The Brunnstrom Stages of Stroke Recovery

The stroke recovery process is not impossible, but it is a bit challenging. Getting your normal life after stroke requires a lot of support and effort. Many patients are afraid of never fully recovering their muscle coordination, and wonder how long it will take to happen if it does.

Luckily, the occupation and physical therapy department understands these worries and has come up with multiple ways to help patients recover their muscle strength and coordination. There are seven-stroke recovery processes through which patients go through.

Commonly known as the Brunnstrom Approach, the seven stages see involuntary movement and spastic as a vital part of the process and utilizes them to aid rehabilitation.

What Is The Brunnstrom Approach?

The Brunnstrom approach is a product of a great Sweden physical therapist Signe Brunnstrom. The Brunnstrom Approach discusses how motor skills can be recovered throughout the patient’s body in seven simple steps.

In normal circumstances, muscle movements result from various muscle groups working together. Researchers  use the term “synergies” to explain the collaboration of the muscles in a human body. The brain plays a huge role in the coordination of the muscles; this becomes disrupted after a stroke.

After suffering from a stroke, your muscles are much weaker due to lack of coordination between the body and brain. As a result, your muscle synergies move in different abnormal patterns.

A majority of the stroke treatments are meant to help a patient’s body adjust to certain movements and muscle synergies. On the other hand, the Brunnstrom Approach encourages and teaches stroke patients to use the abnormal synergy patterns for their greater good.

Since its inception, the method has become one of the most popular and commonly used recovery process methods among patients as well as occupational and physical therapists. It is very effective in clinical settings and significantly improves involuntary muscles after suffering from a stroke.

Stage 1: Flaccidity

The first stage in Brunnstrom’s stroke recovery approach is the first shock period where flaccid paralysis sets in after stroke. Flaccid paralysis (flaccidity) is a medical term used to explain the total lack of voluntary movement.

Paralysis is brought by nerve damage, preventing muscles from receiving vital information from the brain; regardless of whether the brain is capable of moving the muscles or not.

In the initial stages of flaccid paralysis, the stroke patients are unable to move muscles on the affected side of the body. If this stage continues without physical therapy, the muscles become weaker and begin to deteriorate.

Muscles require to be constantly used to maintain their tone and formation, and flaccid paralysis does not let the muscles do this work.

In medical terms, the loss of the muscles is known as hypotonia. Hypotonia causes numbness and weakness interfering with a patient’s quality of life. Besides treatments and physical therapy to reduce hypotonia in Stage 1, lifestyle modifications are necessary to prevent limbs from injury.

Despite the damage that stroke does on the neurological, other muscles, and healthy brain cells can make it up for the damage. The patient’s body is full of multiple tools with the ability to reduce complications and lead them to new recovery phases.

It is advisable to start retraining the body and brain as early as possible, even though the patient may still be struggling with hypotonia and flaccid paralysis.

Stage 2: Dealing with Spasticity Appearance

The second stage in stroke recovery is when the basic limbs synergies redevelop as some muscles get activated and other muscles sharing the system begin to respond.

At this stage, muscles begin to make spastic, small and abnormal movements. While these movements are involuntary, they are positive signs in your recovery phase. However, if the movement does not happen on this stage, there is nothing to worry about.

Muscle synergies are a result of muscle coordinated movements to perform various tasks. The synergies allow certain movement types that involve reciprocal or cooperative activation muscles.

Since they are linked, a single activated muscle may lead to an activation of other muscles. The synergies may not allow the patients to move as they wish after a stroke. However, cell regrowth and neurological development occur after a stroke; new connections are formed in impaired tissues.

Two limb synergies determine an individual’s reactions to cell regrowth during the second stage of recovery.  The first one is the flexor synergy, which includes external rotation of the shoulder, flexion of the elbow, and supination of the forearm.

The second one is the extensor synergy, which involves internal rotation of the shoulder with elbow extension and pronation of the forearm. Besides the muscle synergies, a few stroke survivors also experience spasticity. This is an increase in your normal stretch reflexes. During stage 2, it represents itself as a resistance to passive movement. Stage 2 spasticity leads to movements on the upper body.

Inactive muscles still require stimulation to form connections to neutrons. Though the nerves may have been seriously damaged to allow voluntary movements, it may still happen on later stages of recovery. To keep this option open, keep moving your affected muscles and limbs.

Stage 3: Increased Spasticity

During this stage, spasticity increases to its peak. The stiffness and tightness is a result of the damage the stroke makes to the nerve pathways in the brain and spinal cord that controls the movement of muscles.

Inability to restrict the brain’s motor neurons leads to increased muscle contractions. Spasticity causes the muscles to be abnormally stiff and tight causing pain and discomfort as well as interfering with speech and movement.

Synergy patterns start to emerge on stage 3, and minimal voluntary movement should be expected. There is also increased involuntary movement at this stage because the patient can initiate the muscle movement but not control it yet.

The latter is strengthened by occupation and physical therapy. Muscles suffering from severe spasticity like the ones in stage 3 of stroke recovery may not be easily exercised. Caregivers and patients should be taught on the importance of exercising daily and maintaining range of motion. It is advisable to avoid any stressful activities at this stage of early training.

Passive range-of-motion (PROM) exercises should be done on this stage to improve the patient’s range of motion. Treatment includes how far the patient’s body can move, for example bending the knee to the chest or raising the hand over the head.

Stage 4: Decreased Spasticity

At stage 4, spasticity starts decreasing. Patients will, therefore, start regaining their control in their extremes and they will have a limited ability to move normally. The movements will still be non-aligned with muscle synergies, but this improves rapidly at this stage.

The main focus of this stage is to improve muscle control and strengthen the muscles. Now you can continue to work on a range of motion and building up the strength of your limbs because you are regaining your motor control and can, therefore, make limited controlled movements.

Do not neglect muscle stretching at this point, despite the progress it is still important.

Therapists use an active-assisted range of motion (AAROM) exercises when a stroke patient gains the ability to make controlled movements but still needs to practise  the moves or make complete movements.

The patients get support from therapists to make the session easier. For instance, the therapist may use their body to hold the limb or use other support devices. SaeboMAS and other gravity-assisted gadgets are imperative in improving a patient’s movement.

Once a patient has regained control and can perform several exercises without assistance, they can begin active range-of-motion (AROM) exercises. The latter involves moving the affected areas to their maximum range, for example rotating a wrist or bending an elbow.

AROM exercises come with several advantages such as increased endurance, muscle strength, and flexibility. It is important to note that range-of-motion exercises should be done on both the affected and non-affected sectors.

Patients are advised to consult physiotherapists when designing their stage 4 recovery exercises. This is to ensure they are taught on the right tools and equipment, right exercises, and professional assistance in the first weeks.

Stage 5: Complex Movement Combinations

At this stage, spasticity reduces significantly, and the synergy patterns are more coordinated hence making voluntary movements possible and more advanced. Although a patient may still be having abnormal movements, they seriously decline on stage 5.

The patients will have the ability to do more for themselves as they can now control the affected limbs and even move them deliberately. Isolated movements at this juncture are also possible.

It is worthwhile to note that all voluntary movements involve the brain sending motor impulses for controlled movement.

Thoughts start the motor signals and involve a reaction to sensory stimuli. The sensory stimuli triggering voluntary reaction are located in many sectors of the brain.

All voluntary movements are for specific purposes. They are practised moves that are perfected through repetition and require less attention. The moves include using utensils to feed, swinging a bat, combing hair, driving a vehicle and swimming.

Stage 6: Spasticity Disappears

At stage 6, a patient’s fully recovery is around the corner. The spasticity and abnormal movements end completely, and motor control is regained. A patient at this stage can move affected parts in a coordinated way to extremities. This is because the synergy patterns become more coordinated at this stage.

Stage 7: Normal Function Returns

The final stage of the Brunnstrom’s Approach is when a patient regains full control in affected areas. They can now move their hands, feet, legs, arms voluntarily in a controlled manner.

The patients have full control of their muscles, so the synergies have also returned to their normal state. At this point, both the patient and the therapist have accomplished their common goal and objective.

Stroke Recovery In 7 Stages: Spasticity As A Process

Through the seven stages of stroke recovery, Brunnstrom changed the whole idea and concept of approaching stroke recovery that occupational and physical therapies were using initially. She explained that the abnormal movements and spasticity were part of the recovery process.

She made it possible for patients to benefit themselves from abnormal movements instead of ignoring them and subsidizing them.

In every phase, there are increasing synergies for use. With the help of the Brunnstrom Approach, occupational and physical therapists help patients to use the synergies available to them. Through these techniques, movement and motor skills are improved and eventually regained.

PS: There is no one verified stroke recovery process that applies to every patient. The stages explained above may not work for every patient. However, therapists are using Brunnstrom Approach to help patients recover as it has been proven to be effective. With the improved medical technology, therapists can incorporate tools such as SaeboMAS, SaeboGlove, and SaeboReach with Brunnstrom approach to help patients gain independence.

CARE Concierge provides Nurses, Therapists & Caregivers to the home to assist the family and patient with stroke recovery. Our professional caregivers provide care while our Physiotherapist and Speech Therapists provide the necessary treatments to support recovery, all this in the comforts of your own home. For more information, contact CARE Concierge at 1300 22 8822 or on WhatsApp at +60327243828