The differential diagnosis of children with joint hypermobility: a review of the literature

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.

Pediatric joint hypermobility: a diagnostic framework and narrative review

BACKGROUND

Hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are debilitating conditions. Diagnosis is currently clinical in the absence of biomarkers, and criteria developed for adults are difficult to use in children and biologically immature adolescents. Generalized joint hypermobility (GJH) is a prerequisite for hEDS and generalized HSD. Current literature identifies a large proportion of children as hypermobile using a Beighton score ≥ 4 or 5/9, the cut off for GJH in adults. Other phenotypic features from the 2017 hEDS criteria can arise over time. Finally, many comorbidities described in hEDS/HSD are also seen in the general pediatric and adolescent population. Therefore, pediatric specific criteria are needed. The Paediatric Working Group of the International Consortium on EDS and HSD has developed a pediatric diagnostic framework presented here. The work was informed by a review of the published evidence.

OBSERVATIONS

The framework has 4 components, GJH, skin and tissue abnormalities, musculoskeletal complications, and core comorbidities. A Beighton score of ≥ 6/9 best identifies children with GJH at 2 standard deviations above average, based on published general population data. Skin and soft tissue changes include soft skin, stretchy skin, atrophic scars, stretch marks, piezogenic papules, and recurrent hernias. Two symptomatic groups were agreed: musculoskeletal and systemic. Emerging comorbid relationships are discussed. The framework generates 8 subgroups, 4 pediatric GJH, and 4 pediatric generalized hypermobility spectrum disorders. hEDS is reserved for biologically mature adolescents who meet the 2017 criteria, which also covers even rarer types of Ehlers-Danlos syndrome at any age.

CONCLUSIONS

This framework allows hypermobile children to be categorized into a group describing their phenotypic and symptomatic presentation. It clarifies the recommendation that comorbidities should be defined using their current internationally accepted frameworks. This provides a foundation for improving clinical care and research quality in this population.

Bilateral temporomandibular joint luxation in a 6-month-old child: Case report

BACKGROUND

Luxation of the temporomandibular joint (TMJ) is an acute condition associated with translocation of the condylar joint out of its functional position. Traumatic causes are more common in childhood, while non-traumatic causes are very rare.

CLINICAL PRESENTATION

A 6-month-old patient was brought to a rural hospital emergency department with the inability to close her mouth. The patient was diagnosed with anterior TMJ luxation after the examination, and no additional imaging was requested. Reduction was performed with gas sedation accompanied by paracetamol for pain.

CONCLUSION

In rare cases, non-traumatic TMJ luxation may be observed after excessive crying or vomiting in infants. Examination findings are generally sufficient for diagnosis. Reduction is performed with the classical manual method, especially in childhood. One issue that should not be ignored is the possibility of recurrence after dislocation.

Hand Impairment and Function in Children and Adolescents With Heritable Disorders of Connective Tissue

Importance: Heritable disorders of connective tissue (HDCTs) affect hand function and participation in daily activities for children and adolescents.

Objective: To describe hand impairment and function and determine the extent to which hand impairment and function explain the variation in self-reported functional performance.

Design: Cross-sectional observational study.

Setting: Specialist tertiary hospital.

Participants: Children and adolescents ages 8–18 yr with HDCTs (N = 73).

Intervention: None.

Outcomes and Measures: Hand function outcomes included grip strength (digital dynamometer), manipulation and dexterity (Functional Dexterity Test, Nine-Hole Peg Test), and fine motor skills (Bruininks–Oseretsky Test of Motor Proficiency). Upper limb hypermobility was assessed using the Upper Limb Hypermobility Assessment Tool. Hand pain and fatigue were recorded for a timed button test and 3- and 9-min handwriting tasks. Functional performance was measured using the Childhood Health Assessment Questionnaire.

Results: Scores on all hand function measures were below expected norms. Pain and fatigue were significantly worse after the writing tasks (p < .001) but not the button test (p > .40). Secondary students had significantly lower handwriting scores than primary students (p = .03) but similar grip strength z scores (p = .95). Variation in self-reported functional performance was explained by grip strength (6%) and upper limb hypermobility and dexterity (16%).

Conclusions and Relevance: Young people with HDCTs have poor hand function attributable to poor grip strength and hand pain and fatigue. Comprehensive upper limb evaluation and ongoing monitoring throughout the school years are warranted to inform timely intervention.

What This Article Adds: Children and adolescents with heritable disorders of connective tissue have difficulty with hand function that affect their participation in daily activities. The results of this study can help clinicians identify, assess, and monitor daily activities, performance skills, and symptoms of children and adolescents with HDCTs to promote their participation in all aspects of daily life.

Evaluation of postural control in children with increased femoral anteversion

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

An association between excessive valgus hindfoot alignment and postural stability during single-leg standing in adolescent athletes

BACKGROUND

Diminished balance is associated with the incidence of ankle and lower extremity injuries in adolescents. Although flexible flatfoot is a common foot condition in pediatric and adolescent populations, the association between balance control and foot morphology remain unclear in adolescent athletes.

METHODS

Rearfoot angle in the double-limb standing position, body mass index (BMI), and isometric muscle strength related to the knee joint were retrospectively reviewed in 101 adolescent athletes (75 boys and 26 girls) with a mean age of 14.0 years (range 12-17). Postural stability during single-leg standing on static and dynamic platforms was investigated using Balance System SD in 119 feet without functional ankle instability. The participants were divided according to their rearfoot angle into control (less than 7°) and valgus (greater than or equal to 7°) groups. The measured parameters were compared between the control and valgus groups using Welch's t-test, and P values < 0.05 were considered statistically significant. Multiple regression analysis was conducted to identify the factors that significantly influenced postural control.

RESULTS

The average rearfoot angle was 4.6° in all participants. An excessive valgus rearfoot angle was detected in 53 feet (26.2%). No significant difference was found between the groups in terms of BMI and isometric knee muscle strength. Although no statistical differences were observed in postural stability on the static platform between the control and valgus groups, the valgus group demonstrated poorer postural stability for single-leg standing on the dynamic platform. Multiple regression analysis revealed that BMI and rearfoot angle were significantly associated with a poor postural control on the dynamic platform.

CONCLUSIONS

Our findings suggest that excessive rearfoot valgus specifically contributes to the deterioration of postural stability in adolescent athletes, and that rearfoot alignment should be evaluated for the adolescent population to prevent sports-related lower extremity injury.

Outcome measures for assessing change over time in studies of symptomatic children with hypermobility: a systematic review

Background

Generalised joint hypermobility (GJH) is highly prevalent among children and associated with symptoms in a fifth with the condition. This study aimed to synthesise outcome measures in interventional or prospective longitudinal studies of children with GJH and associated lower limb symptoms.

Methods

Electronic searches of Medline, CINAHL and Embase databases from inception to 16th March 2020 were performed for studies of children with GJH and symptoms between 5 and 18 years reporting repeated outcome measures collected at least 4 weeks apart. Methodological quality of eligible studies were described using the Downs and Black checklist.

Results

Six studies comprising of five interventional, and one prospective observational study (total of 388 children) met the inclusion criteria. Interventional study durations were between 2 and 3 months, with up to 10 months post-intervention follow-up, while the observational study spanned 3 years. Three main constructs of pain, function and quality of life were reported as primary outcome measures using 20 different instruments. All but one measure was validated in paediatric populations, but not specifically for children with GJH and symptoms. One study assessed fatigue, reporting disabling fatigue to be associated with higher pain intensity.

Conclusions

There were no agreed sets of outcome measures used for children with GJH and symptoms. The standardisation of assessment tools across paediatric clinical trials is needed. Four constructs of pain, function, quality of life and fatigue are recommended to be included with agreed upon, validated, objective tools.

Is There an Association between the Familial Form of Generalized Joint Hypermobility and Developmental Dysplasia of the Hip in Children?

Background and Objectives:

This study aimed to examine the association between the familial generalized joint hypermobility (GJH) and developmental dysplasia of the hip (DDH) in children.

Materials and Methods:

All infants and children included in this case (with DDH)–control study were examined for features of GJH by the revised Beighton's Test Scale (BTS), provided that they had no teratogenic or pathological causes of DDH or GJH.

Results:

Two hundred and eight participants were included in this study: 101 (48.6%) cases and 107 (51.4%) controls; age mean 16.57 [standard deviation (SD) 18.1] months; 61.1% (127) females and 38.9% (81) males. The odds ratio was 2.1 (95% confidence interval 1.197–3.679). The cases had a higher value of BTS score (mean = 4.7, SD = 3.015) when compared with the controls (mean = 3.42, SD = 3.448). The difference was statistically significant, but the correlation coefficient (r) between the study groups and BTS scores was weak (r = 0.194, P = 0.005). The correlation gained slight improvement by justification of the age to obtain homogeneity between the groups (r = 0.276, P < 0.001), but deteriorated and lost its significance when the sex was controlled as a confounder (r = 0.121, P = 0.082). There was a gradual increase in the mean BTS score from grade 1 to grade 4 of DDH but without a statistically significant value (r = 0,132, P = 0.128).

Conclusion:

The familial GJH has a weak positive correlation with DDH but cannot be considered as a possible risk factor for it.

Fetal Fractures in an Infant with Maternal Ehlers-Danlos Syndrome, CCDC134 Pathogenic Mutation and a Negative Genetic Test for Osteogenesis Imperfecta

Intrauterine fractures are a rare clinical finding caused by abnormal early-life osteogenesis. In this case report, we reported a male infant with twenty-three intrauterine/fetal fractures resembling osteogenesis imperfecta and tested negative for COL1A1 and COL1A2 mutations. The infant’s mother had Ehlers–Danlos syndrome, hypermobility type. Whole-genome sequencing revealed that there were no pathologic mutations previously documented to be associated with intrauterine fracture. Genetic mutations reported to be associated with fragility fractures were identified. These include the pathogenic homozygous mutation in the CCDC134 gene. Other genetic variants that might be responsible for variable expressivity of the skeletal manifestation include the homozygous variants of the genes CCDC134, COL15A1 and ZFPM1, and the heterozygous variants of the genes MYH3, BCHE, AUTS2. This is the first reported case of in utero fractures, that was confirmed by X-ray after birth, in an infant who had no genetic evidence for osteogenesis imperfecta, had a homozygous pathogenic mutation of an osteogenesis gene and whose mother had Ehlers-Danlos syndrome hypermobility type. Therefore, we have identified a new genetic cause for in utero fractures. If after birth, this infant were found to have these fractures in various stages of healing with a negative genetic test for osteogenesis imperfecta he would have been misdiagnosed as due to nonaccidental trauma.

Pain Phenotypes in Rare Musculoskeletal and Neuromuscular Diseases

For patients diagnosed with a rare musculoskeletal or neuromuscular disease, pain may transition from acute to chronic; the latter yielding additional challenges for both patients and care providers. We assessed the present understanding of pain across a set of ten rare, noninfectious, noncancerous disorders; Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Fibrodysplasia Ossificans Progressiva, Fibrous Dysplasia/McCune-Albright Syndrome, Complex Regional Pain Syndrome, Duchenne Muscular Dystrophy, Infantile- and Late-Onset Pompe disease, Charcot-Marie-Tooth Disease, and Amyotrophic Lateral Sclerosis. Through the integration of natural history, cross-sectional, retrospective, clinical trials, & case studies we described pathologic and genetic factors, pain sources, phenotypes, and lastly, existing therapeutic approaches. We highlight that while rare diseases possess distinct core pathologic features, there are a number of shared pain phenotypes and mechanisms that may be prospectively examined and therapeutically targeted in a parallel manner. Finally, we describe clinical and research approaches that may facilitate more accurate diagnosis, monitoring, and treatment of pain as well as elucidation of the evolving nature of pain phenotypes in rare musculoskeletal or neuromuscular illnesses.

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.

Clinical Presentation of Spasticity and Passive Range of Motion Deviations in Dyskinetic Cerebral Palsy in Relation to Dystonia, Choreoathetosis, and Functional Classification Systems

Objectives: To map the presence, severity, and distribution of spasticity and passive range of motion (pROM) deviations in dyskinetic cerebral palsy (DCP), and to explore their relation with dystonia, choreoathetosis, and functional abilities.Methods: This cross-sectional study included 53 participants with DCP. Spasticity was assessed with the Modified Ashworth Scale, limited- and increased pROM (hypermobility) with a goniometer, dystonia and choreoathetosis with the Dyskinesia Impairment Scale, gross motor and manual abilities with corresponding functional classification systems.Results: Spasticity and limited pROM were correlated with dystonia of the upper limbs (0.41< r_s<0.47, <0.001 < p < .002) and lower limbs (0.31< r_s<0.41, 0.002 < p < .025), and both functional systems of gross motor (0.32< r_s<0.51, <0.001 < p < .018) and fine manual abilities (0.34< r_s<0.44, 0.001 < p < .014). Hypermobility is correlated only with choreoathetosis of the lower limbs (0.44, p = .001).Conclusions: Coexisting spasticity and pROM deviations in DCP are functionally limiting and should be addressed accordingly. Hypermobility may lead to an increased luxation risk.

Lack of joint hypermobility increases the risk of surgery in adolescent idiopathic scoliosis

Generalized joint hypermobility (GJH) is a risk factor for developing adolescent idiopathic scoliosis (AIS); however, it is not known whether joint hypermobility influences the risk of progression to surgery. Beighton joint hypermobility scores were assessed in 570 female AIS patients. Multivariate analysis was carried out to determine whether Beighton hypermobility scores were predictors of surgical intervention. In this female AIS cohort, 24.7% (141/570) had GJH (Beighton score ≥4). Multivariate analysis showed that GJH did not influence the risk of surgery, although having no joint hypermobility (Beighton score=0) increased risk (odds ratio: 1.89; P=0.003). Females who had no hypermobility (score=0) had significantly larger curves than individuals who scored at least one point on the Beighton scale [50° (interquartile range: 26) vs. 42° (interquartile range: 24), P=0.001]. Evaluation of specific measures of joint hypermobility indicated that females who could not touch their palms to the floor were 2.1-fold more likely to have surgery than patients who could perform this task (P=0.001). None of the other features measured on the Beighton score correlated with surgical risk. The lack of joint hypermobility increases the odds of surgery in females with AIS. Specifically, inability to touch the palms to the floor is an indicator of progression to surgery.

Correlation between hypermobility score and injury rate in artistic gymnastics

BACKGROUND

Generalized joint hypermobility (GJH) is suggested as a contributing factor for injuries in young athletes and adults. It is presumed that GJH causes decreased joint stability, thereby increasing the risk of joint and soft tissue injuries during sports activities. The aim of this study was to determine the correlation between the hypermobility score (using the Beighton`s modification of the Carter-Wilkinson criteria of hypermobility) in gymnasts and injury rate, during the period of one year.

METHODS

This study observed 24 artistic gymnasts (11-26 years old), members of Qatar National Team in artistic gymnastics. We examined the Beighton joint hypermobility screen and a seasonal injury survey. The gymnasts characteristics (age, gender) and gymnastics characteristics (training per day and number of years in training artistic gymnastics) and their relations to injury rate were also included.

RESULTS

The most common injury was the lower back pain injury, followed by knee, shoulder, hip and ankle injuries. We found strong correlation of number of years gymnastics training and injury rate (P<0.001). There is no significant correlation in the numbers of training hours during one week and hypermobility score to numbers of injuries (P>0.05).

CONCLUSIONS

According to this study there is no correlation between GJH and injury rate in artistic gymnasts in Qatar. Total training period in gymnastics have greater contribution in injury rate.

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

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

Stretching the Spines of Gymnasts: A Review

Gymnastics is noted for involving highly specialized strength, power, agility and flexibility. Flexibility is perhaps the single greatest discriminator of gymnastics from other sports. The extreme ranges of motion achieved by gymnasts require long periods of training, often occupying more than a decade. Gymnasts also start training at an early age (particularly female gymnasts), and the effect of gymnastics training on these young athletes is poorly understood. One of the concerns of many gymnastics professionals is the training of the spine in hyperextension-the ubiquitous 'arch' seen in many gymnastics positions and movements. Training in spine hyperextension usually begins in early childhood through performance of a skill known as a back-bend. Does practising a back-bend and other hyperextension exercises harm young gymnasts? Current information on spine stretching among gymnasts indicates that, within reason, spine stretching does not appear to be an unusual threat to gymnasts' health. However, the paucity of information demands that further study be undertaken.

The relationship between foot posture, body mass, age and ankle, lower-limb and whole-body flexibility in healthy children aged 7 to 15 years

Background

The complex relationship between foot posture, flexibility, body mass and age in children is not well understood. The objectives of this post hoc analysis were to explore the relationships between foot posture, flexibility, body mass in children aged seven to 15 years.

Methods

Thirty healthy, asymptomatic children (20 girls, 10 boys) aged 7 to 15 years with a mean age (SD) of 10.7 (2.3) years, were recruited through the Auckland University of Technology (AUT) Podiatry Clinic, Auckland, New Zealand. Clinical data were collected by a podiatrist with 20 years’ experience and included: height and weight (for Body Mass Index), Foot Posture Index-6 (FPI), Beighton score, Lower Limb Assessment Scale score (LLAS); and ankle lunge angle. For this post hoc analysis, Pearson’s test and Spearman’s rho were used to explore relationships between variables. Statistical significance level was p < 0.05.

Results

Data for each of the 30 participants for each variable were included in analyses, which returned the following statistically significant results: higher FPI was associated moderately with higher Beighton score (r = 0.44, p = 0.01); greater lunge angle was associated moderately with higher Beighton (r = 0.40, p = 0.02) and LLAS (r = 0.42, p = 0.02) scores; older age was associated strongly with higher BMI (r = 0.52, p = <0.01) and moderately with lower Beighton (r = −0.41, p = 0.024) and LLAS (r = −0.40, p = 0.03) scores; and higher Beighton score was associated strongly with higher LLAS (r = 0.85, p = <0.01). There was no difference in foot posture between girls and boys (p = 0.21).

Conclusions

In this sample of healthy, asymptomatic children age 7 to 15 years, children with a more pronated foot type exhibited greater lower limb and whole-body flexibility, but not greater ankle joint flexibility. There was strong agreement between lower-limb and whole-body flexibility. This study highlights the importance of assessing the paediatric flat foot in the context of a developing body.

Girls with generalized joint hypermobility display changed muscle activity and postural sway during static balance tasks

OBJECTIVES

To study knee muscle activity and static postural sway in girls with generalized joint hypermobility (GJH).

METHOD

Sixteen girls with GJH and 11 girls with non-GJH (NGJH) aged 14 years, randomly recruited among schoolchildren, participated in this study. GJH inclusion criteria were: Beighton score minimum 6/9 and one hypermobile knee; for NGJH: Beighton score maximum 5/9 and no knees with hypermobility. The participants performed a static two-legged balance test with eyes open (2EO) and eyes closed (2EC) and a one-legged stance test with eyes open (1EO). Postural sway (centre of pressure path length, COPL) was calculated, along with rambling and trembling components. Surface electromyography (sEMG) from the quadriceps (Q), hamstrings (H), and gastrocnemius (G) muscles was recorded, expressed as a percentage of the maximum voluntary EMG (%MVE), and the co-contraction index (CCI) of Q, H, and G muscle activity was calculated. Knee function was self-reported using the Knee Injury and Osteoarthritis Outcome Score for children (KOOS-Child).

RESULTS

GJH had a significantly lower lateral HQ CCI and a higher medial/lateral HQ CCI ratio in all balance tasks. Group mean EMG varied from 1.3%MVE in Q (during 2EO) to 15.7%MVE in G (during 1EO). GJH had larger postural sway length than NGJH during 2EC (COPL 1.64 vs. 1.37 m/min, p < 0.001). Rambling and trembling components did not differ between groups.

CONCLUSIONS

Girls with GJH and at least one hypermobile knee performed, compared with NGJH, static balance tasks with higher medial knee muscle activity relative to the lateral activity, and larger postural sway when vision was eliminated. The short- and long-term consequences should be studied further.

Joint hypermobility syndrome: a review for clinicians

The term 'joint hypermobility' describes synovial joints that move beyond a normal range of motion. 'Joint hypermobilty syndrome' may also be associated with significant symptoms and impaired quality of life. The purpose of this review is to help the generalist to recognise the condition, exclude significant alternative diagnoses and understand the multidisciplinary approach to management.

Nosology and inheritance pattern(s) of joint hypermobility syndrome and Ehlers-Danlos syndrome, hypermobility type: a study of intrafamilial and interfamilial variability in 23 Italian pedigrees

Joint hypermobility syndrome (JHS) and Ehlers-Danlos syndrome, hypermobility type (EDS-HT) are two markedly overlapping heritable connective tissue disorders. The cumulative frequency of JHS and EDS-HT seems high, but their recognition remains an exclusion diagnosis based on different sets of diagnostic criteria. Although proposed by a panel of experts, clinical identity between JHS and EDS-HT is still a matter of debate due to unknown molecular basis. We present 23 families with three or more individuals with a diagnosis of JHS and/or EDS-HT. Rough data from the 82 individuals were used to assess the frequency of major and minor criteria, as well as selected additional features. A series of statistical tools were applied to assess intrafamilial and interfamilial variability, emphasizing intergenerational, and intersex differences. This study demonstrates marked heterogeneity within and between families in terms of agreement of available diagnostic criteria. In 21 pedigrees affected individuals belong to two or three phenotypic sub-categories among JHS, EDS-HT, and JHS + EDS-HT overlap. Intergenerational analysis depicts a progressive shifting, also within the same pedigree, from EDS-HT in childhood, to JHS + EDS-HT in early adulthood and JHS later in life. Female-male ratio is 2.1:1, which results lower than previously observed in unselected patients' cohorts. In these pedigrees, JHS, EDS-HT, and JHS + EDS-HT segregate as a single dominant trait with complete penetrance, variable expressivity, and a markedly evolving phenotype. This study represents a formal demonstration that EDS-HT and JHS contitute the same clinical entity, and likely share the same genetic background, at least, in familial cases.

Fifteen-minute consultation: A structured approach to the management of hypermobility in a child

OBJECTIVE

To present a structured approach for an outpatient consultation of a child with hypermobility.

METHOD

Review of the literature and a description of the approach commonly adopted in a paediatric out-patient setting.

CONCLUSIONS

A focused history and examination is the key to reaching an appropriate differential diagnosis and planning management for children with hypermobility.

CASE

A 10-year-old child is referred to your general paediatric clinic with frequent 'cracking and clicking' of her joints and a history of intermittent aches and pains over the last 6 months.

Exercise in children with joint hypermobility syndrome and knee pain: a randomised controlled trial comparing exercise into hypermobile versus neutral knee extension

BACKGROUND

Knee pain in children with Joint Hypermobility Syndrome (JHS) is traditionally managed with exercise, however the supporting evidence for this is scarce. No trial has previously examined whether exercising to neutral or into the hypermobile range affects outcomes. This study aimed to (i) determine if a physiotherapist-prescribed exercise programme focused on knee joint strength and control is effective in reducing knee pain in children with JHS compared to no treatment, and (ii) whether the range in which these exercises are performed affects outcomes.

METHODS

A prospective, parallel-group, randomised controlled trial conducted in a tertiary hospital in Sydney, Australia compared an 8 week exercise programme performed into either the full hypermobile range or only to neutral knee extension, following a minimum 2 week baseline period without treatment. Randomisation was computer-generated, with allocation concealed by sequentially numbered opaque sealed envelopes. Knee pain was the primary outcome. Quality of life, thigh muscle strength, and function were also measured at (i) initial assessment, (ii) following the baseline period and (iii) post treatment. Assessors were blinded to the participants' treatment allocation and participants blinded to the difference in the treatments.

RESULTS

Children with JHS and knee pain (n=26) aged 7-16 years were randomly assigned to the hypermobile (n=12) or neutral (n=14) treatment group. Significant improvements in child-reported maximal knee pain were found following treatment, regardless of group allocation with a mean 14.5 mm reduction on the visual analogue scale (95% CI 5.2 - 23.8 mm, p=0.003). Significant differences between treatment groups were noted for parent-reported overall psychosocial health (p=0.009), specifically self-esteem (p=0.034), mental health (p=0.001) and behaviour (p=0.019), in favour of exercising into the hypermobile range (n=11) compared to neutral only (n=14). Conversely, parent-reported overall physical health significantly favoured exercising only to neutral (p=0.037). No other differences were found between groups and no adverse events occurred.

CONCLUSIONS

Parents perceive improved child psychosocial health when children exercise into the hypermobile range, while exercising to neutral only is perceived to favour the child's physical health. A physiotherapist prescribed, supervised, individualised and progressed exercise programme effectively reduces knee pain in children with JHS.

TRIAL REGISTRATION

Australia & New Zealand Clinical Trials Registry; ACTRN12606000109505.

Ehlers-danlos syndrome in orthopaedics: etiology, diagnosis, and treatment implications

Ehlers-Danlos syndrome is a heterogeneous connective tissue condition characterized by varying degrees of skin hyperextensibility, joint hypermobility, and vascular fragility. Joint dislocations, musculoskeletal pain, atrophic scars, easy bleeding, vessel/viscera rupture, severe scoliosis, and obstetric complications may occur. These manifestations are secondary to abnormal collagen, with specific molecular defects in types I, III, and V collagen; they may also be related to tenascin-X, which has been identified in some patients. Ehlers-Danlos syndrome has been classified into 6 types, with variable degrees of joint instability, skin hyperextensibility, wound healing difficulty, and vascular fragility. Diagnosis begins with recognition of the signs and symptoms of global hypermobility and referring appropriate patients for genetic consultation. It is important to accurately identify patients with Ehlers-Danlos syndrome to initiate appropriate musculoskeletal treatment, optimize anesthetic and postoperative management, perform appropriate vascular screening, and help families address their concerns with other families and advocacy groups.

Effects of neoprene wrist/hand splints on handwriting for students with joint hypermobility syndrome: a single system design study

PURPOSE

Pain associated with hypermobility of wrist and hand joints can contribute to decreased handwriting output. This study examined the effectiveness of a neoprene wrist/hand splint in reducing pain and increasing handwriting speed and endurance for students with joint hypermobility syndrome.

METHODS

Multiple baseline, single system design (SSD) methodology was used. Four ninth grade students with handwriting difficulties because of joint hypermobility syndrome participated in this study.

RESULTS

Visual and statistical (two standard deviation band method) analyses indicated a significant decrease in handwriting speed when using the splint for three out of four participants. No significant change in pain or endurance was noted during intervention. There was a significant decrease in pain following withdrawal of the splint for three participants.

CONCLUSION

Evidence from this study does not support use of this particular splint for decreasing pain and increasing handwriting speed and endurance for ninth grade students with joint hypermobility syndrome.

Beighton score: a valid measure for generalized hypermobility in children

OBJECTIVE

To evaluate the validity of the Beighton score as a generalized measure of hypermobility and to measure the prevalence of hypermobility and pain in a random population of school age children.

STUDY DESIGN

Prospective study of 551 children attending various Dutch elementary schools participated; 47% were males (258) and 53% (293) females, age range was 6 to 12 years. Children's joints and movements were assessed according to the Beighton score by qualified physiotherapists and by use of goniometry measuring 16 passive ranges of motion of joints on both sides of the body.

RESULTS

More than 35% of children scored more than 5/9 on the Beighton score. Children who scored high on the Beighton score also showed increased range of motion in the other joints measured. Moreover 12.3% of children had symptoms of joint pain, and 9.1% complained of pain after exercise or sports. Importantly, this percentage was independent of the Beighton score. There were no significant differences in Beighton score for sex in this population.

CONCLUSION

The Beighton score, when goniometry is used, is a valid instrument to measure generalized joint mobility in school-age children 6 to 12 years. No extra items are needed to improve the scale.

Generalized joint hypermobility and risk of lower limb joint injury during sport: a systematic review with meta-analysis

BACKGROUND

Generalized joint hypermobility is a highly prevalent condition commonly associated with joint injuries. The current literature has conflicting reports of the risk of joint injury in hypermobile sporting participants compared with their nonhypermobile peers. Systematic reviews have not been conclusive and no meta-analysis has been performed.

PURPOSE

This review was undertaken to determine whether individuals with generalized joint hypermobility have an increased risk of lower limb joint injury when undertaking sporting activities.

STUDY DESIGN

Systematic review with meta-analysis.

METHODS

Studies were identified through a search without language restrictions of PubMed, CINAHL, Embase, and SportDiscus databases from the earliest date through February 2009 with subsequent handsearching of reference lists. Inclusion criteria for studies were determined before searching and all included studies underwent methodological quality assessment by 2 independent reviewers. Meta-analyses for joint injury of the lower limb, knee, and ankle were performed using a random effects model. The difference in injury proportions between hypermobility categories was tested with the z statistic.

RESULTS

Of 4841 identified studies, 18 met all inclusion criteria with methodological quality ranging from 1 of 6 to 5 of 6. A variety of tests of hypermobility and varied cutoff points to define the presence of generalized joint hypermobility were used, so the authors determined a standardized cutoff to indicate generalized joint hypermobility. Using this criterion, a significantly increased risk of knee joint injury for hypermobile and extremely hypermobile participants compared with their nonhypermobile peers was demonstrated (P < .001), whereas no increased risk was found for ankle joint injury. For knee joint injury, a combined odds ratio of 4.69 (95% confidence interval, 1.33-16.52; P = .02) was calculated, indicating a significantly increased risk for hypermobile participants playing contact sports.

CONCLUSION

Sport participants with generalized joint hypermobility have an increased risk of knee joint injury during contact activities but have no altered risk of ankle joint injury.

Ehlers-Danlos syndrome

We present a clinical case of a 63-year old Caucasian man with Ehlers-Danlos syndrome who was admitted with atrial fibrillation and arterial hypertension. We present this not as a cardiological case but instead address the key questions of differential diagnosis, diagnosis criteria, management and improving the patient's quality of life.