Clinical Assessment Symptoms

Many patients have difficulty in describing the symptoms of neuropathy. Pain and paresthe-siae are personal experiences, but there is marked variation in the description of symptoms between individuals with similar pathological lesions. This has important implications for the assessment of symptoms; Huskisson (1976) clearly stated that 'pain is apersonal psychological experience and an external observer can play no part in its direct measurement.' When recording symptoms in clinical practice, physicians must therefore avoid the temptation to 'interpret' or 'translate' patient reports; instead, they should record the patient's description verbatim.

A number of simple symptom screening questionnaires are available to record symptom quality and severity. A simplified neuropathy symptom score (NSS), which was used in the European prevalence studies, could also be useful in clinical practice (Young et al. 1993; Cabezas-Cerrato 1998). With the NSS, patients are asked questions about their experience of pain and discomfort in their legs. A maximum score of 9 is possible. A symptom score of 3-4 implies mild symptoms, 5-6 moderate symptoms and 7-9 severe symptoms (Table 17.1).

The Michigan Neuropathy Screening Instrument (MNSI) is a brief 15-item questionnaire that can be administered to patients as a screening tool for neuropathy (Feldman et al. 1996).

Other similar symptom scoring systems, such as the Diabetic Neuropathy Symptom (DNS) Score, have also been described (Feldman et al. 1996). The DNS Score is a four-item symptom score, consisting of the following items: 1) unsteadiness in walking; 2) pain, burning or aching at legs or feet; 3) prickling sensation in the legs or feet; and 4) numbness in legs or feet. Presence is scored 1, absence 0, with a maximum score of 4 points.

Simple visual analogue or verbal descriptive scales [VAS/VDS] may be used to follow patients' responses to treatment of their neuropathic symptoms (Scott & Huskisson 1976; Meijer et al. 2002; Ziegler 2003). VAS is a straight line, the ends of which are defined as the extreme limits of the sensation or response to be measured. However, identification of neuropathic symptoms is not useful as a diagnostic or screening tool in the assessment of DPN, as shown by Franse et al. (2000). Up to 50 % of patients with significant neurological deficits may be asymptomatic.

It is well recognised that both symptoms and deficits may have an adverse effect on quality of life (QOL) in DPN (Vileikyte 1999). The NeuroQol, a recently developed and validated QOL instrument, also includes a symptom checklist and may be used as an outcome measure in future clinical studies (Vileikyte et al. 2003).

Table 17.1 The Neuropathy Symptom Score

Neuropathy Symptom Score (NSS)

Patient Response


Have you, in the last 6 months, had any pain or Burning, Numbness, Tingling = 2 discomfort in your legs and feet when you are not Fatigue, Cramping, Aching = 1


Is this pain & discomfort most felt in the:

Others = 0

Are these symptoms at their worst during the: Night = 2

Have these symptoms ever kept you awake at Yes = 1


Is there anything that can improve the pain and/or Yes, Walk = 2


Total NSS out of 9

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