An Epidemiology Study of BFS (Part I)

ABSTRACT:

The purpose of this paper is to explore a statistical or epidemiology study about Benign Fasciculation Syndrome (BFS). In particular, the goal of the paper is to investigate if correlation exists between BFS symptoms, potential triggers, physical response, and remedies.

The method used was to collect data from an internet survey created on Google Drive. Data was obtained from 527 people over 3 years. Of the 527 responses to the survey a total of 438 were evaluated within this paper. Hence, 89 survey entries were deemed as outliers for a variety of reasons. The data was modeled using a linear regression analysis to determine if there is statistical significance between symptoms, potential causes or triggers, body areas affected by BFS, and potential remedies. Data points with high statistical significance were then evaluated using a Spearman Correlation method to find if correlation exists. The data results are shown in Table 1 through Table 7 and the outcomes are discussed in detail.

To conclude, this paper will combat the fallacies about survey usefulness and accuracy and highlight inadequacies of controlled studies, clinical trials, and patient observation. The paper tackles the misconceptions about BFS including it being truly benign to people chronically afflicted by the disorder and the true definition of BFS and what distinguishes it from other peripheral nerve hyperexcitation disorders. The discussion section of the paper also explores other possibilities about BFS such as mycoplasma acting as a catalyst to transform triggers or causes into symptoms; multiple causes triggering unique BFS symptoms; and the possibility of BFS afflicting certain personality types more readily.

INTRODUCTION:

Defining and understanding neurological disorders can be medically challenging. Benign Fasciculation Syndrome (BFS) is a disorder characterized by fasciculation or muscle twitching of unexplained causes. Other BFS symptoms may include muscle fatigue, cramps, pins and needles sensations, paresthesia, muscle vibrations, headaches, itching, sensitivity to temperatures, numbness, muscle stiffness, muscle soreness and pain. [1] BFS is considered to be a disorder of Peripheral Nerve Hyperexcitability (PNH). BFS or PNH causes are not entirely understood and hence the need for this study. Some theories state that the cause of BFS or PNH may involve the potassium channel of the nerve terminal's inability to properly close its gates when a motor nerve impulse reaches the nerve terminal, resulting in a still-remaining active muscle fiber. [2] This imbalance is what causes involuntary impulses that consequently stimulate the nerve endings causing them to fire and twitch. [1,3,4]

OBJECTIVE:

The objective of this paper and survey is to perform a statistical or epidemiology study of BFS to better define an understudied and misunderstood disorder, especially amongst those chronically afflicted by the syndrome. Like many neurological disorders, there is no known cure for BFS. While this disorder is considered “benign” it contains symptoms that are very real and in some cases both psychologically and physically debilitating. [5] This is primarily due to the chronic and progressive nature of the disorder in some individuals. Most neurologists and doctors will tell chronic BFS patients that their symptoms are “not debilitating”. This is a misconception about the disorder. The statistical analysis of BFS from the survey proves that symptoms in many people are chronic (high frequency and intensity) and progressive. One study claims that up to 1% of the population may suffer from BFS. [6] BFS, for most people, is benign and insignificant, but those individuals with chronic symptoms 24/7, BFS can wreak havoc on their lives. Chronic BFS patients are prone to dealing with anxiety since their early onset symptoms are similar to other crippling disorders such as Parkinson’s disease, Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis (MS), and even brain tumors. Because of their symptoms, many BFS patients have often undergone advanced medical testing including Magnetic Resonance Imaging (MRI) performed on the brain as well as an Electromyography (EMG) to rule out other neurological disorders. [1] Based on a Microsoft Research Study conducted by White and Horvitz, there is a .50 probability that a quick internet search on “muscle twitching” leads them to sites related to ALS. Needless to say, this causes a great deal of distress for the individual knowing the relationship of twitching and ALS. In fact, some fairly recent studies have cited rare cases of individuals who started with twitching and cramping symptoms and developed ALS years later. [7] While these cases are extremely rare, the knowledge of them can cause continual anxiety in the chronic BFS patient.

Chronic BFS patients have similar symptoms to other neurological disorders including Neuromyotonia (NMT), Benign Cramp Fasciculation Syndrome (BCFS), fibromyalgia, Reflex Sympathetic Dystrophy (RSD), stiff person syndrome, continuous muscle fiber activity, continuous motor nerve discharges, Isaac Syndrome, and Morvan’s Syndrome with some differentiated by an EMG. [1] For this reason many remedies attempted to relieve BFS symptoms are exactly the same as those remedies used for NMT, BCFS, RSD and other neurological disorders. [1] At this time there is no evidence that BFS patients are any more likely to acquire other more serious neurological disorders, such as ALS or MS, than any person without BFS. [4] After all, if evidence existed BFS patients are more likely to contract ALS or MS then more doctors would be studying the syndrome.

If BFS is always benign in the eyes of most neurologists, then why do people with BFS go through advanced medical testing and take powerful medications such as anti-seizure, anti-depressant, sleeping pills, benzodiazepines, muscle relaxants and other strong medications to relieve symptoms? The answer is because there are people with extreme chronic cases of BFS.

METHODS:

The methods used to calculate results in this paper can be found in Appendices I, II, III, IV, and V. Each appendix covers Study Background, User Groups, Survey and Data, Data Analysis, and Sample Size computations respectively.

RESULTS:

Tables 1 through 7 below have the Spearman correlation data for a defined classification of variables. For this study, the variables were grouped into seven classifications – General, Causes / Triggers, Stressors (those variables that can make BFS symptoms worse), Symptoms, Body Parts Affected, Remedies, and Various. For instance, the General classification of variables consists of 7 parameters: age, sex, region, number of years with symptoms, years diagnosed, EMG, and MRI. The Various classification includes variables such as are symptoms getting worse over time or what part of the day is worse for symptoms. Results shown in italic fonts indicates moderate correlation and results in bold fonts indicate strong correlation. Normal font indicates only weak correlation. Parenthesis ( ) around the result indicates a negative correlation.

Parameter Definition Key (Most are self-explanatory):

General:

Age – What is the age of the survey participant?

Sex – What is the gender of the survey participant (Male or Female)?

Region – What continent of residence does the survey participant reside?

Symptom Stressors:

Sickness1 – Are BFS symptoms exasperated by an illness?

Exercise1 – Are BFS symptoms exasperated by exercise?

Stress1 – Are BFS symptoms exasperated by stress or anxiety?

Various:

Remedies – Did any remedies tried by the survey participant make symptoms worse?

Missing – Are any potential remedies missing from the survey list?

Time – Are symptoms getting worse or better over time?

Day – What time of day are symptoms worse?

Altitude – Do symptoms get worse at altitude?

Triggers / Causes:

Chemicals – Did exposure to chemicals such as organophosphates trigger symptoms?

Other – Does the survey participant feel their BFS symptoms were triggered by something not mentioned in the survey?

Table 1: General Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Age	Years with BFS Symptoms, (Stress / Anxiety), History, (Stress Anxiety 1), Muscle Stiffness, Lower Leg
Sex	Region, (Feet), Lower Leg, (Hip Buttock)
Region	Sex, Stress Anxiety, (History), (Muscle Relaxant), (Diet), (Remedies)
Years Diagnosed	Years with BFS Symptoms, EMG, (Stress / Anxiety), Exercise1, Lower Leg, Anti-Seizure
Years with BFS Symptoms	Age, Years Diagnosed, (Stress Anxiety), Exercise1, (Stress Anxiety1), Twitching, Sensitivity to Temperatures, Lower Leg, Time
EMG	Years Diagnosed, MRI, Sickness, (Stress / Anxiety), (Stress Anxiety1), Back, Anti-Seizure, Benzodiazepine
MRI	EMG, Prescription Drugs, Spine and Neck Injury, Pins and Needles , Cramps, Diet, Remedies

What information can be processed from the correlation data in Table 1? One example will be evaluated from each table to show how to read and understand the data. It is important to note that positive correlation means the parameters track proportionally and negative correlation (parenthesis around the result) means the parameters track inversely proportional.

From Table 1 the Years with BFS Symptoms (YBFS) parameter is evaluated. From the correlation it can be concluded that older people in the survey have had BFS longer (no surprise); older people are less likely to have stress or anxiety induced BFS; exercise is more likely to exasperate symptoms in people who have had BFS for long periods of time; stress is less likely to exasperate symptoms in people who have had BFS for a long periods of time; twitching and sensitivity to temperatures will get worse over time; and symptoms will predominately remain in the lower legs.

Table 2: Symptom Stressor Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Sickness1	Sickness, Exercise1, Stress / Anxiety1, Missing
Exercise1	YD, YBFS, Exercise1, Other, Sickness1, Stress / Anxiety1, (Anti-Depressant), (Muscle Relaxant)
Stress / Anxiety1	(Age), (Years with BFS Symptoms), (EMG), Stress / Anxiety, (Other), Sickness1, Diet, Benzodiazepine

From Table 2, the Stress and Anxiety (SA1) parameter is examined. Stress or anxiety is more likely to exasperate symptoms in younger people; people with stress induced BFS are less likely to get an EMG; people with stress induced BFS are more likely to have symptoms exasperated by stress; a sickness may also exasperate symptoms; people with stress induced BFS are less likely to have another trigger or cause; and diet and Benzodiazepine drugs may work best to control symptoms.

Table 3: Symptom Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Twitching	Years with BFS Symptoms, Stress / Anxiety, Pins and Needles, Lower Leg, (Anti-Depressant), (Diet), (Benzodiazepine), Time
Pins and Needles	MRI, Twitching, Numbness, Vibration / Buzzing Sensation, Feet
Cramps	MRI, Numbness, Muscle Pain and Soreness, Lower Leg
Muscle Fatigue and Weakness	Muscle Stiffness, Muscle Pain and Soreness, Feet, Lower Leg, Anti-Seizure, Massage
Headaches	Itching, Neck / Head
Itching	(Exercise), Headaches, Muscle Stiffness, Sensitivity to Temperatures, Neck / Head
Numbness	Pins and Needles, Cramps, Muscle Stiffness, Sensitivity to Temperatures, Anti-Depressant
Muscle Stiffness	Age, Muscle Fatigue and Weakness, Itching, Numbness, Muscle Pain and Soreness, Diet
Vibration / Buzzing Sensation	(Vaccine), Pins and Needles, Feet, (Muscle Relaxant), Benzodiazepines
Muscle Pain / Soreness	Cramps, Muscle Fatigue and Weakness, Muscle Stiffness, Sensitivity to Temperatures, Hands, Anti-Depressants
Sensitivity to Temperatures	Years with BFS Symptoms, Itching, Numbness, Muscle Pain and Soreness, Homeopathic Treatments

From Table 3, the Twitching symptom is explored. Twitching will get worse for most BFS patients over time and it’s the primary symptom in stress induced BFS; people who have twitching as a symptom may also experience pins and needles as a secondary symptom; and twitching will generally occur in the lower leg and remedies such as anti-depressants, diet, and benzodiazepine drugs may not help or make matters worse.

Table 4: Body Area Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Feet	(Sex), Spine or Neck Injury, Pins and Needles, Muscle Fatigue and Weakness, Vibration / Buzzing Sensation, Lower Leg, Hands
Lower Leg	Age, Sex, Years Diagnosed, Years with BFS Symptoms, Twitching, Cramps, Muscle Fatigue and Weakness, Feet, (Arms / Shoulders)
Upper Leg	Hip / Buttock, Abdomen, Arms / Shoulders
Hip / Buttock Region	(Sex), Upper Leg, Back
Back	EMG, HBR, Abdomen, Chest, Arms / Shoulders, Anti-Shoulders
Abdomen	Upper Leg, Back, Chest, (Yoga)
Chest	Back, Abdomen, Neck Head, Arms / Shoulder, Anti-Seizure
Neck / Head	Headaches, Itching, Chest, Hands, Arms / Shoulder, Massage, Remedies
Hands	Sickness, Muscle Pain and Soreness, Feet, Neck / Head, Arms / Shoulders
Arms / Shoulder	(Lower Leg), Upper / Leg, Back, Chest, Neck / Head, Hands

From Table 4 the Lower Leg parameter is examined. The lower leg is most likely to affect older male BFS patients; twitching is the primary symptom along with secondary symptoms of cramping and muscle fatigue and weakness; and people with lower leg symptoms are less likely to have BFS symptoms in the arms and shoulders, but highly likely to have symptoms in the feet.

Table 5: Remedy Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Anti-Seizure	Years Diagnosed, EMG, (Spine or Neck Injury), Sickness, Exercise, Muscle Fatigue Weakness, Back, (Chest)
Anti-Depressants	(Exercise1), (Twitching), Numbness, Muscle Pain and Soreness
Sleeping Pills	Exercise
Muscle Relaxants	(Region), History, Exercise1, (Vibration / Buzzing Sensation)
Homeopathic Treatments	Sensitivity to Temperatures, Missing
Supplements	SA1, (Twitching), Muscle Stiffness, Neck / Head
Diet	(Region), MRI
Massage	Sickness, Exercise, Stress / Anxiety1, Muscle Fatigue and Weakness, Neck / Head
Yoga	(Abdomen), (Remedies)
Benzodiazepine Drugs	EMG, Stress Anxiety, (Twitching), Vibration / Buzzing Sensation

From Table 5 the Anti-Seizure (AC) remedy is evaluated. People are more likely to try anti-seizure medications after having been diagnosed for a long period, and more likely to have had an EMG; they are also more likely to have had their BFS symptoms triggered by an illness or exercise and experience muscle fatigue and weakness; and symptoms are likely to occur in the back, but less likely to occur in the chest.

Table 6: Various Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Remedies	(Region), MRI, Chemicals, Prescription Drugs, Neck / Head, (Yoga), Missing, Altitude
Time	Years with BFS Symptoms, Twitching
Day	No Correlation
Missing	Vaccine, Sickness, Sickness1, Homeopathic Treatments, Remedies
Altitude	Sickness, Supplements, Remedies

From Table 6 the Remedies parameter is investigated. People from North America are more likely to have tried a remedy that has made their BFS symptoms worse and they are more likely to get an MRI; people with chemical or prescription drug induced BFS are more likely to have tried a remedy that has made their symptoms worse and the symptoms are likely to happen in the neck and head region of the body; yoga is not helpful and remedies that are helpful are missing from the survey; and altitude or low pressure can also make symptoms worse.

Table 7: Cause or Trigger Parameter Correlation

Parameter	Parameters with Weak, Moderate, and Strong Spearman Correlation
Flu Shot / Vaccine	Chemicals, (Vibration / Buzzing Sensation), Missing
Chemicals	Vaccine, Prescription Drugs, Spine or Neck Injury, Remedies
Prescription Drugs	MRI, Chemicals, Sickness, Remedies
Spine and Neck Injury	MRI, Chemicals, Feet, (Anti-Seizure)
Sickness	EMG, Prescription Drugs, Sickness1, Hands, Anti-Seizure, Massage, Missing, Altitude
Exercise	Stress Anxiety, Exercise1, (Itching), Anti-Seizure, Sleeping Pills, Massage
Stress / Anxiety	(Age), Region, (Years Diagnosed), Years with BFS Symptoms, (EMG), Exercise, Stress / Anxiety 1, (Twitching), Massage
History	Age, (Region), Muscle Relaxant
Other	Exercise1, (Stress / Anxiety1)

From Table 7 the Stress and Anxiety trigger parameter is examined. Stress induced BFS is more likely to happen in younger patients from Europe and they are less likely to have an EMG; stress will exasperate symptoms, but not necessarily twitching; and massage works best to alleviate symptoms.

The above examples should help the reader figure out how to read the correlation data for all parameters in all tables.