Neurotherapy – treatment for stroke patients F Add to Radial Ext Abd to Ulnar E Abd to Radial F Add to

1. Conventional Therapy – old classification F

2. Motor Learning Side Side Side Ulnar Side
a. More modern approaches T F Add E Abd Ext Add F Abd
b. Uses the brain to train the body 


PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION

- A system of promoting the response of neuromuscular mechanism by
stimulating the proprioceptors (found in intrafusal fibers)
- Stimulation of proprioceptors will contract muscle
- Stretch - stimulate muscle spindle
- Use of spiral and diagonal movement patterns
- technique is the interaction of three broad concepts (proprioception,
neuromuscular and facilitation)
- the facilitation of proprioception will promote motor learning in
synergistic muscle groups
- normal movements are spiral and diagonal in character

HISTORICAL PERSPECTIVE
• Dr. Herman Kabat (1940s) introduced PNF at Kabat-Keiser Institute
• Margaret Knott, PT & Dorothy Voss, PT under Dr. Kabat, developed PNF
book LOWER EXTREMITY UNILATERAL PATTERNS
D1 Flex D1 E D2 Flex D2 Ext
PRINCIPLES H FADER EXABIR FABIR EADER
• Potentials that have not been fully developed K
• Rhythmic and reversing in character of movement
A DF PF DF PF
• Orderly sequence of total patterns of movement and posture (D1 & D2)
• Repetition for retention of motor learning Subtalar Inv Ev Ev Inv
• Goal-directed activities Ext, Abd to Tibial F Add to E Abd to F Add to Tibial
Toes
• Selection of appropriate sensory cues Side Fibular Side Fibular Side Side

BASIC NEUROPHYSIOLOGICAL PRINCIPLES HEAD, NECK AND TRUNK

by Sir Charles Snerrington Trunk UE LE
1. Reciprocal Inhibition D Flex L Flex + Rotation to L D1 Ext L; D2 Ext R D2 Flex L; D1 Flex R
- contraction of muscles is accompanied by simultaneous DFlexR Flex + Rotation to R D1 Ext R; D2 Ext L D2 Flex R; D1 Flex L
inhibition of their antagonist D Ext L Extend + Rotate to L D2 Flex L; D1 Flex R D1 Ext L; D2 Ext R
2. Successive Induction D Ext R Extend + Rotate to R D2 Flex R; D1 Flex L D1 Ext R; D2 Ext L
- an increased excitation of the agonist muscle follow stimulation
Ro L Rotation to L D1 Ext L; D1 Flex R D1 Ext L; D1 Flex R
and contraction of their antagonist (stimulating quads=stimulating
hams) Ro R Rotation to R D1 Ext R; D1 Flex L D1 Ext R; D1 Flex L
3. Irradiation
- spreading and increased strength of a response ➡Unilateral Diagonal Patterns
** After discharge - effect of a stimulus continues after stimulus stops ‣ UE
** Reciprocal Summation - succession of weak stimuli occurring within a ‣ LE
certain period of time to cause exertion ‣ Head, neck and trunk
** Spatial Summation - weak stimuli simultaneously in different areas = ➡ Bilateral Patterns
excitation ‣ Symmetric patterns
- paired extremities move at same time
‣ Asymmetric patterns
- paired extremities move to same side
- facilitate trunk rotation
‣ Reciprocal patterns
‣ paired extremities move at opposite direction
➡ Upper & Lower Extremities Combined Movements
- Ipsilateral patterns
- Contralateral patterns
- Diagonal reciprocal patterns
eg.swimming
UPPER EXTREMITY UNILATERAL PATTERNS *In documentation, movement kung saan papunta yung force (final position)
D1 Flex D1 Ext D2 Flex D2 Ext
PNF PROGRESSIONS
Rotation,
Rotation, Abd, Rotation, Add, Rotation, Add, ✓ Total to individuated
Abd, ✓ Proximal to distal, distal to proximal
ST Anterior Posterior Posterior
Anterior ✓ Mobile to stable
Elevation Depression Elevation - Stability = add posture
Depression
✓ Gross to selective
GH FADER EABIR FABER EXADIR ✓ Reflexive to deliberate
Elbow can be flexed or extended - Quick stretch —> voluntary movement
RU Supination Pronation Supination Pronation ✓ Overlapping to integrative
W Flex RD E UD E RD F UD ✓ Incoordinate to coordinate

reinanakamurz NEUROTHERAPIES 1 of 4
 -Isometric holding is facilitated first on one side of the joint,
BASIC PNF PROCEDURES
followed by alternate holding of the antagonist muscle groups
➡ Manual Contact (MC) - Indications: instability in weight bearing and holding poor
- refers to how and where the therapist places her hand on the antigravity control, weakness, ataxia
patient ❖ Reversal of Antagonists
- pressure as a facilitatory mechanism a. Slow Reversal
- placed on the skin overlying the target muscle groups and in the - SR involves an isotonic contraction of the antagonist, followed by
direction of the movement an isotonic contraction of the agonist
- pressure or scratching of skin overlying the antagonist inhibits the b. Slow Reversal Hold
agonist; the antagonist is facilitated - SRH involves an isotonic contraction, followed by isometric
- May be used to give patient security in the presence of pain contraction of the antagonist, followed by an isotonic contraction
- May be used as a sensory cue to help the patient understand the of the agonist
direction of the anticipated movement - Indication: inability to reverse directions, muscle imbalances,
➡ Command and Communication weakness, incoordination, lack of endurance
- Guide the start of the movement c. Rhythmic Stabilization
➡ Stretch (STR) - Simultaneous isometric contractions of both agonist and antagonist
- the stretch stimulus is the placing of body segments in positions that patterns and results in co-contraction of opposing muscle groups
lengthen the muscles - Indications: instability in weight-bearing and holding, poor
- *Stretch Reflex - can be elicited manually by quickly taking the part antigravity control, weakness, ataxia, LOM due to muscle tightness,
past the point of tension painful muscle splinting
➡ Traction (TR) d. Quick Reversal
- separating the joint surfaces to promote movement and inhibit pain - Requires rapidly alternating isotonic contractions of antagonists
- pulling action
- indications:stimulate afferent nerve endings and facilitate flexor RELAXATION
muscles, mobilising patterns ➡ Contract Relax (CR)
➡ Approximation (AP) - Indications: LOM caused by tightness, spasticity
- Compressing the joint surfaces promotes stability, weight bearing or
➡ Hold Relax (HR)
maintenance of posture - Indications: LOM caused by muscle tightness, muscle spasm and
- pushing action
pain
- Indication:
➡ Slow Reversal – Hold – Relax (SRHR)
➡ Maximal Resistance (MR)
- Isotonic contraction followed by an isometric contraction of the
-
antagonistic pattern, then a brief period of voluntary relaxation,
➡ Timing; Timing for emphasis (TE) followed by an isotonic contraction of the agonist pattern.
➡ Rhythmic Rotation (RRo)
SPECIFIC TECHNIQUES - Slow, passive, rhythmic, rotation of the body or body part around a
longitudinal axis followed by passive movement into newly gained
range
- Indication: hypertonia with limitations in function or ROM

BOBATH APPROACH
aka Neurodevelopment Technique (NDTs)
Essential Problems Of Patients With Neurological Dysfunction

ABNORMAL TONE
➡ Flaccidity
- Limbs feel heavy or floppy and relaxed
- Provide no resistance or assistance to passive motion
- (-) placing response
FACILITATION ➡ Spasticity
- Limbs are stiff and assume abnormal positions
❖ Directed to Agonist
- Resist lengthening during passive movements but may assist passive
a. Repeated Contraction (RC)
- repeated isotonic contractions induced by quick stretches and
movements that require spastic muscles to shorten
➡ Associated Reactions
enhanced by resistance performed through the range or part of the
- Non-functional and involuntary changes in limb position and
range at a point of weakness.
- Indications: weakness, muscle imbalances, lack of endurance
muscle tone
b. Hold-relax-active motion (HRA)
LOSS OF AUTOMATIC POSTURAL CONTROL
- isometric contraction performed in the mid to shortened ranged
followed by voluntary relaxation and passive movement into the ➡ Normal Postural Reactions
✴ Righting Reactions
lengthened range, and resistance to an isotonic contraction through
✴ Equilibrium Reactions
the range
- Indications: an inability to initiate movement, hypotonia, weakness
- ability to maintain in state of equilibrium
✴ Protective Extension Reaction
in the lengthened range, marked imbalances between antagonists.
c. Rhythmic Initiation (RI)
- extension response of the elbow
- Voluntary relaxation followed by passive movement through
➡ Loss of control of postural adjustments that forms “the necessary
background for normal movement and for functional skills”
increasing ROM, followed by active-assisted contraction
progressing to tracking resistance (light, facilitatory resistance) to ➡ Poor trunk control, decreased balanced and protective responses and
poor weight-bearing on the hemiplegic side
isotonic contractions
- Indications: spasticity, rigidity, inability to initiate movement
ABNORMAL COORDINATION
(apraxia), motor learning deficits, communication deficits (aphasia)
d. Alternating Isometrics (AI) – done in the trunk ➡ Results to insufficient, non-functional extremity movements

reinanakamurz NEUROTHERAPIES 2 of 4
 ➡ Timing, sequencing and coordination of muscle activation are - Are used to help the therapist assess the patient’s automatic responses
disturbed to being moved
- Uses:
ABNORMAL FUNCTIONAL PERFORMANCE o To influence postural tone
➡ Inability to integrate the 2 sides of the body to perform activities o Regulate coordination of movements
➡ Loss of specific motor abilities and task-specific behaviors such as o Inhibit abnormal patterns
rolling, sitting up, walking, dressing or bathing independently 
 o Facilitate automatic reactions

B. Reflex Inhibitory Patterns

3 STAGES OF RECOVERY
- are used to inhibit patterns of abnormal muscle tone
1. Initial flaccid - Are partial patterns opposite to the typical abnormal patterns and
2. Stage of Spasticity postural tone that dominate the patient
3. Stage of Relative Recovery - Prevent shunting the sensory inflow into abnormal patterns and
redirect it into normal ones
1. INITIAL FLACCID STAGE
- No interplay whatsoever between the sound and the affected side C. Key Points
- Found soon after the onset of hemiplegia and lasts from a few days to - Usually proximal parts of the body (head, neck, shoulder, pelvis) from
several weeks and may be longer which abnormal reflexes seem to originate
- Patient cannot move his affected side and often does not appreciate that he - A key point is chosen that allow the full pattern of tone to be broken
has an arm or a leg on that side up during the handling by the least restrictive RIP
Goal of Treatment:
✓ Promote proper positioning and bed mobility D. Sensory Stimulation
✓ Bed Positioning using Reflex Inhibiting Patterns (RIPs) - Used for hypotonic patients and other that appear to be weak
- Never done unless the patient is in rip in order to shunt the inflow to
2. STAGE OF SPASTICITY desired channels
- The stage that most patient with residual hemiplegia comes out for out- - Aimed at local response
patient tx - Weight-bearing with pressure and resistance
Goal of Treatment: • Elicit increase postural tone
✓ Dissociate the synergy pattern by developing control of • Decrease involuntary movement
intermediate joints - Placing and holding
• Ability to arrest a movement at any stage automatically or
✓ ROM, Stretching
voluntarily
3. STAGE OF RELATIVE RECOVERY - Tapping
- Patients are not severely affected at the beginning and who have a good *Bobath Concept: does not want any reflexes or abnormal movement
spontaneous recovery or who have done well in treatment
Goal of Treatment:
BRUNNSTROM APPROACH
✓ Improve quality of gait and use of affected hand
aka Movement Therapy in Hemiplegia
ASSUMPTIONS OF NEURODEVELOPMENTAL TREATMENT
MOVEMENT THERAPY
- It is important to remediate foundation skills like midline symmetry,
righting reactions, trunk rotation that make normal skill acquisition - Use of motor patterns available to the patient at any point in the recovery
possible process
- Normal movement is learned by experiencing what a normal movement - Synergies, reflexes and other abnormal movement patterns are normal
feels like parts of the recovery process that the patient must go through before
- Postural control is essential for limb movements normal voluntary movement can occur
- You cannot impose normal movements on abnormal muscle tone
- Plasticity of human brain (neuroplasticity) BASIC LIMB SYNERGIES
❖ UE Flexor Synergy
‣ Shoulder Retraction, Elevation, ER, Abduction to 90
‣ Elbow flexion
‣ Forearm supination
GENERAL PRINCIPLES OF TREATMENT ❖ UE Extensor Synergy
- Treatment should avoid movements and activities that increase muscle ‣ Shoulder protraction, IR, Adduction
tone or produce abnormal responses in the involved side ‣ Elbow extension
- Treatment should be directed toward the development of normal patterns ‣ Forearm Pronation
of posture and movement; movement patterns selected are not based on
the developmental sequence but on patterns important to function ❖ LE Flexor Synergy
- The hemiplegic side should be incorporated into all treatment activities to ‣ Hip flexion, ER, Abduction
reestablish symmetry and increase functional use ‣ Knee flexion
- Treatment should produce a change in the quality of movement and ‣ Ankle DF, Inversion
functional performance of the involved side ‣ Toes DF

TREATMENT TECHNIQUES ❖ LE Extensor Synergy

Handling Techniques ‣ Hip extension, IR, Adduction
Reflex Inhibitory Patterns (RIP’s) ‣ Knee extension
Key Points ‣ Ankle PF, inversion
Sensory Stimulation ‣ Toes PF

ATTITUDINAL OR POSTURAL REFLEXES

A. Handling Techniques
- The manner of control of the patient through RIP’s and their ✤ Tonic Neck and Labyrinthine Reflexes
movement to elicit righting and equilibrium responses - Aka Magnus’s and de Kleijin’s reflexes

reinanakamurz NEUROTHERAPIES 3 of 4
 ✴STNR ✓ Recovery bears resemblance with the normal infantile motor
✴ATNR development
✴ Tonic Labyrinthine Reflex - reflex to voluntary movements o gross to fine
✤ Tonic Lumbar Reflexes - proximal to distal control
- Ability of the body to maintain upright position
SHOULDER AND ELBOW
ASSOCIATED REACTIONS (Sequential Recovery Stages and Evaluation Procedure)
Stage 1
✴ Mirror Synkinesis Flaccidity
- Movement seen on the affected side in response to voluntary Stage 2
forceful movements in other parts of the body The basic limb synergies or some components now make their
- Resisted flexion of the (N) UE elicits flexion of the affected UE appearance
- Resisted flexion of the (N) LE elicits extension of the affected LE Stage 3
The basic limb synergies or some of their components are
✴ Homolateral Synkinesis performed voluntarily and are sufficiently developed to show
- Mutual dependency between the synergies of the UE and LE definite joint movement

✴ Raimiste’s Phenomenon Stage 4

- Abduction phenomenon Place hand behind body, shoulder flexion to 900, pronate-
- Resisted ABD of unaffected side, ABD of affected side supinate forearm with elbow at 900 at the side
- Adduction phenomenon Stage 5
Arm raising to abduction, arm raising forward and overhead,
✴ Soque’s Phenomenon pronate-supinate with extended elbow
- extension of fingers when the shoulder is flexed
- for patients with grasping problems (di makarelease) Stage 6
Isolated joint movements are now freely performed
✴ Marie-foix Phenomenon
- aka Bechterev’s reflex
- passive PF of the toes of a patient in supine with hip and knee in HAND
slight flexion elicits mass flexor response including ankle DF
(Sequential Recovery Stages and Evaluation Procedure)
Stage 1
SEQUENTIAL RECOVERY STAGES Flaccidity
Stage 2
Stage 1 - Flaccidity Little or no active finger flexion
Stage 2 - Spasticity begins to develop Stage 3
Stage 3 - Spasticity reaches its peak Mass grasp
Stage 4 - Spasticity begins to decline Hook grasp with no release
Stage 5 - Spasticity continues to decline Reflex finger extension possible but not voluntary
Stage 6 - Spasticity disappears Stage 4
Stage 7 - Normal motor function is restored Lateral prehension, release by thumb movement, semivoluntary
**7th – NORMAL finger extension, small range
Stage 5
SEQUENTIAL RECOVERY STAGES AND EVALUATION PROCEDURES Palmar prehension, possibly cylindrical and spherical grasp,
Stage 1 - Flaccidity voluntary mass extension of digits
- No movement on either reflex or voluntary basis Stage 6
All prehensile types under control, full-range voluntary extension
Stage 2 - Spasticity begins to develop of digits, individual finger movements present
- Basic limb synergies or some of their components may appear as
associated reactions or minimal voluntary movement responses TRUNK AND LOWER LIMB
may be present (Sequential Recovery Stages and Evaluation Procedure)
Stage 1
Stage 3 - Spasticity reaches its peak Flaccidity
- Semi-voluntary stage; patient is able to to initiate movement but is
Stage 2
unable to control the form of movement, which will be the basic Minimal voluntary movements of the LE
limb synergies Stage 3
Hip-knee-ankle flexion in sitting and standing
Stage 4 - Spasticity begins to decline Stage 4
- Some movement combinations that do not follow the paths of the
Sitting, knee flex beyond 900, foot sliding backward on floor
basic limb synergies are mastered, first with difficulty then with Voluntary ankle DF s lifting foot off the floor
increasing ease Stage 5
Standing, isolated NWB knee flexion, hip extension
Stage 5 - Spasticity continues to decline Standing isolated, ankle DF, knee extension, heel forward in
- More difficult movement combinations are mastered as basic limb
position of short step
synergies lose their dominance over motor acts Stage 6
Standing, hip abduction beyond range obtained from elevation
Stage 6 - Spasticity disappears of pelvis
- individual joint movements become possible and coordination
Sitting, reciprocal action of inner and outer hams combined with
reaches normalcy ankle inversion and eversion
Remember:
✓ Recovery may be arrested at any stage
✓ A stage in the recovery stage is not skipped

reinanakamurz NEUROTHERAPIES 4 of 4