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6/29/2018
Dr Subbanna MD
Dr Subbanna MD, Neurologist (MD)
Category: Medical
Satisfied Customers: 6,418
Experience: American Board Certified Neurologist, Internal Medicine
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Hi, thanks for the question, and I am very glad to help you again with your health concerns. Like I have said many times previously too I really do not think my diagnosis of you are not at all having als of any kind will change, however if you are having more questions please let me know.

Best Regards!

Dr Subbanna MD

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Customer reply replied 1 month ago
Thank you. I had another emg today. On my right arm due to my concerns of thenar atrophy and forearm twitching. It was totally normal. Bicep. Tricep. Forearm extensor. 1DI. And apb. All normal. Question. My twitching is on the hypothenar side of my forearm. Not the thenar side. I am glad the thenar needle was clean, but would this emg in 5 arm muscles rule out all twitching in the arm as worrisome. I do still twitch on many places across my body.
Customer reply replied 1 month ago
The other question I have still relates to possible bulbar/ respiratory issues. I still continue to have exercise intolerance. I used to be able to ride the bike for an hour easily. Now it is harder, my heart rate is quite high and I sweat much more. Though not obvious to others I feel my tongue is heavy and some words are not clear. I continue to clear my throat after I eat. The other effects are an oily skin area at my hairline and heat intolerance. Do these add up to als concern in any way? I also feel like it is harder to breathe on my back but seem to go to sleep on my back without much problem. Breathing during the day seems a bit laboured but this could be my extreme anxiety. Thanks for continuing to answer my questions.

You are welcome, I appreciate for all these additional information. I am preparing & typing my answer now, and I will post my answer here as soon as it is ready. Typing may take few minutes and I will follow up with you and post my answer here the moment I finish with my typing.

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Okay I am ready; I am posting my answer here;

At the outset once again I want to inform and reassure you there is definitely no suspicion for als of any kind in you

Your fear for als is totally unfounded

I see you have had another emg test, this time for the right upper extremity, but as expected it too has come fully normal

Does not surprise me at all because you can have any number of emg tests they all will come normal

The muscles tested will cover for the whole right upper extremity, even if the hypothenar muscles were not tested but c8/t1 muscles such as apb, fdi etc were tested so this covers the c8/t1 and ulnar nerve supplied muscles too

So this emg is more than enough to rule out als in the right upper limb too

ALS in other limbs has already been ruled out

And bulbar als too has been ruled out

While you did not have a tongue muscle emg but you did have some cranial nerve sampling which had come normal

And you have had para spinal muscles tested and normal too

So you have had very extensive sampling of muscles and this has clearly ruled out als of any kind in you

Of course the innumerable neurological clinical examinations too have all come normal

You have had bulbar clinical examinations coming normal too

While I understand you are still fearing about the possibility of bulbar als, but you are really not having any true bulbar als symptoms

The symptoms you have been having are all just subjective in nature

If someone is having bulbar als related symptoms, even in early stages family members such as wife etc are not going to miss speech changes etc

They will also bring to your notice that you are having difficulties while eating or drinking or breathing etc

It does not appear your wife has ever raised concerns about your speech or swallowing or breathing etc and this categorically rules out you are having any real symptoms and implies your symptoms must be subjective in nature

If someone has severe health anxiety and constantly worries about a serious illness then they are going to experience some subjective symptoms related to that illness

For example if you worry about heart disease then chest pain etc can occur which is just psychological

Similarly if you worry about als then you will start experiencing als related symptoms such as the ones mentioned earlier

But the pattern of the symptoms will tell us whether these are true heart attack or als symptoms or just subjective symptoms

Your pattern of the symptoms always point towards only one thing – that is psychological, and nothing else

All your symptoms including muscle weakness, atrophy, twitching, skin changes, breathing issues, speech issues, swallowing issues, fatigue/exercise intolerance etc etc are all just subjective symptoms and have nothing to do with als of any kind

Once again I can very categorically reassure you, there is absolutely no suspicion for als of any kind in you, your symptoms are all just psychological and subjective in nature, there is not even one iota of suspicion for als of any kind in you, you are 10000% not having bulbar or limb or any other forms of als for sure, your symptoms are all 10000% psychological, so please not to be scared.

Wishing you the best health!

All the very best!

Please let me know if you have any additional questions or if you want to discuss this further. And please take a moment and kindly click a positive rating (preferably 5 Star/Excellent) to credit for the time & professional effort put by me in answering your health question, and this is the only way I will be credited for my service to you. Rating me now will not close your question and if you have follow-up or additional questions you can ask them after the rating too!

Best Regards!

Dr Subbanna MD

For future questions you can follow up either here, or you can reach me directly with "a question for Dr Subbanna MD" through my Just Answer direct link mentioned below here;

http://www.justanswer.com/medical/expert-drsubbannamd

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Customer reply replied 1 month ago
Thank you for the depth of your response. I just find it hard to believe that my exercise issues are not a concern. I have always been so in tune with my fitness and I just don’t feel right. Very fatigued with a weak voice after the working out.
Customer reply replied 1 month ago
the specific forearm muscle that is twitching (on the hypothenar side of forearm) does not need to be needled to rule out any issues. As long as the nerve root is tested.
Also, the paraspinals would for sure rule out breathing/ respiratory onset concerns? Thank you.
Customer reply replied 1 month ago
with all of these tests over a 2 month period or more, you truly feel that I am 10000% healthy. You don’t think there is any way that I could have als at all? 6 neuros. 5 emgs. Many clinical neuro exams. Most key muscles tested other than tongue. Could all of these doctors miss even early onset als? Is there any chance of that? Can’t get out my head the stories of folks whose first symptom
Was exercise intolerance. They had not had all the tests I have have though. Hey had not had even one test or emg.

You are welcome, it is impossible for someone to have als, even the beginning stage of als but keep fully clearing neurological examinations and emg testings one after another like this, this clearly indicates your symptoms are totally psychological in nature. Psychological symptoms can mimic any serious illnesses, there are individuals who appeared to have developed stroke or seizures and have repeatedly visited er but eventually confirmed to be totally psychological issues. And yes since the c8/t1 spinal motor neurons have already been tested through apb and fdi so it is perfectly fine to not to test hypothenal muscles, and the paraspinal muscle emg test coming normal indicates the respiratory muscles are normal too.

With 6 neuros, 5 emgs, many clinical neuro exams there is no way als can ever go missed in any individual, it is impossible even to imagine how als can be missed in you after such extensive clinical and emg evaluations, so you are 10000% not having als of any kind.

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Customer reply replied 1 month ago
I have a sore right shoulder. I meant to get the neuro to needle the r deltoid, but got caught up in the anxiety of the test. IF the sore feeling was als related, would the the nerve root that supplies be biceps and tricep be sufficient to pick up any issues in the shoulder or would it need to be needled independently. I believe the doctor talked about testing c5 and c6. Thanks so much.

Shoulder muscle, the deltoid muscle is supplied by the spinal motor neurons at c5 and c6, while triceps is supplied by c5,6,7 but biceps is supplied by the exact same c5,6 spinal motor neurons and motor roots that supply deltoid too - so biceps coming normal automatically rule out als involving deltoid muscle too. You are welcome.

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Customer reply replied 1 month ago
Increased heart rate at rest and while sleeping. Woke up with it racing last night. Is this breathing related or heart related. Also seems to spike by just rolling over. I know you aren’t a cardiologist but looking for your thoughts. I do have bicuspid Aortic Valve and wonder if this could be related. Exercise intolerance as well?
Customer reply replied 1 month ago
No headache in the morning. Breathing does feel laboured a bit. Some yawning in am.

Most individuals having bicuspid aortic valve do not develop any heart related problems so I feel your symptoms are not heart related either, but regarding the heart possibility you may try to discuss with a cardiologist only. Your symptoms appear just anxiety related and nothing else.

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Customer reply replied 1 month ago
Thank you. So you truly believe that my current concerns are anxiety related. Fatigue during the day. Exercise intolerance. Breathing. Subjective speaking issues. Oily skin. That truly, if these issues were als related, it would have been discovered by now after 2 months,6 neuros and 5 emgs even though bulbar emg was not done. Thank you.

You are welcome, yes, I truly and 10000% believe your symptoms are just anxiety related rather than related to any illnesses, including als of any kind too. And there is no need for any bulbar emg since bulbar clinical examination was normal.

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Customer reply replied 1 month ago
Hi Sir,
As you know, I worry about the odd autonomic related issues I am having. Heat intolerance, oily skin, sweating. Are these issues related to ALS in any way. Have you ever heard of this as presentation or as issues later in the disease at all. These are the things that are new and different and I am having a tough time accepting them as benign. I once loved being out in the sun. Now I sweat and get uncomfortable in mere minutes. many thanks.

Hi Sir, these autonomic symptoms certainly appear anxiety related. Autonomic symptoms are among the most common anxiety related symptoms. However if you still are unable to accept these are not real then you need to try to see a neurologist who conducts autonomic nervous system testing. Anyhow I have not come across a single case of als who had autonomic symptoms from the beginning, even at later stages of their als they never had this prominent autonomic symptoms. I am 10000% not suspecting als of any kind in you. welcome.

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Customer reply replied 1 month ago
Hi Doctor. I have always had normal reflexes, babinski, Hoffman etc. My worries are bulbar and respiratory. If I had als, would these signs typically be present or are they less prominent in bulbar. Really trying to rule out bulbar. Thank you. All clinical exams normal.

Hi, even if you have only bulbar als, during neurological examination certain upper motor neuron symptoms are expected to be detected such as the ones you have mentioned above, but irrespective of anything else, no one else has thought you are having bulbar symptoms including your family and the innumerable number of neurologists you have seen so far, and your bulbar examinations were normal too - so you are 10000% not a case of bulbar als too. Welcome.

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Customer reply replied 1 month ago
I am really having a hard time with the exercise intolerance. I can convince myself that I am not slurring and my tongue is not weak. Difficulty on the bike is hard to rationalize.
Customer reply replied 1 month ago
Thoughts?
Customer reply replied 1 month ago
Thank you for the bulbar response above.
Customer reply replied 1 month ago
the bulbar symptoms, you believe, are all subjective in nature. Because all of the neuros have not noted anything. In particular, neurologist neuro muscular specialist said normal tongue bulk and strength. Palate good. Facial strength full. Could I really have any bulbar issues with this assessment? Biting my tongue still a bit.

Yes, all your symptoms are subjective in nature, if you are having bulbar als then it is impossible during clinical examination no bulbar findings ever got detected, also so much exercise intolerance but without any clinical findings or emg findings is impossible, so all your symptoms have to be 10000% subjective. Welcome.

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Customer reply replied 1 month ago
That is what I am really hoping. That with all of my testing and neuro assessments, that if my exercise intolerance was from als, it would be supported by other findings consistent with als. And I have none at all. Neither clinical or emg.
Customer reply replied 1 month ago
even though I feel like I am having tongue mobility issues. Moving it around in my mouth etc, this would be noted in tongue strength tests as well as the neuro watching my tongue during assessment. Feels like it doesn’t move as well in touching my back left molars when compared to my right. Probably too much testing. Also, my lip seal has been tested each time by puffing out my cheeks and resisting the doc pushing is on them. No way my lips can be weak, right?
Customer reply replied 1 month ago
Also had no jaw jerk when with the neuro specialist. Does this point away from bulbar?

The jaw jerk is not much helpful reflex test when it is absent. Your symptoms are definitely subjective and definitely no als of any kind in you.

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Customer reply replied 1 month ago
Hi Doctor. Woke up today with a very heavy chest. Feels tough to breathe. Is there really no chance that this cannot be respiratory or bulbar onset. I feel so tired and the breathing is upsetting. Is there at all a chance that so many neuros have missed soemrthjng. I know that it can take a while for als to present. It does take some folks up to a year for diagnosis. How am I different than those folks. Let me know your true thoughts on this. Is it becoming worrisome at all. Thank you for your care. Sincerely.
Customer reply replied 1 month ago
CAn this really be only anxiety. It feels so real. Especially the exercise intolerance and breathing.
Customer reply replied 1 month ago
Weak voice as well.
Customer reply replied 1 month ago
Is there anything alarming as I continue to worry about symptoms.

Hi, I am really not suspecting als for the various reasons that I have already explained to you under this question thread, as well under the previous question threads too. Like I said previously too if you are still suspecting als then you may strongly consider taking more opinions because my answer is not going to change, I truly & 10000% believe you are not a case of als of any kind. Welcome.

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Customer reply replied 1 month ago
Please tell me this many doctors could not be wrong.

It is impossible for so many doctors to go wrong and miss als in you - so 10000% you cannot be a case of als.

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Customer reply replied 1 month ago
No need for bulbar emg?
Customer reply replied 1 month ago
you totally think that all of the clinical exams would have noted anything of concern in the bulbar, cranial nerve area, right.
Customer reply replied 1 month ago
At least 5 exams.

Yes, bulbar als has definitely been ruled out with so many clinical examinations coming normal, and bulbar emg is certainly not needed.

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Customer reply replied 1 month ago
Hi Doctor. Noticed weak neck muscles today. Seem to be a little bit of atrophy on the left side. Head ache and stiff neck today. Worried that this is another symptom not ruled out be emg. I have. It had a cranial emg though I did have one on the trapezius on the same side. Can I take solace in this. The trap is inervated partly by the cranial nerve. Please share your thoughts. Neck atrophy on the same side as I had a trap emg 5 weeks ago. Also all neuro exams noted full neck extension and flexion strength. Thank you. Sir.
Customer reply replied 1 month ago
Cranial nerve XI. Both the neck and he trap innevated by XI. Is the clean emg in trap 5 weeks ago a good sign. Thanks sir.

Hi, no I am 10000% not suspecting als in you of any kind, your symptoms are all 10000% subjective, welcome sir.

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Customer reply replied 1 month ago
Is my assessment of the trap emg accurate. Can it help with reassurance at all. If I need the special offer for an answer please pass along. Thank you.

Yes, your trap emg assessment is certainly accurate, you are 10000% not having als of any kind. Once again my strong advice is to consider discussing your case with other experts here and/or with neurologists in the clinic since my evaluation on you that you are 10000% having only psychological symptoms and 10000% no als of any type - is not at all going to change, welcome.

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Customer reply replied 1 month ago
Hi Doctor. Very worried about my neck. New symptoms. Will you answer a question or please send me a special offer. Thank you for your consideration.

Hello, as I had advised earlier too please consider consulting other experts at this site and/or consulting neurologists in the clinic since I am really not suspecting als of any kind in you and my diagnosis is not at all going to change, welcome.

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Customer reply replied 1 month ago
I am 100% certain that I have it. Can I give you an update.

Hi, since I am 10000% not suspecting als of any kind in you but since you still are worried about the possibility of als in you, accordingly I will opt-out from this question and return this question back to the expert pool so that if you wish you may consider obtaining opinions from other experts too.

Please try to avoid replying to this post, otherwise this question may get locked back to me again and prevent other experts from taking up your question.

Wishing you all the very best!

Best Regards!

Dr Subbanna MD

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Dr. Ravoof
Dr. Ravoof, Doctor
Category: Medical
Satisfied Customers: 7,067
Experience: Experienced Physician in the field of Medicine and Surgery.
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Dear customer,

Your expert has opted out. Do you have any remaining questions?

Thank you!

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Customer reply replied 1 month ago
Hi Doctor. Glad to pay for your response. Had an emg of the masseter muscle today. Is that along with the previous trap emg enough to rule out bulbar. Thank you for your care and consideration.

Dear customer,

Thank you for replying.

Yes, these investigations are sufficient and together with the clinical examination will rule out bulbar and other forms of ALS. You can safely relax.

Take care.

Please rate the answer with 5-stars, by clicking the 5-stars above with your mouse (or with your finger on a mobile device).
It will be very generous of you to also consider a bonus.
Thank you!

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Customer reply replied 1 month ago
Hi Doctor. I am so scared about als. Have seen 6 neuros. Have had 5 emgs. None on bulbar except today. Which was just the masseter. I feel my neck is smaller on the left side. Sternomastoid muscle. All of clinical exams have been normal. Tongue strength. No wasting. Have had a sore neck for a few days since noticing the smaller neck. On inspection today, the doctor did not note any difference. He was not willing to emg the tongue or neck, but did the masseter. Thank you. All other emgs and clinical exams have been normal with no problems at all.

Dear customer,

You are very welcome!!

You are suffering from health anxiety which is making you scared. You are not suffering from any physical condition. I strongly recommend that you purchase the below-linked books from your local bookstore and online. Please read these books and apply the advice to your life. Your health anxiety will gradually reduce and you will feel better.

https://www.amazon.com/Its-Not-Your-Head-Sick/dp/1572309938/

https://www.amazon.com/Things-Might-Terribly-Horribly-Wrong/dp/1572247118

Take care.

Please rate the answer with 5-stars, by clicking the 5-stars above with your mouse (or with your finger on a mobile device).
It will be very generous of you to also consider a bonus.
Thank you!

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Customer reply replied 1 month ago
I have significant exercise intolerance and feel I have difficulty breathing while lying down. I am anxious for sure. But very difficult to ignore the other symptoms. Throat clearing after eating as well. Based on all my assessments and emgs, you truly believe that I am fine no question.

Dear customer,

Thank you for replying.

Your symptoms are certainly not neurological. You can safely rule out ALS and other neurological causes. I truly believe that you are fine and there is no question regarding this in view of all your assessments and EMGs.

Consulting an internal medicine specialist will help since other causes such as anemia, hormonal problems, and also anxiety needs to considered as a possible cause for your symptoms.

Take care.

Please rate the answer with 5-stars, by clicking the 5-stars above with your mouse (or with your finger on a mobile device).
It will be very generous of you to also consider a bonus.
Thank you!

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Customer reply replied 1 month ago
I have spent too much time researching and know that bulbar onset can start very gradually. Throat clearing etc. I guess the trap and masseter emg can rule it out for sure?
Customer reply replied 1 month ago
Also. Could the breathing issues be connected to any diaphragm/ respiration issues that can occur with als.
Dear customer,
Thank you for replying.These tests will definitely rule it out for sure.Breathing issues are not not related to diaphragm or any nerve disorder since this can be easily detected clinically. You can safely relax and be confident that your symptoms are not neurologically related.Take care.Please rate the answer with 5 Stars.Thank you so much!
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Customer reply replied 1 month ago
Just a little more help please. Totally feel like I have als. Even though there have been many docs and emgs saying I am fine. My neck is weak. I have significant exercise intolerance, tough to breathe on my back at night. All bulbar/ respiratory issues. I bite my tongue at times. I feel like a mispronounce words at times but no one has said that I slur. Is there any possible way that 5 neuros and many emgs could be wrong. How helpful is a masseter emg and a trap emg determining bulbar? Thank you, sir.

Dear customer,
You are very welcome!!

With these tests you can safely rule out bulbar ALS. Your symptoms are likely to be due to anxiety. They are not alarming or worrisome.

Take care.

Dr. Ravoof
Dr. Ravoof, Doctor
Category: Medical
Satisfied Customers: 7,067
Experience: Experienced Physician in the field of Medicine and Surgery.
Verified
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Dr Subbanna MD
Neurologist (MD)
6,418 satisfied customers
I accidentally pricked myself with a sewing needle that one
Hi. I accidentally pricked myself with a sewing needle that one of the teenagers I work with was using. she doesn't remember pricking herself with the same needle. Should I be concerned?… read more
Dr Subbanna MD
Dr Subbanna MD
Neurologist (MD)
6,418 satisfied customers
I have one question please, I take Thyroxine 50 micrograms
Hello, I have one question please, I take Thyroxine 50 micrograms for thyroid functionality, one tablet per day. Today I took two tablets by mistake. Is this a problem? Thanks.… read more
Dr Subbanna MD
Dr Subbanna MD
Neurologist (MD)
6,418 satisfied customers
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Disclaimer: Information in questions, answers, and other posts on this site ("Posts") comes from individual users, not JustAnswer; JustAnswer is not responsible for Posts. Posts are for general information, are not intended to substitute for informed professional advice (medical, legal, veterinary, financial, etc.), or to establish a professional-client relationship. The site and services are provided "as is" with no warranty or representations by JustAnswer regarding the qualifications of Experts. To see what credentials have been verified by a third-party service, please click on the "Verified" symbol in some Experts' profiles. JustAnswer is not intended or designed for EMERGENCY questions which should be directed immediately by telephone or in-person to qualified professionals.

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