Awareness of Hypermobility in the Clinic

I recently had three clients present with recurring spinals symptoms, for which they had been receiving manipulative therapy for varying degrees of time. They were finding that their symptom control was becoming less and less with this form of intervention. I will often see a client with this presentation, but what was different with this group, was their young age and ease of symptom provocation.

After a comprehensive examination, it was determined they had no underlying red flag pathology, not PMH or history of trauma, but they all had benign hypermobility syndrome.

A hypermobile joint is one whose range of movement exceeds the norm for that individual, taking into consideration age, sex and ethnic background. Joint mobility is limited by ligamentous structures. Thus hypermobility occurs as a result of a dysfunction in the ligamentous tissues. Hypermobility may be inherited or acquired. Athletic groups like gymnasts and dancers through training programs can increase their joint flexibility.

Joint mobility is maximal at birth, declines rapidly in childhood and then more gradual through adulthood. Women are generally more lax than males and there is a wide variation in ethnic groups.

Traditionally the Beighton Score measured hypermobility, but this scale has significant limitations and has been improved upon by the Brighton scale.

Assessment Scores

Beighton Score 1988

The Beighton Score has long been the most common form for hypermobility assessment. A score of 5 or more is considered a positive finding of hypermobility. Noted limitations of this scoring system include;

  1. If the score involves < 5 joints (pauci-articular) it may not be flagged as being significant
  2. It doesn't take into account other related clinical features of hypermobility (neurophysiological, connective tissue & autonomic)
  3. It doesn't indicate/grade the severity of hypermobility (either yes or no)
  4. It doesn't evaluate all commonly involved joints (e.g. missing out the hips and shoulders)

Brighton Criteria 2000

For these reasons the scoring system was re-evaluated and the Brighton
Criteria were created in attempt to correct these deficiencies.

Major Criteria

  • A Beighton score ≥ 4/9 (currently or historically)
  • Arthralgia for longer that 3 months ≥ 4 joints

Minor Criteria

  • A Beighton score of 1, 2, or 3/9 (0, 1, 2 or 3 if aged 50+)
  • Arthralgia > 3/12 in 1-3 joints or back pain or spondylosis, spondylolysis/thesis
  • Dislocation in more than one joint, or more than once in the same joint
  • Three or more soft tissue lesions (e.g. bursitis, epicondylitis, tendonitis)
  • Marfanoid habitus (tall, slim, Arm Span to Height ratio > 1.03, Hand length to Height ratio > 11%, Foot length to Height ratio > 15%)
  • Abnormal skin (striae, hyperextensibility, thin skin, abnormal scarring)
  • Eye signs (drooping eyelids, myopia or anti-mongoloid slant)
  • Varicose veins, hernia or uterine/rectal prolapse

Benign Joint Hypermobility Syndrome

When hypermobility becomes symptomatic (painful) the 'hypermobility syndrome' is said to exist. Due to the outcomes being more favourable than other HDCT the term Benign Joint Hypermobility Syndrome (BJHS) is used, although as this clinical situation now involves pain, it is often 'not so benign'.

BJHS is diagnosed in the presence of;

  1. Two major criteria or
  2. One major criterion and two minor criteria or
  3. Four minor criteria or
  4. Two minor criteria will suffice if there is an unequivocally affected first-degree relative

Heritable Disorder of Connective Tissue (HDCT)

These are rare, genetically determined connective tissue diseases due to an altered encoding of the collagen, elastic or fibrillin proteins. Clinical examples are Marfan's Syndrome, Ehlers-Danlos syndrome & Osteogenesis Imperfecta. These all have hypermobility as a common cardinal sign, but their cardinal signs aren't limited only to the musculoskeletal system.

With the overlap of signs between HDCT & BJHS, an unanswered question at present is whether the BJHS 'symptomatic hypermobility' is part of the HDCT spectrum of disorders. Some specialists argue that BJHS is one and the same as the hypermobility type of Ehlers-Danlos

Interestingly it has been demonstrated that people with HDCT are nonresponsive to local anaesthetics, in comparison to a normal but hypermobile population. This may mean that they would be less responsive to dry needling for pain relief, but I can't confirm or refute this possibility from my reading or experience.

While not always the case that this type of presentation have hypermobility as a comorbidity, it just emphasised that this type of client is not best suited to have repeated manipulative thrusts of tissue, that is already extensible beyond a normal range.

My management strategy is simple;

Step 1. Identify incorrect/poor habits that place their tissue at near end range for prolonged periods of time

Step 2. Education about the importance of why to avoid these end range positions

Step 3. Strengthen them; self awareness, power, endurance, eccentric and concentric.

Looking forward to seeing your thoughts in the Comments section.

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