Chief Concern Series: Diagnosing Neuropathy

Hello and welcome back to the neurotransmitters. We are today continuing our chief concern series. So for all of our primary care and other non neurology colleagues, hopefully this one goes out to you. I am joined as always by the relentless educator, Dr. Galina Geigman. Thank you again for joining me on this adventure and our special guest for today, Dr. Marcus Pinto, an adult neurologist and peripheral nerve and neuromuscular specialist at the Mayo Clinic in Rochester, Minnesota. Thank you so much for joining us today. It's my honor. Thank you, Michael. And thank you, Galina, for inviting me. So Galina, go ahead and kick us off. What are we starting up on today? Yeah. Well, thanks again, Michael, for letting me join as your co-conspirator in this special series. I'm super excited for today's topic, which is kind of the new, the patient with a new sensory change. And we're actually going to dive into, I think, the history and kind of how patients come in. But Marcus, I just want to just start with, I mean, I know you're a specialist, but you know, how often do you get this referral from primary care doctors? And I can't tell you enough that in my clinic, I often hear, you know, the referral is actually written neuropathy. And the patient comes in, they say, "I'm here for my neuropathy." And you know, they use this term. So I'm curious how often are you seeing this? And when you kind of actually drill down to what patients complain of, how is it, you know, what are the symptoms, I guess, in a way that really bring people in for this, for this chief concern? Yeah. So, yeah, that's a very common, I think. And also, I do EMG. So, you know, it's a very common indication for EMG, the question of neuropathy and I completely agree with you. I think a lot of times, patients start to feel abnormal, sensory changes in their body. And they always attribute to neuropathy right away. And they usually come to you saying they do have a neuropathy. And Google tells them as well, right? If you type, I think, and you want to say, "Parastegia," and you want to say, "Numors and Qing Ling" in the speech, you know, that Google will tell you. So I think the most important thing when someone is complaining to you about new numbers or new Qing Ling, you know, so patients, so I usually tell my residents, you know, and my fellows to not, because the definitions of numbers and Qing Ling, you know, they are a little bit, so the textbook definition would be that numbers is the kind of a novel kind type of sensation that you feel like on your dentist, for example, kind of a numbs you for anesthesia. And the Qing Ling will be the Qing Ling prickling sensation. But it's very hard for the patients to differentiate that and also to differentiate numbers, which also by textbook definition, numbers and Qing Ling are both positive symptoms. And the decreased sensation or lack of sensation, it's a negative symptom, you know. So usually patients do not complain much about that. When we talk about, you know, it's kind of a specificity of symptoms. So the decreased sensation, the lack of sensation, usually they will tell you that they can't feel the temperature in the soles of their feet when they walk in the beach. Or they leave in Minnesota, like I leave, when they go outside, kind of a bear foot, the know in the winter, they can't feel that the floor is very cold. Or there's no. So, you know, whenever the patient tells you a negative symptom that is much more specific of neuropathy and objective that they may be having a neuropathy, but there's not the most common. So then, you know, life is complicated. So that number is in Qing Ling, as I told you, they're positive symptoms. And they can happen from neuropathy, from venous insufficiency, from muscle skeletal issues, you know, just you stay in the same position for a long time. So there are so many other causes, other than neuropathy, you know, that I think people should be aware of. And usually what is important to me is not only that they feel it, but where they feel, and is it constant or not. So and why where they feel. So it's because if you have any numbness or tingling, any sensory changes in your legs, but not in your feet, that's very unlikely to be a neuropathy. If you have sensory changes in your hands, that you wake up at night, you shake your hand and it improves. This is most likely carpal tunnel syndrome. If you have, for example, sensory changes in your like lateral thigh, and you, you know, you have an abnormal BMI, you know, you have your overweight, your obese, or you do a lot of, for example, kind of you wear a lot of tight clothing, or you work in construction, you know, and then you have sensory changes in your lateral thigh, which is maybe mental diaparastatic. So the location of the symptoms is so important that you have, for example, cervical spine disease, and then you have intimate and shooting sensory changes to your arms. So the classic sensory changes of peripheral neuropathy, which is a process that, you know, is worse in the feet than in the legs and thighs and also worse in the hands than in your shoulders and forearms. So you must have a distal, which means hand and feet symptoms. If they are constant or not, there's a very important question. Usually, intimate and sensory changes are what you call benign, and benign means can be anything else. Okay. Can be muscle skeletal, can be vain, can be any other cause, other than neuropathy. So neuropathy usually cause constant symptoms. So whenever someone tells you that they have constant, numbers and chingling their feet, that increases the likelihood, it's not diagnostic at all, okay, it's not that specific. Like, for example, the decreased sensation in your entire foot when you walk in the beach again, but that makes, it's more likely than if they're intermittent. And I just posted on X doing a little bit of also here of advertising house in my ex accounts. And you guys can follow me there and I post neuropathy stuff and usually just neuropathy posts come from the clinic. I don't have an agenda. I don't have like you guys very organized. You have like schedule and series of posts. I don't have that. Marcus, what's the, what's your handle for folks to find you there? Yeah. So it's Marcus and may R.C.U.S.V. Pinto, like the Pinto bean. So P.I.N.T.O, okay, yeah, so Marcus V.Pinto, okay, find me there. So I even posted that because of the in clinic, I was teaching a fellow this and someone else heard, oh, good, I never heard about it because I learned this from one of my faculty in my personal fellowship, which is, so I always ask the patients, if they come for sensory changes, I always ask them in the office to close their eyes and they close their eye and make them close their eyes. They don't close their, close, close. And then they close. And I say, okay. So now try to concentrate in your own body, okay? And they give them like two, three seconds. And then they say, okay, do you feel anything abnormal in your feet or your legs? I ask them that because why I say that? Because intermittent part of seizures, I can also be neuropathy because, you know, you all know that our brain is very powerful. Our brain has a power to block any type of sensory kind of inputs. That's why people go to war. They lose a limp and they keep running, you know, they keep fighting. So we like, if you, Michael and I are you going to, if you lose the armature office, I'm sure you're going to pass out on the floor, going to be a cold blue and all that. So, but no, but your brain is able to block signals and that's why I also that's any kind of a patient that has a sensory complaint or pain or any sort of sensory change. If they go on vacation, the symptoms get better. But going back to, you know, going back to the question. Then I ask them to close their eyes, constantly in the body and say, hey, do you feel anything abnormal in your feet? And if they usually say, no, I've never studied this, okay, it's just kind of a historic and neurology education, okay, I would be an interesting, I think even someone would say, oh, you should study this. I was interested to study this prospectively. But if you do that and they say, no, that they don't feel anything abnormal in their feet, it's unlikely that they have a sensory neuropathy, okay, so I always do that with everyone. And people can then, the primary care doctor office anywhere can just ask that. And if they say that when they close their eyes, they constantly their body and they steal the few, then they have a abnormal sensation in their feet so that increases again, they likely they may have an neuropathy. Interesting. I'll try that one out. Yeah. Tell me what you think. Now, that kind of raises the question because we were talking about positive negative symptoms. And one of the, I think the most other than the typical ones like balance problems, a lot people were describing pain of some character or another, what role does pain have in your diagnostic assessment, or does it factor in at all or comes in at the end when we talk about treatment? Yeah, no, no. That's a very good question because it's usually, you know, the watch, or the patient comes for because usually the negative symptoms, the balance and the lack of sensation, they usually don't complain about it. So usually only when it gets more severe, like for example, you all know in your college, like you see a patient, for example, with negative motor symptoms, you know, if they don't have any positive sensory symptoms, like pain or parasthesia, they may only show up to your office when they are significantly impaired and disabled because they just, you know, the symptoms, they are not like stroke like any kind of a chronic symptom. They come slowly progressive and then it's very helpful for the patient to know exactly when it started. And that is pain, it's much easier because it's painful, they will always be reminded of that. So the pain, I also use positive sensory symptoms, parasthesia and chingling, but I've not been as chingling and usually if the pain is constant, not constant, the same kind of pattern, the neuropathic pain can be described by the patient as essentially anything other than achy pain. So very rarely through neuropathic pain is achy, usually achy is musculoskeletal or any other kind. Very rarely is neuropathic, however, it's possible, you know, so be careful because patients don't really all know. And it's not easy to describe how you feel, you know, and for many people, many, many people like my wife, for example, she has migraines and she took like 10 years to tell me her migraine was throbbing. She couldn't describe to me the throbbing nature of her migraine, she's a physician, you know, so just because you know, life is much harder than what's within the textbook. So I think keeping an open mind it, but usually description will be of a burning and a shocking, like a zingga, as some patients can describe, it's kind of a kind of a knife stabbing sometimes, but it is usually we will affect not only one location, it's an important thing, so where do you feel the pain? So usually going to be of a kind of a stalk, sock or gloves, distribution, you know, for the pain, or sometimes a distribution of a specific nerve, but very rarely will be at a focal spot. If someone say, hey, I have a focal spot in my foot that hurts like hell, that's usually non-narapathy, food arthritis, for example, and I usually ought to do also, we haven't talked about it yet, but as an neuropathy doctor, patients always apologize to me about their feet. They say, oh, no, I'm a neuropathy doctor. You know, I see the uglis feeding the world because you go to their feet and I palpate their feet. I press the balls of their foot, I press, you know, the kind of, for example, the common thing in some people, some I think is neuropathy, which is whenever people have a plantar fasciitis, so more common runners, people who are on their feet a lot, and there are two things important for plantar fasciitis. One, so you ask them, when in the day, your pain is the worst, because plantar fasciitis is when they step out of bed, and the other thing is to go to their foot and press the middle of their foot, just go, you know, say, hey, I'm gonna press your foot, you see, then you're going to, you know, press the foot to see the tenderness there, you know, because it's spread the fasciitis they may have, but also arthritis of, you know, of the metatastel, joints, and all that, it's the same thing, you have to palpate. Some people you see, some people have, like, we don't know why, but some people have, don't know about it, but they have a very kind of a small fat pad in their feet, and their feet, like, usually plainness, you know, and also flat foot, and they have no protection, you know, of the bones, they develop more commonly arthritis of the feet, and all that. But again, usually the neuropathic pain will be usually worse at night, usually we also worse when they walk, worse when they keep standing, you know, if someone tells you, oh, I have pain, my feet, and then at night, and then I stand up in a walk, and that's make it better. It's weird. So maybe, okay, think about sometimes rarely, but sometimes we've seen the office, people showing up with sensory changes, and they have a restless leg syndrome, you know, which you all know can be associated with neuropathy, but sometimes it's just RLS. So using, I think, you know, a good history and a good exam helps a lot, seeing patients with neuropathy. Great points. Yeah, I love the discussion about how difficult it is to describe this sometimes. I feel like I'm keeping like a mental log of just the interesting things people say, like they'll say my feet are like cinder blocks, or I feel like I'm wearing socks all the time, or they say, oh, don't put bed sheets on my feet, you know, I don't touch my feet. And also, the one I hear a lot, quite a lot, is like my legs are heavy or they're weak. And so I think as a neurologist, you have to take, you know, the grain of salt, the description and then verify with the exam. But I often hear people complain of weakness, when they really mean like a sensory taxi. For example, that makes it difficult to, you know, find grip things or to find the right place. So when they're walking, and we'll definitely get to the exam. But I was wondering actually, Marcus, do you ask about autonomic symptoms? I feel like this is something I think about sometimes on the history, especially when I'm suspecting small fiber neuropathy. And I want to maybe get a little bit more information, because, you know, as we know on exam that, that may not necessarily be so revealing, could you talk a little bit about that? And if you, would you ask that? And if so, how, how do you ask about that? Yeah, you know, I always ask you, so the, you know, the, the, the, the review of systems of neuropathy that I usually do, I always ask about autonomic symptoms. I always ask about bulbous symptoms. I always ask about fever, night sweats, and I always ask about weight loss. And I also, I always ask about skin changes, you know, rashes, you know, I always ask about it. So all my fellows need to come with, you know, all just questions and so, and just questions to ask it and, and give me the answers when I staff them. So, but then going back to autonomic. So autonomic symptoms are tricky. Okay. Why? Because they are sensitive, but they are not specific of true autonomic dysfunction. So for example, someone can tell you that they have dry eyes. And dry mouth, and that can be a, you know, jogger syndrome or can be if they take, like, do oxygen, or they take something, I don't know. So, so I think, I always ask, but I think the most significant ones, the most specific ones are gastroparesis. So when they never, they tell you, say, hey, doctor, you know, especially when it's, when they spontaneously tell you, I think, I think I also, when they complain without you asking, always specificity, you know, I think is increased because a lot of times, like the gut, you know, you probably see that as well, that patients, they are nice people, they want to be nice to their doctors. They usually, they think that saying yes to our questions, they're going to satisfy us. And then they say, yes. So anyway, this is what I see a lot of times, people, the patients, they try to be nice to their doctors, and they don't know that, you know, they should be very thoughtful when answering the question, but going back to the symptom. So, gastroparesis. So whenever they tell you that they used to eat a normal fume, you know, they can eat like only like 10% of it. They have a lot of, you know, they, they feel bloated all the time when they eat just a little bit and usually ask them for examples or whenever they can give you examples of things they have eaten. Hey, I ate like half an apple for lunch and I was completely full or I ate like a full meal at X restaurant and then I was throwing up, you know. So gastroparesis is very specific with early society, what you're talking about and also easy bloating. And they also think that orthostatic hypertension is very specific. And so whenever I ask, hey, do you feel light headed when you stand up? Like all of us, right? So if you go to the beach and then you stay there, you know, kind of, for like five hours and you're taking the liquor and you stand up, you're going to feel like headed. Maybe you can pass out. So it's always important for you to, to ask the patient what situation and how often that happens. And when it's true autonomic dysfunction, they will tell you that I stand up, I have to hold myself a lot of times I feel I'm going to pass out. And then after like 30 seconds or so, I can go and all summer, we'll have episode of sync up, you know. So whenever, you know, it happens quite frequently. They have just near sync up sensation or they have already syncopized. So that is very specific because if you do have a neuropathy and orthostatic hypertension, this will send you to a bucket of a very few types of neuropathy that can cause, you know, orthostatic hypertension. And it will help you in your diagnostic work up and treat the patient, you know. But yes, again, I do believe that asking for autonomic symptoms is very important. But again, with a grain of salt, that for example, you can have patients with fibromyalgia patients know with chronic fatigue syndrome, who will respond yes to a lot of your questions. And then it will be the frequency and also your exam and the testing that will help you out differentiating these disorders because very important fibromyalgia is not a small fibromyropathy. Okay, so that's a very important concept that you can afford in the literature is confusing. And especially because of the European, we can bad mouth them here. I hope they don't hear. But they are the ones who create a lot of confusion regarding this. Hypophosphatemia is often under recognized, but the downstream consequences such as osteomalacia, fractures and functional decline can be substantial. For our listeners, a single most important actionable message today is to check a phosphate. It's not on the typical campaign also you have to order it when the story fits. I thought, you know, to that point that there were, were they the ones who have done some studies that show that there's an increased incidence of small fibromyropathy in the fibromyalgia population? Yes, yes, yes. So this will look at comorbidity, not a positive kind of thing. Yeah, I've got to talk more about the point is that you brought it up is that a lot of times would be very hard for you to differentiate clinically if they have, you know, small fibromyropathy fibromyalgia. The most important thing we have to talk about is the exam because, you know, it's diagnostic criteria for small fibromyropathy for you to have an abnormal sensory exam and you must have decreased sensation for pinprick or temperature. And or if you have hyperalgesia, you know, which is you just touch someone with a pimple, they scream out, you know, so and it's not like they just say, Oh, yeah, it's a little painful. No, it's like you stick them, you just go touch the pinprick sensation and they will scream out in pain or have a lot of pain. So that should be true, you know, hyperalgesia or if they have allodinia, which is someone who has pain to non-painful stimuli. So you just go with your finger and then the point that you mentioned, Galina, it's a specific complain usually. If a patient complained to you that they cannot, when they, when they sleep, they cannot put any sheet on their feet, so the bad sheet can't touch their feet is usually a specific symptom of neuropathy. As usually they have either hyperesthesia, which is they feel that touch stimulus more prominently or they have allodinia, which is they will feel pain with any touch of that region, you know, and but usually when the allodinia is reproducible at the office, that is very specific that Jesus is some kind of neuropathy going on. So let's talk. We've kind of been dancing around it a little bit, but let's talk about the physical exam a little bit. So, you know, a lot of people, both neurologists and non-nerologists can sometimes get a little uncomfortable with aspects of the peripheral anatomy examination. So what are the things that you think are the most important and that you see most often done incorrectly? Okay. Okay. Yeah. Yeah. You know, in special, we know that, you know, the neurologic examination is not easy to do and and a lot of provider share away from doing. So I think we could try to divide into motor, reflexes, and sensory for neuropathy. And also gage, you know, I think gage is very important and now so as we are talking mostly to non-nerologist, you know, I think that asking your patient to walk in your office, you know, or what else have the office in the corridor, I think will give you a lot of information and why. So if they walk and they think that they are walking normally, that's great. So then, you know, if they're walking normally, so you can say that most likely they don't have significant more impairment, they most likely don't have significant imbalance, even though they may be complaining, but you don't see it, they're walking with a, you know, narrow base, they're turning okay, they are not almost falling on you, you know, so you don't have to be in yourrologist, say, oh, this is a stappage gage, oh, this is a sensory attack, say gage. No, you just bark. You know, you see people in the streets walking, we as neurologists, we are always looking at people, you know, walking in the streets all the time and diagnosing them, but no, but you don't have to be that. So just see them walk. If they walk normally, that shows you a lot, and if the patient has an neuropathy, it's not a severe neuropathy. And now so, you know, after the gait exam, I always, I also have people walking on their heels and on their toes. That is more difficult for them, you know, is difficult to interpret, but I usually hold their hands for balance, because I want to do that mostly for the strength because I also tip toes and heel walking, that is also balancing to it, you know, the old people. So then I ask them to, I hold their hands and I see how they walk and they can give me a lot of information. So they can go high on their heels, you know, and their feet off the ground and take a few steps. That's great. So the dorsif flexion of the ankles, you know, and they're completely normal. So again, this is not a severe neuropathy, if they can walk on their tip toes, they don't have to be like a ballerina, I joke, I say, oh, let's see, oh, I say, well, good ballerina, bad ballerina, I joke with them, but I ask them to walk on their toes. And if they can do that, you know, kind of going high on their tip toes and walk forward, this also means a lot to you that's, you know, there is no severe neuropathy going on. And I always also do tend and walking, which again, is also more difficult to interpret. But again, if you use the normal abnormal, can help you a lot. So if you have someone a 60-year-old person who should be walking, you know, who should be able to walk five, ten steps on tendon, on the heel toe walking or tendon walking, that also means to you say, oh, the balance of this person is completely normal, okay? If they can't tendon walk and they do not just kind of step aside or fall, that you can you as a primary care doctor, you could use that as a normal abnormal testing, you know, and don't have to put that much of an emphasis on, oh, if they took one step or two steps, you may be normal, but you know, but you can just use as a specific evaluation to not having to refer someone, you know, for neurology. So I think that can be helpful. And then I always, always ask them, you know, the stance exam, I ask them to put their feet together, looking forward. I usually ask them to, you know, to just lay their hands on their side, but you can also ask them to cross their, you know, their hands on their chest and with the hand touching their shoulders, and then close their eyes with myself close to them, looking for the wrong but sign. And if they can stay with us closer for 20 seconds or so without stepping aside, you know, that's usually also a sign that they do not have significant large fiber sensation loss. Talk about gauge and stance, and then moving forward, the motor exam. So the motor exam, again, it's not easy to do, especially the way we do and you know, to check and, but I think if you feel comfortable, so two very strong muscles. So the TBL is interior, the muscle that lifts the foot off, that does dorsif flexion of the ankle, okay, or dorsif flexion of the foot, which is kind of a complicated from anatomy to think about, but lift the foot off of the ground, you know, so TBL is interior and the interior leg, that muscle is very strong. So you should not be able to break anyone even if it's an old person without putting your weight on it. So I would recommend to people, for example, just come with your hand like your finger. So you can even ask them with the seating on the office couch or chair, and then you just come to their side, keep your heels on the ground and then you put them a put your foot off the ground. It should be able to do that when they do that, you go with your hand and you push down. You can't put your weight on it because otherwise you may be able to break them, but then you go push down and see if you have a few resistance and you should not be able to break anyone. And this is very important and also the planter flexion, you know, which is the tiptoe is best examined with doing the tiptoe walking, because planter flexion, guys, it's a very strong muscle to test, but if you check the ankle, dorsif flexion only for neuropathy, it's already a lot, you know, it's already where you're going to give a lot of information because to test toe weakness, you need to be an neurologist, you know, because it's you need to test with your index and you go there and then you press. So you know, it's so easy to break a toe flexion or extension of anyone, you know, of course, you again can use like, okay, if I cannot do that, this person is kind of very strong body builder, but I would recommend you not test toe toe, toe strength, because it's much harder, but foot dorsif flexion, you know, and planter flexion and the tiptoe walking, I think that can be, give you a lot of information again, because if you do not have ankle dorsif flexion weakness, you do not have a severe neuropathy as a quick aside, what we're kind of thinking about, you know, like muscle bulk, as it relates to your findings on your strength exam, how often do you find that people have diminished muscle bulk before they have like a functional change in their strength exam findings, just in question. I think for neuropathy, you know, as the usual neuropathy, we will affect more the leg and the hand than the feet, sorry, than the thighs, because it's hard to know, it's hard. I think Michael, a lot of times for you to know like how they may tell you, my legs usually don't know to be much, much larger or my muscle bulk, but I think on examination, I think when you see atrophy, you know, I think atrophy will mean to you, chronicity, and we will mean to, for example, this is someone who shows up to your office, complaining only of barato foot drop, and then you look at their legs, they have very high arches, they have very ugly feet, because the toes get very hammered, you know, so, and then they have high arches, hammer toes, and they have thin legs, you know, and they tell you that yeah, my legs were used to be much larger than theirs, and now they are so thin, so, and then the thighs are usually too normal size, so usually, and they don't have pain, it'll be a motor predominant process, usually going to be an inherited neuropathy, like a charcoal maritouff disease, you know, so I think looking for atrophy, hammer toes, and also high arches will help you with the chronicity, and usually will suggest an inherited process, and usually will be people who have neuropathy for many years, but they may show up to you saying that neuropathy started three months ago, right, that is a good story of, you know, Dr. Peter Jake, you know, who just passed away, I think last month, I will, who founded our neuropathy center here and everything, so a neighbor of his, he had noticed it for many years, he had bilateral foot drop, and had a step edge gate, so he already suspected the neighbor had charcoal maritouff disease, and then his neighbor shows up to his office a few years later, telling him that the weekend has started three months before, and they say, no, no, no, I know your my name, I've seen you walking for five, six years, you have just for a long time, so just to tell you that the patient perception of time also sometimes can be a little tricky, but that's why also we discussed it in the history that, because he's offline actually, so the best diagnostic too for neuropathy will be time, so seeing your patient back will bring you so much information, because if this patient shows up to you with a three month history of symptoms, you know, and you don't remember how he was doing, or he's a new patient to you, okay, because it's a patient of yours, and you know them for like 10 years, and Jesus is very different, okay, sure, let's go ahead and pull the trigger on an investigation or referral, but if someone coming up to you that you don't know well with new symptoms, yeah, see them back in two, three months, because if it's a kind of a rapidly progressive neuropathy, you see, or they will report to you like a few weeks later, or monthly, let's say, hey, Doc, I think you need to see me back again, because this thing is worsening, now I'm needing a cane, I wasn't needing a cane, I'm needing a walker or so, so I think that time is a great diagnostic tool for neuropathy. It's so helpful to hear you talk about the elements of the exam that you would do, the motor testing, the gate, I didn't hear sensory testing though, so let's put ourselves in the exam room of a PCP, who granted may not have a tuning fork, I hear that all the time. So what can they do, you know, without that, and let's say they have one, I'm how would they use it, and how helpful is that, just important to document that at the time of their first scene. You gave us a lot of information, how even just where the symptoms are, how the symptoms have come on the current city, that's very helpful diagnostically, there are a lot of things, I agree with you, I always do strength testing, mostly to verify the severity and if there's a motor component, but let's just talk a little bit about the sensory testing. Yeah, I think the sensory testing is, I think reflexes are also important, you know, if you feel skilled testing reflexes, I think if a patient of any type of age has neuropathy and the ankle reflexes are present, you can also say they don't have a severe neuropathy of any age, so especially if they are older, because after 60 you can have absentee ankle reflexes and it can be normal, but I know that ankle reflexes are not easy to test, you know, so then the reflexes, but again, you can use the normal abnormal rule and whenever you think it's normal and present that also reassures you that you're not dealing with something severe and sinister, but going to the sensory exam, sensory exam is very subjective. So then you have to tell the patient, you know, you tell them to close their eyes and explain well what you're going to do. So I think if you do not have a tiny fork, I think that's kind of, you know, yeah, we all have it. So you, but using, I think a cotton or like a, or a Kleenex, you know, can be helpful to you. And now so using either like a pin, a pin break, you know, a pin break into any kind of pin, you just go to your office and say, most of Dr. office has something, you know, they put there with a pin, get that pin and examine the patient, then you just cart it, okay, don't put it back and don't put it back. That's all good practice. You just cart it, okay, just cart it off the used, then you ask the desk for more pins. But I think, I think a pin, I also, but this is the one is harder to find, but I love a temperature sensation. I think temperature is more specific than pin, but let's do one by one. Let's first use the, the Kleenex, you know, so usually I tell the patient, I go with my Kleenex very lightly and I just touch their toes very lightly and I say, Hey, oh, so now you tell me, so am I touching you and I will touch with the Kleenex in the toe and the big toe usually only and then you say, yeah, and I say, where say my toe. So if they can feel a very light Kleenex, you know, or a cotton, I usually lose more cotton or ball. So if they can feel that, you can also again say, this patient does not have a severe neuropathy, okay, because the light touch is either minimally affected or normal, okay. So then if they do not feel the cotton, then I use my finger and then I touch them with my finger. If they also don't feel my finger, then I do pressure with my finger, okay, let's see if they can feel. If they can't feel that, yeah, it's severe neuropathy, okay, they should be able to feel your finger if they can't feel when you use to know kind of when you when you press with your finger. So that's the sign of usually a severe neuropathy, but that's the light touch and my touch is usually not as sensitive as the other ones that we're going to talk about now, which are Pemprek and the temperature. So the Pemprek, so usually I go with the pin and then you know, I touch them with the pin at the big toe and I say, hey, can you feel I'm touching you, okay? And they can, if they feel what I do is I do not ask normal or abnormal, I just say, can you feel they can? And then I go with my pin climbing up the foot, going up the foot up to the leg. And then then I ask the say, hey, do you feel the same all the way up, okay? I try to ask specific questions, I do not say, hey, I do say, what do you feel? Do you think it's normal? It's not normal. Oh, because for the patient is so hard and usually I also use a specificity in my question. So I do not ask when I check, for example, the toe and the knee, I do not ask, do you feel less at the toe than the knee because they want to be nice to you and say, yes, I feel less at my toe than my knee. So do the opposites. I use their niceness on, you know, on my behalf and their behalf as well. So I go and say, okay, I touch the toe and the knee and I say, hey, do you feel the same on both sides? And, you know, and they will say, yes or no? Usually I give value when they say, and the toe should feel more than the knee, okay? That should be the normal because of how we were innervated and how we were, we have alluded as a species. So because we have more skin receptors at the foot and at the hand then at the thigh and at the shoulders and the face is where you have you feel the most, okay? So, but then I go with my pimprech and then if they say it's abnormal at the toe compared to the knee, I say, okay, so if you think the knee is normal, I do, if the knee is 100%, how much you give me at the toe, okay? And then if they give me like 95, it's normal, okay? And another good, another good pro as well is, if they ask you to repeat, it's because it's normal, okay? Whenever they ask you to repeat, it's because the difference is so small that they are having asked you to do it again. So, anyway, I don't remember the case that I trusted that it was truly abnormal because it's completely subjective. You don't know the patient's feeling, so you have to try to be specific when you do it. So that's the pimprech and then I usually don't go up and neuropathy, the loss will be it more at the feet than the leg, and I usually go up to where they feel normal. And I ask, where do you feel normal again? And then that's where, and usually it's going to be symmetric on both sides, okay? If they don't have anything on top of it. And that's light touch, the pimprech, light touch, pimprech. And then, oh, pimprech also, if they say they don't feel at all at the big toe, what I usually do is usually the pins have a dull kind of a head or they have a dull part of it. So I usually do, I ask them to tell me which one is the pin, which one is the dull part. And then, and then I only say it's absence when they cannot differentiate both. And I feel that is helpful. Then temperature, I love temperature sensation because I think, you know, it's, and I like more, you know, I have this, this privilege of the office I work. We have kind of a termista and we have a hot thing there like that you can use and test like a hot sensation, heat sensation on the patient. But I think you can also use code. You can get like an ice pack, you know, everyone has an ice pack and it gives an ice pack. And I usually test the dorsum of the foot and compare it to the knee, okay, or the lateral leg. And, and then you see if they feel it different, you know, the, the cold, coldness or the heat on both. And it's the same 100% type of thing. And why I say temperature, I think temperature is more of objective. So we are more used to few as human beings, temperature difference. That's why, you know, you go take a shower, put your hands, or you put your foot. So anyway, we don't like the few pain or pimprech. We usually are not well and well trained on differentiating those. So I like temperature. I think temperature gives you a more specific exam. And, and, and if you do have neuropathy, you should have a temperature sensation, diminishing it at the toes and the feet, especially if you're thinking about a small fiber neuropathy, which, you know, again, by definition, you should have an abnormal exam. Even before you do any kind of testing. So we can talk about when you go testing, I have a spiel on the small fiber neuropathy. It's my fellows and everything, you know, I don't know how to proceed, so let's not jump there now. But, but, and then if you do like, if you do light touch and you do one of those temperature or, or a pimprech, I think you're doing great, you know, it's much more than, oh, others. And remember, for the primary kind of docs, that's the monofilament, 10 grams monofilament, that you guys, some of you haven't used for diabetic neuropathy. That is not that great for the diagnosis of the diabetic neuropathy. So that is more, I know the people have studied that and that is a ways to even, you know, but to be honest, I think that this is more, I just tell you more about, you know, kind of the risk of developing ulcers and, you know, and kind of the planter, protection of the foods we call, and they call, but so then I do not examine patients with a monofilament, okay? Because I feel that our exam is more sensitive, but a monofilament can be a tool you can use. And especially if you follow the protocols, they have a field, you know, that you have like five spots in the foot that you should pass and the way you should do it. But it makes things more complicated. So this is my opinion. I think if you just do just quick exam of the toes, it's going to be faster and easier, I feel. What are your thoughts on the broken tongue depressors as your pen, quote, unquote? Well, I think anything that can, can you flick some kind of pain? I think it's fine. You know, anything. I think creativity, you know, it's great. I think, you know, and, and I'm all down for anything that you can adapt. So for example, in the hospital, Michael, I knew you were a hospital. So I have used like a, like a pap, diapaps again that just came and was kind of cold. And then I tested, you know, with the, with the diapaps again, I think it's just going to be creative if, if, if you, whatever you have available, you're not going to harm the patient. Yeah, sure do it. I know if I filled a exam glove up with ice water before. See? See? Yeah. So I have to, I know we're moving on to our proprioception and vibration. What's the relative benefits? Do we need to do both on every patient's? What's your perspective on that? Yeah. That's a good question. You are not neurologist, you know, I think that, because, because proprioception exam is not easy, you know, so I do, I do, I do, I do, I do, at least for model of sensation in all of my, because I'm in your operating doctor, you know, so I do for living, testing people's infection. Yeah. That's what I do. So then I, I test in everyone vibration, I touch and temperature, and sometimes both. Okay. You know, five in, and it's almost everyone I see for your property, but then I think vibration. I think if you are not a neurologist and you do vibration, you're doing great. And four and, and you should, you don't need to do proprioception. I think going to be, you know, going to punch a lot of subjectivity and complexity on doing, and you may find it abnormal and it's not abnormal because you have to train the patient how to do it. Because like, I don't know if you guys have thought about it, but who tests for proprioception on neurologist, you know, so I do that in my daughter. She loves it. She's seven year old. She loves to do the tests of the toll. She has to do again. They let's do it again, because it's, you know, it's kind of fun, but no one does it. So people have like seven years old, if never, no one has ever asked them to move their toll. So you have to, to, to stop, to teach them how to do it, you know, and be, but then I think vibration is better. And then if vibration, how to do it? So you get your tiny fork. You can just, this is, lend that on the floor. Okay. Because you're going to break it, okay? Because you can also heat on your hand, but then to heat like you have to heat it, it's a lot. So your hand is going to be bread and kind of hurting after it. So you can just, it was limb on the floor and then, and your passage. So I, I know people have studied this on the second people few and all that. I don't like that. I think that's very subjective. So what I usually do is I, I just let my tiny fork on the ground. And then I put on the toes, hey, do you feel it? And it's a yell, I feel it. Okay. And then I take it out. And then I do it again and compare the toe and the knee, okay? And then I say, hey, do you feel the same here and here? And they say, no, I said, where did you feel more? I said, yeah, the knee. And there's okay. So if the knee is 100%, how much you give me the toe? And that's how I do it. And then I usually attach, you know, the big toe, the ankle and the knee. So if the person tells me that the toe is normal, I do not do the ankle or the knee. And for the evaluation of, so in patients with posterior core myelopathy, they can have properception, more affected than vibration or sometimes both the same is equally affected. But for neuropathy, okay, you will essentially never see a patient that properception is more affected than vibration. So only doing vibration is completely fine. Now a quick word, I've had students show up with different frequencies of tuning fork on their rotations from time to time. What's the gospel truth here for what frequency we should be using? Yeah, I think I think 128 or he and Mayo, we don't know anyway, I don't know, I just want to even don't know why I think was Peter jik, we use 165, you never find it. You can only buy if you go to specific websites, but the 128 to 165, I think you're fine. You should not use the 256 or the ones which are lower than 128. Excellent. Great point. Any other special maneuvers that you might do during your exam that come up in edge cases or that you think that could be a quick and dirty addition for our primary care colleagues. So we're talking about the ankle week and age, we're talking about the reflexes, we're talking about the sensation. Yeah, I would talk about if they ask you to repeat, it's going to be normal and great as normal. I think that whenever you also look at their feet, this is obvious, but I think it's important to say, you look at their feet and they have like anosa or they have like a pain on it. Something, because you're just, oh my god, I found it. It's very, very specific, they have a severe neuropathy. Because whenever you have people have ulcers in their feet, okay, that's a good point. Whenever they have ulcers in their feet, it's usually not only sensory dysfunction, okay. It's usually sensory together with autonomic, because also the healing is affected, okay. So for example, you guys may have seen patients with CIGP, they don't have ulcers in their feet. You might have seen patients with like, let me see all the common neuropathy that you see. Nutrition neuropathy. I'll call neuropathy. I'm not going to see ulcer in their feet, all connotitional, if they don't have diabetes, okay. Because diabetes not only affects the sensory nervous fibres, also affects the autonomic nervous fibres, and that we will affect with tissue healing, okay. And yeah, and if you have a patient with ulcer in your neuropathy, please send them to an neurologist, you know, or you know, if they have diabetes, it's usually going to be a pretty controlled diabetic, so you need to work with them on that. Or sometimes, if you don't have diabetes, okay, oh, that's a good problem. But we don't have diabetes, and they have ulcers in their feet and neuropathy, long-send neuropathy. This might be Sharkoma-Hiturth disease, because there's a specific genes that also they help with tissue healing. So they know there are specific forms of CMT that, or in some cases, they, there is a sensory CMT called Hereditary Sensory Autonomic Neuropathy, so that they may have very much of increased risk of ulcers in the feet and amputations without having any other systemic cause. So the common questions in the office is they have dyspacient with a very healthy person, and they keep having ulcers in their feet is so weird, and they, we can't find a cause of neuropathy if we look at four monoclonal proteins and all that, even on an herb biopsy, never do an herb biopsy to people, because an herb biopsy won't, never going to heal, okay, they are going to have a sapsis from it, yeah, and it's an important point. So, but, but if you have ulcers in the feet and no diabetes and all that clear cause, it might be inherited. So that brings us to a great question. So let's say we're, we're some sort of neuropathy is in front of us, whether it's small fiber, mixed fiber, large fiber maybe. What kind of testing do we need to do after we've kind of seen them taking the story, gotten an exam? What kind of testing has, do we have in common between these different types of neuropathy that are kind of like good to do across the board? Okay, so, so I think that the, and you can say it, mixed large and small fiber because most of neuropathy are mixed large and small fiber, okay, very rarely neuropathy is only affected large fibers, very rarely only affect the small fibers, you know, so isolated is small fiber neuropathy is rare. So we did a study here, I wasn't on staff yet, but some of my colleagues did a study here, I normally said county minister, and they found that isolated is small fiber neuropathy, which means people with paraceties and or pain the feet abnormal sensory exam and a confirmatory test, okay, either quantitative sudomurotash or QST or skin biopsy, okay, confirming the small fiber dysfunction and normal EMG, normal nerve conduction studies. So to be called isolated is small fiber neuropathy or true is small fiber neuropathy, you should have a normal EMG that is rare, it's a rareer than CIGP, okay, so CIGP instance and I must say the count is 1.6 per 100,000 of is small fiber neuropathy is 1.3, so it's anyway, but some people think it's very common, you know, usually the patients we will also have the large fibers affected it should be, you know, so then what task to do? So I think, you know, a blood workup is the most important for any kind of neuropathy, I think that's, I don't know, it's how to think for, I think a primary care provider, no neurologist, to phenotype a neuropathy, I have pulse on it, it's just a little bit of a propaganda here on my thing, but it's not easy, okay, it's not easy, so I think that whenever patient has like ankle weakness, whenever they have it, if normal gauge, whenever they have it falls on neuropathy, they should be seen by a specialist, okay, and as you send them for a specialist, you also should send them for an EMG, okay, so an EMG is only helpful in situations where, you know, I think you must, before your patient, as a primary care doctor, because they have diabetes and you examine them, they have some neuropathy, so why do you need an EMG on them? Oh, for baseline, you have your exam for baseline, you don't have to order an EMG for that, there's a lot of literature on this, and I do not recommend EMGs for those that they caught neuropathy's obvious, for example, you have someone who started eating peanut butter, okay, this is a real case, the person started to went vegan and they went vegan, but they also were only eating peanut butter, nothing else, peanut butter and water, like it was anyway, per person, wasn't a more decision, this person develop a horrible painful sandstone neuropathy, okay, was a nutrition neuropathy, because peanut butter doesn't have all the nutrients you need for your life, you know, it's a person who didn't know that, so then in this person, do they need an EMG? No, they don't, you know, it's kind of a, you do, of course, the blood work we're going to talk about here, they check for vitamins and you're going to replace the vitamins and tell them to change the diets piece, but do they need an EMG? I don't think you need an EMG, it depends a lot to where you are and in your practice, but I think for the primary care docs and non-neurologist, I think you only need an EMG if you are referring them to someone, to be honest, I don't think you should wait the EMG results to refer to someone, and why? Because it depends, I don't know who you're going to do your EMG, some neurophysiologists know they exaggerate when they're reporting some virtue of neuropathy, then I also have posted about it, so if someone rely on a lower-limb study only EMG to call someone having a severe neuropathy, okay? So that's an important point, so if you think it's a bad neuropathy, do upper and lower-limb and why? Because if the upper-limb connections are normal or near normal, this is not a severe neuropathy, okay? And again, it's been going back to the primary care docs, so what kind of blood work to do? I think you should check the CBC, usually do a comprehensive metabolic panel because I also want to see the liver enzymes, because if the liver enzymes are normal, this is not hepatitis, okay? If the kidney just function, there's normal creatinine, all that is normal, this is not chronic kidney disease, so and then you do a CBC because, you know, you may once in a blue moon, you may see someone with poem syndrome or something very, like a unicorn may show up to your office, because unicorns live, you know, they exist. And then, and then you see like a mock lipid normal CBC, okay, sure, you know, hematology or something, very profound anemia, so you know, you can have macrosythosis, you know, and then you're going to do your B12 and then you're going to find out, so just a B12 deficiency. So CBC, there's metabolic panel, you also, because also sometimes, you know, the metabolic panel is going to help you, for example, you have a very low B1 dispersion, for example, from like monotretion, for example, you know, so I think just basic tests help you a lot. And then I always do a B12 fall H and B1 and B6, some people, and why I do that? And I also do copper, you know, because maybe copper, they may have no need, but I do copper and zinc, and why I do that? Because I feel that zinc is a great one for nutrition, so because usually you usually don't know, this of course never take that, you know, fully from your own, a portfolio of neurologists about nutrition, but if you have a normal zinc, you're probably not malnourishing, okay, to the point of just the monotretion caused your neuropathy. But, but, but, anyway, the, so again, B12, B1, which I mean, copper, zinc, and B6, and YB6, because people take supplements, they don't tell you, they take just supplements, they buy online, then I always tell my patients, never buy multivitamin online, never go to Costco, Walmart, Walgreens, buy them off the shelf ones, cheap ones, okay, because the super vegan, whatever, you know, they always come, but sometimes with a lot of vitamins, and then they can have the patient, because hyper, hyper, vitamin O's of B6 can cause neuropathy, not bad one, a sensory ganglionopathy, okay, so that's what I usually do. It's basic workup, and I don't think that any primary care doc need to do, if you don't really find a patient for neurologist, if you're neuropathy, you don't need to do a SPAP or immunification, and why I say that, I say because all these monoclonal associated neuropathy, you know, amyledosis, pome syndrome, IgM associated neuropathy, they are all severe neuropathy, they are all progressive, okay, so if you're not referring to your patient or neurologist, I don't think you need to look for an MGUS, because you're not going to know how to interpret, and then you're going to refer to hematology, who not like this referral, you know, because it don't like to see MGUS, and I know that well because I know them. So I don't think you should, so if you do a basic metabolic panel as I told you, CBC and the vitamins, and also of course check A1C, and also check a lipid panel, okay, that's an important point, lipid panel, and why, that is growing evidence, especially coming from my friends from the University of Michigan, you know, Brian Kalenha, Melissa Elapro, Dr. Alfa Feldman, that obesity, okay, hyperlipidemia is associated with neuropathy, especially in type 2 diabetics, so they can even make the neuropathy progress faster. So tell your patients to eat healthier, exercise, you know, even that is a person there who does research in mice, so then she kind of put them to exercise and change their diet and all these things, and she has shown improvement of neuropathy in just mice. They're doing trials now there with a bedathric surgery, also GLP1 and all that, but improve your metabolism, you know, may also help you out with your neuropathy. Excellent, that's a ton of information, and you know, we've been kind of splitting these into two partners, as far as like assessment and diagnosis, and then a second part on treatment, so we're going to have to ask you, can we have you back at some point in the future for to talk about some treatment management type strategies? No, yeah, yeah, that'll be great, yeah, because they think, yeah, because you know, yeah, we do, I think neuropathy, there's a lot of education due to the cage for patients, you know, so we have to tell them a lot of things, and it's a lot of perspectives, you know, and the patient needs to understand, because they can get better frustrated, you know, because neuropathy, you know, I learned that's my fellowship, that's a lot of neuropathy management is patient coping with it, you know, so they need to understand well what you're saying, and so it'll be a pleasure, yeah, let's get to the next one. Yeah, and I know, as a quick plug for Marcus's channel, I've learned a lot of stuff, that's on x@marcusvpinto, I really enjoyed the one, especially, right, the kind of the number we always quote, you know, one out of five cases, end up being idiopathic, but with a little more legwork and skull sweat, you can sometimes get that number even lower. So, very interesting stuff, I'm not going to go into that, because that gets a little more esoteric, but yeah, great online education to be found on Marcus's profile. Marcus, thanks so much for joining us today, and I feel like we got a little window into what it's like to be one of your fellows and just dropping knowledge right and left. Thank you so much for those tips, pearls. I love, I can just imagine you, you know, depending on your kind of, it's depending on a knee and putting a cotton ball against the toes and kind of revealing truth. So, thank you so much for joining us, and I can't wait for part two. I couldn't agree with you more that the management depends so much on a partnership around education and really like prognostication, kind of talking about prognosis and love just want to underscore that tincture, you know, time is kind of part of our diagnostic process. So, thanks again for those tips. My pleasure, I'll be in honor to come back here and my, you know, one of my goals, and that's why to just channel, I put politics aside, okay, because I use my Twitter as my neuropathy blog, I put everything aside, and I try to help people, you know, because only at my office I won't be able to help as much as I want, so it's my pleasure to be here, and now we pleasure come back. Awesome. Well, thank you everybody for listening, and make sure to tune in next time as we talk more about neuropathy management, and you can always find our stuff at the neurotransmitters.com, and we are also on x@neural_podcast. Thank you both again, and we'll talk again real soon. Bye-bye. Bye!