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twitches and muscle shaking

  I am male, 35 years old.  I have been experiencing all over muscle twitches for about 18 months and muscle shaking on exertion for about 2 years (when I look back, I probably had the shakiness to a lesser extent for about 5 years).  13 months ago I had seen a neurologist and had an EMG and MRI of Head and neck.  All test results were normal.  Follow up exams showed "brisk" reflexes but all else normal.  For a period of time the twitching and shaking seemed to decrease in intensity, but lately they have returned to about the same intensity as last years peak.  Also lately I have experienced what I consider abnormal fatiguing in my arms and especially hands.  I have not, however, seemed to have lost much strength if any.  For the last 3 years I have also been on and off medicaiton for depression.  I have used paxil and prozac. I am currently no on medicaiton.  Right now I seem to be somewhat depressed as well.  I often think that I am neurotic and that I have blown all of these symptoms out of proportion.  Sometimes I think that I have ALS, even though I have not lost much strength if any ( I do however feel more fatigued than I think I should be).
  I have been wondering if I could have ALS or some other degenerative condition.  Could the EMG study have been too early?  I am embarrassed to go back to my doctor because I don't know if my symptoms are real or enough to cause real concern.  
  I would appreciate any and all insight and advice.
The muscle twitches may be a phenomenon called fasciculations. This is where a small part of a muscle twitches but not in coordination with the rest of the muscle. It may be so subtle that you just feel it (painless) or sometimes the twitches can be seen on the surface (like a bag o worms) under the skin.
Fasciculations don't necessarily mean anything bad. It is true that you can see fascics in situations in which the motor nerve has been damaged (for example "pinched nerve" or neuropathy or motor neuron disease). However, fascics are NOT diagnostic of anything in particular. There is a syndrome of benign fasciculations which is seen in perfectly normal people with no neurologic damage. Fascics are commonly brought out by exertion.
It is not uncommon for a physiologic tremor (which everyone has to some degree) to be apparent after exertion. Sometimes people have a benign condition called essential tremor which isn't due to any damage to the nervous system per se. Essential tremor, like physiologic tremor, is often made more prominent after exercise - it's related to the circulating epinephrine (adrenaline) in your body. It is one of the reasons why epinephrine blocking agents (beta blockers such as propranolol) can work for essential tremor.
Note, though, that essential tremor doesn't include fasciculations. Also, there is no reason from your description to suggest you might have ET.
Brisk reflexes can be normal, especially if they are symmetric and if there is no demonstrable weakness or spasticity.
Fatiguability can be related to depression, or any number of ill-defined processes which may or may not point to neurologic disease.
Notice the theme in all the above: it is possible that you have no damage to your nervous system, in which case the symptoms don't represent anything dangerous. However, it is possible that there is something buried under all that (I don't think ALS would be very high on my list, though). It is simply impossible to tell in this format.
I recommend re-evaluation by your doctor. We see this all the time - patients come to us for an explanation of symptoms, even if treatment per se is not necessary. Sometimes just knowing what is going on (or at least knowing that there isn't anything bad even if your doctor doesn't make a firm diagnosis) is worth the visit.
My personal approach is that when I'm not certain of the diagnosis, I have people come back to me at some point in the future for reevaluation. Sometimes on the second visit the picture is a lot more clear, either in favor of "no problem" or making a neurologic disease more apparent.
So, it isn't a waste of your (or your doctor's) time for you to go back. Let him/her decide whether any repeat tests are necessary.
I hope this helps. If you wish, we are available at 800 223-2273. Ask for neurology appointments at 4-5559. Any general neurologist on staff here can see you. CCF MD mdf.

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