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Hello.
I have a question for anyone currently teaching in podiaty schools. What tests do you expect students to perform when evaluating for the presence of diabetic peripheral neuropathy?
Thankyou.

Well i'm not a teacher in a school but i can remember what i was expected to do as a student being taught this subject;
1)Light touch with cotton wool across the ten dermatomes on the feet
2)Sharp and blunt touch with the neurotip (both ends) across the ten dermatomes of the feet
3)Temperature...hot and cold on the dorsum and plantar aspect of the feet
4)Vibration on the boney prominences from the apex of the 1st toe, then the medial side of the 1st mtpjt, then the medial malleolus and finally the patella.
This was the only testing we did the pt had to have their eyes closed for 1 and 2 to avoid suggestion from the brain. We were actively encouraged to sometimes not touch the feet at all. All this was back in 1993 so things may have changed now and i know in clinic we do not use the neurotip so much now but the 10g monofilament.

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HELENEAUSTINMy location

I'm not teaching this subject, but as far as I know the students learn to use a monofilament (semmes-weinstein) as well as surplus on what is mentioned above. Another important point in the evaluation of the diabetic foot is not only the screening, but the education dependent on the result of the screening.

bare in mind that the protocol needed to be followed to avoid bias in the screening is crucial as well!

The cotton wool test we don't use

cheers

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Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium

Hi

What do people tell their patients in regards to each area being tested?

What do different people use to test for temperature?

Cheers
RStone

In my opinion it's very important when doing a neurological examination.
People try to compensate the loss of feeling by looking/hearing
It's amazing how they try to react as normal as possible.

So I always let the patients know what they should expect to feel and then ask them to close their eyes and tell me if it's the left or right foot that is being tested
I had patients who reacted on the 'sound' of a monofilament making contact with the skin. They could say with their eyes closed that they 'felt' something on left foot even when I made the sound by using the monofilament my own hand...

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Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium

Hi

Sorry ... I actually meant what do people tell their patients in way of explanation of each test indicates.

Cheers
RStone

I am not a teacher either, but I was taught that Diabetes is a dorsal column disease, and as such vibration, proprioception, and two point touch discrimination is diminished. In my office I prefer proprioception of the 2nd MPJ, as it is the easiest and quickest test. This will usually show diminution in all diabetics.
The idea of using the Semmes Weinstein 5.07 monofilament wire came from the work on lepers in Louisiana. The findings were that the inability to perceive 10g of force on the skin results in ulcers. They found that the force supplied by a Semmes Weinstein 5.07 was equal to 10 grams. Clinically, I find diminution of sensation when the blood sugar is greater than 140, except in long standing diabetics, where the sensation can be diminished with lower blood sugars.
Other tests that are important are the Achilles reflex, which is diminished with a neuropathy, and the Abadie’s sign (which is the insensitivity to pain over the Achilles tendon).
We were taught to test light touch (the anterior spinal thalamic tract) in general, but not specifically in neuropathy.
Pain and temperature are mediated through the lateral spinal thalamic tracts. A sharp needle (usually found in the reflex hammer) was used to test it.

Regards,
Stanley