Right Hemisphere Syndrome and Left Hemiplegia in Stroke Rehabilitation

Human brain is a mystery, so its injury may cause not only physical handicap but also mysterious psychological or so we call higher brain function disorders. In order to contrast, the therapist first outlines the right hemiplegia (hemi-paralysis) caused by left hemisphere injuries. Brain is split into two hemispheres, right and left. In terms functioning, the left hemisphere mainly controls the right side of the body, and vice versa, because the main nerve routes named pyramidal tracts originate from hemispheres, cross at the brainstem, and control the sides. In terms of psychology and intellect, left hemisphere is called the brain of logic having language integrating centers named Broca and Wernicke Areas and mainly serves for logical processing of the nervous stimuli such as language or calculation. Therefore, right hemiplegia (hemiparesis) often accompanies aphasia, higher integrating disorder of speech. In spite of critical speech disorder, overall statistical results of recovery among right hemiplegia (left hemisphere injuries) is better than the counterpart, mysteriously. Patients’ core personality does not change, and they seems to be more motivated better than the patients with left hemiplegia in recovering to more normal life like before.

Right hemisphere, on the contrary, is called the brain of intuition having control of intuitive processing like spacial orientation, but which seems to be integrating both hemisphere functions rather than working only independently. Not only physically having left hemiplegia and being more difficult to recover than the counterpart but also its injuries accompany strange psychological or higher brain function disorders named right hemisphere syndrome, so patients, families, or therapists face one of the most difficult problems in stroke rehabilitation. Amid distinctly depending on the cases, the major symptom of it is left unilateral agnosia and is strange because right hemiplegia doesn’t accompany right unilateral agnosia.

The therapist was in charge of an outpatient with left hemiplegia caused by right cerebral infarction but had become to walk with brace and even drive his car using his right hand and leg. His wife confessed he had had car accident at a junction when he had been turning to the right. A senior occupational therapist who had been specialized in the higher brain function disorders once pointed out that all the left hemiplegia patients show more or less the left unilateral spacial agnosia then they neglect their closer portion of left space. The cause of the accident of the outpatient must have been that, the therapist guessed, and it is a dangerous symptom. Not only spacial agnosia but it accompanies unilateral body agnosia which neglects their left body in no relation with the decreased sensation. In experiment, patients’ eyes follow the object moving to the left slowly but quick movement called saccade is difficult. After ending up reading a line to the right, the eyes quickly change the direction to the left head of the next line. It is called saccade movement, and can be used as a treatment, too. This problematic left unilateral spacial agnosia seems to be related not only sensation but also so many of their physical function that treatment programs need to be dealt with holistic approach rather than focusing on itself. The sense of their body axis or line of gravity may be deviated.

He was in charge of a former geo-science professor of a university who had left hemiplegia during his freshman days. When therapy team saw the tomography of his brain, a vast area of his right hemisphere showed low density (black) and could have represented the severity of disability. PTs focus more on recovery of physical functioning such as walking, and the earlier we start, the better the effectiveness of treatment. Patients can generally become to walk again even with brace and/or cane. During his treatment session of 40 minutes a day the therapist kept feeling different type of patient's problems which were not totally physical but rather personality change including distinct symptoms such as unilateral (spatial and body) agnosia. We once challenged playing Go in a break time. Go is a sophisticated game like Asian chess locating black and white stones alternatively selecting a crossing point out of 19 by 19 line square board. With simple rule but in the vast battle field, Go is the most complicated game in tactics and needs reading the future with strength of intellect. When we did, the therapist found that the ex-professor seldom located his stones in his left, and closer side among the 319 point areas so was defeated easily, even though he had been strong before stroke.

In accordance with such an unfamiliar attention disorder of unilateral special and/or body neglect, nurses and therapists in supporting the patient's daily life suffered from a unique balance problem so called pusher syndrome that Pat Davies described in 'Steps to Follow.' When standing up and transferring from bed to wheelchair, the patient pushed his body toward left (affected) side and supporters needed more power in assisting their activity. In sitting, also, the patient pushed toward left even when the body leaning to left; very unusual balance problem and accompanied excessive power of his right limbs. In acute stages leaning to affected side was a common symptom, but pushing toward leaning side was very unusual; logical?

Motor impersistence is another difficult symptom in right hemisphere syndrome with which patients can’t keep a movement or focusing on treatment exercise. In case right after the stroke and during the recovery stage they can get great improvement when they cooperate with the treatment and rehabilitation, but these symptoms may cause their recovery limited. In the case of ex-professor, training such as walking was very much difficult due to lack of concentration or persistence. Beginner therapist could have attributed to the patient's lack of motive or enthusiasm to recover, and which may have easily happened even in experienced experts. His colleague OT was skillful in treating both physically and psychologically for example letting him at a standing table. The OT was very strict in attitude with rod, using peg board for eye movement in standing for stimulating body sensation at the same time. Over half a year treatment, the patient managed to walk with cane and brace supervised by someone. In addition, the symptom of left unilateral spacial agnosia showed improvement or at least he intentionally adjusted his vision and attention somehow.

Another symptom, talkativeness than before stroke comes after overcoming early stages of disarticulation, or speech disturbance of motor control which is different from aphasia of right hemiplegia. One woman he treated became very loquacious and her stories jumped around topics. Further, what many team members suffered most from right hemisphere syndrome was the change of personality as a whole, which was somehow deviated and not consistent as before stroke. So was the ex-professor’s case, too, then the therapist was skeptical if he were a lazy person even if having been very diligent before. As a result, the recovery of left hemiplegia is not so well compared with right hemiplegia.

For treatment and rehabilitation, whole member have to well know the core nature of their disabilities which must be different in each case. Occupational therapists are generally responsible in analyzing and assessing their psychological condition and every team member had better share the understanding, or the patients may easily have accidents. Team work is necessary and has to be oriented by in-depth understanding of each case by knowledge of specialties. A lot of researches come in periodicals or books, because the problems of right hemisphere syndrome are multi-disciplinary in nature, in the field neurological rehabilitation, physical therapy, occupational therapy, speech, language and hearing therapy, psychology, nursing, social working, and physical medicine and rehabilitation as a whole. Comprehensive test batteries are developed by many researchers.

The therapist now explains his background of practice learned from worldwide. Therapists young and experienced gathered in 1982 to Bobath Hospital, a new rehabilitation hospital in Osaka, Japan, named after British physiotherapist Berta 1) 3), and psychiatrist and neurophysiologist Karel Bobath 2) 3). Among some neurophysiological approaches developed for neurological conditions worldwide after WW II, the Bobaths are one of the pioneering mentors who organized courses for cerebral palsy and adult hemiplegia (stroke.) Physical therapists, occupational therapists, speech therapists, physicians, nurses, or teachers worldwide are multidisciplinary team members trained by them and instructors. Adopting and educating the Bobath Approach, the leading experts in the hospital not only treated patients, trained young professionals, but also lead Japan's health care system centering, localizing, and applying to insurance system. The Bobaths and instructors worldwide wrote a lot of periodicals, course notes, and summarized their works into books. Being a practitioner Berta was honored Ph. D. by Boston University, which must keep their resources. The Bobaths applied the principles of baby development for neurology and once called the approach Neuro-developmental Treatment (NDT) and finally defined as a holistic approach. For the treatment of psychological conditions in left hemiplegia, therapists applied their principles and concepts, too.

20th century is said of that has found brain and baby, and lots of scholars, researchers, and practitioners joined these fields. Therefore, not only Berta and Karel Bobath, but also major neurophysiological practitioners and researchers have to be named here for the successor's appreciation. Kabat, Knot, and Voss 4) created a new technique named proprioceptive neuromuscular facilitation. Ayres A J 5) 6), OT is famous in her idea and practice on sensory integration. Recently Carr J. 7) 8), and Shephard, R. 7) 8) 9), have become leading practitioners and researchers.

In summary, left hemiplegia caused by right hemisphere cerebral vascular accident also has strange nature of psychological problems named right hemisphere syndrome. Major symptoms are aphagia, or difficulty in eating, disarticulation, or problem of vocalization, left unilateral (spacial or body) agnosia, pusher syndrome, motor impersistence, talkativeness, and/or the change of personality as a whole. People don’t necessarily show all of these but may have some symptoms based on the causal portion or the extent of injuries of the hemisphere. Their recovery and rehabilitation is somehow limited compared with right hemiplegia because mainly of the psychological disorders. The therapist has described major symptoms of left hemiplegia after stroke and accompanying psychological problems staff members face daily and popularly, but there are lots of other higher brain function disorders caused by and depending on the severity and portions of the brain. Agnosia as a whole can be said of a characteristic and popular problem of perception. Apraxia is a problem of integrating motor functions or confusion of them. These symptoms appear even if they aren’t well known to general public. Readers allow the therapist only introducing and outlining the popular agnosia and apraxia, and let him serve additional researches on each case in clinical environment.

References:

  1. Bobath, Berta. Adult Hemiplegia: Evaluation and Treatment 3rd Ed. London: Butterworth-Heinemann. 1990.

  2. Bobath, Karel. A Neurophysiological Basis for the Treatment of Cerebral Palsy 2nd Ed. London: Mac Keith Press. 1991.

  3. Bobath, Berta, and Bobath, Karel. Motor Development in the Different Types of Cerebral Palsy. London: Butterworth-Heinemann. 1975.

  4. Davies, Patricia M. Steps to Follow: The Comprehensive Treatment of Patients with Hemiplegia Springer; 2nd edition. 2004.

  5. Voss, A R M. Proprioceptive Neuromuscular Facilitation: Patterns and Techniques 3rd Ed. Lippincott Williams & Wilkins. 1985.

  6. Ayers A J. Sensory Integration and the Child: 25th Anniversary Edition. Western Psychological Services. 2005.

  7. Ares, A J. Love, Jean: Inspiration for Families Living with Dysfunction of Sensory Integration. Crestport Press. 2004.

  8. Carr, J. and Shephard, R. Neurological Rehabilitation: Optimizing Motor Performance. 2nd Ed. London: Churchill Livingstone. 2011.

  9. Carr, J. & Shephard, R. Stroke Rehabilitation - Guidelines for Exercise and Training to Optimize Motor Skill. London: Butterworth-Heinemann. 2002.

  10. Shephard, R. Physiotherapy in Pediatrics 3rd Ed. London: Butterworth-Heinemann. 1995.


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