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1362405475 semi quantitative assess neurop

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semi quantitative assess neurop

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1362405475 semi quantitative assess neurop

  1. 1. 11 Assessing Sensory NeuropathyAssessing Sensory Neuropathy Sanjeev KelkarSanjeev Kelkar Conjoint LecturerConjoint Lecturer Faculty of healthFaculty of health University of NewcastleUniversity of Newcastle AustraliaAustralia
  2. 2. 2 Motor Sensory Autonom MyelinatedMyelinated Thinly myelinated Un- myelinated Thinly myelinated Un- myelinated Aα Aα/β Aδ C Aδ C LARGE SMALL Muscle control Touch, vibration, position perception Cold perception, pain Warm perception, pain Heart rate, blood pressure, sweating, GIT function A simplified view of the peripheral nervous system. GIT, gastrointestinal tract.
  3. 3. 3 Clinical presentation of large-fibreClinical presentation of large-fibre neuropathiesneuropathies • Impaired vibration perception (often the firstImpaired vibration perception (often the first objective evidence) and position sense.objective evidence) and position sense. • Depressed tendon reflexes.Depressed tendon reflexes. • AAδδ type deep-seated gnawing, dull, like atype deep-seated gnawing, dull, like a toothache in the bones of the feet or eventoothache in the bones of the feet or even crushing or cramp-like pain.crushing or cramp-like pain.
  4. 4. 4 Clinical presentation of large-fibreClinical presentation of large-fibre neuropathiesneuropathies • Sensory ataxia (waddling like a duck)Sensory ataxia (waddling like a duck) • Wasting of small muscles of feet withWasting of small muscles of feet with hammertoes (intrinsic minus feet and hands)hammertoes (intrinsic minus feet and hands) with weakness of hands and feet.with weakness of hands and feet. • Shortening of the achilles tendon with pesShortening of the achilles tendon with pes equinus.equinus. • Increased blood flow (hot foot).Increased blood flow (hot foot).
  5. 5. 5 Need to Detect, Quantify and PreventNeed to Detect, Quantify and Prevent Neuropathy In Diabetes.Neuropathy In Diabetes. Foot UlcerationFoot Ulceration GangreneGangrene AmputationAmputation
  6. 6. 6 Androclese and the lionAndroclese and the lion • After identifying lionsAfter identifying lions foot/paw problem,foot/paw problem, Androcleas removedAndrocleas removed the thorn in his paw.the thorn in his paw. Treated his ulcersTreated his ulcers and may be theyand may be they lived happily everlived happily ever after…….!!!!after…….!!!!
  7. 7. 7 Pay backPay back All patients of diabetes of someAll patients of diabetes of some duration need testing.duration need testing. Every third person is likely to be aEvery third person is likely to be a neuropathic.neuropathic. We must know his relative risk toWe must know his relative risk to prevent ulcerationprevent ulceration A worthwhile investment, likely toA worthwhile investment, likely to pay back more than usual .pay back more than usual . Androcleas says every third lionAndrocleas says every third lion diabetic has the painless thorndiabetic has the painless thorn of neuropathy. He needsof neuropathy. He needs quantification.quantification. The third Lion
  8. 8. 8 Factors and markers of low-risk versus high-Factors and markers of low-risk versus high- risk diabetic feetrisk diabetic feet Low-risk foot High-risk footLow-risk foot High-risk foot All of the following:All of the following: One or more of theOne or more of the following:following: following:following: Intact protective sensation Loss of protectiveIntact protective sensation Loss of protective sensationsensation Pedal pulses present Absent pedal pulsesPedal pulses present Absent pedal pulses No severe deformity Significant footNo severe deformity Significant foot deformitydeformity
  9. 9. 9 Factors and markers of low-risk versus high-Factors and markers of low-risk versus high- risk diabetic feetrisk diabetic feet Low-risk foot High-risk footLow-risk foot High-risk foot All of the following:All of the following: One or more of theOne or more of the following:following: following:following: No prior foot ulcer History of foot ulcer orNo prior foot ulcer History of foot ulcer or callus pre-ulcerative calluscallus pre-ulcerative callus No amputation Prior amputationNo amputation Prior amputation Normal joint mobility. Limited joint mobilityNormal joint mobility. Limited joint mobility
  10. 10. 10 What do we have to assess Neuropathy?What do we have to assess Neuropathy? Need to assess associated risk of ulceration in a neuropathic Need to distinguish Neuropathic and non neuropathic patients Need to establish wide range of quantitated gradation of sensory deficits for comparison on Follow up Need simple testing equipment
  11. 11. 11 Tuning fork - 1Tuning fork - 1 • The sensory exam should be done in a quiet andThe sensory exam should be done in a quiet and relaxed setting. First apply the tuning fork on therelaxed setting. First apply the tuning fork on the patient’s wrists (of elbow, or clavicula) so thatpatient’s wrists (of elbow, or clavicula) so that patient knows what to expect.patient knows what to expect. • The patient must not be able to see if and whereThe patient must not be able to see if and where the examiner applies the tuning fork. The tuningthe examiner applies the tuning fork. The tuning fork is applied on a bony part on the dorsal side offork is applied on a bony part on the dorsal side of the distal phalanx of the first toe.the distal phalanx of the first toe. • It should be applied perpendicularly with a constantIt should be applied perpendicularly with a constant pressure.pressure.
  12. 12. 12 Tuning fork - 2Tuning fork - 2 • Repeat this applications twice, but alternate thisRepeat this applications twice, but alternate this with at least one “sham” application, in which thewith at least one “sham” application, in which the tuning fork is not vibrating.tuning fork is not vibrating. • The test is positive if the patient correctly answeredThe test is positive if the patient correctly answered at least two out of three applications, and negativeat least two out of three applications, and negative (at risk for ulceration) with two out of three incorrect(at risk for ulceration) with two out of three incorrect answers.answers. • If the patient is unable to sense the vibrations at theIf the patient is unable to sense the vibrations at the big toe, the test is repeated more proximallybig toe, the test is repeated more proximally (malleolus, tibial tuberositas).(malleolus, tibial tuberositas). • Encourage the patient during testing.Encourage the patient during testing.
  13. 13. 13 Vibration perception assessed with 128 Hz tuning fork
  14. 14. 14 The Rydel Seiffer tuning fork : An inexpensive device for screening diabetic patients with high risk foot. Vijay Viswanathan et al. Pract. Diab. Int.(In print). It is a 128HZ graduated tuning fork which allows quantifiable assessment of vibration perception in the feet of diabetic patients.
  15. 15. 15 Differing methods to measure VPT Method Technique Usefulness 128-Hz tuning fork Sensation normal(cf.hand/ Only to detect presence forehead,reduce or absent or absence of neuropathy Reidell-Seiffer graduated tuning fork Ascending method Coefficient of variation compares (Firma Martin, favorably with more complex Tuttlingen, Germany) techniques below Biothesiometer (Biomedical Instrument Ascending method Largely superseded by Newbury, OH) Neurothesiometer Neurothesiometer
  16. 16. 16 Pressure perception assessed with 5.07/10g Semmes- Weinstein monofilament. Plantar aspect of first and fifth metatarso- phalageal joints gives best sensitivity (80%) and specificity (86%) (McGill.M et al, 1999 – Diabetes Care)
  17. 17. 17 • In an recent study in an outpatient clinic, whichIn an recent study in an outpatient clinic, which examined the reproducibility of screening using aexamined the reproducibility of screening using a monofilament, biothesiometer and palpation ofmonofilament, biothesiometer and palpation of pedal pulses, only the monofilament gavepedal pulses, only the monofilament gave adequately reproducible results (over 85%) foradequately reproducible results (over 85%) for measurements repeated after 2 weeks.measurements repeated after 2 weeks. [Klenerman L, et al. Diabet Med 1996].[Klenerman L, et al. Diabet Med 1996].
  18. 18. 18 Detection of neuropathyDetection of neuropathy • Identification of neuropathy based on insensitivityIdentification of neuropathy based on insensitivity to a 10 gm (5.07) nylon monofilament isto a 10 gm (5.07) nylon monofilament is convenient and appears to be cost-effective.convenient and appears to be cost-effective. [Gadsby R, McInnes A. Diabet Med 1998][Gadsby R, McInnes A. Diabet Med 1998]
  19. 19. 19 Semmes-Weinstein monofilament - 1Semmes-Weinstein monofilament - 1 • Sensory examination should be done in a quietSensory examination should be done in a quiet and relaxed setting. First apply theand relaxed setting. First apply the monofilament on the patient’s hands (or elbow,monofilament on the patient’s hands (or elbow, or forehead) so the patients know what toor forehead) so the patients know what to expect.expect. • The patient must not be able to see if andThe patient must not be able to see if and where the examiner applies the filament. Thewhere the examiner applies the filament. The three sites to be tested on both feet arethree sites to be tested on both feet are indicated.indicated.
  20. 20. 20 Semmes-Weinstein monofilament - 2Semmes-Weinstein monofilament - 2 • Apply the monofilament perpendicular to theApply the monofilament perpendicular to the skin surface.skin surface. • Apply sufficient force to cause the filament toApply sufficient force to cause the filament to bend or buckle.bend or buckle. • The total duration of the approach, skin contact,The total duration of the approach, skin contact, and removal or the filament should beand removal or the filament should be approximately 2 seconds.approximately 2 seconds.
  21. 21. 21 Semmes-Weinstein monofilament - 3Semmes-Weinstein monofilament - 3 • Apply the filament along the perimeter of andApply the filament along the perimeter of and not on an ulcer site, callus, scar or necroticnot on an ulcer site, callus, scar or necrotic tissue. Do not allow the filament to slidetissue. Do not allow the filament to slide across the skin or make repetitive contact atacross the skin or make repetitive contact at the test site.the test site. • Press the filament to the skin and ask thePress the filament to the skin and ask the patient IF they feel the pressure appliedpatient IF they feel the pressure applied (yes/no) and next WHERE they feel the(yes/no) and next WHERE they feel the pressure applied (left/right foot).pressure applied (left/right foot).
  22. 22. 22 • Semmes-Weinstein monofilament –Semmes-Weinstein monofilament – 44 • Repeat this application twice at the same site, butRepeat this application twice at the same site, but alternate this with at least one “sham” application,alternate this with at least one “sham” application, in which no filament is applied (total threein which no filament is applied (total three questions per site).questions per site). • Protective sensation is present at each site if theProtective sensation is present at each site if the patients correctly answers two out of threepatients correctly answers two out of three applications. Protective sensation is absent withapplications. Protective sensation is absent with two out of three incorrect answers, and the patienttwo out of three incorrect answers, and the patient is then considered to be at risk of ulceration.is then considered to be at risk of ulceration. • Encourage the patients during testingEncourage the patients during testing..
  23. 23. 23 MonofilamentsMonofilaments to detect the foot at risk,to detect the foot at risk, That too for multiple use.That too for multiple use. Up to five patients can be tested with one Monofilament
  24. 24. 24 Semmes-Weinstein monofilament - 5Semmes-Weinstein monofilament - 5 Monofilament: When applied perpendicular toMonofilament: When applied perpendicular to thethe foot it buckles at a force of 10 gms, tests touchfoot it buckles at a force of 10 gms, tests touch && pressurepressure Areas to be tested - metatarsal heads of first,Areas to be tested - metatarsal heads of first, third and fifth and the plantar surface of heel.third and fifth and the plantar surface of heel.
  25. 25. 25 Semmes-Weinstein monofilament - 5Semmes-Weinstein monofilament - 5 The validity of SW monofilamentThe validity of SW monofilament for predicting the neuropathy byfor predicting the neuropathy by nerve conduction study criterianerve conduction study criteria are confirmed by Perkins BA,are confirmed by Perkins BA, 2001,2001,
  26. 26. 26 Semmes-Weinstein monofilament - 5Semmes-Weinstein monofilament - 5 SW Monofilament has a SensitivitySW Monofilament has a Sensitivity 77%, specificity 98% with a + ve and –77%, specificity 98% with a + ve and – ve likelihood ratios of 10.2 and 3.4ve likelihood ratios of 10.2 and 3.4 respectively for 4 to8 imperceptiblerespectively for 4 to8 imperceptible stimuli on great toe bilaterally.stimuli on great toe bilaterally. (Perkins, BA 2001)(Perkins, BA 2001)
  27. 27. 27 Semmes-Weinstein monofilament - 6Semmes-Weinstein monofilament - 6 Monofilaments help classify foot at risk forMonofilaments help classify foot at risk for touch pressure. (5.07/10gms)touch pressure. (5.07/10gms) Diagnosed clinically by reduced sensitivityDiagnosed clinically by reduced sensitivity to 10 g Semmes Weinstein monofilament. andto 10 g Semmes Weinstein monofilament. and pricking sensation using the Waardenbergpricking sensation using the Waardenberg wheel or similar instrument testing sensation towheel or similar instrument testing sensation to light touch and pinprick - Sensitivity 71%light touch and pinprick - Sensitivity 71%
  28. 28. 28 Semmes-Weinstein monofilament - 7Semmes-Weinstein monofilament - 7 Filament not to be applied over theFilament not to be applied over the calluscallus The advantage of the assessment withThe advantage of the assessment with monofilaments is a foot at risk can bemonofilaments is a foot at risk can be decided in 2 seconds and segregated fordecided in 2 seconds and segregated for detailed analysisdetailed analysis
  29. 29. 29 Semi-Quantitative test forSemi-Quantitative test for neuropathic assessmentneuropathic assessment Pricking sensation can be tested by usingPricking sensation can be tested by using the Waardenberg wheel or similarthe Waardenberg wheel or similar instrumentinstrument testing sensation totesting sensation to light touch and pinprick -light touch and pinprick -

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