Journal Article Review January 2018

January, 2018:  How does long-standing, type I diabetes affect upper limb function?
Gutefeldt, K et al: Upper extremity impairments in type 1 diabetes with long duration; common problems with great impact on daily life. Disabil Rehabil. 2017 Nov 5  [Epub ahead of print]
Swedish investigators recently published a population study comparing 703 patients with insulin-dependent (type 1) diabetes of at least 20 years duration with a similarly sized group of age-matched control individuals selected from a national population register.
All participants filled out a self-administered questionnaire. This covered demographic data, smoking history, occupation, current sick leave, physical activity, and any complications in the diabetic patient group.  The survey also inquired about 5 common upper extremity impairments and any previous surgery for carpal tunnel syndrome or trigger finger.  The participants then filled out the standardized Health Assessment Questionnaire (HAQ), which includes 20 questions in 8 categories inquiring about their degree of activity limitation in the past week.
The researchers asked all participants to have their blood tested and 78% of patients and 75% of controls did so. All of the diabetic patients were either taking multiple insulin injections or were using an insulin pump.
RESULTS: Ten percent of both groups smoked. Women were slightly over represented in the control group (61%) compared to the diabetic patients (55%), and the control group was slightly older (average 54 years vs 50 years). Body mass index (BMI) scores were 26 for both groups.
Statistically significant differences were noted in the following areas.
Night waking with numbness and tingling: patients 48%, controls 28%
Shoulder pain and stiffness: 38% patients, 18% controls
Hand stiffness: 34% patients, 15% controls
Triggering: patients 31%, controls 12%
Dupuytren contracture: 28% patients, 7% controls
Absence of all five upper extremity impairments and any history of either trigger or carpal tunnel release: 21% patients, 56% controls
Presence of all 5 impairments: 6% patients, 1% controls
Previous trigger release: 22% patients, .1% controls
Persistent symptoms following trigger finger release: 9% patients, .1% controls
Previous carpal tunnel release: 26% patients, 5% controls
Persistent paresthesias following carpal tunnel release: 11% patients, 2% control
Women were at higher risk for having any of the impairments, as were those diabetic patients with longer duration of disease, higher BMI scores, and increased glycemic index (HbA1c) scores.
Smoking did not show any significant association with any of the 5 studied upper extremity impairments among patients, but smoking was correlated with increased incidence of shoulder stiffness, hand stiffness, and Dupuytren disease in the control group.
In absence of any upper limb impairments, diabetic patients did not show any activity limitation compared to controls; but for each impairment, the diabetic patients showed more activity limitation compared to controls.
The authors note that their study is limited by the fact that their data were based on a self-reported questionnaire and not a clinical examination. Conversely, a strength of their study is the large number of diabetic patients combined with a matched control group.
COMMENT: This study confirms my general impression that, in addition to well-known retinal and wound healing issues, diabetic patients are more prone to soft tissue upper extremity conditions and that they do not respond as well to trigger and carpal tunnel releases. All diabetic patients with soft tissue conditions should be cautioned about their guarded prognosis and should be encouraged to control their glycemic index and BMI to the extent possible. The extreme case would be a woman with insulin-dependent diabetes for over 35 years with an increased glycemic index and a high BMI. She may need a lot of therapy following trigger or carpal tunnel release.