Analysis of joint mobility patterns among preschool children

Variability of joint hypermobility in children: a meta-analytic approach to set cut-off scores

Current international consensus of the appropriate Beighton score cut-off to define if a child has generalised joint hypermobile or not is based upon expert opinion. Our aim was to determine the prevalence of Beighton scores of children worldwide to provide a recommendation for establishing the Beighton score cut-off to identify generalised joint hypermobility in children. We used AMED, OVID Medline, Embase and CINAHL to find published articles from inception to April 2024 describing Beighton scores of children up to and including 18 years from the general population. We extracted study demographics including country of publication, total number of participants, summary data about the age and sex of participant, Beighton scores and any cut-off used where authors deemed children hypermobile and how many children were rated at the corresponding Beighton scores. There were 37 articles reporting on the prevalence or incidence of hypermobility at cut-off scores from 28,868 participants. Using the cut-off of ≥ 6 resulted in a prevalence of 6% for studies reporting male data and 13% for studies reporting female data. Limited data reporting availability precluded further sub-analysis at a Beighton score of ≥ 7, age, pubertal status and ethnicity.    Conclusion: The working threshold for identifying generalised joint hypermobility in children should be a Beighton score of 6 or more. Our analysis also suggests a Beighton score of 7 or greater may be appropriate in childhood, particularly for females. What is Known: • The working threshold for identifying generalised joint hypermobility in children previously was set based on expert opinion. What is New: • The threshold to identify hypermobility in children should be at a minimum of ≥ 6 on the Beighton score.

Comparison of Terminal Elbow Extension between Humans and Baboons (Papio anubis)

It is assumed that hyperextension of the elbow joint beyond 0° in humans is due to local ligament and other soft tissue laxity. The common extant old-world olive baboon (Papio anubis), with a quadrupedal gait, commonly has a mild elbow joint flexion contracture. This study compares anatomic and functional roles of the olecranon-coronoid notch angle of the proximal ulna and the anterior direction of its opening on terminal elbow extension in humans and baboons. Active terminal elbow extension was measured in 211 elbows of skeletally mature humans using the neutral zero method. Passive elbow extension and radiographs were performed on 60 extremities of 30 anesthetized baboons. The mean olecranon-coronoid notch angle for humans and baboons was 22.2 ± 6.0° and 11.3 ± 3.2°, respectively (P < 0.001). Mixed effect regression analysis showed that the magnitude of the angle was a significant predictor of terminal elbow extension (P < 0.001) when accounting for species. Also, the causal mediation analysis showed that 18% of the difference in terminal elbow extension between species could be attributed to the olecranon-coronoid notch angle (P < 0.001). Anatomic dissection of 16 baboon arms showed that sectioning of all the anterior soft tissue structures increased mean terminal elbow extension from -18.2 ± 5.9° to -7.1 ± 6.0° and that further elbow extension was blocked primarily by the intact humeroulnar joint. The size of the notch angle and the positioning of its anterior proximal opening played a significant role in deciding terminal elbow extension in both species.

An investigation of sensory processing skills in toddlers with joint hypermobility

BACKGROUND

Children with Generalized Joint Hypermobility (GJH) may have a motor developmental delay in the early period and subluxation, fatigue, autonomic dysfunction, and pain arising from ligaments and other soft tissues in advanced ages. Additionally, there is a loss of proprioceptive sensation in children and adults with GJH.

AIMS

This study aimed to evaluate sensory processing skills in toddlers with GJH.

STUDY DESIGN

A cross-sectional study.

SUBJECTS

Fifty-eight children aged between 12 and 14 months were included in the study. These children were divided into two groups: with and without GJH (31 with GJH and 27 without GJH).

OUTCOME MEASURES

The sensory processing skills of the children in the study were evaluated with the Test of Sensory Functions in Infants (TSFI).

RESULTS

The scores in the subtests of TSFI in response to tactile deep pressure, adaptive motor functions, visual-tactile integration, and response to vestibular stimuli were higher in favor of children without GJH (p < 0.05). The total TSFI score was higher in the group without GJH (p < 0.05).

CONCLUSIONS

Sensory processing problems were found in toddlers with GJH. Sensory motor development should be evaluated in children with GJH, and an appropriate early intervention program should be planned.

Ligamentous laxity in children with achondroplasia: Prevalence, joint involvement, and implications for early intervention strategies

Achondroplasia (ACH), the most common form of skeletal dysplasia, is characterized by severe disproportionate short stature, rhizomelia, exaggerated lumbar lordosis, brachydactyly, macrocephaly with frontal bossing and midface hypoplasia. Ligamentous laxity has been reported as a striking feature of ACH, but its prevalence and characteristics have not been systematically evaluated yet. There is growing evidence that ligamentous laxity can be associated with chronic musculoskeletal problems and may affect motor development leading to abnormal developmental trajectories. This study aimed to assess the prevalence of ligamentous laxity in children with ACH through standardized tools, the Beighton scale and its modified version for preschool-age children. A total of 33 children (mean age 6.4 ± 3.2 years; age range 1-12.5 years) diagnosed with ACH by the demonstration of a pathogenic variant in the FGFR3 gene and 33 age- and sex-matched healthy controls were included in the study. Both ligamentous laxity assessment and neurological examinations were performed; medical history was also collected from caregivers. Children with ACH showed a 2 times higher risk of ligamentous laxity than the group without skeletal dysplasia (OR = 2.2; 95% CI = 1.0 to 4.7), with 55% of children meeting the diagnostic criteria for hypermobility. No significant difference in ligamentous laxity was observed between males and females. Joint involvement analysis revealed characteristic patterns, with knee hypermobility observed in 67% of patients, while rare was elbow hypermobility. Longitudinal assessments indicated a decreasing trend in ligamentous laxity scores over time, suggesting a potential decrease in hypermobility issues during adulthood. The findings of this study provide valuable insights into the prevalence and characteristics of ligamentous laxity in ACH. Implementation of standardized ligamentous laxity assessments might guide patients' follow-up and facilitate early interventions, helping to prevent pain and improve outcomes and quality of life for such patients. Further prospective studies are needed to explore the natural history of ligamentous laxity in ACH and investigate the potential impact of emerging pharmacological treatments upon hypermobility.

Relationship and New Prospectives in Joint Hypermobility in Children with Autism Spectrum Disorder: Preliminary Data

Autism spectrum disorder (ASD) and joint hypermobility (JH) are considered two different etiological and clinical entities that most often appear in childhood. Despite growing increased research showing a co-occurrence for both conditions, a link between them is rarely established in clinical settings, and the relationship between ASD and JH has not so far been completely investigated in all age groups of ASD children. This preliminary study examined a cohort of 67 non-syndromic ASD children aged 2-18 years (sex ratio M:F = 12:1) showing different degrees of cognitive impairment and autism severity, using the Beighton scale and its revised version. A total of 63% of ASD patients aged 2-4 years and 73% of ASD patients aged ≥5 years presented significant scores of hypermobility. No significant correlation was found comparing total laxity score and cognitive assessments and severity of autistic symptomatology (p > 0.05). The results suggest that JH could be considered as a clinical characteristic of ASD patients and it needs to be assessed in order to schedule a better rehabilitation program.

Donor-Site Complication of Severe Valgus Ankle Deformity in an Adult With Ehlers-Danlos Syndrome Following Free Vascularized Fibular Grafting

Valgus deformity of the ankle joint is a well-known and relatively common donor-site complication of free vascularized fibular graft harvest in children. Due to children having naturally greater ligamentous laxity than adults, the tibiofibular syndesmosis can be compromised with the loss of the fibular shaft, leading to valgus ankle deformity (VAD). Syndesmotic stabilization with screws is commonly recommended in subsets of pediatric patients at the greatest risk of this complication. In adults, the occurrence of VAD is seldom reported in the literature following fibular graft harvest. As such, no recommendation for syndesmotic stabilization exists in the adult population. We present a case of end-stage VAD in an adult patient with Ehlers-Danlos syndrome (EDS) following free vascularized fibular graft harvest. We hypothesize that other patients with generalized joint hypermobility may face the same complication and, thus, recommend the consideration of syndesmotic stabilization or primary syndesmotic fusion at the time of graft harvest in this patient population.

The Ulnar Olecranon-Coronoid Notch Angle Affects Terminal Elbow Extension in Children and Adolescents

BACKGROUND

Limitations to terminal elbow extension (TEE) in pediatric populations have been commonly associated with the degree of ligamentous laxity and not bony factors. Ligamentous laxity, quantified through the Beighton score, is criticized for unreliably assessing joint mobility. This study aims to show that the olecranon-coronoid notch angle (OCNA) affects TEE in healthy children and adolescents.

METHODS

A retrospective study of 711 pediatric patients treated for upper extremity and shoulder injuries was cross-sectionally studied at 2 tertiary centers from 2014 to 2021. Radiographs were used to measure the OCNA, humerocondylar angle, proximal anterior ulnar angle, and the presence of secondary centers of ossification. A 2-axis goniometer measured clinical TEE to a firm endpoint. The statistical analysis studied the relationships between OCNA and TEE and the effect that age and sex have on these measurements.

RESULTS

Increased TEE was associated with increased OCNA (P<0.001) when accounting for age and sex. The average OCNA was 30.0 degrees (7.5 degrees), and the average TEE was 5.6 degrees (8.0 degrees). There was a difference in OCNA between subjects who had elbow hypoextension, normal TEE, and elbow hyperextension (P<0.001). The most common injuries were distal radius fractures (182, 26%), elbow sprains and contusions (111, 16%), distal both bone forearm fractures (95, 14%), single or both bone shaft fractures (77, 11%), and supracondylar fractures (74, 11%).

CONCLUSION

These results show that the orientation of the opening of the olecranon-coronoid notch influences the arc of TEE motion in a healthy pediatric population. The notch restrains TEE by activating the bony block mechanism between the olecranon apophysis and the olecranon fossa. The measurement of the OCNA can serve as a reproducible and quantitative method to predict hypomobility to hypermobility of TEE motion.

LEVEL OF EVIDENCE

Prognostic study: Level II.

Oxidative Stress and Musculoskeletal Pain in University Students with Generalized Joint Hypermobility: A Case-Control Study

Objective

The current case–control study aimed to evaluate generalized joint hypermobility (GJH) and its association with pain intensity, cellular oxidative stress, and collagen-associated disorders in university students aged 18–25 years old.

Background

Joint hypermobility has been recognized in healthy subjects and people who are carriers of cellular disorders in connective tissues. Cellular tissue oxidative stress and collagen-associated disorders were shown to be associated with joint hypermobility (JH).

Materials and Methods

A total of 300 university students aged 18–25 years were randomly invited from different medical and science faculties in Mansoura university, Mansoura, Egypt to participate in this case–control study. Only 280 university students who had no exclusion criteria like chronic health problems, physical disability, musculoskeletal disorders, and body mass index (BMI) of ≥25 underwent an initial clinical interview and Beighton scoring as measures of GJH. Pain intensity, physical activity, oxidative stress parameters; TAC, TOC, OSI, and collagen-associated parameters; cellular prolidase activity and hydroxyproline were evaluated by using a prevalidated questionnaire, colorimetric, and immunoassay techniques.

Results

GJH was significantly reported in 57.1% of the study population, and most of them are females. Compared to men, females with GJH showed poor physical activity, lower TAC, and significantly higher levels of TOC, OSI, cellular prolidase activity, and hydroxyproline. Based on our findings, a high Beighton score is closely related to the tissue levels of prolidase, hydroxyproline, antioxidant activity, pain intensity, and poor physical activity in the female with GJH compared to men.

Conclusion

GJH was significantly reported in 57.1% of the study population, and most of them are females. The incidence of GJH showed to be associated with poor physical activity, abnormal cellular oxidative stress, and collagen abnormalities measured by significant increase in change in cellular prolidase activity and hydroxyproline.

Clinical assessment of generalized ligamentous laxity using a single test: is thumb-to-forearm apposition enough?

The complete Beighton criteria, commonly used to establish the diagnosis of generalized ligamentous laxity (GLL), include nine discrete examination maneuvers. However, busy examiners may perform only a single maneuver (e.g. passive apposition of the thumb to the forearm) as a rapid method of assessment. We hypothesize that the use of a single-joint hypermobility test does not reliably identify the presence of GLL. Healthy patients 2-18 years old presenting to a general pediatric orthopaedic clinic were screened for participation. Exclusion criteria included the presence of a systemic illness, neuromuscular disease, and inability to complete the examination. Subjects were assessed for GLL according to the Beighton criteria, using a cutoff score of 5. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio were calculated for the thumb-to-forearm apposition test with the composite Beighton score used as the gold standard. Two hundred and four patients were included in the study, 111 females and 93 males, with an average age of 10.7 years. The prevalence of GLL was 13.3%. When thumb-to-forearm apposition was performed unilaterally, the PPV was poor (34%). Conversely, the NPV was excellent (99%). Sensitivity of thumb-to-forearm motion was extremely high (99%), although the specificity of this test was modest (67%). The likelihood ratio was fair (+3.3). Performing the test bilaterally did not significantly change its utility. Thumb-to-forearm apposition testing was equally effective in identifying the presence of GLL in males and females. When performed in isolation, assessment of thumb-to-forearm apposition has a poor PPV, excellent NPV, and modest likelihood ratio. It is an extremely sensitive test, with only fair specificity. Other upper extremity tests of GLL perform similarly. Therefore, while single tests like thumb-to-forearm apposition may be helpful for 'ruling out' GLL, they are less reliable at identifying it correctly. When single tests are used to identify GLL in either clinical or research settings, the results should be interpreted with caution. Level of evidence Level I (diagnostic).

The Beighton Score as a measure of generalised joint hypermobility

The Beighton Score (BS) is a set of manoeuvres in a nine-point scoring system, used as the standard method of assessment for Generalised Joint Hypermobility (GJH). It was originally developed as an epidemiological tool used in screening large populations for GJH, but later adopted as a clinical tool for diagnostic purposes. Its ability to truly reflect GJH remains controversial, as joints within the scoring system are predominantly of the upper limb and disregard many of the major joints, preventing a direct identification of GJH. Furthermore, a consistent finding in the literature whereby the BS failed to identify hypermobility in joints outside the scoring system suggests its use as an indirect indicator of GJH is also not viable. As such, the collective findings of this review demonstrate a need for a change in clinical thinking. The BS should not be used as the principle tool to differentiate between localised and generalised hypermobility, nor used alone to exclude the presence of GJH. Greater emphasis should be placed on a clinician’s judgement to identify or exclude GJH, according to its full definition.

Psychosocial and Motor Characteristics of Patients With Hypermobility

OBJECTIVES

To identify psychosocial and motor aspects related to joint hypermobility (JH) in a sample from almost all Brazilian states by age range and sex; to characterize JH by the Beighton total score ≥4, ≥5, and ≥6 according to sex and age and atypicality in the sitting position and in the hands; identify, in the total sample, manifestations of "growing pain" and its location, fatigue, attention deficit, anxiety, insomnia, drowsiness, apathy, depression, delay in walking, not crawling or crawling differently, school performance, spatial orientation and/or temporally impaired, social isolation, and being stigmatized as "lazy/clumsy/apathetic".

METHODS

This retrospective, observational, quantitative, and cross-sectional study used data obtained through analyses of descriptive and inferential crossings between 2012 and 2020 of 482 medical records of individuals between 1 and 76 years of age, from most Brazilian states. All patients previously diagnosed with "joint hypermobility syndrome" (JHS) and "Ehlers-Danlos syndrome hypermobility type" (EDS-HT) had their medical records reassessed, following the guidelines established in 2017. The analysis of GJH was performed using the updated method by Beighton method; atypical characteristics were investigated in the hands and the ability to sit in the "W" and the "concave" positions. The characteristics and manifestations of "growing pain" and its location were analyzed in the total sample, fatigue, insomnia, drowsiness, apathy, depression, social isolation, attention deficit, anxiety, stigmatization as "lazy," clumsy/restless, impaired school performance, and spatial and/or temporal orientation. Descriptive and inferential statistical methods were used, such as Mean, Median, Mode, Standard Deviation, Standard Error, Maximum Value, Minimum Value, Komolgorov-Smirnov, Significance, Relative Value, Absolute Value, Mann-Whitney U, and Correlation of Spearman.

RESULTS

JH in the total sample predominated in the upper limbs, the majority were women, represented by 352 (73.02%), 15 years old or older with 322 (66.80%), 312 (64.73%) had a Beighton total score ≥6, which decreased as the age increased. Always sitting in the "concave" position was represented by 54.15% and the ability to sit in the "W" position by 39.21%; signs on the hands totaled between 27.59 and 44.19% with a significant correlation between the variables. Among the characteristics, fatigue predominated, followed by an awkward/clumsy/restless individual, attention deficit, anxiety and stigmatized as "lazy," insomnia, drowsiness, apathy, depression, impaired spatial and/or temporal orientation, and social isolation. From the total sample, pain in the lower limbs was reported by 55.81% and having or having had "growing pain" was reported by 36.93%, delay in walking occurred in 19.92%, 15.35% did not crawl or crawled differently, and for 12.86%, school performance was impaired. Higher Beighton total scores showed a trend towards motor implications and correlation between variables. Ability to still sit in the "concave" position was possible for 54.15% and to sit in the "W" position for 39.21%.

CONCLUSION

In the total sample, the JH characteristic prevails in the upper limbs of female children, adolescents and adults, with a total Beighton score ≥6. Most sit in the "concave" position and less than half also sit in the "W" position and with atypical hand postures. The higher Beighton scores, which include the upper limbs, show a tendency to not crawl or crawl differently, delayed ambulation, and impaired school performance. The predominance of JH in the upper limbs is suggestive of a justification for not crawling or crawling differently. Characteristics of atypical motor performance in hands and sitting posture, in addition to fatigue, pain since childhood, anxiety, apathy, depression, sleep disorders, stigmatization, attention deficit, spatial and/or temporal orientation impairment, and social isolation are characteristics. suggestive of psychosocial implications at different ages. Future studies with motor and psychosocial aspects of people with JH will help to identify the phenotype of this population and consequent guidance for clinical management based on the motor and psychosocial aspects of people with JH.

Prevalence of joint hypermobility in children and adolescents: A systematic review and meta-analysis

Background:

The inconsistent results of different studies regarding the prevalence of joint hypermobility (JH) or joint laxity in children and adolescents made us conduct a meta-analysis on the prevalence of JH in this age group.

Materials and Methods:

We searched electronic databases including Trip, Scopus, Medline, Embase, PubMed, and Google Scholar; some Iranian databases including Iran Medex and Magiran; and Scientific Information Database to find studies in which the prevalence of JH in children and adolescents had been reported since January 1990 to April 2017. In this process, two researchers evaluated the articles separately while they were not aware of each other's method, and they extracted and matched the information.

Results:

Necessary data of twenty studies (15,097 boys and 6048 girls) were entered into this meta-analysis. The age range in these studies was 3–19 years. According to the meta-analysis conducted on the twenty studies, it was determined that the total prevalence of JH among children and adolescents was 34.1% (95% confidence interval [CI]: 33.3%–34.8%). Based on the results obtained from the studies, a significant heterogeneity (I₂ index equals to 99,415 and P ≤ 0.001) was shown, so we used random-effects model; moreover, the overall assessment of studies showed a statistically significant publication bias (P = 0.02). In total, the prevalence in girls was equal to 32.5% (95% CI: 31.4%–33.7%), and in boys, it was equal to 18.1% (95% CI: 17.2%–19.1%).

Conclusion:

According to this meta-analysis, studies showed high heterogeneity, and the prevalence of JH in children and adolescents around the world was equal to 34.1% (95% CI: 33.3%–34.8%) in total, whereas it was higher in girls and lower in older ages.

Revisiting the Beighton Criteria: Does Ligamentous Laxity Testing Correlate With Shoulder Range of Motion Norms in a North American, Pediatric Population?

BACKGROUND

Ligamentous laxity testing using the Beighton score is frequently used as part of the pediatric shoulder examination. However, the relationship between generalized ligamentous laxity (GLL) and shoulder range of motion (ROM) remains unexamined in children, and normative data for these clinical tests have not been well established. In this study, we establish normative data for shoulder range of motion and GLL in a healthy, diverse pediatric population and investigate whether Beighton testing correlates with shoulder ROM in children.

METHODS

Healthy subjects age 2 to 18 years with isolated lower extremity complaints were recruited. Passive shoulder ROM measurements for forward flexion (FF), abduction (ABD), internal rotation (IR), external rotation (ER), and extension (EXT) were obtained using a long-armed goniometer. The Beighton score was obtained, with a positive test defined as ≥5. Descriptive statistics were used to stratify data on the basis of age and sex. Interclass correlation coefficients (ICCs) were calculated. Spearman's r was calculated to determine correlations between the Beighton score and shoulder ROM. Predictive indices of a positive Beighton test to identify patients with high shoulder mobility (ROM in the top 15 percentile, or 1 SD above the mean) were calculated.

RESULTS

A total of 202 subjects were enrolled and evaluated. Passive ROM norms by age and sex were determined. Intraclass correlation coefficients for all shoulder ROM measurements were substantial to excellent. Female individuals had greater ROM than age-matched male individuals, but this trend was largely statistically insignificant. Pearson's correlation between age and shoulder ROM was significant for FF, ABD, EXT, and ER (r=-0.52 to -0.20, P<0.001). Based on a Beighton score of ≥5, the prevalence of GLL was 10% in male and 15% in female individuals. Spearman's correlation between Beighton score and shoulder ROM was significant for 3 of 5 ROM measurements: FF, ER, and EXT (r=0.30 to 0.39, P<0.001).

CONCLUSIONS

Normative pediatric shoulder ROM and joint laxity data have been established in a healthy, diverse population of children. Beighton testing exhibits only a weak to moderate correlation, despite statistical significance, with shoulder ROM and is poorly predictive for high ROM in children.

LEVEL OF EVIDENCE

Level I- Diagnostic.

Generalized joint hypermobility among school-aged children in Majmaah region, Saudi Arabia

Generalized joint hypermobility (GJH) is common among schoolchildren and usually benign. However, it may progressively lead to joint pain and developmental delay. Identifying GJH in school-aged children would facilitate the monitoring of early changes and planning for early rehabilitative intervention. Epidemiological studies addressing the prevalence of GJH among children in the Gulf region and Arab ethnicity are lacking. Hence, we aimed to determine the prevalence, pattern, and factors associated with GJH among school-aged children in the Majmaah region, Saudi Arabia. Male and female school-aged children 8–14 years of age from the Majmaah region of Saudi Arabia participated in this cross-sectional study. Beighton score was used to assess GJH. Personal characteristics such as age, height, weight, body mass index, and handedness were also collected. Descriptive statistics were obtained for personal characteristics, the point prevalence of hypermobility, frequency of Beighton score distribution, and prevalence of GJH. The associations between specific factors and the presence of GJH were analyzed using chi-square and Mann-whitney tests. Using the Beighton score cutoff ≥ 4 and ≥ 6, 15.2% and 7.6% of the school children in our study were diagnosed with GJH respectively. The prevalence of GJH was higher among females (16.8%) than among males (13.4%), but the difference was not statistically significant. The elbow joints (17.2%) were the most common hypermobile joints and the trunk (0.7%) was the least involved. The children with GJH were younger and had lesser BMI compared to children without GJH (P < 0.05). The prevalence reported in this study among school-aged children was comparable with those reported worldwide.

Risk of Injury in Physically Active Students: Associated Factors and Quality of Life Aspects

Background: The aim of this study was to assess the potential factors of hypermobility and pain threshold on the risk of injury in physically active students and to verify which domains of quality of life are rated lower by young people with a history of injuries. Methods: The study included 278 students (138 women and 140 men) who regularly undertake physical activity. Anthropometric measurements, body composition, pain threshold, incidence of hypermobility syndrome, information on the history of injuries to the locomotor system, and the quality of life of the study participants were collected. Results: In the group studied, hypermobility and pain threshold had a statistically significant related on the risk of injury. Participants with a history of injuries had lower scores for an individual’s overall perception of their own health and the physical domain. There were also significant differences in the psychological domain of the quality of life between males and females with a history of injuries. Conclusion: In the studied group, the risk of injuries was related to diagnosed hypermobility and pain threshold measured on the lower limbs. The study also showed that people with a history of injuries had statistically significantly lower scores in the individual general perception of their own health and in the physical domain. Gender had a significant impact on the quality of life of people with injuries.

Does the item 'hands on floor' add value to the Beighton score in identifying joint hypermobility?

OBJECTIVE

Different assessment tools are used to screen for joint hypermobility. One of the most commonly used tools is the Beighton score. However, the inclusion of the item "hands on floor" (HOF) has been questioned, as this maneuver is not a pure measure of the range of motion because it involves multiple joints and stretching of muscular structures. This study therefore aimed to determine the value of the HOF item to the Beighton score in children aged 6-11 years.

METHODS

Exploratory research involved children in Grades 1-4 attending four different primary schools in South Africa. Children with a severe medical or neurological condition were excluded from the study. Hypermobility was determined as a score ≥5/8 on the Beighton score excluding the HOF item.

RESULTS

A total of 460 children (median age 8.58 years [interquartile range, 7.33-9.50]) were tested, of which 34.57% were hypermobile. However, only 8.91% of all children scored positive on HOF. Although a significant association was found between HOF and the hypermobility classification (p=0.007), 86.16% of the hypermobile children could not place their hands flat on the floor. Internal consistency improved slightly when HOF was removed from the scale (α changed from 0.698 to 0.703), with a weak corrected item-total correlation (r=0.16). The specificity of the item HOF in identifying hypermobility is high (93.69%); however, the sensitivity is very low (13.84%).

CONCLUSION

This study does not show an additional value of the item HOF of the Beighton score in children.

Prevalence and unique patterns of lower limb hypermobility in elite ballet dancers

OBJECTIVES

Determine the prevalence of lower limb hypermobility in elite dancers and secondarily to describe the patterns of mobility.

DESIGN

Cross sectional.

SETTING

Self-report questionnaires and physical assessments were undertaken at a tertiary dance institution and a professional ballet company.

PARTICIPANTS

Fifty-seven pre-professional and 29 professional ballet dancers (21±4years, 64% female, mean 13.7years training) were recruited.

MAIN OUTCOME MEASURES

Lower Limb Assessment Score (LLAS) was used to assess hypermobility. Prevalence was determined by descriptive statistics, between-leg and -group comparisons were analysed using the chi-square statistic and the pattern of mobility by cluster analyses.

RESULTS

The right leg was significantly more hypermobile than the left for the whole cohort (44% vs 40% meeting ≥7/12 for the LLAS; LLAS mean/12(SD): right:5.0(2.4) and 7.6(1.9); left:4.8(2.1) and 6.7(2.0) in pre-professionals and professionals respectively (p = 0.02)). Subtalar pronation (p < 0.001) and hip abduction/external rotation (left:p = 0.01; right:p < 0.001) were significantly more hypermobile bilaterally in professionals. Three hypermobility profiles on the left and four on the right lower limb were identified.

CONCLUSIONS

This paper presents unique lower limb hypermobility profiles identified in elite dancers.

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

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

Is Self-Reported Physical Fitness Useful for Estimating Fitness Levels in Children and Adolescents? A Reliability and Validity Study

Background and objective: The assessment of physical fitness has become a necessary issue in epidemiological studies, since a reduction in fitness is directly associated with early mortality. Therefore, the development of simple, accurate, and inexpensive methods is necessary to measure physical fitness. This study aimed to determine the reliability and validity of the criteria and constructs of the International Fitness Scale (IFIS), Portuguese version, in Brazilian pediatric populations. Methods: A total of 190 children aged 3-10 years and 110 adolescents aged 11-17 years were enrolled in an observational study of reliability and validity. For reliability, the participants completed a questionnaire twice (with an interval of 15 days). To test the criterion validity, we analyzed the agreement between the questionnaire and physical tests (20-m shuttle run test, handgrip strength, standing long jump tests, 4 × 10-m shuttle run test, and back-saver sit and reach test), and the construct validity was estimated by agreement between the questionnaire and high blood pressure. The reliability was analyzed by kappa coefficients. The agreement between the testing and retesting of the questionnaire was evaluated by kappa coefficients. We applied a 2 × 2 table to estimate the specificity, sensitivity, and accuracy of the questionnaire. Results: The mean age of the children was 6.7 years (n = 190), and for the adolescents it was 14.6 years (n = 110). The questionnaire reliability showed an almost perfect score (κ ≥ 0.93 in children and κ ≥ 0.88 in adolescents). The questionnaire showed moderate criterion validity (κ ≥ 0.40 in children and adolescents) as well as moderate construct validity (κ ≥ 0.40) in the components of general conditioning, cardiorespiratory capacity, muscular strength, and speed/agility in children and in the components of cardiorespiratory capacity, muscle strength, and speed/agility in adolescents. The questionnaire was a sensitive method for measuring physical fitness. Conclusions: The Portuguese version of the IFIS is a reliable and valid method for measuring physical fitness in pediatric populations.

Joint hypermobility is a marker for anxiety in children

BACKGROUND

Joint hypermobility syndrome (JHS) has been found to be associated with anxiety disorders in clinical and nonclinical populations, but to date no studies have evaluated this association in children. The main goal of this study is to evaluate JHS along with anxiety, somatic and behavioral measures in children to clarify if JHS is associated with any of these variables in this age range.

METHODS

A sample of 160 children (74 girls and 86 boys) ranging from 5 to 17 o were recruited from a Child-Adolescent Mental Health clinic to participate in the study. All children underwent a diagnostic interview using the Mini International Neuropsychiatric Interview for Children and Adolescents. Instruments used include the Child Behavior Checklist (CBCL), the Screening Questionnaire to detect Hypermobility (SQ-CH) and the Children Manifested Anxiety Scale (CMAS-R).

RESULTS

The prevalence of JHS in this sample was 22%, and this was significantly higher in girls (31%) than in boys (14%) (χ2=6.83; P=.001). The JHS group scored significantly higher in the CMAS-R total anxiety (F=4.51; P=.035), CMAS-R Physiological anxiety (F=7.19; P=.008) and the CBCL somatic complaints (F=8.46; 0.004) and regression analyses showed that these 3 variables were predictors of JHS (χ2=36.77; P<.001; r2=0.22). The JHS group also scored higher in some behavioral measures.

CONCLUSION

Children with JHS have higher frequency of anxiety disorders and higher intensity of physiological anxiety, somatic complaints, and therefore, JHS might be used as marker for this anxiety phenotype in youngsters.

Effect of generalized ligamentous hyperlaxity related of quality of life in the foot: a case controlled study

Generalized ligamentous hyperlaxity (GLH) has been shown to predispose an individual to a number of orthopaedic conditions. Little is known about how GLH affects people' foot health-related quality of life. This study analyses a sample of people with GLH and people without GLH with normalised reference values of the scores collected with regard to using the Foot Health Status Questionnaire (FSHQ). A total of 100 respondents with mean age of 22.69 ± 3.78 years old, who attended a health centre were classified as GLH (n = 50) or non-GLH (n = 50). The GLH was determined of the patients with and without GLH using assessment with Beighton tool and the scores on the FHSQ were compared. The control group recorded higher scores in the First Section for foot pain, foot function and general foot health, and lower scores in footwear. In the Second Section, they obtained higher scores in social capacity and lower scores in physical activity, vigour and general health. Differences between the two groups were evaluated through a t-test for independent samples, showing statistical significance (P<0.001). This study has detected measurable differences of association between GLH (Beighton score ≥4) with impaired quality of life related to foot health.

The effectiveness of a multidisciplinary intervention strategy for the treatment of symptomatic joint hypermobility in childhood: a randomised, single Centre parallel group trial (The Bendy Study)

INTRODUCTION

Joint hypermobility is common in childhood and can be associated with musculoskeletal pain and dysfunction. Current management is delivered by a multidisciplinary team, but evidence of effectiveness is limited. This clinical trial aimed to determine whether a structured multidisciplinary, multisite intervention resulted in improved clinical outcomes compared with standard care.

METHOD

A prospective randomised, single centre parallel group trial comparing an 8-week individualised multidisciplinary intervention programme (bespoke physiotherapy and occupational therapy in the clinical, home and school environment) with current standard management (advice, information and therapy referral if deemed necessary). The primary endpoint of the study was between group difference in child reported pain from baseline to 12 months as assessed using the Wong Baker faces pain scale. Secondary endpoints were parent reported pain (100 mm visual analogue scale), parent reported function (child health assessment questionnaire), child reported quality of life (child health utility 9-dimensional assessment), coordination (movement assessment battery for children version 2) and grip strength (handheld dynamometer).

RESULTS

119 children aged 5 to 16 years, with symptomatic hypermobility were randomised to receive an individualised multidisciplinary intervention (I) (n = 59) or standard management (S) (n = 60). Of these, 105 completed follow up at 12 months. No additional significant benefit could be shown from the intervention compared to standard management. However, there was a statistically significant improvement in child and parent reported pain, coordination and grip strength in both groups. The response was independent of the degree of hypermobility.

CONCLUSION

This is the first randomised controlled trial to compare a structured multidisciplinary, multisite intervention with standard care in symptomatic childhood hypermobility. For the majority, the provision of education and positive interventions aimed at promoting healthy exercise and self-management was associated with significant benefit without the need for more complex interventions.

TRIAL REGISTRATION

The trial was registered prospectively with the national database at the Clinical Research Network (UKCRN Portfolio 9366). The trial was registered retrospectively with ISRCTN ( ISRCTN86573140 ).

Infantile Supracondylar Humeral Fractures (Patients Less Than Two Years of Age): Twice as Common in Females and a High Rate of Malunion with Lateral Column-Only Fixation

BACKGROUND

The age range for supracondylar humeral fractures spans from 1 to 14 years of age; most published studies have analyzed patients as non-age-segregated cohorts. Some isolated studies focused on the upper age range, demonstrating a male predominance and more severe fractures. The purpose of the current study was to analyze a large cohort of patients with surgically treated supracondylar humeral fractures at the low end of the age range (<2 years of age).

METHODS

Patients <2 years of age were identified from surgical billing records. Pin constructs were categorized as lateral column-only fixation or medial and lateral column fixation. All patients were followed through fracture-healing. Substantial loss of reduction was defined as a Baumann angle that changed ≥10° between surgery and healing or as a lateral rotation percentage (i.e., Gordon index) of ≥50% at the time of healing. The Fisher exact test was used for statistical analysis.

RESULTS

One hundred and three patients met our inclusion criteria. There were 69 female and 34 male patients (a 2:1 female-to-male ratio). Two patients did not have adequate follow-up radiographs. Of the 46 patients with bicolumnar fixation, 5 (11%) demonstrated loss of reduction compared with 20 (36%) of 55 patients with lateral column-only fixation. This difference between the groups was significant (p = 0.005). The group with lateral column-only fixation had 4.7-times-higher odds of loss of reduction (95% confidence interval, 1.6 to 13.8). A subset of patients had in-cast imaging that allowed calculation of the posterior sagittal cast index (a measure of cast fit). Eight of 15 patients who had a posterior sagittal cast index of ≥0.20 experienced loss of reduction, while only 1 of 19 patients with a cast index value of <0.20 had loss of reduction (p = 0.004).

CONCLUSIONS

Supracondylar humeral fractures were twice as common in females in this very young cohort. We also found a nearly 5-times-higher odds of loss of reduction when fracture fixation was of the lateral column only.

LEVEL OF EVIDENCE

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

Joint Laxity in Preschool Children Born Preterm

OBJECTIVE

To evaluate the prevalence of joint laxity in children born preterm assessed in the first 2 years, the relationship between joint laxity and motor performance at preschool age, and possible changes over time in a subgroup of children followed longitudinally.

STUDY DESIGN

The revised scale of Beighton Score was used to evaluate joint laxity in a population of 132 preschool children born preterm between 24 and 32 weeks of gestational age. All were assessed for joint laxity between 12 and 24 months of age. Children also performed the Movement Assessment Battery for Children-Second Edition between the age of 3 years and 6 months and 4 years; the age at onset of independent walking also was recorded.

RESULTS

The total Beighton Score ranged between 0 and 8. Twenty percent of the cohort showed joint laxity. No differences related to sex or gestational age were observed. Children born preterm with joint laxity achieved later independent walking and achieved lower scores on Movement Assessment Battery for Children-Second Edition than those without joint laxity. In 76 children born preterm, an assessment for joint laxity was repeated once between 25 and 36 months and again after >36 months. No statistically significant difference was observed between the 3 assessments.

CONCLUSIONS

The Beighton Score can be used to assess generalized joint laxity in children born preterm. As the presence of joint laxity influenced motor competences, the possibility to early identify these infants in the first 2 years is of interest to benefit from early intervention and potentially improve gross motor skills and coordination.

Survey on joint hypermobility in university students aged 18-25 years old

BACKGROUND

Joint hypermobility is defined as a wide range of movements beyond the physiological limits, it has been recognized in healthy people, gymnasts, acrobats, and carriers of genetic affections of connective tissue. A survey among young adults was conducted to describe the frequency of joint hypermobility, estimating its impact on function and quality of life.

METHODS

Volunteer university students aged 18 to 25 years old who answered a valid 5-item questionnaire about hypermobility, a physical activity questionnaire, and the Brazilian version of the Medical Outcome Survey Short Form 36 (SF-36) were included. Hypermobility was also assessed by a guided self-examination, with Beighton's criteria being scored and scores greater than or equal to 4 or less than 4 being discriminated.

RESULTS

A total of 388 subjects were included, of which 299 were women (77.06%) and 89 were men (22.94%); the median age was 23 years old. Generalized joint hypermobility (Beighton score ≥ 4) was observed in 104 individuals (26.8%). Localized hypermobility (Beighton score 1-3) was observed in 135 (34.79%) individuals, where the hypermobility of the 5th finger was the most frequent in 165 (57.47%) individuals, followed by hypermobility of the thumb in 126 (32.56%) individuals, hypermobility of the elbows and knees each in 72 (18.6%) individuals, and hypermobility of the spine in 69 (17.79%) individuals. The descriptive observation of physical activity indicated regular practice. The correlation coefficients between the SF-36 domains and hypermobility scores were very low and statistical comparison not significant.

CONCLUSION

In this population of youngsters, predominantly women, localized hypermobility was more frequent than generalized hypermobility; however, with low impact on health domains and quality of life scores, estimated in each domain of the SF-36, the physical and mental component scores, and the time dedicated to physical activity.

Development and validation of self-reported line drawings of the modified Beighton score for the assessment of generalised joint hypermobility

Background

The impracticalities and comparative expense of carrying out a clinical assessment is an obstacle in many large epidemiological studies. The purpose of this study was to develop and validate a series of electronic self-reported line drawing instruments based on the modified Beighton scoring system for the assessment of self-reported generalised joint hypermobility.

Methods

Five sets of line drawings were created to depict the 9-point Beighton score criteria. Each instrument consisted of an explanatory question whereby participants were asked to select the line drawing which best represented their joints. Fifty participants completed the self-report online instrument on two occasions, before attending a clinical assessment. A blinded expert clinical observer then assessed participants’ on two occasions, using a standardised goniometry measurement protocol. Validity of the instrument was assessed by participant-observer agreement and reliability by participant repeatability and observer repeatability using unweighted Cohen’s kappa (k). Validity and reliability were assessed for each item in the self-reported instrument separately, and for the sum of the total scores. An aggregate score for generalised joint hypermobility was determined based on a Beighton score of 4 or more out of 9.

Results

Observer-repeatability between the two clinical assessments demonstrated perfect agreement (k 1.00; 95% CI 1.00, 1.00). Self-reported participant-repeatability was lower but it was still excellent (k 0.91; 95% CI 0.74, 1.00). The participant-observer agreement was excellent (k 0.96; 95% CI 0.87, 1.00). Validity was excellent for the self-report instrument, with a good sensitivity of 0.87 (95% CI 0.81, 0.91) and excellent specificity of 0.99 (95% CI 0.98, 1.00).

Conclusions

The self-reported instrument provides a valid and reliable assessment of the presence of generalised joint hypermobility and may have practical use in epidemiological studies.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0464-8) contains supplementary material, which is available to authorized users.

Joint hypermobility and oligoarticular juvenile idiopathic arthritis: What relationship?

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessing Joint Hypermobility in Preschool-Aged Children

OBJECTIVE

To provide a revision of the Beighton score adapted for children younger than the age of 5 years, to apply the revised version in a cohort of preschool age children, and to verify the reliability of the revised version in a cohort of preschool children with genetic syndromes associated with hypermobility.

STUDY DESIGN

The revised Beighton score was applied in a population of preschool children to evaluate joint hypermobility in 5 parts of the body, bilaterally (passive dorsiflexion of the fifth finger; passive hyperextension of the elbow; passive hyperextension of the knee; passive apposition of the thumb to the flexor side of the forearm; passive dorsiflexion of the ankle joint). The frequency distribution of the total scores was calculated with a range between 0 and 10.

RESULTS

A total of 284 healthy preschool children (146 boys and 138 girls) and 26 preschool children with genetic disorders (15 boys and 11 girls) were assessed. Mean age was 33.6 ± 12.7 months. A score ≤4 was found in more than 90% of the whole cohort; therefore, a cut-off score >4 was used to identify hypermobility. Twenty-two of the 284 (7%) healthy children and 23 of the 26 children (89%) with genetic syndromes associated with hypermobility had a score >4. The joints reporting a greater incidence of hypermobility were "apposition of the thumb to the forearm" and "passive dorsiflexion of the ankle," in 34% and 22% respectively. No differences related to sex or age were observed.

CONCLUSIONS

The revised version of the Beighton score can be used to define generalized hypermobility for children up to 5 years of age and to assess and follow-up longitudinally patients with isolated hypermobility or those in whom the laxity is associated with other clinical features.

Sex differences in cerebral palsy on neuromotor outcome: a critical review

Sex differences have been reported in children with cerebral palsy (CP), with males having a higher risk of developing CP, but it is not entirely clear whether sex may also affect the severity of motor impairment. The aim of the present study was to critically review the existing literature on sex influence on neuromotor outcome in children with CP. The published papers confirm that CP occurs more frequently in males than in females. Within different types of CP or individual level of impairment, however, there was limited evidence that sex also had an effect on their performance.

Is Motor Performance in 5.5-Year-Old Children Associated with the Presence of Generalized Joint Hypermobility?

OBJECTIVE

To determine the prevalence of generalized joint hypermobility (GJH) in Dutch children aged 5.5 years, and to examine the association between GJH and motor performance and development over time.

STUDY DESIGN

A prospective cohort of 249 children was recruited. GJH was assessed with the Beighton test at age 5.5 years. Motor performance was evaluated at age 2.0 years using the Bayley Scales of Infant Development, Second Edition and at age 5.5 years using the Movement Assessment Battery for Children-Second Edition (subscore categories: manual dexterity, aiming and catching, and static and dynamic balance).

RESULTS

In 249 children, the prevalence of GJH, defined by the Beighton test score, was 34.1% for a score ≥ 4, 22.5% for a score ≥ 5, and 16.5% for a score ≥ 6. No significant association was found between GJH and total motor performance. Manual dexterity in girls (Beighton score ≥ 4) was positively associated with higher level of motor performance (β [SE] = 0.38 [0.17]; P = .028), ranging from +0.04 SD to +0.72 SD, even after correction for covariates. A significant interaction between GJH and body mass index (BMI) growth was found, indicating that the effect of GJH on the rate of development of motor performance declines with increasing BMI growth (β = 0.05 [0.02]; P = .031).

CONCLUSION

In this healthy pediatric cohort, GJH was present in one-third of the sample, and no significant association was found between GJH and total motor performance. The effect of GJH on the rate of development of motor performance appears to decline with increasing BMI growth. Longitudinal prospective studies are recommended to detect influences of GJH on motor performance over time, as well as the influence of body composition and Beighton cutoff points.

The examination of the musculoskeletal system based only on the evaluation of pelvic-hip complex muscle and trunk flexibility may lead to failure to screen children for generalized joint hypermobility

Objective

The aim of the study was to evaluate whether the clinical assessment of the pelvic-hip complex muscle and trunk flexibility is sufficient for diagnosing generalized joint hypermobility (GJH).

Design

A cross-sectional study.

Setting

Center of Body Posture in Olsztyn, North East Poland.

Participants

The study included 136 females and 113 males aged 10–13 years.

Main outcome measures

In order to assess muscle flexibility, the straight leg raise (SLR) test (for hamstring) and modified Thomas test for one- (O-JHF) and two-joint (T-JHF) hip flexors were performed. To evaluate trunk flexibility the fingertip-to-floor (FTF) and lateral trunk flexion (LTF) tests were used. The GJH occurrence was assessed with the use of nine-point Beighton scale (threshold value ≥5 points for females, ≥4 for males). The analysis was carried out separately for females and males.

Results

There were no significant differences between females with versus without GJH, and males with versus without GJH regarding SLR (p = 0.86, p = 0.19 for females and males, respectively), O-JHF (p = 0.89, p = 0.35 for females and males, respectively), T-JHF (p = 0.77, p = 0.4 for females and males, respectively), FTF (p = 0.19, p = 0.84 for females and males, respectively) and LTF (p = 0.58, p = 0.35 for females and males, respectively) tests results.

Conclusions

Clinical examination of the pelvic-hip complex muscles and trunk flexibility by use of SLR, O-JHF, T-JHF, FTF and LTF revealed to be insufficient in diagnosing GJH in children aged 10–13 years. Thus, the Beighton scale should be considered a standard element of physiotherapeutic examination of the musculoskeletal system in children and youth.

Generalised joint hypermobility in caucasian girls with idiopathic scoliosis: relation with age, curve size, and curve pattern

The aim of the study was to assess the prevalence of generalised joint hypermobility (GJH) in 155 girls with idiopathic scoliosis (IS) (age 9–18 years, mean 13.8 ± 2.3). The control group included 201 healthy girls. The presence of GJH was assessed with Beighton (B) test. GJH was diagnosed in 23.2% of IS girls and in 13.4% of controls (P = 0.02). The prevalence of GJH was significantly (P = 0.01) lower in IS girls aged 16–18 years in comparison with younger individuals. There was no difference regarding GJH occurrence between girls with mild (11–24°), moderate (25–40°), and severe scoliosis (>40°) (P = 0.78), between girls with single thoracic, single lumbar, and double curve scoliosis (P = 0.59), and between girls with thoracic scoliosis length ≤7 and >7 vertebrae (P = 0.25). No correlation between the number of points in B and the Cobb angle (P = 0.93), as well as between the number of points in B and the number of the vertebrae within thoracic scoliosis (P = 0.63), was noticed. GJH appeared more often in IS girls than in healthy controls. Its prevalence decreased with age. No relation between GJH prevalence and curve size, curve pattern, or scoliosis length was found.

Muscle strength, joint range of motion, and gait in children and adolescents with osteogenesis imperfecta

PURPOSE

To analyze clinical and functional features of children and adolescents with osteogenesis imperfecta (OI).

METHODS

A cross-sectional study of 62 participants examined clinical, body structure and function and activity features.

RESULTS

A total of 31 participants had OI type I, 9 had type III, and 22 had type IV. Mild (type I) and moderate/severe (types III and IV) OI differed significantly in occurrence of fractures, presence of bone deformities, the use of intramedullary rods, bone mineral density, and bisphosphonate therapy. Age of gait acquisition showed an association with overall joint range of motion and an inverse relationship with overall muscle strength. Level of ambulation was associated with overall muscle strength and inversely associated with overall joint range of motion.

CONCLUSIONS

Features vary according to OI type. Moderate and severe forms of OI are associated with greater functional limitation, influenced by fracture history, which negatively affects the acquisition and level of ambulation.

Prevalência de hipermobilidade articular em crianças pré-escolares

A hipermobilidade articular é a capacidade de realizar movimentos em amplitudes maiores que a normal. O presente estudo teve como objetivo estabelecer a prevalência de hipermobilidade articular em crianças pré-escolares da Rede Municipal de Educação de Londrina/PR. O estudo foi do tipo transversal com amostra constituída de 366 crianças, de 5 e 6 anos de idade. Verificou-se que, das crianças pré-escolares avaliadas, 198 (54,1%) apresentaram hipermobilidade articular, sendo 96 (59,6%) do sexo feminino e 102 (49,8%) do masculino. A hipermobilidade articular foi encontrada com maior frequência nas articulações de cotovelo e joelho, onde ocorreu a hiperextensão. Não houve diferença estatisticamente significante entre os grupos masculino e feminino em relação à hipermobilidade articular (χ²=3,539, p=0,072). Pode-se concluir que a hipermobilidade articular nas crianças pré-escolares foi achado comum, compatível com a faixa etária da população avaliada no estudo.

Pain, balance, activity, and participation in children with hypermobility syndrome

PURPOSE

To describe hypermobility, balance, pain, activity, and participation in children with hypermobility and compare these characteristics with those of a control group.

METHOD

Twenty children aged 8 to 16 years with hypermobility syndrome (HMS) or Ehlers-Danlos syndrome and a control group of 24 children of the same age participated in the study. Hypermobility was assessed according to the Del Mar scale, balance was assessed with the Bruininks-Oseretsky test of motor proficiency, and participation in daily life activities was assessed with the frequency of participation questionnaire. Pain and physical activity were assessed in a diary.

RESULTS

In comparison with the control group, the children with hypermobility had significantly more hypermobile joints and more pain and scored lower in the balance test, and their activity was affected on a daily basis.

CONCLUSION

Pain appears to affect activity and participation in children with HMS. Balance is decreased in children with HMS compared with healthy controls.

IINCIDENCE OF ANKLE SPRAINS IN SOCCER PLAYERS WITH JOINT HYPERMOBILITY SYNDROME

Objective: Eighty-three soccer players aged between 14 and 19 years, in the basic category of a professional soccer club in the city of Belo Horizonte, were followed up during the 2009 season. Methods: A prospective observational cohort study was conducted, in which these soccer players were divided randomly into two groups. The first consisted of individuals with joint hypermobility syndrome (JHS), totaling 22 players, and the second was a control group with 61 players without this syndrome, determined through a physical examinati. Results: Both groups were studied with regard to incidence of ankle sprains. At the end of this period, the data were compiled and statistical analysis was performed. A total of 43 cases of ankle injury due to sprains were recorded, of which nine episodes were in players with JHS, thus making p = 0.106. The significance level was 5%. Conclusion: We were able to conclude that in our study there was insufficient evidence to assert that there is an association with increased incidence of ankle sprains among patients with JHS.

Epidemiology of generalized joint laxity (hypermobility) in fourteen-year-old children from the UK: a population-based evaluation

Objective

Although diagnostic criteria for generalized ligamentous laxity (hypermobility) in children are widely used, their validity may be limited, due to the lack of robust descriptive epidemiologic data on this condition. The present study was undertaken to describe the point prevalence and pattern of hypermobility in 14-year-old children from a population-based cohort.

Methods

We performed a cross-sectional analysis using the Avon Longitudinal Study of Parents and Children, a large population-based birth cohort. Hypermobility among children in the cohort (mean age 13.8 years) was measured using the Beighton scoring system. Objective measures of physical activity were ascertained by accelerometry. Data on other variables, including puberty and socioeconomic status, were collected. Simple prevalence rates were calculated. Chi-square tests and logistic regression analyses were used to assess associations of specific variables with hypermobility.

Results

Among the 6,022 children evaluated, the prevalence of hypermobility (defined as a Beighton score of ≥4 [i.e., ≥4 joints affected]) in girls and boys age 13.8 years was 27.5% and 10.6%, respectively. Forty-five percent of girls and 29% of boys had hypermobile fingers. There was a suggestion of a positive association between hypermobility in girls and variables including physical activity, body mass index, and maternal education. No associations were seen in boys.

Conclusion

We have shown that the prevalence of hypermobility in UK children is high, possibly suggesting that the Beighton score cutoff of ≥4 is too low or that this scoring is not appropriate for use in subjects whose musculoskeletal system is still developing. These results provide a platform to evaluate the relationships between the Beighton criteria and key clinical features (including pain), thereby testing the clinical validity of this scoring system in the pediatric population.

Joint hypermobility in children with idiopathic scoliosis: SOSORT award 2011 winner

Background

Generalized joint hypermobility (JHM) refers to increased joint mobility with simultaneous absence of any other systemic disease. JHM involves proprioception impairment, increased frequency of pain within joints and tendency to injure soft tissues while performing physical activities. Children with idiopathic scoliosis (IS) often undergo intensive physiotherapy requiring good physical capacities. Further, some physiotherapy methods apply techniques that increase joint mobility and thus may be contraindicated.

The aim of this paper was to assess JHM prevalence in children with idiopathic scoliosis and to analyze the relationship between JHM prevalence and the clinical and radiological parameters of scoliosis. The methods of assessment of generalized joint hypermobility were also described.

Materials and methods

This case-control study included 70 subjects with IS, aged 9-18 years (mean 13.2 ± 2.2), Cobb angle range 10°-53° (mean 24.3 ± 11.7), 34 presenting single curve thoracic scoliosis and 36 double curve thoracic and lumbar scoliosis. The control group included 58 children and adolescents aged 9-18 years (mean 12.6 ± 2.1) selected at random. The presence of JHM was determined using Beighton scale complemented with the questionnaire by Hakim and Grahame. The relationship between JHM and the following variables was evaluated: curve severity, axial rotation of the apical vertebra, number of curvatures (single versus double), number of vertebrae within the curvature (long versus short curves), treatment type (physiotherapy versus bracing) and age.

Statistical analysis was performed with Statistica 8.1 (StatSoft, USA). The Kolmogorov-Smirnov test, U Mann-Whitney test, Chi² test, Pearson and Spermann correlation rank were conducted. The value p = 0.05 was adopted as the level of significance.

Results

JHM was diagnosed in more than half of the subjects with idiopathic scoliosis (51.4%), whilst in the control group it was diagnosed in only 19% of cases (p = 0.00015). A significantly higher JHM prevalence was observed in both girls (p = 0.0054) and boys (p = 0.017) with IS in comparison with the corresponding controls. No significant relation was found between JHM prevalence and scoliosis angular value (p = 0.35), apical vertebra rotation (p = 0.86), the number of vertebrae within curvature (p = 0.8), the type of applied treatment (p = 0.55) and the age of subjects (p = 0.79). JHM prevalence was found to be higher in children with single curve scoliosis than in children with double curve scoliosis (p = 0.03).

Conclusions

JHM occurs more frequently in children with IS than in healthy sex and age matched controls. No relation of JHM with radiological parameters, treatment type and age was found. Systematically searched in IS children, JHM should be taken into account when physiotherapy is planned.

Pain intensity and quality of life perception in children with hypermobility syndrome

Hypermobility syndrome (HMS) is a major source of morbidity in children. Impaired quality of life (QoL) has been observed recently in adults with HMS; however, this issue is yet to be investigated in children with this condition. This study compared pain intensity and QoL in children with HMS with healthy controls. It also examined the relationship between pain intensity and QoL in children with HMS. Following ethical approval, 29 children diagnosed with HMS and 37 healthy children aged 8-15 years participated. Informed written consent was obtained from participants and their parents/guardians. Average knee pain over the past week was examined using the Coloured Analogue Scale. QoL was measured via the Pediatric Quality of Life Inventory. Mann-Whitney U tests were performed to compare pain and QoL scores between the two groups. Spearman Rho correlation analysis was performed to examine the relationship between pain and QoL. Overall QoL scores in each domain were significantly lower in children with HMS (all p < 0.001) compared with the controls. Pain intensity was significantly higher in children with HMS compared with their healthy counterparts (p < 0.001). A strong negative correlation was observed between pain intensity and overall QoL and all the domains (r range = -0.614 to -0.717; all p < 0.001). In conclusion, the findings of the present study imply that pain and QoL assessment might form important components of clinical examination for children diagnosed with HMS. These children may benefit from appropriate treatment programmes to alleviate pain intensity and improve QoL.

Incidence of joint hypermobility syndrome in a military population: impact of gender and race

BACKGROUND

Joint hypermobility syndrome is defined by abnormal laxity in multiple joints in association with symptomatic joint pain. Previous studies in small populations suggest a predominance of female gender and nonwhite race among those diagnosed with hypermobility syndrome.

QUESTIONS/PURPOSES

We investigated the epidemiology of joint hypermobility in a large military population, presuming this syndrome would be less prevalent in this specialized population but that demographic analysis would reveal risk factors for this rare condition.

METHODS

We queried the Defense Medical Epidemiology Database by race, gender, military service, and age for the years 1998 to 2007 using the International Classification of Diseases, 9th Revision code 728.5 (hypermobility syndrome).

RESULTS

We identified 790 individuals coded for joint hypermobility syndrome among a population at risk of 13,779,234 person-years for a raw incidence rate of 0.06 per 1000 person-years. Females had a higher incidence rate for joint hypermobility syndrome compared with males. Racial stratification showed service members of white race had higher rates of joint hypermobility syndrome compared with service members categorized as black and "other."

CONCLUSIONS

In a large, established military database it appears joint hypermobility syndrome is a rare condition within the young, active population we studied and female gender is the most important risk factor.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Flexibilidade anterior do tronco no adolecente após o pico da velocidade de crescimento em estatura

Flexibilidade anterior do tronco (FAT) é um componente importante dos exames clínico e de aptidão física utilizado como indicador da função vertebral. O teste mais utilizado para sua quantificação é o sentar-e-alcançar (TSA), que considerara como padrão de normalidade o toque das mãos nos pés, com critérios e parâmetros de análise que independem das variáveis. Neste estudo, investigou-se a FAT em adolescentes, após o pico da velocidade de crescimento em estatura, em função do sexo, da velocidade de execução e dos dados antropométricos. Os índices foram obtidos em centímetros; o peso corporal em kg. Participaram 102 adolescentes, sendo 45 mulheres e 57 homens, entre 16 e 20 anos de idade. Resultados indicam que o fator sexo, dados antropométricos e a velocidade de execução do teste influenciam os índices de flexibilidade; a avaliação da função vertebral não pode ter como critério de normalidade atingir os pés pelo TSA, e que a velocidade rápida leva a melhores resultados. Em resumo, os resultados indicam que tocar os pés, é um critério que exclui da normalidade da função vertebral aproximadamente 50% dos adolescentes. Assim, o critério para tomada de decisão quanto ao encaminhamento do adolescente para recuperação de maiores índices de flexibilidade precisa ser revisto.

Hypermobility disorders in children and adolescents

It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.