NEUROLOGIC PT 1 | NEU3102.

8 Brunnstrom’s Techniques: LE | Bobath

NAME| PLM BSPT 3 – 1 (3rd Year – 1st Semester)

BRUNNSTOM LE muscles causes drooping of the pelvis to the

I. Gait Analysis contralateral side while walking (“parang
II. Gait Training kumekembot habang naglalakad”).
III. Alternate Responses of Antagonistic DO NOT SHARE!
Muscles If right side is affected = left side of pelvis drops
IV. Standing + Walking (since it has crossing action)
V. Obstacle Clearance
VI. Stairs

BOBATH
I. Importance of Inhibition
II. Stages of Recovery
III. Associated Reactions
IV. Late Stages of Recovery
V. Stage of Relative Recovery
VI. Reflex Inhibiting Pattern
VII. Flaccid Stage
Date of Lecture: October 19, 2022
BRUNNSTROM LE
GAIT ANALYSIS
Demo: https://www.youtube.com/watch?
 Note taking v=Rz7V1i8kYGU&ab_channel=MedSchoolMadeE
 Check each component asy

What do you need to check when it comes to GAIT TRAINING

Brunnstrom’s treatment in the LE and gait /  What do you need to check?
posture?
 Tailored Treatment
 Position during Quiet Standing: What do we still need to take notes aside from
 Hips (ER), Knee (Extended), Ankle posture and gait?
(Dorsiflexed)
 Hips are in extension, but a bit  Active muscles during the gait
abducted or externally rotated. If  The study, however, confirmed a
we don’t have passive activation of number of common clinical
hip abductors, dropping of the observations: that the stance phase
pelvis or Trendelenburg sign might on the affected side of these
occur. patients is considerably shorter,
and the swing phase
A Trendelenburg gait is an abnormal gait resulting correspondingly longer, than on
from a defective hip abductor mechanism. The the normal side; that the
primary musculature involved is the gluteal quadriceps and the gastrocnemius
musculature, including the gluteus medius and and soleus muscles (antigravity
gluteus minimus muscles. The weakness of these muscles) on the paretic side are
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active throughout stance phase;  When you have stroke, both flexor and
and that all muscle groups on the extensor synergies might manifest at the
nonparetic side intensify their same time.
activity, compared to normal human  Upon activation, if it’s flexor
locomotion. synergy, all of the flexor muscles
 Triceps surae, although they are DO NOT SHARE! will be activated at the same time.
part of anti-gravity muscles, This also applies with extensor
gastrocnemius isn’t really part of synergy. Hence, you cannot really
that combination of muscles since move one component at a time,
it’s more powerful; hence, soleus is unless you are already in STAGE 6.
the one responsible for anti-  Stage 6: you can move one joint
gravity. individually voluntarily
Tip: Anti-gravity muscles are mostly the  When your patient is going to walk,
extensors; if it’s the flexors, you might have you want to introduce the
already been fallen (“tumiklop ka na”); thus, volitionary effort. If you may
posture must be assessed first. observe, the exercises indicated here
is for UE progression.
What are the possible complications during quiet  Brunnstrom: You want to release the
standing when you have stroke? reflexes, give reflexes a
background tension, give
 Patients with hemiplegic gait following
resistance, then active movement
stroke typically walk with a decreased
[whether UE – hand, neck, trunk – or
speed, decreased and asymmetrical step
LE à same principles]
length, decreased stance and single
support times on the affected side, Tailored Treatment
changes in joint kinematics, and overall
asymmetry in many of the measurable  Whatever the treatment is, it must be
metrics. tailored with the patient (“hindi de
 Activated synergy: Extensor synergy kahon”). Even the old books, they
recommend tailoring the treatment to each
 Hip: Extension, Adduction, Internal
individual patient.
Rotation
 Aside from hip-ankle-knee, what do we
 Knee: Extension
need upon standing control and gait?
 Ankle: Plantarflexion & Inversion
 TRUNK CONTROL AND
 Toes: Flexion
BALANCE: If trunk control (muscle
 Two things to look for (that might be
strength) is not good, listing or fall
spastic but should not be)
might occur. According to
 Hips must be abducted but d/t Brunnstrom, the patient’s fear of
extension synergy, it becomes falling is your biggest enemy.
adducted. Absence of abduction Instead of focusing on right muscles
results to hip drop. to be activated and right movements,
 Ankle must be dorsiflexed, but d/t he would be focusing more on his
extensor synergy, it becomes risk to fall or be out balance, hence
plantarflexed and inverted. mutual trust and confidence upon
 Here, we may opt to do breaking of doing the assessment is needed.
synergies by introducing the mixing
of synergies little-by-little.
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 Aside from motor control and motor Why do you have to activate your Hip flexor
balance, you may also need to check muscles?
on pt’s COGNITION.
 In order to prevent fall, the patient
 Aside from Cognition, you may also
should be taught how to balance their
need to check on pt’s
trunk, specifically in an anterior-
PERCEPTION. DO NOT SHARE!
posterior direction.
 It’s possible that the pt
 In gait cycle, alternating concentric
already has an odd vision.
muscle activation of the agonist and
 E.g., Vertical Alignment
antagonist muscle happens.
 Whenever you’re going to train the
 The patient is unable to
pt for Gait training, you must look at
immediately activate the
the MOTOR RESPONSE as well,
agonist and antagonist in
and how to modify it.
succession. Therefore, you
Modification of Motor Response should gradually exercise
each part separately.
 Synergy > Motor Activities  E.g., a taut band – when a muscle is
 Muscle synergy to facilitate or to already shortened, it will generate
control the motor activities. minimal force because it is already
 Muscle synergy must be corrected short, and you will shorten it more.
first because it dominates motor As opposed to a lengthened muscle,
activities when present. wherein a long muscle has more
 The modification will only be done room for shortening, generating a
when the motor activities are better force.
dominated.  Ask the patient to hold and
 Stage 3: don’t lean on the chair. Relax
 Because you can't control your the neck, don’t get the force
muscles due to the powerful muscle from the cervical area.
synergy, you must modify your Strengthen the core and relax.
response.  Iliopsoas – for hip flexion;
 There are ways to modify motor activities iliacus – originates from the
especially in quite standing iliac fossa; psoas major –
 Progression of walking originates from T12-L4 that
 Supine à side-lying à is why there is a trunk
slow/short sitting à movement. So, you want to
assisted/quiet standing à activate a muscle that is
weight shifting à combined with trunk and hip
perturbation à stepping à because most of the hip
stepping c obstacles flexors came from pelvis
àstepping c assist down to knee. Here, there is a
 Mobilityà Stabilityà Controlled trunk motion and hip motion.
Mobilityà Skills  Again, we can do leaning back
mobility, stability, isometrics (have
Methods
the patient hold the position), then
 Bilateral Contraction of Hip Flexor while leaning back we can
Muscles
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simultaneously flex the hip of the

patient.
 Bilateral hip flexion is easier for the
patient as it is just lean back and
forward only.
 Unilateral Hip Flexion DO NOT SHARE!

Figure 5-2: Unilateral hip flexor activation. A)

Support of hip in flexed position. B) Removal of
support with command "Hold your leg up, don't let Figure 5-2: Unilateral hip flexor activation.
it drop." C. Voluntary hip flexion superimposed.
C) Voluntary hip flexion superimposed.
 In unilateral hip flexion, you will lift
the leg one at a time while leaning  [BOOK] Because muscles can
back. produce more tension during
 This is difficult for the patient; isometric or lengthening contractions
hence, we cannot expect them to than during shortening contractions,
perform it easily or right away. the therapists assist in hip flexion
 [BOOK] Immediately following a just enough to lift the foot off the
backward trunk inclination or while ground, then gives the command
such inclination is still progress, the “Hold,” or “Don’t let your foot
patient makes an effort to flex the hip down on the floor”. During this
with respect to the trunk. attempt, the patient sits on the front
 The timing of this attempt is crucial, portion of the chair so that the trunk
for it must be made before the – thigh angle becomes obtuse. The
tension in the hip flexor muscles, patient then superimposes his
developed during trunk inclination is voluntary effort, taking advantage of
critical, for it must be made before the background tension previously
the tension in the hip flexor muscles, established.
developed during trunk inclination,  Activation of DF
has subsided.  Patient in supine position, knee
flexion, hold, then progress to
extension. Then, dorsiflex again until
it reaches the point where patient can
extend and dorsiflex again.
 Bechterev Reflex: Patient in sitting
position then the PT will apply a
quick, passive plantarflexion

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resistance, and the patient’s response Early stance phase is composed of heel strike,
will be in dorsiflexion and mass loading response, and midstance. Its components
flexion of LE (hip, knee, ankle). include hip flexion, knee extension, and ankle
 In Marie-Foix, you will put light dorsiflexion.
resistance on hip flexion to elicit
The spasticity is broken d/t knee extension while
dorsiflexion on the patient. This can
DO NOT SHARE!
flexion. So, the synergies are interchanging again.
be done in sitting and supine
position.  Reflex
 Related to the homolateral
limb synkinesis wherein if
you activate one part of the
synergist, the distal part will
also activate.
 Apply gentle or light
resistance only just enough to
activate the muscles; we do
not want to give too much
tension because it may not Figure 5-3: Bechterev’s/ Marie-Foix reflex. A.
activate the muscle or may Hand grip. B. Resulting flexor response.
cause over spastic activation
 In the early stance phase, if you are
and there will be no
going to stand and take a step, you
backroom tension.
want to activate tonic labyrinthine
[BOOK] The close association that exists between reflex.
the dorsiflexor muscles of the ankle and the hip  A well-known procedure for
flexor muscles in patients with hemiplegia was eliciting response in the dorsiflexor
pointed out by Marie and Foix (1916), who muscles of the ankle is to resist hip
classified the phenomenon as "coordination flexion when the latter motion is
synkinesis". under voluntary control.
 But when the patient has no
In more recent years, the linkage between these two
control of hip flexion, passive
groups of muscles has been referred to as
plantar flexion of the toes is
"confusion movement" (Phelps, 1938; Egel, 1948).
administered – This manipulation
The latter term appears rather unsuitable, since the
usually elicits a mass flexor
two movements are component parts of a well-
response, which includes a
organized pattern.
dorsiflexion of the ankle. The
By evoking the total flexor synergy of the lower response is known as Bechterev's
limb while resisting its hip flexion component, a reflex.
contraction of the dorsiflexor muscles of the ankle  Sometimes it is referred to as
can almost always be brought about in patients with the Marie-Foix reflex – The
hemiplegia. reflex is elicited with the
patient in the supine
Requirements For the Early Stance Phase
position, knee and hip
Since you have already perfected standing and its flexed slightly. The limb
component, you want to prepare for the early stance position and the physical
phase. therapist's grip around the
patient's toes, when
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voluntary effort is added,  When reflex contractions of the

are illustrated in Figure 5-3A dorsiflexor muscles of the ankle have
and B. been evoked a number of times, the
 Such as tonic labyrinthine reflex patient's voluntary effort is
because tone of LE depends on superimposed on the reflex
whether the pt is info forward flexion
DO NOT SHARE! contraction. The proper timing of
(“nakayuko”) or extended. the voluntary effort with the reflex
 Symmetric Tonic Neck Reflex contraction is of utmost
(fence position) may be employed to importance because the reflex
elicit good flx and ext tone then tension may fade out rather
apply resistance to facilitate rapidly.
background tension then perform  When a good reflex response is
volitionary activation. obtained – the physical therapist
 Neck ventro-flexion à UE resists the total flexor movement
flx & LE ext by pressing against the dorsum of
 Neck dorsiflx/ extension à the patient's foot, while
UE ext & LE flx simultaneously giving the
 DF activation + Hip Knee Ext emphatic command "Don't let me
 Coordination Synkinesis pull your foot down."
Phenomenon or Confusion  If the ankle response is poor –
Movement (usuitable term) – it is manual resistance may also be
the close association that exist given to hip flexion, but ankle
between the DF muscles of the ankle resistance alone is preferred
and the hip flexor muscles in because this is the movement to be
hemiplegic pts. emphasized.
 By evoking the total flexor synergy  Volitionary – synergies and reflex
of LE while resisting its hip flexion are repeatedly done à then
component – a contraction of the DF isometric contraction is applied.
mms of the ankle can almost always  Ideally, we want the pt to
be brought about in hemiplegic pts. always elicit a reflex. E.g., Pt
 Bechterev’s Reflex may be in full supine c Bechterev’s
employed reflex (PF the toes) then
 Passive PF of the toes is allows the pt to flex at hip
administered when the pt has joint and maintain that
no hip flexion control à to position (isomets). Then PT
elicit mass flexor response. will resist the hip flexion c
 Passive PF to elicit mass command “Hold the mvt,
flexion, particularly DF that don’t let me pull me down”
is very important in gait (if à resulting to a quick
absent/ impaired à foot elicitation of background
drop/ steppage/ dragging/ tension, hence the reflex is
foot slap gait). performed repeatedly. Allow
 Biglaang PF = feet will flex the the pt to relax then repeat
(bounce). the reflex then apply
 Introduce voluntary effort à resist reflex resistance throughout hip
flexion mvt (habang pataas)
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until the pt is able to perform the extended position is gradually

flexion c background tension. approached (Fig. 5- 4A, B, and C).
 Reinforce Voluntary Movement
 Resistance + Reflex
 The next step in training the
dorsiflexor muscles of the ankleDO is NOT SHARE!
to have the patient actively
attempt to initiate the movement
without the use of reflex elicitation.
 The supine position, incorporating
hip and knee flexion, or the sitting
position may now be utilized.
 The physical therapist places one
hand on the patient's thigh on the
involved side just above the knee,
pressing down slightly; should the
hip flexor muscles contract together
with the pretibial muscles, the
pressure is increased. Figure 5-4: Ankle DF in supine. A. Initiation in
 Local facilitatory measures, such as position of full hip and knee flexion. B. With
quick stretch, vigorous rubbing of gradual decrease in amount of hip and knee flexion.
the skin over the bellies of the C. Approaching full knee extension. Note that the
pretibial muscles, or percussion of activity will become more difficult as the patient
their tendons as they pass the ankle approaches full knee extension.
joint often prove effective.
 If the patient is sitting, ankle
 Even though the hip flexor
dorsiflexion is attempted with
muscles may become active,
increasing amounts of knee
movement at the hip joint
extension (Fig. 5-5A and B).
must not be permitted at this
 It may be necessary for the
time because the objective is
patient to move his buttocks
to obtain a more isolated
forward on the chair (i.e.,
response at the ankle.
"slouch") in order to decrease
 A lengthening or isometric
the amount of stretch on the
contraction is first required ("Don't
hamstring muscles.
let me pull your foot down"), then a
shortening con¬ traction ("Now pull
your foot up again").
 It must be kept in mind that these
procedures are directed toward
increasing the patient's ability to
activate and control ankle
dorsiflexion with knee and hip
extension. Thus, if the patient is
supine, the procedure is repeated in
positions incorporating less and less Figure 5-5: Ankle dorsiflexion in sitting position.
flexion of the hip and the knee, so A. With knee flexed. B. With knee extended.
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 When a patient can voluntarily hip and knee extension are

dorsiflex the ankle while sitting on introduced. When hip and
an ordinary chair, he changes to a knee extension can be
higher chair, sitting on its edge only; maintained actively while the
then he stands leaning his buttocks patient dorsiflexes the ankle,
against a table of proper height, then
DO NOT SHARE! synergy influence has
stands with his back to a wall, and diminished, and a nonsynergy
finally stands without support with pattern has been successfully
the affected foot forward in a introduced.
position of a short step (Fig. 5-6A  Then introduce volitionary effort:
and B). AAROM
 The amount of stabilization  Instruct and guide the pt how
and local facilitation offered to perform AAROM of knee
by the physical therapist is flexion and DF, either in
gradually diminished as supine or sitting position.
better voluntary control is  At any point, where the pt
gained. can perform even small
volitionary effort – effort will
be removed because we want
the pt to bbe independent ang
not dependent to PT.
 Move LE towards Extension
 If pt is supine à PT may perform
gradual LE flexion and DF – until
DF c knee extended.
 DF inv (vs) DF ev

Figure 5-6: Ankle dorsiflexion sitting on higher

surface. A. With hip extension increased. B.
Standing with full hip and knee extension.
 The stepwise sequence of gaining
control of ankle dorsiflexion
incorporates hip and knee
extension first passively and then
actively.
 That is, in the supine and
sitting positions the physical
therapist passively moves the
limb into increasing amounts
of extension.
 As the patient moves from
ordinary chair to higher chair Figure 5-7: Foot eversion with hand placement on
and then to standing, active lateral aspect of dorsum.
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 Importance in terms of activation of respect to dorsiflexion of the

movement (recall extensor synergies ankle.
(Inv foot) and ankle & foot actions  The above procedure follows the
such as trcieps surae for PF, tibialis general principles of (1) having the
anterior for Inv & DF). are, at least in part, under voluntary
 The point is, although we want our DO NOT SHARE! control, or that may be expected to
pt to have foot inverted while succeed in the near future; (2)
walking we still want them to have modifying the movements that
DF à because inv foot make them at have been obtained to include other
risk for fall, ankle sprain. Hence, we components; and (3) requiring
want inversion to assist DF, with this isometric or lengthening
we are not completely breaking the contractions before shortening
spasticity/ synergy. contractions.
 Once the pt mastered DF c inversion
To activate DF and hip-knee extension à
à we now evert the pt’s foot (it is
gradually extend the LE of pts, c supine as initial
easier to do DF when ankle is
position à side-lying à long sitting à short sitting
inverted).
(low chair) à sitting at the edge of high chair for
 Throughout the training of the support (leaning against the plinth) à standing.
pretibial muscles, attention is paid to
proper positioning of the ankle and
to the placement of the resisting hand
Brunnstrom also allows facilitation of mm
for the purpose of causing the long
activation such as through tapping, stroking, etc. on
toe extensor muscles and, eventually,
the tibialis or other certain muscles.
the peroneal muscles to participate.
 The physical therapist's resisting Another facilitation and inhibition technique is
hand gradually moves laterally Rood’s Technique: It may be used all throughout
across the dorsum of the foot (Figure the technique. It is commonly used in pediatric
5-7). The therapist may also apply a cases.
sudden inversion movement of the
Abduction
patient's foot to evoke a stretch reflex
in the peroneal muscles; if the  Trendelenburg limp is a very common
tension created is enhanced by feature of hemiplegic gait, observable during
resistance, the duration of the muscle the early stance and midstance phases when
tension may be prolonged. weight is borne through the involved lower
 Percussion or stroking over the extremity. In normal gait, the hip abductors
evertor muscles, and sometimes a are active during these phases and serve to
vigorous rubbing on the lateral stabilize the pelvis laterally.
aspect of the foot, may also be  In hemiplegic gait, however, the hip
effective. abductors fail to respond effectively, and
 Commands may be used such as lateral instability of the pelvis results. This
"Hold your foot steady; don't let me failure is attributable particularly to the
turn your foot in," and later, "Now influence of synergy. Early stance requires
turn your foot out again." simultaneous activation of the hip and knee
 These techniques may be extensor muscles, components of the
applied in all the positions extensor synergy, and the hip abductors,
described previously with components of the flexor synergy.
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 As long as synergy influence pre¬ àStanding weight shifting à

dominates, the desired activation of the hip Standing full hip abduction
and knee extensors will also produce an  *Unilateral Hip Abduction (Hip-Hiking)
undesired activation of the hip adductors.  Accessory Movements
 Aside from hip flexion & dorsiflexion,  Trunk-Shoulder rotation
check the ABDUCTION (Trendelenburg DO NOT SHARE!  Trunk lateral flexion
Sign)  Stabilize the trunk
 Raimiste's Phenomenon: resisted  Don’t let the affected hip drop. (B)
abduction or adduction of the sound hips should be aligned. PT must
limb evokes a similar reaction in the support the px waist.
affected limb.  *Cane
 Associated reactions are also evoked  Based on Brunnstrom, you don’t
by Yawning, Sneezing and need Unilateral activation that
Coughing. much because the patient uses
 Reflex cane, thus there’s already a much-
 Voluntary Effort imposed on voluntary needed support for activation.
movt  Unilateral activation is
 Facilitation mostly done to orthopedic px.
 Voluntary activation  Mass activation is
 REFLEX à RESIST (Voluntary recommended to stroke px.
effort) ALTERNATE RESPONSES OF
 3-5 seconds until effort ANTAGONISTIC MUSCLES
disappears; until the px
responds favorably. Knee Flexors + Extensors
 With greater hip ABD à
 Teach the patient the how to alternately
AAROM à AROM
activate the knee flexors and extensors. Px
 Supine à side-lying à
with synergy has a hard time executing
standing with hands behind
alternating actions
the back holding on a surface.
 Supine
 Standing (weight shifting) c
 Knee no longer “locked” in
equal time on B extremities
extension but held in slight
à AROM full abduction of
flexion.
either extremity in single leg
 Limit hip flexion and
stance then measure the time
increase knee ROM
it takes for them to hold in an
 Px pulls knee towards chest,
abducted position.
PT holds the foot down 
─ BEGIN IN THE
Heel slides
UNAFFECTED
 Heels slides requires partial
SIDE.
inhibition of hip flexors and
 Progression of Hip Abduction
active contraction of knee
 REFLEX à Resistance à AAROM flexors
à AROM  Patient has VOLITIONARY
 Supine à Side-lying à Standing effort
with both hands on the back

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 PT must assist the backward

sliding or aid by lifting the
lower portion of px thigh just
enough t to reduce friction 
PT grip above the knee to
DO NOT SHARE! manipulate and palpate
 Px’s back must always be
resting on the chair’s back
rest.
 Assuming that the px has
learned to incline the trunk
forward while supporting the
elbow on the affected side wit
 Sidelying the normal hand, PT must
 Px in sidelying position. palpate knee flexors to know
Knee PROM is done by that it has been activated
moving the leg into flexion- during the activation. (1)
extension, supporting on the trunk forward bending in
ankle sitting elongates the two joint
 Advantageous: (1) muscles this facilitating its
gravitational influence on the contraction.
LE had been reduced creating  Forward inclination of the
a lighter “load” for the px to trunk may increase the px
lift (2) knee flexion may be ability to flex knee
facilitated by the influence of  When knee cannot be flex
the asymmetrical tonic beyond 90 degrees, the px
labyrinthine reflex  learns to synchronize forward
favoring the upper most inclination of the trunk with
limbs in this position an effort to slide the foot
 Assist px on the ankle so that backwats
during flexion of knee: foot  ADVANTAGES: activation
dorsiflex; knee extension: of the following mm: biceps
foot plantar flex femoris. Semitendinosus,
 Sitting semimembranosus
 Px sits in a firm chair and
places his foot forward on the
floor, heel touching and the
knee short of full extension.
Px slides the foot backward,
touching the floor with the
heel and then with the ball of
the foot, as the foot slides
underneath the chair and the
knee flexes to an acute angle
 Must be first performed to the
NORMAL SIDE
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 Px leans on the table so that

the trunk is supported
partially, hips flexed, &
forearms resting on the tables
 Knee flexion is isolated 
DO NOT SHARE! can be resisted but shouldn’t
cause hip adduction
 Stroking of posterior thigh
muscles may also be required
to initiate movements
 Alteration of the position is
done when the px is able to
use the hands instead of the
forearm to increase the
amount of hip extension,
promote stability of SH jt
complex via WB through UE
 HEEL SLIDES IN SEMI
STANDING
 Developing weight bearing
 Semi standing
but not giving 100% weight
 Sitting on surfaces with
in the foot.
graduated heights effectively
increases the amount of hip
extension and enables the
development of reciprocal
knee flexion and extension
independent of synergy
influence at the knee

 Pawing
 Half prone position can be
used very effectively.
 “Pawing” has been coined
for this exercise because it
 Half prone resembles the movements of
 Fear of falling is diminished a horse’s pawing as the
in this position. Px is able to animal scapes the ground
put weight on his UE with his forefoot.

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 As the patient flexes the  Flexion of the affected knee

knee, he is instructed to can be performed while hip
plantar flex the ankle so on the affected side is kept
that the toes scrape the floor. extended, it is a sign that the
 As knee flexion continues hemiplegic lim synergies no
and the foot is lifted entirely
DO NOT SHARE! longer influence the pt’s
off the floor, pt is instructed movement.
to dorsiflex the foot as he  Brunnstrom doesn’t like
initiates knee extension and using parallel bars, he want
to maintain that the pt to do it by themselves
dorsiflexion as the knee  Skater’s waltz hold
comes into full extension so  For good/ improve knee
that the heel of the foot stability: may give mini
strikes that floor first, squats to pt. So the knee
followed by the entire sole. wouldn’t buckle when
 The muscular associations standing
required for various phases
of gait materialize in a
satisfactory manner and the
pt’s confidence in his abilities
increases.
 Lack of confidence = pt rely
too heavily on knee
extension; may cause hip
adduction and ankle plantar
flexion.

STANDING + WALKING
 Knee stability in standing
 WB on affected limb is likely to
evoke a response of the quadriceps
muscles, but satisfactory knee
 Standing stability does not always materialize.
 Half prone position is  The pt must learn to support weight
gradually modified to a momentarily on a slightly flexed
standing position w the pt knee.
facing and leaning against
higher object.  Standing knee bends
 The pt stands fully erect,  PT stands behind pt,
using hand support only. supporting trunk on both
sides of the chest.
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
Pt is guided in shifting flexion to allow the affected limb to swing
weight toward the affected through freely in walking.
side w both knee slightly  It has some resemblance to a bicycling
flexed. movement, as it goes around and around.
 A satisfactory response of the  The pt uses hand support to minimize
knee extensor muscles will DO NOT SHARE! balancing difficulties and perform w the
probably be evoked on the normal and then with the affected limb.
affected side.  At first. PT may have to assist in keeping the
 Lat wt shifting ball of the foot in contact with the ground on
 Used to prepare the pt for affected side during the backward scarping
unilateral weight bearing. movement.
 Using the skater’s waltz  Affected limb performs four to six times
position, the pt is instructed before a change is made to other side.
to slowly and rhythmically  Requires simultaneous use of knee flexor
shift all his weight first to and hip extensor muscles and is therefore
the unaffected side and then difficult as long as the basic limb synergies
to the affected foot. are influential.
 *marking the time  The pt may first practice a slow movement
 Requires momentary full of hip-knee flexion with emphasis on knee
weight bearing on the flexion in the following manner.
affected limb while the other  The contact of the foot with the ground is
limb is raised off the ground. maintained during the backward movement,
 Antigravity muscles usually and when the foot is taken off the ground,
respond under circumstances the foot is made to follow the inner side of
of forced WB. the normal leg, sliding up toward the knee.
 Pt is instructed to flex both  This requires a considerable amount of
knees slightly, shift all weight activity of the knee flexor muscles and a
to the uninvolved side and reciprocal decrease in tension.
shift the involved foot off the
ground momentarily. Trunk Rotation with Arm Swing
 When foot is returned to the
ground, weight is shifted This exercise is designed to mobilize the trunk to
entirely to involved side and permit participation by the trunk and free
the uninvolved foot is lifted swinging of the arms, first in standing, then in
off the ground. walking. As the trunk rotates, the body weight is
 Establishing proper rhythm in shifted from one side to the other; the arms tend to
pregait activities helps instill participate automatically, probably influenced by
an even cadence during afferent impulses originating in the lumbar region.
actual ambulation.
It is well known that patients. with hemiplegia tend
Preparation for “Swing-Through” in Walking to walk without adequate trunk rotation and, if
spasticity is present in the upper limb, with the
elbow flexed and the shoulder immobilized.
 Purpose: obtain a rapid release of tension Although full return to normal arm swinging cannot
in quadriceps muscles and sufficient knee be expected as long as spasticity persists, the benefit
that may be derived from training is not to be
ignored.
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In normal individuals, as the trunk rotates fully

and freely to the left, the left arm swings behind
the body until the dorsum of the hand reaches
the gluteal region; simultaneously, the right arm
swings in front of the body, the palm of the hand
approaching the left side of the body in the DO NOT SHARE!
region of the greater trochanter. For the patient
with hemiplegia a less perfect movement is to be
expected. The arms should be "wrapped" around the
body as a result of the trunk movement, not by
forceful effort by the patient. The therapist may
stand behind the patient, aiding the movements of
the arms without forcing them, also being ready to
support the patient should he lose his balance (Fig.
5-16A and B).

The next step is slow walking with exaggerated

trunk rotation. The arm movements are somewhat
modified - the entire "wraparound" is not
attempted. It is understood that when the left foot
steps forward the trunk rotates toward the left and
the right arm swings forward and across the body;
but to avoid confusion, no mention is made to the
patient of right and left. He is simply told to start  Important: balance and coordination
walking. As he does so, he is assisted to get the  Without arm swing, you cannot really swing
arms moving in the right directions. The rhythm or move your trunk forward.
must not be sacrificed, even though trunk and arm  Guide the patient, PT will control where
movements may not be perfect. Manual movement the weight will shift and the rotation of
corrections are avoided because these may increase the trunk of the patient.
spasticity and frighten the patient, and may even  Place hands on the pelvis of the patient
throw him off balance  Put weight on the RIGHT and the trunk
will rotate on the LEFT
 Put weight on the LEFT and the trunk
will rotate on the RIGHT
 Patient and PT should rotate together
 Better to use a guard belt
 Next progression is walking (skater’s waltz)
 You will now do walking with trunk
rotation
Obstacle Clearance
 For patients who tend to drag the foot on
the affected side during swing phase, low
and narrow obstacles are placed across
the walking path at regular intervals

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corresponding to the patient’s comfortable patient to perfect the alternating movements

stride. during walking (at hindi lang paisa-isa).
 Clearing such obstacles is not excessively
Music to Promote Rhythm
difficult for patients with hemiplegia
because the total flexor synergy may be  A suitable melody played or hummed at
utilized. DO NOT SHARE! the proper speed often aids the patient with
 But good judgment with respect to hemiplegia to gain rhythm in walking.
placement of the affected foot before  It is particularly enjoyed by patients in
lifting it over the obstacle is advanced recovery stages.
necessary, or the obstacle will be  Music may also prove useful for more
knocked down fancy footwork, such as stepping forward,
 A slow walking rhythm is maintained as backwards, and sideward, as in the
the right and the left foot step over practice of certain fundamental dance steps,
obstacles of equal height. all for the purpose of gaining better control
 For reasons of safely and to remove the of the affected limb.
patient’s fear of falling, the physical  But a fast rhythm may cause interference
therapist walks next to the patient, by spasticity and must be avoided.
supporting him as described.  The response to music differs considerably
 The walking rhythm is maintained at the end among patients; hence its use should be
of the obstacle course as both PT and patient selected accordingly.
continue to step over imaginary obstacles  Use music that is slow and with a steady
that are described as becoming lower and phase.
lower until they are less than an inch high
 Clearing obstacles in walking is also Note: If volitionary effort – PROMes, AAROMes,
recommended for patients with other gait AROMes, resistance. If there aren’t any (flaccid?),
deviations, and all patients should be given elicit reflexes first then resist them (background
the opportunity to walk on and off carpets. tension). This serves as your PROMes, AAROMes.

Stairs
BOBATH
 The extent to which patients with
hemiplegia may learn to manage stairs BOBATH TREATMENT
depends on the severity of the
involvement and on the availability of Why is Inhibition important in Bobath Treatment?
handrails on one or both sides.  Inhibition is a very important factor in
 It is well to remember that when stair the control of posture and movement.
walking is first attempted, the patient’s  Both phylogenetically and
UNAFFECTED FOOT LEADS IN ontogenetically it is responsible for
ASCENDING, the AFFECTED FOOT IN the modifications of the total patterns
DESCENDING; and that, if a handrail is of movement into the selective
available only on the unaffected side when movements of higher integration.
the patient ascends, he may have to  Inhibiting a movement = Bobath
descend backward.  Direct to the volitional effort
 MRP – always the affected leg; Brunnstrom  Facilitating a movement = Brunnstrom
– affected or unaffected, it doesn’t matter as
 Over layering excess with the
long as you break the synergy. You want the
volitional effort
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 Goals of Bobath treatment: more specific. Don't put in Bobath as his treatment
 For pt to be INDEPENDENT and to is quite broad.
get the pt out of the bed
Associated Reactions
 Bobath treatment sets their goals,
usually, short-term goals  Bobath states that even if you induced the
 According to Bobath, every
DO NOT SHARE! movement, if the movement is spastic, it is
component must be perfect first still wrong since it’s just an associated
before going to the next reaction.
 “Kung hindi mo pa kayang  All reflexes are inhibited immediately.
umupo, bakit kita  Associated reactions, reflexes and
papatayuin?” everything else must only be used in LMNL.
 For the pt to be prepared for  LMNL:
AMBULATION  Scoliosis
 Important in ambulation:  Polio
─ Motor Control =  Bell’s Palsy
Balance and  Though clinically speaking, there is
Coordination nothing wrong with using it unless
 For the pt to have a good motor the clinic you’re working at is a
response and motor control specialty clinic.
 Correct or inhibit the abnormal
RIP technically is not an opposite of the synergy.
tones
It mixes up the synergy.
 At any stage, the main
problem of Bobath is =  For Bobath, when trying to break the
SPASTICITY or the spasticity, do it one by one or break one
abnormal tone and part only.
coordination  Start simple then go to the complex
 Bobath treatment is commonly used in Pedia side. Hence, it would be difficult for
rather than Brunnstrom. the pt.
Stages of Recovery (Bobath) Strongest Component of the synergy of UE:
ELBOW FLEXION. (Regardless with hand or
 Initial Flaccid Stage
shoulder, start with the weaker component ->
 Stage 1 (Brunnstrom) strongest component)
 Stage of Spasticity
 Stage 2-5 Do repeated movt, until spasticity is gone, then
 Stage of Relative Recovery do extension and then flexion.
 Stage 6-7 If the patient has good prognosis, then exhibit the
In Bobath's treatment, he kind of lumped everything movement simultaneously. However, it is still
in. According to him "don't pay attention to dependent on the grade of spasticity.
spascticity, don't pay attention to reflexes matic, Most of the time, for severe cases, we did it one
inhibit everything". Wherein with Brunnstrom, he's segment at a time
taking it one by one. The stages are direct 1 to 3 for
Bobath, but 1 to 7 for Brunnstrom.  Bobath also says that you have to dissociate
spastic pattern.
However, when you write in IE, for the assessment  We break the spasticity that is called
part, you always put in Brunnstrom because he is “shunting”
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 The abnormal pattern is override. his own and unassisted movement. The
 We do not want the abn patient has to learn to control actively the
pattern to take over the widespread total patterns of spasticity.
normal patterns.
 After shunting, you overlay it with active  Bobath reiterated that your isolated
movement. DO NOT SHARE! movement can only take place when there is
 For patient to have functional carry no spasticity.
over  Independent movement can trigger
 You don’t want the reflexes to your spasticity -> altered normal
override the normal pattern. pattern as you have your synergy.
 You want to move the pt as soon as  Q: Can synergy happen at once? Or
you can one at a time?
 Always try the patient to move  It is mixed. It is rarely seen
independently. one by one.
 At the same time, pt.’s  In Bobath, you want to reinforce again the
spasticity may return. proximal areas rather than distal area.
 You should always take into account  Neurology based: You want to
the stage of pt.’s spasticity, grading reinforce the proximal first before
or severity and what could be the the distal so that when you move
specific triggers. your distal part, there will be no
 Trigger of spasticity may instability of the body.
include:  If the patient stands, all starts with
─ Yawning trunk. If the trunk stability is not
─ Sneezing good, the patient will not be able to
─ Coughing stand and walk properly.
─ It may also include  Baby controls first their trunk and
movt of neck, flexion neck then learn to reaching
or extension (milestones)
─ Trunk movement  Orthopedic based: more concern of
when standing etc. pain experienced by the patient.
 Spasticity does not come only More of addressing the pain.
on volitional movements, but Late Stages of Recovery: Use of Advanced
also in involuntary Movements.
movements as well as fear.
─ Stiffness when afraid.  Further break down the patterns
 Book: As mentioned before, spasticity is not  Increase inhibitory control (e.g., Tapping,
confined to anyone muscle or muscle group squeezing, slow stroke, stretches,
but is coordinated in definite synergic movement)
patterns. Their inhibition reduces spasticity, Stage of Relative Recovery
and this can be done by the therapist
changing and dissociating the spastic  Book: Patients who reach the third stage of
patterns, i.e., by 'shunting' (see p. 18). relative recovery will be those who were not
However, without the patient being active severely affected at the beginning and who
while the therapist changes a position, there have made a good spontaneous recovery, or
is rio carry-over of this inhibitory action into who have done well in treatment.
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 Spasticity is slight at this stage and does  The main reflex inhibiting pattern which
not, therefore, prevent movement. counteracts both extensor and flexor
 Transient increase of spasticity, however, spasticity of the leg is abduction with
still occurs when the patient uses effort, external rotation and extension of hip and
walks fast, or gets excited; coordination then knee
deteriorates DO NOT SHARE!  Another important reflex inhibiting pattern
 Dynamic Actions is rotation of the shoulder girdle against
 You want patients to become more active the pelvis and, more importantly, of the
and independent pelvis against the shoulder girdle.
 Rood’s approach  One component at a time
 Important in proximal: trunk, head  Want proximal more than the distal
shoulders and pelvic girdle  Facilitate normal movement even not
 Pelvic rotation helps decrease or break the independent.
spasticity.
 Hands placed on hips, alternating facing at Upper Extremity
right and left, trunk twisting  Head and neck extended → shoulder
 Importance: it can move everything externally rotated → elbow extended →
including the distal joints from the shoulder forearm supinated → wrist and hand
to elbow as well as legs moves IR and ER to extended.
move pelvis.
 Distal structures are still important because Lower Extremity
it influences the proximal structures  Abducted and externally rotated (ABER),
especially on weight bearing. extension of hip and knee
Reflex inhibiting pattern (RIP)  Why do we want ABER?
 We want good hip ABER due
 Book: when the tx has become more active to the possibility of
and dynamic, reflex inhibiting movement Trendelenburg sign on the
patterns are used instead of static postures. patient if the corresponding
 It is used not only to inhibit abnormal muscles are weak.
postural reactions, but at the same time  Gluteal muscles
facilitate active automatic and voluntary  If the patient has poor
movements. abduction movement, it may
 Inhibition facilitates and facilitation manifest on the patient as hip
inhibits. drop
 The dissociation of the total patterns of  If there is an active spasticity,
spasticity serves not only to obtain voluntary it may manifest as hip hike
and selective movements, but also gives the  Breaking of synergy, we want
patient control over whole sequences of both to have volitional movement
voluntary and automatic movements. of the muscles.
 We want ABER movement
 The main reflex inhibiting patterns
during quite standing
counteracting flexor spasticity in the trunk
and arm is extension of neck and spine and  The type of gait may manifest depending on
external rotation' of the arm and shoulder the case of the patient
with extended elbow Pelvis and Scapular movement

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 Scapular mobility unaffected LE of the pt

 Move the shoulder against the him/herself.
opposite pelvic girdle  When he is lying on the sound side, the
 “Parang sa brunnstrom yung shoulder of the affected side should be
magkabilaang rotation, contralateral brought well forward, the arm supported
rotation para may arm swing” DO NOT SHARE! on a pillow and extended at the elbow.
When lying on the affected side, his
In bobath method we want to fix the alternating involved shoulder should be brought well
activation of agonist and antagonist muscles forward - the arm is then in external
What we want is to break spasticity and Inhibit- rotation and extended at the elbow
facilitate the good muscles or the muscles that we
want to move
FLACCID STAGE
 During this stage, the only thing that a PT
can do are PROMs
 Bobath recommends some treatment during
this stage but it is not set in stone
Bed Mobility
 Difference to brunnstrom is that the pt Fig 6.2a With hands clasped, turning towards sound
would clasp their hand instead of their wrist. side.
 PT should always be on the affected side Note: Movement started with shoulder forward;
 Turning to the side procedure: knee kept in slight flexion with small pillow
 Turning should commence with the
upper part of the body and, in order
to do this, the patient must first learn
to lift the affected arm with the good
arm, and to clasp his hands.
 He should then lift his clasped hands,
with elbows extended, to the
horizontal and, if possible, above his
head. From there, he should move
his arms first to one side and then to
the other Fig 6.2b Pelvis moved forward
 “bwelo”
 Turning over to the sound side
should also be started with his arms
and trunk, his hands clasped. He will
then need only minimal help, if any,
to turn his pelvis and move the
affected leg to the sound side
 The PT can also place the
affected LE over to the

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Fig 6.2c Turning towards affected side, shoulder it towards his sound side and up,
well forward while he supports himself on the
affected forearm.
 Turning to the sound side to sit up
 The PT will help him to move the
procedure:
affected leg over the edge of the bed
 Patient starts with clasped hands and
DO NOT SHARE!  While the patient moves his sound
supports himself on the sound
leg over the edge of the bed, the PT
forearm while he brings the sound
pushes his head further up from the
leg over the edge of the bed into a
affected side to the sound side and so
half-sitting position
to sitting up
 The PT may help him to sit up by
 If the patient's arm is not too. spastic
moving his head towards the affected
in flexion, she should place and hold
side. At the same time, she moves
the affected hand extended on the
the affected leg over the edge of the
bed, so that the patient extends his
bed with her other hand
elbow. During this phase, the sound
 Some patients may not need
arm is free to help the upward
the help of the PT to lower
movement of the trunk
the affected leg over the edge
of the bed
 The patient would also help
by pushing using the
unaffected arm
 With hands clasped, they start to turn
the trunk and then the pelvis. The
feet are on the bed and both knees
are kept together when turning over
Acc to ma’am: The PT should support the LE of the
patient as the patient performs the activity. Fig 6.4d (Left) Sitting up over the affected side
Fig 6.4e (Right) Therapist or nurse moves patient’s
head towards sound side

Fig 6.4a Sitting up over the sound side

Note: Keep affected shoulder and arm well forward
Fig 6.4f Therapist moves shoulder and extend arm
 Turning to the affected side to sit up
forward. Patient uses sound arm for support
procedure:
 The PT supports the pt’s head on the  Lying down from sitting
affected side and helps him to move
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 The PT holds the affected hand of

the patient, his arm externally rotated
and extended diagonally forward at
shoulder height.
 The patient slowly lies down, using
his unaffected arm for support DO NOT SHARE!
 The PT will prevent retraction of the
shoulder and flexion of the affected
arm
 The patient the lifts the unaffected
leg on to the bed. If possible, he
should then bend the affected leg at
the knee and move it onto the beo.
Fig 6.5a: Patient sitting. Before standing up,
Sitting and Standing up patient’s affected arm is held round the PT’s waist.
 The PT should never be on the patient’s  The PT will fix the patient’s arm against her
unaffected side when he sits, stands or body with her forearm, so that both the PT’s
walks, since he can use his unaffected side hands will be free to help the patient to stand
and does not need her there. up.
 If the PT takes weight on his affected side,  Before the patient’s to stands up, the PT will
the patient will gradually overcome his fear help the patient to move forward from the
of falling. hips, since the patient tends to retract the
Sitting up to Stand affected shoulder and leas his trunk
backwards, especially on the affected side.
 With the patient sitting on the bed, the PT
will stand in front of him and let him place
his unaffected arm around her waist to hold
on to her.
 The PT will then take the affected arm and,
with one hand under the patient’s armpit, lift
the patient’s shoulder, rotate the arm
outwards and extend the elbow.
 The PT will bring the arm forward and
against her waist just like the unaffected
arm.

Fig 6.5b: Patient stand up, moving trunk forward at

hips.
 The PT will stand in front of the px, both the
px hands forward.

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 The knees of the pc should be together in

mid-line and the feet parallel at right angel
to the knees
 The affected foot should not be in front of
the unaffected one because he will not take
weight on it. DO NOT SHARE!
 The PT should give some pressure on the
knee of the affected leg to give him the
sensation of weightbearing before the px
stands up
 The px should look at the PT. The PT will
then press her knees against the patient’s
knees and help the px to rise in the same
way as the PT helped him to rise from the Fig 6.6c: Patient practicing bilateral arm movements
bed. with clasped hands

Exercise for dressing and bed pan (Inidoro)

 Using the bedpan
 Pelvic / Gluteal Bridging
 The PT is at the unaffected
side to assist the patient
because patient has no
strength.
 Parameters
 3 sh then progress until
patient can do 10 sh or more
Fig 6.5c: Patient standing up from, or sitting down  Patient should be able to do
into, wheelchair longer sh for function
 During flaccid stage exercise are
Exercise for the patient when in the wheelchair dedicated for bed mobility, bridging,
 The PT will teach the patient an AAROM strengthening of unaffected side,
AAROMEs
exercises and will do for 10 reps, 1-3 sets
 The patient will perform a bilateral arm
exercise, a position which brings his Book: The nurse will help him if necessary to bend
shoulder will forward and extends the the affected leg and place his foot flat on the bed.
elbow. This allows the patient to have both The patient will 'then bend the sound leg and place
arms forward, and he can see his affected that foot parallel with and close to the affected foot.
arm and hand as weel. The nurse will fix both feet with one hand and ask
 As he gets used to this position in the the patient to lift his pelvis. She will then place the
wheelchair, he will be prepared to do the bedpan under the pelvis. The patient should keep his
same when sitting at a table. legs bent. If the affected foot does not remain in the
initial position and slips away, the patient can fix it
with the sound foot

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DO NOT SHARE!

Fig.6.3b Fixing patient's foot with pressure down on

flexed knee of hemiplegic leg, followed by-

Fig. 63a Patient lifts pelvis with feet fixed by therapist .

Book: The patient pushes himself up in bed if he has

slipped down With help from the nurse, the patient
follows through 'the first part of the movement described
above when using the bedpan. His feet, which have been
drawn up close to his pelvis, are held by the nurse who
tells him to push himself upwards towards the head of Fig. 63c Lifting pelvis to move patient upwards in bed.
the bed. The patient may find this difficult. The nurse
should then fix his affected foot with one hand and help
him up from the shoulder with her other hand. This is
best done by placing her hand under his arm-pit, at the
same time lifting the shoulder upwards and forwards, or
she may lift his pelvis and help him in this way to push
himself forwards (Figs. 6.3b, c).

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