Crossed Hemiplegia; Causes, Symptoms, Treatment

Occupational therapy

• Occupational therapy – Occupational Therapists may specifically help with hemiplegia with tasks such as improving hand function, strengthening the 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.

Rehabilitation & Therapy for Hemiplegia

1. Improving motor control

a. Neurofacilitatory Techniques

In Stroke Physical Therapy these therapeutic interventions use sensory stimuli (e.g. quick stretch, brushing, reflex stimulation, and associated reactions), which are based on neurological theories, to facilitate movement in patients following stroke. The following are the different approaches

• Bobath Concept- Berta & Karel Bobath’s approach focuses to control responses from the damaged postural reflex mechanisms. Emphasis is placed on affected inputs facilitation and normal movement patterns (Bobath, 1990).
• ii.Brunnstrom – Brunnstrom approach is one form of neurological exercise therapy in the rehabilitation of stroke patients. The relative effectiveness of Neuro-developmental treatment versus the Brunnstrom method was studied by Wagenaar and colleagues from the perspective of the functional recovery of stroke patients. The result of this study showed no clear differences in the effectiveness of the two methods within the framework of functional recovery.
• iii.Rood – Emphasise the use of activities in developmental sequences, sensation stimulation, and muscle work classification. Cutaneous stimuli such as icing, tapping, and brushing are employed to facilitate activities.
• iv. Proprioceptive neuromuscular facilitation (PNF) – Developed by Knott and Voss, they advocated the use of peripheral inputs as stretch and resisted movement to reinforce existing motor response. Total patterns of movement are used in the treatment and are followed in a developmental sequence.

b. Learning theory approach

• i. Conductive education – In Stroke Physical Therapy, Conductive education is one of the methods in treating neurological conditions including hemiplegic patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach using the concept of CE for adult hemiplegia. The patient is taught how to guide his movements towards each task-part of the task by using his own speech – rhythmical intention.
• ii. Motor relearning theory – Carr & Shepherd, both are Australian physiotherapists, developed this approach in 1980. It emphasizes the practice of functional tasks and the importance of relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and tasks are important. There is no evidence adequately supporting the superiority of one type of exercise approach over another. However, the aim of the therapeutic approach is to increase physical independence and to facilitate the motor control of skill acquisition and there is strong evidence to support the effect of rehabilitation in terms of improved functional independence and reduced mortality.

c. Functional electrical stimulation (FES) 

• FES is a modality that applied a short burst of electrical current to the hemiplegic muscle or nerve. In Stroke Physical Therapy, FES has been demonstrated to be beneficial to restore motor control, spasticity, and reduction of hemiplegic shoulder pain and subluxation.  A recent meta-analysis of the randomized controlled trial study showed that FES improves motor strength. A study by Faghri has identified that FES can significantly improve arm function, electromyographic activity of posterior deltoid, the range of motion and reduction of severity of subluxation and pain of the hemiplegic shoulder.

d. Biofeedback

• Biofeedback is a modality that facilitates the cognizant of electromyographic activity in selected muscle or awareness of joint position sense via visual or auditory cues. In Stroke Physical Therapy the result of studies in biofeedback is controversial. A meta-analysis of 8 randomized controlled trials of biofeedback therapy demonstrated that electromyographic biofeedback could improve motor function in stroke patients.
• A conflicting meta-analysis study by showing that biofeedback was not efficacious in improving the range of motion in the ankle and shoulder in a stroke patient. Moreland conducted another meta-analysis that concluded that EMG biofeedback alone or with conventional therapy did not superior to conventional physical therapy in improving upper- extremity function in the adult stroke patient.

2. Hemiplegic shoulder management

Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after stroke, whereas subluxation is found in 80% of stroke patients. It is associated with the severity of the disability and is common in patients in rehabilitation settings. Suggested interventions are as follows:

• a. Exercise – Active weight-bearing exercise can be used as a means of improving motor control of the affected arm; introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and pain. In Stroke Physical Therapy, Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles while simultaneously facilitating muscles that are not active (Donatelli, 1991). According to Robert (1992), the amount of shoulder pain in hemiplegia was related most to loss of motion. He advocated that the provision of ROM exercise (caution to avoid improvement) as treatment as early as possible.
• b. Functional electrical stimulation – Functional electrical stimulation (FES) is an increasingly popular treatment for hemiplegic stroke patients. It has been applied in stroke physical therapy for the treatment of shoulder subluxation spasticity and functionally, for the restoration of function in the upper and lower limb. In Stroke Physical Therapy, Electrical stimulation is effective in reducing pain and severity of subluxation, and possibly in facilitating recovery of arm function
• c. Positioning & proper handling – In Stroke Physical Therapy, proper positioning and handling of the hemiplegic shoulder, whenever in bed, sitting and standing or during lifting, can prevent shoulder injury is recommended in the AHCPR & SIGN guidelines for stroke rehabilitation. In Stroke Physical Therapy, positioning can be therapeutic for tone control and neuro-facilitation of stroke patients (Davies, 1991). Braus et al 94 found shoulder hand syndrome reduced from 27% to 8% by the instruction to everyone including family on handling technique.
• d. Neuro-facilitation
• e. Passive limb physiotherapy – Maintenance of a full pain-free range of movement without traumatizing the joint and the structures can be carried out. In Stroke Physical Therapy, at no time should pain in or around the shoulder joint be produced during treatment.
• f. Pain relief physiotherapy – Passive mobilization as described by Maitland can be useful in gaining relief of pain and range of movement. In Stroke Physical Therapy other treatment modalities such as thermal, electrical, cryotherapy, etc. can be applied for shoulder pains or musculoskeletal in nature.
• g. Reciprocal pulley – The use of reciprocal pulley appears to increase the risk of developing shoulder pain in stroke patients. It is not related to the presence of subluxation or to muscle strength.
• h. Sling – In Stroke Physical Therapy the use of a sling is controversial. No shoulder support will correct a glenohumeral joint subluxation. However, it may prevent the flaccid arm from hanging against the body during functional activities, thus decreasing shoulder joint pain. They also help to relieve downward traction on the shoulder capsule caused by the weight of the arm.

3. Limb physiotherapy

• Limb physiotherapy/Stroke Physical Therapy includes passive, assisted-active and active range-of-motion exercise for the hemiplegic limbs. This can be effective management for the prevention of limb contractures and spasticity and is recommended within AHCPR. Self-assisted limb exercise is effective for reducing spasticity and shoulder protection. Adams and coworkers recommended passive full-range-of-motion exercise for a paralyzed limb for potential reduction of complication for stroke patients

4. Chest physiotherapy

• In Stroke Physical Therapy, evidence shows that both cough and forced expiratory technique (FET) can eliminate induced radio aerosol particles in the lung field. Directed coughing and FET can be used as a technique for bronchial hygiene clearance in stroke patients.

5. Positioning

• In Stroke, Physical Therapy consistent “reflex-inhibitory” patterns of posture in resting is encouraged to discourage physical complication of stroke and to improve recovery (Bobath, 1990).
• Meanwhile, therapeutic positioning is a widely advocated strategy to discourage the development of abnormal tone, contractures, pain, and respiratory complications. It is an important element in maximizing the patient’s functional gains and quality of life.

6. Tone management

• A goal of Stroke Physical Therapy interventions has been to “normalize tone to normalize movement.” Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by therapists, weight-bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting.
• Research on tone-reducing techniques has been hampered by the inadequacies of methods to measure spasticity and the uncertainty about the relationship between spasticity and volitional motor control.
• The manual stretch of finger muscles, pressure splints, and dantrolene sodium do not produce apparent long-term improvement in motor control. Dorsal resting hand splints reduced spasticity more than volar splints, but the effect on motor control is uncertain while TENS stimulation showed improvement for chronic spasticity of lower extremities.

7. Sensory re-education

• Bobath and other therapy approaches recommend the use of sensory stimulation to promote the sensory recovery of stroke patients.

8. Balance retraining

• Re-establishment of balance function in patients following stroke has been advocated as an essential component in the practice of stroke physical therapy. Some studies of patients with hemiparesis revealed that these patients have a greater amount of postural sway, the asymmetry with greater weight on the non-paretic leg, and a decreased ability to move within a weight-bearing posture. Meanwhile, research has demonstrated moderate relationships between balance function and parameters such as gait speed, independence, wheelchair mobility, reaching, as well as dressing. Some tenable support on the effectiveness of treatment of disturbed balance can be found in studies comparing the effects of balance retraining plus physiotherapy treatment and physiotherapy treatment alone.

9. Fall prevention

• In Stroke Physical Therapy, falls are one of the most frequent complications and the consequences of which are likely to have a negative effect on the rehabilitation process and its outcome.
• According to the systematic review of the Cochrane Library, which evaluated the effectiveness of several fall prevention interventions in the elderly, there was significant protection against falling from interventions that targeted multiple, identified, risk factors in individual patients. The same is true for interventions which focused on behavioral interventions targeting environmental hazards plus other risk factors

10. Gait re-education

• Recovery of independent mobility is an important goal for the immobile patient, and much therapy is devoted to gait-reeducation. Bobath assumes abnormal postural reflex activity is caused by dysfunction so gait training involved tone normalization and preparatory activity for gait activity.
• In contrast, Carr and Shepherd advocate task-related training with methods to increase strength, coordination and flexible MS system to develop skill in walking while Treadmill training combined with the use of a suspension tube. Some patient’s body weight can effective in regaining walking ability when used as an adjunct to convention therapy 3 months after active training.

11. Functional Mobility Training

• To handle the functional limitations of stroke patients, functional tasks are taught to them based on movement analysis principles. In Stroke Physical Therapy these tasks include bridging, rolling to sit to stand and vice versa, transfer skills, walking and staring, etc.
• Published studies report that many patients improve during rehabilitation. The strongest evidence of benefit is from studies that have enrolled patients with chronic deficits or have included a no-treatment control group.
• Meanwhile, early mobilization helps prevent compilations e.g. DVT, skin breakdown contracture and pneumonia. Evidence has shown better orthostatic tolerance and earlier ambulation.

12. Upper limb training

By 3 months poststroke, approximately 37% of the individuals continue to have decreased upper extremities (UE) function. Recovery of UE function lags behind that of the lower extremities because of the more complex motor skill required of the UE in daily life tasks. That means many individuals who have a stroke are at risk for a lowered quality of life. Many approaches to the physical rehabilitation of adults post-stroke exist that attempt to maximize motor skill recovery. However, the literature does not support the efficacy of any single approach. The followings are the current approaches to motor rehabilitation of the UE.

• a. Facilitation models – They are the most common methods of intervention for the deficits in UE motor skills including Bobath, proprioceptive neuromuscular facilitation, Brunnstrom’s movement therapy, and Rood’s sensorimotor approach. There is some evidence that practice based on the facilitation models can result in improved motor control of UE. However, an intervention based on the facilitation models has not been effective in restoring the fine hand coordination required for the performance of actions.
• b. Functional electric stimulation – In Stroke Physical Therapy, Functional electric stimulation (FES) can be effective in increasing the electric activity of muscles or increased active range of motion in individuals with stroke. Some evidence showed that FES may be more effective than facilitation approaches.
• c. Electromyographic biofeedback – In Stroke Physical Therapy, biofeedback can contribute to improvements in motor control at the neuromuscular and movement levels. Some studies have shown improvements in the ability to perform actions during post-testing after biofeedback training. However, the ability to generalize these skills and incorporate them into daily life is not measured.
• d. Constraint-induced therapy – Constraint-Induced (CI) therapy was designed to overcome the learned nonuse of the affected UE. In the most extreme form of CI therapy, individual post-stroke is prevented from using the less affected UE by keeping it in a splint and sling for at least 90% of their waking hours. Studies have found that the most extreme of CI therapy can effect rapid improvement in UE motor skill and that is retained for at least as long as 2 years. However, CI therapy currently is effective only in those with distal voluntary movement.

13. Mobility appliances and equipment

• Small changes in an individual’s local ‘environment’ can greatly increase independence, use of a wheelchair or walking stick. However, little research has been done for these ‘treatments’. It is acknowledged that walking aids and mobility appliances may benefit selected patients.

14. Acupuncture 

• The World Health Organisation (WHO) has listed acupuncture as a possible treatment for pariesis after stroke. Studies had sown its beneficial effects on stroke rehabilitation.
• Hua had reported a significant difference in changes of neurological score between the acupuncture group and the control group after 4 weeks of treatment in an RCT and no adverse effects were observed in patients treated with acupuncture.

15. Vasomotor training 

• Early stimulation of the muscle pump can reduce the venous stasis and enhance the general circulation of the body. It then hastens the recovery process.

16. Edema management

• Use of intermittent pneumatic pump, elastic stocking or bandages and massage can facilitate the venous return of the oedematous limbs. Therefore, the elasticity and flexibility of the musculoskeletal system can be maintained and enhance the recovery process and prevent complications like pressure ulcers.

Homeopathic Medicines for Hemiplegia