Physical Therapy Management of the Hypermobile Patient

1. Physical Therapy Management of the Hypermobile Patient Terry S. Olson, PT, MHS, FAAOMPT

2. Definition of Hypermobility EDS and Hypermobility Role of Exercise and Protection Case Overview

3. What is Hypermobility? • Connective tissue proteins such as collagen give the body its intrinsic toughness. When they are differently formed, the results are mainly felt in the "moving parts" - the joints, muscles, tendons, ligaments - which are laxer and more fragile than is the case for most people. The result is joint laxity with hypermobility and with it comes vulnerability to the effects of injury.

4. Ehlers-Danlos Syndrome and Hypermobility • Classical – skin hyperextensibility, tissue fragility, and joint hypermobility • Hypermobility – joint hypermobility dominant characteristic, joint subluxation and dislocation, limb and joint pain

5. Ehlers-Danlos Syndrome and Hypermobility • Kyphoscoliosis – generalized joint laxity and severe muscle hypotonia, scoliosis, tissue and organ fragility • Arthrochalasia – congenital hip dislocaton, severe generalized joint hypermobility, recurrent subluxations, tissue fragility andmuscle hypotonia

6. Ehlers-Danlos Syndrome and Hypermobility • Vascular – organ fragility with possibility of arterial or organ rupture, tendon or muscle rupture, joint hypermobility primarily in digits • Dermatosparaxis – severe skin fragility, skin soft, doughy, and redundant, may have large hernias (umbilical, inquinal)

7. Ehlers-Danlos Syndrome and Hypermobility • Hypermobility and joint laxity are important considerations for the Physical Therapist when treating the patient with Ehlers-Danlos, with treatment focusing on joint protection and dynamic stabilization.

8. “Muscle stiffness” is a term used to describe the spring-like quality of the muscle. When a muscle has high stiffness, increased force is required to cause lengthening of the muscle. “Muscle stiffness” has been described in the biomechanical and neurophysiological literature as one of the most crucial variables in joint stabilization. In the knee, a link has been established between receptors in the ligaments of the joint and “muscle stiffness”. Johansson H, Sjolander P, et al 1991 Receptors in the knee joint ligaments and their role in the biomechanics of the joint. CRC Critical Reviews in Biomedical Engineering 18:341-368 Johansson H, Sjolander P, et al 1991 A sensory role for the cruciate ligaments. Clinical Orthopaedics and Related Research 268:161-178 Exercise and Joint Protection

9. Exercise and Joint Protection • It is possible that the sensory properties of structures within the joints can be modified by the contraction of the local stability muscles. Besides providing mechanical stability to the joints, these muscles could contribute to the sensory feedback mechanisms associated with the joint structures themselves, i.e., the joint capsules and ligaments. Blasier, Carpenter and Houston in their 1994 study, “Shoulder Proprioception: Effect on Joint Laxity, Joint Position and Direction”, found that tightening of the joint structures with active muscle contraction, increased the proprioceptive acuity of the shoulder joint.

10. Exercise and Joint Protection • “Dynamic Stabilization”, or the use of exercise to promote joint stabilization, occurs when tonic (postural and slow twitch) motor units are activated. • Tonic motor units are activated during tonic continuous low-load activation of the muscle, maximizing “muscle stiffness”. This can be influenced by the speed of the activity or muscle contraction. • Muscle contractions performed in the shortened range of the muscle length are critical in establishing the sensitivity and optimal functional capacity of the sensory feedback system of the muscle.

11. Exercise and Joint Protection • Co-contraction and co-activation of muscle groups provide the biomechanical forces for joint stability and protection, especially if performed in midrange, or neutral, joint positions. • Closed-chain exercise is superior for muscle protection of the joint, although open-chain exercise is also beneficial and necessary, especially if performed in the protected portion of range of motion.

12. Case Presentation • 25 year old female with diagnosis of lumbar back pain, left hip pain and EDS-multiple areas of pain complaint, most notable in back and L hip • Pain complaints up to 8/10 level with standing > 1 hour, as well as with ADL’s • Objective signs of multiple joint hypermobility, with back pain reproduction with stressing of lumbar segments 1 and 2

13. Case PresentationTreatment • Initial emphasis on symptom alleviation using modalities, gentle joint mobilization and biomechanical correction, as well as “assisted” exercise in protected and asymptomatic range of motion • Biomechanical counseling on joint protection, as well as back care education regarding lifting, sitting and ADL’s • Progression into dynamic stabilization exercise as pain symptoms decreased

14. Bilateral Squat, < 20% Body Weight, Ankle, Knee and Hip ROM/Strengthening, Also Used for Lumbar Stabilization

15. Bilateral Squat, < 20% Body Weight, Ankle, Knee, Hip ROM/Strengthening, Also Used for Lumbar Stabilization

16. “Unweighted” Walking, Up To 70% Body Weight, Ankle, Knee, Hip, Lumbar Spine ROM/Strengthening

17. “Unweighted” Step Up/Step Down, Up To 70% Body Weight, Ankle, Knee, Hip ROM/Strengthening

18. “Unweighted” Step Up/Step Down, Up To 70% Body Weight, Ankle, Knee, Hip ROM/Strengthening

19. Exercise to Improve Trunk StabilityTrunk Stablilizers not Activated vs Trunk Stabilizers Activated

20. Exercise to Promote Trunk Stability and Upper Extremity ControlUnstable vs Stable Unstable vs Stable

21. Exercise to Promote Trunk Stability and Upper Extremity ControlUnstable vs Stable

22. Exercise to Promote Trunk Stability and Lower Extremity ControlUnstable vs Stable

23. Case PresentationResults • Patient was seen for 9 visits over a 5 week period. Initial treatment consisted of gentle mobilization of symptomatic areas, coupled with assisted exercise, utilizing assisted treadmill walking and total gym. • Patient was progressed to a stabilization and progressive strengthening exercise program as symptoms decreased. • Pain complaints were reduced to a 1/10 level. • Patient able to stand and sit greater than two hours without symptoms, as well as lift baby without increase in symptoms.

24. Physical Therapy Management • Modalilties, including cold, heat, electrical stimulation, TENS, ultrasound, etc. • Exercise - emphasis on controlled range of motion, or “range of control”. Pool is beneficial. • Massage – monitor skin integrity, especially if cross friction.

25. Physical Therapy Management • Use of splints or bracing. • Manual therapy – be careful of vigorous end of range stretching secondary to inherent hypermobility. • Patient education regarding ergonomics, joint protection, body mechanics, etc. LOTS OF EDUCATION!

26. Thank You!