BRUNNSTROM MOVEMENT

THERAPY APPROACH

Ms.Meglen
• Developed by Signe Brunnstrom, a Physical therapist from Sweden.

• She developed this approach for Hemiplegics.

• Approach based on motor pattern available to the patients , and initiated to normal then complex movement
patterns.

• She noticed damaged CNS undergoes “an evolution in Reverse” and regressed to Phylogenetically older
pattern of movement.
 Principles
• Treatment must progress developmentally.

• When no movement exists , facilitate using reflexes, associated reactions, proprioceptive facilitation, exteroceptive
facilitation to develop muscle tension in preparation of voluntary movement.

• When voluntary effort produces a response , ask patient to hold (isometric) followed by an eccentric (controlled
lengthening) contraction and finally a concentric (shortening) contraction.

• Reduce or drop out facilitation as quickly as the patient shows evidence of volitional control.

• No primitive reflexes are stage III.

• Place emphasis on willed movement to overcome the linkages between part of synergies, i.e:ask them to do a
familiar movement involving a goal object.

• Have the patient repeat correct movement, once elicited to learn it.

• Practice should include functional activities, to increase the willed aspect and to relate the sensations to Goal
directed movement.
 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).

 These synergies, Appear during the early spastic period of recovery.

• Flexor synergies Upper Extremity
• Extensor synergy of upper limb
• Flexor synergy of Lower limb
 Extensor synergy of Lower limb

Dominant Hip adduction, knee extension & ankle plantar flexion.

Weakest: Hip extension and internal rotation

•
• Characteristic of synergistic movement
• The flexor synergy dominates in upper limb and extensor synergy in lower limb.

• Performance of synergistic movements may be influenced by postural mechanisms .

• The resting posture of the limb is represented by the dominant components of both flexor and extensor
synergies
• EVALUATION:
• Evaluation using the Brunnstrom Movement Therapy approach is appropriate for persons who have had a stroke
and who have occupational dysfunction secondary to sensorimotor impairment.

1.Sensation:
• The sensory evaluation precedes the motor evaluation.

• The patient’s ability to recognize movements of the affected arm and to localize touch in the hand without
looking at the site of stimulus, they are associated with better eventual recovery of voluntary movement.

• Sensory evaluation guides the therapist’s for choice of facilitation modalities to improve movement.
2.Tonic Reflexes
• Tonic reflexes are assessed to determine whether they can be used in early treatment to initiate movement
when none exists.

• The primitive tonic brainstem reflexes that may be present include the symmetrical and asymmetrical tonic
neck reflexes, tonic labyrinthine reflexes, and tonic lumbar reflexes.
3.Associated Reactions
• Associated reactions are involuntary movements or patterned, reflexive increases of tone in muscles that
would be expected to contract to cause the movement.

• Associated reactions are triggered by effortful voluntary movement.

• They are seen in the involved extremities of stroke patients when other parts of the body are resisted during
movement or when the patient makes an effort to move.

• Associated reactions are evaluated to determine which can be used to facilitate movement when no voluntary
movement exists.
• Associated Reactions:

• Resistance to flexion of the uninvolved leg causes extension of the involved extremity, and resistance to
extension of the uninvolved leg causes flexion of the involved extremity.

• Mirror synkinesis/Imitation synkinesis: Resisted grasp by the uninvolved hand causes a grasp
reaction in the involved hand.

• Homolateral synkinesis : Attempt to flex the involved leg or resistance to leg flexion causes a flexor
response in the involved arm.
• Souque’s phenomenon: Actively or passively raising the affected arm above the horizontal causes the
fingers to extend and abduct.

• Raimiste’s phenomenon : Resistance to abduction or adduction of the unaffected lower limb results in a
similar response in the opposite affected leg.

• Instinctive Grasp Reaction :Closure of hand in response to contact of stationary object with palm of the
hand.

• Instinctive Avoiding Reaction: Stroking over palmar surface of hand in distal direction causes
hyperextension of fingers in a characteristic fashion
• Level of Recovery of Voluntary Movement:
• Evaluated using an instrument that sequences motor performance after stroke from reflex to full voluntary
control.

• In preparation for evaluation, the patient is made physically and psychologically comfortable.

• Each motion is demonstrated to the patient, who performs with unaffected extremity followed by affected
one.

• Instructions should be given in functional terms. For eg: to test the flexor synergy of the upper extremity, say
“Touch your ear” and, for the extensor synergy, say “Reach out to touch your [opposite] knee”.

• No facilitation is used during the evaluation.

• The Brunnstrom Stages:
• lists the six stages of recovery of the proximal upper extremity and the hand that Brunnstrom .

• On average, stroke patients proceed through these stages, recovery of a particular patient may stop at any stage.

• To date, there are no reliable ways to predict which patients will recover voluntary movement.

• Brunnstrom stages I to VI are useful to designate summarily the status of voluntary control. The patient is
reported to be in the stage at which he or she can accomplish all motions specified for that stage. Because
progress is gradual.
• Sometimes the patient is in transition between stages. Then therapists reports the level as II going on III, III
going on IV.

• The upper and lower extremities and the hand may all be in different stages of recovery at a given time.
 Stages
• Stage I:Flaccidity (No voluntary movement)

• Stage II: Spasticity Begins(synergies can be elicited reflexively. Flexion develops before extension)

• Stage III: Spasticity at Peak Level(Beginning of voluntary movement, but only in synergy )

• Stage IV: Spasticity Starts Declining(some movements deviating from synergy)

• Stage V:Spasticity Further declines/Spasticity Waning(Independence from basic synergy)

• Stage VI: spasticity minimal .(Individual Movement is possible with near normal co-ordination)

• Stage VII:Individual Joint Movement is possible with same rate and rhythm as unaffected limb.
• Arm
• I. Flaccidity: no voluntary movement .

• II. Synergies can be elicited reflexively; flexion develops before extension; spasticity developing.

• III. Beginning voluntary movement, but only in synergy; increased spasticity, which may become marked.
• Battery of tests:
• IV. Some movements deviating from synergy: (spasticity decreasing )

a. Hand behind back.

b. Arm to forward horizontal position.

c. Pronation and supination with the elbow flexed to 90°.

• V. Independence from basic synergies (spasticity waning)

a. Arm to side horizontal position

b. Arm forward and overhead

c. Pronation and supination with elbow fully extended.

• VI. Isolated joint movements freely performed with near normal coordination; spasticity minimal

• Speeds test
• Patient position: High sitting
• Hand to chin
• Hand to opposite shoulder
• Hand to opposite knee
• Hand

I. Flaccidity

II. Little or no active finger flexion

III. Mass grasp or hook grasp; no voluntary finger extension or release

IV. Semi-voluntary finger extension in a small range of motion;

lateral prehension with release by thumb movement
V. Palmar prehension
a. Cylindrical and spherical grasp (awkward).
b. Voluntary mass finger extension (variable range of motion)

VI. All types of prehension and grips are possible (improved skill).
a. Voluntary finger extension (full range of motion).
b. Individual finger movements
 • Lower limb:
• I:Flaccidity (No voluntary movement)

• II: Spasticity begins

• III: Hip flexion, knee flexion and ankle dorsiflexion(supine).

• IV: Knee flexion beyond 90 degree(sitting)

Ankle dorsiflexion with heel on floor(sitting)

• V: Isolated knee flexion with Hip extension(Standing)

• Isolated ankle dorsiflexion with Knee extension(Standing)
• VI: Hip Abduction(standing)
• Hip internal and external rotation with inversion and eversion of foot(sitting).
• General Management :
• Stage 1 and 2:
• facilitatory techniques(quick stretch, tapping over muscle belly, surface stroking)
• Associated reactions
• Passive movement through each of the synergy pattern.

• Stage 2 and stage 3

• Aim: to gain voluntary control of synergy
• Facilitatory techniques
• Resistance to voluntary movements
• Verbal commands
• Repetition
• Weight bearing on joints
• Stage 4 and stage 5
• Aim: To break synergy by mixing components from antagonist
• by adding heavy amount of activities.
• increasing New and complex pattern of movement.

• Stage 5 and stage 6

• Aim : to achieve ease in performance.
• By performing isolated motions.
• By increasing speed of movement.
• Gross motor movements to fine manipulations.
THANK YOU