How to Help Your Preemie with Hemiparesis Learn to Stand and Walk

Hemiparesis is defined as significant weakness affecting one side of the body. The word Hemiparesis is made up of two words – Hemi which means half, and Paresis – which means weakness.

What Causes Hemiparesis?

Hemiparesis can be caused by any type of blockage or interruption of blood flow to the brain; with premature babies, this type of interruption is usually caused by an Intraventricular Hemorrhage.

What is an Intraventricular Hemorrhage?

An intraventricular hemorrhage is bleeding into the ventricles of the brain. The ventricles of the brain are cavities that are filled with Cerebral Spinal Fluid (CSF) that provides the brain with nutrition.

What are the Effects of Hemiparesis?

Weakness on one side of your baby’s body (hemiparesis) can affect her in a wide variety of ways depending on how severe the weakness is and if there is any type of spasticity (tightness) of the muscles; Your baby’s ability to control her head, sit up, roll over, creep, crawl and walk could all be adversely affected. This type of injury is usually caused by an Intraventricular Hemorrhage (IVH) on the opposite side of the brain.

Why Preemies and Micro-Preemies are More Susceptible to IVH

The young underdeveloped brain of the premature infant has many tiny fragile blood vessels close to the floor of the ventricles. Prior to the 35th week of gestation, there is a part of the brain called the Germinal Matrix which develops close to the ventricles. After the 35th week, this part of the brain disappears.

However, a baby that is born before 35 weeks of gestation needs to wait for this part of his brain to develop and so is much more susceptible to an IVH. The tiny blood vessels in the germinal matrix can rupture during the first few days of life, causing blood to flow into the ventricles resulting in an IVH.

Types of Intraventricular Hemorrhage (IVH)

There are four grades of IVH. Grades I is mild, Grade II is moderate, and Grades III and IV are severe. Approximately 50% of all Mirco-Preemies will suffer from an IVH, whereas only about 15% of older preemies suffer from IVH’s.

These Intraventricular Hemorrhages (IVH) are commonly referred to as “Brain Bleeds” in the NICU. The reason that only 15% of the older preemies suffer from IVH is because their germinal matrix has already disappeared along with its blood vessels.

If the IVH is a grade I or II then there is only a small chance that there will be long-term damage to the brain. The reason for this is because all or most of the blood would be contained in the ventricles, therefore adding no pressure to the surrounding brain tissue.

However, if the bleed is a grade III, then there is enough blood to block the normal flow of CSF through the ventricles. This type of blockage can cause Hydrocephalus (excessive pressure within the skull and possible enlargement of the brain).

This type of blockage can be relieved by inserting a small tube or catheter called a ventriculoperitoneal shunt (VP shunt) to drain the excess fluid into the baby’s stomach.

A grade IV bleed (IVH) is characterized by blood flowing into the ventricles and out into the surrounding brain tissue. The result is damage to any brain cells that are touched by blood. This type of bleed is very serious and can cause Cerebral Palsy, with possible long term consequences.

How to Tell If Your Preemie Has Hemiparesis?

Quite often hemiparesis can go unnoticed (sometimes for months), because many parents don’t know what to look for and how to recognize this problem.

Parents may observe that their baby is using one arm or kicking one leg more than the other and think this means their baby will be right or left handed. But “handedness” or your baby’s preference for using one hand over the other does not appear until your baby is well past his first birthday.

If you notice that your baby is using one arm or leg more than the other, please notify your doctor immediately. The doctor will most likely request a CAT Scan to determine if your baby had an IVH.

How to Check Your Baby’s Muscles for Tightness or Abnormal Tone

One of the more common side effects of an IVH is spasticity (tightness) or stiffness of the muscles on the affected side of the body. If your baby had a brain bleed on the right side of his brain, then his left leg and left arm will be affected.

The process of determining which leg and arm are affected is a fairly simple one. Look at the way your baby moves his arms and legs to see if he is moving one side more than the other.

You should also check to see if the muscles on one side of his body are stiffer than the muscles on the other side. Bend and move your baby’s wrists, elbows, ankles, knees and hips to see if there is greater freedom of movement of the joints on one side of the body when compared to the other side.

Feel and squeeze the muscles of your baby’s arms and legs to see if they are “tight”. If there is excessive tightness in your baby’s muscles and limited movement of his joints you should massage his muscles, stretch his muscles, and perform a range of motion exercises to his joints daily.

Below are a series of simple stretching and range of motion exercises that can be used daily to help your baby normalize his muscle tone while gaining strength of his lower extremities.

How to Stretch Your Baby’s Tight Heel Cords

Benefits: Helps to promote a conventional heel-to-toe gait pattern where baby’s heel touch the ground first; thereby reducing toe-walking. This type of stretching also helps to increase how far your baby’s ankle joint can move.

Activity: Right Heel Cord Stretch

  • Put your baby to sit on your right leg to stretch the right heel cord.
  • Move baby’s toes upwards towards the knee.

Straighten Baby’s Knee While Maintaining the Toes In the Upright Position

  • Put your baby to sit on your lap sideways on your right leg.
  • With your right hand bend his right knee so that the lower part of his leg his hanging freely from your hand.
  • Use your left hand to move his right ankle joint and move his toes upwards as if attempting to touch his toes to his kneecap.
  • Straighten his right knee while keeping his toes in the “up” position.
  • Use your fingers to pull downwards on his back of his heel. This position will stretch his calf muscles.
  • Maintain this position for 30 seconds.
  • Repeat this exercise 10 times for the affected foot.
  • Look at and listen to your baby for any signs of pain or discomfort during this stretching exercise; Stop the stretch immediately if your baby begins to cry.

Range of Motion Exercises to the Ankle Joint

Benefits: Helps to maintain the smoothness of movement of the joint and limits the accumulation of tissue in the joint capsule which can in turn limit how well the joint moves.

The ankle joint is referred to as a hinge joint, formed where the bottom of the Tibia and Fibula bones meet the Talus bone on the top of the foot.

How to Perform Ankle Range of Motion Exercises Up/Down (Right Ankle)

  • Put your baby to sit on your lap sideways on your right leg.
  • With your right hand bend his right knee so that the lower part of his leg his hanging freely from your hand.
  • Use your left hand to grasp his ankle joint so that your hand is around his instep close to the bottom of the Tibia bone.
  • Bend his right ankle joint up and down 10 times.

Side to Side Movements of Baby’s Ankles (Inversion and Eversion)

Benefits: Stretches the ligaments on the inside and outside of your baby’s ankle joint

How to Perform Inversion/Eversion Exercises to Ankle Joint

Hold your baby’s ankle joint with your fingers directly under his Tibia bone (close to the heel) and move his ankle side to side slowly.

  • Put your baby to lie on his tummy on a bed or couch.
  • Using your left hand, hold his leg just below the knee so that the lower part of his foot is stable.
  • With your right hand grasp his ankle with your thumb and forefinger on either side of his heel.
  • Tilt his ankle so that his foot bends IN.
  • Tilt his ankle outwards so that his foot bends all the way out as far as it can go without causing him pain.
  • Repeat this type of IN/OUT twisting of his ankle joint 10 times.

After you have completed a stretching regiment with your baby it’s time to move on to some weight bearing (standing with support) on his feet.

Weight Bearing In Standing with Support at Hips

Benefits: Helps to increase the strength of the weaker leg while building baby’s confidence in putting weight on the affected limb.

How to Perform Standing Weight Bearing Exercises with Support around His Trunk

Use downward pressure at your baby’s hips to help him stand with his feet flat on the floor.

  • Sit on the floor and put your baby to stand in front of you with your hands on his hips.
  • Using firm and persistent downward pressure on his hips pull him back and down so that he stands with both heels on the ground.
  • Help him to maintain this position for as long as he can tolerate it.

Single Limb Weight Bearing Exercises with Support around the Upper Body

Support your baby around her hips and shift her body weight from one leg to the next.

  • Sit on the floor and put your baby to stand in front of you with your hands on her hips for support.
  • When she is stable on her feet, slowly lean her upper body over towards the weak side until her other foot comes up off the ground.
  • Stay alert to catch her if the leg she is standing on collapses!

Single Limb Weight Bearing Exercises using a Chair for Support

Benefits: Helps to build baby’s confidence with regard to bearing her body weight on the weak (hemiparetic) leg.

Use one hand to support her hips while bending her knee with your other hand.

How to Perform Weight Bearing Exercises using a Chair

  • Using a folding chair or sofa, put one of your baby’s favorite toy on the chair and encourage her to crawl and get it.
  • Help her pull to stand using the chair for support.
  • Sit on the ground with her and pick up her “strong” leg up off the ground so that she has to stand on her “weak” (hemiparetic) leg.
  • Make sure that her foot is flat with her heel on the ground.

Baby Lunges

Benefits: Promotes balance on one leg, strengthens upper thigh and buttocks muscles.

  • Put your baby to kneel on the couch facing you and move the affected leg forward so that she is in a half kneeling position with the affected leg in front of her body.
  • Put baby to kneel on couch facing you and then move her “weak” leg forward in front of her body
  • Cue your baby to stand up from the half kneeling position bearing all of her bodyweights on the affected leg.

How to Perform Baby Lunges With Your Baby

  • Put a small folding chair in front of the couch and sit on the chair facing the couch.
  • Put your baby to kneel on the couch in front of you with your hands on either side of her upper body.
  • Using your left hand, move her right foot in front of her body, slightly off to the right side.
  • Support her at her hips in this position for a few seconds.
  • Using your hands cue her to stand up by moving forward and bearing her body weight through her “weak” leg.
  • Repeat this exercise 10 times in a row.

Conclusion

The premature infant with weakness (hemiparesis) on one side of his body will often have spasticity (tightness) of the muscles on the affected side. It’s, therefore, imperative that you stretch and perform a range of motion exercises to the muscles and joints prior to any type of strengthening exercises or activities. The reason for this specific order of activities is that stretching and range of motion will provide your baby’s body with a chance to loosen up his muscles and improve the mobility of his joints prior to strengthening exercises. In addition, the range of motion exercises to the joints prior to exercise, allows you to position the joints in their most functional position before starting to exercise. In addition, the stretching and range of motion activities lets your baby know what type of activity is about to begin and gives him a chance to get ready to exercise. Use these recommended stretches and exercises daily and your baby’s hemiparesis will soon be a thing of the past.

The reason for this specific order of activities is that stretching and range of motion will provide your baby’s body with a chance to loosen up his muscles and improve the mobility of his joints prior to strengthening exercises. In addition, the range of motion exercises to the joints prior to exercise, allows you to position the joints in their most functional position before starting to exercise. In addition, the stretching and range of motion activities lets your baby know what type of activity is about to begin and gives him a chance to get ready to exercise. Use these recommended stretches and exercises daily and your baby’s hemiparesis will soon be a thing of the past.

In addition, the stretching and range of motion activities lets your baby know what type of activity is about to begin and gives him a chance to get ready to exercise. Use these recommended stretches and exercises daily and your baby’s hemiparesis will soon be a thing of the past.