Joint Hypermobility: Physical Function and Balance for Older Adults & A Literature Review of the Association of Postural Sway

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:

1. 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.
2. 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.
3. Magee D. Orthopedic Physical Assessment. 6th ed. St. Louis, Missouri: Elsevier Saunders; 2014.
4. 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.
5. 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.