Brunnstrom

Brunnstrom’s Approach
By
Abraham M. Joshua
Associate Professor and Head
Department of Physical Therapy
Deputy Chief Superintendent (Manipal University)
Kasturba Medical College, Mangalore

Contents
Introduction
General Principles
Brunnstrom’s Recovery Stages
Principles Of Evaluation
Training Procedures

Introduction
• Signe Brunnstrom developed this approach in
early 1950’s.
• Brunnstrom 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.
• Techniques as training procedures.
• 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.

General Principles
• As development progress, reflexes become
modified and their components rearranged into
purposeful movement through the influence of
higher centers.
• Reflexes and whole-limb movement patterns
represent normal stages of development. They
are considered to be “normal” when the CNS
has reverted to an earlier development stages.

• Hierarchy in the central nervous system is
reflected in normal development as well as in
hemiplegia.
• Parallel between recovery from stroke and
normal development.
• From this premise, reflex activity is used as
the basis for voluntary movement and
treatment procedures dependent on the stage
of recovery reached i.e. reflexes and primitive
movement patterns to facilitate recovery.

• Sub-cortical motion synergy that can be elicited
on a reflex basis may serve as a wedge by
which a limited amount of willed movement
may be learned. i.e.; reflexes to be used to
elicit movement when none exists as part of a
normal developmental sequence.
• Facilitation of recovery process is seen to take
place in developmental stages. Stages have
only to be achieved and not perfected.
• Patient has to be encouraged to undertake
activities in the sitting position as soon as
possible.

• Newly generated correct motions must be
practiced to be learned and practicing within
the context of daily activities enhances further
learning.
• Proprioceptive and exteroceptive stimuli can be
used therapeutically to evoke desired motion or
tonal changes.
• Based on the observations of recovery
following stroke, this approach makes use of
associated reactions, tonic reflexes and the
development of basic limb synergies to
facilitate movement.
• Use of such procedures is temporary.

Basic Limb Synergies:
• Normal subject - synergistic motor behavior
• Normal synergistic movement are limitless.
• Coupling together of muscles in an orderly
fashion for producing purposeful movements
with maximum precision and minimum waste of
energy.
• Stroke patient exhibit only few movement
patterns which are stereotypic in nature,
referred as BLS.
• BLS do not permit different combination of
muscles.

• The group of muscles constituting a BLS act
together as a bound unit.
• BLS - gross flexor (flexor synergy) or gross
extensor movement (extensor synergy).
• There are four BLS. Two for UE & two for LE.
• BLS are considered as primitive, automatic
and reflexive, highly similar.
• Reflects the loss of inhibitory control exerted
by higher centers.
• Appear during early spastic period and can
be evoked volitionally or reflexly.

• The movement within the BLS is considered
easier to achieve.
• BLS have strong (dominant) and weak
components.
• During the early recovery stage almost all
patients tend to initiate movement pattern by
strong component.
• Influence of tonic reflexes on BLS.

Extremity Type of
BLS
Components forming
synergy
Strong and
weak muscle
components
Upper limb Flexor
synergy
1.Retraction and/or
elevation of the shoulder
2.External rotation of the
shoulder
3.Abduction of the shoulder
to around 90°
4.Flexion of the elbow to an
acute angle
5.Full-range supination of
the forearm.
6.Flexion of the wrist and the
digits frequently seen, but
is by no means universal.
Elbow flexors and
shoulder
elevators are the
strong
components.
Shoulder
abductors and
external rotators
and supinators
are the weak
components.

Extremity Type of
BLS
Components forming
synergy
Strong and
weak muscle
components
Upper limb Extensor
synergy
1.Protraction of the shoulder
2.Internal rotation of the
shoulder
3.Adduction of the arm in
front of the body.
4.Extension of the elbow to
complete range.
5.Full-range pronation of
the forearm.
6.Extension of the wrist with
fist closure frequently
seen, but is by no means
universal.
Shoulder
addutors and
internal rotators
are the strong
components.
Elbow extensors
are the weak
component.

Extremity Type of
BLS
Components forming
synergy
Strong and
weak muscle
components
Lower limb Flexor
synergy
1.Flexion of the hip.
2.Abduction and external
rotation of the hip.
3.Flexion of the knee to
about 90°.
4.Dorsiflexion and inversion
of the foot.
5.Dorsiflexion of the toes.
Components of
flexor synergy
tend to be
weaker with
respect to
extensor
synergy. Flexor
synergy is
usually initiated
by hip flexion.

Extremity Type of
BLS
Components forming
synergy
Strong and
weak muscle
components
Lower limb Extensor
synergy
1.Extension of the hip.
2.Adduction and internal
rotation of the hip.
3.Extension of the knee to
complete range.
4.Plantar flexion and
inversion of the foot.
5.Plantar flexion of the toes
is frequent, but is by no
means universal.
Knee extensors
are the strongest
and usually the
patients tend to
use it to initiate
the extensor
synergy. Even
hip adductors
and plantar
flexors are
strong
components.

Typical Attitude of Lower Limb

• Movements of a BLS occur in the opposite
direction from those of the antagonistic
synergy.
• Inversion is a common component.
• Antagonist of the dominant component of one
synergy is the weakest of the other synergy.
• The weakness of the components can be
explained neuro-physiologically (arises as a
result of stretching of the spastic antagonist
when movement is attempted).
• Some amount of spasticity is likely to occur in
the weak muscles.

• When the BLS dominate, the quantity and
the quality of movements depend on the
relative strength of individual components
of the synergy and the manner in which the
components interact.
• Typical arm posture results from the
combination of strongest components of
BLS.
• In the lower extremity the attitude will be
extensor in nature owing to the domination
of extensor synergy.

• Strong extensor synergy components in the
lower limb makes the patient fail to achieve hip
abduction necessary for standing balance and
ambulation.
• Knee extensors are the most dominant and
most spastic of the extensor synergy, followed
closely by the hip adductors : makes standing
and walking difficult.

Evolution and Dissolution of Nervous
system:
• Hughling Jackson (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 re-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.

Postural reflexes
• Postural or attitudinal reflexes such as TNR,
TLR and Tonic Lumbar Reflexes get integrated
as the nervous system matures.
• The tonic neck reflexes are evoked by neck
movements :
– Symmetrical or asymmetrical.
– The tonal variation produced by STNR is identical
on both left and right side of the body.
– For ATNR the tonal variations are opposite on the
left and the right limbs
• TLR evoked by changes in the position of the
head in space.

• Tonic lumbar reflexes are elicited by changes in
position of the upper part of the body with
respect to the pelvis.
• These attitudinal reflexes easily demonstrable
in certain CNS pathologies.
• If strong, they make the voluntary movements
difficult.
• They are still a part of the normal
neurophysiological equipment and under
various circumstances their facilitating effects
can be evident.

• Postural reflexes are exaggerated (in
stroke/CP/TBI etc)- released reflexes.
• May make the voluntary movements difficult
or impossible.
- For instance, effects of TLR on elbow extension.
Associated Reactions: “Reflex tensing of
muscles or involuntary movements.”
• Frequently seen in patients with hemiparesis.
• Voluntary forceful movements may elicit such
reactions in the affected side.
• Tensing or movement usually appears within
few seconds and may occur in several or all
the joints of the affected limb or limbs.

• The muscular tension may continue even after
the stimulus that evoked the reaction ceases.
• Riddoch and Buzzard (1921) defined it as
“automatic activities which fix or alter the
posture of a part or parts when some other
part of the body is brought into action by either
voluntary effort or reflex stimulation”.
• More in spastic limb.
• Walsh (English neurologist): “released
postural reactions deprived of voluntary
control”.
• Usually flexor or extensor in nature and may
require repeated stimuli.
• Yawning, sneezing and coughing elicits it.

• Raimiste (French neurologist): reported many
associated reactions.
• In supine position, strong resistance to
noninvolved side hip adductors moved the
affected side hip into adduction and
resistance to hip abductors elicited abduction
movement of affected hip. (Raimiste’s hip
adduction and abduction phenomenon
respectively).
• Adduction appears readily as compared to
abduction.

• The attitudinal reflexes are believed to
influence the outcome of associated reactions.
• Brunnstrom: In the upper limb the reactions
were of the same type as the movement;
whereas, for flexor and extensors of lower
extremity the reactions were opposite.
• However, a mutual dependency appears to
exist between the synergies of the affected
side upper and lower extremities which she
referred as “homolateral limb synkinesis” i.e.
flexion of affected upper or lower limb tends to
evoke or facilitate flexion of the ipsilateral limb
and extension tends to evoke extension.

• A reaction alike Raimiste’s phenomenon was
observed by Brunnstrom in the upper
extremity (shoulder adduction and abduction
phenomenon).
• According to Raimiste, such tendency to
move both legs simultaneously is present
even in normal subjects. However, conscious
effort can easily prevent it.

Hand reactions and restoration of hand
functions
• In humans, the evolution of grasping function
may be traced back to simple stretch reflex.
• Denny-Brown(1956) & Twitchell (1958): normal
maturation and activities of higher centers on
lower centers transforms such reactions into
more and more elaborate mechanisms until
normal adult hand functions evolve.
• Twitchell (1951) identified seven steps in the
restoration of hand functions which proceeds in
a manner that closely resembles the
evolutionary one.

• Recovery can cease before the last stage is
reached (Twitchell).
• Those patients who exhibited the true grasp
reflex could progress to full recovery
(Twitchell), i.e. with the affected hand they
could perform the skills equal to that of the
uninvolved hand.
• Neurophysiologically, the restoration of hand
function in stroke patients follows a
sequence.

Stretch reflex
Proprioceptive traction response
True grasp reflex
Instinctive grasp reaction
Instinctive avoidance reaction
Normal hand functions

Stage Features
I Tendon reflexes return and become hyperactive.
II Characterized by development of spasticity in the long flexors which
can be felt as resistance on passive motions.
III Proprioceptive stimuli facilitate voluntary finger flexion.
IV Characterized by elicitation of proprioceptive traction response, i.e. a
stretch of the flexor muscles of any one joint of the limb evokes or
facilitate contraction of the flexor muscles of all the joints. The body
righting reactions have either facilitating or inhibiting effect on this
response.
V Control of hand movements possible without proprioceptive stimuli.
VI During this stage, grasp is greatly reinforced by tactile stimuli in the
palm of the hand and is also characterized by decline of spasticity.
VII True grasp reflex is elicited with further decline of spasticity. Has two
phases, a catching phase and a holding phase. Difference between
grasp reflex and proprioceptive traction response - the former is
evoked by a tactile stimulus and the latter is elicited by a stretch.

Instinctive grasp reaction:
• Stimulus - a stationary contact of any solid
object with the palm of the hand.
• Response - an involuntary fist closure with
the patient unable to release the object.
• Patient may not have any difficulty to open or
close the hand in the absence of the object.
• Seen at birth, but subsequently disappears
as the brain matures.
• Pathologies affecting the frontal cerebral
lobe cause the reappearance of the same.

Instinctive avoiding reaction:
• Seen in patients with parietal lobe lesions.
• If arm is held in a forward-upward direction,
fingers and thumb tends to be held in
extension.
• Stimulus- a stroking of a solid object on the
palmar surface towards the distal direction.
• Response is exaggeration of the hand posture.
Not an uncommon feature in children with
cerebral palsy.
• Neurophysiologically, both instinctive grasp
and instinctive avoiding reactions are
considered as “Transcortical Release”.

BRUNNSTROM’S RECOVERY STAGES
• Brunnstrom: stereotyped sequence of events takes
place during recovery.
• Seven stages.
• Depending on the severity of the insult and the
degree of sensory involvement recovery may get
arrested at any stage in the process.
• Stages cannot be skipped.
• In some cases, especially when the insult is minor,
the recover may proceed rapidly with no distinct
observable stages.
• Believes that the stages of recovery resemble the
normal infantile motor development.

Recovery stage Features
Stage I Seen soon after the acute episode; affected limbs are
essentially flaccid; no voluntary or reflexive movement
possible.
Stage II As recovery begins, BLS or some of their components
appear as associated reaction or some of the
components of BLS appears with considerable voluntary
effort; spasticity begins to develop (particularly in the
dominant components).
Stage III The patient gains voluntary control on B.L.S; full range
of all synergy components is not mandatory; spasticity
reaches its peak; considered as the semivoluntary
stage.
Stage IV Some movement combinations that do not follow the
paths of B.L.S are mastered, first with difficulty and then
with ease; spasticity begins to decline; the influence of
spasticity on nonsynergistic movements is readily
observable

Recovery stage Features
Stage V As recovery continues, more difficult movement
combinations away from the path of BLS are
mastered; dominance of BLS over motor control
reducing; spasticity continues to decline.
Stage VI Individual joint movements possible; coordination
reaching normalcy; absence of spasticity.
Stage VII Normal motor functions restored.

Principles of Evaluation
• Purpose of evaluation is to note the degree of
recovery and the evaluation procedure should
be based on recovery stages.
• Evaluation procedure to be brief and easy to
administer, minimizing overly fatigue of
patient and waste of time available for
treatment.
• 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.

• Brunnstrom had developed and tried several
evaluation forms and found many of them
unsatisfactory or cumbersome.
• Later, she revised the form and produced a
simplified one.
• This form had only minimal test items which
helps to identify the level of motor control and
stage of recovery.
• Patients might be in transition phase.
• Stage of recovery for upper limb and lower
extremities may not be alike.

• Patient should be physically and mentally
comfortable prior to evaluation.
• No facilitation techniques used and no
movements beyond his capabilities are
demanded.
• The evaluation of upper limb in sitting. It
consists of test for passive motion sense of the
joints and the level of motor control.
• Sensory evaluation should precede the motor
evaluation.
• Each motion has to be demonstrated to the
patient prior to motor evaluation.
• Clear and simple instructions.

• Percentage of ROM in each joint is recorded.
• Speed test for movement, if the patient is in
4-6 stages, i.e. hand from lap to chin or hand
from lap to opposite knee in five seconds.
• Upper limb evaluation also consists of test for
finger tip recognition, wrist stabilization for
grasp and wrist flexion, extension and
circumduction.
• For digits, hand functions such as mass
grasp, mass extension, hook grasp,
cylindrical grasp, prehension, individual finger
movements and skilled activities like
buttoning and unbuttoning shirt.

• Evaluation of trunk and lower limb is
performed with patient sitting on a chair and in
standing.
• Even for trunk and lower limb, passive motion
sense, sole sensation, trunk balance and the
level of motor control to be tested.
• Trunk balance can be tested both in sitting
with no back support and in standing.
• The type of ambulation i.e. whether with or
without brace or cane or support, or escort
also to be assessed.

• Ankle, knee and hip attitude in stance phase
and swing phase, arm swing, cadence and
steps per minute are the components
analyzed under gait assessment

Stage Extremity Test item
Stage IV Upper extremity 1. Hand to sacral region or placing
the hand behind the body
2. Elevation of the arm to a
forward-horizontal position
3. Pronation and supination of
forearm with elbow at 90°
Stage V Upper extremity 1. Arm raising to a sideward-
horizontal position
2. Elevation of the arm to a forward
and over head position
3. Pronation and supination of
forearm with elbow extended
with arm forward-horizontally
elevated.

Stage Extremity Test item
Stage IV Lower extremity 1. Ability to flex the knee beyond
90° with the foot sliding
backward on the floor
2. While the patient is sitting
Voluntary dorsiflexion of the
ankle without lifting the foot off
the floor in sitting
Stage V Lower extremity 1. Isolated non-weight bearing
knee flexion with hip in
extension or near extension in
standing
2. Isolated dorsiflexion of the
ankle with knee extended and
the heel kept forward as if for
heel strike

TRAINING PROCEDURES
• Therapist must have adequate confidence in
her knowledge, skill and judgment.
• Essential to have a constructive patient-
therapist relationship.
• Both for evaluation and treatment, if the
patient lacks confidence in the therapist, he
may feel ill at ease and will be reluctant to
make the effort required.
• During training sessions, tasks that the patient
can master or almost master will be
demanded, as repeated failures may lead to
frustration and disappointment.

Recommended bed posture and bed
exercises
• When the flaccid condition prevails, the
positioning of the limbs in the bed - most
favorable way without interference by spastic
muscles.
• In supine: Lower limb has a tendency for
extensor posture with hip in abduction and
lateral rotation- slight hip and knee flexion
maintained by a small pillow under the knee
with lateral support of the knee to prevent hip
abduction and external rotation is
recommended.
• No clothing should be in contact with the foot.

• The affected upper extremity is supported on a
pillow in a position that is comfortable for the
patient.
• To avoid inferior subluxation of the
glenohumeral joint, attention has to be given
not to keep the humerus in abduction with
respect to the scapula.
• Avoid traction on the affected arm and he
should be instructed to support his affected arm
with the normal hand.
• While the flaccidity predominates, passive
motions of the limb are first carried out and
then developed into active assisted
movements.

• The program is expanded to include head,
neck, and trunk movements. The patient should
be taught to move around in bed, sit up and
turn to side lying while protecting the affected
arm.
• Turning can be promoted with the affected arm
kept close to the body, thus rolling over his
affected arm.
• If the patient complains of pain in the shoulder,
then the patient can be taught to roll to affected
side with the affected arm held at the wrist by
the sound hand.

• For many patients, turning to the sound side
difficult.
• Turning to sound side should be performed by
bringing the affected limb into partial flexion
with momentary stabilization of the position by
the therapist.
• Then, the patient should attempt turn over by
swinging arms and the affected knee across
the body.
• Later, as the control improves it should be
performed as a continuous movement from the
supine to the side lying with no assistance.
• As soon as possible, treatment should
incorporate trunk and neck exercises in sitting
position.

• Exercises in sitting aims to:
– improve trunk balance,
– gain control on trunk movements
– provide a face to face encounter (valuable
especially in aphasic) and
– facilitates opportunity to gain voluntary control
of affected upper extremity.
• Ensure adequate head, neck and trunk
flexibility for trunk balance.
• In sitting, trunk rotations can be performed by
placing patient’s arms close to the body.

• Initially, trunk rotation should be performed
gently within small range and then the range
should be gradually increased.
• Throughout the movement, the patient should
look straight ahead in order to provide certain
amount of neck mobilization.
• Many patients may have a tendency to list or
lean towards the affected side.
• Listing phenomenon can be as a result of
perceptual deficits or due to lack of activity of
affected side trunk muscles to check the
movement when COG shifts to sound side.

• Essential to overcome uneven weight bearing.
• Evoking balance responses by deliberately
disturbing the COG by “pushing the patient” in
different directions particularly in the direction
towards he tends to list helps to minimize the
listing tendency and promotes trunk symmetry.
• Cradle his affected arm when perturbations are
given.

• If listing due to perceptual deficiency,
attempts to be made to help him gain a
better appreciation of spatial relations.
• Reinforcement of afferent impulses from
the receptors for position, kinesthetic,
pressure and light touch senses and use of
visual clues.
• Other methods to overcome listing:
– Repetitive head and trunk movements,
– use of temporary raise under the buttocks on
one side or other and a light touch by the
normal hand on a vertical or horizontal
stationary object.

• Trunk inclination exercises for gaining trunk
control. i.e. bending the trunk forward and
obliquely forward on his hips with little or no
forward flexion of the spine can be incorporated
to the treatment.
• Emphasis to cradle affected arm.
• Therapist may have to guide the trunk and arm
movements by holding her hands under the
patient’s elbow (also helps to gain
Glenohumeral and Scapular motions).
• While sitting, head and neck movements may
be utilized to facilitate shoulder girdle
movements over which patient may have
little or no control.

• Resistance to lateral head motion towards the
affected side may promote elevation of
scapula.
• Emphasizing on isometric or eccentric muscle
contraction by giving commands like “hold” or
“don’t let me pull your head away from your
shoulder” followed by concentric muscle
contraction by commands like “get your
shoulder closer to the ear” can be utilized to
attain control over shoulder elevation.

Upper Limb Training:
• Voluntary control or at least partial control of
BLS is a prerequisite.
• Just as in normal motor development, it is not
essential to perfect the activities before
attempts are made for more advanced stages
of motor developmental sequences.
• If the patient is in flaccid stage, to initiate BLS,
associated reactions or attitudinal reflexes can
be utilized.

• Such reactions enable background tension in
muscles and then to gain voluntary control
over BLS, volitional effort to be superimposed.
• Usually, the first associated reactions in upper
extremity are observed in flexors.
• Once the patient is able to initiate movement
on a voluntary basis, reflex assistance has to
be withdrawn and movement patterns that
deviate from BLS to be introduced.
• Movement therapy becomes more meaningful
only if the patient utilizes BLS or its
components for functional activities.

• Though, the BLS can be utilized for many
household activities, there are controversies
regarding its long-term advantages and
disadvantages. For instance, the possibility of
one-armed-ness or neglect can be overcome
by early usage of BLS.
• Long term use of BLS for functional activities
may promote excessive reliance on the BLS
which may reinforce the components of BLS,
in turn hindering the potential of further
recovery.
• Use of the BLS in practical activities must be
controlled, based on therapist’s knowledge
of the individual patient.

• In the early stage, rapid passive range of
motion exercise may evoke spasticity in the
dominant components of the BLS which the
patient may be able to sense and be able to
assist in achieving the movements.
• However, the efforts must be modulated and
very gentle passive movements for gaining
more normalized tone has to be introduced, if
excessive spasticity develops in them.

• Initially shoulder girdle movements such as
elevation, depression, retraction and protraction
can be stressed.
• Later, shoulder flexion movements have to be
performed bilaterally and then unilaterally.
• If the patient is unable to perform shoulder
movements, then the therapist will have to
assist or guide the movement and
simultaneously she might have to use
percussion or cutaneous stimulation over the
muscles in order to activate them.

Shoulder pain and subluxation:
• To necessitate normal glenohumeral rhythm,
the therapist may have to guide the patient’s
scapula into upward rotation during shoulder
movements.
• When passively mobilizing, if the patient
complaints of shoulder pain secondary to
stretching of spastic muscles, then
mobilization of the shoulder joint without
forceful stretching of tense muscles have to
be attempted.
• Anticipation of pain – increase the tension in
the spastic muscles.

• For such patients, attempts to be made to
guide the movement of the arm with respect to
the trunk without the patient sensing the
movement of the arms.
• Trunk rotation exercises help to utilize the tonic
reflexes to alternatively increase and reduce
the tension in the pectoralis major muscle
enabling a larger range of shoulder abduction
without pain.
• Once no pain on passive movement, active
assisted movements of the arm with respect to
the trunk can be started.

• Even promoting activity in all the components
of flexor synergy -essential for a pain free
shoulder movement.
• As the training progresses, however,
emphasis is also given in developing extensor
synergy and eventually, both the synergies
are combined in a “roundabout” fashion for
producing painless movements.
• Activation of muscles around the shoulder
joint is needed- to maintain the integrity of the
joint.

• Normal tone and activity of the rotator cuff
muscles, especially supraspinatus plays an
important role in preventing the glenohumeral
separation.
• Flexor synergy can be used to facilitate
background tension in the supraspinatus and
other external rotators.
• Later, a more isolated contraction of the
external rotators should be stressed.

Techniques for improving motor control:
• Use of strong or dominant components of a
synergy to strengthen the weaker ones. For
example, “waist squeezing” or pronation of
forearm prior to the patient’s effort for elbow
extension.
• The movements are guided in the beginning
before active assisted, active and resisted
exercises are given. For example, when the
patient performs bilateral “classic rowing
exercise” , the therapist can guide the
movement and later, resistance can be applied
to the affected side.

• In bilateral rowing exercise, the push phase is
initiated and executed using the flexor synergy
and the pull phase using the extensor synergy
of the affected extremity.
• Local stimulation can also facilitate muscle
contraction. E.g. vigorous back and forth
stroking of the skin over the weak muscles and
use of proprioceptive or proximal traction
response (mentioned earlier) to facilitate
muscle contraction.
• Use of visual guidance and attitudinal
reactions.

• Use of postural reactions such as tonic neck,
tonic labyrinthine and tonic lumbar reflexes
for providing a background tension in the
weak muscles.
• Isometric and lengthening contractions to be
attempted before shortening contractions.
“Place after positioning” the affected limb.
• In order to gain better motor control “reversal
of movement direction” can be utilized. E.g.
“push and pull exercise” in sitting can be
used to strengthen weak extensor synergy
and can also promote better control of flexor
and extensor synergy.

• Weight bearing through affected arm, in
sitting or other functional positions promotes
background activity in the weak synergic
muscles.
• As the patient gains more control over the
movement, the therapist’s assistance and
use of facilitatory and postural reflexes
should be withdrawn.

Serratus Anterior Training:
• Flexor synergy may enable 90° abduction at
shoulder.
• On inspection and palpation: strong contraction
of Trapezius and Deltoid muscles with winging
of scapula.
• Idle nature of Serratus Anterior. Factors:
– Excessive spasticity in pectoralis major muscle and
– painful range of motion at the shoulder for raising
the affected arm overhead.
• Certain amount of control of muscles belonging
to the two BLS of upper extremity and mobility
of scapula are the pre-requisites for facilitating
Serratus Anterior.

• To facilitate this muscle:
– patient should be in sitting position with the arm
supported in a forward-horizontal direction. He
should be requested to reach forward, which
may be assisted and mean time therapist should
briskly stretch the serratus muscle.
– Commands like “don’t let me push your arm
back” should be simultaneously given.
– Isometric and later eccentric activity of the
muscle.
– If pectoralis major muscle overacts, the affected
arm should be brought into more abducted
position and the facilitation technique should be
repeated.

– Once isometric and eccentric muscle
contractions are possible, concentric exercises
as “arm to ear”, “arm to opposite shoulder” and
eventually “arm above head” should be taught.
– To gains more voluntary control, “reversal of
movement” should be introduced.
– Guidance, assistance and resistance offered by
the therapist for the movement synergies and
their individual components should be gradually
withdrawn.

Upper limb training for recovery stages IV & V
• Certain level of control of two BLS is a pre-
requisite.
• Training procedures aim at -modifying the
available motor responses and reinforcing the
willed impulses -to overcome the still existing,
although diminishing linkage between BLS.
• Movement combinations that deviate from the
paths of BLS must be introduced in order to
-break up the strong linkage.
• Activate those muscles which do not belong to
BLS.

• Patients may find difficulty in initiating
movements away from the path of either
synergy.
• Functional activities which resemble the BLS
can be used as variations in movement
direction. For instance,
– Variation of the “classic rowing” pattern.
Incorporating shoulder abduction during the pull
phase and shoulder adduction during the push
phase for variations.
– Similarly, modification of either synergy to bring the
hand to mouth (usually, the patient brings his hand
to the mouth with simultaneous abduction of the
arm and the head turns to meet the hand), opposite
shoulder, forehead and top and back part of head.
Subject to be directed to press his elbow firm
against the side of the body.

• Use proprioceptive, exteroceptive & hold
after positioning.
• The desired movement paths have to be
demonstrated first (by passive
movements) to provide sensory impulses
to facilitate better control over the
attempted voluntary movement.
• Training procedures also include bringing
hand first to ipsilateral ear and then to
contralateral ear and also promote back
and forth stroking movement.

• Stroking can be performed by the use of
palm of the hand, provided that there is no
excessive tension in the finger flexor
muscles or else with a closed fist.
• Forward-horizontal direction movement of
the arm with elbow flexion and more lateral
movements require dissociation of pectoralis
major from triceps.
• A step-by-step modification of the voluntarily
performed extensor synergy is essential.

• To bring the entire affected arm behind the
body, participation of subscapularis along with
dissociation of pectoralis major from elbow
extensors is required.
• Patient may initiate arm to rear of body using
one of the either synergy. Alternatives are-
– If standing balance is satisfactory, trunk rotation
movements (movement not confined between chest
and pelvis, but incorporating the hips), gradually
increasing in range, with arms hanging lose by the
side of the body.
– Use of momentum while attempting to bring the
arm backwards
– Guidance and assistance may be required for some
time before the patient succeeds in bringing the arm
backward as a free movement.

• For bringing the arm forward to horizontal
position and side-horizontal position requires
adequate scapulothoracic movements and
voluntary control over the upper extremity.
• Guidance and assistance, isometric or
eccentric prior to concentric activity and
reversal of movement directions to gain control
over movement combinations away from BLS.
• Once the patient moves to stage IV or V,
functional activities that are possible with those
new muscle combinations to be stressed.
• Functional activities will boost the patients
motivation, improves coordination and control.

Training program for stage VI of upper limb
• Not all patients can reach this level.
• This stage- the influence of synergies is least
on the movement combinations.
• Lack of resistance to passive movements.
• Individual joint movements are performed in the
normal or near normal fashion.
• A general tendency for the recovery of the hand
to lag behind the rest of the affected upper
limb.

• If the hand functions do not recover completely,
the patient may feel those skilled movements
performed by the affected hand as awkward
and he may continue to use it as a secondary
hand.
• Motivate the patient to utilize his affected hand
for most of the functional activities so that the
coordination and control will improve and
becomes comparable to the sound hand.

Training program for hand functions
• The effectiveness of the hand to perform skillful
activities is directly related to the function of
entire upper extremity.
• The restoration of hand function is
predominantly a flexor phenomenon and
progresses somewhat same way as normal
restoration of hand function.
• Aim: to promote mass grasp and mass release
of objects. Later, more refined prehension.
• Use of symmetrical associated reactions and
imitation synkinesis to facilitate functional
movements.

• If unable to initiate finger flexion on a voluntary
basis, proximal traction response may help to
achieve a mass grasp provided that he has
some control of the proximal components of the
flexor synergy.
• Maintain the patient’s wrist in extension and a
command like “squeeze the fingers” could be
given.
• Normally, a strong linkage exists between the
muscles stabilizing the wrist in extension and
fingers into flexion (following stroke, this linkage
is usually disturbed, which should be re-
established).

• Use of proprioceptive or exteroceptive
stimulation over the proximal portion of the
wrist extensors along with commands like
“squeeze your fingers” may promote finger
flexion with the wrist in extended position.
• Later, gradually withdraw the support given to
the wrist and commands like “hold your wrist”
and “don’t drop it down” to be incorporated.
Wrist extension is a component part of the
extensor synergy.
• Therefore, stabilizing the wrist in extension with
the arm and the elbow in flexion is also
essential.

• If the spasticity of the finger flexors is
extensive, the affected hand’s thumb may be
held flexed in the palm of the hand with other
fingers close tightly over the thumb and makes
release of the fingers impossible.
• Brunnstrom has advised a series of
manipulations, cutaneous stimulation, favorable
body and arm postures to release the tension in
the finger flexors and evoke background
tension in the extensor muscles for preparation
of voluntary finger extension.

• For instance, the therapist can sit face to face
to the patient and then, she should pull out
the patient’s thumb by gripping the base of it
(around the muscles of the thenar eminence)
with simultaneous passive supination of
forearm.
• If the tension in the flexors is marked, the
wrist can be held in some degree of flexion.
• Next, supinate and pronate the forearm
slowly and repeatedly with cutaneous
stimulation over the dorsum of the wrist and
hand, when the forearm is in supination. This
technique may help the hand to open
partly or fully.

• Once background tension develops in the
extensor muscles, the patient may actively
participate in opening the hand with the
forearm in the supinated position.
• Even rolling of the fingers into flexion is
believed to stretch the finger extensors which
may elicit stretch reflexes, thus aiding in
transfer of tension from flexors to extensors.
• Souques’s position and friction over the ulnar
aspect of the dorsum of the forearm with the
arm supported may also encourage to relieve
the tension within the finger flexors.

• Summation of voluntary effort with the above-
mentioned reflex stimulation may result in
active finger extension.
• Once the extensor response of the digits is
well established, the patient has to be
requested to alternatively make the fist and
open the fist with the arm gradually kept in
lowered position.
• Care has to be taken to avoid contact of the
reflexogenic zone of the hand.
• Indiscriminate use of a rubber ball in the
affected hand given to strengthen the grip
must be discouraged.

• Voluntary thumb movements frequently begin
to appear when voluntary mass extension of
the fingers becomes possible.
• Enabling the movement of the thumb away
from the contact of the index finger is utmost
important for learning lateral prehension and
advanced prehension for functional activities.
• While moving the thumb away from the index
finger, the patient should be requested not to
generate excessive effort as it can flex the
thumb and the other fingers.

• Application of friction or gentle local
percussion over the tendons of abductor
pollicis longus and the extensor pollicis brevis
muscles near the wrist may abet thumb
movements.
• Depending on the severity of CVA, the
restoration of hand function can halt at any
stage and seldom recover completely.
• Hemiplegic patients with sensory deficiency
may find difficulty to maintain grip without
conscious effort.
• Similarly, presence of instinctive avoidance
reaction or instinctive grasping reaction makes
prehensile movements difficult or
impossible and will continue till the
influence of these reactions diminishes.

Gait Abnormalities and Gait Training for
Hemiplegia
• Restoration of safe standing and safe walking
in a near normal pattern forms the key
components of training procedure.
• Gait patterns of patients with hemiplegia
depends on the severity of the involvement
and the manner of compensation the patient
adopts.
• Combination of muscles required for
generating normal locomotion is not identical
to the BLS.

• Challenging job for the therapist to find ways
and means of modifying the gross movement
synergies to bring about functional muscle
combinations resembling normal human
locomotion.
• When comparing muscle action of hemiplegic
patients with normal subjects there are
considerable changes in phasic action of
muscles.
• Stance phase on the affected side -
considerably shorter.
• Swing phase - correspondingly longer.

• Knee extensors and the plantar flexors on
the involved side are active throughout
stance phase.
• Poor performance of affected extremity
necessitates, alters and intensifies muscle
activity of the normal lower extremity.
• Energy consumed by them for locomotion is
considerably high with reduced speed and
cadence.
• Two main factors that cause locomotion
difficulties in hemiplegia:
– firm linkage of muscle groups in accordance with
the dictum of primitive movements synergies
– slowness of reactions of the muscle groups.

When BLS dominate the motor behavior,
those muscle combinations essential for
normal locomotion will be hindered.
• Rapid rise and fall in muscle tension required
for normal locomotion will not materialize in
these patients.
• While analyzing the gait, the behavior of the
affected ankle, knee, and hip during the
stance and swing phase have to be carefully
studied.
• Comparison of the muscle activities in the
hemiplegic gait and normal gait is as follows:

Phase
of gait
Joint Motor behavior in normal
subjects
Motor behavior in
hemiplegic side of patient
Early
stance
phase
At
ankle
joint
During heel strike, the angle
between foot and the leg is
approximately 90° and as
the weight is shifted to the
forward foot, eccentric
contraction of the pretibial
muscles helps the sole to
gradually and smoothly
lower down to the ground.
Activity of these muscles is
also needed for stabilizing
the ankle preventing sudden
plantar flexion of the ankle.
Dominance of BLS with
anticipation of weight
bearing on the involved
lower limb frequently
activates all the extensor
synergy components. This
prevents the normal
association of the ankle
dorsiflexors and the knee
extensors essential for heel
strike causing simultaneous
contact of heel and forefoot
to the ground. If the
spasticity is marked, the toe
may first come in contact
with the ground.

Phase of
gait
Joint Motor behavior in
normal subjects
Motor behavior in
Between
early
stance
and
midstance
phase
At
Knee
joint
When heel strikes the
ground, the knee is nearly
extended. Immediately after
the heel strike, a cushioning
response consisting of initial
flexion of short duration and
small range precedes the
knee extension. This flexion-
extension response at the
knee helps to keep the path
of COG from rising and
falling abruptly, aiding a
smooth forward translatory
motion of the body. During
the flexion movement of the
knee there is maximum
activity of quadriceps muscle
which prevents buckling of
the knee and it ceases when
the limb moves to midstance.
If the limb is flaccid, attempts
to support the body weight
through the affected limb
causes buckling of the knee.
On the contrary, if the limb is
spastic, mild to severe
hyperextension of the knee
may occur making the normal
flexion-extension moment
impossible. Hyperextension
of the knee may also result
from excessive tension in the
plantar flexors which prevents
a forward pivoting of the leg
at the ankle which normally
should happen during the
locomotion.

Phase of
gait
subjects
Motor behavior in
Between
early
stance
and
midstance
phase
At
Hip
joint
In these phases, activity of
the hip abductors provides
lateral stabilization of the
pelvis which prevents the
opposite side of the pelvis
from dropping. Immediately
after heel strike the hip
extensors is found to show
brief burst of activity which
ceases soon before
midstance.
During weight bearing,
dominance of extensor
synergy components
(including the hip adductors)
causes failure of hip
abductor muscles to
respond, thus compromising
lateral stability of the pelvis
leading to a Trendelenburg
limp (the pelvis of the
normal side lowers when the
affected side weight bears)
which will not be obvious if
the patient uses a cane or
external support. Patient
may incline his trunk
laterally to advance
forwards.

Phase of
gait
subjects
Motor behavior in
Midstance
phase
At
ankle
Once the metatarsal heads
contact the ground, the
activity of dorsiflexors
reduces. During this
phase, the leg pivots
forward about the ankle
joint causing reduction of
the angle between the foot
and the leg. A gradual and
eccentric contraction of the
calf muscles begins when
the body weight advances
in front of the ankle joint
preventing excessive
pivoting of the leg at the
ankle.
Attempt to advance the body
weight in front of the ankle
joint increases the tension
within spastic calf muscles
preventing forward pivoting
motion of the leg at the
ankle joint. As a result, the
patient will find difficulty in
advancing the normal foot to
proper distance making the
stride length unequal and
the swing phase too rapid. If
the tension within the calf
muscles is marked, the
involved limb may lead all
along with drawing of the
normal foot up to, but not
beyond the affected one.

Phase of
gait
normal subjects
Motor behavior in
Late
stance
phase
At
ankle
This phase is characterized
by rising of the heel from the
ground with simultaneous
flexion of the knee in order to
prepare the limb for forward
swing. In this phase,
concentric activity of the
plantar flexors occurs and it
increases for generating an
effective “push-off”. Activity
of the plantar flexors brings
the foot into 20° plantar
flexion. Thus the “push-off”
produced by the calf
muscles activity along with
inactivity of the knee
extensors, activity of other
muscles and the
gravitational forces are
responsible for initiating the
forward swing of the limb.
Tension within the quadriceps
persists in this phase and
prevents the knee from flexing.
As a result the combination
necessary for push-off and
initiation of the swing phase
will not materialize. Therefore,
the patient has to rely on
compensatory methods such
as external rotation and
adduction or circumduction or
excessive hip hiking in order to
bring the limb forward.

Phase of
gait
normal subjects
Motor behavior in
Late
stance
phase
At
knee
joint
In this phase, the
inhibition of the
quadriceps muscles
activity enables the knee
to flex in order to initiate
the forward swing of the
limb.
The strong bond existing
between the calf muscles and
the quadriceps muscles does
not allow the muscle
combination required for
initiation of the forward swing
of the limb.
Late
stance
phase
At
hip
joint
To prepare the limb for
forward swing, there will
be flexion of the hip. The
flexion of hip
accompanies the flexion
of the knee and plantar
flexion of ankle. Activity of
the superficial hip flexors
is responsible for
initiating it.
Normal combination required
for preparation for forward
swing will be difficult or
impossible due to the
dominance of the BLS. Lack
of hip flexion and knee flexion
along with persistence of calf
muscles activity prevents
effective push-off.

Phase
of gait
Joint Motor behavior
in normal
Motor behavior in hemiplegic side
Swing
phase
At
ankle
joint
Slight activity of
pretibial muscles
through out this
phase prevents
the foot from
dropping down.
Dominance of the extensor synergy
components prevents the activity of
dorsiflexors causing talipes equinus
and insufficient ground clearance.
The ankle may also invert markedly
making the gait unsafe for the
patient. The patient may utilize the
flexor synergy components in an
exaggerated manner to dorsiflex the
ankle for clearing the ground.

Phase
of gait
Joint Motor behavior
in normal
Motor behavior in hemiplegic
side
Swing
phase
At
knee
joint
Muscular and
gravitational
forces bring
about the forward
acceleration of
the limb. Most of
swing phase, the
muscular activity
is minimal and
inertia is
responsible for
forward motion.
Persistence of extensor synergy
until the late stance phase makes
the knee stiff. In such situations,
the patient may often use the total
flexor synergy for flexing the knee
joint and frequently the onset of
knee flexion is delayed due to poor
push-off. Therefore, the involved
side knee will be lifted forward and
upward with leg hanging more or
less vertical and foot well above
the ground, as if the patient is
stepping over an obstacle.

Phase
of gait
Joint Motor
behavior
in normal
Motor behavior in hemiplegic side
Swing
Phase
At hip
joint
If extensor synergy dominates, the normal
shortening of the limb essential for swing
through will not materialize. In such
circumstances, the patient may circumduct
or hike the pelvis to clear the ground. If the
hip is held stiff, he may tilt the pelvis
backward and use the abdominal
musculature and the gait will resemble that
of ankylosed hip. The patient may also use
the total flexor synergy for flexing the hip
joint as mentioned earlier. If the motor
control is poor, the patient may use the hip
adductors to drag the affected limb forwards.
In such situations, the patient will never
advance his affected limb beyond the normal
foot and the pelvis will stay behind the
affected side with the hip held in external
rotation and foot in eversion.

Gait Training
• During the flaccid and later in spastic stages
these patients may use one or other forms of
compensation and may become good or fair
walkers. Compensations are characterized by
poor gait pattern which is stubbornly resistant
to correction.
• To avoid such compensatory strategies, right
from the early days, concentrate on preparation
for walking while postponing actual gait keeping
in mind that our aims are to restore safe
standing and a safe gait as normal as possible.

• However, in most severely involved patients,
when chances to progress beyond the synergy
stages appear slim, a compromise has to be
reached and our objective should be to make
them modestly ambulant. For such patients,
BLS may help to to overcome the problem of
ambulation.
• Preparation for gait should commence from the
early period (Weight bearing exercises and
trunk balance in sitting and standing).

• Components necessary for normal gait
– Modification of motor response to obtain muscle
associations resembling those required for
normal gait.
– Reversal of movement direction and
– Strengthening the weak muscles
• Treatment should follow a stepwise series of
activities with increasing complexity,
progressing from the least demanding
position (supine) to the most demanding
position (standing).

Training procedures to improve gait:
• Dominance of synergies may make the
severely involved patients unable to restore
their normal gait.
• In minimally involved, modification of motor
responses may not be necessary as the
synergies lose their dominance leading to
spontaneous return of normal/near normal gait.
• Many of the patients who falls between these
extremes require modification of motor
responses to attain a near normal gait.
• Training should consist of techniques to
strengthen weak components of flexor synergy.

• To facilitate hip flexion control bilateral
contraction followed by unilateral contraction
of affected side hip flexors can be attempted.
For instance,
– inclining the trunk backwards and forwards when the
patient sits on a chair, produces a lengthening contraction
and shortening contraction of hip flexors respectively. Trunk
inclination movements also activate the abdominal
muscles. Commands like “hold” when the patient inclines
forwards will promote isometric contraction of hip flexors.
• If no control over hip flexion: Marie Foix reflex
or Bechterev’s reflex (quick passive plantar
flexion of the toes in supine position with hip
and knee in slight flexion) to a total flexion
response.

• Later, voluntary effort should be superimposed
on reflexive stimulation, followed by training
activation of dorsiflexors in combination with hip
and knee extension.
• To generate a better motor control, attempts
should be made to initiate ankle dorsiflexion
movement without reflex assistance.

Predominance of extensor synergy
No normal association of hip abduction with hip
and knee extension
Trendelenburg limp (common in many
hemiplegic patients).

• Attempts to activate hip abductors and
associate it with hip and knee extension.
• Can be achieved by reflexive elicitation of hip
abductor - use of Raimiste’s hip abduction
phenomenon in supine, use of local
facilitatory techniques, superimposition of
voluntary effort on the reflex contraction by
commands like “spread your legs” and
promotion of isometric contraction of hip
abductors in side-lying for gaining better
control over the hip abductors.

• Later, attempts should be made to abduct the
affected limb. E.g. side kicking movement in
standing.
• Hiking or elevating the pelvis of the sound
side also necessitates a strong contraction of
the hip abductor muscles of the affected side.
• If the methods of activation of hip abductors
is successful, then commands like grow tall
on each step can be incorporated to generate
smooth walking pattern with a suitable
cadence dictated.
• If elimination of Trendelenburg limp is
difficult, use of a cane can be encouraged.

• If the ankle dorsiflexion response is poor:
manual resistance to hip flexion movement
and local facilitatory techniques can be tried.
• Attempts to promote voluntarily dorsiflexion
of the ankle while sitting on a higher chair
(later even in standing posture should be
attempted).
• Even facilitation of eversion of the subtalar
joint along with dorsiflexion of the ankle is
essential to activate the peroneal muscles
which lies idle.

• Activation of evertors prevent abnormal
association of inversion along with
dorsiflexion of the ankle.
• Use of stretch reflex, percussion or
exteroceptive stimulation over the evertor
muscles and efforts to isometrically contract
the muscle may promote better motor control
of the ankle and subtalar joint.
• For smooth locomotion : Reversal of direction
to promote alternating knee flexion and
extension movement. (training indicated in
supine, side lying, sitting and standing
positions).

• For weak knee flexors: Associated reactions,
use of exteroceptive stimulation over the
hamstring muscles may induce knee flexion, if
not, use of side lying position may eliminate the
influence of gravitational force and minimize the
effect of TLR.
• Training the patient to slide the foot on the floor
while sitting on a chair helps to guide and
provide sensation of isolated knee flexion
motion.
• Sitting on tall chairs and sliding the foot back
and forth underneath the chair enables further
development of reciprocal knee flexion and
extension.

• To promote heel strike and push-off in gait,
reciprocal ankle dorsiflexion with knee
extension, and ankle plantar flexion with knee
flexion (in forward lean position). Later, the
position should be gradually modified to a
standing.
• In spite of increased tension within the
quadriceps, affected knee may buckle and
cause a fall or hyperextension of the knee.
Partial squat with even weight bearing, weight
shifts and lifting of the sound leg and later
involved leg of the ground may improve the
knee stability & minimize buckling
/hyperextension.

• Spasticity and dominance of BLS determine the
full return of normal arm swing, rotation and
counter rotation of the pelvis and trunk.
Appropriate training to promote arm swing
along with trunk rotation.
• For instance while standing, rotation of the
trunk slowly to either side with the patient
asked to wrap his arms. Later, when he learns
to voluntarily wrap his arms, attempts to walk
with exaggerated trunk rotation can be
incorporated. However, care should be taken to
maintain the rhythm, even if the trunk and arm
movements are not perfect.

Brunnstrom

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