Articular symptoms in hypermobile schoolchildren: a prospective study

Idiopathic musculoskeletal pain in Indian children-Prevalence and impact on daily routine

OBJECTIVES

To study the prevalence of idiopathic musculoskeletal pain (IMSP) in school going children and its impact on daily life.

METHODS

One thousand eighteen apparently healthy school children aged 5-16 years were assessed and analysed for IMSP and its associated problems. Standard tests for significance were applied.

RESULTS

One hundred and sixty-five (16.2%) children mostly males (55.2%) reported IMSP. Lower limbs (52.1%) were the most common location of pain. More than 1 year of pain history was present in 15%. Thirty-seven percent children complained of discomfort during walking, 30.9%, had pain during physical exercise, 29.2% had difficulty attending lessons and 4.2% had interference in pursuing hobbies. The children were also further sub grouped into preadolescents and adolescents. There was significant difference in pain duration and duration of each pain episode in the two groups (p=0.01). A significant number of children (21.2%) with IMSP reported school absenteeism (p<0.001). A significant number of adolescents had history positive for contact sports (p=0.001). Sleep disturbances were also reported to be higher in children with IMSP (29% vs. 5.7%, p=0.001). Other associated problems in children with IMSP found were day time tiredness (51.1%), headache (47.3%) and abdominal pain (24.8%).

CONCLUSIONS

Prevalence of IMSP in school children aged 5-16 yrs was found to be 16.2% and a significant percentage of these children experience interference with daily activities including school absenteeism.

[Idiopathic musculoskeletal pain in Indian Children-prevalence and impact on daily routine]

OBJECTIVES

To study the prevalence of idiopathic musculoskeletal pain (IMSP) in school going children and its impact on daily life.

METHODS

One thousand eighteen apparently healthy school children aged 5-16 years were assessed and analysed for IMSP and its associated problems. Standard tests for significance were applied.

RESULTS

One hundred and sixty five (16.2%) children mostly males (55.2%) reported IMSP. Lower limbs (52.1%) were the most common location of pain. More than 1 year of pain history was present in 15%. Thirty seven percent children complained of discomfort during walking, 30.9%, had pain during physical exercise, 29.2% had difficulty attending lessons and 4.2% had interference in pursuing hobbies. The children were also further sub grouped into preadolescents and adolescents. There was significant difference in pain duration and duration of each pain episode in the two groups (p=0.01). A significant number of children (21.2%) with IMSP reported school absenteeism (p<0.001). A significant number of adolescents had history positive for contact sports (p=0.001). Sleep disturbances were also reported to be higher in children with IMSP (29% vs. 5.7%, p=0.001). Other associated problems in children with IMSP found were day time tiredness (51.1%), headache (47.3%) and abdominal pain (24.8%).

CONCLUSIONS

Prevalence of IMSP in school children aged 5-16 yrs was found to be 16.2% and a significant percentage of these children experience interference with daily activities including school absenteeism.

Age-related joint space narrowing independent of the development of osteoarthritis of the shoulder

Purpose:

It is commonly accepted that the glenohumeral joint space remains unchanged until the onset of osteoarthritis, at which point progressive degenerative changes, and joint space narrowing occur. The aim of this study was to evaluate the radiographic width of the glenohumeral joint space in patients of different ages: Those with otherwise normal radiographs, those with a history of instability, those with calcific tendonitis, and those with a radiologic diagnosis of osteoarthritis.

Materials and Methods:

In this retrospective study, two independent investigators measured the glenohumeral joint width on true anteroposterior and axillary views of standardized shoulder radiographs taken from 2002 to 2009. The digital image resolution was 0.01 mm. Group I comprised 60 patients with normal shoulder radiographs, Group II comprised 53 patients with instability but normal radiographs, Group III comprised 109 patients with radiologically proven calcific tendonitis, and Group IV comprised 120 patients with manifest osteoarthritis.

Results:

The interobserver reliability (r) was 0.621-0.862. The mean joint space width was significantly different among Groups I-IV (central anteroposterior: 4.28 ± 0.75 mm, 3.12 ± 0.73 mm, 2.87 ± 0.80 mm, and 1.47 ± 1.07 mm, respectively; P = 0.001; central axillary: 6.12 ± 1.09 mm, 3.92 ± 0.77 mm, 3.34 ± 0.84 mm, and 1.08 ± 1.12 mm, respectively; P = 0.001). There was a significant negative correlation between the joint space width and age at all measured levels in both projections (P < 0.001).

Conclusions:

The glenohumeral joint space width decreases with increasing age beginning in early adulthood, and this effect is enhanced by osteoarthritis.

Level of Evidence:

Level II, retrospective study.

Multimodal chiropractic care of pain and disability for a patient diagnosed with benign joint hypermobility syndrome: a case report

OBJECTIVE

The purpose of this case report is to describe multimodal chiropractic care of a female patient diagnosed with benign joint hypermobility syndrome (BJHS) and a history of chronic spine pain.

CLINICAL FEATURES

A 23-year-old white female presented for chiropractic care with chronic low back pain, neck pain, and headaches. The patient was diagnosed with BJHS, including joint hypermobility of her thumbs, elbows, right knee, and lumbopelvic region. A 6-year history of low back pain and varicose veins in her posterior thighs and knees were additional significant diagnostic findings of BJHS.

INTERVENTIONS AND OUTCOMES

The treatment consisted of spinal and extremity manipulation, Graston technique, and postisometric relaxation combined with sensory motor stimulation and scapular stabilization exercises. The patient was seen 15 times over an 18-week period. After 18 weeks of care, the Revised Oswestry Low Back Questionnaire and Headache Disability Index demonstrated clinically important improvements with her low back pain and headache; but little change was noted in her neck pain as measured by the Neck Disability Index.

CONCLUSION

This patient with BJHS who had decreased disability and spine pain improved after a course of multimodal chiropractic care.

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries

OBJECTIVE

To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6-18 years).

BACKGROUND

Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches.

RECOMMENDATIONS

Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.

Anterior cruciate ligament reconstruction in patients with generalized joint laxity

Generalized joint laxity is a genetically determined component of overall joint flexibility. The incidence of joint laxity in the overall population is approximately 5% to 20%, and its prevalence is higher in females. Recently it was noticed that individuals with generalized joint laxity are not only prone to anterior cruciate ligament injuries but also have inferior results after a reconstruction. Therefore, an anterior cruciate ligament reconstruction in patients with generalized laxity should be undertaken with caution due to the higher expected failure rate from the complexity of problems associated with this condition. It is also necessary to identify the risk factors for the injury as well as for the post operative outcome in this population. A criterion that includes all the associated components is necessary for the proper screening of individuals for generalized joint laxity. Graft selection for an anterior cruciate reconstruction in patients with ligament laxity is a challenge. According to the senior author, a hamstring autograft is an inferior choice and a double bundle reconstruction with a quadriceps tendon-bone autograft yields better results than a single bundle bone-patella tendon-bone autograft. Future studies comparing the different grafts available might be needed to determine the preferred graft for this subset of patients. Improved results after an anterior cruciate ligament reconstruction can be achieved by proper planning and careful attention to each step beginning from the clinical examination to the postoperative rehabilitation.

[Hiperlaxity ligamentous (Beighton test) in the 8 to 12 years of age school population in the province of Granada]

The Beighton test is the most commonly used tool for detecting ligamentous hiperlaxity, characterized by excessive joint mobility. This descriptive-transversal study examines a sample of 2956 children (49,9% boys and 50,1% girls), from eight to twelve years of age, living in the province of Granada, The study aims to show the incidence level of hiperlaxity among the school-aged population, while establishing its frequency in relation to gender and age, and determining the area with the highest number of cases within the province of Granada. The Beighton test was used for data collection. The sample showed that 25, 4% of individuals got a positive Beighton result (laxity), and girls had a higher incidence level (62,1%) than boys. The results show as well a similar level of incidence among boys and girls between eight and ten years of age; however, the incidence decreases among younger children (under 8 years). Regarding the geographical areas, the distribution is quite heterogeneous, but we were able to highlight the difference between a result of 50% in Area 4 and 12% in Area 2, due to genetic and racial factors. In conclusion, the results obtained through this study show a lower hiperlaxity incidence compared to the results found in the American continent and they are slightly higher than those from other European and African countries.

Non-specific neck pain in schoolchildren: prognosis and risk factors for occurrence and persistence. A 4-year follow-up study

This study investigated the natural course of neck pain (NP) in 9-12-year-olds during a 4-year follow-up. Risk factors for the occurrence and persistence of weekly NP were explored separately for boys and girls. At baseline, 1756 schoolchildren completed a questionnaire eliciting musculoskeletal pain symptoms, other physical, and psychological symptoms and frequency of physical activity, and were tested for joint hypermobility. Symptoms during the preceding three months were asked using a five-level frequency classification. Re-evaluation was performed after one and four years using identical questionnaires. During follow-up, 24% reported none, 71% fluctuating, and 5% persistent weekly NP. The frequency of NP at baseline was linearly related to weekly NP during follow-up in both genders (P<0.001). Furthermore, a significant increasing linear trend towards a more persistent course of NP was seen in children with weekly other musculoskeletal and/or other physical and psychological symptoms at baseline. Among originally neck pain-free pre-/early adolescents, weekly other musculoskeletal pain symptoms (only in girls) and other physical and psychological symptoms (in both genders) predicted the occurrence of weekly NP during follow-up. In conclusion, neck pain in schoolchildren tends to fluctuate, but there also seems to exist a subgroup (5%) with persistent NP already in pre-/early adolescents, or even earlier. Co-occurrence of frequent other musculoskeletal symptoms and/or markers of psychological stress with frequent NP are risk indicators for a more persistent course, at least within next few years. Since adult chronic NP problems might originate in childhood, further studies are needed, including preventive interventions.

Risk factors for development of non-specific musculoskeletal pain in preteens and early adolescents: a prospective 1-year follow-up study

BACKGROUND

Musculoskeletal pain symptoms are common in children and adolescents. These symptoms have a negative impact on children's physical and emotional well-being, but their underlying aetiology and risk factors are still poorly understood. Most of the previous cohort studies were conducted among mid and/or late adolescents and were mainly focused on a specific pain location (e.g. low back pain or neck pain). The purpose of this study is to estimate occurrence of new-onset pain symptoms, in all musculoskeletal locations, in preteens and early adolescents and investigate risk factors for development of these symptoms.

METHODS

1756 schoolchildren (mean age 10.8) were recruited from schools in southern Finland. Information was extracted as to whether they experienced musculoskeletal pain and a total of 1192 children were identified as free of musculoskeletal pain symptoms. Information was collected on factors which could potentially predict the development of musculoskeletal pain: headache, abdominal pain, sadness/feeling down, day-time tiredness, difficulty in falling asleep, waking up during nights, level of physical activity and hypermobility. These children were followed-up 1-year later and those with new episodes of non-traumatic and traumatic musculoskeletal pain symptoms were identified.

RESULTS

A total of 1113 schoolchildren (93% of baseline pain-free children) were found at one-year follow-up. New episodes of musculoskeletal pain were reported by 21.5% of these children. Of them 19.4% reported non-traumatic pain and 4.0% reported traumatic pain. The neck was the most commonly reported site with non-traumatic pain, while the lower limb was the most common site for traumatic pain. The independent risk factors for non-traumatic musculoskeletal pain were headache (OR = 1.68, [95% CI 1.16-2.44]) and day-time tiredness (OR = 1.53, [95% CI 1.03-2.26]). The risk factors for traumatic musculoskeletal pain were vigorous exercise (OR = 3.40 [95% CI 1.39-8.31]) and day-time tiredness (OR = 2.97 [95% CI 1.41-6.26]).

CONCLUSION

This study highlights that there may be two types of pain entities with both distinct and common aspects of aetiology. For primary prevention purposes, school healthcare professionals should pay attention to preteens and early adolescents practicing vigorous exercise (predictor of traumatic pain), reporting headache (predictor of non-traumatic pain) and reporting day-time tiredness (predictor of both types of pain).

Is musculoskeletal history and examination so different in paediatrics?

Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.

Why do idiopathic scoliosis patients participate more in gymnastics?

The influence of physical and sporting activities (PSA) on idiopathic scoliosis (IS) is still obscure. The aim of this study was to investigate whether such an influence exists and if so, to determine its characteristics. Two hundred and one teenagers with IS and a control group of 192 adolescents completed an epidemiological questionnaire. Those practising gymnastics were more numerous in the IS group than in the control group. Moreover, the practice of gymnastics was chosen before IS was diagnosed. As gymnastic activities are considered neither as a therapy nor as a precursor of IS, the distribution observed could be linked to a common factor that both increases the likelihood of IS and favors the practice of gymnastics. Joint laxity (JL) may be such a common factor, and was therefore tested (wrist and middle finger) on 42 girls with IS and 21 girls of a control group. IS patients, practising gymnastics or not, showed a higher JL than the control group practising gymnastics or not. Furthermore, the groups practising gymnastic activities did not show higher JL levels than the other groups. Children with a high JL could be drawn toward gymnastics because of their ability to adapt to the constraints of this sport. Girls with a high JL may therefore be prone to developing IS. The fact that most teenagers with IS practise gymnastics could be related to a higher JL.

[Joint hypermobility: prevalence and relationship with musculoskeletal pain]

OBJECTIVES

(1) To determine the prevalence of joint hypermobility in children aged 4-14 years old without organic disease of the locomotor system; (2) to compare the prevalence of hypermobility in children with and without arthralgia and (3) to analyze the influence of certain variables on the development of arthralgia.

PATIENTS AND METHODS

We performed an observational study in a sample of children aged 4-14 years old living in Area 4 of the Community of Madrid (Spain). Joint hypermobility was evaluated using a goniometer. Hypermobility was defined using Beighton's criteria.

RESULTS

A total of 222 subjects were analyzed: 176 in the primary care setting and 46 in the emergency department of a referral hospital. Of the 222 children, 43 reported arthralgia. The prevalence of hypermobility (> or = 4 criteria) was 55 % (123/222), reaching 71 % (49/69) in children aged less than 8 years. No significant differences were found in the prevalence of hypermobility in children with and without arthralgia (65 % and 53 % respectively). Of the variables analyzed (age, sex, country of origin, primary care/emergency department setting) only differences in the absolute number of Beighton criteria present in children with and without arthralgia (4.34 +/- 2.47 and 3.48 +/- 2.35, p = 0.03) were detected, which disappeared when at least four criteria (definition of hypermobility) were required.

CONCLUSIONS

Fifty-five percent of the population studied and 71 % of those younger than 8 years old met the criteria for joint hypermobility. In the sample analyzed, the presence of joint hypermobility did not seem to favor the development of arthralgias.

Prognosis of non-specific musculoskeletal pain in preadolescents: A prospective 4-year follow-up study till adolescence

Musculoskeletal pain is common in children but studies on the outcome and predictive factors for persistence/recurrence of these symptoms are scarce. A baseline cross-sectional survey of 1,756 schoolchildren (mean age 10.8) identified 564 (32.1%) children with musculoskeletal pain. At baseline, these children were evaluated using a structured questionnaire and examined for hypermobility and physical fitness. The children were re-evaluated after one year, and four years (at adolescence) using the same pain questionnaire. At 1-year follow-up, 53.8% (95% CI 48.8-58.8) of the children reported pain persistence (persistent preadolescent musculoskeletal pain). At 4-year follow-up, 63.5% (95% CI 58.7-68.1) of them had musculoskeletal pain. Neck was the site with most persistent/recurrent musculoskeletal pain. Those with persistent preadolescent musculoskeletal pain had approximately three times higher risk of pain recurrence (OR=2.90 [95% CI 1.9-4.4]). In the univariate analysis, female gender, older age group (11+), hypermobility, co-existence of psychosomatic symptoms, having high disability index, and reporting combined musculoskeletal pain at baseline predicted pain recurrence at adolescence. In the multivariate analysis, age, headache, hypermobility and having combined musculoskeletal pain were found as independent predictors. Statistically significant sex interactions were found for age, depressive feelings, waking up during nights and hypermobility. More psychosomatic symptoms predicted pain recurrence in girls than in boys, and hypermobility was a strong predictor in females only. Musculoskeletal pain in preadolescents is not a self-limiting phenomenon and more studies are still warranted to explore its determinants aiming to improve the long-term outcome of these symptoms.

Contributing factors to the persistence of musculoskeletal pain in preadolescents: a prospective 1-year follow-up study

A 1-year follow-up of two preadolescent age cohorts with musculoskeletal pain at least once a week was conducted to analyze predictive factors for the persistence of musculoskeletal pain. Of the 564 children with pain at baseline, representing one third of the sample studied, 515 (91.3%) could be followed and 452 (80.1%) children with complete data were included for the logistic regression analysis. A structured questionnaire included questions on pain and also on several psychosomatic symptoms and amount of exercise. Joint hypermobility together with the questionnaire data were included in the logistic regression analysis. One half of subjects with pain at baseline still reported pain at follow-up, indicating persistent pain. Boys had a lower risk for the persistence of pain than girls and the risk for the persistence of pain increased 1.2 times per age year. When further adjusted for all the other studied risk determinants, high subjective disability index due to pain (OR 3.2, 95% CI 1.5-6.6) and day tiredness (OR 1.9, 95% CI 1.2-3.0) were the most significant predictors. This might indicate that psychological distress contributes to the persistence of non-specific musculoskeletal pain of different locations in preadolescents. In clinical work not only pain but its interference with daily activities should be noticed.

Joint hypermobility and fibromyalgia in schoolchildren

OBJECTIVES

To test the hypothesis that joint hypermobility may play a part in the pathogenesis of pain in fibromyalgia, schoolchildren were examined for the coexistence of joint hypermobility and fibromyalgia.

METHODS

The study group consisted of 338 children (179 boys, 159 girls; mean age 11.5 years, range 9-15 years) from one public school in Beer-Sheva, Israel. In the assessment of joint hypermobility, the criteria devised by Carter and Bird were used. Any child who met at least three of five criteria was considered to have joint hypermobility. Children were considered to have fibromyalgia if they fulfilled the 1990 American College of Rheumatology criteria for the diagnosis of fibromyalgia, namely, widespread pain in combination with tenderness of 11 or more of the 18 specific tender point sites. The blind assessments of joint hypermobility (by AG) and fibromyalgia (by DB) were carried out independently.

RESULTS

Of the 338 children 43 (13%) were found to have joint hypermobility and 21 (6%) fibromyalgia; 17 (81%) of the 21 with fibromyalgia had joint hypermobility and 17 (40%) of the 43 with joint hypermobility had fibromyalgia. Using chi 2 statistical analysis, joint hypermobility and fibromyalgia were found to be highly associated.

CONCLUSIONS

This study suggests that there is a strong association between joint hypermobility and fibromyalgia in schoolchildren. It is possible that joint hypermobility may play a part in the pathogenesis of pain in fibromyalgia. More studies are needed to establish the clinical significance of this observation.