ELSEVIER
`
`Journal of Diabetes and Its Complications 23 (2009) 32- 39
`
`J
`
`Diabetes
`Complications
`
`WWW.JDCJOURNAL.COM
`
`Hand disorders, hand function, and activities of daily living 1n
`elderly men with type 2 diabetes*
`
`Ragnhild I. Cederlund\ Niels Thomsen\ Soley ThrainsdottirC, Karl-Fredrik Erikssond,
`Goran Sundkviste, ffi, Lars B. Dahlin b,*
`
`a Division of Occupational Therapy, Department of Health Sciences, Varda! Foundation, University Hospital Malmo, Lund University, Malmo, Sweden
`bDepartment of Clinical Sciences, Malmo, Hand Surgery, University Hospital Malmo, Lund University, Malmo, Sweden
`cDepartment of Clinical Sciences, Malmo, Neurology, University Hospital Malmo, Lund University, Malmo, Sweden
`dDepartment of Clinical Sciences, Malmo, Vascular diseases, University Hospital Malmo, Lund University, Malmo, Sweden
`eDepartment of Clinical Sciences, Malmo, Diabetes Neurology and Epidemiology, University Hospital Malmo, Lund University, Malmo, Sweden
`
`Received 7 May 2007; received in revised form 13 August 2007; accepted 6 September 2007
`
`Abstract
`
`Aims/Hypothesis: This study aimed to examine hand disorders, symptoms, overall hand function, activities of daily living (ADLs), and
`life satisfaction in elderly men with type 2 diabetes mellitus (DM), impaired glucose tolerance (IGT), and normal glucose tolerance (NGT).
`Methods: Subjects were interviewed and evaluated with a battery of clinical and laboratory tests, including hand assessment, and a
`questionnaire. Results: HbAlc differed between groups (highest in DM, especially in long-term DM). Limited joint motion (LJM), for
`example, prayer sign and Dupuytren's contracture, was most common in individuals with DM, followed by individuals with IGT, as
`compared to those with NGT. Vibrotactile sense was impaired symmetrically in tbe index and little fingers in DM. However, there were no
`differences for sensibility, dexterity, grip strength, and cold intolerance between groups. Individuals with long-term (> 15 years) DM were
`more affected regarding sensibility and ADL than individuals with short-term DM, who had more sleep disturbances. ADL difficulties were
`less among IGT subjects. Vibrotactile sense showed correlations with Semmes-Weinstein monofilament test and static two-point
`discrimination. Conclusions/Interpretation: Dupuytren's contracture and impaired vibrotactile sense in finger pulps occurred in patients
`with DM but not in those with IGT, although LJM occurred in botb IGT and DM patients. A longer duration ofDM was associated with more
`severe neuropathy and ADL difficulties. Life satisfaction was high, and hand disorders did not have a significant impact on ADL.
`© 2009 Elsevier Inc. All rights reserved.
`
`Keywords: Diabetes mellitus; Neuropathy; Hand function; Vibration sense; Impaired glucose tolerance; Sensibility; Dexterity; Grip strength; ADL; LJM
`
`1. Introduction
`
`Diabetes mellitus (DM) is associated with musculoske(cid:173)
`letal disorders predominantly in patients with type 1 DM
`(Chammas et al., 1995; Dyck et al., 1993). Few studies
`have assessed such abnormalities in patients with either
`
`* The authors declare that no conflicts of interest exist.
`* Corresponding author. Department of Clinical Sciences, Mahnii, Hand
`Surgery, Mahnii University Hospital, SE-205 02 Mahnii, Sweden. Tel.: +46
`40 33 67 69; fax: +46 40 92 88 55.
`E-mail address: lars.dahlin@med.lu.se (L.B. Dahlin).
`ffi Goran Sundvist passed away in 2006.
`
`1056-8727/09/$ - see front matter © 2009 Elsevier Inc. All rights reserved.
`doi: 10.1 0l 6/j.jdiacomp.2007.09 .002
`
`type 2 DM or impaired glucose tolerance (IGT) matched
`for age and gender (Ardic, Soyupek, Kahraman, &
`Yorgancioglu, 2003; Cetinus, Buyukbese, Uzel, Ekerbicer,
`& Karaoguz, 2005; Gamstedt, Holm-Glad, Ohlson, &
`Sundstrom, 1993). Most studies assessing hand function
`have used only a single test, such as grip strength or
`perception threshold (Cetinus et al., 2005; Rahman,
`Griffin, Rathmann, & Wareham, 2003). Overall hand
`function combining an assessment of sensibility, dexterity,
`and grip strength is rarely studied in DM. Furthermore,
`there are no population-based studies (Eriksson &
`Lindgarde, 1990; Eriksson et al., 1994) defining overall
`hand function and its impact on activity of daily living
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`R.I Cederlund et al. I Journal of Diabetes and Its Complications 23 (2009) 32-39
`
`33
`
`(ADL) in patients with type 2 DM or IGT (Dyck et al.,
`1993). An association between hand function and ADL has
`been demonstrated in patients with vibration-induced
`neuropathy (Cederlund, Nordenskiold, & Lundborg,
`2001 ). Thus, studies in well-defined populations of
`individuals with various glucose tolerances and with a
`specific gender and age are crucial for understanding how
`DM and IGT may influence the musculoskeletal and
`nervous systems of the hands with its consequences on
`ADL. The consequences of DM may be determined by
`factors such as severity of the disease and the impact on
`ADL (Bruce, Davis, & Davis, 2005; Castaneda, Bermudez,
`& Tucker, 2000; Miller, Rejeski, Reboussin, Ten Have, &
`Ettinger, 2000; Wray, Ofstedal, Langa, & Blaum, 2005).
`Our aim was to systematically define hand disorders [ e.g.,
`Dupuytren's contracture,
`limited joint motion (LJM)],
`symptoms (e.g., cold intolerance, pain), hand function,
`ADL performance, and life satisfaction in elderly men with
`type 2 DM, IGT, and normal glucose tolerance (NGT),
`matched for age, height, and body mass index (BMI)
`recruited from a prospective, population-based study
`initiated between 1975 and 1979.
`
`2. Subjects, materials, and methods
`
`The study was designed as a cross-sectional investigation
`with an explorative approach. The ethics committee gave
`approval of the study, and informed consent was obtained
`from subjects.
`
`2.1. Subjects
`
`A health screening program of 48-year-old men was
`conducted in the city of Malmo, Sweden, between 1975 and
`1979. Of a total population of 9033, 6956 men agreed to
`participate in an oral glucose tolerance test (OGTT; Eriksson
`& Lindgarde, 1990; Eriksson et al., 1994). Four hundred
`twenty-three subjects with an abnormal OGTT on two
`consecutive occasions were invited to participate in a long(cid:173)
`term intervention. Between 1989 and 1991, the same
`individuals, now with a mean age of 61 years (±2 S.D.),
`were screened again and reclassified according to the WHO
`criteria (DM, IGT, NGT). The following two groups were
`identified: 51 individuals with IGT and 69 individuals with
`DM. A group of 62 individuals with NGT was randomly
`matched according to gender, age, height, and BMI. Between
`2003 and 2005, the same individuals, now with a mean age
`of 74.8±1.3, were invited to a follow-up study. Among the
`182 original individuals, 46 had died (24 with DM, 10 with
`IGT, and 12 with NGT), 12 were too seriously affected to
`participate (3 with DM, 6 with IGT, and 3 with NGT), 7 had
`moved away from the Malmo area (2 with DM, 3 with IGT,
`and 2 with NGT), and 10 declined participation (5 with DM,
`2 with IGT, and 3 with NGT), thereby leaving 107
`individuals for a follow-up (Thrainsdottir, Englund, Rosen,
`Petersson, & Sundkvist, 2006). After initialization of the
`
`present study, another 12 patients with DM and 3 with NGT
`were lost due to intercurrent disease or death. Finally, four
`patients were excluded due to a suspected hereditary
`neuropathy with flexion deformities in the feet (one patient)
`or neuropathy associated with deficiency of vitamin B 12. The
`final losses of participants in the three groups were as
`follows: 46/69 ( 67%) subjects in DM, 21/51 ( 41 % ) in IGT,
`and 27/62 (44%) in NGT. The remaining 88 participants
`were classified into three groups (DM, IGT, NGT) based on
`OGTT 1989-1991 (NGT, n=35; IGT, n=30; DM, n=23) and
`OGTT 2003-2005 (NGT, n=26; IGT, n=l 7; DM, n=45).
`Twenty-five patients had constant NGT, 7 patients had
`constant IGT, and 23 had constant DM between 1989-1991
`and 2003-2005.
`
`2.2. Clinical assessment
`
`Interviews and assessments were performed by the same
`occupational therapist who was unaware of the individuals'
`glucose tolerance.
`
`2.2.1. Demographic data
`Demographic data on age, marital status, living accom(cid:173)
`modation, smoking habits, and hand problems were
`registered.
`
`2.2.2. Hand disorders, symptoms, and fanction
`Questions regarding hand disorders and symptoms,
`occurrence of decreased range of motion in the shoulder
`and hand (prayer sign), trigger fingers, Dupuytren's
`contracture, nerve entrapments, and hand infections were
`recorded (no/yes) and examined. Cold intolerance was
`quantified with a visual analogue scale (VAS).
`For assessment of hand function, seven tests were
`performed on both hands according to a previous protocol
`with reliable and validated instruments (for details, see
`Cederlund, Iwarsson, & Lundborg, 2003):
`
`1. Vibration sense, using tactilometry (PID AB, Malmo,
`Sweden) within the frequencies 8-500 Hz, thereby
`calculating a sensibility index (SI) reflecting dysfunc(cid:173)
`tion of vibration sense (large fiber neuropathy) as
`compared to a reference population (calculation of an
`SI, i.e., the area beneath the curve divided by the area
`beneath the curve from the reference population;
`Stromberg, Dahlin, & Lundborg, 1998). Index and
`little fingers were investigated bilaterally.
`2. Semmes-Weinstein monofilament (SWF) testing was
`performed for assessment of perception of touch/
`pressure. Measurement on three critical sites for
`median and ulnar nerve, respectively, gave six sites
`for each hand (maximum score of 30).
`3. Static two-point discrimination (s2PD) using the
`Dellon Disk-Criminator.
`4. Shape/Texture Identification (STI) test using the index
`finger (Jerosch-Herold, 2005).
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`34
`
`R.I Cederlund et al. I Journal of Diabetes and Its Complications 23 (2009) 32-39
`
`5. Purdue Pegboard Test (Casanova, Casanova, &
`Young, 1991) to test finger dexterity (mean score of
`three consecutive trials).
`6. Grip strength with Jamar dynamometer (GBM Med(cid:173)
`ical AB, Stockholm, Sweden; mean value of three
`successive trials) and with Grippit electronic instru(cid:173)
`ment (AB Detektor, Gothenburg, Sweden; mean force
`over 10 s).
`7. Key pinch and pinch strength with Pinch gauge (GBM
`Medical AB, Stockholm, Sweden; mean value of three
`successive trials).
`
`2.2.3. Activities of daily living
`A self-administered validated questionnaire, Evaluation
`of Daily Activity Questionnaire (EDAQ; Nordenskiold,
`Grimby, Hedberg, Wright, & Linacre, 1996), was used to
`evaluate ADL performance (Cederlund et al., 2001 ). The
`questionnaire consists of 102 daily activity items (rating
`score ranges from O to 3, where 0=without any difficulty,
`1 =with some difficulty, 2=with much difficulty, and 3=unable
`to do). EDAQ also includes a number of VAS measurements
`of perceived bodily symptoms (pain related to movement,
`joint stiffuess, decreased range of motion, anxiety, sleeping
`difficulties, and overall life satisfaction).
`
`2.3. Data analysis
`
`The Kruskal-Wallis test was used for group comparisons,
`and the Mann-Whitney U test was used for bivariate
`comparisons. Chi-square test was performed on dichoto(cid:173)
`mized values. For correlations, Spearman rs values were
`calculated. All tests were two tailed, and P<.05 was
`considered statistically significant. Data are presented as
`median (min-max) or mean (S.D.). The statistics were
`computed with SPSS version 12.0.
`The study was approved by the Ethics Committee, Lund
`University (LU 508-03).
`
`3. Results
`
`Data were analyzed based on the results from the OGTT
`1989-1991 and 2003-2005.
`
`3.1. Diagnosis based on OGTT 1989-1991
`
`3.1.1. Hand disorders, symptoms, and HbAlc
`Basic raw data are presented in Table 1. Demographic
`features, including age, marital status (75% of the men were
`cohabitant or married), living accommodation, and smoking
`habits, were not statistically different between the groups.
`HbAlc differed significantly between the three groups and
`was highest in those with DM. Hand disorders, such as the
`prayer sign and Dupuytren' s contracture, were more frequent
`in patients with DM. Individuals with IGT also showed more
`common LJM in the fingers (prayer sign) than NGT
`
`individuals. Many subjects experienced cold intolerance
`but with no difference between the groups.
`
`3.1.2. Hand/unction
`Vibrotactile sense in both the index and little fingers was
`symmetrically reduced in patients with DM compared to
`those with IGT and NGT, reflecting impaired vibrotactile
`sense in finger pulps innervated by the median and ulnar
`nerves, respectively.
`
`3.1.3. ADL, bodily symptoms, and life satisfaction
`The individuals rated life satisfaction as high, with few
`difficulties in ADL performance ( e.g., opening lids and
`packages, buttoning, climbing stairs, and taking long walks).
`IGT subjects had less ADL problems than those with NGT
`and DM. All bodily symptoms were rated low with no
`differences between groups.
`
`3.2. Diagnosis based on OGTT 2003-2005
`
`When data were analyzed based on the OGTT in 2003-
`2005, HbAlc was significantly higher in DM [6.1 % (3.9-
`9.3)], as compared to NGT [4.5% (3.9-5.3)] and IGT [4.6%
`(4.1-5.4); P<.001 (two missing values in DM group)]. The
`frequency of the prayer sign (P<.048), Dupuytren's
`contracture (P<.02), and diminished vibrotactile sense in
`the left index finger (P<.035) was significantly greater in
`DM compared to NGT and IGT combined. No differences
`were observed between NGT and IGT subgroups for any of
`the parameters.
`
`3.3. Long-term versus short-term diabetes
`
`Hand disorders, symptoms, function, and ADL perfor(cid:173)
`mance were analyzed in 23 individuals with constant
`diabetes since 1989-1991 (long term), as compared to 22
`individuals with newly discovered diabetes (short term;
`Table 2). HbAlc was higher in long-term diabetes.
`Sensibility was impaired in some fingers of individuals
`with long-term DM, for example, disturbed vibrotactile
`sense in three out of four fingers. ADL difficulties were more
`common in patients with long-term DM. Sleeping disorders
`were, however, more common in newly diagnosed diabetes.
`
`3. 4. Correlation between sensibility, dexterity, and vibro(cid:173)
`tactile sense
`
`Statistically significant correlations between SWF, s2PD,
`and vibrotactile sense (rs=-.55 to .67, P<.03; Table 3) were
`observed in respective fingers, mostly on the right side in all
`88 individuals, in 23 individuals with long-term diabetes,
`and in 25
`individuals with NGT. We also observed
`significant correlations between HbAlc and prayer sign
`(rs=,29, P<.01), Dupuytren's contracture (rs=,24, P=.03),
`and vibrotactile sense (left index finger; rs=-.26, P=.02)
`among all 88 individuals. Significant correlations were
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`R.l Cederlund et al. I Journal of Diabetes and Its Complications 23 (2009) 32-39
`
`35
`
`Table I
`Hand disorders, symptoms, function, ADLs, and life satisfaction in 88 individuals with diabetes, IGT, and NGT based on an OGTT 1989-1991
`
`Age (years)
`Marital status: partner/alone
`HbAlc (%)
`Hand disorders
`Decreased range of motion in shoulder (no/yes)
`Decreased range of motion in hand (no/yes)
`Prayer sign (no/yes)
`Trigger finger (no/yes)
`Dupuytren's contracture (no/yes)
`Hand infections (no/yes)
`Sensibility
`SW monofilament, right median nerve (0-15)
`SW monofilament, right ulnar nerve (0-15)
`SW monofilament, left median nerve (0-15)
`SW monofilament, left ulnar nerve (0-15)
`s2PD, right index finger (mm)
`s2PD, right little finger (mm)
`s2PD, left index finger (mm)
`s2PD, left little finger (mm)
`S TI test, right (0-6)
`STI test, left (0-6)
`Vibrotactile sense a
`Vibrotactile sense, right index finger, SI
`Vibrotactile sense, right little finger, SI
`Vibrotactile sense, left index finger, SI
`Vibrotactile sense, left little finger, SI
`Dexterity
`Purdue Pegboard Test, right side (n)
`Purdue Pegboard Test, left side ( n)
`Strength
`Grip strength, right hand (kg)
`Grip strength, left hand (kg)
`Pinch strength, right side (kg)
`Pinch strength, left side (kg)
`Key pinch strength, right side (kg)
`Key pinch strength, left side (kg)
`Grippit endurance, right side (N)
`Grippit endurance, left side (N)
`Bodily symptoms
`Anxiety (VAS 0-10)
`Sleep disturbances (VAS 0-10)
`Pain related to movement (VAS 0-10)
`Joint stiffness (VAS 0-10)
`Reduced range of motion (VAS 0-10)
`Cold intolerance (no/yes)
`Cold intolerance (VAS 0-10)
`ADL
`ADL difficulties (no/yes)
`ADL difficulties (EDAQ 102 items; n)
`Life satisfaction (VAS 0-10)
`
`NGT (n~35)
`
`75 (1.4)
`28/7
`4.6 (3.9-5.4)
`
`32/3
`33/2
`34/1
`32/3
`31/4
`34/1
`
`12 (9-15)
`12 (9-15)
`13 (5-15)
`13 (11-15)
`4 (3-10)
`4 (3-10)
`4 (3-15)
`5 (4-6)
`5 (2-6)
`6 (0-6)
`
`0.98 (0.18-1.30)
`0.90 (0.16-1.28)
`1.01 (0.20-1.31)
`1.01 (0.46-1.28)
`
`10 (5-15)
`11 (1-15)
`
`41 (26-63)
`40 (19-69)
`8.5 (4-12)
`8.0 (4.5-13.5)
`10 (5-13)
`9.5 (6.5-13)
`282 (76-495)
`255 (78-463)
`
`0.9 (1.86)
`1.3 (1.99)
`0.9 (1.82)
`1.5 (2.30)
`0.9 (2.08)
`20/15
`1.3 (2.07)
`
`8/27
`3 (0-29)
`8.3 (1.77)
`
`IGT (n~30)
`
`75 (1.4)
`19/11
`5.3 (3.9-7.6)
`
`25/5
`30/0
`24/6
`28/2
`25/5
`30/0
`
`12 (9-15)
`12 (11-15)
`13 (10-15)
`13 (9-15)
`4 (4-6)
`4 (4-6)
`4 (4-8)
`4 (4-7)
`5 (2-6)
`5 (1-6)
`
`1.02 (0.37-1.42)
`0.91 (0.32-1.30)
`0.95 (0.33-1.31)
`0.98 (0.17-1.36)
`
`11 (8-15)
`10 (8-15)
`
`42 (30-58)
`42 (29-60)
`8.5 (7-12)
`8.5 (5.5-13)
`9.75 (7.5-14)
`9.0 (7-13)
`262 (84-448)
`247 (130-408)
`
`0.4 (1.05)
`1.1 (1.5)
`0.7 (1.29)
`0.8 (1.29)
`0.7 (1.26)
`19/11
`1.2 (2.12)
`
`12/18
`I (0-12)
`9.0 (1.81)
`
`DM (n~23)
`
`75 (1.2)
`19/4
`7.2 (4.6-9.3)
`
`22/1
`22/1
`15/8
`21/2
`13/10
`22/1
`
`12(9-15)
`12 (7-14)
`12 (9-15)
`12 (9-15)
`4 (4-7)
`5 (3-8)
`4 (3-7)
`4 (3-7)
`6 (1-6)
`5 (2-6)
`
`0.83 (0.35-1.11)
`0.72 (0.30-1.04)
`0.86 (0.44-1.22)
`0.81 (0.39-1.14)
`
`10(7-13)
`10(6-13)
`
`41 (19-51)
`39 (19-41)
`8.0 (4.5-11.5)
`8.0 (2.5-10)
`9.0 (5.5-13)
`9.0 (4-11)
`269 (169-479)
`253 (162-378)
`
`0.3 (0.77)
`0.4 (1.06)
`1.4 (2.40)
`0.7 (1.15)
`1.0 (1.90)
`13/10
`2.0 (2.79)
`
`5/18
`4 (0-27)
`9.0 (1.53)
`
`P value
`
`ns
`ns
`.0001
`
`ns
`ns
`.005
`ns
`.008
`ns
`
`ns
`ns
`ns
`ns
`.017
`ns
`ns
`ns
`ns
`ns
`
`.016
`.006
`.023
`.007
`
`ns
`ns
`
`ns
`ns
`ns
`ns
`ns
`ns
`ns
`ns
`
`ns
`ns
`ns
`ns
`ns
`ns
`ns
`
`.225
`.039
`ns
`
`Values are expressed as median (min-max) or mean (S.D.). P values are expressed if they are <.05 (based on Kruskal-Wallis analysis of variance with
`subsequent Mann-Whitney U test or chi-square test as presented in Section 3 and below). An SI <0.8 is considered abnormal (Stromberg et al., 1998). HbAlc
`was different between all three groups (one value missing in IGT and DM). Regarding LJM (prayer sign), the individuals with IGTand DM were both different
`from those with NGTwith an increased frequency in the former two conditions. Vibrotactile sense was impaired in DM. ADL difficulties were less prominent
`in IGT than in NGT and DM.
`a SI based on a reference population.
`
`found between HbAlc and STI (left side; rs=-.53, P=.01)
`and especially between HbAlc and Grippit (rs=-.44 to -.52,
`P=.02-.04) among long-term DM patients (n=23). There
`were significant correlations between HbA 1 c and s2PD in all
`
`individuals with DM (2003-2005;
`fingers in the 43
`rs=,32-.41, P=.01-.04). No other significant correlations
`were found between other tests except in 23 individuals with
`long-term DM between STI on the right side and the
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`36
`
`R.l Cederlund et al. I Journal of Diabetes and Its Complications 23 (2009) 32-39
`
`Table 2
`Hand disorders, symptoms, function, and AD Ls in 23 individuals with diabetes since 1989-1991 (long term) and in 22 individuals with diabetes for the period
`2003-2005 (short term)
`
`Type 2 diabetes, long term(> 15 years; n~23)
`
`Type 2 diabetes, short term (<15 years; n~22)
`
`P values
`
`HbAlc (%)
`Dupuytren's contractures (no/yes)
`SW monofilament, right ulnar nerve (0-15)
`s2PD, right index finger (mm)
`s2PD, right little finger (mm)
`Vibrotactile sense, right index finger
`Vibrotactile sense, right little finger
`Vibrotactile sense, left little finger
`Sleep disturbances (VAS 0-10)
`ADL difficulties (EDAQ 102 items; n)
`
`7.2 (4.6-9.3)
`13/10
`12 (7-14)
`4 (4-7)
`5 (3-8)
`0.83 (0.35-1.11)
`0. 72 (0.30- 1.04)
`0.81 (0.39-1.14)
`0.4 (1.06)
`4 (0-28)
`
`5.7 (3.9-7.6)
`18/4
`12 (11-15)
`4 (4-6)
`4 (4-6)
`1.00 (0.37-1.42)
`0.94 (0.32-1.30)
`1.00 (0.17-1.36)
`1.1 (1.60)
`I (0-14)
`
`.01
`.055
`.039
`.007
`.040
`.036
`.004
`.024
`.048
`.025
`
`Data are presented as median (min-max) or mean (S.D.), andP values are obtained by analyses using the Mann-Whitney Utest or chi-square test. The value
`of vibrotactile sense is an SI (calculated in relation to reference population). An SI value of <0.8 is considered pathological (Stromberg et al., 1998). HbAlc
`was only available from 22 and 21 subjects.
`
`vibrotactile sense in the right index finger (rs=,52, P=.01)
`and between the Purdue Pegboard Test on the right side and
`the vibrotactile sense in the right index finger (rs=.47,
`P=.038).
`
`4. Discussion
`
`Most studies of musculoskeletal hand disorders in DM
`(Arkkila & Gautier, 2003; Chammas et al., 1995; Gamstedt
`et al., 1993; Jennings, Milner, & Ward, 1989; Smith,
`
`Burnet, & McNeil, 2003) include multiple confounders
`such as sex (i.e., including both men and women) and age
`(i.e., assessing adolescents and the elderly) and include a
`mixture of both type 1 and type 2 DM. To avoid these
`potential confounders, we examined representative sub(cid:173)
`groups of a large population of individuals with the same
`gender and similar age (around 75 years) with NGT, IGT,
`or type 2 DM. The latter two groups, but not NGT, had
`been followed meticulously for many years with glucose
`control and lifestyle advice. This may explain the lack of
`overall differences in hand disorders ( except LJM and
`
`Table 3
`Correlations between vibrotactile sense (right/left hand) and sensibility in all (a) 88 individuals, (b) individuals with constant diabetes since 1989-1991, and (c)
`25 individuals with constant NGT between 1989 and 2005
`
`Vibrotactile sense
`
`Right digit II
`
`.396; P:c;.00I a
`.586; P~.003b
`.571; P~.003c
`
`-.310; P~.004a
`-.550; P~.008b
`nsc
`
`Sensibility
`
`SW monofilament, right median nerve
`
`SW monofilament, right ulnar nerve
`
`SW monofilament, left median nerve
`
`SW monofilament, left ulnar nerve
`
`s2PD, right index finger
`
`s2PD, right little finger
`
`s2PD, left index finger
`
`s2PD, left little finger
`
`Right digit V
`
`Left digit II
`
`Left digit V
`
`.469; P:c;.00I a
`.483; r~.02ob
`.443; P~.027c
`
`.318; P~.003a
`nsb
`.497; P~.0llc
`
`-.340; P~.00I a
`-.485; P~.022b
`nsc
`
`nsa
`nsb
`nsc
`
`.457; P:c;.00[a
`.551; P~.006b
`.668; p::;_001
`
`nsa
`nsb
`nsc
`
`For correlations, Spearman r, values were calculated. Values are statistically significant correlation coefficient (r,) when comparisons are used.
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`R.I Cederlund et al. I Journal of Diabetes and Its Complications 23 (2009) 32-39
`
`37
`
`Dupuytren's contracture), symptoms, and function (bilat(cid:173)
`erally impaired vibrotactile sense) between the groups
`reflecting the strict glycemic control between these
`subgroups. Our individuals had participated in the overall
`study with the aim to follow the evolution of glucose
`tolerance since 1975-1979. During the follow up period
`since 1989-1991, no particular selection regarding hand
`function or dysfunction was made among all individuals.
`From the initial 423 subjects with an abnormal OGTT
`(1975-1979; initial cohort, n=6956), 120 subjects with DM
`and IGT were matched with 62 subjects of NGT (1989-
`1991). The limitation of our study is that the dropout rate
`was higher among subjects with DM (67%), as compared
`to subjects with IGT and NGT (41-44%). The 46 patients
`with DM lost for follow-up was mainly due to intercurrent
`diseases or death. This may reflect a more serious impact of
`DM complications, thereby underestimating the observed
`symptoms and dysfunctions in this group of subjects.
`Dupuytren's contracture, based on our strict definition of
`the condition, was more common among patients with DM
`but at a higher frequency than previously reported (Ardic
`et al., 2003; Chammas et al., 1995). However, very few
`patients with DM underwent operation for Dupuytren's
`contracture, suggesting that this condition in DM is
`moderate, rarely requiring surgical intervention. Patients
`with DM generally have a higher prevalence of carpal tunnel
`syndrome, probably because of an increased susceptibility of
`the nerve to compression, but carpal tunnel syndrome and
`trigger fingers were infrequent; only a few patients had
`undergone surgery for any of these conditions. Our patients
`had type 2 DM and, unlike those with type 1 DM, may not
`confer an increased vulnerability to compression. Patients
`with long-term DM had a significantly higher HbAlc and a
`higher frequency of Dupuytren's contracture, reflecting the
`importance of duration of diabetes and severity of hypergly(cid:173)
`cemia (Gamstedt et al., 1993)-a factor also important for
`vibrotactile sense in the lower extremity (Bergenheim,
`Borssen, & Lithner, 1992) and in finger pulps (Gregersen,
`1968). A novel finding was that subjects with IGT, in spite of
`a low number of ADL problems, had an impaired range of
`motion in the sensitive proximal interphalangealjoints of the
`hands (prayer sign) but did not differ in any other parameter
`except for their having higher HbAlc. This indicates that
`moderate glucose dysmetabolism has influence on the
`musculoskeletal system, but not on the nervous system, in
`the upper limb, although neuropathy has been shown to exist
`in the legs of such individuals (Sumner, Sheth, Griffin,
`Comblath, & Polydefkis, 2003). Furthermore, HbAlc did
`not correlate with vibrotactile sense but correlated with
`impaired grip strength (Grippit), suggesting that a certain
`glucose level may induce muscle dysfunction. The glucose
`dysmetabolism, that is, level of HbAlc, correlated to the
`presence of Dupuytren's contracture and LJM. One may
`question if signs ofDupuytren's contracture in DM may be a
`separate entity compared to NGT. In the future, it would be
`interesting to investigate advanced glycation end products
`
`from tissues in well-defined cohorts to hopefully illuminate
`mechanism behind these findings.
`Reliable and validated well-known tests (Cederlund et al.,
`2003) were used to examine sensibility, dexterity, and grip
`strength to thoroughly evaluate any hand dysfunction to
`address deficiencies in previous research. Thus, previous
`studies have been limited as they have tested only muscle
`strength (Andersen, Poulsen, Mogensen, & Jakobsen, 1996;
`Cetinus et al., 2005). We did not find any impairment in
`muscle strength in DM, irrespective of duration, or in IGT,
`which is in contrast to DM patients of both genders with a
`short duration of disease (Cetinus et al., 2005). Our
`individuals were matched for age and gender ( all men),
`with no difference in other factors such as profession,
`dominant hand, or BMI (Eriksson & Lindgarde, 1990;
`Eriksson et al., 1994; Sundkvist et al., 2000), which might
`explain the similarity between our groups. Furthermore,
`although our patients with type 2 DM had signs oflarge fiber
`neuropathy, detected by an impaired vibrotactile sense, they
`did not differ in muscle strength in their hands (Andersen et
`al., 1996), as compared to IGT or NGT subjects. Further(cid:173)
`more, vibrotactile sense did not correlate to the measured
`muscle strength but correlated to SWF and s2PD, mainly on
`the right side, which we cannot explain. The important
`finding was that of impaired vibrotactile sense (present main
`marker of neuropathy) in all investigated fingers (areas
`innervated by the median and ulnar nerves) in patients with
`DM but not in those with IGT, which is suggestive of
`neuropathy in the former group. Also, the duration of DM
`influenced the presence ofneuropathy. Thus, examination of
`vibrotactile sense in finger pulps innervated by the median
`and ulnar nerves may be a good screening method for
`neuropathy in DM. Unfortunately, we have no electrophy(cid:173)
`siological data of all these patients. Neurophysiological signs
`of neuropathy are important to detect. The task for future
`research is to compare our method with a gold standard
`(neurophysiology) for neuropathy. Cold intolerance, a
`common symptom after nerve injury, did exist in many
`individuals but did not differ between the groups, in contrast
`to previous reports in type 2 DM (Konen, Curtis, &
`Summerson, 1996).
`Surprisingly, although the type 2 DM patients had signs of
`neuropathy (i.e., impaired vibrotactile sense; de Wytt,
`Jackson, Hockings, Joyner, & Strakosch, 1999; Rahman
`et al., 2003; Stromberg et al., 1998), they did not experience
`increased ADL difficulties compared to those with NGT. SI
`or subjects with several fingers with a low SI (>0.8) did not
`correlate with ADL difficulties. In contrast, long-term DM
`had low SI and more ADL difficulties. Taken together, it
`indicates that the relation between vibrotactile sense and
`ADL performance is complex. Many of the men still lived
`with their wife, which may explain a diminution of ADL
`difficulties and limit any difference between groups.
`However, common problems, such as opening lids and
`packages, buttoning, climbing stairs, and taking long walks,
`occurred in individuals within all groups and occurred with
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`38
`
`R.l Cederlund et al. I Journal of Diabetes and Its Complications 23 (2009) 32-39
`
`greater frequency in those with long-duration DM (Gamstedt
`et al., 1993). Impairment of mobility and difficulties in ADL
`performance in elderly patients with type 2 DM have been
`reported in large community-based (Bruce et al., 2005) and
`national panel studies (Wray et al., 2005). We have no
`explanation of the lower number of ADL problems among
`IGT subjects, although we examined a smaller group of
`clinically well-controlled individuals with IGT and patients
`with DM. Future research may also direct against individual
`factors, such as if subjects that live with a wife/cohabitant
`and with good coping strategies may handle their DM better.
`Generally, our subjects scored high in life satisfaction
`without frequent anxiety (Konen et al., 1996). Minor sleep
`disturbances occurred, surprisingly more frequent in those
`with short-term DM (Sridhar & Madhu, 1994). Sleep
`disturbances may give rise to metabolic changes and are
`associated with an increased risk of developing type 2 DM
`(Kawakami, Takatsuka, & Shimizu, 2004; Nilsson, Roost,
`Engstrom, Hedblad, & Berglund, 2004), independent of
`other known risk factors for development ofDM, although a
`confounding effect of increased BMI has been reported
`(Ayas et al., 2003; Resnick et al., 2003). The present reported
`sleep disturbance in short-term DM had no impact on life
`satisfaction, which may reflect adaptation or that elderly men
`have other reasons for interrupted sleep.
`The clinical implications of our results are that type 2 DM
`confers on the patients' Dupuytren's contracture, LJM, and
`neuropathy (particularly impaired vibrotactile sense) in
`hands. These conditions generally do not impair ADL in
`short-term DM, thereby not requiring intervention (rehabi(cid:173)
`litation or hand surgery). However, long-term DM with
`higher HbAlc and neuropathies are associated with a higher
`frequency of ADL difficulties, which is why consultation for
`any further intervention should be considered. Strict glucose
`control, as a component in treatment and health control
`studies, seems crucial since IGT subjects only have few
`disorders (only LJM in finger joints) and minor ADL
`difficulties. Simple tests of sensibility, like monofilament
`tests, may be administered clinically, if tactilometry is not
`available, since they correlate to each other.
`In conclusion, in a well-defined population of elderly
`men, Type 2 DM, but not IGT, is associated with
`Dupuytren' s contracture and impaired vibrotactile sense
`(i.e., neuropathy), which correlated with SWF and s2PD in
`the finger pulps innervated by the median and ulnar nerves.
`Both DM and IGT subjects had a higher HbAlc than NGT
`subjects as well as LJM in finger joints (prayer sign),
`indicating the importance of glucose dysmetabolism. How(cid:173)
`ever, these abnormalities were not associated with ADL
`performance or life sa