Prevalence of Musculoskeletal Disorders in Type 2 Diabetes Mellitus

most commonly occurring type that affects obese persons or who have family history of diabetes. Several musculoskeletal disorders are associated with type 2 diabetes. This study was intended to check the prevalence of musculoskeletal disorders in type 2 diabetes mellitus. For this purpose, a descriptive cross-sectional study was conducted in the general population of Abbottabad. A total of 250 subjects of age group 30-90 years. Participants were asked to fill a self-administered questionnaire containing demographics and other questions which included levels of hyperglycemia, pain and its common site, muscle cramps and abnormal sensations. Other questions were about difficulty in getting in and out of chair, opening medicine bottle or jar, bending or kneeling, walking and problems with dressing, eating, bathing or other personal care. All these questions were answered on a 5 points scale. The study employed convenient sampling technique and data was further analyzed using SPSS version 20. According to the results; all patients experienced pain. 24% had no difficulty getting in and out of chair and 4.4% were unable to do. 42.8% participants had no difficulty in opening bottle or jar while 1.6% are unable to do. 13.2% participants had no difficulty in bending or kneeling and 8.4% patients were unable to bend or kneel. 44.8% participants had no difficulty in walking, only 1.6% patients were unable to walk. 19.6% participants were not at all bothered by back problem and 5.6% were extremely bothered by back problem. 45.2% participants were not at all bothered by problems with dressing, eating, bathing or other personal care and 1.2% were extremely bothered. 32.4% were not at all bothered by pain and stiffness and only 2% were extremely bothered. Thus, it was concluded that MSK disorders among diabetics result in pain and disability. Most of the patients were suffering from low back pain and were unable to bend or kneel. Abstract


Introduction
Type II diabetes is characterized by decreased insulin secretion or insulin resistance in the body. This type comprises 80% to 90% of all cases of DM. It is the most commonly occurring type that affects obese persons or those who have a family history of diabetes. It is most common in women than in men (1). Several musculoskeletal disorders are associated with diabetes. These disorders depend on age and duration of diabetes. Diagnosis is based on clinical as well as radiological examination (2). Diabetes Mellitus causes changes in articular and peri-articular structures. Musculoskeletal disorders in diabetes are divided into three categories: (1) Disorders that cause complications of diabetes, for example, decreased joint mobility or diabetic arthropathy, stiff hand syndrome and muscular infarction.
(2) Incidence of increased disorders among people with diabetes, for example, Dupuytren's disease, adhesive capsulitis, neuropathic arthropathy, osteopenia, polymyositis, flexor tenosynovitis, septic Type II diabetes is characterized by decreased insulin secretion or insulin resistance in the body. It is the most commonly occurring type that affects obese persons or who have family history of diabetes. Several musculoskeletal disorders are associated with type 2 diabetes. This study was intended to check the prevalence of musculoskeletal disorders in type 2 diabetes mellitus. For this purpose, a descriptive cross-sectional study was conducted in the general population of Abbottabad. A total of 250 subjects of age group 30-90 years. Participants were asked to fill a self-administered questionnaire containing demographics and other questions which included levels of hyperglycemia, pain and its common site, muscle cramps and abnormal sensations. Other questions were about difficulty in getting in and out of chair, opening medicine bottle or jar, bending or kneeling, walking and problems with dressing, eating, bathing or other personal care. All these questions were answered on a 5 points scale. The study employed convenient sampling technique and data was further analyzed using SPSS version 20. According to the results; all patients experienced pain. 24% had no difficulty getting in and out of chair and 4.4% were unable to do. 42.8% participants had no difficulty in opening bottle or jar while 1.6% are unable to do. 13.2% participants had no difficulty in bending or kneeling and 8.4% patients were unable to bend or kneel. 44.8% participants had no difficulty in walking, only 1.6% patients were unable to walk. 19.6% participants were not at all bothered by back problem and 5.6% were extremely bothered by back problem. 45.2% participants were not at all bothered by problems with dressing, eating, bathing or other personal care and 1.2% were extremely bothered. 32.4% were not at all bothered by pain and stiffness and only 2% were extremely bothered. Thus, it was concluded that MSK disorders among diabetics result in pain and disability. Most of the patients were suffering from low back pain and were unable to bend or kneel.
(3) Disorders that have a possible association with diabetes but are not proven, for example, osteoarthritis and carpal tunnel syndrome (3). Body-weight programs and exercises improve metabolic control more than exercise alone. Lifestyle modification combined with aerobic exercise shows effectiveness in managing metabolic control. Although studies have shown the positive effect of resistance training on hyperglycemia and metabolic control.. However, in moderately obese and sedentary type II diabetics, circuit-type resistance training seems more appropriate. Aerobic exercise is considered best for type II DM. Several studies have shown the effect of exercise on insulin sensitivity and control of hyperglycemia. In some published studies, the author suggests an optimal exercise program for type II diabetics. This program includes cardiorespiratory fitness, endurance and strength training programs. It involves a combination of resistance training and aerobic exercises (4).

Study Design
A descriptive and cross-sectional study was carried out on a general population of Abbottabad. A convenient sampling technique was used to draw the sample size. Inclusion criteria for participants were (a) Patients with Type II Diabetes, (b) age above 30 years, and (c) both genders. The exclusion criteria for samples were (a) type I diabetics, (2) patients with MSK impairments due to congenital disabilities and trauma, and (3) participants with an age below 30 years.

Sample Size
A sample size of 250 participants was deemed appropriate, calculated using the Raosoft online sample size calculator.

Ethical Considerations
The study was approved by the ethical review board of the Women's Institute of Rehabilitation Sciences, Abbottabad. Informed written consent was obtained from all participants willing to participate.

Data Collection Procedure
All the diabetic patients were screened. After finding their suitability per inclusion and exclusion criteria, they were requested to participate in the study. Informed written consent was taken from the subjects. The primary questionnaire was implicated to them. The questionnaire contained close-ended questions. Data was successfully sought from 250 subjects.

Data Analysis
The data was entered and analyzed through SPSS version 20. Frequencies and percentages were calculated to determine the prevalence of musculoskeletal impairments in patients with type II diabetes mellitus. The bar charts, pie charts and tables were categorized for each variable. The association was found out by using the chi-square test in which the P-value of 0.05 depicted an insignificant correlation. Table 1 shows the distribution of participants concerning their ages. Group 1 (30-50 years), Group 2 (51-70 years), and Group 3 (71-90 years) and their respective percentages were 32%, 55.2% and 12.8%. Table 2 shows the gender of the participants. 101 were males, and 149 were females. Fig 1 shows the age of diagnosis of patients with type 2 DM. Out of 250 subjects, 29.60% were included in Group 1 (30-40 years), 32.40% were in Group 2 (41-50 years), 24% were in Group 3 (51-60 years) and 14% in group 4 (61-70 years). Fig. 2 shows the level of hyperglycemia in different groups; Group 1 (150-250 mg/dl), Group 2 (251-400 mg/dl) and Group 3 (above 400 mg/dl). 51.2% of participants were in group 1, 42.4% in group 2 and 6.4% in group 3. Fig. 3 shows that 33.6% of participants exercise regularly and 66.4% didn't. Fig.  4 shows that all participants experienced pain in their bodies. Fig. 5 shows that 65.2% of diabetics had abnormal sensations in their bodies, while 34.8% of patients had no abnormal sensations. Table No 3 shows that 41.6% people with diabetes had muscle cramps, and 58.4% had not reported any muscle cramps. Table 4 shows three groups of patients having a common site of pain. 28% of participants experienced pain in the upper limb, 47.6% in the lower limb and 24.4% in spine (mainly lower back). Fig  had hyperglycemia level 251-400 mg/dl and 1.6% had hyperglycemia level above 400 mg/dl. 1.6% of subjects were unable to walk. Among them, 0.8% had hyperglycemia level 251-400 mg/dl, and 0.8% had hyperglycemia levels above 400 mg/dl. Pearson Chi-Square test.1 was applied to show an association between the level of hyperglycemia and a common site of pain. The p value obtained was .245, which revealed no significant association. Another association was found between the level of hyperglycemia and difficulty getting in and out of a chair employing the Pearson Chi-Square test.2. Pvalue obtained was .000, which was less than .05. It is concluded that there is a significant association between the level of hyperglycemia and difficulty getting in and out of the chair.

Discussion
According to the results of this study, all patients were suffering from pain. So it can be concluded that MSK pain was more common in type 2 diabetics than any other disorder. The rheumatological manifestations were more common among females. Roy A. (2013) conducted a study on 100 participants (N=100). In his study, he concluded that diabetic patients who have musculoskeletal disorders were 76% and 24% of patients don't have these disorders. The mean age of 100 participants was 45.19 years. Among 100 diabetic patients, 75% suffered from musculoskeletal disorders and the 25% were pain-free. The severity of pain was such that 2% of patients had mild pain, 67% had moderate pain and 7% had severe pain. The pattern of musculoskeletal disorders was that 8% of patients had swelling, 2% had stiff joints, 10% had muscle weakness, arthritis was present in 5% of patients, tendinitis in 5% of diabetics, frozen shoulder in 8% and movement limitations in 38% diabetics.
Results of the diagnosed musculoskeletal problems were that 8% were suffering from frozen shoulder, 11% had osteoarthritis, 8% had rheumatoid arthritis, 1% had ankylosing spondylitis, 4% had carpal tunnel syndrome, neck pain was present in 27% patients, 8% had other musculoskeletal problems and 24% had no problem (2). In this study, out of 250 subjects, 40.40% (101) were males and 50.60% (149) were females. All patients were suffering from pain, the most common pain site was lower limbs (47.6%

Conclusion and Recommendations
Based on study findings, it has been concluded that the prevalence of MSK disorders was common in all subjects suffering from type II DM. Females were affected more. The most common site of pain was the lower limbs. Most of the diabetic subjects had moderate difficulty in getting in and out of the chair. Difficulty in opening medicine bottle and difficulty in walking was not reported by most of the diabetic subjects included in this study. Most of the patients with DM type II could perform eating, dressing, bathing and other personal hygiene activities without being bothered. Subjects with high levels of hyperglycemia had more difficulty in performing daily activities. Therefore, in order to prevent and treat these disorders, it is important to control glucose level, perform physiotherapy exercises which can be achieved through diabetes awareness campaigns and seminars.

Conflict of Interest
There is no conflict of interest.