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Michigan Neuropathy Screening Instrument (MNSI) and Mich. Diabetic Neuropathy Score (MDNS)
Please note that this section is an archive (last updated in June 2006). [disclaimer]
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Overview |
Instrument Reviews |
Construct Overviews |
Book Compendium Reviews |
Internet Site Reviews
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Practical Information
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Instrument Name:
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Michigan Neuropathy Screening Instrument (MNSI) and Mich. Diabetic Neuropathy Score (MDNS)
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Instrument Description:
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The MNSI was developed by the Michigan Diabetes Research and Training Center (MDRTC) to screen for diabetic neuropathy. Though it includes a 15-item self-report questionnaire (that assesses foot sensations such as pain, sensitivity to temperature, and numbness), the MNSI is typically scored using only a physical examination component. The physical examination screening questions focus on a foot inspection, assessment of vibration sensation, and grading of ankle reflexes. The MNSI is designed for use by health care professionals in the outpatient setting to screen patients for distal symmetric sensorimotor polynueuropathy (DN). The instrument is the first part of a two-step assessment approach; patients screening positive on the MNSI are then evaluated based on the Michigan Diabetic Neuropathy Score (MDNS) and nerve conduction assessments to confirm and stage the diagnosis of DN.
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Price:
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Free; available through MDRTC website under “Research Contacts.”
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Administration Time:
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4-5 minutes. (Ref: 5)
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Publication Year:
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1994
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Item Readability:
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Flesch-Kincaid grade level of 2.4, meaning a person with a second grade education could comprehend the instrument.
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Scale Format:
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The questionnaire items are dichotomous; the physical exam items receive scores of 0, 0.5, or 1 each. (Ref: www.med.umich.edu/mdrtc). The MDNS yields a composite score based on clinical examination and nerve conduction tests.
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Administration Technique:
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Self-report questionnaire and physical examination (followed by the use of the MDNS for determining staging neuropathy).
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Scoring and Interpretation:
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MNSI—
Questionnaire: Responses of “yes” to items 1-3, 5-6, 8-9, 11-12, and 14-15 are counted as one point. Responses of “no” on items 7 and 13 are one point. Items 4 and 10 are not counted in the scoring. Scores range from 0-13. (Ref: www.med.umich.edu/mdrtc) Higher scores indicate more severe neuropathy symptoms. However, these items are not utilized in the final MNSI scores; only the physical examination score is used.
Physical exam: The physical examination includes foot inspection, vibration sensation assessment and evaluation of ankle reflexes. Five parameters are scored for the right and left feet individually. Items 1 and 2 receive scores of 0 or 1 for each foot . Items 3-5 receive scores of 0, 0.5 or 1 for each foot . Scores range from 0-8 on examination portion. (Ref: www.med.umich.edu/mdrtc) A score of more than 2 identifies patients with diabetic neuropathy, and referral to a neurologist for a more detailed examination (using the MDNS) is warranted. (Ref: 1-2)
MDNS—
Clinical Exam: Assesses 3 sensory modalities, vibratory threshold, pain and touch. Maximum score is 46. Developers recommend a score greater than 6 to indicate neuropathy.
Nerve Conduction: Patient’s nerve conduction velocity is compared to norms. “Abnormal” is defined as velocity less than the first percentile.
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Forms:
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No information found.
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Research Contacts
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Instrument Developers:
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EL Feldman, MD, PhD; MJ Stevens, MBBCH; PK Thomas, CBE, MD; MB Brown, PhD; N Canal, MD; DA Greene, MD
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Instrument Development Location:
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University of Michigan MDRTC; Royal Free Hospital, London; San Raffaele Hospital, Milan.
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Instrument Developer Email:
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No information found.
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Instrument Developer Website:
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www.med.umich.edu/mdrtc
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Annotated Bibliography
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1. Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N, Greene DA. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabetes Care November 1994;17(11):1281-1289. [PMID:7821168]
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Purpose:
To report on the development of a 2-stage assessment to simplify diagnosis and staging of diabetic neuropathy.
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Sample:
56 outpatients (31 men and 25 women) with type I or II diabetes from the MDRTC outpatient clinics. Mean age=47.5 years, 27 with type I diabetes and 29 with type II diabetes, mean years of illness duration=15.3 years.
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Methods:
Patients were diagnosed according to the San Antonio Consensus statement criteria and the Mayo Clinic Protocol, the MNSI and MDNS and other neuropathy tests. Cut scores and staging criteria for the MNSI and MDNS are recommended based on comparisons with the other assessments.
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Implications:
The authors recommend a cut score of 2 for the screen (i.e. those who score greater than 2 are positive on the screen). (Note: The questionnaire portion of the MNSI did not have strong correlations with indicators of defined neuropathy; as such, only the physical examination score (0-8) is suggested for future use. The authors conclude that the MNSI is an effective and inexpensive screen for DN.
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2. Feldman EL, Stevens MJ. Clinical testing in diabetic peripheral neuropathy. Can J Neurol Sci 1994 Nov;21(4):S3-7.[PMID:7874610]
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Purpose:
To describe the two-step outpatient neuropathy program developed by the authors.
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Sample:
Does not have a study sample. Samples from previously published studies are mentioned.
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Methods:
Non-applicable.
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Implications:
The Michigan neuropathy program assessment system can assist in early detection of diabetic neuropathy.
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3. Bax G, Fagherazzi C, Piarulli F, Nicolucci A, Federe D. Reproducibility of Michigan Neuropathy Screening Instrument (MNSI). Diabetes Care August 1996; 19(8):904-5. [PMID:8842620]
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Purpose:
In a letter to the journal, reproducibility of tests using the vibratory and thermal perception thresholds are compared.
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Sample:
100 patients with diabetes. Mean age was 57(± 8) years. Mean disease duration was 12 years (± 7) years.
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Methods:
Kohen’s statistical test (K) was performed for several techniques of diagnosing neuropathy.
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Implications:
The MNSI physical examination showed acceptable reproducibility, and requires qualified operators and attention to quality control. |
4. Fedele D, Comi G, Coscelli C, Cucinotta D, Feldman EL, Ghirlanda G, Greene DA, Negrin P, Santeusanio F, the Italian Diabetic Neuropathy Committee. A multicenter study on the prevalence of diabetic neuropathy in Italy. Diabetes Care May 1997;20(5):836-43. [PMID: 9135952]
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Purpose:
To estimate the prevalence of neuropathy among diabetic outpatients in Italy.
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Sample:
8,757 diabetic outpatients administered the 2-part Michigan assessment protocol This included the physical examination of the MNSI, called the DNI in this study, followed (as indicated) by the MDNS.
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Methods:
Comparison of the Michigan program with other established instruments.
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Implications:
Neuropathy is common among outpatients with diabetes. Approximately 1/3 had neuropathy, defined as scoring greater than 2 on the screening instrument. Severity increased with age and disease duration.
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5. Lunetta M, Le Moli R, Grasso G, Sangiorgio L. A simplified diagnostic test for ambulatory screening of peripheral diabetic neuropathy. Diabetes Research and Clinical Practice March 1998;39(3):165-72.[PMID: 9649948]
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Purpose:
To evaluate reliability and reproducibility of the MNSI physical examination.
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Sample:
80 diabetic patients, of whom 25 had type I diabetes (mean age=44 years, duration of diabetes=14 years, treatment by insulin) and 55 had type II diabetes (mean age=53 years, duration of diabetes=14 years, treatment by oral hypoglycaemic medication).
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Methods:
The MNSI was given by two diabetologists, and then repeated a week later. Patients then went to a neurologist for the MDNS. Results of the MNSI and MDNS were compared according to the two observers.
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Implications:
Based on a cut-score of 2.5, the MNSI appears to be a rapid and reproducible test for diabetic neuropathy.
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top
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Factors and Norms
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Factor Analysis Work:
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No information found.
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Normative Information Availability:
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No information found.
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Reliability Evidence
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Test-retest:
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No information found.
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Inter-rater:
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Kohen’s K coefficient was 0.62 in a study of inter- (K=0.61) and intra-rater (K=0.61; 0.63) agreement for the physical examination portion of the MNSI. The foot exam had a lower repeatability of K=0.14-0.67. (Ref: 3-4) Inter-rater reproducibility was 88.75% using a sample of 80 diabetic patients, while intra-rater reproducibility performed after a one-week time interval was 95 and 94% for the two raters. (Ref: 5) In this study, a correlation of r=0.53 (p<0.005) was found between diabetologist and neurologist scoring of the MNSI physical examination and the MDNS clinical scores.
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Internal Consistency:
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No information found.
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Alternate Forms:
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No information found.
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Validity Evidence
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Construct/ Convergent/ Discriminant:
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Using the status based on the Mayo Clinic criteria, the MNSI physical examination (score greater than 2) had a sensitivity of 80%, specificity of 95%, positive predictive value of 97%, and negative predictive value of 74%. (Ref 1) Another study found that using a cut-score of 2.5 yielded a sensitivity of 78.6% and specificity of 75%. (Ref: 5) MDNS score correlated significantly with other diabetic neuropathy tests with the exception of the Neuropathy Symptom Profile (r=0.36, p>0.05). The questionnaire portion correlated significantly only with the Neuropathy Symptom Profile (r=0.60, p<0.05). (Ref: 1) The concordance between the MNSI and the MDNS in identifying patients was estimated at 83.5% in one study (Ref: 4). No significant correlation was found between number of nerves with reduced velocity and score on the MNSI.
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Criterion-related/ Concurrent/ Predictive:
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Age and disease duration were correlated with the severity of neuropathy as diagnosed by the program: average age of nonneuropathic patients=55 years, average age of neuropathic patients=58-59 years; average duration of disease in nonneuropathic patients=10 years, average duration of disease in neuropathic patients=12 years for class 1, 13 years for class 2, and 15 years for class 3. (Ref: 4)
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Content:
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The items for the MNSI were chosen to, in the opinion of the authors, “reflect common symptoms reported in DN together with two questions to record non-neuropathic and primarily vascular symptoms.” (Ref: 1) However, no formal expert review of construct domains or items is reported.
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Responsiveness Evidence:
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No information found.
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Scale Application in VA Populations:
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No information found.
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Scale Application in non-VA Populations:
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Yes. (Ref: 1,3-5)
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Comments
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The published evidence suggests that, in situations where resources are limited, the MNSI and the MDNS are valuable tools for screening and staging DN. They can be administered in a relatively brief amount of time and, on the whole, have evidenced good reproducibility of scores. The authors note, however, that the instruments are not intended as replacements for established DN assessment protocols (San Antonio consensus statement and the Mayo criteria).
No authors address if or how they utilize the questionnaire portion of the MNSI, which proved helpful in identifying symptoms, though not in differentiating diagnosable neuropathy. It is therefore unclear from the published literature whether the functional use of the MNSI self-report questionnaire section continues to be used and if so, for what purpose (e.g., history).
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