We are all aware that peripheral neuropathy plays a role in the developement of diabetic foot ulcerations, in addition to poor nutritional status and vasculopathy. The consequences of developing a foot ulcer are severe; greater than 60% of non-traumatic amputations in the western world are performed on persons with diabetes and the majority of these amputations are preceded by some form of ulceration. It is well documented that there is significant mortality and morbidity at five years following amputation.

This reality demands that we understand the etiology of diabetic ulceration and establish preventative measures to minimize new ulcerations in our diabetic patients. Toward that end, each clinical exam should include an evaluation of patients peripheral neurological status. There are a number of modalities available to establish a baseline status and to evaluate deviations from that baseline.

In your practice, what modalities do you employ to evaluate patients neurological status?

I think the key point here is using more than just one modality. Many have gotten into the habit of equating SWMF to a neuro exam in the diabetic patient, and this is a BAD HABIT. The eval / exam of neuropathy starts with the patient history (burning, numbness, tingling), then continues with the physical findings of autonomic skin changes, light touch, SWMF, tuning fork, and temperature perception. Motor neuropathy should also be documented, and if available, I recommend the VPT (vibration perception threshold) meter be used to quantify the vibratory loss.

Dr. Steinberg made the most important point about history being
paramount in diagnosing diabetic peripheral neuropathy (DPN).
Symptoms usually precede signs in DPN and sounding like Larry Harkless
"patients will tell you if they have neuropathy if you just LISTEN to
them."

Also, remember that the SWMF and VPT are tools to
diagnose Loss of Protective Sensation (LOPS) which is a more profound
neuropathy - placing the patient at risk for ulceration. I agree with
Dr. Steinberg, they shouldn't be your only tools to diagnose DPN./>
Peter Dyck's work at Mayo has revealed that 5-10% of diabetic
patients that present with neuropathic symptoms have a cause OTHER
THAN DIABETES for their neuropathy. Therefore, it is extremely
important to uncover "treatable or reversible" causes of neuropathy
before diagnosing DPN.

To do this, I use the history,
physical exam (sensory, motor, and autonomic) and order lab work to
uncover common causes of neuropathy. CBC, BMP, AST/ALT, TSH, RA,
HLA-B27, B12, HIV and Hep Screen in some, serum immunoglobulins in
some.

If the pattern or timeline of neuropathy doesn't fit
that of diabetes, then order a urine microalbumin to see if they have
microproteinuria (a clue that they have early nephropathy - supporting
the dx of DPN).

An EMG is helpful to uncover the pattern of
DPN. Most often (>90%) DPN is length-dependent, symmetrical and axonal (100%). So
if the EMG uncovers otherwise, you may consider a sural nerve
biopsy.

I think the main point is, just because a patient
has diabetes and neuropathy, doesn't mean it's diabetic neuropathy.