Back, Neck Pain Increased in Diabetes; Key Culprits Unclear

People with diabetes have a significantly greater likelihood of experiencing low back, neck, or spinal pain compared to those without diabetes, according to a new systematic review and meta-analysis.

However, data on whether there is a causal relationship between diabetes itself and musculoskeletal pain or whether the cause involves one of the common risk factors for diabetes, such as obesity, are lacking, say the researchers.

“Diabetes and low back pain and neck pain seem to be somehow connected,” observed senior author Manuela Ferreira, MD, from the University of Sydney’s Institute of Bone and Joint Research, in Australia, in a press statement from her institution.

“We can’t say how, but these findings suggest further research into the link is warranted,” she said.

Type 2 diabetes and low back pain both have a strong relationship with obesity and lack of physical activity, so a logical progression of this research might be to examine these factors in more detail,” she said.

35% Increased Risk for Back Pain in Diabetes Patients

The researchers note that people with diabetes are more likely to present with chronic somatic pain, including painful diabetic peripheral neuropathy, but the link between musculoskeletal pain and diabetes remains unclear.

For this analysis, published online February 21 in PLOS One, Daniel Pozzobon, a PhD student at the University of Sydney, and colleagues identified 11 studies that met the criteria of investigating the association between diabetes and back, neck, or spinal pain.

Among them, five studies, involving 131,431 patients, showed an increased likelihood of reporting back pain among people with diabetes compared to those without diabetes (odds ratio [OR], 1.35; P < .001).

In addition, two studies of 6560 persons showed increased reports of neck pain compared to those without diabetes (OR, 1.24; P = .01). Back and neck pain were defined as having pain, aching, or stiffness in the neck or back on most days.

The increased risk is notable in light of the prevalence of diabetes, Pozzobon noted.

“Given how prevalent type 2 diabetes is, if having diabetes means you are 35% more likely to also have low back pain, at the population level, these [data] can be quite important,” he told Medscape Medical News.

Two studies in the analysis included only patients with type 2 diabetes; the rest did not specify between type 1 and type 2 diabetes.

In the only longitudinal study in the analysis, there was no indication of an increased risk of developing neck, lower back, or spinal pain over time with diabetes.

Other results showed a stronger association with diabetes and back pain among people who sought care for diabetes (OR, 2.72).

“A possible explanation for those seeking care for diabetes being at higher odds of developing low back pain is that these patients are more likely to have uncontrolled diabetes and therefore more severe symptoms,” Pozzobon speculated.

Is Obesity the Common Denominator? Diabetes Affects Muscle, Tissue

Obesity in men older than 18 years was associated with a ninefold increased risk for type 2 diabetes, and as many as 30% of people with obesity develop chronic back pain over the course of 10 years. Thus, it is reasonable to assume that a higher body mass index (BMI) is a factor in back pain.

Yet, two of the four studies that adjusted for BMI found the increased risk for low back pain with diabetes remained after adjusting for obesity, suggesting that other factors need to be considered.

Obesity is further associated with a reduced level of physical activity, which could increase the risk for back or neck pain, and increased physical activity is known to help decrease the risk for low back pain and type 2 diabetes, the authors point out.

Alternatively, the “biochemical milieu of diabetes” itself can take a toll on muscle and tissue in ways that could result in chronic pain, the authors suggest.

Hyperglycemia and dyslipidemia can cause tissue damage, and poorly controlled diabetes could further reduce muscle blood flow and increase the possibility of cartilage inflammation.

The effects could lead to “the degeneration of intervertebral discs and consequently spinal canal stenosis, which are both common causes of low back and neck pain,” they speculate.

Other pain-related conditions that are known to be more common in patients with diabetes include intervertebral disc herniation of both the cervical and lumbar spine, the loss of muscle mass and strength, and an increased risk for sarcopenia, which is also associated with musculoskeletal pain, the authors add.

“Despite these associations and our results having shown a direct link between low back, neck or spinal pain and diabetes, there is insufficient evidence to support the notion that diabetes will increase the risk of future low back, neck or spinal pain,” they summarize.

Consideration of Role of Medications, Insulin Recommended

In considering the full range of possible causes of pain in patients with diabetes, additional research should investigate the role of medications, including insulin, which are known to affect blood flow and could influence muscle loss, Pozzobon and colleagues indicate.

“Future studies should aim to elucidate the mechanisms of the association to provide an opportunity to target preventive and management strategies for people with diabetes,” they write.

It is recommended that clinicians consider the potential comorbidity of chronic pain in the treatment of diabetes.

“It is possible [that back and neck pain in diabetes patients] is underrecognized by physicians,” Pozzobon told Medscape Medical News.

“It is important that patients and healthcare professionals emphasize the role of exercise and healthy lifestyle behavior as a way of managing both prevalent and disabling conditions,” he said.

The authors have disclosed no relevant financial relationships.

PLoS One. Published February 21, 2019. Full text

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