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Prevalence and consequences of musculoskeletal pain in the upper and lower extremities: A cross-sectional analysis of patients with type 1 and type 2 diabetes in Denmark
Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, DenmarkCentre for Evidence-Based Orthopaedics, Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
Department of Endocrinology, Odense University Hospital, Odense, DenmarkDepartment of Clinical Research, University of Southern Denmark, Odense, DenmarkOpen Patient Exploratory Network, University of Southern Denmark, Odense, Denmark
Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, DenmarkThe Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, DenmarkDepartment of General Practice, Erasmus MC, Rotterdam, the Netherlands
Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, DenmarkChiropractic Knowledge Hub, Odense, Denmark
Pain in extremities is common in patients with type 1 and 2 diabetes from Denmark.
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Women report more pain than men, and shoulder pain shows the highest prevalence.
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Lower extremity pain is more common in type 2 diabetes than in type 1.
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One-half reported decreased physical activity, and one-third sought care within a year.
Abstract
Aims
To describe the one-week and 12-month prevalence of musculoskeletal pain in the upper and lower extremities and consequences in relation to care seeking, leisure time activity, and work life in patients with type 1 and 2 diabetes.
Methods
A cross-sectional survey including adults diagnosed with type 1 and 2 diabetes from two Danish secondary care databases. Questions covered pain prevalence (shoulder, elbow, hand, hip, knee, ankle) and its consequences based on the Standardised Nordic Questionnaire. Data was presented using proportions (95 % confidence intervals).
Results
The analysis included 3767 patients. The one-week prevalence was 9.3–30.8 % and 12-month prevalence 13.9–41.8 %, highest for shoulder pain (30.8–41.8 %). The prevalence was similar between type 1 and 2 diabetes for the upper extremity, but higher in type 2 for the lower extremity. Women had a higher pain prevalence for any joint for both diabetes types, while estimates did not vary between age groups (<60 or ≥60 years). More than half of the patients had reduced their activities at work or leisure time, and more than one-third had sought care during the past year because of pain.
Conclusions
Musculoskeletal pain in the upper and lower extremities is common in patients with type 1 and 2 diabetes from Denmark, with considerable consequences for work and leisure activities.
One in 10 adults, 537 million people worldwide, are living with diabetes, a chronic disease characterised by high blood glucose levels, associated with several complications and responsible for 6.7 million deaths in 2021 [
]. Diabetes is associated with a range of common musculoskeletal (MSK) conditions such as osteoarthritis, osteoporosis, neuropathy, and rheumatoid arthritis [
]. Known less common rheumatologic disorders associated with diabetes are stiff hand syndrome, Dupuytren’s contracture, adhesive capsulitis, trigger finger, carpal tunnel syndrome, diffuse idiopathic skeletal hyperostosis, Charcot arthropathy, and generally reduced joint mobility [
]. Less known, however, is whether patients with diabetes also suffer from more common non-specific and regional pain syndromes that are endemic in the population. In Denmark, 56.4–57.3 % of the general population report MSK pain during the past 14 days, and patients with diabetes report MSK pain more frequently [
]. However, these previous studies reporting on MSK pain in patients with diabetes are either small, do not differentiate between diabetes types, or do not report on specific pain sites [
]. Preliminary evidence suggests that MSK pain is not a trivial complaint in patients with diabetes because it may complicate the patient’s progress and translates into a higher healthcare load and treatment burden [
Therefore, this study aims to describe the prevalence and characteristics of pain in the upper extremity (shoulder, elbow, hand) and lower extremity (hip, knee, ankle) in patients with type 1 and 2 diabetes from two diabetes care centres in the Region of Southern Denmark. Secondly, describe the consequences of MSK pain on care-seeking and physical activity at work and during leisure time.
2. Method
2.1 Study design
This is a cross-sectional survey based on two large clinical diabetes cohorts in the Region of Southern Denmark, Denmark. The reporting adheres to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cross-sectional studies (STROBE).
2.2 Population
Patients ≥ 18 years of age diagnosed with type 1 and 2 diabetes and registered in two large Danish hospitals (Hospital South West Jutland and Odense University Hospital) were invited to participate. This cohort has been described in detail elsewhere [
A survey was distributed through Odense Patient Exploratory Network (OPEN) via the official Danish electronic mail distribution system (e-Boks), established in 2014 and used by 91.7 % of Danish residents for their secured digital mail. Responses were captured using a REDCap database. The questionnaire consisted of the Standardised Nordic Questionnaire [
] and questions about education, occupation, physical job exposures, and physical activity at work and during leisure time. The Standardised Nordic Questionnaire has two sections [
]. Section 1 has 40 items identifying body regions causing MSK problems. Completion is aided by a body map illustrating the nine symptom sites, i.e. neck, shoulders, upper back, elbows, low back, wrist/hands, hips, knees and ankles/feet. Respondents are asked if they have had any pain/trouble at the specific sites during the past 12 months and the past seven days which has interfered with their normal activity [
]. Section 2 consists of 25 questions that elicit any accidents affecting each area, functional impact at home and work (change of job or duties), duration of the problem, and seeking care (assessments and treatments by a health professional) [
]. Additional information was collected from the diabetes registries, including diabetes type, gender, age, and BMI. Further details about the data collection have been described elsewhere [
The Danish Board of Health and the Danish Patient Safety Authority approved access to the two clinical cohorts (file 3–30132031/1). All participants provided informed consent to participate in the study. The study was conducted according to the Declaration of Helsinki.
2.4 Variables
Age and gender: Statistics Denmark generated the age and sex of everyone in the sample frame before scrambling the CPR number.
Type of diabetes: The Danish National Patient Register records all hospital, emergency room, and ambulatory secondary care clinic encounters. Using the last discharge diagnosis recorded in the register, the diabetes type was determined using the ICD10 codes: E10.XX for type 1 diabetes, E.11.XX for type 2, E13.XX for secondary diabetes and E14.XX for unspecified diabetes. The quality of the register is high, and the level of incorrect discharge diagnosis is below 3 % [
Participant characteristics were presented using n (proportion). The prevalence of MSK pain was presented using n (proportion) with a 95 % Confidence Interval (CI). The prevalence of pain in the six different body regions (shoulder, elbow, hand, hip, knee, ankle) was estimated separately for type 1 and 2 diabetes and presented by gender (men or women) and age (< 60 or ≥ 60 years). Type 1 Diabetes and secondary diabetes were pooled, and unspecified diabetes was excluded from this analysis. The consequences of pain in the six body regions were estimated using n (proportion) with a 95 % CI and presented separately for diabetes type 1 and 2 and combined. Non-response for questions (i.e., empty cells) was considered a negative answer (i.e. not having pain). Stata (StataCorp LLC, Texas, USA) version 17.0 was used for the statistical analyses.
3. Results
The questionnaire was distributed to 10582 patients with diabetes with a 36.0 % response rate, and data from 3767 patients were included in the analysis (Fig. 1). Men accounted for 59.8 % of the patients, and most of the patients were between 51 and 70 years (Table 1) [
3.1 Prevalence of musculoskeletal pain in the upper and lower extremities
Musculoskeletal pain in the upper and lower extremities was common in patients with diabetes, with the only major difference between those with type 1 and type 2 diabetes being a generally higher prevalence of lower extremity pain in type 2 diabetes (Table 2). The one-week prevalence ranged from 9.3 % (elbow) to 30.8 % (shoulder) (type 1) and 9.9 % (elbow) to 30.5 % (shoulder) (type 2), while 41.8 % and 40.5 % of patients with type 1 and type 2 diabetes reported shoulder pain the past year, respectively (Table 2). The prevalence was consistently higher in women than men for all body regions (Table 2). Minor differences between age groups were found, with prevalence in type 1 being somewhat lower in patients ≥ 60 years for the elbow (past 12 months 11.6 % vs 14.9 %) and higher for the hip (past 12 months 25.1 % vs 19.6 %) and ankle (past seven days 29.9 % vs 20.7 %, and past 12 months 33.1 % vs 28.0 %) (Table 2). The prevalence of pain in type 2 was lower for the upper extremity in patients ≥ 60 years except for the hand (past seven days), while for the lower extremity, it was higher for the hip (past 12 months) and hand (past seven days), and lower for the knee (past 12 months) (Table 2). The prevalence of pain was generally higher in type 2 diabetes compared with type 1 for age subgroups (< 60 years or ≥ 60 years) (Table 2), but only for the lower extremity proportions for the total group (Table 2). Of all patients, 56.3–71.6 % reported having pain for more than 30 days within the past year, and slightly more patients with type 2 diabetes reported more than 30 days of MSK pain in the upper and lower extremities compared to those with type 1 (Table 3).
Table 2Prevalence of pain in the upper and lower extremities in patients with type 1 and 2 diabetes by gender and age.
Men
Women
< 60 years
60 years or above
Total
Body region
n (%, 95 % CI)
n (%, 95 % CI)
n (%, 95 % CI)
n (%, 95 % CI)
n (%, 95 % CI)
Diabetes type 1
(n = 889)
(n = 737)
(n = 1125)
(n = 501)
(n = 1626)
Shoulder
Past 12 months
335 (37.7, 34.6; 40.9)
345 (46.8, 43.2; 50.4)
475 (42.2, 39.4; 45.1)
205 (40.9, 36.7; 45.23)
680 (41.8, 39.4; 44.2)
Past seven days
237 (26.7, 23.9; 29.7)
263 (35.7, 32.3; 39.2)
345 (30.7, 28.0; 33.4)
155 (30.9, 27.0; 35.1)
500 (30.8, 28.6; 33.0)
Elbow
Past 12 months
103 (11.6, 9,6; 13.9)
123 (16.7, 14.2; 19.6)
168 (14.9, 13.0; 17.1)
58 (11.6, 9.1; 14.7)
226 (13.9, 12.3; 15.7)
Past seven days
69 (7.8, 6.2; 9.7)
83 (11.2, 9.1; 13.7)
109 (9.7, 8.1; 11.6)
43 (8.6, 6.4; 11.4)
152 (9.3, 8.0; 10.9)
Hand
Past 12 months
222 (25.0, 22.2; 28.0)
301 (40.8, 37.3; 44.4)
359 (31.9, 29.2; 34.7)
164 (32.7, 28.8; 37.0)
523 (32.2, 29.9; 34.5)
Past seven days
155 (17.4, 15.1; 20.1)
219 (29.7, 26.5; 33.1)
255 (22.7, 20.3; 25.2)
119 (23.8, 20.2; 27.7)
374 (23.0, 21.0; 25.1)
Hip
Past 12 months
149 (16.8, 14.4; 19.3)
197 (26.7, 23.7; 30.0)
220 (19.6, 17.3; 22,0)
126 (25.1, 21.5; 29.1)
346 (21.3, 19.4; 23.3)
Past seven days
106 (11.9, 10,0; 14.2)
134 (18.2, 15.6; 21.1)
159 (14.1, 12.2; 16.3)
81 (16.1, 13.2; 19.7)
240 (14.8, 13.1; 16.5)
Knee
Past 12 months
261 (29.4, 26.5; 32.4)
262 (35.5, 32.12; 39.1)
352 (31.2, 28.6; 34.0)
171 (34.1, 30.1; 38.4)
523 (32.2, 29.9; 34.5)
Past seven days
176 (19.8, 17.3; 22.5)
166 (22.5, 19.6; 25.7)
229 (20.3, 18.1; 22.8)
113 (22.6, 19.1; 26.4)
342 (21.0, 19.1; 23.1)
Ankle
Past 12 months
234 (26.3, 23.5; 29.3)
247 (33.5, 30.2; 37.0)
315 (28.0, 25.5; 30.7)
166 (33.1, 29.1; 37.4)
481 (29.6, 27.4; 31.8)
Past seven days
171 (19.2, 16.8; 22,0)
197 (26.7, 23.7; 30.0)
233 (20.7, 18.4; 23.2)
135 (26.9, 23.2; 31.0)
368 (22.6, 20.7; 24.7)
Diabetes type 2
(n = 1364)
(n = 777)
(n = 859)
(n = 1282)
(n = 2141)
Shoulder
Past 12 months
510 (37.4, 34.9; 40.0)
357 (45.9, 42.5; 49.5)
397 (46.2, 43,0; 49.6)
470 (36.7, 34.0; 39.3)
867 (40.5, 38.4; 42.6)
Past seven days
378 (27.7, 25.4; 30.2)
275 (35.4, 32.1; 38.8)
287 (33.4, 30.3; 36.6)
366 (28.5, 26.1; 31.0)
653 (30.5, 28.6; 32.5)
Elbow
Past 12 months
159 (11.7, 10.0; 13.5)
143 (18.4, 15.8; 21.3)
154 (17.9, 15.5; 20.6)
148 (11.5, 9.9; 13.4)
302 (14.1, 12.7; 15.6)
Past seven days
108 (7.9, 6.6; 9.5)
104 (13.4, 11.2; 16.0)
109 (12.7, 10.6; 15.1)
103 (8.0, 6.7; 9.7)
212 (9.9, 8.7; 11.2)
Hand
Past 12 months
342 (25.1, 22.8; 27.4)
292 (37.6, 34.2; 41.0)
279 (32.5, 29.4; 35.7)
355 (27.7, 25.3; 30.2)
634 (29.6, 27.7; 31.6)
Past seven days
253 (18.5, 16.6; 20.7)
217 (27.9, 24.8; 31.1)
194 (22.6, 20.0; 25.5)
276 (21.5, 19.4; 23.9)
470 (22.0, 20.2; 23.8)
Hip
Past 12 months
342 (25.1, 22.8; 27.4)
276 (35.6, 32.2; 39.0)
232 (27.0, 24.1; 30.0)
386 (30.1, 27.7; 32.7)
618 (28.9, 27,0; 30.8)
Past seven days
252 (18.4, 16.5; 20.6)
210 (27.0, 24.0; 30.2)
168 (19.6, 17.0; 22.3)
294 (22.9, 20.7; 25.3)
462 (21.6, 19.9; 23.4)
Knee
Past 12 months
505 (37.0, 34.5; 39.6)
357 (45.9, 42.5; 49.5)
366 (42.6, 39.3; 45.9)
496 (38.6, 36.1; 41.4)
862 (40.3, 38.2; 42.4)
Past seven days
358 (26.2, 24.0; 28.6)
245 (31.5, 28.3; 34.8)
251 (29.2, 26.3; 32.4)
352 (27.5, 25.1; 30.0)
603 (28.2, 26.3; 30.1)
Ankle
Past 12 months
485 (35.6, 33.1; 38.1)
331 (42.6, 39.2; 46.1)
325 (37.8, 34,6; 41.1)
491 (38.3, 35.7; 41,1)
816 (38.1, 36.0; 40.2)
Past seven days
385 (28.2, 25.9; 30.7)
254 (32.7, 29.5; 36.1)
238 (27.7, 24.8; 30.8)
401 (31.3, 28.8; 33.9)
639 (29.8, 28,0; 31.8)
Abbreviations: n, number of patients; CI, Confidence Interval. In Table, non-response was considered as no pain.
Musculoskeletal pain in the upper and lower extremities considerably impacted leisure time, work, and care-seeking behaviour (Table 3). Approximately one-third of all patients reported having sought care within the past year, with the highest prevalence for the shoulder (44.4 %) and lowest for the knee (25.7 %). One of four reported change of work tasks because of pain, and the same proportion reported being unable to work due to pain for more than 30 days in the past year (Table 3). Further, the prevalence of reduced leisure activity the past year was higher for type 2 compared to type 1 for the lower extremity (62.5–68.3 % vs 56.5–58.9 %) and for seeking care for the knee (27.5 % vs 22.9 %) (Table 3). Change of work tasks was higher for type 1 for the hand and type 2 for the knee. Generally, more patients with type 2 reported being unable to work the past year for more than 30 days across all body regions.
4. Discussion
MSK pain was common in patients with type 1 and 2 diabetes from two diabetes centres in the Region of Southern Denmark, with shoulder pain having the highest prevalence, and lower extremity pain being more common in diabetes type 2 as compared to type 1. More women than men reported pain, but age had relatively little influence. MSK pain considerably impacted patients´ leisure time and work life. A slightly larger proportion of patients with type 2 diabetes experienced consequences of pain in daily activity, care-seeking, and work life.
Patients with diabetes report a considerably higher prevalence of MSK pain in the upper and lower extremities than the general Danish population. In a nationally representative sample of the Danish population aged 16 and older, the overall pain prevalence during the past 14 days ranged between 2.8 % and 12.8 % for the upper extremity versus 9.3–30.8 % in our study and 5.4–9.8 for the lower extremity vs 14.8–29.8 % in our study [
]. Similar to our findings, the shoulder had the highest pain prevalence in the extremities in the general population, and a higher proportion of women reported MSK pain compared with men [
]. Another Danish survey study (n = 951) using a different questionnaire (Danish Health and Morbidity Survey 2005 Questionnaire) and pain definition (Yes, very bothered; Yes, bothered a little; or No) also found that MSK pain (pain in the shoulder and neck; pain in the arm, hand, knee and/or hip) in type 2 diabetes was significantly higher compared with age, gender, and region matched controls [
] found the association between type 2 diabetes and back pain was non-significant after adjusting for MSK risk factors but remained for hip and neck/shoulder pain. Despite different methodologies and patient selection, our findings add to the growing evidence that patients with diabetes have high prevalence of MSK pain, highlighting a significant clinical problem that needs to be addressed - because being physically active is a cornerstone in the treatment of diabetes, but MSK pain may be an obstacle that needs assessment and adequate treatment to improve the possibility for being physically active [
A relatively high proportion of patients in our study reported that pain in the extremities influenced their ability to be physically active at work (ranging from 27.0 % to 33.9 % across body regions for the total group) and during leisure time (55.2–64.9 %), and many sought care (25.7–44.4 %), which is of concern. To our knowledge, few studies report the consequences of MSK pain in the upper and lower extremities in the general population. In a large Dutch study, approximately half of the patients with MSK pain reported care-seeking within the last 12 months, which is higher than the proportions found in this study [
]. On the other hand, 4.0–7.5 % of the population reported work leave > 30 days compared to our findings, where 18.2–26.7 % were prevented from working > 30 days during the last 12 months. Besides being a potential obstacle to physical activity, MSK pain can negatively impact multiple aspects of patient health, including sleep, cognitive processes and brain function, mood/mental health, cardiovascular health, and overall quality of life [
]. A patient with both diabetes and MSK pain (i.e. multimorbidity) has a greater risk of premature death, poorer function and quality of life, and increased healthcare utilisation [
]. However, recent promising initiatives for the global treatment of multimorbidity have the potential to benefit patients with diabetes and MSK pain in order to improve the self-care behaviours [
This study has some limitations. The response rate was 36.0 %, which is low but comparable with participation rates in surveys that have solely used e-Boks as their means of recruitment [
Self-protection strategies and health behaviour in patients with inflammatory rheumatic diseases during the COVID-19 pandemic: results and predictors in more than 12 000 patients with inflammatory rheumatic diseases followed in the Danish DANBIO registry.
Paper- or web-based questionnaire invitations as a method for data collection: cross-sectional comparative study of differences in response rate, completeness of data, and financial cost.
]. Since all patients were included from existing diabetes cohorts and not from the general population, we did not expect the proportion of type 1 and type 2 to represent the proportion of each type of diabetes in the general population (i.e., 85–95 % with type 2 and 5–15 % with type 1). Furthermore, a recent analysis on the same cohort [
] found non-responder bias (i.e., related to age, diabetes type, comorbidity burden, and socioeconomic status), meaning that our findings may be non-representative of Danish patients with diabetes. Non-response to questions was considered as no pain, a common and accepted approach in other Danish register-based studies such as the Danish Twin registry [
]. However, this is an important bias that could result in an underestimation of MSK pain in the current study. Furthermore, the patients were included from two of many Danish diabetes centres. However, our findings are important to determine the prevalence and consequences of MSK conditions in a secondary care diabetes population.
5. Conclusion
Pain in the upper and lower extremities is common in Danish patients with type 1 and 2 diabetes, with considerable impact on daily activity, care-seeking, and work life. A larger proportion of patients with type 2 diabetes than type 1 is affected by the consequences of pain. Future studies should investigate mechanisms behind the high co-occurrence of diabetes and MSK pain in the upper and lower extremities. Clinicians should be aware that patients with both diabetes and MSK may suffer from comorbidities that could benefit from adequate clinical management.
Funding
Odense University Hospital free research found funded the expenses related to study administration and expenses related to Statistics Denmark. The funder was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Dr Skou is currently funded by a grant from Region Zealand (Exercise First) and two grants from the European Union’s Horizon 2020 Research and Innovation Program, one from the European Research Council (MOBILIZE, grant agreement No 801790) and the other under grant agreement No 945377 (ESCAPE). All outside the submitted study.
Dr Hartvigsen has received multiple grants for research from Danish and International Grant Agencies, including the European Union, Danish Ministry of Science and Education, Danish Regions, National Institutes of Health (USA), and from charities, including the European Center for Chiropractic Research Excellence, and the IMK Foundation. All outside the submitted study.
Competing interest
The authors declare no conflicts of interest related to this work.
Acknowledgements
We want to acknowledge Amalie Frost Stammerjohan, who was responsible for assembling the electronic questionnaire booklet and conducting the pilot study. We want to acknowledge Claus Bogh Juhl, Department of Endocrinology, Hospital of Southwest Jutland, and Jan Erik Henriksen, Steno Diabetes Center Odense, Odense University Hospital, for the data extraction through the clinical databases.
References
International Diabetes Federation. IDF Diabetes Atlas. 10th ed. Brussels, Belgium: International Diabetes Federation, 2021.
Self-protection strategies and health behaviour in patients with inflammatory rheumatic diseases during the COVID-19 pandemic: results and predictors in more than 12 000 patients with inflammatory rheumatic diseases followed in the Danish DANBIO registry.
Paper- or web-based questionnaire invitations as a method for data collection: cross-sectional comparative study of differences in response rate, completeness of data, and financial cost.
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