Inter-tester reproducibility and inter-method agreement of two variations of the Beighton test for determining Generalised Joint Hypermobility in primary school children

Generalized Joint Hypermobility Is Associated with Type-A Hip Dysplasia in Patients Undergoing Periacetabular Osteotomy

BACKGROUND

Joint hypermobility may be associated with developmental dysplasia of the hip (DDH), but no definite conclusion has been reached. On the basis of long-term clinical observations, we hypothesized that joint hypermobility was associated with the occurrence, imaging findings, and clinical symptoms of DDH.

METHODS

We conducted a case-control study that included 175 Chinese Han patients between 13 and 45 years of age with Hartofilakidis type-A hip dysplasia. All of these patients underwent periacetabular osteotomy (PAO) between November 2021 and February 2023. An additional 76 individuals of comparable age and sex but without hip dysplasia were selected from the general population to serve as healthy controls. The Beighton 9-point scoring system was used to evaluate joint hypermobility, and a score of ≥4 was defined as generalized joint hypermobility. Standing anteroposterior pelvic radiographs were reviewed. For patients with DDH, the lateral center-edge angle, Tönnis angle, Sharp angle, lateralization of the femoral head, and patient-reported outcomes (iHOT-12, HHS, and WOMAC) were also collected to determine the radiographic severity or clinical symptoms of DDH.

RESULTS

Patients with DDH had an elevated prevalence of generalized joint hypermobility compared with that in the healthy population (27% versus 12%; p = 0.009). Among patients with DDH, those with concomitant generalized joint hypermobility had lower lateral center-edge angles (3.55° versus 9.36°; p = 0.012), greater lateralization of the femoral head (13.78 versus 12.17 mm; p = 0.020), greater standardized lateralization of the femoral head (0.64 versus 0.54; p = 0.009), and lower iHOT-12 scores (35.22 versus 40.96; p = 0.009) than did those without concomitant generalized joint hypermobility. Further multivariable linear regression analysis revealed that higher Beighton scores and younger age were predictive of more severe hip dysplasia. However, the Beighton score was not found to be independently associated with patient-reported outcomes according to multivariable linear regression analysis.

CONCLUSIONS

The prevalence of generalized joint hypermobility was greater in patients with DDH than in healthy controls. A higher degree of joint hypermobility was also correlated with more severe hip dysplasia. These results suggest that joint laxity, in addition to bone or cartilage factors, is an important factor related to DDH.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Present but Ignored: Physical Condition and Health-Related Quality of Life in College-Aged Females with Generalized Joint Hypermobility

BACKGROUND

Generalized joint hypermobility (GJH) is prevalent among young adults, necessitating effective monitoring of musculoskeletal health, particularly among college-aged females. This study aimed to identify physical fitness and health-related quality of life (HR-QoL) characteristics associated with GJH.

METHODS

A total of 67 participants were assessed: 26 with GJH (mean age 20.06, SD 1.2 years), and 41 without (mean age 20.15, SD 2.2 years). Assessments included hypermobility, anthropometric data, foot posture, balance, flexibility, strength, and HR-QoL. We used the Mann-Whitney test for two independent samples, categorical variables were analyzed with Cramer's V test. The results indicated that participants with GJH exhibited inferior balance and back muscle static strength endurance but greater flexibility compared to those without GJH. Significant differences were observed in foot posture. However, handgrip strength, explosive strength, and abdominal muscle static strength endurance did not differ significantly between groups. No significant differences were observed in HR-QoL components between the two groups. In conclusion, there appears to be a link between GJH and increased flexibility, impaired balance, reduced back muscle static strength endurance, and altered posture of both feet.

Application of non-parametric correlations to compare the compliance of Beighton and Sachse tests in the assessment of hypermobility based on research of the fitness instructors group

BACKGROUND

Joint hypermobility is a spectrum of symptoms associated with connective tissue disorders. The main feature is the increased range of joint mobility. Hypermobility is rarely recognised in clinical practice. The diagnosis is based on the evaluation of diagnostic tests, mainly the Beighton score. The divergence of research methods means that patients do not receive a proper diagnosis and treatment.

METHODS

The study used the Beighton score and the Sachse scale. Both tests are "all-or-none-tests". Non-parametric correlations were used to assess the concordance effect. To this end, two methods were adopted, i.e., the Spearman Rank Correlation and Kendall tau Rank Correlation. The values of correlation coefficients were calculated, respectively, rho and Kendall tau. The study involved 30 women working as fitness instructors.

RESULTS

Consent results of hypermobility assessment for both methods were obtained in 3 cases, while the discrepancy in the hypermobility statement concerns measurements made in 10 participants. This cursory assessment already indicates a significant differentiation of results obtained for both methods.

DISCUSSION

To the best of our knowledge, there are not many studies comparing different HSD diagnostic methods. The Beighton score is the most commonly used, but the selection of only 5 joints for the examination does not show the systemic nature of hypermobility. A reliable methodology should be based not only on goniometric measurements of selected joints.

CONCLUSION

The expanded correlation analysis of Beighton and Sachse hypermobility tests indicates their poor compliance. Therefore, there is a need to standardise hypermobility spectrum disorder diagnostics, which may affect the objectification and credibility of these diagnostics.

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

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

Musculoskeletal Health Complaints and Associated Risk Factors in Freshmen Music Students

BACKGROUND

Evidence concerning the development of musculoskeletal health complaints (MHCs) among music students is limited due to inappropriate study designs. We aimed to assess the occurrences of MHCs and associated risk factors in freshmen music students compared to students from other disciplines.

METHODS

A prospective cohort study was conducted. Risk factors such as pain-related, physical, and psychosocial variables were measured at baseline. Episodes of MHCs were recorded monthly.

RESULTS

A total of 146 music students and 191 students from other disciplines were analyzed. In the cross-sectional comparison, pain-related, physical, and psychosocial variables were significantly altered in music students compared to students from other disciplines. Furthermore, music students with current MHCs differed significantly from music students without current MHCs with respect to physical health, pain, and history of MHCs. Our longitudinal analysis showed that monthly MHCs were higher in music students compared to students from other disciplines. Independent predictors for monthly MHCs in music students were current MHCs and reduced physical function. Predictors for MHCs in students from other disciplines were a history of MHCs and stress.

CONCLUSIONS

We provided insight into the development of MHCs and risk factors in music students. This may help in the creation of targeted, evidence-based prevention and rehabilitation.

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.

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.

Interrater and Intrarater Reliability of the Beighton Score: A Systematic Review

Background:

The Beighton score is commonly used to assess the degree of hypermobility in patients with hypermobility spectrum disorder. Since proper diagnosis and treatment in this challenging patient population require valid, reliable, and responsive clinical assessments such as the Beighton score, studies must properly evaluate efficacy and effectiveness.

Purpose:

To succinctly present a systematic review to determine the inter- and intrarater reliability of the Beighton score and the methodological quality of all analyzed studies for use in clinical applications.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review of the MEDLINE, Embase, CINAHL, and SPORTDiscus databases was performed. Studies that measured inter- or intrarater reliability of the Beighton score in humans with and without hypermobility were included. Non-English, animal, cadaveric, level 5 evidence, and studies utilizing the Beighton score self-assessment version were excluded. Data were extracted to compare scoring methods, population characteristics, and measurements of inter- and intrarater reliability. Risk of bias was assessed with the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) 2017 checklist.

Results:

Twenty-four studies were analyzed (1333 patients; mean ± SD age, 28.19 ± 17.34 years [range, 4-71 years]; 640 females, 594 males, 273 unknown sex). Of the 24 studies, 18 reported raters were health care professionals or health care professional students. For interrater reliability, 5 of 8 (62.5%) intraclass correlation coefficients and 12 of 19 (63.2%) kappa values were substantial to almost perfect. Intrarater reliability was reported as excellent in all studies utilizing intraclass correlation coefficients, and 3 of the 7 articles using kappa values reported almost perfect values. Utilizing the COSMIN criteria, we determined that 1 study met “very good” criteria, 7 met “adequate,” 15 met “doubtful,” and 1 met “inadequate” for overall risk of bias in the reliability domain.

Conclusion:

The Beighton score is a highly reliable clinical tool that shows substantial to excellent inter- and intrarater reliability when used by raters of variable backgrounds and experience levels. While individual components of risk of bias among studies demonstrated large discrepancy, most of the items were adequate to very good.

Validity of the self-reported five-part questionnaire as an assessment of generalized joint hypermobility in early pregnancy

Background

The assessment of generalized joint hypermobility is difficult due to differences in classification methods and in the performance of joint mobility assessment. The primary aim was to evaluate the validity of the self-reported five-part questionnaire, 5PQ, for identifying generalized joint hypermobility using the Beighton score as reference test. The secondary aim was to describe how joint angles measured in degrees included in the Beighton score varied in different cut-off levels in the self-reported 5PQ and the Beighton score.

Methods

A cross-sectional validity study with a total of 301 women in early pregnancy, mean age of 31 years, were included in the study. The participants answered the self-reported 5PQ before the joint angles were measured. To standardize the joint mobility measurement, a structural protocol was used. The sensitivity, specificity, receiver operating characteristic curve, area under curve, positive- and negative predictive value, positive likelihood ratio and Spearman’s rank correlation between the self-reported 5PQ ≥ 2 and the Beighton score ≥ 5 were used as main outcome measures in the validity analyses. Joint angles, measured in degrees, were calculated with means in relation to different cut-off levels.

Results

There was moderate correlation between the self-reported 5PQ and the Beighton score. The highest combined sensitivity, 84.1%, as well as specificity, 61.9%, was on 5PQ cut-off level ≥ 2, with a 38% false-positive rate, a moderate area under curve, a low positive predictive value and likelihood ratio, and a high negative predictive value. The odds of a self-reported 5PQ, cut-off level ≥ 2, among women with generalized joint hypermobility, Beighton ≥5, was low indicating a low post-test probability. The mean for all joint angles measured in degrees increased with increased cut-off levels, both in the Beighton score and in the self-reported 5PQ. However, there was a significant variation for each cut-off level.

Conclusions

There is uncertainty in identifying generalized joint hypermobility in young women using the self-reported 5PQ with a cut-off level of ≥2 when the Beighton score ≥ 5 is used as the reference test. The strength of the self-reported 5PQ is to rule-out women without generalized joint hypermobility.

Reliability of a musculoskeletal profiling test battery in elite academy soccer players

The study aimed to quantify the measurement error / reliability of a musculoskeletal profiling test battery administered in young, elite academy soccer players, and to examine if the order in which the test battery was administered, and who it was administered by, influenced reliability. Players (n = 75; age 12–20 years; stature 1.47–1.95 m; body mass 36–89 kg) from U-12 to U-23 age groups were assigned to either: 1) intra-rater-fixed order; 2) intra-rater-non-fixed order; 3) inter-rater-fixed order; or, 4) inter-rater-non-fixed order groups. On two separate occasions separated by 3 to 7 days, 12 raters conducted a musculoskeletal profiling test battery comprising 10 tests (Supine Medial Hip Rotation, Supine Lateral Hip Rotation, Hamstring 90/90, Prone Medial Hip Rotation [degrees]; Combined Elevation, Thoracic Rotation, Weight-Bearing Dorsiflexion, Y-Balance [centimetres]; Beighton, Lumbar Quadrant [categorical]). The measurement error / reliability for tests measured in degrees and centimetres was evaluated using the intraclass correlation (relative reliability), coefficient of variation and ratio limits of agreement (absolute reliability). Intraclass correlations varied from 0.04 (“poor”) to 0.95 (“excellent”), coefficient of variation from 2.9 to 43.4%, and the ratio limits of agreement from 1.058 (*/÷ 1.020) to 2.026 (*/÷ 1.319) for the tests measured in degrees and centimetres. The intraclass correlation, coefficient of variation and ratio limits of agreement were smallest for five out of eight tests measured in degrees and centimetres when the tests were administered in an intra-rater-fixed test order. These findings emphasise that different testing methods, and the administration of a musculoskeletal profiling test battery using a less than optimal design, will influence measurement error and hence test reliability. These observations need to be considered when investigating musculoskeletal function and age, injury, training or asymmetry in young, elite academy soccer players.

Development of a return to play checklist following patellar instability surgery: a Delphi-based consensus

PURPOSE

To date, there is no consensus for the appropriate timing or functional evaluation for safe return to play following patellar instability surgery. The purpose of this study is to develop a consensus-based return to play checklist following patellar stabilization surgery using the Delphi method.

METHODS

A 3-part survey series was conducted following the systematic guidelines of the Delphi technique for gathering consensus from experts in the management of patellofemoral instability. All surveys were completed between July and November of 2017. A literature search was performed in SCOPUS and PubMed to identify existing sources on return to play following patellar instability surgery and determining patellofemoral joint strength in athletes, which served as the basis for the surveys.

RESULTS

12 of the 19 selected participants (63%) completed the first-round survey, 11 of those 12 participants (92%) completed the second-round survey, and 10 of these 11 participants (91%) completed the final survey. Of the final ten participants, there was representation from seven different states in the USA. Nine of the ten (90%) respondents endorsed the final checklist. The final checklist included eight overarching domains with defined and reproducible objective criteria.

CONCLUSION

The standardized list of objective and reproducible criteria for rehabilitation outlined below should help practitioners focus more on patient-centred factors and less on arbitrary timelines. No prior study has gathered consensus from experts on this topic; therefore, this study should serve as a benchmark to help guide patients back to sport safely.

LEVEL OF EVIDENCE

V.

Reproducibility protocol for diagnostic procedures in Manual/Musculoskeletal Medicine

The International Academy of Manual/Musculoskeletal Medicine (IAMMM) has completely revised the protocol for reproducibility studies of diagnostic procedures in Manual/Musculoskeletal Medicine (M/M Medicine). The protocol was and is aimed at the practitioners in the field of M/M Medicine. This IAMMM protocol can be used in a very practical way and makes it feasible to perform reproducibility studies equally well in private practices and clinics for M/M Medicine with two or more physicians and as by educational boards of the societies of M/M Medicine. This IAMMM protocol provides practical solutions for sample size calculations in reproducibility studies using kappa statistics. Step by step, many different statistical aspects of reproducibility studies are explained, resulting in a very structured protocol format of how to perform a reproducibility study using overall agreement and the kappa value as statistical outcome.

Prevalence of generalized joint hypermobility, musculoskeletal injuries, and chronic musculoskeletal pain among American university students

The objective of this study was to investigate the prevalence of generalized joint hypermobility (GJH) in a university-aged population, whether young adults (aged 18–25 years) with GJH are prone to sustain more musculoskeletal injuries, and are more likely to suffer from chronic musculoskeletal pain. The study used an interactive survey to gather data; GJH was assessed using a cut-off Beighton score of ≥5 in accordance with the 2017 International Classification of EDS criteria. The analyzed sample consisted of 482 female and 172 male participants from Florida Gulf Coast University (USA). The prevalence of GJH in a university-aged population can be estimated at 12.5%. Women did not have higher rates of GJH than men. However, female participants showed significantly higher rates of hypermobility of the spine as well as the right knee and elbow joints. The Beighton scores did not differ by ethnicity/race. Female participants had a lower rate of self-reported injuries than male participants, although this difference was not significant. There was no difference in the proportion of all participants classified within different categories (0; 1–4; 5–9) of Beighton scores and whether or not they reported having been injured. Male and female participants reported chronic pain of joints and neck or back at the same rates across the Beighton score categories. Female participants, however, reported higher pain intensity for chronic neck and back pain. This study increases knowledge about a correlation between GJH, musculoskeletal injuries, and chronic pain of joints, neck, and back in a university-aged population.

Hypermobility, developmental coordination disorder and physical activity in an Irish paediatric population

OBJECTIVE

The primary aim of the study was to explore the prevalence of generalized joint hypermobility (GJH) and generalized hypermobility spectrum disorder (gHSD) using the new classification system in a community paediatric physiotherapy service in Ireland. The second aim was to explore the relationship between GJH, gHSD and physical activity level, while considering the association of probable developmental coordination disorder (pDCD).

METHODS

A case-controlled cross-sectional study of children aged 6-12 years, recruited from the community paediatric physiotherapy department (n = 32) and a local school (n = 41), was carried out. A Beighton score of ≥6/9 distinguished GJH. The new framework for hypermobility spectrum disorder (HSD) was used. Self-reported physical activity level was measured using the Physical Activity Questionnaire-Older Children. A parent-reported validated questionnaire screened for pDCD.

RESULTS

The prevalence of GJH was 21.9% of children attending physiotherapy. One child in the physiotherapy group was identified as having gHSD, with a prevalence of 3.1%. There was no significant difference in physical activity level between children with and without GJH attending physiotherapy (independent samples t-test, p = 0.28). Probable developmental coordination disorder (pDCD) was observed in 71.9% of children attending physiotherapy. There was no significant difference in the number of children with pDCD in those with and without GJH (Fisher's exact test, p = 0.370).

CONCLUSIONS

This study was the first to explore the prevalence of GJH and gHSD in the paediatric physiotherapy population in Ireland. The presence of GJH did not affect self-reported physical activity level or motor coordination in children attending physiotherapy.

Evaluation of ligament laxity during pregnancy

OBJECTIVE

Pregnancy-related changes in ligament laxity have been shown to be associated with various disorders such as back pain or pelvic floor disorders. The purpose of this study was to assess laxity changes during pregnancy by confronting different methods in order to suggest a simple clinical tool helping to prevent the aforementioned problems.

DESIGN

Seventeen pregnant women were evaluated at the first, second and third trimesters as cases and 16 non-pregnant women participated as controls. Ligamentous laxity was measured using an extensometer for the metacarpophalangeal joint of the index, a fingertip to floor test and a sit and reach test to assess hip and lumbar flexibility and the Beighton score. Statistical analysis included independent samples t-tests, analysis of variance and Pearson correlation coefficients.

RESULTS

Laxity of the metacarpophalangeal joint increased by 11% from the first to the second trimester of pregnancy and stabilized until delivery. The Beighton score was significantly higher in the second trimester of pregnancy (p < 0.05). The flexibility of the hip and lumbar vertebra showed a significant increase of the distance measured between the foot soles and the middle fingers at third trimester (p < 0.05). A moderate correlation was observed between the results given by the extensometer and the Beighton score in both the cases and the control group at first trimester (r = 0.60, p < 0.05) but none was found for the two hip and lumbar flexibility tests.

CONCLUSION

Laxity reached its maximum at the second trimester. The combination of an objective measurement by the extensometer and a global evaluation of the laxity by the Beighton' score for example may be useful for a daily assessment of laxity. However, the chosen clinical tests don't seem appropriate to be used alone in pregnant women.

Hypermobility in individuals with Kabuki syndrome: The effect of growth hormone treatment

Kabuki syndrome (KS) is a multiple congenital malformation syndrome which has been described across all ethnic groups. Most KS patients possess two genetic subtypes: KMT2D-associated, autosomal-dominant KS type 1 (KS1; OMIM 147920); and KDM6A-associated, X-linked-dominant KS type 2. Generalized joint hypermobility is one feature of KS, but its exact incidence and pattern is not well described in the literature. As part of our prospective study on the metabolic and growth effect of GH treatment, we assessed children from our Dutch Kabuki cohort who were eligible for growth hormone therapy. We assessed severity and pattern of joint hypermobility, both before and after 24 months of growth hormone replacement therapy. The prevalence of hypermobility was 31% in boys and 14% in girls using the Beighton score and 69% in boys and 57% in girls using the Bulbena score. This varies from the general population where girls are more affected. After 2 years of growth hormone treatment, there was a statistically significant decrease in the presence of joint hypermobility to 6% using the Bulbena score and none with respect to the Beighton score. We hypothesized that this result suggests a direct effect of growth hormone on connective tissue in patients with KS.

Musculoskeletal pain and musculoskeletal syndromes in adolescents are related to electronic devices

OBJECTIVE

To evaluate television and simultaneous electronic devices use in adolescents with musculoskeletal pain and musculoskeletal pain syndromes.

METHODS

A cross-sectional study was performed in 299 healthy adolescents of a private school. All students completed a self-administered questionnaire, including: demographic data, physical activities, musculoskeletal pain symptoms, and use of simultaneous television/electronic devices (computer, internet, electronic games, and cell phones). Seven musculoskeletal pain syndromes were also evaluated: juvenile fibromyalgia, benign joint hypermobility syndrome, myofascial syndrome, tendinitis, bursitis, epicondylitis, and complex regional pain syndrome.

RESULTS

Inter-rater agreement between pretest and retest was 0.83. Musculoskeletal pain and musculoskeletal pain syndrome were found in 183/299 (61%) and 60/183 (33%), respectively. The median age (15 [10-18] vs. 14 [10-18] years, p=0.032) and years of education (10 [5-12] vs. 9 [5-12] years, p=0.011) were significantly higher in adolescents with musculoskeletal pain when compared with those without this condition. The frequencies of female gender (59% vs. 47%, p=0.019), cell phone use (93% vs. 81%, p=0.003), and simultaneous use of at least two electronic devices (80% vs. 67%, p=0.011) were significantly higher in the former group. Further comparisons between adolescents with and without musculoskeletal pain syndromes revealed that the frequency of female gender was significantly higher in the former group (75% vs. 25%, p=0.002), and with a significantly reduced median of weekends/holidays electronic games use (1.5 [0-10] vs. 3 [0-17]h/day, p=0.006).

CONCLUSIONS

A high prevalence of musculoskeletal pain/syndromes was observed in female adolescents. Musculoskeletal pain was mostly reported at a median age of 15 years, and students used at least two electronic devices. Reduced use of electronic games was associated with musculoskeletal pain syndromes.

Inter- and intra-rater reliability for measurement of range of motion in joints included in three hypermobility assessment methods

BACKGROUND

Comparisons across studies of generalized joint hypermobility are often difficult since there are several classification methods and methodological differences in the performance exist. The Beighton score is most commonly used and has been tested for inter- and intra-rater reliability. The Contompasis score and the Hospital del Mar criteria have not yet been evaluated for reliability. The aim of this study was to investigate the inter- and intra-rater reliability for measurements of range of motion in joints included in these three hypermobility assessment methods using a structured protocol.

METHODS

The study was planned in accordance with guidelines for reporting reliability studies. Healthy adults were consecutively recruited (49 for inter- and 29 for intra-rater assessments). Intra-class correlations, two-way random effects model, (ICC 2.1) with 95% confidence intervals, standard error of measurement, percentage of agreement, Cohen's Kappa (κ) and prevalence-adjusted bias-adjusted kappa were calculated for single-joint measured in degrees and for total scores.

RESULTS

The inter- and intra-rater reliability in total scores were ICC 2.1: 0.72-0.82 and 0.76-0.86 and for single-joint measurements in degrees 0.44-0.91 and 0.44-0.90, respectively. The difference between ratings was within 5 degrees in all but one joint. Standard error of measurement ranged from 1.0 to 6.9 degrees. The inter- and intra-rater reliability for prevalence of positive hypermobility findings the Cohen's κ for total scores were 0.54-0.78 and 0.27-0.78 and in single joints 0.21-1.00 and 0.19-1.00, respectively. The prevalence- and bias adjusted Cohen's κ, increased all but two values.

CONCLUSIONS

Following a structured protocol, the inter- and intra-rater reliability was good-to-excellent for total scores and in all but two single joints, measured in degrees. The inter- and intra-rater reliability for prevalence of positive hypermobility findings was fair-to-almost perfect for total scores and slight-to-almost-perfect in single joints. By using a structured protocol, we attempted to standardize the assessment of range of motion in clinical and in research settings. This standardization could be helpful in the first part of the process of standardizing the tests thus avoiding that assessment of GJH is based on chance.

Identifying lower limb specific and generalised joint hypermobility in adults: validation of the Lower Limb Assessment Score

BACKGROUND

The Lower Limb Assessment Score (LLAS) has only been validated in a paediatric population. The aim of this study was to validate the use of the LLAS in an adult population by: i) evaluating its ability to discriminate between different extents of lower limb hypermobility, ii) establishing a cut-off score to identify lower limb hypermobility, and iii) determining if the LLAS is able to identify Generalised Joint Hypermobility (GJH).

METHODS

Participants were recruited across three groups representing varying degrees of hypermobility. They were assessed using the LLAS, Beighton score and clinical opinion. Pearson's correlation coefficient and MANOVA were used to assess between-group differences in the LLAS. The cut-off score was determined using median and inter-quartile ranges and the Receiver Operator Characteristic Curve. The ability of the LLAS to identify GJH was assessed using percent agreement with clinical opinion.

RESULTS

One hundred twelve participants aged 18-40 years were recruited. The LLAS distinguished the control from the likely hypermobile and known hypermobile cohorts (both p < 0.001), as well as the likely hypermobile from the known hypermobile cohort (p = 0.003). The LLAS cut-off score for identifying lower limb hypermobility was ≥7/12 with a specificity of 86% and sensitivity of 68%. The LLAS accurately identified those with GJH with high percentage agreement compared to clinical opinion across all cohorts (69-98%).

CONCLUSIONS

The LLAS is a valid tool for identifying lower limb specific hypermobility and GJH in adults at a cut-off score of ≥7/12. It demonstrates excellent specificity and moderate sensitivity, and discriminates well between extents of hypermobility.

Measurement properties of clinical assessment methods for classifying generalized joint hypermobility-A systematic review

The purpose was to perform a systematic review of clinical assessment methods for classifying Generalized Joint Hypermobility (GJH), evaluate their clinimetric properties, and perform the best evidence synthesis of these methods. Four test assessment methods (Beighton Score [BS], Carter and Wilkinson, Hospital del Mar, Rotes-Querol) and two questionnaire assessment methods (Five-part questionnaire [5PQ], Beighton Score-self reported [BS-self]) were identified on children or adults. Using the Consensus-based Standards for selection of health Measurement Instrument (COSMIN) checklist for evaluating the methodological quality of the identified studies, all included studies were rated "fair" or "poor." Most studies were using BS, and for BS the reliability most of the studies showed limited positive to conflicting evidence, with some shortcomings on studies for the validity. The three other test assessment methods lack satisfactory information on both reliability and validity. For the questionnaire assessment methods, 5PQ was the most frequently used, and reliability showed conflicting evidence, while the validity had limited positive to conflicting evidence compared with test assessment methods. For BS-self, the validity showed unknown evidence compared with test assessment methods. In conclusion, following recommended uniformity of testing procedures, the recommendation for clinical use in adults is BS with cut-point of 5 of 9 including historical information, while in children it is BS with cut-point of at least 6 of 9. However, more studies are needed to conclude on the validity properties of these assessment methods, and before evidence-based recommendations can be made for clinical use on the "best" assessment method for classifying GJH. © 2017 Wiley Periodicals, Inc.

Posterior hip instability relocation testing: a resident's case report

BACKGROUND

Micro-instability (non-radiographic clinical instability) continues to gain recognition as a problem at the hip. Although most research has been directed to anterior hip instability, posterior hip instability (PHI) has also garnered attention. PHI is under recognized, difficult to identify, and confused with other hip pathologies such as a simple sprain or strain. A novel clinical test is introduced that may have helped identify PHI in this patient. Additionally, a conservative rehabilitation approach emphasizing stabilization exercises is described.

CASE DESCRIPTION

A 29-year-old female presented with complaints of posterior lateral and anterior hip pain of 1.5 years duration. Upon initiating an aggressive stretching program, her pain worsened. Examination revealed limited and painful hip flexion, and positive anterior impingement testing for femoroacetabular impingement. Both tests were significantly less painful with more motion when retested with manual repositioning of the femoral head from posterior to anterior, referred to as posterior relocation testing. The patient was instructed to discontinue stretching. A stabilization plan was established including strengthening of the deep external rotators with trunk and lower quarter neuromuscular re-education.

OUTCOME

The patient completed 12 appointments over 2.5 months. At discharge, the patient reported improvements with pain and function. The Lower Extremity Functional Scale improved from 64/80 to 77/80 and Oswestry Disability Questionnaire improved from 8 to 0%.

DISCUSSION

PHI may have contributed to this patient's symptoms. The posterior relocation test may assist clinicians with identification of PHI, thus directing treatment toward stabilization and neuromuscular control rather than interventions designed to increase mobility.

LEVEL OF EVIDENCE

4.

Joint hypermobility and oligoarticular juvenile idiopathic arthritis: What relationship?

AIM

Oligoarticular onset juvenile idiopathic arthritis (oJIA) is characterised by a prevalent lower limb involvement, antinuclear antibodies (ANA) positivity and high risk of anterior uveitis. As we observed that oJIA patients frequently present with joint hypermobility (JH), we investigated whether there was a relationship between oJIA and JH.

METHODS

Our series consisted of children with oJIA, as defined by the International League of Associations for Rheumatology criteria, for whom complete clinical data of at least 2 years' duration were available. Clinical and laboratory data, collected at disease onset and at the last follow-up, included: sex, age, presence of JH according to the Beighton score, disease activity, presence of uveitis, ANA, treatment and outcome.

RESULTS

A total of 274 oligoarticular JIA patients (224 female, 50 male; mean age: 11.5) followed on average for 6.6 years, entered the study. The mean age at disease onset was 4.9 years, ANA were positive in 83.9% and uveitis occurred in 20.8%. JH was present in 70.8% of cases at onset, in 44.5% at the last evaluation. JH was more frequent in females (73.7%) than in males (58.0%) (P = 0.028). Uveitis was less frequent in hypermobile children both at diagnosis (17.5 vs. 28.7%, P = 0.037) and during overall disease course (23.7 vs. 36.3%, P = 0.034). Of 163 subjects with at least 5-year follow-up, the full clinical remission rate was significantly higher in JH patients (50.5%) than in those without JH (42.3%; P = 0.042).

CONCLUSION

In patients with oligoarticular JIA, JH is more frequent than in healthy subjects, uveitis less frequent and the long-term outcome better.

Hypermobility and Musculoskeletal Pain in Adolescents

OBJECTIVE

To determine the prevalence of generalized joint hypermobility (GJH) in a large cohort of Australian children and determine the associations between GJH and musculoskeletal pain.

STUDY DESIGN

This is a cross-sectional analysis of the Western Australian Pregnancy Cohort (Raine) Study. Hypermobility was measured in 1584 participants at 14 years of age using the Beighton scoring system, along with a range of other factors including musculoskeletal pain status. Logistic regression models were used to assess independent associations of GJH with factors of interest.

RESULTS

The prevalence of GJH was 60.6% and 36.7% in girls and boys, respectively, when defined as a Beighton score of ≥4; when defined as ≥6, it was 26.1% and 11.5%. In girls, positive associations between GJH and higher socioeconomic status and better motor competence were observed. In boys, positive associations between GJH and lower body mass index were observed. After adjusting for potential confounders, an association between number of pain areas in the last month and made worse with sport were identified in boys but not girls.

CONCLUSION

The high prevalence rates of GJH as defined by commonly used Beighton cutoff values in this cohort highlight the need to question the appropriateness of these cutoffs in future studies. Future prospective studies of the association between GJH and musculoskeletal pain should be adjusted for confounding variables identified in this study, and be powered for sex-specific analyses owing to the differing prevalence rates and hypermobility correlates in male and female samples.

The association between generalized joint hypermobility and active horizontal shoulder abduction in 10-15 year old competitive swimmers

Background

Increased shoulder mobility and Generalised Joint Hypermobility (GJH) are assumed to be predisposing risk factors for shoulder injuries. The association between GJH and shoulder mobility among competitive swimmers is unknown. The aim was to study the association between GJH and active horizontal shoulder abduction (AHSA) in young, competitive swimmers and to describe normative values of AHSA in this group.

Methods

In total, 92 swimmers (10–15 years) without shoulder pain participated. GJH was evaluated with the Beighton Tests (BT) for joint hypermobility. Shoulder mobility was measured as maximum AHSA. A multiple regression model was used to assess associations between GJH and AHSA.

Results

Overall, positive associations were found between GJH and AHSA. An increase of BT score was associated with an increase of AHSA, seen as an increased AHSA of 3.9°, 5.7° and 7.9° by BT cut off points ≥5/9, ≥6/9 and ≥7/9, respectively. Normative values for AHSA ranged from 40° to 52°, depending on age.

Conclusions

Positive associations were found between GJH and AHSA, as maximum AHSA range increased with increasing BT scores. Due to lack of shoulder mobility tests in the BT scoring system, the AHSA test seems to be a promising supplemental test.

Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain

BACKGROUND/AIM

Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA.

METHODS

This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ(2)/Fisher exact test, and OR with significance level >0.05.

RESULTS

Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA.

CONCLUSIONS

Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum.

When flexibility is not necessarily a virtue: a review of hypermobility syndromes and chronic or recurrent musculoskeletal pain in children

Chronic or recurrent musculoskeletal pain is a common complaint in children. Among the most common causes for this problem are different conditions associated with hypermobility. Pediatricians and allied professionals should be well aware of the characteristics of the different syndromes associated with hypermobility and facilitate early recognition and appropriate management. In this review we provide information on Benign Joint Hypermobility Syndrome, Ehlers-Danlos Syndrome, Marfan Syndrome, Loeys-Dietz syndrome and Stickler syndrome, and discuss their characteristics and clinical management.

The extent and risk of knee injuries in children aged 9-14 with Generalised Joint Hypermobility and knee joint hypermobility - the CHAMPS-study Denmark

Background

Generalised Joint Hypermobility (GJH) is suggested as an aetiological factor for knee injuries in adolescents and adults. It is presumed that GJH causes decreased joint stability, thereby increasing the risk of knee injuries during challenging situations like jumping and landing. The aim was to study the extent and risk of knee injuries in children with GJH and knee hypermobility.

Methods

In total, 999 children (9–14 years) were tested twice during spring 2012 and 2013 with Beighton´s Tests (BT) for hypermobility, a 0–9 scoring system. GJH was classified with cut-point ≥5/9 on both test rounds. On basis of weekly cell phone surveys of knee pain, children requiring clinical examination were seen. Traumatic and overuse knee injuries were registered by WHO ICD-10 diagnoses. Logistic regression and Poisson regression models with robust standard errors were used to examine the association between GJH and knee injuries, taking into account clustering on school class levels.

Results

Totally, 36 children were classified GJH on both test rounds. Overuse knee injuries were the most frequent injury type (86 %), mainly apophysitis for both groups (61 %), other than patella-femoral pain syndrome for the control group (13 %). For traumatic knee injuries, distortions and contusions were most frequent in both groups (51 % resp. 36 %), besides traumatic lesions of knee tendons and muscles for the control group (5 %). No significant association was found between overuse knee injuries and GJH with/without knee hypermobility (OR 0.69, p = 0.407 resp. OR 0.75, p = 0.576) or traumatic knee injuries and GJH with/without knee hypermobility (OR 1.56, p = 0.495 resp. OR 2.22, p = 0.231).

Conclusions

Apophysitis, distortions and contusions were the most frequent knee injuries. Despite the relatively large study, the number of children with GJH and knee injuries was low, with no significant increased risk for knee injuries for this group. This questions whether GJH is a clinically relevant risk factor for knee injuries in school children aged 9–14 years. A fluctuation in the individual child´s status of GJH between test rounds was observed, suggesting that inter- and intra-tester reproducibility of BT as well as growth may be considered important confounders to future studies of children with GJH.