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The best way to detect early onset of diabetic peripheral neuropathy

By Barry L. Jacobs D.O. 2 years ago 4528 Views No comments

In Diabetic Peripheral Neuropathy (DPN) cutaneous pinprick sensation deteriorates early and gradually over time. Therefore, as a testing modality, it can be exploited for both sensitivity and if the technique is correct, for subtle specificity.

Continuous Pinprick Comparison (CPC) is far better than conventional pinprick technique because the latter only utilizes a binary response. ‘All or nothing’ is bound to provide many false negative results because sensory loss is incremental. The patient is asked only IF they can feel the sensation and not to rate HOW MUCH they feel it.

If a comparative, analogue scale is introduced, the technique is able to demonstrate subtle loss of sensation by degree. This will enable the detection of sensation deficit by pinprick testing to precede other modalities and more accurately reflect progress of deficit.

The provision of an analogue scale then affords the facility to more reliably predict patients at risk of complication and facilitate cost effective management.

How To Do It

In the past pinprick sensation testing has been dismissed clinically because it is typically used only in a binary, "on or off" fashion which produces largely false negative results. Essentially, where pinprick perception has diminished, patients can still report a stimulus though there is no facility to express magnitude. In consequence pinprick appears insensitive to neuropathy by virtue of it being applied to the wrong question.

If the technique is modified to employ a continuous repetitive comparison with a control area of skin, effectively unaffected by pathology, whilst asking the patient to express their sensitivity in the affected area on a simple scale of 1-5 (where "normal" is 5) it is possible to establish a subtle analogue scale from verbal feedback.

When a different observer/operator repeats the procedure on the same subject it is a simple matter to re-establish the new ‘5’. Furthermore intra and inter-operator test reliability can be significantly facilitated by use of a rapid repetitive application technique to iron out random variations in application pressure and nociceptor distribution.

In short pinprick is often the first sensation to be lost (sensitivity) and the most easily assessed accurately (specificity) providing the correct technique is employed.

Below is a table of modalities and their strengths in detecting neuropathy.






Ease of application in primary care Setting






Very Sensitive in the young

(Goes Early)

Very Sensitive in the young

(Goes Early)

Very insensitive (Goes late)

Very Sensitive in all age groups (Goes early)


Very Unspecific

absent in middle stages and physiologically less sensitive in the elderly

Very specific in the young

and physiologically less sensitive in the elderly

Very Specific but only to crude/late loss

Very Specific with CPC as caters to an analogue/

Predictive scale

Inter & Intra Observer /Operator Reliability

Not Very reliable due to inter-operator error in application

Not very reliable due to accuracy of equipment

Very reliable with new instrument

Very reliable with CPC

Proven by North West Study nearly 10,000 patient cohort and crude test

Abbott et al, 2002, The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort 2002 Diabetes UK. Diabetic Medicine, 19, 377–384

Medipin is an FDA listed, all-plastic precision instrument which was designed to avoid skin puncture whilst, simultaneously, significantly heightening stimulation at lower application pressures by exploiting the phenomenon of neural lateral inhibition. A specially faceted and blunted point is situated within a surrounding annular component that serves to both micro stretch the skin and create an artificial center surround field.

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