HEMIPLEGIA – neurological, sequellar, complex disorder
The hemiplegia, respectively the hemiparesis, means the total or partial paralysis of one half (left or right) of the body, that is, the loss of voluntary motility and alteration of the muscle tonus of the limbs on one side of the body.
According to the increase or decrease of the muscle tonus, the hemiplegia hemiparesis may be spastic or lax.
The motor deficit appears due to a lesion of the pyramidal way, beam of nervous fibers going from the cerebral cortex towards various levels of the spinal marrow, and sending the muscle contraction command.
Most frequently, the lesion occurs following a stroke (ischemic or hemorrhagic), a craniocerebral traumatism a cerebral tumor or an infection of the central nervous system.
The loss of the central command and the alteration of the muscular tonus alters the normal movement, determining various degrees of difficulty in the patients’ execution of their current activity: maintain orthostatism, walk, eat, get dressed, body care.
Apart from the motor deficit, there are also other disturbances of the normal functions, such as: balance alteration, coordination troubles, loss of sphincter control, muscular-articular pains, difficulty in swallowing (dysphagia), sensitivity disorders, disturbances of perception and communication (aphasia, dysarthria), vision disturbances (hemianopia), facial paresis, personality and emotional disorders (psychic liability and depression), cognitive disturbances (attention, memory, thinking) , in the serious cases reaching even dementia.
The patients’ state tends to be improved in time, but the function recovery degree and the duration of recovery depends first of all on the external support (rehabilitation treatment and family support) given to the patient.
In conclusion, hemiplegia means the occurrence of deficiencies at the level of various systems, resulting in a complex structure of invalidity, entailing the need the precociously initiate the patient’s rehabilitation treatment and the obligation to observe a certain calendar in order to obtain favorable results, respectively to improve the functional status, to prevent sequelae and complications, to obtain the highest degree of functional independence, social and family and professional integration, as well as to increase the quality of life.
The recovery of the hemiplegic patient is achieved by introducing him in a complex and individualized recovery plan, not limited by time, which starts in the intensive care section and continues in a medical rehabilitation service, and also at the patient’s home.
The studies show that the delay by more than 2 months of the recovery treatment doubles the rehabilitation period. In the first 6-8 months after the occurrence of the disease, a continuous recovery is necessary. It is recommended to carry out a daily schedule of 1-2 hours, in one or two stages, for at least 5 days/week, at least in the first 2-3 months after the outburst. Subsequently, if the evolution is favorable and the recovery program is executed independently by the patient, then the supervised sessions may occur 2 times/week, for at least 1 year (experts’ opinion).
The importance of the rehabilitation treatment is enormous in terms of the benefits brought directly to the patient, and as regards society, as the patients may take back their autonomy for self-care and sometimes even the productive activity.
The rehabilitation activity of the hemiplegic patient supposes team work, where every specialist has a well-determined and equally important part: neurologist, medical rehabilitation doctor, psychologist, kinetotherapist, physiotherapist, ergotherapist, orthesist.
The recovery treatment focuses mainly on the management of the disability and on the reduction of the handicap.
The diagnosis represents the first link of this process, and it determines both the recovery strategy, and any possible restrictions in the rehabilitation process.
To draft the recovery plan, a correct and precocious diagnosis is required, as well as a well-managed medicine treatment, identification of deficits and disabilities and of individual limitations (pre-existing pathology), followed by the setting and adaptation of therapeutic interventions to them, according to the best goals for every patient.
The patient participates actively in the drafting of the plan, together with all the members of the rehabilitation team and with the family. The plan will be reviewed and updated according to the patient’s evolution throughout the treatment.
The success of therapy is to the greatest extent conditioned by the patient’s degree of collaboration, we must succeed in “reconciling” the patients with their disease, teach them what rehabilitation means in this suffering, and how to use the instruments that this science has, to be able to control and improve the disability induced by the disease.
The main objective of the treatment is to regain independence and to increase the patient’s quality of life.
The general objectives of treatment are:
- Combat pain
- Control spasticity
- Increase the articular mobility and the muscle force and strength
- Correct the vicious postures of the body and of the affected limbs
- Increase and improve the postural control, balance, coordination and the correct patterns of movement
- Increase the motor control, regain/improve the correct image of movement
- Maintain-increase the performance of the unaffected limbs
- Learn the palliative movements
- Reeducate walking
- Reeducate sensitivity
- Reeducate speech
- Reeducate the hand, regain ability
- Reeducate the sphincterian control
- Regain and automatize usual movements
- Increase and adapt the capacity to effort
The treatment means are:
a. Medicine treatment set by the neurologist and cardiologist
b. Physical-kinetic treatment:
– Therapeutic massage: sedative and toning
– Antalgic electrotherapy: currents of low and medium frequency, ultrasound, short waves, laser-therapy, shockwave-therapy.
– Therapy of spasticity: Huffschmidt currents, MDF
– Electrostimulation: currents of low and medium frequency
– Kinetic therapy: correcting and prophylactic postures, passive, passive-active (FNP techniques), active and active assisted kinetic therapy, by special devices and machines.
– Occupational therapy
– Helping devices – orthesis, walking frame, cane
c. Speech recovery
d. Cognitive recovery
e. Psychological counseling
The patient receives a treatment chart where the procedures set in the rehabilitation plan drafted by team members following clinical assessment are recorded.
The term of the treatment is set according to the complexity of deficits and to the patient’s compliance and implication in the therapeutic process.
The intensity and rhythmicity of the treatment procedures are adapted to each case. The minimum and maximum time dedicated to each procedure is individualized according to the patient’s tolerance and capacity to bear, which depend on the severity of deficits, medical stability, mental status and functional level.
The criteria of inclusion in the treatment are: patient with spastic hemiparesis of 2 months – 4 years, absence of psychiatric history, sufficient cognitive and linguistic function, acceptable compliance related to the recovery treatment.
The exclusion criteria are: patients with severe cognitive and communication deficits or compliance not adapted to the requirements of the rehabilitation program.
When setting the diagnosis, together with the clinical examination, we are using the following assessment tests: FIM scale (Functional Independence Measure) and appraisal of daily activities ADL (Activities of Daily Living) and IADL (Instrumental Activities of Daily Living) to assess functional independence, VAS scale for pain, Ashworth scale, altered, to test spasticity, FAC scale to assess walking, Rankin scale and the balance chart of the hemiplegic patient, MMSE test (Mini Mental State Evaluation) to assess the cognitive state, as well as the testing of the patient’s compliance and trust in the treatment.
To apply the treatment, we are using: electrotherapy devices to generate low and medium frequency currents, ultrasound and short waves, device for laser-therapy and shockwave-therapy, device to generate low frequency magnetic fields; room and devices for kinetic therapy: table, trellis, ergometric bicycle, pedal set, table for occupational therapy, materials and devices to test and recover sensitivity and ability, blood pressure monitors to monitor blood pressure during treatment.
The combination between the specific neurological medication and the recovery procedures improve the deficits, avoid complications and speed up the reaching of functional parameters providing a certain degree of autonomy.
Criteria of inclusion of the patient suffering from AVC into a complex recovery program (Brandstater in deLisa):
1. Stable neurologic status;
2. Persistent significant neurologic deficit;
3. Disability affecting at least 2 of the following categories: mobility, self-care activities, communication, sphincterian control, deglutition;
4. Sufficient cognitive function to learn;
5. Sufficient communication ability to work with therapists;
6. Sufficient physical ability to tolerate the active program;
Like many neurologic diseases, hemiplegia is also characterized by the slow aggravation of deficits, the recovery procedures in this case aiming at maintaining a certain degree of autonomy and at delaying complications of vital risk.