A 22 year old male patient sees a doctor because he is suffering from flaccid pa

Question

A 22 year old male patient sees a doctor because he is suffering from flaccid paralysis of the left side of his face. His eyelid and the corner of his mouth are drooping, and his eye constantly waters. The right side of his face seems to be unaffected. The condition came on suddenly, over the course of 24 hours. Upon interviewing the patient, the doctor discovered that he suffered from flu-like symptoms several days before, but has not experienced a rash or skin discoloration.

From what condition is the patient likely suffering? What is a possible cause of his condition? What is the physological cause of his condition? What can the doctor do for the patient?

Explanation / Answer

Flaccid paralysis is a specific type of paralysis where your muscles cannot contract at all. This can cause serious problems, since breathing is controlled by the muscle in your diaphragm. Imagine if all your muscles turn to jello, you would flop over like a jellyfish! This is, essentially, what happens during flaccid paralysis.

Patient might loose motor control Eventually, loss of muscle tone occurs, where muscle becomes weak and starts to atrophy.

Causes of Flaccid Paralysis

Flaccid paralysis can be caused by infections and toxins, or damage to the spinal cord or brain. Polio, botulism, and curare are examples of this type of damage. All of these problems cause flaccid paralysis by preventing messages in the brain from getting to the muscle.

Imagine a factory. The factory workers keep doing what they need to because they have instructions from the boss. If the communication with the boss was cut off, they would eventually stop working. The boss is like the brain and the workers are like the muscle.

In above case patient may experienced/exposed to stroke or botulism toxin.

There is no set amount of time that the flaccid stage remains. For some it can resolve in days, others weeks or months. Most stroke patients I see don't remain flaccid and do gain some amount of tone which can range anywhere from minimal to severe.

During the flaccid stage, it is important to keep the arm supported and positioned well. Retrograde massage can be used to help with hand/forearm edema (unless massage is contraindicated due to CHF or similar diagnosis). You can use pillows or a tray to help support the weak arm. Slings are an option, but I don't personally like slings because they immobilize the arm and often cause poor positioning and alignment. If I do use a sling, it's usually only when a patient with a flaccid arm is walking. I like the Giv-Mohr sling for walking a patient with a flaccid arm or subluxed shoulder.

As far as exercises, it is important to do passive range of motion. Self passive range of motion exercises can be viewed at www.stroke-rehab.com/passive-range-of-motion.html. The main precaution is to be careful with overhead range of motion and only move the shoulder in a pain-free range. If the patient is unable to do passive range, the caregiver can do it. Examples of a caregiver doing passive range of motion can be viewed on video at www.stroke-rehab.com/stroke-rehab-exercises.html under the passive range of motion paragraph.

Other exercises that should be performed involve weight bearing and facilitation. Weight bearing can be done by the caregiver placing the patient's open hand on a flat surface (i.e. mat, bed, book), supporting the patient's elbow so the arm won't buckle, and having the patient lean and put weight down through the flaccid arm and hand. One can also tap the muscles to try an initiate movement. To help bend the arm, you can tap the biceps. To help straighten the arm, the triceps can be tapped. To help straighten the knee, tap the quadriceps. Weight bearing can also be practiced through the leg, but it is best to establish sitting balance first and have a physical therapist help with weight bearing through the leg to prevent the patient from falling. If the patient is unable to stand and weight bear even with the help of a therapist, a hi-lo mat can be used to start weight bearing. I often will have the patient sit on the edge of a high-lo mat that is raised with the patient's feet on the floor. Raising the mat and having the patient reaching forward allows for increased weight bearing through the legs, but this is an activity that should be done with the therapist.

Sometimes the extremities appear flaccid but actually do have a little tone and ability to move. For the arm, a hand towel can be placed on a table and the stroke patient can try to slide it forward. I often use a single tip cane, support the patient's hand on the cane and let them try to push it forward and back (the end of the cane is on the floor while I'm supporting the patients hand on the handle). Sometimes I will place the patient's hand on a table, ball or mat and see if they can hold it there without it falling or sliding off. These are a couple of beginning exercises that can be tried to see if there is any active arm movement.

Electrical stimulation can be used to initiate muscle contractions and prevent muscle atrophy in some patients. Other patients may not be able to use e-stim due to contraindications such as having a defibrillator or pacemaker so one must check with their MD first.

The last note I want to add is do not pull on the flaccid arm and make sure the arm and leg are positioned well. Often a patient will sit on the arm or have the arm/leg contorted in a bad position without even knowing it. It is important to tell the patient to frequently look at the weak extremities and see where they are positioned.

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