Hemiplegia
Hemiplegic children have involvement of the arm and leg on  one side of the body. The upper extremity is more severely involved than the lower. Spastic hemiplegia constitutes 20% of cases with spastic CP. These children generally have very few associated problems. Communication is unimpaired most of the time. They may have seizures, learning and behavioural problems. Functional prognosis is good compared to other types because one side of the body is normal. All hemiplegic children learn to walk by the age of three. They become independent in the activities of daily living. Seizures, mild mental retardation,  learning difficulties and behavioural disturbances may complicate the management and integration into the society.

Common musculoskeletal problems

The shoulder is adducted and internally rotated, the elbow is flexed and pronated, the wrist and fingers are flexed, the thumb is in the palm. The hip is flexed and internally rotated, the knee is flexed or extended, the ankle is in plantar flexion. The foot is generally in varus, although valgus deformity may also be  seen. The hemiplegic side is short and atrophic depending on the severity of involvement.

Musculoskeletal problems in hemiplegia

Upper extremity

• Shoulder -  Internal rotation, Adduction
• Elbow -  Pronation, Flexion
• Wrist – Flexion
• Hand – Flexion , Thumb-in-palm

Lower extremity

• Hip – Flexion, Internal rotation
• Knee – Flexion, Extension
• Ankle – Plantar flexion
• Foot – Varus

Treatment consists of physiotherapy, occupational therapy, bracing, botulinum toxin injections and orthopaedic surgery. Some children may need speech therapy and antiepileptic medication.

Treatment in hemiplegia

• Physiotherapy – Prevent contractures, Strengthen weak muscles, Establish a better walking pattern
• Occupational therapy – Functional use of upper extremity, Activities of daily living
• Bracing
  Lower extremity  –>  Solid or hinged AFOs
  Upper extremity  –>   Functional or resting hand splints
• Botulinum toxin A
  Lower extremity – Rectus femoris and gastroc spasticity
  Upper extremity – Pronator flexor spasticity
• Orthopaedic surgery – Correction of Pes equinovarus, Stiff knee, Femoral anteversion

Physiotherapy & occupational therapy

Motor problems of the hemiplegic child are usually mild. Physiotherapy is prescribed to prevent contractures of the involved side, to strengthen the weak muscles, to enable functional use of the upper extremity and to establish a better walking pattern. The basic program for the lower extremity consists of hip, knee, ankle range of motion exercises; rectus femoris, hamstring and gastrocnemius muscle stretching and agonist muscle strengthening. Do not neglect the back extensors and pelvic girdle muscles. Prescribe occupational therapy to gain hand function. Activities that involve both hands may improve the use of the involved side. Inhibiting the sound extremity and forcing the involved one to work is a novel method called constraint induced therapy. This method has certain beneficial effects but it is frustrating for most children. Children with hemiplegia do not need physiotherapy for ambulation. Prognosis for independent walking is very good. Physiotherapy is beneficial to prevent contractures of the ankle. In most of the cases the physiotherapy and occupational therapy can be accomplished on an outpatient basis or home program.

Botulinum toxin A

Botulinum toxin injections are used for upper and lower extremity spasticity in the young child. The toxin reduces gastrocnemius-soleus and rectus femoris spasticity in the lower extremity. The child uses his braces more efficiently and may develop a better walking pattern. Early relief of spasticity may prevent shortening of the gastrocnemius muscle and delay or eliminate the need for surgical intervention. In the upper extremity, inject botulinum toxin to relax wrist, finger and thumb flexors so that the child may gain forearm supination and wrist stabilization. Relaxing the spastic muscles with botulinum toxin injections may aid the treatment team to visualize how the child will function when his spastic muscles are surgically lengthened. However, the toxin cannot show its real effect in some older children with already shortened muscles. Botulinum toxin may be combined with surgery in the older child. Inject muscles which have mild spasticity and no shortening with Botulinum toxin and surgically lengthen the severely spastic short muscles. This combination approach adopted in the recent years enables a swifter return of function, less complications and less muscle weakness because of less extensive orthopaedic surgery.

Bracing

Upper extremity bracing
There are two indications for hand splints in hemiplegia. One is to prevent deformity and the other is to improve function. Night splints help stretch muscles and maintain range of motion.Tone usually decreases at night, therefore the use of resting splints at night to prevent deformity is questionable. The child’s compliance with night splints is generally poor. Use day splints to increase function by either supporting the wrist in 10o extension, the thumb in opposition or both. Keep in mindthat day splints prevent sensory input in the already compromised hand.

Lower extremity bracing
AFOs stabilize the ankle and foot and keep it in the plantigrade position for weight bearing. They are set in 5o dorsiflexion to avoid genu recurvatum or at neutral to prevent knee flexion. If the foot remains fixed the child has to extend the knee. Correct all fixed contractures before giving braces. Use hinged AFOs for mono and hemiplegic patients especially when they have active dorsiflexion.

Type of brace   <–>  Indication

• Solid AFO                        <–> Equinus and equinovarus
• AFO in 5 dorsiflexion <–> Equinus & genu recurvatum
• Hinged AFOs                  <–> Equinus and equinovarus if the child:
  a.     can tolerate the hinge
  b.     has varus-valgus control
  c.     has 5o passive dorsiflexion
• Supramallleolar orthoses (SMO)  <–> Mild varus – valgus deformity
  without equinus