is asked to hold (isometric) the contraction.  - If successful, the patient is asked for an eccentric (controlled lengthening) contraction.  - Finally, a concentric (shortening) contraction.  - Reversal of the movement between the agonist and antagonist.  Facilitation is reduced or dropped out as quickly as the patient shows voluntary control (pathological reflexes and associated reactions).  Correct movement is repeated.  Practice should be in the form of ADL.  N.B. All pathological and physiological methods of facilitation are indicated during the first three motor stages. While, only the physiological methods of facilitation are indicated during the recovery stages (4, 5 & 6).