Neuro Sensory Assessment

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Neuro-SensoryAssessment

For Patients with DiabetesPrecious Santayana


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Nerves are the pathways for messages to be sentto and from the brain about pain, temperature

and touch. Nerves carry messages to yourmuscles telling them how and when to move.Diabetes is one of the main causes of nervedamage, called diabetic peripheral neuropathy.

!his can cause burning, tingling, pain, numbnessand"or wea#ness in your feet and legs leading toinstability when standing or wal#ing. Nearly $%&of people with diabetes have some degree of

nerve damage. Diabetic peripheral neuropathycan progress slowly and it can ta#e many yearsuntil it becomes debilitating. If diagnosed early,its eects can be minimized


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!he following is a list of common symptoms associated withdiabetic peripheral neuropathy'

(y feet tingle. ) feel *pins and needles+ in my feet.

) have burning, stabbing or shooting pain in my feet.

(y feet are very sensitive to touch.

(y feet and legs hurt at night.

(y feet get very cold or very hot.

(y feet are numb and feel dead.

) dont feel pain when ) get a blister or another inury to my foot.

) cant feel my feet when )m wal#ing.

!he muscles in my feet and legs are wea#.

) am unsteady when ) stand or wal#.

) have trouble feeling heat or cold in my feet.

) have open sores on my feet or legs that heal very slowly.

)t seems li#e my feet have changed shape.


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Signs and symptoms

)n type D(, distal polyneuropathy typically becomes

symptomatic after many years of chronic prolongedhyperglycemia, whereas in type /, it may be apparentafter only a few years of #nown poor glycemic controlor even at diagnosis. Symptoms include the following'

Sensory 0 Negative or positive, di1use or focal2usually insidious in onset and showing a stoc#ing-and-glove distribution in the distal e3tremities

(otor 0 Distal, pro3imal, or more focal wea#ness,sometimes occurring along with sensory neuropathy4sensorimotor neuropathy5

Autonomic 0 Neuropathy that may involve thecardiovascular, gastrointestinal, and genitourinarysystems and the sweat glands


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Clinical Screening for SensoryNeuropathy

Screening techni6ues are used todetect early signs of sensoryneuropathy. !his recognition is

essential to prevent foot ulceration inpatients with diabetes.

!he Semmes-7einstein

mono8lament test is considered thegold standard for identifying loss ofprotective sensation in the feet of

patients with DPN.


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9nce a patient has developed a footulceration and presents to the o:cewithout obvious signs of discomfort,

there is no reason to continue usingthe S7( test.

Sensation of the foot may be

interpreted on a spectrum fromdiminished to absent.


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Clinical Screening for Sensory Neuropathy


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9ther Screening !ools


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Semmes-7einstein (ono8laments

provide a non-invasive evaluation ofcutaneous sensation levels throughout thebody with results that are obective and

repeatable. indicated in diagnoses including nerve

compression syndromes, peripheralneuropathy, thermal inuries and

postoperative nerve repair. each is individually calibrated to deliver its

targeted force within a $& standard deviation.


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. ;est the patients e3tremity on a stable, paddedsurface. !esting should be done in a 6uiet area tohelp the patient fully attend to the testingprocedure. 9cclude the patients vision by using ashield or by having the patient loo# away.

/. )f callus is resent at an of the sites then test at


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?. )t is not necessary to test every area of thes#in when performing an evaluation. @hec#smay be done over areas innervated by

di1erent nerves. For the hand, test thepalmar surface of the inde3 8nger and thumbto evaluate median nerve function2 test the

little 8nger and hypothenar eminence to

evaluate the ulnar nerve2 and test the dorsumof the hand to evaluate the radial nerve 4seeFigure 5. For the foot, test the sites indicatedin Figure /.


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$. Press the 8lamentat a %B angle againstthe s#in until it bows.

Cold in place for .$seconds and thenremove 4see Figure

=5. A single responseindicates a positiveresponse.


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. )f the patient responds to the stimulus in all sites,normal cutaneous sensation can be documentedand the e3amination is complete. )f the patientdoes not respond to the stimulus, choose the ne3tlargest mono8lament and repeat the process.

E. 7hen the patient indicates a response, recordthe result using the colored pencil that correspondsto the color on the handle. 7hen representing

mono8laments of the same color, notate whichmono8lament sie was used 4see Figure ?5.

!hreshold levels indicated in Figure $ can be usedto interpret test results.


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/G-C !uning For#!est bony prominences

Ape3 st

st (PH

(edial malleolus

I!wang the tuning for# lightly and apply the Jat, circular surface toa bony sensitive area 4e.g. the elbow5

As# the patient to describe the sensation they can feel 4you need tobe sure the patient can feel Ibuing"humming and not ust pressureor cold5

;epeat on the foot, testing the ape3 of the st 8rst.

As# the patient what they can feel. ;ecord a positive response if

they feel the same sensation that they felt at the elbow. 4)f thepatient can only feel cold or pressure this is a negative response5

)f the patient does not feel vibration at the ape3 st, movepro3imally up the limb to the ne3t test site, the st (PH followed bythe medial malleolus.


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KP! !esting

Kibration perception threshold testing4KP!5 is performed using a handhelddevice 4Lio-!hesiometer, Lio-medical)nstrument @ompany, Newbury, 9C5

!he clinical techni6ue employed issimilar to the tuning for#, where theprobe is placed at the distal hallu3.

!he amplitude on the device is adusteduntil the patient can distinctly sense avibratory stimulus.


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;eJe3 !esting!o screen for sensory neuropathyprimarily focuses on e3amining thean#le reJe3.

!he clinician aligns the an#le into aneutral position and stri#es the Achillestendon with a neurological hammer.

An abnormal result is demonstrated bycomplete absence of an#leplantarJe3ion.

@ompared to other lower e3tremityreJe3es, the an#le reJe3 is the mostsensitive for detecting early signs of

neuropathy.


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;eJe3 !esting


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;eJe3 !esting

A normal refex will cause the oot to

plantar fex (i.e. move into your


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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;eJe3 !esting


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Pin Pric# !esting

involves the super8cialapplication of a sterile safety pinat the forefoot with enoughmanual pressure to slightly

deform the s#in. Abnormal 8ndings are concluded

if a patient cannot detect thesharp stimulus.

9ne of the primary indicationsfor this testing modality is tolocate a focal area of sensoryloss.


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PSSD

Pressure Speci8ed Sensory Device 4PSSDM5

most accurate way of testing the lowere3tremity for sensoryde8cits.

!his computer-based device is able to quantifyand recordboth speci8c peripheral nervethreshold levelsand peripheral nerveinnervation density4which reJects a3onaldegeneration5.

As a result, the PSSDM is able to identifypathologic changes in nerves at subclinicallevels and it is pain free.
http://www.thefootanklecenter.com/pressure-specified-sensory-device-pssd.htmlhttp://www.thefootanklecenter.com/pressure-specified-sensory-device-pssd.html


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)pswich !ouch !est

A.#.a. Touch the toestest

!he test simplyinvolves very lightly

touching si3 toes,three on each foot asshown to 8nd out howmany of the touches

are felt. )mportantlythe touch must begentle, light as afeather and brief.


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)pswich !ouch !est


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)pswich !ouch !est

!he touch must be lightas a feather, and brief 40/ seconds5' do not press,prod or po#e tap

or stro#e the s#in. )f the person did notrespond do not attemptto get a reaction bypressing harder. !hey didnot feel2 this should berecorded as not felt.

Oou must not toucheach toe more than once.

)f not felt do not repeat


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)pswich !ouch !est

sing the inde3 8nger,touch the tips of toesfollowing the se6uence-------------------

)f the subect correctlysays right or left, circleIO on the diagramright.

)f not felt this must berecorded by circling INon the diagram right.

!here is no secondchance.


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)pswich !ouch !est

. ;emove soc#s and shoes and rest the subect with their feetlaying on a sofa or bed.

/. ;emind them which is their ;)QC! and R


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)pswich !ouch !est

. !he pictures also show which si3 toes should betouched and the se6uence.

E. So, start by lightly touching the tip of the toemar#ed 4right big toe5 with the tip of your inde3

8nger. !he patient will respond by saying right ifthey feel the touch.

G. ;ecord the result by circling IO on the attachedrecord sheet. )f they did not respond, circle IN.

. Now move to the toe mar#ed /, the right littletoe, record the result, followed by the toe mar#ed =,the left big toe etc.

%. @ontinue until all the si3 toes has been chec#ed.


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)pswich !ouch !est

N9;(AR S


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)pswich !ouch !est

)(PA);

Neuro Sensory Assessment

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