Dr. Hitesh Kumar
Neurology
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Patient's Query
Hi doctor,
I am 28 years old and anxious about the possibility of ALS. About two months back, I had vitamin D (9 ng/mL) and B 12 deficiency (182 pg/mL). Symptoms were low back pain, tingling sensation in the right leg with stiffness, occasional shooting pain from back to legs used to get better with rest, and an episode of nausea, acidity, and vomiting. These were corrected since my B12 is 476, and D is 80. Since then, my movement has been slow, and I feel fatigued, some days less some days more. My legs feel sore after walking a small distance, and I walk slowly with small steps. I have fasciculations and sometimes throbbing sensation in the muscles in thighs, calves, the upper arm that lasts for two to three seconds and always happens while I am at rest a few times every day. Also, climbing stairs feels like a task; it feels a lot of pressure on the legs, mostly left, and calves would feel achy afterward. When I wake up in the morning, legs mostly below the knees have a dull ache that gets better with the day, but the slow movement and left leg issue has persisted, and if I try walking fast, the legs feel sore, stretched behind the knees and become tired. While I can do normal daily stuff, I do not have a normal swift movement as before. Multiple doctors' visits have resulted in normal blood reports and other reports like LFT, Thyroid, RFT, CBC, etc. I currently take Mecobalamin 1000 mcg.
Hello,
Welcome to icliniq.com.
As you mentioned symptom of lower back pain, with tingling in the right leg and occasional shooting pain from back to legs, it may be a radicular pain due to nerve root pressure or irritation in the lower spine.
Fasciculations can happen in many illnesses (apart from ALS) like anxiety or benign fasciculation syndrome or cramp fasciculation syndrome or myotonia.
I would like to know some further information about your symptoms:
1. Since when you started to have lower back pain and shooting pain from the back to the leg and tingling sensations in the right leg?
2. In which situation this pain get worsened: standing or walking or running or forward bending or lifting some weight or prolonged sitting or something else?
3. Since when you started to have fasciculations over different body parts?
4. Do you have to think of any part of your leg or arm?
5. Do you have any weakness in hand grip or foot movements or wearing footwear or buttoning and unbuttoning shirt or doing fine work by hands, etc.?
6. Do you have any joint pains or joint swelling? If yes, which joints are involved?
Other information:
1. How is your sleep in a routine? - Do you get sleepy soon after lying in bed? Or it takes a long time? Once sleepy, do you have frequent awakenings during sleep? Do you feel fresh on awakening from sleep in the morning?
2. How is your usual mood in day-to-day activities? Happy or toward the sad side (thinking about past events) or the worried side (thinking about future things, is it irritable or something else)?
3. How is your appetite?
The Probable causes
Investigations to be done
Differential diagnosis
Preventive measures
Regarding follow up
Patient's Query
Hi doctor,
Thank you for your reply.
After taking vitamin B12, it went away in just a week, and I no longer have low backache or tingling sensation in my right leg. Walking at a normal pace makes it slightly sore and feels stretched, especially on the left leg behind the knees and upper calf. I cannot run or lift weights these days since I feel pretty tired. Two months before, I used to feel jolts like sensation in early and when trying to sleep, in leg and body that I never had before.
I have no problem doing fine work or foot movement, but overall I have become slow, and strength has reduced the whole body. Somedays, it is more, but then some days I feel it is somewhat better. Like yesterday, I felt some sensation then weakness in both my lower arms, but they became normal within a few hours. I have no joint pain or swelling.
Other information are, sleep routine has improved now, which was the worst two months. Now, I get to sleep after an hour of going to bed. I do not feel fresh in the morning; I feel head heaviness and fatigue. I am constantly checking my body for symptoms of ALS and mostly lying in bed. If I try to do some activity, I start feeling more tired and sick. I cannot stand or keep walking for hours like before as I would begin to feel soreness in legs, more on the left leg, and overall fatigued. Normal but not as before three months.
My main concern lately has been the discomfort with the left leg and the possibility of ALS starting. In my previous visits to the clinic, my reflexes and strength were tested by asking to press against the clinician's arm and raising my legs, etc. They told me that they were familiar and denied EMG or NCV, but I cannot climb stairs usually or walk 100 meters perfectly as before. It has been a cyclic episode of what feels like recovery for some days then again regression.
Hello,
Welcome back to icliniq.com.
The stretchy feeling behind the knee and calf muscles after walking can be symptoms of the PIVD lumbosacral region, which can be myalgia, and such feeling can be there in a low mood or anxiety state. I would request you to elaborate on the "jolt like sensation" while trying to sleep. What you exactly feel in that?:
As per your description of mood, it seems as if you are very anxious nowadays. You already consulted a neurologist, and in your clinical examination, muscle power and reflexes were told to be normal. I am surprised why you are thinking so much about it being ALS? did some doctor told you a possibility of having ALS? or you speculated by searching on the internet? If clinical examination showed no clinical abnormality, a significantly less likely chance to have ALS at present. If you are persistently worried so much, it will affect your health. It is better if you can revisit the neurologist physically and discuss all your concerns again. You can also undergo some further investigations to rule out another thing that can mimic the same symptoms. Such symptoms can also be present in an anxiety state; I suggest you consult a psychiatrist and psychologist for psychological evaluation, counseling sessions, or medications (if required) for your exaggerated anxiety, which is also affecting sleep.
Investigations to be done
Differential diagnosis
Preventive measures
Patient's Query
Hi doctor,
Thank you for your reply.
A jolt like sensation and others usually varies, and I feel below. Some that occur while trying to sleep are sudden shocks like sensation that sometimes move my whole leg and others just arm or just fingers. The ones in the thigh, upper arms, back of the shoulder, upper chest occurs when I am lying flat on back or resting and feels like throbbing of whole large muscle without limb movement, never in the wrist, hand, or feet. Still, the moment I try to see them, they go away, remain just for few seconds only. The ones in the calves and lower thigh are small ones and occur while resting after trying to walk but vanish if I do a slight small movement or try to see them by removing trousers. Thanks for reassuring me.In my last visit, I was told it is a progressive thing, so it is not possible to feel better some days and worse on others, and at this age, it is exceptional. My cause of worry is if everything is fine, then why do I feel this fatigue and not like before and the movement issue in general like smaller steps, especially with left leg. I also wanted to know if I am right-handed, so is it fine for the left part to be a bit weaker like I can stand on the right leg for longer than the left. Is there anything I can monitor by myself to rule it out? I will try to get the tests done and follow the recommendations.
Hello,
Welcome back to icliniq.com.
The feeling of sudden shock-like sensation that sometimes moves the whole leg or arm, or fingers while going into sleep can be "Hypnogogic Myoclonus," which is a normal phenomenon while a person is going into sleep. The feeling inside leg and arm muscles, which you cannot see, might be subjective only. Instead, fasciculations are visible by eyes, and muscle is visible to twitch that time. Feeling fatigued can be due to numerous causes, including low mood depression or anxiety state. You can discuss with your neurologist about your gait (slow or small steps) with a neurologist. If you still do not find anything specific, try to consult a psychiatrist or a psychologist for your low and worried mood.
Along with it, start daily jogging in the morning 20 to 30 minutes. Exercise is an excellent mood enhancer and releases endorphins in the body. Also, it is beneficial for general health being (that is even without any cost).
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