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Comparison of Hand Function Between Children With Type 1 Diabetes Mellitus and Children Without Type 1 Diabetes Mellitus

Atay, Canan PT, MSc; Kaya Mutlu, Ebru PT, PhD; Taskiran, Hanifegul PT, PhD; Ozgen, Ilker Tolga MD

Author Information
doi: 10.1097/PEP.0000000000000465
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Type 1 diabetes mellitus (T1DM) is one of the most common chronic endocrine and metabolic conditions among children and adolescents.1 The number of children diagnosed with diabetes is increasing every year.2

Diabetic skeletal muscle disorders, or myopathy, is a common clinical symptom observed in individuals with T1DM.3 It is characterized by lower muscle mass, generalized weakness, functional weakness, and an overall reduced physical capacity. Several studies have emphasized the importance of increased physical activity in improving the glycemic control in T1DM.3,4

Muscle weakness contributes to the increased risk of physical disability associated with diabetes in children.5 Impaired muscle strength has been reported in subjects with diabetes as a late complication of severe diabetic peripheral neuropathy (DPN) with motor nerve involvement.6 However, other studies have indicated that reduced muscle strength may occur earlier in the course of diabetes, independent of diabetic peripheral neuropathy, and could affect the upper limbs.7

Diabetic arthropathy is a condition that is characterized by thickened skin and limited mobility of the joints in the hands and fingers, leading to flexion contractures or limitations.6 Many musculoskeletal disorders often cause pain and functional limitations and may affect routine daily activities.8 Although hyperglycemia has been linked to myopathy, the relationship between hand muscle function and daily life activities in people with T1DM has not yet been extensively examined. In addition, children and health care providers may not be aware of these preventable complications.9 However, there is little mention of musculoskeletal disorders or recommendations for routine follow-up for possible arthropathy. Therefore, the primary purpose of this study is to compare the hand function of the children aged between 8 and 12 years with T1DM with that of the children without T1DM. The secondary purpose is to assess range of motion (ROM), muscle strength, and health-related quality of life (HRQoL) in the children with T1DM compared with the children without T1DM.


This is a cross-sectional study that was conducted in consecutive children with T1DM from a community center in the Medipol University, Faculty of Medicine, Department of Pediatrics Endocrinology, who were referred to the clinical laboratory of the Physiotherapy Department of the University of Medipol and were studied between December 2014 and May 2015.

Ethical approval for this study was obtained from the Human Research Ethics Committee of Medipol University (IRB: 10840098-300). Participants and their parents were informed about the study, and informed consent was obtained.

Sample size was calculated by Raosoft Inc. With a power of 95%, an error of more than 5%, and 3% for incidence of children with T1DM, the minimal sample size was estimated at 45 participants to detect a statistically significant difference between the T1DM group and children without T1DM. To allow for attrition, the sample size was set at 51 per group.

Of the children examined in the pediatric endocrinology clinic within the study period, the first 51 and their parents were asked to participate in the study. They were invited to an interview at Medipol University. Five participants were excluded from the study because they met the exclusion criteria. Therefore, 46 children (dropout rate, 9.8%) (21 boys and 25 girls) and their parents were included.

The children without T1DM and their parents were selected from primary and secondary schools near the hospital. The group of children without T1DM was formed from students aged 8 to 12 years who met inclusion criteria and came to school with their parents on the selection day. A total of 51 children and their parents were included as the children without T1DM.

The inclusion criteria were as follows: children were aged 8 to 12 years at recruitment and had a confirmed diagnosis of T1DM for a period greater than 1 year. The exclusion criteria included any other disease affecting the physical activity level, diabetes diagnosis known to be non-type 1, and severe social deprivation. None of the children had reading problems that hindered them from completing self-rating scales. They were no history of any known psychiatric treatment and mental deficiency based on parent report.

Participants' weight and height were measured, and the body mass index (BMI) was calculated as weight/height2. Clinical features, such as the T1DM duration and HbA1c, were assessed by an endocrinologist. HbA1c levels were measured by turbidimetric inhibition immunoassays and were presented by National Glycohemoglobin Standardization Program unit (%). The HbA1c levels represented the measurements in the previous month. A physical therapist checked the children's history and completed the demographic data form. Outcome measurements were performed by another physical therapist with 7 years of experience at a university clinic. All participants received the same verbal cues and directions for all outcome measurements.

Outcome Measurements

The primary outcome measures included the hand function level, as determined by the Jebsen-Taylor Hand Function Test (JTHFT) and Purdue-Pegboard Test (PPT). The secondary outcomes measures included the ROM, muscle strength, and Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0).

Hand Function Level. Hand function speed and dexterity were assessed with the JTHFT,10 which is a commonly used standardized test for assessing upper extremity efficiency; it is reliable, valid and normative for children. The Jebsen test evaluates both the dominant and nondominant hand skills and supplies an objective assessment of the hand function involved in a series of 7 subtests of activities of daily living (ADL). We used the subtests of (1) writing a 24-letter short sentence; (2) turning over a 3×5-inch (7.5 cm × 12.5 cm) card; (3) picking up a small common object; (4) stacking checkers; (5) simulated feeding with beans and a spoon; (6) moving large, light objects on a board; and (7) moving large, heavy objects on a board. The time (in seconds) taken to perform the 7 subtests was measured with the same stopwatch. The writing subtest was conducted, assessed, and scored with only the dominant hand. The reliability of the JTHFT for children has previously been reported (the dominant and nondominant hands were intraclass correlation coefficient (ICC) 0.74 and 0.72, respectively).11

The PPT (Lafayette Instrument Co, USA, model 32025) measures manual dexterity. This validated and reliable test was used to evaluate fine hand motor proficiency.12 The PPT includes 4 subtests and involves a board with 2 parallel rows, each of which has 25 holes. The participants are required to pick up and place metal pins, one at a time, into a row of the holes first with the dominant hand, then with the nondominant hand and then with both hands. The score is the number of pins placed in 30 seconds. In addition, the fourth and final subtest is a bimanual assembly task where the participant builds structures by placing a pin, washer, collar, and second washer with both hands in 60 seconds. The same stopwatch was used in the PPT for both the T1DM and children without T1DM groups. Test-retest reliabilities for PPT ranged from 0.60 to 0.76 for 1 trial scores and 0.82 to 0.92 for 3 trial scores.13

Range of Motion. Shoulder flexion, abduction, and adduction; forearm pronation and supination; and wrist flexion and extension active ROM were measured, as described by Clarkson,14 using a universal goniometer. In this study, 3 repetitions were performed in each direction, and the average value was recorded for analysis. Interrater reliability of measurements of ROM for upper extremity joints were ICC = 0.75.15

Finger mobility was measured in the second to fifth fingers while the children were sitting. The elbow was flexed, and the forearm was resting on a table in supination. The children flexed the interphalangeal joints while maintaining 0° extension at the metacarpophalangeal joints. A ruler measurement was taken from the pulp or tip of the middle finger to the distal palmar crease.14

Muscle Strength. The muscle strength of shoulder flexors, extensors, abductors, internal rotators, and external rotators; elbow flexors and extensors; and wrist flexors and extensors were measured using a hand-held dynamometer, the Nicholas Manual Muscle Tester (The Lafayette Instrument Company, Lafayette, Indiana, model 01160). The measurements were recorded in kg/N. This dynamometer allowed a measurement of muscle strength from 0.0 to 199.9 kg, with 0.1 kg precision. The participants practiced once to learn the test procedure.16 The test participants were asked to forcibly contract their muscle while a resistive force was applied by the dynamometer in the opposite direction of the intended movement. During the test, the device recorded the maximal isometric strength of the muscle in kg/N. Each muscle was assessed 3 times, and the mean value was calculated. Test-retest reliability in hand-held dynamometry in children has been reported by Stuberg and Metcalf,17 and test-retest correlation coefficients ranged from 0.74 to 0.99 in their study.

The hand-held JAMAR dynamometer (Jamar, Jackson, Michigan) was used to measure gross power fist grip. Pinch Gauge (PG) by B&L Engineering Co was designed to assess the strength of pinch grip of the finger. Each of the psychometric tests had good inter-rater reliability and high test re-test reliability.18

The American Society of Hand Therapists proposed a standardized arm position for grip strength evaluation, as determined with the shoulder in adduction, both elbows at 90° flexion, and the wrist in a neutral position.19 The participants were instructed to sit on a chair and asked to squeeze the device as hard as possible for 3 attempts for each measurement with dominant and nondominant sides. The mean maximum values of 3 evaluations (kilograms force) were recorded and used in the analyses.20

Health-Related Quality of Life. The PedsQL 4.0 self-report form for children aged 8 to 12 years was used to assess the children's HRQoL. The scale consists of child self-report and parent proxy reports. The scale includes a total of 23 items. The total scale score, physical health summary score, and psychosocial health summary score were calculated. Items were scored between 0 and 100: 0 (100) = never a problem; 1 = (75) almost never; 2 = (50) sometimes; 3 = (25) almost always; and 4 = (0) always. Higher PedsQL scores indicate better HRQoL. The Turkish version of the PedsQL was used; the internal consistency of the child self-report was determined to be 0.86, and that of the parent proxy report was 0.88.21


The data were evaluated using the Statistical Package for Social Science 21.0 program for Windows and by analyzing descriptive statistics (frequency, mean, and standard deviation). Before the statistical analysis, the Kolmogorov-Smirnov test was used to test for a normal distribution of the data. All continuous variables were normally distributed. Independent sample t tests were used to compare age, BMI, disease duration, and HbA1c between children with T1DM and children without T1DM. The χ2 test was used to compare the sex and dominant side ratio between the groups. Performance on the JTHFT, PPT, ROM, muscle strength, and HRQoL was compared across the 2 groups by means of multivariate analysis of variance (MANOVA). Since multiple dependent variables were used, MANOVA analysis was performed with group as a main factor. Since our outcomes are naturally correlated, this procedure was considered better than Bonferroni inequality correction, which would increase type II error. In addition, significant main effects for both groups were examined using Bonferroni corrections to each test to reduce type I error. P values less than .05 were considered statistically significant. Bonferroni correction P values were determined based on number of dependent variables. According to this issue, P values were .003 for the JTHFT and upper extremity ROM, .01 for the PPT, .006 for finger mobility, .002 for upper extremity muscle strength, .008 for pinch strength, .02 for handgrip strength, .008 for PedsQL-child self-report, and PedsQL-parent proxy report.


There were no significant differences in demographic background between groups. Group characteristics are shown in Table 1. A comparison hand function is shown in Table 2. A 1-way between-groups MANOVA was performed to investigate group differences in the subtests of the JTHFT. Seven dependent variables were used: writing, card turning, small common object, stimulated feeding, stacking checkers, large, light objects, and large, heavy objects with both hands. In this analysis, we have 13 dependent variables to investigate; therefore, we would divide 0.05 by 13, giving a new α level of 0.003. Preliminary assumption testing was conducted to check for normality, linearity, univariate and multivariate outliners, homogeneity of variance-covariance matrices, and multicollinearity, with no serious violations noted. There was a statistically significant difference between groups on the combined dependent variables (F = 3.178, P = .001; Wilks λ = 0.66, partial η2 = 0.33). When the results for the dependent variables were considered separately, the subtests of the JTHFT in the writing test showed significantly longer subtest times in the dominant side of the children with T1DM (F = 10.997, P = .001; partial η2 = 0.10) compared with the children without T1DM, using a Bonferroni-adjusted α level of 0.003. In addition, the T1DM group had significantly longer subtest times for card turning (F = 22.528, P = .001; partial η2 = 0.192), moving large, light objects (F = 12.338, P = .001; partial η2 = 0.11), and large, heavy objects on a board (F = 9.731, P = .002; partial η2 = 0.09) on the nondominant side compared with the children without T1DM. However, there was no statistically significant difference between groups on the PPT (F = 0.722, P = .57; Wilks λ= 0.97, partial η2 = 0.03).

TABLE 1 - Demographic and Clinical Features of the Children With T1DM and Children Without T1DM
Demographic Children With T1DM (n = 46) Children Without T1DM (n = 51) P
Mean (SD) Mean (SD)
Age, y 9.8 (1.6) 9.6 (1.6) .43
BMI, kg/m2 17.8 (3.2) 17.8 (3.1) .99
Disease duration, y 2.7 (1.7)
HbA1c (NGSP unit), % 8.1 (1.6)
n (%) n (%)
Male 21 (45.7) 26 (51) .52
Female 25 (54.3) 25 (49)
Dominant side
Right 42 (91.3) 47 (92.2) .87
Left 4 (8.7) 4 (7.8)
Abbreviations: BMI, body mass index; HbA1c, hemoglobin A1c; NGSP, National Glycohemoglobin Standardization Program; SD, standard deviation; T1DM, type 1 diabetes mellitus.

TABLE 2 - Comparisons of JTHFT and PPT Scores Between Children With T1DM and Children Without T1DM
Children With T1DM (n = 46) Children Without T1DM (n = 51) F P
Mean (SE) 95% CI Mean (SE) 95% CI
Dominant 22.80 (1.22) 20.37-25.23 17.19 (1.16) 14.88-19.50 10.997 .001a
Card turning
Dominant 5.45 (0.22) 5.00-5.91 4.72 (0.21) 4.29-5.15 5.396 .022
Nondominant 6.63 (0.22) 6.18-7.07 5.15 (0.21) 4.73-5.58 22.528 .001a
Small common object
Dominant 6.32 (0.16) 6.00-6.64 5.66 (0.15) 5.36-5.97 8.807 .004
Nondominant 6.73 (0.21) 6.31-7.16 6.60 (0.20) 6.20-7.01 0.195 .660
Simulated feeding
Dominant 11.19 (0.50) 10.19-12.19 10.23 (0.48) 9.28-11.18 1.902 .171
Nondominant 16.13 (0.88) 14.38-17.87 14.17 (0.83) 12.51-15.83 2.595 .111
Stacking checkers
Dominant 3.60 (0.16) 3.29-3.92 3.17 (0.15) 2.87-3.47 3.820 .054
Nondominant 4.21 (0.14) 3.92-4.50 3.64 (0.13) 3.37-3.92 7.996 .006
Large, light objects
Dominant 3.73 (0.13) 3.48-3.99 3.47 (0.12) 3.22-3.71 2.252 .137
Nondominant 4.19 (0.13) 3.93-4.46 3.54 (0.12) 3.29-3.80 12.338 .001a
Large, heavy objects
Dominant 4.08 (0.11) 3.85-4.31 3.62 (0.10) 3.41-3.84 8.426 .005
Nondominant 4.6 (0.15) 4.37-4.97 4.02 (0.14) 3.73-4.30 9.731 .002a
PPT, n
Pins right 13.47 (0.30) 12.86-14.09 13.92 (0.29) 13.33-14.50 1.082 .301
Pins left 12.26 (0.26) 11.73-12.78 12.84 (0.25) 12.34-13.34 2.566 .113
Pins bimanual 19.95 (0.51) 18.93-20.98 20.66 (0.49) 19.69-21.64 0.991 .322
Pins bimanual assembly 27.02 (0.84) 25.34-28.69 28.27 (0.80) 26.68-29.86 1.159 .284
Abbreviations: CI, confidence interval; JTHFT, Jebsen-Taylor Hand Function Test; PPT, Purdeu-Pegboard Test; SE, standard error; T1DM, type 1 diabetes mellitus.
aBonferroni-adjusted α level of 0.003.

Tables 3 and 4 include a comparison of ROM and muscle strength among the participants. A comparison of the groups showed no significant differences in upper extremity ROM (F = 1.100, P = .37; Wilks λ = 0.90, partial η2 = 0.09), finger mobility (F = 1.146, P = 0.34; Wilks λ = 0.90, partial η2 = 0.09), upper extremity muscle strength (F = 3.178, P = .001; Wilks λ = 0.66, partial η2 = 0.46), and pinch strength (F = 1.110, P = .36; Wilks λ = 0.93, partial η2 = 0.07). However, there was a statistically significant difference between groups on the handgrip strength (F = 5.341, P = .006; Wilks λ = 0.89, partial η2 = 0.10). When the results for the dependent variables (dominant and nondominant sides of handgrip strength) were considered separately, the T1DM group had significantly lower handgrip strength on the nondominant side (F = 5.522, P = .021; partial η2 = 0.05) compared with the children without T1DM, using a Bonferroni-adjusted α level of 0.025.

TABLE 3 - Comparisons of Upper Extremity Range of Motion and Finger Mobility Between Children With T1DM and Children Without T1DM
Children With T1DM (n = 46) Children Without T1DM (n = 51) F P
Mean (SE) 95% CI Mean (SE) 95% CI
The assessment of upper extremity range of motion, °
Shoulder flexion
Dominant 179.10 (0.47) 178.16-180.05 180 (0.45) 179.16 to 180.89 1.854 .177
Nondominant 179.75 (0.16) 179.41-180.09 180 (0.16) 179.68 to 180.31 1.110 .295
Shoulder abduction
Dominant 179.34 (0.44) 178.45-180.23 180 (0.42) 179.15 to 180.84 1.110 .295
Nondominant 179.80 (0.13) 179.53-180.07 180 (0.12) 179.74 to 180.25 1.110 .295
Shoulder internal rotation
Dominant 64.03 (1.28) 61.47-66.59 68.03 (1.22) 65.60 to 70.47 5.080 .027
Nondominant 65.18 (1.23) 62.73-67.64 67.74 (1.17) 65.41 to 70.07 2.254 .137
Forearm pronation
Dominant 89.78 (0.15) 89.48-90.08 90 (0.14) 89.71 to 90.28 1.110 .295
Nondominant 89.78±0.15 89.48-90.08 90 (0.14) 89.71 to 90.28 1.110 .295
Forearm supination
Dominant 89.78 (0.15) 89.22-90.11 90 (0.21) 89.57 to 90.42 1.110 .295
Nondominant 89.67 (0.22) 89.22-90.11 90 (0.21) 89.57 to 90.42 1.110 .295
Wrist flexion
Dominant 89.1 (0.43) 88.27-89.98 90 (0.41) 89.18 to 90.81 2.131 .148
Nondominant 88.95 (0.53) 87.90-90.01 90 (0.5) 89.0 to 91.0 2.034 .157
Wrist extension
Dominant 68.04 (0.78) 66.48-69.60 70 (0.47) 68.52 to 71.48 3.267 .074
Nondominant 69.06 (0.45) 68.17-69.96 70 (0.42) 69.15 to 70.85 2.259 .136
Finger mobility (second to fifth fingers), cm
Second finger
Dominant 0.21 (0.56) 0.10-0.32 0.02 (0.05) −0.08 to 0.13 6.092 .015
Nondominant 0.19 (0.04) 0.09-0.28 0.01 (0.04) −0.07 to 0.09 7.983 .006
Third finger
Dominant 0.11 (0.03) 0.03-0.19 0.00 (0.03) −0.07 to 0.07 4.680 .033
Nondominant 0.11 (0.36) 0.04-0.18 0.00 (0.03) −0.06 to 0.06 5.467 .021
Fourth finger
Dominant 0.08 (0.28) 0.02-0.13 0.00 (0.02) −0.05 to 0.05 4.382 .039
Nondominant 0.11 (0.04) 0.03-0.19 0.00 (0.03) −0.07 to 0.07 4.285 .041
Fifth finger
Dominant 0.06 (0.28) 0.008-0.11 0.01 (0.02) −0.04 to 0.06 1.966 .164
Nondominant 0.10 (0.04) 0.02-0.18 0.00 (0.03) −0.07 to 0.07 3.363 .070
Abbreviations: CI, confidence interval; SE, standard error; T1DM, type 1 diabetes mellitus.

TABLE 4 - Comparisons of Upper Extremity Muscle Strength, Pinch Strength, and Handgrip Strength Between Children With T1DM and Children Without T1DM
Children With T1DM (n = 46) Children Without T1DM F P
Mean (SE) 95% CI Mean (SE) 95% CI
Assessments of upper extremity muscle strength, kg
Shoulder flexion
Dominant 6.81 (0.27) 6.28-7.35 6.96 (0.25) 6.28-7.35 0.162 .689
Nondominant 7.22 (0.33) 6.56-7.89 7.13 (0.31) 6.50-7.76 0.038 .846
Shoulder extension
Dominant 6.69 (0.29) 6.12-7.27 6.46 (0.27) 5.92-7.01 0.338 .562
Nondominant 6.14 (1.16) 3.83-8.44 7.60 (1.10) 5.41-9.79 0.833 .364
Shoulder abduction
Dominant 6.61 (0.27) 6.06-7.16 5.96 (0.26) 5.44-6.48 2.919 .091
Nondominant 5.75 (0.22) 5.30-6.21 6.22 (0.21) 5.79-6.65 2.230 .139
Shoulder internal rotation
Dominant 4.12 (0.21) 3.69-4.56 4.47 (0.20) 4.06-4.88 1.302 .257
Nondominant 3.90 (0.22) 3.45-4.35 4.41 (0.21) 3.98-4.83 2.659 .106
Shoulder external rotation
Dominant 4.89 (0.21) 4.47-5.31 4.37 (0.20) 3.97-4.77 3.207 .076
Nondominant 4.82 (0.24) 4.35-5.30 4.85 (0.22) 4.40-5.30 0.007 .934
Elbow flexion
Dominant 9.57 (0.41) 8.75-10.38 9.49 (0.39) 8.72-10.27 0.017 .897
Nondominant 9.60 (0.45) 8.70-10.50 9.17 (0.43) 8.32-10.03 0.460 .499
Elbow extension
Dominant 8.01 (0.31) 7.39-8.64 7.59 (0.29) 7.00-8.19 0.933 .337
Nondominant 7.57 (0.28) 7.01-8.13 7.65 (0.26) 7.12-8.19 0.046 .831
Wrist flexion
Dominant 5.39 (0.20) 4.99-5.80 5.39 (0.19) 5.01-5.77 0.000 .986
Nondominant 5.37 (0.22) 4.94-5.81 5.34 (0.20) 4.92-5.75 0.014 .906
Wrist extension
Dominant 6.33 (0.27) 5.79-6.88 6.42 (0.26) 5.90-6.94 0.050 .824
Nondominant 6.11 (0.26) 5.57-6.64 6.29 (0.25) 5.79-6.80 0.264 .609
Assessments of pinch strength, kg
Lateral grip
Dominant 4.57 (0.15) 4.25-4.88 4.49 (0.15) 4.19-4.79 0.125 .724
Nondominant 4.39 (0.13) 4.12-4.67 4.30 (0.13) 4.04-4.56 0.229 .633
Palmar grip
Dominant 3.62 (0.12) 3.38-3.86 3.50 (0.11) 3.27-3.73 0.502 .480
Nondominant 3.49 (0.12) 3.25-3.74 3.51 (0.11) 3.27-3.74 0.005 .944
Fingertip grip
Dominant 3.53 (0.12) 3.29-3.78 3.27 (0.11) 3.04-3.50 2.349 .129
Nondominant 3.35 (0.12) 3.10-3.59 3.12 (0.11) 2.88-3.35 1.738 .191
Assessments of handgrip strength, kg
Dominant 33.23 (1.60) 30.05-36.41 36.36 (1.52) 33.33-39.38 1.997 .161
Nondominant 30.16 (1.52) 27.13-33.18 35.09 (1.44) 32.22-37.96 5.522 .021a
Abbreviations: CI, confidence interval; SE, standard estimated; T1DM, type 1 diabetes mellitus.
aBonferroni-adjusted α level of 0.025.

A comparison of PedsQL is shown in Table 5. MANOVA yielded (F = 2.141, P = .04; Wilks λ = 0.87, partial η2 = 0.12) for PedsQL-child self-report and (F = 1.107, P = .36; Wilks λ = 0.93, partial η2 = 0.07) for PedsQL-parent proxy report, indicating that there were only differences in PedsQL-child self-report between the groups. When the results for the dependent variables (physical health summary score, psychosocial health summary score, emotional functioning, social functioning, school functioning, and total scale score) were considered separately, the T1DM group had significantly lower score of PedsQL-child self-report, except for score of social functioning (F = 3.691, P = .05; partial η2 = 0.04) compared with the children without T1DM, using a Bonferroni-adjusted α level of 0.008.

TABLE 5 - Comparisons of the Pediatric Quality of Life Between Children With T1DM and Children Without T1DM
Children With T1DM (n = 46) Children Without T1DM (n = 51) F P
Mean (SE) 95% CI Mean (SE) 95% CI
PedsQL-child self-report
PHSS 78.46 (2.10) 74.28-82.64 87.11 (1.99) 83.15-91.08 8.891 .004a
PsHSS 78.79 (1.81) 75.19-82.40 87.31 (1.72) 83.89-90.74 11.569 .001a
Emotional functioning 70.97 (2.70) 65.61-76.34 83.33 (2.56) 78.23-88.42 10.990 .001a
Social functioning 89.02 (1.77) 85.49-92.54 93.72 (1.68) 90.37-97.07 3.691 .058
School functioning 76.05 (2.06) 71.97-80.15 85.00 (1.95) 81.11-88.88 9.883 .002a
TSS 78.72 (1.75) 75.23-82.21 87.24 (1.67) 83.93-90.56 12.360 .001a
PedsQL-parent proxy report
PHSS 72.01 (2.89) 66.26-77.75 74.74 (2.77) 69.22-80.25 0.463 .498
PsHSS 73.9 (2.19) 69.56-78.25 78.90 (2.1) 74.76-83.10 2.745 .101
Emotional functioning 63.8 (2.8) 58.24-69.36 72.40 (2.68) 67.06-77.73 4.905 .029
Social functioning 84.02 (2.6) 78.83-89.21 84.8 (2.50) 79.82-89.77 0.046 .830
School functioning 74.56 (2.49) 69.62-79.51 79.4 (2.38) 74.65-84.14 1.963 .165
TSS 73.34 (2.145) 69.08-77.60 77.72 (2.05) 73.63-81.80 2.171 .144
Abbreviations: CI, confidence interval; PedsQL, Pediatric Quality of Life Inventory; PHSS, physical health summary score; PsHSS, psychosocial health summary score; SE, standard error; TSS, total scale score.
aBonferroni-adjusted α level of 0.008.


Durations of writing on the dominant hand and card turning and moving large objects on the nondominant hand were significantly longer in the JTHFT of the children with the T1DM group compared with the children without T1DM. The group with T1DM had significantly lower handgrip strength on the nondominant side compared with the children without T1DM. The total scale score of HRQoL was significantly lower in the T1DM group (P = .001) compared with the children without T1DM.

Assessing hand function in children is limited to neurologic and orthopedic diseases in the literature. Many studies on adults, which probe the relationship between diabetes mellitus and the hand function, have indicated that poor metabolic control negatively affects hand function at advanced age to a significant level.22–24 Dexterity, as a measure of hand function, which may be described by 2 related terms consisting of manual dexterity and fine dexterity, is an important component of a thorough hand evaluation. Manual dexterity is the ability to handle objects with the hand. Fine dexterity refers to in-hand manipulations as separate skills from the gross motor grasp and release skills associated with manual dexterity.25 In addition, dexterity tests can measure the rate of task completion, in-hand manipulation, and/or dynamic force control.26 For our study we chose to examine the rate or time for task completion using the JTHFT and the PPT. Our results from the PPT support that the task duration of the T1DM group was longer than that of the children without T1DM, but no statistically significant difference was found between the groups in terms of fine dexterity. In the literature, the JTHFT is recommended as the assessment of choice to evaluate manual and fine dexterity, and the PPT is recommended to assess only fine dexterity. This may explain why there was no significant difference between the groups in the PPT.

There was significant difference in the card turning, moving large, light objects, and large, heavy objects of JTHFT results because the JTHFT assesses ADL with an emphasis on gripping skills, a skill we found to be significantly different in the nondominant hand in our subjects with T1DM. This finding was supported by Duff et al26 in which they stated that hand strength was associated with dexterity. Several studies support that children with T1DM performed fewer ADL.4,27,28 Here, we may speculate that it is caused by the more-than-adequate assistance in ADL that parents provide to their children with diabetes due to the T1DM. In addition, hand strength has been found to be associated with findings on the Strength-Dexterity Test designed by Duff et al.26

Rosenbloom29 provides information regarding limited joint motion and the severe long-term implications and complications from this diabetes-related condition. A decrease in this prevalence will increase the quality of life of diabetic children.29,30 Furthermore, it has been reported that a limitation of joint motion could be an indicator for the early development of microvascular complications in T1DM.31 There is evidence that limited ROM is significantly more frequent in patients with diabetes and also that it may be associated with diabetes duration, poor metabolic control, and presence of microvascular complications.32 In our study, there was no statistical difference between groups in upper extremity ROM and finger mobility. This may be interpreted as a consequence of the young age of the group and short duration of disease in the study.

In a study by Krause et al,3 a loss in the peak power of contraction was detected in the muscles of individuals with T1DM. They reported that the reasons for the loss in muscle strength were a loss of growth in glycolytic muscle fibers and atrophy, although many other factors could also contribute to this loss of muscle. Balducci et al5 investigated the correlation of muscle strength in people with diabetes, using a retrospective study, and evaluated the conditions that affect the abnormalities in muscle and bone strength. In addition, they studied the association between muscle strength and motor nerve function and the degree of micro- and macrovascular complications. The results supported that muscle strength in the upper and lower extremities is correlated and that greater muscle strength meant better motor nerve function. Wallymahmed et al33 evaluated aerobic capacity and handgrip strength and analyzed their relationship with the body composition and glycemic index in children with T1DM. Whereas the handgrip strength was higher in males than in females, there was no difference in the aerobic capacity between genders. They expressed that the handgrip test depicted a negative correlation with age, duration of diabetes, BMI, and weight. No significant difference in upper extremity muscle strength and pinch meter results was found between the groups in our study. A loss of muscle strength, including handgrip strength, was associated with the development of physical disability in diabetes.5 In the handgrip measurements, although the children without T1DM yielded better results for both hands, a statistically significant difference was detected in the results for the nondominant hand only. Moreover, hand dominance is an important factor that influences the values of grip and pinch strength.34 Along with being undistinguished, we may interpret that it is caused by reduced strength in the nondominant hand. In addition, reduced handgrip strength in the nondominant hand might contribute to lower scores found in card turning and manipulating large objects.

HRQoL may reflect capacity and competence to manage their diabetes treatment and achieve treatment goals.35 Adolescents with poor HRQoL are at risk of psychological problems, reduced compliance and adherence to treatment, and poor metabolic control. Several studies reported lower HRQoL in youths27,35 and adolescents,36 whereas others did not find a difference in youths and adolescents compared with controls, similar to our findings. Interestingly, the present study found that children reported significantly poorer HRQoL scores, except for social functioning, than did children without T1DM. This may be related to the young age that T1DM may not have affected social functioning while impacted other HRQoL scores. In the children's quality of life scale that we used for the family, we found that parents were unaware of the problems experienced by their children, needing further investigation. In addition, parents of both groups, children with T1DM and children without T1DM rated children's emotional functioning lowest as reported in a review study.35 However, the total scale score of children with T1DM was significantly lower than that of their peers. Thus, caregivers must take a closer look at HRQoL of children with T1DM.

Study Limitations

The most important limitation of our study was that the results of both the children with T1DM and children without T1DM were measured by the same physical therapist; therefore, the evaluator was not blind. We did investigate the long-term effects of diabetes. All children were Caucasians and were from a single clinic, limiting the generalization of the results. Including the primary school in the same territory into the study as the children without T1DM and comparing it with the T1DM group eliminates one possible bias in our study.


Although American Diabetes Association's37,38 clinical practice guidelines recommend frequent analyses of the eyes, kidneys, and cardiovascular and nervous systems, the presence of musculoskeletal disorders is rarely mentioned. Based on our study, we think that musculoskeletal disorders, such as an evaluation of hand function, should be included in the routine history for children diagnosed with T1DM. The hand function of children with T1DM, particularly on the dominant side for writing and the nondominant side for card turning and moving large object, might limit hand function to adeptly perform function needed in daily living. Their perceived overall quality of life was poorer than that of the children without T1DM, although family reports failed to infer this. The hand function of children with T1DM should be followed over the long term, and due precautions should be taken. Therefore, a multidisciplinary approach to maximize the functional abilities and overall quality of life for children with T1DM is required.


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children; hand function; Jebsen-Taylor Hand Function Test; quality of life; type 1 diabetes mellitus

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