The Toronto Clinical Scoring System (TCSS) refers to screening tests for diabetic polyneuropathy that are suited for annual screening. The authors are from Beth Israel Deaconness Medical Center, Harvard Medical School, Toronto General Hospital, University of Toronto and affiliated institutions.

Patient selection: diabetic


Screening tests:

(1) 10-gram Semmes-Weinstein monofilament on non-callused site on dorsum of first toe

(2) superficial pain sensation (using sterile Neurotip) on non-callused site on dorsum of first toe

(3) vibration testing by on-off method placing a 128-Hz tuning fork applied to bony prominence bilaterally situated at the dorsum of the first toe just proximal to the nail bed

(4) vibration testing by the timed method (see below)


Vibration timed method (most complex):

(1) 128-Hz tuning fork applied to the same bony prominences bilaterally at the dorsum of the first toe

(2) time to undetectable vibration in seconds

(3) control time based on application of tuning fork to the dorsal aspect of the examiner's distal phalanx of the thumb


Criteria for abnormal test: >= 5 incorrect responses for 8 stimuli applied

Criteria for normal test: <= 1 incorrect response for 8 stimuli applied


All of the tests had an AUC in range 0.70 to 0.73 with monofilament and on-off vibration comparable.


The likelihood ratio for an abnormal test was 26.6 for on-off vibration vs 10.2 for monofilament.


Annual screening for diabetic neuropathy should be conducted using one of the first 3 screening methods.

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