80 Table 1 Neurological tests for clinical signs of small fiber neuropathy (SFN) Test Function Small fiber assessment (eyes closed) Sensory signs with comparative assessment Define dermatomic, mono/multineuropathic and polyneuropathic distribution Cotton bud Tactile hypoesthesia and dynamic mechanical allodynia Sharp stimulation Hypoalgesia, analgesia and punctuate allodynia Pain stimulation Hyperalgesia, hypoalgesia and analgesia Thermal sensation (cold tuning fork) Thermal hypoesthesia and thermal allodynia Pupil abnormalities, sweating, skin flushing or discolouration, orthostatic hypotension and heart frequency Dysautonomia Large fiber, spinal cord and cerebral assessment 128 Hz graduated tuning fork Vibratory sensation Coordination Cerebellar and sensory function Romberg’s test Proprioception and sensory ataxia Hoffmann’s sign Upper motor neuron lesion Reflex test decreased or absent Radiculopathy, large fiber polyneuropathy, Reflex test increased Upper motor neuron lesion Diadochokinesia test Cerebellar ataxia Motion sense hallux Position sense Quantitative Sensory Testing QST is a psychophysical instrument that can be influenced by the patient’s focus and the way instructions are given by the person administering the test. In order to standardize instructions, the DFNS has developed a Standard Operating Procedures file (SOP)20 which describes how to perform QST measurements. They also performed a large study to define normative values.13 TTT measurements were performed at both hands and feet. The order of measurements was clearly described in the SOP file of the DFNS20 and took desensitization due to pain thresholds into account by performing them as the last measurement. MLe was not mentioned in the SOP file, but since the detection threshold lies below the pain threshold, MLe was performed before assessment of the pain thresholds. Eventually, it was performed next to MLi since it should yield the same detection thresholds. First, the most affected side or the dominant hand side was identified as the test side. A single test round was conducted at the forearm on the contralateral side. For the full protocol, every parameter was measured three times. The mean of the three measurements was used as the result. The full protocol was always executed at the contralateral side first, followed by the test side. The dorsal sides of the hands were measured first, followed by the dorsal sides of the feet. MLe was only performed at the test side. An overview of the order, type and frequency of testing is presented in Table 2. 5 84 5
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