Graduated Tuning Fork Research Articles

Vibration perception among children and adolescents with Charcot-Marie-tooth disease and implications for foot posture

BackgroundAlterations in vibration perception among children and adolescents with Charcot-Marie-Tooth disease might explain observed changes in foot posture. Therefore, this cross-sectional study compared the vibration perception of the lower limbs in youths with and without Charcot-Marie-Tooth disease and verified the cut-off value of the distal vibration perception for the Charcot-Marie-Tooth group. In addition, associations between dynamic plantar pressure, vibration perception and isometric muscle strength were investigated. MethodsParticipants aged 9–18 (Charcot-Marie-Tooth group n = 32; Typical group n = 32) had vibration perception measured by a 128-Hz graduated tuning fork. The static and dynamic foot posture were evaluated by the Foot Posture Index and pressure distribution measuring system, respectively. For the Charcot-Marie-Tooth group, a hand-held dynamometer evaluated the isometric muscle strength of the lower limbs. FindingsChildren with Charcot-Marie-Tooth disease presented impaired vibration perception at the distal phalanx of the hallux and head of the first metatarsal compared to their typically developing peers, while adolescents with Charcot-Marie-Tooth disease showed impairment in all the tested regions compared to their typically developing peers. The cut-off value for vibration perception for participants with Charcot-Marie-Tooth disease was 5.7, considering the original grade of the tuning-fork 128 Hz. Among the associations established for the Charcot-Marie-Tooth group, a greater vibration perception at the distal phalanx of the hallux was associated with a longer rearfoot contact time (β = 31.02, p = 0.04). InterpretationThese new findings may guide the clinical evaluation and rehabilitation treatment for children and adolescents with Charcot-Marie-Tooth disease.

Peripheral sensory nerve function, type 2 diabetes and frailty among men with cardiovascular disease

ObjectiveTo investigated the cross-sectional association between peripheral sensory nerve function and frailty among community-dwelling men, and examine whether type 2 diabetes (T2D) modifies this association. MethodsA sample of 349 men [mean age = 77.1 ± 6.4 years; 37 % with T2D] who previously (1990–1998) participated in the Bezafibrate Infarction Prevention (BIP) trial, underwent assessment of frailty and legs vibratory thresholds (LVT), a measure of peripheral sensory nerve function, as part of the BIP Neurocognitive study during 2011–2013. LVT was assessed using a graduated tuning fork and frailty was assessed using the Fried criteria. An ordered logistic regression model was used to assess the link between LVT and degrees of frailty and to test for effect modification by T2D. ResultsOverall, 117 (33.5 %) of patients were non-frail, 134 (38.4 %) pre-frail, and 98 (28.1 %) frail. A significant interaction between LVT and T2D with regard to frailty was found. Among men with T2D, estimated OR (95%CI) for increasing frailty at the 1st, 2nd, and 3rd as compared to the top LVT quartile were 13.5 (3.4–54.3), 5.9 (1.5–23.5), and 4.4 (1.20–16.0), respectively. Among men without T2D, the estimated ORs for increasing frailty in patients at the 1st, 2nd, and 3rd quartiles compared to the top LVT quartile were 2.8 (1.1–7.4), 1.6 (0.6–4.1), and 2.5 (1.0–6.5), respectively. ConclusionFrailty is significantly associated with worsening peripheral sensory nerve function, particularly among men with T2D.

Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability

BackgroundTesting of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes.MethodsThree podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year’s clinical experience. The intra- (Cohen’s К) and inter-rater (Cohen’s or Fleiss’ К) reliability of each test was determined.ResultsFifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38–0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41–0.95, p < 0.01). The 10-site monofilament (К: 0.44–0.77) outperformed the 4-site test (К: 0.34–0.67) and the dampened tuning fork method (К: 0.41–0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52–0.57) and graduated methods (К: 0.50–0.57).ConclusionWe support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.

Venlafaxine to prevent oxaliplatin-induced neuropathy?: A pilot randomized placebo-controlled trial.

e20734 Background: Previous pilot data suggested venlafaxine could prevent acute and chronic oxaliplatin-related neuropathy (Durand et al, Ann Oncol, 2012, p200). The purpose of this randomized, placebo-controlled, double-blinded pilot study was to try to obtain additional data to support conducting a phase III trial to test the use of venlafaxine to prevent oxaliplatin neurotoxicity. Methods: 50 patients scheduled to undergo oxaliplatin-based therapy (FOLFOX) for stage II-III (67%) or stage IV (33%) colon cancer, from 9 sites between 02/2012 and 03/2014, were randomized to receive venlafaxine XR (37.5 mg) or placebo, twice daily, through last dose of oxaliplatin, and then titrated off. Acute neuropathy was evaluated with a standard patient questionnaire (Loprinzi et al, JCO, 2014, p997). Prior to each oxaliplatin dose, neurotoxicity was evaluated via several mechanisms: the EORTC QLQ CIPN20, the NCI CTCAE v4.0, an oxaliplatin-specific scale, and a Rydel-Seiffer graduated tuning fork. Results: Baseline pt...

Utility of Quantitative Sensory Testing and Screening Tools in Identifying HIV-Associated Peripheral Neuropathy in Western Kenya: Pilot Testing

Background/AimNeuropathy is the most common neurologic complication of HIV but is widely under-diagnosed in resource-constrained settings. We aimed to identify tools that accurately distinguish individuals with moderate/severe peripheral neuropathy and can be administered by non-physician healthcare workers (HCW) in resource-constrained settings.MethodsWe enrolled a convenience sample of 30 HIV-infected outpatients from a Kenyan HIV-care clinic. A HCW administered the Neuropathy Severity Score (NSS), Single Question Neuropathy Screen (Single-QNS), Subjective Peripheral Neuropathy Screen (Subjective-PNS), and Brief Peripheral Neuropathy Screen (Brief-PNS). Monofilament, graduated tuning fork, and two-point discrimination examinations were performed. Tools were validated against a neurologist's clinical assessment of moderate/severe neuropathy.ResultsThe sample was 57% male, mean age 38.6 years, and mean CD4 count 324 cells/µL. Neurologist's assessment identified 20% (6/30) with moderate/severe neuropathy. Diagnostic utilities for moderate/severe neuropathy were: Single-QNS - 83% sensitivity, 71% specificity; Subjective-PNS-total - 83% sensitivity, 83% specificity; Subjective-PNS-max and NSS - 67% sensitivity, 92% specificity; Brief-PNS - 0% sensitivity, 92% specificity; monofilament - 100% sensitivity, 88% specificity; graduated tuning fork - 83% sensitivity, 88% specificity; two-point discrimination - 75% sensitivity, 58% specificity.ConclusionsPilot testing suggests Single-QNS, Subjective-PNS, and monofilament examination accurately identify HIV-infected patients with moderate/severe neuropathy and may be useful diagnostic tools in resource-constrained settings.

How to better systematize the diagnosis of neuropathy?

Two attitudes can be proposed, one consisting of making a diagnosis of neuropathy, the other seeking to grade the stage that it has reached in order to give a prognosis and above all determine the right way in which to educate the patient. In order to do this, it is important for the diagnosis to be thorough. It should be based both on listening to what the patient has to say and examining him/her. It is vital to listen to the patient because the warning signs are discreet, yet very evocative, and they will be a great help in making a positive diagnosis. They should not be confused with signs of arterial damage. They should then be interpreted by means of clinical examination and the tools that are available, i.e. essentially monitoring the osteo-tendinous reflexes and sensory signs. The sensory signs can only be studied with high-quality instruments, i.e. either a monofilament of proven technical quality and that should be used with care in line with good clinical practice recommendations, or by using a graduated tuning fork, or a neuroesthesiometer which will make it possible to obtained graduated responses, not simply binary responses of the "yes/no" variety. A whole series of scores have been put forward combining both functional and physical signs, making it possible to try to quantify the stage reached and the extent of the neuropathy. It is only by using a thorough and regularly applied routine that we can progress to establishing a better prognosis and providing a better educational service for the patient.

131st ENMC International workshop: Selection of Outcome Measures for Peripheral Neuropathy Clinical Trials: 10–12 December 2004, Naarden, The Netherlands

131st ENMC International workshop: Selection of Outcome Measures for Peripheral Neuropathy Clinical Trials: 10–12 December 2004, Naarden, The Netherlands

Tuning fork (128 Hz) versus Neurothesiometer: a comparison of methods of assessing vibration sensation in patients with diabetes mellitus

The current study compared the effectiveness of the graduated tuning fork (128 Hz) and the neurothesiometer in assessing vibration sensation perception in patients presenting with type II diabetes mellitus. A quota sample of patients (n = 21; age range 43-73 years) were assessed using the neurothesiometer and tuning fork by two investigators at five sites on both feet. There was a positive correlation between the results for the two methods of assessment for both investigators, and also between the results for both tools at three individual sites. Overall, there was 66.2% agreement between the results obtained from the two investigators using the tuning fork at each site; however, Kappa values only reached statistical significance at one site, indicating variability between the results from the two tools. This study suggests that assessment of vibration sensation with the tuning fork may be unreliable. These preliminary findings are based on a small sample size; thus further research is warranted.

Use of the Rydel–Seiffer graduated tuning fork in the assessment of vibration threshold in postherpetic neuralgia patients and healthy controls

Background and aims: Afferent large fibre impairment has been reported as a useful predictor of postherpetic neuralgia (PHN) in patients with acute herpes zoster infection, using an electromechanical device to provide quantitative vibrametry. We aimed to demonstrate a clinically significant increase in vibration threshold in individuals with PHN compared to age-matched controls, using the portable and affordable Rydel–Seiffer graduated tuning fork. Methods: We studied 45 PHN subjects aged over 55 years, and 45 age-matched controls with no history of herpes zoster infection. We excluded subjects with a history of disorders associated with neuropathy or immunocompromise. Measurements were performed at the ulnar styloid process and the head of the first metatarsal on the right side, in a warm room with the subject seated. Readings were taken in triplicate and the data analysed by a repeated measures design. Results: We observed a significant difference in vibration threshold at both wrist and toe between the PHN and control groups ( p<0.001). Age-stratification of subjects produced an increased and clinically useful difference between the two groups at both sites in subjects between 55 and 70 years ( p<0.0001). Conclusions: We have shown a statistically significant decrease in vibration sensitivity in individuals with PHN aged 55–70 years compared to age-matched healthy controls, using the Rydel–Seiffer graduated tuning fork. A prospective study of patients with acute zoster infection is needed to determine the sensitivity and specificity of the graduated tuning fork in predicting PHN in patients with acute zoster infection.

The Rydel Seiffer tuning fork: an inexpensive device for screening diabetic patients with high‐risk foot

AbstractConsidering the simple and inexpensive nature of the graduated tuning fork, we evaluated its usefulness in screening for vibratory sensation loss in non‐diabetic and diabetic subjects, compared with the values obtained with biothesiometer. The vibration perception scores were tested in 195 non‐diabetic healthy control subjects (n=195, M:F, 80:115, Mean±SD, age 50.3±10.4 (years), in 455 Type 2 diabetic subjects who had signs and symptoms of sensory neuropathy and abnormal biothesiometric readings (reading&gt;25V), (n=455, M:F 326:129, Mean Age 58.1±7.7 years, HbA1c 10.1±2.4%) and in 471 diabetic patients with no evidence of neuropathy by biothesiometry. (M:F 299:172, Mean Age 48.0±7.5 years, HbA1c 9.5±2.2%). Patients with neuropathy had a lower mean score of 4.5±2.6 compared with the non‐neuropathy cases (7.7±0.5, P&lt;0.001). Among the 455 patients identified as having neuropathy by abnormal biothesiometric values, 235 had an abnormal tuning fork score of ≤4.0. Tuning fork scores were normal in all the 471 non‐neuropathy cases, thus giving a specificity of 100%. This study shows that the graduated tuning fork has a high specificity and a fairly good sensitivity in the diagnosis of diabetic foot problems. Copyright © 2001 John Wiley &amp; Sons, Ltd.

Quantitative sensory testing and risk factors of diabetic sensory neuropathy.

The goal of this study was to identify risk factors for diabetic peripheral sensory neuropathy in type 2 diabetes mellitus in a Chinese population. Peripheral sensory neuropathy was detected by quantitative sensory testing (5.07/10 g monofilament, neurometer and 128-Hz Riedel Seiffert graduated tuning fork). Those who had two or more abnormal quantitative sensory testings were defined as having diabetic sensory neuropathy. Of the 558 non-insulin dependent diabetes mellitits subjects, 62 (11.1%) had peripheral neuropathy. In 59 (10.6%) detection was by monofilament testing, 45 (8.1%) by graduated tuning fork, and 189 (33.9%) by neurometer. In a multivariate logistic regression model, age and insulin therapy were significantly associated with peripheral neuropathy. Age, serum triglyceride, height, and fasting plasma glucose were independently associated with large fiber neuropathy. Our results confirm the previously identified multiple risk factors of diabetic neuropathy. Different quantitative sensory testings detect different nerve fiber defects. The weak correlation between these tests indicates the need to use more than one test in screening for diabetic neuropathy.

Measuring vibration threshold with a graduated tuning fork in normal aging and in patients with polyneuropathy

OBJECTIVETo provide clinically useful vibration threshold normal values.METHODSThe graduated Rydel-Seiffer tuning fork was evaluated in 198 healthy controls and 59 patients with a polyneuropathy. The measures were done in triplicate...

The Tuning Fork Revisited

The performance of the Rydel-Seiffer graduated tuning fork was examined in healthy subjects and in various groups of diabetic patients in order to evaluate its efficacy for identifying patients whose loss of vibration sensation may expose them to the risk of foot injury. Vibration perception score measured with the tuning fork declined with age (p less than 0.001) in the control subjects. It correlated well (r = -0.90, p less than 0.001) with the thresholds obtained with an electromagnetic instrument (Vibrameter) in diabetic patients, in whom vibration perception score was impaired compared with control subjects (4.0 +/- 1.8 (+/- SD) vs 5.4 +/- 1.4, p less than 0.001). Age-related Rydel-Seiffer tuning fork vibration sensation was impaired in 79% of 38 ulcerated feet of 26 patients. The tuning fork score was less than or equal to 4.0 in 95% of the ulcerated feet. We conclude that the Rydel-Seiffer graduated tuning fork is a suitable tool for screening for sensation loss and that diabetic patients with a tuning-fork score of less than or equal to 4.0 are vulnerable to ulceration.

Measuring Vibration Sensations With Graduated Tuning Fork: Simple and Reliable Means to Detect Diabetic Patients at Risk of Neuropathic Foot Ulceration

To find a simple and reliable means to measure vibration sensations, 189 diabetic patients and 88 control subjects were tested at different sites with a graduated tuning fork. Within-test variation at big toes reached 8.4% in diabetic patients vs. 2.2% in control subjects. Mean contralateral variation was 7.5% in diabetic patients vs. 2.5% in control subjects. Tuning-fork sensations were inversely correlated with duration of diabetes, whereas no correlation was found with HBA1c levels or the severity of retinopathy. Ninety-nine (52%) patients had vibratory sensation at big toes of less than 99th percentile of normal values for age. In addition, 51% of the patients with clinical symptoms at extremities (n = 67), 70% of the patients without tendon reflexes (n = 50), and 75% of the patients with abnormal nerve conduction velocities (n = 60) also had low vibration sensations. All patients with lower-limb injuries (n = 7) had values at big toes of less than 2. Altogether, the graduated tuning fork represents a simple and reliable alternative to quantitate vibration sensations. Long-term follow-up of asymptomatic patients will indicate whether these abnormalities reflect underlying neuropathy. Patients with abnormal values at screening will necessitate additional investigations and special foot-care education programs.