The clinical identification of peripheral neuropathy among older persons

doi:10.1053/apmr.2002.35656

Archives of Physical Medicine and Rehabilitation

Volume 83, Issue 11, November 2002, Pages 1553-1558

https://doi.org/10.1053/apmr.2002.35656 Get 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 Cell	With PN (n=68)	Without PN (n=32)	P*
Mean age ± SD (y)	65.6±9.0	67.4±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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^☆: Supported by the US Public Health Service (grant nos. K23 AG 00989-01, 1P30 AG 08808).

^☆☆: 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].

^★★: Supplier

^♢: a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

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ArticlesThe clinical identification of peripheral neuropathy among older persons☆,☆☆,★,★★,♢

Abstract

Section snippets

Participants

Results

Discussion

Conclusion

Acknowledgements

Neurol Clin

Lancet

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Lancet

Prevalence of diabetes, impaired fasting glucose and impaired glucose tolerance in U.S. adults: The Third National Health and Nutrition Examination Survey, 1988-1994

Diabetes Care

Sensory neuropathy in non-insulin-dependent diabetes mellitus: The San Luis Valley Diabetes Study

Am J Epidemiol

A prospective study of risk factors for diabetic foot ulcer

Diabetes Care

Risk factors for amputation in patients with diabetes mellitus: a case control study

Ann Intern Med

Diabetic peripheral neuropathy impairs balance beyond the effects of aging and diabetes alone [abstract]

Diabetes

Problems with gait and posture in neuropathic patients with insulin-dependent diabetes mellitus

Diabetes Med

Peripheral neuropathy: a true risk factor for falls

J Gerontol A Biol Sci Med Sci

“Numbness of the feet” is a poor indicator for polyneuropathy in type 2 diabetic patients

Diabet Med

Neurological signs in the elderly

Age Ageing

Morphological study of the aging human peripheral nerve

Clin Neuropath

Clinical and electrophysiological study of the peripheral nervous system in the elderly

J Neurol

Report and recommendations of the San Antonio Conference on diabetic neuropathy

Diabetes Care

Clinical and neuropathological criteria for the diagnosis and staging of diabetic polyneuropathy

Brain

A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy

Diabetes Care

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