Many patients have told me that they feel an enormous fatigue during the day and when night arrives they feel completely exhausted. I wonder if it is a normal condition or if you need to worry.

My answer is not clinical, it is not an answer addressed to competent doctors in the subject, but practice.

“A hemiplegic patient does not last 24 hours, lasts 48 hours a day”

With this statement I would like to highlight the burden of physical and mental commitment to which we are subjected after a stroke.

All our cognitive skills reside in our brain and any alteration of the biology of our nervous system modifies them negatively.
We can classify our cognitive abilities in:

    ● Care
    ● Memory
    ● Perception
    ● Representations
    ● Learning

 
The Organization of these cognitive processes transformations allows the construction of our behavior and our actions, including the movement and language.

Therefore, our ability to move through the world and communicate intimately depends on the integrity of our cognitive faculties. Therefore, after a stroke the patients often suffer paralysis of one half of his body and, sometimes, in the case of right hemiplegia, even the loss of language (aphasia).

It is not just a muscle problem. It is cognitive.

The family of a patient who had survived a stroke cannot understand his extreme propensity to fatigue during the day and attribute this condition to laziness or lack of willpower.
In fact, I would like to ask them to imagine the immense effort that a hemiplegic patient has to face in his everyday life, from the first moment of the morning.

Moving with a hemiparesis

What you can immediately sense, by just looking, are the motor difficulties on a hemiplegic patient, who has to cope with the daily challenges by himself and manage it with only a lateral half of his body. This obligates him to reduce movements, many usually absent or altered by the spasticity.

Therefore, considering the purely physical effort, we can validate what I just said at the beginning: “One day… is worth two”.

The characteristic gestures on specific motor skills from hemiplegics patients, usually generate problems that go beyond the lack of strength or movements.

As we know, one of the first enemies of post-stroke is spasticity which is understood as a tightening of the muscles and the involuntary contractions under tension.

You should be able then to listen to some of the patient’s comments about post stroke, since it will allow us a better understanding of their experiences or when the body is in motion to help us understand how to organize the movement.

Examples of leg descriptions

“I feel the heavy leg as a tree trunk”
“My leg is like a pylon”
“I feel as if rubber bands were pulling”
“It is a piece of wood”
“I feel like a large rock”
“The foot is glued to the ground”
“The fingers cling to the ground”
“The foot is like a table”

Although the list is very long, we can already see what the common aspects from all of these experiences are.

Our only way to communicate (the most intimate feeling related to our body) is through a metaphor, an analogy that can be understood by our interlocutor.

It is when the patient said: “If you want to understand what I feel during the movement of my body, you have to imagine that in place of the leg you would have…. a tree trunk, a stone, a piece of wood”.

Each analogy that the patient produces to express his feelings is not random, because it means what his feelings are. It is similar to the feeling that would give you a live specified image, but what is more important is that it allows us to understand his way of moving you have to consider such sensations.

Going back to the descriptions of the leg, we can see that every expression requires a great deal of effort for the movement: Move a pylon requires an immense effort, walking with a leg that looks like a wooden trunk needs considerable energy for the movement, and so on.

Vicious circle

It is here, in this passage, which starts the vicious process: in fact, as we have made strides, one of our enemies is spasticity, we see it increases when they are specifically under stress; and in time, along with the lack of power, usually produces the feeling of extremities as harder and heavier . Moving a part of our rigid and heavy body exposes us to turn into a higher voltage that causes a greater reflex contraction of the muscles which, in turn, will make the movement harder and heavier.

Attention difficulties

After a brain injury the problems that are experienced by a hemiplegic patient do not only reduce his motor abilities, but also the cognitive. Even after a stroke, we still keep our intelligence, but it does not mean that our attention span and concentration have not been affected by the same injury.

Various types of attention disorders:

  • Attention difficulties can find generic difficulties like keeping the attention for a long period of time
  • Difficulty of being able to identify where and what he should keep his attention
  • .

  • Difficulty knowing how to switch attention from one point to another, and
  • The ability to divide attention when developing different objectives at the same time
  • .

    All these attention skills are essential for movement organization but more with a movement that has all the problems mentioned before.

    Therefore, when we think about tiredness from a hemiplegic patient, we must take into consideration these aspects.

    Try to imagine the resources that he requires only for a few steps. It is not a coincidence that the hemiplegic patient often walks visibly absorbed and concentrated, and that distractions can have effects on his quality of walking. In fact, when I want to evaluate the amount of care needed for patients when walking, I ask them to count from 100 to 0, trying to divert their attention from the body in order to evaluate their real automation when walking.

    Perceptual disorders

    Most of the time I ask my patients this question: “How do you feel this part of the body?”, they will answer me that it has no sensitivity, then you can get the fact that thanks to a simple testing, you can realize that in fact, the sensitivity of the treated party is different to the opposite side.

    This is due to the reason that sensitivity of the affected party is not only of skin, which responds to simple stimulation of contact: “If you touch me I will know what are you touching and where”, but it also has to do with more complex and elaborate information, such as the address and the amplitude of the joints’ movement or sensitivity when pressured. Even if they seem to have not been altered, when compared to the other side of the body it expresses a difference.

    By only perceiving our bodies in different ways between your left and right side makes us understand that moving inside the world with two different forms of sensitivity is a very difficult task; if we also add that some parts of the body do not allow us to have a complete perception, the task becomes even more complex.

    If we look at them, in fact, we can often see that the hemiplegic patient when walking, has directed his view toward his feet for two reasons, to control with his view the actual movement of the feet and their relationship; and because the view is a perceptual channel that often does not suffer any injury and it is the most reliable when getting information from the body.

    To this list of perception difficulties, we must add the perception through the pressure of the foot sole and the load through all the lower extremity. Indeed to move weight in an effective manner from a foot which we do not have an accurate perception or direction, the magnitude when loading, means not to be able to predict the effects this will have in our balance. For this reason, the use of a cane is necessary because it represents an extension of our body, a third leg that it should be managed and control.

    Forecasting and anticipation of results

    Even if we are not aware, every move is planned and anticipated; this allows us to make effective gesture each time we do that. To make it clear, we are talking about the brain process that allows us to avoid post holes when we walk and before ending at the same time. To make this prediction of the movement effects we need to have readily available all the necessary information for drawing up an effective image of our movement.

    If this process is related to what you just discussed with respect to problems of perception, we realize how this prediction requires much effort. It is not a coincidence that the hemiplegic patient often refers being afraid during the walk; in fact the unknown generates fear from what we often cannot predict and meet.

    Problem resolution

    To explain this aspect, I will take the simple example of the southpaws. It is a common saying that left-handers have a higher intelligence. This saying comes from the difficulties left-handers encounter living in a world designed for right-handers.

    The southpaw has to solve daily problems related to the movement and adjust to tools and objects designed for right-handers. This probably gives you a greater mental flexibility for adaptation; however the skills acquired through everyday problem-solving efforts. Hemiplegic patient must also face daily problems of movement during his activities and is often forced to handle certain actions with one hand counting only partially on him, resulting in the absorption of care, physical, and mental energies.

    Conclusions

    The daily life difficulties related to hemiplegic patients are not limited to a short list; therefore it would be enough to make us think about why the hemiplegic gets tired more easily than a healthy person anyway.

    I invite the readers, family, or patients to leave a comment when having their own difficulties, in order to enrich the knowledge on this topic with real-life experiences.

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