The Brunnstrom Approach is a neurodevelopmental treatment approach for stroke rehabilitation developed in the 1970s. It involves 6 stages of motor recovery: 1) flaccidity, 2) appearance of spastic synergies, 3) semi-voluntary movement, 4) combining movements, 5) complex voluntary movement, 6) restoration of normal movement. Treatment progresses the patient through these stages using reflexes, associated reactions, proprioceptive stimuli and resistance training. Evaluation assesses motor function, sensory loss, and spasticity through tests of range of motion, grasp, and speed of movement. The goal is to facilitate normal motor control and functional use of the affected limb.

1. Brunnstrom Approach
Presenter : Ashik Dhakal
Moderator : Mr Sydney Roshan Rebello

2. • The Brunnstrom Approach was developed in the 1970’s by Signe
Brunnstrom, physical and occupational therapist from Sweden, on her
book (movement therapy in Hemiplegia).

3. • Theoretical foundation
• Sherrington 1800s, (afferent - efferent mechanisms are retained)
• Jackson, late 1884, explained three different centres for evolution
of movement (lowest, middle (rolandic region), frontal lobes).

4. Basic Limb Synergies
• Normal movement — synergistic motor behaviour — the coupling together of
muscles in an orderly fashion as a means by which purposeful movement is achieved
with maximal precision and minimal waste of energy.
• In most patient the flaccidity that follows the acute episode is sooner or later replaced
by spasticity.
• Beevor stated “Muscles may be paralysed for one movement but not for another.”

5. Different synergies
• Mass movement patterns in response to stimulus or voluntary effort or both
• Flexor Synergy (Gross flexor movement)
• Extensor Synergy (Gross extensor movement)
• Mixed Synergy (Combination of the strongest components of the
synergies)
• Appear during the early spastic period of recovery

6. Basic limb synergies: UL
Scapula: • Retraction and/ or elevation
Flexor Synergy Shoulder • Abduction and external rotation
Elbow • Flexion
Forearm • Supination

7. Typical variation of flexor synergy

8. Scapula • Protraction and/ or depression
Extensor Synergy Shoulder • Adduction and internal rotation
Elbow • Extension
Forearm • Pronation

9. Basic limb synergies: LL
Hip • Flexion, abduction and external rotation
Flexor Synergy Knee • Flexion
Ankle • Dorsiflexion
Toe • Extension

11. Hip • Extension, adduction and internal rotation
Extensor Synergy Knee • Extension
Ankle • Plantarflexion
Toe • Flexion

13. Mixed Synergy: UL
Flexor Extensor
Strongest Elbow Flexion Shoulder adduction and internal rotation
Next
strongest
Forearm Pronation
Weakest
Shoulder abduction and external
rotation
Elbow extension

14. Mixed synergy

15. The Typical Hemiplegic Posture
Head • Laterally flexed toward the affected side
UL
• Scapula- depressed, retracted
• Shoulder- adducted, IR
• Elbow- flexed
• Forearm- pronated
• Wrist- flexed, ulnarly deviated
• Fingers- flexed
Trunk • Laterally flexed toward the affected side
LL
• Pelvis- posteriorly elevated, retracted
• Hip- IR, adducted, extended
• Knee- extended
• Ankle- plantarflexed, inverted, supinated
• Toes- flexed

16. Principle of Treatment
• Treatment must progress developmentally (reflex, voluntary, functional)
• Movement is facilitated using
1. Reflexes
2. Associated reactions
3. Proprioceptive and exteroceptive stimuli
4. Resistance

17. 1. Reflexes
• STNR

19. • ATNR

20. • Tonic Labyrinthine Reflex
• Supine : extensor tone is maximal
• Prone : extensor tone is minimal

21. • Tonic Lumbar Reflex
• Trunk rotation to right :- Inc flexor tone rt UE and lft LE, inc extensor
tone in L UE and R LE
• Trunk rotation to left - opposite.

22. 2. Associated Reactions
• Riddoch and Buzzard defines associated reactions as “automatic activities
which fix or alter the posture of a part or parts when some other part of the body
is brought into action by either voluntary effort or reflex stimulation”
• In most patients voluntary forceful movements in other part of the body readily
elicit such reactions in the affected limb.
• More commonly elicited when spasticity is present than when condition is
flaccid.
• It may also be present years after the onset of hemiplegia.

23. • Brunnstrom observed (1951-1952)
• UE- movements employed, elicited the same reactions in the affected limb. Eg,
flexion tended to evoke flexion and extension tended to evoke extension.
• LE- movements employed, elicited opposite reactions in the affected limb

24. Associated reactions evoked by yawning, sneezing and coughing
• Yawn in a patient with hemiplegia — involuntary muscle contraction in the
affected upper limb.
• The stimulus must have an automatic character because if the patient
voluntarily initiates a yawn or a morning stretch the reactions do not
develop.
• Cough and sneezing evoke sudden muscular contractions of short duration.

25. • Homolateral Limb Synkinesis
• The response of one extremity to stimulus will elicit the same
response in its epsilateral extremity, i.e, efforts at flexion of an
upper extremity causes flexion of the lower extremity.

26. • Raimiste’s Phenomenon
• Resisted abduction or adduction of the sound limb evokes a similar response in
the affected limb
• In Raimiste’s phenomenon, in contrast, the stimulus and the response are of the
same type, i.e, adduction evokes adduction.

27. Hand reactions
• Proprioceptive Traction Response
• Stretch of any of the flexors muscles in the UL facilitates contraction of flexor
muscles in all other joints.
• Instinctive Grasp Reaction
• Closure of hand in response to contact of stationary object with palm, and
unable to release the object.
• Without object in the hand person has no difficulty in opening and closing of
the hand.

28. • Instinctive Avoiding Reaction
• Stroking over palmar surface in distal direction cause hyperextension of the fingers
• Pt reaches out to grasp the object, as the affected hand approach the object, the
fingers hyperextend.

29. • Souque’s Phenomenon
• Elevation of the affected arm 90degree (shoulder) causes the
paralysed fingers to extend automatically
• Used to facilitate release of fingers

30. • Tonic thumb reflex
• When affected UE is elevated above horizontal with forearm
supination, thumb extension is facilitated.
• Imitation Synkinesis
• Mirroring of movements occur in the affected side when movements
are attempted or performed on the unaffected side.
• Flexion of the unaffected side will evoke flexion of the affected side.

31. Principles for evaluating progress in hemiplegia
• It should be based on typical recovery stages of these patients, as an indication of
the approximate extent of the recovery of the central nervous system.
• It should be brief and easy to administer so as not to overly fatigue the patient.
• It should avoid complicated equipment, yet function with a considered amount of
objectivity.
• It should be standardised and administered by personnel familiar with the motor
behaviour of patients with hemiplegia.

32. Brunnstrom Recovery stages in Hemiplegia
• With seven stages, the Brunnstrom Approach breaks down how motor
control can be restored throughout the body after suffering a stroke.
STAGES CHARACTERISTICS
Stage 1
• Period of flaccidity
• Neither reflex nor voluntary movements are present
Stage 2
• Basic limb synergies may appear as associated reactions
• Spasticity begins mostly evident in strong components (FS prior to
ES)
• Minimal voluntary movement responses may be present
Stage 3
• Patient starts to gain voluntary control over movement synergies
• Spasticity reaches its peak
• Semi voluntary stage, as individual is able to initiate movement
but unable to control it

33. STAGES CHARACTERISTICS
Stage 4
• Some movement combinations outside the path of basic limb
synergies patterns are mastered
• Spasticity begins to decline
Stage 5
• More difficult combinations are mastered
• Spasticity continues to decline
Stage 6
• Individual joint movement becomes possible
• Co-ordination approaches normally
• Spasticity disappears: individual is more capable of full movement
patterns
Stage 7 • Normal motor functions are restored

34. Evaluation form

35. Motor test upper extremity

38. Gross testing for Sensory loss
1. Joint sense :
• Patient is seated and blindfolded after explanation of the procedure.
• Affected UE is supported by examiner and moved to different positions.
• Therapists ask patient to perform identical position with unaffected UE.

39. 2. Touch sensation
• The palmar aspect of the finger - tips are touched with the rubber end of a
pencil.
• Patient is asked to determine without looking which fingertip is touched
on affected UE.
3. Sole sensation
• Without looking, the patient is asked to determine if an object is touching
and pressing against sole of foot or not and where it is being touched.

40. Speed test :
• Used to assess spasticity during any recovery stage as long as patient has sufficient
AROM.
• Patient seated on a chair w/o armrest, and keeping head erect.
• Two movements studied :
• Hand moved from lap to chin requiring complete range of elbow flexion.
• Hand is moved from lap to opposite knee requiring full range of elbow
extension.
• Number of full strokes completed in 5 seconds is recorded, first on unaffected and
then on affected.

42. Motor test for hand
• Stage 1 : flaccidity
• Stage 2 : little or no active finger flexion
• Stage 3 : mass grasp; use of hook grasp but no release; no voluntary finger extension;
possibly reflex extension of digits.
• Stage 4 : lateral prehension, release by thumb movement; semi voluntary finger extension,
small range
• Stage 5 : palmar prehension ; possibly cylindrical and spherical grasp, awkwardly
performed and with limited functional use; voluntary mass extension of digits, variable
range
• Stage 6 : all prehensile types under control; skill improving; full-range voluntary extension
of digits; individual finger movements present, less accurate than on opposite side.

43. • Treatment
1. Bed positioning
• Starts when the pt is in flaccid state.
• Should be placed opposite the pattern of greater amount of
muscle tone.
2. Bed Exercises
• Passive and active assisted movements
• Turning supine to side lying (affected side, unaffected side)

45. 3. Trunk movement and balance
• Early goal in treatment is to gain sitting balance
• Most of hemiplegic patient demonstrate listing to the affected side which may result in a fall, if
appropriate equilibrium responses do not occur.
• To train, disturb the patient’s erect sitting posture (forward-backward and side-to-side direction.

46. Trunk bending forward and oblique forward

47. 4. Upper limb training
• Stage 1 and 2 : aim is to elicit muscle tone and synergic pattern in reflex
basis using variety of facilitation procedure like associated reactions, tonic
reflex.
• Flexor synergy : proximal traction response, tapping over the biceps.
(usually appears first so begin with elicit flexor synergy)
• Extensor synergy : Tapping over the triceps.
• Quick stretch and surface stroking of the skin over muscles— activate
muscles.

48. • Stage 2 and 3
• Aim : to achieve voluntary control of the synergic patterns.
• Accomplished by repetition of alternating performance of the synergy
patterns, first with assistance and facilitation of therapist.
• Facilitation is provided through resistance to voluntary motion,
verbal commands, tapping and cutaneous stimulation
• Followed by without facilitation.
• Bilateral Rowing movements with the therapist holding the patient’s
hand is useful activity for reciprocal motion of the synergies that should
be started during this time.

49. • Stage 4 and 5
• Aim : to break the synergy by combining antagonistic synergy.
• Stage 5 and 6
• Aim : to achieve ease in performance of movement combinations and
isolated motions and to increase speed of movement.
• Complex movement combinations and isolated movements.

50. 5. Lower limb training
• Aim : to modify the gross movement synergies and facilitate movement
combination
• It includes trunk balance and activation of specific muscle groups followed by
gait training.

51. 6. Hand training
• Hand training separately as recovery of hand function does not always
coincide with arm recovery.
• First goal : Achieve mass grasp
• Proximal traction response,
• Maintain wrist in extension, arm and elbow supported by the therapist.
• Command patient to squeeze.

52. • Second goal : Achieve wrist fixation for grasp
• Percussion of wrist extensors and ask patient to squeeze simultanously.
• Alternate “squeeze” and “stop squeeze”
• Repeat until active response from wrist extensors is achieved.
• Support is removed, and patient holds the contraction (facilitated by tapping)
• If successful, ask patient to perform eccentric contraction followed by
concentric contraction.

53. Stage 3 and 4
• (1st series of manipulation)
• Position : therapist seats in front of patient
• Pull thumb out of palm by grasping thenar eminence
• Passively supinate the forearm
• Alternate pronation and supination (emphasizing supination)
• Decrease pressure on thumb (pronation)
• Facilitate cutaneous stimulation over dorsum of hand (supination)

54. • (2nd series of manipulation)
• Same position as 1st series
• Rapid stroking over phalanges distally (PIP and DIP)
• (3rd series of manipulation)
• Facilitates forearm pronation and finger extension
• Pull thumb out of palm
• Perform souque’s position
• Gradually discontinue support as active response is achieved.

55. Stage 4
• Patient pulls thumb away from index finger
• Percussion at abductor pollicis longus extensor pollicis brevis.
• Functional use of lateral prehension is encouraged. eg., holding cards, using
a key

56. • Stage 5
• Encourage advances prehension pattern through activities
• In order of increasing difficulty: palmar prehension, cylindrical grasp,
spherical grasp.
• Stage 6
• Individual finger movement
• Provide home program of activities to encourage individual finger use,
speed and accuracy

57. References
• Brunnstrom’s movement therapy in hemiplegia by Kathryn
sawner, Jeanne Lavigne.

58. Thank you