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Wesley A, Coussens M, Chan C, Pacey V, Bray P, Nicholson LL. Conservative management of hand impairment in children and adolescents with heritable disorders of connective tissue: A scoping review. Phys Occup Ther Pediatr 2023; 44:19-41. [PMID: 37125678 DOI: 10.1080/01942638.2023.2199846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 04/02/2023] [Indexed: 05/02/2023]
Abstract
AIMS To synthesize and critically appraise available interventions in the conservative management of hand impairment for children and adolescents with heritable disorders of connective tissue (HDCT). METHODS A search of peer-reviewed literature and online platforms were included with data regarding hand impairment and function, conservative management and outcome measures extracted and appraised. Levels of evidence were applied to published literature. RESULTS Ten peer-reviewed papers, eleven webpages and YouTube videos met the inclusion criteria. Reported interventions included: strengthening, orthoses, assistive equipment, education and pacing. Evidence of intervention effectiveness and evidence-based guidance on dosage were absent, with no consistency of outcome measures monitoring intervention effectiveness. Online platforms posted by health professionals predominantly provided advice for families without clinical detail of interventions. CONCLUSIONS There is a consistent suite of interventions identified in both peer-reviewed literature and online platforms used by clinicians and families to manage hand impairment for children and adolescents with HDCT. Clear dosage parameters and outcome measures are needed in future intervention studies to determine the effectiveness of interventions and guide clinicians in how best to treat hand impairment. Increasing accountability and quality of online resources posted by health professionals for families is warranted to ensure dosage details and precautions are provided.
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Affiliation(s)
- Alison Wesley
- Occupational Therapy Department, The Children's Hospital at Westmead, Sydney, Australia
- Department of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Marie Coussens
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Cliffton Chan
- Department of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Verity Pacey
- Department of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Paula Bray
- Department of Medicine and Health, The University of Sydney, Sydney, Australia
- The Sydney Children's Hospitals Network, Sydney, Australia
| | - Leslie L Nicholson
- Department of Medicine and Health, The University of Sydney, Sydney, Australia
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Whalen KC, Crone W. Multidisciplinary Approach to Treating Chronic Pain in Patients with Ehlers-Danlos Syndrome: Critically Appraised Topic. J Pain Res 2022; 15:2893-2904. [PMID: 36124037 PMCID: PMC9482467 DOI: 10.2147/jpr.s377790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/06/2022] [Indexed: 11/23/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of 13 related connective tissue disorders with a combined prevalence of 1 in 5000 people, with the most common noted as hypermobile EDS (hEDS). The EDS genetic condition is thought to affect both males and females equally, although most symptomatic patients are female. EDS causes a myriad of symptoms, including skin hyperextensibility and fragility, easy bruising and bleeding, joint hypermobility, subluxation, dislocation, and chronic pain. Pain is one of the most common symptoms of EDS, leading to disability and decreased quality of life. Current guidelines for treating chronic pain in EDS are lacking. Clinicians focus on a conservative multidisciplinary approach in patients with EDS, which avoids surgical interventions and its accompanying risks of morbidity and mortality. The multidisciplinary approach includes physiotherapy, occupational therapy, cognitive behavioral therapy, and pharmacologic interventions to decrease pain. This review identifies literature examining the components of this conservative multidisciplinary approach and their effectiveness across the PubMed, EMBASE, CINAHL, Web of Science, and Trip databases, using the terms "Ehlers-Danlos Syndrome AND Pain Management" that was then subsequently evaluated. The evaluation of this current literature provides weak evidence to support the efficacy of the individual components of the conservative multidisciplinary approach. Lack of alternative approaches leaves medical providers with little choice but to suggest these pain control methods, despite low-grade evidence of weak evidence of their efficacy. More research into the pathophysiology of chronic pain in EDS could help identify additional modes and rationales for therapy.
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Affiliation(s)
- Kiley C Whalen
- Center for Physician Assistant Studies, Albany Medical College, Albany, NY, USA
| | - Wilson Crone
- Center for Physician Assistant Studies, Albany Medical College, Albany, NY, USA
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3
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Long M, Kiru L, Kassam J, Strutton PH, Alexander CM. An investigation of the control of quadriceps in people who are hypermobile; a case control design. Do the results impact our choice of exercise for people with symptomatic hypermobility? BMC Musculoskelet Disord 2022; 23:607. [PMID: 35739514 PMCID: PMC9219138 DOI: 10.1186/s12891-022-05540-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background People with symptomatic hypermobility have altered proprioception however, the origin of this is unclear and needs further investigation to target rehabilitation appropriately. The objective of this investigation was to explore the corticospinal and reflex control of quadriceps and see if it differed between three groups of people: those who have symptomatic hypermobility, asymptomatic hypermobility and normal flexibility. Methods Using Transcranial Magnetic Stimulation (TMS) and electrical stimulation of peripheral nerves, motor evoked potentials (MEPs) and Hoffman (H) reflexes of quadriceps were evoked in the three groups of people. The threshold and latency of MEPs and the slope of the input–output curves and the amplitude of MEPs and H reflexes were compared across the groups. Results The slope of the input–output curve created from MEPs as a result of TMS was steeper in people with symptomatic hypermobility when compared to asymptomatic and normally flexible people (p = 0.04). There were no other differences between the groups. Conclusion Corticospinal excitability and the excitability at the motoneurone pool are not likely candidates for the origin of proprioceptive loss in people with symptomatic hypermobility. This is discussed in the light of other work to suggest the receptor sitting in hypermobile connective tissue is a likely candidate. This suggests that treatment aimed at improving receptor responsiveness through increasing muscle tone, may be an effective rehabilitation strategy.
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Affiliation(s)
- Michael Long
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Louise Kiru
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jamila Kassam
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul H Strutton
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK. .,Department of Therapies, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
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Maarj M, Coda A, Tofts L, Williams C, Santos D, Pacey V. Outcome measures for assessing change over time in studies of symptomatic children with hypermobility: a systematic review. BMC Pediatr 2021; 21:527. [PMID: 34839813 PMCID: PMC8628404 DOI: 10.1186/s12887-021-03009-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Muhammad Maarj
- Narrabeen Sports Medicine Centre, Sydney Academy of Sport, Sydney, Australia. .,Department of Health Sciences, Newcastle University, Newcastle, Australia.
| | - Andrea Coda
- Department of Health Sciences, Newcastle University, Newcastle, Australia.,Priority Research Centre Health Behaviour, Hunter Medical Research Institute HMRI, Newcastle, Australia
| | - Louise Tofts
- Narrabeen Sports Medicine Centre, Sydney Academy of Sport, Sydney, Australia.,Department of Health Professions, Macquarie University, Sydney, Australia
| | - Cylie Williams
- Department of Physiotherapy, Monash University, Melbourne, Australia
| | - Derek Santos
- Department of Health Sciences, Queen Margaret University, Scotland, UK
| | - Verity Pacey
- Department of Health Professions, Macquarie University, Sydney, Australia
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Jensen AM, Andersen JQ, Quisth L, Ramstrand N. Finger orthoses for management of joint hypermobility disorders: Relative effects on hand function and cognitive load. Prosthet Orthot Int 2021; 45:36-45. [PMID: 33834743 PMCID: PMC7978036 DOI: 10.1177/0309364620956866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 08/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Joint hypermobility refers to joints that move beyond their normal limits. Individuals with hypermobility of the fingers experience difficulties in activities of daily living. Finger orthoses are available for managing hypermobility of the fingers, but their effectiveness has received little attention in scholarly literature. OBJECTIVES To determine if use of custom fit finger orthoses leads to improvements in time needed to perform standardised hand function tests, and attentional demand required to perform these tests, in individuals with joint hypermobility syndrome, Hypermobile Ehlers-Danlos syndrome or Classical Ehlers-Danlos syndrome. STUDY DESIGN Repeated-measures study. METHODS Fourteen participants performed three different hand function tests (target box and block test, writing and picking up coins), with and without their finger orthoses. Time to complete each test was recorded as a measure of functional performance. Brain activity was recorded in the pre-frontal cortices as a measure of attentional demand. RESULTS Functional performance significantly improved for all but one test (picking up coins with non-dominant hand) when participants wore finger orthoses (p < 0.05). Activity in the pre-frontal cortex was lower when using the orthosis to perform the coin test (dominant hand; p < 0.05). No differences were observed in other tests (p > 0.05). CONCLUSIONS Results suggested that finger orthoses improved hand function and provided limited evidence to suggest that they may also affect attentional demand. While the limited sample does not provide conclusive evidence supporting the use of finger orthosis in this clinical population, results warrant further investigation in large scale longitudinal studies or randomised controlled trials.
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Affiliation(s)
| | | | | | - Nerrolyn Ramstrand
- CHILD Research Group, School of Health and Welfare, Jönköping University, Jönköping, Sweden
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Palmer S, Davey I, Oliver L, Preece A, Sowerby L, House S. The effectiveness of conservative interventions for the management of syndromic hypermobility: a systematic literature review. Clin Rheumatol 2020; 40:1113-1129. [PMID: 32681365 PMCID: PMC7895781 DOI: 10.1007/s10067-020-05284-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 12/13/2022]
Abstract
Introduction ‘Syndromic hypermobility’ encompasses heritable connective tissue disorders such as hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders which are characterised by excessive joint range of motion and pain. Conservative interventions such as exercise are the cornerstone of management, yet their effectiveness is unclear. Aim To systematically appraise the effectiveness of conservative management for people with syndromic hypermobility. Method A systematic online database search was conducted (AMED, BND, CINAHL Plus, MEDLINE, PEDro, PsychINFO and SportDiscus). Potential articles were assessed for eligibility by two researchers against the following criteria: adults and children with a hEDS/HSD diagnosis (or equivalent diagnosis using specific criteria); non-pharmacological or non-surgical interventions; outcomes related to pain, physical function, psychological well-being or quality of life. Controlled trials and cohort studies were included. Critical Appraisal Skills Programme checklists were used to assess methodological quality. Results Eleven studies were included, comprising eight controlled trials and three cohort studies. All studies investigated interventions that had exercise as the primary component. Three small controlled studies demonstrated superior effects of conservative management relative to a control group. However, those studies only focused on a single area of the body, only recruited women, and had no long-term follow-up. All studies reported improvements in a wide range of outcomes over time. Conclusion Controlled trial evidence for the superiority of conservative management over comparators is weak. There is some evidence that people improve over time. Robust randomised controlled trial research of the long-term effectiveness of ‘whole-body’ (rather than individual joints or body areas) conservative management is required.Key Points • Conservative management is the cornerstone of management of syndromic hypermobility. • The review found that evidence for the effectiveness of conservative management relative to no treatment or other conservative comparators was weak. • However, there was consistent evidence for effectiveness from pre- to post-treatment. • Further robust randomised controlled trial evidence is required. |
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Affiliation(s)
- Shea Palmer
- Department of Allied Health Professions, Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK.
| | - Indi Davey
- Department of Allied Health Professions, Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Laura Oliver
- Department of Allied Health Professions, Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Amara Preece
- Department of Allied Health Professions, Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Laura Sowerby
- Department of Allied Health Professions, Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Sophie House
- Department of Allied Health Professions, Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
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Van Meulenbroek T, Conijn AEA, Huijnen IPJ, Engelbert RHH, Verbunt JA. Multidisciplinary Treatment for Hypermobile Adolescents with Chronic Musculoskeletal Pain. JOURNAL OF REHABILITATION MEDICINE. CLINICAL COMMUNICATIONS 2020; 3:1000033. [PMID: 33884135 PMCID: PMC8008726 DOI: 10.2340/20030711-1000033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND To determine whether adolescents with generalized hypermobility spectrum disorder/ hypermobile Ehlers-Danlos syndrome (G-HSD/ hEDS) show changes in the level of disability, physical functioning, perceived harmfulness and pain intensity after completing multidisciplinary rehabilitation treatment. METHODS Pre-test post-test design. Fourteen adolescents with G-HSD/hEDS participated. The multidisciplinary rehabilitation treatment consisted of a combination of physical training and exposure in vivo. Physical training aims to improve aerobic capacity, muscle strength and propriocepsis for compensating hypermobility. Exposure in vivo aims to decrease disability and pain-related fear. Pre- and post-treatment assessments were conducted to assess the level of disability, physical functioning (motor performance, muscle strength and physical activity level), perceived harmfulness and pain intensity. RESULTS After completing multidisciplinary rehabilitation treatment, the adolescents showed a significant and clinically relevant improvement (improvement of 67%, p<0.01) in functional disability. Furthermore, significant improvements were found in motor performance (p < 0.01), muscle strength (p < 0.05), perceived harmfulness (p < 0.01) and pain intensity (p <0.01) after completing multidisciplinary rehabilitation treatment. CONCLUSION Multidisciplinary rehabilitation treatment leads to a significantly and clinically relevant improvement in the level of disability for adolescents with G-HSD/hEDS. Positive effects were also found in physical functioning, perceived harmfulness and pain intensity. Although the results of this multidisciplinary rehabilitation treatment for adolescents with G-HSD/hEDS are promising, further study is needed to confirm these findings in a randomized design.
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Affiliation(s)
- Thijs Van Meulenbroek
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Arnoud E A Conijn
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Ivan P J Huijnen
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Raoul H H Engelbert
- Centre of Expertise Urban Vitality, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, The Netherlands
- Department of Rehabilitation, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanine A Verbunt
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
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