After experiencing a stroke, one of the most common aftereffects is hemiplegia, whether partial or complete.
Hemiplegia affects the patient not only through the inability to perform various actions such as walking or self-care, but also deeply at the psychological level, often leading to the recurring thought that they can no longer be self-sufficient.
Frequently asked questions such as: Is recovery possible?, Is it permanent?, How long will it take to recover? are inevitably raised by both the patient and their family.
What’s important to understand is that hemiplegia is treatable. The main goal of treatment is to help the patient become as independent as possible in daily life, ultimately achieving the highest possible quality of life.
Daily consistency and dedication are essential for a prompt recovery, as well as early care for the patient. That is why it is important to seek the help of specialized therapists as soon as possible, so they can establish exercise routines and evaluate the extent of the sequela.
To achieve this, it is necessary to understand the different phases or stages based on the patient’s current condition.
When determining the activities for each stage, the specialist will take into account factors such as the patient’s age, physical condition, and of course, how their body and functions have been affected as a result of hemiplegia.
Initial phase: Flaccid stage
A stroke causes a sudden and complete change, leaving the patient with no time to adapt. They are confused and disoriented, and experience different sensations on both sides of the body. In a way, it can be said that they feel divided into “two halves.”
Since there is no balance or support from the arm on the affected side, the patient has a strong fear of falling in that direction, which increases spasticity. Even healthy individuals tend to become rigid when afraid of falling. All of this leads the patient to ignore the affected side and orient themselves entirely toward the healthy side, an effect that must be counteracted in treatment, not reinforced.
Therapy that begins in the early stages should help the patient bear weight on the affected side and learn to balance on that side while sitting and standing. It should also focus on promoting bilateral function of the arms and trunk, to enable the necessary interaction between the healthy side and the affected side.
The initial stage begins shortly after the onset of hemiplegia and can last from a few days to several weeks, or even longer. The patient is unable to move the affected side and often does not even recognize that they have an arm or leg on that side. They have lost their previous movement patterns and, at first, even the movements on the healthy side are inadequate to compensate for the loss of function on the affected side.
The patient now has to use their healthy side differently and does not immediately know how to do so. At this stage, there is no restriction in the range of motion during passive movements of the affected side. Although signs of spasticity may not yet be present, scapular retraction can be observed with some resistance to passive forward movement of the shoulder girdle. The fingers and wrist may be slightly flexed, and during fast passive extension, some resistance may be noticeable.
There may also be some resistance to full supination of the forearm and wrist when performed with the elbow extended. The first signs of spasticity are felt during dorsiflexion of the ankle and toes with the hip and knee extended, and in some cases, there is mild resistance to foot pronation.
In the early stages, the caregiver plays a fundamental role in the patient’s rehabilitation, especially while the patient remains confined to bed or a chair and requires extensive care. At this point, it is possible to make mistakes in handling that could have a negative impact on future treatment and rehabilitation outcomes. Proper positioning and handling of the affected person can help prevent excessive spasticity, as well as contractures, shoulder pain, and even neglect of the affected side.
Position Changes for the Hemiplegic Patient
Arm and Head
Bed Position: Patient lying on their back
To prevent shoulder retraction: place the arm extended along the body on a pillow slightly higher than the trunk. Position the hand extended on the pillow or, preferably, supinated against the outer edge of the pillow.
It is very important to position the head turned toward the healthy side, and to place the affected shoulder on the pillow as far forward as possible.
Pelvis and leg
Different positions are needed for patients with extensor spasticity and those without it.
Patients with a flexor tendency in the leg and absence of extensor tone
These patients remain flaccid rather than spastic for a longer period after a severe stroke.
The flexor tendency is dangerous for rehabilitation. If the flexor pattern is allowed to set in and contractures develop, this type of patient will not have sufficient extensor tone to help them rise, stand, or walk.
Therefore, it is necessary to prevent flexor contractures of the hip and knee, pressure ulcers on the leg, and foot supination.
The patient should lie on their back in bed. A pillow or sandbag is placed under the pelvis on the affected side to elevate it (to prevent pelvic retraction). The pillow should be long enough to support the outer side of the thigh. This prevents external rotation of the leg; however, it should not go beyond the neutral position, meaning it should not cause internal rotation. If there is excessive extension or supination of the ankle, a board can be placed against the foot to allow for dorsiflexion and pronation.
Patients who develop extensor spasticity in the early stages
This will allow them to stand up, but it will prevent knee flexion during walking. The patient tends to retract the pelvis, which leads to excessive external rotation of the leg.
Their position in bed should not always be on their back. They should also learn to lie on the healthy side as well as on the affected side.
As in the previous section, support the pelvis and elevate it forward with a sandbag or pillow. To prevent excessive extensor spasticity, the patient needs support under the knee using a small foam pillow, with the knee slightly flexed. No board should be placed against the foot, as the patient will press against it with their toes.
Exercises in the First Flaccid Stage
Rotation from Supine to Side-Lying Position
One of the first activities that should be worked on with the patient is rotation to both sides.
The supine position, or dorsal decubitus, is an anatomical position of the human body characterized by:
- Body position lying face up, generally on a plane parallel to the ground
- Neck in a neutral position, with the gaze directed toward the zenith
- Upper limbs extended alongside the trunk with the palms of the hands facing upward
- Lower limbs also extended, with feet in neutral flexion and big toes pointing upward
As a result, the patient should not remain in the supine position at all times. They must learn early on to use the trunk, that is, the shoulder girdle and pelvis, to rotate and position themselves in a side-lying position for part of the day.
Preparing the Patient for Sitting and Standing
The following exercise should prepare the patient to sit up from the supine position, transitioning through the side-lying position and from there to a standing position.
Scapular Mobilization Exercise
Although not all patients who suffer a stroke present similar motor deficits, many of them do show comparable impairments. Lesions in the central nervous system often cause problems with or completely eliminate motor behavior.
Alterations such as reduced frequency of neuronal activation, difficulties in the sequencing and coordination of movements, decreased motor impulses, and/or sensory disorders will significantly impact the functional performance of the affected upper limb. This condition of the muscles and joints in hemiplegia is due to the lack of regulation from brain-derived influences, which leads to a disorganization of the neurological mechanisms responsible for controlling posture, balance, and movement.
In the initial stages of hemiplegia, there is a decrease in muscle tone or flaccidity on the affected side of the body. The patient cannot feel or move the limbs. The hand and fingers become flexed, and the shoulder girdle retracts and drops.
Upper limb impairments are common in hemiplegic patients who have suffered a stroke. These impairments can lead to joint fixations, permanent deformities, pain, and limitations in functionality. Proper treatment in the early stages, along with correct guidance and supervision, can prevent secondary complications and support the gradual recovery of these patients.
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