1. Physical Therapy for Hemiplegia Patients
物理治療師
陳貞吟

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

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. Clinical practice Normal lying posture

17. Clinical practice normal sitting posture

18. Clinical practice normal pattern from lying to sit

19. 感謝各位的聆聽
歡迎指教