Brunnstrom’s approach focused on the evaluation and treatment of post-stroke hemiplegia, and is particularly well known for her evaluation method, which is still widely used not only today, but also in the West, where her evaluation method was used as the basis for the development of the Fugl-Meyer evaluation method, and in the East, where the Ueda-Min evaluation method was developed. In treatment, she developed a treatment system that mainly utilizes joint responses and abnormal synergistic movements, which is also one of the commonly used treatments for motor dysfunction caused by central nervous system disorders.
1. Relevant neurophysiological basics
In Brunnstrom’s method, the joint response and abnormal synergistic action are often mentioned, but since they have been introduced in the section of Bobath therapy, the reader can refer to the relevant chapters.
2. Basic views of treatment
(1) The joint response and abnormal synergy are considered to be part of the normal sequence of recovery of motor function after brain disorders and should be utilized rather than suppressed.
(2) In the early stage of recovery from hemiplegia, due to the dysfunction of the central nervous system, the correction of movements by the higher centers is affected, and because the original reflexes of the limbs reappear, joint responses and synergistic movements appear Brunnstrom believes that these effects and reflexes can be used to elicit muscle responses, which are then combined with subjective effort to produce a semi-autonomous movement that has been enhanced. Therefore, in the absence of random movements, full use should be made of proprioceptive and extracorporeal skin stimulation to induce synergistic movements, as well as the use of joint responses to elicit muscle contraction on the affected side.
(3) Consciousness and sensation have an important role in recovery. Brunnstrom believes that hemiplegia is not only a motor dysfunction, but more importantly a sensory impairment, and believes that motor impairment is caused by sensory impairment, so it can be called a sensory-motor disorder. This view has been supported by the studies of Mptt,Sherrington and others. Therefore, it is important to emphasize conscious concentration, full use of sensory and audiovisual feedback, and active participation in functional recovery.
3. Methods and Techniques
(1) Evaluation As mentioned above, Brunnstrom’s 6-level evaluation method for recovery of motor function in post-stroke hemiplegia has been recognized worldwide, and its method is described here.
The 6 levels of upper limb recovery and its tests: (sitting position)
(1) No random movement at all: there is a feeling of heaviness when the upper limb is lifted passively.
② Synergistic movements and joint reactions begin to appear: synergistic movements of flexors precede those of extensors, and spasticity is not obvious.
(③) Emergence of synergistic movements with some regularity: spasticity when moving the joint (when assessing the range of motion of the joint, it can be recorded by reaching 1/4, 2/4, 3/4 of the full range of motion or by none, incomplete, or complete). To check for synkinesis of the flexors, have the patient touch his or her ipsilateral ear with the diseased hand, and to check for synkinesis of the extensors, have the patient point the affected hand toward the healthy side of the inner ankle.
④ Spasticity is reduced and the synergistic action starts to separate: when checking, ask the patient to put the affected hand behind the waist, if this action can be completed, it means that the synergistic action of the extensor muscle has separated, or ask the patient to extend the upper limb and bend the elbow forward by 90°, or to make the movement of rotating forward and backward when the upper arm is close to the side of the body without bending the elbow by 90°, if this can be completed, it means that the synergistic action has separated, but the movement of rotating backward is still slightly difficult in this period.
(5) Further dissociation of synergistic movements: The spasticity is further reduced and confirmed by the patient’s ability to abduct the straightened affected limb by 90° or more, or to place the forearm overhead, which is a further improved movement pattern compared to stage IV. This is also evidenced by the patient’s ability to flex the upper extremity of the straightened diseased side 90° forward and make a palmar upward and upward turning movement.
(vi) Complete loss of synkinesis: the movement is the same as that of the healthy side. There is no spasticity when moving the affected limb passively, and the speed of movement is normal. 6 levels of hand recovery and their tests: Since the functional recovery of the hand is not consistent with that of the shoulder and elbow, they are performed separately.
① Flaccid paralysis with no random movements.
② Almost no active contraction of fingers.
③Can make group grip or hook grip or hook grip.
④Can make lateral pinch and can make thumb release by movement.
⑤Can make cylindrical and spherical grasp, more clumsy digging, fingers have different degrees of group extension.
⑥Can make various types of grasping, fingers can do full arbitrary extension, and fingers can move freely individually.
6 levels of lower limb recovery and spring test: supine position in stages I-III, sitting position in order IV, standing position in stages V and VI.
① Flaccid paralysis.
② A little casual movement can be seen slightly.
③Shift from basic concerted movements to casual movements, usually with predominance of the extensor muscles of the lower limbs.
④Take the sitting position so that the knee joint is flexed more than 90°, the foot should be moved back to the lower back of the bed chair, and dorsiflexion is possible when the foot is extended from under the bed.
⑤ Straighten the hip joint in the standing position, in which the knee can be slightly flexed and then do the “rest” position, and the extended foot can do the dorsiflexion action.
(6) In the standing position, with the hip abducted, the pelvis can be lifted, and in the sitting position, the lower leg can be alternately rotated internally and externally, and the foot can be turned in and out.
(2)Treatment
(1) Application of joint response When there is no random movement of the affected upper limb, such as making the flexor muscle of the healthy upper limb resist contraction, it can cause joint response of the flexor muscle of the affected upper limb. The phenomenon of making the flexor muscle of the upper limb on the healthy side resist contraction, causing the joint response of the extensor muscle of the upper limb on the affected side is sometimes called the mirror joint response. The Raimist’s phenomenon is a joint response-like activity of hip abduction and adduction, such as applying resistance to the abduction or adduction of the healthy lower limb while lying supine, which will cause the same action of the affected limb see Figure 3-2-19.
(2) Application of synergistic movements to the limb when there is spasticity in the early stages of hemiplegic recovery can be induced like a joint response, when the patient moves a joint, all the muscles associated with the synergistic movement contract automatically with this movement, resulting in a stereotyped movement pattern. Among the synergistic movements of the flexors, flexion of the elbow is the first movement induced. Since most patients have difficulty producing shoulder motion and have pain in moving the shoulder joint, starting to use the synergistic movement of flexion of the elbow can promote scapular supination and abduction in order to painlessly increase the range of motion of the shoulder joint, and in addition, when the neck is flexed to the affected side, supination of the scapula can be induced. There is a tendency for extensor synergism to follow flexor synergism, and the pectoralis major is a powerful component of extensor synergism that can be induced by a response similar to Raimiste’s phenomenon by the physician supporting the patient’s upper extremity in a position between horizontal abduction and by retraction, having the patient exert force to bring the two upper extremities together, and applying resistance to the proximal end of the healthy arm Medially, resistance is applied, which can enhance the tone of the adductor muscles of the affected limb.
When the synergistic action is established, it should be used in functional recovery, for example, when writing with the healthy hand, using the extensor synergy can stabilize the object, and in addition, using this synergy can facilitate the patient to extend the upper arm into the sleeve of the outer garment, and the flexor synergistic action can help to carry objects, such as outer garments and handbags. Push and pull activities will enhance these two synergistic movements, such as slating, knitting and ironing are alternating and repetitive applications of flexor and extensor synergistic movements.
(3) Other
① Inhibit the role of hand flexors, when hemiplegia in finger flexor tension, the palm of the hand is a tight fist, the method of inhibition is to passively extend the thumb from the palm, forearm rotation back, tight pressure on the big fish interval, a few seconds later the wrist and finger flexion becomes relaxed, the fingers can be extended as Figure 3-2-36.
② Training of the upper limb: In the early stage when the patient has no casual movement, the first use of shoulder supination, through the contraction of the oblique square muscle to cause the flexion of the affected upper limb synergy, at this time, if the upper limb on the healthy side of the flexion to apply resistance or make his head turned to the healthy side, due to the asymmetric cervical tension reflex (ATNR) is more likely to promote the affected limb flexion synergy, as mentioned before on the healthy side of the flexion of the elbow to apply resistance, can also induce the affected elbow flexion Brunnstrom also believes that the above-mentioned effects can be enhanced by adding electrically stimulated massage and snapping to the skin of the affected limb at this time.
③ Separation of independent movements from synergistic movements.
A. Separation of hand muscle synergistic movements (same as 3) of ① movements and methods), in which the extension of the thumb should not be overexerted. As in Figure 3-2-36
B, the separation of lower limb synergistic action: when the lower limb flexor muscle tension is strong, the physician in the patient’s supine position, holding both heels upward about 30 °, and a rhythmic lateral swing to swing their lower limbs, can inhibit their flexor muscle tension as shown in Figure 3-2-37.
C, foot dorsiflexion promotion: Marie-Foix reflex can be used, when the hip flexion can not promote foot dorsiflexion, first passively make their toes plantar flexion, can induce including hip, knee, ankle flexion, foot that dorsiflexion, in the induced at the same time, the patient should be encouraged to strengthen its casual movement, strengthening the moment is very important, do well can accelerate the separation of its synergistic movements as Figure 3-2-38. foot dorsiflexion can also be Hand or brush massage along the lateral side of the dorsum of the foot to the heel to promote as in Figure 3-2-39.
(3) Current evaluation of Brunnstrom therapy
1, it is believed that Brunnstrom method integrates the application of central facilitation, peripheral and proprioceptive stimulation, starting from synergistic movements and over to disassociation from synergism, so that the limbs, hands and fingers gradually restore their functions, which is more affirmed.
2. The proposed bridge-type exercise can free the stroke patient from lower limb synergy, which is beneficial to train the lower limb function.
3.The recovery of Brunnstrom’s 6 levels is more affirmed, and the Fugl-Meyer evaluation method has been derived from it in the West, and the Ueda Min method has been derived from it in the East.
4. Although neurophysiologists are sure about Brunnstrom’s treatment method, most therapists still do not like to use it.