PERFORMANCE OF TWO DIFFERENT CLINICAL SCORING SYSTEMS IN DIAGNOSING DISTAL SENSORY POLYNEUROPATHY IN PATIENTS WITH TYPE-2 DIABETES
AbstractBackground: Early diagnosis of distal peripheral neuropathy (DSPN) the commonest diabetes complications, helps prevent significant morbidity. Clinical parameters are useful for detection, but subjectivity and lack of operator proficiency often results in inaccuracies. Comparative diagnostic accuracy of Diabetic Neuropathy Symptom (DNS) score and Diabetic Neuropathy Examination (DNE) score in detecting DSPN confirmed by nerve conduction studies (NCS) has not been evaluated. This study compares the performance of these scores in predicting the presence of electro physiologically proven DSPN. The objective of this study was to compare the diagnostic accuracy of DNS and DNE scores in detecting NCS proven DSPN in type-2 diabetics, and to determine the frequency of sub-clinical DSPN among type-2 diabetics. Methods: In this cross-sectional study the DNS score and DNE score were determined in 110 diagnosed type-2 diabetic patients. NCS were carried out and amplitudes, velocities and latencies of sensory and motor nerves in lower limb were recorded. Results: Comparison between the two clinical diagnostic modalities and NCS using Pearson's chi square test showed a significant association between NCS and DNE scores (p-value =.003, specificity 93%). The DNS score performed poorly in comparison (p-value=.068, specificity 77%). When the two scores were taken in combination the specificity in diagnosing DSPN was greater (p-value=.018, specificity 96%) than either alone. 33% of patients had subclinical neuropathy. Conclusion: DNE score alone and in combination with DNS score is reliable in predicting DSPN and is more specific than DNS score in evaluating DSPN. Both tests lack sensitivity. Patients without any evidence of clinical neuropathy manifest abnormalities on NCS.Keywords: diabetic neuropathy; nerve conduction studies; clinical scoring systems
Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, et al The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology 1993;43:817–24.
Tesfaye S1, Boulton AJ, Dyck PJ, Freeman R, Horowitz M, Kempler P, et al. Diabetic neuropathies: update on definitions, diagnostic criteria and estimation of severity (The Toronto Expert Group Meeting 2009). Diabetes Care 2010;33(10):2285–93.
Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Trends in lower extremity amputations in people with and without diabetes in England. 1996-2005. Diabetes Res Clin Pract 2010;87(2):275–82.
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217–28.
Llewelyn JG, Tomlinson DR, Thomas PK. Diabetic Neuropathies. In: Dyck PJ, Thomas, PK, editors. Peripheral Neuropathy. Fourth Edition. Philadelphia: Elsevier;2005:1951–92.
Dyck PJ. Detection characterization, and staging of polyneuropathy assessed in diabetics. Muscle Nerve 1988;11:21–32.
Dyck PJ. Severity and staging of diabetic polyneuropathy. In: Gries FA, Cameron NE, Low PA, Ziegler D, editors. Textbook of Diabetic Neuropathy.Stuttgart: Thieme 2003;170–5.
Dyck PJ1, Overland CJ, Low PA, Litchy WJ, Davies JL, Dyck PJ, et al. Signs and symptoms versus nerve conduction studies to diagnose diabetic sensorimotor polyneuropathy: Cl vs. NPhys trial. Muscle Nerve 2011;42:157–64.
Dyck PJ, Norell JE, Tritschler H, Schuette K, Samigullin R, Ziegler D. Challenges in design of multicenter trials: end points assessed longitudinally for change and monotonicity. Diabetes Care 2007;30:2619–25.
Boulton AJM, Malik RA, Arezzo JC, Sosensko JM1.DiabeticSomatic neuropathies. Technical Review. Diabetes Care 2004;27(6):1458–78.
Mendell JR, Sahenk Z: Painful sensory neuropathy. N Engl J Med 2003;248:1243–55.
Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, et al. North-West Diabetes Foot Care Study: The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–84.
Meijer JWG, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP. Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score. Diabet Med 2002;19:962–5.
Meijer JW1, van Sonderen E, Blaauwwiekel EE, Smit AJ, Groothoff JW, Eisma WH et al. Diabetic Neuropathy Examination: a hierarchical scoring system to diagnose distal polyneuropathy in diabetes. Diabetes Care 2000;23:750–3.
Meijer JW, Bosma E, Lefrandt JD, Links TP, Smit AJ, Stewart RE, et al. Clinical diagnosis of diabetic polyneuropathy with the diabetic neuropathy symptom and diabetic neuropathy examination scores. Diabetes Care 2003;26:697–701.
Bril V: Electrophysiologic testing. In Textbook of Diabetic Neuropathy. Gries FA, Cameron NE, Low PA, Ziegler D, Eds. Stuttgart, Thieme, 2003;177–84.
Dyck PJ, Carter RE, Litchy WJ. Modeling nerve conduction criteria for diagnosis of diabetic polyneuropathy. Muscle Nerve 2011;44(3):340–5.
Liu MS, Hu BL, Cui LY, Tang XF, Du H, Li BH. Clinical and neuro physiological features of 700 patients with diabetic peripheral neuropathy. Zhonghua Nei Ke Za Zhi 2005;44:173–6.
Rota E, Quadri R, Fanti E, Poglio F, Paolasso I, Ciaramitaro P et al. Clinical and electrophysiological correlations in type-2 diabetes mellitus at diagnosis. Diabetes Res Clin Pract 2007;76:152–4.
David C.Preston, Barbara Shapiro Comte. Electromyography and Neuromuscular Disorders: Clinical-Electrophysiologic Correlations. 3rd edition. London: Elsevier; 2012.
Dyck PJ, Albers JW, Andersen H, Arezzo JC, Biessels GJ, Bril V et al. Diabetic polyneuropathies: update on research definition, diagnostic criteria and estimation of severity. Diabetes Metab Res Rev 2011;27:620–8.
Yasuda H, Sanada M, Kitada K, Terashima T, Kim H, Sakaue Y et al. Rationale and usefulness of newly devised abbreviated diagnostic criteria and staging for diabetic polyneuropathy. Diabetes Research and Clinical Practice 2007;77:178–83.
Viswanathan V, Thomas N, Tandon N, Asirvatham A, Rajasekar S, Ramachandran A, et al. Profile of diabetic foot complications and its associated complications–a multicentric study from India. J Assoc Physicians India 2005;53:933–6.
Mythili A, Kumar KD, Subrahmanyam KA, Venkateswarlu K, Butchi RG. A Comparative study of examination scores and quantitative sensory testing in diagnosis of diabetic polyneuropathy. Int J Diabetes Dev Ctries 2010;30(1):43–48.
Bril V, Tomika S, Buchnan RA, Perkins BA. Reliability and validity of the modified Toronto Clinical Neuropathy Score in diabetic sensorimotor polyneuropathy. Diabet Med 2009;26(3):240–6.
Apfel SC, Asbury AK, Bril V, Burns TM, Campbell JN, Chalk CH et al. Ad Hoc Panel on Endpoints for Diabetic Neuropathy Trials. Positive neuropathic sensory symptoms as endpoints in diabetic neuropathy trials. J Neurol Sci 2001;189:3–5.
Franse LV, Valk GD, Dekker JH, Heine RJ, van Eijk JTM. Numbness of the feet is a poor indicator for polyneuropathy in type-2 diabetic patients. Diabet Med 2000;17:105–10.
Jayaprakash P, Bhansali A, Bhansali S, Dutta P, Anantharaman R, Shanmugasundar G et al. Validation of bed side methods in evaluation of diabetic peripheral Neuropathy. Indian J Med Res 2011;133(6):645–9.
Asad A, Hameed MA, Khan UA, Butt MA, Ahmed N, Nadeem A. Comparison of nerve conduction studies with diabetic neuropathy symptom score and diabetic neuropathy examination score in type-2 diabetics for detection of sensory motor polyneuropathy. JPMA 2009;59:594.
Perkins BA, Bril V. Diabetic neuropathy: A review emphasizing diagnostic methods. Clin Neurophysiol 2003;114:1167–75.
Franssen H, van den Bergh PY. Nerve conduction studies in polyneuropathy: practical physiology and patterns of abnormality. Acta Neurol Belg 2006;106:73–81.