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Hemiplegia

Original Editor - Mandeepa Kumawat Top Contributors - Mandeepa Kumawat, Muhammad Arslan, Lucinda hampton, Kim Jackson, Vidya Acharya, Rucha Gadgil and Alexandra Stead

Introduction

Hemiplegia is paralysis of the muscles of the lower face, arm, and leg on one side of the body. The main characteristic of this disease is motor deficits, but other impairments have also been observed eg., sensation, speech, memory, and cognition impairment.[1] The most common cause of hemiplegia is stroke, which damages the corticospinal tracts in one hemisphere of the brain.[2] Other causes of hemiplegia include trauma e.g., spinal cord injury, brain tumours, and brain infections.[3]

Hemiplegia is managed medically and by comprehensive neurological rehabilitation.[4] Physical therapy interventions which also includes mirror therapy has shown better outcome on motor outcomes and functional performance.

Aetiology

Hemiplegia can result from a variety of neurological conditions that affect the motor pathways of the brain or spinal cord. The causes may be vascular, infective, neoplastic, traumatic, congenital, demyelinating, or, less commonly, psychological in origin. The major causes include:

Signs and Symptoms of Hemiplegia

Symptoms of hemiplegia vary from person to person depending on the cause of hemiplegia and on the severity of the condition. Symptoms of hemiplegia include:[13][14]

  • Impaired motor skills
  • Difficulty grasping or holding on to objects
  • Weakness of muscles or stiffness on one side of the body
  • Permanently contracted muscles or muscle spasticity
  • Poor balance
  • Difficulty walking

Management of Hemiplegia

Individuals diagnosed with hemiplegia typically receive a multidisciplinary rehabilitation program with physical therapists, occupational therapists, speech and language therapists, and mental health professionals.[15]

Physical therapy treatment includes:

Neurodevelopmental techniques:

Neurodevelopmental approaches are incorporated to enable normal movement patterns, enhance postural control and decrease abnormal muscle tone.

Bobath Approach (Neurodevelopmental Treatment - NDT): Guided handling & positioning to facilitate normal movement patterns and to inhibit abnormal movement patterns.[16]

Brunnstrom Movement Therapy: Provides recovery stages after stroke to help encourage voluntary movement by implementing the use of synergistic movement patterns.[17]

Rood Approach: sensory stimulation of brush, tap, ice and extended stretch to inhibit or facilitate muscle activity.[18]

Proprioceptive Neuromuscular Facilitation (PNF): Enhancing strength, coordination, and motor control through diagonals and spirals using manual resistance.[19]

Coordination Exercises: Activities which enhance the timing, accuracy and smoothness of the movements involved in functional activities.[20]

Motor relearning program

The Motor Relearning Program focuses on the practice of functional tasks and the facilitation of normal movement patterns, aiming to restore functional motor performance.[21]

Task-Specific Training: Practicing task-specific activities that have meaning and significance during the day to enhance functional performance including reaching and grasping, standing, and walking.[22]

Repetitive Functional Task Practice: Using high repetition of functional movements to initiate motor recovery and promote neuroplasticity.[23]

Constraint-Induced Movement Therapy (CIMT): Limiting use of the non-affected limb and promoting intensive use of the affected one, which is used to overcome learned non-use and to enhance the upper extremity function.[24][25]

Strengthening & conditioning

Strength training focuses on increasing the strength of muscles, strength endurance, and independence in function.[26]

Progressive Resistance Training: gradually increasing resistance to strengthen affected muscles.[27]

Active Free and Active-Assisted Exercises: Voluntary (independent) movement within the range of motion that is available. Active-assisted exercises are performed by therapist/caregiver helps the patient when he/she cannot perform the movement. [28]

Functional Strengthening: Activities like sit-to-stand, squats, step up, and stair climbing, which are similar to activities in everyday life.[29]

Balance & coordination training

Balance interventions are used to decrease fall risk and increase mobility.[30] Both static and dynamic balance training will be used, weight shifting exercises, and the use of balance boards or unstable surfaces.[31]

Static Balance Training: Maintaining balance in sitting or standing position in a stationary position.[32]

Dynamic Balance Training: Activities where movement must be performed and balance maintained, e.g. reaching/stepping.[33]

Weight-Shifting Exercises: encourage symmetrical weight bearing and increase postural stability.[34]

Balance Boards and Unstable Surfaces: Challenge to the sensory and motor systems to improve balance reactions and coordination.[35]

Gait training

Treadmill exercise (body weight supported or not), overground gait training, step training, stair climbing and use of assistive devices (walker, cane) are main part of gait training in patient with hemiplegic stroke.[36][37]

Body Weight-Supported Treadmill Training: Hemiplegic rehabilitation with body weight supported treadmill training (BWSTT) promotes repetitive task-specific gait training, increases walking speed and enhances postural control by reducing the body weight load and making it safer for gait retraining in hemiplegia patients.[38]

Exoskeleton-assisted gait training: It is evidence-based rehabilitation technology that is being applied to patients with hemiplegia after stroke. It helps to generate repetitive, symmetrical and task-specific stepping patterns by supplying powered assistance to the lower limbs during walking. This decreases the patient's physical workload, improves gait kinematics, and enhances walking endurance and intensity. High-repetition, assist-as-needed gait training could also enhance balance, muscle activation, and neuroplasticity in people with severe gait impairments following stroke, using exoskeleton devices.[39]

Overground Gait Training: To enhance gait quality and endurance in patients with hemiplegic stroke by performing walking in the community.[40]

Step Training and Stair Climbing: Improves lower limb strength, co-ordination and functional mobility.[41]

Assistive Device Training: Using walking sticks, canes or orthoses, as appropriate, to make people walk more safely and independently.[42]

Neurofacilitation & tone management

Positioning: Proper alignment in bed, sitting, and standing to prevent contractures and pressure injuries; maintain symmetrical posture; support affected limb in functional alignment; reduce abnormal tone and spastic posturing; improve comfort and respiratory function; prevent shoulder subluxation and soft tissue shortening.[43][44]

Weight-Bearing Activities: These activities promote proprioceptive input and sensory awareness, facilitate co-contraction, and muscle activation in the affected limb. It also improves joint stability and alignment, reduces spasticity through sustained loading, enhances postural control, symmetry in sitting or standing, and also supports normalisation of tone through sustained pressure.[45][46]

Thermal Therapy: Cryotherapy reduces spasticity and muscle overactivity.[47] Heat therapy may improve tissue extensibility and reduce stiffness, enhances comfort during stretching and exercise, supports preparation for therapeutic activity, and assists in short-term modulation of tone and pain reduction .[48]

Functional electrical stimulation (FES)

Improves voluntary muscle activation in weak or paretic muscles, enhances motor relearning through repetitive patterned stimulation, assists correction of foot drop during gait, improves upper limb functional reach and grasp activities, promotes neuroplasticity through task-specific stimulation, and increases functional independence during mobility and daily activities to correct foot drop and upper limb activation.[49]

Upper limb rehabilitation

Upper extremity rehabilitation is focused on improving voluntary motor control, strength, coordination, and functional use of the affected arm and hand, reduce learned non-use, enhance neuroplasticity, and restore participation in activities of daily living; and treatment is task-oriented with emphasis on repetitive, meaningful, and goal-directed practice to improve reach, grasp, release, and bimanual coordination.[50]

Mirror Therapy: A technique that utilises visual illusion created by the reflected intact limb in a mirror to stimulate the motor cortex regions on the affected side, which promotes reorganisation of the motor cortex, sensorimotor integration, decreases neglect, improves motor planning, and enhances voluntary movement and functional recovery of the upper limb; frequently applied during early and chronic stroke rehabilitation.[51]

Bilateral Arm Training: uses simultaneous, symmetrical or coordinated movements of both arms to promote interhemispheric balance and motor relearning; promotes coordination between arm movements; promotes proximal stability and distal control; facilitative to functional task performance, e.g., lift and carry; can be used to improve arm control at the shoulder and elbow to achieve hemiplegic improvements.[52]

Task Oriented Rehabilitation

Task oriented rehabilitation is a functional and neuroplasticity based approach of repetitive practice of meaningful and goal-oriented activities for the purpose of improving motor control and independence in the real-life settings, the emphasis is on performing meaningful goal-oriented tasks such as reaching, grasping, transferring, feeding and walking rather than isolated movements. The training is focused on specific functional goals identified by the patient and therapist, ensuring high relevance and motivation, repetitive execution of task components helps to promote motor learning, decrease learned non-use, and improve cortical reorganisation, progression is provided by increasing task complexity, environmental challenges, speed and accuracy. Feedback is provided to enhance performance and correction of movement errors. Overall, task-oriented rehabilitation aims to restore efficient movement patterns, improve functional independence and enhance participation in home, community, and vocational activities in individuals with hemiplegic stroke.[53][54]

Cardiovascular and endurance training

Cardiovascular and endurance training plays a key role during stroke rehabilitation to increase aerobic capacity, improve fatigue, optimise cardiovascular fitness, and enhance participation in everyday and community activities; aerobic exercise enhances neuroplasticity, walking efficiency and decreases the risk of recurrent cardiovascular events that are common following stroke.[55]

Walking Programs: Structured, progressive walking programs which improve walking endurance, speed and efficiency, include indoor and outdoor walking, treadmill walking, interval walking, and CAT walking; progression involves increasing walking duration, distance, speed, and environmental complexity; walking programs benefit cardiovascular fitness, walking performance, and walking independence in community mobility.[56]

Cycling Exercises: Lower limb, repetitive rhythmic exercise using stationary or recumbent bicycle to augment muscle strength and endurance of lower limbs, cardiovascular fitness, bilateral coordination, and provide a safe exercise for aerobic conditioning without high balance demands; may be performed with or without bicycle assistance, depending on level of weakness.[57]

Aerobic Conditioning: Structured aerobic exercise programs at moderate intensity that includes activities such as walking, cycling, stepping, treadmill training, or arm ergometry improves cardiovascular endurance, exercise tolerance, oxygen consumption, and physical fitness which decreases fatigue, improves mood, and increases participation in activities of daily living and community-based activities.[58][59]

Adjunct modern techniques

Virtual Reality Therapy: Computer-generated interactive environments that replicate real-life activities and rehabilitation tasks, offering enriched sensory feedback and high-intensity repetitive practice, while keeping the patient motivated. It can be used for upper limb training, balance training, gait training and cognitive-motor tasks and is able to achieve motor learning, neuroplasticity and functional recovery through engaging task-oriented activities.[60]

Robotic-Assisted Therapy: Use of robotic equipment and electromechanical systems to aid, guide, or resist motion of the upper or lower extremity. It is task-specific with higher repetitions and precise control for different movement patterns. It improves motor recovery, strength, coordination, and functional performance, especially in those with severe motor impairments who are unable to independently produce sufficient voluntary movement.[61][62]

Biofeedback Therapy: Provides real-time information about muscle activity, weight distribution, posture, balance, or movement quality to help patients recognise abnormal movement and learn better voluntary motor control. It often uses electromyographic (EMG) biofeedback, force plates, pressure platforms, or motion sensors, and involves active participation of the patient for motor learning, balance, gait performance and functional task execution.[63][64]

Outcome Measures

Outcome measures are applied to assess and evaluate the impairments, activity limitations, participation restriction, and to determine the effectiveness of rehabilitation interventions.[65][66] The outcome measures used should reflect the clinical condition, recovery phase, and rehabilitation objectives of the patient:

Motor Function

Fugl-Meyer Assessment – tests balance, joint range of motion, joint pain, sensation and motor recovery after a stroke.[67]

Brunnstrom Recovery Stages – represents the classifications of motor recovery after hemiplegia.[68]

Muscle tone and spasticity

Modified Ashworth Scale – grading spasticity according to the resistance felt when muscles are passively stretched.[69][70]

Modified Tardieu Scale – measures the response of muscles to stretch at different velocities to assess muscle spasticity.[71]

Balance and Postural Control

Berg Balance Scale – assesses static and dynamic balance abilities[72]

Modified Functional Reach Test – limits of stability and balance[73]

Postural Assessment Scale for Stroke – assesses postural control in sitting and standing[74]

Complications

Hemiplegia may result in a variety of musculoskeletal, neurological, functional, cardiopulmonary, skin, psychological and communication issues.[75]

Musculoskeletal problems are associated with spasticity of the muscles, contractures, joint stiffness, decreased range of motion, shoulder subluxation, pain (particularly shoulder pain) and muscle disuse atrophy.[76][77]

Neurological dysfunction can manifest as motor deficits, incorrect movement patterns, sensory deficits, proprioceptive deficits and, in some cases, seizures, depending on the cause of brain injury. Most functional problems include trouble walking, poor balance, higher risk of falling and lower independence level in activities of daily living.[78]

Cardiopulmonary complications can occur as a result of immobility, such as deep vein thrombosis, decreased cardiovascular endurance, deconditioning, and aspiration pneumonia in individuals with a dysphagia disorder.[79][80]

Skin conditions like pressure ulcers can also develop because of extended periods of time spent in bed and/or bad positioning.[81]

Psychological problems are depression, anxiety, emotional instability, and social withdrawal, and may also be cognitive deficits like impairments in memory and attention.[82] Other communication difficulties and swallowing disorders such as dysarthria, aphasia and dysphagia are additional factors that make it harder for people to live independent and healthy lives.[83][84]

Overall, these complications are associated with higher long-term disability, burden of care and lower participation in social and functional activities.

Further Physiotherapy Management Approaches

See the following pages:

References

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