Approaches to Therapeutic

Exercise and Activity for

Neurological and Developmental
Conditions
(Bobath and Brunnstrom Approaches
Car & Shepherd )
 Sensorimotor Approaches
• Bobath approach
• Brunnstrom’s movement therapy
• Rood approach
• Proprioceptive neuromuscular facilitation
 Theoretical basis…
• Neurodevelopmental model
• Reflex theory
• Hierarchical theory
• Systems approach
 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)
 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)
 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
 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
 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
 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 mutual relationship between the
various levels so that each level will alternate
between command and subordinate roles in
relation to the other levels.

(Keshner, , 1981)
Bobath Approach

Concepts and Principles

 History…
• Developed by Dr. Karel Bobath, a
neuropsychiatrist, and Mrs. Berta Bobath, a
physical therapist
• 1943 – while working with children with
cerebral palsy
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
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
 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
 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
 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
 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
Reconstruction of
the
NDT approach
 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
 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
 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
Problems in the adult patient with
stroke
• Abnormal tone
• Loss of postural control
• Abnormal coordination
• Abnormal functional performance
 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
 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)
 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
 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
 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
 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
 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
 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
 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
 What is handling?
Manner of controlling the patient through
tone influencing patterns

• Normal patterns of activity used to modify

abnormal patterns of posture and movement
o Total TIPs: whole body is controlled in a
reversal of the abnormal pattern
o Partial TIPs: some body parts remain
free to move
• TIPs are utilized via KPCs
 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
 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
 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
 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
 OLD THEORY
Hierarchical brain organization (Reflex
model)
Normal postural reflex mechanism as the Postural control is learned together with
basis of normal movement
Static postures and positions used for
treatment
Progressing the client through normal
developmental milestones
Development of control proceeds in a
cephalocaudal direction
Work on components of motions which
the child will then apply to function
NEW THEORY
Systems Model
the skill; feedback and feedforward
mechanisms needed for efficient
movement control
Client is an active participant in the
session
Developmental milestones serve as
guidelines but should not be strictly
adhered to
Control of movement develops in
proximal to distal or distal to proximal
directions
Client must work on functional tasks to
learn the skill
Brunnstrom’s Movement
Therapy
Concepts and Principles
 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”
– 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

 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
 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
Basic limb synergies: UE
Mixed synergy: UE
Flexor Extensor
Mixed synergy: LE
Flexor Extensor
 The Typical Hemiplegic Posture
HEAD Lateral y flexed toward the affected side
UPPER LIMB Scapula – depressed, retracted
Shoulder – adducted, IR
Elbow – flexed
Forearm – pronated
Wrist – flexed, ulnarly deviated
Fingers - flexed
TRUNK Lateraly flexed toward the affected side
LOWER LIMB Pelvis – posteriorly elevated, retracted
Hip – IR, adducted, extended
Knee – extended
Ankle – plantarflexed, inverted, supinated
Toes - flexed
 Attitudinal and postural reflexes
• Tonic Neck Reflexes
– Symmetric TNR
stimulus response
Neck flexion Upper extremity flexion
Lower extremity extension
Neck extension Upper extremity extension
Lower extremity flexion

– Asymmetric TNR
stimulus response
Neck lateral Jaw side:
rotation upper extremity extension
lower extremity flexion
Skull side:
upper extremity flexion
lower extremity extension
• Tonic Labyrinthine Reflexes
stimulus response

supine Limbs tend to move in extension

prone Limbs tend to move in flexion

• Tonic Lumbar Reflex

stimulus response
Trunk rotation (R) Increased flexor tone
(R) UE and (L) LE
Increased extensor tone
(L) UE and (R) LE
Trunk rotation (L) Increased flexor tone
(L) UE and (R) LE
Increased extensor tone
(R) UE and (L) LE
 Associated reactions
• Investigation by Walshe (1923)
– Associated reactions are released postural
reactions deprived of voluntary control

• Investigation by Simons (1923)

– Position of the head has a marked influence on
the outcome of the associated rections
– Limb reactions evoked closely resemble tonic
neck reflexes

• Observations by Brunnstrom (1951,1952)

– UE: movements employed elicited the same
reactions in the affected limb
– LE: movements employed elicited opposite
reactions in the affected limb
 Associated reactions
• Observations by Brunnstrom
(1951, 1952)

– may be evoked in a limb that is essentially flaccid,

although latent spasticity may be present

– 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

– may be present years after the onset of hemiplegia

 Associated Reactions
• Observations by Brunnstrom (1951,1952)

– repeated stimuli may be required to evoke a

response

– tension in the muscles of the affected limb

decrease rapidly after cessation of stimulus that
evoked the associate directions

– attitudinal reflexes influence the outcome of

associated reactions
 Associated reactions
• 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
 Associated reactions
• 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)

1. Tendon reflexes return and become

hyperactive
2. Spasticity develops; resistance to passive
motion is felt
3. Voluntary finger flexion occurs, if facilitated
by proprioceptive stimuli
 Hand reactions
4. 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

5. Control of hand without proprioceptive

stimuli begins
 Hand reactions
6. Grasp is reinforced by tactile stimulus on
the palm of the hand; spasticity declines

7. 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
• Instinctive Grasp Reaction
– Stationary contact with the palm of the hand results
to closure of the hand

• 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

• Soque’s Finger Phenomenon

– Elevation of the hemiplegic arm beyond the
horizontal results to estension and abduction of the
fingers
 Recovery stages in hemiplegia
STAGE CHARACTERISTICS

Stage 1 •Period of flaccidity

•Neither reflex nor voluntary movements are present

Stage 2 •Basic limb synergies may appear as associated reactions

•Spasticity begins mostly evident in strong components
(flexor synergy appear prior to extensor synergy)
•Minimal voluntary movement responses may be present

Stage 3 •Patient starts to gain voluntary control over movement

synergies
•Spasticity reaches its peak
•Semi-voluntary stage as individual is able to initiate
movement but unable to control it
STAGE CHARACTERISTICS

Stage 4 •Some movement combinations outside the path of

basic limb synergy patterns are mastered
•Spasticity begins to decline

Stage •More difficult combinations are mastered

5 •Spasticity continues to decline
Stage •Individual joint movement becomes possible
6 •Coordination approaches normalcy
•Spasticity disappears: individual is more capable of
full movement patterns
Stage Normal motor functions are restored
7
 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
 Treatment Principles
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
 Treatment Principles
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.
 Treatment Principles
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

MOTOR RELEARNING
PROGRAMM
• The motor learning approach developed by Carr and
Shepherd used in the treatment of individuals with
neurological difficulties.
• This approach is based around the principle that the brain
is dynamic and capable of reorganisation and adaptation
following injury to the brain or spinal cord.
• The Carr and Shepherd approach encourages active
participation of the patient making treatment functional
and task orientated in order to achieve the best possible
recovery following injury.