Original article

Physiotherapists’ experience of using the abbreviateddiagnostic criteria for diabetic and non­diabetic patients
Tomoyasu Ishiguro1*, Toshihiro Kawae1, Daisuke Iwaki2, Yuki Nakashima2, Kenichi Fudeyasu212

Makuhari Human Care Faculty Department of Physical Therapy, Tohto University
Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital

Abstract
This study aimed to examine the positivity rate of the abbreviateddiagnostic criteria proposed by the Diabetic Neuropathy Study Group inJapan. The medical records of the participants were retrospectively examined
and classified as DPN＋ for diabetes with neuropathy, DPN− for diabetes
without neuropathy, and NDM for patients without diabetes. Afterinterviewing patients for subjective symptoms, we conducted vibration
sensation and Achilles tendon reflex tests. The results showed that themean value of vibratory sensation time was 8.3±2.0 seconds in the NDM,
8.5±2.3 seconds in the DPN−, and 5.9±2.3 seconds in the DPN＋ groups.
The DPN − group had a significantly longer vibratory sensation timecompared to the DPN＋. There were participants whose vibration sensing
time, one of the diagnostic criteria, was less than 10 seconds, even in theNDM. Furthermore, participants were categorized into four groups based onage. The mean value of vibratory sensation time in DPN＋ was significantly
lower in NDM and DPN−, each all-age groups. Except for the NDM groupof 71 years or older, there was no age-related decrease in vibratory
sensation values. However, it has been shown that there are changes inneural mechanisms associated with aging, increases in sensory thresholds,and differences in vibratory sensation depending on the measurement site. It
is necessary to accumulate more data to study the effect of aging on thevibration sensation and measurement site. In recent years, there have been
many reports of diabetic neuropathy affecting motor function. Therefore, it
seems necessary to include motor function in the physiotherapy evaluation ofdiabetic patients with neuropathy due to ADC.

Introduction
The number of patients with diabetes has been
increasing worldwide, and according to the International
Diabetes Federation, the global prevalence was 463
million in 2019 and is expected to reach 700 million by20451) . Diabetes mellitus is on the rise in Japan as well.
According to the National Health and Nutrition

Submitted Mar. 9. 2022
Accepted Jul. 4. 2022
*Correspondence
Tomoyasu Ishiguro
Makuhari Human Care Faculty
Department of Physical Therapy,
Tohto University
E-mail:tomoyasu.ishiguro@tohto.ac.jp
Keywords: three keywords
Diabetic neuropathy
Vibratory sensation
Aging

Examination Survey of 2008, the number of patients withdiabetes is estimated at 10 million, and is expected toincrease with the aging population2). The goals of diabetes
treatment in Japan are to normalize blood glucose levels
and to reduce the onset and progression of complications,as well as the rising cost of medical care. According to
the 2007 National Health and Nutrition Examination

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Survey, the incidence of the three major complications ofdiabetes, neuropathy, retinopathy, and nephropathy were
11.8%, 10.6%, and 11.1%, respectively3).
Diabetic neuropathy is a problem that physiotherapists
should be aware of because, in serious cases, it canreduce motor function, cause foot ulcers and result in
lower limb amputations. Previous studies have shown that
diabetic neuropathy affects muscle strength and balance.
Nomura et al. measured the knee extension muscle force(KEF) in 1442 patients with diabetes and investigated therelationship between neuropathy and age. They found nodifference in KEF between patients with or without
neuropathy in the 30-49 age group, but it was significantly
lower in older patients with neuropathy (50-69 years and70-87 years).4) Furthermore, Antonio et al. compared theswaying area as an index of balance ability and found that
it was greater in patients with diabetes compared to thosewithout5) , Hewston et al. reported that the incidence offalls was significantly higher in elderly patients with type2 diabetes and that this was caused by impaired balance
due to diabetic neuropathy6). Therefore, physicaltherapists need to adequately evaluate these patients inorder to plan quality physical therapy programs andmanage risks.
The nerve conduction velocity testing have been usedas diagnostic criteria for diabetic neuropathy7)8) , but theyrequire and are not suitable for rehabilitation use due toconsiderable patient’s burden. In comparison, theabbreviated diagnostic criteria ( ADC ) proposed by theDiabetic Neuropathy Study Group in Japan are is simpler
and conducted with devices commonly used inrehabilitation assessments, such as reflex hammers andtuning forks, which do not take up much space9) . On theother hand, many patients undergoing physiotherapy havea diagnosis of diabetes mellitus, but the pathogenesis andseverity of the disease are unclear.
Therefore, knowing the rate of positive neuropathy
with ADC in non-diabetic patients would also be importantdata for physiotherapy assessment. The aim of this study
is to investigate the positive rate of ADC in non-diabetic
patients and in diabetic patients.

Methods
The study included outpatients who visited Clinic A
between 2015 and 2016. Patients with obvious central
nervous system abnormalities, such as cerebral

hemorrhage or infarction, heavy alcohol consumption, or ahistory of peripheral neuropathy due to bone fracture
were excluded, as were patients younger than 30 years
and older than 80 years of age. For the diagnosis of
diabetic neuropathy, the same physiotherapist assessed all
the subjects using the ADC and the results were used by
the doctors to classify those with diabetic neuropathy(DPN＋) and those without diabetic neuropathy (DPN−).
The physicians also classified the subjects into groups
without diabetes (NDM) based on blood test results.
We also investigated the effect of age by categorizing
the patients into four groups: (A 1) 31-50 years, (A 2) 5160 years, (A 3) 61-70 years, and (A 4) 71-80 years.
Prior to the measurements, the room temperature wasset at 26-28 °C in the summer and 22-24 °C in the winter.
According to a previous study10), the sensation of the footdiminishes immediately after walking, so the test was
carried out after 15 to 30 minutes of rest. We used theADC proposed by the Diabetic Neuropathy Study Groupin Japan to determine diabetic neuropathy in allparticipants. After interviewing patients for subjective
symptoms ( only existing symptoms were used ) , weconducted vibratory sensation and Achilles tendon reflex
tests, in that order. The vibration test was conducted inthe supine position. The duration of vibratory sensation
was measured with a stopwatch from the medial malleoliof each leg using a 128 Hz tuning fork, and the right andleft mean values were calculated. An aluminum C 128
tuning fork (Yufu Seiki G-157 A) with a total length of 21
cm was used as the vibration sensor. A sensing time of 10seconds or greater was considered normal, and less than
10 seconds was considered abnormal. The Achilles tendon
reflex was performed in the Babinski limb position or on
all fours. A 22 cm long Babinski reflex hammer ( AizenCorporation) was used. The Achilles tendon reflex was
considered normal when it was observed and abnormalwhen it was not. Patients who fulfilled at least two of thefollowing criteria were diagnosed with DPN : concerns
about bilateral sensory symptoms in their toes and thesoles of their feet, bilateral diminished or absent Achilles
tendon reflexes, and bilateral decreased vibratory
sensations in the medial malleoli. Written and oral
explanations of the purpose of the study and thepublication of data were provided to the participants by
their attending physicians, and consent was obtained fromall of them. This study was approved by the Research

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Ethics Committee of Health Science University (No.01).

Table 2

Subjective symptoms, Achilles tendon reflex, andvibration sensation test results based on the ADC

Data analysis
EZR ( Easy R ) was used for the statistical analysis.
Tukey as a multiple comparison test among the threegroups. χ2-test was used for the frequency of subjectivesymptoms, Achilles tendon reflex, and vibration sensation
abnormalities in the ADC, and Statistical significance wasset at P＜0.05.

Results
A total of 270 patients were included in this study, and54 were classified as NDM, 81 as DPN−, and 135 as DPN＋. The ADC positivity rate for all participants was 50.4%.
The DPN− group was significantly younger than both theNDM and DPN ＋ groups. The DPN − group had asignificantly longer disease duration compared to the DPN＋. (Table 1)
Table 1

Characteristics of the study participants stratified bythe three groups

The top line shows the number of participants ; the bottom line isexpressed as a percentage.
χ2-test was used for the frequency of subjective symptoms, Achilles
tendon reflex, and vibration sensation abnormalities.

The vibratory sensation time among the three groups
was 8.3±2.0 seconds for NDM, 8.5±2.3 seconds for DPN−, and 5.9±2.3 seconds for DPN＋. The DPN− had asignificantly longer vibratory sensation time than the DPN＋. The median for each group was 8.1 (max-min: 3.912.8) for NDM, 8.3 (3.6-12.4) for DPN− and 5.5 (2.2-13.1)
for DPN＋. (Figure 1)

BMI: Body mass index, HbA1c: Hemoglobin A1cThe tukey as a multiple comparison test among the three groups.
*: P＜0.05 DPN− vs DPN＋, NDM†: P＜0.05 DPN＋ vs DPN−As for the subjective symptoms, there was a significant
difference between the three groups, which were presentin 9% of the NDM group (n＝5), 26% of the DPN− (n＝21), and 61% of the DPM ＋ ( n ＝ 82 ) . Achilles tendon
reflexes were significantly different among the groups aswell, prevalent in 7% of the NDM group (n＝4), 20% ofthe DPN− (n＝16), and 87% of the DPN＋ (n＝117).
With respect to vibrational sensation, 72% of the NDMgroup (n＝39) were reported as abnormal, compared to
67% of the DPN (n＝54) and 93% of the DPN＋ group (n＝126). (Table 2)

Figure 1

The results of the vibratory sensation time stratified
by the three groups
The tukey as a multiple comparison test among the three groups*: P＜ 0.05 DPN＋ vs DPN−.

To examine the effect of age, the NDM, DPN−, andDPN ＋ were divided into four age groups, and thevibratory sensation time was later compared. The results
showed that the vibratory sensation time of the DPN＋group was significantly shorter than that of NDM andDPN−. No significant difference was found between NDMand DPN− in any age group. In all groups, we observe atendency towards a decrease in the sensation of vibration

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with age, but A 4 in the NDM group showed the greatest
decrease compared to all other age groups. (Table 3)
Table 3

Effect of age on vibration sensation among thethree groups

The tukey as a multiple comparison test among the three groups.
*: P＜ 0.05 A 4 vs A 1, A 2 A 3. †: P＜ 0.05 DPN＋ vs DPN−, NDM

Discussion
This study validated the positivity rate of diabetic
neuropathy by assessing with the ADC and included
patients with and without diabetes. Because the original
ADC requires two mandatory items, “has diabetes” and“ can deny peripheral neuropathy other than diabetic
neuropathy, ” it is not appropriate to use the ADC for
participants who do not have diabetes. On the other hand,since these diagnostic criteria were anticipated to beaffected by aging, the ADC was also administered to nondiabetic participants in this study.
Our results revealed that 72% of the NDM group also
felt vibrating for less than 10 seconds. In an
epidemiological survey conducted in six prefectures inTohoku using the ADC, 35.8% of participants had
neuropathy11) , whereas this rate was 16.2% in a survey
conducted by Yokoyama et al. The prevalence ofneuropathic complications varies between domesticstudies. This is due to the variety of clinical presentations
and the lack of international diagnostic criteria. TheMichigan Neuropathy Screening Instrument ( MDNS )12)
and the Toronto Clinical Neuropathy Score (TCNS)13) are
well-known diagnostic criteria for diabetic neuropathy. InJapan, the invasive nerve electric velocity test can beused to assess severity. But the one proposed by theDiabetes Neuropathy Association is widely used in clinicalpractice and is simple and easy to use Association iswidely used in clinical practice and is simple and easy touse, with a reported sensitivity of 68% and specificity ofmore than 70%9).
Although the MDNS, TCNS, and ADC differ in thecontent and evaluation of each test item, especially interms of neurological symptoms and feet observation,

there is consistency in the general idea. These criteria
are mainly qualitative tests, and only the vibration
sensation test is quantitative in nature and has beenreported to be highly correlated with nerve conduction
velocity according to previous studies 14) . All threemethods use a C 128 tuning fork for vibration testing, andthe MDNS uses the on-off and the time method on thedorsal side of the hallux interphalangeal joint. However,these have not been sufficiently studied, and it has been
pointed out that the threshold of detection varies withage. Our study found that the SE of the DPN＋ group wasapproximately 6 seconds, whereas that of the DPN− andNDM groups were 8 seconds, suggesting that thevibratory sensation value is an evaluation index that
increases the SE. Decorps et al. found that the thresholdsof touch, vibration and pain increase with age, incomparison with the decrease in nerve conduction
velocity 15) . The DPN＋ group showed significantly lower
values than the DPN− and NDM in all age subgroups.
Age did not show any effect in the NPD or NMD groups,
with the exception of the 71 to 80 age group, except in
the 71-80-year-old category of the latter. To obtain acutoff value for vibration sensation, it is necessary to use
the data from patients who are definitively diagnosed withneuropathy based on quantitative testing such as nerve
conduction velocity. In this study, it was not possible toclarify the extent to which the effect of aging taken into
consideration.
In addition, the MDNS and TCNS use the dorsal side of
the hallux interphalangeal joint, which differs from themedial malleoli of the simplified diagnostic criteria. Martinet al. reported that the threshold of vibration sensation
increases with age and that the percentage ofabnormalities is higher in greater toe compared to theindex finger16) . In recent years, there have been severalstudies on the effect of diabetic neuropathy on locomotor
activity using the simple diagnostic criteria. According toNomura et al., knee extensor strength was shown to beaffected by age4) , and Kataoka et al. reported a decreasein the hallux grip strength in these patients17).
One of the limitations of this study is that nerve
conduction velocity testing is said to be useful inassessing neurological deficits, and therefore futurestudies should be based on nerve conduction velocity
testing.
In conclusion, it is possible to estimate the motor

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function of patients with diabetes using simple diagnostic
criteria. Future studies should focus on gathering moredata on the effect of aging on vibration sensation andmeasurement sites.

Conflict of Interest
The authors declare no conflict of interest.

References
１）International Diabetes Federation: Worldwide toll ofdiabetes. https : / / diabetesatlas. org / en / sections /worldwide-toll-of-diabetes. html ( accessed July 14,2021)
２）Ministry of Health, Labour and Welfare: Results of
the National Health and Nutrition Survey, 2016 :Ministry of Health, Labour and Welfare. https://www.
mhlw. go. jp / stf / houdou / 0000177189. html ( accessedJuly 14, 2021)
３）Ministry of Health, Labour and Welfare : Report ofthe 2007 National Health and Nutrition Survey :Ministry of Health, Labour and Welfare. https://www.
mhlw.go.jp/bunya/kenkou/eiyou 09/01.html (accessedJuly 14, 2021)
４） Nomura T, Ishiguro T, Ohira M, et al. : Diabetic
polyneuropathy is a risk factor for decline of lower
extremity strength in patients with type 2 diabetes. J
Diabetes Investig 9: 186-192, 2018５）Nardone A, Grasso M, Schieppati M: Balance control
in peripheral neuropathy : are patients equally
unstable under static and dynamic conditions ? Gait
Posture 23: 364-373, 2006
６） Hewston P, Deshpande N : Falls and Balance
Impairments in Older Adults with Type 2 Diabetes:
Thinking Beyond Diabetic Peripheral Neuropathy.
Can J Diabetes 40: 6-9, 2016７）Partanen J, Niskanen L, Lehtinen J, et al.: NaturalHistory of Peripheral Neuropathy in Patients withNon-Insulin-Dependent Diabetes Mellitus. N Engl J
Med 333: 89-94, 1995
８） Dyck PJ, Karnes JL, O’Brien PC, et al. : TheRochester Diabetic Neuropathy Study: reassessmentof tests and criteria for diagnosis and staged severity.
Neurology 42: 1164-1170, 1992
９）Yasuda H, Sanada M, Kitada K, et al.: Rationale andusefulness of newly devised abbreviated diagnostic
criteria and staging for diabetic polyneuropathy.

Diabetes Res Clin Pract 77 Suppl 1: S 178-183, 2007１０）Ohtomo K, Ishiguro T, Yamada M. A Study on theInfluence of Gait and Rest on a Touch Test among
TypeII Diabetes Mellitus Patien. Physical Therapy
Japan 30: 397-401, 2003
１１）Satoh J, Baba M, Yagihashi S, et al.: Frequency ofDiabetic Polyneuropathy (DPN) and ClinicalSignificance of Achilles Tendon Reflex in Diagnosisof DPN. J Japan Diab Soc 50: 799-806, 2007
１２） Feldman EL, Stevens MJ, Thomas PK, et al. : Apractical two-step quantitative clinical andelectrophysiological assessment for the diagnosis andstaging of diabetic neuropathy. Diabetes Care 17 :1281-1289, 1994
１３）Bril V, Tomioka S, Buchanan RA, et al.: Reliability
and validity of the modified Toronto Clinical
Neuropathy Score in diabetic sensorimotor
polyneuropathy. Diabet Med 26: 240-246, 2009１４） Deshpande N, Metter E. j, Ling S, et al. :Physiological correlates of age-related decline invibrotactile sensitivity. Neurobiol Aging 29: 765-773,
2008１５）Decorps J, Saumet JL, Sommer P, et al.: Effect ofageing on tactile transduction processes. Ageing Res
Rev 13: 90-99, 2014
１６） Martin CL, Waberski BH, Pop-Busui R, et al. :Vibration perception threshold as a measure of distal
symmetrical peripheral neuropathy in type 1
diabetes : results from the DCCT / EDIC study.
Diabetes Care 33: 2635-2641, 2010１７）Kataoka h, Miyatake N, Kitayama N, et al.: Decrease
in toe pinch force in male type 2 diabetic patientswith diabetic nephropathy. Clin Exp Nephrol 22: 647652, 2018

JAHS 13(2):49-53, 2022 53