Deteriorating tactile sensation in patients with hand syndromes associated with diabetes: A two-year observational study

Abstract

Aims

To observe the natural history of hand function during a two-year period in participants with hand syndromes associated with diabetes and to determine factors related to changing function.

Methods

Hand function was measured over three annual visits using Disability of the Arm, Shoulder and Hand (DASH) and SF-36v2 questionnaires, grip strength, light touch and 9-hole peg tests. Light touch was tested with WEST monofilaments at 7 sites on the hand (score 35 to 0). Data were analyzed using repeated-measures ANOVA, Spearman's correlation, and Wilcoxon signed-rank tests.

Results

Participants (n = 60) were aged 61 ± 10.5 years, 57% female, diagnosed with diabetes and at least one of four associated hand disorders. Presentations of carpal tunnel syndrome, or past release (n = 27, 45%) and trigger finger (n = 24, 40%) were common. Tactile sensation was reduced during the two-year period (median, range; 30 months, 25–40 months). Initial median (inter-quartile range) scores for the dominant hand of 25.5 (22–28.5) were reduced to 23 (21.5–27). This sensory loss was weakly associated with HbA1c (r = 0.30, p = 0.05) and occurred predominantly in participants with trigger finger (p = 0.05).

Conclusions

Light touch perception was reduced in longstanding diabetic hand syndromes. Tactile abnormalities that were detected by clinical examination progressed during a two year period and were related to metabolic control and musculoskeletal diagnosis.

Introduction

The hands are a target for several musculoskeletal complications related to diabetes which can result in progressively impaired hand function. The syndrome of limited joint mobility is specific to diabetes whereas trigger finger, carpal tunnel syndrome and atypical Dupuytren' disease are more prevalent in patients with diabetes (Ardic et al., 2003, Arkkila and Gautier, 2003, Cagliero et al., 2002, Fraser et al., 1979). The mechanisms behind the development of these hand syndromes are uncertain but it is currently thought that diabetes may alter the amount and quality of the connective tissues (Arkkila & Gautier, 2003) and render the median nerve more susceptible to entrapment in the carpal tunnel (Fraser et al., 1979). The median nerve will be more susceptible to daily mechanical stresses and entrapment if it has been subjected to prior ischemia (Fraser et al., 1979), when distal symmetrical neuropathy is present (Perkins, Olaleye, & Bril, 2002) or when trigger finger or the syndrome of limited joint mobility is present (Chaudhuri et al., 1989, Rottgers et al., 2009).

Overall, management is more challenging and interventions more complex and less successful in individuals with hand syndromes and diabetes (Baumgarten et al., 2007, Griggs et al., 1995, Kiylioglu et al., 2009, Ozkul et al., 2002, Stahl et al., 1997). Multiple fingers can develop triggering and outcomes from corticosteroid injection are poorer (Rozental, Zurakowski, & Blazar, 2008). Skin thickening and neuropathy are thought to contribute to the associated stiffness and clumsiness (Kapoor & Sibbitt, 1989). Excision of the ulnar slip of the flexor digitorum superficialis has been recommended as an additional procedure to A1 pulley release to improve tendon excursion (Marcus, Culver, & Hunt, 2007) and limited joint mobility has complicated recovery following fasciectomy for Dupuytren's contracture (Fournier, Papanas, Compson, & Maltezos, 2008). Many uncertainties remain regarding which factors may be responsible for differences in outcomes for these hand syndromes, strategies for prevention or more successful intervention.

Little is known about the natural history of these hand conditions. The natural history of carpal tunnel syndrome in the general population has been found to be variable but observation of the natural history of the other hand conditions has been neglected. Symptoms and electrophysiological abnormalities associated with carpal tunnel syndrome may fluctuate or spontaneously resolve over several years (Padua et al., 1999, Resende et al., 2003). Shorter duration of symptoms, younger age and avoiding aggravating activities are associated with spontaneous improvement (Padua et al., 1999). In the single study that compared the natural history of carpal tunnel syndrome in patients with and without diabetes, patients with diabetes did not show similar improvements in symptoms over the course of a year (Kiylioglu et al., 2009).

This study observed the natural history of the hand conditions associated with diabetes in order to determine whether aspects of the hand's functions deteriorated over time and which factors were associated with the observed change in impairments or daily activities.