Apr 23, 2020
Understanding the Brunnstrom Stages of Stroke Recovery

What are the Brunnstrom Stages of Stroke Recovery?

The Brunnstrom stages of recovery, also known as the Brunnstrom approach 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.

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.

What to do for Stroke Rehabilitation 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 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. 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, 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 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.

Stretching spastic arm

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. 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 to move more complexly.

What can I do in this stage?
Strengthening 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.

lifting weights

Stage 6: Spasticity Disappears and Coordination Reappears

During this stage of motor recovery, spasticity 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 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.

Clarice Torrey
Clinical Manager / Occupational Therapist

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