Dysautonomia: "The finger wrinkling test can be used as a screening test before tilt table testing"

[pattismith]

Evaluation of the finger wrinkling test: a pilot study

S. van Barneveld,

1,3 J. van der Palen,2,5 and M. J. A. M. van Putten1,4
2010
Abstract
Purpose
Tilt table testing mainly evaluates the systemic cardiovascular part of the autonomic nervous system, while it is assumed that the finger wrinkling test assesses the peripheral part of the autonomic nervous system. In this study we explored whether the finger wrinkling test could be a useful test for autonomic dysfunction and whether the clinical evaluation of wrinkling can be improved by digital analysis of photographs.

Methods
As much as 20 healthy subjects and 15 patients underwent tilt table testing and finger wrinkling testing. During the finger wrinkling test the right hand was immersed in water at 40°C. The degree of wrinkling was assessed with a 5-point clinical scale at baseline, 5, 15 and 30 min of immersion. Photographs were taken at the same intervals. Several features were evaluated using digital analysis: length and gradient of automatically detected wrinkle and mean, maximum, minimum, variance and derivative of grey value of pixels.

Results
Clinical scoring of wrinkling allowed differentiation between healthy subjects and patients with a normal and an abnormal response to tilt table testing.
Relevant features obtained with digital analysis were mean grey value and the gradient of automatically detected wrinkle. McNemar’s test showed no difference in test results between the tilt table test and the finger wrinkling test with a kappa of 0.68.

Conclusion
The finger wrinkling test can be used as a screening test before tilt table testing. Visual evaluation of wrinkling is still superior to digital analysis of photographs.

 

[pattismith]

"Previous studies have shown that the degree of wrinkling is less in patients with diabetes mellitus or hemiparkinsonism than in healthy subjects [7, 8"


Table 1
Explanation of the 5-point clinical scale [7]
Grade Description
0 No evidence of any skin wrinkling at the fingertip
1 The fingertip was not completely smooth
2 Two or less lines of wrinkling on the fingertip
3 Three or more lines of wrinkling on the fingertip
4 Wrinkling completely distorting the pulp of the fingertip

"During the tilt table test blood pressure, heart rate and ECG were recorded for 10 min in a horizontal position, 10 min in tilted position of 60° and another 10 min in horizontal position. The result was considered abnormal if there were signs of orthostatic hypotension with a systolic drop of more than 20 mmHg and diastolic drop of more than 10 mmHg or/and if there was no compensatory heart rate acceleration more than 10–20 bpm after tilting to 60°.

During the finger wrinkling test the right hand was immersed in a tempex bucket filled with water at 40°C. Temperature was measured before and after the finger wrinkling test. Maximum decrease in temperature was 2°C over the total measurement period of 30 min. The degree of wrinkling was assessed with the 5-point clinical scale at baseline, 5, 15 and 30 min of immersion. Only digiti 2–5 were judged, because it was difficult to make a good photograph of the thumb. Scores of digiti 2–5 were summed."

The photographs are taken from left to right at t = 0, 5, 15 and 30 min.
a Patient with an abnormal result on finger wrinkling test. Score at clinical scale at t = 30 min is 1.
b Result of a healthy subject. Score at clinical scale at t = 30 min is 4

Table 5
Three different cutoff values with their corresponding sensitivity and specificity
Cutoff value Sensitivity (%) Specificity (%)
4..............................….80........................93
8.................................100..................…...83
12........................…….100.......................60

 

[Hufsamor]

I GOT to try this

 

[pattismith]

I GOT to try this

i think I will do the test in my bath tub, it will make it easier...

 

[borko2100]

I did your test for 15 minutes and I look more like A than B. Why am I not surprised?

 

[pattismith]

First time something is abnormal in one of my test ever: I score zero at any time, even at 30 minutes.
I don't have POTS nor OI, but I suspected autonomic anomaly, so now I can prove it, thank to this test.

This doesn't tell if the damage is peripheral or central, but it means so much to me.

What is remarkable in my test (and we can see it either in the A patient above), is that the more the finger stay in the hot water, the more it looks rehydrated and plumped, and the less it shows wrinkles!

My husband who is going out of 12 months of toxic chemotherapy did the test, and the wrinkles show only at 30, mn for him, probably from toxic peripheral nerve damage....

 

[pattismith]

my husband pruney fingers, and mine below at 30 min

 

[Wishful]

Quite interesting. Last time I worked with hot water for a lengthy period, I got normal wrinkling. No POTS or OI either. ME doesn't seem to be affecting that part of my body functions.

My brain is probably all wrinkly too.

 

[Murph]

This is so cool! Thanks for sharing it.

I can't remember the last time my fingers got wrinkly like that. But it was a common feature of my childhood...

(As a kid in Australia we called the effect "pruney" - wrinkled like a prune.)

I'm going to do this test and I bet I come out smooth.

 

[Jyoti]

Fascinating! But I may have to be the 'exception that proves the rule?' I had a very abnormal TTT recently(POTS and OI), I have ridges on my fingers and when I tried this test, they wrinkled up right pruney in 15 minutes.

 

[pattismith]

Fascinating! But I may have to be the 'exception that proves the rule?' I had a very abnormal TTT recently(POTS and OI), I have ridges on my fingers and when I tried this test, they wrinkled up right pruney in 15 minutes.

that's really interesting!
we seem to have different autonomic dysfunctions, and most doctors don't have answers to our problems.
I guess we have to do our own researches to find why some autonomic functions are affected and other are not, and to what kind of lesion it can relate.

The finger skin wrinkling test is known for relying to the sympathetic system (all the neurologic systems connect the brain to the organs via nerve fibers)

sympathetic fibers arise from the spine between T1 and L2

To complicate further the system, there afferent sympathetic fibers (from the organ to the brain), and efferent fibers (from the brain to the organ).

We can see on this picture that afferent fibers go through the Dorsal Root Ganglions, whereas the efferent do not:

http://www.anatomyqa.com/anatomy/ge...c-nervous-system-sympathetic-parasympathetic/
https://www.wikiwand.com/en/Sympathetic_ganglion
https://www.researchgate.net/figure...ent-fibers-from-the-myocardium_fig2_311882668

 

[pattismith]

better pictures to show afferent (to the brain) and efferent (to the organ) sympathetic fibers.

We need to find testing to understand which level of our autonomic system fails, and what kind of fibers are injured (afferent, efferent, in the spine, in the DRG, in the paraspinal ganglion chain, or is it in the brain?)

http://www.allometric.com/tom/courses/bil265/bil265goods/13_nervous_system.html

 

[sb4]

Cant remember where I read this but I heard that wrinkling fingers is a nervous system reaction to hands getting wet that allows us to increase grip in these conditions. So it makes sense if you have some nervous system abnormalities it could show up in finger wrinkles.

 

[pattismith]

Cant remember where I read this but I heard that wrinkling fingers is a nervous system reaction to hands getting wet that allows us to increase grip in these conditions. So it makes sense if you have some nervous system abnormalities it could show up in finger wrinkles.

Yes it's a sympathetic autonomic reaction, but research has shown it wasn't helping to grip wet things, so not sure of the significance..;

by the way I have cracked the mystery of my zero score, it's Small Fiber Neuropathy (which can be both sensory and autonomic) from my current hyperthyroid state!


Skin wrinkling for diagnosing small fibre neuropathy: comparison with epidermal nerve density and sympathetic skin response

1. H L Teoh1,
2. A Chow2,
3. E P Wilder-Smith2

Abstract
Objective: To compare simple tests of small nerve fibre function with intraepidermal nerve fibre density (IENFD) in the evaluation of small fibre neuropathy (SFN).

Methods: Patients with idiopathic SFN of the hands were prospectively studied. Evaluation involved clinical examination, nerve conduction studies, sympathetic skin response (SSR) and skin wrinkling stimulated by water and EMLA (eutectic mixture of local anaesthetics).

Results: Of 21 patients, 16 (76%) had low IENFD, 15 (71%) impaired water-induced wrinkling, 14 (67%) impaired EMLA-induced wrinkling, and nine (43%) abnormal SSR.

Conclusions: Stimulated skin wrinkling was nearly as sensitive as IENFD in diagnosing SFN, whereas SSR was of less use. Stimulated skin wrinkling is a useful supportive test when IENFD or other tests of small nerve fibre function are not available.

 

[kangaSue]

Bear in mind that having a normal result to the finger wrinkle test doesn't rule out the possibility of having restricted Autonomic Neuropathy. I have a normal result in doing this test but I am diagnosed with restricted Autonomic Neuropathy, in having sudomotor and cardiovagal dysfunction.

But then again, I have deeply wrinkled hands and fingers to start with and in this paper, it's said that;
[There were three patients with wrinkled hands at baseline. All these patients had abnormal results on tilt table test. Maybe wrinkled hands predict the outcome of the tilt table test.]

 

[pattismith]

@kangaSue , thank you for pointing it. Wrinkling test would be rather a Small Fiber Neuropathy test (with autonomic nerve involved) than a proximal autonomic test.

Also for patients with wrinkled hands at baseline, I wonder what result they got at 5,15 and 30 minutes, did the wrinkles staid, leave or worsened?


"Recent studies suggest that the finger wrinkling test evaluates the more distal portion of the autonomic nervous system [9, 10]. Teoh et al. [9] showed that the finger wrinkling test is a useful supportive test for diagnosing small fibre neuropathy. Wilder-Smith et al. [10] established that the finger wrinkling test can be used for predicting intraepidermal nerve fibre density. The correlation between the results of tilt table testing and finger wrinkling testing found in our pilot study suggests that in a significant fraction of patients both parts of the autonomic system are affected."

"A striking result of this pilot study is the differentiation between healthy subjects and patients by clinical scores at baseline. There are some explanations for this finding. There were three patients with wrinkled hands at baseline. All these patients had abnormal results on tilt table test. Maybe wrinkled hands predict the outcome of the tilt table test."

 

[bread.]

interesting, isn‘t it? such a seemingly little observation with such importance!

 

[kangaSue]

Also for patients with wrinkled hands at baseline, I wonder what result they got at 5,15 and 30 minutes, did the wrinkles staid, leave or worsened?

Come to think of it, I don't think I had much change but only did a 15 minute test which another paper I read suggested to be the optimum time frame to assess sympathetic sudomotor function.
https://pdfs.semanticscholar.org/76ce/3921cbb257819c0eacb0d3a5029f58877a33.pdf

Wrinkling test would be rather a Small Fiber Neuropathy test (with autonomic nerve involved) than a proximal autonomic test.

As I understand it, Small Fiber Neuropathy alone affects just the extremities but when it involves affecting autonomic fibres too, you have Autonomic Neuropathy for all intents and purposes.

I haven't actually had a skin punch biopsy done for SFN but have had burning sensation in the feet and calves for as long as I have had severe GI dysmotility problems (gastroparesis).

As far as my GI (motility specialist) was concerned, I had no other signs of having a more widespread autonomic problem despite my having constant low bp and not sweating much. Autonomic function testing showed their professional opinion (or just personal judgement) to be well wide of the mark.

 

[pattismith]

As I understand it, Small Fiber Neuropathy alone affects just the extremities but when it involves affecting autonomic fibres too, you have Autonomic Neuropathy for all intents and purposes.

I too thought that SFN just involves sensory fibers (also called somatic fibers), but reading articles showed me that autonomic sympathetic fibers (also called autonomic) are involved as well:

wikipedia:
"Small fiber peripheral neuropathy is a type of peripheral neuropathy that occurs from damage to the small unmyelinated peripheral nerve fibers. These fibers, categorized as C fibers and small Aδ fibers, are present in skin, peripheral nerves, and organs.[1] The role of these nerves is to innervate the skin (somatic fibers) and help control autonomic function (autonomic fibers)."

In this very informative article about SFN:


A - Tests for selective evaluation of somatic small fibers
Thermoregulatory sweat test
Quantitative sensory testing
Contact heat evoked potentials
B - Tests for selective evaluation of autonomic small fibers
Quantitative sudomotor axonal reflex testing
Skin wrinkling test
Sympathetic skin responses
Heart rate response to deep breathing and Valsalva test (cardiovagal function tests)
C - Tests for evaluation of somatic and/or autonomic small fibers
Skin biopsy
In vivo confocal microscopy


Causes of small fiber neuropathy.

Metabolic and/or nutritional
Diabetes mellitus, metabolic syndrome/glucose intolerance, insulin neuritis11,17
Chronic renal insufficiency18
Thiamine or B12 deficiency (myeloneuropathy spectrum)11,19
Hyper- or hypothyroidism11,20
Hyperlipidemia21
Infectious Leprosy22
HIV23, HTLV24
Hepatitis C25
Chagas disease26
Amyloidosis Systemic27
Familial (familial amyloid polyneuropathy)28
Autoimmune Celiac disease15
Sjögren's disease29
Inflammatory bowel disease13,14
Systemic lupus erythematosus30
Rheumatoid arthritis31
Sarcoidosis32
Guillain-Barré syndrome variants33
Drugs Extensive list, chronic metronidazole, statins, anti-TNF inhibitor, bortezomib11,34
Toxins Thallium, arsenic, alcohol35,36
Vaccinations37
Hereditary forms Hereditary sensory and autonomic neuropathy, Fabry disease, sodium channelopathies, Wilson's disease, Pompe disease, Fragile X-associated tremor/ataxia syndrome, Ehlers-Danlos syndrome Neurodegenerative Parkinson's disease, Amyotrophic lateral sclerosis 42,43
Cryptogenic

(Note: I think we can add Fibromyalgia in this list)

 

[kangaSue]

I too thought that SFN just involves sensory fibers (also called somatic fibers), but reading articles showed me that autonomic sympathetic fibers (also called autonomic) are involved as well

The terms Small Fiber Neuropathy and Autonomic Neuropathy are used interchangeably in many medical articles which doesn't make it easy for us lay people to get a handle on things.
Some of the autonomic dysfunction papers that I have read suggest that having a positive skin punch biopsy for SFN and having an abnormal result for QSART test (with having reduced sweating) to be Autonomic Neuropathy.