Brunnstrom Stages of Motor Recovery
The Brunnstrom stages of motor recovery are a standardized six-stage framework that describes the sequential pattern of motor recovery following stroke, progressing from flaccidity to spasticity and finally to voluntary movement control.
The Six Brunnstrom Stages
Stage 1: Flaccidity
- Complete flaccidity with no voluntary movement
- Absence of muscle tone
- No resistance to passive movement
- No reflexes elicited
Stage 2: Basic Synergy Development
- Beginning development of spasticity
- Minimal voluntary movements emerge
- Basic limb synergy patterns appear
- Increased resistance to passive movement
- Strong basic limb synergies may be elicited as associated reactions
Stage 3: Voluntary Synergistic Movement
- Spasticity becomes more pronounced
- Voluntary movement possible but only within synergy patterns
- For upper limb: flexor synergy (shoulder retraction, abduction, external rotation; elbow flexion; forearm supination; wrist and finger flexion)
- For lower limb: flexor synergy (hip flexion, abduction, external rotation; knee flexion; ankle dorsiflexion)
- Patient can initiate synergistic movements but cannot move outside these patterns
Stage 4: Movement Deviating from Synergy
- Spasticity begins to decrease
- Some movement combinations outside of synergy patterns become possible
- Patient can perform simple movements that combine elements of different synergies
- For upper limb: hand to lumbar spine, hand behind head
- For lower limb: hip flexion with knee extension
Stage 5: Relative Independence from Basic Synergies
- Spasticity continues to decrease
- More complex movement combinations outside synergy patterns
- Greater range of voluntary movement
- Increased motor control with more isolated joint movements
- Coordination still impaired compared to unaffected side
Stage 6: Coordinated Voluntary Movement
- Spasticity largely disappears
- Near-normal coordination and motor control
- Individual joint movements become possible
- Fluid, coordinated movement patterns emerge
- May still have some deficits in speed, precision, and endurance compared to pre-stroke function
Clinical Application and Significance
Research has demonstrated that the Brunnstrom stages have strong psychometric properties, including:
- High Rasch reliability (0.91-0.92) for both upper extremity and overall motor assessment 1
- Good responsiveness to change with effect size of 0.35-0.41 1
- Useful for quantifying post-stroke motor function and monitoring recovery progress
Recovery Patterns and Prognosis
- Motor recovery typically progresses through these stages sequentially
- Most significant recovery occurs within the first six months post-stroke 2
- Approximately half of stroke patients show improvement of at least one Brunnstrom stage within the first year 2
- Factors associated with better motor recovery include:
- Shorter initial hospital length of stay (<30 days)
- Higher Barthel Index scores at discharge (≥10)
- Absence of complications at discharge 2
Assessment Considerations
- The Brunnstrom stages assess three key areas: arm, hand, and lower extremity
- Assessment should be performed at regular intervals during rehabilitation to track progress
- The stages can be transformed into interval-level measures for more precise quantification of motor function 1
- Can be used in conjunction with other assessment tools like the Fugl-Meyer Assessment
Treatment Implications
Different therapeutic approaches may be more effective at different Brunnstrom stages:
- Brunnstrom hand manipulation has shown greater effectiveness than Motor Relearning Program approaches for hand rehabilitation in chronic stroke patients 3
- Mirror therapy combined with conventional rehabilitation has demonstrated significant improvement in Brunnstrom stages for lower extremity recovery 4
Understanding a patient's current Brunnstrom stage helps clinicians select appropriate therapeutic interventions and set realistic recovery goals, ultimately improving morbidity, mortality, and quality of life outcomes for stroke patients.