Chapter 6. Paralysis and other movement disorders

- a generalized concept in neurology, in which there is an inability for muscles to perform their inherent function, in particular to contract. Paralysis is not a separate disease, but only a symptom of some disease or disorder in the functioning of the human body. Failure to treat paralysis in a timely manner can lead to complications, such as:

• Persistent neurological defect in the form of lack of muscle strength
• Irreversible hardening of muscles or formation of an immobile joint

Types of paralysis

There are a couple of main classifications of the described disease. The first is in terms of its etiology:

• central (spastic), as the name suggests, occurs as a result of damage to the central nervous system and contributes to muscle hypertonicity;
• peripheral (flaccid) is a consequence of damage to the nervous system in the periphery and reduces the tonic characteristics of muscles up to atrophy, leading to their thinning and exhaustion.

Based on the location of paralysis, the following types are identified:

• monoplegia – paralysis of a single limb;
• hemiplegia – paralysis of the arms and legs located on one side of the body, which can paralyze the same part of the face;
• paraplegia – dysfunction of exclusively upper or exclusively lower extremities;
• tetraplegia – dysfunction of four limbs.
• In addition, paralysis can be temporary or permanent.

Symptoms

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The main manifestation of paralysis is the complete absence of muscle strength in any muscle or muscle group. In connection with localization, the following manifestations are distinguished:

• a complete lack of muscle strength in the muscles of the upper limbs, as a result of which it becomes impossible to perform actions such as grasping an object, lifting, bending and straightening the arm;
• complete lack of muscle strength in the muscles of the lower extremities, which is accompanied by a lack of active movements in the affected limb;
• drooping of the head forward, which is observed with paralysis of the posterior muscles of the neck.

In addition, slurred speech, deviation of the tongue to the side when protruding it from the mouth, and food retraction during meals may be noted. In some cases, there is a violation of the movement of the eyeballs, which is manifested by a lack of coordinated eye movement, resulting in the development of strabismus or the so-called “gaze palsy.” Also, with some paralysis, dysfunction of the pelvic organs develops, which is accompanied by automatic reflex emptying of the bladder and the inability to voluntarily defecate (fecal incontinence).

It is important to note that there are fundamental differences between peripheral and central paralysis. Signs of central paralysis:

• lack of muscle strength;
• reduction in the volume of active movements;
• decreased range of passive movements;
• increased muscle tone (hypertonicity);
• increased deep reflexes;
• decreased surface reflexes;
• the presence of pathological reflexes;
• absence of fascicular and/or fibrillary twitches.

Signs of peripheral paralysis:

• decrease in muscle strength in the innervation zone of the corresponding neuron;
• reduction in the volume of active movements;
• increase in the range of passive movements;
• decreased muscle tone (hypotonia);
• preservation of surface reflexes;
• decreased deep reflexes up to areflexia;
• development of muscle wasting or atrophy;
• the presence of fibrillar and/or fascicular twitching.

Causes

As noted above, paralysis does not come on its own. Its manifestation is caused by the development of any disease in the patient. The most common underlying causes of paralysis are outlined below.

• spinal and cerebral injuries;
• poisoning (heavy metals, salts of heavy metals, household and industrial poisons, alcoholic and narcotic substances, pharmacological compounds, etc.);
• oncological formations, including cancer;
• serious infections that negatively affect all organs (meningitis, polio, tuberculosis, syphilis, etc.);
• metabolic disorders, metabolic processes;
• botulism is an extremely serious infectious disease that leads to injury to the nervous system (medulla oblongata and spinal cord); caused by the entry into the body of a spore-forming rod, the product of which is botulinum toxin;
• non-compliance with proper nutrition standards;
• neglect of the rules of a healthy lifestyle;
• hereditary pathologies that negatively affect the functioning of the central and peripheral nervous system; these pathological anomalies often accompany various disorders of motor coordination;
• injuries sustained by the baby during childbirth;
• blood flow disturbance;
• abscess formations in the spinal cord or brain;
• inflammation of the spinal cord (myelitis) and brain (encephalitis);
• Guillain-Baré syndrome is an acute autoimmune disorder;
• transient ischemic attacks - temporary disruption of blood flow;
• demyelination (decay of the myelin sheath, which is responsible for the electrical insulation of neurons and the speed of information transmission between them) as a result of encephalomyelitis, multiple sclerosis or another disease, possibly of a chronic nature;
• myasthenia gravis – an autoimmune ailment characterized by atypically accelerated fatigue of muscle fibers; the symptoms of the indicated disease progress after a person undergoes active physical activity and weaken after rest;
• myopathy is a chronic pathology that affects neuromuscular cells;
• epilepsy is a neurological disorder characterized by spontaneous seizures;
• A stroke is a sudden interruption in the blood supply to the brain.

Unilateral types of paralysis (monoplegia and hemiplegia) most often occur as a result of a stroke. Moreover, if there is a disruption in the blood supply to the left hemisphere of the brain, then the right side of the body becomes paralyzed, and vice versa.

In medical practice, there are quite a large number of examples when paralysis turned out to be a consequence of psychological problems, a neurotic disorder. The psychogenic nature of the syndrome necessarily requires specific rehabilitation measures, in particular, work with a psychologist, psychotherapist or psychiatrist.

Symptoms

There are types of paralysis that occur as a separate disease. In particular, these are bulbar and Bell's palsy. And here the symptoms of each disease are already highlighted.

Bulbar palsy can be either acute or progressive. Poliomyelitis is a form of acute paralysis. Here, at the initial stage, the following are common: dizziness, headaches, fever, uneven breathing and a very weak pulse. The voice may be nasal, making speech difficult to understand. A person cannot eat food - food cannot be held in the mouth. The disease progresses quickly and is always fatal.

Progressive paralysis is usually seen in men. But, unlike polio, it lasts longer (on average, it lasts from one to three years). Fatal outcome is also typical.

Bell's palsy is facial paralysis. Typically, paralysis appears on one side of the face. There can be many reasons: infectious diseases, cancerous tumors or simple hypothermia. The disease is accompanied by migraines and severe pain in the head. Bell's palsy has virtually no fatal outcomes, but treatment is strictly necessary. Because if it is not treated, over time only surgical intervention (surgery) will help correct the situation.

Symptoms and complications

Since the root causes of paralysis can be completely different, its symptoms are quite diverse.

Paralysis that is just beginning to develop is characterized by loss of sensation in the limbs and impaired functioning of some muscles. Over time, the patient stops feeling the painful effects. Due to impaired blood flow in the affected area, nearby internal organs lack nutrients that ensure the stability of their structure and functionality. When it comes to damage to the neural centers responsible for the management of natural needs, the paralyzed person is no longer able to control urination and defecation.

A patient suffering from paralysis should be especially closely monitored for changes in well-being. When paralysis is provoked by reasons from the organic sphere, it is accompanied by reflex changes, disorders of the tonic state of muscles, including atrophic ones. However, with a temporary form of paralysis, there are no changes in muscle tone and reflex characteristics in the tendons.

With spastic paralysis of the lower extremities, which appears when the central motor neuron is damaged, atypical muscle reflexes occur. Their excitability increases significantly, and involuntary movements may occur. Sometimes this subtype of paralysis is accompanied by loss of speech abilities.

The peripheral, or flaccid, type of paralysis is characterized by atonic changes in the muscles (they relax very much, regardless of the will of their owner), which tend to reach their atrophy, as well as the disappearance of reflexes. It is characterized by a deeper degree of damage to the musculoskeletal system. His victim is not only unable to move, but is also doomed to constantly remain in a lying position. Typically, such paralysis occurs when the spinal cord is damaged in the lumbosacral region and can be an unpleasant aggravating addition to the spastic paralysis described above.

In addition to the already depressing situation with paralysis, concomitant diseases begin to develop. Complications of paralysis include various pathologies of the cardiovascular system, respiratory organs, bones and muscles.

Cerebral palsy (CP) - symptoms and treatment

For the treatment of cerebral palsy, it is important to have an early start, an individual approach, continuity and succession at different stages (when each specialist supports and improves the results achieved by the previous doctor). Treatment is combined with educational work, occupational therapy (medical rehabilitation that teaches the patient to restore or acquire everyday skills, occupational therapy). It is necessary to include the child’s family members in the work to comply with the principle of continuity [5].

There are several main approaches to the treatment of cerebral palsy:

1. Method of functional therapy - kinesiotherapy, exercise therapy, physical therapy, hardware kinesiotherapy, functional massage techniques.
2. Conservative orthopedic treatment - orthosis, casting, postural management (use of technical means of rehabilitation - verticalizers, seat supports).
3. Drug treatment with oral antispastic drugs.
4. Botulinum toxin preparations , which belong to the group of local muscle relaxants and reduce spasticity. The drug relaxes the spastic muscle into which it was injected. They do not have a systemic effect, that is, they do not affect internal organs and the brain, but act only at the injection site.
5. Intrathecal (injection into the bone marrow membrane) of baclofen using a pump is a constant injection into the space between the hard shell of the spinal cord and the yellow ligament using a pump into the patient’s body of the drug “Baclofen”, which has a systemic effect and relaxes all spasmodic muscles. The big disadvantage of the drug is the need to monitor the dose and refill the pump. Pump installation is available only in large federal and territorial clinics.
6. Orthopedic surgery includes a large number of different operations that are aimed at lengthening muscles, restoring the hip joint in case of dislocation, forming a correct arch of the foot and full support of the foot, restoring a more even posture in case of scoliosis.

Treatment approaches are used depending on the severity of cerebral palsy and the age of the child. Functional therapy, conservative orthopedic treatment and postural management can be used from a very early age. Botulinum therapy is usually used from 2 years of age . The use of these approaches in combination with continuous long-term treatment and correction of all comorbid (associated) disorders ensures the high effectiveness of complex treatment. Oral antispastic drugs for cerebral palsy are often used to a limited extent due to the development of systemic side effects.

When treated with botulinum toxin type A (BTA), the maximum possibility of disease modification is observed at the age of 2-5 years . At older school age, botulinum therapy helps to solve local motor problems, reduce pain from prolonged spasms, facilitate care for patients with severe motor disorders, and also maintain the body in a sitting or standing position [8].

Kinesitherapy is a method of teaching and restoring a child’s motor activity through repeated repetitions of physiological movements, taking into account the ontogenesis of motor skills. The most effective methods are Vojta therapy, Bobath therapy, and PNF therapy [7].

An integral part of the rehabilitation process for children with cerebral palsy is psychological and speech therapy assistance and social adaptation. It consists of teaching children speech skills, communicating with other children around them, developing fine motor skills, and teaching self-service skills.

Orthopedic treatment helps eliminate contractures and deformities, as well as create a rational position for the child. Treatment includes special therapeutic positions during rest and sleep hours, staged correction of contractures using plaster splints and circular bandages. Of great importance is the prevention of secondary deformations and contractures in children during the period of rapid growth at 5-7 years and then from 12-15 years , when there is a tendency to the formation and recurrence of contractures.

For persistent contractures, surgical treatment is performed, but not earlier than 3 years of age , since active bone growth occurs before this and with early surgical treatment, relapses may occur due to the growth of the child. In modern neuroorthopedics, they try to delay surgical treatment as long as possible so as not to cause setbacks in the future.

In the postoperative period, the development of optimal positions of the body and limbs, rational compensatory devices, and the development of self-care skills continues. Prosthetic and orthopedic support is essential - the selection and adaptation of special auxiliary devices that help correct posture: verticalizers, seat supports, walkers, splints, devices for the lower limbs and torso [7].

Diagnostics

Before treatment for leg paralysis begins, it must be properly diagnosed. In this case, an integrated approach is important.

Diagnosis of paralysis must be made by a highly qualified doctor - an osteopath, neurologist, neuropathologist or neurosurgeon.

The doctor checks his patient’s reflexes, muscle tone, and conducts various tests. It is extremely important to rule out other diseases that have similar symptoms. In particular, it is necessary to exclude Bell's palsy, multiple sclerosis, and cerebral palsy.

Bell's palsy is a paralysis of the facial nerve, resulting in paresis of the upper and lower parts of the face. Mechanically, it is associated with swelling of the facial nerves caused by immune or viral pathology. Even the notorious herpes virus can act as the latter.

In multiple sclerosis, the myelin cells in the brain or spinal cord are affected. This is a type of chronic autoimmune disease.

Cerebral palsy is considered almost the most severe illness in the field of neurology. When it occurs, damage to the brain occurs, or the latter simply remains underdeveloped, as well as a violation of motor functions, the functioning of the speech center, the vestibular apparatus, a deterioration in learning, perception, and adaptive skills.

Moving away from the topic, we note that the Osteopathy Center successfully works with the above problems. Clients with such diagnoses, if not completely cured, receive serious relief and noticeable progress during rehabilitation.

Instrumental diagnostics is a diagnostic technique using the latest and well-proven apparatus and devices.

Such diagnostic methods include the well-known ones:

• computed tomogram - is a complex method of processing and measuring tissue density using a computer;
• magnetic resonance imaging – allows you to thoroughly examine the areas of the back and head and clarify the diagnosis;
• X-ray examination;
• electroneuromyogram - to assess bioelectroactivity, the speed of nerve impulses;
• electroencephalogram - for differential assessment of the electrical activity of cerebral zones;
• neurosonographic examination - is another non-invasive study, makes it possible to study the functioning of the brain and the condition of the tissues inside the skull, carried out by emitting ultrasonic waves; Suitable for use only in very young children, whose fontanel is not yet covered with a bone layer.

You will also need to take blood and urine tests, check the level of leukocytes and red blood cells, the fact of intoxication, and the presence of an inflammatory focus.

Patient examination

In order to establish the cause and type of paralysis, neurologists at the Yusupov Hospital conduct a comprehensive examination of the patient.
During the interview, the doctor asks the patient in which muscles there is a lack of strength, when he noticed the motor function disorder and for what reason it arose. The neurologist clarifies whether the patient’s relatives had similar diseases, and whether he connects the development of the pathological process with the presence of harmful substances (organic solvents, heavy metal salts) in the environment. The doctor then performs a neurological examination:

• assessment of muscle strength on a five-point scale;
• search for other symptoms of neurological pathology (facial asymmetry, lack of reflexes, muscle thinning, strabismus);
• determination of sensitivity, height of reflexes.

After a physical examination, he orders laboratory tests.
A general blood test can detect signs of inflammation (an increase in the number of leukocytes, erythrocyte sedimentation rate). In a biochemical study, an increase in the level of creatine kinase is found. A toxic blood test can detect the presence of harmful substances in the body. Patients in the neurology clinic of the Yusupov Hospital are examined using innovative research methods. Electroneuromyography is performed by leading experts in the field of physiology of the nervous system - neurophysiologists. Using a computer program, they assess the speed of nerve impulse transmission along nerve fibers and determine conduction blocks.

By analyzing electroencephalography data, the electrical activity of different parts of the brain is assessed. Using computed tomography and magnetic resonance imaging of the brain and spinal cord, the structure of these anatomical structures is studied layer by layer, a violation of the structure of their tissue is identified, the presence of abscesses (cavities filled with pus), hemorrhages, tumors, and foci of decay of nervous tissue are determined. Magnetic resonance angiography allows you to assess the patency and integrity of intracranial arteries and detect volumetric processes in the brain. If indicated, patients have the opportunity to consult a neurosurgeon.

Prevention

The preventive measures that doctors recommend in this case are extremely simple. It is necessary to lead a healthy lifestyle, eat right, drink plenty of clean water, exercise, vigilantly listen to your well-being, monitor your health, get enough sleep and be less nervous.

Preventive general health sessions in an osteopractor’s office will help prevent all sorts of problems leading to paralysis, as well as identify and eliminate them at the very beginning of their destructive effect on the body.