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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 13  |  Issue : 4  |  Page : 353-362

A study of musculoskeletal manifestations of diabetes mellitus and their association with HbA1C among diabetic patients


1 Department of General Medicine, ESIC MC & PGIMSR Model Hospital, Rajajinagar, Bangalore, India
2 Department of General Medicine, KLE JGMM Medical College, Hubballi, India
3 Department of Paediatrics, ESIC MC & PGIMSR Model Hospital, Rajajinagar, Bangalore, Karnataka, India

Date of Submission26-Aug-2022
Date of Decision23-Sep-2022
Date of Acceptance06-Oct-2022
Date of Web Publication21-Dec-2022

Correspondence Address:
Dr. Vaibhav S Bellary
Department of General Medicine, ESIC-PGIMSR Model Hospital, Plot No. 207, Sector 51, Saptagiri, BUDA, Laxmitek, Belgaum, Karnataka 590001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_91_22

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  Abstract 

Background: The prevalence of diabetes mellitus (DM) is increasing significantly throughout the world. While the vascular complications of diabetes are well recognized and account for the principle mortality and morbidity from the condition, the musculoskeletal manifestations of diabetes are common and not life-threatening, which are an important cause for morbidity, pain, and disability. The most common reported forms of various musculoskeletal manifestations of DM include adhesive capsulitis, hand syndromes such as limited joint mobility syndrome (LJMS), Dupuytren’s contracture (DC), and carpal tunnel syndrome (CTS), flexor tenosynovitis, reflex sympathetic dystrophy, diffuse idiopathic skeletal hyperostosis (DISH), Charcot’s joints, diabetic amyotrophy (DA), and osteoarthritis. Materials and Methods: The study was conducted on a total of 150 patients with type 2 DM for a duration of at least 5 years in Bangalore during the study period from January 2020 to June 2021. The patients fulfilling the inclusion criteria were enrolled for the study after obtaining informed consent. Detailed history was taken and general physical examination was done to determine the musculoskeletal manifestations of DM. The Disability of Arm Shoulder and Hand (DASH) questionnaire was also completed as per the patient’s responses. Laboratory reports were collected, data compiled, and the data were analyzed. Results: Of the 150 cases enrolled, the maximum number of cases belonged to the age group of 36–50 years. About 64% of the diabetic cases were suffering from musculoskeletal disorders (MSDs) (LMJS, CTS, shoulder capsulitis, DC, trigger finger, DISH, DA). Among the MSDs, the highest prevalence was by LJMS (28%). There was a positive correlation among the duration of diabetes, HbA1C, and the DASH score among patients with MSDs in this study and this is statistically significant (P < 0.05). We also see that MSDs are present in 72.7% of the females and 57.1% of the males in the study and this was statistically significant (P = 0.048). Conclusion: MSDs have a high prevalence in diabetic patients. With advancing age and uncontrolled HbA1C levels, the number of MSDs was more as well as the severity as indicated by the DASH score. Early and better glycemic control in diabetic patients can reduce the morbidity associated with MSDs as evidenced by the reduced intensity of DASH score in well-controlled patients.

Keywords: DASH score, diabetes mellitus, frozen shoulder, limited joint mobility syndrome, morbidity, musculoskeletal complications


How to cite this article:
Bellary VS, Shetty SN, Bellary SO, Rao NU. A study of musculoskeletal manifestations of diabetes mellitus and their association with HbA1C among diabetic patients. J Diabetol 2022;13:353-62

How to cite this URL:
Bellary VS, Shetty SN, Bellary SO, Rao NU. A study of musculoskeletal manifestations of diabetes mellitus and their association with HbA1C among diabetic patients. J Diabetol [serial online] 2022 [cited 2023 Feb 4];13:353-62. Available from: https://www.journalofdiabetology.org/text.asp?2022/13/4/353/364641




  Key Message: Top


The most debilitating complications of diabetes, which are the musculoskeletal disorders (MSDs), have to be screened for in every diabetic patient as the strict glycemic control in these diabetics early on can decrease the morbidity and significantly improve the quality of life and also decrease the economic burden created for the management and recovery from these MSDs.


  Introduction Top


Diabetes mellitus (DM) is one of the most common non-communicable diseases worldwide. It is the fourth leading cause of death in most developed countries and there is substantial evidence that it is an epidemic in many developing countries. India being the diabetic capital of the world, diabetes is said to be the silent killer of our country. One in 2 (232 million) people with diabetes are left undiagnosed.[1] The rising prevalence of diabetes and other non-communicable diseases is driven by a combination of factors like increasing use of tobacco and tobacco products, unhealthy diets (fast food), rapid urbanization, sedentary lifestyles, and increasing life expectancy due to improved healthcare facilities. The chronic complications of diabetes are broadly divided into microvascular and macrovascular, with the former having much higher prevalence than the latter.[2] Microvascular complications include neuropathy, nephropathy, and retinopathy, whereas macrovascular complications consist of cardiovascular disease, stroke, and peripheral artery disease. Finally, there are other complications of diabetes that cannot be classified in the above categories such as dental diseases, reduced resistance to infections, birth complications among women with gestational diabetes, and musculoskeletal conditions. Diabetic patients may suffer from a wide spectrum of musculoskeletal manifestations of DM itself, which can cause pain and dysfunction in the patients and affect the treatment negatively or reduce the quality of life. Although most of these conditions are also seen in non-DM cases, they are more frequently observed in DM patients but are not specific. End-organ damages are usually evaluated and the more hampering musculoskeletal manifestations are wavered off. Musculoskeletal disorders (MSDs) are the most common cause of severe long-term pain and physical disability, and they affect hundreds of millions of people around the world.[3] A diagnosis of musculoskeletal dysfunctions in the diabetic patients is made by detailed history and clinical examination. The most common reported forms of various musculoskeletal manifestations of DM include adhesive capsulitis, hand syndromes such as limited joint mobility syndrome (LJMS), Dupuytren’s contracture (DC), carpal tunnel syndrome (CTS), flexor tenosynovitis, reflex sympathetic dystrophy, diffuse idiopathic skeletal hyperostosis (DISH), Charcot’s joints, diabetic amyotrophy (DA), and osteoarthritis.[4],[5] Thus, this study demonstrates the co-relation of severity of DM and its duration with the musculoskeletal manifestations associated with it, which can worsen the quality of life and also the day-to-day activities, thus increasing morbidity and mortality.

Aims and objectives

  • 1. To estimate the proportion of type 2 diabetic patients suffering from musculoskeletal manifestations of DM.


  • 2. To describe the patterns of musculoskeletal manifestations among the type 2 diabetic patients.


  • 3. To determine the association of severity of musculoskeletal manifestations in upper limbs [based on Disability of Arm Shoulder and Hand (DASH) score] in type 2 diabetic patients with recent HbA1C levels.



  Materials and Methods Top


The present study was conducted in ESIC MC and PGIMSR hospital in Bengaluru, Karnataka, India. Ethical clearance for the study was obtained from the Institutional Ethics Committee [No. 532/L/11/12/Ethics/ESICMC&PGIMSR/Estt.Vol.IV].

The present study was carried out among 150 adult patients (18 years and above) with type 2 DM for a duration of at least 5 years who either attended the Medicine OPD or those who were admitted in the Medicine ward during the study period from January 2020 to June 2021 fulfilling the inclusion criteria. The patients fulfilling the inclusion criteria were enrolled for the study after obtaining informed consent. A thorough clinical evaluation was carried out and recorded in the protocol. For all patients included in the study, we recorded the following demographic features including age, sex, education, and occupation. We then obtained the following clinical information including type and duration of diabetes (in years) and HBA1C levels of patients. MSDs were assessed using a targeted medical history, standardized physical examination, and investigations. CTS was diagnosed on the basis of clinical symptoms such as pain and sensory disturbances in the thumb, index, middle, and outer half of the ring fingers. Diagnosis of shoulder capsulitis (SC) was based on the limitations of active and passive shoulder joint movements in all directions, especially rotational movements. LJMS was evaluated by the patient “Prayer sign.” The diagnosis of DC was based on one or more of the following four features on examination: a palmar or digital nodule, tethering of the palmar or digital skin, a pretendinous band, and a digital flexion contracture. Trigger finger (TF) was diagnosed by palpating a nodule or thickened flexor tendon with locking happening in extension and flexion of any finger. DISH was diagnosed when patients had symptoms or physical findings such as spinal stiffness and restricted motion of the thoracic spine and based on the presence of the characteristic radiographic findings, including flowing linear calcification and ossification along the anterolateral aspects of the vertebral bodies, most often affecting the thoracic spine. DA was diagnosed clinically after ruling out other causes as no definitive test exists for it as of now. Charcot neuroarthropathy was diagnosed with thorough history and physical examination when a patient presented with an acute erythematous, warm, or edematous foot, with or without any significant history of trauma or surgery, especially for patients with diabetes and peripheral neuropathy with these symptoms.

A questionnaire, namely DASH, was employed and scoring was done accordingly called as DASH score, with regard to the points tallied to the questions answered by the diabetic patient diagnosed with one or more of the above-mentioned MSDs associated with DM. To assess the severity of these MSDs, a scoring system called DASH score has been used. The DASH questionnaire is an upper-extremity specific outcome measure that was introduced by the American Academy of Orthopedic Surgeons in collaboration with a number of other organizations.[6] The DASH score is used to estimate the severity of the musculoskeletal manifestation of the upper limbs. The DASH score is calculated from a questionnaire which is a 30-item questionnaire that looks at the ability of a patient to perform certain upper extremity activities.[7],[8],[9] This questionnaire is a self-report questionnaire that patients can rate difficulty and interference with daily life on a 5-point Likert scale.[7],[8] The DASH can detect and differentiate small and large changes of disability over time after surgery in patients with upper-extremity musculoskeletal disorders.

Inclusion criteria

  • 1) Patients willing to give written informed consent;


  • 2) Adult patients (18 years and above) with type 2 DM with a duration of at least 5 years.


Exclusion criteria

  • 1) Patient not willing to give written informed consent;


  • 2) Diabetes in pregnancy, patients with cancer, and those undergoing chemotherapy;


  • 3) Neurological disorders such as stroke, multiple sclerosis, Guillain–Barré syndrome, and intracranial space-occupying lesions;


  • 4) Patients with prior deformities with various conditions, e.g., trauma;


  • 5) Patients with primary joint disease;


  • 6) Musculoskeletal manifestations of other conditions such as hypothyroidism;


  • 7) DM with acute complications such as diabetic ketoacidosis, shock, or acute renal failure.


Method of statistical analysis

  • The data were collected and entered into an Excel spreadsheet and analyzed using the software SPSS (Statistical Package for Social Sciences) version 20 [IBM SPSS Statistics (IBM Corp., Armonk, NY, USA, released 2011)].


  • Data were subjected to the normalcy test (Shapiro–Wilk test). Data showed non-normal distribution. Hence, non-parametric tests were applied.


  • Descriptive statistics of the explanatory and outcome variables were calculated by mean, standard deviation for quantitative variables, and frequency and proportions for qualitative variables.


  • Unpaired t-test was applied to test the mean difference between the groups with respect to duration of surgery.


  • Pearson’s correlation was calculated and scatter plots were drawn to calculate the correlation among duration of diabetes, HbA1C, and DASH score.


  • The level of significance was set at 5%.


      Results and Analysis Top


    A total of 150 patients were enrolled for the study. Of them, the maximum number of cases belonged to the age group of 36–50 years (46.7%), followed by 51–65 years (31.3%), then 66–80 years (16%), and finally >80 years (6%), as seen in [Table 1]. The mean age was 55.10 ± 13.407 years, as seen in [Table 1] and [Figure 1].
    Table 1: Distribution of patients by gender

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    Figure 1: Distribution of patients by age

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    [Table 2] and [Figure 2] depict the gender distribution of the 150 cases of which 56% were males and the rest 44% were females.
    Table 2: Distribution of patients by age

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    Figure 2: Distribution of patients by sex

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    Among the participants, 64% of the diabetic cases were suffering from MSDs, whereas 36% were devoid of these issues, as seen in [Table 3] and [Figure 3].
    Table 3: Diabetic patients with musculoskeletal manifestations

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    Figure 3: Diabetic patients with musculoskeletal manifestations

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    As depicted in [Table 4] and [Figure 4], we see that 2.7% of the cases had a total of three musculoskeletal manifestations of DM. Majority of these patients have at least one such manifestation (48.7%) and 12.7% of them had two MSDs.
    Table 4: Presence of musculoskeletal disorders

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    Figure 4: Presence of musculoskeletal manifestations

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    [Table 5] and [Figure 5] show us the distribution of these MSDs among the diabetic patients for a duration of at least 5 years. We found that the highest prevalence was for LJMS (28%), followed by frozen shoulder (12.7%), DC (12%), DISH (10%), CTS (%), TF (5.3%), Charcot’s joint (4%), and DA (2%), respectively, of the MSDs among the diabetic cases.
    Table 5: Prevalence of musculoskeletal manifestations in the study

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    Figure 5: Distribution of the musculoskeletal manifestations of diabetes mellitus

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    The mean age among the patients with MSDs was 58.91 ± 13.959 years and that among them without MSDs was 48.33 ± 9.122 years. The HbA1C levels were 8.52 ± 1.465 among those with MSDs and 6.76 ± 1.027 among those without MSDs. The DASH score was 53.48 ± 23.539 and 14.89 ± 22.617 among those with MSDs and without MSDs, respectively. All these were statistically significant with a P-value less than 0.05, as seen in [Table 6].
    Table 6: Association of musculoskeletal disorders with age, HbA1C, and DASH score

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    The mean age among the patients with LJMS was 62.21 ± 13.619 years and that among them without LJMS was 52.33 ± 12.314 years. The HbA1C levels were 8.81 ± 1.534 among those with LJMS and 7.53 ± 1.437 among those without LJMS. The DASH score was 56.88 ± 22.915 and 32.86 ± 29.361 among those with LJMS and without LJMS, respectively. All these were statistically significant with a P-value less than 0.05, as seen in [Table 7].
    Table 7: Association of limited joint mobility syndrome with age, HbA1C, and DASH score

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    In [Table 8], we see that the mean age of the patients with DC was 62.61 ± 13.630 years and those without DC was 54.08 ± 13.097 years. The HbA1C levels were 9.06 ± 1.305 and 7.73 ± 1.539 and the DASH scores were 63.11 ± 17.977 and 36.38 ± 29.551 among those with DC and without DC, respectively. These differences were statistically significant as P < 0.05.
    Table 8: Association of Dupuytren’s contracture with age, HbA1C, and DASH score

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    As depicted in [Table 9], we see that there is no significant association of TF with age, HbA1c levels, and DASH score. The mean age of patients with TF was 55.00 ± 19.332 years and without TF was 55.11 ± 13.092 years.
    Table 9: Association of trigger finger with age, HbA1C, and DASH score

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    There is no significant association of CTS with age, HbA1C levels, and DASH score in these patients, as shown in [Table 10]. The mean age of patients with CTS was 52.92 ± 11.285 years and in those without CTS was 55.29 ± 13.595 years.
    Table 10: Association of carpal tunnel syndrome with age, HbA1C, and DASH score

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    Here, we see that the DASH scores were 51.42 ± 21.001 among the patients with frozen shoulder and 37.87 ± 30.411 among the patients without frozen shoulder, as seen in [Table 11].
    Table 11: Association of frozen shoulder with age, HbA1C, and DASH score

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    The mean age among the patients with DISH and those without DISH was 62.07 ± 13.385 and 54.33 ± 13.244 years, and the HbA1C levels were 8.67 ± 1.676 and 7.80 ± 1.540 among the patients with and without DISH, respectively. This difference is statistically significant as P-value is less than 0.05, as seen in [Table 12].
    Table 12: Association of diffuse idiopathic skeletal hyperostosis with age, HbA1C, and DASH score

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    The mean age among the patients with and without Charcot’s joints was 74.17 ± 9.283 and 54.31 ± 12.977 years, respectively. The HbA1C levels were 9.83 ± 1.835 and 7.81 ± 1.511 among those with and without Charcot’s joint, respectively. The DASH score was 67 ± 24.576 among the patients with Charcot’s joint and 38.44 ± 29.387 among the patients without Charcot’s joint. All these were statistically significant, as shown in [Table 13].
    Table 13: Association of Charcot’s joint with age, HbA1C, and DASH score

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    The mean age was 72.33 ± 20.404 and 54.75 ± 13.097 years among the patients with DA and those without it, respectively, and this difference was statistically significant with a P-value of 0.024, as seen in [Table 14].
    Table 14: Association of diabetic amyotrophy with age, HbA1C, and DASH score

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    [Table 15] shows the positive correlation among the duration of diabetes, HbA1C, and the DASH score among patients with MSDs and this is statistically significant (P < 0.05).
    Table 15: Correlation of duration of diabetes, HbA1C, and DASH score in patients with musculoskeletal manifestations

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    Among the diabetic patients without MSDs, there was a positive correlation seen only between HbA1C levels and the DASH score, which was statistically significant (P = 0.000), as depicted in [Table 16].
    Table 16: Correlation of duration of diabetes, HbA1C, and DASH score in patients without musculoskeletal manifestations

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    [Figure 6] shows the association of DASH score with the duration of DM. [Figure 7] depicts the association of HbA1C with the duration of DM. [Figure 8] highlights the association of DASH score with HbA1C levels.
    Figure 6: Association of DASH score with duration of diabetes

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    Figure 7: Association of HbA1C with duration of diabetes

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    Figure 8: Association of DASH score with HbA1C

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    In [Table 17] and [Figure 9], we see that MSDs are present in 72.7% of the females and 57.1% of the males in the study, and this was statistically significant (P = 0.048).
    Table 17: Correlation of gender with musculoskeletal manifestation

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    Figure 9: Prevalence of musculoskeletal disorders in male and female cases

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    No significant correlation is seen between the sex of the patients and MSDs, as seen in [Table 18].
    Table 18: Comparison of male and female diabetic patients with musculoskeletal manifestations

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      Discussion Top


    In the present study, a total of 150 patients were enrolled and of them, the maximum number of cases belonged to the age group of 36–50 years (46.7%), followed by 51–65 years (31.3%), then 66–80 years (16%), and finally >80 years (6%). About 56% (84) of the total were males and the rest 44% (66) were females. We see that MSDs are present in 72.7% of the females and 57.1% of the males in the study, and this was statistically significant (P = 0.048). Among the participants, 64% of the diabetic cases were suffering from MSDs of which the highest prevalence was by LJMS (28%), followed by frozen shoulder (12.7%), Dupuytren’s contracture (12%), DISH (10%), CTS (%), TF (5.3%), Charcot’s joint (4%), and DA (2%) among the diabetic cases. Apruzzese and co-workers[10] concluded that 30% of patients with type 1/2 diabetes have some hand/shoulder diseases.

    In the present study, 2.7% of the cases had a total of three musculoskeletal manifestations of DM. Majority of these patients have at least one such manifestation (48.7%) and 12.7% of them had two MSDs. A study conducted by Arkkila and Gautier[11] concluded that increased incidence of DM life expectancy of diabetes patients leads to increased musculoskeletal impairments. Moren-Hybbinette et al.[12] conducted a study on 60 diabetic patients with shoulder pain in order to trace the natural history of the disease and concluded that the triad of painful shoulder, hand syndrome, and restricted hip joint mobility was strongly correlated with the duration of diabetes and retinopathy. A study conducted by Shah et al.[13] concluded that upper extremity impairments in the studied sample of patients with diabetes were common, severe, and related to complaints of pain and disability.

    The study yielded a positive correlation among the duration of diabetes, HbA1C, and the DASH score among the patients with MSDs and this is statistically significant (P < 0.05), i.e., a longer duration of diabetes had a higher HbA1C level as well as a higher DASH score. A positive correlation between DASH score and diabetic nephropathy, total body fat, and body fat percentage has been established by Tuzun and Bozirli[14] and also that DASH questionnaire is a useful instrument for measuring functional disability in upper extremity complaints of DM patients.

    Thus, we can conclude that patients with higher HbA1C levels, i.e., uncontrolled sugars, had a higher DASH score. These patients had more number of MSDs when compared with those with controlled sugars. As a result, these patients had significantly increased disability thus affecting their day-to-day activities as well as causing a significant reduction in quality of life and increasing the morbidity.

    Limitations

    The study is limited due to the small sample size and also that it is a single-center study.


      Conclusion Top


    MSDs have an increased prevalence in diabetic patients. Many of these disorders are treatable especially if diagnosed early on and can improve the quality of life by reducing the morbidity associated with these disorders. Diabetes must be considered as one of the differentials for any patient presenting with any of these MSDs. The examination of the locomotor system in diabetic patients plays a very important part as it yields significant information regarding any of these debilitating diseases. Thus, awareness, early detection, and prompt management of these musculoskeletal manifestations can significantly improve the quality of life as well as decrease the morbidity and mortality of these diabetic patients.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Ethical approval

    The present study was conducted in ESIC MC and PGIMSR Hospital in Bengaluru, Karnataka, India. Ethical clearance for the study was obtained from the Institutional Ethics Committee [No. 532/L/11/12/Ethics/ESICMC&PGIMSR/Estt.Vol.IV].



     
      References Top

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    Diabetes Facts and Figures [Internet]. International Diabetes Federation—Home. 2020. Available from: https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. [Last accessed on 30 Dec 2021].  Back to cited text no. 1
        
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    Deshpande AD, Harris-Hayes M, Schootman M Epidemiology of diabetes and diabetes-related complications. Phys Ther 2008;88:1254-64.  Back to cited text no. 2
        
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    Special Theme. Bone and joint decade 2000–2010. Bull World Health Organ 2003;81:646-56.  Back to cited text no. 3
        
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    Paul C The burden of musculoskeletal conditions at the start of the new millennium. Report of a WHO Scientific Group. Geneva: WHO Technical Report Series, 919, 2003, pp. 218. ISBN: 92-4-120919-4. Int J Epidemiol 2004;34:228-9.  Back to cited text no. 4
        
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    Smith LL, Burnet SP, McNeil JD Musculoskeletal manifestation of diabetes mellitus. Br J Sports Med 2003;17:945-70.  Back to cited text no. 5
        
    6.
    Hudak PL, Amadio PC, Bombardier C Development of an upper extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder and Hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602-8.  Back to cited text no. 6
        
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    The DASH outcome measure. Available from: http://www.dash.iwh.on.ca. [Last accessed on 15 Nov 2021].  Back to cited text no. 7
        
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    Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C Measuring the whole or the parts?: Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Therapy 2001;14:128-42.  Back to cited text no. 8
        
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    Beaton DE, Davis AM, Hudak P, McConnell S The DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure: What do we know about it now? Br J Hand Therapy 2001; 6:109-18.  Back to cited text no. 9
        
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    Cagliero E, Apruzzese W, Perlmutter GS, Nathan DM Musculoskeletal disorders of the hand and shoulder in patients with diabetes mellitus. Am J Med 2002;112:487-90.  Back to cited text no. 10
        
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    Arkkila PE, Gautier JF Musculoskeletal disorders in diabetes mellitus: An update. Best Pract Res Clin Rheumatol 2003;17:945-70.  Back to cited text no. 11
        
    12.
    Morén-Hybbinette I, Moritz U, Scherstén B The clinical picture of the painful diabetic shoulder--natural history, social consequences and analysis of concomitant hand syndrome [Internet]. Acta Medica Scandinavica. U.S. National Library of Medicine; 1987. Available from: https://pubmed.ncbi.nlm.nih.gov/2436441/. [Last accessed on 20 Oct 2022].  Back to cited text no. 12
        
    13.
    Shah KM, Clark BR, McGill JB, Mueller MJ Upper extremity impairments, pain and disability in patients with diabetes mellitus. Physiotherapy 2015;101:147-54.  Back to cited text no. 13
        
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    Tuzun DD, Bozirli ED Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and diabetic complications. Endocr Abstr 2015;1:22-31.  Back to cited text no. 14
        


        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18]



     

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