Sri B.

Ayyavaru Reddy Memorial College of Nursing PARAPLEGIA

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Paralysis is a loss or impairment of motor function in one or more muscle groups as a result of a lesion of the neuromuscular mechanism. When applied to motor function, paralysis is the loss of voluntary movement, precluding the use of muscles, tendons, or joints that normally control body movements. Paralysis is a sign of an underlying condition such as paraplegia or quadriplegia. Paraplegia refers to weakness or paralysis of both legs and the lower part of the body. Quadriplegia or tetraplegia refers to weakness or paralysis of all four extremities. Paralysis is the result of an interruption of one or more motor pathways at any point from the cerebrum to the muscle fiber. This interruption can be caused by spinal cord injuries (fractures, dislocations) incurred from blunt trauma, automobile and boating accidents, falls, or sports injuries. Spinal cord disease or other diseases and conditions may also interrupt neuromuscular functioning. Paralysis may be manifested by partial or complete loss of function of the involved muscles and may be temporary or permanent. Complete paralysis indicates a total loss of function below the level of the injury. Incomplete paralysis indicates that the individual has some motor function below the injury level. If all the peripheral motor nerve fibers supplying a muscle are interrupted, all voluntary, postural, and reflex movements are lost. In loss of motor nerve fibers outside the central nervous system (brain and spinal cord), the muscle becomes loose and soft and does not resist passive stretching, a condition known as flaccidity. Muscle tone appears to be reduced (hypotonia or atonia), and atrophy of the muscles occurs. If this effect occurs in only a portion of motor fibers supplying the muscle, the result is partial paralysis. In partial paralysis, there is less atrophy, and the tendon reflex will be reduced but not completely lost. In conditions involving the brain or spinal cord, the paralysis may be spastic, in which case the affected muscles are stiff and movements are awkward as a result of damage to the upper motor neuron system. In paraplegia, paralysis of the legs may develop as a result of diseases of the spinal cord, nerve roots, or peripheral nerves; it may also result from hereditary causes, spinal tumors, and injury. Paraplegia may be either acute or chronic. In acute spinal cord diseases, paralysis or weakness affects all muscles below a given level, often with a loss of sensation, including pain and temperature. In bilateral disease or injury of the spinal cord, there may be loss of bladder and bowel function. The most common cause of acute paraplegia is spinal cord trauma, usually associated withfracture/dislocation of the spine. Other causes are obstruction (thrombosis) of the spinal artery, occlusion of aortic branches due to an aneurysm, orhemorrhage into the spinal cord (hematomyelia) due to a blood vessel (vascular) malformation, the use of anti-coagulant medications, or bleeding diseases. In adults, multiple sclerosis is the most common cause of chronic spinal paraplegia. Other conditions that may cause chronic paraplegia includevitamin B12 deficiency, protruded cervical disc and cervical spondylosis, syphilitic meningomyelitis, brain abscess and other infections, classic motor neuron disease (amyotrophic lateral sclerosis or ALS),syringomyelia, and degenerative disease of the spinal cord of unknown cause. An infectious or inflammatory process such as transverse myelitis may be responsible, but an etiology is often not determined. Hereditary spastic paraplegia (HSP), also called familial spastic paraparesis, is characterized by progressive spasticity in the lower extremities that can become severe and incapacitating. It develops as a result of degeneration of corticospinal tracts inside the spinal cord; the longer fibers that supply the legs are more affected than fibers that supply the arms. HSP is considered
1 By Ms. K. Leelavathi Bsc. Nrsng. Asst. Lecturer in Medical Surgical NursingII

Sri B. Ayyavaru Reddy Memorial College of Nursing

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to be a group of heterogeneous syndromes described as uncomplicated or pure when only the spine is involved, and as complicated if neurologic abnormalities such as ataxia, epilepsy, mental retardation, dementia, visual or hearing dysfunction, or adrenal insufficiency are also involved. Quadriplegia is the result of injury to the brain or cervical spine or may result from diseases of the peripheral nerves, muscles, myoneural junctions, gray matter of the spinal cord, brainstem, or cerebrum. The lesion typically occurs in the cervical area of the spinal cord. Depending on the lesions location in the cervical area, paralysis of the arms may be flaccid and areflexic in type, and that of the legs may be spastic. Compression of the cervical spinal cord segments may occur with osteo- or rheumatoid arthritis. The incidence of quadriplegia is difficult to determine due to the various possible underlying causes of the paralysis. Both paraplegia and quadriplegia occur less often than paralysis of one side of the body (hemiplegia). Risk: Motor vehicle and boating accidents are the main causes of spinal cord injury leading to paralysis, followed by sports-related injuries, acts of violence, falls, and other causes. Sports and recreation are the second most common cause of acute spinal cord injury worldwide, representing 20% or more cases in various countries (Tator). Whites and males are at increased risk for spinal cord injury, with a male-to-female ratio of 4:1; about half of all cases of spinal cord injury occur in those between 16 and 30 years of age (Dawodu). Approximately 80% of all sports-related spinal cord injuries occur in males (Tator). Incidence and Prevalence: Spinal cord injury affects 30 to 60 people in 1 million each year: 27.9% have total paraplegia, and 18.5% have total tetraplegia or quadriplegia (Dawodu). Increased incidence of spinal cord injury is found among individuals who participate in sports such as diving, football, hockey, gymnastics, and motor sports (Tator). Two million individuals in the US live with some form of paralysis of the extremities (Tator). Hereditary paraplegia is rare, with only 3 individuals in 100,000 estimated to be affected in most populations, including fewer than 10,000 cases in the US (Paik). Diagnosis History: Individuals who have experienced spinal cord injury may present with various levels of impairment and may describe reduced or completely absent sensory or motor function in the extremities and torso. In cases of paralysis, individuals may report a history of traumatic injury, brain tumor or abscess, orinfection. The individual may report weakness of muscles in the limbs, loss of sensation, increased muscle tone (spasticity), or loss of muscle tone (flaccidity). Individuals with paraplegia may report a history of a traumatic injury; brain tumor; or diseases of the spinal cord, nerve roots, or peripheral nerves. The individual may report weakness of the muscles of both lower extremities, loss of pain and temperature sensation below a particular level, and loss of position and vibratory sense. Quadriplegic individuals may report weakness of the muscles of all four extremities. Flaccidity of the arms and spasticity of the legs are typical patterns of paralysis. The individual may also experience pain in the neck and shoulders, numbness of the hands, and, if mobile, may report or exhibit staggering gait and postural imbalance (ataxia). A complete health history is obtained, including current and prior disease conditions or injuries.
2 By Ms. K. Leelavathi Bsc. Nrsng. Asst. Lecturer in Medical Surgical NursingII

Sri B. Ayyavaru Reddy Memorial College of Nursing

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Physical exam: A complete physical examination may reveal the presence of recent multiple injuries sustained in trauma. Paralysis and/or restricted movement of extremities may be seen. Motor strength and sensory testing is usually done using an impairment scale (ASIA or Frankel scales). The neurological exam may reveal spinal cord damage and localize the level of injury in individuals with paralysis. Spastic movement and increased tendon reflexes may be evident. Peripheral nerve damage is indicated by muscle wasting (atrophy) and weakness with reduced tendon reflexes. Affected muscles may reveal involuntary contraction or twitching of groups of muscle fibers (fasciculation). In individuals who are paraplegic, the neurological exam may reveal spinal cord damage and localize the level of injury. A rectal examination may be done to check motor function or sensation of the anal musculature; if function is fully present and the sacral function is intact, as in a sacral-sparing spinal injury, normal or near normal bladder and rectal function may be present. In other individuals, the bladder and sphincter muscles may be affected and result in loss of bladder and rectal function. Sensory loss is more prominent in the distal segments of the limbs. In hereditary spastic paraplegia, the individual may have normal upper extremity muscle tone with weakness in the legs; muscle wasting may be seen as well as signs of diminished sensation in the lower extremities, gait disturbances, high arched feet, and pathologic increases in lower extremity reflexes. In quadriplegia, the neurological exam may reveal brain damage or lesions of the cervical spinal cord. In diplegia, the legs are more affected than the arms. There may be dislocation of spinal cord segments, especially in the presence of rheumatoid arthritis. In individuals with triplegia, the exam may reveal spastic weakness of one limb followed by involvement of the other limbs in a "round the clock" pattern. Loss of pain and temperature sensation may be observed. Tests: For paralysis, paraplegia, and quadriplegia, diagnostic tests include x-rays, CT scan, or MRI. The diagnostic tests may reveal a spinal cord injury or tumor in individuals with paralysis, lesions of the spinal cord or an extrinsic mass that narrows the spinal canal in individuals with paraplegia, atrophy of the spinal cord and cerebral cortex in hereditary spastic paraplegia, and lesions of the cervical spinal cord in individuals with quadriplegia. Electromyography tests the electrical activity of the muscles. A lumbar puncture (spinal tap) may be performed to rule out infection, and it often demonstrates a dynamic block and increase in cerebrospinal fluid protein. Complete blood count, serum chemistry panel, and urinalysis can be helpful in determining health status and possible underlying disease processes. Rheumatoid factor may be assayed to confirm rheumatoid arthritis. Genetic testing may be needed to help diagnose hereditary spastic paraplegia. Treatment Paralysis Treatment depends upon the type, location, and extent of the paralysis. The primary consideration in treatment of spinal cord injury (trauma) is to decompress and stabilize the spine. Surgery can relieve pressure if present. If there is a blockage in the spinal canal due to a tumor, chemotherapy andradiation may be indicated. Bacterial infections are treated with antibiotics. Steroids are also indicated to help decrease the likelihood of permanent neurologic damage. In cases of temporary paralysis, physical therapy is used to retrain and strengthen
3 By Ms. K. Leelavathi Bsc. Nrsng. Asst. Lecturer in Medical Surgical NursingII

Sri B. Ayyavaru Reddy Memorial College of Nursing

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muscles and joints so that some degree of mobility is possible after recovery. If there is complete loss of function, supportive measures such as physical therapy to prevent joints from becoming locked and contracted and avoidance of complications from prolonged immobility (pressure ulcers, blood clots, urinary tract infections,constipation) should be instituted. Paraplegia Treatment depends on the cause of the paraplegia. If it is due to spinal cord injury, then decompression and stabilization of the spine are of primary importance. Surgery can relieve pressure if present. Less common causes, such as arterial thrombosis, may require administration of thrombolytic agents. Infections should be treated with appropriate antibiotics. In the case of transverse myelitis, antibacterial and antiviral agents, along with steroids, may be indicated. Surgery to relieve pressure from a mass lesion may be indicated. Quadriplegia Treatment depends on the cause of the quadriplegia. If it is due to spinal cord injury, then immobilization of the spine is of primary importance. Surgery can relieve pressure if present. Less common causes, such as arterial thrombosis, may require administration of thrombolytic agents. Infections should be treated with appropriate antibiotics. If a tumor is causing spinal cord compression, surgery may relieve the pressure. Recovery from spinal cord transection is not a possibility at this time. Rehabilitation If an individual becomes a quadriplegic or paraplegic either through illness or trauma, there is a lengthy rehabilitation process involved. The duration and frequency of the rehabilitative process is dictated by the degree of injury and disability. In the hospital, therapy goals focus on prevention of further illness. Respiratory therapy includes deep-breathing exercises and chest percussions performed by the therapist to keep the lungs clear of mucus. Respiratory therapists also routinely assess individuals on ventilators to determine their continued need for assisted breathing. Physical therapists establish a routine for changing an individual's position in bed to prevent skin breakdown, and teach family members how to comply with a positioning schedule. Physical therapists also instruct family members in how to stretch the individual's limbs to maintain flexibility and begin strengthening exercises for any muscles that may have movement.Occupational therapists assess an individual's potential for self-care. Both physical and occupational therapists focus on increasing sitting tolerance and balance. Psychologists and psychiatrists are a crucial link in the rehabilitation process, helping to focus individuals on attainable goals and treating the depression that often occurs after spinal cord injury. Once individuals are medically stable, they are transferred to a rehabilitation hospital for a few weeks (or longer) for more intensive therapy. Physical therapists continue instruction in bed mobility, transferring to and from the wheelchair with a sliding board, and begin teaching wheelchair mobility. Individuals who have fractures of one of the first four cervical vertebrae learn to utilize a mouth control system to propel the wheelchair. Other individuals learn to use a joystick control. As wheelchair skills progress, individuals learn to maneuver their wheelchairs outside and to perform activities. Some individuals with partial paralysis may be able to learn to stand in the parallel bars for improved strength and balance, with progression to walking with forearm crutches through a combination of weight shifting and upper body momentum. For these individuals, therapists work on safe ambulation in the community.
4 By Ms. K. Leelavathi Bsc. Nrsng. Asst. Lecturer in Medical Surgical NursingII

Sri B. Ayyavaru Reddy Memorial College of Nursing

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Occupational therapists help individuals maximize independence in self-care by teaching feeding techniques and strategies for performing assisted activities of daily living. Although individuals with fractures above C5 cannot perform self-care, family members may be taught how to assist the individual while maintaining his or her sense of independence. Physical and occupational therapists order special adaptive equipment and wheelchairs to maintain correct posture and sitting balance and teach pressure relief techniques to prevent skin breakdown. Speech therapists assess individuals for safe swallowing strategies. In addition, therapists devise communication techniques for those who are ventilator-dependent, as well as teaching exercises to improve speech volume and clarity for all individuals. Individuals with fractures of C5 and below may be discharged to outpatient physical and occupational therapy to maximize functional gains and reinforce mobility techniques learned in the rehabilitation hospital. Individuals cleared by their physicians to drive can be assessed for car adaptations and driving school during outpatient physical therapy. Individuals with fractures above C5 may be eligible for in-home physical and occupational therapy to focus on reinforcing family care of the individual.Vocational rehabilitation may be appropriate to help individuals learn new workplace skills. Complications Paralysis Joints may become locked in both temporary and permanent paralysis. Complications from permanent paralysis caused by prolonged immobility include limb deformities, pressure sores (decubitus ulcers), blood clots (deep vein thrombosis), fluctuating blood pressure and body temperature,osteoporosis, respiratory and urinary tract infections, and constipation. Psychological stress due to loss of body functions most often results in depression. Paraplegia Complications include urinary and fecal incontinence that sometimes requires ostomy, respiratory infections (pneumonia, atelectasis), coronary heart disease, autonomic dysreflexia, urinary tract infections, kidney stones, kidney and liver insufficiency, gallstones, constipation, pressure sores (decubitus ulcers), and osteoporosis. Chronic severe pain and spasmmay also complicate paraplegia. Extreme physical inactivity may cause elevation in blood lipids (cholesterol and triglycerides), resulting in an increased risk of cardiovascular diseases. Psychological stress from loss of body functions most often causes depression. Quadriplegia Complications include urinary and fecal incontinence that sometimes requires ostomy, respiratory infections (pneumonia, atelectasis), coronary heart disease, autonomic dysreflexia, urinary tract infections, kidney stones, kidney and liver insufficiency, gallstones, constipation, pressure sores (decubitus ulcers), and osteoporosis. Chronic severe pain and spasmmay also complicate quadriplegia. Extreme physical inactivity may cause elevation in blood lipids (cholesterol and triglycerides), resulting in an increased risk of cardiovascular diseases. Psychological stress from loss of body functions most often causes depression.

By Ms. K. Leelavathi Bsc. Nrsng. Asst. Lecturer in Medical Surgical NursingII