Benign fasciculation syndrome
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Benign fasciculation syndrome (BFS) is a neurological disorder characterized by fasciculation (twitching) of various voluntary muscles in the body. The twitching can occur in any voluntary muscle group but is most common in the eyelids, arms, legs, and feet. Even the tongue may be affected. The twitching may be occasional or may go on nearly continuously. Usually intentional movement of the involved muscle causes the fasciculations to cease immediately, but they may return once the muscle is at rest again.
Signs and symptoms
- Fasciculations (Primary Symptom)
- Generalized fatigue
- Muscle pain
- Exercise intolerance
- Globus sensations
- Muscle cramping 
Less common symptoms include:
BFS symptoms are typically present when the muscle is at rest and are not accompanied by severe muscle weakness  In some BFS cases, fasciculations can "jump" from one part of the body to another. For example, it could start in a leg muscle, then in a few seconds jump to the forehead, then the abdomen, etc. While only one part of the body is affected at a time, hardly a beat is missed as it jumps from one area to the next. Because fasciculations can occur on the head, this strongly suggests the brain as the generator due to its exclusive non-dependence on the spinal cord. (Together, the brain and spinal cord comprise the central nervous system.)
Though twitching is sometimes a symptom of serious diseases such as spinal injury, muscular dystrophy, Lyme Disease, multiple sclerosis or amyotrophic lateral sclerosis (ALS), it is much more often due to more benign causes such as BFS, over-exertion etc.
The precise cause of BFS is unknown, and, in fact, it's not known if it's a disease of the motor nerves, the muscles, 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.
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 disease) neuropathy, motor neuron diseases such as ALS, etc.) must be eliminated before BFS can be assumed. An important diagnostic tool here is the electromyography (EMG). Since BFS appears to cause no actual nerve damage (at least as seen on the EMG), patients will likely exhibit a completely normal EMG (or one where the only abnormality seen is fasciculations).
Another important step in diagnosing BFS is checking the patient for clinical weakness. Clinical weakness is often determined through a series of strength tests, such as observing the patients ability to walk on his or her heels and toes. Resistance strength tests may include raising each leg, pushing forward and backward with the foot and/or toes, squeezing with fingers, spreading fingers apart, and pushing with or extending arms and/or hands. In each such test the test provider will apply resisting force and monitor for significant differences in strength abilities of opposing limbs or digits. If such differences are noted or the patient is unable to apply any resisting force, clinical weakness may be noted.
Lack of clinical weakness along with normal EMG results (or those with only fasciculations) largely eliminates more serious disorders from potential diagnosis.
In the absence of clinical and electromyographic findings of neurogenic disease, the diagnosis of benign fasciculations is made. I suggest that patients like this be followed for a year or longer with clinical and electromyographic exams at about 6-month intervals before one becomes secure in the diagnosis that the fasciculations are truly benign. My approach to treating fasciculations that appear to be benign is to first reassure the patient that no ominous disease seems to be present.
Some degree of control of the fasciculations may be achieved with the same medication 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. In cases where fasciculations are caused by magnesium deficiency (medicine), supplementing magnesium can be effective in reducing symptoms.
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).
If pain or muscle aches are present alongside fasiculations, patients may be advised to take over-the-counter pain medications such as Ibuprofen or Acetaminophen during times of increased pain. Other forms of pain management may also be employed. Prior to taking any over-the-counter medications, individuals should initiate discussions with their health care provider(s) to avoid adverse affects associated with long-term usage or preexisting conditions.
The prognosis for those suffering from diagnosed Benign Fasciculation Syndrome is generally regarded as being good to excellent. The syndrome causes no known long-term physical damage. Patients may suffer elevated anxiety even after being diagnosed with the benign condition. Such patients are often directed towards professionals who can assist with reductions and understanding of stress/anxiety, or those who can prescribe medication to help keep anxiety under control.
Spontaneous remission has been known to occur, and in cases where anxiety is thought to be a major contributor, symptoms are typically lessened after the underlying anxiety is treated. In a study by the Mayo Clinic 121 individuals diagnosed with Benign Fasciculation Syndrome were assessed 2–32 years (~7 years average) after diagnosis. Of those patients there were no cases of BFS progressing to a more serious illness, and 50% of the patients reported significant improvement in their symptoms at the time of the follow-up. Only 4% of the patients reported symptoms being worse than those present at the time of their diagnosis.
- Hart, I.; Maddison, P.; Newsom-Davis, J.; Vincent, A.; Mills, K. R. (August 2002). "Phenotypic Variants of Autoimmune Peripheral Nerve Hyperexcitability". Brain 125 (8): 1887–1895. doi:10.1093/brain/awf178. PMID 12135978.
- Allan H. Ropper; Robert H. Brown. "Chapter 55. Disorders of Muscle". Adams and Victor's Principles of Neurology (8th ed.). pp. 1277–1278.
- Mitsikostas, D. D.; Karandreas, N.; Coutsopetras, P.; Piperos, P.; Lygidakis, C.; Papageorgiou, C. (April 1998). "Fasciculation Potentials in Healthy People". Muscle & Nerve 21 (4): 533–535. PMID 9533790.
- Kincaid, J. C. (August 1997). "Muscle pain, fatigue, and fasciculations". Neurological Clinic 15 (3): 697–709. PMID 9227959.