sectional and longitudinal studies haveassessed the sensitivity of the 10-gmonofilament and have shown it to be auseful tool to identify patients at risk of foot ulceration.
Of the simple quanti-tative sensory testing instruments thatare used in clinical practice,the mostcommon is the bioesthesiometer (Bio-medical Instruments,Newbury,Ohio).This assesses in a semiquantitative man-ner the perception of vibration and hassimilarly been shown to be a useful pre-dictor of foot ulcer risk.
MANAGEMENTIs It DPN?
The management approach to patientsconsidered to have DPN is provided inTable 3. First,it must be rememberedthat there are numerous causes of peripheral neuropathy,of which diabetesis probably the most common. However,exclusion of other causes,particularlymalignant disease and toxic causes,is of paramount importance. Exclusion of such potentially serious conditions asmalignant disease (e.g.,small-cell carci-noma presenting as a paraneoplasticsyndrome),toxic causes (e.g.,alcohol),and infections (diseases such as HIV) isessential.
available to record symptom qualityand severity. Among these is the Michi-gan Neuropathy Screening Instrument,which is a brief 15-item question-naire.
It is also increasingly recog-nized that both symptoms and deficitsmay have an adverse effect on qualityof life in diabetic neuropathy,
and spe-cific questionnaires have been devel-oped for the assessment of the impactof neuropathy on quality of life. Simi-larly,composite scores have been usedto assess clinical signs,and one that isincreasingly used is a modified Neu-ropathy Disability Score (NDS).
TheNDS,shown in Figure 1,can be easilyperformed in the clinic setting andtakes only a minute or two to complete.The maximum deficit score is 10,which would indicate complete loss of sensation to all sensory modalities andabsent reflexes. In a longitudinal Euro-pean community-based study,an NDSof
6 was equated with an increasedrisk of insensate foot ulceration.
A number of simple devices may beused for clinical screening; the mostwidely used is the Semmes-Weinsteinmonofilament.
This filament assessespressure perception when gentle pres-sure is applied sufficient to buckle thenylon filament. A number of cross-
Volume 23, Number 1, 2005
In most cases,further investigation,such as detailed quantitative sensorytesting in electrophysiology,whichwould require referral to a neurologist,isnot essential. Abnormal electrophysiolo-gy simply confirms the presence of aneuropathy but does not indicate theunderlying cause.
Initial Therapy and Counseling
Once a diagnosis is established,givingpatients a full explanation of their condi-tion,allaying their fears and misconcep-tions,and informing them that the painmay resolve in time can be extremelyreassuring. Simple physical treatments,such as the use of a bed cradle to lift thebed clothes off of hyperaesthetic skin,can be beneficial. Advice on suitablefootwear may also be provided. Inpatients with relatively mild pain,simpleanalgesics or anti-inflammatory agentsmay be sufficient to treat the discomfort.
The most effective method of achievingstable normoglycemia is pancreas orislet cell transplantation. However,thisis not practical in most cases because itis mainly available to patients with end-stage diabetic nephropathy who havecombined pancreas and renal transplantsor in special cases of young people withtype 1 diabetes.Although there have been no ran-domized,controlled trials of intensiveinsulin therapy in the management of diabetic neuropathy,data from a numberof observational studies suggest that sta-ble glycemic control is of the greatestimport. A recent study using continuousglucose monitoring confirmed thatpainful symptoms were associated witherratic blood glucose control.
Havingsaid this,there is no evidence thatpatients whose diabetes has been wellcontrolled on oral hypoglycemic agentswill benefit in terms of pain relief bytransferring to insulin.
A large number of therapeutic agentshave been proposed for the management
Figure 1. The Modified Neuropathy Disability Score
Neuropathy Disability Score (NDS)Right LeftVibration Perception Threshold
128-Hz tuning fork; apex of big toe:normal = can distinguish vibrating/ not vibrating
Temperature Perception on Dorsumof the Foot
Normal = 0Use tuning fork with beaker of Abnormal = 1ice/warm water
Apply pin proximal to big toe nail justenough to deform the skin;trial pair = sharp,blunt;normal = can distinguish sharp/not sharp
Present = 0Present withreinforcement = 1Absent = 2NDS Total out of 10