Abstract: Background and Objectives: Diabetic Peripheral Neuropathy (DPN) is a common complication in patients with diabetes mellitus. It often misdiagnosed or underdiagnosed. This study aimed to described the assessment of DPN among clinicians. Materials and Methods: A survey conducted at Bethesda Hospital and Panti Rapih Hospital, Yogyakarta, Indonesia. The survey included the questions about gender, duration of clinical practices, the frequency of handling neuropathy case per week, diagnosis of neuropathy, type of instrument or method to make a diagnosis of DPN. Results: Most of physicians have already assessed for the presence of neuropathy in diabetic patients routinely. About 88.3% physicians made a diagnosis of DPN through symptoms. No physicians used a monofilament to diagnosed neuropathy. Moreover, more than 90% physicians did not know how to use monofilament as an instrument to diagnose neuropathy. Other instruments such as; questionnaires, nerve conduction study and tuning-fork were also rarely used. Conclusion: Most of physicians have already screened for the presence of DPN among diabetic patients. However, the method used is still limited to history taking.
INTRODUCTION
Asian countries contribute to more than 60% of the world’s diabetic population1. Diabetes mellitus is common in Indonesia. The prevalence of diabetes mellitus based on diagnosis by physicians in all age in 2018 was 1.5% from all population in Indonesia. Age 55-64 was the peak age of diabetes mellitus (6.3%) and dominated by female (1.8%)2.
Diabetic Peripheral Neuropathy (DPN) is a peripheral nerve dysfunction. It is a symmetric sensorimotor disturbance characterized by deficits in tactile sensitivity, vibration sense, lower-limb proprioception and kinesthesia3,4. The DPN is the commonest cause of neuropathy and a common complication which can affect up to 90% of patients with diabetes mellitus5,6. It causes substantial morbidity due to foot ulceration and amputation, gait disturbance and fall-related injury6,7. The DPN lowers quality of life and increases health costs associated with diabetes significantly7,8. Primary care practitioners are expected to better assess for and treat DPN9. Unfortunately, DPN is often misdiagnosed or underdiagnosed6,7,10,11. Methods for DPN detection are also underutilized in primary care practice12.
Based on these findings, it is important to examine the method of doctors in Indonesia to diagnose DPN. The main objective of this study was to described the assessment of DPN among clinicians. The secondary objective was to identify the type of instrument or method to diagnose DPN.
MATERIALS AND METHODS
A survey performed at Bethesda Hospital and Panti Rapih Hospital, Yogyakarta, Indonesia, from May-June, 2019. The inclusion criteria of subjects were a certified physicians by Indonesian Physicians Association and working as a clinicians in daily practices. Physicians who work as a lecturer and/or researcher, who do not provide a treatment to patients would be excluded in this study. The DPN has been defined by the Toronto Consensus Panel on Diabetic Neuropathy as a “Symmetrical, length-dependent sensorimotor polyneuropathy attributable to metabolic and microvessel alterations as a result of chronic hyperglycemia exposure and cardiovascular risk covariates”13.
The data obtained in this study i.e., (i) Gender, (ii) Duration of clinical practices, (iii) The frequency of handling neuropathy case per week, (iv) Diagnosis of neuropathy and (v) Type of instrument or method to make a diagnosis of DPN. Duration of clinical practices classified to <5 years, 5-10 years and >10 years. The frequency of handling neuropathy case classified to no case, 5-10 cases/week, 10-20 cases/week and >20 cases/week. Type of instrument or method to make a diagnosis of DN differed to using Nerve Conduction Study (NCS), monofilament, questionnaire and symptoms. Range of sensory symptoms in DPN may include: loss of pain sensation, tingling, “pins and needles” sensation, burning, lancinating or shooting pain (electric shocks), allodynia (painful sensation to an inoffensive stimuli), tingling and prickling sensations (paresthesias) or hyperalgesia (increased sensitivity to painful stimuli)13.
Other questions i.e., (i) Do you check for the presence of neuropathy in diabetic patients routinely?, (ii) Do you have a monofilament?, (iii) Can you do a monofilament test?, (iv) Do you use an ID pain, Diabetic Neuropathy Symptom (DNS) questionnaire or Diabetic Neuropathy Examination (DNE) score? and (v) Do you use a tuning fork? Each question has a yes or no answer choices. All results stated in percentage.
The NCS is an electrodiagnosis non-invasive test to measures nerve function objectively. Monofilament defined as an instrument to detect peripheral neuropathy by using 10 g Semmes-Weinstein monofilament (SWME)14. Tuning fork defined as a 128 Hz metal in “Y” shape which is used as vibration test15,16. In the DNS, the patients questioned whether they have unsteadiness in walking, burning, aching pain, tenderness, pricking sensations and numbness of their legs or feet. The answer is “yes” (positive/1 point) if a symptom occurred more times a week during the last 2 weeks or “no” (negative/no point) if it did not. The maximum score is 4 points (0 point indicates the absence of polyneuropathy whereas, 1-4 point(s) indicates the presence of polyneuropathy). The DNE score consists of eight items, i.e., two testing muscle strength, one a tendon reflex and five sensations. The maximum score is 16. A score of >3 points is considered abnormal17.
RESULTS
There were 60 physicians included in this study. Those physicians consist of 52 general practitioners (86.7%) and 8 neurologist (13.3%). The subjects dominated by male (55%) (Fig. 1). Most of them have already work for less than 5 years (Fig. 2).
On their daily practice, 45% physicians handle <10 neuropathy cases/week, whereas the other 45% handle 10-20 neuropathy cases/week (Fig. 3). The DPN, radiculopathy and entrapment were the most common neuropathy diagnosis (Fig. 4).
Most of physicians (60%) have already assessed for the presence of neuropathy in diabetic patients routinely. About 88.3% physicians made a diagnosis of DPN through symptoms.
| Table 1: Answers of survey | ||||
| Answer | ||||
| Yes | No | Questions | Number |
Percentage |
Number |
Percentage |
| Do you check for the presence of neuropathy in diabetic patients routinely? | 36 |
60 |
24 |
40 |
| Do you have a monofilament? | 3 |
5 |
57 |
95 |
| Can you do a monofilament test? | 5 |
8 |
55 |
92 |
| Do you use an ID pain, DNS or DNE test? | 4 |
7 |
56 |
93 |
| Do you use a tuning-fork? | 1 |
2 |
59 |
98 |
| DNS: Diabetic neuropathy symptom, DNE: Diabetic neuropathy examination | ||||
| Fig. 1: | Physicians gender distribution |
| Fig. 2: | Physicians duration of practice |
No physicians used a monofilament to diagnosed neuropathy. Moreover, more than 90% physicians did not know how to use monofilament as an instrument to diagnose neuropathy as shown in Table 1. Other instruments, such as; ID pain, DNS, DNE and tuning-fork were also rarely used as shown in Fig. 5.
| Fig. 3: | Number of neuropathy case per week |
| Fig. 4: | Variation of neuropathy diagnosis DN: Diabetic neuropathy, PSP: Post stroke pain, PHN: Post herpetic neuralgia |
| Fig. 5: | Type of instrument to detect diabetic peripheral neuropathy NCS: Nerve conduction study |
DISCUSSION
This current study revealed that most of physicians have already assessed for the presence of neuropathy in diabetic patients routinely through patient’s symptoms. Diabetes mellitus is a major health problem in Indonesia18. The DN is the most frequent complication in diabetes mellitus patients in Indonesia (13-78%)19. It was the fourth leading type of neuropathy from all cases in Indonesia (9.6%)20.
In the present study, the subjects dominated by general practitioners. About 60% from all subjects have already assessed for the presence of DPN in diabetic patients routinely. This number was expected to be higher due to the high prevalence of DPN in Indonesia. Since, Indonesian health care system foccused in the primary care, general practitioners play an important role in diagnosis of DPN. General practioners are expected to increase their skill and knowledge to be able to diagnose DPN precisely. Therefore, the morbidity and mortality caused by DPN can be decreased
Based on the result of this study, 88.3% physicians made a diagnosis of DPN through symptoms such as; loss of pain sensation, tingling, “pins and needles” sensation, burning, lancinating or shooting pain, allodynia, tingling and prickling sensations or hyperalgesia. These typical symptoms of DPN occur symmetrical, distal to proximal, in “stocking-glove” pattern15. It is sufficient to made DPN diagnosis based on the clinical presentation or the presence of these typical symptoms and may not require additional evaluation or referral15,21. Unfortunately, estimated up to half of patients with DPN may be asymptomatic for a period of time15,22. In this case, further examination using various instruments is important.
In this study, there was no physicians using a monofilament to diagnose DPN. Moreover, 92% physicians did not know how to use monofilament as an instrument to diagnose DPN. Monofilament is a a simple, effective and inexpensive device for screening or early detection of DPN even though monofilament is a cheap and easy to use, this instrument is rarely used. This statement supported by previous studies by Baraz et al.23 and Brown et al.24. However, a systematic review and meta-analysis concluded that monofilament tests had limited sensitivity for screening DPN25.
From 60 physicians, there was only 1 physician (2%), who use tuning fork as an instrument to detect DPN. The 128 Hz tuning fork is useful to test vibratory sensation14,16 . In the study by Sobhy9, vibration test is more complex and less feasible for regular use in primary care. The monofilament was shown to be both accurate and feasible to implement in primary care. The use of both tools will be better because some DPN patients have small myelinated and unmyelinated fibers dysfunction, that convey sensations of light touch, pain and temperature, while other patients may have large fibers dysfunction, that are responsible for vibratory sensation and joint position sense26.
The NCS is a non-invasive electrodiagnostic to measure peripheral nerve function, both motor and sensory nerves. It provides a higher level of specificity and sensitivity. The advantage of NCS compared to other instruments is the objectivity and reliability14,21. However, it required special equipment and only assesses large fiber21. It also need a special skill to use NCS. In this study, only 3.3% physicians were used NCS to detect DPN.
Evaluation of neuropathic symptoms and signs using validated questionnaires is better than those that does not21. There are many questionnaires to detect DPN such as; ID pain, DNS, DNE, Michigan Neuropathy Screening Instrument (MNSI), Total Symptom Score (TSS), Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Neuropathic Pain Questionnaire (NPQ) and Toronto Clinical Neuropathy Score (TCNS) etc. These questionnaires are inexpensive, fast and easy to perform in clinical practice to detect DPN early. The limitation of using questionnaires i.e., it is subjective and depend on the subject's cooperation and response. It also has a limited sensitivity and has to be used along with other investigations17,21. In this study, it only 8.3% physicians who use questionnaires to diagnose DPN.
CONCLUSION
Most of physicians have already screened for the presence of DPN among diabetic patients. However, the method used is still limited to history taking. Examination using a validated questionnaire and other tools is required to improve the accuracy of DPN diagnosis. An accurate diagnosis may lead to a proper treatment. Therefore, the morbidity and mortality due to DPN can be reduced. Physicians, especially general practitioners are expected to be more careful in examining patients with diabetes.
SIGNIFICANCE STATEMENT
This study discover the lack of use of instruments that can be beneficial for diagnose DPN in daily practice. This study will help to raise awareness of the physicians to use an instrument to diagnose DPN. The use of standardized instrument such as; monofilament, tuning fork and questionnaires, may improve the accuracy of diagnosis.