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3 basic types of interventions in Brunnstrom method
- sensory cues
- associated reactions
- reflexes
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what area of th CNS did Brunnstrom tap into to help pts regain movement? what's her technique called?
- motor cortex
- central facilitation technique
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Beevor's axiom
a muscle maybe paralyzed for one movement but not another
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UE flexion synergy
- scapula: elevation (75-100%) retraction (50%)
- shoulder: abd 90 degrees, ER 90 degrees
- elbow: full flexion
- supination: full
- wrist flexion: 20 degrees
- finger flexion: full
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UE extension synergy
- scapula: protaction (50%) depression (50%)
- shoulder: add to midline, IR 60-90 degrees
- elbow extension: full
- pronaation: full
- wrist extension: 20 degrees
- finger flexion: full
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symmetrical tonic neck reflex
- flex neck: LEs ext, UEs flex
- ext neck: LEs flex, UEs ext
- (basically your legs get you away from what you're looking at)
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asymmetrical tonic neck reflex
turn head to one side, and the limbs on that side will extend while te lmbs on the other side flex
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tonic labyrinthine reflex
- if pt is supine this greatly increases extensor tone
- if prone this nominally increases flexor tone
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tonic lumbar reflex
rotate trunk to one side --> tennis player pose: the UE on that side flexes, as does the contralat LE, while the others ext
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relative influences of Brunstrum's reflexes
- TNR strontest of all, but UE > LE
- T Lab. R -- UE>LE
- T Lumb. R LE>UE, but weakest reflex compared to the above
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associated reactions in facilitating synergy for UEs
- flex of one UE -->flex of other
- ext of one UE -->ext of other
- start w PT resisting the unaffected side to get overflow into affected side
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homolateral limb synkinesis
what an LE does, the ipsilat UE wants to do too, and vice versa (good w flex/ext)
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stages 1 and 7 of Brunnstroms stages of recovery
- stage 1: no voluntary movement at all. Flacid. No spasticity, reflexes, clonus.
- stage 7: full normal movement
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In Brunnstrom's stages of recovery, when does pt first begin to break out of synery and see a decrease in spasticity?
stage 4
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Brunnstrom's stage 2
stage 2: weak associated reactions. Spasticity developing. No voluntary movement, but some reflexes or spasticity. No clonus yet
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Brunnstrom's stage 3
stage 3: basic limb synergies, spasticity increased. No isolated OOS movements.
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Brunnstrom stage 5
stage 5: partial indep frm synergy. multiple isolated movements possible
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Brunnstrom's stage 6
stage 6: isolated joint movement, good recovery but still residual problems like impaired speed
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seated trunk control exercises
- (Rood was all about stability before mobility)
- first - pt has arms cradled - we help pt just stay upright
- then - work on forward flexion, side flexion, rotatating side to side -- this is for dynamic sitting balance
- you can hold pt's arms, scap, a portion of hand, whatever is appropriate
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ways to make seated trunk control exercises more complex
- reach arms across body at various angles
- cross legs
- move forward to edge of table to reduce contact/support from table
- sit on softer cushion or a ball
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4 UE treatment goals for Brunnstrom
- 1. Attain synergy patterns
- 2. Increase activation of weak components (don't let disuse lead to weakness!)
- 3. Attain volitional and selective control (move muscles w/o their synergists)
- 4. Decrease co-activation (synergies) of muscles
beware of fatigue - it can act neg on control and increase synergies, so give pts rest as needed
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what to do for mild spasticity? for mod to severe spasticity?
- mild: stretch slowly, strengthen
- mod-sev: splinting, positioning devices, drugs
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a list of UE movements/muscles that are likely to be quite spastic (so you have to stretch these and strengthen their antagonists)
- scap depressors
- scap retractors
- shoulder extensors
- shoulder adductors
- shoulder IRs
- elbow flexors
- pronators
- wrist flexors
- finger flexors
- pec major - flex, add, IR humerus
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LE strong spasticity movements/actions (so stretch these and strengthen their antagonists)
- hip ext
- knee ext
- plantarflex
- foot inversion (equinovarus)
the extension spasticity helps w standing but not w gait
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3 popular causes of pain in the CVA pop
- shoulder mismanagement
- spasticity
- not doing prevention (fyi, if having a hard time planning a program, ask yrself what's likely to go wrong over time, and then prevent that)
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ways to manage pain
- slow passive movements
- prevent traction on GHJ and brachial plexus
- prevent mishandling of UE, esp shoulder (teach pt's family)
- maintain full ROM
- prevent edema
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a few ideas on how to prevent edema for CVAs
- positioning - elevate limb
- rocking chairs so pt's pumping ankles
- compression
- hands in WC should be above heart
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general Brunnstrom treatment techniques
- resistance: to increase tone and volitional/synergistic mvmnt - use tactile clues to recruit muscles
- effort: increased effort increses muscle tone. Use associated reactions like homolateral limb synchinesis
- reflexes: TNR TLabR TLumbR
- eliminate: all the above asap
- once synergy is present: work to get OOS asap!
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