Hemiparesis, also called unilateral paresis, is the weakness of one entire side of the body ( meaning 'half'). Hemiplegia, in its most severe form, is the complete paralysis of one entire side of the body. Either hemiparesis or hemiplegia can result from a variety of medical causes, including congenital conditions, blunt trauma, tumors, traumatic brain injury, and stroke.
Signs and symptoms Different types of hemiparesis can impair different bodily functions. Some effects, such as weakness or partial paralysis of a limb on the affected side, are generally expected. Other impairments can appear upon external examination to be unrelated to the limb weakness, but are nevertheless also caused by damage to the affected side of the brain.
Loss of motor skills People with hemiparesis often have difficulties maintaining their balance due to limb paralysis, leading to an inability to properly shift body weight. This makes performing everyday activities, such as dressing, eating, grasping objects, or using the bathroom, more difficult. Hemiparesis with origin in the lower section of the brain creates a condition known as ataxia, a loss of both gross and fine motor skills, which often manifests as a staggering and stumbling gait. Pure motor hemiparesis, a form of hemiparesis characterized by one-sided weakness in the leg, arm and face, is the most commonly diagnosed form of hemiparesis.
Pusher syndrome
Pusher syndrome is a clinical disorder following left- or right-sided brain damage, in which patients actively push their weight away from the non-hemiparetic side to the hemiparetic side. This is in contrast to most stroke patients, who typically prefer to bear more weight on their nonhemiparetic side. Pusher syndrome can vary in severity and leads to a loss of postural balance. The lesion involved in this syndrome is thought to be in the posterior thalamus on either side, or in multiple areas of the right cerebral hemisphere.
A diagnosis of pusher syndrome includes observation of three behaviours. The most obvious one is the patient's regularly occurring (not just occasional) tendency to spontaneously hold a body posture in which the torso is longitudinally tilted toward the paretic side of the body. The second is the patient's use of the nonparetic extremities including abduction and extension of the extremities of the non-affected side, to help in the push toward the affected (paretic) side, resulting in an abnormal lateral tilt of the body axis. The third is that, when a care provider tries to realign the patient's body to an upright posture, the patient spontaneously pushes back against the attempt, feeling this normal posture to be off balance.
The pusher syndrome is present in 10.4% of patients with acute stroke and hemiparesis, and may increase the time needed for physical rehabilitation. The Copenhagen Stroke Study found that patients who presented with ipsilateral pushing took an average of 3.6 additional weeks to reach the same functional outcome, as measured by the Barthel Index, compared with acute-stroke and hemiparesis patients who did not engage in ipsilateral pushing.
Pushing behaviour demonstrates that these patients' perception of their body posture in relation to gravity has been altered. They experience their body as oriented "upright" when the body is actually tilted to the side of the brain lesion. At the same time, their processing of visual and vestibular inputs when determining the subjective visual vertical seems to be normal. When they are sitting, the pushing presents as a strong lateral lean toward the affected side. When they stand up, the pushing creates a highly unstable situation as they are unable to support their body weight on the weakened lower extremity. The resulting increased risk of falls must be addressed with therapy aimed at correcting their altered proprioceptive perception of vertical.
Pusher syndrome is sometimes confused with hemispatial neglect, and the two terms are sometimes (incorrectly) used interchangeably. Some older theories suggested that hemispatial neglect is what leads to pusher syndrome. However, hemispatial neglect occurs mostly when there is a right-hemisphere lesion, and one study found that pusher syndrome is also present in patients with left hemisphere lesions (which generally also lead to aphasia).
Neglect and aphasia are not the cause of pusher syndrome, although both are highly correlated with it (possibly because the brain structures associated with these syndromes are close to each other).
Physical therapists treating patients with pusher syndrome focus on motor learning strategies that reduce its ill effects, such as the use of verbal cues, consistent feedback, and practice correcting orientation and shifting weight, for example sitting with their stronger side next to a wall and repeatedly leaning towards the wall, thus gradually re-training the brain to recognize true vertical.
A physical-therapy approach for patients with pusher syndrome debuted in 2003 suggests that the visual control of vertical upright orientation, which is undisturbed in these patients, is the most important intervention. In sequential order, treatment is designed to enable patients to realize their altered perception of vertical, use visual aids for feedback about body orientation, learn the movements necessary to reach proper vertical position, and maintain vertical body position while performing other activities.
Classification of pusher syndrome Individuals who present with pusher syndrome or lateropulsion, as defined by Davies, vary in their degree and severity of this condition and therefore appropriate measures need to be implemented in order to evaluate the level of "pushing". There has been a shift towards early diagnosis and evaluation of functional status for individuals who have had a stroke and presenting with pusher syndrome in order to decrease the time spent as an in-patient at hospitals and promote the return to function as early as possible. Moreover, in order to assist therapists in the classification of pusher syndrome, specific scales have been developed with validity that coincides with the criteria set out by Davies' definition of "pusher syndrome". In a study by Babyar et al., an examination of such scales helped determine the relevance, practical aspects and clinimetric properties of three specific scales existing today for lateropulsion. The three scales examined were the Clinical Scale of Contraversive Pushing, Modified Scale of Contraversive Pushing, and the Burke Lateropulsion Scale. The results of the study show that reliability for each scale is good; moreover, the Scale of Contraversive Pushing was determined to have acceptable clinimetric properties, and the other two scales addressed more functional positions that will help therapists with clinical decisions and research.
Causes The most common cause of hemiparesis and hemiplegia is stroke. Strokes can cause a variety of movement disorders, depending on the location and severity of the lesion. Hemiplegia is common when the stroke affects the corticospinal tract. Other causes of hemiplegia include spinal cord injury, specifically Brown-Séquard syndrome, traumatic brain injury, or disease affecting the brain. A permanent brain injury that occurs during the intrauterine life, during delivery or early in life can lead to hemiplegic cerebral palsy. As a lesion that results in hemiplegia occurs in the brain or spinal cord, hemiplegic muscles display features of the upper motor neuron syndrome. Features other than weakness include decreased movement control, clonus (a series of involuntary rapid muscle contractions), spasticity, exaggerated deep tendon reflexes and decreased endurance.
The incidence of hemiplegia is much higher in premature babies than term babies. There is also a high incidence of hemiplegia during pregnancy and experts believe that this may be related to either a traumatic delivery, use of forceps or some event which causes brain injury. There is tentative evidence of an association with undiagnosed celiac disease and improvement after withdrawal of gluten from the diet.
Other causes of hemiplegia in adults include trauma, bleeding, brain infections and cancers. Individuals who have uncontrolled diabetes, hypertension or those who smoke have a higher chance of developing a stroke. Weakness on one side of the face may occur and may be due to a viral infection, stroke or a cancer.
Common causes Vascular: cerebral hemorrhage, stroke, cerebral palsy Infective: encephalitis, meningitis, brain abscess, cerebral palsy, spinal epidural abscess, COVID-19 Neoplastic: glioma, meningioma, brain tumors, spinal cord tumors Demyelination: multiple sclerosis, disseminated sclerosis, ADEM, neuromyelitis optica Traumatic: cerebral lacerations, subdural hematoma, epidural hematoma, cerebral palsy, vertebral compression fracture Iatrogenic: local anaesthetic injections given intra-arterially rapidly, instead of given in a nerve branch. Ictal: seizure, Todd's paralysis Congenital: cerebral palsy, Neonatal-Onset Multisystem Inflammatory Disease (NOMID) Degenerative: ALS, corticobasal degeneration Parasomnia: sleep paralysis
Mechanism Movement of the body is primarily controlled by the pyramidal (or corticospinal) tract, a pathway of neurons that begins in the motor areas of the brain, projects down through the internal capsule, continues through the brainstem, decussates (or cross midline) at the lower medulla, then travels down the spinal cord into the motor neurons that control each muscle. In addition to this main pathway, there are smaller contributing pathways (including the anterior corticospinal tract), some portions of which do not cross the midline.
Because of this anatomy, injuries to the pyramidal tract above the medulla generally cause contralateral hemiparesis (weakness on the opposite side as the injury). Injuries at the lower medulla, spinal cord, and peripheral nerves result in ipsilateral hemiparesis.
In a few cases, lesions above the medulla have resulted in ipsilateral hemiparesis: In several reported cases, patients with hemiparesis from an old contralateral brain injury subsequently experienced worsening of their hemiparesis when hit with a second stroke in the ipsilateral brain. The authors hypothesize that brain reorganization after the initial injury led to more reliance on uncrossed motor pathways, and when these compensatory pathways were damaged by a second stroke, motor function worsened further. A case report describes a patient with a congenitally uncrossed pyramidal tract, who developed right-sided hemiparesis after a hemorrhage in the right brain.
Diagnosis Hemiplegia is identified by clinical examination by a health professional, such as a physiotherapist or doctor. Radiological studies like a CT scan or magnetic resonance imaging of the brain should be used to confirm injury in the brain and spinal cord, but alone cannot be used to identify movement disorders. Individuals who develop seizures may undergo tests to determine where the focus of excess electrical activity is.
Hemiplegia patients usually show a characteristic gait. The leg on the affected side is extended and internally rotated and is swung in a wide, lateral arc rather than lifted in order to move it forward. The upper limb on the same side is also adducted at the shoulder, flexed at the elbow, and pronated at the wrist with the thumb tucked into the palm and the fingers curled around it.
Assessment tools There are a variety of standardized assessment scales available to physiotherapists and other health care professionals for use in the ongoing evaluation of the status of a patient's hemiplegia. The use of standardized assessment scales may help physiotherapists and other health care professionals during the course of their treatment plant to: