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Dr. Witfill provides comprehensive diabetic foot evaluations and treatment protocols specializing in the treatment of neuropathy.
Condition

Peripheral Neuropathy results from damage to the peripheral nervous system, which is responsible for transmitting information between the brain, the spinal cord, and the rest of the body. Hundreds of types of peripheral neuropathy have been identified, each with a defining set of symptoms. People commonly report numbness, tingling, and a prickly sensations. Others develop an extreme sensitivity to touch, while others develop muscle weakness and muscle wasting. Severe symptoms can include burning pain which is typically worse at night, limb paralysis, and organ or gland dysfunction.

Autonomic Neuropathy is a group of disorders that damage the nerves supplying the internal body structures that regulate numerous 'automatic' body functions such as blood pressure, heart rate, sweating, and bowel, bladder, and sexual function. If the cause can be identified and treated, the autonomic nerves may repair or regenerate.

Symptoms may improve with proper treatment. Most symptoms of autonomic neuropathy are uncomfortable but they can be debilitating in severe cases, especially if adequate blood pressure is not maintained while standing (this is called orthostatic hypotension).

There is a large variety of treatment options available for peripheral neuropathy. Some are more successful than others and some are dependent on the causes and type of neuropathy being treated.

Diagnosing Neuropathy can be difficult and can not always be diagnosed by clinical history and exam alone. 
Traditionally EMG and NCV studies are utilized to confirm neuropathy, however in the early stages of small fiber neuropathy the most common form of neuropathy that diabetic patients have the NCV studies are often normal.

At Dunnellon Podiatry Center, Dr. Stacy Witfill often utilizes epidermal nerve fiber density testing to diagnose small fiber neuropathy.
Epidermal nerve fiber density testing (ENFD) is not a new technology, in fact, this technique has been used by neurologists for roughly 15 years. This test takes advantage of the fact that most forms of peripheral neuropathy progress in a distal to proximal fashion, beginning with the body's smallest and most distal nerve twigs (C fibers and A delta fibers), and then progressing proximally.

This is why our diabetic patients so often present with peripheral neuropathy in a stocking like distribution. Those that exhibit neuropathy in this pattern, without involvement of large nerve fibers are said to have small fiber peripheral neuropathy. If the nerve pathology progresses proximally to involve larger nerves, the neuropathy becomes mixed.
Treatments

Topical medications that one can apply to their skin such as Capsaicin, Biofreeze, Cryoderm, or Zostrix can offer relief. They are good for early symptoms or for add-on therapy in addition to oral medications.

Many of the over the counter medications and vitamin supplementations have little or no scientific evidence but are often taken by patients in an attempt to relieve pain. Examples are Evening Primrose Oil, Grape Seed Extract, Vitamin B6 and B12. Vitamin B1 (Thiamine) has more evidence in studies to help pain and numbness associated with neuropathy.

Prescription supplemental medications do have scientific studies and/or journal articles studying their use in treating peripheral neuropathy. Some have shown to a significant benefit in treating peripheral neuropathy for some patients because it addresses the underlying etiology of the neuropathy not just treating the symptoms. Studies have shown that there can be actual improvement in the quantity and quality of epidermal nerve cells after taking prescription medications such as Metanx for 6 months. These medications have minimal to no side effects and have no known significant drug to drug interactions and are often safe for patients to take with prescription medications. Examples are Neuremedy and Metanx. Neuremedy is a more bioactive form of vitamin B1 (thiamine) known as benfotiamine. Adequate blood levels of Thiamine are essential for the proper functioning of the nervous system.

Recent studies have shown that many people with peripheral neuropathy, especially when it is from Diabetes Mellitus are low in this essential micro-nutrient. Often it is helpful for patients to have their homocysteine level and thiamine levels blood levels checked as part of the neuropathy work-up. If the homocysteine level is high, I often will recommend Metanx treatment. If thiamine levels are low, I recommend Neuromedy treatment. Benfotiamine is available through the office, please speak to Dr. Witfill about it.

Other oral prescriptions are numerous and can have varying affects and relief of pain. None of them offer a cure, they are for symptomatic relief only. Examples are Lyrica, Cymbalta, Neuronntin (Gabapentin), Ellavil (Amittryptiline), Effexor, Nortryptiline, Tegretol (Carbamezepine). Lyrica is now one of the more widely used medications and is effective in pain relief. Neurontin (Gabapentin) is also a very commonly used medication. At times treating neuropathy is a trial and error type of process to achieve adequate control of symptoms.  Some medications(Lidocaine,elavil,gabapentin) can be compounded into a effective topical cream which helps eliminate unwanted side effects.

Alternative medicine treatment options consist of acupuncture, massage, anodyne therapy, infrared light therapy, magnet therapy and more. Some of these methods have a scientific basis behind them and others simply offer pain relief temporarily with anecdotal evidence. There are many alternative treatment options that patientscan pursue. Before spending a great deal of money or time on these alternative treatments, one may want to ask for patient references on the effectiveness of these types of treatments.
The chief advantages of Epidermal Nerve Fiber Density Testing (ENFD) over other testing methods are as follows:

  •  Purely objective measure of small nerve disease
  •  May predict the onset of neuropathy
  •  Able to be readily performed in an office setting
  •  Provides a baseline so that the benefits of therapeutic  agents may be measured 
  •  Highly specific and sufficiently sensitive and
  •  Relatively quick and easy to perform.
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