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Paralysis

Introduction

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:

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.

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Symptoms

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.
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Causes

Common causes of paralysis

The three most common causes of paralysis are:

  • stroke, which accounts for around one in three cases of paralysis
  • spinal cord injury, which accounts for around one in four cases (the spinal cord is a long bundle of nerves that runs through the spine and plays a vital role in helping control the muscles of the body)
  • multiple sclerosis, which accounts for around one in five cases (multiple sclerosis is a condition where the immune system mistakenly attacks the nervous system)

These three conditions are discussed in more detail below.

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 oxygen and nutrients provided by the blood to function properly. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain damage that often results in paralysis.

There are two main causes of strokes:

  • ischaemic (accounting for 70% of all cases), where the blood supply is stopped due to a blood clot
  • haemorrhagic, when a weakened blood vessel supplying the brain bursts and causes brain damage

For more information, see the Health topic on Stroke.

Spinal cord injury

The spinal cord is a thick cable of nerves that runs through the neck and spine. Its main function is to transmit signals from the brain to the various muscles of the body. The spinal cord also passes nerve signals, such as heat or cold sensations, back to the brain.

Damage to the neck or spine can damage the spinal cord. This means the brain may no longer be able to transmit signals to the muscles, causing paralysis.

Exactly where the injury occurs can have a significant effect on how severe and wide ranging the paralysis is. Generally, the higher up the spine the injury occurred, the worse the paralysis.

For example, an injury in the middle of the spine will usually result in paraplegia (paralysis in the lower limbs), whereas an injury in the neck (such as a broken neck) will usually result in quadriplegia (paralysis in all four limbs) as well as loss of normal lung function, meaning that the person will need a ventilator to breathe.

The most common causes of spinal cord injury are:

  • motor vehicle accidents
  • accidents while working
  • accidents during sporting or other types of activity
  • falls

The nature of these causes means that most spinal cord injuries occur in men (who account for 80% of all cases) and younger people. An estimated half of all spinal cord injuries occur in people aged 16-30 years old.

Multiple sclerosis

Multiple sclerosis (MS) is a condition in which the nerve fibres in the spinal cord become damaged by the immune system (the body’s defence against infection).

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 your nerve fibres becomes damaged, which disturbs the messages coming to and from your brain and can lead to paralysis.

For more information, see the Health topic on Multiple sclerosis.

Less common causes of paralysis

Less common causes of paralysis 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 (metastasis) from other parts of the body into the brain or spinal cord, leading to paralysis.

For more information, see the Health topics on Brain tumour (malignant) and Cancer.

Cerebral palsy

Cerebral palsy is a set of neurological conditions that affect a child's movement and co-ordination. Neurological conditions affect the brain and nervous system.

Cerebral palsy is caused by damage to the brain, which normally occurs before, during or soon after birth. Known possible causes of cerebral palsy include:

  • infection in 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 known as spastic quadriplegia, where a person has such a high degree of muscle stiffness (spasticity) in all their limbs that they cannot use them.

For more information, see the Health topic on Cerebral palsy.

Friedreich’s ataxia

Friedreich’s ataxia is a rare genetic (inherited) condition. Friedreich’s ataxia is caused by a mutation in a gene known as the GAA gene.

This mutation results in the body not producing enough of a protein called frataxin. Frataxin is thought to play a role in the regulation of iron levels inside nerve cells.

As not enough frataxin is 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 gradual but increasing paralysis in their legs, meaning they will eventually need a wheelchair or some other sort of mobility aid.

For more information, see the Health topic on Ataxia.

Guillain-Barré syndrome

Guillain-Barré syndrome is a rare and poorly understood condition caused by damage to the peripheral nervous system. 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 these nerves, causing them to become inflamed (swollen).

Inflammation of the peripheral nerves leads to a tingly, numb sensation in the arms and legs.

This can eventually result in 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.

For more information, see the Health topic on Guillain-Barré syndrome

Lyme disease

Lyme disease is a bacterial infection that is spread to people by infected ticks. Ticks are small insects 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.

For more information, see the Health topic on Lyme disease.

Motor neurone disease

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

Specifically, nerve cells known as motor neurones are affected by MND.

Motor neurones are specialised nerve cells that control important voluntary muscle movements, such as walking.

MND causes progressive muscle weakness, which eventually results in total body paralysis.

For more information, see the Health topic on Motor neurone disease.

Post-polio syndrome

Post-polio syndrome (PPS) is a poorly understood condition that affects older people who were exposed to a polio infection. Polio is a type of virus that was relatively common in the 1940s and 1950s, but is now extremely rare in the UK thanks to NHS vaccination programmes.

For reasons that are unclear, people can develop additional symptoms 10-40 years after being infected with polio.

People with PPS can experience symptoms of muscle weakness, which can result in paralysis in the affected muscles.

Severe head injury

A severe head injury can cause brain damage. Even though the brain is protected by the bony skull, the surface of the brain can tear or bruise as it bumps against the skull. This can damage blood vessels and nerves.

Paralysis can result from some cases of severe head injury if a part of the brain that controls specific muscles becomes damaged. 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.

For more information, see the Health topic on Severe head injury.

Spina bifida

Spina bifida refers to a series of birth defects that affect the development of the spine and nervous system.

The most serious type of spina bifida is myelomeningocele, which occurs in 1 in every 1,000 births.

Myelomeningocele causes extensive damage to the nervous system that can often result in partial or total permanent paralysis of the lower limbs.

For more information, see the Health topic on Spina bifida.

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Diagnosis

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)
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Treatment

There is currently no cure for paralysis. Treatment focuses on helping you adapt to life with paralysis by making you as independent as possible.

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

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

Mobility aids

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

Wheelchairs

There are two main types of wheelchair:

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

Wheelchairs are available free of charge from the NHS, but the range of models is limited. If you want a more sophisticated and expensive model, you will have to pay for it, although your primary care trust will fund some of the cost.

There is also a relatively new type of wheelchair known as a standing chair, which acts like a wheelchair but allows the person to rise to a standing position. This reduces the person's risk of developing pressure sores. However, standing chairs can be expensive and are heavier than standard chairs.

For more information, see Direct Gov: wheelchairs.

Orthoses

Orthoses are an alternative to wheelchairs. Orthoses are braces, usually made of plastic or metal, that are designed to improve the function of a limb and compensate for muscle weakness.

Examples of orthoses include:

  • wrist-hand orthoses, which are designed to convey force from a functioning wrist to paralysed fingers
  • ankle-foot orthoses, which are designed for people with some function in their lower limbs to help them move their feet while walking
  • knee-ankle-feet orthoses, which are designed for people with quadriplegia (paralysis in the lower limbs) to stabilise the knee and ankle and let them swing their legs when walking

A neuroprosthesis is a newer type of orthosis. Neuroprotheses are based on a technique called functional electrical stimulation (FES). FES uses electrodes to deliver electrical currents to the muscles in the legs or arms. These currents then stimulate the muscles to move in the same way that the brain used to stimulate the muscles.

FES is not suitable for people who have conditions that directly damage the nerves in the legs, such as motor neurone disease or Guillain-Barré syndrome. This is because the nerves will not react to the electrical currents.

Depending on the complexity of the neuroprosthesis and its associated FES system, it can cost from £1,300 up to £32,000.

Using orthoses can be physically demanding so they may not be suitable for everyone. You may wish to use both a wheelchair and an orthosis.

Assistive technology

There is a wide range of assistive technology that can help you maintain your independence and improve your quality of life. Examples include:

  • environmental control units, which are voice-activated control units that 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 in your mouth, and cursors that can be controlled with a laser beam attached to your head

For more information on the types of assistive technology available, visit the websites of the Disabled Living Foundation and the National Centre for Independent Living. These organisations provide advice and support for people living with paralysis.

Driving

It is usually possible to drive a car even if you have very limited muscle function in your hands and arms.

A number of devices can be used to adapt the controls of a car to meet the needs of a person with paralysis. For example, the pedals of the car can be replaced by levers or an electrical switching system, and the steering wheel can be adapted so you steer it using your wrists or arms rather than having to grip it with your hands.

Another charity for people living with a disability, called Ricability, has an excellent collection of resources and information on driving on its website.

Bladder and bowel management

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 the nerves that control the bowel and bladder are located at the base of the spinal cord.

Most people use a catheter to empty their bladder of urine. A catheter is a thin flexible tube that is inserted into the urethra (the opening in the penis or vagina that urine flows out of) or through a hole in the abdomen (tummy). The catheter is then guided into the bladder, allowing urine to flow through it and into a drainage bag.

It is important to ensure that your bladder is emptied regularly as an overly full bladder can trigger a serious complication called autonomic dysreflexia. See Paralysis – complications for more information on autonomic dysreflexia. You can be taught to perform this technique so you can carry it out at home at your convenience.

For more information, see the Health topic on urinary catheterisation.

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

  • bowel retraining, which aims to improve the consistency of your stools, help you establish a regular time to empty your bowels, and help you find ways of stimulating your bowels to empty
  • a colostomy, which is an operation where a section of the bowel is diverted and attached to an opening in the abdominal wall

For more information, see the Health topics on Bowel incontinence and Colostomy.

Neuropathic pain

Neuropathic pain is pain caused by damage to the nerves. Many people with spinal cord injury, and some with other types of paralysis, have chronic (long-term) pain that persists for weeks, months and sometimes years after the initial injury or incident that caused paralysis.

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

Medications used to treat neuropathic pain include:

  • amitriptyline
  • pregabalin

Many of these medications can cause a wide range of side effects. Therefore, it can take some time to identify a suitable medication that is effective in controlling your symptoms but does not cause unpleasant side effects that put you off taking it.

Side effects caused by the medications listed above include:

  • dry mouth
  • constipation
  • sweating
  • problems passing urine
  • slight blurring of vision
  • drowsiness
  • dizziness
  • tiredness

There have been reports of people suddenly having thoughts of hurting or killing themselves when taking amitriptyline. If this happens to you, contact your GP or go to your nearest hospital straight away.

It may be helpful to tell a close friend or relative that you are taking amitriptyline  and ask them to tell you if they notice changes in your behaviour or are worried about the way you are acting.

Breathing difficulties

If you had a spinal cord injury at C3 or above (the upper neck), your diaphragm will be paralysed. The diaphragm is a thick dome-shaped muscle that helps you breathe in and out.

As you will no longer have a functioning diaphragm, you will need a ventilator to help you breathe. A ventilator is a mechanical device designed to replicate the function of the diaphragm by regulating the pressure of the lungs.

There are two ways this can be done:

  • negative pressure ventilator, where the ventilator creates a vacuum (a total absence of air) around the lung, which causes the chest to expand and pull in air
  • positive pressure ventilator, where the ventilator pushes oxygen directly into the lungs

Positive pressure ventilators are more widely used as they are generally smaller and more convenient.

A positive pressure ventilator can be:

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

A non-invasive ventilator system carries a smaller risk of causing a lung infection such as pneumonia. However, non-invasive ventilator systems are not suitable for people with more extensive paralysis who have difficulties swallowing.

An alternative to using a ventilator is a device known as a phrenic nerve stimulator. The phrenic nerve controls the diaphragm.

The device is surgically implanted in the chest and it sends regular electrical impulses to the phrenic nerve, which in turn causes the diaphragm to contract and expand, filling the lungs with air.

Reduced cough

Another problem that affects most people with paralysis is that their ability to cough is either reduced or entirely lacking. This is because the cough reflex is triggered by muscles in the abdomen (tummy) and between the ribs pressing down onto the lungs. If these muscles have been paralysed, the force of a person's cough can be greatly reduced.

This is potentially serious because our ability to cough means we can clear our lungs from a build-up of mucus and other types of secretion. A reduced cough can lead to the lungs becoming congested, increasing the risk of a lung infection.

One technique that can be used to compensate for a reduced coughing ability is known as an assisted cough. This involves getting a friend or carer to push against the outside of your stomach while you attempt to cough.

A number of devices can be used to help you cough. These usually consist of vests that can contract (squeeze) against your lungs, compensating for the loss of muscle action.

Because of your loss of ability to cough, it is important to take several precautions to reduce your risk of developing a lung infection:

  • Sit up every day and turn regularly while lying down to prevent the build-up of phlegm.
  • Make sure you cough regularly, either by getting someone to help you perform an assisted cough, or by using a ‘cough vest’.
  • Drink plenty of water, which will help dilute any phlegm, making it easier to cough up.
  • Avoid smoking or being in close contact with people who smoke, as tobacco smoke damages the tissue of the lungs, making them more vulnerable to infection.
  • Get the influenza and pneumococcal vaccinations, as these will help reduce your risk of developing influenza and pneumonia (neither vaccine is 100% effective so it is still important to take the precautions discussed above).

Spasticity and muscle spasms

Spasticity is a medical term meaning abnormally stiff and rigid muscles. Many people with paralysis develop spasticity and involuntary muscle spasms (cramping and contraction of the muscles).

Spasticity and muscle spasms are usually the result of the section of the spinal cord below the point of injury ‘misfiring’ and sending abnormal signals to the limbs.

In some circumstances, spasticity and muscle spasms can be useful. For example, if you had only partial paralysis in your legs then the stiffness of the muscles may make your legs easier to control. Some people find that a series of muscle spasms can make it easier for them to empty their bladder or bowel.

However, in other circumstances, 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 diazepam, which is usually taken in tablet form.

Side effects of diazepam include:

  • drowsiness
  • slurred speech
  • constipation
  • nausea
  • incontinence

If diazepam is not effective, a number of alternative muscle relaxants can be used, such as dantrolene and tizanidine. These have similar side effects to diazepam.

Botulinum toxin

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

The effects of the injection normally last for up to three months. The treatment is most effective when a programme of stretching and physical therapy follows the injections.

Intrathecal baclofen therapy

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

The pump delivers regular doses of a medicine, known as baclofen, directly to the nerves. Baclofen blocks some of the nerve signals that cause muscle stiffness.

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Recommendations

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.

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Complications

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:

  • 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:

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.

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