Brief Communication
Relevance of ankle reflex as a screening test for diabetic peripheral neuropathy Mohd Mustufa Malik, Sushil Jindal, Shaifali Bansal, Vivek Saxena, Uma Shankar Shukla1 Departments of Medicine, and 1Community Medicine, Peoples College of Medical Sciences and Research Centre, Bhanpur, Bhopal, Madhya Pradesh, India
A B S T R A C T Background and Objective: The primary objective of this study is to find out if testing ankle reflex (AR) alone is an effective screening tool for diabetic peripheral neuropathy and the secondary objective of this study is to compare its sensitivity and specificity with biothesiometer vibration perception threshold (VPT), which is the gold standard. Materials and Methods: A total of 450 patients with diabetes mellitus attending endocrine out-patient department from year 2012 January to 2013 July were included in this study. All patients underwent clinical assessment of AR compared with VPT by biothesiometer. Results: AR is sensitive (81.09%) specific (81.679%) with diagnostic accuracy of (81.22%) and agreement between biothesiometer and AR is significant ( = 0.538 P < 0.0001). Conclusion: AR is at par the gold standard that is biothesiometer VPT. Key words: Ankle reflex, biothesiometer, vibration perception threshold
INTRODUCTION
(AR) because diabetic peripheral neuropathy affects both sensory and motor components.
Diabetes mellitus is now established as one of the leading causes of morbidity and mortality throughout the world. Most of these ill-effects on health can be almost entirely attributed to long-term complications of diabetes. Neuropathy is among the most common and troublesome complications that affect diabetic patients. It is not only a cause of increased morbidity, but also mortality due to its autonomic component. In over half of the patients, neuropathy may be silent and only come to attention when the patient develops a diabetic foot. Simple screening test such as 10 g Semmes-Weinstein monofilament examination, vibration perception threshold (VPT), superficial pain test are suggested for diagnosis of peripheral neuropathy in diabetic clinic, but these are sensory tests. In order to assess the motor and sensory function, we may include ankle reflex
RESEARCH QUESTION
Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.119641
Is testing AR as effective as VPT for diabetic peripheral neuropathy? Aims and objectives
• •
To find out if testing AR alone is an effective screening tool to rule out diabetic peripheral neuropathy To compare sensitivity and specificity of AR testing with VPT.
MATERIALS
AND
METHODS
Materials
• • •
Biotheisometer Indoor/outdoor diabetic patients in medicine department of PCMS and RC Rubber hammer to test reflex.
Methods
A total of 450 patients with diabetes mellitus attending endocrine out-patient department from year 2012 January
Corresponding Author: Dr. Mohd Mustufa Malik, 23 Mughalpura, Near Sultania School, Shahjahanabad, Bhopal - 462 001, Madhya Pradesh, India. E-mail: [email protected]
S340
Indian Journal of Endocrinology and Metabolism / 2013 / Vol 17 / Supplement 1
Malik, et al.: Relevance of ankle reflex for diabetic peripheral neuropathy
Table 1: Association between AR and VPT VPT AR Present Absent Total
Total
Present
Absent
566 132 698
37 165 202
603 297 900
AR: Ankle reflex, VPT: Vibration perception threshold, Sensitivity: 81.089%, Specificity: 81.679%, Accuracy: 81.22%, Agreement: Significant (k=0.538, P < 0.0001)
600
566 AR Present AR Absent
500 400 300 200
165
132 100 37 0 Present
Absent VPT
compared with VPT by biothesiometer. When compared with VPT, AR is sensitive (81.09%) specific (81.679%) with diagnostic accuracy of (81.22%) and agreement between biothesiometer and AR is significant ( = 0.538, P < 0.0001) [Table 1 and Figure 1].
DISCUSSION In the present study, we have used VPT of >15 V[1,2] as the standard for the diagnosis of neuropathy. The use of VPT for the diagnosis of neuropathy has been well validated by clinical studies with sensitivity and specificity of 80 and 98% respectively.[3] Presence or absence of AR co-relates well with the gold standard VPT to test for peripheral neuropathy. Testing VPT uses an expensive instrument and is cumbersome as compared with testing AR, which is part of routine clinical examination. Since peripheral sensory neuropathy is a pivotal element in the causal pathway to both foot ulceration and amputation, selecting a quick, inexpensive and accurate instrument to evaluate the high-risk patient is essential to make decisions. Hence, apart from VPT, we may also use AR to evaluate peripheral neuropathy.
Figure 1: Distribution of ankle reflex according to vibration perception threshold
CONCLUSION
to 2013 July have been included in this study. All patients under went clinical assessment such as AR compared with VPT by biothesiometer.
The good correlation between VPT with AR shows that this simple bed side test can be useful in clinical practice.
Inclusion criteria
REFERENCES
•
Known diabetics.
1.
Exclusion criteria
• • • •
Previous history of diabetic foot Known case of hypothyroidism Patients on beta blocker Previous history of central nervous system disorders.
RESULTS A total of 450 patients have been included in the study and 900 lower limbs have been examined for AR and
2.
3.
Saha D, Saha K, Dasgupta PK. Vibration sense impairment in diabetes mellitus. Indian J Physiol Pharmacol 2011;55:381-3. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care 1994;17:557-60. Perkins BA, Olaleye D, Zinman B, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care 2001;24:250-6.
Cite this article as: Malik MM, Jindal S, Bansal S, Saxena V, Shukla US. Relevance of ankle reflex as a screening test for diabetic peripheral neuropathy. Indian J Endocr Metab 2013;17:S340-1. Source of Support: Nil, Conflict of Interest: None declared.
Indian Journal of Endocrinology and Metabolism / 2013 / Vol 17 / Supplement 1
S341
Copyright of Indian Journal of Endocrinology & Metabolism is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Relevance of ankle reflex as a screening test for diabetic peripheral neuropathy Mohd Mustufa Malik, Sushil Jindal, Shaifali Bansal, Vivek Saxena, Uma Shankar Shukla1 Departments of Medicine, and 1Community Medicine, Peoples College of Medical Sciences and Research Centre, Bhanpur, Bhopal, Madhya Pradesh, India
A B S T R A C T Background and Objective: The primary objective of this study is to find out if testing ankle reflex (AR) alone is an effective screening tool for diabetic peripheral neuropathy and the secondary objective of this study is to compare its sensitivity and specificity with biothesiometer vibration perception threshold (VPT), which is the gold standard. Materials and Methods: A total of 450 patients with diabetes mellitus attending endocrine out-patient department from year 2012 January to 2013 July were included in this study. All patients underwent clinical assessment of AR compared with VPT by biothesiometer. Results: AR is sensitive (81.09%) specific (81.679%) with diagnostic accuracy of (81.22%) and agreement between biothesiometer and AR is significant ( = 0.538 P < 0.0001). Conclusion: AR is at par the gold standard that is biothesiometer VPT. Key words: Ankle reflex, biothesiometer, vibration perception threshold
INTRODUCTION
(AR) because diabetic peripheral neuropathy affects both sensory and motor components.
Diabetes mellitus is now established as one of the leading causes of morbidity and mortality throughout the world. Most of these ill-effects on health can be almost entirely attributed to long-term complications of diabetes. Neuropathy is among the most common and troublesome complications that affect diabetic patients. It is not only a cause of increased morbidity, but also mortality due to its autonomic component. In over half of the patients, neuropathy may be silent and only come to attention when the patient develops a diabetic foot. Simple screening test such as 10 g Semmes-Weinstein monofilament examination, vibration perception threshold (VPT), superficial pain test are suggested for diagnosis of peripheral neuropathy in diabetic clinic, but these are sensory tests. In order to assess the motor and sensory function, we may include ankle reflex
RESEARCH QUESTION
Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.119641
Is testing AR as effective as VPT for diabetic peripheral neuropathy? Aims and objectives
• •
To find out if testing AR alone is an effective screening tool to rule out diabetic peripheral neuropathy To compare sensitivity and specificity of AR testing with VPT.
MATERIALS
AND
METHODS
Materials
• • •
Biotheisometer Indoor/outdoor diabetic patients in medicine department of PCMS and RC Rubber hammer to test reflex.
Methods
A total of 450 patients with diabetes mellitus attending endocrine out-patient department from year 2012 January
Corresponding Author: Dr. Mohd Mustufa Malik, 23 Mughalpura, Near Sultania School, Shahjahanabad, Bhopal - 462 001, Madhya Pradesh, India. E-mail: [email protected]
S340
Indian Journal of Endocrinology and Metabolism / 2013 / Vol 17 / Supplement 1
Malik, et al.: Relevance of ankle reflex for diabetic peripheral neuropathy
Table 1: Association between AR and VPT VPT AR Present Absent Total
Total
Present
Absent
566 132 698
37 165 202
603 297 900
AR: Ankle reflex, VPT: Vibration perception threshold, Sensitivity: 81.089%, Specificity: 81.679%, Accuracy: 81.22%, Agreement: Significant (k=0.538, P < 0.0001)
600
566 AR Present AR Absent
500 400 300 200
165
132 100 37 0 Present
Absent VPT
compared with VPT by biothesiometer. When compared with VPT, AR is sensitive (81.09%) specific (81.679%) with diagnostic accuracy of (81.22%) and agreement between biothesiometer and AR is significant ( = 0.538, P < 0.0001) [Table 1 and Figure 1].
DISCUSSION In the present study, we have used VPT of >15 V[1,2] as the standard for the diagnosis of neuropathy. The use of VPT for the diagnosis of neuropathy has been well validated by clinical studies with sensitivity and specificity of 80 and 98% respectively.[3] Presence or absence of AR co-relates well with the gold standard VPT to test for peripheral neuropathy. Testing VPT uses an expensive instrument and is cumbersome as compared with testing AR, which is part of routine clinical examination. Since peripheral sensory neuropathy is a pivotal element in the causal pathway to both foot ulceration and amputation, selecting a quick, inexpensive and accurate instrument to evaluate the high-risk patient is essential to make decisions. Hence, apart from VPT, we may also use AR to evaluate peripheral neuropathy.
Figure 1: Distribution of ankle reflex according to vibration perception threshold
CONCLUSION
to 2013 July have been included in this study. All patients under went clinical assessment such as AR compared with VPT by biothesiometer.
The good correlation between VPT with AR shows that this simple bed side test can be useful in clinical practice.
Inclusion criteria
REFERENCES
•
Known diabetics.
1.
Exclusion criteria
• • • •
Previous history of diabetic foot Known case of hypothyroidism Patients on beta blocker Previous history of central nervous system disorders.
RESULTS A total of 450 patients have been included in the study and 900 lower limbs have been examined for AR and
2.
3.
Saha D, Saha K, Dasgupta PK. Vibration sense impairment in diabetes mellitus. Indian J Physiol Pharmacol 2011;55:381-3. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care 1994;17:557-60. Perkins BA, Olaleye D, Zinman B, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care 2001;24:250-6.
Cite this article as: Malik MM, Jindal S, Bansal S, Saxena V, Shukla US. Relevance of ankle reflex as a screening test for diabetic peripheral neuropathy. Indian J Endocr Metab 2013;17:S340-1. Source of Support: Nil, Conflict of Interest: None declared.
Indian Journal of Endocrinology and Metabolism / 2013 / Vol 17 / Supplement 1
S341
Copyright of Indian Journal of Endocrinology & Metabolism is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
