Joint hypermobility and genetic collagen disorders: are they related?

The effect of hamstrings foam rolling on tissue mechanical properties as measured by MyotonPRO in healthy men - A randomized controlled trial

INTRODUCTION

Foam Rolling (FR) is one of the most popular self-administered therapeutic method, however, its actual impact on mechanical properties of myofascial tissue remains unclear. Moreover, there is an ongoing debate concerning the critical physiological mechanisms activated in therapies using the mechanical pressure and the optimal selection of pressure parameters. This study aimed to determine the effect of FR on mechanical properties (elasticity, stiffness etc.) of myofascial tissues of posterior thigh, compare them with interventions containing certain elements of FR without mechanical pressure on the tissue, and try to determine the main causative factor for FR effects.

METHOD

Ninety-six active, healthy men (age 18-35) were randomly assigned to one of six groups within the randomized controlled trial design. The interventions (independent factor: intervention) were: Foam Rolling (ROL), FR-like-movement without roller (MOV), sitting straight - control (SIT). All interventions were applied for 30 or 120 s (independent factor: time). The primary outcomes were biomechanical parameters measured with the MyotonPRO device in six groups distinguished by the experimental factors. Measurements were taken at the baseline and after the interventions (repeated measures factor). Mixed model of ANOVA was applied to test for statistical differences.

RESULTS

No significant differences were revealed for the two independent factors, the repeated measures factor as well as their all interactions.

CONCLUSIONS

As far as the effect exerted on mechanical properties of the myofascial tissue is concerned, FR intervention could not be regarded superior to other interventions (FR-like-movement without a roller) or control condition (sitting straight).

Autism in the context of joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes: A systematic review and prevalence meta-analyses

Increasing research suggests a link between autism spectrum disorders and joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes. However, no study systematically examined the available literature about the relationship between these conditions. A systematic literature search was conducted to identify studies (a) examining the link between autism, joint hypermobility, hypermobility spectrum disorders or Ehlers-Danlos syndrome, and (b) reporting the frequency of autism spectrum disorders in people with joint hypermobility, hypermobility spectrum disorders or Ehlers-Danlos syndrome, or vice versa. Prevalence meta-analyses were performed. Twenty articles met the inclusion criteria. Twelve studies explored joint hypermobility/hypermobility spectrum disorders/Ehlers-Danlos syndrome in autistic people. Six explored autism spectrum disorders/autistic traits in people with hypermobility spectrum disorders/Ehlers-Danlos syndrome. Two studies examined autism spectrum disorders in relatives of patients with hypermobility spectrum disorders/Ehlers-Danlos syndrome, and two explored autistic traits and joint hypermobility in non-clinical samples. Out of 15 studies examining the association between autism spectrum disorders/autistic traits and joint hypermobility/hypermobility spectrum disorders/Ehlers-Danlos syndrome, 12 reported significant results. The overall prevalence of joint hypermobility in autistic individuals was 22.3%, but it was higher (31%) when only studies assessing joint hypermobility clinically (excluding self-reports) were considered. The overall prevalence of hypermobility spectrum disorders/Ehlers-Danlos syndrome in autistic samples was 27.9%, but 39% if hypermobility spectrum disorders/Ehlers-Danlos syndrome were assessed clinically. Despite the heterogeneity of studies, these results suggest an association between autism and joint hypermobility/hypermobility spectrum disorders/Ehlers-Danlos syndrome that should be confirmed in further research.Lay abstractIncreasing research suggests a link between autism spectrum disorders (ASD) and joint hypermobility (JH), hypermobility spectrum disorders (HSD), and Ehlers-Danlos syndromes (EDS). However, no study systematically examined the available literature about the relationship between these conditions. To fill this gap, we conducted a systematic literature search to identify studies: (a) examining the link between autism, JH, HSD, or EDS, and (b) reporting the frequency of ASD in people with JH, HSD, or EDS, or vice versa. Prevalence meta-analyses were performed. Twenty articles met the inclusion criteria. Twelve studies explored JH/HSD/EDS in autistic people. Six explored ASD/autistic traits in people with HSD/EDS. Two studies examined ASD in relatives of patients with HSD/EDS, and two explored autistic traits and JH in non-clinical samples. Out of 15 studies examining the association between ASD/autistic traits and JH/HSD/EDS, 12 reported significant results. The overall prevalence of JH in autistic individuals was 22.3%, but it was higher (31%) when only studies assessing JH clinically (excluding self-reports) were considered. The overall prevalence of HSD/EDS in autistic samples was 27.9%, but 39% if HSD/EDS were assessed clinically. Despite the heterogeneity of studies, these results suggest an association between autism and JH/HSD/EDS that should be confirmed in further research.

Phenotypic Presentation of Children with Joint Hypermobility: Preclinical Signs

INTRODUCTION

Joint hypermobility (JH) is mobility beyond the normal range of motion. JH can be an isolated finding or a characteristic of a syndrome. Characteristics related to the sitting position with atypical body positions, such as sitting in splits (S), with the foot on the head (F), in W (W), in a concave shape (C), episodes of dislocations, and subluxations, suggest impacts on body mechanics since childhood, with damage to the conformation of the joints.

OBJECTIVES

Identify preclinical signs of JH, in addition to Beighton Score (BS), through signs that are easily recognized early by pediatricians and family members to avoid possible joint deformities in the future.

METHODS

The medical records of 124 children (59.7% girls) between one and nine years old were analyzed. JH was assessed using the BS, a history of luxations/subluxations, and the concave (C), "W", "splits" (S), and foot (F) on head sitting positions.

RESULTS

The concave sitting position was the most common, followed by W, F, and S in decreasing order. A total of 52.4% of the children had BS > 6, with a higher prevalence among girls (60.8%) compared to boys (40.0%); a difference statistically significant (p = 0.024, Fisher's exact test). Thirty-two patients (27.4%) had luxations/subluxations with the higher scores.

CONCLUSIONS

Sitting in S, F, W, and C positions are preclinical phenotypic characteristics of JH, easily identified by pediatricians and family members to prevent possible joint deformities. BS ≥ 6 is more frequently observed in all positions. The majority of the total sample has BS > 6, with a significant female gender influence. Among those with a history of occasional joint dislocations and subluxations, half of them have the highest BS scores.

Trends in surgical procedures for shoulder instability among patients with Ehlers-Danlos syndrome or joint hypermobility syndrome

Background

Joint hypermobility syndrome (JHS) and Ehlers-Danlos Syndrome (EDS) are connective tissue disorders characterized by increased joint laxity, affecting musculoskeletal health and quality of life. In this study, we explored recent trends in surgical treatment of shoulder instability among patients with these disorders.

Methods

We searched the PearlDiver Mariner database, which includes deidentified US all-payer claims data from 2010 to 2020. We used procedure and diagnostic codes for EDS and JHS to select patients. The primary outcome was the yearly trend in relative utilization of the following 4 shoulder instability procedures: arthroscopic stabilization, Latarjet coracoid transfer, open capsulolabral repair, and open capsulolabral shift.

Results

Among 109,274 patients with EDS and 453,885 with JHS, 3.4% and 0.8% underwent shoulder instability procedures, respectively. Arthroscopic stabilization was the predominant treatment, with a mean utilization rate of 78% for EDS and 83% for JHS. Notably, the age at surgery increased for EDS patients but decreased for JHS patients. Female patients represented large proportions of those undergoing procedures in both the EDS group (83%) and the JHS group (77%).

Conclusions

Our findings indicate a consistent preference for arthroscopic stabilization in treating shoulder instability in patients with EDS and JHS. The trends in age suggest shifts in treatment strategies, possibly influenced by advancements in nonoperative interventions or varying symptom severity. The higher proportion of female patients aligns with the known prevalence of connective tissue disorders in women. Future research should explore outcomes, complications, and specific EDS subtypes to guide optimal treatment strategies for these challenging connective tissue disorders.

'I Have Had to Stop Singing Because I Can't Take the Pain': Experiences of Voice, Ability, and Loss in Singers With Hypermobility Spectrum Disorders

OBJECTIVE

This study explored the voice experience, singing ability, and wellbeing of singers diagnosed with Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (h-EDS).

STUDY DESIGN

This was a mixed-method study. A purposive sampling strategy was used. Data were collected via an online survey, using written closed and open-ended questions.

METHODS

276 adults completed the survey. This study focuses on a subset of professionally-trained singers (n=71). Responses elicited information about participants' voice health and function, symptoms of hypermobility, singing experiences and training. Data were analysed using template analysis.

RESULTS

Many participants reported wide vocal ranges and enjoyment of singing but 74.6% of participants across all age groups (18-60 years) experienced voice difficulties. Three common themes were identified: (1) 'My unreliable voice': The ups and downs; (2) Wider effects of HSD/h-EDS on singers, and (3) Need for acknowledgment and support.

CONCLUSIONS

Voice difficulties and hypermobility-related health conditions affected the participants' abilities to sing and perform; this impacted their professional and personal opportunities, communication, relationships, and wellbeing. Our results indicate that symptoms of voice disorder worsen over time. We suggest practical strategies that singers and training providers could implement to support hypermobile singers. More research is needed to fully understand voice difficulties in singers with HSD/H-EDS and to inform tuition and support.

"Could a subset of joint mobility tests define generalized joint hypermobility?": A descriptive observational inception study

BACKGROUND

Generalized joint hypermobility is an inherited collagen phenotype based on clinical assessments of joint mobility. However, there is no international consensus to define generalized joint hypermobility, both considering which joint mobility tests should be included and limits for joint hypermobility.

OBJECTIVES

The primary aim of the study was to identify a subset of joint mobility tests to define generalized joint hypermobility. A further aim was to evaluate standardized limits for the classification of hypermobility in different joint types throughout the body.

METHODS

A total of 255 early pregnant women were included in the study. Joint mobility was measured according to a structured protocol. Correlation and principal component analysis were used to find a subset of joint mobility tests. To classify hypermobility in each joint mobility test, five different standard deviation levels plus 0.84, plus 1.04, plus 1.28, plus 1.64 and plus 2 were used, corresponding to 20%, 15%, 10%, 5% and 2.5% of the normal distribution.

RESULTS

No subset of joint mobility test could define generalized joint hypermobility. The higher the standard deviation levels, the higher the limit to classify joint hypermobility and the lower the prevalence. As a result of no subset of joint mobility tests were found to define generalized joint hypermobility, different combinations of major and minor joints in upper and lower limbs and the axial skeleton, were systematically developed. These combinations were evaluated for each standard deviation level, resulting in a prevalence of generalized joint hypermobility between 0% and 12.9% and a clear variation in how the hypermobile joint mobility tests were distributed.

CONCLUSION

It is probably not possible to choose a subset of joint mobility tests to define GJH. In order not to overlook generalized joint hypermobility, a broader assessment of different joint types and sizes of joints appears to be needed. The prevalence of generalized joint hypermobility is dependent on joint hypermobility limit and the chosen combination of joint mobility tests.

Joint Hypermobility Syndrome and Membrane Proteins: A Comprehensive Review

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

Echocardiographic abnormalities and joint hypermobility in Chinese patients with Osteogenesis imperfecta

BACKGROUND

Very little is known about the characteristics of echocardiographic abnormalities and joint hypermobility in Chinese patients with osteogenesis imperfecta (OI). The aim of our study was to investigate the characteristics, prevalence and correlation of echocardiographic abnormalities and joint hypermobility in Chinese patients with OI.

METHODS

A cross-sectional comparative study was conducted in pediatric and adult OI patients who were matched in age and sex with healthy controls. Transthoracic echocardiography was performed in all patients and controls, and parameters were indexed for body surface area (BSA). The Beighton score was used to evaluate the degree of joint hypermobility.

RESULTS

A total of 48 patients with OI (25 juveniles and 23 adults) and 129 age- and sex-matched healthy controls (79 juveniles and 50 adults) were studied. Four genes (COL1A1, COL1A2, IFITM5, and WNT1) and 39 different mutation loci were identified in our study. Mild valvular regurgitation was the most common cardiac abnormality: mild mitral and tricuspid regurgitation was found in 12% and 36% of pediatric OI patients, respectively; among 23 OI adults, 13% and 17% of patients had mild mitral and tricuspid regurgitation, respectively, and 4% had mild aortic regurgitation. In multiple regression analysis, OI was the key predictor of left atrium diameter (LAD) (β=-3.670, P < 0.001) and fractional shortening (FS) (β = 3.005, P = 0.037) in juveniles, whereas for adults, OI was a significant predictor of LAD (β=-3.621, P < 0.001) and left ventricular mass (LVM) (β = 58.928, P < 0.001). The percentages of generalized joint hypermobility in OI juveniles and adults were 56% and 20%, respectively. Additionally, only in the OI juvenile group did the results of the Mann‒Whitney U test show that the degree of joint hypermobility was significantly different between the echocardiographic normal and abnormal groups (P = 0.004).

CONCLUSIONS

Mild valvular regurgitation was the most common cardiac abnormality in both OI juveniles and adults. Compared with OI adults, OI juveniles had more prevalent and wider joint hypermobility. Echocardiographic abnormalities may imply that the impairment of type I collagen is more serious in OI. Baseline echocardiography should be performed in OI patients as early as possible.

The Association Between Joint Laxity and Post-Dural Puncture Headache

Objective This study aimed to investigate the relationship between joint laxity and post-dural puncture headache (PDPH). Methods A total of 123 patients with PDPH - 73 females and 50 males - were included in the study. The patients were examined regarding joint laxity and classified into two groups according to the Beighton score. Those with a Beighton score between 0 and 3 were classified as Group I, and those with a score greater than 4 were classified as Group II. Data related to the demographic characteristics of the patients, time of onset of PDPH, severity, need for medical treatment, need for an epidural blood patch, and length of hospital stay were recorded, and a comparison was made between the two groups. Results There was no significant difference between the groups in terms of age, gender distribution, and PDPH onset time (p>0.05). In Group II, which included patients positive for joint laxity, total headache duration, headache severity, need for medical treatment, need for epidural blood patch, and hospital stay were significantly higher than in Group I (p<0.05). Conclusion Joint laxity may increase the risk of PDPH after spinal anesthesia and may affect treatment processes. The Beighton score can determine the development and severity of PDPH in patients with joint laxity. Assessing joint laxity and Beighton score can improve clinical decision-making in managing PDPH and positively affect patient outcomes.

Outcomes of rectal prolapse surgery in patients with benign joint hypermobility syndrome

BACKGROUND

Rectal prolapse is a debilitating disorder of the pelvic floor, and treatment outcomes are variable. Previous studies have identified underlying benign joint hypermobility syndrome (BJHS) in some patients. We sought to determine the outcomes of these patients after undergoing ventral rectopexy surgery (VMR).

METHODS

All consecutive patients who were referred to the pelvic floor unit at our institution between February 2010 and December 2011 were considered for recruitment into the study. Following recruitment, they were assessed using the Beighton criteria to determine the presence or absence of benign joint hypermobility syndrome. Both groups underwent similar surgical interventions and were then followed up. The need for revisional surgery was recorded in both groups.

RESULTS

Fifty-two patients [34 normal; M:F, 1:6; median age 61 (range 22-84) years; 18 BJHS; M:F, 0:1; median age 52 (range 25-79) years] were recruited. A total of 42 patients completed the full 1-year follow-up (26 normal, 16 benign joint hypermobility syndrome). Patients with benign joint hypermobility syndrome were significantly younger (median age 52 versus 61 years, p < 0.001) with male to female ratio of 0:1 versus 1:6, respectively. In addition, they were significantly more likely to require revisional surgery than those without the condition (31% versus 8% p < 0.001). In most cases, this was in the form of a posterior stapled transanal resection of the rectum procedure.

CONCLUSIONS

Patients with BJHS presenting for rectal prolapse surgery were younger and are more likely to require further surgery for rectal prolapse recurrence than those without the condition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

The Association of Variants within Types V and XI Collagen Genes with Knee Joint Laxity Measurements

Joint laxity is a multifactorial phenotype with a heritable component. Mutations or common polymorphisms within the α1(V) (COL5A1), α1(XI) (COL11A1) and α2(XI) (COL11A2) collagen genes have been reported or proposed to associate with joint hypermobility, range of motion and/or genu recurvatum. The aim of this study was to investigate whether polymorphisms within these collagen-encoding genes are associated with measurements of knee joint laxity and computed ligament length changes within the non-dominant leg. One hundred and six healthy participants were assessed for genu recurvatum (knee hyperextension), anterior-posterior tibial translation, external-internal tibial rotation and ligament length changes during knee rotation of their non-dominant leg. Participants were genotyped for COL5A1 rs12722 (T/C), COL11A1 rs3753841 (C/T), COL11A1 rs1676486 (T/C) and COL11A2 rs1799907 (A/T). The genotype-genotype combination of any two or more of the four COL5A1 rs12722 CC, COL11A1 rs3753841 CC, COL11A1 rs1676486 TT and COL11A2 rs1799907 AA genotypes was associated with decreased active and passive knee hyperextension. These genotype-genotype combinations, including sex (male), increased age and decreased body mass collectively, also contributed to decreased passive knee hyperextension. These findings suggest that COL5A1, COL11A1 and COL11A2 gene-gene interactions are associated with knee hyperextension measurements of the non-dominant leg of healthy individuals.

Reproducibility of Hypermobility Assessment Scales for Children When Performed Using Telehealth versus In-Person Modes

AIMS

Evaluate reproducibility of hypermobility assessments using in-person versus telehealth modes.

METHODS

Hypermobility of 20 children (7-12 years) was evaluated using the Beighton Score, Upper Limb Hypermobility Assessment Tool (ULHAT), and Lower Limb Assessment Score (LLAS) via in-person and telehealth modes. Agreement between the two modes was examined using percentage of exact agreement (%EA and %EA ± 2), Limits of Agreement (LoA) and Smallest detectable change (SDC). Reliability was calculated using intra-class correlation coefficients (ICCs).

RESULTS

Agreement between modes for total Scores was best for the Beighton (%EA = fair, %EA ± 2 = good), then the ULHAT (%EA = poor, %EA ± 2 = excellent), and LLAS (%EA = poor, %EA ± 2 = fair). Total scores for all scales showed wide LoA, large SDC (25-31%), and fair to good reliability (ICC = 0.54-0.61). Exact agreement for Generalized Joint Hypermobility classification was excellent for the Beighton (≥7/9 threshold) and fair for the ULHAT and LLAS (≥7/12 threshold). Percentage of individual test items with good/excellent agreement was highest for the Beighton (78%, 7/9 items), then the ULHAT (58%, 14/24) and LLAS (42%, 10/24).

CONCLUSION

Total Scores of hypermobility scales showed low exact agreement between in-person and telehealth, but fair-excellent agreement within two points. Classification using the Beighton ≥7/9 threshold was excellent. Research is recommended to increase accuracy of online assessments.

Lateral abdominal muscles of adults with hypermobility may be partially impaired during contraction

Background

Muscle function may be impaired in people with generalised hypermobility, yet prior studies have primarily focused on muscles within the extremities. We aimed to examine changes in lateral abdominal muscle (transversus abdominis (TrA) and the external (EO) and internal abdominal obliques (IO)) thickness and length during contraction between participants with and without hypermobility.

Methods

This cross-sectional study examined 12 participants with hypermobility and 12 age-matched, sex-matched, height-matched and weight-matched participants without hypermobility. The Beighton and Belavy-Owen-Mitchell score assessed systemic hypermobility. Muscle thickness and length were measured via panoramic ultrasound scans at rest and during contraction.

Results

When compared with rest across all lumbar levels (L1–L5), contraction produced a lesser increase in TrA thickness (β=0.03, p=0.034) for participants with hypermobility compared with control. No group-by-condition interaction was observed for TrA length across all lumbar levels (L1–L5; p=0.269). Contraction produced a greater decrease in EO thickness (β=0.08, p=0.002) at L3 only for participants with hypermobility compared with control. No group-by-condition interactions were observed for IO thickness.

Conclusion

Participants with hypermobility had partially impaired lateral abdominal muscle function given a lesser ability to increase TrA muscle thickness during contraction compared with controls.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Translational relevance of forward genetic screens in animal models for the study of psychiatric disease

Psychiatric disorders represent a significant burden in our societies. Despite the convincing evidence pointing at gene and gene-environment interaction contributions, the role of genetics in the etiology of psychiatric disease is still poorly understood. Forward genetic screens in animal models have helped elucidate causal links. Here we discuss the application of mutagenesis-based forward genetic approaches in common animal model species: two invertebrates, nematodes (Caenorhabditis elegans) and fruit flies (Drosophila sp.); and two vertebrates, zebrafish (Danio rerio) and mice (Mus musculus), in relation to psychiatric disease. We also discuss the use of large scale genomic studies in human populations. Despite the advances using data from human populations, animal models coupled with next-generation sequencing strategies are still needed. Although with its own limitations, zebrafish possess characteristics that make them especially well-suited to forward genetic studies exploring the etiology of psychiatric disorders.

Association between generalized joint laxity and knee joint movement in female university students

[Purpose] This study investigated the association between generalized joint laxity and knee joint movement in female university students. [Participants and Methods] The study included 21 female university students. Generalized joint laxity was measured using the Beighton criteria for joint hypermobility. Acceleration and angular velocities of the tibia during knee extension were measured along three axes using a triaxial accelerometer. Sampling data were expressed as root mean squares. The Mann–Whitney U test was used to determine differences in the acceleration and angular velocities along each axis between the generalized joint laxity and non-generalized joint laxity groups. Spearman’s rank correlations were used to confirm the association between these parameters. [Results] The rotational angular velocity was greater in the generalized joint laxity than in the non-generalized joint laxity group, and we observed a significant correlation between Beighton scores and the X-axis angular velocity. Furthermore, rotational angular velocity was positively correlated with anterior–posterior acceleration and extension angular velocity. [Conclusion] These findings suggest that rotational angular velocity of the tibia during knee extension is associated with generalized joint laxity in female university students.

Generalized Joint Hypermobility and Anxiety Are Serious Risk Factors for Dysfunctioning in Dance Students: A One-Year Follow-Up Study

Young professional dancers find themselves in a demanding environment. GJH within dancers is often seen as aesthetically beneficial and a sign of talent but was found to be potentially disabling. Moreover, high-performing adolescents and young adults (HPAA), in this specific lifespan, might be even more vulnerable to anxiety-related disability. Therefore, we examined the development of the association between the presence of Generalized Joint Hypermobility (GJH) and anxiety within HPAA with a one-year follow-up. In 52.3% of the HPAA, anxiety did not change significantly over time, whereas GJH was present in 28.7%. Fatigue increased significantly in all HPAA at one year follow-up (respectively, females MD (SD) 18(19), p < 0.001 and males MD (SD) 9(19), p < 0.05). A significantly lower odds ratio (ß (95% CI) 0.4 (0.2−0.9); p-value 0.039) for participating in the second assessment was present in HPAA with GJH and anxiety with a 55% dropout rate after one year. This confirms the segregation between GJH combined with anxiety and GJH alone. The fatigue levels of all HPAA increased significantly over time to a serious risk for sick leave and work disability. This study confirms the association between GJH and anxiety but especially emphasizes the disabling role of anxiety. Screening for anxiety is relevant in HPAA with GJH and might influence tailored interventions.

Juvenile Fibromyalgia

Juvenile fibromyalgia is a common referral in pediatric rheumatology settings. Providing a clear diagnosis and explanation of altered pain processing offers reassurance that pain has a biologic basis and the symptoms are part of a recognized pain syndrome. Physicians should acknowledge the impact of chronic pain and associated symptoms on patient's lives and take time to understand contributing factors including stress, mood, inactivity, and lifestyle factors. The optimal treatment for juvenile fibromyalgia is multidisciplinary, focusing on education about juvenile fibromyalgia, along with physical therapy, cognitive behavioral therapy, sleep hygiene, healthy lifestyle habits, and medications for symptom management as appropriate.

Oxidative Stress and Musculoskeletal Pain in University Students with Generalized Joint Hypermobility: A Case-Control Study

Objective

The current case–control study aimed to evaluate generalized joint hypermobility (GJH) and its association with pain intensity, cellular oxidative stress, and collagen-associated disorders in university students aged 18–25 years old.

Background

Joint hypermobility has been recognized in healthy subjects and people who are carriers of cellular disorders in connective tissues. Cellular tissue oxidative stress and collagen-associated disorders were shown to be associated with joint hypermobility (JH).

Materials and Methods

A total of 300 university students aged 18–25 years were randomly invited from different medical and science faculties in Mansoura university, Mansoura, Egypt to participate in this case–control study. Only 280 university students who had no exclusion criteria like chronic health problems, physical disability, musculoskeletal disorders, and body mass index (BMI) of ≥25 underwent an initial clinical interview and Beighton scoring as measures of GJH. Pain intensity, physical activity, oxidative stress parameters; TAC, TOC, OSI, and collagen-associated parameters; cellular prolidase activity and hydroxyproline were evaluated by using a prevalidated questionnaire, colorimetric, and immunoassay techniques.

Results

GJH was significantly reported in 57.1% of the study population, and most of them are females. Compared to men, females with GJH showed poor physical activity, lower TAC, and significantly higher levels of TOC, OSI, cellular prolidase activity, and hydroxyproline. Based on our findings, a high Beighton score is closely related to the tissue levels of prolidase, hydroxyproline, antioxidant activity, pain intensity, and poor physical activity in the female with GJH compared to men.

Conclusion

GJH was significantly reported in 57.1% of the study population, and most of them are females. The incidence of GJH showed to be associated with poor physical activity, abnormal cellular oxidative stress, and collagen abnormalities measured by significant increase in change in cellular prolidase activity and hydroxyproline.

Generalized Joint Laxity Is Associated With Increased Failure Rates of Primary Anterior Cruciate Ligament Reconstructions: A Systematic Review

PURPOSE

To investigate patients with generalized joint laxity (GJL) after primary anterior cruciate ligament reconstruction (ACLR) as to the risk of ACLR failure, graft selection success rates, and overall clinical outcomes.

METHODS

A systematic review of the PubMed and EMBASE databases was performed to identify studies published from the inception of the databases through February 4, 2020. The inclusion criteria were original studies written in English involving outcomes of patients with GJL who had undergone primary ACLR.

RESULTS

Nine studies met the inclusion criteria, which included 1,869 patients. Most underwent isolated bone-patellar tendon-bone (BPTB; n = 1062) or hamstring autograft (n = 696) ACLR. Overall, higher graft failure rates tended to occur in patients with GJL compared with patients without GJL (range per study: 6%-30% vs 0%-12.3%). Inferior results were also found patients with GJL in patient-reported outcome measures and postoperative knee stability determined by KT, Lachman, and pivot-shift tests. BPTB autografts tended to have lower failure rates than hamstring autografts in patients with GJL (range per study: 6%-21% vs 17.6%-30%). Only 1 study determined outcomes of a combined ACLR and extra-articular augmentation in patients with GJL.

CONCLUSIONS

Patients with GJL are at an increased risk of inferior outcomes and graft failure after primary ACLR. BPTB autografts may have more favorable stability outcomes compared with hamstring autografts in patients with GJL. However, the reported stability parameters and KT results, even with a BPTB autograft, remain inferior to non-GJL published results, and the added benefit of an extra-articular procedure to supplement the primary ACLR deserves consideration.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III investigations.

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.

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.

Generalized Joint Hypermobility and Anxiety in Adolescents and Young Adults, the Impact on Physical and Psychosocial Functioning

The purpose of this study was to study the association between the presence of generalized joint hypermobility (GJH) and anxiety within a non-clinical high performing group of adolescents and young adults. Second, to study the impact of GJH and/or anxiety on physical and psychosocial functioning, 168 adolescents and young adults (mean (SD) age 20 (2.9)) were screened. Joint (hyper)mobility, anxiety, and physical and psychosocial functioning were measured. In 48.8% of all high performing adolescents and young adults, GJH was present, whereas 60% had symptoms of anxiety. Linear models controlled for confounders showed that adolescents and young adults with GJH and anxiety had decreased workload (ß (95%CI) -0.43 (-0.8 to -0.08), p-value 0.02), increased fatigue (ß (95%CI) 12.97 (6.3-19.5), p-value < 0.01), and a higher level of pain catastrophizing (ß (95%CI) 4.5 (0.5-8.6), p-value 0.03). Adolescents and young adults with only anxiety had increased fatigue (ß (95%CI) 11 (4.9-19.5). In adolescents and young adults with GJH alone, no impact on physical and psychosocial functioning was found. Adolescents and young adults with the combination of GJH and anxiety were significantly more impaired, showing decreased physical and psychosocial functioning with decreased workload, increased fatigue, and pain catastrophizing. Presence of GJH alone had no negative impact on physical and psychosocial functioning. This study confirms the association between GJH and anxiety, but especially emphasizes the disabling role of anxiety. Screening for anxiety is relevant in adolescents and young adults with GJH and might influence tailored interventions.

The Beighton Score as a measure of generalised joint hypermobility

The Beighton Score (BS) is a set of manoeuvres in a nine-point scoring system, used as the standard method of assessment for Generalised Joint Hypermobility (GJH). It was originally developed as an epidemiological tool used in screening large populations for GJH, but later adopted as a clinical tool for diagnostic purposes. Its ability to truly reflect GJH remains controversial, as joints within the scoring system are predominantly of the upper limb and disregard many of the major joints, preventing a direct identification of GJH. Furthermore, a consistent finding in the literature whereby the BS failed to identify hypermobility in joints outside the scoring system suggests its use as an indirect indicator of GJH is also not viable. As such, the collective findings of this review demonstrate a need for a change in clinical thinking. The BS should not be used as the principle tool to differentiate between localised and generalised hypermobility, nor used alone to exclude the presence of GJH. Greater emphasis should be placed on a clinician’s judgement to identify or exclude GJH, according to its full definition.

Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes

The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.

Increased Joint Mobility Is Associated With Impaired Transversus Abdominis Contraction

Mitchell, UH, Owen, PJ, Rantalainen, T, and Belavý, DL. Increased joint mobility is associated with impaired transversus abdominis contraction. J Strength Cond Res XX(X): 000-000, 2020-Increased joint mobility is a risk factor for joint injury, but muscle function may be able to compensate for it. Current evidence suggests reduced force production capacity in people with hypermobility. However, little is known about the lumbar spine. The purpose of this cross-sectional study was to assess whether there was a link between joint mobility and transverse abdominis and multifidus muscles contraction, muscles ascribed a core-stability role. Using a modified quantitative version of the Beighton scale (BOM score), we measured joint mobility of 30 middle-aged individuals without low back pain. These scores were correlated with magnetic resonance imaging-derived measures of transverse abdominis and multifidus muscle contraction during a spinal loading maneuver. The level of significance was set for p ≤ 0.05. The results showed greater joint mobility (a higher BOM score) correlated (r = 0.468; p = 0.009) with reduced transversus abdominis (TrA) shortening during contraction (i.e., less muscle shortening in people with greater joint mobility). The trunk subdomain score exhibited a correlation of 0.354 with TrA length change, but this did not reach statistical significance (p = 0.055). The subdomains of the BOM score did not correlate significantly with each other (p ≥ 0.097). No association was seen between multifidus contraction and joint mobility. The results suggest that greater general joint mobility is associated with impaired contraction of the TrA muscle. This should be considered when coaching athletes or treating patients with (functional) spinal instability. The quantitative approach we developed to measure joint mobility could be used in the future studies of global flexibility.

Generalized joint hypermobility among school-aged children in Majmaah region, Saudi Arabia

Generalized joint hypermobility (GJH) is common among schoolchildren and usually benign. However, it may progressively lead to joint pain and developmental delay. Identifying GJH in school-aged children would facilitate the monitoring of early changes and planning for early rehabilitative intervention. Epidemiological studies addressing the prevalence of GJH among children in the Gulf region and Arab ethnicity are lacking. Hence, we aimed to determine the prevalence, pattern, and factors associated with GJH among school-aged children in the Majmaah region, Saudi Arabia. Male and female school-aged children 8-14 years of age from the Majmaah region of Saudi Arabia participated in this cross-sectional study. Beighton score was used to assess GJH. Personal characteristics such as age, height, weight, body mass index, and handedness were also collected. Descriptive statistics were obtained for personal characteristics, the point prevalence of hypermobility, frequency of Beighton score distribution, and prevalence of GJH. The associations between specific factors and the presence of GJH were analyzed using chi-square and Mann-whitney tests. Using the Beighton score cutoff ≥ 4 and ≥ 6, 15.2% and 7.6% of the school children in our study were diagnosed with GJH respectively. The prevalence of GJH was higher among females (16.8%) than among males (13.4%), but the difference was not statistically significant. The elbow joints (17.2%) were the most common hypermobile joints and the trunk (0.7%) was the least involved. The children with GJH were younger and had lesser BMI compared to children without GJH (P < 0.05). The prevalence reported in this study among school-aged children was comparable with those reported worldwide.

The Association of Self-Reported Generalized Joint Hypermobility with pelvic girdle pain during pregnancy: a retrospective cohort study

Background

Pelvic girdle pain (PGP) is common during pregnancy but the causes remain poorly understood. Generalized joint hypermobility (GJH) is an inherited trait, with joint mobility beyond normal limits and is assumed to be related with PGP. The aim of this project was to study the association between self-reported GJH and the presence of PGP during pregnancy.

Methods

In this cohort study, 4884 Swedish-speaking women were consecutively recruited at their first visit for registration in the national antenatal screening programme in Sweden. We used the five-part questionnaire (5PQ) to assess GJH and pain drawings to identify PGP. Our primary outcome was the presence of PGP during the entire pregnancy and secondary outcomes were PGP in each trimesters. We tested the associations with logistic regression analysis, and adjusted for age and ethnicity.

Results

In all, 2455 (50.3%) women responded to both questionnaires. The prevalence of self-reported GJH was 28.7%. A higher proportion of women with GJH than women without GJH reported PGP during the entire pregnancy (47.9% vs. 41.0%), particularly in trimester 1 (31.6% vs. 22.0%). Thus, women with GJH also had higher odds of PGP during the entire pregnancy (adjusted odds ratio (aOR) 1.27: 95% CI 1.11–1.47) and in trimester 1 (aOR 1.54: 95% CI 1.20–1.96), but the associations were not statistically significant in trimester 2 (aOR 1.24: 95% CI 0.82–1.88) or trimester 3 (aOR 1.20: 95% CI 0.99–1.45). The odds of PGP in pregnancy increased with increasing numbers of positive answers to the 5PQ (p for linear trend < 0.001) for the entire pregnancy and in trimester 1 (p for linear trend < 0.001), but not in trimesters 2 or 3 (p = 0.13 and p = 0.06, respectively).

Conclusions

Compared to women with normal joint mobility, women with GJH had higher odds of reporting PGP during pregnancy and the odds increased with number of positive responses to the 5PQ. The associations were present in trimester 1 but did not reach statistical significance in trimester 2 and 3.

Is joint hypermobility related to preterm birth?

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical management of benign joint hypermobility syndrome: a case series

BACKGROUND

Benign Joint Hypermobility Syndrome (BJHS) is a relatively prevalent condition of the spectrum of heritable connective tissue disorders, with musculoskeletal, visceral and psychological manifestations. The conservative management of the musculoskeletal symptomatology must be modified for optimal effectiveness and minimal sequelae.

PURPOSE

To provide an overview of the presentation, assessment, chiropractic management, and outcomes of patients with BJHS.

STUDY DESIGN

Case series.

DISCUSSION

Recognizing joint hypermobility as a significant contributing factor in patients presenting with musculoskeletal complaints is often challenging. The lack of awareness of BJHS may delay the diagnosis as well as effective management. Manual therapy should be used judiciously; active exercise is an essential element of care. We provide an overview of the presentations, assessment, chiropractic management, and outcomes of three patients with BJHS. Future clinical trials are necessary to determine effective clinical management strategies for patients with BJHS.

Hypermobility in Hallux Valgus

The interaction between hypermobility and hallux valgus remains both contemporary and incendiary. The difficulty in setting clinical and radiological parameters to diagnose and the complexity of questions that circumnutate the philosophy among etiology and denouement, fires up the debate regarding these conditions. Outcomes among procedures that address or neglect ray instability are still used as argument for any group of believers or nonbelievers. Through proving the true existence of hypermobility and its relationship with bunions, our colleges and professors have produced an incredible amount of excellent data that helped us better comprehend the hallux valgus syndrome in a general manner.

High Prevalence of Connective Tissue Gene Variants in Professional Ballet

BACKGROUND

There is a high prevalence of hypermobility spectrum disorder (HSD) in dancers. While there is no known genetic variant for HSD, hypermobile Ehlers-Danlos syndrome is a genetic disorder that exists within HSD. There are many connective tissue disorders (CTDs) with known (and unknown) genes associated with hypermobility. Hypermobility has distinct advantages for participation in flexibility sports, including ballet.

PURPOSE

To determine the prevalence of gene variants associated with hypermobility in a large professional ballet company.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

In this cross-sectional investigation, 51 professional male and female dancers from a large metropolitan ballet company were eligible and offered participation after an oral and written informed consent process. Whole blood was obtained from peripheral venipuncture, and DNA was isolated. Isolated DNA was subsequently enriched for the coding exons of 60 genes associated with CTD that included hypermobility as a phenotype, including Ehlers-Danlos syndromes, osteogenesis imperfecta, Marfan syndrome, and others. Genes were targeted with hybrid capture technology. Prepared DNA libraries were then sequenced with next-generation sequencing technology. Genetic database search tools (Human Gene Mutation Database and e!Ensembl, http://useast.ensembl.org/ ) were used to query specific variants. Descriptive statistics were calculated.

RESULTS

Of 51 dancers, 32 (63%) agreed to participate in DNA analysis (mean ± SD age, 24.3 ± 4.4 years; 18 men, 14 women). Twenty-eight dancers had at least 1 variant in the 60 genes tested, for an 88% prevalence. A total of 80 variants were found. A variant in 26 of the 60 genes was found in at least 1 dancer. Among the 28 dancers with variants, 16 were found in the TTN gene; 10 in ZNF469; 5 in RYR1; 4 in COL12A1; 3 in ABCC6 and COL6A2; 2 in ADAMTS2, CBS, COL1A2, COL6A3, SLC2A10, TNC, and TNXB; and 1 in ATP6V0A2, B4GALT7, BMP1, COL11A1, COL5A2, COL6A1, DSE, FBN1, FBN2, NOTCH1, PRDM5, SMAD3, and TGFBR1. Nine variants found in this population have never been reported. No identified variant was identical to any other variant. No identified variant was known to be disease causing. In the general population, the prevalence of each variant ranges from never reported to 0.33%. In the study population, the prevalence of each variant was 3.13%. There was no association between hypermobility scores and genetic variants.

CONCLUSION

Genetic variants in CTD-associated genes are highly prevalent (88%) in professional ballet dancers. This may significantly account for the high degree of motion in this population.

Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome after ACL reconstruction: a systematic review

Objectives

To investigate the association between generalised joint hypermobility (GJH) and ACL injury risk. Secondary aims involved evaluating associations between GJH and postoperative outcome (including graft-failure risk, knee laxity and patient-reported outcome). Furthermore, we aimed to compare the performance of different grafts in patients with GJH.

Methods

Databases MEDLINE/PubMed, EMBASE and the Cochrane Library were searched, including 2760 studies. Two reviewers independently screened studies for eligibility. A modified version of the MINORS score was applied for quality appraisal. Studies assessing GJH while reporting the risk of ACL injury and/or postoperative outcome were included.

Results

Twenty studies were included, using several different methods to determine GJH. There was consistent evidence showing that GJH is a risk factor for unilateral ACL injury in males, while in females, the results were conflicting. There was limited evidence associating GJH with increased knee laxity 5 years postoperatively. There was consistent evidence of inferior postoperative patient-reported outcome in patients with GJH. Moreover, there was limited yet consistent evidence indicating that patellar-tendon autografts are superior to hamstring-tendon autografts in patients with GJH in terms of knee laxity and patient-reported outcome. There was insufficient evidence to draw conclusions regarding the outcomes of bilateral ACL injury and graft failure.

Conclusions

In men, GJH was associated with an increased risk of unilateral ACL injury. Moreover, GJH was associated with greater postoperative knee laxity and inferior patient-reported outcome. Based on the available evidence, a patellar-tendon autograft appears to be superior to a hamstring-tendon autograft in patients with GJH. However, the included studies were heterogeneous and there is a need for consensus in the assessment of GJH within sports medicine.

Diagnosed prevalence of Ehlers-Danlos syndrome and hypermobility spectrum disorder in Wales, UK: a national electronic cohort study and case-control comparison

OBJECTIVES

To describe the epidemiology of diagnosed hypermobility spectrum disorder (HSD) and Ehlers-Danlos syndromes (EDS) using linked electronic medical records. To examine whether these conditions remain rare and primarily affect the musculoskeletal system.

DESIGN

Nationwide linked electronic cohort and nested case-control study.

SETTING

Routinely collected data from primary care and hospital admissions in Wales, UK.

PARTICIPANTS

People within the primary care or hospital data systems with a coded diagnosis of EDS or joint hypermobility syndrome (JHS) between 1 July 1990 and 30 June 2017.

MAIN OUTCOME MEASURES

Combined prevalence of JHS and EDS in Wales. Additional diagnosis and prescription data in those diagnosed with EDS or JHS compared with matched controls.

RESULTS

We found 6021 individuals (men: 30%, women: 70%) with a diagnostic code of either EDS or JHS. This gives a diagnosed point prevalence of 194.2 per 100 000 in 2016/2017 or roughly 10 cases in a practice of 5000 patients. There was a pronounced gender difference of 8.5 years (95% CI: 7.70 to 9.22) in the mean age at diagnosis. EDS or JHS was not only associated with high odds for other musculoskeletal diagnoses and drug prescriptions but also with significantly higher odds of a diagnosis in other disease categories (eg, mental health, nervous and digestive systems) and higher odds of a prescription in most disease categories (eg, gastrointestinal and cardiovascular drugs) within the 12 months before and after the first recorded diagnosis.

CONCLUSIONS

EDS and JHS (since March 2017 classified as EDS or HSD) have historically been considered rare diseases only affecting the musculoskeletal system and soft tissues. These data demonstrate that both these assertions should be reconsidered.

Sex hormones in association with general joint laxity and hypermobility in the temporomandibular joint in adolescents-results of the epidemiologic LIFE child study

OBJECTIVES

The aim of this cross-sectional study was to investigate whether sex hormones (testosterone, oestradiol, sex-hormone-binding globulin = SHBG) are associated with general joint laxity (GJL) and hypermobility or derangements of the temporomandibular joint (TMJ) in adolescents.

METHODS

Within the LIFE Child study, 970 adolescents (10-18 years) were included. GJL was assessed using the Beighton test. Maximum mouth opening (MMO) and clinical clicking sounds as signs of disc displacement (DD) in the TMJ were assessed according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Serum levels of sex hormones were assessed using standardised laboratory analyses.

RESULTS

Hypermobile joints were found in 54.9% (N = 532) of the sample; females were more affected than males (61.4% vs. 51.8%, P < 0.001). Using logistic regression analyses, the odds ratio (OR) for having >1 hypermobile joints increased to 1.15 (95% confidence interval [CI]: 1.04-1.27) in males and 1.09 (95% CI: 1.02-1.17) in females per 10 units of the SHBG serum level, compared to those without hypermobile joints-after controlling for the effect of age, adjusted BMI, pubertal development (Tanner scale), testosterone as well as oestradiol levels. Female subjects with >1 hypermobile joints showed a higher OR (1.89; 95% CI: 1.05-3.43) for having clinical clicking sounds in the TMJ and a 3.28 times higher OR (95% CI: 1.44-7.44) for MMO ≥ 55 mm.

CONCLUSIONS

We observed age- and gender-independent associations of higher SHBG serum levels with GJL in adolescents. Moreover, hypermobile female adolescents show a more frequent hypermobility of the TMJ and clinical signs of DD.

Joint hypermobility is not positively associated with prevalent multiple joint osteoarthritis: a cross-sectional study of older adults

BACKGROUND

This cross-sectional study evaluated associations of joint hypermobility and multiple joint osteoarthritis (MJOA) in a community-based cohort of adults 45+ years of age.

METHODS

MJOA and joint hypermobility data were from 1677 participants (mean age 69 years, 68% women) who completed research clinic visits during 2003-2010. Prevalent MJOA was defined in four ways. Radiographic OA (rOA) was defined as Kellgren-Lawrence (KL) > 2 at any included study joint; symptomatic OA (sxOA) required both symptoms and rOA in a joint. Joint hypermobility was defined as a Beighton score of > 4. Separate logistic regression models were used to estimate odds ratios (OR) between joint hypermobility and each MJOA definition, adjusting for age, sex, race, body mass index, and baseline visit.

RESULTS

In this cohort, 4% had Beighton score > 4 and 63% met any definition of MJOA. Joint hypermobility was associated with significantly lower odds of radiographic and symptomatic MJOA-1 (multiple joint OA-definition 1: involvement of > 1 IP (interphalangeal) nodes and > 2 sites of hip, knee, and spine; 74 and 58% lower, respectively). However, for the other MJOA definitions (i.e., MJOA-2:involvement of > 2 IP joints, > 1 carpometacarpal [CMC] joints, and knee or hip sites; MJOA-3: involvement of > 5 joint sites from among distal interphalangeal, proximal interphalangeal, CMC, hip, knee, or spine sites; and MJOA-4:involvement of > 2 lower body sites (hip, knee, or spine), there were no statistically significant associations. For associations between site-specific hypermobility and any MJOA definition, most adjusted ORs were less than one, but few were statistically significant.

CONCLUSIONS

Overall, joint hypermobility was not positively associated with any definition of prevalent MJOA in this cohort, and an inverse association existed with one definition of MJOA. Longitudinal studies are needed to determine the contribution of hypermobility to the incidence and progression of MJOA outcomes.

Relationship of Joint Hypermobility with Ankle and Foot Radiographic Osteoarthritis and Symptoms in a Community-Based Cohort

OBJECTIVE

To explore associations of joint hypermobility (a condition where range of motion is greater than normal) with ankle and foot radiographic osteoarthritis (OA) and symptoms in a large community-based cohort of African American and white adults ages 55-94 years old.

METHODS

Ankle and foot radiographs and joint hypermobility data (Beighton score for joint hypermobility criteria) were available for 848 participants (from 2003 to 2010) in this cross-sectional study. General joint hypermobility was defined as a Beighton score ≥4 (range 0-9); knee hypermobility was defined as hyperextension of at least 1 knee. Standing anteroposterior and lateral foot radiographs were read with standard atlases for Kellgren-Lawrence grade, osteophytes, and joint space narrowing (JSN) at the tibiotalar joint, and for osteophytes and JSN to define OA at 5 foot joints. Ankle or foot symptoms were self-reported. Separate person-based logistic regression models were used to estimate associations of ankle and foot OA and symptom outcomes with hypermobility measures, adjusting for age, sex, race, body mass index, and history of ankle/foot injury.

RESULTS

This sample cohort included 577 women (68%) and 280 African Americans (33%). The mean age of the participants was 71 years, with a mean body mass index of 31 kg/m2 . The general joint hypermobility of the participants was 7% and knee hypermobility was 4%. Having a history of ankle injury was 11.5%, and foot injury was 3.8%. Although general joint hypermobility was not associated with ankle and foot outcomes, knee hypermobility was associated with ankle symptoms, foot symptoms, and talonavicular OA (adjusted odds ratios of 4.4, 2.4, and 3.0, respectively).

CONCLUSION

Knee joint hypermobility may be related to talonavicular OA and to ankle and foot symptoms.

Hypermobility and sports injury

Objective

To determine whether there is an association between hypermobility and sports injury.

Methods

A quantitative observational approach using a cross-sectional survey was adopted. Individuals were identified as hypermobile or not. All participants were asked to complete two questionnaires: one asking demographic information and the other injury-specific. Fisher’s exact test was used for statistical analysis.

Results

114 individuals participated in the study, 62 women and 52 men. 26% of the participants were hypermobile. There was no significant association between hypermobility and sports injury (p=0.66). There was a significant increase in joint and ligament sprain among the non-hypermobile (NH) group covering all sports (p=0.03). Joint dislocation was found exclusively among hypermobile individuals. The duration of injury in hypermobile individuals was higher than NH. The use of oral painkillers or anti-inflammatories in the semiprofessional group was greater than the general population.

Conclusion

Hypermobility is relatively common among individuals, and there is a lot of anecdotal evidence associating it with increased rates of injuries. This project finds that NH individuals are more likely to sustain a ligament or joint sprain in sports. This is due to increased joint laxity and flexibility preventing injury. There were important limitations to this study which will be addressed in further work. These include assessing for pauciarticular hypermobility and focusing on one sport to investigate its association with sports injury in those who are hypermobile or not. It would also be important to focus on one specific joint, assessing its flexibility and association with injury.

Updates in Clinical and Genetics Aspects of Hypermobile Ehlers Danlos Syndrome

Efforts on recognition, diagnosis, and management of the presumed, most common connective tissue disorder hypermobile Ehlers-Danlos syndrome have been an ongoing challenge, even decades after the description of this condition. A recent international consortium proposed a revised Ehlers-Danlos syndrome classification, an update much needed since Villefranche nosology, in 1998. Hypermobile Ehlers-Danlos syndrome is the only subtype in these groups of syndromes with no known genetic cause(s). This effort brought significant attention to this often underappreciated condition. This review provides an update of the clinical and genetic aspects of hypermobile Ehlers-Danlos syndrome for clinicians and researchers.

Multiple Roles of Tenascins in Homeostasis and Pathophysiology of Aorta

Tenascins are a family of large extracellular matrix (ECM) glycoproteins. Four family members (tenascin-C, -R, -X, and -W) have been identified to date. Each member consists of the same types of structural domains and exhibits time- and tissue-specific expression patterns, suggesting their specific roles in embryonic development and tissue remodeling. Among them, the significant involvement of tenascin-C (TNC) and tenascin-X (TNX) in the progression of vascular diseases has been examined in detail. TNC is strongly up-regulated under pathological conditions, induced by a number of inflammatory mediators and mechanical stress. TNC has diverse functions, particularly in the regulation of inflammatory responses. Recent studies suggest that TNC is involved in the pathophysiology of aneurysmal and dissecting lesions, in part by protecting the vascular wall from destructive mechanical stress. TNX is strongly expressed in vascular walls, and its distribution is often reciprocal to that of TNC. TNX is involved in the stability and maintenance of the collagen network and elastin fibers. A deficiency in TNX results in a form of Ehlers–Danlos syndrome (EDS). Although their exact roles in vascular diseases have not yet been elucidated, TNC and TNX are now being recognized as promising biomarkers for diagnosis and risk stratification of vascular diseases.

Sensorimotor control and neuromuscular activity of the shoulder in adolescent competitive swimmers with generalized joint hypermobility

INTRODUCTION

Shoulder pain is highly prevalent in competitive swimmers, and generalized joint hypermobility (GJH) is considered a risk factor. Sensorimotor control deficiencies and altered neuromuscular activation of the shoulder may represent underlying factors.

RESEARCH QUESTION

To investigate whether competitive swimmers with GJH including shoulder hypermobility (GJHS) differ in shoulder sensorimotor control and muscle activity from those without GJH and no shoulder hypermobility (NGJH).

METHODS

Competitive swimmers (aged 13-17) were recruited. GJHS or NGJH status was determined using the Beighton score (0-9) and Rotès-Quérol test (positive/negative). Inclusion criteria for GJHS were a Beighton score ≥5 and minimum one hypermobile shoulder, while NGJH was defined as a Beighton score ≤3 and no shoulder hypermobility. Three prone lying, upper-extremity weight-bearing shoulder stabilometric tests were performed on a force platform: Bilateral upper-extremity support eyes open (BL-EO) and eyes closed (BL-EC) and unilateral upper-extremity support eyes open (UL-EO). Surface electromyography (SEMG) was measured from the upper trapezius, lower trapezius, serratus anterior, infraspinatus and pectoralis major muscles. SEMG was normalized using maximal voluntary isometric contractions and presented relative to maximal voluntary SEMG (%MVE). Co-contraction index (CCI) was calculated for the following muscle pairs: upper trapezius-lower trapezius, upper trapezius-serratus anterior, and infraspinatus-pectoralis major. Between-group differences in stabilometric parameters, %MVE, and CCI were analyzed with a mixed effects model.

RESULTS

Thirty-eight swimmers were enrolled as GJHS (n = 19) or NGJH (n = 19). There were no group differences in stabilometric parameters or CCI. GJHS displayed significantly decreased (29%) pectoralis major activity during BL-EO compared to NGJH (5.35 ± 1.77%MVE vs. 7.51 ± 1.96%MVE; p = 0.043).

SIGNIFICANCE

Adolescent competitive swimmers with GJHS displayed no shoulder sensorimotor control deficiencies and no generally altered shoulder muscle activity pattern, except for decreased pectoralis major activity in BL-EO. Longitudinal studies are needed to investigate whether decreased pectoralis major activation contributes to the development of shoulder pain in swimmers with GJHS.

The Upper Limb Hypermobility Assessment Tool: A novel validated measure of adult joint mobility

BACKGROUND

Existing measures of generalized joint hypermobility do not include commonly affected upper limb joints.

OBJECTIVE

To evaluate the reliability of a novel clinically-applicable measure of upper limb joint mobility, its ability to discriminate between varying extents of hypermobility, identify generalized joint hypermobility, and to establish a cut-point for hypermobility classification.

DESIGN

Validation of a diagnostic tool.

METHOD

Participants were sought from three groups - healthy controls, likely and known hypermobiles, and assessed using the Upper Limb Hypermobility Assessment Tool (ULHAT), Beighton score and clinical opinion. Pearson's correlation coefficient examined individual group and whole cohort relationships between upper limb hypermobility, age, gender and ethnicity. MANOVA investigated between-group differences in ULHAT scores. Median interquartile ranges and ROC Curve analysis identified the cut-off score for identification of upper limb hypermobility. Percent agreement with clinical opinion assessed the ability of the ULHAT to identify generalized joint hypermobility.

RESULTS

112 adult participants (mean age 24.3 ± 5.5years) across the three groups were assessed. Inter-rater reliability of the tool was high (ICC2,1 = 0.92). The cut-point was established at ≥7/12 (sensitivity 0.84, specificity 0.77, +LR 3.7, -LR 0.2). Upper limb hypermobility did not vary with age or ethnicity (both p > 0.12), but was greater in females (p < 0.001). The ULHAT discriminated between the three groups and identified generalized hypermobility.

CONCLUSIONS

The 12-item ULHAT measures mobility of multiple upper limb joints in all movement planes. Using a cut-off of ≥7/12 in adults, the ULHAT is a reliable and valid tool for identifying upper limb hypermobility and generalized joint hypermobility.

Survey on joint hypermobility in university students aged 18-25 years old

BACKGROUND

Joint hypermobility is defined as a wide range of movements beyond the physiological limits, it has been recognized in healthy people, gymnasts, acrobats, and carriers of genetic affections of connective tissue. A survey among young adults was conducted to describe the frequency of joint hypermobility, estimating its impact on function and quality of life.

METHODS

Volunteer university students aged 18 to 25 years old who answered a valid 5-item questionnaire about hypermobility, a physical activity questionnaire, and the Brazilian version of the Medical Outcome Survey Short Form 36 (SF-36) were included. Hypermobility was also assessed by a guided self-examination, with Beighton's criteria being scored and scores greater than or equal to 4 or less than 4 being discriminated.

RESULTS

A total of 388 subjects were included, of which 299 were women (77.06%) and 89 were men (22.94%); the median age was 23 years old. Generalized joint hypermobility (Beighton score ≥ 4) was observed in 104 individuals (26.8%). Localized hypermobility (Beighton score 1-3) was observed in 135 (34.79%) individuals, where the hypermobility of the 5th finger was the most frequent in 165 (57.47%) individuals, followed by hypermobility of the thumb in 126 (32.56%) individuals, hypermobility of the elbows and knees each in 72 (18.6%) individuals, and hypermobility of the spine in 69 (17.79%) individuals. The descriptive observation of physical activity indicated regular practice. The correlation coefficients between the SF-36 domains and hypermobility scores were very low and statistical comparison not significant.

CONCLUSION

In this population of youngsters, predominantly women, localized hypermobility was more frequent than generalized hypermobility; however, with low impact on health domains and quality of life scores, estimated in each domain of the SF-36, the physical and mental component scores, and the time dedicated to physical activity.

The Beighton score as a predictor of Brighton criteria in sport and dance

OBJECTIVES

To determine the efficacy of using the Beighton joint hypermobility score as a predictor of Brighton criteria components, considering the influence of gender and sports participation.

DESIGN

Cross sectional study design.

SETTING

A University.

PARTICIPANTS

Sixty-five female rugby players, 38 male rugby players, 61 netball players, 42 female dancers, 40 male controls and 40 female controls.

MAIN OUTCOME MEASURES

The Beighton score was assessed using the Beighton and Horan Joint Mobility Index. The Brighton criteria was used to assess joint hypermobility syndrome. A binary logistic regression was performed for a pooled sample (n = 286), and subsequently for gender and sport to assess the Beighton score as a predictor of Brighton criteria.

RESULTS

Beighton scores were found to be a predictor of arthralgia (P = 0.002), dislocation and subluxation (P = 0.048) in the pooled analysis; a predictor of dislocation and subluxation (P = 0.047) in males and arthralgia (P = 0.001) in females. Beighton scores were a predictor of arthralgia in female rugby (P = 0.003) and in female controls (P = 0.012).

CONCLUSIONS

The potential of the Beighton score to predict joint arthralgia and dislocation/subluxation may allow clinicians to implement effective injury prevention strategies.

Dorsal Wrist Plication for Midcarpal Instability

PURPOSE

Midcarpal instability (MCI) is a cause of chronic wrist pain for which treatment remains controversial. This study's purpose was to determine the outcome of a treatment algorithm for MCI that included immobilization and surgical interventions.

METHODS

We prospectively enrolled 23 consecutive patients (12 males, average age 27 years) with 27 symptomatic wrists. All had generalized wrist pain with an average duration of 22 months. All had MCI and a catch-up clunk that reproduced the symptoms. Initial treatment was full immobilization for 6 weeks. When necessary, recurrence after immobilization was treated with an anatomically based surgical procedure to plicate the dorsal capsule and extrinsic ligaments to stabilize the midcarpal joint. Failure of surgical plication was followed by 4-corner intercarpal arthrodesis when necessary. Patients were observed for instability, grip strength, wrist motion, and Patient-Rated Wrist Evaluation.

RESULTS

For 22 wrists there was partial relief of symptoms with full-time cast or orthosis immobilization; however, symptoms quickly returned with mobilization. The other wrists had previously been immobilized and patients refused further nonsurgical care. All patients underwent surgical plication of the dorsum of the wrists. Postoperative follow-up (35 months) showed statistically significant improvements in grip strength and Patient-Rated Wrist Evaluation scores. All patients had improved pain at final follow-up. Most improvement was in female patients aged under 25 years, with hypermobility and without major traumatic or work-related injuries. This contrasted with poorer outcomes in men aged over 25years who had moderate or severe trauma that was mostly work-related. Instability recurred in 2 patients who then had a 4-corner arthrodesis.

CONCLUSIONS

Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. Surgical midcarpal capsular plication was less effective in men with posttraumatic instability. The capsular plication procedure was successful in young female patients with ligament laxity and a history of only minor or repetitive trauma and no history of major trauma.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.