• Recovery

    Brunnstrom's Order of Recovery

    1 Flaccidity (immediately after onset): no voluntary movement initiated
    2 Spasticity: basic synergy patterns appear, minimal voluntary movement possible
    3 Voluntary control over synergies: with increase in spasticity
    4 Some movement patterns out of synergy can be mastered: synergy still predominates, decrease in spasticity
    5 If progress continues, more complex movement combinations can be learned as basic synergies lose their dominance: more decrease in spasticity can be seen
    6 Spasticity disappears: more individual joint movements and normal coordination
    7 Normal function is restored

    Other Predictors of Revovery

    Severity of UE weakness at onset (complete arm paralysis at onset has poor prognosis for recovery of useful hand function)

    Timing of hand movement return (some motor recovery of hand by 4 weeks has 70% chance of making full/good recovery)

    Poor prognosis: no measurable grasp by 4 weeks, severe proximal spasticity, prolonged flaccidity, late return of tapping response (facilitation)

  • Spasticity

    Abnormal velocity-dependent resistance to passive movement of involved muscles at rest and posturing during ambulation or with noxious stimuli


    Non-invasive stretching
    splints, orthoses
    serial casting
    electrical stimulation
    cold modalities
    Botulinum toxin
    (useful in focal control of spasticity like at wrist and finger flexors or ankle invertors)
    (rarely used, limited by adverse effects like pain with injection, post-injection dysesthesia/chronic pain)
    Baclofen Oral
    Intrathecal baclofen pump:
    some evidence that with physical therapy it can help improve walking speed/functional mobility in post-stroke spastic hemiplegia
    Surgery may be useful in selected cases to improve function, hygiene, pain

    Note: side effects of medications (baclofen, benzodiazepines, clonidine, tizanidine) usually limit their usefulness in stroke patients

  • Dysphagia


    Bedside Swallow Evaluation (BSE)

    minimally invasive, looking for overt cough or difficulty during swallowing trials, may evaluate gag reflex/pharyngeal sensation

    Aspiration is missed on BSE 40-60% of the time (silent aspiration)

    Predictors on BSE: abnormal cough, cough after swallow, dysphonia, dysarthria, abnormal gag reflex, voice change after swallow

    Videofluoroscopic swallow study (VFSS)

    aka modified barium swallow (MBS), gold standard for evaluation and treatment of dysphagia

    Different amounts and consistencies of solids/liquids mixed with barium are swallowed while fluoroscopically visualizing the patient’s swallowing anatomy

    Aspiration can be reliably diagnosed on a VFSS

    Predictors of aspiration on VFSS: delayed initiation of swallow reflex or pharyngeal peristalsis

    Fiberoptic endoscopic evaluation of swallowing (FEES)

    a more comprehensive evaluation of the pharyngeal stage of swallowing

    Observes natural bolus flow and containment vs potential bolus obstruction; reaction to presence of residue, penetration, aspiration; effectiveness of cough

  • Aphasia
    Speech Component Impaired?
    This describes:Global

    Aphasias List

    Type Description
    Anomic temporoparietal injury, angular gyrus; may also see alexia or agraphia
    Conduction injury to parietal operculum (arcuate fasciculus), insula or deep to supramarginal gyrus (usually left side); literal paraphasias, targeting of words
    Transcortical sensory watershed lesion isolating Broca’s/Wernicke’s areas from posterior brain, angular gyrus or posterior-inferior temporal lobe; echolalia, neologisms
    Wernicke’s posterior superior temporal gyrus of dominant (usually left) hemisphere; marked paraphasias, neologisms, alexia and agraphia
    Transcortical motor frontal lobe, anterior/superior to Broca’s area or in the subcortical area deep to Broca’s area; reduced rate, initiation, organization of speech
    Broca’s posterior-inferior frontal lobe of dominant (usually left) hemisphere; telegraphic speech, paraphasias, articulatory errors or struggling
    Mixed transcortical
    aka. isolation aphasia, lesions in borders of frontal, parietal, and temporal areas; decreased rate and initiation of speech, echolalia
    Global various sizes and locations but usually involves left MCA distribution; ranges from mutism to total repetitive jargon or neologistic output
  • References

    Zorowitz RD, Baerga E, Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York, NY: Demos Medical; 2015. Chapter 1, Stroke. P.41-95.

    Harvey RL, Roth EJ, Yu DT, Celnik P, Braddom RL. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: W.B. Saunders Company; 2011. Chapter 50, Stroke Syndromes. P.1177-1222.

    Twitchell TE. The restoration of motor function following hemiplegia in man. Brain. 1951;74:443–480.

    Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther. 1966;46:357–375.

    Zhang J, Zhou Y, Wei N, Yang B, Wang A, Zhou H, et al. (2016) Laryngeal Elevation Velocity and Aspiration in Acute Ischemic Stroke Patients. PLoS ONE 11(9): e0162257. https://doi.org/10.1371/journal.pone.0162257