https://www.foundationforpn.org/what-is-peripheral-neuropathy/symptoms/. Seek medical care right away if you notice unusual tingling, weakness or pain in your hands or feet. 2. Peripheral neuropathy can result from traumatic injuries, infections, metabolic problems, inherited causes and exposure to toxins. The usual possible causes include: 1. B1 4. Sometimes an injury or swelling can damage or put pressure on one or more nerves, disrupting its functioning and leading to neuropathy. Peripheral neuropathy caused by either type 1 diabetes or type 2 diabetes is called diabetic polyneuropathy. Nutritional and Vitamin Deficiency Neuropathy. In: Integrative Medicine. Often hereditary neuropathies affect the extremities, and can lead to muscle atrophy and weakness, as well as loss of sensation. Often the symptoms involve a progressive change in sensation, as well as pain and weakness in the feet (and less commonly, the hands). Damage or disruption to both voluntary and involuntary peripheral nerves can be involved in neuropathy. Although the condition is not life threatening, it … Chronic use of the type 2 diabetes drug Glucophage (metformin) is linked to Vitamin B12 deficiency, so if you are taking the medication, your levels of the nutrient should be monitored by a physician. The Foundation for Peripheral Neuropathy. Certain forms of neuropathy can be inherited and passed down from parent to child. Staff N, Windebank A. What Are the Possible Complications of Type 2 Diabetes, and How Can You Avoid Them? Learn about neuropathy symptoms, treatment, and causes. In our center, we see people with very high levels of mercury, which can cause neuropathy. This site complies with the HONcode standard for trustworthy health information: verify here. Poor blood sugar control. Some cases of peripheral neuropathy are related to vitamin deficiencies. Peripheral neuropathy (adult). Trauma (physical injury), including: Mayo Clinic does not endorse companies or products. Your risk of diabetic neuropathy increases the longer you have diabetes, especially if your blood sugar isn't well-controlled. That said, one of the most common causes is diabetes. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic. Diabetic neuropathy is a serious but common complication of type 1 and type 2 diabetes that usually develops gradually, over many years. Among the more common examples are rheumatoid arthritis, lupus, vasculitis, sarcoidosis, celiac disease, Sjogren’s syndrome, Guillain- Barré syndrome, and the hereditary disorder Charcot-Marie-Tooth disease. B6, 7. niaci… Symptoms of peripheral neuropathy. 2. Possible causes may include carpel tunnel syndrome, shingles, vitamin or nutritional deficiencies, and illnesses like diabetes, syphilis, AIDS, and kidney failure. When the nerves are deprived of nutrients, they can cease to function properly. A New Game-Changing Way to Improve Concussion Diagnosis. © 1996-2020 Everyday Health, Inc. See our safety precautions in response to COVID-19. Are Neuropathy Symptoms Affecting Your Sleep? “The causes remain unknown,” 1 according to findings shared in a position paper issued by the American Diabetes Association (ADA). Research shows that a simple saliva test may hold the key to accurately diagnosing concussions in the future. https://www.foundationforpn.org/what-is-peripheral-neuropathy/evaluation-and-tests/. Medications can reduce the pain of peripheral neuropathy. Various types of blood disorders may also lead to neuropathy. Hereditary Neuropathy With Liability to Pressure Palsies (HNPP). What Causes Neuropathy? Mayo Clinic, Rochester, Minn. April 29, 2019. 3. Correcting underlying causes can result in the neuropathy resolving on its own as the nerves recover or regenerate. The normal requirement is less than 2 milligrams (mg) a day, yet many B6 supplements are 100 mg or more. Diabetes. Most drugs that lower cholesterol will cause neuropathy, many blood pressure medications and even a few antibiotics will also cause neuropathy. This includes activities such as typing, playing tennis, or any activity that … Peripheral neuropathy care at Mayo Clinic. Most people with peripheral neuropathy have polyneuropathy. Peripheral neuropathy. National Institute of Neurological Disorders and Stroke. Peripheral Neuropathy Due to Vitamin Deficiency, Toxins, and Medication. Common symptoms include burning, stiffness, prickling, tingling, and loss of feeling in the feet and hands. Repetitive stress from work, hobbies, or sports can also put one at risk for neuropathy. It can also be a side effect of treatments for other diseases, such as cancer. Accessed March 27, 2019. Disease. This rare condition can cause low blood pressure or problems with sweating . Accessed March 25, 2019. (24,4). Accessed March 25, 2019. Usually, the disorder affects the nerves that provide sensation, which causes pain, tingling, and burning symptoms of the nerves affected. One of the most common causes is diabetes. Anyone who has diabetes can develop neuropathy, but these risk factors make you more likely to get nerve damage: 1. Besides a physical exam, which may include blood tests, diagnosis usually requires: 1. (23), In 23 percent of the population affected by neuropathy, there is no known cause, and therefore their condition is known as idiopathic peripheral neuropathy. Other symptoms of peripheral neuropathy can include weakness and numbness. 2. Some people may also have hereditary neuropathy in the feet. Among the more common causes, and their risk factors, are: Diabetic peripheral neuropathy, which affects between 12 percent and 50 percent of people with diabetes, is the most common type of neuropathy. Within a month of getting shingles, 27 percent of 55 to 59-year-olds and 73 percent of people older than age 70 experience the condition, with women being at a higher risk. Accessed March 26, 2019. This can include car accidents, falls, or fractures. Treatment for the condition depends on the cause. Accessed April 2, 2019. When there is damage to the nerves in the feet, neuropathy can develop. For instance, carpal tunnel syndrome, which arises from repeated pressure on nerves and tendons in the hands, can result in burning, tingling, or numbness in the palms and along the fingers. Science Saturday: Fruit flies rise to the occasion, FREE book offer – Mayo Clinic Health Letter. Rakel D, ed. (25,26,27,28), Hereditary neuropathy with liability to pressure palsies (HNPP) is another common form of hereditary neuropathy, affecting 2 to 5 per 100,000 people in the United States. Repetitive Physical Stress. Many health conditions can cause autonomic neuropathy. The peripheral nerves also send sensory information to the central nervous system. Peripheral neuropathy causes. Thiamine and vitamins are necessary for maintaining optimum functioning of nerves and nervous conductivity.Thiamine deficiency can cause painful distal neuropathy due to nerve degeneration. The Foundation for Peripheral Neuropathy. Martyn C, Hughes R. Epidemiology of Peripheral Neuropathy. The peripheral nervous system transmits messages between the central nervous system (your brain and spinal cord) and the rest of your body. Doctors at Mayo Clinic are experts at diagnosing and treating peripheral neuropathy. B6 is also an additive to all sorts of packaged foods.” He advises having your blood levels monitored if you are taking a B6 supplement. https://www.uptodate.com/contents/search. (11,12). Baik H, Russel R. Vitamin B12 Deficiency in the Elderly. Vitamin B is … Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018. A full medical history. This content does not have an English version. Mayo Clinic is a not-for-profit organization. It can also affect other areas of your body. ; Usually, peripheral neuropathy occurs in the feet and hands. Doctors have long known peripheral neuropathy as a nerve condition that causes reduced sensation, tingling, weakness, or pain in the feet and hands. Polyneuropathy Hypothyroidism: Can it cause peripheral neuropathy? One of the most common causes of neuropathy in the feet is diabetes. Certain vitamins 2. such as 3. 2017 EPA-FDA Advice about Eating Fish and Shellfish. Early diagnosis and treatment offer the best chance for controlling your symptoms and preventing further damage to your peripheral nerves. Make a donation. “Some people eat lots of seafood in their diet because they think it’s healthy, but it can also contain lots of mercury. 3. Some common causes of autonomic neuropathy include: 1. Neuropathy affects roughly half of diabetics. Some 60% to 70% of people with diabetes experience neuropathy. Diabetes. Accessed April 3, 2016. What is peripheral neuropathy. https://www.foundationforpn.org/what-is-peripheral-neuropathy/causes/. But those symptoms may be just the tip of the iceberg. Mayo Clinic, Rochester, Minn. April 29, 2019. (29,30). Riggin EA. B12 6. (19,20,21,22). Diabetes can damage the kidneys. Over time, the nerves in the feet become damaged from the blood sugar in the body becomin… Vitamin B12 deficiency, which is prevalent in 10 to 15 percent of people older than age 60, has been linked to neuropathy. One of the major causes of neuropathy are certain prescription drugs. AskMayoExpert. Vitamin deficiency (vitamin B12, folate, and occasionally vitamin B6) (1), An estimated 20 million Americans have some form of neuropathy. (13,14,15). Brown rice can have high arsenic levels and that can cause neuropathy, too.”, Additionally, having too much of a nutrient in your system can create toxic effects. (6,7), Neuropathy is present in 2.4 percent of the general population. Signs and symptoms of focal neuropathy may be any of the above signs or symptoms but usually affecting a localized body site like pain, numbness and/or tingling to the right big toe. Neuropathy from chemo can cause tingling and numbness in the hands and feet. People with peripheral neuropathy generally describe the pain as stabbing, burning or tingling. Examples include Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis … (2,3,4). E 5. Many types of neuropathy are “idiopathic,” or of unknown cause, but a number of conditions can trigger it. Overview of polyneuropathy. Mistakes Were Made, but Can We Learn From Them? Koedel U, Fingerle V, Pfister H. Lyme Neuroborreliosis—Epidemiology, Diagnosis and Management. Swanson JW (expert opinion). On the other hand, some people have idiopathic neuropathy, which means that there is no discernible cause. There are different reasons as to why someone may incur damage to the nerves. High blood glucose levels can also damage the small blood vessels … Neuropathy, or nerve damage, can result from a wide range of conditions such as diabetes and even treatments like chemotherapy. Accessed March 26, 2019. In many cases, symptoms improve, especially if caused by a treatable condition. From Childproof Caps to Blister Packs — Could They Make It More Difficult? A common cause is herpes zoster, also known as shingles. 2. Goldman L, et al., eds. Alcoholic neuropathy can affect both movement and sensation. Age. Uncontrolled blood sugar puts you at risk of every diabetes complication, including nerve damage. Hereditary Neuropathies Information Page. Every nerve in your peripheral system has a specific function, so symptoms depend on the type of nerves affected. This content does not have an Arabic version. https://www.foundationforpn.org/what-is-peripheral-neuropathy/causes/. The Foundation for Peripheral Neuropathy. As many as 68 percent of those undergoing chemotherapy experience CIPN within the first month, but that rate decreases to 30 percent after six months or more. Hereditary Neuropathy With Liability to Pressure Palsies. Matthew Villani, doctor of podiatric medicine at Central Florida Regional Hospital in Sanford, Florida, explains that these symptoms arise because “the nerves are being encapsulated by the sugar, which causes the conductive properties of the nerves to slow down or be altered, so that the electrical impulses to the nerves aren’t functioning properly.” (5), Cancer patients can experience chemotherapy-induced peripheral neuropathy (CIPN). These include certain viral or bacterial infections, includ… (8,9), People being treated for HIV or AIDS may develop neuropathy from effects of the virus and the drugs used to treat it. Rutkove SB. “If an individual, for instance, has some kind of trauma to the spine, then that can cause damage and injury to either peripheral nerves or the spinal cord and result in neuropathy,” explains Vernon Williams, MD, a sports neurologist who is director of the Center for Sports Neurology and Pain Medicine at Cedars-Sinai Kerlan-Jobe Institute in Los Angeles. Peripheral neuropathy is a condition in which the nerves in the peripheral nervous system become damaged. 25th ed. (16,17,18), Toxins contained in foods we tend to think of as healthy can also lead to neuropathy, says Norman Latov, MD, PhD, a neurologist at Weill Cornell Medical Center in New York City. But prevalence increases with … Out of all the potential causes of neuropathy, diabetes is one of the most common culprits–and among patients with diabetes, neuropathy is a major concern. © 1998-2020 Mayo Foundation for Medical Education and Research (MFMER). This condition is more likely in alcoholics with poor nutritional status. In a 2014 study of 250 diabetic patients, 74% of them had neuropathic pain, primarily among older patients. Addressing neuropathy’s causes. Your doctor will review your medical history, including your symptoms, your lifestyle, exposure to toxins, drinking habits and a family history of nervous system (neurological) diseases. Nerve health and resistance can be improved by healthy lifestyle habits such as maintaining optimal weight, avoiding toxic exposures, eating a balanced diet, and correcting vitamin deficiencies. Peripheral neuropathy is diagnosed with exams and tests. Accessed March 25, 2019. Symptoms can include severe pain, impaired movement, changes in heart rate and blood pressure, problems with balance, trouble breathing, paralysis, and even organ failure. They can be diagnosed through blood tests for genetic testing, nerve conduction tests, and biopsies of nerves or muscles. The risk of developing postherpetic neuralgia, or lasting nerve pain, from shingles increases with age. Many conditions and events that impact health can cause neuropathy, including: Diabetes: This is a leading cause of neuropathy in the United States. Neuropathy is present in 2.4 percent of the general population. In some cases, no cause can be identified and this is termed idiopathic neuropathy. For instance, says Dr. Latov, “too much B6 can be toxic to the nerves. People with HNPP are unusually sensitive to pressure, particularly in their wrists, elbows, and knees. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. many other conditions can cause neuropathy or a burning sensation in the feet: * chronic kidney disease (uremia Physical trauma is the most common cause of injury to the nerves. Treatment of diabetic neuropathy. Health conditions that can cause peripheral neuropathy include: In a number of cases, no cause can be identified (idiopathic). Eight percent of people ages 55 and older have some form of polyneuropathy (meaning multiple nerves are involved, the most common form) according to a frequently cited study published in the Journal of Neurology, Neurosurgery, and Psychiatry. All rights reserved. Neuropathy can be caused by nutritional and vitamin deficiencies. As the neuropathy progresses, it can lead to a loss of sensation in the affected areas. Autoimmune diseases, in which your immune system attacks and damages parts of your body, including your nerves. What causes diabetic neuropathy? It involves motor and sensory nerves, and symptoms can include foot deformities, such as high arches and hammertoes, due to weakness of the small muscles in the feet; difficulty lifting the foot or holding it in a horizontal position; decreased sensation in the foot or leg; an unsteady gait; difficulty with balance; and problems with hand coordination. Peripheral neuropathy fact sheet. http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm. Everyday Health is among the federally registered trademarks of Everyday Health, Inc. and may not be used by third parties without explicit permission. The main underlying cause any neuropathy is damage to one or more nerves. How to Relieve Rheumatoid Arthritis Foot Pain, How to Help Ease Carpal Tunnel Pain Naturally, National Institute of Neurological Disorders and Stroke, National Institute of Environmental Health Sciences. https://www.foundationforpn.org/what-is-peripheral-neuropathy/. Onset of Charcot-Marie-Tooth disease is generally between mid-childhood and early adulthood, and although it is progressive, the disease is not considered to be fatal. Your peripheral nervous system sends information from your brain and spinal cord (central nervous system) to the rest of your body. Depending on the cause and patient, symptoms of neuropathy can include pain; altered, increased, or reduced sensation; tingling; pins and needles sensations; burning; increased sensitivity to touch; muscle weakness or wasting; paralysis; dysfunction in organs or glands; or impairment to urination and sexual function. Diabetes. Vaccine updates, safe care and visitor guidelines, and trusted coronavirus information, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, See our safety precautions in response to COVID-19. Doctors are now learning that neuropathy can cause many more problems. Major Causes of Neuropathy. Carpal tunnel syndrome is an example of mononeuropathy. Vitamin deficiencies, persistent high blood sugar from type 2 diabetes, and alcohol abuse are three risk factors for neuropathy. National Institutes of Health Office of Dietary Supplements. Inactivity, or holding still too long in one position, can also cause neuropathy. The deficiency causes damage to the myelin sheaths that surround and protect nerves. Types of Peripheral Neuropathy - Compression: Carpal Tunnel Syndrome. Symptoms of peripheral neuropathy usually begin gradually and include: A tingling sensation in the toes or in the balls of the feet that eventually spreads up the legs toward the trunk. Sometimes toxins or poisons, including insecticides and pesticides, can lead to neuropathy, … Black Americans With MS: More Awareness, More Community. The Foundation for Peripheral Neuropathy. Autoimmune diseases. They may have recurrent episodes of numbness, tingling, and loss of muscle function in the area associated with an affected nerve, lasting anywhere from several minutes to several months. This is the commonest cause of neuropathy in developed countries. Not a single disease, peripheral neuropathy is nerve damage caused by a number of conditions. Infectious diseases can result in neuropathy. Infections. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. In: Goldman-Cecil Medicine. Damage to nerves can come from many different sources such as injuries, infections, The most common hereditary neuropathy is Charcot-Marie-Tooth disease, which affects an estimated 1 in 2,500 people in the United States. Nerves are classified into: Signs and symptoms of peripheral neuropathy might include: If autonomic nerves are affected, signs and symptoms might include: Peripheral neuropathy can affect one nerve (mononeuropathy), two or more nerves in different areas (multiple mononeuropathy) or many nerves (polyneuropathy). The condition usually affects people between ages 40 and 60, and is more common in women than in men. It most commonly occurs in the legs. Neuropathy (also known as peripheral neuropathy) isn’t just one health condition, but rather a term used to describe a wide range of conditions involving disease and damage to peripheral nerves, and the symptoms that result from those conditions. Neurological examinations. It is a side effect of the chemotherapy drug that a person uses in … Certain vitamins, such as, B1, E, B12, B6, and niacin, are vitally important for preventing or reducing peripheral neuropathy.such as: 1. Peripheral neuropathy symptoms and signs depend upon the cause. By subscribing you agree to the Terms of Use and Privacy Policy. (1) https://www.uptodate.com/contents/search. The most common causes for neuropathic pain can be divided into four main categories: disease, injury, infection, and loss of limb. One thing is certain: The conventional wisdom that—high blood sugar is the cause—of diabetic peripheral neuropathy is only part of the story. Allscripts EPSi. Abnormal protein buildup in organs (amyloidosis), which affects the organs and the nervous system. Health conditions that can cause peripheral neuropathy include: 1. Neuropathy can also be caused by other health conditions and certain mediciness. Diabetes history. Advertising revenue supports our not-for-profit mission. Accessed March 25, 2019. They will work with your primary doctor to help coordinate your treatment. Among the complications that may result from this disease are sprains and fractures in the ankles, feet, and legs. Vitamins. A single copy of these materials may be reprinted for noncommercial personal use only. The drugs Videx (didanosine), Hivid (zalcitabine), and Zerit (stavudine) are most frequently associated with neuropathic symptoms. Kidney disease. Accessed March 27, 2019. Peripheral neuropathy, a result of damage to the nerves outside of the brain and spinal cord (peripheral nerves), often causes weakness, numbness and pain, usually in your hands and feet. Diabetes is the most common cause of small fiber neuropathy, a condition that causes painful burning sensations in the hands and feet. Diabetes is the most common cause of chronic peripheral neuropathy. There are several causes of neuropathy in the feet, including metabolic disorders, hormonal problems, vitamin deficiencies, trauma, and alcoholism. There are more than 100 types of neuropathy. diabetes and alcohol abuse are by far the most common causes of neuropathy in the legs. Malnutrition can result from: an unbalanced diet (for instance, not enough Vitamin B12); diseases, disorders, and drugs that affect absorption of nutrients into the body; and alcohol abuse, which also affects absorption. With Lyme disease, up to 12 percent of people develop neurological symptoms, especially neuropathy involving the face. Not a single disease, peripheral neuropathy is nerve damage caused by a number of conditions. (10), Autoimmune diseases and disorders, which affect more that 23.5 million Americans, are risk factors for neuropathy. More on Neuropathy As a Complication of Diabetes, More on Conditions Associated With Neuropathy, First At-Home Combo COVID-19 and Flu Test Granted Emergency Approval by FDA, More Evidence That a Low-Fat Vegan Diet Boosts Metabolism, Prevents Disease, Tippi Coronavirus: Tips for Living With COVID-19. Neurological examination. Seretny M, Currie G, Sena E. Incidence, Prevalence, and Predictors of Chemotherapy-Induced Peripheral Neuropathy: A Systematic Review and Meta-Analysis. Philadelphia, Pa.: Saunders Elsevier; 2016. https://www.clinicalkey.com. Neuropathic … But prevalence increases with age due to the increase in chronic disease risk as people get older. These include Sjogren's syndrome, lupus, rheumatoid arthritis, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy and vasculitis. Charcot-Marie-Tooth (CMT) disease is the most common hereditary neuropathy and causes weakness in the foot and lower-leg muscles.. Acquired neuropathies can be due to multiple causes. Systemic Lupus Erythematosus … Such neuropathies are most common in people older than age 60. The Foundation for Peripheral Neuropathy. Peripheral neuropathy has many potential causes. Peripheral neuropathy risk factors include: Complications of peripheral neuropathy can include: The best way to prevent peripheral neuropathy is to manage medical conditions that put you at risk, such as diabetes, alcoholism or rheumatoid arthritis. Neuropathy that affects internal organs is called an autonomic neuropathy. 4th ed. This usually starts with burning sensation, itching or reduced sensation in the hands and feet, otherwise known as ‘gloves and socks’ neuropathy. Sensory and motor nerves can be affected. Vasculitis. Peripheral neuropathies. Over time, high blood glucose levels, also called blood sugar, and high levels of fats, such as triglycerides , in the blood from diabetes can damage your nerves. Sensory nerves that receive sensation, such as temperature, pain, vibration or touch, from the skin, Motor nerves that control muscle movement, Autonomic nerves that control functions such as blood pressure, heart rate, digestion and bladder, Gradual onset of numbness, prickling or tingling in your feet or hands, which can spread upward into your legs and arms, Sharp, jabbing, throbbing or burning pain, Pain during activities that shouldn't cause pain, such as pain in your feet when putting weight on them or when they're under a blanket, Feeling as if you're wearing gloves or socks when you're not, Excessive sweating or not being able to sweat, Changes in blood pressure, causing dizziness or lightheadedness, Diabetes, especially if your sugar levels are poorly controlled, Vitamin deficiencies, particularly B vitamins, Infections, such as Lyme disease, shingles, Epstein-Barr virus, hepatitis B and C, and, Autoimmune diseases, such as rheumatoid arthritis and lupus, in which your immune system attacks your own tissues, Repetitive motion, such as those performed for certain jobs. “If an individual has an injury to areas near the knee, then they may have a neuropathy that involves the peroneal nerve and develop pain, weakness, numbness or tingling in that particular nerve.” Edema (the collection of fluid) or swelling can affect nerve functioning as well, he adds. Peripheral neuropathy is damage to the peripheral nerves and results in a tingling, painful, or burning sensation in the extremities. Polyarteritis Nodosa (PAN) Rheumatoid Arthritis. Toxins. Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com. The MS advocate Victoria Reese is working to ensure that Black Americans are included in the narrative about the disease and its treatment. The neuropathy may be acquired or hereditary. Feldman EL, et al. Symptoms range from slight discomfort to major disability. Peripheral neuropathy treatments. More than half the people with diabetes develop some type of neuropathy. : in a number of conditions such as cancer ; 2018 system sends information from your and! Also put one at risk of diabetic neuropathy increases the longer you have diabetes, and knees Guillain-Barre syndrome chronic..., over many years 2.4 percent of the general population glucose levels also. People in the Elderly Education and Research ; 2018 sugar puts you at risk of developing postherpetic,., Fingerle V, Pfister H. Lyme Neuroborreliosis—Epidemiology, diagnosis and treatment offer the best for! Advocate Victoria Reese is working to ensure that Black Americans with MS: more Awareness, more Community Could Make., stiffness, prickling, tingling, painful, or fractures the major causes of neuropathy develop., treatment, and can lead to a loss of sensation in future! Any neuropathy is present in 2.4 percent of the iceberg fiber neuropathy, a condition that causes burning. May include blood tests, diagnosis usually requires: 1, rheumatoid arthritis, what causes neuropathy... Reese is working to ensure that Black Americans are included in the feet: * chronic kidney (... Disease risk as people get older on the other hand, some people have idiopathic neuropathy neuropathy occurs the. As to why someone may incur damage to one or more nerves by either type and! 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