Assessment of sensory neuropathy in patients with diabetic foot problems

Validity and Reliability of a Vibration-Based Cell Phone in Detecting Peripheral Neuropathy among Patients with a Risk of Diabetic Foot Ulcer

The aim of this study was to determine the validity and reliability of a vibration-based cell phone in detecting peripheral neuropathy among individuals with a risk of diabetic foot ulcer (DFU). The current study consisted of 3 phases: a pilot study, concurrent validity study, and interreliability study. A 128 Hz tuning fork and vibration-based cell phone using the Vibrations-Test app was compared in the primary care setting. The pilot study confirmed that the vibration-based cell phone has an adequate reliability (r > 0.70, P < .001). The concurrent validity test involved 96 participants (aged 55.78 ± 8.32 years). The Pearson correlation test found the highest correlation in the fifth metatarsal heads (r = 0.741, right feet; 0.772, left feet; P < .001). In the 4 primary care settings, the interrater reliability between nurses of the vibration-based cell phone were k = 1.000, 1.000, 1.000, and 0.720. The concurrent validity test found moderate to strong correlation results and that the interrater reliability had a strong agreement that was almost perfect. Thus, vibration-based cell phone applications can be used as screening tools for detecting neuropathy among individuals with a risk of DFU.

Relationship between Cognitive Impairment and Depressive Symptoms with Somatosensory Functions in Diabetic and Non-Diabetic Older Adults and Its Impact on Quality of Life

Aging is an inevitable process that impacts the peripheral and central nervous systems and is considered one of the strongest risk factors for neurodegenerative diseases. In addition, when it also presents with diabetes mellitus, the risk of neurological damage may be further increased. This current study aimed to explore the relationships between peripheral sensory system decline and cognitive functions, the symptoms of depression, and quality of life (QoL) as metrics of central nervous system impairment in institutionalized older adults. A total of 95 individuals participated in this case-control study, which included diabetics and non-diabetics. The superficial sensory pathway was assessed in terms of thermal sensation, nociception, and non-discriminative touch, and the deep sensory pathway was evaluated by assessing vibration and light touch-pressure sensations. To assess function at the intellectual level, the Mini-Mental State Examination (MMSE) and Trail Making Test (TMT) cognitive functional tests were used, while the symptoms of depression and QoL were explored by employing the Yesavage Geriatric Depression Scale and EuroQol 5D questionnaire (EQ-5D), respectively. In the overall population analyses, altered thermal sensation was significantly associated with cognitive impairment (CI; p < 0.05). In turn, bivariate analyses and a binary logistic regression showed that the symptoms of depression and QoL were significantly related to altered vibratory sensation when assessed using a medical tuning fork (p < 0.05). In the group of diabetic patients, those with CI also had significantly lower thermal sensation (p < 0.05) and non-discriminative touch sensation, although this was only a trend (p = 0.055). Diabetics with depression had a significantly worse non-discriminative touch (p < 0.05) and vibratory sensation when tested with a tuning fork (p < 0.05). In addition, poorer QoL was associated with reduced sensitivity to heat (p < 0.05), light touch pressure (p < 0.05), and vibrations when assessed either with a tuning fork (p < 0.05) or a biothesiometer (p < 0.05). In contrast, no relationships were found between sensory functions and cognitive assessments in non-diabetic patients. These findings indicate that superficial sensitivity damage was related to CI, while deep sensation alterations were related to depression and poor QoL, with diabetes apparently further strengthening these relationships.

Plantar threshold sensitivity assessment using an automated tool-Clinical assessment comparison between a control population without type 2 diabetes mellitus, and populations with type 2 diabetes mellitus, with and without neuropathy symptoms

Diabetic peripheral neuropathy is often classified as a loss of sensation in the extremities, particularly in elderly populations. The most common diagnosis technique is with the use of the hand-applied Semmes-Weinstein monofilament. This study's first aim was to quantify and compare sensation on the plantar surface in healthy and type 2 diabetes mellitus populations with the standard Semmes-Weinstein hand-applied methodology and a tool that automates this approach. The second was to evaluate correlations between sensation and the subjects' medical characteristics. Sensation was quantified by both tools, at thirteen locations per foot, in three populations: Group 1-control subjects without type 2 diabetes, Group 2-subjects with type 2 diabetes and with neuropathy symptoms, and Group 3-subjects with type 2 diabetes without neuropathy symptoms. The percentage of locations sensitive to the hand-applied monofilament, yet insensitive to the automated tool was calculated. Linear regression analyses between sensation and the subject's age, body mass index, ankle brachial index, and hyperglycemia metrics were performed per group. ANOVAs determined differences between populations. Approximately 22.5% of locations assessed were sensitive to the hand-applied monofilament, yet insensitive to the automated tool. Age and sensation were only significantly correlated in Group 1 (R2 = 0.3422, P = 0.004). Sensation was not significantly correlated with the other medical characteristics per group. Differences in sensation between the groups were not significant (P = 0.063). Caution is recommended when using hand-applied monofilaments. Group 1's sensation was correlated to age. The other medical characteristics failed to corelate with sensation, despite group.

Current perception threshold testing in chronic ankle instability

BACKGROUND

Damage to sensory input is an underlying pathology of chronic ankle instability (CAI). Therefore, it is necessary to evaluate the sensory function of patients with CAI. The present study quantitatively evaluated sensory nerve function in patients with CAI and healthy controls using current perception threshold (CPT) measurements, as well as the influence of sex, age, and body mass index (BMI) on CPT values and the relations between CPT frequencies.

METHODS

Fifty-nine subjects with CAI and 30 healthy controls participated in this study. CPT values at the anterior talofibular ligament region were recorded on the injured and uninjured sides in CAI patients and on both sides in the healthy control group. Between group differences were compared. The influence of sex, age and BMI on CPT values was evaluated. Correlations between different frequencies were also studied.

RESULTS

There were no significant differences in age, sex, height, weight or BMI between the CAI and healthy control groups. The CPT values did not show a significant difference by sex. The CPT values did not significantly correlate with age or BMI. Compared to the control group, the CAI group had significantly higher CPT values on the injured and uninjured sides under 250-Hz and 5-Hz electrical stimuli; the difference between the groups was significant (p < 0.01), and the effect size were large. No significant difference was observed under 2000-Hz stimuli. There were correlations between CPT values at different frequencies (p < 0.01), especially 250 Hz and 5 Hz.

CONCLUSION

The present study revealed increased sensory thresholds in 250-Hz- and 5-Hz-related sensory nerve fibres in the injured and uninjured ankles of patients with CAI. This increase may indicate dysfunction of A-delta and C fibres. Sex, age and BMI did not significantly impact CPT values. There were correlations between CPT values at different frequencies, especially 250 Hz and 5 Hz.

LEVEL OF EVIDENCE

Level III, case-control study.

The utility of Vibratip in accurate identification of loss of protective sensation in the contralateral foot of patients admitted with a diabetic foot ulcer

BACKGROUND AND AIMS

Diabetic foot ulcer (DFU) is a debilitating complication of type 2 DM. Complexity of foot examination often precludes proper clinical assessment of the foot during routine evaluation. We assessed the utility of novel device, vibratip, both singly and in combination with standard bedside tools for assessment of loss of protective sensation.

METHODS

75 patients admitted with DFU were included in the study. Clinical examination of the contralateral foot was done - temperature perception, vibration, pinprick sensation, Achilles tendon reflex and Neuropathy disability score were assessed. Testing using 10 g Monofilament, Vibratip and biothesiometer were also done. Considering the biothesiometer as the reference standard, three bedside tests (Vibratip, 10 g monofilament and 128 Hz tuning fork) were compared against it singly and in combinations.

RESULTS

When compared against biothesiometer, vibratip performed significantly well with a positive predictive value of 90.3% and specificity of 84.2%. Sensitivity, however, was only 50%. On combining bedside tests, the best combination strategy was seen with vibratip and 10 g monofilament, which improved the sensitivity to 62.5%. Combining all three bedside tests further improved sensitivity to 64.3%.

CONCLUSION

All the patients with an at-risk foot may not be identified with vibratip alone. Nevertheless, an abnormal result is almost always associated with loss of protective sensation, and such persons should be suitably educated.

LIMITATIONS

Due to small size of the study population, it is not possible to generalize the findings to all patients with diabetes mellitus. A larger study would be required to provide more confirmatory findings.

Association between Sleep Quality and Painless Diabetic Peripheral Neuropathy Assessed by Current Perception Threshold in Type 2 Diabetes Mellitus

BACKGROUND

It is known that the painful sensation of diabetic peripheral neuropathy (DPN) results in sleep problems in type 2 diabetes mellitus (T2DM). However, it is not known that the painless DPN also is associated with poor sleep quality in T2DM. The purpose of the current study was to investigate the association between painless DPN and poor sleep quality in T2DM.

METHODS

A total of 146 patients of T2DM who do not have any painful symptoms of DPN were recruited into the study. Among the patients, painless DPN was diagnosed by using the current perception threshold test. Sleep quality was assessed using the Pittsburgh Sleep Quality Index questionnaire.

RESULTS

The percentage of painless DPN was significantly higher in the poor sleep quality group than the good sleep quality group (70.0% vs. 35.5%, P<0.001). In the subscale results, stimulus values at 2,000 Hz, hypoesthesia and hyperesthesia were more common in the poor sleep quality group than in the good sleep quality group (45.7% vs. 25.0%, P=0.009; 34.3% vs. 18.4%, P=0.029; 40.0% vs. 19.7%, P=0.007, respectively). The association of painless DPN and poor sleep quality remained significant after adjustment for significant covariates (odds ratio, 3.825; 95% confidence interval, 1.674 to 8.742; P<0.001).

CONCLUSION

The current study showed that painless DPN was associated with poor sleep quality. Future studies are required to clarify the pathophysiologic causal relationship between painless DPN and sleep quality.

Comparison of Clinical Tests for Peripheral Diabetic Neuropathy in a Type 1 Diabetes Cohort

OBJECTIVE

To examine the performance and agreement of 5 modalities for testing sensory neuropathy against a neurothesiometer among Hispanic patients with type 1 diabetes (T1D) in an outpatient setting.

METHODS

A cross-sectional study was conducted at a tertiary reference center in Mexico City. Sensitivity, specificity, predictive values, and likelihood ratios were calculated using a VibraTip device, 128 Hz tuning fork, and the Semmes-Weinstein 5.07/10 g monofilament test, Ipswich touch test (IpTT), and pinprick test (PPT). The VPT obtained using a neurothesiometer was used as the standard. Agreement between tests was calculated using kappa coefficients.

RESULTS

Our study included 78 patients (156 examinations), of whom 56.4% were females. The mean age was 38.2 ± 13.0 years, and the mean body mass index was 24.6 ± 4.8 kg/m². The best sensitivity was found for IpTT and VibraTip (89.7% and 79.3%, respectively), while the PPT and IpTT had the highest positive predictive values (94.4% and 92.9%, respectively). The highest kappa coefficients were obtained for the IpTT vs neurothesiometer (kappa coefficient [κ] = 0.893, P < .001), followed by VibraTip vs neurothesiometer (κ = 0.782, P < .001). The VibraTip vs IpTT also had a substantial agreement (κ= 0.713, P < .001).

CONCLUSION

Our findings demonstrated that the IpTT had the best diagnostic performance and agreement compared with the standard in this cohort of Hispanic patients with T1D. The IpTT is a useful, simple test for diabetic neuropathy screening. These findings support its inclusion in future guidelines for diabetic foot examination.

Evaluation of Serum Vitamin D Levels in Diabetic Foot Infections: A Cross-Sectional Study in a Tertiary Care Center in South India

Background

The impact of diabetic foot infections is enormous in India. Studies on vitamin D levels in diabetes mellitus foot infections are scarce. The primary objective of the present study was to compare the serum vitamin D level between diabetics with foot infections and those without foot infections and the secondary objective was to assess the association between the vitamin D level and the severity of foot infections and outcomes.

Methods

The study included 176 type 2 diabetics who attended Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, between September 2012 and June 2014. The serum vitamin D level was measured for 88 diabetics with foot infections (Group 1) and 88 without foot infections (Group 2) using the ELISA 25OH vitamin D DIAsource kit (DIAsource ImmunoAssays S.A., Belgium) and compared. Both groups were followed up for 6 months for outcomes. The qualitative variables were analyzed using the χ2 test and the quantitative variables using the Student t test. The statistical analyses were performed using SPSS, version 17.0. A P value of less than 0.05 was considered significant.

Results

The mean serum vitamin D level was not significantly different between the two groups (P=0.306). Among the patients in Group 1 who either required amputations or died, 97.44% had subnormal vitamin D levels in contrast to 59.18% in those who were grafted or achieved wound healing (P=0.001). Among those who achieved wound healing within 6 months, 78.9% had normal vitamin D levels (P=0.0006).

Conclusion

The study found no significant difference in the serum level of vitamin D between diabetics with and without foot infections. However, vitamin D deficiency was associated with a poor outcome in diabetics with foot infections.

Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines: A systematic review

AIM

Diabetic foot complications are the main reason for hospitalization and amputation in people with diabetes and have a prevalence of up to 25%. Clinical practice guidelines are recommendations based on evidence with the aim of improving health care. The main aim of this study was to carry out a systematic review of the levels of the evaluation and treatment strategies that appear in the clinical practice guidelines focus on diabetic foot or diabetes with diabetic foot section. Another objective of this study was to perform an analysis of the levels of evidence in support of the recommendations made by the selected clinical practice guidelines.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and a quality assessment by the Appraisal of Guidelines for Research and Evaluation (AGREE II) were performed. The databases checked were "NICE", "Cinahl", "Health Guide", "RNAO", "Sign", "PubMed", "Scopus" and "NCG". The search terms included were "diabetic foot", "guideline(s)", "practice guideline(s)" and "diabetes."

RESULTS

Twelve articles were selected after checked inclusion criteria and quality assessment. A summary and classification of the recommendations was completed.

CONCLUSIONS

The heterogeneity of levels of evidence and grades of recommendation of the CPGs included regarding the management, approach and treatment of DF makes it difficult to interpret and assume them in clinical practice in order to select the most correct procedures. Despite this and according to the detailed study of the guidelines included in this work, it can be concluded that the highly recommendable interventions for DF management are debridement (very high level of evidence and strongly recommended), foot evaluation (moderate level of evidence and fairly recommended) and therapeutic footwear (moderate level of evidence and fairly recommended).

Easier operation and similar power of 10 g monofilament test for screening diabetic peripheral neuropathy

Objective

The 10 g Semmes–Weinstein monofilament evaluation (SWME) of 4 sites on each foot is recommended for distal symmetric polyneuropathy screening and diagnosis. A similar method has been proposed to diagnose ‘high-risk’ (for ulceration) feet, using 3 sites per foot. This study compared the effectiveness of SWME for testing 3, 4 and 10 sites per foot to identify patients with diabetic neuropathy.

Methods

We included 3497 subjects in a SWME of 10 sites; records from the 10-site SWME were used for a SWME of 3 and 4 sites. Neuropathy symptom scores and neuropathy deficit scores were evaluated to identify patients with diabetic peripheral neuropathy.

Results

The sensitivities of the 10 g SWME for 3, 4 and 10 sites were 17.8%, 19.0% and 22.4%, respectively. The Kappa coefficients for the SWME tests of 3, 4 and 10 sites were high (range: 0.78–0.93).

Conclusions

There were no significant differences in the effectiveness of 3-, 4- and 10-site SWME testing for diabetic peripheral neuropathy screening. SWME testing of 3 sites on each foot may be sufficient to screen for diabetic neuropathy.

Reference Values and Influencing Factors Analysis for Current Perception Threshold Testing Based on Study of 166 Healthy Chinese

The current perception threshold (CPT) is a device which can evaluate different sensory fibers quantitatively through different frequencies of the electrical stimulus and has been applied in clinical practice. Previous studies have implied that CPT values may be affected by age, gender, and other factors, yet not conclusively. The objective of our study is to clarify the influencing factors of CPT values and establish a reference value range. Twenty healthy volunteers recruited publicly and 146 subjects who took CPT tests in the census of the national project cardiovascular and cerebrovascular diseases in rural areas of China from 2013 to 2015 were analyzed. Past medical history and demographic characteristics such as age, gender, and occupation were collected. Each subject was tested on the left index finger (or back of the left hand) and the right hallux. CPT values of 2000, 250, and 5 Hz on both sites were recorded for statistical analysis. Gender differences were shown at 2000 Hz CPT on the back of the hand and hallux (p < 0.01), and male subjects had a higher CPT. Age had a positive correlation with 250 Hz CPT on the index finger (p < 0.05, r = 1.5), 2000 Hz CPT on the back of the hand (p < 0.001, r = 1.2) and index finger (p < 0.05, r = 2.5). Manual workers had a higher 250 Hz CPT on the hallux than mental workers (p < 0.01). After investigating the impact of different factors on CPT testing, we established the reference value for subjects with different characteristics.

Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience

Charcot neuropathic osteoarthropathy of the foot is a relatively common complication of diabetic neuropathy. Incorrect diagnosis and improper treatment often result in the extremity having to be amputated. This paper summarises the current view on the etiology, diagnostics, and treatment of diabetic Charcot neuropathic osteoarthropathy, with particular focus on preserving the extremity through surgical intervention from our own experiences.

Alternative Quantitative Tools in the Assessment of Diabetic Peripheral and Autonomic Neuropathy

Here we review some seldom-discussed presentations of diabetic neuropathy, including large fiber dysfunction and peripheral autonomic dysfunction, emphasizing the impact of sympathetic/parasympathetic imbalance. Diabetic neuropathy is the most common complication of diabetes and contributes additional risks in the aging adult. Loss of sensory perception, loss of muscle strength, and ataxia or incoordination lead to a risk of falling that is 17-fold greater in the older diabetic compared to their young nondiabetic counterparts. A fall is accompanied by lacerations, tears, fractures, and worst of all, traumatic brain injury, from which more than 60% do not recover. Autonomic neuropathy has been hailed as the "Prophet of Doom" for good reason. It is conducive to increased risk of myocardial infarction and sudden death. An imbalance in the autonomic nervous system occurs early in the evolution of diabetes, at a stage when active intervention can abrogate the otherwise relentless progression. In addition to hypotension, many newly recognized syndromes can be attributed to cardiac autonomic neuropathy such as orthostatic tachycardia and bradycardia. Ultimately, this constellation of features of neuropathy conspire to impede activities of daily living, especially in the patient with pain, anxiety, depression, and sleep disorders. The resulting reduction in quality of life may worsen prognosis and should be routinely evaluated and addressed. Early neuropathy detection can only be achieved by assessment of both large and small- nerve fibers. New noninvasive sudomotor function technologies may play an increasing role in identifying early peripheral and autonomic neuropathy, allowing rapid intervention and potentially reversal of small-fiber loss.

Measurement of current perception thresholds using the Neurometer(®) - applicability in diabetic neuropathy

The incidence of diabetes mellitus is continuously growing worldwide, while the specific chronic complications that it induces have a negative impact on life expectancy andquality, entailing extremely high costs of healthcare services. Diabetic peripheral neuropathy is one of the most common chronic complications of diabetes, affecting almost half of diabetic people during life.

This review aims at summarizing the evidence on the advantages and the usefulness of current perception threshold measurement for peripheral diabetic neuropathy assessment. Among the different methods used for the screening and diagnosis of diabetic neuropathy, measurement of current perception threshold using the Neurometer® has the ability to assess three sub-types of nerve fiber by producing transcutaneous electrical stimuli at frequencies of 2000, 250 and 5 Hz.

Current evidence shows that this method provides a useful, noninvasive evaluation technique of patients with peripheral nervous system disorders, being able to detect neuropathy in the earliest and asymptomatic stages.

The current perception threshold test differentiates categories of mechanical neck disorder

STUDY DESIGN

Cross-sectional discriminative analysis.

OBJECTIVE

To determine whether current perception threshold (CPT) can differentiate between categories of patients with mechanical neck disorders (MNDs).

BACKGROUND

Neck pain is the third most common musculoskeletal disorder and affects a third of all adults each year. It can present as neck pain without musculoskeletal signs, neck pain with musculoskeletal signs but no neurological signs, or neck pain with neurological signs. CPT testing can assess altered sensory perception that may reflect neurological changes.

METHODS

Patients with MNDs (n = 106) were classified into 3 groups, based on a standardized musculoskeletal examination process performed by an experienced physiotherapist who was blinded to CPT scores. The 3 groups were defined as neck pain without musculoskeletal signs (MND I) (n = 60), neck pain with musculoskeletal signs (MND II) (n = 29), and neck pain with neurological signs (MND III) (n = 17). A rapid protocol of CPT testing was performed at 3 frequencies (5, 250, and 2000 Hz), using 3 dermatomal locations on the hand. A 1-way analysis of variance with post hoc comparison and effect sizes was calculated to compare the mean CPT scores between the groups. A binary logistic-regression model was used to predict probability of higher CPT in MND III and to create a receiver-operating-characteristic curve.

RESULTS

Mean CPT differed significantly across the 3 MND groups (MND I, 9.7; MND II, 10.6; and MND III, 11.8; P<.001; η(2) = 0.6). Post hoc comparisons indicated differences between MND I and MND II (P = .05) and between MND II and MND III (P = .01) that had large effect sizes (MND I versus II, d = 1 and MND II versus III, d = 2.2). CPT testing was able to distinguish between MND II and III when a threshold value of greater than 11 was used to indicate MND III. The predicted probability of abnormal CPT in MND III had an estimated 73% sensitivity and 81% specificity; the odds ratio was 11.5 (P = .001) for the differentiation capacity of CPT between MND II and III, with a cutoff of 11. The area under the receiver-operating-characteristic curve was 0.84 (95% confidence interval: 0.72, 0.96; P<.001).

CONCLUSION

CPT testing has moderate discriminatory accuracy, specificity, and sensitivity for classification of MND categories into neck pain with or without neurological signs. J Orthop Sports Phys Ther 2014;44(7):532-540. Epub 10 May 2014. doi:10.2519/jospt.2014.4691.

Reproducibility of current perception threshold with the Neurometer(®) vs the Stimpod NMS450 peripheral nerve stimulator in healthy volunteers: an observational study

PURPOSE

Current methods of assessing nerve blocks, such as loss of perception to cold sensation, are subjective at best. Transcutaneous nerve stimulation is an alternative method that has previously been used to measure the current perception threshold (CPT) in individuals with neuropathic conditions, and various devices to measure CPT are commercially available. Nevertheless, the device must provide reproducible results to be used as an objective tool for assessing nerve blocks.

METHODS

We recruited ten healthy volunteers to examine CPT reproducibility using the Neurometer(®) and the Stimpod NMS450 peripheral nerve stimulator. Each subject's CPT was determined for the median (second digit) and ulnar (fifth digit) nerve sensory distributions on both hands - with the Neurometer at 5 Hz, 250 Hz, and 2000 Hz and with the Stimpod at pulse widths of 0.1 msec, 0.3 msec, 0.5 msec, and 1.0 msec, both at 5 Hz and 2 Hz. Intraclass correlation coefficients (ICC) were also calculated to assess reproducibility; acceptable ICCs were defined as ≥ 0.4.

RESULTS

The ICC values for the Stimpod ranged from 0.425-0.79, depending on pulse width, digit, and stimulation; ICCs for the Neurometer were 0.615 and 0.735 at 250 and 2,000 Hz, respectively. These values were considered acceptable; however, the Neurometer performed less efficiently at 5 Hz (ICCs for the second and fifth digits were 0.292 and 0.318, respectively).

CONCLUSION

Overall, the Stimpod device displayed good to excellent reproducibility in measuring CPT in healthy volunteers. The Neurometer displayed poor reproducibility at low frequency (5 Hz). These results suggest that peripheral nerve stimulators may be potential devices for measuring CPT to assess nerve blocks.

Assessment of sensory neuropathy in patients with diabetic foot problems

Our aim of this study was to compare the accuracy of three different modalities for testing sensory neuropathy in diabetic patients with and without diabetic foot problems. The three devices used included the pin-prick testing using the Neurotip® (PPT), the Semmes-Weinstein 5.07/10 g monofilament testing (SWMT), and the rapid-current perception threshold (R-CPT) measurements using the Neurometer® testing. Our study population consisted of 54 patients (108 feet) with diabetic foot problems treated at the National University Hospital in Singapore by our multi-disciplinary diabetic foot care team. Our results showed no difference in sensory neuropathy detected by PPT and 5.07/10 g SWMT in both the pathological and normal foot. In the pathological foot, there was significant increase in sensory neuropathy detected by the Neurometer® device at both the big toe and ankle sites as compared to PPT and 5.07/10 g SWMT. In the normal foot, there was a significant increase in sensory neuropathy detected by the Neurometer® device at the big toe site only as compared to PPT and 5.07/10 g SWMT. Finally, the Neurometer® measurements detected a statistically higher proportion of feet with sensory neuropathy as compared to detection by the PPT or 5.07/10 g SWMT.