Stroke recovery stages by Brunnstrom

Stroke recovery stages

This article will go through the Brunnstrom stroke recovery stages. And what to expect as you recover and pass through all of the stages.

Stroke recovery stages are the steps that help therapists/survivors to track their stroke recovery progress.

After the stroke happens, your muscles become extremely weak due to the lack of coordination between the body and brain. This causes the muscle synergy to move in an unexpected pattern. Most treatments for stroke patients still focus on trying to inhibit abnormal movements and muscle synergies. On the other hand, these stages teach patients how to use those synergy patterns to their advantage. And allow the patients to gain most of their recovery roadmap.

What are the Brunnstrom Stroke Recovery Stages?

In 1960, Signe Brunnstrom, a physical therapist in Sweden, developed his view on the “stroke recovery stages”.

His unique approach highlights the 2 main things. The sequence of motor development and reorganization of the brain after stroke. 

Brunnstrom stroke recovery stages serve as a roadmap. And also as a guide to check where you’re at during the process of recovery regarding the physical abilities of your body.

These steps and stages have become a popular choice among both occupational and physical therapists. As well as patients since its inception. It is also highly effective in clinical settings. And can dramatically improve voluntary muscle movements for all stroke patients.

In this article, we will highlight all seven different stages. Brunnstrom did a good job of breaking down how motor control can be restored. Especially throughout the body after suffering a stroke.

  1. Flaccidity
  2. The Appearance of Spasticity
  3. Abnormal Muscle Tightness
  4. Reduced Spasticity
  5. Continuous Decrease in Spasticity
  6. Coordination Reappears

Stage 1: Flaccidity

The first stroke recovery stage represents a period of shock. Right immediately after stroke where flaccid paralysis sets in. 

Flaccidity is the medical term when a patient is missing all voluntary movement. Flaccid paralysis happens because of nerve damage. That’s preventing the muscles from receiving correct signals from the brain. Whether or not the brain is still able to move those muscles.

In the early state of flaccidity, patients encounter multiple difficulties. The stroke victims cannot trigger any muscle movements on the affected side of their body. If this continues for long enough without physical therapy or intervention. The unused muscles become much weaker and atrophy beings to settle. In simple terms, muscles need to be used in order to retain their tone and definition. While flaccidity prevents muscles from doing this important work.

The medical term for this muscle tone loss is called hypotonia. Hypotonia causes weakness and numbness that vigorously interferes with a patient’s quality of life. In addition to treatments and therapy exercises that reduce the severity of hypotonia. This condition also requires lifestyle changes such as protecting the affected limbs from injury. Though stroke does serious damage to the brain. Other healthy brain cells and muscles can help make up for some of the damage. In reality, the patient’s own body is full of mechanisms that reduce complications. While increasing the patient’s likelihood of entering new stages of recovery. It’s never too early to start retraining the body and brain after a stroke. Even if the patients are still experiencing the signs of flaccidity and hypotonia.

What can the patient do during this stage?

The passive motion simply means that you are using your other arm to assist with the movement. Or with someone else that can assist them in moving your arm.

The main reason to start exercises above is that they increase sensory input to the brain. Currently, there aren’t many signals being sent from the brain to the muscles for activating them. But the brain can receive the signals from the skin and muscles when you feel touched or do any movement. Those signals remind your brain that the affected side is still there and ready to start learning again!

Stage 2: The Appearance of Spasticity

The second stroke recovery stage represents the progress of some basic limb synergies. As certain muscles are being stimulated or activated again. And other muscles in the same system begin to respond.  During this stage, muscles begin to make small, abnormal, and spastic movements. While these movements are still mostly involuntary. They are a promising sign your recovery is going the right way. But still, minimal voluntary movements might or might not be present in stage two.

Muscle synergies are a common result of muscle coordination to perform different tasks. These synergies allow common patterns of movement. Movements that involve either cooperative or reciprocal muscle activation. We should all know that muscles are linked. And it means that one activated muscle may lead to partial or complete response in other muscles in that area. These synergies can cause some limitations to the patient’s muscles to certain movements. They can prevent them from completing the voluntary movements they want to make. However, the process of neuroplasticity is always happening after a stroke. It’s a sign that some new connections may be formed to handle impaired muscle tissue.

The synergy of two limbs determines a patient’s reactions to cell regrowth during stroke recovery stages. Firstly, the flexor synergy, includes the external shoulder rotation, elbow flexion, and forearm supination. And the extensor synergy, includes internal shoulder rotation, elbow extension, and forearm pronation. Pronation and supination are terms that describe the up or down orientation of your hand. When your forearm faces up, it’s supinated. When your forearm faces down, it’s pronated. Mentioned synergies can produce one or both of the following postures. Which indicate varying levels of brain trauma caused by stroke.

What else can a stroke patient experience in during stroke recovery stages?

It has shown that 40 percent of stroke survivors also experience signs of spasticity during this stage. This is a speed-dependent increase in your normal stretch reflexes. And during this stage, it presents as resistance to passive movements. Spasticity can also contribute to the convulsive upper body movements characteristic of the flexor and extensor synergies.

Unused limbs still need stimulants to maintain and form connections to the neurons. Even if the nerves that control your affected limbs may be too damaged to create voluntary movements. It could still be possible to regain movement in later stroke recovery stages. In order to leave the possibility of regaining movement openly. Even to prevent the body’s tendency toward learned non-use. It’s important to continue using and moving the patient’s affected limbs and muscles as much as possible. 

What can the patient do during this stage?

All of the focus still lays in passive range of motion exercises. Even though with spasticity, passive movement can be difficult. When we don’t move our joints, the ligaments start to stiffen and can make movement difficult in the future. Think of it as the door hinge that can get rusty and hard to open over time if it’s taken care of. Oil your joints with different movements. Such as passive or active-assisted range of motion.

Active-assisted range of motion is the combination of the passive and active range of motion. Patients may be able to activate their shoulder muscles to lift their arms up. But still not all the way up. The goal for this range of motion is to activate the muscle as much as you can. And then with the help of your unaffected hand move the joint through the full range of motion.

Stage 3: Increase in Spasticity or Abnormal Muscle Tightness

During stroke recovery stage 3, spasticity in muscles increases and reaches its peak. Spasticity is a condition where muscles are unusually stiff or tight. It is a cause of damage from a stroke to nerve pathways that control muscle movement. The lack of capability to restrict the brain’s motor neurons causes muscles to contract way too often. Spasticity causes a bizarre increase in tone and muscle stiffness. And it can interfere with speech, movement, or cause discomfort and pain.

Synergy patterns also start to show and minimal voluntary movements should be present. The increased involuntary movement happens because you are able to initiate movement in the muscle. But not yet control it. The display of synergy patterns between muscles facilitates voluntary movements. Which become stronger with physical and occupational therapy.

Muscles with extreme spasticity, are likely to be more limited to exercise and may require bigger help to do this. Caregivers and patients should be well informed about the importance of the range of motion and daily exercises. It is also very important to minimize stressful activities this early in rehabilitation therapy.

What can the patient do during this stage?

You should continue with your passive or active-assistive range of motion exercises. But it’s also important to understand your synergies so you can use them purposefully. The more signals sent from the brain to the muscle the stronger those signals become. And the best way to increase the number of signals is by the combination of exercises and daily activities.

In this stage, we use two synergy patterns. And those are the flexor and extensor synergies. 

A flexor synergy for the arm would have a rotation of the shoulder outward. While at the same time the forearm rotates out and the elbow flexes. This is the movement that happens when you try to touch the ear on the same side of your body.

An extensor synergy is completely opposite of the flexor one. The shoulder rotates inward, the elbow straightens out, and the forearm rotates downward. This is the movement that happens when you try to touch the opposite knee with the back of your hand.

If we know muscles that want to work together, we can use them to help function even better. For example, you might be working on feeding yourself. But struggles happen when you try to reach your mouth. If you think about moving your shoulder should you also move your elbow and get closer to your mouth? Little shifts like this can help you be more successful. Which will surely help encourage you to keep on going!

Stage 4: Reduced Spasticity

During the fourth stage of stroke recovery, spastic muscle movement begins to decrease. Stroke victims should regain control mostly in the extremities. While they still have a limited ability for normal movement. The movements may still be a little bit out of sync with muscle synergies. But this will improve quickly over the course of this stage.

The focus in this stage lays in strengthening and improving muscle control. Now that you are regaining some motor control. And you can also start to make normal, controlled movements on a limited basis. You can start to build the strength back in your limbs and continue to work on your range of motion. Stretching out your muscles is still crucial in this stage.  

Therapists in this stage use active-assisted range of motion exercises. Especially since a stroke patient has some ability to move. But still needs help to exercise or complete the full movement. A therapist may help guide the movement with their own body parts. Or even use some equipment such as bands to support the patient.

Patients can begin active range-of-motion exercises once they have regained some muscle control. And can perform some of these exercises without needed assistance. They involve a special spectrum of exercises. Such as moving a limb along its full motion range, for example bending an elbow or rotating a wrist. These exercises are designed to increase flexibility, muscle strength, and endurance. But don’t forget that exercises should be practiced equally on both the affected and unaffected sides of the body.

How can patients build their stroke recovery plan during stroke recovery stages?

Of course, when it comes to building a stroke recovery exercise program for this stage. Patients should always consult with a professional physical or occupational therapist. Or they can use Motus Health, an physical and cognitive therapy mobile application designed by a group of medical experts. That offers everything a patient and his caretaker need in one place.

What can the patient do during this stage?

This is when we want to focus on isolating different sets of movements. And strengthen connections in the brain to muscles with active range of motion exercises. Repetition is a key for neural reorganization. We can’t repair the damage that has happened because of a stroke. But we can for sure teach a different area of the brain to do its job. We want to focus patients on movements outside of our muscle synergies. The final goal is to improve how their brain is sending its signals to the rest of the body.

Step 5: Continuous Decrease in Spasticity

In this stroke recovery stage, spasticity continues to decline even more. While synergy patterns within the muscles also become more coordinated. Allowing voluntary movements to become more and more complex. Abnormal movements also start to dramatically decline during this stage. But some of those movements may still occur, so don’t worry.

The stroke patient will be able to make more controlled and calculated movements. Especially in the limbs that have been affected by the stroke. In this stage, isolated joint movements can also be a possibility.

All voluntary movements involve brain function and signals. They send out the motoric impulses that can control movement. These motor signals are initiated by thoughts. And they must also involve a response to sensory stimulants. This is very important! Because these sensory stimulants that trigger voluntary responses are dealt with in different parts of the brain. 

Voluntary movements should be goal-directed and purposeful. They have learned movements that improve with repetition or practice. And require much less attention. Mentioned movements are associated with daily activities. Such as hair combing, driving a car, swimming, and using utensils.

What can the patient do during this stage?

The strengthening of muscles is the key part of this stage. We’ve seen a lot of progressions in the stages above, but also in the treatment and therapy. We’ve started this journey with passive range of motion exercises. Then moved to an active-assisted range of motion, then an active range of motion within different muscle synergies. And at the last muscle isolation.

Now it’s time to step up with the exercises and add resistance to movement. Patients should add small weights or a household item like a water bottle to their exercises.

Step 6: Coordination Reappears

At the last stroke recovery stage, spasticity in muscle movement should disappear completely. Stroke patients are now able to move individual joints. And synergy patterns become much more coordinated and thought off. Motor control is almost fully restored, and patients can coordinate complex movements in the affected extremities. Abnormal or spastic movements have disappeared, and a full recovery from stroke may just be on the horizon.

What can the patient do during this stage?

As always the patient should continue strengthening the muscles that need more work. And also add coordination exercises that incorporate both sides of the body. Activities such as golfing, shuffling cards, etc. If there’s something you used to do that you want to get back to doing. Right now it’s your time to practice it. The patient’s brain requires huge amounts of motivation to practice the coordination required for all of the exciting activities. Patients can also start some of the cognitive/brain exercises in their recovery plan.

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