Brunnstrom approach

 Developed by Signe Brunnstrom

 Theoretical foundations:
 Sherrington
 Magnus
 Jackson
 Twitchell
 Signe Brunnstrom developed this approach in early 1950’s.
 Brunstrom is a therapist from Sweden
 She used motor control literature and observations of the
patients procedures - in a trial and error fashion.
 Later modified- in the light of neurophysiological knowledge.
 Successful procedures were replicated from patient to
patient.
 The goals set for the patient should be achievable.
 Movement recovery tends to be stereotypic.
 Patients exhibits only few stereotypic movement patterns -
Basic Limb Synergies (BLS).
 BLS are considered to recover first; dominant muscle groups
controls the pattern of responses and as recovery progresses,
independent voluntary movements begin.
 Spasticity - key to progression from synergistic to non-
synergistic movement
Assumptions
 Reflex- Hierarchical theory
 Lower level reflexes get modified & rearranged into purposeful
movements through influence of higher centers
 Reflexes & primitive movement patterns can used to facilitate the
recovery of voluntary mvts.
 Proprioceptive and exteroceptive stimuli can be used to evoke
desired motion or alter tone
 Recovery of voluntary movts occur in sequence
 Newly produced correct movements must be practiced to be
learned
 Practice within the context of daily activities enhances learning
process
General Principles
 As development progress, reflexes
become modified and their
components rearranged into
purposeful movement through the
influence of higher centers.
 Reflexes and whole-limb
movement patterns represent
normal stages of development. They
are considered to be “normal” when
the CNS has reverted to an earlier
development stages.
 Stroke appears to result in
development in Reverse. Reflexes
and primitive movement patterns
should be used to facilitate recovery
of voluntary movement post stroke
 Hierarchy in the central nervous
system is reflected in normal
development as well as in
hemiplegia.
 Parallel between recovery from
stroke and normal development.
 From this premise, reflex activity is
used as the basis for voluntary
movement and treatment
procedures dependent on the stage
of recovery reached i.e. reflexes
and primitive movement patterns
to facilitate recovery.
 Contd..
 Proprioceptive and exteroceptive stimuli
can be used therapeutically to evoke
desired motion or tonal changes.
 Stroke proceeds in sequence from mass
stereotype flexor or extensor movement
pattern to movement that combines
features of two patterns and finally two
discrete moments of each joint at will.
 the stereotype movement patterns are
called limb synergies
 Synergy in the sense refers to patterned
movements of entire limb in response to a
stimulus for to voluntary effort
 Newly generated correct motions must
be practiced to be learned and
practicing within the context of daily
activities, that enhances further
learning.
 Based on the observations of recovery
following stroke, this approach makes
use of associated reactions, tonic
reflexes and the development of basic
limb synergies to facilitate movement.
 Use of such procedures is temporary
Contd..
 Facilitate the patient’s progress throughout the recovery
stages
 Use of postural and attitudinal reflexes to increase and
decrease tone of muscles
 Stimulation of skin over the muscle produces contraction
 Resistance facilitates contraction
Basic limb synergies
 Mass movement patterns in response to stimulus or
voluntary effort or both
 Gross flexor movement (flexor synergy)
 Gross extensor movement (extensor synergy)
 Combination of the strongest components of the synergies
(mixed synergy)
 Appear during the early spastic period of recovery
 The movement within the BLS is considered easier to
achieve.
 BLS have strong (dominant) and weak components.
 Flexor synergy of UE
Scapula Retraction and/elevation

Shoulder Abduction & external rotation

Elbow Flexion

Forearm Supination

Wrist Flexion

Fingers Flexion

Dominant/ strongest component Elbow flexion

Weakest component Shoulder Abduction & external rotation

 Extensor synergy of upper limb
Scapula Protraction and/ depression

Shoulder Adduction & internal rotation

Elbow Extension

Forearm Pronation

Wrist Extension or flexion

Fingers Extension or flexion

Dominant/ strongest component Shoulder adduction & internal

rotation
Weakest component Elbow extension
Flexion synergy (LL)
Hip Flexion, abduction & external rotation

Knee Flexion

Ankle Dorsiflexion and inversion

Toes Extension

Strongest component Hip flexion

Weakest component Hip abduction and external rotation

 Extensor synergy (LL)
Hip Extension, adduction & internal rotation

Knee Extension

Ankle Plantar flexion and inversion

Toes Flexion

Strongest component Hip adduction, knee extension & ankle plantar flexion

Weakest component Hip extension and internal rotation

Evolution and Dissolution of Nervous
system
 Hughling Jackson (A British neurologist)-
 The phylogenetic organization of the nervous centers occurs on
three levels.
 This organization is recapitulated during ontogenesis.
 These three levels or groups of nervous centers are integral part
of the fully developed CNS of a normal subject.
 Three levels - lowest, middle & higher motor centers.
 Lowest motor centers:- few movement combinations that are
mostly automatic in nature.
 The middle motor centers:- represent more combinations that
are more voluntary and less automatic in nature.
 The higher motor centers:- numerous combinations which are
mostly voluntary.
 Following pathologies like CVA the nervous system reverts
to a lower level of evolution-“dissolution” of the nervous
system or “evolution in reverse”.
 Patients with severe CNS involvement must rely on the
lowest motor centers which provide few movement
combinations that are automatic in nature.
 Less severe involved patients may recover sufficiently to
utilize the middle motor centers.
 However, full motor recovery needs normal functioning of
the middle motor centers with least involvement of highest
center.
Developmental Reflexes
Tonic neck reflexes

STNR ATNR
TLR
Associated reactions
 Observations by Brunnstrom (1951, 1952)
 May be evoked in a limb that is essentially flaccid, although
latent spasticity may be present
 May occur in the affected limb under a variety of condition:
in the presence of spasticity, when a degree of voluntary
control has been achieved, and after spasticity has subsided
 May be present years after the onset of hemiplegia
 HOMOLATERAL LIMB
SYNKINESIS
 The response of one
extremity to stimulus will
elicit the same response in
its ipsilateral extremity

 RAIMISTE’S
PHENOMENON
 Resisted abduction or
adduction of the sound
limb evokes a similar
response in the affected
limb
 INSTINCTIVE GRASP
REACTION
 Closure of hand in response to
contact of stationary object with
palm of the hand
 Seen in frontal lobe lesions
 INSTINCTIVE AVOIDING
REACTION
 Stroking over palmar surface of
hand in distal direction causes
hyperextension of fingers in a
characteristic fashion
 Seen in parietal lobe lesions
 PROPRIOCEPTIVE
TRACTION RESPONSE
 Stretch of any of the flexor
muscles in upper limb evokes or
facilitates contraction of flexor
muscles all other joints in upper
limb
 IMITATION SYNKINESIS
 Mirroring of movements
occur in the affected side
when movements are
attempted or performed
on the unaffected side
 E.g.-Flexion of the
unaffected side will evoke
flexion of the affected side
 Used generally to facilitate
movements on the affected
side
 Yawning
 Flexor synergy is elicited
during initiation of yawn
 Coughing and Sneezing
 Evoke sudden muscular
contractions of short duration
 SOUQUES PHENOMENON
 Elevation of the affected arm
causes the paralyzed fingers
to extend automatically
 Used to facilitate release of
fingers
 Movement is facilitated using
 Reflexes
 Associated reactions
 Proprioceptive and exteroceptive stimuli
 Resistance
Evaluation
 Sensory evaluation
 Tonic reflexes
 Associated reactions
 Basic limb synergies
 The traditional neurological examination procedures like MMT
for muscle strength evaluation does not give any information
about the stage of recovery and the real muscle strength.
 Traditional MMT will create errors in grading muscle strength.
 Purpose of evaluation is to note the degree of recovery and the
evaluation procedure should be based on recovery stages.
MOTOR TEST- SHOULDER AND ELBOW
 Stage 1.
 No voluntary movement
 Limbs feel heavy
 Flaccidity
 Stage 2.
 Basic limb synergies appear
 Flexor synergy appear before extensor synergy
 Spasticity develops in elbow flexors
 Stage 3.
 Basic limb synergies become stronger
 Flexor synergy tested by asking the patient to scratch behind the
ear
 Extensor synergy tested by asking the patient to touch between
the knees held together
 Usually synergies does not combine in stage 3
 Stage 4.
 4A: Placing the hand behind the body
 4B: Elevation of the arm to a forward horizontal Position
 4C: Pronation- supination with elbow at 90.
 Stage 5.
 5A: Arm raising to a side-horizontal position
 5B: Arm raising forward and overhead
 5C: Pronation- supination with elbow extended
 Stage 6.
 Isolated joint movements
Hand
 Stage 1: Flaccidity
 Stage 2: Little or no active finger flexion
 Stage 3:
 Mass grasp
 Hook grasp but no release
 No voluntary finger extension
 Possible reflex extension of digits
 Stage 4:
 Lateral prehension
 Release by thumb movement
 Semi voluntary finger extension, small range
 Stage 5:
 Palmar prehension
 Possibly cylindrical & spherical grasp
 Awkwardly performed with limited use
 Voluntary mass extension of digits
 Stage 6:
 Individual finger movements
 Voluntary extension of digits
 Less accurate than opposite side
Trunk & LL
 Stage 1. Flaccidity
 Stage 2. Minimal voluntary movement of lower limb
 Stage 3. Hip knee ankle flexion in lying & standing
 Stage 4.
 Sitting, knee flexion beyond 90⁰ with the foot sliding backward
on the floor,
 Voluntary dorsiflexion of the ankle without lifting the foot of
the floor
 Stage 5.
 Standing, isolated non weight bearing knee flexion with hip in
extension or nearly extended
 Standing, isolated dorsiflexion of the ankle with knee in
extension.
 Stage 6.
 Standing, hip abduction beyond range obtained from elevation
of the pelvis
 Sitting, reciprocal action of the inner & outer hams muscles,
combined with inversion & eversion