Screening

Screening for peripheral neuropathy

Screening for peripheral neuropathy should be undertaken in patients with:[1]​​[39]​​​

  • Type 2 diabetes, from diagnosis

  • Type 1 diabetes, 5 years after diagnosis

  • Metabolic syndrome or impaired glucose tolerance with symptoms of peripheral neuropathy.

Screening is conducted at least annually thereafter, using symptoms and signs. Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small-fibre function) and vibration sensation using a 128-Hz tuning fork (for large-fibre function). All people with diabetes should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation. Foot evaluation should also include vascular assessment and inspection of the skin. Note that patients with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit.​[39]

The Michigan Neuropathy Screening Instrument (MNSI) and similar symptom scoring systems are useful in clinical research.[114][115][116][117]

Electrophysiological testing or referral to a neurologist is rarely needed, except in situations where diagnosis is unclear or the clinical features are atypical:[1]​​[39]​​

  • Motor deficits greater than sensory deficits

  • Marked asymmetry of the neurological deficits

  • Initial symptoms in the upper extremities

  • Rapid progression.

Screening for autonomic neuropathy

The American Diabetes Association (ADA) recommends that clinicians assess symptoms and signs of autonomic neuropathy in people with diabetes starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes, and at least annually thereafter and with evidence of other microvascular complications, particularly kidney disease and diabetic peripheral neuropathy. Screening can include asking about orthostatic dizziness, syncope, or dry cracked skin in the extremities. Signs of autonomic neuropathy include orthostatic hypotension, a resting tachycardia, or evidence of peripheral dryness or cracking of skin.​[39]

In practice, further testing may not be needed, as it may not affect management or outcome. However, according to the ADA, further testing can be considered if symptoms are present and will depend on the end organ involved but might include cardiovascular autonomic testing, sweat testing, urodynamic studies, gastric emptying, or endoscopy/colonoscopy.​[39]​

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