tenda Health

The Brunnstrom approach and stages of stroke recovery were developed by a Swedish physiotherapist named Sydney Brunnstrom in the 1960s. The approach was used to help medical professionals better understand movement recovery after a stroke.

This approach is unique because it views typically problematic muscle tone like spasticity as an indicator that recovery is actually happening. It’s important to note though that these stages aren’t perfectly linear. You may not start at stage one and then move through them all in sequence. In fact, it’s pretty common for stroke survivors to get stuck in one of these stages. But the more that you understand about each one, the better you can advocate for yourself.

Stage I: Flaccidity.

This stage primarily happens after a severe brain injury or stroke. Often, you won’t see this phase in someone who has had a mild or moderate stroke. There’s usually no voluntary or active movement, and the affected limbs may be limp and floppy. Now there are two main things that we want to consider in this stage: passive range of motion and positioning strategies.

Passive range of motion is when someone can’t actively move, and they have to have someone else passively move and stretch their affected limbs. Why is this so important? Well, it all comes back to neuroplasticity. We want the brain to begin remaking those neural connections or pathways from the brain to the body. There has to be some sort of input for that to happen, which is why stretching and passive movement is so important. Having someone move and stretch the affected limb is a great way to get this process started, as well as to prevent any muscle or tendon shortening which can lead to contractures. Contractures are where muscles are permanently shortened, and movement can be extremely limited.

The second thing we want to consider in this stage are positioning strategies. It’s really important to keep the affected limb positioned safely to avoid injuries and also to prevent and manage shoulder subluxation. It’s important to note that you want to keep your arms out of traditional slings that put your arm in internal rotation for long. You’ll want to support the upper arm and the shoulder, whether it’s with pillows if you’re laying down on your back or on your side, or keeping the arm supported on a table while sitting up.

Stage 2: Spasticity Develops.

Someone might notice tighter muscle tone that gets worse with quick movements. That muscle tone change is also known as spasticity. In simple terms, spasticity is essentially caused by two things: an abnormally triggered reflex which causes muscles to tighten and contract too much, and by the injured part of the brain’s inability to stop that overactive reflex. Now, while it might seem counter-intuitive, the development of spasticity from the first stage of flaccidity is actually a good thing. This means that the brain is trying to remake those pathways. It’s just that the connection is weak. It is sort of like having a hard time hearing someone when a cell phone signal is weak. You get parts of the conversation but not all of it.

You may also notice that some abnormal limb synergies develop in this stage. Abnormal limb synergies are when you get multiple unwanted muscle movements that are happening at the same time, and they may make it hard to do daily things. Muscles begin to move, but it’s usually involuntary. You might see elbows, wrists, and fingers bend without really trying. It becomes slightly more difficult to have someone move your limbs in this stage.

Now, even though there is little motor control in this stage, you want to try to continue moving your recovering limb as much as you can. It’s okay if that movement isn’t perfect or if you only get just a tiny amount. It becomes easy in this stage to develop something called learned non-use or learning to not use your affected side. Even if you’re able to get some active movement, continue to have someone do slow stretches and passively move your affected side.

Stage III: Increased Spasticity.

Unfortunately, spasticity gets worse before it gets better. That abnormally triggered reflex and the brain’s inability to stop that reflex continues to cause tight, stiff, and sometimes painful muscles, resulting in limited movement. Again, though, an increase in spasticity means that the brain is trying to remake those pathways because movement can become really limited in this stage.

There are a lot of things that we need to consider now in regards to pain and tightness. Personally, I usually recommend talking with your doctor or neurologist about medications, Botox injections, or even acupuncture treatments that can help relieve stiffness and pain. Those options don’t actually treat the underlying cause of spasticity, but they can help treat the symptoms. This is important because if you’re able to limit spasticity, even temporarily, you can work on movement, which is necessary to create

Stage IV: Decreased Spasticity

As spasticity begins to decrease in this stage, you may notice the return of some voluntary movements and improved control and coordination over those movements. This is a crucial stage for making movement gains, so it’s important to capitalize on it with various strategies, including continuing with a daily exercise routine for your recovery. If you don’t have anyone to help, I have many general workouts for stroke recovery that you can request.

You can also ask your doctor or therapist about using functional e-stim or electrical stimulation to continue making gains. However, the most important thing is to keep moving your affected limbs as much as possible by yourself or with someone’s help. Fight learned non-use by using that affected side in as many daily activities as possible, such as getting dressed, taking a shower, and even making a meal.

Stage V: Minimal Spasticity

In this stage, brain signals to the affected limbs are improving while spasticity still lingers but doesn’t impede movement too much. You may find complex movements easier and notice dexterity and fine motor skills returning. Some abnormal limb synergies begin improving at this point.

Continue focusing on active exercises while moving into strengthening routines during daily activities. Focus on more controlled and fine motor movements like picking up utensils or holding a pencil to write with your affected hand repetitively.

Stage VI: No Spasticity And Return Of Coordination

Spasticity completely resolves in this stage where motor control is almost fully restored except for lingering coordination issues. Continue active range of motion exercises along with strengthening routines while starting home dexterity routines where small deliberate movements can be honed in upon.

Stage VII: Normal Movement

In this final stage of Brunstrom’s approach towards stroke rehabilitation therapy; spasticity isn’t present anymore because effective communication between muscles & brain has been established again leading towards typical normal movement returns.

Keep actively moving and strengthening your whole body if you are in this stage. However, it’s important to have the expectation of two steps back, one step forward because stroke recovery progress is slow and doesn’t happen in any expected or linear pattern.

Every stroke survivor’s journey is different based on the severity of the stroke, where it happened in the brain, and how healthy someone was before their stroke. Regardless of what stage you’re in, there’s always a possibility for progress as long as survivors put real effort into their recovery journey without letting plateaus stop them.

Let me know if learning about these stages of recovery feels helpful to you on your own recovery journey by leaving a comment below! See you in the next post.