BRUNNSTROM APPROACH

                                         

                                 BRUNNSTROM APPROACH

1.      THEORY`:

·         Brunnstrom was a physical therapist from Sweden.  

·         Theory development in the    United  States   extended from the World War II years through the 1970s.          

·         Clinical observations and research led to the development of the treatment approach she called movement therapy. Applied movement therapy, also known as the Brunnstrom approach

2.      THEORETIC FOUNDATIONS:

·         Brunnstrom evolved her treatment approach after study of the literature in neurophysiology, CNS mechanisms, and effects of CNS damage, sensory systems and related topics, and clinical observations and application of training procedures.

·         Brunnstrom based her intervention on the concept that the damaged CNS has undergone an “evolution in reverse” and regressed to former patterns of movement.  

·         These patterns include the limb synergies, which are gross patterns of limb flexion and extension that originate in primitive spinal cord patterns and primitive reflexes.

·         In the normal individual these primitive movement patterns are thought to be modified through the influence of higher centers of CNS control.  

·         The goal is to allow progress through the stages of recovery toward more normal and complex movement patterns.

·         Brunnstrom recommended that the patient should be aided to gain control of the limb synergies and that selected sensory stimuli can help the patient initiate and gain control of movement. Once the synergies can  be performed voluntarily, they            are modified and movement combinations that deviate from the synergy pattern can be performed  

             2.1 Limb Synergies

·         A group of muscles acting as a bound unit in a primitive and stereotypical manner.

·         The muscles acting in synergy are linked and cannot act alone.      

·         If one muscle in the synergy is activated, each muscle in the synergy responds partially or completely. As a result, the patient cannot perform isolated            movements when bound by these synergies.

                   Flexor synergy of  the UE          

·         UE consist scapular adduction and elevation, shoulder abduction and external rotation, elbow flexion, forearm supination, wrist flexion, and finger flexion.           

·         Hypertonicity (spasticity) is usually greatest in the elbow flexion component and least in shoulder abduction and external rotation.  

                Extensor synergy of the UE          

·         UE consists of scapular abduction and depression, shoulder adduction and internal rotation, elbow extension, forearm pronation, and wrist and finger flexion or extension.    

·         Shoulder adduction and internal rotation are usually the most hypertonic componentsof the extensor synergy, with much less    tone in the elbow extension component         

                   Flexor synergy of the LE

·         LE consists of hip flexion, abduction, and external rotation; knee flexion; ankle dorsiflexion and inversion; and toe extension.

·         Hip flexion is usually the component with the  highest tone, and hip abduction         and external rotation are  the components with the least tone.    

                   Extensor synergy of the LE       

·         LE consists of hip abduction, extension, and internal rotation; knee extension; ankle plantar flexion and inversion; and toe flexion.

·         Hip abduction, knee extension, and ankle plantar flexion are usually the most hypertonic components, whereas hip extension and internal rotation are usually less hypertonic.

          2.2 Characteristics of Synergistic Movement

·         The flexor synergy is more often seen in the arm, and the extensor synergy is more common in the leg.

·         When the patient performs the synergy, the components with the greatest degree of hypertonicity are    often most apparent, rather than the entire classical patterns just described.   

·         The resting  posture of the limb, particularly  the arm, is usually characterized by a position that represents the most hypertonic components of  both flexor and extensor synergies   

         2.3 Motor Recovery Process

                      Arm

1.      Flaccidity: no voluntary movement or stretch reflexes

2.      Synergies can be elicited reflexively; flexion develops before extension; spasticity developing

3.      Beginning voluntary movement, but only in synergy; increased spasticity, which may become marked

4.      Some movements deviating from synergy:  

·         Hand behind back  

·         Arm to forward horizontal position

·         Pronation and supination with the elbow flexed to 90°; spasticity decreasing

5.      Independence from basic synergies  

·         Arm to side horizontal position  

·         Arm forward and overhead  

·         Pronation and supination with elbow fully extended; spasticity waning

6.      Isolated joint movements freely performed with near normal coordination; spasticity minimal

                    Hand

1.      Flaccidity  

2.      Little or no active finger flexion

3.      Mass grasp or hook grasp; no voluntary finger extension or release

4.      Semi-voluntary finger extension in a small range of motion; lateral prehension with release by thumb movement

5.      Palmar prehension

·         Cylindrical and spherical grasp (awkward)

·          Voluntary mass finger extension (variable range of motion)

6.      All types of prehension (improved skill).

·         Voluntary finger extension (full range of motion).

·         Individual finger movements

                    Leg

1.      Flaccidity

2.      Spasticity develops; minimal voluntary movements

3.      Spasticity peaks; flexion and extension synergy present; hip-knee-ankle flexion in sitting and standing

4.      Knee flexion past 90 degrees in sitting, with foot sliding backward on floor; dorsiflexion with heel on floor and knee flexed to 90 degrees

5.      Knee flexion with hip extended in  standing; ankle dorsiflexion with hip and knee extended

6.      Hip abduction in sitting or standing;  reciprocal internal and external  rotation    of hip combined with  inversion and eversion of ankle in sitting

2.4  Associated Reactions Identified by Brunnstrom

1.      Resistance to flexion of the uninvolved leg causes extension of the involved extremity, and resistance to extension of the uninvolved leg causes flexion of the involved extremity.

2.      Attempt to flex the involved leg or resistance to leg flexion causes a flexor response in the involved arm. This reaction is called homolateral synkinesis.

3.      Actively or passively raising the affected arm above the horizontal causes the fingers to extend and abduct. This is Souque’s phenomenon.

4.      Resistance to abduction or adduction of the unaffected lower limb results in a similar response in the opposite affected leg. This is Raimiste’s phenomenon

5.      Resisted grasp by the un involved hand cause a grasp reaction in the involved  hand this example of mirror synkinesis

6.      Stationary contact with the palm of the hand results to closure of the hand. this is instinctive grasp reaction

7.      With the arm elevated in a forward up ward direction the fingers and thumb hyperextented storking the palm in a distal direction exaggerates the posture. This is instinctive avoiding reaction

8.      Yawning : flexor synergy is elicited during intiation of yawn

9.      Coughing and sneezing: Evoke  sudden muscular contractions of short duration

                   2.5 Tonic Reflexes

·         Tonic reflexes are assessed to determine whether they can be used in early treatment to initiate movement when none exists. The primitive tonic brainstem reflexes that may be present include the symmetrical and asymmetrical tonic neck reflexes, tonic labyrinthine reflexes, and tonic lumbar reflexes

                  2.6 Sensation

·         The sensory evaluation precedes the motor evaluation.

·         The patient’s ability to recognize movements of the affected arm and to localize touch in the hand without looking are especially noted because they are associated with better eventual recovery of voluntary movement of the arm and hand.

·         The results of the sensory evaluation guide the therapist’s choice of facilitation modalities to improve movement or alert the therapist to encourage the patient to substitute visual feedback for lost movement or position senses.

3.      ASSUMTIONS:

·         In normal motor development, spinal cord and brainstem reflexes become modified and their components become rearranged into purposeful movement through the influence of higher centers.

·         Because reflexes and whole-limb movement patterns are normal stages of development and because stroke appears to result in “development in reverse,” reflexes and primitive movement patterns should be used to facilitate the recovery of voluntary movement post stroke. Brunnstrom (1956) believed that no reasonable training method should be left untried. She stated, “It may well be that a subcortical motion synergy which can be elicited on a reflex basis may serve as a wedge by means of which a limited amount of willed movement may be learned” .

·         Proprioceptive and exteroceptive stimuli can be used to evoke desired motion or tonal changes.

·         Recovery of voluntary movement post stroke proceeds in sequence from mass stereotyped flexor or extensor movement patterns to movements that combine features of the two patterns and, finally, to discrete movements of each joint at will. The stereotyped movement patterns are called limb synergies. Synergyin this sense refers to patterned movements of the entire limb in response to a stimulus or to voluntary effort.

·         Newly produced correct motions must be practiced to be learned.

·         Practice with in the context of daily activities enhances the learning process.

4.      PRINCIPLES:

·         Treatment progresses developmentally from evocation of reflex responses to willed control of voluntary movement to automatic functional motor behavior.

·         When no motion exists, facilitate it using reflexes, associated reactions, proprioceptive facilitation, and/or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement.

·         Elicit reflex responses and associated reactions in combination with the patient’s voluntary effort to move, which produces semi-voluntary movement; this allows the patient to feel the sensory feedback associated with movement and the satisfaction of having moved to some degree voluntarily.

·         Proprioceptive and exteroceptive stimuli also assist in eliciting movement. Resistance, a proprioceptive stimulus, promotes a spread of impulses to other muscles to produce a patterned response (associated reaction), whereas tactile stimulation (exteroceptive) and muscle or tendon tapping (proprioceptive) facilitate only the muscles related to the stimulated area.

·         When voluntary effort produces a response, ask the patient to hold (isometric) the contraction. If successful, ask for an eccentric (controlled lengthening) contraction and finally a concentric (shortening) contraction.

·         Even when only partial movement is possible, stress reversal of movement from flexion to extension in each treatment session.

·         Reduce or drop out facilitation as quickly as the patient shows evidence of volitional control. Drop out facilitation procedures in order of their stimulus-response binding. Reflexes, in which the response is stereotypically bound to a certain stimulus, are the most primitive and are dropped out of treatment first. Responses to exteroceptive stimulation are least stereotyped, and therefore, tactile stimulation is eliminated last. No primitive reflexes, including associated reactions, are used beyond stage III.

·         Place emphasis on willed movement to overcome the linkages between parts of the synergies. Willed movement means that the patient is trying to accomplish it. Patients may be more successful if you ask them to do familiar movements involving a goal object (Trombly & Wu, 1999; Wu et al., 2000).

·         Have the patient repeat correct movement, once elicited, to learn it. Practice should involve functional activities to increase the willed aspect and to relate the sensations to goal-directed movement.

5.      EVALUATION:

   Evaluation in the Brunnstrom Movement Therapy Approach Determine the following:

                   1. Proprioceptive and exteroceptive sensory status

                   2. Effect of tonic reflexes on the patient’s movement

                   3. Effect of associated reactions on the patient’s movement

                   4. Level of recovery of voluntary motor control

6.      GENERAL TREATMENT GOALS AND METHODS :

·         Before initiating any intervention strategies, the occupational therapist performs a thorough evaluation of the patient’s motor, sensory, perceptual, and   cognitive functions.    

·         The motor evaluation yields information about   stage of recovery, muscle tone  passive motion sense, hand function, and sitting and standing balance.

7.      TREATMENT :

7.1 Bed Positioning

·         Proper bed positioning begins immediately when the patient is in the flaccid stage.   

·         Proper positioning promotes normal alignment and can decrease the influence of hypertonic muscles.    

·         This is important in the prevention of contractures and deformity

·         Abduction of the UE should be avoided because this position can contribute to shoulder subluxation.    

·         The patient is instructed to use the unaffected hand to support the affected arm when moving in            bed.

               7.2 Balance and Trunk Control

·         Early in treatment the patient needs to develop balance, a prerequisite for functional activities.        

·         Demonstrating a “listing” (leaning) toward the affected side.  

·         To facilitate upright posture, treatment   should focus on improving trunk control through a variety of sitting balance exercises with focus on anterior and posterior pelvic tilts and lateral weight  shifting.

·         To elicit balance responses, the patient is gently pushed forward, backward, and side to side. Reaching for objects in various locations while seated demands dynamic trunk balance responses

·         Brunnstrom emphasized promoting contraction of trunk muscles on the uninvolved side first by pushing the patient off balance toward the involved side. Then, once it is determined that the person has that skill, recovery from a push toward or reach toward the uninvolved side is sought.

·         This requires contraction of the trunk muscles on the involved side. The patient is pushed or asked to reach only to the point at which he or she can hold the position and regain upright posture.

·         The patient is guarded throughout. Training then progresses to promote trunk flexion, extension, and rotation. Practice in forward flexion of the trunk is assisted. The patient crosses the arms with the uninvolved hand under the involved elbow and the uninvolved forearm supporting the involved forearm. The therapist, sitting facing the patient, supports the patient under the elbows and assists in trunk flexion forward, avoiding any pull on the shoulders

·         Return from trunk flexion is performed actively by the patient. Then, while sitting without back support and with the involved arm supported as described, the patient is pushed backward and encouraged to regain upright posture actively.

·         The clinician should support the affected arm to protect the shoulder during these balance-challenging activities. Supporting the arm also prevents the patient from grasping the supporting surface during the activity.

·         As trunk control improves, the clinician initiates and assists the patient to bend the trunk in various directions.    

·         Trunk rotation can be combined with head movements in the opposite direction of the trunk rotation, so that the tonic neck and tonic lumbar reflexes can be used to begin to elicit the shoulder components of the upper extremity synergies. The arms and trunk move in one direction, and the head turns in the opposite direction.

                   7.3 Shoulder Range of Motion

·         Brunnstrom believed that traditional passive exercises may actually contribute to pain in these  patients.

·         The shoulder joint should  be mobilized through guided trunk motion without forceful stretching.

·         The clinician guides the arm gently and passively into shoulder flexion while the patients attentions focused on the trunk motion

                  7.4 Retraining Proximal Upper Extremity Control

                          Stages I to III

·         The goal of treatment is to promote voluntary control of the synergies and to encourage their use in functional activities.

·         In these stages, all movements occur in synergy patterns but with increasing voluntary initiation and control of these patterns.

·         To move the patient from stage I (flaccidity) to stage II (beginning synergy), the basic limb synergies are elicited at a reflex level, using as many reflexes, associated reactions, and facilitation procedures as are necessary to elicit a response.

·         Patient attempts bilateral scapular elevation, resistance is given to the uninvolved scapula. If the involved scapula elevates as an associated reaction, resistance is added on the involved side as the patient is asked to hold.

·         Unilateral scapular elevation of the involved arm is attempted next; it may be achieved as a result of the previous procedures. If the patient cannot do the motion, the therapist supports the patient’s arm and assists the patient to elevate the scapula. Percussion or stroking over the upper trapezius facilitates muscle contraction.

·         The therapist tells the patient to hold and “Don’t let me push your shoulder down.” After repeated holding with some resistance added, the patient does an eccentric contraction, that is, lets the shoulder down slowly. Then a concentric, or shortening, contraction is attempted when the person is told, “Pull your shoulder up toward your ear.”

·         Active scapular elevation evokes other flexor components and tends to inhibit the pectoralis major. The patient repeats scapular elevation and relaxation as the therapist gently abducts the shoulder in increasing increments.

·         Once shoulder elevation and some active abduction have been achieved, external rotation and forearm supination are included in the movement. Reversal of movements to the opposite direction is done from the start, and this begins to develop some components of the extensor synergy

·         The extensor synergy tends to follow the flexor synergy but may have to be assisted in its initiation. Contraction of the pectoralis major, a strong component of the extensor synergy, can be elicited by the associated reaction in which the therapist supports the patient’s arms in a position between horizontal abduction and adduction, instructs the patient to bring his arms together, and resists the uninvolved arm just proximal to the elbow.

·         As bilateral contraction occurs, the patient is instructed, “Don’t let me pull your arms apart.” Then the patient attempts to bring the arms together voluntarily.

·         The predominance of excess tone in the elbow flexors and relative weakness of elbow extensors, elbow extension is usually more difficult to obtain, but it can be assisted by the methods in Procedures for Practice

·         Other means that may be used to facilitate extension movement include use of supine position (tonic labyrinthine reflex); having the patient watch the extremity, which requires head turning and pulls in the asymmetrical tonic neck reflex; working with the forearm pronated, which is a strong component of the extensor synergy; and rotating the trunk toward the uninvolved side to facilitate extension of the involved arm via the tonic lumbar reflex.

·         After the patient achieves elbow extension in weight bearing, the goal is to encourage active elbow extension free of weight bearing. Unilateral manual resistance is offered to the patient’s attempts to move into an extension synergy pattern. Resistance gives direction to the patient’s effort and facilitates a stronger contraction.

·         As the synergies come under voluntary control, they should be used in functional activities. The extensor synergy can be used to stabilize an object to be worked on by the other arm, to push the arm into the sleeve of a garment to smooth out a sheet on the bed, or to sponge off the kitchen counter. The flexor synergy can be used functionally to assist in carrying items (such as a coat, handbag, or briefcase); feeding oneself; putting on glasses; and combing the hair. Bilateral pushing and pulling reinforce both synergies.

·         Bilateral identical movements performed independently (i.e., no ball or stick connecting the two limbs) were observed to improve movement of the hemiplegic arm when that arm was tested unilaterally.

·         The improvement was limited to the practiced movement patterns but was maintained over time (Mudie & Matyas, 2000). Sanding, weaving, ironing, and polishing use the flexor and extensor synergies alternately.

                  Stages IV to VI

·         To promote movement deviating from synergy, motions that begin to combine components of synergies in small increments are encouraged as a transition from stage III to stage IV.

·         The patient begins to extend the arm consistently in response to the unilateral manual resistance that the therapist provides, the therapist guides the direction of movement away from the extensor synergy pattern and toward greater shoulder abduction in conjunction with elbow extension.

·         This breaks up the synergistic relationships of shoulder adduction with elbow extension and shoulder abduction with elbow flexion. The therapist directs the patient to push the hand into the therapist’s hand and moves the hand in small increments away from the patient’s midline. When the triceps and pectoralis major are disassociated, the synergies no longer dominate.

·         In stages IV and V, the goal of treatment is to “condition the synergies,” that is, to promote voluntary movement combining components of the two synergies into increasingly varied combinations of movements that deviate from synergy. Proprioceptive and exteroceptive stimuli are still used in this phase of training, but tonic reflexes and associated reactions, appropriate in the earlier stages when reflex behavior was desirable

·         The first out-of-synergy motion of stage IV is hand behind the body, which combines relative shoulder abduction (flexor synergy) with elbow extension and forearm pronation or internal rotation (extensor synergy).

·         As the hand reaches the back of the patient, the patient strokes the dorsum of the hand against the body to complete the sensory awareness of the movement. Stroking the dorsum of the hand on the back is thought to give direction to the attempted voluntary movement. If the patient cannot do the full motion actively, the therapist passively moves the patient’s arm into final position and strokes the dorsum of the patient’s hand against the sacrum. The patient, while attempting to do the movement independently, is assisted into and out of the pattern, which gradually becomes voluntary with practice.

·         The second out-of-synergy motion is shoulder flexion to a forward horizontal position with the elbow extended. If the patient cannot flex the shoulder forward actively, even with the therapist providing local facilitation and guidance of movement, the arm is brought passively into position. While tapping over the anterior and middle deltoid muscles, the therapist asks the patient to hold the position. If the patient can hold after positioning, active motion in small increments is sought, starting with lowering of the arm lowed by active shoulder flexion.

·         Stroking and rubbing of the triceps are used to help the patient keep the elbow straight as the arm is raised. Repetitive non-resistive activities are used to motivate this action. Raising the arm to forward horizontal is involved in any vertically mounted game, such as tic-tac-toe or checkers (using Velcro tabs to secure the pieces), or in reaching for objects in a cupboard

·         The third motion sought in stage IV is pronation and supination with the elbow flexed to 90°. Initially, pronation can be resisted with the elbow extended, and gradually, the elbow can be brought into flexion as the resistance to pronation is repeated. This motion has been achieved when resistance is no longer required and the patient can supinate and pronate with the elbow near the trunk. Practice should include activities that require turning objects such as a knob, a screwdriver, or a dial, to reinforce it. Some games, such as skittles, are knob operated and require rotary motions, as do card games that require turning the cards over and the adapted dice game.

·         Movement in stage V entails active attempts by the patient to move in patterns increasingly away from synergy. The attempts are bolstered by use of quick stretch and tactile stimulation. Each new motion is incorporated into functional activities.

·         Although it is Brunnstrom’s approach to regain motion through exercise and then introduce functional activities to practice the motion, indicates that goal is a powerful organizer of movement, therefore, functional activities should be introduced earlier in treatment.

·         The first motion sought in stage V is arm raised to side horizontal, which combines full shoulder abduction with elbow extension. Activities that have game pieces or materials that can be placed on a high table to the side of the patient to encourage side horizontal movement to play the game or do the project are useful in encouraging this motion. The table can be gradually moved to require more and more horizontal abduction and elbow extension. Other activities that could be used to encourage this motion include weaving on a floor loom, table tennis, driving golf balls, hitting a baseball, and washing

·         The second motion of stage V is arm overhead. To achieve it, the scapula must upwardly rotate. The serratus anterior must be specifically retrained to do this. If the scapula is bound by spastic retractor muscles, passive mobilization may be necessary before seeking an active protraction response. Passive mobilization of the scapula is done by grasping the vertebral border and repeatedly and slowly rotating it as the arm is passively moved into an overhead position. Once the scapula is mobilized, the serratus is activated in its alternative duty of scapula protraction by placing the arm in the forward horizontal position and asking and assisting the patient to reach forward.

·         Apply quick stretches by pushing backward into scapular retraction to activate the serratus. Bilateral sanding will allow the stronger uninvolved arm to help the weaker one. Table tennis would still be useful, as would shooting baskets and putting on overhead garments every day. Washing a wall or painting it with a roller requires repeated reversal of movement up overhead and down.

·         The third motion sought in stage V is supination and pronation (external and internal rotation) with the elbow extended. To improve supination, the elbow is at first kept close to the trunk and gradually extended.The best way to achieve control of supination and pronation with the elbow extended is to have the patient use both hands in activities of interest that entail supination and pronation in various arm positions. One such activity is grasping a beach ball with the arms outstretched and rotating it so the affected arm is on top (pronated) and the unaffected arm is on the bottom (supinated) and vice versa. The patient can graduate to handling a smaller ball, such as a basketball. Adapted games, such as an adapted dice game, that capture the patient’s attention and interest have been found to be more effective than exercise.

                    7.5 Retraining Hand and Wrist Control

·         Training techniques for return of function in the hand are presented separately from the rest of the upper extremity because the hand may be at a different stage of recovery from that of the arm.

·         If the patient cannot initiate active finger flexion (hand stage I) or mass grasp (hand stage II), the traction response in which stretch of the scapular adductors produces reflex finger flexion or an associated reaction of resisted grasp by the unaffected hand may be used in combination with voluntary effort.

·         Initially, so stability of the wrist in extension must be developed. It is easier for the patient to stabilize the wrist in extension when the elbow is extended; therefore, training starts with the elbow extended and the wrist supported by the therapist. The wrist extensor muscles are facilitated, and the therapist directs the patient to do a forceful grasp by saying, “Squeeze!” That grasp should promote normal synergistic contraction of the facilitated wrist extensors. This is repeated until the wrist extensors are felt to respond, allowing the therapist to remove support from the wrist with the command, “Hold.”

·         Tapping on the wrist extensor muscles facilitates holding. Once wrist extension and grasp with the elbow extended are possible, the process of positioning, percussion, and hold is repeated in increasing amounts of elbow flexion.

·         Emphasis in this stage of training is on wrist stability, although wrist flexion, extension, and circumduction may also be practiced.

·         To move from hand stage III (flexion) to hand stage IV (semi-voluntary mass extension) spasticity of the finger flexors must be relaxed using a series of manipulations. The second motion sought at hand stage IV is lateral prehension and release. The patient attempts to move the thumb away from the index finger to gain release of lateral prehension while the therapist percusses or strokes over the extensor pollicis longus and abductor pollicis longus tendons to facilitate this motion. Once the patient has some active release, functional use of lateral prehension is encouraged. Activities include holding a book while reading, holding or dealing cards, using a key, and dressing.

·         Once the patient can extend the fingers voluntarily to release objects, advanced prehensile patterns (hand stage V) are encouraged through activities. As the patient progresses, activities are chosen to reinforce particular prehensions at more precise levels. Holding a pencil or paintbrush encourages palmar prehension. Spherical grasp is used to pick up or hold round objects such as containers or an orange. Cylindrical grasp is used to hold the handles of tools.

·         Individual finger movements (hand stage VI) may be regained in rare instances. The patient should be given a home program of activities to encourage more and more individual finger use and to increase speed and accuracy of finger movements but should also be cautioned about expecting full recovery.

8.      PROCEDURES:

  8.1 Procedures to Develop Elbow Extension

           Rowing

1.      Sit facing the patient.

2.      Cross your arms so that your right hand grasps the patient’s right hand and your left hand grasps the patient’s left hand.

3.      Resist as the pronated, uninvolved extremity moves toward the involved knee. This elicits elbow extension in the involved arm through an associated reaction.  

4.      At the same time, assist the involved arm into extension toward the uninvolved knee.

5.      Still holding the patient’s hands, guide movements into flexion combined with supination

6.      Repeat steps 3 to 5 until you feel the affected limb actively extending.

7.      Then, offer resistance bilaterally.

8.      Then, reinforce voluntary effort of the involved extremity by asking the patient to hold against resistance to that limb only.

9.      Facilitate the extensors by lightly and repeatedly pushing the involved arm back toward elbow flexion, which causes quick stretches to the triceps.

                         Weight Bearing

                                    it is further developed through use of bilateral weight bearing.

1.      Have the patient lean forward onto extended arms supported by a low stool or cushions placed in front. To make it comfortable for the patient, place a sandbag, pillow, or towel on the stool.

2.      Stroke the skin over the triceps vigorously or tap over the triceps tendon while the patient attempts to bear weight on both outstretched arms

3.      Once this is successful, have the patient shift weight so that the involved extremity bears more of the weight of the upper trunk.

4.      Again, tap the tendon and apply tactile stimulation to the triceps.

5.      In the unilateral weight-bearing position, have the patient do functional tasks such as holding down objects with the affected arm while working on them with the other hand, such as holding a piece of wood while sawing, hammering, or painting it; holding a package steady while opening it, addressing it, or fastening it; or supporting body weight while polishing or washing large surfaces with the uninvolved arm.

8.2  Procedures to Develop Finger Extension  

1.      Release the patient’s grasp by holding the thumb into extension and abduction.

2.      Still holding the thumb, slowlyand rhythmically supinate and pronate the forearm.

3.      Apply cutaneous stimulation over the dorsum of the hand while the forearm is supinated.  

4.      With the forearm still supinated, apply rapid, repeated stretch to the extensors of the fingers by repeatedly rolling them toward the palm

5.      Continue these manipulations until flexion relaxes.

6.      Slowly pronate the forearm and elevate the arm above horizontal to evoke a finger extensor response (Souque’s phenomenon).

7.      Stroke over the dorsum of the fingers and forearm as the patient attempts extension. To avoid a buildup of flexor tension, do not allow the patient to exert more than minimal effort. Imitation synkinesis, in which the normal side performs a motion that is difficult for the involved side (Boissy et al., 1997), may be observed when the patient attempts finger extension.   

8.      After the fingers can be voluntarily extended with the arm raised, gradually lower the arm.

9.      If there is a decreased range in extension, repeat all above manipulations to again inhibit flexion and facilitate extension.

10.  Provide opportunities for the patient to reach and pick up large, lightweight objects and to release them. Putting bagels, apples, or oranges into a basket is one example of an activity to practice finger extension. The larger the object, the greater the extension required. Other extensor-type activities require the hand to be used flat, such as smoothing out a garment while ironing or a sheet while making the bed.