Brunnstrom Movement Therapy

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Introduction

The Brunnstrom approach is a widely used movement therapy approach used by clinicians. This approach highly focuses synergic pattern of spastic muscles on the recovery of stroke patients through various stages. There is no specialized training available in this approach.

History

Signe Brunnstrom, a Swedish physical therapist developed this approach in the 1960s. Her work on hemiplegia was based on various traditional neurophysiological theories of motor control. She tried various trial and error on motor and verbal reactions to each procedure or from observations of patients. There are several methods on rehabilitation of stoke patients however very little evidence is present.

Assumptions

Brunnstrom made assumptions regarding the motor control and reactions of stroke patients to form a basis for the principles of movement strategy. These are as follows :-

• In normal motor development, reflexes become modified into purposeful movements and thus recovery in stroke appears to result development in reverse as reflexes are used to facilitate and learn purposeful movements. Brunnstrom believed that no reasonable training method should be left untried and stated "It may well be that a subcortical motion synergy which can be elicited on a reflex basis may serve as a wedge by means of which limited amount of willed movement can be learned"
• Proprioceptive and exteroceptive stimuli can be used to provoke desired motion or tonal changes
• Recovery of voluntary movement in poststroke proceeds in sequence from mass patterns to discrete movements voluntarily. The stereotyped movements are called limb synergies .
• Repetition is a must of learned movements.
• Practice in context of ADL's enhances learning

Principles

The principles of Movement therapy are as follows :-

• Treatment progresses in a developmental sequence from reflexes to voluntary to functional movements.
• When no motion exists, movement can be facilitated using reflexes, associated reactions, proprioceptive/exteroceptive stimuli to develop muscle tension.
  1. Reflex and associated reactions are combined with voluntary effort which produces semi-voluntary movement thus providing sensory feedback and satisfaction.
  2. Various stimuli given assist in eliciting movement. Resistance (proprioceptive stimuli) promotes a spread of impulses to other muscles to produce an associated reaction whereas a tactile stimuli facilitates muscles only to stimulated area.
• The client is asked to hold (isometric) a response if voluntary effort is done. If possible, he is asked for an eccentric (controlled lengthening) followed by concentric (controlled shortening) contraction.
• Even if a partial movement is possible, reversal of movement is stressed within each session.
• Facilitation techniques are dropped a soon as the client shows voluntary control. Responses to exteroceptive stimuli are least stereotyped thus tactile stimuli is last to be eliminated. No primitive reflexes are used beyond stage 3.
• Emphasis is more on voluntary movement and similar ADL's are encouraged to perform.
• Correct movement, once elicited, should be repeated and practiced.

Evaluation

Evaluation is done to select the treatment pattern and check the prognosis of the condition. It includes determination of the following:-

1. Sensory examination - Determines client's ability to recognize movements and touch without looking. Results help in determining the choice of facilitation technique the therapist can use or alert the therapist to use visual feedback to compensate for lost sensation
2. Level of recovery of voluntary control -
3. Effect of tonic reflexes on the patient's movement
4. The effect of associated reactions on patient's movement