Joint Hypermobility Syndrome: Recognizing a Commonly Overlooked Cause of Chronic Pain

Lower extremity inter-joint coupling angles and variability during gait in pediatric hypermobility spectrum disorder

Complex musculoskeletal complications in children with hypermobility spectrum disorder (HSD) include pain, proprioception deficits, and joint instability, which may result in movement dysfunction during walking. However, no studies have explored the inter-joint coordination deficits in children with HSD. The purpose of this study was to determine the lower extremity inter-joint coupling angles, patterns, and variability during walking in children with HSD compared to children without HSD (non-HSD). Ankle, knee, and hip kinematics during the stance phase of walking in 18 children with HSD and 18 children without HSD were measured using three-dimensional motion analysis. Coupling angles, patterns, and variability of hip-knee, hip-ankle, and knee-ankle were quantified in the sagittal, frontal, and transverse planes using vector coding techniques. Statistical modeling of coupling angles on sine and cosine scales and bootstrapped standard errors were used to compare coupling angles between HSD and non-HSD groups. Permutational multivariate analysis of variance and statistical non-parametric mapping two-sample t-tests were used to compare the coupling patterns and variability between HSD and non-HSD groups, respectively. Our results indicated that coupling angles, patterns, and variability were not significantly different between the groups. These findings suggest that lower extremity inter-joint coordination and its variability during walking might not be a promising area for further research or intervention in children with HSD. Further research could use other biomechanical methods to investigate coordination deficits in pediatric patients with HSD, and how aging and disease progression are associated with coordination deficits in individuals with HSD.

Present but Ignored: Physical Condition and Health-Related Quality of Life in College-Aged Females with Generalized Joint Hypermobility

BACKGROUND

Generalized joint hypermobility (GJH) is prevalent among young adults, necessitating effective monitoring of musculoskeletal health, particularly among college-aged females. This study aimed to identify physical fitness and health-related quality of life (HR-QoL) characteristics associated with GJH.

METHODS

A total of 67 participants were assessed: 26 with GJH (mean age 20.06, SD 1.2 years), and 41 without (mean age 20.15, SD 2.2 years). Assessments included hypermobility, anthropometric data, foot posture, balance, flexibility, strength, and HR-QoL. We used the Mann-Whitney test for two independent samples, categorical variables were analyzed with Cramer's V test. The results indicated that participants with GJH exhibited inferior balance and back muscle static strength endurance but greater flexibility compared to those without GJH. Significant differences were observed in foot posture. However, handgrip strength, explosive strength, and abdominal muscle static strength endurance did not differ significantly between groups. No significant differences were observed in HR-QoL components between the two groups. In conclusion, there appears to be a link between GJH and increased flexibility, impaired balance, reduced back muscle static strength endurance, and altered posture of both feet.

Physical therapy interventions in generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome: a scoping review

PURPOSE

Physical therapy (PT) plays a central role in treating individuals with Generalized Hypermobility Spectrum Disorder (G-HSD) and Hypermobile Ehlers-Danlos Syndrome (hEDS). However, there is limited research describing these individuals' PT management. This review aims to systematically map the evidence on PT interventions to treat this patient population.

METHODS

A systematic literature search of PubMed, CINAHL, and Embase from January 2000 to April 2023 was performed. After the screening process, studies were appraised and classified based on the type of PT interventions used. Five reviewers independently assessed the articles.

RESULTS

The search produced 757 articles. Twenty-eight met the inclusion criteria. The studies included 630 participants, mostly female, with a mean age of 26.2 (ranging from 2 to 69). The PT interventions used were therapeutic exercise, patient instruction, motor function training, adaptive equipment, manual therapy, and functional training.

CONCLUSIONS

The evidence indicates that therapeutic exercise and motor function training are efficacious methods to treat individuals with G-HSD and hEDS. There is also weak evidence for using adaptive equipment, patient instruction, manual therapy, and functional training. Recent studies emphasize multidisciplinary care and understanding of the psychological impact of G-HSD/hEDS. Additional research is needed to determine the effectiveness and dosage of PT interventions.

Joint Hypermobility Syndrome and Membrane Proteins: A Comprehensive Review

Ehlers-Danlos syndromes (EDSs) constitute a heterogeneous group of connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Asymptomatic EDSs, joint hypermobility without associated syndromes, EDSs, and hypermobility spectrum disorders are the commonest phenotypes associated with joint hypermobility. Joint hypermobility syndrome (JHS) is a connective tissue disorder characterized by extreme flexibility of the joints, along with pain and other symptoms. JHS can be a sign of a more serious underlying genetic condition, such as EDS, which affects the cartilage, bone, fat, and blood. The exact cause of JHS could be related to genetic changes in the proteins that add flexibility and strength to the joints, ligaments, and tendons, such as collagen. Membrane proteins are a class of proteins embedded in the cell membrane and play a crucial role in cell signaling, transport, and adhesion. Dysregulated membrane proteins have been implicated in a variety of diseases, including cancer, cardiovascular disease, and neurological disorders; recent studies have suggested that membrane proteins may also play a role in the pathogenesis of JHS. This article presents an exploration of the causative factors contributing to musculoskeletal pain in individuals with hypermobility, based on research findings. It aims to provide an understanding of JHS and its association with membrane proteins, addressing the clinical manifestations, pathogenesis, diagnosis, and management of JHS.

Hereditary Connective Tissue Diseases and Risk of Post-Acute SARS-CoV-2

We completed a retrospective review of data collected by the JH-CROWN consortium based on ICD10 codes for a hospitalized cohort. The severity and prevalence of COVID-19 and development of PASC within heritable connective tissue diseases were unknown; however, clinical observation suggested a thorough examination was necessary. We compared rates of disease severity, death, and PASC in connective tissue diseases versus the entire cohort as well as in diabetes and hypertension to determine if connective tissue disease was a risk factor. Of the 15,676 patients in the database, 63 (0.40%) had a connective tissue disease, which is elevated relative to the distribution in the population, suggesting a higher risk of severe disease. Within these 63 patients, 9.52% developed PASC compared to 2.54% in the entire cohort (p < 0.005). Elucidation of populations at high risk for severe disease and development of PASC is integral to improving treatment approaches. Further, no other study to date has examined the risk in those with connective tissue diseases and these data support a need for enhanced awareness among physicians, patients, and the community.

Development and feasibility of a function-based preventive intervention for lifestyle-related disorders

BACKGROUND

The enormous effect of lifestyle-related disorders on health of the global population warrants the development of preventive interventions. Focusing on musculoskeletal health and physical activity may be a way to encourage necessary lifestyle changes by making them more concrete and understandable. The aims of the current study were to develop a function-based preventive intervention aimed at lifestyle-related disorders in physically inactive 40-year-old people and to investigate the feasibility of the intervention. The feasibility study aimed to solve practical and logistical challenges and to develop the intervention based on the experiences of participants and involved clinical personnel according to defined criteria.

METHODS

Development of the standardised functional examination was based on literature-validated tests and clinical reasoning. Development of a risk profile was based on the functional examination and similar profiles which have already proved feasible. The feasibility of the functional examination and risk profile, together with function-based lifestyle counselling was tested on 27 participants in a pilot study with two physiotherapist examinations over a four-month period. Practical results and feedback from participants and collaborating personnel were examined.

RESULTS

The functional examination consists of 20 established tests not requiring specialised equipment or training which were deemed relevant for a middle-aged population and a sub-maximal ergometer test. The risk profile consists of seven functional dimensions: cardiovascular fitness, strength in upper extremity, lower extremity and trunk, mobility, balance and posture, and three non-functional dimensions: weight, self-assessed physical activity and pain. Each dimension contains at least two measures. The participants appreciated the intervention and found it motivating for making lifestyle changes. They found the tests and risk profile understandable and could see them as tools to help achieve concrete goals. The examination required 60-75 min for one physiotherapist. The recruitment rate was low and recruited participants were highly motivated to making lifestyle changes.

CONCLUSION

This project developed a functional test battery and risk profile aimed at inactive 40-year-olds which fulfilled our feasibility criteria. Functional screening and lifestyle counselling were found to be of value to a sub-group of inactive 40-year-olds who were already motivated to improve their health situations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05535296 first posted on 10/09/2022.

Exploring the biopsychosocial impact of hypermobility spectrum disorders and Ehlers-Danlos syndrome in an adult population: a protocol for a scoping review

BACKGROUND

Conditions such as hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndrome (EDS) are most often diagnosed when an individual has joint flexibility beyond the normal physiological limits. Additional characteristics and symptoms include pain and fatigue with individuals also being more likely to report feelings of anxiety and depression. Due to the varied presentation of these conditions, there is a lack of understanding amongst the various healthcare professionals (HCPs) individuals present to, leading to delayed diagnoses and negative experiences for the individuals themselves. This scoping review therefore aims to map the known biopsychosocial impact of adults with HSD and EDS.

METHODS

The scoping review will follow the six-step framework as outlined by Arskey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) checklist. The search will be conducted using the following databases: AMED, CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, PubMed PEDro. Full-text published articles in the English language (excluding literature and systematic reviews) with adult samples (over the age of 18 years) and a diagnosis of a HSD or EDS, published between 2012 and 2022, will be included in the review.

DISCUSSION

This review will aim to explore the existing literature for the reported biopsychosocial impact of adults with a HSD or EDS. It will also aim to further acknowledge the gaps in understanding of the condition, how the condition and the impact of the condition is being measured and what HCPs are involved in supporting such individuals. These gaps will be used to inform a future systematic review. It is the overall goal to increase the knowledge of HCPs and the quality of life of adults living with a joint hypermobility condition.

Behavior Problems Associated with Pain and Paresthesia

Pain is a subjective, aversive sensory and emotional experience and can cause or exacerbate problem behaviors. In this review, the biobehavioral model of pain is introduced and used to improve understanding by veterinarians of pain mechanisms and their relationship with problem behaviors. A range of potential indicators of discomfort are presented, illustrated by selected cases from the authors' behavior and pain referral clinics. Various myths exist around pain resulting in barriers to reporting assessment and treatment. Veterinarians should always consider discomfort in any case presenting with a problem behavior.

Association of joint hypermobility with range of cervical motion and its impact on the motor unit loss in patients with Hirayama disease

INTRODUCTION/AIMS

Some patients with Hirayama disease (HD) may have generalized joint hypermobility (GJH), which may excessively increase cervical range of motion (ROM) and then worsen the HD. The purpose of this study was to identify the frequency of GJH in HD patients and to analyze the effect of GJH on cervical ROM and the severity of HD.

METHODS

The Beighton scoring system (≥4) was used to diagnose GJH in 84 HD patients. All patients underwent assessments of cervical-flexion/extension ROM; motor unit number estimation in bilateral abductor pollicis brevis (APB) muscles; handgrip strength; and the disabilities of the arm, shoulder, and hand assessments.

RESULTS

Concomitant GJH was identified in 20 (23.8%) HD patients. The HD patients with GJH exhibited greater cervical-flexion (P < .001) and cervical-extension (P = .033) ROM than those without GJH. Both greater single motor unit potential amplitudes (symptomatic side: P = .005; less-symptomatic side: P = .011) and lower motor unit numbers (symptomatic side: P = .008; less-symptomatic side: P = .013) in bilateral APB, along with lower compound muscle action potential amplitudes on the symptomatic-side APB (P = .039), were observed in patients with GJH than those without GJH. There was a mild negative correlation between motor unit number and cervical-flexion ROM in HD patients (symptomatic side: r = -0.239, P = .028; less-symptomatic side: r = -0.242, P = .027).

DISCUSSION

The frequency of GJH in HD patients may be higher than in the general population. Importantly, GJH may exacerbate excessive cervical-flexion ROM, thereby worsening motor unit loss in HD patients. A cautious approach should be taken when treating HD due to possible comorbid GJH.

Wrist Injuries in Climbers

BACKGROUND

Acute and chronic injuries to the wrist are among the most common sport-related complaints of climbing athletes but have not been extensively evaluated in this population. Therefore, it is important to categorize climbing injuries to the wrist, analyze risk factors, and assess treatment outcomes.

PURPOSE

To evaluate the distribution, outcomes, and influencing factors of wrist injuries in climbers.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Climbing athletes with wrist injuries who presented to our specialized sports medical center over the course of 4 years (2017-2020) were selected. All had prospectively completed questionnaires including their climbing-specific background (years of training, climbing level, training methods, etc). Injuries were analyzed (International Climbing and Mountaineering Federation [UIAA] grade and diagnosis), and treatment methods and outcomes were retrospectively assessed with a minimum follow-up of 2 years. Parameters included the climbing score, visual analog scale for pain score, Patient-Rated Wrist Evaluation (PRWE) score, and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score including the sport component (DASH-Sport) score before and after treatment as well as time to return to climbing.

RESULTS

A total of 69 patients (25 female, 44 male) with 78 wrist injuries were identified and analyzed. Of these, 7 injuries were bilateral, occurring at the same time, and 2 injuries were independent reinjuries to either the same or the contralateral side. In addition, 24 injuries (30.8%) were acute, while 54 (69.2%) were chronic. Overall, 2 injuries had a UIAA grade of 3; all others had a UIAA grade of 2. The most frequent injuries were synovitis of the ulnocarpal recess, ulnar impaction, bone marrow edema of the lunate, wrist sprains (joint capsular pain with stress, with no pathological finding on magnetic resonance imaging), and wrist ganglion cysts. Nonoperative treatment was performed for 61 of the injuries, while 17 were treated surgically. In 51 cases (65.4%), injuries healed without consequences; in 27 cases (34.6%), discomfort remained. The visual analog scale pain score decreased from 4.8 ± 1.9 before treatment to 0.7 ± 1.0 after treatment (P < .001), the PRWE score decreased from 53.6 ± 24.9 to 10.3 ± 13.1 (P < .001), the QuickDASH score improved from 53.0 ± 16.6 to 20.0 ± 20.2 (P < .001), and the DASH-Sport score improved from 82.0 ± 16.1 to 38.1 ± 23.5 (P < .001). The climbing score improved from 2.5 ± 1.1 to 4.3 ± 1.0 points (P < .001). The patient-reported number of days with pain was negatively correlated with changes in the PRWE score (r = -0.351; P < .001), QuickDASH score (r = -0.316; P = .007), and climbing score (r = -0.264; P = .025) as well as the number of days without climbing (r = -0.266; P = .025). The number of days without climbing was positively correlated with changes in the PRWE score (r = 0.369; P < .001).

CONCLUSION

Wrist injuries in climbers constituted a diverse set of diagnoses. Ulnar-sided injuries were most common, and many patients had >1 diagnosis. Outcomes for all treatment methods (surgery and nonoperative care) were favorable, but approximately one-third of climbers had persistent wrist discomfort after treatment, underscoring the need for accurate diagnoses and acute and expert care.

Clinical characteristics of patients with hypermobile type Ehlers-Danlos syndrome (hEDS) and generalized hypermobility spectrum disorders (G-HSD): an online survey

To examine the perspective of individuals with Hypermobile Ehlers-Danlos Syndrome (hEDS) and Generalized Hypermobility Spectrum Disorder (G-HSD), needed to help identify priorities and improve the lives of people living with these conditions. We conducted an online survey between November 2021 and January 2023. Participants were recruited through the Ehlers-Danlos Society's Research Surveys website. We obtained 483 responses and 396 were analyzed. 80% of the survey's respondents were individuals with hEDS, 90% were females, 30% were between 21 and 30, and 76% lived in North America, with 85% of the participants living in North America indicated being White or European American. Participants reported exercising from none to less than three times per week, with no physical therapy treatment. Ninety-eight percent of participants reported pain mainly at the neck (76%), lower (76%) and upper back (66%), knees (64%), shoulders (60%), and hips (60%). Approximately 80% of participants reported fatigue, joint hypermobility, joint instability, interference with daily activities, gastrointestinal problems, orthostatic hypotension, muscle weakness, and emotional distress. About 60% of respondents indicated walking issues, balance issues, and reduced joint proprioception. Nearly 40% of participants reported pelvic floor dysfunction and cardiovascular problems. Participants with hEDS and G-HSD reported pain on an average (SD) of 6.4 (± 1.3) and 5.9 (± 1.5) days in a typical week, respectively. People with hEDS and G-HSD desperately need more effective treatment options, a better diagnostic process, and education among health care providers.

The association between keratoconus and systemic manifestations of connective tissue hyperlaxity

PURPOSE

To evaluate the correlation between keratoconus and systemic manifestations of tissue hyperlaxity in the general population.

METHODS

In this population based cross-sectional study 940,763 medical records of Israeli adolescents and young adults in military service were reviewed. Demographic and medical data were extracted. The prevalence of ligament injuries, habitual orthopedic deformities and umbilical/inguinal hernia was evaluated in cases with and without keratoconus. The association was tested using uni- and multivariant analyses.

RESULTS

Overall 938,411 adolescents and adults were included. Mean age was 17.55 ± 1.50 years, and 40.70% were female. Keratoconus was documented in 1,529 cases, with a prevalence of 0.16%. Compared to the general population, patients with keratoconus were significantly more likely to be diagnosed with genu varum/valgus (OR = 2.75, CI 1.48-5.13, p = 0.0015), pes planus (OR = 1.97, 95% CI: 1.62-2.38, p < 0.0001), scoliosis (OR = 1.88, 95% CI: 1.45-2.43, p < 0.0001) and umbilical/inguinal hernias (OR = 2.18, 95% CI: 1.47-3.24, p = 0.0001). On multivariate analysis the results remained significant (p < 0.05 for all). Joint injuries (ankle sprains, shoulder dislocation and injury to knee ligaments and menisci) were not significantly related to keratoconus (p > 0.05 for all).

CONCLUSIONS

In this large cohort of adolescents and young adults, an association was found between keratoconus and connective tissue hyperlaxity manifestations involving the knees, feet, spine and abdomen. These findings suggest that keratoconus might be a manifestation of a generalized connective tissue disorder, rather than just a local ocular phenomenon.

Psychological interventions for individuals with Ehlers-Danlos syndrome and hypermobility spectrum disorder: a scoping review

PURPOSE

To identify the nature and extent of the evidence on psychological interventions among individuals with Ehlers-Danlos Syndrome (EDS) and Hypermobility Spectrum Disorder (HSD).

MATERIALS AND METHODS

Eligible studies reported on psychological interventions for individuals of all ages with EDS and/or HSD. All studies published in English were included, with no restrictions to publication year or status. MEDLINE, CINAHL, EMBASE, and PsycINFO were searched. Two reviewers independently screened studies and abstracted data.

RESULTS

This scoping review included 10 studies reporting on EDS, HSD, or both. Only cohort studies and case studies were identified. Four studies investigated Cognitive Behavioural Therapy (CBT), one investigated Dialectical Behavioural Therapy (DBT), two investigated psychoeducation, two investigated Intensive Interdisciplinary Pain Treatment (IIPT), and one investigated Acceptance Commitment Therapy (ACT). Interventions targeted pain management, self-destructive behaviours, and related psychological issues (e.g., depression/anxiety). Sample sizes were small (n < 50) for most studies and interventions were generally poorly described.

CONCLUSIONS

There is a critical need for high-quality research surrounding psychological interventions for individuals with EDS/HSD. Psychological interventions for these individuals are understudied and existing studies lack validity. Researchers should investigate psychological interventions for individuals with all types of EDS/HSD with high-quality studies to validate findings from the existing studies.

Donor-Site Complication of Severe Valgus Ankle Deformity in an Adult With Ehlers-Danlos Syndrome Following Free Vascularized Fibular Grafting

Valgus deformity of the ankle joint is a well-known and relatively common donor-site complication of free vascularized fibular graft harvest in children. Due to children having naturally greater ligamentous laxity than adults, the tibiofibular syndesmosis can be compromised with the loss of the fibular shaft, leading to valgus ankle deformity (VAD). Syndesmotic stabilization with screws is commonly recommended in subsets of pediatric patients at the greatest risk of this complication. In adults, the occurrence of VAD is seldom reported in the literature following fibular graft harvest. As such, no recommendation for syndesmotic stabilization exists in the adult population. We present a case of end-stage VAD in an adult patient with Ehlers-Danlos syndrome (EDS) following free vascularized fibular graft harvest. We hypothesize that other patients with generalized joint hypermobility may face the same complication and, thus, recommend the consideration of syndesmotic stabilization or primary syndesmotic fusion at the time of graft harvest in this patient population.

Comorbidities of Rural Children and Adolescents with Migraine and without Migraine

(1) Background: Migraine is associated with comorbidities that are common in the general rural pediatric population. The purpose of this study is to evaluate the differences in the occurrence of comorbidities between rural children and adolescents with and without migraine. (2) Methods: A cross-sectional, secondary data analysis using electronic medical records of 1296 patients (53.8% females, aged 12.4 ± 3.2) was completed. Mann-Whitney U test was used to detect the difference in the number of comorbidities between the two groups. Chi-square test was used to identify the differences in the number of comorbidities, which were classified as low (0-1 comorbidities), medium (2-3 comorbidities), and high (4 or plus comorbidities) degree of comorbidities. (3) Results: Significant differences were found between those children and adolescents with migraine vs. those without for depression (p < 0.0001), anxiety (p < 0.0001), and Ehlers-Danlos Syndrome (EDS; p = 0.0309). A marginally significant difference was found between those children and adolescents with migraine (47.2%; n = 306) vs. those without (42.1%; n = 273) for unhealthy weight (p = 0.0652). Approximately 40% of the migraineurs had 2-3 comorbidities, whereas 32% of the non-migraineurs had 2-3 comorbidities (p = 0.0003). (4) Conclusions: Findings demonstrate the importance of identifying comorbidities associated with rural pediatric migraine in order to develop effective treatment strategies that optimize patient outcomes.

Joint Hypermobility and Fatigue Are Associated With Injuries in a Group of Preprofessional Ballet Dancers

INTRODUCTION

Strenuous preprofessional ballet training places young students at an increased risk of injury. This represents a major concern for aspiring dancers since a link has been described between injury and dropping out. It is therefore important to identify physical and psychological factors related to injuries in dance for prevention purposes.

METHODS

In this cross-sectional study, we explored the frequency and characteristics of injuries, as well as their physical and psychological determinants in preprofessional ballet dancers. Seventy-three participants (women = 75.6%; mean age = 13.7; SD = 1.8) were evaluated with the Beighton criteria for joint hypermobility and self-questionnaires assessing injuries in the last 18 months, fatigue, fear of injury, and motivation.

RESULTS

Most of participants (61.6%) experienced injuries in the last 18 months, mainly in the lower limbs, and due to overuse. Multivariate analyses showed that joint hypermobility and fatigue predict injury status in this sample.

CONCLUSION

These results confirm previous reports suggesting that physical factors such as fatigue and joint hypermobility, that are frequent in ballet dancers, should be taken into account in order to prevent injuries.

Hypermobility spectrum disorders: A review

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.

Increased Prevalence of Generalized Joint Hypermobility Observed in Patients With Recurrent Temporomandibular Joint Dislocation

BACKGROUND

Generalized joint hypermobility (GJH), determined by the Beighton score, is a fundamental part of diagnosing benign joint hypermobility syndrome (BJHS), which may also present extra-articular manifestations, and is determined by the Brighton criteria.

PURPOSE

This study was designed to investigate whether there is an association between recurrent temporomandibular joint (TMJ) dislocation and these disorders.

STUDY DESIGN, SETTING, AND SAMPLE

A retrospective cross-sectional study was conducted. Hospital-based patients with a history of recurrent TMJ dislocation were compared to population-based patients that did not experience TMJ dislocations or any other TMJ disorders. Age and sex matching were performed between the study groups. All subjects reached the age of skeletal maturity.

PREDICTOR VARIABLE

A history of recurrent TMJ dislocations.

MAIN OUTCOME VARIABLES

Measurements of Beighton score (range from 0 to 9 with a score of ≥ 4 indicating GJH) and correspondence to the Brighton criteria (with at least two "major" criteria or one "major" criterion plus two "minor" criteria or four "minor" criteria indicating BJHS).

COVARIATES

Included age and sex.

ANALYSES

Mann-Whitney U-test for continuous variables and the χ² test or Fisher's exact test for categorical variables. Statistical significance was set at P < .05.

RESULTS

A total of 68 participants were included, of whom 34 patients presented with recurrent TMJ dislocations compared with a control population of 34. The Mean participants were 31.35 ± 8.06 years, and 29.4% (n = 20) were males. Of the dislocation group, 16 (47.0%) patients had a Beighton score of 4 or higher. The Beighton sum score was significantly higher, with a TMJ dislocation group mean score of 3.06 ± 2.8, compared with a control score of 0.82 ± 1.1 (P = .001). A total of 58.8% (n = 20) of the TMJ dislocation group participants met the Brighton criteria versus none (0.0%) of the control group (P = .001).

CONCLUSION

We found an association between recurrent TMJ dislocation and GJH. An association with BJHS was also found, based mainly on articular manifestations. Early detection of these disorders in patients suffering from recurrent TMJ dislocation may help identify individuals at increased risk for joint instabilities and allow the implementation of appropriate preventive management strategies.

Identifying sex-specific injury predictors as a key factor in maintaining optimal physical activity levels

BACKGROUND

Optimal physical activity is known to reduce cardiovascular, respiratory and endocrine system diseases and, as a consequence, improve quality of life. An important risk factor for reinjuries during normal exercise is the initial connective tissue pathology. The variety of clinical dysplastic manifestations significantly complicate the timely diagnosis of this comorbidity.

AIM

To establish pathognomonic sex-specific dysplasia phenotypes that indicate a particular sensitivity to physical exertion.

METHODS

The study involved 117 participants with recurrent musculoskeletal injuries that occurred during normal exercise. There were 67 women (57.26%) and 50 men (42.74%), which made it possible to compare the presence of the identified signs between sexes. A validated questionnaire was used to screen their connective tissue status.

RESULTS

Ranking the most commonly revealed dysplasia signs depending on their clinical significance made it possible to establish pathognomonic sex-specific phenotypes that indicated a particular susceptibility to injuries. Individualized programs of optimal physical activity are necessary for men with chest deformities, flat-valgus feet, dolichostenomelia, arachnodactylia, hemorrhoids, abdominal muscle diastasis and recurrent hernias. In women, special sensitivity to physical exertion was associated with a combination of signs such as asthenic body, joint hypermobility, overly soft auricles, thin hyperelastic skin, atrophic striae, telangiectasias and varicose veins. Of particular importance were universal signs such as gothic palate, scoliosis, kyphosis, leg deformities, temporomandibular joint crunching, and moderate to high myopia.

CONCLUSION

Participants’ connective tissue condition should be considered when designing optimal physical activity programs. Identifying the established sex-specific dysplasia phenotypes will allow timely optimization of training loads, thus reducing the risk of injury.

The biopsychosocial impact of hypermobility spectrum disorders in adults: a scoping review

Joint hypermobility affects approximately 30% of the United Kingdom (UK) population, characterised by the ability to move joints beyond the physiological limits. Associated conditions include Ehlers-Danlos syndrome and hypermobility spectrum disorders, affecting individuals across physical, psychological and social levels detrimentally impacting their health and wellbeing. The scoping review aims to describe the known biopsychosocial impact of joint hypermobility conditions in adults over the last decade. Additional objectives include to (1) identify the types of studies that address these factors, (2) to understand how the impact of the condition is measured and managed and (3) what healthcare professionals (HCPs) are involved. The scoping review was conducted using the five-stage framework by Arksey and O'Malley. The search strategy related to two main keywords, "hypermobility" and, "biopsychosocial" across a number of electronic databases. A pilot search was conducted to determine the suitability of the databases and terms. Following the search, the data was extracted and charted, summarised and narratively reported. 32 studies met the inclusion criteria. The majority were conducted in either the UK or United States of America and case-control in design. The biopsychosocial impact was wide-ranging including, but not limited to, musculoskeletal system and dermatology, gastroenterology, mood and anxiety disorders, education and employments. This review is the first of its kind to summarise all reported symptoms and impact of joint hypermobility conditions in adults, highlighting a clear need to promote a multidisciplinary and holistic approach in raising awareness of these conditions and improving their management.

A Comprehensive Review: Chronic Pain Sequelae in the Presence of Ehlers-Danlos Syndrome

PURPOSE OF REVIEW

Patients diagnosed with Ehlers-Danlos syndromes (EDS), and especially those with the hypermobility subtype, often experience a diverse range of acute and chronic pain conditions throughout their lifetime. These can present in a variety of different phenotypes and comorbidities, making it difficult to develop structured treatment protocols. This review seeks to summarize the current literature to address old and novel treatments for EDS.

RECENT FINDINGS

Historically, medications and surgery have been used to treat patients with EDS but with low efficacy. Newer therapies that have shown promising effects for both decreasing pain and increasing quality of life include physical/occupational therapy, transcutaneous electrical nerve stimulation units, trigger point injections, low-dose naltrexone, and laser therapy. In addition, addressing the psychosocial aspects of pain with EDS through methods like cognitive behavioral therapy and patient education has shown to be vital in minimizing pain. Most research also emphasizes that pain management should not only focus on pain reduction, but on helping reduce symptoms of hypermobility, central sensitization, and fatigue to make an impactful difference. Research on pain in EDS is still limited with good clinical practice guidelines often limited by poor sample size and lack of clinical studies. Treatment options should be structured based on the specific type of pain pathology and presenting symptoms of each patient and their comorbidities. Future research should attempt to prioritize larger sample sizes, clear definitions of EDS subtypes, randomized trials for treatment efficacy, and more studies dedicated to non-musculoskeletal forms of pain.

An investigation of body awareness, fatigue, physical fitness, and musculoskeletal problems in young adults with hypermobility spectrum disorder

BACKGROUND AND OBJECTIVES

Hypermobility Spectrum Disorder (HSD) is associated with excessive joint range of motion and the presence of musculoskeletal symptoms. The objective of this study was to examine body awareness, physical fitness parameters, fatigue levels, and musculoskeletal disorders in young adults with HSD and compare them with those without HSD.

METHODS

Young individuals in the age range of 18-24 years were included in the study. Joint hypermobility of individuals was determined by the Beighton Score. Evaluations were made using the Body Awareness Questionnaire, the Fatigue Severity Scale, the Eurofit Physical Fitness Test Battery, and the Cornell Musculoskeletal Discomfort Questionnaire.

RESULTS

A total of 94 healthy individuals (74 females, 20 males, mean age 21.44 years, SD ± 1.19 years), 47 with HSD and 47 without HSD, were included in the study. It was concluded that body awareness and fatigue levels were similar in two groups (p > 0.05). When physical fitness parameters were examined, there was a significant difference between the two groups in Sit and Reach test and the dominant side grip strength (p < 0.05). There was a significant difference between the two groups in the neck, back, dominant wrist, and total musculoskeletal problems (p < 0.05).

CONCLUSION

It was concluded that young individuals with HSD had more flexibility, lower grip strength, more pain especially in the neck and back region, and more musculoskeletal disorders in general. Joint hypermobility is a factor to be considered in evaluating functional performance in these individuals.

Kinematic alterations of the ankle in subjects with generalized joint hypermobility compared with the controls: A cross-sectional study

INTRODUCTION

Generalized joint hypermobility (GJH) is a hereditary connective tissue disease in which the range of motion (ROM) of multiple joints exceeds the normal range, and the ROM varies with age, gender, and ethnicity. At present, the six-degree-of-freedom (6-DOF) of ankle kinematics among people with GJH have not been studied. To investigate the kinematic characteristics in the ankle during treadmill gait of university students with generalized joint hypermobility compared to normal participants. We hypothesized that compared to the participants in the control group, those with GJH would exhibit kinematic characteristics of poorer active motion stability in the ankle during treadmill gait.

METHODS

Healthy university student volunteers aged 18-24 (excluding those with a history of ankle trauma, etc.) were recruited and divided into a control group (50 volunteers) and a GJH group (Beighton score ≥4, 50 volunteers). Data of the 6-DOF kinematics of ankle was collected using a 3D gait analysis system. Variables were evaluated using independent t-tests and Wilcoxon signed-rank tests.

RESULTS

In the proximal/distal parameter, proximal displacement was significantly increased in the GJH group compared with the control group during 4-9% and 96-97% of the gait phase (loading response and terminal swing phase), with an increase of (0.1-0.2 cm, p < .05). Regarding the proximal/distal, internal/external, plantarflexion/dorsiflexion, and anterior/posterior parameters, the participants with GJH exhibited greater ROM than those in the control group throughout the gait cycle (0.24 ± 0.22 cm vs. 0.19 ± 0.15 cm, p = 0.047, 5.56 ± 2.90° vs. 4.48 ± 3.30°, p = .020, 23.05 ± 5.75° vs. 20.36 ± 4.91°, p < .001, 0.65 ± 0.30 cm vs. 0.55 ± 0.27 cm, p = .018). However, ROM of inversion/eversion translation was found to be decreased in the GJH group compared to the control group (8.92 ± 1.59° vs. 9.47 ± 1.37°, p = .009). In addition, there was no statistical difference between the GJH group and the control group in ROM of medial/lateral translation (0.05 ± 0.06 cm vs. 0.04 ± 0.05 cm, p = .131).

CONCLUSION

Our results confirm that our hypothesis is not valid. Although there were a few differences in each gait parameter of the ankle between the GJH group and the control group, the difference was not significant. These results indicate that the presence of GJH has less effect on ankle kinematics and enhance our knowledge of the relationship between GJH and 6-DOF of ankle kinematics.

A Diagnosis of Camptodactyly With Benign Joint Hypermobility Syndrome in a Patient Presenting With Fixed Flexion Deformity of the Fingers and Striae

Camptodactyly is a genetic disorder that causes fixed flexion deformity of one or more fingers of single or both hands. It is very rare and the occurrence is very low amongst the children. It is linked to a handful of congenital connective tissue syndromes. It is passed onto generations with reduced expressivity. However, its association with benign joint hypermobility syndrome is rarely known. Joint hypermobility syndrome is a condition where there is extreme joint flexibility and it is related to a set of articular and extra-articular sequelae. We herein report a case of camptodactyly with benign joint hypermobility syndrome in a patient presenting with fixed flexion deformity of the fingers, joint hyperextensibility, and striae.

Association between the Beighton Score and Stress Ultrasonographic Findings of the Anterior Talofibular Ligament in Healthy Young Women: A Cross-Sectional Study

The Beighton score (BS) is widely used to evaluate generalized joint laxity. However, the association between the BS and lateral ankle laxity is unclear. This study compared the ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) between high- (≥6) and low- (≤3) BS groups of healthy young women. The ATFL lengths of healthy young women were measured in the stress and nonstress positions using the previously reported technique from March 2021 to January 2022. The ATFL ratio (ratio of stress to nonstress ATFL length) was used as an indicator of lateral ankle laxity. The anterior drawer test (ADT) was performed. The correlation between the BS and US findings was also examined. A total of 20 (high-BS group) and 61 (low-BS group) subjects with a mean age of 23.8 ± 1.0 years were included. The high-BS group showed a higher grade of ADT than the low-BS group. No significant differences were found in the nonstress and stress ATFL lengths and ATFL ratio (1.10 ± 0.05 vs. 1.09 ± 0.05, p = 0.19) between the groups. No correlation was found between the BS and US findings. In conclusion, this study did not detect significant differences in the US findings of the ATFL between the high- and low-BS groups.

Variant connective tissue (joint hypermobility) and dysautonomia are associated with multimorbidity at the intersection between physical and psychological health

The symptoms of joint hypermobility extend beyond articular pain. Hypermobile people commonly experience autonomic symptoms (dysautonomia), and anxiety or related psychological issues. We tested whether dysautonomia might mediate the association between hypermobility and anxiety in adults diagnosed with mental health disorders and/or neurodevelopmental conditions (hereon referred to as patients), by quantifying joint hypermobility and symptoms of autonomic dysfunction. Prevalence of generalized joint laxity (hypermobility) in 377 individuals with diagnoses of mental health disorders and/or neurodevelopmental conditions was compared to prevalence recorded in the general population. Autonomic symptom burden was compared between hypermobile and non-hypermobile patients. Mediation analysis explored relationships between hypermobility, autonomic dysfunction, and anxiety. Patient participants had elevated prevalence of generalized joint laxity (38%) compared to the general population rate of 19% (odds ratio: 2.54 [95% confidence interval: 2.05, 3.16]). Hypermobile participants reported significantly more autonomic symptoms. Symptoms of orthostatic intolerance mediated the relationship between hypermobility and diagnosis of an anxiety disorder. Patients with mental health disorders and/or neurodevelopmental conditions have high rates of joint hypermobility. Accompanying autonomic dysfunction mediates the association between joint hypermobility and clinical anxiety status. Increased recognition of this association can enhance mechanistic understanding and improve the management of multimorbidity expressed in physical symptoms and mental health difficulties.

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

Background

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

Methods

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

Results

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

Conclusions

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

Cutaneous manifestations of orthostatic intolerance syndromes

Dysautonomia refers to a group of autonomic nervous system disorders that affect nearly 70 million people worldwide. One subset of dysautonomia includes syndromes of orthostatic intolerance (OI), which primarily affect adolescents and women of childbearing age. Due to the variability in disease presentation, the average time from symptom onset to diagnosis of dysautonomia is 6 years. In general, there is a paucity of dermatological research articles describing patients with dysautonomia. The objective of this review is to summarize the existing literature on cutaneous manifestations in dysautonomia, with an emphasis on syndromes of OI. A PubMed database of the English-language literature (1970–2020) was searched using the terms “dysautonomia”, “orthostatic intolerance”, “cutaneous”, “skin”, “hyperhidrosis”, “hypohidrosis”, “sweat”, and other synonyms. Results showed that cutaneous manifestations of orthostatic intolerance are common and varied, with one paper citing up to 85% of patients with OI having at least one cutaneous symptom. Recognition of dermatological complaints may lead to an earlier diagnosis of orthostatic intolerance, as well as other comorbid conditions.

The Effect of a Novel Training Program to Improve Trunk Stability Push Up Performance in Active Females: A Pilot Study

BACKGROUND

Trunk stability is a risk factor commonly associated with lower extremity injuries, particularly in females. Performance on trunk stability tasks, such as the Trunk Stability Push Up (TSPU), is less than optimal in females. Current corrective programs include few females, and clinically, improvements for females have been minimal.

PURPOSE/HYPOTHESIS

The purpose of this pilot study was to determine the effectiveness of a novel trunk stability intervention program in improving TSPU performance in a cohort of active female participants. It was hypothesized that ≥60% of participants would improve their TSPU scores to ≥2 via Functional Movement Screen™ (FMS™) criteria following a novel six-week intervention program.

STUDY DESIGN

Pilot Cohort Study.

METHODS

Participants were screened for pain with lumbar and shoulder clearing tests and hypermobility was assessed using Beighton scores. Additional testing included a breathing screen, the FMS™, Y-Balance Test-Lower Quarter and Y-Balance Test-Upper Quarter. Participants who scored a 1 on the TSPU received a home exercise program instructed by student physical therapists. Exercises focused on improving awareness of lumbar spine position and thoracic spine mobility. Participants returned for follow-ups after two and four weeks for instruction in exercise progression, which increased postural demand on the lumbar spine and upper extremities, and utilized closed-chain, multiplanar stability strategies.

RESULTS

Nine of 20 participants (45%) scored ≥2 on the TSPU at posttest. Due to the COVID-19 pandemic, only 12 participants were able to complete all posttest outcome measures. No significant differences were noted in the remaining outcome measures. Conclusion: The results of this study indicate that a multiplanar exercise approach, combining anti-extension and anti-rotation training, was beneficial for inducing trunk stability improvements in some active females.

LEVEL OF EVIDENCE

2b.

The Effectiveness of Physical Therapy in Patients with Generalized Joint Hypermobility and Concurrent Temporomandibular Disorders-A Cross-Sectional Study

Temporomandibular disorders (TMD) consist of a group of symptoms such as: pain of temporomandibular joints, masticatory muscles or surrounding tissues, dysfunctions of TMJs’ mobility, and crepitation. The Hypermobility Joint Syndrome (HJS) manifests in the flaccidity of joint structures, an increase in the range of joint motion, and occurs more often in the young and women. The aim of this study was to present the occurrence of HJS among patients with myogenic TMD and disc displacement with reduction. The secondary goal was to assess the effectiveness of physiotherapy directed to TMD with coexisting HJS. The study involved 322 patients with symptoms of TMD. HJS was diagnosed using the Beighton Scale, which confirmed its occurrence in 26 cases. 79 subjects (7 males and 72 females; mean age, 33.9 ± 10.4 years) were selected and divided into two groups: HJS + TMD (n = 26; 2 males and 24 females; mean age, 27.1 ± 9.4 years) and TMD (n = 53; 5 males and 48 females; mean age, 37.4 ± 9.2 years). These patients completed 3-week physiotherapy management. Before and after physiotherapy, the myofascial pain severity on Numeric Pain Rating Scale, linear measurement of maximum mouth opening, and opening pattern, were assessed. To demonstrate differences between the results, the level of significance for statistical analysis was set at α = 0.05. A statistically significant improvement was obtained in decreasing myofascial pain in both groups. Coordination of mandibular movements was achieved in both groups. Generalized joint hypermobility occurred among patients with TMD. Physiotherapy directed to TMD was effective in reducing myofascial pain and restoring TMJ’s coordination also in patients with HJS.

Dysautonomia in hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders is associated with exercise intolerance and cardiac atrophy

Dysautonomia is a recognized manifestation in patients with joint hypermobility (JH) disorders. Symptoms can be highly debilitating and commonly include physical deconditioning and poor aerobic fitness. In this study, the prevalence of dysautonomia, range of associated symptoms, patient-reported physical activity levels, and echocardiographic features were assessed retrospectively in a cohort of 144 patients (94% female) with hypermobile Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD). Echocardiographic parameters of left ventricular size and function were compared between patients with and without dysautonomia as well as to reported values from healthy controls. Dysautonomia was identified in 65% of female and 44% of male subjects and was associated with a high burden of symptomatology, most commonly exercise intolerance (78%). Exercise capacity was limited by dysautonomia, often postural symptoms, in half of all patients. We observed a reduction in physical activity following the onset or significant flare of hEDS/HSD, most strikingly noting the proportion of dysautonomic patients with sedentary lifestyle, which increased from 44% to 85%. JH-related dysautonomia was associated with smaller cardiac chamber sizes, consistent with the previous reports in positional orthostatic tachycardia syndrome. Dysautonomia is prevalent in patients with hEDS/HSD, and exercise intolerance is a key feature and leads to drastic decline in physical activity. Unfavorable cardiac geometry may underlie dysautonomia symptoms and may be due to cardiac atrophy in the setting of aerobic deconditioning.

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

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

Chronic Low Back Pain Occurring in Association With Hypermobility Spectrum Disorder and Ehlers-Danlos Syndrome

BACKGROUND

This review paper outlines recent advances in diagnostic criteria for hypermobility spectrum disorder (HSD) and its association with Ehlers-Danlos syndrome (EDS), as well as current literature on the association between joint hypermobility syndrome and lumbar back pain. We outline the optimal multidisciplinary management of lumbar back pain in the context of joint hypermobility syndrome, as well as the indications and possible side effects of surgical management of patients with these conditions.Several studies have suggested a link between chronic low back pain and hypermobility. HSD has been described as an excessive range of motion in a joint, when accounting for patient demographics. The nomenclature surrounding symptomatic joint hypermobility has varied historically, and various groups, including most notably the international EDS consortium, have introduced new classification schemes to acknowledge the systemic effects of joint hypermobility, which were previously poorly understood.

METHODS

Narrative literature review.

RESULTS

Not applicable.

CONCLUSIONS

Lower back pain experienced in patients on the HSD-EDS spectrum is multifactorial in origin and should not be considered solely in anatomical terms. Caution has been advised in the surgical management of patients on the HSD-hEDS spectrum, particularly where the subtype is unclear. The vascular type of EDS has a particular propensity for severe bleeding complications. Rates of perioperative complications after lumbar spinal surgery in the hypermobile EDS population have been reported to be up to 50%. When hypermobility and chronic lumbar back pain coexist, we advocate management in a multidisciplinary setting involving physiotherapists, pain physicians, surgeons, and psychologists.

Update in the management of lipedema

Lipedema is a chronic feminine disease that causes abnormal fat deposition in lower limbs and occasionally upper limbs. Easy bruising and pain are common. Lipedema patients suffer from both physical and psychological disability. Despite the relatively high prevalence and the impact on the quality of life, little is known about the disease. The majority of patients are misdiagnosed as lymphedema or obesity. The objective was to perform a non-systematic review on lipedema literature, related to diagnosis and therapy. Regarding pathophysiology, alterations are not exclusively confined to adipose tissue. Lymphatic dysfunction, cardiovascular variations, blood capillary fragility and increased permeability are common. Patients often present with neurological alterations and hormonal malfunction. Elevated cutaneous sodium has been documented. Due to the absence of a defined etiology, evidence-based research is difficult in the management of lipedema. The setting of realistic expectations is important for both patient and medical care provider. The major aims of the management are multimodal for improvements in the quality of life; reduction in heaviness and pain, reshaping the affected limbs, weight control, improvements in mobility. Compression garments, physical therapy, exercise regimens, diet and psychological counseling are necessities. For selected patients, surgical treatment is an added option.

Hypermobile Disorders and Their Effects on the Hip Joint

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

Recent developments in natural and synthetic polymeric drug delivery systems used for the treatment of osteoarthritis

Osteoarthritis (OA), is a common musculoskeletal disorder that will progressively increase in older populations and is expected to be the most dominant cause of disability in the world population by 2030. The progression of OA is controlled by a multi-factorial pathway that has not been completely elucidated and understood yet. However, over the years, research efforts have provided a significant understanding of some of the processes contributing to the progression of OA. Both cartilage and bone degradation processes induce articular cells to produce inflammatory mediators that produce proinflammatory cytokines that block the synthesis of collagen type II and aggrecan, the major components of cartilage. Systemic administration and intraarticular injection of anti-inflammatory agents are the first-line treatments of OA. However, small anti-inflammatory molecules are rapidly cleared from the joint cavity which limits their therapeutic efficacy. To palliate this strong technological drawback, different types of polymeric materials such as microparticles, nanoparticles, and hydrogels, have been examined as drug carriers for the delivery of therapeutic agents to articular joints. The main purpose of this review is to provide a summary of recent developments in natural and synthetic polymeric drug delivery systems for the delivery of anti-inflammatory agents to arthritic joints. Furthermore, this review provides an overview of the design rules that have been proposed so far for the development of drug carriers used in OA therapy. Overall it is difficult to state clearly which polymeric platform is the most efficient one because many advantages and disadvantages could be pointed to both natural and synthetic formulations. That requires further research in the near future.

Do Plantar Pressure and Loading Patterns Vary with Joint Hypermobility in Young Females?

BACKGROUND

Joint hypermobility is a connective tissue disorder that increases joint range of motion. Plantar pressure and foot loading patterns may change with joint hypermobility. We aimed to analyze static plantar pressure in young females with and without joint hypermobility.

METHODS

Joint laxity in 27 young females was assessed cross sectionally using the Beighton and Horan Joint Mobility Index. Participants were divided into the hypermobility (score, 4-9) and no hypermobility (score, 0-3) groups according to their scores. Static plantar pressure and forces were recorded using a pedobarographic mat system.

RESULTS

Higher peak pressures (P = .01) and peak pressure gradients (P = .025) were observed in the nondominant foot in the hypermobility group. According to the comparison of dominant and nondominant feet in each group, the hypermobility group showed significantly higher peak pressures (P = .046), peak pressure gradients (P = .041), and total force values (P = .028) in the nondominant foot.

CONCLUSIONS

The plantar pressure and loading patterns vary in young females with joint hypermobility. Evaluation of plantar loading as an injury prevention tool in individuals with joint hypermobility syndrome can be suggested.

Pelvic Girdle Pain, Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review

Pelvic girdle pain (PGP) refers specifically to musculoskeletal pain localised to the pelvic ring and can be present at its anterior and/or posterior aspects. Causes such as trauma, infection and pregnancy have been well-established, while patients with hypermobile joints are at greater risk of developing PGP. Research exploring this association is limited and of varying quality. In the present study we report on the incidence, pathophysiology, diagnostic and treatment modalities for PGP in patients suffering from Hypermobility Spectrum Disorder (HSD) and Hypermobility-Type Ehlers-Danlos Syndrome (hEDS). Recommendations are made for clinical practice by elaborating on screening, diagnosis and management of such patients to provide a holistic approach to their care. It appears that this cohort of patients are at greater risk particularly of mental health issues. Moreover over, they may require a multidisciplinary approach for their management. Ongoing research is still required to expand our understanding of the relationship between PGP, HSD and hEDS by appropriately diagnosing patients using the latest updated terminologies and by conducting randomised control trials to compare outcomes of interventions using standardised patient reported outcome measures.

Reliability of the beighton score and impact of generalized joint mobility and resting scapular position on Median Neurodynamic Test 1

INTRODUCTION

There is a lack of understanding of the impact of generalized joint mobility, joint hypermobility, and resting scapular position on neurodynamic testing of the median nerve. The objectives of the study were to determine: 1) the reliability of the Beighton score (BS) with and without the cutoff score for general joint hypermobility (GJH); 2) if there are differences in the Median Neurodynamic Test 1 (MNT 1) based on the Beighton cutoff score for GJH; 3) if there are differences in the MNT 1 based on an assessment of resting scapular position; 4) if there are relationships between the BS with and without the cutoff score for GJH, resting scapular position, and MNT 1.

METHODS

Testing was performed by two testers at two-time intervals at least 1 week apart. The population of interest was healthy asymptomatic adults. The outcome measures included the BS, resting scapular position, and MNT 1.

RESULTS

Intraclass correlation coefficients (ICC_2,1) were 0.52 for intertester reliability at visit 1 and 0.86 at visit 2, with intratester reliability of 0.88 for Tester 1 and 0.71 for Tester 2 for the BS. Intertester prevalence-adjusted bias-adjusted kappa (PABAK) values for the Beighton GJH cutoff scores were 0.80-0.84 and 0.80 to 0.92 for intratester reliability. There were no statistically significant differences or relationships for any of the other variables of interest.

CONCLUSION

Joint mobility and resting scapular position are not confounding variables when performing MNT 1 in an asymptomatic population.

Elastic fibers in orthopedics: Form and function in tendons and ligaments, clinical implications, and future directions

Elastic fibers are an essential component of the extracellular matrix of connective tissues. The focus of both clinical management and scientific investigation of elastic fiber disorders has centered on the cardiovascular manifestations due to their significant impact on morbidity and mortality. As such, the current understanding of the orthopedic conditions experienced by these patients is limited. The musculoskeletal implications of more subtle elastic fiber abnormalities, whether due to allelic variants or age-related tissue degeneration, are also not well understood. Recent advances have begun to uncover the effects of elastic fiber deficiency on tendon and ligament biomechanics; future research must further elucidate mechanisms governing the role of elastic fibers in these tissues. The identification of population-based genetic variations in elastic fibers will also be essential. Minoxidil administration, modulation of protein expression with micro-RNA molecules, and direct injection of recombinant elastic fiber precursors have demonstrated promise for therapeutic intervention, but further work is required prior to consideration for orthopedic clinical application. This review provides an overview of the role of elastic fibers in musculoskeletal tissue, summarizes current knowledge of the orthopedic manifestations of elastic fiber abnormalities, and identifies opportunities for future investigation and clinical application.

DNA Methylation Patterns of Chronic Explosive Breaching in U.S. Military Warfighters

Background: Injuries from exposure to explosions rose dramatically during the Iraq and Afghanistan wars, which motivated investigation of blast-related neurotrauma. We have undertaken human studies involving military "breachers" -exposed to controlled, low-level blast during a 3-days explosive breaching course. Methods: We screened epigenetic profiles in peripheral blood samples from 59 subjects (in two separate U.S. Military training sessions) using Infinium MethylationEPIC BeadChips. Participants had varying numbers of exposures to blast over their military careers (empirically defined as high ≥ 40, and conversely, low < 39 breaching exposures). Daily self-reported physiological symptoms were recorded. Tinnitus, memory problems, headaches, and sleep disturbances are most frequently reported. Results: We identified 14 significantly differentially methylated regions (DMRs) within genes associated with cumulative blast exposure in participants with high relative to low cumulative blast exposure. Notably, NTSR1 and SPON1 were significantly differentially methylated in high relative to low blast exposed groups, suggesting that sleep dysregulation may be altered in response to chronic cumulative blast exposure. In comparing lifetime blast exposure at baseline (prior to exposure in current training), and top associated symptoms, we identified significant DMRs associated with tinnitus, sleep difficulties, and headache. Notably, we identified KCNN3, SOD3, MUC4, GALR1, and WDR45B, which are implicated in auditory function, as differentially methylated associated with self-reported tinnitus. These findings suggest neurobiological mechanisms behind auditory injuries in our military warfighters and are particularly relevant given tinnitus is not only a primary disability among veterans, but has also been demonstrated in active duty medical records for populations exposed to blast in training. Additionally, we found that differentially methylated regions associated with the genes CCDC68 and COMT track with sleep difficulties, and those within FMOD and TNXB track with pain and headache. Conclusion: Sleep disturbances, as well as tinnitus and chronic pain, are widely reported in U.S. military service members and veterans. As we have previously demonstrated, DNA methylation encapsulates lifetime exposure to blast. The current data support previous findings and recapitulate transcriptional regulatory alterations in genes involved in sleep, auditory function, and pain. These data uncovered novel epigenetic and transcriptional regulatory mechanism underlying the etiological basis of these symptoms.

Morphological signs of connective tissue dysplasia as predictors of frequent post-exercise musculoskeletal disorders

Background

Connective tissue dysplasia (CTD) is a risk factor for musculoskeletal disorders. Changes caused by disorganization of collagen and elastin fibers lead to the inability of withstanding heavy mechanical stress. In clinical practice, diagnosis of these disorders depends on physical and anthropomorphic evaluation.

Methods

Forty-eight patients with frequent post-exercise musculoskeletal disorders were evaluated for CTD. The control group included 36 healthy participants. Both groups were evaluated via therapeutic examination with assessment of anthropometric indicators and physical-physiological evaluation, surveying and gathering of anamnesis. Based on testing results, study participants were evaluated on CTD presence and risk factors.

Results

All experimental group patients had connective tissue dysplasia of moderate and severe degree, with a total score of 49.44 ± 13.1. Certain morphological characteristics showed prevalence, allowing to determine pathognomonic predictors of high predisposition to frequent post-exercise musculoskeletal disorders. Back pain (100%), asthenic syndrome and kyphotic spinal deformation (75%), high gothic palate, hypermobility of joints and the auricles, excessive elasticity (63%), varicose veins of the lower extremities (56%) and hemorrhoids (56%), changes in the shape of the legs and temporomandibular joint (50%) showed to be significant clinical factors indicating possible connective tissue dysplasia.

Conclusions

The presence of these diagnostically significant morphological signs of CTD in humans is a pathognomonic predictor of a high predisposition to frequent injuries. Their early detection helps promote proper appointment of adequate physical activity regimen and develop treatment for the underlying cause.

Pain Symptomatology and Management in Pediatric Ehlers-Danlos Syndrome: A Review

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.

Signs of Intracranial Hypertension, Hypermobility, and Craniocervical Obstructions in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

The pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is unknown. In this study, we test the hypothesis that hypermobility, signs of intracranial hypertension (IH), and craniocervical obstructions may be overrepresented in patients with ME/CFS and thereby explain many of the symptoms. Our study is a retrospective, cross-sectional study, performed at a specialist clinic for referred patients with severe ME/CFS as defined by the Canada Consensus Criteria. The first 272 patients with ME/CFS were invited to participate, and 229 who provided prompt informed consent were included. Hypermobility was assessed using the Beighton Score. IH was assessed indirectly by the quotient of the optic nerve sheet diameter (ONSD)/eyeball transverse diameter on both sides as measured on magnetic resonance imaging (MRI) of the brain. We also included assessment of cerebellar tonsil position in relation to the McRae line, indicating foramen magnum. Craniocervical obstructions were assessed on MRI of the cervical spine. Allodynia was assessed by quantitative sensory testing (QST) for pain in the 18 areas indicative of fibromyalgia syndrome (FMS). A total of 190 women, mean age 45 years, and 39 males, mean age 44 years, were included. Hypermobility was identified in 115 (50%) participants. MRI of the brain was performed on 205 participants of whom 112 (55%) had an increased ONSD and 171 (83%) had signs of possible IH, including 65 (32%) who had values indicating more severe states of IH. Cerebellar tonsils protruding under the McRae line into the foramen magnum were identified in 115 (56%) of the participants. MRI of the cervical spine was performed on 125 participants of whom 100 (80%) had craniocervical obstructions. Pain at harmless pressure, allodynia, was found in 96% of the participants, and FMS was present in 173 participants or 76%. Compared to a general population, we found a large overrepresentation of hypermobility, signs of IH, and craniocervical obstructions. Our hypothesis was strengthened for future studies on the possible relation between ME/CFS symptoms and hypermobility, IH, and craniocervical obstructions in a portion of patients with ME/CFS. If our findings are confirmed, new diagnostic and therapeutic approaches to this widespread neurological syndrome should be considered.

Racial variations in knee joint laxity: A comparative study of the Jordanian Arab and Malay populations

BACKGROUND

A high incidence of joint laxity has been reported among Asians compared with Western populations, but clear differences between more specific ethnic populations have not been established. This study aimed to determine the average knee laxity in the Malaysian and Jordanian populations.

METHODS

Jordanian and Malaysian medical students from our institution were invited to participate in the study. General demographic data and factors affecting joint laxity were obtained from each participant using a printed questionnaire. Both knees were examined using the anterior drawer test while in 90° of flexion. Knee laxity was measured by three separate independent investigators through a knee laxity tester.

RESULTS

One hundred and eighty-six participants (95 females) were enrolled in the study. Among them, 108 Malaysians participated. The Jordanians had significantly higher knee laxity in both knees compared with the Malaysians. The mean average right knee laxity for Jordanians was 2.98 mm vs. 2.72 mm for Malaysians (P = 0.005). Similarly, the mean average left knee laxity for Jordanians was 2.95 mm, while for Malaysians, it was 2.62 mm (P = 0.0001). Furthermore, smokers had significantly more laxity in both knees. After performing a multivariate linear regression analysis for all factors, race was the only independent factor that affected knee laxity in both knees.

CONCLUSIONS

Race is directly associated with knee laxity. Jordanians tend to have more laxity in knee joints compared with Malaysians. Larger multi-center and genetic studies are recommended to establish the racial differences between different ethnic groups.

FEATURES OF CLINICAL SYMPTOMS AND SIGNS, HEMATOLOGICAL AND BIOCHEMICAL PARAMETERS IN CHILDREN WITH JOINT HYPERMOBILITY IN A LATE PERIOD UPON THE CHORNOBYL NPP ACCIDENT

OBJECTIVE

establishing the types and frequency of disembriogenetic stigma in children with joint hypermobility given the clinical and laboratory features, genetic component and endocrine regulation of these disorders in a late period upon the accident.

MATERIALS AND METHODS

Children (n = 109) inhabiting the radiologically contaminated territories and having the connective tissue dysplasia (CTD) signs were involved in the study. Diseases in family history, ossalgia complaints, fractures in a personal history, bone disembriogenetic stigma, joint hypermobility, type of somatic diseases, blood serum biochemical parameters (namely calcium, alkaline phosphatase, total protein, cholesterol, creatinine, iron, ferritin content), serum cortisol, free thyroxine, pituitary thyroid-stimulating hormone (TSH) levels, free amino acid composition in urine and radiation dose were considered.

RESULTS

Radiation doses in children having the CTD ranged from (0.37 ± 0.11) mSv to (0.56 ± 0.10) mSv with no difference from that in those without CTD. Joint hypermobility (JHM) correlated with cancer in family history (rs = 0.53) and lower extremity varicose vein disease (rs = 0.40) (p < 0.05). Incidence of ossalgia, easy fatigability, and bone fractures was higher in children with CTD. Anomalies of the dentofacial system were first in line (38.5 %) in these children. Proportion of children with grade II JHM and platypodia was lower (rs = 0.42), but with lower extremity deformations was higher (rs = 0.68) (p < 0.05) vs. in the control group. Iron and ferritin deficiencies both with lymphocytosis were more common in children with CTD than in the comparison group (p < 0.05). The increased content of oxyproline, lysine, proline both with glycine deficiency were detected in children having the CTD, i.e. an imbalance of amino acids from the collagen content was observed featuring a predominance of catabolic processes over anabolic ones. There was a direct correlation between the TSH level and the JHM grade (rs = 0.49), although the values of hormone concentration in these children did not exceed the reference range (maximum values were 3.3 μIU/ml).

CONCLUSIONS

The revealed abnormalities in amino acid content, ferrokinetics, and thyroid function indices can affect the collagen formation, organic matrix structure of bone tissue and significantly deregulate the hemato- poiesis. The later can underlie the pathways of haematologic malignancy development.

Is joint hypermobility related to preterm birth?

AIM

The aim of this study was to investigate whether women giving preterm birth have joint hypermobility.

METHODS

The study included 44 women giving preterm birth (study group) and 48 women with the history of term birth (control group). After demographic data were recorded, the presence of joint hypermobility based on the Beighton diagnostic criteria and subgroup scores were noted down. Total Beighton scores were compared between the study and control groups.

RESULTS

The total Beighton scores were significantly higher in the study group (p < .001). The study group had the highest hypermobility score for elbow hyperextension and the lowest hypermobility score for thumb hyperextension.

CONCLUSIONS

It should be kept in mind that joint hypermobility detected during follow-up of pregnancy can be related to the risk of preterm birth. Informing pregnant women with joint hypermobility about the possibility of preterm birth could be helpful.

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

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