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Prevalence and Correlation of Pain in Fatigued Patients with Diabetes in Taif City, Saudi Arabia

Diabetes mellitus (DM) is one of the common chronic diseases worldwide. Approximately 422 million people have been diagnosed with DM worldwide; in Saudi Arabia, the prevalence is 30%. DM has many complications that are known to cause pain and fatigue to the patients. Moreover, chronic pain and fatigue are highly associated with a decreased quality of life. Pain and fatigue studies on diabetic patients are still insufficient in Saudi Arabia especially in Taif city. Thus, the aim of this study is to evaluate the prevalence and correlation of pain in fatigued patients with diabetes in Taif city, Saudi Arabia. A cross-sectional study was conducted from October 2020 to March 2021. The sample size included 200 participants from Taif city. Inclusion criteria encompassed those who were ≥15 years of age and had diabetes for at least one year. Those who did not have diabetes or were younger than 15 years of age were excluded. A self-administrated electronic questionnaire was used to collect the data. The statistical analysis of data was performed using IBM statistics version 20. A total of 55.2% of the participants reported the presence of pain. Legs and feet were the most frequent locations of the pain. There was association between pain and age, gender, depression, anxiety, and physical activity. In contrast, there was no association between the type of diabetes and fatigue severity or between the type of diabetes and pain severity. Pain is a highly prevalent symptom in diabetic patients. Highlighting the importance of improving modifiable risk factors in diabetic patients is paramount in reducing the effect of pain and fatigue on those patients.


INTRODUCTION
Diabetes mellitus (DM) is a common chronic disorder that a general practitioner treats during clinical practice (1). Approximately 422 million people worldwide have been diagnosed with DM (2), while the overall prevalence in Saudi Arabia is 30% (3). Pain is the most frequent complaint that may make patients visit a primary healthcare provider (4)(5)(6); pain is defined as uncomfortable sensations in the body, and it may be acute or chronic.
Chronic pain is a highly prevalent and disabling symptom among diabetic patients (7). There are many conditions and complications related to DM, which are known to cause pain for the patients. For example, micro vascular complications of DM can cause painful peripheral neuropathy, which affects 16% of diabetic patients (8).
Furthermore, entrapment neuropathy (e.g., carpal tunnel syndrome and trigger fingers) can be secondary to DM (8). Chronic pain, which is associated with diabetes, is greatly variable and considerably affects patients' lives (9). Pain has been reported by many patients to affect sleep and daily activities and to cause emotional distress (10)(11)(12). In addition to diabetes-related complications, pain may contribute to chronic severe disabling fatigue (13), which is strongly correlated with pain in diabetic patients (8).
A Saudi cross-sectional study showed a significant association between diabetes and chronic pain. The most common pain sites among diabetic patients were lower limbs, abdominal area, and neck as reported by 11.1, 6.7, and 4.4% of the patients, respectively (14). Another recently published study determined that diabetic patients were more prone to develop chronic pain (15).
Menting J et al. evaluated the prevalence, severity, and location of pain among fatigued diabetic patients. The pain was reported by 72% of their cohort with female predominance, and fatigue severity was proportionally related to the number of diabetes-related complications (8). A study by Bair MJ determined that pain was strongly associated with poorer mental health and physical activity (16).
Diabetes is one of the most common and growing health problems globally. However, the number of studies on pain and fatigue in diabetic patients is still insufficient in Saudi Arabia, especially in Taif. Therefore, this study aimed to determine the prevalence and correlation of pain in fatigued diabetic patients in Taif city, Saudi Arabia.

MATERIALS AND METHOD:
A cross-sectional study was conducted from October 2020 to March 2021 with a sample size of 200 participants who were randomly selected from Taif residents. Our study aimed to determine the prevalence of pain in fatigued diabetic patients in Taif  Yes-no questions to assess the presence of pain and, if present, evaluate the location and type of pain were asked. A short form of the McGill pain questionnaire to classify pain character and intensity was obtained from the participants. Fatigue screening and evaluation of concentration, motivation, physical activity, and fatigue-related problems in the past two weeks were assessed using the checklist individual strength (CIS) survey with a score ranging from 8 to 56. High fatigue severity is associated with a high score.
All statistical analyses were performed with IBM statistics version 20. The normality of distribution was assessed using the Kolmogorov-Smirnov test. Data for continuous variables were expressed as the mean +/− SD and median (range). Categorical variables were described as frequency (percentage). Parametric and non-parametric tests were used to determine the association between numeric variables according to distribution normality. A Chi-square test was used to compare categorical variables. The significance level was set at ≤0.05.

RESULTS AND DISCUSSION
The primary objective of this study was to assess the association between pain and fatigue and diabetes. The demographical data are shown in Table 1 (Table 3).
Regarding chronic pain, most of our patients exhibited joint arthritis (46.40%) followed by peripheral neuropathy and disc herniation in the lower back, 25.40% and 18.80%, respectively.
Our results showed no association between the type of diabetes and fatigue severity (p = 0.470) or between the type of diabetes and pain severity (p = 0.390). In addition, the severity of pain and fatigue was not correlated with diabetes duration in years, (p = 0.239) and (p = 0.566), respectively. There was no relation between HbA1c level and the presence of pain (p = 0.092).
In contrast, we determined that there was significant association between age and pain (p =    The abovementioned results are consistent with the results of this study, which suggested that leg and foot pain, followed by pain in lower back, shoulders, and whole body were most frequently encountered in diabetics. Similarly, recently published data by Aldossari KK et al. (14) have also reported that lower limb and back pain was most prevalent in their study group.
The VAS score in our study was 5.15 and was considered moderate in severity, as explained by Boonstra AM et al. (19).
Regarding chronic pain, most of our patients exhibited joint arthritis (46.40%) followed by peripheral neuropathy and disc herniation in the lower back, i.e., 25.40% and 18.80%, respectively; however, the recently published data by Aldossari KK et al. showed that lower limb and back pain was most prevalent in their study group; however, this was not specifically determined because arthritis could be the source of pain (14).
The mean score of fatigue in our study was 70.35 (SD = 36.95). This is considered high compared to the score in a study performed in Netherland (i.e., 45.9). We do not know the exact reason for this; however, the higher proportion of co-morbidities in our study may partially explain this increased score (8).
No association was observed between the type of diabetes and fatigue in our study. However, in Norway, fatigue was significantly associated with type 1 diabetes (20). This result was obtained possibly because a different questionnaire was used in the Norway study. The longer duration of diabetes and being female are strongly associated with pain, as has been described in different studies (8,21).
In contrast to our study, pain has been associated with the level of HbA1c in the study conducted in the USA; this result may be related to the methods used in the abovementioned study, which gave them more accurate results than ours (16 Neuropsychiatric symptoms (i.e., anxiety and depression) were determined to be associated with pain in different studies (8, 22). Anxiety was determined to be significantly associated with pain in our study. People complaining of pain are usually less physically active. The more physical activity that people perform, the higher is their pain tolerance (23). This was shown well in our study because there was significant association between pain and physical activity, which was similar to the results obtained by M. J. Bair et al. (16).
Moreover, hypertension was the most common DM comorbidity in our study (29.2%). This association between DM and hypertension is well-known. This association is likely due to the role of the adrenergic system in the pathogenesis of both DM and hypertension (24).
Retinopathy and neuropathy as diabetes-related complications are the predominantly reported complications in our patients. They are both strongly associated. Neuroretinal nerve fiber dysfunction has been noted with the presence of neuropathy (25).
Regarding the pain characters, our study determined that throbbing pain, shooting pain, cramping pain, aching pain, and burning pain were significantly associated with the HbA1c level. Diabetic neuropathic pain is usually characterized by tingling, burning, sharp, shooting, lancinating, or electrical sensation (26,27).
In our study, painkillers were used by 84.4% of diabetics. Because pain affects the quality of life, long-term use of painkillers (including opioids) has been shown in a higher proportion of patients with diabetes (28).
Our study was limited by small sample size and lack of clinical assessment of the patients.
Future studies are needed to evaluate a larger sample size of diabetic patients using physical examination.