Think about the growth and changes to our physical skeleton and to our skeletal muscles as we reach physical maturity by age 15, 20, 25 and 30. . Not only do we grow to our adult size, but our reproductive system becomes active as well. It is amazing, when you consider the magnitude of these changes, when things work out normally and when we are able to function well as full sized adults for most of our lives. [ considering how much we grow and how much our proportions change and how much our hormones change] .
For some, the mind will begin to suddenly go through different levels of failure, making it difficult to think or remember or even move normally, compared to our baseline before becoming sick…….
The changes to motor function should make doctors think of problems affecting the skeletal muscle system, but the problems of the skeletal muscle system are often dismissed. The skeletal muscle system involves muscle involved with swallowing, feeding, breathing, and other forms of motor activity. Injury to these muscles will make voluntary action more difficult. Intact muscle is needed for all of these voluntary and semi voluntary actions, and we will not be aware of damage to the deeper internal skeletal muscles, upon we depend for many essential functions.
Some of us will have weakened skeletal muscles because of birth asphyxia [eg. like Paula] or because of growing up under conditions of poverty and undernutrition [like Paula’s parents and siblings] or because of some genetic problem affecting the skeletal muscles [like Paula’s mother and her siblings, possibly] or because of physical trauma and injury [ eg. being hit by a bus in early childhood].
Sometimes, skeletal muscle weakness or injury will result in a visible disability [eg, limping] and sometimes the skeletal muscle weakness will be hard to see without careful evaluation [as with Paula’s hidden depressed respiratory rate and active exhaling.]
We are used to thinking of skeletal muscle and its use as voluntary and we tend to forget that voluntary use of the skeletal muscle system will require more effort and more work if parts of it are weakened by illness or injury , impairing its function, voluntary or not.
Different stages of respiratory failure can be caused by injury or illness affecting the strength of the underlying skeletal muscle system alone, even when the lungs function normally.
An already weakened skeletal muscle system can be made worse by further illness or injury and this will affect a person’s ability to move air in and out of their body AND their ability to manage their endogenous carbon dioxide properly. Carbon dioxide is continually produced by the own body’s cells. Our internal stock of endogenous C02 is necessary and important to the function of the brain and body [see past blogposts] AND like any endogenous substance in the body, must be kept in check, in order to avoid dose related toxicity. The skeletal muscle system keeps our internal production of carbon dioxide in check by exhaling the excess that is not needed. As we learnt in earlier last blogposts, endogenous carbon dioxide is not a waste product, it is an important cerebral vasodilator and is necessary to the normal blood flow to the brain and the head and is key to the maintenance of normal intracranial pressure and to the normal function of the brain and the mind.
The brain monitors endogenous carbon dioxide for this reason and is usually able to adjust the respiratory rate and depth in order to manage levels of this endogenous chemical within its normal limits…..unless….there is a mechanical problem with the ventilatory system that affects the ability of the skeletal respiratory muscles [or nerve fibres or ganglions or ???] to move air in and out, despite the wishes of the regulatory systems of the brain. A respiratory rate that “sticks” and is stuck at a slow or a fast rate at baseline is like a car with a gas pedal does not respond normally to your foot. The speed of the car will be hard to control.
This is why it is so important to check carefully for active exhalation [very abnormal] or a respiratory rate which is too low or too high at baseline at rest. Checking respiratory rate only tells you the state of the respiratory skeletal muscles and the ventilatory system, it doesn’t’t tell you anything about the health of the lungs; for the health of the lungs, it is necessary to evaluate tidal volume. Both respiratory rate and tidal volume will tell you whether the exchange of fresh air and stale air is normal enough to maintain normal function of the mind, brain and body.
Measuring both respiratory rate and tidal volume will tell you if the exchange of air is adequate or not and will tell you if there is a risk of ventilatory failure [due to weak respiratory skeletal muscles] or of respiratory failure due to COPD [chronic obstructive pulmonary disorder ]. It is very important to check both the skeletal muscle ventilatory system and the pulmonary system, especially when the person becomes ill and looks sick [with or without fever] and especially if they complain of any level of “brain fog”. Abnormal internal levels of gases, any internal gases-oxygen, carbon dioxide, or the other gaseous transmitters that have more recently been discovered, will cause brain fog and levels of cognitive impairment and memory impairment, including memory for one’s own personal facts, habits and personality, often reversible depending on which internal gas is the culprit.
Brain fog is a colloquial [ordinary] expression referring to difficulty thinking normally; higher than normal levels of endogenous carbon dioxide will lead to brain fog and other levels of mental confusion. Stable [general or local] neuromuscular weakness will result in stable brain fog that can remain in place for months, years or decades unless rehabilitative and supportive medical treatment is provided to offset the effects of this muscular weakness.
This mental confusion [cognitive impairment, partial amnesia and other [hidden] forms of personal memory loss with unpleasant mood [such as anguish, dyspnea and/or depressed mood] can be due to hidden retention of exogenous carbon dioxide [ C02 retention can occur without visible signs of respiratory distress if neuromuscular weakness is involved] . Neuromuscular injury and weakness affecting the ventilatory system needs to be investigated and corrected as soon as possible before the patient suffered too much of a decline in their function, in their quality of life and fore too much damage to their work and to their relationships occurs.
Unfortunately doctors are not trained to deal with adult onset exacerbations of skeletal muscle weakness unless it becomes so severe as to cause death [ALS, MS, Cystic Fibrosis, etc..]. In the early stages of these progressive neuromuscular diseases, the non specific signs are often misdiagnosed as depression and other psychiatric conditions for this very reason. And many of these progressive neuromuscular diseases will eventually affect the function of the brain and the mind, most likely [we think] because they weaken the respiratory muscles and the normal exchange of air in the body.
Many psychiatric illnesses cause adult onset of “brain Fog” and dysphoric unpleasant mood or ” intoxicated”, euphoric and labile mood. It is possible that local injury to the ventilatory system is involved. Yet psychiatrists know nothing about the dose related signs and symptoms of imbalances of invisible endogenous carbon dioxide in the blood and their effects [reversible…always reversible…unless you die [eventually highly toxic PC02 will be lethal but it should take a long long time as the body has many ways to deal with its irregularities of its own products].
I imagine that retaining c02 in toxic amounts it is not entirely different from slowly drinking alcohol in toxic amounts, but in this case carbon dioxide is naturally produced by the person’s body as a product of living cells, but due to skeletal muscle weakness cannot keep it in check sufficiently to prevent dose related toxic results to mind, brain and body. And both chronic effects of [exogenous] alcoholism and of [endogenous and invisible ] C02 retention can often take a long time to kill you, during which you may become quite impaired.
In many diseases affecting the skeletal muscles, including breathing muscles, treatment consists of preventing obstruction, preventing and treating infection [hidden or not] and non invasive help to clear secretions and to help move air in and out sufficiently, nutritional enhancement and rehabilitation to try to strengthen muscles that are weak. This attention to skeletal muscles and providing help to move air more effectively, when the system breaks down, helps prevent brain fog and helps to retain a normal quality of life for as long as possible.
In the cases like Paula’s this kind of supportive medical treatment might be curative, since she only becomes weaker and only gets “brain fog” during exacerbations of her injured ventilatory system, her condition is not progressive, so the solution is simple. She only needs supportive medical help during exacerbations of her permanent non visible condition.
Continual monitoring of her minute ventilation using modern noninvasive technology in ambulatory patients] would catch any episodes of hidden ventilatory failure causing episodes of mental confusion, when her brain fog impairs Paula’s ability to communicate her distress.
This is what modern psychiatric diagnosis and treatment SHOULD look like, for attacks like Paula’s.
This is what Dr Emile Kraepelin expected would happen eventually , when scientists looked at the data he collected during his studies on remitting/relapsing attacks of bipolar depression [and bipolar mania].
The protocols of psychiatric diagnosis need to be changed to include evaluation of the 4 or more major vital signs that may be driving the changes to mood, mind and locomotor activity and speed.
To be continued……