Hypermobile Patients

Hypermobility: The "bendy" patients

Hypermobility: Causes and implications for care

Good luck getting a hammer to help you when you are dealing with a screw. The tool must address the problem.  Joint HYPOmobility means that the joint does not move enough.  This is a wonderful chance to implement chiropractic manipulation, among other options. Often times though, we see joint HYPERmobility. This is when a joint, or in this case many joints, moves too much. There are various reasons why, and in this discussion, I’d like to talk about generalized hypermobility. Hypermobility is a spectrum and is present to some degree in western populations at a rate of about 10%, with a significant predisposition towards females.

A joint is hypermobile when its range of movement exceeds the norm for that individual.  We take into consideration age, sex, and ethnic background. The maximal range of movement that a joint is capable of is determined by the tightness of the ligaments, amount other things. The primary cause of hypermobility is ligamentous laxity. This is genetic and is determined by their fibrous protein genes. Of particular importance in this respect are the genes that encode for elastin, fibrillin, and especially collagen. It is the most common protein in our bodies, making up 25 percent to 35 percent of the total protein content of your body.

Collagen

Like all proteins, collagen consists of amino acids.  . Collagen actually is a family of proteins rather than one specific protein, plus it is a complex molecule, so you won’t see a simple chemical structure for it. From person to person, these collagen structures can vary subtly.  This affects how it might function. The word collagen comes from the Greek word “kolla,” which means “glue.”  It is not just in ligaments, but in other connective tissues such as your fascia (which wraps around muscles) and your skin.

Most all of the collagen in our bodies consists of types I, II, and III collagen, although at least 16 different forms of the protein are known.  Type I is gram for gram, stronger than steel!

Collagen is often depicted in diagrams as a fiber, and it can be.  Especially in ligaments or fascial tissue.  But it also permeates many other tissues, filling the extracellular matrix of bone and cartilage among other things.  As a complex protein it is somewhat variable and does not have a fixed  chemical formula.

Collagen variabilities

How our DNA specifically codes for collagen and other fibrous proteins, determine their function. In the generally hypermobile patients, these proteins are just more pliable.  In other genetic disorders, connective tissues may be lax to the point of detriment, affecting various physiological systems.  The Beighton test is a fast, easy and effective way to assess hyper mobility, and the potential need for further treatment, testing or referral.

Beighton Hypermobility Test

If you recall in our initial assessment, I may have asked you to touch your thumb to your forearm, or bend your fingers backwards.  These are part of the Beighton Hypermobility Index test. It’s a simple and effective test to identify and grade hypermobility.

Nine point Beighton hypermobility score

The ability to RightLeft
1. Passively dorsiflex the fifth metacarpophalangeal joint to ⩾ 90°11
2. Oppose the thumb to the volar aspect of the ipsilateral forearm11
3. Hyperextend the elbow to ⩾ 10°11
4. Hyperextend the knee to ⩾ 10°11
5. Place hands flat on the floor without bending the knees   1
Total possible score   9
  • One point can be gained for each side for manoeuvres 1–4 so that the hypermobility score will have a maximum of 9 points if all are positive.

This young lady was able to touch thumbs to forearms bilaterally, elbows past 10degs, bilaterally pinky past 90deg and the palms to the floor.  For her, the knee extension is actually just shy of 10deg, so no points.  Her Beighton score was 7/10.  It is highly unlikely she has any serious connective tissue disorders, but her tissue is fundamentally different than mine.  Her treatment will need to be different as well.

Beighton Implications

Beightons is great for its simplicity, but it lacks in much specificity.  A high score is most likely a condition we can call “benign hypermobility syndrome.” Its not linked to any other pathological conditions.  It has ramifications on best practices for treatment, but nothing serious.  A high score (8-9/10) can also be justification to explore for more sinister conditions.  These include osteogenesis imperfecta, Ehlers-Danlos and Marfans syndromes. These conditions may have been missed by other providers and the tend to score a 9/9 on the Beighton Test. Some further testing or a referral to a rheumatologist might be indicated.

Benign Hypermobility: The Bendy Ones

For the majority of higher scores, I just call them genetically bendy.  Their molecular structure for collagen, and other proteins, is somewhat different than mine.  This comes with certain benefits, and down sides.  Lax joints are inherently less stable.  They are more apt to sublux or dislocate, and are generally more susceptible to the effects of trauma. Soft tissues too can be less resilient, muscle tears and tendonopathies may occur with increased frequency. The spine might be susceptible and lumbar disc prolapse. Pars defects and spondylolisthesis occur with increased frequency.

On the other hand, many (perhaps most) hypermobile subjects have few or no problems and enjoy a symptom free life. The lumbar disc may be slightly more prone to a severe injury, but they are often more resilient to repetitive bending/twisting and general wear and tear. Like other patients, they tend to have problems at certain times of their life and not at others. It is not always possible to pinpoint the determining factors, although a change in lifestyle, particularly involving unaccustomed physical exercise, is the usual precipitating factor.

Things to consider

Joint hypermobility can be acquired through sheer hard work.  This might be seen in yoga, dancers, gymnast etc.  However, I firmly believe that the vast majority of these athletes were actually drawn to (and excel in) these activities via their propensity for  mobility.  This population can benefit from steering away from more of the same actives and training, and towards something they do not genetically excel at. This is usually controlled strength training.  High intensity, ballistic type training might be apt to injure them, especially performing in fatigued states. They stand to benefit considerably from a more tempoed and controlled lifting regimen.

This sort of activity might not be the first logical intervention we would make, but as a longer term goal, absolutely.  They generally stand to benefit from learning to stiffen their joints as is needed in strength training.  Especially a squat, deadlift, or press.

Chiropractic treatment for hypermobile patients

Manipulation might still be used, but predominately their treatment will need to address stability issues. I’ve talked about centration vs decentration here before, but centration means that the joint is in an optimal position to transmit force, decentration means it is not.  This model is a helpful way to view the dynamic relationship of joint stability (the ability of a joint to stay in place with forces trying to knock it out of place)

Joint Stabilization Model

In the bendy population, we could describe the passive section here as being a bit smaller, less robust. It is therefore extremely important that the other two sections are able to compensate.  The musculature and nervous system must be both capable and intelligent enough to fire at the right times to prevent decentration.

These patients will likely fail a course of tradition chiropractic treatment, focused on manipulation. They are equally likely to fail a traditional Physical Therapy focused on stretching. They are apt to have knots or trigger points as pain generators. These knots/TrPs are often the last line of defense they have.  The brain lays down these local areas of spasm to help compensate for a dysfunctional stabilization system.  They leave the person with a sensation of being tight, when that’s not exactly the case. Treating the TrP is important, but the manual work can’t be the end.  I actually strongly advocate for a non-stretching treatment for these patients when possible, such as trigger point dry needling.  We have to show the body an alternative way of stabilization.  Otherwise the brain will simply relay that spasm and trigger point. I advocate for DNS based training, transitioning towards controlled resistance training.

Key points for addressing pain in the hypermobile population

  • Identifying hypermobile patients is important in terms of making the appropriate referral and in tailoring treatment.
  • Manipulation and stretching techniques have a place in helping control pain.
  • Most hypermobile patients will need a slightly modified approach. Their fitness regimes likely need gearing towards productive activities.  This can help with long term management.
  • The bulk of time in treatment should likely bias towards stabilization training.

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