Transcript Physical Therapy Management of the Hypermobile Patient

Physical Therapy Management
of the
Hypermobile Patient
Terry S. Olson, PT, MHS, FAAOMPT
Overview
 Definition of
Hypermobility
 EDS and
Hypermobility
 Role of Exercise and
Protection
 Case
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.
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
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
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)
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.
Exercise and Joint Protection
 “Muscle stiffness” is a term
used to describe the springlike 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
 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.
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.
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.
Case Presentation
• 25 year old female with
diagnosis of lumbar back
pain, left hip pain and EDSmultiple 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
Case Presentation
Treatment
• 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
Bilateral Squat, < 20% Body Weight, Ankle, Knee and Hip
ROM/Strengthening, Also Used for Lumbar Stabilization
Bilateral Squat, < 20% Body Weight, Ankle, Knee, Hip
ROM/Strengthening, Also Used for Lumbar Stabilization
“Unweighted” Walking, Up To 70% Body Weight, Ankle,
Knee, Hip, Lumbar Spine ROM/Strengthening
“Unweighted” Step Up/Step Down, Up To 70% Body
Weight, Ankle, Knee, Hip ROM/Strengthening
“Unweighted” Step Up/Step Down, Up To 70% Body
Weight, Ankle, Knee, Hip ROM/Strengthening
Exercise to Improve Trunk Stability
Trunk Stablilizers not Activated
vs
Trunk Stabilizers Activated
Exercise to Promote Trunk Stability and
Upper Extremity Control
Unstable vs Stable
Unstable vs Stable
Exercise to Promote Trunk Stability and
Upper Extremity Control
Unstable
vs
Stable
Exercise to Promote Trunk Stability and
Lower Extremity Control
Unstable
vs
Stable
Case Presentation
Results
 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.
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.
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!
Thank You!