The Relationship of Hand Abnormalities to Diabetes and Diabetic Retinopathy

Lawson, P; Maneschi, F.; Kohner, E M

doi:10.2337/diacare.6.2.140

Cited by 75 publications

(47 citation statements)

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“…Limitation of motion may also occur secondary to microangiopathy or neuropathy (13). The reported prevalence of limited joint mobility ranges from 11% to 55% in patients with insulin-dependent diabetes mellitus (IDDM) (3-5, [14][15][16][17][18][19][20][21][22][23][24], from 30% to 70% in patients with non-insulindependent diabetes mellitus (18,21,23-25), and from 1% to 20% in nondiabetic subjects (3,17,19,21,23,24). These wide ranges in reported prevalence are due to differences among the studies in terms of population selection, assessment methodology, and definition of limited joint mobility.…”

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A quantitative assessment of limited joint mobility in patients with diabetes

Schulte

Roberts

Zimmerman

et al. 1993

Arthritis & Rheumatism

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Objective. The syndrome of limited joint mobility is a common but not widely recognized musculoskeletal complication of diabetes. The purpose of this study was to further characterize this syndrome using quantitative goniometric measures.Methods. Cross-sectional analysis of a sample population was performed to establish the prevalence, location, and severity of limited joint mobility and to determine its relationship to extraarticular manifestations and complications of diabetes. Passive range of motion of both upper extremities was measured by goniometry in 70 adult patients with insulin-dependent diabetes mellitus and 70 nondiabetic controls who were group-matched for age, sex, and general activity level. Joint mobility was assessed by both individual joint motions and a composite scoring technique. Results. Analysis of individual joints and composite scores revealed significant differences between dominant and nondominant extremities in both the control and the diabetic groups. Diabetic patients were generally less flexible than nondiabetic subjects throughout the arm, especially in shoulder and finger joints. In the full study population, multivariate analysis revealed that advanced age, male sex, and the presence of diabetes were associated with decreased passive range of motion for a majority of joints (P < 0.05). In the diabetes group, passive range of motion was significantly correlated (P < 0.05) with age, sex, duration of diabetes, and to a variable extent, glucose control, but was not correlated with the presence of clinically significant neuropathy, retinopathy, nephropathy, or peripheral vascular disease, with activity level, or with hand dominance. Stepwise regression analysis failed to identify single key joint motion(s) to serve as possible screening tests in predicting generalized limited joint mobility of the upper extremity. Finally, the effect of limb usage on range of motion in flexion may differ in diabetic and nondiabetic subjects.Conclusion. Limited joint mobility is a generalized phenomenon occurring throughout the upper extremities of many diabetic patients. It is significantly related to age, sex, and to a variable extent duration of diabetes and glucose control. It is not related to the standard complications of diabetes as defined in this study.

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confidence: 99%

A quantitative assessment of limited joint mobility in patients with diabetes

Schulte

Roberts

Zimmerman

et al. 1993

Arthritis & Rheumatism

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“…Rosenbloom concedes that there is a lack of relationship between collagen glycosylation and LJM, and presumably to thick skin. The statistical relationship described by Monnier [7] showed a correlation coefficient (r) between joint stiffness and skin collagen fluorescence of 0.34. This may have struggled to significant levels, but the measure of dependance of one variable on the other (r2), of 0.12, indicates that we must look elsewhere for causative association.…”

Section: The Skin In Diabetes Mellitusmentioning

confidence: 99%

“…The stable end-products of the non-enzymatic browning reaction which are thought to be responsible for increased cross-linking, packing, and stiffening of collagen are fluorescent. Monnier et al [6] demonstrated that fluorescence of skin collagen increased linearly with age, but that 95% of 41 Type 1 (insulin-dependent) diabetes patients had abnormal increases for age, and that the degree of skin collagen fluorescence correlated with the presence of retinopathy, nephropathy, and LJM.The suggestion that cautious interpretation of LJM is needed because of its frequency in the normal population is in reference to a study [7] in older patients, in whom age and occupation-related changes in the finger joints confound interpretation, as does the presence of Dupuytren contracture. This is most definitely not the case in the young patients originally and subsequently reported by numerous investigators.…”

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“…The suggestion that cautious interpretation of LJM is needed because of its frequency in the normal population is in reference to a study [7] in older patients, in whom age and occupation-related changes in the finger joints confound interpretation, as does the presence of Dupuytren contracture. This is most definitely not the case in the young patients originally and subsequently reported by numerous investigators.…”

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confidence: 99%

“…The suggestion that this is simply a duration effect has been made without comparisons to duration-matched control subjects nor the application of statistical methods to determine the interaction of duration with other factors [13]. In older patients, particularly those with Type 2 (non-insulin dependent) diabetes, the association of LJM and microvascular disease, although significant, is less striking [7,[15][16][17]. …”

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Diabetic thick skin and stiff joints

Rosenbloom

1989

Diabetologia

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In their review, Goodfield and Millard [1] list this condition under the rubric "Cutaneous features of vascular insufficiency", and term it "cheiro-arthropathy". They indicate that enthusiastic use of the test involving approximation of the palmar surfaces of the fingers leads to detection of abnormalities in many normal people, that the joint stiffness in the fingers is a result of stiffness of the skin, and that the lack of correlation with non-enzymatic glycosylation indicates that the browning reaction is not causal. Furthermore, they suggest that the association of limited joint mobility (LJM) with chronic complications may simply reflect the fact that all of these features are more likely in those with longer duration and poorer diabetes control. None of these notions is supportable, including the classification and terminology.Firstly, considering the syndrome of LJM, particularly as it occurs in young patients [2], to be a result of cutaneous vascular insufficiency has no experimental basis. Biopsy study of the associated skin changes shows thickening of the dermis and epidermis with accumulation of collagen and loss of skin appendages, compared to control biopsies [3,4]. Biochemical study does, indeed, fail to show that skin collagen glycosylation correlates with LJM [5,6] or with microvascular complications [6]. Skin collagen glycosylation does, however, correlate with HbA1 levels, reflecting the ketoamine link, an early step in the non-enzymatic browning reaction. Thus, glycosylation in the skin simply reflects recent diabetic control and not long-standing processes that would lead to abnormalities in the connective tissue. The stable end-products of the non-enzymatic browning reaction which are thought to be responsible for increased cross-linking, packing, and stiffening of collagen are fluorescent. Monnier et al. [6] demonstrated that fluorescence of skin collagen increased linearly with age, but that 95% of 41 Type 1 (insulin-dependent) diabetes patients had abnormal increases for age, and that the degree of skin collagen fluorescence correlated with the presence of retinopathy, nephropathy, and LJM.The suggestion that cautious interpretation of LJM is needed because of its frequency in the normal population is in reference to a study [7] in older patients, in whom age and occupation-related changes in the finger joints confound interpretation, as does the presence of Dupuytren contracture. This is most definitely not the case in the young patients originally and subsequently reported by numerous investigators. Control populations of patients under 25 have been found to have an absence of any detectible limitation using the same techniques applied to age-comparable young people with diabetes having frequencies of limitation in the 30% range [2].The authors suggest that LJM results from skin stiffness. This does not appear to be the case in youngsters with LJM, most of whom do not have clinically apparent thickened skin, but periarticular connective tissue thickening on radiographs and by palpati...

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