Joint hypermobility and genetic collagen disorders: are they related?

Gait kinematics and passive knee joint range of motion in children with hypermobility syndrome

Hypermobility syndrome (HMS) is characterised by generalised joint laxity and musculoskeletal complaints. Gait abnormalities have been reported in children with HMS but have not been empirically investigated. The extent of passive knee joint range of motion (ROM) has also not been well reported in children with HMS. This study evaluated gait kinematics and passive knee joint ROM in children diagnosed with HMS and healthy controls. Thirty-seven healthy children (mean age±SD=11.5±2.6 years) and 29 children with HMS (mean age±SD=11.9±1.8 years) participated. Sagittal knee motion and gait speed were evaluated using a VICON 3D motion analysis system. Passive knee ROM was measured with a manual goniometer. Independent t-tests compared the values of sagittal knee motion and gait speed between the two groups. Mann-Whitney U tests compared passive knee ROM between groups. Passive ROM (extension and flexion) was significantly higher (both p<0.001) in children with HMS than the healthy controls. Peak knee flexion (during loading response and swing phase) during walking was significantly lower (both p<0.001) in children with HMS. Knee extension in mid stance during walking was significantly increased (p<0.001) in children with HMS. However, gait speed was not statistically (p=0.496) different between the two groups. Children with HMS had higher passive knee ROM than healthy children and also demonstrated abnormal knee motion during gait. Gait re-education and joint stability exercise programmes may be of value to children with HMS.

An exploration of the prevalence of hypermobility and joint hypermobility syndrome in Omani women attending a hospital physiotherapy service

BACKGROUND AND OBJECTIVES

Joint hypermobility syndrome (JHS) is an inherited disorder of connective tissue. It presents as a condition in which there are neuromusculoskeletal signs and symptoms, including pain, without the inflammatory component of a joint disease such as rheumatoid arthritis. Re-attendance in rheumatology clinics, re-injury and prolonged rehabilitation are also features of JHS. The primary aims of this study were to establish the prevalence of hypermobility and JHS in those attending physiotherapy clinics with neuromusculoskeletal disorders in Oman.

METHODS

A cross-sectional case control study design was used. The participant population included Omani women, aged 18-50 years, attending physiotherapy services for musculoskeletal complaints. The comparison population comprised women of a similar age and ethnic origin who were staff at the hospital. The primary outcome measures were the Beighton Score and the Brighton Criteria.

RESULTS

A total of 184 subjects were recruited into the study. These consisted of 94 in the participant group and 90 in the comparison group. Hypermobility was recorded in 51% of the participant group and 30% of the comparison group. The number of participants with JHS was 55%, while 21% of the comparison group exhibited features of the JHS phenotype without pain. A significant number of participants with JHS were re-attending for treatment compared with those without JHS.

CONCLUSIONS

This study confirms a high prevalence of JHS among subjects with musculoskeletal signs and symptoms and that re-attendance for physiotherapy treatment is more frequent in subjects with JHS than in those without.

Do hypermobile subjects without pain have alteration to the feedback mechanisms controlling the shoulder girdle?

OBJECTIVES

It has been reported that hypermobile subjects have proprioceptive deficits. However, it remains unclear whether pain-free subjects with hypermobility also have deficits.

METHODS

Ten subjects with hypermobility and nine without hypermobility were recruited following ethical approval and informed consent. Shoulder mobility, joint position sense (JPS) and a reflex of trapezius evoked from arm afferents were compared.

RESULTS

There was greater shoulder mobility in the hypermobile group (p = 0.004). There were no differences in shoulder JPS between the groups (p = 0.27), although, the hypermobile group displayed a larger degree of variability (p = 0.014). Finally, there were no differences in the latency of upper and lower trapezius reflexes evoked from arm afferents (p = 0.86 and 0.98, respectively).

CONCLUSIONS

In a group of people with hypermobility without shoulder problems, there was no difference in either shoulder JPS or reflex latency when compared with a non- hypermobile group. The relevance of pain to proprioceptive deficits is discussed.

Comparative clinical profile of postural orthostatic tachycardia patients with and without joint hypermobility syndrome

BACKGROUND

Autonomic dysfunction is common in patients with the joint hypermobility syndrome (JHS). However, there is a paucity of reported data on clinical features of Postural orthostatic tachycardia syndrome (POTS) in patients suffering from JHS.

METHODS

This retrospective study was approved by our local Institutional Review Board (IRB). Over a period of 10 years, 26 patients of POTS were identified for inclusion in this study. All these patients had features of Joint Hypermobility Syndrome (by Brighton criterion). A comparison group of 39 patients with other forms of POTS were also followed in the autonomic clinic during the same time. We present a descriptive report on the comparative clinical profile of the clinical features of Postural Orthostatic Tachycardia patients with and without Joint Hypermobility syndrome. The data is presented as a mean+/-SD and percentages wherever applicable.

RESULTS

Out of 65 patients, 26 patients (all females, 20 Caucasians) had POTS and JHS. The mean age at presentation of POTS was 24+/-13 (range 10-53 years) vs 41+/-12 (range 19-65 years), P=0.0001, Migraine was a common co morbidity 73 vs 29% p=0,001. In two patients POTS was precipitated by pregnancy, and in three by surgery, urinary tract infection and a viral syndrome respectively. The common clinical features were fatigue (58%), orthostatic palpitations (54%), presyncope (58%), and syncope (62%).

CONCLUSIONS

Patients with POTS and JHS appear to become symptomatic at an earlier age compared to POTS patients without JHS. In addition patients with JHS had a greater incidence of migraine and syncope than their non JHS counterparts.

Joint hypermobility syndrome pain

Joint hypermobility syndrome (JHS) was initially defined as the occurrence of musculoskeletal symptoms in the presence of joint laxity and hypermobility in otherwise healthy individuals. It is now perceived as a commonly overlooked, underdiagnosed, multifaceted, and multisystemic heritable disorder of connective tissue (HDCT), which shares many of the phenotypic features of other HDCTs such as Marfan syndrome and Ehlers-Danlos syndrome. Whereas the additional flexibility can confer benefits in terms of mobility and agility, adverse effects of tissue laxity and fragility can give rise to clinical consequences that resonate far beyond the confines of the musculoskeletal system. There is hardly a clinical specialty to be found that is not touched in one way or another by JHS. Over the past decade, it has become evident that of all the complications that may arise in JHS, chronic pain is arguably the most menacing and difficult to treat.

Prevalence of joint hypermobility and patterns of articular manifestations in patients with inflammatory bowel disease

Objective. The objective is the investigation of Joint Hypermobility (JH) and the Hypermobility Syndrome (HMS) in patients with inflammatory bowel disease (IBD). Methods. We examined 83 patients with IBD and 67 healthy individuals for the presence of JH. Patients were excluded if they were under 18 or over 50 years of age and if they had other conditions which affect joint mobility. The x² and the Fisher exact test were used appropriately between study groups. Odds ratios (ORs) for the risk of JH and HMS in IBD groups were calculated. Results. A total of 150 individuals (83 IBD patients and 67 healthy controls) participated in the study. 69 IBD patients, 41 with Crohn's Disease (CD) and 28 with ulcerative colitis (UC), were finally eligible. JH was detected in 29 CD patients (70.7%), in 10 UC patients (35.7%), and in 17 healthy control subjects (25.4%). Significant difference was detected on JH in CD patients as compared to UC patients (P = .0063) and controls (P < .0001). The estimated OR for JH was 7.108 (95% CI: 2.98–16.95) in CD and 1.634 (95% CI: 0.63–4.22) in UC patients. HMS was detected in 5 (12.2%) CD and in 1 (3.57%) UC patients. The OR for HMS in CD was 3.75 (95% CI: 0.41–34.007), while 7 (17.1%) CD patients had overlapping symptoms for both HMS and early spondylarthropathy. Conclusions. JH and the HMS are common in CD patients, thus articular manifestations should be carefully interpreted. This implies an involvement of collagen varieties in the pathogenesis of IBD.

[Hiperlaxity ligamentous (Beighton test) in the 8 to 12 years of age school population in the province of Granada]

The Beighton test is the most commonly used tool for detecting ligamentous hiperlaxity, characterized by excessive joint mobility. This descriptive-transversal study examines a sample of 2956 children (49,9% boys and 50,1% girls), from eight to twelve years of age, living in the province of Granada, The study aims to show the incidence level of hiperlaxity among the school-aged population, while establishing its frequency in relation to gender and age, and determining the area with the highest number of cases within the province of Granada. The Beighton test was used for data collection. The sample showed that 25, 4% of individuals got a positive Beighton result (laxity), and girls had a higher incidence level (62,1%) than boys. The results show as well a similar level of incidence among boys and girls between eight and ten years of age; however, the incidence decreases among younger children (under 8 years). Regarding the geographical areas, the distribution is quite heterogeneous, but we were able to highlight the difference between a result of 50% in Area 4 and 12% in Area 2, due to genetic and racial factors. In conclusion, the results obtained through this study show a lower hiperlaxity incidence compared to the results found in the American continent and they are slightly higher than those from other European and African countries.

A unified multiscale mechanical model for soft collagenous tissues with regular fiber arrangement

In this paper the mechanical response of soft collagenous tissues with regular fiber arrangement (RSCTs) is described by means of a nanoscale model and a two-step micro-macro homogenization technique. The non-linear collagen constitutive behavior is modeled at the nanoscale by a novel approach accounting for entropic mechanisms as well as stretching effects occurring in collagen molecules. Crimped fibers are reduced to equivalent straight ones at the microscale and the constitutive response of RSCTs at the macroscale is formulated by homogenizing a fiber reinforced material. This approach has been applied to different RSCTs (tendon, periodontal ligament and aortic media), resulting effective and accurate as proved by the excellent agreement with available experimental data. The model is based on few parameters, directly related to histological and morphological evidences and whose sensitivity has been widely investigated. Applications to simulation of some physiopathological mechanisms are also proposed, providing confirmation of clinical evidences and quantitative indications helpful for clinical practice.

[The joint hypermobility syndrome in a Cuban juvenile population]

In order to review the rise in joint hypermobility syndrome, identify the patterns associated with this diagnosis and correlate its most relevant symptoms, we did a descriptive transversal analytic study in a group of 280 young people of both genders between 15 and 17 years of age. A survey was carried out by the authors in order to get reach these objectives. The data were analyzed by means of descriptive statistics and processed with the Epidat3.1 software package. Results are shown in charts.

RESULTS

The joint hypermobility syndrome (JHS) was diagnosed in 32 people (11,4% of the population studied) with mean age 15,7 years, predominance in the female sex and in the white skin group (p<0,01) 53.1% of those patients with hypermobility presented skin lesions associated to hereditary diseases of the connective tissue; among them the most relevant clinical sign was the presence of hematomas (p=0.003). Symptoms of dysautonomia were associated to JHS (p⩽0.05) and correlated positively with the presence of hematomas. Moderate and severe chronic pain was also a feature of patients with the syndrome (p=0.001) and was correlated in a positive manner to the hematomas.

CONCLUSIONS

Vascular affection as demonstrated by the formation of hematomas was the skin lesion more important among young people with JHS in this study. These lesions can be representative of the syndrome and a translate a larger damage at the connective tissue level.

Neonatal familial Evans syndrome associated with joint hypermobility and mitral valve regurgitation in three siblings in a Saudi Arab family

The occurrence of autoimmune hemolytic anemia and immune thrombocytopenia in the absence of a known underlying cause led to the diagnosis of Evans syndrome in a 9-month-old male. Subsequently, a similar diagnosis was made in two siblings (a 3-year-old boy and a 1-day-old girl). The 9-month-old had a chronic course with exacerbations. He was treated with steroids, intravenous immunoglobulin and colchicine with a variable response. He died of congestive heart failure at the age of 8 years. The brotherâs disease course was one of remission and exacerbation. With time, remissions were prolonged and paralleled an improvement in joint hypermobility. The sister died of sepsis after a chronic course with severe exacerbations. Only two families with Evans syndrome have been reported in the English medical literature. In one report (in a Saudi Arab family), the disease was associated with hereditary spastic paraplegia.

The COL5A1 genotype is associated with range of motion measurements

There is an interest in identifying the intrinsic risk factors, including altered musculotendinous flexibility, that may be associated with musculotendinous injuries. We have recently shown that a sequence variant, namely the BstUI restriction fragment length polymorphism (RFLP), within the COL5A1 gene is associated with chronic Achilles tendinopathy. Mutations within COL5A1 have been implicated in Ehlers Danlos syndrome, a condition that is characterized by joint hypermobility. The aim of this study was to investigate the association of sequence variants within COL5A1 and musculotendinous range of motion (ROM). The sit and reach (SR) and the passive straight leg raise (SLR) were measured on 119 Caucasian subjects with either a past, current or no history of Achilles tendon injuries. The subjects were genotyped for four sequence variants within the 3'-UTR of the COL5A1 gene. Gender (P=0.016), age (P=0.011) and the BstUI RFLP (P=0.010) jointly contributed significantly to the optimal SLR model which accounted for 19.3% of the variance. The factors contributing significantly to SR, which accounted for 28.8% of the variance, were weight (P=0.004), age (P<0.001) and the BstUI RFLP (P=0.001). These data suggest that the COL5A1 BstUI RFLP is independently associated with lower limb ROM within the cohort investigated in this study.

Inverse association of general joint hypermobility with hand and knee osteoarthritis and serum cartilage oligomeric matrix protein levels

OBJECTIVE

Extensive joint hypermobility, lower serum cartilage oligomeric matrix protein (COMP) levels, and early-onset osteoarthritis (OA) are phenotypes of inherited pseudoachondroplasia and multiple epiphyseal dysplasia. However, few studies have evaluated the association between articular hypermobility and primary OA. We undertook the present study to evaluate this association and to test the hypothesis that COMP levels are associated with hypermobility in patients with OA and individuals without OA.

METHODS

Two separate cohorts were available for analysis, the CARRIAGE (CARolinas Region Interaction of Aging Genes and Environment) extended family and a subset of the GOGO (Genetics of Generalized Osteoarthritis) sibpair cohort. In the CARRIAGE family, we performed hand and knee examinations and hypermobility evaluations (Beighton criteria) and obtained sera for measurement of COMP and hyaluronan (HA). Data on COMP and HA levels and extensive joint radiographic and hypermobility data were also available for the GOGO cohort.

RESULTS

The prevalence of hypermobility was 13% in the CARRIAGE family and 5% in the GOGO cohort. In the CARRIAGE family, hypermobility was associated with a significantly reduced prevalence of hand (especially proximal interphalangeal joint) and knee OA and lower mean serum COMP levels, both in the total cohort and in non-hand-OA subgroups. These results were further validated in the GOGO subsets without radiographic OA, in which hypermobility was also associated with a significantly reduced mean serum COMP level (P < 0.0001 adjusted for age). Serum HA levels did not differ in relation to hypermobility in either cohort.

CONCLUSION

The present results indicate that there is an inverse relationship between hypermobility and hand and knee OA, and that hypermobility is associated with lower serum COMP levels. Genetic variations of the COMP gene may account for some subgroups of benign joint hypermobility.

The differential diagnosis of children with joint hypermobility: a review of the literature

BACKGROUND

In this study we aimed to identify and review publications relating to the diagnosis of joint hypermobility and instability and develop an evidence based approach to the diagnosis of children presenting with joint hypermobility and related symptoms.

METHODS

We searched Medline for papers with an emphasis on the diagnosis of joint hypermobility, including Heritable Disorders of Connective Tissue (HDCT).

RESULTS

3330 papers were identified: 1534 pertained to instability of a particular joint; 1666 related to the diagnosis of Ehlers Danlos syndromes and 330 related to joint hypermobility.There are inconsistencies in the literature on joint hypermobility and how it relates to and overlaps with milder forms of HDCT. There is no reliable method of differentiating between Joint Hypermobility Syndrome, familial articular hypermobility and Ehlers-Danlos syndrome (hypermobile type), suggesting these three disorders may be different manifestations of the same spectrum of disorders. We describe our approach to children presenting with joint hypermobility and the published evidence and expert opinion on which this is based.

CONCLUSION

There is value in identifying both the underlying genetic cause of joint hypermobility in an individual child and those hypermobile children who have symptoms such as pain and fatigue and might benefit from multidisciplinary rehabilitation management.Every effort should be made to diagnose the underlying disorder responsible for joint hypermobility which may only become apparent over time. We recommend that the term "Joint Hypermobility Syndrome" is used for children with symptomatic joint hypermobility resulting from any underlying HDCT and that these children are best described using both the term Joint Hypermobility Syndrome and their HDCT diagnosis.

Motor performance in children with generalized hypermobility: the influence of muscle strength and exercise capacity

PURPOSE

The aim of this study was to investigate whether muscle strength and functional exercise capacity (FEC) influence motor performance in children with generalized joint hypermobility.

METHODS

Forty-one children (mean age: 8.1 years) with symptomatic generalized hypermobility were included. Motor performance was assessed using the Körperkoordinationstest für Kinder (KTK) and the Movement Assessment Battery for Children. Muscle strength and FEC were measured with a handheld dynamometer and the 6-minute walk test.

RESULTS

Only muscle strength was significantly positively associated with motor performance on the KTK. FEC was significantly decreased. Children's scores on the KTK were significantly lower (p < 0.001) compared with scores on the Movement Assessment Battery for Children.

CONCLUSIONS

The KTK is a more sensitive tool for detecting motor problems in children with generalized joint hypermobility, but is not associated with FEC. Along with the KTK, the 6-minute walk test can be used to independently assess and evaluate FEC.

Avaliação da flexibilidade muscular entre meninos e meninas de 7 e 8 anos

A flexibilidade muscular tem importante papel na prevenção de algumas patologias musculoesqueléticas, além de influenciar a postura. A criança em desenvolvimento apresenta maior flexibilidade. O objetivo deste foi avaliar a flexibilidade de crianças de 7 e 8 anos e a existência de diferença entre sexo e idade para essa variável. Foram avaliadas 230 crianças das escolas municipais da cidade de Amparo, SP. A amostra constituiu-se de 130 meninas e 100 meninos saudáveis, com índice de massa corporal menor que o 85º percentil, que não praticavam esporte institucionalizado ou exercício físico em freqüência maior que duas vezes e/ou 3 horas por semana. A flexibilidade foi medida pelo teste da distância do 3º dedo ao solo. Os dados foram tratados estatisticamente para verificar a existência de diferenças de sexo e idade, adotando-se o nível de significância de 5%. Foi encontrada diferença significante de sexo (p=0,05), tendo as meninas apresentado maior distância (29,15±8,80 cm) 3º dedo-solo que os meninos (27,41±10,01 cm). Não houve diferenças entre as idades (p=0,725). As meninas apresentaram menor flexibilidade que os meninos.

Benign Joint Hypermobility Syndrome: Psychological Features and Psychopathological Symptoms in a Sample Pain-Free at Evaluation

30 subjects with BJHS (Hypermobile) ( M age = 32.3 yr., SD = 10.4) and two control groups, 25 healthy subjects (Healthy) ( M age = 33.9 yr., SD = 93) and 30 fibromyalgic patients (Fibromyalgic) ( M age = 32.2 yr., SD = 9.4), were given the Symptom Checklist-90-R, the Illness Behavior Questionnaire, the Female Functional Symptoms Frequency (FFF) and the Male Functional Symptoms Frequency (MFF), derived from the DSM-III–R, evaluating functional somatic disturbances and their intensity, and the Symptom Questionnaire. The mean scores for the Hypermobile group showed significant psychological distress and increased frequency and intensity of somatic symptoms. Scores on Anxiety and Somatic Symptoms, General Hypochondriasis, Disease Conviction, Affective Disturbance, Denial, and Irritability were significantly higher in the Hypermobile than in the Healthy group. Elevated scores were found for the Fibromyalgic group on the Illness Behavior Questionnaire subscales for Psychological vs Somatic Focus, Disease Affirmation, and Discriminating Factors when compared with the Hypermobile group. Considerable emotional symptoms were detected which should not be underestimated by physicians when establishing an integrated biopsychosocial therapy.

Whole-spine dynamic magnetic resonance study of contortionists: anatomy and pathology

OBJECT

Whole-spine magnetic resonance (MR) images were obtained using a cylindrical 3-T MR imaging system in 5 contortionists to assess the pathological changes possibly associated with the practice of contortion. Whole-spine dynamic MR images were obtained using a 1-T open MR imaging system in 2 of these contortionists with the purpose of defining the range of motion (ROM) achieved during extreme contortion. The range of spinal motion in this unique population was then quantified.

METHODS

The study included 5 female contortionists 20-49 years of age. Imaging was performed using open 1-T and cylindrical 3-T high-field MR imaging systems. Data were viewed and analyzed with DICOM-compliant tools. Real-time, dynamic, and standard MR imaging allowed for quantification of the contortionists' ROM.

RESULTS

There was a difference of 238 degrees between full spinal extension and full flexion. Three of the 5 contortionists had 4 anterosuperior limbus vertebrae at T-11 and the upper lumbar levels.

CONCLUSIONS

Whole-spine dynamic MR imaging is a valuable tool for the evaluation of the extreme ROM in contortionists, allowing for the quantification of extreme mobility. The limbus fractures present in 3 of the 5 contortionists is postulated to be due to avulsion on hyperextension. Future research may open the use of whole-spine dynamic MR imaging into such areas as pain management and traumatic spinal injuries.

Connective tissue disorder--a new subgroup of boys with slow transit constipation?

PURPOSE

Slow transit constipation (STC) is a form of chronic constipation, with delayed colonic passage of stool. Possible etiologies include reduced neurotransmitter levels, reduced interstitial cells of Cajal density, or a disorder of connective tissue (CT) synthesis. A common CT disorder is generalized joint hypermobility (GJH). This study aimed to investigate whether there was a greater prevalence of GJH among patients with STC than controls.

METHODS

Children (aged 7-17) diagnosed with STC by radio/nuclear transit study were recruited from outpatient clinics. Controls (no history of constipation) were recruited from outpatient clinics and a scout jamboree. Hypermobility was assessed using the Beighton score (4 or more = hypermobile). This project received ethical approval by the human research ethics committee.

RESULTS

Thirty-nine STC subjects and 41 controls were measured. Of 39 STC subjects, 15 (38%) were hypermobile, compared to 8 (20%) of 41 controls (P = .06). Analyzed by gender, 10 (38%) of 26 STC males and 1 (4%) of 23 control males were hypermobile (P < .01).

CONCLUSIONS

These results show that GJH is higher in STC children, particularly males, suggesting that a disorder of CT synthesis plays a role in the etiology of STC. Further research is required to ascertain the nature of any relationship and how this knowledge may aid our understanding and treatment of STC.

Quantification of wrist joint laxity

PURPOSE

Laxity may be a trigger for chronic unidentified wrist pain. To determine whether this is the case, first an objective method to quantify wrist laxity needs to be defined. This study investigates different quantification methods (reference tests) from the literature and compares these with the judgment of 2 independent experienced clinicians (index test, or gold standard).

METHODS

Fifty healthy women (ages 19-43 y) without wrist complaints were included. For each subject, both clinicians were asked to give a laxity score for both wrists on a Likert scale of 1 to 5 (1 = very stiff, 5 = very lax). Subjects also had 3 reference tests: the Garcia-Elias method (passive range of motion), the Beighton method (general hypermobility), and the active range of motion method (specially designed measurement device).

RESULTS

There was no significant difference between the average laxity scores of clinicians 1 and 2. The intraclass correlation between clinician 1 and clinician 2 was significant but low. Correlation between the clinicians with the Garcia-Elias test as well as the Beighton method was significant but low (0.431 and 0.378). The correlation between reference tests was higher but still moderate.

CONCLUSIONS

This study showed that the index test used (clinical assessment) did not produce a satisfactory quantification of wrist laxity. Also, the reference tests are not suitable for quantification of laxity and seem to measure mobility rather than laxity. To quantify wrist laxity in a reliable and clinically relevant manner, it seems that consensus needs to be established between clinicians as to what elements of (abnormal) wrist motion define the wrist as "lax." In addition the development and testing of a measurement device that quantifies wrist translation might be needed for determining an objective score for wrist laxity.

Hypermobility and the hypermobility syndrome

Hypermobile joints by definition display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility, when associated with symptoms is termed the joint hypermobility syndrome or hypermobility syndrome (JHS). JHS is an under recognised and poorly managed multi-systemic, hereditary connective tissue disorder, often resulting in a great deal of pain and suffering. The condition is more prevalent in females, with symptoms frequently commencing in childhood and continuing on into adult life. This paper provides an overview of JHS and suggested clinical guidelines for both the identification and management of the condition, based on research evidence and clinical experience. The Brighton Criteria and a simple 5-point questionnaire developed by Hakim and Grahame, are both valid tools that can be used clinically and for research to identify the condition. Management of JHS frequently includes; education and lifestyle advice, behaviour modification, manual therapy, taping and bracing, electrotherapy, exercise prescription, functional rehabilitation and collaborative working with a range of medical, health and fitness professionals. Progress is often slow and hampered by physical and emotional setbacks. However with a carefully considered management strategy, amelioration of symptoms and independent functional fitness can be achieved.

Asthma and airways collapse in two heritable disorders of connective tissue

OBJECTIVES

This study investigated the clinical impression that there was an increased prevalence of respiratory disorders in both the Hypermobility Syndrome (HMS)/Benign Joint Hypermobility Syndrome (BJHS) and Ehlers-Danlos Syndrome (EDS), compared with the normal population.

METHODS

A questionnaire was distributed to 509 subjects (221 healthy controls, 126 HMS, 162 EDS) who documented respiratory symptoms and previously diagnosed respiratory and atopic disorders. A subgroup of 157 responders underwent full clinical and serological assessments, and 57 subjects were assessed physiologically.

RESULTS

A significant increase in the frequency of a wide range of respiratory symptoms and reduced exercise tolerance was observed in subjects with both HMS and EDS compared with controls. In particular, there was an increased prevalence of asthmatic symptoms (HMS: OR 2.4, 95% CI 1.4-4.1, p = 0.002; EDS: OR 3.1, 95% CI 1.8-5.2, p<0.001) and atopy (HMS: OR 2.7, 95% CI 1.6-4.5, p<0.001; EDS: OR 2.6, 95% CI 1.6-4.4, p<0.001), which was subsequently confirmed by clinical assessment. Pulmonary physiological studies revealed increased lung volumes, impaired gas exchange and an increased tendency of both the lower and upper airways to collapse.

CONCLUSIONS

We have demonstrated, for the first time, that individuals with HMS/BJHS and EDS have respiratory symptoms in association with various pulmonary physiological abnormalities. The increased prevalence of asthma may be due to linkage disequilibrium between the genes causing these conditions or a function of the connective tissue defect itself. In the non-asthmatic population, changes in the mechanical properties of the bronchial airways and lung parenchyma may underlie the observed increased tendency of the airways to collapse.

A new phenotypical variant of intrauterine growth restriction?

OBJECTIVES

A link between intrauterine growth restriction and major adult-onset diseases has been reported. In this study we observed a series of hitherto-unrecognized clinical features in a population of children with intrauterine growth restriction.

PATIENTS AND METHODS

A total of 77 Italian children (aged 9.45 +/- 2.08 years) with antenatally diagnosed intrauterine growth restriction and small-for-gestational-age birth, along with their parents, were examined. The children with intrauterine growth restriction and were small for gestational age were subdivided into 2 groups ("variant" versus control subjects) according to evidence of auricle morphology deviation from normal. The following variables were determined: (1) external ear auricle geometry; (2) function of the posterior communicating arteries of the circle of Willis, as assessed by transcranial Doppler ultrasonography; (3) articular mobility, as assessed by Beighton's 9-point scale; (4) skin softness; and (5) distortion product-evoked otoacoustic emissions.

RESULTS

Intrauterine growth restriction-variant children (n = 27) showed a significant female predominance, a lower proportion of maternal pregnancy-induced hypertension/preeclampsia, and a higher head circumference as compared with intrauterine growth restriction control subjects. Mothers of small-for-gestational-age-variant children showed significantly different auricular geometry parameters as compared with the intrauterine growth restriction controls mothers. An excess of bilaterally nonfunctioning posterior communicating arteries was observed both in the children with the intrauterine growth restriction-variant phenotype and their mothers as compared with the control groups. Significantly increased proportions of joint hypermobility and skin softness were observed in the intrauterine growth restriction-variant children as compared with controls subjects. Children with the intrauterine growth restriction-variant phenotype and their mothers showed bilateral distortion product-evoked otoacoustic emissions notches versus none in the control subjects, with an associated reduction of the area under the curve in both the intrauterine growth restriction-variant children and their mothers. No significant differences between the variant and control groups regarding the fathers were observed.

CONCLUSIONS

We propose that the observed phenotypical constellation may represent an unrecognized variant of intrauterine growth restriction.

Flexibilidade anterior do tronco no adolecente após o pico da velocidade de crescimento em estatura

Flexibilidade anterior do tronco (FAT) é um componente importante dos exames clínico e de aptidão física utilizado como indicador da função vertebral. O teste mais utilizado para sua quantificação é o sentar-e-alcançar (TSA), que considerara como padrão de normalidade o toque das mãos nos pés, com critérios e parâmetros de análise que independem das variáveis. Neste estudo, investigou-se a FAT em adolescentes, após o pico da velocidade de crescimento em estatura, em função do sexo, da velocidade de execução e dos dados antropométricos. Os índices foram obtidos em centímetros; o peso corporal em kg. Participaram 102 adolescentes, sendo 45 mulheres e 57 homens, entre 16 e 20 anos de idade. Resultados indicam que o fator sexo, dados antropométricos e a velocidade de execução do teste influenciam os índices de flexibilidade; a avaliação da função vertebral não pode ter como critério de normalidade atingir os pés pelo TSA, e que a velocidade rápida leva a melhores resultados. Em resumo, os resultados indicam que tocar os pés, é um critério que exclui da normalidade da função vertebral aproximadamente 50% dos adolescentes. Assim, o critério para tomada de decisão quanto ao encaminhamento do adolescente para recuperação de maiores índices de flexibilidade precisa ser revisto.

Familial orthostatic tachycardia

PURPOSE OF REVIEW

Postural tachycardia syndrome is an autonomic disorder primarily of younger women. The patient population is heterogeneous, making diagnosis and treatment a challenge. A mutation in the norepinephrine (noradrenaline) transporter gene prompted further genetic analysis.

RECENT FINDINGS

Eleven new mutations were found in the human norepinephrine transporter gene, although none were directly associated with postural tachycardia syndrome. The 5'-flanking -1012C --> T variant of the dopamine beta-hydroxylase gene was slightly increased and protection was associated with a reduced incidence of two mutations in the endothelial nitric oxide synthase gene, and one in endothelin-1. Mutations in other disease-related genes suggest a potential relationship with the pathogenesis of postural tachycardia syndrome. Benign joint hypermobility syndrome, for example, shares similar autonomic symptoms and is linked to a mutation in tenascin-X. Additional genetic findings are discussed as potential contributors to vascular health and neurodegeneration.

SUMMARY

Genetic testing can reveal molecular mechanisms of disease and provide an additional strategy for diagnosis and treatment of heterogeneous patient populations such as postural tachycardia syndrome. It is quite likely that the pathogenesis of this disorder will be attributed to numerous genetic mutations, both subtle and overt. Therefore, continued study of the relationships between genotype and phenotype are necessary to better understand this syndrome and others with associated dysautonomia.

Joint hypermobility and skin elasticity: the hereditary disorders of connective tissue

The hereditary disorders of connective tissues (HDCTs) encompass a spectrum of conditions linked pathophysiologically by abnormalities of collagen, fibrillin, and matrix proteins. The clinical picture ranges from morbidity because of musculoskeletal, skin, ocular and visceral pathologies to mortality from acute vascular collapse. For many of the conditions, there is a considerable overlap in clinical features, although severity varies; appreciating the subtle differences in presentation is vital to the clinician in determining the diagnosis. Though conditions associated with severe vascular pathology are rare, other hereditary disorders of connective tissues such as the joint hypermobility syndrome and Stickler's disease are common and probably underrecognized. Abnormal skin elasticity and scaring, joint hypermobility, and chronic arthralgia are important clues that should trigger the clinician to search for underlying hereditary disorders of connective tissues. In this article, we discuss the spectrum of clinical findings, management, and genetic screening of the more common hereditary disorders of connective tissues, highlighting their diagnostic criteria and their differences.

Exercise tolerance in children and adolescents with musculoskeletal pain in joint hypermobility and joint hypomobility syndrome

OBJECTIVES

Musculoskeletal pain is a common complaint in a pediatric health care practice, but exercise tolerance has never been described in detail in these children. Our objectives for this study were to evaluate the maximal exercise capacity, including peak heart rate and oxygen consumption, of children with pain-related musculoskeletal problems, particularly in children with (symptomatic) generalized joint hypermobility and hypomobility, during a bicycle ergometry test to exhaustion; to evaluate muscle strength, bone mineral density, and sports activities in these children and to associate these observations with exercise capacity; and to compare these results with reference values.

METHODS

Thirty-two children (mean age: 12.1 years; SD: 3.4 years; range: 6.2-20.1 years; 62% male) with musculoskeletal pain-related syndromes (joint hypermobility syndrome [n = 13] and joint hypomobility syndrome [n = 19]) participated. The reference group consisted of 117 healthy primary school prepubertal children, 167 healthy secondary school adolescents, and 98 young adults (249 girls and 133 boys; mean age total reference group: 14.5 +/- 4.0 years; range: 8-20.8 years). Anthropometry, range of joint motion, muscle strength, bone mineral density (speed of sound and broadband ultrasound attenuation), sports activities, and a maximal exercise test using an electronically braked cycle ergometer were performed, and the patient stopped because of volitional exhaustion. Expired gas analysis and heart rate and transcutaneous oxygen saturation by pulse oximetry measurements also were performed.

RESULTS

Children with joint hypomobility syndrome as well as children with joint hypermobility syndrome had a higher mean z score (SD) of weight and BMI compared with the reference group. A significantly decreased absolute peak oxygen consumption and relative peak oxygen consumption in both patient groups was found compared with control subjects. In 14 of 32 children with a z score relative peak oxygen consumption of less than -2, maximal heart rate was significantly decreased compared with 18 children with a z score relative peak oxygen consumption of -2 or more (mean [SD] z score speed of sound: -1.3 [0.8] vs -0.5 [1.0] and mean [SD] heart rate: 175.9 [11.5] vs 187.5 [10.9], respectively). In the total group, a high significant correlation between the z score of relative peak oxygen consumption and the z score of the speed of sound was found as well as with z score of BMI. Sixteen (50%) of 32 participated in sports activities with (mean: 0.9 hours/week; SD: 1.4 hours/week), whereas in the control group, 12% of did not participate in sports activities (mean: 2.8 hours/week; SD: 2.2 hours/week). Children who participated in sports activities had a (borderline) significant increased mean (SD) z score of absolute peak oxygen consumption and mean (SD) z score of broadband ultrasound attenuation compared with children who did not participate in sports activities (-0.3 [1.1] vs -1.2 [1.3] and -0.45 [0.8] vs -0.9 [0.5], respectively).

CONCLUSIONS

In children with musculoskeletal pain-related syndromes, particular in children with (symptomatic) generalized joint hypermobility and hypomobility, maximal exercise capacity is significantly decreased compared with age- and gender-matched control subjects. The most probable explanation for the reduced exercise tolerance in our patients is deconditioning.

The frequency of hypermobility and its relationship with clinical findings of fibromyalgia patients

The etiology and pathogenic mechanisms of fibromyalgia (FM) are unknown. A number of studies have suggested that there was a link between hypermobility and FM. In this study, we aimed to expose the frequency of hypermobility in FM patients and its relation with clinical findings. For this reason, 236 women (118 FM women as study group and 118 healthy women as control group) were enrolled in the study. Joint hypermobility was evaluated in the participants by using Beighton scoring system. The rate of joint hypermobility among FM patients (Beighton score of at least 4 or more) was found to be higher than the control group (46.6 vs 28.8%). This result was also statistically meaningful (p<0.05). In addition, the mean Beighton score of FM group was observed to be higher than the control (3.68 vs 2.55, p<0.001). Although not reaching statistical difference (p>0.05), more severe clinical findings were observed in FM patients with hypermobility when compared with ones without.

Clinical study of hereditary disorders of connective tissues in a Chilean population: joint hypermobility syndrome and vascular Ehlers-Danlos syndrome

OBJECTIVE

To demonstrate the high frequency and lack of diagnosis of joint hypermobility syndrome (JHS) and the seriousness of vascular Ehlers-Danlos syndrome (VEDS).

METHODS

Two hundred forty-nine Chilean patients with hereditary disorders of the connective tissues (CTDs) and 64 control subjects were evaluated for the diagnoses of JHS and VEDS using the validated Brighton criteria, as compared with the traditional Beighton score. In addition, the presence of blue sclera was determined, with the degree of intensity graded as mild, moderate, or marked.

RESULTS

The frequency of hereditary CTDs was 35%, with diagnoses of JHS in 92.4% of subjects, VEDS in 7.2%, and osteogenesis imperfecta in 0.4%. The Beighton score proved to be insufficient for the diagnosis of JHS (35% of subjects had a negative score), whereas the Brighton criteria yielded positive findings (a diagnosis of JHS) in 39% of control subjects. Blue sclera was frequent, being identified in 97% of JHS patients and 94% of VEDS patients. Moderate osteopenia/osteoporosis was observed in 50% of patients with VEDS and 26% of those with JHS. Dysautonomia, dyslipidemia, and scoliosis were more frequent in VEDS patients than in JHS patients. The typical JHS facial appearance and the "hand holding the head sign" were identified. Raynaud's phenomenon was extremely rare in JHS patients (2%). Ruptured uterus and cerebral aneurysm occurred in 12% and 6% of VEDS patients, respectively. Spontaneous pneumothorax was more frequent in VEDS patients (11%) than in JHS patients (0.9%).

CONCLUSION

JHS is very frequent but usually undiagnosed. The Beighton score is an insufficient method for JHS diagnosis. We recommend that physicians learn to recognize the typical facial features of JHS and be able to identify blue sclera. We also propose that validated hypermobility criteria be routinely used. Further research is needed to determine why the prevalence of JHS is so high in Chile.

Adolescent flexibility, endurance strength, and physical activity as predictors of adult tension neck, low back pain, and knee injury: a 25 year follow up study

OBJECTIVE

To examine whether adolescent flexibility, endurance strength, and physical activity can predict the later occurrence of recurrent low back pain, tension neck, or knee injury.

METHODS

In 1976, 520 men and 605 women participated in a sit and reach test (flexibility) and a 30 second sit up test (endurance strength). In 1976 and 2001 (aged 37 and 42 years) they completed a questionnaire. Lifetime occurrence and risk of self reported low back pain and self reported, physician diagnosed tension neck and knee injury were calculated for subjects divided into tertiles by baseline results of strength and flexibility tests.

RESULTS

Men from the highest baseline flexibility tertile were at lower risk of tension neck than those from the lowest tertile (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.28 to 0.93). Women from the highest baseline endurance strength tertile were at lower risk of tension neck than those from the lowest tertile (OR 0.60, 95% CI 0.40 to 0.91). Men from the highest baseline endurance strength tertile were at higher risk of knee injury than those from the lowest tertile (OR 1.96, 95% CI 1.05 to 3.64). Men who at school age participated in physical activity were at lower risk of recurrent low back pain (OR 0.61; 95% CI 0.42 to 0.88) than those who did not.

CONCLUSIONS

Overall good flexibility in boys and good endurance strength in girls may contribute to a decreased risk of tension neck. High endurance strength in boys may indicate an increased risk of knee injury.

The evolution of human fatness and susceptibility to obesity: an ethological approach

Human susceptibility to obesity is an unusual phenomenon amongst animals. An evolutionary analysis, identifying factors favouring the capacity for fat deposition, may aid in the development of preventive public health strategies. This article considers the proximate causes, ontogeny, fitness value and evolutionary history of human fat deposition. Proximate causes include diet composition, physical activity level, feeding behaviour, endocrine and genetic factors, psychological traits, and exposure to broader environmental factors. Fat deposition peaks during late gestation and early infancy, and again during adolescence in females. As in other species, human fat stores not only buffer malnutrition, but also regulate reproduction and immune function, and are subject to sexual selection. Nevertheless, our characteristic ontogenetic pattern of fat deposition, along with relatively high fatness in adulthood, contrasts with the phenotype of other mammals occupying the tropical savannah environment in which hominids evolved. The increased value of energy stores in our species can be attributed to factors increasing either uncertainty in energy availability, or vulnerability to that uncertainty. Early hominid evolution was characterised by adaptation to a more seasonal environment, when selection would have favoured general thriftiness. The evolution of the large expensive brain in the genus Homo then favoured increased energy stores in the reproducing female, and in the offspring in early life. More recently, the introduction of agriculture has had three significant effects: exposure to regular famine; adaptation to a variety of local niches favouring population-specific adaptations; and the development of social hierarchies which predispose to differential exposure to environmental pressures. Thus, humans have persistently encountered greater energy stress than that experienced by their closest living relatives during recent evolution. The capacity to accumulate fat has therefore been a major adaptive feature of our species, but is now increasingly maladaptive in the modern environment where fluctuations in energy supply have been minimised, and productivity is dependent on mechanisation rather than physical effort. Alterations to the obesogenic environment are predicted to play a key role in reducing the prevalence of obesity.

Generalized Joint Hypermobility Is More Common in Chronic Fatigue Syndrome Than in Healthy Control Subjects

OBJECTIVES

This study aimed at (1) comparing the prevalence of generalized hypermobility in patients with chronic fatigue syndrome (CFS) and healthy volunteers, (2) examining the clinical importance of generalized hypermobility in patients with CFS, and (3) examining whether knee proprioception is associated with hypermobility in patients with CFS.

METHODS

Sixty-eight patients with CFS filled out two self-reported measures (for the assessment of symptom severity and disability), were questioned about muscle and joint pain, and were screened for generalized hypermobility. Afterward, the patients performed a knee repositioning test (assessment of knee proprioception), and it was examined whether or not they fulfilled the criteria for benign joint hypermobility syndrome (BJHS). Sixty-nine age- and sex-matched healthy volunteers were screened for generalized joint hypermobility and performed the same knee repositioning test.

RESULTS

Compared with the healthy volunteers (4.3%, 3/68), significantly more patients with CFS (20.6%, 14/69) fulfilled the criteria for generalized joint hypermobility (Fisher exact test, P < .004). No associations were found between generalized joint hypermobility and the self-reported measures (including pain severity) or knee proprioception (Spearman correlation analysis). Knee proprioception was similar in both groups (Mann-Whitney U = 1961, z = -1.745, P = .81). Forty patients with CFS (58.8%) fulfilled the criteria for BJHS.

CONCLUSIONS

These data indicate that a subgroup of patients with CFS present with generalized joint hypermobility and most patients with of CFS fulfill the diagnostic criteria for BJHS. There appears to be no association between musculoskeletal pain and joint hypermobility in patients with CFS.

Relationship of Q angle and joint hypermobility and Q angle values in different positions

Patellar malalignment is the most important reason for anterior knee pain. Patellar alignment is commonly determined by the measurement of the quadriceps (Q) angle. In this study, our primary aim was to investigate the Q angle difference between healthy individuals with and without joint hypermobility. The other objectives were to compare the Q angle values, which were measured in supine and upright positions, to determine hypermobility frequency among healthy males in a certain population, and to investigate the correlation between the existent skeletal deformities and Beighton score levels. Two hundred fifty-three healthy male college students were examined for hypermobility and skeletal deformities. According to the Beighton scoring system, three groups (n=20) were formed, and Q angle measurements were performed on the 60 individuals in both supine and upright positions. In the comparison of the groups, the mean Q angle values in healthy hypermobile individuals were found to be significantly higher than that of the nonhypermobile ones (p<0.05). No statistical difference was found between Q angle values in supine and upright positions (p>0.05). The frequency of joint hypermobility (Beighton score 4 or more) was found to be 29.25% in this population. No correlation was determined between existent skeletal deformities and Beighton score values (p>0.05). In conclusion, the Q angle evaluation among healthy hypermobile individuals may have a prognostic value for probable knee pathologies that may appear in the future.

Analysis of joint mobility patterns among preschool children

CONTEXT AND OBJECTIVE

Standardization of normal joint mobility criteria is complex, especially for preschool children, for whom differentiation from hypermobility (JH) is even more difficult. This study aimed to investigate joint mobility of the fifth finger, wrist, elbow, knee and trunk among preschool children, estimate the incidence of JH and evaluate the effect of gender and age and the applicability of standard criteria for identifying JH among preschool children.

DESIGN AND SETTING

Cross-sectional descriptive and quantitative study, at São José do Rio Preto medical school.

METHODS

1,120 healthy children (534 boys, 47.7%; 586 girls, 52.3%; age range: 4-7 years) were evaluated using Beighton scores. Passive extension of fifth finger (> 90 degrees), passive apposition of thumb to forearm, active extension of elbow and knee (> 10 degrees) and anterior trunk flexion placing flat hand on ground were assessed. One point was scored for each positive result (maximum: 9). Scores > 4 were considered to be JH. Students t test and variance analysis were used for statistical analysis.

RESULTS

JH was observed in 80% of wrists, 53.3% of fifth fingers, 36.6% of elbows, 14% of trunks and 12.5% of knees. Scores > 4 were found for 64.6% of the children. Females had higher angular values. Lower scores were associated with greater age.

CONCLUSIONS

JH is a common condition among preschool children and currently available methods are inadequate. New parameters and criteria should be developed for identifying JH among these children.

Oral health in prevalent types of Ehlers-Danlos syndromes

BACKGROUND

The Ehlers-Danlos syndromes (EDS) comprise a heterogenous group of heritable disorders of connective tissue, characterized by joint hypermobility, skin hyperextensibility and tissue fragility. Most EDS types are caused by mutations in genes encoding different types of collagen or enzymes, essential for normal processing of collagen.

METHODS

Oral health was assessed in 31 subjects with EDS (16 with hypermobility EDS, nine with classical EDS and six with vascular EDS), including signs and symptoms of temporomandibular disorders (TMD), alterations of dental hard tissues, oral mucosa and periodontium, and was compared with matched controls.

RESULTS

All EDS subjects were symptomatic for TMD and reported recurrent temporomandibular joint (TMJ) dislocations. Abnormal pulp shape (13%) and pulp calcification (78%) were observed in subjects affected with classical EDS. Caries experience was higher in EDS compared with controls and was related to poor oral hygiene, influenced by increased mucosal fragility and restraint of (wrist) joint mobility. The overall periodontal status in EDS was poor, with 62% of EDS subjects presenting high periodontal treatment needs (community periodontal index for treatment need, CPITN = II).

CONCLUSION

Oral health may be severely compromised in EDS as a result of specific alterations of collagen in orofacial structures. When considering dental treatment in EDS, a number of tissue responses (mucosa, periodontium, pulp) and precautions (TMJ dislocation) should be anticipated.

Osteogenesis imperfecta: a case with hand deformities

In a 51-year-old woman with a history of fractures and dislocations after low intensity trauma in childhood, intensive blue sclera, short stature, and hearing loss, the diagnosis of osteogenesis imperfecta (OI) was suspected. She was referred to our clinic with hand deformities and left knee pain and stiffness. She had difficulty in walking and reported a history of immobilization for 6 months because of knee pain. She had bilateral flexion contracture of the elbows which occurred following dislocations of the elbows in childhood. She had Z deformity of the first phalanges, reducible swan-neck deformity of the third finger of the left and the second finger of the right hand, flexion contracture of the proximal interphalangeal joint of the fifth finger of the left hand, and syndactyly of the third and fourth fingers of the right hand. Flexion contractures of both knees were observed. Pes planus and short toes were the deformities of the feet. Acute phase reactants of the patient were normal. She had no history of arthritis or morning stiffness. Bone mineral density evaluated by dual-energy X-ray absorptiometry (DEXA) showed severe osteoporosis of the femur and lumbar vertebrae. She had radiographic evidence of healed fractures of the left fibula, the third metacarpal, and the fourth and fifth middle phalanges of the right hand. OI, affecting the type I collagen tissue of the sclera, skin, ligaments, and skeleton, presenting with ligament laxity resulting in subluxations and hand deformities may be misdiagnosed as hand deformities of rheumatoid arthritis.