Physical Therapy for Hemiplegia Patients 物理治療師 陳貞吟

Theories for stroke rehabilitation Brunnstrom theory PNF theory Motor relearning theory Bobath theory: NDT: Neural-Developmental Theory

Brunnstrom Theory Aim To encourage the return of voluntary movement in hemiplegia patient through the use of reflex activity and a range of sensory stimulation. The choice of stimulation varies depending on which stage the patient has reached in the recovery process.

Brunnstrom Theory Basis of practice Recovery progresses from subcortical to cortical control of muscle function. The stages of recovery Flaccidity Presence of basis synergy on a reflex level Voluntary control of the movement synergies Ability to mix components of antagonistic synergies but influence of spasticity still observable More difficult movement combinations mastered; limbs synergies lose their dominance Individual joint movements become possible Normal motor function is restored.

Brunnstrom Theory Treatment The choice and use of sensory stimulation depends on the stage of recovery. The process is employed until the primitive synergies are established, then facilitation is used to develop some voluntary control. The preparation for walking should be emphasized early but that extensive walking should be postponed in order to avoid the development of a poor gait pattern Uses primitive reflexes to initiate movement and encourages the use of mass patterns in the early stages of motor recovery

PNF Theory Proprioceptive Neuromuscular Facilitation Primary for the patient with neuromuscular dysfunction Aim to promote movement and functional synergies of movement by maximizing peripheral input

PNF Theory Basis of practice Treatment People who move normally have passed through a developmental sequence Diagonal and spiral patterns of active and passive movements are encouraged Treatment Providing appropriate sensory stimulus Following activities in a developmental sequence Patterns and techniques

Motor relearning Theory By Carr and Shepherd Aim To enable the disabled person to learn how to perform or improve performance of actions critical to everyday life. Utilizing theories of learning, in particular the use of practice and knowledge of results to encourage people to learn and self monitor Knowledge of biomechanics for analyzing movements and performance of tasks

Motor relearning Theory Basis of practice The motor control of posture and movement are interrelated and that appropriate sensory input will help modulate the motor response to a task The program is based on Elimination of unnecessary muscle activity Feedback Practice The link between postural adjustment and movement Task analysis and measurement are viewed as essential elements of the framework.

Motor relearning Theory Treatment Movement analysis and training follow the four steps Analysis of the task Practice of the missing components Practice of the task Transference of training A series of task has been chosen because learning by normal subjects has been shown to be task-specific with minimal carry-over from one activity to another Manual guidance is used as a support or for demonstration and, not for providing sensory input Unwanted activities are limited by choosing an appropriate level of activity.

Bobath theory: NDT Aim Basis of practice To improve the quality of movement on the affected side Key point control is to allow patients the experience of normal afferent input Basis of practice The movement will be abnormal if it stems from a background of abnormal tone Performing abnormal movements will reinforce more abnormal movements Tone could be influenced by altering the position or movement of proximal joints of the body

Bobath Theory: NDT Treatment Treatment centre around the facilitation of corrected movement by a therapist who handles the body at key points of control In recent years treatment has become more active , dynamic and functionally directed. Movement are not isolated to individual joints but take place in patterns

Bobath theory: NDT To help the patient to gain control over the released patterns of spasticity by their own inhibition Auto-inhibition Give patient normal kinematics sensation input to facilitated normal posture and movement Muscle strengthening is not viewed as part of treatment There are no set “Bobath exercise” No more passive stretch, but active participation

Clinical practice Rehabilitation by compensation is to a large extent responsible for an increase in spasticity and for the inactivity of the involved side Patient and PT must work together. People learn best in different ways Rehabilitation by compensation雖然可以使p‘t 快速出院和獨立, 但是日後需要花更多的金錢和時間來矯正abnormal pattern, 而且不一定會成功

Clinical practice Trunk alignment and activity are critical aspects of limb movement Appropriate preparatory postural responses Weight bearing is an effective tool Safe function  Safe balance No good alignment, no normal movement Correct posture alignment Give enough sensory input( visual, auditory, tactile, proprioception …) Facilitation

Clinical practice Normal lying posture

Clinical practice normal sitting posture

Clinical practice normal pattern from lying to sit

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