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8/6/2019 Norma [Search Engine com

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~ A CASE STUDY ~~ A CASE STUDY ~


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Differential diagnosis and degree of involvement will varyfrom patient to patient

What works for YOUR patient?


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One Step At A TimeStage 1: FlaccidityNo voluntary or reflexive activity ispresent in either involved limb.

Associated reactions cannot be elicited.Stage 2: The basic movement synergiesor some of their components may be

elicited reflexively as associatedreactions. Minimal voluntary motionpresent. Spasticity, first seen asresistance to passive stretch, begins to

develop


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Stage 3: Spasticity becomes moremarked. The basic movement synergiesmay be performed voluntarily, althoughfull range of all components may belacking.Stage 4: Movements which deviate fromthe basic synergies can be

accomplished on a volitional basis.Spasticity begins to decline.


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Stage 5: Basic synergies lose their dominance over volitional behavior andthe patient becomes increasingly moreadept at performing movementcombinations which differ greatly fromthe synergies. Spasticity continues todecrease.Stage 6: Spasticity is essentially absent.

Isolated muscle actions can beperformed freely.Stage 7: Restoration of normal motor function


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And Then Comes the ButAnd Then Comes the But

Recovery may be arrested at any stageRecovery may be arrested at any stagedepending on severity of insult, degree of depending on severity of insult, degree of sensory involvement, etc.sensory involvement, etc.

A stage in the recovery process is never A stage in the recovery process is never skipped. However, in cases of slight damage,skipped. However, in cases of slight damage,recovery may proceed so rapidly that certainrecovery may proceed so rapidly that certainstages may not be observablestages may not be observable

Associated reactions, particularly the basic Associated reactions, particularly the basicmovement synergies, may still appear under movement synergies, may still appear under stress conditions such as sudden fright, anxiety,stress conditions such as sudden fright, anxiety,sneezing, loud noises, etc.sneezing, loud noises, etc.


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Different ApproachesDifferent ApproachesM uscle ReM uscle Re- -education Approach (1920s)education Approach (1920s)Neurodevelopmental Approaches (1940Neurodevelopmental Approaches (1940- -70s)70s)

S ensorimotor Approach (Rood, 1940s)S ensorimotor Approach (Rood, 1940s)M ovement Theory Approach (Brunnstrom,M ovement Theory Approach (Brunnstrom,1950s)1950s)NDT Approach (Bobath, 1960NDT Approach (Bobath, 1960- -70s)70s)

Motor Relearning Program for StrokeMotor Relearning Program for Stroke(1980s)(1980s)

C ontemporary TaskC ontemporary Task- -Oriented ApproachOriented Approach(1990s)(1990s)


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But TONY !?

Which one do I use?


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Muscle Re-education Approach

Ultimate Goal = Development of coordinated movement patterns.Training begins with learning thecontrol of individual muscles on acognitive level


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Roods Sensorimotor ApproachInvolves superficial cutaneous stimulationusing stroking, brushing, icing, or musclestimulation with vibration, tendon tapping,

and joint compression to evoke voluntarycontraction or inhibition of

proximal muscles


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Brunnstroms Approach

Emphasised the synergistic patterns of movementthat develop during recovery from hemiplegia. Sheencouraged flexor and extensor synergies duringearly recovery, hoping that synergistic activation of muscle would, with training, transition intovoluntary activation.

Patients are taught to use and voluntarily controlthe motor patterns available to them at aparticular point during their recovery process

Enhances specific synergies through use of cutaneous/proprioceptive stimuli, and centralfacilitation.


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FLEXIONFLEXION EXTENSIONEXTENSION

ShoulderShoulderGirdleGirdle Elevation and/orRetraction Depression & ProtractionShoulderShoulder Abduction &

External rotation*Adduction,Internal rotation

ElbowElbow *Flexion Extension

ForearmForearm Supination *Pronation


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FLEXIONFLEXION EXTENSIONEXTENSION

HipHip *Flexion,Abduction,External rotation

Extension,*Adduction,Internal rotation

KneeKnee Flexion *Extension

AnkleAnkle *DF *PF

FootFoot Inversion Inversion


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ASSOCIATED REACTIONSASSOCIATED REACTIONS

UE:UE:Flex of uninvolved = Flex of involvedFlex of uninvolved = Flex of involved

Ext of uninvolved = Ext of involvedExt of uninvolved = Ext of involved

LE:LE:Flex of uninvolved = Ext of involvedFlex of uninvolved = Ext of involved

Ext of uninvolved = Flx of involvedExt of uninvolved = Flx of involved

INVOLVED:INVOLVED:Flex = FlexFlex = Flex

Ext = Ext Ext = Ext


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Bobaths NeurodevelopmentalTechnique Approach

(NDT)GOAL Normalize tone by inhibiting spasticity

Inhibit primitive patterns of movement Facilitate autonomic, voluntary reactions and

subsequent normal movement patterns*Suppress abnormal muscle patterns before normal

patterns are introduced*Mass synergies avoided because although they may

strengthen weak, unresponsive muscles, theyreinforce abnormally increased tonic reflexes(spasticity)


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RIP Reflex Inhibiting Posture

In Sitting Symmetry with head in midline

Trunk in midline Pelvis in neutral position

Hips in line with knees (90 degrees break ext tone) Balls of feet under knees UE relaxes with elbows at 90 deg of flex but not fully

ext, hands on knees, palms down towards supinationwith fingers open


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K nott and Voss PNF ApproachK nott and Voss PNF ApproachProprioceptive Neuromuscular Proprioceptive Neuromuscular

S timulationS timulationUs e s s piral and diagonal component s Us e s s piral and diagonal component s of movement rather than traditionalof movement rather than traditionalmovement s in cardinal plane s of movement s in cardinal plane s of motionmotionGOALGOAL Facilitating movement pattern s that willFacilitating movement pattern s that will

have more functional relevance than thehave more functional relevance than thetraditional technique of s trengtheningtraditional technique of s trengtheningindividual group mu s cle sindividual group mu s cle s

R elie s on quick s tretching and manualR elie s on quick s tretching and manualre s is tance of mu s cle activation of there s is tance of mu s cle activation of thelimb s in functional direction s.limb s in functional direction s.


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Static BalanceStatic BalanceRhythmic StabilizationRhythmic StabilizationDynamic StabilizationDynamic Stabilization

Available ROM for Standing Available ROM for Standing

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