Endocrinol Metab.  2016 Jun;31(2):230-238. 10.3803/EnM.2016.31.2.230.

Recent Advances in Diagnostic Strategies for Diabetic Peripheral Neuropathy

• Won JC
• Park TS

• KMID: 2308852
• DOI: http://doi.org/10.3803/EnM.2016.31.2.230

Abstract

Diabetes is an increasing epidemic in Korea, and associated diabetic peripheral neuropathy (DPN) is its most common and disabling complication. DPN has an insidious onset and heterogeneous clinical manifestations, making it difficult to detect high-risk patients of DPN. Early diagnosis is recommended and is the key factor for a better prognosis and preventing diabetic foot ulcers, amputation, or disability. However, diagnostic tests for DPN are not clearly established because of the various pathophysiology developing from the nerve injury to clinical manifestations, differences in mechanisms according to the type of diabetes, comorbidities, and the unclear natural history of DPN. Therefore, DPN remains a challenge for physicians to screen, diagnose, follow up, and evaluate for treatment response. In this review, diagnosing DPN using various methods to assess clinical symptoms and/or signs, sensorineural impairment, and nerve conduction studies will be discussed. Clinicians should rely on established modalities and utilize current available testing as complementary to specific clinical situations.

Keyword

Diabetic neuropathies; Early diagnosis; Evaluation studies as topic; Electrophysiology

MeSH Terms

Amputation
Comorbidity
Diabetic Foot
Diabetic Neuropathies
Diagnostic Tests, Routine
Early Diagnosis
Electrophysiology
Evaluation Studies as Topic
Follow-Up Studies
Humans
Korea
Natural History
Neural Conduction
Peripheral Nervous System Diseases*
Prognosis
Ulcer

Figure

• 

  Fig. 1 Bedside neurological and sensory nerve testing. (A) Vibration. Patients are notified when they cannot feel the vibrations from a 128-Hz tuning fork (first interphalangeal joint of the great toe) when the toes are extended, and the investigator feels the vibration and measures the time when the feeling disappeared. A time difference ≥10 seconds between the investigator and the patient is considered abnormal [33]. (B) Pressure: 10-g monofilaments are pressed on 10 points on the sole and dorsum of the feet until the monofilament begins to bend (100 mN). If the patient has sensation in fewer than seven points, the results is considered abnormal [33]. Four sites per foot, such as the hallux and metatarsal heads 1, 3, and 5, should be screened [4]. (C) Noxious stimuli and (D) light touch. The patient is touched on the foot using a sterile pin, toothpick, and cotton wisp and asked to identify a "sharp or dull" or "light touch" with their eyes closed [33]. (E) Warm/cold. Tip-therm (temperature discriminator; AXON GmbH) is a pen-like device with a plastic cylinder on one end and a metal cylinder on the other end, which is applied to the dorsum of each foot at irregular intervals so patients can identify the sensation as cold or not with their eyes closed [32]. (F) Sudomotor function. Indicator tests (Neuropad, miro Verbandstoffe) are applied to both soles at the level of the first and second metatarsal heads. The time to color change from blue to pink is more than 10 seconds; the result is considered abnormal [34].

• 

  Fig. 2 Definition and severity assessment of diabetic peripheral neuropathy (DPN) proposed by the Toronto Diabetic Neuropathy Expert Group. Numbers in each column refer to the definitions of the minimal criteria for DPN, and the number in parentheses is the stage of severity: 1 ("possible"), 2 ("probable"), or 3 ("confirmed") for clinical practice and 3 or 4 ("subclinical") for research studies [6]. Severity is staged based on the symptoms, signs, and nerve conduction (NC) abnormalities: stage 0, no NC abnormality; 1a, subclinical but without symptoms or signs; 1b, subclinical with signs but no symptoms; 2a, subclinical with symptoms regardless of signs; and 2b (not shown here), subclinical with unequivocal weakness of ankle dorsiflexion [5].

• 

  Fig. 3 Diagnostic approach to diabetic peripheral neuropathy (DPN) proposed by the Korean Diabetes Association [7].

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