Benefits and liabilities of hypermobility in the back pain disorders of industrial workers

The concomitant diagnosis of fibromyalgia and connective tissue disorders: A systematic review

BACKGROUND

Anecdotally, fibromyalgia syndrome (FMS) and connective tissue disorders (hypermobile Ehlers-Danlos Syndrome (hEDS), Hypermobility Spectrum disorders (HSD) and Generalized Joint Hypermobility (GJH)) manifest overlap in their diagnostic approach and symptomatic features. Understanding this overlap is important for accurate diagnosis and the success of subsequent management. This study therefore aimed to identify the prevalence of concomitant diagnosis of FMS and hEDS/HSD/GJH in adults and their shared symptomatic manifestations using a systematic review.

METHODS

MEDLINE (via EBSCO host) was systematically searched. Observational research (case-control or single group) studies were considered for inclusion, where adults screened for hEDS/HSD/GJH and FMS were compared in terms of diagnostic prevalence, and musculoskeletal and non-musculoskeletal manifestations. Studies on pediatric populations were excluded. The quality of the included studies was assessed using the National Institute of Health Quality Assessment of Case-Control Studies and Jonna Briggs Critical Appraisal checklist for prevalence studies. The review was registered prospectively in PROSPERO (CRD42020216283).

FINDINGS

The review included eleven studies: nine case-control studies and two single group studies. The prevalence of concomitant diagnosis of hEDS/HSD and FMS ranged from 68%-88.9% and from 8.0 to 64.2% for GJH and FMS. The prevalence and severity of a range of objective and patient-reported features were similar between hEDS/HSD and FMS, including joint pain (duration, persistence, SF-36-pain component score); joint swelling; muscle weakness; neurological problems; multidimensional pain inventory-activity; dysautonomia and total autonomic symptoms burden (including orthostatic intolerance, reflex syncope, vasomotor, gastrointestinal, diarrhea, constipation and pupillomotor domains); function; and quality of life. Shared symptomatic features between GJH and FMS were mean pain level, tender points count, total myalgia score and psychological impact.

INTERPRETATION

There may be overlapping symptomatology and diagnostic prevalence of FMS and hEDS/HSD/GJH. Clinicians should consider both diagnoses to ensure appropriate diagnosis and management.

Symptomatic Joint Hypermobility Is Associated with Low Back Pain: A National Adolescents Cohort Study

Background: Low back pain (LBP) is a widespread medical complaint affecting many people worldwide and costing billions. Studies suggest a link between LBP and joint hypermobility. This study aimed to examine the association between symptomatic joint hypermobility (SJH), LBP, and gender. Methods: Data were obtained from a medical database containing 17-year-old candidates’ records before recruitment into mandatory military service. According to the Regulations of Medical Fitness Determination, information on disability codes associated with LBP and SJH was retrieved. Results: According to this national survey, the prevalence of SJH is 0.11% (1355 cases out of 1,220,073 subjects). LBP was identified in 3.7% of the cohort (44,755 subjects). Subjects were further subdivided into LBP without objective findings (LBPWF) (3.5%) and LBP with objective findings (LBPOF) (0.2%). The association between SJH and LBP was examined: the Odds Ratio (OR) was 2.912 (p < 0.0001). The odds rations for LBPWF and LBPOF were further calculated to be 2.914 (p < 0.000) and 2.876 (p < 0.000), respectively. Subjects with SJH were almost three times more prone to LBPWF and LBPOF. Conclusion: SJH is strongly associated with LBP in young adults. Further pathophysiological research is needed.

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

BACKGROUND

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

METHODS

Narrative literature review.

RESULTS

Not applicable.

CONCLUSIONS

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

Are Asian hands more flexible than their Caucasian counterparts?

Introduction

Though there is a general perception that Asian hands have an increased range of movements in all their joints, there is very little written in the literature on this topic. Our unit caters to a multiethnic population and it has been our experience that the outcomes after hand surgery are generally better in Asian hands. This study was aimed at comparing the range of movements between two cohorts of volunteers: Asians and Caucasians.

Methods

Data were collected on their ethnicity, gender, age, handedness and any medical conditions. The Beighton score was measured for all subjects and range of movements was measured using a standard goniometer. Totally, 114 subjects were enrolled into the study, which included 53 men (46%).

Results

There were 59 Caucasians and 55 Asians. The range of movements of wrist and hand was greater in Asians and the difference was statistically significant ( p < 0.05). Men in general had greater range of movement of the fingers whereas women had greater range of movement of the thumb. There was no difference between Asian men and women with regard to wrist movements. However, Caucasian women had greater wrists movements than Caucasian males. The average Beighton score was the highest in Asian women (7), followed by Asian men (6). Caucasian men and women had an average Beighton Score of 2.

Discussion

Normative data for different ethnic groups are important for hand therapy as they can guide rehabilitation protocols. Our study demonstrates that a difference in hand flexibility between British Asians and their Caucasian counterparts exists.

Association of benign joint hypermobility with spinal segmental motion and its clinical implication in active young males

STUDY DESIGN

A retrospective case-control analysis of prospectively collected data.

OBJECTIVE

First, to evaluate spinal intervertebral mobility in patients with joint hypermobility (JHM) and matched controls without JHM, and second, to investigate the influence of JHM on back pain, disability, and general health status in young males.

SUMMARY OF BACKGROUND DATA

Despite the significance of benign JHM in the musculoskeletal feature, there have been no studies regarding low back pain and segmental motion in subjects with JHM. Furthermore, the clinical significance of the excessive segmental motion in young males with JHM remains unknown.

METHODS

The JHM group included 32 subjects who had Beighton scale score of 4 or more according to 9° Beighton scale. The age-matched 32 young males without JHM were selectively included in the control group. In both groups, Oswestry Disability Index (ODI), visual analogue pain scale (VAS) for back pain, and Short-Form 36 was assessed. Radiological sagittal plane motions for each segment and whole lumbar spine were calculated as the difference between the Cobb angle measurements in the flexion and extension plain radiographs. In the lateral radiograph with neutral standing position, the intervertebral disc heights were also measured at each segment.

RESULTS

The JHM group showed significantly larger range of motion and higher intervertebral disc height at each matched segment than the control group. The JHM group had significant increased VAS for back pain and ODI score, compared with control group. The Short-Form 36 physical function, role physical, role emotional, and physical component summary in the JHM group were significantly lower than in the control group.

CONCLUSION

This study shows that young males with JHM were found to have excessive lumbar segmental motion that was associated with increased low back pain, disability, and limited physical activity.

Survey of faulty postures and associated factors among Chinese adolescents

OBJECTIVE

This study investigates the prevalence of common faulty postures among adolescents and identify if significant relationships existed among the number of faulty postures, psychologic distress, and musculoskeletal symptoms.

METHODS

The Musculoskeletal Questionnaire and Chinese Health Questionnaire were randomly distributed to 300 high school students in the Tainan area. On-campus postural screening, which included digital photography, manual muscle tests, and flexibility tests, was also performed.

RESULTS

Two hundred eighty-seven participants completed all of the evaluations. The most common faulty posture was uneven shoulder level (36%), followed by forward head posture (25%). There was a sex difference between groups. The incidence of forward head posture for the male students was higher than that of the female students (P < .0001). In addition, the high psychologic distress group tended to have a higher prevalence of uneven shoulder height than that of the low psychologic distress group (P < .0001). As for the correlation analysis, the researchers did not find a high correlation among the scores of the faulty posture, psychologic distress, and musculoskeletal symptoms.

CONCLUSION

The results of this study show that the incidence of faulty posture was high for the adolescent group, especially for the uneven shoulder level. Subjects' awareness about being assessed might decrease the incidence for some faulty posture. However, the relationships among the number of faulty postures, psychologic distress, and musculoskeletal symptoms were low. We suggest that there are multiple factors that might contribute to musculoskeletal symptoms; faulty posture could be one important factor that causes symptoms.

Accuracy of the clinical examination to predict radiographic instability of the lumbar spine

Forty-nine patients with low-back pain referred for flexion-extension radiographs due to suspicion of lumbar instability were studied to examine the relationship between the clinical presentation and the presence of radiographic instability of the lumbar spine. Patients had a mean age of 39.2 (+/-11.3) years, with a mean Oswestry score of 20.4% (+/-13.3). The median duration of symptoms was 78 days. All patients underwent both a radiographic and clinical examination. The reliability of the radiographic variables was high, while the reliability of clinical variables ranged from moderate to good. Twenty-eight patients (57%) had radiographic instability based on published norms. Clinical variables related to the presence of radiographic instability were age, lumbar flexion range of motion, total extension range of motion, the Beighton scale for general ligamentous laxity, and segmental intervertebral motion testing. The presence of at least 53 degrees of lumbar flexion or a lack of hypomobility with intervertebral motion testing resulted in a positive likelihood ratio of 4.3 (95% CI: 1.8, 10.6), for predicting radiographic instability. The results of this study indicate that various factors from the clinical examination are useful for predicting radiographic instability. If the findings of this study can be replicated, these clinical factors could be used to inform treatment decision-making without a sole reliance on radiographic assessment.

Gender differences in sick leave related to back pain diagnoses: influence of pregnancy

STUDY DESIGN

A cross-sectional population-based study was conducted.

OBJECTIVE

To investigate the influence of pregnancy on any gender differences in sickness absence related to back pain diagnoses in the group 16 to 44 years of age.

SUMMARY OF BACKGROUND DATA

Back pain diagnoses are a major reason for sickness absence, especially among pregnant women. There is, however, little knowledge on the extent to which back pain during pregnancy may account for any differences in sickness absence when compared with men and nonpregnant women.

METHODS

Data on sick leave periods certified by a physician were combined from two research databases: one including all insured persons (n = 50,167) and one including pregnant women (n = 1342) for the duration of 1 year.

RESULTS

When pregnant women were subtracted from "all women," nonpregnant women had the same cumulative incidence of sickness absence related to back pain diagnoses as men. Among "all women" sick-listed with back pain diagnoses, 37% were pregnant, a finding not evident from official statistics. Sickness absence increased with age among nonpregnant women and men, but decreased among pregnant women.

CONCLUSIONS

The proportion of sickness absence related to back pain diagnoses did not differ between nonpregnant women and men ages 16 to 44 years. The importance of back pain diagnosis as a reason for sickness absence may thus be overrated among nonpregnant women.

Articular hypermobility in Icelandic 12-year-olds

OBJECTIVE

To examine the prevalence of articular hypermobility and its relationship to musculoskeletal pain in Icelandic 12-yr-olds, and to obtain baseline data for a prospective study on the subject.

METHODS

A total of 267 12-yr-olds were examined for articular hypermobility by the Beighton criteria. The children also answered a questionnaire concerning musculoskeletal pain and injuries, sports and musical activity.

RESULTS

The prevalence of hypermobility (defined as >/=4 Beighton criteria) was 40.5% in girls and 12.9% in boys. Despite slight trends for hypermobile subjects to be less active in sports and to report more joint pain, no correlation could be found between hypermobility and musculoskeletal symptoms.

CONCLUSIONS

An unusually marked sex difference in hypermobility exists among Icelandic 12-yr-olds, but hypermobility does not seem to affect joint symptoms or leisure activities at this age.