Cheiroarthropathy in Type 1 Diabetes Common, Underappreciated

Miriam E. Tucker

June 24, 2013

CHICAGO — A group of musculoskeletal conditions including frozen shoulder and carpal-tunnel syndrome, collectively known as "cheiroarthropathy," is extremely common in people with longstanding type 1 diabetes and is an important source of functional disability in this population, new data from the Diabetes Control and Complications Trial (DCCT) indicate.

The findings were presented here at the American Diabetes Association (ADA) 2013 Scientific Sessions, in a special symposium commemorating the 30th anniversary of the launch of the landmark DCCT and its long-term follow-up study, the Epidemiology of Diabetes Interventions and Complications (EDIC). The major results from this were previously reported.

The full extent to which cheiroarthropathy affects those with type 1 diabetes had not been fully appreciated, said Mary E. Larkin, RN, MSN, CDE, assistant director of the Diabetes Research Center and EDIC study coordinator at Massachusetts General Hospital, Boston, who presented the new findings. These conditions are believed to be related to an accumulation of advanced glycosylation end products, she said

Detailed assessment of cheiroarthropathy was not part of the original EDIC plan, but investigators created an ancillary study for it in 2011 — year 18 of EDIC — after several study coordinators observed how often study subjects complained about the conditions, which also include flexor tenosynovitis ("trigger finger"), and a thickening of the hand tissues that causes joint flexion and results in the positive "prayer sign," in which patients are unable to place the palms of their hands flatly against one another.

"It's an underrecognized complication of type 1 diabetes," Ms. Larkin told Medscape Medical News, adding that physicians should be sure to ask patients with type 1 diabetes if they're suffering from any of these conditions. "It's definitely something that patients are concerned about, and I think it can be incorporated into regular diabetes care. Affected patients might benefit from referral for occupational hand therapy and/or orthopedic or rheumatology care."

EDIC co–principal investigator Bernard Zinman, MD, director of the Leadership Sinai Centre for Diabetes, Toronto, Ontario, agrees. He told Medscape Medical News: "Its impact in type 1 diabetes is much greater than we thought… We see patients all the time who complain of this, but we poo-poo it, because it's not blindness or kidney disease. The consequences of these conditions are not as dramatic as failing vision and amputation, but it affects quality of life," said Dr. Zinman,

Two Thirds of DCCT/EDIC Patients Had Cheiroarthropathy

Ms. Larkin presented data from a cross-sectional study of 1217 EDIC subjects who were available for analysis. In all, two thirds were found to have at least 1 of the 5 cheiroarthropathy conditions. A third of the total group had 1, 20% had 2, and 10% had 3 such complications. The most common was adhesive capsulitis ("frozen shoulder"), in 12%; carpal tunnel syndrome was seen in 8%; prayer sign and trigger finger in 6% each; and Dupuytren's contracture in 1%.

The research, believed to be the first of its kind to systematically assess cheiroarthropathy with objective measures, included a medical history, physical exam, and the use of goniometry to measure range of motion in the shoulder. Patients also filled out the 30-item validated Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).

Compared with the subjects who didn't have cheiroarthropathy, the 807 patients with the conditions were significantly older (52.3 vs 50.8 years, P = .002), were more commonly female (53% vs 38%, P < .0001), had longer duration of diabetes (31.2 vs 28.9 years, P < .0001), and had higher time-weighted HbA1c values over the course of DCCT/EDIC (8.0% vs 7.8%, P = .0004).

Cheiroarthropathy was also associated with the presence of retinopathy and neuropathy, but not nephropathy. There was no significant difference in cheiroarthropathy occurrence between the 2 original DCCT treatment groups (intensive vs conventional glycemic control), but the proportion of each type of cheiroarthropathy increased as HbA1c levels rose, Ms. Larkin noted.

On univariate analysis, cheiroarthropathy was most strongly associated with diabetes duration (odds ratio 2.80), retinopathy (2.19), and female gender (1.9).

Disability scores were significantly worse for those with cheiroarthropathy, as well as for women and those with higher HbA1c values (all P < .0001).

"Cheiro was associated with pain and functional limitation that can affect routine daily activities," Ms. Larkin noted. "Hopefully through the results of this study we'll raise the profile," she concluded.

Ms. Larkin has reported no relevant financial relationships. Dr. Zinman is a consultant for and/or receives research support from Abbott Diabetes Care, Amylin Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, Novo Nordisk, and Merck.

American Diabetes Association (ADA) 2013 Scientific Sessions. DCCT/EDIC 30th Anniversary Symposium-Contributions and Progress, presented June 22, 2013.

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