(iii) Brunnstrom therapy Brunnstrom’s method focused on the evaluation and treatment of post-stroke hemiplegia, and is especially famous 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. Wang Bo, Department of Rehabilitation, Songwon Traditional Chinese Medicine Hospital 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. In Brunnstrom’s approach, the combined 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 chapter. (1) The joint response and abnormal synergism are considered to be part of the normal sequence of motor recovery after brain disorders and should be utilized rather than suppressed. (2) In the early stages 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 of the reappearance of the primitive reflexes of the limbs, joint reactions and synergistic movements appear Brunnstrom believes that these actions and reflexes can be used to elicit muscle responses, which are then combined with subjective effort to produce a semi-autonomous movement that is reinforced. 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 contractions on the affected side, and when some degree of synergistic movement has been established, various methods are used to inhibit the synergistic component, so that it is separated into a more single movement, and finally go to separate training. (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 necessary to emphasize the concentration of consciousness, the full use of sensory and audiovisual feedback, and the 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. 6 levels of upper limb recovery and their tests: (sitting position) ① complete absence of random movements: 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) The onset 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 affected 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 and does not bend 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 than in 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 activity. 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 this state you can slightly flex the knee and then do the “rest” position, the extended foot can do dorsiflexion. (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 to joint response When there is no random movement of the affected upper limb, if the flexor muscle of the healthy upper limb is made to 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, in addition, making the flexor muscle of the upper limb on the affected side resist contraction, will cause the flexor muscle of the lower limb on the affected side to act in concert, which is called the ipsilateral joint band movement. 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 movement of the affected limb see Figure 3-2-19. 2) Application of synergistic movements in the recovery of hemiplegia In the early stage when there is spasticity, the synergistic action of the limb, can be induced like a joint response, when the patient moves a joint, all the muscles associated with the synergistic action 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, 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 garment, handbag, etc. 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 hemiplegic 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, after a few seconds the flexion of the wrist joint and fingers becomes relaxed, the fingers can be extended as shown in Figure 3-2-36. Figure 3-2-36 Methods to promote finger relaxation ② Training of the upper limb: In the early stage of the patient has no casual At this time, if resistance is applied to the flexion of the upper limb on the healthy side or the head is turned to the healthy side, the asymmetric cervical tension reflex (ATNR) is more likely to promote the flexion of the affected limb, and as mentioned above, applying resistance to the flexion of the elbow on the healthy side can also induce the flexion of the elbow joint on the affected side, and vice versa for the extension of the elbow. Brunnstrom also believes that the above-mentioned effects can be enhanced by adding electrical stimulation massage and buckling to the skin of the affected limb at this time. (3) Separation of independent movements from the synergistic movements: A. Separation of the synergistic movements of the hand muscles (same movements and methods as in 3) No. 1), in which the thumb is not extended with excessive force. As in Figure 3-2-36 B. Separation of lower extremity synergistic action: When the lower extremity flexor tone is strong, the physician holds both heels upward about 30° in the patient’s supine position and swings both lower extremities with a rhythmic lateral swing, which can suppress the flexor tension as in Figure 3-2-37. Figure 3-2-37 Separation of lower extremity synergistic action C. Promotion of foot dorsiflexion: Marie-Foix reflex can be used when When hip flexion cannot promote foot dorsiflexion, first passively make its toes plantar flexion, can induce including hip, knee, ankle flexion, foot that is dorsiflexion, in the same time, should encourage the patient to strengthen its casual movement, the moment of strengthening is very important, do well can accelerate the separation of its synergistic action as Figure 3-2-38. foot dorsiflexion can also be promoted by hand or brush along the lateral side of the dorsum of the foot to the heel of the motor brush as Figure 3-2-39. Figure 3-2-38 Separation of synergistic movements of foot dorsiflexion Figure 3-2-39 Separation of synergistic movements of foot dorsiflexion (brush method) (3) Current evaluation of Brunnstrom therapy (1) The Brunnstrom method is considered to be a combination of central facilitation, peripheral and proprioceptive stimulation, starting from synergistic movements and progressing to detachment from synergistic movements, so that the limbs, hands and fingers gradually regain their functions. affirmative. (2) The proposed bridging movement can free the stroke patient from lower limb synergy and facilitate the training of lower limb function. (3) The Fugl-Meyer evaluation method has been developed in the West and the Ueda-Min method has been developed in the East. (4) Although neurophysiologists affirm Brunnstrom’s treatment method, most therapists still do not like to use it. (iv) Rood therapy The prominent feature of Rood therapy is to cause stimulation or inhibition through stimulation applied on the skin. (1) The skin-muscle shuttle reflex related to γ-transmission is shown in Figure 3-2-40. As shown in Figure 3-2-40, stimulation of the skin covering the attachment points of tendons and muscle bellies, impulses are transmitted to the spinal cord, and through γ-transmission to the muscle shuttle, which can have a facilitative or inhibitory effect on the muscle, depending on the nature and mode of stimulation. On the other hand, some skin-muscle reflexes are not related to γ efferent nerves. (2) Skin-muscle reflexes unrelated to the γ efferent nerve. As shown in Figure 3-2-41, stimulation of the hair on the skin, through the hair or afferent nerve, projects impulses to the motor cortex via the dorsal root spinal-thalamic pathway, causing excitation of the thalamus at the beginning of the vertebral tract, and then out to the spinal cord via the corticospinal tract and to the muscle via the α-transmitter, which can also produce a facilitatory or inhibitory response to the muscle by stimulating the skin. Figure 3-2-40 Skin-saccade reflexes S-skin, SP-spinal cord, M-saccade, γ-γ efferent Figure 3-2-41 Skin-saccade reflexes unrelated to γ efferent nerves 2. Basic principles (1) Different stimuli applied to the skin produce facilitative or inhibitory effects on the motor system. (2) Motor development proceeds in the order of A→G in Figure 3-2-42. Figure 3-2-42 The sequence of motor development A – supine retraction, B – flip, C – prone with the abdomen as the fulcrum, head and feet on stilts, D – elbow brace prone, E – hand and knee stand, F – stand, G – walk (3) Motor control from (3) Motor control from low to high level is divided into four stages ① activity, ② stability, ③ controlled activity, ④ skill: motor control is related to motor development, A, B, C in the above figure belongs to! level, C, D, E, F belong to 2) level, on the basis of D moving from one side to the other, pushing the shoulder back and pulling forward, unilateral weight-bearing, on the basis of E swaying and moving, unilateral weight-bearing, on the basis of F weight transfer and unilateral weight-bearing, etc. belong to 3) level. On the basis of D, the head makes skillful movements, the free hand makes skillful movements, on the basis of E, the torso makes reciprocal activities diagonal type activities, the free hand makes skillful movements and F and G are at the level of 4). The control of movement should be trained from low to high level. 3. methods and techniques (1) promotion and inhibition of muscles 1) methods of promotion: applicable to flaccid paralysis, weak contraction, etc. (1) tactile: A, fast brush finger, with a small electric brush, one end is equipped with bundles of soft hairs, electric brush rotation when the soft hairs open, stimulate the skin or hair on the surface of the muscle, 3 to 5 seconds, if 3 to 5 still no response, can repeat the stimulation 3 to 5 times, also in the corresponding segment of the skin stimulation for 5 seconds. The method excites the high threshold C sensory fibers and promotes γ motor neurons. The effect peaks 30 to 40 minutes after stimulation. B. Tapping the skin: Tapping the skin on the surface of the stimulated muscle can promote the response of the extraspinal muscles. Tapping the skin between the fingers on the back of the hand, the skin between the toes on the back of the foot or the palm and the sole of the foot can cause the retraction response of the limb. This method excites the low-threshold A fibers. ② of temperature: the main application of ice stimulation, local stimulation for 3 to 5 seconds, can promote muscle contraction, but also the result of excitation of C fibers, but about 30 seconds after ice stimulation often cause rebound phenomenon, that is, from excitation to inhibition, which should be noted. ③ proprioception, etc.: A. Fast and lightly tensor the muscle. B. Stretching the internal attachment muscles of the hand. C. stretching to the limit of ROM before further stretching. D. resisted contraction. E. Apply pressure or push on the muscle belly. F．Tap on the tendon or muscle belly. G．Pressure on the bony prominence. H．Forceful compression of the joint. ④Special sensory stimulation: suction adaptations ammonia, etc. (2) Methods of inhibition: for spasticity or other cases of high muscle tone. (1) gentle compression of the joint, (2) pressure on the tendon attachment points, (3) pushing and moistening of the skin surface of the posterior basal branch innervation (skin surface of the paraspinal muscles) with firm light pressure, (4) continuous stretching, (5) slow turning of the patient from the supine or prone position to the lateral position, (6) medium temperature stimulation, non-sensory warm local baths, hot wet compresses, etc. (2) For hypermobility applied to conditions such as tardive dyskinesia, carry out the method of distal fixation and proximal movement, such as having the patient take the hand and knee position hand and knee position without moving, but in this position, make the trunk move anteriorly, posteriorly, left, right and diagonally, such as a more limited range, slowly stroke or rub the skin of the muscle surface. (3) The main principle of retraining motor function is to proceed in the order of motor development. (1) Considered as a whole: according to the order in the previous Figure 3-2-40. In terms of training motor control, the sequence of mobility → stability → controlled movement → skillful movement should be carried out. (2) From local consideration: flexion should be taken before extension, adduction before abduction, ulnar side before radial side, and finally rotation. In terms of which is first, the distal or proximal end, the first should be for for limb proximal fixation distal activity → distal fixation, proximal activity → proximal fixation, distal free learning skillful activity. 4. Current evaluation of Rood therapy (1) It is believed that facilitation through skin stimulation has a solid neurophysiological basis. (2) The facilitation effect of freezing and brushing is only effective at the time of treatment and within 45-60 seconds of cessation, with the brushing effect being better. (3) To get the effect of attention, the stimulation time should be longer, but the effect is still not lasting after stopping. (4) It is believed that this method further develops the traditional PNF. (5) It is wrong to believe that when skin stimulation is performed first, followed by muscle pulling for promotion, the interval between the two is 30 minutes. In fact, an interval of more than 5 minutes is no longer effective. (5) How to choose the application of neurophysiological therapy (PNF) There are various kinds of NPF, each with its own theory and viewpoint, how to choose the application? In this regard, Basmajian, a renowned expert in rehabilitation medicine, has made the point that a therapist who is capable of combining all methods in an eclectic manner, rather than adhering to one method alone, can be the best armed therapist who is able to treat patients with a variety of difficult neurological disorders in a comfortable manner in rehabilitation practice. We undoubtedly agree with this viewpoint, and it is best to seek out a method that is practical and effective for the patient by drawing on the strengths of various schools of thought. However, in order to facilitate the reader’s choice of application, the experience of the first 50 years of this century is summarized for the reader’s reference, based on the experience of authorities. 1. According to the overall muscle tone of the patient to choose Table 3-2-13 from the table, it can be seen that when the muscle tone is low, all four can be applied, but for the case of high muscle tone, only applicable Bobath, Rood two methods, and Rood method is only suitable for high tension of the muscle on the antagonistic muscle which is worth noting when applied. Table 3-2-13 Selection of NPF according to muscle tone Tension is too low Tension is too high 1. Bobath uses reflexes such as rollover and balance to elicit a response 1. Bobath uses RIP 2. Brunnstrom uses the combined response primitive reflex to elicit a response 2. Rood uses skin stimulation to facilitate stimulation of the antagonist muscle 3. PNF uses diagonal activity 4. Skin stimulation facilitation method 2. Choose according to the local condition of the patient, if the action is local, choose the items listed according to the local condition according to Table 3-2-14. Table 3-2-14 Local application of NPT techniques Local conditions Method of application Purpose Effect 1. flaccid paralysis with near-zero muscle response Stimulate nerves or muscles with electric current, record their electromyograms and provide feedback to the patient Maintain tissue elasticity, prevent muscle atrophy, and demonstrate to the patient that recovery is still possible by artificially inducing significant muscle contraction and by recording the electrical activity of residual motor units with an electromyograph The presence of a maximum random contraction of the remaining functional muscles (so-called strong muscles) induces a contraction of the weak muscles against resistance and eliminates spasm. muscle tremors, passive ROM activity, guiding very weak or unstable random movements through the correct track, providing it with enhanced sensory feedback, verbal feedback, and reminding the patient of the sensations generated by the muscle contraction or movement Directing attention to the affected limb when it is at rest; helping the patient to pay attention to kinesthetic input when the affected limb is moving Facilitating 4. active muscles that are moderately strong but are subject to antagonistic muscles in resting position and movement Putting the spastic muscle in a position of reflex inhibition (including the use of vestibular stimulation to induce a wide range of changes in muscle tone) and slow prolonged stretching by hand or by applying a brace or splint relieves the patient of the limitation of range of motion due to muscle spasm; changes the muscle tone to a more normal position at rest Inhibition 5. Inhibited 6. Muscles are strong in independent contractions, but muscle imbalance or lack of reciprocal relaxation allows abnormal joint position and limited range of motion Movement of the head and body causes TLR, TNR, and balance responses of the limbs and trunk Modulates the resting distribution of muscle tone and enhances the experience of posture and Mixed 7. active muscle remains relatively weak, but contraction tension increases with casual effort Rapid traction (or fast traction of the synergic muscle followed by slow traction of its counterpart); followed by repeated tapping or trembling on the muscle belly Applied during the period before casual movement is required Facilitation 8. same as 7. skin stimulation, finger brushing or stimulation Discrete facilitation of individual muscle contractions to maximize proprioceptive facilitation Facilitation 9. The tension needs to be locally regulated to balance the muscle and thus allow the patient to adopt a more normal posture and perform short, fast movements in a more balanced manner. In the antagonistic muscles of the spastic muscles, either type of facilitation is applied to relax the spastic muscles through reciprocal innervation. When the patient is relaxed, the tone is in the normal range, but when attempting any random movement of varying complexity, the tone fluctuates and is unstable as in tardive dyskinesia, reinforcing motor sensation or replacing it with artificial electronic sensors providing position feedback, thereby enhancing the patient’s positional stability and controlling short and fast movements with this message. Continuous induction: rhythmic stabilization, joint compression To achieve proximal postural stability, promote co-contraction of synergic and antagonistic muscles Facilitate 12. ataxia and tardive dyskinesia Implement various resistance training with equipment (against various hydraulic resistances) Strengthen weak muscles while limiting movement to the desired track (and easily and objectively quantify) Facilitate