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Paralysis - A Guide

Paralysis is the loss of the ability to move one or more muscles. It may be associated with loss of feeling and other bodily functions

Overview
Causes of Paralysis
Symptoms of Paralysis
Diagnosing paralysis
Treating Paralysis
Living with Paralysis

Overview 

Paralysis is not usually caused by problems with the muscles themselves, butby problems with the nerves or spinal cord the brain uses tocontrol muscles. A person with paralysis will usually have some formof nerve damage.

Classifying paralysis

Paralysis can be:

  • localised – where a specific section of the body is paralysed, such as the face or hand
  • generalised – where a larger area of the body is affected

There are also a number of medical terms used to describe different types of paralysis. For example:

  • monoplegia – where one limb is paralysed
  • hemiplegia – where the arm and leg on one side of the body are paralysed
  • paraplegia – where both legs and sometimes the pelvis and some of the lower body are paralysed
  • tetraplegia – where both the arms and legs are paralysed (also known as quadriplegia)

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Causes of paralysis  

The four most common causes of paralysis are stroke, head injury, spinal cord injury and multiple sclerosis.

Stroke

A stroke is a serious medical condition that occurs when the blood supply to your brain is disturbed.

Like all organs, the brain needs a constant supply of blood that contains oxygen and nutrients to function properly.

If the blood supply is restricted or stopped, brain cells will beginto die, which can lead to brain damage that often results in paralysis.

Read more about stroke.

Head injury

A severe head injury can cause brain damage. The brain's surface cantear or bruise as it bumps against the skull, damaging blood vessels andnerves.

Paralysis can occur if a part of the brain that controls specific muscles is damaged during a severe head injury.

Damage to the left side of the brain can cause paralysis on the rightside of the body, and damage to the right side of the brain can causeparalysis on the left side of the body.

Spinal cord injury

The spinal cord is part of your central nervous system. It is a thickbundle of nerves that runs from your brain, down through the neck andspine, inside a canal of vertebrae.

Its main function is to transmit signals to and from the brain andbody. For example, the spinal cord passes nerve signals, such as hot orcold sensations, back to the brain.

If the neck or spine is injured, the spinal cord can also be damaged.This means the brain may no longer be able to transmit signals to themuscles, causing paralysis.

The exact location where the spinal injury occurs can have asignificant effect on how severe and wide-ranging the paralysis is. Thehigher up the spine the injury occurs, the worse the paralysis will be.For example, an injury in the middle of the spine will usuallycause paraplegia (paralysis of the lower limbs).

A neck injury, such as a broken neck, will usually result intetraplegia (paralysis in all four limbs, also known as quadriplegia),as well as loss of normal lung function, which means the person willneed to use a ventilator to breathe.

Read more about how the level of spinal cord injury is determined.

The most common causes of spinal cord injury are:

  • motor vehicle accidents
  • accidents while working
  • accidents during sports or other types of activity
  • falls
  • spinal cord paralysis caused by disease rather than injury 

The nature of these causes means that most spinal cord injuries occurin men (who account for 80% of all cases) and younger people. It isestimated that half of all spinal cord injuries occur in people whoare 16 to 30 years of age.

Multiple sclerosis

Multiple sclerosis (MS) is a condition where nerve fibres in thespinal cord become damaged by the immune system (the body's naturaldefence against infection and illness).

The immune system mistakenly attacks a substance called myelin, whichsurrounds nerve fibres and helps with the transmission of nervesignals.

In MS, the myelin around the nerve fibres becomes damaged, whichdisturbs the messages coming to and from the brain. This can resultin paralysis.

Read more about multiple sclerosis.

Less common causes of paralysis

There are also a number of less common causes, which are listed below.

Cancer

Cancers that develop in the brain, such as a high-grade brain tumour, can cause paralysis, usually on one side of the body.

Alternatively, cancers can spread (metastasise) from other parts ofthe body into the brain or spinal cord, leading to paralysis.

Cerebral palsy

Cerebral palsy is a set of neurological conditions (those that affectthe brain and nervous system) that affect a child's movement andco-ordination.

Cerebral palsy is caused by brain damage, which usually occursbefore, during or soon after birth. Some possible causes of cerebralpalsy include:

  • infection during early pregnancy
  • a difficult or premature birth
  • bleeding in the baby's brain
  • abnormal brain development in the baby

The most severe type of cerebral palsy is called spasticquadriplegia, where a person has such a high degree of muscle stiffness(spasticity) in all of their limbs that they are unable to use them.

Read more about cerebral palsy.

Friedreich's ataxia

Friedreich's ataxia is a rare genetic condition that affects around 1 in every 25,000people in England. It is caused by a mutation in a gene known as the GAAgene.

The mutation results in the body not producing enough of the proteinfrataxin. Frataxin is thought to play a role in the regulation of ironlevels inside nerve cells.

Because of the lack of enough frataxin being produced, the level ofiron and other toxic substances starts to build up inside the nervecells, damaging them.

Many people with Friedreich's ataxia experience a gradualincrease of paralysis in their legs. They will eventually need to use awheelchair or another type of mobility aid.

Guillain-Barré syndrome

Guillain-Barré syndrome is a rare and poorly understoodcondition caused by peripheral nervous system damage. The peripheralnervous system is the network of nerves that controls the body's sensesand movements.

In Guillain-Barré syndrome, the body's immune system attacks thenerves of the peripheral nervous system, which causes them to becomeinflamed.

This nerve damage results in a tingly, numb sensation in the arms andlegs, which can eventually lead to temporary paralysis of the arms,legs and face.

Most people with Guillain-Barré syndrome make a full recovery in afew weeks or months and do not experience any other associated problems.

Read more about Guillain-Barré syndrome

Lyme disease

Lyme disease is a bacterial infection spread by infected ticks.

Ticks are small arachnids that feed on the blood of mammals,including humans. The ticks release bacteria that can damage the nerves,leading to temporary paralysis of the face.

Read more about Lyme disease.

Motor neurone disease

Motor neurone disease (MND) is a rare, incurable condition. Overtime, the nerves in the brain and spine gradually lose function(neurodegeneration).

Nerve cells known as motor neurones are affected by MND. Motorneurones are specialised nerve cells that control voluntary musclemovements, such as walking. MND causes progressive muscle weakness,which eventually leads to total body paralysis.

Read more about motor neurone disease.

Spina bifida

Spina bifida is a term that describes a series of birth defects that affect development of the spine and nervous system.

Myelomeningocele is the most serious type of spina bifida, occurringin 1 in every 1,000 births. It causes extensive damage to the nervoussystem, which can often result in partial or total permanent paralysisof the lower limbs.

Read more about spina bifida.

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Symptoms of paralysis 

Paralysis can be classified in anumber of different ways. For example, it can be localised, affecting aparticular part of the body, or generalised, affecting a wider area.

Examples of localised paralysis include:

  • facial paralysis – which is usually limited to one side of the face
  • paralysis of the hand
  • paralysis of the vocal cords – vocal cords arebands of tissue and muscle used to generate speech; paralysis usuallyonly affects one vocal cord, which means the person is able to speak buttheir voice will be hoarse

Examples of generalised paralysis include:

  • monoplegia – where one limb is paralysed
  • hemiplegia – where the arm and leg on one side of the body are paralysed
  • paraplegia – where both legs are paralysed, or sometimes the pelvis and some of the lower body
  • tetraplegia (also known as quadriplegia) – here both the arms and legs are paralysed

Temporary and permanent paralysis

Paralysis can either be temporary or permanent.

Bell's palsy is a relatively common cause of temporary paralysis that causes temporary facial paralysis.

Sometimes paralysis that occurs after a stroke can also be temporary.

Paralysis caused by serious injury, such as a broken neck, is usually permanent.

Partial or complete paralysis

Paralysis can be:

  • partial – where there is some muscle functionand sensation; for example, if a person can move one leg but not theother, or feel sensations such as cold and heat
  • complete – where there is complete loss of muscle function and sensation in affected limbs

Spastic or flaccid paralysis

Paralysis can be:

  • spastic – where muscles in affected limbs areunusually stiff or display spasms, and movements are not under thecontrol of the individual (read about spastic paraplegia)
  • flaccid – where muscles in affected limbs are floppy and weak; muscles in flaccid paralysis may shrivel

People with spastic paralysis may experience muscle weaknesswith spasms (involuntary muscle contractions). People with flaccidparalysis often experience muscle weakness without spasms.

In some conditions, such as motor neurone disease or cerebral palsy, it is possible to experience episodes of spastic paralysis followed by flaccid paralysis, or the other way around.

Levels of spinal cord injury

When assessing the extent of a spinal cord injury, it is a case ofdetermining where on the spine the injury occurred, and howbadly related nerves and muscles have been affected.

The spinal cord is measured using a number and lettering system basedon the vertebrae (disc-shaped bones that help support the spine andneck).

Your spine is made up of 24 vertebrae in total, consisting of:

  • seven cervical vertebrae in the neck – measured as C1 to C7
  • 12 thoracic vertebrae in your chest area – measured as T1 to T12
  • five lumbar vertebrae in your lower back – measured as L1 to L5

People with a spinal cord injury between C1 and C7 are likely to have paralysis in all four limbs (tetraplegia).

The extent of the paralysis and subsequent loss of muscle function will depend on how high up the injury occurred. For example:

  • someone with a C1 to C4 spinal cord injury will have little orno movement in their limbs and will probably only be able to move theirhead and possibly their shoulders – they will also need a ventilator toassist their breathing
  • someone with a C7 spinal cord injury will be able to extend their elbows and may have some movement in their fingers
  • someone with a T2 to T12 spinal cord injury will have fullyfunctional muscles in the top half of their body, but little or nofunction in their lower limbs and will need a wheelchair
  • someone with an L1 to L5 injury could have limited movement intheir hips, knees and feet, but is likely to need a wheelchair or othertype of mobility aid, such as a walking frame

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Diagnosing paralysis 

Diagnosing paralysis is not usually necessary if the cause is obvious  for example, if paralysis has occurred after a stroke.

If tests are needed to help diagnose paralysis, the type of tests required will depend on the underlying cause.

Some tests used to help determine the extent of paralysis include:

  • X-ray – wheresmall doses of radiation are passed through your body to create animage of the denser areas, such as your bones; X-rays can be a usefulway of assessing damage to your spine or neck
  • CT scan – wherea computer is used to assemble a series of X-ray images to build up amore detailed picture of your bones and tissue; CT scans are often usedto assess the extent of damage after a severe head injury or spinal cord injury
  • MRI scan – whichuses strong magnetic fields and radio waves to produce a detailed imageof the inside of your body; an MRI scan can help detect brain damage orspinal cord damage 
  • myelography – away of checking the nerve fibres in your spinal cord in more detail (aspecial fluid called contrast dye is injected into the nerves,which makes them show up very clearly on an X-ray, CT scan or MRI scan)
  • electromyography – wheresensors are used to measure the electrical activity in your muscles andnerves; electromyography is often used to diagnose Bell's palsy (temporary facial paralysis) .

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Treating paralysis 

There is currently no cure for permanent paralysis. The aim of treatment is to help a person adapt to life with paralysis by making them as independent as possible.

Another important goal of treatment is to address health problems andassociated complications that arise from paralysis, such as pressure ulcers.

Various treatment options and aids available for people with paralysis are described below.

Mobility aids

A range of mobility aids, such as wheelchairs, are available for people with paralysis.

Wheelchairs

There are two main types of wheelchair:

  • manual wheelchairs – designed for people with good upper body muscle strength
  • electric wheelchairs – designed for people with poor upper body muscle strength or quadriplegia (paralysis in all four limbs)

The NHS supplies wheelchairs free of charge, but the range of modelsavailable is often limited. If you want a more sophisticated model, youwill have to pay some or all of the cost. Your local clinicalcommissioning group (CCG) may be able to help fund some of the cost. Find your local CCG.

There is also a relatively new type of wheelchair known as a standingchair, which functions like a wheelchair but allows the person to riseto a standing position. This helps reduce their risk of developingpressure sores. However, standing chairs can be expensive and areheavier than standard chairs.

Buying a Wheelchair

Orthoses

Orthoses are an alternative to wheelchairs. They are braces, usuallymade of plastic or metal, designed to improve the function of a limb andcompensate for muscle weakness.

Examples of orthoses include:

  • wrist-hand orthoses – designed to transfer force from a functioning wrist to paralysed fingers
  • ankle-foot orthoses – designed for people with some lower limb function to help them move their feet while walking
  • knee-ankle-feet orthoses – designed for peoplewith tetraplegia (paralysis in the lower limbs, also knownas quadriplegia) to stabilise the knee and ankle and let them swingtheir legs when walking

A neuroprosthesis is a newer type of orthosis that uses electrodes(small metallic discs stuck to your skin) to deliver electrical currentsto muscles in the legs or arms. The currents stimulate the muscles tomove in the same way that the brain would normally.

A neuroprosthesis is not suitable for people with conditions that directly damage the nerves in the legs, such as motor neurone disease and Guillain-Barré syndrome. This is because the nerves will not react to the electrical currents.

Neuroprotheses are expensive. Depending on the complexity of the neuroprosthesis, it can cost from £1,300 to £32,000.

Using orthoses can be physically demanding, so they may not besuitable for everyone. Alternatively, you may decide to use both awheelchair and an orthosis.

Assistive technology

There is also a wide range of assistive technology that can help aperson with paralysis maintain their independence and improvetheir quality of life. Examples include:

  • environmental control units – voice-activated control units you can use to control things such as lighting, temperature or the telephone in your home
  • specially adapted computers – such asvoice-activated computers, special keyboards that can be controlledusing a stick placed in the mouth, and cursors that can be controlledwith a laser beam attached to the head

You can find further information about the types of assistive technology available on the  National Centre for Independent Living (NCIL) website. They provide advice and support for people living with paralysis.

Driving

It may be possible for you to drive a car, even if you have limited muscle function in your hands and arms.

Devices can be used to adapt the controls of a car to meet the needsof a person with paralysis. For example, the pedals can be replaced withlevers or an electrical switching system, and the steeringwheel adapted so you steer using your wrists or arms, rather than havingto grip it with your hands.

Bladder and bowel management

Almost all types of spinal cord injury and many types of generalisedparalysis result in the loss of normal bowel and bladder function. Thisis because nerves that control the bowel and bladder are located at thebase of the spinal cord.

Most people use a catheter to empty urine from their bladder. Acatheter is a thin, flexible tube inserted into the urethra (the openingin the penis or vagina that urine flows out of) or through a hole inthe abdomen (tummy). 

The catheter is then guided into the bladder, allowing urine to flow through it and into a drainage bag.

There are many methods that can be used to manage a paralysedbladder. The recommended method will depend on your ability, the stateof your bladder, and the resources available.

It is important to ensure your bladder is emptied regularly because an overly full bladder can trigger a serious complication called autonomic dysreflexia in high spinal cord injuries.

Read more about urinary catheterisation.

There are two main treatment options to help people with paralysis empty their bowel:

  • bowel retraining – this aims to improve theconsistency of your stools and establish a regular time to empty yourbowel, as well as helping you find ways of stimulating your bowel toempty
  • alternative methods, such as enemas – where liquid is injected into your bowel to help stimulate it to empty
  • a colostomy – an operation where a section of the bowel is diverted and attached to an opening in the abdominal wall

Neuropathic pain

Neuropathic pain is pain caused by nerve damage.

Many people with a spinal cord injury, and some with other types ofparalysis, have long-term pain that persists for weeks, months, orsometimes years after the injury or incident that caused the paralysis.

Unlike most other types of pain, neuropathic pain does not usually respond well to ordinary painkillers, such as paracetamol or ibuprofen. Alternative medications are usually required, such as amitriptyline or pregabalin.

These types of medication can cause a wide range of side effects,so it can take time to identify one that is suitable and effective atcontrolling your symptoms without causing unpleasant side effects.

Possible side effects include a dry mouth, sweating, drowsiness and vision problems.

There have been reports of people having suicidal thoughts whiletaking amitriptyline. If this happens, you should contact your GP or goto your nearest hospital immediately.

It may be helpful to tell a relative or close friend you are takingamitriptyline and to ask them to let you know if they notice any changesin your behaviour.

Breathing difficulties

If you have had a spinal cord injury to the upper neck, yourdiaphragm will be paralysed. The diaphragm is a thin, dome-shaped musclethat helps you breathe in and out.

As your diaphragm will not be able to help you breathe, you will needbreathing assistance from a ventilator. A ventilator is a machine thatcarries out the job of the diaphragm by controlling lung pressure.

This can be done in one of two ways, using either a:

  • negative pressure ventilator – where theventilator creates a vacuum (a total lack of air) around the lung, whichcauses your chest to expand and pull in air
  • positive pressure ventilator – where the ventilator pushes oxygen directly into your lungs

Positive pressure ventilators are more widely used because they areusually smaller and more convenient. A positive pressure ventilator caneither be:

  • invasive – where an incision is made in the throat and a tube inserted into the trachea (windpipe)
  • non-invasive – where a tube is inserted into the nose, or air is supplied through a mouthpiece

Non-invasive ventilators carry a smaller risk of causing a lung infection such as pneumonia, but aren't suitable for people with more extensive paralysis who have difficulty swallowing.

An alternative to using a ventilator is a device called a phrenicnerve stimulator. The phrenic nerve controls the diaphragm. The deviceis surgically implanted in the chest and sends regular electricalimpulses to the phrenic nerve, causing the diaphragm to contract andexpand and fill the lungs with air.

Reduced cough

Another problem that affects most people with paralysis is that theirability to cough is reduced. This is because the cough reflex istriggered by muscles in the abdomen (tummy) and between the ribspressing down on to the lungs.

If these muscles are paralysed, the force of a person's cough can begreatly reduced. This is potentially serious because a person's abilityto cough enables them to clear their lungs of a build-up of mucus andother secretions. A reduced cough can cause the lungs to becomecongested, increasing the risk of a lung infection.

One technique used to compensate for this is known as an assistedcough. It involves a relative or carer pushing against the outside ofyour stomach while you attempt to cough.

There are also a number of devices available to help you cough. Theyusually consist of vests that can contract (squeeze) against your lungs,compensating for the loss of muscle action.

It is important you take precautions to reduce your risk of developing a lung infection by:

  • sitting up every day and turning regularly while lying down to prevent a build-up of phlegm
  • making sure you cough regularly
  • drinking plenty of water to dilute any phlegm, making it easier to cough up
  • avoiding smoking or being in close contact with people who smoke
  • getting the flu vaccination and pneumococcal vaccination as they help reduce your risk of developing influenza and pneumonia

Spasticity and muscle spasms

Spasticity is a medical term that means abnormally stiff and rigidmuscles. Many people with paralysis develop spasticity and involuntarymuscle spasms (where muscles cramp and contract).

Spasticity and muscle spasms are usually caused by the section of thespinal cord below the point of the injury "misfiring" and sendingabnormal signals to the limbs.

In some cases, spasticity and muscle spasms can be useful. Forexample, if you have partial paralysis in your legs, the stiffness inyour muscles may make your legs easier to control.

Some people also find that a series of muscle spasms makes it easierfor them to empty their bladder or bowel. But in other cases, spasticityand muscle spasms can be painful, affect mobility and interfere withdaily activities.

Treatments for spasticity and muscle spasms are discussed below.

Muscle relaxants

The first type of medication you may be prescribed is a muscle relaxant, such as baclofentizanidine or dantrolene, usually taken in tablet form.

Sedatives like diazepam should be avoided, except in severe cases. All of these medicines may cause sedation as a side effect.

Botulinum toxin

If muscle relaxants are not effective, an injection of botulinum toxin (Botox) may be given for localised spasms. It works by blocking the signals from the brain to the affected muscles.

The effects of the injection usually last for up to three months. Thetreatment is most effective when used in conjunction with a programmeof stretching and physiotherapy.

Intrathecal baclofen therapy

Another possible treatment is intrathecal baclofen therapy. Thisinvolves surgically implanting a small pump on the outside of the bodyconnected to the spinal cord.

The pump delivers regular doses of baclofen directly to the spine. Itblocks some of the nerve signals that cause muscle stiffness.

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Living with Paralysis

If you are paralysed, it is important you take measures to prevent getting pressure ulcers.

Regular pressure relief in the wheelchair or in bed is essential to prevent pressure sores.

Skin care and pressure ulcers

Taking care of your skin is important if you have paralysis as you have an increased risk of developing a pressure ulcer.

Pressure ulcers develop when sustained pressure interrupts the bloodsupply to parts of the body. Blood contains oxygen and other nutrientsrequired to keep tissue healthy. Without a constant supply of blood,tissue damage occurs and the tissue will eventually die.

Pressure ulcers do not develop in people with normal mobility becausethe body's regular movements stop pressure building up in any one partof the body.

For example, when you are asleep you may think you are lying still, but you will probably shift position up to 20 times a night.

If a person is unable to move regularly because of paralysis,pressure ulcers can quickly develop, sometimes over the course of a fewhours.

Changing your position regularly is an effective way of preventingpressure ulcers. As a general rule, wheelchair users should change theirposition at least once every 15 to 30 minutes.

If you need to stay in bed, you should change your position at leastonce every two hours. If you are unable to change position yourself, acarer or relative can assist you.

Special cushions, mattresses and other pressure-relieving devices arealso available to help reduce pressure on your affected limbs.

It's also important to keep the skin in the affected area clean anddry. Wet skin is more vulnerable to damage from sustained pressure.

Regularly check your skin for any signs of pressure ulcers. Theyusually begin as an area of red, unbroken skin that either feels warmand spongy or hard to the touch.

You can usually prevent affected skin getting worse by keeping itclean and not putting undue pressure on it until it has healed.

If the skin has broken or looks like an open wound or blister, you should contact your care team for advice.

Read more about pressure ulcers.

Exercise

If possible, it is important to exercise regularly and achieve a goodlevel of fitness if you are paralysed. The reasons for this are:

  • the fitter you are, the better your general level of health will be and the lower your risk of developing complications
  • regular exercise will help improve your bladder and bowel function
  • improved muscle strength will make it easier for you to use awheelchair or orthosis and prevent problems associated with usingmobility devices, such as shoulder or arm pain
  • maintaining a certain amount of muscle strength will prevent your muscles in the affected limbs becoming severely weakened

In the first few days or weeks after the accident or injury thatcaused your paralysis, or as part of your long-term treatment plan, youwill be introduced to a physiotherapist (a specialist in physicalrehabilitation and exercise).

Your physiotherapist will discuss different exercises andactivities you can do. Depending on the extent of your paralysis,recommended exercises and activities may include:

  • weightlifting – an excellent way to improve upper body strength
  • hand cycling – arm cycles are specially designed bicycles powered by turning handles with your hands, rather than pedals with your feet
  • horse riding
  • wheelchair basketball
  • wheelchair racing
  • wheelchair tennis

If your paralysis is so severe that you are unable to carry out anyvoluntary exercise, functional electrical stimulation (FES) may berecommended. FES uses electrodes (small metallic discs placed on yourskin) to deliver electrical currents to the muscles in your legs or armsto stimulate movement.

People with extensive paralysis can use a FES bike to exercise. It issimilar in appearance to a normal indoor exercise bike, but has aseries of electrodes attached to your legs. These stimulate your musclesso you are able to turn the bike's pedals.

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