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The clinical identification of peripheral neuropathy among older persons,☆☆,,★★,

https://doi.org/10.1053/apmr.2002.35656Get rights and content

Abstract

Richardson JK. The clinical identification of peripheral neuropathy among older persons. Arch Phys Med Rehabil 2002;83:1553-8. Objective: To identify simple clinical rules for the detection of a diffuse peripheral neuropathy among older outpatients. Design: Observational, blinded, controlled study. Setting: A tertiary-care electrodiagnostic laboratory and biomechanics laboratory. Participants: One hundred research subjects, 68 with electrodiagnostic evidence of peripheral neuropathy, between the ages of 50 and 80 years. Interventions: Not applicable. Main Outcome Measurements: One examiner, unaware of the results of electrodiagnostic testing, evaluated Achilles' and patellar reflexes, Romberg testing, semiquantified vibration, and position sense at the toe and ankle in all subjects, and unipedal stance time and the Michigan Diabetes Neuropathy Score in a subset of subjects. Results: Significant group differences were present in all clinical measures tested. Three signs, Achilles' reflex (absent despite facilitation), vibration (128Hz tuning fork perceived for <10s), and position sense (<8/10 1-cm trials) at the toe, were the best predictors of peripheral neuropathy on both univariate and logistic regression (pseudo R2=.744) analyses. The presence of 2 or 3 signs versus 0 or 1 sign identified peripheral neuropathy with sensitivity, specificity, and positive and negative predictive values of 94.1%, 84.4%, 92.8%, and 87.1%, respectively. Values were similar among subgroups of subjects with and without diabetes mellitus. When other clinicians applied the technique to 12 more subjects, excellent interrater reliability regarding the presence of peripheral neuropathy (κ=.833) and good to excellent interrater reliability for each sign (κ range,.667–1.00) were shown. Conclusion: Among older persons, the presence of 2 or 3 of the 3 clinical signs strongly suggested electrodiagnostic evidence of a peripheral neuropathy, regardless of etiology. Age-related decline in peripheral nerve function need not be a barrier to the clinical recognition of a diffuse peripheral neuropathy among older persons. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Participants

The control and peripheral neuropathy subjects were examined as part of a screening process for other studies that investigated the effects of peripheral neuropathy on postural stability among older persons. The majority of the peripheral neuropathy and all of the control subjects had been referred to the electrodiagnostic laboratory by their primary physicians for symptoms and/or signs consistent with a lower-extremity peripheral neurologic disorder. Reasons for referral for the 68 peripheral

Results

One hundred subjects were included in the analyses. Sixty-eight of the subjects were in the peripheral neuropathy group, and 32 were in the control group. Although there were no group differences in age, gender, or BMI, the peripheral neuropathy subjects were significantly taller and heavier than the control subjects (table 1).

. Demographic characteristics of subjects with and without peripheral neuropathy

Empty CellWith PN (n=68)Without PN (n=32)P*
Mean age ± SD (y)65.6±9.067.4±8.8.359
Gender, n (% women)

Discussion

The boundary between normal peripheral nerve function and peripheral neuropathy is not always distinct, and this is particularly true for older patients. The present study identified peripheral neuropathy by using electrodiagnostic results as the standard. Although electrodiagnostic studies are imperfect, they are generally accepted and do not require sustained concentration or attention on the part of the patient, representing an advantage for the older patient population studied here. Despite

Conclusion

Peripheral neuropathy is common among older persons, and its detection is clinically relevant. This study found a strong correlation between semiquantitative physical examination techniques and the presence of peripheral neuropathy determined electrodiagnostically. However, as with all studies, these findings should be replicated by others before widespread clinical use is considered. The examination techniques described cannot replace electrodiagnostic studies that, unlike the physical

Acknowledgements

I thank Ken Guire for his patience and expertise while providing statistical consultation.

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      A 128 Hz Tuning Fork (Ragg Gardiner Brown Co, 11 Furnace Hill, Sheffield, S3 7AF, England) was used to measure VDT. Such devices are widely used in clinical practice and research (Fillyaw et al., 1989; Richardson, 2002; O'Neill et al., 2006; Botez et al., 2009; O'Conaire et al., 2011). A pen cap of 14 mm diameter was used to establish standardised vibration amplitudes.

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    Supported by the US Public Health Service (grant nos. K23 AG 00989-01, 1P30 AG 08808).

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    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

    Reprint requests to James K. Richardson, MD, Dept of Physical Medicine and Rehabilitation, University of Michigan Medical Center, MPB D5200, Ann Arbor, MI 48109-0718, e-mail: [email protected].

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