Video tutorials and service material

By carrying out a screening quickly, you can recognise diabetic sensorimotor polyneuropathy (DSPN) in good time and thus prevent complications!

Here you will find expert videos, service material and the most important information for an examination for DSPN according to guidelines - summarised in a compact and practical way.

Digital Screening Assistant

Here you will find a digital application for collecting the results of screening for DSPN. The tool also facilitates the documentation of examination findings in the digital patient record and supports follow‑up monitoring. The screening assistant is a digitalized and modified version of the German Practice Guidelines.*

To the assistant
* German Practice Guidelines. Diabetologie 2024; 19 (Suppl 2): S322–S336. English version: Exp Clin Endocrinol Diabetes 2025; 133: 308–320. DOI: 10.1055/a-2312-0661.

To the assistant

Service Materials for Clinical Practice

Here you will find a paper-based clinical examination form, patient information materials (for distribution in your practice) available in five languages, Consensus recommendations for the screening and management of diabetic neuropathy.

To the download area

Video: Diabetic neuropathy - guideline-compliant examination in 5 minutes

The physician and neuropathy expert Dr. Gidon Bönhof demonstrates how a guideline-compliant examination can be carried out and what to look out for.

Video: The ten most common pitfalls in neuropathy examinations

Neuropathy expert Prof. Dr. Dan Ziegler explains what is often done wrong during the examination and what to look out for.

Examination for DSPN

  • Patients with type 2 diabetes should be screened from the time of diabetes diagnosis,
  • while patients with type 1 diabetes should be screened no later than five years after diabetes diagnosis.
  • If the screening is negative, you should repeat it annually.
  • In clinical practice, the diagnosis should be made on the basis of specific neuropathy scores.
  • If the diagnosis is not clear, the patient should be referred to a specialist who can carry out a complex neuropathy examination.

The examination for diabetic sensorimotor polyneuropathy (DSPN) includes the anamnesis, a clinical examination and simple neurological tests to check the function of the nerve fibres.

Apart from the general anamnesis information provided by the patient, recording of current diabetes-specific findings is of particular relevance. Typical indications of neuropathic impairment include symptoms such as parestheses, tingling, burning / pain, numbness, or a tendency to trip and fall. These should be determined by asking targeted questions of the patient. Use of the neuropathy symptom score (NSS) is recommended to record and quantify symptoms.

The clinical examination and inspection of the feet should be performed on both sides. Observe the following items:

  • Signs of impaired circulation (e.g. temperature and skin colour),
  • Skin lesions, or
  • Foot deformations.
  • Measurement of the foot pulses (can indicate impaired circulation).

Simple neurological tests are recommended to determine deficits as they can record the function of both the large and small nerve fibres. These examinations should also always be performed bilaterally and under comparison of sides. Use of the neuropathy deficit score (NDS) is recommended to record and quantify neuropathic deficits.

Examination of the function of the large nerve fibres:

  • Examination of the Achilles tendon reflex,
  • Examination of vibration sensation with the 128-Hz Rydel-Seiffer tuning fork,
  • Examination of pressure and touch sensitivity with 10-g monofilament.

Examination of the function of the small nerve fibres:

  • Examination of temperature sensation, e.g., with Tip-Therm® or cold metal,
  • Examination of pain sensation, e.g., with Neurotips or toothpicks.

Neuropathy scores

Neuropathic symptoms and deficits can be recorded and assessed using the Neuropathy Symptom Score (NSS), the Neuropathy Deficit Score (NDS) and a pain scale (visual analogue scale (VAS) or 11-point numerical rating scale (NRS)) to quantify the findings and monitor progress.

  • NSS: Determination of whether symptoms typical of neuropathy are present based on the type, time and localisation of the symptoms
  • NDS: Determination of neuropathic deficits using neurological tests, which are carried out on both sides
  • VAS/NRS: Determination of pain intensity, especially to assess the success of pain therapy during the course of treatment

A clinical examination form with NSS, NDS, a pain scale (NRS), practical tips and the respective threshold values can be downloaded here. You can use the form to record and evaluate all findings.

Early therapy

Once a diagnosis has been made, therapy should be initiated early in order to prevent the progression of the disease and subsequent complications.

The aim of the therapy is to halt the progression of nerve damage, alleviate the patient's symptoms and prevent secondary complications such as diabetic foot syndrome.

You can find more information about the therapy here.

Further diagnostics

Further, more complex diagnostics are recommended if the suspected diagnosis cannot be confirmed by the neurological examinations already performed1. The further examinations should be carried out by a specialist and include:

  • Measurement of nerve conduction velocity: records the function of the large nerve fibres.
  • Measurement of nerve fibre density and other nerve fibre properties: records the function of the small nerve fibres. The nerve fibre density can be measured by means of a skin biopsy (minimally invasive) or in the cornea by corneal confocal microscopy (non-invasive).
  • Quantitative measurement of temperature and pain sensitivity: records the function of the small nerve fibres.

Differential diagnosis

Not every neuropathy in diabetics is a diabetic neuropathy. A mixed pathogenesis is often probable. It is therefore important to consider other factors that can trigger or exacerbate neuropathy. These include:

  • Alcohol consumption – an alcohol anamnesis should be obtained from the patient.
  • Vitamin B1 deficiency - this is common in diabetes patients2.
  • Vitamin B12 deficiency - this can occur in particular when taking metformin3,4.

The differential diagnosis should also take into account whether, for example, renal insufficiency, peripheral arterial occlusive disease (PAOD), hypothyroidism, paraproteinaemia, occupational toxicity or side effects of medication are present. Additional involvement of the autonomic nervous system should also be investigated.

The German national care guideline "Neuropathy in adults with diabetes" recommends the determination of the following laboratory parameters for the differential diagnostic clarification: Blood count, creatinine, ESR, TSH, vitamin B12, folic acid, alanine aminotransferase (ALAT), gamma-GT and immunoelectrophoresis (paraproteinaemia)1.

Follow-up

The German national care guideline "Neuropathy in adults with diabetes" recommends a follow-up depending on the current findings5:

  • For patients with neuropathy or suspected neuropathy, a check-up at least every six months is recommended.
  • In the case of additional complaints, pre-existing foot deformities or peripheral arterial occlusive disease (PAOD), examination intervals of three months are advisable.

Documentation using neuropathy scores can be helpful for follow-up purposes.

Bibliography:

  1. German Medical Association (BÄK), National Association of Statutory Health Insurance Physicians (KBV), Association of the Scientific Medical Societies in Germany (AWMF). National care guidelines for neuropathy in adult diabetes - long version, 1st edition. Version 5. 2011.
  2. Thornalley PJ, Babaei-Jadidi R, Al Ali H, Rabbani N, Antonysunil A, Larkin J, Ahmed A, Rayman G, Bodmer CW. High prevalence of low plasma thiamine concentration in diabetes linked to a marker of vascular disease. Diabetologia. 2007;50(10):2164-70.
  3. Niafar M, Hai F, Porhomayon J, Nader ND. The role of metformin on vitamin B12 deficiency: a meta-analysis review. Intern Emerg Med. 2015 Feb;10(1):93-102.
  4. Damião CP, Rodrigues AO, Pinheiro MF, Cruz RA Filho, Cardoso GP, Taboada GF, Lima GA. Prevalence of vitamin B12 deficiency in type 2 diabetic patients using metformin: a cross-sectional study. Sao Paulo Med J. 2016;134(6):473-479.
  5. German Medical Association (BÄK), National Association of Statutory Health Insurance Physicians (KBV), Association of the Scientific Medical Societies in Germany (AWMF). National care guidelines for neuropathy in adult diabetes - long version, 1st edition. Version 5. 2011.