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

Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities for mucocutaneous bleeding disorders

BACKGROUND

Excessive or abnormal mucocutaneous bleeding (MCB) may impact all aspects of the physical and psychosocial wellbeing of those who live with it (PWMCB). The evidence base for the optimal diagnosis and management of disorders such as inherited platelet disorders, hereditary hemorrhagic telangiectasia (HHT), hypermobility spectrum disorders (HSD), Ehlers-Danlos syndromes (EDS), and von Willebrand disease (VWD) remains thin with enormous potential for targeted research.

RESEARCH DESIGN AND METHODS

National Hemophilia Foundation and American Thrombosis and Hemostasis Network initiated the development of a National Research Blueprint for Inherited Bleeding Disorders with extensive all-stakeholder consultations to identify the priorities of people with inherited bleeding disorders and those who care for them. They recruited multidisciplinary expert working groups (WG) to distill community-identified priorities into concrete research questions and score their feasibility, impact, and risk.

RESULTS

WG2 detailed 38 high priority research questions concerning the biology of MCB, VWD, inherited qualitative platelet function defects, HDS/EDS, HHT, bleeding disorder of unknown cause, novel therapeutics, and aging.

CONCLUSIONS

Improving our understanding of the basic biology of MCB, large cohort longitudinal natural history studies, collaboration, and creative approaches to novel therapeutics will be important in maximizing the benefit of future research for the entire MCB community.

A Case of Early Osteoarthritis in a Patient With Ehlers-Danlos Syndrome

We present a case of early onset osteoarthritis in a patient with Ehlers-Danlos syndrome (EDS) and a history of developmental dysplasia of the hip. Ehlers-Danlos syndrome (EDS) is part of a wide spectrum of connective tissue disorders characterized by hyperextensible skin, hypermobile joints, and tissue fragility. Presentation varies from mild hyperextensibility of the skin and joints to debilitating physical disabilities and vascular complications because of genetic defects in type one and three collagen synthesis. Collagen is the most abundant protein in nearly all parts of the body and errors in the production of this protein have widespread effects. Therefore, we suggest a multidisciplinary approach to the management of patients with EDS, with an emphasis on patient education, to aid in the prevention and early detection of complications.

An investigation of the control of quadriceps in people who are hypermobile; a case control design. Do the results impact our choice of exercise for people with symptomatic hypermobility?

Background

People with symptomatic hypermobility have altered proprioception however, the origin of this is unclear and needs further investigation to target rehabilitation appropriately. The objective of this investigation was to explore the corticospinal and reflex control of quadriceps and see if it differed between three groups of people: those who have symptomatic hypermobility, asymptomatic hypermobility and normal flexibility.

Methods

Using Transcranial Magnetic Stimulation (TMS) and electrical stimulation of peripheral nerves, motor evoked potentials (MEPs) and Hoffman (H) reflexes of quadriceps were evoked in the three groups of people. The threshold and latency of MEPs and the slope of the input–output curves and the amplitude of MEPs and H reflexes were compared across the groups.

Results

The slope of the input–output curve created from MEPs as a result of TMS was steeper in people with symptomatic hypermobility when compared to asymptomatic and normally flexible people (p = 0.04). There were no other differences between the groups.

Conclusion

Corticospinal excitability and the excitability at the motoneurone pool are not likely candidates for the origin of proprioceptive loss in people with symptomatic hypermobility. This is discussed in the light of other work to suggest the receptor sitting in hypermobile connective tissue is a likely candidate. This suggests that treatment aimed at improving receptor responsiveness through increasing muscle tone, may be an effective rehabilitation strategy.

Evaluation of Dental Status and Temporomandibular Joint in Children With Generalized Joint Hypermobility

OBJECTIVE

The aim of this study was to evaluate the dental status and temporomandibular diseases (TMDs)-related symptoms in children with generalized joint hypermobility (GJH) and compare them with healthy controls (HCs).

METHODS

This is a cross-sectional, observational study carried out between September 2016 and April 2017. A total of 124 children with GJH (n = 62) and HC (n = 62) were enrolled. The GJH was assessed with the Beighton hypermobility score. The subjects were screened for dental status and TMD-related symptoms. The assessment included the index for "decayed," "missing," and "filled teeth" (DMFT, dmft); plaque; gingival bleeding; tooth mobility; and temporomandibular joint (TMJ) evaluation.

RESULTS

The mean Beighton hypermobility score was 6.3 ± 1.2 in the GJH group. Visible plaque index and gingival bleeding index scores were found to be significantly higher in children with GJH then in the HC (p = 0.031, p = 0.023). No differences were found regarding the DMFT scores between the groups (p = 0.16). Temporomandibular disorder-related symptom frequencies were significantly higher in children with GJH (p < 0.001). The most common clinically determined sign of TMD was clicking with a maximum active mouth-opening. Combined TMJ symptoms and TMD were observed in approximately one third of the children with GJH.

CONCLUSIONS

The presence of GJH in a child may be indicative of future dental or TMJ problems, and it may cause dental problems due to increased gingival bleeding index and visible plaque index scores. Therefore, children with GJH require preventive dental and TMJ care.

Physical therapy treatment of hypermobile Ehlers-Danlos syndrome: A systematic review

Physiotherapy techniques are regularly prescribed in the hypermobile type Ehlers-Danlos syndrome (hEDS) and they are appreciated by the patients. The objective of this systematic review was to investigate the effect of the different physiotherapy techniques related to the children and adult patients with hEDS. PubMed, SPORTDiscus, Cochrane Library, PEDro, Scopus, and Embase databases were analyzed from inception to April 2020. Characteristics of the studies (authors), patients (sample size, sex, age, Beighton score), and nonpharmacological treatment (length of the program, number of session, duration of the session, and type of intervention), and the results with the dropout rate were extracted. From the 1045 retrieved references, 6 randomized controlled trial with a sample size ranging from 20 to 57 patients were included in the systematic review. There was a huge heterogeneity in the interventions. The durations of the program were from 4 to 8 weeks. Pain or proprioception demonstrated significant improvements in the intervention group regardless of the type of intervention. A benefit of the inspiratory muscle training was observed on functional exercise capacity. The quality of life was systematically improved. Physiotherapy benefits on proprioception and pain in patients with hEDS even if robust randomized control studies are missing.

Hypermobile Disorders and Their Effects on the Hip Joint

Hypermobility, or joint hyperlaxity, can result from inherited connective tissue disorders or from micro- or macrotrauma to a joint. The supraphysiologic motion of the hip joint results in capsuloligamentous damage, and these patients have a propensity to develop femoroacetabular impingement syndrome (FAIS) and labral injury. In this review, the recent literature evaluating the definitions, history, incidence, genetics, and histology of hypermobile disorders is investigated. We then review the clinical evaluation, natural history, and resulting instability for patients presenting with a hypermobile hip. Lastly, treatment options and outcomes will be highlighted.

Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes

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.

Anterior Segment Analysis and Evaluation of Corneal Biomechanical Properties in Children with Joint Hypermobility

Objectives:

To compare anterior segment parameters and biomechanical analysis of the cornea in children with joint hypermobility (JH) and healthy children.

Materials and Methods:

Cross-sectional case-control study. Fifty eyes of 25 children with JH were compared with 74 eyes of 37 healthy age- and sex-matched controls in terms of refractive, anterior segment topographic, and corneal biomechanical measurements. Axial length (AL) was measured with a Nidek AL-Scan biometry device; corneal-compensated intraocular pressure (IOPcc), Goldmann-correlated IOP (IOPg), corneal hysteresis (CH), and corneal resistance factor (CRF) were measured with a Reichert ocular response analyzer (ORA). Central corneal thickness (CCT), anterior chamber depth (ACD), K1/K2 values, iris diameter, and anterior chamber volume (ACV) were measured with a Sirius topography device.

Results:

Mean age in the JH group was 10.56±4.03 years, while that of the control group was 11.27±2.59 years (p=0.23). Spherical equivalent was -0.22±1.02 diopter (D) in the JH group and -0.12±1.12 D in the control group (p=0.60); CCT was 23.01±0.82 µm in the JH group and 23.17±0.82 µm in the control group (p=0.33). There were no significant differences between the two groups in terms of age, sex, IOP, IOPcc, IOPg, CH, CRF, AL, K1, K2, iris diameter, ACD, and ACV.

Conclusion:

JH, which causes increased flexibility of the joints, was concluded not to cause a significant change in the corneal biomechanical markers of CRF and CH or in anterior segment topographic parameters.

Surgical-orthodontic treatment in patients with Ehlers–Danlos syndrome: a report of two familial cases

Introduction:Ehlers–Danlos syndromes (EDS) are a group of rare inherited connective tissue disorders that affect the synthesis and structure of collagen in a ubiquitous manner. The clinical presentation can vary according to the associated genetic mutation. The 2017 international classification of EDS describes 13 types of EDS.Observation: The first part of this paper describes the surgical-orthodontic treatment for two sisters affected by a common and familial form of EDS, with a follow-up period of 8 years. The main symptoms were agenesis, impacted teeth, and delayed eruptions.Discussion: The second part proposes a review of oro-dental manifestations and discusses therapeutic approaches for patients with EDS.Conclusion: EDS can affect the oro-dental region with numerous consequences. Recognition of clinical symptoms and radiological signs is essential to provide appropriate dental care. Moreover, complete clinical and radiological assessment can allow early diagnosis of EDS.

Prevalence of generalized joint hypermobility, musculoskeletal injuries, and chronic musculoskeletal pain among American university students

The objective of this study was to investigate the prevalence of generalized joint hypermobility (GJH) in a university-aged population, whether young adults (aged 18–25 years) with GJH are prone to sustain more musculoskeletal injuries, and are more likely to suffer from chronic musculoskeletal pain. The study used an interactive survey to gather data; GJH was assessed using a cut-off Beighton score of ≥5 in accordance with the 2017 International Classification of EDS criteria. The analyzed sample consisted of 482 female and 172 male participants from Florida Gulf Coast University (USA). The prevalence of GJH in a university-aged population can be estimated at 12.5%. Women did not have higher rates of GJH than men. However, female participants showed significantly higher rates of hypermobility of the spine as well as the right knee and elbow joints. The Beighton scores did not differ by ethnicity/race. Female participants had a lower rate of self-reported injuries than male participants, although this difference was not significant. There was no difference in the proportion of all participants classified within different categories (0; 1–4; 5–9) of Beighton scores and whether or not they reported having been injured. Male and female participants reported chronic pain of joints and neck or back at the same rates across the Beighton score categories. Female participants, however, reported higher pain intensity for chronic neck and back pain. This study increases knowledge about a correlation between GJH, musculoskeletal injuries, and chronic pain of joints, neck, and back in a university-aged population.

Central fatigue is greater than peripheral fatigue in people with joint hypermobility syndrome

PURPOSE

People with Joint Hypermobility Syndrome (JHS) suffer with fatigue. The purpose of this project was to investigate the contribution of central and peripheral fatigue.

METHODS

Electrical stimulation of the musculocutaneous nerve to biceps brachii, and transcranial magnetic stimulation over the motor cortex supplying biceps brachii were used. Peripheral and central fatigue were assessed during a control, fatiguing and recovery phase protocol.

RESULTS

JHS participants perceived greater fatigue during the protocol compared to a control group and did not recover. Central and peripheral fatigue did not occur in the control group. However, the JHS group showed central fatigue. MEP amplitude increased in the JHS group during the fatiguing protocol (p < 0.01) before recovering. Superimposed twitch amplitude increased in the JHS group during the fatiguing protocol and stayed elevated during the recovery phase (p < 0.04). Time to peak (TTP) amplitude of the torque generated by the TMS was longer in the JHS group (p < 0.05). RMS during MVCs decreased during the fatiguing protocol reaching significance during the recovery phase (p < 0.01).

CONCLUSION

JHS participants suffered central but not peripheral fatigue. A modified strength programme to target this is discussed.

Oro-dental characteristics in patients with hypermobile Ehlers-Danlos Syndrome compared to a healthy control group

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a hereditary disorder that affects the connective tissue and collagen structures in the body characterised by joint hypermobility, skin hyperextensibility and tissue fragility.

OBJECTIVE

The aim of the study was to investigate the oro-dental characteristics including measurements of tooth size of 26 patients with hypermobile EDS (hEDS), differentiated by a genetic test, compared to 39 healthy controls.

METHODS

Interview, clinical and radiological examination on panoramic radiograph and cone-beam computed tomographic (CBCT) scan were performed. Statistical analyses included Fisher's exact test, paired t test and multiple logistic and linear models adjusted for age and gender.

RESULTS

The experience of xerostomia (P = 0.039), local anaesthetic insufficiency (P < 0.001) and tooth extraction complications (P < 0.003) were significantly higher in hEDS compared to controls. The debris index was significantly higher in hEDS (P < 0.001), and the distance between the cement-enamel junction (CEJ) and the bone level on the upper left first incisor and molar and the lower right first molar was significantly larger in hEDS compared to controls (P = 0.021, P = 0.024, P = 0.021, respectively). The crown heights of the upper and lower first incisors were significantly smaller (P = 0.001, P = 0.003, P = 0.002, P < 0.001, respectively) in hEDS compared to controls. When adjusting for debris index, only the distance between CEJ and the marginal bone level on the upper left and lower right molar was associated with hEDS.

CONCLUSION

The results indicate that xerostomia, resistance to local anaesthesia, tooth extraction complications, poor oral hygiene, larger distance between CEJ and marginal bone level and small crown heights can be found in patients with hEDS.

Gleno-humeral abduction measurement in patients with Ehlers-Danlos syndrome

BACKGROUND

No genetic tests or other investigations are available to establish the definitive diagnosis of Ehlers-Danlos syndrome (EDS). A presumptive diagnosis can be made based on a converging set of findings, including a family history of the disease, the patient's medical history, and the physical findings. The Beighton score is currently the reference standard tool for assessing joint hypermobility, which must be present in at least 5 of 9 tested joints. However, joint hypermobility testing may be challenging, for instance in patients with pain during mobilisation and/or tight hamstring muscles. Furthermore, the Beighton score may be less than 5 in patients with other unequivocal evidence of EDS. The objective of this study was to assess the contribution of gleno-humeral abduction measurement to the diagnosis of EDS.

HYPOTHESIS

Gleno-humeral abduction measurement using a standardised method assists in the diagnosis of EDS.

METHODS AND MATERIAL

Retrospective case-control study comparing 110 patients with known EDS (cases) to 100 controls.

RESULTS

Gleno-humeral abduction was significantly greater in the cases than in the controls, irrespective of age, sex, and Beighton score. Gleno-humeral abduction beyond 90° was 92.5% sensitive and 96.4% specific. Inter-examiner reproducibility of gleno-humeral abduction measurement was excellent.

DISCUSSION

Increased gleno-humeral abduction may be sufficient to demonstrate joint hypermobility and to suggest EDS in patients whose personal and family history is consistent with this diagnosis.

LEVEL OF EVIDENCE

III, case-control study.

Inspiratory muscle strength training improves lung function in patients with the hypermobile Ehlers-Danlos syndrome: A randomized controlled trial

As exertional inspiratory dyspnea is a common disabling complaint in hypermobile Ehlers-Danlos syndrome (hEDS) often also known as joint hypermobility syndrome (JHS), we investigated inspiratory muscle (IM) strength in patients with hEDS, and we assessed the effects of IM training (IMT) on IM strength, lung function, and exercise capacity. A prospective evaluation of IM strength followed by a randomized controlled trial of IMT was performed in women with hEDS. Sniff nasal inspiratory pressure (SNIP) was used to routinely measure IM strength and IMT was carried out using a pressure threshold device. IM strength (main outcome), cardiopulmonary function, exercise capacity, and emotional distress of both the treated and control groups were evaluated at the start and at the end of the 6-week training period. IM strength was reduced (<80% of predicted) in 77% of patients (80/104). Lung function was normal, although 24% of patients had a higher forced expiratory vital capacity (FVC) than normal and 12% of patients had a higher total lung capacity (TLC) than normal. Both the IMT and control groups (n = 20) had similar baseline characteristics. Significant changes were noted only in the IMT group after IMT. At the end of the program, IMT improved SNIP (20%) (before: 41 ± 17 cm H₂ O [28, 53] vs. after: 49 ± 18 cm H₂ O [34;65]), six-minute walking distance (6MWD) (60 m) (455 ± 107 m [379,532] vs. 515 ± 127 m [408, 621]), and forced expiratory volume in one second (FEV1) (285 mL) (94 ± 14% pred [84,104] vs. 103 ± 11% pred [94, 112]). IM strength is significantly reduced in patients with hEDS. IMT improved IM strength, lung function, and exercise capacity. Our findings suggest that IMT should be added to usual care.

The association between Ehlers-Danlos syndrome-hypermobility type and gastrointestinal symptoms in university students: a cross-sectional study

BACKGROUND

Patients with Ehlers-Danlos syndrome-hypermobility type (EDS-HT) have increased prevalence of gastrointestinal (GI) symptoms, particularly reflux and dyspepsia. EDS-HT is associated with dysautonomia, psychopathology, and chronic pain which can be associated with GI symptoms. The association between GI symptoms and EDS-HT in a 'non-patient' population and the effect of the above-mentioned factors has never been studied.

METHODS

In a cross sectional study, a hypermobility questionnaire was used to screen university students; further clinical examination established the diagnosis of EDS-HT. Validated questionnaires assessed for GI, somatic, pain and autonomic symptoms, psychopathology and quality of life (QOL). These were compared in students with and without EDS-HT; logistic regression analysis examined associations between EDS-HT, GI symptoms and other variables.

KEY RESULTS

Of 1998 students screened, 162 were included: 74 EDS-HT (21.0 years, 53% female) vs 88 Non-EDS-HT (21.5 years, 65% female). Compared to non-EDS-HT students, EDS-HT students were more likely to have multiple GI symptoms (41.9% vs 27.3% P=.05), particularly postprandial fullness (34.4% vs 15.9%, P=.01) and early satiety (32% vs 17%, P=.03), greater autonomic (P<.001) and somatic symptoms (P=.04) but not psychopathology (P>.8). The association between EDS-HT and postprandial symptoms was dependent on autonomic factors but independent of pain and psychopathology. Pain-related QOL scores were reduced in the EDS-HT group (80 vs 90, P=.03).

CONCLUSIONS AND INFERENCES

The previously described association between EDS-HT, dyspepsia, pain and autonomic symptoms in patients is also present in non-patient groups. Future studies are necessary to explore the etiological role of connective tissue in GI and extra intestinal symptoms.

A connective tissue disorder may underlie ESSENCE problems in childhood

BACKGROUND

Ehlers-Danlos syndrome hypermobility type, also known as Joint Hypermobility Syndrome (EDS-HT/JHS), is the most common hereditary disorder of the connective tissue (HDCT). It is characterized by tissue fragility, joint hypermobility and a wide range of articular and non-articular manifestations, which often appear in infancy. The clinical picture of EDS-HT/JHS is poorly known by the medical community, as is the presence of "ESSENCE" (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) problems in affected children.

AIM

The present work reviews the clinical and empirical evidence for ESSENCE difficulties in children with EDS-HT/JHS.

METHOD

A narrative review of the literature was undertaken following a comprehensive search of scientific online databases and reference lists. This included publications of quantitative and qualitative research.

RESULTS

Motor abnormality, hyperactivity/hypoactivity, inattention, speech/language, social interaction, behavioral, sleep, feeding and emotional problems are ESSENCE difficulties for which there is some evidence of an association with EDS-HT/JHS.

CONCLUSION

Children with EDS-HT/JHS present ESSENCE problems that often coexist and tend to be recognized before the HDCT. Clinicians encountering children with ESSENCE problems should consider the possibility of an underlying HDCT such as EDS-HT/JHS, probably influencing neurodevelopmental attributes in a subgroup of children. Awareness of these interconnected clinical problems might help improve early referral, diagnosis and treatment of EDS-HT/JHS.

Ehlers-Danlos Syndrome Presenting as Severe Headache in a Young Adult

A 27-year-old male with a positive family history of abdominal aortic aneurysm presented to his primary care physician and ultimately to the emergency department with the worst headache of his life and hypertension. An aneurysm of the right internal carotid artery was noted on CT and MRI. Upon further imaging and analysis, multiple vascular abnormalities were found, including possible dissection or pseudoaneurysm and multifocal narrowing and dilatation of the arteries of the head and neck. The patient underwent genetic testing revealing Ehlers-Danlos, type IV.

Ectomorphic somatotype and joint hypermobility are linked in panic and agoraphobic patients: a case-control study

OBJECTIVE

To test whether there is an association between somatotype measures, joint hypermobility (JH), and panic and/or agoraphobia (PA).

METHOD

Sociodemographic characteristics, somatotype, and JH status were assessed in 60 patients (30 men and 30 women) with PA and 60 non-clinical controls, matched by age and gender.

RESULTS

Patients and controls categorized by gender did not differ in terms of age, educational degree, marital status, or labour situation. There were significant differences between mean somatotype groups both in men and women. Men and women somatotype patients were significantly less endomorphic and more ectomorphic than controls. Hypermobility was significantly more frequent in both male and female patients. In the entire sample, 38.3% of patients and 13.3% of controls were categorized as ectomorphic (χ(2) = 8.5, p = 0.004). After adjusting for age and sex, ectomorphic somatotype was independently related to JH status [OR = 3.25, 95% CI 1.35-7.8, p = 0.008].

CONCLUSIONS

Since PA may be associated with JH, it is suggested that the relationship found between panic and ectomorphic somatotype might be mediated through JH.

Multimodal chiropractic care of pain and disability for a patient diagnosed with benign joint hypermobility syndrome: a case report

OBJECTIVE

The purpose of this case report is to describe multimodal chiropractic care of a female patient diagnosed with benign joint hypermobility syndrome (BJHS) and a history of chronic spine pain.

CLINICAL FEATURES

A 23-year-old white female presented for chiropractic care with chronic low back pain, neck pain, and headaches. The patient was diagnosed with BJHS, including joint hypermobility of her thumbs, elbows, right knee, and lumbopelvic region. A 6-year history of low back pain and varicose veins in her posterior thighs and knees were additional significant diagnostic findings of BJHS.

INTERVENTIONS AND OUTCOMES

The treatment consisted of spinal and extremity manipulation, Graston technique, and postisometric relaxation combined with sensory motor stimulation and scapular stabilization exercises. The patient was seen 15 times over an 18-week period. After 18 weeks of care, the Revised Oswestry Low Back Questionnaire and Headache Disability Index demonstrated clinically important improvements with her low back pain and headache; but little change was noted in her neck pain as measured by the Neck Disability Index.

CONCLUSION

This patient with BJHS who had decreased disability and spine pain improved after a course of multimodal chiropractic care.

Ehlers-danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations

Ehlers-Danlos syndrome, hypermobility type, constituting a phenotypic continuum with or, perhaps, corresponding to the joint hypermobility syndrome (JHS/EDS-HT), is likely the most common, though the least recognized, heritable connective tissue disorder. Known for decades as a hereditary condition with predominant rheumatologic manifestations, it is now emerging as a multisystemic disorder with widespread manifestations. Nevertheless, the practitioners' awareness of this condition is generally poor and most patients await years or, perhaps, decades before reaching the correct diagnosis. Among the various sites of disease manifestations, skin and mucosae represent a neglected organ where the dermatologist can easily spot diagnostic clues, which consistently integrate joint hypermobility and other orthopedic/neurologic manifestations at physical examination. In this paper, actual knowledge on JHS/EDS-HT is summarized in various sections. Particular attention has been posed on overlooked manifestations, including cutaneous, mucosal, and oropharyngeal features, and early diagnosis techniques, as a major point of interest for the practicing dermatologist. Actual research progresses on JH/EDS-HT envisage an unexpected link between heritable dysfunctions of the connective tissue and a wide range of functional somatic syndromes, most of them commonly diagnosed in the office of various specialists, comprising dermatologists.

Ocular features in joint hypermobility syndrome/ehlers-danlos syndrome hypermobility type: a clinical and in vivo confocal microscopy study

PURPOSE

To investigate ocular anomalies in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type (JHS/EDS-HT).

DESIGN

Prospective, cross-sectional study.

METHODS

Forty-four eyes of 22 consecutive patients with an established diagnosis of JHS/EDS-HT and 44 eyes of 22 age- and gender-matched control subjects. Administration of a standardized questionnaire (Ocular Surface Disease Index) and a complete ophthalmologic examination, including assessment of best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, indirect ophthalmoscopy, tear-film break-up time, Schirmer I testing, axial length and anterior chamber depth measurement, corneal topography, corneal pachymetry, and confocal microscopy. Main outcome measures included comparing ocular anomalies in JHS/EDS-HT and control eyes.

RESULTS

JHS/EDS-HT patients reported dry eye symptoms more commonly than controls (P < .0001). Scores of tear-film break-up time and Schirmer I test were significantly lower in JHS/EDS-HT eyes (P < .0001). Minor lens opacities were significantly more common in the JHS/EDS-HT group (13.6%; P < .05). Pathologic myopia with abnormal vitreous was found in 7 JHS/EDS-HT eyes (15.9%) and 0 controls (P = .01). Corneas were significantly steeper and the best-fit sphere index was significantly higher in JHS/EDS-HT group (P < .01). By confocal microscopy, the JHS/EDS-HT group showed lower density of cells in the superficial epithelium (P < .001) and higher density of stromal keratocytes in anterior and posterior stroma (P < .0001).

CONCLUSIONS

The most consistent association of eye anomalies in the JHS/EDS-HT group included xerophthalmia, steeper corneas, pathologic myopia, and vitreous abnormalities, as well as a higher rate of minor lens opacities. These findings indicate the need for ophthalmologic survey in the assessment and management of patients with JHS/EDS-HT.

Impact of joint laxity and hypermobility on the musculoskeletal system

Excessive joint laxity, or hypermobility, is a common finding of clinical importance in the management of musculoskeletal conditions. Hypermobility is common in young patients and in general is associated with an increased incidence of musculoskeletal injury. Hypermobility has been implicated in ankle sprains, anterior cruciate ligament injury, shoulder instability, and osteoarthritis of the hand. Patients with hypermobility and musculoskeletal injuries often seek care for diffuse musculoskeletal pain and injuries with no specific inciting event. Orthopaedic surgeons and other healthcare providers should be aware of the underlying relationship between hypermobility and musculoskeletal injury to avoid unnecessary diagnostic tests and inappropriate management. Prolonged therapy and general conditioning are typically required, with special emphasis on improving strength and proprioception to address symptoms and prevent future injury. Orthopaedic surgeons must recognize the implications of joint mobility syndromes in the management and rehabilitation of several musculoskeletal injuries and orthopaedic disorders.

Association between psychopathological factors and joint hypermobility syndrome in a group of undergraduates from a French university

OBJECTIVE

To explore the frequency of Joint Hypermobility Syndrome (JHS) among university students and assess whether a relationship exists between this collagen condition and certain psychological variables.

METHOD

A cross-sectional sample of 365 undergraduates at a French university was assessed with the Brighton's criteria for JHS, Somatosensory Amplification Scale (SSAS), Liebowitz Social Anxiety Scale (LSAS), and Hospital Anxiety and Depression Scale (HADS).

RESULTS

39.5% of the participants met Brighton's criteria for JHS. Scores of somatosensory amplification were higher among participants with JHS (t = -2.98; p = 0.03) independent of gender. Female participants with JHS had higher scores in depression (t = -2.01; p = 0.04) and general anxiety (t = -2.35; p = 0.01) than women without JHS. The percentage of males with a medium/high level of social anxiety was greater among participants with JHS (78.6% vs. 41.7%; chi2 = 6.18;p = 0.01). Logistic regression demonstrated that male sex and low level of somatosensory amplification are variables contrary to the presence of JHS.

CONCLUSION

JHS is a frequent condition among young people evaluated. JHS is associated with psychological distress and higher levels of somatosensory amplification.

Multiple triggering in a girl with Ehlers-Danlos syndrome: case report

We report a case of multiple triggering associated with Ehlers-Danlos syndrome. We postulate that the propensity for tendon degeneration in Ehlers-Danlos syndrome coupled with repetitive microtrauma might lead to fraying of the tendon fibers and, consequently, triggering. Indeed, in our case, debridement of the tendons rather than resection of A1 pulley resulted in a good long-term functional outcome 2 years after surgery.

Absence of inferior labial and lingual frenula in Ehlers-Danlos syndrome: a minor diagnostic criterion in French patients

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a heterogenous group of diseases that can be potentially life threatening in the vascular form. The diagnosis is mainly based on a clinical score including many items that demonstrate skin, mucosa, joint, and vessel involvement. The score is particularly helpful in hypermobile and classical forms but can be normal in the vascular type. The absence of the lingual and inferior labial frenula was reported to be a useful diagnostic tool in a series of 12 patients with classical and hypermobile EDS. However, two further reports have contested the value of this sign.

OBJECTIVE

To determine the diagnostic value of the absence of inferior labial or lingual frenula in EDS.

METHODS

Patients with EDS were prospectively recruited from November 2006 to April 2007 in a French tertiary center. Each patient was examined to check for the presence or absence of the oral frenula and matched with two controls seen from February to May 2007.

RESULTS

Forty-three patients (ratio female/male of 2.07 : 1, mean age 31 years, range 4-63 years), 4 with classical EDS, 19 with hypermobile EDS, and 20 with vascular-type EDS, were included and matched with 86 controls. The sensitivity of the absence of the inferior labial frenulum was 42% (95% CI 27, 58) and for the lingual frenulum was 53.5% (95% CI 38, 69). The specificity was 99% (95% CI 94, 100) and 98% (95% CI 92, 100), respectively. In the vascular group, 13 of 20 patients were affected (sensitivity = 65% [95% CI 41, 85]; specificity = 97% [95% CI 87, 100]; odds ratio = 72 [95% CI 8, 645]). Inter-observer agreement was excellent (kappa value 0.91).

CONCLUSION

The absence of the inferior labial frenulum or lingual frenulum is a specific sign of EDS that can be easily checked by a physician. It can be helpful in the early diagnosis of the disease, including the vascular type, in affected families. It can also be helpful to distinguish between joint hypermobility syndrome and the hypermobile type of EDS in patients with joint hypermobility.

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.

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.

Rituximab for the treatment of rheumatoid arthritis

Rituximab has been approved by the United States Food and Drug Administration in combination with methotrexate for the treatment of rheumatoid arthritis in patients who failed to achieve adequate benefit from tumor necrosis factor-alpha inhibitors. Rituximab is a biologic agent that depletes peripheral B cells--an action thought to reduce rheumatoid arthritis activity--and induces prolonged clinical improvement. Two 1000-mg infusions administered 2 weeks apart can result in a response that lasts for months. Most patients will require retreatment, but the effect of repeated dosing on patient outcomes has not yet been determined. Combination therapy with methotrexate is recommended as this appears to achieve the best outcomes. Rituximab also has been shown to be safe, although the lack of long-term efficacy and safety data limit its use. More studies are needed, but this agent has been demonstrated to be safe and effective in patients who fail to achieve adequate clinical response to methotrexate and tumor necrosis factor-alpha inhibitors.

[Absence of inferior labial or lingual frenula in Ehlers-Danlos syndrome: a new diagnostic criterion?]

BACKGROUND

Ehlers-Danlos syndrome comprises a rare and heterogeneous group of diseases affecting the skin, joints and vessels. Diagnosis is based on clinical score since molecular testing is not routinely available. High sensitivity and specificity concerning the absence of inferior labial and lingual frenula has been reported in Ehlers-Danlos syndrome, but the diagnostic value of this finding has been contested.

PATIENTS AND METHODS

We here report the cases of 2 female patients, one with a vascular form of Ehlers-Danlos syndrome complicated by spontaneous dissection of the carotid and vertebral arteries, and the other with classic type; in both women, inferior labial and lingual frenula were absent.

DISCUSSION

We discuss the discrepancies between the 3 published studies dealing with abnormalities of the inferior labial and lingual frenula in Ehlers-Danlos syndrome. We suggest routine oral examination in patients with suspected Ehlers-Danlos syndrome. The diagnostic value of absence of oral frenula in Ehlers-Danlos syndrome requires confirmation by a prospective study.

Tumor necrosis factor as a therapeutic target of rheumatologic disease

TNF-alpha is a crucial pro-inflammatory and immunoregulatory cytokine that is central to the pathogenesis of various inflammatory and autoimmune conditions. A number of controlled trials have shown effectiveness for TNF-alpha inhibitors in several diseases, in particular rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and Crohn's disease. These agents may also be useful in additional autoimmune conditions. The introduction of TNF-alpha inhibitors has revolutionized the therapeutic approach and treatment paradigms especially for patients with rheumatoid arthritis. Despite extensive investigation, the full profile of their mechanisms of action remain incompletely understood. Optimal use of these agents requires consideration of their possible adverse effects. In addition to the presently available TNF-alpha blockers, other agents targeting this key mediator are under study. Recent advances and future directions in anti-TNF-alpha therapy are discussed in this paper.

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.

Impfungen in der Erwachsenenrheumatologie

Patients with rheumatic diseases who are undergoing immunosuppressive therapy have a substantially increased risk of infection compared to the normal population, and are thus candidates for preventive measures. In accordance with the recommendations of the Standing Vaccination Commission of the Robert Koch Institute (Ständigen Impfkommission, STIKO), these individuals, in analogy with other patients with chronic diseases, belong to a risk group for which vaccination against pneumococci and influenza is recommended. Published studies indicate that a limited immune response is possible for patients undergoing immunosuppressive therapy. Here, methotrexate in particular appears to interfere with the success of vaccination against pneumococci. However, a limited immune response against influenza antigens was observed under immunosuppression with mycophenolate mufti, cyclosporine und azathioprine. Consideration must be given to the fact that a patient under continual immunosuppression has a reduced duration of protective immune response. New studies on tumor necrosis factor (TNF) inhibitors indicate that there should be no interference with pneumococcus infection. The possibly variable vaccination success of patients undergoing TNF inhibitor treatment is qualified by the fact that all published results show that the expected immune response after an influenza vaccination is very good. Vaccination strategies in cases in which the use of rituximab and abatacept is planned are currently unclear.