Brief Answer:
Expert Counseling- An EXCELLENT IDEA for your well being in the New Year!

Detailed Answer:
Good evening sir and many thanks for specifically choosing me as your neurologist of choice to help with your concerns.

I understand the summary statements you've made about your condition but am less clear on the exact way in which I can be of the most service to you since I believe you have all but explained in rather textbook fashion the underpinnings and framework of what is referred to in the modern day as Health Anxiety. Please understand that I am a NEUROLOGIST whose specialty area is that of the brain, the spinal cord, their connections to muscles, organs, and how all this functions or malfunctions in related disease states.

Therefore, your best utilization of my services is in the recognition of possible organic neurological disease followed by ways to confirm/diagnosis the condition and finally, options to treat or intervene in order to cure, cope, or at least understand what is afoot.

My expertise wanes when we go outside that rubrick. Having said that I have treated many people worried about things such as ALS, MS, PARKINSON'S, ALZHEIMER'S, etc. and so I do have experiential knowledge of what things look like when there is a lot of anxiety overshadowing organic disease. However, because I am a neurologist I am not well trained in the aspects of how best to intervene or TREAT the anxiety half of the equation. I hope this makes sense to you.

I did find a website which is actually a blogsite which I felt was quite interesting and spot on in a number of areas when it comes to HEALTH ANXIETY. I liked the fact that the distinction was made between a person suffering from this entity and HYPOCHONDRIASIS. I am confident that you are in the former and not the latter category. So that you may also enjoy the same insights and philosophies of the gentleman who runs the blogsite I am supplying you with a link for your consideration. I really like it and plan to use it for more of my patients who come back to me from time with time with additional anxiety issues related to their medical states. In fact, the site is run by a countryman of yours...I think he's got some brilliant ideas. Hope you get as much from reading his work as I did:

http://www.nomorepanic.co.uk/articles/healthanxiety

Now, to your statements about twitching. I notice that in your medical history you were previously diagnosed with HL and are now in remission since 2005. Congratulations to you and your doctors for putting that nuisance disease in its place. Now you've got muscles that are twitching in the calf and other places which has been going on for a few months and you have brought this up to your doctors who have competently and diligently worked to discover the cause of the problem but have found nothing of import. At the very least they've not found any signs of muscle weakness, loss of strength, or muscle mass loss (atrophy). And so once again, congratulations on coming up with that very important clean XXXXXXX of health.

Therefore, what we're left with is a condition of twitching of muscles which started in the left calf and has become more widespread over several months.

In my practice, my choice of diagnostic tests from the neurological side of things (and after all appropriate labs have been obtained and confirmed) would be an MRI of the brain and very possibly the spinal cord (depending upon where the majority of muscle twitching is coming from) with gadolinium contrast. This study can effectively RULE OUT the diagnosis of MS if no lesions can be demonstrated of a demyelinating nature. I see no point in doing anything more aggressive such as a spinal tap or any other sophisticated diagnostic imaging if the MRI were clean.

As far as the issue of ALS, I'm sure you must know from your reading that 30 years old is far too young to be legitimately worried about such a problem though it certainly is documented in the literature that 30 year olds have been found to have contracted ALS. However, those CONFIRMED patients also had a clinical picture quite different than yours and if we look even more carefully you may also be very hard pressed to find ANYBODY presenting with nothing more than muscle twitching in the ABSENCE of muscle weakness or muscle mass loss.

There is a condition also known as Benign Fasciculation Syndrome for which I even came up with some prose since I was being asked so frequently about ALS when the Ice Bucket Challenge came out some 2 years ago. I am going to include that in this writing. Tell me what you think of the poem and how well you may resonate with what it tells us:

An Ode to BFS (Benign Fasciculation Syndrome)

If it twitches while in song,
If it twitches and it's strong,
If it twitches, twitches,
Twitches, TWITCHES ALL night long.

If it twitches here or there,
If it twitches everywhere,
Yet the fibers do not rustle,
When you go to make a muscle.

And you've been to Doctor 1,
And you've been to Doctor 2,
And you've been to Doctor 3,
But they all just look at you!

And you've done your labs,
Your sticks, your jabs,
And those painful EMG's
To be told you're fine,
You're good- Go home
An allergy to Cheese?

So finally, you arrive at home
And those muscles twitch no less.
Think back to what your Granny said,
"Dear Child- it's BFS!"

Dariush Saghafi, MD


I realize you haven't mentioned an EMG/NCV study yet but I wouldn't necessarily advocate for one either based on the clinical and historical information that all you have is twitching and nothing more. If twitching became MYOCLONIC JERKING (much more forceful jumping of limbs or joints) or if definite weakness or muscle atrophy began showing up either by your clothes getting loose, noticing a significant unprovoked weight loss, or there being a noticeable thinning down of the meat of your fingers and the muscles on the palms then, an electrical study would be in order. Otherwise, I would continue to search for metabolic or other causes for the twitching and simply distract yourself away from caring about it anymore.

And there is one other detail you should remember and that is neither ALS nor MS have any specific blood tests that can diagnose them. Still to this day we have clinical judgement calls which are the accepted way of diagnosing the condition. While imaging studies and some labs are highly suggestive of either of these conditions it is the clinical/historical information as well as the clinician's perspective that leads to the diagnosis. Of course, in MS and ALS there are such things as biopsies that could be taken which can definitely identify the disease under a microscope when you 've got a seasoned and diligent pathologist. However, in MS I've never had any opportunity to actually have to biopsy a brain or spinal cord to MAKE a diagnosis. I believe that would border on the ridiculous, not to mention virtually unnecessary/unethical. Clinical criteria are tight enough and the science is at a point where a doctor's diagnosis is quite adequate based upon his examination results. In ALS, there have been those instances when a nerve biopsy was the test of choice when EMG/NCV studies were either borderline or inconclusive.

Therefore, I must conclude that based upon information you've provided I find no causes to be clinically suspicious of motor neuron disease either of the ALS or any other type. That is not the same as saying that such diseases will never happen but it's simply not a diagnosis that can be seriously considered as a neurologist based on the data at hand.

As far as the MS is concerned....I have no issues with keeping that idea front and center for the time being (though it's not necessarily in the top 3 possible diagnoses with your symptoms) and if I were your doctor I'd be happy to order more definitive diagnostic tests in order to rule MS out but I'd do nothing more at this point than an MRI of the head and spinal cord (based upon location of fasciculatory activity). If diffusely spread out all over the body then, I would consider doing the 3 segments of the cord (cervical, thoracic, and lumbar). If the fasciculations are all localized to upper extremities and chest only then, I would recommend cervical spine and maybe upper thoracic only. If confined to the legs then, I would consider doing lower thoracic and lumbar spines only.

By the way, what if I were to tell you that a major risk factor for muscle twitchings or fasciculations were FATIGUE itself?....Same holds for caffeine, nightmares, taking of new medications, interactions between drugs you may be on and so on.

I hope this addresses your concerns and that you'll keep me in mind for future questions regarding these or other neurological/medical issues I may be able to help answer.

I'd appreciate your rating this interaction on a HIGH STAR SCALE if you found the information informative and would be grateful for a few words of feedback.

Write to me at: bit.ly/drdariushsaghafi for additional comments, concerns, or to provide status updates if possible. I'd like to know how things turn out for you as the information may help guide opinions in patients with similar issues.

All the best to you during these holidays!

This consult request has taken a total of 119 minutes of time to read, research, and respond.

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Brief Answer:
Weakness is LACK OF or REDUCED STRENGTH

Detailed Answer:
When a neurologist or any physician rates muscle power as strong or weak it is against a 5 point scale which usually sees 5 as the maximum (normal and full strength) and 0 as meaning flaccid without any ability to contract even 1 single muscle fiber. Then, there's everything in between. There really is no OTHER way to grade or distinguish muscle strength in MND or anything else for that matter. If a person suffered from a stroke the same scale would apply and the doctor would be looking for the same ability of the patient to contract their muscle against force or resistance and grade it as full and maximal vs. absent or somehow weak. Perhaps, you are talking about distinguishing FATIGUE from WEAKNESS? That's different and involves the difference between how a person FEELS which is nothing a doctor can assess....purely subjective judgement call on the patient's part vs. STRENGTH (or lack thereof; weakness) which can be quantified on the scale as I told you above.

A health care provider will know immediately if a muscle is weak or not when testing it or while watching a person move a limb or joint. It's part of the standard examination procedure.

I hope this addresses your concerns and that you'll keep me in mind for future questions regarding these or other neurological/medical issues I may be able to help answer.

Thank you for your grading the responses on a HIGH STAR SCALE. It is much appreciated. I hope the information was helpful.

Write to me at: bit.ly/drdariushsaghafi for additional comments, concerns, or to provide status updates if possible. I'd like to know how things turn out for you as the information may help guide opinions in patients with similar issues.

All the best to you during these holidays!

This consult request has taken a total of 129 minutes of time to read, research, and respond.

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