Hemiparesis and hemiplegia are inherently unpredictable and challenging, with symptoms changing over time. Adequate intervention, including extensive physical therapy, can substantially improve the chances of a full recovery but results can be attained only if extensive therapy is applied; if activities chosen are meaningful, occasionally modified and customised.
Hemiparesis (or unilateral paresis) and Hemiplegia are nervous system
disorders. While hemiparesis refers to weakness on one side of the body,
hemiplegia is a paralysis that affects one side of the body. An injury
can produce both symptoms at different times making it difficult to
treat. An injury to the spinal cord or brain interferes with the body’s
ability to send or receive signals to the region of the body affected by
the injury. The affected side is usually the opposite of the side of the
brain being injured (injury to the right side of the brain - affects the
left side of the body).
Most prevalent causes of both disorders are mild to moderate nerve or
brain damage, often related to strokes, infections, brain injuries or
spinal cord injuries, which affect the central nervous system (CNS).
Hemiparesis or hemiplegia may develop in a region of the brain that
affects movement or perception. The most common cause of both injuries
is a stroke. Other causes for the condition are possible:
- Damage to the neurons due to a degenerative disorder such as
Parkinson’s or MND
- Brain infections such as meningitis
- Brain cancer or lesions
- Traumatic injuries, such as a blow to the head during a car accident
- Congenital disorders such as cerebral palsy
Stroke is a broad term that refers to cerebrovascular accident, blood
vessels (artery) that supply the blood (oxygen) to the brain become
blocked or begin to bleed (National Stroke Audit, 2016, National
Australian Stroke Foundation). There are three types of stroke; cerebral
haemorrhage, cerebral infarction and Transient Ischemic Attack (TIA). A
haemorrhagic stroke is a bleed in the brain, an infarction (also known
as ischaemic stroke) is caused by a blockage, such as a blood clot or a
fatty plaque, in the artery supplying the brain. TIA (also called a
“mini stroke”) is caused by a temporary clot and does not cause
permanent disability, however, it can be a warning sign pointing to a
more serious stroke about to happen. Therefore, urgency in treatment is
essential as the brain damage, due to the lack of oxygen may be more
Ischaemic stroke is more common, accounting for 80% of stroke incidents
(National Stroke Foundation 2012). According to Australian Bureau of
Statistics (ABS) for 2015, stroke is the third leading cause of death in
Australia, with 10,869 fatalities and mostly affecting individuals
65years of age and older.
Symptoms of hemiplegia: difficulty moving one side of the body and loss
in sensation on that side, keeping one hand in a fist, difficulty
swallowing or with speech, breathing difficulties, difficulty with bowel
or bladder control.
Movement dissociation (selective disorder) may occur in one of the three
forms of the movement: voluntary, automatic and reflex. The ability to
isolate movement at specific joints is crucial for most activities.
Weakness of the hand, foot, shoulder, and hip is the most frequent
motor-deficit profile. The
main cause of motor weakness is damage to the primary crossed
corticospinal tract. Therefore, common symptoms are difficulties with
motor skills and weakness in large areas on one side of the body (e.g.
difficulty lifting arms). Examination is usually administered to rule
out other causes, such as: muscle strains, pinched nerves or loss of
The evaluation of Hemiparesis may involve Fugl-Meyer Assessment (FMA)
scale to assess the sensorimotor impairment in individuals who have had
the stroke Pusher
syndrome may develop and cause a person to shift their weight to the
affected side, which makes movement painful and also reduces motor
skills. The assessment of the severity of pusher syndrome can be
achieved by Functional Reach Test.
The Chedoke-McMaster Stroke Assessment (CMSA) measures two components
evaluating motor impairment and disability. The Stroke Rehabilitation Assessment of
Movement (STREAM) measures voluntary movements and general mobility.
Treatment for Hemiparesis and Hemiplegia
Though hemiparesis and hemiplegia produce different symptoms, they are
substantially similar in cause and treatment. Neither of them is a
progressive disorder (unless result of a brain tumour), therefore,
recovery is possible. However, due to lack of mobility, other
complications may occur. To treat either condition, a doctor will first
look at what caused the symptoms and then decide which treatment would
work the best. When a stroke is the cause, the damage may not be
reversed, but a number of treatments will help restore some or even most
functioning. Rehabilitation is recommended to regain maximum function
and quality of life and usually it is in some form of occupational
therapy. It is crucial that patients include some form of rehabilitation
to improve their condition.
Spasticity following a stroke occurs in about 30% of patients, so to
determine its magnitude neuroimaging is essential. Some of these
patients develop spasticity within first six weeks after the stroke and
most of them affect the elbow, wrist and the ankle. In the upper limbs, the most frequent pattern of arm spasticity is
internal rotation and adduction of the shoulder coupled with
flexion at the elbow (fig.2), the wrist and the fingers (fig 3.).
A high degree of paresis and hypoesthesia at stroke onset are identified
as one of its predictors. Spasticity affects the quality of life, induce
pain, ankylosis, muscle weakness but it also reduces the effects of
rehabilitation (fig 1).
Nelles and collegues demonstrated, by using Positron Emission Tomography
(PET) scans, a correlation between the movement recovery in patients
with hemiparesis and increase of brain metabolism in the
Struppler and his team also showed (PET scans) that the improvement in a
motor task, most specifically finger extension, was related to an
increase of neural activation in parieto-premotor areas, which is known
to be interrelated to motor areas which control arm and hand movements.
Further, an additional increase of the brain metabolism was also
observed in the SMA and CMA.
For example, constraint-induced movement therapy (CI Therapy), Mirror
Therapy (MT) or extensive Awareness Drawing Therapy (ADT) are very
beneficial. After the stroke most people avoid using impaired limbs,
behaviour called learned non-use. They rely on their unaffected side but
if an arm or hand is paralysed, it is crucial to improve its function by
treating it as normally as possible and not neglecting it. CI movement
therapy usually consists of constraining the unaffected side, which
forces the brain to adjust and rebuild, or in some cases even create new
neural pathways. Mirror therapy uses the unaffected limb to stimulate
motor function of the hemiparetic limb, in which the mirror is used to
“trick” the brain.
Drawing Awareness Therapy is in this sense similar to CI therapy, as it
employs constraints (if necessary) of the healthy arm, and at the same
time requires concentration and awareness during exercises, which helps
with deep elaborate learning, strengthens the new neural pathways and
improves motor coordination.
An example: After constraining the healthy arm place the affected limb
on the white paper where it can be seen (this is important if the person
lacks awareness) then feel the pencil between your fingers. Let your
fingers (use your palm too) play with the pencil. Then, while being
fully concentrated on every movement, connect the dots (already placed
on the piece of paper) by drawing deliberate continuous lines (without
breaking your wrist) in a direction asked of you by your therapist.
Drawing exercises are created for different purposes: drawing for the
exercises of shoulders and elbows, or for the fine motor control skills
– wrist and finger exercises. Each exercise is devised for a specific
task that requires certain skills to be acquired, hence to force the
brain to adjust. Furthermore, effects of drawing exercises are magnified
if motor imagery is introduced. As noted by Hy and his colleagues, gait
training with motor imagery training significantly improved the balance
and gait abilities of chronic stroke patients, in comparison to gait
training alone. When investigating whether motor imagery training improves
hand function in chronic stroke patients, Dijkerman et al.(2004)
demonstrated that patients improved on many tasks but imagery alone
without supervision may improve performance on the trained task only. Even though extensive research demonstrates that supervised training
sessions are extremely beneficial in treating hemiparesis and other
motor weaknesses, not many established rehabilitation centres
incorporate those therapies into their programs, and too often patients
are released without any aftercare treatment plans.
Another treatment that has shown results is Guided movement therapy.
Therapist should choose activities that have meaning to the person to
encourage participation. It is similar to Drawing Awareness Therapy but
the therapist places a hand over the person’s hand to help him/her
correctly manipulate objects during a task. Affected upper extremity
should be positioned in shoulder protraction, while arm is brought
forward, spine aligned, and finger extended. When sitting, both feet
should be flat on the floor and both arms supported on a table or on
Therapeutic electrical stimulation (TES) has demonstrated some
short-term improvement in arm function and range of motion, subluxation
and pain reduction; however, evidence is inconclusive for long-term
Physical, occupational, or exercise therapy, be it CI therapy or
extensive Drawing Awareness Therapy may restore functioning and help the
brain work around the injury and therefore, increase and support later
independence. It can be achieved even if the injury is not recent.
Furthermore, psychotherapy is welcomed to address the psychological
impact of a severe injury. Alternative treatments such as acupuncture
and dietary changes are also helpful.
Prognosis and aftercare
Hemiparesis and hemiplegia are inherently unpredictable and challenging,
with symptoms changing over time. Adequate intervention, including
extensive physical therapy, can substantially improve the chances of a
full recovery but results can be attained only if extensive therapy is
applied; if activities chosen are meaningful, occasionally modified and
customised. Psychotherapy is also important, since the overwhelming
nature of these injuries can interfere with the patient’s motivation in
the absence of immediate improvements.
Many hospitals that have specialised units dedicated to stroke, either‘
comprehensive stroke centre’ or ‘primary stroke centre’, significantly
improve the recovery of stroke patients. There are various types of
stroke units, with different range of functions and services
available—acute stroke units, comprehensive stroke units and stroke
However, due to limited resources most stroke units offer short-term
rehabilitation programs and struggle with the continuity of adequate
care for stroke patients. Those patients can benefit from further
rehabilitation even years after the event of stroke.
Drawing Therapy Centres provide a range of therapies aimed at helping
individuals regain their physical capacity needed to remain in their own
homes and improving their quality of life. In accordance with National
Stoke Audit’s recommendations they also commonly provide psychological
assessments and support.