Acta Medica Iranica 2014. 52(7):519-527.

Rapid screening of diabetic polyneuropathy: selection of accurate symptoms and signs in an outpatient clinical setting.
Laily Najafi, Mohammad E Khamseh, Mojtaba Malek, Hamid R Baradaran, Seyed Mojtaba Aghili, Maryam Kia, Rokhsareh Aghili


Clinical assessment of distal symmetric polyneuropathy (DPN) involves the evaluation of symptoms and signs. Although there are numerous tools to evaluate DPN, there is still a need to determine the most sensitive, specific, and accurate tests to detect DPN in a busy outpatient clinical setting. A total of 107 patients with type 2 diabetes were examined using Michigan Neuropathy Screening Instrument (MNSI). Total score of the instrument was used as a standard to calculate sensitivity, specificity and diagnostic accuracy of every single item of MNSI to find the most accurate and applicable test for evaluation of DPN. In patients' history, the most sensitive (99.4%) and accurate (78%) symptoms were muscle cramp and weakness. Numbness and prickling had lower sensitivity (72.6% and 67.9%, respectively) but greater specificity (65.2% and 47.8%). In physical assessment, the most accurate signs were appearance of feet (81.3%), ankle reflexes (67.2%), and vibration perception (63.5%). Monofilament test had a sensitivity of 16.7%, accuracy of 31.7% with specificity of 87%. Findings show that symptoms such as a muscle cramp, weakness, numbness, and prickling, as well as signs such as ankle reflexes, appearance of feet, and vibration could be used as the most accurate tests for rapid diagnosis of DPN. In addition, the results suggest that monofilament examination may not be the optimum test to detect high risk patients.


Diabetic neuropathy; MNSI; Symptoms; Signs

Full Text:



Vinik AI, Mehrabyan A. Diabetic neuropathies. Med Clin North Am 2004;88(4):947-99.

Kumar SP, Adhikari P, Jeganathan PS, et al. Physiotherapy management of painful diabetic peripheral neuropathy: A current concepts review of treatment methods for clinical decision-making in practice and research. Int J Curr Res Rev 2010;9(2):29-39.

Carrington AL, Shaw JE, Van Schie CH, et al. Can motor nerve conduction velocity predict foot problems in diabetic subjects over a 6-year outcome period? Diabetes Care 2002;25(11):2010-5.

Boulton AJ, Gries FA, Jervell JA. Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabet Med 1998;15(6):508-14.

Dyck PJ, Davies JL, Litchy WJ, et al. Longitudinal assessment of diabetic polyneuropathy using a composite score in the Rochester Diabetic Neuropathy Study cohort. Neurology 1997;49(1):229-39.

Kimura J. Principles and pitfalls of nerve conduction studies. Ann Neurol 1984;16(4):415-29.

Simpson JA. Fact and Fallacy in Measurement of Conduction Velocity in Motor Nerves. J Neurol Neurosurg Psychiat 1964;27(5):381-5.

Perkins BA, Bril V. Diabetic neuropathy: a review emphasizing diagnostic methods. Clin Neurophysiol 2003;114(7):1167-75.

Khamseh ME, Vatankhah N, Baradaran HR. Knowledge and practice of foot care in Iranian people with type 2 diabetes. Int Wound J 2007;4(4):298-302.

Asad A, Hameed MA, Khan UA, et al. Reliability of the neurological scores for assessment of sensorimotor neuropathy in type 2 diabetics. J Pak Med Assoc 2010;60(3):166-70.

Vatankhah N, Noudeh YJ, Khamseh ME, et al. Screening people with type 2 diabetes at risk for foot ulceration in Iran. Diabetes Technol Ther 2010;12(9):731-6.

Boyraz O, Saracoglu M. The effect of obesity on the assessment of diabetic peripheral neuropathy: a comparison of Michigan patient version test and Michigan physical assessment. Diabetes Res Clin Pract 2010;90(3):256-60.

Michigan Diabetes Research and Training Center. University of Michigan Health System. (Accessed in Jan 14, 2014, at

Muscle Cramps. Better Medicine from healthgrades. (Accessed in Feb 14, 2014, at

Kuwabara S, Misawa S. Pharmacologic intervention in axonal excitability: in vivo assessment of nodal persistent sodium currents in human neuropathies. Curr Mol Pharmacol 2008;1(1):61-7.

Andreassen CS, Jakobsen J, Flyvbjerg A, et al. Expression of neurotrophic factors in diabetic muscle--relation to neuropathy and muscle strength. Brain 2009;132(Pt 10):2724-33.

Andersen H, Gadeberg PC, Brock B, et al. Muscular atrophy in diabetic neuropathy :a stereological magnetic resonance imaging study. Diabetologia 1997;40(9):1062-9.

Baker D, Evans M, Cryer P, et al. Hypoglycaemia and glucose sensing. Diabetologia 1997;40(Suppl 3):B83-8.

Gutierrez EM, Helber MD, Dealva D, et al. Mild diabetic neuropathy affects ankle motor function. Clin Biomech (Bristol, Avon) 2001;16(6):522-8.

Andersen H, Poulsen PL, Mogensen CE, et al. Isokinetic muscle strength in long-term IDDM patients in relation to diabetic complications. Diabetes 1996;45(4):440-5.

Salsich GB, Brown M, Mueller MJ. Relationships between plantar flexor muscle stiffness, strength, and range of motion in subjects with diabetes-peripheral neuropathy compared to age-matched controls. J Orthop Sports Phys Ther 2000;30(8):473-83.

Andreassen CS, Jakobsen J, Andersen H. Muscle weakness: a progressive late complication in diabetic distal symmetric polyneuropathy. Diabetes 2006;55(3):806-12.

Dyck PJ, Davies JL, Wilson DM, et al. Risk factors for severity of diabetic polyneuropathy: intensive longitudinal assessment of the Rochester Diabetic Neuropathy Study cohort. Diabetes Care 1999;22(9):1479-86.

Franse LV, Valk GD, Dekker JH, et al. Numbness of the feet' is a poor indicator for polyneuropathy in Type 2 diabetic patients. Diabet Med 2000;17(2):105-10.

Sacco Ide C, Joao SM, Alignani D, et al. Implementing a clinical assessment protocol for sensory and skeletal function in diabetic neuropathy patients at a university hospital in Brazil. Sao Paulo Med J 2005;123(5):229-33.

Aminoff MJ, Asbury AK. Numbness, Tingling and Sensory loss. In: Longo DL, Kasper DL, Jameson JL, et al, editors. Harrison's Principles of Internal Medicine. 8th ed. New York: Mc Graw Hill; 2012: p. .

Tres GS, Lisboa HR, Syllos R, et al. Prevalence and characteristics of diabetic polyneuropathy in Passo Fundo, South of Brazil. Arq Bras Endocrinol Metabol 2007;51:987-92.

Shehab DK, Al-Jarallah KF, Abraham M, et al. Back to basics: ankle reflex in the evaluation of peripheral neuropathy in type 2 diabetes mellitus. QJM 2012;105(4):315-20.

Meijer JW, van Sonderen E, Blaauwwiekel EE, et al. Diabetic neuropathy examination: a hierarchical scoring system to diagnose distal polyneuropathy in diabetes. abetes Care 2000;23(6):750-3.

Bowditch MG, Sanderson P, Livesey JP. The significance of an absent ankle reflex. J Bone Joint Surg Br 1996;78(2):276-9.

Grewal G, Sayeed R, Yeschek S, et al. Virtualizing the assessment: a novel pragmatic paradigm to evaluate lower extremity joint perception in diabetes. Gerontology 2012;58(5):463-71.

Powers AC. Diabetes Mellitus. In: Longo DL, Kasper DL, Jameson JL, et al, editors. Harrison's Principles of Internal Medicine. 18th ed. New York: Mc Graw Hill; 2012: p. 2968-3002.

Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008;299(7):806-13.

Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293(2):217-28.

Perkins BA, Olaleye D, Zinman B, et al. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care 2001;24(2):250-6.

Jayaprakash P, Bhansali A, Bhansali S, et al. Validation of bedside methods in evaluation of diabetic peripheral neuropathy. Indian J Med Res 2011;133(6):645-9.

Elliott J, Tesfaye S, Chaturvedi N, et al. Large-fiber dysfunction in diabetic peripheral neuropathy is predicted by cardiovascular risk factors. Diabetes Care 2009;32(10):1896-900.

Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005;28(4):956-62.

Malik RA, Tesfaye S, Newrick PG, et al. Sural nerve pathology in diabetic patients with minimal but progressive neuropathy. Diabetologia 2005;48(3):578-85.

Gelber DA, Pfeifer MA, Broadstone VL, et al. Components of variance for vibratory and thermal threshold testing in normal and diabetic subjects. J Diabetes Complications 1995;9(3):170-6.

Bril V, Kojic J, Ngo M, et al. Comparison of a neurothesiometer and vibration in measuring vibration perception thresholds and relationship to nerve conduction studies. Diabetes Care 1997;20:1360-2.

Chong PS, Cros DP. Technology literature review: quantitative sensory testing. Muscle Nerve 2004;29(5):734-47.

Armstrong DG. The 10-g monofilament: the diagnostic divining rod for the diabetic foot? Diabetes Care 2000;23(7):887.

Armstrong DG, Lavery LA, Vela SA, et al. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med 1998;158(3):289-92.

de Sonnaville JJ, Colly LP, Wijkel D, et al. The prevalence and determinants of foot ulceration in type II diabetic patients in a primary health care setting. Diabetes Res Clin= Pract 1997;35(2-3):149-56.

Shin JB, Seong YJ, Lee HJ, et al. Foot screening technique in a diabetic population. J Korean Med Sci 2000;15(1):78-82.

Lee S, Kim H, Choi S, et al. Clinical usefulness of the twosite Semmes-Weinstein monofilament test for detecting diabetic peripheral neuropathy. J Korean Med Sci 2003;18(1):103-7.

Kanji JN, Anglin RE, Hunt DL, et al. Does this patient with diabetes have large-fiber peripheral neuropathy? JAMA 2010;303(15):1526-32.

Dros J, Wewerinke A, Bindels PJ, et al. Accuracy of monofilament testing to diagnose peripheral neuropathy: a systematic review. Ann Fam Med 2009;7(6):555-8.

Miranda-Palma B, Sosenko JM, Bowker JH, et al. A comparison of the monofilament with other testing modalities for foot ulcer susceptibility. Diabetes Res Clin Pract 2005;70(1):8-12.

Feng Y, Schlosser FJ, Sumpio BE. The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. J Vasc Surg 2009;50(3):675-82.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.