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An update on sensory testing
Dr. Sanjeev Kelkar M.D.
1st
National Foot Group Meeting
Bangalore – 22nd
July 2001
Diabetic Sensory Neuropathy:1
• 85% of Diabetic Foot problem is neuropathic.
• It is the insensate foot that causes consid...
Diabetic Sensory Neuropathy:2
• Variety of trauma known.
• Diagnosis of sensory neuropathy often late when trauma
has alre...
Diabetic Sensory Neuropathy:3
• Late Diagnosis due to:
• Patient factors.
• No pain, no complaint
• Ulcer but no pain, no ...
Diabetic Sensory Neuropathy:4
• Clinical examination (when done)
• Reveals evidence of neuropathy as
- Loss of reflexes
- ...
Diabetic Sensory Neuropathy:5
• Clinically: Positive symptoms
• Dysesthesia
• Paresthesia
• Hyperesthesia
Examination:
Cou...
Diabetic Sensory Neuropathy:6
Clinical Examination depends upon –
Clarity of communication by the physician.
Clarity of un...
Diabetic Sensory Neuropathy:5
Quantifying the loss of function useful to correlate –
Degree of loss to the likelihood of d...
Diabetic Sensory Neuropathy:8
What sensations can vibration sense
Pain on analog scale – (suffers most on account subjecti...
Instruments for quantification:I
• Quantification needs instrumentation.
• Available or:
• Light touch + pressure
• SW mon...
Instruments for Quantification:2
• Simple, well tested method
• Identifies easily foot at risk if the patient cannot sense...
Instruments for Quantification:3
• To test vibration sense
• Tuning fork – frequency of 128
• Diagnoses per sense or absen...
Instruments for Quantification:2
• Graduated tuning fork:
• Weighted and graduated for 0 – 10
• The apex of the triangle r...
Instruments for Quantification:5
• Biothesiometer:
• Delivers vibrations in micron displacements increasing
with increasin...
Instruments for Quantification:2
• Indian version available.
• Normal range on 300 normal, non diabetic Indian doctors
and...
Instruments for Quantification:7
• Indian version tested in 75 patients by Dr. Vijay
Viswanathan against an English Biothe...
Instruments for Quantification:8
• Heat and cold perception thresholds
• Foreign instruments available but difficult to ge...
Correlations: 1
• “If any one sensation tested is abnormal, then the
possibility that there will be at least one more abno...
Correlations: 2
• Abnormality detected on Monofilaments has equal
sensitivity and specificity with an abnormality detected...
Correlations: 3
• Biothesiometer voltage value on insensate vibration, of 25
volts, exposes the foot to risk of ulceration...
Achievements
• Monofilaments in Indian version also available
• Biothesiometer available
• Heat and cold perception thresh...
1362404404 an update on sensory testing
1362404404 an update on sensory testing
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1362404404 an update on sensory testing

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1362404404 an update on sensory testing

  1. 1. An update on sensory testing Dr. Sanjeev Kelkar M.D. 1st National Foot Group Meeting Bangalore – 22nd July 2001
  2. 2. Diabetic Sensory Neuropathy:1 • 85% of Diabetic Foot problem is neuropathic. • It is the insensate foot that causes considerable morbidity. • Repetitive, unnoticed trauma results in inflammation and ulceration.
  3. 3. Diabetic Sensory Neuropathy:2 • Variety of trauma known. • Diagnosis of sensory neuropathy often late when trauma has already resulted in foot ulcer
  4. 4. Diabetic Sensory Neuropathy:3 • Late Diagnosis due to: • Patient factors. • No pain, no complaint • Ulcer but no pain, no complaint • Physician: • No complaint, no examination 7% of patients were ever examined in one of the Bangalore study in all years of diabetes.
  5. 5. Diabetic Sensory Neuropathy:4 • Clinical examination (when done) • Reveals evidence of neuropathy as - Loss of reflexes - Loss of pain, touch heat and cold sensation or decrease - Loss of proprioception - Loss of vibration sense
  6. 6. Diabetic Sensory Neuropathy:5 • Clinically: Positive symptoms • Dysesthesia • Paresthesia • Hyperesthesia Examination: Could still be insensate to touch, pain, temperature – The painless – Painful foot.
  7. 7. Diabetic Sensory Neuropathy:6 Clinical Examination depends upon – Clarity of communication by the physician. Clarity of understanding of patient and clear response. Difficult to quantify.
  8. 8. Diabetic Sensory Neuropathy:5 Quantifying the loss of function useful to correlate – Degree of loss to the likelihood of developing morbidity Important for early diagnosis of foot at risk develop preventive strategies.
  9. 9. Diabetic Sensory Neuropathy:8 What sensations can vibration sense Pain on analog scale – (suffers most on account subjective variation of pain threshold, severity perception pressure: force/area sense of pressure - quantifiable
  10. 10. Instruments for quantification:I • Quantification needs instrumentation. • Available or: • Light touch + pressure • SW monofilaments • A nylon fiber, held again a foot and bent, • Gives 10 gms of weight / pressure
  11. 11. Instruments for Quantification:2 • Simple, well tested method • Identifies easily foot at risk if the patient cannot sense the 10 gm pressure. • Correlates well with other tests.
  12. 12. Instruments for Quantification:3 • To test vibration sense • Tuning fork – frequency of 128 • Diagnoses per sense or absence of vibration sense but does not indicate quantifiable severity of loss.
  13. 13. Instruments for Quantification:2 • Graduated tuning fork: • Weighted and graduated for 0 – 10 • The apex of the triangle rises from 0 – 10 • If vibrations are perceived beyond 6, vibration sense considered normal. • At best semi quantitative.
  14. 14. Instruments for Quantification:5 • Biothesiometer: • Delivers vibrations in micron displacements increasing with increasing voltage applied. • Loss of vibration sense quantifiable well in terms of voltage applied, • V read off simply on the panel.
  15. 15. Instruments for Quantification:2 • Indian version available. • Normal range on 300 normal, non diabetic Indian doctors and nurses, across the country • 4 to 9 volts • Much higher thresholds in diabetics with neuropathy upto 48 volts, vibrations not perceived.
  16. 16. Instruments for Quantification:7 • Indian version tested in 75 patients by Dr. Vijay Viswanathan against an English Biothesiometer. • P value for inter instrumental interpersonal variation, on first analysis – not significant • Correlates well, needs more stringent analyses – under way.
  17. 17. Instruments for Quantification:8 • Heat and cold perception thresholds • Foreign instruments available but difficult to get Indian version being developed by NNEF.
  18. 18. Correlations: 1 • “If any one sensation tested is abnormal, then the possibility that there will be at least one more abnormal sensation is high”. Dyke - Thomas
  19. 19. Correlations: 2 • Abnormality detected on Monofilaments has equal sensitivity and specificity with an abnormality detected on biothesiometer. • Quantifiable accuracy of course is greater with biothesiometer.
  20. 20. Correlations: 3 • Biothesiometer voltage value on insensate vibration, of 25 volts, exposes the foot to risk of ulceration 43 times more than a normal foot. • Proportionate increase in risk is present with lower but above normal voltage measurements.
  21. 21. Achievements • Monofilaments in Indian version also available • Biothesiometer available • Heat and cold perception threshold under development. • Materials tested for taking foot impressions for castes – available graduated tuning fork developed, more refinement under way.

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