Brunnstrom’s Movement

Therapy
Dr Anil Muragod
 History…
• Developed by Brunnstrom, a physical
therapist from Sweden
• Theoretical foundations:
 Sherrington
 Magnus
 Jackson
 Twitchell
 Premise
 When the CNS is injured, as in CVA, an
individual goes through an “evolution in
reverse”
– Movement becomes primitive, reflexive,
and automatic

 Changes in tone and the presence of

reflexes are considered part of the
normal process of recovery
 Principles of treatment
 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
 Important! (Limb Synergies)
• Muscles are neurophysiologically linked and
cannot act alone or perform all of their
functions
• If one muscle in the synergy is activated,
each muscle in the synergy responds
partially or completely
• Patient CANNOT perform isolated
movements when bound by these synergies
Basic limb synergies: UE
Mixed synergy: UE
Flexor Extensor
Mixed synergy: LE
Flexor Extensor
 The Typical Hemiplegic Posture
HEAD Lateral y flexed toward the affected side
UPPER LIMB Scapula – depressed, retracted
Shoulder – adducted, IR
Elbow – flexed
Forearm – pronated
Wrist – flexed, ulnarly deviated
Fingers - flexed
TRUNK Lateraly flexed toward the affected side
LOWER LIMB Pelvis – posteriorly elevated, retracted
Hip – IR, adducted, extended
Knee – extended
Ankle – plantarflexed, inverted, supinated
Toes - flexed
 Attitudinal and postural reflexes
• Tonic Neck Reflexes
– Symmetric TNR
stimulus response
Neck flexion Upper extremity flexion
Lower extremity extension
Neck extension Upper extremity extension
Lower extremity flexion

– Asymmetric TNR
stimulus response
Neck lateral Jaw side:
rotation upper extremity extension
lower extremity flexion
Skull side:
upper extremity flexion
lower extremity extension
• Tonic Labyrinthine Reflexes
stimulus response

supine Limbs tend to move in extension

prone Limbs tend to move in flexion

• Tonic Lumbar Reflex

stimulus response
Trunk rotation (R) Increased flexor tone
(R) UE and (L) LE
Increased extensor tone
(L) UE and (R) LE
Trunk rotation (L) Increased flexor tone
(L) UE and (R) LE
Increased extensor tone
(R) UE and (L) LE
 Associated reactions
• Investigation by Walshe (1923)
– Associated reactions are released postural
reactions deprived of voluntary control

• Investigation by Simons (1923)

– Position of the head has a marked influence on
the outcome of the associated rections
– Limb reactions evoked closely resemble tonic
neck reflexes

• Observations by Brunnstrom (1951,1952)

– UE: movements employed elicited the same
reactions in the affected limb
– LE: movements employed elicited opposite
reactions in the affected limb
 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

 Associated Reactions
• Observations by Brunnstrom (1951,1952)

– repeated stimuli may be required to evoke a

response

– tension in the muscles of the affected limb

decrease rapidly after cessation of stimulus that
evoked the associate directions

– attitudinal reflexes influence the outcome of

associated reactions
 Associated reactions
• 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
 Associated reactions
• Yawning
– Flexor synergy is elicited during initiation of
yawn

• Coughing and Sneezing

– Evoke sudden muscular contractions of short
duration
 Hand reactions
• Steps to restoration of hand function
(Twitchell, 1951)

1. Tendon reflexes return and become

hyperactive
2. Spasticity develops; resistance to passive
motion is felt
3. Voluntary finger flexion occurs, if facilitated
by proprioceptive stimuli
 Hand reactions
4. Proprioceptive traction response can be
elicited
– Aka proximal traction response
– Stretch of flexors of one of the joints of the
upper limb facilitates a contraction of the flexor
muscles of other joints of the same limb thus
producing total limb shortening

5. Control of hand without proprioceptive

stimuli begins
 Hand reactions
6. Grasp is reinforced by tactile stimulus on
the palm of the hand; spasticity declines

7. True grasp reflex can be elicited; spasticity

further declines
– Elicited by disctally moving deep pressure over
certain areas of the palm and digits
» Catching phase: weak contraction of flexors and
adductors upon stimulus
» Holding phase: proceeds when traction is done on
muscles activated in the catching phase
 Other hand reactions
• Instinctive Grasp Reaction
– Stationary contact with the palm of the hand results
to closure of the hand

• Instinctive Avoiding Reaction

– With the arm elevated in a forward-upward
direction, the fingers and thumb hyperextend;
stroking the palm in a distal direction exaggerates
the posture

• Soque’s Finger Phenomenon

– Elevation of the hemiplegic arm beyond the
horizontal results to estension and abduction of the
fingers
 Recovery stages in hemiplegia
STAGE CHARACTERISTICS

Stage 1 •Period of flaccidity

•Neither reflex nor voluntary movements are present

Stage 2 •Basic limb synergies may appear as associated reactions

•Spasticity begins mostly evident in strong components
•Minimal voluntary movement responses may be present

Stage 3 •Patient starts to gain voluntary control over movement

synergies
•Spasticity reaches its peak
•Semi-voluntary stage as individual is able to initiate
movement but unable to control it
STAGE CHARACTERISTICS

Stage 4 •Some movement combinations outside the path of

basic limb synergy patterns are mastered
•Spasticity begins to decline

Stage •More difficult combinations are mastered

5 •Spasticity continues to decline
Stage •Individual joint movement becomes possible
6 •Coordination approaches normalcy
•Spasticity disappears: individual is more capable of
full movement patterns
Stage Normal motor functions are restored
7
 Arm
1. Flaccidity-no voluntary movement
2. Synergies developing- flexion usually develops before
extension (may be a weak associated reaction or voluntary
contraction with or without joint motion); spasticity developing
3. Beginning voluntary movement, but only in synergy; increased
spasticity, which may become marked
4. Some movements deviating from synergy
a. Hand behind body
b. Arm to forward-horizontal position;
c. Pronation-supination with elbow flexed to 900; spasticity
decreasing.
5. Independence from the basic synergies
a. Arm to side-horizontal position
b. Arm forward and overhead
c. Pronation-supination with elbow full extended;
spasticity waning
6. Isolated joint movements freely performed
with near normal coordination; spasticity
minimal
 Hand
1. Flaccidity
2. Little or no active finger flexion
3. Mass grasp or hook grasp no voluntary finger extension or
release
4. Lateral prehension with release by thumb movement semi
voluntary finger extension (small range of motion)
5. Palmar prehension cylindrical and spherical grasp (awkward)
voluntary mass finger extension(variable range of motion )
6. All types of prehension (improved skill) Voluntary finger
extension (full range of motion)
Individual finger movements
 Lower limb
1. Flaccidity
2. Minimal voluntary movements of the lower limb
3. Hip-Knee-ankle flexion in sitting and standing
4. Sitting, knee flexion beyond 90 degrees with the
foot sliding Backward on the floor; voluntary
dorsiflexion of the ankle without Lifting the
off the floor
5. Standing, isolated non weight-bearing Knee
flexion, hip extended or nearly extended; standing,
isolated dorsiflexion of the ankle, Knee extended,
heel forward in a position of a short step
6. Standing, hip abduction beyond range obtained
from elevation of the pelvis; sitting, reciprocal
action of the inner and outer Hamstring muscles,
resulting in inward and outward rotation of the leg at
the knee, combined with inversion and eversion of
the ankle.
 Treatment Principles
1. Treatment progress developmentally

2. When no motion exists, movement is

facilitated using reflexes, associated
reactions, proprioceptive facilitation and or
exteroceptive facilitation to develop muscle
tension in preparation for voluntary
movement
 Treatment Principles
3. Resistance (proprioceptive stimulus)
promotes a spread of impulses to produce a
patterned response while tactile stimulation
facilitates only the muscle related to the
stimulated area
 Treatment Principles
4. When voluntary effort produces or
contribute to a response, patient is asked to
hold the contraction (isometric). If
successful, an eccentric (contracted
lengthening) is performed and finally a
concentric (shortening) contraction is done.
 Treatment Principles
5. When even partial movement is possible
reversal of movement from flexion to extension
is stressed
6. Facilitation is reduced or dropped out as quickly
as the patient shows evidence of volitional
control.
7. No primitive reflexes, including associated
reactions, are used beyond Stage 3.
8. Correct movement once elicited is repeated