1. HYPERMOBILITY SYNDROME/EDS III
LORRAINE FRIEL
EXTENDED SCOPE PRACTITIONER
CENTRE FOR RHEUMATIC DISEASES
GLASGOW ROYAL INFIRMARY

2. HYPERMOBILITY & HYPERMOBILITY SYNDROME
Range of movement in excess of the accepted normal range of motion at a joint, taking into account the age, gender and ethnic background of the individual (Grahame 2010)
Musculoskeletal symptoms in the presence of generalised joint hypermobility but in the absence of other defined rheumatic diseases (Kirk et al 1967)

3. What is joint hypermobility syndrome?
Pereception of JHS as a mild or trivial condition with lax joints, pain, joint dislocation/subluxation, possible OA in later life.
This has changed…..
Now considered an inherited, genetically determined multisystemic disorder of connective tissues rendering them more vulnerable to injury and mechanical failure.
E effects of injury

4. WHAT IS HMS?
A family of related genetically based conditions. The protein affected varies and the degree of difference varies
Marfans Syndrome
Ehlers-danlos
Benign Joint Hypermobility syndrome

5. Presentation Chronic pain and kinesiophobia
Joint laxity,subluxations/dislocations
Vulnerability to injury
Rest at EOR/”lock” joints and poor posture habits
Dysfunctional movement patterns
Poor healing and slower recovery
Easy bruising and tendency towards bleeding

6. Non articular presentation
Fatigue
Deconditioning
Autonomic dysfunction
Pelvic organ prolapse
Urinary incontinence
Psychological
POTS

7. Examination Observation – skin, postural alignment Range of movement
Functional activities
Muscle testing
Neurological testing
Passive movement
Ligament integrity
Balance/proprioception

8. Good postural alignment
Muscular and skeletal balance which protects the supporting structures against injury and progressive deformity
Muscles function most efficiently
Optimum positions for thoracic and abdominal organs

9. Habitual postures Frequently rest at EOR and poor postural alignment
Stress and strain in HM collagenous tissues
Decreased muscle use leading to stiffness, weakness, deconditioning, fatigue

10. Poor postural alignment
Faulty relationship produces stress and strain on supporting structures
Less efficient balance

11. Active movement Look well Move well
Subjective and objective often at odds
Check ‘normal’ range for that patient

12. Assess muscle function
Breathing
Transversus abdominus
Deep multifidus
Pelvis floor
Timing, atrophy, loss of tonic function, loss of co-ordination, asymmetry, length
Overactivity in globa, muscles – quads, latissimus, pects, obliques, erector spinae

13. Muscle strategy High load strategy for low load task
Produces excessive compression, loss of mobility, loss of shock absorbtion
Tendency to rely on ‘ankle strategy’ to maintain balance

14. Functional movement testing
One leg stand
Standing knee bend
Walking
Heel raise
Sit to stand

15. Management
Time – listen to story, answer questions, identify needs/expectations, address fears/barriers
Communication – greater benefit and cost effectiveness when patients who expressed apreference received their preferred treatment
Reassurance – finally have diagnosis, not life threatening, can be proactive

16. Prioritise treatment Try to avoid chasing the pain
Patients expectations
Short and long term goals
Achievable
Enjoyable

17. Treatments Supports Tape
Pre-exercising readiness – breathing, relaxation, pain relieving modalities, manual therapy, posture re education

18. Correct movement dysfunction
Start in non weight bearing, pain free positions
Closed chain
Improve joint positioning and awareness

19. Joint stability and control
Challenge stability
Improve balance and coordination
Incorporate into weightbearing and functional positions
Introduce unpredictability using balance boards, wobble cushions, gym ball

20. Stretching
Often advised not to stretch –danger of overstretching/damage
Reassure and educate – good to stretch
Maintain muscle length, joint range, stretch out old injuries and muscle spasm
No stretching beyond their hypermobile range

21. Education
Be positive
Joint care – avoidance of unhelpful postures and activities
Pacing
Discuss lifestyle modifications – occupation, family life, sport, pregnancy and other health issues

22. General fitness
Encourage lifelong commitment to exercise and maintenance of good general fitness
Encourage normal activities and return to sport
Pilates, yoga, exercise in water, walking

23. Main aim of treatment Increase function Decrease disability
Self management
Treatment often takes longer(many affected areas, longer healing time, mismanaged in past)
Complete resolution rarely occurs

24. Contacts/resources www.hypermobility.org www.ehlers-danlos.org