Modified Total Neuropathy Score Sheet
Modified Total Neuropathy Score SheetSensory Symptoms:0 =no symptoms1 =symptoms limited to the tips of fingers or toes2 =symptoms extend to ankle or wrist3 =symptoms extend to above ankle or above wrist to the level of knee or elbow4 =symptoms above knee or elbow and /or severe disabling symptoms that affect normal functioning and/or neuropathic pain that requires narcotic analgesiaIf symptoms are asymmetrical from side-to-side, grade the worst side.ItemScoreParesthesias (tingling)L/R/BNumbness (“dental work anesthesia”)L/R/BNeuropathic pain (aching, burning, stabbing)L/R/BMyalgias or CrampsL/R/BTOTAL SENSORY SYMPTOM SCORE (0-4)Use average score from A-D, round up to next whole number.Motor Symptoms:0 =no difficulty1 =with slight difficulty2 =with moderate difficulty3 =require some help or an assistive device4 =total loss of function ItemScoreHand: Dexterity (buttoning, writing, tying shoe laces, opening tight jars, or inserting key in lock)L/R/BFoot: Walking (unsteady on feet, walking on tip toes or on heels, or operating pedals in car)L/R/BLegs: Climbing steps, or standing up from a chairL/R/BArms: Combing hair, or reaching up to a high shelfL/R/BTOTAL MOTOR SYMPTOM SCORE (0-4)Use average score from A-D, round up to next whole number.Neurological Examination:SENSORY0 =normal1 =absent/decreased in index finger or great toe2 =absent/decreased up to ankle or wrist3 =absent/decreased up to elbow or knee4 =absent/decreased above the level of knee or elbowIf symptoms are asymmetrical from side-to-side, grade the worst side. ItemScorePin levelL/R/BVibration (From quantitative vibration testing compared to norms in Bloom paper)L/R/BTOTAL SENSORY SCORE (0-8)MOTOR0 =normal (MMT ≥4+)1 =mild weakness, but can overcome some resistance (MMT 3+ to 4)2 =moderate weakness, can overcome gravity (MMT 33 =severe weakness with gravity eliminated (MMT 1 to 2)4 =paralysis (MMT 0)If symptoms are asymmetrical from side-to-side, grade the worst side.ItemScoreAnkle DFL/R/BFinger spreadL/R/BWrist EXTL/R/BTOTAL MOTOR SCORE (0-4)Use score from weakest muscle group. REFLEXLocationLRP = presentPR = present with reinforcementA = absentBiceps TricepsBrachioradialisKneeAnkle0 =all reflexes normal (Biceps, Triceps, Brachioradialis, Knee, and ankle)1 = ankle reflex reduced2 = ankle reflex absent3 = ankle reflex absent, others reduced4 = all reflexes absentTOTAL REFLEX SCORE (0-4)Add the scores from each section to obtain the total mTNS score. Sensory symptoms (0-4) Motor symptoms (0-4)Pin sensibility (0-4)Vibration sensibility (0-4)Motor function (0-4)Deep tendon reflexes (0-4)TOTAL mTNS SCORE (0-24)Instructions for Modified Total Neuropathy Score“I am going to test the function of your nerves of your arms and legs. You will need to take off your shoes.”“I am going to ask you some questions about sensory symptoms you may or may not be experiencing.”If symptoms are asymmetrical from side-to-side, grade the side the participant reports as the worst side, circle L or R. If the symptoms are symmetrical, circle B for both.“Do you have tingling of your fingers or toes?”If yes, “show me how far up your arm(s) or leg(s) the tingling goes.” Have the participant indicate by pointing to the transition point. “Does the tingling affect what you do from day to day?” Score per instructions on the score sheet.If no, record 0 on the score sheet.“Do you have numbness, like dental work anesthesia, of your fingers or toes?”If yes, “show me how far up your arm(s) or leg(s) the tingling goes.” Have the participant indicate by pointing to the transition point. “Does the tingling affect what you do from day to day?” Score per instructions on the score sheet.If no, record 0 on the score sheet.“Do you have aching, burning, or stabbing pain in your fingers or toes?”If yes, “show me how far up your arm(s) or leg(s) the tingling goes.” Have the participant indicate by pointing to the transition point. “Does the tingling affect what you do from day to day?” “Do you take pain medicine because of the pain?” Score per instructions on the score sheet.If no, record 0 on the score sheet.“Do you have muscle pain or cramps in your fingers or toes?”If yes, “show me how far up your arm(s) or leg(s) the tingling goes.” Have the participant indicate by pointing to the transition point. “Does the tingling affect what you do from day to day?” Score per instructions on the score sheet.If no, record 0 on the score sheet.“I am going to ask you several questions about the use of your hands, feet, legs, and arms during day to day activities.”“Do you have difficulty with any of the following activities: buttoning, writing, tying shoe laces, opening tight jars, or inserting a key in a lock?”If yes to any of the above questions, “would you say you have ‘slight difficulty’, ‘moderate difficulty’, ‘require some help or use an assistive device’, or ‘can’t do at all’” Score per instructions on the score sheet.If no, record 0 on the score sheet.“Do you have difficulty with any of the following activities: walking (e.g. do you feel unsteady on your feet, walk on tip toes or heels) or operating the pedals in your car?”If yes to any of the above questions, “would you say you have ‘slight difficulty’, ‘moderate difficulty’, ‘require some help or use an assistive device’, or ‘can’t do at all’” Score per instructions on the score sheet.If no, record 0 on the score sheet.“Do you have difficulty climbing steps or standing up from a chair?”If yes to any of the above questions, “would you say you have ‘slight difficulty’, ‘moderate difficulty’, ‘require some help or use an assistive device’, or ‘can’t do at all’” Score per instructions on the score sheet.If no, record 0 on the score sheet.“Do you have difficulty combing your hair or reaching up to a high shelf?”If yes to any of the above questions, “would you say you have ‘slight difficulty’, ‘moderate difficulty’, ‘require some help or use an assistive device’, or ‘can’t do at all’” Score per instructions on the score sheet.If no, record 0 on the score sheet. “I am going to test your ability to sense sharp. You will need to keep your shoes off and close your eyes.”“I am going to touch you with the sharp end of a safety pin. It should feel like this (demonstrate on the clavicle). This time, I want you to tell me if it feels sharp or dull.”Touch the participant with the sharp end of the safety pin on the pad of the index finger and the plantar surface of the great toe. (If they report sharp, record a 0. If they report dull, record a 1. If they report no feeling, continue to next test site.)Touch dorsum of talocrural joint line and dorsum of wrist joint line. (If they report sharp, record a 1. If they report dull, record a 2. If they report no feeling, continue to next test site.)Touch cubital fossa and medial knee joint line. (If they report sharp, record a 2. If they report dull, record a 3. If they report no feeling, continue to next test site.)Touch arm and thigh. (If they report sharp, record a 3. If they report dull or no feeling, record a 4.)Leave vibration question blank (You will use the Biothesiometer and the Bloom table to gather this information—see Biothesiometer protocol)“I am going to test the strength of muscles that move your wrist.”Use manual muscle testing position to test wrist extensors, ankle DF and finger spread (hand intrinsics).If symptoms are asymmetrical from side-to- side, grade the worst side. Circle L or R. Circle B if symptoms are symmetrical. “I am going to test several reflexes of your arms and legs.”Use Hoppenfeld technique for all reflex testing SEE BELOWBiceps brachii—Participant is sitting with right arm flexed and supported. Place thumb over the biceps tendon in the cubital fossa, stretching it slightly. Tap thumb or directly on tendon. Repeat 5 times, if no response then ask patient to clench their teeth. Repeat 5 times, if no response record ‘absent reflex’. REPEAT ON THE LEFTTriceps brachii—Participant is sitting with arm supported in abduction, elbow flexed. Palpate triceps tendon just above olecranon. Tap directly on tendon. Repeat 5 times, if no response then ask patient to clench their teeth. Repeat 5 times, if no response record ‘absent reflex’. REPEAT ON THE LEFTQuadriceps femoris—Participant is sitting with knee flexed, foot unsupported. Tap tendon of quadriceps muscle between the patella and tibial tuberosity. Repeat 5 times, if no response then ask participant to clasp their fingers and try to pull them apart. Participant releases hands just before tap hammer. Repeat 5 times, if no response record ‘absent reflex’. REPEAT ON THE LEFTAchilles—Participant is sitting with knee flexed and foot held in slight dorsiflexion. Tap tendon just above its insertion on the calcaneus. Maintaining slight tension on the gastrocnemius-soleus group improves the response. Repeat 5 times, if no response then ask participant to clasp their fingers and try to pull them apart. Participant releases hands just before tap hammer. Repeat 5 times, if no response record ‘absent reflex’. REPEAT ON THE LEFTBrachioradialis--Support the participant’s RIGHT arm in the same manner used to elicit the biceps reflex. Using the flat edge of the reflex hammer, tap the brachioradialis at the distal 1/3 of the radius to elicit a contraction of the muscle.HOW TO RECORD RESPONSES: If present, record as present (P). If needed, repeat 5 times, if no response ask the participant to clench their jaw. If a response, then record as present with reinforcement (PR). If necessary, repeat 5 times, if no response record ‘absent reflex’.Score the reflex portion of the TNS as per the instructions on the score sheet.Resources: Personal communication with Dr. Cornblath, 2003, Cornblath et al., 1999; Hoppenfeld Physical Examination of the Spine and Extremities (1976)Instructions for the Biothesiometer“I am going to test your ability to feel vibrations in your hands, feet, ankle, and wrist. You will need to keep off your shoes and socks.”1. Position the participant so they are sitting with their feet flat on the ground and their right arm supported on a bedside table. 2. Touch the Biothesiometer to the person’s clavicle, “I will rest this vibrator on a bony prominence and then slowly turn up the amplitude until you tell me you feel the vibration, like this. As soon as you feel it, say ‘on’, then I will turn down the amplitude until the vibration feeling goes away. As soon as it goes away, say ‘off’.” 3. Test the first test site: PLANTAR ASPECT OF GREAT TOE OPPOSITE THE NAIL BED (norms)Be sure to hold the vibrator perpendicular to the test site.Do not press the vibrator into the skin, allow gravity to place it while you stabilize the position with your hand. Record the appearance and disappearance voltage on the report form. Their vibration threshold is the average between these numbers and this is what is compared to age norms. REPEAT ON THE LEFT SIDE4. Test the second test site: PALMER ASPECT OF THUMB OPPOSITE THE NAIL BED (norms)Same instructions as in step #35. Test the third site: HEAD OF ULNA OF THE RIGHT WRISTSame instructions as in step #36. Reposition the patient, so they are lying on their LEFT side7. Test the fourth site: MEDIAL MALLEOLUS OF THE RIGHT ANKLE (norms)Same instructions as in step #3Resources: Bloom et al., 1984 (test sites/norms), Shy et al., 2003 (Method of limits technique)Biothesiometer Score SheetAppearanceDisappearanceAverage Pad of great toeRight ______Left _______Right ______Left _______Right ______Left _______Medial MalleolusRight ______Left _______Right ______Left _______Right ______Left _______Pad of thumbRight ______Left _______Right ______Left _______Right ______Left _______Head of ulnaRight ______Left _______Right ______Left _______Right ______Left _______Validity and Reliability: Total Neuropathy Scale: Inter- and intrarater reliability of the TNS was excellent (0.966 and 0.986 respectively). The cross-sectional validation study showed excellent correlations among all measures of neuropathy (Cornblath et al 1999).Modified Total Neuropathy Scale: mTNS is highly correlated to TNS score (r=0.99; P<0.001) (Wampler et al 2006)There was no significant difference between scores between visit 1 and visit 2 for the mTNS meaning it has good reliability (unpublished data Wampler et al)Can discriminate between neuropathy from taxane in women with breast cancer compared to healthy age matched women (Wampler et al, 2006)Moderately correlated with balance. Sensory organization test r=-0.638, p = 0.002 (Wampler et al, 2006)ReferencesBloom S, Till S, Sonksen P, Smith S. Use of a biothesiometer to measure individual vibration thresholds and their variation in 519 non-diabetic subjects. Br Med J (Clin Res Ed) 1984;288:1793–1795. Cornblath DR, Chaudhry V, Carter K, et al. Total neuropathy score: validation and reliability study. Neurology 1999;53:1660–1664.Shy ME, Frohman EM, So YT, Arezzo JC, Cornblath DR, Giuliani MJ, Knicaid JC, Ochoa JL, Parry GJ, Weimer LH. Quantitative sensory testing. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2003;60:898-904.Wampler MA, Miakowski C, Hamel K, et al. The Modified Total Neuropathy Score: A Clinically Feasible and Valid Measure of Taxane-Induced Peripheral Neuropathy in Women with Breast Cancer. The Journal of Supportive Oncology 2006;4(8):9-16. ................
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