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The Brunnstrom Approach - Neurological Rehabilitation

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The Brunnstrom approach is a widely used movement therapy approach used by clinicians. This approach highly focuses synergic pattern of spastic muscles on the recovery of stroke patients through various stages. There is no specialized training available in this approach.

Brunnstrom Approach


Signe Brunnstrom, a Swedish physical therapist developed this approach in the 1960s. Her work on hemiplegia was based on various traditional neurophysiological theories of motor control.

She tried various trial and error on motor and verbal reactions to each procedure or from observations of patients. There are several methods on rehabilitation of stoke patients however very little evidence is present.


Brunnstrom made assumptions regarding the motor control and reactions of stroke patients to form a basis for the principles of movement strategy. These are as follows:
In normal motor development, reflexes become modified into purposeful movements and thus recovery in stroke appears to result development in reverse as reflexes are used to facilitate and learn purposeful movements.

Brunnstrom believed that no reasonable training method should be left untried and stated "It may well be that a subcortical motion synergy which can be elicited on a reflex basis may serve as a wedge by means of which limited amount of willed movement can be learned"

Proprioceptive and exteroceptive stimuli can be used to provoke desired motion or tonal changes

Recovery of voluntary movement in post stroke proceeds in sequence from mass patterns to discrete movements voluntarily. The stereotyped movements are called limb synergies .

Repetition is a must of learned movements.


The principles of Movement therapy are as follows:

Treatment progresses in a developmental sequence from reflexes to voluntary to functional movements.

When no motion exists, movement can be facilitated using reflexes, associated reactions, proprioceptive/exteroceptive stimuli to develop muscle tension.

Reflex and associated reactions are combined with voluntary effort which produces semi-voluntary movement thus providing sensory feedback and satisfaction.

Various stimuli given assist in eliciting movement. Resistance (proprioceptive stimuli) promotes a spread of impulses to other muscles to produce an associated reaction whereas a tactile stimuli facilitates muscles only to stimulated area.

The patient is asked to hold (isometric) a response if voluntary effort is done. If possible, he is asked for an eccentric (controlled lengthening) followed by concentric (controlled shortening) contraction.

Even if a partial movement is possible, reversal of movement is stressed within each session.

Facilitation techniques are dropped a soon as the patient shows voluntary control. Responses to exteroceptive stimuli are least stereotyped thus tactile stimuli is last to be eliminated. No primitive reflexes are used beyond stage 3.

Emphasis is more on voluntary movement and similar ADL's are encouraged to perform.

Correct movement, once elicited, should be repeated and practiced.


Evaluation is done to select the treatment pattern and check the prognosis of the condition. It includes determination of the following:-

Sensory examination

Determines patient's ability to recognize movements and touch without looking. Results help in determining the choice of facilitation technique the therapist can use or alert the therapist to use visual feedback to compensate for lost sensation.

Level of recovery of voluntary control

Brunnstrom listed stages of recovery for upper and lower extremities and for hand.

For upper and lower extremities, the recovery stages are as follows:

For hand, the stages are as follows:-

Stages / Pattern

  • Muscles are flaccid on the involved side
  • The patient evidences minimal spasticity,and little or no active finger flexion is possible.
  • The patient is able to hold on to a handle placed in the hand but unable to release through voluntary finger extension. Reflex extension may be possible
  • The patient is able to release by lateral thumb movement with minimal finger extension or through normal functional synergy. That is, he or she is able to grasp with the fingers while the wrist is extended and able to release the fingers while the wrist is flexed.
  • Voluntary mass extension of digits is possible, and the patient is able to control cylindrical and spherical grasp with limited functional use.
  • The patient demonstrates voluntary extension of fingers, lateral, palmar, and three-point prehension and individual finger movements are possible
Although patients proceed through these stages, a particular patient may stop at any stage. Till date, there are no reliable methods that can predict the outcome of recovery of stroke patients.

No facilitation is used during evaluation. Each motion is demonstrated on the unaffected side of the patient and asked to perform voluntarily at the affected extremity.

The Fugl-Meyer scale was developed as the first quantitative evaluative instrument for measuring sensorimotor stroke recovery, based on Twitchell and Brunnstrom’s concept of sequential stages of motor return in the hemiplegic stroke patient.

The Fugl-Meyer is a well-designed, feasible and efficient clinical examination method that has been tested widely in the stroke population. Its primary value is the 100-point motor domain, which has received the most extensive evaluation.

However, Fugl-Meyer test still holds good, possibly because it follows a hierarchical scoring system based on the level of difficulty in performing the tasks

Stages / Pattern

  • The patient evidences flaccidity, with little or no resistance to passive motion and no initiation of voluntary movement
  • Spasticity begins to develop, and initiation of synergies is possible on voluntary effort or an as associated reaction.
  • There is increased resistance due to spasticity, and limb synergies are performed voluntarily.
  • Spasticity is less evident than earlier, and movement combinations that deviate from synergies are possible.
  • There is minimal resistance from spasticity, and individual as well as complex movement combinations are possible independent of synergy
  • Spasticity is difficult to demonstrate unless movements are performed with rapidity, and synergies do not interfere with performance

Effect of tonic reflexes on the patient's movement

Tonic reflexes should be assessed, in early treatment to initiate movement when none exists. The primitive reflexes that are usually present are asymmetrical and symmetrical tonic neck reflexes, tonic labyrinthine and lumbar reflexes.

The effect of associated reactions on patient's movement

Associated reactions are involuntary movement or patterned reflexive tonal increase in those muscles that are expected to be in contrast to cause movement. These reactions are seen in affected extremities when other unaffected extremities are resisted or effort is made in affected extremity. These are evaluated to determine which facilitation method can be used.

Associated reactions seen in stroke patients are as follows:-

  • Flexor Synergy
  • Extensor Synergy
  • Raimeste's Phenomenon (Resistance to Hip abduction or adduction of noninvolved extremity causes same motion in involved leg)
  • Resistance to flexion of noninvolved leg causes extension of the involved extremity and resistance to extension of noninvolved side causes flexion of involved extremity.
  • Resisted grasp of noninvolved hand causes grasp reaction in the involved hand.
  • Flexor movement or tone may be elicited in involved arm when the patient attempts to flex the leg or leg flexion is resisted. This reaction is called homolateral synkinesis.
  • Souque's Phenomenon - Increased tone of involved arm above horizontal evokes an extension and abduction of fingers.
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