1
|
Kelly M, Kagan RP, Yoo J. Increased Opioid Use in Patients With Ehlers-Danlos Syndrome Before and After Total Hip Arthroplasty. Arthroplast Today 2024; 27:101390. [PMID: 38690094 PMCID: PMC11058070 DOI: 10.1016/j.artd.2024.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/12/2024] [Accepted: 03/24/2024] [Indexed: 05/02/2024] Open
Abstract
Background Ehlers-Danlos syndrome (EDS), a disorder affecting synthesis of collagen, typically presents with chronic pain, hypermobility, and early osteoarthritis. EDS patients undergoing total hip arthroplasty (THA) are at risk of dislocation and revision. Opioid use and impact on outcomes among this population remain unknown. Methods A retrospective review was performed with a large national database querying the International Classification of Disease, tenth revision procedure codes identifying 1,244,368 primary THAs from 2015-2020. Two hundred thirty-eight EDS patients underwent THA and were propensity matched with population control based on age, sex, and obesity when comparing opioid prescription. To compare dislocation and revision outcomes, EDS patients were stratified into those receiving opioid prescriptions and those not. Multivariate analysis evaluated the association. Results EDS patients were more likely prescribed opioids 90 days before (49.1% vs 34.7.0%, P < .0001) and after THA (59.7% vs 41.2%, P < .0001), with more preoperatively (1163.6 mme ±1562.8, P < .0001) and postoperatively (900.1 mme ±1235.9, P < .0001) than controls. In EDS patients prescribed opioids 90 days before THA, dislocation rate was 12.8% vs 7.1% not prescribed (odds ratio 2.08, 95% confidence interval 0.85-5.1). 14.8% of EDS patients who received opioids 90 days after THA dislocated vs 2.1% not prescribed (odds ratio 8.13, 95% confidence interval 1.87-35.7). Conclusions EDS patients are more likely prescribed opioids before and after THA. Opioid prescription was associated with risk of dislocation, though we caution interpretation of causation. However, this suggests that the risks of worse outcomes in EDS patients undergoing THA are multifactorial. We should look at strategies to reduce opioid use prior to THA.
Collapse
Affiliation(s)
- Mackenzie Kelly
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Ryland P. Kagan
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Jung Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
2
|
Guedry SE, Langley BO, Schaefer K, Hanes DA. Integrative medicine for hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndromes (EDS): a feasibility study. Disabil Rehabil 2024:1-14. [PMID: 38353245 DOI: 10.1080/09638288.2024.2314713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE Hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndromes (EDS) are multisystem conditions marked by dysfunctional connective tissue. This feasibility study evaluated a 9-week integrative medicine program in this population. METHODS Using a single-arm study design, adults with HSD or EDS were given recommendations for an anti-inflammatory Mediterranean diet and self-management with additional behavioral and psychosocial support. Preliminary data on feasibility based on recruitment and retention, adherence to the diet, mobile app tracking, changes to perceived well-being via health outcomes, and satisfaction with care were obtained. RESULTS Thirteen participants were enrolled within a 4-month timeframe. Eight participants completed the study. Three participants met dietary tracking requirement in at least 4 of 8 intervention weeks and met the macronutrient requirements in at least half of the weeks tracked. No decreases in VAS pain scores after 5 and 9 weeks were noted; however, 62.5% (n = 5) of participants had decreased pain at 9 weeks, compared to baseline. There were significant improvements (p<.05) in six of twelve measurements of satisfaction with care at the end of the intervention. CONCLUSION This study provides a foundation for future research on patient experience and introduces a novel treatment paradigm focused on nutrition and self-management. Trial Registration: National Institutes of Health clinicaltrials.gov; identifier: NCT04734041. IMPLICATIONS FOR REHABILITATION Lifestyle and dietary interventions are relatively safe and well tolerated in the hypermobility spectrum disorder (HSD) and Ehlers-Danlos disorder (EDS) population.Participants in our 9-week integrative medicine program actively engaged in self-management of their condition and showed promising adherence to dietary and tracking requirements.Effective treatment of the intricacies and dynamics of these highly variable and clinically heterogeneous disorders may require a network of healthcare providers, integrative healthcare, as well as behavioral and psychosocial support.Dietary tracking through mobile apps might help promote self-efficacy and adherence to dietary changes.Symptom tracking might be an effective way for patients to track changes to their health and could provide valuable information for health professionals engaged in managing the disorders.
Collapse
Affiliation(s)
- Sara E Guedry
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Blake O Langley
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
- School of Nursing, University of WA, Seattle, WA, USA
| | - Kerry Schaefer
- Co-investigator, Healthy Living Community Clinic, Portland, OR, USA
| | - Douglas A Hanes
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| |
Collapse
|
3
|
Börsch N, Mücke M, Maier A, Conrad R, Pantel JT, Sellin J, Mani K, Chopra P. Treating pain in patients with Ehlers-Danlos syndrome : Multidisciplinary management of a multisystemic disease. Schmerz 2024; 38:12-18. [PMID: 38189943 DOI: 10.1007/s00482-023-00778-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND The clinical picture of people with Ehlers-Danlos syndromes (EDS) is complex and involves a variety of potential causes of pain. This poses major challenges to patients and healthcare professionals alike in terms of diagnosis and management of the condition. OBJECTIVES The aim of the article was to provide an overview of the specific pain management needs of patients with EDS and address their background. MATERIAL AND METHODS A selective literature search was performed to highlight the current state of research on pain management in EDS patients. RESULTS Affected patients require multimodal pain management considering their individual needs, disease-specific features, and comorbidities. CONCLUSION Medical awareness and evidence need to be further improved to enhance the medical care situation of these patients with complex needs.
Collapse
Affiliation(s)
- Natalie Börsch
- Institute for Digitalization and General Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany.
- Center for Rare Diseases (ZSEA), Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Martin Mücke
- Institute for Digitalization and General Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Rare Diseases (ZSEA), Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Andrea Maier
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Muenster, Muenster, Germany
| | - Jean Tori Pantel
- Institute for Digitalization and General Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Rare Diseases (ZSEA), Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Julia Sellin
- Institute for Digitalization and General Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Rare Diseases (ZSEA), Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Kyros Mani
- Institute for Digitalization and General Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Rare Diseases (ZSEA), Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Pradeep Chopra
- Center for Complex Conditions, Brown Medical School, Providence, RI, USA
| |
Collapse
|
4
|
Colman M, Syx D, De Wandele I, Rombaut L, Wille D, Malfait Z, Meeus M, Malfait AM, Van Oosterwijck J, Malfait F. Sensory Profiling in Classical Ehlers-Danlos Syndrome: A Case-Control Study Revealing Pain Characteristics, Somatosensory Changes, and Impaired Pain Modulation. THE JOURNAL OF PAIN 2023; 24:2063-2078. [PMID: 37380025 DOI: 10.1016/j.jpain.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
Pain is one of the most important yet poorly understood complaints in heritable connective tissue disorders (HCTDs) caused by monogenic defects in extracellular matrix molecules. This is particularly the case for the Ehlers-Danlos syndrome (EDS), paradigm collagen-related disorders. This study aimed to identify the pain signature and somatosensory characteristics in the rare classical type of EDS (cEDS) caused by defects in type V or rarely type I collagen. We used static and dynamic quantitative sensory testing and validated questionnaires in 19 individuals with cEDS and 19 matched controls. Individuals with cEDS reported clinically relevant pain/discomfort (Visual Analogue Scale ≥5/10 in 32% for average pain intensity the past month) and worse health-related quality of life. An altered somatosensory profile was found in the cEDS group with higher (P = .04) detection thresholds for vibration stimuli at the lower limb, indicating hypoesthesia, reduced thermal sensitivity with more (P < .001) paradoxical thermal sensations (PTSs), and hyperalgesia with lower pain thresholds to mechanical (P < .001) stimuli at both the upper and lower limbs and cold (P = .005) stimulation at the lower limb. Using a parallel conditioned pain modulation paradigm, the cEDS group showed significantly smaller antinociceptive responses (P-value .005-.046) suggestive of impaired endogenous pain modulation. In conclusion, individuals with cEDS report chronic pain and worse health-related quality of life and present altered somatosensory perception. This study is the first to systematically investigate pain and somatosensory characteristics in a genetically defined HCTD and provides interesting insights into the possible role of the ECM in the development and persistence of pain. PERSPECTIVE: Chronic pain compromises the quality of life in individuals with cEDS. Moreover, an altered somatosensory perception was found in the cEDS group with hypoesthesia for vibration stimuli, more PTSs, hyperalgesia for pressure stimuli, and impaired pain modulation.
Collapse
Affiliation(s)
- Marlies Colman
- Center for Medical Genetics, Ghent University Hospital, Ghent, East Flanders, Belgium; Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium; Pain in Motion International Research Consortium, Belgium
| | - Delfien Syx
- Center for Medical Genetics, Ghent University Hospital, Ghent, East Flanders, Belgium; Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Inge De Wandele
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Lies Rombaut
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Deborah Wille
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Zoë Malfait
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Mira Meeus
- Pain in Motion International Research Consortium, Belgium; Spine, Head and Pain Research Unit Ghent, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Anne-Marie Malfait
- Department of Internal Medicine, Division of Rheumatology, Rush University Medical Center, Chicago, Illinois
| | - Jessica Van Oosterwijck
- Pain in Motion International Research Consortium, Belgium; Spine, Head and Pain Research Unit Ghent, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, Ghent, East Flanders, Belgium; Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| |
Collapse
|
5
|
Camerota F, Mariani R, Cordiano G, Di Trani M, Lodato V, Ferraris A, Pasquini M, Celletti C. The Language of Pain in the Hypermobile Ehlers-Danlos Syndrome: Metaphors as a Key to Understanding the Experience of Pain and as a Rehabilitation Tool. Brain Sci 2023; 13:1042. [PMID: 37508973 PMCID: PMC10377642 DOI: 10.3390/brainsci13071042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Ehlers-Danlos syndromes are a heterogeneous group of Heritable Connective Tissue Disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Among the different types, the hypermobile Ehlers-Danlos syndrome is the most frequent and includes generalized joint hypermobility as the major diagnostic criterion. Joint hypermobility in hypermobile Ehlers-Danlos syndrome is often associated with pain that does not always allow the use of effective pain-reducing treatments. Patients with hEDS constantly describe their pain in detail. Eighty-nine patients with hEDS diagnoses were recruited and evaluated. They were asked to describe their pain in writing. The texts were examined through Linguistic Inquiry and Word Count. Correlational analyses were conducted between pain perception and language. A comparison of high/low pain perception and the quality of metaphors was carried out. The results showed that language quality varies depending on how much pain is perceived. The greater the pain is perceived, the lesser the positive effects and the greater the negative effects and dehumanizing metaphors are being used. Moreover, a greater pain seems to be related to a verbal experience of greater isolation and less self-care. In conclusion, the use of metaphors is a useful tool for examining illness experience and may help clinicians in the rehabilitation program.
Collapse
Affiliation(s)
- Filippo Camerota
- Physical Medicine and Rehabilitation, Umberto I University Hospital, 00161 Rome, Italy
| | - Rachele Mariani
- Department of Dynamic and Clinical Psychology, and Health Studies Sapienza, University of Rome, 00133 Rome, Italy
| | | | - Michela Di Trani
- Department of Dynamic and Clinical Psychology, and Health Studies Sapienza, University of Rome, 00133 Rome, Italy
| | - Valentina Lodato
- Laboratory of Medical Genetics, Department of Experimental Medicine, San Camillo Forlanini Hospital, Sapienza University of Rome, 00185 Rome, Italy
| | - Alessandro Ferraris
- Laboratory of Medical Genetics, Department of Experimental Medicine, San Camillo Forlanini Hospital, Sapienza University of Rome, 00185 Rome, Italy
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Claudia Celletti
- Physical Medicine and Rehabilitation, Umberto I University Hospital, 00161 Rome, Italy
| |
Collapse
|
6
|
Schubert-Hjalmarsson E, Fasth A, Ickmans K, Mårdbrink EL, Söderpalm AC, Lundberg M. Central sensitization in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome-a feasibility study. Pilot Feasibility Stud 2023; 9:97. [PMID: 37316864 DOI: 10.1186/s40814-023-01320-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/16/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Pain is a major symptom in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. Although the underlying mechanism causing generalized pain in children with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome is unclear, central sensitization has been suggested as a possible explanation. The aim of this study was to explore the feasibility of a study protocol for a future case-control study, investigating features of central sensitization in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. METHODS Central sensitization features were measured in ten patients and nine healthy controls aged 13-17 years via experimental pain measurement quantifying primary and secondary hyperalgesia, endogenous pain modulation, and exercise-induced hyperalgesia. Descriptive statistics were used. Frequency, median, and range values were calculated. RESULTS Eleven out of 57 patients chose to participate. No control could be recruited through public schools. Therefore, a convenience sampling strategy was used for the recruitment of the control group. The process of assessing primary and secondary hyperalgesia, endogenous pain modulation, and exercise-induced hyperalgesia was well tolerated by all participants (patients and controls). When assessing endogenous pain modulation via conditioned pain modulation, two participants in the patient group and three in the control group did not achieve a pain experience ≥ 3 on the numerical rating scale when immersing their hands in cold water. CONCLUSION This study investigated the feasibility, safety, and toleration of experimental pain measurements in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. Although the test protocol proved to be sufficiently feasible for use with the participant group, it will need to be adapted in the main study in order to obtain more reliable data. Recruitment, especially of participants for the control group, can be a major obstacle for future studies and requires careful planning. TRIAL REGISTRATION Researchweb.org, 270,501. Registered on 9 May 2019.
Collapse
Affiliation(s)
- Elke Schubert-Hjalmarsson
- Division of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Physiotherapy, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology and Immunology, Silvia Children's Hospital, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Queen, Sweden
| | - Kelly Ickmans
- Pain in Motion (PAIN) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
- Movement & Nutrition for Health & Performance Research Group, Department of Movement & Sport Sciences, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eva-Lott Mårdbrink
- Department of Physiotherapy, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Ann-Charlott Söderpalm
- Department of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mari Lundberg
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
7
|
Carroll MB. Hypermobility spectrum disorders: A review. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:60-68. [PMID: 37637226 PMCID: PMC10457547 DOI: 10.2478/rir-2023-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/21/2023] [Indexed: 08/29/2023]
Abstract
It remains a clinical challenge identifying when joint hypermobility (JH) is responsible for pain. Previous nomenclature utilized terms such as (benign) joint hypermobility syndrome (JHS) but this was updated in 2017 as advances in genetics provide a basis for nearly all variants of Ehlers-Danlos syndrome (EDS) with the exception of hypermobile EDS (hEDS). New terminology describes hypermobility spectrum disorders (HSDs) as the updated term for JHS. Diagnosis of a subtype of HSDs should be considered in patients who have JH coupled with the presence of secondary musculo-skeletal manifestations (trauma, chronic pain, disturbed proprioception, and other manifestations) and at the exclusion of hEDS. Extra-articular manifestations are common. Treatment relies on management strategies for other chronic pain syndromes with a multidisciplinary approach likely optimal. Lifestyle modifications focus on weight loss and exercise. Physical therapy helps strengthen periarticular muscles, improving mobility. Pharmacologic therapies focus on judicious use of non-steroidal anti-inflammatory drugs and acetaminophen. Serotonin and norepinephrine reuptake inhibitor may help widespread pain. Avoidance of opioids remains prudent. The purpose of this review is to provide clinicians the rationale for the update in nomenclature, understand the musculoskeletal and extra-articular manifestations of the subtypes of HSDs, considerations when making the diagnosis, and treatment.
Collapse
Affiliation(s)
- Matthew B Carroll
- Rheumatology, Singing River Health System, 3603 Bienville Blvd, Ocean Springs, MS 39564, USA
| |
Collapse
|
8
|
de Koning LE, Warnink-Kavelaars J, van Rossum MA, Bosman D, Menke LA, Malfait F, de Boer R, Oosterlaan J, Engelbert RHH, Rombaut L. Somatic symptoms, pain, catastrophizing and the association with disability among children with heritable connective tissue disorders. Am J Med Genet A 2023. [PMID: 37186039 DOI: 10.1002/ajmg.a.63204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 05/17/2023]
Abstract
The aim of the present study was to investigate the nature and prevalence of nonspecific somatic symptoms, pain and catastrophizing in children with Heritable Connective Tissue Disorders (HCTD), and to determine their association with disability. This observational, multicenter study included 127 children, aged 4-18 years, with Marfan syndrome (MFS) (59%), Loeys-Dietz syndrome (LDS) (8%), Ehlers-Danlos syndromes (EDS) (12%) and hypermobile Ehlers-Danlos syndrome (hEDS) (23%). The assessments included the Children's Somatization Inventory or parent proxy (CSI, PCSI), pain visual-analogue scale (VAS), SUPERKIDZ body diagram, Pain Catastrophizing Scale Child or parent proxy (PCS-C, PCS-P) and Childhood Health Assessment Questionnaire (CHAQ-30). Data from children aged ≥8 years were compared to normative data. In children ≥ 8 years (n = 90), pain was present in 59%, with a median of 4 (IQR = 3-9) pain areas. Compared to normative data, the HCTD group reported significantly higher on the CSI (p ≤ 0.001, d = 0.85), VAS pain intensity (p ≤ 0.001, d = 1.22) and CHAQ-30 (p ≤ 0.001, d = 1.16) and lower on the PCS-C (p = 0.017, d = -0.82) and PCS-P (p ≤ 0.001, d = -0.49). The intensity of nonspecific somatic symptoms and pain explained 45% of the variance in disability (r2 = 0.45 F(2,48) = 19.70, p ≤ 0.001). In children ≤ 7 years (n = 37), pain was present in 35% with a median of 5(IQR = 1-13) pain areas. The mean(SD) VAS scores for pain intensity was 1.5(2.9). Functional disability was moderately correlated to the number of pain areas (r = 0.56, p ≤ 0.001), intensity of nonspecific somatic symptoms (r = 0.63, p ≤ 0.001) and pain (r = 0.83, p ≤ 0.001). In conclusion, this study supports the need for comprehensive assessment of nonspecific somatic symptoms, pain, and disability in children with HCTD to allow tailored treatment.
Collapse
Affiliation(s)
- Lisanne E de Koning
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jessica Warnink-Kavelaars
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
| | - Marion A van Rossum
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Diederik Bosman
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Leonie A Menke
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital/Ghent University, Ghent, Belgium
| | - Rosa de Boer
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Raoul H H Engelbert
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Lies Rombaut
- Center for Medical Genetics, Ghent University Hospital/Ghent University, Ghent, Belgium
| |
Collapse
|
9
|
Guerrieri V, Polizzi A, Caliogna L, Brancato AM, Bassotti A, Torriani C, Jannelli E, Mosconi M, Grassi FA, Pasta G. Pain in Ehlers-Danlos Syndrome: A Non-Diagnostic Disabling Symptom? Healthcare (Basel) 2023; 11:healthcare11070936. [PMID: 37046863 PMCID: PMC10094213 DOI: 10.3390/healthcare11070936] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/18/2023] [Accepted: 03/23/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Ehlers-Danlos syndrome (EDS) is a phenotypically and genetically heterogeneous group of connective tissue disorders. Currently, diagnosis of EDS is based on a series of clinical and genetic tools. On the other hand, the hypermobile form has not yet been characterized from a genetic point of view: it is considered a part of a continuous spectrum of phenotypes, ranging from isolated non syndromic joint hypermobility, through to the recently defined hypermobility spectrum disorders (HSD). The aim of this study is to characterize the pain symptom that is not considered among the diagnostic criteria but is relevant to what concerns the quality of life of patients with EDS. (2) Methods: A review of the literature was performed on two medical electronic databases (PubMed and Embase) on 20 December 2022. Study selection and data extraction were achieved independently by two authors and the following inclusion criteria were determined a priori: published in the English language and published between 2000 and 2022. (3) Results: There were fifty eligible studies obtained at the end of the search and screen process. Pain is one of the most common symptoms found in Ehlers-Danlos (ED) patients. Different causes seem to be recognized in different phases of the syndrome. (4) Conclusions: Pain is a nonspecific symptom and cannot be considered among the diagnostic criteria, but it is a negative predictive factor in the quality of life of patients with EDS. Therefore, proper evaluation and treatment is mandatory.
Collapse
Affiliation(s)
- Viviana Guerrieri
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Alberto Polizzi
- Department of Othopaedics and Traumatology, Fondazione Poliambulanza Istituto Ospedaliero, 25124 Brescia, Italy
| | - Laura Caliogna
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Alice Maria Brancato
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Alessandra Bassotti
- Regional Center of Ehlers-Danlos Syndrome, IRCCS Ca'Granda Foundation Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Camilla Torriani
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Eugenio Jannelli
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Mario Mosconi
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Federico Alberto Grassi
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| | - Gianluigi Pasta
- Department of Othopaedics and Traumatology, Fondazione Policlinico IRCCS San Matteo, University of Pavia, 27100 Pavia, Italy
| |
Collapse
|
10
|
Benattia A, Benistan K, Frank M, Boussouar S. [Respiratory manifestations of Ehlers-Danlos syndromes]. Rev Mal Respir 2023; 40:254-264. [PMID: 36740495 DOI: 10.1016/j.rmr.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/01/2023] [Indexed: 02/07/2023]
Abstract
Ehlers-Danlos syndromes (EDS) represent a heterogeneous group of heritable connective tissue disorders characterized by the clinical "triad" consisting in joint hypermobility, skin hyperextensibility and tissue fragility. Respiratory manifestations associated with EDS are frequent and variable. They vary mainly according to the type of EDS. In hypermobile and classical EDS, the most frequent non-vascular types, dyspnea is a common symptom. Its etiologies are wide-ranging and can coexist in the same patient: asthma, respiratory muscle weakness, chest wall abnormalities, upper and lower airway collapse. The prevalence of obstructive sleep apnea syndrome in nvEDS is high. Identification of the relevant dyspnea mechanism is essential to providing appropriate therapeutic measures. In vascular EDS (vEDS), the main pulmonary complications are pneumothorax, hemothorax and hemoptysis. As they frequently precede the diagnosis of vEDS by several years, it is imperative to raise the possibility of vEDS in a young patient with spontaneous pneumothorax or hemothorax. The presence of suggestive computed tomography parenchymal abnormalities (emphysema, clusters of calcified nodules, cavitated nodule) can be an aid to diagnosis. Treatment is based on the usual approaches, which must be carried out with caution by an experienced operator fully informed of the diagnosis. Better knowledge of respiratory manifestations of EDS by the pneumological community would improve patient care and pave the way for further research.
Collapse
Affiliation(s)
- A Benattia
- Service de pneumologie, hôpital Saint-Louis, AP-HP, Paris, France.
| | - K Benistan
- Centre de référence des syndromes d'Ehlers-Danlos non vasculaires, hôpital Raymond-Poincaré, AP-HP, Garches, France; UMR U1179 Inserm, université Versailles Saint-Quentin, Montigny-le-Bretonneux, France
| | - M Frank
- Département de génétique, centre national de référence pour les maladies vasculaires rares, centre de référence européen VASCERN MSA, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Inserm, U970 PARCC, université de Paris, Paris, France
| | - S Boussouar
- Service d'imagerie cardio-vasculaire et thoracique, hôpital Pitié-Salpêtrière, AP-HP, Paris, France; Inserm, laboratoire d'imagerie biomédicale, CNRS, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| |
Collapse
|
11
|
Colman M, Syx D, de Wandele I, Rombaut L, Wilie D, Malfait Z, Meeus M, Malfait AM, Van Oosterwijck J, Malfait F. Sensory profiling in classical Ehlers-Danlos syndrome: a case-control study revealing pain characteristics, somatosensory changes, and impaired pain modulation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.24.23286404. [PMID: 36865307 PMCID: PMC9980260 DOI: 10.1101/2023.02.24.23286404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Pain is one of the most important, yet poorly understood complaints in heritable connective tissue disorders (HCTD) caused by monogenic defects in extracellular matrix molecules. This is particularly the case for Ehlers-Danlos syndromes (EDS), paradigm collagen-related disorders. This study aimed to identify the pain signature and somatosensory characteristics in the rare classical type of EDS (cEDS) caused by defects in type V or rarely type I collagen. We used static and dynamic quantitative sensory testing and validated questionnaires in 19 individuals with cEDS and 19 matched controls. Individuals with cEDS reported clinically relevant pain/discomfort (VAS ≥5/10 in 32% for average pain intensity the past month) and worse health -related quality of life. Altered sensory profile was found in the cEDS group with higher (p=0.04) detection thresholds for vibration stimuli at the lower limb indicating hypoesthesia, reduced thermal sensitivity with more (p<0.001) paradoxical thermal sensations, and hyperalgesia with lower pain thresholds to mechanical (p<0.001) stimuli at both the upper and lower limbs and to cold (p=0.005) stimulation at the lower limb. Using a parallel conditioned pain paradigm, the cEDS group showed significantly smaller antinociceptive responses (p-value between 0.005 and 0.046) suggestive of impaired endogenous central pain modulation. In conclusion, Individuals with cEDS report chronic pain and worse health-related quality of life, and present altered somatosensory perception. This study is the first to systematically investigate pain and somatosensory characteristics in a genetically defined HCTD and provides interesting insights on the possible role of the ECM in the development and persistence of pain.
Collapse
Affiliation(s)
- Marlies Colman
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Consortium
| | - Delfien Syx
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Inge de Wandele
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Lies Rombaut
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Deborah Wilie
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Zoë Malfait
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Mira Meeus
- Spine, Head and Pain SPINE Research Unit Ghent, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Consortium
| | - Anne-Marie Malfait
- Department of Internal Medicine, Division of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica Van Oosterwijck
- Spine, Head and Pain SPINE Research Unit Ghent, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Consortium
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
- Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
12
|
Doolan BJ, Lavallee ME, Hausser I, Schubart JR, Michael Pope F, Seneviratne SL, Winship IM, Burrows NP. Extracutaneous features and complications of the Ehlers-Danlos syndromes: A systematic review. Front Med (Lausanne) 2023; 10:1053466. [PMID: 36756177 PMCID: PMC9899794 DOI: 10.3389/fmed.2023.1053466] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction The Ehlers-Danlos syndromes (EDS) comprise a group of inherited connective tissue disorders presenting with variable fragility to skin, soft tissue, and certain internal organs, which can cause significant complications, particularly arterial rupture, bowel perforation and joint difficulties. Currently, there are 14 proposed subtypes of EDS, with all except one subtype (hypermobile EDS) having an identified genetic etiology. An understanding of the extracutaneous features and complications within each subtype is key to maximizing clinical care and reducing the risk of further complications. Methods A systematic review of EDS-related extracutaneous features and complications was undertaken. Results We identified 839 EDS cases that met the inclusion criteria. We noted a high prevalence of joint hypermobility amongst kyphoscoliotic (39/39, 100%), spondylodysplastic (24/25, 96.0%), and hypermobile (153/160, 95.6%) EDS subtypes. The most common musculoskeletal complications were decreased bone density (39/43, 90.7%), joint pain (217/270, 80.4%), and hypotonia/weakness (79/140, 56.4%). Vascular EDS presented with cerebrovascular events (25/153, 16.3%), aneurysm (77/245, 31.4%), arterial dissection/rupture (89/250, 35.5%), and pneumothorax/hemothorax. Chronic pain was the most common miscellaneous complication, disproportionately affecting hypermobile EDS patients (139/157, 88.5%). Hypermobile EDS cases also presented with chronic fatigue (61/63, 96.8%) and gastrointestinal complications (57/63, 90.5%). Neuropsychiatric complications were noted in almost all subtypes. Discussion Understanding the extracutaneous features and complications of each EDS subtype may help diagnose and treat EDS prior to the development of substantial comorbidities and/or additional complications. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022308151, identifier CRD42022308151.
Collapse
Affiliation(s)
- Brent J. Doolan
- School of Basic and Medical Biosciences, St. John’s Institute of Dermatology, King’s College London, London, United Kingdom,*Correspondence: Brent J. Doolan,
| | - Mark E. Lavallee
- Department of Orthopedics, University of Pittsburgh Medical Center of Central PA, Pittsburgh, PA, United States
| | - Ingrid Hausser
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jane R. Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, United States
| | - F. Michael Pope
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust (West Middlesex University Hospital), London, United Kingdom
| | - Suranjith L. Seneviratne
- Institute of Immunity and Transplantation, Royal Free Hospital and University College London, London, United Kingdom,Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo, Sri Lanka
| | - Ingrid M. Winship
- Department of Genetic Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Nigel P. Burrows
- Department of Dermatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| |
Collapse
|
13
|
Jeong HJ, Engel JM, Wilwert O, Muriello M, Basel D, Slavens BA. Pain Characteristics and Symptom Management in Children with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorder. Phys Occup Ther Pediatr 2023; 43:630-643. [PMID: 36647261 DOI: 10.1080/01942638.2022.2163601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/04/2022] [Accepted: 12/25/2022] [Indexed: 01/18/2023]
Abstract
AIMS This study aims to investigate pediatric hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) pain features and management strategies. METHODS This is a mixed-methods, cross-sectional study design using patient-reported outcomes in 21 children diagnosed with hEDS/HSD. Children who reported bothersome pain were interviewed for pain features. The Child Activity Limitation Interview-21, the Brief Pain Inventory pain interference items, and the Functional Disability Inventory were used to investigate pain interference. To evaluate psychological symptoms regarding pain, the pediatric version of the Survey of Pain Attitude and the child version of the Pain Catastrophizing Scale were used. RESULTS Nineteen children had bothersome pain and of them, eight children reported constant pain. The most frequently reported regions of pain were at the ankle (mild pain) and the back (moderate-to-severe pain). Children reported mild-to-moderate pain interference and believed medications were beneficial for their pain management. Nineteen children sought treatment and of those 16 children used to exercise and acetaminophen and 13 visited physicians as a means of treatment. Parents were overall satisfied with their child's treatment (13 out of 19). CONCLUSIONS Sufficient awareness of pain-related symptoms and understanding of the treatment strategies in early childhood is needed to prevent deleterious consequences in adulthood.
Collapse
Affiliation(s)
- Hyo-Jung Jeong
- Orthopaedic and Rehabilitation Engineering Center, Marquette University, Milwaukee, Wisconsin, USA
- Department of Rehabilitation Sciences & Technology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Joyce M Engel
- Department of Rehabilitation Sciences & Technology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Olivia Wilwert
- Department of Rehabilitation Sciences & Technology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Michael Muriello
- Division of Genetics, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Donald Basel
- Division of Genetics, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Brooke A Slavens
- Department of Rehabilitation Sciences & Technology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| |
Collapse
|
14
|
De Wandele I, Colman M, Hermans L, Van Oosterwijck J, Meeus M, Rombaut L, Brusselmans G, Syx D, Calders P, Malfait F. Exploring pain mechanisms in hypermobile Ehlers-Danlos syndrome: a case-control study. Eur J Pain 2022; 26:1355-1367. [PMID: 35442549 DOI: 10.1002/ejp.1956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 03/31/2022] [Accepted: 04/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The hypermobile type of Ehlers-Danlos syndrome (hEDS) is a heritable connective tissue disorder, associated with joint hypermobility and prominent chronic pain. Because experimental pain testing in hEDS is scarce, the underlying mechanisms are still poorly understood. OBJECTIVE The present study assesses endogenous pain facilitation and pain inhibition in hEDS, using a protocol for temporal summation of pain (TSP), conditioned pain modulation (CPM), and exercise-induced hypoalgesia (EIH). METHODS Twenty women with hEDS and 20 age-matched healthy controls participated. After evaluating thermal and mechanical pain thresholds (PPT), TSP was assessed using 10 repetitive painful pressure stimuli. CPM was provoked using pressure as the test stimulus and hand immersion in hot water (46°) as the conditioning stimulus. EIH was assessed after a submaximal cycling protocol. RESULTS The hEDS group demonstrated reduced PPTs and showed significantly more TSP after repeated painful stimuli than the control group. The increase in PPTs caused by the submaximal cycling protocol (EIH) did not reach statistical significance in the hEDS group. Furthermore, in comparison to the healthy control group, the hEDS group demonstrated significantly less EIH at the quadriceps test location. At the trapezius, EIH did not significantly differ between groups. No significant differences were found between the hEDS group and control group in the CPM response. CONCLUSION The results demonstrate increased TSP in hEDS, suggesting increased central pain facilitation. EIH should be studied more extensively, but may be disturbed when evaluated in working muscles. The CPM results are inconclusive and require more research.
Collapse
Affiliation(s)
- Inge De Wandele
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marlies Colman
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium.,Ghent University, Department of Biomolecular Medicine, Ghent, Belgium.,Pain in Motion international research group, Belgium
| | - Linda Hermans
- Pain in Motion international research group, Belgium.,Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium
| | - Jessica Van Oosterwijck
- Pain in Motion international research group, Belgium.,Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium
| | - Mira Meeus
- Pain in Motion international research group, Belgium.,Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium
| | - Lies Rombaut
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium
| | | | - Delfien Syx
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium.,Ghent University, Department of Biomolecular Medicine, Ghent, Belgium
| | - Patrick Calders
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium.,Ghent University, Department of Biomolecular Medicine, Ghent, Belgium
| |
Collapse
|
15
|
De Baets S, De Temmerman M, Calders P, Malfait F, Van Hove G, Vanderstraeten G, De Wandele I, Van de Velde D. The Impact of Hypermobile “Ehlers-Danlos Syndrome” and Hypermobile Spectrum Disorder on Interpersonal Interactions and Relationships. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:832806. [PMID: 36188999 PMCID: PMC9397711 DOI: 10.3389/fresc.2022.832806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
Background People with Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders are hampered in their social participation, especially in the social relationships they have. Objective The aim of this study is to research the impact of hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobile Spectrum Disorders (HSD) on interpersonal interactions and relationships. Methods A phenomenological hermeneutic study was performed. Semi-structured interviews were used to explore the experiences of 11 participants. Results Four themes emerged from the data analysis. (1) people with hEDS or HSD can no longer do what they want to do and that affects their identity, (2) people with hEDS or HSD have to find a balance in the amount of activities they participate in, (3) having hEDS or HSD influences how to ask for, accept and give help, and (4) Relationships are affected in persons with hEDS or HSD. As well as changes in the social network, different types of relationships are influenced by the disease, including relationship with their partner, their children, their friends, strangers, fellow-sufferers and health care professionals.
Collapse
Affiliation(s)
- Stijn De Baets
- Occupational Therapy Research Group, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- *Correspondence: Stijn De Baets
| | - Marieke De Temmerman
- Occupational Therapy Research Group, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Fransiska Malfait
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Geert Van Hove
- Department of Special Needs Education, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Guy Vanderstraeten
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Inge De Wandele
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Dominique Van de Velde
- Occupational Therapy Research Group, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
16
|
Masterclass: Hypermobility and hypermobility related disorders. Musculoskelet Sci Pract 2022; 57:102465. [PMID: 34808594 DOI: 10.1016/j.msksp.2021.102465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/27/2021] [Accepted: 10/10/2021] [Indexed: 01/24/2023]
Abstract
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.
Collapse
|
17
|
Malfait F, Colman M, Vroman R, De Wandele I, Rombaut L, Miller RE, Malfait AM, Syx D. Pain in the Ehlers-Danlos syndromes: Mechanisms, models, and challenges. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2021; 187:429-445. [PMID: 34797601 DOI: 10.1002/ajmg.c.31950] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 12/27/2022]
Abstract
Chronic pain is one of the most common, yet poorly studied, complaints in people suffering from Ehlers-Danlos syndromes (EDS). This heterogeneous group of heritable connective tissue disorders is typically characterized by skin hyperextensibility, joint hypermobility, and generalized connective tissue fragility. Most EDS types are caused by genetic defects that affect connective tissue biosynthesis, thereby compromising collagen biosynthesis or fibrillogenesis and resulting in a disorganized extracellular matrix. Even though chronic pain is a major source of disability, functional impairment, and psychosocial suffering in EDS, currently used analgesics and other treatment strategies provide inadequate pain relief and thus represents an important unmet medical need. An important contributor to this is the lack of knowledge about the underlying mechanisms. In this narrative review, we summarize the current understanding of pain and the associated mechanisms in EDS based on clinical studies focusing on questionnaires and experimental pain testing as well as studies in animal models of EDS. In addition, we highlight the challenges, gaps, and opportunities in EDS-pain research.
Collapse
Affiliation(s)
- Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Marlies Colman
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Robin Vroman
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Inge De Wandele
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Lies Rombaut
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Rachel E Miller
- Division of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anne-Marie Malfait
- Division of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Delfien Syx
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| |
Collapse
|
18
|
Sharp HEC, Critchley HD, Eccles JA. Connecting brain and body: Transdiagnostic relevance of connective tissue variants to neuropsychiatric symptom expression. World J Psychiatry 2021; 11:805-820. [PMID: 34733643 PMCID: PMC8546774 DOI: 10.5498/wjp.v11.i10.805] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/12/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
The mind is embodied; thoughts and feelings interact with states of physiological arousal and physical integrity of the body. In this context, there is mounting evidence for an association between psychiatric presentations and the expression variant connective tissue, commonly recognised as joint hypermobility. Joint hypermobility is common, frequently under-recognised, significantly impacts quality of life, and can exist in isolation or as the hallmark of hypermobility spectrum disorders (encompassing joint hypermobility syndrome and hypermobile Ehlers-Danlos syndrome). In this narrative review, we appraise the current evidence linking psychiatric disorders across the lifespan, beginning with the relatively well-established connection with anxiety, to hypermobility. We next consider emerging associations with affective illnesses, eating disorders, alongside less well researched links with personality disorders, substance misuse and psychosis. We then review related findings relevant to neurodevelopmental disorders and stress-sensitive medical conditions. With growing understanding of mind-body interactions, we discuss potential aetiopathogenetic contributions of dysautonomia, aberrant interoceptive processing, immune dysregulation and proprioceptive impairments in the context of psychosocial stressors and genetic predisposition. We examine clinical implications of these evolving findings, calling for increased awareness amongst healthcare professionals of the transdiagnostic nature of hypermobility and related disorders. A role for early screening and detection of hypermobility in those presenting with mental health and somatic symptoms is further highlighted, with a view to facilitate preventative approaches alongside longer-term holistic management strategies. Finally, suggestions are offered for directions of future scientific exploration which may be key to further delineating fundamental mind-body-brain interactions.
Collapse
Affiliation(s)
- Harriet Emma Clare Sharp
- Department of Medical Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, East Sussex, United Kingdom
- Department of Psychiatry, Sussex Partnership NHS Foundation Trust, Worthing, BN13 3EP, West Sussex, United Kingdom
| | - Hugo D Critchley
- Department of Medical Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, East Sussex, United Kingdom
- Department of Psychiatry, Sussex Partnership NHS Foundation Trust, Worthing, BN13 3EP, West Sussex, United Kingdom
| | - Jessica A Eccles
- Department of Medical Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, East Sussex, United Kingdom
- Department of Psychiatry, Sussex Partnership NHS Foundation Trust, Worthing, BN13 3EP, West Sussex, United Kingdom
| |
Collapse
|
19
|
Caliogna L, Guerrieri V, Annunziata S, Bina V, Brancato AM, Castelli A, Jannelli E, Ivone A, Grassi FA, Mosconi M, Pasta G. Biomarkers for Ehlers-Danlos Syndromes: There Is a Role? Int J Mol Sci 2021; 22:ijms221810149. [PMID: 34576312 PMCID: PMC8469247 DOI: 10.3390/ijms221810149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 02/05/2023] Open
Abstract
Ehlers-Danlos syndromes (EDS) are an inherited heterogeneous group of connective tissue disorders characterized by an abnormal collagen synthesis affecting skin, ligaments, joints, blood vessels, and other organs. It is one of the oldest known causes of bruising and bleeding, and it was described first by Hippocrates in 400 BC. In the last years, multiple gene variants involved in the pathogenesis of specific EDS subtypes have been identified; moreover, new clinical diagnostic criteria have been established. New classification models have also been studied in order to differentiate overlapping conditions. Moreover, EDS shares many characteristics with other similar disorders. Although distinguishing between these seemingly identical conditions is difficult, it is essential in ensuring proper patient care. Currently, there are many genetic and molecular studies underway to clarify the etiology of some variants of EDS. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. In this review, we focused on the study of two of the most common forms of EDS—classic and hypermobile—by trying to identify possible biomarkers that could be of great help to confirm patients’ diagnosis and their follow up.
Collapse
Affiliation(s)
- Laura Caliogna
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Viviana Guerrieri
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Salvatore Annunziata
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
- Correspondence: ; Fax: +39-0382-502806
| | - Valentina Bina
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Alice Maria Brancato
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Alberto Castelli
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Eugenio Jannelli
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Alessandro Ivone
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Federico Alberto Grassi
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Mario Mosconi
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| | - Gianluigi Pasta
- Orthopedic and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (L.C.); (V.G.); (A.M.B.); (A.C.); (E.J.); (A.I.); (F.A.G.); (M.M.); (G.P.)
| |
Collapse
|
20
|
Mittal N, Mina DS, McGillis L, Weinrib A, Slepian PM, Rachinsky M, Buryk-Iggers S, Laflamme C, Lopez-Hernandez L, Hussey L, Katz J, McLean L, Rozenberg D, Liu L, Tse Y, Parker C, Adler A, Charames G, Bleakney R, Veillette C, Nielson CJ, Tavares S, Varriano S, Guzman J, Faghfoury H, Clarke H. The GoodHope Ehlers Danlos Syndrome Clinic: development and implementation of the first interdisciplinary program for multi-system issues in connective tissue disorders at the Toronto General Hospital. Orphanet J Rare Dis 2021; 16:357. [PMID: 34376220 PMCID: PMC8353438 DOI: 10.1186/s13023-021-01962-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 07/18/2021] [Indexed: 11/22/2022] Open
Abstract
Ehlers-Danlos Syndrome (EDS) are a heterogeneous group of genetic connective tissue disorders, and typically manifests as weak joints that subluxate/dislocate, stretchy and/or fragile skin, organ/systems dysfunction, and significant widespread pain. Historically, this syndrome has been poorly understood and often overlooked. As a result, people living with EDS had difficulty obtaining an accurate diagnosis and appropriate treatment, leading to untold personal suffering as well as ineffective health care utilization. The GoodHope EDS clinic addresses systemic gaps in the diagnosis and treatment of EDS. This paper describes a leap forward—from lack of awareness, diagnosis, and treatment—to expert care that is tailored to meet the specific needs of patients with EDS. The GoodHope EDS clinic consists of experts from various medical specialties who work together to provide comprehensive care that addresses the multi-systemic nature of the syndrome. In addition, EDS-specific self-management programs have been developed that draw on exercise science, rehabilitation, and health psychology to improve physical and psychosocial wellbeing and overall quality of life. Embedded into the program are research initiatives to shed light on the clinical presentation, underlying mechanisms of pathophysiology, and syndrome management. We also lead regular educational activities for community health care providers to increase awareness and competence in the interprofessional management of EDS beyond our doors and throughout the province and country.
Collapse
Affiliation(s)
- Nimish Mittal
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. .,Temerty Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada. .,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada. .,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Aliza Weinrib
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada
| | - P Maxwell Slepian
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Psychology, York University, Toronto, ON, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada
| | - Stephanie Buryk-Iggers
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Camille Laflamme
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Laura Hussey
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Joel Katz
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada.,University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| | - Lianne McLean
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Dmitry Rozenberg
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Temerty Faculty of Medicine, Division of Respirology, Ajmera Transplant Program, Toronto General Hospital Research Institute, UHN, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yvonne Tse
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Colleen Parker
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division to Temerty Faculty of Medicine, Division of Gastroenterology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Arnon Adler
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - George Charames
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Robert Bleakney
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Christian Veillette
- Department of Surgery, Division of Orthopedics, University of Toronto, Toronto, ON, Canada
| | - Christopher J Nielson
- Department of Surgery, Division of Orthopedics, University of Toronto, Toronto, ON, Canada
| | - Sandra Tavares
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Stephanie Varriano
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Juan Guzman
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Hanna Faghfoury
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Temerty Faculty of Medicine, Division of Medical Genetics, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- GoodHope Ehlers Danlos Syndrome Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anaesthesiology and Pain Medicine, University Health Network, Toronto, ON, Canada.,University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
21
|
Leone CM, Celletti C, Gaudiano G, Puglisi PA, Fasolino A, Cruccu G, Camerota F, Truini A. Pain due to Ehlers-Danlos Syndrome Is Associated with Deficit of the Endogenous Pain Inhibitory Control. PAIN MEDICINE 2021; 21:1929-1935. [PMID: 32176287 DOI: 10.1093/pm/pnaa038] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Although pain is a common complication of the hypermobile type of Ehlers-Danlos syndrome, its underlying mechanisms are still an issue of controversy. In this psychophysical study, we aimed at testing small-fiber function and the endogenous pain inhibitory control in patients with pain due to Ehlers-Danlos syndrome. METHODS In 22 patients with pain due to Ehlers-Danlos syndrome and 22 healthy participants, matched for age and sex, we tested small-fiber function using quantitative sensory testing and the endogenous pain inhibitory control using the conditioned pain modulation (CPM) protocol. As quantitative sensory testing methods, we included thermal pain and mechanical pain thresholds and the wind-up ratio. The CPM protocol consisted of two heat painful stimuli, that is, a test stimulus and a conditioning stimulus. RESULTS All patients complained of widespread pain. Quantitative sensory testing revealed no small-fiber deficit; in the area of maximum pain, we found an increased wind-up ratio. Whereas in the healthy participants the CPM protocol showed that the test stimulus rating was significantly reduced during conditioning, in patients with pain due to hEDS, the test stimulus rating increased during conditioning. CONCLUSIONS Our psychophysical study showing that patients with pain due to hEDS have an increased wind-up ratio in the area of maximum pain and abnormal CPM protocol suggests that in this condition, pain is associated with central sensitization, possibly due to deficit of the endogenous pain inhibitory control. These data might be relevant to pharmacological treatment.
Collapse
Affiliation(s)
| | - Claudia Celletti
- Department of Physical medicine and Rehabilitation, Sapienza University, Rome, Italy
| | | | - Paola Anna Puglisi
- Faculty of Information Engineering, Informatics, and Statistics, Sapienza University, Rome, Italy
| | | | - Giorgio Cruccu
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Filippo Camerota
- Department of Physical medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Andrea Truini
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| |
Collapse
|
22
|
Nijs J, George SZ, Clauw DJ, Fernández-de-Las-Peñas C, Kosek E, Ickmans K, Fernández-Carnero J, Polli A, Kapreli E, Huysmans E, Cuesta-Vargas AI, Mani R, Lundberg M, Leysen L, Rice D, Sterling M, Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. THE LANCET. RHEUMATOLOGY 2021; 3:e383-e392. [PMID: 38279393 DOI: 10.1016/s2665-9913(21)00032-1] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 12/15/2022]
Abstract
Chronic pain is a leading cause of disability globally and associated with enormous health-care costs. The discrepancy between the extent of tissue damage and the magnitude of pain, disability, and associated symptoms represents a diagnostic challenge for rheumatology specialists. Central sensitisation, defined as an amplification of neural signalling within the CNS that elicits pain hypersensitivity, has been investigated as a reason for this discrepancy. Features of central sensitisation have been documented in various pain conditions common in rheumatology practice, including fibromyalgia, osteoarthritis, rheumatoid arthritis, Ehlers-Danlos syndrome, upper extremity tendinopathies, headache, and spinal pain. Within individual pain conditions, there is substantial variation among patients in terms of presence and magnitude of central sensitisation, stressing the importance of individual assessment. Central sensitisation predicts poor treatment outcomes in multiple patient populations. The available evidence supports various pharmacological and non-pharmacological strategies to reduce central sensitisation and to improve patient outcomes in several conditions commonly seen in rheumatology practice. These data open up new treatment perspectives, with the possibility for precision pain medicine treatment according to pain phenotyping as a logical next step. With this view, studies suggest the possibility of matching non-pharmacological approaches, or medications, or both to the central sensitisation pain phenotypes.
Collapse
Affiliation(s)
- Jo Nijs
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic pain rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium; Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, and Center for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham NC, USA
| | - Daniel J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kelly Ickmans
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic pain rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Josué Fernández-Carnero
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Andrea Polli
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Eleni Kapreli
- Clinical Exercise Physiology and Rehabilitation Research Laboratory, Physiotherapy Department, Faculty of Health Sciences, University of Thessaly, Lamia, Greece
| | - Eva Huysmans
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic pain rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Antonio I Cuesta-Vargas
- Cátedra de Fisioterapia, Universidad de Malaga, Andalucia Tech, Instituto de Investigacion Biomédica de Malaga (IBIMA) Grupo de Clinimetria (F-14), Malaga, Spain
| | - Ramakrishnan Mani
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy and Pain@Otago Research Theme, University of Otago, Dunedin, New Zealand
| | - Mari Lundberg
- Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, and Center for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Laurence Leysen
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - David Rice
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand; Waitemata Pain Service, Department of Anaesthesiology and Perioperative Medicine, Waitemata District Health Board, Auckland, New Zealand
| | - Michele Sterling
- Recover Injury Research Centre and NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, University of Queensland, Brisbane, QLD, Australia
| | - Michele Curatolo
- CLEAR Center for Musculoskeletal Disorders, Harborview Injury Prevention and Research Center, and Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle WA, USA
| |
Collapse
|
23
|
Pain-related behaviors and abnormal cutaneous innervation in a murine model of classical Ehlers-Danlos syndrome. Pain 2021; 161:2274-2283. [PMID: 32483055 DOI: 10.1097/j.pain.0000000000001935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Classical Ehlers-Danlos syndrome (cEDS) is a connective tissue disorder caused by heterozygous mutations in one of the type V collagen-encoding genes, COL5A1 or COL5A2. cEDS is characterized by generalized joint hypermobility and instability, hyperextensible, fragile skin, and delayed wound healing. Chronic pain is a major problem in cEDS patients, but the underlying mechanisms are largely unknown, and studies in animal models are lacking. Therefore, we assessed pain-related behaviors in haploinsufficient Col5a1 mice, which clinically mimic human cEDS. Compared to wild-type (WT) littermates, 15 to 20-week-old Col5a1 mice of both sexes showed significant hypersensitivity to mechanical stimuli in the hind paws and the abdominal area, but responses to thermal stimuli were unaltered. Spontaneous behaviors, including distance travelled and rearing, were grossly normal in male Col5a1 mice, whereas female Col5a1 mice showed altered climbing behavior. Finally, male and female Col5a1 mice vocalized more than WT littermates when scruffed. Decreased grip strength was also noted. In view of the observed pain phenotype, Col5a1 mice were crossed with NaV1.8-tdTomato reporter mice, enabling visualization of nociceptors in the glabrous skin of the footpad. We observed a significant decrease in intraepidermal nerve fiber density, with fewer nerves crossing the epidermis, and a decreased total nerve length of Col5a1 mice compared to WT. In summary, male and female Col5a1 mice show hypersensitivity to mechanical stimuli, indicative of generalized sensitization of the nervous system, in conjunction with an aberrant organization of cutaneous nociceptors. Therefore, Col5a1 mice will provide a useful tool to study mechanisms of pain associated with cEDS.
Collapse
|
24
|
Vermeulen S, De Mits S, De Ridder R, Calders P, De Schepper J, Malfait F, Rombaut L. Altered multi‐segment ankle and foot kinematics during gait in patients with Hypermobile Ehlers‐Danlos Syndrome/Hypermobility spectrum disorder. A case‐control study. Arthritis Care Res (Hoboken) 2020; 74:841-848. [DOI: 10.1002/acr.24526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/21/2020] [Accepted: 12/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Stefan Vermeulen
- Department of Rehabilitation Sciences Ghent University Ghent Belgium
| | - Sophie De Mits
- Department of Rheumatology Ghent University Hospital Ghent Belgium
- Department of Podiatry Artevelde University of Applied Sciences Ghent Belgium
| | - Roel De Ridder
- Department of Rehabilitation Sciences Ghent University Ghent Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences Ghent University Ghent Belgium
| | - Joris De Schepper
- Department of Podiatry Artevelde University of Applied Sciences Ghent Belgium
| | | | - Lies Rombaut
- Center for Medical Genetics Ghent University Hospital Ghent Belgium
| |
Collapse
|
25
|
Casanova EL, Baeza-Velasco C, Buchanan CB, Casanova MF. The Relationship between Autism and Ehlers-Danlos Syndromes/Hypermobility Spectrum Disorders. J Pers Med 2020; 10:E260. [PMID: 33271870 PMCID: PMC7711487 DOI: 10.3390/jpm10040260] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/29/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022] Open
Abstract
Considerable interest has arisen concerning the relationship between hereditary connective tissue disorders such as the Ehlers-Danlos syndromes (EDS)/hypermobility spectrum disorders (HSD) and autism, both in terms of their comorbidity as well as co-occurrence within the same families. This paper reviews our current state of knowledge, as well as highlighting unanswered questions concerning this remarkable patient group, which we hope will attract further scientific interest in coming years. In particular, patients themselves are demanding more research into this growing area of interest, although science has been slow to answer that call. Here, we address the overlap between these two spectrum conditions, including neurobehavioral, psychiatric, and neurological commonalities, shared peripheral neuropathies and neuropathologies, and similar autonomic and immune dysregulation. Together, these data highlight the potential relatedness of these two conditions and suggest that EDS/HSD may represent a subtype of autism.
Collapse
Affiliation(s)
- Emily L. Casanova
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29615, USA;
| | - Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, University of Paris, 92100 Boulogne Billancourt, France;
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, 34000 Montpellier, France
| | | | - Manuel F. Casanova
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29615, USA;
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY 40292, USA
| |
Collapse
|
26
|
Brodwall EM, Pedersen M, Asprusten TT, Wyller VBB. Pain in adolescent chronic fatigue following Epstein-Barr virus infection. Scand J Pain 2020; 20:765-773. [PMID: 32892183 DOI: 10.1515/sjpain-2020-0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/08/2020] [Indexed: 11/15/2022]
Abstract
Objectives Acute Epstein-Barr virus (EBV) infection is a trigger of Chronic Fatigue (CF) and Chronic Fatigue Syndrome (CFS). The aim of this cross-sectional study was to investigate pain symptoms and pressure pain thresholds in fatigued and non-fatigued adolescents six months after acute EBV-infection, and in healthy controls. This study is part of the CEBA-project (CF following acute EBV infection in adolescents). Methods A total of 195 adolescents (12-20 years old) that had undergone an acute EBV infection six months prior to assessment were divided into fatigued (EBV CF+) and non-fatigued (EBV CF-) cases based on questionnaire score. The EBV CF+ cases were further sub-divided according to case definitions of CFS. In addition, a group of seventy healthy controls was included. Symptoms were mapped with questionnaires. Pressure pain thresholds were measured through pressure algometry. One way ANOVA were used for between-group analyses. Linear regression analyses were used to explore associations between Pediatric Quality of Life (dependent variable), pain symptoms and other variables within the EBV (CF+) group. Results The EBV CF+ group had significantly higher scores for pain symptoms as compared with the EBV CF- group and healthy controls, but pressure pain threshold did not differ significantly. The number of pain symptoms as well as pain severity were strongly and independently associated with quality of life. Conclusions CF and CFS following acute EBV-infection in adolescents is characterized by high pain symptom burden, which in turn is associated with a decline in quality of life. Pain in CF and CFS is of considerable clinical importance, and should be a focal point for further investigation and intervention in these patient groups.
Collapse
Affiliation(s)
- Elias Myrstad Brodwall
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway
| | - Maria Pedersen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway
| | - Tarjei Tørre Asprusten
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway
| | - Vegard Bruun Bratholm Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
27
|
Feldman ECH, Hivick DP, Slepian PM, Tran ST, Chopra P, Greenley RN. Pain Symptomatology and Management in Pediatric Ehlers-Danlos Syndrome: A Review. CHILDREN-BASEL 2020; 7:children7090146. [PMID: 32967103 PMCID: PMC7552757 DOI: 10.3390/children7090146] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
Abstract
Ehlers-Danlos syndromes (EDS) are a group of connective tissue disorders that manifest with hyperextensibility of joints and skin, and general tissue fragility. While not a major criterion for clinical diagnosis, pain is a frequently endorsed symptom across subtypes of EDS. As such, the present review aims to summarize research to date on pain characteristics and management, and the relationship between such pain symptomatology and quality of life in pediatric EDS. Characteristics of pain, including theorized etiology, relative intensity and extent of pain are described, as well as descriptions of frequently endorsed pain sites (musculoskeletal, and non-musculoskeletal). Interventions related to the management of musculoskeletal (e.g., pharmaceutical intervention, physical therapy) and non-musculoskeletal pain (e.g., pharmaceutical and psychological interventions) are discussed, highlighting the need for additional research related to pediatric pain management in the context of hypermobility syndromes. In addition, the relationship between pain in pediatric EDS and quality of life is described. Finally, limitations of literature to date are described and recommendations for future lines of research are outlined.
Collapse
Affiliation(s)
- Estée C. H. Feldman
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA;
- Correspondence:
| | - Daniel P. Hivick
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA;
| | - P. Maxwell Slepian
- Toronto General Hospital, University Health Network, Toronto, ON M5G 2C4, Canada;
| | - Susan T. Tran
- Department of Psychology, DePaul University, Chicago, IL 60614, USA;
| | - Pradeep Chopra
- Alpert Medical School, Brown University, Providence, RI 02903, USA;
| | - Rachel Neff Greenley
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA;
| |
Collapse
|
28
|
Ritelli M, Venturini M, Cinquina V, Chiarelli N, Colombi M. Multisystemic manifestations in a cohort of 75 classical Ehlers-Danlos syndrome patients: natural history and nosological perspectives. Orphanet J Rare Dis 2020; 15:197. [PMID: 32736638 PMCID: PMC7393722 DOI: 10.1186/s13023-020-01470-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022] Open
Abstract
Background The Ehlers-Danlos syndromes (EDS) are rare connective tissue disorders consisting of 13 subtypes with overlapping features including joint hypermobility, skin and generalized connective tissue fragility. Classical EDS (cEDS) is principally caused by heterozygous COL5A1 or COL5A2 variants and rarely by the COL1A1 p.(Arg312Cys) substitution. Current major criteria are (1) skin hyperextensibility plus atrophic scars and (2) generalized joint hypermobility (gJHM). Minor criteria include additional mucocutaneous signs, epicanthal folds, gJHM complications, and an affected first-degree relative. Minimal criteria prompting molecular testing are major criterion 1 plus either major criterion 2 or 3 minor criteria. In addition to these features, the clinical picture also involves multiple organ systems, but large-scale cohort studies are still missing. This study aimed to investigate the multisystemic involvement and natural history of cEDS through a cross-sectional study on a cohort of 75 molecularly confirmed patients evaluated from 2010 to 2019 in a tertiary referral center. The diagnostic criteria, additional mucocutaneous, osteoarticular, musculoskeletal, cardiovascular, gastrointestinal, uro-gynecological, neuropsychiatric, and atopic issues, and facial/ocular features were ascertained, and feature rates compared by sex and age. Results Our study confirms that cEDS is mainly characterized by cutaneous and articular involvement, though none of their hallmarks was represented in all cases and suggests a milder multisystemic involvement and a more favorable natural history compared to other EDS subtypes. Abnormal scarring was the most frequent and characteristic sign, skin hyperextensibility and gJHM were less common, all without any sex and age bias; joint instability complications were more recurrent in adults. Some orthopedic features showed a high prevalence, whereas the other issues related to the investigated organ systems were less recurrent with few exceptions and age-related differences. Conclusions Our findings define the diagnostic relevance of cutaneous and articular features and additional clinical signs associated to cEDS. Furthermore, our data suggest an update of the current EDS nosology concerning scarring that should be considered separately from skin hyperextensibility and that the clinical diagnosis of cEDS may be enhanced by the accurate evaluation of orthopedic manifestations at all ages, faciocutaneous indicators in children, and some acquired traits related to joint instability complications, premature skin aging, and patterning of abnormal scarring in older individuals.
Collapse
Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Brescia, Italy
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy.
| |
Collapse
|
29
|
Abstract
Joint hypermobility refers to the ability that a joint has to move beyond its normal range of motion. It is common in the general population, particularly in children. While many individuals manifesting joint hypermobility are healthy, this feature can accompany a wide range of symptoms and systemic disorders, whose management can be influenced by their prompt recognition. Given the increasing attention that joint hypermobility is attracting in various fields of medicine, many practitioners are asked to approach more carefully joint hypermobility, in order to avoid over- and under-diagnosis of related disorders. Among the most common conditions featuring joint hypermobility there are hypermobility spectrum disorders and hereditary connective tissue disorders, in particular, the Ehlers-Danlos syndromes. In children, joint hypermobility also accompany a variety of disorders affecting neurodevelopment. The nature of such an association is protean, as joint hypermobility may occur in selected congenital neuromuscular disorders, monogenic multiple malformation/intellectual disability syndromes, and well-known and emerging genomic syndromes. In addition, joint hypermobility seems strongly associated with developmental coordination disorders. This review offers an overview on definitions, assessment procedures, patterns of associated manifestations and disorders related to joint hypermobility, as well as treatment principles of associated musculoskeletal pain for practitioners that are not familial with this issue but encounter people featuring this physical attribute in their daily activity.
Collapse
Affiliation(s)
- Marco Castori
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy -
| |
Collapse
|
30
|
Ghasemi M, Rajabally YA. Small fiber neuropathy in unexpected clinical settings: a review. Muscle Nerve 2020; 62:167-175. [PMID: 31943276 DOI: 10.1002/mus.26808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 01/07/2020] [Accepted: 01/11/2020] [Indexed: 12/12/2022]
Abstract
Small fiber neuropathy (SFN) is being recognized with increasing frequency in neuromuscular practice due to improved diagnostic techniques. Although there are some common etiologies, up to one-third of cases are considered idiopathic. In recent years, several disorders have unexpectedly been reported in association with SFN, on clinical grounds and complementary investigations, including quantitative sensory testing, intraepidermal nerve fiber density and confocal corneal microscopy. Knowledge of these disorders is important in clinical practice as increased awareness enables prompt diagnosis of SFN in these settings and early optimal therapeutic management of affected patients. Furthermore, these new developments may lead to a better understanding of the pathophysiologic mechanisms underlying SFN in these different disorders as well as, in some cases, an expanded spectrum of affected organs and systems. This article reviews these reported associations, their possible pathophysiologic bases, and the potential resulting management implications.
Collapse
Affiliation(s)
- Majid Ghasemi
- Regional Neuromuscular Service, University Hospitals Birmingham, Birmingham, United Kingdom.,Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, University Hospitals Birmingham, Birmingham, United Kingdom.,Aston Medical School, Aston University, Birmingham, United Kingdom
| |
Collapse
|
31
|
To M, Strutton PH, Alexander CM. Central fatigue is greater than peripheral fatigue in people with joint hypermobility syndrome. J Electromyogr Kinesiol 2019; 48:197-204. [PMID: 31442925 DOI: 10.1016/j.jelekin.2019.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 07/08/2019] [Accepted: 07/22/2019] [Indexed: 11/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- May To
- Physiotherapy Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Paul H Strutton
- Department of Surgery and Cancer, Imperial College London, Charing Cross Campus, Fulham Palace Road, London W6 8RF, UK
| | - Caroline M Alexander
- Physiotherapy Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK; Department of Surgery and Cancer, Imperial College London, Charing Cross Campus, Fulham Palace Road, London W6 8RF, UK.
| |
Collapse
|
32
|
Bennett SE, Walsh N, Moss T, Palmer S. Understanding the psychosocial impact of joint hypermobility syndrome and Ehlers-Danlos syndrome hypermobility type: a qualitative interview study. Disabil Rehabil 2019; 43:795-804. [PMID: 31318301 DOI: 10.1080/09638288.2019.1641848] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Little attention has been paid to psychosocial factors in Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome (hypermobility type). This study sought to identify the psychosocial impact by examining participants' lived experiences; and identify characteristics of effective coping. MATERIALS AND METHODS Adults with Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome (Hypermobility Type) were invited to discuss their own lived experiences and the impact of the condition. All met recognized criteria for clinically significant joint hypermobility, and had a self-confirmed diagnosis. The transcripts were coded and analyzed using inductive thematic analysis. RESULTS Seventeen participants (14 women, 3 men) purposively selected to broadly represent different genders, ages and ethnicities. Analysis identified five key themes: healthcare limitations, a lack of awareness of Joint Hypermobility, and Ehlers-Danlos Syndrome (Hypermobility Type) among healthcare professionals; a restricted life; social stigma; fear of the unknown; and ways of coping. CONCLUSIONS The results highlight the significant psychosocial impact on participants' lives. Coping approaches identified included acceptance, building social networks, learning about joint hypermobility, and adapting activities. Physiotherapists supported regular exercise. Further research should consider potential interventions to improve information provision, address psychological support, and increase awareness of hypermobility among healthcare professionals.Implications for rehabilitationParticipants who had help from family members to complete activities described guilt and shame, highlighting the need for a greater rehabilitation focus on maintaining independence.Difficulties with sexual relationships due to prolapse or erectile dysfunction, and associated anxieties have indicated a need for greater awareness of these issues within primary care.The provision of reliable information and materials is vital, both for healthcare professionals and patients, to reduce misinformation and fear.Physiotherapists with knowledge of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome hypermobility type were cited as sources of support and hope, which helped people to cope with and manage their condition.
Collapse
Affiliation(s)
- Sarah E Bennett
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Nicola Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Timothy Moss
- Department of Health and Social Sciences, Centre for Appearance Research, University of the West of England, Bristol, UK
| | - Shea Palmer
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| |
Collapse
|
33
|
De Baets S, Calders P, Verhoost L, Coussens M, Dewandele I, Malfait F, Vanderstraeten G, Van Hove G, Van de Velde D. Patient perspectives on employment participation in the "hypermobile Ehlers-Danlos syndrome". Disabil Rehabil 2019; 43:668-677. [PMID: 31287330 DOI: 10.1080/09638288.2019.1636316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND "Ehlers-Danlos syndrome" (EDS) is a heritable connective disorder influencing multiple aspects of daily life. Most studies have focused on describing the physical symptoms and level of disability, but little knowledge exists about the psychosocial effects of the pathology. Participation in employment is an aspect that strongly influences quality of life of patients with chronic pathologies. This study, therefore, aimed to explore the lived experiences in employment participation of patients diagnosed with "hypermobile EDS". METHODS An inductive thematic analysis, using semi-structured interviews was used. Nine patients, purposively selected by a continuum sampling strategy, were included. Interviews were audio-recorded and transcribed verbatim. RESULTS Data analysis resulted in three main themes: (1) elements assisting participation in employment, (2) limitations in employment participation, and (3) unemployment due to the "hypermobile EDS". On the one hand, the results show that related health complaints can impede employment participation to an important extent. On the other hand, patients also report several aspects of work that can affect their well-being in a positive way. CONCLUSION There are specific reasons for a person with "hypermobile EDS" to participate in employment. These reasons are different for each person and may even vary in time.Implications for rehabilitation"Hypermobile EDS" greatly impacts activities and participation in daily life. "Living with limitations" is the central theme in the lives of "Hypermobile EDS" patients.Various aspects influence work participation in people with "Hypermobile EDS", such as work pressure, tasks, and transport to work.Work has positive effects in the lives of people with "Hypermobile EDS."Work can create difficulties when the job requirements and tasks do not match the functional abilities of a person with "Hypermobile EDS."
Collapse
Affiliation(s)
- Stijn De Baets
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Liesbeth Verhoost
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marieke Coussens
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Inge Dewandele
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Fransiska Malfait
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Guy Vanderstraeten
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Geert Van Hove
- Department of Special Needs Education, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Dominique Van de Velde
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
34
|
Bénistan K, Martinez V. Pain in hypermobile Ehlers‐Danlos syndrome: New insights using new criteria. Am J Med Genet A 2019; 179:1226-1234. [DOI: 10.1002/ajmg.a.61175] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/22/2019] [Accepted: 04/07/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Karelle Bénistan
- Centre de référence des syndromes d'Ehlers‐Danlos non vasculairesHôpital Raymond Poincaré, Garches, Assistance Publique Hôpitaux de Paris Garches France
| | - Valeria Martinez
- Département d'anesthésie et consultation douleurHôpital Raymond Poincaré, Garches, Assistance Publique Hôpitaux de Paris Garches France
- Centre d'Evaluation et de Traitement de la Douleur, F‐92100 FranceINSERM, U‐987, Hôpital Ambroise Paré Boulogne‐Billancourt France
- Université Versailles Saint‐Quentin Montigny‐Le‐Bretonneux France
| |
Collapse
|
35
|
Hastings J, Forster JE, Witzeman K. Joint Hypermobility among Female Patients Presenting with Chronic Myofascial Pelvic Pain. PM R 2019; 11:1193-1199. [PMID: 30729750 DOI: 10.1002/pmrj.12131] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Female chronic pelvic pain is estimated to affect up to 24% of adult women, many of whom have a component of myofascial pelvic pain. Although an association of joint hypermobility and pelvic pain has been hypothesized, limited data are available that estimate the prevalence of joint hypermobility in this population. OBJECTIVE To estimate the prevalence of generalized hypermobility spectrum disorder (G-HSD) among female patients with chronic myofascial pelvic pain and examine the association between G-HSD and other frequent pelvic pain-associated complaints. STUDY DESIGN Retrospective case control. SETTING Tertiary referral center within a university-affiliated public health system. PATIENTS Adult women who were diagnosed with myofascial pelvic pain during a 1-year period (n = 77 with G-HSD and n = 241 without G-HSD). METHODS Data were abstracted via chart review of patients meeting inclusion criteria. OUTCOMES The primary outcome of this study was the prevalence of G-HSD among patients with persistent myofascial pelvic pain. Secondary outcomes included the prevalence of dyspareunia, provoked vestibulodynia, stress urinary incontinence, irritable bowel syndrome, hip pain, low back pain, and fibromyalgia in patients with persistent myofascial pelvic pain with and without G-HSD. RESULTS Twenty-four percent (N = 77; 95% CI: 19.6, 29.4) of myofascial pelvic pain patients also met criteria for G-HSD. After adjusting for confounders, the odds in favor of having G-HSD was 3.55 higher (95% CI: 1.50, 8.40) (P = .004) in females with dyspareunia; 7.46 higher (95% CI: 2.41, 23.1) (P < .001) with low back pain; 3.76 higher (95% CI: 1.35, 10.5) (P = .02) with stress urinary incontinence; 4.72 higher (95% CI: 2.00, 11.2) (P < .001) with irritable bowel syndrome; and 3.12 higher (95% CI: 1.36, 7.13) (P = .007) with hip pain. There was no significant association identified between provoked vestibulodynia or fibromyalgia and G-HSD. CONCLUSION The estimated prevalence of G-HSD is higher in chronic myofascial pelvic pain patients than in the general population with statistically significant associations with several comorbid conditions. Characterizing these associations is the first step in developing effective, evidence-based screening recommendations. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Julie Hastings
- Division of Advanced Gynecology, Department of Obstetrics and Gynecology, Dignity Health Medical Group, St. Joseph's Hospital, Phoenix, AZ.,University of Arizona College of Medicine, Tucson, AZ.,Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Jeri E Forster
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, CO.,Rocky Mountain Mental Illness, Research and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Kathryn Witzeman
- Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, CO
| |
Collapse
|
36
|
Zhou Z, Rewari A, Shanthanna H. Management of chronic pain in Ehlers-Danlos syndrome: Two case reports and a review of literature. Medicine (Baltimore) 2018; 97:e13115. [PMID: 30407326 PMCID: PMC6250522 DOI: 10.1097/md.0000000000013115] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Ehlers-Danlos syndromes (EDSs) are a heterogeneous group of heritable connective tissue disorders involving defective collagen synthesis. Patients with EDS are prone for chronic myofascial pain, apart from other comorbidities. Although the initial pathology is commonly nociceptive, progression of EDS leads to neuropathies and central sensitization of pain signals. Overall, approximately 90% or more EDS patients suffer from chronic pain. There are no existing guidelines to manage chronic pain in EDS patients. In this article, we illustrate 2 case reports of EDS patients with chronic pain and review the relevant literature regarding the pathological considerations and management of chronic pain in EDS. PATIENT CONCERNS Our first patient had worsening multiple joint pains despite treatment with medications and a recent diagnosis of EDS-type 3. The second patient had a complicated history including longstanding EDS and multiple previous surgeries. She was referred due to concern about complex regional pain syndrome (CRPS) in her upper extremity. DIAGNOSES For the first patient, apart from chronic pain due to her EDS, her history also revealed that she suffered from kinesiophobia. For the second patient, a detailed clinical assessment revealed no signs of CRPS but instead a generalized worsening of EDS symptoms. INTERVENTIONS Both patients were evaluated by the multidisciplinary team consisting of a pain physician, nurse, pain psychologist, and a kinesiologist. Their treatment involved optimization of daily medications, participation in pain self-management sessions that included cognitive behavioral therapy, graded exercises, coping, and relaxation strategies. OUTCOMES Both patients demonstrated significantly better pain control and achieved overall improvement in daily living. LESSONS EDS is a complex illness with a multitude of symptoms. As in our patients, EDS patients also suffer from panic and anxiety disorders that increase the burden of pain. Apart from optimization of medications, EDS patients are best managed by a multidisciplinary approach that includes pain education and life style changes. The caution that they are resistant to local anesthetics is unwarranted. Appropriate pain interventions in selected patients may have a role to decrease pain intensity.
Collapse
Affiliation(s)
| | | | - Harsha Shanthanna
- Department of Anesthesia, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
37
|
Guarnieri V, Castori M. Clinical Relevance of Joint Hypermobility and Its Impact on Musculoskeletal Pain and Bone Mass. Curr Osteoporos Rep 2018; 16:333-343. [PMID: 29915965 DOI: 10.1007/s11914-018-0460-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW To summarize current evidence on the links between joint hypermobility (JH) and Ehlers-Danlos syndromes (EDS), with pain and reduced bone mass; to illustrate an updated approach to JH and EDS. RECENT FINDINGS In 2017, a novel classification for EDS and JH has been published. Increasing data demonstrate that pain is a major disability determinator in JH and EDS. Recent findings confirm a complex pathogenesis for pain in JH and EDS and suggest a potential role for joint instability, central sensitization and small fiber neuropathy. Some papers present bone mass reduction as an associated feature of JH and EDS. The association is preliminary and reflects heterogeneous mechanisms. Assessment of patients with JH/EDS is now well-structured and based on an integrated approach of clinical evaluations and molecular testing. Pain and reduced bone mass are possibly common satellite manifestations of JH/EDS and need expert consult for appropriate interpretation and management.
Collapse
Affiliation(s)
- Vito Guarnieri
- Division of Medical Genetics, IRCCS-Casa Sollievo della Sofferenza, Poliambulatorio "Papa Giovanni Paolo II", 2nd Floor, Viale Padre Pio 7, 71013, San Giovanni Rotondo, Foggia, Italy
| | - Marco Castori
- Division of Medical Genetics, IRCCS-Casa Sollievo della Sofferenza, Poliambulatorio "Papa Giovanni Paolo II", 2nd Floor, Viale Padre Pio 7, 71013, San Giovanni Rotondo, Foggia, Italy.
| |
Collapse
|
38
|
Abstract
This article focuses on creating an orderly approach to history taking, examination, and ordering appropriate investigations when caring for a child with joint complaints. It classifies complaints as those with and without pain, swelling, or fever and of short or long duration. It recommends an approach to the physical examination and both suggests and discourages various laboratory and imaging studies.
Collapse
Affiliation(s)
- Kathleen A Haines
- Pediatric Immunology, Section of Pediatric Rheumatology and Immunology, Department of Pediatrics, Seton Hall-Hackensack Meridian School of Medicine, Hackensack University Medical Center, 30 Prospect Avenue, Room WFAN 360, Hackensack, NJ 07601, USA.
| |
Collapse
|
39
|
Baban A, Castori M. Pharmacological resources, diagnostic approach and coordination of care in joint hypermobility-related disorders. Expert Rev Clin Pharmacol 2018; 11:689-703. [PMID: 29979900 DOI: 10.1080/17512433.2018.1497973] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Joint hypermobility (JH) is the hallmark of many hereditary soft connective tissue disorders, including Ehlers-Danlos syndromes and related disorders, disorders of the TGFβ-pathway, lateral meningocele syndrome, arterial tortuosity syndrome, and cutis laxa syndromes. Contemporary practice separates individuals with isolated, non-syndromic JH from patients with Mendelian syndromes and those with hypermobility spectrum disorders. The latter is a new nosologic entity grouping together individuals with JH and related musculoskeletal manifestations, but lacking inclusion criteria for well-defined and/or single-gene disorders. Area covered: Nomenclature of JH and JH-related disorders are summarized on a practically oriented perspective. Critical areas of clinical management comprise pain; cardiovascular and respiratory issues; fatigue and dysautonomia; bone fragility; and capillary, skin and soft tissue fragility. Medical management stands on low-evidence data. Ongoing preclinical and clinical studies are aimed to reach a more personalized pharmacological approach to the management of the cardiovascular risk, musculoskeletal pain, and reduced bone mass. Expert commentary: Correct classification of patients with JH-related disorders needs a systematic approach, in which a wide array of molecular tests should be intermingled with strong clinical competences in highly specialized settings. A multispecialty, hierarchical approach should be encouraged for optimal coordination of care in systemic phenotypes.
Collapse
Affiliation(s)
- Anwar Baban
- a Department of Pediatric Cardiology and Cardiac Surgery , IRCCS-Ospedale Pediatrico Bambino Gesù , Rome , Italy
| | - Marco Castori
- b Division of Medical Genetics , IRCCS-Casa Sollievo della Sofferenza , San Giovanni Rotondo , FG , Italy
| |
Collapse
|
40
|
Baeza-Velasco C, Bulbena A, Polanco-Carrasco R, Jaussaud R. Cognitive, emotional, and behavioral considerations for chronic pain management in the Ehlers–Danlos syndrome hypermobility-type: a narrative review. Disabil Rehabil 2018; 41:1110-1118. [DOI: 10.1080/09638288.2017.1419294] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, University Paris Descartes - Sorbonne Paris Cité, Boulogne Billancourt, France
- Inserm U1061, La Colombière Hospital, Montpellier, France
| | - Antonio Bulbena
- Department of Psychiatry, Autonoma University of Barcelona, Barcelona, Spain
| | | | - Roland Jaussaud
- Department of Internal Medicine and Clinical Immunology, Medicine School, University of Lorraine, CHRU Nancy, Nancy, France
| |
Collapse
|
41
|
Scheper MC, Nicholson LL, Adams RD, Tofts L, Pacey V. The natural history of children with joint hypermobility syndrome and Ehlers-Danlos hypermobility type: a longitudinal cohort study. Rheumatology (Oxford) 2017; 56:2073-2083. [PMID: 28431150 DOI: 10.1093/rheumatology/kex148] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives The objective of the manuscript was to describe the natural history of complaints and disability in children diagnosed with joint hypermobility syndrome (JHS)/Ehlers-Danlos-hypermobility type (EDS-HT) and to identify the constructs that underlie functional decline. Methods One hundred and one JHS/EDS-HT children were observed over 3 years and assessed at three time points on the following: functional impairments, quality of life, connective tissue laxity, muscle function, postural control and musculoskeletal and multi-systemic complaints. Cluster analysis was performed to identify subgroups in severity. Clinical profiles were determined for these subgroups, and differences were assessed by multivariate analysis of covariance. Mixed linear regression models were used to determine the subsequent trajectories. Finally, an exploratory factor analysis was used to uncover the underlying constructs of functional impairment. Results Three clusters of children were identified in terms of functional impairment: mild, moderately and severely affected. Functional impairment at baseline was predictive of worsening trajectories in terms of reduced walking distance and decreased quality of life (P ⩽ 0.05) over 3 years. Multiple interactions between the secondary outcomes were observed, with four underlying constructs identified. All four constructs (multi-systemic effects, pain, fatigue and loss of postural control) contributed significantly to disability (P ⩽ 0.046). Conclusion Children diagnosed with JHS/EDS-HT who have a high incidence of multi-systemic complaints (particularly, orthostatic intolerance, urinary incontinence and diarrhoea) and poor postural control in addition to high levels of pain and fatigue at baseline are most likely to have a deteriorating trajectory of functional impairment and, accordingly, warrant clinical prioritization.
Collapse
Affiliation(s)
- Mark C Scheper
- ACHIEVE, Center for Applied Research, Faculty of Health, University of Applied Sciences Amsterdam.,Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Lesley L Nicholson
- Kids Rehab, The Children's Hospital at Westmead.,Discipline of Biomedical Sciences
| | | | - Louise Tofts
- Kids Rehab, The Children's Hospital at Westmead.,Narrabeen Sports Medicine Centre, Sydney Academy of Sport.,Discipline of Paediatrics and Child Health, University of Sydney
| | - Verity Pacey
- Department of Health Professions, Macquarie University.,Department of Endocrinology, The Children's Hospital at Westmead, Sydney, NSW, Australia
| |
Collapse
|
42
|
Engelbert RHH, Juul-Kristensen B, Pacey V, de Wandele I, Smeenk S, Woinarosky N, Sabo S, Scheper MC, Russek L, Simmonds JV. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:158-167. [PMID: 28306230 DOI: 10.1002/ajmg.c.31545] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
New insights into the phenotype of Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome-hypermobile type (hEDS) have raised many issues in relation to classification, diagnosis, assessment, and treatment. Within the multidisciplinary team, physical therapy plays a central role in management of individuals with hypermobility related disorders. However, many physical therapists are not familiar with the diagnostic criteria, prevalence, common clinical presentation, and management. This guideline aims to provide practitioners with the state of the art regarding the assessment and management of children, adolescents, and adults with JHS/hEDS. Due to the complexity of the symptoms in the profile of JHS/hEDS, the International Classification of Functioning, Disability and Health (ICF) is adopted as a central framework whereby the umbrella term of disability is used to encompass functions, activities and participation, as well as environmental and personal factors. The current evidence-based literature regarding the management of JHS/hEDS is limited in size and quality and there is insufficient research exploring the clinical outcomes of a number of interventions. Multicenter randomized controlled trials are warranted to assess the clinical and cost-effectiveness of interventions for children and adults. Until further multicenter trials are conducted, clinical decision-making should be based on theoretical and the current limited research evidence. For all individuals diagnosed with JHS/hEDS, international consensus and combined efforts to identify risk profiles would create a better understanding of the pathological mechanisms and the potential for optimizing health care for affected individuals. © 2017 Wiley Periodicals, Inc.
Collapse
|
43
|
Hope L, Juul-Kristensen B, Løvaas H, Løvvik C, Maeland S. Subjective health complaints and illness perception amongst adults with Joint Hypermobility Syndrome/Ehlers–Danlos Syndrome-HypermobilityType – a cross-sectional study. Disabil Rehabil 2017; 41:333-340. [DOI: 10.1080/09638288.2017.1390695] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Lena Hope
- Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Birgit Juul-Kristensen
- Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Department of Sports Sciences and Clinical Biomechanics, Research Unit of Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
| | - Helene Løvaas
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | - Camilla Løvvik
- Uni Research Health, Uni Research, Bergen, Norway
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Silje Maeland
- Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Uni Research Health, Uni Research, Bergen, Norway
| |
Collapse
|
44
|
Scheper MC, Pacey V, Rombaut L, Adams RD, Tofts L, Calders P, Nicholson LL, Engelbert RHH. Generalized Hyperalgesia in Children and Adults Diagnosed With Hypermobility Syndrome and Ehlers-Danlos Syndrome Hypermobility Type: A Discriminative Analysis. Arthritis Care Res (Hoboken) 2017; 69:421-429. [PMID: 27483212 DOI: 10.1002/acr.22998] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/22/2016] [Accepted: 07/19/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Lowered pressure-pain thresholds have been demonstrated in adults with Ehlers-Danlos syndrome hypermobility type (EDS-HT), but whether these findings are also present in children is unclear. Therefore, the objectives of the study were to determine whether generalized hyperalgesia is present in children with hypermobility syndrome (HMS)/EDS-HT, explore potential differences in pressure-pain thresholds between children and adults with HMS/EDS-HT, and determine the discriminative value of generalized hyperalgesia. METHODS Patients were classified in 1 of 3 groups: HMS/EDS-HT, hypermobile (Beighton score ≥4 of 9), and healthy controls. Descriptive data of age, sex, body mass index, Beighton score, skin laxity, and medication usage were collected. Generalized hyperalgesia was quantified by the average pressure-pain thresholds collected from 12 locations. Confounders collected were pain locations/intensity, fatigue, and psychological distress. Comparisons between children with HMS/EDS-HT and normative values, between children and adults with HMS/EDS-HT, and corrected confounders were analyzed with multivariate analysis of covariance. The discriminative value of generalized hyperalgesia employed to differentiate between HMS/EDS-HT, hypermobility, and controls was quantified with logistic regression. RESULTS Significantly lower pressure-pain thresholds were found in children with HMS/EDS-HT compared to normative values (range -22.0% to -59.0%; P ≤ 0.05). When applying a threshold of 30.8 N/cm2 for males and 29.0 N/cm2 for females, the presence of generalized hyperalgesia discriminated between individuals with HMS/EDS-HT, hypermobility, and healthy controls (odds ratio 6.0). CONCLUSION Children and adults with HMS/EDS-HT are characterized by hypermobility, chronic pain, and generalized hyperalgesia. The presence of generalized hyperalgesia may indicate involvement of the central nervous system in the development of chronic pain.
Collapse
Affiliation(s)
- M C Scheper
- University of Applied Sciences and Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - V Pacey
- The Children's Hospital at Westmead and Macquarie University, Sydney, New South Wales, Australia
| | - L Rombaut
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - R D Adams
- University of Sydney, Sydney, New South Wales, Australia
| | - L Tofts
- The Children's Hospital at Westmead and University of Sydney, Sydney, New South Wales, Australia
| | | | - L L Nicholson
- The Children's Hospital at Westmead and University of Sydney, Sydney, New South Wales, Australia
| | - R H H Engelbert
- University of Applied Sciences and Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
45
|
Kumar B, Lenert P. Joint Hypermobility Syndrome: Recognizing a Commonly Overlooked Cause of Chronic Pain. Am J Med 2017; 130:640-647. [PMID: 28286166 DOI: 10.1016/j.amjmed.2017.02.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 01/24/2017] [Accepted: 02/20/2017] [Indexed: 12/11/2022]
Abstract
Joint hypermobility syndrome, also known as benign hypermobility syndrome, is a connective tissue disease characterized by joint instability, chronic pain, and minor skin changes. It shares many clinical features of Ehlers-Danlos syndrome, Hypermobility Type; enough so that many authorities consider them as one disease process. Approximately 3% of the general population is believed to have joint hypermobility syndrome, but despite this high prevalence, due to lack of awareness, heterogeneity of clinical presentation, and reliance on physical examination for diagnosis, it is largely overlooked by primary care physicians as well as by specialists. This leads to delayed or missed opportunities for diagnosis, and inappropriate interventions that frustrate both providers and patients. We review the literature regarding the pathophysiology, diagnosis, treatment options, and prognosis of joint hypermobility syndrome, and advocate for primary care physicians to consider it in the differential diagnosis of patients with chronic pain.
Collapse
Affiliation(s)
- Bharat Kumar
- Division of Immunology, University of Iowa, Iowa City.
| | - Petar Lenert
- Division of Immunology, University of Iowa, Iowa City
| |
Collapse
|
46
|
Dave AJ, Selzer F, Losina E, Usiskin I, Collins JE, Lee YC, Band P, Dalury DF, Iorio R, Kindsfater K, Katz JN. The association of pre-operative body pain diagram scores with pain outcomes following total knee arthroplasty. Osteoarthritis Cartilage 2017; 25:667-675. [PMID: 27986621 PMCID: PMC5403582 DOI: 10.1016/j.joca.2016.12.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/18/2016] [Accepted: 12/07/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Approximately 20% of total knee arthroplasty (TKA) recipients have suboptimal pain relief. We evaluated the association between pre-surgical widespread body pain and incomplete pain relief following TKA. METHOD This prospective analysis included 241 patients with knee osteoarthritis (OA) undergoing unilateral TKA who completed questionnaires preoperatively and up to 12 months post-operatively. Questionnaires included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale and a body pain diagram. We derived the number of non-index painful body regions from the diagram. We used Poisson regression to determine the association between painful body regions identified preoperatively and both WOMAC pain at follow-up and improvement in pain as defined by the minimal clinically important difference (MCID). RESULTS Mean subject age was 66 years (SD 9), and 61% were females. Adjusting for age, sex, co-morbid conditions, baseline pain, pain catastrophizing, and mental health, we found that more widespread body pain was associated with a higher likelihood of reporting 12-month WOMAC pain score >15 (relative risk [RR] per painful body region 1.39, 95% CI 1.18-1.63) and a greater likelihood of failing to achieve the MCID (RR 1.47, 95% CI 1.16-1.86).). Pain catastrophizing was an independent predictor of persistent pain and failure to improve by the MCID (RR 3.57, 95% CI 1.73-7.31). CONCLUSIONS Pre-operative widespread pain was associated with greater pain at 12-months and failure to reach the MCID. Widespread pain as captured by the pain diagram, along with the pain catastrophizing score, may help identify persons with suboptimal TKA outcome.
Collapse
Affiliation(s)
- A J Dave
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - F Selzer
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - E Losina
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - I Usiskin
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J E Collins
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Y C Lee
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P Band
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - D F Dalury
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Iorio
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - K Kindsfater
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J N Katz
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
47
|
Morlino S, Dordoni C, Sperduti I, Venturini M, Celletti C, Camerota F, Colombi M, Castori M. Refining patterns of joint hypermobility, habitus, and orthopedic traits in joint hypermobility syndrome and Ehlers-Danlos syndrome, hypermobility type. Am J Med Genet A 2017; 173:914-929. [PMID: 28266107 DOI: 10.1002/ajmg.a.38106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 12/07/2016] [Indexed: 01/13/2023]
Abstract
Joint hypermobility syndrome (JHS) and Ehlers-Danlos syndrome, hypermobility type (EDS-HT) are two overlapping heritable disorders (JHS/EDS-HT) recognized by separated sets of diagnostic criteria and still lack a confirmatory test. This descriptive research was aimed at better characterizing the clinical phenotype of JHS/EDS-HT with focus on available diagnostic criteria, and in order to propose novel features and assessment strategies. One hundred and eighty-nine (163 females, 26 males; age: 2-73 years) patients from two Italian reference centers were investigated for Beighton score, range of motion in 21 additional joints, rate and sites of dislocations and sprains, recurrent soft-tissue injuries, tendon and muscle ruptures, body mass index, arm span/height ratio, wrist and thumb signs, and 12 additional orthopedic features. Rough rates were compared by age, sex, and handedness with a series of parametric and non-parametric tools. Multiple correspondence analysis was carried out for possible co-segregations of features. Beighton score and hypermobility at other joints were influenced by age at diagnosis. Rate and sites of joint instability complications did not vary according to age at diagnosis except for soft-tissue injuries. No major difference was registered by sex and dominant versus non-dominant body side. At multiple correspondence analysis, selected features tend to co-segregate in a dichotomous distribution. Dolichostenomelia and arachnodactyly segregated independently. This study pointed out a more protean musculoskeletal phenotype than previously considered according to available diagnostic criteria for JHS/EDS-HT. Our findings corroborated the need for a re-thinking of JHS/EDS-HT on clinical grounds in order to find better therapeutic and research strategies. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Silvia Morlino
- Unit of Clinical Genetics, San Camillo-Forlanini General Hospital, Rome, Italy
| | - Chiara Dordoni
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Medical Faculty, University of Brescia, Brescia, Italy
| | | | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital,, Brescia, Italy
| | - Claudia Celletti
- Division of Physical Therapy and Rehabilitation, Department of Orthopedic Sciences, Sapienza University, Umberto I University Hospital, Rome, Italy
| | - Filippo Camerota
- Division of Physical Therapy and Rehabilitation, Department of Orthopedic Sciences, Sapienza University, Umberto I University Hospital, Rome, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Medical Faculty, University of Brescia, Brescia, Italy
| | - Marco Castori
- Unit of Clinical Genetics, San Camillo-Forlanini General Hospital, Rome, Italy
| |
Collapse
|
48
|
Chopra P, Tinkle B, Hamonet C, Brock I, Gompel A, Bulbena A, Francomano C. Pain management in the Ehlers-Danlos syndromes. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:212-219. [DOI: 10.1002/ajmg.c.31554] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
49
|
Castori M, Tinkle B, Levy H, Grahame R, Malfait F, Hakim A. A framework for the classification of joint hypermobility and related conditions. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:148-157. [PMID: 28145606 DOI: 10.1002/ajmg.c.31539] [Citation(s) in RCA: 296] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the last decade, growing attention has been placed on joint hypermobility and related disorders. The new nosology for Ehlers-Danlos syndrome (EDS), the best-known and probably the most common of the disorders featuring joint hypermobility, identifies more than 20 different types of EDS, and highlights the need for a single set of criteria to substitute the previous ones for the overlapping EDS hypermobility type and joint hypermobility syndrome. Joint hypermobility is a feature commonly encountered in many other disorders, both genetic and acquired, and this finding is attracting the attention of an increasing number of medical and non-medical disciplines. In this paper, the terminology of joint hypermobility and related disorders is summarized. Different types of joint hypermobility, its secondary musculoskeletal manifestations and a simplified categorization of genetic syndromes featuring joint hypermobility are presented. The concept of a spectrum of pathogenetically related manifestations of joint hypermobility intersecting the categories of pleiotropic syndromes with joint hypermobility is introduced. A group of hypermobility spectrum disorders is proposed as diagnostic labels for patients with symptomatic joint hypermobility but not corresponding to any other syndromes with joint hypermobility. © 2017 Wiley Periodicals, Inc.
Collapse
|
50
|
Tinkle B, Castori M, Berglund B, Cohen H, Grahame R, Kazkaz H, Levy H. Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:48-69. [PMID: 28145611 DOI: 10.1002/ajmg.c.31538] [Citation(s) in RCA: 237] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue. It has been described largely in those with musculoskeletal complaints including joint hypermobility, joint subluxations/dislocations, as well as skin and soft tissue manifestations. Many patients report activity-related pain and some go on to have daily pain. Two undifferentiated syndromes have been used to describe these manifestations-joint hypermobility syndrome and hEDS. Both are clinical diagnoses in the absence of other causation. Current medical literature further complicates differentiation and describes multiple associated symptoms and disorders. The current EDS nosology combines these two entities into the hypermobile type of EDS. Herein, we review and summarize the literature as a better clinical description of this type of connective tissue disorder. © 2017 Wiley Periodicals, Inc.
Collapse
|