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It is better to have a manual muscle testing in these patients and perform the graded active ROm exercises in these patients. Walking training of these patient on the sloped treadmill added both conditioning and strengthening of these patients. A patient with stroke have many other problems apart from the muscle weakness. During the early stages of stroke, flaccidity with no movement is common. Usually this is replaced by the development of spasticity, hyperreflexia, and mass patterns of movements, termed synergies. Muscle involved in synergies are so strongly linked together that that isolated movement outside the mass synergistic patterns are not possible. As recovery progresses, the spasticity and synergies begin to decline and advanced movement patterns become possible. Brunnstrom has described these patterns in detail.

Sequential Recovery Stages in Hemiplegia as described by Brunnstrom:

Stage 1

Recovery from hemiplegia occurs in stereo typed sequence of events that begin with a period of flaccidity immediately after the acute episode. No movements of limbs can be elicited.

Stage 2

As recovery begins the basic limb synergies or some of their components may appear as associated reactions, or minimal voluntary movement responses may be present. At this time spasticity begin to develop.

Stage 3

Thereafter patient begins voluntary control of movement synergies, although full range of all synergy componentsdoes not necessarily develop. Spasticity has further increased and may become severe.

Stage 4

Some movement combinations that do not follow the paths of either synergy are mastered, first with difficulty, then with more ease and spasticity begins to decline.

Stage 5

If progress continues, more difficult movement combinations are learned as the basic limb synergies lose their dominance over motor control.

Stage 6

With the disappearnace of spasticity, individual joint movements become possible and coordination approach normal. From here on, as the last recovery step, normal motor function is restored, but this last stage is not achieved by all, for the recovery process may plateau at any stage.

Synergy Patterns of Extremities

Upper Extremity

Flexion Synergy components

Scapular retraction/elevation or hyperextension
Shoulder abduction, external rotation
Elbow flexion
Forearn pronation
Wrist and fingers flexion

Extension Synergy Components

Scapular protraction
Shoulder adduction, internal rotation
Elbow extension
Forearm pronation
Wrist and fingers flexion]

Lower Extremity

Flexion Synergy Components

Hip flexion, abduction, external rotation
Knee Flexion
Ankle dorsiflexion, inversion
Toe dorsiflexion

Extension Synergy Components

Hip extension, adduction, internal rotation
Knee Extension
Ankle plantar flexion, inversion
Toe Plantar flexion

It may help you to understand the managment in Stroke