Diseases » Muscle conditions » Causes

Causes of Muscle conditions

Causes of Muscle conditions (Diseases Database):

The follow list shows some of the possible medical causes of Muscle conditions that are listed by the Diseases Database:

• Calpainopathy
• Desmin-related myopathy
• Ethanol
• X-linked myopathy with excessive autophagy
• Myoneurogastrointestinal encephalopathy syndrome
• Walker-Warburg syndrome
• Fukuyama congenital muscular dystrophy
• Vitamin D dependent rickets type 1
• Hypokalaemia
• Very long-chain acyl-CoA dehydrogenase deficiency
• Emery-Dreifuss muscular dystrophy, autosomal dominant
• Proximal renal tubular acidosis
• Rigid spine muscular dystrophy type 1
• Becker muscular dystrophy
• Mitochondrial trifunctional protein deficiency
• Glycogenosis type 2
• Myotubular myopathy, X-linked
• Glycerol kinase deficiency
• Spheroid body myopathy
• Pravastatin
• Prednisolone
• Glutaric acidemia type 2
• Carey-Fineman-Ziter syndrome
• HIV-1 disease
• Emery-Dreifuss muscular dystrophy, X-linked
• Marinesco-Sjogren-Garland syndrome
• Myotubular myopathy
• Ullrich congenital muscular dystrophy
• Carnitine deficiency myopathy
• Atorvastatin
• Emery-Dreifuss muscular dystrophy, autosomal recessive
• Duchenne muscular dystrophy
• Zidovudine
• Barth syndrome
• Glycogenosis type 3
• Inclusion body myopathy, autosomal recessive
• Colchicine
• Muscular dystrophy, late-onset distal
• Nemaline myopathy, autosomal dominant
• Nonaka myopathy
• Bethlem myopathy
• Tel Hashomer camptodactyly syndrome
• Muscle-eye-brain disease
• Carnitine palmitoyltransferase 2 deficiency
• Limb girdle muscular dystrophy
• Central core myopathy
• Chloroquine
• Osteomalacia
• Congenital muscular dystrophy, autosomal recessive
• Rosuvastatin
• Phosphogylcerate mutase 2 deficiency
• Simvastatin
• Amyloidosis
• Short chain acyl-CoA dehydrogenase deficiency
• MERRF
• Triosephosphate isomerase deficiency
• Carnitine deficiency (systemic)
• Welander muscular dystrophy
• Christian syndrome 1
• Hypothyroidism
• Amish nemaline myopathy
• Nemaline myopathy, autosomal recessive

Source: Diseases Database

Muscle conditions Causes: Book Excerpts

• Differential Diagnosis - Muscle Weakness – Distal
• Differential Diagnosis - Muscle Weakness – Proximal
• Medical causes - Muscle flaccidity [Muscle hypotonicity]
• Medical causes - Muscle weakness
• Medical causes - Muscle spasms [Muscle cramps]
• Medical causes - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• Medical causes - Muscle spasticity [Muscle hypertonicity]
• Medical causes - Accessory muscle use
• Medical causes - Muscle atrophy [Muscle wasting]
• Causes and incidence - Muscular dystrophy
• Medical causes - Muscle flaccidity [Muscle hypotonicity]
• Medical causes - Muscle weakness
• Medical causes - Muscle spasms [Muscle cramps]
• Medical causes - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• Medical causes - Muscle spasticity [Muscle hypertonicity]
• Medical causes - Accessory muscle use
• Medical causes - Muscle atrophy [Muscle wasting]
• Differential Overview - Muscle Cramps
• Medical causes - Muscle spasms
• Medical causes - Muscle weakness
• Medical causes - Accessory muscle use
• Medical causes - Muscle spasms
• Medical causes - Muscle spasticity
• Medical causes - Muscle flaccidity [Muscle hypotonicity]
• Medical causes - Muscle weakness
• Medical causes - Muscle spasms [Muscle cramps]
• Medical causes - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• Medical causes - Muscle spasticity [Muscle hypertonicity]
• Medical causes - Accessory muscle use
• Medical causes - Muscle atrophy [Muscle wasting]

Muscle conditions as a symptom:

Conditions listing Muscle conditions as a symptom may also be potential underlying causes of Muscle conditions. Our database lists the following as having Muscle conditions as a symptom of that condition:

• Chitayat-Moore-Del Bigio syndrome
• Complex 1 mitochondrial respiratory chain deficiency
• Cytochrome C Oxidase Deficiency
• Koussef nichols syndrome
• Kousseff-Nichols syndrome
• Mental retardation - myopathy - short stature - endocrine defect
• NADH CoQ reductase, deficiency of
• Powell-Venencie-Gordon syndrome
• Richieri-Costa Da Silva syndrome
• Treft-Sanborn-Carey syndrome

Medical news summaries relating to Muscle conditions:

The following medical news items are relevant to causes of Muscle conditions:

• Baycol should have been pulled from the market sooner
• Statin drugs carry low risk of muscle damage leading to kidney failure
• More news »

Related information on causes of Muscle conditions:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Muscle conditions may be found in:

• Hidden causes of Muscle conditions

Causes of Muscle conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Muscle conditions.

Muscle Weakness – Distal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Guillain-Barré syndrome (GBS)
  –Acute, acquired, or monophasic
  –Ascending weakness and parasthesias
• Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
• Compression neuropathy
  –Trauma
  –Neoplasm (e.g., plexiform neurofibroma in neurofibromatosis type 1)
• Charcot-Marie-Tooth
  –Defect in peripheral myelin protein
  –Causes distal segmental demyelination
  –Manifested by distal muscle atrophy and weakness
• Drug-induced
  –Phenytoin
  –Isoniazid
  –Nitrofurantoin
  –Vincristine
  –Zidovudine
• Spinal muscular atrophy
• Juvenile segmental spinal muscular atrophy
• Miller-Fisher syndrome
  –Clinical triad of ataxia, ophthalmoplegia, and areflexia
• Tick paralysis
• Juvenile amyotrophic lateral sclerosis
• Giant axonal neuropathy
• Vitamin B12 deficiency
• Toxic neuropathy
  –Arsenic
  –Lead
  –Mercury
  –Thallium
  –Glue sniffing
• Uremic neuropathy
• Idiopathic axonal neuropathy
• Hereditary distal myopathy
• Inclusion body myopathy
• Rheumatoid arthritis
• Refsum disease
• Metachromatic leukodystrophy
• Krabbe disease
• Cockayne syndrome
• Conversion reaction
  –Usually fluctuating and unpredictable

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Muscle Weakness – Proximal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Duchenne and Becker muscular dystrophy
• Spinal muscular atrophy
• Spinal cord disorders
  –Trauma
  –Myelitis
  –Neoplasm
  –AVM
  –Hemorrhage
  –Tansverse myelitis
• Limb-girdle myasthenia
• Dermatomyositis
• Congenital myopathies
  –Central core disease
  –Myotubular
  –Nemaline (rod)
  –Congenital fiber-type disproportion
• Facioscapulohumeral syndrome
• Limb-girdle muscular dystrophies
• Glycogen storage myopathies
• Endocrine myopathies
  –Hypo- and hyperthyroidism
  –Hyperparathyroidism
  –Adrenalism
• Polymyositis
• GM2 gangliosidosis
• Pompe disease
  –Glycogen storage disease type II
  –Acid maltase deficiency
• McArdle disease
• Carnitine deficiency
• Fatty acid oxidation defects
• Mitochondrial disorders
• Steroid-induced myopathy
• Slow channel syndrome
• Toxins
  –Organophosphates
  –Aminoglycosides
  –Tetrodotoxin (pufferfish)
• Conversion reaction
• Myasthenia gravis

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Muscle flaccidity [Muscle hypotonicity]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Amyotrophic lateral sclerosis

Progressive muscle weakness and paralysis are accompanied by generalized flaccidity. Typically, these effects begin in one hand, spread to the arm, and then develop in the other hand and arm. Eventually, they spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle cramps and coarse fasciculations, hyperactive DTRs, slight leg muscle spasticity, dysphagia, dysarthria, excessive drooling, and depression.

Brain lesions

Frontal and parietal lobe lesions may cause contralateral flaccidity, weakness or paralysis and, eventually, spasticity and possibly contractures. Other findings include hyperactive DTRs, a positive Babinski’s sign, loss of proprioception, stereognosis, graphesthesia, anesthesia, and thermanesthesia.

Guillain-Barré syndrome

Guillain-Barré syndrome causes muscle flaccidity. Progression is typically symmetrical and ascending, moving from the feet to the arms and facial nerves within 24 to 72 hours of its onset. Associated findings include sensory loss or paresthesia, absent DTRs, tachycardia (or, less commonly, bradycardia), fluctuating hypertension and orthostatic hypotension, diaphoresis, incontinence, dysphagia, dysarthria, hypernasality, and facial diplegia. Weakness may progress to total motor paralysis and respiratory failure.

Huntington’s disease

Besides flaccidity, progressive mental status changes up to and including dementia and choreiform movements are major symptoms. Others include poor balance, hesitant or explosive speech, dysphagia, impaired respirations, and incontinence.

Muscle disease

Muscle weakness and flaccidity are features of myopathies and muscular dystrophies.

Peripheral nerve trauma

Flaccidity, paralysis, and loss of sensation and reflexes in the innervated area can occur.

Peripheral neuropathy

Flaccidity usually occurs in the legs as a result of chronic progressive muscle weakness and paralysis. It may also cause mild to sharp burning pain, glossy red skin, anhidrosis, and a loss of vibration sensation. Paresthesia, hyperesthesia, or anesthesia may affect the hands and feet. DTRs may be hypoactive or absent.

Seizure disorder

Brief periods of syncope and generalized flaccidity commonly follow a generalized tonic-clonic seizure.

Spinal cord injury

Spinal shock can result in acute muscle flaccidity or spasticity below the level of injury. Associated signs and symptoms also occur below the level of injury and may include paralysis; absent DTRs; analgesia; thermanesthesia; loss of proprioception and vibration, touch, and pressure sensation; and anhidrosis (usually unilateral). Hypotension, bowel and bladder dysfunction, and impotence or priapism may also occur. Injury in the C1 to C5 region can produce respiratory paralysis and bradycardia.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Muscle weakness: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Amyotrophic lateral sclerosis (ALS)

ALS typically begins with muscle weakness and atrophy in one hand that rapidly spread to the arm and then to the other hand and arm. Eventually, these effects spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency.

Anemia

Varying degrees of muscle weakness and fatigue are exacerbated by exertion and temporarily relieved by rest. Other signs and symptoms include pallor, tachycardia, paresthesia, and bleeding tendencies.

Brain tumor

Signs and symptoms of muscle weakness vary with the location and size of the tumor. Associated findings include a headache, vomiting, diplopia, decreased visual acuity, a decreased level of consciousness (LOC), pupillary changes, decreased motor strength, hemiparesis, hemiplegia, diminished sensations, ataxia, seizures, and behavioral changes.

Guillain-Barré syndrome

Rapidly progressive, symmetrical weakness and pain ascends from the feet to the arms and facial nerves and may progress to total motor paralysis and respiratory failure. Associated findings include sensory loss or paresthesia, muscle flaccidity, loss of DTRs, tachycardia or bradycardia, fluctuating hypertension and orthostatic hypotension, diaphoresis, bowel and bladder incontinence, facial diplegia, dysphagia, dysarthria, and hypernasality.

Herniated disk

Pressure on nerve roots leads to muscle weakness, disuse and, ultimately, atrophy. The primary symptom is severe low back pain, possibly radiating to the buttocks, legs, and feet — usually on one side. Diminished reflexes and sensory changes may also occur.

Hypercortisolism

Hypercortisolism may cause limb weakness and eventually atrophy. Related cushingoid features include buffalo hump, moon face, truncal obesity, purple striae, thin skin, acne, elevated blood pressure, fatigue, hyperpigmentation, easy bruising, poor wound healing, and diaphoresis. The male patient may be impotent; the female patient may exhibit hirsutism and menstrual irregularities.

Myasthenia gravis

Gradually progressive skeletal muscle weakness and fatigue are the cardinal symptoms of myasthenia gravis. Typically, weakness is mild upon awakening, but worsens during the day. Early signs include weak eye closure, ptosis, and diplopia; blank, masklike facies; difficulty chewing and swallowing; nasal regurgitation of fluid with hypernasality; and a hanging jaw and bobbing head. Respiratory muscle involvement may eventually lead to respiratory failure.

Osteoarthritis

Osteoarthritis is a chronic disorder that causes progressive muscle disuse and weakness that lead to atrophy.

Parkinson’s disease

Muscle weakness accompanies rigidity in Parkinson’s disease, a degenerative disorder. Related findings include a unilateral pill-rolling tremor, a propulsive gait, dysarthria, bradykinesia, drooling, dysphagia, masklike facies, and a high-pitched, monotone voice.

Peripheral nerve trauma

Prolonged pressure on or injury to a peripheral nerve causes muscle weakness and atrophy. Other findings include paresthesia or sensory loss, pain, and loss of reflexes supplied by the damaged nerve.

Potassium imbalance

With hypokalemia, temporary generalized muscle weakness may be accompanied by nausea, vomiting, diarrhea, decreased mentation, leg cramps, diminished reflexes, malaise, polyuria, dizziness, hypotension, and arrhythmias.

With hyperkalemia, weakness may progress to flaccid paralysis accompanied by irritability and confusion, hyperreflexia, paresthesia or anesthesia, oliguria, anorexia, nausea, diarrhea, abdominal cramps, tachycardia or bradycardia, and arrhythmias.

Rhabdomyolysis

Signs and symptoms include muscle weakness or pain, a fever, nausea, vomiting, malaise, and dark urine. Acute renal failure, due to renal structure obstruction and injury from the kidneys’attempt to filter myoglobin from the bloodstream, is a common complication.

Rheumatoid arthritis

With rheumatoid arthritis, symmetrical muscle weakness may accompany increased warmth, swelling, and tenderness in involved joints; pain; and stiffness, restricting motion.

Seizure disorder

Temporary generalized muscle weakness may occur after a generalized tonic-clonic seizure; other postictal findings include a headache, muscle soreness, and profound fatigue.

Spinal trauma and disease

Trauma can cause severe muscle weakness, leading to flaccidity or spasticity and, eventually, paralysis. Infection, tumor, and cervical spondylosis or stenosis can also cause muscle weakness.

Stroke

Depending on the site and extent of damage, a stroke may produce contralateral or bilateral weakness of the arms, legs, face, and tongue, possibly progressing to hemiplegia and atrophy. Associated effects include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, vision disturbances, an altered LOC, amnesia and poor judgment, personality changes, bowel and bladder dysfunction, a headache, vomiting, and seizures.

Other causes

Drugs

Generalized muscle weakness can result from prolonged corticosteroid use, digoxin, and excessive doses of dantrolene. Aminoglycoside antibiotics may worsen weakness in patients with myasthenia gravis.

Immobility

Immobilization in a cast, a splint, or traction can lead to muscle weakness in the involved extremity; prolonged bed rest or inactivity results in generalized muscle weakness.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Muscle spasms [Muscle cramps]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Amyotrophic lateral sclerosis (ALS)

With ALS, muscle spasms may accompany progressive muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then spread to the other hand and arm. Eventually, muscle weakness and atrophy affect the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity progressing to spasticity, coarse fasciculations, hyperactive deep tendon reflexes (DTRs), dysphagia, impaired speech, excessive drooling, and depression.

Arterial occlusive disease

Arterial occlusion typically produces spasms and intermittent claudication in the leg, with residual pain. Associated findings are usually localized to the legs and feet and include loss of peripheral pulses, pallor or cyanosis, decreased sensation, hair loss, dry or scaling skin, edema, and ulcerations.

Cholera

Muscle spasms, severe water and electrolyte loss, thirst, weakness, decreased skin turgor, oliguria, tachycardia, and hypotension occur along with abrupt watery diarrhea and vomiting.

Dehydration

Sodium loss may produce limb and abdominal cramps. Other findings include a slight fever, decreased skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, muscle twitching, seizures, nausea, vomiting, and oliguria.

Hypocalcemia

The classic feature is tetany — a syndrome of muscle cramps and twitching, carpopedal and facial muscle spasms, and seizures, possibly with stridor. Chvostek’s and Trousseau’s signs may be elicited. Related findings include paresthesia of the lips, fingers, and toes; choreiform movements; hyperactive DTRs; fatigue; palpitations; and cardiac arrhythmias.

Muscle trauma

Excessive muscle strain may cause mild to severe spasms. The injured area may be painful, swollen, reddened, or warm.

Respiratory alkalosis

The acute onset of muscle spasms may be accompanied by twitching and weakness, carpopedal spasms, circumoral and peripheral paresthesia, vertigo, syncope, pallor, and extreme anxiety. With severe alkalosis, cardiac arrhythmias may occur.

Spinal injury or disease

Muscle spasms can result from spinal injury, such as a cervical extension injury or spinous process fracture, or from spinal disease such as infection.

Other causes

Drugs

Common spasm-producing drugs include diuretics, corticosteroids, and estrogens.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm (dissecting). Mild to moderate abdominal rigidity occurs with abdominal aortic aneurysm, a life-threatening disorder. Typically, it’s accompanied by constant upper abdominal pain that may radiate to the lower back. The pain may worsen when the patient lies down and may be relieved when he leans forward or sits up. Before rupture, the aneurysm may produce a pulsating mass in the epigastrium, accompanied by a systolic bruit over the aorta. However, the mass stops pulsating after rupture. Associated signs and symptoms include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, and mild to moderate tenderness with guarding. Significant blood loss causes signs of shock, such as tachycardia, tachypnea, and cool, clammy skin.

❑ Insect toxins. Insect stings and bites, especially black widow spider bites, release toxins that can produce generalized, cramping abdominal pain, usually accompanied by rigidity. These toxins may also cause a low-grade fever, nausea, vomiting, tremors, and burning sensations in the hands and feet. Some patients develop increased salivation, hypertension, paresis, and hyperactive reflexes. Children commonly are restless, have an expiratory grunt, and keep their legs flexed.

❑ Mesenteric artery ischemia. A life-threatening disorder, mesenteric artery ischemia is characterized by 2 to 3 days of persistent, low-grade abdominal pain and diarrhea leading to sudden, severe abdominal pain and rigidity. Rigidity occurs in the central or periumbilical region and is accompanied by severe abdominal tenderness, fever, and signs of shock, such as tachycardia and hypotension. Other findings may include vomiting, anorexia, and diarrhea or constipation. Always suspect this disorder in patients older than age 50 who have a history of heart failure, arrhythmia, cardiovascular infarct, or hypotension.

❑ Peritonitis. Depending on the cause of peritonitis, abdominal rigidity may be localized or generalized. For example, if an inflamed appendix causes local peritonitis, rigidity may be localized in the right lower quadrant. If a perforated ulcer causes widespread peritonitis, rigidity may be generalized and, in severe cases, boardlike.

Peritonitis also causes sudden and severe abdominal pain that can be localized or generalized. In addition, it can produce abdominal tenderness and distention, rebound tenderness, guarding, hyperalgesia, hypoactive or absent bowel sounds, nausea, and vomiting. Usually, the patient also displays fever, chills, tachycardia, tachypnea, and hypotension.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Muscle spasticity [Muscle hypertonicity]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Amyotrophic lateral sclerosis (ALS)

ALS commonly produces spasticity, spasms, coarse fasciculations, hyperactive deep tendon reflexes (DTRs), and a positive Babinski’s sign. Earlier effects include progressive muscle weakness and flaccidity that typically begin in the hands and arms and eventually spread to the trunk, neck, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include dysphagia, dysarthria, excessive drooling, and depression.

Epidural hemorrhage

With epidural hemorrhage, bilateral limb spasticity is a late and ominous sign. Other findings include a momentary loss of consciousness after head trauma, followed by a lucid interval and then a rapid deterioration in the level of consciousness (LOC). The patient may also develop unilateral hemiparesis or hemiplegia; seizures; fixed, dilated pupils; a high fever; a decreased and bounding pulse; a widened pulse pressure; elevated blood pressure; an irregular respiratory pattern; and decerebrate posture. A positive Babinski’s sign can be elicited.

Spinal cord injury

Spasticity commonly results from cervical and high thoracic spinal cord injury, especially from incomplete lesions. Spastic paralysis in the affected limbs follows initial flaccid paralysis; typically, spasticity and muscle atrophy increase for up to 1¼ to 2 years after the injury, and then gradually regress to flaccidity. Associated signs and symptoms vary with the level of injury, but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive DTRs, a positive Babinski’s sign, sexual dysfunction, priapism, hypotension, anhidrosis, and bradycardia.

Stroke

Spastic paralysis may develop on the affected side following the acute stage of a stroke. Associated findings vary with the site and extent of vascular damage and may include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, vision disturbances, an altered LOC, amnesia and poor judgment, personality changes, emotional lability, bowel and bladder dysfunction, a headache, vomiting, and seizures.

Tetanus

Tetanus is a rare, life-threatening disease that produces varying degrees of spasticity. In generalized tetanus — the most common form — early signs and symptoms include painful jaw and neck stiffness, trismus, a headache, irritability, restlessness, a low-grade fever with chills, tachycardia, diaphoresis, and hyperactive DTRs. As the disease progresses, painful involuntary spasms may spread and cause boardlike abdominal rigidity, opisthotonos, and a characteristic grotesque grin known as risus sardonicus. Reflex spasms may occur in any muscle group with the slightest stimulus. Glottal, pharyngeal, or respiratory muscle involvement can cause death by asphyxia or cardiac failure.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Accessory muscle use: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Acute respiratory distress syndrome (ARDS). In ARDS, a life-threatening disorder, accessory muscle use increases in response to hypoxia. It’s accompanied by intercostal, supracostal, and sternal retractions on inspiration and by grunting on expiration. Other characteristics include tachypnea, dyspnea, diaphoresis, diffuse crackles, and a cough with pink, frothy sputum. Worsening hypoxia produces anxiety, tachycardia, and mental sluggishness.

❑ Airway obstruction. Acute upper airway obstruction can be life-threatening — fortunately, most obstructions are subacute or chronic. Typically, this disorder increases accessory muscle use. Its most telling sign, however, is inspiratory stridor. Associated signs and symptoms include dyspnea, tachypnea, gasping, wheezing, coughing, drooling, intercostal retractions, cyanosis, and tachycardia.

❑ Amyotrophic lateral sclerosis. Typically, this progressive motor neuron disorder affects the diaphragm more than the accessory muscles. As a result, increased accessory muscle use is characteristic. Other signs and symptoms include fasciculations, muscle atrophy and weakness, spasticity, bilateral Babinski’s reflex, and hyperactive deep tendon reflexes. Incoordination makes carrying out routine activities difficult for the patient. Associated signs and symptoms include impaired speech, difficulty chewing or swallowing and breathing, urinary frequency and urgency and, occasionally, choking and excessive drooling. ( Note: Other neuromuscular disorders may produce similar signs and symptoms.) Although the patient’s mental status remains intact, his poor prognosis may cause periodic depression.

❑ Asthma. During acute asthma attacks, the patient usually displays increased accessory muscle use. Accompanying it are severe dyspnea, tachypnea, wheezing, a productive cough, nasal flaring, and cyanosis. Auscultation reveals faint or possibly absent breath sounds, musical crackles, and rhonchi. Other signs and symptoms include tachycardia, diaphoresis, and apprehension caused by air hunger. Chronic asthma may also cause barrel chest.

❑ Chronic bronchitis. With chronic bronchitis, a form of COPD, increased accessory muscle use may be chronic and is preceded by a productive cough and exertional dyspnea. Chronic bronchitis is accompanied by wheezing, basal crackles, tachypnea, jugular vein distention, prolonged expiration, barrel chest, and clubbing. Cyanosis and weight gain from edema account for the characteristic label of “blue bloater.” A low-grade fever may occur with secondary infection.

❑ Emphysema. Increased accessory muscle use occurs with progressive exertional dyspnea and a minimally productive cough in this form of COPD. Sometimes called a pink puffer, the patient will display pursed-lip breathing and tachypnea. Associated signs and symptoms include peripheral cyanosis, anorexia, weight loss, malaise, barrel chest, and clubbing. Auscultation reveals distant heart sounds; percussion detects hyperresonance.

❑ Pneumonia. Bacterial pneumonia usually produces increasedaccessory muscle use. Initially, this infection produces a sudden high fever with chills. Its associated signs and symptoms include chest pain, a productive cough, dyspnea, tachypnea, tachycardia, expiratory grunting, cyanosis, diaphoresis, and fine crackles.

❑ Pulmonary edema. With acute pulmonary edema, increased accessory muscle use is accompanied by dyspnea, tachypnea, orthopnea, crepitant crackles, wheezing, and a cough with pink, frothy sputum. Other findings include restlessness, tachycardia, ventricular gallop, and cool, clammy, cyanotic skin.

❑ Pulmonary embolism. Although signs and symptoms vary with the size, number, and location of the emboli, pulmonary embolism is a life-threatening disorder that may cause increased accessory muscle use. Typically, it produces dyspnea and tachypnea that may be accompanied by pleuritic or substernal chest pain. Other signs and symptoms include restlessness, anxiety, tachycardia, a productive cough, a low-grade fever and, with a large embolus, hemoptysis, cyanosis, syncope, jugular vein distention, scattered crackles, and focal wheezing.

❑ Spinal cord injury. Increased accessory muscle use may occur, depending on the location and severity of the injury. An injury below Ll typically doesn’t affect the diaphragm or accessory muscles, whereas an injury between C3 and C5 affects the upper respiratory muscles and diaphragm, causing increased accessory muscle use.

Associated signs and symptoms of spinal cord injury include unilateral or bilateral Babinski’s reflex, hyperactive deep tendon reflexes, spasticity, and variable or total loss of pain and temperature sensation, proprioception, and motor function. Horner’s syndrome (unilateral ptosis, pupillary constriction, facial anhidrosis) may occur with lower cervical cord injury.

❑ Thoracic injury. Increased accessory muscle use may occur, depending on the type and extent of injury. Associated signs and symptoms of this potentially life-threatening injury include an obvious chest wound or bruising, chest pain, dyspnea, cyanosis, and agitation. Signs of shock, such as tachycardia and hypotension, occur with significant blood loss.

Other causes

❑ Diagnostic tests and treatments. Pulmonary function tests (PFTs), incentive spirometry, and intermittent positive-pressure breathing can increase accessory muscle use.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Muscle atrophy [Muscle wasting]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Amyotrophic lateral sclerosis (ALS)

Initial symptoms of ALS include muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then develop in the other hand and arm. Eventually, weakness and atrophy spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity, fasciculations, hyperactive DTRs, slight leg muscle spasticity, dysphagia, impaired speech, excessive drooling, and depression.

Burns

Fibrous scar tissue formation, pain, and loss of serum proteins from severe burns can limit muscle movement, resulting in atrophy.

Hypothyroidism

Reversible weakness and atrophy of proximal limb muscles may occur in hypothyroidism. Associated findings commonly include muscle cramps and stiffness; cold intolerance; weight gain despite anorexia; mental dullness; dry, pale, cool, doughy skin; puffy face, hands, and feet; and bradycardia.

Meniscal tear

Quadriceps muscle atrophy, resulting from prolonged knee immobility and muscle weakness, is a classic sign of meniscal tear, a traumatic disorder.

Multiple sclerosis

Multiple sclerosis is a degenerative disease that may produce arm and leg atrophy as a result of chronic progressive weakness; spasticity and contractures may also develop. Associated signs and symptoms typically wax and wane and include diplopia and blurred vision, nystagmus, hyperactive DTRs, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, an ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Osteoarthritis

Osteoarthritis is a chronic disorder that eventually causes atrophy proximal to involved joints as a result of progressive weakness and disuse. Other late signs and symptoms include bony joint deformities, such as Heberden’s nodes on the distal interphalangeal joints, Bouchard’s nodes on the proximal interphalangeal joints, crepitus and fluid accumulation, and contractures.

Parkinson’s disease

With Parkinson’s disease, muscle rigidity, weakness, and disuse may produce muscle atrophy. The patient may exhibit insidious resting tremors that usually begin in the fingers (pill-rolling tremor), worsen with stress, and ease with purposeful movement and sleep. He may also develop bradykinesia; a characteristic propulsive gait; a high-pitched, monotone voice; masklike facies; drooling; dysphagia; dysarthria; and, occasionally, oculogyric crisis or blepharospasm.

Peripheral neuropathy

With peripheral neuropathy, muscle weakness progresses slowly to flaccid paralysis and eventually atrophy. Distal extremity muscles are generally affected first. Associated findings include a loss of vibration sense; paresthesia, hyperesthesia, or anesthesia in the hands and feet; mild to sharp, burning pain; anhidrosis; glossy red skin; and diminished or absent DTRs.

Protein deficiency

If chronic, protein deficiency may lead to muscle weakness and atrophy. Other findings include chronic fatigue, apathy, anorexia, dry skin, peripheral edema, and dull, sparse, dry hair.

Rheumatoid arthritis

Muscle atrophy occurs in the late stages of rheumatoid arthritis as joint pain and stiffness decrease range of motion (ROM) and discourage muscle use.

Spinal cord injury

Trauma to the spinal cord can produce severe muscle weakness and flaccid, then spastic, paralysis, eventually leading to atrophy. Other signs and symptoms depend on the level of injury, but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive DTRs, a positive Babinski’s reflex, sexual dysfunction, priapism, hypotension, and anhidrosis (usually unilateral).

Other causes

Drugs

Prolonged steroid therapy interferes with muscle metabolism and leads to atrophy, most prominently in the limbs.

Immobility

Prolonged immobilization from bed rest, casts, splints, or traction may cause muscle weakness and atrophy.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Muscular dystrophy: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Muscular dystrophy is caused by various genetic mechanisms. Duchenne’s and Becker’s muscular dystrophies are X-linked recessive disorders. Both result from defects in the gene coding for the muscle protein dystrophin; the gene has been mapped to the Xp21 locus.

The incidence muscular dystrophy is about 1 in 651,450 persons in the United States. Duchenne’s and Becker’s muscular dystrophies affect males almost exclusively.

Facioscapulohumeral dystrophy is an autosomal dominant disorder. Limb-girdle dystrophy is usually autosomal recessive. These two types affect both sexes about equally.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Muscle flaccidity [Muscle hypotonicity]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyotrophic lateral sclerosis

Progressive muscle weakness and paralysis are accompanied by generalized flaccidity. Typically, these effects begin in one hand, spread to the arm, and then develop in the other hand and arm. Eventually, they spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle cramps and coarse fasciculations, hyperactive deep tendon reflexes, slight leg muscle spasticity, dysphagia, dysarthria, excessive drooling, and depression.

Brain lesions

Frontal and parietal lobe lesions may cause contralateral flaccidity, weakness or paralysis, and eventually, spasticity and possibly contractures. Other findings include hyperactive deep tendon reflexes, positive Babinski’s sign, loss of proprioception, stereognosis, graphesthesia, anesthesia, and thermanesthesia.

Cerebellar disease

With this disease, generalized muscle flaccidity or hypotonia is accompanied by ataxia, dysmetria, intention tremor, slight muscle weakness, fatigue, and dysarthria.

Guillain-Barré syndrome

This disorder causes muscle flaccidity. Progression is typically symmetrical and ascending, moving from the feet to the arms and facial nerves within 24 to 72 hours of onset. Associated findings include sensory loss or paresthesia, absent deep tendon reflexes, tachycardia (or, less often, bradycardia), fluctuating hypertension and orthostatic hypotension, diaphoresis, incontinence, dysphagia, dysarthria, hypernasality, and facial diplegia. Weakness may progress to total motor paralysis and respiratory failure.

Huntington’s disease

Besides flaccidity, progressive mental status changes up to and including dementia and choreiform movements are major symptoms. Others include poor balance, hesitant or explosive speech, dysphagia, impaired respirations, and incontinence.

Muscle disease

Muscle weakness and flaccidity are features of myopathies and muscular dystrophies.

Peripheral nerve trauma

Flaccidity, paralysis, and loss of sensation and reflexes in the innervated area can occur.

Peripheral neuropathy

Flaccidity usually occurs in the legs as a result of chronic progressive muscle weakness and paralysis. It may also cause mild-to-sharp burning pain, glossy red skin, anhidrosis, and loss of vibration sensation. Paresthesia, hyperesthesia, or anesthesia may affect the hands and feet. Deep tendon reflexes may be hypoactive or absent.

Poliomyelitis

Damage to the anterior horn cells in the spinal cord and brain stem causes flaccid weakness and loss of reflexes. The large, proximal muscles of the limbs are most commonly affected.

Seizure disorder

Brief periods of syncope and generalized flaccidity commonly follow a generalized tonic-clonic seizure.

Spinal cord injury

Spinal shock can result in acute muscle flaccidity or spasticity below the level of injury. Associated signs and symptoms also occur below the level of injury and may include paralysis; absent deep tendon reflexes; analgesia; thermanesthesia; loss of proprioception and vibration, touch, and pressure sensation; and anhidrosis (usually unilateral). Hypotension, bowel and bladder dysfunction, and impotence or priapism may also occur. Injury in the C1 to C5 region can produce respiratory paralysis and bradycardia.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Muscle weakness: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyotrophic lateral sclerosis

This disorder typically begins with muscle weakness and atrophy in one hand that rapidly spread to the arm and then to the other hand and arm. Eventually, these effects spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency.

Anemia

Varying degrees of muscle weakness and fatigue are exacerbated by exertion and temporarily relieved by rest. Other signs and symptoms include pallor, tachycardia, paresthesia, and bleeding tendencies.

Brain tumor

Signs and symptoms of muscle weakness vary with the location and size of the tumor. Associated findings include headache, vomiting, diplopia, decreased visual acuity, decreased level of consciousness, pupillary changes, decreased motor strength, hemiparesis, hemiplegia, diminished sensations, ataxia, seizures, and behavioral changes.

Guillain-Barré syndrome

Rapidly progressive, symmetrical weakness and pain ascends from the feet to the arms and facial nerves and may progress to total motor paralysis and respiratory failure. Associated findings include sensory loss or paresthesia, muscle flaccidity, loss of deep tendon reflexes, tachycardia or bradycardia, fluctuating hypertension and orthostatic hypotension, diaphoresis, bowel and bladder incontinence, facial diplegia, dysphagia, dysarthria, and hypernasality.

Head trauma

Severe head injury can cause varying degrees of muscle weakness. Other findings include decreased level of consciousness, otorrhea or rhinorrhea, raccoon eyes and Battle’s sign, sensory disturbances, and signs of increased intracranial pressure.

Herniated disk

Pressure on nerve roots leads to muscle weakness, disuse, and ultimately, atrophy. The primary symptom is severe low back pain, possibly radiating to the buttocks, legs, and feet—usually on one side. Diminished reflexes and sensory changes may also occur.

Hodgkin’s lymphoma

Muscle weakness may accompany the classic sign of painless, progressive lymphadenopathy. Other findings include paresthesia, fatigue, and weight loss.

Hypercortisolism

This disorder may cause limb weakness and eventually atrophy. Related cushingoid features include buffalo hump, moon face, truncal obesity, purple striae, thin skin, acne, elevated blood pressure, fatigue, hyperpigmentation, easy bruising, poor wound healing, and diaphoresis. The male patient may be impotent; the female patient may exhibit hirsutism and menstrual irregularities.

Hypothyroidism

Reversible weakness and atrophy of proximal limb muscles may occur in hypothyroidism. Accompanying findings commonly include muscle cramps; cold intolerance; weight gain despite anorexia; mental dullness; dry, pale, doughy skin; puffy face, hands, and feet; impaired hearing and balance; and bradycardia.

Multiple sclerosis

Muscle weakness in one or more limbs may progress to atrophy, spasticity, and contractures. Other findings typically wax and wane and may include diplopia and blurred vision, vision loss, nystagmus, hyperactive deep tendon reflexes, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Myasthenia gravis

Gradually progressive skeletal muscle weakness and fatigue are the cardinal symptoms of this disorder. Typically, weakness is mild upon awakening but worsens during the day. Early signs include weak eye closure, ptosis, and diplopia; a blank, masklike facies; difficulty chewing and swallowing; nasal regurgitation of fluid with hypernasality; and a hanging jaw and bobbing head. Respiratory muscle involvement may eventually lead to respiratory failure.

Osteoarthritis

This chronic disorder causes progressive muscle disuse and weakness that lead to atrophy.

Paget’s disease

As this disease progresses, muscle weakness or paralysis may develop, along with paresthesia and pain. The patient may also have bowed tibias, frequent fractures, and kyphosis.

Parkinson’s disease

Muscle weakness accompanies rigidity in this degenerative disorder. Related findings include a unilateral pill-rolling tremor, propulsive gait, dysarthria, bradykinesia, drooling, dysphagia, masklike facies, and a high-pitched, monotonic voice.

Peripheral nerve trauma

Prolonged pressure on or injury to a peripheral nerve causes muscle weakness and atrophy. Other findings include paresthesia or sensory loss, pain, and loss of reflexes supplied by the damaged nerve.

Peripheral neuropathy

With this disorder, muscle weakness progresses slowly to flaccid paralysis, generally affecting distal extremities first. It may be accompanied by loss of vibration sense; paresthesia, hyperesthesia, or anesthesia in the hands and feet; hypoactive or absent deep tendon reflexes; mild-to-sharp burning pain; anhidrosis; and glossy red skin.

Poliomyelitis

Rapidly developing asymmetrical muscle weakness, progressing to flaccid paralysis, occurs with paralytic poliomyelitis. Associated signs and symptoms include moderate fever, headache, vomiting, lethargy, irritability, and widespread pain. As the disorder progresses, it may produce loss of superficial and deep reflexes, paresthesia, hyperalgesia, urine retention, constipation, abdominal distention, nuchal rigidity, and Hoyne’s, Kernig’s, and Brudzinski’s signs. Bulbar paralytic poliomyelitis produces symptoms of encephalitis, along with facial weakness, dysphasia, dysphagia, and respiratory abnormalities.

Polymyositis

This disorder produces insidious or acute onset of symmetrical limb and trunk muscle weakness and tenderness. Weakness may progress to facial, neck, pharyngeal, and laryngeal muscles. Associated findings include hypoactive deep tendon reflexes, dysphagia, and dysphonia.

Potassium imbalance

With hypokalemia, temporary generalized muscle weakness may be accompanied by nausea, vomiting, diarrhea, decreased mentation, leg cramps, diminished reflexes, malaise, polyuria, dizziness, hypotension, and arrhythmias.

With hyperkalemia, weakness may progress to flaccid paralysis accompanied by irritability and confusion, hyperreflexia, paresthesia or anesthesia, oliguria, anorexia, nausea, diarrhea, abdominal cramps, tachycardia or bradycardia, and arrhythmias.

Protein deficiency

Prolonged protein deficiency may lead to muscle weakness and wasting, chronic fatigue, apathy, anorexia, lethargy, dry skin, and dull, sparse, dry hair.

Rhabdomyolysis

Signs and symptoms include muscle weakness or pain, fever, nausea, vomiting, malaise, and dark urine. Acute renal failure, due to renal structure obstruction and injury from the kidneys’attempt to filter the myoglobin from the bloodstream, is a common complication.

Rheumatoid arthritis

With this disease, symmetric muscle weakness may accompany increased warmth, swelling, and tenderness in involved joints; pain; and stiffness, restricting motion.

Seizure disorder

Temporary generalized muscle weakness may occur after a generalized tonic-clonic seizure; other postictal findings include headache, muscle soreness, and profound fatigue.

Spinal trauma and disease

Trauma can cause severe muscle weakness, leading to flaccidity or spasticity and, eventually, paralysis. Infection, tumor, and cervical spondylosis or stenosis can also cause muscle weakness.

Stroke

Depending on the site and extent of damage, a stroke may produce contralateral or bilateral weakness of the arms, legs, face, and tongue, possibly progressing to hemiplegia and atrophy. Associated effects include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, visual disturbance, altered level of consciousness, amnesia and poor judgment, personality changes, bowel and bladder dysfunction, headache, vomiting, and seizures.

Thyrotoxicosis

This disorder may produce insidious, generalized muscle weakness and atrophy. Other effects include anxiety, fatigue, heat intolerance, diaphoresis, tremors, tachycardia, palpitations, ventricular or atrial gallop, dyspnea, weight loss, an enlarged thyroid, and warm, flushed skin. Exophthalmos may be present.

Other causes

Drugs

Generalized muscle weakness can result from prolonged corticosteroid use, digoxin, and excessive doses of dantrolene sodium. Aminoglycoside antibiotics may worsen weakness in patients with myasthenia gravis.

Immobility

Immobilization in a cast, a splint, or traction can lead to muscle weakness in the involved extremity; prolonged bed rest or inactivity results in generalized muscle weakness.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Muscle spasms [Muscle cramps]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyotrophic lateral sclerosis

With this disorder, muscle spasms may accompany progressive muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then spread to the other hand and arm. Eventually, muscle weakness and atrophy affect the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity progressing to spasticity, coarse fasciculations, hyperactive deep tendon reflexes, dysphagia, impaired speech, excessive drooling, and depression.

Arterial occlusive disease

Arterial occlusion typically produces spasms and intermittent claudication in the leg, with residual pain. Associated findings are usually localized to the legs and feet and include loss of peripheral pulses, pallor or cyanosis, decreased sensation, hair loss, dry or scaling skin, edema, and ulcerations.

Cholera

Muscle spasms, severe water and electrolyte loss, thirst, weakness, decreased skin turgor, oliguria, tachycardia, and hypotension occur along with abrupt watery diarrhea and vomiting.

Dehydration

Sodium loss may produce limb and abdominal cramps. Other findings include a slight fever, decreased skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, muscle twitching, seizures, nausea, vomiting, and oliguria.

Fracture

Localized spasms and pain are mild if the fracture is nondisplaced, intense if it’s severely displaced. Other findings include swelling, limited mobility and, possibly, bony crepitation.

Hypocalcemia

The classic feature is tetany—a syndrome of muscle cramps and twitching, carpopedal and facial muscle spasms, and seizures, possibly with stridor. Both Chvostek’s and Trousseau’s signs may be elicited. Related findings include paresthesia of the lips, fingers, and toes; choreiform movements; hyperactive deep tendon reflexes; fatigue; palpitations; and cardiac arrhythmias.

Hypothyroidism

Muscle involvement may produce spasms and stiffness, along with leg muscle hypertrophy or proximal limb weakness and atrophy. Other findings include forgetfulness and mental instability; fatigue; cold intolerance; dry, pale, cool, doughy skin; puffy face, hands, and feet; periorbital edema; dry, sparse, brittle hair; bradycardia; and weight gain despite anorexia.

Muscle trauma

Excessive muscle strain may cause mild to severe spasms. The injured area may be painful, swollen, reddened, or warm.

Respiratory alkalosis

Acute onset of muscle spasms may be accompanied by twitching and weakness, carpopedal spasms, circumoral and peripheral paresthesia, vertigo, syncope, pallor, and extreme anxiety. With severe alkalosis, cardiac arrhythmias may occur.

Spinal injury or disease

Muscle spasms can result from spinal injury, such as cervical extension injury or spinous process fracture, or from spinal disease such as infection.

Other causes

Drugs

Common spasm-producing drugs include diuretics, corticosteroids, and estrogens.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm (dissecting)

Mild to moderate abdominal rigidity occurs in abdominal aortic aneurysm, a life-threatening disorder. It’s typically accompanied by constant upper abdominal pain that may radiate to the lower back. The pain may worsen when the patient lies down and may be relieved when he leans forward or sits up. Before rupture, the aneurysm may produce a pulsating mass in the epigastrium, accompanied by a systolic bruit over the aorta. However, the mass stops pulsating after rupture. Associated signs and symptoms include mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, and mild to moderate abdominal tenderness with guarding. Significant blood loss causes signs of shock, such as tachycardia, tachypnea, and cool, clammy skin.

Mesenteric artery ischemia

This life-threatening disorder is characterized by 2 to 3 days of persistent, low-grade abdominal pain and diarrhea leading to sudden, severe abdominal pain and rigidity. Rigidity occurs in the central or periumbilical region and is accompanied by severe abdominal tenderness, fever, and signs of shock, such as tachycardia and hypotension. Other findings may include vomiting, anorexia, diarrhea, and constipation. Always suspect mesenteric artery ischemia in patients older than age 50 who have a history of heart failure, arrhythmias, cardiovascular infarct, or hypotension.

Peritonitis

Depending on the cause of peritonitis, abdominal rigidity may be localized or generalized. For example, if an inflamed appendix causes local peritonitis, rigidity may be localized in the right lower quadrant. If a perforated ulcer causes widespread peritonitis, rigidity may be generalized and, in severe cases, boardlike.

Peritonitis also causes sudden and severe abdominal pain that can be localized or generalized. It can also produce abdominal tenderness and distention, rebound tenderness, guarding, hyperalgesia, hypoactive or absent bowel sounds, nausea, and vomiting. Most patients also experience fever, chills, tachycardia, tachypnea, and hypotension.

Pneumonia

In lower lobe pneumonia, severe upper abdominal pain and tenderness accompany rigidity that diminishes with inspiration. Associated signs and symptoms include blood-tinged or rusty sputum, dyspnea, achiness, headache, fever, sudden onset of chills, crackles, egophony, decreased breath sounds, dullness on percussion, and a dry, hacking cough.

Other causes

Insect toxins

Insect stings and bites, especially black widow spider bites, release toxins that can produce generalized cramping abdominal pain, usually accompanied by rigidity. These toxins may also cause low-grade fever, nausea, vomiting, tremors, and burning sensations in the hands and feet. Some patients develop increased salivation, hypertension, paresis, and hyperactive reflexes. Children commonly are restless, have an expiratory grunt, and keep their legs flexed.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Muscle spasticity [Muscle hypertonicity]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyotrophic lateral sclerosis

This disorder commonly produces spasticity, spasms, coarse fasciculations, hyperactive deep tendon reflexes, and a positive Babinski’s sign. Earlier effects include progressive muscle weakness and flaccidity that typically begin in the hands and arms and eventually spread to the trunk, neck, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include dysphagia, dysarthria, excessive drooling, and depression.

Epidural hemorrhage

With this disorder, bilateral limb spasticity is a late and ominous sign. Other findings include a momentary loss of consciousness after head trauma, followed by a lucid interval and then a rapid deterioration in level of consciousness. The patient may also develop unilateral hemiparesis or hemiplegia; seizures; fixed, dilated pupils; high fever; decreased and bounding pulse; widened pulse pressure; elevated blood pressure; irregular respiratory pattern; and decerebrate posture. A positive Babinski’s sign can be elicited.

Multiple sclerosis

Muscle spasticity, hyperreflexia, and contractures may eventually develop; earlier muscle changes include progressive weakness and atrophy. Associated signs and symptoms typically wax and wane and may include diplopia, blurring or loss of vision, nystagmus, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Spinal cord injury

Spasticity commonly results from cervical and high thoracic spinal cord injury, especially from incomplete lesions. Spastic paralysis in the affected limbs follows initial flaccid paralysis; typically, spasticity and muscle atrophy increase for up to 1¼ to 2 years after the injury, then gradually regress to flaccidity. Associated signs and symptoms vary with the level of injury but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive deep tendon reflexes, positive Babinski’s sign, sexual dysfunction, priapism, hypotension, anhidrosis, and bradycardia.

Stroke

Spastic paralysis may develop on the affected side following the acute stage of a stroke. Associated findings vary with the site and extent of vascular damage and may include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, visual disturbance, altered level of consciousness, amnesia and poor judgment, personality changes, emotional lability, bowel and bladder dysfunction, headache, vomiting, and seizures.

Tetanus

This rare, life-threatening disease produces varying degrees of spasticity. In generalized tetanus, the most common form, early signs and symptoms include painful jaw and neck stiffness, trismus, headache, irritability, restlessness, low-grade fever with chills, tachycardia, diaphoresis, and hyperactive deep tendon reflexes. As the disease progresses, painful involuntary spasms may spread and cause boardlike abdominal rigidity, opisthotonos, and a characteristic grotesque grin known as risus sardonicus. Reflex spasms may occur in any muscle group with the slightest stimulus. Glottal, pharyngeal, or respiratory muscle involvement can cause death by asphyxia or cardiac failure.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Accessory muscle use: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acute respiratory distress syndrome (ARDS)

In ARDS—a life-threatening disorder—accessory muscle use increases in response to hypoxia. It’s accompanied by intercostal, supracostal, and sternal retractions on inspiration and by grunting on expiration. Other characteristics include tachypnea, dyspnea, diaphoresis, diffuse crackles, and a cough with pink, frothy sputum. Worsening hypoxia produces anxiety, tachycardia, and mental sluggishness.

Airway obstruction

An acute upper airway obstruction can be life-threatening; fortunately, most obstructions are subacute or chronic. Typically, this disorder increases accessory muscle use. Its most telling sign, however, is inspiratory stridor. Associated signs and symptoms include dyspnea, tachypnea, gasping, wheezing, coughing, drooling, intercostal retractions, cyanosis, and tachycardia.

Amyotrophic lateral sclerosis (ALS)

Because ALS affects the diaphragm more than the accessory muscles, increased accessory muscle use is characteristic of this disorder. Other signs and symptoms include fasciculations, muscle atrophy and weakness, spasticity, bilateral Babinski’s reflex, and hyperactive deep tendon reflexes. Incoordination makes carrying out routine activities difficult for the patient. Associated signs and symptoms include impaired speech; difficulty chewing or swallowing and breathing; urinary frequency and urgency; and, occasionally, choking and excessive drooling. ( Note: Other neuromuscular disorders may produce similar signs and symptoms.) Although the patient’s mental status remains intact, his poor prognosis may cause periodic depression.

Asthma

During acute asthma attacks, the patient usually displays increased accessory muscle use accompanied by severe dyspnea, tachypnea, wheezing, productive cough, nasal flaring, and cyanosis. Auscultation reveals faint or possibly absent breath sounds, musical crackles, and rhonchi. Other signs and symptoms include tachycardia, diaphoresis, and apprehension caused by air hunger. Chronic asthma may also cause barrel chest.

Chronic bronchitis

In this form of COPD, increased accessory muscle use may be chronic and is preceded by a productive cough and exertional dyspnea. Chronic bronchitis is accompanied by wheezing, basal crackles, tachypnea, jugular vein distention, prolonged expiration, barrel chest, and clubbing. Patients with chronic bronchitis are sometimes called “blue bloaters” because of the cyanosis and weight gain from edema that commonly occur. Low-grade fever may occur with secondary infection.

Diffuse infiltrative (or fibrotic) lung disease

In diffuse infiltrative lung disease, progressive pulmonary degeneration eventually increases accessory muscle use. Typically, though, the patient reports progressive dyspnea on exertion as his chief complaint. He may also have a cough, anorexia, weakness, fatigue, vague chest pain, tachypnea, and crackles at the base of the lungs.

Emphysema

Increased accessory muscle use occurs with progressive exertional dyspnea and a minimally productive cough in this form of COPD. These patients are sometimes called “pink puffers” because of their characteristic pursed-lip breathing, tachypnea, and a pink or red complexion. Associated signs and symptoms include peripheral cyanosis, anorexia, weight loss, malaise, barrel chest, and clubbing. Auscultation reveals distant heart sounds; percussion detects hyperresonance.

Pneumonia

Bacterial pneumonia initially produces sudden high fever with chills. Associated signs and symptoms include increased accessory muscle use, chest pain, productive cough, dyspnea, tachypnea, tachycardia, expiratory grunting, cyanosis, diaphoresis, and fine crackles.

Pulmonary edema

In acute pulmonary edema, increased accessory muscle use is accompanied by dyspnea, tachypnea, orthopnea, crepitant crackles, wheezing, and a cough with pink, frothy sputum. Other findings include restlessness, tachycardia, ventricular gallop, and cool, clammy, cyanotic skin.

Pulmonary embolism

Although signs and symptoms vary with the size, number, and location of the emboli, this life-threatening disorder may cause increased accessory muscle use. Common findings include dyspnea and tachypnea that may be accompanied by pleuritic or substernal chest pain. Other signs and symptoms include restlessness, anxiety, tachycardia, productive cough, low-grade fever and, with a large embolus, hemoptysis, cyanosis, syncope, jugular vein distention, scattered crackles, and focal wheezing.

Spinal cord injury

An injury below Ll typically doesn’t affect the diaphragm or accessory muscles, whereas an injury between C3 and C5 affects the upper respiratory muscles and diaphragm, causing increased accessory muscle use.

Associated signs and symptoms of spinal cord injury include unilateral or bilateral Babinski’s reflex; hyperactive deep tendon reflexes; spasticity; and variable or total loss of pain and temperature sensation, proprioception, and motor function. Horner’s syndrome (unilateral ptosis, pupillary constriction, facial anhidrosis) may occur in lower cervical cord injury.

Thoracic injury

Increased accessory muscle use may occur, depending on the type and extent of the injury. Associated signs and symptoms of this potentially life-threatening injury include an obvious chest wound or bruising, chest pain, dyspnea, cyanosis, and agitation. Signs of shock, such as tachycardia and hypotension, occur with significant blood loss.

Other causes

Diagnostic tests and treatments

Pulmonary function tests, incentive spirometry, and intermittent positive-pressure breathing can increase accessory muscle use.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Muscle atrophy [Muscle wasting]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyotrophic lateral sclerosis

Initial symptoms of this progressive disease include muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then develop in the other hand and arm. Eventually, weakness and atrophy spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity, fasciculations, hyperactive deep tendon reflexes, slight leg muscle spasticity, dysphagia, impaired speech, excessive drooling, and depression.

Burns

Fibrous scar tissue formation, pain, and loss of serum proteins from severe burns can limit muscle movement, resulting in atrophy.

Compartment syndrome and Volkmann’s ischemic contracture

With this acute disorder, muscle atrophy is a late sign of irreversible ischemia, along with contractures, paralysis, and loss of pulses. Earlier signs and symptoms include severe pain that increases with passive muscle movement, along with weakness and paresthesia.

Herniated disk

Here, pressure on nerve roots leads to muscle weakness, disuse, and ultimately, atrophy. The primary symptom is severe lower back pain, possibly radiating to the buttocks, legs, and feet and commonly accompanied by muscle spasms. Diminished reflexes and sensory changes may also occur.

Hypercortisolism

This disorder may cause limb weakness and eventually atrophy. Related cushingoid features include buffalo hump, moon face, truncal obesity, purple striae, thin skin, acne, easy bruising, poor wound healing, elevated blood pressure, fatigue, hyperpigmentation, and diaphoresis. The male patient may be impotent; the female patient may develop hirsutism and menstrual irregularities.

Hypothyroidism

Reversible weakness and atrophy of proximal limb muscles may occur in hypothyroidism. Associated findings commonly include muscle cramps and stiffness; cold intolerance; weight gain despite anorexia; mental dullness; dry, pale, cool, doughy skin; puffy face, hands, and feet; and bradycardia.

Meniscal tear

Quadriceps muscle atrophy, resulting from prolonged knee immobility and muscle weakness, is a classic sign of this traumatic disorder.

Multiple sclerosis

This degenerative disease may produce arm and leg atrophy as a result of chronic progressive weakness; spasticity and contractures may also develop. Associated signs and symptoms typically wax and wane and include diplopia and blurred vision, nystagmus, hyperactive deep tendon reflexes, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Osteoarthritis

This chronic disorder eventually causes atrophy proximal to involved joints as a result of progressive weakness and disuse. Other late signs and symptoms include bony joint deformities, such as Heberden’s nodes on the distal interphalangeal joints, Bouchard’s nodes on the proximal interphalangeal joints, crepitus and fluid accumulation, and contractures.

Parkinson’s disease

With this disorder, muscle rigidity, weakness, and disuse may produce muscle atrophy. The patient may exhibit insidious resting tremors that usually begin in the fingers (pill-rolling tremor), worsen with stress, and ease with purposeful movement and sleep. He may also develop bradykinesia; a characteristic propulsive gait; a high-pitched, monotone voice; masklike facies; drooling; dysphagia; dysarthria; and occasionally, oculogyric crisis or blepharospasm.

Peripheral nerve trauma

Injury to or prolonged pressure on a peripheral nerve leads to muscle weakness and atrophy. Associated findings include paresthesia or sensory loss, pain, and loss of reflexes supplied by the damaged nerve. Paralysis may also occur.

Peripheral neuropathy

With this disorder, muscle weakness progresses slowly to flaccid paralysis and eventually atrophy. Distal extremity muscles are generally affected first. Associated findings include loss of vibration sense; paresthesia, hyperesthesia, or anesthesia in the hands and feet; mild to sharp, burning pain; anhidrosis; glossy red skin; and diminished or absent deep tendon reflexes.

Protein deficiency

If chronic, this may lead to muscle weakness and atrophy. Other findings include chronic fatigue, apathy, anorexia, dry skin, peripheral edema, and dull, sparse, dry hair.

Radiculopathy

Damaged spinal nerve roots can cause muscle atrophy as well as weakness, paralysis, severe pain and, at times, loss of feeling in the areas supplied by the affected nerves.

Rheumatoid arthritis

Muscle atrophy occurs in the late stages of this disorder, as joint pain and stiffness decrease range of motion and discourage muscle use.

Shy-Drager syndrome

This rare, progressive neurologic syndrome is characterized by muscle atrophy, orthostatic hypotension, incontinence, tremor, rigidity, incoordination, and ataxia. It’s most common in young and middle-aged adults.

Spinal cord injury

Trauma to the spinal cord can produce severe muscle weakness and flaccid, then spastic, paralysis, eventually leading to atrophy. Other signs and symptoms depend on the level of injury but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive deep tendon reflexes, positive Babinski’s reflex, sexual dysfunction, priapism, hypotension, and anhidrosis (usually unilateral).

Stroke

Stroke may produce contralateral or bilateral weakness and eventually atrophy of the arms, legs, face, and tongue. Associated signs and symptoms depend on the site and extent of vascular damage and may include dysarthria, aphasia, ataxia, apraxia, agnosia, and ipsilateral paresthesia or sensory loss. The patient may develop visual disturbance, altered level of consciousness, amnesia and poor judgment, personality changes, and emotional lability. He may also report bowel and bladder dysfunction, vomiting, headache, and seizures.

Thyrotoxicosis

This disorder may produce insidious, generalized muscle weakness and atrophy. Related findings include extreme anxiety, fatigue, heat intolerance, diaphoresis, tremors, tachycardia, palpitations, ventricular or atrial gallop, dyspnea, weight loss, and an enlarged thyroid. Exophthalmos may be present.

Other causes

Drugs

Prolonged steroid therapy interferes with muscle metabolism and leads to atrophy, most prominently in the limbs.

Immobility

Prolonged immobilization from bed rest, casts, splints, or traction may cause muscle weakness and atrophy.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Muscle Cramps: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ordinary muscle cramp

❑ Overuse

❑ Dehydration

❑ Drugs/toxins

❑ Hypokalemia

❑ Hyponatremia

❑ Hyperventilation

❑ Vascular insufficiency

❑ Restless legs syndrome

❑ Hypocalcemia

❑ Dystonia

❑ Amyotrophic lateral sclerosis

❑ Hemifacial spasms

❑ Spinal cord lesion

❑ Muscle enzyme deficiency

❑ Myotonic dystrophy

❑ Black widow spider bite

❑ Tetanus

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Muscle spasms: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Amyotrophic lateral sclerosis (ALS)

With ALS, muscle spasms may accompany progressive muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then spread to the other hand and arm. Eventually, muscle weakness and atrophy affect the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity progressing to spasticity, coarse fasciculations, hyperactive deep tendon reflexes, dysphagia, impaired speech, excessive drooling, and depression.

Arterial occlusive disease

Arterial occlusion typically produces spasms and intermittent claudication in the leg, with residual pain. Associated findings are usually localized to the legs and feet and include loss of peripheral pulses, pallor or cyanosis, decreased sensation, hair loss, dry or scaling skin, edema, and ulcerations.

Cholera

Muscle spasms, severe water and electrolyte loss, thirst, weakness, decreased skin turgor, oliguria, tachycardia, and hypotension occur along with abrupt watery diarrhea and vomiting.

Dehydration

Sodium loss may produce limb and abdominal cramps. Other findings include a slight fever, decreased skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, muscle twitching, seizures, nausea, vomiting, and oliguria.

Fracture

Localized spasms and pain are mild if the fracture is nondisplaced, intense if it’s severely displaced. Other findings include swelling, limited mobility and, possibly, bony crepitation.

Hypocalcemia

The classic feature is tetany — a syndrome of muscle cramps and twitching, carpopedal and facial muscle spasms, and seizures, possibly with stridor. Both Chvostek’s and Trousseau’s signs may be elicited. Related findings include paresthesia of the lips, fingers, and toes; choreiform movements; hyperactive deep tendon reflexes; fatigue; palpitations; and cardiac arrhythmias.

Hypothyroidism

Muscle involvement may produce spasms and stiffness, along with leg muscle hypertrophy or proximal limb weakness and atrophy. Other findings include forgetfulness and mental instability; fatigue; cold intolerance; dry, pale, cool, doughy skin; puffy face, hands, and feet; periorbital edema; dry, sparse, brittle hair; bradycardia; and weight gain despite anorexia.

Muscle trauma

Excessive muscle strain may cause mild to severe spasms. The injured area may be painful, swollen, reddened, or warm.

Respiratory alkalosis

Acute onset of muscle spasms may be accompanied by twitching and weakness, carpopedal spasms, circumoral and peripheral paresthesia, vertigo, syncope, pallor, and extreme anxiety. With severe alkalosis, cardiac arrhythmias may occur.

Spinal injury or disease

Muscle spasms can result from spinal injury, such as cervical extension injury or spinous process fracture, or from spinal disease such as infection.

Other causes

Drugs

Common spasm-producing drugs include diuretics, corticosteroids, and estrogens.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Muscle weakness: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) typically begins with muscle weakness and atrophy in one hand that rapidly spread to the arm and then to the other hand and arm. Eventually, these effects spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency.

Brain tumor

Signs and symptoms of muscle weakness vary with the tumor’s location and size. Associated findings include headache, vomiting, diplopia, decreased visual acuity, decreased level of consciousness (LOC), pupillary changes, decreased motor strength, hemiparesis, hemiplegia, diminished sensations, ataxia, seizures, and behavioral changes.

Guillain-Barré syndrome

With Guillain-Barré syndrome, rapidly progressive, symmetrical weakness and pain ascends from the feet to the arms and facial nerves and may progress to total motor paralysis and respiratory failure. Associated findings include sensory loss or paresthesia, muscle flaccidity, loss of DTRs, tachycardia or bradycardia, fluctuating hypertension and orthostatic hypotension, diaphoresis, bowel and bladder incontinence, facial diplegia, dysphagia, dysarthria, and hypernasality.

Head trauma

Severe head trauma can cause varying degrees of muscle weakness. Other findings include decreased LOC, otorrhea or rhinorrhea, raccoon eyes and Battle’s sign, sensory disturbances, and signs of increased intracranial pressure.

Herniated disk

Pressure on nerve roots from a herniated disk leads to muscle weakness, disuse and, ultimately, atrophy. The primary symptom is severe low back pain, possibly radiating to the buttocks, legs, and feet — usually on one side. Diminished reflexes and sensory changes may also occur.

Hodgkin’s lymphoma

With Hodgkin’s lymphoma, muscle weakness may accompany the classic sign of painless, progressive lymphadenopathy. Other findings include paresthesia, fatigue, persistent fever, night sweats, and weight loss.

Hypercortisolism

Hypercortisolism may cause limb weakness and, eventually, atrophy. Related cush-ingoid features include buffalo hump, moon face, truncal obesity, purple striae, thin skin, acne, elevated blood pressure, fatigue, hyperpigmentation, easy bruising, poor wound healing, and diaphoresis. The male patient may be impotent; the female patient may exhibit hirsutism and menstrual irregularities.

Hypothyroidism

Reversible weakness and atrophy of proximal limb muscles may occur in hypothyroidism. Accompanying findings commonly include muscle cramps; cold intolerance; weight gain despite anorexia; mental dullness; dry, pale, doughy skin; puffy face, hands, and feet; impaired hearing and balance, and bradycardia.

Multiple sclerosis

With multiple sclerosis, muscle weakness in one or more limbs may progress to atrophy, spasticity, and contractures. Other findings typically wax and wane and may include diplopia and blurred vision, vision loss, nystagmus, hyperactive deep tendon reflexes, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Myasthenia gravis

Gradually progressive skeletal muscle weakness and fatigue are the cardinal symptoms of myasthenia gravis. Typically, weakness is mild upon awakening but worsens during the day. Early signs include weak eye closure, ptosis, and diplopia; a blank, masklike facies; difficulty chewing and swallowing; nasal regurgitation of fluid with hypernasality; and a hanging jaw and bobbing head. Respiratory muscle involvement may eventually lead to respiratory failure.

Osteoarthritis

Osteoarthritis is a chronic disorder that causes progressive muscle disuse and weakness that lead to atrophy. Other findings include crepitation; enlarged edematous joints; Heberden’s nodes; increased pain in damp, cold weather; joint stiffness; limited range of motion; pain relieved by resting joints; and smooth, taunt, shiny skin.

Paget’s disease

As Paget’s disease progresses, muscle weakness or paralysis may develop, along with paresthesia and pain. The patient may also have bowed tibias, frequent fractures, and kyphosis.

Parkinson’s disease

Muscle weakness accompanies rigidity in patients with Parkinson’s disease. Related findings include a unilateral pill-rolling tremor, propulsive gait, dysarthria, bradykinesia, drooling, dysphagia, a masklike facies, and a high-pitched, monotonic voice.

Peripheral nerve trauma

Prolonged pressure on or injury to a peripheral nerve causes muscle weakness and atrophy. Other findings include paresthesia or sensory loss, pain, and loss of reflexes supplied by the damaged nerve.

Peripheral neuropathy

With peripheral neuropathy, muscle weakness progresses slowly to flaccid paralysis, generally affecting distal extremities first. It may be accompanied by loss of vibration sense; paresthesia, hyperesthesia, or anesthesia in the hands and feet; hypoactive or absent DTRs; mild to sharp burning pain; anhidrosis; and glossy red skin.

Potassium imbalance

With hypokalemia, temporary generalized muscle weakness may be accompanied by nausea, vomiting, diarrhea, decreased mentation, leg cramps, diminished reflexes, malaise, polyuria, dizziness, hypotension, and arrhythmias.

With hyperkalemia, weakness may progress to flaccid paralysis accompanied by irritability and confusion, hyperreflexia, paresthesia or anesthesia, oliguria, anorexia, nausea, diarrhea, abdominal cramps, tachycardia or bradycardia, and arrhythmias.

Rhabdomyolysis

Signs and symptoms of rhabdomyolysis include muscle weakness or pain, fever, nausea, vomiting, malaise, and dark urine. Acute renal failure due to renal structure obstruction and injury from the kidneys’attempt to filter the myoglobin from the bloodstream is a common complication.

Rheumatoid arthritis

With rheumatoid arthritis, symmetric muscle weakness may accompany increased warmth, swelling, and tenderness in involved joints; pain; and stiffness that restrict motion. These findings typically occur bilaterally.

Seizure disorder

Temporary generalized muscle weakness may occur after a generalized tonic-clonic seizure; other postictal findings include headache, muscle soreness, and profound fatigue. The patient may experience an aura before the seizure.

Spinal trauma and disease

Spinal trauma can cause severe muscle weakness, leading to flaccidity or spasticity and, eventually, paralysis. Infection, tumor, and cervical spondylosis or stenosis can also cause muscle weakness.

Stroke

Depending on the site and extent of damage, a stroke may produce contralateral or bilateral weakness of the arms, legs, face, and tongue, possibly progressing to hemiplegia and atrophy. Associated effects include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, visual disturbance, altered level of consciousness, amnesia and poor judgment, personality changes, bowel and bladder dysfunction, headache, vomiting, and seizures.

Thyrotoxicosis

Thyrotoxicosis may produce insidious, generalized muscle weakness and atrophy. Other effects include anxiety, fatigue, heat intolerance, diaphoresis, tremors, tachycardia, palpitations, ventricular or atrial gallop, dyspnea, weight loss, an enlarged thyroid, and warm, flushed skin. Exophthalmos may be present.

Other causes

Drugs

Generalized muscle weakness can result from prolonged corticosteroid use, digoxin, and excessive doses of dantrolene. Aminoglycoside antibiotics may worsen weakness in patients with myasthenia gravis.

Immobility

Immobilization in a cast, a splint, or traction can lead to muscle weakness in the involved extremity; prolonged bed rest or inactivity results in generalized muscle weakness.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Accessory muscle use: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acute respiratory distress syndrome

In acute respiratory distress syndrome (ARDS), accessory muscle use increases in response to hypoxia. It’s accompanied by intercostal, supracostal, and sternal retractions on inspiration and by grunting on expiration. Other characteristics of this life-threatening disorder include tachypnea, dyspnea, diaphoresis, diffuse crackles, and a cough with pink, frothy sputum. Worsening hypoxia produces anxiety, tachycardia, and mental sluggishness.

Airway obstruction

Acute upper airway obstruction can be life-threatening — fortunately, most obstructions are subacute or chronic. Typically, this disorder increases accessory muscle use. Its most telling sign, however, is inspiratory stridor. Associated signs and symptoms include dyspnea, tachypnea, gasping, wheezing, coughing, drooling, intercostal retractions, cyanosis, and tachycardia.

Amyotrophic lateral sclerosis

Typically, amyotrophic lateral sclerosis (ALS) affects the diaphragm more than the accessory muscles. As a result, increased accessory muscle use is characteristic. Other signs and symptoms of this progressive motor neuron disorder include fasciculations, muscle atrophy and weakness, spasticity, bilateral Babinski’s reflex, and hyperactive deep tendon reflexes. Incoordination makes carrying out routine activities difficult for the patient. Associated signs and symptoms include impaired speech; difficulty chewing or swallowing and breathing; urinary frequency and urgency; and, occasionally, choking and excessive drooling. ( Note: Other neuromuscular disorders may produce similar signs and symptoms.) Although the patient’s mental status remains intact, his poor prognosis may cause periodic depression.

Asthma

During acute asthma attacks, the patient usually displays increased accessory muscle use. Accompanying it are severe dyspnea, tachypnea, wheezing, productive cough, nasal flaring, and cyanosis. Auscultation reveals faint or possibly absent breath sounds, musical crackles, and rhonchi. Other signs and symptoms include tachycardia, diaphoresis, and apprehension caused by air hunger. Chronic asthma may also cause barrel chest.

Chronic bronchitis

With chronic bronchitis, a form of COPD, increased accessory muscle use may be chronic and is preceded by a productive cough and exertional dyspnea. Chronic bronchitis is accompanied by wheezing, basal crackles, tachypnea, jugular vein distention, prolonged expiration, barrel chest, and clubbing. Cyanosis and weight gain from edema account for the characteristic label of “blue bloater.” Low-grade fever may occur with secondary infection.

Emphysema

With emphysema, a form of COPD, increased accessory muscle use occurs with progressive exertional dyspnea and a minimally productive cough. Sometimes called a “pink puffer,” the patient will display pursed-lip breathing and tachypnea. Associated signs and symptoms include peripheral cyanosis, anorexia, weight loss, malaise, barrel chest, and clubbing. Auscultation reveals distant heart sounds; percussion detects hyperresonance.

Pneumonia

Bacterial pneumonia usually produces increasedaccessory muscle use. Initially, this infection produces sudden high fever with chills. Its associated signs and symptoms include chest pain, productive cough, dyspnea, tachypnea, tachycardia, expiratory grunting, cyanosis, diaphoresis, and fine crackles.

Pulmonary edema

With acute pulmonary edema, increased accessory muscle use is accompanied by dyspnea, tachypnea, orthopnea, crepitant crackles, wheezing, and a cough with pink, frothy sputum. Other findings include restlessness, tachycardia, ventricular gallop, and cool, clammy, cyanotic skin.

Pulmonary embolism

Although signs and symptoms vary with the size, number, and location of the emboli, this life-threatening disorder may cause increased accessory muscle use. Commonly, it produces dyspnea and tachypnea that may be accompanied by pleuritic or substernal chest pain. Other signs and symptoms include restlessness, anxiety, tachycardia, productive cough, low-grade fever and, with a large embolus, hemoptysis, cyanosis, syncope, jugular vein distention, scattered crackles, and focal wheezing.

Spinal cord injury

Depending on the location and severity of a spinal cord injury, increased accessory muscle use may occur. An injury below Ll typically doesn’t affect the diaphragm or accessory muscles, whereas an injury between C3 and C5 affects the upper respiratory muscles and diaphragm, causing increased accessory muscle use.

Associated signs and symptoms of spinal cord injury include unilateral or bilateral Babinski’s reflex; hyperactive deep tendon reflexes; spasticity; and variable or total loss of pain and temperature sensation, proprioception, and motor function. Horner’s syndrome (unilateral ptosis, pupillary constriction, facial anhidrosis) may occur with lower cervical cord injury.

Thoracic injury

With thoracic injury, increased accessory muscle use may occur, depending on the type and extent of injury. Associated signs and symptoms of this potentially life-threatening injury include an obvious chest wound or bruising, chest pain, dyspnea, cyanosis, and agitation. Signs of shock, such as tachycardia and hypotension, occur with significant blood loss.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Muscle spasms: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Amyotrophic lateral sclerosis

With amyotrophic lateral sclerosis (ALS), muscle spasms may accompany progressive muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then spread to the other hand and arm. Eventually, muscle weakness and atrophy affect the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity progressing to spasticity, coarse fasciculations, hyperactive deep tendon reflexes, dysphagia, impaired speech, excessive drooling, and depression.

Arterial occlusive disease

Arterial occlusion typically produces spasms and intermittent claudication in the leg, with residual pain. Associated findings are usually localized to the legs and feet and include loss of peripheral pulses, pallor or cyanosis, decreased sensation, hair loss, dry or scaling skin, edema, and ulcerations.

Dehydration

Sodium loss may produce limb and abdominal cramps. Other findings in dehydration include a slight fever, decreased skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, muscle twitching, seizures, nausea, vomiting, and oliguria.

Fracture

Localized spasms and pain are mild if the fracture is nondisplaced, intense if it’s severely displaced. Other findings include swelling, limited mobility and, possibly, bony crepitation.

Hypocalcemia

The classic feature of hypocalcemia is tetany — a syndrome of muscle cramps and twitching, carpopedal and facial muscle spasms, and seizures, possibly with stridor. Both Chvostek’s and Trousseau’s signs may be elicited. Related findings include paresthesia of the lips, fingers, and toes; choreiform movements; hyperactive deep tendon reflexes; fatigue; palpitations; and cardiac arrhythmias.

Hypothyroidism

Muscle involvement may produce spasms and stiffness, along with leg muscle hypertrophy or proximal limb weakness and atrophy. Other findings include forgetfulness and mental instability; fatigue; cold intolerance; dry, pale, cool, doughy skin; puffy face, hands, and feet; periorbital edema; dry, sparse, brittle hair; bradycardia; and weight gain despite anorexia.

Muscle trauma

Excessive muscle strain may cause mild to severe spasms. The injured area may be painful, swollen, reddened, or warm. The patient may report hearing a snapping sound at the time of injury.

Respiratory alkalosis

With respiratory alkalosis, acute onset of muscle spasms may be accompanied by twitching and weakness, carpopedal spasms, circumoral and peripheral paresthesia, vertigo, syncope, pallor, and extreme anxiety. With severe alkalosis, cardiac arrhythmias may occur.

Spinal injury or disease

Muscle spasms can result from spinal injury, such as cervical extension injury or spinous process fracture, or from spinal disease such as infection. The patient may report that the muscle spasms worsen with movement.

Other causes

Drugs

Common spasm-producing drugs include diuretics, corticosteroids, and estrogens.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Muscle spasticity: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) commonly produces spasticity, spasms, coarse fasciculations, hyperactive deep tendon reflexes (DTRs), and a positive Babinski’s sign. Earlier effects include progressive muscle weakness and flaccidity that typically begin in the hands and arms and eventually spread to the trunk, neck, larynx, pharynx, and legs. Progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include dysphagia, dysarthria, excessive drooling, and depression.

Epidural hemorrhage

Bilateral limb spasticity is a late and ominous sign of epidural hemorrhage. Other findings include a momentary loss of consciousness after head trauma, followed by a lucid interval and then a rapid deterioration in level of consciousness (LOC). The patient may also develop unilateral hemiparesis or hemiplegia; seizures; fixed, dilated pupils; high fever; decreased and bounding pulse; widened pulse pressure; elevated blood pressure; irregular respiratory pattern; and decerebrate posture. A positive Babinski’s sign can be elicited.

Multiple sclerosis

Muscle spasticity, hyperreflexia, and contractures may eventually develop in patients with multiple sclerosis; earlier muscle changes include progressive weakness and atrophy. Associated signs and symptoms typically wax and wane and may include diplopia, blurring or loss of vision, nystagmus, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Spinal cord injury

Spasticity commonly results from cervical and high thoracic spinal cord injury, especially from incomplete lesions. Spastic paralysis in the affected limbs follows initial flaccid paralysis; typically, spasticity and muscle atrophy increase for up to 2 years after the injury, then gradually regress to flaccidity. Associated signs and symptoms vary with the level of injury but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive DTRs, positive Babinski’s sign, sexual dysfunction, priapism, hypotension, anhidrosis, and bradycardia.

Stroke

Spastic paralysis may develop on the affected side following the acute stage of a stroke. Associated findings vary with the site and extent of vascular damage and may include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, visual disturbance, altered LOC, amnesia and poor judgment, personality changes, emotional lability, bowel and bladder dysfunction, headache, vomiting, and seizures.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Muscle flaccidity [Muscle hypotonicity]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Amyotrophic lateral sclerosis.Progressive muscle weakness and paralysis are accompanied by generalized flaccidity. Typically, these effects begin in one hand, spread to the arm, and then develop in the other hand and arm. Eventually, they spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle cramps and coarse fasciculations, hyperactive DTRs, slight leg muscle spasticity, dysphagia, dysarthria, excessive drooling, and depression.

Brain lesions.Frontal and parietal lobe lesions may cause contralateral flaccidity, weakness or paralysis and, eventually, spasticity and possibly contractures. Other findings include hyperactive DTRs, a positive Babinski's sign, loss of proprioception, stereognosis, graphesthesia, anesthesia, and thermanesthesia.

Guillain-Barré syndrome.Guillain-Barré syndrome causes muscle flaccidity. Progression is typically symmetrical and ascending, moving from the feet to the arms and facial nerves within 24 to 72 hours of its onset. Associated findings include sensory loss or paresthesia, absent DTRs, tachycardia (or, less commonly, bradycardia), fluctuating hypertension and orthostatic hypotension, diaphoresis, incontinence, dysphagia, dysarthria, hypernasality, and facial diplegia. Weakness may progress to total motor paralysis and respiratory failure.

Huntington's disease.Besides flaccidity, progressive mental status changes up to and including dementia and choreiform movements are major symptoms of Huntington's disease. Others include poor balance, hesitant or explosive speech, dysphagia, impaired respirations, and incontinence.

Muscle disease.Muscle weakness and flaccidity are features of myopathies and muscular dystrophies.

Peripheral nerve trauma.Flaccidity, paralysis, and loss of sensation and reflexes in the traumatized innervated area can occur.

Peripheral neuropathy.With peripheral neuropathy, flaccidity usually occurs in the legs as a result of chronic progressive muscle weakness and paralysis. It may also cause mild to sharp burning pain, glossy red skin, anhidrosis, and a loss of vibration sensation. Paresthesia, hyperesthesia, or anesthesia may affect the hands and feet. DTRs may be hypoactive or absent.

Seizure disorder.Brief periods of syncope and generalized flaccidity commonly follow a generalized tonic-clonic seizure.

Spinal cord injury.Spinal shock can result in acute muscle flaccidity or spasticity below the level of injury. Associated signs and symptoms also occur below the level of injury and may include paralysis; absent DTRs; analgesia; thermanesthesia; loss of proprioception and vibration, touch, and pressure sensation; and anhidrosis (usually unilateral). Hypotension, bowel and bladder dysfunction, and impotence or priapism may also occur. Injury in the C1 to C5 region can produce respiratory paralysis and bradycardia.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle weakness: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Amyotrophic lateral sclerosis (ALS).ALS typically begins with muscle weakness and atrophy in one hand that rapidly spread to the arm and then to the other hand and arm. Eventually, these effects spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency.

Anemia.With anemia, varying degrees of muscle weakness and fatigue are exacerbated by exertion and temporarily relieved by rest. Other signs and symptoms include pallor, tachycardia, paresthesia, and bleeding tendencies.

Brain tumor.Signs and symptoms of muscle weakness vary with a brain tumor's location and size. Associated findings include headache, vomiting, diplopia, decreased visual acuity, decreased level of consciousness (LOC), pupillary changes, decreased motor strength, hemiparesis, hemiplegia, diminished sensations, ataxia, seizures, and behavioral changes.

Guillain-Barré syndrome.Rapidly progressive, symmetrical weakness and pain ascends from the feet to the arms and facial nerves and may progress to total motor paralysis and respiratory failure. With Guillain-Barré syndrome, associated findings include sensory loss or paresthesia, muscle flaccidity, loss of DTRs, tachycardia or bradycardia, fluctuating hypertension and orthostatic hypotension, diaphoresis, bowel and bladder incontinence, facial diplegia, dysphagia, dysarthria, and hypernasality.

Herniated disk.Pressure on nerve roots of herniated disk leads to muscle weakness, disuse and, ultimately, atrophy. The primary symptom is severe low back pain, possibly radiating to the buttocks, legs, and feet—usually on one side. Diminished reflexes and sensory changes may also occur.

Hypercortisolism.Hypercortisolism may cause limb weakness and eventually atrophy. Related cushingoid features include buffalo hump, moon face, truncal obesity, purple striae, thin skin, acne, elevated blood pressure, fatigue, hyperpigmentation, easy bruising, poor wound healing, and diaphoresis. The male patient may be impotent; the female patient may exhibit hirsutism and menstrual irregularities.

Myasthenia gravis.Gradually progressive skeletal muscle weakness and fatigue are the cardinal symptoms of myasthenia gravis. Typically, weakness is mild upon awakening, but worsens during the day. Early signs include weak eye closure, ptosis, and diplopia; blank, masklike facies; difficulty chewing and swallowing; nasal regurgitation of fluid with hypernasality; and a hanging jaw and bobbing head. Respiratory muscle involvement may eventually lead to respiratory failure.

Osteoarthritis.Osteoarthritis is a chronic disorder that causes progressive muscle disuse and weakness that lead to atrophy.

Parkinson's disease.Muscle weakness accompanies rigidity in Parkinson's disease. Related findings include a unilateral pill-rolling tremor, a propulsive gait, dysarthria, bradykinesia, drooling, dysphagia, masklike facies, and a high-pitched, monotone voice.

Peripheral nerve trauma.Prolonged pressure on or injury to a peripheral nerve causes muscle weakness and atrophy. Other findings include paresthesia or sensory loss, pain, and loss of reflexes supplied by the damaged nerve.

Potassium imbalance.With hypokalemia,temporary generalized muscle weakness may be accompanied by nausea, vomiting, diarrhea, decreased mentation, leg cramps, diminished reflexes, malaise, polyuria, dizziness, hypotension, and arrhythmias.

With hyperkalemia, weakness may progress to flaccid paralysis accompanied by irritability and confusion, hyperreflexia, paresthesia or anesthesia, oliguria, anorexia, nausea, diarrhea, abdominal cramps, tachycardia or bradycardia, and arrhythmias.

Rhabdomyolysis.Signs and symptoms of rhabdomyolysis include muscle weakness or pain, fever, nausea, vomiting, malaise, and dark urine. Acute renal failure, due to renal structure obstruction and injury from the kidneys'attempt to filter myoglobin from the bloodstream, is a common complication.

Rheumatoid arthritis.With rheumatoid arthritis, symmetrical muscle weakness may accompany increased warmth, swelling, and tenderness in involved joints; pain; and stiffness, restricting motion.

Seizure disorder.Temporary generalized muscle weakness may occur after a generalized tonic-clonic seizure; other postictal findings include headache, muscle soreness, and profound fatigue.

Spinal trauma and disease.Trauma to the spine can cause severe muscle weakness, leading to flaccidity or spasticity and, eventually, paralysis. Infection, tumor, and cervical spondylosis or stenosis can also cause muscle weakness.

Stroke.Depending on the site and extent of damage, a stroke may produce contralateral or bilateral weakness of the arms, legs, face, and tongue, possibly progressing to hemiplegia and atrophy. Associated effects include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, vision disturbances, altered LOC, amnesia and poor judgment, personality changes, bowel and bladder dysfunction, headache, vomiting, and seizures.

Other causes

Drugs.Generalized muscle weakness can result from prolonged corticosteroid use, digoxin, and excessive doses of dantrolene. Aminoglycoside antibiotics may worsen muscle weakness in patients with myasthenia gravis.

Immobility.Immobilization in a cast, a splint, or traction can lead to muscle weakness in the involved extremity; prolonged bed rest or inactivity results in generalized muscle weakness.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle spasms [Muscle cramps]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Amyotrophic lateral sclerosis (ALS).With ALS, muscle spasms may accompany progressive muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then spread to the other hand and arm. Eventually, muscle weakness and atrophy affect the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity progressing to spasticity, coarse fasciculations, hyperactive deep tendon reflexes (DTRs), dysphagia, impaired speech, excessive drooling, and depression.

Arterial occlusive disease.Arterial occlusion typically produces muscle spasms and intermittent claudication in the leg, with residual pain. Associated findings are usually localized to the legs and feet and include loss of peripheral pulses, pallor or cyanosis, decreased sensation, hair loss, dry or scaling skin, edema, and ulcerations.

Cholera.With cholera, muscle spasms, severe water and electrolyte loss, thirst, weakness, decreased skin turgor, oliguria, tachycardia, and hypotension occur along with abrupt watery diarrhea and vomiting.

Dehydration.With dehydration, sodium loss may produce limb and abdominal cramps. Other findings include a slight fever, decreased skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, muscle twitching, seizures, nausea, vomiting, and oliguria.

Hypocalcemia.The classic feature of hypocalcemia is tetany—a syndrome of muscle cramps and twitching, carpopedal and facial muscle spasms, and seizures, possibly with stridor. Chvostek's and Trousseau's signs may be elicited. Related findings include paresthesia of the lips, fingers, and toes; choreiform movements; hyperactive DTRs; fatigue; palpitations; and cardiac arrhythmias.

Muscle trauma.Excessive muscle strain may cause mild to severe spasms. The injured area may be painful, swollen, reddened, or warm.

Respiratory alkalosis.With respiratory alkalosis, an acute onset of muscle spasms may be accompanied by twitching and weakness, carpopedal spasms, circumoral and peripheral paresthesia, vertigo, syncope, pallor, and extreme anxiety. With severe alkalosis, cardiac arrhythmias may occur.

Spinal injury or disease.Muscle spasms can result from spinal injury, such as a cervical extension injury or spinous process fracture, or from spinal disease such as infection.

Other causes

Drugs.Common muscle spasm-producing drugs include diuretics, corticosteroids, and estrogens.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm
(dissecting).Mild to moderate abdominal rigidity occurs with a dissecting abdominal aortic aneurysm, a life-threatening disorder. Typically, it's accompanied by constant upper abdominal pain that may radiate to the lower back. The pain may worsen when the patient lies down and may be relieved when he leans forward or sits up. Before rupture, the aneurysm may produce a pulsating mass in the epigastrium, accompanied by a systolic bruit over the aorta. The mass stops pulsating after rupture. Associated signs and symptoms include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, and mild to moderate tenderness with guarding. Significant blood loss causes signs of shock, such as tachycardia, tachypnea, and cool, clammy skin.

Insect toxins.Insect stings and bites, especially black widow spider bites, release toxins that can produce generalized, cramping abdominal pain, usually accompanied by rigidity. These toxins may also cause a low-grade fever, nausea, vomiting, tremors, and burning sensations in the hands and feet. Some patients develop increased salivation, hypertension, paresis, and hyperactive reflexes. Children commonly are restless, have an expiratory grunt, and keep their legs flexed.

Mesenteric artery ischemia.A life-threatening disorder, mesenteric artery ischemia is characterized by 2 or 3 days of persistent, low-grade abdominal pain and diarrhea leading to sudden, severe abdominal pain and rigidity. Rigidity occurs in the central or periumbilical region and is accompanied by severe abdominal tenderness, fever, and signs of shock, such as tachycardia and hypotension. Other findings may include vomiting, anorexia, and diarrhea or constipation. Always suspect this disorder in patients older than age 50 who have a history of heart failure, arrhythmia, cardiovascular infarct, or hypotension.

Peritonitis.Depending on the cause of peritonitis, abdominal rigidity may be localized or generalized. For example, if an inflamed appendix causes local peritonitis, rigidity may be localized in the right lower quadrant. If a perforated ulcer causes widespread peritonitis, rigidity may be generalized and, in severe cases, boardlike.

Peritonitis also causes sudden and severe abdominal pain that can be localized or generalized. In addition, it can produce abdominal tenderness and distention, rebound tenderness, guarding, hyperalgesia, hypoactive or absent bowel sounds, nausea, and vomiting. Usually, the patient also displays fever, chills, tachycardia, tachypnea, and hypotension.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle spasticity [Muscle hypertonicity]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Amyotrophic lateral sclerosis (ALS).ALS commonly produces spasticity, spasms, coarse fasciculations, hyperactive deep tendon reflexes (DTRs), and a positive Babinski's sign. Earlier effects include progressive muscle weakness and flaccidity that typically begin in the hands and arms and eventually spread to the trunk, neck, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include dysphagia, dysarthria, excessive drooling, and depression.

Epidural hemorrhage.With epidural hemorrhage, bilateral limb spasticity is a late and ominous sign. Other findings include a momentary loss of consciousness after head trauma, followed by a lucid interval and then a rapid deterioration in the level of consciousness (LOC). The patient may also develop unilateral hemiparesis or hemiplegia; seizures; fixed, dilated pupils; a high fever; a decreased and bounding pulse; a widened pulse pressure; elevated blood pressure; an irregular respiratory pattern; and decerebrate posture. A positive Babinski's sign can be elicited.

Spinal cord injury.Muscle spasticity commonly results from cervical and high thoracic spinal cord injury, especially from incomplete lesions. Spastic paralysis in the affected limbs follows initial flaccid paralysis; typically, spasticity and muscle atrophy increase for up to  11⁄2 to 2 years after the injury, and then gradually regress to flaccidity. Associated signs and symptoms vary with the level of injury, but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive DTRs, a positive Babinski's sign, sexual dysfunction, priapism, hypotension, anhidrosis, and bradycardia.

Stroke.Spastic paralysis may develop on the affected side following the acute stage of a stroke. Associated findings vary with the site and extent of vascular damage and may include dysarthria, aphasia, ataxia, apraxia, agnosia, ipsilateral paresthesia or sensory loss, vision disturbances, altered LOC, amnesia and poor judgment, personality changes, emotional lability, bowel and bladder dysfunction, headache, vomiting, and seizures.

Tetanus.Tetanus is a rare, life-threatening disease that produces varying degrees of muscle spasticity. In generalized tetanus—the most common form—early signs and symptoms include painful jaw and neck stiffness, trismus, headache, irritability, restlessness, a low-grade fever with chills, tachycardia, diaphoresis, and hyperactive DTRs. As the disease progresses, painful involuntary spasms may spread and cause boardlike abdominal rigidity, opisthotonos, and a characteristic grotesque grin known as risus sardonicus. Reflex spasms may occur in any muscle group with the slightest stimulus. Glottal, pharyngeal, or respiratory muscle involvement can cause death by asphyxia or cardiac failure.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Accessory muscle use: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acute respiratory distress syndrome (ARDS).In ARDS, a life-threatening disorder, accessory muscle use increases in response to hypoxia. It's accompanied by intercostal, supracostal, and sternal retractions on inspiration and by grunting on expiration. Other characteristics include tachypnea, dyspnea, diaphoresis, diffuse crackles, and a cough with pink, frothy sputum. Worsening hypoxia produces anxiety, tachycardia, and mental sluggishness.

Airway obstruction.Acute upper airway obstruction can be life-threatening—fortunately, most obstructions are subacute or chronic. Typically, obstruction increases accessory muscle use. However, its most telling sign is inspiratory stridor. Associated signs and symptoms include dyspnea, tachypnea, gasping, wheezing, coughing, drooling, intercostal retractions, cyanosis, and tachycardia.

Amyotrophic lateral sclerosis.Typically, this progressive motor neuron disorder affects the diaphragm more than the accessory muscles. As a result, increased accessory muscle use is characteristic. Other signs and symptoms include fasciculations, muscle atrophy and weakness, spasticity, bilateral Babinski's reflex, and hyperactive deep tendon reflexes. Incoordination makes carrying out routine activities difficult for the patient. Associated signs and symptoms include impaired speech, difficulty chewing or swallowing and breathing, urinary frequency and urgency and, occasionally, choking and excessive drooling. ( Note: Other neuromuscular disorders may produce similar signs and symptoms.) Although the patient's mental status remains intact, his poor prognosis may cause periodic depression.

Asthma.During an acute asthma attack, the patient usually displays increased accessory muscle use. Accompanying it are severe dyspnea, tachypnea, wheezing, a productive cough, nasal flaring, and cyanosis. Auscultation reveals faint or possibly absent breath sounds, musical crackles, and rhonchi. Other signs and symptoms include tachycardia, diaphoresis, and apprehension caused by air hunger. Chronic asthma may also cause barrel chest.

Chronic bronchitis.With chronic bronchitis, a form of COPD, increased accessory muscle use may be chronic and is preceded by a productive cough and exertional dyspnea. Chronic bronchitis is accompanied by wheezing, basal crackles, tachypnea, jugular vein distention, prolonged expiration, barrel chest, and clubbing. Cyanosis and weight gain from edema account for the characteristic label of “blue bloater.” A low-grade fever may occur with secondary infection.

Emphysema.Increased accessory muscle use occurs with progressive exertional dyspnea and a minimally productive cough in this form of COPD. Sometimes called a “pink puffer,” the patient will display pursed-lip breathing and tachypnea. Associated signs and symptoms include peripheral cyanosis, anorexia, weight loss, malaise, barrel chest, and clubbing. Auscultation reveals distant heart sounds; percussion detects hyperresonance.

Pneumonia.Bacterial pneumonia usually produces increased accessory muscle use. Initially, this infection produces a sudden high fever with chills. Its associated signs and symptoms include chest pain, a productive cough, dyspnea, tachypnea, tachycardia, expiratory grunting, cyanosis, diaphoresis, and fine crackles.

Pulmonary edema.With acute pulmonary edema, increased accessory muscle use is accompanied by dyspnea, tachypnea, orthopnea, crepitant crackles, wheezing, and a cough with pink, frothy sputum. Other findings include restlessness, tachycardia, ventricular gallop, and cool, clammy, cyanotic skin.

Pulmonary embolism.Although signs and symptoms vary with the size, number, and location of the emboli, pulmonary embolism is a life-threatening disorder that may cause increased accessory muscle use. Typically, it produces dyspnea and tachypnea that may be accompanied by pleuritic or substernal chest pain. Other signs and symptoms include restlessness, anxiety, tachycardia, a productive cough, a low-grade fever and, with a large embolus, hemoptysis, cyanosis, syncope, jugular vein distention, scattered crackles, and focal wheezing.

Spinal cord injury.Increased accessory muscle use may occur, depending on the location and severity of the injury. An injury below Ll typically doesn't affect the diaphragm or accessory muscles, whereas an injury between C3 and C5 affects the upper respiratory muscles and diaphragm, causing increased accessory muscle use.

Associated signs and symptoms of spinal cord injury include unilateral or bilateral Babinski's reflex, hyperactive deep tendon reflexes, spasticity, and variable or total loss of pain and temperature sensation, proprioception, and motor function. Horner's syndrome (unilateral ptosis, pupillary constriction, facial anhidrosis) may occur with lower cervical cord injury.

Thoracic injury.Increased accessory muscle use may occur, depending on the type and extent of injury. Associated signs and symptoms of this potentially life-threatening injury include an obvious chest wound or bruising, chest pain, dyspnea, cyanosis, and agitation. Signs of shock, such as tachycardia and hypotension, occur with significant blood loss.

Other causes

Diagnostic tests and treatments.Pulmonary function tests (PFTs), incentive spirometry, and intermittent positive-pressure breathing can increase accessory muscle use.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle atrophy [Muscle wasting]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Amyotrophic lateral sclerosis (ALS).Initial symptoms of ALS include muscle weakness and atrophy that typically begin in one hand, spread to the arm, and then develop in the other hand and arm. Eventually, weakness and atrophy spread to the trunk, neck, tongue, larynx, pharynx, and legs; progressive respiratory muscle weakness leads to respiratory insufficiency. Other findings include muscle flaccidity, fasciculations, hyperactive DTRs, slight leg muscle spasticity, dysphagia, impaired speech, excessive drooling, and depression.

Burns.Fibrous scar tissue formation, pain, and loss of serum proteins from severe burns can limit muscle movement, resulting in atrophy.

Hypothyroidism.Reversible weakness and atrophy of proximal limb muscles may occur in hypothyroidism. Associated findings commonly include muscle cramps and stiffness; cold intolerance; weight gain despite anorexia; mental dullness; dry, pale, cool, doughy skin; puffy face, hands, and feet; and bradycardia.

Meniscal tear.Quadriceps muscle atrophy, resulting from prolonged knee immobility and muscle weakness, is a classic sign of meniscal tear.

Multiple sclerosis.Multiple sclerosis may produce arm and leg atrophy as a result of chronic progressive weakness; spasticity and contractures may also develop. Associated signs and symptoms typically wax and wane and include diplopia and blurred vision, nystagmus, hyperactive DTRs, sensory loss or paresthesia, dysarthria, dysphagia, incoordination, an ataxic gait, intention tremors, emotional lability, impotence, and urinary dysfunction.

Osteoarthritis.Osteoarthritis eventually causes atrophy proximal to involved joints as a result of progressive weakness and disuse. Other late signs and symptoms include bony joint deformities, such as Heberden's nodes on the distal interphalangeal joints, Bouchard's nodes on the proximal interphalangeal joints, crepitus and fluid accumulation, and contractures.

Parkinson's disease.With Parkinson's disease, muscle rigidity, weakness, and disuse may produce muscle atrophy. The patient may exhibit insidious resting tremors that usually begin in the fingers (pill-rolling tremor), worsen with stress, and ease with purposeful movement and sleep. He may also develop bradykinesia; a characteristic propulsive gait; a high-pitched, monotone voice; masklike facies; drooling; dysphagia; dysarthria; and, occasionally, oculogyric crisis or blepharospasm.

Peripheral neuropathy.With peripheral neuropathy, muscle weakness progresses slowly to flaccid paralysis and eventually atrophy. Distal extremity muscles are generally affected first. Associated findings include a loss of vibration sense; paresthesia, hyperesthesia, or anesthesia in the hands and feet; mild to sharp, burning pain; anhidrosis; glossy red skin; and diminished or absent DTRs.

Protein deficiency.If chronic, protein deficiency may lead to muscle weakness and atrophy. Other findings include chronic fatigue, apathy, anorexia, dry skin, peripheral edema, and dull, sparse, dry hair.

Rheumatoid arthritis.Muscle atrophy occurs in the late stages of rheumatoid arthritis as joint pain and stiffness decrease range of motion (ROM) and discourage muscle use.

Spinal cord injury.Trauma to the spinal cord can produce severe muscle weakness and flaccid, then spastic, paralysis, eventually leading to atrophy. Other signs and symptoms depend on the level of injury, but may include respiratory insufficiency or paralysis, sensory losses, bowel and bladder dysfunction, hyperactive DTRs, a positive Babinski's reflex, sexual dysfunction, priapism, hypotension, and anhidrosis (usually unilateral).

Other causes

Drugs.Prolonged steroid therapy interferes with muscle metabolism and leads to atrophy, most prominently in the limbs.

Immobility.Prolonged immobilization from bed rest, casts, splints, or traction may cause muscle weakness and atrophy.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

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