Physical Therapy Following a Stroke- The Brunnstrom Approach
The Brunnstrom Approach
The primary goal of physical therapy following a stroke is to assist you to recover normal muscle function and maximize the independence of your life. Your normal muscle movements are produced by groups of muscles that work together as units called synergies (Shumway-Cook, 1995). After a stroke, your brain can no longer coordinate your muscle synergies and your muscles become weak, and this weakness produces abnormal movement patterns. These atypical movement patterns can develop in your arm, or your leg, or both. Therapists focus on treating abnormal muscle synergies because they prevent you from recovering function and maximizing your life after a stroke.
There are many different therapeutic approaches to treating abnormal movement patterns. Prior to the 1950s, if you have undergone physical therapy following a stroke, the therapist would have primarily used a muscle re-education approach. In a muscle re-education approach, a therapist retrains specific and isolated muscles that are weak rather than retraining muscle synergies. After the 1950s, therapists developed neurofacilitation approaches that focus on larger movement problems and overall motor control. Different types of neurofacilitation approaches include the Bobath approach, the Rood approach, proprioceptive neuromuscluar facilitation (PNF), the sensory integration technique, and the Brunnstrom approach. While other approaches focus on inhibiting abnormal synergies or moving parts of the body in opposite directions to the synergy patterns, the Brunnstrom approach encourages patients to actively use abnormal synergy patterns. Therapists have found the Brunnstrom approach to be highly clinically effective in improving voluntary movements.
The Swedish physical therapist Signe Brunnstrom developed the Brunnstrom approach in the 1960s. In the Brunnstrom approach, you move through seven stages as you regain motor control in an arm or leg after a stroke (Brunnstrom 1966, 1970).
1. Your muscles are flaccid and you have no voluntary movements in your affected extremities.
2. You begin to make small and abnormal movement patterns that are not voluntary.
3. You begin to make small movements that are voluntary but abnormal.
4. You begin to make normal movements, but most of your movements are still abnormal.
5. You begin to make normal and voluntary movements that are more complex, and your abnormal movements have diminished.
6. You begin to move your individual joints, and you can coordinate complex reaching movements.
7. Your normal movements have completely returned.
Signe Brunnstrom believed that damage to the brain after a stroke causes your central nervous system to regress to more primitive patterns of movement. Moreover, she believed that abnormal movement patterns are a normal part of recovery. The Brunnstrom approach encourages you to actively use the muscle synergies that are available at each phase of recovery to move your arms or legs, and techniques to facilitate movement are included in this approach. The central tenet of this approach is that as you regain more voluntary motor control your synergies will disappear. This approach has proved to be highly successful, and its techniques are used by many physical therapists to treat patients after a stroke.
Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther. 1966;46:357–75.
Brunnstrom S. Movement Therapy in Hemiplegia: A Neurophysiological Approach. New York: Medical Dept., Harper & Row, 1970.
Sara Cuccurullo. Physical Medicine and Rehabilitation Board Review. New York: Demos Medical Publishing, 2004.
Shumway-Cook and Woollacott. Motor Control: Theory and Practical Application. Lippincott Williams & Wilkins, 1995