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Monday, August 18, 2025

Paralysis


Introduction

Paralysis is the loss or severe impairment of voluntary muscle function, often due to disruption of neural pathways. It can affect any part of the body, and its severity ranges from partial weakness (paresis) to complete loss of movement.

Paralysis can result from:

  • Central nervous system (CNS) lesions (brain, spinal cord).

  • Peripheral nervous system damage (nerves, neuromuscular junction).

  • Muscle disorders (myopathies).

It may be acute (e.g., stroke, spinal trauma, Guillain-Barré syndrome) or chronic (e.g., multiple sclerosis, muscular dystrophy).

Classifications of Paralysis

Based on Distribution

  • Monoplegia: paralysis of one limb.

  • Hemiplegia: paralysis of one side of the body (often from stroke).

  • Paraplegia: paralysis of both lower limbs.

  • Quadriplegia (Tetraplegia): paralysis of all four limbs.

  • Diplegia: symmetrical paralysis (common in cerebral palsy).

Based on Nature

  • Flaccid paralysis: loss of tone (lower motor neuron lesion).

  • Spastic paralysis: increased tone and reflexes (upper motor neuron lesion).

Causes of Paralysis

1. Neurological Causes

  • Stroke (Cerebrovascular accident): ischemic or hemorrhagic lesions interrupt motor pathways.

  • Spinal cord injury: trauma, tumors, infections.

  • Multiple sclerosis (MS): demyelinating autoimmune disease.

  • Amyotrophic lateral sclerosis (ALS): progressive motor neuron degeneration.

  • Cerebral palsy: non-progressive brain injury in infancy.

  • Brain tumors: compress motor areas.

  • Peripheral neuropathies: diabetes, Guillain-Barré syndrome, toxic neuropathies.

2. Infectious Causes

  • Poliomyelitis: viral destruction of anterior horn cells.

  • Herpes zoster (Ramsay Hunt syndrome): facial paralysis.

  • Lyme disease, syphilis, HIV: neuropathies.

3. Traumatic Causes

  • Head injuries.

  • Spinal fractures, dislocations.

  • Peripheral nerve injuries (lacerations, crush injuries).

4. Neuromuscular Junction Disorders

  • Myasthenia gravis.

  • Botulism.

5. Muscular Causes

  • Muscular dystrophies.

  • Inflammatory myopathies (polymyositis, dermatomyositis).

6. Metabolic and Toxic Causes

  • Hypokalemia, hyperkalemia, hypocalcemia, hypophosphatemia.

  • Heavy metal poisoning (lead, arsenic).

Pathophysiology

Paralysis occurs due to interruption of the motor unit:

  1. Upper motor neuron (UMN) lesions (cortex, corticospinal tract, spinal cord above anterior horn).

    • Spastic paralysis.

    • Hyperreflexia, Babinski sign positive.

  2. Lower motor neuron (LMN) lesions (anterior horn, nerve roots, peripheral nerves).

    • Flaccid paralysis.

    • Hyporeflexia, muscle wasting, fasciculations.

  3. Neuromuscular junction pathology (e.g., myasthenia gravis).

    • Fatigable weakness.

  4. Muscle pathology (e.g., muscular dystrophy).

    • Symmetrical weakness, preserved reflex arcs until late stage.

Clinical Presentation

  • Loss of movement: partial or complete.

  • Muscle tone changes: flaccid or spastic.

  • Sensory loss: if sensory tracts affected.

  • Reflex changes: exaggerated in UMN lesions, absent in LMN lesions.

  • Associated features:

    • Dysarthria, facial droop (stroke).

    • Bowel/bladder incontinence (spinal cord injury, MS).

    • Dyspnea (diaphragm paralysis).

    • Fasciculations (motor neuron disease).

Diagnostic Evaluation

1. History and Examination

  • Onset: acute (stroke) vs chronic (MS, ALS).

  • Distribution: mono-, hemi-, para-, quadriplegia.

  • Associated symptoms: headache, trauma, infection, seizures.

  • Neurological exam: reflexes, tone, sensory involvement.

2. Investigations

  • Blood tests: electrolytes (K, Ca, Mg, phosphate), glucose, CBC, ESR, CRP.

  • Neuroimaging:

    • CT head: acute stroke, hemorrhage.

    • MRI brain/spine: MS, tumors, cord compression.

  • Lumbar puncture: demyelinating or infectious disorders.

  • Electromyography (EMG) and Nerve Conduction Studies (NCS): neuropathies, ALS.

  • Genetic testing: muscular dystrophies.

  • Autoantibody tests: acetylcholine receptor antibodies (myasthenia gravis).

Management

Treatment depends on the underlying cause. Management involves acute stabilization, specific treatment, and long-term rehabilitation.

1. Acute Paralysis (Emergency Causes)

a) Stroke

  • Ischemic stroke:

    • Alteplase (rt-PA): 0.9 mg/kg IV (max 90 mg); 10% bolus, remainder infused over 1 hour (within 4.5 hours of onset).

    • Antiplatelets: Aspirin 300 mg orally once daily (after 24 hours of thrombolysis or immediately if not thrombolysed).

  • Hemorrhagic stroke:

    • Blood pressure control: Labetalol IV 10–20 mg bolus, repeat as needed.

    • Neurosurgical evacuation if indicated.

b) Spinal Cord Compression / Injury

  • High-dose corticosteroids (controversial in trauma): Methylprednisolone sodium succinate 30 mg/kg IV bolus, then 5.4 mg/kg/hr for 23 hours (only in specific cases, under neurosurgical guidance).

  • Surgical decompression and stabilization.

c) Guillain-Barré Syndrome (GBS)

  • IV immunoglobulin (IVIG): 0.4 g/kg/day IV for 5 days.

  • Plasma exchange: 4–6 exchanges over 10–14 days.

  • Supportive: ventilatory support if respiratory weakness.

d) Myasthenia Gravis Crisis

  • Acetylcholinesterase inhibitor: Pyridostigmine bromide 60 mg orally every 4–6 hours (maintenance).

  • Crisis management: IVIG or plasma exchange.

  • Corticosteroids (prednisolone 5–60 mg orally daily, titrated).

2. Chronic Paralysis

a) Multiple Sclerosis

  • Relapse treatment: Methylprednisolone 1 g IV daily for 3–5 days.

  • Disease-modifying therapy: interferon beta, glatiramer acetate, fingolimod, natalizumab (specialist initiation).

b) Motor Neuron Disease (ALS)

  • Riluzole: 50 mg orally twice daily (slows progression).

  • Supportive care: non-invasive ventilation, physiotherapy.

c) Muscular Dystrophy

  • Corticosteroids (prednisolone 0.75 mg/kg/day) slow disease progression.

  • Supportive: physiotherapy, orthopedic interventions.

d) Post-stroke or Chronic Spinal Paralysis

  • Antiplatelets, anticoagulants, risk factor management.

  • Spasticity control: Baclofen 5 mg orally TDS, titrated up to 80 mg/day; Tizanidine 2 mg TDS.

  • Botulinum toxin type A injections for focal spasticity.

  • Rehabilitation: physiotherapy, occupational therapy, speech therapy.

3. Symptomatic and Supportive Management

  • Pain management:

    • Neuropathic pain: Gabapentin (300–900 mg/day titrated to 1800–3600 mg/day).

    • Pregabalin: 75 mg orally twice daily (max 600 mg/day).

    • Amitriptyline: 10–25 mg orally at night, titrated upward.

  • Bladder dysfunction: anticholinergics (oxybutynin 5 mg orally twice daily).

  • Bowel care: stool softeners, laxatives.

  • Psychological support: CBT, antidepressants if needed.

  • Assistive devices: wheelchairs, orthotics, mobility aids.

Complications of Paralysis

  • Muscle atrophy and contractures.

  • Pressure ulcers from immobility.

  • Deep vein thrombosis (DVT) and pulmonary embolism.

  • Urinary tract infections due to catheterization.

  • Pneumonia (especially in high spinal cord injuries).

  • Depression and anxiety.

  • Loss of independence and social isolation.

Prognosis

  • Stroke-related paralysis: recovery depends on early treatment and rehabilitation; many regain partial function.

  • Spinal cord injury: prognosis depends on level and severity (complete vs incomplete).

  • GBS: most recover fully, though some have residual weakness.

  • MS and ALS: progressive, but symptom control and therapy improve quality of life.

  • Muscular dystrophy: progressive, supportive management essential.

Preventive and Supportive Strategies

  • Stroke prevention: control hypertension, diabetes, lipids, smoking cessation.

  • Vaccination and infection prevention (GBS, polio).

  • Protective equipment to reduce trauma-related paralysis.

  • Early diagnosis and treatment of metabolic and autoimmune conditions.

  • Rehabilitation and multidisciplinary care for chronic paralysis.

Pharmacological Quick Reference

  • Stroke: Alteplase 0.9 mg/kg IV; Aspirin 300 mg daily.

  • Spinal injury: Methylprednisolone 30 mg/kg IV bolus.

  • GBS: IVIG 0.4 g/kg/day × 5 days.

  • Myasthenia gravis: Pyridostigmine 60 mg Q4–6H.

  • MS relapse: Methylprednisolone 1 g IV × 3–5 days.

  • ALS: Riluzole 50 mg BID.

  • Spasticity: Baclofen 5 mg TDS (max 80 mg/day).

  • Neuropathic pain: Gabapentin 300–900 mg/day; Pregabalin 75 mg BD.




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