A Comparison of Neurorehabilitation Techniques Used to Treat the Effects of Cerebrovascular Accidents
	Neurodevelopmental Technique (NDT)/ Bobath Approach	Movement Therapy/ Brunstrom Approach	Sensorimotor Approach/ Rood Approach	Proprioceptive Neuromuscular Facilitation/ Kabat & Knott Approach
Underlying Theory	To normalize tone, inhibit primitive patterns of movement, and to facilitate automatic, voluntary reactions and subsequent normal patterns.    *Opposite of Brunnstrom	Using primitive synergistic patterns to attempt to improve motor control via central facilitation A damaged CNS regressed to an older pattern of movements Synergies, primitive reflexes, and other abnormal movements are normal parts of recovery before normal movement is obtained   *Opposite of Bobath	Modifying muscle tone and voluntary motor activity using cutaneous sensorimotor stimulation	Stimulation of nerve, muscle, and sensory receptors through manual stimulation via spiral and diagonal movement patterns promotes more functionally relevant movement patterns than movements in the traditional cardinal planes.
Techniques	Therapeutic Handling is primary intervention with NDT Facilitatory inputs Inhibitory inputs Key Points of Control	Enhances specific synergies Process of Recovery	Modifying Sensory/ Motor Input via the following systems: Proprioception Exteroceptive Vestibular Vision Auditory Olfactory Gustatory SI Training Reversal of Antagonists Repeated Contractions Combination of Isotonics Rhythmic Initiation Contract-Relax Hold-Relax Replication (hold-relax active motion) Resisted Progression Rhythmic Rotation
Effectiveness of Approach	There are differences in each of the underlying theories of these approaches; however, there are no consistent significant differences in motor or functional improvement of one approach over another.

 

Neurodevelopmental Technique/ Bobath Approach

(opposite of Brunnstrom Approach)

 Therapeutic Handling: Therapeutic handling is used to influence the quality of the motor response and is carefully matched to the patient’s abilities to use sensory information and adapt movements. It includes neuromuscular facilitation, inhibition, or frequently a combination of the two. Manual contacts are used to:

• Direct, regulate, and organize tactile, proprioceptive and vestibular input
• Direct the client’s initiation of movement more efficiently and with more effective muscle synergies
• Support or change alignment of the body in relation to the BOS and with respect to the force of gravity prior to and during movement sequences
• Decrease the amount of force the client uses to stabilize body segments
• Guide or redirect the direction, force, speed, and timing of muscle activation for successful task completion
• Either constrain or increase the flexibility in the degrees of freedom needed to stabilize or move body segments in a functional activity
• Dense the response of the client to sensory input and the movement outcome and provide nonverbal feed-back for reference of correction
• Recognize when the client can become independent of the therapist’s assistance and take over control of posture and movement
• Direct the client’s attention to meaningful aspects of the motor task

 

Key Point of Control: Key points are parts of the body that the therapist chooses as optimal to control (inhibit or facilitate) postures and movement. Proximal key points include the shoulders and pelvis, which are used to influence proximal segments and trunk. Distal key points upper and lower extremities (typically the hands and feet). Key points of control are also used to provide inhibition of abnormal tone and postures. Examples include:

• Head and trunk flexion decreases shoulder retraction, trunk and limb extension (key points of control: head and trunk).
• Humeral external rotation and flexion to 90 degrees decreases flexion tone of the upper extremity (key point of control: humerus).
• Thumb abduction and extension with forearm supination decreases flexion tone of the wrist and fingers (key point of control: the thumb).
• Femoral external rotation and abduction decreases extensor/adductor tone of the lower extremity (key point of control: hip).
• Facilitation: Components of posture and movement that are essential for successful functional task performance are facilitated through therapeutic handling and key points.
• Inhibition: Components of posture and movement that are atypical and prevent development of desired motor patterns are inhibited. While originally this term referred strictly to the reduction of tone and abnormal reflexes, in current NDT practice it refers to reduction of any underlying impairment that interferes with functional performance. It can be used to:
  • “Prevent or redirect those components of a movement that are unnecessary and interfere with intentional, coordinated movement,
  • Constrain the degrees of freedom, to decrease the amount of force the client uses to stabilize posture
  • Balance antagonistic muscle groups
  • Reduce spasticity or excessive muscle stiffness that interferes with moving specific segments of the body.”

Movement Therapy/ Brunnstrom Approach

(opposite of NDT approach)

 

• Uses primitive synergistic patterns in order to improve motor control through central facilitation.
• Based on concept that damaged CNS regressed to older or less mature patterns of movements (limb synergies and primitive reflexes); thus, synergies, primitive reflexes, and other abnormal movements are considered normal processes of recovery before normal patterns of movements are attained
• Patients are taught to use and voluntarily control the motor patterns available to them at a particular point during their recovery process (e.g., limb synergies)
• Enhances specific synergies through use of cutaneous/proprioceptive stimuli, central facilitation using Twitchell’s recovery
• Opposite to Bobath (which inhibits abnormal patterns of movement)

 

Process of Recovery:

1. Flaccidity (immediately after the onset)

No “voluntary” movements on the affected side can be initiated

2. Spasticity appears

Basic synergy patterns appear

Minimal voluntary movements may be present

3. Patient gains voluntary control over synergies

Increase in spasticity

4. Some movement patterns out of synergy are mastered (synergy patterns still predominate)

Decrease in spasticity

5. If progress continues, more complex movement combinations are learned as the basic synergies lose their dominance over motor acts

Further decrease in spasticity

6. Disappearance of spasticity

Individual joint movements become possible and coordination approaches normal

7. Normal function is restored

Sensorimotor Approach/ Rood Approach

• Proprioception
  • Facilitory
    • Quick Stretchà muscle contraction
    • Resistanceà muscle contraction
    • Joint approximationà joint awareness; co-contraction responses
    • Joint Tractionà joint motion; joint awareness
  • Inhibitory
    • Prolonged Stretchà muscle contraction
    • Inhibitory Pressureà muscle tone
  • Exteroceptive
    • Facilitory
      • Manual Contactà sensory awareness; muscle contraction
      • Light Touchà protection and alerting responses; discriminative responses
      • Maintained Touchà tactile receptors
    • Inhibitory
      • Slow Strokingà generalized tone; reduction of pain
      • Neutral Warmthà generalized tone
      • Prolonged icingà neural and muscle spindle firing; muscle tone; muscle spasms
    • Vestibular
      • Facilitory
        • Vestibular Stimulationà (could be facilitory or inhibitory depending on the person; could facilitate an emotional responses due to the limbic system) active movements; postural/ tonal adjustments
      • Inhibitory
        • Slow vestibular stimulationà generalized relaxation; muscle tone; arousal; sympathetic responses
      • Vision
        • Facilitoryà visual discrimination; conscious awareness; recognition of objects; visual tracking; alerting/ orienting responses; visual proprioception; active movements; postural tone adjustments (could be facilitory or inhibitory depending on the person; could facilitate an emotional responses due to the limbic system)
      • Auditory
        • Facilitoryà auditory discrimination; conscious awareness; recognition of sounds; auditory tracking responses; active movement responses; alerting/ orienting responses (could be facilitory or inhibitory depending on the person; could facilitate an emotional responses due to the limbic system)
      • Olfactory
        • Pleasant, familiar scentsà relaxation; pleasure; positive mood; reduction of tone and hyperkinetic movements (could be facilitory or inhibitory depending on the person; could facilitate an emotional responses due to the limbic system)
        • Noxious scentsà alertness/ orienting responses; active movement responses; active movement responses; postural/ tonal adjustments
      • Gustatory
        • Facilitoryà recognition of tastes; fast adapting
        • Various foods provoke emotional, sensory, and motor responses

 

• SI Training
  • Improves sensory discrimination, ability to identify specific stimuli, and improve perception (selection, attention, and response to sensory inputs) with appropriate use of information to generate specific motor responses

Proprioceptive Neuromuscular Facilitation/ Kabat & Knott Approach

PNF Basic Procedures

Patterns of Movement: normal activity occurs in synergistic and functional movement patterns

• UE Diagonal 1
• UE Diagonal 2
• LE Diagonal 1
• LE Diagonal 2
• Trunk patterns include chop and lift patterns, bilateral lower extremity (LE) patterns, scapula and pelvis pat- terns, and head/neck patterns.

Timing: normal timing ensures smooth, coordinated movement; distalà proximal movements

Timing for Emphasis: Max resistance is used to facilitate a strong contraction & to allow overflow to occur from strong to weak components within a synergistic pattern

Resistance: facilitates muscle contractions and motor control

• Tracking or Light Resistanceà facilitates weak muscles and is usually applied with light stretch
• Maximal Resistanceà generates max effort and is adjusted to ensure smooth, coordinated movement
• Facilitates weak muscles to contract; enhances kinesthetic awareness of motion; increases strength; increase motor control and motor learning

Overflow or Irradiation: the spread of muscle response from stronger muscles to weaker muscles in a synergistic movement pattern; max resistance is the primary mechanism for overflow or irradiation

Manual Contacts: grips are used to provide pressure to tactile and pressure receptors; pressure is applied opposite of the desired direction of motion

Positioning: muscles at optimal range of function allow for optimal muscle responses (length-tension relationship); muscle tension is the greatest at the mid-range of movement

Therapist Position and Body Mechanics: therapists should be positioned in line with the desired motion for optimal direction of resistance

Verbal Commands: preparatory (used to ready & instruct the patient), action (to guide the patient while in motion), corrective (used to provide feedback for modifications of movement)

• Directions should be clear/ concise, strong commands should be used when max movement is the goal, and a soft action voice should be used when relaxation is the goal

Vision: used to guide the patient’s movement, enhance muscle contraction and patterns of movement

Stretch: end range stretch facilitates muscle contraction; repeated stretch can be used to reinforce a contraction in weaker muscles

Approximation (compressing joint surfaces): use to facilitate extensor/ stabilizing muscle contraction and stability; applied during upright, weightbearning positions and in PNF extensor patterns

Traction: used to facilitate muscle contraction and motion, especially in flexion/ pulling patterns; gentle distraction is used to reduce joint pain

 

PNF Techniques

• Reversal of Antagonists: techniques that promote agonist contractions followed by antagonist muscle contractions
• Repeated Contractions: isometric contractions from a lengthened range; enhanced by resistance; induced by quick stretches
• Combination of Isotonics: resisted concentric movementsà agonist movementsà stabilizing contraction THEN eccentric movements à lengthening contractions, moving slowly back to the start position with no relaxation between contractions
• Rhythmic Initiation: voluntary relaxation followed by passive movements progressing to AAROM then active resistive movements then active movements
• Contract-Relax: Strong, small range isotonic contraction of the restricting muscles (antagonists) with emphasis on the rotators is followed by an isometric hold.
• Hold-Relax: Strong isometric contraction of the restricting muscles (antagonists) is resisted, followed by voluntary relaxation, and passive movement into the newly gained range of the agonist pattern.
• Replication: holding a shortened range/ end position of a movement
• Resisted Progression: Manually applied stretch, approximation, and tracking resistance used to facilitate pelvic motion and locomotion; resistance is light in order to not disrupt momentum, coordination, and velocity.
• Rhythmic Rotation: Relaxation is achieved with slow, repeated rotation of a limb at a point where limitation is noticed. As muscles relax the limb is slowly and gently moved into the range.

Resources:

 

Corbett, A. (2012). Stroke. Brain Foundation: Headache Australia. Retrieved on December 9, 2012 from http://brainfoundation.org.au/a-z-of-disorders/107-stroke#effectsofstroke

 

Cuccurullo S, editor. Physical Medicine and Rehabilitation Board Review. New York: Demos Medical Publishing; 2004. Stroke Rehabilitation. Available from: http://www.ncbi.nlm.nih.gov/books/NBK27209/

 

Dickstein, R., Hocherman, S., & Shaham, R. (1986). Stroke Rehabilitation: Three Exercise Therapy Approaches. Physical Therapy Journal, 66 (8).

 

Ernst, E. (1990). A review of stroke rehabilitation and physiotherapy. Stoke. Retrieved on December 10, 2012 from http://stroke.ahajournals.org/content/21/7/1081

 

IPNFA. (2012). What is IPNFA? Proprioceptive Neuromuscular Facilitation from facilitation to participation. Retrieved on November 25, 2012 from http://www.ipnfa.org/index.php?id=115

 

Kollen, B., Lennon, S., Lyons, B., Wheatley-Smith, L., Scheper, M., Buurke, J., Halfens, J., Geurts, A., & Kwakkel, G. (2009). Stroke Rehabilitation What is the Evidence? American Heart Association Journals. Retrieved on November 25, 2012 from http://stroke.ahajournals.org/content/40/4/e89

 

Mayo Clinic Staff. (2012). Stroke. Diseases and Conditions. Retrieved on November 25, 2012 from http://www.mayoclinic.com/health/stroke/DS00150

 

O’Sullivan, S. & Schmitz, T. (2007). Strategies to Improve Motor Function. Physical Rehabilitation 5^th ed. Retrieved on November 25, 2012 from http://www.google.com/url?url=http://docs.thinkfree.com/tools/download.php%3Fmode%3Ddown%26dsn%3D861433&rct=j&sa=U&ei=1JLGUOuvBNTOqQHI9oGwDg&ved=0CBUQFjAA&sig2=4094qnrZ_b4KrzUbJGHsIw&q=physical+rehabilitation+5th+ed+osullivan+and+shmitz+Strategies+to+Improve+Motor+Function+chapter+13&usg=AFQjCNGi1S0r5Dc1uP6pMAu7uWtmIaAWxA