THE BRUNNSTROM STAGES

OF STROKE RECOVERY
BY: Mustafa Zaveri
 WHAT IS THE BRUNNSTROM
APPROACH?
• The Brunnstrom Approach was developed in the 1960’s by Signe Brunnstrom, an
occupational and physical therapist from Sweden. With seven stages, the Brunnstrom
Approach breaks down how motor control can be restored throughout the body after
suffering a stroke.
 SYNERGIES
• Normally, muscle movements are the result of different muscle groups working together.
Researchers have termed this collaboration between muscles as “synergies”. The brain
has the delicate task of coordinating these movements, many of which become severely
affected after a stroke.
• After the stroke has occurred, your muscles become weak due to the lack of coordination
between the brain and body. This causes the muscle synergies to move in abnormal
patterns. Most treatments offered to stroke patients will focus on trying to inhibit atypical
muscle synergies and movements. The Brunnstrom Approach, on the other hand, teaches
patients how to use the abnormal synergy patterns to their advantage.
 STAGE 1: FLACCIDITY
• The first stage in Brunnstrom’s Approach is
the initial period of shock immediately after
stroke where flaccid paralysis sets in.
Flaccid paralysis (flaccidity) is the medical
term for a complete lack of voluntary
movement. This paralysis is caused by
nerve damage that prevents the muscles
from receiving appropriate signals from the
brain, whether or not the brain is still
capable of moving those muscles.
 STAGE 2: DEALING WITH THE
APPEARANCE OF SPASTICITY
• The second stage in stroke recovery marks the redevelopment of some basic limb synergies
as certain muscles are stimulated or activated and other muscles in the same system begin to
respond. Muscles begin to make small, spastic, and abnormal movements during this stage.
While these movements are mostly involuntary, they can be a promising sign during your
recovery. Minimal voluntary movements might or might not be present in stage two.
• These synergies may limit the patient’s
muscles to certain movements, preventing
them from completing the voluntary
movements they want to make. However,
as neurological development and cell
regrowth occur after a stroke, some new
connections may be formed to impaired
muscle tissue.
• Two limb synergies determine a patient’s reactions to cell regrowth during Stage 2 of
recovery. The first, the flexor synergy, includes the external rotation of the shoulder, flexion
of the elbow, and supination of the forearm. The second, the extensor synergy, includes
internal rotation of the shoulder with elbow extension and pronation of the forearm. These
synergies may produce one or both of the following postures, which indicate varying levels
of brain trauma after stroke.
 STAGE 3: INCREASED SPASTICITY
• Spasticity in muscles increases during stage three of stroke recovery, reaching its peak.
Spasticity is a feeling of unusually stiff, tight, or pulled muscles. It is caused by damage
from a stroke to nerve pathways within the brain or spinal cord that control muscle
movement. The lack of ability to restrict the brain’s motor neurons causes muscles to
contract too often. Spasticity causes an abnormal increase in muscle stiffness and tone
that can interfere with movement, speech, or cause discomfort and pain.
• During stage 3, synergy patterns also start to emerge and minimal voluntary movements
should be expected. The increase involuntary movement is due to being able to initiate
movement in the muscle, but not control it (yet). The appearance of synergy patterns and
coordination between muscles facilitate the voluntary movements which become stronger
with occupational and physical therapy.
• Muscles with severe spasticity, like the
ones in stage 3 of stroke recovery, are
likely to be more limited in their ability to
exercise and may require help to do this.
Patients and family/caregivers should be
educated about the importance of
maintaining range of motion and doing
daily exercises. It is important to
minimize highly stressful activities this
early in training.
 STAGE 4: DECREASED SPASTICITY
• During stage four of stroke recovery, spastic muscle movement begins to decline. Patients
will regain control mostly in the extremities, and they will have a limited ability to move
normally. The movements may still be out of sync with muscle synergies, but this will
improve quickly over the length of this stage.
• The focus during this stage is to strengthen and improve muscle control. Now that you are
regaining motor control and can start to make normal, controlled movements on a limited
basis, you can start to build strength back in your limbs and continue work on your range of
motion. Continuing to stretch out your muscles is still important in this stage.
• Therapists use active-assisted range of
motion (AAROM) exercises when a stroke
patient has some ability to move but still
needs help to practice the exercises or
complete the movement. A therapist may
help guide the movement with their own
body (hold the limb, for example) or use
bands and other exercise equipment to
support the patient.
• You can begin active range-of-motion
(AROM) exercises once you have regained
some muscle control and can perform some
exercises without assistance. They often
involve moving a limb along its full range
of motion, like bending an elbow or
rotating a wrist. AROM exercises increase
flexibility, muscle strength, and endurance.
Range-of-motion exercises should be
practiced equally on both the affected and
unaffected sides of the body.
 STAGE 5: COMPLEX MOVEMENT
COMBINATIONS
• In stage 5, spasticity continues to decline and synergy patterns within the muscles also
become more coordinated, allowing voluntary movements to become more complex.
Abnormal movements also start to decline dramatically during stage 5, but some may still be
present.
• The patient will be able to make more controlled and deliberate movements in the limbs that
have been affected by the stroke. Isolated joint movements might also be possible.
 • VOLUNTARY MOVEMENTS ARE PURPOSEFUL AND
GOAL-DIRECTED. THEY ARE LEARNED MOVEMENTS
THAT IMPROVE WITH REPETITION OR PRACTICE AND
REQUIRE LESS ATTENTION. SOME EXAMPLES INCLUDE
COMBING HAIR, SWINGING A BAT, DRIVING A CAR,
SWIMMING, AND USING EATING UTENSILS.

• All voluntary movements involve the brain,

which sends out the motor impulses that
control movement. These motor signals are
initiated by thought and must also involve a
response to sensory stimuli. The sensory
stimuli that trigger voluntary responses are
dealt with in many parts of the brain.
 STAGE 6: SPASTICITY DISAPPEARS
• At stage six, spasticity in muscle movement disappears completely. You are able to move
individual joints, and synergy patterns become much more coordinated. Motor control is
almost fully restored, and you can coordinate complex reaching movements in the affected
extremities. Abnormal or spastic movements have ceased, and a full recovery may be on the
horizon.
 STAGE 7: NORMAL FUNCTION
RETURNS
• The last stage in Brunnstrom’s Approach is when you regain full function in the areas
affected by the stroke. You are now able to move your arms, legs, hands, and feet in a
controlled and voluntary manner.

• Since you have full control over your muscle movements, synergy patterns have also
returned to normal. Reaching stage seven is the ultimate goal for therapists and patients
alike.