What are the most common neurological disorders affecting the musculoskeletal system that clients come to you with?
In the neurological outpatient clinic, we most often see patients with vertebrogenic difficulties, i.e. related to the spine, namely the cervical, thoracic and lumbar spine, which usually arise from repetitive functional blockages. We also frequently have patients with root involvement, most often caused by intervertebral disc prolapse or nerve root oppression by bone ingrowth in degenerative changes of the spine. Spinal segmental blockages lead to restricted range of motion, contraction of the paravertebral muscles along the spine and pain. If root irritation occurs, pain is manifested in the path of innervation of the corresponding compressed root, which leads to numbing of the limb and walking impairment. If the pressure on the nerve root is more pronounced, paralysis may also occur in its innervation area, which, for example, in the lower limbs is manifested by weakening of the toe, which rolls when walking, toe tripping or weakening of toe support. Scoliosis of the spine, oblique pelvis, shortening of the lower limb, arthrosis in the hips or knees, flatfoot, arthrosis of the small joints of the hands, legs, etc., may also contribute to movement disorders. Patients with a narrow spinal canal in the cervical spine with pressure on the spinal cord may experience progressive paralysis of all limbs, and in the thoracic and lumbar region, lower limb disability and pain when walking, which may limit the patient to only a few tens of meters of walking, after which they must stop.
And what are the common neurological difficulties in the upper and lower limbs?
In the area of peripheral nerve involvement, the upper limbs are often affected by nerve compression in the wrist area, which is more common in people who work physically, but also occurs with frequent and prolonged computer work. It is called carpal tunnel syndrome with tingling in the palm and 1st to 3rd fingers of the hand, while motor weakness is rare. The most effective solution is surgical release under local anesthesia, usually the problem is then permanently resolved. Slightly less common is nerve oppression in the elbow area with tingling at the inner edge of the forearm, less commonly with weakening of the 4th and 5th fingers of the hand, mostly from impingement of the elbow area when leaning on the elbow. This problem is solved simply, i.e. by rehabilitation. The diagnosis of polyneuropathy appears in the lower limbs. This is a disease of the peripheral nerves, which most often arises from metabolic or inflammatory disorders. It can be diabetes, thyroid dysfunction, a condition after Lyme disease. It can also occur in patients after chemotherapy treatment due to toxins, in people with ischaemic disease of the lower limbs due to impaired blood supply, alcohol abuse or smoking that impairs blood supply, but there are also congenital, genetically linked forms. This disease is manifested by tingling, sometimes in the fingers and toes, and impaired sensitivity to different qualities of sensation (heat, cold, deep-tissue sensation). Patients may progressively have difficulties with their ankles, mid-calves or knees, possibly even higher. Patients are primarily affected by this diagnosis because of unpleasant and bothersome sensory disturbances; in severe forms and fortunately more rarely, motor impairment with weakness in the lower limbs with stumbling, etc., is also present.
In addition to the diseases mentioned, there are also organic diseases of the nervous system affecting the musculoskeletal system. Can you tell the readers what these diseases are and how they manifest themselves?
There are many organic diseases of the central nervous system (CNS) that lead to movement disorders. For example, strokes, traumas to the brain and spinal cord, CNS tumors or inflammation, extrapyramidal diseases, most famously Parkinson's disease, multifocal disabilities such as demyelinating diseases like cerebral multiple sclerosis, metabolic-toxic CNS diseases and autoimmune systemic diseases. All these diseases lead to varying degrees of musculoskeletal paralysis. Some CNS diseases may be more extensive, but if they do not affect important brain centers, they may be clinically dormant for a long time, such as slow-growing benign tumors of the cerebrospinal fluid, called meningiomas. CNS lesions can lead to paralysis of the cerebral nerves, most commonly the oculomotor nerves, with symptoms of squinting or double vision, which in humans impairs orientation in space and instability when walking; unequal facial nerve palsy with drooping of the eyelid, cheek and corner of the mouth, and restriction of movement of half of the face. It can also cause paralysis of one, two, three or all four limbs with symptoms ranging from mild weakness and impaired fine motor skills to severe disability with inability to control part or all of the limb, often associated with impaired sensitivity and stiffness of the limb. Signs of CNS impairment include some vertigo, which causes instability in standing and walking, or diseases leading to impaired coordination of movement, such as cerebellar, vestibular and extrapyramidal disorders.
Can we talk about the most well-known organic CNS diseases – stroke, Parkinson's disease and cerebral multiple sclerosis – and get a better understanding of them?
Stroke can most commonly be ischemic, when an artery occludes, or embolic, when an artery is occluded by plaque from the sclerotic plaque of a cerebral feeder vessel, or from the heart in cardiac arrhythmia, atrial fibrillation, or the presence of a thrombus on the heart valves, etc. Hemorrhagic strokes are less common, which is when the vessel wall ruptures and blood spills into the brain tissue, which it destroys. These episodes tend to have a more acute course and greater neurological disability. Stroke leads to varying degrees of limb weakness, for example, strength may be impaired, grip may be loose, fine motor skills may be impaired, movement in limbs may be impaired, or in the case of severe disability, half of the body may be paralyzed. The consequences depend mainly on the size and localisation of the CNS damage. Cerebral strokes may only be transient manifestations resolving within 24 hours to complete episodes with varying degrees of permanent sequelae. Parkinson's disease arises due to extrapyramidal disease of the nervous system and basal ganglia. It occurs mostly in older age, the basic manifestation being slowness of movement, reduced to absent arm movements when walking, stiffness of the trunk and limbs, trembling of the limbs, impaired articulation associated with unintelligible speech, shuffling and shortening of steps when walking, even a kind of “tripping”. Treatment today can only slow down the progress of the disease. Cerebral multiple sclerosis mostly affects young people and middle-aged individuals. It is an autoimmune inflammatory demyelinating disease leading to the breakdown or damage of the nerve sheath. This causes impaired conduction of impulse through the nerve fiber, resulting in impaired function. As these demyelinating foci can affect any part of the CNS, the clinical picture of neurological involvement is very varied. Limb weakness, incoordination, numbness, dizziness, visual or auditory disturbances in any part of the body may occur. The modern form of treatment can slow down the progress of the disease, but cannot yet cure it completely.
What factors are most important in the development of these neurological disorders of the musculoskeletal system?
A number of factors influence functional musculoskeletal disorders, such as an unhealthy lifestyle associated with lack of exercise, being overweight, certain metabolic disorders, and muscular imbalances. Organic disorders include, for example, diseases of the muscles or neuromuscular transmission, arthritis of the hips, knees and small joints of the legs, flat feet, injuries to the menisci, ligaments or inflammatory joint diseases.
Can these factors be influenced preventively and prevent the development of nerve-related movement disorders?
As a preventive measure for the musculoskeletal system, it is recommended to exercise regularly if health permits, focus on stretching and strengthening the muscles of the back and limbs, getting plenty of active exercise and walking in the fresh air, reducing excessive body weight and limiting the load on the weight-bearing joints. Medications such as calcium and vitamin D are helpful in the treatment of osteoporosis if proven by densitometry, and chondroprotective agents such as Chondrosulf are given to support cartilage in joint problems. Effective prevention against stroke leading to subsequent movement limitation includes a healthy lifestyle, limiting sugar and fat intake, treating high blood pressure, monitoring serum sugar and fat levels and treatment if necessary. As well as not smoking and reducing excess body weight, with regular cardiological checks, possibly sonographic checks of the heart and cerebral feeding vessels when symptoms occur. Prevention of injuries and not overloading joints is important.
How can people recognise that they should consult a doctor about their movement difficulties as there may be a more serious problem?
A warning sign for a musculoskeletal disorder is pain. Analgesics and non-steroidal anti-inflammatory drugs help to reduce or eliminate pain, but this leads to overuse in the affected area because the pain symptoms protect against overuse. Long-term self-medication without examination by a specialist is therefore not advisable. If the pain recurs frequently, it is advisable to see a specialist and, only after a proper examination, determine the treatment procedure. For the most common vertebrogenic difficulties localized in the spine, it is recommended to apply local dry heat, prevent hypothermia, do not lift heavy loads, do not exercise during the acute phase, adopt a relieving position and do not bathe in hot water. In the case of joint disorders, physical examination is more likely; many joint disorders, especially in the knee area, are caused in young people by overloading during sport. Sudden weakening of the hand or foot should be examined by a neurologist as soon as possible, even if it does not hurt. Early diagnosis and the start of treatment has a much better prognosis.
How is the diagnosis carried out? Do you have all the necessary diagnostic tools available onsite at Health+, or do you refer clients to specialized facilities for certain specialized examinations?
The neurological examination starts with taking a detailed medical history so that we can learn about the patient's previous health problems, injuries, operations or hospitalizations, what they are regularly treated for, what medications they are taking, whether they have any genetic diseases or allergies, etc. And we ask in detail about the symptoms that bring them to the surgery – how long they’ve been lasting, what they depend on, how they developed and so on. We then perform an objective neurological examination. The patient always has to remove his underwear so that we can also see the position of the spine, joints, the state of the muscles, the length of the limbs and any pathologies. We examine the head joints, trunk, limbs, standing and walking, stability and range of motion of the spine and joints. Depending on the diagnosis under consideration, we indicate further necessary examinations. Laboratory testing, x-rays, electroencephalography, consultations with other necessary specialists, and electromyographic testing are provided directly by Health+. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations are organized at cooperating medical institutions, most often in the Na Homolce Hospital and in other Prague hospitals and large polyclinics, such as the Affidea specialized facility, the Diagnostic Centre of the Hořovice Hospital and many others. We have established contracts with a number of facilities, the advantage of which is that we receive the results of our clients' examinations very quickly, or even have images available for inspection. If a client wishes to have an examination in a medical facility close to their home, this can be arranged.
What are the treatment options today for neurological diseases affecting the musculoskeletal system? Is it possible to cure these diseases completely or just to limit their development and health consequences?
The treatment of musculoskeletal diseases in functional disorders, but also in patients with root syndromes, is most often outpatient in the form of repeated physiotherapy, for example, using electrotherapy, massage, mobilization techniques and therapeutic physical education on a neurophysiological basis. The patient is instructed on the method of exercise, which they then carry out on their own at home. If difficulties return, physiotherapy can be repeated, or, in the case of more resistant and severe forms, inpatient rehabilitation treatment or balneotherapy is possible, which is also prescribed for patients after neurosurgical and orthopedic spinal surgery. In the case of acute difficulties, analgesics, non-steroidal antirheumatic drugs are prescribed in the short term, sometimes with myorelaxants, or a series of infusions with an analgesic-myorelaxant mixture, sometimes with corticosteroids if needed. In patients with recurrent root irritation limiting movement, where there is no significant finding on structural examination of the spine, or there is an internal contraindication to surgery, we sometimes choose root spraying with 1% Mesocaine and Depo-Medrol or a caudal pressure block as a form of effective therapy. For these procedures, we most often book our clients into the Na Homolce Hospital. For the treatment of musculoskeletal disorders due to CNS diseases, manifesting as limb paresis, whether mono-, hemi-, tri- or quadri-paresis with spasticity, we choose outpatient and especially repeated inpatient rehabilitation care with a focus on relieving spasticity, improving range of movement and function and improving self-sufficiency. This is usually only successful in the early stages of the disease and in milder disabilities; in patients with severe CNS involvement, the effect is only partial. Some spasticities are alleviated after the application of botulinum toxin, the application of which is also indicated in spasm of the facial nerve.
How is neurology developing in the 21st century in relation to musculoskeletal problems?
Neurology is a medical field where, unfortunately, we encounter some diseases leading to movement disorders in which we are only able to alleviate the course, prolong the patient's quality of life and maintain at least partial self-sufficiency, but we are not able to cure the disease completely. However, in recent years, developments in the treatment of multiple sclerosis using immunotherapy, biological therapy or bone marrow replacement, for example, have advanced considerably. There are, however, a number of neurological diseases that we can successfully treat with minimal remaining or cure completely. Whether it is the treatment of certain smaller tumors that we can stereotactically target and irradiate with a gamma knife, or various neurosurgical procedures to remove larger tumors and vascular malformations, also decompressive neurosurgical operations for traumatic intracranial bleeding or trepanations, drainage with vessel ligation, decompressive laminectomy with removal of intervertebral disc prolapse, spinal canal release in case of stenosis, etc. Chemotherapy has also evolved with the use of agents with less adverse effects. And further developments in the field of neurology are constantly taking place.
The movement of the human body is controlled by the central nervous system. Finally, can you explain for the reader how the connection between the nervous and motor systems works?
The definition of human movement, or locomotion, is the ability to move through space using muscular activity and is provided by the musculoskeletal system, which allows movement in a given space and time. The musculoskeletal system consists of the spinal skeleton, bones, joints, ligaments and muscles. The central nervous system (CNS) controls the movement of this apparatus. Correct and smooth movement requires not only intact CNS function, but also intact skeletal muscles, correct posture of the trunk and limbs, without restriction of the range of movement in the joints, without damage to ligaments, cartilage, etc. Diseases of these structures are then also dealt with by disciplines such as orthopedics, rheumatology or physiotherapy. The movement of this entire system is controlled by the central nervous system, by way of the motor pathways descending from the motor part of the gray cortex called the “gyrus precentralis”, which is the starting point of the “pyramidal pathway” leading information to the motor thalamus, then to the motor centers of the brain stem, and even further to the spinal cord. From there, through nerve roots emanating from the spinal cord, which subsequently divide into peripheral nerves transmitting information from the brain to the muscles of the trunk and limbs. The main function of the motor gray cortex is to control fine motor skills and to participate in movement planning. The motor thalamus connects the cerebellum and the basal ganglia to the motor cortex, whose job is to link sensory and motor skills. The cerebellum coordinates purposeful movement, and the basal ganglia processes the movement program – controlling the direction, range, speed and intensity of movement. The motor centers of the brainstem are then responsible for controlling supporting motor skills, controlling the target movement and regulating muscle tension. The human brain receives information about position through sensory ascending pathways that transmit different types of sensation – touch, pressure, heat, cold, pain. These pathways carry information from receptors located in the periphery, for example, in the soles of the feet or in the palms of the hands, which carry information about the position, the nature of the ground on which the person is standing, or the object he or she is touching, in an ascending direction through the peripheral nerves, the posterior spinal roots via the posterior spinal cords and then via the main sensory pathway, the “tractus spinothalamicus”, to the brainstem, the thalamus and then to the somatosensory area of the gray cortex, the “gyrus postcentralis”, which is adjacent to the motor gray cortex. This information is then processed in the gray cortex and commands the periphery to move along the motor pathway (e.g. changing leg position, snatching hand away from a hot object, etc.). In the motor and sensory gray cortex, there are areas responsible for movement and sensitivity in all parts of the body. When the nervous system at each level is damaged by a pathological process, there is impairment of function and clinical neurological manifestation, which depends on the location and extent of the impairment. This is why the clinical picture of some CNS neurological diseases is so diverse. Peripheral nervous system diseases include lesions affecting peripheral nerves and roots, but also muscle diseases or neuromuscular transmission disorders. Diseases of the central nervous system refer to lesions affecting the spinal cord and brain. However, many neurological diseases can affect both nervous systems.
Thank you for the interview.