It Is a Problem of the Central Nervous System

Handicap international- Pakistan 2006

HEMIPLEGIA

What is it?

It is a problem of the central nervous system.

Hemiplegia is perturbation of controlled movement and decreased feeling in one side of the body. Perturbation of controlled movement can mean: no movement (flaccid hemiplegia) or unwanted/extra movement (spastic hemiplegia).

It is due to a damage of one side of the brain. If it is on the left side, we have a right hemiplegia and if it is on the right side we have a left hemiplegia.

Causes:

Trauma: direct choc on the head

Circulation problem:

Atherosclerosis (decreased circulation): blood travel is blocked; oxygen cannot go to a part of the brain.

Hemorrhagia: too much blood inside the head is making a brain compression and it makes a necrosis.

Disease

Stages of hemiplegia:

There are 3 stages:

-Flaccid stage: no movement.

-Spastic stage: uncontrolled and/or extra movements.

-Recovery stage: controlled movements are coming back.

All hemiplegic patients have first a flaccid hemiplegia. Some are staying at that stage for ever, and some other are evolving to spastic or recovery stage. Spastic hemiplegics can stay spastic or recover.

1- Flaccid stage:

The brain makes, sends and receives messages. If there is a damage toa part of the brain, this area will stop working. This damaged area cannot make messages for a part of the body, send messages to a part of the body, and receive messages from a part of the body.

Just after the brain damage, muscles on one side of the body do not make movement. This can include the muscles of the face, tongue, trunk, upper limb and lower limb.

Some patients will describe a flaccid limb as a dead limb.

This stage can last hours, days, weeks or months and sometimes life.

2- Spastic stage:

After flaccid stage some patients may begin to have uncontrolled and increased movements in leg and arm. This is called spasticity. It generally appears on the strongest muscles. This is because a special part of the brain wants only to send messages to the muscles all the time to tell them to work. They are receiving to much informations.

Generally spastic muscles are:

For upper limb:

-Shoulder: adduction and internal rotation;

-Elbow: flexion and pronation;

-Wrist: flexion;

-Fingers and thumb: flexion and adduction.

For lower limb:

-Hip: extension or flexion, internal rotation, adduction;

-Knee: extension or flexion;

-Ankle: plantar flexion;

-Foot: inversion;

-Toes: flexion.

3- Recovery stage:

The patient has relearned how to make individual movements and the brain has been retrained on how to control different movements.

For some patients, this never happens. They stay at the flaccid or spastic stage forever.

Most of the recovery happens in the 2 first years after the brain injury. If the patient is still at the flaccid stage after 6 months, he might stay flaccid for life.

Why do patients recover?

1-Cerebral plasticity theory: areas which are close to the brain area injured may try to help and do some of the work.

2-Some areas that had only small injury may recover to normal function. Through practice and retraining the patient may be able to control some of spasticity muscles.

Associated problems:

In addition to problems with motricity and sensibility, the hemiplegic patient may also have problems with:

-Speaking (right hemiplegia) but the patient understands

-Knowing one side of the body: hemi-negligence (left hemiplegia)

-Following directions: spatial and temporal troubles: give simple orders

-Controlling emotions

Rehabilitation:

It is important to consider the patient in is whole entity. You are treating a person and not a leg or arm.

Remember, weakness is not the problem. The patient has to learn how to control movement, strengthen muscles does not help the patient.

1- Flaccid stage

-Good positioning:

To keep the joints in a good position, avoid spasticity, support the joints that flaccid muscles cannot support (especially the shoulder) and encourage the patient to look on the hemiplegic side.

-Orient the patient to the hemiplegic side of the body:

The patient’s family must help the patient by encouraging him to look at the hemiplegic side, touch it and use it together with the other side of the body.

-Maintain ROM:

Be careful, stay in physiological ROM especially if the patient does not have sensibility. The patient also has to learn how to make upper limb mobilisation alone.

-Practice functional movements:

The patient should be independent as quick as possible by using the hemiplegic side.

-Balance exercises:

To help the patient increase the trunk control and use both sides of the body together

-Stimulate movements not expected in future spastic muscles:

The patient has to relearn how to move.

-Provide devices:

Especially a wheelchair.

2- Spastic stage

Not all body parts are in the same stage at the same time.

To all the precedents therapies we add:

-Decrease spasticity:

Cf spasticity training

-Weight bearing on hemiplegic side:

It helps giving the joints more information and help them to relearn positions

-Preparation for walking.

-Independencein eating and dressing.

3- Recovery stage:

Continue all appropriate activities from flaccid and spastic stage.

You will start:

-Walking activities.

-Equipments needs.

-House adaptations.

-Community integration.

REMEMBER THAT EVERY HEMIPLEGIC PATIENT IS DIFFERENT.

WORK ON COMMAND AND FUNCTION; RELEARNIG AND CONTROLLING MOVEMENT ARE THE GOAL;

DON’T GIVE UP IT’S NOT SO DIFFICULT