Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

"Journal of clinical and diagnostic research is a welcome change in publishing practices. It aims to reach out to the grass-root level researchers who do not lack in experience, clinical material and ideas, but lack in their knowledge in English language and statistics. The journal achieves it's aim by supporting in these exact domains.
It also gives due credit to all research designs like descriptive and qualitative studies while many journals ignore these important study designs. The rigorous review process does not allow any compromise in quality
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Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



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Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



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Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : February | Volume : 5 | Issue : 1 | Page : 96 - 100

Sensory Changes In The Upper Limb In Type 2 Diabetic Patients - A Case Control Study

SMITA SARKAR*, CHARU EAPEN**, PRABHA ADHIKARI***

* BPT, Post graduate Student, Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore 575003,Karnataka , India; **MPT, (PhD), Associate Professor, Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore 575003 Karnataka, India; ***MD, Professor, Department of Medicine, Kasturba Medical College, Manipal University, Mangalore 575003, Karnataka, India

Correspondence Address :
Charu Eapen, MPT, PhD
Associate Professor,
Department of Physiotherapy,
Kasturba Medical College, Manipal University,
Mangalore 575003 Karnataka ,India.
Telephone number- 0091 824 2445858 Ext 5332
Fax number - 0091 824 2428183
Email address- charu_mak@hotmail.com

Abstract

THE USE OF A TWO POINT DISCRIMINATION TEST IN THE DIAGNOSIS OF UPPER LIMB NEUROPATHY IN TYPE 2 DIABETES Sensory changes are associated with diabetic neuropathy and the assessment of sensation is commonly done in the foot to prevent ulcers. Though sensory changes may be present in the upper limb also, its documentation is not done routinely.

Aims: To find out the two point discrimination values and other sensory changes in the upper limb in type 2 diabetic patients.

Settings and design: This was a cross sectional design using a case control study, which was done in a hospital with both inpatients and outpatients.

Methods and material: 75 subjects with type 2 diabetes were included in the case group; patients with a diagnosed case of neuropathy were excluded. These were compared with age and sex matched subjects in the control group with no diabetes. Vibration sensation, pressure threshold and two point discrimination were assessed on the hands in both the groups. The Duruoz’s Hand Index was used to assess the general functional status with regards to the abilities of daily living in both the groups.

Statistical analysis: The data was analysed by using the SPSS package, version 13, with p values <.05 being taken as significant.

Results: In the diabetic group, approximately 11 % of the patients had the loss of protective sensation; the median value of the vibration sensation was 11 -14 volts as compared to 3-4 volts in the control group and the mean value of the two point discrimination was 4-5mm.The results were significantly different between the diabetic and the control groups. The median value of DHI was eight in the diabetic group.

Conclusions: All the sensations which were checked were altered in the diabetic patients, thus indicating the possible underlying neuropathy changes. The two point discrimination test can be used to detect upper limb neuropathy in patients with type 2 diabetes, which can further be validated with nerve conduction velocity tests. A sensory evaluation should be done in the upper limb, especially with patients who had diabetes for more than five years, for the possible presence of neuropathy.

Keywords

two point discrimination, hand, type 2 diabetes

How to cite this article :

SMITA SARKAR, CHARU EAPEN, PRABHA ADHIKARI. SENSORY CHANGES IN THE UPPER LIMB IN TYPE 2 DIABETIC PATIENTS - A CASE CONTROL STUDY. Journal of Clinical and Diagnostic Research [serial online] 2011 February [cited: 2019 Aug 25 ]; 5:96-100. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=February&volume=5&issue=1&page=96-100&id=1154

INTRODUCTION

Diabetes mellitus is associated with reduced life expectancy, significant morbidity and a diminished quality of life (1), affecting more than 135 million people worldwide and the number is expected to reach approximately 300 million by 2025. (2) Type 2 diabetes accounts for 90-95% of the total diabetes cases (3) and is age related, peaking at 60-69 years of age (4). Because of its gradual progression, usually a mean of 4-7 years will pass by from the initial onset of type 2 diabetes until the time of its diagnosis (3). Diabetic neuropathy is among the most common long term complications of diabetes, affecting up to 50%-60% of the patients who have poor glycaemic control (5). It is one of the most important factors for foot ulceration in diabetes mellitus (DM) patients. (6) In some instances, patients with diabetic neuropathy have few complaints, but their physical examinations reveals mild to moderate severe sensory loss. (7) These symptoms are commonly seen in the feet before they are seen in the hands and arms (upper extremity). (8)
In sensory nerve damage, as the sensory loss ascends and reaches approximately mid calf, it appears in the hands. This gradual evocation causes the typical ‘stocking glove’ sensory loss which reflects preferential damage according to axon length, the longest axons being affected first. (9) Sensibility testing is thus important in diabetic patients with sensory neuropathy to prevent any complications that may arise because of the loss of sensation. Various modalities of touch sensation like pressure, vibration and two-point discrimination (TPD) are used to test sensation loss or sensibility. (10)

The main purpose of the examination of vibration is to assess the evidence of dysfunction in the peripheral sensory nerves in the extremities, mainly during neuropathy, as the vibration sense diminishes with a variety of neuropathies (11) and it may be the first sensation to be lost Its loss can be detected before the loss of the Two point Discrimination. (9) Vibration loss in the upper extremity suggests severe neuropathy. The more severe the vibratory loss, the more likely the finding is to be clinically significant. (9)

Static Two Point Discrimination has been used as a tool to measure sensory loss and to determine digital nerve integrity in diabetes mellitus patients. (10),(6) Although the method is subjective, the patient must report whether or not the pressure is felt, it is more reliable than the previously available methods and it is a quantitative measure of the sensory loss. (6)

The Semmes-Weinstein monofilament testing divided the huge population of diabetes mellitus patients into subjects who were at risk and it is one of the primary screening methods for measuring cutaneous sensibility . (10)

The onset of the loss of sensation in the lower extremities is the commonest symptom which is associated with peripheral neuropathy (12) and all these methods have been shown to be of value in identifying the patients who are at a risk of diabetes related foot complications. (13) Sensory changes may be present in the upper limb, possibly due to the underlying neuropathy. The patients may be unaware of this and may be at a risk of causing harm to their hands through burns or injuries. The aim of this study was to assess and document the sensory changes in the upper limb of the diabetic patients and to compare them with those which were seen in normal individuals.

Material and Methods

This study was approved by the Time Bound Ethical Committee and the Scientific Committee. Informed consent was taken from all the subjects.

Seventy five subjects with type 2 diabetes between the age group of >40 to 82 years and in whom the duration of diabetes was more than five years, were taken for the study by using a non random sampling method. The exclusion criteria were, patients with a diagnosed case of upper limb diabetic neuropathy, neuropathy other than diabetic neuropathy or radiculopathy , patients with autonomic neuropathy andthose with diagnosed neuro musculoskeletal disorders of the hand, symptomatic peripheral vascular disease, traumatic nerve injury of the upper limb, trauma to the hand, congenital anomalies of wrist and hand, skin infections and Hansen’s disease.

The control group consisted of 75 subjects who were matched according to their age and sex and those who were not diagnosed with diabetes.

The Pressure Threshold was tested by using the Touch-Test TM 5 piece Hand Kit (NC12772). The subject’s extremity was rested on a stable, padded surface. The testing was done in a quiet area to help the subject to fully pay attention to the testing procedure. The subject’s vision was occluded. The testing procedure proceeded from the small to large Semmes-Weinstein Monofilaments. It was tested on the palmar surface of the index finger, the little finger and the first dorsum web space. The filament was pressed at a 900 angle against the skin until it was bowed, was held in place for 1.5 seconds and was then removed. A stimulus was applied in the same location up to three times to detect a response. A single response indicated a positive response. For 4.56 and 6.65, the stimulus was applied only once.

The vibration was measured by using Vibrotherm - Dx (serial No – V20611113). The subject’s hands were held in a relaxed, supported position on the table. The procedure was explained to the patients and they were told that they would experience the vibration sensation. Vibration testing was done on the pulps of the index finger and on the little fingers of both the hands. The readings were recorded in Volts.

An Aesthesiometer device (Baseline ® Evaluation Instruments 7-Piece Hand Evaluation Set) which was marked in millimeters was used for checking the two point discrimination. The subject’s hands were fully supported on the examining table, while the vision was occluded. The finger tips of the index finger and the little fingers of both the right and left hands were tested, as they are very important in the active and tactile scanning of an object. The testing was done with a five mm distance between the two points. One or two points were applied lightly to the finger tip in a random sequence in a longitudinal orientation to avoid a crossover from the overlapping digital nerves. The applications were stopped just at a point of blanching. Seven out of ten responses were accurate for scoring. The testing was stopped at 15 mm if the responses were inaccurate at that level.

The Duruöz's Hand Index (DHI) is a functional disability scale, a self-report questionnaire that is efficient in the accurate assessment of hand dysfunction in diabetic patients. (14) The DHI was used to assess the general functional status with regards to the abilities of daily living in both the groups.

All statistical tests were carried out by using the Statistical Package for Social Sciences, version 13.0 for Windows software. The differences were considered as statistically significant at p values <0.05.

The Mann Whitney test was used to find out the differences in the vibration and the two point discrimination between the diabetic and the non diabetic groups. The Students unpaired t test was used to find the difference between the pressure threshold values in both the diabetic and the non diabetic groups. The correlation between the three variables and with the duration of diabetes was done by using Pearson’s Correlation Coefficient at a 95% confidence interval.

Results

The mean duration of diabetes in the subjects was 9.4+5.9 years. When the sensations were correlated to the duration of diabetes, all the sensations showed a partial positive co-relation with the duration of diabetes. Pressure threshold right index (r=0.35, p=.002), vibration right index (r=0.29, p=0.013), two point discrimination right index (r=0.38, p=0.001)
1. Pressure Threshold Variations

The variation in the monofilament which was perceived by the subjects in the diabetic and non diabetic groups is shown in (Table/Fig 1).

(Table/Fig 1): Pressure threshold variation in diabetic and non diabetic group


Comparison
When compared between the groups, the difference in the pressure threshold values was significant for all the three sites (Table/Fig 2).

(Table/Fig 2): Comparison between pressure threshold values in diabetic and non diabetic group
*- Significant (p< .05)

2. Vibration Sensation and Two point discrimination

The diabetic group had a significantly higher value (p<0.0001) as compared to the non diabetic group (Table/Fig 3) and (Table/Fig 4).

3. Correlation between the three sensations which were evaluated.
(Table/Fig 3): Comparison between Vibration perception threshold values in diabetic and non diabetic group

*- Significant (p< .05)

(Table/Fig 4): Comparison between two point discrimination values in diabetic and non diabetic group

*- Significant (p< .05)

A significant correlation was found between two point discrimination and vibration perception on the right side index finger (r =.37, p= .001) and on the right side little finger ( r = .48, p= .000), between pressure threshold and the vibration perception threshold on the right side Index finger ( r =..47, p= .000) and on the right side little finger (r = .49, p= .000). A high correlation was also found between the pressure threshold and two point discrimination on the right side Index finger ( r =.36, p= .002) and on the right side little finger ( r = .36, p= .002).

The Dorouz’s Hand Index median value was 8.00 in the diabetic group.

Discussion

The evaluation of sensibility in the hand of the diabetic patients is of para- mount importance in order to provide the proper identification of the group with neuropathy. Sensory changes in the hand could help to detect the involvement of UL neuropathy in the diabetes group.

In most of the previous studies, various modalities of sensations like temperature, vibration, point localization and 2 PD have been used to measure sensory loss in the diabetic foot (10)](15)(16) Neuropathy is more severe in the lower limbs than in the upper limbs, as the lower limb nerves are affected more often than the upper limb nerves (17); for this reason, probably less studies have assessed UL neuropathy.

In our study, we assessed the sensations and compared the values with age and sex matched non diabetic populations. Patients with the involvement of type 2 diabetes for > 5 years, between the ages of 40 years and 82 years, were taken. Previous studies have mentioned that neuropathy should be suspected in all patients for more than five years. (18),(19) In our study, all the sensations showed a high correlation with the duration of diabetes. Kasturi BA et al study showed that a significant relationship exists between the duration of the disease and the grade of neuropathy. Also, the study observed that the severity of the neuropathy increases as its duration increases. (17) Dutta et al’s study also showed that the prevalence of peripheral neuropathy had a highly significant correlation with the duration of diabetes. (20)

Monofilaments have been shown to be one of the gold-standard instrumentations (21) which can be used for measuring cutaneous sensibility (10), and to check large fibre neuropathy. (5) Our study found that in the non diabetic group, 45.3% subjects were able to perceive 2.83, which showed that normal sensation was present in this group. 54.7% participants were able to perceive a diminished light touch (3.61). These findings could be because of skin thickness and a normal ageing manifestation. (21) This indicates that these participants had fairly used their hands and that they had good temperature appreciation and good protective sensation. (22) But in the diabetic group, 2.83 was not perceived by anyone. Only 32.0% perceived the diminished light touch, 57.3% perceived a diminished protective sensation and 10.7% perceived the loss of protective sensation. According to Callahan AD, the diminished protective sensation indicates the diminished use of the hand, difficulty in manipulating some objects and the tendency to drop objects, and the weakness of the hand. But appreciation of pain and temperature is present that helps to keep a subject away from the injury. The loss of protective sensation indicates little use of the hand, and a diminished or the absence of temperature appreciation, which may cause injury easily. (22) In our study, since 10.7% subjects fell in this category, these subjects needed to be given advice regarding protecting themselves from injury.

When compared between the two groups, the diabetic group was found to have a significantly higher value as compared to the non diabetic group. The reason for the decreased sensation in the diabetic group could be due to the involvement of large myelinated A-beta fibres which were responsible for the pressure threshold. These nerve fibres get involved in neuropathy, thus indicating that neuropathy may be present in the diabetic group. (10)

The ability to feel vibrations is reflected by the function in the large nerve fibres and in the delicate receptors which are located in the finger pulps. (23) The investigation of the Vibrotectile sense in the finger pulps is important to detect any large fibre neuropathy in the hands of diabetics, since such subjects may have neurological symptoms that sometimes may be over looked in clinical practice.

Vibration perception sensitively reflects the disturbances in the function of the fast adapting mechanoreceptors and in the thick myelinated sensory nerve fibres. Both are commonly affected in diabetes (10). We found that there was a highly significant difference between the vibration sensations in both the diabetic and the non diabetic patients . As the vibration is conducted by the large myelinated nerve fibres in the diabetic patients, the longest nerves are affected first, possibly due to a metabolic abnormality, leading to the failure of axonal transport and subsequent degeneration (24), causing more impaired sensations among the diabetic patients. (25)

The two point discrimination (2PD) is the current recommended method for evaluating the loss of sensation or the degree of sensation loss in the diabetic patients. (6) Our study also found that the two point discrimination values were very highly significant between the diabetic and the non diabetic individuals. R. Periyasamy et al in their study, also found that the 2PD values of the DM subjects were always higher than that of the normal subjects. (10)

Our study also found that there was a significant correlation between vibration, perception threshold and two point discrimination in the diabetic group. Vibration sensation is used to detect the changes in neuropathy. Since there was a significant correlation between vibration and two point discrimination, for assessment purposes in clinical settings, the two point discrimination test can be used to detect changes in the upper limb due to neuropathy, as it is a relatively easy test and as elaborate instrumentation is also not required. Whereas in the non diabetic group, there was no significant difference between the vibration perception threshold and the two point discrimination. This indicates that in the non diabetic group, all the tests should to be checked in the clinical settings.

Our study showed that the mean value of DHI was 12.3+14.01 among the diabetic group. As the DHI score ranges between 0-90, the mean value of DHI in our study showed that patients with diabetes had less hand-related activity limitation. In the non diabetic group, activity limitations were not present.

The results of the present study have shown a significant difference in the sensations which were found in the diabetic and the non diabetic groups. All the sensations were found to be decreased in the diabetic groups as compared to those in the non diabetic groups. Though no symptoms were reported by these patients, the clinical evaluation of the sensations revealed the changes. This may suggest the presence of underlying neuropathy, which can be further confirmed by nerve conduction studies. Electrophysiology has been used as the gold standard to detect and verify large fibre neuropathy in the upper extremity. (23) Peripheral neuropathy can be diagnosed if abnormal Nerve Conduction Velocity is present. (20) Nerve Conduction studies (NCSs) are strongly correlated with the underlying structural changes and are the least subjective and the most reliable single criterion standard. (26) Our patients who presented with decreased sensations could be subjected to Nerve Conduction (NC) tests to find any association between the clinical testing methods and the NC test which is considered to be the gold standard. Once neuropathy is established, significant recovery does not occur. Hence, the early detection of neuropathy helps in aggressive treatment. (17)

This study also signifies that sensory changes are present in the hands of diabetics and that a considerable amount of patients fall into the category that needs advice regarding the care of their hands. Sensations should be checked in the hands of patients with diabetes for at least five years.

Contributions of the authors

Smita Sarkar (SS) collected the data, analysis and interpretation of data, wrote and edited manuscript, final approval.
Charu Eapen (CE) conception and design, analysis and interpretation of data, contributed to manuscript, reviewed/edited manuscript, final approval.

Prabha Adhikari (PA) conception and design, analysis and interpretation of data, critically reviewed/edited manuscript, final approval.

Key Message

1. In some instances, patients with diabetic neuropathy have few complaints, but their physical examinations reveals mild to moderate severe sensory loss.
2. The sensibility testing is important in diabetic patients with sensory neuropathy, to prevent any complications that may arise because of the loss of sensation. Various modalities of touch sensation like pressure, vibration and two-point discrimination (TPD) are used to test sensation loss or sensibility.
3. Sensory changes may be present in the upper limb, possibly due to the underlying neuropathy. The patients may be unaware of this and may be at a risk of causing harm to their hands through burns or injuries.
4. All the sensations were found to be decreased in the diabetic group as compared to the non diabetic group. Though no symptoms were reported by these patients, the clinical evaluation of the sensations revealed the changes.
5. Sensations should be checked on the hands of all the patients who have had diabetes for more than five years. Changes in the sensations also indicate the possible presence of neuropathy in the upper limb, which can further be confirmed by Nerve Conduction studies.

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