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 Hierarchy in the central nervous
become modified and their system is reflected in normal
components rearranged into development as well as in
purposeful movement through the hemiplegia.
influence of higher centers.
Parallel between recovery from
Reflexes and whole-limb stroke and normal development.
movement patterns represent
normal stages of development. They
are considered to be “normal” when From this premise, reflex activity is
the CNS has reverted to an earlier used as the basis for voluntary
development stages. movement and treatment
procedures dependent on the stage
of recovery reached i.e. reflexes
Stroke appears to result in and primitive movement patterns
development in Reverse. Reflexes to facilitate recovery.
and primitive movement patterns
should be used to facilitate recovery
of voluntary movement post stroke
Contd..
Newly generated correct motions must
Proprioceptive and exteroceptive stimuli be practiced to be learned and
can be used therapeutically to evoke practicing within the context of daily
desired motion or tonal changes. activities, that enhances further
learning.
Stroke proceeds in sequence from mass
stereotype flexor or extensor movement Based on the observations of recovery
pattern to movement that combines following stroke, this approach makes
features of two patterns and finally two use of associated reactions, tonic
discrete moments of each joint at will. reflexes and the development of basic
limb synergies to facilitate movement.
the stereotype movement patterns are
called limb synergies Use of such procedures is temporary
Synergy in the sense refers to patterned
movements of entire limb in response to a
stimulus for to voluntary effort
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 IMITATION SYNKINESIS
Closure of hand in response to Mirroring of movements
contact of stationary object with occur in the affected side
palm of the hand
Seen in frontal lobe lesions when movements are
INSTINCTIVE AVOIDING attempted or performed
REACTION on the unaffected side
Stroking over palmar surface of E.g.-Flexion of the
hand in distal direction causes unaffected side will evoke
hyperextension of fingers in a
characteristic fashion flexion of the affected side
Seen in parietal lobe lesions Used generally to facilitate
PROPRIOCEPTIVE movements on the affected
TRACTION RESPONSE side
Stretch of any of the flexor
muscles in upper limb evokes or
facilitates contraction of flexor
muscles all other joints in upper
limb
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
