The Brunnstrom stages are a crucial 6-stage framework for assessing stroke motor recovery. Accurately identifying a patient’s stage allows therapists to time interventions effectively, set realistic goals, and significantly improve rehabilitation outcomes.
Analysing the stage of stroke recovery is the first important step in planning the rehabilitation of stroke patients. The Brunnstrom staging is the most reliable way to quantify this staging. Its reliability is further validated by recent neurophysiological evidence on motor recovery in stroke patients2.
Research shows that the Brunnstrom stages closely match with objective measures of spasticity and nerve reflex excitability using methods like the Modified Modified Ashworth Scale (MMAS) and H-reflex parameters.
In this article, we will learn the 6 stages of the Brunnstrom staging system. We will also learn its significance in the rehabilitation processes.
So, What Exactly Are the Brunnstrom Stages?
According to Brunnstrom, there are 6 distinct stages that stroke patients typically progress through. Think of it as a roadmap of recovery—though not everyone reaches the final destination.
To analyse it:
- Make the person sit on the plinth with their leg hanging.
- In this position, instruct the person to raise the affected arm and hold it.
- Observe how high he can raise the arm and at what angle he can hold it.
- Based on this, you can quantify the stage of stroke recovery.
However, just observing and assessing it is a subjective approach. The researchers in Taiwan have developed an objective and accurate way to measure the stage.
They developed a computer-based system based on Fuzzy theory. This includes an accelerometer sensor, which is tied around the wrist of the arm in question. When the arm is told to flex, this sensor system activates and sends the signal to the computer to calculate the stage1.
This automated approach can reliably determine the Brunnstrom stage of a stroke sufferer.
Below is the screenshot of our workshop on ‘Comprehensive management of stroke‘ with Dr BK Nanda (Senior Lecturer, SVNIRTAR) as the resource person. The stroke patient was told to raise the arm and hold it.
Observe the position of the arm and try to guess the Brunnstrom stage of both. We will answer it at the end of this post. For now, let’s proceed with an explanation of each of the 6 Brunnstrom stages.
Stage 1: The Flaccid Stage
This is where it all begins. When a patient first gets a stroke, they experience complete flaccidity—no muscle tone whatsoever.
When the person is stuck in this phase longer, they’re in a state of shock. It gives an indication of raised intracranial pressure (ICP).
Stage 2: Synergy Just Developing
In stage 2 patient starts developing what we call synergy patterns. These are abnormal synergies, not the normal one.
What’s the difference?
Well, when I walk, my hip and knee flex together—that’s normal synergy. When I scratch my scalp, that’s coordinated movement, normal synergy. But in stroke patients, we see abnormal patterns that don’t follow natural movement sequences.
Here’s the thing though: When we see a patient transitioning from complete flaccidity to developing these synergy patterns, we actually get a bit relieved. Why? Because it means the brain is trying to reconnect, trying to send signals down to the muscles.
Stage 3: Synergy and Spasticity Peak
This is when things get intense. The abnormal synergy patterns and spasticity are at their maximum. The patient might be able to lift their arm, but it comes with unwanted movements.
At this stage, you should follow proper steps to assess the cause and degree of spasticity.
Stage 4: Gradual Decline of Synergy and Spasticity
By stage 4, the abnormal patterns begin to fade, and we see more selective, controlled movements emerging.
Stage 5: Further Decline
We’re getting closer to normal now. There’s a significant decline in spasticity, and movements become much more natural and controlled.
Stage 6: Normal
At stage 6 of stroke recovery, normal movement patterns return. The patient has essentially recovered their motor function.
When Is Therapy Most Effective?
Therapy is most effective during phase transitions. What do I mean by that?
Let me give you an analogy that really drives this point home. Imagine Lord Ganesha’s idol being made out of clay. When the clay is wet, you can twist the trunk left or right, modify it as needed.
But once the statue is made and the clay has hardened, can you modify that trunk? Not really, right?
Similarly, treatment works best when the patient is transitioning from one stage to another—especially from stage one to stage two. When they’re changing from flaccidity to developing tone and synergy, that’s when we can really make a difference.
Initially, when a patient is flaccid, we’re actually hoping for them to develop synergy and tone. We want to see those abnormal patterns emerge because it means the nervous system is trying to reconnect.
But once those patterns develop and peak at stage three, our job becomes helping them move beyond these abnormal patterns toward more normal movement.
What Actually Happens to Most Patients?
In practice, patients often get held up in any one stage. I’ve seen patients remain flaccid for 2 months, 3 months, 5 months, or even a year. Some patients remain flaccid until the end of their lives.
Very rarely—we’re talking about maybe 10% of people—they go from stage one all the way to stage six naturally. They do nothing special, and they get along well on their own.
But for the other 90%? They face significant impairment without proper intervention.
Why Understanding These Stages Matters
When we’re assessing a patient and asking them to lift their arm, hold it, keep trying—we’re not just being encouraging. We’re systematically evaluating which Brunnstrom stage they’re in. This tells us:
- What to expect in their recovery journey
- When to intervene most effectively
- How to tailor our treatment approach
- What realistic goals to set
Final Thoughts:
So, were you able to find the Brunnstrom stage of the person in the image above?
The person on the left with almost fully raised arm is at Brunnstrom stage 5, and the person in the left image with raised arm halfway is at stage 3. For a clear idea, you can watch this video.
The Brunnstrom stages give us a framework, a way to understand and communicate about stroke recovery. As a physiotherapist, we should be able to recognise where the patient is right now, understanding the optimal timing for intervention.
FAQ on Brunnstrom Staging
The author is a physiotherapist who has been practising for the last 17 years. He holds a Bachelor's in Physiotherapy (BPT) from SVNIRTAR (Swami Vivekananda National Institute of Rehabilitation and Research), one of the prestigious physiotherapy schools in India.
Whatever he learns dealing with his patient, he shares it with the world through blogs and e-books. He also owns a YouTube channel, "Sunit Physiotherapist" with over 8 lakh active subscribers. Here, he shares everything he gets to learn serving the patient.
