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Physiotherapy in Patients with Joint Hypermobility Syndrome

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".

Ehlers-Danloss Syndrome (EDS) is an inheritable condition which affects the synthesis and viability of collagen as a structural protein. There are at least 10 forms of this condition but Ehlers-Danloss III (three) is also known as benign joint hypermobility syndrome, benign because there are no life-threatening symptoms as occur in some of the other types. These people have smooth, velvety and flexible skin and remarkably hypermobile joints, along with chronic joint or limb pains and recurrent joint dislocations, mostly of the shoulder and the patella. Slow or abnormal wound healing with large and relatively weak scars can also be a feature.

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.

Self management in hypermobility syndrome is the main aim of intervention, with patient education taking a strong role to equip the patient to manage their lifelong condition. Due to the abnormally large ranges of joint movement they are vulnerable to ligament or joint strain if they are held posturally at end range or moved with momentum. Hypermobile patients should practice joint protection like arthritic patients, avoiding party pieces like showing off with extreme movements or joint dislocations. Yoga or high momentum activities such as contact sports are particularly unsuitable for these patients.

Physiotherapists manage the multiple joint and pain problems which hypermobility patients present with. Acute injury is more likely to occur with less trauma and more easily if the person undertakes vigorous exercise of any kind. Shoulder problems are particularly common in hypermobiles as the shoulder is a naturally mobile and unstable joint in normal situations let alone when the ligaments are unusually lax. Keeping the large ball of the arm bone centred on the small socket is a challenge to the muscular control and abnormal muscle patterning is common. Patients may habitually dislocate dislocate on movements, perpetuating the pain problem.

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.

Hypermobility is a lifelong chronic condition so sufferers are faced with managing this daily in all their postures and activities. Dysfunctional muscle patterns are common when the joints are significantly stressed, forcing them into unsuitable positions where they suffer strains. Physiotherapists can help with retraining of muscle patterns and treatment of painful joints but the largest component is self management and therefore patient education.

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