From the Guidelines
Patients commonly get stuck at Brunnstrom Stage 4 during recovery from stroke or brain injury. At this stage, patients have developed some voluntary movement but still exhibit significant spasticity and synergy patterns, making isolated movements difficult. The challenge at Stage 4 is breaking free from these synergy patterns to achieve more selective motor control. Patients can initiate movements outside of synergy patterns but cannot fully complete them with normal coordination. This plateau occurs because neuroplasticity requires intensive, targeted therapy to reorganize neural pathways for independent movement control. Progression beyond this stage typically requires consistent therapy focusing on isolated joint movements, task-specific training, and activities that challenge the patient to move outside established synergy patterns. Factors that may contribute to this plateau include inadequate therapy intensity, secondary complications, learned non-use of the affected limb, or neurological limitations from the original injury. According to a recent study 1, evidence supports the use of botulinum toxin for patients with focal spasticity, which can interfere with function and cause pain, but can also benefit the patient in functional mobility tasks.
Some key points to consider when treating patients stuck at Brunnstrom Stage 4 include:
- The importance of intensive, targeted therapy to reorganize neural pathways for independent movement control
- The use of therapeutic approaches combining repetitive task practice, constraint-induced movement therapy, and functional electrical stimulation to help patients advance beyond this challenging stage
- The potential benefits of botulinum toxin in managing spasticity and improving functional mobility
- The need to address secondary complications, learned non-use of the affected limb, and neurological limitations from the original injury to promote further recovery.
In terms of specific treatment strategies, the study 1 suggests that botulinum toxin may be an effective treatment option for spasticity, but notes that it may not have a dramatically different place in therapy from oral antispasmodics based on efficacy alone. Ultimately, a comprehensive and individualized approach to therapy is necessary to help patients overcome the challenges of Brunnstrom Stage 4 and achieve optimal recovery outcomes.
From the Research
Brunnstrom's Stages of Recovery
- Brunnstrom's stages of recovery are a framework used to describe the progression of motor recovery in patients with hemiplegia after a stroke 2, 3.
- The stages are characterized by different levels of spasticity, muscle tone, and motor control.
Level at Which Patients Usually Get Stuck
- According to the studies, patients with hemiplegia often get stuck at the stage of spasticity, where they experience increased muscle tone and spasms 4, 5, 6.
- This stage is often associated with a plateau in motor recovery, where patients may not show significant improvement in their motor function despite ongoing rehabilitation efforts.
- The use of interventions such as botulinum toxin injections, oral medications, and staged acupuncture may help to reduce spasticity and improve motor function in these patients 2, 5, 6.
Factors Influencing Recovery
- The recovery process can be influenced by various factors, including the severity of the stroke, the presence of comorbidities, and the effectiveness of rehabilitation interventions 2, 3.
- Neurophysiological measures, such as the Hslp/Mslp ratio and H(max)/M(max) ratio, can provide valuable information about the underlying mechanisms of motor recovery and may help to identify patients who are at risk of getting stuck at a particular stage 3.