Bobath vs. PNF vs. Brunnstrom: The "Big Three" Neuro Approaches Compared

In neurological rehabilitation, there is no "one size fits all." Over the last century, three major schools of thought have shaped how we treat stroke and TBI: Bobath (NDT), Proprioceptive Neuromuscular Facilitation (PNF), and Brunnstrom. While modern practice is often eclectic (mixing approaches), understanding the core philosophy of each is vital for exams and clinical reasoning. This guide compares them head-to-head.

1. High-Yield Comparison Table

This table summarizes the fundamental differences in philosophy and technique.

Feature	Bobath / NDT	Brunnstrom	PNF
Philosophy	Inhibit abnormal tone; Facilitate normal movement patterns.	Evolution in reverse; Synergies and reflexes are necessary stages of recovery.	Stimulate proprioceptors to improve neuromuscular response; Use diagonal patterns.
View on Spasticity	Enemy: Must be inhibited/prevented at all costs. Do not strengthen spastic muscles.	Friend (Initially): Encouraged in early stages to gain movement, then modified later.	Addressed via reciprocal inhibition and relaxation techniques (Hold-Relax).
Key Techniques	Reflex Inhibiting Postures (RIPs), Key Points of Control, Handling.	Associated Reactions, 7 Stages of Recovery, Synergistic movement.	D1/D2 Diagonals, Rhythmic Initiation, Slow Reversal, Irradiation.
Sensory Focus	Proprioception & Tactile (Handling).	Exteroceptive (stroking, tapping) & Proprioceptive.	Proprioceptive (Stretch, Resistance, Approximation, Traction).

2. Bobath / NDT (Neuro-Developmental Treatment)

Founders: Berta and Karel Bobath (1940s).
Core Concept: Spasticity and abnormal reflexes prevent normal movement. We must stop ("inhibit") the bad movements and guide ("facilitate") the good ones.

Key Principles:

• Inhibition: Using **Reflex Inhibiting Postures (RIPs)** to reduce tone (e.g., extending a spastic arm).
• Facilitation: The therapist uses **Key Points of Control** (Proximal: Shoulder/Pelvis; Distal: Hand/Foot) to guide the patient’s movement.
• Quality over Quantity: It is better to do one movement correctly than ten movements with a synergy pattern.

3. Brunnstrom Approach (Movement Therapy)

Founder: Signe Brunnstrom (1950s).
Core Concept: The damaged brain regresses to primitive patterns. Recovery follows a set sequence (The 6 Stages). We should **use** reflexes and synergies to get *any* movement, then refine it.

The Major Difference: While Bobath says "Stop the Synergy," Brunnstrom says "Use the Synergy" (in the early flaccid stage) because some movement is better than no movement.

Key Principles:

• Associated Reactions: Resisting the good limb to trigger movement in the bad limb (Raimiste’s phenomenon).
• Synergies: Encouraging Flexor or Extensor synergies initially.
• Progression: The goal is to move *through* the synergy stages to isolated movement.

4. PNF (Proprioceptive Neuromuscular Facilitation)

Founders: Kabat, Knott, and Voss (1940s).
Core Concept: Functional movements in daily life are **spiral and diagonal**, not linear. Strong body parts can help weak ones via **Irradiation** (overflow of energy).

Key Principles:

• Diagonal Patterns: D1 and D2 patterns (Flexion/Extension) for Upper and Lower limbs.
• Maximal Resistance: Resistance is applied to recruit more motor units.
• Stretch Reflex: A quick stretch at the start of the movement facilitates the contraction.
• Irradiation: Resisting the strong leg to make the weak leg contract.

5. Revision Notes (The "Cheat Sheet")

Bobath (NDT): Normalize tone. Hands-on facilitation. Quality is King. Never use abnormal effort.
Brunnstrom: Stages of Recovery. Use reflexes/synergies early. Primitive → Isolated.
PNF: Diagonals (D1/D2). Spirals. Resistance. Irradiation. Good for strengthening and coordination.
Modern View: Motor Relearning Program (MRP) and Task-Specific Training have largely superseded strict adherence to Brunnstrom, but elements of all three are used in eclectic practice.

6. FAQs

Q1. Which approach is best for flaccidity?

Brunnstrom is often favored for flaccidity because it actively encourages reflexes and associated reactions to "wake up" the limb. PNF Rhythmic Initiation is also useful.

Q2. Does Bobath allow strengthening?

Historically, Bobath discouraged heavy resistance because they feared it increased spasticity. Modern NDT has evolved and now incorporates functional strengthening, but traditionally, PNF is the "strengthening" approach.

Q3. What are D1 and D2 patterns?

These are PNF patterns. Example: D1 Flexion is "Safety Belt" motion (grabbing belt, pulling up and across). D2 Flexion is "Drawing a Sword" motion.

7. 10 Practice MCQs

Q1. Which approach strictly discourages the use of abnormal synergistic patterns?

Answer: A) Bobath focuses on inhibiting abnormal patterns to promote normal quality.

Q2. "Irradiation" or overflow of strength from strong to weak muscles is a core concept of:

Answer: B) PNF uses resistance to strong muscles to facilitate weak ones.

Q3. Using "Associated Reactions" (e.g., resisting the good arm to move the bad arm) is characteristic of:

Answer: C) Brunnstrom uses these primitive spinal reflexes to initiate movement in flaccid stages.

Q4. Key Points of Control (Shoulder, Pelvis) are central to:

Answer: A) Therapists use these points to manipulate tone and guide movement.

Q5. Which approach utilizes diagonal and spiral movement patterns?

Answer: C) Based on the observation that functional movements are rarely straight lines.

Q6. Reflex Inhibiting Postures (RIPs) are used to:

Answer: A) Placing a limb in a position that counteracts the spastic pattern.

Q7. According to Brunnstrom, Stage 3 of recovery is characterized by:

Answer: B) Stage 3 is the peak of spasticity where the patient can move voluntarily but ONLY within the synergy.

Q8. "Rhythmic Initiation" is a technique belonging to:

Answer: B) A progression from passive -> active-assisted -> active movement, often used for Parkinson's or high tone.

Q9. Which approach views recovery as "Evolution in Reverse"?

Answer: C) Brunnstrom believed higher centers lose control, revealing primitive spinal reflexes (like in infants).

Q10. In PNF, a "Quick Stretch" is applied to:

Answer: B) Stimulates the muscle spindle to aid initiation of movement.

References

• O’Sullivan, S. B., & Schmitz, T. J. (2019). Physical Rehabilitation. F.A. Davis.
• Voss, D. E., Ionta, M. K., & Myers, B. J. (1985). Proprioceptive Neuromuscular Facilitation. Harper & Row.
• Bobath, B. (1990). Adult Hemiplegia: Evaluation and Treatment. Heinemann Medical Books.
• Sawner, K. A., & LaVigne, J. M. (1992). Brunnstrom's Movement Therapy in Hemiplegia. Lippincott.