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January 6, 2009
Physiotherapy Approach to Benign Joint Hypermobility Syndrome
Collagen is an extremely important connective tissue protein in our bodies, making up significant amounts of our skin, tendons, discs and ligaments. Collagen gives structure to these organs, allowing them to heal normally, to have elasticity, to be strong and to hold together well under the stresses of functional life. It also gives our major blood vessels and other organs the strength they need to remain working correctly. People vary very greatly in the suppleness of their joints and skin and show the whole range from very stiff jointed to very mobile or “double jointed”.
An inheritable abnormality in the synthesis and metabolism of the collagen proteins is the cause of Ehlers-Danloss syndrome which affects the strength and function of the protein. EDS can occur in at least ten forms, but EDS Three is closely related to benign joint hypermobility syndrome, which is benign because the collagen changes do not affect important structures such as the arteries. Extreme joint hypermobility is the commonest sign with smooth skin and a poor ability for skin healing, with wider and thinner scars than normal.
Joint hypermobility syndrome exhibits a series of symptoms and signs including some fragility of the tissues, slower and poorer wound healing, a propensity to joint dislocations, flexible skin and hypermobility of the joints. Along with these findings patients often complain of multiple chronic joint pains which can develop into a pain syndrome. Poor muscle balance around the major joints causes instability and incorrect muscle patterning which can cause joint and muscle pain and limit the ability to do functional things. Contact sports or vigorous physical activities are not appropriate for this group of people.
Self management in hypermobility syndrome is the main aim of intervention, with patient education taking a strong role to equip the patient to manage their lifelong condition. Due to the abnormally large ranges of joint movement they are vulnerable to ligament or joint strain if they are held posturally at end range or moved with momentum. Hypermobile patients should practice joint protection like arthritic patients, avoiding party pieces like showing off with extreme movements or joint dislocations. Yoga or high momentum activities such as contact sports are particularly unsuitable for these patients.
The stresses and strains of daily life and recreational activities tend to result in more acute injuries and pain complaints in hypermobile patients which are managed by physiotherapy to the joints and muscles. Even in normal circumstances the shoulder is very mobile yet unstable but in hypermobile patients the lax connective tissue makes the joint very unstable and difficult to control. The shoulder and surrounding muscle must keep the large ball of the arm bone aligned with the small socket during large movements and this is difficult with hypermobility, leading to abnormal muscle patterns and pain. It is common to have pain due to this and to repeated dislocations.
Hypermobile patients complain commonly of neck, thoracic and lumbar pain, perhaps related to the difficulties keeping spinal stability and the correct muscle balances around the spine. Manipulation is likely to be unhelpful although mobilization techniques, general exercises, strengthening stability muscles and concentrating on core stability are all useful approaches. Gentle weight training can elevate muscle tone to allow the joints to be maintained in a mid range position during movement, avoiding too much play. Knee hyperextension is common and can lead to osteoarthritis, leading physiotherapists to work at the balancing muscles, the hamstrings, to counteract this. Patients often have a few areas of the body which need constant training for best muscle balance and control.
Overall, hypermobile patients have a challenging condition to manage, as over-stress of their joints in any activity can lead to pain. When their joints are stresses they respond by recruiting abnormal muscle patterns, allowing joints to be placed in unhelpful positions and causing them to suffer from end range strains. Patient education is the most important factor in self management, although physiotherapists can help with advice and postural training.
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