Brunnstrom approach

Brunnstrom approach to movement therapy

The term is also used loosely for the Brunnstrom recovery stages, the Brunnstrom hand stages, and therapy techniques that use reflexes, associated reactions, sensory stimulation, and mass movement patterns to facilitate voluntary movement.

In modern practice, Brunnstrom staging is better regarded as a clinical description of impairment and recovery, rather than a stand-alone evidence-based rehabilitation programme. Contemporary stroke rehabilitation emphasises individualised goal setting, multidisciplinary therapy, progressive strengthening, repetitive task-specific practice, gait training, constraint-induced movement therapy in selected patients, and adjuncts such as electrical stimulation, robotics, mirror therapy, or virtual reality where appropriate.

The eponymous term commemorates Signe Brunnstrom (1898–1988), a Swedish-American physiotherapist who developed a neurophysiological approach to hemiplegia testing and therapy during the 1950s–1960s.

---

Historical timeline

1906 – Sherrington and reflex physiology
Sir Charles Scott Sherrington’s The Integrative Action of the Nervous System provided a physiological framework for flexor withdrawal, extensor thrust, and crossed extensor reflexes. Brunnstrom later explicitly linked hemiplegic synergies to these spinal reflex patterns.

1916 – Marie and Foix: syncinésies des hémiplégiques
Pierre Marie (1853–1940) and Charles Foix (1882–1927) described and classified hemiplegic synkinesias in Revue Neurologique as “Les syncinésies des hémiplégiques”. Brunnstrom later cited their terminology of “shortening synkinesis” and “lengthening synkinesis,” corresponding broadly to flexor and extensor synergies.

1951 – Twitchell: sequential motor recovery after hemiplegia
Thomas E. Twitchell (1923–2017) published “The restoration of motor function following hemiplegia in man” in Brain. He observed 121 patients, with 25 followed longitudinally from hospital admission to a comparatively stable stage. The paper is the major pre-Brunnstrom description of ordered post-stroke motor recovery, including early reflex depression, emerging spasticity, flexor and extensor synergies, proprioceptive facilitation, proximal traction response, and recovery of hand function.

1956 – Brunnstrom: associated reactions as therapy
Signe Brunnstrom published “Associated Reactions of the Upper Extremity in Adult Patients with Hemiplegia: An Approach to Training” in Physical Therapy Review. This was an early formulation of her distinctive therapeutic idea: abnormal associated reactions and synergies could be deliberately used in early rehabilitation rather than simply suppressed.

1958 – Reynolds, Archibald, Brunnstrom, Thompson: upper limb neuromuscular testing
G. G. Reynolds, K. C. Archibald, Signe Brunnstrom, and N. Thompson published “Preliminary report on neuromuscular function testing of the upper extremity in adult hemiplegic patients” in Archives of Physical Medicine and Rehabilitation. Brunnstrom later noted that the upper-limb test forms in her 1966 paper were derived from this clinical research programme.

1965 – Brunnstrom: walking preparation
Brunnstrom published “Walking Preparation for Adult Patients with Hemiplegia” in Physical Therapy, extending her approach to lower-limb control, standing, weight transfer, and gait preparation.

1966 – Brunnstrom: motor testing by recovery stage
Brunnstrom published the key paper “Motor Testing Procedures in Hemiplegia: Based on Sequential Recovery Stages.” She opened with the observation that motor restoration in adult hemiplegia occurs in an “almost standardized fashion,” progressing from flaccidity through spasticity and, in some patients, toward near-normal control.

Brunnstrom emphasised that the upper and lower limbs may recover unequally, that progress may arrest at any stage, and that hand recovery does not perfectly parallel limb recovery. Her testing approach was designed not as ordinary muscle testing, but as an assessment of recovery stage, synergy dominance, spasticity, and selective voluntary control.

1970 – Movement Therapy in Hemiplegia
Brunnstrom published Movement Therapy in Hemiplegia: A Neurophysiological Approach, the monograph most responsible for consolidating the eponym. The book was published in New York by Harper & Row and ran to 192 pages.

1975 – Fugl-Meyer Assessment
Axel R. Fugl-Meyer (1934–2012), L. Jääskö, I. Leyman, S. Olsson, and S. Steglind published “The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance.” The Fugl-Meyer Assessment translated Twitchell–Brunnstrom concepts into a quantitative impairment scale assessing motor function, balance, sensation, joint range, and pain.

2002 – Fugl-Meyer measurement review
Gladstone, Danells, and Black reviewed the Fugl-Meyer Assessment, noting that it was developed as the first quantitative evaluative instrument for sensorimotor stroke recovery and was based on Twitchell and Brunnstrom’s concept of sequential motor return.

2012 – Brunnstrom hand manipulation trial
Pandian and colleagues compared Brunnstrom hand manipulation with a motor relearning programme in chronic post-stroke hand rehabilitation. Both improved outcomes, but the study reported greater improvement with the Brunnstrom-based hand protocol; interpretation is limited by outcome-measure alignment and the small, focused clinical question.

2014–2025 – evidence-based rehabilitation era
Cochrane reviews concluded that physical rehabilitation improves function and mobility after stroke, but that no single named approach is clearly superior. The 2025 Cochrane summary suggests functional task training may be useful, while neurophysiological approaches may be no different from, or less effective than, other approaches.

---

Key contributors

• Anna Signe Sofia Brunnström / Signe Brunnstrom (1898–1988) — Swedish-born physiotherapist, clinician, educator, and author. Developed and popularised the Brunnstrom approach to hemiplegia movement therapy and sequential recovery-stage testing. Death date requires editorial checking: Swedish biographical sources list 29 February 1988, while a later clinical kinesiology biographical sketch lists 21 February 1988.
• Thomas E. Twitchell (1923-2017) — neurologist; published the seminal 1951 clinical study of sequential motor recovery after hemiplegia.
• Pierre Marie (1853–1940), French neurologist; with Charles Foix, described hemiplegic synkinesias later incorporated into Brunnstrom’s terminology of flexor and extensor synergies.
• Charles Foix (1882–1927), French neurologist and vascular neurology pioneer; co-author with Marie of the 1916 work on hemiplegic synkinesias.
• Axel R. Fugl-Meyer (1934–2012), rehabilitation physician; led development of the Fugl-Meyer Assessment, which operationalised sequential motor recovery concepts into a quantitative clinical/research scale.

---

Controversies

Use of abnormal synergy: Brunnstrom’s approach was distinctive because it used reflexes, associated reactions, and synergies as early therapeutic tools. Modern rehabilitation generally prioritises task-specific motor learning, strengthening, intensity, and functional practice, making pure Brunnstrom therapy uncommon as a sole framework.

Stages are descriptive, not deterministic: Brunnstrom described a broadly sequential pattern, but also acknowledged unequal limb recovery, variable timing, and plateau at any stage. The hand was specifically noted as more variable than the limb as a whole.

Six versus seven stages: Brunnstrom’s 1966 motor-testing paper used six recovery stages for the limb as a whole. She treated hand recovery separately because it was more variable, and did not assign fixed hand activities to every stage on the test form. The often-quoted “seven steps” are not a formal seven-stage Brunnstrom limb scale; they are Brunnstrom’s summary of Twitchell’s observations on restoration of hand function, including finger jerks, spasticity, proprioceptive facilitation, proximal traction response, voluntary finger flexion, tactile facilitation, and the grasp reflex.

Limited direct trial evidence: There are Brunnstrom-specific trials, particularly for hand rehabilitation, but the broader evidence base supports components such as intensity, repetition, task-specific practice, and selected adjuncts rather than proving superiority of a named neurophysiological school.

Eponym drift: “Brunnstrom approach,” “Brunnstrom movement therapy,” “Brunnstrom stages,” “Brunnstrom recovery scale,” and “Brunnstrom hand manipulation” are often used interchangeably in teaching and clinical shorthand.

---

References

• Marie P, Foix C. Les syncinésies des hémiplégiques. Étude séméiologique et classification. Revue Neurologique. 1916.
• Twitchell TE. The restoration of motor function following hemiplegia in man. Brain. 1951 Dec;74(4):443-80. 
• Brunnstrom S. Associated Reactions of the Upper Extremity in Adult Patients with Hemiplegia: An Approach, to Training. Physical Therapy Review. 1956;36(4):225–236.
• Reynolds GG, Archibald KC, Brunnstrom S, Thompson N. Preliminary report on neuromuscular function testing of the upper extremity in adult hemiplegic patients. Arch Phys Med Rehabil. 1958;39:303–310.
• Brunnstrom S. Walking Preparation for Adult Patients with Hemiplegia. Physical Therapy. 1965;45:17–29.
• Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther. 1966 Apr;46(4):357-75.
• Brunnstrom S. Movement Therapy in Hemiplegia: A Neurophysiological Approach. New York: Harper & Row; 1970.
• Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13-31.
• Gladstone DJ, Danells CJ, Black SE. The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair. 2002 Sep;16(3):232-40.
• Crow JL, Harmeling-van der Wel BC. Hierarchical properties of the motor function sections of the Fugl-Meyer assessment scale for people after stroke: a retrospective study. Phys Ther. 2008 Dec;88(12):1554-67.
• Pandian S, Arya KN, Davidson EW. Comparison of Brunnstrom movement therapy and motor relearning program in rehabilitation of post-stroke hemiparetic hand. J Bodyw Mov Ther. 2012.
• National Clinical Guideline for Stroke. Motor recovery and physical effects of stroke. 2023.
• NICE. Stroke rehabilitation in adults. NG236. 2023.
• Stroke Foundation Australia. Clinical Guidelines for Stroke Management: Occupational therapy summary. 2025.
• Todhunter-Brown A, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev. 2025 update.