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Stages of Stroke Recovery | by heidi

 



A stroke is a medical emergency in which blood flow in the brain is either blocked (called an ischemic stroke) or bleeds (called a hemorrhagic stroke). A stroke can affect a person's movement, coordination, cognition, speaking, and more.1


Recovering from a stroke can be a challenging and emotional process and is different for everyone. The location, extent of the lesion or tissue involvement, time before treatment, and other factors all affect the outlook for recovery.2 However, experts have identified a general pattern of motor recovery from stroke.



This article discusses the Brunnstrom stages of stroke recovery and what you can expect from rehabilitation after a stroke.

An older woman walking with using parallel bars in a rehab center


Brunnstrom Stages of Stroke Recovery

A stroke can affect a person's:


Movement

Coordination

Vision

Speech

Swallowing

Thinking abilities

Emotional processing

The Brunnstrom stages of stroke recovery include seven commonly seen steps in motor (movement) recovery after a stroke.



They were first recorded in the 1960s by Signe Brunnstrom, a Swedish physical therapist who worked with stroke patients experiencing hemiplegia (paralysis on one side of the body).3 Through her clinical experiences, Brunnstrom observed stages of movement restoration that she described as occurring in an "almost standardized fashion."3


To this day, physical and occupational therapists use Brunnstrom's stages to assess motor recovery post-stroke.4


Recovery Is Different for Everyone

Keep in mind, there are no guarantees on timeline or completion through all the stages. Everyone is different, and these steps should be viewed as a general pattern and not an absolute likelihood.


Additionally, the Brunnstrom stages refer to movement recovery in the upper limb, lower limb, and hands. A person may be in different stages of recovery in each extremity. The stages do not address recovery in speech, vision, cognition, or the many other areas in which people experience symptoms post-stroke.


Flaccidity 

The first stage is flaccidity, and occurs immediately post-stroke. Muscles will be weak, limp, or even "floppy."



Because a stroke often affects one side more than the other, this flaccidity may be limited to just one side. Many people also have more severe symptoms in their upper limbs or hands than they do in their lower limbs.



Flaccidity is the result of damage in the brain from the stroke. Due to this damage, the brain can no longer send messages to certain areas of the body to move. The danger of flaccidity is that if it lasts too long, you may lose significant muscle mass and strength.



Flaccidity Exercises

Some interventions during this stage may include:


Range of motion exercises

Positioning (can help prevent sores, joint restrictions, swelling, and dislocation)

Sensory reeducation

Hand-over-hand assist during activities of daily living (such as brushing your hair or teeth).

These techniques help "remind" your brain of your affected side and begin restoring connections through neuroplasticity. Neuroplasticity is the brain's ability to reorganize and build new neuron connections.


Spasticity Appears

The second stage is the appearance of spasticity. Spasticity is muscle stiffness and rigidity.



At rest, your limbs may remain contracted (usually in a "flexed" position, with the elbow and wrist bent), or they may jerk or tremor when you try to move them. You may have some voluntary movement back at this point, but not much.


Spasticity is the result of the brain beginning to rebuild connections with the muscles. In that way, it is actually a good sign. However, the connection is incomplete, which is why muscles may get "stuck" in contracted positions or not move in the way you want them to.


It may become more difficult to move your affected limbs during this stage, due to spasticity, but it's very important to continue moving as much as you can to prevent learned non-use and give yourself the best chance of recovery.


Spasticity Exercises

You will likely continue with passive range of motion exercises and add in active-assisted range of motion exercises (you will try to move as much as you can, and your therapist will physically assist you with the rest). Spasticity exercises may also include:


Sensory reeducation

Hand-over-hand assistance with functional activities

Mirror therapy

Increased Spasticity

In the third stage, spasticity increases even more. This can be incredibly frustrating and you may feel that you are getting worse and not moving forward in your stroke recovery.


Again, this increase in spasticity is actually a good sign (even if it doesn't feel like it), because it means your brain is further rebuilding connections with your muscles.


During this stage you will continue with and progress your therapeutic exercises. You will likely focus on performing as much active movement as you can, although this will be challenging.


Your healthcare provider may prescribe botox injections to help reduce spasticity so you can maximize your movement during therapy.5


Increased Spasticity Exercises

Some helpful exercises in this stage include:


Mirror therapy has been shown to help return active movement to the affected side.6

You may use splints or orthotics (such as a resting hand splint) to help prevent contractures.

Your occupational therapist may also recommend assistive devices, such as a universal cuff for holding a toothbrush or fork, to keep you engaged in functional activities as much as possible during this stage.

Decreased Spasticity

In the fourth stage, spasticity begins to decrease. This is a big milestone in the stroke recovery process.


As spasticity decreases, you will notice improved voluntary movement patterns, but these will still feel jerky, twitchy, and uncoordinated.


Due to remaining spasticity, you may have difficulty with releasing objects. For example, you may be able to grasp a fork but unable to release it. You will likely also be very weak from your lack of voluntary movement in the first three recovery stages.



Decreased Spasticity Exercises

Interventions in this fourth stage will capitalize on your returning voluntary movement.


You will likely focus on active-assisted and active range of motion exercises (where you will move on your own, as much as you can), as well as introduce strengthening exercises.

You will also focus on retraining functional movement patterns, for example practicing dressing, bathing, tabletop games or activities, and more with assistance.

Constraint-induced movement therapy may be introduced at this point, which involves constraining your unaffected side and forcing you to perform exercises or functional activities with your affected side as much as possible.7

Complex Movement Combinations

In the fifth stage, a person can begin to coordinate complex movement combinations. This might include grasping a spoon, loading it with food, bringing it to your mouth, bringing the spoon back to the table, and releasing it.


With improved voluntary movement and coordination, you will become more independent in the things you want and need to do.


Complex Movement Exercises

You will continue with and progress your exercises at this point, perhaps increasing repetitions and resistance during strength training, or focusing more on retraining fine motor skills now that gross motor skills have improved. You will be encouraged to continue using your affected side as much as possible during functional activities and reduce the assistance from your therapist or caregivers.


Spasticity Disappears & Coordination Reappears

In the sixth stage, spasticity is all but gone. With less spastic movements, you will have significantly improved coordination for complex movement patterns.


Focus on practicing and refining coordination and fine motor skills during this stage. You may work on retaining more complex and challenging functional activities, such as meal prep, cooking, cleaning, hobbies, and more.


Normal Function Returns

In the seventh and final stage, normal function returns. You can now perform complex, coordinated, synergistic movement patterns in your affected side just as well as your unaffected side. You are able to return to your meaningful occupations with independence.


This stage is the ultimate goal for patients and their rehabilitation team, but not everyone will reach this point. According to Signe Brunnstrom's original writing in 1966, a small number of patients reach this advanced recovery stage.3


Know that even if you never reach this seventh stage of motor recovery, there are still many therapies, assistive devices, and techniques available for you to continue living a full life.


Spontaneous Recovery

Spontaneous recovery, or rapid improvement in symptoms, is possible, especially in the early stages of stroke recovery. In some fortunate people, this might be a full recovery. In other people, it might mean jumping ahead a stage or two in the recovery process.8


But how does spontaneous recovery happen?


After a stroke, your body tries to clean up the damage in your brain from a bleed or blockage (depending on what type of stroke you had). It also needs to reorganize and rebuild neuronal connections that were destroyed. These neurons connect different areas of the brain, and send messages from your brain to your body. This rebuilding process is called neuroplasticity.


Particularly in the early stages of stroke recovery, neuroplasticity can happen quickly. In these cases, when many new connections have been built, your stroke recovery may seem spontaneous.


Recovery Timeline

Spontaneous recovery is most likely to occur in the first three to six months post-stroke. This is the time when your brain is most "plastic" and intensive therapy is most important.


It was previously believed that a person reached their maximum potential in recovery at six months, but this has since been disproved. A landmark 2019 study found that neuroplasticity and recovery are possible even years after a stroke, so don't give up.9


Possible Setbacks

There are many variables that can affect the outcome of your stroke, and the course of your recovery. These include:2


Location of stroke within the brain

The degree of damage to the brain

Any co-occurring medical conditions

How soon rehabilitation begins post-stroke

The intensity and frequency of therapy

Compliance with therapeutic exercises and home exercise programs

Supportiveness of family, friends, and caregivers

Age at time of stroke

Home safety

Cognitive abilities

Insurance coverage and ability to financially cover rehabilitation, therapy, and any recommended assistive devices, orthotics, or home modifications

Strokes are also not necessarily isolated events; each year, 25% of strokes are recurrent.1 It is essential to prevent further strokes by treating the underlying cause, which may be uncontrolled high blood pressure, atrial fibrillation, heart disease, high cholesterol, diabetes, and more.1

Stroke Statistics

In the United States, stroke is the number one cause of adult disability.10 Each year, about 795,000 people in the United States will have a stroke. About two thirds of these people will survive and require rehabilitation, joining an estimated 7 million stroke survivors.11


Stroke Treatment Options

Stroke treatment is going to look different for each person, because no person and no stroke is the same.


However, most people will work with a rehabilitation team involving a physical therapist, occupational therapist, and speech therapist.1 Therapy usually begins within 24 hours of the stroke because early and high-intensity therapy is associated with the best recovery outcomes.12


Stroke treatment also involves medical interventions. Immediately after your stroke you may be treated in the hospital with tissue plasminogen activator (TPA), or other treatments including surgical procedures. Your neurologist and other healthcare providers will work with you throughout your recovery to adjust your medications.


You will likely receive stroke treatment in a variety of settings, starting with a hospital emergency department. After the initial stroke is treated and you are medically stable, you may be transferred to an inpatient rehabilitation unit at the hospital, or a skilled nursing facility, to receive intensive daily therapy. Based on recommendations from the American Heart Association and American Stroke Association, patients qualify for acute rehab based on outcomes data.


When you are ready, you may return home and continue therapy with home care or in an outpatient therapy clinic.

How to Identify a Stroke

To identify a stroke, remember the acronym FAST:


Facial drooping

Arm weakness

Speech difficulties

Time to call emergency services

Call 911 immediately if you think you or someone else is having a stroke. It's essential to receive treatment as soon as possible to limit brain damage.


Summary

Stroke recovery is unique to each person. However, experts have identified a general pattern of motor recovery. This pattern is detailed in Brunnstrom's seven stages of stroke recovery. The stages include flaccidity, spasticity appears, spasticity increases, spasticity decreases, complex movement combinations, spasticity disappears, and normal function returns.


A Word From Verywell

As you recover from a stroke, it can be frustrating to not have solid answers about how much recovery you can expect, or any specific timeline. Unfortunately, it's impossible to fully know these answers.


However, with tools like Brunnstrom's stages of stroke recovery, you and your healthcare providers and therapists can make educated guesses as to your stage of recovery, the most appropriate therapies, and what to expect next. It's normal to be frustrated, but try to remain hopeful and continue with your rehabilitation plan in order to have the best outcomes.

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