BRUNNSTORM APPROACH FOR

TREATMENT OF HEMIPLEGIA
INTRODUCTION
• Signe Brunnstorm was a physical therapist from
sweden

•Her book on movement therapy in hemiplegia

was published in the year 1970
 Normal movement is characterized by synergistic
motor behavior, that is, the coupling together of
muscles in an orderly fashion as a means by which
purposeful movement is achieved with maximal
precision and minimal waste of energy

 In patients with CVA, the movement patterns are

stereotyped and do not permit different combination
of muscle

 A patient with hemiplegia is unable to recruit these

same muscles for different movement combination
and cannot master individual joint movements
• Following damage to the nervous system, there
is regression to the phylogenetically older
patterns of movement like limb synergies and
primitive reflexes

• The Brunnstorm approach to the treatment of

hemiplegia is based on the use of motor patterns
available at any point in the recovery process
• Brunnstorm saw synergies, reflexes and other
abnormal movement patterns as a normal part of
the process that the patient must go through
before normal voluntary movement can occur
Jackson described the motor representation for skeletal
muscles in the CNS :

• lowest motor centers

•Middle motor centers

•Highest motor centers

LIMB SYNERGIES
•Normal movement is a “synergistic motor
behavior”

•Whereas the “synergies” seen in individuals

with cerebro vascular accident are
“stereotyped” and do not permit different
combinations of muscles

•Beevor (1903) stated that a muscle may be

“paralyzed” for one movement but not for
another
UPPER LIMB
• flexor synergy

• extensor synergy

LOWER LIMB
• flexor synergy

• extensor synergy
 UPPER LIMB:
FLEXOR SYNERGY

• retraction / elevation of the shoulder girdle

• external rotation of the shoulder
• abduction of the shoulder to 90 deg
• flexion of the elbow
• Supination of the forearm
•The dominant component is
elbow flexion
 EXTENSOR SYNERGY

• protraction of the shoulder girdle

• Internal rotation of the shoulder
• Adduction of the arm in front of the body
• Extension of the elbow
• Pronation of the forearm
•Shoulder adduction and internal rotation and forearm
pronation are dominant components
•Finger extension is not seen with either synergy
 LOWER LIMB
FLEXOR SYNERGY
• flexion of the hip
• Abduction and E.R.
of the hip
• flexion of the knee
• D.F. and inversion
of the ankle
• D.F. of the toes
• It is dominated by hip flexion
 EXTENSOR SYNERGY

• extension of the hip

• adduction and internal rotation of the hip
• extension of the knee
• plantar flexion and inversion of the ankle
• plantar flexion of the toes
•The strongest component is knee extension
INTERACTION OF SYNERGY COMPONENTS:

UPPER LIMB ( typical arm posture):

The attitude combines the strongest
Component of flexor synergy
(elbow flexion)
With strong components of extensor synergy
(forearm pronation and shoulder adduction)
POSTURAL REFLEXES

•Symmetric neck reflex

•Asymmetric neck reflex
• Tonic lumbar reflex
•Tonic labrynthine reflex
Influence of postural reflexes
ASSOCIATED REACTIONS
DEFINITION:
• Associated reactions are defined as those
movements which are seen on the affected side
in response to voluntary forceful movements in
other parts of the body
• Walshe (1923) defined associated reactions as
released postural reactions deprived of
voluntary control
• Associated reactions are commonly elicited
when spasticity is present
ASSOCIATED REACTIONS
1. HOMOLATERAL LIMB SYNKINESIS
2. RAIMISTE’S PHENOMENON
• Abduction phenomenon
• Adduction phenomenon
3. PROPRIOCEPTIVE TRACTION RESPONES
4. SOUQUE’S FINGER PHENOMENON
HOMOLATERAL LIMB SYNKINESIS
RAIMISTE’S PHENOMENON
 HAND REACTIONS
 Proprioceptive traction response
stretch of any of the flexor muscles UL evokes or facilitates
contraction flexor muscles all other joint

 The true grasp reflex (Denny- brown 1948)

palmar surface of hands and digits ,
stimulus proximal to distal
Response is flexion of joint over which it moves

Reflex zone – Palmar surface of wrist and

palm (except ulnar portion)
 The Instinctive Grasp Reaction
( Frontal lobe )
stationary contact with palm of the hand

 The Instinctive Avoiding Reaction

(parietal lobe )
stroking – exaggerated hand posture

 Souques’s finger phenomenon

elevation of the affected arm frequently caused the
paralyzed fingers to extend automatically
RECOVERY STAGES
Stage 1 – acute episode, flaccidity, no movt on
either reflex or voluntary basis

Stage 2 – basic limb synergies, some of their

component as associated reactions or minimal
voluntary movt. Spasticity in muscle that
dominate synergy component

Stage 3 – gains voluntary control of movt

synergies , spasticity reaches its peak , recovery
process is semivoluntary
Stage 4 - Some movt that do not follow the paths of
basic limb synergies are mastered, spasticity begins
to decline

Stage 5 - More difficult movt combinations are

mastered , basic limb synergies lose their dominance
over motor acts , spasticity continues to decline

Stage 6 – Individual joint movt become possible &

coordination approaches normalcy , capable of full
spectrum of joint movt as spasticity decreases

Stage 7 – Normal motor function is restored

EVALUATION
1. Sensory evaluation
2. Motor evaluation
• synergies
• Speed tests
3. Balance in sitting and standing
4. Gait analysis
 Sensory evaluation
Gross testing of sensory loss
-Passive motion sense, shoulder, elbow,
forearm and wrist
-Passive motion sense of digits
-Finger tip recognition
-Passive motion sense of lower limb
-Sole sensation
 Motor tests: Shoulder and Elbow
 Recovery stage 1 ( initial stage )
Limbs feel heavy, little no muscular resistance
to movt can be detected

 Recovery stage 2
synergies or some component appear as a
weak associated reactions or on voluntary
attempts to move
Spasticity is developing but may not be marked
Recovery stage 3
 Certain muscles pectoralis major ,
pronators of forearm and flexors of wrist
and digits

 Flexor synergy – “ reach up as if you were

to scratch behind the ear ”

 Extensor synergy – forward – downward

direction to touch palm of examiner's hand
held between the patients knee
Recovery stage 4
- Placing the hand behind the body

- Elevation of the arm to a forward – horizontal

position
( linkage b/n pectoralis major & triceps )

- Pronation – supination , elbow at 90 degrees

Recovery stage 5
- Arm raising to a side-horizontal position
2 components of flexor synergy & extensor synergy
- Arm raising forward and overhead

- Pronation – supination, elbow extended

 Recovery stage 6
Isolated joint movts are freely performed, active movt
with increasing speed may reveal an interference on
affected side

 Speed tests ( stage 4 to 6)

- hand from lap to chin ( complete flexion of elbow )

- hand from lap to opposite knee (full range extension )

 Motor tests: Trunk and lower limb
Stage1 - Flaccidity

Stage 2 - Minimal voluntary movts of LL

Stage 3 - Hip-Knee-ankle flexion in sitting and

standing

Stage 4 – Sitting , knee flexion beyond 90

degrees with foot sliding backward on the floor ;
voluntary DF of the ankle without lifting the foot
off the floor
 Stage 5 – standing , isolated nonweight -
bearing knee flexion, hip extended or
nearly extended ; stand- isolated DF of
ankle knee extended, heel forward in a
position of short step

 Stage 6 – Standing hip abduction beyond

range obtained from elevation of the pelvis
; sitting reciprocal action of inner and outer
hamstrings muscles, resulting from inward
and outward rotation of leg at knee, with
inversion & eversion of ankle
GENERAL PRINCIPLES FOR TREATMENT

1. postural reflexes are used to increase or

decrease tone in specific muscle groups
2. associated reactions are used to initiate or elicit
synergies
3. facilitation of muscle contraction via stretch and
resistance
4. visual and auditory stimualtion
TRAINING PROCEDURES
TRAINING PROCEDURES FOR
TRUNK AND UPPER
EXTREMITY
 BED POSTURE AND EXERCISES
 Bed posture
- Flexor posture lower limb
- Extensor posture lower limb

Recommended bed posture

 Supine : slight hip & knee flexion maintained
under knee; lateral support of the knee to
prevent abduction and ext. rot.
 Choice of bed posture determined on an
individual basis
 Bed exercises
 Passive and active assisted movements

Turning from supine to side lying position

- easier to turn toward the affected side ,
scapula has to be abducted & glenohumeral
joint integrity is maintained

- turning towards the unaffected side, use

normal hand to elevate affected arm , flex the
LL cross to the opposite side
 Trunk and Neck training in
sitting position
Sitting trunk balance
 Symmetrical trunk posture and weight bearing
 Listing phenomenon
 Evoking balancing responses
 Trunk bending forward and obliquely forward
 Trunk rotation
 Head and neck movements
 UPPER LIMB TREATMENT
Rationale
Improve background tension in the affected
limbs by associated reactions or attitudinal
reflexes

 Volitional effort is then superimposed on the

reflexly produced background tension

 When patient is able to initiate movt on

voluntary basis, reflex assistance is
withdrawn ,and movement patterns that deviate
from synergy are introduced
Range of motion
1. Range of motion
2. Evoking associated reaction
3. Flexion Movements
- reinforcement of voluntary abduction
- use of proximal traction response
4. Extension Movements
- Bilateral contraction of the pectoralis major
muscle
 Withdrawal of therapist’s assistance
Rowing activities
 Transition between stages 3&4

 Hand to chin
 Hand to ear , to touch ear on the affected side
then unaffected side ; head rotation is allowed
 Hand to opposite elbow
 Hand to opposite shoulder
 Hand to forehead
 Hand to top of head
 Hand to back part of head
 Stroking movements

-Starting on the fore head, stroking over the top of

the head to back part of the head
- Starting with both hands in lap, the affected hand
performs a stroking movement over the dorsum of
forearm on the normal side and follows the arm
up toward the shoulder or beyond the shoulder
toward the neck
 \
 Extensor activity

- Pectoralis major must be dissociated from the

triceps

- Encourage the resisted extension movts &

guides him in different directions

E.g. push forward-downward, then horizontal

plane then more lateral direction then downward
&back ward direction
 UPPER LIMB TRAINING,
STAGES 4 AND 5

 Stage 4 - movts deviate from basic

synergies

 Stage 5 – more diff . Combinations

E.g. : “push” and “pull”

Arm to rear of body (stage 4)

Start with flexor synergy

Elevates shoulder girdle , hyperextends and

slightly abduct at shoulder , & flexes elbow
allowing forearm more or less vertical with
dorsum touching the lateral part of the hip
E.g. hand to sacrum using flexion
 Starting with extensor activity
successive pushing movts in forward, obliquely
sideward, downward, and backward directions
E.g. Hand to sacrum via extension

Starting with trunk rotation , standing erect

Trunk rotation movts , gradually increasing in
range , & the patient is told to let the arms “flop
around” with out trying control them
E.g. hand to sacrum using trunk rotation in
standing
 Stage 4
 Arm raising forward to horizontal position
 Pronation- supination of forearms, elbow
flexed

Stage 5
 Arm –raising to side horizontal position
 Turning palms up and down, elbow
extended
 Upper limb training stage 6
 Spasticity is disappeared

 Individual joints movts appear

 Encourage advanced prehension activities

 Specific selection of tasks has to treat

 HAND TRAINING
Function of entire UL depends on hand
activities

- First goal is acquition of mass grasp and

mass release of objects

 Grasp elicited by proximal traction

response
 Wrist fixation for grasp
 Wrist positioning
 Activation of the wrist extensor muscles
 Wrist stabilization for grasp, elbow flexed

Release of grasp &

elicitation of extensor reflexes
- Avoid use indiscriminate use of ball
- Avoid contact with the reflexogenic zone
  First stage of manipulations

The thumb is pulled out of the palm by a

grip around the thenar muscles and
supinated the forearm passively.
 Second stage of manipulations
Eliciting the stretch reflexes in finger
extensor muscles further aid in transfer of
tension to these muscles . first swatting and
then rolling movts has to be applied .
 Third Stage of manipulations
Stage includes elevating the arm above
the horizontal position and evoking the
tonic extensor reflexes of the digits.
 Gait patterns in Hemiplegia
 Stance phase - shorter
 Swing phase - longer

Two main factors

Firm linkage of muscle groups with dictum

of movt primitive movt synergies
Slowness of reactions of muscle groups
 Requirements for the early stance
phase
 DF of ankle & abductors of hip must be
activated
 Associated with extensors of hip and knee
- eliciting reflex response in dorsiflexors as
component total flexor synergy
- superimpose voluntary effort on reflex
stimulation
- reinforce the voluntary effort as reflex
stimulation is withdrawn
 Reflex response
- Resist hip flexion when under voluntary control
 Introducing voluntary effort
- Once the reflex evoked number times , the patient
voluntary effort is super imposed
- During reflex elicitation give resistance to ankle , if
its poor given to hip flexion
- Initiate movt without reflex elicitation
- In sitting give resistance to hip flexor & use local
facilitatory techniques
- Lengthening or isometric contraction then
shortening contraction
- Gradually increase the hip and Knee extension
 ABDUCTION
 Trendlenburg limp is common during the early
stance, midstance
 Desired activation of hip abduction with hip and knee
extension will leads undesired activation of the hip
adductors
 Raimiste’s phenomenon
- Use abduction phenomenon
- Superimpose voluntary effort on the reflex contraction
“ spread your feet apart”
 Introduce active & reciprocal motions
- Abduction & Adduction with the hip and knee
extended
 Introduce the reciprocation of movt
- flex the hip and knee as he adducts the hip ; then
extends the hip and knee as he abducts the hip
 Hip abduction , side lying position
 Bilateral activation of the hip abductor muscles
in standing
- abducting first the affected and then unaffected limb
- apply downward pressure on the iliac crest on the
affected side stance and upward on the unaffected
side of pelvis
equal distribution of the body weight and
and equal time spent on the weight bearing on
involved extremity
 Unilateral action of the hip abductors muscles in
standing
- hike the pelvis on the affected side
 ALTERNATE RESPONSES OF
ANTAGONISTIC MUSCLES
 Knee flexors and Knee extensors
- The failure of the quadriceps muscles to
cease to contracting at proper time
- It depend on the flaccidity - spasticity
status
- Supine position
- Side lying position
- Sitting position
- Semistanding position

- Half prone position

- Pawing
 STANDING AND WALKING
 Knee Stability in standing
Patient must learn to support weight
momentarily on a slightly flexed knee
- Standing Knee bends
- Lateral weight shifts
- “Marking time” Knees slightly flexed