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Too few, too many or just right? How many sites should be tested to detect
diabetic peripheral neuropathy

Article · June 2020

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Virginie Blanchette Magali Brousseau-Foley

Université du Québec à Trois-Rivières/University of Quebec at Trois-Rivieres Université du Québec à Trois-Rivières
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Too few, too many
or just right?
How many sites should be tested
to detect diabetic peripheral
neuropathy?
By Virginie Blanchette, Biomed DPM PhD and
Magali Brousseau-Foley, MD DPM MSc

D
iabetic peripheral neuropathy (DPN) in individuals with diabetes.6 However, there are
is a widespread diabetes complication multiple ways to perform this test and interpret
that affects up to 90% of individuals its results.7,9-10
living with diabetes.1 It is commonly
divided in two forms based on the
absence or presence of pain. It is well recognized
Location and Number of Sites
The original SWM 10 g testing technique was
that DPN is a powerful predictor of diabetic foot
designed to test 11 plantar sites: the first, third and
ulceration, and evidence establishes its role in the
fifth metatarsal heads and five corresponding toes,
pathophysiology of new and recurring foot ulcers
the medial and lateral midfoot and the heel.8 The
and lower-extremity amputations.2-3 Early detec-
tion of DPN can help to lower the incidence of dorsal surface between the base of the first and
these diabetic foot complications, and health-care second toes was added to provide a more complete
professionals can therefore adapt their clinical representation of the different peripheral nerves
practices to patients’ needs. Global management and dermatomes of the foot.11 Later, because clin-
of patients with DPN should be tailored according icians needed an easy and reliable test, a 10-site
to this condition.4 technique was developed.12 A number of studies
More than 30 years ago, the 10 g Semmes– have since demonstrated that fewer than 10 sites
Weinstein monofilament (SWM 10 g) testing tech- could allow an equivalent overall accuracy. Table
nique was described as a good method to assess 1 summarizes the evidence for 1-site, 4-site and
loss of protective sensation (LOPS) in the clinical 10-site SWM techniques.7,9,13-15 Moreover, tech-
setting. It is still widely used for DPN screening, niques requiring fewer than 10 sites are more prac-
because, along with the inability to sense vibra- tical when testing individuals with toe amputations,
tions, LOPS represents one component of DPN.4,6 are less time-consuming for professionals and may
This technique is favoured by most clinicians extend durability (lifetime) of the SWM 10 g. It has
because of its accuracy, low cost and conven- also been reported that 4-site testing identified
ience.7-8 A recent meta-analysis demonstrates that 90% of individuals with DPN, with one insensate
SWM 10 g is fairly accurate in diagnosing LOPS forefoot site being consistent for LOPS.7,16 The

30 Wound Care Canada Volume 18, Number 2 · Summer 2020

most common testing site for all described SWM meta-analysis.9 Their internal validity is thus con-
10 g techniques is the hallux, plantar or dorsal, but sidered to be at a higher level.
there is no evidence to confirm that this is the most Three different patient responding techniques
sensitive site for testing LOPS.9 were used in all the studies in Table 1:
There is great variability in the methodologies • yes/no technique
of these studies, including population selection • forced-choice technique
and sample sizes, that limits internal and exter- • yes/no combined with site identification tech-
nal validity to choose the best technique.7,9,13-15 nique
However, some studies—such as Baraz et al.
2014, Lee et al. 2003, Perkins et al. 2001/2010, The yes/no technique is simple: ask the patient
Rayman et al. 2011, Zhang et al. 2017 and Brown whether they feel pressure applied. The forced-
et al. 2017—have fewer methodological flaws choice technique consists of asking the patient
according to potential risk of bias assessment in a to identify whether contact with the SWM 10 g is

Diabetes Canada Guidelines:

Recommendations on How to Perform 10 g Semmes–Weinstein
Monofilament Resting5
1. Apply the SWM 10 g on patient’s hand so that he or she knows what to expect. Encourage
patient during testing by giving positive feedback.
2. The patient must not be able to see whether or where the examiner applies the SWM 10 g.
Apply the SWM 10 g perpendicular to the skin surface and apply sufficient force to cause the
filament to bend or buckle. The total duration of contact, from initial skin contact to removal of
the SWM 10 g, should be approximately 2 seconds.
3. Apply the SWM 10 g along the perimeter of, not on, an ulcer site, callus, scar or necrotic tissue.
Do not allow the SWM 10 g to slide across the skin or make a repetitive contact at the test site.
4. Press the SWM 10 g to the skin and ask the patient whether they feel pressure applied
(‘yes’/’no’) and where they feel the pressure (‘left foot’/’right foot’).
5. Repeat contact twice at the same site, but alternate this with at least one ‘mock’ contact in
which no filament is applied (for total of 3 questions per site).
Protective sensation is present at each site if the patient correctly answers 2 out of 3 contacts.
There is a LOPS with 2 out of 3 incorrect answers. The patient is then considered to be at risk of
diabetic foot ulceration.

Volume 18, Number 2 · Summer 2020 Wound Care Canada 31

Table 1: Evidence for 1-Site, 4-Site and 10-Site SWM Techniques
Studies Number of Sites Tested per Foot Number of Sites Sensitivity Specificity
Insensitive to (%) (%)
Represent LOPS
1-site Technique
Kumar et al. Plantar hallux 1/1 100 78
1991
Pham et al. Dorsal hallux 1/1 91 34
2000
Perkins et al. Dorsal hallux a. 2/8 c. 41 e. 68
2001 (repeated 4 times) b. ≥ 5/8 d. 77 f. 96
Olaleye et al. Dorsal hallux a. 2/8 a. 62 a. 84
2001 (repeated 4 times) b. 3/8 b. 58 b. 92
c. 4/8 c. 35 c. 97
d. 5/8 d. 30 d. 97
Perkins et al. Dorsal hallux Both feet 5/8 72 64
2010* (repeated 4 times)
Najafi et al. Dorsal hallux 3/10 17 87
2014 (repeated 10 times)
Pambianco et Dorsal hallux 3/10 20 98
al. 2011 (repeated 10 times)
Brown et al. Dorsal hallux 1/1 47 73
2017
4-site Technique
Miranda-Palma Plantar hallux; 1/8 86 58
et al. 2005 metatarsal head 1, 3, 5
Jayaprakash et Plantar hallux; Both feet 1/8 63 93
al. 2011 metatarsal base 1, 3, 5
Rayman et al. Tips of toes 1, 3, 5 Both feet 5/8 81 91
2011 dorsal hallux
Bedi et al. Plantar hallux; Both feet 1/8 49 48
2012 metatarsal base 1, 3, 5
Baraz et al. Plantar hallux; Both feet
2014** metatarsal head 1, 3, 5 a. 1/8 a. 51 a. 73
b. 2/8 b. 46 b. 75
c. 4/8 c. 38 c. 87
Zhang et al. Plantar hallux; 1/4 19 96
2017 metatarsal head 1,3, 5
10-site Technique
Armstrong et Dorsal between base toe 1–2; plantar toe 1,3,5; 4/10 > 90 80
al. 1998 metatarsal head 1,3,5; plantar medial and lateral
midfoot; plantar heel
Lee et al. Dorsal between base toe 1–2; plantar toe 1,3,5; ≥ 5/10 93 100
2003 metatarsal head 1,3,5; plantar medial and lateral
midfoot; plantar heel
Zhang et al. Dorsal between base toe 1–2; plantar toe 1,3,5; 1/10 22 94
2017 metatarsal head 1,3,5; plantar medial and lateral
midfoot; plantar heel
* Forced-choice technique
** Yes/no technique and identification of the site

32 Wound Care Canada Volume 18, Number 2 · Summer 2020

perceived at time ‘‘A’’ or ‘‘B”—which may be inad- Accuracy and Durability of
equate, because the response can be guessed Semmes–Weinstein Monofilaments
correctly with a probability of 50%. Therefore, the Commercially available SWM 10 g have signifi-
yes/no technique is expected to be more reliable cant variability within and between devices,
and less time-consuming than the forced-choice and their real bending force varies widely from
technique.7 the initial targeted value of 10 g. For this rea-
A recent study comparing SWM 10 g sensitivity son, they have a short
using 3, 4 and 10 sites demonstrated that every service life and should
technique was equally effective for screening not be used when they
DPN and showed a good level of intra-observer have lost 10% or more
agreement and reproductivity with the yes/no of their initial bending
technique.10 force.20-21 It has been
demonstrated that
Interpretation some monofilaments,
There is no clear answer on how many insensate excluding single-use
sites suggest a patient is at risk of diabetic foot products, can evaluate
ulceration when using SWM 10 g testing. Thus, up to 70 to 90 patients for a 10-site testing
most studies used conservative approaches that, each.20 After testing 10 patients, monofilaments
when adequately performed, were indicative need a recovery time of 24 hours before further
of an at-risk foot in the presence of one insens- use.21 The Canadian BPR suggests that SWM
ate site. When the number of insensate sites 10 g should be rested for two hours following
increases, the test sensitivity remains similar or 100 applications (20 sites per patient for a total
decreases, while the specificity increases.12,17 To of five evaluations).18 Selecting a high-quality
date, there is no controlled clinical trial available instrument and replacing it at regular intervals
investigating the prognostic and predictive val- are important in maintaining testing accuracy.20
ues of SWM 10 g testing to guide clinical decision Proper disinfection of the instrument must be
making and to improve patient outcome such performed between patients, and disposable
as diabetic foot ulcerations and lower extremity SWM 10 g should be used for only one patient.
amputations.7

Recommendations (IWGDF) guidelines suggest testing LOPS with pres-

In general, practice guidelines conclude that two sure and vibration.4 The same recommendation is
different clinical evaluations should be performed made in the Diabetes Canada (DC) guidelines, and
for better test sensitivity to diagnose LOPS.4,18 The they propose the same three testing sites, the plan-
International Working Group on the Diabetic Foot tar hallux, and first and fifth metatarsal heads of

According to the studies listed in Table 1, here is how one should perform SWM 10 g testing with
a conservative interpretation for maximum accuracy with a yes/no technique:
• 1 site tested on the dorsal surface of the hallux (repeated four times): both feet with ≥ 5/8
insensitive sites indicates LOPS.
• 4 sites tested on the plantar surface of the hallux and first, third and fifth metatarsal heads: one
foot with ≥ 1/4 insensitive site indicates LOPS.
• 10 sites tested, including one dorsal site between the base of first and second toe, and nine
plantar sites on first, third and fifth toes, first, third and fifth metatarsal heads, medial and lat-
eral midfoot and heel: ≥ 5/10 insensitive sites indicates LOPS.

Volume 18, Number 2 · Summer 2020 Wound Care Canada 33

both feet in high-risk (for ulceration) feet.5 Wounds 7. Tan LS. The clinical use of the 10 g monofilament and its
limitations: A review. Diabetes Res Clin. 2010;90(1):1–7.
Canada’s Best Practice Recommendations (BPR)
8. Mueller MJ. Identifying patients with diabetes mellitus
for the Prevention and Management of Diabetic
who are at risk for lower-extremity complications:
Foot Ulcers advocates a 10-site testing technique.18 Use of Semmes–Weinstein monofilaments. Phys Ther.
Practical guidelines from the Registered Nurses’ 1996;76(1):68–71.
Association of Ontario support a 4-site testing 9. Wang F, Zhang J, Yu J, Liu S, Zhang R, Ma X, et al. Diagnostic
accuracy of monofilament tests for detecting diabetic
technique that includes the plantar hallux and first, peripheral neuropathy: A systematic review and meta-
third and fifth metatarsal heads.19 analysis. J Diabetes Res. 2017.
10. Zhang Q, Yi N, Liu S, Zheng H, Qiao X, Xiong Q, et al. Easier
operation and similar power of 10 g monofilament test for
Conclusion screening diabetic peripheral neuropathy. J Int Med Res.
Evidence supports 1-, 4- or 10-site SWM 10 g test- 2018;46(8):3278–84.
ing for LOPS, and practice guidelines from various 11. Holewski JJ, Stess RM, Graf PM, Grunfeld C. Aesthesiometry:
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peripheral neuropathy. J Rehabil Res Dev. 1988;25(2):1–10.
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12. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli
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IWGDF and the DC. They all demonstrate a good 1998;158(3):289–292.
13. Dros J, Wewerinke A, Bindels PJ, van Weert HC. Accuracy of
level of reproductivity and should be favoured in
monofilament testing to diagnose peripheral neuropathy: A
the clinical setting. Therefore, whether a 3-, 4- or systematic review. Ann Fam Med. 2009;7(6):555–558.
10-site SWM 10 g testing technique is chosen, 14. Edelman D. Accuracy of monofilament testing for diagnosing
clinicians should be aware of material limitations peripheral neuropathy of the feet varies. Ann Intern Med.
2010;152(10):JC5–11.
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15. Brown JJ, Pribesh SL, Baskette KG, Vinik AI, Colberg SR. A
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34 Wound Care Canada Volume 18, Number 2 · Summer 2020

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cal use of an antimicrobial PVA foam dressing. Poster presented at Symposium on Advances in Skin and Wound Care; April 18-21, 2012; Atlanta, GA. 4.Conwell P, Mikulski L, Tramontozzi M. A comparison of two antimicrobial PVA
foam dressings: a randomized prospective trial comparing PVA foam with two organic pigments to a silver based wound dressing. Poster presented at Symposium on Advanced Wound Care, May 2-5, 2004; Lake Buena Vista, Fla.
5. Malone M, Bjarnsholt T, McBain AJ, et al. The prevalence of biofilms in chronic wounds – a systematic review and meta-analysis of published data. J Wound Care. 2017; Jan 2;26(1):20-25. 6. Percival SL, Suleman L. Slough and
biofilm: removal of barriers to wound healing by desloughing. J Wound Care. 2015; Nov;24(11):498-510. 7. Nakagami G, Schultz G, Gibson DJ, et al. Biofilm detection by wound blotting can predict slough development in pressure
ulcers: a prospective observational study. Wound Rep and Reg. 2017; 25:131-138. 8. Applewhite AJ, Attar P, Liden B, Stevenson Q. Gentian violet and methylene blue polyvinyl alcohol foam antibacterial dressing as a viable form of
autolytic debridement in the wound bed. Surg Technol Int. 2015 May; 26:65-70. 9. Hill R. Optimizing the wound bed by removing devitalized tissue and using methylene blue and gentian violet antibacterial foam dressings: a case series.
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violet. Poster presented at CAWC; October 29 – November 1, 2015; Toronto, ON. 11. Woo KY, Heil J. A prospective evaluation of methylene blue and gentian violet dressing for management of chronic wounds with local infection. Int
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