Self-rated joint hypermobility: the five-part questionnaire evaluated in a Swedish non-clinical adult population

Development, validation, and psychometric analysis of Foot and Ankle Flexibility Index (FAFI)

AIM

To develop a new tool for identifying joint hypermobility of the paediatric foot and ankle, based on a dichotomous scoring system utilising the Lower Limb Assessment Score (LLAS), to separate the foot and ankle items.

MATERIAL AND METHODS

A total of 205 children, aged between 5 and 10 years, participated in a cross-sectional study. The new tool Foot and Ankle Flexibility Index (FAFI) was predicated upon the last 7 items of LLAS, which are specific to the foot and ankle. The internal consistency was measured with Cronbach's test. Kappa statistics with 95% CI were calculated to verify the level of inter-rater and intra-rater agreement for the FAFI.

RESULTS

Cronbach's alpha returned 0.82. The correlations between items returned a mean of 0.59 (range: 0.43-0.74). The discrimination score on the ROC curve (4 points) showed that the model can be used to identify children with joint hypermobility of the foot and ankle. Inter-rater reliability was largely good (ICC = 0.89). Excellent intra-rater reliability was found (ICC = 0.96) CONCLUSIONS: This study identified high reliability between evaluators, and high sensitivity and specificity, for a new reliable and valid tool for the identification of foot and ankle joint hypermobility.

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.

An Open Science MRI Database of over 100 Synaesthetic Brains and Accompanying Deep Phenotypic Information

We provide a neuroimaging database consisting of 102 synaesthetic brains using state-of-the-art 3 T MRI protocols from the Human Connectome Project (HCP) which is freely available to researchers. This database consists of structural (T1- and T2-weighted) images together with approximately 24 minutes of resting state data per participant. These protocols are designed to be inter-operable and reproducible so that others can add to the dataset or directly compare it against other normative or special samples. In addition, we provide a 'deep phenotype' of our sample which includes detailed information about each participant's synaesthesia together with associated clinical and cognitive measures. This behavioural dataset, which also includes data from (N = 109) non-synaesthetes, is of importance in its own right and is openly available.

Closing the Diagnostic Gap in Adolescents and Young Adult Women With Bleeding Disorders: Missed Opportunities

Approximately 2% of the general population have an underlying inherited bleeding disorder, which, for adolescents and young adult women, has both physical risks and adverse psychosocial effects. Heavy menstrual bleeding can be the first sign of an underlying bleeding disorder such as von Willebrand disease and the X-linked bleeding disorders hemophilia A and B. Connective tissue disorders such as Ehlers-Danlos syndrome, in particular the hypermobile subtype, are relatively frequent in the general population and can also cause bleeding symptoms from impaired hemostasis due to defective collagen. For more than 20 years, the American College of Obstetricians and Gynecologists (ACOG) has recommended screening adolescents and young adult women for bleeding disorders when they present with heavy menstrual bleeding. Despite this directive, there is a significant gap from symptom onset to time of diagnosis in this patient population. We must work to effectively close this diagnostic gap by consistently obtaining thorough bleeding histories, performing the appropriate laboratory evaluations, working collaboratively with hematologists, and using tools and materials promoted by ACOG. Improved screening and earlier diagnosis of these individuals can have far-reaching effects that are not limited to heavy menstrual bleeding management and extend to peripartum considerations and prenatal counseling.

High incidence of autonomic dysfunction and postural orthostatic tachycardia syndrome in patients with long-COVID: Implications for management and healthcare planning

BACKGROUND

Autonomic dysfunction including postural orthostatic tachycardia syndrome (POTS) has been reported in individuals with post-acute sequelae of Covid-19 (PASC). However, the degree of dysautonomia in PASC has not been compared to those with POTS and healthy controls.

METHODS

All participants were prospectively enrolled between 5^th August 2021 and 31^st October 2022. Autonomic testing included beat-to-beat hemodynamic monitoring to assess respiratory sinus arrhythmia, Valsalva ratio and orthostatic changes during a 10-minute active standing test as well as Sudomotor assessment. The Composite Autonomic Symptom Score (COMPASS-31) was used to assess symptoms and the Euroquol 5-Dimension survey (EQ-5D-5L) was used to assess health-related quality of life (HrQoL) measures.

RESULTS

A total of 99 participants (n=33 PASC, n=33 POTS and n=33 healthy controls; median age 32 [18], 85.9% females) were included. Compared to healthy controls, the PASC and POTS cohorts demonstrated significantly reduced respiratory sinus arrhythmia (p<0.001), greater heart rate increase during 10-minute active standing test (p<0.001), greater burden of autonomic dysfunction evidenced by higher COMPASS-31 scores across all subdomains (all p<0.001) and poor HrQoL across all EQ-5D-5L domains (all p<0.001), lower median EQ-VAS (p<0.001) and lower utility scores (p<0.001). The majority (79%) of those with PASC met the internationally established criteria for POTS.

CONCLUSION

The prevalence of autonomic symptomology or POTS was high in those with PASC, leading to poor HrQoL and high health disutility. Autonomic testing should be routinely undertaken in those with PASC to aid diagnosis and direct appropriate management to improve health outcomes.

TRIAL REGISTRATION

ANZCTR 12621000476831.

Early Detection of First Carpometacarpal Joint Osteoarthritis Using Magnetic Resonance Imaging Assessment in Women With High Hypermobility Scores

OBJECTIVE

The aim of this study was to explore association between hypermobility and osteoarthritis (OA) at the first carpometacarpal (CMC) joint, using magnetic resonance imaging (MRI) to identify early change in women at high risk of developing OA but without yet established diagnoses.

METHODS

For this observational study, 33 women (aged 30-50 years) with self-reported history of maternal hand OA but without personal diagnoses of OA were recruited. Participants completed a 5-point hypermobility questionnaire. The 20 participants with 2 or more positive responses were categorized with "high hypermobility scores." The remaining 13 were categorized with "low hypermobility scores." Data collection included functional index, hand pain measure, parity, smoking status, and body mass index. Each participant underwent dominant hand radiographic and MRI examination. Imaging studies were interpreted by assessors blinded to hypermobility score categorization.

RESULTS

No significant differences in age, body mass index, parity, functional index, or pain scores were observed between higher and lower hypermobility score groups. Similarly, there were no significant differences between groups for radiographic changes. However, significantly higher proportions of women with higher hypermobility scores were observed on MRI to have abnormalities of trapezium cartilage (75% vs. 38%), metacarpal cartilage (80% vs. 38%), and trapezium bone (70% vs. 31%); p < 0.05 for all.

CONCLUSIONS

First CMC joint structural abnormalities were more frequently observed in women with higher hypermobility scores. Identification of early preradiographic changes in this group supports the concept that early-life joint laxity may contribute to future OA predisposition. Magnetic resonance imaging may be a preferred imaging test for detection of early cartilage changes in people at high risk of CMC joint OA.

A Diagnosis of Camptodactyly With Benign Joint Hypermobility Syndrome in a Patient Presenting With Fixed Flexion Deformity of the Fingers and Striae

Camptodactyly is a genetic disorder that causes fixed flexion deformity of one or more fingers of single or both hands. It is very rare and the occurrence is very low amongst the children. It is linked to a handful of congenital connective tissue syndromes. It is passed onto generations with reduced expressivity. However, its association with benign joint hypermobility syndrome is rarely known. Joint hypermobility syndrome is a condition where there is extreme joint flexibility and it is related to a set of articular and extra-articular sequelae. We herein report a case of camptodactyly with benign joint hypermobility syndrome in a patient presenting with fixed flexion deformity of the fingers, joint hyperextensibility, and striae.

The Relationship Between Generalised Joint Hypermobility and Autism Spectrum Disorder in Adults: A Large, Cross-Sectional, Case Control Comparison

Autism spectrum disorder (ASD) and generalised joint hypermobility (GJH) share a number of clinical manifestations including proprioceptive impairment, motor difficulties, sensory hypersensitivity, and autonomic dysfunction. Clinical observations suggest that GJH is overrepresented in ASD. However, there are currently few systematic studies available. Knowledge about comorbidities may unfold common aetiopathological pathways underlying the association and improve the clinical management. The aim of this large, cross-sectional comparative study is to evaluate the relationship between ASD and GJH in adults. Data on joint hypermobility, symptoms associated with both hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS), lifetime psychiatric diagnoses, psychiatric rating scales for ASD and attention deficit hyperactivity disorder (ADHD), and socio-demographics was collected for 199 individuals with ASD and 419 non-ASD community controls. Logistic regression models adjusting for covariates (age, sex, ethnicity) revealed a significant relationship between ASD and GJH and between ASD and symptomatic GJH, with adjusted odds ratios of 3.1 (95% CI: 1.9, 5.2; p < 0.001) and 4.9 (95% CI: 2.6, 9.0; p < 0.001), respectively. However, the high prevalence of comorbid ADHD in the study sample reduces the generalizability of the results among individuals with ASD without comorbid ADHD. Possibly, an additional ADHD phenotype is the primary driver of the association between ASD and GJH. Furthermore, GJH with additional self-reported symptoms, suggestive of HSD/hEDS, showed a stronger association with ASD than did non-specified GJH, indicating that symptomatic GJH plays a greater role in the relationship than non-specified GJH does. Therefore, the current study underscores the need of careful sample subclassifications. ASD with GJH may represent a novel subgroup of ASD in terms of aetiopathology and clinical presentation. Future research should elucidate the aetiological factors behind the association between ASD and GJH and evaluate how the comorbidity of GJH affects ASD outcomes.

Association between adult attention-deficit hyperactivity disorder and generalised joint hypermobility: A cross-sectional case control comparison

Growing evidence suggests an unexpected association between generalised joint hypermobility (GJH) and several psychiatric conditions, and a shared pathophysiology has been proposed. No previous studies on adult attention-deficit/hyperactivity disorder (ADHD) are available. This study aimed to evaluate the association between adult ADHD and GJH. A total of 431 adults with ADHD and 417 non-ADHD controls were included in this cross-sectional comparative study. GJH was assessed by physical examination following the Beighton scoring system (BSS). Furthermore, musculoskeletal symptoms and skin abnormalities were queried to create a proxy for symptomatic GJH (e.g., Hypermobility spectrum disorders and Ehlers-Danlos syndrome) to differentiate this from non-specified GJH defined by BSS only. Logistic regression examined the influence of ADHD and candidate covariates (age, sex, ethnicity) on GJH and symptomatic GJH, respectively. ADHD was significantly associated with GJH, as defined by the BSS, with adjusted odds ratios of 4.7 (95% confidence interval [CI] 3.0-7.2, p < .005). Likewise, ADHD was significantly associated with symptomatic GJH, as defined by the BSS and additional symptoms, with adjusted odds ratios of 6.9 (CI 95% 4.1-11.9, p < .005). Our results suggest that GJH may represent a marker for an underlying systemic disorder involving both connective tissue and the central nervous system. GJH with additional musculoskeletal symptoms and/or skin abnormalities has a considerable stronger link to adult ADHD than non-specified GJH has, and may need awareness in ADHD management. Future studies should investigate the mechanisms behind this association and how comorbid GJH affects ADHD outcome.

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.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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