A New, Simple, Pragmatic Clinical Staging of Distal Symmetrical Polyneuropathy in Diabetes: Will it Improve Organisation of Diabetic Foot Care?

Length-dependent distal symmetrical polyneuropathy (DSPN) represents a highly prevalent complication associated with diabetes. Current standards for clinical diagnosis, severity assessment, and comprehensive staging of DSPN remain ambiguous. Numerous guidelines advocate for a qualitative evaluation of DSPN, primarily to identify loss of protective sensation (LOPS), without clearly enunciating its temporal importance. This approach has resulted in a lack of recognition of the earlier stages of DSPN within diabetes clinics. Our objective has been to establish a straightforward staging system for DSPN, taking into consideration the temporal trends in the pathogenesis of the condition. We categorise DSPN into five stages: Stage 1 represents absence of evident neuronal disease; Stage 2 involves small fibre changes with or without associated symptoms; Stage 3 comprises large fibre changes, with or without associated symptoms; Stage 4 denotes advanced DSPN characterised by LOPS; and Stage 5 includes LOPS with either a current or past history of neuropathic foot ulceration. We believe that this system may enable appropriate risk screening and significantly stratify DSPN, ideally enhancing the organisation of diabetic foot care through suitable counselling and referral.