Hemiparesis

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]
 Hemiparesis
Specialty Neurology

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 weaknesses 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.[5] Rehabilitation may
take longer in patients that display pusher
behaviour. The Copenhagen Stroke Study
found that patients that presented with
ipsilateral pushing used 3.6 weeks more to
reach the same functional outcome level
on the Barthel Index, than did patients
without ipsilateral pushing.[5]
Pushing behavior has shown that
perception of body posture in relation to
gravity is altered. Patients experience their
body as oriented "upright" when the body
is actually tilted to the side of the brain
lesion. In addition, patients seem to show
no disturbed processing of visual and
vestibular inputs when determining
subjective visual vertical. In sitting, the
push presents as a strong lateral lean
toward the affected side and in standing,
creates a highly unstable situation as the
patient is unable to support their body
weight on the weakened lower extremity.
The increased risk of falls must be
addressed with therapy to correct their
altered perception of vertical.

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]
Karnath[2] summarizes these two
conflicting views, as they conclude that
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. However, the article
goes on to state that it is imperative to
note that both neglect and aphasia are not
the underlying causes of pusher
syndrome.

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 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 suffered
from 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. 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.

The incidence of hemiplegia is much

higher in premature babies than term
babies. There is also a high incidence of
hemiplegia during pregnancy and experts
believe that this may be related to either a
traumatic delivery, use of forceps or some
event which causes brain injury.[10] There
is tentative evidence of an association
with undiagnosed celiac disease and
improvement after withdrawal of gluten
from the diet.[11]
Other causes of hemiplegia in adults
include trauma, bleeding, brain infections
and cancers. Individuals who have
uncontrolled diabetes, hypertension or
those who smoke have a higher chance of
developing a stroke. Weakness on one
side of the face may occur and may be
due to a viral infection, stroke or a
cancer.[12]

Common

Vascular: cerebral hemorrhage, stroke

Infective: encephalitis, meningitis, brain
abscess, spinal epidural abscess
Neoplastic: glioma, meningioma, brain
tumors, spinal cord tumors
Demyelination: multiple sclerosis,
disseminated sclerosis, ADEM,
neuromyelitis optica
Traumatic: cerebral lacerations,
subdural hematoma, epidural
hematoma, vertebral compression
fracture
Iatrogenic: local anaesthetic injections
given intra-arterially rapidly, instead of
given in a nerve branch.
Ictal: seizure, 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 pyramidal (or
corticospinal) tract, a pathway of neurons
that begins in the motor areas of the brain,
projects down through the internal
capsule, continues through the brainstem,
decussates (or cross midline) at the lower
medulla, then travels down the spinal cord
into the motor neurons that control each
muscle. In addition to this main pathway,
there are smaller contributing pathways
(including the anterior corticospinal tract),
some portions of which do not cross the
midline.

Because of this anatomy, injuries to the

pyramidal tract above the medulla
generally cause contralateral hemiparesis
(weakness on the opposite side as the
injury). Injuries at the lower medulla, spinal
cord, and peripheral nerves result in
ipsilateral hemiparesis.

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.
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 physiotherapist or doctor.
Radiological studies like a CT scan or
magnetic resonance imaging of the brain
should be used to confirm injury in the
brain and spinal cord, but alone cannot be
used to identify movement disorders.
Individuals who develop seizures may
undergo tests to determine where the
focus of excess electrical activity is.[18]

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
physiotherapists and other health care
professionals for use in the ongoing
evaluation of the status of a patient’s
hemiplegia. The use of standardized
assessment scales may help
physiotherapists and other health care
professionals during the course of their
treatment plant 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 Fugl-Meyer Assessment of

sensorimotor function (FMA)[20]

The FMA is often used as a measure of

functional or physical impairment
following a cerebrovascular accident
(CVA).[21] It measures sensory and motor
impairment of the upper and lower
extremities, balance in several positions,
range of motion, and pain. This test is a
reliable and valid measure in measuring
post-stroke impairments related to stroke
recovery. A lower score in each
component of the test indicates higher
impairment and a lower functional level for
that area. The maximum score for each
component is 66 for the upper extremities,
34 for the lower extremities, and 14 for
balance. [22] Administration of the FMA
should be done after reviewing a training
manual.[23]

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.[1] Health care
professionals such as physical therapists
and occupational therapists play a large
role in assisting these patients in their
recovery. Treatment is focused on
improving sensation and motor abilities,
allowing the patient to better manage their
activities of daily living. Some strategies
used for treatment include promoting the
use of the hemiparetic limb during
functional tasks, maintaining range of
motion, and using neuromuscular
electrical stimulation to decrease
spasticity and increase awareness of the
limb.

At the more advanced level, using

constraint-induced movement therapy will
encourage overall function and use of the
affected limb.[29] Mirror Therapy (MT) has
also been used early in stroke
rehabilitation and involves using the
unaffected limb to stimulate motor
function of the hemiparetic limb. Results
from a study on patients with severe
hemiparesis concluded that MT was
successful in improving motor and
sensory function of the distal hemiparetic
upper limb.[30] Active participation is
critical to the motor learning and recovery
process, therefore it’s important to keep
these individuals motivated so they can
make continual improvements.[31]
Also speech pathologists work to increase
function for people with hemiparesis.

Treatment should be based on

assessment by the relevant health
professionals, including physiotherapists,
doctors and occupational therapists.
Muscles with severe motor impairment
including weakness need these therapists
to assist them with specific exercise, and
are likely to require help to do this.[32]

Medication

Drugs can be used to treat issues related

to the Upper Motor Neuron Syndrome.
Drugs like Librium or Valium could be used
as a relaxant. Drugs are also given to
individuals who have recurrent seizures,
which may be a separate but related
problem after brain injury.[33]

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.

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.[34]
Physiotherapists can also help reduce
shoulder pain by maintaining shoulder
range of motion, as well as using
Functional electrical stimulation.[35]
Supportive devices, such as braces or
slings, can be used to help prevent or treat
shoulder subluxation[36] in the hopes to
minimize disability and pain. Although
many individuals suffering from stroke
experience both shoulder pain and
shoulder subluxation, the two are mutually
exclusive.[37] 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.[38]

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.

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 (HMWPE,)
carbon fiber; etc) and design may be
changed to address many different
conditions.

and range from the level of ankle to the hip

depending on the level of intervention,
support, or control needed.,

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.[39]

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.[39]

Popular culture
In Barbara Kingsolver's novel, The
Poisonwood Bible, the character Adah is
incorrectly diagnosed, in childhood, as
having hemiplegia.[40][41]
Rock band HAERTS released an EP
called Hemiplegia via Columbia Records
in 2013.[42]
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
hemiplegic migraine
laryngeal paralysis
Paraplegia
Brunnstrom Approach
Paresis

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External links
Classification ICD-10: G81.9 • D

ICD-9-CM: 342.9 ,
094.89 , 438.2 •
MeSH: D006429

Wrong Diagnosis.com General

Hemiplegia Info, Tools & Discussion
 Boards
Chedoke-McMaster Stroke Assessment
[3] Constraint-Induced Movement
Therapy Is Effective In Rehabilitating
Stroke Patients

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