Joint Hypermobility Syndrome – Physiotherapy
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. 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. Patient education for sufferers from benign joint hypermobility syndrome is vital if they are to learn to manage the condition through their lives. The joints will not tolerate significant strains and stresses so end range posture should be avoided as this strains the ligaments and can give pain. Repeated lifting of heavy objects is also likely to be unhelpful. Arthritic patients practice joint protection to manage their condition and this is also important for hypermobile patients, so dislocating a shoulder at a party for fun or getting into extreme positions should be avoided. Strong joint stretching may be unwise as in yoga as may activities with a high risk of joint, tissue or skin damage. 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. Spinal pain is common in hypermobility perhaps secondary to the difficulty in keeping good stability of the joints as forces act upon them. Gentle mobilizations can be performed for local problems but manipulation is likely to be unwise. General exercises to keep the joint moving can be helpful but end range and stretching exercises should be avoided. Gentle weight training and core stability work may help stabilise the spine and other joints, increasing the muscle tone to hold joints in their mid ranges and prevent excessive play. The knees may bend back excessively and suffer arthritic change in time, so work on the hamstrings to counteract this in standing is an option. Often patients need to work on several areas, maintaining muscle strength and control. All postures and activities are a challenge to a patient with hypermobility as unsuitable stresses are very easy to apply, causing pain. The patterns of muscle activity are abnormal when the joints are under load, pushing them into end range positions where the ligaments and capsules suffer from strains. Physiotherapy retraining of poor muscle balance can be helpful but patients need to be constantly vigilant and work at their weaknesses persistently. The most important factor overall is patient education as the condition is a long term one and all physical activities challenge the joints. Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.