Benign fasciculation syndrome
Encyclopedia
Benign fasciculation syndrome (BFS) is a neurological disorder
characterized by fasciculation
(twitching) of various voluntary muscle
s in the body. The twitching can occur in any voluntary muscle group but is most common in the eyelid
s, arm
s, legs
, and feet. Even the tongue
may be affected. The twitching may be occasional or may go on nearly continuously. Any intentional movement of the involved muscle causes the fasciculations to cease immediately, but they may return once the muscle is at rest again.
, generalized fatigue
, exercise intolerance
, globus sensations, muscle cramping, and/or paraesthesias.
Another common feature of the disorder, when seen by physicians, is an increase in the patient's level of anxiety
, especially health-related anxiety . It's not uncommon for the patient to fixate on ALS
, MS
, ME, Parkinson's
, vCJD
, Wilson's Disease
, Dystonia or some other serious neurological disorder, refusing to believe the BFS diagnosis . Many health anxious people are greatly helped by the discussion websites (see External Links section) containing a wealth of knowledge on the conditions and symptoms discussed by long-term suffers willing to help and calm the worries of people mistakenly fearful of having one of the more serious disorders .
, Lyme Disease
, multiple sclerosis
or amyotrophic lateral sclerosis
(ALS), it is much more often due to more benign causes (BFS, over-exertion, etc.), and virtually everyone will experience some episodes of benign fasciculation during their lifetime.
The precise cause of BFS is unknown, and, in fact, it's not known if it's a disease of the motor nerves, the muscle
s, or the neuromuscular junction
. Mitsikostas et al. found that fasciculations "were slightly correlated to the body weight and height and to the anxiety level" in normal subjects. Another factor that seems to be common in many cases is a history of regular strenuous exercise. Attention deficit disorder (or drugs used to treat it) and/or a related disorder may be a contributing factor, and people with essential tremor
appear to have a greater than normal likelihood of developing BFS. In addition, there are likely other genetic and environmental factors that make the patient more susceptible to BFS.
There are some intriguing similarities between BFS and chronic organophosphate poisoning
, but these similarities have not been explored. It may be that chronically elevated levels of stress hormones in the body cause symptoms similar to those caused by organophosphates.
BFS can also be attributed to long term use of anticholinergics such as diphenhydramine
and opiates such as morphine
, but the latter case is usually when withdrawal symptoms are present.
Magnesium Deficiency
can cause both fasciculations and anxiety.
Gluten sensitivity
can result in fasciculations.
) neuropathy, motor neuron diseases such as ALS, etc.) must be eliminated before BFS can be assumed. An important diagnostic tool here is the (EMG). Since BFS appears to cause no actual nerve damage (at least as seen on the EMG), a completely normal EMG (or one where the only abnormality seen is fasciculations) largely eliminates more serious disorders and strongly suggests BFS.
Unlike ALS, BFS symptoms are usually present when the muscle is at rest, and are not accompanied by severe muscle weakness.
Another abnormality commonly found upon clinical examination is a brisk reflex action
known as hyperreflexia
. Standard laboratory tests are unremarkable. According to neurologist John C. Kincaid:
used to treat essential tremor
(beta-blockers and anti-seizure
drugs). However, often the most effective approach to treatment is to treat any accompanying anxiety. No drugs, supplements, or other treatments have been found that completely control the symptoms. Cannabis has been effective at mitigating the severity of the symptoms with minimal to no side effects, particularly Indica strains that are high in the non-psychoactive cannabidiol
(CBD).
In many cases, the severity of BFS symptoms can be significantly reduced through a proactive approach to decrease the overall daily stress
. Common ways to reduce stress include: exercising more, sleeping more, working less, meditation, and eliminating all forms of dietary caffeine
(e.g. coffee, chocolate, cola, and certain over-the counter medications).
Opiate therapy with drugs such as oxycodone can reduce symptoms of pain and nerve activity significantly. Since BFS is a form of peripheral nerve hyper-excitability, the problem lies in the potassium channels. The potassium channel along with the sodium channel are two of the chemical mechanisms within the nerve that are involved with the production of nerve cell signals. Normally these channels function in equilibrium, but in the case of BFS there is a glitch in the potassium channel. Oxycodone works by rectifying potassium channels and results in reduced neuronal excitability. Oxycodone is a controlled substance and can lead to addiction and dependency but when taken properly it can be safe and very effective in treating BFS pain, parathesia, and globus sensation
Neurological disorder
A neurological disorder is a disorder of the body's nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord, or in the nerves leading to or from them, can result in symptoms such as paralysis, muscle weakness, poor coordination, loss of sensation, seizures,...
characterized by fasciculation
Fasciculation
A fasciculation , or "muscle twitch", is a small, local, involuntary muscle contraction and relaxation visible under the skin arising from the spontaneous discharge of a bundle of skeletal muscle fibers...
(twitching) of various voluntary muscle
Skeletal muscle
Skeletal muscle is a form of striated muscle tissue existing under control of the somatic nervous system- i.e. it is voluntarily controlled. It is one of three major muscle types, the others being cardiac and smooth muscle...
s in the body. The twitching can occur in any voluntary muscle group but is most common in the eyelid
Eyelid
An eyelid is a thin fold of skin that covers and protects an eye. With the exception of the prepuce and the labia minora, it has the thinnest skin of the whole body. The levator palpebrae superioris muscle retracts the eyelid to "open" the eye. This can be either voluntarily or involuntarily...
s, arm
Arm
In human anatomy, the arm is the part of the upper limb between the shoulder and the elbow joints. In other animals, the term arm can also be used for analogous structures, such as one of the paired forelimbs of a four-legged animal or the arms of cephalopods...
s, legs
Human leg
The human leg is the entire lower extremity or limb of the human body, including the foot, thigh and even the hip or gluteal region; however, the precise definition in human anatomy refers only to the section of the lower limb extending from the knee to the ankle.Legs are used for standing,...
, and feet. Even the tongue
Tongue
The tongue is a muscular hydrostat on the floors of the mouths of most vertebrates which manipulates food for mastication. It is the primary organ of taste , as much of the upper surface of the tongue is covered in papillae and taste buds. It is sensitive and kept moist by saliva, and is richly...
may be affected. The twitching may be occasional or may go on nearly continuously. Any intentional movement of the involved muscle causes the fasciculations to cease immediately, but they may return once the muscle is at rest again.
Common features
The main symptom of benign fasciculation syndrome usually is focal or widespread involuntary muscle activity (twitching). In addition to the twitching, some sufferers experience painPain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
, generalized fatigue
Fatigue (physical)
Fatigue is a state of awareness describing a range of afflictions, usually associated with physical and/or mental weakness, though varying from a general state of lethargy to a specific work-induced burning sensation within one's muscles...
, exercise intolerance
Exercise intolerance
Exercise intolerance is a condition where the patient is unable to do physical exercise at the level or for the duration that would be expected of someone in his or her general physical condition, or experiences unusually severe post-exercise pain, fatigue, or other negative effects...
, globus sensations, muscle cramping, and/or paraesthesias.
Another common feature of the disorder, when seen by physicians, is an increase in the patient's level of anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, especially health-related anxiety . It's not uncommon for the patient to fixate on ALS
Amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis , also referred to as Lou Gehrig's disease, is a form of motor neuron disease caused by the degeneration of upper and lower neurons, located in the ventral horn of the spinal cord and the cortical neurons that provide their efferent input...
, MS
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
, ME, Parkinson's
Parkinson's disease
Parkinson's disease is a degenerative disorder of the central nervous system...
, vCJD
Creutzfeldt-Jakob disease
Creutzfeldt–Jakob disease or CJD is a degenerative neurological disorder that is incurable and invariably fatal. CJD is at times called a human form of mad cow disease, given that bovine spongiform encephalopathy is believed to be the cause of variant Creutzfeldt–Jakob disease in humans.CJD...
, Wilson's Disease
Wilson's disease
Wilson's disease or hepatolenticular degeneration is an autosomal recessive genetic disorder in which copper accumulates in tissues; this manifests as neurological or psychiatric symptoms and liver disease...
, Dystonia or some other serious neurological disorder, refusing to believe the BFS diagnosis . Many health anxious people are greatly helped by the discussion websites (see External Links section) containing a wealth of knowledge on the conditions and symptoms discussed by long-term suffers willing to help and calm the worries of people mistakenly fearful of having one of the more serious disorders .
Causes
Though twitching is sometimes a symptom of serious diseases such as spinal injury, muscular dystrophyMuscular dystrophy
Muscular dystrophy is a group of muscle diseases that weaken the musculoskeletal system and hamper locomotion. Muscular dystrophies are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.In the 1860s, descriptions of boys who...
, Lyme Disease
Lyme disease
Lyme disease, or Lyme borreliosis, is an emerging infectious disease caused by at least three species of bacteria belonging to the genus Borrelia. Borrelia burgdorferi sensu stricto is the main cause of Lyme disease in the United States, whereas Borrelia afzelii and Borrelia garinii cause most...
, multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
or amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis , also referred to as Lou Gehrig's disease, is a form of motor neuron disease caused by the degeneration of upper and lower neurons, located in the ventral horn of the spinal cord and the cortical neurons that provide their efferent input...
(ALS), it is much more often due to more benign causes (BFS, over-exertion, etc.), and virtually everyone will experience some episodes of benign fasciculation during their lifetime.
The precise cause of BFS is unknown, and, in fact, it's not known if it's a disease of the motor nerves, the muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, or the neuromuscular junction
Neuromuscular junction
A neuromuscular junction is the synapse or junction of the axon terminal of a motor neuron with the motor end plate, the highly-excitable region of muscle fiber plasma membrane responsible for initiation of action potentials across the muscle's surface, ultimately causing the muscle to contract...
. Mitsikostas et al. found that fasciculations "were slightly correlated to the body weight and height and to the anxiety level" in normal subjects. Another factor that seems to be common in many cases is a history of regular strenuous exercise. Attention deficit disorder (or drugs used to treat it) and/or a related disorder may be a contributing factor, and people with essential tremor
Essential tremor
Essential tremor is a slowly progressive neurological disorder whose most recognizable feature is a tremor of the arms that is apparent during voluntary movements such as eating and writing...
appear to have a greater than normal likelihood of developing BFS. In addition, there are likely other genetic and environmental factors that make the patient more susceptible to BFS.
There are some intriguing similarities between BFS and chronic organophosphate poisoning
Organophosphate
An organophosphate is the general name for esters of phosphoric acid. Phosphates are probably the most pervasive organophosphorus compounds. Many of the most important biochemicals are organophosphates, including DNA and RNA as well as many cofactors that are essential for life...
, but these similarities have not been explored. It may be that chronically elevated levels of stress hormones in the body cause symptoms similar to those caused by organophosphates.
BFS can also be attributed to long term use of anticholinergics such as diphenhydramine
Diphenhydramine
Diphenhydramine hydrochloride is a first-generation antihistamine possessing anticholinergic, antitussive, antiemetic, and sedative properties which is mainly used to treat allergies. Like most other first-generation antihistamines, the drug also has a powerful hypnotic effect, and for this reason...
and opiates such as morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
, but the latter case is usually when withdrawal symptoms are present.
Magnesium Deficiency
Magnesium deficiency (medicine)
Magnesium deficiency refers to an intake of dietary magnesium below minimal levels, which can result in numerous symptoms and diseases. These can generally be remedied by an increase of magnesium in diet or oral supplements...
can cause both fasciculations and anxiety.
Gluten sensitivity
Gluten sensitivity
Gluten sensitivity belongs to a spectrum of disorders in which gluten has an adverse effect on the body. It can be defined as a non-allergic and non-autoimmune condition in which the consumption of gluten can lead to symptoms similar to those observed in coeliac disease or wheat allergy .Gluten...
can result in fasciculations.
Diagnosis
Diagnosis of BFS is a "diagnosis of exclusion," in other words, other likely causes for the twitching (mostly forms of neuropathy, such as borreliosis (Lyme diseaseLyme disease
Lyme disease, or Lyme borreliosis, is an emerging infectious disease caused by at least three species of bacteria belonging to the genus Borrelia. Borrelia burgdorferi sensu stricto is the main cause of Lyme disease in the United States, whereas Borrelia afzelii and Borrelia garinii cause most...
) neuropathy, motor neuron diseases such as ALS, etc.) must be eliminated before BFS can be assumed. An important diagnostic tool here is the (EMG). Since BFS appears to cause no actual nerve damage (at least as seen on the EMG), a completely normal EMG (or one where the only abnormality seen is fasciculations) largely eliminates more serious disorders and strongly suggests BFS.
Unlike ALS, BFS symptoms are usually present when the muscle is at rest, and are not accompanied by severe muscle weakness.
Another abnormality commonly found upon clinical examination is a brisk reflex action
Reflex action
A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc; this does not apply to casual uses of the term 'reflex'.-See also:...
known as hyperreflexia
Hyperreflexia
Hyperreflexia is defined as overactive or overresponsive reflexes. Examples of this can include twitching or spastic tendencies, which are indicative of upper motor neuron disease as well as the lessening or loss of control ordinarily exerted by higher brain centers of lower neural pathways...
. Standard laboratory tests are unremarkable. According to neurologist John C. Kincaid:
Treatment
Some degree of control of the fasciculations may be achieved with the same medicationMedication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
used to treat essential tremor
Essential tremor
Essential tremor is a slowly progressive neurological disorder whose most recognizable feature is a tremor of the arms that is apparent during voluntary movements such as eating and writing...
(beta-blockers and anti-seizure
Anticonvulsant
The anticonvulsants are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers, and in the treatment of neuropathic pain. The goal of an...
drugs). However, often the most effective approach to treatment is to treat any accompanying anxiety. No drugs, supplements, or other treatments have been found that completely control the symptoms. Cannabis has been effective at mitigating the severity of the symptoms with minimal to no side effects, particularly Indica strains that are high in the non-psychoactive cannabidiol
Cannabidiol
Cannabidiol is a cannabinoid found in Cannabis. It is a major constituent of the plant, representing up to 40% in its extracts.It has displayed sedative effects in animal tests...
(CBD).
In many cases, the severity of BFS symptoms can be significantly reduced through a proactive approach to decrease the overall daily stress
Stress (medicine)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
. Common ways to reduce stress include: exercising more, sleeping more, working less, meditation, and eliminating all forms of dietary caffeine
Caffeine
Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
(e.g. coffee, chocolate, cola, and certain over-the counter medications).
Opiate therapy with drugs such as oxycodone can reduce symptoms of pain and nerve activity significantly. Since BFS is a form of peripheral nerve hyper-excitability, the problem lies in the potassium channels. The potassium channel along with the sodium channel are two of the chemical mechanisms within the nerve that are involved with the production of nerve cell signals. Normally these channels function in equilibrium, but in the case of BFS there is a glitch in the potassium channel. Oxycodone works by rectifying potassium channels and results in reduced neuronal excitability. Oxycodone is a controlled substance and can lead to addiction and dependency but when taken properly it can be safe and very effective in treating BFS pain, parathesia, and globus sensation