Appendix 8

Rapid Screening for Diabetic Neuropathy

Multiple screening methods are published. These methods are designed to screen for the presence or absence of diabetic neuropathy, as opposed to screening for specific sites on the feet that are at risk of ulceration (multisite testing). If neuropathy is identified by either of these methods, other sites may be tested to identify high-risk areas for ulceration.

Part A:

Rapid Screening for Diabetic Neuropathy Using the 10-g Semmes-Weinstein Monofilament
1.  Show the 10-g Semmes-Weinstein monofilament to the patient.
2.  Touch it first to the patient’s forehead or sternum so that the sensation is understood.
3.  Instruct the patient to say “yes” every time the monofilament stimulus is perceived.
4.  With the patient’s eyes closed, apply the monofilament to the dorsum of the great toe proximal to the nail bed as shown in the illustration below. Use a smooth motion-touch the skin, bend the filament for a full second, then lift from the skin.
5.  Perform this stimulus 4 times per foot in an arrhythmic manner so the patient does not anticipate when the stimulus is to be applied.
6.  For each of the 8 stimuli, assign a score of 0 if it is not perceived, 0.5 if it is substantially less than that perceived on the forehead or sternum, and 1 if it is perceived normally. A score of 3 out of 8 correct responses means that the presence of neuropathy is likely. A score of 3.5 to 5 means that the risk of new onset neuropathy in the next four years is high. A score of 5.5 or greater indicates that there is a low risk of neuropathy onset in the next four years.

Part B:

Rapid Screening for Diabetic Neuropathy Using the 128-Hz
Vibration Tuning Fork (The “On-Off” Method)
1.  Strike the tuning fork against the palm of your hand hard enough that it will vibrate for approximately 40 seconds.
2.  Apply the base of the tuning fork to the patient’s forehead or sternum and ensure that the vibration sensation (not just the touch sensation) is understood.
3.  With the patient’s eyes closed, apply the tuning fork to the bony prominence situated at the dorsum of the first toe just proximal to the nail bed. Ask if the vibration sensation is perceived.
4.  Ask the patient to tell you when the vibration stimulus is stopped, and then dampen the tuning fork with your other hand.
5.  One point is assigned for each vibration sensation perceived (vibration “on”). Another point is assigned if the correct timing of dampening of the vibration is perceived (vibration “off ”).
6.  Repeat this procedure again on the same foot, then twice on the other foot in an arrhythmic manner so the patient does not anticipate when the stimulus is to be applied.
7.  Though this test can be used to rule out the presence of neuropathy, unlike for the monofilament described above, threshold scores do not exist to indicate the risk of future onset of neuropathy.

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