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

Chronic Pain and Joint Hypermobility: A Brief Diagnostic Review for Clinicians and the Potential Application of Infrared Thermography in Screening Hypermobile Inflamed Joints

Joint hypermobility syndromes, particularly chronic pain associated with this condition, including Hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD), present diagnostic challenges due to their multifactorial origins and remain poorly understood from biomechanical and genomic-molecular perspectives. Recent diagnostic guidelines have differentiated hEDS, HSD, and benign joint hypermobility, providing a more objective diagnostic framework. However, incorrect diagnoses and underdiagnoses persist, leading to prolonged journeys for affected individuals. Musculoskeletal manifestations, chronic pain, dysautonomia, and gastrointestinal symptoms illustrate the multifactorial impact of these conditions, affecting both the physical and emotional well-being of affected individuals. Infrared thermography (IRT) emerges as a promising tool for joint assessment, especially in detecting inflammatory processes. Thermal distribution patterns offer valuable insights into joint dysfunctions, although the direct correlation between pain and inflammation remains challenging. The prevalence of neuropathies among hypermobile individuals accentuates the discordance between pain perception and thermographic findings, further complicating diagnosis and management. Despite its potential, the clinical integration of IRT faces challenges, with conflicting evidence hindering its adoption. However, studies demonstrate objective temperature disparities between healthy and diseased joints, especially under dynamic thermography, suggesting its potential utility in clinical practice. Future research focused on refining diagnostic criteria and elucidating the underlying mechanisms of hypermobility syndromes will be essential to improve diagnostic accuracy and enhance patient care in this complex and multidimensional context.

Management of childbearing with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders: A scoping review and expert co-creation of evidence-based clinical guidelines

OBJECTIVE

To co-create expert guidelines for the management of pregnancy, birth, and postpartum recovery in the context of hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD).

DESIGN

Scoping Review and Expert Co-creation.

SETTING

United Kingdom, United States of America, Canada, France, Sweden, Luxembourg, Germany, Italy, and the Netherlands.

SAMPLE

Co-creators (n = 15) included expertise from patients and clinicians from the International Consortium on the Ehlers-Danlos syndromes and Hypermobility Spectrum Disorders, facilitated by the Ehlers-Danlos Society.

METHODS

A scoping review using Embase, Medline, the Cochrane Central Register of Controlled Trials and CINHAL was conducted from May 2022 to September 2023. Articles were included if they reported primary research findings in relation to childbearing with hEDS/HSD, including case reports. No language limitations were placed on our search, and our team had the ability to translate and screen articles retrieved in English, French, Spanish, Italian, Russian, Swedish, Norwegian, Dutch, Danish, German, and Portuguese. The Mixed Methods Appraisal Tool was used to assess bias and quality appraise articles selected. The co-creation of guidelines was based on descriptive evidence synthesis along with practical and clinical experience supported by patient and public involvement activities.

RESULTS

Primary research studies (n = 14) and case studies (n = 21) including a total of 1,260,317 participants informed the co-creation of guidelines in four overarching categories: 1) Preconceptual: conception and screening, 2) Antenatal: risk assessment, management of miscarriage and termination of pregnancy, gastrointestinal issues and mobility, 3) Intrapartum: risk assessment, birth choices (mode of birth and intended place of birth), mobility in labor and anesthesia, and 4) Postpartum: wound healing, pelvic health, care of the newborn and infant feeding. Guidelines were also included in relation to pain management, mental health, nutrition and the common co-morbidities of postural orthostatic tachycardia syndrome, other forms of dysautonomia, and mast cell diseases.

CONCLUSIONS

There is limited high quality evidence available. Individualized strategies are proposed for the management of childbearing people with hEDS/HSD throughout pregnancy, birth, and the postpartum period. A multidisciplinary approach is advised to address frequently seen issues in this population such as tissue fragility, joint hypermobility, and pain, as well as common comorbidities, including dysautonomia and mast cell diseases.

Heredity of pregnancy-related pelvic girdle pain in Sweden

INTRODUCTION

Pelvic girdle pain during and after pregnancy is a major public health problem with significant daily problems for affected women and their families. There is now accumulating evidence that pregnancy-related pelvic girdle pain originates from the sacroiliac joints and the pubic symphysis as well as their extra-articular ligaments. However, the heritability of the disease remains to be determined. We hypothesized that there is an increased familial risk of pregnancy-related pelvic girdle pain.

MATERIAL AND METHODS

A population-based national database linkage registry study of approximately 9.3 million individuals within 4.2 million families in Sweden with a recruitment period from 1997 to 2018. The Swedish Multi-generation register was used to find female pairs of twins, full siblings, half-siblings and first cousins where both in the pairs had a completed pregnancy. The outcome measure was diagnosis of pregnancy-related pelvic girdle pain (International Classification of Diseases-10 O26.7 [1997-2018]) in the first pregnancy. Data was obtained from the Swedish Hospital Discharge Register, the Swedish Outpatient Care Register, the Swedish Medical Birth Register, the Primary Healthcare Register, and Medical Treatment Register. Cox regression analysis was used to calculate adjusted estimated effect of the exposure variable familial history of pregnancy-related pelvic girdle pain on the outcome variable pregnancy-related pelvic girdle pain at first birth.

RESULTS

From the registers, 1 010 064 women pregnant with their first child within 795 654 families were collected. In total, 109 147 women were diagnosed with pregnancy-related pelvic girdle pain. The adjusted hazard ratio for a familial risk of pregnancy-related pelvic girdle pain was 2.09 (95% CI 1.85-2.37) among twins (monozygotic and dizygotic), 1.78 (95% CI 1.74-1.82) in full siblings, 1.16 (95% CI 1.06-1.28) in half-siblings from the mother, 1.09 (95% CI 1.024-1.16) in half-siblings from the father and 1.09 (95% CI 1.07-1.12) in first cousins.

CONCLUSIONS

This nationwide observational study showed a familial clustering of pregnancy-related pelvic girdle pain. The hazard ratio for the condition was associated with the degree of relatedness, suggesting that heredity factors contribute to the development of pregnancy-related pelvic girdle pain. There is no causal treatment available for pregnancy-related pelvic girdle pain and further studies are now encouraged to clarify the specific genetic factors that contribute to the disease and for future targeted interventions.

Generalized joint hypermobility and the risk of pregnancy-related pelvic girdle pain: Is body mass index of importance?-A prospective cohort study

INTRODUCTION

Pelvic girdle pain (PGP) affects approximately 50% of pregnant women. The mechanisms are multifactorial but not fully understood. Women with generalized joint hypermobility (GJH) may be vulnerable to load in the pelvic joints during pregnancy. Our aim was to investigate if women with GJH had an increased risk of PGP and higher pain intensity during and after pregnancy, compared with women with normal joint mobility. We also studied if body mass index (BMI) in early pregnancy influenced that risk.

MATERIAL AND METHODS

A prospective cohort study of 356 women, whose data were collected by self-reports and clinical examinations in early and in late pregnancy and 9 months after childbirth. GJH was present with ≥5/9 points on the Beighton score. PGP was defined by a pain drawing and ≥1 positive test. Pain intensity was measured with a visual analogue scale (0-100 mm). We adjusted for age and origin in logistic regression and ordinal logistic regression analysis.

RESULTS

In early pregnancy, 47.1% of the women with GJH had PGP vs 32.6% of women with normal joint mobility (adjusted odds ratio [aOR] 1.76; 95% confidence interval [CI] 0.86-3.62) and had higher odds of reporting higher pain intensity (aOR 2.04; 95% CI 1.02-4.07). The odds of PGP were highest for women with GJH and BMI ≥25 kg/m2 (aOR 6.88; 95% CI 1.34-35.27) compared with women with normal joint mobility and BMI <25 kg/m2 . The estimated associations were weaker and not statistically significant in late pregnancy or after childbirth.

CONCLUSIONS

Women with GJH did not have an increased risk of PGP during or after pregnancy but reported higher pain intensity in early pregnancy compared with women with normal joint mobility. Since women with combined GJH and BMI ≥25 kg/m2 had the highest odds of PGP in early pregnancy, our results may suggest that health care needs to pay attention to and develop methods to reduce the risk of PGP and delay the onset of pain during pregnancy in women with this combination.

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

The Underrecognized Conditions of Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders in Women

Hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders are conditions that disproportionately affect women and can result in morbidity, disability, and a poorer quality of life. These conditions are often not recognized by health care professionals, leading to significant delays in diagnosis, especially in women. Hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders are known as complex, multisystemic conditions that are frequently comorbid with autonomic dysfunction, mast cell activation syndrome, and autism. Education of health care professionals, including nurses, on these conditions could lead to earlier diagnosis, with improved management and thus better outcomes for those affected by these conditions.

Assessing the Knowledge of Analgesic Drugs Utilization during Pregnancy among Women in Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Pain is a common compensation mechanism in pregnant women that they may face during gestation due to physiological changes. Paracetamol and non-steroidal anti-inflammatory drugs are the most administered analgesic drugs worldwide. Therefore, safety and efficacy are important measures for the use of analgesics during pregnancy.

OBJECTIVE

Assess the knowledge of analgesic drug utilization among Saudi pregnant women.

METHOD

We conducted a self-administered survey with an electronic questionnaire via Google Drive among a sample of 406 Saudi women.

RESULTS

About half of the respondents took analgesics during the first trimester, and 52.5% of women have used analgesics at least once without any medical advice during their gestation. Most participants agreed that paracetamol is the safest and effective analgesic drug during pregnancy, yet 61.8% of women are not aware that analgesics could be detrimental to the fetus if inappropriately administered in the third trimester.

CONCLUSION

Participants have a good perception of the safest and most effective analgesic drug during pregnancy, but they have poor knowledge about analgesics' side effects.

Generalized joint hypermobility and risk of pelvic girdle pain in pregnancy: does body mass index matter?

Background: Women with generalized joint hypermobility may be at increased risk of pregnancy-related pelvic girdle pain, but evidence is inconclusive. Objectives: In this prospective cohort study of 283 pregnant women in Norway, we aimed to study the association of generalized joint mobility with pelvic girdle pain, and to evaluate if pre-pregnancy body mass index was a modifier of the association. Methods: Generalized joint hypermobility was defined as a score of ≥5/9 positive tests on the Beighton score measured in early pregnancy. Primary outcome was evening pain intensity in gestation week 30, measured by a 100 mm visual analogue scale. We applied linear regression analyses to estimate age-adjusted unstandardized beta coefficients. Results: Evening pain intensity was similar among women with Beighton score ≥ 5/9 and women with Beighton score < 5/9 (age-adjusted mean difference 2.8 mm; 95% CI: -9.2 to 14.9 mm). Women with Beighton score ≥ 5/9 and pre-pregnancy body mass index ≥ 25 kg/m², reported higher evening pain than women with Beighton score < 5/9 and pre-pregnancy body mass index <25 kg/m² (age-adjusted mean difference 28.7 mm; 95% CI: 14.3-43.1 mm). Conclusions: Overall, evening pain intensity was similar among pregnant women with and without generalized joint hypermobility. However, women with a combination of generalized joint hypermobility and body mass index ≥25 kg/m² reported higher evening pain compared to women with normal joint mobility and body mass index <25 kg/m², suggesting that body mass index may modify the association. The estimates could be imprecise due to the small study sample, and our findings should be interpreted with caution.

Body perception disturbances in women with pregnancy-related lumbopelvic pain and their role in the persistence of pain postpartum

Background

Lumbopelvic pain (LPP) is common during pregnancy and can have long-lasting negative consequences in terms of disability and reduced quality of life. Therefore, it is crucial to identify women at risk of having pregnancy-related LPP after childbirth. This study aimed to investigate the association between body perception, pain intensity, and disability in women with pregnancy-related LPP during late pregnancy and postpartum, and to study whether a disturbed body perception during late pregnancy predicted having postpartum LPP.

Methods

A prospective cohort study in 130 primiparous women (median age = 30 years) was performed. Pain intensity, disability, and lumbopelvic body perception during the last month of pregnancy and 6 weeks postpartum were assessed with the Numerical Pain Rating Scale (NPRS), Oswestry Disability Index, and Fremantle Back Awareness Questionnaire, respectively. Having pregnancy-related LPP was defined as an NPRS score ≥ 1/10. At both timepoints, women were categorized into three groups; pain-free, LPP with low disability, and LPP with high disability (based on Oswestry Disability Index scores). At each timepoint, body perception was compared between groups, and correlations between body perception, pain intensity, and disability were evaluated in women with LPP by using non-parametric tests. Logistic regression analysis was used to determine whether body perception during the last month of pregnancy predicted the presence of LPP 6 weeks postpartum.

Results

Women with LPP at the end of pregnancy, and 6 weeks postpartum reported a more disturbed body perception compared to pain-free women (p ≤ 0.005). Greater body perception disturbance correlated with higher pain intensity (σ = 0.266, p = 0.008) and disability (σ = 0.472, p < 0.001) during late pregnancy, and with pain intensity 6 weeks postpartum (σ = 0.403, p = 0.015). A disturbed body perception during late pregnancy nearly significantly predicted having postpartum LPP (Odds Ratio = 1.231, p = 0.052).

Conclusions

Body perception disturbance was greater in women experiencing LPP during late pregnancy and postpartum compared to pain-free women, and correlated with pain intensity and disability. Though non-significant (p = 0.052), the results of the regression analysis suggest that greater body perception disturbance during late pregnancy might predict having LPP postpartum. However, future studies should follow up on this.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03704-w.

Pelvic Girdle Pain, Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review

Pelvic girdle pain (PGP) refers specifically to musculoskeletal pain localised to the pelvic ring and can be present at its anterior and/or posterior aspects. Causes such as trauma, infection and pregnancy have been well-established, while patients with hypermobile joints are at greater risk of developing PGP. Research exploring this association is limited and of varying quality. In the present study we report on the incidence, pathophysiology, diagnostic and treatment modalities for PGP in patients suffering from Hypermobility Spectrum Disorder (HSD) and Hypermobility-Type Ehlers-Danlos Syndrome (hEDS). Recommendations are made for clinical practice by elaborating on screening, diagnosis and management of such patients to provide a holistic approach to their care. It appears that this cohort of patients are at greater risk particularly of mental health issues. Moreover over, they may require a multidisciplinary approach for their management. Ongoing research is still required to expand our understanding of the relationship between PGP, HSD and hEDS by appropriately diagnosing patients using the latest updated terminologies and by conducting randomised control trials to compare outcomes of interventions using standardised patient reported outcome measures.