Hemiplegia

What is Hemiplegia?

Hemiplegia (hemi = half; plegia = paralysis), as the name suggests, literally means paralysis of half of the body. If there is muscle weakness without paralysis, it is termed hemiparesis. Therefore, hemiplegia affects only one side of the body, usually affecting the arms and legs, but sometimes the symptoms can also involve the torso. Hemiplegia can occur suddenly, or develop slowly.

Spastic hemiplegia is a type of hemiplegia that causes muscle contractures, which results in loss of muscle control, chronic muscle pain, and aberrant movements. Hemiplegia is often associated with brain damage or head injury. Similar to other forms of paralysis, hemiplegia exhibits significant loss of sensation and control in the affected parts of the body, which is often accompanied by intermittent pain.

Relation of Brain Anatomy with Hemiplegia

• The brain is divided into two cerebral hemispheres, joined along the midline by a band of fibers that bind the two sides together. This structure, which functions like a glue, is known as the corpus callosum.
• It should be noted that one side of the brain is responsible for the movements of the opposite side of the body. Thus, the left side of the brain controls the right side of the body and vice versa.
• Therefore, if the left side of the brain is damaged, the right side of the body will be paralyzed, on in other words, hemiplegia will be on the right (opposite or contralateral)-half of the body.

What are the Causes of Hemiplegia?

There may be multiple causes for hemiplegia. The cause of congenital hemiplegia remains unclear. The major causes of acquired hemiplegia are briefly discussed below:

• Brain Injury: Traumatic brain injury on one side of the brain can give rise to hemiplegia on the other side of the body. Brain injury can occur from road accidents, falls, violence, as well as other causes. The types of brain injuries that can occur include cerebral lacerations, subdural/epidural hematoma, and compression fractures in the vertebral column.
• Stroke: Hemiplegia can occur as a result of stroke, which is technically termed as cerebrovascular accident (CVA). Other causes include transient ischemic attack (TIA), commonly known as mini-strokes. Stroke is the most common cause of hemiplegia.
• Aneurysms and Hemorrhage: The development of a brain aneurysm (weakening and bulge of the arterial wall) can be fatal, especially if it bursts. Moreover, brain hemorrhage can be equally devastating. Both these conditions can cause hemiplegia. Hemorrhage can also occur in newborns. This type of hemorrhage is termed intraventricular hemorrhage of the newborn (IVH).
• Infections: Brain infections such as meningitis and encephalitis are very serious and if untreated, can result in hemiplegia, among other complications. Other causes include brain abscess and spinal epidural abscess.
• Brown-Séquard Syndrome: This is a specific type of spinal cord injury that is named after Charles-Édouard Brown-Séquard who first described the condition in 1850. It is caused by damage to one half of the spinal cord, resulting in paralysis and loss of proprioception on the same (ipsilateral) side as the lesion, and loss of pain and temperature sensation on the opposite (contralateral) side as the lesion.
• Demyelinating Diseases: Diseases that give rise to demyelination in the brain can cause hemiplegia. Some examples of these diseases include multiple sclerosis acute necrotizing myelitis, disseminated sclerosis, and acute disseminated encephalomyelitis (ADEM).
• Brain Cancers: Various types of cancers of the brain, including glioma, astrocytoma, CNS lymphoma, meningioma, and spinal cord tumors can damage the brain, resulting in hemiplegia.
• Degenerative Diseases: Various forms of degenerative diseases can destroy the neurons in the brain, as well as at various levels of the spinal. Some of these diseases include amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease, corticobasal degeneration, and Parkinson’s disease.
• Congenital Diseases: These include cerebral palsy and neonatal-onset multisystem inflammatory disease (NOMID). Importantly, cerebral palsy can be caused by forceps delivery.

What are the Symptoms and Signs of Hemiplegia?

There are several symptoms and signs associated with hemiplegia. The major ones are highlighted below:

• Loss of Motor Functions: Loss of motor skills lead to clumsy movements and difficulty in performing everyday tasks. The affected side cannot be moved, or moved with great difficulty. As a result, walking becomes a problem, often characterized by staggering or stumbling. Another characteristic feature is that the fist on the affected side remains clenched. Damage to the brain stem leads to a condition called ataxia, which is characterized by loss of both gross and fine motor skills.
• Loss of Sensation: Sensation can be lost on one side of the body, which may be total or partial loss of sensation. In case of partial loss of sensation, there may be unusual sensations or tingling on the affected side.

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• Mental Aberrations: These can be characterized by changes in cognition, mood, and perception.
• Seizures & Muscle Spasm: Seizures and spastic attacks can severely debilitate the hemiplegic patient. Seizures and chronic muscle spasm can be extremely painful for the patient.
• Pusher Syndrome: This syndrome arises from traumatic brain injuries and causes a person with hemiplegia to shift their weight to the affected side. This greatly hinders motor skills, making it painful and difficult for the patient to walk. Pusher syndrome is evaluated by three scales for accurately determining the prognosis, in addition to identifying the cause of symptoms. These scales include the following:
• Clinical Scale of Contraversive Pushing
• Modified Scale of Contraversive Pushing
• Burke Lateropulsion Scale
• Speech and Associated Problems: The hemiplegic patient can face difficulty in speaking, often manifesting as slurred speech. This is also accompanied by swallowing and breathing difficulties.

How do you Diagnose Hemiplegia?

Diagnosis of hemiplegia can be based upon

• Clinical evaluation and physical examination to test muscle strength and sensation. These will enable the doctor to clinically diagnose the patient.

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However, in order to pinpoint the exact cause of the hemiplegia, some other tests may also be ordered. These are briefly highlighted below:

• Blood Tests: These tests can include a complete blood count (CBC), hemoglobin (Hb) level, erythrocyte sedimentation rate (ESR), as well as other tests for blood biochemistry. These can establish various underlying causes, such as infection, blood disorders, hemoglobinopathies, and cancer, among others.
• Computed Tomography (CT) Scan: This is a powerful, non-invasive, imaging procedure that combines X-rays with computer technology and allows pictures to be taken from many angles of the brain. The images are presented as slices at all levels of the brain. A comprehensive CT scan of the brain can accurately diagnose any structural abnormalities such as brain tumors, aneurysms, vasculitis and any brain injuries.
• Magnetic Resonance Imaging (MRI): This is an extremely accurate non-invasive and highly sensitive procedure that uses electromagnetic waves to obtain detailed images of the tissues. MRI can accurately identify any abnormalities in the brain. Like CT scans, MRI also uses a computer interface to generate the images. The difference between the two is that the former uses X-rays, while the latter uses a magnetic field and no radioactivity is involved.
• Electroencephalography (EEG): An EEG can be used for diagnostic purposes by measuring the electrical activity of the brain. Any abnormalities in the brain can be detected by corresponding changes in the EEG pattern. Importantly, EEG is particularly useful for locating the origin of seizures in the brain by analyzing the electrical activity.

How do you Treat Hemiplegia?

Treatment of hemiplegia involves a multi-pronged approach. Besides doctors, the role of physical therapists and occupational therapists is vital for regaining functionality of the hemiplegic patient. Treatment aims at improving sensation and motor abilities, so that the patient can perform the daily activities and be as independent as much as possible. Some of the major strategies that can be adopted for treating patients with hemiplegia include the following:

• Medicines: Medicines can be used for treating symptoms as well as underlying causes. For example, drugs are used for treating upper motor neuron syndrome. Librium can be administered to relax the patient. Other drugs are used to treat recurrent seizures following brain injury. Antibiotics are used to treat any brain infections. Blood thinners such as warfarin or heparin can be administered to clear any blood clots and prevent strokes.
• Neuromuscular electrical stimulation (NMES): This uses high-intensity electrical stimulation to maintain size and functionality of the muscles. Importantly, this can appreciably decrease spasticity and increase the awareness of the existence of the limbs.
• Surgery: Surgery mainly focuses on treatment of secondary issues. These include involuntary muscle contractions, spinal damage, contractures, or damage to the ligaments or tendons. For example, in case of contractures, the surgeon usually cuts the ligaments for relieving the tension. Surgery can also be used to treat aneurysms as well as to remove any blockages in the blood vessels of the brain.
• Alternative Medicine: Alternative medicines such as Chinese Medicine (acupuncture) and Unani medicine have been reported to be effective for the treatment of hemiplegia caused by stroke.

Rehabilitation of the Patient

Intensive physical therapy coupled with occupational therapy is the mainstay of the rehabilitation program.

• Physical Therapy: Exercises carried out under the supervision of an experienced physiotherapist can appreciably improve muscle strength, muscle coordination as well as increase the mobility, which helps the patient to walk. Assistive devices like walkers, prosthetics and orthotics such as braces, slings, and splints can help with spasticity and gait. For immobile patients, wheelchairs are used to enable mobility.
• Occupational Therapy: The main goal of occupational therapy is to instill a sense of independence in order to carry out everyday tasks like dressing, eating, brushing teeth and grooming. Occupational therapists help to increase the mobility of the affected hand and increase strength of the muscles of the shoulder and back. Occupational therapists also give advice regarding support groups, family education, and advocacy to the parents and family.
• Psychotherapy: This is an important aspect of the rehabilitation process, particularly in case of traumatic head injury patients. This helps in coping with the psychological effects of severe injury and associated disability.

How do you Prevent Hemiplegia?

There are limited measures that can be adopted for prevention of hemiplegia. Hemiplegia due to cerebral palsy is non-progressive and doesn’t deteriorate with time. However, other causes such as alternating hemiplegia can have serious consequences due to repeated attacks. A few tips for preventing these recurring attacks include the following:

• All recurrent attacks of alternating hemiplegia have specific triggers, such as exposure to high and cold temperatures, mental stress, physical fatigue, and respiratory tract infections. Identifying these triggers and avoiding them can go a long way in preventing the long-term sequelae of these attacks.
• It has been found that flunarizine, a calcium channel blocker, can prevent the occurrence of recurrent attacks of alternating hemiplegia.