Physical Therapy Management of the Hypermobile Patient

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Physical Therapy Management of the Hypermobile
Patient

• Terry S. Olson, PT, MHS, FAAOMPT

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Overview

• Definition of Hypermobility
• EDS and Hypermobility
• Role of Exercise and Protection
• Case

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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.

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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

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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 and muscle
  hypotonia

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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)

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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.

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Exercise and Joint Protection

• 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 18341-368
• Johansson H, Sjolander P, et al 1991 A sensory
  role for the cruciate ligaments. Clinical
  Orthopaedics and Related Research 268161-178

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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.

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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.

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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.

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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 gt
  1 hour, as well as with ADLs
• Objective signs of multiple joint hypermobility,
  with back pain reproduction with stressing of
  lumbar segments 1 and 2

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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 ADLs
• Progression into dynamic stabilization exercise
  as pain symptoms decreased

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Bilateral Squat, lt 20 Body Weight, Ankle, Knee
and Hip ROM/Strengthening, Also Used for Lumbar
Stabilization
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Bilateral Squat, lt 20 Body Weight, Ankle, Knee,
Hip ROM/Strengthening, Also Used for Lumbar
Stabilization
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Unweighted Walking, Up To 70 Body Weight,
Ankle, Knee, Hip, Lumbar Spine ROM/Strengthening
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Unweighted Step Up/Step Down, Up To 70 Body
Weight, Ankle, Knee, Hip ROM/Strengthening
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Unweighted Step Up/Step Down, Up To 70 Body
Weight, Ankle, Knee, Hip ROM/Strengthening
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Exercise to Improve Trunk StabilityTrunk
Stablilizers not Activated vs Trunk
Stabilizers Activated
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Exercise to Promote Trunk Stability and Upper
Extremity ControlUnstable vs Stable
Unstable vs Stable
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Exercise to Promote Trunk Stability and Upper
Extremity ControlUnstable
vs Stable

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

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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.

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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!

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Thank You!