J Endocrinol Metab

Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc

Journal website http://www.jofem.org

Original Article

Volume 1, Number 1, April 2011, pages 21-26

The Diagnostic Sensitivity, Specificity and Reproducibility of the Clinical Physical Examination Signs in Patients of Diabetes Mellitus for Making Diagnosis of Peripheral Neuropathy

**Table 1.** Clinical Examination Index Tests Used in the Current Study
Modality tested	Test procedure	Interpretation of abnormal test
Cutaneous sensations	Equipment: 10 g Semmes Weinstein monofilament Procedure: Cutaneous touch sensation tested on ten sites of spirit alcohol wiped foot. These sites were i) dorsal surface of the foot between the base of the first and second toes, ii) first toe, iii) third toe, iv) fifth toe, v) the first metatarsal head, vi) third metatarsal head, vii) fifth metatarsal head, viii) medial midfoot, ix) lateral midfoot and x) heel. The monofilament was pressed perpendicular to the test site with enough pressure to bend the monofilament for 1 sec. Patients was asked to answer “Yes” or “No”, when felt or did not feel the press of the monofilament, respectively.	If a patient did not perceive the filament at more than 4 out of 10 sites, then the test was considered abnormal.
Vibration test	Equipment: 128 hertz vibration fork Procedure: The stimulus was applied over the distal phalanx of the large toe. The patient reported whether they felt vibration sense and then reported when it stoped in order to assess the minimal threshold to perceive the stimulus.	If the patient did not perceive the vibration it would be labeled as absent vibration sensation or impaired vibration.
Ankle reflex	Equipment: Standard percussion hammer Procedure: The ankle reflex was elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer with other hand, and noting plantar flexion.	A positive result would be the jerking of the foot towards its plantar surface (plantar flexion) and the contraction of calf muscles and its absence was labeled as absent ankle reflex.

Table 1. Clinical Examination Index Tests Used in the Current Study

Modality tested

Test procedure

Interpretation of abnormal test

Cutaneous sensations

Equipment: 10 g Semmes Weinstein monofilament
Procedure: Cutaneous touch sensation tested on ten sites of spirit alcohol wiped foot. These sites were i) dorsal surface of the foot between the base of the first and second toes, ii) first toe, iii) third toe, iv) fifth toe, v) the first metatarsal head, vi) third metatarsal head, vii) fifth metatarsal head, viii) medial midfoot, ix) lateral midfoot and x) heel.
The monofilament was pressed perpendicular to the test site with enough pressure to bend the monofilament for 1 sec. Patients was asked to answer “Yes” or “No”, when felt or did not feel the press of the monofilament, respectively.

If a patient did not perceive the filament at more than 4 out of 10 sites, then the test was considered abnormal.

Vibration test

Equipment: 128 hertz vibration fork
Procedure: The stimulus was applied over the distal phalanx of the large toe. The patient reported whether they felt vibration sense and then reported when it stoped in order to assess the minimal threshold to perceive the stimulus.

If the patient did not perceive the vibration it would be labeled as absent vibration sensation or impaired vibration.

Ankle reflex

Equipment: Standard percussion hammer
Procedure: The ankle reflex was elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer with other hand, and noting plantar flexion.

A positive result would be the jerking of the foot towards its plantar surface (plantar flexion) and the contraction of calf muscles and its absence was labeled as absent ankle reflex.

**Table 2.** Reproducibility of Physical Signs
Observer 1 (Medical student) vs. Observer 2 (Physician)	Impaired vibration	Impaired sensation	Absent ankle reflex
Percent agreement	83	82	77
Kappa	0.35	0.53	0.45
95% CI	0.11 - 0.60	0.35 - 0.72	0.27 - 0.64

Table 2. Reproducibility of Physical Signs

Observer 1 (Medical student) vs. Observer 2 (Physician)

Impaired vibration

Impaired sensation

Absent ankle reflex

Percent agreement

Kappa

0.35

0.53

0.45

95% CI

0.11 - 0.60

0.35 - 0.72

0.27 - 0.64

**Table 3.** Accuracy of Physical Signs
Variable	Sensitivity	Specificity	LR+	LR-	PPV	NPV
Sensory
Parasthesia	50 (36.84 - 63.16)	41.3 (27.82 - 55.86)	0.85	1.21	50 (37.1 - 62.8)	41.3 (28.88 - 55.66)
Dysthesia	50 (30.59 - 69.41)	42.11 (31.40 - 43.40)	0.86	1.18	21.4 (12.7 - 33.81)	72.72 (58.15 - 83.65)
Impaired vibration	25.93 (15.58 - 38.79)	80.43 (67.12 - 90.01)	1.33	0.92	19.57 (9.99 - 32.880	74.07 (61.21 - 81.42)
Impaired sensations	27.78 (17.09 - 40.79)	71.74 (57.53 - 83.29)	0.98	1.01	53.57 (37.81 - 70.460	45.83 (34.82 - 57.26)
Absent ankle reflex	72.22 (59.21 - 82.91)	45.65 (31.74 - 60.09)	1.33	0.16	54.35 (39.91 - 68.26)	27.78 (17.09 - 40.79)
Motor
Motor weakness symptom	63.16 (47.11 - 77.22)	40.32 (28.69 - 52.84)	1.06	0.91	59.68 (47.16 - 71.31)	36.84 (22.73 - 52.89)
Absent ankle reflex	78.95 (63.91 - 89.71)	46.77 (34.64 - 59.20)	1.48	0.45	52.23 (40.80 - 65.36)	21.05 (10.29 - 36.09)
Mixed
Parasthesia	50 (30.59 - 69.41)	42.11 (31.40 - 43.40)	0.86	1.18	21.42 (12.70 - 33.81)	72.72 (58.15 - 83.65)
Dysthesia	66.67 (46.36 - 83.16)	34.21 (24.22 - 45.39)	1.01	0.97	65.79 (54.6 - 75.7)	33.33 (16.84 - 53.64)
Motor weakness symptom	45.83 (26.96 - 65.66)	32.89 (23.05 - 44.02)	0.68	1.64	17.74 (10.2 - 29.0)	65.48 (49.89 - 78.78)
Impaired vibration	25 (10.81 - 44.92)	85.53 (76.24 - 92.15)	1.73	0.88	14.47 (7.85 - 23.76)	75 (55.08 - 89.18)
Impaired sensations	33.33 (16.84 - 53.64)	72.37 (61.53 - 81.53)	1.21	0.92	27.63 (18.47 - 38.47)	66.67 (46.36 - 83.16)
Absent ankle reflex	75 (55.08 - 89.19)	43.42 (32.63 - 54.71)	1.33	0.58	56.58 (45.29 - 67.37)	25 (10.81 - 44.92)

Table 3. Accuracy of Physical Signs

Variable

Sensitivity

Specificity

LR+

LR-

PPV

NPV

Sensory

Parasthesia

50 (36.84 - 63.16)

41.3 (27.82 - 55.86)

0.85

1.21

50 (37.1 - 62.8)

41.3 (28.88 - 55.66)

Dysthesia

50 (30.59 - 69.41)

42.11 (31.40 - 43.40)

0.86

1.18

21.4 (12.7 - 33.81)

72.72 (58.15 - 83.65)

Impaired vibration

25.93 (15.58 - 38.79)

80.43 (67.12 - 90.01)

1.33

0.92

19.57 (9.99 - 32.880

74.07 (61.21 - 81.42)

Impaired sensations

27.78 (17.09 - 40.79)

71.74 (57.53 - 83.29)

0.98

1.01

53.57 (37.81 - 70.460

45.83 (34.82 - 57.26)

Absent ankle reflex

72.22 (59.21 - 82.91)

45.65 (31.74 - 60.09)

1.33

0.16

54.35 (39.91 - 68.26)

27.78 (17.09 - 40.79)

Motor

Motor weakness symptom

63.16 (47.11 - 77.22)

40.32 (28.69 - 52.84)

1.06

0.91

59.68 (47.16 - 71.31)

36.84 (22.73 - 52.89)

Absent ankle reflex

78.95 (63.91 - 89.71)

46.77 (34.64 - 59.20)

1.48

0.45

52.23 (40.80 - 65.36)

21.05 (10.29 - 36.09)

Mixed

Parasthesia

50 (30.59 - 69.41)

42.11 (31.40 - 43.40)

0.86

1.18

21.42 (12.70 - 33.81)

72.72 (58.15 - 83.65)

Dysthesia

66.67 (46.36 - 83.16)

34.21 (24.22 - 45.39)

1.01

0.97

65.79 (54.6 - 75.7)

33.33 (16.84 - 53.64)

Motor weakness symptom

45.83 (26.96 - 65.66)

32.89 (23.05 - 44.02)

0.68

1.64

17.74 (10.2 - 29.0)

65.48 (49.89 - 78.78)

Impaired vibration

25 (10.81 - 44.92)

85.53 (76.24 - 92.15)

1.73

0.88

14.47 (7.85 - 23.76)

75 (55.08 - 89.18)

Impaired sensations

33.33 (16.84 - 53.64)

72.37 (61.53 - 81.53)

1.21

0.92

27.63 (18.47 - 38.47)

66.67 (46.36 - 83.16)

Absent ankle reflex

75 (55.08 - 89.19)

43.42 (32.63 - 54.71)

1.33

0.58

56.58 (45.29 - 67.37)

25 (10.81 - 44.92)