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Stern CM, Pepin MJ, Stoler JM, Kramer DE, Spencer SA, Stein CJ. Musculoskeletal Conditions in a Pediatric Population with Ehlers-Danlos Syndrome. J Pediatr 2017; 181:261-266. [PMID: 27908650 DOI: 10.1016/j.jpeds.2016.10.078] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/26/2016] [Accepted: 10/25/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To describe musculoskeletal conditions in children with Ehlers-Danlos syndrome (EDS). STUDY DESIGN A retrospective medical record review was performed, which evaluated 205 patients with EDS (ages 6-19 years) seen in sports medicine or orthopedic clinic at a large pediatric hospital over a 5-year period. RESULTS Female (n = 147) and male (n = 57) patients were identified (mean age 12.7 years). The most common EDS subtype (55.6%) was hypermobility type. Patients had between 1 and 69 visits (median 4), and 764 diagnoses were recorded, most commonly laxity/instability, pain, subluxation, and scoliosis/spinal asymmetry. Nearly one-half of patients (46.8%) received a general diagnosis of pain because no more specific cause was identified, in addition to 8.3% who were diagnosed with chronic pain syndrome. The most common sites of presenting issue were knee (43.4%), back (32.2%), and shoulder (31.2%). Over three-fourths (77.1%) of patients had imaging. Most (88.1%) were prescribed physical therapy and/or other conservative measures, such as rest (40.5%), orthotics (35.6%), and medication (32.2%). Surgery was recommended to 28.8% of the study population. CONCLUSIONS Many pediatric and adolescent patients with EDS experience joint pain, instability, and scoliosis, along with other musculoskeletal issues. Despite extensive workup, the etiology of pain may not be identified. Large numbers of office visits, imaging studies, treatment prescriptions, and specialist referrals indicate considerable use of medical resources and highlight a great need for injury prevention and additional study.
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Affiliation(s)
| | | | | | | | | | - Cynthia J Stein
- Division of Sports Medicine, Department of Orthopedics; Harvard Medical School, Boston, MA.
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Weinstock LB, Myers TL, Walters AS, Schwartz OA, Younger JW, Chopra PJ, Guarino AH. Identification and Treatment of New Inflammatory Triggers for Complex Regional Pain Syndrome: Small Intestinal Bacterial Overgrowth and Obstructive Sleep Apnea. ACTA ACUST UNITED AC 2017; 6:272-6. [PMID: 26867023 DOI: 10.1213/xaa.0000000000000292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Complex regional pain syndrome (CRPS) is evoked by conditions that may be associated with local and/or systemic inflammation. We present a case of long-standing CRPS in a patient with Ehlers-Danlos syndrome in which prolonged remission was attained by directing therapy toward concomitant small intestinal bacterial overgrowth, obstructive sleep apnea, and potential increased microglia activity. We theorize that cytokine production produced by small intestinal bacterial overgrowth and obstructive sleep apnea may act as stimuli for ongoing CRPS symptoms. CRPS may also benefit from the properties of low-dose naltrexone that blocks microglia Toll-like receptors and induces production of endorphins that regulate and reduce inflammation.
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Affiliation(s)
- Leonard B Weinstock
- From the Departments of *Anesthesia and †Internal Medicine, Washington University School of Medicine, St. Louis, Missouri; ‡Specialists in Gastroenterology, LLC, St. Louis, Missouri; §Department of Neurology, Vanderbilt University, Nashville, Tennessee; ‖Sleep and EEG Laboratory, Barnes Jewish West County, BJC Medical Group Center for Sleep Medicine, St. Louis, Missouri; Departments of ¶Psychology, #Anesthesiology, and **Rheumatology, Neuroinflammation, Pain and Fatigue Lab, University of Alabama, Birmingham, Alabama; ††Pain Management Center, Department of Anesthesia, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and ‡‡Department of Anesthesia, Washington University School of Medicine, St. Louis, Missouri
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Castori M. Pain in Ehlers-Danlos syndromes: manifestations, therapeutic strategies and future perspectives. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1238302] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Chiarelli N, Carini G, Zoppi N, Dordoni C, Ritelli M, Venturini M, Castori M, Colombi M. Transcriptome-Wide Expression Profiling in Skin Fibroblasts of Patients with Joint Hypermobility Syndrome/Ehlers-Danlos Syndrome Hypermobility Type. PLoS One 2016; 11:e0161347. [PMID: 27518164 PMCID: PMC4982685 DOI: 10.1371/journal.pone.0161347] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/03/2016] [Indexed: 01/01/2023] Open
Abstract
Joint hypermobility syndrome/Ehlers–Danlos syndrome hypermobility type (JHS/EDS-HT), is likely the most common systemic heritable connective tissue disorder, and is mostly recognized by generalized joint hypermobility, joint instability complications, minor skin changes and a wide range of satellite features. JHS/EDS-HT is considered an autosomal dominant trait but is still without a defined molecular basis. The absence of (a) causative gene(s) for JHS/EDS-HT is likely attributable to marked genetic heterogeneity and/or interaction of multiple loci. In order to help in deciphering such a complex molecular background, we carried out a comprehensive immunofluorescence analysis and gene expression profiling in cultured skin fibroblasts from five women affected with JHS/EDS-HT. Protein study revealed disarray of several matrix structural components such as fibrillins, tenascins, elastin, collagens, fibronectin, and their integrin receptors. Transcriptome analysis indicated perturbation of different signaling cascades that are required for homeostatic regulation either during development or in adult tissues as well as altered expression of several genes involved in maintenance of extracellular matrix architecture and homeostasis (e.g., SPON2, TGM2, MMP16, GPC4, SULF1), cell-cell adhesion (e.g., CDH2, CHD10, PCDH9, CLDN11, FLG, DSP), immune/inflammatory/pain responses (e.g., CFD, AQP9, COLEC12, KCNQ5, PRLR), and essential for redox balance (e.g., ADH1C, AKR1C2, AKR1C3, MAOB, GSTM5). Our findings provide a picture of the gene expression profile and dysregulated pathways in JHS/EDS-HT skin fibroblasts that correlate well with the systemic phenotype of the patients.
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Affiliation(s)
- Nicola Chiarelli
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Bres6cia, Italy
| | - Giulia Carini
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Bres6cia, Italy
| | - Nicoletta Zoppi
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Bres6cia, Italy
| | - Chiara Dordoni
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Bres6cia, Italy
| | - Marco Ritelli
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Bres6cia, Italy
| | - Marina Venturini
- Department of Clinical and Experimental Sciences, Division of Dermatology, Spedali Civili University Hospital, Brescia, Italy
| | - Marco Castori
- Department of Molecular Medicine, Unit of Medical Genetics, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Marina Colombi
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Bres6cia, Italy
- * E-mail:
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Scheper M, Rombaut L, de Vries J, De Wandele I, van der Esch M, Visser B, Malfait F, Calders P, Engelbert R. The association between muscle strength and activity limitations in patients with the hypermobility type of Ehlers-Danlos syndrome: the impact of proprioception. Disabil Rehabil 2016; 39:1391-1397. [PMID: 27339264 DOI: 10.1080/09638288.2016.1196396] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The patients diagnosed with Ehlers-Danlos Syndrome Hypermobility Type (EDS-HT) are characterized by pain, proprioceptive inacuity, muscle weakness, potentially leading to activity limitations. In EDS-HT, a direct relationship between muscle strength, proprioception and activity limitations has never been studied. The objective of the study was to establish the association between muscle strength and activity limitations and the impact of proprioception on this association in EDS-HT patients. METHODS Twenty-four EDS-HT patients were compared with 24 controls. Activity limitations were quantified by Health Assessment Questionnaire (HAQ), Six-Minute Walk test (6MWT) and 30-s chair-rise test (30CRT). Muscle strength was quantified by handheld dynamometry. Proprioception was quantified by movement detection paradigm. In analyses, the association between muscle strength and activity limitations was controlled for proprioception and confounders. RESULTS Muscle strength was associated with 30CRT (r = 0.67, p = <0.001), 6MWT (r = 0.58, p = <0.001) and HAQ (r = 0.63, p= <0.001). Proprioception was associated with 30CRT (r = 0.55, p < 0.001), 6MWT (r = 0.40, p = <0.05) and HAQ (r = 0.46, p < 0.05). Muscle strength was found to be associated with activity limitations, however, proprioceptive inacuity confounded this association. CONCLUSIONS Muscle strength is associated with activity limitations in EDS-HT patients. Joint proprioception is of influence on this association and should be considered in the development of new treatment strategies for patients with EDS-HT. Implications for rehabilitation Reducing activity limitations by enhancing muscle strength is frequently applied in the treatment of EDS-HT patients. Although evidence regarding treatment efficacy is scarce, the current paper confirms the rationality that muscle strength is an important factor in the occurrence of activity limitations in EDS-HT patients. Although muscle strength is the most dominant factor that is associated with activity limitations, this association is confounded by proprioception. In contrast to common belief proprioception was not directly associated with activity limitations but confounded this association. Controlling muscle strength on the bases of proprioceptive input may be more important for reducing activity limitations than just enhancing sheer muscle strength.
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Affiliation(s)
- Mark Scheper
- a Faculty of Health, ACHIEVE , Center for Applied Research, University of Applied Sciences Amsterdam , Amsterdam , The Netherlands.,b Department of Rehabilitation , Academic Medical Centre, University of Amsterdam , Amsterdam , The Netherlands
| | - Lies Rombaut
- c Department of Rehabilitation Sciences and Physiotherapy , Ghent University , Ghent , Belgium
| | - Janneke de Vries
- a Faculty of Health, ACHIEVE , Center for Applied Research, University of Applied Sciences Amsterdam , Amsterdam , The Netherlands.,b Department of Rehabilitation , Academic Medical Centre, University of Amsterdam , Amsterdam , The Netherlands
| | - Inge De Wandele
- c Department of Rehabilitation Sciences and Physiotherapy , Ghent University , Ghent , Belgium
| | - Martin van der Esch
- a Faculty of Health, ACHIEVE , Center for Applied Research, University of Applied Sciences Amsterdam , Amsterdam , The Netherlands.,d Reade, Amsterdam Rehabilitation Research Centre , Amsterdam , The Netherlands
| | - Bart Visser
- a Faculty of Health, ACHIEVE , Center for Applied Research, University of Applied Sciences Amsterdam , Amsterdam , The Netherlands
| | | | - Patrick Calders
- c Department of Rehabilitation Sciences and Physiotherapy , Ghent University , Ghent , Belgium
| | - Raoul Engelbert
- a Faculty of Health, ACHIEVE , Center for Applied Research, University of Applied Sciences Amsterdam , Amsterdam , The Netherlands.,b Department of Rehabilitation , Academic Medical Centre, University of Amsterdam , Amsterdam , The Netherlands
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Cazzato D, Castori M, Lombardi R, Caravello F, Bella ED, Petrucci A, Grammatico P, Dordoni C, Colombi M, Lauria G. Small fiber neuropathy is a common feature of Ehlers-Danlos syndromes. Neurology 2016; 87:155-9. [PMID: 27306637 DOI: 10.1212/wnl.0000000000002847] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/01/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To investigate the involvement of small nerve fibers in Ehlers-Danlos syndrome (EDS). METHODS Patients diagnosed with EDS underwent clinical, neurophysiologic, and skin biopsy assessment. We recorded sensory symptoms and signs and evaluated presence and severity of neuropathic pain according to the Douleur Neuropathique 4 (DN4) and ID Pain questionnaires and the Numeric Rating Scale (NRS). Sensory action potential amplitude and conduction velocity of sural nerve was recorded. Skin biopsy was performed at distal leg and intraepidermal nerve fiber density (IENFD) obtained and referred to published sex- and age-adjusted normative reference values. RESULTS Our cohort included 20 adults with joint hypermobility syndrome/hypermobility EDS, 3 patients with vascular EDS, and 1 patient with classic EDS. All except one patient had neuropathic pain according to DN4 and ID Pain questionnaires and reported 7 or more symptoms at the Small Fiber Neuropathy Symptoms Inventory Questionnaire. Pain intensity was moderate (NRS ≥4 and <7) in 8 patients and severe (NRS ≥7) in 11 patients. Sural nerve conduction study was normal in all patients. All patients showed a decrease of IENFD consistent with the diagnosis of small fiber neuropathy (SFN), regardless of the EDS type. CONCLUSIONS SFN is a common feature in adults with EDS. Skin biopsy could be considered an additional diagnostic tool to investigate pain manifestations in EDS.
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Affiliation(s)
- Daniele Cazzato
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Marco Castori
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Raffaella Lombardi
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Francesca Caravello
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Eleonora Dalla Bella
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Antonio Petrucci
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Paola Grammatico
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Chiara Dordoni
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Marina Colombi
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Giuseppe Lauria
- From 3rd Neurology Unit and Skin Biopsy (D.C., R.L., F.C., E.D.B., G.L.), Peripheral Neuropathy and Neuropathic Pain Laboratory, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan; Unit of Medical Genetics (M.C., P.G.), Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy; Neurology Unit (A.P.), San Camillo-Forlanini Hospital, Rome; and Division of Biology and Genetics (C.D., M.C.), Department of Molecular and Translational Medicine, University of Brescia, Italy.
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De Wandele I, Rombaut L, De Backer T, Peersman W, Da Silva H, De Mits S, De Paepe A, Calders P, Malfait F. Orthostatic intolerance and fatigue in the hypermobility type of Ehlers-Danlos Syndrome. Rheumatology (Oxford) 2016; 55:1412-20. [DOI: 10.1093/rheumatology/kew032] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Indexed: 01/26/2023] Open
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Scheper MC, Juul-Kristensen B, Rombaut L, Rameckers EA, Verbunt J, Engelbert RH. Disability in Adolescents and Adults Diagnosed With Hypermobility-Related Disorders: A Meta-Analysis. Arch Phys Med Rehabil 2016; 97:2174-2187. [PMID: 26976801 DOI: 10.1016/j.apmr.2016.02.015] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/05/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To (1) establish the association of the most common reported symptoms on disability; and (2) study the effectiveness of treatment on disability in patients with Ehlers-Danlos syndrome-hypermobility type (EDS-HT)/hypermobility syndrome (HMS). DATA SOURCES An electronic search (Medical Subject Headings and free-text terms) was conducted in bibliographic databases CENTRAL/MEDLINE. STUDY SELECTION Comparative, cross-sectional, longitudinal cohort studies and (randomized) controlled trials including patients with HMS/EDS-HT aged ≥17 years were considered for inclusion. A class of symptoms was included when 5 publications were available. In regards to treatment (physical, cognitive interventions), only (randomized) controlled trials were considered. Surgical and medicinal interventions were excluded. DATA EXTRACTION Bias was assessed according to the methodological scoring tools of the Cochrane collaboration. Z-score transformations were applied to classify the extent of disability in comparison with healthy controls and to ensure comparability between studies. DATA SYNTHESIS Initially, the electronic search yielded 714 publications, and 21 articles remained for analysis after selection. The following symptoms were included for meta-analysis: pain (n=12), fatigue (n=6), and psychological distress (n=7). Pain (r=.64, P=.021), fatigue (r=.91, P=.011), and psychological distress (r=.86, P=.018) had a significant impact on disability. Regarding treatment, a significant pain reduction was achieved by a variety of physical and cognitive approaches. Treatment effectiveness on disability was not established. CONCLUSIONS Disability can affect patients with HMS/EDS-HT significantly and is highly correlated with both physical and psychological factors. Although evidence is available that physical and psychological treatment modalities can induce significant pain reduction, the evidence regarding disability reduction is lacking.
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Affiliation(s)
- Mark C Scheper
- Amsterdam Center for Innovative Health Practice, Center for Applied Research, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, The Netherlands; Department of Rehabilitation, Academic Medical Center, Amsterdam, The Netherlands.
| | - Birgit Juul-Kristensen
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark; Institute of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway
| | - Lies Rombaut
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Eugene A Rameckers
- Department of Rehabilitation Medicine, Maastricht University Medical Center, CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands; Adelante Center of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands; Master of Pediatric Physical Therapy, University of Applied Sciences, AVANS+, Breda, The Netherlands
| | - Jeanine Verbunt
- Department of Rehabilitation Medicine, Maastricht University Medical Center, CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands; Adelante Center of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Raoul H Engelbert
- Amsterdam Center for Innovative Health Practice, Center for Applied Research, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, The Netherlands; Department of Rehabilitation, Academic Medical Center, Amsterdam, The Netherlands
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Di Stefano G, Celletti C, Baron R, Castori M, Di Franco M, La Cesa S, Leone C, Pepe A, Cruccu G, Truini A, Camerota F. Central sensitization as the mechanism underlying pain in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. Eur J Pain 2016; 20:1319-25. [DOI: 10.1002/ejp.856] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2016] [Indexed: 12/25/2022]
Affiliation(s)
- G. Di Stefano
- Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - C. Celletti
- Physical Medicine and Rehabilitation Division; Policlinico Umberto I; Sapienza University; Rome Italy
| | - R. Baron
- Division of Neurological Pain Research and Therapy; Universitätsklinikum Schleswig-Holstein; Kiel Germany
| | - M. Castori
- Division of Medical Genetics; Department of Molecular Medicine; San Camillo-Forlanini Hospital; Sapienza University; Rome Italy
| | - M. Di Franco
- Rheumatology Unit; Department of Internal Medicine and Medical Specialities; Sapienza University; Rome Italy
| | - S. La Cesa
- Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - C. Leone
- Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - A. Pepe
- Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - G. Cruccu
- Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - A. Truini
- Department of Neurology and Psychiatry; Sapienza University; Rome Italy
| | - F. Camerota
- Physical Medicine and Rehabilitation Division; Policlinico Umberto I; Sapienza University; Rome Italy
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Dave AJ, Selzer F, Losina E, Klara KM, Collins JE, Usiskin I, Band P, Dalury DF, Iorio R, Kindsfater K, Katz JN. Is there an association between whole-body pain with osteoarthritis-related knee pain, pain catastrophizing, and mental health? Clin Orthop Relat Res 2015; 473:3894-902. [PMID: 26443774 PMCID: PMC4626500 DOI: 10.1007/s11999-015-4575-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 09/28/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Greater levels of self-reported pain, pain catastrophizing, and depression have been shown to be associated with persistent pain and functional limitation after surgeries such as TKA. It would be useful for clinicians to be able to measure these factors efficiently. QUESTIONS/PURPOSES We asked: (1) What is the association of whole-body pain with osteoarthritis (OA)-related knee pain, function, pain catastrophizing, and mental health? (2) What is the sensitivity and specificity for different cutoffs for body pain diagram region categories in relation to pain catastrophizing? METHODS Patients (n = 267) with knee OA undergoing elective TKA at one academic center and two community orthopaedic centers were enrolled before surgery in a prospective cohort study. Questionnaires included the WOMAC Pain and Function Scales, Pain Catastrophizing Scale (PCS), Mental Health Inventory-5 (MHI-5), and a pain body diagram. The diagram documents pain in 19 anatomic areas. Based on the distribution of the anatomic areas, we established six different body regions. Our analyses excluded the index (surgically treated) knee. Linear regression was used to evaluate the association between the total number of nonindex painful sites on the whole-body pain diagram and measures of OA-related pain and function, mental health, and pain catastrophizing. Generalized linear regression was used to evaluate the association between the number of painful nonindex body regions (categorized as 0; 1-2; or 3-6) with our measures of interest. All models were adjusted for age, sex, and number of comorbid conditions. The cohort included 63% females and the mean age was 66 years (SD, 9 years). With removal of the index knee, the median pain diagram score was 2 (25(th), 75(th) percentiles, 1, 4) with a range of 0 to 15. The median number of painful body regions was 2 (25(th), 75(th) percentiles, 1, 3). RESULTS After adjusting for age, sex, and number of comorbid conditions, we found modest associations between painful body region categories and mean scores for WOMAC physical function (r = 0.22, p < 0.001), WOMAC pain (r = 0.20, p = 0.001), MHI-5 (r = -0.31, p < 0.001), and PCS (r = 0.27, p < 0.001). A nonindex body pain region score greater than 0 had 100% (95% CI, 75%-100%) sensitivity for a pain catastrophizing score greater than 30 but a specificity of just 23% (95% CI, 18%-29%) . A score of 3 or greater had greater specificity (73%; 95% CI, 66%-79%) but lower sensitivity (53%; 95% CI, 27%-78%). CONCLUSIONS We found modest associations between the number of painful sites on a whole-body pain diagram and the number of painful body regions and measures of OA-related pain, function, pain catastrophizing, and mental health. Patients with higher self-reported body pain region scores might benefit from further evaluation for depression and pain catastrophizing. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Amish J. Dave
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115 USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Faith Selzer
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Elena Losina
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.189504.10000000419367558Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Kristina M. Klara
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
| | - Jamie E. Collins
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Ilana Usiskin
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA
| | - Philip Band
- grid.137628.90000000121698901Department of Biochemistry and Molecular Pharmacology, NYU Langone Orthopaedic Surgery, NYU School of Medicine, New York, NY USA ,grid.137628.90000000121698901NYU Langone Orthopaedic Surgery, NYU School of Medicine, New York, NY USA
| | - David F. Dalury
- grid.416700.4Department of Orthopaedic Surgery, University of Maryland St Joseph Medical Center, Towson, MD USA
| | - Richard Iorio
- grid.137628.90000000121698901NYU Langone Orthopaedic Surgery, NYU School of Medicine, New York, NY USA
| | | | - Jeffrey N. Katz
- grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA USA ,grid.62560.370000000403788294Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115 USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
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Larson CM, Stone RM, Grossi EF, Giveans MR, Cornelsen GD. Ehlers-Danlos Syndrome: Arthroscopic Management for Extreme Soft-Tissue Hip Instability. Arthroscopy 2015. [PMID: 26198768 DOI: 10.1016/j.arthro.2015.06.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To present outcomes in a series of patients with Ehlers-Danlos syndrome (EDS)-hypermobility type who underwent hip arthroscopy for associated hip pain and extreme capsular laxity. METHODS A retrospective chart review identified 16 hips with confirmed EDS--hypermobility type that underwent hip arthroscopy for continued pain and capsular laxity. All patients had complaints of "giving way" and pain, an easily distractible hip with manual traction under fluoroscopy, and a patulous capsule at the time of surgery. No patient had osseous evidence of acetabular hip dysplasia or prior confirmed hip dislocation. Outcomes were evaluated preoperatively and postoperatively with the modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey (SF-12), and a visual analog scale (VAS) for pain. RESULTS Evidence of symptomatic femoroacetabular impingement (FAI) was found in 15 hips (93.8%). The 16th hip had subjective giving way with a positive anterior impingement test and was easily distractible, had a labral tear, and had a patulous capsule at the time of surgery. The mean follow-up period was 44.61 months (range, 12 to 99 months). The mean preoperative lateral center-edge angle was 31.8° (range, 25° to 44°), and the mean Tönnis angle was 3.6° (range, -2° to 8°). Mean femoral version measured on computed tomography (CT) scans was 19.2° (range, -4.0° to 31.0°). Of the hips, 13 underwent primary arthroscopy and 3 underwent revision. All hips underwent hip arthroscopy with an interportal capsular cut only and arthroscopic capsular plication. There were 13 labral repairs, 2 labral debridements, 8 rim resections, 15 femoral resections, 2 psoas tenotomies, and 1 microfracture. Improved stability with an inability to distract the hip with manual traction under fluoroscopy was noted in all hips after plication. The mean alpha angle preoperatively was 58.7° on anteroposterior radiographs and 63.6° on lateral radiographs compared with 47.4° and 46.1°, respectively, postoperatively. There were significant improvements for all outcomes (mHHS, P = .002; SF-12 score, P = .027; and VAS score, P = .0004). The mean mHHS, SF-12 score, and VAS score were 45.6 points, 62.4 points, and 6.5 points, respectively, preoperatively compared with 88.5 points, 79.3 points, and 1.6 points, respectively, at a mean follow-up of 45 months. No EDS patients were lost to follow-up or excluded from analysis. The mean improvement in mHHS from preoperatively to postoperatively was 42.9 points, and there were no iatrogenic dislocations. One patient underwent further revision arthroscopy for recurrent pain, subjective giving way, and capsular laxity. CONCLUSIONS FAI and extreme capsular laxity can be seen in the setting of EDS. Although increased femoral version was common, acetabular dysplasia was not common in our study. Meticulous capsular plication, arthroscopic correction of FAI when present, and labral preservation led to dramatic improvements in outcomes and subjective stability without any iatrogenic dislocations in this potentially challenging patient population. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Christopher M Larson
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, U.S.A..
| | - Rebecca M Stone
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | - Emma F Grossi
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | - M Russell Giveans
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | - Geoffrey D Cornelsen
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, U.S.A
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Scheper MC, de Vries JE, Verbunt J, Engelbert RHH. Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome (hypermobility type): it is a challenge. J Pain Res 2015; 8:591-601. [PMID: 26316810 PMCID: PMC4548768 DOI: 10.2147/jpr.s64251] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Generalized joint hypermobility (GJH) is highly prevalent among patients diagnosed with chronic pain. When GJH is accompanied by pain in ≥4 joints over a period ≥3 months in the absence of other conditions that cause chronic pain, the hypermobility syndrome (HMS) may be diagnosed. In addition, GJH is also a clinical sign that is frequently present in hereditary diseases of the connective tissue, such as the Marfan syndrome, osteogenesis imperfecta, and the Ehlers-Danlos syndrome. However, within the Ehlers-Danlos spectrum, a similar subcategory of patients having similar clinical features as HMS but lacking a specific genetic profile was identified: Ehlers-Danlos syndrome hypermobility type (EDS-HT). Researchers and clinicians have struggled for decades with the highly diverse clinical presentation within the HMS and EDS-HT phenotypes (Challenge 1) and the lack of understanding of the pathological mechanisms that underlie the development of pain and its persistence (Challenge 2). In addition, within the HMS/EDS-HT phenotype, there is a high prevalence of psychosocial factors, which again presents a difficult issue that needs to be addressed (Challenge 3). Despite recent scientific advances, many obstacles for clinical care and research still remain. To gain further insight into the phenotype of HMS/EDS-HT and its mechanisms, clearer descriptions of these populations should be made available. Future research and clinical care should revise and create consensus on the diagnostic criteria for HMS/EDS-HT (Solution 1), account for clinical heterogeneity by the classification of subtypes within the HMS/EDS-HT spectrum (Solution 2), and create a clinical core set (Solution 3).
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Affiliation(s)
- Mark C Scheper
- School of Physiotherapy, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Janneke E de Vries
- School of Physiotherapy, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Rehabilitation Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - Jeanine Verbunt
- Department of Rehabilitation Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
- Adelante, Center of expertise in Rehabilitation and Audiology, Hoensbroek, the Netherlands
| | - Raoul HH Engelbert
- School of Physiotherapy, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Castori M, Morlino S, Ghibellini G, Celletti C, Camerota F, Grammatico P. Connective tissue, Ehlers-Danlos syndrome(s), and head and cervical pain. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2015; 169C:84-96. [DOI: 10.1002/ajmg.c.31426] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Winger A, Kvarstein G, Wyller VB, Sulheim D, Fagermoen E, Småstuen MC, Helseth S. Pain and pressure pain thresholds in adolescents with chronic fatigue syndrome and healthy controls: a cross-sectional study. BMJ Open 2014; 4:e005920. [PMID: 25287104 PMCID: PMC4187660 DOI: 10.1136/bmjopen-2014-005920] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Although pain is a significant symptom in chronic fatigue syndrome (CFS), pain is poorly understood in adolescents with CFS. The aim of this study was to explore pain distribution and prevalence, pain intensity and its functional interference in everyday life, as well as pressure pain thresholds (PPT) in adolescents with CFS and compare this with a control group of healthy adolescents (HC). METHODS This is a case-control, cross-sectional study on pain including 120 adolescents with CFS and 39 HCs, aged 12-18 years. We measured pain frequency, pain severity and pain interference using self-reporting questionnaires. PPT was measured using pressure algometry. Data were collected from March 2010 until October 2012 as part of the Norwegian Study of Chronic Fatigue Syndrome in Adolescents: Pathophysiology and Intervention Trial. RESULTS Adolescents with CFS had significantly lower PPTs compared with HCs (p<0.001). The Pain Severity Score and the Pain Interference Score were significantly higher in adolescents with CFS compared with HCs (p<0.001). Almost all adolescents with CFS experienced headache, abdominal pain and/or pain in muscles and joints. Moreover, in all sites, the pain intensity levels were significantly higher than in HCs (p<0.001). CONCLUSIONS We found a higher prevalence of severe pain among adolescents with CFS and lowered pain thresholds compared with HCs. The mechanisms, however, are still obscure. Large longitudinal population surveys are warranted measuring pain thresholds prior to the onset of CFS. TRIAL REGISTRATION NUMBER Clinical Trials, NCT01040429; The Norwegian Study of Chronic Fatigue Syndrome in Adolescents: Pathophysiology and Intervention Trial (NorCAPITAL) http://www.clinicaltrials.gov.
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Affiliation(s)
- Anette Winger
- Faculty of Health Sciences, Institute of Nursing, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - Gunnvald Kvarstein
- Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Vegard Bruun Wyller
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Oslo University Hospital, Norway
- Department of Pediatrics, Akershus University Hospital, Norway
| | - Dag Sulheim
- Department of Pediatrics, Oslo University Hospital, Norway
- Department of Pediatrics, Lillehammer County Hospital, Lillehammer, Norway
| | - Even Fagermoen
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Milada Cvancarova Småstuen
- Faculty of Health Sciences, Institute of Nursing, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - Sølvi Helseth
- Faculty of Health Sciences, Institute of Nursing, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
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