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Small Fiber Neuropathy



Small Fiber Neuropathy, sometimes referred to as Autonomic Neuropathy, is caused by damage to the small nerves that supply feeling to the body, assist in breathing, regulate heart rate, control perspiration and aid with digestion.

Neuropathy is defined as a collection of disorders that occur when nerves or the peripheral nervous system (the part of the nervous system outside the brain and spinal cord) are damaged.

Small Fiber Neuropathy is a common neuromuscular disorder associated with many medical conditions, including diabetes mellitus, amyloidosis, HIV infection, connective tissue diseases and pharmacological neurotoxicity. In many cases, particularly in elderly patients, no specific cause is found. The clinical presentation usually consists of cutaneous pain, sensory loss and autonomic dysfunction, which can lead to functional impairment. Some patients may present with pain as the primary or the only symptom, but pain is inherently subjective and difficult to measure or quantify. A sensitive and specific diagnostic tool is thus essential for making a correct diagnosis and providing appropriate subsequent management.

Skin Biopsies are a safe procedure with minimal discomfort that allows somatic fibers carrying temperature and pain sensation to be differentiated from autonomic fibers.

Loss of epidermal nerve fibers correlates with increased severity of neuropathy and a higher risk of developing neuropathic pain. Skin nerve fibers can regenerate, and their regrowth rate could be a marker of early axonal damage in patients at risk of developing peripheral neuropathy.

A skin biopsy can be repeated in close proximity to a previous biopsy to assess the progression of neuropathy and the response to neuroprotective treatments - and can be used as a measure of outcomes in clinical trials.

Small caliber nerve fibers consist of somatic and autonomic fibers. They play key roles in cutaneous nociception, thermoreceptor and autonomic function. Autonomic function can be assessed by specializing tests which quantify sweat output and assess cardiovascular regulation. However, not all patients with Small Fiber Neuropathy have autonomic involvement, so a test that will assess the somatic fibers may be useful. These fibers are small, and many are unmyelinated with very slow conduction velocities, and therefore, their conduction responses cannot be captured and evaluated by routine nerve conductor studies. This gap has been filled by a histological method to evaluate cutaneous nerve fiber density.

The most common causes of small fiber neuropathy are diabetes, pre-diabetes, and metabolic syndrome. Studies have shown that up to 50 percent of patients with Fibromyalgia suffer from Small Fiber Neuropathy. There are a multitude of clinical papers stating that punch biopsies should be routinely used to diagnose Fibromyalgia. Additional papers and studies also state that Small Fiber Neuropathy is the first finding for neurological sequel from diabetes. Another chronic pain clinic that treats patients not only for Fibromyalgia, but also chronic back and neck pain found that 50 percent of their patients are suffering from Small Fiber Neuropathy as well. The implications from this are stunning.

There is currently a general feeling that all the patients on chronic opioids are opioid addicts and do not have a real diagnosis or problem warranting treatment. This test will allow providers to screen for Small Fiber Neuropathy and diagnose up to 50 percent more patients.

There are many options available for treating Small Fiber Neuropathy. The most effective ones address the underlying cause. Most often, the focus of treatment is on symptom control. If the cause is diabetes, pre-diabetes, or metabolic syndrome, papers have shown the symptoms improve by treating the insulin resistance, de-conditioning and vitamin deficiencies.

Some people are also helped by physical therapy, well balanced diets, avoiding exposure to toxins, exercise, vitamin supplements, limiting or avoiding alcohol, prescription drugs or other complementary and integrative therapies.

All providers know how well patients do in comprehensive functional restoration programs. Now we know why. Studies also show the nerves regenerating and growing back with the proper managed treatments.

A punch biopsy is done with a circular blade ranging in size from 1 mm to 8 mm. The blade, which is attached to a pencil-like handle, is rotated down through the epidermis and dermis, and into the subcutaneous fat, producing a cylindrical core of tissue. An incision made with a punch biopsy is easily closed with one or two sutures. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method. Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. The disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases. The common punch size used to diagnose most inflammatory skin conditions is the 3.5 or 4mm punch.

Rami Packard and her husband have owned several businesses, all in the customer service industries. After owning a home care agency, serving as a resident director at an assisted living facility, and being a small business consultant for years, she found RX2Live. She is currently serving as the Regional Developer for the Northern Florida and Southern Georgia markets. Rami keeps busy assisting medical practices as they grow their practices and keep their patients well. She also assists with senior and corporate wellness programs. She has a passion for health and wellness and loves sharing this with the community. To learn more about how your practice can benefit from implementing this Medically Necessary procedure into your daily routine contact or visit

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