The History of Neurologic Rehabilitation

What are the 4 neuromuscular facilitation single approaches?

Brunnstrom

NDT

PNF

Rood

What is the main Brunnstrom's Approach principle?

stroke recovery is predictable and progresses through identifiable stages

What are the 6 stroke progression stages in Brunnstrom's Approach?

1. Extremities are flaccid (no movement and decreased tone)

2. Spasticity begins to develop, gradual voluntary movements

3. Voluntary movements through partial ROM of synergy pattern

4. Begin to move out of synergy, spasticity starts to decline

5. Synergies lose dominance

6. Isolated movement is possible, coordination near normal

What is an abnormal synergy pattern present after stroke?

involuntary, stereotypical muscle linkages that prevent isolated joint movement

What is the abnormal post-stroke flexor synergy pattern for the upper extremity?

Scapula: retraction and elevation

Shoulder: abd and ER

Elbow: flex - what initiates synergy to happen

Forearm: supination

Wrist: flex

Fingers/thumb: flex and add

What is the abnormal post-stroke extension synergy pattern for the upper extremity?

Scapula: protraction and depression

Shoulder: add (initiates synergy to happen), IR

Elbow: extension

Forearm: pronation (initiates synergy to happen)

Wrist: flex or ext

Fingers/thumb: flex and add

What is the abnormal post-stroke flexion synergy pattern for the lower extremity?

Pelvis: elevation and retraction

Hip: flex (initiates synergy), abd, ER

Knee: flex

Ankle: DF and inv

Toe: DF

What is the abnormal post-stroke extension synergy pattern for the lower extremity?

Hip: ext, add (initiates synergy), IR

Knee: ext (initiates synergy)

Ankle: PF (initiates synergy) and inv

Toes: PF

What treatment does Brunnstrom emphasize?

embrace synergies through early recovery and use them to aid in regaining voluntary motor control

Issue with using synergies as a treatment method

difficult to unlearn due to neuroplasticity so only practicing synergies leads to only being able to move in synergies and difficulty in initiating isolated movement

What is the modern shift of the Brunnstrom Approach

dynamic systems theory

What is the view of the dynamic systems theory?

movement emerges from multiple interacting systems rather than single hierarchy

What is the foundation of Neurodevelopmental Treatment (NDT)/Bobath approach?

1. learn normal movement patterns through functional activity

2. reflex mechanisms are central to how movement is organized and relearned

What treatment is emphasized in the NDT/Bobath approach?

manual contact at key points of control is used to facilitate or inhibit movement

What are the goals of the Proprioceptive Neuromuscular Facilitation (PNF) approach?

1. Increase patient's ability to move or remain stable

2. Achieve coordinated, functional movement

3. Build stamina and manage fatigue

PNF Movement Patterns: UE D1 Flexion

flex/add/ER

scapula: anterior elevation

PNF Movement Patterns: UE D1 Extension

ext/abd/IR

scapula: posterior depression

PNF Movement Patterns: UE D2 flexion

flex/abd/ER

scapula: posterior elevation

PNF Movement Patterns: UE D2 extension

ext/add/IR

scapula: anterior depression

PNF Movement Patterns: LE D1 flexion

flex/add/ER

PNF Movement Patterns: LE D1 extension

ext/abd/IR

PNF Movement Patterns: LE D2 flexion

flex/abd/ER

PNF Movement Patterns: LE D2 extension

ext/add/IR

PNF Techniques

Rhythmic Initiation

Agonist Reversals

Repeated Contractions

Slow reversals

Alternating Isometrics

Rhythmic Stabilization

Contract-Relax Active Movement

Hold Relax

Rhythmic Initiation

PROM --> AAROM --> AROM --> resisted ROM

Purpose of Rhythmic Intitiation

initiate movement

facilitate improvement in speed, direction, quality of movement

Agonist Reversal

concentric --> eccentric --> concentric contractions of agonist muscle repeated

Purpose of Agonist Reversals

increase joint ROM

improve strength and coordination of movement

Repeated Contractions

isotonic contraction of agonist

Purpose of Repeated Contractions

increase AROM, strength, and endurance of agonist

relaxation of antagonist

Slow Reversals

concentric contractions of antagonist muscle groups without relaxation between reversals

Purpose of Slow Reversals

increase agonist motion

strengthen agonist/antagonist

Alternating Isometrics

isometric of agonist than antagonist

Purpose of Alternating Isometrics

increase isometric strength of postural muscles of trunk and proximal muscles

Rhythmic Stabilization

simultaneous isometric of agonist/antagonist

Purpose of Rhythmic Stabilization

improve postural control, balance, and stability in various functional, WB positions

Contract Relax

PROM of limb to ROM limitation in the agonist pattern and then a max iso contraction of antagonist is performed and resisted

Purpose of Contract Relax

relaxation of muscles antagonist to active muscle group to increase ROM into agonist movement pattern

Hold Relax

iso contraction of muscle then relaxation and elongation during relaxation phase

Purpose of Hold Relax

relaxation and increased ROM

What is the main principle of the Rood Approach?

sensory stimulus is used to determine/drives motor responses

Sensory Stimulation Techniques Involved in the Rood Approach

light touch

tapping

quick stretch

quick ice

traction

approximation

resistance

prolonged stretch

deep pressure

neutral warmth

slow stroking

prolonged cold

Application of Light Touch

quick light strokes over muscle using either fingers, cotton, or a brush to facilitate contraction of underlying muscle

Application of Tapping

brisk taps with fingertips over tendon or muscle belly of involved muscle to facilitate phasic contraction of muscle

Application of Quick Stretch

A quick over elongation of a muscle (often applied at its lengthened range) facilitates contraction of the muscle.

Application of Quick Ice

quick stroking with ice on the skin over the muscle belly facilitates contraction of the underlying muscle

Application of Traction

manually applied distraction force to a joint or limb segment causes muscle relaxation and promotes movement

Application of Approximation

Compression of a joint or body segment stimulates co-contraction of muscles around the body segment and promotes stability

Application of Resistance

manual application of force away from the axis of motion at the joints as the patient is asked to move or to stabilize

Application of Prolonged Stretch

slow passive lengthening of a muscle to inhibit its contraction

Application of Deep Pressure

manual pressure across longitudinal axis of the muscle tendon causes relaxation of the muscle

Application of Neutral Warmth

wrapping of body or limb in blanket, towel, or air splint for purpose of general relaxation

Application of Slow Stroking

slow stroking with the hand along midline of the back, near the posterior rami, for 3 to 5 min leads to calming of the patient

Application of Prolonged Cold

application of an ice pack or ice massage over a muscle leads to its relaxation and reduction of pain

What 2 systems does the Rood Approach believe neuromuscular function is organized around?

mobility and stability

Mobility System Characteristics

light work

phasic muscles - on/off, concentric/eccentric

Stability System Characteristics

heavy work

tonic muscle - sustained/postural muscles

What are the 2 sequences for organizing treatment progression in the Rood Approach?

vital function sequence - foundational physiologic functions (like responsiveness)

skeletal function sequence - movement and postural control

What are the 4 levels of motor control in the Rood Approach?

1. Mobility - free active motion that translates body through space

2. Stability - fixes body part to allow for WB

3. Controlled mobility - WB position where proximal part moves on fixed distal part

4. Skill - non-WB position where free distal part is moving

What is the main principle of modern neurorehabilitation?

practice function do not just treat impairments (principle of specificity - practice makes perfect, so if you want to progress function practice function)