|Year : 2020 | Volume
| Issue : 2 | Page : 282-286
Musculoskeletal manifestations in type 2 diabetes mellitus in South India
Ankita Gharge, Adithi Kellarai, SP Prakash
Department of General Medicine, KS Hegde Medical Academy, Mangalore, Karnataka, India
|Date of Submission||05-Jun-2020|
|Date of Decision||08-Jun-2020|
|Date of Acceptance||15-Jun-2020|
|Date of Web Publication||21-Dec-2020|
Dr. Adithi Kellarai
Department of General Medicine, KS Hegde Hospital, Deralakatte, Nithyananda Nagar, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objectives: Diabetes mellitus (DM) is a chronic metabolic disease with high morbidity and mortality. Musculoskeletal disorders (MSDs) are a wide range of problems resulting in pain and impaired physical function in these patients. These disorders are usually neglected and pose a hindrance in delivering an effective exercise regimen, which is the mainstay in the treatment of DM along with diet and medications. Hence, we conducted this study to identify and describe the MSDs seen in Type 2 DM (T2DM) and to correlate it with glycemic control. Methodology: A prospective cross-sectional study was conducted in a tertiary care hospital in the coastal district of Dakshina Kannada in Karnataka for 18 months. Patients with T2DM were screened for MSD and if present were included for the study. Demographic data, symptoms of MSD, and laboratory data like fasting and postprandial blood sugars and glycated hemoglobin (HbA1C) were collected using suitable data collection form. Data were analyzed using descriptive statistics. Results: A total of 80 patients with T2DM and MSD were included in the study, where 40 (50%) were male and 40 (50.0%) were female. The mean age of the study population was 58.54 ± 10.09 years. The mean fasting blood sugar level was 185 ± 36.12, Postprandial blood sugar level was 251.70 ± 55.51 and HbA1C level was 9.92 ± 1.46. The most common MSD among the patients with T2DM was frozen shoulder which accounted for 42/80 (52%) patients. Subjects with carpal tunnel syndrome (CTS) (P– 0.004) and Charcot joint (P– 0.003) had significantly higher mean HbA1c values than in subjects without these disorders. The mean HbA1C values among subjects with trigger finger (P– 0.012) and frozen shoulder (P– 0.011) were significantly lower than in subjects without the respective disorders. Conclusion: MSDs are highly prevalent among patients with T2DM. The most common MSD to manifest in patients with T2DM is frozen shoulder. There is positive correlation between HbA1c and presence of CTS and Charcot's joint and negative correlation between HbA1c and presence of trigger finger and frozen shoulder. Many of these disorders are treatable especially if diagnosed early and can improve quality of life in diabetic patients by reducing morbidity associated with these disorders.
Keywords: Glycated hemoglobin, musculoskeletal disorder, type 2 diabetes mellitus
|How to cite this article:|
Gharge A, Kellarai A, Prakash S P. Musculoskeletal manifestations in type 2 diabetes mellitus in South India. J Datta Meghe Inst Med Sci Univ 2020;15:282-6
|How to cite this URL:|
Gharge A, Kellarai A, Prakash S P. Musculoskeletal manifestations in type 2 diabetes mellitus in South India. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 16];15:282-6. Available from: http://www.journaldmims.com/text.asp?2020/15/2/282/304253
| Introduction|| |
Diabetes mellitus (DM) is a chronic metabolic disease with high morbidity and mortality. It is the fourth leading cause of death in most high income countries and is one of the most challenging health problems in the 21st century., India is a home to the second largest population of diabetic patients. The diabetic epidemic continues to grow exponentially with the prevalence of diabetes increasing from 26 million in 1990 to 65 million in 2016. This chronic disorder results in increased morbidity and mortality secondary to the vascular and nonvascular complications it poses. Musculoskeletal disorders (MSDs) are a wide range of problems resulting in pain and impaired physical function in these patients. Exact pathophysiology of the development of these disorders is unknown, however, the role of advanced glycation end (AGE) products has been proposed. There is a possible association of long-term blood sugar control and development of MSDs. As most of these disorders invariably affect the quality of life and management of diabetes, early identification, treatment, and prevention of disabilities is crucial.
MSDs in patients with DM may be secondary to intrinsic complications of diabetes or may represent higher incidence in diabetics than in nondiabetics. MSDs seen in diabetics include Dupuytren's contracture, trigger finger, carpel tunnel syndrome (CTS), frozen shoulder, limited joint mobility syndrome, diffuse idiopathic skeletal hyperostosis (DISH), and Charcot joint., These disorders are usually neglected and not given much weightage during routine clinical examination as is required for such vascular complications. MSDs also pose a hindrance in delivering an effective exercise regimen, which is the mainstay in the treatment of DM along with diet and medications.,
Taking all this into consideration, this study was carried out to identify and describe MSDs in the patients with Type 2 DM (T2DM) and to correlate the glycemic control with manifestation of MSD in these patients.
| Methodology|| |
A prospective cross-sectional study was conducted in a tertiary care hospital in the coastal district of Dakshina Kannada in Karnataka over a period of 18 months from January 2018 to June 2019. All patients with T2DM who presented to our hospital within the time period were screened from symptoms of MSD and if present were included in our study. Patients with previously diagnosed MSDs prior to the diagnosis of diabetes and patients with Type 1 DM were excluded from the study. Diabetic patients diagnosed with diabetic ketoacidosis or shock, chronic renal failure or chronic liver disease was also excluded from the study.
The sample size was calculated using N = (Z21−α/2P [1 − P])/d2 where N = number, Z = standard normal variant, = level of significance (5%), d = precision (5%), P = anticipated proportion (15%). N = (1.92) 2 × 0.75 × (1 − 0.75)/(0.1) 2 = 72 which was rounded off to 80 samples.
The study was initiated after obtaining approval from the institutional ethics committee and the patient data collection form was prepared based on the requirements of the study. After obtaining informed consent from all the subjects, patients were interviewed for relevant clinical history. Data collected included the age, gender, past history, family history, social history, symptoms, and duration of MSD. Clinical examination of the musculoskeletal system was performed to assess the severity of the disorder by Gait, Arms, Legs, Spine examination and specific rheumatologic examinations. Fasting blood sugar, postprandial blood sugar and glycated hemoglobin (HbA1c) levels were measured. The diagnosis of CTS was confirmed with a nerve conduction study in all diabetic patients with symptoms. X-ray of the joints was done to rule out differential diagnosis wherever indicated.
The statistical analysis was performed by STATA 11.2 (College Station, TX, UA). Shapiro–Wilk test has been used to find the normality. Qualitative data were documented using frequency and percentage. Quantitative variables are presented as mean and standard deviation. Chi-square test for goodness of fit was used to measure the association between the MSDs and glycemic controls and it is expressed as frequency and percentage. Student's independent sample t-test was used to find the significance in difference in prevalence of MSD among various HbA1c categories and it is expressed as mean and standard deviation. P < 0.05 considered as statistically significance.
Ethical approval for this study (KSHMA/2018-19/450) was provided by the Ethical Committee of KS Hegde Medical Academy, on 22/11/2018.
| Results|| |
A total of 80 patients with T2DM and MSD were included in the study, where 40 (50.0%) were male and 40 (50.0%) were female. The mean age of the study population was 58.54 ± 10.09 years. The mean fasting blood sugar level was 185 ± 36.12, postprandial blood sugar level was 251.70 ± 55.51 and HbA1C level was 9.92 ± 1.46. Most patients had uncontrolled blood sugar with HbA1C of 7%–10% in 49 (61.25%) participants, followed by >10% values among 28 (35.00%) subjects and only 3 (3.75%) patients with HbA1c values ≤7%.
The most common MSD among the patients with T2DM was Frozen shoulder which accounted for 42/80 (52%) patients [Figure 1]. The other MSDs included Dupuytren's contracture (3%), trigger finger (9%), CTS (32%), and Charcot joint (4%). DISH, reflex sympathetic dystrophy, and limited joint mobility syndrome were not seen in our study group.
When we compared the mean HbA1c levels with the presence of MSDs, it was observed that subjects with CTS (P– 0.004) and Charcot joint (P– 0.003) had significantly higher HbA1c values than in subjects without these disorders. The mean HbA1C values among subjects with trigger finger (P– 0.012) and frozen shoulder (P = 0.011) were significantly lower than in subjects without the respective disorders [Table 1]. When we analyzed the difference in the prevalence of MSD among various HbA1c categories, we observed a statistical significant difference in distribution of CTS. There was an increase in prevalence with increasing HbA1c i.e., 53.6%(n = 15) of subjects with HbA1C >10 (P = 0.009) had CTS. There was a negative correlation between the prevalence of frozen shoulder and HbA1c. The prevalence was 66.7% among patients with ≤7 and 63.3% in patients with HbA1c values between 7 and 10 (P = 0.028). There was no statistically significant difference in the prevalence of Dupuytren's contracture, trigger finger, and Charcot joint among different categories of HbA1c [Table 2].
|Table 1: Mean glycated hemoglobin value and it is association in patients with musculoskeletal disorders|
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|Table 2: Difference in prevalence of musculoskeletal disorders among various glycated hemoglobin|
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| Discussion|| |
MSDs have always been neglected despite them leading to an increased incidence of morbidity in type 2 diabetes. Data regarding the progression of the MSDs in diabetics are minimal. However, several studies have shown that controlling the levels of blood sugars in patients with diabetes can slow down the progression of microvascular complications. This in turn may reduce the rate at which the sequelae of microvascular disease develop. This study tends to shed light on need for diagnosing and treating this disability in diabetic community and create awareness about its relationship with glycemic control.
Musculoskeletal complications affect all age groups, however, their prevalence generally increases with age., We found a similar trend in our study wherein, among the 80 included patients, most of the patients fell under the age range of 51–70 years with the mean being 58 years. The age group was also found to have a significant influence on the diagnosis of MSD. Due to a lack of awareness about these disorders, a large number of patients were diagnosed for first time in this study. This highlights the need to look for specific MSD in individuals with DM during routine examination.
The prevalence of MSD is much higher in diabetic population when compared to nondiabetic individuals. Bashir et al. conducted a meta-analysis and found 58.15% prevalence of MSD in patients with diabetes. However, this number is highly variable in other studies depending on the definition used in the study population. A number of theories have been proposed for increased prevalence of MSDs among patients with DM. The development of MSD can be attributed to being as a consequence of diabetic complications, consequences of metabolic derangements inherent to diabetes, or secondary to etiologic mechanisms similar to micro vascular disease. Among the various MSD, those affecting the hand and shoulder seem occur more commonly in diabetic patients. This finding was also demonstrated in our study where frozen shoulder, CTS, and trigger finger were the most common MSD.
The objective of our study was not to determine the prevalence of MSD among diabetics, but rather describe the various MSD and the frequency with which they appear in diabetic patients. Even though few studies have concluded that osteoarthritis as the most common MSD secondary to DM, we did not include patients with osteoarthritis in our study as it is not generally thought of as complications of diabetes and the association between the two is uncertain. The most common MSD, we found in our population was frozen shoulder. Frozen shoulder also called as adhesive capsulitis affects unilateral or bilateral shoulders and results in severe debility and restrictions among the patient suffering from the same. Studies demonstrate 19%–29% of diabetics present with Adhesive capsulitis compared with approximately 5% of controls. Adhesive capsulitis has been described as one of the disorders which share etiologic mechanisms with microvascular disease. Most microvascular complications are associated with uncontrolled blood sugars. Yian et al. were not able to demonstrate association between the two but subsequent studies conducted by Chan et al. demonstrated cumulative HbA1c was associated with an increased incidence of adhesive capsulitis., An interesting finding that we noted in our study was that subjects with frozen shoulder had a lower HbA1c as compared to subjects without, and it negatively correlated with HbA1c values.
CTS is another common MSD involving the hand. Frequency of the syndrome has been observed in 15%–25% of diabetic patients. In our study, along with an increased prevalence and positive correlation of CTS with HbA1C the gender distribution in the CTS subgroup was predominated by females (16/26) as compared to males (10/26). Many studies have demonstrated female gender, older age as risk factor for CTS. Our findings are also in accordance with a study published by Paranthakan and Govindarajan in 2017 wherein they report uncontrolled diabetes to be a major cause for CTS and also mention the female sex to be more affected than the males.
Trigger finger also called as flexor tenosynovitis is another important MSD associated with DM. Certain studies have shown association with duration of DM but not with glycemic control. In our study, seven patients were diagnosed as having trigger finger. Even though the mean HbA1c level was low, most patients did had poorly controlled diabetes with 6 of them having HbA1c values between 7 and 10, with only one patient having HbA1c ≤7. Similarly, a study conducted by Cagliero et al. substantiates our results by reporting the prevalence of flexor tenosynovitis in diabetic patients to range from 5% to 36% with a higher incidence in people who have impaired glucose tolerance.
Charcot's arthropathy affecting the ankle and foot is relatively uncommon MSD seen in long standing diabetics with peripheral neuropathy. The three patients in our study who suffered from Charcot joint were 70 years or older in age. This finding in accordance with the results of a study conducted by Salini et al., in 2018, wherein they have reported the mean age of diabetic patients with Charcot joints as 63 ± 8.36 years. Another study conducted by Younis et al. in 2015 conclude a statistical significance in the occurrence of Charcot joints and an increased HbA1c value which again supports the results of our study where the HbA1c levels were >10 in all the three patients having this disorder. In our study, we even aimed to include MSD such as DISH, Reflex sympathetic dystrophy and limited joint mobility syndrome. However, none of the patients enrolled in the study presented with these complications.
The exact pathophysiology of the development in MSD is unknown but some have attributed the formation and accumulation of AGE products (AGEs) and their crosslinking of collagen. The relation of these complications with blood sugars and HbA1C has baffled many as the results from various studies are conflicting. In our study, we noticed a positive correlation between HbA1c and presence of CTS and Charcot joint. However, we could not demonstrate a similar association for other MSD.
There are some important limitations to our study. Since we included only patients with MSD and T2DM we could not estimate the overall prevalence of MSD in diabetic population. Ours was a hospital-based study, hence we included patients visiting our department with symptoms of MSD or diagnosed during the hospital stay. Our sample does not reflect patients who have neglected the symptoms. However, we were able to ascertain and describe the various MSD we encounter in diabetics and their relation to blood sugar control. Studies in India pertaining to MSD in diabetic patients in clinical setting is limited and our study sheds light on the need to do carry out basic rheumatologic examination during clinical assessment of diabetic patients to deliver effective exercise regimen.
| Conclusion|| |
MSDs are highly prevalent among patients with T2DM. Many of these disorders are treatable especially if diagnosed early and can improve quality of life by reducing morbidity associated with these disorders. Diabetes must be considered as one of differential diagnosis for any patient with MSD. There is a significant relationship between higher HbA1c levels and presence of certain MSD. The most common MSD to manifest in patients with T2DM is frozen shoulder. India being diabetic capital of world we suggest to concentrate more on secondary complications of diabetes and include joint examination as part of routine check-up in all diabetics. Thus, having an awareness of the potential musculoskeletal complications of diabetes can be an invaluable part of diabetes care.
We would like to acknowledge the support of Dr. Raghav Sharma, the Head of Department of General Medicine, K. S. Hegde Hospital for his support and encouragement.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]