We are excited to report the results of recently published research article utilizing the ETF. This study by Raymond et al. from the Journal of Diabetes Science and Technology has recommended the ETF as the best choice of vibration testing instruments to pair with Semmes-Weinstein monofilament testing when performing lower extremity sensation testing in diabetic patients. This study protocol compared the ETF to the traditional 128 Hz tuning fork and biothesiometer in terms of ease of use, testing time and standardization of vibration output. The authors recommended the ETF over the other devices. We welcome the results of this study and look forward to more research papers validating the clinical use of the ETF.
Although more closely associated with carpal tunnel syndrome, hypothyroidism is a recognized cause of peripheral neuropathy. While the mechanism of neuropathy in untreated hypothyroidism is unclear, researchers have theorized that it may be attributed to the deposition of mucopolysaccharides or to the accumulation of soft tissue edema in proximity to peripheral nerves. Regardless of the precise mechanism, it is hypothesized that these underlying metabolic derangements cause nerve entrapments resulting in the demyelinating polyneuropathy described in the literature. Symptoms including tingling, numbness and paresthesia are most often reported in the hands and feet of afflicted patients.
Clinical Case I
A 62 y/o male with untreated hypothyroidism* of a 8-10 year duration presented complaining of progressively worsening paresthesia and numbness in the forefoot bilaterally of a one year duration. Patient history was negative for degenerative disc disease, diabetes or alcoholism.
Labs: Comprehensive Metabolic Panel, Vitamin B12, Folate, ESR, Lyme disease antibody and Free T4 were negative. TSH was elevated.
Neurological Testing: Office-based screening revealed reduced sharp sensation in the left foot, normal 10gm monofilament testing and reduced vibratory sensation as documented by a timed vibration test with the ETF (TVT 7.4s right hallux, 8.4s left hallux).
*The patient notes being placed on thyroid hormone replacement therapy after his initial diagnosis. He admits to going against medical advice and discontinuing it after several months.
Clinical Case II
A 54 y/o male with undiagnosed hypothyroidism presented with progressive numbness in the toes over past 1-2 years. Patient history was negative for degenerative disc disease, diabetes or alcoholism.
Labs: Random blood glucose, Vitamin B12, Folate, Lyme disease antibody were negative. TSH was elevated and Free T4 was below normal.
Neurological testing: Office-based screening revealed reduced sharp sensation at the hallux bilaterally, normal 10gm monofilament test and reduced vibratory sensation as documented by a timed vibration test with the ETF (TVT 7.5s right 5th metatarsal head, 7.6s left 5th metatarsal head).
NCV/EMG testing confirmed peripheral neuropathy consistent with a demyelinating process in the feet bilaterally.
Although an uncommon cause of peripheral neuropathy, undiagnosed or untreated hypothyroidism should be suspected in cases where more obvious etiologies are ruled out. Fortunately, patient symptoms often resolve with appropriate thyroid hormone replacement therapy over a 6-12 month period if treated promptly.
Combined Electrochemical Treatment (CET) is a newer form of therapy emerging from leading pain management providers for the treatment of neuropathic pain. CET combines a local anesthetic block with an Electronic Signal Treatment (EST), a sophisticated electrical cell signaling modality delivered to the affected aspects of the body transcutaneously (1).
A diabetic male patient with a six year history of refractory pedal neuropathic pain underwent 28 EST treatments and 4 nerve blocks over a 10 week period. Painful sensory symptoms and numbness subsided by 90%. Pre-treatment ETF128 timed vibration tests (TVT) at the first metatarsal heads were 0 seconds bilaterally. Post-treatment TVT readings were 6.9s on the right and 10.6s on the left demonstrating a clear improvement in vibratory sensation. These findings correlate well with new research suggesting nerve regrowth after CET confirmed by Epidermal Nerve Fiber Density testing (2).
1. Odell RH Jr, Sorgnard RE.Anti-inflammatory effects of electronic signal treatment. Pain Physician. 2008 Nov-Dec;11(6):891-907.
2. Carney, PM, et al. Regenerating Nerves Destroyed by Neuropathy. 5th International Congress on Neuropathic Pain. May 17, 2015. Nice, France.
*ETF clinical cases are presented to demonstrate the diagnostic utility of the ETF128. Cases are derived from actual ETF customer practices. Customers are encouraged to submit their own cases for future posts.
Large fiber peripheral neuropathy (PN) impairing somatosensory feedback and normal motor responses can occur in a variety of diseases. It is generally acknowledged that most elderly patients will have some loss of peripheral neurological function though it is seldom formally diagnosed. This age-related or “senescent” form of neuropathy can result in the same loss of large fiber nerve function as its better known correlate diabetic PN (DPN).
Regardless of the cause, large fiber PN can result in loss of proprioception, touch, vibratory sensation and muscle strength. These impairments can result in balance and postural control deficits predisposing patients to falls. Falls have long been acknowledged as a major healthcare issue affecting elderly and diabetic patients at higher rates than the general population. Large fiber PN has been determined to be a significant contributor to these falls. Recent research reveals that assessement of the Vibration Perception Threshold (VPT), equivalent to the 25v setting on the standard Biothesiometer, is an effective PN screening method for a Fall Risk Assessment protocol among elderly patients.
In light of these recommendations, the ETF can be seen as an appropriate choice when considering methods of performing recommended screening tests as part of a Fall Risk Assessment. This feature is available in the Contant Mode which provides the same vibration as the Biothesiometer at the 25v level. Using the ETF in Constant Mode, the patient can simply give a “yes” or “no” answer as to whether or not they feel the vibration. Superior portability and ease of use make the ETF ideally suited to point-of-care VPT screening in clinics and hospitals when evaluating patients for fall risk.