Hemiplegia, a condition characterized by paralysis or weakness on one side of the body, often results from an acquired brain injury in children, but can also present with nearly any neuromuscular condition. While the physical impairments associated with hemiplegia are usually quite visible—muscle weakness, limited range of motion, and coordination difficulties—one of the more subtle challenges is the neglect of the affected side. This phenomenon is known as hemispatial neglect or unilateral neglect, and it can significantly impact a child’s independence, body symmetry, overall development and quality of life.
Most children we see at Therahappy present with a range of hemispatial neglect in upper limbs, lower limbs, and sometimes both. It is imperative to rule out the possibility of a visual disturbance such as cortical visual impairment. Problems with visual processing and/ or visual acuity can mimic the presentation of hemipatial neglect.
Another thing to consider is presentation of ATNR, or asymmetrical tonic neck reflex. This reflex moves the limbs and body in conjunction with the direction the head is turned. This looks like a “fencer” pose in babies and should integrate by six months of age. When it is retained one side is usually more affected than the other, and can also mimic the presentation of hemispatial neglect.
Lastly, if a child had torticollis as an infant, it is likely that the side that held the restriction in torticollis, will also be the weaker, and often neglected, side by nature. When it comes to torticollis, however, the paradox of which came first, the chicken or the egg – the torticollis or the neurological determinant of a preferred side can be difficult to weed out.
These are all things that should be considered when treating hemispatial neglect in children.
Treating Hemispatial Neglect in Children
There are many ways to bring awareness to the neglected side in children, but tailoring the treatment to the child’s specific needs and “just right” challenge is going to be the key to unlocking the child’s unmet potential.
Weightbearing
Weight bearing is fundamental to treating hemiplegia in stroke patients and it is no wonder this method is the gold standard for regaining, or often in a child’s case, developing function. With access to about 17,000 touch receptors, the palms possess unique and unparalleled access to the neural networks in the brain. The palm teaches the child that they can support themselves, pull themselves up, feel their own body’s force against an object. The palm also detects the many tactile stimuli in their environment. This is why I emphasize to my families that exposing a child with a neurological delay who struggles with unilateral neglect, and aversion to sensation in the hands in particular, that exposing the palms to a variety of natural things in their world will help development their sensory system, and eventually help them use their hands for function.
The Wilbarger Deep Pressure and Proprioceptive Technique
Mostly used by occupational therapists, The Wilbarger Method involves a combination of gentle deep pressure applied to the skin (especially the arms, legs, and back) followed by proprioceptive input through the use of specific techniques like joint compressions or tactile stimulation. This process aims to calm the nervous system, reduce sensory sensitivities, and help individuals organize sensory input more effectively.
Visual Cues
In neuroplasticity we know what fires together, wires together and adding a visual cue to the neglected side like some colorful stickers or therapy tape to the neglected limb(s), can piggyback off the neural pathway of the visual system to fire the motor control of the affected side. This may be more effective in the upper limbs, and of course if the child has functional vision.
Proprioceptive Cues
In children with neuromuscular conditions, it is imperative to consider that their proprioceptive threshold is a lot higher than most typically developing children. They often do not feel their bodies as adequately as others do, and have limited or broken neural pathways that give them information about where their body is in space, and just how much weight each limb is. We can almost be certain if a child is not using one side of their body, their hippocampus or brain map, is a poor presentation of their true body’s physicality. This disconnect between what they are feeling in and about their body, and what they actually are in real life heavily contributes to their motor control on a global scale.
Some tangible proprioceptive cues are adding half or one pound ankle weights to the affected limb(s). Use in small increments of time, and slowly build as the child tolerates more. Some children love this, and others do not as the weight makes movement against gravity more difficult.
Another way to increase proprioceptive input to the affected side is “fast” brushing the limb from shoulder to palm, or hip to foot. This is slightly more forceful than a gentle massage, but not harsh enough to mark the skin. Most of the kids I see, regardless of their muscle tone, LOVE this.
Arm or leg squeezes and joint compressions are another great way to add proprioception before engaging the child in a functional activity.
Constraint Induced Movement Therapy
This modality works by restraining the unaffected limb (e.g., using a sling or mitt) to force the patient to use the affected side of the body. Through repetitive practice and structured tasks, CIMT aims to improve motor function, enhance neuroplasticity, and increase the use of the affected limb in everyday activities. As one can probably imagine, this is an intense measure to take and requires dedication on all who care for the child in order to obtain the results that this modality can bring.
Electrical Stimulation
Often times the children who neglect one side, keep the neglected hand in a fisted position. This is an indication that there is weakness in that side and high sensitivity in the palm. Left in a fisted position for years, this could lead to an irreversible wrist contracture. Using neuromuscular stimulation on the arm and hand of the neglected side is a great way to help build the brain map of the affected side, bring awareness and involve both sides of the body in an engaging activity. Of course, NMES can also be used in lower limbs, too. Always consult with a trained professional on muscle choice for electrodes and parameters for the NMES unit.
Add to the conversation, what are some ways you have used for your child that has helped bring awareness to the affected side?
Disclosure: Any purchases made through the Amazon links will earn me a small commission fee, but no additional fee to you.