Benefits and disadvantages of joint hypermobility among musicians

Articular hypermobility is a protective factor for hand osteoarthritis

OBJECTIVE

Very few studies have evaluated the association of articular hypermobility and radiographic osteoarthritis (OA) in humans. We assessed hypermobility and its relationship to radiographic hand OA in a family-based study.

METHODS

A total of 1,043 individuals were enrolled in the multicenter Genetics of Generalized Osteoarthritis study, in which families were required to have 2 siblings with radiographic OA involving >/=3 joints (distributed bilaterally) of the distal interphalangeal (DIP), proximal interphalangeal (PIP), or carpometacarpal (CMC) joint groups, and OA in at least one DIP joint. Radiographic OA was defined as a score of >/=2 on the Kellgren/Lawrence scale in one or more joints within the group. The Beighton criteria for assessment of hypermobility were recorded on a 0-9-point scale. Hypermobility was defined as a Beighton score of >/=4, a threshold generally used to establish a clinical diagnosis of joint laxity. A threshold of >/=2 was also evaluated to assess lesser degrees of hypermobility. The Beighton score for the present was calculated based on clinical examination, and that for the past was based on recall of childhood hypermobility in the first 2 decades of life. The association of hypermobility and radiographic OA of the PIP, CMC, and metacarpophalangeal joints was evaluated in all participants and in men and women separately. Multiple logistic regression was used to examine the relationship of hypermobility with radiographic OA in each joint group, after adjusting for age and sex. The association of hypermobility and DIP OA was not evaluated, because evidence of DIP OA was required for study inclusion.

RESULTS

Using a threshold Beighton score of 4, 3.7% of individuals were classified as hypermobile based on the present examination, and 7.4% were classified as hypermobile based on the past assessment. A significant negative association between present hypermobility and age was observed. In persons with hypermobility, the odds of OA in PIP joints was lower (for present, odds ratio [OR] 0.34, 95% confidence interval [95% CI] 0.16-0.71; for past, OR 0.43, 95% CI 0.24-0.78). Similar results were obtained using a threshold Beighton score of 2. The lower odds of PIP OA with hypermobility were significant after adjusting for sex and age (for present, OR 0.44, 95% CI 0.20-0.94; for past, OR 0.48, 95% CI 0.26-0.87).

CONCLUSION

This study demonstrated a joint-protective effect of hypermobility for radiographic OA of PIP joints. In contrast to previous studies showing an association of hypermobility and CMC OA, in this cohort there was no evidence for increased odds of OA in any joint group of the hand in association with articular hypermobility.

Joint hypermobility

Joint hypermobility is an area of neglect in rheumatology. That is not to say it is overlooked by rheumatologists. It is spotted when sought, but for many unfortunate patients, here the story ends. The act of recognition becomes the goal in itself rather than the medium through which effective therapy can be provided. This chapter serves to reinforce the clinical and epidemiological importance of a common disorder whose significance is under-appreciated and impact largely ignored. In contradistinction to our earlier chapter, published in 2000, which took for its remit the heritable disorders of connective tissue in general, the current one focuses on the commonly encountered (so-called benign) joint hypermobility syndrome, its recognition, epidemiology, clinical features and management according to the most recent literature.

Examination and interface with the musician

Musicians are special patients and this fact has to find expression in the history taking and examination of musicians. The consulting hand surgeon has to develop a consistent concept of history taking and examination that respects all the specific facets of the musician's environment and techniques, besides and beyond the usual hand surgical standards. There has to be an emphasis on exhaustive examination of subtle technical and ergonomic details, which in many cases reveals the pathogenic origin or source of the musician's complaint. From this can be delivered the clues for establishing the specific solutions and therapy concepts, whereas the standard hand surgical concepts might be misleading.

Neuromuscular problems in musicians

BACKGROUND

Musicians are an occupational (or avocational) group that may on occasion have highly specific health care problems apparently caused by or adversely affecting instrumental performance. Neurologists have been intimately involved in the development of a burgeoning interest in these disorders and, because of the nature of the most common symptoms, neurologists can expect to be called upon to evaluate such patients.

REVIEW SUMMARY

In this review, the most common playing-related disorders are discussed. These include the regional pain syndromes, primarily involving the neck and upper extremity, the focal neuropathies, again predominantly involving the upper extremity, and the focal dystonias or occupational cramps, which typically affect the hand or the cranial-innervated muscles involved in the embouchure (the relationship of the facial musculature to the mouthpiece of the instrument). Risk factors contributing to the development of these disorders are reviewed, the diagnostic approach is described, and the management of these playing-related problems is summarized. Aspects in which the instrumental musician may differ from other patients commonly seen by the neurologist, particularly with respect to the types of problems seen, methods of evaluation, and therapeutic strategies, are emphasized.

CONCLUSIONS

Many unanswered questions remain in each of these areas. Neurologists and neuroscientists are in an excellent position to help fill the voids in our knowledge base. It is hoped that the reader will be stimulated to participate in this effort.

Incidence of overuse syndromes of the upper limb in young pianists and its correlation with hand size, hypermobility and playing habits

The incidence of overuse syndromes of the elbow, wrist and hand was evaluated in a series of 66 pianists: 28 presented such a pathology. No significant correlation with starting age, or duration and intensity of practice was revealed. Smaller hands lead to more frequent overuse syndromes, in both males and females. Conditioning, sports activity, playing a second or third instrument, warming-up before playing and stretching afterwards did not influence the incidence of overuse syndromes. Pianists were not more hypermobile than a sex- and age-matched control group, nor was there any significant difference in hypermobility between pianists with and without overuse problems. There was no significant difference in incidence between the left and right side.

Heritable disorders of connective tissue

This chapter seeks to draw readers' attention to the importance of the heritable disorders of connective tissue in clinical practice. It describes the principal features of the Marfan and Ehlers-Danlos syndromes, osteogenesis imperfecta and benign joint hypermobility syndrome, their clinical and prognostic similarities and differences, and their distinguishing features. Recently revised international classifications drawing on advances in molecular genetics are described in detail. Wherever possible, patients' symptoms are explained on the basis of the altered biomechanics of genetically aberrant connective tissue matrix proteins. Finally, the chapter draws attention to the often unrecognized burden of chronic pain borne by patients with these conditions, a feature of which many rheumatologists seem unaware, and sets out a rational and holistic approach to treatment and management that is based on the best currently available evidence.

Articular hypermobility in Icelandic 12-year-olds

OBJECTIVE

To examine the prevalence of articular hypermobility and its relationship to musculoskeletal pain in Icelandic 12-yr-olds, and to obtain baseline data for a prospective study on the subject.

METHODS

A total of 267 12-yr-olds were examined for articular hypermobility by the Beighton criteria. The children also answered a questionnaire concerning musculoskeletal pain and injuries, sports and musical activity.

RESULTS

The prevalence of hypermobility (defined as >/=4 Beighton criteria) was 40.5% in girls and 12.9% in boys. Despite slight trends for hypermobile subjects to be less active in sports and to report more joint pain, no correlation could be found between hypermobility and musculoskeletal symptoms.

CONCLUSIONS

An unusually marked sex difference in hypermobility exists among Icelandic 12-yr-olds, but hypermobility does not seem to affect joint symptoms or leisure activities at this age.

Hypermobility and peripartum pelvic pain syndrome in pregnant South African women

OBJECTIVE

To determine the incidence and correlation of joint hypermobility (HM) and peripartum pelvic pain (PPPP) in an homogeneous pregnant South African population.

STUDY DESIGN

A cross-sectional study among Cape Coloured pregnant women. Joint mobility was measured by Beighton score; PPPP with a specially developed PPPP score.

RESULTS

Using the Beighton scores with a cut-off point of HM > or = 5/9, only 4.9% of the 509 pregnant women were hypermobile. Hyperextension of the elbow was the largest contributor to HM (35.4%). No correlation of HM with the incidence of PPPP was established. Only 20 very mild cases of PPPP were recorded. Back pain increased significantly during pregnancy to a mean of 38%. Right handedness occurred in 95.9%. No significant relation was found between HM and the non-dominant side.

CONCLUSION

Hypermobility in pregnant Cape Coloured women was surprisingly low (4.9%) with a decrease with age, but no increase during pregnancy. Peripartum pelvic pain is virtually absent and has no correlation with joint laxity. Back pain increased during pregnancy to a mean of 38%. Right handedness was high (96%) in comparison with the world-wide figure of 85%. No correlation was found between the dominant body side and hypermobility.

Joint hypermobility and genetic collagen disorders: are they related?

The HDCTs constitute a heterogeneous group of rare genetically determined diseases, the best known of which are Ehlers-Danlos and Marfan syndromes and osteogenesis imperfecta. Hypermobility is a feature common to them all, but it is also a feature that is highly prevalent in the population at large. Symptomatic hypermobile subjects (whose symptoms are attributable to their hypermobility) are said to be suffering from the benign joint hypermobility syndrome, which has many features that overlap with the HDCTs. It is not yet known whether there is a variety of hypermobility (symptomatic or otherwise) that is not part of a connective tissue disorder.

Hypermobility in two Dutch school populations

OBJECTIVE

To determine the presence of hypermobility and differences between females and males in a Dutch population.

STUDY DESIGN

Joint mobility was measured in a primary and a secondary school population. Beighton and Biro measurements were used. The data were evaluated statistically.

RESULTS

Using the Beighton score, 15.5% of group I (n = 252; 4-13 years) and 13.4% of group II (n = 658; 12-17 years) were hypermobile. Hypermobility was found more in females than in males, the difference being significant in the older group. Overall, hypermobility did not significantly diminish with ageing, although the individual joints did not show a significant decrease in mobility with ageing. Hypermobility was significantly more pronounced at the non-dominant body side in both groups. The Quetelet-index did not show a significant relation to hypermobility.

CONCLUSION

Hypermobility was found more in females than in males, with a trend of decrease of hypermobility with ageing. The non-dominant body side proved to be more hypermobile and the Quetelet-index did not show a relation to hypermobility. Beighton's measurements proved best, since Biro considers the two body sides being equal.

Pathogenesis and treatment of osteoarthritis

OA represents the final common pathway of a number of pathologic processes. The challenge is to define and classify the subsets of OA to understand the causes and to devise specific therapies. Effective chondroprotective therapies will be most useful when applied to high-risk individuals before the emergence of symptomatic OA. This will be feasible only with an improved understanding of the complex interaction of genes and environment in the OA disease process. Moreover, identifying the heritable bases of this disease will provide insight into the molecular mechanisms of the complex pathway that results in OA. Clinicians who encounter and treat OA patients can look forward to the development of more effective and innovative therapies based on a rapidly improving understanding of OA.

Lower extremity injuries in college athletes: relation between ligamentous laxity and lower extremity muscle tightness

OBJECTIVE

Two components of flexibility, muscle tightness, and ligamentous laxity in college athletes were studied to determine whether these factors were associated with the incidence of lower extremity injuries.

DESIGN

Prospective cohort study.

SETTING

College athletic department.

PARTICIPANTS

201 college athletes.

OUTCOME MEASURES

College men and women athletes were tested for ligamentous laxity with the Beighton scale and for muscle tightness with a new scale based on the tightness of the iliopsoas, iliotibial band, hamstring, rectus femoris, and gastrocsoleus muscles. Lower extremity injuries incurred during practice and play were recorded during the following year.

RESULTS

Of the 201 athletes tested, 71 sustained 115 injuries. For each additional point on the 9-point ligamentous laxity scale (9 = hyperlax), the risk of injury decreased 16%. For each additional point on the 10-point muscle-tightness scale (10 = all muscles tight), the risk of injury increased 23%. The two scores were moderately inversely correlated (Spearman's rho = -0.3; p < .001). Women had greater mean (+/- SD) laxity scores than men (3.3 +/- 2.2 vs. 1.8 +/- 2.0; p < .001) and lower mean overall muscle tightness scores (1.5 +/- 1.6 vs. 3.5 +/- 2.1; p < .001). Among Women athletes, the rate of lower extremity injury was unrelated to ligamentous laxity or to flexibility. Among men, lower extremity injuries were associated with lower ligamentous laxity scores (p = .008) and greater muscle tightness (p = .04).

CONCLUSIONS

This study introduces a new scale for lower extremity muscle tightness. Tight ligaments and muscles are related to injury in men, but not women, college athletes. A preseason flexibility program may decrease injuries in college men athletes.

Musculoskeletal and neuromuscular conditions of instrumental musicians

Performing Arts Medicine is a broad field that includes the study of medical conditions and injuries incurred by dancers, instrumental musicians, and vocalists. This article summarizes the most relevant literature of approximately the past 10 years concerning the musculoskeletal and neuromuscular conditions of musicians. A literature search was done for relevant articles in English by physicians or scientists. Some older, but fundamental, articles are included; incidental case reports were excluded to the extent possible. Included were articles on incidence, prevalence, pathophysiology, diagnosis, treatment, and biomechanical studies in musicians. Although nearly all of these conditions are the same ones seen in the general work force, it is clear that their occurrence patterns in the professional musician are unique, as is their impact on the life and livelihood of the patient. The content of the Arts Medicine literature does not permit a truly critical review. Research in the last 10 years appears not to have been done in a true blinded, random case-controlled fashion. Many authors support their statements with only their respective clinical experiences. The research cited here includes 58 series, 9 case studies, 5 surveys, 2 pre/post intervention studies, and 1 double-blind crossover clinical trial.

Benefits and liabilities of hypermobility in the back pain disorders of industrial workers

OBJECTIVES

Back pain disorders, sometimes called 'the nemesis of medicine and the albatross of industry', are ubiquitous, but have stubbornly defied diagnosis and treatment. Hypermobility syndrome, which is also very common, has been called 'an enigma of human physiology'. Both conditions have attracted wide attention and interest only recently. In an earlier study, we considered the benefits and liabilities of joint hypermobility by studying 660 musicians in the USA. In a parallel manner, the present study analysed the back pain disorders of 606 workers in a Swedish high-technology industrial plant in the context of spinal hypermobility.

SUBJECTS AND METHODS

The 606 industrial workers were examined for spinal hypermobility using a standard protocol, and interviewed for work-related body-posture requirements and the low back, shoulder and neck pain disorders experienced by them. The data were analysed for associations between hypermobility and physical complaints as a whole, and by taking into account gender and body-postures at work.

RESULTS

Twenty-six per cent (37) of 144 workers with hypermobility but only 14% (64) of 453 without hypermobility experienced back pain (P < 0.002). Among the 326 workers with sitting or standing jobs, 40% (29) of 71 with hypermobility had back pain, whereas only 12% (30) of the 255 without hypermobility experienced back pain (P < 0.001). The corresponding numbers with back pain for 235 in jobs with changing body-postures were 4.5% (3) of 66 with hypermobility and 14% (14) of 169 without hypermobility (P = 0.04).

CONCLUSIONS

Hypermobility of the spine is an asset if the work requires change of body-posture, but a liability for those in a standing or sitting assignment. It reinforces a similar hypothesis proposed by Larsson et al.

Differences in joint mobility and foot pressures between black and white diabetic patients

Limited joint mobility is common in diabetes and is related to high foot pressures and foot ulceration. We have examined the differences in joint mobility and foot pressures in four groups matched for age, sex, and duration of diabetes: 31 white diabetic, 33 white non-diabetic, 24 black diabetic, and 22 non-diabetic black subjects. Joint mobility was assessed using a goniometer at the fifth metacarpal, first metatarsal, and subtalar joints. In-shoe and without shoes foot pressures were measured using an F-Scan system. Neuropathy was evaluated using clinical symptoms (Neuropathy Symptom Score), signs (Neuropathy Disability Score), and Vibration Perception Threshold. There was no difference between white and black diabetic patients in Neuropathy Symptom Score, Neuropathy Disability Score, and Vibration Perception Threshold. Subtalar joint mobility was significantly reduced in white diabetic patients (22 +/- 7 degrees) compared to white controls (26 +/- 4 degrees, black diabetic patients (25 +/- 5 degrees), and black controls (29 +/- 7 degrees), and increased in black controls compared to white controls and black diabetic patients (level of statistical significance p < 0.05). Without shoes foot pressures were higher in white diabetic patients (8.31 +/- 400 kg cm-2) compared to white controls (6.81 +/- 2.31 kg cma2), black diabetic patients (6.2 +/- 2.53 kg cm-2) and black controls (5.00 +/- 1.24 kg cm-2) and lower in black controls compared to white and black diabetic patients (p < 0.05 in all cases). We conclude that racial differences exist in joint mobility and foot pressures between black and white subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Work absence in a cohort with benign back pain: Prospective study with 10 year follow-up

A cohort of nearly 1000 men with some level of back problems at time of their drafting were prospectively followed over a 10-year period. In connection with drafting for military service they answered a questionnaire and were clinically examined. The main aim of the study was to follow work absence and the impact of back pain on everyday life. Everyday problems because of the back pain did not significantly increase over the follow-up period and self-reported work absence decreased. Heavy work was associated with an increased risk for work absence but not for back/neck problems.