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Peebles KC, Jacobs C, Makaroff L, Pacey V. The use and effectiveness of exercise for managing postural orthostatic tachycardia syndrome in young adults with joint hypermobility and related conditions: A scoping review. Auton Neurosci 2024; 252:103156. [PMID: 38401460 DOI: 10.1016/j.autneu.2024.103156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/06/2024] [Accepted: 02/10/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. It may occur in isolation, but frequently co-exists in individuals with hypermobile variants of Ehlers-Danlos Syndrome (EDS) and related conditions (chronic fatigue syndrome [CFS] and fibromyalgia). Exercise is recommended for non-pharmacological POTS management but needs to be individualised. This scoping review explores the current literature on use and effectiveness of exercise-based management for POTS, with specific focus on individuals with joint hypermobility and related conditions who experience hypermobility, and/or pain, and/or fatigue. METHODS A systematic search, to January 2023, of Medline, EMBASE, AMED, CINAHL and the Cochrane library was conducted. Studies that reported on adolescents and adults who had been diagnosed with POTS using standard criteria and underwent an exercise-based training intervention were included. RESULTS Following full-text screening, 10 articles were identified (2 randomised control trials, 4 comparative studies and 4 case reports). One comparative study reported a small subset of participants with EDS and one case report included an individual diagnosed with CFS; the remainder investigated a wider POTS population. Overall, 3 months of endurance followed by resistance exercise, graduating from the horizontal-to-upright position reduced POTS symptoms and improved quality-of-life. CONCLUSION The findings highlight a paucity of higher-level studies documenting exercise for POTS management in people with joint hypermobility and related conditions. Results from the wider POTS population demonstrate exercise is safe and effective. Large, well-designed clinical studies exploring exercise for POTS management adapting to meet the complex musculoskeletal and non-musculoskeletal features of symptomatic joint hypermobility are needed.
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Affiliation(s)
- Karen C Peebles
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Charl Jacobs
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Logan Makaroff
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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2
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Wilson GN, Tonk VS. Clinical-Genomic Analysis of 1261 Patients with Ehlers-Danlos Syndrome Outlines an Articulo-Autonomic Gene Network (Entome). Curr Issues Mol Biol 2024; 46:2620-2643. [PMID: 38534782 DOI: 10.3390/cimb46030166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 03/28/2024] Open
Abstract
Systematic evaluation of 80 history and 40 history findings diagnosed 1261 patients with Ehlers-Danlos syndrome (EDS) by direct or online interaction, and 60 key findings were selected for their relation to clinical mechanisms and/or management. Genomic testing results in 566 of these patients supported EDS relevance by their differences from those in 82 developmental disability patients and by their association with general rather than type-specific EDS findings. The 437 nuclear and 79 mitochondrial DNA changes included 71 impacting joint matrix (49 COL5), 39 bone (30 COL1/2/9/11), 22 vessel (12 COL3/8VWF), 43 vessel-heart (17FBN1/11TGFB/BR), 59 muscle (28 COL6/12), 56 neural (16 SCN9A/10A/11A), and 74 autonomic (13 POLG/25porphyria related). These genes were distributed over all chromosomes but the Y, a network analogized to an 'entome' where DNA change disrupts truncal mechanisms (skin constraint, neuromuscular support, joint vessel flexibility) and produces a mirroring cascade of articular and autonomic symptoms. The implied sequences of genes from nodal proteins to hypermobility to branching tissue laxity or dysautonomia symptoms would be ideal for large language/artificial intelligence analyses.
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Affiliation(s)
- Golder N Wilson
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- KinderGenome Genetics Private Practice, 5347 W Mockingbird, Dallas, TX 75209, USA
| | - Vijay S Tonk
- Director of Medical Genetics and the Cytogenomic Laboratory, Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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Gibson D, Mehler PS. A new conceptual model for anorexia nervosa: A role for connective tissue? Int J Eat Disord 2024; 57:537-542. [PMID: 38372082 DOI: 10.1002/eat.24172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/20/2024]
Abstract
The etiology of anorexia nervosa (AN) remains to be fully elucidated, and current theories also fail to account for the direct effect of starvation on the health of the organs and tissues, specifically the connective tissue present in most organs of the body. Individuals with hereditary disorders of connective tissue manifest with clinical symptoms that overlap with AN, as the abnormal connective tissue also contributes to many of the other extra-articular manifestations of these hereditary disorders. This article hypothesizes that a similar pathophysiology may also contribute to the clinical presentation of AN. Therefore, a better understanding is needed to elucidate: (1) the relationship between abnormal connective tissue and AN, (2) the impact of starvation toward the development of abnormal connective tissue and how this manifests clinically, (3) the etiology of autonomic nervous system changes contributing to the dysautonomia in AN, and (4) how the sensory signals sent from potentially abnormal connective tissue to the central nervous system impact interoception in AN. A conceptual model incorporating abnormal connective tissue is provided. PUBLIC SIGNIFICANCE: The etiology of AN remains poorly understood and current theories fail to account for the direct impact of starvation on the health of the organs and tissues of the body. There is significant clinical overlap between AN and hereditary connective tissue disorders. This paper attempts to provide a new conceptual model for AN in which abnormal connective tissue contributes to the underlying pathogenesis.
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Affiliation(s)
- Dennis Gibson
- ACUTE Center for Eating Disorders and Severe Malnutrition at Denver Health, Denver, Colorado, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Philip S Mehler
- ACUTE Center for Eating Disorders and Severe Malnutrition at Denver Health, Denver, Colorado, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Eating Recovery Center, Denver, Colorado, USA
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Hertel A, Black WR, Walton LM, Martin JR, Jones JT. Cardiovascular Symptoms, Dysautonomia, and Quality of Life in Adult and Pediatric Patients with Hypermobile Ehlers-Danlos Syndrome: A Brief Review. Curr Cardiol Rev 2024; 20:CCR-EPUB-137768. [PMID: 38275067 PMCID: PMC11071672 DOI: 10.2174/011573403x271096231203164216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/09/2023] [Accepted: 10/25/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Hypermobile Ehlers-Danlos Syndrome (hEDS) is a connective tissue disorder characterized by joint hypermobility and other systemic manifestations, such as cardiovascular symptoms, musculoskeletal pain, and joint instability. Cardiovascular symptoms, such as lightheadedness and palpitations, and types of dysautonomia, including postural orthostatic tachycardia syndrome (POTS), are frequently reported in adults with hEDS and have been shown to negatively impact quality of life (QoL). OBJECTIVE This brief review will be an overview of co-occurring symptoms in POTS and hEDS to inform potential cardiovascular screening procedures. RESULTS While many patients with hEDS report cardiovascular symptoms, few have structural abnormalities, suggesting that dysautonomia is likely responsible for these symptoms. One validated screening measure for dysautonomia symptom burden is the Composite Autonomic Symptom Scale (COMPASS-31). Studies have found that adults with POTS, hEDS, and both POTS and hEDS have higher COMPASS-31 scores than the general population, suggesting a high symptom burden due to dysautonomia, which leads to impaired QoL. CONCLUSION While studies have examined cardiovascular symptoms and the impact of dysautonomia in adults with and without hEDS, there is scant literature on dysautonomia in pediatric patients with hEDS. Therefore, more studies on cardiovascular symptoms and dysautonomia, as they relate to the quality of life in pediatric patients with hEDS, are needed. This brief review summarizes the current literature on dysautonomia and cardiovascular symptoms in pediatric and adult populations with hEDS.
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Affiliation(s)
- Amanda Hertel
- School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - William R. Black
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University, Columbus, USA
| | - Lindsey Malloy Walton
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Julie R. Martin
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Jordan T. Jones
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Lynch-Jordan AM, Connelly M, Guite JW, King C, Goldstein-Leever A, Logan DE, Nelson S, Stinson JN, Ting TV, Wakefield EO, Williams AE, Williams SE, Kashikar-Zuck S. Clinical Characterization of Juvenile Fibromyalgia in a Multicenter Cohort of Adolescents Enrolled in a Randomized Clinical Trial. Arthritis Care Res (Hoboken) 2023; 75:1795-1803. [PMID: 36537193 DOI: 10.1002/acr.25077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/01/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Juvenile fibromyalgia (JFM) is a complex chronic pain condition that remains poorly understood. The study aimed to expand the clinical characterization of JFM in a large representative sample of adolescents with JFM and identify psychological factors that predict pain interference. METHODS Participants were 203 adolescents (ages 12-17 years) who completed baseline assessments for the multisite Fibromyalgia Integrative Training for Teens (FIT Teens) randomized control trial. Participants completed the Pain and Symptom Assessment Tool, which includes a Widespread Pain Index (WPI; 0-18 pain locations) and Symptom Severity checklist of associated somatic symptoms (SS; 0-12) based on the 2010 American College of Rheumatology criteria for fibromyalgia. Participants also completed self-report measures of pain intensity, functional impairment, and psychological functioning. RESULTS Participants endorsed a median of 11 painful body sites (WPI score) and had a median SS score of 9. Fatigue and nonrestorative sleep were prominent features and rated as moderate to severe by 85% of participants. Additionally, neurologic, autonomic, gastroenterologic, and psychological symptoms were frequently endorsed. The WPI score was significantly correlated with pain intensity and catastrophizing, while SS scores were associated with pain intensity and all domains of physical and psychological functioning. Depressive symptoms, fatigue, and pain catastrophizing predicted severity of pain impairment. CONCLUSION JFM is characterized by chronic widespread pain with fatigue, nonrestorative sleep, and other somatic symptoms. However, how diffusely pain is distributed appears less important to clinical outcomes and impairment than other somatic and psychological factors, highlighting the need for a broader approach to the assessment and treatment of JFM.
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Affiliation(s)
- Anne M Lynch-Jordan
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Christopher King
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Deirdre E Logan
- Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Sarah Nelson
- Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer N Stinson
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Tracy V Ting
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Emily O Wakefield
- University of Connecticut School of Medicine and Children's Medical Center, Hartford
| | - Amy E Williams
- Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana
| | - Sara E Williams
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Susmita Kashikar-Zuck
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Wilson GN. A Clinical Qualification Protocol Highlights Overlapping Genomic Influences and Neuro-Autonomic Mechanisms in Ehlers-Danlos and Long COVID-19 Syndromes. Curr Issues Mol Biol 2023; 45:6003-6023. [PMID: 37504295 PMCID: PMC10378515 DOI: 10.3390/cimb45070379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
A substantial fraction of the 15% with double-jointedness or hypermobility have the traditionally ascertained joint-skeletal, cutaneous, and cardiovascular symptoms of connective tissue dysplasia and its particular manifestation as Ehlers-Danlos syndrome (EDS). The holistic ascertainment of 120 findings in 1261 EDS patients added neuro-autonomic symptoms like headaches, muscle weakness, brain fog, chronic fatigue, dyspnea, and bowel irregularity to those of arthralgia and skin laxity, 15 of these symptoms shared with those of post-infectious SARS-CoV-2 (long COVID-19). Underlying articulo-autonomic mechanisms guided a clinical qualification protocol that qualified DNA variants in 317 genes as having diagnostic utility for EDS, six of them identical (F2-LIFR-NLRP3-STAT1-T1CAM1-TNFRSF13B) and eighteen similar to those modifying COVID-19 severity/EDS, including ADAMTS13/ADAMTS2-C3/C1R-IKBKG/IKBKAP-PIK3C3/PIK3R1-POLD4/POLG-TMPRSS2/TMPRSS6-WNT3/WNT10A. Also, contributing to EDS and COVID-19 severity were forty and three genes, respectively, impacting mitochondrial functions as well as parts of an overlapping gene network, or entome, that are hypothesized to mediate the cognitive-behavioral, neuro-autonomic, and immune-inflammatory alterations of connective tissue in these conditions. The further characterization of long COVID-19 natural history and genetic predisposition will be necessary before these parallels to EDS can be carefully delineated and translated into therapies.
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Affiliation(s)
- Golder N Wilson
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, and KinderGenome Genetics Private Practice, 5347 W Mockingbird, Dallas, TX 75209, USA
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Petracek LS, Broussard CA, Swope RL, Rowe PC. A Case Study of Successful Application of the Principles of ME/CFS Care to an Individual with Long COVID. Healthcare (Basel) 2023; 11:healthcare11060865. [PMID: 36981522 PMCID: PMC10048325 DOI: 10.3390/healthcare11060865] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Persistent fatigue is one of the most common symptoms of post-COVID conditions, also termed long COVID. At the extreme end of the severity spectrum, some individuals with long COVID also meet the criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), raising the possibility that symptom management approaches for ME/CFS may benefit some long COVID patients. We describe the long-term outcomes of a 19-year-old male who developed profound impairment consistent with ME/CFS after a SARS-CoV-2 infection early in the pandemic. We evaluated and treated him using our clinic’s approach to ME/CFS. This included a history and physical examination that ascertained joint hypermobility, pathological reflexes, physical therapy maneuvers to look for a range of motion restrictions in the limbs and spine, orthostatic testing, and screening laboratory studies. He was found to have profound postural tachycardia syndrome, several ranges of motion restrictions, and mast cell activation syndrome. He was treated according to our clinic’s guidelines for managing ME/CFS, which included manual physical therapy maneuvers and both non-pharmacologic measures and medications directed at postural tachycardia syndrome and mast cell activation. He experienced significant improvement in his symptoms over 30 months. His case emphasizes how the application of the principles of treating ME/CFS has the potential to provide a direction for treating long COVID.
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Affiliation(s)
| | | | | | - Peter C. Rowe
- Correspondence: ; Tel.: +1-410-955-9229; Fax: +1-410-614-1178
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Pietri-Toro JM, Gardner OK, Leuchter JD, DiBartolomeo G, Hunter JA, Forghani I. Prevalence of cardiovascular manifestations in patients with hypermobile Ehlers-Danlos syndrome at the University of Miami. Am J Med Genet A 2023; 191:1502-1507. [PMID: 36866504 DOI: 10.1002/ajmg.a.63168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/07/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
Cardiovascular system involvements have been frequently reported in hypermobile Ehlers-Danlos Syndrome (hEDS). Mitral valve prolapse (MVP) and aortic root dilatation are included in the 2017 international classification criteria for hEDS. Different studies have found conflicting results regarding the significance of cardiac involvement in hEDS patients. We conducted a retrospective review of cardiac involvement in patients diagnosed with hEDS based on the 2017 International diagnostic criteria to provide further evidence toward more defined and reliable diagnostic criteria and recommended cardiac surveillance. A total of 75 hEDS patients with at least one diagnostic cardiac evaluation were included in the study. The most common reported cardiovascular complaints were lightheadedness (80.6%), followed by palpitations (77.6%), fainting (44.8%), and chest pain (32.8%). Of the 62 echocardiogram reports, 57 (91.9%) showed trace/trivial to mild valvular insufficiency, and 13 (21%) had additional abnormalities such as grade I diastolic dysfunction, mild aortic sclerosis, and trivial or small pericardial effusion. Of the 60 electrocardiograms (ECG) reports, 39 (65%) were normal, and 21 (35%) reported minor abnormalities or normal variants. Even though many hEDS patients in our cohort experienced cardiac symptoms, the presence of a significant cardiac abnormality was very low.
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Affiliation(s)
- Jariselle M Pietri-Toro
- Department of Pediatrics, Holtz Children's Hospital/Jackson Health System, Miami, Florida, USA
| | - Olivia K Gardner
- Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
| | - Jessica D Leuchter
- Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
| | | | - Juanita A Hunter
- Department of Pediatrics, Holtz Children's Hospital/Jackson Health System, Miami, Florida, USA.,Miller School of Medicine, University of Miami, Coral Gables, Florida, USA
| | - Irman Forghani
- Miller School of Medicine, Department of Human Genetics, University of Miami, Coral Gables, Florida, USA
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Clarke JE, Reyes JM, Luther E, Govindarajan V, Leuchter JD, Niazi T, Ragheb J, Wang S. Chiari I malformation management in patients with heritable connective tissue disorders. World Neurosurg X 2023; 18:100173. [PMID: 36969375 PMCID: PMC10031113 DOI: 10.1016/j.wnsx.2023.100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
Background Chiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges. Objective This study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD. Methods Patients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26). Results 38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001). Conclusions Patients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.
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Igharo D, Thiel JC, Rolke R, Akkaya M, Weis J, Katona I, Schulz JB, Maier A. Skin biopsy reveals generalized small fibre neuropathy in hypermobile Ehlers-Danlos syndromes. Eur J Neurol 2023; 30:719-728. [PMID: 36437696 DOI: 10.1111/ene.15649] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Ehlers-Danlos syndromes are hereditary disorders of connective tissue that are characterized by joint hypermobility, skin hyperextensibility and tissue fragility. The most common subtype is the hypermobile type. In addition to symptoms of small fibre neuropathy (SFN) due to damage to the small peripheral nerve fibres, with degeneration of the distal nerve endings, autonomic disorders such as postural tachycardia syndrome (PoTS) are frequently reported features in patients with hypermobile Ehlers-Danlos syndrome (hEDS). To date, the underlying pathophysiological mechanisms are still not completely understood. STUDY PURPOSE To better understand pathophysiological mechanisms of small fiber neuropathy and autonomic neuropathy in hypermobile Ehlers-Danlos Syndromes. METHODS We prospectively investigated 31 patients with hEDS compared to 31 healthy controls by using skin biopsy, quantitative sensory testing, tilt-table testing, the painDetect, Small Fibre Neuropathy Screening List and the COMPASS-31 (Composite Autonomic Symptom Score 31) questionnaire. RESULTS Nineteen (61%) patients with hEDS were diagnosed with SFN, and 10 (32%) fulfilled the criteria for PoTS. Patients with hEDS had significantly higher heart rates than controls. According to quantitative sensory testing, these patients had generalized thermal and tactile hypesthesia. Skin biopsy revealed significantly reduced intraepithelial nerve fibre density proximally (thigh) and distally (lower leg) in patients compared to controls. This was consistent with various complaints of pain and sensory disturbances in both the proximal and distal body regions. CONCLUSION These results confirm histologically proven SFN as a common feature in patients with hEDS, revealing a generalized distribution of nerve fibre loss. Regarding the frequently reported autonomic and neuropathic dysfunctions, the findings support SFN as an important, but not the only, underlying pathomechanism.
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Affiliation(s)
- Denver Igharo
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joana C Thiel
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Merve Akkaya
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joachim Weis
- Institute of Neuropathology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Istvan Katona
- Institute of Neuropathology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Andrea Maier
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
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Yoshikawa Y, Koto T, Ishida T, Uehara T, Yamada M, Kosaki K, Inoue M. Rhegmatogenous Retinal Detachment in Musculocontractural Ehlers-Danlos Syndrome Caused by Biallelic Loss-of-Function Variants of Gene for Dermatan Sulfate Epimerase. J Clin Med 2023; 12:jcm12051728. [PMID: 36902515 PMCID: PMC10002920 DOI: 10.3390/jcm12051728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/12/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023] Open
Abstract
Musculocontractural Ehlers-Danlos syndrome, caused by biallelic loss-of-function variants for dermatan sulfate epimerase (mcEDS-DSE), is a rare connective tissue disorder. Eight patients with mcEDS-DSE have been described with ocular complications, including blue sclera, strabismus, high refractive errors, and elevated intraocular pressure. However, a case with rhegmatogenous retinal detachment (RRD) has not been reported. We report our findings in a 24-year-old woman who was diagnosed with mcEDS-DSE in childhood and presented to our clinic with an RRD in the left eye. The RRD extended to the macula and was associated with an atrophic hole. The patient underwent scleral buckling surgery and cryopexy with drainage of subretinal fluid through a sclerotomy under local anesthesia. The sclera did not appear blue but was very thin at the sclerotomy site. The patient developed frequent bradycardia during the surgery. Subretinal or choroidal hemorrhages were not observed intraoperatively; however, a peripapillary hemorrhage was observed one day after operation. The retina was reattached postoperatively, and the peripapillary hemorrhage was absorbed after one month. The peripapillary retinal hemorrhages, thin sclera, and bradycardia were most likely due to the fragility of the eye. The genetic diagnosis of mcEDS-DSE played an important role before and during the surgery by alerting the surgeons to possible surgical complications due to the thin sclera.
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Affiliation(s)
- Yuji Yoshikawa
- Kyorin Eye Center, School of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka 181-8611, Tokyo, Japan
- Department of Ophthalmology, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama, Iruma 350-0495, Saitama, Japan
| | - Takashi Koto
- Kyorin Eye Center, School of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka 181-8611, Tokyo, Japan
| | - Tomoka Ishida
- Kyorin Eye Center, School of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka 181-8611, Tokyo, Japan
| | - Tomoko Uehara
- Center for Medical Genetics, School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku, Tokyo 160-8582, Tokyo, Japan
| | - Mamiko Yamada
- Center for Medical Genetics, School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku, Tokyo 160-8582, Tokyo, Japan
| | - Kenjiro Kosaki
- Center for Medical Genetics, School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku, Tokyo 160-8582, Tokyo, Japan
| | - Makoto Inoue
- Kyorin Eye Center, School of Medicine, Kyorin University, 6-20-2 Shinkawa, Mitaka 181-8611, Tokyo, Japan
- Correspondence: ; Tel.: +81-422-47-55110 (ext. 2606); Fax: +81-422-46-9309
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Doolan BJ, Lavallee ME, Hausser I, Schubart JR, Michael Pope F, Seneviratne SL, Winship IM, Burrows NP. Extracutaneous features and complications of the Ehlers-Danlos syndromes: A systematic review. Front Med (Lausanne) 2023; 10:1053466. [PMID: 36756177 PMCID: PMC9899794 DOI: 10.3389/fmed.2023.1053466] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction The Ehlers-Danlos syndromes (EDS) comprise a group of inherited connective tissue disorders presenting with variable fragility to skin, soft tissue, and certain internal organs, which can cause significant complications, particularly arterial rupture, bowel perforation and joint difficulties. Currently, there are 14 proposed subtypes of EDS, with all except one subtype (hypermobile EDS) having an identified genetic etiology. An understanding of the extracutaneous features and complications within each subtype is key to maximizing clinical care and reducing the risk of further complications. Methods A systematic review of EDS-related extracutaneous features and complications was undertaken. Results We identified 839 EDS cases that met the inclusion criteria. We noted a high prevalence of joint hypermobility amongst kyphoscoliotic (39/39, 100%), spondylodysplastic (24/25, 96.0%), and hypermobile (153/160, 95.6%) EDS subtypes. The most common musculoskeletal complications were decreased bone density (39/43, 90.7%), joint pain (217/270, 80.4%), and hypotonia/weakness (79/140, 56.4%). Vascular EDS presented with cerebrovascular events (25/153, 16.3%), aneurysm (77/245, 31.4%), arterial dissection/rupture (89/250, 35.5%), and pneumothorax/hemothorax. Chronic pain was the most common miscellaneous complication, disproportionately affecting hypermobile EDS patients (139/157, 88.5%). Hypermobile EDS cases also presented with chronic fatigue (61/63, 96.8%) and gastrointestinal complications (57/63, 90.5%). Neuropsychiatric complications were noted in almost all subtypes. Discussion Understanding the extracutaneous features and complications of each EDS subtype may help diagnose and treat EDS prior to the development of substantial comorbidities and/or additional complications. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022308151, identifier CRD42022308151.
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Affiliation(s)
- Brent J. Doolan
- School of Basic and Medical Biosciences, St. John’s Institute of Dermatology, King’s College London, London, United Kingdom,*Correspondence: Brent J. Doolan,
| | - Mark E. Lavallee
- Department of Orthopedics, University of Pittsburgh Medical Center of Central PA, Pittsburgh, PA, United States
| | - Ingrid Hausser
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jane R. Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, United States
| | - F. Michael Pope
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust (West Middlesex University Hospital), London, United Kingdom
| | - Suranjith L. Seneviratne
- Institute of Immunity and Transplantation, Royal Free Hospital and University College London, London, United Kingdom,Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo, Sri Lanka
| | - Ingrid M. Winship
- Department of Genetic Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Nigel P. Burrows
- Department of Dermatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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13
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Orthostatic Intolerance and Chiari I Malformation. Neurosurg Clin N Am 2023; 34:43-54. [DOI: 10.1016/j.nec.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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14
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Petracek LS, Eastin EF, Rowe IR, Rowe PC. Orthostatic intolerance as a potential contributor to prolonged fatigue and inconsistent performance in elite swimmers. BMC Sports Sci Med Rehabil 2022; 14:139. [PMID: 35870963 PMCID: PMC9308026 DOI: 10.1186/s13102-022-00529-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022] Open
Abstract
Background Athletic underperformance is characterized by fatigue and an inability to sustain a consistent exercise workload. We describe five elite swimmers with prolonged fatigue and athletic underperformance. Based on our work in myalgic encephalomyelitis /chronic fatigue syndrome, we focused on orthostatic intolerance as a possible contributor to symptoms. Methods Participants were referred for evaluation of fatigue and underperformance to the Chronic Fatigue Clinic at the Johns Hopkins Children’s Center. All patients were evaluated for overtraining syndrome, as well as for features commonly seen in myalgic encephalomyelitis/chronic fatigue syndrome. The latter included joint hypermobility, orthostatic intolerance, and non-IgE mediated milk protein intolerance. Orthostatic intolerance was tested by performing a ten-minute passive standing test or a head-up tilt table test. Results Orthostatic testing provoked fatigue and other symptoms in all five swimmers, two of whom met heart rate criteria for postural tachycardia syndrome. Treatment was individualized, primarily consisting of an increased intake of sodium chloride and fluids to address orthostasis. All patients experienced a relatively prompt improvement in fatigue and other orthostatic symptoms and were able to either return to their expected level of performance or improve their practice consistency. Conclusions Orthostatic intolerance was an easily measured and treatable contributor to athletic underperformance in the five elite swimmers we describe. We suggest that passive standing tests or formal tilt table tests be incorporated into the clinical evaluation of athletes with fatigue and underperformance as well as into scientific studies of this topic. Recognition and treatment of orthostatic intolerance provides a new avenue for improving outcomes in underperforming athletes.
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Frangakis C, Kohler B, Georgiades CS. CT-Guided Celiac Ganglion Block for Neurogenic Gastrointestinal Dysmotility. J Vasc Interv Radiol 2022; 33:1492-1499. [PMID: 35995120 DOI: 10.1016/j.jvir.2022.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/02/2022] [Accepted: 08/12/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To determine whether celiac ganglion block can serve as a diagnostic test for dysautonomia as the cause of gastrointestinal dysmotility-related symptoms. MATERIALS AND METHODS This was an institutional review board-approved, prospective, single-arm, registered study, from January 2020 to May 2021, and included patients aged 14-85 years with gastrointestinal symptoms of food intolerance, abdominal pain, or angina. Patients with nonneurogenic causes (ie, chronic cholecystitis, peptic ulcer disease, gastroesophageal reflux, and malabsorption syndrome) were excluded. All 15 patients underwent computed tomography-guided celiac ganglion block with 100 mg of liposomal bupivacaine. Patients filled out the dysautonomia-validated questionnaire Composite Autonomic Symptom Score 31 (COMPASS-31) before and after intervention. Differences (before vs after) were compared with the exact permutation method. RESULTS Fifteen women (median age, 17 years; range, 14-41 years) were included. Average COMPASS-31 score improved significantly, from baseline 11 (SD ± 2.8) to 4 (SD ± 1.9) (improvement, 7 points ± 2.8; P < .001). All patients reported significant reduction in abdominal angina. Fourteen of the 15 patients (93%) reported complete resolution, and 14 of 15 (93%) reported a significant reduction in non-postprandial abdominal pain (P < .01). Only 1 patient reported no improvement. Eight of those 14 patients (57%) reported complete resolution of abdominal pain. There was a significant improvement in functional scores (vomiting, P = .01; constipation frequency, P = .02; constipation severity, P < .01; and nausea, P < .01). The rate of minor and major adverse events was 13% and 0%, respectively, per the Society of Interventional Radiology adverse event classification. CONCLUSIONS Celiac ganglion block is a safe diagnostic tool for confirming dysautonomia as the underlying condition in patients with gastrointestinal dysmotility-related symptoms. It could provide early diagnosis, lead to definitive treatment (ganglionectomy) earlier, or obviate unnecessary surgery.
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Affiliation(s)
| | - Beatriz Kohler
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | - Christos S Georgiades
- Division of Interventional Radiology, Johns Hopkins University, Baltimore, Maryland.
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16
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Ghoraba HH, Moshfeghi DM. Retinal arterial tortuosity in Ehlers-Danlos syndromes. Eye (Lond) 2022:10.1038/s41433-022-02278-x. [PMID: 36241846 DOI: 10.1038/s41433-022-02278-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/07/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To report a novel finding of retinal arterial tortuosity (RAT) associated with Ehlers-Danlos syndromes (EDS). METHODS We queried the STAnford Research Repository (STARR) database to identify patients diagnosed with EDS. We included patients with a confirmed diagnosis of any subtype of EDS who had any form of readable retinal imaging including colour fundus photos, autofluorescence, red-free photos, red-free optical coherence tomography photos and fluorescein angiography. Patients who had no retinal imaging and those with no confirmed EDS diagnosis were excluded. Retinal images were reviewed for RAT and were graded into no, possible and definite RAT. Eyes with definite RAT were further graded into mild, moderate and severe. Eyes with definite RAT were again subclassified according to the type of involved vessels into first-order arteriolar, macular and arteriovenous. RESULTS A total of 307 patients were identified using the STARR tool and 142 patients were included. Mean age was 40.9 ± 18.1 years and 87% were female. Underlying EDS subtypes were hypermobile EDS (69.7%), classical EDS (2.8%), vascular EDS (2.1%), myopathic EDS (0.7%) and not specified (24.6%). We graded 37.3% of patients with definite RAT, 10.6% with possible RAT and 52.1% with no RAT. In patients with definite RAT, we graded 39.2% of eyes with mild RAT, 40.2% with moderate RAT and 20.6% with severe RAT. In all, 84.9% showed involvement of first-order retinal arterioles, 35.8% showed involvement of macular arterioles and 1.9% showed arteriovenous involvement. CONCLUSIONS Variable degrees of RAT are associated with EDS.
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Affiliation(s)
- Hashem H Ghoraba
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Darius M Moshfeghi
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA.
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17
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Smith SJ, Sichlau M, Sewall LE, Smith BH, Chen B, Khurana N, Rowe PC. An online survey of pelvic congestion support group members regarding comorbid symptoms and syndromes. Phlebology 2022; 37:596-601. [PMID: 35831253 DOI: 10.1177/02683555221112567] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Patients with pelvic congestion syndrome (PCS) often report overlapping somatic symptoms and syndromes. The objective of this study was to explore the prevalence of co-existing symptoms and self-reported syndrome diagnoses among women with PCS and to inform future research hypotheses. Methods A brief online survey was offered to members of a PCS support group website. Responses were assessed for self-reported co-existing symptoms and formal diagnoses, including: chronic fatigue syndrome, fibromyalgia, postural tachycardia syndrome, irritable bowel syndrome, migraines, interstitial cystitis, and temporomandibular joint dysfunction. Results Of a total of 6000 members, there were 398 respondents; 232 (59%) had not yet been treated for PCS. Among these, the most prevalent co-existing symptoms were as follows: severe fatigue (72%), dizziness (63%), IBS symptoms (61%), brain fog (33%), migraines (49%), polyuria or dysuria (41%), excessive sweating (31%), TMJ pain (31%), and loose skin or lax joints (18%). These are much higher than reported for the general female population. The most commonly self-reported comorbid syndrome diagnoses for the overall group of 398 were: irritable bowel syndrome (29%), fibromyalgia (13%), spinal nerve problems (18%), interstitial cystitis (10%), postural tachycardia syndrome (9%), hypertension (11%), chronic fatigue syndrome (10%), and Ehlers-Danlos syndrome (6%). Other than with hypertension, these rates are variably higher than in the general population. Conclusion Several self-reported co-existing symptoms and syndromes are more prevalent in members of a PCS support group relative to the reported prevalence in the general population. More formal investigation is warranted to evaluate this finding and to investigate potential etiologic links. Ehlers-Danlos Syndrome appears to be common in self identifying PCS women.
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Affiliation(s)
- Steven J Smith
- Vascular and Interventional Professionals, LLC, Hinsdale, IL, USA
| | - Michael Sichlau
- Vascular and Interventional Professionals, LLC, Hinsdale, IL, USA
| | - Luke E Sewall
- Vascular and Interventional Professionals, LLC, Hinsdale, IL, USA
| | - B Holly Smith
- Center for the Advanced Study of Human Paleobiology, George Washington University, Washington, DC, USA
| | - Brenda Chen
- University of California, Los Angeles, CA, USA
| | - Neal Khurana
- Vascular and Interventional Specialists of Siouxland, Dakota Dunes, ND, USA
| | - Peter C Rowe
- Dept of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
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18
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Thwaites PA, Gibson PR, Burgell RE. Hypermobile Ehlers-Danlos syndrome and disorders of the gastrointestinal tract: What the gastroenterologist needs to know. J Gastroenterol Hepatol 2022; 37:1693-1709. [PMID: 35750466 PMCID: PMC9544979 DOI: 10.1111/jgh.15927] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 05/11/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Hypermobile Ehlers-Danlos syndrome (hEDS) and the hypermobility spectrum disorders (HSD) can be challenging to diagnose and manage. Gastrointestinal symptoms and disorders of gut-brain interaction are common in this cohort and multifactorial in origin. The primary aim of this review is to arm the gastroenterologist with a clinically useful understanding of HSD/hEDS, by exploring the association of gastrointestinal disorders with HSD/hEDS, highlighting current pathophysiological understanding and providing a pragmatic approach to managing these patients. METHODS Literature relevant to the gastrointestinal system and hypermobile Ehlers-Danlos syndrome was systematically searched, critically appraised, and summarized. RESULTS Diagnosis is based upon clinical criteria and a genetic basis is yet to be defined. The prevalence of many gut symptoms, including abdominal pain (69% vs 27%, P < 0.0001), postprandial fullness (34% vs 16%, P = 0.01), constipation (73% vs 16%, P < 0.001), and diarrhea (47% vs 9%, P < 0.001) are significantly higher in HSD/hEDS compared with non-HSD/hEDS individuals. Disorders of gut-brain interaction are also common, particularly functional dyspepsia. The pathophysiology of gut symptoms is poorly understood but may involve effects of connective tissue laxity and its functional consequences, and the influence of autonomic dysfunction, medication and comorbid mental health disorders. Awareness is the key to early diagnosis. Management is limited in evidence-base but ideally should include an integrated multidisciplinary approach. CONCLUSIONS HSD/hEDS is a multisystemic disorder in which gastrointestinal symptoms, particularly related to disorders of gut-brain interaction are common. Deficiencies in knowledge regarding the pathophysiological processes limit evidence-based interventions and remain important areas for future research.
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Affiliation(s)
- Phoebe A Thwaites
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - Rebecca E Burgell
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
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International Perspectives on Joint Hypermobility: A Synthesis of Current Science to Guide Clinical and Research Directions. J Clin Rheumatol 2022; 28:314-320. [PMID: 35661088 PMCID: PMC9422750 DOI: 10.1097/rhu.0000000000001864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT There is exponential clinical and research interest in joint hypermobility due to recognition of the complexity of identification, assessment, and its appropriate referral pathways, ultimately impacting management. This state-of-the-science review provides an international, multidisciplinary perspective on the presentation, etiology, and assessment of joint hypermobility, as it presents in those with and without a systemic condition. We synthesize the literature, propose standardizing the use of terminology and outcome measures, and suggest potential management directions. The major topics covered are (i) historical perspectives; (ii) current definitions of hypermobility, laxity, and instability; (iii) inheritance and acquisition of hypermobility; (iv) traditional and novel assessments; (v) strengths and limitations of current assessment tools; (vi) age, sex, and racial considerations; (vii) phenotypic presentations; (viii) generalized hypermobility spectrum disorder and hypermobility Ehlers-Danlos syndrome; and (ix) clinical implications and research directions. A thorough understanding of these topics will equip the reader seeking to manage individuals presenting with joint hypermobility, while mindful of its etiology. Management of generalized joint hypermobility in the context of a complex, multisystem condition will differ from that of acquired hypermobility commonly seen in performing artists, specific athletic populations, posttrauma, and so on. In addition, people with symptomatic hypermobility present predominantly with musculoskeletal symptoms and sometimes systemic symptoms including fatigue, orthostatic intolerance, and gastrointestinal or genitourinary issues. Some also display skeletal deformities, tissue and skin fragility, and structural vascular or cardiac differences, and these warrant further medical follow-up. This comprehensive review on the full spectrum of joint hypermobility will assist clinicians, coaches/sports trainers, educators, and/or researchers in this area.
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20
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De Baets S, De Temmerman M, Calders P, Malfait F, Van Hove G, Vanderstraeten G, De Wandele I, Van de Velde D. The Impact of Hypermobile “Ehlers-Danlos Syndrome” and Hypermobile Spectrum Disorder on Interpersonal Interactions and Relationships. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:832806. [PMID: 36188999 PMCID: PMC9397711 DOI: 10.3389/fresc.2022.832806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
Background People with Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders are hampered in their social participation, especially in the social relationships they have. Objective The aim of this study is to research the impact of hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobile Spectrum Disorders (HSD) on interpersonal interactions and relationships. Methods A phenomenological hermeneutic study was performed. Semi-structured interviews were used to explore the experiences of 11 participants. Results Four themes emerged from the data analysis. (1) people with hEDS or HSD can no longer do what they want to do and that affects their identity, (2) people with hEDS or HSD have to find a balance in the amount of activities they participate in, (3) having hEDS or HSD influences how to ask for, accept and give help, and (4) Relationships are affected in persons with hEDS or HSD. As well as changes in the social network, different types of relationships are influenced by the disease, including relationship with their partner, their children, their friends, strangers, fellow-sufferers and health care professionals.
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Affiliation(s)
- Stijn De Baets
- Occupational Therapy Research Group, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- *Correspondence: Stijn De Baets
| | - Marieke De Temmerman
- Occupational Therapy Research Group, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Fransiska Malfait
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Geert Van Hove
- Department of Special Needs Education, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Guy Vanderstraeten
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Inge De Wandele
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Dominique Van de Velde
- Occupational Therapy Research Group, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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21
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Peebles KC, Tan I, Butlin M, Collins F, Tofts L, Avolio AP, Pacey V. The prevalence and impact of orthostatic intolerance in young women across the hypermobility spectrum. Am J Med Genet A 2022; 188:1761-1776. [PMID: 35224842 PMCID: PMC9305471 DOI: 10.1002/ajmg.a.62705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/16/2022] [Accepted: 02/08/2022] [Indexed: 11/10/2022]
Abstract
Orthostatic intolerance (OI) is frequently reported in young women with generalized hypermobility spectrum disorder (G-HSD) and hypermobile EDS (hEDS). However, it remains currently unclear whether OI is a comorbidity or fundamental part of the pathophysiology of G-HSD or hEDS. This study investigated the prevalence and impact of OI in young women across the hypermobility spectrum. Forty-five women (14-30 years, 15 controls, 15 G-HSD, and 15 hEDS) undertook a head-up tilt (HUT) and active stand test. Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Hypotension (OH) were assessed using age-related criteria. Autonomic dysfunction and quality-of-life questionnaires were also completed. The prevalence of POTS was higher in women with G-HSD than hEDS and control groups during HUT (43% vs. 7% and 7%, respectively, p < 0.05), but similar between groups during the active stand (47%, 27%, and 13% for G-HSD, hEDS, and control, respectively). No participants had OH. hEDS and G-HSD participants reported more severe orthostatic symptoms and poorer quality of life than controls. Although POTS was observed in hypermobile participants, there is no conclusive evidence that its prevalence differed between groups due to differences between the HUT and active stand assessments. Nevertheless, OI and broader autonomic dysfunction impacted on their quality of life.
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Affiliation(s)
- Karen C Peebles
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Isabella Tan
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Mark Butlin
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Felicity Collins
- Department of Medical Genomics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Louise Tofts
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Narrabeen Sports and Exercise Medicine Centre, Sydney, Australia
| | - Alberto P Avolio
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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22
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Masterclass: Hypermobility and hypermobility related disorders. Musculoskelet Sci Pract 2022; 57:102465. [PMID: 34808594 DOI: 10.1016/j.msksp.2021.102465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/27/2021] [Accepted: 10/10/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Hypermobile joints display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility may present in a single joint, a few joints or in multiple joints and may be congenital or acquired with training, disease or injury. Hypermobile joints may be asymptomatic or may be associated with pain, fatigue, multisystemic complaints and significant disability. Furthermore, joint hypermobility may be a sign of an underlying hereditary disorder of connective tissue. PURPOSE This masterclass aims to provides a state-of-the-art review of the aetiology, epidemiology, clinical presentation, assessment and management of joint hypermobility and hypermobility related disorders using an evidence based and biopsychosocial approach. The new framework for classifying the spectrum of joint hypermobility disorders along with new diagnostic criteria for the hypermobile Ehlers Danlos syndrome, published by an international consortium of clinical experts and researchers in 2017 is integrated into the paper. IMPLICATIONS FOR PRACTICE People with joint hypermobility related disorders present to healthcare professionals with a wide range of symptoms which extend beyond the musculoskeletal system. Early recognition and treatment are key to effective management. A biopsychosocial and patient empowerment approach to functional restoration is recommended.
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23
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Williams SE, Tran ST, Lynch-Jordan A, Goldschneider KR, Ting TV, Kashikar-Zuck S, Neilson D. Healthcare utilization among youth with Ehlers-Danlos syndrome hypermobile type. Am J Med Genet A 2022; 188:1109-1117. [PMID: 34989147 DOI: 10.1002/ajmg.a.62625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/31/2021] [Accepted: 12/11/2021] [Indexed: 01/27/2023]
Abstract
Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited disorders of connective tissue. EDS hypermobility type (EDS-HT), characterized by joint hypermobility, is most common and increasingly recognized in pediatrics. Treatment involves protecting joints, preventing injuries, and managing symptoms/comorbidities. Pediatric EDS-HT patients often see multiple medical providers; however, data on healthcare utilization (HCU) in this population are lacking. This retrospective, electronic chart review examines HCU data 1 year prior and subsequent to a new diagnosis of EDS-HT using Villefranche criteria. Demographics, diagnoses, and HCU (office visits, therapies, hospital encounters/procedures, and tests) were obtained for N = 102 youth attending a Connective Tissue Disorder Clinic over a 21-month timeframe. After EDS-HT diagnosis, HCU patterns shifted to reflect greater involvement of therapy (physical, psychological, and occupational) and symptom management. More genetics, rheumatology, and orthopedics visits occurred prediagnosis, and more physical therapy, pain management, cardiology, and neurology visits occurred postdiagnosis. Testing and hospital encounter/procedure frequencies did not change. Overall, the pattern of HCU changed from diagnostic to treatment, in accordance with evidence-based EDS-HT care. Understanding HCU patterns of pediatric patients with EDS-HT can elucidate patient interaction with the health care system, with the potential to inform and improve the standard of care.
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Affiliation(s)
- Sara E Williams
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Susan T Tran
- Department of Psychology, DePaul University, Chicago, Illinois, USA
| | - Anne Lynch-Jordan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Pain Management Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kenneth R Goldschneider
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Pain Management Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tracy V Ting
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Susmita Kashikar-Zuck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Pain Management Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Derek Neilson
- Department of Genetics, Phoenix Children's, Phoenix, Arizona, USA
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24
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Csecs JLL, Dowell NG, Savage GK, Iodice V, Mathias CJ, Critchley HD, Eccles JA. Variant connective tissue (joint hypermobility) and dysautonomia are associated with multimorbidity at the intersection between physical and psychological health. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2021; 187:500-509. [PMID: 34806825 DOI: 10.1002/ajmg.c.31957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/26/2021] [Accepted: 11/09/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Jenny L L Csecs
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Nicholas G Dowell
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - Georgia K Savage
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, UK.,UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Christopher J Mathias
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, UK.,UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Neurovascular Medicine (Pickering Unit), St Mary's Hospital, Imperial College London, London, UK
| | - Hugo D Critchley
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Jessica A Eccles
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
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25
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Kolacz J, Kovacic K, Lewis GF, Sood MR, Aziz Q, Roath OR, Porges SW. Cardiac autonomic regulation and joint hypermobility in adolescents with functional abdominal pain disorders. Neurogastroenterol Motil 2021; 33:e14165. [PMID: 33991431 DOI: 10.1111/nmo.14165] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Joint hypermobility (JH) is associated with autonomic nervous system dysregulation and functional abdominal pain disorders (FAPDs). Understanding the neurophysiological processes linking these conditions can inform clinical interventions. Autonomic activity regulates gastrointestinal (GI) sensorimotor function and may be a key mechanism. The aims of this study were to examine the relation of JH with dynamic autonomic activity and parasympathetic regulation in adolescents with FAPDs and identify optimal JH cutoff scores that best index autonomic regulation in FAPDs. METHODS A total of 92 adolescents with FAPDs and 27 healthy controls (age 8-18 years; 80% female) were prospectively enrolled. JH was assessed by Beighton scores. ECG recordings were conducted during supine, sitting, and standing posture challenges. ECG-derived variables-heart period (HP), respiratory sinus arrhythmia (RSA), and vagal efficiency (VE)-were analyzed using linear regression and mixed effects modeling. KEY RESULTS Beighton scores of ≥4 optimally distinguished autonomic function. Adolescents with FAPD and JH had reduced VE compared to adolescents with FAPDs without JH (B = 18.88, SE = 6.25, p = 0.003) and healthy controls (B = 17.56, SE = 8.63, p = 0.044). These subjects also had lower and less dynamic RSA and HP values during posture shifts, with strongest differences in supine position and using the VE metric. CONCLUSIONS & INFERENCES Suboptimal autonomic regulation indexed by reduced vagal efficiency may be a mechanism of symptoms in hypermobile FAPD patients with Beighton score ≥ 4. Autonomic disturbance may serve as potential intervention target for patients with JH and functional GI disorders.
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Affiliation(s)
- Jacek Kolacz
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Traumatic Stress Research Consortium, Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Katja Kovacic
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Gregory F Lewis
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Intelligent Systems Engineering, Indiana University, Bloomington, IN, USA
| | - Manu R Sood
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Qasim Aziz
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Olivia R Roath
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Stephen W Porges
- Traumatic Stress Research Consortium, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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26
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Mittal N, Santa Mina D, Buryk-Iggers S, Lopez-Hernandez L, Hussey L, Franzese A, Katz J, Laflamme C, McGillis L, McLean L, Rachinsky M, Rozenberg D, Slepian M, Weinrib A, Clarke H. The GoodHope Exercise and Rehabilitation (GEAR) Program for People With Ehlers-Danlos Syndromes and Generalized Hypermobility Spectrum Disorders. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:769792. [PMID: 36188836 PMCID: PMC9397788 DOI: 10.3389/fresc.2021.769792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022]
Abstract
Introduction: The Ehlers-Danlos Syndromes (EDS) and Generalized Hypermobility Spectrum Disorders (G-HSD) comprise a heterogeneous group of genetic disorders of abnormal synthesis and/or maturation of collagen and other matricellular proteins. EDS is commonly characterized by manifestations such as multi joint hypermobility that can lead to musculoskeletal pains, subluxations and dislocations, fragile skin, organ dysfunction, and chronic significant diffuse pain with fatigue, deconditioning eventuating to poor quality of life. Evidence suggests exercise and rehabilitation interventions may ameliorate symptoms of unstable joints, recurrent subluxations/dislocations, and chronic widespread musculoskeletal pain. To date, there have only been a few reports describing exercise and rehabilitation care strategies for people with EDS. Methods: In this manuscript, we describe the GoodHope Exercise and Rehabilitation (GEAR) program, its overarching principles, as well as the program development and delivery model. The GEAR program aims to decrease functional impairment, reduce pain, increase confidence in symptom self-management, and provide a community of support for people with EDS/G-HSD. To achieve these goals, we detail the model of care that includes exercise and rehabilitation therapy, education for self-management, and support accessing relevant community resources. Strengths and Limitations of the Study: GEAR represents a novel exercise and rehabilitation care model for people with G-HSD and various clinical EDS subtypes, beyond the commonly included hEDS subtype. Systematic collection of data via validated measurements is ongoing and will guide the refinement of GEAR and support the development of emerging exercise and rehabilitation programs for people with EDS.
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Affiliation(s)
- Nimish Mittal
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- *Correspondence: Nimish Mittal
| | - Daniel Santa Mina
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stephanie Buryk-Iggers
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Laura Hussey
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Alyssa Franzese
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Joel Katz
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Psychology, Faculty of Health, York University, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Camille Laflamme
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Lianne McLean
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Dmitry Rozenberg
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Respirology, Temerty Faculty of Medicine, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Maxwell Slepian
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Aliza Weinrib
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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27
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Starling CT, Nguyen QBD, Butler IJ, Numan MT, Hebert AA. Cutaneous manifestations of orthostatic intolerance syndromes. Int J Womens Dermatol 2021; 7:471-477. [PMID: 34621961 PMCID: PMC8484984 DOI: 10.1016/j.ijwd.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/05/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
| | - Quoc-Bao D Nguyen
- Department of Dermatology, UTHealth McGovern Medical School at Houston, Houston, Texas
| | - Ian J Butler
- Department of Pediatrics, UTHealth McGovern Medical School at Houston, Houston, Texas
| | - Mohammed T Numan
- Department of Pediatrics, UTHealth McGovern Medical School at Houston, Houston, Texas
| | - Adelaide A Hebert
- Department of Dermatology, UTHealth McGovern Medical School at Houston, Houston, Texas.,Department of Pediatrics, UTHealth McGovern Medical School at Houston, Houston, Texas
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28
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[Tachycardia and syncope in a 15-year-old teenager]. Herzschrittmacherther Elektrophysiol 2021; 32:425-428. [PMID: 34553241 DOI: 10.1007/s00399-021-00805-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
Patients with highly symptomatic tachycardia may suffer significantly; in addition to a standardized rule-out of structural heart disease, secondary causes need to be excluded. Disorders such as inappropriate sinus tachycardia and postural tachycardia syndrome are caused by cardiac autonomic dysregulation which may be part of a rare underlying noncardiac disease.
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29
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Do T, Diamond S, Green C, Warren M. Nutritional Implications of Patients with Dysautonomia and Hypermobility Syndromes. Curr Nutr Rep 2021; 10:324-333. [PMID: 34510391 PMCID: PMC8435108 DOI: 10.1007/s13668-021-00373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 08/30/2023]
Abstract
PURPOSE OF REVIEW Dysautonomia and hypermobility syndrome are two distinct but often overlapping clinical conditions that are recognized for their complex multiorgan system afflictions. The purpose of this review is to investigate dietary strategies to reduce symptoms and augment quality of life in this growing patient population. RECENT FINDINGS There is increasing evidence supporting dietary modifications to include food rich in probiotics and prebiotics, along with fiber supplements to reduce gastrointestinal symptoms. Adequate salt and fluid intake may reduce orthostatic hypotension symptoms. Dietary supplements may help with osteoarticular, musculoskeletal, and fatigue symptoms. Individualized diet strategies and supplements can reduce the multiorgan system symptoms observed in dysautonomia and hypermobility syndrome.
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Affiliation(s)
- Toan Do
- Internal Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Sarah Diamond
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Caitlin Green
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Malissa Warren
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
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30
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Ruiz Maya T, Fettig V, Mehta L, Gelb BD, Kontorovich AR. Dysautonomia in hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders is associated with exercise intolerance and cardiac atrophy. Am J Med Genet A 2021; 185:3754-3761. [PMID: 34331416 DOI: 10.1002/ajmg.a.62446] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/16/2021] [Accepted: 07/16/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Tania Ruiz Maya
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Veronica Fettig
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lakshmi Mehta
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce D Gelb
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy R Kontorovich
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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31
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Raj SR, Bourne KM, Stiles LE, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Diedrich A, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Darbari A, Vernino S. Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting - Part 2. Auton Neurosci 2021; 235:102836. [PMID: 34246578 PMCID: PMC8455430 DOI: 10.1016/j.autneu.2021.102836] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
The National Institutes of Health hosted a workshop in 2019 to build consensus around the current state of understanding of the pathophysiology of postural orthostatic tachycardia syndrome (POTS) and to identify knowledge gaps that must be addressed to enhance clinical care of POTS patients through research. This second (of two) articles summarizes current knowledge gaps, and outlines the clinical and research priorities for POTS. POTS is a complex, multi-system, chronic disorder of the autonomic nervous system characterized by orthostatic intolerance and orthostatic tachycardia without hypotension. Patients often experience a host of other related disabling symptoms. The functional and economic impacts of this disorder are significant. The pathophysiology remains incompletely understood. Beyond the significant gaps in understanding the disorder itself, there is a paucity of evidence to guide treatment which can contribute to suboptimal care for this patient population. The vast majority of physicians have minimal to no familiarity or training in the assessment and management of POTS. Funding for POTS research remains very low relative to the size of the patient population and impact of the syndrome. In addition to efforts to improve awareness and physician education, an investment in research infrastructure including the development of standardized disease-specific evaluation tools and outcome measures is needed to facilitate effective collaborative research. A national POTS research consortium could facilitate well-controlled multidisciplinary clinical research studies and therapeutic trials. These priorities will require a substantial increase in the number of research investigators and the amount of research funding in this area.
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Affiliation(s)
- Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kate M Bourne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA; Dysautonomia International, East Moriches, NY, USA
| | - Mitchell G Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Amanda J Miller
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, USA; Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Italo Biaggioni
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andre Diedrich
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David M Systrom
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Glen A Cook
- Department of Neurology, Uniformed Services University, Bethesda, MD, USA
| | - Taylor A Doherty
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | | | - Blair P Grubb
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, USA
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Julian M Stewart
- Center for Hypotension, Departments of Pediatrics and Physiology, New York Medical College, Valhalla, NY USA
| | - Amy C Arnold
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Laura A Pace
- Center for Genomic Medicine and Department of Pediatrics, Division of Medical Genetics and Genomics, University of Utah, Salt Lake City, UT, USA
| | - Jonas Axelsson
- Department of Clinical Immunology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jeffrey P Moak
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Brent P Goodman
- Neuromuscular Division, Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Kamal R Chémali
- Department of Neurology, Eastern Virginia Medical School, Division of Neurology, Neuromuscular and Autonomic Center, Sentara Healthcare, Norfolk, VA, USA
| | - Tae H Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Anil Darbari
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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32
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Eccles JA, Thompson B, Themelis K, Amato ML, Stocks R, Pound A, Jones AM, Cipinova Z, Shah-Goodwin L, Timeyin J, Thompson CR, Batty T, Harrison NA, Critchley HD, Davies KA. Beyond bones: The relevance of variants of connective tissue (hypermobility) to fibromyalgia, ME/CFS and controversies surrounding diagnostic classification: an observational study. Clin Med (Lond) 2021; 21:53-58. [PMID: 33479068 DOI: 10.7861/clinmed.2020-0743] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fibromyalgia and myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) are poorly understood conditions with overlapping symptoms, fuelling debate as to whether they are manifestations of the same spectrum or separate entities. Both are associated with hypermobility, but this remains significantly undiagnosed, despite impact on quality of life. OBJECTIVE We planned to understand the relevance of hypermobility to symptoms in fibromyalgia and ME/CFS. METHOD Sixty-three patient participants presented with a confirmed diagnosis of fibromyalgia and/or ME/CFS; 24 participants were healthy controls. Patients were assessed for symptomatic hypermobility. RESULTS Evaluations showed exceptional overlap in patients between fibromyalgia and ME/CFS, plus 81% met Brighton criteria for hypermobility syndrome (odds ratio 7.08) and 18% met 2017 hypermobile Ehlers-Danlos syndrome (hEDS) criteria. Hypermobility scores significantly predicted symptom levels. CONCLUSION Symptomatic hypermobility is particularly relevant to fibromyalgia and ME/CFS, and our findings highlight high rates of mis-/underdiagnosis. These poorly understood conditions have a considerable impact on quality of life and our observations have implications for diagnosis and treatment targets.
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Affiliation(s)
- Jessica A Eccles
- Brighton and Sussex Medical School, Falmer, UK, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK and Sussex Partnership Foundation NHS Trust, Brighton, UK
| | | | | | | | | | - Amy Pound
- Brighton and Sussex Medical School, Falmer, UK and Sussex Partnership Foundation NHS Trust, Brighton, UK
| | | | - Zdenka Cipinova
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Jean Timeyin
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Charlotte R Thompson
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK and Brighton and Sussex Medical School, Falmer, UK
| | - Thomas Batty
- Brighton and Sussex Medical School, Falmer, UK and Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Neil A Harrison
- Brighton and Sussex Medical School, Falmer, UK and Cardiff University Brain Research Imaging Centre, Cardiff, UK
| | - Hugo D Critchley
- Brighton and Sussex Medical School, Falmer, UK, University of Sussex, Falmer and Sussex Partnership Foundation NHS Trust, Brighton, UK
| | - Kevin A Davies
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK and Brighton and Sussex Medical School, Falmer, UK
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33
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Martinez KL, Mauss C, Andrews J, Saboda K, Huynh JM, Sanoja AJ, Jesudas R, Byers PH, Laukaitis CM. Subtle differences in autonomic symptoms in people diagnosed with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders. Am J Med Genet A 2021; 185:2012-2025. [PMID: 33826221 DOI: 10.1002/ajmg.a.62197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 02/09/2021] [Accepted: 02/26/2021] [Indexed: 12/31/2022]
Abstract
The hypermobile Ehlers-Danlos syndrome (hEDS) GENE study is a multicenter, cohort study with the goal to identify genes associated with hypermobile EDS. Of the 148 people enrolled in the hEDS GENE study, 98 meet the 2017 hEDS criteria, 27 have a hypermobility spectrum disorder (HSD) and 23 are asymptomatic family members. More than 80% of participants are female with an average age of 41 years. Each participant has completed seven questionnaires to quantify disease-related symptomatology. People with hypermobility experience a variety of physical and somatic symptoms, especially in the areas of fatigue, kinesiophobia, gastrointestinal, and autonomic function. These cause a significant decrease in health-related quality of life. The frequency and severity of most symptoms were indistinguishable between participants with hEDS and HSD; however, there were significant differences in autonomic symptoms. Less than 20% of participants had autoantibodies known to be associated with dysautonomia. Subtle symptomatic differences in people meeting the 2017 diagnostic criteria suggest focusing further etiologic studies on autonomic pathways.
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Affiliation(s)
- Kiana L Martinez
- Genetics Graduate Interdisciplinary Program, University of Arizona, Tucson, Arizona, USA
| | - Corina Mauss
- Arizona Cancer Center, University of Arizona, Tucson, Arizona, USA.,Department of Medicine, University of Arizona, Tucson, Arizona, USA.,Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
| | - Jennifer Andrews
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
| | - Kathylynn Saboda
- Arizona Cancer Center, University of Arizona, Tucson, Arizona, USA
| | - Julie M Huynh
- College of Medicine, University of Arizona, Tucson, Arizona, USA
| | | | - Rohith Jesudas
- St. Jude's Children's Research Hospital, Memphis, Tennessee, USA
| | - Peter H Byers
- Departments of Pathology and Medicine, University of Washington, Seattle, Washington, USA
| | - Christina M Laukaitis
- Arizona Cancer Center, University of Arizona, Tucson, Arizona, USA.,Department of Medicine, University of Arizona, Tucson, Arizona, USA
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Henderson FC, Rowe PC, Narayanan M, Rosenbaum R, Koby M, Tuchmann K, Francomano CA. Refractory Syncope and Presyncope Associated with Atlantoaxial Instability: Preliminary Evidence of Improvement Following Surgical Stabilization. World Neurosurg 2021; 149:e854-e865. [PMID: 33540088 DOI: 10.1016/j.wneu.2021.01.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The proclivity to atlantoaxial instability (AAI) has been widely reported for conditions such as rheumatoid arthritis and Down syndrome. Similarly, we have found a higher than expected incidence of AAI in hereditary connective tissue disorders. We demonstrate a strong association of AAI with manifestations of dysautonomia, in particular syncope and lightheadedness, and make preliminary observations as to the salutary effect of surgical stabilization of the atlantoaxial motion segment. METHODS In an institutional review board-approved retrospective study, 20 subjects (16 women, 4 men) with hereditary connective tissue disorders had AAI diagnosed by computed tomography. Subjects underwent realignment (reduction), stabilization, and fusion of the C1-C2 motion segment. All subjects completed preoperative and postoperative questionnaires in which they were asked about performance, function, and autonomic symptoms, including lightheadedness, presyncope, and syncope. RESULTS All patients with AAI reported lightheadedness, and 15 had refractory syncope or presyncope despite maximal medical management and physical therapy. Postoperatively, subjects reported a statistically significant improvement in lightheadedness (P = 0.003), presyncope (P = 0.006), and syncope (P = 0.03), and in the frequency (P < 0.05) of other symptoms related to autonomic function, such as nausea, exercise intolerance, palpitations, tremors, heat intolerance, gastroesophageal reflux, and sleep apnea. CONCLUSIONS This study draws attention to the potential for AAI to present with syncope or presyncope that is refractory to medical management, and for surgical stabilization of AAI to lead to improvement of these and other autonomic symptoms.
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Affiliation(s)
- Fraser C Henderson
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, Maryland, USA; Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA; Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA.
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Malini Narayanan
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, Maryland, USA; Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA; Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA
| | - Robert Rosenbaum
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, Maryland, USA; Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA; Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA; Department of Neurosurgery, Walter Reed-Bethesda National Military Medical Center, Bethesda, Maryland, USA
| | - Myles Koby
- Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA
| | - Kelly Tuchmann
- Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Prevalence of joint hypermobility syndromes in pediatric postural orthostatic tachycardia syndrome. Auton Neurosci 2021; 231:102770. [PMID: 33388686 DOI: 10.1016/j.autneu.2020.102770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/12/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patients with postural orthostatic tachycardia syndrome (POTS) have been shown to exhibit comorbid joint hypermobility manifested as Ehlers-Danlos syndrome (EDS) or hypermobility spectrum disorder (HSD). The prevalence of EDS and HSD in POTS has been demonstrated in smaller studies combining adult and pediatric patients. We examined a large series of pediatric patients to determine their prevalence in children with POTS. MATERIALS AND METHODS Patients 18 years old, or less, at initial evaluation at our clinic were included. POTS was diagnosed based on at least six months of frequent debilitating symptoms of orthostatic intolerance, plus a consistent heart rate increase of at least 40 beats per minute without orthostatic hypotension on standing test. Patients with a Beighton score of at least 5/9 plus other systemic findings suggestive of EDS were further evaluated in Connective Tissue Disorders clinics. RESULTS There were 362 patients meeting inclusion criteria, of which 82 patients had EDS (22.7%) and 141 patients had HSD (39.0%). Patients with EDS had an earlier median age at symptom onset (12.1 vs. 13.5 years, p=0.004) and longer median symptom duration (2.5 vs. 1.5 years, p=0.0008) compared to patients without hypermobility. CONCLUSIONS Our evaluation of a large series of pediatric patients with POTS revealed that over one-fifth of patients had EDS and over one-third of patients had HSD. The awareness of the prevalence of comorbidities such as hypermobility disorders may help inform providers diagnosing and caring for these patients.
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Tai FWD, Palsson OS, Lam CY, Whitehead WE, Sperber AD, Tornblom H, Simren M, Aziz I. Functional gastrointestinal disorders are increased in joint hypermobility-related disorders with concomitant postural orthostatic tachycardia syndrome. Neurogastroenterol Motil 2020; 32:e13975. [PMID: 32803794 DOI: 10.1111/nmo.13975] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Individuals with hypermobility spectrum disorders/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) frequently fulfill criteria for Rome IV functional gastrointestinal disorders (FGIDs). Postural orthostatic tachycardia syndrome (POTS) is also commonly reported in HSD/hEDS and may impact on co-morbidity with and severity of FGIDs, although this remains to be studied. We determined the impact of concomitant POTS and HSD/hEDS on their association with Rome IV FGIDs. METHODS With the help of the charity organization Ehlers-Danlos Support UK, an online cross-sectional health survey was completed by individuals with HSD/hEDS. The survey enquired for (a) self-reported doctor diagnosis of POTS, chronic fatigue syndrome, and fibromyalgia, (b) the presence and symptom frequency of Rome IV FGIDs, and (c) anxiety and depression scores. KEY RESULTS Of 616 subjects with HSD/hEDS, 37.5% reported a doctor diagnosis of POTS. POTS-positive individuals were significantly younger than POTS-negative subjects (37 vs 40 years, P = 0.002), more likely to report chronic fatigue syndrome (44% vs 31%, P < 0.0001), and showed a trend toward increased prevalence of fibromyalgia (44% vs 37%, P = 0.06) and higher depression score (P = 0.07). POTS-positive subjects were also more likely to fulfill criteria for Rome IV FGIDs across various organ domains and experienced both upper and lower gastrointestinal symptoms significantly more frequently. The increased associations for FGIDs and GI symptom frequency remained unchanged in HSD/hEDS subjects with POTS following adjustments for age, chronic fatigue syndrome, fibromyalgia, and depression scores. CONCLUSIONS AND INFERENCES The high FGID burden in HSD/hEDS is further amplified in the presence of POTS. Future studies should elucidate the mechanism by which POTS arises in HSD/hEDS and is associated with increased GI symptoms.
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Affiliation(s)
- Foong Way David Tai
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Olafur S Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Ching Y Lam
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans Tornblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simren
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Imran Aziz
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Casanova EL, Baeza-Velasco C, Buchanan CB, Casanova MF. The Relationship between Autism and Ehlers-Danlos Syndromes/Hypermobility Spectrum Disorders. J Pers Med 2020; 10:E260. [PMID: 33271870 PMCID: PMC7711487 DOI: 10.3390/jpm10040260] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/29/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022] Open
Abstract
Considerable interest has arisen concerning the relationship between hereditary connective tissue disorders such as the Ehlers-Danlos syndromes (EDS)/hypermobility spectrum disorders (HSD) and autism, both in terms of their comorbidity as well as co-occurrence within the same families. This paper reviews our current state of knowledge, as well as highlighting unanswered questions concerning this remarkable patient group, which we hope will attract further scientific interest in coming years. In particular, patients themselves are demanding more research into this growing area of interest, although science has been slow to answer that call. Here, we address the overlap between these two spectrum conditions, including neurobehavioral, psychiatric, and neurological commonalities, shared peripheral neuropathies and neuropathologies, and similar autonomic and immune dysregulation. Together, these data highlight the potential relatedness of these two conditions and suggest that EDS/HSD may represent a subtype of autism.
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Affiliation(s)
- Emily L. Casanova
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29615, USA;
| | - Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, University of Paris, 92100 Boulogne Billancourt, France;
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, 34000 Montpellier, France
| | | | - Manuel F. Casanova
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29615, USA;
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY 40292, USA
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The first case report of Kyphoscoliotic Ehlers-Danlos syndrome of chinese origin with a novel PLOD1 gene mutation. BMC MEDICAL GENETICS 2020; 21:214. [PMID: 33129265 PMCID: PMC7599977 DOI: 10.1186/s12881-020-01154-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/20/2020] [Indexed: 11/24/2022]
Abstract
Background Kyphoscoliotic Ehlers-Danlos syndrome (kEDS) is a rare autosomal recessive connective tissue disorder characterized by progressive kyphoscoliosis, congenital muscular hypotonia, marked joint hypermobility, and severe skin hyperextensibility and fragility. Deficiency of lysyl hydroxylase 1 (LH1) due to mutations of PLOD1 (procollagen-lysine, 2-oxoglutarate 5-dioxygenase 1) gene has been identified as the pathogenic cause of kEDS (kEDS-PLOD1). Up to now, kEDS-PLOD1 has not been reported among Chinese population. Case presentation A 17-year-old Chinese male patient presenting with hypotonia, joint hypermobility and scoliosis was referred to our hospital. After birth, he was found to have severe hypotonia leading to delayed motor development. Subsequently, joint hypermobility, kyphoscoliosis and amblyopia were found. Inguinal hernia was found at age 5 years and closed by surgery. At the same time, he presented with hyperextensible and bruisable velvety skin with widened atrophic scarring after minor trauma. Dislocation of elbow joint was noted at age of 6 years. Orthopedic surgery for correction of kyphoscoliosis was performed at age 10 years. His family history was unremarkable. Physical examination revealed elevated blood pressure. Slight facial dysmorphologies including high palate, epicanthal folds, and down-slanting palpebral fissures were found. He also had blue sclerae with normal hearing. X-rays revealed severe degree of scoliosis and osteopenia. The Echocardiography findings were normal. Laboratory examination revealed a slightly elevated bone turnover. Based on the clinical manifestations presented by our patient, kEDS was suspected. Genetic analysis revealed a novel homozygous missense mutation of PLOD1 (c.1697 G > A, p.C566Y), confirming the diagnosis of kEDS-PLOD1. The patient was treated with alfacalcidol and nifedipine. Improved physical strength and normal blood pressure were reported after 12-month follow-up. Conclusions This is the first case of kEDS-PLOD1 of Chinese origin. We identified one novel mutation of PLOD1, extending the mutation spectrum of PLOD1. Diagnosis of kEDS-PLOD1 should be considered in patients with congenital hypotonia, progressive kyphoscoliosis, joint hypermobility, and skin hyperextensibility and confirmed by mutation analysis of PLOD1.
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Cyanosis With Dysautonomia Mimics Raynaud Disease. J Clin Rheumatol 2020; 26:e254-e255. [PMID: 31389817 PMCID: PMC7523574 DOI: 10.1097/rhu.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Roeder M, Thiel S, Baumann F, Sievi NA, Rohrbach M, Kohler M, Gaisl T. Increased augmentation index in patients with Ehlers-Danlos syndrome. BMC Cardiovasc Disord 2020; 20:417. [PMID: 32933483 PMCID: PMC7493396 DOI: 10.1186/s12872-020-01684-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 08/25/2020] [Indexed: 01/06/2023] Open
Abstract
Background Ehlers-Danlos Syndrome (EDS) comprises a heterogeneous group of diseases characterized by joint hypermobility, connective tissue friability, and vascular fragility. Reliable prognostic factors predicting vascular disease progression (e.g. arterial aneurysms, dissections, and ruptures) in EDS patients are still missing. Recently, applanation tonometry derived augmentation index (AIx), an indirect marker of arterial stiffness, has shown to be positively associated with progression of aortic disease in Marfan syndrome. In this study, we assessed aortic AIx in patients with EDS and matched healthy controls. Methods We performed noninvasive applanation tonometry in 61 adults with EDS (43 women and 18 men aged 39.3 ± 14.6 years) and 61 age-, gender-, height-, and weight-matched healthy controls. Radial artery pulse waveforms were recorded and analyzed using the SphygmoCor System (AtCor Medical, Sydney, NSW, Australia). Calculated AIx was adjusted to a heart rate of 75/min. Groups were compared and association between AIx and EDS was determined by univariate and multivariate regression analysis. Results EDS patients were categorized in classical type EDS (34%), hypermobile type EDS (43%), vascular type EDS (5%), or remained unassignable (18%) due to overlapping features. EDS patients showed a significantly increased aortic AIx compared to healthy controls (22.8% ± 10.1 vs 14.8% ± 14.0, p < 0.001). EDS showed a positive association with AIx; independent of age, sex, height, blood pressure, medication, and pack years of smoking. Conclusions Patients with EDS showed elevated AIx, indicating increased arterial stiffness when compared to healthy controls. Further investigations are needed in order to assess the prognostic value of increased AIx for cardiovascular outcomes in patients with EDS.
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Affiliation(s)
- Maurice Roeder
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sira Thiel
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Frederic Baumann
- Clinical and Interventional Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Noriane A Sievi
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Marianne Rohrbach
- Division of Metabolism and Children's Research Center University Children's Hospital Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Centre for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland.
| | - Thomas Gaisl
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Williams ML. Global warming, heat-related illnesses, and the dermatologist. Int J Womens Dermatol 2020; 7:70-84. [PMID: 33537396 PMCID: PMC7838243 DOI: 10.1016/j.ijwd.2020.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 12/23/2022] Open
Abstract
Global warming, provoked by the greenhouse effect of high levels of atmospheric gases (most notably carbon dioxide and methane), directly threatens human health and survival. Individuals vary in their capacity to tolerate episodes of extreme heat. Because skin is the organ tasked with heat dissipation, it is important for dermatologists to be versed in the physiology of cutaneous heat dissipation and cognizant of clinical settings in which the skin’s thermoregulatory responses may be impaired. When the external temperature is lower than that of the skin, the skin releases internal heat through direct thermal exchange with the environment, a process that is aided by an expansion of cutaneous blood flow and eccrine sweating. Cooling through the evaporation of sweat is effective even when the external temperature exceeds that of skin. Many factors, including environmental and physiological (e.g., age and sex), and pathological (e.g., preexisting illnesses, disorders of eccrine function, and medications) considerations, affect the skin’s capacity to thermoregulate. Identification of individuals at increased risk for heat-related morbidity and mortality will become increasingly important in the care of patients.
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Affiliation(s)
- Mary L Williams
- Departments of Dermatology and Pediatrics, University of California San Francisco, San Francisco, CA, United States
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Tran ST, Jagpal A, Koven ML, Turek CE, Golden JS, Tinkle BT. Symptom complaints and impact on functioning in youth with hypermobile Ehlers-Danlos syndrome. J Child Health Care 2020; 24:444-457. [PMID: 31370685 DOI: 10.1177/1367493519867174] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS), a genetic connective tissue disorder, involves several body systems which makes symptom management and functioning difficult. The aim of this study was to understand pediatric hEDS patients' symptoms and primary complaints. Additionally, we examined the cumulative impact of symptoms on physical and psychological functioning. Thirty-four youth with hEDS were recruited from a genetics clinic and reported the hardest thing about having hEDS, their pain, fatigue, physical symptoms, functional disability, anxiety, and depression. Physical symptoms (pain and fatigue) and limitations (keeping up with friends) were reported as the most difficult parts of having hEDS. A higher number of somatic symptoms was the strongest predictor of disability, anxiety, and depression. Physical symptoms are subjectively distressing and significantly related to impairments in physical and psychological functioning. Thus, addressing these varied symptoms in treatment may yield better functioning in youth with hEDS.
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Affiliation(s)
- Susan T Tran
- Department of Psychology, DePaul University, Chicago, IL, USA
| | - Anjana Jagpal
- Department of Psychology, DePaul University, Chicago, IL, USA
| | - Marissa L Koven
- Department of Psychology, DePaul University, Chicago, IL, USA
| | - Carolyn E Turek
- Department of Psychology, DePaul University, Chicago, IL, USA
- Children's Hospital of Orange County, Orange, CA, USA
| | - Julia S Golden
- Department of Psychology, DePaul University, Chicago, IL, USA
| | - Brad T Tinkle
- Peyton Manning Children's Hospital, Indianapolis, IN, USA
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van Meulenbroek T, Huijnen IPJ, Simons LE, Conijn AEA, Engelbert RHH, Verbunt JA. Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain. Scand J Pain 2020; 21:22-31. [PMID: 32862151 DOI: 10.1515/sjpain-2020-0023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/12/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVES A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability. CONTENT Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability. SUMMARY AND OUTLOOK It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.
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Affiliation(s)
- Thijs van Meulenbroek
- Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands.,and Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Maastricht, The Netherlands
| | - Ivan P J Huijnen
- Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands.,and Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Maastricht, The Netherlands
| | - Laura E Simons
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Arnoud E A Conijn
- Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Raoul H H Engelbert
- Department of Rehabilitation, Amsterdam University Medical Centers, University of Amsterdam, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Department of Pediatrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands; and ACHIEVE, Centre for Applied Research, Faculty of Health, University of Applied Sciences Amsterdam,The Netherlands
| | - Jeanine A Verbunt
- Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands.,and Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Maastricht, The Netherlands
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Ritelli M, Venturini M, Cinquina V, Chiarelli N, Colombi M. Multisystemic manifestations in a cohort of 75 classical Ehlers-Danlos syndrome patients: natural history and nosological perspectives. Orphanet J Rare Dis 2020; 15:197. [PMID: 32736638 PMCID: PMC7393722 DOI: 10.1186/s13023-020-01470-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022] Open
Abstract
Background The Ehlers-Danlos syndromes (EDS) are rare connective tissue disorders consisting of 13 subtypes with overlapping features including joint hypermobility, skin and generalized connective tissue fragility. Classical EDS (cEDS) is principally caused by heterozygous COL5A1 or COL5A2 variants and rarely by the COL1A1 p.(Arg312Cys) substitution. Current major criteria are (1) skin hyperextensibility plus atrophic scars and (2) generalized joint hypermobility (gJHM). Minor criteria include additional mucocutaneous signs, epicanthal folds, gJHM complications, and an affected first-degree relative. Minimal criteria prompting molecular testing are major criterion 1 plus either major criterion 2 or 3 minor criteria. In addition to these features, the clinical picture also involves multiple organ systems, but large-scale cohort studies are still missing. This study aimed to investigate the multisystemic involvement and natural history of cEDS through a cross-sectional study on a cohort of 75 molecularly confirmed patients evaluated from 2010 to 2019 in a tertiary referral center. The diagnostic criteria, additional mucocutaneous, osteoarticular, musculoskeletal, cardiovascular, gastrointestinal, uro-gynecological, neuropsychiatric, and atopic issues, and facial/ocular features were ascertained, and feature rates compared by sex and age. Results Our study confirms that cEDS is mainly characterized by cutaneous and articular involvement, though none of their hallmarks was represented in all cases and suggests a milder multisystemic involvement and a more favorable natural history compared to other EDS subtypes. Abnormal scarring was the most frequent and characteristic sign, skin hyperextensibility and gJHM were less common, all without any sex and age bias; joint instability complications were more recurrent in adults. Some orthopedic features showed a high prevalence, whereas the other issues related to the investigated organ systems were less recurrent with few exceptions and age-related differences. Conclusions Our findings define the diagnostic relevance of cutaneous and articular features and additional clinical signs associated to cEDS. Furthermore, our data suggest an update of the current EDS nosology concerning scarring that should be considered separately from skin hyperextensibility and that the clinical diagnosis of cEDS may be enhanced by the accurate evaluation of orthopedic manifestations at all ages, faciocutaneous indicators in children, and some acquired traits related to joint instability complications, premature skin aging, and patterning of abnormal scarring in older individuals.
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Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Brescia, Italy
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy.
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Kucharik AH, Chang C. The Relationship Between Hypermobile Ehlers-Danlos Syndrome (hEDS), Postural Orthostatic Tachycardia Syndrome (POTS), and Mast Cell Activation Syndrome (MCAS). Clin Rev Allergy Immunol 2020; 58:273-297. [PMID: 31267471 DOI: 10.1007/s12016-019-08755-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In recent years, an association between hypermobile Ehlers-Danlos syndrome (hEDS), mast cell activation syndrome (MCAS), and postural orthostatic tachycardia syndrome (POTS) has garnered attention and patients are increasingly presenting with this triad. However, a real relationship between these entities is unclear due to a lack of scientific validity. We conducted an extensive review of the literature using two different search strategies. A narrower strategy included 88 searches of various combinations of terms for each of the three conditions, yielding 19 unique papers. A broader search included 136 searches of various combinations of terms but included all forms of EDS and yielded 40 unique papers. Of these, only four and nine papers from the narrower and broader search strategies were original research articles. None of these papers resulted from a combination of the search terms for the three conditions. All three clinical entities are controversial in either existence or pathogenesis. MCAS is a poorly defined clinical entity, and many studies do not adhere to the proposed criteria when establishing the diagnosis. Patients previously diagnosed with EDS hypermobility type may not meet the new, stricter criteria for hEDS but may for a less severe hypermobility spectrum disorder (HSD). The pathophysiology of POTS is still unclear. An evidence-based, common pathophysiologic mechanism between any of the two, much less all three conditions, has yet to be described. Our review of the literature shows that current evidence is lacking on the existence of MCAS or hEDS as separate or significant clinical entities. Studies proposing a relationship between the three clinical entities are either biased or based on outdated criteria. The reason behind the purported association of these entities stems from an overlapping pool of vague, subjective symptoms, which is inadequate evidence to conclude that any such relationship exists.
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Affiliation(s)
| | - Christopher Chang
- Florida Atlantic University, Boca Raton, FL, USA.
- Joe DiMaggio Children's Hospital, 1131 North 35th Avenue, Suite 220, Hollywood, FL, 33021, USA.
- University of California, Davis, CA, USA.
- Florida International University, Miami, FL, USA.
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Abstract
Postural orthostatic tachycardia syndrome (POTS) is a clinically heterogeneous disorder with multiple contributing pathophysiologic mechanisms manifesting as symptoms of orthostatic intolerance in the setting of orthostatic tachycardia (increase in heart rate by at least 30 beats per minute upon assuming an upright position) without orthostatic hypotension. The three major pathophysiologic mechanisms include partial autonomic neuropathy, hypovolemia, and hyperadrenergic state. Patients often will exhibit overlapping characteristics from more than one of these mechanisms. The approach to the treatment of POTS centers on treating the underlying pathophysiologic mechanism. Stockings, abdominal binders, and vasoconstrictors are used to enhance venous return in partial neuropathic POTS. Exercise and volume expansion are the main treatment strategies for hypo-volemic POTS. For hyperadrenergic POTS, beta-blockers and avoidance of norepinephrine reuptake inhibitors is important. Attempts should be made to discern which pathophysiologic mechanism(s) may be afflicting patients so that treatment regimens can be individualized.
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Affiliation(s)
- Philip L. Mar
- Division of Cardiology, Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri 63110, USA
| | - Satish R. Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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Swai J, Hu Z, Zhao X, Rugambwa T, Ming G. Heart rate and heart rate variability comparison between postural orthostatic tachycardia syndrome versus healthy participants; a systematic review and meta-analysis. BMC Cardiovasc Disord 2019; 19:320. [PMID: 31888497 PMCID: PMC6936126 DOI: 10.1186/s12872-019-01298-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background A number of published literature has reported that, physiologically, heart rate variability (HRV) in patients with postural orthostatic tachycardia syndrome (POTS) to be greatly confounded by age, sex, race, physical fitness, and circadian rhythm. The purpose of this study was to compare between POTS patients versus healthy participants, in terms of heart rate (HR) and HRV after Head-Up tilt test (HUTT), by systematic review and meta-analysis of available published literature. Methods MEDLINE (using PubMed interphase), EMBASE and SCOPUS were systematically searched for observational studies comparing POTS patients versus healthy patients, in terms of HR and HRV. HRV was grouped into Time and frequency domain outcome measurements. The time domain was measured as mean RR- interval and mean the square root of the mean of squares of successive R-R waves (rMSSD) in milliseconds. The frequency domain was measured as mean values of Low frequency power (LF), High frequency power (HF), LF/HF-ratio, LF-normalized units (LF(n.u)) and HF-normalized units (HF(n.u)). Demographic data, comorbidities, and mean values of HR, RR- interval, rMSSD, LF, HF, LF/HF-ratio, LF-(n.u) and H.F-n.u were extracted from each group and compared, by their mean differences as an overall outcome measure. Computer software, RevMan 5.3 was utilized, at a 95% significance level. Results Twenty (20) eligible studies were found to report 717 POTS and 641 healthy participants. POTS group had a higher mean HR (p < 0.05), lower mean RR-Interval (p < 0.05), lower rMSSD (p < 0.05) than healthy participants. Furthermore, POTS group had lower mean HF(p > 0.05), lower mean LF(p > 0.05), and lower mean HF(n.u) (p > 0.05), higher LF/HF-Ratio (p > 0.05) and higher LF(n.u) (p > 0.05) as compared to healthy participants. Conclusion POTS patients have a higher HR than healthy patients after HUTT and lower HRV in terms of time domain measure but not in terms of frequency domain measure. HR and time domain analyses of HRV are more reliable than frequency domain analysis in differentiating POTS patients from the healthy participants. We call upon sensitivity and specificity studies.
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Affiliation(s)
- Joel Swai
- Department of Internal medicine, Benjamin Mkapa Hospital, Dodoma city, Tanzania. .,Department of Nephrology and Rheumatology, Xiangya Third Hospital, Central South University, Changsha city, Hunan, People's Republic of China.
| | - Zixuan Hu
- Department of Gastroenterology, Xiangya Third Hospital, Central South University, Changsha city, Hunan, People's Republic of China
| | - Xiexiong Zhao
- Department of Cardiology, Xiangya Third Hospital, Central South University, Changsha city, Hunan, People's Republic of China
| | - Tibera Rugambwa
- Department of Obstetrics and Gynecology, Mbeya Zonal Referral Hospital, Mbeya city, Tanzania
| | - Gui Ming
- Department of Nephrology and Rheumatology, Xiangya Third Hospital, Central South University, Changsha city, Hunan, People's Republic of China
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Russek LN, Stott P, Simmonds J. Recognizing and Effectively Managing Hypermobility-Related Conditions. Phys Ther 2019; 99:1189-1200. [PMID: 31158283 DOI: 10.1093/ptj/pzz078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 01/09/2019] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Leslie N Russek
- Physical Therapy Department, Clarkson University, Potsdam, NY 13699 (USA)
| | | | - Jane Simmonds
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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De Baets S, Calders P, Verhoost L, Coussens M, Dewandele I, Malfait F, Vanderstraeten G, Van Hove G, Van de Velde D. Patient perspectives on employment participation in the "hypermobile Ehlers-Danlos syndrome". Disabil Rehabil 2019; 43:668-677. [PMID: 31287330 DOI: 10.1080/09638288.2019.1636316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND "Ehlers-Danlos syndrome" (EDS) is a heritable connective disorder influencing multiple aspects of daily life. Most studies have focused on describing the physical symptoms and level of disability, but little knowledge exists about the psychosocial effects of the pathology. Participation in employment is an aspect that strongly influences quality of life of patients with chronic pathologies. This study, therefore, aimed to explore the lived experiences in employment participation of patients diagnosed with "hypermobile EDS". METHODS An inductive thematic analysis, using semi-structured interviews was used. Nine patients, purposively selected by a continuum sampling strategy, were included. Interviews were audio-recorded and transcribed verbatim. RESULTS Data analysis resulted in three main themes: (1) elements assisting participation in employment, (2) limitations in employment participation, and (3) unemployment due to the "hypermobile EDS". On the one hand, the results show that related health complaints can impede employment participation to an important extent. On the other hand, patients also report several aspects of work that can affect their well-being in a positive way. CONCLUSION There are specific reasons for a person with "hypermobile EDS" to participate in employment. These reasons are different for each person and may even vary in time.Implications for rehabilitation"Hypermobile EDS" greatly impacts activities and participation in daily life. "Living with limitations" is the central theme in the lives of "Hypermobile EDS" patients.Various aspects influence work participation in people with "Hypermobile EDS", such as work pressure, tasks, and transport to work.Work has positive effects in the lives of people with "Hypermobile EDS."Work can create difficulties when the job requirements and tasks do not match the functional abilities of a person with "Hypermobile EDS."
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Affiliation(s)
- Stijn De Baets
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Liesbeth Verhoost
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marieke Coussens
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Inge Dewandele
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Fransiska Malfait
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Guy Vanderstraeten
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Geert Van Hove
- Department of Special Needs Education, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Dominique Van de Velde
- Occupational Therapy Program, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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50
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Martin A. An acquired or heritable connective tissue disorder? A review of hypermobile Ehlers Danlos Syndrome. Eur J Med Genet 2019; 62:103672. [PMID: 31102747 DOI: 10.1016/j.ejmg.2019.103672] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/27/2019] [Accepted: 05/12/2019] [Indexed: 12/13/2022]
Abstract
Hypermobile Ehlers Danlos Syndrome (hEDS) is a multifaceted disorder that is difficult to diagnose and manage primarily due to the unknown causes. Research on hEDS continues to evolve but tangible progress will be realized when the growing body of evidence compliments clinical practice. This critical review of the literature aims to stimulate lateral thinking about the pathogenesis, diagnosis and management of hEDS. The current international classification of Ehlers Danlos Syndrome introduced stricter diagnostic criteria for hEDS, which bore a blanket category (hypermobility spectrum disorders) for conditions presenting with symptomatic joint hypermobility, but do not match the hEDS diagnostic criteria. One would argue hEDS is another all-encompassing classification for heritable connective tissue disorders and or acquired musculoskeletal conditions without a definitive molecular basis. As scientific research progresses to accommodate validated and or annulled hypotheses, the plethora of unknowns in hEDS continue to challenge healthcare outcomes and care experiences.
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Affiliation(s)
- Anne Martin
- England Centre for Practice Development, Faculty of Health and Wellbeing, Canterbury Christ Church University, Canterbury, North Holmes Road, CT1 1QU, UK.
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