Infantile Hemiplegia

Original Editor - Ayelawa Samuel Top Contributors - Ayelawa Samuel, Kim Jackson and Lucinda hampton

Introduction

Infantile or congenital hemiplegia refers to brain injuries that occur before or at birth and lead to hemiplegia. Juvenile hemiplegia is seen in patients who sustained injuries above the age of 1 year.

Hemiplegia is the physical manifestation of an injury to a specific area of the brain that controls motor function. Hemiplegia may develop suddenly, or evolve over days, weeks or months. Additionally some infants who appear normal in the newborn period may show symptoms of hemiplegia only after voluntary hand use develops (about 4-5 months of age). Hemiplegia can also be short-lived or permanent.

Hemiparesis/hemiplegia though rare in children is a cause of significant mortality and morbidity. Infections continue to be important cause of neurodeficit, at least in the developing countries.

Etiology

It is very important to understand that the etiology and features of infantile hemiplegia are different from that of adult hemiplegia. The below is a list of a few of the more common causes:

• Cerebrovascular Accident (CVA) or stroke
• Intraventricular Hemorrhage of the newborn (IVH)
• Thrombosis: embolism or hemorrhage
• Transient ischemic attack (TIA)
• Head Trauma:  brain contusion, subdural hematoma or epidural hematoma
• Brain tumor (Primary or metastatic disease)
• Infection:  brain abscess, encephalitis, subdural empyema or meningitis
• Vasculitis
• Demyelinating disease:  multiple sclerosis, acute necrotizing myelitis
• Congenital or perinatal injury
• Arterovenous malformations

Clinical features

Symptoms may include:

• Stiffness and weakness in muscles on one side of the body
• Only using one hand during play or favouring one hand before the age of 3 years
• Keeping one hand in a fist
• Difficulty with walking and balance
• Difficulty with fine motor tasks like writing or using scissors
• Delay in reaching expected developmental milestones eg rolling over, sitting up, crawling, or smiling
• Muscle spasms
• Emotion-depression
• Epilepsy convulsions occur in the major in the majority of cases and is one of the most common and distressing symptoms is the occurrence of convulsive seizures.
• Mental Changes-Changes in mentality has led the parents to seek advice. The mental changes cover a wide range from virtual imbecility at the one extreme, to the mildest retardation at the other, but this is often associated with an asocial outlook, which may well be related to the convulsive episodes.

Ranges of problems which may affect movement ability

• Persistent posturing and patterning movements
• Stiffness of movements of several types
• Floppiness and weakness
• Limited useful range of movement
• Intellectual difficulties and/or motivation
• Central sensory deficits
• Epilepsy

Diagnosis

There is no medical test that confirms the diagnosis of infantile hemiplegia. The diagnosis is made on the basis of various types of information gathered by the child's health care provider and, in some cases, other consultants

Management

(a) Conventional therapies ( Therapeutic Exercises, Traditional Functional Retraining)

• Range of motion Exercises
• Muscle Stretching Exercises
• Splinting
• fitness training
• Compensatory Techniques.

(b) Bed positioning;

Lying on the affected side;

• one or two pillows for head
• affected shoulder positioned comfortably.
• Place unaffected leg forward on one or two pillows.
• Place pillows in front or behind to give support.

Lying on unaffected side

• One or two pillow for the head
• Affected arm forward and supported on pillow(s)
• Affected leg backwards on one or two pillows
• Place pillows behind.

(c) Neurofacilitatory techniques such as 

• Bobath: it is an approach that focuses to control responses from damaged postural reflex mechanism. Emphasis is placed on affected inputs facilitation and normal movement patterns.
• Rood: Emphasize the use of activities in developmental sequences, sensation stimulation and muscle work classification. Cutaneous stimuli such as icing, tapping and brushing are employed to facilitate activities.
• Proprioceptive neuromuscular facilitation(PNF): they advocated the use of peripheral inputs as stretch and resisted movement to reinforce existing motor response. Total patterns of movement are used in treatment and are followed in a developmental sequence. 

(d) Learning theory approach such as 

• conductive education
• motor relearning theory: it emphasizes the practice of functional tasks and importance of relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and tasks are important.
• Biofeedback: it is a modality that facilitates the cognizant of electromyographic activity in selected muscle or awareness of joint position sense via visual or auditory cues.

(e) Functional Electrical stimulation

this is a modality that applied a short burst of electrical current to hemiplegic muscle or nerve. It reduces spasticity in hemiplegic patient.

(f) Conventional Gait training:

Conventional gait training has focused on part-practice of components of gait in preparation for walking. Includes

• Symmetrical weight bearing training
• Weight shifting
• Stepping training(swinging/clearance)
• Heel strike
• Single leg standing
• Push off/ Calf rise. Followed by, 

Circuit training (reaching in sitting and standing, sit-to-stand, step-ups, heel lifts, isokinetic strengthening, walking over obstacles, up and down slopes.