Paralysis is the loss of ability to move one or more muscles of the body. Some people with paralysis also lose sensation from the affected body part. For example, they may not notice a pin pressed against the skin of their legs if their legs are paralysed.

Paralysis is not usually caused by problems with the muscles, but by problems with the nerves that the brain uses to control the muscles (the nerves are usually damaged).

How common is paralysis?

It is hard to estimate how widespread paralysis is in Wales as cases are not recorded in the same way as cancer or heart attacks, for example.

A recent study carried out in the United States found that 1 in every 50 people had some degree of paralysis. While there may be some difference in rates of cases in Wales, it is unlikely that the figures will be widely different.

Paralysis can have a wide range of causes, such as stroke (a serious condition where the blood supply to the brain is disturbed) and multiple sclerosis (a condition where the immune system mistakenly attacks the nervous system). Injury to the spine is another common cause of paralysis.

Living with paralysis

The type and extent of paralysis will determine the impact it has on a person’s quality of life and day-to-day activities (see Paralysis – symptoms for more information).

For example, many people with paralysis that affects their lower limbs (paraplegia) lead relatively independent and active lives using a wheelchair to carry out their daily activities.

However, people with paralysis affecting both their hands and their legs (quadriplegia) need a great deal of support and are unlikely to be able to live without a dedicated carer.

Paralysis can cause a number of associated secondary conditions such as:

• urinary incontinence: being unable to control the passage of urine from the bladder
• bowel incontinence: stools (faeces) can leak uncontrollably from the back passage
• pressure ulcers: sores that develop on the skin when the skin is placed under prolonged pressure

Dealing with these secondary conditions is another important factor in living with paralysis.

Outlook

The outlook for people with paralysis can vary depending on the underlying cause.

In some cases, the paralysis is only temporary and the outlook is good, for example after a stroke.

The outlook for paralysis due to spinal cord injury or multiple sclerosis is poor as the paralysis is usually permanent. However, this does not mean that a person with permanent paralysis cannot have a good quality of life.

Many people with paralysis take part in a range of different activities, from driving to waterskiing and even mountain climbing.

Paralysis can be classified in a number of ways, which are explained below.

Localised or generalised paralysis

Paralysis can be either:

• localised, where only a specific section of the body is paralysed
• generalised, where a larger portion of the body is paralysed

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 (bands of tissue and muscle used to generate speech), which usually only affects one vocal cord, meaning that a person can still speak but their voice sounds very 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
• quadriplegia (also known as tetraplegia), where both the arms and legs are paralysed

Temporary or permanent paralysis

Paralysis can either be temporary or permanent.

A relatively common cause of temporary paralysis is a condition called Bell’s palsy, which causes temporary facial paralysis. Some cases of paralysis associated with stroke are also 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 a complete loss of muscle function and sensation in the affected limbs

Spastic or flaccid paralysis

Paralysis can be:

• spastic, where the muscles in the affected limbs are unusually stiff
• flaccid, where the muscles in the affected limbs are floppy and weak

People with spastic paralysis may experience muscle spasms and people with flaccid paralysis often experience muscle weakness.

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

If you have experienced a spinal cord injury, you will probably hear a lot of talk, and sometimes confusing terminology, about the level of a spinal cord injury.

A spinal cord injury level is essentially where along the spine the injury took place and how badly the related nerves and muscles have been affected.

The spinal cord is measured using a number and lettering system that is based on vertebrae (ridges of bone that help support the spine and neck).

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

• 7 cervical vertebrae in the neck, measured as C1 to C7
• 12 thoracic vertebrae in your chest area, measured as T1 to T12
• 5 lumbar vertebrae in your lower back, measured as L1 to L5

People with a spinal cord injury between the C1 and C7 level are likely to have paralysis in all four limbs (quadriplegia). 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-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 with 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 T1-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 require a wheelchair.
• Someone with an L1-L5 injury could have some limited movement in their hip, knees and feet, but it is likely they will need a wheelchair or some other type of mobility aid, such as a walking frame.

Exactly what tests and procedures are used to help in your diagnosis will depend on the underlying cause.

Diagnosis may not be necessary if the cause of your paralysis is obvious, for example if it follows a stroke.

Some general tests that can be used include:

• X-ray, where waves of energy are used to create an image of your bones (X-rays can be a useful way of assessing damage to your spine or neck)
• CT scan, where a computer is used to put together a series of X-rays to build up a more detailed picture of your bones and tissue (CT scans are often used to assess the state of damage after a serious head 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 and can detect damage to the brain or spinal cord
• myelography, which is a way of checking the nerve fibres in your spinal cord in more detail (a special fluid known as a contrast dye is injected into the nerves and this makes the nerves 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 in the diagnosis of Bell’s palsy)

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 that are 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 because the body automatically makes hundreds of regular movements that prevent pressure building up on 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 twenty times a night.

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

Making regular and frequent changes to your position is one of the most effective ways of preventing pressure ulcers. As a general rule, wheelchair users will need to change their position at least once every 15-30 minutes. People who are confined to bed will need to change their position at least once every two hours.

If you are unable to change position yourself, a carer or relative can assist you.

There is also a wide range of cushions, mattresses and other pressure-relieving devices that can be used to reduce pressure on your affected limbs.

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 feels warm and spongy or alternatively hard to the touch. You can usually prevent the affected skin from getting worse by keeping it clean and avoiding putting any pressure on the skin until it has healed.

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

For more information, see the Health topic on Pressure ulcers.

Exercise

If you have paralysis, it is important to do regular exercise and try to achieve a good level of fitness. There are a number of important reasons for this:

• The fitter you are, the better your general state of health and the lower your risk of developing complications.
• Regular exercise helps improve 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 prevents the muscles in the affected limbs becoming severely weakened.

In the first few days or weeks after your paralysis happened, 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 be able to discuss different exercises and activities that 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 that are 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 recommend. FES uses electrodes to deliver electrical currents to the muscles in the legs or arms to stimulate movement. See Paralysis – treatment for more information.

One system used to help people with extensive paralysis to exercise is the FES bike. This looks much like a typical indoor exercise bike, but it contains a series of electrodes that are attached to your legs. These stimulate your muscles to cycle the pedals of the bike.

Autonomic dysreflexia

Autonomic dysreflexia is a potentially life-threatening complication. It can affect people with paralysis due to a spinal cord injury that occurred at T5 level or higher (the middle of the chest).

Autonomic dysreflexia is caused by a problem with the autonomic nervous system. The autonomic nervous system is the part of your nervous system that helps regulate many of the functions of your body that you never have to think about, such as:

• blood pressure
• digestion
• breathing

Autonomic dysreflexia occurs when a trigger irritates the normal working of your autonomic nervous system. Your autonomic nervous system then sends a signal to the brain, essentially seeking advice on how to deal with the irritant. However, due to the injury in your spinal cord, the signal is unable to reach your brain.

The blocked signal then triggers a series of abnormal reflexes, which cause your autonomic nervous system to raise your blood pressure and slow your heartbeat.

Symptoms of autonomic dysreflexia

Signs and symptoms of autonomic dysreflexia include:

• pounding headache
• intense feeling of anxiety and apprehension
• intense sweating above the level of your injury
• tightness in your chest
• red blotches in your skin above the level of your injury
• slow heartbeat (fewer than 60 beats a minute)
• dilated (widened) pupils
• goosebumps
• unexplained erection and ejaculation of semen

If it is not treated, autonomic dysreflexia can lead to seizures and bleeding inside the brain, which can be fatal.

Triggers of autonomic dysreflexia

The most common trigger for autonomic dysreflexia is a problem with the bladder, such as:

• a urinary tract infection, which is an infection of the kidneys, bladder, ureter (tube that runs from the kidneys to the bladder) or urethra (the tube that runs from the bladder through which urine passes)
• the bladder containing too much urine
• blocked catheter (tube used to drain the bladder)
• the bag used to drain the bladder being too full
• bladder stones

Other triggers for autonomic dysreflexia include:

• constipation 
• haemorrhoids (piles)
• pressure ulcers
• ingrown toenail
• burns, including sunburn
• sexual activity
• period cramps
• pregnancy
• giving birth
• bone fractures

Treating autonomic dysreflexia

The first thing to do if you suspect autonomic dysreflexia is to sit up (if possible) or raise your head upright. If you can lower your legs, do so.

The next important step is to identify the trigger. As the most common trigger is a problem with the bladder, check your catheter system first. Check whether:

• your catheter is blocked or twisted
• your drainage bag is full
• the catheter is fully inserted into the drainage bag
• the drainage bag is higher than your bladder

If you do not have a catheter attached, you should immediately have urinary catheterisation.

If your bladder does not appear to be the trigger, next check your bowel. Use your finger to check if there are any hardened stools inside your rectum (back passage). It is recommended that you use gloves coated with a lubricant.

If you do detect any stools, gently remove them with your finger.

If neither your bladder nor bowel appears to be the trigger, check your skin for any pressure ulcers or ingrown toenail. Loosen any clothing from skin or toes that appear to be damaged.

If none of the actions above identify the trigger or relieve symptoms, immediately call your care team for advice. If this is not possible, call NHS Direct Wales on 0845 4647.

Depression

Experiencing paralysis, especially unexpected paralysis, can be a devastating and traumatic experience. Many people go through the classic stages of grief:

• Denial. You may initially refuse to believe that your paralysis is incurable and think you will be able to resume your former lifestyle.
• Anger. You may lash out at friends, family or medical staff.
• Bargaining. You may try to bargain with your doctors, asking for any sort of ‘miracle cure’.
• Depression. You may lose all interest in life and feel your situation is hopeless.
• Acceptance. In time, most people come to terms will having paralysis and begin adapting to living with the condition.

Some people have difficulties reaching the acceptance stage and become stuck in depression. It is estimated that around 20-30% of people with permanent paralysis are affected by depression.

It is important not to ignore any signs or symptoms that you may be depressed. Not only can depression affect your rehabilitation, but the symptoms of depression can also rapidly worsen if not promptly treated. For example, it is estimated that rates of suicide may be as much as six times higher in people with spinal cord injuries than in the general population. 

For more information, see the Health topic on Depression.

People who experience depression after paralysis usually come to terms with the condition. One study which looked at people who had been living with paraplegia (paralysis of the lower limbs) for many years found that 83% of them reported having either an above-average or average quality of life.

Sex life and fertility

Paralysis can have an impact on both your sex life and fertility, but even severe paralysis does not necessarily mean you will be unable to have children or have sexual intercourse.
 
Paralysis can affect a man’s ability to get and maintain an erection and his ability to ejaculate sperm.

Erection

There are two types of erection:

• a reflex erection, caused by something touching your penis or other sensitive part of your body
• a psychogenic erection, caused by sexual thoughts or seeing something sexually stimulating, such as a pornographic film

As the nerves that control the reflex erection are located at the very base of the spine, the ability to achieve a reflex erection is usually retained even in the most serious cases of paralysis.

However, the nerves that control a psychogenic erection are located much higher up in the spine, so men with high-level partial paralysis and almost any type of complete paralysis are unlikely to be able to have a psychogenic erection.

If you can only have a reflex erection, it is still possible to have sexual intercourse, although you may find it harder to maintain an erection for a prolonged period of time (known as erectile dysfunction).

Treatment options for erectile dysfunction include medications such as sildenafil (sold under the brand name Viagra), which increase the flow of blood to your penis, and penis pumps, which create a vacuum and cause blood to rush to your penis.

For more information, see the Health topic on Erectile dysfunction.

Ejaculation

The type and location of your paralysis will also affect whether you will be able to ejaculate sperm.

Studies have found that:

• For lower-level paralysis (T12 or lower), ejaculation is retained in 70% of men with partial paralysis and 17% of men with total paralysis.
• For upper-level paralysis (T11 or higher), ejaculation is retained in 30% of men with partial paralysis and almost never in men with total paralysis.

If you lose the ability to ejaculate but you want to have children, a number of different techniques can be used to obtain a sample of sperm. This can then be used in a fertility treatment, such as intrauterine insemination (where a sample of sperm is taken and then implanted into a woman’s womb through a tube).

A widely used technique is known as penile vibratory stimulation (PVS). PVS uses a specially designed vibrator that is placed against the underside of the penis. The vibrator stimulates the nerve endings of the penis, triggering ejaculation. The process normally takes 10–30 minutes to complete.

As it is important to store the sperm sample as quickly as possible, PVS is usually carried out in the private room of a fertility clinic.

If PVS is unsuccessful, an alternative technique known as rectal probe electroejaculation (RPE) can be use. Again, an RPE is typically performed in a fertility clinic. During an RPE, an electric probe will be inserted into your rectum. The probe then delivers a small electrical pulse to the rectum, which stimulates the nerves and triggers an ejaculation. The sperm can then be collected.

Women

In women with paralysis, physical libido (sex drive) and fertility are usually unaffected.

Many women may experience a reduction in their sex drive due to psychological and emotional factors, such as concerns about their body image or having to use a bladder or bowel control system, such as a catheter or colostomy.

You will probably find that your vagina no longer becomes lubricated when you are sexually aroused. This is because nerves located higher up in the spine trigger the process of lubrication. You can compensate for this by using an artificial water-based lubricant, such as KY jelly (do not use Vaseline as this will irritate your vagina).

There is usually no reason why a paralysed pregnant woman cannot have a standard vaginal delivery during labour.

Pregnant woman with a spinal cord injury T6 or higher have an increased risk of developing autonomic dysreflexia, so it is important to remain alert for the symptoms and report them immediately to your GP or midwife.