Basics of Paraplegia Physiotherapy

The Basics of Paraplegia

Paraplegia is almost always the result of damage to the brain, spinal cord, or both. In most cases, spinal cord injuries to the thoracic, lumbar, or sacral spinal cord are to blame. When these injuries occur, signals cannot travel to and from the lower regions of the body, and the body is prevented from sending signals back up the spinal cord to the brain.

Thus, paraplegics not only struggle with movement below the level of injury; they also experience extensive loss of sensation. This sensation loss varies from a feeling of tingling or reduced feeling below the level of injury to a complete inability to feel anything below the level of injury.

Some injuries produce temporary paralysis in one or both legs. Even a broken leg can look like paraplegia in the right circumstances, as can the aftermath of a seizure, allergic reaction, and some surgical compilations. Consequently, doctors should not be quick to diagnose paraplegia immediately after an injury. Instead, it can take anywhere from a few hours to several days to diagnose this condition. Your doctor will need to look at your brain and/or spinal cord to see if there are damaged nerves or tissue that impede the ability of signals to travel to and from the legs. Those tests might include:

• Blood tests to assess whether an infection, cancer, or other problem contributes to the paraplegia. 
• A lumbar puncture to remove a small quantity of fluid from your spinal cord to assess for infections, bleeding, certain cancers, or certain inflammatory conditions. 
• CT scans or MRIs to see your brain and spinal cord. 
• Myelography X-rays to envision your spinal cord and brain. 

Types of Paraplegia

While paraplegia is typically characterized by the paralysis of the legs, there are different types of paraplegia where the symptoms can vary in severity. Some of types of paraplegia include:

Incomplete or Partial Paraplegia (Paraparesis)

There may be occasions where paraplegia does not fully affect both legs. For example, one leg may be fully paralyzed, while the other has limited or even normal function. This is sometimes known as “incomplete paraplegia,” and can be the result of many different conditions.

In some cases, a case of complete paraplegia may develop into a case of partial paraplegia following rehabilitation therapy for paraplegia. On the other hand, a degenerative condition may cause a case of incomplete paraplegia to become complete paraplegia as symptoms progress.

When some functionality remains in either leg, it may also be referred to as paraparesis, though there is some debate as to whether it should be referred to as such.

Complete Paraplegia

This is when the paraplegic retains no feeling or function in their legs whatsoever. A complete paraplegic is unable to use both legs and may experience other issues, such as a loss of bladder/bowel control.

This is common with complete spinal cord injuries in the thoracic and lumbar regions of the spine. Injuries to the cervical region of the spine are more likely to cause quadriplegia (paralysis of the arms and legs).

Complete vs Incomplete Paraplegia

The primary difference between complete and incomplete paraplegia is whether the paraplegic retains some (or most) of their ability to use or feel either leg. Where a complete paraplegic might not have any functionality or sensation in both legs, a case of incomplete paraplegia may leave the paraplegic with some sensation or motor control.

Hereditary Spastic Paraplegia

The National Institute of Neurological Disorders and Stroke (NINDS) defines hereditary spastic paraplegia (or HSP) as “a group of inherited disorders that are characterized by progressive weakness and spasticity (stiffness) of the legs.”

Symptoms of hereditary spastic paraplegia include:

• Stiffness in the legs;
• Impaired vision from cataracts and optic nerve issues;
• Epilepsy;
• Lack of muscle coordination (ataxia); and
• Cognitive impairment.

This is a variation of paraplegia that can be inherited from a parent, so it is important to know if any family members have the condition. If there is a history of HSP in the family, then that is a definite risk factor for hereditary spastic paraplegia.

HSP is typically diagnosed via a neurological examination to rule out other conditions that may cause the same symptoms.

Quadriplegia Vs Paraplegia

Some people may get paraplegia and quadriplegia confused because the two terms are so similar. The major difference between paraplegia vs quadriplegia is that:

• Paraplegia is a paralysis of the legs.
• Quadriplegia is the paralysis of the legs and arms.

Both conditions are typically the result of injuries or diseases affecting the brain and spinal cord. In the case of spinal cord injuries, damage to the cervical spine (i.e. the neck bones) is more likely to result in quadriplegia than injuries lower down on the spine.

What Causes Paraplegia?

The overwhelming majority of paraplegics have perfectly healthy legs. The problem instead resides in the brain or spinal cord. The spinal cord is akin to the body's relay system, sending signals down into the body from the brain and relaying signals from the body to the brain. The brain processes and makes sense of these signals, before sending important information about how to react and feel down the spinal cord and back to the body.

When either the brain or spinal cord do not work properly, these signals may be weak or nonexistent. Consequently, spinal cord injuries (SCIs)—which affect more than 200,000 Americans, with more than 2,500 new cases each year—are the leading cause of paralysis, including paraplegia. According to data from the National Spinal Cord Injury Statistical Center (NSCISC), the leading causes of spinal cord injuries include:

• Car and motorcycle accidents (38.3%)
• Falls (31.6%)
• Violence, the most common source of which is gunshot wounds (13.8%)
• Sports and recreational activities, with diving accidents leading the way (8.2%)
• Medical or surgical injuries (4.6%)
• Other/unspecified (3.5%)

Most spinal cord and brain injuries are traumatic in nature, which means they result from a sudden blow to the area, usually due to an accident. Some injuries, though, are non-traumatic, and usually attributable to diseases or genetic anomalies. A few other causes of paraplegia include:

• Strokes, the most common cause of non-traumatic paraplegia. 
• Genetic disorders, such as hereditary spastic paraplegia. 
• Oxygen deprivation to the brain or spinal cord due to choking, childbirth complications, and other injuries. 
• Autoimmune disorders. 
• Infections of the brain or spinal cord. 
• Tumors, lesions, or cancer of the brain or spinal cord. 
• Spinal cord disorders such as syrinx.

Paraplegia Risk Factors

While paraplegia is usually the result of a disease or accidental injury (meaning they can happen to anyone), there are certain risk factors that increase your chances of becoming paraplegic. It should be noted that a risk factor is not a cause of paraplegia, it is simply something that is common among paraplegics or may contribute to a paraplegia-causing injury or disease.

Here is a shortlist of common paraplegia risk factors:

Gender

According to the National Spinal Cord Injury Statistical Center (NSCISC), “78% of new SCI cases are male.” Since SCI is a common cause of paraplegia, this makes men more likely to become paraplegic than women.

Age

NSCISC data shows that the average age of a person who suffers a spinal cord injury is now 43 (up from 29 a few decades ago). Senior citizens with osteoporosis and other conditions affecting bone health are also more likely to suffer a severe SCI during a fall or other accident.

Occupation

Certain jobs and sports increase the likelihood of severe impacts to the head or spinal column—which can increase the risk of becoming paraplegic. Examples include Law enforcement, construction work, boxing, football, diving, and hockey.

Familial Health History

Certain inherited nerve diseases and other conditions can be contributing factors to brain and spinal injuries that increase the risk of developing paraplegia.

Paraplegia Symptoms and Signs

Paraplegia is a variable condition. The same person might experience symptoms that change over time, or that even alter from one day to the next. Proper therapy can greatly affect the prognosis and improvement of the disease, but many outcomes appear random. There is much we do not yet understand about the brain and spinal cord, so doctors are not yet sure why some people spontaneously recover while others languish without progress even with intense therapy.

In some cases, symptoms improve as swelling in the injured area dissipates. Treatment of infection and disease-related processes may also reduce or reverse symptoms, or slow the improvement of paraplegia. Thus the best source for information on how paraplegia might affect your life is your doctor. Know, however, that even the best doctors cannot be certain about the prognosis, and you should not allow even a grim prognosis to undermine your motivation to keep working toward recovery.

Some of the most common effects of paraplegia include:

• Loss of sensation below the site of the injury. Higher injuries will typically produce greater loss of sensation.
• Phantom sensations in the body, unexplained pain, electrical sensations, or other intermittent feelings in the lower half of the body.
• A decrease in or loss of sexual function, libido, or fertility.
• Difficulty with bladder and bowel function.
• Loss of mobility below the level of injury.
• Changes in mood; depression is common among people with a new paraplegia diagnosis.
• Weight gain, particularly if your caloric intake is not adjusted to account for your reduced activity level.
• Secondary infections in the lower half of the body, particularly bedsores and skin problems.
• Secondary problems at the site of the injury, such as infections or lesions.
• Autonomic dysreflexia—rapid heartbeat, spikes in blood pressure, and other changes in autonomic function related to spinal nerve damage or traumatic brain injury.
• Chronic pain.
  

Diagnosis for Paraplegia

To accurately diagnose the type of paraplegia a person is experiencing and its cause, a doctor will typically perform an in-depth examination. These examinations are necessary to identify the best paraplegia therapy and exercise regimen for the patient to increase their life expectancy and promote wellness.

Diagnosing paraplegia may involve:                   

• Extensive medical imaging (x-rays, MRIs, CT scans, etc.);
• Neurological examinations (to check for neurological abnormalities affecting leg function);
• Electromyography (to test response to muscle stimuli); and
• Family health history (to check for hereditary factors that may contribute to the paraplegia/paraparesis).

Once the diagnosis is complete, a doctor may begin recommending a paraplegia exercise regimen and therapy schedule to help the patient cope with paraplegia.

Living with Paraplegia

Paraplegia is a life-altering condition for many—whether they were born with a hereditary condition that caused a slow change or suffered a sudden illness or accident that caused paraplegia.

Learning how to live with paraplegia is important for the paraplegic and for those around them. When a loved one loses function in their legs, it requires everyone they know to adapt.

Complications of Paraplegia

There are many medical complications that paraplegia can cause beyond removing the ability to walk. Not being able to stand up and move can cause a variety of additional conditions that can range from being mildly inconvenient and/or painful to being potentially life-threatening.

Here are some of the common medical complications that can arise from paraplegia:

Pressure Sores

The inability to move can cause sores to develop on the legs or buttocks. To prevent this, it is important to engage in paraplegia exercises and to adjust positions regularly if possible.

Urinary Tract Infections

Urinary retention is a common side effect of paraplegia since the link between the brain and the nerves controlling the bowels and bladder is damaged. This can also lead to urinary tract infections (UTIs) as bacteria may sit in the urinary tract and infect the bladder. Antibiotics can help clear UTIs, while indwelling catheters or intermittently using a catheter to drain the urine can help prevent urine retention.

Chronic Depression

Living with paraplegia can be extremely difficult. It is common for paraplegics to become extremely depressed following a paraplegia-causing injury or illness. It is important for paraplegics to find support—both from loved ones and from support groups.

Circulatory Disorders

Another common side effect of not being able to move freely is the development of circulatory disorders. Engaging in exercise or finding an occupational therapy specialist can help.

Paraplegia and Sex

A loss of function and feeling in the sexual organs is extremely common among paraplegics. Many people assume that paralysis eliminates the possibility of sex. However, being paralyzed from below the level of injury does not have to be the end of your sex life.

For men, it may still be possible to achieve erections using “reflex triggers” (contact-based stimuli to erogenous zones—like the phallus—on the male body). Reflex triggers using penile vibrators can help paralyzed men achieve an erection and even ejaculation in some cases —although some may not be able to if the sacral spinal nerves themselves are damaged.

For women, a loss of sensation in the vagina can make it difficult to achieve lubrication and orgasm. Tiffiny Carlson, an SCI survivor who has guest blogged for spinalcord.com, noted the importance of experimenting to find alternative erogenous zones to stimulate pleasure from sexual intercourse. It can also help to use “bedroom aids” such as lube to enhance intercourse.

For both men and women, finding alternatives to standard intercourse (such as engaging in more extended foreplay) can help couples maintain an active and healthy sex life after paraplegia.

Paraplegia Cures and Recovery

Many people with paraplegia look for a miracle “paraplegia cure” to alleviate their condition. While there is no known cure for paraplegia in all its forms, there are things that people can do to speed their recovery and even potentially restore some of their legs’ functionality.

Paraplegia recovery can be a long and difficult process as paraplegics learn to cope with their paraplegia symptoms. There are numerous steps to recovering from paraplegia—steps that may change depending on the cause and severity of the condition.

Some basic steps to paraplegia recovery include:

1. Seeking Immediate Medical Attention after an Injury. Timely care following a major TBI or SCI can have an enormous impact on the severity of symptoms and even the likelihood of survival. High-quality therapy and care can help prevent the exacerbation of injuries, which helps to limit the severity of paraplegia symptoms (such as keeping a case of incomplete paraplegia from becoming complete paraplegia).
2. Investigating Your Paraplegia Recovery Options. From surgical procedures to rehabilitation therapy and dietary changes, it is important to investigate all of your potential avenues of recovery. While a perfect paraplegia therapy does not exist (yet), many of these recovery options can help to alleviate the side effects of paraplegia and help improve the quality of life for paraplegics.
3. Trying to Locate Paraplegia/Paralysis/SCI Support Groups. There are numerous support groups for paraplegics and others who live with some form of paralysis (and their loved ones). Many of these groups can help provide a place to find good advice and support. Additionally, they may be able to point paraplegics and their loved ones towards other resources, such as financial assistance programs that can help cover the cost of medical treatment, home modifications, and physical therapy.
4. Making Modifications to Accommodate Mobility Limitations. Part of recovering from any condition that limits mobility is making modifications to the home that increase accessibility. For paraplegics who may be restricted to a wheelchair, this may involve installing workarounds for steps (such as ramps or wheelchair lifts), redesigning spaces with appliances so they are easier to reach or move around in, and widening doorways to make it easier to push a wheelchair or other mobility aid through.
5. Considering Psychological Therapy. Many people, paraplegics included, underestimate the psychological effects that a loss of mobility can impose. For paraplegics, it can be crucial to seek out a specialist in psychological therapy—especially when the paraplegia is caused by a traumatic brain injury. Those who know a paraplegic may want to help them look for a qualified therapist as well. It is all too easy to miss the signs of psychological distress that lead to depression or worse.

As noted earlier, some (or all) of these steps may change. For any paraplegia recovery plan, it is important to consult a qualified physician before starting any therapy regimen.