Technical Section

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ibration Sensory Thresholds Depend On Pressure of Applied Stimulus

LESLIE M. LOWENTHAL, MBBS, MRCP, AND T. DEREK R. HOCKADAY, DPhil, FRCP

Vibration sensory thresholds (VSTs) were estimated in 40 healthy subjects and 8 with diabetic peripheral neuropathy. A vibrameter and a biothesiometer were used at four sites and at differing pressures. In normal subjects, with the vibrameter at 200 g, mean VST SE for all sites was 1.87 |xm 0.22 and at 400 g dropped to 1.08 |Jim 0.15 (P < .0001). In 20 of these subjects with a biothesiometer at 200 and 400 g, mean VST fell from 12.8 1.5 to 11.1 1.1 (arbitrary units) (P = .01) when the greater pressure was applied. In the 8 subjects with peripheral neuropathy, with the vibrameter at 200 and 400 g, respectively, mean VST fell from 70.7 26 to 7.2 1.8. VST in these subjects was estimated again after 1 mo and showed strong correlations with the previous values. Biothesiometer results correlated with vibrameter results at all sites. Thus, VST decreases as the pressure of the applied stimulus is increased and this effect appears to be more marked in peripheral neuropathy. This has important consequences in monitoring this condition. Diabetes Care 10:100-102, 1987
he difficulty of establishing objective and quantitative results in the measurement of sensation is well recognized. This applies to diabetic peripheral neuropathy because it is often desirable to assess the course of this condition with or without treatment. Vibration sensation appears particularly amenable to quantitative assessment, and numerous electromagnetic devices have been developed for this (1,2). Certain limitations in these measurements are known to exist as a result of damping the probe (3), and instruments that measure the excursion of the vibrating probe have therefore been developed. The effect of stimulus pressure has long been thought to be important in the estimation of vibration sensory thresholds (VST), and many have standardized probe pressures before conducting experiments in vibration sensibility (4-7). The hypothesis that increasing probe pressure reduces the VST was tested and confirmed by Cohen and Lindley (8) and examined in a healthy population (4) with weights < 100 g. In a clinical setting, we estimate that weights of 200-500 g are used. The effect of pressure in determining VST in peripheral neuropathy has not been established. We quantified the effect of stimulus pressure on VST in normal adults and in diabetics with peripheral neuropathy.
SUBJECTS AND METHODS

Forty healthy volunteers, mean age 36 yr (12 SD), without clinical evidence of peripheral neuropathy, were tested on the vibrameter. Half of these also had biothesiometer measurements. Eight patients with diabetic peripheral neuropathy, mean age 58 7 yr with mean duration of diabetes 22 yr, were tested. All but one were insulin dependent. All were severely symptomatic and were without recordable sural sensory nerve conduction velocities. Two instruments were used to assess VST. The vibrameter (Somedic, Stockholm, Sweden), which measures displacement of a probe in micrometers and has a built-in pressure transducer, allows for damping of the probe's movements by the skin and can be adjusted to maintain a constant excursion of the probe. The biothesiometer (Biomedical Instruments, Cleveland, OH) gives a reading of the voltage applied to a vibrating probe. The voltage is proportional to the square of the probe amplitude. VST was estimated at four sites in random order: i) tip of index finger, 2) dorsum of hand over second metacarpal bone, 3) tip of great toe, and 4) dorsum of foot over first metatarsal bone. The weight of the applied probe was ad-

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TABLE 1 Effect of increasing instrumental weight on VST at different sites with a vibrameter in normal subjects Weight (g) 200 Toe Foot Finger Hand 2.77 2.46 1.56 0.73 0.44 0.56 0.23 0.10 400 1.59 0.28* 1.03 0.17' 1.13 0.16t 1.20 0.74 1.47 0.52

600
0.14 0.13* 0.23 0.07 1.43 0.68 1.37 0.52

800 0.22 0.88 0.98 0.05

42.4 31.1, 97.1 16.5, and 55.1 60.9, respectively, and dropped at 400 g to 9.7 16.5 (P = .01), 5.6 6.7 (P < .01), 5.82 8.54 (P < .01), and 7.5 14.8 (P < .05), respectively (Table 2). Correlations (rs) with readings taken 1 mo later were .97, .90, .73, and .76, respectively. In all but one patient, neuropathy was so severe that readings went beyond the scale of the biothesiometer, precluding its use with these subjects.
DISCUSSION

0.58 0.08t

Values are in \xm SEM. P values are from paired t tests, comparing pressure value with preceding pressure value. ' P < .0001, t P < .001, * P < .05.

justed in random order to 200, 400, 600, or 800 g. The weights are equivalent to 1.5, 3, 4-5, and 6 g/mm2 pressure, respectively. In the biothesiometer, only the first two pressures were used, and this was achieved by a system of weights and pulleys. Subjects were requested to say when they first felt a vibratory stimulus, and the reading given was recorded by an independent observer. Each threshold value was the mean of three readings. Statistical evaluation was by paired t tests, zero-order correlation, or Spearman's rank correlation.

RESULTS

Normal Subjects. Mean VST for all sites with a vibrameter was 1.87 |xm at 200 g and dropped to 1.08, 0.98, and 1.00 |xm at 400, 600, and 800 g, respectively. Such a decrease was seen at each site separately (Table 1). With a biothesiometer, mean values for all sites fell from 12.8 1.5 at 200 g to 11.1 1.1 at 400 g (P = .01) (arbitrary units). Vibrameter readings correlated with biothesiometer readings at all sites, at any pressure; e.g., rs = 0.87 (P < .001) at 200 g at the tip of the great toe.
Diabetics with peripheral neuropathy. Mean VST at the

e have observed a considerable reduction in VST as the pressure of the applied stimulus is increased, by increasing the weight from 200 to 400 g, but this was not seen at weights >400 g. (We estimated the weight of a biothesiometer, allowed to rest loosely in the hand, to be 320 g.) This effect is seen both in healthy subjects and, more markedly, in those with diabetic peripheral neuropathy. The reason for these observations is unknown, but it may be that more vibration sensation receptors are triggered with greater pressure. The consequences of this study are relevant for the clinician using a tuning fork or for the investigator of a longitudinal study of peripheral neuropathy observing either the natural history of the condition or the effects of treatment. In diabetic peripheral neuropathy these findings are important when studying the effects of improved glycemic control or aldose reductase inhibitors on vibration sensory thresholds. We feel it is imperative to control for pressure when assessing vibration sensory thresholds.

toe, foot, finger, and hand at 200 g was 88.4 22.7,

TABLE 2 Effect of increasing instrumental weight on VST with a vibrameter in diabetics with peripheral neuropathy Weight (g) 200 Toe Foot Finger Hand 88.4 42.4 97.1 55.1 22.7 31.1 9.7 5.6 5.8 7.5 400 16.5* 6.7* 8.5* 14.8t

ACKNOWLEDGMENTS: We thank P. Patel, who helped recruit patients and acted as an independent observer, and D. Renton, who helped prepare the manuscript. L.M.L. is supported by Pfizer Ltd., United Kingdom. The Sheikh Rashid Diabetes Unit is funded by the Oxford Diabetes Trust. Part of this material was presented as an abstract to the Medical Research Society, July 1985 (din Sci 69: 83P, 1985).

From the Sheikh Rashid Diabetes Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK. Address correspondence and reprint requests to Dr. L. M. Lowenthal, Sheikh Rashid Diabetes Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK.

REFERENCES

69.7 60.9

' P < .01 and t P < -05 by Mann-Whitney U test when comparing the preceding value.

1. Cosh JA: Studies on the nature of vibration sense. Clin Sci 12:131-51, 1953 2. Gregg EC: Absolute measurement of the vibratory threshold. Arch Neurol Psychiatry 66:403-11, 1951 3. Goldberg JM, Lindblom U: Studies in vibration sensibility. ] Neurol Neurosurg Psychiatry 42:793-803, 1979

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4. Steiness I: Vibratory perception in normal subjects, a biothesiometric study. Acta Med Scand 158:315-25, 1957 5. Gerard FA: Perception of mechanical vibration. } Gen Psychol 22:243-308, 1940 6. Gilmer BH: Relation of vibratory sensitivity to pressure. J Exp Psychol 21:456-63, 1937

7. Dyck P: Detection thresholds of cutaneous sensation in humans. In Peripheral Neuropathy. Philadelphia, PA, Saunders, 1984, p. 1111 8. Cohen LA, Lindley SB: Standardized method of determining vibration sensory threshold for diagnosis and screening. Am] Psychol 51:44-63, 1938

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