Hypermobility Spectrum Disorder and Ehlers-Danlos Syndrome

Hypermobility is often a general term given to those whose bodies are able to move and stretch more than is considered for the normal range of motion. In this blog I will mainly talk about the musculoskeletal (MsK) presentations of this disorder. You can get this at a local joint level or more generalised global joint level. Further reading can be from the EDS society.

Over the years in the UK, specialists like Rodney Grahame started to make the suggestion that for some, being hypermobile, could be a problem. He and his team noted there seemed to be a link between flexible or very flexible people and pain. He felt that it was often overlooked and that so much of the time these patients were being misdiagnosed and so mismanaged.

In the earlier days of diagnoses, Hypermobility Syndrome (HMS) was the name given to patients whose joints moved outside their normal range and also had pain. Diagnostic criteria such as the Beighton and Brighton scores were used. HMS was also called Hypermobility Type 3, which was part of the larger syndrome of connective tissue disorders called Ehlers-Danlos Syndrome or EDS.

Over time and with increased awareness, further understanding and renewed research, the original diagnostic thoughts are still used, with the additional of new criteria. The diagnosis given to patients has also changed and been broken down to more specific Hypermobility Spectrum Disorder (HDS) or Hypermobile EDS (hEDS). There are differences to each of these…

The main differences between HDS and hEDS are beyond the need for this paper and the differences need to be thoroughly looked at by a doctor/osteopath/physiotherapist/chiropractor with an interest in this area before a complete diagnosis is given. Having the correct diagnosis and treatment plan is more important that giving patients labels.

In a nutshell, and from a MsK point of view, both HSD and hEDS can make tissues more vulnerable to overstrain and injury. It can be painful, extremely frustrating and lead to fear and anxiety. I also think it is important to add here that pain is so much more complex than we used to think and it is not just a measure of increased pain equals more tissue damage.

Diagnosis

The diagnosis of HDS/EDS needs to be from a medical doctor or a qualified practitioner such as a registered osteopath, physiotherapist or chiropractor with a specialist interest.

A thorough case history, family history and examination needs to be completed to get a full understanding as to why the patient is suffering and to make a comprehensive diagnosis. The list of signs and symptoms linked to HSD/hEDS can be extensive.

A look at the conditions

For some with HSD or hEDS the symptoms could be at all levels of the spectrum from the very mild to more severe and/or all levels in-between.

A list of signs and symptoms could be long and could be widespread, but it covers chronic muscle, tendon, ligament or joint pain. This pain is often (although not always) relieved by rest. Ankles that sprain easily, clicky joints, a jaw that clicks. It may have been an incident (such as an ankle sprain) that his triggered a set of symptoms. Patients with HDS/hEDS are often clumsy, may get foggy thought patterns and fatigue more easily that others. Other symptoms that can coexist are palpitations, abomination concerns, anxiety, POTS (postural orthostatic tactical syndrome) or mast cell activation syndrome (MCAS).

Osteopathic TT for treatment for the severe HSD/hEDS patient ideally needs a team of like minded practitioners that address the needs of the patient.

From my point of view, Msk treatments need to be aimed at giving some pain relief and giving the patient strategies to manage their pain and movement patterns. I tend to avoid giving patients stretching to do as I feel that this could lead to more instability going forwards. This can lead to more chronic muscle tightness and pain as the body tries to protect itself by creating more tightness to stabilise itself.

I feel that osteopathy is great at providing relief for pain using gentle treatments and manipulation and some acupuncture. The more this is layered in with a gradual and progressive exercise programme to increase the patients capacity the better.

HDS/hEDS patients are a tough population to work with as there can be many bumps in the road of the journey. Just as they feel better, something else can start to become aggrieved. So, it is for this reason, that I feel that education for the patients is so key. For them to understand that pain is not always dangerous, it is just a message that is important. They need to be treated as a whole. They also need to also be aware of how vulnerable their bodies can be to changes that try to occur over and above the rate at which their body can adapt. Bodies can and do adapt. Those with HSD or hEDS can take longer to gain more capacity and resilience.

As our bodies gain greater capacity, they are able to deal with more. That is what strength and control is all about. Stretching does not give you greater ability to lift things in the garden or to bend to lift your child off the floor. Strength does!

From a movement point of view, aiming for efficiency and balance is useful so that one part of ones body is not talking all the hit for something else that is not working. Gait assessment can be useful to see what part of the patients gait makes the rest of their system struggle.

I often use the expression that I want people to have ‘reactive bodes’. What I mean by this is your bodies move and your muscles react to the movement. This sort of goes away from the ‘bracing’ model (unless you are picking 100kgs off the floor!!), which I am not sure I agree with.

By bracing or ‘pre-tensioning’ our body, it does not allow our body to move as it should and it isolates certain areas. Our bodies are amazingly integrated. When we move, no muscle EVER works by itself and so I am not sure how useful it is to isolate muscles when we exercise.


If you use a ‘Clam’ exercise as an example. This is when we lie on our side and lift the top leg up and down to ‘isolate’ and work your gluteus medius muscle. First of all, this muscle NEVER, ever works by itself when we move. But also, depending on your size and weight, the weight of your leg is not even close to what is needed to walk, run and squat etc. This muscle works as part of a ‘team’ of muscles and so are all best served working together as this is what happens when we move.

Having HDS/hEDS can certainly put challenges in front of you. There can be a few or many bumps along the road. But it does not mean that you cannot have a full life. As with many medical problems having a good mindset, a thorough understanding and having good capacity in your body all just helps. It is also ok to be frustrated with your body at times. Having a great bunch of people around you too massively helps.

Blog post by James Dodd BSc (hons) Ost. FAFS. Registered with the GOsC

Hypermobility and the Gut

Hypermobility Syndrome and Gut Problems

A few years ago, one of our osteopaths Annie Fonfé did her final year dissertation on ‘Hypermobility Syndrome and Bruxism’ (teeth grinding or clenching).  One of her questions she asked the patients was ‘did they or had they ever suffered with stomach problems or been diagnosed with IBS’.  She found that a significant portion of hypermobile patients did indeed suffer with stomach concerns of some description.

A recent study lead by Professor Aziz (Professor of Neurogastroenterology at Queen Mary Hospital of London) found that patients with hypermobility syndrome/disorder often suffer chronic abdominal pain and a range of gut symptoms.  They are frequently misdiagnosed, undiagnosed or wrongly diagnosed and have poor quality of life said Professor Aziz.  He went on to say that this observation allows us to provide a better explanation of symptoms to our patients and tailor our treatments more effectively.

Hypermobility syndrome is a major problem and it is often undiagnosed and so the patients are mismanaged.  Hypermobility can be helped to a greater extent if clinicians are aware of the bigger picture it can present with.  If it was understood to a more fully, patients could be more empowered to create strategies for self help as well as directed help towards the correct therapists.

Functional Exercise and Training – The Why and the What!

Tri-Plane Movement and Functional Training, these are both current words used to describe movement and training by the personal training and allied health professions (osteopath, physiotherapist, exercise physiologist and chiropractor). The health and fitness industry is going through yet another change, just like the swiss ball was the man of the moment in the 90′s, pilates and the core were the trend of the early 2000′s, many trainers and health professionals are now focusing on training movement rather than muscle, training functional exercises rather than non functional exercises, training groups of muscles rather than muscles in isolation.

What this means in simplistic terms is that trainers and health professionals etc are now moving away from the body building approach to training and conditioning (that is isolated weight training) and moving towards training that integrates movement with resistance that mimics upright function such as gait and other movement patterns that we perform on a daily basis i.e. squat, sit to stand, step up and down, push, pull & rotate. Trying to use gravity as the driver by doing exercise on your feet or upright, rather than on your back or in a machine stimulates your proprioception much more effectively than fixing an area, therefore creating the correct chain reaction needed for full and appropriate muscle function.

This does not suggest that one training approach or philosophy is better than the other, it fundamentally comes down to what the specific individuals goal is. For a body builder looking to compete, then traditional weight lifting techniques that have been proven to produce muscle gain is required. For the olympic power lifter, olympic lifts are practiced. For the sporting indivdiual, there will be likely a combination of functional movement exercises as well as some strength, olympic and powerlifting techniques. For the individual wanting to improve their overall wellbeing, strength and mobility, there is also likely to be a combination of the above.

So what does Tri-plane movement, functional training etc etc mean. Tri-Plane movement simply refers to movement in the three planes (sagittal, frontal and transverse planes). If we look at the individual who is standing upright, the best way to describe movement in the sagittal plane is forwards and backwards movement. Movement in the the frontal plane refers to side to side movement (that is laterally stepping or performing a lateral lunge). Movement in the the transverse plane is when movement occurs with rotation. That is, whilst standing you twist and turn to move or lunge backwards and laterally. Everyday movement occurs in all three planes at a bone and joint level and this is why there is this growing change in the way that training is being carried out. Previously most gyms and training programs were focused on training muscles in machines and/or functional training was restricted to movement purely up and down i.e squat movement or forwards (anterior lunge). As our understanding of functional biomechanics and movement improves, so does our training approaches and philosophy. Now days we are seeing more and more clients perform movements that involve all three planes of movement, involving less equipment and with movements that mimic real life activity.

Functional Training is probably one of the biggest buzz words in the health and fitness industry at this particular moment. There are many indivdiuals out there claiming to provide functional training. Functional training is certaintly not something that is new, rather it has been around for many many years and simply relates to training that mimics how we function. How this training relates to how we function will depend totally upon what and why we are training. For an individual who sits for their job for their entire life and wants to improve this, then training should focus on improving their ability to sit whilst working. For those individuals who are wanting to improve their everyday movement, that is sit, stand, walk, step up and down, squat, lunge etc etc, then training should reflect this. For the sporting individual, the training should mimic the sporting requirements, movements or athletic components that are that sport. So functional training has many meanings and therefore can be interpreted in many different ways.

For the general public, when we look at the body and how it functions, the most common movements or positions we are in involve walking (gait), sitting, standing, squatting, lunging, stepping up and down, single leg balancing, pushing, pulling and twisting. All of these movements are impacted by gravity and ground reaction force and these are two other factors that should be taken into consideration when prescribing a program. Gravity is something that we are always working against to remain upright. Therefore gravity is something that can easily be used to increase or decrease the degree of difficulty of an exercise. Ground reaction force relates to Newton’s laws and how force in one direction results in an equal and opposite amount of force in the opposite direction. This can be related to jumping and landing on the ground whereby an amount of force is exerted downwards and then the force will be transferred back into the legs and must be either shifted or absorbed by the body. So when it comes to functional training and tri-plane movement training, hopefully now you will have a little bit more of an understanding of what, why and how this might be prescribed in relation to yours or anyone else’s training program.

In our opinion, functional exercise should be used more and more when rehabilitating injuries or with patients post surgery. The more you get patient’s bodies working proprioceptively and in 3 planes, their bodies can start to ‘switch on’ to allow them to recover better and stronger.

To find out more about changing your training program, making it a little bit more functional in relation to your specific goals, incorporating exercises that involve training in all three planes, then contact Back to Back – The Earlsfield Osteopath on 020 8605 2323 or click here

Hypermobility part 2 (March 2012)

Hypermobility Syndrome – part 2

James Dodd

Part 1 of this article looked at giving readers a better understanding of Hypermobility Syndrome (HMS) and the implications it may have on the musculoskeletal system. Having a greater understanding of the common problems associated with hypermobility syndrome, how it is diagnosed and its relationship to other connective tissues disorders provides us with a solid base by which we can then go about developing a corrective exercise program. Part 2 aims to provide a more extensive look at assessing the hypermobile patient and taking a region specific approach to training. A detailed case history and screening process should alert you to any problematic areas or regions which may be predisposing, maintaining or aggravating your patient’s musculoskeletal problems. Static observation will help you to define any asymmetries in posture. Observation from all three views (frontal, lateral and posterior) will help you focus on areas of possible dysfunction. Functional testing in sagittal, frontal and transverse planes may highlight other areas of dysfunction

Muscle and Movement Testing

Carry out stretches and tests to identify weak, tight and shortened muscles. Take particular care in the hypermobile patient as range of movement may be much greater than expected. They are also good at ‘cheating’ to hide a dysfunctional area.

Assess functional activities such as gait, step up/down, lunge, squat, one leg stand and reach, anterior reach, posterior reach and push up for functional capability. Look for asymmetries, imbalances and glitches within the movement patterns to alert you to potential areas of dysfunction. Common causes of dysfunctional movements could be inhibited/over facilitated muscle activity in agonist/antagonist or synergistic muscles, tight and short or weak and lengthened muscles, hypo/hypermobile joints or body regions and balance, proprioception and coordination problems.

Always remember to seek advice from your patient’s general practitioner, osteopath or physiotherapist if you suspect any serious possible musculoskeletal problems or red flags.

A Regional Approach to Training the Hypermobile Patient

Common presenting features in the hypermobile patient include the following:

Shoulder, hip, neck, lower back, knee and foot pain

Poor body awareness, balance and proprioception

Flat, pronated feet

Hyperextended knees

Anterior pelvis

Clicking/popping joints

Hyperkyphotic or reduced movement in the thoracic spine. This could also be chronic muscle spasm

Tight and shortened hamstrings, gastrocnemius, iliotibial band, tensor fascia lata, pectoralis major/minor muscles

Weak anterior deep neck muscles, iliopsoas, core stabilizers and gluteals

Poor core stability

Upper rib breathing and poor diaphragmatic breathing

A good case history, observation and assessment should highlight any areas of dysfunction and will help you to focus on devising a program that will help restore optimal health and posture. Foam rollers, static stretching, active stretching and Muscle Energy Techniques (MET) are treatment strategies that can help stretch, activate and restore muscle balance. Remember to train the patient as a whole. The body works as one, and all systems are connected. Therefore, any one problem or area can predispose to a dysfunction elsewhere. The tissues are generally weaker and more vulnerable to injury than the non-hypermobile patient.

Hypermobility and the Lower Back

Poor overall functional stability is common among those individuals with lower back pain. In conjunction with poor stability, the hypermobile patient may also have poor kinesthesia and proprioception.

Focus training on:

Improving body awareness (anterior and posterior tilting of the pelvis)

Finding neutral spine

Teaching diaphragmatic breathing

Activating core muscles

Incorporating core muscle activation into functional activities

Balance, proprioception and coordination

Look for an ability to activate the core muscles:

Without co-contraction of more global muscles such as the rectus abdominis and external oblique muscles

Independently breathing

Diaphragmatic breathing? (often you will observe upper chest breathing)

Exercises that will be useful for the patient with core stability issues include:

Anterior and posterior tilting of the pelvis (standing, supine).

Core muscle activation (supine, prone, side-lying and four-point kneel).

Core muscle activation standing, seated.

Remember to isolate muscle activation and then integrate into functional activities.

Hypermobility and the Neck

Hypermobile patients may present with a history of neck complaints, ranging from the acute ‘wry’ neck to chronic neck pain. Individuals may present with an upper crossed syndrome pattern, which could be predisposed, maintained and aggravated by hypermobility, work and lifestyle postures such as sitting and slouching.

Look for:

Forward head posture (chin poking forwards)

Increased kyphosis (rounding) through the thoracic spine and Cervico-Thoracic C7/T1 region (base of the neck)

Reduced mobility through the thoracic and cervical spine

Tight upper trapezius, levator scapular, pectoral minor, sternocleidomastoid and scalene muscles

Weak rhomboids, lower trapezius and deep anterior neck flexors

Winging, elevated or protracted scapulars. Look for asymmetries in static

observation, movement and muscle weakness in shoulder stabilizers

Focus training on:

Lengthening short and tightened muscles

Strengthening weak muscles

Activating inhibited and de-facilitating over active muscles

Balance, proprioception and coordination

Exercises that will be useful for the patient with upper crossed syndrome and neck pain include:

Scapular retraction and setting

Ys and Ts exercise

Other useful exercises that aim to improve mobility of the neck, strengthen deep anterior neck flexors and increase body awareness include:

Chin tucks (similar to an emu neck movement)

Isometric neck flexion (using soft ball to push head against)

Isometric lateral neck flexion (using soft ball to push head against)

Pulling shoulder blades backwards and down, whilst lifting sternum to the roof

For more information on isometric neck exercises, see Paul Chek’s “How to Eat, Move and Be Healthy!”

Hypermobility and the Shoulder

The shoulder is the most unstable joint in the body, and often the hypermobile person will have a glenohumeral joint and/or scapulothoracic joint dysfunction. Problems may develop due to poor neuromuscular control, increased laxity of the capsule and rotator cuff weakness. Individuals may also present with subacromial impingement signs and symptoms. In some circumstances, your patient may require referral to an osteopath or physiotherapist to rehabilitate and teach correct scapulothoracic setting and glenohumeral positioning before commencing an exercise program. Focus training on:

Scapulothoracic setting

Rotator cuff strengthening

Stretching tight and shortened muscles i.e. pectoralis major and minor

Strengthening weak muscles i.e. serratus anterior, rhomboids, lower trapezius

Training functional exercises which address adjacent areas (cervical, thoracics, lumbars and hip/pelvis), muscular slings, synergistic and agonist/antagonist muscles

Hypermobility and the Hip

Like the shoulder, the hip is a ball and socket joint that has a large range of movement. It is essential that the neuromuscular, active and passive systems are working effectively to allow adequate movement and yet stabilize the region sufficiently. The hypermobile person is more likely to suffer from clicking/popping hip. The exact cause of this could vary from an intra to extra articular causes such as a tight iliopsoas to a labral tear or loose body. It may or may not be associated with pain. In those individuals presenting with extreme or constant pain, refer them off to the GP, sports medical doctor, osteopath or physiotherapist for further assessment. Typically, hypermobile patients will have poor control of their hip, pelvic and lumbar regions, and these often need to be addressed to correct any imbalances and prevent further problems developing.

Focus training on:

Lumbar (lower back) stability

Hip stability

Weak iliopsoas

Weak gluteus medius and maximus

Tight hamstrings, iliotibial band, tensor fascia lata

Balance, proprioception and coordination

Hypermobility and the Knee

Patellofemoral problems are common in hypermobile individuals. The cause of patellofemoral problems can be both structural and non-structural related. Common causes include a variable Q angle, genu varum, increased foot pronation and biomechanical and muscle imbalances.

Focus training on:

Tight iliotibial band, tensor fascia lata, hamstrings, gastrocnemius

Weak vastus medialis, gluteal muscles

Pronation and supination foot

Balance, coordination and proprioception

Exercises that will be useful for the client include:

Seated heel presses (helps to activate vastus medialis)

Foam rolling ITB and quadriceps muscles

Exercises that will be useful for the patient include:

Seated heel press (helps to activate vastus medialis)

Lunge – Forward

Lunge – Multiplanar

Squat – Against Wall with SB

Squat Touchdown – 1 Leg

Step Up to Balance – Frontal Plane

Hypermobility and the Foot

Pronated (flat) feet is common in the hypermobile patient. Over pronating can lead to problems with the subtalar joint, mid and forefoot, possibly causing plantar fasciitis and other problems up the biomechanical chain. Over pronation will cause internal rotation of the tibia and fibula, therefore potentially creating dysfunctions further up the chain at the knee, hip/pelvis and lower back. Individuals with flat feet may benefit from an exercise program or orthotics prescription.

Focus training on:

Tight plantar fascia, gastrocnemius and soleus muscles

Activation and control of tibialis anterior, peroneal muscles

Tight iliotibial band and weak gluteal muscles

Balance, coordination and proprioception

Exercises that will be useful for the patient include:

Active plantarflexion and dorsiflexion of the foot

Rolling feet inwards (pronation) and outwards (supination)

Single leg balance (stable to labile surface i.e. wobble board, bosu ball)

Swiss ball squat with ball between the knees finishing with standing on toes

Exercises that will be useful for the patient include:

Side to Side Hip Swing (Hip)

Balance Hold 1 Leg – Overhead Anterior Reach

Balance Hold 1 Leg – Overhead Posterior Reach

Hypermobility and Balance and Proprioception

Hypermobile individuals are likely to have poor balance, proprioception and kinesthesia. Exercises that challenge these components will translate over to improvement of general daily activities and reduce the likelihood of injury.

Exercises that will be useful for the patient include:

1 Leg Balance

1 Leg Balance Reach (anterior, posterior, lateral)

Balance Hold 1 Leg – Overhead Anterior Reach

Balance Hold 1 Leg – Overhead Lateral Reach

Step Up to Balance – Frontal Plane

Equipment such as wobble boards, Bosu Balls, cones, Airex Balance Pad, Swiss ball, Theraband, etc. can be added to further challenge balance and proprioception.

References:

Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.

Gray, G. Functional Video Digest Series

Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.

Janda, V. Muscle Function Testing, Butterworths, London, 1983.

Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.

Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.

Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.

Osar, E. Complete Hip & Lower Extremity Conditioning.

Osar, E. Complete Shoulder & Upper Extremity Conditioning.

Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.

Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism

Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

www.ehlers-danlos.org <http://www.ehlers-danlos.org>

www.hypermobility.org <http://www.hypermobility.org>

www.marfan.org <http://www.marfan.org>

www.marfanssyndrome.net <http://www.marfanssyndrome.net>

www.medicinenet.com/hypermobility_syndrome <http://www.medicinenet.com/hypermobility_syndrome>

http://medlineplus.gov/

www.oif.org <http://www.oif.org> (Osteogenesis Imperfecta)

www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http://www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html>

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Hypermobility pt 1 (January 2012)

Hypermobility Syndrome – part 1

James Dodd

There is Hypermobility and Hypermobility Syndrome (HMS). Hypermobility syndrome is the hypermobile patient with symptoms. Not all hypermobile patients are, or ever become symptomatic. HMS is a condition many individuals often experience their entire lives without ever having it diagnosed and managed correctly. Hypermobility has certain implications for the joint itself, as well as the surrounding ligaments, bones, joint capsules, muscles and tendons. It is important for a hypermobile patient’s well-being that they have effective neuromuscular control and active and passive systems that can support the joints in the body. Hypermobile joints by definition are those “displaying a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual.” Hypermobility Syndrome, also known as Joint Hypermobility Syndrome or Benign Hypermobility Syndrome, is defined as ‘generalized joint laxity with associated musculoskeletal complaints in the absence of any systemic disease’. HMS is an inherited form of a connective tissue disorder. Those with Hypermobility Syndrome are believed to experience pain as a result of joint microtrauma, which has been caused by overuse and/or misuse of the tissues in which there is an inherent weakness in the collagen.

It’s signs and symptoms are so often missed and so it goes undiagnosed and so is mismanaged. This means the suffering patient can go on suffering unnecessarily.

Common Features of Hypermobility

•Females are often more mobile than males.

•Mobility varies amongst ethnicity (Asian populations seem to be more affected than European populations).

•Mobility decreases with age.

•Hypermobility can be inherited or acquired i.e. repeated subluxation of the shoulder joint.

•Hypermobility Syndrome is typically determined by the genetic make up of the individual, in particular the genes causing hypermobility are those that are responsible for the production of collagen, elastin, fibrillin and tenascin.

•Certain sports and activities (i.e., gymnastics, ballet dancing, swimming) have shown to have a greater number of individuals with hypermobility.

•Musculoskeletal regions commonly affected include the achilles tendon, patellofemoral joint, rotator cuff, carpal tunnel, cervical and lumbar spine (non specific lower back pain and medial and lateral epicondyles.

•Hypermobile individuals may suffer from clicking, spondylolithesis and pars fractures.

•Hypermobility is a risk factor for the development of early Osteoarthritis.

•Fibromyalgia is commonly diagnosed in individuals with Hypermobility Syndrome

Diagnosis

The Beigton Score System (below) is a 9-point scale originally introduced to recognize hypermobile patients within the population. Primary health care practitioners now use it as a common screening process to help determine whether an individual has hypermobility.

•Passively dorsiflex 5th metacarpophalangeal joint to > 90 degrees (2 points)

•Passively take thumb to forearm (2 points)

•Passive hyperextend the elbow to > 10 degrees (2 points)

•Passively hyperextend the knee to > 10 degrees (2 points)

•Actively place hands flat on floor without bending the knees (1 point)

There can be a total score of 9. The revised diagnostic criteria for hypermobility requires you to get a Beigton score of 4/9 and have arthralgia (joint pain) for longer than three months in more than four or more joints.

There is also the Brighton Criteria that aids in the diagnosis of Hypermobility Syndrome. These include:

Dislocation and/or subluxation in more than one joint and on one or more occasions.

Abnormal skin: striae, thin skin, increased stretch of skin.

Eye signs: drooping eyelid or myopia

Varicose veins, hernia, or uterine/rectal problems

Soft tissue rheumatism (i.e., epicondylitis, tenosynovitis, synovitis)

Hypermobility and Connective Tissue Disorders

Marfan’s Syndrome, Ehlers-Danlos Syndrome and Osteogenesis Imperfecta are each genetic disorders in which the connective tissue of the individual is affected. Each disorder is different in its epidemiology, incidence and clinical presentation. While it is beyond the realm of this article to discuss each of these conditions in detail, if you have a patient with one of these disorders, you should conduct further reading in order to gain a better understanding of the disorder, its implications and how you can alter your training program to better suit your patient.

Rehabilitation and Exercise Prescription

Management of the patient will largely depend upon his/her age, current physical condition, hypermobility state and personal goals. The primary aim of dealing with any hypermobile patient should be to reduce disability and increase function. This should incorporate a holistic approach which addresses not only the fitness components but also addresses dietary, work and other lifestyle components.

Hypermobility and Acute or Chronic Injury

The acute hypermobile client should be managed like any other acute musculoskeletal injury. During the acute stages, you should be aiming to reduce swelling, inflammation, pain and restrict any aggravating or maintaining factors. Always refer your patient to a medical practitioner or hospital if you suspect anything serious. In the sub-acute or chronic hypermobile patient, the aim should be to restore normal function and reduce pain to a comfortable level. This could range from prescribing an exercise program to referring your patient for specific treatment from a GP, Physiotherapist, Osteopath or Podiatrist. It is always best to seek treatment from a practitioner that that works with and understands the implications of HMS. Failing to correctly manage with your client’s sub-acute/chronic injury could result in the development of compensatory patterns, which in turn could lead to problems developing elsewhere.

Program Design

Training the hypermobile patient requires special attention to certain training principles. You need to consider all joint, muscle and ligament actions when training, making sure that you train throughout the entire range of movement and training the muscles for isometric, isotonic, concentric and eccentric actions.

Stability of a joint is determined by the integrity of the musculoskeletal system (muscle, tendon, capsule, ligament and articular surfaces) and the neural control system (motor and sensory). It is important to address these aspects when devising a program in order to develop optimum function.

The key fitness components that need addressing in the hypermobile client include:

Proprioception

Balance

Coordination

Kinesthesia

Core stability

Endurance

Strength

Controlled flexibility

Cardiovascular fitness

Each of these fitness components requires extra attention in clients with Hypermobility Syndrome. However, each program will differ considerably depending upon each patient (i.e., client age, current physical state, hypermobility and goals). Programs could range from being as simple as improving one’s functional state (i.e., daily living activities such as walking, squatting, sitting up and down) to training elite athletes. Essentially, you will need to assess each case individually and design a program specific to the client’s needs.

Your program should try to:

Train function. Include functional activities such as push/pull, step up/down, squat, lunge and rotation exercises in your program.

Strengthen muscles equally and ensure there is a balance among agonist, antagonist and synergistic muscles.

Train movements rather than muscles, when possible.

Progress from slow to fast, stable to unstable, simple to complex, non weight bearing to weight bearing, closed chain to open chain, one plane to multi plane.

In Part 2 of this article, I will be taking a more in depth look at the individual assessment of the hypermobile patient and how we can deal with the common musculoskeletal issues one may have. The article has been divided into bodily regions, outlining what we should be looking for in the assessment, how this interacts with other regions of the body and how we can go about correcting these problems.

References:

Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.

Gray, G. Functional Video Digest Series <http:> </http:>

Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.

Janda, V. Muscle Function Testing, Butterworths, London, 1983.

Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.

Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.

Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.

Osar, E. Complete Hip & Lower Extremity Conditioning.

Osar, E. Complete Shoulder & Upper Extremity Conditioning.

Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.

Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism <http:> .</http:>

Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

www.ehlers-danlos.org <http:> </http:>

www.hypermobility.org <http:> </http:>

www.marfan.org <http:> </http:>

www.marfanssyndrome.net <http:> </http:>

www.medicinenet.com/hypermobility_syndrome <http:> </http:>

http://medlineplus.gov/

www.oif.org <http:> (Osteogenesis Imperfecta)</http:>

www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http:></http:>

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