Physiotherapy in Patients with Joint Hypermobility Syndrome
Posted in Fitness on January 5th, 2009Our ligaments, tendons, discs and skin are made up of forms of collagen, one of the most important structural proteins in our bodies. This gives our tissues the ability to heal, its elasticity, its integrity and its strength, allowing us to have strong and healthy joints and skin which will put up with the stresses life puts upon them. Collagen is also responsible for the strength and integrity of our arteries and many other bodily structures. Human populations show great variation in collagen function from those who are very stiff jointed to those who are very mobile jointed or “double jointed”.
Ehlers-Danloss syndrome is caused by an abnormality in the way collagen is produced and acted upon in the body, causing an inheritable deficiency in the strength of the substance. 10 forms of EDS are known to exist, with much overlap, and EDS Three is considered the same as benign joint hypermobility syndrome, called benign because the serious changes such as in the arteries are not present in this form. Very hypermobile joints are the most obvious sign of this syndrome, with a smooth, flexible skin which tends to heal slowly and scar poorly in terms of wide and thin scars.
Patients with joint hypermobility syndrome show various symptoms and signs: joint hyper-mobility; less skin strength; reduced healing of wounds; easy bruising; skin flexibility and likelihood to dislocate easily. Sufferers from this syndrome may develop a chronic pain syndrome with constant and persistent joint pain, with incorrect muscle balances leading to joint stability problems and poor muscle balance. Functionally hypermobile patients can be very limited in normal activities or suffer pain when undertaking them and are unable to join in with vigorous activities or contact sports.
Advice to patients is very important and education should be a priority to allow them to manage their condition over the long term. Avoidance of excessive or repeated heavy lifting and other movements which put stresses and strains on the hypermobile joints is important and patients should avoid end-range postures which strain the lax ligaments. Joint protection, as in arthritic joints, is essential and patients should avoid showing off by performing “party pieces” such as dislocating a joint voluntarily or other extreme tissue manoeuvres. Stretching the joints strongly may worsen the underlying problems, and any activity carrying high risk of skin damage should be avoided.
As it takes far less trauma to damage a hypermobile joint than a normal one the incidence of acute injuries is higher in these patients as they go about their daily activities. The joint injuries and general painful problems which occur are managed by physiotherapy intervention. The shoulder is a highly mobile but unstable joint in the best circumstances and in hypermobile patients it presents particular problems of stability. The socket is small and the shoulder girdle muscle control must keep the humeral head aligned against it, difficult if the pattern of muscle action is abnormal. Repeated subluxation or dislocation with consequent pain is common and difficult to treat.
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.