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Hemiplegia
Classification and external resources
ICD-10 G802, G81
ICD-9 342-343, 438.2
MeSH D006429

Hemiplegia /he.mə.pliː.dʒiə/ is total paralysis of the arm, leg, and trunk on the same side of the body. Hemiplegia is more severe than hemiparesis, wherein one half of the body has less marked weakness.[1] Hemiplegia and Hemiparesis may be congenital, or they might be acquired conditions resulting from an illness, an injury, or a stroke.

Hemiplegia is not an uncommon medical disorder. In elderly individuals, strokes are the most common cause of hemiplegia. In children, the majority of cases of hemiplegia have no identifiable cause and occur with a frequency of about one in every thousand births. Experts indicate that the majority of cases of hemiplegia that occur up to the age of two should be considered to be cerebral palsy until proven otherwise.[2]

Causes

The most common cause of hemiplegia is stroke. Strokes can cause a variety of movement disorders, depending on the location and severity of the lesion. Hemiplegia is common when the stroke affects the corticospinal tract. Other causes of hemiplegia include spinal cord injury, specifically Brown-Séquard syndrome, traumatic brain injury, or disease affecting the brain. As a lesion that results in hemiplegia occurs in the brain or spinal cord, hemiplegic muscles display features of the Upper Motor Neuron Syndrome. Features other than weakness include decreased movement control, clonus (a series of involuntary rapid muscle contractions), spasticity, exaggerated deep tendon reflexes and decreased endurance.

The incidence of hemiplegia is much higher in premature babies than term babies. There is also a high incidence of hemiplegia during pregnancy and experts believe that this may be related to either a traumatic delivery, use of forceps or some event which causes brain injury.[3]

Other causes of hemiplegia in adults include trauma, bleeding, brain infections and cancers. Individuals who have uncontrolled diabetes, hypertension or those who smoke have a higher chance of developing a stroke. Weakness on one side of the face may occur and may be due to a viral infection, stroke or a cancer.[4]

Medial medullary syndrome

Main article: medial medullary syndrome

Common causes by etiology

Pathogenesis

The exact cause of hemiplegia is not known in all cases, but it appears that the brain is deprived of oxygen and this results in the death of neurons. When the corticospinal tract is damaged, the injury is usually manifested on the opposite side of the body. For example if one has an injury to the right side of the brain, the hemiplegia will be on the left side of the body. This happens because the motor fibres of corticospinal tract ( also called pyramidal fibres), which take origin from the motor cortex in brain, cross to the opposite side in the lower part of medulla oblangata and then descend down in spinal cord to supply their respective muscles. Depending on the site of lesion in brain, the severity of hemiplegia varies. A lesion in internal capsule where all the motor fibres are condensed in a small area, will cause dense hemiplegia i.e complete loss of power of all muscles of one half of body while a lesion at cortical or subcortical level will cause varied amount of weakness of one half of the body.

Signs and Symptoms

Hemiplegia means severe weakness of the limbs on one side of the body but the specific features can vary tremendously from person to person. Problems may include:

  • Difficulty with gait
  • Difficulty with balance while standing or walking
  • Having difficulty with motor activities like holding, grasping or pinching
  • Increasing stiffness of muscles
  • Muscle spasms
  • The majority of children who develop hemiplegia also have abnormal mental development
  • Behavior problems like anxiety, anger, irritability, lack of concentration or comprehension
  • Emotions — depression
  • Shoulder pain — Often associated with a loss of external rotation of the glenohumeral joint, commonly due to the increased tone of the Subscapularis muscle and Pectoralis major muscle [7]
  • Shoulder Subluxation[7]

Diagnosis

Hemiplegia is identified by clinical examination by a health professional, such as a physiotherapist or doctor. Radiological studies like a CT scan or magnetic resonance imaging of the brain should be used to confirm injury in the brain and spinal cord, but alone cannot be used to identify movement disorders. Individuals who develop seizures may undergo tests to determine where the focus of excess electrical activity is.[8]

Hemiplegia patients usually show a characteristic gait. The leg on the affected side is extended and internally rotated and is swung in a wide, lateral arc rather than lifted in order to move it forward. The upper limb on the same side is also adducted at the shoulder, flexed at the elbow, and pronated at the wrist with the thumb tucked into the palm and the fingers curled around it.[9]

Treatment

Treatment should be based on assessment by the relevant health professionals, including physiotherapists, doctors and occupational therapists. Muscles with severe motor impairment including weakness need these therapists to assist them with specific exercise, and are likely to require help to do this.[10]

Pharmacological: Drugs can be used to treat issues related to the Upper Motor Neuron Syndrome. Drugs like Librium or Valium could be used as a relaxant. Drugs are also given to individuals who have recurrent seizures, which may be a separate but related problem after brain injury.[11]

Surgery: Surgery may be used if the individual develops a secondary issue of contracture, from a severe imbalance of muscle activity. In such cases the surgeon may cut the ligaments and relieve joint contractures. Individuals who are unable to swallow may have a tube inserted into the stomach. This allows food to be given directly into the stomach. The food is in liquid form and instilled at low rates. Some individuals with hemiplegia will benefit from some type of prosthetic device. There are many types of braces and splints available to stabilize a joint, assist with walking and keep the upper body erect.

Rehabilitation: Rehabilitation is the main treatment of individuals with hemiplegia. In all cases, the major aim of rehabilitation is to regain maximum function and quality of life. Both physical and occupational therapy can significantly improve the quality of life.

Physical Therapy: Physical therapy can help improve muscle strength & coordination, mobility (such as standing and walking), and other physical function using different sensorimotor techniques.[12] Physiotherapists can also help reduce shoulder pain by maintaining shoulder range of motion, as well as using Functional electrical stimulation.[13] Supportive devices, such as braces or slings, can be used to help prevent or treat shoulder subluxation [14] in the hopes to minimize disability and pain. It should be noted that although many individuals suffering from stroke experience both shoulder pain and shoulder subluxation, the two are mutually exlusive.[15] A treatment method that can be implemented with the goal of helping to regain motor function in the affected limb is constraint-induced movement therapy. This consists of constraining the unaffected limb, forcing the affected limb to accomplish tasks of daily living.[16]

Occupational Therapy: Occupational therapy may help the individual train daily living activities like brushing teeth, combing hair or dressing. Initially, one may undergo therapy at a rehabilitation center but many of these exercises can also be done at home and become part of daily life routine.[17]

Assessment Tools: There are a variety of standardized assessment scales available to physiotherapists and other health care professionals for use in the ongoing evaluation of the status of a patient’s hemiplegia. The use of standardized assessment scales may help physiotherapists and other health care professionals during the course of their treatment plant to:
- Prioritize treatment interventions based on specific identifiable motor and sensory deficits
- Create appropriate short and long term goals for treatment based on the outcome of the scales, their professional expertise and the desires of the patient
- Evaluate the potential burden of care and monitor any changes based on either improving or declining scores
Three of the most commonly used scales in the assessment of hemiplegia are:
1. The Fugl-Meyer Assessment of Physical Performance (FMA) [18]
-The FMA is often used as a measure of functional or physical impairment following a cerebrovascular accident(CVA).[19] It measures sensory and motor impairment of the upper and lower extremities, balance in several positions, range of motion, and pain. This test is a reliable and valid measure in measuring post-stroke impairments related to stroke recovery. A lower score in each component of the test indicates higher impairment and a lower functional level for that area. The maximum score for each component is 66 for the upper extremities, 34 for the lower extremities, and 14 for balance. [20]
2. The Chedoke-McMaster Stroke Assessment (CMSA) [21]
-This test is a reliable measure of two separate components evaluating both motor impairment and disability.[22] The disability component assesses any changes in physical function including gross motor function and walking ability. The disability inventory can have a maximum score of 100 with 70 from the gross motor index and 30 from the walking index. Each task in this inventory has a maximum score of seven except for the 2 minute walk test which is out of two. The impairment component of the test evaluates the upper and lower extremities, postural control and pain. The impairment inventory focuses on the seven stages of recovery from stroke from flaccid paralysis to normal motor functioning.
3. The STroke REhabilitation Assessment of Movement (STREAM) [23]

The STREAM consists of 30 test items involving upper-limb movements, lower-limb movements, and basic mobility items. It is a clinical measure of voluntary movements and general mobility (rolling, bridging, sit-to-stand, standing, stepping, walking and stairs) following a stroke. The voluntary movement part of the assessment is measured using a 3-point ordinal scale (unable to perform, partial performance, and complete performance) and the mobility part of the assessment uses a 4-point ordinal scale (unable, partial, complete with aid, complete no aid). The maximum score one can receive on the STREAM is a 70 (20 for each limb score and 30 for mobility score). The higher the score, the better movement and mobility is available for the individual being scored.[24]

Prognosis

Hemiplegia is not a progressive disorder, except in progressive conditions like a growing brain tumour. Once the injury has occurred, the symptoms should not worsen. However, because of lack of mobility, other complications can occur. Complications may include muscle and joint stiffness, loss of aerobic fitness, muscle spasms, bed sores, pressure ulcers and blood clots.[25]

Sudden recovery from hemiplegia is very rare. Many of the individuals will have limited recovery, but the majority will improve from intensive, specialised rehabilitation. Potential to progress may differ in cerebral palsy, compared to adult acquired brain injury. It is vital to integrate the hemiplegic child into society and encourage them in their daily living activities. With time, some individuals may make remarkable progress. [26]

See also

References

  1. Hemiplegia/Hemiparesis
  2. Hemiplegia symptoms, treatment and therapy Retrieved on 2010-02-02
  3. Hemiplegia in children Children's hemiplegia and stroke association. Retrieved on 2010-02-02
  4. What is Hemiplegia HemiHelp Portal. Retrieved on 2010-02-02
  5. http://www.samehlabib.com/Books/Neurology.doc
  6. http://www.lakesidepress.com/pulmonary/Sleep/sleep-paralysis.htm
  7. 7.0 7.1 Turner-Stokes L, Jackson D (May 2002). Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clin Rehabil 16 (3): 276–98.
  8. Forms of cerebral palsi: Hemiplegia Origins of cerebral palsi Online Portal. Retrieved on 2010-02-02
  9. The Stanford 25: Gait Abnormailities
  10. Patten C, Lexell J, Brown HE (May 2004). Weakness and strength training in persons with poststroke hemiplegia: rationale, method, and efficacy. J Rehabil Res Dev 41 (3A): 293–312.
  11. Hemiplegia and hemiparesis Gait disorders Portal. Retrieved on 2010-02-02
  12. Barreca S, Wolf SL, Fasoli S, Bohannon R (December 2003). Treatment interventions for the paretic upper limb of stroke survivors: a critical review. Neurorehabil Neural Repair 17 (4): 220–6.
  13. Price CI, Pandyan AD (February 2001). Electrical stimulation for preventing and treating post-stroke shoulder pain: a systematic Cochrane review. Clin Rehabil 15 (1): 5–19.
  14. Ada L, Foongchomcheay A, Canning C (2005). Supportive devices for preventing and treating subluxation of the shoulder after stroke. Cochrane Database Syst Rev (1): CD003863.
  15. Zorowitz RD, Hughes MB, Idank D, Ikai T, Johnston MV (March 1996). Shoulder pain and subluxation after stroke: correlation or coincidence?. Am J Occup Ther 50 (3): 194–201.
  16. Wittenberg GF, Schaechter JD (December 2009). The neural basis of constraint-induced movement therapy. Curr. Opin. Neurol. 22 (6): 582–8.
  17. Hemiplegia definition About Online Portal. Retrieved on 2010-02-02
  18. Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S (1975). The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 7 (1): 13–31.
  19. Sullivan KJ, Tilson JK, Cen SY, et al. (February 2011). Fugl-Meyer assessment of sensorimotor function after stroke: standardized training procedure for clinical practice and clinical trials. Stroke 42 (2): 427–32.
  20. Sullivan, S.B. (2007). "Stroke" O’Sullivan, S.B.; Schmitz, T.J. Physical Rehabilitation, 5th, Philadelphia PA: F.A. Davis.
  21. Gowland C, Stratford P, Ward M, et al. (January 1993). Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke 24 (1): 58–63.
  22. Valach L, Signer S, Hartmeier A, Hofer K, Steck GC (June 2003). Chedoke-McMaster stroke assessment and modified Barthel Index self-assessment in patients with vascular brain damage. Int J Rehabil Res 26 (2): 93–9.
  23. Daley K, Mayo N, Wood-Dauphinée S (January 1999). Reliability of scores on the Stroke Rehabilitation Assessment of Movement (STREAM) measure. Phys Ther 79 (1): 8–19; quiz 20–3.
  24. (2007) Physical Rehabilitation, 5th, 736, Philadelphia PA: F.A. Davis.
  25. Hemiplegia overview, causes and risk factors Healthopedia Portal. Retrieved on 2010-02-02
  26. Hemiplegia review guide Organized wisdom Portal. Retrieved on 2010-02-02

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