Assessment Approaches for Asymptomatic and Painless Diabetic Peripheral Neuropathy: A Scoping Review

Abstract

This registration documents a scoping review examining assessment approaches for asymptomatic and painless diabetic peripheral neuropathy. The review aimed to map how asymptomatic, painless, subclinical, sensory-loss, loss-of-protective-sensation, and related clinically silent neuropathy phenotypes are defined and assessed in people with diabetes, compare the clinical applicability of available assessment approaches across healthcare settings, and identify evidence gaps linking neuropathy detection with measurable patient-safety and harm-prevention outcomes. The review was conducted following Joanna Briggs Institute methodological guidance for scoping reviews and was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, PRISMA-ScR. Eligibility was structured using the Population–Concept–Context framework. The population included people with type 1 or type 2 diabetes. The concept focused on objective or clinically applicable assessment of neuropathy in the absence of pain or recognizable symptoms, including asymptomatic, painless, subclinical, sensory-loss, unrecognized neuropathy, and loss of protective sensation. The context was broad and included primary care, outpatient diabetes services, podiatry, hospitals, pediatric services, rehabilitation, community care, and home care. Six information sources were searched on 18 July 2026 without a publication-year restriction: PubMed, Scopus, CINAHL through EBSCOhost, the Cochrane Library, SciELO, and Wiley Online Library. The search retrieved 3,106 records. After removal of 683 duplicates, 2,423 unique records were screened, and 18 studies met the final eligibility criteria. Data were charted by phenotype definition, assessment domain, healthcare setting, resource requirements, and downstream safety outcomes. Statistical pooling was not undertaken because of heterogeneity in phenotype definitions, populations, reference standards, assessment thresholds, and outcomes. The review found that objective nerve dysfunction may be present despite the absence of neuropathic pain or recognizable symptoms. Electrophysiological testing, bedside neurological examination, monofilament testing, vibration assessment, quantitative sensory testing, sudomotor assessment, skin biopsy, and laser-evoked potentials evaluated different physiological or clinical domains and were not clinically interchangeable. The evidence did not establish a universally superior assessment pathway. Importantly, none of the included studies directly evaluated whether detection of asymptomatic, painless, or subclinical neuropathy reduced foot ulceration, burns, falls, Charcot neuroarthropathy, hospitalization, infection, or amputation, and no included study evaluated a nurse-led screening pathway. The principal contribution of the review is therefore to clarify the complementary roles and limitations of different assessment approaches and to identify the unresolved evidence gap between detection of clinically silent diabetic peripheral neuropathy, implementation of preventive action, and measurable patient-safety outcomes. Future research should evaluate prospective implementation pathways using standardized phenotype definitions, clearly specified assessment and referral thresholds, and patient-important outcomes.