1. 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

2. 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

3. Sensorimotor Approaches
Bobath approach
Brunnstrom’s movement therapy
Rood approach
Proprioceptive neuromuscular facilitation

4. Theoretical basis… Neurodevelopmental model Reflex theory
Hierarchical theory
Systems approach

5. 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)

6. 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)

7. 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

8. 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

9. 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

10. 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)

11. Concepts and Principles
Bobath Approach
Concepts and Principles

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

13. 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

14. 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

15. 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

16. 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

17. Traditional View Principles of treatment Techniques
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

18. 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

19. Reconstruction of the NDT approach
Hierarchical Theory
Systems Theory
Reconstruction of the NDT approach

20. 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

21. 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

22. 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

23. Problems in the adult patient with stroke
Abnormal tone
Loss of postural control
Abnormal coordination
Abnormal functional performance

24. 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

25. 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)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Facilitation-Inhibition
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

33. What is handling? What are tone influencing patterns (Tip)?
Manner of controlling the patient through tone influencing patterns
What are tone influencing patterns (Tip)?
Normal patterns of activity used to modify abnormal patterns of posture and movement
Total TIPs: whole body is controlled in a reversal of the abnormal pattern
Partial TIPs: some body parts remain free to move
TIPs are utilized via KPCs

34. 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

35. 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

36. 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

37. 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

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

39. Evidence

40. 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.

41. Brunnstrom’s Movement Therapy
Concepts and Principles

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

43. 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

44. Principles of treatment
Facilitate the patient’s progress throughout the recovery stages
Use of postural and attitudinal reflexes to increase and decrease tone of muscles
Stimulation of skin over the muscle produces contraction
Resistance facilitates contraction

45. 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

46. 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

47. Basic limb synergies: UE
Synergy
Flexor
Scapula: retraction and/or elevation
Shoulder: abduction and ext rotation
Elbow: flexion
Forearm: supination
Extensor
Scapula: protraction and /or depression
Shoulder: adduction and int rotation
Elbow: extension
Forearm: pronation

48. Basic limb synergies: UE
Synergy
Flexor
Hip: flexion, abduction, and ext rotation
Knee: flexion
Ankle: dorsiflexion
Toe: extension
Extensor
Hip: extension, adduction, and int rotation
Knee: extension
Ankle: plantarflexion
Toe: flexion

49. Mixed synergy: UE Flexor Extensor
Strongest elbow flexion shoulder adduction internal rotation
Next
strongest forearm pronation
Weakest shoulder abduction elbow flexion
external rotation

50. Mixed synergy: LE Flexor Extensor
Strongest hip flexion hip adduction knee extension
ankle plantarflexion ankle inversion
Weakest hip abduction hip extension
external rotation hip int rotation
toe flexion

51. The Typical Hemiplegic Posture
HEAD
Lateral y flexed toward the affected side
UPPER LIMB
Scapula – depressed, retracted
Shoulder – adducted, IR
Elbow – flexed
Forearm – pronated
Wrist – flexed, ulnarly deviated
Fingers - flexed
TRUNK
Lateraly flexed toward the affected side
LOWER LIMB
Pelvis – posteriorly elevated, retracted
Hip – IR, adducted, extended
Knee – extended
Ankle – plantarflexed, inverted, supinated
Toes - flexed

52. Attitudinal and postural reflexes
Tonic Neck Reflexes
Symmetric TNR
Asymmetric TNR
stimulus
response
Neck flexion
Upper extremity flexion
Lower extremity extension
Neck extension
Upper extremity extension
Lower extremity flexion
stimulus
response
Neck lateral rotation
Jaw side:
upper extremity extension
lower extremity flexion
Skull side:
upper extremity flexion
lower extremity extension

53. Tonic Labyrinthine Reflexes
Attitudinal and postural reflexes
Tonic Labyrinthine Reflexes
Tonic Lumbar Reflex
stimulus
response
supine
Limbs tend to move in extension
prone
Limbs tend to move in flexion
stimulus
response
Trunk rotation (R)
Increased flexor tone
(R) UE and (L) LE
Increased extensor tone
(L) UE and (R) LE
Trunk rotation (L)

54. 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

55. 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

56. 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

57. Associated reactions Homolateral Limb Synkinesis Raimiste’s Phenomenon
The response of one extremity to stimulus will elicit the same response in its ipsilateral extremity
Raimiste’s Phenomenon
Resisted abduction or adduction of the sound limb evokes a similar response in the affected limb

58. Associated reactions Yawning Coughing and Sneezing
Flexor synergy is elicited during initiation of yawn
Coughing and Sneezing
Evoke sudden muscular contractions of short duration

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

60. Hand reactions 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
Control of hand without proprioceptive stimuli begins

61. Hand reactions
Grasp is reinforced by tactile stimulus on the palm of the hand; spasticity declines
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

62. 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
Soque’s Finger Phenomenon
Elevation of the hemiplegic arm beyond the horizontal results to estension and abduction of the fingers

63. Recovery stages in hemiplegia
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

64. Recovery stages in hemiplegia
CHARACTERISTICS
Stage 4
Some movement combinations outside the path of basic limb synergy patterns are mastered
Spasticity begins to decline
Stage 5
More difficult combinations are mastered
Spasticity continues to decline 6
Individual joint movement becomes possible
Coordination approaches normalcy
Spasticity disappears: individual is more capable of full movement patterns 7
Normal motor functions are restored

65. Treatment Principles 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

66. 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

67. 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.

68. 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 Correct movement once elicited is repeated

69. 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). Brunnstrom’s Movement Therapy in hemiplegia: A Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.