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Dynamic Chiropractic – August 26, 2009, Vol. 27, Issue 18
Dynamic Chiropractic
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Dynamic Chiropractic

The Chiropractor's Role in Managing Diabetes

By Joseph DiDuro, DC, MS, DABCN

Just how many patients who seek chiropractic care have diabetes? Furthermore, why should it matter to chiropractors? The diabetes epidemic is probably the greatest health problem facing developed and developing nations alike.

The current global prevalence of diagnosed diabetes is 165 million and is estimated to increase to 250 million by 2010 and to 330 million by 2025. These alarming figures do not include undiagnosed diabetes or pre-diabetic states.1

If that's not enough of a reason, diabetes mellitus (DM) has clearly been associated with several musculoskeletal disorders (see table).2-7 These musculoskeletal complaints tend to lead more patients with diabetes to the chiropractic office. When you add to this the increasing incidence of DM, along with the life expectancy of the diabetic patient, there is an increased prevalence of older patients presenting to the chiropractor with DM.2 It is more important than ever for clinicians to understand the musculoskeletal alterations in diabetic patients. Most chiropractors do not need an article on limited joint mobility or shoulder capsulitis, but they may need a primer on how these musculoskeletal disorders relate to the nerve damage caused by DM.

Musculoskeletal Disorders Associated With Diabetes Mellitus (DM)2-7
Intrisic Complications of DM
Limited joint mobility
Stiff hand syndrome
Diabetic muscular infarction
Increased Incidence With DM
Dupuytren's disease
Shoulder capsulitis
Neuropathic arthroplasty
Osteopenia (in type I)
Flexor tenosynovitis
Acute proximal neuropathy
Proximal motor neuropathy
Pyomyositis
Diffuse idiopathic skeletal hyperostosis
Possible Association With DM
Osteoarthritis
Carpal Tunnel Syndrome

Peripheral nervous system compromise is a common long-term complication of diabetes. In severe cases, this can lead to limb amputations and sudden cardiac death secondary to autonomic polyneuropathy.1 Peripheral neuropathy leading to an increased risk of falling is the most common neurological deficit seen in patients with DM.8

The central nervous system is affected secondarily by diabetic macrovascular disease, with an increased incidence of stroke. Direct cerebral effects of metabolic aberrations result in a diabetes duration-related cognitive decline - so-called primary diabetic encephalopathy - and may even predispose patients to Alzheimer's disease.1

When trying to understand how many patients with DM will present with peripheral neuropathy, we can look at data from a family practice. In this setting, the prevalence of at least one bilateral sensory deficit rose from 26 percent for 65- to 74-year olds, to 54 percent for those 85 and older.9 The most common deficit was loss of ankle reflex, followed by loss of fine touch. Only 40 percent of those with bilateral deficits reported having a disease known to cause peripheral neuropathy.

Peripheral sensory deficits are common in the elderly. In most cases, a medical cause is not obvious. Their consequences may not be benign, such as constant pain or balance disorders that lead to falls. The proportions of patients with one or more deficits who reported symptoms were as follows: numbness of extremities, 28 percent; pain or discomfort, 48 percent; restless legs, 31 percent; trouble walking, 44 percent; and trouble with balance, 35 percent. Twenty-nine percent (72 of 246) reported none of these symptoms. Back and neck pain were usually not associated with neurologic deficits.

With the increase use of CAM by older patients, combined with the musculoskeletal disorders associated with diabetes, we completed a study to answer several research questions. The first was accomplished by a retrospective, blind chart review to investigate what percentage of patients over 50 years of age attending the Palmer College of Chiropractic Clinic informed the clinic of their diabetic condition.10 Second, the chart review gathered data to correlate the patient's chief complaint with common musculoskeletal and neurologic complications of diabetes. Third, we investigated if policy changes in record-keeping, which specifically asked for a history of DM, would increase student chiropractors' awareness of patients that report diabetes.

Patient records were searched for a diagnosis of diabetes mellitus. Records were divided into three subgroups: Group A, July 2004-December 2005; Group B, January 2005-June 2005; and Group C, July 2005-December 2005.10 Patient charts were reviewed (average age 59 years; 51 percent male) with an overall prevalence of 9.9 percent of patients reporting being affected by diabetes mellitus. This is congruent with the U.S. average. There was no significant difference between groups. Changes in patient intake questionnaires did not improve recognition of older patients with diabetes.10

This study demonstrated that chiropractors should become aware that a percentage of the patients in their practice over age 50 have been given a diagnosis of DM. In an average chiropractic office, we could assume that this percentage could be anywhere from 9 percent to 11 percent. In my practice, which focuses on treating peripheral neuropathy, we surveyed the chart results from each new patients that entered our practice in the first three months we opened (n=267). We found that among patients over age 50 (40 percent male), the percentage who reported a diagnosis of DM jumped to 19.5 percent (n=48), almost double the national average.

It is important to remember that our practice specifically targets patients who may have signs and symptoms of peripheral neuropathy, so our percentage should be higher than average. Since the prevalence of at least one bilateral sensory deficit also rises with age from 26 percent for patients ages 65 to 74, to 54 percent for those 85 and older, the senior section of your practice may harbor greater neurologic defects.9

Proper recognition of the musculoskeletal manifestations of patients with DM should aid the chiropractor in the field and alert them to the possible neurological consequences of DM. With baby boomers becoming the lion's share of the health care population, older patients seeking chiropractic care should be examined and treated for the neurological manifestations of DM.

References

  1. Sima AA. Diabetes underlies common neurological disorders. Ann Neurol, 2004;56(4):459-61.
  2. Arkkila PE, Gautier JF. Musculoskeletal disorders in diabetes mellitus: an update. Best Pract Res Clin Rheumatol, 2003;17(6):945-70.
  3. Jacobs-Kosmin D, DeHoratius RJ. Musculoskeletal manifestations of endocrine disorders. Curr Opin Rheumatol, 2005;17(1):64-9.
  4. Crispin JC, Alcocer-Varela J. Rheumatologic manifestations of diabetes mellitus. Am J Med, 2003;114(9):753-7.
  5. Liote F, Orcel P. Osteoarticular disorders of endocrine origin. Baillieres Best Pract Res Clin Rheumatol, 2000;14(2):251-76.
  6. Werner RA, Franzblau A, Gell N, et al. Risk factors for visiting a medical department because of upper-extremity musculoskeletal disorders. Scand J Work Environ Health, 2005;31(2):132-7.
  7. Smith LL, Burnet SP, McNeil JD. Musculoskeletal manifestations of diabetes mellitus. Br J Sports Med, 2003;37(1):30-5.
  8. Schwartz AV, Hillier TA, Sellmeyer DE, et al. Older women with diabetes have a higher risk of falls: a prospective study. Diabetes Care, 2002;25(10):1749-54.
  9. Mold JW, Vesely SK, Keyl BA, et al. The prevalence, predictors, and consequences of peripheral sensory neuropathy in older patients. J Am Board Fam Pract, 2004;17(5):309-18.
  10. DiDuro JO, Lopez DL. Prevalence of patients with diabetes mellitus at the Palmer College of Chiropractic Clinic: a retrospective study. Presented at the 134th Annual Meeting & Exposition of the American Public Health Association, Nov. 6, 2006, Boston.

Dr. Joseph DiDuro, a 1986 graduate of Palmer College of Chiropractic, is in private practice in Casa Grande, Ariz. He completed postgraduate work (master's degree in clinical research) at the Palmer Center for Chiropractic Research in 2006 and has participated in numerous research projects. Contact Dr. DiDuro with questions and comments regarding this article at .

Dynamic Chiropractic

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