Case studyMale, 64 years old· 5 min read

Spastic hemiplegia with right-sided hemiparesis – a case study

Speech difficultiesHand and upper limbGait difficulties

Prepared by the NORMAN Neurological Rehabilitation Centre.

This case study does not constitute medical advice and does not replace a consultation with a specialist or an individual diagnosis. For questions about your own health, please contact a doctor or physiotherapist.

Therapy results

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Patient details

Sex

Male

Age

64 years old

Main diagnosis

  • post-stroke spasticity
  • spastic right-sided hemiplegia
  • status post intracerebral haemorrhage

Comorbidities

  • sequelae of intracerebral haemorrhage
  • right-sided hemiparesis
  • speech disorder of the aphasic type
  • joint contracture
  • status post botulinum toxin injection into the muscles of the right upper and lower limb

Functional status

This case describes a patient following a haemorrhagic stroke with established right-sided hemiparesis of a spastic nature. On functional assessment, the most striking findings were limitations affecting the right upper and lower limb, including increased muscle tone and impaired hand and upper limb function requiring targeted therapy.

A speech disorder of the aphasic type was noted. The patient remained in coherent contact and understood simple commands. The records describe difficulties with verbal communication, indicating a need for speech rehabilitation, while comprehension of speech was partially preserved.

In terms of mobility, the patient walked with a tripod stick over short distances and used a wheelchair over longer distances. He was able to transfer from the wheelchair to a couch and to move from a sitting to a standing position and back again.

Significant medical events

Botulinum toxin was administered on account of post-stroke spasticity. The preparation was injected into the muscles of the right upper and lower limb, including the flexor muscles of the wrist, fingers and thumb, as well as the muscles of the lower limb associated with the spastic positioning of the foot and toes.

Rehabilitation included, among other things, individual general fitness exercises, neurophysiological methods, the PNF method, stretching of muscles and tendons, gait training with equipment, free active exercises, balance exercises, training in locomotor activities, active verticalisation and hydromassage.

Patient status on completion of hospital treatment

At the final assessment, spastic right-sided hemiparesis persisted, along with impaired function of the right upper and lower limb. The patient still required work on hand function, sensation, gait and balance re-education and positioning of the right upper limb as part of further rehabilitation after stroke.

He used a tripod stick when walking and a wheelchair over longer distances. The records also indicated a need for further rehabilitation at home or on an outpatient basis.

Next stage of rehabilitation

After completing the treatment stage described here, the patient continued the process of neurological rehabilitation.

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Neurological rehabilitation stay

Symptoms and deficits described in this case

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