semi quantitative assess neurop

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
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
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
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
Need to Detect, Quantify and PreventNeed to Detect, Quantify and Prevent
Neuropathy In Diabetes.Neuropathy In Diabetes.
Foot UlcerationFoot Ulceration
GangreneGangrene
AmputationAmputation

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…….!!!!

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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
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
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

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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
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.

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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.

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Vibration
perception
assessed with
128 Hz tuning
fork

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.

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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

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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)

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• 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].

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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]

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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.

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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.

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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).

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• 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..

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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

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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.

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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,

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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)

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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%

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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

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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 -