Exploring Benign Fasciculation Syndrome

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Unionjedi

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It is really interesting, newer neurology textbooks all have large areas discussing benign fasciculation syndrome, where older textbooks bearly mention anything. Here is a section from a neurology textbook we use in medical school. Let me know what you guys thinkPersistent Benign FasciculationsA few random fasciculations in the muscles of the calf, small muscles of the hand or of the face, or elsewhere are seen in most normal individuals. They are of no significance but can be a source of worry to physicians and nurses who have heard or read that fasciculations are an early sign of amyotrophic lateral sclerosis. A simple clinical rule is that fasciculations in relaxed muscle are not indicative of motor system disease unless there is associated weakness, atrophy, or reflex change.Frequently a healthy individual experiences intermittent twitching of a muscle (or even part of a muscle), such as one of the muscles of the thenar eminence, eyelids, calves, or orbicularis oculi. It may continue for days. Lay persons refer to it as "live flesh." Also, penicillin may destabilize the polarization of distal motor endings and cause twitching. Electromyographically, these benign fasciculations tend to be more constant in location and more frequent and rhythmic than the ominous fasciculations of amyotrophic lateral sclerosis, but such distinctions are not entirely reliable. Quantitative study of the motor unit size may be helpful in these circumstances by demonstrating normally modeled units in the benign form and abnormally large units due to reinnervation in the case of motor neuron disease (see Motor Unit Potentials in Denervation).Occasionally, benign fasciculations are widespread and may last for months or even years. In several of our patients they have recurred in bouts separated by months and lasting several weeks. No reflex changes, sensory loss, nerve conduction, EMG abnormality (other than fasciculations), or increase in serum muscle enzymes are found. Low energy and fatigability in some of these patients may suggest an endogenous depressive illness, yet the fasciculations are not explained by this mechanism. Commonly, patients report a sense that the muscles affected by the twitching are weak but this cannot be confirmed by testing, and several of our patients, curiously the majority of whom were physicians, have complained of equally troubling migratory zones of paresthesias (Romero et al). Pain, of aching or burning type, may increase after activity and cease during rest. Fatigue and a sense of weakness are frequent complaints. We suspect that this fasciculatory state reflects a disease of the terminal motor nerves, for a few of our patients have shown slowing of distal latencies, and Cöers and associates have found degeneration and regeneration of motor nerve terminals. However, the majority of these cases are of a benign nature and settle down in a matter of weeks or months. In the cases reported by Hudson and colleagues, the condition, even after years, did not progress to spinal muscular atrophy, a polyneuropathy, or amyotrophic lateral sclerosis. Eventual recovery can be expected. This conforms to our experience and to that reported from the Mayo Clinic where 121 patients with benign fasciculations, followed in some cases for more than 30 years, showed no progression of symptoms and did not acquire motor neuron disease or neuropathy (Blexrud et al). It should be acknowledged, however, that there are infrequent patients with seemingly benign fasciculations in whom the EMG shows some abnormal features (e.g., rare fibrillations) in numerous muscles and who later develop the other features of motor neuron disease. Carbamazepine, and to a lesser extent phenytoin, has been helpful in reducing the fasciculations and sensations of weakness.Cramp-Fasciculation SyndromeThis is a variant of the aforementioned entity in which fasciculations are conjoined with cramps, stiffness, and systemic features such as exercise intolerance, fatigability, and muscle aches. Although affected individuals may be to some degree disabled by these symptoms, the prognosis is good. The salient finding on physiologic studies is that stimulation of peripheral nerves results in sustained muscle firing due to prolonged trains of action potentials in the distal motor nerve. This may be brought out in special electrophysiologic testing as described by Tahmoush and colleagues. In effect, this is a mild form of neuromyotonia (see later). In a small number of patients with cramp-fasciculation syndrome it is possible to demonstrate the presence of autoantibodies directed against voltage-gated axonal potassium channels. Carbamazepine or gabapentin may be beneficial.
 
Wow, nice info!I have a question... after reading this am i correct to say that an EMG can tell the difference between cramp-fasciculation syndrome and just plain fasciculation syndrome?
 
Good question. I should look into it. I don't there should be a difference, because in both cases, there should just be fasciculations and nothing else.
 
I am confused by this. My impression that random widespread twitches were indicative of BFS or another benign condition, and that localized non-stop twitching was associated more with ALS. This seems to say the opposite.
 
The text is basically stating the following:Normal people have occasional muscle twitches in a few areas of the body that are considered normal.The occasional special people like us, have widespread body twitches that are benign and are associated with all the things that the paragraph is talking about like fatigue, paresthesias, perceived weakness etc.From talking to all my professors, ALS patients due have widespread twitches but only later on in the disease. All of the anterior horn cells don't just die off at once, it is progressive where once enough muscles are involved then the twitches are considered widespread, its not widespread early on.
 
It's easy to parse every phrase here and look right past the really important entries. I think we should also pay extra attention to "They are of no significance but can be a source of worry to physicians and nurses who have heard or read that fasciculations are an early sign of amyotrophic lateral sclerosis. A simple clinical rule is that fasciculations in relaxed muscle are not indicative of motor system disease unless there is associated weakness, atrophy, or reflex change." Whether localized or widespread, rhythmic or hit-and-run, twitches that are NOT accompanied by these things are NOT ALS. Note also how the text clearly implies that information that points to twitching is an "early sign" of ALS is, in general, incorrect. "Heard or read" is not the same as "are justifiably concerned about." AND--note references to what so many of us have experienced--fatigue and weakness--"but this cannot be confirmed by testing."So, to repeat, "A simple clinical rule is that fasciculations in relaxed muscle are not indicative of motor system disease unless there is associated weakness, atrophy, or reflex change"--REAL weakness, atrophy and changes in reflexes as determined by a qualified medical professional, not by comparing dents and dimples or whacking ourselves on the knee with a hammer. (And there have even been people here who have had twitching and atrophy/weakness that were found to be caused by something "un-sinister.") Thanks for a very informative post.Mark
 
I think possibly localized refers to the fact that the same twitch hits the same place over and over when the twitch is occuring. For instance, if I am twitching in my thenar/thumb pad then the twitch stays in the same place on my thumb pad, and does not move up, down, left, or right. It is localized where it starts. Then a minute later I may have one in my calf and it stays in the same spot in my calf. If anyone has seen the YouTube video of the guy with fasciculations then you will notice his shoulder fasciculations move around the shoulder, almost like it is rolling. That is just my take.
 
I know this is probably driving everyone crazy, but just to clarify....so is it bad if I get a twitch in the same exact spot for a while? Because, I guess, that is how mine tend to be. I say 'widespread' at times, because I guess it seems like I've had them in many different places, but I kinda tend to have the same twitch, in the same place as a hotspot for a while, and then it may move on. But, I generally tend to stay with the same hotspots, like my left thigh twitches pretty regularly each day. I might feel a couple pops here and there, but I do have my 'regulars'. Does that sound familiar? I guess we all read things like this and get panicky because of the way we are interpreting it. Don't forget, the calming words of "BFS in a Nutshell" have kept alot of us sane during our twitching. So, when a new thing comes out, and the wording is sort of like the wording in the Bible, where it's interpreted differently by each person that reads it, it can be very unsettling. I wonder sometimes if I'm describing my twitches in the wrong way, even to the neuro. I do sometimes think that mine have a pretty clear pattern. I had a twitch one time on my left hand that was there for a very long time. That one moved on, but will come back to the same exact place now and then. Anyway, just trying to clear this up in my head!~! (Which is twitching, by the way)...Val
 
The twitching in my calves are not on the same spot,they are numerous and different nerves twitch at different places and at different intervals just like the shoulder in the ALS video.BUT.....they do not roll.One single twitch in ALS does have its own chracteristics.Im not saying one rolling twitch is an ALS twitch but they do look different.I think when they talk about widespread twitches they mean exactly that.If they examined ALS widespread twiching it would be everywhere[arms,hands,fingers elbows,legs ,feet everywhere],all of the time.Confined to a location in BFS meaning- on the same spot constantly,but then again it still dosent mean anything to any neuro unless they find Muscle weakness or atrophy,thats the procedure.
 
I LOVED this POST! , VERY USEFUL! I too read it different the first time then the second third and fourth by widespread twitching. Gelianna broke it down for me though! Im 28 Im supposed to be out drinking and playing poker on Saturday night and not studying twitches . But I am pregnant and I am limited. lol I just hope the twitching doesnt interfere in my poker playing next weekend @ the casino!!! :)
 
Yikes~~I know what you mean, I worry because of the location of my twitches also. I've been getting them alot in my upper body, such as my arms, shoulders, neck, face, tongue. So, those places definitely make me more nervous, because for one thing they get your attention so much more than if you have twitches on the lower part of your body, but also like you said, just what we've read. I've read about the tongue being a worse place, but I didn't really know about the shoulders and arms. Although, I think, but I'm not exactly sure how he said it, that my neuro said that with als, you will see twitching in the shoulders, and chest more. At the time, I didn't worry about this cause I didn't have it there yet. It seemed like it was more the lower half of my body, such as my thighs. It's also the weirdest thing lately, I told my son tonight, that when I lay down in bed, I can hear something popping, and I can't really tell where it's coming from, it kind of sounds like it's deep within my neck, or in my ear. But, it's very irritating. I also seem to be having trouble with my speech tonight, so hopefully that's just all anxiety that goes along with this. I hate this so much, cause it took me so long to get over my anxiety due to the heart palpitations, and finally I've been living my life more or less free of that for the last few years or so, and now this. This is sort of sending me back into that anxiety mode, where I get nervous when I'm too far away from home, etc. I know it doesn't make any sense, it's just a sense of comfort I get from being in my surroundings. Anyway, so has anyone else heard that the shoulders and arms are bad places to get them? Does anyone else get them there? Thanks, talk to you soon, Val
 
I dont think a twitch in the calve,hand ,arm,eye lid,foot.etc all happening at the same time is classed as widespread fasciculations,that is not what they mean,no way.
 
This whole debate over what "widespread" means is sort of stressful, cause I think we all had in our own heads what that meant. In my mind, I would think widespread means exactly what it sounds like, that the twitching is widespread all over your body. I don't think it matters whether or not they happen at the exact same time, or a few seconds or minutes apart from each other. I will notice that if I'm having a bad day, sort of like a flare-up, I'll have twitching all over my body, all day long, here and there. It usually will not be just in one place all day long, although I've had hotspots that will be pretty persistent, but generally, there are others. That is what I think widespread means, not widespread over that one muscle group, but widespread over your whole body. Val
 
I thought we DID have diffuse widespread fasics.....I guess I'm a little confused on this. For months now, I've been feeling reassured because of all of the talk about how "widespread fasics are better"....and that is what I assumed I had, because mine seem to be here and there. Is that considered bad now?? Now I'm nervous because I'm thinking that I was interpreting something wrong all this time. I thought widespread meant what it sounds like it means, at least to me, that they are in several different areas of your body each day. I will have hotspots that bother me in that one particular area that will last anywhere from days to weeks to over a month, but with that hotspot, I also have others. Is that considered a bad thing? Yikes~~I HOPE I wasn't taking it the wrong way....after all this time of feeling better!! I thought, reading some of the posts on here, that many people have the twitching in many different areas. I do feel somedays like mine are completely bodywide, like I will feel them down my back, on my neck, legs, arms, shoulders, facial areas, etc. I thought this was pointing towards a more benign process. From what I understood, and read many times, with als, the twitching will more or less be in one particular spot, and move on slowly from there, as the muscle dies. Anyway, thanks for any help! Val
 
Val, you descibe benign fascics the sort that everyone gets. I think we have all forgotten that fascics are not a clinical diagnosis for anything serious unless weakness,atrophy etc is present.It dosent matter what they look like or how they are described,saying that my EMG guy looked at my rolling ,widespread, multiple, spreading fascics ,shook his head and said "thats not MND".
 
It's nice to actually see BFS in a text book, but I think all the debate over what was said does go to show that unfortunately they did not do a very comprehensive job at explaining it here. We have a condition that is located in the peripheral nervous system, not the central nervous system, so I don't know why it mentions ALS at all. The are completely different conditions and there is a lot of research that shows that. In fact, BFS and BCFS shouldn't even be under different headings as many neurologists would consider them both Peripheral Nerve Hyperexciteability (PNH) and can be cause by the exact same thing, such as autoimmunity. So it's a little frustrating to see that whoever wrote the text really didn't examine the issue that thoroughly.Thank you for sharing it though.
 
Not to pound this into the ground....but....that's interesting Sir_Trouserz, that's the first time that I heard that about the peripheral vs. the central nervous system. So, als is a disease of the central nervous system? Can you tell the difference? Cause I feel like my WHOLE nervous system is on edge all the time, whether it be my heart palpitations, my twitching, my general internal shaky feeling, etc. I was wondering, if you have time, if you could clarify the difference. Like you haven't helped me enough already, I'm so sorry to be greedy! I hope you are doing well. I'm SO glad it's the weekend! Time for some sleep, hopefully!! Talk to you soon, Val
 

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