What is Paralysis?

NHS statistics and charity data estimate that the number of people injured or diagnosed with a life-changing spinal cord injury in the UK is 2,500 per year, whilst the total number of people living with a spinal cord injury in the UK is 50,000, and every day three people in the UK are told they will never walk again.

The following statistics related to the kind of spinal cord injury which often results in paralysis, capture some of the scale of the problem (source Spinal Research):

• Approximately 1,000 people per year suffer a spinal cord injury in the UK and Ireland.
• Most of those affected are young adults.
• Around 80% of those affected are male.
• In the region of 50,000 people in the UK and Ireland are living with the effects of paralysis.
• The economic cost of paralysis is estimated to be £1 billion per annum.
• Currently, a spinal cord injury which causes paralysis cannot be cured.

Stroke is another factor causing paralysis, according to the Stroke Association:

• Stroke strikes every five minutes.
• 100,000 people have a stroke each year.
• There are 1.3 million stroke survivors in the UK.

What is paralysis?

Paralysis refers to temporary or permanent loss of voluntary muscle movement in a body part or region. People can experience localised, generalised, partial or complete paralysis. It 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.

What are the different types of paralysis?

• Quadriplegia, also known as tetraplegia – this is a spinal cord injury that means you suffer paralysis everywhere below your neck – that is your hands, arms, trunk, legs and pelvic organs.
• Paraplegia – a spinal cord injury that results in the entire lower half of your body being paralysed – that is your trunk, legs and pelvic organs.
• Diplegia – the same area of your body is affected on both sides – that is both legs, both sides of the face, both arms, etc.
• Hemiplegia – one side of your body is affected – that is your arm and leg on your left side, for example.
• Monoplegia – only one limb is affected – that is your left leg, your right arm, etc.
• Facial paralysis, also known as facial palsy – this generally refers to weakness of the facial muscles, mainly resulting from temporary or permanent damage to the facial nerve.

What are the signs and symptoms of paralysis?

The signs and symptoms of paralysis vary, depending on the type and cause of the issue. The most common paralysis symptom is the loss of muscle function in one or more parts of the body.

Other symptoms that may accompany paralysis include:

• Involuntary spasms or twitches.
• Muscle weakness.
• Numbness or pain in the affected muscles.
• Stiffness.
• Visible signs of muscle loss (muscle atrophy).

Being unable to move independently is associated with a number of significant health conditions and outcomes. Higher spinal cord injuries which affect the muscles involved with breathing have their own risks and are associated with higher incidence of serious illness.

Without control over movement, a person is at risk of:

• Pressure damage to the skin and underlying tissues.
• Moisture damage to the skin, from sweat and incontinence, plus an increased risk of fungal skin infections.
• Obesity, coupled with muscle degeneration.
• Depression – becoming paralysed triggers a number of huge lifestyle changes which can be overwhelming and can contribute to significant mental health problems. A life-changing injury, alongside permanent disability, changes in lifestyle and which can affect family life, recreational activities, and work or education, takes time and support to come to terms with.
• Pneumonia – alongside an inability to cough and clear mucous, and which may be exacerbated by an inability to change position and poor sitting balance.
• Aspiration – an impaired swallow means that food or fluid can enter the respiratory tract and cause aspiration pneumonia.
• Difficulty managing complex care needs – some people with high spinal cord injuries have tracheostomies, and some need part- or full-time mechanical ventilation. Some people with high spinal cord injuries need to have their nutrition and hydration needs met through an alternative to the oral route, usually a percutaneous endoscopic gastrostomy (PEG). While this can all be well-managed with a trained care team, it does inevitably mean that activities take a little more planning and organisation than for people without complex care needs.

What causes paralysis?

Different causes can trigger different types of paralysis. A stroke is the most common underlying condition that triggers partial or complete paralysis in a person. In partial paralysis, the person is still in partial control of the affected muscle; in complete paralysis, the person has no control over the affected muscle tissue.

Monoplegia is often the side effect of cerebral palsy. In cerebral palsy, the brain loses the ability to control certain muscles of the body. Infants and early adolescents are mostly affected by cerebral palsy.

Hemiplegia is most often caused due to injuries to the spinal cord or when the left and right sides of the brain are not communicating properly through the corpus callosum. Hemiplegia is also caused by a stroke, which affects the functioning of one side of the brain.

Paraplegia is often caused after the person experiences an injury in the brain, or the spinal cord or both. In people who are paraplegic, the signals that are sent to the lower part of the body from the brain are not sent back up to the brain through the spinal cord. This lack of communication with the brain causes the person to not only lose motor functions but also results in loss of sensation. In a few cases, serious injuries to the leg, an allergic reaction or side effects of seizure can exhibit the form of paraplegia.

Quadriplegia is a form of paralysis where all four limbs are affected. In this condition, the signals that are sent from the brain to the regions below the neck are not sent back, thereby causing impairment in the hands and legs of the person. The spinal cord is charged with the job of sending signals to and receiving signals from the brain. In quadriplegia, this ceases to function, thereby causing the condition. Injuries to the spinal cord or the brain can trigger the onset of quadriplegia. As the injuries to the affected area heal or when the inflammation in the brain decreases, the chance of recovering from this condition is possible.

Although the most commonly known cause of facial paralysis is Bell’s palsy, there are actually many different causes of facial palsy. A person with Bell’s palsy may initially fear that they are having a stroke; however, in Bell’s palsy, the paralysis affects the entire half of the face, including the forehead (whereas typically with a stroke, the forehead is spared). Also, in Bell’s palsy there is no weakness of the hands, arms or legs.

The most prominent conditions that can lead to paralysis include but are not limited to:

• Acute Flaccid Myelitis.
• Amyotrophic Lateral Sclerosis.
• Brachial Plexus Injury.
• Brain Injury.
• Brain Tumours.
• Cerebral Palsy.
• Guillain-Barré Syndrome.
• Leukodystrophies.
• Lyme Disease.
• Multiple Sclerosis.
• Muscular Dystrophy.
• Neurofibromatosis.
• Parkinson’s disease.
• Post-Polio Syndrome.
• Spina Bifida.
• Spinal Cord Injury.
• Spinal Tumours.
• Stroke.
• Transverse Myelitis.
• Tumours.
• Viral infections.

Paralysis can also be caused by spinal cord or brain damage, for example during/after a car accident, falls such as an accident at work or sports injury.

Other causes of paralysis not related to other conditions can include but are not limited to:

• Birth Trauma.
• Medications.
• Poisons/Toxins.
• Surgery.
• Trauma.

Can paralysis be prevented?

In some cases, depending upon the cause of the paralysis, preventative measures might have prevented the paralysis from happening, particularly if the paralysis was caused by an accident. When involved in any activity that could present a risk for spinal cord injury (SCI) or brain injury, everyone involved should be made aware of safety precautions and the ways the conditions of the activity could be dangerous.

Preventative measures include:

• Using safety equipment as required, for example, safety helmets, safety belts and/or harnesses etc.
• Following any health and safety instructions as required.
• Preventing falls.
• Not engaging in risky behaviour such as diving into too-shallow water or playing sports without wearing the proper safety gear or taking proper precautions which can lead to spinal cord injuries. Driving at speed – motor vehicle crashes are the leading cause of spinal cord injuries for people under 65.
• Limiting alcohol use. Alcohol use is involved in about 25% of traumatic spinal cord injuries.
• To avoid stroke, lower blood pressure as high blood pressure is a huge factor, doubling or even quadrupling the stroke risk if it is not controlled. Lose weight – obesity, as well as the complications linked to it, raises the risk of having a stroke. Increasing exercise – exercise contributes to losing weight and lowering blood pressure, but it also stands on its own as an independent stroke reducer.

How severe is paralysis?

As we have seen, paralysis comes in many different forms and it can be temporary or permanent or even come and go.

The types and severity of paralysis can include:

• Complete paralysis is when someone can’t move or control their paralysed muscles at all. They also may not be able to feel anything in those muscles.
• Partial or incomplete paralysis is when a person still has some feeling in, and possibly control over, their paralysed muscles.
• Localised paralysis – this affects just one specific area, such as the face, hands, feet, or vocal cords.
• Generalised paralysis – this is more widespread in a person’s body and is grouped by how much of their body is affected. The type usually depends on where their brain or spinal cord is injured.

Paralysis can be stiff or spastic, when the muscles are tight and jerky. Most people with cerebral palsy have spastic paralysis. Paralysis can also be floppy or flaccid, when the muscles sag and eventually shrink.

The type and extent of paralysis will determine the impact it has on a person’s quality of life and day-to-day activities. For example, a person who has lower limb paralysis (paraplegia) will usually be able to lead a relatively independent and active life, using a wheelchair to carry out their daily activities. However, a person with paralysis that affects both their arms and their legs (tetraplegia/quadriplegia) will need a great deal of support, and it is unlikely they will be able to live without a dedicated carer.

How is paralysis diagnosed?

Diagnosing paralysis is not always 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 – this is 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 useful way of assessing damage to your spine or neck.
• CT scan – this is 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 used to assess the extent of damage after a severe head injury or spinal cord injury.
• MRI scan – this 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 – this is a way of checking the nerve fibres in the 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 – this is where sensors are used to measure the electrical activity in the muscles and nerves; electromyography is often used to diagnose Bell’s palsy, which is temporary facial paralysis.

How is paralysis treated?

There is currently no cure for paralysis, except in certain conditions. In cases of permanent paralysis, treatment aims to:

• Help a person live as independently as possible.
• Address any associated complications that arise from paralysis, such as pressure ulcers (sores that develop when the affected area of tissue is placed under too much pressure).
• Address bladder and bowel problems that are secondary to paralysis.
• Treat spasms and complications resulting from paralysis.

The first type of medication that a person with paralysis may be prescribed is a muscle relaxant, such as tizanidine or dantrolene, usually taken in tablet form. Sedatives such as diazepam are generally avoided, except in severe cases. All of these medicines may cause sedation as a side effect.

Mobility aids such as wheelchairs and orthoses can help a person with paralysis. Manual wheelchairs are designed for people with good upper body strength. Electric wheelchairs are designed for people with poor upper body muscle strength or paralysis in all four limbs. Orthoses are an alternative to wheelchairs. They are braces made of metal or plastic designed to improve the function of a limb and compensate 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.

Using orthoses can be physically demanding, so they may not be suitable for everyone. Alternatively, a person may decide to use both a wheelchair and an orthosis.

Neuroprosthesis is a newer type of orthosis that uses electrodes (these are small metallic discs stuck to your skin) to deliver electrical currents to muscles in the legs or arms. The currents stimulate the muscles to move 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.

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 – these are voice-activated control units that a person can use to control things such as lighting, temperature or the telephone in their 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.

It may be possible for a person who has paralysis to drive a car, even if they have limited muscle function in their 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 they steer using their wrists or arms, rather than having to grip it with their hands.

Almost all types of spinal cord injury and many types of generalised paralysis 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. A catheter is a thin, flexible tube inserted into the urethra; that is the opening in the penis or vagina where urine flows out of, or through a hole in the abdomen. 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 the person’s ability, the state of their bladder, and the resources available. It is important to ensure that the bladder is emptied regularly because an overly full bladder can trigger a serious complication called autonomic dysreflexia in high spinal cord injuries.

Many people with a spinal cord injury, and some with other types of paralysis, have long-term pain that persists for weeks, months, or sometimes years after the injury or incident that caused the paralysis. Neuropathic pain is pain caused by nerve damage. Unlike most other types of pain, neuropathic pain does not usually respond well to ordinary painkillers, such as paracetamol or ibuprofen, so alternative medications are usually prescribed. 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 at controlling an individual person’s symptoms without causing unpleasant side effects. Possible side effects include a dry mouth, sweating, drowsiness and vision problems.

In a person who has had a spinal cord injury to the upper neck, their diaphragm will be paralysed. The diaphragm is a thin, dome-shaped muscle that helps a person to breathe in and out. As their diaphragm will not be able to help them breathe, they 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 – this is where the ventilator creates a vacuum (a total lack of air) around the lung, which causes the chest to expand and pull in air.
• Positive pressure ventilator – this is where the ventilator pushes oxygen directly into the 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), or 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 these are not suitable for people with more extensive paralysis who have difficulty swallowing.

An alternative to using a ventilator is a device called a phrenic nerve 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.

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 and between the ribs pressing down onto 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. There are a number of devices available to help a person with paralysis to cough. They usually consist of vests that can contract against their lungs, compensating for the loss of muscle action.

Physiotherapy – a physiotherapist will assess problems and recommend suitable exercises and activities for a person with paralysis. There are different types of exercise to increase strength, stamina and flexibility. Physiotherapists use a variety of interventions to help a person to do this. For example, the physiotherapist will help to practise specific activities such as standing, walking and reaching for objects.

Occupational therapists play an important role in helping the person to find ways to carry out everyday activities and help them to maintain their independence. For example, they may make sure that the individual has any special equipment that they might require at home. They assess any difficulties they might have, including problems with movement. They might ask the individual to practise certain activities to regain skills and build their strength. They often work with other professionals, such as physiotherapists and speech and language therapists.

Paralysis, particularly if it is unexpected, can be a devastating and traumatic experience. Unsurprisingly, many people who are paralysed experience depression. It is important not to ignore any signs or symptoms of depression. As well as affecting rehabilitation, symptoms can also quickly worsen if they are not treated promptly. However, research has shown most people with paralysis are eventually able to come to terms with the condition, particularly with support and counselling.

Final thoughts

• Aspire provides practical help to people who have been paralysed by spinal cord injury, telephone 020 8954 5759. For free legal advice call 0800 030 20 40.
• Spinal Injuries Association (SIA) – Support line 0800 980 0501.
• Back Up Trust – Back Up is for everyone affected by spinal cord injury, regardless of age, level of injury, or background.
• Disabled Living Foundation – DLF is a national charity providing impartial advice, information and training on independent living since 1969. Helpline 0300 999 0004.
• Sportability, a registered charity, provides sport and challenging pursuits for people with paralysis around the UK.
• Stroke Association is a place for information and support if you or someone you know has been affected by stroke 0303 3033 100.