The Brunnstrom stages of stroke recovery is one proposed model of how someone with hemiplegia will recover movement. It was developed by a physical therapist in the 1960s and proposes that this sequence of recovery falls into six loosely defined stages.
The main beliefs in this model are that movement recovery starts with muscle synergy patterns. As someone progresses in their recovery, ideally, these patterns will develop into more coordinated movement.
When I first learned of this theory back in school, my thought is that it was developed and intended to follow normal brain development. This helped me to understand the proposed sequence of events.
In normal brain development, infants move in what we call primitive synergy patterns. These patterns are believed to be hard-wired into our little neonatal brains from birth. Babies have to main movements. All flexion or all extension. That is it. The hips, knees, and ankles all flex or all three joints extend. End of story.
As a baby’s brain develops, they learn how to move out of these patterns. The first sign of this is when an oldeer infant starts learning to crawl.
They are now learning how to move “out of these synergy patterns”. For example, they learn how to keep the knee bent while they extend the hip. This is the first signs of “coordinated movement”.
And of course, this continues into walking, running, jumping…etc.
The parallel is that this is kind of the foundation of Brunnstrom’s proposed sequence of events that happens after damage to the brain (ie: stroke).
Brunnstrom’s Stages of Motor Recovery
If we follow Brunnstrom’s sequence, a therapist would encourage movement synergies in the early stages as this would be the first step in regaining “coordinated movement”. Now, regardless of where you read about this, it is clear that no one is suggesting that everyone with hemiplegia will follow this exact sequence. How far an individual will progress through these stages depends on the size of the damaged area in the brain, motivation, post-stroke medical and rehab care, family support, and the presence of any co-morbid conditions.
It is also clear in the literature on this proposed sequence that an individual can plateau at any stage.
But generally speaking here are the stages.
Immediately following the injury to the brain, there is a period where there is no movement in the arm or leg on the affected side. In other words the limb is flaccid
2. Movement Synergies Emerge
You start to see signs of movement in the arm or leg (no longer flaccid). A synergistic type movement pattern might be in response to a stimulus. The movement is characterized by either a flexor or extensor pattern. Movement may or may not be voluntary.
3. Movement Synergies become stronger
Movement synergies become more pronounced. These movement patterns are more voluntary and less in response to a stimulus. However, the patient is unable to demonstrate movement control outside of a patterned movement. In other words “all flexion or all extension”. Similar to the infant in the above example.
4. Movement Synergies Start to Decline
The patient’s movement is now characterized by fewer “restrictions”. The synergistic patterns are still present, however, they are not as pronounced. Similar to a crawling infant. You see signs of a “flexion” synergy in the legs, but they are able to move out of this pattern slightly when they try to advance their body forward
5. Movement Synergies Continue to Decline
At this stage, there is greater ability to move out of a flexor or extensor synergy pattern. The patient is able to demonstrate a more isolated joint movement. For example, they might be able to straighten the knee without pointing the foot.
6. No Sign of a Movement Synergy
The final stage according to the Brunnstrom stages of motor recovery is near normal movement and coordination. This means a patient can dorsiflex their ankle while extending the knee while walking. This type of movement control requires isolated joint movement (straightening the leg while flexing the ankle) while adding a complex condition (for example walking). In this stage the patient does not show any sign of the foot inverting or point at inappropriate times during the walking cycle.