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Trudgian R, Flood T. An exploration of the journey to diagnosis of Ehlers-Danlos Syndrome (EDS) for women living in Australia. PLoS One 2024; 19:e0307574. [PMID: 39052631 PMCID: PMC11271888 DOI: 10.1371/journal.pone.0307574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Ehlers-Danlos syndromes (EDS) is an umbrella term for a group of hereditary connective tissue disorders usually featuring hyperextensible skin, easy bruising, poor healing, and joint hypermobility. According to international Ehlers-Danlos support groups, the average time to diagnosis of this rare genetic condition is 10-12 years. Consequently, the journey to diagnosis can potentially be traumatic. This pilot study aims to explore female patients' journey to a diagnosis of EDS while living in Australia. MATERIALS AND METHODS Over six weeks, from January to February 2023, a survey was distributed on EDS social media platforms including Facebook and LinkedIn. Ethical approval was obtained through the Ulster University Institute of Nursing and Health Research Ethics Filter Committee (FCNUR). Thematic and statistical analysis of the anonymous data was completed during March 2023. RESULTS 152 women completed the survey. More than half of the respondents first noticed symptoms of EDS more than 15 years prior to diagnosis and more than three quarters of respondents received other diagnoses prior to their EDS diagnosis. Most respondents saw their general practitioner, a physiotherapist and/or a rheumatologist prior to being correctly diagnosed with the condition. While some respondents had positive experiences with these health professionals, many felt that they were not listened to and, after doing their own research, had to educate their health professional/s about EDS. CONCLUSION This pilot survey demonstrated that the journey to diagnosis of EDS for women in Australia is frequently long and traumatic. Participants indicated that more EDS education and training is needed for health professionals, especially GPs, to improve the diagnostic process. IMPLICATIONS FOR PRACTICE Participants called for their self-reported symptoms to be listened to by health professionals and to be met with empathy and an open mind instead of being dismissed. Additional education and training to health professionals about connective tissue disorders including EDS may aid earlier diagnosis in Australia.
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Affiliation(s)
- Rachel Trudgian
- Skills for Development Pty Ltd., Clear Mountain, Queensland, Australia
| | - Terri Flood
- School of Health Sciences, Ulster University, Derry~Londonderry, United Kingdom
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2
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Penny HA, Aziz I, Lam C. Mast cell activation and nutritional disorders in patients with hypermobility. Curr Opin Gastroenterol 2024; 40:225-232. [PMID: 38393310 DOI: 10.1097/mog.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW Individuals with joint hypermobility disorders are increasingly referred to gastroenterology services for support with the investigation and management of gastrointestinal complaints. Individuals can present with a myriad of complex coexisting diagnoses, the inter-relationship of which is unclear. This review discusses the proposed association between hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) with disorders of mast cell activation and provides an overview of gastrointestinal symptoms and nutritional outcomes in this patient cohort. RECENT FINDINGS It is unclear whether a true association between hEDS/HSD and mast cell activation disorders exists. There is a high prevalence of nonspecific gastrointestinal symptoms in individuals with hEDS/HSD and patients may be at risk of macro-nutrient and micro-nutrient deficiencies, although the current evidence base is limited. SUMMARY We advocate a pragmatic approach to the investigation and management of gastrointestinal symptoms in patients with hEDS/HSD. This centres on excluding organic pathology, discussing the overlap with disorders of gut-brain interactions, trialling evidence-based therapies targeting individual symptoms, and supporting nutritional deficiencies where present via the least invasive approach. Engagement with a broad multidisciplinary team is also important to support the holistic needs of this patient cohort.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Ching Lam
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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3
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Yekkalam N, Novo M, Wänman A. Treatments related to temporomandibular disorders among patients with prevalent types of Ehlers-Danlos syndrome in Sweden. Cranio 2024:1-12. [PMID: 38415674 DOI: 10.1080/08869634.2024.2319565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
The aim of this study was to assess the received TMD treatment modalities and the perceived outcome among the frequent types of EDS. A digital questionnaire was sent to the member of the National Swedish EDS Association during January-March 2022. The subsamples of hypermobile and classical EDS were constructed. Almost 90% reported TMD symptoms. Bite splint therapy, counselling, jaw training and occlusal adjustment were reported as the most common treatments with no statistically significant difference in terms of good effect between the two subsamples. Hypermobile and classical EDS might consider as an entity with regards to TMD.
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Affiliation(s)
- Negin Yekkalam
- Department of Odontology, Clinical Oral Physiology, Umeå University, Umeå, Sweden
| | - Mehmed Novo
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Anders Wänman
- Department of Odontology, Clinical Oral Physiology, Umeå University, Umeå, Sweden
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4
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Ritelli M, Chiarelli N, Cinquina V, Vezzoli M, Venturini M, Colombi M. Looking back and beyond the 2017 diagnostic criteria for hypermobile Ehlers-Danlos syndrome: A retrospective cross-sectional study from an Italian reference center. Am J Med Genet A 2024; 194:174-194. [PMID: 37774134 DOI: 10.1002/ajmg.a.63426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
The most common conditions with symptomatic joint hypermobility are hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD). Diagnosing these overlapping connective tissue disorders remains challenging due to the lack of established causes and reliable diagnostic tests. hEDS is diagnosed applying the 2017 diagnostic criteria, and patients with symptomatic joint hypermobility but not fulfilling these criteria are labeled as HSD, which is not officially recognized by all healthcare systems. The 2017 criteria were introduced to improve diagnostic specificity but have faced criticism for being too stringent and failing to adequately capture the multisystemic involvement of hEDS. Herein, we retrospectively evaluated 327 patients from 213 families with a prior diagnosis of hypermobility type EDS or joint hypermobility syndrome based on Villefranche and Brighton criteria, to assess the effectiveness of the 2017 criteria in distinguishing between hEDS and HSD and document the frequencies of extra-articular manifestations. Based on our findings, we propose that the 2017 criteria should be made less stringent to include a greater number of patients who are currently encompassed within the HSD category. This will lead to improved diagnostic accuracy and enhanced patient care by properly capturing the diverse range of symptoms and manifestations present within the hEDS/HSD spectrum.
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Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marika Vezzoli
- Unit of Biostatistics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
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5
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Stembridge N, Doolan BJ, Lavallee ME, Hausser I, Pope FM, Seneviratne SL, Winship IM, Burrows NP. The role of cutaneous manifestations in the diagnosis of the Ehlers-Danlos syndromes. SKIN HEALTH AND DISEASE 2023; 3:e140. [PMID: 36751332 PMCID: PMC9892481 DOI: 10.1002/ski2.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/11/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) comprise a group of inherited connective tissue disorders presenting with features of skin hyperextensibility, joint hypermobility, abnormal scarring and fragility of skin, blood vessels and some organs. The disease is generally diagnosed through the cluster of clinical features, though the addition of genetic analysis is the gold standard for diagnosis of most subtypes. All subtypes display skin manifestations, which are essential to the accurate clinical diagnosis of the condition. Furthermore, cutaneous features can be the first and/or only presenting feature in some cases of EDS and thus understanding these signs is vital for diagnosis. This review focuses on particular cutaneous features of each EDS subtype and their clinical importance. Provision of a specific diagnosis is important for management, prognosis and genetic counselling, often for family members beyond the individual.
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Affiliation(s)
- Natasha Stembridge
- Department of DermatologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Brent J. Doolan
- St John's Institute of DermatologySchool of Basic and Medical BiosciencesKing's College LondonLondonUK
- Guy's and St Thomas' NHS Foundation TrustLondonUK
| | - Mark E. Lavallee
- Department of OrthopedicsUniversity of Pittsburgh Medical Center of Central PAPittsburghPennsylvaniaUSA
| | - Ingrid Hausser
- Institute of PathologyHeidelberg University HospitalHeidelbergGermany
| | - F. Michael Pope
- Department of DermatologyChelsea and Westminster Hospital NHS Foundation Trust (West Middlesex University Hospital)LondonUK
| | - Suranjith L. Seneviratne
- Institute of Immunity and TransplantationRoyal Free Hospital and University College LondonLondonUK
- Nawaloka Hospital Research and Education FoundationNawaloka HospitalsColomboSri Lanka
| | - Ingrid M. Winship
- Department of Genetic MedicineThe Royal Melbourne HospitalMelbourneVictoriaAustralia
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
| | - Nigel P. Burrows
- Department of DermatologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
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6
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RNA-Seq of Dermal Fibroblasts from Patients with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders Supports Their Categorization as a Single Entity with Involvement of Extracellular Matrix Degrading and Proinflammatory Pathomechanisms. Cells 2022; 11:cells11244040. [PMID: 36552803 PMCID: PMC9777098 DOI: 10.3390/cells11244040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are clinically overlapping connective tissue disorders of unknown etiology and without any validated diagnostic biomarker and specific therapies. Herein, we in-depth characterized the cellular phenotype and gene expression profile of hEDS and HSD dermal fibroblasts by immunofluorescence, amplicon-based RNA-seq, and qPCR. We demonstrated that both cell types show a common cellular trait, i.e., generalized extracellular matrix (ECM) disarray, myofibroblast differentiation, and dysregulated gene expression. Functional enrichment and pathway analyses clustered gene expression changes in different biological networks that are likely relevant for the disease pathophysiology. Specifically, the complex gene expression dysregulation (mainly involving growth factors, structural ECM components, ECM-modifying enzymes, cytoskeletal proteins, and different signal transducers), is expected to perturb many ECM-related processes including cell adhesion, migration, proliferation, and differentiation. Based on these findings, we propose a disease model in which an unbalanced ECM remodeling triggers a vicious cycle with a synergistic contribution of ECM degradation products and proinflammatory mediators leading to a functional impairment of different connective tissues reflecting the multisystemic presentation of hEDS/HSD patients. Our results offer many promising clues for translational research aimed to define molecular bases, diagnostic biomarkers, and specific therapies for these challenging connective tissue disorders.
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7
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Hakimi A, Bergoin C, Mucci P. What are the most important symptoms to assess in hypermobile Ehlers-Danlos syndrome? A questionnaire study based on the Delphi technique. Disabil Rehabil 2022; 44:8325-8331. [PMID: 34927503 DOI: 10.1080/09638288.2021.2012839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE This study aims to determine from questionnaires, submitted to patients with Ehlers-Danlos syndrome hypermobile type (hEDS), what symptoms they perceive as having the most impact on their well-being and, according to them, what symptoms should be assessed. MATERIALS AND METHODS Three rounds of online questionnaires were conducted following the Delphi method. The first round allowed us to obtain the most important symptoms to assess according to the patients. The second and third round aimed at ranking the categories according to their order of importance. Establishment of a consensus was evaluated using Kendall's coefficient of concordance. RESULTS A total of 118 responses were analyzed for the first round and 87 for the second and the third round. Ten categories were extracted from the first round. Ranking of the 10 categories in the second round did not reach consensus (W = 0.33, p < 0.001) nor did the four most important categories in the third round (W = 0.43, p < 0.001). However, three categories stand out from ranking: "pain", "fatigue and sleep disorders", and "musculoskeletal disorders". CONCLUSIONS These categories seem to be the most important to assess in patients with hEDS, despite the lack of consensus on this ranking.Implications for rehabilitationPain, fatigue and sleep disorders, and musculoskeletal disorders should be given high consideration in the assessment of patients with hypermobile Ehlers-Danlos syndrome (EDS).The high phenotypic variability in the hypermobile EDS requires individualized assessment for each patient and a multidisciplinary approach.
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Affiliation(s)
- Adrien Hakimi
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France.,Clinique de la Mitterie, Lomme, France
| | - Cyrille Bergoin
- Clinique de la Mitterie, Lomme, France.,Cabinet de pneumologie, Tourcoing, France
| | - Patrick Mucci
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
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8
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Royer SP, Han SJ. Mechanobiology in the Comorbidities of Ehlers Danlos Syndrome. Front Cell Dev Biol 2022; 10:874840. [PMID: 35547807 PMCID: PMC9081723 DOI: 10.3389/fcell.2022.874840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Ehlers-Danlos Syndromes (EDSs) are a group of connective tissue disorders, characterized by skin stretchability, joint hypermobility and instability. Mechanically, various tissues from EDS patients exhibit lowered elastic modulus and lowered ultimate strength. This change in mechanics has been associated with EDS symptoms. However, recent evidence points toward a possibility that the comorbidities of EDS could be also associated with reduced tissue stiffness. In this review, we focus on mast cell activation syndrome and impaired wound healing, comorbidities associated with the classical type (cEDS) and the hypermobile type (hEDS), respectively, and discuss potential mechanobiological pathways involved in the comorbidities.
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Affiliation(s)
- Shaina P. Royer
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, United States
| | - Sangyoon J. Han
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, United States
- Department of Mechanical Engineering, Michigan Technological University, Houghton, MI, United States
- Health Research Institute, Michigan Technological University, Houghton, MI, United States
- *Correspondence: Sangyoon J. Han,
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9
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Levine D, Work B, McDonald S, Harty N, Mabe C, Powell A, Sanford G. Occupational Therapy Interventions for Clients with Ehlers-Danlos Syndrome (EDS) in the Presence of Postural Orthostatic Tachycardia Syndrome (POTS). Occup Ther Health Care 2021; 36:253-270. [PMID: 34520307 DOI: 10.1080/07380577.2021.1975200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is often seen in clients with Ehlers-Danlos syndrome (EDS), primarily hypermobile EDS. Research has shown clients with EDS and POTS may experience limitations affecting not only their physical function, but also their social, emotional, and mental well-being. Using a client-centered approach, occupational therapy practitioners assess health, well-being, symptomatology (fatigue, muscle pain, dizziness, etc.), participation and engagement in occupation, and provide interventions to improve quality of life. This paper will address occupational therapy interventions to treat common symptomatology for clients with EDS in the presence of POTS, including environmental modifications, use of adaptive equipment and orthoses, exercise and fall prevention, energy conservation and pacing, sleep hygiene, and routine and habit development to promote optimal engagement in meaningful occupations.
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Affiliation(s)
- David Levine
- Department of Physical Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Brittany Work
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Susan McDonald
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Nicole Harty
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Carolee Mabe
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Alison Powell
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Graceline Sanford
- Department of Occupational Therapy, The University of Tennessee at Chattanooga, Chattanooga, TN, USA
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10
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Aubry-Rozier B, Schwitzguebel A, Valerio F, Tanniger J, Paquier C, Berna C, Hügle T, Benaim C. Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different? Rheumatol Int 2021; 41:1785-1794. [PMID: 34398260 PMCID: PMC8390400 DOI: 10.1007/s00296-021-04968-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/06/2021] [Indexed: 01/04/2023]
Abstract
Diagnosing hypermobile Ehlers–Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18–73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18–26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.
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Affiliation(s)
| | | | - Flore Valerio
- Rheumatology, HFR Fribourg, Villars-sur-Glâne, Switzerland
| | - Joelle Tanniger
- Physiotherapy, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Célia Paquier
- Physiotherapy, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Chantal Berna
- Center for Integrative and Complementary Medicine & Pain Center, Division of Anesthesiology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Hügle
- Rheumatology and Rehabilitation, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Charles Benaim
- Rheumatology and Rehabilitation, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland. .,Department of Medical Research, Clinique Romande de Réadaptation, Sion, Switzerland.
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11
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Mittal N, Mina DS, McGillis L, Weinrib A, Slepian PM, Rachinsky M, Buryk-Iggers S, Laflamme C, Lopez-Hernandez L, Hussey L, Katz J, McLean L, Rozenberg D, Liu L, Tse Y, Parker C, Adler A, Charames G, Bleakney R, Veillette C, Nielson CJ, Tavares S, Varriano S, Guzman J, Faghfoury H, Clarke H. The GoodHope Ehlers Danlos Syndrome Clinic: development and implementation of the first interdisciplinary program for multi-system issues in connective tissue disorders at the Toronto General Hospital. Orphanet J Rare Dis 2021; 16:357. [PMID: 34376220 PMCID: PMC8353438 DOI: 10.1186/s13023-021-01962-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 07/18/2021] [Indexed: 11/22/2022] Open
Abstract
Ehlers-Danlos Syndrome (EDS) are a heterogeneous group of genetic connective tissue disorders, and typically manifests as weak joints that subluxate/dislocate, stretchy and/or fragile skin, organ/systems dysfunction, and significant widespread pain. Historically, this syndrome has been poorly understood and often overlooked. As a result, people living with EDS had difficulty obtaining an accurate diagnosis and appropriate treatment, leading to untold personal suffering as well as ineffective health care utilization. The GoodHope EDS clinic addresses systemic gaps in the diagnosis and treatment of EDS. This paper describes a leap forward—from lack of awareness, diagnosis, and treatment—to expert care that is tailored to meet the specific needs of patients with EDS. The GoodHope EDS clinic consists of experts from various medical specialties who work together to provide comprehensive care that addresses the multi-systemic nature of the syndrome. In addition, EDS-specific self-management programs have been developed that draw on exercise science, rehabilitation, and health psychology to improve physical and psychosocial wellbeing and overall quality of life. Embedded into the program are research initiatives to shed light on the clinical presentation, underlying mechanisms of pathophysiology, and syndrome management. We also lead regular educational activities for community health care providers to increase awareness and competence in the interprofessional management of EDS beyond our doors and throughout the province and country.
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Affiliation(s)
- Nimish Mittal
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. .,Temerty Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada. .,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada. .,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Aliza Weinrib
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada
| | - P Maxwell Slepian
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Psychology, York University, Toronto, ON, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada
| | - Stephanie Buryk-Iggers
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Camille Laflamme
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Laura Hussey
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Joel Katz
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada.,University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| | - Lianne McLean
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Dmitry Rozenberg
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Temerty Faculty of Medicine, Division of Respirology, Ajmera Transplant Program, Toronto General Hospital Research Institute, UHN, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yvonne Tse
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Colleen Parker
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Arnon Adler
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - George Charames
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Robert Bleakney
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Christian Veillette
- Department of Surgery, Division of Orthopedics, University of Toronto, Toronto, ON, Canada
| | - Christopher J Nielson
- Department of Surgery, Division of Orthopedics, University of Toronto, Toronto, ON, Canada
| | - Sandra Tavares
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Stephanie Varriano
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Juan Guzman
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Hanna Faghfoury
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Temerty Faculty of Medicine, Division of Medical Genetics, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
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12
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Scicluna K, Formosa MM, Farrugia R, Borg I. Hypermobile Ehlers-Danlos syndrome: A review and a critical appraisal of published genetic research to date. Clin Genet 2021; 101:20-31. [PMID: 34219226 DOI: 10.1111/cge.14026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/08/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) are a collection of rare hereditary connective tissue disorders with heterogeneous phenotypes, usually diagnosed following clinical examination and confirmatory genetic testing. Diagnosis of the commonest subtype, hypermobile Ehlers-Danlos Syndrome (hEDS), relies solely on a clinical diagnosis since its molecular aetiology remains unknown. We performed an up-to-date literature search and selected 11 out of 304 publications according to a set of established criteria. Studies reporting variants affecting collagen proteins were found to be hindered by cohort misclassification and subsequent lack of reproducibility of these genetic findings. The role of the described variants affecting Tenascin-X and LZTS1 is yet to be demonstrated in the majority of hEDS cases, while the functional implication of associated signaling pathways and genes requires further elucidation. The available literature on the genetics of hEDS is scant, dispersed and conflicting due to out-dated nosology terminology. Recent literature has suggested the role of several promising candidate mechanisms which may be linked to the underlying molecular aetiology. Knowledge of the molecular genetic basis of hEDS is expected to increase in the near future through the mainstream use of high-throughput sequencing combined with the updated classification of EDS, and the upcoming Hypermobile Ehlers-Danlos Genetic Evaluation (HEDGE) study.
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Affiliation(s)
- Kirsty Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta
| | - Melissa M Formosa
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.,Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Rosienne Farrugia
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.,Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Isabella Borg
- Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta.,Medical Genetics Unit, Department of Pathology, Mater Dei Hospital, Msida, Malta.,Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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Gensemer C, Burks R, Kautz S, Judge DP, Lavallee M, Norris RA. Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes. Dev Dyn 2021; 250:318-344. [PMID: 32629534 PMCID: PMC7785693 DOI: 10.1002/dvdy.220] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.
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Affiliation(s)
- Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Randall Burks
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Kautz
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P. Judge
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Mark Lavallee
- Department of Family Medicine, Wellspan Health, York, Pennsylvania
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
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Kindgren E, Quiñones Perez A, Knez R. Prevalence of ADHD and Autism Spectrum Disorder in Children with Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome: A Retrospective Study. Neuropsychiatr Dis Treat 2021; 17:379-388. [PMID: 33603376 PMCID: PMC7882457 DOI: 10.2147/ndt.s290494] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 12/19/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) are both characterized by generalized hypermobility, in combination with pain, affected proprioception, and pronounced fatigue. Clinical observation indicates that behavioral problems, hyperactivity, and autistic traits are overrepresented in children with those conditions. The purpose of this retrospective study was to establish the prevalence of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) among children with HSD and hEDS treated in our clinic since 2012. SUBJECTS AND METHODS Since Ehlers-Danlos syndrome (EDS) diagnostic criteria and international classification were changed in 2017, we equate the older diagnosis EDS hypermobility type with the newer hEDS and the older hypermobility syndrome with HSD. A registry search from the computerized medical record system found 201 children (88 boys, 113 girls) aged 6-18 years who were treated at our pediatrics department with the diagnoses HSD or EDS. All medical records (113 with HSD, 88 with EDS) were reviewed, and key symptoms such as fatigue and pain, as well as diagnosis of ADHD/ASD, were recorded. RESULTS All EDS cases could be classified as hEDS. Of the entire study cohort, 16% had a verified ADHD diagnosis and a further 7% were undergoing ADHD diagnostic investigation. Significantly more children with hEDS had ADHD compared to children with HSD (p=0.02). In the age group 15-16 years, 35% of those with hEDS had ADHD and, among those aged 17-18 years, ADHD was present in 46%. Children with coexisting ADHD showed a significantly higher proportion of associated symptoms such as fatigue, sleep-problems, and urinary tract problems. ASD had been verified in 6% of the children. Of those with ASD, 92% had sleep problems. CONCLUSION This study shows a strong association between HSD or hEDS and ADHD or ASD. Therefore, children with HSD or hEDS may need to be routinely screened for neuropsychiatric symptoms.
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Affiliation(s)
- Erik Kindgren
- Department of Pediatrics, Skaraborg Hospital, Skövde, Sweden.,Division of Pediatrics, Department of Biomedical and Clinical Sciences (BKV), Medical Faculty, Linköping University, Linköping, Sweden
| | | | - Rajna Knez
- Department of Pediatrics, Skaraborg Hospital, Skövde, Sweden.,Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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