Rajiv Gandhi University of Health Sciences, Karnataka



Rajiv Gandhi University of Health Sciences, Karnataka | |

|Curriculum Development Cell |

|CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION |

|Registration No. |: |

|Name of the Candidate |: MS. YERI SHUBHA ANAND |

|Address |: SDM College of Physiotherapy, Dharwad. |

|Name of the Institution |: SDM College of Physiotherapy, Dharwad. |

|Course of Study and Subject |: MASTER OF PHYSIOTHERAPY |

| |TWO YEARS DEGREE COURSE |

| |(PHYSIOTHERAPY IN ADULT NEUROLOGY |

| |AND PSYCHOSOMATIC DISORDERS) |

|Date of Admission to Course |: 2/06/08 |

|Title of the Topic |: A STUDY TO DETERMINE CORRELATION |

| |BETWEEN DURATION OF DIABETES AND |

| |GRIP STRENGTH IN DIABETES MELLITUS. |

|Brief resume of the intended work |: Attached |

|Signature of the Student |: |

|Guide Name |: MR. CHANDRAGOUDA B. PATIL |

|Remarks of the Guide |: |

|Signature of the Guide |: |

|Co-Guide Name |: |

|Signature of the Co-Guide |: |

|HOD Name |: MS. KIRAN S. SIRIGERI |

|Signature of the HOD |: |

|Principal Name |: MS. KIRAN S. SIRIGERI |

|Principal Mobile No. |: 9886089451 |

|Principal E-mail ID |: sdmcpt@ |

|Remarks of the Principal |: |

|Principal Signature |: |

| | |

|a) |BRIEF RESUME OF THE STUDY |

| | |

| |Introduction: |

| |As per the World Health Organization (WHO), Diabetes Mellitus is a heterogeneous metabolic disorder characterized |

| |by common feature of chronic hyperglycemia with disturbance of carbohydrate, fat and protein metabolism. Diabetes |

| |mellitus is a leading cause of morbidity and mortality.1 |

| | |

| |The prevalence of diabetes for all age groups world wide was estimated to be 2.8% in 2000 and 4.4% in 2030. The |

| |total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The |

| |prevalence of diabetes is higher in men than women.2 In India, the prevalence of diabetes was 3.8% in 1995.3 |

| |Diabetes is divided into 4 major categories depending on etiology: Type 1, type 2, gestational and other specific |

| |types.1 In type 1 diabetes, the final common pathway is beta cell destruction by autoimmune process which leads to |

| |insulin deficiency. Type 2 diabetes is characterized by varied degrees of insulin resistance and relative insulin |

| |deficiency. |

| | |

| |Globally type 1 diabetes mellitus and type 2 diabetes mellitus account for 10-20% and 80-90% of all cases |

| |respectively.1 The peak incidence of type 1 diabetes mellitus is 10 to 12 years in girls and 12 to 14 years in |

| |boys,4 whereas the peak incidence of type 2 diabetes mellitus is 60-65 years.5 The age of onset of type 1 diabetes|

| |mellitus is less than 35 years while that of type 2 diabetes mellitus is more than 40 years.1 |

| | |

| |Long term complications of diabetes mellitus include retinopathy with potential loss of vision, nephropathy leading|

| |to renal failure, peripheral neuropathy with risk of foot ulcers, amputation and charcot joints.6 |

| | |

| |Diabetes mellitus is also associated with a variety of musculoskeletal disorders.7 |

| | |

| |Hand abnormalities represented by Dupuytren’s contracture, limited joint mobility, carpal tunnel syndrome, flexor |

| |tenosynovitis occur in approximately 50% of the diabetic patients affecting their activity and decreasing the |

| |quality of their life. These disturbances have a high prevalence in people with long duration of diabetes |

| |mellitus.8 |

| | |

| |Complications involving the foot have received much attention in clinical practice and in literature. Less |

| |attention has been given to the hand though hand function has been said to be significantly lower in the diabetic |

| |group.9 |

| | |

| |Grip strength is one of the basic components to be considered in the examination of hand function which gives us |

| |overall status of the hand function.10 Hand dynamometers have been used to evaluate grip strength objectively.11 |

| | |

| |Need for the study: |

| | |

| |Various studies have explained the role of exercises in diabetes mellitus.12,13 Less importance has been given to |

| |the hand in diabetes mellitus, though hand function is crucial for productivity and quality of life.9 |

| | |

| |There are numerous studies where grip strength in diabetes mellitus were studied but the duration of diabetes |

| |mellitus was not taken into consideration , even though the prevalence of complications and hand abnormalities are |

| |said to increase with the duration of diabetes mellitus.14,15 |

| | |

| |Emphasis on duration of diabetes is a priority as to avoid complications which |

| | |

| |eventually hamper the health of individual. So the need of the study is to correlate duration of diabetes mellitus |

| |and isometric grip strength. |

| | |

| |RESEARCH HYPOTHESIS: |

| | |

| |H1: There will be a correlation between duration of diabetes and isometric grip strength in diabetes mellitus |

| |subjects. |

| | |

| |H0: There will be no correlation between duration of diabetes and isometric grip strength in diabetes mellitus |

| |subjects. |

| | |

| |REVIEW OF LITERATURE: |

| | |

| |Diabetes mellitus is associated with a variety of musculoskeletal disorders.7 |

| |Douloumpakas I studied the prevalence of musculoskeletal disorders in 208 subjects with type 2 diabetes mellitus |

| |where in he concluded that 82.6% of the subjects exhibited musculoskeletal abnormalities.7 |

| | |

| |Reports in the literature have described hand lesions in diabetic subjects including flexor tendinitis, skin |

| |thickening, limited joint mobility and loss of fine motor control.9 Lundback et al stressed that stiffness of |

| |subcutaneous tissue in the hand of diabetic patients might have an influence on strength measurement.16 |

| | |

| |Gamstedt A studied the prevalence of hand abnormalities like carpal tunnel syndrome, Dupuytren’s contracture, |

| |flexor tenosynovitis and limited joint mobility in 100 diabetic subjects. It was found that the prevalence of hand |

| |abnormalities is high and increases with duration of diabetes.14 |

| | |

| |In another study, Jennings AM assessed limited finger joint mobility, Dupuytren’s contracture and complications of |

| |diabetes in 233 type 2 diabetic subjects. It was found that connective tissue abnormalities in hand are associated |

| |with complications of diabetes.17 |

| | |

| |Starkman HS in his study evaluated limited joint mobility of the hand by visual examination in 361 diabetic |

| |patients and found that limited joint mobility was evident in 58% of diabetic subjects. Limited joint mobility and |

| |neuropathy was significantly related to duration of diabetes.18 |

| | |

| |In a study done by Casanova JE 15 diabetic subjects were randomly selected and hand function was assessed using |

| |three standardized functional tests. It was found that hand function was significantly reduced in diabetic group.9 |

| | |

| |Cox J in his study examined the relationship between hand strength and hand function using Disability of Arm, |

| |Shoulder and Hand questionnaire (DASH) and the Jebsen Hand function test. Hand function and grip strength were |

| |found to be significantly correlated with each other.19 |

| | |

| |Several studies have attributed several complications like retinopathy, nephropathy and neuropathy.20,21 20% of |

| |type 2 diabetes mellitus patients suffer from diabetic neuropathy.22 Diabetic neuropathy per se is associated with |

| |peripheral muscle impairment.23 Since diabetic neuropathy and hand abnormalities are said to be significantly |

| |related to the age of onset and duration of diabetes, establishing relationship between grip strength and duration |

| |of diabetes becomes important. |

| | |

| |Grip strength testing has been used in the assessment of upper limb impairment.24 |

| | |

| |Grip strength is said to have a curvilinear relationship to age, which results in an increase in grip strength with|

| |increasing age to reach a peak at 30-45 years and then a decrease with increasing age. There is a positive |

| |correlation between grip strength, bodyweight and height in healthy subjects. The positive relationship between |

| |grip strength, weight and height may not occur in individuals with hand dysfunction, although this has not been |

| |extensively investigated.25 |

| | |

| |According to American Society of Hand Therapists, the standardized testing position for grip strength is as |

| |follows: subject is seated in a straight backed chair with feet flat on the floor. Shoulder adducted and neutrally |

| |rotated, elbow flexed at 90 degrees, forearm in neutral position and wrist between 0 |

| |and 30 degrees extension and between 0 and 15 degrees of ulnar deviation. In all cases arm should not be supported |

| |by the examiner or the arm rest. 25 |

| | |

| |The preferred method when obtaining a maximal grip is to use the mean of three trials. There has been a consistent |

| |trend for the mean of three trials to produce the highest reliability. Review of literature recommends a 60 second |

| |rest period between trials on isometric tests, the 60 second rest period was found to have a significantly smaller |

| |percentage of declining grip strength from the first to the last trial and the highest intraclass correlation |

| |coefficient. It has been recommended that a three second or less pinch or grip is sufficient to register a maximum |

| |reading.25 |

| | |

| |Hand held dynamometer has been said to be a valid and reliable instrument for measuring grip strength.26 |

| | |

| |OBJECTIVES OF THE STUDY: |

| | |

| |1. To determine the correlation between duration of diabetes and isometric grip strength in diabetes mellitus |

| |subjects. |

| | |

|b) |PROCEDURE, MATERIALS AND METHODS: |

| | |

| |SOURCE OF DATA COLLECTION: |

| |Department of Physiotherapy and Department of Medicine, |

| |S. D. M. College of Medical Sciences and Hospital, Dharwad. |

| | |

| |METHOD OF DATA COLLECTION: |

| |Material: |

| |1. Data collection sheet. |

| |2. Hand dynamometer. (India Medico Instruments IMI:1417) |

| |3. Sphygmomanometer. (Diamond) |

| |4. Stethoscope. (Littman) |

| |5. Weighing machine. (Krups) |

| |6. Stadiometer. (QuickMedicals) |

| |7. Half circle universal Goniometer. (India Medico Instruments IMI:1432) |

| | |

| |Inclusion Criteria: |

| |1. Subjects of either gender of any age with diabetes mellitus. |

| |2. Age, gender and BMI matched non-diabetic subjects. |

| | |

| |Exclusion Criteria: |

| |1. Any musculoskeletal condition or neurological condition interfering with the assessment. |

| |2. Uncontrolled cardio respiratory conditions. |

| | |

| |Study Design: Cross-sectional study. |

| |Study duration: 1 year. |

| | |

| |Sample: 15 diabetic subjects were randomly assigned to a pilot study. Their grip strength was calculated using the |

| |hand dynamometer. The average of |

| |three readings was taken. The group mean and standard deviation was derived and sample size was calculated.27 |

| | |

| |Therefore a total of 274 subjects will be taken for the study. 137 diabetic subjects and 137 non-diabetic subjects |

| |will be taken for the study such that their age, gender and BMI are matched. Thus there will be two groups as |

| |follows: |

| |Group A: Subjects with diabetes mellitus. |

| |Group B: Age, gender and BMI matched non-diabetic subjects. (control) |

| | |

| |PROCEDURE: |

| | |

| |Ethical clearance has been obtained from the institution. Subjects fulfilling the inclusion criteria and willing to|

| |participate will be included in the study. Subsequently written consent will be obtained from them. Group A will |

| |include subjects with diabetes mellitus. Group B (control) will include similar age, gender and BMI matched non |

| |diabetic subjects. Demographic data will be collected. Brief history with emphasis on history of diabetes mellitus |

| |will be taken. A routine evaluation will be done. Subsequently isometric Grip strength will be measured using hand |

| |dynamometer (India Medico Instruments IMI: 1417), the reliability of which has been ascertained by pilot study |

| |which was already undertaken on 15 subjects. The standardized testing position for grip strength as prescribed by |

| |American Society of Hand Therapists will be used and a mean of three trials will be taken.25 Body Mass Index will |

| |be calculated by dividing body weight in kilograms by the square of height in meters.28 BMI of non-diabetic |

| |subjects will be matched with diabetic subjects as per WHO guidelines.29 The duration of diabetes will be |

| |considered based upon the first documented diagnosis till the date of assessment. |

| | |

| |Statistical Test Used: 1. Z test. |

| |2. Pearson’s correlation test. |

| |3. Chi square test. |

| | |

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| | |

| |DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? |

| |IF SO DESCRIBE BRIEFLY – YES. |

| |Hand dynamometer. |

| | |

| | |

| | |

| |HAS ETHICAL CLEARANCE BEEN OBTAINED BY YOU – YES. |

| | |

|c) |REFERENCE LIST: |

| | |

| |1. Mohan H. Textbook of pathology. 5th ed. New Delhi: Jaypee Brothers |

| |Medical Publishers; 2005. p. 842-48. |

| | |

| |2. Sarah W, Gojka R, Anders G, Richard S, Hilary K. Global Prevalence |

| |of Diabetes. Diabetes Care [serial online] 2004 May [cited 2008 Sep 4]; |

| |27(5):1047-53. Available from: URL: |

| |http;//who.int/diabetes/facts/en/diabcare0504.pdf |

| | |

| |3. Park K. Park's Textbook of Preventive and Social Medicine.18th ed. |

| |Jabalpur: Banarsidas Bhanot Publishers; 2005. p.312. |

| | |

| |4. Poretsky L. Principles of Diabetes Mellitus. 2nd ed. Boston: Springer |

| |Publishers; 2002. p.107,116. |

| | |

| |5. Price CP, Andrew J, Jocelyn. Point of care testing. 2nd ed. Washington: |

| |American Association for Clinical Chemistry Publishers; 2004. p. 309. |

| | |

| |6. Stewart P. Diagnosis and Classification of Diabetes Mellitus. Diabetes |

| |Care [serial online] 2008 Jan [cited 2008 Sep 4];31 Suppl 1:55-60. |

| |Available from: URL: |

| | |

| | |

| |7. Douloumpakas I, Pyrpasopoulou A, Triantafyllou. Prevalence of |

| |musculoskeletal disorders in patients with type 2 diabetes mellitus: a pilot |

| |study. Hippokratia [serial online] 2007 [cited 2008 Nov 2]; 11(4):216-18. |

| |Available from: URL: |

| | |

| | |

| |8. Mota M, Panus C, Mota E, Sfredel V. Hand abnormalities of the patients |

| |with diabetes mellitus. Rom J Intern Med [serial online] 2001[cited 2008 |

| |Nov 2]; 39:89-95. Available from: URL: |

| | |

| | |

| |9. Casanova JE, Casanova JS, Young MJ. Hand function in patients with |

| |diabetes mellitus. Southern Medical Journal [serial online] 1991 September |

| |[cited 2008 Sep 10]; 84(9):1111-1113. Available from: URL: |

| | |

| | |

| |10. Elizabeth AK, Michael CV. The relation between elbow position and grip |

| |strength. The American Journal of Occupational Therapy [serial online] |

| |1992 Jun [cited 2008 Aug 10]; 46(6):509-12. Available from: URL: |

| | |

| | |

| |11. O’ Sullivan SB. Physical rehabilitation Assessment and Treatment. 4th ed. |

| |New Delhi: Jaypee Brothers Medical Publishers; 2004. p.120-21. |

| | |

| |12. Dunstan DW, Robin MD, Owen N. High intensity resistance training |

| |improves glycemic control in older patients. Diabetes Care [serial online] |

| |2002 [cited 2008 Aug 11]; 25:1729-36. Available from: URL: |

| | |

| | |

| |13. Henk M, De Feyter, Stephen FP. Exercise training improves glycemic |

| |control in long-standing, insulin-treated type 2 diabetes patients. Diabetes |

| |care [serial online] 2007 October [cited 2008 Aug 11]; 30(10):2511-13. |

| |Available from: URL: |

| | |

| | |

| |14. Gamstedt A, Holm-Glad J, Ohlson CG, Sundstrom M. Hand |

| |abnormalities are strongly associated with the duration of diabetes |

| |mellitus. J Intern Med [serial online] 1993 August [cited 2008 Nov 2]; |

| |234(2):189-193. Available from: URL: |

| | |

| | |

| |15. Smith LL, Burnet SP, McNeil JD. Musculoskeletal manifestations of |

| |diabetes mellitus. Br J Sports Med [serial online] 2003 [cited 2008 Nov 2]; |

| |37:30-5. Available from: URL: |

| | |

| | |

| |16. Cetinus E, Mehmet AB, Murat U, Ekerbicer H, Ahmet K. Hand grip |

| |strength in patients with type 2 diabetes mellitus. Diabetes Research and |

| |Clinical Practice [serial online] 2005 [cited 2008 Jul 1]; 70:278-86. |

| |Available from: URL: |

| | |

| | |

| |17. Jennings AM, Milner PC, Ward JD. Hand abnormalities are associated |

| |with the complications of diabetes in type 2 diabetes. Diabet Med [serial |

| |online] 1989 Jan [cited 2008 Nov 2]; 6(1):43-7. Available from: URL: |

| | |

| | |

| |18. Starkman HS, Gleason RE, Lawrence IR, Donald M, JS Soeldner. |

| |Limited joint mobility of the hand in patients with diabetes mellitus: |

| |relation to chronic complications. Annals of the Rheumatic Diseases |

| |[serial online] 1986 [cited 2008 Nov 2]; 45:130-5. Available from: URL: |

| | |

| |blobtype=pdf |

| | |

| |19. Cox J, Sandi S, Kramer J. Is There a Relationship between Hand |

| |Strength and Hand Function? Journal of Hand Therapy [serial online] |

| |2006 Dec [cited 2008 Nov 2]; 19(4):444-5. Available from: URL: |

| | |

| | |

| |20. Premalata G, Rema M, Mohan V. Complications of diabetes mellitus at |

| |diagnosis in South Indian type 2 diabetic patients. Int J Diab Dev |

| |Countries [serial online] 1998 [cited 2008 Oct 31]; 18:1-3. Available from: |

| |URL: |

| | |

| |21. Hoogwerf BJ. Complications of diabetes mellitus. Int J Diab Ctries [serial |

| |online] 2005 [cited 2008 Oct 31]; 25:63-9. Available from: URL: |

| | |

| | |

| |22. Ashok S, Ramu M, Mohan V. Prevalence of neuropathy in type 2 |

| |diabetic patients attending a diabetes centre in South India. J Assoc |

| |Physicians India [serial online] 2002 [cited 2008 Oct 30]; 50:546-50. |

| |Available from: URL: |

| | |

| | |

| |23. Davidson S. Davidson’s principles and practice of medicine. 23rd ed. |

| |Edinburgh: Churchill Livingstone; 2006. p. 843-4. |

| | |

| |24. Blair SJ, McCormick E, Bear-Lehman J, Fess EE, Rader E. Evaluation |

| |of impairment of the upper extremity. Clin Orthop Relat Res [serial online] |

| |1987 Aug [cited 2008 Nov 2]; 221:42-58. Available from: URL: |

| | |

| | |

| |25. Innes E. Handgrip strength testing: A review of the literature. Australian |

| |Occupational Therapy Journal [serial online] 1999 [cited 2008 Aug 11]; |

| |46:120-40. Available from: URL: |

| | |

| | |

| |26. Bohannon RW. Test-retest reliability of hand-held dynamometry during a |

| | |

| |single session of strength assessment. Phys Ther [serial online] 1986 Feb |

| |[cited 2008 Aug 11]; 66(2): 206-9. Available from: URL: |

| | |

| | |

| |27. Hicks CM. Research Methods for Clinical Therapists. 4th ed. Edinburgh: |

| |Churchill Livingstone; 2004. p. 28-30. |

| | |

| |28. McArdle WD, Frank IK, Victor L. Exercise Physiology: Energy, |

| |Nutrition, and Human Performance. 6th ed. Baltimore: Lippincott |

| |Williams and Wilkins; 2007. p. 774. |

| | |

| |29. Brown SC, Miller WC, Jane ME. Exercise Physiology: Basis of Human |

| |Movement in Health and Disease. 6th ed. London : Lippincott |

| |Williams & Wilkins; 2007. p. 529-30. |

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