Prevalence of musculoskeletal disorders in patients with diabetes mellitus: A systematic review and meta-analysis

Abstract

BACKGROUND:

Diabetes mellitus (DM) is associated with musculoskeletal disorders (MSDs) and is often not clinically diagnosed and managed. There are also no systematic reviews of literature relating to the prevalence of MSDs among people with diabetes.

OBJECTIVE:

To determine the prevalence and areas of the body affected by MSDs in diabetic patients.

METHODS:

A literature search of the electronic databases of CINAH, PubMed, Web of Science and Google Scholar using the keywords of “MSDs and DM” as the search term was conducted. Pooled estimates were calculated using a meta-analysis of proportion.

RESULTS:

Five thousand and eighty-eight studies were identified from the databases; 21 studies fulfilled the inclusion criteria and were included in the review. Five studies were of high quality, 13 were of moderate quality and three were of low quality. The prevalence of all types of MSDs among patients with diabetes was 58.15% (95% CI 41.4%–73.9%). The hand was the most common area of the body affected being 33.05% (95% CI 21.1–46.13) followed by the shoulder.

CONCLUSIONS:

A high prevalence of MSDs was found among diabetic patients with the hand and shoulder being the most frequently reported areas affected. However, future studies with a larger sample and the relevant type of diabetes are required.

Keywords

Musculoskeletal disorders diabetes prevalence

1. Background

Diabetes mellitus (DM) is a chronic metabolic disorder characterised by hyperglycemia, which results from the inability of the body to produce or use insulin [1]. In 2015 the global prevalence of diabetics was estimated to be 415 million and is expected to rise to over 642 million by 2040 with Asians being the most affected by the diabetes epidemic [2]. In 2015 the International Diabetes Federation (IDF) estimated 14.2 million diabetic patients in Africa which excluded about 67% of individuals not diagnosed and this projection is expected to rise to 34.2 million by 2040 [2].

The pathology of DM results in an effect on connective tissues which causes alterations to the periarticular and skeletal systems [3]. The high glucose levels in diabetic individuals affect cell function, alter the extracellular matrix components and damage the connective tissue [4, 5]. Although changes in connective tissue physiology have been documented in DM, the pathophysiology leading to musculoskeletal disorders in patients with DM is not well understood [4]. Diabetic patients who do not manage their blood glucose levels, have continuous hyperglycemia. This leads to an increase in advanced glycation end products which results in stiffness of connective tissue and subsequent aggravated musculoskeletal pain [6]. Musculoskeletal disorders in diabetic patients are often associated with a variety of musculoskeletal complications like adhesive capsulitis of the shoulder, hyperuricemia and cheiroarthropathy with the prevalence increasing significantly in recent years and affecting their quality of life [7]. Additionally, other MSDs associated with DM include: carpal tunnel syndrome, dupulytrens contracture, osteoarthritis and hyperostosis [8].

Musculoskeletal pathologies are a major public health challenge which contributes to pain, loss of function of the affected limbs and absence from work. This has a negative impact on the health care system and the diabetic individuals which include the use of primary care hospitals, disruption of daily life and loss of productivity through functional limitation and activity restrictions [9]. A common but often neglected effect of diabetes is ‘stiffness’ which is the musculoskeletal impairment created by connective tissue damage causing the limitation of joint movement [10]. Previous studies have also indicated that the increased musculoskeletal pain in diabetic could also relate to vascular insufficiency [11], neuropathy [12], decreased insulin-like growth factor 1, accelerated osteoporosis, obesity and a sedentary lifestyle [13].

The high prevalence of MSDs in the diabetic population therefore requires a greater review and understanding by all health care professionals. This will be important to guide all relevant health care professionals and policy makers in putting appropriate intervention strategies in place for managing diabetic related musculoskeletal disorders [14]. This will also facilitate research studies to evaluate and manage interventions for diabetic patients with MSDs. There are limited studies on MSDs in DM, especially in developing countries. Many studies on the prevalence of musculoskeletal complications among diabetic patients have been conducted with small sample sizes and produced inconsistent results [15, 16, 17]. Therefore, further epidemiological studies of MSDs in DM could provide insights into the pathogenesis of musculoskeletal disorders. A systematic review and meta-analysis could benefit and provide information on the problems encountered by studies on the prevalence of MSDs among diabetic patients and provide direction for future studies on the epidemiology of MSDs in this population. There are no documented systematic review of the literature and meta-analysis on the prevalence of MSDs among patients with diabetes. This review was therefore designed to determine the prevalence of MSDs using the available literature to estimate the prevalence of these in DM. Therefore, the design of this study was a systematic review with meta-analysis to determine the prevalence of MSDs in patients with DM.

2. Methods

2.1 Inclusion and exclusion criteria

Figure 1.

Literature search results.

Studies with subjects of 18 years or older with a diabetic population, with subjects who have a prevalence for MSDs, and studies that are written in English and have relevant findings. Studies with data on children, without reporting on the outcomes of interest, opinion articles and reviews were excluded from the study.

2.2 Search strategy

A systematic review of the literature using devised criteria with the search strategy based on key words was undertaken. The initial screening of relevant abstracts followed by the complete text by two reviewers was performed. This was followed by the classification of the internal validity of the selected articles and graded according to the strength of the evidence using established and validated tools for prevalence studies.

A comprehensive electronic Search Strategy through CINAHL, PubMed, EMBASE, Web of Science and Google Scholar was carried out from the inception of the databases to March 2017. Relevant keywords as recommended by an expert in diabetes and a medical librarian were selected with two concepts of search terms combined that described MSDs and diabetes. This review utilised a broad definition of MSDs and diabetes to capture the relevant information within the electronic databases. The MSD keywords included pain related to the: shoulder, elbow, hand, wrist, back, neck, cervical spine, hip, knee, ankle and the foot. Arthritis, bone, joint and muscle dysfunctions were also included. The diabetes keywords included: diabetes mellitus, type 1 and 2 diabetes. All identified titles were merged into the reference management software package (Mendeley Desktop version 1.17.10 2008–2016 Mendeley Ltd., USA).

2.3 Data extraction

All duplicates were eliminated by BK and the relevant studies assessed using the inclusion criteria. The abstracts of the studies meeting the inclusion criteria were scrutinised further by BK and SSM. If the abstract did not clearly indicate whether a study should be included, the entire study was reviewed. The full text of all the relevant studies were evaluated by two researchers (BK and SSM) to ensure the eligibility of the article for inclusion in the review. Disagreements regarding study eligibility were resolved through discussions and a review by a third researcher (FF). The search and selection results are presented in Fig. 1.

Table 1
Summary of the findings of the included studies

Study	Design	Type of	Population	N	Prevalence of MSD			Quality
		DM			MSD	Upper extremities	Lower extremities	score 1–8
Ahmad et al., 2012	OS	2	India	325		24.4% Shoulder adhesive capsulities		6
Shah et al., 2015	OS	2	USA	336	63%	Shoulder pain and disability		6
Rajendran et al., 2011	OS	2	India	206		42% hand contracture, 10% carpel tunnel syndrome		4
Mohan et al., 2014	OS	2	Indian	100	49%	18% OA, 32% Cheiroarthropathy, Carpe l tunnel syndrome 15%, Dupuytren’s contractures 13%, Frozen shoulder 12%,Neuropathetic joint 6%, Flexor tenosynovitis 8%, Diffuse idiopathetic skeletal hyperostosis 6%		3
Douloumpakas et al., 2007	OS	2	Greece	208	82.6%			5
Attar et al., 2012	OS	2	Saudi Arabia	252	17.9%			5
Pai et al., 2015	RS	DM 1,2	Taiwan	39,516, 6,586 DM 32,930 Non DM	56.9%	Neck and shoulder pain		7
Aydeniz et al., 2008	CS	1,2	Turkey	102, 101 non DM	51%	Cheiroartropathy		3
Barki et al., 2013	CS	1,2	Pakistan	375		1.Frozen shoulder 63%. 2. 44.02%, 1 Capel tunnel syndrome 14.03% 2. 14.6%, 1. OA 52.2% 2. 52.5%, RA 1. 5.2% 11.3%, FM 1. 12.2%, 2. 13.5%, DC 1. 1.2% 2. 5.0%	Lower extremities, included	4
Kidwali et al., 2013	CS	2	Pakistan	210		Hand 20%, limited shoulder mobility 9.5%, Capel tunnel syndrome 9%		3
Fatemi et al., 2015	CS	DM	Iran	188	55%	Shoulder 90.5%, 36.5% hand		5
Mathew et al., 2011	OS	2	India	310	42.58%	Frozen shoulder 20.6%	Knee 33.4%	6
Laslett et al., 2007	OS	DM	Australia	189	35%	Shoulder pain		5
Mustafa et al., 2016	OS	2	Jordan	1000		63.1% hand contractures, 18.6% Dupuytren contractures		6
Font et al., 2014	OS	2	USA	100		59% Bursitis/tendinitis		4
Sultana et al., 2015	OS	2	Bangladeshi	1800	77.8%	Shoulder capsulitis		5
Pal et al., 1986	OS	1,2	UK	109		49% Hand stiffness in type 2, 52% Hand stiffness in type 1 and 19% shoulder stiffness		5
Rosenbloom et al., 1981	OS	DM	USA	309	30%	Small and large joint limited mobility		4
Ardic et al., 2003	OS	2	Turkey	78	21.8%	Dupuytren’s disease		4
Thomas et al., 2007	OS	DM	UK	865 Diabetic patients, 202 non DM	25.7%	Shoulder pain		5
Ramchurn et al., 2009	OS	DM	UK	96	75%	Shoulder capsulitis 25%, carpal tunnel syndrome 20%, tenosynovitis 29%, limited joint mobility 28%, Dupuytrens contractures 13%		5

OS $=$ Observational study; RS $=$ Retrospective study; CS $=$ Cross-sectional study; DM $=$ Diabetes Mellitus; MSD $=$ Musculoskeletal disorders.

2.4 Quality of publication

Figure 2.

Musculoskeletal disorders in patients with diabetes.

The methodological quality of the prevalence studies were selected and assessed according to the guidelines for critical appraisal of health literature research: prevalence or incidence of a health problem [18]. The highest score was 8 and lowest possible score 1. Each article was evaluated and scored according to eight criteria: (i) Study design and sampling method; this item was considered adequate if the study design was observational and if the sampling method included either the whole population or a random sample; (ii) sampling frame; this was adequate if it had minimal bias (e.g., derived from census data); (iii) sample size; was adequate if the sample size was $>$ 300; (iv) appropriate measurement was adequate if the objective was suitable and standard criteria were used to measure the health outcome; (v) outcomes measured by independent assessors; was adequate if the health outcome was measured objectively in an unbiased manner by independent trained assessors who were not aware of the subjects’ diabetic or clinical status; (vi) response rate; was accepted if this was 70% or greater and if an attempt was made to obtain information about the reasons for non-participation and the characteristics of the group of non-responders; (vii) results; this was accepted if the estimates of prevalence were given with confidence intervals and in detail by a subgroup, if appropriate; and (viii) study subjects; was accepted if the subjects and setting, were described in detail and matched the criteria of this review. On application of the above criteria the findings were classified according to MSDs or related body regions affected.

Figure 3.

Forex plot of musculoskeletal disorders in patients with diabetes.

Figure 4.

Funnel plot of musculoskeletal disorders in patients with diabetes.

2.5 Statistical analysis

Descriptive statistics are expressed as percentages for the pooled prevalence and individual studies with the meta-analysis of proportion carried out to statistically pool MSD prevalence results, using standardised prevalence estimates from the studies. The analysis was performed using MedCalc software version 5. A random effects model was employed as this assumes that there is heterogeneity present among the studies which cannot readily be explained [19]. The number of cases of MSDs and total sample size were entered for individual studies and a pooled prevalence was calculated. Forest and funnel plots were constructed for MSD prevalence and the body region reported for all studies.

Figure 5.

Meta-analysis of prevalence of shoulder disorders.

3. Results

Five thousand and eighty-eight studies were identified from the database; 21 studies that fulfilled the inclusion criteria and were included in the review as shown in Fig. 1. The methodological quality scores ranged from 2 to 8 points. The studies were classified as high, with a score of $>$ 6; moderate, if they score $>$ 4, and low if the score was $<$ 4. From these studies, five were of high quality, 13 were of moderate quality, and three were rated low quality as in Table 1. The most prevalent MSDs occurred in patients with type 2 DM as reported in 12 studies. Four studies reported in both type 1 and 2 and five studies did not indicate the type of DM.

Figure 6.

Forex plot of shoulder disorders.

Figure 7.

Funnel plot of shoulder disorders.

All studies were cross-sectional with no longitudinal study as shown in Table 1. A total of 13,744 patients with diabetes were analysed. The largest sample size was 39,516 (6586 with DM and 32930 non DM). Eight included studies [9, 11, 15, 16, 17, 20, 21, 22] that reported MSDs prevalence had a total of 3,290 patients with MSDs, as shown in Fig. 2. Ten studies [7, 14, 15, 16, 17, 22, 23, 24, 25, 26] reported the prevalence of shoulder disorders among patients with diabetes and they included 9,244 patients as shown in Fig. 5. Eleven studies [3, 4, 10, 12, 14, 19, 21, 24, 28, 29, 30] reported the prevalence of hand syndrome among patients with diabetes and they included 2,773 patients, as shown in Fig. 8.

3.1 Meta-analysis of proportion

3.1.1 Prevalence of musculoskeletal disorders among diabetes patients

Eight studies reported on the prevalence of MSDs among diabetes patients [9, 11, 12, 16, 17, 20, 21, 22], with a total of 3,290 patients as shown in Fig. 2. The pooled prevalence of MSDs among adults with DM was 58.1% (95% CI 41.42%–73.96%). The forest plot is shown in Fig. 3 and the funnel plot in Fig. 4 with significant heterogeneity factors ( $p<$ 0.0001).

3.1.2 Prevalence of musculoskeletal disorders in body region

Prevalence of shoulder disorders

Ten studies reported on the prevalence of shoulder pain among patients with DM [7, 14, 15, 16, 17, 22, 23, 24, 25, 26], with total of 9,244 patients as in Fig. 3. The pooled prevalence of shoulder disorders among the studies was 31.6% (95% CI 13.0–53.8) shown in Fig. 5, with forest and funnel plots shown in Figs 6 and 7 respectively.

Prevalence of hand syndromes

Eleven studies reported the prevalence of hand musculoskeletal disorders among patients with diabetes [3, 4, 29, 10, 14, 15, 16, 17, 24, 27, 28], with a total of 2,773 patients. The pooled prevalence was 33.05% (95% CI 21.19–46.13), as shown in Fig. 8 and forest and funnel plots in Figs 9 and 10, respectively. There was significant heterogeneity of the studies, at $p<$ 0.001, as in Fig. 8.

Figure 8.

Meta-analysis of prevalence of hand syndrome.

Figure 9.

Forex plot of hand syndrome.

Figure 10.

Funnel plot of hand syndrome.

4. Discussion

To our knowledge, this is the first systematic review and meta-analysis related to epidemiology of MSDs among patients with DM. We wanted to determine the prevalence of MSDs in type 1 and 2 DM and the region of the body most affected. The limitation of our review and meta-analysis is that not all studies reported on the type of DM which limited us from conducting further analysis to ascertain the differences. Additionally, only a few studies compared the prevalence of MSDs in subjects without DM.

This review identified a substantial heterogeneity between countries, type of diabetes, and the methodological quality of the studies. The high level of heterogeneity made it difficult to establish single prevalence results for specific body regions. By identifying these challenges, the researchers are of the view that this review will be beneficial in focusing the efforts of future research to overcome these aspects. Of the various approaches to estimating the prevalence of MSDs among diabetics, none of the studies reported on the one-year prevalence of MSDs among diabetics or pointed to its prevalence in general. The funnel plot of the meta-analysis for the prevalence of MSDs demonstrated studies with less precise estimated effects and this may be related to the small sample size of the studies. A similar observation was noted for the prevalence of shoulder and hand disorders. This inconsistency in sample size has resulted in precise estimations of the studies varying with future studies considering larger sample sizes to avoid heterogeneity and produce higher precise estimated effects.

The results of our review study have implications and relevance for clinical practice. These are that there was a high prevalence of MSDs among patients with DM and there may be risk of disability due to these disorders. Early diagnosis, with prompt referral and treatment, may help to prevent progression to chronic conditions and improving health outcomes and minimize the economic burden associated with the management of diabetic related musculoskeletal disorders.

In addition, rheumatologists, orthopedic surgeons and physiotherapists, during their assessment of patients with MSDs, should enquire about the blood glucose status of the patient or whether there is a prevalence of DM. In the absence of a conclusive response or if such a history is absent, the health care professional should consider an assessment of fasting blood glucose levels. During this systematic review and meta-analysis a number of methodological problems were identified. The most common were no common case definition of MSDs, lack of appropriate sampling frame of the population and small sample sizes. These problems affect the validity of the study. Inappropriate sampling frames may result in the possibility of under representation of certain patients with MSDs. While census data provides one of the few datasets that are thought to have minimal bias, these are costly and tend to be over a period measured in years, thereby limiting their utility in monitoring and evaluation studies. Telephone interviews and self-administered questionnaires are more feasible than personal interviews, but may not be the most accurate [7].

Our review and meta-analysis revealed an overall high prevalence of 58.1% (95% CI 41.42–73.97) MSDS among patients with diabetes. This review showed that the most reported body regions was the hand followed by shoulder disorders, cheiroarthopathy, dupuytrens contractures, and carpel tunnel syndrome. The pooled prevalence was 33.05%, making these the highest regions of the body where MSD was always reported. Previous studies reported the association of DM with the hand syndrome and the duration of DM not necessary as a risk factor for hand disorders as well as age or gender [1]. Cheiroarthropathy, also known as limited joint mobility of the hand, was one of the highest abnormalities reported by the studies [3, 12, 16], with a prevalence of 32%, 51% and 29%, respectively. This demonstrates that cheiroarthropathy is among the most highly reported MSDs in DM patients. This abnormality can be detected clinically by the inability of the two palms to come together completely, with the wrists maximally flexed, forming the prayer sign. The symptoms of this condition increases slowly with pain by movement of the hands. Most of the literature reported this condition among type 1 DM [31]. The difference in prevalence may be due to the varying use of glycemic control in the two types of DM. Treatment usually optimises glucose control and exercise. Physiotherapists can play a vital role in reducing pain and prevention of disability by improving the mobility of the small joints.

Musculoskeletal disorders in the shoulder, was the second-most reported musculoskeletal disorders among patients with DM. Most studies [7, 9, 16, 22, 23, 24] reported shoulder adhesive capsulitis and frozen shoulder, neck and shoulder pain, with some reports of it occurring in up to 90% of the sample of 188 patients. The estimated prevalence is 31% (95% CI 13.0–53.8) and this rate is within the range mostly reported by the literature [32]. Studies show that the most disabling shoulder abnormality is adhesive capsulitis, which is also known as frozen shoulder, or shoulder periarthritis or oblitertive bursitis [32]. It is characterised by progressive and painful restriction of the shoulder movement, especially external rotation and abduction [1]. This condition is associated with the duration of diabetes and age of the patients but the studies do not identify the type of diabetes.

5. Conclusion

The results established that there was high prevalence of musculoskeletal disorders among patients with diabetes with the hand the most reported region affected. The prevalence rate varied in all the studies. To improve the variations in the studies, methodological quality and homogeneity are required by researchers. Subsequent studies could compare the prevalence of MSDs, related type of diabetes, gender and research related to the spine and lower limbs. There is also a need for physiotherapists and related rehabilitation professionals to assess the outcome of their interventions for this population. This will improve the activities of daily living, functional activities and quality of life of these individuals. There is also relevance for clinicians and policy makers to be aware of the high prevalence of MSDs among patients with diabetes and the importance of early identification and intervention to prevent disability.

Footnotes

Acknowledgments

The authors gratefully acknowledge the College of Health Sciences at the University of KwaZulu-Natal and the Medical Liberian for the support.

Conflict of interest

None to report.

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. Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles Ligaments Tendons J [Internet]. 2016; 6(1): 26-34. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4915459