DIABETES; A HINDRANCE IN MUSCULOSKELETAL DISEASES

Background: Diabetes mellitus (DM) affects connective tissues in many ways and causes different alterations in periarticular and skeletal systems. Musculoskeletal complaints (MSCs) are among the major health problems worldwide and the most frequent cause of long term sickness. 
Objectives: To assess the prevalence, treatment pattern of musculoskeletal diseases with diabetes mellitus and to evaluate the impact of patient counselling overcome the barriers of diabetes in musculoskeletal disease. 
Materials & Methods: A prospective observational study was carried out for a period of six months at Departments of Orthopedic and General medicine, Basaveshwara Medical College & Research center and Ambarish’s Clinic,Chithradurga. A total of 118 subjects were included as per study criteria. 
Results: Among 118 subjects 17 (14.4%) had musculoskeletal manifestations with DM. The study shows that 55.9% patients were males and 44.06% were females. The maximum number of patients comes under the age of 51-60yrs.The NSAIDs prescribed were Diclofenac (8.69%), Paracetamol (8.69%) and Piroxicam 4(8.69%) and the Antidiabetic drugs in present study were Oral hypoglycemic followed by Insulin. Most of the patients are affected with Osteoarthritis (47.05%), followed by Adhesive capsulitis (11.76%) and Osteoporosis (11.76%). 
Conclusion: The study reveals that the prevalence of musculoskeletal disease with DM is significantly high and osteoarthritis is the common disease. Males are more affected than females with an age group of 51-60. 
Key words: Diabetes mellitus, musculoskeletal disease, prevalence, prescription pattern.


INTRODUCTION
Diabetes mellitus is a group of disorders characterized by chronic hyper glycaemia due to relative insulin deficiency, or resistance or both 1 .According to world health organization (WHO) statistics published in 2013, approximately 347 million people worldwide suffer from diabetes, and by 2023diabetes will be the seventh leading cause of death 2 . India is popularly known as a "diabetes capital of the world". 3 The causes of increased musculoskeletal pain in people with diabetes are probably related to vascular insufficiency, neuropathy, decreased insulin-like growth factor, accelerated osteoporosis, obesity sedentary life style and other factors. 2 DM affects connective tissues in many ways and causes different alterations in periarticular and skeletal systems. Several musculoskeletal disorders have been described, which can be divided into three categories: A) Disorders which represent intrinsic complications of diabetes, such as limited joint mobility or diabetic cheiroarthropathy, stiff hand syndrome, and diabetic muscular infraction. B) Disorders with an increased incidence among diabetics, such as Dupuytren's disease, Shoulder capsulitis, neuropathic arthropathy, osteopenia(in type 1 DM),Flexor Tenosynovitis, septic arthritis, acute proximal neuropathy, proximal motor neuropathy, Pyomyositis and the diffuse idiopathic skeletal Hyperostosis(DISH) syndrome, Backache . C) Disorders for which a possible association with diabetes has been proposed but not proven yet, such as osteoarthritis and the carpal tunnel syndrome. 4 Rheumatic disorders in DM have been associated with disease duration, degree of metabolic control and the presence of end organ damage. 5 Non -steroidal anti-inflammatory drugs (NSAID's) are widely prescribed for the treatment of pain and inflammation in patients with various musculoskeletal. 6 Most currently available traditional NSAIDs act by inhibiting COX enzyme. The inhibition of COX-2 is thought to mediate, the antipyretic, analgesic, and anti-inflammatory actions of traditional NSAIDs, while the simultaneous inhibition of cyclooxygenase-1(COX-1). 7 The oral Anti-diabetic drug classes were Biguanides, Sulfonylureas, Alpha-Glucosidase Inhibitor, Repaglinide and Thiazolidinediones. Metformin was the only prescribed Biguanides. Insulin was prescribed for patients with type 2 Diabetes mellitus. 8 Co-morbidity among patients with diabetes is associated with considerable consequences for health care and related costs. 9 Management of every patient should commence with a detailed assessment at the initial diagnosis including an appraisal of diabetes complications and risk factors for complications. This provides the basis for continuing care that includes a treatment plan, treatment administration, monitoring, and review. 10 Health promotion has been described as, the process of enabling people to increase control over, and to improve, their health. There are five strategies to improve better patient care: Build healthy public policy, Create supportive environments, Strengthening community action, Developing personal skills, Re-orienting health services. 11

Inclusion Criteria
 Inpatients and outpatients of Orthopedic and Medicine departments.  Subjects of both genders.  Subjects who were diagnosed with any musculoskeletal disorder and Type 2 Diabetes mellitus for more than 2 years.  Subjects who were above 30 years.

Exclusion Criteria
 Pregnant and lactating women.  Subjects who met with accident as well as fractures.  Subjects who were at Coma stage.

STATISTICAL ANALYSIS
The collected data was entered in Microsoft Excel 2010 version and Descriptive method was used for the analysis.

Distribution of subjects according to age.
Out of 118 patients, maximum number of patients comes under the age of 51-60 and minimum number of patients comes under the age of 81-90.

Impact of patient counselling
During the visit 1, the subjects were having various problems associated with musculoskeletal disease and diabetes. Patient counselling was done and the patients were reviewed in the subsequent visit which revealed that the knowledge about the disease has improved with reduction in complaints. 11 patients showed improvement in their condition, 4 patients remained the same whereas 2 patients only had slight improvement.

DISCUSSION
The present prospective interventional study was conducted to assess the prevalence and treatment pattern of musculoskeltal disease associated with diabetes and to assess the impact of patient counselling in the outpatients and inpatients of In the study population 47.05% had Osteoarthritis, followed by Adhesive capsulitis (11.76%),Osteoporosis(11.76%).Attar SM., conducted a study on Musculoskeletal manifestations in diabetic patients at a tertiary center. 12 And the results found that the most common manifestations were carpal tunnel syndrome, shoulder adhesive capsulitis and diabetic amyotrophy which is also the pattern seen in another study done by Kidwai SS et al., on Upper limb musculoskeletal abnormalities in type 2 diabetic patients in low socioeconomic strata in Pakistan. 13 In this present study the knowledge about the disease, effectiveness of therapy, role of selfcare management were assessed by direct interaction with patient and it shows positive response which is further supported by the results of a similar study conducted by Rashid M et al., on Prevalence of Co-morbidities in Type 2 Diabetes Mellitus Patients, the Awareness Level and the Impact of Pharmacist's Patient Education Program. 9

CONCLUSION
According to the analyzed results and from review of literature, the conclusions made are; 1. Prevalence of musculoskeletal disease with diabetes was significantly high.
2. This can be attributed to the prevalence of gender inequality as a result of which males are preferentially taken to tertiary care institutes for treatment as compared to females with a similar severity of illness.
3. Osteoarthritis was most common disease found in musculoskeletal diseases. 4. The optimum management of individual patients may vary in the clinical course of the disease and individual needs. 5. Mostly prescribed Antidiabetic drugs were Oral hypoglycemic followed by Insulin. 6. For musculoskeletal diseases NSAIDs like diclofenac, Paracetamol and piroxicam were most commonly prescribed.
7. The knowledge regarding disease, diet and life style modification among musculoskeletal disorder with diabetes mellitus was improved after the patient education.

ACKNOWLEDGEMENT
I am highly indebted to my guide Dr.Bharathi D R, Principal SJM College of Pharmacy, Chitradurga, for their continuous support, Dr.Ambarish Sharma for the motivation and guidance throughout the tenure of this work inspite of hectic schedule who truly remain driving spirit and their experience gave me light in this work and helped me in clarifying he abstruse concepts.