Benign joint hypermobility in childhood

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

INTRODUCTION/AIMS

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of comorbid benign joint hypermobility and juvenile fibromyalgia syndromes on pediatric functional gastrointestinal disorders

OBJECTIVES

Musculoskeletal pain has a considerable frequency in pediatric outpatients. Benign joint hypermobility (BJHS) and juvenile fibromyalgia syndrome (JFMS) are non-inflammatory causes of musculoskeletal pain. In these syndromes, pain is often accompanied by various symptoms such as fatigue, sleep difficulties, mood disorders, cognitive dysfunction, dizziness, headaches, abdominal pain, irritable bowel syndrome, and restless legs syndrome. Functional dyspepsia, functional vomiting, functional abdominal pain, functional constipation, and irritable bowel syndrome all together are termed functional gastrointestinal (GI) disorders. We aimed to evaluate the functional gastrointestinal disorders association of BJHS and JFMS.

METHODS

Patients aged 10-18 years who were diagnosed with functional GI disorder in the pediatric gastroenterology department were included in the study. The findings of BJHS and JFMS were evaluated by the pediatric rheumatology department. Scales for anxiety, somatization, and depression were administered by a child psychiatrist. COMPASS 31 scoring was used in autonomic dysfunction.

RESULTS

The prevalence of JFMS and BJHS was 64% and 32%, respectively in children with a functional GI disorder. Retrosternal chest pain, dysphagia, early satiation, nausea, vomiting, and regurgitation were common in JFMS (p = 0.007; p = 0.005; p = 0.018; p = 0.002, p = 0.013; p = 0.014, respectively). Gastrointestinal symptoms did not differ with BJHS. One hundred six (88.3%) and 99 (82.5%) had orthostatic intolerance and reflex syncope, respectively. One hundred three (85.6%) had anxiety symptoms, 101 (84.2%) had somatization symptoms, and 102 (85%) had depression symptoms.

CONCLUSIONS

Functional GI disorders, JFMS, and BJHS are complex intertwined disorders influenced by emotional distress. Therefore, a multidisciplinary approach is necessary for the diagnosis and treatment process.

Developmental Coordination Disorder and Joint Hypermobility in Childhood: A Narrative Review

Children with developmental coordination disorder (DCD) and joint hypermobility could present an overlap of symptoms and motor functional difficulties. The link between these two clinical conditions has not yet been clarified. Recent studies reported a high incidence (30–50%) of motor delay in children who are referred to hypermobility and of enhanced joint hypermobility in children with DCD. The aim of this study was to provide a critical review of the literature outlining the association between DCD or limited motor performance and joint hypermobility. Studies were eligible for inclusion if they were written in English and human-based. All the studies were first selected, looking for the presence of a clinical association between developmental coordination disorder or motor performance and hyperlaxity and reporting details of outcome. After a review of the full texts, 16 articles for a total of 1898 children met the inclusion criteria. In general, there was evidence of a higher incidence of motor delay or DCD in children who are referred to hypermobility and of enhanced joint hypermobility in children with DCD with similar range of functional difficulties. These results could influence the way to support children with rehabilitation and the type of intervention according to the prevalence of one of the two conditions.

Evaluation of postural control in children with increased femoral anteversion

BACKGROUND

Femoral anteversion is defined as the angular difference between the axis of the femoral neck and the transcondylar axis of the knee and the most common cause of an in-toe gait in children.

RESEARCH QUESTION

Does increased femoral anteversion (IFA) adversely affect postural stability and balance in healthy children?

METHODS

Sixteen children with IFA aged 10-15 years and an age-matched control group of 16 children who were growing typically were included. Postural stability (PS), limits of stability (LoS), and the modified clinical test of sensory integration of balance (mCTSIB) were used to evaluate postural control by "Biodex Balance System® (BBS)" and Balance Error Scoring System (BESS), which is a visual observation of instability in 3 stance positions under 6 different conditions, were performed for all cases. SPSS v.20 program was used for data analysis. Independent Samples T-test or Mann Whitney U test were used for between-group comparisons depending on the distribution properties of the data. The significance level was set at p < 0.05.

RESULTS

A significant difference was found between the groups for overall and anterior/posterior stability index in PS (p < 0.05), all parameters of LoS (p < 0.05) and mCTSIB (p < 0.05). Also there was a significant difference between the BESS firm surface (p = 0.007), BESS foam surface (p < 0.001), and total surface scores (p < 0.001).

SIGNIFICANCE

The results indicate that the children with IFA were significantly more unstable in all parameters of BBS and BESS when compared to their healthy peers. This shows that postural stability and balance are impaired in healthy children with IFA. To the extent of our knowledge, this study is the first to examine the postural control problems associated with IFA in healthy children.

Evaluation of Dental Status and Temporomandibular Joint in Children With Generalized Joint Hypermobility

OBJECTIVE

The aim of this study was to evaluate the dental status and temporomandibular diseases (TMDs)-related symptoms in children with generalized joint hypermobility (GJH) and compare them with healthy controls (HCs).

METHODS

This is a cross-sectional, observational study carried out between September 2016 and April 2017. A total of 124 children with GJH (n = 62) and HC (n = 62) were enrolled. The GJH was assessed with the Beighton hypermobility score. The subjects were screened for dental status and TMD-related symptoms. The assessment included the index for "decayed," "missing," and "filled teeth" (DMFT, dmft); plaque; gingival bleeding; tooth mobility; and temporomandibular joint (TMJ) evaluation.

RESULTS

The mean Beighton hypermobility score was 6.3 ± 1.2 in the GJH group. Visible plaque index and gingival bleeding index scores were found to be significantly higher in children with GJH then in the HC (p = 0.031, p = 0.023). No differences were found regarding the DMFT scores between the groups (p = 0.16). Temporomandibular disorder-related symptom frequencies were significantly higher in children with GJH (p < 0.001). The most common clinically determined sign of TMD was clicking with a maximum active mouth-opening. Combined TMJ symptoms and TMD were observed in approximately one third of the children with GJH.

CONCLUSIONS

The presence of GJH in a child may be indicative of future dental or TMJ problems, and it may cause dental problems due to increased gingival bleeding index and visible plaque index scores. Therefore, children with GJH require preventive dental and TMJ care.

Assessment of foot posture and related factors in patients with knee osteoarthritis

Objectives

The aim of this study was to compare foot posture between patient and control groups, and to identify factors associated with foot posture abnormality in knee osteoarthritis (OA).

Patients and methods

This case-control study included a total of 115 patients (26 males, 89 females; mean age: 54.4±9.3 years; range, 29 to 73 years) with OA and 77 healthy controls (20 males, 57 females; mean age: 52.1±8.1 years; range, 32 to 69 years) between May 2019 and July 2019. The participants were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analog Scale (VAS), and the Beighton criteria. Radiological assessments were performed using the Kellgren-Lawrence grading, condylar plateau angle, and medial tibiofemoral joint width. The Foot Posture Index-6 (FPI-6) was used for foot posture analysis and three groups were formed as supinated, neutral, and pronated postures.

Results

Foot posture was significantly different between the patient and control groups (p<0.05). Of the patients with knee OA, significant differences were found in the VAS, WOMAC-pain, WOMAC-physical function, and WOMAC-total (p<0.05) among the foot postures. No significant difference was found among the foot posture groups in terms of the radiological parameters and WOMAC-stiffness (p>0.05). Hypermobility and WOMAC-total scores were significantly associated with foot posture abnormality (p<0.05).

Conclusion

Joint hypermobility and foot posture are the factors which may influence the clinical characteristics of knee OA. Foot posture and joint hypermobility should be taken into consideration during the examination and management of patients with knee OA.

Impact of heritable disorders of connective tissue on daily life of children: Parent perspectives

AIM

The aim of this study was to investigate parent perspectives on how heritable disorders of connective tissue (HDCT) affect a child's everyday life. In addition, this study aimed to determine if parents seeking health professional services perceive their children with HDCT to have difficulties with activities reliant on hand function.

METHODS

This cross-sectional study used a questionnaire for parents to explore the impact of an HDCT on a child's ability to carry out everyday activities. Parents of children (8-18 years) attending a tertiary connective tissue dysplasia clinic, over a 12-month period, were invited to participate.

RESULTS

We analysed 100 surveys completed by parents. Children with Ehlers-Danlos syndrome-hypermobile type, joint hypermobility syndrome (48%) and osteogenesis imperfecta (42%) were the largest diagnostic groups represented. Pain (73%) and fatigue (68%) were the most common symptoms parents perceived to affect day-to-day activities. More parents were satisfied with their child's self-care (61%) than school participation (33%). Keeping up with handwriting (71%) and gross motor activities (70%) were the most frequently reported difficulties at school. Most parents (65%) reported leisure activity difficulties, with pain (64%) and fatigue (60%) as the main contributing factors.

CONCLUSIONS

This study has provided new knowledge about the concerns of parents with their child's engagement in everyday life including the impact of HDCT on hand function. Further research is needed on effective management strategies to reduce symptoms and improve hand function for these children.

Anterior Segment Analysis and Evaluation of Corneal Biomechanical Properties in Children with Joint Hypermobility

Objectives:

To compare anterior segment parameters and biomechanical analysis of the cornea in children with joint hypermobility (JH) and healthy children.

Materials and Methods:

Cross-sectional case-control study. Fifty eyes of 25 children with JH were compared with 74 eyes of 37 healthy age- and sex-matched controls in terms of refractive, anterior segment topographic, and corneal biomechanical measurements. Axial length (AL) was measured with a Nidek AL-Scan biometry device; corneal-compensated intraocular pressure (IOPcc), Goldmann-correlated IOP (IOPg), corneal hysteresis (CH), and corneal resistance factor (CRF) were measured with a Reichert ocular response analyzer (ORA). Central corneal thickness (CCT), anterior chamber depth (ACD), K1/K2 values, iris diameter, and anterior chamber volume (ACV) were measured with a Sirius topography device.

Results:

Mean age in the JH group was 10.56±4.03 years, while that of the control group was 11.27±2.59 years (p=0.23). Spherical equivalent was -0.22±1.02 diopter (D) in the JH group and -0.12±1.12 D in the control group (p=0.60); CCT was 23.01±0.82 µm in the JH group and 23.17±0.82 µm in the control group (p=0.33). There were no significant differences between the two groups in terms of age, sex, IOP, IOPcc, IOPg, CH, CRF, AL, K1, K2, iris diameter, ACD, and ACV.

Conclusion:

JH, which causes increased flexibility of the joints, was concluded not to cause a significant change in the corneal biomechanical markers of CRF and CH or in anterior segment topographic parameters.

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

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

Increased femoral anteversion-related biomechanical abnormalities: lower extremity function, falling frequencies, and fatigue

BACKGROUND

Increased femoral anteversion (IFA) is defined as forwardly rotated femoral head relative to the transcondylar knee axis which may have a potential to reduce the functional quality of adolescents. Therefore, the aim of our study was to investigate the effects of IFA on lower-extremity function, falling frequency, and fatigue onset in neurologically intact children.

RESEARCH QUESTION

Does increased femoral anteversion influence lower extremity function, falling frequency and fatigue on set in healthy children?

METHODS

Sixty-five participants with increased femoral anteversion (IFA) and thirty-two healthy peers as control were included into the study. For the function, the lower extremity function form (LEFF) which is adapted from Lower Extremity Function Test used. Falling frequency and fatigue onset time were assessed by a Likert-type scale. In addition, the activities which cause frequently fall for the participants were questioned.

RESULTS

Lower extremity function was found deteriorated (p= 0.02) and falling frequency was higher (p = 0.00) in IFA than in controls. Fatigue onset time was not different between groups, although lower extremity function was strongly correlated with fatigue onset (rho = -0.537, p < 0.001). IFA children fall four times more during running (60%), three times more during fast walking (21.42%) than their healthy peers (14.28%, 7.14% respectively).

SIGNIFICANCE

IFA leads functional problems, especially in the form of high falling frequencies. According to the LEFF score, the most difficult functional parameters for these children were walking long distances, becoming tired, walking more than a mile, and standing on one spot. Also, shorter fatigue onset time may worsen the lower-extremity function secondarily. Because of the higher frequency of falling and functional problems, children with IFA may be more defenseless to injuries, especially in high-motor-skill activities such as running and soccer.

Managing low back pain in active adolescents

Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order relevant investigations is considered. An overview of contemporary pain mechanisms is provided, with specific reference to the wide range of risk factors for persistent low back pain. Education and exercise framed within a biopsychosocial framework are the cornerstones of treatment. There is a lack of data on more comprehensive personalized treatment approaches among adolescents. One such approach - Cognitive Functional Therapy - which has shown promise in adults and active adolescents with low back pain, is described and illustrated using a case study. The most promising avenues, in practice and research, may be those that view adolescent low back pain as less of a local structural spinal issue and more of an indication of the general health of the adolescent.

Range of Ankle Dorsiflexion in a Group of Adults with Ligamentous Laxity

BACKGROUND

Ligamentous or joint laxity is a clinical entity characterized by increased joint mobility beyond the range of motion regarded as normal, and joint mobility is an effective indicator of the degree of laxity. We examined the influence of ligamentous laxity on the range of ankle dorsiflexion with the knee flexed and extended, comparing lax adults with a control (nonlax) group.

METHODS

The sample comprised 400 individuals: 200 in the control group (mean ± SD age, 32.49 ± 11.06 years) and 200 in the lax group (mean ± SD age, 29.82 ± 9.40 years). The Beighton criteria were applied to each participant to diagnose laxity or nonlaxity, and sex, age, and angle range of bilateral dorsiflexion with the knee extended and flexed were recorded.

RESULTS

The mean ± SD dorsiflexion range with the knee straight was 16.14° ± 5.29° left ankle and 21.21° ± 4.93° right ankle in the lax group and 12.94° ± 4.17° left ankle and 17.08° ± 4.40° right ankle in the control group. The respective values with the knee flexed were 15.84° ± 5.31° and 21.21° ± 4.80° in the lax group and 12.95° ± 3.95 and 17.23° ± 4.25° in the control group.

CONCLUSIONS

In this sample, ankle dorsiflexion range in the lax group was 4° bigger than that in the control group in both knee positions.

The Effects of Resistance Training on Health of Children and Adolescents With Disabilities

Many parents still hesitate to encourage their children to participate in resistance training programs. This is unfortunate since recent research shows that resistance training can positively affect children's health. This narrative review aims to present an overview of the health-associated effects resistance training can provide particularly in children and adolescents with disabilities by describing its effects on muscle strength, physical function, mental health, self-concept, obesity, and injury prevention. To illustrate the variety of possible fields of application, the effects of resistance training in children and adolescents suffering from Charcot-Marie-Tooth disease, cerebral palsy, Down syndrome, Ehlers-Danlos syndrome, joint hypermobility, juvenile idiopathic arthritis, obesity, and spina bifida are discussed. Although randomized controlled trials with a sufficiently large sample size are rare, the research presented in this review indicates that this mode of training might be a potent tool to improve mental and physical health by improving muscle strength, body composition, self-concept or functionality, reducing pain or injury risk, and strengthening bone or tendons even in the most vulnerable groups of children with physical or mental disability. Furthermore, it has to be emphasized that compared with other types of treatment resistance training is considered to be without adverse effects.

Understanding Adolescent Low Back Pain From a Multidimensional Perspective: Implications for Management

Synopsis Low back pain (LBP) is the leading cause of disability worldwide. It often begins in adolescence, setting a course for later in life. We have tracked the course of LBP in the Raine Study cohort from the age of 14 years into early adulthood. Our work has found that LBP is already prevalent in individuals at 14 years of age and increases throughout adolescence and into early adulthood. It is often comorbid with other musculoskeletal pain. For some adolescents, LBP has little impact; for others, its impact includes care seeking, taking medication, taking time off from school and work, as well as modifying physical and functional activity. Of concern is the increasing prevalence of LBP with impact across adolescence, reaching adult rates by 22 years of age. The predictors of disabling LBP in adolescence are multidimensional. They include female sex, negative back pain beliefs, poor mental health status, somatic complaints, involvement in sports, and altered stress responses. Genetics also plays a role. Ironically, the factors that we have historically thought to be important predictors of LBP, such as "poor" spinal posture, scoliosis, carrying school bags, joint hypermobility, and poor back muscle endurance, are not strong predictors. This challenges our clinical beliefs and highlights that adolescent LBP needs a flexible and targeted multidimensional approach to assessment and management. In most cases, we recommend a cognitive functional approach that challenges negative LBP beliefs, educates adolescents regarding factors associated with their LBP, restores functional capacity where it is impaired, and encourages healthy lifestyle habits. J Orthop Sports Phys Ther 2017;47(10):741-751. Epub 12 Sep 2017. doi:10.2519/jospt.2017.7376.

Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history

The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue. It has been described largely in those with musculoskeletal complaints including joint hypermobility, joint subluxations/dislocations, as well as skin and soft tissue manifestations. Many patients report activity-related pain and some go on to have daily pain. Two undifferentiated syndromes have been used to describe these manifestations-joint hypermobility syndrome and hEDS. Both are clinical diagnoses in the absence of other causation. Current medical literature further complicates differentiation and describes multiple associated symptoms and disorders. The current EDS nosology combines these two entities into the hypermobile type of EDS. Herein, we review and summarize the literature as a better clinical description of this type of connective tissue disorder. © 2017 Wiley Periodicals, Inc.

Ampleness of head movements of children and adolescents with sensorineural hearing loss

INTRODUCTION

Head movements are controlled by the vestibular system. Children with sensorineural hearing loss can present restrictions in ampleness of head movements due to damage in the vestibule-cochlear systems, resulting from injury in the inner ear.

OBJECTIVE

To evaluate the ampleness of head movements of children with normal hearing and children with sensorineural hearing loss and compare data between groups.

METHODS

Cross-sectional study that evaluated the ampleness of head movements of 96 students, being 48 with normal hearing and 48 with sensorineural hearing loss, of both sexes, with aged between 7 and 18 years old. The performance of ampleness of head movements was analyzed by a manual goniometric evaluation, according the references proposed by Marques. To the statistical analysis we used the t-Student test in case of normality of the data or the Mann-Whitney test when did not applied the suppositions of normality.

RESULTS

Hearing loss children showed less mean in ampleness of all movements of head compared to normal hearing children, pointing difference to movements of flexion (p = 0,001), lateral inclination to the right (p = 0,025) and lateral rotation to the left (p = 0,021).

CONCLUSION

Hearing loss children showed reduction in the ampleness of these head movements: flexion, lateral inclination to the right and lateral rotation to the left compared to normal hearing children.

Cervical Spine Joint Hypermobility: A Possible Predisposing Factor for New Daily Persistent Headache

The objective of this study was to suggest that joint hypermobility (specifically of the cervical spine) is a predisposing factor for the development of new daily persistent headache (NDPH). Twelve individuals (10 female, 2 male) with primary NDPH were evaluated by one of two physical therapists. Each patient was tested for active cervical range of motion and for the presence of excessive intersegmental vertebral motion in the cervical spine. All patients were screened utilizing the Beighton score, which determines degree of systemic hypermobility. Eleven of the 12 NDPH patients were found to have cervical spine joint hypermobility. Ten of the 12 NDPH patients had evidence of widespread joint hypermobility with the Beighton score. Based on our findings we suggest that joint hypermobility, specifically of the cervical spine, may be a predisposing factor for the development of NDPH.

Musculoskeletal pain in schoolchildren across puberty: a 3-year follow-up study

BACKGROUND

Chronic Musculoskeletal Pain (MSP) in children can be due to non-inflammatory conditions, such as the benign joint hypermobility syndrome (BJHS) or idiopathic MSP (IMSP). Aim of the study was to evaluate type and persistence of MSP in a cohort of schoolchildren with MSP followed for 3 years, in order to identify the main risk factors.

METHODS

Healthy schoolchildren, aged 8-13 years, underwent a general and rheumatologic examination, focusing on presence of chronic MSP, defined as continuous or recurrent pain lasting more than 3 months and heavily interfering with daily life activities, presence of generalized joint hypermobility, the body mass index and the pubertal stage. All symptomatic subjects were re-evaluated 3 years later with the same methods.

RESULTS

Seventy of the 88 symptomatic subjects of the initial cohort of 289 were re-evaluated 3 years later. Of these, 38 (54.3 %) still presented MSP, including 19 with BJHS and 19 with IMSP. Main symptoms were lower limbs arthralgia and myalgia. MSP persisted more in females than in males (p = 0.038) and in pubertal rather than pre-pubertal subjects (p = 0.022); these subjects recovered significantly more both from BJHS (p = 0.004) and IMSP (p = 0.016). Gender did not influence the distribution of MSP according to pubertal stage.

CONCLUSIONS

Female gender, BJHS and pubertal stage are important risk factors for persistence of MSP. Further studies are needed to evaluate the natural history of MSP towards adulthood and the role of the pubertal age.

Children with visual impairments may have altered joint movement: an observational case-control study

To assess the articular range of motion in children with congenital visual impairment. Were evaluated 75 children between five and twelve years old, 49 with normal visual acuity and 26 visually impaired. Two evaluators performed the measure of active and passive range of motion by goniometry of shoulder and hip in all axes of motion. All examiners made a test of correlation between data obtained, to determine the inter-rater reliability, using the intraclass correlation coefficient (ICC). In individuals with visual impairments was statistically significant difference, with higher range of motion in individuals with visual impairments to medial and lateral rotation of shoulder and hip lateral rotation. Were found: high correlation in the inter-rater reliability (ICC>0.70) for 9 (22.5%) groups of articular range of motion, moderate correlation (0.7>ICC>0.5) for 25 (62.5%) groups and low correlation to 6 (15%) groups ranges of motion. Sampled children with congenital visual impairment showed greater joint mobility for rotational range of motion of the shoulder and hip than children with normal visual acuity, although they have also shown lower values for articular range of motion in abduction and extension in shoulders.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Effect of generalized joint hypermobility on knee function and muscle activation in children and adults

INTRODUCTION

We investigated muscle activation strategy and performance of knee extensor and flexor muscles in children and adults with generalized joint hypermobility (GJH) and compared them with controls.

METHODS

Muscle activation, torque steadiness, electromechanical delay, and muscle strength were evaluated in 39 children and 36 adults during isometric knee extension and flexion. Subjects performed isometric maximum contractions, submaximal contractions at 25% maximum voluntary contraction (MVC), and explosive contractions.

RESULTS

Agonist activation was reduced, and coactivation ratio was greater in GJH during knee flexion compared with controls. Torque steadiness was impaired in adults with GJH during knee flexion. No effect of GJH was found on muscle strength or electromechanical delay. Correlation analysis revealed an association between GJH severity and function in adults.

CONCLUSIONS

The results indicate that muscle activation strategy and quality of force control were significantly affected in adults with GJH during knee flexion, whereas only muscle activation strategy was affected in children with GJH.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Knee function in 10-year-old children and adults with Generalised Joint Hypermobility

PURPOSE

Knee function is reduced in patients with Benign Joint Hypermobility Syndrome. The aim was to study knee function in children and adults with Generalised Joint Hypermobility (GJH) and Non-GJH (NGJH)).

MATERIALS AND METHODS

In a matched comparative study, 39 children and 36 adults (mean age children 10.2 years; adults 40.3 years) were included, comprising 19 children and 18 adults with GJH (Beighton ≥ 5/9; Beighton ≥ 4/9), minimum one hypermobile knee, no knee pain (children), and 20 children and 18 adults with NGJH (Beighton <5; Beighton <4). Totally, 85% of the adults were parents to these children. Knee function was determined by self-reported physical fitness (100mm VAS), Knee injury and Osteoarthritis Outcome Score (KOOS) (only adults), measured maximum isokinetic knee strength (60°/s) and peak vertical jump displacement (PVJD), with calculated knee strength balance, Hamstring/Quadriceps (H/Q) ratio and peak rate of force development (PRFD).

RESULTS

Adults with GJH had lower knee function (KOOS: pain, p=0.001; symptoms, p=0.001; Activities of Daily Living, p=0.001; Sport/Recreation, p=0.003; knee-related quality of life, p<0.001), and H/Q ratio (0.46 vs. 0.54, p=0.046) than adults with NGJH, regardless of age and knee pain. Both GJH groups had normal physical fitness, isokinetic knee strength, and (only children) H/Q ratio.

CONCLUSIONS

Children at 10 years with GJH have normal, but adults with GJH have impaired knee function. To track the risk of developing impaired knee function, children with GJH must be followed longitudinally. Meanwhile, attention to knee function may be given to children with GJH who have parents presenting GJH.

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

Hypermobility syndrome (HMS) is a major source of morbidity in children. Impaired quality of life (QoL) has been observed recently in adults with HMS; however, this issue is yet to be investigated in children with this condition. This study compared pain intensity and QoL in children with HMS with healthy controls. It also examined the relationship between pain intensity and QoL in children with HMS. Following ethical approval, 29 children diagnosed with HMS and 37 healthy children aged 8-15 years participated. Informed written consent was obtained from participants and their parents/guardians. Average knee pain over the past week was examined using the Coloured Analogue Scale. QoL was measured via the Pediatric Quality of Life Inventory. Mann-Whitney U tests were performed to compare pain and QoL scores between the two groups. Spearman Rho correlation analysis was performed to examine the relationship between pain and QoL. Overall QoL scores in each domain were significantly lower in children with HMS (all p < 0.001) compared with the controls. Pain intensity was significantly higher in children with HMS compared with their healthy counterparts (p < 0.001). A strong negative correlation was observed between pain intensity and overall QoL and all the domains (r range = -0.614 to -0.717; all p < 0.001). In conclusion, the findings of the present study imply that pain and QoL assessment might form important components of clinical examination for children diagnosed with HMS. These children may benefit from appropriate treatment programmes to alleviate pain intensity and improve QoL.

Survey of Paediatric Occupational Therapists' Understanding of Developmental Coordination Disorder, Joint Hypermobility Syndrome and Attention Deficit Hyperactivity Disorder

Evidence suggests that developmental coordination disorder (DCD) co-occurs with attention deficit hyperactivity disorder (ADHD) and joint hypermobility syndrome (JHS). Paediatric occupational therapists working with children with DCD need to consider the impact of co-occurring conditions on the children they assess and treat. A survey investigating the knowledge base and understanding relating to these conditions was conducted. The results showed that therapists (n = 225, response rate 23%) have an understanding of DCD; however, a more detailed knowledge of ADHD and JHS would allow them to consider the impact of the overlapping nature of these conditions. This highlights a training need to ensure understanding of these conditions and appropriate management.

Benign joint hypermobility syndrome: a cause of childhood asthma?

Benign joint hypermobility syndrome (BJHS) is a hereditable disorder of connective tissue, which is characterized by the occurrence of multiple musculoskeletal problems in hypermobile individuals who do not have a systemic rheumatological disease. Rectal, uterine and mitral prolapses, varicose veins, myopia and recurrent urinary tract infections are more common in patients with BJHS, which indicates a diffuse anomaly in the structure of connective tissue rather than a limited involvement of the musculoskeletal system. Asthma, as a complex trait disease, develops after environmental exposure to innocuous allergens, infectious agents and air pollutants in susceptible individuals on the basis of their genetics. However, genetic factors cannot explain the recent rise in the prevalence, morbidity, or mortality of asthma. Asthma may also be caused by a connective tissue defect. Changes in the mechanical properties of the bronchial airways and lung parenchyma may underlie the increased tendency of the airways to collapse in asthmatic children. In this paper, we postulate that BJHS may lead to persistent childhood wheezing by causing airway collapse through a connective tissue defect that affects the structure of the airways.

Motor competence and physical activity in 8-year-old school children with generalized joint hypermobility

OBJECTIVE

Because the criteria used for diagnosing between generalized joint hypermobility (GJH) and musculoskeletal complaints, as well as relations between GJH and an insufficient motor development and/or a reduced physical activity level differ, the prevalence of GJH varies considerably. The aim of this study was to survey the prevalence of GJH defined by a Beighton score at >or=4, >or=5, or >or=6 positive tests of 9 and benign joint hypermobility syndrome (BJHS) in Danish primary school children at 8 years of age. A second aim was to compare children with and without GJH and BJHS regarding motor competence, self-reported physical activity, and incidence of musculoskeletal pain and injuries.

METHODS

A cross-sectional study of 524 children in the second grade from 10 public schools was performed. A positive response rate was obtained for 416 (79.4%) children, and 411 (78.4%) children were clinically examined and tested for motor competence, whereas questionnaire response to items comprising musculoskeletal pain and injuries, in addition to daily level and duration of physical activity, corresponded to 377 (71.9%) children.

RESULTS

In total, 29% of the children had GJH4, 19% had GJH5, 10% had GJH6, and 9% had BJHS, with no gender difference. There was no difference in daily level and duration of physical activity and in frequency of musculoskeletal pain and injuries between those with and without GJH. Children with >or=GJH5 as well as with >or=GJH6 performed better in the motor competence tests.

CONCLUSION

Motor competence and physical activity are not reduced in primary school children at 8 years of age with GJH or BJHS. It is recommended that a potential negative influence on the musculoskeletal system over time, as a result of GJH, be investigated by longitudinal studies.

[The joint hypermobility syndrome in a Cuban juvenile population]

In order to review the rise in joint hypermobility syndrome, identify the patterns associated with this diagnosis and correlate its most relevant symptoms, we did a descriptive transversal analytic study in a group of 280 young people of both genders between 15 and 17 years of age. A survey was carried out by the authors in order to get reach these objectives. The data were analyzed by means of descriptive statistics and processed with the Epidat3.1 software package. Results are shown in charts.

RESULTS

The joint hypermobility syndrome (JHS) was diagnosed in 32 people (11,4% of the population studied) with mean age 15,7 years, predominance in the female sex and in the white skin group (p<0,01) 53.1% of those patients with hypermobility presented skin lesions associated to hereditary diseases of the connective tissue; among them the most relevant clinical sign was the presence of hematomas (p=0.003). Symptoms of dysautonomia were associated to JHS (p⩽0.05) and correlated positively with the presence of hematomas. Moderate and severe chronic pain was also a feature of patients with the syndrome (p=0.001) and was correlated in a positive manner to the hematomas.

CONCLUSIONS

Vascular affection as demonstrated by the formation of hematomas was the skin lesion more important among young people with JHS in this study. These lesions can be representative of the syndrome and a translate a larger damage at the connective tissue level.

Motor performance in children with generalized hypermobility: the influence of muscle strength and exercise capacity

PURPOSE

The aim of this study was to investigate whether muscle strength and functional exercise capacity (FEC) influence motor performance in children with generalized joint hypermobility.

METHODS

Forty-one children (mean age: 8.1 years) with symptomatic generalized hypermobility were included. Motor performance was assessed using the Körperkoordinationstest für Kinder (KTK) and the Movement Assessment Battery for Children. Muscle strength and FEC were measured with a handheld dynamometer and the 6-minute walk test.

RESULTS

Only muscle strength was significantly positively associated with motor performance on the KTK. FEC was significantly decreased. Children's scores on the KTK were significantly lower (p < 0.001) compared with scores on the Movement Assessment Battery for Children.

CONCLUSIONS

The KTK is a more sensitive tool for detecting motor problems in children with generalized joint hypermobility, but is not associated with FEC. Along with the KTK, the 6-minute walk test can be used to independently assess and evaluate FEC.

Hypermobility and the hypermobility syndrome

Hypermobile joints by definition display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility, when associated with symptoms is termed the joint hypermobility syndrome or hypermobility syndrome (JHS). JHS is an under recognised and poorly managed multi-systemic, hereditary connective tissue disorder, often resulting in a great deal of pain and suffering. The condition is more prevalent in females, with symptoms frequently commencing in childhood and continuing on into adult life. This paper provides an overview of JHS and suggested clinical guidelines for both the identification and management of the condition, based on research evidence and clinical experience. The Brighton Criteria and a simple 5-point questionnaire developed by Hakim and Grahame, are both valid tools that can be used clinically and for research to identify the condition. Management of JHS frequently includes; education and lifestyle advice, behaviour modification, manual therapy, taping and bracing, electrotherapy, exercise prescription, functional rehabilitation and collaborative working with a range of medical, health and fitness professionals. Progress is often slow and hampered by physical and emotional setbacks. However with a carefully considered management strategy, amelioration of symptoms and independent functional fitness can be achieved.

Exercise tolerance in children and adolescents with musculoskeletal pain in joint hypermobility and joint hypomobility syndrome

OBJECTIVES

Musculoskeletal pain is a common complaint in a pediatric health care practice, but exercise tolerance has never been described in detail in these children. Our objectives for this study were to evaluate the maximal exercise capacity, including peak heart rate and oxygen consumption, of children with pain-related musculoskeletal problems, particularly in children with (symptomatic) generalized joint hypermobility and hypomobility, during a bicycle ergometry test to exhaustion; to evaluate muscle strength, bone mineral density, and sports activities in these children and to associate these observations with exercise capacity; and to compare these results with reference values.

METHODS

Thirty-two children (mean age: 12.1 years; SD: 3.4 years; range: 6.2-20.1 years; 62% male) with musculoskeletal pain-related syndromes (joint hypermobility syndrome [n = 13] and joint hypomobility syndrome [n = 19]) participated. The reference group consisted of 117 healthy primary school prepubertal children, 167 healthy secondary school adolescents, and 98 young adults (249 girls and 133 boys; mean age total reference group: 14.5 +/- 4.0 years; range: 8-20.8 years). Anthropometry, range of joint motion, muscle strength, bone mineral density (speed of sound and broadband ultrasound attenuation), sports activities, and a maximal exercise test using an electronically braked cycle ergometer were performed, and the patient stopped because of volitional exhaustion. Expired gas analysis and heart rate and transcutaneous oxygen saturation by pulse oximetry measurements also were performed.

RESULTS

Children with joint hypomobility syndrome as well as children with joint hypermobility syndrome had a higher mean z score (SD) of weight and BMI compared with the reference group. A significantly decreased absolute peak oxygen consumption and relative peak oxygen consumption in both patient groups was found compared with control subjects. In 14 of 32 children with a z score relative peak oxygen consumption of less than -2, maximal heart rate was significantly decreased compared with 18 children with a z score relative peak oxygen consumption of -2 or more (mean [SD] z score speed of sound: -1.3 [0.8] vs -0.5 [1.0] and mean [SD] heart rate: 175.9 [11.5] vs 187.5 [10.9], respectively). In the total group, a high significant correlation between the z score of relative peak oxygen consumption and the z score of the speed of sound was found as well as with z score of BMI. Sixteen (50%) of 32 participated in sports activities with (mean: 0.9 hours/week; SD: 1.4 hours/week), whereas in the control group, 12% of did not participate in sports activities (mean: 2.8 hours/week; SD: 2.2 hours/week). Children who participated in sports activities had a (borderline) significant increased mean (SD) z score of absolute peak oxygen consumption and mean (SD) z score of broadband ultrasound attenuation compared with children who did not participate in sports activities (-0.3 [1.1] vs -1.2 [1.3] and -0.45 [0.8] vs -0.9 [0.5], respectively).

CONCLUSIONS

In children with musculoskeletal pain-related syndromes, particular in children with (symptomatic) generalized joint hypermobility and hypomobility, maximal exercise capacity is significantly decreased compared with age- and gender-matched control subjects. The most probable explanation for the reduced exercise tolerance in our patients is deconditioning.

Is musculoskeletal history and examination so different in paediatrics?

Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.

Hypermobility disorders in children and adolescents

It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.

Analysis of joint mobility patterns among preschool children

CONTEXT AND OBJECTIVE

Standardization of normal joint mobility criteria is complex, especially for preschool children, for whom differentiation from hypermobility (JH) is even more difficult. This study aimed to investigate joint mobility of the fifth finger, wrist, elbow, knee and trunk among preschool children, estimate the incidence of JH and evaluate the effect of gender and age and the applicability of standard criteria for identifying JH among preschool children.

DESIGN AND SETTING

Cross-sectional descriptive and quantitative study, at São José do Rio Preto medical school.

METHODS

1,120 healthy children (534 boys, 47.7%; 586 girls, 52.3%; age range: 4-7 years) were evaluated using Beighton scores. Passive extension of fifth finger (> 90 degrees), passive apposition of thumb to forearm, active extension of elbow and knee (> 10 degrees) and anterior trunk flexion placing flat hand on ground were assessed. One point was scored for each positive result (maximum: 9). Scores > 4 were considered to be JH. Students t test and variance analysis were used for statistical analysis.

RESULTS

JH was observed in 80% of wrists, 53.3% of fifth fingers, 36.6% of elbows, 14% of trunks and 12.5% of knees. Scores > 4 were found for 64.6% of the children. Females had higher angular values. Lower scores were associated with greater age.

CONCLUSIONS

JH is a common condition among preschool children and currently available methods are inadequate. New parameters and criteria should be developed for identifying JH among these children.

Is chronic fatigue syndrome a connective tissue disorder? A cross-sectional study in adolescents

OBJECTIVES

To investigate whether constitutional laxity of the connective tissues is more frequently present in adolescents with chronic fatigue syndrome (CFS) than in healthy controls. Increased joint hypermobility in patients with CFS has been previously described, as has lower blood pressure in fatigued individuals, which raises the question of whether constitutional laxity is a possible biological predisposing factor for CFS.

DESIGN

Cross-sectional study.

PARTICIPANTS

Thirty-two adolescents with CFS (according to the criteria of the Centers for Disease Control and Prevention) referred to a tertiary hospital and 167 healthy controls.

METHODS

The 32 adolescents with CFS were examined extensively regarding collagen-related parameters: joint mobility, blood pressure, arterial stiffness and arterial wall thickness, skin extensibility, and degradation products of collagen metabolism. Possible confounding factors (age, gender, height, weight, physical activity, muscle strength, diet, alcohol consumption, and cigarette smoking) were also measured. The results were compared with findings in 167 healthy adolescents who underwent the same examinations.

RESULTS

Joint mobility, Beighton score, and collagen biochemistry, all indicators of connective tissue abnormality, were equal for both groups. Systolic blood pressure, however, was remarkably lower in patients with CFS (117.3 vs. 129.7 mm Hg; adjusted difference: -13.5 mm Hg; 95% confidence interval [CI]: -19.1, -7.0). Skin extensibility was higher in adolescents with CFS (mean z score: 0.5 vs. 0.1 SD; adjusted difference: 0.3 SD; 95% CI: 0.1, 0.5). Arterial stiffness, expressed as common carotid distension, was lower in adolescents with CFS, indicating stiffer arteries (670 vs 820 mum; adjusted difference: -110 mum; 95% CI: -220, -10). All analyses were adjusted for age, gender, body mass index, and physical activity. Additionally, arterial stiffness was adjusted for lumen diameter and pulse pressure.

CONCLUSIONS

These findings do not consistently point in the same direction of an abnormality in connective tissue. Patients with CFS did have lower blood pressure and more extensible skin but lacked the most important parameter indicating constitutional laxity, ie, joint hypermobility. Moreover, the collagen metabolism measured by crosslinks and hydroxyproline in urine, mainly reflecting bone resorption, was not different. The unexpected finding of stiffer arteries in patients with CFS warrants additional investigation.

Joint hypermobility syndrome in childhood. A not so benign multisystem disorder?

OBJECTIVES

Joint hypermobility (JH) or "ligamentous laxity" is felt to be an underlying risk factor for many types of musculoskeletal presentation in paediatrics, and joint hypermobility syndrome (JHS) describes such disorders where symptoms become chronic, often more generalized and associated with functional impairment. Clinical features are felt to have much in common with more severe disorders, including Ehlers-Danlos syndrome (EDS), osteogenesis imperfecta and Marfan syndrome, although this has not been formally studied in children. We defined the clinical characteristics of all patients with joint hypermobility-related presentations seen from 1999 to 2002 in a tertiary referral paediatric rheumatology unit.

METHODS

Patients were identified and recruited from paediatric rheumatology clinic and ward, and a dedicated paediatric rheumatology hypermobility clinic at Great Ormond Street Hospital. Data were collected retrospectively on the patients from the paediatric rheumatology clinics (1999-2002) and prospectively on patients seen in the hypermobility clinic (2000-2002). Specifically, historical details of developmental milestones, musculoskeletal or soft tissue diagnoses and symptoms, and significant past medical history were recorded. Examination features sought included measurements of joint and soft tissue laxity, and associated conditions such as scoliosis, dysmorphic features, cardiac murmurs and eye problems.

RESULTS

One hundred and twenty-five children (64 females) were included on whom sufficient clinical data could be identified and who had clinical problems ascribed to JH present for longer than 3 months. Sixty-four were from the paediatric rheumatology clinic and 61 from the hypermobility clinic. No differences were found in any of the measures between the two populations and results are presented in a combined fashion. Three-quarters of referrals came from paediatricians and general practitioners but in only 10% was hypermobility recognized as a possible cause of joint complaint. The average age at onset of symptoms was 6.2 yr and age at diagnosis 9.0 yr, indicating a 2- to 3-yr delay in diagnosis. The major presenting complaint was arthralgia in 74%, abnormal gait in 10%, apparent joint deformity in 10% and back pain in 6%. Mean age at first walking was 15.0 months; 48% were considered "clumsy" and 36% as having poor coordination in early childhood. Twelve per cent had "clicky" hips at birth and 4% actual congenital dislocatable hip. Urinary tract infections were present in 13 and 6% of the female and male cases, respectively. Thirteen and 14%, respectively, had speech and learning difficulties diagnosed. A history of recurrent joint sprains was seen in 20% and actual subluxation/dislocation of joints in 10%. Forty per cent had experienced problems with handwriting tasks, 48% had major limitations of school-based physical education activities, 67% other physical activities and 41% had missed significant periods of schooling because of symptoms. Forty-three per cent described a history of easy bruising. Examination revealed that 94% scored > or =4/9 on the Beighton scale for generalized hypermobility, with knees (92%), elbows (87%), wrists (82%), hand metacarpophalangeal joints (79%), and ankles (75%) being most frequently involved.

CONCLUSIONS

JHS is poorly recognized in children with a long delay in the time to diagnosis. Although there is a referral bias towards joint symptoms, a surprisingly large proportion is associated with significant neuromuscular and motor development problems. Our patients with JHS also show many overlap features with genetic disorders such as EDS and Marfan syndrome. The delay in diagnosis results in poor control of pain and disruption of normal home life, schooling and physical activities. Knowledge of the diagnosis and simple interventions are likely to be highly effective in reducing the morbidity and cost to the health and social services.

The relationship between generalized joint hypermobility and motor development

PURPOSE

The aim of this study was to investigate the relationship between the presence and localization of joint hypermobility and delay in motor development.

METHODS

A retrospective chart review was performed. All children younger than 2.5 years of age and between four and 12 years of age with generalized joint hypermobility were included. Generalized joint hypermobility was assessed using the criteria of Bulbena. In children between one and 2.5 years of age, motor development was measured using the Bayley Scales of Infant Development. In children four to 12 years of age, the Movement Assessment Battery for Children was used.

RESULTS

Data from 72 children were available for analysis. In nine of 16 children younger than 2.5 years of age, a delay in motor development was found without a significant association between the delay in motor development (yes/no) and the Bulbena score (odds ratio: 0.4; 95% confidence interval: 0.07-2.1). In children between four and 12 years of age, a severe delay in motor development was present in 14 of 56 children (25%), while 12 of 56 children (21%) were at risk and 30 of 56 (54%) were age appropriate. No significant association between delay in motor development and the Bulbena score was found (odds ratio: 1.3; 95% confidence interval: 0.8-2.1). The age of independent walking was not significantly associated with the number of hypermobile joints (Bulbena score) (linear regression coefficient: 0.3; 95% confidence interval: -1.5 - 2.1).

CONCLUSIONS

Although severe delays in motor development may be observed in approximately one third of children with generalized joint hypermobility, there is no association between the amount of generalized joint hypermobility and delay in motor development.

[Joint hypermobility: prevalence and relationship with musculoskeletal pain]

OBJECTIVES

(1) To determine the prevalence of joint hypermobility in children aged 4-14 years old without organic disease of the locomotor system; (2) to compare the prevalence of hypermobility in children with and without arthralgia and (3) to analyze the influence of certain variables on the development of arthralgia.

PATIENTS AND METHODS

We performed an observational study in a sample of children aged 4-14 years old living in Area 4 of the Community of Madrid (Spain). Joint hypermobility was evaluated using a goniometer. Hypermobility was defined using Beighton's criteria.

RESULTS

A total of 222 subjects were analyzed: 176 in the primary care setting and 46 in the emergency department of a referral hospital. Of the 222 children, 43 reported arthralgia. The prevalence of hypermobility (> or = 4 criteria) was 55 % (123/222), reaching 71 % (49/69) in children aged less than 8 years. No significant differences were found in the prevalence of hypermobility in children with and without arthralgia (65 % and 53 % respectively). Of the variables analyzed (age, sex, country of origin, primary care/emergency department setting) only differences in the absolute number of Beighton criteria present in children with and without arthralgia (4.34 +/- 2.47 and 3.48 +/- 2.35, p = 0.03) were detected, which disappeared when at least four criteria (definition of hypermobility) were required.

CONCLUSIONS

Fifty-five percent of the population studied and 71 % of those younger than 8 years old met the criteria for joint hypermobility. In the sample analyzed, the presence of joint hypermobility did not seem to favor the development of arthralgias.

Advances in paediatric rheumatology: beyond NSAIDs and joint replacement

Over the previous three decades there have been a number of dramatic changes in our understanding of both the pathogenesis and epidemiology of the rheumatic diseases of childhood. Improvements in the classification of paediatric-onset arthritides and international collaboration in terms of multicentre research have led to the development of new therapeutic agents and better methods of outcome assessment for these chronic and often disabling conditions. Fortunately for children with paediatric rheumatic diseases treatment regimes are now available that provide excellent disease control for many and remission induction for some. Challenges include clearer definition of the genetics and pathogenesis of the diseases, delineation of reliable biological markers for diagnosis and monitoring of disease activity. The future should also herald early identification of those with a poorer prognosis, together with the design of more powerful, safer and cheaper remission-inducing agents, given to the right patients at the right time.

Pediatric generalized joint hypomobility and musculoskeletal complaints: a new entity? Clinical, biochemical, and osseal characteristics

OBJECTIVE

To describe the clinical features, osseal characteristics, and collagen biochemistry in children who attended our clinic with predominantly generalized hypomobility of the joints, in combination with musculoskeletal complaints or abnormal walking, and no known syndrome or known rheumatic, neurologic, skeletal, metabolic, or connective tissue disorder was present.

METHODS

Nineteen children who attended the Children's Hospital of the University Medical Center Utrecht for generalized hypomobility of the joints (mean age: 11.6; standard deviation: 2.7), in combination with musculoskeletal complaints or abnormal walking as primary complaints (symptomatic generalized hypomobility [SGH]), were compared with an age-matched reference group of 284 healthy children with normal mobility of the joints. Anthropometrics, range of joint motion, muscle strength, exercise tolerance, motor development, quantitative ultrasound measurements of bone, and degradation products of collagen in urine were studied. Collagen modifications were determined in skin biopsies of 3 children and in hypertrophic scar tissue of another child, all with SGH.

RESULTS

The range of joint motion was significantly decreased in almost all joints of all 19 children and after adjustment for age, gender, body weight, and height, significantly lower than that of the reference group (-108.3 degrees; 95% confidence interval [CI]: -136.9 to -79.8). Quantitative ultrasound measurements as well as urinary pyridinoline cross-link levels were, after adjustment for possible confounders, significantly lower in SGH children (broad-band ultrasound attenuation: -9.6 dB/MHz [95% CI: -17.4 to -1.9]; speed of sound: -25.0 m/s [95% CI: -39.7 to -10.3]; hydroxylysylpyridinoline: -50.1 micromol/mmol [95% CI: -87.6 to -12.6], lysylpyridinoline: -21.3 micromol/mmol [95% CI: -34.0 to -8.6]). An increased amount of pyridinoline cross-links per collagen molecule was observed in skin and hypertrophic scar tissue, in combination with increased amounts of collagen.

CONCLUSION

SGH in children is considered a new clinical entity with specific clinical characteristics and might be related to an increased stiffness of connective tissue as a result of higher amounts of collagen with increased cross-linking.

Relationship between foot angles and hypermobility scores and assessment of foot types in hypermobile individuals

This study proposed to assess foot types and radiological examination of feet of individuals with hypermobility syndrome in comparison to healthy matched controls for age, sex, and body mass index. The relationship between foot angles and hypermobility scores of subjects in both groups were also~assessed. Twenty individuals having joint hypermobility syndrome previously diagnosed according to Beighton and Bulbena scores were compared to 20 healthy subjects. Standing anteroposterior (AP) and lateral weigthbearing radiographs of feet of the individuals were taken. Foot angles and foot types were evaluated on the AP and lateral views. The mean +/- SD of Beighton and Bulbena scores were significantly higher in the hypermobile individuals (p <.001) than in controls. In both groups, Egyptian and square types of feet were mostly encountered (p >.05). Bilateral calcaneal pitch (CP) angles (p <.001), bilateral talometatarsal (TM) angles (p <.01), and right apex angles (p <.05) were significantly low in hypermobile individuals, whereas first metatarsophalangeal (MTP) angles were significantly high (right foot, p <.01; left foot, p <.05) as compared to the control group. Hypermobility scores correlated negatively with bilateral CP and TM angles and positively with bilateral first MTP angles. No correlation was found for the other~angles. These finding suggest that foot angles (especially CP, TM and first MTP angles) are in relation with severity of hypermobility. There was no difference between foot types in the hypermobile individuals and healthy controls. These angles may be useful for clinically monitoring the foot health in the hypermobile individuals.

The prevalence of joint hypermobility among high school students

OBJECTIVE

The aim of this study was to determine the prevalence of joint hypermobility among high school students and to define the characteristics of patients with joint hypermobility.

METHODS

The students underwent complete history and physical examination. In order to designate marfanoid habitus, body weight, height, and span/height and upper/lower segment ratios were recorded. The degree of joint hypermobility was scored by the Beighton scoring system. The following features were also examined: arthralgia, myalgia, low back pain, sciatica, spinal deformities, temporomandibular joint pain and crepitus, effusion, swan neck deformity, arachnodactyly, joint dislocation, joint sprain, Raynaud's phenomenon, stria, varicose veins, abdominal and inguinal hernia, heart disease history, myopia, dropping eyelids, and antimongoloid slant.

RESULTS

Eight hundred sixty-one students (433 females and 428 males) with a mean age of 15.4+/-1.1 years (range 13-19) were examined. Joint hypermobility was observed in 101 (11.7%) of the students. According to the Beighton scoring system, the majority of these (61.4%) were observed to score 4. Our results show that phenotype has no relation with joint mobility. Of the total number of students, there were 31 male (7.2%) and 70 female (16.2%) hypermobile subjects. The difference between sexes was highly significant (P=0.00005). Joint sprain was detected in 14 of hypermobile students (13.9%) and 50 of nonhypermobile students (6.6%). Its presence was the only significant parameter between hypermobile and nonhypermobile students (P=0.0094).

CONCLUSIONS

Joint hypermobility was found in 11.7% of the students in our study, and the results are in harmony with the previous studies on Western populations. Although hypermobility does not seem to be very problematic in young people, as in our focus group, we believe that it is important for physicians to recognize this problem to ensure correct diagnosis and treatment, since it may lead to mimic rheumatic diseases in the future.

Joint hypermobility

Joint hypermobility is an area of neglect in rheumatology. That is not to say it is overlooked by rheumatologists. It is spotted when sought, but for many unfortunate patients, here the story ends. The act of recognition becomes the goal in itself rather than the medium through which effective therapy can be provided. This chapter serves to reinforce the clinical and epidemiological importance of a common disorder whose significance is under-appreciated and impact largely ignored. In contradistinction to our earlier chapter, published in 2000, which took for its remit the heritable disorders of connective tissue in general, the current one focuses on the commonly encountered (so-called benign) joint hypermobility syndrome, its recognition, epidemiology, clinical features and management according to the most recent literature.