OTB 520: Week 9

Brunnstrom & NDT

DR. CHERYL BOUCAKIS
READ PEDRETTI: PP. 802-804 & 822-827 (TABLE 31-2)
Student Learning Objectives

 Identify, and demonstrate initial skill in application of,

appropriate interventions (Brunnstrom & NDT) to improve
occupational performance for individuals with selected
neurological disabilities.
 Understand and apply Brunnstrom & NDT has a preparatory
method to facilitate occupational performance.
 Integrate Brunnstrom & NDT within an occupation-centered
and client-centered approach to evaluation and intervention.
Lecture Outline

 Brunnstrom  NDT
 Intro  Intro
 Evaluation  Principles
 Flexor & Extensor Synergies  Evaluation
 Associated Reactions  Intervention
 Synergy Patterns: Levels of  EBP
Recovery
 Treatment Principles
 Current View - EBP
Brunnstrom Movement
Therapy Approach
 Introduction to Brunnstrom

 Developed by Signe Brunnstrom a PT for those with CVA

 Idea that clients with a CVA go through evolution in reverse
 Clearly outlined motor recovery in stages in synergy patterns
 Emphasis of treatment is facilitation of movement from reflexive to volitional
 (Schultz-Krohn, Pope-Davis, Jourdan, & Mclaughlin-Gray, 2013)

 When extremity is completely flaccid, encourage reflexive activity and use reflexive responses to
promote progression through predictable stages of recovery.
 As muscle tone and active motion is gained, further utilize reflexive activity combined with sensory
input to gain further AROM, endurance, strength, and function.
 As active muscle control is gained, normalize spastic tone and promote movement postures away
from massed patterned reflexive motions towards individual joint control and isolated motions.
 (Henrichon, 2017)
 Evaluation

 Assess sensation to determine what may be intact (to utilize sensory

input effectively)
 Assess reflexes: (TLR, ATNR, STNR, Tonic Lumbar) those present can
be utilized in the intervention process
 Assess muscle tone
 Assess for any AROM and for presence of any synergy patterns
 Recommended use of Fugle-Meyer (completed example in online
Radomski chapter 25 via http://thepoint.lww.com )
 (Latham, 2014, Henrichon, 2017)
Flexor Synergy of the UE

What is the position of each?  Elbow flex is strongest and occurs first
 Scapula =  Evoke flexor synergy by applying
pressure to shldr elevation or elbow
 Shoulder =
flexion in the uninvolved UE
 Elbow =
 Develops 1st (before ext synergy)
 Forearm =
 To test state “touch your ear (or chin)”
 Wrist & Digits =
 ICE video example: L UE flexion synergy
 https://videos.icelearningcenter.com/b
aypathuniversity/search?q=outpatient%
20assessment%20part%204
Extensor Synergy of the UE

What is the position of each?  Pectoralis major is strongest with shldr

horizontal abd and IR appearing first,
 Scapula =
pronation next strongest, elbow ext is
 Shoulder = weakest
 Elbow =  Can be evoked by applying pressure
 Forearm = to horizontal abd of the uninvolved UE

 Wrist & Digits =  To test state “reach out to touch your

opposite knee”
Associated Reactions

 Resistance to flexion of the uninvolved LE causes ext of the involved

extremity, resistance to ext of the uninvolved LE causes flex of the
involved extremity
 Resisted grasp by the uninvolved hand causes a grasp reaction in
the involved hand (Mirror synkinesis)
 Attempt to flex the involved leg or resistance to leg flex causes a
flexor response in the involved arm (Homolateral synkinesis)
 Active or passive raising of the affected arm causes the fingers to
extend and abd (Souque’s phenomenon)
 Resistance to adb or add of the unaffected LE results in similar
response to the opposite LE (Raimiste’s phenomenon)
 Levels of Recovery:
Synergy Patterns

Stage of
Recovery Leg Arm Hand
1

6
 Treatment Principles

 Treatment progresses developmentally from reflex responses to voluntary movement to automatic

functional motor behavior
 Utilize proprioceptive (resistance, tapping tendon) and exteroceptive (tactile) stimuli to elicit
movement
 When voluntary movement occurs, 1) ask client to hold (isometric contraction), if able progress to 2)
eccentric (controlled lengthening) contraction and finally 3) concentric (shortening) contraction
 Always stress movement in both flex and ext once client is able to move voluntarily
 Repeat correct movements once completed, should involve functional tasks/goals to increase
willed motivation
 Develop Elbow Ext: Rowing (https://www.youtube.com/watch?v=mPxtvpgsz6U) & Weight bearing
(Latham, 2014)
Current Views & Evidence

 Brunnstrom’s traditional theory. Currently, in practice, intentionally

promoting associated reactions and reflexive movement is NOT
advocated, as we now know such reflexive movement does not lead to
development of purposeful, functional motor control.
 Current thinking reflects that ‘normalizing’ muscle tone is not necessarily
paramount – rather, improving function is the focus: functional use of
the musculoskeletal system is possible despite abnormal tone.
 Wagenaar et al., 1990 - Evidence shows no significant difference than
NDT, both resulted in improvements but not control group to determine if
improvements were spontaneous or not
 Bobath
Neurodevelopmental
Treatment (NDT)
 Introduction to NDT

 Developed by Berta Bobath, a gymnast and physical therapist, and her husband, Karel
Bobath, a physician in 1940s (became NDT in 1950s)
 Goal to normalize muscle tone, inhibit primitive reflexes, and facilitate normal postural
reactions
 Techniques include: handling, weight bearing over affected limb, positions for B use of
body, avoid sensory input that may impact muscle tone
 NDT continues to be revised and updated with new evidence
(Schultz-Krohn, Pope-Davis, Jourdan, & Mclaughlin-Gray, 2013)

 NDT training and certification websites:

 http://www.ndta.org/
 http://www.recoveringfunction.com/
 Principles of NDT

 Belief in recovery
 A problem solving approach to restore movement and participation in those
with UMN lesions (CP and hemiplegia in CVA)
 Regain movement, postural control, and quality of movement
 Compensation is discouraged - Why do you think this is?
 Approach: facilitation, mobilization, practice motor skills for certain tasks,
practice task themselves, teach caregivers proper positioning
(Schultz-Krohn, Pope-Davis, Jourdan, & Mclaughlin-Gray, 2013)
 Evaluation

 Top-down approach beginning with an interview for occupational profile and goals
 Next observation of performance in occupations
 1) assess client’s ability to maintain alignment in postures needed for occupations
 2) Determine the typical motor skills needed for the task
 3) Assess client’s alignment and movement during basic motor skills needed for everyday tasks
= reaching, sit to stand, transferring, and functional goals established
 4) Determine underlying impairments that may be contributing to the movement dysfunction
 Changes in muscle strength, tone, activation, and sensory processing
 Assessed in upright postures during activity through observation, handling, and pt subjective report
 Placing =
 (Schultz-Krohn, Pope-Davis, Jourdan, & Mclaughlin-Gray, 2013)
 Intervention Sequence

 1) Preparation:
 Analysis of movement components needed for occupation by looking at body in segments and flow
of movement
 Setup the environment to promote participation and proper alignment
 Mobilization for needed ROM prior to task
 2) Movement & 3) Function
 Tasks setup to work on specific motor skills
 Skills usually addressed outside occupation then incorporated into the whole task
 Use of Handling and guiding with the client an active participant decreased as function is gained
 Closed chain to open chain
 (Schultz-Krohn et al., 2013)
 Intervention: NDT Handling

 Inhibition  Facilitation
 Used for abnormal tone and coordination,  Used when muscle tone is normal or when
goal to decrease spasticity and spasticity is not present
block/eliminate abnormal movement
 Used to activate automatic postural
patterns
responses
 Restore normal alignment in the trunk and
 Provides sensation of normal movement to
extremities by lengthening spastic muscles
the hemiplegic side
 Teach methods for decreasing abnormal
 Stimulate muscles to contract isometrically,
posture of UE and LE in tasks
eccentrically, or isotonically
 RIPs (reflex-inhibiting patterns) =
 Practice movements with therapist providing
some resistance
 Teach ways to incorporate the involved side
in function
 Intervention: NDT Handling

 Normalize tone
 Activate movement responses
 Provide re-education on normal movements
 Provide sensory input (tactile, proprioceptive, kinesthetic) to counteract loss of sensory memory
 Address secondary impairments
 (Henrichon, 2017)

 Key points of control

 Certain hand placements that are most effective for controlling the patient’s movement
 Provide control of problem areas and allow for movement patterns desired
 Proximal key points =
 Distal key points =
 (Levit, 2014)
 Intervention

 Active use of Involved UE  Practice to increase motor performance (Levit,

 Placing Response =
2014)
 Occupations as a means
 Weight bearing
 Used to practice and strengthen movement control
 Used in hemiplegic UE to maintain muscle on the hemiplegic UE
length, moralize tone, and increase activity in
the muscles of the trunk and arm  Therapist may use handling to introduce occupation
and then withdraw letting client practice without
 An active process by moving weight over the assistance
stable arm  Occupations as an end
 Use specific compensation that supports the goals of
handling
 Incorporate the involved UE into task performance, to
prevent spasticity and abnormal coordination

 24/7 & Interdisciplinary

 Evidence

 NDT as a ‘living concept’ – expected the theory to change and progress over time.
 Criticisms of NDT include accusations of the techniques being too passive (some NDT clinicians
discourage client movement if they are only able to move abnormally).
 On the positive side, because of the emphasis on incorporating the hemiplegic extremities (vs.
compensatory one-handed techniques) NDT can send a more hopeful message to the client
for neurological recovery.
 NDT techniques can be hard to research, as they are individualized to the client, and techniques
such as handling are hard to quantify.
 Overall limited lower level research (primarily case study report of clients and therapists)
 No support that NDT is a superior treatment method but also no support that it was not effective.
 Most studies indicate that although NDT is effective, it is not necessarily any more effective than
other rehabilitation interventions.
Application Assignment

 Discussion Board Post: (recommended but not required, to read and

respond to peers)
 Having studied the Task-Oriented Approach, Rood, PNF, Brunnstrom, &
NDT.
 What philosophies, approaches, and interventions do they have in
common?
 How do these approaches contradict each other?
 What are the pros and cons of ‘hanging onto’ traditional approaches, vs.
progressing forward with newer approaches that have a stronger research
basis?
References

 Latham, C. A. T. (2014). Online chapter 25: Optimizing motor behavior using the Brunnstrom movement
therapy approach. In M. V. Radomski & C.A. T. Latham (Eds.). Occupational therapy for physical
dysfunction, pp. 667-689. Philadelphia: Lippincott Williams & Wilkins.
 Levit, K. (2014). Online chapter 24: Optimizing motor behavior using the Bobath approach. In M.V.
Radomski & C.A.T. Latham (Eds.). Occupational Therapy for Physical Dysfunction, (pp. 642-666).
Philadelphia: Lippincott Williams & Wilkins.
 Henrichon, K. & Anton, C. (2017). Brunnstrom. Lecture at Bay Path University. East Longmeadow, MA.
 Henrichon, K. & Anton, C. (2017). Neuro-developmental treatment. Lecture at Bay Path University. East
Longmeadow, MA.
 Sabari, J.S., Capasso, N., and Feld-Glazman, R. (2014). Optimizing motor planning and performance in
clients with neurological disorders. In M. V. Radomski & C.A. T. Latham (Eds.). Occupational therapy for
physical dysfunction, (pp. 614-674). Philadelphia: Lippincott Williams & Wilkins.
 Schultz-Krohn, W., Pope-Davis, S.A., Jourdan, J.M., and Mclaughlin-Gray, J. (2013). Traditional sensorimotor
approaches to intervention. In H.M. Pendleton & W. Schultz-Krohn, W. (Eds.) Pedretti’s Occupational
therapy: Practice skills for physical dysfunction, pp. 796-830. St. Louis, Missouri: Mosby.
 Images from Google Images