Paralysis rehabilitation at home

The importance of the first minutes

The physician's role in treating paralysis during the first minutes, hours, and first few days is extremely important. The medical team's task is to eliminate life-threatening conditions and stabilize the patient. How much brain tissue is damaged and what permanent deficits occur depend on the treatments applied at that time. The faster you receive appropriate treatment, the better the chances of reducing the consequences. The later you receive proper care, the higher the likelihood of severe lasting deficits.

As a result of intensive treatment, the life-threatening condition usually resolves after a few days. From that point on the aim of treatment becomes rehabilitation — saving the patient's future. A physiotherapist arrives at the bedside and begins passive and, if possible, active mobilization. In addition, you may receive electrotherapy (denervated current or, in other words, muscle stimulation) treatments. In hospital the intensive care and these treatments usually last one to two weeks, after which the patient is discharged home.

The importance of home treatment

And this is where something goes very wrong in Hungary! Perhaps it is not explained carefully enough, or as a patient you do not realize that leaving the hospital only means the end of intensive care.

For some reason most patients do not recognize that eliminating paralysis only begins at that point. Success depends only partly on the rehabilitation professionals. To a greater extent you are dependent on yourself (and, of course, on the help of your family). Returning home is only the beginning of a long road, not the end! This path can last for years!

In recovery from paralysis, under the direction of a (neuro)rehabilitation specialist and with the help of a physiotherapist, physical therapist, etc., most of the work must be done by you. No one can exercise for you, practice continuously for you, or perform treatments multiple times a day in your place.

If you have become paralyzed, your greatest enemies can be passivity, giving up, and expecting help from others. Of course, returning home paralyzed you may feel that everything is lost.

But let us see what rehabilitation is and why it must be done.

Definition of rehabilitation

The collection of medical procedures and services whose aim is to restore or replace the loss of function caused by disease (mobility limitation, speech disorder, etc.), or to develop new methods that compensate for the lost ability. Medical rehabilitation inherently includes especially physiotherapy, movement therapy, speech therapy, psychological care, occupational therapy, as well as the provision of medical aids and training in their use.

Everything that happens after you return home should serve to eliminate the paralysis or at least improve functions enough so that you can perform daily activities independently.

In the Hungarian healthcare system, the overwhelming part of rehabilitation practically falls on you and your family members. Read my article: The shortcomings of rehabilitation services

Although a few lucky patients may reach a rehabilitation institute, the work there rarely exceeds the level of a short holiday.

Do not believe that this is all that can be done to eliminate paralysis!

Consequences of paralysis

Paralysis occurs when the motor area of your brain is damaged (central paralysis) or when an individual nerve fiber running from your spine to a muscle is injured (peripheral paralysis). In these cases the impulse that initiates movement either is not generated (central paralysis) or does not reach the muscle (peripheral paralysis). Therefore you cannot produce voluntary muscle contractions in the affected muscles.

In both forms the movement commands do not reach your muscle. However, in central paralysis the nerve fibers running from the spinal cord to the muscle and back are intact, whereas in peripheral paralysis the nerve fiber is completely or partially damaged (that is, impulses do not travel up or down it). Consequently, rehabilitation must be guided and performed differently in the two types of paralysis.

When you are healthy, muscle contraction is triggered by electrical impulses starting in your brain, which travel via the spinal cord and motor nerves to your muscle. The muscle contracts, the joint moves, and the movement is produced. Continuous sensory feedback about body position, muscle tension, and other sensations is sent to your brain. This ensures you can "set" the movement to the required degree.

Central paralysis and its rehabilitation

In central paralysis part of the motor area of your brain is damaged. The so‑called upper motor neuron (which carries the motor impulse from the brain to the spinal cord) becomes nonfunctional. A particular muscle or muscle group becomes paralyzed — the one whose motor nerve would have originated from the damaged brain area.

In central paralysis the goal of rehabilitation is for another area of your brain to take over and "relearn" the lost motor function. With constant practice — even if nothing seems to move — you can retrain your brain how to move the paralyzed muscle.

Some opinions claim that ten thousand repetitions are needed for relearning. That means you need relentless practice, even when hope seems absent!

• If after a stroke you sit slumped in an armchair doing nothing, you have no chance of recovery.
• If someone occasionally comes and moves your paralyzed hand, massages the muscles, but you still do nothing yourself, your chances do not improve.
• If your paralyzed muscles are treated daily with a muscle stimulator, you have taken a tiny step toward improvement. But this alone is far from enough for a breakthrough success.
• If you continuously try to repeat the movements that were lost, your brain will constantly work to find the connection with the affected muscle. This already greatly improves your odds.

If you practice a lot and are lucky, gross movements will return first. That is, you will be able to move the paralyzed limb but not yet coordinate it — for example, you may be able to lift your arm but cannot grasp a cup because your hand cannot "focus on a point."

For home treatment of central paralysis you need the support of a physiotherapist and a good quality muscle stimulator device (for example MyoBravo, Genesy 300 Pro or Premium 400).

The physiotherapist teaches the movements you must perform. Electrotherapy helps prevent muscle wasting, supports the return of muscle strength and stimulates regeneration.

When gross movements have returned, the physiotherapist will teach other exercises. From that point it is worth investing in another device that assists in relearning fine movements. The simplest tool is a biofeedback device (for example SineBravo) which gives feedback about the strength of muscle contraction. It is even more effective if your device combines biofeedback and ETS functions. During attempted voluntary movements the device augments with a muscle stimulation impulse and thus helps you regain the lost function! The DuoBravo is a biofeedback+ETS device, that is, it provides biofeedback‑triggered muscle stimulation.

After a stroke, practice should begin as soon as possible following the onset of paralysis, already in the hospital — immediately after life‑threatening conditions have been resolved. It must be continued at home for months, possibly for 1–2 years.

Peripheral paralysis and its rehabilitation

Peripheral paralysis is caused by damage or dysfunction of the so‑called "lower motor neuron," the motor nerve running from the spinal cord to the muscle. It can arise for various reasons and to varying degrees. Because of the nerve fiber's dysfunction, the brain impulse is interrupted after the spinal cord and does not reach the affected muscles, so there is no muscle contraction and no movement can occur.

In clinical practice the muscle that has lost its motor nerve is called a "denervated muscle."

The muscle goes through three stages after the neural connection is severed (denervation):

1. immediate loss of voluntary motor function,
2. rapid decrease in muscle mass (muscle atrophy) and loss of the muscle's structural elements (sarcomeres), and
3. degeneration of muscle fibers, during which connective tissue and fat replace the muscle fibers. This is a permanent state.

Regular electrotherapy slows or entirely prevents the atrophy process, so the muscle's functionality can be maintained until the nerve regenerates.

Nerve healing and regeneration is a very slow process. Typically a nerve fiber regenerates 0.1–0.2 mm per day, at best about 1 mm under optimal conditions. In the case of a lumbar nerve injury the length to the toes can be 60–80 cm. That means it can take years for the nerve to "reach the muscle" again. The muscle cannot survive that long without its nerve. Without contractions the muscle atrophies within one and a half to two years, connective tissue replaces muscle tissue, and even if the nerve regenerates, the muscle will no longer function — the paralysis remains.

For peripheral paralysis you must prepare for long rehabilitation. As mentioned above, nerve regeneration is incredibly slow! Optimally it "grows back" about 1 millimeter in a few days. A nerve running from the spine to the toes of an adult male can be up to 100 cm long (i.e., 1000 millimeters). Thus full regeneration may require three and a half to four years. This is such a long period that without treatment the paralyzed muscle will deteriorate.

In peripheral paralysis the most important task is to keep the limb muscles functional until the nerve recovers. For this you can use only denervated muscle stimulation (denervated current treatment). If you do not treat the paralyzed muscles every day, by the time the nerve recovers you will have lost the chance for recovery. The muscle will be destroyed; even if the nerve reconnects it will not work.

The problem is that muscles that have lost their motor nerve (so‑called denervated muscles) cannot be stimulated in the same way as described for central paralysis.

Denervated muscle treatment requires a special impulse. Only with much longer stimulation can the muscle be induced to contract, and it also fatigues more quickly from stimulation. A device specialized for treating peripheral paralysis is the PeroBravo, or alternatively the Genesy 600 or the Genesy 1500 devices.

Recommendation

If paralysis ruins your life, everything may seem hopeless. A non-moving hand or foot makes even basic tasks impossible.

As detailed above, the condition can mostly be improved. Some luck is required for complete recovery of all functions. A realistic expectation is the recovery of basic skills. With those you can live your daily life without others' constant help.

Your recovery largely depends on you!

However, you need a rehabilitation specialist, a physical therapist, and a physiotherapist. They will determine what treatments you should perform at home, what exercises to do, etc. They do not need to be with you every day, but you should meet them every few weeks so they can recommend modifications based on your improvements or changes. Between checkups your fate is in your own hands. Others can only help, encourage, and support, but they cannot practice or perform treatments in your place. Only you can do that!

Nerve regeneration is particularly slow. Years may pass before you see your paralyzed hand or foot move again. You must not give up faith in recovery and you must not stop treatments.

Huge mental strength and perseverance are required. And also good quality therapeutic devices, because without a stimulator the chance for paralysis rehabilitation is very small.