Joint Hypermobility: Physical Function and Balance for Older Adults & a Literature Review of the Association of Postural Sway
by: Jaime Hankins, SPT
Background:
As I was growing up, my friends and family often referred to me as ‘double jointed’ when I proudly demonstrated my ability to move my arms and legs beyond normal limits. Being a competitive gymnast, I used this increased range of motion, or joint hypermobility, to my advantage. However, years later those same joints have, at times, been a source of pain and discomfort when participating in activities such as yoga or martial arts. As a physical therapy student, I want to know more about the implications of joint hypermobility across the lifespan not only for myself but also for future patients. Is there a typical prognosis for a child with this condition? As this child becomes an adult, are there certain activities they should or should not engage in? What are preventative measures to ensure hypermobile joints do not become painful? What is to be expected as this person enters into older adulthood? I was underwhelmed by the time dedicated to this topic in our classwork however it appears there is good reason for this: the amount of evidence-based research on joint hypermobility is extremely limited.
Luckily, I read about a potential Capstone research project lead by UNC faculty that specifically pertained to joint hypermobility. Having no exposure to participating in a research project prior to entering the DPT program, I was apprehensive about participating yet I accepted the challenge. I knew this would not only further my understanding of hypermobility and the critical role research plays in physical therapy but also potentially expand others knowledge of joint hypermobility as well.
Purpose:
Someone may be considered to have joint hypermobility, or Generalized Joint Hypermobility (GJH) if they are able to move their joints beyond a normal range when considering a person’s age, gender and ethnic background.1It is estimated that anywhere from 4.9% to 23.9% of the US population have GJH.2For some, this condition does not cause discomfort however, other people may experience pain, inflammation, joint dislocations or other symptoms classifying them as having Joint Hypermobility Syndrome.3Russek et al. reported that of the 436 US physical therapists surveyed, 38.8% were not familiar with the diagnosis of joint hypermobility syndrome and 73.2% of them were not familiar with the assessment tool utilized to diagnose joint hypermobility syndrome. Furthermore, if joint hypermobility was diagnosed, the evidence for treatment methods is lacking. A systematic review by Palmer et al.4 reports that while exercise may be beneficial for those with joint hypermobility, there is a lack of evidence to determine what type of therapeutic exercise is best. Smith et al.5 reported a similar lack of evidence when also taking into account exercise programs as well as proprioception training and splinting.
Need:
In early conversations with the UNC faculty leading my Capstone project, I learned that there is a general lack of research in the current literature on joint hypermobility. This finding was substantiated when I searched for articles related to the treatment of a painful, hypermobile knee joint in my Evidence Based Practice II class in the fall of 2017. The literature that does exist about joint hypermobility typically pertains to children, young adults or those with heritable disorders of connective tissue such as Ehlers-Danlos syndrome. Of the articles reviewed for my previous assignment as well as this Capstone literature review, many authors conclude with a statement regarding the lack of evidence and call for more future research. The extent to which GJH affects physical function and balance is also not well known. To fill this void, I have created two products for my Capstone project.
Products:
One product created for my Capstone is an Abstract reflecting the work of a cross-sectional study from data obtained in the Johnston County Osteoarthritis Project. This study concentrated on the association for older adults between joint hypermobility and physical function outcome measures. These measures included tandem stance time and a functional reach test to assess balance and an 8-foot walk test to examine gait speed. This abstract will be submitted to the American College of Rheumatology and Association of Rheumatology Health Professionals for consideration of presentation at the annual meeting in October 2018.
The other product created was a Literature Review to investigate the current studies for associations between static balance, specifically postural sway, and joint hypermobility. The goal is to submit this literature review to be published by the Orthopaedic Physical Therapy Practice magazine.
As mentioned above, during my Evidence Based Practice II course in the fall of 2017, I created a Critically Appraised Topic (CAT) that focused on the clinical question “For a 40 year old female with painful knee joint hypermobility, is strength training more effective than proprioceptive training to improve pain as measured by the Numeric Pain Rating Scale?” Based on this question, I focused on knee hypermobility and the effectiveness of strengthening exercise versus proprioceptive exercises for pain relief when searching and selecting articles for inclusion.
Self-Assessment:
My personal goals for this project were to better understand and successfully complete a literature review as well as gain experience in the research aspect of physical therapy. I used online sources to read about how to achieve these goals but nothing I read compared to the act of doing it myself. This is when I had true, unique learning experiences such as raw data interpretation and searching for patterns of continuity between study reports. These experiences coupled with the aid and guidance of my committee members lead to a successful completion of my goals. I feel that this project has enhanced my ability to search for and evaluate existing literature to make me a more effective evidence-based clinician and improved my writing skills to carry with me in all aspects of my future career.
Acknowledgments:
I would like to express my gratitude to Carla Hill PT, DPT, OCS, Cert. MDT and Dr. Yvonne Golightly, PT, MS, Ph.D. for being my Capstone committee, providing multiple rounds of edits and encouraging me throughout this process. When I was overwhelmed and confused by my literature review search results, Carla was there to help narrow my focus and find a clear voice. Yvonne’s data analysis skills taught me the process behind this type of research and her data interpretation brought clarity to numbers on a page.
References:
- Jindal P, Narayan A, Ganesan S, MacDermid J. Muscle strength differences in healthy young adults with and without generalized joint hypermobility: a cross-sectional study. BMC Sports Science, Medicine and Rehabilitation. 2016;8(1). doi:10.1186/s13102-016-0037-x.
- Russek L, LaShomb E, Ware A, Wesner S, Westcott V. United States Physical Therapists’ Knowledge About Joint Hypermobility Syndrome Compared with Fibromyalgia and Rheumatoid Arthritis. Physiotherapy Research International. 2014;21(1):22-35. doi:10.1002/pri.1613.
- Magee D. Orthopedic Physical Assessment. 6th ed. St. Louis, Missouri: Elsevier Saunders; 2014.
- Palmer S, Bailey S, Barker L, Barney L, Elliott A. The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review.Physiotherapy. 2014;100(3):220-227. doi:10.1016/j.physio.2013.09.002.
- Smith T, Bacon H, Jerman E et al. Physiotherapy and occupational therapy interventions for people with benign joint hypermobility syndrome: a systematic review of clinical trials. Disability and Rehabilitation. 2013;36(10):797-803. doi:10.3109/09638288.2013.819388.
5 Responses to “Joint Hypermobility: Physical Function and Balance for Older Adults & A Literature Review of the Association of Postural Sway”
Carla Hill
Jamie,
Great job on your Capstone! I appreciate your persistence searching for research to analyze for this project. It was surprising to me how little we know about the impact of joint hypermobility on balance and functional measures. This is important to explore for both the younger population (are those individuals susceptible to athletic injuries that predisposes them to development of arthritis later in life?) and the older population (are those individuals more or less likely to fall or have mobility impairments even if no longer hypermobile due to tissue changes associated with aging?). There are many questions yet to be answered about this population that may be seen in the PT clinic. Thank you for your devoted effort throughout the semester to synthesize what is known and highlight the gaps that need to be addressed in the future.
Jaime Hankins
Hey Ben,
Thanks so much for reading through my project! And to try to answer your question, as you know the Beighton criteria addresses four bilateral joints and then the trunk maneuver. Three of the bilateral joints addressed pertain to the upper extremities so to narrow the focus and further analyze the joints most likely contributing to the physical functions of gait and balance, the knee and trunk maneuver were specifically addressed. And yes, as I’m sure you remember from several demonstrations in class of those with tight hamstrings attempting to bend over and touch the floor with their hands, this does demonstrate hamstring flexibility however, it is one maneuver also currently included in the Beighton criteria for joint hypermobility. Being able to perform the knee maneuver may have represented more of a joint hypermobility while the trunk maneuver was more flexibility so addressing these separately could look for this correlation.
Thanks again for reading Ben!
Jaime
Ben Carrion
Jamie,
Your capstone project is amazing. It was neat to see all of your hard work come together! I have limited experience working with joint hyper mobility but was definitely educated on the topic when I read through your literature review. Thank you for providing additional resources for our class as we transition into the clinic. I’m excited that your abstract will be submitted and hope it is accepted for the seminar in October 2018. I had a quick question: What was your reasoning behind looking specifically at the knee and trunk for hyper mobility in the Johnston county project? I was thinking that the trunk maneuver might be a bigger reflection of flexibility than joint hyper mobility. Once again, great job and am looking forward to your reply!
Jaime Hankins
Hi Alan,
Thank you so much for reading my capstone so thoroughly! In answer to your question, I’d say it is a possibility. However, the Johnston County report was a cross sectional study that captured a snapshot of the physical function of these participants. I think you are thinking what we were thinking after analyzing this data which may be the next step for this project; a prospective study looking at the changes in physical function and balance in relation to joint hypermobility over time. Looks like we will have to ‘stay tuned’ as more information available 🙂
Thanks again Alan,
Jaime
Alan Levinson
Jaime,
Your Capstone on Joint Hypermobility is very thorough and informative. My mock case this semester included joint hypermobility as a component of the patient’s shoulder injury. I have not encountered a diagnosis of joint hypermobility in my clinical rotations (at least not as primary diagnosis), and while I nailed most of the special test for shoulder, I did not conduct a Beighton test.
I find it interesting that so many studies used a range of definitions based on Beighton score. It seems that some standardization could be reached, but for the time being it is not.
I particularly compliment your Literature Review. There is incredible detail among the 5 studies included. In particular, as I mentioned, the variation on Beighton score criteria was significant. You also note that the outcome measure of postural sway likewise had a wide range of variability. Finally, both age and time in stance position could be confounding variables for clinicians to consider. Typically, our joints become less mobile as we age, so presumably that would be true for individuals who are hypermobile.
The conclusion drawn from your Literature Review differs with the Johnston County Osteoarthritis Study which you provided a succinct abstract. With nearly 1,700 subjects recorded over an 8 year period gives a good level of confidence in sample size. The strengths of this study seem to be having established predefined criteria for hypermobility definition, (>= 4/9) and specific cutoffs for balance measures. Also, this study focused on older adults, and as you say, when adjusting for age, race, and gender, no statistical differences were found in balance measures for hypermobile participants.
Would I be correct to suggest that perhaps the age variable did factor in with this difference? The older sample in the Johnston County report may have gained some postural control or stability with tightening over time?