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Quantitative assessment of diabetic peripheral neuropathy with use of the clanging tuning fork test. Endocr Pract. 2007 Jan-Feb;13(1):5-10
Oyer DS, Saxon D, Shah A
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Objective: To describe the clanging tuning fork (CTF) test, a novel method for using the C 128-Hz tuning fork to test for diabetic peripheral neuropathy (DPN), to evaluate the accuracy and reproducibility of this technique, and to compare it with the 5.07 (10 g) Semmes-Weinstein monofilament test.
Methods: To determine the mean and standard deviation for the CTF test, repeated measurements were taken on one toe of 12 patients with diabetes during one visit. After these tests, 30 randomly selected patients were tested on both feet, with right and left scores compared for reproducibility of the results. The scores of the CTF test were compared with the monofilament scores in 45 patients with diabetes. Presence of foot ulcers in 81 patients was correlated with both test scores.
Results: The mean duration of vibration sensation was 10.2 seconds, with a standard deviation of +/-1.3 seconds. The Pearson correlation coefficient comparing the right and the left foot scores for the same patient was 0.947 (P<0.05). Among patients with 8 seconds or less of vibration perception, results of monofilament testing were abnormal only in those whose vibration perception was less than or equal to 4 seconds. Of 32 patients with vibration perception of 4 seconds or less, 50% had normal monofilament test scores, including 29% of 17 patients with absent vibratory sensation.
Conclusion: The CTF test is reproducible and accurate. It provides a quantitative assessment of DPN and can document severe neuropathy, even in the presence of a normal result with the 10-g monofilament test. The risk of foot ulcers, which is associated with diminished vibratory sensation, can therefore be detected earlier and more accurately with the CTF test. The CTF test should replace the 10-g monofilament test as the recommended technique for detection of DPN.
This test has been around for years and years. I was taught this teat when i trained 20years ago. Docs both GPs and Consultants working in diabetes use this test. Thats why they have tuning forks in the clinics !
A quantitive test is to use a neurothesiometer which gives definitive results and can be repeated over time to give a result showing changes in the devlopment of neuropathy.
There is loads of research to show vibration testing.
Monofilaments are cheaper than tuning forks and give evidence based results.
This test has been around for years and years. I was taught this teat when i trained 20years ago. Docs both GPs and Consultants working in diabetes use this test. Thats why they have tuning forks in the clinics !
A quantitive test is to use a neurothesiometer which gives definitive results and can be repeated over time to give a result showing changes in the devlopment of neuropathy.
There is loads of research to show vibration testing.
Monofilaments are cheaper than tuning forks and give evidence based results.
The point of the research was not that a tuning fork test is new or novel - as everyone knows, but to provide a quantitative framework for its use in the clinical environment. As opposed to the subjective nature of using tuning forks to test vibration sense historically.
As such I think it is an important practical piece of work, utilising an instrument which is massively cheaper than a neurothesiometer. Of great importance in places like India and the Pacific Islands, where diabetes is massive, but resources are minsicule.
Must admit, I've never heard of it being described as a 'clanging' tuning fork test - I may be ignorant. A while back I had the opportunity to trial a Rydel-Seiffer tuning fork. Whilst rather cumbersome/awkward to use initially, it proved to be a useful instrument to provide quantative results. Fortunately, I now regularly have access to a neurothesiometer which makes life somewhat easier. Russ.
properly validated monfilaments are significantly cheapert than a tuning fork also.
They do not give exactly the same quanititive results, but can be an excellent test for the presence/abscence of neuropathy as a test. They ahve taken over from tuning forks as the main means of testing in the community in the UK for neuropathy, and have very good research evidence that they are predictive.
I have the advantage to use the neurothesiometer in our diabetic footclinic but all of the tests (tuning fork, monofilament, VPT) only stands with good patiënt education. We have a multicultural(lingual) patient population, and i wonder if they always completely understand what they have to do and how/when to react.
__________________
Ken Van Alsenoy
Artevelde hogeschool
dept. Podiatry
Ghent - Belgium
Hi - read your article with interest, I wonder if you can help me -I am trying to find out who found out that a 128HZ tuning fork could be used to detect neuropathy in daibetic feet - and also : how does it so it? My research has been pathetically unsuccessful so far. I know that the TF ossiclates at 128 cycles per second but can't locate any information to find out why this is significant in realtion to the nerve fibres. Can you help or direct me? Also now need to work out what CTF technique is!!
Currently there's no scientific or economic reason to replace monofilament testing with the tuning fork.
The study cited is interesting, will stimulate debate, but involved very low numbers of patients. More research would need to be done before I'd think about changing current practice.
Using a monofilament is effective at predictiing risk of ulceration (SIGN 2001, NICE 2004, IDF 2005) practical, easy and inexpensive - which is exactly what foot screening needs to be to ensure that it gets done for every person with diabetes.
I am trying to find out who found out that a 128HZ tuning fork could be used to detect neuropathy in daibetic feet - and also : how does it so it?
My understanding is that one of the early effects of DM Neuropathy is the demylination of the nerves. You remember the string of sausages thing where the nerve signal jumps beween "twists" to accelerate conduction? Without that mechanism the nerve impulses travel slower. The 128 mHz vibration identifies whether the conduction speed is sufficient to identify discrete signals per oscilation. So far as i know the 128 mHz is simply an arbitary threshold level.
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Through my observations I usually find patients loose their vibration sensation long before they cannot detect the monofilament
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Sensory neuropathy being a different thing affecting different nerve types.
I am deeply suspicious of testing for neuropathy having seen more than one neuropathic ulcer in patients who could still sense a monofilament!
I remember when i was at uni one of my friends was asked to do a tuning fork test in an osce. Unfortunatly they had missed that lecture and had no idea what to do with it. They therefore used said fork to whack the patients knee for a reflex. How we laughed! Good job it was'nt a neurothesiometer. Heaven knows where that would have ended up!
With hindsight it is terrifying that we were every released onto the public!
Yes - I too have had the very rare cases where people with diabetes and sensitivity to the 10g monofilament have developed foot ulcers.
I recommend the monofilament as part of screening for risk of ulceration. Can't currently see the need for anything else however the computerised national diabetes foot screening tool in Scotland allows for collection of data relating to vibration sense and to sharp blunt perception. But that's not mandatory - just useful data to have because some diabetes specialist podiatrists in Scotland (including myself) want to be able to see if there are patients who developed a foot ulcer, had a raised neurosthesiometer reading and/or failed the neurotip test (loss of 'sharp' perception) but passed the monofilament test.
A fuller assessment could involve monofilaments, neurothesiometer, ankle jerks, proprioception testing, sharp blunt discrimination, hot/cold perception and more or I might send the patient for nerve conduction tests.
But there's a difference between screening and assessment. If screening can be done effectively with inexpensive equipment then it is more likely to get done.
In studies the 10g monofilament (NICE 2004, SIGN 2001) has been shown to be as good atscreening for the risk of diabetic foot ulceration as the Neuropathy Disability Score (Young et al, 1993; Abbott et al, 2002) which uses a Neurotip, tuning fork, hot and cold rods and a tendon hammer.
Clanging tuning fork test
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