How is neurology different from psychiatry? Intuition or tomography – what is more important? Is it possible to prosthetize lost functions, teach a patient to brush his teeth with paresis and do without assistants if his legs are paralyzed? Answered the questions of the Free Press Head of the Department of Neurology and Medical Rehabilitation of the University Clinic of the International Scientific and Educational Center of Moscow State University, Candidate of Medical Sciences Tatyana Peters (Tvorogova).
“SP”: – Tatyana Vasilievna, when there are so many worries and uncertainties in the world, the coronavirus has not yet left the agenda, can we say that people have begun to turn to neurologists more often?
– The trend when they try to make a specialist in all diseases out of a general practitioner, in my opinion, does not really justify itself. When people regularly have headaches or backaches, there are frequent complaints of increased fatigue, weakness – they still come to a neurologist sooner or later. And there is no feeling that there are fewer such patients – on the contrary. Of course, the pandemic has also contributed. We observe a lot of neurological disorders of various profiles, starting with subjective, functional disorders, ending with major neurology.
“SP”: – Let’s clarify: for what set of problems do patients need the help of a neurologist? You are not confused with psychiatrists, for example?
– It is not at all uncommon when people come to a neurologist with complaints about various states of the psychiatric spectrum: anxiety, panic attacks, unstable emotional state, asthenia, aggression. Of course, we can help such patients, we prescribe, if necessary, antidepressants, antipsychotics, sedatives, but the task of a neurologist is different. He deals with the organic part of the nervous system: it is the brain, spinal cord, spinal nerves. With the help of a competent neurological examination, after assessing the clinical symptoms, the neurologist must determine which part of the nervous system has been affected, prescribe an additional examination, and choose a treatment strategy. The psychiatrist is more engaged in functional changes in the psyche, various disorders. However, at the level of cognitive functions (intelligence, memory, speech, etc.), neurology and psychiatry often overlap. In degenerative diseases of the nervous system, for example, dementia, such patients are monitored by both a neurologist and a psychiatrist, complementing each other. Either a competent specialist in both of these areas takes on this function.
Psychologists have their own important mission. Such specialists rarely have a medical education – more often a pedagogical one. However, for a person with depression, for example, it is more correct not only to prescribe antidepressants, but also to refer him to a psychologist who will figure out his behavior patterns, why he reacts in this way and not differently to certain situations,
“SP”: – Forgot about psychosomatologists – is there such a direction?
– Officially, no. Psychosomatics is a significant part of any disease.
The task of a specialist is to understand which particular function of the body was upset due to stressful situations. This is done by neurologists, and psychiatrists, and psychologists, and therapists – each for his part.
“SP”: – There is an opinion that neurology is one of the most intuitive areas in medicine. Do you trust intuition more or instrumental methods?
– Intuition is professional skills and knowledge multiplied by experience. The neurologist is stronger, the more patients he had. At the same time, great experience does not always correlate with age. Some neurologist can sit in one place all his life, seeing three people a day… It is important to have a mind that is still alive, capable of responding to everything new, the ability to doubt. In my opinion, the distinguishing quality of a good doctor is that he does not try to impose his point of view at any cost, he knows how to listen and hear. Therefore, in diagnostics, we usually use a multidisciplinary approach. After examining the patient by the attending physician, he is examined by the head of the department, consulted by a physiotherapist, a physiotherapist. If the general conclusion of the doctors is then confirmed instrumentally, then cheers, the puzzle has developed, the treatment tactics are clear. But it happens that MRI, for example, does not confirm the primary diagnosis. And then I run to the radiologist: it doesn’t work out for me, let’s review it again! And together with a narrow specialist, we think what and how best to do. Such a non-routine, creative process certainly turns on any doctor, and you get real satisfaction from the solved problem! This happens almost every day at ISEC. Literally about every patient, you can make a scientific report. And we regularly report interesting cases at the director’s scientific conferences of the Center.
“SP”: – What instrumental methods do you have today?
— In our clinic, for example, there is a very strong electroneuromyography service — for patients with various diseases of the peripheral nervous system. A very wide group of diseases is polyneuropathies. They are different and are treated very differently. Some are treated very poorly or not at all – you need to learn to live with them, engage in rehabilitation. And doctors can already treat some polyneuritis and this is a very serious therapy. For example, hormonal pulse therapy, which is also important to do correctly. We can do it.
Our doctors are well versed in plasma-substituting techniques. The most famous is plasmapheresis. Roughly speaking, this is the purification of blood from antibodies. Plasma is “taken” from a person, it is purified – autoantibodies, toxins are removed and returned back. Few places in the clinics take severe neurological patients and give them large-volume plasmapheresis. More often they can replace 300 ml, 500 ml, but we, if necessary, can replace 2.5-3 liters for our patients. We have a chic department of extracorporeal methods in the clinic. Excellent recovery. Excellent therapists. With such a team, we can take really very difficult patients.
We have a lot of patients with various back pains, radiculitis. We can diagnose an intervertebral hernia, or a more serious situation, when there is a pinching of the spinal nerve root or even a pinching of the spinal cord in the canal. Then, in a short time, it is necessary to determine the need for surgical treatment, to involve our neurosurgeons. Or prescribe conservative treatment if the operation is not needed for this patient, and then engage in his rehabilitation. We have excellent specialists, physical therapists who deal with patients. When treatment takes place in such cycles, this is a very correct story.
We treat elderly patients with cognitive impairments. Dementia, Alzheimer’s disease, neurodegenerative diseases, including Parkinson’s disease – all these patients can receive a comprehensive examination from us.
“SP”: – Post-Covid added new patients to you?
– Lots of! We observe various conditions that either manifested themselves after covid, or they are covid-associated. For example, as a result of damage to the brain or spinal cord, or peripheral nerves, patients develop paresis, paralysis, weakness in the limbs. We often receive such semi-paralyzed or paralyzed patients. Various polyneuropathies are also associated with the transferred coronavirus. Elderly patients suffer greatly, who were absolutely compensated before covid, even with initial cognitive impairments. Well, after covid, everything that could manifest itself appeared. Now such a patient has the most severe dementia on his face, he cannot take care of himself. We conduct a comprehensive examination, select therapy.
Coronavirus provokes an exacerbation of smoldering, sluggish processes even in younger patients. There is a surge in covid-related degenerative diseases.
“SP”: – Do you treat strokes?
“Today we have a federal vascular program in our country, it works great. According to the protocol, a patient with a stroke is immediately sent to the primary vascular department at the place of residence or at the place where the trouble happened to him. There he is clearly and correctly examined according to a single algorithm. But for patients who have already undergone primary treatment, we can do additional examinations at our place and already conduct them further.
It is believed that the motor defect in a stroke is restored within a year. Speech – and in two years there may be success. But this does not mean that after the expiration of this period it is not necessary to continue working with a person. Once the deviations that have arisen, over time, they pull new ones with them. Any impairment of mobility causes a range of side effects, ranging from trophic disorders, respiratory, hypostatic, and so on.
The task of rehabilitation is not to sew on new nerves. Often, even if we cannot completely correct the situation, it is possible with the help of rehabilitation to try to adapt the person to his defect. I really believe in neuroneogenesis – a new formation of neurons takes place throughout life, this process can be stimulated. There are various methods of neurostimulation, which we also deal with. It is possible, by stimulating the work of the remaining intact cells, to try to restore the function that has been impaired, or to prosthetize it. Or teach a person to do without it.
In our hospital, for example, we now have a patient whose legs are almost completely paralyzed. However, he is fully self-serving. This is a question of proper rehabilitation, which is based on the correct functional assessment of a person. This is done by ergotherapists, this is a very popular medical specialty. The occupational therapist helps the patient to restore his functional activity. Teaches a person with paresis how to brush their teeth, move around, organize space, tells them where to put handrails, pick up a walker. Works with a specific patient, according to his requests and with his defect. Someone has a task after the disease to get up and go to work, but someone needs to at least walk to the toilet and back.
“SP”: – Probably, personalized medicine – this is the medicine of the future?
– This is what we are striving for. I consider it a great advantage that we are not an emergency hospital, we do not have an assembly line and that infernal flow when there is not even a physical opportunity to give the patient as much attention as he needs. We have both resources and opportunities, and an excellent team of doctors. And this is happiness.