Immobility

Last updated on 6th August 2013 by Calum Murray

Assessment for All Patients

1. Full neurological examination looking for patterns of abnormality to answer the questions ‘Where is it?’ & ‘What is it?’.
2. Always remember to see what happens when the patient stands up, or is stood up.
3. Routine bloods including potassium, glucose, B12, CK.
4. Look for infection – MSU, chest x-ray and blood culture.
5. Consider Wernicke’s encephalopathy and subdural haematoma – Rx may be life saving.
6. Do not write ‘CNS grossly intact’ which is another way of saying you have not examined the nervous system.
7. Look for one of the following patterns of neurological disorder. 

No Clear Cut Neurological Signs

1. This is common – an elderly patient with pre-existing cognitive impairment gets a UTI or chest infection. Always check white cell count, CRP, SpO₂, blood culture, chest x-ray and MSU. Usually responds to fluids, antibiotics for infection and physiotherapy.
2. Review medicine chart and refer to consultant/pharmacist if there are meds to be stopped.
3. Off legs in a patient with diabetes means hypoglycaemia until proven otherwise.
4. Always consider subdural haematoma if patient fails to respond to above measures. 

Unilateral Extensor Plantars + Other UMN Signs

1. Stroke most likely – Click to View Section on Management of Acute Stroke 
2. Consider subdural haematoma particularly if history of falls and/or dilatation of opposite pupil.

Bilateral Extensor Plantars

1. Possible cord lesion – triad of bilateral extensor plantars, sensory level and urinary retention is cord compression until proven otherwise. Consider cervical cord injury and need for rigid collar/specialist assessment if upper limb signs present.  Click to View Section on Guillain-Barré Syndrome
2. Possible brain stem lesion – look for cranial nerve palsies, ataxia, nystagmus.
3. Longstanding and associated with progressive brain degeneration – multi infarct dementia.

Absent Knee and Ankle Jerks  ± Sensory Loss

1. Guillain-Barre syndrome – flaccid paralysis with absent jerks that may progress to quadriparesis and respiratory insufficiency in 48 hours in 20% of cases. Lumbar/interscapular pain commonly present at onset. May have sensory symptoms but sensory signs are usually slight. Important to check FVC and call anaesthetist if falling or less than 12 ml/kg. Differential includes botulism.
2. Acute phase of cord lesion (see above).
3. Polyneuropathy – if chronic.

Proximal Symmetrical Weakness With Preserved Reflexes and no Sensory Loss

1. This is much more commonly due to a systemic problem eg acute illness or metabolic upset.
2. Neurological diagnoses to consider are polymyositis (check CK), osteomalacia (check Vit D and bone profile) and myasthenia gravis (look for fatigueability).
3. Alcohol can cause acute, subacute and chronic myopathy. 

Ataxia With Normal Sensory and Motor Function

1. Wernicke’s encephalopathy – classically confusion, ophthalmoplegia with diplopia, polyneuropathy and cerebellar ataxia.
2. Consider cerebellar disease eg infarct, haemorrhage, tumour, phenytoin or carbamazepine toxicity, alcoholism.

Pre-existing Neuro Disease, Especially Parkinson’s Disease, Multiple Sclerosis & Myasthenia Gravis

1. Progressive disease – Parkinsons, Multiple sclerosis, myasthenia – Click to View Section on Parkinson’s Disease
2. True exacerbation – Multiple sclerosis – Click to View Section on Multiple Sclerosis
3. Intercurrent illness – Patients sent in with an ‘extension’ to their previous stroke often prove to have an intercurrent infection.