Hemiplegia

Complete paralysis affecting one side of the body due to brain or spinal cord injury

Table of Contents

Quick Facts

  • Type: Neurological Disorder
  • ICD-10: G81.9
  • Affects: One body side
  • Recovery: Variable

Overview

Hemiplegia is a condition characterized by complete paralysis of one side of the body, affecting the arm, leg, and often facial muscles on the same side. The term comes from the Greek words "hemi" (half) and "plegia" (paralysis). This condition results from damage to the motor pathways in the brain or spinal cord that control voluntary movement, specifically affecting the corticospinal tract which crosses over in the brainstem, causing paralysis on the opposite side of the body from where the brain injury occurred.

It's important to distinguish hemiplegia from hemiparesis, which refers to weakness rather than complete paralysis of one side. While hemiparesis involves reduced strength and motor control, hemiplegia represents a more severe form where voluntary movement is completely absent. The condition can be congenital, appearing at birth or in early childhood often due to cerebral palsy, or acquired later in life, most commonly following a stroke.

Hemiplegia affects approximately 1 in 1,000 children and is a leading cause of disability following stroke in adults. The impact extends beyond physical limitations, affecting independence, mobility, communication, and quality of life. However, with comprehensive rehabilitation and support, many individuals with hemiplegia can achieve significant functional improvements and lead fulfilling lives. The brain's neuroplasticity allows for some recovery and adaptation, particularly when intervention begins early.

Symptoms

Hemiplegia presents with a constellation of symptoms affecting motor function, sensation, and associated body systems. The severity and specific manifestations vary depending on the location and extent of brain damage.

Primary Motor Symptoms

Complete Paralysis

Loss of voluntary movement on affected side

 Muscle Flaccidity/Spasticity

Initial flaccidity followed by increased tone

 Altered Reflexes

Hyperreflexia and pathological reflexes

 Gait Disturbances

Circumduction gait when ambulation possible

Stages of Motor Recovery

Flaccid Stage (Initial)

  • Complete loss of muscle tone
  • No voluntary movement
  • Absent or diminished reflexes
  • Risk of shoulder subluxation
  • Dependent edema in affected limbs

Spastic Stage (Weeks to Months)

  • Increased muscle tone (spasticity)
  • Hyperactive reflexes
  • Clonus (rhythmic muscle contractions)
  • Flexor synergy patterns in arm
  • Extensor synergy patterns in leg
  • Positive Babinski sign

Sensory Symptoms

  • Loss of sensation on affected side
  • Impaired proprioception (position sense)
  • Altered temperature perception
  • Reduced pain sensation
  • Tingling or burning sensations
  • Neglect syndrome (ignoring affected side)

Associated Symptoms

Communication Difficulties

  • Aphasia: Language impairment (left hemisphere damage)
  • Dysarthria: Slurred speech from facial weakness
  • Dysphagia: Swallowing difficulties
  • Facial droop: Asymmetric facial expression

Cognitive and Perceptual Changes

  • Memory impairment
  • Attention deficits
  • Visual field defects (hemianopia)
  • Spatial perception problems
  • Executive function difficulties

Secondary Complications

  • Contractures: Joint stiffness from immobility
  • Pressure sores: From prolonged positioning
  • Deep vein thrombosis: Due to immobility
  • Pneumonia: Aspiration risk
  • Urinary tract infections: From catheter use
  • Depression and anxiety: Psychological impact

Functional Limitations

  • Inability to walk independently
  • Difficulty with transfers (bed to chair)
  • Impaired activities of daily living
  • Loss of fine motor skills
  • Balance and coordination problems
  • Increased fall risk

Age-Specific Presentations

Pediatric Hemiplegia

  • Delayed motor milestones
  • Preference for one hand before 12 months
  • Asymmetric crawling or scooting
  • Toe walking on affected side
  • Growth discrepancy between sides

Adult-Onset Hemiplegia

  • Sudden onset with stroke
  • Progressive onset with tumors
  • Associated vascular symptoms
  • Greater functional impact

Causes

Hemiplegia results from damage to the motor pathways in the brain or upper spinal cord. The specific cause determines the onset pattern, associated symptoms, and prognosis. Understanding the underlying cause is crucial for appropriate treatment and prevention of further damage.

Vascular Causes (Most Common in Adults)

Ischemic Stroke

  • Thrombotic stroke: Blood clot forms in brain artery
  • Embolic stroke: Clot travels from elsewhere (heart, carotid)
  • Small vessel disease: Lacunar strokes
  • Watershed infarcts: Between vascular territories
  • Accounts for 87% of all strokes

Hemorrhagic Stroke

  • Intracerebral hemorrhage: Bleeding within brain tissue
  • Subarachnoid hemorrhage: Bleeding around brain
  • Arteriovenous malformation (AVM): Rupture
  • Aneurysm rupture: Sudden severe bleeding
  • Often more severe than ischemic stroke

Traumatic Causes

Traumatic Brain Injury (TBI)

  • Penetrating injury: Gunshot, sharp objects
  • Closed head injury: Falls, motor vehicle accidents
  • Diffuse axonal injury: Shearing forces
  • Contusion: Bruising of brain tissue
  • Epidural/subdural hematoma: Blood collection

Spinal Cord Injury

  • High cervical injuries (C1-C4)
  • Brown-Séquard syndrome (hemisection)
  • Trauma from accidents or falls
  • Penetrating spinal injuries

Congenital and Perinatal Causes

Cerebral Palsy

  • Prenatal factors:
    • Intrauterine infections
    • Maternal health conditions
    • Genetic abnormalities
    • Placental problems
  • Perinatal factors:
    • Birth asphyxia
    • Premature birth
    • Low birth weight
    • Kernicterus (severe jaundice)

Developmental Abnormalities

  • Hydrocephalus
  • Porencephaly
  • Schizencephaly
  • Polymicrogyria
  • Periventricular leukomalacia

Neoplastic Causes

  • Primary brain tumors:
    • Gliomas
    • Meningiomas
    • Astrocytomas
  • Metastatic tumors: From lung, breast, melanoma
  • Spinal cord tumors: Compression of motor pathways
  • Paraneoplastic syndromes: Immune-mediated

Infectious Causes

  • Meningitis: Bacterial, viral, fungal
  • Encephalitis: HSV, West Nile, Japanese encephalitis
  • Brain abscess: Localized infection
  • Tuberculoma: TB of the brain
  • Neurocysticercosis: Parasitic infection
  • HIV-related: Toxoplasmosis, PML

Inflammatory and Autoimmune Causes

  • Multiple sclerosis: Demyelinating disease
  • Acute disseminated encephalomyelitis (ADEM): Post-infectious
  • Vasculitis: Blood vessel inflammation
  • Systemic lupus erythematosus: CNS involvement
  • Antiphospholipid syndrome: Increased clotting

Metabolic and Toxic Causes

  • Hypoglycemia: Severe, prolonged
  • Hypoxic-ischemic injury: Cardiac arrest, drowning
  • Carbon monoxide poisoning: Basal ganglia damage
  • Drug toxicity: Chemotherapy, immunosuppressants
  • Mitochondrial disorders: MELAS syndrome

Other Causes

  • Hemiplegic migraine: Temporary hemiplegia
  • Todd's paralysis: Post-seizure weakness
  • Conversion disorder: Psychogenic
  • Moyamoya disease: Progressive vessel narrowing
  • Sturge-Weber syndrome: Vascular malformation

Risk Factors

Understanding risk factors for hemiplegia helps identify individuals at higher risk and implement preventive strategies. Risk factors vary by age group and underlying cause.

Vascular Risk Factors

Modifiable Risk Factors

  • Hypertension: Leading modifiable risk factor
  • Diabetes mellitus: Increases stroke risk 2-4 fold
  • Smoking: Doubles stroke risk
  • High cholesterol: Atherosclerosis development
  • Obesity: BMI >30 increases risk
  • Physical inactivity: Sedentary lifestyle
  • Excessive alcohol: >2 drinks/day
  • Drug use: Cocaine, amphetamines

Non-Modifiable Risk Factors

  • Age: Risk doubles each decade after 55
  • Gender: Men higher risk until menopause
  • Race/ethnicity: Higher in African Americans
  • Family history: Genetic predisposition
  • Previous stroke/TIA: Recurrence risk

Perinatal Risk Factors

Maternal Factors

  • Advanced maternal age (>35 years)
  • Multiple pregnancies
  • Infections during pregnancy
  • Preeclampsia/eclampsia
  • Substance abuse
  • Inadequate prenatal care
  • Maternal diabetes

Birth-Related Factors

  • Premature birth (<37 weeks)
  • Low birth weight (<2500g)
  • Birth asphyxia
  • Prolonged or difficult labor
  • Emergency cesarean section
  • Breech presentation
  • Placental abruption

Cardiac Risk Factors

  • Atrial fibrillation: 5-fold increased stroke risk
  • Coronary artery disease: Shared risk factors
  • Heart failure: Reduced cardiac output
  • Valvular disease: Embolic risk
  • Prosthetic heart valves: Clot formation
  • Endocarditis: Septic emboli

Lifestyle and Environmental Factors

  • Occupation hazards: Head injury risk
  • Contact sports: Traumatic brain injury
  • Motor vehicle use: Without safety measures
  • Falls risk: Elderly, balance problems
  • Violence: Assault, gunshot wounds

Medical Conditions

  • Blood disorders:
    • Sickle cell disease
    • Polycythemia
    • Thrombophilia
  • Autoimmune conditions:
    • Antiphospholipid syndrome
    • Systemic lupus erythematosus
    • Vasculitis
  • Infections:
    • HIV/AIDS
    • Syphilis
    • Tuberculosis

Medication-Related Risks

  • Oral contraceptives (especially with smoking)
  • Hormone replacement therapy
  • Anticoagulation therapy (hemorrhage risk)
  • Chemotherapy agents
  • Immunosuppressants

Diagnosis

Diagnosing hemiplegia involves comprehensive neurological assessment, identifying the underlying cause, and evaluating the extent of functional impairment. Early and accurate diagnosis is crucial for initiating appropriate treatment and rehabilitation.

Clinical Assessment

History Taking

  • Onset pattern: Sudden vs. gradual
  • Associated symptoms: Headache, seizures, fever
  • Risk factors: Vascular, trauma, infections
  • Medications: Anticoagulants, antiplatelets
  • Family history: Stroke, genetic conditions
  • Developmental history: For pediatric cases

Neurological Examination

  • Mental status: Consciousness, cognition, speech
  • Cranial nerves: Facial asymmetry, visual fields
  • Motor assessment:
    • Muscle strength (0-5 scale)
    • Muscle tone (flaccid vs. spastic)
    • Deep tendon reflexes
    • Pathological reflexes (Babinski)
  • Sensory testing: Touch, pain, proprioception
  • Coordination: If movement present
  • Gait analysis: If ambulatory

Imaging Studies

CT Scan (Initial Emergency)

  • Rapid assessment for hemorrhage
  • Rules out mass lesions
  • Shows established infarcts
  • Identifies hydrocephalus
  • CT angiography for vascular assessment

MRI Brain

  • Diffusion-weighted imaging (DWI): Early ischemic changes
  • T2/FLAIR: Chronic changes, edema
  • Gradient echo: Microhemorrhages
  • MR angiography: Vascular anatomy
  • MR perfusion: Tissue viability

Other Imaging

  • Carotid ultrasound: Stenosis evaluation
  • Echocardiography: Cardiac source of emboli
  • Transcranial Doppler: Intracranial vessels
  • Cerebral angiography: Gold standard for vessels

Laboratory Tests

Acute Phase

  • Complete blood count
  • Coagulation studies (PT/INR, aPTT)
  • Blood glucose
  • Electrolytes
  • Renal function
  • Liver function tests
  • Cardiac enzymes
  • Inflammatory markers (ESR, CRP)

Specialized Tests

  • Hypercoagulability panel: Young stroke patients
  • Autoimmune markers: ANA, anti-cardiolipin
  • Genetic testing: CADASIL, MELAS
  • Infectious workup: If suspected
  • Toxicology screen: Drug-related causes

Electrophysiological Studies

  • EEG: Seizure activity, encephalopathy
  • EMG/NCS: Peripheral vs. central
  • Evoked potentials: Pathway integrity
  • Transcranial magnetic stimulation: Motor pathway assessment

Functional Assessment Tools

Motor Function

  • Fugl-Meyer Assessment: Comprehensive motor evaluation
  • Action Research Arm Test: Upper limb function
  • Berg Balance Scale: Balance assessment
  • 10-Meter Walk Test: Gait speed

Activities of Daily Living

  • Barthel Index: Basic ADL independence
  • Functional Independence Measure (FIM): Comprehensive function
  • Modified Rankin Scale: Global disability
  • Stroke Impact Scale: Quality of life

Pediatric-Specific Assessments

  • Gross Motor Function Classification System (GMFCS): Mobility levels
  • Manual Ability Classification System (MACS): Hand function
  • Pediatric Evaluation of Disability Inventory (PEDI): Functional skills
  • Quality of Upper Extremity Skills Test (QUEST): Arm function

Differential Diagnosis

  • Hemiparesis (incomplete paralysis)
  • Todd's paralysis (post-seizure)
  • Hemiplegic migraine
  • Conversion disorder
  • Multiple sclerosis exacerbation
  • Brain tumor with edema
  • Hypoglycemic hemiplegia

Treatment Options

Treatment of hemiplegia requires a multidisciplinary approach focusing on addressing the underlying cause, preventing complications, and maximizing functional recovery through comprehensive rehabilitation. The approach varies based on cause, severity, and individual needs.

Acute Management

Emergency Interventions

  • Stroke protocols:
    • IV thrombolysis (tPA) within 4.5 hours
    • Mechanical thrombectomy within 24 hours
    • Blood pressure management
    • Antiplatelet therapy
  • Hemorrhage management:
    • Reversal of anticoagulation
    • Blood pressure control
    • Surgical evacuation if indicated
    • Management of increased intracranial pressure
  • Trauma care:
    • Stabilization of spine
    • Surgical decompression
    • Management of associated injuries

Medical Management

Spasticity Treatment

  • Oral medications:
    • Baclofen - GABA agonist
    • Tizanidine - Alpha-2 agonist
    • Dantrolene - Direct muscle relaxant
    • Diazepam - Benzodiazepine
  • Botulinum toxin injections:
    • Targeted muscle groups
    • Effects last 3-6 months
    • Combined with therapy
  • Intrathecal baclofen pump:
    • Severe generalized spasticity
    • Programmable delivery
    • Lower systemic side effects

Pain Management

  • Neuropathic pain medications (gabapentin, pregabalin)
  • NSAIDs for musculoskeletal pain
  • Antidepressants (duloxetine, amitriptyline)
  • Physical modalities (heat, cold, TENS)

Rehabilitation Therapies

Physical Therapy

  • Early mobilization: Prevent complications
  • Range of motion exercises: Maintain joint flexibility
  • Strengthening: Unaffected and affected sides
  • Balance training: Sitting and standing
  • Gait training:
    • Parallel bars
    • Body weight support treadmill
    • Assistive devices (cane, walker)
    • Orthotics (AFO for foot drop)
  • Constraint-induced movement therapy: Force use of affected limb

Occupational Therapy

  • Activities of daily living training:
    • Dressing techniques
    • Bathing and grooming
    • Feeding strategies
    • Toileting adaptations
  • Upper extremity rehabilitation:
    • Fine motor skills
    • Hand therapy
    • Splinting for positioning
  • Adaptive equipment:
    • One-handed devices
    • Environmental modifications
    • Wheelchair assessment
  • Cognitive rehabilitation: If deficits present

Speech and Language Therapy

  • Aphasia treatment
  • Dysarthria management
  • Swallowing assessment and therapy
  • Alternative communication methods
  • Cognitive-communication therapy

Advanced Rehabilitation Technologies

  • Robotic-assisted therapy:
    • Lokomat for gait training
    • Upper limb robots
    • Exoskeletons
  • Functional electrical stimulation (FES):
    • Muscle activation
    • Foot drop systems
    • Upper limb FES
  • Virtual reality therapy: Motor learning
  • Transcranial magnetic stimulation: Enhance plasticity
  • Brain-computer interfaces: Emerging technology

Surgical Interventions

  • Orthopedic procedures:
    • Tendon lengthening
    • Tendon transfers
    • Osteotomies for deformity
    • Joint fusion for stability
  • Neurosurgical procedures:
    • Selective dorsal rhizotomy
    • Deep brain stimulation
    • Motor cortex stimulation

Psychosocial Support

  • Psychological counseling:
    • Adjustment to disability
    • Depression and anxiety treatment
    • Family counseling
  • Social services:
    • Disability benefits
    • Home modifications
    • Vocational rehabilitation
  • Support groups: Peer connections
  • Caregiver education: Training and respite

Long-term Management

  • Secondary prevention:
    • Risk factor modification
    • Antiplatelet/anticoagulation therapy
    • Regular medical follow-up
  • Complication prevention:
    • Skin care protocols
    • DVT prophylaxis
    • Nutrition optimization
    • Bone health maintenance
  • Ongoing therapy:
    • Maintenance programs
    • Home exercise programs
    • Periodic reassessment

Prevention

While not all causes of hemiplegia can be prevented, many strategies can significantly reduce risk, particularly for vascular causes which account for the majority of adult cases. Prevention focuses on risk factor modification and early intervention.

Primary Prevention - Stroke Risk Reduction

Blood Pressure Control

  • Target: <130/80 mmHg for most adults
  • Lifestyle measures:
    • DASH diet
    • Sodium restriction (<2.3g/day)
    • Regular exercise
    • Weight management
  • Medications: ACE inhibitors, ARBs, diuretics as needed
  • Home monitoring: Track progress

Diabetes Management

  • HbA1c target <7% for most adults
  • Regular blood glucose monitoring
  • Medication adherence
  • Dietary management
  • Annual complications screening

Cholesterol Management

  • Statin therapy for high-risk individuals
  • Dietary modifications
  • Regular lipid monitoring
  • Target LDL based on risk profile

Lifestyle Modifications

  • Smoking cessation:
    • Counseling programs
    • Nicotine replacement therapy
    • Prescription medications
    • Support groups
  • Physical activity:
    • 150 minutes moderate exercise/week
    • Strength training 2x/week
    • Balance exercises for elderly
  • Healthy diet:
    • Mediterranean or DASH diet
    • 5+ servings fruits/vegetables daily
    • Whole grains
    • Limited saturated fat
  • Alcohol moderation: ≤1 drink/day women, ≤2 men

Medical Management

Atrial Fibrillation

  • Anticoagulation based on CHA2DS2-VASc score
  • Rate or rhythm control
  • Regular INR monitoring if on warfarin
  • Left atrial appendage closure if contraindicated

Carotid Stenosis

  • Screening in high-risk individuals
  • Medical management (statins, antiplatelets)
  • Carotid endarterectomy if >70% stenosis
  • Carotid stenting as alternative

Perinatal Prevention

Prenatal Care

  • Regular prenatal visits
  • Maternal infection screening and treatment
  • Management of maternal conditions
  • Avoiding teratogens
  • Folic acid supplementation
  • Rh incompatibility prevention

Delivery Management

  • Fetal monitoring during labor
  • Prompt intervention for fetal distress
  • Skilled delivery attendance
  • Neonatal resuscitation preparedness

Injury Prevention

  • Traffic safety:
    • Seat belt use
    • Child car seats
    • Helmet use (bicycles, motorcycles)
    • Avoiding distracted driving
  • Fall prevention:
    • Home safety assessments
    • Remove trip hazards
    • Adequate lighting
    • Grab bars in bathrooms
    • Balance and strength exercises
  • Sports safety:
    • Proper protective equipment
    • Technique training
    • Concussion protocols

Secondary Prevention

  • Post-stroke/TIA:
    • Antiplatelet therapy (aspirin, clopidogrel)
    • Aggressive risk factor control
    • Regular follow-up
    • Medication adherence
  • Monitoring and screening:
    • Annual health check-ups
    • Blood pressure monitoring
    • Cholesterol screening
    • Diabetes screening
    • ECG for arrhythmias

Public Health Measures

  • Community education programs
  • Stroke awareness campaigns (FAST)
  • Access to preventive healthcare
  • Workplace safety regulations
  • Environmental modifications

When to See a Doctor

Recognizing when to seek medical attention for hemiplegia or its warning signs is crucial. Immediate action can be life-saving and significantly impact recovery outcomes.

Emergency Situations - Call 911 Immediately

FAST Warning Signs

  • F - Face Drooping: One side of face droops or is numb
  • A - Arm Weakness: One arm is weak or numb
  • S - Speech Difficulty: Slurred speech or trouble speaking
  • T - Time to Call 911: Every minute counts

Additional Emergency Signs

  • Sudden severe headache with no known cause
  • Sudden confusion or trouble understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance
  • Sudden numbness of face, arm, or leg
  • Loss of consciousness or seizures

Urgent Medical Evaluation (Same Day)

  • Transient symptoms:
    • Brief weakness that resolves (TIA)
    • Temporary numbness or tingling
    • Episodes of confusion
    • Temporary vision changes
  • Progressive symptoms:
    • Gradually worsening weakness
    • Increasing difficulty walking
    • Progressive speech problems
  • Post-injury symptoms:
    • Weakness after head trauma
    • Delayed symptoms after accident
    • Persistent headache after injury

Schedule Appointment For

  • Risk assessment:
    • Multiple stroke risk factors
    • Family history of stroke
    • Irregular heartbeat
    • Previous TIA or stroke
  • Concerning symptoms:
    • Recurring headaches with neurological symptoms
    • Unexplained falls or balance problems
    • Memory or cognitive changes
    • Personality changes

For Existing Hemiplegia Patients

Seek Immediate Care For

  • New or worsening weakness
  • Seizures (new onset)
  • High fever with stiff neck
  • Severe, worsening spasticity
  • Signs of deep vein thrombosis
  • Chest pain or breathing difficulty
  • Severe pain unresponsive to medication

Contact Healthcare Provider For

  • Medication issues:
    • Side effects from spasticity medications
    • Need for dose adjustments
    • Medication interactions
  • Functional changes:
    • Decreased mobility
    • Increased falls
    • Difficulty with daily activities
    • Equipment needs
  • Complications:
    • Skin breakdown or pressure sores
    • Urinary tract infection symptoms
    • Constipation or bowel issues
    • Swallowing difficulties

Pediatric Considerations

Parents should seek evaluation if child shows:

  • Strong hand preference before 12 months
  • Not meeting motor milestones
  • Asymmetric movements
  • Difficulty with feeding
  • Seizures or unusual movements
  • Regression of skills

Regular Follow-up Schedule

  • Acute phase: Weekly to monthly
  • Subacute phase: Monthly to quarterly
  • Chronic phase: Every 3-6 months
  • Therapy reviews: As recommended
  • Annual comprehensive evaluation

Related Conditions

Hemiplegia is associated with various neurological conditions and complications. Understanding these relationships helps in comprehensive management and anticipating potential challenges.

Stroke

Most common cause of adult hemiplegia

 Cerebral Palsy

Leading cause of childhood hemiplegia

 Traumatic Brain Injury

Can cause hemiplegia from brain damage

 Multiple Sclerosis

May cause temporary or permanent hemiplegia

Movement Disorders

  • Hemiparesis: Partial weakness vs. complete paralysis
  • Spasticity: Increased muscle tone and stiffness
  • Dystonia: Involuntary muscle contractions
  • Athetosis: Slow, writhing movements
  • Chorea: Irregular, jerky movements

Associated Neurological Conditions

  • Epilepsy - common in brain injury
  • Aphasia - language impairment
  • Apraxia - motor planning difficulty
  • Hemianopia - visual field loss
  • Hemispatial neglect - ignoring affected side

Complications and Comorbidities

  • Musculoskeletal:
    • Contractures
    • Osteoporosis
    • Heterotopic ossification
    • Shoulder subluxation
  • Cardiovascular:
    • Deep vein thrombosis
    • Pulmonary embolism
    • Orthostatic hypotension
  • Psychological:

Differential Diagnoses

  • Todd's paralysis: Temporary weakness after seizure
  • Hemiplegic migraine: Reversible hemiplegia
  • Alternating hemiplegia: Rare childhood disorder
  • Functional neurological disorder: Psychogenic weakness
  • Brain tumor: Progressive hemiplegia
Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of hemiplegia or any medical condition. If you or someone you know is experiencing sudden weakness, paralysis, or other stroke symptoms, call 911 immediately.

References

  1. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8(8):741-754.
  2. Novak I, Morgan C, Fahey M, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep. 2020;20(2):3.
  3. Kwakkel G, Veerbeek JM, van Wegen EE, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol. 2015;14(2):224-234.
  4. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update. Stroke. 2019;50(12):e344-e418.
  5. Pollock A, Baer G, Campbell P, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev. 2014;(4):CD001920.