Hemiplegia Onset & Symptoms Quiz

Hemiplegia Onset & Course

• Acute onset and regressive course: Commonly caused by vascular, infective, or traumatic lesions.
• Gradual onset and progressive course: Usually associated with neoplastic lesions (tumors).
• Remittent and relapsing course: Characteristic of conditions like Multiple Sclerosis (MS).

Hemiplegia Symptoms and Signs: Acute Lesions

• Stage of flaccidity (Flaccid Paralysis, Shock Stage): Lasts 2 - 6 weeks. Shorter duration indicates a better prognosis.
  • Complete absence of voluntary movement: Affected limb(s) show no voluntary movement due to severe muscle weakness.
  • Hypotonia: Muscles are extremely soft and floppy due to reduced muscle tone.
  • Absence of reflexes: Tendon reflexes may be absent, and there may be no plantar response.
  • Drooping of the face: Facial muscles on the affected side may sag, leading to asymmetrical facial appearance.
  • Difficulty in swallowing and speaking: Dysphagia (difficulty swallowing) and dysarthria (difficulty speaking) may be present.
• Stage of spasticity (Spastic Paralysis, Stage of Established Hemiplegia):
  • Weakness of one side of the body: Affects the progravity muscles more than the antigravity muscles.
    • Upper Limb (UL): Extensors are weaker than flexors
    • Lower Limb (LL): Flexors are weaker than extensors
  • Hypertonia (spasticity): Spastic paralysis of the antigravity muscles, resulting in a clasp-knife type paralysis. This follows a pyramidal distribution pattern.
    • UL: Flexors are more spastic than extensors.
    • LL: Extensors are more spastic than flexors.
    • UL & LL: Adductors are more spastic than abductors.
  • Deep reflexes: Exaggerated on the paralyzed side (biceps, triceps, knee, and ankle reflexes). Pathological deep reflexes (normally absent) may appear: finger reflex, patellar reflex, adductor reflex. Clonus may be elicited in the ankle, less frequently in the knee or wrist.
  • Lost superficial reflexes: The abdominal reflex is lost on the paralyzed side.
  • Positive Babinski sign: Dorsiflexion of the big toe with or without fanning of the other toes upon eliciting the plantar response.
  • Reappearance of primitive reflexes: ASTNR, STNR, TLS, TLP, TLR, TTR, PSR

Hemiplegia Symptoms and Signs: Gradual Lesions

• Hemiplegia progresses directly to the stage of spasticity.

Factors Influencing Hemiplegia Recovery

• Reduction of cerebral edema
• Absorption of damaged tissue
• Improved local vascular flow
• Lateral sprouting (plasticity)

Common Causes of Shoulder Pain in Stroke

• Shoulder subluxation
• Impingement syndrome
• Frozen shoulder
• Shoulder hand syndrome

Hemiplegia Assessment and Planning

• General examination: Routine physical assessment
• Neurological examination:
  • Examination of mental function
  • Examination of speech
  • Examination of cranial nerves
  • Examination of motor system
  • Examination of sensory system
  • Examination of coordination
  • Examination of postural mechanism
  • Examination of synergies
  • Examination of gait
  • Examination of daily living activities (ADL)

Hemiplegia: Flaccid Stage (Stage of Shock)

• Description: Characterized by low muscle tone or flaccidity. The duration varies from a short period to several weeks or months. Short duration is associated with a better prognosis.
• Physiotherapy aims:
  • Save the patient's life (improve respiration, circulation, and prevent secondary complications like DVT).
  • Improve postural reactions (trunk control, righting reactions, protective reactions, postural tone).
  • Minimize the effects of tonal abnormality.
  • Increase sensory awareness (orientation of the affected side).
  • Maintain range of motion and prevent secondary complications.
  • Stimulate muscles on the affected side (encourage active participation of the patient).
  • Prepare the patient for sitting up and standing (early mobility).
  • Improve orofacial function.

Hemiplegia: Flaccid Stage: Physiotherapy Methods

• Save patient life: Respiratory exercises, circulatory exercises, improved renal function, and careful attention to patient's nutrition.
• Improve postural reaction: Improve trunk control and promote the development of higher-level postural reactions (righting, equilibrium, and protective). Reduce primitive reflexes.
• Facilitation techniques:
  • Proprioceptive stimuli
  • Exteroceptive stimulation
  • Vestibular facilitation
  • Positioning
  • ROM exercises
  • Orofacial training

Hemiplegia: Spastic Stage (Stage of Established Hemiplegia)

• Goals:
  • Facilitate selectivity (fractionation)
  • Improve postural reactions and trunk control
  • Minimize the effect of spasticity
  • Increase strength of weak muscles
  • Decrease shoulder pain
  • Improve joint proprioception
  • Improve locomotion

Hemiplegia: Spastic Stage: Physiotherapy Methods

• Improve fractionation: PNF technique
• Improve postural reaction: Improve trunk control and promote higher-level postural reactions (righting, equilibrium, and protective). Reduce primitive reflexes.
• Inhibitory techniques:
  • Proprioceptive inhibition
  • Local anesthesia
  • Vestibular inhibition
  • Resisted and endurance exercises
  • Decrease shoulder pain
  • Proprioceptive exercises
  • Gait training

Hemiplegia: Hysterical

• Description: Patient exhibits paralysis in the absence of an organic pyramidal lesion.

Hemiplegia: Causes

• Vascular causes: Most common
  • Thrombotic: Cerebral infarction.
    • Cerebral atherosclerosis
    • Vasculitis
    • Blood diseases causing hyperviscosity
    • Circulation diseases (slow circulation): Heart failure, systemic hypotension
  • Embolic: Cerebral infarction
    • Heart (most common): Mitral stenosis with atrial fibrillation
    • Distal vessels: Deep venous thrombosis
    • Rare sources: Lungs or bones
  • Hemorrhagic: Intracranial hemorrhage
    • Intracerebral: Bleeding within the brain substance, may leak into ventricles. Can compress vital centers. The middle cerebral artery is commonly affected.
    • Subarachnoid: Bleeding in the subarachnoid space
    • Subdural or extradural: Blood often forms a hematoma.

Hemiplegia: Causes of Intracranial Hemorrhage

• Hypertension: Most common cause of intracranial hemorrhage.
• Rupture of intracranial aneurysm, angioma, or A-V malformation: Most common cause of subarachnoid hemorrhage.
• Hemorrhagic blood diseases: Hemophilia
• Anticoagulants
• Trauma to the head: Most common cause of subdural hemorrhage

Hemiplegia: Diagnosis

• Confirmed diagnosis through CT and MRI scans.

Hemiplegia: Variability in Clinical Picture

• The clinical picture of hemiplegia can vary significantly depending on:
  • The cause of the lesion
  • The site of the lesion
  • The time course of onset

Hemiplegia: Clinical Picture Variations: Cause of Lesion

• Vascular causes: It's crucial to differentiate the clinical picture in thrombotic, embolic, and hemorrhagic lesions.

Hemiplegia: Clinical Picture Variations: Site of Lesion

• The lesion causing hemiplegia can occur at three main levels:
  • Spinal cord: Lesion on one side of the cord between C1 and C5 segments, often caused by stab wounds, disc prolapse, or tumor. This leads to Brown-Sequard syndrome.
  • Brain stem: Lesion on one side of the brain stem resulting in crossed hemiplegia.
  • Cerebral: Lesion can occur in the cortex, subcortex, or internal capsule.

Hemiplegia: Brown-Sequard Syndrome

• Description: Characterized by:
  • Ipsilateral hemiplegia
  • Ipsilateral deep sensory loss
  • Contralateral superficial sensory loss (pain and temperature)

Hemiplegia: Crossed Hemiplegia

• Description: Characterized by:
  • Hemiplegia on the opposite side of the lesion
  • Cranial nerve paralysis of LMN nature on the same side of the lesion

Hemiplegia: Cerebral Lesion

• Description:
  • Cortical: May be associated with one or more of the following symptoms:
    • Coma if the lesion is extensive
    • Convulsions if the lesion is irritative
    • Contralateral cortical sensory loss if the parietal lobe is involved
    • Aphasia and agraphia if the lesion is in the dominant hemisphere
  • Subcortical: Similar to cortical hemiplegia but with more extensive paralysis.
  • Capsular: Characterized by:
    • Complete hemiplegia associated with UMN facial and hypoglossal paralysis on the opposite side of the lesion
    • Hemi-hyposthesia on the opposite side of the lesion
    • No convulsions, aphasia, or coma.