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Weakness

By

Michael C. Levin

, MD, College of Medicine, University of Saskatchewan

Last full review/revision Aug 2021| Content last modified Aug 2021
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Weakness refers to loss of muscle strength. That is, people cannot move a muscle normally despite trying as hard as they can. However, the term is often misused. Many people with normal muscle strength say they feel weak when the problem is fatigue Fatigue Weakness refers to loss of muscle strength. That is, people cannot move a muscle normally despite trying as hard as they can. However, the term is often misused. Many people with normal muscle... read more or when their movement is limited because of pain or joint stiffness.

For a person to intentionally move a muscle (called a voluntary muscle contraction), the brain must generate a signal that travels a pathway from

  • The brain

  • Through nerve cells in the brain stem and spinal cord

  • Through nerves from the spinal cord to the muscles (called peripheral nerves)

  • Across the connection between nerve and muscle (called a neuromuscular junction)

Using the Brain to Move a Muscle

Moving a muscle usually involves communication between the muscle and the brain through nerves. The impetus to move a muscle may originate in the brain, as when a person consciously decides to move a muscle—for example, to pick up a book.

Or the impetus to move a muscle may originate with the senses. For example, special nerve endings in the skin (sensory receptors) enable people to sense pain or a change in temperature. This sensory information is sent to the brain, and the brain may send a message to the muscle about how to respond. This type of exchange involves two complex nerve pathways:

  • The sensory nerve pathway to the brain

  • The motor nerve pathway to the muscle

  • If sensory receptors in the skin detect pain or a change in temperature, they transmit an impulse (signal), which ultimately reaches the brain.

  • The impulse travels along a sensory nerve to the spinal cord.

  • The impulse crosses a synapse (the junction between two nerve cells) between the sensory nerve and a nerve cell in the spinal cord.

  • The impulse crosses from the nerve cell in the spinal cord to the opposite side of the spinal cord.

  • The impulse is sent up the spinal cord and through the brain stem to the thalamus, which is a processing center for sensory information, located deep in the brain.

  • The impulse crosses a synapse in the thalamus to nerve fibers that carry the impulse to the sensory cortex of the cerebrum (the area that receives and interprets information from sensory receptors).

  • The sensory cortex perceives the impulse. A person may then decide to initiate movement, which triggers the motor cortex (the area that plans, controls, and executes voluntary movements) to generate an impulse.

  • The nerve carrying the impulse crosses to the opposite side at the base of the brain.

  • The impulse is sent down the spinal cord.

  • The impulse crosses a synapse between the nerve fibers in the spinal cord and a motor nerve, which is located in the spinal cord.

  • The impulse travels out of the spinal cord along the length of the motor nerve.

  • At the neuromuscular junction (where nerves connect to muscles), the impulse crosses from the motor nerve to receptors on the motor end plate of the muscle, where the impulse stimulates the muscle to move.

If the sensation occurs suddenly and is severe (as when stepping on a sharp rock or picking up a cup of very hot coffee), the impulse may travel to the spinal cord and directly back to the motor nerve, bypassing the brain. The result is a quick response of a muscle—by immediately withdrawing from whatever is causing the pain. This response is called a spinal reflex.

Also, the amount of muscle tissue must be normal, and the tissue must be able to contract in response to the signal from the nerves. Therefore, true weakness results only when one or more part of this pathway―brain, spinal cord, nerves, muscles, or the connections between them―is damaged or diseased.

Weakness may develop suddenly or gradually. Weakness may affect all of the muscles in the body (called generalized weakness) or only one part of the body. For example, depending on where the spinal cord is damaged, spinal cord disorders may cause weakness only of the legs.

Symptoms depend on which muscles are affected. For example, when weakness affects muscles of the chest, people may have difficulty breathing. When weakness affects muscles that control the eyes, people may have double vision.

Complete muscle weakness causes paralysis. People may have other symptoms depending on what is causing the weakness. Weakness is often accompanied by abnormalities in sensation, such as tingling, a pins-and-needles sensation, and numbness.

Causes of Weakness

Because malfunction in the same part of the signal pathway causes similar symptoms regardless of cause, the many causes of muscle weakness are usually grouped by the location of the cause (see table Some Causes and Features of Muscle Weakness Some Causes and Features of Muscle Weakness Weakness refers to loss of muscle strength. That is, people cannot move a muscle normally despite trying as hard as they can. However, the term is often misused. Many people with normal muscle... read more ). That is, causes are grouped as those that affect the brain, spinal cord, peripheral nerves, muscles, or connections between nerves and muscles. However, some disorders affect more than one location.

Common causes

Causes differ depending on whether weakness is generalized or affects only specific muscles.

For generalized weakness, the most common causes are

For weakness in specific muscles, the most common causes are

Less common causes

In people with a seizure disorder, one side of the body may become weak after a seizure stops (called Todd paralysis). The weakness usually subsides over several hours.

Fatigue

Many people report weakness when their problem is actually fatigue Fatigue Fatigue is when a person feels a strong need to rest and has so little energy that starting and sustaining activity is difficult. Fatigue is normal after physical exertion, prolonged stress... read more . Common causes of fatigue include a severe illness, cancer, a chronic infection (such as HIV infection Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection is a viral infection that progressively destroys certain white blood cells and can cause acquired immunodeficiency syndrome (AIDS). HIV is transmitted... read more Human Immunodeficiency Virus (HIV) Infection , hepatitis Overview of Hepatitis Hepatitis is inflammation of the liver. (See also Overview of Acute Viral Hepatitis and Overview of Chronic Hepatitis.) Hepatitis is common throughout the world. Hepatitis can be Acute (short-lived) read more , or mononucleosis Infectious Mononucleosis Epstein-Barr virus causes a number of diseases, including infectious mononucleosis. The virus is spread through kissing. Symptoms vary, but the most common are extreme fatigue, fever, sore throat... read more Infectious Mononucleosis ), heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) , kidney failure Overview of Kidney Failure This chapter includes a new section on COVID-19 and acute kidney injury (AKI). Kidney failure is the inability of the kidneys to adequately filter metabolic waste products from the blood. Kidney... read more , liver failure Liver Failure Liver failure is severe deterioration in liver function. Liver failure is caused by a disorder or substance that damages the liver. Most people have jaundice (yellow skin and eyes), feel tired... read more , anemia Overview of Anemia Anemia is a condition in which the number of red blood cells is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts... read more , chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome, also called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), refers to long-standing severe and disabling fatigue without a proven physical or psychologic... read more , fibromyalgia Fibromyalgia Fibromyalgia is characterized by poor sleep, fatigue, mental cloudiness, and widespread aching and stiffness in soft tissues, including muscles, tendons, and ligaments. Poor sleep, stress, strains... read more , and mood disorders (such as depression Depression A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to... read more ).

Multiple sclerosis can cause fatigue that increases when people are exposed to heat and humidity.

Evaluation of Weakness

First, doctors try to determine whether people are weak or simply tired. If people are weak, doctors then determine whether the weakness is severe enough or worsening quickly enough to be life threatening. Doctors also try to identify the cause.

Warning signs

In people with weakness, the following symptoms are cause for concern:

  • Weakness that becomes severe over a few days or less

  • Difficulty breathing

  • Difficulty raising the head while lying down

  • Difficulty chewing, talking, or swallowing

  • Loss of the ability to walk

When to see a doctor

People who have any warning sign should go to an emergency department immediately. Immediate medical attention is crucial because weakness accompanied by a warning sign can worsen quickly and cause permanent disability or be fatal.

People without warning signs should call their doctor. The doctor can decide how quickly they need to be seen based on their symptoms and other disorders they have.

If the weakness worsens gradually (over months to years), people should discuss the problem with their doctor at their next visit.

What the doctor does

Doctors ask people to describe in detail what they are experiencing as weakness. Doctors ask

  • When the weakness began

  • Whether it began suddenly or gradually

  • Whether it is constant or is worsening

  • Which muscles are affected

  • Whether and how the weakness affects the ability to do certain activities, such as breathing, brushing their teeth or hair, speaking, swallowing, standing up from a seated position, climbing stairs, and walking

  • Whether they have other symptoms that indicate malfunction of the nervous system, such as speech or vision problems, loss of sensation or memory, or seizures

  • Whether any activity or condition (such as heat or repetitive use of a muscle) makes the weakness worse

What seems to be sudden weakness is sometimes gradual weakness, but people do not notice it until they can no longer do something, such as walking or tying their shoes.

Based on the description of weakness, doctors can often identify the most likely causes, as for the following:

  • A muscle disorder: Weakness beginning in the hips and thighs or the shoulders (that is, people have difficulty standing up or lifting their arms overhead) and no effect on sensation

  • A peripheral nerve disorder: Weakness beginning in the hands and feet (that is, people have difficulty lifting a cup, writing, or stepping over a curb) and loss of sensation

Doctors also ask about other symptoms, which may suggest one or more possible causes. For example, if people with back pain and a history of cancer report weakness in a leg, the cause may be cancer that has spread and put pressure on the spinal cord.

Doctors ask about conditions that increase risk of disorders that cause weakness. For example, They ask people whether they have high blood pressure and atherosclerosis (which increase the risk of stroke) or have traveled to area whether Lyme disease is common.

People are asked about symptoms that suggest fatigue Fatigue Fatigue is when a person feels a strong need to rest and has so little energy that starting and sustaining activity is difficult. Fatigue is normal after physical exertion, prolonged stress... read more or another problem, rather than true muscle weakness. Fatigue tends to cause more general symptoms than true muscle weakness, and fatigue does not follow a particular pattern. That is, it is present all the time and affects the whole body. People with true muscle weakness often report difficulty doing specific tasks, and the weakness follows a pattern (for example, becomes worse after walking).

Doctors ask about past and current use of drugs, including alcohol and recreational drugs.

Whether family members have had similar symptoms can help doctors determine whether the cause is hereditary.

Doctors observe how the person walks. How people walk may suggest the disorder that is causing symptoms or its location. For example, if people drag a leg, do not swing one arm as much as the other when walking, or both, their symptoms may be caused by a stroke. Doctors also check for other signs that the nervous system is malfunctioning, such as loss of coordination or sensation.

Muscles Motor Nerves When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the nervous system. Examination of the nervous system—the... read more are checked for size and unusual unintended movements (such as involuntary twitches and shaking). Doctors note how smoothly muscles move and whether there is involuntary resistance to movement (detected when doctors try to move a muscle that they have asked the person to relax).

Reflexes Reflexes When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the nervous system. Examination of the nervous system—the... read more are checked. Reflexes are automatic responses to a stimulus. For example, doctors test the knee jerk reflex by gently tapping the muscle tendon below the kneecap with a rubber hammer. Normally, the knee then jerks involuntarily. This evaluation helps doctors identify which part of the nervous system is probably affected, as for the following:

  • The brain or spinal cord: If reflexes are very easy to trigger and are very strong

  • The nerves: If reflexes are hard to trigger and are slow or absent

Muscle strength Muscle strength When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the nervous system. Examination of the nervous system—the... read more is tested by asking the person to push or pull against resistance or to do maneuvers that require strength, such as walking on the heels and tiptoes or standing up.

A general physical examination is done to look for other symptoms that may suggest a cause, such as shortness of breath (possibly caused by a heart or lung disorder).

Generally, if the history and physical examination do not detect specific abnormalities that suggest a brain, spinal cord, nerve, or muscle disorder, the cause is likely to be fatigue.

Table
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Testing

Other testing is done based on where doctors think the problem is:

  • A brain disorder: Magnetic resonance imaging (MRI) or, if MRI is not possible, computed tomography (CT)

  • A spinal cord disorder: MRI or, if MRI is not possible, CT myelography and sometimes a spinal tap (lumbar puncture)

  • A peripheral nerve disorder (including polyneuropathies) or a neuromuscular junction disorder: Electromyography and usually nerve conduction studies

  • A muscle disorder (myopathy): Electromyography, usually nerve conduction studies, and possibly MRI, measurement of muscle enzymes, muscle biopsy, and/or genetic testing.

Occasionally, MRI is not available or cannot be done—for example, in people who have a pacemaker, another implanted metal device, or other metal (such as shrapnel) in their body. In such cases, another test is substituted.

For CT myelography Myelography Diagnostic procedures may be needed to confirm a diagnosis suggested by the medical history and neurologic examination. Electroencephalography (EEG) is a simple, painless procedure in which... read more Myelography , CT is done after a needle is inserted into the lower back to inject a radiopaque contrast agent (which can be seen on x-rays) into the fluid that surrounds the spinal cord.

If people have no symptoms besides weakness and no abnormalities are detected during the examination, test results are usually normal. However, doctors sometimes do certain blood tests, such as

  • A complete blood cell count (CBC)

  • Measurement of levels of electrolytes (such as potassium, calcium, and magnesium), sugar (glucose), and thyroid-stimulating hormone

  • Erythrocyte sedimentation rate (ESR), which can detect inflammation

Blood tests are sometimes done to evaluate kidney and liver function and to check for the hepatitis virus.

Treatment of Weakness

Physical and occupational therapy can help people adapt to permanent weakness and compensate for loss of function. Physical therapy can help people maintain and sometimes regain strength.

Essentials for Older People: Weakness

As people age, the amount of muscle tissue and muscle strength tend to decrease. These changes occur partly because older people may become less active but also because the production of the hormones that stimulate muscle development decreases. Thus, for older people, bed rest during an illness can have a devastating effect. Compared with younger people, older people start out with less muscle tissue and strength at the beginning of the illness and lose muscle tissue more quickly during the illness.

Drugs are another common cause of weakness in older people because older people take more drugs and are more susceptible to side effects of drugs (including muscle damage and problems with nerves).

When evaluating older people who report weakness, doctors also focus on conditions that do not cause weakness but interfere with balance, coordination, vision, or mobility or that make movement painful (such as arthritis). Older people may mistakenly describe the effects of such conditions as weakness.

Regardless of what is causing weakness, physical therapy can usually help older people function better.

Key Points

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