Approach that promoting voluntary movement of particular part with combination of associated reaction and reflexes.

1. BRUNNSTROM’S
HAND FUNCTION
RECOVERY STAGES
AZIMAH BT HASSAN
2012255702
940507-02-5320

2.  Definition of CVA
 Types of CVA
 Recovery stage of hand
 Principle of Brunnstrom Approach
 Treatment implementation of Brunnstrom and Bilateral training
 Component of hand function

3. DEFINITION OF CVA
• Sudden death of some brain cells due to lack of oxygen
when the blood flow to the brain is impaired by blockage
or rupture of an artery to the brain. A CVA is also
referred to as a stroke.
Retrieved from www.thestrokefoundation.com
• Symptoms of stroke depend on area of body effected

4. TYPES OF CVA
 TIA (Transient Ischemic Attack)
- known as “mini stroke”
- temporary blockage of artery
 Ischemic
- blockage of artery
- 2 types: embolic and thrombotic
 Hemorrhagic
- ruptured of blood vessel
- 2 types: intracerebral and subarachnoid

5. RECOVERY STAGES OF HAND
STAGE III
Mass grasp or hook grasp. No voluntary finger extension. No voluntary release.
STAGE II
Little or no active finger flexion
STAGE I
Flaccidity
STAGE VI
All types of prehension.
STAGE V
Palmar prehension (spherical and cylindrical grasp). Voluntary finger extension in variable ROM.
STAGE IV
Lateral prehension (thumb release). Semivoluntary finger extension in small
ROM.

6. BRUNNSTROM’S MOVEMENT THERAPY
APPROACH
• Developed by the Swedish physical therapist Signe Brunnstrom
• Encourages development of synergistic pattern during early
recovery to transition to voluntary activation
• Facilitates recovery through a specific sequence, promotion of
movement from reflexive to volitional

7. TREATMENT PRINCIPLES
• Treatment progress developmentally
• The use of reflexes and associated reactions to produce muscle
tension, then voluntary movement
• Facilitation of muscle tone by proprioceptive and exteroceptive
stimuli
• When effort produces response, ask patient to "hold“
• Reduce facilitation when volition increase
• Repetition of movement for motor learning

8. TREATMENT IMPLEMENTATION
(STAGE 1 AND STAGE 2)
 ACHIEVE MASS GRASP
- Proximal traction response
- Maintain wrist in extension, arm and elbow supported by therapist
- Command patient to squeeze

9.  ACHIEVE WRIST FIXATION
- Percussion at wrist extensor (proximal part ) and
ask patient to squeeze simultaneously
- Alternate “squeeze” and ”stop squeeze”
- Repeat until active response from wrist extensors is achieved
- Support is removed, and patient holds the contraction
(facilitated by tapping).
- If successful, ask patient to perform eccentric contraction
followed by concentric contraction

10. (STAGE 3 AND STAGE 4)
(1st series of manipulation)
 Position: therapist seats in front of patient
 Pull thumb out of palm by grasping thenar eminence
 Passively supinate the forearm
 Alternate pronation and supination (emphasizing supination)
 Decrease pressure on thumb (pronation)
 Facilitate cutaneous stimulation over dorsum of hand (supination)

11. (2nd series of manipulation)
 Same position as 1st series
 Rapid stroking over phalanges distally (PIP & DIP)
(3rd series of manipulation)
 Facilitate forearm pronation and finger extension
 Pull thumb out of palm
 Perform souques’s position
 Gradually discontinue support as active response is achieved

12. (STAGE 4)
 Patient pulls thumb away from index finger
 Percussion at abductor pollicis longus extensor pollicis brevis
 “Twiddle” for further control of thumb movement
 Functional use of lateral prehension is encouraged.
e.g. (Holding cards, Using a key )

13. (STAGE 5)
 Encourages advanced prehensive pattern through activities
 In order of increasing difficulty:
- palmar prehension, cylindrical grasp, spherical grasp
(STAGE 6)
 Individual finger movement
 Provide home program of activities to encourage individual finger
use, speed, and accuracy

14. BIMANUAL TRAINING
 By Mudie, Matyas in 1996
 Is addressed by the use of bilateral arm movement with
ADLs and is hypothesized to be more functional than
unilateral arm
 Activates damaged hemisphere through
interhemispheric connections
(C.P Latimer, et al., 2010)

15. NEURAL MECHANISM OF BILATERAL TRAINING
 Symmetrical bilateral activities simultaneously activate same neural
network in both hemisphere
 Unilateral activity is believed to cause interhemispheric inhibition
that prevents contralateral hemisphere to move the opposite limb
 Bilateral training reduces interhemispheric inhibition by activation
of both hemisphere simultaneously
 Right and left hemisphere have symmetrical organization for hand
control in motor cortex
(J.H Cauragh, et al., 2005)

16. BIMANUAL TRAINING
• Bimanual symmetrical tasks
- Fold a towel
- Push-ups against wall
• Bimanual alternative tasks
- Arm cycling
- Typing on a keyboard
• Bimanual complimentary tasks
- Pour water from jug to cup
- Scooping coins from table
- Hold newspaper – turn over the pages
(McCombe Waller, et al., 2008)

17. HAND FUNCTION

18.  REACHING
- forward : GH joint flexion
- backward : GH joint extension
- sideward : GH joint abduction
- shoulder elevation
- GH joint external rotation
- elbow extension
- forearm pronation and supination
- wrist extension

19.  GRASP
- wrist and finger flexion
- thumb opposition
- finger extension
1. Hook grasp (holding handles of bag)
2. Lateral prehension (grasp small object )
3. Palmar prehension (grasp small object; required thumb
opposition)
4. Cylindrical grasp (pick up and hold larger objects)
5. Spherical grasp (rapid fist closure and release)

20.  RELEASE
- wrist extension
- finger extension (MCP joint)
- thumb abduction and extension (CMC)

21.  MANIPULATION
- wrist extension with finger flexion and extension
- thumb opposition
- combined flexion and rotation of 5th finger and thumb (e.g. cupping)
- independent finger flexion and extension

22. MANIPULATION AND DEXTERITY PRACTICE
• Tapping tasks
- touch each finger tip to thumb in sequence as
fast as possible (within a given time)
- tapping table with single fingers
• Hand – cuping tasks to train opposition of radial and
ulnar sides of hand
- scooping coins from table to palm of hands
• Pick – up different objects between thumb and fingers
- pick-up objects between thumb and 4th, 5th finger
- pick -up piece of paper from opposite shoulder
- stack dominoes
- pick up lid of large jar using “spider grip”

23. • Pick up larger objects from one side of table to
other side (vary weight, distance to be moved)
- pick up jug of water and and pour into glass
• More difficult tasks
- type on a computer keyboard
- tracing a circle without touching the lines
- turn door handles walk while carrying a glass of
water

24. REFERENCES
Carr, J. H., & Shepherd, R. B. (1982). A motor relearning programme for stroke.
Rockville, MD: Aspen.
Carr, J. H., & Shepherd, R. B. (2003). Stroke rehabilitation: Guidelines for exercise
and training to optimize motor skill. London: Butterworth-Heinemann.
Sainburg ,R.L., Good, D. Przybyla. A. (2013). Bilateral Synergy: A Framework for
Post-Stroke Rehabilitation. Journal of Neurology & Translational Neuroscience.
Sawner, K.,& Lavigne, J. (1992). Brunnstrom’s movement therapy in hemiplegia. A
neurophysiological approach (2nd ed.). Philadelphia: Lippincolt.
Smits, G.J., & Boone, S.C.E. (2000). Hand Recovery After Stroke: Exercises and
Results Measurements. Boston, Butterworth-Heinemann.
Winstein, J.C.,& Rose, K.D (2005).Bimanual Training After Stroke: Are Two Hands
Better Than One? Topics in Stroke Rehabilitation, 11, 20-30. doi: 10.1310/
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