Strokes and Hemiplegia: Causes, Effects, and Brain Damage

• Strokes and hemiplegia are neurological conditions affecting movement and function

Stroke

• Occurs when blood flow to the brain is blocked or interrupted
• Can also occur due to sudden bleeding in the brain
• A stroke is an insult/injury/event to the brain
• Consequences range widely, from death to permanent dysfunction
• Recovery can be partial or complete

Hemiplegia

• It is a non-progressive condition of paralysis affecting one side of the body
• It sometimes results from a stroke
• It may be caused by genetics, stroke, spinal cord injury, or other brain injuries
• Paralysis occurs on the opposite side of the brain lesion

Effects of Hemiplegia

• Effects depend on the location and severity of the brain damage
• Can be temporary or permanent
• May range from almost imperceptible symptoms to severe disability with spasticity and sensory loss

Brain Damage After a Stroke

• Left brain damage can result in right-side paralysis and speech/memory deficits, and cautious behavior
• Right brain damage can result in left-side paralysis, perceptual/memory deficits, and quick/impulsive behavior

Hemiplegia Symptoms Post-Stroke

• Muscles on the affected side will be weak or flaccid in the acute phase
• Flaccid paralysis can lead to spastic paralysis, though some flaccidity may remain
• Lesions interfere with the brain's control over spinal cord activity, causing uninhibited alpha motor neuron firing
• Paralysis can develop into a flexor or extensor pattern based on uninhibited dominant reflexes

Common Symptom Patterns

• Flexor pattern in upper limbs combined with extensor pattern in the lower limb is common in hemiplegia

Other Symptoms of Hemiplegia

• Altered posture due to spasticity
• Altered gait, often circumducted
• Hemiplegic shoulder includes GH ADD, IR, and scapular retraction
• Seizures, edema, pain, and compensatory changes
• Sensory deficit
• Shoulder-hand syndrome with decreased ROM, pain, and edema
• Neglect of the affected side
• Behavioral and emotional changes
• Visual impairment and speech difficulties are possible
• Cognitive impairment

Observations

• Focus on spasticity pattern on the affected side
• Look for circumducted gait and note any balance or weight-shifting impairments
• Note use of ambulatory aids like canes or walkers
• Observe muscle bulk differences between affected and unaffected sides
• Functional abilities vary depending on stroke severity and spasticity or flaccidity
• Note postural asymmetries and neglect of the affected side

Hemiplegic Gait

• A hemiplegic gait involves swinging the affected leg outward in a circle (circumduction)
• The affected upper limb is often carried across the trunk for balance
• This gait is neurogenic or flaccid
• There is a video available for reference

Types of Strokes

• A stroke occurs when blood supply to the brain is interrupted
• This leads to impairment of brain cells
• Ischemic stroke
• Hemorrhagic stroke
• Transient ischemic attack (TIA - lasts less than 24 hours)
• Tumors, infections, or brain swelling can also cause strokes

Risk Factors: Controllable

• Unhealthy weight/hypertension
• High cholesterol, diabetes, heart disease
• Physical inactivity
• Excessive alcohol and drug abuse
• Smoking
• Stress
• Birth control/hormone replacement therapy (HRT)

Risk Factors: Not Controllable

• Sex
• Age
• Family history
• Ethnicity
• Personal circumstances
• History of stroke or TIA

Modifiable Risk Factors

• The main modifiable risk factors include blood pressure and atherosclerosis
• Hypertension increases the risk of hemorrhagic strokes
• Atherosclerosis increases the risk of ischemic strokes

Warning Signs

• Sudden and severe symptoms are key
• Sudden numbness or weakness, especially on one side of the body
• Sudden confusion or trouble speaking or understanding
• 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: Look for facial drooping
• Arms: Check if the person can raise both arms equally
• Speech: Note any slurred or jumbled speech
• Time: Act quickly, call EMS/9-1-1 immediately

Stroke Recovery: Brunnstrom Stages

• Flaccidity: No voluntary movements can be initiated
• Spasticity: Basic synergy patterns and minimal voluntary movements
• Voluntary Control: Patient gains voluntary control over synergies; spasticity increases
• Out of Synergy: Some movements mastered with synergy patterns; spasticity decreases
• Complex Combinations: Basic synergies lose dominance over motor acts
• Disappearance of Spasticity: Individual joint movements possible, coordination returning
• Normal Function: Function is restored

Brunnstrom Stages of Stroke Recovery

• Flaccidity: muscles are not able to move, and feel limp and floppy
• Spasticity Appears: muscles may begin to tighten reflexively and have difficulty relaxing
• Increased Spasticity: certain muscles tighten more and can be difficult to relax
• Decreased Spasticity: involuntary muscle tightness (spasticity) starts to decrease
• Spasticity Continues to Decrease: the spasticity is minimal, allowing your affected side to move more complexly
• Spasticity Disappears & Coordination Reappears: the muscles may begin to tighten reflexively and have difficulty relaxing

Progression Through Stages

• Progression through stages may not be linear or complete
• Providing a prognosis is difficult
• Many people remain in one of the stages permanently

Brunnstrom Stage & Massage Emphasis

• Stage 1 (Flaccidity): PROM, passive stretching (gentle), position to support the upper limb (shoulder support)
• Stage 2 (Spasticity Appears): Gentle PROM (slow), massage for sensory stimulation
• Stage 3 (Spasticity Increases): Continue techniques, increased emphasis on stress reduction, massage to relax, and may be using splints
• Stage 4 (Spasticity Decreases): Continue techniques, added emphasis on use of recovering limbs with home care, PNF patterning
• Stage 5 (Spasticity Minimal): Continue with above, begin strengthening routine, PNF patterning (RROM)
• Stage 6 (Spasticity Disappears): Continue with above, focus on fine motor skills

Synergy

• Synergy in stroke recovery involves a pattern where a whole series of muscles are recruited when only a few are needed
• Example: Shoulder abducts and elevates and the wrist flexes, when trying to reach forward

Synergy: Upper Limb

• Five upper limb spasticity patterns
• All five upper limb patterns could be combined with any spastic hand and finger position

Assessment

• Palpation, postural assessment
• ROM
• Sensory testing

Goals

• Promote relaxation
• Decrease pain
• Addressing postural changes/muscle imbalances
• Decrease edema
• Decrease spasticity
• Maintain joint health
• Full body integration

Treatment Planning and Rationale

• Relaxation and stress management are important because stress worsens spasticity
• PROM and stretching are important to prevent neglect of the affected limb, maintain sensory mapping, and prevent contracture formation
• Lowering the tone of spastic or overused muscles is important to decrease contracture formation
• Decreasing edema promotes tissue health
• Stimulating muscles outside of synergy patterns or opposite to spasticity
• PROM and joint play for joint health
• Full body integration for overall wellbeing