Measuring vibration threshold with a graduated tuning fork in normal aging and in patients with polyneuropathy
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J Neurol Neurosurg Psychiatry 1998;65:743–747 743
Measuring vibration threshold with a graduated
tuning fork in normal aging and in patients with
polyneuropathy
I S J Martina, R van Koningsveld, P I M Schmitz, F G A van der Meché, P A van Doorn,
for the European Inflammatory Neuropathy Cause and Treatment (INCAT) group
Abstract devices have been developed, such as the
Objective—To provide clinically useful Biothesiometer, the Optacon, and the compu-
vibration threshold normal values. ter assisted sensory examination.3–5 Although
Methods—The graduated Rydel-SeiVer these instruments are useful in experimental
tuning fork was evaluated in 198 healthy studies, they are of little use in daily practice.
controls and 59 patients with a polyneu- The size of the apparatus, the duration of
ropathy. The measures were done in trip- examination, the demand on patients’ coopera-
licate at four locations: the distal tion, and their cost are in sharp contrast with
interphalangeal joint of the index finger, the needs of a simple and valid instrument for
ulnar styloid process, interphalangeal use in routine neurological investigation. With
joint of the hallux, and internal malleolus. the introduction of the 64 Hz graduated tuning
The values obtained with this tuning fork fork by Rydel and SeiVer (Martin, Tuttlingen,
in healthy controls and patients with Germany) in 1903 it seemed as if all the needs
polyneuropathy were compared with the were fulfilled in providing an instrument which
values of an electronic device, the Vi- was easy to apply, inexpensive, and reliable for
brameter. quantifying impairment of vibration sense.6
Results—Vibration sense was better per- However, this tool has been largely neglected
ceived in the arms compared with the legs. by neurologists and thus far, only a few papers
There was a significant age related decline have reported on its use.7–14 Clinically useful
of vibration sense at all locations. The normal values for vibration sense using this
values from the Rydel-SeiVer tuning fork tuning fork were provided by one study only.7
and the Vibrameter were significantly These values were obtained by examining 73
correlated in both groups. The sensitivity healthy controls only at the hallux, which ham-
of these two instruments for the four sites pers their general applicability. Other studies
examined in the polyneuropathy group acquired their own normal vibration values,
ranged from 29–76% and 31–73%, respec- but unfortunately from only a few healthy
tively and was the highest at the hallux for controls.8 11 No study has provided normal
both instruments. values for the arms. The primary aim of this
Department of Conclusion—This study provides clinical study was to obtain specific normal vibration
Neurology, University
useful normal values of vibration thres- threshold values for the Rydel-SeiVer tuning
Hospital Rotterdam, fork at four examination sites in a large number
dr Molewaterplein 40, hold for the Rydel-SeiVer tuning fork.
3015 GD, Rotterdam, This is a simple and easily applicable of healthy controls. In addition, the values
The Netherlands instrument that assesses vibration sense achieved using the device in healthy controls
I S J Martina semiquantitatively and should therefore and in patients with a polyneuropathy were
R van Koningsveld have a place in routine neurological compared with those obtained with an elec-
F G A van der Meché
examination. tronic device, the Vibrameter.15
P A van Doorn
(J Neurol Neurosurg Psychiatry 1998;65:743–747)
Department of
Statistics, Daniel den Keywords: vibration sense; graduated tuning fork; aging Participants and methods
Hoed Cancer Centre, HEALTHY CONTROLS
University Hospital Healthy controls were recruited from hospital
Rotterdam, Groene Abnormalities in sensory qualities are frequent personnel, companions (relatives, friends) of
Hilledijk 301, 3075 EA, complaints of patients with peripheral neu- patients visiting our outpatient clinic, and from
Rotterdam, The ropathies. Impairment of vibration sense, espe- homes for elderly people. Two hundred and
Netherlands
P I M Schmitz cially starting distally in the limbs, may be a fourteen potential controls were interviewed
sign of peripheral nerve dysfunction.1 Tra- and examined. Those with sensory symptoms,
Correspondence to: ditionally, a non-graduated tuning fork, which sensory signs including absent vibration sense,
Dr ISJ Martina, Department was invented in 1711 and introduced by a history of alcohol misuse, using drugs which
of Neurology, University
Hospital Rotterdam, Dr Bonnafont as a diagnostic test in general medi- may cause a polyneuropathy or influence their
Molewaterplein 40, 3015 cine, is used for the evaluation of the vibration cooperation, and those with a disease which
GD Rotterdam, The sense.2 This simple instrument measures the might induce a polyneuropathy, were excluded
Netherlands. Telephone
0031 10 4639222; fax 0031
presence or absence of vibration, but unfortu- from the study. The selected participants had a
10 4633208. nately does not quantitatively provide the lucid consciousness and their history did not
degree of dysfunction of vibration sense. It is of show any mental or psychological illness.
Received 2 December 1997 clinical importance that the vibration sense Standard neurological examination was per-
and in revised form
1 April 1998 should be measured quantitatively and consist- formed with special interest in the sensory
Accepted 6 April 1998 ently. For this purpose several electronic qualities. Six age groups (Downloaded from http://jnnp.bmj.com/ on March 17, 2015 - Published by group.bmj.com
744 Martina, van Koningsveld, Schmitz, et al
of about 35 participants. Sixteen subjects (nine
8 8 men; seven women; mean age 81 (SD 8.5)
years; range 65–93 years) were excluded from
7
analysis, based on absent vibration perception
6 6 in at least one region tested. Eight had an
absent vibration sense at the hallux and the
internal malleolus, seven only at the hallux, and
4 4 4 one only at the internal malleolus. Nine
subjects had absent and four decreased (−3/
−3) ankle jerks. The ankle reflexes were normal
2 2 in the remaining three patients. These patients
were considered to have subclinical disease.
The problem of the selection of participants for
0 0
normal vibration threshold values is discussed
later.
A B C D E F
PATIENTS WITH POLYNEUROPATHY
Figure 1 Extremities of the graduated tuning fork at rest (A) and during vibration
(B→F). Intersection between lower and upper triangles moves from 0 (minimum score) to 8 Fifty nine ambulatory patients from our outpa-
(maximum score) with decreasing vibration amplitude (↔). tient clinic (31 men; 28 women; mean age 56.8
(SD 15.9) years; range 14–87 years) with a
8.0 clinical and electrophysiologically supported
polyneuropathy were enrolled in this study.
7.0 They were stratified into age group, as
I
described above, and sex. Each age group con-
6.0 sisted of about 10 participants. These patients
II
had a mild polyneuropathy with limited
Tuning fork values
5.0 sensory disturbances and walking problems.
The aetiologies of the polyneuropathies were
4.0 diabetes mellitus (11 cases), hereditary motor
sensory neuropathy type I (five cases), and type
3.0
II (two cases), systemic disease (three cases),
amyloidosis (three cases), drug induced (two
2.0
cases), thyroid dysfunction (one case) and vita-
I Mean min B12 deficiency (one case). Fourteen
1.0 II 5% Lower limit patients had a chronic idiopathic axonal
polyneuropathy. In 17 cases no cause was
0.0
determined.
10 20 30 40 50 60 70 80 90 100
Age (y) ASSESSMENT TOOLS
Figure 2 Vibration threshold values obtained by the Rydel-SeiVer tuning fork at the index The Rydel-SeiVer tuning fork is a graduated
finger. Residual standard deviation (SDres = residual standard deviation around the mean fork which determines the ability of subjects to
regression line)=0.62. y mean=7.69−0.01 × age; y 5%=6.67−0.01 × age. discriminate various vibration intensities. The
8.0
two arms of this tuning fork bear calibrated
weights at their extremities (fig 1).6 8 A triangle
7.0
and an arbitrary scale from 0 (minimum score)
I to 8 (maximum score) imprinted on the
6.0
weights allow assessment of vibration thresh-
II old. Once the arms are swinging, the fork
Tuning fork values
5.0 vibrates at 64 Hz and the triangles on the
weights appear double. The intersection of
4.0 these two virtual triangles moves from 0 to 8 in
an exponential way with decreasing vibration
3.0 amplitude of the arms. The vibration extinc-
tion threshold is considered as the nearest
2.0 value to the apparent point of intersection of
the virtual triangles when the subject indicates
I Mean that vibration is no longer perceived. The
1.0
II 5% Lower limit
Vibrameter (Somedic, Stockholm, Sweden,
0.0 Type III) is a device which determines
10 20 30 40 50 60 70 80 90 100 vibration sense electronically. It has been
Age (y) extensively described by Goldberg and Lindb-
lom and consists essentially of a hand held
Figure 3 Vibration threshold values obtained by the Rydel-SeiVer tuning fork at the ulnar vibrating probe which vibrates at 100 Hz.15 The
styloid process. Residual standard deviation (SDres = residual standard deviation around
the mean regression line)=0.55. y mean=7.60−0.0079 × age; y 5%=6.68−0.0079 × age. vibration amplitude of this probe increases
from zero to a maximum of 399.9 µm.
60–69, 70–79, >80 years) were formed. One
hundred and ninety eight healthy controls (93 TEST PROCEDURES
men; 105 women; mean age 55.1 (SD 18.0) All participants gave informed consent before
years; range 19–93 years) stratified for sex were the study. All measurements were performed
enrolled in this study. Each age group consisted by one investigator (RvK) and the vast majorityDownloaded from http://jnnp.bmj.com/ on March 17, 2015 - Published by group.bmj.com
Measuring vibration threshold with a graduated tuning fork 745
8.0 women; total n=100), and all patients with
polyneuropathy. Vibration threshold was
7.0 measured according to the method of limits.15
The subjects were asked to indicate when the
6.0 vibration stimulus was felt for the first time
(perception threshold) and when this stimulus
Tuning fork values
5.0
I
disappeared again (disappearance threshold).
The average of these three paired measure-
4.0 ments was considered the vibration threshold
at the location investigated. The Vibrameter
II
3.0 was applied resting on its own weight and its
equilibration was electronically controlled.
2.0 Each cycle of measurement included catch
I Mean trials with a resting probe.
1.0
II 5% Lower limit
STATISTICS
0.0 Vibration threshold reference values for the
10 20 30 40 50 60 70 80 90 100 Rydel-SeiVer tuning fork were calculated for
Age (y) the four sites examined, depending on age and
Figure 4 Vibration threshold values obtained by the Rydel-SeiVer tuning fork at the
sex, using linear and quadratic regression
hallux. Residual standard deviation (SDres = residual standard deviation around the analysis at a chosen specificity of 95%. The 5%
mean regression line)=0.99. y mean=7.38−0.026 × age; y 5%=5.75−0.026 × age. lower limits for the Rydel-SeiVer tuning fork
were estimated for each site of examination as
8.0 the mean−1.65*Sres. The mean was defined as
the mean vibration threshold for a certain age
7.0
(and sex) and Sres was considered the residual
6.0 standard deviation around the regression line.
Tuning fork values
The 95th percentile vibration threshold values
Ia
5.0 for the Vibrameter were also calculated. The
Ib obtained limits were estimated and further
4.0 used to determine new specificities and sensi-
IIa
3.0
tivities for both instruments. A vibration sense
IIb
was considered to be abnormal if the corre-
I Mean sponding value was below the 5% lower limit
2.0
II 5% Lower limit when examined with the tuning fork or above
a Female
1.0 the 95th percentile vibration value when investi-
b Male
gated with the Vibrameter at the same site of
0.0 examination. The correlation between the two
10 20 30 40 50 60 70 80 90 100 instruments was analysed by Spearman’s rank
Age correlation test. All analyses were performed
Figure 5 Vibration threshold values obtained by the Rydel-SeiVer tuning fork at the using Stata 5.0 for Windows 95 (Stata Statisti-
internal malleolus. Residual standard deviation (SDres = residual standard deviation cal Software: Release 5.0. 702 University Drive
around the mean regression line)=0.89; sex = 1 (male); sex = 0 (female). y East, College station, TX: Stata Corporation
mean=6.80−0.51 × sex−0.0002 × age × age; y 5% (female)=5.33−0.0002 × age × age;
y 5% (male)=4.82−0.0002 × age × age. 1997). A p valueDownloaded from http://jnnp.bmj.com/ on March 17, 2015 - Published by group.bmj.com
746 Martina, van Koningsveld, Schmitz, et al
Table 1 Normal vibration threshold values (5% lower cificity of 80% and a sensitivity of 83%. The
limit) in healthy controls (with the Rydel-SeiVer tuning specificity and sensitivity for the Vibrameter
fork)
were 86% and 78%, respectively. The corre-
For the upper extremities For the lower extremities sponding specificity and sensitivity when at
least two sites investigated showed an abnormal
Age (y) Values Age (y) Values
vibration sense was 94% and 63% for the tun-
6.5 4.5 ing fork, and 98% and 61% for the Vibrameter.
41–85 >6.0 41–60 >4.0
>85 >5.5 61–85 >3.5
>85 >3.0
Discussion
Sites of examination: dorsum of the distal interphalangeal joint The present study provides clinical useful nor-
of the index finger, the ulnar styloid process, dorsum of the
interphalangeal joint of the hallux ,and the internal malleolus.
mal values for the vibration sense using the
Values are 0–8; the vibration threshold values are presented in graduated Rydel-SeiVer tuning fork at four
rounded numbers. sites of examination. These normal values are
diVerent from those provided by the literature.
tion sense were better in the arms than in the Claus et al stated that subjects up to 40 years
legs. In addition, there was a significant should score at least 6/8 and those older than
(pDownloaded from http://jnnp.bmj.com/ on March 17, 2015 - Published by group.bmj.com
Measuring vibration threshold with a graduated tuning fork 747
distal regions, possibly due to a metabolic this tuning fork. We propose to incorporate this
abnormality leading to failure of axonal pocket sized instrument in the routine neuro-
transport and subsequent degeneration.27 logical examination.
The sensitivity of the Rydel-SeiVer tuning
fork for patients with a polyneuropathy is
We thank professor KV Toyka for advising us to use the gradu-
highly dependent on the selection of patients. ated Rydel-SeiVer tuning fork in the INCAT studies. This study
In patients with predominantly motor signs was part of the Biomed-project number BMH4-CT96 0324.
and those with only small size myelinated/
unmyelinated nerve disturbances it might be 1 Schaumburg HH, Berger AR, Thomas PK. Anatomical
expected that the sensitivity for detecting classification of peripheral nervous system disorders. In:
Disorders of peripheral nerves, 2nd ed. Philadelphia: FA Davis,
vibration sense abnormalities using this tuning 1992:10–24.
fork will be low. The vast majority of the 2 Bickerton RC, Barr GS. The origin of the tuning fork. J R
Soc Med 1987;80:771–3.
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in 519 non-diabetic subjects. BMJ 1984;288:1793–5.
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hung des vibrationsempfindens. Nervenarzt 1988;59:138–
This correlation was, however, moderate and 42.
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sense with graduated tuning fork. Diabetes Care 1990;13:
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Measuring vibration threshold with a graduated
tuning fork in normal aging and in patients with
polyneuropathy
I S J Martina, R van Koningsveld, P I M Schmitz, F G A van der Meché and P
A van Doorn
J Neurol Neurosurg Psychiatry 1998 65: 743-747
doi: 10.1136/jnnp.65.5.743
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