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, but by problems with the nerves or spinal cord the brain uses to control muscles. A person with paralysis will usually have some form of 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)

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 begin to 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 can tear or bruise as it bumps against the skull, damaging blood vessels and nerves.

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

Spinal cord injury

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

Its main function is to transmit signals to and from the brain and body. For example, the spinal cord passes nerve signals, such as hot or cold 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 the muscles, causing paralysis.

The exact location where the spinal injury occurs can have a significant effect on how severe and wide-ranging the paralysis is. The higher up the spine the injury occurs, the worse the paralysis will be.For example, an injury in the middle of the spine will usually cause 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 will need 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 the spinal cord become damaged by the immune system (the body’s natural defence against infection and illness).

The immune system mistakenly attacks a substance called myelin, which surrounds nerve fibres and helps with the transmission of nerve signals.

In MS, the myelin around the nerve fibres becomes damaged, which disturbs the messages coming to and from the brain. This can resul tin 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 of the body into the brain or spinal cord, leading to paralysis.

Cerebral palsy

Cerebral palsy is a set of neurological conditions (those that affect the brain and nervous system) that affect a child’s movement and co-ordination.

Cerebral palsy is caused by brain damage, which usually occurs before, during or soon after birth. Some possible causes of cerebral palsy 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 GAA gene.

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

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

Many people with Friedreich’s ataxia experience a gradual increase of paralysis in their legs. They will eventually need to use a wheelchair or another type of mobility aid.

Guillain-Barré syndrome

Guillain-Barré syndrome is a rare and poorly understood condition caused by peripheral nervous system damage. The peripheral nervous system is the network of nerves that controls the body’s senses and movements.

In Guillain-Barré syndrome, the body’s immune system attacks the nerves of the peripheral nervous system, which causes them to become inflamed.

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

Most people with Guillain-Barré syndrome make a full recovery in a few 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 nervous system, which can often result in partial or total permanent paralysis of the lower limbs.

Read more about spina bifida.

 

Symptoms of paralysis

Paralysis can be classified in a number of different ways. For example, it can be localised, affecting a particular 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 are bands of tissue and muscle used to generate speech; paralysis usually only affects one vocal cord, which means the person is able to speak but their 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 function and sensation; for example, if a person can move one leg but not the other, 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 are unusually stiff or display spasms, and movements are not under the control 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 weakness with spasms (involuntary muscle contractions). People with flaccid paralysis 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 of determining where on the spine the injury occurred, and how badly related nerves and muscles have been affected.

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

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 or no movement in their limbs and will probably only be able to move their head and possibly their shoulders – they will also need a ventilator to assist 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 fully functional muscles in the top half of their body, but little or no function in their lower limbs and will need a wheelchair
• someone with an L1 to L5 injury could have limited movement in their hips, knees and feet, but is likely to need a wheelchair or other type of mobility aid, such as a walking frame

 

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 – where small doses of radiation are passed through your body to create an image of the denser areas, such as your bones; X-rays can be a usefulway of assessing damage to your spine or neck
• CT scan – where a computer is used to assemble a series of X-ray images to build up a more 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 – which uses strong magnetic fields and radio waves to produce a detailed image of the inside of your body; an MRI scan can help detect brain damage or spinal cord damage
• myelography – away of checking the nerve fibres in your spinal cord in more detail (a special 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 – where sensors are used to measure the electrical activity in your muscles and nerves; electromyography is often used to diagnose Bell’s palsy (temporary facial paralysis) .

 

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 and associated 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 models available is often limited. If you want a more sophisticated model, youwill have to pay some or all of the cost. Your local clinical commissioning 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 standing chair, which functions like a wheelchair but allows the person to riseto a standing position. This helps reduce their risk of developing pressure sores. However, standing chairs can be expensive and are heavier than standard chairs.

Buying a Wheelchair

Orthoses

Orthoses are an alternative to wheelchairs. They are braces, usually made 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 people with tetraplegia (paralysis in the lower limbs, also known as quadriplegia) to stabilise the knee and ankle and let them swing their legs when walking

A neuroprosthesis is a newer type of orthosis that uses electrodes(small metallic discs stuck to your skin) to deliver electrical currents to 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 be suitable for everyone. Alternatively, you may decide to use both a wheelchair and an orthosis.

Assistive technology

There is also a wide range of assistive technology that can help a person with paralysis maintain their independence and improve their 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 as voice-activated computers, special keyboards that can be controlled using a stick placed in the mouth, and cursors that can be controlled with a laser beam attached to the head

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 needs of a person with paralysis. For example, the pedals can be replaced with levers or an electrical switching system, and the steering wheel adapted so you steer using your wrists or arms, rather than having to 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. This is because nerves that control the bowel and bladder are located at the base 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 opening in the penis or vagina that urine flows out of) or through a hole int he 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 paralysed bladder. The recommended method will depend on your ability, the state of 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 the consistency of your stools and establish a regular time to empty yourbowel, as well as helping you find ways of stimulating your bowel to empty
• 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, or sometimes 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 a tcontrolling 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 while taking amitriptyline. If this happens, you should contact your GP or go to your nearest hospital immediately.

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

Breathing difficulties

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

As your diaphragm will not be able to help you breathe, you will need breathing assistance from a ventilator. A ventilator is a machine that carries 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 the ventilator creates a vacuum (a total lack of air) around the lung, which causes 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 are usually smaller and more convenient. A positive pressure ventilator can either 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 device is surgically implanted in the chest and sends regular electrical impulses to the phrenic nerve, causing the diaphragm to contract and expand and fill the lungs with air.

Reduced cough

Another problem that affects most people with paralysis is that their ability to cough is reduced. This is because the cough reflex is triggered by muscles in the abdomen (tummy) and between the ribs pressing down on to the lungs.

If these muscles are paralysed, the force of a person’s cough can be greatly reduced. This is potentially serious because a person’s ability to cough enables them to clear their lungs of a build-up of mucus and other secretions. A reduced cough can cause the lungs to become congested, increasing the risk of a lung infection.

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

There are also a number of devices available to help you cough. They usually 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 rigid muscles. Many people with paralysis develop spasticity and involuntary muscle spasms (where muscles cramp and contract).

Spasticity and muscle spasms are usually caused by the section of the spinal cord below the point of the injury “misfiring” and sending abnormal signals to the limbs.

In some cases, spasticity and muscle spasms can be useful. For example, if you have partial paralysis in your legs, the stiffness in your 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, spasticity and muscle spasms can be painful, affect mobility and interfere with daily 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 baclofen, tizanidine 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. The treatment is most effective when used in conjunction with a programme of stretching and physiotherapy.

Intrathecal baclofen therapy

Another possible treatment is intrathecal baclofen therapy. This involves surgically implanting a small pump on the outside of the body connected to the spinal cord.

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

 

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 blood supply to parts of the body. Blood contains oxygen and other nutrients required 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 be cause the body’s regular movements stop pressure building up in any one part of 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 few hours.

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

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

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

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

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

You can usually prevent affected skin getting worse by keeping it clean 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 good level 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 a wheelchair or orthosis and prevent problems associated with using mobility 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 that caused your paralysis, or as part of your long-term treatment plan, you will be introduced to a physiotherapist (a specialist in physical rehabilitation and exercise).

Your physiotherapist will discuss different exercises and activities 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 any voluntary exercise, functional electrical stimulation (FES) may be recommended. FES uses electrodes (small metallic discs placed on your skin) to deliver electrical currents to the muscles in your legs or arms to stimulate movement.

People with extensive paralysis can use a FES bike to exercise. It is similar in appearance to a normal indoor exercise bike, but has a series of electrodes attached to your legs. These stimulate your muscles so you are able to turn the bike’s pedals.