The Brunnstrom approach is a physical therapy technique developed in the 1950s to facilitate motor recovery following a stroke. It is based on the theory that recovery follows a reverse developmental sequence, progressing from reflexive movement to voluntary isolated joint movements. The approach uses basic limb synergies, associated reactions, and sensory stimulation to elicit movement at each stage of recovery. Treatment progresses the patient through six stages of recovery, reducing facilitation as voluntary control increases. The goal is to develop movement patterns that deviate from primitive reflexes into independent joint control.

1. BRUNSTOM APPROACH
SUBMITTED BY: USMAN YAKUBU YOLA DOKA
SUBMITTED TO: DR SANGHAMITRA JENA
MPTN6007, Semester 4

2. Outline
History and Introduction
Basic Limb Synergy
Associated reaction
Sensory evaluation
Stages of motor recovery
Treatment Principle

3. History
 Brunnstrom’s approach was developed by
the physical therapist from Sweden in the
early 1950’s
 Brunnstrom used motor control theory and
observations of the patients
 Procedure: in a “trial & error” fashion
 Later modified: in light of
neurophysiological knowledge

4.  The basic premises of this approach are: In
normal persons, spinal cord and brain stem
reflexes become modified during
development and their components
rearranged into purposeful movement by
the influence of higher centers. Since
reflexes represent normal stages of
development, they can be used when the
CNS has reverted to an earlier
developmental stage as in hemiplegia.
 Also, she believed that:
I. Reflexes should be used to elicit
movement when none exists (normal
developmental sequence).
II. Proprioceptive and extroceptive stimuli
also can be used therapeutically to evoke
desired motion or tonal changes.

5. Reflex Theory
 Movement is controlled by stimulus response
 Reflexes are the basis for movement -
Reflexes are combined into actions that
create behavior
 CLINICAL IMPLICATIONS
 Use sensory input to control motor output
Hierarchical Theory
 Characterized by a top-down structure, in
which higher centers are always in charge of
lower centers.
 CLINICAL IMPLICATIONS
 Identify & prevent primitive reflexes
 Reduce hyperactive stretch
 Normalize tone

6.  When the CNS is injured, as in
cerebrovascular accident, an individual goes
through an “evolution in
reverse”. Movement becomes primitive,
reflexive and automatic.
 Changes in tone and the presence of
reflexes considered as a normal process of
recovery.
 Movement recovery tends to be
stereotypic.
 Patients exhibit only few stereotypic
movement patterns: Basic Limb Synergies.
 Based on observations of recovery following
a stroke, this approach makes use of
associated reactions, tonic reflexes and the
development of basic limb synergies to
facilitate movements.

7. Basic Limb
Synergies:
 Normal synergistic movements are
purposeful movements with maximum
precision and minimum waste of energy.
 Basic limb synergy (BLS) do not permit
different combination of muscles
 BLS are considered as primitive, automatic
and reflexive due to loss of inhibitory
control from higher centers
 Mass movement patterns in response to
stimulus or voluntary effort both Gross
flexor movement (Flexor Synergy), Gross
extensor movement (Extensor Synergy) and
Combination of the strongest component of
the synergies (Mixed Synergy)
 Appear during the early spastic period of
recovery

8. Basic Limb Synergies
Upper Limb Flexor Synergy:
Scapula: Retraction / Elevation Shoulder:
Abduction and External rotation
Elbow: Flexion
Forearm: Supination
Wrist and Finger: Flexion
Upper Limb Extensor Synergy:
Scapula: Protraction / Depression Shoulder:
Adduction and Internal rotation
Elbow: Extension
Forearm: Pronation
Wrist: Extension
Finger: Flexion

9. Lower Limb Extensor Synergy:
Pelvis: posterior tilt
Hip: Extension, Adduction & Internal rotation
Knee: Extension
Ankle: Plantarflexion
Toes: Flexion
Lower Limb Flexor Synergy:
Pelvis: anterior tilt
Hip: Flexion, Abduction & External rotation
Knee: Flexion
Ankle: Dorsiflexion
Toes: Extension

10. Upper Limb Mixed Synergy:
Scapula retraction
Shoulder add.+IR
Elbow flexion
Forearm pronation
Wrist & fingers flexion
Lower Limb Mixed Synergy:
Pelvis post tilt
hip add.+IR
Knee extension
Ankle & toes plantarflexion

11. Associated Reactions:
 Associated reactions are automatic responses
of the involved limb resulting from action
occurring in some other part of the body,
either by voluntary or reflex stimulation (e.g.,
resistance or ATNR). They are commonly
elicited when some degree of spasticity is
present and are infrequently seen in a limb
exhibiting minimal muscle tone. Generally
speaking, although not true in every case,
associated reactions elicit the same direction
of movement (i.e., flexion evokes flexion) and
the opposite direction (i.e., flexion evokes
extension) in the lower extremity.

12.  Souques’ Phenomenon: Elevation of the affected arm above the
horizontal evokes an extension and abduction response of the fingers.
 Raimiste’s Phenomenon: Resistance applied to abduction or adduction of
the nonaffected lower extremity evokes a similar reaction in the affected
limb.
 Homolateral Limb Synkineses: It has been noted that a dependency exists
between the synergies of the involved upper and lower extremities. Thus,
flexion of the involved upper extremity will elicit flexion of the involved
lower extremity.

13. Sensory evaluation:
 Joint sense: With the patient seated and is blindfolded; the
affected upper limb is supported by the examiner and moved to
different positions asking the patient to perform identical
position with the unaffected extremity.
 Touch sensation: The palmer aspect of the finger tips are touched
with a rubber end of a pencil and the patient is asked to
determine without looking which fingertip is touched.
 Sole sensation: the patient, without looking, is asked to determine
if an object is touching and pressing against his sole of the foot
or not and where.

14. Postural Reactions:
 Asymmetric Tonic Neck Reflex (ATNR): Head rotation to the left causes
extension of left arm and leg and flexion of right arm and leg; head
rotation to the right causes extension of right arm and leg and flexion
of left arm and leg.
 Symmetric Tonic Neck Reflex (STNR): Flexion of the neck results in
flexion of the arms and extension of the legs; extension of the neck
results in extension of the arms and flexion of the legs.
 Tonic Labyrinthine Reflex (TLR): Prone lying position facilitates flexion;
the supine position facilitates extension. The reflex can also be
thought of as inhibition of extensor tone in the prone position

15. Brunnstrom
Recovery
Stages:
 Stage 1: The patient is completely flaccid, no voluntary
movement, and patient is confined to bed.
 Stage 2: Basic limb synergy develops, no voluntary
movement, can be done as spasticity appears but is not
marked.
 Stage 3: Basic limb synergy develops voluntarily and is
marked, spasticity is marked. (This is the stage of maximal
spasticity).
 Stage 4: Spasticity begins to decrease, four movement
combinations deviate from basic limb synergies and become
available, which are:
Placing the hand behind the body, alternative pronation-
supination with the elbow at 90° flexion and elevation of the arm
to a forward horizontal position).
 Stage 5: There is relative independence of the basic limb
synergies. Spasticity is wanning, and movements can be
performed as arm raising to a side horizantal position,
alternative pronation- supination with the elbow extended
and bringing hand over the head.
 Stage 6: There are isolated joint movements.

16.  Speed test :It can be used to assess
spasticity during anyone of the recovery
stages, provided that the patient has
sufficient active ROM. The patient is seated
on a chair without armrest leaning against
chair back and keeping the head erect. The
two movements studied are:
1. The hand is moved from lap to chin,
requiring complete range of elbow
flexion.
2. The hand is moved from lap to opposite
knee, requiring full range of elbow
extension.
A stopwatch is used and the number of full
strokes completed in 5 seconds is recorded,
first on the unaffected then on the affected
side

17. Treatment
Principles
1. Treatment progress developmentally, so facilitate the
patient’s progress throughout the recovery stages.
2. When no motion exists,movement is facilitated using
reflexes, associated reactions, proprioceptive
facilitation/exteroceptive facilitation to develop
muscle tension in preparation for voluntary
movement
3. Resistance (proprioceptive stimulus) promotes a
spread of impulses to produce a patterned response
while tactile stimulation facilitates only the muscle
related to stimulated area
4. When voluntary effort produces or contribute to a
response, patient is asked to hold the isometric
contraction. If successful eccentric is performed and
finally a concentric contraction is done.
5. Facilitation is reduced or dropped out as quickly as
the patient shows evidence of volitional control.
6. No primitive reflexes, including associated reactions,
are used beyond stage 3.
7. Correct movement once elicited is repeated

18. REFERENCES
1. Pedretti L and Early M: Occupational Therapy:
Practice skills for physical dysfunction. 5th
ed., Mosby, London, 2001
2. Sawner and Lavinge (1992) Brunnstom’s
movement therapy in hemiplegia: A
neurophysiological approach; second edition.
3. Pandian, S., Arya, K. N., & Davidson, E. (2012).
Comparison of Brunnstrom movement
therapy and Motor Relearning Program in
rehabilitation of post-stroke hemiparetic
hand: a randomized trial. Journal of
bodywork and movement therapies, 16(3),
330–337.