How to prevent HemiplegiaHow to prevent Hemiplegia Reduce body weight to avoid obesity.Reduce body weight to avoid obesity. Reduce the physical and mental stress.Reduce the physical and mental stress. Increasing overall physical conditioningIncreasing overall physical conditioning Avoid smoking.Avoid smoking. Regular use of hypertension drugs.Regular use of hypertension drugs. Exercise regularly. Exercise regularly.

Paralysis of one side of the body due to Paralysis of one side of the body due to pyramidal tract lesion at any point from its origin pyramidal tract lesion at any point from its origin in the cerebral cortex down to the fifth cervical in the cerebral cortex down to the fifth cervical segment.segment.

Risk Factor of HemiplegiaRisk Factor of HemiplegiaDiabetes MellitusDiabetes MellitusHigh Blood Pressure High Blood Pressure High Cholesterol level High Cholesterol level Obesity Obesity Smoking Smoking Sedentary lifestyle Sedentary lifestyle

Causes of HemiplegiaCauses of Hemiplegia Vascular Causes:Vascular Causes: ThrombosisThrombosis Atherosclerosis.Atherosclerosis. Blood Disease.Blood Disease. EmbolicEmbolic HeartHeart Deep venous thrombosisDeep venous thrombosis HemorrhageHemorrhage HypertensionHypertension Rupture of intracranial aneurysmRupture of intracranial aneurysm

Hemiplegia Back PainHemiplegia Back Pain InfectiveInfectiveEncephalitisEncephalitisNeoplasticNeoplasticMeningiomaMeningiomaDemyelinationDemyelinationDisseminated SclerosisDisseminated SclerosisTraumaticTraumaticCongenital Congenital CPCPHystricalHystrical

Site of LesionSite of LesionSpinal CordSpinal Cord At the level of C1-C5 At the level of C1-C5 Brown - Sequard syndromeBrown - Sequard syndromeBrain StemBrain Stem Mid brain-Pones-MedullaMid brain-Pones-MedullaCerebralCerebral Cortical- Subcortical- CapsularCortical- Subcortical- Capsular

According to the OnsetAccording to the OnsetAcute LesionAcute Lesion Stage of FlaccidityStage of Flaccidity Stage of SpasticityStage of Spasticity

Gradual LesionGradual Lesion Stage of SpasticityStage of Spasticity

Stage of Flaccidity:Stage of Flaccidity:Last from 2-6 weeksLast from 2-6 weeksOn the paralysed side there is On the paralysed side there is

complete lose of muscle tone and complete lose of muscle tone and absence of deep reflexabsence of deep reflex

May be accompanied with ComaMay be accompanied with Coma

Stage of Spasticity:Stage of Spasticity:Paralysis of one side of the bodyParalysis of one side of the body (Affect the progravity more than the (Affect the progravity more than the

antigravity muscles)antigravity muscles)Spasticity of the paralysed muscles Spasticity of the paralysed muscles

(Affect the antigravity more than the (Affect the antigravity more than the progravity muscles)progravity muscles)

Exaggerated deep reflex and lose Exaggerated deep reflex and lose superficial reflex.superficial reflex.

Rehabilitation TeamRehabilitation Team PhysicianPhysician physiotherapistphysiotherapist Social workersSocial workers PsychologistPsychologist NurseNurse Occupational therapistOccupational therapist Vocational counselorVocational counselor

Consideration Before AssessmentConsideration Before Assessment The clinic should be cleaned, suitable temperature The clinic should be cleaned, suitable temperature

of room, and ready instrumentation to use.of room, and ready instrumentation to use. Plinths should be wide, suitable height, clean Plinths should be wide, suitable height, clean

blankets.blankets. Behavior and social aspect should be noticed.Behavior and social aspect should be noticed. Notice patient from head to ankles.Notice patient from head to ankles. Explain to patient what will happen.Explain to patient what will happen. Covering patient till the beginning the assessment. Covering patient till the beginning the assessment. Discover disabilities that responsible for restriction Discover disabilities that responsible for restriction

of ADL.of ADL. Discover abilities that are suitable for ADL Discover abilities that are suitable for ADL

performance. performance.

Considerations During AssessmentConsiderations During Assessment Good fixation of target joint during assessment.Good fixation of target joint during assessment. Patient completely relaxed (physically & mentally) Patient completely relaxed (physically & mentally)

during assessment.during assessment. All movements and test procedure should be within All movements and test procedure should be within

the limit of pain.the limit of pain. Removing tight clothes during assessment.Removing tight clothes during assessment. Explain the tests procedure to the patient.Explain the tests procedure to the patient. Close communications during assessmentClose communications during assessment..

DIAGNOSTIC INTERVIEWDIAGNOSTIC INTERVIEWPersonal History:Personal History: Name: Name: To be familiar with the patientTo be familiar with the patient Age: Age: occurs in people aged 40-50 years occurs in people aged 40-50 years

(cerbrovascular stroke)(cerbrovascular stroke) Sex:Sex: affects men and women equally affects men and women equally Marital status: Marital status: Married or singleMarried or single Style of life:Style of life: his habits, activities and if he living a his habits, activities and if he living a

sedentary life. It assist in providing the therapist with sedentary life. It assist in providing the therapist with hint about causes and the expected prognosis.hint about causes and the expected prognosis.

OccupationOccupation:: as people in certain job are more as people in certain job are more susceptible to some disease. Most plan of treatment susceptible to some disease. Most plan of treatment require occupational modification.require occupational modification.

Personal HistoryPersonal History Environmental Environmental

assessment:assessment: is the patient is the patient living in crowded and noisy living in crowded and noisy area or not, which floor, and area or not, which floor, and availability of Facilities .availability of Facilities .

Weight:Weight: obesity increase obesity increase the difficulty in performing the difficulty in performing activities.activities.

Past historyPast history Hereditary and Genetic diseases.Hereditary and Genetic diseases. Previous and multiple trauma.Previous and multiple trauma. Diabetes Mellitus.Diabetes Mellitus. Cardiac problems and Hypertension.Cardiac problems and Hypertension. Previous surgeryPrevious surgery.. Associated Trauma or injury.Associated Trauma or injury. Drug use.Drug use. Cancer or tumor.Cancer or tumor.

Present historyPresent historyMechanism of injury.Mechanism of injury.

Onset and course of disease:Onset and course of disease: o Acute onset and regressive course Acute onset and regressive course (Vascular, (Vascular,

Infective. Traumatic lesion)Infective. Traumatic lesion)o Gradual onset and progressive course Gradual onset and progressive course

(Neoplastic lesion)(Neoplastic lesion)o Remittent and relapsing courseRemittent and relapsing course (DS) (DS)

Duration of symptoms:Duration of symptoms: Flaccid Stage: Flaccid Stage: 2-6 weeks2-6 weeks Spastic Stage: Spastic Stage: After Flaccid StageAfter Flaccid Stage

Functional activities of daily livingFunctional activities of daily livingWhat problems interfere What problems interfere

with ADL:with ADL: Hygiene:Hygiene: affected affected Dressing and Dressing and

undressing:undressing: affected. affected. Feeding:Feeding: affected affected Gait ambulation:Gait ambulation:

affected.affected. Transfer activities:Transfer activities:

affected.affected.

There are 4 grades There are 4 grades for evaluationfor evaluation::

**Can’t do itCan’t do it..

**Do it with maximum Do it with maximum assistanceassistance..

**Do it with minimal Do it with minimal assistanceassistance..

**Do it without Do it without assistanceassistance..

Assistive DevisesAssistive Devises

Social and psychological statusSocial and psychological status

Attitude and behavior: Attitude and behavior: Nervous, Nervous, depressed, accepted.depressed, accepted.

Relationship with family.Relationship with family. Review of a patient’s home, work, Review of a patient’s home, work,

recreational activities. recreational activities. Information should be obtained on Information should be obtained on

patient’s patient’s prior functionalprior functional and and present present functionalfunctional levels on these tasks. levels on these tasks.

Vocational assessmentVocational assessment

If the patient can return If the patient can return to his job or need new to his job or need new

suitable one?suitable one?

Chief complainChief complain Difficulties in performing ADL Difficulties in performing ADL Difficulty walking Difficulty walking Problems with balanceProblems with balance Difficulty using arms to dress, feed self, or Difficulty using arms to dress, feed self, or

perform other tasks perform other tasks Urinary incontinenceUrinary incontinence Decreased sensation, numbness, or tingling Decreased sensation, numbness, or tingling

on affected side of the body on affected side of the body Difficulty speaking and/or or understanding Difficulty speaking and/or or understanding

wordswords DepressionDepression

Medical RecordMedical Record Drugs:Drugs: (according to the cause of the (according to the cause of the

disease).disease). Reports:Reports: (all reports from other physician- (all reports from other physician-

previous investigations).previous investigations). Laboratory tests. Laboratory tests. (blood test)(blood test) Vital signs.Vital signs. Bowel or bladder incontinenceBowel or bladder incontinence Vision, hearing, speech records.Vision, hearing, speech records. Cardiopulmonary reports. Cardiopulmonary reports. Electrocephalogram EEG Electrocephalogram EEG (to measure electrical (to measure electrical

activity of the brain)activity of the brain)

Computed Tomography (CT)Computed Tomography (CT)

Magnetic Resonance Imaging Magnetic Resonance Imaging (MRI)(MRI)

Screening and scanning Screening and scanning examinationexamination

General inspectionGeneral inspection:: General health.General health. Wearing glasses, Wearing glasses,

hearing aidshearing aids Relation between Relation between

family.family. Proportion of body Proportion of body

parts.parts. Weight& height.Weight& height.

Posture assessmentPosture assessment;; Posterior, anterior and Posterior, anterior and

lateral views. lateral views. From static and dynamic From static and dynamic

positions.positions.• Position of head & neck.Position of head & neck.• Levels of shoulders.Levels of shoulders.• ScoliosisScoliosis• Chest shape .Chest shape .• Level of waist (ASIS).Level of waist (ASIS).• Anterior or posterior pelvic Anterior or posterior pelvic

tilting.tilting.• Any deformities of upper Any deformities of upper

and lower limbs.and lower limbs.

Screening and scanning Screening and scanning examinationexamination

Involuntary MovementInvoluntary Movement Function:Function: Observe any functional Observe any functional

disabilities during taking his disabilities during taking his cloth off.cloth off.

Gait:Gait: PPhases of gait or any hases of gait or any

abnormalities in gaitabnormalities in gait wearing assisted devices.wearing assisted devices.

Specific InspectionSpecific Inspection

Inspect the trunk and Inspect the trunk and extremities for signs of extremities for signs of asymmetry, lesions, scars, asymmetry, lesions, scars, trauma, deformities or trauma, deformities or previous surgery.previous surgery.

Involuntary movement: Involuntary movement: Chorea, Athetosis, TremorsChorea, Athetosis, Tremors ConvulsionConvulsion Face Texture: Face Texture: Deviation of mouth angleDeviation of mouth angle Skin:Skin: color, hair patches, scars, wounds , of the skin color, hair patches, scars, wounds , of the skin Bones:Bones: alignment, deformity. alignment, deformity. Muscle:Muscle: Spasticity, spasm, atrophy Spasticity, spasm, atrophy

PalpationPalpation

Soft tissues of upper and lower limbs .Soft tissues of upper and lower limbs . Changes in temperature or texture.Changes in temperature or texture. Mobility of the skin. Mobility of the skin. Tenderness.Tenderness. Spastic and atrophied muscles.Spastic and atrophied muscles.

Comprehensive Motor Control AssessmentComprehensive Motor Control AssessmentExamination of the Mental FunctionExamination of the Mental Function State of consciousness:State of consciousness: Alert Drowsiness ComaAlert Drowsiness Coma Orientation for Time and Place.Orientation for Time and Place. Memory:Memory: Immediate Recent RemoteImmediate Recent Remote Communication Abilities:Communication Abilities: Vision Hearing SpeechVision Hearing Speech Behavior and Psychological Status:Behavior and Psychological Status: Depression AngryDepression Angry Intelligence:Intelligence: IQ IQ

Examination of SpeechExamination of Speech Sensory Aphasia:Sensory Aphasia:1)Visual:1)Visual: Visual AgnosiaVisual Agnosia AlexiaAlexia2)Auditory:2)Auditory: Auditory AgnosiaAuditory Agnosia Motor Aphasia:Motor Aphasia: Verbal aphasiaVerbal aphasia AgraphiaAgraphia

Sensory Examination Superficial sensationSuperficial sensationTouch, Pain, Temperature Touch, Pain, Temperature ( compare on each side of limbs)( compare on each side of limbs)

Semmes Weinstein monofilament testSemmes Weinstein monofilament test

Pin prick testPin prick test

Sensory Examination

Vibration senseVibration sense The use of a 256-Hz tuning The use of a 256-Hz tuning

fork over different bony fork over different bony prominance. prominance.

Deep SensationDeep Sensation

Joint Sense Sense of position Sense of position

sense of movementsense of movement

Romberg’s Test

Muscle sense

Deep SensationDeep Sensation

Sensory ExaminationSensory Examination

2-point discrimination

Cortical SensationCortical Sensation Tactile Localization

Cortical SensationCortical Sensation

StereognosisStereognosis

GraphosthesiaGraphosthesia

Perceptual SensePerceptual Sense

Examination of Cranial NervesExamination of Cranial Nerves Oculomotor Nerve (3Oculomotor Nerve (3rdrd cranial nerve): cranial nerve): Ask patient to look upwardAsk patient to look upward abducent Nerve (6abducent Nerve (6thth cranial nerve): cranial nerve): Ask patient to look laterallyAsk patient to look laterally Facial Nerve (7Facial Nerve (7thth cranial nerve): cranial nerve): Ask patient to smile and showing teethAsk patient to smile and showing teeth Absence of nasolabial fold and dropping angle of Absence of nasolabial fold and dropping angle of

mouthmouth Hypoglossal nerve (12Hypoglossal nerve (12thth cranial nerve): cranial nerve): Deviation of tongue toward the affected sideDeviation of tongue toward the affected side Ask patient to push his check with the tip of tongueAsk patient to push his check with the tip of tongue

Muscle Tone AssessmentMuscle Tone Assessment Spasticity or hypertonia of the paralysed Spasticity or hypertonia of the paralysed

muscles of the clasp-knife type:muscles of the clasp-knife type:It affect It affect the antigravitythe antigravity more than more than the progravitythe progravity

muscles.muscles. In UL:In UL: the flexors more spastic than the the flexors more spastic than the

extensorsextensors In LL:In LL: the extensors more spastic than the the extensors more spastic than the

flexorsflexors

Factors affecting Muscle toneFactors affecting Muscle tone

AnxietyAnxiety TemperatureTemperature TensionTension Drugs Drugs FearFear Fullness of bladderFullness of bladder Position of the headPosition of the head Environmental conditionEnvironmental condition Vision and hearingVision and hearing PainPain

Assessment of Muscle ToneAssessment of Muscle TonePassive MovementPassive MovementAshworth Scale :Ashworth Scale :To perform this test, the part is moved through To perform this test, the part is moved through

the joint range-of-motion (ROM).the joint range-of-motion (ROM). Ashworth Score CriteriaAshworth Score Criteria:: 00 No increase in toneNo increase in tone 11 Slight increase in tone, giving a “catch” when Slight increase in tone, giving a “catch” when

the limb is moved in flexion or extensionthe limb is moved in flexion or extension 22 More marked increase in tone, but limb easily More marked increase in tone, but limb easily

flexedflexed 33 Considerable increase in tone; passive Considerable increase in tone; passive

movement difficultmovement difficult 44 Limb rigid in flexion or extensionLimb rigid in flexion or extension

Assessment of Muscle ToneAssessment of Muscle Tone Shaking:Shaking:Wrist and AnkleWrist and Ankle

Drop arm TestDrop arm Test

Postural tonePostural tone::Righting and Righting and

Equilibrium ReactionsEquilibrium Reactions

Examination of Muscle PowerExamination of Muscle Power Paralysis or Weakness of one side of the Paralysis or Weakness of one side of the

body.body. It affect theIt affect the progravityprogravity more than themore than the

antigravityantigravity muscles.muscles.

Upper limbs:Upper limbs: The ExtensorsThe Extensors are weaker are weaker than than the Flexorsthe Flexors..

Lower limbs:Lower limbs: The FlexorsThe Flexors are weaker than are weaker than the Extensorsthe Extensors

Examination of Muscle PowerExamination of Muscle PowerShoulder Joint:Shoulder Joint: C4-C5C4-C5

Elbow Joint:Elbow Joint: C5,6,7C5,6,7

Medial and Lateral RotationMedial and Lateral Rotation

AdductionAdductionAbductionAbduction

ExtensionExtensionFlexionFlexion

FlexionFlexion ExtensionExtension

Examination of Muscle PowerExamination of Muscle PowerWrist joint:Wrist joint: C7,8C7,8

FlexionFlexion ExtensionExtension

Hand:Hand:C8-T1C8-T1

Fingers and ThumbFingers and Thumb

Abduction, AdductionAbduction, AdductionFlexion, ExtensionFlexion, Extension

Examination of Muscle PowerExamination of Muscle Power

Abdominal Muscles:Abdominal Muscles:T6-T12T6-T12

Examination of Muscle PowerExamination of Muscle PowerFlexion: L1-2-3

Eversion: L5-S1Eversion: L5-S1

Inversion: L4-L5 Inversion: L4-L5

Plantarflexion: S1-2 Plantarflexion: S1-2

Dorsiflexion: L4-5 Dorsiflexion: L4-5

Flexion: L5-S1-2Flexion: L5-S1-2 Extension: L2-3-4Extension: L2-3-4

Extension: L4-5-S1-2Extension: L4-5-S1-2

Hip JointHip Joint

Knee JointKnee Joint

Ankle Joint and FootAnkle Joint and Foot

Abduction: L5-S1Abduction: L5-S1 Adduction: L2-3-4 Adduction: L2-3-4

Examination of ReflexesExamination of ReflexesA)A) Deep ReflexesDeep ReflexesExaggerated deep reflex in HemiplegiaExaggerated deep reflex in Hemiplegia

Biceps Reflex(C5,6)Biceps Reflex(C5,6)

Triceps Reflex(C6,7)Triceps Reflex(C6,7)

Deep ReflexesDeep Reflexes Brachioradialis reflex (C5,6)Brachioradialis reflex (C5,6)

Deep ReflexesDeep Reflexes

Achilles tendon (Ankle) reflex(S1,2) Achilles tendon (Ankle) reflex(S1,2)

Knee reflex(L2,3,4) Knee reflex(L2,3,4)

Lost on the paralysed sideLost on the paralysed sideB) Superficial ReflexesB) Superficial Reflexes

Abdominal Reflex (T6-T12)Abdominal Reflex (T6-T12)

Planter Reflex (S1-S2)Planter Reflex (S1-S2)

Positive Babinski SignPositive Babinski Sign

Test For ClonusTest For Clonus

Clonus :Clonus : Is a rhythmical series of Is a rhythmical series of contraction in response to the sudden contraction in response to the sudden sustained stretch of the tendon of the sustained stretch of the tendon of the muscle.it appear in the UMNLmuscle.it appear in the UMNL..

Ankle ClonusAnkle Clonus

Range of Motion AssessmentRange of Motion Assessment Active and Passive ROMActive and Passive ROM

Range of Motion AssessmentRange of Motion AssessmentElectrogoniometerElectrogoniometer

Universal goniometerUniversal goniometer

Long and Round measurementLong and Round measurement Circumferential measurements:Circumferential measurements: By tape By tape

measurement to determine atrophy of lower measurement to determine atrophy of lower limb muscles (quadriceps, calf muscles).limb muscles (quadriceps, calf muscles).

Long Measurement:Long Measurement: Measure leg lengths Measure leg lengths from anterior superior iliac spine to medial from anterior superior iliac spine to medial malleolus by Tape measurement.malleolus by Tape measurement.

Functional AssessmentFunctional Assessment•Dressing and undressingDressing and undressing•Transferee activitiesTransferee activities•Gait and ambulationGait and ambulation•Ability to get up from chair or on/off the Ability to get up from chair or on/off the examination table examination table •Using assistive deviceUsing assistive deviceThere are 4 grade for evaluation:There are 4 grade for evaluation:

*Can’t do it.*Can’t do it.

*Do it with maximum assistance.*Do it with maximum assistance.

*Do it with minimal assistance.*Do it with minimal assistance.

*Do it without assistance.*Do it without assistance.

Balance AssessmentBalance Assessment

Coordination assessmentCoordination assessment Finger-to-nose test Finger-to-nose test

Finger-to-finger test

Finger-to-doctor's finger test

Coordination assessmentCoordination assessment

Heel-to-knee test Heel-to-knee test

Gait AssessmentGait Assessment

The gait of hemiplegic patients is circumduction The gait of hemiplegic patients is circumduction GaitGait

1)patient walk across the room under observation and 1)patient walk across the room under observation and gross gait abnormalities should be notedgross gait abnormalities should be noted..

2(Heel to toes 3(Walk on toes 4(Walk on heels

Special TestsSpecial Tests Upright Motor Control Test:Upright Motor Control Test:

Upright Motor Control TestUpright Motor Control Test

A) Knee extension:A) Knee extension:patient bends both knees to approximately 30 patient bends both knees to approximately 30 degrees and then lifts the unaffected leg off the degrees and then lifts the unaffected leg off the ground. ground. Grades: Grades: Strong: Strong: straightens the flexed knee to full straightens the flexed knee to full extension.extension. Moderate:Moderate: supports body weight on the flexed supports body weight on the flexed knee.knee. Poor:Poor: unable to support body weight on the unable to support body weight on the flexed knee flexed knee

Upright Motor Control TestUpright Motor Control TestB) Knee flexion:B) Knee flexion: The patient stands as straight as possible and The patient stands as straight as possible and brings the knee and foot on the affected side up brings the knee and foot on the affected side up toward the chest as high and as fast as possible, toward the chest as high and as fast as possible, repeated three times.repeated three times. Grades: Grades: Strong: Strong: joint flexes more than 60 joint flexes more than 60 degrees degrees Moderate: Moderate: joint flexes less than 60 joint flexes less than 60 degrees or cannot complete three efforts in degrees or cannot complete three efforts in 10 seconds. 10 seconds. Poor: Poor: cannot make flexion.cannot make flexion.

Postural AssessmentPostural Assessment Computerized Posture Analysis Computerized Posture Analysis

Postural AssessmentPostural Assessment

Moire TopographyMoire Topography

3D/4D Formetric3D/4D Formetric

Postural AssessmentPostural Assessment

Postural AssessmentPostural Assessment

posturalprintposturalprint

Postural AssessmentPostural Assessment

Posture Evaluation Kit

3D Motion Analysis System3D Motion Analysis SystemRange of Motion AssessmentRange of Motion Assessment

Evaluation of Muscles StrengthEvaluation of Muscles StrengthIsokinetic DynamometerIsokinetic Dynamometer

Isokinetic DynamometerIsokinetic Dynamometer

Evaluation of Muscles StrengthEvaluation of Muscles Strength

Dynamometer :Dynamometer : For trunk and lower limb movementsFor trunk and lower limb movements

Lumbar Extension Lumbar Rotation

DynamometerDynamometer Ankle Plantar FlexionAnkle dorsi Flexion

Hip Flexion Knee Flexion

Evaluation of Muscles StrengthEvaluation of Muscles Strength

Digital Muscle Tester Digital Muscle Tester

Gait EvaluationGait Evaluation3D motion analysis and force platform3D motion analysis and force platform

Detect different kinetics and kinematics of gait.Detect different kinetics and kinematics of gait.

Gait EvaluationGait Evaluation Detect any abnormalities in gaitDetect any abnormalities in gait

Balance AssessmentBalance Assessment

TetraxTetrax Balance MasterBalance Master Balance ManagerBalance Manager

Muscle Tone AssessmentMuscle Tone Assessment

Detect abnormalities of muscle tone.

Electromyography