A stroke is a life-threatening affliction that can lead to a host of complications to a person’s mobility, coordination, cognition and more. If a stroke is detected and treated early, a stroke survivor can potentially avoid poorer health outcomes and have a much better recovery rate. Still, the stroke recovery process can be a bumpy journey. Depending on factors such as the severity of the stroke, recovery occurs differently from person to person. Nevertheless, the physical and emotional stress that arises from the process can make it all the more difficult to adjust to, let alone stay positive.
What is the Brunnstrom Approach?
In the 1960s, the late Signe Brunnström, a renowned physical therapist, published her findings on motor recovery in persons recovering from hemiplegia (a medical condition resulting in paralysis in one side of the body, due to a stroke or other brain injury). She noted that regardless of the severity of their affliction, the recovery process occurs in a linear, “almost standardised” sequence of stages. The major difference stems from how long each stage takes for each person, and which area is affected. A person may be in different stages of recovery in each of these areas.
This model of stroke recovery is known as the Brunnstrom stages, of which there are seven in total.
- Stage 1: Flaccidity
- Stage 2: Spasticity
- Stage 3: Increased Spasticity
- Stage 4: Reduced Spasticity
- Stage 5: Complex Movement Combinations
- Stage 6: Spasticity Disappears
- Stage 7: Normal Functions Return
These stages are still in use today to assess a person’s post-stroke physical recovery process. They help guide treatment based on the stage that the stroke survivor is currently at, but only on the physical aspect. The stages do not cover speech, vision, cognition or other areas affected by a stroke.
If your loved one had a stroke and is now recovering from it, here is what you need to know about the seven Brunnstrom stages.
Stage 1: Flaccidity
The first stage occurs immediately after a stroke. During this stage, the muscles will feel weak, limp and “floppy”. This is where flaccid paralysis sets in, indicating an inability to perform any voluntary movements. Nerve damage caused by the stroke prevents muscles from receiving the correct signals from the brain, even if the brain can still coordinate any muscle movement. Depending on which side of the brain is affected, the opposing side of the body will be paralysed. For example, if damage occurs on the left side of the brain, this results in right-side paralysis.
The main danger of flaccidity is this inability of your loved one to move any affected limbs. Long term flaccidity can lead to weakened muscle mass and strength, which can further compromise the recovery process. In order to maintain the muscles’ strength, passive range of motion exercises can be done. Because your loved one is unable to move on their own, someone (either you, a relative, or a trained physiotherapist) will help them exercise their limbs, enabling the brain to slowly restore its neural connections to the affected areas (known as neuroplasticity).
Other methods include positioning to prevent bed sores, joint pain or other issues arising from being bedridden, and even guided physical assistance with performing activities of daily living (ADLs).
Stage 2: Spasticity
In this stage, spasticity (muscle stiffness or rigidity) begins to appear. During this stage, your loved one’s brain has steadily rebuilt some lost connections to affected areas, and this shows the muscles are becoming stimulated again. However, these connections are partial or incomplete, resulting in muscles becoming “stuck” in fixed or contracted positions, tightening reflexively, or not responding to voluntary movements. Occasional muscle spasms or tremors may also happen during this time.
Spasticity is usually a good sign, since this means that muscle coordination is slowly returning. However, there will be difficulty in moving the affected limbs because of this spasticity, as not all connections to other interlinked muscles may have healed sufficiently. These do hinder your loved one’s ability to make certain movements with the affected limbs.
Passive range of motion exercises will still be important in keeping the muscles healthy, but active range of motion exercises can also be introduced slowly. Any little bit of movement is good to promote further healing of your muscular and nerve functions in the affected areas.
A combination of active and passive range of motion exercises are a good way to promote recovery. Your loved one will need to activate their muscles as much as they can, followed by using their unaffected hand to move the joint through the full range of motion. Make sure to do this gradually, as rushing the process could end up worsening their condition.
Stage 3: Increased Spasticity
At stage 3, spasticity increases and reaches its peak. At this point, certain muscles might tighten even more than they did and are harder to relax. Spasticity may even cause an abnormal increase in muscle stiffness and tone, which could adversely affect speech and mobility, or may even cause much discomfort or pain in your loved one. There may also be an increase in involuntary movements, which stems from the ability to move the affected muscles but not control it effectively.
Being at stage 3 may feel very frustrating because of the hindrances and unpleasant sensations your loved one will experience. However, this is still a good sign of progress, as your brain has made further connections with the affected areas of your loved one’s body. Passive and active range of motion exercises will still be needed, with an emphasis on improving your loved one’s active movement as much as possible.
Your loved one’s therapist may also encourage the coordination of specific muscle synergies to work in favour of your loved one’s actions. Incorporating exercises into basic ADLs can be beneficial in encouraging their progress, but caution must still be taken so that your loved one does not stress themselves too much. If necessary, a botox injection may be administered to help reduce spasticity, but this is no substitute for regular exercise.
Mirror therapy may also be considered to help improve the odds of recovery. Mirror therapy involves placing a mirror between the affected limb and its corresponding unaffected limb (for example, a mirror between the left and right arms). This creates a visual illusion of the affected limb. In performing actions using the unaffected limb, it helps trick the brain into thinking that the affected limb is functioning well, which can lead to positive recovery outcomes.
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Stage 4: Reduced Spasticity
Getting to this stage may see a reduction of spasticity in your loved one. They will regain more control of their muscles, and have a limited ability to move like normal. There is still poor coordination in their movement, with some twitchiness, stiffness and/or out of sync movements, but this is still an important milestone to reach.
At this point, therapy will involve active and active-assisted range of motion exercises, together with strengthening exercises to rebuild muscle mass and help with recovering muscle and motor control. Repetition at a consistent pace will greatly help speed up the recovery process, but be sure not to rush it. Make sure they do regular stretches as well to improve their flexibility.
At this point, it is a good idea to start focusing on retraining your loved one’s motor coordination abilities and functional movement patterns. This includes teaching them how to dress, how to maintain their hygiene, and more. Be sure to assist them through the process, as the lingering spasticity will still hinder them from being able to do things on their own.
Stage 5: Complex Movement Combinations
Stage 5 sees a further reduction in spasticity, with your loved one’s brain having greater success in forming connections to the affected muscles. This allows your loved one to make more voluntary movements, and more importantly, enabling these movements to be much more complex. There is a significant reduction in abnormal movements or twitching, but could still happen infrequently.
At this stage, your loved one may be able to perform actions such as combing their hair, grabbing objects and holding utensils, all without much difficulty. Keeping up with regular exercises, muscle strengthening and retraining motor skills will help your loved one regain their independence in no time. Make sure to keep encouraging them as they progress.
Stage 6: Spasticity Disappears
Your loved one’s motor control will have almost returned to normal by this stage. Spasticity has all but disappeared completely, and this means your loved one will have far less spastic movements, or none at all. Their coordination with their complex movement combinations also sees a vast improvement, and individual joints on their affected side are now able to move freely and without any discomfort or pain.
If your loved one has kept up with their exercise and training routine, they will be able to care for themselves without requiring assistance from you or the accompanying therapist or nurse. This is a great sign! They can now focus on refining on their motor coordination and control so that they can effectively perform ADLs like they used to.
Stage 7: Normal Functions Return
The final stage is when your loved one regains their normal functions. Your loved one is now able to perform voluntary movements without difficulty, and are able to independently perform ADLs without any assistance. This is the ultimate goal for all recovering stroke survivors, but not everyone will achieve this stage. Nonetheless, it is still important to work towards this goal with the help of new assistive devices, therapy methods and treatment options that are becoming available to the public. Clinical trials may yield positive results in delivering quality care to help stroke survivors achieve this final stage.
There can be occasions where spontaneous recovery occurs. This could mean a rapid, positive progression from one stage to another (including skipping one or two additional stages), or for more fortunate persons, leading to a full recovery in record time.
Spontaneous recovery is most likely to occur in the first three to six months after a stroke, at a time when intensive therapy can help promote significant recovery. The body is busy repairing the damage caused by the stroke, and will need to rebuild the lost neural connections that were destroyed by the stroke – what is known as neuroplasticity. At the early stages of recovery, neuroplasticity can happen quickly, or is strongly promoted thanks to therapy interventions or other factors. The faster this occurs, the faster your loved one’s recovery progresses.
Even so, spontaneous recovery does not just happen to anyone. Various factors can impede the outcome of your loved one’s stroke recovery, including (but not limited to):
- The severity of the stroke
- The degree of damage to the brain
- How soon rehabilitation begins after the stroke
- The intensity and frequency of therapy
- Age when the stroke occurred
- State of cognitive faculties
- Whether this was a recurrent stroke
It is therefore important to be able to catch stroke signs early before they can cause more damage to your loved one. Learning the ways to identify a stroke early and getting them immediate medical attention can mean the difference between a short or lengthy stay at the hospital.
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