Hemiparesis
Hemiparesis | |
---|---|
Specialty | Neurology |
Symptoms | Loss of motor skills on one side of body |
Causes | Stroke |
Hemiparesis, or unilateral paresis, is weakness of one entire side of the body (hemi- means "half"). Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke.[1]
Signs and symptoms
Depending on the type of hemiparesis diagnosed, different bodily functions can be affected. Some effects are expected (e.g., partial paralysis of a limb on the affected side). Other impairments, though, can at first seem completely non-related to the limb weakness but are, in fact, a direct result of the damage to the affected side of the brain.[1]
Loss of motor skills
People with hemiparesis often have difficulties maintaining their balance due to limb paralysis leading to an inability to properly shift body weight. This makes performing everyday activities such as dressing, eating, grabbing objects, or using the bathroom more difficult. Hemiparesis with origin in the lower section of the brain creates a condition known as ataxia, a loss of both gross and fine motor skills, often manifesting as staggering and stumbling. Pure Motor Hemiparesis, a form of hemiparesis characterized by sided weakness in the leg, arm, and face, is the most commonly diagnosed form of hemiparesis.[1]
Pusher syndrome
Pusher syndrome is a clinical disorder following left or right brain damage in which patients actively push their weight away from the nonhemiparetic side to the hemiparetic side. In contrast to most stroke patients, who typically prefer more weight-bearing on their nonhemiparetic side, this abnormal condition can vary in severity and leads to a loss of postural balance.[2] The lesion involved in this syndrome is thought to be in the posterior thalamus on either side, or multiple areas of the right cerebral hemisphere.[3][4]
With a diagnosis of pusher behaviour, three important variables should be seen, the most obvious of which is spontaneous body posture of a longitudinal tilt of the torso toward the paretic side of the body occurring on a regular basis and not only on occasion. The use of the nonparetic extremities to create the pathological lateral tilt of the body axis is another sign to be noted when diagnosing for pusher behaviour. This includes abduction and extension of the extremities of the non-affected side, to help in the push toward the affected (paretic) side. The third variable that is seen is that attempts of the therapist to correct the pusher posture by aiming to realign them to upright posture are resisted by the patient.[2]
In patients with acute stroke and hemiparesis, the disorder is present in 10.4% of patients.
Pushing behavior has shown that perception of body
Pusher syndrome is sometimes confused with and used interchangeably as the term hemispatial neglect, and some previous theories suggest that neglect leads to pusher syndrome.[2] However, another study had observed that pusher syndrome is also present in patients with left hemisphere lesions, leading to aphasia, providing a stark contrast to what was previously believed regarding hemispatial neglect, which mostly occurs with a right hemisphere lesion.[6]
Although both neglect and aphasia are highly correlated with pusher syndrome possibly due to the close proximity of relevant brain structures associated with these two respective syndromes, they are not the underlying causes of pusher syndrome.[2]
Physical therapists focus on motor learning strategies when treating these patients. Verbal cues, consistent feedback, practicing correct orientation and weight shifting are all effective strategies used to reduce the effects of this disorder.[7] Having a patient sit with their stronger side next to a wall and instructing them to lean towards the wall is an example of a possible treatment for pusher behaviour.[2]
A new (2003) physical therapy approach for patients with pusher syndrome suggests that the visual control of vertical upright orientation, which is undisturbed in these patients, is the central element of intervention in treatment. In sequential order, treatment is designed for patients to realize their altered perception of vertical, use visual aids for feedback about body orientation, learn the movements necessary to reach proper vertical position, and maintain vertical body position while performing other activities.[2]
Classification of pusher syndrome
Individuals who present with pusher syndrome or lateropulsion, as defined by Davies, vary in their degree and severity of this condition and therefore appropriate measures need to be implemented in order to evaluate the level of "pushing". There has been a shift towards early diagnosis and evaluation of functional status for individuals who have had a stroke and presenting with pusher syndrome in order to decrease the time spent as an in-patient at hospitals and promote the return to function as early as possible.[8] Moreover, in order to assist therapists in the classification of pusher syndrome, specific scales have been developed with validity that coincides with the criteria set out by Davies' definition of "pusher syndrome".[9] In a study by Babyar et al., an examination of such scales helped determine the relevance, practical aspects and clinimetric properties of three specific scales existing today for lateropulsion.[9] The three scales examined were the Clinical Scale of Contraversive Pushing, Modified Scale of Contraversive Pushing, and the Burke Lateropulsion Scale.[9] The results of the study show that reliability for each scale is good; moreover, the Scale of Contraversive Pushing was determined to have acceptable clinimetric properties, and the other two scales addressed more functional positions that will help therapists with clinical decisions and research.[9]
Causes
The most common cause of hemiparesis and 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. A permanent brain injury that occurs during the intrauterine life, during delivery or early in life can lead to hemiplegic cerebral palsy. 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.[citation needed]
The incidence of hemiplegia is much higher in premature babies than term babies. There is also a high incidence of hemiplegia during
Other causes of hemiplegia in adults include
Common
- Vascular: cerebral hemorrhage, stroke, cerebral palsy
- Infective: spinal epidural abscess
- Neoplastic: spinal cord tumors
- Demyelination: neuromyelitis optica
- Traumatic: cerebral lacerations, subdural hematoma, epidural hematoma, cerebral palsy, vertebral compression fracture
- Iatrogenic: local anaesthetic injections given intra-arterially rapidly, instead of given in a nerve branch.
- Ictal: Todd's paralysis
- Congenital: cerebral palsy, Neonatal-Onset Multisystem Inflammatory Disease (NOMID)
- Degenerative: ALS, corticobasal degeneration
- Parasomnia: sleep paralysis[13]
Mechanism
Movement of the body is primarily controlled by the
Because of this anatomy, injuries to the pyramidal tract above the medulla generally cause
In a few cases, lesions above the medulla have resulted in ipsilateral hemiparesis:
- In several reported cases, patients with hemiparesis from an old contralateral brain injury subsequently experienced worsening of their hemiparesis when hit with a second stroke in the ipsilateral brain.[14][15][16] The authors hypothesize that brain reorganization after the initial injury led to more reliance on uncrossed motor pathways, and when these compensatory pathways were damaged by a second stroke, motor function worsened further.[citation needed]
- A case report describes a patient with a congenitally uncrossed pyramidal tract, who developed right-sided hemiparesis after a hemorrhage in the right brain.[17]
Diagnosis
Hemiplegia is identified by clinical examination by a health professional, such as a
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.[19]
Assessment tools
There are a variety of standardized assessment scales available 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
Some of the most commonly used scales in the assessment of hemiplegia are:
The FMA is often used as a measure of functional or physical impairment following a
- The Chedoke-McMaster Stroke Assessment (CMSA)[24]
This test is a reliable measure of two separate components evaluating both motor impairment and disability.[25] 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. A training workshop is recommended if the measure is being utilized for the purpose of data collection.[26]
- The Stroke Rehabilitation Assessment of Movement (STREAM)[27]
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.[28]
Treatment
Treatment for hemiparesis is the same treatment given to those recovering from strokes or brain injuries.
At the more advanced level, using
Also speech pathologists may work to increase function for people with hemiparesis.[34]
Treatment should be based on assessment by the relevant health professionals, including
Medication
Drugs can be used to treat issues related to the Upper Motor Neuron Syndrome. Drugs like
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.[citation needed]
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 (PT) can help improve muscle strength & coordination, mobility (such as standing and walking), and other physical function using different sensorimotor techniques.[40] Physiotherapists can also help reduce shoulder pain by maintaining shoulder range of motion, as well as using Functional electrical stimulation.[41] Supportive devices, such as braces or slings, can be used to help prevent or treat shoulder subluxation[42] in the hopes to minimize disability and pain. Although many individuals with stroke experience both shoulder pain and shoulder subluxation, the two are mutually exclusive.[43] 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.[44]
Occupational therapy
Occupational therapists may specifically help with hemiplegia with tasks such as improving hand function, strengthening hand, shoulder and torso, and participating in activities of daily living (ADLs), such as eating and dressing. Therapists may also recommend a hand splint for active use or for stretching at night. Some therapists actually make the splint; others may measure your child's hand and order a splint. OTs educate patients and family on compensatory techniques to continue participating in daily living, fostering independence for the individual - which may include, environmental modification, use of adaptive equipment, sensory integration, etc.[citation needed]
Orthotic Intervention
Orthotic devices are one type of intervention for relieving symptoms of hemiparesis. Commonly called braces, orthotics range from 'off the shelf' to custom fabricated solutions, but their main goal is alike, to supplement diminished or missing muscle function and joint laxity. A wide range of orthotic treatment can be designed by a Certified Orthotist (C.O.) or Certified Prosthetist Orthotist (C.P.O). Orthotics may be made of metal, plastic, or composite material (such as fiberglass, dyneema (
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.[46]
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.[46]
Popular culture
- In Barbara Kingsolver's novel, The Poisonwood Bible, the character Adah is incorrectly diagnosed, in childhood, as having hemiplegia.[47][48]
- Rock band HAERTS released an EP called Hemiplegia via Columbia Records in 2013.[49]
- In the 1994 Jodie Foster film Nell, the title character portrayed by Foster has developed her own language (idioglossia), developed in part due to the distinct speech patterns of her mother, caused by her hemiplegia due to a stroke.
- In the anime series Mobile Suit Gundam: Iron-Blooded Orphans, the protagonist Mikazuki Augus is paralyzed in the entire right half of his body after a fierce battle with the Mobile Armor Hashmal. In order to defeat the Mobile Armor, he was forced to deactivate the safety limiter on his Gundam's neural interface and overloading the connection between him and the Mobile Suit for the necessary power.
See also
- Alternating hemiplegia
- Brunnstrom Approach
- Hemiplegic migraine
- Laryngeal paralysis
- Paraplegia
- Paresis
References
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- ^ "HAERTS Announce Debut EP Hemiplegia, Out 9/17 on Columbia Records". broadwayworld.com. 2013-08-08. Retrieved 2013-10-19.