Hemiplegia

1. Hemiplegia

2. How to prevent Hemiplegia • Reduce body weight to avoid obesity. • Reduce the physical and mental stress. • Increasing overall physical conditioning • Avoid smoking. • Regular use of hypertension drugs. • Exercise regularly.

3. Hemiplegia • Paralysis of one side of the body due to pyramidal tract lesion at any point from its origin in the cerebral cortex down to the fifth cervical segment.

4. Risk Factor of Hemiplegia • Diabetes Mellitus • High Blood Pressure • High Cholesterol level • Obesity • Smoking • Sedentary lifestyle

5. Causes of Hemiplegia • Vascular Causes: • Thrombosis • Atherosclerosis. • Blood Disease. • Embolic • Heart • Deep venous thrombosis • Hemorrhage • Hypertension • Rupture of intracranial aneurysm

6. Hemiplegia Back Pain • Infective • Encephalitis • Neoplastic • Meningioma • Demyelination • Disseminated Sclerosis • Traumatic • Congenital • CP • Hystrical

7. Site of Lesion • Spinal Cord • At the level of C1-C5 • Brown - Sequard syndrome • Brain Stem • Mid brain-Pones-Medulla • Cerebral • Cortical- Subcortical- Capsular

8. According to the Onset • Gradual Lesion • Stage of Spasticity • Acute Lesion • Stage of Flaccidity • Stage of Spasticity • Stage of Flaccidity: • Last from 2-6 weeks • On the paralysed side there is complete lose of muscle tone and absence of deep reflex • May be accompanied with Coma

9. Stage of Spasticity: • Paralysis of one side of the body (Affect the progravity more than the antigravity muscles) • Spasticity of the paralysed muscles (Affect the antigravity more than the progravity muscles) • Exaggerated deep reflex and lose superficial reflex.

10. Rehabilitation Team • Physician • physiotherapist • Social workers • Psychologist • Nurse • Occupational therapist • Vocational counselor

11. ASSESSMENT

12. Consideration Before Assessment • The clinic should be cleaned, suitable temperature of room, and ready instrumentation to use. • Plinths should be wide, suitable height, clean blankets. • Behavior and social aspect should be noticed. • Notice patient from head to ankles. • Explain to patient what will happen. • Covering patient till the beginning the assessment. • Discover disabilities that responsible for restriction of ADL. • Discover abilities that are suitable for ADL performance.

13. Considerations During Assessment • Good fixation of target joint during assessment. • Patient completely relaxed (physically & mentally) during assessment. • All movements and test procedure should be within the limit of pain. • Removing tight clothes during assessment. • Explain the tests procedure to the patient. • Close communications during assessment.

14. DIAGNOSTIC INTERVIEW Personal History: • Name: To be familiar with the patient • Age: occurs in people aged 40-50 years (cerbrovascular stroke) • Sex:affects men and women equally • Marital status: Married or single • Style of life: his habits, activities and if he living a sedentary life. It assist in providing the therapist with hint about causes and the expected prognosis. • Occupation:as people in certain job are more susceptible to some disease. Most plan of treatment require occupational modification.

15. Personal History • Environmental assessment: is the patient living in crowded and noisy area or not, which floor, and availability of Facilities . • Weight:obesity increase the difficulty in performing activities.

16. Past history • Hereditary and Genetic diseases. • Previous and multiple trauma. • Diabetes Mellitus. • Cardiac problems and Hypertension. • Previous surgery. • Associated Trauma or injury. • Drug use. • Cancer or tumor.

17. Present history Mechanism of injury. Onset and course of disease: • Acute onset and regressive course (Vascular, Infective. Traumatic lesion) • Gradual onset and progressive course (Neoplastic lesion) • Remittent and relapsing course (DS) Duration of symptoms: • Flaccid Stage: 2-6 weeks • Spastic Stage: After Flaccid Stage

18. Functional activities of daily living There are 4 grades for evaluation: *Can’t do it. *Do it with maximum assistance. *Do it with minimal assistance. *Do it without assistance. What problems interfere with ADL: • Hygiene: affected • Dressing and undressing: affected. • Feeding: affected • Gait ambulation: affected. • Transfer activities: affected. Assistive Devises

19. Social and psychological status • Attitude and behavior: Nervous, depressed, accepted. • Relationship with family. • Review of a patient’s home, work, recreational activities. • Information should be obtained on patient’s prior functional and present functional levels on these tasks.

20. Vocational assessment If the patient can return to his job or need new suitable one?

21. Chief complain • Difficulties in performing ADL • Difficulty walking • Problems with balance • Difficulty using arms to dress, feed self, or perform other tasks • Urinary incontinence • Decreased sensation, numbness, or tingling on affected side of the body • Difficulty speaking and/or or understanding words • Depression

22. Medical Record • Drugs:(according to the cause of the disease). • Reports:(all reports from other physician- previous investigations). • Laboratory tests. (blood test) • Vital signs. • Bowel or bladder incontinence • Vision, hearing, speech records. • Cardiopulmonary reports. • Electrocephalogram EEG (to measure electrical activity of the brain)

23. Radiological Examination

24. Computed Tomography (CT)

25. Magnetic Resonance Imaging (MRI)

26. Screening and scanning examination General inspection: • General health. • Wearing glasses, hearing aids • Relation between family. • Proportion of body parts. • Weight& height.

27. Posture assessment; • Posterior, anterior and lateral views. • From static and dynamic positions. • Position of head & neck. • Levels of shoulders. • Scoliosis • Chest shape . • Level of waist (ASIS). • Anterior or posterior pelvic tilting. • Any deformities of upper and lower limbs.

28. Screening and scanning examination • Involuntary Movement • Function: Observe any functional disabilities during taking his cloth off. • Gait: • Phases of gait or any abnormalities in gait • wearing assisted devices.

29. Inspect the trunk and extremities for signs of asymmetry, lesions, scars, trauma, deformities or previous surgery. Involuntary movement: Chorea, Athetosis, Tremors Convulsion Face Texture: Deviation of mouth angle Skin: color, hair patches, scars, wounds , of the skin Bones: alignment, deformity. Muscle: Spasticity, spasm, atrophy Specific Inspection

30. Palpation • Soft tissues of upper and lower limbs . • Changes in temperature or texture. • Mobility of the skin. • Tenderness. • Spastic and atrophied muscles.

31. Comprehensive Motor Control Assessment Examination of the Mental Function • State of consciousness: Alert Drowsiness Coma • Orientation for Time and Place. • Memory: Immediate Recent Remote • Communication Abilities: Vision Hearing Speech • Behavior and Psychological Status: Depression Angry • Intelligence: IQ

32. Examination of Speech • Sensory Aphasia: 1)Visual: • Visual Agnosia • Alexia 2)Auditory: • Auditory Agnosia • Motor Aphasia: • Verbal aphasia • Agraphia

33. Sensory Examination • Superficial sensation Touch, Pain, Temperature ( compare on each side of limbs) • Semmes Weinstein monofilament test • Pin prick test

35. Sensory Examination • Deep Sensation • Vibration sense The use of a 256-Hz tuning fork over different bony prominance. • Joint Sense • Sense of position • sense of movement

36. Deep Sensation • Romberg’s Test • Muscle sense

37. Sensory Examination • Cortical Sensation • Tactile Localization • 2-point discrimination

38. Cortical Sensation • Stereognosis • Graphosthesia • Perceptual Sense

39. Examination of Cranial Nerves • Oculomotor Nerve (3rd cranial nerve): • Ask patient to look upward • abducent Nerve (6th cranial nerve): • Ask patient to look laterally • Facial Nerve (7th cranial nerve): • Ask patient to smile and showing teeth • Absence of nasolabial fold and dropping angle of mouth • Hypoglossal nerve (12th cranial nerve): • Deviation of tongue toward the affected side • Ask patient to push his check with the tip of tongue

40. Muscle Tone Assessment • Spasticity or hypertonia of the paralysed muscles of the clasp-knife type: It affect the antigravity more than the progravity muscles. • In UL:the flexors more spastic than the extensors • In LL:the extensors more spastic than the flexors

41. Factors affecting Muscle tone • Anxiety • Temperature • Tension • Drugs • Fear • Fullness of bladder • Position of the head • Environmental condition • Vision and hearing • Pain

42. Assessment of Muscle Tone • Passive Movement Ashworth Scale : To perform this test, the part is moved through the joint range-of-motion (ROM). Ashworth Score Criteria: 0No increase in tone 1Slight increase in tone, giving a “catch” when the limb is moved in flexion or extension 2More marked increase in tone, but limb easily flexed 3Considerable increase in tone; passive movement difficult 4Limb rigid in flexion or extension

43. Assessment of Muscle Tone • Shaking: Wrist and Ankle • Drop arm Test • Postural tone: Righting and Equilibrium Reactions

44. Examination of Muscle Power • Paralysis or Weakness of one side of the body. • It affect theprogravitymore than theantigravitymuscles. • Upper limbs:The Extensors are weaker than the Flexors. • Lower limbs:The Flexors are weaker than the Extensors

45. Examination of Muscle Power Shoulder Joint:C4-C5 Flexion Extension Medial and Lateral Rotation Abduction Adduction Elbow Joint:C5,6,7 Flexion Extension

46. Examination of Muscle Power Wrist joint:C7,8 Extension Flexion Hand:C8-T1 Fingers and Thumb Flexion, Extension Abduction, Adduction

47. Examination of Muscle Power Abdominal Muscles:T6-T12

48. Examination of Muscle Power Flexion: L1-2-3 Extension: L4-5-S1-2 Hip Joint Adduction: L2-3-4 Abduction: L5-S1 Flexion: L5-S1-2 Extension: L2-3-4 Knee Joint Dorsiflexion: L4-5 Inversion: L4-L5 Ankle Joint and Foot Eversion: L5-S1 Plantarflexion: S1-2

50. Examination of Reflexes • Deep Reflexes Exaggerated deep reflex in Hemiplegia Biceps Reflex(C5,6) Triceps Reflex(C6,7)