Back to Basics in Diagnosing Diabetic Polyneuropathy With the Tuning Fork!

Meijer, J. W. G.; Smit, Andries J.; Lefrandt, Johan; Hoeven, van der Johannes; Hoogenberg, Klaas; Links, Thera P.

doi:10.2337/diacare.28.9.2201

Cited by 89 publications

(53 citation statements)

References 20 publications

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“…1 Tests for this clinical examination are vibration perception (using a 128-Hz tuning fork), pressure sensation (using a 10-g monofi lament at least at the distal halluces), ankle refl exes, and pinprick. 1,2,21 When in doubt, a nerve conduction test might be necessary to establish a fi rm diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review

Dros¹,

Wewerinke²,

Bindels³

et al. 2009

The Annals of Family Medicine

149

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PURPOSE We wanted to summarize evidence about the diagnostic accuracy of the 5.07/10-g monofi lament test in peripheral neuropathy. METHODSWe conducted a systematic review of studies in which the accuracy of the 5.07/10-g monofi lament was evaluated to detect peripheral neuropathy of any cause using nerve conduction as reference standard. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. RESULTSWe reviewed 173 titles and abstracts of articles to identify 54 potentially eligible studies, of which 3 were fi nally selected for data synthesis. All studies were limited to patients with diabetes mellitus and showed limitations according to the QUADAS tool. Sensitivity ranged from 41% to 93% and specifi city ranged from 68% to 100%. Because of the heterogenous nature of the studies, a meta-analysis could not be accomplished.CONCLUSIONS Despite the frequent use of monofi lament testing, little can be said about the test accuracy for detecting neuropathy in feet without visible ulcers. Optimal test application and defi ning a threshold should have priority in evaluating monofi lament testing, as this test is advocated in many clinical guidelines. Accordingly, we do not recommend the sole use of monofi lament testing to diagnose peripheral neuropathy. 2009;7:555-558. doi:10.1370/afm.1016. Ann Fam Med INTRODUCTIONP eripheral neuropathy causes loss of sensation and increases the risk of ulceration of the feet. Timely identifi cation of loss of protective sensation may allow preventive intervention. Peripheral neuropathy is a complication in approximately 50% of patients with diabetes, and up to 50% of patients with peripheral neuropathy may not have symptoms. [1][2][3] Several tests are used to detect peripheral neuropathy, including vibration perception, application of warmth and cold, and nerve conduction studies, which are assumed to be the reference standard.4 Electrodiagnostic tests can be complex, expensive, and time consuming, which hampers their widespread use, especially in primary care, where for most patients peripheral neuropathy is diagnosed and treated.Monofi lament testing is an inexpensive, easy-to-use, and portable test for assessing the loss of protective sensation, and it is recommended by several practice guidelines to detect peripheral neuropathy in otherwise normal feet. 1,5,6 Monofi laments, often called Semmes-Weinstein monofi laments, are calibrated, single-fi ber nylon threads, identifi ed by values ranging from 1.65 to 6.65, that generate a reproducible buckling stress. The higher the value of the monofi lament, the stiffer and more diffi cult it is to bend. Three monofi laments commonly used to diagnose periph- M ONO FIL A MEN T T ES T ING F OR PER IPHER A L NEUROPAT HYeral neuropathy are the 4.17, 5.07 and 6.10.7-9 Forces required to bend these monofi laments are 1, 10, and 75 g, respectively. The fi lament is placed on the patient's skin (usually the feet); when there is considerable loss of sensation, the patient will not be...

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Section: Discussionmentioning

confidence: 99%

Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review

Dros¹,

Wewerinke²,

Bindels³

et al. 2009

The Annals of Family Medicine

149

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“…Studies including larger sample sizes are needed to further investigate associations between diabetic polyneuropathy and respiratory neuromuscular function in diabetic patients. Finally, several tests for diagnosing and rating polyneuropathy have been introduced in clinical practice [47]. It cannot be excluded with certainty that the application of tests other than the NSS and NDS used in the current study could have led to different ratings.…”

Section: Discussionmentioning

confidence: 89%

“…It cannot be excluded with certainty that the application of tests other than the NSS and NDS used in the current study could have led to different ratings. However, currently no gold standard exists for diagnosing diabetic polyneuropathy [48] and the tests applied in this study meet the required criteria as outlined previously [47,48].…”

Section: Discussionmentioning

confidence: 99%

Diabetic polyneuropathy is associated with respiratory muscle impairment in type 2 diabetes

et al. 2007

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Aims/hypothesis Diabetes has a major negative effect on intensive care unit outcome. This has been partly attributed to impaired respiratory neuromuscular function. However, data on respiratory neuromuscular involvement in diabetes are lacking. This study therefore aimed to assess respiratory neuromuscular function related to diabetic polyneuropathy in patients with type 2 diabetes. Methods Respiratory neuromuscular function was assessed by the use of volitional tests and twitch mouth (TwPmo) and twitch transdiaphragmatic (TwPdi) pressures during non-volitional bilateral anterior magnetic phrenic nerve stimulation in 21 male type 2 diabetic patients without pulmonary disease and in 23 healthy, well-matched controls (forced expiratory volume in 1 s 103±11 vs 103±12% predicted; p=0.9). Results Both volitionally assessed maximal inspiratory and expiratory mouth pressures, and sniff nasal and transdiaphragmatic pressures were comparable between diabetic patients and controls (p>0

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“…The distal vibration test was scored on the basis of the report of a loss of vibration by the participant ,10 s before the examiner perceived the loss of vibration (normal to mild), $10 s (mild to moderate), or the inability of the patient to feel the maximum vibration of the tuning fork (severe to total). The predictive value and reproducibility of the tuning fork test for peripheral neuropathy has been shown to be better than that of a monofilament test (27). In addition, subjects were evaluated for slow and fast proprioceptive sensations at the distal phalange of the great toe.…”

Section: Peripheral Neurologic Examinationmentioning

confidence: 99%

Transcobalamin 776C→G polymorphism is associated with peripheral neuropathy in elderly individuals with high folate intake

Sawaengsri

Bergethon

Qiu

et al. 2016

The American Journal of Clinical Nutrition

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Background: The 776C/G polymorphism of the vitamin B-12 transport protein transcobalamin gene (TCN2) (rs1801198; Pro259Arg) is associated with a lower holotranscobalamin concentration in plasma. This effect may reduce the availability of vitamin B-12 to tissues even when vitamin B-12 intake is adequate. Clinical outcomes associated with vitamin B-12 insufficiency could potentially be worsened by high folate intake. Objective: We determined the association of the TCN2 776C/G polymorphism and folate intake with peripheral neuropathy in elders with normal plasma concentrations of vitamin B-12. Design: Participants in this cross-sectional study (n = 171) were from a cohort of community-based, home-bound elderly individuals aged $60 y who underwent an evaluation by physicians including an assessment for peripheral neuropathy. Participants were administered food-frequency and general health status questionnaires, anthropometric measurements were taken, and a fasting blood sample from each subject was collected. Results: Odds of neuropathy were 3-fold higher for GG genotypes than for CC genotypes (OR: 3.33; 95% CI: 1.15, 9.64). When folate intake was .2 times the Recommended Dietary Allowance (800 mg), GG genotypes had 6.9-fold higher odds of neuropathy than CC genotypes (OR: 6.9; 95% CI: 1.31, 36.36). There was no difference between the genotypes in the odds of peripheral neuropathy when folate intake was #800 mg (OR: 1.5; 95% CI: 0.18, 12.33). Conclusion: The TCN2 776C/G polymorphism is associated with increased odds of peripheral neuropathy in the elderly, even with a normal vitamin B-12 status, especially if their folate intake is .2 times the Recommended Dietary Allowance.Am J Clin Nutr 2016;104:1665-70.

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Back to Basics in Diagnosing Diabetic Polyneuropathy With the Tuning Fork!

Cited by 89 publications

References 20 publications

Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review

Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review

Diabetic polyneuropathy is associated with respiratory muscle impairment in type 2 diabetes

Transcobalamin 776C→G polymorphism is associated with peripheral neuropathy in elderly individuals with high folate intake

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