facial or limb weakness in adults - NICE guidance - suspected neurological conditions - recognition and referral

Last edited 05/2019

Limb or facial weakness in adults

Summary points from NICE guidance relating to limb or facial weakness in adults are:

Sudden-onset limb weakness

• be aware that sudden-onset weakness, even in restricted distribution (for example, sudden hand weakness), may be caused by a stroke or transient ischaemic attack - assess possible TIA/stroke

Rapidly progressive symmetrical limb weakness

• refer immediately adults with rapidly (within 4 weeks) progressive symmetrical limb weakness for neurological assessment and assessment of bulbar and respiratory function

Severe low back pain together with other symptoms

• refer immediately, in line with local pathways, adults who have severe low back pain radiating into the leg and new-onset disturbance of bladder, bowel or sexual function, or new-onset perineal numbness, to have an assessment for cauda equina syndrome

Rapidly progressive weakness of a single limb or hemiparesis

• refer urgently adults with very rapidly (within hours to days) progressive weakness of a single limb or hemiparesis for investigation, including neuroimaging, as per NICE urgent brain and central nervous system cancers guidance

Slowly progressive limb or neck weakness

For adults with slowly (within weeks to months) progressive limb or neck weakness

• refer for an assessment for neuromuscular disorders, based on recognition and referral for possible motor neurone disease
  
  
• refer urgently if there is any evidence of swallowing impairment
  
  
• refer immediately if there is breathlessness at rest or when lying flat

Lower limb claudication symptoms

• be aware that lower limb claudication symptoms in adults with adequate peripheral circulation might be caused by lumbar canal stenosis and need specialist assessment and imaging.

Recurrent limb or facial weakness as part of a functional neurological disorder

• be aware that, for adults who have been diagnosed with a functional neurological disorder by a specialist, recurrent limb weakness might be part of the disorder and the person might not need re-referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed as described in the relevant sections of this guideline
  
  
• advise adults with limb or facial weakness ascribed to a functional neurological disorder that their limb or facial weakness might fluctuate and evolve over time and might increase during times of stress.

Compression neuropathy

For adults with clear features of compression neuropathy of the radial nerve, common peroneal nerve or ulnar nerve and no features of a nerve root lesion (radiculopathy):

• refer to orthotic services for a splint review the symptoms after 6 weeks, and
  
  
• refer for neurological assessment if there is no evidence of improvement.

For adults with features of radiculopathy, see cervical or lumbar radiculopathy

• advise adults with compression neuropathy to avoid any activity that might lead to further pressure on the affected nerve

Bell's palsy

• do not routinely refer adults with an uncomplicated episode of Bell's palsy (unilateral lower motor neurone pattern facial weakness affecting all parts of the face and including weakness of eye closure) and no evidence of another medical condition such as middle ear disease
  
  
• advise adults with Bell's palsy about eye care, and explain that Bell's palsy improves at different rates and maximum recovery can take several months
  
  
• consider referring adults with Bell's palsy who have developed symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) 5 months or more after the onset of Bell's palsy for neurological assessment and possible treatment.

Reference:

• NICE (May 2019). Suspected neurological conditions: recognition and referral