Neuro-Sensory

Assessment
For Patients with Diabetes
Precious Santayana

Nerves are the pathways for messages to be sent

to and from the brain about pain, temperature
and touch. Nerves carry messages to your
muscles telling them how and when to move.
Diabetes is one of the main causes of nerve
damage, called diabetic peripheral neuropathy.
This can cause burning, tingling, pain, numbness
and/or weakness in your feet and legs leading to
instability when standing or walking. Nearly 50%
of people with diabetes have some degree of
nerve damage. Diabetic peripheral neuropathy
can progress slowly and it can take many years
until it becomes debilitating. If diagnosed early,
its effects can be minimized

The following is a list of common symptoms associated with

diabetic peripheral neuropathy:

My feet tingle.
I feel pins and needles in my feet.
I have burning, stabbing or shooting pain in my feet.
My feet are very sensitive to touch.
My feet and legs hurt at night.
My feet get very cold or very hot.
My feet are numb and feel dead.
I dont feel pain when I get a blister or another injury to my foot.
I cant feel my feet when Im walking.
The muscles in my feet and legs are weak.
I am unsteady when I stand or walk.
I have trouble feeling heat or cold in my feet.
I have open sores on my feet or legs that heal very slowly.
It seems like my feet have changed shape.

Signs and symptoms

In type 1 DM, distal polyneuropathy typically becomes
symptomatic after many years of chronic prolonged
hyperglycemia, whereas in type 2, it may be apparent
after only a few years of known poor glycemic control
or even at diagnosis. Symptoms include the following:
Sensory Negative or positive, diffuse or focal;
usually insidious in onset and showing a stockingand-glove distribution in the distal extremities
Motor Distal, proximal, or more focal weakness,
sometimes occurring along with sensory neuropathy
(sensorimotor neuropathy)
Autonomic Neuropathy that may involve the
cardiovascular, gastrointestinal, and genitourinary
systems and the sweat glands

Clinical Screening for Sensory

Neuropathy
Screening techniques are used to
detect early signs of sensory
neuropathy. This recognition is
essential to prevent foot ulceration in
patients with diabetes.
The Semmes-Weinstein
monofilament test is considered the
gold standard for identifying loss of
protective sensation in the feet of
patients with DPN.

Clinical Screening for Sensory

Neuropathy

Clinical Screening for Sensory

Neuropathy
Once a patient has developed a foot
ulceration and presents to the office
without obvious signs of discomfort,
there is no reason to continue using
the SWM test.
Sensation of the foot may be
interpreted on a spectrum from
diminished to absent.

Clinical Screening for Sensory Neuropathy

Clinical Screening for Sensory Neuropathy

Clinical Screening for Sensory Neuropathy

Clinical Screening for Sensory

Neuropathy

Other Screening Tools

Semmes-Weinstein Monofilaments
provide a non-invasive evaluation of
cutaneous sensation levels throughout the
body with results that are objective and
repeatable.
indicated in diagnoses including nerve
compression syndromes, peripheral
neuropathy, thermal injuries and
postoperative nerve repair.
each is individually calibrated to deliver its
targeted force within a 5% standard deviation.

Semmes-Weinstein Monofilaments
1. Rest the patients extremity on a stable,
surface. Testing should be done in a quiet
help the patient fully attend to the
procedure. Occlude the patients vision by
shield or by having the patient look away.

padded
area to
testing
using a

2. Explain the testing procedure to the patient and

instruct the patient to respond when the stimulus is
felt by saying touch or yes. Nonverbal patients
may tap the table lightly when the stimulus is felt.
3. Note any areas of callus, abrasion, scarring or
other blemishes by drawing on the recording form .
While testing, proceed from distal to proximal and
from small to large monofilaments.
*If callus is present at any of the sites then test at

Semmes-Weinstein Monofilaments
4. It is not necessary to test every area of the
skin when performing an evaluation. Checks
may be done over areas innervated by
different nerves. For the hand, test the
palmar surface of the index finger and thumb
to evaluate median nerve function; test the
little finger and hypothenar eminence to
evaluate the ulnar nerve; and test the dorsum
of the hand to evaluate the radial nerve (see
Figure 1). For the foot, test the sites indicated
in Figure 2.

Semmes-Weinstein Monofilaments

Semmes-Weinstein Monofilaments
5. Press the filament
at a 90 angle against
the skin until it bows.
Hold in place for 1.5
seconds and then
remove (see Figure
3). A single response
indicates a positive
response.

Semmes-Weinstein Monofilaments
6. If the patient responds to the stimulus in all sites,
normal cutaneous sensation can be documented
and the examination is complete. If the patient
does not respond to the stimulus, choose the next
largest monofilament and repeat the process.
7. When the patient indicates a response, record
the result using the colored pencil that corresponds
to the color on the handle. When representing
monofilaments of the same color, notate which
monofilament size was used (see Figure 4).
Threshold levels indicated in Figure 5 can be used
to interpret test results.

Semmes-Weinstein Monofilaments

128-Hz Tuning Fork

Test bony prominences

Apex 1st
1st MPJ
Medial malleolus
Twang the tuning fork lightly and apply the flat, circular surface to
a bony sensitive area (e.g. the elbow)
Ask the patient to describe the sensation they can feel (you need to
be sure the patient can feel buzzing/humming and not just pressure
or cold)
Repeat on the foot, testing the apex of the 1st first.
Ask the patient what they can feel. Record a positive response if
they feel the same sensation that they felt at the elbow. (If the
patient can only feel cold or pressure this is a negative response)
If the patient does not feel vibration at the apex 1st, move
proximally up the limb to the next test site, the 1st MPJ followed by
the medial malleolus.

VPT Testing
Vibration perception threshold testing
(VPT) is performed using a handheld
device (Bio-Thesiometer, Bio-medical
Instrument Company, Newbury, OH)
The clinical technique employed is
similar to the tuning fork, where the
probe is placed at the distal hallux.
The amplitude on the device is adjusted
until the patient can distinctly sense a
vibratory stimulus.

Reflex Testing
To screen for sensory neuropathy
primarily focuses on examining the
ankle reflex.
The clinician aligns the ankle into a
neutral position and strikes the Achilles
tendon with a neurological hammer.
An abnormal result is demonstrated by
complete
absence
of
ankle
plantarflexion.
Compared to other lower extremity
reflexes, the ankle reflex is the most
sensitive for detecting early signs of
neuropathy.

Reflex Testing

Reflex Testing

A normal reflex will cause the foot to

plantar flex (i.e. move into your

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Reflex Testing

Pin Prick Testing

involves
the
superficial
application of a sterile safety pin
at the forefoot with enough
manual pressure to slightly
deform the skin.
Abnormal findings are concluded
if a patient cannot detect the
sharp stimulus.
One of the primary indications
for this testing modality is to
locate a focal area of sensory
loss.

PSSD
Pressure Specified Sensory Device (PSSD)
most accurate way of testing the lower
extremity for sensory deficits.
This computer-based device is able to quantify
and record both specific peripheral nerve
threshold levels and peripheral nerve
innervation density (which reflects axonal
degeneration).
As a result, the PSSD is able to identify
pathologic changes in nerves at subclinical
levels and it is pain free.

Ipswich Touch Test

A.k.a. Touch the toes
test
The
test
simply
involves very lightly
touching
six
toes,
three on each foot as
shown to find out how
many of the touches
are felt. Importantly
the touch must be
gentle, light as a
feather and brief.

Ipswich Touch Test

Ipswich Touch Test

The touch must be light
as a feather, and brief (1
2 seconds): do not press,
prod or poke tap
or stroke the skin.
If the person did not
respond do not attempt
to get a reaction by
pressing harder. They did
not feel; this should be
recorded as not felt.
You must not touch
each toe more than once.
If not felt do not repeat

Ipswich Touch Test

Using the index finger,
touch the tips of toes
following the sequence
-------------------
If the subject correctly
says right or left, circle
Y on the diagram
right.
If not felt this must be
recorded by circling N
on the diagram right.
There is no second
chance.

Ipswich Touch Test

.

1 Remove socks and shoes and rest the subject with their feet
laying on a sofa or bed.
2. Remind them which is their RIGHT and LEFT leg, pointing this
out by firmly touching each leg, saying this is your right when
the right leg is touched and this is your left side when the left is
touched. If you face the soles of their feet their right is on your left.
3. Ask them to close their eyes and keep them closed until the end
of the test.
4. Inform them that you are going to touch their toes and ask them
to say right or left as soon as they feel the touch and depending on
which foot was touched.
5. Perform the touch, using your index (pointing finger) as shown
in the photos and diagrams.

Ipswich Touch Test

6. The pictures also show which six toes should be
touched and the sequence.
7. So, start by lightly touching the tip of the toe
marked 1 (right big toe) with the tip of your index
finger. The patient will respond by saying right if
they feel the touch.
8. Record the result by circling Y on the attached
record sheet. If they did not respond, circle N.
9. Now move to the toe marked 2, the right little
toe, record the result, followed by the toe marked 3,
the left big toe etc.
10. Continue until all the six toes has been checked.

Ipswich Touch Test

NORMAL SENSATION
If you felt the touch at all
six or five of the six toes, as
shown in the example
below, then your sensation
is normal and you are not at
increased risk of developing
a foot problem because of
lack of sensation. However,
you must continue having
the more detailed foot
checks that you should be
receiving annually.

Ipswich Touch Test

IMPAIRED SENSATION
If you did not feel
when touched at two
or more of the six
toes, as shown in the
examples
below,
then you are very
likely
to
have
reduced
sensation
and may be at risk of
a diabetic foot ulcer.
This needs to be