VibraTip: A pocket-sized disposable device for testing the integrity of sensation in the outpatient setting.
ABSTRACT Aims To compare the Ipswich Touch Test and the VibraTip with the Neuropathy Disability Score and the vibration perception threshold for detecting the 'at-risk' foot. Methods We directly compared the Ipswich Touch Test and the VibraTip with both the Neuropathy Disability Score ≥ 6 and the vibration perception threshold ≥ 25 V indicating 'at-risk' feet in 83 individuals. Results The vibration perception threshold and Neuropathy Disability Score tests exhibited almost perfect agreement with each other (P < 0.001). The VibraTip and Ipswich Touch Test results were identical (P < 0.001). The VibraTip and Ipswich Touch Test results also exhibited almost perfect agreement with the vibration perception threshold (P < 0.001) and the Neuropathy Disability Score (P < 0.001). Conclusions These two simple and efficient tests are easy to teach, reliable and can be used in any setting, and neither requires an external power source. We conclude that both the VibraTip and the Ipswich Touch Test are reliable and sensitive tests for identifying the 'high-risk' foot. © 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.
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ABSTRACT: Coming events cast their shadow before them'. This quote from James Joyce could not be more appropriate when screening and risk stratifying those people with diabetes who are at greatest risk of foot ulceration and potential lower extremity amputations. © 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.Diabetic Medicine 06/2012; · 3.24 Impact Factor
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ABSTRACT: At any one time 2% to 4% of the diabetic population is likely to have an active foot ulcer. Peripheral neuropathy, foot deformity, and trauma (often from ill-fitting footwear) represent the commonest causal pathway to foot ulceration. All patients with diabetes require an annual foot screen, and those found to be at risk require specialist foot care and preventive foot-care education. Identification of the high-risk foot can be achieved without the need for expensive equipment. Understanding the implications of loss of protective sensation is essential in reducing the all too high incidence of foot problems in diabetes.The Medical clinics of North America 09/2013; 97(5):775-90. · 2.18 Impact Factor
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ABSTRACT: New modalities are now available to improve the diagnosis of diabetic polyneuropathy (DPN). The present review discusses the progress achieved in this area. First, the minimal diagnostic criteria have been better clarified. Moreover, there are now new bedside tests available, such as the indicator test Neuropad, NeuroQuick, Ipswich Touch Test (IpTT), Vibratip, NC-stat(®)/DPNCheck™ for automated nerve conduction study (NCS), tactile circumferential discriminator, steel ball-bearing, and SUDOSCAN(®), while more sophisticated modalities include skin biopsy and corneal confocal microscopy (CCM). Some tests can be used as screening tools, including primary care setting (Neuropad, IpTT, Vibratip, automated NCS), while others are more suitable for research, including evaluation of DPN in prospective studies (CCM, skin biopsy). Importantly, there is some evidence of earlier DPN diagnosis with the aid of some tests (Neuropad, skin biopsy, CCM). Further advantages provided by different tests are educational value and self-examination. Thus far, the potential of these tests has not been fully utilised. In particular, they have not been validated against standardised clinical examination scores in terms of predicting foot ulcers and amputations. Hence, it now remains to investigate the potential benefits from the widespread use of these tests for earlier and easier diagnosis of DPN in the everyday clinic.Endocrine 05/2014; · 3.53 Impact Factor
Short Report: Care Delivery
A pocket-sized disposable device for testing the integrity
of sensation in the outpatient setting
F. L. Bowling1, C. A. Abbott2, W. E. Harris3, S. Atanasov1, R. A. Malik2and A. J. M. Boulton1
1Manchester Diabetes Centre, University of Manchester and Central Manchester Foundation Trust,2Division of Cardiovascular Medicine, Core Technology
Facility, University of Manchester and Central Manchester Foundation Trust and3Division of Biology and Ecology, Manchester Metropolitan University,
Accepted 1 June 2012
perception threshold for detecting the ‘at-risk’ foot.
To compare the Ipswich Touch Test and the VibraTip with the Neuropathy Disability Score and the vibration
and the vibration perception threshold ‡ 25 V indicating ‘at-risk’ feet in 83 individuals.
We directly compared the Ipswich Touch Test and the VibraTip with both the Neuropathy Disability Score ‡ 6
each other (P < 0.001). The VibraTip and Ipswich Touch Test results were identical (P < 0.001). The VibraTip and Ipswich
Touch Test results also exhibited almost perfect agreement with the vibration perception threshold (P < 0.001) and the
Neuropathy Disability Score (P < 0.001).
The vibration perception threshold and Neuropathy Disability Score tests exhibited almost perfect agreement with
requires an external power source. We conclude that both the VibraTip and the Ipswich Touch Test are reliable and sensitive
tests for identifying the ‘high-risk’ foot.
These two simple and efficient tests are easy to teach, reliable and can be used in any setting, and neither
Diabet. Med. 29, 1550–1552 (2012)
Diabetic peripheral neuropathy, one of the most common
chronic complications, may be asymptomatic in up to 50% of
cases . All patients with diabetes should therefore undergo a
careful clinical examination of their feet at least once a year .
Current screening methods include the 10-g monofilament, the
vibration perception threshold, the Neuropathy Disability
Score and the recently described Ipswich Touch Test . The
VibraTip? (McCallan Medical Limited, Nottinghamshire, UK)
has been specifically designed to overcome barriers associated
with other methods, such as the high cost for purchase and
replacement, as well as training provision in device use :
when activated, it provides a stimulus of 128 Hz. Both the
VibraTip and the Ipswich Touch Test can be used for testing
the integrity of sensation in clinic and by the bedside. The
Ipswich Touch Test requires no equipment, whilst the VibraTip
(Fig. 1a and b) is easily portable with a rounded head that
almost any angle. Manufacturer’s guidelines report a maximum
vibration of 35 min if the button is held down continuously,
which in clinical terms should equate to several months usage
allowing for approximately 10–20 s of vibration per patient.
Thus, for the first time, we compared these two new tests with
established screening tests for the ‘at-risk’ diabetic foot.
Patients and methods
The study included 83 individuals with varying neuropathy
severity recruited from diabetes clinics: mean (? sd) age
62 ? 12 years, BMI 30.1 ? 8.1 kg⁄m2and diabetes duration
14.4 ? 10.6 years.
The study was performed in both the community and
hospital settings and by eight different healthcare professionals.
The instructions for use of the VibraTip were as follows :
touch the patient’s hallux twice with the rounded tip of the
VibraTip, each time for approximately 1 s, explaining ‘this is
touch one’ and ‘this is touch two’ whilst randomly activating
the VibraTip on either the first or second touch.
The vibration perception threshold values were measured on
the apices of both halluces using the Neurothesiometer. The
Correspondence to: Frank L. Bowling.
ª 2012 The Authors.
Diabetic Medicine ª 2012 Diabetes UK
Neuropathy Disability Score was derived from examination of
pain sensation using a Neurotip? , vibration sensation using
a 128-Hz tuning fork, temperature sensation on the apices of
the hallux and ankle reflex using a tendon hammer . Sensory
modalities were scored for each side as either present (score of
0) or reduced⁄absent (score of 1) for each side. Reflexes were
recorded as normal (score of 0), present with reinforcement (1)
or absent (2) per side. The maximum score is 10, indicating
sensory loss to all modalities and absent ankle reflexes, whereas
a score of 0 represents intact sensation . Patients were
diagnosed as having ‘at-risk’ neuropathic feet when Neuropa-
thy Disability Score was ‡ 6 .
The Ipswich Touch Test involves lightly touching⁄resting the
tip of the index finger for 1–2 s on the apex of the hallux and
the 3rd and 5th apices of the lesser digits .
Examiners were instructed not to poke, prod or tap in case
this may elicit a sensation other than light touch. Patients were
asked to close their eyes and give a simple yes when they per-
A vibration perception threshold of ‡ 25 V and a Neuro-
pathy Disability Score ‡ 6 were used as cut-offs for detecting
the ‘at-risk’ foot [5,7]. We directly compared the Ipswich
Touch Test and the VibraTip with both of the above.
All analyses were performed using SPSS version 16.0 (SPSS
Inc., Chicago, IL, USA) and Microsoft Excel 2007. Cohen’s
kappa was calculated to estimate diagnostic reliability between
the VibraTip and the Ipswich Touch Test, and to compare with
the vibration perception threshold and the Neuropathy Dis-
ability Score . Interpretation of the degree of diagnostic
reliability was based on the standard scale of Landis and Koch
(1977), with 0.61 < j < 0.80 corresponding to ‘substantial
agreement’ and 0.81 < j < 1.0 corresponding to ‘almost
perfect agreement’. The sensitivity, specificity, negative predic-
tive value, positive predictive value, negative likelihood ratio
and positive likelihood ratio were also measured for each test,
using the method of Altman and Bland .
The protocol for undertaking neuropathy assessment was
approved by the local research ethics committee of the North
Manchester Health Authority (LREC).
Vibration perception threshold and Neuropathy Disability
Score tests exhibited almost perfect agreement with each other
(j = 0.948, P < 0.001). VibraTip and Ipswich Touch Test
results were identical (j = 1.0, P < 0.001). Thus, statistical
results are presented for each established test comparison
to avoid unnecessary redundancy.
The VibraTip and the Ipswich Touch Test results exhibited
almost perfect agreement with the vibration perception
threshold (j = 0.973, P < 0.001) and the Neuropathy Disabil-
ity Score (j = 0.921, P < 0.001).
Sensitivity between the VibraTip and the Ipswich Touch Test
was 100% for both vibration perception threshold and Neu-
ropathy Disability Score. Very high specificity was found
between the new tests and the vibration perception threshold
(96.6%) and the Neuropathy Disability Score (90.3%),
respectively. Very high positive predictive value was found
between the new tests and both the vibration perception
threshold (98.2%) and the Neuropathy Disability Score
(94.5%). The new tests exhibited 100% negative predictive
value relative to both vibration perception threshold and
FIGURE 1 (a) VibraTip held between the thumb and forefinger, with rounded end placed lightly on the pulp of the hallux. Squeeze the device firmly
between the fingers. (b) VibraTip pocket-size device measuring 2 · 1 cm.
ª 2012 The Authors.
Diabetic Medicine ª 2012 Diabetes UK
Neuropathy Disability Score. The tests showed high positive
likelihood ratio compared with vibration perception threshold
(29.0) and Neuropathy Disability Score (10.3). Finally, the new
tests showed a negative likelihood ratio of 0 for both vibration
perception threshold and Neuropathy Disability Score.
Our results confirm a high concordance between two new and
simple tests: the VibraTip and the Ipswich Touch Test when
compared with the vibration perception threshold and the
Neuropathy Disability Score, which are established tests for
identifying patients at ‘high risk’ of foot ulceration. The
VibraTip and the Ipswich Touch Test exhibited almost perfect
agreement with each other and the diagnosis results were
identical. Both of these simple and efficient tests can be used in
an inpatient or outpatient setting, and particularly in areas
where funding or training is limited; neither require an external
power source. Although not demonstrated in the study, the
application of light touch by a clinician may vary greatly in its
execution between clinicians. The advantage of the VibraTip is
the fact that it uses vibration rather than pressure, thereby
providing a stimulus that remains constant between patients.
We conclude that both the VibraTip and the Ipswich Touch
Test are reliable and sensitive tests for identifying the ‘high-risk’
foot and may be included in future algorithms for the com-
prehensive diabetic foot examination .
Nothing to declare.
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DIABETICMedicineA disposable device for testing sensation in outpatients • F. L. Bowling et al.
ª 2012 The Authors.
Diabetic Medicine ª 2012 Diabetes UK