Using a neurothesiometer for a neurological test instead of a tuning fork based on

evidence and findings.

The value of the Rydel-Seiffer tuning fork as a predictor of diabetic polyneuropathy

compared with a neurothesiometer

The tuning fork has proved a reliable instrument to quantify vibration sensations . Because of
the more simple graduation of its scale when compared with the neurothesiometer (scale
ranging between 0 and 50 hz , the tuning fork had an apparently lower intra- and
interobserver variability. However, for the diagnosis of abnormal bedside tests and
symptomatic neuropathy, its sensitivity was very high and the specificity was doubled when
compared with the neurothesiometer, which was only 26%; we further demonstrated a very
high positive predictive value for the tuning fork.
(Vibration perception test)
Some differences of VPT measurements with both devices might be due to the stimulation of
different large or medium-sized sensory nerve fibres by the single instruments, which vibrate
at different frequencies. However, we found a high agreement between the tuning fork and
the neurothesiometer. Evidently, the graded scale of the tuning fork allows a more accurate
quantification of vibration perception than a standard tuning fork without scaling permits.
VPT was normal in 1917 subjects and abnormal in 105 (5.2%) patients when measured by the
tuning fork. Patients with an abnormal vibration test were significantly (P < 0.0001) older
than subjects with a normal vibration sense, while diabetes duration and HbA1c of the former
were also significantly elevated. The same was true for the percentages of an abnormal 10-g
monofilament test (66.7% vs. 7.2%, P < 0.0001. Finally, the VPT measured by the
neurothesiometer was 2.5 times higher in patients with an abnormal tuning fork test
(32.0 9.8 vs. 12.5 6.4 V, P < 0.0001). The plot of the difference of both methods against
their mean yielded a good agreement of the two VPT measurements, and the tuning fork had
a high sensitivity and positive predictive value for the diagnosis of abnormal bedside tests
and for symptomatic neuropathy.
Kastenbauer, T., Sauseng, S., Brath, H., Abrahamian, H., & Irsigler, K. (2004). The value of
the Rydel-Seiffer tuning fork as a predictor of diabetic polyneuropathy compared with a
neurothesiometer. Diabetic Medicine, 21(6), 563-567. http://dx.doi.org/10.1111/j.14645491.2004.01205.x

Tuning fork (128 Hz) versus Neurothesiometer: a comparison of

methods of assessing vibration sensation in patients with diabetes
mellitus

Whilst there was a good level of agreement between both investigators for both tools, the
Kappa values for the tuning fork results were poor. Furthermore, both investigators only
identified the same three (of the eight) patients who felt tuning fork vibration at all 10 sites.
There was some variation between both investigators' results at all sites (site 3 on right foot
which was significant only at the p < 0.05 level). Again, this result may have been due to the
individual sites or difficulty in locating the precise area by the investigators.
These results are only moderately reproducible, suggesting that the tools are only effective in
gross evaluation of the sensory system. The findings from this study do not support earlier
findings by Masson and colleagues who found the results of the tuning fork to be
reproducible (especially in patients with diabetes mellitus).
The prongs of the tuning fork were drawn together and twanged until vibration was evident,
and then placed on the skin over bony prominences at several sites. The neurothesiometer
was then placed over the same sites, and the voltage was gradually increased until the patient
reported feeling vibration. Five bony sites on both feet (i.e. first and fifth metatarsal heads,
styloid process and lateral malleolus) were tested, as literature suggested that these are the
most susceptible areas to neuropathic ulceration
A number of factors may have affected the results, and these must be taken into consideration
in this study. The use of the neurothesiometer is limited by the fact that it is very difficult to
apply the head at a standard pressure, and thus, it is subject to operator and technique
variability. In the same study, there was variation of perception of vibration sensation
between anatomical sites of the lower limb when using the neurothesiometer
This study suggests that assessment of vibration awareness with the conventional tuning fork
may be unreliable. The findings of this study were concurrent with the findings obtained by
Cheng and colleagues who questioned the sensitivity of the tuning fork and reported that the
tuning fork detected only 8.1% of patients previously diagnosed as having peripheral
neuropathy. There was, however, a positive correlation between the results from both tools.
Although statistically significant, the correlation was moderate (0.71 and 0.49), and an
extremely strong correlation is desirable as both tools are proposing to determine the
presence or absence of peripheral neuropathy. This result may have been affected by sample
size. A more detailed and larger study examining the relationship between increasing
neurothesiometer vibration output and corresponding tuning fork perception is therefore
recommended. The literature also demonstrates that a number of other contributing factors
warrant investigation in order to provide an accurate comparison of these two tools. It would
also be of interest to extend the current study to investigate inter-rater variability more closely
by marking all bony sites accurately. In addition to this, there is also an ongoing need for

more rigorous investigation into the use of these assessment tools for patients presenting with
type I diabetes mellitus.
O'Neill, J., Mccann, S., & Lagan, K. (2005). Tuning fork (128 Hz) versus
Neurothesiometer: a comparison of methods of assessing vibration
sensation in patients with diabetes mellitus. International Journal Of
Clinical Practice, 60(2), 174-178. http://dx.doi.org/10.1111/j.17421241.2005.00650.x
Diagnostic Accuracy of Clinical Methods for Detection of Diabetic Sensory Neuropathy.
To determine the accuracy of clinical methods for detection of sensory neuropathy as
compared to biothesiometry.
Method- Average of 3 vibration perception threshold values measured with a biothesiometer
on distal hallux was calculated. Ten gm monofilament was used to examine touch sensation
over dorsal surfaces of great toes. Vibration sensation was checked over the tips of great toes
using 128Hz tuning fork. Ankle jerks were checked bilaterally.
Neuropathy (vibration perception threshold > 25 volts) was present in 34 (21.12%) out of 161
patients and 93 (57.76%) were symptomatic. Measures of diagnostic accuracy for
monofilament, tuning fork and ankle jerks were: sensitivity 41.18%, 55.88% and 64.71%;
CONCLUSION: Clinical methods are high accurate and specific diagnosis in picking up
symmetric sensory neuropathy in patients with type 2 diabetes, particularly when multiple
signs are combined.
Arshad, A. R., & Alvi, K. Y. (2016). Diagnostic Accuracy of Clinical Methods for Detection
of Diabetic Sensory Neuropathy. Journal of the College of Physicians and Surgeons
Pakistan, 26(5), 374-379.