In healthy body movement, muscles work together synergistically, orchestrated by messages from the brain through the nervous system. A stroke damages blood flow in the brain affecting signals to the muscles. The brain’s neuroplasticity allows it to rebuild damaged systems in another part of the brain if appropriate and repetitive stimulation allows the brain to “relearn” these movements.
In the 1960s a Swedish physical therapist named Signe Brunnstrom developed a framework to understand how muscle control returned after stroke or other damage to the central nervous system. Immediately after a stroke, muscles may be flaccid (little or no movement), then they may develop spastic tightening or involuntary movement. While some recovery approaches look upon spastic movement as a negative, Mr. Brunnstrom developed a method of recovery that recognizes spastic movement as a sign of the brain’s rebuilding efforts. His approach has been broken into seven stages.
If you or a loved one has a stroke, understanding the seven stages of recovery will help you see each step or movement in a positive light and encourage you to cooperate with therapies with the hope of full recovery.
Stage 1: Flaccidity
Immediately after a stroke, the muscles are weak, limp, and/or floppy. Little or no voluntary movement is possible on the affected side. This is called flaccid paralysis or flaccidity.
At this point, you’re likely unable to perform movements on your own. If the muscles are not moved, however, they will begin to atrophy. Therefore, it is critical to get your muscles moving as soon as possible. Passive range-of-motion exercises, in which someone else moves the affected limbs for you, help to stimulate the brain’s neuroplasticity and begin to repair the nerve connections to the muscles.
Passive range-of-motion exercises can also limit spasticity when the brain begins to recover. Proper positioning of flaccid limbs also aids in recovery.
Stage 2: Spasticity appears
At this stage, the brain begins to send messages to the muscles again, but the messages are incomplete or incorrect. This can cause muscles to tighten. While you may feel discouraged by this, it is actually a sign that healing has begun.
Passive range-of-motion exercises should continue, and as soon as possible, active-assisted range-of-motion exercises should begin. For instance, if you’re able to raise your arm partially, lift it as far as you can, then a therapist or other helper continues to lift your arm the rest of the way. Limbs should be gently encouraged to stretch or move just a bit farther than they are willing to go.
Stage 3: Spasticity increases
Spasticity generally continues to increase as the brain tries to redevelop proper communication with the muscles. You may be tempted to think you’re regressing, but in fact, the brain is trying even harder to send signals, so it’s another good sign. However, it can be quite uncomfortable. Splints or braces can help – for instance, a brace on the hand to prevent fingers from curling too tightly – but should absolutely not be used as a replacement for mobility exercises. A Botox injection may be prescribed by your doctor if pain is acute, but should only be a temporary treatment to alleviate the symptom; it should not be considered a cure. The only cure is more work on your limbs.
You certainly don’t want to stop here at this uncomfortable stage. Continue your exercises, both passive and active-assisted. The more you work at it, the faster you will retrain your brain and reach the next stage.
Stage 4: Spasticity decreases
At this point, after your hard work and the help of therapists and loved ones, your voluntary control begins to return. Large motor skills tend to return first. You may feel unsure or wobbly in these movements, but with constant repetition and the support of your therapist or helper, you will become stronger. The brain is continuing its neural reorganization and must receive frequent, repetitive messages to teach the new part of the brain how to respond and build muscle synergies.
Strengthening is key in this stage. Most exercises at this point are active range-of-motion exercises, where you as the patient are initiating and completing the action, but your therapist may continue with active-assisted exercises and even passive exercises on muscles that still have some spasticity
Stage 5: Complex movement returns
At this stage, you are able to perform more controlled and deliberate movements, such as combing your hair, pouring milk into your coffee, and feeding yourself. You may still have some spasticity or tightness, but it has minimal effect on your movements.
You don’t want to stop at that, however. Your goal is no more spasticity and the return to normal function! Continue with your therapy and exercises, as the focus will now be on fine-tuning, for instance, improving foot drop when you walk. The more you work at it and add rehabilitation-specific exercise as a permanent part of your daily regimen, the faster you will get to the next stage.
Stage 6: Spasticity disappears
At this point, all abnormal movements and spasticity have disappeared. Joints and muscle movements are much more coordinated. As you continue your recovery-directed exercises, you are quickly on the way to the final stage.
Stage 7: Normal function returns
Normal function means that you now have complete, voluntary control of all affected muscles. How long it takes to reach this point varies from patient to patient. Everyone is different, and each stroke affects people differently. But perseverance can get you farther than any experts may have ever imagined.
It’s important that, after so much work, you do not have another stroke. Lifestyle changes may be necessary in order to decrease the risk of a second stroke, which occurs in 25% of stroke patients. You may also want to use a stroke detection system such as Neuralert, which looks much like a smartwatch and signals chosen medical personnel within 15 minutes of signs of asymmetric arm movement, the classic sign of stroke onset. Quick medical intervention can dramatically decrease the adverse effects of a stroke. Talk to your doctor about using Neuralert Stroke Detection wristbands if you are at high risk for stroke.