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Paralysis - the loss of muscle power
A guide for patients and carers
What are the symptoms of paralysis?
The actual symptoms of paralysis and how a person copes with them will depend on a number of factors. These include what has caused the paralysis; how it began;which part or parts of the body are affected; and whether or not there are additional symptoms.
In some circumstances the onset is sudden or rapid e.g. following injury or stroke. In others it develops gradually so that there is a period of weakness or clumsiness, which may get steadily worse or may come and go, before there is actual loss of movement. This means the practical difficulties that a person experiences may be at their worst from the beginning, they may fluctuate or they may get worse over time.
Obviously the effects of paralysis will vary according to which part(s) of the body are involved and how widespread the paralysis is. In addition to limb weakness, the muscles of the central part of the body or trunk can be affected. This is sometimes referred to as truncal paralysis. Paralysis of the muscles of the chest and abdomen interferes with breathing and with activities such as sitting up or turning in bed.
The impact the paralysis has on a person will also be influenced by whether or not it is their preferred or dominant side which is affected - a right-sided paralysis or hemiplegia is likely to present a right-handed person with more severe problems than a left-handed person and vice versa.
Damage to motor neurones does not usually occur in isolation except in motor neurone disease itself. Most injuries or disease processes which interfere with the motor pathways of the nervous system will also affect the nerves carrying sensory information (pain, temperature, etc.), and those nerves which control internal organs such as the heart, lungs, intestines and the glands, which make up the autonomic nervous system. When it is the brain that is injured or diseased, a person’s mental powers, language or behaviour may also be affected.
SPASTICITY AND FLACCIDITY
Spasticity
Typically, spastic paralysis causes increased tightness in the muscles when they are at rest and often results in abnormal limb positionings. When a joint is bent it is said to be flexed and when straight, extended. When someone is sitting, the knee is flexed and when standing the knee is extended. The abnormal postures that occur with spasticity can include excessive flexion or extension of the limbs. Thus a spastic arm may adopt a position with the elbow and wrist bent, or flexed, and the fingers tightly clenched. In the legs, the knee and ankle may be similarly flexed or be held abnormally straight or extended.
People with spastic paralysis may also experience repeated spasms where the arm or leg jerks, sometimes painfully, into a bent (flexor spasm) or straightened-out position (extensor spasm). Another abnormal movement that sometimes occurs is called ‘clonus’ where there is rapid, regular shuddering movement especially at the ankles or knees when they are placed in a particular position.
A number of factors can make spasticity worse. These include mental stress, tension, anger or excitement, all of which can make the involuntary tightness worse. Cold weather, fever, pain and unrelated illnesses like bladder infections can do the same. Some positions can make spasticity more likely and some other positions reduce its effects. Although the muscles are abnormally tight with spasticity and the affected limb may adopt an odd position, the muscles themselves look healthy and of normal size.
Flaccidity
Flaccid muscles tend to be loose and weak, hanging limply rather than taking up particularly abnormal positions. The muscles also often look thin and wasted. The most evident difficulty is that the person may be unable to lift the limb or support themselves on their legs.
Mixed pictures
To add to our confusion, in those who suffer a sudden major injury which damages the upper motor neurones, such as occurs in head and spinal cord injury, there may be a temporary period in which the muscles are loose and flaccid for a few days or weeks before the stiffening up of spasticity occurs. Progressive conditions like motor neurone disease may result in a change from flaccidity to spasticity over a period of weeks, months or longer.
Direct effects of paralysis
Everyday tasks such as eating, washing, bathing, dressing, going to the toilet and generally getting around may pose significant problems for someone with paralysis. The term ‘activities of daily living’ (ADL) is often used to describe these actions. Of course there are many other everyday things that everyone does, and which people normally take for granted, that do not involve movement - so that strictly speaking not all ADLs are necessarily affected. However, this is a useful term to cover such items rather than listing them each time they come up.
The ability to do things like using a knife and fork, drinking from a cup, using a toothbrush and combing your hair are likely to be more difficult if there is paralysis of the upper limbs. Someone who is in a wheelchair as a result of paraplegia may be able to manage these upper limb ADLs but have problems which mainly relate to mobility. They may have difficulties getting out of their wheelchair and into an armchair, bed or bath, and vice versa. Also, of course, there are the obstacles of stairs and uneven surfaces. Getting dressed is likely to be made difficult by either arm or leg weakness as it often takes a lot of coordinated manoeuvres to get into our clothes. Occupational therapists, who are experts in ADL matters, can help with this by breaking the task of dressing into upper half and lower half, referring to essentially above and below the waist.
Indirect effects of paralysis
Paralysis can be looked upon as involuntary immobility. Immobility, from whatever cause, can have widespread effects on almost all systems of the body. Especially if it is long-lasting, it can lead to changes in the circulation and respiration, alter the workings of the kidneys and gastrointestinal system and result in changes to tissues such as skin, muscles and bones. In people who have profound paralysis, much of the nursing care is directed at minimising these effects and trying to prevent the complications that they can cause.
Changes to muscles, bones and joints can explain some of the discomfort or pain that may accompany paralysis. It may be difficult to decide just where these aches or pains are coming from and to know precisely what is causing them, but paralysis of one group of muscles may result in excess forces pulling on others or abnormal stress on joints. In addition, particularly where there is spasticity and the limbs are held in abnormal postures, there may be various changes to tissues surrounding a joint including shortening of muscles and tendons. If another person tries to straighten the limb out or bend the limb they discover it is not possible to do so to the full extent of the normal range of movement about that joint. Such a reduction in the range of movement is called a contracture. Contractures can interfere with activities such as dressing and can make it difficult to get into a comfortable sitting position.
The muscles also provide a degree of protection to the joints. When this protection is lost because of paralysis and another person, in assisting the paralysed person, unintentionally mishandles them, the joints can become damaged. This is thought to be one of the probable causes of shoulder pain which is common in people with hemiplegia after stroke. Similarly, care is needed to avoid strain or damage to joints when a person with paralysis affecting the legs is bearing their body weight in standing.
Involuntary muscle spasms associated with spasticity can lead to damage to the skin and can increase the risk of pressure sores, particularly when paralysis is associated with sensory loss as described below.
As we know, the heart pumps the blood around the body, but under normal circumstances the muscles also help the blood to circulate. The heart and arteries force the rich, oxygen-filled blood to the organs and tissues, but then the veins have to get the blood back to the lungs and heart. When the muscles of our limbs contract this helps squeeze the blood in the veins back around the body. If the muscles are paralysed, particularly the large ones in the legs, the circulation tends to slow down. This can result in fluid building up around the ankles or even higher up. This swelling is called oedema.
Another possible consequence of paralysis is the formation of blood clots in the large veins of the lower limbs. Such a clot is called a ‘thrombus’ and as the veins concerned lie deep inside the leg, this complication is termed a deep venous thrombosis, which can be a serious problem. Fortunately it is a relatively uncommon complication, but sometimes people with paralysis are given drugs called anticoagulants to prevent these blood clots from forming.
Associated symptoms
The commoner causes of paralysis often damage other parts of the nervous system as well as the motor neurones, such as the sensory and autonomic pathways. This means that paralysis is frequently accompanied by numbness, strange feelings or pain as a result of damage to sensory nerves. Loss of sensation makes the risk of injury to the skin more likely, especially over areas under pressure such as the buttocks. This leads to the risk of pressure sores, which are areas where the skin has broken down to expose underlying tissues. As the skin normally protects these tissues from infection, one of the major problems with pressure sores is that they serve as an entry point for bacteria, which cause infection.
If the autonomic nervous system is affected, the working of the organs, glands and tissues of the body may be disrupted. Under normal circumstances we are unaware of our autonomic nervous system working and cannot consciously influence how it works. Any disruption to it, however, can result in problems such as constipation, loss of control of urination, sexual difficulties, abnormal sweating and the body’s temperature control system going haywire. Even our breathing and heart rate can be affected.
Injuries or diseases affecting the brain may also lead to difficulties with thinking or mental processes and to changes of behaviour; problems with balance; and difficulties with vision, speaking, swallowing and so forth. These issues need to be addressed along with the loss of movement when a person is being treated and is learning to cope with paralysis.
Obviously the effects of paralysis will vary according to which part(s) of the body are involved and how widespread the paralysis is. In addition to limb weakness, the muscles of the central part of the body or trunk can be affected. This is sometimes referred to as truncal paralysis. Paralysis of the muscles of the chest and abdomen interferes with breathing and with activities such as sitting up or turning in bed.
The impact the paralysis has on a person will also be influenced by whether or not it is their preferred or dominant side which is affected - a right-sided paralysis or hemiplegia is likely to present a right-handed person with more severe problems than a left-handed person and vice versa.
Damage to motor neurones does not usually occur in isolation except in motor neurone disease itself. Most injuries or disease processes which interfere with the motor pathways of the nervous system will also affect the nerves carrying sensory information (pain, temperature, etc.), and those nerves which control internal organs such as the heart, lungs, intestines and the glands, which make up the autonomic nervous system. When it is the brain that is injured or diseased, a person’s mental powers, language or behaviour may also be affected.
SPASTICITY AND FLACCIDITY
Spasticity
Typically, spastic paralysis causes increased tightness in the muscles when they are at rest and often results in abnormal limb positionings. When a joint is bent it is said to be flexed and when straight, extended. When someone is sitting, the knee is flexed and when standing the knee is extended. The abnormal postures that occur with spasticity can include excessive flexion or extension of the limbs. Thus a spastic arm may adopt a position with the elbow and wrist bent, or flexed, and the fingers tightly clenched. In the legs, the knee and ankle may be similarly flexed or be held abnormally straight or extended.
People with spastic paralysis may also experience repeated spasms where the arm or leg jerks, sometimes painfully, into a bent (flexor spasm) or straightened-out position (extensor spasm). Another abnormal movement that sometimes occurs is called ‘clonus’ where there is rapid, regular shuddering movement especially at the ankles or knees when they are placed in a particular position.
A number of factors can make spasticity worse. These include mental stress, tension, anger or excitement, all of which can make the involuntary tightness worse. Cold weather, fever, pain and unrelated illnesses like bladder infections can do the same. Some positions can make spasticity more likely and some other positions reduce its effects. Although the muscles are abnormally tight with spasticity and the affected limb may adopt an odd position, the muscles themselves look healthy and of normal size.
Flaccidity
Flaccid muscles tend to be loose and weak, hanging limply rather than taking up particularly abnormal positions. The muscles also often look thin and wasted. The most evident difficulty is that the person may be unable to lift the limb or support themselves on their legs.
Mixed pictures
To add to our confusion, in those who suffer a sudden major injury which damages the upper motor neurones, such as occurs in head and spinal cord injury, there may be a temporary period in which the muscles are loose and flaccid for a few days or weeks before the stiffening up of spasticity occurs. Progressive conditions like motor neurone disease may result in a change from flaccidity to spasticity over a period of weeks, months or longer.
Direct effects of paralysis
Everyday tasks such as eating, washing, bathing, dressing, going to the toilet and generally getting around may pose significant problems for someone with paralysis. The term ‘activities of daily living’ (ADL) is often used to describe these actions. Of course there are many other everyday things that everyone does, and which people normally take for granted, that do not involve movement - so that strictly speaking not all ADLs are necessarily affected. However, this is a useful term to cover such items rather than listing them each time they come up.
The ability to do things like using a knife and fork, drinking from a cup, using a toothbrush and combing your hair are likely to be more difficult if there is paralysis of the upper limbs. Someone who is in a wheelchair as a result of paraplegia may be able to manage these upper limb ADLs but have problems which mainly relate to mobility. They may have difficulties getting out of their wheelchair and into an armchair, bed or bath, and vice versa. Also, of course, there are the obstacles of stairs and uneven surfaces. Getting dressed is likely to be made difficult by either arm or leg weakness as it often takes a lot of coordinated manoeuvres to get into our clothes. Occupational therapists, who are experts in ADL matters, can help with this by breaking the task of dressing into upper half and lower half, referring to essentially above and below the waist.
Indirect effects of paralysis
Paralysis can be looked upon as involuntary immobility. Immobility, from whatever cause, can have widespread effects on almost all systems of the body. Especially if it is long-lasting, it can lead to changes in the circulation and respiration, alter the workings of the kidneys and gastrointestinal system and result in changes to tissues such as skin, muscles and bones. In people who have profound paralysis, much of the nursing care is directed at minimising these effects and trying to prevent the complications that they can cause.
Changes to muscles, bones and joints can explain some of the discomfort or pain that may accompany paralysis. It may be difficult to decide just where these aches or pains are coming from and to know precisely what is causing them, but paralysis of one group of muscles may result in excess forces pulling on others or abnormal stress on joints. In addition, particularly where there is spasticity and the limbs are held in abnormal postures, there may be various changes to tissues surrounding a joint including shortening of muscles and tendons. If another person tries to straighten the limb out or bend the limb they discover it is not possible to do so to the full extent of the normal range of movement about that joint. Such a reduction in the range of movement is called a contracture. Contractures can interfere with activities such as dressing and can make it difficult to get into a comfortable sitting position.
The muscles also provide a degree of protection to the joints. When this protection is lost because of paralysis and another person, in assisting the paralysed person, unintentionally mishandles them, the joints can become damaged. This is thought to be one of the probable causes of shoulder pain which is common in people with hemiplegia after stroke. Similarly, care is needed to avoid strain or damage to joints when a person with paralysis affecting the legs is bearing their body weight in standing.
Involuntary muscle spasms associated with spasticity can lead to damage to the skin and can increase the risk of pressure sores, particularly when paralysis is associated with sensory loss as described below.
As we know, the heart pumps the blood around the body, but under normal circumstances the muscles also help the blood to circulate. The heart and arteries force the rich, oxygen-filled blood to the organs and tissues, but then the veins have to get the blood back to the lungs and heart. When the muscles of our limbs contract this helps squeeze the blood in the veins back around the body. If the muscles are paralysed, particularly the large ones in the legs, the circulation tends to slow down. This can result in fluid building up around the ankles or even higher up. This swelling is called oedema.
Another possible consequence of paralysis is the formation of blood clots in the large veins of the lower limbs. Such a clot is called a ‘thrombus’ and as the veins concerned lie deep inside the leg, this complication is termed a deep venous thrombosis, which can be a serious problem. Fortunately it is a relatively uncommon complication, but sometimes people with paralysis are given drugs called anticoagulants to prevent these blood clots from forming.
Associated symptoms
The commoner causes of paralysis often damage other parts of the nervous system as well as the motor neurones, such as the sensory and autonomic pathways. This means that paralysis is frequently accompanied by numbness, strange feelings or pain as a result of damage to sensory nerves. Loss of sensation makes the risk of injury to the skin more likely, especially over areas under pressure such as the buttocks. This leads to the risk of pressure sores, which are areas where the skin has broken down to expose underlying tissues. As the skin normally protects these tissues from infection, one of the major problems with pressure sores is that they serve as an entry point for bacteria, which cause infection.
If the autonomic nervous system is affected, the working of the organs, glands and tissues of the body may be disrupted. Under normal circumstances we are unaware of our autonomic nervous system working and cannot consciously influence how it works. Any disruption to it, however, can result in problems such as constipation, loss of control of urination, sexual difficulties, abnormal sweating and the body’s temperature control system going haywire. Even our breathing and heart rate can be affected.
Injuries or diseases affecting the brain may also lead to difficulties with thinking or mental processes and to changes of behaviour; problems with balance; and difficulties with vision, speaking, swallowing and so forth. These issues need to be addressed along with the loss of movement when a person is being treated and is learning to cope with paralysis.
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