CH25 Optimizing motor behavior using the Brunnstrom Movement Therapy Approach

Transcription

1 CH25 Optimizing motor behavior using the Brunnstrom Movement Therapy Approach p 劉倩秀老師

2 Assumptions of the Brunnstrom Movement Therapy Approach In normal motor development, spinal cord and brainstem reflexes become modified and their components become rearranged into purposeful movement through the influence of higher centers.

3 Cont. Because reflexes and whole-limb movement pattern are normal stages of development and because stroke appears to result in development in reverse, reflexes and primitive movement patterns should be used to facilitate the recovery of voluntary movement post stroke. Proprioceptive and exteroceptive stimuli can be used to evoke desired motion or tonal changes.

4 Cont. Recovery of voluntary movement post stroke proceeds in sequence from mass stereotyped flexor or extensor movement patterns to movements that combine features of the two patterns and, finally, to discrete movements of each joint at will. Newly produced correct motions must be practiced. Practice within the context of daily activities enhances the learning process

5 Principles of the Brunnstrom Movement Therapy Approach 1 Treatment progresses developmentally from evocation of reflex response to willed control of voluntary movement to automatic functional motor behavior.

6 Cont. 2 When no motion exists, facilitate it using reflexes, associated reactions, proprioceptive facilitation, and/or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement.

7 Cont. 3 Elicit reflex responses and associated reactions in combination with the patient s voluntary effort to move, which produces semi-voluntary movement; this allows the patient to feel the sensory feedback associated with movement and the satisfaction of having moved to some degree voluntarily.

8 Cont. 4. Proprioceptive and exteroceptive stimuli also assist in eliciting movement. Resistance, a proprioceptive stimulus, promotes a spread of impulses to other muscles to produce a patterned response (associated reaction), whereas tactile stimulation (exteroceptive) and muscle or tendon tapping (proprioceptive) facilitate only the muscle related to the stimulated area.

9 Cont. 5 When voluntary effort produces a response, ask the patient to hold (isometric) the contraction. If successful, ask for an eccentric (controlled lengthening) contraction and finally a concentric (shorting) contraction.

10 Cont. 6 Even when only partial movement is possible, stress reversal of movement from flexion to extension in each treatment session.

11 Cont. 7 Reduce facilitation as quickly as the patient shows evidence of volitional control. Drop out facilitation procedures in order of their stimulus-response binding. Reflexes are the most primitive and are dropped out of treatment first. Responses to exteroceptive stimulation are least stereotyped, and therefore, tactile stimulation is eliminated last. No primitive reflexes, including associated reaction, are used beyond stage III.

12 Cont. 1. Place emphasis on willed movement to overcome the linkages between parts of the synergies. Patient may be more successful if you ask them to do familiar movements involving a goal object.

13 Cont. 9 Have the patient repeat correct movement, once elicited, to learn it. Practice should involve functional activities to increase the willed aspect and to relate the sensations to goal-directed movement.

14 Evaluation Sensation Tonic reflexes Associated reactions Level of recovery of voluntary movement

15 Cont. Sensation The sensory evaluation precedes the motor evaluation. The results of sensory evaluation guide the therapist s choice of facilitation modalities to improve movement. CH7, p.223 Touch awareness Pinprick or pain awareness Temperature awareness Proprioception

16 Cont. Tonic reflexes Tonic reflexes are assessed to determine whether they can be used in early treatment to initiate movement when none exists. ATNR STNR TLR Tonic lumbar

17 ATNR Tonic lumbar reflex Sti: rotate upper trunk in relation to the pelvis Response: Increased flexor tone in U/E, extensor tone in L/E on the side toward which the trunk is turned

18 TLR- prone position TLR supine position

19 STNR in extension STNR in flexion

20 Cont. Associated reactions(協同反應;聯合反應) Associated reaction are involuntary movements, reflexive increases of tone in muscles that would be expected to contract to cause the movement. Be triggered by effortful voluntary movement

21 Cont. Basic limb synergies (協同動作) Limb synergies are instances of associated reactions. When the patient initiates a movement of one joint, all muscles that are linked in synergy with that movement automatically contact, causing a stereotyped movement pattern (固著化的動作型態). Flexor synergy U/E; L/E Extensor synergy U/E; L/E

22 flexor synergy of upper extremity Scapular retraction / elevation Shoulder abduction and external rotation Elbow flexion (strongest component) Forearm supination Wrist and finger is variable Instruction: Touch your ear Cont.

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24 Extensor synergy of upper extremity Scapular protraction Shoulder horizontal adduction and internal rotation (strongest component) Elbow extension Forearm pronation Wrist and finger is variable Instruction: Reach out to touch your opposite knee Cont.

25 Cont. Upper extremity flexor synergy usually develops before extensor synergy. When both synergies are developing and spasticity is marked, the strongest components of the flexion and extension synergies sometimes combine to produce the typical upper extremity posture in hemiplegia: Add and internal rotated Elbow flexed Forearm pronated Wrist and fingers flexed

26 Cont. Flexor synergy of lower synergy Hip flexion (strongest component), abduction, and external rotation Knee flexion Dorsiflexion and inversion of the ankle Toes dorsiflexion Extensor synergy of lower synergy Hip extension, adduction, and internal rotation; Knee extension Ankle plantar flexion and inversion (strongest component) Toes plantarflexion

27 Cont. Other associated reactions identified by Brunnstrom 1. Resistance to flexion of the uninvolved leg causes extension of the involved extremity, and resistance to extension of the uninvolvd leg cause flexion of the involved extremity.

28 2. Resisted grasp by the uninvolved hand causes a grasp reaction in the involved hand. (mirror synkinesis)鏡像協同動作 3. Attempt to flex the involved leg or resistance to leg flexion causes a flexor response in the involved arm. (homolateral synkinesis)同側協同動作

29 4. Actively or passively raising the affected arm above the horizontal causes the fingers to extend and abduct. (Souque s phenomenon) raising the involved upper extremity above 100 degrees with elbow extension will produce extension and abduction of the fingers 5. Resistance to abduction or adduction of the unaffected lower limb results in a similar response in the opposite affected leg. (Raimiste s phenomenon)

30 Level of recovery of voluntary movement The Brunnstrom stages The Fugl-Meyer Assessment of Motor Function

31 Brunnstrom stages Arm I. flaccidity: no voluntary movement or stretch reflexes II. Synergies can be elicited reflexively; flexion develops before extension; spasticity developing III. Beginning voluntary movement, but only in synergy; increased spasticity, which may become marked

32 IV: some movements deviating from synergies 1. Hand behind back 2. Arm forward horizontal position 3. Pronation and supination with the elbow flexed to 90 ; spasticity decreasing V: independence from basic synergies 1. Arm to side horizontal position 2. Arm forward and overhead 3. Pronation and supination with elbow fully extended; spasticity waning VI: isolated joint movements freely performed with near normal coordination; spasticity minimal

33 Hand 1. Flaccidity 2. Little or no active finger flexion 3. Mass grasp or hook grasp; no voluntary finger extension or release 4. Semi-voluntary finger extension in a small range of motion; lateral prehension with release by thumb movement 5. Palmar prehension 1. Cylindrical and spherical grasp (awkward) 2. Voluntary mass finger extension (variable range of motion) 6. All types of prehension (improved skill) 1. Voluntary 劉倩秀老師 finger extension (full 03/04/2009 range of motion) 2. Individual finger movements

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35 Evaluation to determine (Practice 25-2) 1. Propriceptive and exteroceptive sensory status 2. Effect of tonic reflexes on the patient s movement 3. Effect of associated reactions on the patient s movement 4. Level of recovery of voluntary motor control

36 Treatment 1. Rehabilitation trunk control 2. Retraining proximal upper extremity control

37 Rehabilitating trunk control Hemiplegia: poor trunk control Promote contraction of trunk muscles on uninvolved side first by pushing off balance toward the involved side Trunk extension / flexion

38 Trunk forward flexion

39 Retraining proximal upper extremity control General format for treatment practice 25-4 Because recovery proceeds sequentially, once the stage of recovery is identified, the short-tern goal is the next step in the sequence Stages I to III Stages IV to VI

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41 Stages I-III Treatment goal: To promote voluntary control of the synergies To encourage their use in functional activities Stages I to II From flaccidity to beginning synergy Using reflexes, associated reactions, facilitation procedures

42 1. Initiate scapular elevation Position: patient s arm supported on a table in shoulder abduction with elbow flexion Patient is asked to lateral flexion of neck toward the involved side Therapist gives resistance to the head and shoulder 2. Active contraction by associated reaction Patient is asked to bilateral scapular elevation, Therapist give resistance to the uninvolved scapular As patient elevate scapular with associated reaction Therapist give劉倩秀老師 resistance03/04/2009 to the involved scapular Patient is asked to hold it

43 Develop elbow extension - rowing

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45 Develop elbow extension - weight bearing

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47 Practice extensor synergy functionally Put the arm into the sleeve of a garment To smooth out a sheet on the bed To sponge off the kitchen counter

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49 Practice flexor synergy functionally Carrying coat or handbag Feeding oneself Putting on glasses Combing the hair Practice both synergies functionally Sanding, weaving, ironing, polishing Alternating and repeating movement

50 Stages IV to VI Treatment goal: To promote movement deviating from synergy condition the synergies, To promote voluntary movement combining components of the two synergies into increasingly varied combinations of movements that deviate from synergy Technique Proprioceptive and exteroceptive stimuli are still used Associated reaction is no longer used

51 The first out-of-synergy motion of stages IV Combine Shoulder abduction (flexor synergy) Elbow extension, forearm pronation, internal rotation (extensor synergy) A swinging motion of the arm combined with trunk rotation helps to get the hand behind the body. Sitting or standing The patient strokes the dorsum of the hand against the body (give the direction to the attempted voluntary movement) Functional tasks Putting a belt on when the patient is standing Tucking a shirt into trousers

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53 The second out-of-synergy motion of stages IV Combine Shoulder flexion with foreword horizontal Elbow extension If the patient cannot flex the shoulder forward actively.. The arm is brought passively into position Manual guidance Ask patient to hold the position Facilitating technique tapping over the anterior and middle deltoids muscles If the patient can hold the after positioning Patient is asked to lower of the arm followed by active shoulder flexion Stroking of triceps are used to help the patient keep the elbow straight as the arm is raised Repetitive non-resistive activities Raising the arm to forward horizontal is involved in any vertically mounted games (tick-tac-toe, checkers (Velcro tabs) ) Reaching for objects in a cupboard

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55 The third out-of-synergy motion of stages IV combine forearm pronation elbow flexion Functional activities forearm pronate while elbow extension elbow can be brought into flexion gradually Activities require turning objects (knob, screwdriver..)

56 The first motion of stages V Combine Shoulder side horizontal / abduction Elbow extension table tennis, driving golf ball, hitting a baseball, washing dishes (F25-13)

57 The second motion of stages V Serratus anterior must be specifically retrained. Passive mobilization of the scapula Grasping the vertical border and repeatedly and slowly rotating it as the arm is passively moved into and overhead position Placing the arm in forward horizontal position and asking and assisting the patient to reach forward Therapist moving the arm incrementally overhead Practice with functional activities Bilateral sanding box Putting on overhead garments every day Washing a wall or painting it with roller

58 What drives upward rotation of the scapula? During the early phase of upward rotation, the scapula and the clavicle move together around an axis through the sternoclavicular (SC) joint, the only joint where the scapula and shoulder girdle attach to the axial skeleton. The SC joint's anteroposterior (AP) axis is somewhat oblique and passes near the base of the scapular spine. Around this axis, serratus anterior (SA) and upper trapezius (UT) produce upward rotation moments. Once tension in the costoclavicular ligament prevents further elevation of the clavicle at the sternoclavicular joint, the axis for scapular rotation moves to the acromioclavicular (AC) joint. The "X" illustrates the AC joint's antero-posterior axis. Around this axis, the serratus anterior (SA) and the lower trapezius (LT) produce upward rotation moments.

59 edu/msatlas/shserant.html ch/~maurel/pictures/charm/wp3/serratus_anteri or.gif

60 The third motion of stages V Combine Forearm supination Elbow extension To improve supination, the elbow is at first kept close to the trunk and gradually extended. Patients use both hands in activities of interest that entail supination and pronation in various arm positions Grasping beach ball with the arms outstretched and rotating it