Organ dysfunction, movement disorders in diseases of the nervous system

Paresis is a partial paralysis in which the patient is unable to perform various actions and movements, which is caused by serious damage to the central or peripheral nervous system.

Diagnosis of paresis in the neurology clinic of the Yusupov Hospital is comprehensive, with the involvement of specialists from various fields of medicine: psychoneurologists, otolaryngologists, neurosurgeons, psychiatrists, pulmonologists.

In the labyrinth of terms

The scientific name of this pathology is paraparalysis (otherwise known as paraplegia). It’s very easy to remember: a pair of arms, a pair of legs (because this problem can also affect the lower extremities).

Paralysis (or plegia) is a complete loss of the ability to move (and not only in the limbs).

Unlike paraparalysis, paraparesis is a more “gentle” variant of the manifestation of pathology in the extremities, “sent from above” from the brain to both sides of the body at once.

Here, only the arms or only the legs are “beaten off” and therefore do not work. The movements in them are so weakened that they cannot perform the work intended for them, but there is sensitivity, so the limbs are only half deprived of life.

In other words, paresis is almost paralysis, but not complete: movements, sharply limited in volume and strength, are possible, but they are uncontrollable by the owner of the body.

For final clarity with strength and sensitivity in the limbs, it is worth remembering the ancient languages:

• mono
  paresis or monoplegia - a destructive process in one limb;
• pair
  paresis or paraplegia - the same in two identical limbs (upper or lower);
• hemiparesis
  or hemiplegia - the development of a process in one half of the body;
• tetra
  paresis or tetraplegia is a pathology of all four (both upper and lower, both right and left) limbs.

Paraparesis of the limbs: causes and treatment

Paresis is a neurological syndrome that is characterized by a weakening of the muscle strength of the limbs due to damage to the pathways of nerve signals. A more severe form of pathology is paralysis (plegia), in which voluntary movements are completely absent.

Hemiparesis is a violation of motor functions in one half of the body (for example, the right arm and right leg). Monoparesis, when the pathology affects only one limb, upper or lower (one arm or one leg), paraparesis – both limbs are affected. Triparesis and tetraparesis are lesions of three or all limbs, respectively.

According to the level of damage to the nervous system, paresis can be divided into: central, peripheral, mixed, psychogenic. Degree of severity of the disease: mild, moderate, deep, complete paralysis. In this case, only one of the muscles of the limb, a group of muscles (flexors and extensors) of the limb, or part of the limb can weaken.

Flaccid paresis is characterized by a condition in which there is a pronounced relaxation and some atrophy of the muscle fibers of the limb without their shortening or overstrain, and a gradual extinction of reflexes.

Spastic paresis is characterized by a combination of weakened motor capabilities with simultaneous involuntary tension or even spasms of the muscles.

Any damage to the pathways along which nerve signals move from the neurons of the cerebral cortex to the spinal cord and then to the peripheral nerve endings can cause problems with motor functionality. Nerve impulses that do not reach the target do not convey excitation to a specific muscle or group of muscles, as a result of which the muscle fibers weaken or completely atrophy. Lesions and diseases of the brain and spinal cord can cause paresis or paralysis of the limbs.

Causes of the disease

Quite often, the causes of paresis are damage, compression or disease of the spinal column, spinal cord, nerve roots or blood vessels that wash them. The main reasons for the development of paraparesis:

• traumatic injury to the spine, spinal cord or nerve roots;
• protrusion or herniation of intervertebral discs;
• spinal instability, osteochondrosis, spondylosis, spinal stenosis and other back diseases;
• spinal cord tumors of various etiologies;
• abscess of the spinal cord, its membranes or epidural space;
• hereditary genetic predisposition, congenital anomalies or birth injuries;
• infectious lesions and autoimmune diseases;
• myelopathy;
• sclerosis;
• diseases of the vascular system;
• deficiency of B vitamins, in particular B12, etc.

Symptoms

When the upper motor pathway (from the brain to the spinal cord) is damaged, central paresis is formed, which is characterized by weakness in the affected limbs and a gradual increase in spasticity. Damage to the lower motor pathway (from the spinal cord to the peripheral nerves) forms peripheral paresis, which is accompanied by weakness and thinning (weight loss) of the muscle fibers of the affected limb and their involuntary contraction.

Some common signs of paraparesis:

• loss of sensation in the limbs or constant cold;
• pain, swelling, weakening of muscle fibers;
• difficulty in flexion and/or extension of joints (knee, ankle, hip, elbow, etc.) with their gradual deformation;
• gradual decrease in reflex reactions;
• difficulty or inability to fully straighten the leg and step on the heel;
• uncertainty and unsteadiness of gait.

Pathological symptoms of paraparesis can appear very quickly, rapidly gaining strength, or they can have a sluggish regression. But in both cases, treatment and recovery are quite slow. In especially severe and advanced cases, dysfunction of the pelvic organs is connected to paresis of the lower extremities.

In addition, muscle weakness quite often leads to a deterioration in the patient’s psychological state. He becomes irritable and aggressive, or vice versa: lethargic, apathetic, sleeps poorly, loses his appetite. In some cases, there is an increase in temperature, decreased immunity, or dysfunction of the digestive system.

In infants, paraparesis of the lower extremities is diagnosed after birth trauma. This is a kind of reinsurance so that the child is under the control of the parents and the attending physician (orthopedist, neurologist) and receives the necessary procedures and therapy. At an older age, after an appropriate examination, the diagnosis is removed or confirmed with the establishment of disability.

In children, at the initial stages of the development of the disease, only mild discomfort is felt, then pain occurs in areas where the peripheral nerves are damaged. With the progression of acute diseases of the central nervous system, paresis and paralysis develop spontaneously and very quickly.

Patients with complete loss of sensation in the lower extremities (for example, with spastic paralysis) often do not respond to burns, bruises and require special care. For example, the formation of bedsores or trophic ulcers, swelling and cyanosis of the legs cause a lot of trouble for medical staff.

Diagnosis of paraparesis

Diagnosis of paresis occurs exclusively clinically without the use of additional instrumental studies. A comparative description of the muscle strength of the limbs of different sides of the body (with hemiparesis), standard resistance tests, and a classic test with the Barre test (when the patient is asked to hold his arms or legs suspended for a long time) are carried out. If there is paresis, after 20 seconds the extended limb will gradually descend.

To identify the causes of paraparesis of the limbs, the following hardware and laboratory tests are used:

• MRI of the brain and/or spinal cord, spinal column or CT scan – diagnostics;
• myelography;
• study of liquor fluid;
• electromyography or electroneuromyography;
• general and biochemical blood test;
• diagnosis of HIV infections and syphilis;
• determination of the level of vitamin B12 and folic acid in the blood;
• search for genetic predisposition or cancer.

Treatment of the disease

Treatment of paresis is always prescribed in a comprehensive manner. This includes treatment of the underlying disease that caused muscle weakness, and the study of the pathology itself. For example, a combination of heat applications and limb massage improves the trophism of soft tissues and the passage of nerve impulses along the motor pathway. Individually designed passive gymnastics in combination with general massage activates muscle contractions, and the gradual addition of active movements and increasing strength load with resistance increases the volume and strength of muscle tissue. However, all actions must be strictly dosed, carried out with the help of a physiotherapist or rehabilitation doctor, with the coordination of all procedures with the treating doctor.

At the next stages of treatment, exercise therapy courses, swimming, physiotherapy (electromyostimulation, magnetic field treatment), manual therapy (acupuncture, acupuncture, specialized massages, etc.) are included. The use of various psychotechniques and trainings to raise the patient’s psychological mood showed good results.

Surgical intervention for paraparesis is offered quite rarely.
It is mainly aimed at eliminating the original disease such as: spinal instability, spinal stenosis, herniated intervertebral discs, tumors of the brain or spinal cord, etc. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

“Plege” means blow - the reasons are available

For what reason does a decline in muscle strength occur, accompanied by a complete absence of voluntary movements in both arms (or legs) - paraplegia?

For this condition to develop, one of the motor pathways of the nervous system must be affected, each of which bears the name of the researcher who discovered it.

Depending on the cause that caused it and the speed of onset of the condition, paraplegia can be:

1. Acute
   , which can develop as a result of an electrolyte imbalance such as severe hypokalemia, or due to a stroke, both of the brain and spinal cord, or as a result of compression of the spinal cord caused by a vertebral fracture (compression myelitis).
2. A subacute
   variant of development is a possible result of a “drama” that plays out in the brain or spinal cord under the influence of a bacterial infection (myelitis and meningomyelitis of an infectious nature, including polio), or a liquorodynamic (like a hydraulic) shock, or a consequence of ischemia of some kind. either part of the nervous system, or the cause may be a congenital deformity of the spine.
3. A sluggish form
   of the disorder can manifest itself as a parasitic infection of the central nervous system, as well as a tumor that has arisen in it, or a herniation of the spinal cord, as well as spondyloarthrosis. Or there may be no obvious cause at all - an idiopathic variant of flaccid paraplegia.

In the case of damage to the nervous system of organic origin, paraplegia is called organic, in the case of mental genesis - psychogenic, mainly - hysterical.

The basis of organic paraplegia, most often spastic, is damage to the nervous system (both peripheral and central) due to atherosclerosis, arteritis, which lead to the formation of foci of softening of the brain of a bilateral nature, while psychogenic paraplegia is a predominantly sluggish course of the disorder.

Paraplegia occurs as a consequence of amyotrophic lateral sclerosis or multiple sclerosis, and also occurs with syringomyelia.

Why is “water hammer” the reason for the development of paraplegia?

With this pathology (due to confusion in the control of electrical currents), the normal flow of cerebrospinal fluid, the main fluid connecting all levels of the nervous system, is always disrupted.

So “water breaks the mill” is a popular wisdom; it cannot be said more precisely.

Causes

The main reasons for the development of paresis include:

• birth injuries (most often the occurrence of distal paresis is associated with birth injury in the brachial plexus);
• hemorrhage;
• cerebral stroke;
• typical multiple sclerosis;
• prolonged migraine;
• other disorders of the spinal cord or brain.

Sometimes paresis develops in patients with laryngotracheitis, typhoid fever, syphilis, botulism and syringomyelia.

Flaccid paresis of the lower extremities (for example, peripheral paresis of the lower extremities) can occur due to various diseases. It manifests itself as a decrease in strength in one or more muscles.

The clinical picture depends on the cause and type

In the case of spastic paraplegia of central origin, the most often diagnosed is the symmetry of the pathology of the corticospinal or pyramidal motor tract, which can arise at any of its levels.

The appearance of paraplegia of peripheral origin is usually due to either the involvement of both anterior horns of the spinal cord in the process, or there is a connection with the pathology of the anterior roots, plexuses, and peripheral nerves.

A characteristic feature of spastic paraplegia, in addition to signs of paralysis of the muscles of the limbs of the same name, is the appearance of symptoms of muscular hypertonicity (spastic hypertension).

Extrapyramidal system in the central nervous system

Lower spastic paraplegia can be of the following nature:

• flexor flexion;
• and extensor extensor type.

For the flexor type (Babinski paraplegia, which occurs due to a particularly large process in the spinal cord, or in patients with a high degree of exhaustion or with the development of bedsores), hypertonicity is characteristic, leading to the development of contractures in the flexor muscles of the hip and lower leg.

Extensor paraplegia, which has a predominant distribution, is characterized by hypertonicity of the extensor muscles of the hip and leg, with the involvement of the plantar flexors of the feet, which leads to straightening of the lower extremities.

Tendon and periosteal reflexes in this type of disorder are excessive - but the skin reflexes fade and pathological reflexes appear, both extensor and flexion, as well as protective and synkinesis reflexes (global and coordinating).

Spasticity

Spastic paraplegia is manifested by an increase in the level of knee and Achilles reflexes, as well as the appearance of pathological reflexes (Gordon, Schaeffer, Babinsky, Oppenheim, Rossolimo).

Babinski reflex

The possibility of developing this paraparalysis can be caused by both a symmetrical subcortical lesion of the corona radiata and involvement of the pyramidal system in the process (at the level of the internal capsule or on one of the sections of the corticospinal tract).

One of the most common causes of paraplegia is transverse spinal cord injury. Moreover, with symmetrical damage to the spinal cord, the following appears:

• when the upper cervical segments are involved - spastic tetraplegia;
• in case of damage to the thoracic segments - lower spastic paraplegia.

The manifestation of the pathology will be expressed by the protective reflex Bekhterev - Marie - Foix: in response to heat, cold, or painful stimulation of the limb due to flexion in the hip, knee and ankle joints.

The occurrence of synkinesias (coordinating friendly movements) is also characteristic: the tibial phenomenon-Strumpel synkinesis with involuntary flexion of the foot with its supination and simultaneous extension of its big toe when trying to flex the limb at the knee and hip joints and Raymist synkinesis - repetition of actions by the affected leg (adduction and abduction) performed with a healthy leg.

Motor symptoms of spastic paraplegia are accompanied by disturbances of coordination, sensitivity, tissue trophism and pelvic disorders.

With a complete transverse section of the spinal cord with damage to the pyramidal and extrapyramidal tracts, spinal spastic paraplegia can develop into flaccid paraplegia with attenuation of not only tendon, but also periosteal reflexes and muscle atony.

Sluggish development of the disorder

Flaccid paraplegia is caused by bilateral damage to peripheral motor neurons due to:

• polio;
• spinal injury;
• plexites;
• polyneuritis;
• intramedullary tumors.

A characteristic feature is the absence of muscle tone in the limbs, attenuation of reflexes, both tendon and periosteal, muscle atrophy with suppression of electrical excitability (degeneration reaction) and with electromyogram indicators indicating damage to peripheral motor neurons.

Pathology of central motor neurons leads to paraplegia, flaccid either permanently or at certain stages of development, most often at the beginning or at the very end of the disease.

A pathology that continues throughout the entire duration of the disease in a sluggish form, characterized by atony, attenuation of tendon and periosteal reflexes, is always a manifestation of complete or almost complete rupture of the spinal cord due to injury. It is manifested by depression of sensitivity, advanced disorders of the pelvic organs, and bedsores.

If flaccid paraplegia occurs suddenly as a result of injury, this does not always indicate a complete transection of the spinal cord - this picture may be a consequence of diaschiosis. As it weakens, the symptoms of flaccid give way to the symptoms of spastic paraplegia.

A process that spreads more and more throughout the spinal cord and compresses it more and more. A tumor of the spinal cord occurs, which leads to the fact that his paraplegia, spastic at the beginning, eventually turns into flaccid.

Paraplegia that develops due to bilateral damage to peripheral motor neurons is always flaccid paraplegia, characterized, in addition to atony, by extinction of tendon and periosteal reflexes.

Spastic paraplegia - main types

There is a significant difference between flaccid peripheral paraplegia and those of central origin: the former result in muscle loss of mass and irreversible degeneration of their structure with a drop in electrical excitability.

Symptoms

Patients with paresis of the lower extremities experience the following symptoms:

• gait changes: gait disturbance is associated with weakening of the pelvic girdle muscles. The patient’s steps become “waddling” from one foot to the other;
• the leg muscles weaken: it is difficult for the patient to walk and even get up from a sitting position;
• the tone of the extensor muscles of the lower extremities decreases: when raising the legs, the feet may hang helplessly;
• hypotonicity or hypertonicity of muscles occurs;
• deep or pathological reflexes appear (Zhukovsky, Babinsky);
• the activity of the circulatory system is disrupted: lack of movement of the legs and feet leads to a deterioration in their blood supply and atrophy of the walls of blood vessels, which can lead to the development of disorders of the entire cardiovascular system.

Strumpel's paraplegia

Synonyms for the name: Erb-Charcot-Strumpel disease, or familial spastic paraplegia.

This is a disease with an inherited defect of the nervous system - bilateral degeneration of glia of the pyramidal tracts in the cords (lateral and anterior) at the level of the thoracic and lumbar regions of the spinal cord, with the involvement in subsequent stages of the pyramidal fibers of the brain stem and partial death of Betz cells in the motor zone of the cerebral cortex.

The mechanism of inheritance is autosomal dominant, or autosomal recessive, or it is X-linked; the genes responsible for the transmission of pathology have already been identified.

Due to genetic heterogeneity, the disease can manifest itself between the 1st and 7th decades of life as symmetrical lower spastic paraplegia, manifested by:

• gradual development;
• early appearance of tendon reflexes;
• rapid fatigue of the legs from walking;
• stiffness;
• cramps in the leg muscles of a tightening nature;
• spastic gait;
• increased level of tendon reflexes;
• clonus of the feet and patellas;
• the formation of contractures and deformities of the feet with the formation of a “hollow foot” - with its shortening and increase in height.

When the upper extremities are involved, which happens in the advanced stage of the disease, this does not affect sensitivity and intelligence.

Possible damage to the optic and oculomotor nerves (II and III pairs of cranial nerves), the occurrence of dysarthria, ataxia, nystagmus, and intention tremor.

MRI demonstrates a picture of characteristic atrophy of the spinal cord along its entire length, with particular severity in the cauda equina region.

In differential diagnosis, this disease is indicated by:

• late onset of the disease with a slowly progressive course, complicated by spastic paraplegia, with normal psychomotor development;
• maintaining the patient’s ability to walk until adulthood;
• health of heterozygous family members.

Associated symptoms

With a bilateral process in the cerebral cortex with a tumor in the upper third of the precentral gyrus, spastic lower paraparalysis is often accompanied by Jacksonian epilepsy with the appearance of clonic convulsions with their onset in the leg muscles.

In children, spastic diplegia is characterized by insurmountable spasticity of the leg muscles with a pronounced adductor dominance and the formation of a characteristic gait, or even the inability to walk independently. The pathology is also manifested by combined athetotic hyperkinesis of the muscles of the arms and face.

General principles of treatment

The main actions should be aimed at eliminating the causes of paraplegia:

• surgical removal of the tumor;
• elimination of spina bifida;
• treatment of nervous system infections;
• and similar measures.

Prescription of medications is made taking into account the nature of the pathology.

With spastic paraplegia, electrotherapy can lead to increased contractures, while with its peripheral origin, this method of influence will give a favorable result.

In case of multiple sclerosis, or systemic sclerosis, spondylitis of tuberculous etiology, mud therapy is contraindicated.

With lower paraplegia, the emphasis should be on the development of the muscles of the upper extremities, the condition of which determines the subsequent fate of the patient. And here the first step to getting out of helplessness is learning the art of sitting in bed.

Symptomatic treatment is prescribed to relieve the underlying concomitant pathology. Antihypertensive, anticonvulsant and antispasmodic drugs, and agents to improve tissue trophism are prescribed.

Balneological procedures are also used, and the use of mud therapy, massage and exercise therapy is indicated.

From the practice of a neurologist

As an example, it is worth citing a treatment regimen for lower paraplegia, of central origin, due to spinal cord injury in a young patient, where complex treatment had a noticeable effect:

• Actovegin
  - intravenous stream;
• Trental
  - intravenously;
• Prozerin
  ;
• vitamin B12
  intramuscularly;
• massage of the lower extremities
  in combination with physical therapy;
• acupuncture and electrical myostimulation
  of extensor muscles

This is a set of measures that were prescribed in addition to independent physical activity on the shoulder girdle and early learning to sit in bed, to help overcome the fear of which psychotherapy sessions helped.

The combination also gave satisfactory results:

• muscle relaxant Mydocalm
  ;
• Sibazon,
  which has a complex sedative-hypnotic, anticonvulsant and anxiolytic effect ;
• Pentoxifylline
  is a means to improve microcirculation;
• Milgamma
  is a complex of B vitamins;
• ATP
  - tissue energy stimulator;
• Cerebrolysin
  is a nootropic drug.

Possibility of complications and prognosis

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Prognostically, flaccid and spastic flexor paraplegia is less favorable than spastic extensor paraplegia. The inability to develop labor skills due to muscle weakness of the legs should also be considered an unfavorable prognosis for the patient.

Complications of the disease are complete loss of the ability to move independently due to the progression of the emerging pathology, disability and the appearance of pelvic disorders and trophic disorders-bedsores.

There are currently no proven, reassuring treatments for paraplegia.

Comparatively good results are obtained only by using traditional Chinese medicine methods in the form of acupressure, reflexology, acupuncture, using electric needles and a lamp with Chinese herbs, drinking fresh herbal infusions prepared according to an individual recipe, herbal boluses and similar methods of influence.

Diagnostics

An important role in the diagnosis of paresis belongs to a careful collection of anamnesis and determination of how prone the patient is to the occurrence of typical psychogenic reactions.

Microlaryngoscopy is used for modern examination of patients with laryngeal paresis at the Yusupov Hospital. In addition, radiography and computed tomography of the larynx are additionally prescribed. Clinic specialists evaluate neuromuscular transmission and muscle contractility. To confirm the diagnosis, an X-ray examination may be prescribed.

When diagnosing paresis of the limbs, the extent of distribution and localization of existing muscle weakness is taken into account.