Stroke and Hemiplegia

Stroke

• Characterized as an UMN lesion
• Occurs when blood flow to the brain is blocked or when there is sudden bleeding in the brain
• A stroke is an insult/injury/event to the brain.
• Consequences range from death to permanent dysfunction, partial recovery, or full recovery.

Hemiplegia

• Also characterized as an UMN lesion
• It is a non-progressive condition of paralysis on one side of the body
• Sometimes results from a stroke, but can be caused by genetics, spinal cord injuries, or other brain injuries
• Paralysis occurs on the opposite side of the brain lesion
• Effects depend on the location and severity of the brain damage
• Can be temporary or permanent, ranging from subtle to severely disabling, with spasticity and sensory/perceptual loss

Hemiplegia Symptoms

• Appear immediately post stroke
• Muscles on the affected side are initially weak or flaccid in the acute phase, then gradually lead to spastic paralysis, though some flaccidity can remain
• Lesions interfere with the brain's control, causing uninhibited alpha motor neuron firing
• Paralysis can develop into a flexor or extensor pattern based on dominant reflexes
• Flexor pattern in the upper limb combined with an extensor pattern in the lower limb is the most common pattern

Other Symptoms Include

• Altered posture, circumducted gait, and hemiplegic shoulder with GH add, IR, and scapular retraction
• Seizures, edema, pain, compensatory changes, sensory deficits, and shoulder-hand syndrome (decreased ROM of GH & hand, throbbing pain & edema)
• Neglect of affected side, behavioral & emotional changes, visual impairment, speech difficulties, and cognitive impairment

Observations

• Spasticity patterns on the affected side
• Impaired circumducted gait, balance, and weight shifting
• Use of ambulatory aids
• Muscle bulk differences between the affected and unaffected sides
• Functional abilities vary based on stroke severity and spasticity/flaccidity
• Postural asymmetries and neglect of the affected side
• Intensive rehab typically lasts 18 months

Strokes: Types and Causes

• Occurs when blood supply to the brain is interrupted, impairing brain cells
• Impairment level depends on the location and degree of damage
• Three main types: ischemic (blood clot), hemorrhagic (vessel bursts), and transient ischemic attack (TIA - lasts less than 24 hours)
• In rare cases, underlying conditions like tumors, infections, or brain swelling from injuries or illnesses can cause a stroke
  • Right-side strokes can lead to impulsivity
  • Left-side strokes yield slower, more controlled behavior

Risk Factors

• Controllable factors: unhealthy weight, physical inactivity, excessive alcohol/drug abuse, smoking, stress, birth control/hormone replacement therapy
• Uncontrollable factors: sex, age, family history, ethnicity, personal circumstances, history of stroke or TIA
• Main modifiable risk factors are blood pressure (hypertension with hemorrhagic strokes) and atherosclerosis (ischemic strokes)

Warning Signs

• Sudden numbness or weakness in the face, arm, or leg, especially on one side
• Sudden confusion, trouble speaking, or understanding speech
• Sudden vision problems in one or both eyes
• Sudden difficulty walking, dizziness, or problems with balance and coordination
• Severe headache with no known cause

Stroke First Aid - FAST

• Face: Facial numbness or weakness, especially on one side
• Arm: Arm numbness or weakness, especially on one side
• Speech: Slurred speech or difficulty speaking or understanding
• Time: Urgency to call EMS/9-1-1 immediately

Stroke Recovery - Brunnstrom Stages

• Stage 1: Flaccidity immediately after stroke onset - no voluntary movements on the affected side can be initiated
• Stage 2: Spasticity appears basic synergy patterns are present and minimal voluntary movements are possible
• Stage 3: Patient gains voluntary control over synergies with increased spasticity
• Stage 4: Some movement patterns out of synergy are mastered, but synergy patterns still dominate, with decreased spasticity
• Stage 5: More complex movement combinations are learned as basic synergies lose dominance, with further decreased spasticity
• Stage 6: Disappearance of spasticity where individual joint movements become possible and coordination approaches normal
• Stage 7: Normal function is restored

Brunnstrom Stage Massage Emphasis

• Stage 1 (Flaccidity): PROM, passive gentle stretches, and positioning support of the upper limb, especially the shoulder
• Stage 2 (Spasticity develops & abnormal synergies): involves slow, gentle PROM and massage for sensory stimulation
• Stage 3 (Spasticity increases): continuing massage techniques with increased emphasis on stress reduction and massage to relax spastic/synergistic areas, splints may be used
• Stage 4 (Spasticity decreases): continuing massage techniques, added emphasis on the recovering arm in homecare and ADLs, PNF patterning (PROM, AROM) is introduced
• Stage 5 (Spasticity continues to decrease): involves continuing massage techniques and beginning a strengthening routine with PNF patterning (RROM)
• Stage 6 (Spasticity disappears & coordination reappears): continuing massage techniques, focusing on fine motor skills

Synergy

• Describes the recruitment of a whole series of muscles when only a few are needed

Synergy - Example

• Reaching forward, the shoulder abducts and elevates, and the wrist flexes

Synergy - Upper Limb

• The most common flexor synergy includes shoulder internal rotation/adduction, elbow flexion, forearm supination, and wrist flexion
• An extensor synergy exists as well

Assessment

• Use palpation, ROM measurements, and sensory testing to determine status

Goals

• Goals are to promote relaxation, decrease pain and edema
• Goals are to address postural changes/muscle imbalances.
• Goals are to decrease spasticity
• Goals are to maintain joint health
• Goals are for full body integration

Treatment Planning / Rationale

• Relaxation and stress management are used because stress makes spasticity worse
• PROM and stretching are important to prevent neglect of the affected limb, maintain sensory mapping, and prevent contracture formation
• Focus on lowering the tone of spastic or overused muscles, important for decreasing contracture formation
• Decreasing edema is important for tissue health
• Stimulate muscles outside of synergy or opposite to spasticity
• PROM and joint play is used to maintain joint health
• Full body integration is intended for overall wellbeing
• ROODs, PNF, Stretching/strengthening are used as needed