Long-term glycemic control influences the onset of limited joint mobility in type 1 diabetes

Reversal for metabolic syndrome criteria following the CHANGE program: What are the driving forces? Results from an intervention community-based study

Objective

To examine the impact of the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) program on the reversal of one or more metabolic syndrome (MetS) criteria among community members with MetS and define the significant predictors of upholding individual MetS criterion from 2020 to 2023.

Methods

The program enrolled 278 community members with/or at risk of MetS. Participants followed regular physical activity and a Mediterranean diet for 12 months with the assistance of a registered dietitian and a kinesiologist. A licensed practical nurse and/or registered nurse measured participants' weight, height, waist circumference, and blood pressure and withdrew blood samples for laboratory investigations. Physical activity, physical fitness, Mediterranean diet score (MDS), anthropometric measurements, and laboratory investigations were assessed at the baseline and every three months. Descriptive statistics were calculated, and binary logistic regression analysis was performed to define the significant predictors of upholding each criterion of the MetS.

Results

Participants' mean age was 60.5 ± 11.7 years, and 74.8% were females. Participants with MetS decreased by 5.04% by the end of the program. The percentage of participants with each MetS criterion showed a significant decrease at the end of the study, except for low HDL, which remained with no change. Moreover, the mean of physical activity, physical fitness tests, and MDS scores showed a significant increase after the 12 months of study. Compared to baseline, daily sedentary and screen times showed a significant decrease at the end of the program (8.6 vs. 7.2 and 3.2 vs. 2.6 hours, respectively). Logistic regression analysis revealed that age, female gender, low educational attainment, physical activity, physical fitness, and screen time were significant predictors for upholding one or more MetS criteria.

Conclusion

MetS criteria can be reversed following the CHANGE program. Sociodemographic and lifestyle features are significant predictors for upholding MetS criteria. The program is cost-effective considering its low cost and could lead to significant savings on healthcare costs. Further studies among different communities are recommended to confirm the generalizability of the results.

Higher body mass index increases the risk of shoulder adhesive capsulitis in young adults: a nationwide cohort study

BACKGROUND

The impact of overweight on the incidence of shoulder adhesive capsulitis (AC) has not been clearly proven. This study aimed to investigate the association between overweight and AC by age using a large-scale nationwide population-based cohort in Korea.

METHODS

We analyzed clinical data from 3,517,066 individuals older than 20 years who had undergone a National Health Insurance Service health checkup in 2009. Patients who visited a hospital or private clinic to treat shoulder pain at least three times in 1 year and were assigned a diagnostic code for AC (International Classification of Diseases,10th Revision code M75.00) were identified using claims data during a median follow-up duration of 8.3 years. Hazard ratios (HRs) and 95% confidence intervals for AC were calculated using the Cox proportional hazards model.

RESULTS

The adjusted HR for AC in the < 40 year group started to increase in overweight status and was associated with the severity of obesity (body mass index (BMI) < 18.5; 0.654 (0.613-0.697), <23; 1, <25; 1.272 (1.231-1.315), <30; 1.322 (1.281-1.364), ≥30; 1.332 (1.253-1.416)). But in the 40-64 year group and the ≥ 65 year group, there was no significant increasing trend of HR for AC according to BMI level. We conducted a subgroup analysis based on the BMI 23 for defining overweight and presence of comorbidities including diabetes and hyperlipidemia. The adjusted HR for AC was highest with overweight and comorbidities of diabetes and hyperlipidemia (diabetes; 1.528 (1.508-1.549), hyperlipidemia; 1.212 (1.199-1.226)).

CONCLUSIONS

In the young age group (20-40 years), a higher BMI level increased the HR for AC. Overweight along with diabetes or hyperlipidemia significantly increased the risk of AC.

The Risk of Shoulder Adhesive Capsulitis in Individuals with Prediabetes and Type 2 Diabetes Mellitus: A Longitudinal Nationwide Population-Based Study

BACKGRUOUND

This study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and shoulder adhesive capsulitis (AC) using a large-scale, nationwide, population-based cohort in the Republic of Korea.

METHODS

A total of 3,471,745 subjects aged over 20 years who underwent a National Health Insurance Service medical checkup between 2009 and 2010 were included in this study, and followed from the date of their medical checkup to the end of 2018. Subjects were classified into the following four groups based on the presence of dysglycemia and history of diabetes medication: normal, prediabetes, newly diagnosed T2DM (new-T2DM), and T2DM (claim history for antidiabetic medication). The endpoint was new-onset AC during follow-up. The incidence rates (IRs) in 1,000 person-years and hazard ratios (HRs) of AC for each group were analyzed using Cox proportional hazard regression models.

RESULTS

The IRs of AC were 9.453 (normal), 11.912 (prediabetes), 14.933 (new-T2DM), and 24.3761 (T2DM). The adjusted HRs of AC in the prediabetes, new-T2DM, and T2DM groups were 1.084 (95% confidence interval [CI], 1.075 to 1.094), 1.312 (95% CI, 1.287 to 1.337), and 1.473 (95% CI, 1.452 to 1.494) compared to the normal group, respectively. This secular trend of the HRs of AC according to T2DM status was statistically significant (P<0.0001).

CONCLUSION

This large-scale, longitudinal, nationwide, population-based cohort study of 3,471,745 subjects confirmed that the risk of AC increases in prediabetic subjects and is associated with T2DM status.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

Musculoskeletal complications in patients with diabetes mellitus

Musculoskeletal conditions are common in patients with diabetes. Several musculoskeletal disorders are viewed as chronic complications of diabetes because epidemiological studies have revealed high correlations between such complications and diabetes, but the pathophysiological links with diabetes remains unclear. Genetic predispositions, shared risk factors, microvascular impairments, progressive accumulation of advanced glycation end-products, and diabetic neuropathy may underlie the development of musculoskeletal disorders. Musculoskeletal complications of diabetics have received less attention than life-threatening microvascular or macrovascular complications. Here, we review several diabetic musculoskeletal complications with a focus on the clinical importance of early recognition and management, which would improve quality of life and physical function.

Cheiroarthropathy and tendinopathy in diabetes

Joint problems commonly occur in people with diabetes. Cheiroarthropathy affects the hands and results in painless limited finger joint extension, appearing to be associated with longer diabetes duration and the presence of microvascular complications. The prevalence of cheiroarthropathy seems to be falling, perhaps as a result of improvements in glycaemic management. Non-enzymatic glycation of collagen results in abnormally crosslinked protein resistant to degradation with subsequent increased build-up of collagen in joints. The management of cheiroarthropathy is predominantly conservative, with occupational and hand therapy at the forefront. Tendinopathy is more common in people with diabetes than those without, and is associated with obesity and insulin resistance. As with cheiroarthropathy, the exact causative mechanism of tendinopathy in diabetes is not known, but may be linked to inflammation, apoptosis and increased vascularity of affected tendons, driven by hyperinsulinaemia. Local fat pads have also been suggested to play a role in the pathogenesis of tendinopathy.

Glycemic Control Maintained over Time and Joint Stiffness in Young Type 1 Patients: What Is the Mathematical Relationship?

BACKGROUND

It is widely known that diabetes can induce stiffness and adversely affect joint mobility even in young patients with type 1 diabetes mellitus (T1D). The aim of this study was to identify a mathematical model of diabetes mellitus long-term effects on young T1D patients.

METHODS

Ankle joint mobility (AJM) was evaluated using an inclinometer in 48 patients and 146 healthy, sex- BMI-, and age-matched controls. Assuming time invariance and linear superposition of the effects of hyperglycemia, the influence of T1D on AJM was formalized as an impulse response putting into relationship past supernormal HbA1c concentrations with the ankle total range of motion. The proposed model was identified by means of a nonlinear evolutionary optimization algorithm.

RESULTS

AJM was significantly reduced in young T1D patients (P < .001). AJM in both plantar and dorsiflexion was significantly lower in subjects with diabetes than in controls (P < .001). The identified impulse response indicates that impaired metabolic control requires 3 months to bring out its maximum effect on the reduction of AJM, while the following long-lasting decay phase with the expected AJM recovery times, normally depends on the slow turnover of collagen. HbA1c concentration levels above 7.2% are sufficient to produce a reduction of ankle ROM.

CONCLUSIONS

In young patients with T1D the lack of glycemic control over time affects AJM. HbA1c levels can serve as a relevant prognostic factor for assessing the progression of LJM in subjects with diabetes.

Musculoskeletal problems in diabetes mellitus

Diabetic patients may suffer from a wide range of musculoskeletal disorders that can cause pain and some dysfunctions in the patient and affect the treatment negatively or reduce the quality of life by causing problems in the implementation of exercise programs, which are very important in the treatment of patients with Diabetes Mellitus. Although most of these problems are also seen in non-diabetics, they are more frequently observed but are not specific to diabetics. Their physiopathology is not fully understood; there is some evidence suggesting that macro- and microvascular complications of diabetes are responsible. A diagnosis of musculoskeletal dysfunctions in diabetic patients is made by clinical findings, and there is currently no specific treatment. If the treatment of problems requires corticosteroid use, diabetes can be hard to manage. In this review, we summarized the general features, diagnosis, and treatment modalities of frequent and important musculoskeletal disorders in diabetic patients.

Type 1 diabetes, sport practiced, and ankle joint mobility in young patients: What is the relationship?

BACKGROUND/OBJECTIVE

It is known that patients with diabetes can develop limited joint mobility (LJM) and that this can depend on the metabolic control maintained and the duration of the disease. The aims of this study were to verify the presence of ankle joint mobility (AJM) deficits in both plantar and dorsiflexion in young type 1 diabetic patients (T1D) considering also the possible role of sport practiced as a further factor, able to modify AJM.

METHODS

AJM was evaluated by an inclinometer in 82 T1D patients (M/F: 48/34), mean age 12.9 ± 2.6 years, body mass index (BMI) 19.7 ± 3.6 kg/m² , duration of diabetes 5.6 ± 3.3 years, mean HbA1c 7.5 ± 1.0% and in 226 healthy controls (M/F: 146/80), age-, gender-, and BMI-matched practicing different sports (soccer, volleyball, basketball, and dance).

RESULTS

The patients' ankle range of motion was significantly lower than that in controls (132.7 ± 22.3° vs 126.1 ± 17.9°; P < .017). In particular, ankle plantar flexion was significantly lower in the patients group (31.6° ± 7.9° vs 28.5° ± 6.6°; P < .002). Soccer players showed lower AJM in both groups: patients (120.1 ± 15.9° vs 127.3 ± 18.1) and controls (119.4 ± 21.1° vs 142.0 ± 18.1; P < .0001) than subjects practicing other sports or who were sedentary. In both groups, patients and controls, age, sex, duration of disease, hemoglobin 1Ac, and BMI have not been shown to be correlated to the mobility assessed.

CONCLUSIONS

The results of this study, in addition to confirming the negative effect of diabetes on AJM of young T1D patients, suggest that during these evaluations the sport-related effect should be considered because it can induce significant changes of AJM.

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature

BACKGROUND

Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot.

OBJECTIVES

The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers.

METHODOLOGY

An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications.

RESULTS

Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed.

CONCLUSION

Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

Limited Joint Mobility Progression in Type 1 Diabetes: A 15-Year Follow-Up Study

OBJECTIVE

To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility.

METHODS

Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1_c), urinary albumin excretion (UAE), and ophthalmoscopy.

RESULTS

Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001).

CONCLUSIONS

In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

Scleroderma Mimickers

Cutaneous fibrosing disorders encompass a diverse array of diseases united by the presence of varying degrees of dermal sclerosis. The quality and distribution of skin involvement, presence or absence of systemic complications and unique associated laboratory abnormalities often help to distinguish between these diseases. It is imperative that an effort is made to accurately differentiate between scleroderma and its mimics, in order to guide long-term management and facilitate implementation of the appropriate treatment modality where indicated.

Relationship Between Skin Intrinsic Fluorescence--an Indicator of Advanced Glycation End Products-and Upper Extremity Impairments in Individuals With Diabetes Mellitus

BACKGROUND

Accumulation of advanced glycation end products (AGEs) is thought to contribute to limited joint mobility in people with diabetes mellitus (DM), but the relationships among AGEs, shoulder structural changes, movement, and disability are not understood.

OBJECTIVE

The purpose of this study was to determine the differences and relationships among skin intrinsic fluorescence (SIF), a proxy measure of AGEs, biceps and supraspinatus tendon thickness, upper extremity movement, and disability in groups with and without DM.

DESIGN

This was a cross-sectional, case-control study.

METHODS

Fifty-two individuals participated: 26 with type 2 DM and 26 controls matched for sex, age, and body mass index. The main outcome measures were: SIF; biceps and supraspinatus tendon thickness; 3-dimensional peak shoulder motion; and Disability of the Arm, Shoulder and Hand (DASH) questionnaire scores.

RESULTS

Mean SIF measurements were 19% higher in the DM group compared with the control group (P<.05). Biceps tendons (mean and 95% confidence interval [CI]) (4.7 mm [4.4, 5.0] versus 3.2 mm [2.9, 3.5]) and supraspinatus tendons (6.4 mm [5.9, 6.8] versus 4.9 mm [4.4, 5.3]) were thicker and peak humerothoracic elevation (139° [135°, 146°] versus 150° [146°, 155°]) and glenohumeral external rotation (35° [26°, 46°] versus 51° [41°, 58°]) were reduced in the DM group compared with the control group (P<.05). In the DM group, SIF was correlated to biceps tendon thickness, DASH score, and shoulder motion (r=.44-.51, P<.05). The SIF score and shoulder strength explained 64% of the DASH scores (P<.01).

LIMITATIONS

Because this was a cross-sectional study design, a cause-effect relationship could not be established.

CONCLUSIONS

Accumulation of AGEs in the connective tissues of individuals with DM appears to be associated with increased tendon thickness and decreased shoulder joint mobility and upper extremity function. Physical therapists should be aware of these possible metabolic effects on structure, movement, and disability when treating people with diabetes.

Shoulder limited joint mobility in people with diabetes mellitus

BACKGROUND

Limited joint mobility at the shoulder is an understudied problem in people with diabetes mellitus. The purpose of this study was to determine the differences in shoulder kinematics between a group with diabetes and those without diabetes.

METHODS

Fifty-two participants were recruited, 26 with diabetes and 26 non-diabetes controls (matched for age, BMI and sex). Three-dimensional position of the trunk, scapula and humerus were collected using electromagnetic tracking sensors during scapular plane elevation and rotation movements.

FINDINGS

Glenohumeral external rotation was reduced by 11.1°-16.3° (P<0.05) throughout the humerothoracic elevation range of motion, from neutral to peak elevation, in individuals with diabetes as compared to controls. Peak humerothoracic elevation was decreased by 10-14°, and peak external rotation with the arm abducted was decreased 22° in the diabetes group compared to controls (P<0.05). Scapulothoracic and glenohumeral internal rotation motions were not different between the two groups.

INTERPRETATION

Shoulder limited joint mobility, in particular decreased external rotation, was seen in individuals with diabetes as compared to control participants. Future research should investigate causes of diabetic limited joint mobility and strategies to improve shoulder mobility and prevent additional detrimental changes in movement and function.

Upper extremity impairments, pain and disability in patients with diabetes mellitus

OBJECTIVES

To determine the severity of, and relationships between, upper extremity impairments, pain and disability in patients with diabetes mellitus, and to compare upper extremity impairments in patients with diabetes with non-diabetic controls.

DESIGN

Case-control, cross-sectional design.

SETTING

University-based, outpatient diabetes centre and physical therapy research clinic.

PARTICIPANTS

Two hundred and thirty-six patients with diabetes attending an outpatient diabetes clinic completed the Shoulder Pain and Disability Index (SPADI) questionnaire. A detailed shoulder and hand examination was conducted on a subgroup of 29 volunteers with type 2 diabetes, and 27 controls matched for age, sex and body mass index.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

SPADI score, passive shoulder range of motion (ROM) and strength, grip strength, hand sensation, dexterity and limited joint mobility of the hand.

RESULTS

Sixty-three percent (149/236) of patients with diabetes reported shoulder pain and/or disability [median SPADI score 10.0 (interquartile range 0.0 to 39.6)]. Compared with the control group, the subgroup of patients with diabetes had substantial reductions in shoulder ROM, shoulder muscle strength, grip and key pinch strength (P<0.05). Patients with diabetes had a greater prevalence of decreased sensation (26/27 vs 14/27) and limited joint mobility of the hand (17/27 vs 4/27) compared with the control group. Total SPADI score was negatively correlated (P<0.05) with shoulder ROM (r=-0.42 to -0.74) and strength measures (r=-0.44 to -0.63) in patients with diabetes.

CONCLUSIONS

Upper extremity impairments in this sample of patients with diabetes were common, severe and related to complaints of pain and disability. Additional research is needed to understand the unique reasons for upper extremity problems in patients with diabetes, and to identify preventative treatments.

The association of metabolic syndrome markers with adhesive capsulitis

BACKGROUND

Research has associated adhesive capsulitis with diabetes mellitus but suggests that glucose-mediated injury may begin before diabetes is diagnosed. The period preceding diabetes is often marked by metabolic syndrome.

METHODS

We investigated the relationship between metabolic syndrome components (insulin resistance, hypertension, dyslipidemia, and obesity) and the development of adhesive capsulitis using a case-control study. We retrospectively reviewed 150 consecutive adhesive capsulitis patient charts to determine the prevalence of obesity and of medications used for treating metabolic syndrome elements and compared these with previously reported nationwide values.

RESULTS

The prevalence of anti-hyperglycemia medications in the adhesive capsulitis cohort was 18.4% (95% confidence interval [CI], 12.9%-25.7%), twice the national rate of diagnosed diabetes of 7.6% (95% CI, 6.7%-8.5%). In the 20- to 39-year-old group, the prevalence of anti-hyperglycemic medications, 26.3% (95% CI, 11.8%-48.8%), was over 10 times the nationwide rate. The overall prevalence of hypertensive medication use in the adhesive capsulitis group, 33.1% (95% CI, 25.9%-41.2%), was notably higher than the nationwide rate, 21.6% (95% CI, 19.8%-23.4%). In the 40- to 64-year-old group, the prevalence of hypertensive medication use, 36.8% (95% CI, 28.6%-46.0%), was notably higher than the nationwide rate of 24.5% (95% CI, 22.2%-27.0%). The prevalence of anti-lipid medications and obesity was similar between the groups.

CONCLUSIONS

The relationship between adhesive capsulitis and metabolic syndrome remains unclear. Our results confirm previous work associating hyperglycemia with adhesive capsulitis. We have also shown a possible association of hypertension, part of metabolic syndrome and a proinflammatory condition, with adhesive capsulitis, which has not been previously described.

[Association between limited joint mobility syndrome and risk of accidental falls in diabetic patients]

INTRODUCTION

Limited joint mobility syndrome (LJMS) appears exclusively in both type 1 and type 2 diabetic patients. It is characterized by a limited range of digital motion, with involvement of small joints of the hands. It initially affects the proximal interphalangeal joints, followed by wrists, elbows, shoulders, knees, and axial skeleton. The diagnosis can be made by the simple "prayer sign" test. The objective was to study the prevalence of diabetic patients with LJMS, and to evaluate the association between LJMS and metabolic control, and the risk of accidental falls.

PATIENTS AND METHODS

A cross-sectional study was conducted in the San Fernando II Health Centre, Madrid (suburbs). The sample consisted of 184 patients with a diagnosis of diabetes of over 5 years from November to March, 2013. The prayer sign was used to define which patients had LJMS. Fall risk was determined using the Timed Up & Go test.

RESULTS

A total of 99 patients (53.8%) (95% CI 46.6 to 61) had a positive prayer sign. No statistically significant relationship was found with HbA1c, but there was an association with the Timed Up & Go test (P<.001) (95% CI 1.173 to 1.611). The patients with LJMS had a moderate risk of falls compared with those without LJMS, which was of low risk.

CONCLUSIONS

The prevalence of LJMS is high. This is the first study that shows a relationship between LJMS and the risk of falls in diabetic patients.

Cutaneous manifestations in children with diabetes mellitus and obesity

Obesity and diabetes are chronic diseases that affect people all over the world, and their incidence is increasing in both children and adults. Clinically, they affect a number of organs, including the skin. The cutaneous manifestations caused or aggravated by obesity and diabetes are varied and usually bear some relation to the time that has elapsed since the onset of the disease. They include soft fibromas, acanthosis nigricans, striae, xerosis, keratosis pilaris, plantar hyperkeratosis, fungal and bacterial skin infections, granuloma annulare, necrobiosis lipoidica, psoriasis, and atopic dermatitis. In this review article we present the skin changes found in children with diabetes mellitus and obesity and related syndromes and highlight the importance of the skin as a tool for establishing clinical suspicion and early diagnosis of systemic disease.

Patients with Type 2 diabetes mellitus have a worse functional outcome post knee arthroplasty: a matched cohort study

Knee arthroplasty provides not only pain relief but also an improvement in function and range of movement. Limited joint mobility is a common complication of diabetes mellitus. We therefore examined functional outcome post total knee arthroplasty in a cohort of subjects with (n=367) and a cohort matched for age, sex, BMI and functional movement at baseline, without diabetes mellitus (n=367). Participants were examined at baseline (pre-operatively), 1, 5 and 10 years post TKA. There was no significant difference in fixed flexion, maximal flexion or total range of movement between the two groups at baseline. By 1 year the group with diabetes had a significantly lower maximal flexion (p<0.001), total range of movement (p<0.001) and Knee Society Score (p=0.034). Similar results were observed at years 5 (except for the KSS) and 10 post procedure. At 5 years post arthroplasty a significant increase was observed in fixed flexion (p=0.026) in the diabetic group. Ten years post arthroplasty yielded similar results. This study demonstrates that the pre-operative presence of diabetes mellitus leads to a worse outcome post knee arthroplasty, although no significant difference was demonstrable in KSS at 5 years (p=0.35) suggesting patient satisfaction remains high during this period.

Rheumatic manifestations of diabetes mellitus

DM is associated with various musculoskeletal manifestations. The strength of this relationship varies among the various musculoskeletal disorders; the associations are based mostly on epidemiologic data. For most of these conditions, definitive pathophysiologic correlates are lacking.Hand and shoulder disorders occur more frequently than other musculoskeletal manifestations of DM. Recognition of the association between DM and shoulder adhesive capsulitis, DD, and stenosing flexor tenosynovitis facilitates their correct diagnosis in the setting of DM and prompt initiation of appropriate treatment, which may include optimizing glycemic control. Conversely, awareness and identification of the characteristic musculoskeletal manifestations of DM may facilitate earlier diagnosis of DM and initiation of glucose-lowering therapy to retard the development of diabetic complications.Much less has been published about the musculoskeletal complications of DM than about its micro- and macrovascular complications. Prospective case-control cohort studies are needed to establish the true prevalence of musculoskeletal complications of DM and the metabolic syndrome, especially in this era of tighter glycemic control.The potential relationship between DM and the development of OA needs to be clarified in large, prospective, case-control cohort studies. The effect on musculoskeletal manifestations of various therapeutic regimens to manage DM should be studied prospectively. Treatment regimens for some musculoskeletal conditions associated with DM, such as DISH, should be studied in larger prospective, randomized,controlled clinical trials.At the molecular level, further studies are warranted to clarify the potential contribution of AGEs and adipokines to the development of OA and diabetic musculoskeletal syndromes, such as shoulder adhesive capsulitis, DD, stenosing flexor tenosynovitis, and LJM. Identification of such molecular targets for therapy would promote the development of additional treatments for these and other rheumatic diseases.

Monitoring endocrine function

This article reviews current knowledge concerning the monitoring of endocrine function in patients in the clinical setting. Monitoring techniques are discussed and literature is reviewed regarding diabetes mellitus, thyroid, and parathyroid disorders, pheochromocytoma, adrenal insufficiency, and carcinoid tumors.

Longitudinal relation between limited joint mobility, height, insulin-like growth factor 1 levels, and risk of developing microalbuminuria: the Oxford Regional Prospective Study

AIMS

To determine risk factors for development of microalbuminuria (MA) in relation to detection of limited joint mobility (LJM+) of the interphalangeal joints in a longitudinal cohort of type 1 diabetic (T1DM) subjects.

METHODS

A total of 479 T1DM subjects diagnosed <16 years were followed from diagnosis of diabetes with annual assessments consisting of assessment of LJM, measurement of HbA1c and insulin-like growth factor 1 (IGF-1), and three urine samples for albumin:creatinine ratio (ACR).

RESULTS

After a median follow up of 10.9 years, 162 subjects (35.1%) developed LJM at median age 13.0 years and duration 5.2 years. More subjects developed LJM after compared to before puberty (67.6 v 32.4%). In LJM+ compared to LJM- subjects, HbA1c (mean 10.1 (SD 1.6) v 9.6 (1.4) %)) and ACR levels (median 1.1 (range 0.2-242.9) v 0.9 (0.4-70.7) mg/mmol) were higher, and in a Cox model probability of developing LJM was related to puberty and higher HbA1c levels. ACR levels were higher after detection of LJM compared to before (median 1.2 (range 0.4-102.6) v 0.8 (0.2-181.9) mg/mmol). Probability of developing MA was related to puberty, HbA1c, female sex, and presence of LJM (a 1.9-fold increased risk). Both LJM and MA were associated with lower height SDS (LJM: mean 0.0 (SD 1.0) v 0.2 (1.1); MA: 0.0 (1.0) v 0.2 (SD 1.0)) and lower IGF-1 levels.

CONCLUSION

The development of LJM was associated with an increased risk of microalbuminuria, independent of glycaemic control. Risk for both microalbuminuria and LJM was associated with puberty, reduced growth, and reduced IGF-1 levels, and may indicate underlying shared pathogenic mechanisms.

Reduced prevalence of limited joint mobility in type 1 diabetes in a U.K. clinic population over a 20-year period

OBJECTIVE

Limited joint mobility (LJM), one of the earliest clinically apparent long-term complications of type 1 diabetes, is a risk marker for subsequent microvascular complications. We hypothesize that the prevalence of LJM may have decreased during the past two decades due to improved standards of glycemic control.

RESEARCH DESIGN AND METHODS

A single observer performed a survey in 204 consecutive patients with type 1 diabetes (106 men and 98 women, age 27 +/- 1 years, HbA(1c) 8.3 +/- 0.1%, duration of diabetes 14.5 +/- 0.8 years, insulin dose 63 +/- 2 units/day). We used the same examination method and criteria for assessment of LJM as used by us in an earlier study in 1981-1982.

RESULTS

The prevalence of LJM has fallen from 43 to 23% between the 1980s and 2002 (P < 0.0001). The relative risk for LJM in 2002 compared with the 1981-1982 cohort was 0.53 (0.40 < RR < 0.72, P < 0.0001). The prevalence of LJM was increased with longer duration of diabetes (<10 years, 13%; 10-20 years, 19%; 20-29 years, 30%; >30 years, 65%; P < 0.001). The relative risk for those with a mean HbA(1c) <7% in 2002 was 0.3 (0.1 < RR < 1.2, P = 0.05) when compared with those with mean HbA(1c) >7%.

CONCLUSIONS

The present study confirms the hypothesis that the prevalence of LJM is lower than 20 years ago and that improved standards of glycemic control and diabetes care may have contributed to this occurrence. Joint limitation in type 1 diabetes is strongly associated with duration of diabetes. The presence of LJM remains a common and important clinical marker for subsequent microvascular disease and can be a useful clinical tool for identification of patients at increased risk.

Early subclinical limited axial and large joint flexibility in type 1 diabetes mellitus adolescents

OBJECTIVE

The objective of this study was to compare the axial and large joint mobility in adolescents with and without type 1 diabetes mellitus (DM1).

PATIENT AND METHODS

To check this relationship, 72 DM1 adolescents aged 9-20 years were admitted into the trial and compared with 46 healthy control subjects aged 10-18 years. The youths were compared with regard to anthropometrics (age, proportion female/male, weight, height, and BMI) data. The years from DM1 diagnosis and HbA(1c) (index) were 4.9 +/- 3.6 years and 1.40 +/- 0.39%, respectively. The values of the tests of flexibility of the movements of cervical joint, the abduction of scapular, wrist and back-lumbar joints and abduction of lame-femoral were obtained through the Fleximeter.

RESULTS

The DM1 patients and controls did not differ regarding age (DM1 median 16, range 9-20 years vs. controls 16, range 10-18 years) and BMI (DM1 mean+/-S.D. 21.49 +/- 3.69 kg/m(2) vs. controls 20.76 +/- 2.81 kg/m(2)). The scapular, back-lumbar, and lame-femoral flexibility were, respectively, significantly lower (P < .001) in DM1 adolescents (175 +/- 8 degrees , 107 +/- 4 degrees , 66 +/- 10 degrees) compared with controls (189 +/- 13, 116 +/- 14, 76 +/- 12), but the cervical joint mobility was the same in both groups (DM1: 98 +/- l2 degrees vs. control: 101 +/- 13 degrees).

CONCLUSION

Thus, the results of our study show a subclinical limited axial and large joint mobility in DM1 adolescents. Future prospective studies are needed to ascertain whether the joint limitations found in these DM1 adolescents will persist into adulthood and play a role in the development of other diabetic complications.

Rheumatic manifestations of diabetes mellitus

An epidemic of diabetes is currently raging in the US and developed countries, and is affecting almost 10% of the US population. The association between several rheumatic disorders and diabetes mellitus is gaining attention, and with recent data showing that more than 30% of patients with type 1 or type 2 diabetes have some hand or shoulder diseases, the magnitude of this problem is becoming more evident. Although some syndromes are observed exclusively in patients with diabetes, the majority of the rheumatic diseases found in patients with diabetes are also seen in the non-diabetes population, albeit at a much lower prevalence. The exact mechanisms by which the specific metabolic abnormalities of diabetes impact on the pathogenesis of its rheumatic manifestations are not clear. Further studies are needed to better understand the role of diabetes on the development of these disorders.

The effect of ankle equinus upon the diabetic foot

The association between ankle equinus and common foot pathologies such as Achilles tendinitis, metatarsalgia, Morton's neuroma, hallux abductovalgus, and plantar fasciitis has been described. However, the association between ankle equinus and diabetic foot pathology has only been recognized recently. Over half of the non-traumatic amputations occurring in the United States are related to complications of diabetes. It is imperative that risk factors for lower extremity ulceration and amputation are identified and addressed. This article reviews the effect of ankle equinus deformity on the diabetic foot and the available treatment options. New data on the prevalence of equinus in a population of patients with diabetes are also presented.

Limited joint mobility in type 1 diabetic patients: associations with microangiopathy and subclinical macroangiopathy are different in men and women

OBJECTIVE

To study the relationship of limited joint mobility (LJM) in type 1 diabetic patients with microvascular complications, hypertension, and early atherosclerosis and to determine whether sex has an influence on possible associations.

RESEARCH DESIGN AND METHODS

A total of 335 consecutive unselected patients (191 women and 144 men), aged 14-40 years, were studied for LJM, retinopathy, nephropathy (stages III and IV), and hypertension. Standard laboratory tests were performed; the intima-media thickness (IMT) of the carotid arteries, which reflects the extent of early atherosclerosis, was measured by high-resolution ultrasound, and plaques were identified.

RESULTS

The frequency of LJM was 33.7% (29.8% in women and 38.9% in men). Subjects with LJM had a longer diabetes duration (P < 0.001) than those without (women 16.7 +/- 9.1 vs. 10.3 +/- 6.0 years; men 15.0 +/- 9.0 vs. 9.4 +/- 6.3 years). Age, HbA1c, lipids, and systolic/diastolic blood pressure were not different between men and women with or without LJM. Men with LJM had a higher albumin excretion rate (37.1 vs. 13.1 microg/min, P < 0.05) than those without LJM and showed a higher risk of proteinuria (odds ratio 1.8, 95% CI 1.2-2.7; P < 0.05), retinopathy (2.4, 1.7-3.5; P < 0.001), and hypertension (1.7, 1.2-2.6; P < 0.05). The occurrence of these complications was not different between women with and without LJM, but only women with LJM had a greater IMT (0.59 +/- 0.13 vs. 0.55 +/- 0.10 mm, P < 0.05) and a higher risk of plaques (odds ratio 2.1, 95% CI 1.3-3.4; P < 0.05) than women without LJM. In a multiple logistic regression analysis, adjusted for age and diabetes duration, male sex independently predicted the presence of LJM. Moreover, LJM proved to be an independent predictor of retinopathy in men only.

CONCLUSIONS

LJM is an indicator of microvascular disease in men, and LJM is associated with early macrovascular disease in women.

Changes in frequency and severity of limited joint mobility in children with type 1 diabetes mellitus between 1976-78 and 1998

OBJECTIVE

Limited joint mobility (LJM), the earliest clinically apparent long-term complication of type 1 diabetes mellitus, is a risk indicator for microvascular complications, and its appearance is primarily affected by long-term metabolic control. We hypothesized that the prevalence of LJM had decreased during the past 20 years.

STUDY DESIGN

We examined 312 subjects with type 1 diabetes mellitus, aged 7 to 18 years, using the same examination method and criteria as in studies of 515 subjects in this age group carried out between 1976 and 1978 for whom primary data were available, including age, duration of diabetes, and LJM stage. Statistical analyses included exact chi(2) tests, independent sample t tests, and unconditional logistic regression.

RESULTS

There was a >4-fold reduction in frequency of LJM between 1976-78 and 1998 (31% vs 7%, P <.001), with a decrease in the proportion having moderate or severe LJM (35% vs 9%, P =.025).

CONCLUSIONS

These findings confirm the hypothesis that the prevalence of LJM has decreased, most likely the result of improved blood glucose control during the past 2 decades.