Sensory

Motor
Approaches
version II
BRUNSTROM THEORY
Asma khalid
Developed by Signe Brunnstrom, a
physical therapist from Sweden

Theoretical foundations:
 Sherrington
 Magnus
 Jackson
 Twitchell

History…
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
It emphasizes the synergic pattern of
movement which develops during
recovery from hemiplegia. This approach
encourages development of flexor and
extensor synergies during early recovery,
with the intention that synergic activation
of muscles will, with training, transition
into voluntary activation of movements.

BRUNSTROM THEORY
 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

Principles of treatment
Attitudinal and postural reflexes
Tonic Neck Reflexes
 Symmetric TNR

 Asymmetric TNR
Tonic Labyrinthine Reflexes

Tonic Lumbar Reflex

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.
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

Important! (Limb Synergies)

 • Scapula: retraction and/or
elevation
Flexor • Shoulder: abduction and
Synergy ext rotation
• Elbow: flexion
• Forearm: supination

• Scapula: protraction and /or

Extenso depression
r • Shoulder: adduction and int
rotation
Basic
Synergy limb
• Elbow: synergies:
extension UE
• Forearm: pronation
Basic limb synergies: LE
Mixed synergy: UE

Flexor Extensor
Strongest elbow flexion shoulder
Strongest
adduction elbow flexion shoulder
internal
adduction
rotation internal rotation

Next
strongest forearm pronation
forearm pronation

Weakest shoulder abduction elbow

elbow
flexionflexion
external rotation
 Strongest hip flexion hip adduction
knee extension
ankle plantar flexion
ankle inversion

Weakest hip abduction hip extension

external rotation hip int rotation
Mixed synergy: LE
toe flexion
The Typical Hemiplegic Posture
Recovery stages in hemiplegia
1. Treatment progress developmentally. Reflexes used
include;
a) Tonic neck reflex
b) Tonic labyrinthine reflex
c) Tonic lumbar reflex
d) Resistance to voluntary contraction of noninvolved limb
e) Sensory stimulation(quick stretch, passive movement, tapping,
surface stroking, positioning and posture on muscle belly or
tendon)

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.

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
Anna Jean Ayres 1920-1988
The Mother of Sensory Integration
 first identified sensory integrative
dysfunction
 struggled with learning problems
similar to those she would later study
 made discovery that such children
had neural disorder resulting in
inefficient organization of sensory
input received by nervous system
 developed diagnostic tools for
identifying the disorder and proposed
therapeutic approach
 Research has had profound influence
in field of occupational therapy
 SI Definitions
SENSORY INTERGRATION: Neuronal process occurring at
cellular level, which organizes sensory input for use. The
"use" may be a perception of the body or the world, or an
adaptive response, or a learning process, or the
development of some neural function. Through sensory
integration, the many parts of the nervous system work
together so that a person can interact with the
environment effectively and experience appropriate
satisfaction.
SENSORY INTEGRATIVE DYSFUNCTION: An irregularity or
disorder in brain function that makes it difficult to
integrate sensory input effectively. Sensory integrative
dysfunction may be present in motor, learning,
social/emotional, speech/language or attention disorders.

- Alabama Occupational Therapy Association, 2000

Not a ‘cookbook’: Treatment is based on
results of intensive assessment of
individual sensory developmental level
and needs.
Basic Principles used to guide intervention
strategy using a variety of sensorimotor
activities.

Treatment Approach
 SI intervention is highly individualized, therefore no set
protocol or techniques are available.
 In children the target populations are those with
developmental disorders including learning disabilities,
autism, pervasive developmental disorder, developmental
co-ordination disorder.
 Intervention centers around controlled and purposeful
exposure to sensory input, and development of adaptive
responses to sensory self and environment.
 SI treatment incorporates basic neuro-developmental
theory (bottom up approach).

Treatment Principles
Primary Goal: Improve the way the brain
processes, organizes sensation to be used
for perception, adaptation, and learning.

Treatment Goals
Secondary Goals and Expected Outcomes
of SI Intervention:
 Regulation of arousal states and attention
 Development of body scheme;
 Postural-motor and bilateral integration of function;
 Praxis for organizing behavior;
 Fine and Gross motor skills (handwriting);
 Visual-auditory aspects of learning ;
 Receptive and expressive language;
 Psychosocial functions (ex: self-concept, self-efficacy);
 Independence in ADLs
Originally developed in 1927 by Julius
Fuchs, an orthopedic surgeon.
Published in 1927 in Berlin by Julius Fuchs
(1888-1953).
The application to neurological and
arthritic dyskinesias was made in 1050s
by Manfred Blashy (physiatrist) and
Elsbeth Harrison & Ernest Fuchs
(Occupational therapists).

Fuchs: Orthokinetics
Focuses on physical effects to materials
placed over muscle bellies.
Originally applied to fractures, scoliosis,
and other orthopedic problems.
The basic idea is to use a segment or cuff
composed of elastic and inelastic parts.

principles
The inelastic/inactive field- covers the
parts where support and muscle inactivity
are desired.
The elastic/active field- where muscle
activity is desired.
Passive field materials (those that are
cool, rigid, and smooth) produce inhibitory
effect
Active field materials (those, warm,
expansive, and textured) produce
facilitatory effect
Cuffs were made of lather and molded
directly to the patient.
They are made of Ace bandage or sewing
elastic1-6 inch wide.
Two or three layers thick for active field
Three to four layers thick in inactive field.
1. Rapid pain relief
2. Increase muscle strength
3. Increase ROM
4. Muscle re-education
5. Improvement of coordination

result
Worn repeatedly, all day while individual
is active.
The greater the imbalance initially b/w
agonist and antagonist muscle group, the
quicker the effects will be noticed.

This is an effective, inexpensive procedure

that supplies continuous input when patient
is not “in therapy”.

frequency
Thank You