There are six Brunnstrom stages that describe the process of movement recovery after stroke. Here's what each stage means for your arm and what you can do for home exercise to maximize function.

Understanding the Brunnstrom Stages of Stroke Recovery

What are the Brunnstrom Stages of Stroke Recovery?
The brunnstrom stages is one of the most well-known stroke recovery stages which
is also known as the Brunnstrom approach. The Brunnstrom stages was developed by
physical therapist Signe Brunnstrom in the 1960’s. When a stroke occurs,
typically it affects one side of the body. The Brunnstrom approach describes the
sequence of motor development and reorganization of the brain after stroke. So
you can check the status of your stroke recovery through the Brunnstrom stages.

You can think of it as a built in organizational system. Our brain automatically
recruits lower functioning reflexes, just to get any movement. Then it begins to
sort out what is useful and what connections we need to build at a higher level.

It's also a way to know what movement actions to take advantage of during your
post stroke rehabilitation.


Table of contents

 * Stage 1: Flaccidity
 * Stage 2: Spasticity Appears
 * Stage 3: Increased Spasticity
 * Stage 4: Decreased Spasticity
 * Stage 5: Spasticity Continues to Decrease
 * Stage 6: Spasticity Disappears and Coordination Reappears
 * How long will it take to recover from stroke?




What to do for Stroke Rehabilitation or stroke recovery in each stage


Stage 1: Flaccidity
During this stage the muscles on your affected side aren't able to move and they
might feel limp and floppy.

What can I do during this stage?
Passive range of motion [https://www.youtube.com/watch?v=7G97Fu3GuVU] is one of
the most important exercises you can do in this stage. Passive simply means that
you are using your other arm to assist with movement or someone else is moving
your arm for you.

The main reason to complete these exercises is that it increases sensory input
to the brain. Right now, there aren’t any signals being sent from the brain to
the muscle to activate it, but you can send signals from the skin and muscles
about touch and movement to the brain and remind your brain that your affected
side is awake and ready to learn again!

Stage 2: Spasticity Appears
In this stage, muscles may begin to tighten reflexively and have difficulty
relaxing. This is called spasticity
[https://www.neofect.com/us/blog/spasticity-and-stroke]. This movement is
usually involuntary and in response to an outside stimulus, such as a poke. The
brain is still having a difficult time sending any signals to the muscles for
voluntary movement.

What can I do in this stage?
Passive range of motion continues to be key in this stage. With spasticity
[http://www.neofect.com/us/blog/how-to-improve-spasticity-spinal-cord-injury/],
even passive movement can be challenging. When we don’t move a joint, the
tendons start to stiffen and can make movement even more difficult in the
future. Think of it as the hinge of a door that can get rusty and hard to open
over time if it’s not taken care of. Oil your joints with movement either
passive or active-assisted range of motion.

Active-assisted range of motion [https://www.youtube.com/watch?v=-hise8ZUIAk] is
a combination of passive and active range of motion. You might be able to
activate your shoulder muscles to lift your arm up, but not all the way. For
active assisted range of motion, you want to activate the muscle as much as you
can and then use your unaffected hand to move the joint through the full range
of motion.



Stage 3: Increased Spasticity
During this stage, certain muscles might tighten more and can be more difficult
to relax. Multiple muscles might fire together when we try to move our affected
side. This is called a muscle synergy and we can use our synergies to complete
an activity if we understand it.

What can I do in this stage?
In addition to keeping up with your passive or active-assistive range of motion
exercises, it’s important to understand your synergies so you can use them
purposefully. The more we can send signals from the brain to the muscle the
stronger those signals become, and the best way to increase the amount of
signals is to incorporate your exercises into the things you already do during
the day.

There are two typical synergy patterns in this stage: the flexor synergy and the
extensor synergy. A flexor synergy at the arm would have the shoulder rotating
outward, at the same time the elbow flexes and forearm rotates out. Think about
the movement that happens when you try to touch the ear on the same side of your
body.

An extensor synergy is opposite: the shoulder rotates inward, the elbow
straightens, and the forearm rotates downward. Think about the movement that
would happen if the back of your hand touched the inside of your opposite knee.

If we know that these are the muscles that want to fire together, we can use it
to help function. For instance, you might be working on feeding yourself, but
struggling to reach your mouth. If you think about moving your shoulder does it
help move your elbow and get closer to your mouth? Little shifts in thinking can
help you be more successful, which will help encourage you to keep going!

Stage 4: Decreased Spasticity
During this stage of motor recovery, the involuntary muscle tightness
(spasticity) starts to decrease. Your brain is more successful at sending
signals to specific muscles to activate. You’re still likely to use muscle
synergies, but you're able to move outside of them as well.

What can I do in this stage?
This is when we want to focus on isolating movements and strengthening those
connections in the brain to certain muscles with active range of motion
exercises [https://www.youtube.com/watch?v=XeYfdku7RA0]. Repetition is critical
for neural-reorganization. We can’t repair the damage that was done to the brain
after stroke, but we can teach a different area of the brain to do its job. We
want to do movements outside of our muscle synergies to improve how our brain
sends signals.

Stage 5: Spasticity Continues to Decrease
During this stage of motor recovery, the signals from the brain to the muscle
are even more successful and the muscle tightening of spasticity is minimal,
allowing your affected side after stroke to move more complexly.

What can I do in this stage?
Strengthening [https://www.youtube.com/watch?v=EVQcgYQyzz0] is the key
ingredient in this stage. We’ve seen a progression in the stages, but also in
the treatment. We’ve started with passive range of motion, then moved to active
assisted range of motion, then active range of motion within synergies, then
isolating muscles. Now it’s time to add resistance to movement. Add small
weights or use a household item like a half-full water bottle to your exercises.
Incorporate theraband or theraputty to your daily routine.



Stage 6: Spasticity Disappears and Coordination Reappears
During this stage of motor recovery, spasticity
[hhttp://www.neofect.com/us/blog/how-to-improve-spasticity-spinal-cord-injury/] 
disappears completely and coordination quickly begins to improve. During this
stage motor control is almost fully restored!

What can I do in this stage?
Continue strengthening the muscles that need strengthening and add coordination
exercises that incorporate both sides of the body: golfing, shuffling cards,
etc. If there’s something you used to do that you want to get back to doing,
practice it. Your brain will be motivated to practice the coordination required
for an exciting activity.

How long will it take to recover from stroke?
As much as we'd like for there to be a clear cut answer, every person is
different. Some may see more rapid progress in days, weeks, or months after
stroke. It might take years for others. Some people may some may spend more time
than they would like to on a stage.

We do know that recovery has no end date. Some stroke patients and stroke
survivors(stroke victims) might not have an occupational therapist or
rehabilitation program to follow. Each day is a new opportunity to look at where
we're at and take action to get to where we want to be. The Brunnstrom approach
gives us roadmap.



--
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Stroke Recovery

The National Institutes of Health Stroke Scale (NIHSS) is a stroke assessment tool for clinicians to evaluate and document the impact of stroke on a patient.

What is the National Institutes of Health Stroke Scale (NIHSS)?

The National Institutes of Health Stroke Scale (NIHSS)
[https://www.sralab.org/rehabilitation-measures/national-institutes-health-stroke-scale] 
is an clinical assessment that is used to evaluate and document stroke severity.
This assessment is first performed by a certified clinician in the emergency
department once a patient is suspected of having a stroke. The test will be
repeated throughout hospitalization to determine progression of stroke.



The NIHSS includes 11 items and is scored out of 42 points, with greater scores
indicating greater disability. The NIHSS looks at many domains including
alertness, visual function, muscle strength (in the face, arms, and legs),
sensory function, coordination, and language comprehension and production.



NIHSS scores can be used to predict short and long-term functional recovery from
stroke. Results from this assessment help clinicians create an optimal medical
and therapy treatment plan. Because the NIHSS is complicated, the medical team
may choose to explain results in simpler terms to a stroke patient or their
loved ones. It is important to know that you can always ask a doctor, nurse, or
therapist to explain things in greater detail or differently to ensure that you
fully understand.

Learn More:

NIH Stroke Scale International [http://www.nihstrokescale.org/]
View the NIHSS Instrument [stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf]
Learn what an NIHSS Score Means
[https://www.mdcalc.com/nih-stroke-scale-score-nihss]

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