![]() The impaired pressure sensation was determined when the patient could not perceive the applied pressure at one or more of the three sites. The pressure sensation was assessed by the Semmes Weinstein 4.31 monofilament at the planter aspects of the great toe, the first metatarsal and the fifth metatarsal. Note that before the examinations, the examiner applied the vibrating tuning fork on the patient's wrist, to make sure that the patient could recognize the vibration. The examination was repeated three times per site, and the vibratory sensation at a site was evaluated by the mean value of the three records at the site. The examiner recorded the time (seconds) for which the patient could perceive the vibration. The patient was instructed to tell the examiner when the patient felt the vibration stop. At the same time, the examiner began counting the seconds. The examiner stroked the end of a 128‐Hz tuning fork hard enough that the sides touched, and immediately placed the vibrating tuning fork firmly on the bony prominence of the site of interest. The vibratory sensation was evaluated by a 128‐Hz tuning fork at the medial malleolus, the great toe and the fifth toe, as follows 8. The vibratory sensation, the Achilles tendon reflex and the pressure sensation were assessed by one certified diabetes educator. ![]() The study was in accordance with Ethical Guidelines for Epidemiological Research in Japan, and was approved by the human ethics committee of Osaka University. We used a retrospective clinical database of 547 Japanese patients with diabetes mellitus who had their peripheral neurological findings assessed between 20. The aim of the current study was to compare the vibratory sensations assessed by a 128‐Hz tuning fork at different sites in Japanese diabetic patients. It would be of clinical use if the assessment at some alternative sites was clinically validated. In addition, some diabetic patients will suffer from foot lesions at the very site where it is generally recommended to carry out the neurological assessment. However, to date, few data are available about the association between the test at the medial malleolus and at the great toe in Japanese diabetic patients, which has made it difficult to compare the reports from Japan and those from overseas about vibratory sensation. In Japan, vibratory sensation in diabetic patients is often assessed with a 128‐Hz tuning fork at the medial malleolus 8, whereas it is often assessed at the great toe overseas 4. In clinical practice, diabetic peripheral neuropathy is evaluated by the combination of several examinations, including the assessment of vibratory sensation 4. Its periodic assessment is clinically important in the management of diabetes mellitus. It is not only associated with unpleasant symptoms, which impairs quality of life, but is also associated with diabetic foot, resulting in tissue loss and amputation 4. Peripheral neuropathy is a major complication of diabetes mellitus 1.
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