The 7 Stages of Stroke Recovery

Stroke recovery stages vary for each person. Healing after a stroke can be a challenging and emotional process, and it is different for everyone.

A stroke can affect a person's:

• Movement
• Coordination
• Vision
• Speech
• Swallowing
• Thinking abilities
• Emotional processing

The location, extent of the lesion or tissue involvement, time before treatment, and other factors all affect the outlook for recovery. However, experts have identified a general pattern of motor recovery from stroke.

This article discusses the Brunnstrom stages of stroke recovery and what you can expect from rehabilitation after a stroke.

Brunnstrom Stages of Stroke Recovery

The Brunnstrom stages of stroke recovery include seven common steps in motor (movement) recovery after a stroke.

The steps were first recorded in the 1960s by Signe Brunnstrom, a Swedish physical therapist who worked with stroke patients who had paralysis on one side of the body (hemiplegia).

Through her experiences with patients, Brunnstrom noticed certain stages of movement restoration that she described as occurring in an "almost standardized fashion."

Today, physical and occupational therapists still use Brunnstrom's stages to assess motor recovery post-stroke.

Stroke Recovery Stage One: Flaccidity 

The first stage of stroke recovery is flaccidity. It occurs immediately after a stroke. Post-stroke, muscles will be weak, limp, or even "floppy."

A stroke often affects one side more than the other, so flaccidity can be limited to just one side. Many people have more severe symptoms in their upper limbs or hands than they do in their lower limbs.

Flaccidity happens when there is damage in the brain from a stroke. The brain can no longer send messages to certain areas of the body to move. The danger of flaccidity is that if it lasts too long, you can lose significant muscle mass and strength.

Stroke Recovery Stage Two: Spasticity

The second stage of stroke recovery is the appearance of muscle stiffness and rigidity (spasticity).

At rest, your limbs may stay contracted (usually in a "flexed" position, with the elbow and wrist bent), or they may jerk or tremor when you try to move them. You may have some voluntary movement back at this point, but not much.

Spasticity happens as the brain starts to rebuild connections with the muscles. 

In a way, spasticity is sort of a positive thing. However, the connection is incomplete at this stage of stroke recovery, which is why the muscles can get "stuck" in contracted positions or not move in the way you want them to.

Spasticity can make it harder to move your affected limbs during this stage, but it's very important to continue moving as much as you can to prevent learned non-use and give yourself the best chance of recovery.

Stroke Recovery Stage Three: Increased Spasticity

In the third stage of stroke recovery, spasticity increases. This can be frustrating and you may feel that you are getting worse and not moving forward in your stroke recovery.

Try to remember that the increase in spasticity is actually positive, even if it doesn't feel like it. Your brain is still working to rebuild connections with your muscles.

During this stage of stroke recovery, you will continue with and progress in your therapeutic exercises. You will likely focus on performing as much active movement as you can, although this will be challenging.

Your provider may prescribe Botox injections to help reduce spasticity, which will help you maximize your movement during therapy.

Stroke Recovery Stage Four: Decreased Spasticity

In the fourth stage, spasticity starts to decrease. This is a big milestone in the stroke recovery process.

As spasticity decreases, you will notice improved voluntary movement patterns, but your movements will still feel jerky, twitchy, and uncoordinated.

With the remaining spasticity, you may still have trouble releasing objects. For example, you might be able to grasp a fork but unable to let go of it. 

You will likely still be very weak from the lack of voluntary movement in the first three recovery stages of stroke recovery.

Stroke Recovery Stage Five: Complex Movement Combinations

In the fifth stage of stroke recovery, it’s time to start coordinating complex movement combinations. 

This can include actions like grasping a spoon, loading it with food, bringing it to your mouth, bringing the spoon back to the table, and releasing it.

With improved voluntary movement and coordination, you will become more independent in doing the things you want and need to do.

Stroke Recovery Stage Six: Spasticity Disappears & Coordination Reappears

In the sixth stage, the spasticity is all but gone. With fewer spastic movements, you will have much better coordination for doing complex movement patterns.

At this stage of stroke recovery, focus on practicing and refining your coordination and fine motor skills. 

You may start working on retaining more complex and challenging functional activities, such as meal prep, cooking, cleaning, hobbies, and more.

Stroke Recovery Stage Seven: Normal Function Returns

In the seventh and final stage of stroke recovery, your normal function returns. 

You can now perform complex, coordinated, synergistic movement patterns in your affected side just as well as your unaffected side. You are able to return to your meaningful occupations with independence.

While this stage is the big goal for patients, not everyone will reach this stage after having a stroke.

According to Signe Brunnstrom's original writing in 1966, only a small number of patients got to this advanced recovery stage.

Spontaneous Recovery

Spontaneous recovery, or rapid improvement in symptoms, is possible—especially in the early stages of stroke recovery. 

For some people, spontaneous recovery might be a full recovery. In other people, it means jumping ahead a stage or two in the stroke recovery process.

After a stroke, your body tries to clean up the damage in your brain from a bleed or blockage (depending on what type of stroke you had). 

It also needs to reorganize and rebuild neuronal connections that were destroyed. 

These neurons connect different areas of the brain and send messages from your brain to your body. This rebuilding process is called neuroplasticity.

In the early stages of stroke recovery, neuroplasticity can work fast. When many new connections have been built, your stroke recovery may seem spontaneous.

Possible Setbacks In Stroke Recovery

There are many factors that can affect the outcome of your stroke and the course of your recovery, including:

• Location of stroke in the brain
• The degree of damage to the brain
• Other medical conditions you have
• How soon rehabilitation starts after a stroke
• The intensity and frequency of therapy
• Compliance with therapeutic exercises and home exercise programs
• Supportiveness of family, friends, and caregivers
• Age at the time of stroke
• Safety of home environment
• Cognitive abilities
• Insurance coverage and ability to financially cover rehabilitation, therapy, and any recommended assistive devices, orthotics, or home modifications

Strokes are also not necessarily isolated events. Each year, 25% of strokes are recurrent.

You can lower your risk of future strokes by addressing the risk factors you have—for example, treating uncontrolled high blood pressure, atrial fibrillation, heart disease, high cholesterol, and diabetes.

Stroke Treatment Options

Stroke treatment is different for each person because everyone (and every stroke) is different. 

However, most people will work with a rehabilitation team that includes a physical therapist, occupational therapist, and speech therapist.

Therapy usually needs to start within 24 hours of a stroke because early and high-intensity therapy is associated with the best recovery outcomes.

Stroke treatment also involves medical care. Immediately after a stroke, you might be treated in the hospital with tissue plasminogen activator (TPA), or surgical procedures.

A neurologist and other healthcare providers will work with you throughout your recovery to adjust your medications and talk to you about treatment options. 

Stroke treatment takes place in a variety of settings, often starting in a hospital emergency department. 

After the initial stroke is treated and you are medically stable, you might get transferred to an inpatient rehabilitation unit at the hospital, or a skilled nursing facility, to receive intensive daily therapy. 

Based on recommendations from the American Heart Association and American Stroke Association, patients qualify for acute rehab based on their outcomes.

When you are ready, you may go home and continue therapy with home care or in an outpatient therapy clinic.

Summary

Stroke recovery is unique to each person. However, most providers assess progress using Brunnstrom's seven stages of stroke recovery, which include the following: flaccidity, spasticity appears, spasticity increases, spasticity decreases, complex movement combinations, spasticity disappears, and normal function returns.

How long it takes a person to move through the stages of stroke recovery and how many stages they successfully make it through varies. Other factors like overall health, socioeconomics, and the type and severity of the stroke affect recovery.

Keep in mind, even years after a stroke, people can achieve meaningful stroke recovery because the brain is able to keep adjusting and changing.