Brunnstrom’s

Movement Therapy
Concepts and Principles
History…
• Developed by Signe Brunnstrom, a physical therapist from Sweden
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
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

• Scapula: retraction and/or

elevation
Flexor • Shoulder: abduction and ext
Synergy rotation
• Elbow: flexion
• Forearm: supination

• Scapula: protraction and

Extenso /or depression
r • Shoulder: adduction and int
rotation
Synergy • Elbow: extension
• Forearm: pronation
 Basic limb synergies: LE

• Hip: flexion,
abduction, and ext
Flexor rotation
Synergy • Knee: flexion
• Ankle: dorsiflexion
• Toe: extension

• Hip: extension,
adduction,
Extenso and
int rotation
r • Knee: extension
• Ankle: plantarflexion
Synergy • Toe: flexion
Mixed synergy: UE
Flexor Extensor

Strongest elbow flexion shoulder adduction

internal rotation

Next
strongest forearm pronation

Weakest shoulder abduction elbow flexion

external rotation
Mixed synergy: LE
Flexor Extensor

Strongest hip flexion hip adduction

knee extension
ankle plantarflexion ankle
inversion

Weakest hip abduction hip extension

external rotation hip int rotation
toe flexion
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
ATTITUDINAL AND POSTURAL REFLEXES
• 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

• 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
(flexor synergy appear prior to extensor synergy)
•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
RECOVERY STAGES IN HEMIPLEGIA
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
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. Facilitation is reduced or dropped out as quickly
as the patient shows evidence of volitional control.

6. No primitive reflexes, including associated

reactions, are used beyond Stage 3.

7. Correct movement once elicited is repeated

Reference
Bandong, A. (2008). Approaches to therapeutic exercise: Concepts, principles, and
strategies. Power point lecture presentation in PT 154.
Bobath B (1990). Adult hemiplegia: Evaluation and treatment (3rd ed). Oxford,
Heinemann Medical Books.
Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore,
McGraw-Hill Inc.
Sawner K & LaVigne J (1992). Brunnstrom’s Movement Therapy in hemiplegia: A
Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.