BRUNNSTROM’S MOVEMENT THERAPY IN HEMIPLEGIA

 HISTORY
 Developed by Signe Brunnstrom, a physical therapist from Sweden
 Theoretical foundations: Sherrington, Magnus, Jackson, Twitchell

 PREMISE
 When the CNS is injured, as in CVA, an individual goes through an “evolution in reverse”
o Movement becomes primitive, reflexive, and automatic
 Changes in tone and the presence of reflexes are considered part of the normal process of recovery

 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

MOTOR BEHAVIOR OF ADULT PATIENTS IN HEMIPLEGIA

 Basic limb synergies

 Mass movement patterns in response to stimulus or voluntary effort or both
o Gross flexor movement (flexor synergy)
o Gross extensor movement (extensor synergy)
o Combination of the strongest components of the synergies (mixed synergy)
 Appear during the early spastic period of recovery
 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

 BASIC UE LIMB SYNERGIES:

FLEXION EXTENSION MIXED SYNERGY

Scapula Retraction and/elevation Protraction and/ depression Strongest: Shoulder
Abduction & external Adduction & internal adduction & IR; elbow
Shoulder flexion
rotation rotation
Elbow Flexion Extension Next strongest: forearm
Forearm Supination Pronation pronation
Wrist Flexion Extension or flexion
Fingers Flexion Extension or flexion Weakest: Shoulder
abduction & ER and
Dominant Elbow flexion Shoulder adduction & IR elbow flexion
Weakest Shoulder abduction & ER Elbow extension

 BASIC LE LIMB SYNERGIES

 FLEXION EXTENSION MIXED SYNERGY
Hip Flex, abd & ER Ext, add & internal rotation
Strongest: hip flexion, hip
Knee Flexion Extension adduction, knee extension,
Ankle Dorsiflexion PF and inversion ankle PF and inversion
Toes Extension Flexion Weakest: hip abduction &
external rotation, hip
Dominant Hip flexion Hip add, knee ext & ankle PF
extension & internal
Weakest Hip abd and external rotation, toe flexion
Hip extension and internal rotation
rotation

 THE TYPICAL HEMIPLEGIC POSTURE

HEAD LATERALLY FLEXED TOWARD THE AFFECTED SIDE

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

 ATTITUDINAL AND POSTURAL REFLEXES

o TONIC NECK REFLEXES

RESPONSE
STIMULUS
Symmetric TNR Asymmetric TNR
Neck flexion Upper extremity flexion JAW SIDE:
Lower extremity extension upper extremity extension
Neck extension Upper extremity extension lower extremity flexion
Lower extremity flexion SKULL SIDE:
Neck lateral rotation upper extremity flexion
lower extremity extension

o TONIC LABYRINTHINE REFLEXES (BLUE) & TONIC LUMBAR REFLEX (ORANGE)

STIMULUS RESPONSE STIMULUS RESPONSE
Supine Limbs tend to Trunk Increased flexor tone (R) UE and (L) LE
move in extension rotation (R) Increased extensor tone (L) UE and (R) LE
Prone Limbs tend to Trunk Increased flexor tone (L) UE and (R) LE
move in flexion rotation (L) Increased extensor tone (R) UE and (L) LE
  Tonic Lumbar Reflexes (Shimamoto and Nakajima, 1951)
o Reflexes are elicited by changes in the position of the upper part of the body with
respect to the pelvis
o TLumR-Rot: Rotation of front part of chest to (R) facilitates flexion of (R) UE
with concurrent extension of (L) UE and extension of (R) LE with concurrent
flexion of (L) LE
o TLumR-LatFlex: Lateral flexion of chest to (R) facilitates flexion of (R) UE
with concurrent extension of (L) UE and extension of (R) LE with concurrent
flexion of (L) LE
o TLumR-Flexion: Forward flexion of chest facilitates either flexion or
extension* of (B) UEs and extension of (B) LEs *extension of (B) UEs is more
usual
o TLumR-Extension: Extension of chest facilitates either flexion* or extension of
(B) UEs and flexion of (B) LEs *flexion of (B) UEs is more usual

 Influence Of Postural Reflexes

 Patient may be able to perform voluntary flexor and extensor movements only by using the
facilitating effects of one or the other of these reflexes

 ASSOCIATED REACTIONS
 Investigation by Walshe (1923) - Associated reactions are released postural reactions deprived of
voluntary control
 Investigation by Simons (1923)
o Position of the head has a marked influence on the outcome of the associated rections
o Limb reactions evoked closely resemble tonic neck reflexes
 Observations by Brunnstrom (1951,1952)
o UE: movements employed elicited the same reactions in the affected limb
o LE: movements employed elicited opposite reactions in the affected limb
o may be evoked in a limb that is essentially flaccid, although latent spasticity may be present
o 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
o may be present years after the onset of hemiplegia
o repeated stimuli may be required to evoke a response
o tension in the muscles of the affected limb decrease rapidly after cessation of stimulus that
evoked the associate directions
o attitudinal reflexes influence the outcome of associated reactions
 Reflex tensing of muscles and involuntary limb movement

 Voluntary forceful movements in other parts of the body readily elicit such reactions in the affected
limbs.

 Generally… (left)
 Homolateral Limb Synkinesis - 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
 Yawning - Flexor synergy is elicited during initiation of yawn
 Coughing and Sneezing - Evoke sudden muscular contractions of short duration

 HAND REACTIONS
 Steps to restoration of hand function (Twitchell, 1951)
o Tendon reflexes return and become hyperactive
o Spasticity develops; resistance to passive motion is felt
o Voluntary finger flexion occurs, if facilitated by proprioceptive stimuli
o 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
o Control of hand without proprioceptive stimuli begins
o Grasp is reinforced by tactile stimulus on the palm of the hand; spasticity declines
o 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
 Other hand reactions
o Instinctive Grasp Reaction – Stationary contact with the palm of the hand results to closure of
the hand.
o 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
o Soque’s Finger Phenomenon – Elevation of the hemiplegic arm beyond the horizontal results
to estension and abduction of the fingers

 RECOVERY STAGES AND EVALUATION PROCEDURES

STAGE CHARACTERISTICS
Stage 1 a) Period of flaccidity and neither reflex nor voluntary movements are present
Stage 2 a) Basic limb synergies may appear as associated reactions
b) Spasticity begins mostly evident in strong components (flexor synergy appear prior to
extensor synergy)
c) Minimal voluntary movement responses may be present
Stage 3 a) Patient starts to gain voluntary control over movement synergies
b) Spasticity reaches its peak
c) Semi-voluntary stage as individual is able to initiate movement but unable to control it
Stage 4 a) Some movement combinations outside the path of basic limb synergy patterns are
mastered
b) Spasticity begins to decline
Stage 5 a) More difficult combinations are mastered
b) Spasticity continues to decline
Stage 6 a) Individual joint movement becomes possible
b) Coordination approaches normalcy
c) Spasticity disappears: individual is more capable of full movement patterns
 Stage 7 a) Normal motor functions are restored

 Recovery may be arrested at any stage in the process

o Depending on the severity of the insult and the degree of sensory involvement
 A stage in the recovery process is not skipped
o In cases of only slight insult to CNS, recovery may be so rapid that distinct stages may
not be observable
 In stages 4 and 5, movements that resemble synergy (stage 4) are more easily achieved than those
that deviate greatly from synergy (stage 5)
 Stages bear a resemblance to normal infantile motor development
o Reflex -> Voluntary
o Gross -> Fine
o Proximal control -> Distal control

 EXAMINATION
 Gross Sensory Loss
o Passive Motion Sense (Shoulder, Elbow, Forearm, and Wrist)
o Passive Motion Sense (Digits)
o Fingertip Recognition
o Passive Motion Sense (Lower Limb)
o Others:
 Position sense
 Sole sensation
 Motor Tests
o Shoulder and Elbow
STAGE Motor Test (for shoulder and elbow)
1 No voluntary movement
2 (flexor synergy components usually appear first)
Weak associated reactions or voluntary attempts to move
3 Flexor synergy (usually done first): reach up and scratch behind the ear
Extensor synergy: reach in a forward-downward direction between patient’s knees
4 Placing the hand behind the body; elevation of the arm to a forward-horizontal position
Pronation-supination, elbows at 90° close to body
5 Arm-raising to a side-horizontal position; arm-raising forward and overhead
Pronation-supination, elbow extended in a side-horizontal position
6 Speed tests: Hand from lap to chin (elbow flex) or hand from lap to opp knee (elbow ext)
7 May now use regular MMT
o Hand
STAGE Motor Test (for hand)
1 No voluntary movement
2 Little or no active finger flexion
3 Mass grasp; hook grasp but no release
No voluntary finger extension (possible reflex extension)
4 Lateral prehension with release by thumb movement
Small range semivoluntary finger extension
5 Palmar prehension; possible cylindrical and spherical grasp (awkwardly performed and
with limited functional use) and voluntary mass extension of digits (ranges may vary)
6 All prehension types under control; skills improving and full-range voluntary extension of
digits; and individual finger movements present (less accurate than on opposite side)
 7 May now use regular MMT

o Trunk and Lower Limb

STAGE Motor Test (Trunk and Lower Limb)
1 No voluntary movement
2 Minimal voluntary movements of the lower limb
3 Hip-knee-ankle flexion in sitting and standing
4 Sitting: Knee flexion beyond 90° with the foot sliding backward on the floor and
voluntary dorsiflexion of the ankle without lifting the foot off the floor
5 Standing: Isolated nonweight-bearing knee flexion (hip extended or nearly extended) and
isolated ankle dorsiflexion (knee extended, heel forward in short-step position)
6 Standing: Hip abduction beyond range obtained from pelvic elevation
Sitting: Reciprocal action of the inner & outer hamstring muscles, resulting in inward and
outward rotation of the leg at the knee, combined with inversion and eversion of the ankle
7 May now use regular MMT

 Gait Analysis
o Proceed when patient is sufficiently advanced while noting deviations at ankle, knee and hip
in both stance and swing phases.

 TREATMENT PRINCIPLES
1. 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.
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
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.
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 3.
7. Correct movement once elicited is repeated

 TRAINING PROCEDURES FOR TRUNK AND UPPER EXTREMITY

1) Bed Posture And Bed Exercises
 Bed Posture
o Management starts when flaccidity prevails
o Limbs may be placed in the most favorable positions without interference by spastic
muscles
o Typical Flexor Posture (LE)
 Usually appears first
 Hip external rotation and abduction with knee flexion
o Typical Extensor Posture (LE)
 Appears later
 Hip extension and adduction with knee extension and ankle plantarflexion
o Recommended Bed Posture (LE)
 Alternate supine position with sidelying
 Supine:
  If extensor synergy dominant, slight hip and knee flexion maintained by a small
pillow under the knee
 If flexor synergy dominant, knee in extension
 Prevent hip abduction and external rotation by applying lateral support at the
knee
 Proper support of bedclothes to prevent them from pressing on foot
o Recommended Bed Posture (UE)
 Upper limb supported on pillow in a position comfortable to patient
 Avoid:
 Abduction of the humerus with respect to the scapula
 Traction on the affected arm during patient handling
 Instruct patient to use the normal arm to support the affected arm when moving
around in bed
 Bed Exercises
o Passive and Active Assisted Movements
o Turning
 Supine to Sidelying (both sides)
 Prone positioning (‘unlocking’ flexed joints)

2) Trunk and Neck Training in Sitting Position

 Sitting Trunk Balance o Evoking Balance Responses
o Symmetrical Trunk Posture and  Trunk Bending Forward and Obliquely
Weight Bearing Forward
o The Listing Phenomenon  Trunk Rotation
 Head and Neck Movements

3) Upper Limb Treatment (Stages 1-3)

 Range of Motion o Use of Proximal Traction
 Evoking Associated Reactions Response
 Flexion Movements  Extension Movements
o Shoulder pain and techniques o Bilateral contraction of the
for painless shoulder pectoralis major muscles
movements  Early Training of the Serratus Anterior
o Shoulder subluxation and  Withdrawal of Therapist’s Assistance
techniques for prevention and  Practical Use of the Basic Limb
treatment Synergies
o Reinforcement of voluntary
abduction

4) Upper Limb Treatment (Transitions From Stage 3 To Stages 4-5)

 Introducing Variations in Movement Directions (Transition from Stage 3 to Stage 4)
o Flexor and extensor activities
 Exercises to Continue Transition from Stage 3 to Stage 4
o Arm to rear of body
 Starting with flexor synergy
 Starting with extensor synergy
 Starting with trunk rotation in erect standing
o Arm-raising Forward to Horizontal
o Pronation-supination of Forearms, Elbows Flexed
  Exercises to Continue Transition from Stage 4 to Stage 5
o Arm-raising to Side-horizontal Position
o Turning Palms Up and Down, Elbows Extended
 Upper Limb Treatment (Transitions from Stage 5 to Stage 6)
o Approach varies from patient-to-patient and are individualized

5) Hand Training
 Influence of Imitation Synkinesis o Second stage of manipulations
 Grasp Elicited by Proximal Traction o Third stage of manipulations
Response o Tonic thumb reflex
 Wrist Fixation for Grasp  Alternate Fist Closure and Fist Opening
o Synergy influence on wrist  Sensations that Precede or Accompany
muscles Voluntary Finger Extension
o Wrist positioning  Transition to Voluntary Finger
o Activation of wrist extensor Extension
muscles o Semivoluntary mass extension
o Wrist stabilization for grasp, of digits
elbow flexed o Individual thumb movements
o Hyperactive wrist extensor  Voluntary Finger Extension
muscles  Prehension Types
 Release of Grasp and Elicitation of o Hook grasp
Extensor Responses o Lateral prehension
o First stage of manipulations o Advanced prehension

 GAIT PATTERNS IN HEMIPLEGIA

 Muscle Action in Normal Walking o Firm linkage of muscle groups
Compared with That of the Limb in accordance with the dictum
Synergies of primitive movement
 Ambulation difficulties in patients with synergies
hemiplegia are related to 2 main factors: o Slowness of reactions of the
muscle groups
 WALKING PREPARATION AND GAIT TRAINING
 Components o Bilateral contraction of hip
o Trunk Balance flexor muscles
o Modification of Motor o Unilateral contraction of hip
Responses of the Lower Limb flexor muscles
o Alternate Responses of
Antagonistic Muscles o Activating the dorsiflexor
o Standing and Walking muscles of the ankle
 Trunk Balance (Bechterev’s/Marie-Foix
o Trunk listing in sitting Reflex)
 Beevor’s observations o Requirements for the early
 Deficiency of stance phase
perception  Alternate Responses of Antagonistic
 Modification of Motor Responses of the Muscles
Lower Limb o Knee flexors and knee extensors
o Indications for special training o Predominance of flexion in the
procedures lower limb
 Standing and Walking
 o Knee stability in standing o Assisted walking
o Preparation for ‘Swing-through’ o Walking instructions
in walking o Obstacle clearance
o Trunk rotation with arm swing o Stairs
o Automatic gait

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