PT 154: Therapeutic Exercise III Ms. Mary Grace M. Jordan, PTRP 23 November 2009

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. Bobath Approach Concepts and Principles

12. History… • Developed by Dr. KarelBobath, 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 • 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 theNDT 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 • Facilitation • 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? 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

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 includedfor further analysis. • There was no evidence of superiority ofBobath on sensorimotor control of upper and lower limb, dexterity,mobility, activities of daily living, health-related qualityof life, and cost-effectiveness. • Only limited evidence was foundfor 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

48. Basic limb synergies: UE

49. Mixed synergy: UE Flexor Extensor

50. Mixed synergy: LE Flexor Extensor