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.
Patients can only examine and handle their own feet if they have adequate visual acuity and joint mobility. We therefore studied the physical capacity of patients with neuropathy to perform the preventive footcare measures previously taught. The study included three groups of diabetic outpatients, comparable for age and duration of diabetes: (1) 38 patients with neuropathic ulcers; (2) 21 patients with neuropathy, but no ulcers; (3) 30 patients without neuropathy. Visual acuity and joint mobility, expressed as minimum eye-metatarsum and heel-buttock distances, did not differ between uncomplicated neuropathic and non-neuropathic patients: visual acuity was sufficient in 95% of neuropathic patients without ulceration and in 87% of non-neuropathic patients; joint mobility was in the normal range in both groups. However, 71% of complicated neuropathic patients had insufficient visual acuity for correct foot examination, and their joint mobility was reduced compared with uncomplicated neuropathic and non-neuropathic patients.
We thank Mezitis et al. for pointing out the decline in Chemstrip bG (Boehringer Mannheim test Glycemie 20-800) values over time. We also assure them that in our study, the reflectance meters were indeed recalibrated for the lot number of the stored strips. Before beginning our study, we were aware that there are multiple sources of error that may be introduced in the use of self-monitoring of blood glucose. We thought it was more reliable to ask the patients to store the strips than to allow them to record their own values. In light of recent work, caution is clearly necessary in comparing the values obtained over 1 wk with those obtained over 1 mo. In our study, however, the actual effect of glyburide compared with placebo was made during equal periods, i.e., monthly. The patterns of response would therefore have been reliable during the treatment arms. We also emphasize that the primary method of assessing glycemie control was by glycosylated hemoglobin and that the patterns of change in Chemstrip bG were merely a reflection of these more reliable estimations of control.
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