Jan 9, 2024
Brunnstrom Stage and Modified Ashworth stages
Stroke is a neurological condition that can cause a wide range of motor impairments in patients. Brunnstrom Stage and Modified Ashworth stages are two commonly used methods to describe the severity and progression of motor impairment in patients with stroke.
Brunnstrom Stage is a seven-stage model that describes the recovery of motor function following a stroke. The stages are based on the pattern of motor recovery, with each stage reflecting the return of specific movement patterns. In Stage 1, the patient experiences flaccidity, with no voluntary movement in the affected limb. In Stage 2, the patient begins to experience some spasticity, with the appearance of basic limb synergies. In Stage 3, the patient shows increased spasticity, with the appearance of voluntary movement, but only within the context of basic limb synergies. In Stage 4, the patient experiences decreased spasticity, with the emergence of voluntary movement outside of the basic limb synergies. In Stage 5, the patient experiences further improvement in voluntary movement, with the ability to perform complex movement patterns. In Stage 6, the patient experiences near-normal movement patterns, with only slight residual deficits. In Stage 7, the patient has complete recovery of motor function.
Modified Ashworth Scale (MAS) is a commonly used tool to assess spasticity in stroke patients. MAS is a six-point rating scale that measures the degree of spasticity in a muscle or muscle group. The scale ranges from 0 to 4, with 0 indicating no spasticity and 4 indicating rigid spasticity. A score of 1 indicates slight spasticity, with a catch and release or minimal resistance throughout the range of motion. A score of 2 indicates moderate spasticity, with a catch when the limb is moved in flexion or extension. A score of 3 indicates considerable spasticity, with a catch followed by resistance throughout the remainder of the range of motion. A score of 4 indicates severe spasticity, with the affected limb rigid in flexion or extension.
In summary, Brunnstrom Stage and Modified Ashworth stages are important tools used in the assessment and treatment of motor impairment in stroke patients. These scales allow healthcare providers to monitor the progress of recovery and tailor treatment plans to each patient's individual needs. By using these scales, healthcare providers can help stroke patients achieve their maximum level of independence and quality of life.
Exercises for Walking in Stroke Patients
Exercises for Walking in Stroke Patients
Bending the knee while lying down: While the patient is lying on their back, a person attempts to bend and open their knee by rubbing the patient's foot on the bed. This exercise corresponds to Brunnstrom Stage 1 or Modified Ashworth 0.
Gain: The gain of this exercise is that it practices knee flexion required for walking and provides proprioceptive input from the foot.
"Sudden toe bending exercise: While the patient is lying down, a person attempts to make their leg rise into the air while the knee is bent by suddenly bending the patient's big toe. This exercise corresponds to Brunnstrom Stage 2 or Modified Ashworth 2-1+.
Gain: The gain of this exercise is to provide hip-knee flexion by making use of reflexes.
Sitting stepping exercise: While sitting, lift your hemiplegic leg from the hip and pull it towards your chest, then lower it back to the ground. Repeat the same movement with the other leg. Perform this exercise 10 times in total. If the movement feels easy, you can hold your leg up for a few seconds. In this way, if you have full control, try to keep your leg up against resistance by pressing the upper part of your thigh with your hand. This exercise corresponds to Brunnstrom Stage 3 or Modified Ashworth 3.
Gain : The gain of this exercise is a preparation exercise for walking. It is tried to gain the hip flexion required for walking.
Leg cross-leg exercise: Sit with your feet touching the ground. Put your healthy leg on top of your hemiplegic leg and hold for 10 seconds. Lower your leg slowly. With the thumb of your hemiplegic hand on top, interlock your fingers and stretch your arms forward. For safety, a person can stand on your healthy side. This exercise corresponds to Brunnstrom Stage 3 or Modified Ashworth 3.
The gain of this exercise is to transfer weight to the hemiplegic leg.
Exercise to put the hemiplegic leg on the healthy side: Place the hemiplegic foot on the outside of your healthy knee and bend your knee. With the thumb of your hemiplegic hand on top, interlock your fingers, stretch your arms forward, press your hemiplegic knee for 10 seconds, and release (repeat 5 times). This exercise corresponds to Brunnstrom Stage 3 or Modified Ashworth 3.
Gain: The gain of this exercise is to provide inhibition of extensor dominance of the lower extremity.
Bridge building exercise: Lie on your back. Pull your knees towards you and let the soles of your feet touch the ground. Then slowly lift your waist upwards, hold this position for a few seconds, and slowly lower it. This exercise corresponds to Brunnstrom Stage 3 or Modified Ashworth 3.
You can put a pillow under your hips to facilitate movement. (Provides external support - narrows the range of motion.)
Lifting the strong leg in the bridge position: In this position, cut the contact of the healthy leg with the ground and straighten your knee in the air. Wait for a few seconds and slowly come back to your original position.
(Brunnstrom Stage 3/Modified Ashworth 3)
Gain -7: It provides hip stabilization from closed kinetics to open kinetics, while maintaining hip rotator control while maintaining eccentric and concentric control of the knee.
Bridge position cross-leg exercise: In the bridge position, throw your healthy leg over your hemiplegic leg and repeat the same movement.
(Brunnstrom Stage 3/Modified Ashworth 3)
Benefit-8: It is a starting exercise for weight bearing in the lower extremities. It is important for trunk control.
Sliding the foot on the wall: Lie on your back with your healthy side next to the wall. While your right leg is straight, bend the knee of your hemiplegic leg and press your foot against the wall. Move the foot up and down the wall.
(Brunnstrom Stage 4/Modified Ashworth 2)
Gain: It is a weight-bearing exercise for hip-knee flexion-IR. It is intended to prevent circumduction gait.
Weight transfer exercise on the knee: Stand on your knees on a soft ground(may be mat).Make small swings with your torso towards one right hip and one left hip without lifting your knees off the ground. A person can hold your arms when you are in a position where your fingers are clasped and your arms are extended forward so that the thumb of your hemiplegic hand is on top.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: There is a weight transfer on the hips.
Rhythmic arm swinging exercise: While standing, try to swing your arms back and forth by slowly rotating your torso. To help with movement, a person can give acceleration to the hemiplegic person's arm by gently pushing through the arm.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: Arm swing, which is an important component of walking, is tried to be gained.Arm swing helps balance when walking and ensures the preservation of energy.
Knee bending exercise against gravity: Lean over a high table and rest your forearms on the table with your palms facing each other.Bend your hemiplegic knee against gravity, cut off the contact of the foot with the ground, stop for a few seconds and come to the starting position.repeat 6-8 times.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: It is performed in order to obtain knee flexion for the swing phase.
Taking a step forward with the firm side on the ladder: Hold the handrail with the firm side hand.Take a step forward with your strong leg. Hold for a few seconds and bring your foot to the starting position.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: There is weight transfer to the hemiplegic leg.It is aimed at the posture phase of walking.
Taking a step back and forth with the firm side: While standing, take a step forward with your firm foot by rotating your firm side hip.(Your feet will take a T shape.)Repeat the same movement by stepping backwards with the solid side.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: It is aimed at the posture phase of walking. Provides mobility to the hip.
Knees slightly bent counting exercise: When the knees are in a slightly bent position, lift one foot off the ground and try to put weight on the other foot.Then press your foot to the ground and repeat the same movement with the other foot.Repeat 10 times for each leg.You can do the exercise with support from a person with your hands.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: Pelvic elovation is studied with weight transfer.
Knee bending exercise behind the chair: Hold on to the chair with both hands while you are behind the chair.Put your hemiplegic foot on the back.Bend and straighten your hemiplegic knee 10 times. Be careful not to completely cut off the contact of the foot with the ground while bending the knee.Perform the exercise so that only the heel is raised.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: It is directed to the swing phase of walking.
Knee bending exercise behind the chair 2: Hold on to the chair with both hands while you are behind the chair.Hemiplegic foot bend and straighten your knee 10 times next to the solid foot(feet are not adjacent).Be careful not to completely cut off the contact of the foot with the ground while bending the knee.Perform the exercise so that only the heel is raised.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: It is directed to the swing phase of walking.
Firm side behind the chair leg opening exercise from side to side: Hold on to the chair with both hands while you are behind the chair.Firm side open and close your leg to the side so that your foot is out of contact with the ground.repeat it 10 times.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: Weight is transferred to the hemiplegic side.
Walking with an auxiliary device: The tripod is handled securely when using a tripod.The tripod is thrown forward first.Then the hemiplegic leg is thrown forward.Then the intact leg is thrown next to the hemiplegic leg.Patients who use a cane also perform the same movement with a cane.
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: The fear of falling and the risk of falling are reduced.It is aimed to normalize the characteristics of normal walking, such as walking speed,cadence and step length,and to increase independence.It becomes easier to put a load on the affected limb.
Walking to the side: Take 5 steps in sequence towards your solid and hemiplegic side by taking support from a fixed place.(2 sets)
(Brunnstrom Stage 4 / Modified Ashworth 2)
Gain: The ability to walk on the side is necessary to be able to maneuver in tight places.It strengthens the lateral muscles of the leg and trunk. November 19, 2019.
Counting exercise on the knee: Stand on your knees on a soft ground(may be mat).In turn, lift your knees off the ground and put weight on the other knee. A person can hold your arms when you are in a position where your fingers are clasped and your arms are extended forward so that the thumb of your hemiplegic hand is on top.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: There is a weight transfer on the knees.
Sit-up exercise: For weight transfer purposes, stand up and sit down again while the hemiplegic foot is on the back, the thumb of the hemiplegic hand is on top, clasp your fingers and put your arms in an extended forward position.repeat 5 times.You can make it difficult by starting the exercise from a high chair and reducing your sitting height over time.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Weight transfer happens.The training from sitting to standing up, which is most commonly used when performing normal activities in daily life, is characterized by an increase in the center of gravity and is defined as a preliminary walk for walking.
Sit-up training increases the walking distance with step length on the affected and unaffected side in order to restore the distortions in the response to gravity changes in a stroke patient.With this exercise, the risk of falling of a hemiplegic person is also reduced.The dynamic balance required for dynamic stability increases.
Step to the side with the solid side on the ladder exercise: Stand in a standing side position so that your solid side is on the ladder side.Step on the ladder from the side with your firm leg while holding the ladder by the handrail with your firm hand.Hold for a few seconds and bring your foot to the starting position.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: There is weight transfer to the hemiplegic leg.It is aimed at the posture phase of walking.
Hemiplegic side leg opening exercise behind the chair: Hold on to the chair with both hands while you are behind the chair.Hemiplegic side open and close your leg to the side so that your foot is out of contact with the ground.repeat it 10 times.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Hip abduction is attempted to be gained for the swing phase. Tuesday.
Slightly bent knees walking exercise: Take 10 steps forward while the knees are in a slightly bent position.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Increases quadriceps muscle strength.The knee check is checked.
Equine equine exercise: The firm foot is slowly driven back.The knee is bent and the leg is lifted upwards.The knee opens forward and a big step forward is taken.The same movement is repeated with the hemiplegic leg.do it 6-8 times.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: It is done in preparation for the swinging phase.
Walking back and forth on flat ground: Take 10 steps forward and then 10 steps backward and complete the exercise.(2 sets)
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Walking towards the back is an important activity for functional walking training.It is necessary for trunk control and for hip hyperextension during the rocking phase.
Walking on different floors(Soft): Repeat the above forward, backward, sideways and tandem walking exercises on the mat.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Provides different proprioceptive input.
Walking by jumping over an obstacle: Create an obstacle intermittently from objects such as 4 books or pieces of wood 3-4 cm thick on the ground.First of all, after passing the object with one step, bring your other step next to your foot.Walk past objects forward like this.(5 rounds) After doing the same exercise, walk forward so that you pass the object with one step and pass the next object with the other step.(5 laps)
(Brunnstrom stage 5 / Modified Ashworth 1-1+-2)
Gain: Extends the duration of the swinging phase.It can be used in patients who rub their feet.
Walking by drawing 8 between two objects: Place two water bottles or dumbbells upright on the ground Decently.Starting by walking on one side of the first body, move to the opposite cross edge of the other body, and after walking around it, move to the edge of the first body that you did not start walking on.you will have drawn the number 8.(5 rounds)Then repeat the same exercise starting from the other side of the object and drawing 8.(5 laps)
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Functionality is gained in walking.The rotation activity is studied.
Climbing stairs: Hold on to the handrail with a firm hand.First, put your solid leg up on the step.Then take the hemiplegic leg with you.(10 steps)
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Stair descent: Hold on to the handrail with a firm hand.First, place your hemiplegic leg on the bottom step.Then take the strong leg with you.(10 steps)
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Prepares the patient for situations encountered in daily life, gives functionality.
Walking on the ramp: Walk by taking 10 steps forward, backward and sideways on a slightly sloping floor.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: Prepares the patient for situations encountered in daily life, gives functionality.
Pedaling: Do a pedaling movement with the hemiplegic side in a standing position with support from the chair.(10 times)
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Gain: It is aimed at the swinging phase of walking.
Weight transfer exercise in the crawling position: Stand in the crawling position on a soft ground(may be mat).Lift your arms and legs one by one in turn and stretch them forward.Wait a few seconds and return to the crawling position again.
Gain: The crawling position stimulates the antispathic position for the upper and lower extremities. There is weight transfer to the extremities.Balance improves.
Hitting the ball with a solid foot: When you are in the same position as the above movement, you can hit the ball with your solid foot in front.You can move the ball back and forth under your foot.
(Brunnstrom Stage 5 / Modified Ashworth 1-1+-2)
Drawing a shape with a firm foot: Hold on to two chairs with both hands.(A fixed object)Draw a shape with your fingertip on the floor, taking your firm foot forward, or write your name.Return to the starting position again.
(Brunnstrom Stage 6/Modified Ashworth 0-1)
Gain: There is weight transfer to the hemiplegic leg.It is aimed at the posture phase of walking.
Taking a crooked step: When the feet are side by side(not adjacent), a crooked step is taken from the front with the hemiplegic leg, and then the solid leg is brought to its side.In order to make the exercise more difficult, it is tried to take a cross step from behind with a hemiplegic leg.6-8 steps are taken.
(Brunnstrom Stage 6/Modified Ashworth 0-1)
Gain: It is directed to the oscillation phase of walking. Tuesday.
Tandem walking: Step forward in a straight line with the heel of one foot touching the fingertip of the other foot.Repeat with the other foot.(10 steps)
(Brunnstrom stage 6/Modified Ashworth 0-1)
Gain: The area touching the ground is narrowed,the center of gravity is moved to the middle line.It helps to improve balance and coordination.
Walking sideways by jumping over an obstacle: After passing the object with one step on the same obstacle course, complete the course in such a way that you bring your other foot next to it.At the end of the track, start by stepping to the side with your other foot and return to the beginning of the track.(10 laps)
(Brunnstrom stage 6/Modified Ashworth 0-1)
Gain: It is directed to the oscillation phase. Tuesday.Pelvic elevation is also studied.