Pain intensity and quality of life perception in children with hypermobility syndrome

The Impact of Podiatric Intervention on the Quality of Life and Pain in Children and Adolescents with Hypermobility

The purpose of this study was to evaluate the effect of custom-made orthotics on pain, health-related quality of life (HRQoL), function and fatigue in children and adolescents with generalised joint hypermobility (GJH) and lower limb pain. Fifty-three children aged 5-18 years were fitted with custom-made polypropylene orthotics. Visual analogue scale (VAS) assessed lower limb pain severity, Paediatric Quality of Life Inventory assessed HRQoL and fatigue and six-minute walk test (6 MWT) measured functional endurance at baseline, at 1 month and 3 months post-intervention. A mixed model including a random intercept for participant and a fixed effect for time was used to assess differences in outcomes over time. Fifty-two children completed the study (mean age 10.6-years). Children reported significantly reduced pain (mean VAS reduction -27/100, 95%CI: -33, -21), improved HRQoL (mean total improvement 11/100, 95%CI: 7, -15), functional capacity (mean 6MWT improvement 27 m, 95%CI: 18, -36) and fatigue (mean total improvement 13/100, 95%CI: 9, -17) after 1 month of wearing the custom-made orthotics. From 1 month to 3 months there was further statistically but not clinically significant reduction in pain while benefit on other outcomes was maintained. In this study, children with GJH reported reduced lower limb pain, improved HRQoL, functional endurance and fatigue after a month post-fitting of custom-made orthotics which was maintained over a 3 month period. Orthotics were well-tolerated with no serious adverse events reported.

Hypermobility prevalence, measurements, and outcomes in childhood, adolescence, and emerging adulthood: a systematic review

General Joint Hypermobility (GJH) is a common condition found in 2-57% of the population. Of those with GJH, 10% suffer from accompanying physical and/or psychological symptoms. While the understanding of GJH in the general population is unfolding, its implication in a cohort of children, adolescents and young adults are not yet understood. This systematic review explored GJH's prevalence, tools to measure it, its physical and psychosocial symptoms, with a special interest in aesthetic sports. The CINHAL, MEDLINE, PsycINFO, SPORTDiscus and Scopus databases were searched for relevant studies. Inclusion criteria were (1) Age range of 5-24; (2) Participants had GJH; (3) A measurement for GJH; (4) Studies written in English language. Study screening for title, abstract and full text (when needed) and quality assessment were performed by two independent individuals. 107 studies were included in this review and were thematically grouped into six clusters expressing different foci: (1) GJH's Core Characteristics; (2) Orthopedic; (3) Physical Other; (4) Psychosocial; (5) Treatment and (6) Aesthetic Sports. The review revealed a growing interest in GJH in this cohort in the last decade, especially regarding non-musculoskeletal physical implications and psychosocial aspects. Prevalence varied between different ethnic groups and as a parameter of age, gender and measurement. The most widespread tool to measure GJH was the Beighton scale, with a cut-off varying between 4 and 7. Children show fewer, but similar GJH implication to those in the general population, however, more research on the topic is warranted, especially regarding psychosocial aspects and treatment.

Biomechanical changes in the gastrocnemius medius-Achilles tendon complex in people with hypermobility spectrum disorders: A cross-sectional compression sonoelastography study

Objective

This study aimed to assess the biomechanical impact of Hypermobility Spectrum Disorders (HSD) on the elasticity of the gastrocnemius medius-Achilles tendon (GM-AT) complex.

Methods

Using a cross-sectional design, the GM-AT complex elasticity was compared using sonoelastography (SEG) in an HSD group and healthy controls during rest and maximal isometric plantar flexion contraction.

Results

The HSD group comprised 28 patients (26 women); mean ± SD age 28.7 ± 8.4 years, compared to 28 controls (26 women); 31.5 ± 8.7 years. During rest, greater elasticity was identified in HSD relative to controls at the GM-AT musculotendinous junction (strain ratio 2.05 ± 1.31 vs. 1.48 ± 0.49), mid-AT (3.60 ± 1.97 vs. 2.66 ± 1.00), and distal AT (4.57 ± 2.69 vs. 3.22 ± 1.94) (all p < 0.05). During contraction, no significant differences were found between groups at the GM-AT musculotendinous junction (3.40 ± 2.16 vs. 2.62 ± 1.07), mid AT (10.75 ± 5.29 vs. 8.49 ± 3.53), or distal AT (8.55 ± 5.39 vs. 8.83 ± 3.51) (all p > 0.05). No significant differences were found between groups in the GM strain ratio during rest (4.05 ± 1.43 vs. 3.62 ± 0.78), or contraction (4.23 ± 1.29 vs. 4.19 ± 1.31). Exploratory Receiver Operator Characteristics curve analysis suggested low sensitivity and specificity of the strain ratio for the diagnosis of HSD.

Conclusion

People with HSD have greater GM-AT complex elasticity. Although statistically significant group differences were identified, further research is required to establish the diagnostic, clinical, and research utility of strain ratio measurements.

Validation of an Electronic Visual Analog Scale App for Pain Evaluation in Children and Adolescents With Symptomatic Hypermobility: Cross-sectional Study

BACKGROUND

Rapid advances in mobile apps for clinical data collection for pain evaluation have resulted in more efficient data handling and analysis than traditional paper-based approaches. As paper-based visual analogue scale (p-VAS) scores are commonly used to assess pain levels, new emerging apps need to be validated prior to clinical application with symptomatic children and adolescents.

OBJECTIVE

This study aimed to assess the validity and reliability of an electronic visual analogue scale (e-VAS) method via a mobile health (mHealth) App in children and adolescents diagnosed with hypermobility spectrum disorder/hypermobile Ehlers-Danlos syndrome (HSD/HEDS) in comparison with the traditional p-VAS.

METHODS

Children diagnosed with HSD/HEDS aged 5-18 years were recruited from a sports medicine center in Sydney (New South Wales, Australia). Consenting participants assigned in random order to the e-VAS and p-VAS platforms were asked to indicate their current lower limb pain level and completed pain assessment e-VAS or p-VAS at one time point. Instrument agreement between the 2 methods was determined from the intraclass correlation coefficient (ICC) and through Bland-Altman analysis.

RESULTS

In total, 43 children with HSD/HEDS aged 11 (SD 3.8) years were recruited and completed this study. The difference between the 2 VAS platforms of median values was 0.20. Bland-Altman analysis revealed a difference of 0.19 (SD 0.95) with limits of agreement ranging -1.67 to 2.04. An ICC of 0.87 (95% CI 0.78-0.93) indicated good reliability.

CONCLUSIONS

These findings suggest that the e-VAS mHealth App is a validated tool and a feasible method of collecting pain recording scores when compared with the traditional paper format in children and adolescents with HSD/HEDS. The e-VAS App can be reliably used for pediatric pain evaluation, and it could potentially be introduced into daily clinical practice to improve real-time symptom monitoring. Further research is warranted to investigate the usage of the app for remote support in real clinical settings.

Impact of Pain Neuroscience Education Program in Community Physiotherapy Context on Pain Perception and Psychosocial Variables Associated with It in Elderly Persons: A Ranzomized Controlled Trial

This study investigated the long-term effect (six-months) of a Pain Neuroscience Education (PNE) program on pain perception, quality of life, kinesiophobia and catastrophism in older adults with multimorbidity and chronic pain. Fifty participants (n = 50) were randomly assigned to the pain education therapy group (PET; n = 24) and control group (CG; n = 26). The PET group received six sessions (i.e., once a week, 50 min) about neurophysiology of pain while the CG carried on with their usual life. Perception of pain through the visual analogue scale (VAS), quality of life (EQ-5D questionnaire), kinesiophobia (TSK-11) and catastrophism (PCS) were assessed after six months since the last PNE session. Statistically significant differences on VAS (t₍₄₈₎ = 44, p = 0.01, ES = 0.42 [0.13, 0.65]) was found in favor to PET group. No other statistically significant differences were found. This study found that the application of a PNE intervention in an isolated form was able to significantly reduce pain perception with low effect size in the long-term (six months after intervention) in elderly people with chronic pain.

Masterclass: Hypermobility and hypermobility related disorders

INTRODUCTION

Hypermobile joints display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility may present in a single joint, a few joints or in multiple joints and may be congenital or acquired with training, disease or injury. Hypermobile joints may be asymptomatic or may be associated with pain, fatigue, multisystemic complaints and significant disability. Furthermore, joint hypermobility may be a sign of an underlying hereditary disorder of connective tissue.

PURPOSE

This masterclass aims to provides a state-of-the-art review of the aetiology, epidemiology, clinical presentation, assessment and management of joint hypermobility and hypermobility related disorders using an evidence based and biopsychosocial approach. The new framework for classifying the spectrum of joint hypermobility disorders along with new diagnostic criteria for the hypermobile Ehlers Danlos syndrome, published by an international consortium of clinical experts and researchers in 2017 is integrated into the paper.

IMPLICATIONS FOR PRACTICE

People with joint hypermobility related disorders present to healthcare professionals with a wide range of symptoms which extend beyond the musculoskeletal system. Early recognition and treatment are key to effective management. A biopsychosocial and patient empowerment approach to functional restoration is recommended.

Indicators of Health-Related Quality of Life in Cats With Degenerative Joint Disease: Systematic Review and Proposal of a Conceptual Framework

Objectives: The assessment of health-related quality of life (HRQoL) is becoming increasingly important in companion animals. This study describes a systematic review and development of a proposed conceptual framework to assess HRQoL in cats with osteoarthritis (OA). Methods: The conceptual framework was developed according to published guidelines. A comprehensive search of the CAB Direct, Scopus, PubMed, and Web of Science databases was carried out for publications in English from inception to November 12, 2019. Search words used were "cat", "feline", "chronic pain", "pain", and "quality of life". Publications were selected if they were full-text and peer-reviewed, based on primary data, and identified or measured behavioral symptoms of chronic musculoskeletal pain in cats. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A data extraction form was developed from categories identified in the literature review and piloted on a small number of studies to ascertain the appropriateness for relevant data extraction. Categories were then finalized, and key domains were identified. The domains were then synthesized to develop a conceptual framework. Results: A total of 454 studies were identified, of which 14 met the eligibility criteria and were included in the meta-synthesis. All 14 were assessed to be of good quality. Seven domains related to HRQoL in cats with OA were thematically identified from the data: mobility, physical appearance, energy and vitality, mood, pain expression, sociability, and physical and mental wellbeing. The three main HRQoL domains were pain expression, mobility, and physical and mental wellbeing, which impacted all the others. Pain and mobility impacted all six other domains, with increased pain and decreased mobility negatively impacting physical appearance, energy and vitality, mood, sociability, and physical and mental wellbeing. Conclusions and Relevance: This is the first study to develop an evidence-based conceptual framework for the assessment of HRQoL in cats with OA. The proposed conceptual framework suggests that effective management of chronic pain in cats may improve their overall HRQoL.

Outcome measures for assessing change over time in studies of symptomatic children with hypermobility: a systematic review

Background

Generalised joint hypermobility (GJH) is highly prevalent among children and associated with symptoms in a fifth with the condition. This study aimed to synthesise outcome measures in interventional or prospective longitudinal studies of children with GJH and associated lower limb symptoms.

Methods

Electronic searches of Medline, CINAHL and Embase databases from inception to 16th March 2020 were performed for studies of children with GJH and symptoms between 5 and 18 years reporting repeated outcome measures collected at least 4 weeks apart. Methodological quality of eligible studies were described using the Downs and Black checklist.

Results

Six studies comprising of five interventional, and one prospective observational study (total of 388 children) met the inclusion criteria. Interventional study durations were between 2 and 3 months, with up to 10 months post-intervention follow-up, while the observational study spanned 3 years. Three main constructs of pain, function and quality of life were reported as primary outcome measures using 20 different instruments. All but one measure was validated in paediatric populations, but not specifically for children with GJH and symptoms. One study assessed fatigue, reporting disabling fatigue to be associated with higher pain intensity.

Conclusions

There were no agreed sets of outcome measures used for children with GJH and symptoms. The standardisation of assessment tools across paediatric clinical trials is needed. Four constructs of pain, function, quality of life and fatigue are recommended to be included with agreed upon, validated, objective tools.

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.

The effects of joint hypermobility syndrome on the kinematics and kinetics of the vertical jump test

PURPOSE

Biomechanical impairments are not apparent during walking in people with Joint Hypermobility Syndrome (JHS). This research explored biomechanical alterations during a higher intensity task, vertical jumping.

MATERIALS AND METHODS

This cross-sectional study compared a JHS group (n = 29) to a healthy control group (n = 30). Joint kinematics and kinetics were recorded using a Qualisys motion capture system synchronized with a Kistler platform. Independent sample t-tests and standardised mean differences (SMD) were used for statistical analysis.

RESULTS

No significant statistical or clinical differences were found between groups in joint kinematics and jump height (p ≥ 0.01). Sagittal hip and knee peak power generation were statistically lower in the JHS group during the compression phase (p ≤ 0.01), but not clinically relevant (SMD < 0.5). Clinically relevant reductions were found in the JHS group knee and ankle peak moments during the compression phase, and hip and knee peak power generation during the push phase (SMD ≥ 0.5), although these were not statistically significant (p ≥ 0.01).

CONCLUSION

The JHS group achieved a similar jump height but with some biomechanical alterations. Further understanding of the joint biomechanical behavior could help to optimize management strategies for JHS, potentially focusing on neuromuscular control and strength/power training.

Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain

OBJECTIVES

A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability.

CONTENT

Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability.

SUMMARY AND OUTLOOK

It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

The Prevalence of Hypermobility in Children with Irritable Bowel Syndrome and Functional Abdominal Pain Is Similar to that in Healthy Children

OBJECTIVES

To test the hypothesis that the prevalence of joint hypermobility is greater in children with irritable bowel syndrome and functional abdominal pain than in healthy control children and is related to gastrointestinal symptoms and psychosocial distress (anxiety, depression, and somatization).

STUDY DESIGN

Children (irritable bowel syndrome, n = 109; functional abdominal pain, n = 31; healthy control, n = 69), 7-12 years of age completed prospective 2-week pain and stooling diaries and child- and parent-reported measures of anxiety, depression, and somatization. Joint hypermobility was determined using Beighton criteria (score of ≥4 or 6). We also examined possible relationships between Beighton score, race, body mass index, gastrointestinal symptoms, and psychosocial distress.

RESULTS

Beighton scores were similar between groups, as was the proportion with joint hypermobility. Scores were higher in girls (3.1 ± 2.4) than boys (2.3 ± 1.8; P = .004) and decreased with age (P < .001; r = -0.25). Race and body mass index did not impact joint hypermobility prevalence. Beighton scores were not related to abdominal pain or stooling characteristics. Participants with a score of ≥4 and ≥6 had greater somatization and depression by child report (P = .017 and P = .048, respectively). No association was seen for anxiety. There was no significant association between joint hypermobility and psychosocial distress measures per parent report.

CONCLUSIONS

Contrary to the adult literature, the prevalence of joint hypermobility does not differ among children with irritable bowel syndrome, functional abdominal pain, or healthy control children. The presence or severity of joint hypermobility does not correlate with abdominal pain or stooling characteristics. Somatization and depression by child report appear to have a relationship with joint hypermobility.

'I was cracking more than everyone else': young adults' daily life experiences of hypermobility and jaw disorders

Most studies on general joint hypermobility (GJH) and temporomandibular disorders (TMD) are quantitative and have concluded that joint hypermobility is a risk factor for development of TMD. The present qualitative study aimed to explore young adults' daily life experiences of GJH, specifically these relating to jaw function, and their experiences of medical and dental care providers. Semi-structured interviews were conducted with nine young adults (18-22 yr of age) and data were analysed using qualitative content analysis. The overarching thematic category that emerged was 'Hypermobility in daily life', which was broken into six subthemes and three themes: 'emotional perception', 'dealing with symptoms', and 'outside influences'. Participants' narratives centred on experiences of complex symptoms, awkward jaw function and joint noises, feeling different, and a lack of support from general medical and dental care providers. The findings show that young adults with joint hypermobility need early support from medical and dental care providers for managing their symptoms and conditions related to GJH. Future studies are warranted to develop guidelines for professionals in medical and dental care to detect and prevent forthcoming problems and to offer relevant support to hypermobile youths.

Generalized joint hypermobility and perceived harmfulness in healthy adolescents; impact on muscle strength, motor performance and physical activity level

Objective: The first aim of this study was to determine whether adolescents with asymptomatic Generalized Joint Hypermobility (GJH) have a lower level of physical functioning (physical activity level, muscle strength and performance) compared to non-hypermobile controls. Secondly, to evaluate whether the negative impact of perceived harmfulness on physical functioning was more pronounced in adolescents with asymptomatic GJH.Methods: Cross-sectional study. Sixty-two healthy adolescents (mean age 16.8, range 12-21) participated. Hypermobility (Beighton score), perceived harmfulness (PHODA-youth) and muscle strength (dynamometry), motor performance (Single-Leg-Hop-for-Distance) and physical activity level (PAL) (accelerometry) were measured. Hierarchical regression analyses were used to study differences in physical functioning and perceived harmfulness between asymptomatic GJH and non-hypermobile controls.Results: Asymptomatic GJH was associated with increased knee extensor muscle strength (peak torque/body weight; PT/BW), controlled for age and gender (dominant leg; ß = 0.29; p = .02). No other associations between asymptomatic GJH and muscle strength, motor performance and PAL were found. Perceived harmfulness was not more pronounced in adolescents with asymptomatic GJH.Conclusions: Adolescents with asymptomatic GJH had increased knee extensor muscle strength compared to non-hypermobile controls. No other differences in the level of physical functioning was found and the negative impact of perceived harmfulness was not more pronounced in adolescents with asymptomatic GJH.

Recognizing and Effectively Managing Hypermobility-Related Conditions

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome-hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

Factors affecting quality of life in children and adolescents with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders

Hypermobile Ehlers-Danlos syndrome (hEDS) is a hereditary disorder of connective tissue, often presenting with complex symptoms can include chronic pain, fatigue, and dysautonomia. Factors influencing functional disability in the pediatric hEDS population are incompletely studied. This study's aims were to assess factors that affect quality of life in children and adolescents with hEDS. Individuals with hEDS between the ages 12-20 years and matched parents were recruited through retrospective chart review at two genetics clinics. Participants completed a questionnaire that included the Pediatric Quality of Life Inventory (PedsQL™), PedsQL Multidimentional Fatigue Scale, Functional Disability Inventory, Pain-Frequency-Severity-Duration Scale, the Brief Illness Perception Questionnaire, measures of anxiety and depression, and helpful interventions. Survey responses were completed for 47 children and adolescents with hEDS/hypermobility spectrum disorder (81% female, mean age 16 years), some by the affected individual, some by their parent, and some by both. Clinical data derived from chart review were compared statistically to survey responses. All outcomes correlated moderately to strongly with each other. Using multiple regression, general fatigue and pain scores were the best predictors of the PedsQL total score. Additionally, presence of any psychiatric diagnosis was correlated with a lower PedsQL score. Current management guidelines recommend early intervention to prevent disability from deconditioning; these results may help identify target interventions in this vulnerable population.

Pain and sleep quality in children with non-vascular Ehlers-Danlos syndromes

The objective of this study was to explore the factors contributing to quality of life in pediatric patients with non-vascular Ehlers-Danlos syndromes (EDS). Data were analyzed on 41 children with a diagnosis of non-vascular EDS from the de-identified data available from the National Institute on Aging (NIA) study of heritable disorders of connective tissue. Children under age 19 years were seen as part of a long-term evaluation project from 2003 to 2013 on a larger natural history of patients with heritable disorders of connective tissue. Data collected included medical history, physical examination findings, diagnostic study results, and responses on validated questionnaires. We reviewed a sub-cohort of children with a diagnosis of non-vascular EDS and explored pain severity and interference via the Brief Pain Inventory, and sleep quality via the Pittsburgh Sleep Quality Index. Pain severity had a strong correlation with pain interference, and both were similar to other disorders that include chronic pain reported in the literature. Sleep quality did not correlate with pain severity or interference, but all patients had poor sleep quality in comparison to historical controls. We conclude that pain and sleep are significant issues in the pediatric non-vascular EDS population, and future research may be directed toward these issues.

The feasibility of a randomised controlled trial of physiotherapy for adults with joint hypermobility syndrome

BACKGROUND

Joint hypermobility syndrome (JHS) is a heritable disorder associated with laxity and pain in multiple joints. Physiotherapy is the mainstay of treatment, but there is little research investigating its clinical effectiveness.

OBJECTIVES

To develop a comprehensive physiotherapy intervention for adults with JHS; to pilot the intervention; and to conduct a pilot randomised controlled trial (RCT) to determine the feasibility of conducting a future definitive RCT.

DESIGN

Patients' and health professionals' perspectives on physiotherapy for JHS were explored in focus groups (stage 1). A working group of patient research partners, clinicians and researchers used this information to develop the physiotherapy intervention. This was piloted and refined on the basis of patients' and physiotherapists' feedback (stage 2). A parallel two-arm pilot RCT compared 'advice' with 'advice and physiotherapy' (stage 3). Random allocation was via an automated randomisation service, devised specifically for the study. Owing to the nature of the interventions, it was not possible to blind clinicians or patients to treatment allocation.

SETTING

Stage 1 - focus groups were conducted in four UK locations. Stages 2 and 3 - piloting of the intervention and the pilot RCT were conducted in two UK secondary care NHS trusts.

PARTICIPANTS

Stage 1 - patient focus group participants (n = 25, three men) were aged > 18 years, had a JHS diagnosis and had received physiotherapy within the preceding 12 months. The health professional focus group participants (n = 16, three men; 14 physiotherapists, two podiatrists) had experience of managing JHS. Stage 2 - patient participants (n = 8) were aged > 18 years, had a JHS diagnosis and no other musculoskeletal conditions causing pain. Stage 3 - patient participants for the pilot RCT (n = 29) were as for stage 2 but the lower age limit was 16 years.

INTERVENTION

For the pilot RCT (stage 3) the advice intervention was a one-off session, supplemented by advice booklets. All participants could ask questions specific to their circumstances and receive tailored advice. Participants were randomly allocated to 'advice' (no further advice or physiotherapy) or 'advice and physiotherapy' (an additional six 30-minute sessions over 4 months). The physiotherapy intervention was supported by a patient handbook and was delivered on a one-to-one patient-therapist basis. It aimed to increase patients' physical activity through developing knowledge, understanding and skills to better manage their condition.

MAIN OUTCOME MEASURES

Data from patient and health professional focus groups formed the main outcome from stage 1. Patient and physiotherapist interview data also formed a major component of stages 2 and 3. The primary outcome in stage 3 related to the feasibility of a future definitive RCT [number of referrals, recruitment and retention rates, and an estimate of the value of information (VOI) of a future RCT]. Secondary outcomes included clinical measures (physical function, pain, global status, self-reported joint count, quality of life, exercise self-efficacy and adverse events) and resource use (to estimate cost-effectiveness). Outcomes were recorded at baseline, 4 months and 7 months.

RESULTS

Stage 1 - JHS is complex and unpredictable. Physiotherapists should take a long-term holistic approach rather than treating acutely painful joints in isolation. Stage 2 - a user-informed physiotherapy intervention was developed and evaluated positively. Stage 3 - recruitment to the pilot RCT was challenging, primarily because of a perceived lack of equipoise between advice and physiotherapy. The qualitative evaluation provided very clear guidance to inform a future RCT, including enhancement of the advice intervention. Some patients reported that the advice intervention was useful and the physiotherapy intervention was again evaluated very positively. The rate of return of questionnaires was low in the advice group but reasonable in the physiotherapy group. The physiotherapy intervention showed evidence of promise in terms of primary and secondary clinical outcomes. The advice arm experienced more adverse events. The VOI analysis indicated the potential for high value from a future RCT. Such a trial should form the basis of future research efforts.

CONCLUSION

A future definitive RCT of physiotherapy for JHS seems feasible, although the advice intervention should be made more robust to address perceived equipoise and subsequent attrition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29874209.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 47. See the NIHR Journals Library website for further project information.

Hypermobility in Adolescent Athletes: Pain, Functional Ability, Quality of Life, and Musculoskeletal Injuries

Study Design Cross-sectional. Background Generalized joint hypermobility (GJH) may increase pain and likelihood of injuries and also decrease function and health-related quality of life (HRQoL) in elite-level adolescent athletes. Objective To assess the prevalence of GJH in elite-level adolescent athletes, and to study the association of GJH with pain, function, HRQoL, and musculoskeletal injuries. Methods A total of 132 elite-level adolescent athletes (36 adolescent boys, 96 adolescent girls; mean ± SD age, 14.0 ± 0.9 years), including ballet dancers (n = 22), TeamGym gymnasts (n = 57), and team handball players (n = 53), participated in the study. Generalized joint hypermobility was classified by Beighton score as GJH4 (4/9 or greater), GJH5 (5/9 or greater), and GJH6 (6/9 or greater). Function of the lower extremity, musculoskeletal injuries, and HRQoL were assessed with self-reported questionnaires, and part of physical performance was assessed by 4 postural-sway tests and 2 single-legged hop-for-distance tests. Results Overall prevalence rates for GJH4, GJH5, and GJH6 were 27.3%, 15.9%, and 6.8%, respectively, with a higher prevalence of GJH4 in ballet dancers (68.2%) and TeamGym gymnasts (24.6%) than in team handball players (13.2%). There was no significant difference in lower extremity function, injury prevalence and related factors (exacerbation, recurrence, and absence from training), HRQoL, or lengths of hop tests for those with and without GJH. However, the GJH group had significantly larger center-of-pressure path length across sway tests. Conclusion For ballet dancers and TeamGym gymnasts, the prevalence of GJH4 was higher than that of team handball players. For ballet dancers, the prevalence of GJH5 and GJH6 was higher than that of team handball players and the general adolescent population. The GJH group demonstrated larger sway in the balance tests, which, in the current cross-sectional study, did not have an association with injuries or HRQoL. However, the risk of having (ankle) injuries due to larger sway for the GJH group must be studied in future longitudinal studies. J Orthop Sports Phys Ther 2017;47(10):792-800. doi:10.2519/jospt.2017.7682.

Hypermobility and Musculoskeletal Pain in Adolescents

OBJECTIVE

To determine the prevalence of generalized joint hypermobility (GJH) in a large cohort of Australian children and determine the associations between GJH and musculoskeletal pain.

STUDY DESIGN

This is a cross-sectional analysis of the Western Australian Pregnancy Cohort (Raine) Study. Hypermobility was measured in 1584 participants at 14 years of age using the Beighton scoring system, along with a range of other factors including musculoskeletal pain status. Logistic regression models were used to assess independent associations of GJH with factors of interest.

RESULTS

The prevalence of GJH was 60.6% and 36.7% in girls and boys, respectively, when defined as a Beighton score of ≥4; when defined as ≥6, it was 26.1% and 11.5%. In girls, positive associations between GJH and higher socioeconomic status and better motor competence were observed. In boys, positive associations between GJH and lower body mass index were observed. After adjusting for potential confounders, an association between number of pain areas in the last month and made worse with sport were identified in boys but not girls.

CONCLUSION

The high prevalence rates of GJH as defined by commonly used Beighton cutoff values in this cohort highlight the need to question the appropriateness of these cutoffs in future studies. Future prospective studies of the association between GJH and musculoskeletal pain should be adjusted for confounding variables identified in this study, and be powered for sex-specific analyses owing to the differing prevalence rates and hypermobility correlates in male and female samples.

Development and initial validation of the Bristol Impact of Hypermobility questionnaire

OBJECTIVES

Stage 1 - to identify the impact of joint hypermobility syndrome (JHS) on adults; Stage 2 - to develop a questionnaire to assess the impact of JHS; and Stage 3 - to undertake item reduction and establish the questionnaire's concurrent validity.

DESIGN

A mixed methods study employing qualitative focus groups and interviews (Stage 1); a working group of patients, clinicians and researchers, and 'think aloud' interviews (Stage 2); and quantitative analysis of questionnaire responses (Stage 3).

SETTING

Stages 1 and 2 took place in one secondary care hospital in the UK. Members of a UK-wide patient organisation were recruited in Stage 3.

PARTICIPANTS

In total, 15, four and 615 participants took part in Stages 1, 2 and 3, respectively. Inclusion criteria were: age ≥18 years; diagnosis of JHS; no other conditions affecting physical function; able to give informed consent; and able to understand and communicate in English.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The development of a questionnaire to assess the impact of JHS.

RESULTS

Stage 1 identified a wide range of impairments, activity limitations and participation restrictions In Stage 2, a draft questionnaire was developed and refined following 'think aloud' analysis, leaving 94 scored items. In Stage 3, items were removed on the basis of low severity and/or high correlation with other items. The final Bristol Impact of Hypermobility (BIoH) questionnaire had 55 scored items, and correlated well with the physical component score of the Short Form 36 health questionnaire (r=-0.725).

CONCLUSIONS

The BIoH questionnaire demonstrated good concurrent validity. Further psychometric properties need to be established.

Is Motor Performance in 5.5-Year-Old Children Associated with the Presence of Generalized Joint Hypermobility?

OBJECTIVE

To determine the prevalence of generalized joint hypermobility (GJH) in Dutch children aged 5.5 years, and to examine the association between GJH and motor performance and development over time.

STUDY DESIGN

A prospective cohort of 249 children was recruited. GJH was assessed with the Beighton test at age 5.5 years. Motor performance was evaluated at age 2.0 years using the Bayley Scales of Infant Development, Second Edition and at age 5.5 years using the Movement Assessment Battery for Children-Second Edition (subscore categories: manual dexterity, aiming and catching, and static and dynamic balance).

RESULTS

In 249 children, the prevalence of GJH, defined by the Beighton test score, was 34.1% for a score ≥ 4, 22.5% for a score ≥ 5, and 16.5% for a score ≥ 6. No significant association was found between GJH and total motor performance. Manual dexterity in girls (Beighton score ≥ 4) was positively associated with higher level of motor performance (β [SE] = 0.38 [0.17]; P = .028), ranging from +0.04 SD to +0.72 SD, even after correction for covariates. A significant interaction between GJH and body mass index (BMI) growth was found, indicating that the effect of GJH on the rate of development of motor performance declines with increasing BMI growth (β = 0.05 [0.02]; P = .031).

CONCLUSION

In this healthy pediatric cohort, GJH was present in one-third of the sample, and no significant association was found between GJH and total motor performance. The effect of GJH on the rate of development of motor performance appears to decline with increasing BMI growth. Longitudinal prospective studies are recommended to detect influences of GJH on motor performance over time, as well as the influence of body composition and Beighton cutoff points.

Quality of life prediction in children with joint hypermobility syndrome

AIMS

To assess the child- and parent-reported health-related quality of life (HRQOL) of children with joint hypermobility syndrome (JHS), to compare these with other chronic paediatric conditions and to determine whether symptoms experienced by children with JHS can predict their HRQOL.

METHODS

Eighty-nine children with JHS and one of their parents completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale, the Multidimensional Fatigue Scale and the Pediatric Pain Questionnaire. Anthropometric measures and reported symptoms were recorded. Child-reported HRQOL scores were compared with parent report, and both child- and parent-reported HRQOL scores of children with JHS were compared with those of children with other chronic conditions. Stepwise multiple regression was undertaken to determine whether any combination of measures could predict HRQOL.

RESULTS

Parent- and child-reported HRQOL scores were strongly correlated (r = 0.6-0.84, all P < 0.001); however, parents of children with JHS perceived lower overall HRQOL (mean difference = 4.44, P = 0.001), physical (mean difference = 7.11, P < 0.0001) and emotional functioning (mean difference = 5.24, P = 0.011) than their children. When considered together with previously reported HRQOL scores for children with other chronic conditions, parent and child scores were similarly strongly correlated (r = 0.93, P = 0.001). Multiple regression revealed that 75% of the variance in child-reported HRQOL scores was accounted for by a child's level of pain and fatigue, and presence of stress incontinence symptoms (P < 0.0001).

CONCLUSION

Children with JHS experience poor HRQOL and disabling fatigue, with parent scores providing a good proxy. Pain, fatigue and the presence of stress incontinence symptoms have the greatest impact on their HRQOL.

Diagnosis, Management and Assessment of Adults with Joint Hypermobility Syndrome: A UK-Wide Survey of Physiotherapy Practice

Joint hypermobility syndrome (JHS) is a heritable disorder associated with excessive joint range of motion and pain in the absence of inflammatory joint disease. It is a relatively common cause of musculoskeletal pain but is generally understood to be under-recognized and poorly managed in clinical practice. The present study therefore aimed to identify how JHS is diagnosed, managed and assessed in routine physiotherapy practice. A survey tool was developed from similar physiotherapy surveys of musculoskeletal practice, a review of the literature, and consultation with researchers and clinicians. Paper copies of the final survey were sent to 201 randomly selected secondary care organizations across the UK and an electronic version was advertised through physiotherapy professional networks. A total of 66 responses (80% women) were received from physiotherapists, with a wide range of clinical experience. Only 32% of respondents reported that they had received formal training in JHS management. The Brighton diagnostic criteria for JHS were not often used (only 31% of respondents). The stated aims of physiotherapy and the specific interventions employed seem well matched, with a focus on advice, education, exercise and self-management. Although pain relief was not reported as a high priority in terms of treatment aims, pain was most often assessed as an outcome, suggesting a mismatch between what clinicians aim to achieve and what they measure. The results suggest that reported management strategies are broadly appropriate to long-term musculoskeletal conditions but additional training specific to JHS may be required, particularly in diagnosis and assessment.

Joint hypermobility syndrome subclassification in paediatrics: a factor analytic approach

OBJECTIVE

To determine if exploratory factor analysis can identify subtypes comprising recognisable clinical patterns of the presenting signs and symptoms of children with joint hypermobility syndrome (JHS).

PATIENTS

Eighty-nine children with JHS aged 6-16 years.

METHODS

Twelve tests comprising anthropometric, musculoskeletal and functional assessments were conducted. Signs, symptoms and family history were recorded. Exploratory factor analysis was performed, factor scores generated, and correlations calculated to identify associations.

RESULTS

Sixty-six percent of the variance in the score set could be accounted for by five JHS subtypes (Eigenvalues >1). Factor 1, 'joint affected' JHS, had loadings on multiple joint pain, recurrent joint instability and postural orthostatic hypotension symptoms, and factor scores were associated with worse pain (r=0.48, p<0.01), fatigue (r=-0.54, p<0.01) and reduced health-related quality of life (HRQOL) (r=-0.5, p<0.01). Factor 2, 'athletic' JHS, loaded on muscle endurance, balance and motor skill proficiency, and scores were associated with less fatigue (r=0.3, p<0.01) and better HRQOL (r=0.44, p<0.01). Factor 3, 'systemic' JHS, loaded on skin involvement, incontinence symptoms, bowel involvement and recurrent joint instability, and was associated with reduced HRQOL (r=-0.24, p=0.03). Factor 4, 'soft tissue affected' JHS, loaded on recurrent soft tissue injuries and reduced muscle length, and was associated with greater fatigue (r=-0.43, p<0.01) and reduced HRQOL (r=-0.44, p<0.0001). Factor 5, 'high BMI' JHS, had high loadings on body mass index (BMI) for age, muscle endurance and no gastrointestinal involvement, and was associated with higher pain (r=0.33, p<0.01).

CONCLUSIONS

The presenting signs and symptoms of children with JHS can be summarised in five clinically recognisable subtypes.

Proprioceptive acuity into knee hypermobile range in children with joint hypermobility syndrome

BACKGROUND

Children with Joint Hypermobility Syndrome (JHS) have reduced knee joint proprioceptive acuity compared to peers. Altered proprioception at end of range in individuals with JHS is hypothesised to contribute to recurrent joint injuries and instability. This study aims to provide the first objective comparison of functional knee joint proprioceptive acuity in hyperextension range compared to early flexion range in children with JHS.

METHODS

Active, weight-bearing knee joint proprioceptive acuity in both hyperextension and early flexion range was tested with a purpose-built device. Proprioceptive acuity was measured using the psychophysical method of constant stimuli to determine ability to discriminate between the extents of paired active movements made to physical stops. The smallest difference in knee range of motion that the child is able to correctly judge on at least 75% of occasions, the Just Noticeable Difference (JND), was calculated using Probit analysis. Knee pain, muscle strength, amount of physical activity and patient demographic data were collected.

RESULTS

Twenty children aged 8-16 years with JHS and hypermobile knees participated. Eleven children demonstrated better proprioceptive acuity in flexion, and 9 in hyperextension (z = 0.45, p = 0.63). Matched pairs t-test found no significant difference in children's ability to discriminate between the same extents of movement in the hyperextension or flexion directions (mean JND difference 0.11°, 95% CI -0.26° - 0.47°, p = 0.545). However, 3 children could not discriminate movements in hyperextension better than chance. Proprioceptive acuity scores were positively correlated between the two directions of movement (r = 0.55, p = 0.02), with no significant correlations found between proprioceptive acuity and age, degree of hypermobility, muscle strength, pain level, amount of physical activity or body mass index centile (r = -0.35 to -0.03, all p ≥ 0.13).

CONCLUSION

For a group of children with JHS involving hypermobile knees, there was no significant difference between knee joint proprioceptive acuity in early flexion and in hypermobile range when measured by a functional, active, weight-bearing test. Therefore, when implementing a proprioceptive training programme, clinicians should focus training throughout knee range, including into hyperextension. Further research is needed to determine factors contributing to pain and instability in hypermobile range.

Overview of neurodevelopment and pain research, possible treatment targets

Pain is a common presenting and often persistent symptom for children with rheumatological disease. Pain is not clearly related to disease severity in children with inflammatory juvenile idiopathic arthritis, and presentations of non-inflammatory musculoskeletal pain are common but there is limited evidence to guide management. Pain assessment must extend beyond measures of pain severity to more fully evaluate characteristics of pain, functional impact and psychosocial effects and family interactions. Evaluation of mechanisms of joint pain in adults has identified potential treatment targets, but additional studies are required as the acute and long-term impacts of pain and injury change during postnatal development. Genotyping, sensory evaluation and neuroimaging may better characterize chronic musculoskeletal pain, identify high-risk groups and/or provide additional outcome measures to monitor disease and treatment progress. An integrated approach to management is required to effectively select and target interventions, reduce pain and disability and improve long-term outcome.

The functional consequences of generalized joint hypermobility: a cross-sectional study

Background

Generalized Joint Hypermobility (GJH) has been found to be associated with musculoskeletal complaints and disability. For others GJH is seen as a prerequisite in order to excel in certain sports like dance. However, it remains unclear what the role is of GJH in human performance. Therefore, the purpose of the study was to establish the association between GJH and functional status and to explore the contribution of physical fitness and musculoskeletal complaints to this association.

Methods

A total of 72 female participants (mean age (SD; range): 19.6 (2.2; 17-24)) were recruited among students from the Amsterdam School of Health Professions (ASHP) (n = 36) and the Amsterdam School of Arts (ASA), Academy for dance and theater (n = 36) in Amsterdam, The Netherlands. From each participant the following data was collected: Functional status performance (self-reported Physical activity level) and capacity (walking distance and jumping capacity: side hop (SH) and square hop (SQH)), presence of GJH (Beighton score ≥4), muscle strength, musculoskeletal complaints (pain and fatigue) and demographic characteristics (age and BMI).

Results

GJH was negatively associated with all capacity measures of functional status. Subjects with GJH had a reduced walking distance (B(SE):-75.5(10.5), p = <.0001) and jumping capacity (SH: B(SE):-10.10(5.0), p = .048, and SQH: B(SE):-11.2(5.1), p = .024) in comparison to subjects without GJH, when controlling for confounding: age, BMI and musculoskeletal complaints. In participants with GJH, functional status was not associated with performance measures.

Conclusion

GJH was independently associated with lower walking and jumping capacity, potentially due to the compromised structural integrity of connective tissue. However, pain, fatigue and muscle strength were also important contributors to functional status.

Exercise in children with joint hypermobility syndrome and knee pain: a randomised controlled trial comparing exercise into hypermobile versus neutral knee extension

BACKGROUND

Knee pain in children with Joint Hypermobility Syndrome (JHS) is traditionally managed with exercise, however the supporting evidence for this is scarce. No trial has previously examined whether exercising to neutral or into the hypermobile range affects outcomes. This study aimed to (i) determine if a physiotherapist-prescribed exercise programme focused on knee joint strength and control is effective in reducing knee pain in children with JHS compared to no treatment, and (ii) whether the range in which these exercises are performed affects outcomes.

METHODS

A prospective, parallel-group, randomised controlled trial conducted in a tertiary hospital in Sydney, Australia compared an 8 week exercise programme performed into either the full hypermobile range or only to neutral knee extension, following a minimum 2 week baseline period without treatment. Randomisation was computer-generated, with allocation concealed by sequentially numbered opaque sealed envelopes. Knee pain was the primary outcome. Quality of life, thigh muscle strength, and function were also measured at (i) initial assessment, (ii) following the baseline period and (iii) post treatment. Assessors were blinded to the participants' treatment allocation and participants blinded to the difference in the treatments.

RESULTS

Children with JHS and knee pain (n=26) aged 7-16 years were randomly assigned to the hypermobile (n=12) or neutral (n=14) treatment group. Significant improvements in child-reported maximal knee pain were found following treatment, regardless of group allocation with a mean 14.5 mm reduction on the visual analogue scale (95% CI 5.2 - 23.8 mm, p=0.003). Significant differences between treatment groups were noted for parent-reported overall psychosocial health (p=0.009), specifically self-esteem (p=0.034), mental health (p=0.001) and behaviour (p=0.019), in favour of exercising into the hypermobile range (n=11) compared to neutral only (n=14). Conversely, parent-reported overall physical health significantly favoured exercising only to neutral (p=0.037). No other differences were found between groups and no adverse events occurred.

CONCLUSIONS

Parents perceive improved child psychosocial health when children exercise into the hypermobile range, while exercising to neutral only is perceived to favour the child's physical health. A physiotherapist prescribed, supervised, individualised and progressed exercise programme effectively reduces knee pain in children with JHS.

TRIAL REGISTRATION

Australia & New Zealand Clinical Trials Registry; ACTRN12606000109505.

Children with generalised joint hypermobility and musculoskeletal complaints: state of the art on diagnostics, clinical characteristics, and treatment

INTRODUCTION

To provide a state of the art on diagnostics, clinical characteristics, and treatment of paediatric generalised joint hypermobility (GJH) and joint hypermobility syndrome (JHS).

METHOD

A narrative review was performed regarding diagnostics and clinical characteristics. Effectiveness of treatment was evaluated by systematic review. Searches of Medline and Central were performed and included nonsymptomatic and symptomatic forms of GJH (JHS, collagen diseases).

RESULTS

In the last decade, scientific research has accumulated on all domains of the ICF. GJH/JHS can be considered as a clinical entity, which can have serious effects during all stages of life. However research regarding the pathological mechanism has resulted in new potential opportunities for treatment. When regarding the effectiveness of current treatments, the search identified 1318 studies, from which three were included (JHS: n = 2, Osteogenesis Imperfecta: n = 1). According to the best evidence synthesis, there was strong evidence that enhancing physical fitness is an effective treatment for children with JHS. However this was based on only two studies.

CONCLUSION

Based on the sparsely available knowledge on intervention studies, future longitudinal studies should focus on the effect of physical activity, fitness, and joint stabilisation. In JHS and chronic pain, the effectiveness of a multidisciplinary approach should be investigated.

Management of pain and fatigue in the joint hypermobility syndrome (a.k.a. Ehlers-Danlos syndrome, hypermobility type): principles and proposal for a multidisciplinary approach

Joint hypermobility syndrome (JHS), or Ehlers-Danlos syndrome (EDS) hypermobility type (EDS-HT), is a underdiagnosed heritable connective tissue disorder characterized by generalized joint hypermobility and a wide range of visceral, pelvic, neurologic, and cognitive dysfunctions. Deterioration of quality of life is mainly associated with pain and fatigue. Except for the recognized effectiveness of physiotherapy for some musculoskeletal features, there are no standardized guidelines for the assessment and treatment of pain and fatigue. In this work, a practical classification of pain presentations and factors contributing in generating painful sensations in JHS/EDS-HT is proposed. Pain can be topographically classified in articular limb (acute/subacute and chronic), muscular limb (myofascial and fibromyalgia), neuropathic limb, back/neck, abdominal and pelvic pain, and headache. For selected forms of pain, specific predisposing characteristics are outlined. Fatigue appears as the result of multiple factors, including muscle weakness, respiratory insufficiency, unrefreshing sleep, dysautonomia, intestinal malabsorption, reactive depression/anxiety, and excessive use of analgesics. A set of lifestyle recommendations to instruct patients as well as specific investigations aimed at characterizing pain and fatigue are identified. Available treatment options are discussed in the set of a structured multidisciplinary approach based on reliable outcome tools.