Exercise beliefs and behaviours of individuals with Joint Hypermobility syndrome/Ehlers-Danlos syndrome - hypermobility type

An online pain management program for people with hypermobile Ehlers-Danlos Syndrome or hypermobility spectrum disorder: a three-staged development process

PURPOSE

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs.

MATERIALS AND METHODS

A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS).

RESULTS

396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability".

CONCLUSIONS

A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

Effects of compression garments on balance in hypermobile Ehlers-Danlos syndrome: a randomized controlled trial

PURPOSE

To evaluate the immediate and 4-week effects of compression garments (CG) on balance using a force platform during 8 different visual, static, and dynamic conditions in hypermobile Ehlers-Danlos Syndrome (hEDS) patients.

METHODS

Thirty-six participants were randomly assigned to a group: physiotherapy alone (PT, n = 19) or physiotherapy and daily CG wearing for 4 weeks (PT + CG, n = 17). Both attended 12 physiotherapy sessions (strengthening, proprioception, and balance exercises) for 4 weeks. Primary outcome: sway velocity of the centre of pressure (COP) measured before, immediately with the CG, and at 4 weeks. Secondary outcomes: ellipse area, Romberg quotient, and pain.

RESULTS

Sway velocity in dynamic conditions decreased immediately with the CG. After 4 weeks of intervention, sway velocity (95% CI 4.36-39.23, effect size 0.93) and area (95% CI 146-3274, effect size 0.45) on the laterally oscillating platform with eyes-closed improved more in the PT + CG group than the PT group. Romberg quotient on foam cushion improved more in the PT + CG than the PT group. Pain decreased in both groups after 4 weeks with no between-group difference.

CONCLUSION

CG combined with physiotherapy improved dynamic balance measured with COP variables significantly more than physiotherapy alone in people with hEDS.

TRIAL REGISTRATION

NCT03359135.

The use and effectiveness of exercise for managing postural orthostatic tachycardia syndrome in young adults with joint hypermobility and related conditions: A scoping review

PURPOSE

Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. It may occur in isolation, but frequently co-exists in individuals with hypermobile variants of Ehlers-Danlos Syndrome (EDS) and related conditions (chronic fatigue syndrome [CFS] and fibromyalgia). Exercise is recommended for non-pharmacological POTS management but needs to be individualised. This scoping review explores the current literature on use and effectiveness of exercise-based management for POTS, with specific focus on individuals with joint hypermobility and related conditions who experience hypermobility, and/or pain, and/or fatigue.

METHODS

A systematic search, to January 2023, of Medline, EMBASE, AMED, CINAHL and the Cochrane library was conducted. Studies that reported on adolescents and adults who had been diagnosed with POTS using standard criteria and underwent an exercise-based training intervention were included.

RESULTS

Following full-text screening, 10 articles were identified (2 randomised control trials, 4 comparative studies and 4 case reports). One comparative study reported a small subset of participants with EDS and one case report included an individual diagnosed with CFS; the remainder investigated a wider POTS population. Overall, 3 months of endurance followed by resistance exercise, graduating from the horizontal-to-upright position reduced POTS symptoms and improved quality-of-life.

CONCLUSION

The findings highlight a paucity of higher-level studies documenting exercise for POTS management in people with joint hypermobility and related conditions. Results from the wider POTS population demonstrate exercise is safe and effective. Large, well-designed clinical studies exploring exercise for POTS management adapting to meet the complex musculoskeletal and non-musculoskeletal features of symptomatic joint hypermobility are needed.

Perspectives of the World Health Organization's physical activity guidelines among patients with musculoskeletal conditions: A mixed-methods survey

INTRODUCTION

Physical activity (PA) promotion is a core element of musculoskeletal rehabilitation. Many people with musculoskeletal conditions do not meet PA guidelines, such as those provided by the World Health Organization (WHO). This study aimed to explore the level of awareness and perspectives on the WHO PA guidelines among people with musculoskeletal conditions and identify how patients can be supported with PA in clinical practice.

METHODS

A mixed-method cross-sectional survey was conducted using a uniquely developed questionnaire, which was disseminated to patients attending outpatient physiotherapy or occupational therapy appointments. The questionnaire collected data on participant characteristics, awareness and perspectives on the WHO guidelines and suggestions for supporting patients with PA in clinical practice. Descriptive statistics and content analysis were used to analyse the quantitative and qualitative data respectively.

RESULTS

One-hundred and two responses were included in the analysis. Forty-two percent of respondents were aware of the guidelines, 50% knew why they existed and 53% felt they were achievable. Perspectives varied, ranging from the guidelines being positive and aiding motivation to being unachievable. Some respondents felt an individualised approach is required. Suggestions for supporting patients with PA included facilitating social support, providing education, exercise groups and personalised advice, and signposting to community services.

CONCLUSION

There is limited awareness of the WHO PA guidelines and a variety of perspectives on the guidelines among patients with musculoskeletal conditions. There is a need to enhance the promotion of the guidelines in clinical practice, whilst considering local context and individual patient's circumstances.

A qualitative study of pain and related symptoms experienced by people with Ehlers-Danlos syndromes

Introduction

Individuals with Ehlers-Danlos syndromes (EDS) often have complex and multi-faceted symptoms across the lifespan. Pain and the related symptoms of fatigue and sleep disorders are common. The objective of this qualitative study was to understand how participants manage their pain and related symptoms.

Methods

The design was a qualitative thematic content analysis. Twenty-eight interviews were conducted to collect data from individuals who were participants in a prior quantitative longitudinal study. A semi-structured interview guide was designed to focus on and understand the trajectory of pain, sleep, fatigue, and general function. The interview continued with questions about coping mechanisms and obstacles to maintaining a sense of well-being.

Results

Symptoms reported by participants were widespread and often interwoven. Pain was universal and often resulted in fatigue and disordered sleep which impacted physical function. Most participants reported that their symptoms worsened over time. Participants reported a wide range of effective interventions and most reported developing self-care strategies to adapt to their disabilities/limitations. Solutions included complementary interventions discovered when conventional medicine was unsuccessful. Very few relied on a "system" of health care and instead developed their own strategies to adapt to their disabilities/limitations.

Discussion

EDS symptoms are often debilitating, and their progression is unknown. For most participants, symptoms worsened over the time. Even though participants in our study, by experience, were self-reliant, the importance of knowledgeable medical providers to help guide self-care should be emphasized.

A novel method of assessing balance and postural sway in patients with hypermobile Ehlers-Danlos syndrome

Patients with hypermobile Ehlers-Danlos syndrome (hEDS) frequently suffer from poor balance and proprioception and are at an increased risk for falls. Here we present a means of assessing a variety of balance and postural conditions in a fast and non-invasive manner. The equipment required is commercially available and requires limited personnel. Patients can be repeatedly tested to determine balance and postural differences as a result of disease progression and aging, or a reversal following balance/exercise interventions.

A Comprehensive Review: Chronic Pain Sequelae in the Presence of Ehlers-Danlos Syndrome

PURPOSE OF REVIEW

Patients diagnosed with Ehlers-Danlos syndromes (EDS), and especially those with the hypermobility subtype, often experience a diverse range of acute and chronic pain conditions throughout their lifetime. These can present in a variety of different phenotypes and comorbidities, making it difficult to develop structured treatment protocols. This review seeks to summarize the current literature to address old and novel treatments for EDS.

RECENT FINDINGS

Historically, medications and surgery have been used to treat patients with EDS but with low efficacy. Newer therapies that have shown promising effects for both decreasing pain and increasing quality of life include physical/occupational therapy, transcutaneous electrical nerve stimulation units, trigger point injections, low-dose naltrexone, and laser therapy. In addition, addressing the psychosocial aspects of pain with EDS through methods like cognitive behavioral therapy and patient education has shown to be vital in minimizing pain. Most research also emphasizes that pain management should not only focus on pain reduction, but on helping reduce symptoms of hypermobility, central sensitization, and fatigue to make an impactful difference. Research on pain in EDS is still limited with good clinical practice guidelines often limited by poor sample size and lack of clinical studies. Treatment options should be structured based on the specific type of pain pathology and presenting symptoms of each patient and their comorbidities. Future research should attempt to prioritize larger sample sizes, clear definitions of EDS subtypes, randomized trials for treatment efficacy, and more studies dedicated to non-musculoskeletal forms of pain.

Rationale and Feasibility of Resistance Training in hEDS/HSD: A Narrative Review

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are genetic conditions characterized by increased joint hypermobility, often in the presence of other signs or symptoms if syndromic. This hypermobility can result in significant pain and ultimately decreased participation in recreational or competitive activity. Rehabilitation of patients with hEDS/HSD is not well understood, particularly since presentation can be relatively heterogenous. Regardless, more research is needed, particularly regarding resistance training, to allow patients with hEDS/HSD to participate in the activities they enjoy. The purpose of this narrative review is to provide an overview of the clinical features displayed by those with hEDS/HSD that have been found to be improved with resistance training in other populations, and to present the current evidence for resistance training in all types of study designs, ranging from case studies to randomized controlled trials.

An investigation of the control of quadriceps in people who are hypermobile; a case control design. Do the results impact our choice of exercise for people with symptomatic hypermobility?

Background

People with symptomatic hypermobility have altered proprioception however, the origin of this is unclear and needs further investigation to target rehabilitation appropriately. The objective of this investigation was to explore the corticospinal and reflex control of quadriceps and see if it differed between three groups of people: those who have symptomatic hypermobility, asymptomatic hypermobility and normal flexibility.

Methods

Using Transcranial Magnetic Stimulation (TMS) and electrical stimulation of peripheral nerves, motor evoked potentials (MEPs) and Hoffman (H) reflexes of quadriceps were evoked in the three groups of people. The threshold and latency of MEPs and the slope of the input–output curves and the amplitude of MEPs and H reflexes were compared across the groups.

Results

The slope of the input–output curve created from MEPs as a result of TMS was steeper in people with symptomatic hypermobility when compared to asymptomatic and normally flexible people (p = 0.04). There were no other differences between the groups.

Conclusion

Corticospinal excitability and the excitability at the motoneurone pool are not likely candidates for the origin of proprioceptive loss in people with symptomatic hypermobility. This is discussed in the light of other work to suggest the receptor sitting in hypermobile connective tissue is a likely candidate. This suggests that treatment aimed at improving receptor responsiveness through increasing muscle tone, may be an effective rehabilitation strategy.

Exploring pain mechanisms in hypermobile Ehlers-Danlos syndrome: a case-control study

BACKGROUND

The hypermobile type of Ehlers-Danlos syndrome (hEDS) is a heritable connective tissue disorder, associated with joint hypermobility and prominent chronic pain. Because experimental pain testing in hEDS is scarce, the underlying mechanisms are still poorly understood.

OBJECTIVE

The present study assesses endogenous pain facilitation and pain inhibition in hEDS, using a protocol for temporal summation of pain (TSP), conditioned pain modulation (CPM), and exercise-induced hypoalgesia (EIH).

METHODS

Twenty women with hEDS and 20 age-matched healthy controls participated. After evaluating thermal and mechanical pain thresholds (PPT), TSP was assessed using 10 repetitive painful pressure stimuli. CPM was provoked using pressure as the test stimulus and hand immersion in hot water (46°) as the conditioning stimulus. EIH was assessed after a submaximal cycling protocol.

RESULTS

The hEDS group demonstrated reduced PPTs and showed significantly more TSP after repeated painful stimuli than the control group. The increase in PPTs caused by the submaximal cycling protocol (EIH) did not reach statistical significance in the hEDS group. Furthermore, in comparison to the healthy control group, the hEDS group demonstrated significantly less EIH at the quadriceps test location. At the trapezius, EIH did not significantly differ between groups. No significant differences were found between the hEDS group and control group in the CPM response.

CONCLUSION

The results demonstrate increased TSP in hEDS, suggesting increased central pain facilitation. EIH should be studied more extensively, but may be disturbed when evaluated in working muscles. The CPM results are inconclusive and require more research.

The psychological burden associated with Ehlers-Danlos syndromes: a systematic review

CONTEXT

Ehlers-Danlos syndromes (EDS) are disorders of connective tissue that lead to a wide range of clinical presentations. While we are beginning to understand the association between EDS and psychological manifestations, it is critical that we further elucidate the relationship between the two. Understanding the correlation between EDS and mental health will better ensure swift diagnosis and effective treatment for patients.

OBJECTIVES

This study aims to systematically examine and report the prevalence of psychiatric disorders in the EDS population.

METHODS

The PubMed database was searched on June 14, 2021 for articles published from January 2011 to June 2021. We included original, evidence-based, peer-reviewed journal articles in English that reported information on psychiatric disorders among EDS patients. Psychiatric disorders and psychological conditions were limited to those included in the "psychology" and "mental disorders" Medical Subject Headings (MeSH) search terms defined by the National Library of Medicine. Publications identified utilizing this search strategy by M.K. were imported into the Covidence system, where they first underwent a title and abstract screening process by three independent reviewers (M.K., K.L., H.G.). During the full-text review, two independent reviewers read the full text of the questionable articles to assess their eligibility for inclusion. Studies were excluded if they did not meet our target objective or if they were not in English or if they were opinion pieces, conference abstracts, or review articles. Data were extracted from the shortlisted studies by reviewers. During the data extraction phase, the quality and risk of publication bias were assessed by two independent reviewers utilizing the National Institutes of Health (NIH) Study Quality Assessment Tools. Any disagreements in study selection, data extraction, or quality assessment were adjudicated via discussion between the two reviewers, utilizing a third reviewer as a decider if necessary.

RESULTS

Out of 73 articles identified, there were no duplicates. A total of 73 records were screened, but only 40 articles were assessed in full text for eligibility. A total of 23 articles were ultimately included, which collectively discussed 12,298 participants. Ten (43.5%) of the included studies were cross-sectional in design, three (13.0%) were case reports, and three (13.0%) were retrospective chart reviews. The remaining seven (30.4%) articles were either case-control, cohort, qualitative, controlled observational, or validation studies. Twelve (52.2%) of the studies reported data on depression disorders, six of which reported prevalence data. Nine (39.1%) of the studies reported data on anxiety disorders, five of which reported prevalence data. Studies that reported nonprevalence data presented odds-ratio, mean scores on psychiatric evaluations, and other correlation statistics. Psychiatric disorders that were most reported in these articles were mood disorders (n=11), anxiety disorders (n=9), and neurodevelopmental disorders (n=7). Although the reports varied, the highest psychiatric prevalence reports in EDS patients involved language disorders (63.2%), attention-deficit/hyperactivity disorder (ADHD) (52.4%), anxiety (51.2%), learning disabilities (42.4%), and depression (30.2%).

CONCLUSIONS

Although mood disorders were cited in more articles, the highest reported prevalence was for language disorders and ADHD. This discrepancy highlights the importance of performing more research to better understand the relationship between EDS and psychiatric disorders.

Exposure in Vivo as a Treatment Approach to Target Pain-Related Fear: Theory and New Insights From Research and Clinical Practice

Pain-related fear (PRF) can be a significant factor contributing to the development and maintenance of pain-related disability in individuals with persistent pain. One treatment approach to target PRF and related avoidance behavior is exposure in vivo (EXP). EXP has a long history in the field of anxiety, a field that is constantly evolving. This Perspective outlines recent theoretical advancements and how they apply to EXP for PRF, including suggestions for how to optimize inhibitory learning during EXP; reviews mechanistic work from neuroimaging supporting the targeting of PRF in people with chronic pain; and focuses on clinical applications of EXP for PRF, as EXP is moving into new directions regarding who is receiving EXP (eg, EXP in chronic secondary pain) and how treatment is provided (EXP in primary care with a crucial role for physical therapists). Considerations are provided regarding challenges, remaining questions, and promising future perspectives.

IMPACT

For patients with chronic pain who have elevated pain-related fear (PRF), exposure is the treatment of choice. This Perspective highlights the inhibitory learning approach, summarizes mechanistic work from experimental psychology and neuroimaging regarding PRF in chronic pain, and describes possible clinical applications of EXP in chronic secondary pain as well as in primary care.

Masterclass: Hypermobility and hypermobility related disorders

INTRODUCTION

Hypermobile joints display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility may present in a single joint, a few joints or in multiple joints and may be congenital or acquired with training, disease or injury. Hypermobile joints may be asymptomatic or may be associated with pain, fatigue, multisystemic complaints and significant disability. Furthermore, joint hypermobility may be a sign of an underlying hereditary disorder of connective tissue.

PURPOSE

This masterclass aims to provides a state-of-the-art review of the aetiology, epidemiology, clinical presentation, assessment and management of joint hypermobility and hypermobility related disorders using an evidence based and biopsychosocial approach. The new framework for classifying the spectrum of joint hypermobility disorders along with new diagnostic criteria for the hypermobile Ehlers Danlos syndrome, published by an international consortium of clinical experts and researchers in 2017 is integrated into the paper.

IMPLICATIONS FOR PRACTICE

People with joint hypermobility related disorders present to healthcare professionals with a wide range of symptoms which extend beyond the musculoskeletal system. Early recognition and treatment are key to effective management. A biopsychosocial and patient empowerment approach to functional restoration is recommended.

Updates on the psychological and psychiatric aspects of the Ehlers-Danlos syndromes and hypermobility spectrum disorders

The field of the psychiatric and psychological aspects of Ehlers-Danlos syndromes (EDS) has been understudied and neglected for many years. People with EDS are often classified as "somatizers" by untrained clinicians. However, research on the biological basis of EDS is improving our understanding of the physiology and psychopathology of the disorder. In this article, we consider the literature on the psychopathological dimensions associated with EDS as well as the EDS symptoms in psychiatric conditions since our review in 2017. Literature confirms that psychological processes (i.e., fear, emotional distress, or negative emotions) in EDS have a significant impact on the outcomes of EDS. Common systemic associations are found between anxiety disorders and EDS as well as significant correlations with neurodevelopmental, eating, mood, and sleep disorders. There is limited but increasing evidence of an association between EDS and suicidal thoughts and behaviors, which should be further explored. The broad spectrum of human anxiety and associated somatic symptoms (beyond anxiety disorders) appears to be the core of the psychopathology in EDS and therefore, detecting and assessing EDS might be a new opportunity for psychiatric nosology to develop more inclusive phenotypes like the Neuroconnective Phenotype that include both somatic and psychological manifestations.

Some cases of hypermobile Ehlers-Danlos syndrome may be rooted in mast cell activation syndrome

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.

Occupational Therapy Interventions for Clients with Ehlers-Danlos Syndrome (EDS) in the Presence of Postural Orthostatic Tachycardia Syndrome (POTS)

Postural orthostatic tachycardia syndrome (POTS) is often seen in clients with Ehlers-Danlos syndrome (EDS), primarily hypermobile EDS. Research has shown clients with EDS and POTS may experience limitations affecting not only their physical function, but also their social, emotional, and mental well-being. Using a client-centered approach, occupational therapy practitioners assess health, well-being, symptomatology (fatigue, muscle pain, dizziness, etc.), participation and engagement in occupation, and provide interventions to improve quality of life. This paper will address occupational therapy interventions to treat common symptomatology for clients with EDS in the presence of POTS, including environmental modifications, use of adaptive equipment and orthoses, exercise and fall prevention, energy conservation and pacing, sleep hygiene, and routine and habit development to promote optimal engagement in meaningful occupations.

Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different?

Diagnosing hypermobile Ehlers–Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18–73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18–26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.

A review of respiratory manifestations and their management in Ehlers-Danlos syndromes and hypermobility spectrum disorders

BACKGROUND

Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) are a heterogeneous group of heritable genetic connective tissue disorders with multiple characteristics including joint hypermobility, tissue fragility, and multiple organ dysfunction. Respiratory manifestations have been described in EDS patients, but have not been systematically characterized. A narrative review was undertaken to describe the respiratory presentations and management strategies of individuals with EDS and HSD.

METHODS

A broad literature search of Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL was undertaken from inception to November 2020 of all study types, evaluating EDS/ HSD and pulmonary conditions. This narrative review was limited to adult patients and publications in English.

RESULTS

Respiratory manifestations have generally been described in hypermobile EDS (hEDS), classical and vascular EDS subtypes. Depending on EDS subtype, they may include but are not limited to dyspnea, dysphonia, asthma, sleep apnea, and reduced respiratory muscle function, with hemothorax and pneumothorax often observed with vascular EDS. Respiratory manifestations in HSD have been less frequently characterized in the literature, but exertional dyspnea is the more common symptom described. Respiratory symptoms in EDS can have an adverse impact on quality of life. The respiratory management of EDS patients has followed standard approaches with thoracotomy tubes and pleurodesis for pleural manifestations, vocal cord strengthening exercises, continuous positive pressure support for sleep apnea, and exercise training. Reduced respiratory muscle function in hEDS patients responds to inspiratory muscle training.

CONCLUSION

Respiratory symptoms and manifestations are described in EDS and HSD, and have generally been managed using conservative non-surgical strategies. Research into the prevalence, incidence and specific respiratory management strategies in EDS and HSD is needed to mitigate some of the associated morbidity.

Developing a self-management intervention to manage hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS): an analysis informed by behaviour change theory

PURPOSE

Hypermobility Spectrum Disorders (HSD) and Hypermobile Ehlers-Danlos Syndrome (hEDS) are heritable connective tissue disorders associated with joint instability and pain, but with scant guidance for supporting patients. The aim was to determine recommendations for an HSD/hEDS self-management intervention.

MATERIALS AND METHODS

Barriers to self-management were mapped onto the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation-Behaviour (COM-B) model in a behavioural analysis. A modified Nominal Group Technique was used to prioritise behaviour change technique (BCT) interventions (n = 9 women).

RESULTS

Possible BCTs incorporated.

EDUCATION

Incorporating self-help strategies, education to improve their knowledge of HSD/hEDS, and how to judge information about HSD/hEDS.

TRAINING

In activity pacing, assertiveness and communication skills, plus what to expect during pregnancy, when symptoms can worsen.

ENVIRONMENTAL RESTRUCTURING AND ENABLEMENT

Support from occupational therapists to maintain independence at work and home.

MODELLED BEHAVIOUR

That illustrates how other people with HSD/hEDS have coped with the psychosocial impact.

CONCLUSIONS

This study is the first to apply theoretically-informed approaches to the management of HSD/hEDS. Participants indicated poor access to psychological support, occupational therapy and a lack of knowledge about HSD/hEDS. Future research should evaluate which intervention options would be most acceptable and feasible.Implications for rehabilitationPatients with Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome can be active partners in the co-design of behaviour change interventions.Behaviour change interventions should target psychological support and patient education, particularly patient information.Additional behaviour change interventions included environmental restructuring and enablement; adaptations to participants' environment with input from occupational therapy.Participants were keen to suggest opportunities for behavioural modelling; positive fist-person modelling narratives, written by those with HSD/hEDS, which addressed how they coped with the psychosocial impact of their condition.

Chronic Low Back Pain Occurring in Association With Hypermobility Spectrum Disorder and Ehlers-Danlos Syndrome

BACKGROUND

This review paper outlines recent advances in diagnostic criteria for hypermobility spectrum disorder (HSD) and its association with Ehlers-Danlos syndrome (EDS), as well as current literature on the association between joint hypermobility syndrome and lumbar back pain. We outline the optimal multidisciplinary management of lumbar back pain in the context of joint hypermobility syndrome, as well as the indications and possible side effects of surgical management of patients with these conditions.Several studies have suggested a link between chronic low back pain and hypermobility. HSD has been described as an excessive range of motion in a joint, when accounting for patient demographics. The nomenclature surrounding symptomatic joint hypermobility has varied historically, and various groups, including most notably the international EDS consortium, have introduced new classification schemes to acknowledge the systemic effects of joint hypermobility, which were previously poorly understood.

METHODS

Narrative literature review.

RESULTS

Not applicable.

CONCLUSIONS

Lower back pain experienced in patients on the HSD-EDS spectrum is multifactorial in origin and should not be considered solely in anatomical terms. Caution has been advised in the surgical management of patients on the HSD-hEDS spectrum, particularly where the subtype is unclear. The vascular type of EDS has a particular propensity for severe bleeding complications. Rates of perioperative complications after lumbar spinal surgery in the hypermobile EDS population have been reported to be up to 50%. When hypermobility and chronic lumbar back pain coexist, we advocate management in a multidisciplinary setting involving physiotherapists, pain physicians, surgeons, and psychologists.

Electromyographic muscle activity and three-dimensional scapular kinematics in patients with multidirectional shoulder instability

OBJECTIVE

To investigate differences in EMG muscle activity and scapular kinematics during elevation in the scapular plane between healthy controls, participants with multidirectional shoulder laxity (MDL), and patients with multidirectional shoulder instability (MDI) who are diagnosed with hypermobile Ehlers-Danlos syndrome (hEDS) or Hypermobility Spectrum Disorder (HSD).

METHODS

Twenty-seven women with hEDS/HSD and MDI, 27 female healthy control subjects, and 28 female subjects with MDL participated in this study. Scapular 3D kinematic data were obtained using 8 Oqus Qualisys cameras. Simultaneously, surface electromyography (EMG) was used to measure muscle activity of the upper, middle, and lower trapezius, infraspinatus, latissimus dorsi, serratus anterior, posterior deltoid, and pectoralis major during arm elevation in the scapular plane. Group differences were assessed using statistical parametric mapping.

RESULTS

Regarding scapular kinematics, significantly less upward rotation was observed in hEDS/HSD patients with MDI compared to both healthy controls and MDL subjects. Significantly less posterior tilt was seen in hEDS/HSD patients compared to MDL subjects. Furthermore, significantly higher EMG activity of the infraspinatus, middle trapezius, and posterior deltoid was found in hEDS/HSD patients with MDI.

CONCLUSION

hEDS/HSD patients with MDI demonstrate altered scapular kinematics and increased EMG muscle activity compared to subjects without MDI. These findings could serve as stepping stone for future research regarding treatment strategies in patients belonging to the hypermobility spectrum.

Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain

OBJECTIVES

A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability.

CONTENT

Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability.

SUMMARY AND OUTLOOK

It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

Validity of the self-reported five-part questionnaire as an assessment of generalized joint hypermobility in early pregnancy

Background

The assessment of generalized joint hypermobility is difficult due to differences in classification methods and in the performance of joint mobility assessment. The primary aim was to evaluate the validity of the self-reported five-part questionnaire, 5PQ, for identifying generalized joint hypermobility using the Beighton score as reference test. The secondary aim was to describe how joint angles measured in degrees included in the Beighton score varied in different cut-off levels in the self-reported 5PQ and the Beighton score.

Methods

A cross-sectional validity study with a total of 301 women in early pregnancy, mean age of 31 years, were included in the study. The participants answered the self-reported 5PQ before the joint angles were measured. To standardize the joint mobility measurement, a structural protocol was used. The sensitivity, specificity, receiver operating characteristic curve, area under curve, positive- and negative predictive value, positive likelihood ratio and Spearman’s rank correlation between the self-reported 5PQ ≥ 2 and the Beighton score ≥ 5 were used as main outcome measures in the validity analyses. Joint angles, measured in degrees, were calculated with means in relation to different cut-off levels.

Results

There was moderate correlation between the self-reported 5PQ and the Beighton score. The highest combined sensitivity, 84.1%, as well as specificity, 61.9%, was on 5PQ cut-off level ≥ 2, with a 38% false-positive rate, a moderate area under curve, a low positive predictive value and likelihood ratio, and a high negative predictive value. The odds of a self-reported 5PQ, cut-off level ≥ 2, among women with generalized joint hypermobility, Beighton ≥5, was low indicating a low post-test probability. The mean for all joint angles measured in degrees increased with increased cut-off levels, both in the Beighton score and in the self-reported 5PQ. However, there was a significant variation for each cut-off level.

Conclusions

There is uncertainty in identifying generalized joint hypermobility in young women using the self-reported 5PQ with a cut-off level of ≥2 when the Beighton score ≥ 5 is used as the reference test. The strength of the self-reported 5PQ is to rule-out women without generalized joint hypermobility.

Bone Disease in Patients with Ehlers-Danlos Syndromes

PURPOSE OF REVIEW

To summarize the bone findings, mainly bone mass and fracture risk, in Ehlers-Danlos syndromes (EDS).

RECENT FINDINGS

Low bone mineral density and fractures seem to be frequent in some of the rare EDS types (kyphoscoliotic, arthrochalasia, spondylodysplastic, and classic-like EDS). For the more prevalent hypermobile and classic EDS types, some case-control studies found mildly decreased bone mineral density, but it was not clear that fracture rates were increased. Nevertheless, abnormalities in vertebral shape seem to be common in classical and hypermobile EDS types. In a cohort of individuals with EDS followed since birth, no fractures were observed during infancy. Bone mineral density varies widely among the different types of EDS, and vertebral abnormalities seem to be common in classical and hypermobile EDS. It might be justified to perform spine radiographs and bone mineral density assessments in newly diagnosed EDS.

'I was cracking more than everyone else': young adults' daily life experiences of hypermobility and jaw disorders

Most studies on general joint hypermobility (GJH) and temporomandibular disorders (TMD) are quantitative and have concluded that joint hypermobility is a risk factor for development of TMD. The present qualitative study aimed to explore young adults' daily life experiences of GJH, specifically these relating to jaw function, and their experiences of medical and dental care providers. Semi-structured interviews were conducted with nine young adults (18-22 yr of age) and data were analysed using qualitative content analysis. The overarching thematic category that emerged was 'Hypermobility in daily life', which was broken into six subthemes and three themes: 'emotional perception', 'dealing with symptoms', and 'outside influences'. Participants' narratives centred on experiences of complex symptoms, awkward jaw function and joint noises, feeling different, and a lack of support from general medical and dental care providers. The findings show that young adults with joint hypermobility need early support from medical and dental care providers for managing their symptoms and conditions related to GJH. Future studies are warranted to develop guidelines for professionals in medical and dental care to detect and prevent forthcoming problems and to offer relevant support to hypermobile youths.

Recognizing and Effectively Managing Hypermobility-Related Conditions

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome-hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

Understanding the psychosocial impact of joint hypermobility syndrome and Ehlers-Danlos syndrome hypermobility type: a qualitative interview study

PURPOSE

Little attention has been paid to psychosocial factors in Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome (hypermobility type). This study sought to identify the psychosocial impact by examining participants' lived experiences; and identify characteristics of effective coping.

MATERIALS AND METHODS

Adults with Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome (Hypermobility Type) were invited to discuss their own lived experiences and the impact of the condition. All met recognized criteria for clinically significant joint hypermobility, and had a self-confirmed diagnosis. The transcripts were coded and analyzed using inductive thematic analysis.

RESULTS

Seventeen participants (14 women, 3 men) purposively selected to broadly represent different genders, ages and ethnicities. Analysis identified five key themes: healthcare limitations, a lack of awareness of Joint Hypermobility, and Ehlers-Danlos Syndrome (Hypermobility Type) among healthcare professionals; a restricted life; social stigma; fear of the unknown; and ways of coping.

CONCLUSIONS

The results highlight the significant psychosocial impact on participants' lives. Coping approaches identified included acceptance, building social networks, learning about joint hypermobility, and adapting activities. Physiotherapists supported regular exercise. Further research should consider potential interventions to improve information provision, address psychological support, and increase awareness of hypermobility among healthcare professionals.Implications for rehabilitationParticipants who had help from family members to complete activities described guilt and shame, highlighting the need for a greater rehabilitation focus on maintaining independence.Difficulties with sexual relationships due to prolapse or erectile dysfunction, and associated anxieties have indicated a need for greater awareness of these issues within primary care.The provision of reliable information and materials is vital, both for healthcare professionals and patients, to reduce misinformation and fear.Physiotherapists with knowledge of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome hypermobility type were cited as sources of support and hope, which helped people to cope with and manage their condition.