Gait kinematics and passive knee joint range of motion in children with hypermobility syndrome

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.

The association of pain with gait spatiotemporal parameters in children with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder

BACKGROUND

Children with hypermobility spectrum disorder/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) have a high prevalence of chronic pain, which may influence gait dynamics. However, little is known about pain outcomes and their association with gait spatiotemporal parameters in children with HSD/hEDS.

RESEARCH QUESTION

Does pain correlate with gait spatiotemporal parameters in children with HSD/hEDS?

METHODS

Eighteen children with HSD/hEDS and eighteen typically developing (TD) children participated in the study. The current level of pain (0-10 on the numeric rating scale), modified Brief Pain Inventory, and Pain Catastrophizing Scale-Child version were implemented to assess pain in children with HSD/hEDS. All children completed a gait analysis at a self-selected speed. Mean and variability (measured using the coefficient of variation) of gait spatiotemporal parameters were analyzed. Gait parameters included stride length, stride time, gait speed, percent stance time, and step width. A Mann-Whitney U-test was used to compare the gait parameters between children with HSD/hEDS and TD children. Spearman correlations were used to examine the relationships between pain and gait spatiotemporal parameters in children with HSD/hEDS.

RESULTS

Children with HSD/hEDS had a longer percent stance time compared to TD children (p = 0.03). Lower pain interference in relationships with other people was significantly associated with faster gait speeds (ρ = -0.55, p = 0.03). Children with HSD/hEDS also had greater pain interference during mobility (ρ = 0.5, p = 0.05) and going to school (ρ = 0.65, p = 0.01), which were significantly correlated with greater stride length variability. Greater pain interference during enjoyment of life was significantly associated with greater percent stance time variability (ρ = 0.5, p = 0.05). Greater pain catastrophizing was correlated with decreased step width variability in children with HSD/hEDS (ρ = -0.49, p = 0.05).

SIGNIFICANCE

Pain interference and catastrophe were significantly associated with gait spatiotemporal variability. Our findings suggest that assessing pain-associated gait alterations may help understand the clinical features and gait kinematics of children with HSD/hEDS.

Estimation of Lower Limb Joint Angles and Joint Moments during Different Locomotive Activities Using the Inertial Measurement Units and a Hybrid Deep Learning Model

Using inertial measurement units (IMUs) to estimate lower limb joint kinematics and kinetics can provide valuable information for disease diagnosis and rehabilitation assessment. To estimate gait parameters using IMUs, model-based filtering approaches have been proposed, such as the Kalman filter and complementary filter. However, these methods require special calibration and alignment of IMUs. The development of deep learning algorithms has facilitated the application of IMUs in biomechanics as it does not require particular calibration and alignment procedures of IMUs in use. To estimate hip/knee/ankle joint angles and moments in the sagittal plane, a subject-independent temporal convolutional neural network-bidirectional long short-term memory network (TCN-BiLSTM) model was proposed using three IMUs. A public benchmark dataset containing the most representative locomotive activities in daily life was used to train and evaluate the TCN-BiLSTM model. The mean Pearson correlation coefficient of joint angles and moments estimated by the proposed model reached 0.92 and 0.87, respectively. This indicates that the TCN-BiLSTM model can effectively estimate joint angles and moments in multiple scenarios, demonstrating its potential for application in clinical and daily life scenarios.

The effects of joint hypermobility on pain and functional biomechanics in adolescents with juvenile fibromyalgia: secondary baseline analysis from a pilot randomized controlled trial

BACKGROUND

Joint hypermobility is a common clinical finding amongst hereditary connective tissue disorders that is observed in pediatric rheumatological settings, and often associated with chronic pain. Joint hypermobility may also contribute to deficits in physical functioning and physical activity, but previous findings have been inconsistent. It is possible that physical activity impairment in joint hypermobility may be due to chronic aberrant movement patterns subsequent to increased joint laxity.

METHOD

As part of a larger randomized pilot trial of juvenile onset fibromyalgia (JFM), a secondary analysis was conducted to explore whether adolescents with JFM and joint hypermobility differed from non-joint hypermobility peers in terms of pain, daily functioning, and biomechanics (i.e., kinetics and kinematics) during a moderately vigorous functional task.

RESULTS

From the larger sample of adolescents with JFM (N = 36), 13 adolescents (36.1%) met criteria for joint hypermobility and 23 did not have joint hypermobility. Those with joint hypermobility exhibited poorer overall functioning (Md = 20, Q1,Q3 [5.8, 7.6] vs. Md = 29, Q1,Q3 [5.1, 7.6]) but there were no differences in pain (Md = 6.9, Q1,Q3 [22, 33], vs. Md = 6.45, Q1,Q3 [15, 29.5]). Inspection of time-series plots suggests those with joint hypermobility exhibited decreased hip flexion and frontal plane hip moment (e.g., resistance to dynamic valgus) during the landing phase (early stance) and greater hip and knee transverse plane moments during the propulsion phase (late stance) of the drop vertical jump task (DVJ). No other differences in lower extremity biomechanics were observed between study groups.

CONCLUSIONS

In this exploratory study, there were small but notable differences in biomechanics between patients with JFM who also had joint hypermobility versus those without joint hypermobility during a landing and jumping task (e.g., DVJ). These differences may indicate decreased joint stiffness during landing, associated with increased joint laxity and decreased joint stability, which may put them at greater risk for injury. Further study with a larger sample size is warranted to examine whether these biomechanical differences in patients with JFM and joint hypermobility affect their response to typical physical therapy or exercise recommendations.

The relationship between kinaesthesia, motor performance, physical fitness and joint mobility in children living in Nigeria

PURPOSE

This study aimed to determine the relationship between kinaesthesia, motor performance, fitness, and joint mobility in children.

METHODS

A descriptive cross-sectional study was conducted involving children from two primary schools in the South-Eastern part of Nigeria. The Beighton criteria were used to measure joint mobility. Motor performance, fitness, and kinaesthesia were measured in all the children. Spearman's rank correlation was used to evaluate the relationship between the outcomes.

RESULTS

A total of 91 children (51.6% girls) participated in the study. The mean age of the children was 8.20 ± 1.98 years. Using a Beighton score of ≥ 6, Generalized Joint Hypermobility (GJH) was identified in a total of 35 (38.46%) children and was more prevalent in females (60.0%). Joint mobility had significant correlations with most fitness and motor performance items, but not kinaesthesia. Agility & power, and motor performance seem to be reduced if mobility is larger. Kinaesthesia was correlated with most fitness and motor performance items, indicating that better fitness and better motor performance cooccur with better kinaesthesia or vice versa.

CONCLUSION

Joint mobility may have a significant influence on fitness and motor performance in children. Hence, it may be useful for future studies to investigate how fitness and motor performance modulate the onset and progression of musculoskeletal symptoms in GJH.

Diagnosis of generalized joint hypermobility with gait patterns using a deep neural network

Generalized joint hypermobility (GJH) describes the situation that the range of joint motion exceeds the normal range. GJH is found to increase the risk of knee-related injury and osteoarthritis, challenging the athletic ability of the population. Gait signals are directly related to hip and knee athletic conditions, and have been shown to have significant changes with GJH by our previous research. But gait data are noisy, and vary with age, gender, weight, and ethnicity, which makes them hard to analyze with traditional statistical methods. In this study, we proposed an end-to-end deep learning model to recognize the patterns of the gait signals. The model consists of convolutional network blocks, residual network blocks, and attention blocks. Our dataset is composed of 452 samples of gait data obtained by a three-dimension motion capture system, with the six-degree-of-freedom kinematic data of hip, knee, and ankle joints during level walking, downhill, and uphill walking. The model achieves 95.77% accuracy and 98.68% specificity with a recall of 76.84% while is more efficient than traditional machine learning methods. The trained model can be run on economical friendly devices, and provide help for immediate and precise diagnosis of GJH. It is also meaningful to consider its application in large-scale GJH screening, which can contribute to sports medicine.

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

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

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

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

Generalized joint hypermobility subjects without knee hyperextension have greater walking anterior tibial translation and flexion angle than those with knee hyperextension

BACKGROUND

The walking knee kinematic results of generalized joint hypermobility (GJH) subjects were controversial in previous studies. We proposed that this could be related to the knee statuses of GJH subjects with/without knee hyperextension (KH) and assumed that there are significant sagittal knee kinematic differences between GJH subjects with/without KH during gait.

RESEARCH QUESTION

Do GJH subjects with KH exhibit significantly different kinematic characteristics than those without KH during walking?

METHODS

35 GJH subjects without KH, 34 GJH subjects with KH, and 30 healthy controls were recruited in this study. A three-dimensional gait analysis system was used to record and compare the knee kinematics of the participants.

RESULTS

Significant walking knee kinematics differences were found between GJH subjects with/without KH during walking. GJH subjects without KH had greater flexion angles (4.7-6.0°, 24-53 % gait cycle (GC), p < 0.001; 5.1-6.1°, 65-77 % GC, p = 0.008) and anterior tibial translation (ATT) (3.3-4.1 mm, 0-4 % GC, p = 0.015; 3.8-4.3 mm, 91-100 % GC, p = 0.01) than those with KH. Compared to controls, GJH without KH exhibited increased ATT (4.0-5.7 mm, 0-26 % GC, p < 0.001; 5.1-6.7 mm, 78-100 % GC, p < 0.001), and range of motion of ATT (3.3 mm, p = 0.028) whereas GJH with KH only exhibited increased extension angle (6.9-7.3°, 62-66 % GC, p = 0.015) during walking.

SIGNIFICANCE

The findings confirmed the hypothesis and suggested that GJH subjects without KH had more walking ATT and flexion angle asymmetries than those with KH. This may raise concerns about the differences in knee health and risk of knee diseases between GJH subjects with/without KH. However, further investigations should be done to explore the exact influence of walking ATT and flexion angle asymmetries in GJH subjects without KH.

An exploratory study of clinical characteristics and gait features of adolescents with hypermobility disorders

BACKGROUND

In adolescents with non-pathological and pathological joint hypermobility, gait deviations have been associated with pain and fatigue. It remains unclear what distinguishes the non-pathological form of joint hypermobility (JH) from pathological forms (i.e. hypermobile Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorders (HSD). Our objective was to identify discriminative clinical characteristics and biomechanical gait features between adolescents with hEDS/HSD, JH, and healthy controls (HC).

METHODS

Thirty-two adolescents were classified into three subgroups (hEDS/HSD=12, JH=5, HC=15). Clinical characteristics (e.g. pain intensity and surface, fatigue, functional disability) were inventoried. The gait pattern was assessed using a three-dimensional, eight-camera VICON MX1.3 motion capture system, operating at a sample rate of 100 Hz (VICON, Oxford, UK). Spatiotemporal parameters, joint angles (sagittal plane), joint work, joint impulse, ground reaction force and gait variability expressed as percentage using Principal Component Analysis (PCA) were assessed and analysed using multivariate analysis. Multivariate analysis data is expressed in mean differences(MD), standard error(SE) and P-values.

RESULTS

The hEDS/HSD-group had significantly higher fatigue score (+51.5 points, p = <0.001) and functional disability (+1.6, p < .001) than the HC-group. Pain intensity was significantly higher in the hEDS/HSD-group than the other subgroups (JH; +37 mm p = .004, HC; +38 mm, p = .001). The hEDS/HSD-group showed significantly more gait variability (JH; +7.2(2.0)% p = .003, HC; + 7.8(1.4)%, p = <0.001) and lower joint work (JH; -0.07(0.03)J/kg, p = .007, HC; - 0.06(0.03)J/kg, p = .013) than the other subgroups. The JH-group showed significantly increased ankle dorsiflexion during terminal stance (+5.0(1.5)degree, p = .001) compared to hEDS/HSD-group and knee flexion during loading response compared to HC-group (+5.7(1.8) degree, p = .011).

SIGNIFICANCE

A distinctive difference in gait pattern between adolescents with non-pathological and pathological joint hypermobility is found in gait variability, rather than in the biomechanical features of gait. This suggests that a specific gait variability metric is more appropriate than biomechanical individual joint patterns for assessing gait in adolescents with hEDS/HSD.

Upslope walking increases anterior tibial translation deficiency in patients with generalized joint hypermobility

BACKGROUND

Generalized joint hypermobility (GJH) is a highly prevalent disease that frequently affects the knee joint. The current literature has conflicting results about whether patients with GJH had knee kinematics deficiency during gait. This could be because most of the testing environment (level walking) was gentle and low-demanding for patients when studying their knee kinematics. With a high-demanding knee function and sagittal firm structure requirement, upslope walking was thought to stimulate sagittal knee kinematics deficiency in patients with GJH.

RESEARCH QUESTIONS

However, only little investigation reported whether upslope walking could stimulate knee kinematic deficiency or not. We hypothesize that upslope walking can increase sagittal knee kinematic deficiency between GJH subjects and healthy controls.

METHODS

A three-dimensional motion analysis was conducted to explore whether upslope walking could stimulate sagittal knee kinematic deficiency in patients with GJH. A total of 44 patients with GJH and 44 healthy controls were recruited. Subjects walked on both level and upslope (15%) conditions when the kinematic data were collected. SPM1D analysis was taken to explore the differences between groups.

RESULTS

Our results showed that upslope walking could significantly increase knee flexion angle and anterior tibial translation in both GJH patients and healthy controls (p < 0.05). The increments of anterior tibial translation (values in upslope walking minus values in level walking) of GJH patients were greater than those of healthy controls (magnitude varying from 2.5 to 2.9 mm during 0-3% gait cycles (GC), p = 0.034; 1.4-2.9 mm during 93-100%GC, p = 0.012).

SIGNIFICANCES

The findings partially confirmed our hypothesis and suggested that upslope walking could increase anterior tibial translation deficiency in patients with GJH. Upslope walking may be a practical motion task in studying the weakness of knee kinematics of GJH subjects for researchers and scholars. Patients with GJH may face a more challenging knee kinematic environment than healthy controls in up-sloped activities.

The 6DOF knee kinematics of healthy subjects during sloped walking compared to level walking

BACKGROUND

Level Walking is a frequent functional movement during daily life. However, sloped walking is also common. Exploring 6DOF knee kinematics during sloped walking is important. It provides a reference for the rehabilitation, safety, and knee health of patients with knee diseases walking on sloped surfaces.

RESEARCH QUESTION

The study aimed to explore 6DOF knee kinematics characteristics during sloped walking compared to level walking. We hypothesized that tibial anteroposterior translation and flexion angle (the sagittal plane) were significantly different from those of level walking.

METHODS

One hundred young, healthy adults (50 males and 50 females) were recruited for this study. A three-dimensional gait analysis system was used to collect 6DOF knee kinematics during level and sloped walking. The slope was set to ± 15% when the sloped walking was performed.

RESULTS

Sloped walking mainly increased knee flexion angle (upslope, 2.5-26.2°, 1-100% gait cycle (GC), p < 0.05; downslope, 1.7-11.9°, 15-95% GC, p < 0.05) and anterior tibial translation (upslope, 0.7-4.1 mm, 3-54% GC & 0.6-2.1 mm, 80-94% GC; downslope, 1.0-2.2 mm, 21-69% GC) in the participants' knees. However, participants' other 4DOF knee kinematics during sloped walking were significantly different from those during level walking (p < 0.05). Participants had 'drastically changeable' knee kinematic alterations in the transverse and coronal plane (the other 4DOF knee kinematics) during sloped walking compared to level walking.

SIGNIFICANCE

Our results confirmed the hypothesis. Sloped walking significantly increased anterior tibial translation (in most GC) and flexion angle. These kinematic changes in healthy subjects should be evaluated and further explored for patients with knee diseases, such as anterior cruciate ligament deficiency. Our findings are meaningful for their rehabilitation or safety or knee health while walking on sloped surfaces. Our study may provide a pilot reference for the 6DOF knee kinematic exploration of sloped walking.

DeepBBWAE-Net: A CNN-RNN Based Deep SuperLearner For Estimating Lower Extremity Sagittal Plane Joint Kinematics Using Shoe-Mounted IMU Sensors In Daily Living

Measurement of human body movement is an essential step in biomechanical analysis. The current standard for human motion capture systems uses infrared cameras to track reflective markers placed on the subject. While these systems can accurately track joint kinematics, the analyses are spatially limited to the lab environment. Though Inertial Measurement Unit (IMU) can eliminate the spatial limitations of the motion capture system, those systems are impractical for use in daily living due to the need for many sensors, typically one per body segment. Due to the need for practical and accurate estimation of joint kinematics, this study implements a reduced number of IMU sensors and employs machine learning algorithm to map sensor data to joint angles. Our developed algorithm estimates hip, knee, and ankle angles in the sagittal plane using two shoe-mounted IMU sensors in different practical walking conditions: treadmill, level overground, stair, and slope conditions. Specifically, we proposed five deep learning networks that use combinations of Convolutional Neural Networks (CNN) and Gated Recurrent Unit (GRU) based Recurrent Neural Networks (RNN) as base learners for our framework. Using those five baseline models, we proposed a novel framework, DeepBBWAE-Net, that implements ensemble techniques such as bagging, boosting, and weighted averaging to improve kinematic predictions. DeepBBWAE-Net predicts joint kinematics for the three joint angles under all the walking conditions with a Root Mean Square Error (RMSE) 6.93-29.0% lower than base models individually. This is the first study that uses a reduced number of IMU sensors to estimate kinematics in multiple walking environments.

Masterclass: Hypermobility and hypermobility related disorders

INTRODUCTION

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

PURPOSE

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

IMPLICATIONS FOR PRACTICE

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

Advances in assessment of hypermobility-related disorders

There has been increasing recognition in recent years of the prevalence and impact of symptoms which extend beyond the musculoskeletal system on the lives of people with hypermobility-related disorders. This has led researchers to develop more comprehensive assessment tools to help direct and monitor treatment. This article presents some of the latest assessment and diagnostic developments and their implications for practice from a physical therapy perspective.

The Influence of Asymptomatic Hypermobility on Unanticipated Cutting Biomechanics

BACKGROUND

Generalized joint hypermobility is an important risk factor for knee injuries, including to the anterior cruciate ligament (ACL). Examining movement patterns specific to hypermobile individuals during sport-specific movements could facilitate development of targeted recommendations and injury prevention programs for this population.

HYPOTHESIS

Asymptomatic hypermobile participants will present kinematics measures suggestive of a greater risk of noncontact knee or ACL injuries.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Forty-two (15 asymptomatic hypermobile and 27 nonhypermobile) individuals performed unanticipated side-step cutting on their dominant and nondominant legs. Ankle, knee, hip, pelvis, and trunk angles in all planes of motion were collected during the first 100 ms after initial contact using a 3-dimensional infrared system. Precontact foot-ground angles were also extracted. Data from hypermobile and nonhypermobile groups were compared using multiple regression models with sex as a confounder. When nonsignificant, the confounder was removed from the model. Effect sizes (Hedge g) were calculated in the presence of significant between-group differences.

RESULTS

Hypermobile individuals presented with lower minimum knee valgus angles with a mean difference of 3.5° (P = 0.03, Hedge g = 0.69) and greater peak knee external rotation angles with a mean difference of -4.5° (P = 0.04, Hedge g = 0.70) during dominant leg cutting, and lower peak ankle plantarflexion angles with a mean difference of 4.5° (P = 0.03, Hedge g = 0.73) during nondominant leg cutting compared with nonhypermobile individuals.

CONCLUSIONS

Based on current scientific evidence, however, the identified differences are not crucial biomechanical injury risk factors that could predispose asymptomatic hypermobile individuals to noncontact knee or ACL injuries.

CLINICAL RELEVANCE

Further research is needed to highlight differences between hypermobility groups. Knowledge of the differences between these groups may change the physical activity recommendations, prevention of injury, and rehabilitation approaches.

No difference in knee muscle activation and kinematics during treadmill walking between adolescent girls with and without asymptomatic Generalised Joint Hypermobility

Background

Altered knee muscle activity in children with asymptomatic Generalized Joint Hypermobility (GJH) is reported during isometric contraction, static and dynamic balance tasks and jumping, but has not been studied during gait. Therefore, the aim was to investigate group differences in knee muscle activity simultaneously with knee joint kinematics during treadmill walking between children with and without GJH.

Methods

Girls 14–15 years of age with GJH (inclusion criteria: Beighton score ≥6 of 9 and positive hyperextension ≥10° (one/both knees)) and a matched control group without GJH (inclusion criteria: Beighton score ≤5 and no knee hyperextension ≥10° ) were recruited. In total 16 participants with GJH and 10 non-GJH participants were included in the study.

Surface electromyography (sEMG) was measured from the quadriceps, hamstrings and gastrocnemius muscles of the dominant leg during treadmill walking. Maximal voluntary isometric contractions while sitting were used for normalisation of sEMG to % of Maximum Voluntary EMG (%MVE). Knee joint angles during treadmill walking were measured by electrogoniometer. Furthermore, co-contraction index (CCI) was calculated, and presented for muscle groups of hamstrings-quadriceps (HQ) and gastrocnemius-quadriceps (GQ). CCI of medial and lateral sides of the knee, including ratio of the medial and lateral CCI for HQ and GQ were calculated.

Results

No group differences were found in demographics, muscle activation level, nor CCI and CCI ratios. However, participants with GJH displayed significantly decreased knee joint angle, mean (153º vs. 156º; p =0.03) and minimum (105º vs. 111º; p=0.01), during treadmill walking compared with controls.

Conclusion

Muscle activity during gait was not different between participants with GJH and non-GJH participants. However, participants with GJH displayed minor but statistically significant increased knee flexion during gait. Since the clinical consequences of increased knee joint flexion during gait are unknown, future studies should follow a larger cohort longitudinally during overground walking for development of clinical complications in this group.

Prevalence and dynamic characteristics of generalized joint hypermobility in college students

BACKGROUND

Generalized joint hypermobility (GJH) is a common, but often ignored, condition characterized by general joint laxity, which is reported to increase one's risk of anterior cruciate ligament (ACL) injury and osteoarthritis. Nevertheless, it is not clearly learned in the prevalence and dynamic characteristics in college students.

RESEARCH QUESTION

Is the active motion stability in the six-degree-of-freedom (6DOF) kinematics of the knee joint of people with GJH poorer than that of others?

METHODS

This is a cross-sectional study. A population of 489 college students was recruited who was divided into two groups: a GJH group (Beighton score ≥ 4, n = 54) and a normal group (Beighton score < 4, n = 435). A paper questionnaire with questions about the participants' demographic characteristics and musculoskeletal disorder symptoms was collected. A three-dimensional gait analysis system was used to collect the participants' knee joint kinematic parameters during treadmill walking. Variables were evaluated using independent t-tests and Wilcoxon signed-rank tests.

RESULTS

The prevalence of GJH was found to be 11.0 % among college students. Participants with GJH exhibited a greater active range of motions in the anterior/posterior translation than the normal (P =  0.026). Participants with GJH exhibited greater flexion at the end of the terminal stance (P = 0.039) and greater anterior translation of the tibia during almost the whole gait period than the normal group (P＜0.05) during the treadmill gait. A greater external angle was found in GJH group during the periods of middle stance (P = 0.008).

SIGNIFICANCE

GJH with a prevalence of 11.0 % among college students should be paid attention. Poor active motion stability in anterior/posterior translation may play an important role in the development of knee joint instability, potentially resulting in subsequent ACL deficiency and the development of knee osteoarthritis among people with GJH.

Recognizing and Effectively Managing Hypermobility-Related Conditions

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

Physical and mechanical therapies for lower limb symptoms in children with Hypermobility Spectrum Disorder and Hypermobile Ehlers-Danlos Syndrome: a systematic review

Background

Hypermobility Spectrum Disorder and Hypermobile Ehlers Danlos Syndrome are two common heritable genetic disorders of connective tissue. Both conditions are characterised by excessive joint range of motion and the presence of musculoskeletal symptoms, and are associated with joint instability, motion incoordination, decreased joint position sense, and musculoskeletal pain. Hypermobility Spectrum Disorder is the new classification for what was previously known as Joint Hypermobility Syndrome. This systematic review evaluates the evidence for physical and mechanical treatments for lower limb problems in children with Hypermobility Spectrum Disorder and Hypermobile Ehlers Danlos Syndrome.

Methods

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PUBMED and CINAHL were searched to October 2017 for randomised controlled trials (RCT) and quasi-RCTs evaluating physical and mechanical interventions for lower limb problems in children with hypermobility. Two authors independently screened studies for eligibility for inclusion and three review authors independently assessed risk of bias of included studies. One author extracted and analysed statistical data, which were checked by a second author.

Results

Two RCTs including a total of 86 participants were eligible for inclusion. Trials evaluated differences between generalised versus targeted physiotherapy programs and between performing knee extension exercises to the neutral versus hypermobile range. There was no clear benefit of any of the physical therapies evaluated.

Conclusion

There is very limited evidence to guide the use of physical and mechanical therapies for lower limb problems in children with Hypermobility Spectrum Disorder and Hypermobile Ehlers Danlos Syndrome. Mechanical therapies have not been evaluated in RCTs and results of the two RCTs of physical therapies do not definitively guide physical therapy prescriptions. Current studies are limited by small sample sizes and high attrition rates. No physical therapy has been compared to a sham intervention no intervention or no intervention, so overall effectiveness is unknown.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29874209.

FUNDING

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

Evaluating the immediate effects of wearing foot orthotics in children with Joint Hypermobility Syndrome (JHS) by analysis of temperospatial parameters of gait and dynamic balance: A preliminary study

Joint Hypermobility Syndrome (JHS) in children, presents with increased joint range of motion and can lead to altered gait strategies and reduced dynamic balance. Despite limited evidence foot orthoses are sometimes prescribed to patients with JHS with the aim to improve the stability of their gait pattern and theoretically reduce associated symptoms of fatigue and joint pain. The purpose of this study was therefore to analyse the immediate effects of 'off the shelf' orthoses on temporospatial parameters of gait and dynamic balance in this cohort.

METHODS

A total of 21 patients were recruited for the study (13 female) with a median age of 10 years (IRQ = 4.12). Each patient had their gait analysed using the GAITRite walkway in their own footwear and immediately after being prescribed the orthoses. Gait was tested at both the patients' preferred speed and when asked to walk slower to challenge their dynamic balance.

RESULTS

Gait appeared more synchronised, with a reduction in step length and width variability, when participants were provided with orthotics. The variation was greatest when participants were asked to walk slower. Double stance was significantly less at slower speeds when orthotics were added (1.61%, 95% CI = 0.34, 2.89, p = 0.015) CONCLUSION: Results of this study indicate that orthotics have a definite immediate influence on gait patterns in patients with JHS. Future studies should investigate the long-term effects of orthotics in this population and include outcome measures for symptoms such as pain.

The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos syndrome

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.

Development and initial validation of the Bristol Impact of Hypermobility questionnaire

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Reliability and minimal detectable change of gait kinematics in people who are hypermobile

OBJECTIVE

To evaluate intra- and inter-session reliability of gait data in hypermobile and normal adults, and from this, determine the minimum detectable change (MDC) through 3D gait analysis (GA) measurement.

METHODS

Thirteen people with normal flexibility (Beighton score 0.82 ± 1.2) and 14 hypermobile people (Beighton score 5.6 ± 1.6) completed three separate GA sessions. Lower limb joint kinematics were recorded in three planes of motion. Intra- and inter-session variability was calculated and compared using single factor ANOVA. MDC at 95% confidence level was calculated for the hypermobile cohort.

RESULTS

There was no significant difference between hypermobile and normal flexibility adults in intra- or inter-session variability for any parameters measured. For both groups, mean intra-session variability was under 2.0° for all joints in all three planes. Inter-session variability was greater; sagittal plane joint angles were most reliable, showing less than 3.0° variability for all joints. Frontal plane variability was below 3.5°. Highest variability was seen in internal/external rotation angles, with hip, knee and ankle showing 4.6°, 5.1° and 3.2° variability respectively. These reliability values are reflected in MDC results, with pelvis and sagittal plane joint angles showing the lowest MDCs.

CONCLUSIONS

In hypermobile people, 3DGA kinematic parameters are repeatable. Hypermobile people's joint laxity does not affect variability of their kinematic gait analysis measures. The results will help guide future clinical trial design; future work should ensure that differences expected to be observed are measurable, and exceed the MDC for a given parameter.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome (hypermobility type): it is a challenge

Generalized joint hypermobility (GJH) is highly prevalent among patients diagnosed with chronic pain. When GJH is accompanied by pain in ≥4 joints over a period ≥3 months in the absence of other conditions that cause chronic pain, the hypermobility syndrome (HMS) may be diagnosed. In addition, GJH is also a clinical sign that is frequently present in hereditary diseases of the connective tissue, such as the Marfan syndrome, osteogenesis imperfecta, and the Ehlers-Danlos syndrome. However, within the Ehlers-Danlos spectrum, a similar subcategory of patients having similar clinical features as HMS but lacking a specific genetic profile was identified: Ehlers-Danlos syndrome hypermobility type (EDS-HT). Researchers and clinicians have struggled for decades with the highly diverse clinical presentation within the HMS and EDS-HT phenotypes (Challenge 1) and the lack of understanding of the pathological mechanisms that underlie the development of pain and its persistence (Challenge 2). In addition, within the HMS/EDS-HT phenotype, there is a high prevalence of psychosocial factors, which again presents a difficult issue that needs to be addressed (Challenge 3). Despite recent scientific advances, many obstacles for clinical care and research still remain. To gain further insight into the phenotype of HMS/EDS-HT and its mechanisms, clearer descriptions of these populations should be made available. Future research and clinical care should revise and create consensus on the diagnostic criteria for HMS/EDS-HT (Solution 1), account for clinical heterogeneity by the classification of subtypes within the HMS/EDS-HT spectrum (Solution 2), and create a clinical core set (Solution 3).

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

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

Joint hypermobility syndrome: a review for clinicians

The term 'joint hypermobility' describes synovial joints that move beyond a normal range of motion. 'Joint hypermobilty syndrome' may also be associated with significant symptoms and impaired quality of life. The purpose of this review is to help the generalist to recognise the condition, exclude significant alternative diagnoses and understand the multidisciplinary approach to management.

Kinematics and kinetics of people who are hypermobile. A systematic review

There are many studies investigating movement in individuals with hypermobile joints such that it is timely to systematically review the literature. This review concerns studies of lower limb tasks that compared kinematics and kinetics of hypermobile people with healthy controls. Its aims were to determine the quality of research completed so far and to collate what information is available regarding these factors in order to identify gaps in knowledge and provide direction for future research. A systematic search of AMED, CINAHL, Embase and MEDLINE databases alongside hand searching identified six articles fulfilling the selection criteria. Quality was evaluated using a modified Downs & Black [1] 'Quality Index' checklist and data extraction undertaken. All six articles investigated gait. Two rated as low quality and four as moderate quality. One study was omitted from data extraction to avoid a possible duplication of results. Of the remaining studies, three investigated Generalised Joint Hypermobility and two investigated Joint Hypermobility Syndrome. Sixty seven different outcome measures were used across the studies to quantify differences in gait, and these are summarised. For some of the common factors studied, conflicting findings were reported. There is no convincing evidence that hypermobile gait differs from normal in a consistent manner, and in addition, confounding factors such as pain have not been addressed. Data-dredging may have been an issue in the reviewed articles, and future research would benefit by linking outcome measures to clinically relevant factors. There is a lack of research into any task other than gait.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Gait pattern in 9-11-year-old children with generalized joint hypermobility compared with controls; a cross-sectional study

Background

To study differences in gait patterns in 10-year-old children with Generalized Joint Hypermobility (GJH) and with no GJH (NGJH).

Methods

A total of 37 children participated (19 GJH, 18 NGJH, mean age 10.2 (SD 0.5) years). Inclusion criteria for GJH were a Beighton score of ≥5, with at least one hypermobile knee joint; for NGJH a Beighton score of ≤4, and no hypermobile knees and for both groups no knee pain during the previous week. All children were recorded by five video cameras, while they walked across three force platforms. Net joint moments were calculated in 3D by inverse dynamics and peak values provided input to statistical analyses.

Results

In the frontal plane, children with GJH had a significantly lower peak knee abductor moment and peak hip abductor moment. In the sagittal plane, the peak knee flexor moment and the peak hip extensor moment were significantly lower in the GJH group although the absolute difference was small.

Conclusions

The walking pattern was the same for children with GJH and for healthy children, as there were no differences in kinematics, but it was, however, performed with different kinetics. Children with GJH walked with lower ankle, knee and hip joint moments compared to children with NGJH. However, the clinical importance of these differences during normal gait is unknown. To obtain this knowledge, children with GJH must be followed longitudinally.

Trial registration

The study was approved by the Committee on Biomedical Research Ethics for Copenhagen and Frederiksberg, Denmark (jnr. KF01-2006-178).

Variables associated with performance of an active limb movement following within-session instruction in people with and people without low back pain

Modification of a movement pattern can be beneficial in decreasing low back pain (LBP) symptoms. There is variability, however, in how well people are able to modify performance of a movement. What has not been identified is the factors that may affect a person's ability to modify performance of a movement. We examined factors related to performance of active hip lateral rotation (HLR) following standardized instructions in people with and people without LBP. Data were collected during performance of HLR under 3 conditions: passive, active, and active instructed. In people with LBP, motion demonstrated during the passive condition (r = 0.873, P < 0.001), motion demonstrated during the active condition (r = 0.654, P = 0.008), and gender (r = 0.570, P = 0.027) were related to motion demonstrated during the active-instructed condition. Motion demonstrated during the passive condition explained 76% (P < 0.001) of the variance in motion demonstrated during the active-instructed condition. A similar relationship did not exist in people without LBP. The findings of the study suggest that it may be important to assess motion demonstrated during passive HLR to determine how difficult it will be for someone with LBP to modify the performance of HLR. Prognosis should be worst for those who display similar movement patterns during passive HLR and active-instructed HLR.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Australia & New Zealand Clinical Trials Registry; ACTRN12606000109505.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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