Suggest treatment for fatigue and back pain

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Posted on Thu, 30 Apr 2015 in General Health
Question: Dear Dr. Saghafi,

I am writing with an update on my condition and how I am doing.

Firstly, I would like to say that I am doing very well. I found an excellent physiotherapist and my back pain and urological problems have markedly improved thanks to lots of exercise that I take.

I found that my fatigue had essentially 2 components - one had to do with possible slight compression of arteries at the back of the neck due to cervicobrachial syndrome - I'm working on this in physiotherapy. The second component was general psychological well-being - and here the XXXXXXX has done wonders. Magic is there. Really.

The tremor and hand dyscoordination are mildly present but no longer something that bothers me in every-day activity. The same applies to occasional speech, memory and concentration difficulties.

The plan of treatment I have prescribed to myself is EEG biofeedback, EMG biofeedback to help with the bladder and muscle control, vitamin supplements, cheerful mood and an optimistic outlook.

The only thing that persists stubbornly is the reading problem. You wouldn't believe (or maybe would) how incredibly hard it has been to find a neuroophtalmologist in this country who has a video-oculograph to measure saccadic eye movements while reading... ergh... I still have not had my eyes examined but it's on its way.

My question for you today is twofold:
1) Last week I underwent a detailed EEG examination at the greatest capacity in neurology in the CR. He found the following: Basic rhythm is high frequency highly irregular (in frequency) alpha, relatively higher on the left, diffused theta to XXXXXXX sometimes higher sharp alpha on the whole surface, AAR +, i. XXXXXXX doesn't change much. Analysed sequences both short and long show almost identical frequency 10.5 on the right and 11 Hz on the right. XXXXXXX 18/6 with a large increase in XXXXXXX on the left and occipital bilateral (during psychotests). Without focal or EP changes.

The finding points to an infectious origin. Suspected osteomyelitis and secondary brain inflammation.

Now - this is quite interesting. Remember that in 2013 late Autumn I had my wisdom teeth extracted. Straight after that I had my first temporal lobe seizures, which repeated every time the doctors tightened up my braces, which I had had for 2 years by then. Preceding that - chronic right TMJ pain for as long as I had the braces.

In January 2014 add bronchitis, with right TMJ pain, further neurological symptoms.

CT scan of the head reveals a large asymmetry, where the right TMJ looks as if it had suffered from trauma. No MRI done.

Sounds far-fetched? Perhaps... But I am quite convinced that a secondary inflammation caused my problems. Where did that come from? TMJ? perhaps?

Without any kind previous information the XXXXXXX pointed to my right TMJ as a source of some infection... it's not scientific proof (and I'm a man of science don't forget) but whatever - as crazy as it sounds he's been able to help me manipulate my psyche with immediate and permanent benefits so I trust this guy and his magic.

What things speak against this hypothesis? well it seems really far fetched and unlikely.. There's almost no literature on it but I've come across a few people online who had temporal seizures after wisdom teeth extraction...

2) After the removal of my braces I got a removable retainer which I used until January this year when I had quite a bad infection so I stopped using it. Last week I went to see my orthodontist for a check up and he insisted that I restart using the retainer. After 1 night I got really dull pain in my right TMJ radiating into both lower and upper teeth and it's painful to drink any kind of liquid... The pain is like a milder version of when they take out your tooth..

Well well... What do I do about this?

I would prescribe myself an MRI of the right TMJ and I wouldn't use the retainer until the results are obtained.

Naturally, i don't wanna get brain infection again, but also don't wanna get crooked teeth again... Tough call.

Otherwise I'm doing surprisingly well. I'll be in touch about the results of all the biofeedback... When that's finished and I still have reading difficulty I'll turn to Dr. XXXXXXX

All the best and thank you for your answer.

James

P.S. don't get the impression that I'm again obsessively focused on the diagnosis... Far from it - I've been spending most of my time on getting better. However, I face a biblical dilemma of whether to attempt to use the retainer again or give it up completely and precaution is my god now. For that, I kind of have to reach a conclusion about the correct diagnosis. There and back again. Does it make sense?

XXXX
doctor
Answered by Dr. Dariush Saghafi 28 hours later
Brief Answer:
So nice to hear from you again and good to hear you're improving

Detailed Answer:
As I had mentioned in my email to you...my intent is answer your questions in stages and since it has been a long wait since you submitted and since this network only gives a limited amount of time to answer these questions before sending to the general pot for all to have a go at it...I'm going to put something down for the first part of your question on the EEG because there are a couple of observations I have to make about your analysis...which I'm sure is an analysis in part given to you by the neurologist.

So let me just clarify a couple of observations on the EEG before I submit this so hopefully, it doesn't get gobbled up by some other rogue physicians looking for scraps of questions to add to their belt buckles and wallets! HA!

1) Last week I underwent a detailed EEG examination at the greatest capacity in neurology in the CR. He found the following: Basic rhythm is high frequency highly irregular (in frequency) alpha, relatively higher on the left, diffused theta to XXXXXXX sometimes higher sharp alpha on the whole surface, AAR +, i. XXXXXXX doesn't change much. Analysed sequences both short and long show almost identical frequency 10.5 on the right and 11 Hz on the right. XXXXXXX 18/6 with a large increase in XXXXXXX on the left and occipital bilateral (during psychotests). Without focal or EP changes.

The finding points to an infectious origin. Suspected osteomyelitis and secondary brain inflammation.

>>>> Let's pick this EEG reading apart a little. Now mind you I am not an electromyographer by trade. My knowledge is that of any normal General Adult Neurologist who does read and understand the interpretations of electrophysiologists. My subspecialty work is in HEADACHES. Having said that there are certain things in this interpretation that I have really never heard of and there are a couple of things I take exception with so just to raise those points first.

The things I've never heard of.....:

1. Highly Irregular basic alpha rhythm with an asymmetric frequency side to side in an awake, alert, and otherwise normally conscious individual such as yourself.

2. Aside from Herpes Simplex Viral Infections which show a very specific EEG pattern called PLEDS (Periodic Lateralized Epileptiform Discharges) I am unaware of any other type of infection of the brain such as an absecess or meningitis even which has a specific signature pattern that is recognizable and able to make a diagnosis as you've suggested:

"The finding points to an infectious origin. Suspected osteomyelitis and secondary brain inflammation."

I'm not sure WHICH finding you believe POINTS to the infectious origin.

3. Left sided alpha dominance. Typically, the dominance of the alpha rhythm is greater on the right side with higher voltage. A difference of 20-50% is considered a normal variant is does not necessarily indicate anything pathological. Greater than a 50% difference in voltage and rhythm frequency is significant an needs to be correlated to clinical symptoms....otherwise, it's simply a normal variant.


For now and for the purpose of filing something with the network I am going to stop here and send this on to you. I will pick up with more comments on the EEG upon your return message.

Again, very nice to hear you're doing better.




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi 2 hours later
Hi, thanks!

Well I don't know what the professor meant when he said that the findings point to an infectious origin. I just provided a word-by-word translation. I want to ask him personally when he's fee for a consult in a couple of weeks.

I'm not saying I agree with his conclusions.. that's kind of too far deep into the science for me to even consider that I might be able to understand it...

I hope he just didn't put it there .... for fun... I dunno :-)
doctor
Answered by Dr. Dariush Saghafi 23 hours later
Brief Answer:
Just the skinny, huh?

Detailed Answer:
Ok...just the nuts and bolts of what I think.....I feel kind of naked doing this but here goes.....

Ahem--- EEG with all those findings don't mean very much to me since some of the findings are normal variants and in my opinion couldn't explain any of the symptoms you had such as Temporal lobe seizures...if that's what they were, or other funny things that were going on. Other findings such as XXXXXXX waves in a patient who is perfectly conscious, functional, and not halfway encephalopathic or in Stage 3 sleep makes no sense. Theta and XXXXXXX waves typically should not be present at all in an awake and active individual.

Bottom line, I don't get the same interpretation or IMPORTANCE of the myriad of changes in electrical patterns...but honestly, I don't see most of them as anything but normal variants and I doubt they explain much.

No such thing as a specific infectious etiology suggested by ANY PATTERN OF EEG that I know of but I am glad to ask one of my colleagues at the hospital tomorrow.

I'm going to need to stop at this point for tonight....but will return for the last interpretation phase tomorrow which will be make the 3 question tally, correct? So we can tackle the TMJ question on the next response.

I don't have a hard time believing that you could've suffered seizures after wisdom teeth being taken care of or removed for a number of reasons so I don't disagree or find it difficult to explain that. Funny thing is that your EEG really doesn't show an active epileptogenic focus.

Cheers!

Cheers.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi 2 hours later
Interesting... Thank you.

I'm not sure I understand well what you said - are the delta-theta waves normal or do they signify something pathological? If they should not be present in a healthy individual, perhaps they are those that point to an infectious origin?

How about inflammatory (auto-immune) aetiology of the EEG pattern? In individuals after ADEM or MS?

Best,

XXXX
doctor
Answered by Dr. Dariush Saghafi 23 hours later
Brief Answer:
EEG reading contains questionable elements given your cognitive abilities

Detailed Answer:
I think the EEG read contains things that are not clinically relevant due to their being normal physiological variants coupled with things which don't quite make sense since they are TYPICALLY seen in pathological states or are paradoxically present (theta waves in a fully awake and alert individual such as yourself with good mental capacities; despite either your symptoms or physical findings, often represents SERIOUS ORGANIC BRAIN DISEASE which would not be compatible with your good thinking abilities and thought content).
XXXXXXX waves are mostly reported in people in deep sleep although they can be present in a small amount over the occipital areas (where they concentrate mostly anyways in an awake individual) and are often not able to be correlated to anything going on in an awake, oriented, and alert individual..

There is no EEG pattern that I am aware of which is SPECIFIC to any type of pathology in the brain having to do with INFECTION except HERPES SIMPLEX which causes PLEDS. Otherwise, the only thing that an EEG is really GREAT AT DETECTING with any degree of SPECIFICITY is epileptic activity or to a lesser extent levels of consciousness and alertness although one must a little careful since people in coma can have an EEG that look like the person is awake and active...yet they are actually in coma.....referred to as ALPHA COMA.....

Other than that there is no EEG pattern that is able to point with certainty to ADEM, MS, or bacterial infections such as a meningitis, toxoplasmosis, histoplasmosis, fungal infections, etc. etc. There are generalities that can be looked for in the EEG wave patterns clearly associated with all those specific states of infection but nothing that will leave a brain still "sparking" after the infection has cleared. And as far as I know you do not have ANY TYPE of infectious process which is chronic or ongoing that could leave the fingerprint of what has been read.

EEG is not a SENSITIVE test for the detection of autoimmune brain disease. CSF and blood markers beat that test out everyday of the week. If you can't find it in those fluids...or if you do...then, that's the answer...EEG will not add anything to the diagnosis once laboratory evidence is positive for something.

Of course, there is no laboratory or CSF marker which is specific either for MS, Lupus, ADEM, or even a viral syndrome. It still comes down to clinical judgement coupled with imaging results.

My epileptologist colleague agrees with my impressions that I've mentioned. He thinks that the EEG findings were "overread" and thinks there should've been more clinical information taken into consideration and commented on before finalizing the report.. An EEG read is really only as good to a clinician as the explanation that the reader can provide which focuses on why the patient was sent in the first place.

Maybe I should've started this whole discussion with that last sentence in the above paragraph. Too late! HAHA!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi 49 minutes later
Hi,

thanks! now it's much clearer. From the lumbar puncture results, there is an ongoing present mild secondarily-induced inflammation in my brain right now (more like an inflammation that's slowly going away I guess). Could that perhaps be causing those strange brainwaves?

Briefly, what are those generalities that can be looked for that correlate with autoimmune processes? I guess they're not theta or XXXXXXX brainwaves?

The thing is that this is not the first EEG that found the theta and XXXXXXX waves. The week-long monitoring in hospital did so as well; plus another 15-minute EEG.

btw, thanks for asking an epileptologist, much appreciated!

Coming back to the secondarily induced inflammation - I'm looking for the place in my body where the inflammation originated and from where it got to the brain... TMJ or the wisdom teeth holes seem like good candidates given my history, although just to an uneducated mind of mine.

Thanks again.

All the best.



doctor
Answered by Dr. Dariush Saghafi 20 hours later
Brief Answer:
Brainwaves

Detailed Answer:
A most intriguing topic but unfortunately, to the best of my knowledge it is one of the least understood of all diagnostic tests that we have for the brain in terms of what the results really mean clinically and especially where pathology is concerned. You would think that since brainwaves were "discovered and a way to record them implemented in about 1930 that we'd be much more knowledgeable as to what certain disease signatures were or what the general effects of inflammation or infection were or even what certain rhythms indicated with respect to pathology when human beings were engage in something as universally simple as quiet physiological sleep.

But unfortunately, the SCIENCE does not yet exist that is universally grounded and accepted and so it is still a "wide open field" and speculation can be as reasonable to forward in terms of explaining different phenomenon as lab data which often appears to be of one type when looking at one group of patients but then, rapidly changes and becomes different in a different group of patients. I believe the problem lies somewhat in the fact that is is hard to make the call when we see certain waveforms peeking out in a single recording for a person whether or not that represents pathology or normal variant for that individual. In a person with a fixed deficit of some type (e.g. stroke, bullet wound, abscess formation, congenital btain malformation) it may be easier to interpret recordings if they are constantly the same. But in a person without any such physical focality to speak of (such as yourself) a 20 minute recording that demonstrates some admixture of XXXXXXX and theta waves (in addition to the balance of what your study read) is no more specific when trying to "guess" the pathology than a single abnormally high blood pressure reading would be to interpret in a person who is normally not known to be hypertensive. The fact is, we know that blood pressures change CONSTANTLY and so we don't worry nor do we try interpreting a single aberrant pressure as indicative of anything important. If clinical signs are present that seem to be consistent with high blood pressure of an acute nature such as headache, nausea, vomiting, blurred vision, etc. then, we have more data to chew on and sometimes that makes things easier to explain and other times it could add confusion to the picture.

Again, always trying to come back to your case, XXXXXXX and theta waves and what they mean I believe is entirely speculative and so the doctor who read your study is at his XXXXXXX to offer opinion as to what all the different waves may mean but our standardized understanding of those waveforms (theta and XXXXXXX especially in your study) are not to going to check with what is currently known about them when taking clinical data into account.

Bottom line? I CANNOT DISAGREE with anyone who would propose that one explanation of the generators of the mixed picture of XXXXXXX and theta waves could be some inflammatory process in the brain which is either resolving or ongoing if it were due to an autoimmune problem of some sort. At the same time, I can't find evidence in the literature which firmly supports the supposition either. It's simply not something that is well known at this time.

Generalities of EEG interpretation when it comes to processes such as MS, ADEM, Lupus cerebritis, cerebral vasculitis are those of SLOWING of the background rhythm (the alpha waveform) and that's the SINGLE MOST CONSISTENT and clinically relevant finding that can be expressed in patients with autoimmune diseases affecting the brain. Nothing more than that....generalized slowing. If there happens to be a predominance of a theta rhythm or a XXXXXXX rhythm or anything else that can be called on a study then, it is up to the discretion to interpret whether or not that is related to the state of alertness of the patient or not (i.e. is the patient awake and alert, drowsy and encephalopathic, or asleep/comatose). If such slowing the EEG or such predominant background rhythms can be localized to a certain area of the brain then, it could be certainly theorized the GENERATOR for that particular rhythm or slowing is at that location. That would be even more believable if an MRI were to show an area of stroke, PLAQUE formation in MS, or damage as in trauma. Otherwise, it would be speculative (especially on surface recordings) as to exactly WHERE the generator was....much as when a person wants to say that their headache is "RIGHT HERE!" as they point to the back of their head. The assumption being that the GENERATOR OF THE ABNORMAL PAIN SIGNAL AND HENCE THE AREA BEING AFFECTED IN THE BRAIN were right where the headache was being felt. Sometimes that is true but often it is not.

So again, SLOWING of the dominant rhythm is what we generally talk about and look for in a person who has pathological findings cognitively, behaviorally, or who is suffering a flareup or bout of some autoimmune process. The presence of XXXXXXX and theta waves may or may not be relevant to that discussion.

If there was an infection that actually got into the brain then, oral source is as good as pharyngeal or other respiratory point of contact as any.

I never used braces for my teeth when growing up...neither did most of my sibs.....that rite of passage was only beginning to come of age. Now, you can't be a teenager without having your own personal set(s) of braces. I've got over $10,000 worth of bills for all my kids to prove that..though I always swore I would never fall into that trap. My wife had other plans!




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Dariush Saghafi 4 hours later
Oh wow, thanks for such a detailed and educational answer!

I'm copy pasting this whole discussion. In September I'm staring a degree in Cognitive Science at University College London and this will come in extremely useful. Actually, all our discussions are worth keeping and coming back to.

Really, what this shows is that there's an XXXXXXX number things which just can't be found on the internet, despite the "infinite" amount of information that is there.

There's no way I could have learnt any of this anywhere unless I went through the same process as you - getting medical education and many years of experience. It's very humbling.

I would've said that it's a shame that from the dozens of doctors (maybe reaching one hundred now!) I have not met a single one with such immense amount of knowledge, expertise and humility as you, not to mention the interest you take in healing your patients. What I say instead is that it's amazing that there are people like you accessible to mere mortals such as me.

What all of this also shows me is the limitations of research and science and how little we actually know about the human body, especially the brain. It points to a nice area of research I will hopefully soon be involved in.

You've helped me make several important realisations and get many insights into science in general. For that I owe you my sincere gratitude.

Not to mention the fact that you helped me get to the bottom of things of my mysterious 'health' problem, which may remain shrouded in mystery, yet I am satisfied with the conclusion that some kind of inflammatory process took place on the borderline between psychological and neurological.

If there's one thing I've realised through this process it is that I am consciousness and my body is the manifestation of my inner state. Therefore, any kind of disease is psychogenic, not in the medical sense of the term, but from the broadest perspective.

I have made an interesting observation - when I stopped wearing braces everything started getting better, especially when I stopped using the retainer. When I restarted, the fatigue came back together with back pain. I've realised that the fatigue was in great part due to some sort of headache (and guess who suggested that first?) with a shooting pain behind the eyes and spastic blinking. Guess what? I removed the braces, took a relatively heavy dose of ibuprofen - headache and fatigue are gone. (of course, I don't need to keep using ibuprofen, it was just a quick relief).

Since I got my first seizures immediately after wisdom teeth removal,.... since the fatigue and back pain started and got worse during the orthodontic treatment... and since all the other symptoms started a few months after wisdom teeth extraction... I don't wanna blame everything on the braces (see above). BUT I do think they made everything worse if not contributed to the infection and inflammation, if not directly caused it. I've always felt that it was somehow related, albeit in mysterious ways.

For these reasons I've decided to stop using the retainer and consult a jaw specialist again. Better have crooked teeth than brain inflammation.

Now "off I go" onto recovery and A LIFE. And what a ride has it been! I will stay in touch about my progress and when I'm contacting Dr. XXXXXXX

(yeah I've made two similar endings in the past HAHA and here I am back.... maybe I'll provide some data from video-oculography for you to look at but otherwise I guess i release you from duty :-)

Thank you!

All the best,

XXXX



doctor
Answered by Dr. Dariush Saghafi 14 hours later
Brief Answer:
Braces and the trouble one can get into to

Detailed Answer:
Thank you very kindly for your words of praise. I wish I felt quite the enthusiasm of having really been of that much import to your improvements. If anything I've said along the way has been of value then, my mission was accomplished.

I'm happy to hear of your ongoing improvements as they occur and how your life unfolds in the future. Your profession will be eternally grateful for your services and so too will those you serve. Your persistence and unquenchable thirst for knowledge is what paved the path to finally discovering the Lost City of Atlantis.

I agree.....braces in your case are likely problematic....steer clear.....as I said, I never had braces, never owned contact lenses, and never felt the need to blow dry my hair or put mousse and other chemicals on top of head.....I am still and always be mortal but I believe I've taken at least a half dozen or more problems off the table of what I'll have to worry or face as my time draws near!

HAHA!

Be well and be happy.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Dariush Saghafi

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