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diabetic neuropathy is one of the most frequent diabetic foot lesions , affecting 2040% of persons with diabetes .
neuropathy increases the risk for diabetic foot ulcers , which precede 84% of lower limb amputations , and is associated with decreased quality of life and a high mortality rate .
currently accepted screening methods for diabetic neuropathy include pressure perception using the 10 g monofilament , superficial pain perception , and vibration perception . in a recent study in trinidad , teelucksingh et al . showed that in addition to these screening tests , the simple enquiry of the unrecognised loss of one 's slippers [ the slipping slipper sign ( sss ) ] has 83% sensitivity and 91% specificity for detecting the presence of severe neuropathy in patients with diabetes .
we evaluated whether the slipping slipper sign was also associated with diabetic neuropathy in jamaica and calculated the sensitivity , specificity and positive predictive value ( ppv ) for the sss in this setting .
we analyzed data from 69 participants comprising a sub - sample of participants in a study of diabetic foot complications at the diabetes clinic at the university hospital of the west indies ( uhwi ) .
ethical approval was obtained from the uhwi / university of the west indies/ faculty of medical sciences ethics committee and written informed consent was obtained from all participants prior to administration of questionnaires or performing tests .
the primary study encompassed data collected by trained research nurses from a stratified random sample of 188 patients from the uhwi diabetes clinic .
anthropometric measurements were done along with foot examinations that included a general assessment ( for amputations , ulcer or foot infections ) , a vascular examination using ankle brachial index and a neurological examination . the neurological exam consisted of pain perception , assessed 0.5 cm proximal to the nail - fold of the great toe , using the neuropen device and neurotips ( owen mumford , oxford , england ) ; vibration perception , assessed at the dorsal aspect the distal inter - phalangeal joints of the great toe , using a 128 hz tuning fork ; and pressure perception , assessed at the plantar surface of the great toe and the head of the 1 , 3r and 5 metatarsals , using a 10 g monofilament .
in addition to the above , a foot care questionnaire , which included a question on the sss , was completed by 69 participants . for evaluation of the slipping slipper sign participants were asked : have you ever lost your slipper from your feet while walking and not realized that you had done so ?
we obtained proportions of persons with a positive sss and compared proportion with positive sss for participants with any one of the three types of neuropathy or for those having impairment of one , two or all three manifestations of neuropathy .
bivariate analyses were performed by the chi square (  ) test and fisher 's exact test as appropriate .
sensitivity , specificity , and positive predictive value for the various types of neuropathy were calculated .
eighty - eight per cent ( 88% ) of participants in the study reported wearing slippers at some time .
the proportion of persons with positive sss and calculated sensitivity , specificity and ppv are shown in table 1 .
of the 69 participants 28 ( 40.6% ) had evidence of neuropathy ( impaired pain perception , vibration perception or pressure perception ) on clinical examination .
prevalence of neuropathy was higher among men ( 71.4% ) compared with women ( 32.7% ) .
the proportion of participants with sss for each type of neuropathy is shown in figure 1 .
all eight patients with a positive sss had evidence of neuropathy on at least one of the three sensory testing modalities used .
this translated to a sensitivity of 28.6% , specificity of 100% and ppv 100% for neuropathy on at least one of the three sensory modalities tested .
for pressure perception by monofilament sensitivity for the sss was 25.9% , specificity was 97.6% and ppv 87.5% .
impaired vibration perception had sensitivity of 33.3% , specificity of 91.7% , and ppv of 37.5% .
sensitivity was higher for impaired pain perception ( 58% ) , but specificity and ppv were similar ( specificity 98.3% , ppv 87.5% ) .
the presence of sss was also associated with the severity of neuropathy ( p for trend < 0.001 ) as illustrated in figure 2 . among patients with severe neuropathy defined as having impairment on two or more testing modalities 46% had a positive sss , which translated to a sensitivity of 46.2% , specificity of 96.4% , and ppv of 75% . 

table 1number , proportion , sensitivity , specificity and positive predictive value for patients with positive and negative slipping slipper sign by neuropathy status and testing modality.characteristicsss positive n ( % ) sss negative n ( % ) p valuesensitivity % specificity % ppv%any neuropathy on examination * ( n=28)8 ( 28.6)20 ( 71.4)<0.00128.6100100severe neuropathy ( n=13)6 ( 46.2)7 ( 53.8)<0.00146.296.4%75.0impaired pain perception ( n= 12)7 ( 58.3)5 ( 42.7)<0.00158.398.387.5impaired vibration perception ( n= 9)3 ( 33.3)6 ( 66.7)0.06333.391.737.5impaired monofilament ( n=27)7 ( 25.9)20 ( 74.1)0.00525.997.687.5sss , slipping slipper sign ; ppv , positive predictive value.*examination findings consisting of any combination of impaired pain perception , impaired vibration , or impaired pressure perception on monofilament testing;having impairment of two or more of the modalities above .
p - value is for difference in proportion for sss positive and sss negative . 
 
examination findings consisting of any combination of impaired pain perception , impaired vibration , or impaired pressure perception on monofilament testing ; having impairment of two or more of the modalities above .
p - value is for difference in proportion for sss positive and sss negative . 

figure 1proportion of participants with positive slipping slipper sign for each neuropathy testing modality and for any neuropathy (= impairment of any of the three modalities tested i.e. monofilament , vibration perception and pain perception ) . 
 
proportion of participants with positive slipping slipper sign for each neuropathy testing modality and for any neuropathy (= impairment of any of the three modalities tested i.e. monofilament , vibration perception and pain perception ) . 

this study corroborates the association between the sss and peripheral neuropathy , in particular its association with more severe neuropathy based on number of positive tests . in this
apart from teelucksingh 's paper we found no other published reports on the sss . in light of the strong association of neuropathy with the development of diabetic foot ulceration , lower extremity amputation , and charcot arthropathy , detection of peripheral neuropathy is of paramount importance to prevent lower extremity complications .
although sensory perception testing methods ( such as 10 g monofilament , pain perception and vibration testing ) are sensitive in identifying patients at risk for foot ulceration , the sss allows the clinician to identify patients with severe neuropathy with a single question and no testing equipment . adding this question to the regular diabetic history will serve to alert the clinician of the patients ' high - risk status .
we note that although the sensitivity of the sss in this study was relatively low ( 28.6% for any neuropathy ) , this may reflect a higher proportion of persons with mild neuropathy in our study compared to teelucksingh 's original study .
this is supported by that fact that in our study sensitivity was higher among persons with impairment on two or more modalities ( 46.2% ) and for impaired pain perception ( 58% ) , which may be considered markers of more severe neuropathy as compared to impaired vibration perception or pressure perception .
we therefore support teelucksingh 's position that the sss is a useful addition to the physician 's tool box as a novel method for mass screening for feet at risk because it is simple and has no cost implications . in light of the low sensitivity for overall neuropathy in this study
, it can not replace formal sensory testing , however it has the potential to be limb - saving and may be a useful adjuvant to conventional methods of screening for severe neuropathy and to identify patients who should be advised against wearing slippers .
we acknowledge that the low sensitivity of the sss and ready availability of other screening tools may limit the applicability of the sss in developed countries ; however , the test could be of high value in low resource settings , to identify patients with high - risk feet and thus ensure that they receive adequate care .
additionally , the sss could be used in public education campaigns to alert patients of the presence of neuropathy and to encourage them to seek medical attention .
further studies are warranted to assess frequency of the sss among patients with established neuropathy and to assess its predictive validity for the development of diabetic foot complications .
studies evaluating the incorporation of the sss in neuropathy screening instruments may also demonstrate additional uses of the test .
this study evaluated the ability of the slipping slipper sign ( defined as unknowingly losing a slipper while walking ) to identify diabetic neuropathy in jamaican patients . 
 a single question was used to ascertain the presence of the slipping slipper sign ( sss ) among 69 patients attending a diabetes clinic . 
 nurses assessed pain , vibration and pressure perception among the same patients in order to detect diabetic neuropathy . 
 the sensitivity , specificity and positive predictive value for the sss were calculated . 
 eight participants ( men=5 , women=3 ) reported positive sss . 
 the sss had a sensitivity of 28.6% , specificity of 100% and positive predictive value ( ppv ) 100% for neuropathy on at least one of the three tests . 
 these findings indicate that the sss has high specificity and ppv for diabetic neuropathy but the sensitivity is low . 
 the sign may be a useful adjuvant to conventional methods of screening for severe neuropathy .