What are the differences in management and treatment between hemiplegia and hemiparesis?

Hemiplegia vs Hemiparesis: Management and Treatment Differences

Both hemiplegia (complete paralysis) and hemiparesis (partial weakness) affecting one side of the body are managed using the same evidence-based rehabilitation framework, with treatment intensity and specific interventions adjusted based on severity of motor impairment rather than the diagnostic label itself. 1

Key Clinical Distinction

• Hemiplegia refers to complete paralysis of one side of the body (face, arm, and leg), representing the most severe end of the spectrum 2
• Hemiparesis indicates partial weakness or incomplete paralysis on one side, with some preserved motor function 1
• Both conditions result from contralateral brain lesions affecting the motor cortex, corona radiata, or internal capsule 2

Unified Rehabilitation Approach

Early Mobility and Balance Training

All patients with hemiplegia/hemiparesis should receive balance training regardless of severity, as stroke frequently affects balance and leg use in both conditions. 1

• Effective interventions include trunk training, task-oriented activities, force platform biofeedback, and partial body weight support treadmill training 1
• Mixed approaches combining neurophysiological and motor learning methods are more effective than single approaches 1
• Critical elements for community ambulation include reasonable walking speed, endurance, and balance; some patients may require wheelchairs for longer distances 1

Upper Extremity Rehabilitation

Task-specific, motor training-based interventions should be prioritized as they induce neuroplasticity and produce functional gains. 1

• For hemiplegia (unilateral involvement): Constraint-Induced Movement Therapy (CIMT) or bimanual training are recommended 1
• Patients must meet minimum motor criteria for CIMT: 20-degree wrist extension and 10 degrees for each finger, without sensory or cognitive deficits 1
• Functional dynamic orthoses may facilitate repetitive task-specific training 1
• Transcranial direct current stimulation (tDCS) is recommended as an adjunct (Evidence Level A), while repetitive transcranial magnetic stimulation (rTMS) may be considered (Evidence Level B) 1

Functional Electrical Stimulation

FES is recommended for patients with impaired muscle contraction, particularly those with ankle/knee/wrist motor impairment, regardless of whether they have complete paralysis or partial weakness. 1

• FES is specifically recommended for shoulder subluxation and gait training after stroke 1
• Treatment produces short-term increases in motor strength and control, though evidence for long-term functional gains is limited 1

Spasticity Management

Spasticity management is critical in both conditions as velocity-dependent increases in muscle tone can interfere with functional recovery and lead to contractures. 1

• Botulinum toxin injections into subscapularis and pectoralis muscles should be used for hemiplegic shoulder pain related to spasticity 1
• Gentle stretching and mobilization techniques focusing on external rotation and abduction are essential 1
• Active range of motion should be increased gradually while restoring alignment and strengthening shoulder girdle muscles 1

Pain Management

Hemiplegic shoulder pain affects up to 29% of patients within the first year and requires systematic assessment and treatment to prevent rehabilitation delays. 1

• Assessment must include evaluation of tone, strength, soft tissue changes, joint alignment, pain levels, and orthopedic changes 1
• First-line: Acetaminophen or ibuprofen for pain relief if no contraindications exist 1
• Second-line: Subacromial corticosteroid injections for rotator cuff or bursa inflammation 1

Complex Regional Pain Syndrome (CRPS) Prevention and Treatment

Active, active-assisted, or passive range of motion exercises must be used to prevent CRPS in all patients with hemiplegia/hemiparesis. 1, 3

• Diagnosis is based on clinical findings: pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, dorsal finger edema, trophic skin changes, hyperaesthesia, and limited range of motion 1, 3
• Triple phase bone scan showing increased periarticular uptake in distal upper extremity joints assists diagnosis 1, 3
• Treatment: Oral corticosteroids 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1, 3

Severity-Based Modifications

For Severe Hemiplegia (Complete Paralysis)

• Multichannel FES for gait impairment may be considered, though evidence is insufficient for routine recommendation 1
• Wheelchair mobility may be necessary, especially for longer distances 1
• Adaptive devices should be evaluated individually to improve safety and function when other methods are unavailable 1

For Hemiparesis (Partial Weakness)

• Greater emphasis on active movement and strengthening exercises 1
• Higher likelihood of achieving independent ambulation 1
• May progress more rapidly through rehabilitation milestones 4

Critical Pitfalls to Avoid

• Never use overhead pulleys, which encourage uncontrolled abduction and increase risk of hemiplegic shoulder pain 3
• Untreated shoulder pain can mask motor function improvement and inhibit rehabilitation participation 1, 3
• Failure to prevent contractures through appropriate positioning and range of motion exercises leads to permanent functional limitations 1
• Hemiplegic shoulder pain contributes to depression, sleeplessness, and reduced quality of life if left untreated 1, 3

Prognosis Considerations

• In cerebral palsy populations with unilateral spastic hemiplegia: 2 in 3 will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence 1
• Upper extremities are typically more severely affected than lower extremities in hemiplegic patterns 5
• Presence of dystonia and ataxia indicates particularly unfavorable prognosis 5