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Csecs JLL, Dowell NG, Savage GK, Iodice V, Mathias CJ, Critchley HD, Eccles JA. Variant connective tissue (joint hypermobility) and dysautonomia are associated with multimorbidity at the intersection between physical and psychological health. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2021; 187:500-509. [PMID: 34806825 DOI: 10.1002/ajmg.c.31957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/26/2021] [Accepted: 11/09/2021] [Indexed: 02/06/2023]
Abstract
The symptoms of joint hypermobility extend beyond articular pain. Hypermobile people commonly experience autonomic symptoms (dysautonomia), and anxiety or related psychological issues. We tested whether dysautonomia might mediate the association between hypermobility and anxiety in adults diagnosed with mental health disorders and/or neurodevelopmental conditions (hereon referred to as patients), by quantifying joint hypermobility and symptoms of autonomic dysfunction. Prevalence of generalized joint laxity (hypermobility) in 377 individuals with diagnoses of mental health disorders and/or neurodevelopmental conditions was compared to prevalence recorded in the general population. Autonomic symptom burden was compared between hypermobile and non-hypermobile patients. Mediation analysis explored relationships between hypermobility, autonomic dysfunction, and anxiety. Patient participants had elevated prevalence of generalized joint laxity (38%) compared to the general population rate of 19% (odds ratio: 2.54 [95% confidence interval: 2.05, 3.16]). Hypermobile participants reported significantly more autonomic symptoms. Symptoms of orthostatic intolerance mediated the relationship between hypermobility and diagnosis of an anxiety disorder. Patients with mental health disorders and/or neurodevelopmental conditions have high rates of joint hypermobility. Accompanying autonomic dysfunction mediates the association between joint hypermobility and clinical anxiety status. Increased recognition of this association can enhance mechanistic understanding and improve the management of multimorbidity expressed in physical symptoms and mental health difficulties.
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Affiliation(s)
- Jenny L L Csecs
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Nicholas G Dowell
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - Georgia K Savage
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, UK.,UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Christopher J Mathias
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, UK.,UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,Neurovascular Medicine (Pickering Unit), St Mary's Hospital, Imperial College London, London, UK
| | - Hugo D Critchley
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
| | - Jessica A Eccles
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, UK
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Afrin LB. Some cases of hypermobile Ehlers-Danlos syndrome may be rooted in mast cell activation syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:466-472. [PMID: 34719842 DOI: 10.1002/ajmg.c.31944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 08/23/2021] [Accepted: 10/16/2021] [Indexed: 12/17/2022]
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS) is the most common type of EDS, yet has remained steadfastly inscrutable vis-à-vis efforts to identify its cellular, molecular, and pathophysiologic roots. Once thought to principally affect just connective tissues, hEDS is now appreciated to be a multisystem disease of great heterogeneity with many symptoms and findings difficult to attribute solely to disordered connective tissue development. In the last decade, there has been growth in the appreciation of the existence of a wide range of disorders of chronic inappropriate mast cell (MC) activation (a large heterogeneous pool of MC activation syndromes [MCAS]) distinguishable from other MC disorders such as rare neoplastic mastocytosis. Via chronic aberrant release of the MC's vast repertoire of potent mediators, MCAS can drive extraordinary arrays of pathologies, most commonly of inflammatory, allergic, and dystrophic natures. Although hEDS is seen in only a minority of MCAS cases, limited studies have identified an association between hEDS and MCAS, fueling speculation that certain variants of MCAS may drive hEDS. No laboratory studies probing cellular or molecular linkages between hEDS and MCAS have been conducted yet, and research efforts to identify the genetic roots of hEDS should also consider those of MCAS.
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Affiliation(s)
- Lawrence B Afrin
- Department of Mast Cell Studies, AIM Center for Personalized Medicine, Purchase, New York, USA
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Dockrell DM, Berg KM, Ralston SH. Mind the gaps: therapists' experiences of managing symptomatic hypermobility in Scotland. Rheumatol Adv Pract 2021; 5:rkab046. [PMID: 34396034 PMCID: PMC8358480 DOI: 10.1093/rap/rkab046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/14/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim was to ascertain occupational therapist (OT) and physiotherapist (PT) experiences of managing hypermobility spectrum disorders (HSDs) and hypermobile Ehlers-Danlos syndrome (hEDS) patients, specifically the training and confidence levels of therapists, use of evidence-based practice, accessibility of pain management and clinical psychology services, and perceived usefulness of a specialist centre in Scotland. Methods A mixed-method survey was distributed to Rheumatology OTs/PTs in Scotland. It included multiple choice and open text questions, which were analysed to reflect therapists’ experiences and perception of service need. Results We found that therapists in Scotland do have expertise in the management of HSD/hEDS patients; however, this expertise tends to be concentrated in secondary care, which makes it difficult for patients who are managed in primary care to access. The majority of respondents reported lack of access to external training (80%). There was difficulty in referral to pain management services (55%) and clinical psychology (28%) among adult therapists. Paediatric services provided considerably better access to these disciplines. Of note, the majority of respondents were in favour of a specialist centre in Scotland for the training and education of therapists (94.7%) and the diagnosis and management of complex HSD/hEDS patients (73.7%). Conclusion More research is needed urgently to evaluate the effectiveness of therapy interventions to underpin a national guideline in order that we can improve outcomes for HSD/hEDS patients. A specialist centre with expert and engaged clinicians would be a valuable asset in coordinating patient-focused research and conducting good-quality clinical trials.
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Affiliation(s)
- Dervil M Dockrell
- Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Kathryn M Berg
- Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Stuart H Ralston
- Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
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Eftekhari H, Maddock H, Pearce G, Raza S, Kavi L, Lim PB, Osman F, Hayat SA. Understanding the future research needs in Postural Orthostatic Tachycardia Syndrome (POTS): Evidence mapping the POTS adult literature. Auton Neurosci 2021; 233:102808. [PMID: 33901811 DOI: 10.1016/j.autneu.2021.102808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/15/2021] [Accepted: 03/27/2021] [Indexed: 01/01/2023]
Abstract
POTS is under diagnosed with an estimated prevalence of 0.2%. North American and Australian researchers, as well as patient groups have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base. AIM To map the POTS evidence base. METHODS Two reviewers systematically searched 12 databases until July 1st 2019 using the search term "Postural Tachycardia Syndrome" (n = 7280) and categorised the literature. Inclusion criteria included all adult published literature with no language restrictions. 779 papers are analysed and mapped. RESULTS Seven themes were identified: symptomology and quality of life 16.8% (n = 132), biomedical topics 16.5% (n = 130), co-morbidities 10.3% (n = 81), non-pharmacological management 9.8% (n = 77), aetiologies 6.9% (n = 53), pharmacological management 6.7% (n = 53), and clinical management 6.6% (n = 52). There 45 subthemes. Quality appraisal of the research studies (n = 233) evaluated design, sample size, outcome measures, data analysis and research biases. 74.8% (n = 175) were observational designs and 25.2% (n = 59) were experimental designs (16 using a randomised controlled design, 11 of which had a sample size greater than 21). 47.4% (n = 111) of studies only measured duration of effect for <1 day. 11.5% (n = 27) of studies reported outcomes using an unvalidated subjective measurement tool. CONCLUSION The volume of adult POTS literature is small and the validity and reliability of the research lacks rigour. The evidence map methodology provides POTS researchers with a benchmark for research thus far. This paper adds an in-depth research appraisal to the broad calls for action, highlighting the pressing need for multicentre, good quality research in POTS, to support guidelines and consensus development in the future.
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Affiliation(s)
- H Eftekhari
- University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain and Northern Ireland.
| | - H Maddock
- Faculty of Health and Life Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - G Pearce
- Faculty of Health and Life Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - S Raza
- Biomedical Sciences, Coventry University, United Kingdom of Great Britain and Northern Ireland.
| | - L Kavi
- PoTS UK, United Kingdom of Great Britain and Northern Ireland.
| | - P B Lim
- Imperial College NHS Healthcare Trust, United Kingdom of Great Britain and Northern Ireland.
| | - F Osman
- University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain and Northern Ireland; Warwick Medical School, University of Warwick, Coventry, United Kingdom of Great Britain and Northern Ireland.
| | - S A Hayat
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
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Csecs JLL, Iodice V, Rae CL, Brooke A, Simmons R, Quadt L, Savage GK, Dowell NG, Prowse F, Themelis K, Mathias CJ, Critchley HD, Eccles JA. Joint Hypermobility Links Neurodivergence to Dysautonomia and Pain. Front Psychiatry 2021; 12:786916. [PMID: 35185636 PMCID: PMC8847158 DOI: 10.3389/fpsyt.2021.786916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/20/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES Autism, attention deficit hyperactivity disorder (ADHD), and tic disorder (Tourette syndrome; TS) are neurodevelopmental conditions that frequently co-occur and impact psychological, social, and emotional processes. Increased likelihood of chronic physical symptoms, including fatigue and pain, are also recognized. The expression of joint hypermobility, reflecting a constitutional variant in connective tissue, predicts susceptibility to psychological symptoms alongside recognized physical symptoms. Here, we tested for increased prevalence of joint hypermobility, autonomic dysfunction, and musculoskeletal symptoms in 109 adults with neurodevelopmental condition diagnoses. METHODS Rates of generalized joint hypermobility (GJH, henceforth hypermobility) in adults with a formal diagnosis of neurodevelopmental conditions (henceforth neurodivergent group, n = 109) were compared to those in the general population in UK. Levels of orthostatic intolerance and musculoskeletal symptoms were compared to a separate comparison group (n = 57). Age specific cut-offs for GJH were possible to determine in the neurodivergent and comparison group only. RESULTS The neurodivergent group manifested elevated prevalence of hypermobility (51%) compared to the general population rate of 20% and a comparison population (17.5%). Using a more stringent age specific cut-off, in the neurodivergent group this prevalence was 28.4%, more than double than the comparison group (12.5%). Odds ratio for presence of hypermobility in neurodivergent group, compared to the general population was 4.51 (95% CI 2.17-9.37), with greater odds in females than males. Using age specific cut-off, the odds ratio for GJH in neurodivergent group, compared to the comparison group, was 2.84 (95% CI 1.16-6.94). Neurodivergent participants reported significantly more symptoms of orthostatic intolerance and musculoskeletal skeletal pain than the comparison group. The number of hypermobile joints was found to mediate the relationship between neurodivergence and symptoms of both dysautonomia and pain. CONCLUSIONS In neurodivergent adults, there is a strong link between the expression of joint hypermobility, dysautonomia, and pain, more so than in the comparison group. Moreover, joint hypermobility mediates the link between neurodivergence and symptoms of dysautonomia and pain. Increased awareness and understanding of this association may enhance the management of core symptoms and allied difficulties in neurodivergent people, including co-occurring physical symptoms, and guide service delivery in the future.
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Affiliation(s)
- Jenny L L Csecs
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Charlotte L Rae
- School of Psychology, University of Sussex, Brighton, United Kingdom
| | - Alice Brooke
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Rebecca Simmons
- Neurodevelopmental Service, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Lisa Quadt
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Georgia K Savage
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Nicholas G Dowell
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Centre for Regenerative Medicine and Devices, University of Brighton, Brighton, United Kingdom
| | - Fenella Prowse
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Department of Medicine, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kristy Themelis
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Department of Psychology, University of Warwick, Coventry, United Kingdom
| | - Christopher J Mathias
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom.,Pickering Unit, Neurovascular Medicine, St Mary's Hospital, Imperial College London, London, United Kingdom
| | - Hugo D Critchley
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom.,Neurodevelopmental Service, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Jessica A Eccles
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom.,Research and Development, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom.,Neurodevelopmental Service, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
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Quantitative measures of tissue mechanics to detect hypermobile Ehlers-Danlos syndrome and hypermobility syndrome disorders: a systematic review. Clin Rheumatol 2020; 39:715-725. [DOI: 10.1007/s10067-020-04939-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 11/27/2022]
Abstract
AbstractHypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are heritable connective tissue disorders associated with pain, activity limitations and participation restrictions. A key feature is reported to be reduced stiffness and increased extensibility and elasticity of connective tissues. Yet diagnosis relies on assessment of joint range of motion, which may be influenced by other factors, and semi-quantitative assessment of forearm skin extensibility. The objective of this systematic review was to determine if quantitative measures of tissue mechanics can discriminate between hEDS/HSD and healthy tissues. Literature was identified via online databases (AMED, CINAHL+, EMBASE, MEDLINE and SportDiscus) and snowballing. Studies were included if participants had a confirmed diagnosis of hEDS/HSD (or equivalent diagnosis) using internationally recognised criteria, a healthy control group was used as a comparator, and objective measures of tissue stiffness, extensibility or elasticity of muscle, tendon, connective tissue or skin were reported. Included studies were critically appraised, followed by group discussion, consensus and narrative synthesis. Two hundred three potentially relevant studies were identified. Application of the inclusion criteria resulted in four studies being included. A range of quantitative approaches to studying tissue mechanics were used, including diagnostic ultrasound. Overall, three of the four studies found that at least one measure of tissue mechanics distinguished between people with hEDS/HSD and healthy controls. The studies were generally conducted and reported to high standards. Quantitative measures of tissue mechanics have the potential to contribute towards more objective diagnosis of hEDS/HSD. Further validation, particularly within diagnostic scenarios, is required.
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Gilliam E, Hoffman JD, Yeh G. Urogenital and pelvic complications in the Ehlers-Danlos syndromes and associated hypermobility spectrum disorders: A scoping review. Clin Genet 2020; 97:168-178. [PMID: 31420870 PMCID: PMC6917879 DOI: 10.1111/cge.13624] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/07/2019] [Accepted: 08/14/2019] [Indexed: 12/19/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) and associated hypermobility spectrum disorders (HSD) are a heterogenous group of connective tissue disorders associated with significant morbidity. The urogenital aspects of these disorders are understudied and there is little guidance on the prevalence, types, or outcomes of urogenital complications in EDS/HSD. Our objective was to perform a scoping review to characterize and synthesize the literature reporting urogenital and pelvic complications in EDS/HSD patients. We performed a systematic search of three databases (Medline, CINAHL, Embase) to January 2019. English language, full-text articles reporting on urogenital or pelvic complications in EDS/HSD were included. A total of 105 studies were included (62 case reports/series, 43 observational) involving patients with hypermobile (23%), vascular (20%), classical (12%) EDS, and HSD (24%). Some studies looked at multiple subtypes (11%) or did not report subtype (33%). Reported complications included urinary (41%), gynecological (36%), obstetrical (25%), renal (9%), and men's health problems (7%), with some studies reporting on multiple areas. Urinary and gynecological complications were most prevalent in patients with HSD, while a broad range of complications were reported in EDS. While further research is required, results suggest a higher index of suspicion for urogenital problems is probably warranted in this population.
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Affiliation(s)
- Elizabeth Gilliam
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jodi D. Hoffman
- Division of Genetics, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Gloria Yeh
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Jesudas R, Chaudhury A, Laukaitis CM. An update on the new classification of Ehlers‐Danlos syndrome and review of the causes of bleeding in this population. Haemophilia 2019; 25:558-566. [DOI: 10.1111/hae.13800] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Rohith Jesudas
- Bleeding and Clotting Disorders Institute Peoria Illinois
| | | | - Christina M. Laukaitis
- Departments of Medicine and Nutrition University of Arizona College of Medicine Tucson Arizona
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