Joint Hypermobility Syndrome and Physiotherapy
Our 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”.
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.
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.
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.