There are six Brunnstrom stages that describe the process of movement recovery after stroke. Here's what each stage means for your arm and what you can do for home exercise to maximize function.

Understanding the Brunnstrom Stages of Stroke Recovery

What are the Brunnstrom Stages of Stroke Recovery?
The brunnstrom stages is one of the most well-known stroke recovery stages which
is also known as the Brunnstrom approach. The Brunnstrom stages 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. So
you can check the status of your stroke recovery through the Brunnstrom stages.

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.


Table of contents

 * Stage 1: Flaccidity
 * Stage 2: Spasticity Appears
 * Stage 3: Increased Spasticity
 * Stage 4: Decreased Spasticity
 * Stage 5: Spasticity Continues to Decrease
 * Stage 6: Spasticity Disappears and Coordination Reappears
 * How long will it take to recover from stroke?




What to do for Stroke Rehabilitation or stroke recovery 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 [https://www.youtube.com/watch?v=7G97Fu3GuVU] 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
[https://www.neofect.com/us/blog/spasticity-and-stroke]. 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
[http://www.neofect.com/us/blog/how-to-improve-spasticity-spinal-cord-injury/],
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 [https://www.youtube.com/watch?v=-hise8ZUIAk] 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.



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 [https://www.youtube.com/watch?v=XeYfdku7RA0]. 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 after stroke to move more complexly.

What can I do in this stage?
Strengthening [https://www.youtube.com/watch?v=EVQcgYQyzz0] 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.



Stage 6: Spasticity Disappears and Coordination Reappears
During this stage of motor recovery, spasticity
[hhttp://www.neofect.com/us/blog/how-to-improve-spasticity-spinal-cord-injury/] 
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(stroke victims) 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.



--
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Stroke Recovery

Part three of the Stroke Lingo blog series reviews clinical words commonly used to describe post-stroke muscle changes including muscle tone, spasticity, and contracture.

Muscle Function Changes After Stroke

If you or your loved one has experienced a stroke, one of the first things your
therapists will look into is your overall muscle tone. By taking a close look at
what your muscles are able to do and what they struggle with, the therapists can
put together a plan of action to help you with strengthening, improving
coordination, and working toward your functional goals. In part 3 of our “Stroke
Lingo” series, let’s talk about words that have to do with muscle tone
dysfunction after a stroke.

Muscle Function Changes After Stroke
Muscle tone: the amount of tension a muscle has at rest. There is a delicate and
complex balance at play with muscle tone, which allows muscles to be flexible
enough to move through space, but firm enough to hold the body steady against
the effects of gravity. “Normal” muscle tone is what helps you to maintain your
posture, and it will generally relax while you are asleep to allow your body to
get comfortable and rest. When a person has “normal” muscle tone, there is a
continual partial amount of tension that allows muscles to react quickly and
smoothly whenever they are needed to make joints move.

An example of how normal muscle tone may affect you while you participate in a
functional task: when you are riding a bike, there is enough tone in your
muscles to keep your body seated upright, and there is enough flexibility to
allow smooth, coordinated movements of the legs and feet to cycle with the
pedals.



Hypertonicity: a high amount of muscle tone, and therefore increased tension and
resistance when the muscle is passively stretched. If you are experiencing
hypertonicity, your stroke may have damaged a part of your brain that controls
the signal from your brain to your muscles. This signal is now firing on
overdrive, causing tension and tightness. It’s as if the muscles just can’t
relax. Sometimes this tension will force the affected arm to pull in and flex
toward the body, making it difficult to move or straighten out. Hypertonicity
limits a joint’s ability to move. It is usually somewhat (or very) difficult to
try to stretch out the joints, and often another person has to help complete
stretches on a daily basis to try to keep at least some flexibility. As you can
imagine, this is totally exhausting, and makes function very difficult.


A hypertonic right arm might rest tightly against the body despite intent to
relax the limb.

Hypertonicity may affect you after your stroke diagnosis, but it is not always
clear exactly when. Some begin to experience it right away, while others notice
their muscles becoming tighter and more difficult to move weeks or months down
the road.

An example of how hypertonicity may affect you while you participate in a
functional task: when you are trying to apply deodorant, you need someone else
to help pull your arm away from your side because of the high amount of tension
pulling your joints closer together and flexing your arm toward your body.

Spasticity: A particular type of hypertonicity, which causes muscles to stiffen
as a reaction to being stretched quickly. Though many people use the word
“spasticity” as a general term to describe anyone with noticeably stiff muscles
following a stroke or brain injury, it actually more specifically refers to
tightness that happens when a quick stretch is applied to the muscle. When you
have spasticity, the tightness can worsen with quicker movements. Spastic
muscles often also need a good amount of [slow] stretching before you engage in
a particular task, so that they have time to lengthen and become flexible
enough. Spasticity is affected by both the sensory and motor parts of the brain
that control your movement. It is considered “overactivity of the stretch
reflex.”

You may have hypertonicity in your muscles without actually having spasticity!

An example of how spasticity may affect you while you perform a functional task:
when you try to quickly open up your fingers from a fisted position in order to
place your hand around your coffee cup, your fingers react to being moved
quickly and tense up even more, forming a tighter fist position.

Contracture: a type of joint deformity related to prolonged tightness that keeps
the joint positioned a specific way for a long time. After an extended time
working on overdrive from hypertonicity, the muscle tissues can become shortened
and hardened. This makes it extremely difficult, if not impossible, to move the
joints around anymore. If you are experiencing contracture, the joints that are
affected are more or less “frozen” in place.

Hypotonicity- a low amount of muscle tone. This is often noted after stroke,
when muscles become completely or partially paralyzed. The muscles may no longer
feel like they have much or any resistance to being stretched and moved around.
Though hypotonia doesn’t automatically mean “weak,” weakness and hypotonia can
often go hand in hand.


A hypotonic right arm might hang limply at one's side despite attempts to move
or reposition the limb.

After a stroke, you may experience a range of levels of “tone”, and your tone
may change along your journey. If you have had a stroke that impacts your
muscles in one of the ways listed above, you may need the help of a therapist to
guide you with best practices to manage the symptoms and work toward using your
arm (and/or leg!) more functionally. There are many types of strategies to
include various modalities, stretches, exercises, and functional task training
that can all help with improved use of the limb and more protected joints. Check
in with your therapist for suggestions tailored to your specific needs!

All content provided on this blog is for informational purposes only and is not
intended to be a substitute for professional medical advice, diagnosis, or
treatment. Always seek the advice of your physician or other qualified health
provider with any questions you may have regarding a medical condition. If you
think you may have a medical emergency, call 911 or your doctor immediately.
Reliance on any information provided by the NEOFECT website is solely at your
own risk.

References:

American Stroke Association: www.stroke.org

Bhimani, R, and Anderson, L. Clinical understanding of spasticity: Implications
for practice. Rehabilitation Research and Practice, 2014: 279175 doi:
10.1155/2014/279175

Stroke Foundation: www.strokefoundation.org.au

Spasticity after stroke

Stroke Lingo Part 3: Muscle Function Changes After Stroke

A stroke is caused by either a blockage of a blood vessel or bleeding in or around the brain, which results in a lack of oxygen to the brain and the death of brain cells.

Spasticity and Stroke

Stroke and Brain Function
A stroke is caused by either a blockage of a blood vessel or bleeding in or
around the brain, which results in a lack of oxygen to the brain and the death
of brain cells.

In the simplest terms the brain receives messages, process messages, and sends
messages. Each area of the brain is responsible for different things. Depending
on the area of the brain that was damaged will determine which messages are
interrupted.

If the area of the brain that was damaged was the signal to send a message to
your bicep and/or tricep muscles (the muscles that bend and straighten your
elbow), you might experience tightness of those muscles due to spasticity.

What is Spasticity?


Spasticity is essentially a reflex. Reflexes are our bodies way of protecting
ourselves. When we touch a hot stove with our hand, our muscles immediately
contract to move our hand out of harms way. This message is not actually coming
from the brain. It would take too long for the signal to go from the skin to the
brain, process it, and send a signal back to the muscle to move away from the
hot object. The pain message from the skin goes to the spinal cord and sends a
signal right away to the muscle to contract. Once the hand is moved away from
the harmful surface the brain has had enough time to process if it is safe for
the muscle to relax, and is able to send a signal to relax the muscle.

In it's truest definition, spasticity occurs in response to quick movement: if
your elbow is quickly extended, it will pull into flexion. This reaction is a
symptom that the brain to muscle messaging system is impaired. But spasticity
and increased tone are also used as general terms to describe any tightness of
muscles that result from damage to the brain or spinal cord. Meaning when the
tightness of a muscle occurs without the quick stretch, such as posturing the
arm in flexion or a muscle tightening during an activity, this is often referred
to as spasticity as well.

What happens after a stroke is that the brain has difficulty sending a signal to
the muscle to relax. Sometimes the message is absent and there is no active
signal and sometimes the message to relax is weak. This is why some people might
tighten when they are running or during an activity. Their brain is working hard
on sending signals to the rest of the body, it doesn't have the time to work on
sending a signal to relax the muscle.

Managing Spasticity
It’s important to note that not all spasticity is bad. Many people with stroke
use their spasticity to assist with standing, transfers, and daily activities.
It’s important to discuss options for managing spasticity and functional
implications with your physician and your occupational or physical therapist.

There are two general approaches that address spasticity: medical management and
physical management. Medical management is decided in collaboration with the
patient and physician. It addresses the neural component that is causing the
muscle tightness. Medical management of spasticity includes oral medications,
neurotoxin or phenol injections, and surgical interventions.

The physical management is typically addressed by a physical or occupational
therapist and addresses the biomechanics of the joint to prevent muscle
shortening, joint deformities, and decreased function. Physical management
includes stretching, muscle strengthening, and intensive repetitions. Physical
and occupational therapists also use electrical stimulation
[https://www.neofect.com/us/blog/can-e-stim-help-jumpstart-outpatient-stroke-rehabilitation] 
and ice as modalities to limit spasticity during exercise or functional
activity.

STRETCHING

Spasticity tightens our muscles and over time the muscle begins to shorten. This
limits our ability to move our joints even further. Stretching has the potential
to quiet the hyper exaggerated reflex for several hours, as well as the benefit
of maintaining range of motion. Stretches should be held for 30 seconds or more
and you may feel a release of the muscle tone.

Splinting and orthotics are used for an even longer stretch. They position a
joint optimally to maintain length of a muscle and prevent contractures.
Depending on the purpose, splints and orthotics are worn during the day or at
night to allow for hours of stretch time.

Weight-bearing is a form of prolonged stretching with the added benefits of
strengthening and increasing bone density. After a stroke the motor function of
the leg tends to return before the arm, and one of the reasons may be the
motivation to walk and the intensive weight bearing of the leg. When we weight
bear or put pressure on our muscles and joints, we are sending signals to the
brain. The brain is getting a lot of feedback from that extremity. Any weight
bearing of the upper extremity either at the wall, table, or floor helps sends
signals to the brain that reminds it the arm is still there.

STRENGTHENING

Strengthening can improve spasticity in two ways. By strengthening the
antagonist (opposing) muscle, it can help inhibit the reaction of the spastic
muscle. When the spastic muscle activates and tries to pull a joint into
flexion, the extensor muscle has the capacity to limit the flexion just by being
stronger.

We must also strengthen the spastic muscle. It might seem that with all that
contracting a spastic muscle would be a strong muscle, but without the brain to
muscle connection a spastic muscle is actually a weak muscle. Utilizing
electrical stimulation or ice prior to strengthening a spastic muscle may be a
way to optimize your strengthening session.

Strengthening can happen any time a muscle is contracted, but depends on the
capability of the person doing the contracting. It has to be somewhat difficult.
The muscle has to fatigue. The person who does not have full active range of
motion, but is able to visibly contract a muscle is strengthening with each
repetition of movement.

Repetition of movement is a rehabilitation strategy not only for strengthening,
but plasticity. Intensive repetitive training or massed practice is the key to
neuroplasticity and improving the way the brain sends signals to the muscles.

INTENSIVE REPETITIVE TRAINING

Voluntary movement has the potential to maintain joint range of motion,
strengthen, and increase plasticity
[https://www.brainhq.com/brain-resources/brain-plasticity/what-is-brain-plasticity/]
. But it’s all about repetition. In a typical therapy session, you might expect
to do 20-30 repetitions of movement. You would be responsible for completing the
movements for each joint on a daily basis. This can become boring and the habit
slowly slips away.



The Neofect Smart Glove [https://www.neofect.com/us/smart-glove] and Smart Board
[https://www.neofect.com/us/smart-board] fit right into the gap of what we know
therapeutically and what is actually happening on a day to day basis. The 
Neofect [https://www.neofect.com/us/] Smart Glove and Smart Board turn your home
program into a fun and motivating way to maintain range of motion, strengthen,
and optimize your functional outcomes.

Every person is unique and has a different rehabilitation journey. Neofect has
experienced occupational therapists to consult with to see what might work for
you.

If you've had a stroke and are looking for an effective solution for your
rehabilitation needs, please look into NEOFECT's line of Smart Rehabilitation
Solutions [https://www.neofect.com/en/pt-solution/].

To learn more, please call (866) 534-4989 or email contactus@neofect.com.

For more information on stasticity and stroke:
American Association of Neurosugical Surgeons - Spasticity
[https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Spasticity]
National Institute of Neurological Disorders and Stroke - Spasticity
Information
Page
[https://www.ninds.nih.gov/Disorders/All-Disorders/Spasticity-Information-Page]
Cleveland Clinic - Spasticity
[https://my.clevelandclinic.org/health/diseases/14346-spasticity]

National Stroke Association - What is Stroke
[https://www.stroke.org/understand-stroke/what-is-stroke/]
Mayo Clinic - Stroke Symptoms and Causes
[https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113]
Stroke Association - About Stroke
[https://www.strokeassociation.org/en/about-stroke]

All content provided on this blog is for informational purposes only and is not
intended to be a substitute for professional medical advice, diagnosis, or
treatment. Always seek the advice of your physician or other qualified health
provider with any questions you may have regarding a medical condition. If you
think you may have a medical emergency, call your doctor or 911 immediately.
Reliance on any information provided by the NEOFECT website is solely at your
own risk.