GKPROJECT

A CO MPAR ATIV E STUD Y TO FIN DO UT THE
EFFECT IVE NESS OF BRUNNSTR OM VS

BO BATH TEC HN IQ UE IN IMP ROVIN G
THE UPPE RLI MB FUN CTI ON OF
HEM IPLEG IC PATIENTS
1
INTRODUCTION
Cerebrovascular accident or stroke is one of the major
causes of debilitation in the world. The major symptoms of
stroke are loss of muscle power, spasticity and in-
coordination of muscle activation. Stroke is the primary
cause of disability and the second leading cause of death
in many Countries, including Taiwan. Although the
mortality rate of stroke has declined, the Incidence and
prevalence of stroke continue to rise. The goal of
rehabilitation is to help Stroke patients to achieve as much
functional independence as possible and to maintain Quality
of life. Rehabilitation has an important role in reducing
the burden of long-term Stroke care on society.
Stroke is a non-traumatic brain injury, caused by
Occlusion or rupture of cerebral blood vessels, and
manifests as sudden appearance of Neurological deficits
characterized by loss of motor control, altered sensation,
cognition or Language impairment and disequilibrium.
Intracranial hemorrhage accounts for about 10- 15% of all
strokes, and the remaining 80-85% is caused by infarction.
2
Disability in stroke affects physical, cognitive and
psychological functions in variable severity. No two strokes
are identical and no two patients respond to treatments
identically. Therefore, The therapeutic approach requires
assessment of every individual patient and demands
Specialized professional knowledge, skills and creativity.
Stroke incidence: The incidence of first ever stroke
ranges from 84/1,00,000 peoples. These incidence change
to 141/1,00,000 peoples. Stroke incidence varies with
sex and age: In the young people of less than 35 years
of age, where stroke incidence is very low, the rate is
slightly higher in women than in men (mettinger et al
1984,lideguard et al 1986,nencini et al 1988). While in
people over the age of 35 years the incidence is
higher in men than in women.
Case fatality rate and survival: Fatality rate represents
the proportion of stroke patients who die early which is
usually defined as within 28 or 30 days of onset. Long term
survival improved (7years) from 22% to 40% in the 1940-
1980. Stroke mortality: The age of specific stroke mortality
3
rate rise sharpely with age from fewer than 10 death
/1,00,000 in people less than 45years of age to more than
1000/1,00,000 in people aged 75years or older.
Hemiplegia or hemiparesis caused by a stroke in the
middle cerebral artery distribution area is commonly seen
within the rehabilitation setting. Initially, limb weakness
and poor control of voluntary movement are noted and
associated with reduced muscle tone. As voluntary
movement improves, nonfunctional mass flexion and
extension of the limbs becomes apparent, i.e., synergy
patterns and mass contraction of multiple muscle
groups. Later, synergistic movement patterns gradually
disappear and, following the neurological motor recovery,
more isolated joint movements gradually develop (Sawner
& La Vigne, 1992).
Spasticity is a velocity-dependent increase in resistance
to muscle stretch that develops after an upper motor
neuron lesion (Lance, 1981; Katz, 1992). Spasticity develops
shortly after a completed stroke and usually persists if
4
recovery is incomplete and it contributes to pain, motor
impairment and disability. Jackson classified symptoms
after a central nervous system lesion as positive or
negative.
Positive symptoms are spontaneous and exaggerated
version of normal functions that reacts to specific
external stimuli. They include spasticity, increased deep
tendon reflexes and hyperactive flexion reflexes.
In contrast, negative symptoms are deficits of normal
behavior or performance and they include loss of dexterity,
loss of strength, and restricted ability to move. Therapeutic
interventions are performed under the assumption that a
cause-and-effect relationship exists between these two
groups of symptoms. And the major focus is to decrease the
positive symptoms and improve the negative symptoms.
General treatment Procedures include various
concepts as follows ‘Johnstone’ Follows developmental
patterns focusing on proximal stability. Use of orally inflated
pressure splints a significant characteristic. ‘Motor re-
learning programme’ Training of motor control based on an
5
understanding of kinematics and kinetics of normal
movement, motor control processes and motor learning.
‘Proprioceptive neuromuscular facilitation (PNF)’ To
maximise sensory stimulation on the pool of anterior horn
cells in order to stimulate purposeful muscular contraction.
‘Rood’ To achieve purposeful muscular contractions by
stimulating the skin through facilitatory strokes.
This paper aims to examine whether there is evidence to
accept neuro-developmental treatment as an effective
approach. A systematic literature search was undertaken.
Fifteen trials have been selected and classified according to
a 5-level hierarchic scale of evidence for clinical
interventions.
Results show no evidence proving the effectiveness of
neuro-developmental treatment or supporting neuro-
developmental treatment as the optimal type of treatment,
but neither do methodological limitations allow for
conclusions of non-efficacy. Methodological aspects of
selected studies are discussed and requirements for further
research are suggested.
6
In this study I have dealing the Neuro-developmental
therapy includes Brunnstrom and Bobath a comparative
study based on the effectiveness between the two groups.
Bobath’ (normal movement or neuro-developmental
approach) Aims to prevent abnormal movements and
adverse plastic adaptation and facilitate normal
movement and subsequent plastic changes.
Bobath – posture appropriate for tasks, suppress
synergies with sensory input and motor feedback.
‘Brunnstrom’ Makes use of abnormal synergies and
incorporates them into functional activities. Conductive
education (Peto) Patients encouraged to verbalise the
activities as they perform them. Focused on function.
STATEMENT OF STUDY
A comparative study to elicit the difference of effects
between brunnstrom approach and bobath approach in
improving the arm function in Hemiplegics patients .
AIM OF STUDY
To findout the effectiveness of brunnstrom and bobath in
7
improving the functional ability in the case of hemiplegic
arm using the motor activity log rating scale.
NEED FOR STUDY
Some researches have been conducted and some
thesis are presented which have proved that brunnstrom
improve the activities and some thesis states that of bobath
and not yet a clear idea is existent about which is better in
the treatment of hemiplegia. So I am decide to perform the
comparative study in the Indian setup about the
effectiveness of brunnstrom and bobath . So that it would
be valuable, helpful and adds up knowledge for the further
physiotherapist.
8
OPERATIONAL DEFINITION
HEMIPLEGIA :
Severe or complete loss of motor function on one side
of the body. This condition is usually caused by brain
diseases that are localized to the cerebral hemisphere
opposite to the side of weakness. Less frequently, brain
stem lesions, cervical spinal cord diseases; peripheral
nervous system diseases, and other conditions may
manifest as hemiplegia. The term hemiparesis refers to mild
to moderate weakness involving one side of the body.
BRUNNSTROM :
Produces motion by provoking primitive movement
pattern or synergetic pattern which intern facilitating the
extensor reflex for simulating the response.
BOBATH :
Inhibition of abnormal tone & posture of released
postural reflex while facilitating specific automatic motor
response (by special technique of handling) resulting in
performance of skilled voluntary movements.

9
NEUROPHYSIOLOGY
The physical handicap resulting from a lesion of the
upper motor neuron is seen in terms of an interference of
normal postural control. The patient’s fundamental problem
is seen in abnormal qualities of postural tone and reciprocal
innervations. The abnormal types of postural tone and the
stereotyped total motor patterns we see in our patients are
the result of disinhibition, i.e of a release of lower patterns
of activity from higher inhibitory control. such release does
not only produce muscular signs, such as exaggerated
stretch and tendon reflexes, but abnormal patterns of
coordination, perhaps philogenetically older postural reflex
mechanisms.
Flaccidity, on the other hand, is due to excessive
inhibition of gamma activity from the cerebellum with lack
of postural tone against gravity. Inhibition is a very
important factor in the control of posture and movement.
Increase of inhibitory control of the maturing brain, the
organism increasingly gains more selective control of
posture against gravity. This process follows a
10
cephalocaudal direction. The action of the total pattern has
to be inhibited prior to the initiation of a localized action.
this means that normal functional and skilled activity are
largely a matter of inhibitory control. The development is
closely associated with the gradual improvement of postural
control against gravity.
Inhibition is active at every level of the CNS. The
difference between lower and higher levels of integration is
only a matter of complexity. At the spinal level it manifests
itself in large patterns of activity, (i.e) in total synergies of
flexion or extension, such as the flexor withdrawal reflex
and the extensor thrust. At higher levels of integration of
the CNS, up to the highest one of conscious control,
inhibition becomes more and more complex and allows for
the fractionation of the original primitive and more total
patterns of movement. Selective movements of parts of the
body and limbs need inhibition of those parts of patterns
which are unnecessary for a specific function. Inhibition
does not only make selective movements possible, but
plays an important role in the grading of movements.
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Reciprocal innervation is the balanced activity of
excitation and inhibition during a movement which controls
its speed, range and direction. Some degree of spasticity is
found in almost every patient with hemiplegia, and it
creates a major problem in the management of the patient.
Severe degrees of spasticity will make movements
impossible; moderate spasticity will allow for some slow
movements, but they will be performed with too much effort
and with abnormal coordination; mild spasticity will allow for
gross movements with fairly normal coordination.
Flaccidity also presents problems, especially during the first
weeks after a stroke. In some cases, it may last only few days,
in others for weeks while, in a few cases, flaccidity may
persist indefinitely. It then usually affects only the arm, and
signs of spasticity will still be found in the wrist and fingers.
The clinical neurologist looks upon spasticity as a local
muscular phenomenon, and tests it by assessing the degree
of resistance a muscle gives to passive stretch. Here, the
characteristics of spasticity are seen to be exaggerated
stretch response, clasp-knife phenomenon and lengthening
and shortening reactions. This view has been supported by

12
the discovery of the dual innervation of muscle, i.e the alpha
and gamma system, and very rarely the alpha, from higher
inhibitory control. This view of spasticity, as a local muscular
phenomenon, provides the basis for treatment which aims at
the avoidance of exaggerated stretch responses by the uses
of splints or braces and of transplants of tendons and other
surgical techniques.
13
CONDITION
HEMIPLEGIA
Definition:
Severe or complete loss of motor function on one side of
the body. This condition is usually caused by brain diseases
that are localized to the cerebral hemisphere opposite to
the side of weakness. Less frequently, brain stem lesions;
cervical spinal cord diseases; peripheral nervous system
diseases; and other conditions may manifest as hemiplegia.
The term hemiparesis refers to mild to moderate weakness
involving one side of the body.
Causes :
The following medical conditions are some of the
possible causes of Hemiplegia. There are likely to be other
possible causes, so ask your doctor about your symptoms.
• Brain injury
• Infective endocarditis
14
• Acute infantile hemiplegia
• Multiple sclerosis
• haemorrhage
• Cerebral angioma
• Cerebral palsy
• Head injury
• Birth injury
• Cerebral contusion
• Traumatic cerebral hemorrhage
• Extradural haematoma
• Cerebral thrombosis
• Hypertensive encephalopathy
• Cerebral embolism
• neoplasm
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• Meningitis
Clinical features:
 Sleeplessness
 Loss of Speech
 Tenderness
 Visual disturbance
 Vomiting
 Vertigo
 Cough
 sneeze
 Lack of co-ordination
 Weakness
 Weber's syndrome
 Benedikt's syndrome
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 Millard-Gubler syndrome
 Involundary movement
 Sphincter disorder
 Incontinence/retention
 Bladder/bowel dysfunction
 Loss of anal control
 Disability
 Wasting of muscle
 Hypertrophy
 Drooping of shoulder
 Cardiovascular disease
 Eye contact
 Reflex sympathetic dystrophy
 Loss of Head control
17
 Loss of Social smile
 Loss of Crawling
 Loss of walking
 Convulsion
 Loss of Cognitive skills
 Loss of Consciousness
 Loss of Intellectual function
 Slowness of movement
 Loss of Cortical sensation :
 Stereognosis
 Baregnosis
 Two point discrimination
 Loss of functional activites
 Circumduction gait
Investigation:
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 X-RAY
 MRI SCAN
 CT SCAN
 BLOOD TEST
Medical management:
• Cerebral oedema may be reduced by mannitol
• Convulsion may be controlled by diazepam(5-10mg) I.M
according to the age of patient.
• Patient was treated piracetum, antiplatelets drugs lipid
lowering drugs, iron,multivitamins & antibiotics.
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PHYSIOTHERAPY ASSESSMENT
SUBJECTIVE ASSESSMENT:
NAME
AGE
SEX
OCCUPATION
ADDRESS
MARITAL STATUS
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
Present illness
• Mental
• Sleep
• Speech
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• Tenderness
• Visual disturbance
• Vomiting
• Vertigo
• Any injury of the head
• Cough/sneeze effect
OBJECTIVE ASSESSMENT:
Motor disorder
• Lack of co-ordination
• Weakness
• Involundary movement
• Relieving/ Precipitating factor
Sensory disorder
• Sphincter disorder
21
• Incontinence/retention
• Bladder/anal control
PAIN HISTORY
PAST HISTORY
• Convulsion
• Meningitis
• Infection
• Trauma
• Encephalitis
• Pneumonia
• Jaundice
• Malnutrition
FAMILY HISTORY
• Epilepsy
• Cardiovascular disease
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• Rh factor
• Inflammation
• Disability
DEVELOPMENT HISTORY
• Eye contact
• Head control
• Social smile
• Crawling/walking
SOCIO-ECONOMIC HISTORY
• Education
• Tobacco
• Cigarette
• Alcohol
• Occupation carrier
MEDICAL HISTORY
• Drug allergy
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SURGICAL HISTORY
• Incision
• Length
• Duration
OBJECTIVE EXAMINATION
Higher function test:
• Consciousness
o Verbal response
Oriented 5
Disoriented 4
Inappropriate words 3
Incomprehensive words 2
No response 1
• Cognitive skill
o Listen to language
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o Name object
o Read/write correctly
o Numerical calculation
o Understanding complex commands
o Dressing
o Copy geometric pattern
• Intellectual function
o Orientation
o Memory
• Emotional state
o Slowness of movement
o Speech
o Aphasia
o Dysarthria
25
• Level of memory
o Short term
o Long term
o Recent
CRANIAL NERVE EXAMINATION
I.OLFACTORY- smell
II.OPTIC-
 Visual acquity
 Visual field
 Pupil
III.OCCULOMOTOR-
 Ocular movement
 Nystagmus
 Pupil
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IV.TRIGEMINAL
 Jaw reflex
 Corneal reflex
 Motor (chew/clench)
 Sensory (ophthalmic/mandible)
V.TROCHLEAR
VI.ABDUCENT
VII.FACIAL Motor
o blink
o Blow
o Smile
o eye brow elevation
Taste
o anterior 2/3 of tongue
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VIII.VESTIBULO COCHLEAR
• Weber test
• Rinne test
IX.GLOSSOPHARYNGEAL
• Gag reflex
• Taste-posterior 1/3 of tongue
X.VAGUS
• Swallowing
• Observe (uvula & soft palate)
XI.ACCESSORY
• Sternocleidomastoid
• Trapezius
XII.HYPOGLOSSAL
• Tongue movement
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Cortical sensation :
• Stereognosis
• Baregnosis
• Two point discrimination
MOTOR SYSTEM
MUSCLE TONE (asworth scale)
• Hypotone
• Hypertone
INSPECTION OF MUSCLE
• Circumference
 Arm
 Fore arm
 Wasting
 Hypertrophy
 Drooping of shoulder
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JOINT ROM
REFLEXES
Superificial
Deep
 Biceps
 Triceps
 Brachioradialis
SENSORY EXAMINATIONS
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
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• crude touch
• Proprioception
• kinesthesia
COORDINATION AND BALANCES
• Equilibrium
• non-equilibrium
LIMB LENGTH MEASUREMENT
POSTURE
GAIT
FUNCTIONAL ASSESSMENT
• Dressing
• feeding
• toileting
• Transfer
• Combing
• brushing
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HAND FUNCTION
• Tip to tip
• spherical
• Side to pad
• hook
• Cylindrical
INVOLUNTARY MOVEMENT
• Chorea
• Athetosis
• tremor
INVESTIGATION
 X-RAY
 MRI SCAN
 CT SCAN
 BLOOD TEST
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REVIEW OF LITERATURE
BRUNNSTROM
Sawner K ,Lavigne J; Brunnstrom movement in
hemiplegia; A neurophysiological Approach, ed 2.
Philadelphia, JB Lippincott company,1992.
Ferraro, M., Palazzolo, J. J., Krol, J., Krebs, H. I., Hogan, N., &
Volpe, B. T. (2003). brunnstrom arm training improves
outcome in patients with chronic stroke. Neurology, 61(11),
1604-1607.
Gowland, C., deBruin, H., Basmajian, J. V., Plews, N., &
Burcea, I. (1992). Agonist and antagonist activity during
voluntary upper-limb movement in patients with stroke.
Phys Ther, 72(9), 624-633.
Kraft, G. H., Fitts, S. S., & Hammond, M. C. (1992).
Techniques to improve function of the arm and hand in
chronic hemiplegia. Arch Phys Med Rehabil, 73(3), 220-227.
Lincoln, N. B., Parry, R. H., & Vass, C. D. (1999).
33
Randomized, controlled trial to evaluate increased intensity
of physiotherapy treatment of arm function after stroke.
Stroke, 30(3), 573-579.
Cavanaugh, J. T., Schenkman, M. (1998). Physical therapy
evaluation and treatment in stroke rehabilitation. Physical
Therapy Case Reports, 1(4), 200-209.
van Vliet PM, Lincoln NB, Robinson E. Comparison of the
content of two physiotherapy approaches for stroke.
Clin.Rehabil. 2001 Aug;15(4):398-414.
BOBATH
Platz T, Eickhof C, van Kaick S, Engel U, Pinkowski C, Kalok
S, Pause M. Impairment-oriented training or Bobath therapy
for severe arm paresis after stroke: a single-blind,
multicentre randomized controlled trial. Clin Rehabil. 2005
Oct;19(7):714-24.
van Vliet PM, Lincoln NB, Foxall A. Comparison of Bobath
based and movement science based treatment for stroke: a
randomised controlled trial. J Neurol Neurosurg Psychiatry.
2005 Apr;76(4):503-8.
34
Wang RY, Chen HI, Chen CY, Yang YR. Efficacy of Bobath
versus orthopaedic approach on impairment and function at
different motor recovery stages after stroke: a randomized
controlled study. Clin Rehabil. 2005 Mar;19(2):155-64.
Paci M. Physiotherapy based on the Bobath concept for
adults with post-stroke hemiplegia: a review of effectiveness
studies. J Rehabil Med. 2003 Jan;35(1):2-7.
Mudie MH, Winzeler-Mercay U, Radwan S, Lee L. Training
symmetry of weight distribution after stroke: a randomized
controlled pilot study comparing task-related reach, Bobath
and feedback training approaches. Clin Rehabil. 2002
Sep;16(6):582-92
Langhammer B, Stanghelle JK. Bobath or motor relearning
programme? A comparison of two different approaches of
physiotherapy in stroke rehabilitation: a randomized
controlled study. Clin Rehabil. 2000 Aug;14(4):361-9.
Lennon, S., & Ashburn, A. (2000). The Bobath concept in
stroke rehabilitation: a focus group study of the experienced
physiotherapists' perspective. Disabil Rehabil, 22(15), 665-
674.
35
Baxter, D., Lennon, S & Ashburn, A. (2001). Physiotherapy
based on the Bobath concept in stroke rehabilitation: a
survey within the UK. Disabil Rehabil, 23(6), 254-262.
GENERAL
Wagenaar RC, meijer OG, van Wieringen PC, et al. The
functional recovery of stroke: A comparison between
bobath and brunnstrom method. Scand J Rehabil med.
1990:22:1-8
The influence of age plays an important role on the clinical
presentation and outcome of stroke. He says that the stroke
primarily affects the elderly. Andrew K et al
1984.international rehab. Med.6;49-53.
Survival of the younger severely impaired may continue to
recover over a longer period. Lind mark B 1988.the
improvement of different motor functions after stroke. Clin.
Rehab.2;275-283.
Recovery of stroke takes place within the first 3 months.
Skilberk C et al 1983. recovery after stroke J neurol.

36
neurosurgery. Psychiatric 46;5-8.
The optimal prediction of arm function outcome at
6months can be made within 4 weeks after onset. Kwakkel
G, kollen BJ, Vander grand J, prevo AJ, stroke G,2003 sep34
(9) 2181-6 E.pub 2003 aug7.
37
DESIGN & METHODOLOGY
STUDY DESIGN
A comparative nature of study between the groups
of I and II
POPULATIONS
Purposive sampling technique was used to select the
10 hemiplegic patients based on the inclusive and exclusive
criteria
SAMPLE SIZE AND SELECTION
A small sample of 10 patients were selected for
this study
DURATION
Minimum three months
STUDY SETTING
This study was conducted at
1. T .R. COLLEGE OF PHYSIOTHERAPY,
2. SRI MURUGAN PHYSIO CLINIC,

38
3. AROGYA PHYSIO CLINIC,
CRITERIA
INCLUSION
Patient with age of 30-60years
Both sexes
Adequate trunk control only hemiplegic arm
Oriented patients
EXCLUSION
• Patient above or below 40-60years
• Associated dysfunction without trunk control
• Disoriented patients
HYPOTHESIS
There is an significant effect of an both brunnstrom
and bobath.
NULL HYPOTHESIS
39
There is no significant effect of an both brunnstrom
and bobath.
MATERIAL USED
 Brunnstrom Treatment Regimen
 Bobath Treatment Regimen
 Motor activity log rating scale
METHODS
A small sample of 10 patients were selected and is
divided into two groups,
Group I-Experimental group with 5 subjects
Group II-Control group with 5 subjects
 Group I were treated with brunnstrom approach
Group II were treated with bobath approach
40
Group – I Experimental Group:
BRUNNSTROM TECHNIQUE
Five patients was selected for this study using the
treatment regimen of brunnstrom neuro-
developmental therapy.
Treatment specifications:
This method of treatment was conducted 4 times
/week over a period of 3 months. The Progression of this
treatment was changed according to the condition of the
patient.
 A pre score was measured at the initial of this
treatment at the end of the 3 months a post score
was measured using the motor activity log rating
scale.
Brunnstrom basic principles:
Uses primitive synergistic patterns in training in
attempting to improve motor control through central
facilitation
41
Based on concept that damages CNS regressed to older
patterns of movements (limb synergies and primitive
reflexes);
Thus synergies, primitive reflexes, and other abnormal
movements are considered normal processes of recovery
before normal patterns of movements are attained
Patients are taught to use and voluntarily control the
motor patterns available to them at a particular point during
their recovery process (e.g., limb synergies)
Enhances specific synergies through use of
cutaneous/proprioceptive stimuli, central
Encourages abnormal patterns of movement (Which is
opposite to Bobath)
TRAINING PROCEDURE :
A.Bilateral contraction of pectoralis muscle (waist squeeze)
B.Semivoluntary elbow extension following “waist squeeze”
42
C.Bilateral rowing activities.
a. Flexor pattern with handshake grip
b. Extensor pattern with thumb grip
c. Thumb grip
d. Handshake grip
D.Eliciting and reinforcing elbow extension.
a.Weight bearing with extended elbow, arm in front.
b.Weight bearing with extended elbow, arm
abducted.
E.Weaning patient from reflex influence.
a.Elbow extension utilizing effect of asymmetrical tonic
neck reflex, head rotated toward affected side
b.Elbow extension with head neutral, no effect of reflex
evident
c.Elbow extension against influence of asymmetrical
43
tonic neck reflex, with head rotated toward sound side.
F.Hand to sacrum using flexion
a.Components of flexor synergy bring the hand to
the lateral side of the hip.
b.Completion of activity utilizing extensor components.
G.Thumb extension reinforced by reflex activity.
H.The patient is taught to release his own finger flexor
tension
a.Starting position with thumb grip
b.Passive supination of the forearm while maintaining
the thumb grip.
I.Technique used to transfer response from finger flexor to
finger extensor muscles
a.release finger flexor tension by pulling the thumb out of
the palm,gripping the thenar eminence while supinating
the forearm passively.
b.“swatting”of the finger extensors to elicit stretch
44
responses
c.“rolling” the fingers into flexion to stretch extensors
d.completion of rolling phase.note:that the finger flexors
are not stretched
e.pronation of forearm while maintaining thumb
extension and contact with the fingertips in preparation
for utilization of souques’s position
f.while maintaining the above manual contact,the
physical therapist has stood up,passively moving the
patient’s arm into souques’s position (90* shoulder
flexion), “molding” the fingers into extension.the
molding motion is initiated by firm contact of the
therapist’s thenar eminence over the patient’s
metacarpophalangeal joints
g.the “molding” motion is completed by stroking distally
over the interpalangeal joints toward the fingertips
h.finger extension may then be reinforced by individually
stretching the finger extensors of each digit.

45
Group-II Control Group:
BOBATH TECHNIQUE
Five patients was selected for this study using the
treatment regimen of bobath neuro developmental therapy
of inhibiting pattern.
Treatment specifications :
This method of treatment was conducted 4 times
/week over a period of 3 months. The Progression of this
treatment was changed according to the condition of the
patient.
 A pre score was measured at the intial of this
treatment at the end of the 3 months a post score
was measured using the motor activity log rating
scale.
Bobath basic principle
The important relationship between sensory Input and
motor output in NDT; for example – visual input in
facilitation of alignment and head control - and the
46
importance of sensory input graded in intensity, rhythm
and duration in handling a client.
To facilitate alignment of the body in relationship to the
base of the support
Proximal and distal keypoints used individually or in
combination in handling and are gradually withdrawn.
Inhibition is a term now used to, for example, reduce
muscle tightness, or, for example, to reduce excessive
patterns of coactivation, and so promote more dynamic
stability.
Task components are prepared for and practised as
well as practice of the whole task within a session.
Learning from errors is encouraged.
There is a progression in the challenge of activities
within a session active responses are encouraged in a
supportive and motivating treatment environment.
Fear or physical discomfort may contribute to difficulty
in movement. Using therapeutic handling and care and
47
respect for the child can help improve self-esteem and
ongoing participation in treatment sessions.
TRAINING PROCEDURE
A.Patient moves trunk against arm and hand to inhibit
flexor spasticity.
a.Initial Position
b.Trunk moves towards arm
c.Trunk moves away from arm
d.Trunk moves sideways from arm
e.Trunk moves forward.therapist controls the hand
f.Therapist doesnot control hand any longer.
B. Auto inhibition of flexor spasticity of arm.
a.Swinging both arm , elbow extended
b.Slowly raising trunk, elbow extended
c.Slowly standing up
48
d.When elbow flexes, patients bends down again
e.Keeping elbow extended when standing up
f.Walking,keeping elbow extended
C.Weight transfer to affected side with support on extended
arm.
D. Weight bearing in sitting on affected side with support on
forearm
C.a. Sitting with support on affected arm, shoulder well
raised, the patient performs small isolated movements of
elbow.
b.Also he moves his trunk forward, backward and
sideways.
49
F.Inhibition of flexor spasticity of affected arm .
(note: shoulder girdle is raised to counteract pressure down.
The patient moves trunk and shoulder girdle while the
therapist inhibits flexor spasticity.)
G.Gendle push-pull stimulates active extension of the arm.
H.Inhibition of flexor spasticity to make placing and holding
of arm possible. Patient moves trunk backwards, forwards,
side ways.
I.Bilateral activities
a.Pushing a roll with clasped hands towards
b.Catch the ball before pushing it back to partner
opposite)
J.Chalk mark using
a.Affected arm extended forward and maintained with
chalk marks using sound hand
b.Patient must also keep affected hand within chalk
marks while raising a heavy object, such as a sand bag,
with the sound arm. The weight can be increased

50
gradually.
c.Patient holding a card-board roll with extended arm
while lifting weights with sound arm.
d.The outcomes are measured using the motor activity
log rating scale and are expressed in graphically and
diagrammatically.
51
DATA ANALYSIS AND INTERPRETATION
Experimen Control
Unpaired ‘t’ test tal group
group
SD = √∑d² – 3.77 6
(∑d)²
n₁+n₂ – 2
3.78 2.33
SE = SD√ 1 + 1
n₁ n₂
Calculated
‘t’ value = ₁ - ₂ 1.05 1.78


SE
Table value t₈@0.05 2.31
 Comparing between the two values the Group I shows
significant results than the Group II.
52
RESULTS AND DISCUSSION
The result of the study shows that group A patients
who were given brunnstrom techniques showed a
remarkable improvement in the reduction of than the
bobath techniques.
This particular study has focused on the improvement
of the functional ability of the patient.
For this study 10 patients was taken and are divided
into two groups. The patients group I was treated with
brunnstrom techniques and group II patients was treated
with bobath techniques. prior to the treatment session , on
the first day functional ability assessment were taken along
with motor activity log rating scale of the affected arm were
measured. The same measurement was taken after the end
of the 1st month, 2nd month, 3rd month respectively.
The result of the study for brunnstrom techniques
group was shown that there is significant improvement in
the values from the pre-treatment to post-treatment which
shows an highly significant value in the functional score.
53
The brunnstrom techniques group has shown an
improvement between the pre-treatment and post-
treatment scores. But in the bobath techniques group show
an low level of significance in pre-treatment to post-
treatment session.
In the previous study made by Ferraro, M., Palazzolo, J. J.,
Krol, J., Krebs, H. I., Hogan, N., & Volpe, B. T. (2003).
brunnstrom arm training improves outcome in patients with
chronic stroke.
In another study made by Gowland, C., deBruin, H.,
Basmajian, J. V., Plews, N., & Burcea, I. (1992). Agonist and
antagonist activity improving the voluntary upper-limb
movement in patients with stroke.
The functional outcome of the patient undergoing
brunnstrom technique shows an significant improvement.
The normal functional activities of arm was
assessed in pre-treatment and post-treatment session
found out that in brunnstrom technique there is
54
significant improvement in the functional activities using
motor activity log rating scale.
From this study it has shown that there is
significant improvement in the functional ability in the
patients receiving brunnstrom technique than patients
receiving bobath technique.
55
CONCLUSION
This study was conducted to findout the effectiveness of
brunnstrom vs bobath in improving arm function in
hemiplegic patients.
This comparative study’s result show that the patients
who were treated with brunnstrom have gived a much
better improvement in arm function that patients who were
treated with bobath.
I hope that the work done by me for the patients a
stepping-stone to success to enhance physiotherapy
treatment for the patients in the future.
LIMITATION & RECOMMENDATION
 A similar study can be done with an increased sample
size.
 Similar study can be conducted in various age group.
56
 Further study can be done on acute stage.
57
BIBLIOGRAPHY
 Bobath B. Adult hemiplegia: Evaluation and treatment. Oxford:
Butterworth-Heineman, 1990.
 Brunnstrom S. Movement therapy in hemiplegia. New York:
Harper & Row, 1970.
 Krebs HI, Aisen ML, Volpe BT, Hogan N. Quantization of
continuous arm movements in humans with brain injury. Proc Natl
Acad Sci USA 96: 4645-4649, 1999. Page 32 of 48
 Mason CR, Gomez JE, Ebner TJ. Hand synergies during reach-
to-grasp. J Neurophysiol 86: 2896-2910, 2001.
 www.google.com
 www.scribd.com
 www.ebook-search-engine.com
 www.pubmed.com
58
GROUP 1 : ( EXPERIMENTAL GROUP)
CASE SHEET 1
SUBJECTIVE ASSESSMENT
NAME : ANAND
AGE :48
SEX; MALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
• Verbal response
• Oriented
59
Cognitive skill
• Dressing
Intellectual function
• Orientation
• Memory
 Level of memory
- Normal
Emotional state
• Slowness of movement
• Speech
• Dysarthria
• Involvement of facial nerve
Cortical sensation
• Stereognosis – normal
• Two point discrimination - normal

60
MOTOR SYSTEM
MUSCLE TONE
• Hypertone
• Circumference
 Arm
• Fore arm muscle Wasting
• Hypertrophy
• Drooping of shoulder
JOINT ROM
REFLEXES
• Exaggerated
Superificial
• Pressure
• pain
61
Deep
• kinesthesia
• Abnormal
POSTURE
GAIT
• Dressing
• feeding
• toileting
• brushing
62
HAND FUNCTION
• spherical
• hook
• Cylindrical
• tremor
PRE SCORE: 0
PHYSIOTHERAPY MANAGEMENT
BRUNNSTROMS TECHNIQUE :
A.Bilateral contraction of pectoralis muscle (waist
squeeze)
B.Semivoluntary elbow extension following “waist
squeeze”

63
tension
I.Technique used to transfer response from finger flexor
to finger extensor muscles
POST SCORE : 4
64
CASH SHEET 2
NAME : GOPALAKRISHNAN
AGE :52
SEX; MALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
o Verbal response
 Oriented
Cognitive skill
• Dressing
65
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
 Slowness of movement
 Speech
 Aphasia
 Involvement of optic nerve
• Baregnosis - normal
• Two point discrimination - normal
66
MOTOR SYSTEM
MUSCLE TONE
• Hypertone
• Circumference
o Arm
o Fore arm
• Wasting (fore arm muscle wasting)
• Hypertrophy
JOINT ROM
REFLEXES
• Exaggerated
Superificial
67
o Light touch
Deep
• crude touch
COORDIATION AND BALANCES
• non-equilibrium
POSTURE
GAIT
• Dressing
• feeding
• toileting
• brushing
HAND FUNCTION
• spherical
• hook
68
• Cylindrical
69
• tremor
PRE SCORE: 1
squeeze)
squeeze”
tension
70
POST SCORE : 5
71
CASH SHEET 3
NAME : POONGOTHAI
AGE :33
SEX: FEMALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
o Verbal response
 Oriented
Cognitive skill
• Dressing
72
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
 Speech
 Dysarthria
 Normal
 Normal
73
MOTOR SYSTEM
 Hypertone
• Circumference
o Arm
o Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
Superificial
Deep
• Biceps
74
• Triceps
• Brachioradialis
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
• crude touch
• Proprioception
• kinesthesia
CO-ORDINATION AND BALANCES
• Equilibrium
75
POSTURE
GAIT
• Dressing
• feeding
• toileting
• Transfer
• Combing
• brushing
HAND FUNCTION
• Tip to tip
• spherical
• Side to pad
• hook
• Cylindrical
76
• Chorea
PRE SCORE: 2
squeeze)
squeeze”
tension
77
POST SCORE : 5
78
CASH SHEET 4:
NAME : VARADHARAJU
AGE :60
SEX; MALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
• Verbal response
• Oriented
Cognitive skill
• Dressing
79
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
• Involvement of trigeminal nerve
• Normal
MOTOR SYSTEM
• Hypertone
80
• Circumference
o Arm
o Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
• Exaggerated
Superificial
- normal
Deep
- normal
81
• Non-equilibrium
POSTURE
GAIT
• Dressing
• feeding
• toileting
• Transfer
• Combing
• brushing
HAND FUNCTION
• Tip to tip
• spherical
82
• Side to pad
• hook
• Cylindrical
• Tremor
PRE SCORE: 0
BRUNNSTROMS TECHNIQUE:
squeeze)
squeeze”

83
84
tension
POST SCORE : 4
85
CASH SHEET 5
NAME : BACKIYAM
AGE :30
SEX; FEMALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
• Verbal response
• Oriented
Cognitive skill
• Dressing
86
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
• Speech
• Dysarthria
• Involvement of optic nerve
• Stereognosis
• Baregnosis

87
MOTOR SYSTEM
• Hypertone
• Circumference
 Arm
 Fore arm
 Wasting
 Hypertrophy
 Drooping of shoulder
JOINT ROM
REFLEXES
 Exaggerated
88
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
• crude touch
• Proprioception
• kinesthesia
• non-equilibrium
89
POSTURE
GAIT
• Dressing
• feeding
• toileting
• Transfer
• Combing
• brushing
HAND FUNCTION
• Tip to tip
• hook
• Cylindrical
• Tremor
90
PRE SCORE: 1
BRUNNSTROMS TECHNIQUE:
squeeze)
squeeze”

tension

POST SCORE : 5
91
GROUP II (CONTROL GROUP)
CASH SHEET 6
NAME : SAKTHIVEL
AGE :55
SEX: MALE
CHIEF COMPLAINT:
CASE SHEET STUDY:
HISTORY:
• Consciousness
• Verbal response
• Oriented
Cognitive skill
• Dressing
92
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
 Speech
 Aphasia
 Involvement of facial nerve
• Stereognosis
• Baregnosis
93
MOTOR SYSTEM
• Hypertone
• Circumference
o Arm
o Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
• Exaggerated
94
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
• crude touch
• Proprioception
• kinesthesia
• non-equilibrium
POSTURE
95
GAIT
• Dressing
• feeding
• toileting
• brushing
HAND FUNCTION
• spherical
• Side to pad
• hook
• Cylindrical
• Chorea
• tremor
PRE SCORE: 1
96
BOBATH TECHNIQUE:
flexor spasticity.
B.Auto inhibition of flexor spasticity of arm.
C.Weight transfer to affected side with support on
extended arm.
D. Weightbearing in sitting on affected side with support
on forearm
E.Inhibition of flexor spasticity of affected arm .
F.Gendle push-pull stimulates active extension of the
arm.
G.Inhibition of flexor spasticity to make placing and
holding of arm possible. Patient moves trunk backwards,
forwards, side ways
H.Bilateral activities.
I.Chalk mark using sound hand
97
POST SCORE: 3
98
CASH SHEET 7
NAME : VELUSAMY
AGE :63
SEX: MALE
CHIEF COMPLAINT:
CASE SHEET STUDY:
HISTORY :
• Consciousness
o Verbal response
 Oriented
Cognitive skill
• Dressing
99
• Orientation
• Memory
 Level of memory
o Recent
Emotional state
 Speech
 Dysarthria
 Involvement of trigeminal nerve
 Stereognosis
 Baregnosis
 Two point discrimination

100
MOTOR SYSTEM
• Hypertone
• Circumference
 Arm
 Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
• Exaggerated
Superificial
• Temperature
101
• pain
Deep
• Vibration
• non-equilibrium
POSTURE
GAIT
• Dressing
• feeding
• toileting
• brushing
HAND FUNCTION
• Tip to tip
102
• Cylindrical
• Tremor
PRE SCORE: 0
BOBATH TECHNIQUE:
flexor spasticity.
extended arm.
on forearm
F.Gendle push-pull stimulates active extension of the arm.

103
forwards, side ways
POST SCORE: 3
104
CASH SHEET 8
NAME: CHANDRA
AGE: 34
SEX; FEMALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
• Verbal response
• Oriented
Cognitive skill
• Dressing
105
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
• Speech
• Aphasia
• Normal
• Stereognosis – normal
106
MOTOR SYSTEM
• Hypertone
• Circumference
 Arm
 Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
Superificial
Deep
• Biceps
• Triceps
107
• Brachioradialis
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
• crude touch
• Proprioception
• kinesthesia
• non-equilibrium
108
POSTURE
GAIT
• Dressing
• feeding
• toileting
• Transfer
• Combing
• brushing
HAND FUNCTION
• Tip to tip
• spherical
• Side to pad
• hook
109
• Cylindrical
• tremor
PRE SCORE: 1
BOBATH TECHNIQUE:
flexor spasticity.
extended arm.
on forearm

forwards, side ways
110
POST SCORE: 3
111
CASH SHEET 9
NAME : RANI
AGE :32
SEX; FEMALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
• Verbal response
• Oriented
Cognitive skill
• Dressing
112
• Orientation
• Memory
 Level of memory
 Normal
Emotional state
• Speech
• Dysarthria
• Normal
• Stereognosis
• Baregnosis
113
MOTOR SYSTEM
• Hypertone
• Circumference
 Arm
 Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
Superificial
114
Deep
• Biceps
• Triceps
• Brachioradialis
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
• crude touch
• Proprioception
• kinesthesia
115
CO-ORDINATION AND BALANCES
• non-equilibrium
POSTURE
GAIT
• Dressing
• feeding
• toileting
• brushing
HAND FUNCTION
• Tip to tip
• Side to pad
• hook
116
• Chorea
• tremor
PRE SCORE: 2
BOBATH TECHNIQUE:
flexor spasticity.
extended arm.
on forearm
holding of arm possible.Patient moves trunk backwards,
117
forwards, side ways
POST SCORE : 4
118
CASH SHEET 10
NAME : THANGAVEL
AGE :58
SEX; MALE
CHIEF COMPLAINT
CASE SHEET STUDY
HISTORY
• Consciousness
• Verbal response
• Oriented
Cognitive skill
• Dressing
119
• Memory
 Level of memory
• Normal
Emotional state
• Speech
• Aphasia
• Involvement of optic nerve
• Steregnosis
• Baregnosis

120
MOTOR SYSTEM
• Hypertone
• Circumference
 Arm
 Fore arm
• Wasting
• Hypertrophy
JOINT ROM
REFLEXES
• Exaggerated
121
Superificial
• Light touch
• Temperature
• Pressure
• pain
Deep
• Vibration
• crude touch
• Proprioception
• kinesthesia
• non-equilibrium

122
POSTURE
GAIT
• Dressing
• feeding
• toileting
• Transfer
• Combing
• brushing
HAND FUNCTION
• Tip to tip
• spherical
• Side to pad
• hook
123
• Cylindrical
124
UNTARY MOVEMENT
• Chorea
• tremor
PRE SCORE: 0
BOBATH TECHNIQUE:
flexor spasticity.
extended arm.
D. Weight bearing in sitting on affected side with support
on forearm
F.Gendle push-pull stimulates active extension of the
arm.
125
forwards, side ways
POST SCORE : 3
126
BRUNNSTROM
NO. OF PRE 1st 2nd 3rd POST
PATIENTS MONTH MONTH MONTH
SCORE SCORE
1. 0 1 3 4 4
2. 1 2 4 5 5
3. 2 3 4 5 5
4. 0 1 3 4 4
5. 1 2 3 5 5
BOBATH
NO. OF PRE 1st 2nd 3rd POST
PATIENTS MONTH MONTH MONTH
SCORE SCORE
1. 1 1 2 3 3
2. 0 1 2 3 3
3. 1 2 3 3 3
4. 2 2 3 4 4
5. 0 1 2 3 3
127
APPENDIX
 Motor activity log rating scale
0 - The weaker arm was not used at all for that activity
(never).
1 - The weaker arm was moved during that activity but
was not helpful (very poor).
2 - The weaker arm was of some use during that
activity but needed some help -from the stronger arm or
moved very slowly or with difficulty (poor).
3 - The weaker arm was used for the purpose indicated,
but movements were slow or were made with only some
effort (fair).
4 - The movements made by the weaker arm were
almost normal but not quite as fast or accurate as
normal (almost normal).
5 - The ability to use the weaker arm for that activity
was as good as before the stroke (normal)
128

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A CO MPAR ATIV E STUD Y TO FIN DO UT THE

EFFECT IVE NESS OF BRUNNSTR OM VS

Cerebrovascular accident or stroke is one of the major

causes of debilitation in the world. The major symptoms of

stroke are loss of muscle power, spasticity and in-

coordination of muscle activation. Stroke is the primary

cause of disability and the second leading cause of death

in many Countries, including Taiwan. Although the

mortality rate of stroke has declined, the Incidence and

prevalence of stroke continue to rise. The goal of

rehabilitation is to help Stroke patients to achieve as much

functional independence as possible and to maintain Quality

of life. Rehabilitation has an important role in reducing

the burden of long-term Stroke care on society.

Stroke is a non-traumatic brain injury, caused by

Occlusion or rupture of cerebral blood vessels, and

manifests as sudden appearance of Neurological deficits

characterized by loss of motor control, altered sensation,

cognition or Language impairment and disequilibrium.

Intracranial hemorrhage accounts for about 10- 15% of all

strokes, and the remaining 80-85% is caused by infarction.

psychological functions in variable severity. No two strokes

are identical and no two patients respond to treatments

identically. Therefore, The therapeutic approach requires

assessment of every individual patient and demands

Specialized professional knowledge, skills and creativity.

Stroke incidence: The incidence of first ever stroke

ranges from 84/1,00,000 peoples. These incidence change

to 141/1,00,000 peoples. Stroke incidence varies with

sex and age: In the young people of less than 35 years

of age, where stroke incidence is very low, the rate is

slightly higher in women than in men (mettinger et al

1984,lideguard et al 1986,nencini et al 1988). While in

people over the age of 35 years the incidence is

higher in men than in women.

Case fatality rate and survival: Fatality rate represents

the proportion of stroke patients who die early which is

usually defined as within 28 or 30 days of onset. Long term

survival improved (7years) from 22% to 40% in the 1940-

1980. Stroke mortality: The age of specific stroke mortality

/1,00,000 in people less than 45years of age to more than

1000/1,00,000 in people aged 75years or older.

Hemiplegia or hemiparesis caused by a stroke in the

middle cerebral artery distribution area is commonly seen

within the rehabilitation setting. Initially, limb weakness

and poor control of voluntary movement are noted and

associated with reduced muscle tone. As voluntary

movement improves, nonfunctional mass flexion and

extension of the limbs becomes apparent, i.e., synergy

patterns and mass contraction of multiple muscle

groups. Later, synergistic movement patterns gradually

disappear and, following the neurological motor recovery,

more isolated joint movements gradually develop (Sawner

& La Vigne, 1992).

Spasticity is a velocity-dependent increase in resistance

to muscle stretch that develops after an upper motor

neuron lesion (Lance, 1981; Katz, 1992). Spasticity develops

shortly after a completed stroke and usually persists if

impairment and disability. Jackson classified symptoms

after a central nervous system lesion as positive or

Positive symptoms are spontaneous and exaggerated

version of normal functions that reacts to specific

external stimuli. They include spasticity, increased deep

tendon reflexes and hyperactive flexion reflexes.