What is the management approach for a patient with right-sided hemiplegia?

Management of Right-Sided Hemiplegia

Immediately initiate early mobilization with formal rehabilitation assessment, combining task-specific motor training with spasticity management and complication prevention, as this approach directly reduces mortality, prevents secondary complications, and maximizes functional recovery. 1, 2

Acute Phase Management

Initial Assessment and Stabilization

• Perform formal rehabilitation assessment immediately after medical stabilization to establish baseline motor function, sensory deficits, and cognitive status 1
• Assess for specific risk factors: NIHSS score, level of consciousness changes, presence of hemiparesis versus complete paralysis, and associated sensory changes 1
• Evaluate for common complications: aspiration risk, bladder dysfunction (post-void residual >100 mL requires scheduled intermittent catheterization every 4-6 hours), and fall risk 1

Early Mobilization Protocol

Begin early, short, frequent exercise sessions within 24-48 hours of stabilization - this is the single most important intervention for reducing mortality and improving functional outcomes 1, 2

• Implement balance training regardless of severity, as stroke affects balance and leg use in all patients with hemiplegia 2
• Use trunk training, task-oriented activities, force platform biofeedback, and partial body weight support treadmill training 2
• Mixed approaches combining neurophysiological and motor learning methods are superior to single-approach interventions 2

Upper Extremity Rehabilitation

Motor Training Selection

Prioritize task-specific, motor training-based interventions as they induce neuroplasticity and produce measurable functional gains 2

• For patients meeting minimum motor criteria (20-degree wrist extension, 10 degrees for each finger, without sensory/cognitive deficits): Use Constraint-Induced Movement Therapy (CIMT) 2
• For patients not meeting CIMT criteria: Use bimanual training 2
• Consider functional dynamic orthoses to facilitate repetitive task-specific training 2, 3

Adjunctive Neuromodulation

• Add transcranial direct current stimulation (tDCS) as adjunct therapy (Evidence Level A recommendation) 2
• Consider repetitive transcranial magnetic stimulation (rTMS) as secondary option (Evidence Level B) 2

Lower Extremity and Gait Training

Functional Electrical Stimulation

Use FES for all patients with impaired muscle contraction, particularly those with ankle/knee motor impairment, regardless of complete paralysis versus partial weakness 2

• FES produces short-term increases in motor strength and control 2
• Specifically indicated for gait training after stroke 2
• For severe hemiplegia, consider multichannel FES, though evidence remains insufficient for routine recommendation 2

Ambulation Goals

• Target reasonable walking speed, endurance, and balance for community ambulation 2
• Accept that some patients with severe hemiplegia will require wheelchairs for longer distances - this is not treatment failure but appropriate functional adaptation 2

Spasticity Management

Spasticity management is critical because velocity-dependent increases in muscle tone interfere with functional recovery and lead to contractures 2

Pharmacologic Interventions

• Use botulinum toxin injections into subscapularis and pectoralis muscles for hemiplegic shoulder pain related to spasticity 2, 4, 3
• This intervention addresses both pain and functional limitation simultaneously 2

Physical Interventions

• Perform gentle stretching and mobilization techniques focusing specifically on external rotation and abduction 2, 4
• Gradually increase active range of motion while simultaneously restoring alignment and strengthening shoulder girdle muscles 2, 4
• Daily stretching of hemiplegic limbs prevents contractures - teach patients and families proper techniques 1

Hemiplegic Shoulder Pain Prevention and Treatment

Hemiplegic shoulder pain affects up to 29% of patients within the first year and delays rehabilitation if untreated 2

Assessment Requirements

• Evaluate tone, strength, soft tissue changes, joint alignment, pain levels, and orthopedic changes 2
• This systematic assessment identifies the specific pain mechanism guiding treatment selection 2

Treatment Algorithm

1. First-line: Acetaminophen or ibuprofen if no contraindications 2, 4, 3
2. Second-line: Subacromial corticosteroid injections for rotator cuff or bursa inflammation 2, 4, 3
3. For spasticity-related pain: Botulinum toxin into subscapularis and pectoralis 2, 4, 3

Positioning and Support

• Position hemiplegic shoulder in maximum external rotation for 30 minutes daily (in bed or chair) to prevent contracture 1
• Use supportive devices and slings to prevent shoulder subluxation 1
• For wheelchair users, lap trays and arm troughs may reduce shoulder pain and subluxation 4

Critical Exercise Restriction

NEVER use overhead pulleys - they encourage uncontrolled abduction and have the highest incidence of causing hemiplegic shoulder pain 2, 4, 3

Complex Regional Pain Syndrome (CRPS) Prevention

Use active, active-assisted, or passive range of motion exercises to prevent CRPS in all patients with hemiplegia 2, 4

Diagnostic Criteria

• Pain and tenderness of metacarpophalangeal and proximal interphalangeal joints 2
• Dorsal finger edema, trophic skin changes, hyperaesthesia, limited range of motion 2
• Triple phase bone scan showing increased periarticular uptake in distal upper extremity joints confirms diagnosis 2

Treatment Protocol

Oral corticosteroids 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 2

Complication Prevention

Contracture Prevention

• Apply resting ankle splints at night and during assisted standing for prevention of ankle contracture in hemiplegic limb 1
• Daily stretching prevents permanent functional limitations 1, 2

Fall Prevention

• Implement fall prevention program with validated risk assessment tool 1
• Most falls occur during transfers, toileting, or attempting activities without supervision - provide assistance during these high-risk activities 1
• Consider bed/chair alarms and video monitoring for high-risk patients (NIHSS ≥8, history of MI, renal insufficiency) 1

Pressure Injury Prevention

• Use Braden scale for objective assessment 1
• Turn regularly, use specialized mattresses and wheelchair cushions until mobility returns 1
• Maintain adequate nutrition and hydration 1

Venous Thromboembolism Prevention

Early mobilization is the primary prevention strategy 1

• Add intermittent pneumatic compression (IPC) if no contraindications 1
• Continue aspirin and ensure adequate hydration 1
• Educate patient and family on importance of IPC compliance 1

Psychosocial Management

Cognitive Rehabilitation

• One in 10 patients develop dementia after stroke - assess mental status as component of neurological examination 1
• Provide cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning 1
• Use enriched environments to increase engagement with cognitive activities 1

Depression Screening and Treatment

Up to one-third of patients develop depression - perform early screening 1

• Provide interventions to enhance rehabilitation and improve recovery 1
• Risk factors include physical disability, stroke severity, prestroke depression, and cognitive impairment 1

Delirium Prevention

One in four patients develop delirium during acute period 1

• Avoid infection, dehydration, and drugs with sedative or neuroactive effects 1
• Regulate sleep/wake cycles and maintain day/night orientation 1
• Provide cognitive stimulation and early mobilization 1
• Consider having family member stay with patient to promote orientation and safety 1
• Antipsychotic agents may be considered short-term only 1

Critical Pitfalls to Avoid

• Untreated shoulder pain masks motor function improvement and inhibits rehabilitation participation 2
• Failure to prevent contractures through appropriate positioning and range of motion leads to permanent functional limitations 2
• Hemiplegic shoulder pain contributes to depression, sleeplessness, and reduced quality of life if left untreated 2
• Aggressive passive range-of-motion exercises performed improperly cause more harm than good - the complex shoulder joint requires controlled, gradual progression 4
• Returning to activity before achieving pain-free motion and adequate strength leads to chronic pain and dysfunction 3