Brunnstrom Principles

• available to the patient at any point in the recovery process

• When no motion exists, movement is facilitated through reflexes, associated reactions

Movement Therapy - used for?

False; Normal parts of the process

True/False: Brunnstrom asserts the synergies, reflexes, and other abnormal movement patterns are abnormal parts of the recovery process

• Treatment progresses developmentally from evocation of reflex responses to willed control of voluntary movement to automatic functional motor behavior.

• During treatment, use the available motor patterns of the patient coinciding with their stage of recovery.

• Synergies, reflexes, and other abnormal movement patterns are normal parts of recovery process that the patient must go through before normal voluntary movement can occur.

Principles of Movement Therapy

• Shoulder retraction, elevation, ER, abduction to 90 deg

• Elbow flexion

• Forearm supination

UE flexor synergy

• Shoulder protraction, IR, adduction

• Elbow extension

• Forearm pronation

UE Extensor Synergy

• Hip flexion, ER, abduction

• Knee flexion

• Ankle DF, inversion

• Toes DF

LE Flexor Synergy

• Hip extension, IR, adduction

• Knee extension

• Ankle PF, inversion

• Toes PF

LE Extensor Synergy

• Tonic Neck and Labyrinthine Reflexes

  • AKA Magnus or De Kleijin’s reflexes

  • STNR

  • ATNR

  • Tonic labyrinthine reflexes

• Tonic Lumbar reflexes

Attitudinal or Postural REflexes

• a primitive reflex in infants that helps them move from a crawling position to a more upright posture.

• This reflex involves a reciprocal movement between the head and the limbs: when the head flexes (bends forward), the arms bend and legs extend, and when the head extends (tilts back), the arms extend and legs flex.

STNR

• a primitive reflex in newborns that appears as a "fencing" posture

• when their head is turned to one side, causing the arm and leg on that side to extend while the opposite limbs flex.

• It's a normal developmental step, but it should disappear or "integrate" by around 5 to 7 months of age.

ATNR

Associated Reactions

movement seen on the affected side in response to voluntary forceful movements in other parts of the body

mutual dependency between the synergies of the UE and LE

Homolateral Synkinesis

• Raimiste’s Phenomenon

• Soque’s Phenomenon

• Marie-foix Phenomenon

Associated Reactions

extension of fingers when the shoulder is flexed

Soque’s Phenomenon

• AKA Bechterev’s Reflex

• Passive PF of the toes of a patient in supine with hip and knee in slight flexion elicits mass flexor response including ankle DF

Marie-foix phenomenon

Stage 1 - flaccidity

Stage 2 - spasticity begins to develop

Stage 3 - spasticity reaches its peak

Stage 4 - spasticity begins to decline

Stage 5 - spasticity continues to decline

Stage 6 - spasticity disappears

Stage 7 - normal motor function is restored

Stages of Motor Recovery (Brunnstrom)

• Flaccidity

• No movement on either reflex or voluntary basis

Stage 1 of Recovery

• Spasticity begins to develop

• Basic limb synergies or some of their components may appear as associated reactions or minimal voluntary movement responses may be present

Stage 2 of Recovery

• Spasticity reaches its peak

• Semi-voluntary stage; patient is able to to initiate movement but is unable to control the form of movement, which will be the basic limb synergies

Stage 3 of Recovery

• Spasticity begins to decline

• Some movement combinations that do not follow the paths of the basic limb synergies are mastered, first with difficulty then with increasing ease

Stage 4 of Recovery

• Spasticity continues to decline

• More difficult movement combinations are mastered as basic limb synergies lose their dominance over motor acts

Stage 5 of Recovery

• Spasticity disappears

• Individual joint movements become possible and coordination reaches normalcy

Stage 6 of Recovery

• Recovery may be arrested at any stage

• A stage in the recovery stage is not skipped

• Recovery bears resemblance with the normal infantile motor development

  • reflex to voluntary movements

  • gross to fine

  • proximal to distal control

Sequential Recovery Stages and Evaluation Procedures

• Stage 1 – Flaccidity

• Stage 2 – the basic limb synergies or some components now make their appearance

• Stage 3 – the basic limb synergies or some of their components are performed voluntarily and are sufficiently developed to show definite joint movement

Shoulder & Elbow Sequential Recovery Stages and Evaluation Procedures: Stage 1-3

• Stage 4 – Place hand behind body, shoulder flexion to 90deg, pronate-supinate forearm with elbow at 90deg at the side

• Stage 5 – Arm raising to abduction, arm raising forward and overhead, pronate-supinate with extended elbow

• Stage 6 – isolated joint movements are now freely performed

Shoulder & Elbow Sequential Recovery Stages and Evaluation Procedures: Stage 4-6

• Stage 1 – Flaccidity

• Stage 2 – Little or no active finger flexion

• Stage 3 – Mass grasp; hook grasp with no release; reflex finger extension possible but not voluntary

Hand Sequential Recovery Stages and Evaluation Procedures: Stage 1-3

• Stage 4 – Lateral prehension, release by thumb movement, Semi-voluntary finger extension, small range

• Stage 5 – Palmar prehension, possibly cylindrical and spherical grasp, voluntary mass extension of digits

• Stage 6 – All prehensile types under control, full-range voluntary extension of digits, individual finger movements present

Hand Sequential Recovery Stages and Evaluation Procedures: Stage 4-6

• Stage 1 – Flaccidity

• Stage 2 – Minimal voluntary movements of the LE

• Stage 3 – Hip-knee-ankle flexion in sitting and standing

Trunk and Lower Limb Sequential Recovery Stages and Evaluation Procedures: Stage 1-3

• Stage 4 – Sitting, knee flex beyond 90deg, foot sliding backward on floor; Voluntary ankle DF s lifting foot off the floor

• Stage 5

  • Standing, isolated NWB knee flexion, hip extension

  • Standing, isolated ankle DF, knee extension, heel forward in position of short step

• Stage 6

  • Standing, hip abduction beyond range obtained from elevation of pelvis

  • Sitting, reciprocal action of inner and outer hams combined with ankle inversion and eversion

Trunk and Lower Limb Sequential Recovery Stages and Evaluation Procedures: Stage 4-6