Brief Answer:
Thank you for your generous HIGH MARK comments

Detailed Answer:
Well, well, well....."Lookie at who the cat drug back in XXXXXXX ....it's that dadburn Neurology feller!" LOL!

Thought I was going to say, "YOU?" HA!

I'm honored that you chose you reask me your questions and I will do my best to answer them to the extent possible...since as you correctly stated...truly making a diagnosis from afar like this is not really possible. I'm sure it wouldn't be a stretch for you to believe that I really feel outside my comfort zone making sweeping statements for folks on a telemedicine network like this without the advantage of being able to SEE them and lay hands on them as is customary in our profession.

Still, I hope that I get it right most of the time....and actually what I THOUGHT you were going to say after watching the game last night was GO XXXXXXX LEAGUE! Ah man....was that a barn burner or what? Being from XXXXXXX you can understand on the one hand how we would naturally just hate seeing the Royals anywhere near the WS...when I was a kid...as bad as the Indians used to be? We used to thrash the Royals at will! LOL....those were the days my friend (as the song goes).

But anyways.....what I thought you were going to say was, "As I put my arm up...I suddenly dropped by beer on top of my head...." Or maybe I thought you were going to say, "When I TRIED getting my arm up over my head.....it just wouldn't seem to go up like the other one did...." Or maybe, "I tripped over my feet a few times last night for no apparent reason....and no throw rugs anywhere either...."

See, those would've set some red flags off to me and I MAY HAVE THOUGHT...."Uh oh...."

But you didn't.....you said something about twitching and weakness? Whew!!! I thought it was something serious my friend! Had me scared there for a minute....

Recall what I said about twitching and BFS...we believe twitching occurs as a result of HYPERACTIVATION OR HYPERSENSITIVITY of the nerve connected to the muscle and its fibers. That is D-I-F-F-E-R-E-N-T TOTALLY DIFFERENT from what happens when there is twitching that occurs as a consequence of dying nerves and as a result atrophying or wasting muscle fibers. That type of twitching is the hallmark of a motor neuron disease and is a reflection of WEAKNESS and bespeaks of things like ALS or ALS itself.

But remember, 60% of people who have ALS presented with their first symptoms to a doctor or to themselves (as it were) with MUSCLE WEAKNESS usually in a limb or in a pair of limbs (generally either upper or lower but not both at the same time) and this weakness often times has a history that well precedes everything else although patients will tell the story as if it all just happened TODAY....usually not so....it usually started very insidiously and without much notice..until they started dropping things or noticing they couldn't unscrew a jar, etc. Then, at some way later date, fasics (or twitches) were noticed and not by the patients either. I find that the vast majority of my ALS do not even notice the fasics when they are early on in the course....and that most of the fasics start in the trunk and then, move outward to the limbs. The fact that you're noticing them...(partly because you're very worried about them) is unusual in an ALS patient.

So, have you got the picture in your mind of WHY I don't believe STILL that this has even a WEAK chance of being ALS (notice I didn't say ZERO chance nor will I ever?). Now, on to your questions:

1. I'm taking it as a sign of weakness in that muscle

>>> Not sure how you decided to interpret this as weakness since you said your arm was clearly and comfortably and EFFORTLESSLY bent at the elbow and raised to be placed behind your head when you noticed the fasics. When did you say "weakness?" I didn't hear you tell me there was any significant effort raising the arm or that it became clearly fatigued back there and you had to drop it....you simply noticed fasics.....so where's the weakness?



2. I'm thinking muscles at rest twitch in BFS but muscles slightly activated should not, correct?

>>>>>> Sorry, again...I'm not sure where this interpretation is coming from or if you are reading something on the internet or is this just your interpretation how things should be to bring back the spectre of ALS when I say, "Be Gone!?!" LOL....I never said there was any correlation between twitching at rest in BFS or twitching while contracted....I'm not sure anybody's really looked at anything like that so I don't think I'm going to attempt to add things to the literature that I can't prove.

In BFS or in any state where there is hyperexcitability of the muscle membranes (such as in toxic drug overdoses) or hyperexcitability of the nerve membrane potentials which have junctions with the muscles (as in medications used to treat psychiatric conditions) there can be twitching. I frankly don't know if it can ONLY happen during activation or ONLY during REST. I certainly have seen examples of my own muscles twitching during periods when I've been exerting a lot of force for one reason or another as well as at rest. During twitching episodes I never experienced or felt weakening of the muscle or anything so again, as they said over and over last night to those pesky Giants......STRIKE 2! HAHA!


3. It's the same this morning. Holding my left arm in the air for several seconds seems to cause a little twitching.

>>>>Again, same thing...I don't think there is any interpretation to this finding that allows one to conclude that this is ALS vs. BFS vs. nothing at all...vs. another form of muscle/nerve disease, vs.....Etcetera., Etcetera., Etcetera.--- (Hey- now I sound like Yul Bryner as the King of Siam!) HA!


I think it's perfectly reasonable for you to want to find a neurologist at this point and ask questions directly and get answers. I am hopeful that he'll back me up...but then, again, the beauty of laying of hands and SEEING with one's own eyes is not to be substituted with anything else..modern, digital, or technological...so I would defer to his decisions. My guess is that since your concern is ALS that he may suggest some blood work just for preliminary checks of certain metabolic parameters that could cause twitching such as thyroid disease, inflammatory markers, for conditions such as vasculitis, and perhaps, occult infection, may be he'd be inclined to get other tests such as B12, Vit. D, and a few other things.

He may or may not recommend an EMG/NCV study which would be considered probably the gold standard test for this diagnosis although if it were me, I would really try and convince you not to undergo such invasive testing if my physical exam and history really didn't reveal much chance at this ALS....I personally hate needles being stuck and activated with jolts of electricity. I hated it when I touched the terminals of a 9v battery when I was kid....I doubt I'd have this type of test done if the neurologist was pretty sure it wasn't ALS.

But, let's see what he says and if he recommends an electrical study or not....

Then, let me know when you get back from that appointment if he is pretty much backing up what I'm saying or not....hell, go ahead and print and show it to him....ahhh...on second thought maybe not....Neurologists are probably only 2nd in Egos to Female Divorce judges....

At any rate, once you get back from the neurologist with an opinion let me know I'd love to send you this poem that I wrote for another patient on this network who it took a lot of convincing to finally get him out of the ALS rut because of all the twitching he was having.

One more thing....ask your family....as many as you possibly can if anybody even back to your grandparents, great aunts, uncles, etc. had either ALS or BFS....of course, nobody is going to know what either of those are or what the differences are....just ask about twitching for years and years and years....that the doctors just told them to live with......VS....wasted muscles, loss of weight, couldn't eat, drink, wheelchair bound, couldn't breathe eventually. Now, those would be recognizable differences between the 2 diseases.

See what you come up with.

Again, as always-- if you've gotten some useful information (and even a few laughs) from this writing please let me know with another one of your patented GENEROUS writeups and criticisms....go ahead and tell me the jokes suck....Good stand comic docs know how to take it and dish it out! LOL.....

If you've got some thoughts you want to share back...as well as telling me who YOU THINK is going to take the WS...then, write back....I'll be standing by to catch those comments and give you my thoughts.

But thusfar, BFS...or NOTHING important if not BFS is my story and I'm stickin' to it!

You know I think this treatise was probably longer than my others to you, no?

This query required 45 minutes of physician specific directed time for review, research, and documentation for final draft envoy.

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Brief Answer:
Bullpen? That's a 7 letter word in Cleveland!

Detailed Answer:
The Indians must have a secret constitution somewhere that the owners only know about which states somewhere in it that we agree to participate in MLB and put a team on the field every year but we absolutely will not, under any circumstance, use, develop, or even think about managing a team that has a BULLPEN. That is against our religion, our culture, and we will simply not tolerate anybody who thinks otherwise....they will simply be traded away to the Yankees, XXXXXXX or any other team destined to be in the Pennant race in the next 3 years and Good Riddens! We don't need them type of people stinkin' up our team locker room!

But thanks for your good wishes....I've waited at least 44 years to see a World Series Championship team....I guess the good news is, potentially I have about another 50 years or so that I still hope for one....so, it's not all done just yet! LOL....


I thought it a big concern that simply holding my left arm extended up in the air for a few seconds would cause muscle twitching in the same area under that bicep.

>>>>>> NOPE--- not a big concern, not a little concern, not any concern....really means nothing in the context of what you're worried about.


My right arm doesn't twitch under those conditions, which heightened my angst.

>>>>>> B-R-E-A-T-H-E and turn down that angst a few notches...until we see what the Indians can do next season!


I guess I just thought that the beginning of denervation would see the muscle start to twitch which would then lead to discernible weakness.

>>>>>60% of all ALS patients see the beginning of denervation as what????

WEAKNESS, WEIGHT LOSS, LOSS OF MUSCLE BULK.....and all of that will generally happen BEFORE or at least be more noticeable to patients and caregivers well ahead of noticing Fasciculations or twitches. If you notice Fasciculations FIRST....you most likely have???? What?????

BENIGN FASCICULATON SYNDROME......see how easy it is to be a medical student?



From what you've told me, that's unlikely.

>>>>>Now, you're talkin'



I'm gathering that it's the muscle losing strength and functionality that often causes the nerve to send out signals for help (twitching).

>>>>>NOT IF IT'S BFS--- In that case the twitching is JUST FOR THE FUN OF IT....or whatever....people have BFS for decades and never see a loss in strength, muscle mass, or tone.


>>>>>In ALS it's the reverse....the problem is the NERVE...not the muscle....remember they didn't call a MOTOR NEURON DISEASE because there's a muscle problem....it's a nerve problem. So when the nerve starts dying off then, the muscle fibers that are innervated lose their BFF's...their soulmates if you will, partners for life....and just like a couple who has been together forever...when one goes, the other soon follows. So it is here, when the nerve begins to falter and die off then, the first thing that starts happening is the muscle starts to experience weakness then, as time goes on and the nerve is less and less able to innervate that muscle that's when you start getting the fasciculations but that's generally after the muscle has begun its downward journey of losing mass, bulk, and then, the twitching really becomes the last ditch effort of the muscle fibers to be sending out MayDay signals begging for SOME NERVE somewhere to come to its rescue.....

THAT'S ALS.....and I do not believe that is what you have in the least under current circumstances with what you've provided me as information and in the ABSENCE of a face to face hands on examination. There's my FULL DISCLAIMER in case you come back after your neurologist's appointment to give me some shocking news.....but I'll tell you....the last time I got shocking news? Geezz.....lemme see...that would've had to have been when XXXXXXX Stevenson said YES to dance with me at the 8th grade Canteen in Shiloh Jr. High School. I had planned to ask her for a slow dance since the 6th grade....ohhh baby was she a hottie.....an 8th grade hottie....yes sirreee.....and I was SOOOO prepared to hear her say NO! that when she said YES....I nearly just walked away by reflex! It was the only time I got my hands around her waist as I shifted my weight from one leg to the other at about 2 feet distant......and that was it.....3 minutes of incredible heaven.....and what did I do while we were dancing?? What any kid in my position would do in that circumstance, Look at the floor, look at my shoes, look at the couples dancing behind us....I think I may have even turned around and seen Pete Borys, and Chuckie Stover givin' me the thumbs up!! And when the song was over?? We flew apart from another like 2 highly charged PROTON particles veering away on an approach at the speed of light!

That was the last time I got really downright shocking, totally unexpected, and (well in this case it was GOOD news) who woulda guessed it news! LOL.


Thanks for all of your time and please enjoy the holidays!

>>>>>YOU TOO SIR! IT'S A PLEASURE.....and remember I'm always here....I'm probably here TOO much if you ask my wife.....but I'm always here....and I wanna know what the neurologist says......cuz I wanna send you that poem....

But I'm not sending it to you till you come back with the Broomstick of the Wicked Witch of the West or is it East? Well, you get the idea! HAHA!

If you've got any final thoughts or questions please ask away...otherwise, I'd love to hear just a few more comments of feedback if you possibly could before you turn out the lights.

Cheers!

This query required 28 minutes of physician directed time for research, review, and final draft documentation for envoy.


P.S. You're not that far away from XXXXXXX you know? Not that I'd seriously think you should come to XXXXXXX for this thing ever....and for sure, I know very competent neurologists in your state.....BUTTT.....'ya never know.....I don't think you're any more than 4 hrs. from us...I think.....just a thought if it might be of use to you in the future.

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