Over the past several years, there has been a gradual increase in the research of joint hypermobility. This is the first comprehensive text I have seen that pulls this research and clinical expertise together. The book is edited by 2 rheumatologists and a physiotherapist (PT) from the United Kingdom. The contributing author list includes 40 different professionals from all over the world. This book is an expansion of a 2003 text specifically addressing joint hypermobility syndrome (JHS) for PTs. Each chapter is well referenced with publications in peer-reviewed journals primarily from the 1980s to the present.
The text is divided into 2 sections: clinical science and therapy. Chapters 1 and 2 give an overview of categories and criteria for each of the heritable disorders of connective tissue (HDCT): JHS, Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfect, and Stickler syndrome. Some professionals feel HDCT is the same as Ehlers-Danlos syndrome as there are many similarities. It is very interesting to see the criterion for diagnosis of each disorder and how they relate. For many years, PTs have used the 9-point Beighton hypermobility scale to screen patients for hypermobility. In this text, the authors reviewed that scale and provided more details, criterion, and specificity to increase accuracy of identifying these patients. The information provided describes the fact that range of motion normally decreases as the body ages and injured joints may not have excessive range of motion due to contractures or adhesions. This may result in discounting of JHS as a diagnosis when in fact the patient has global loose connective tissue. Several other scales and questionnaires are provided, which include symptoms of hypermobility as a child and more precise gradations of increased mobility.
Initial chapters also list the symptoms of JHS and systems affected by JHS. Studies show a 50% increase in urinary incontinence among patients with JHS. Pelvic organ prolapse is also increased in this patient population with one study reporting 53.8% of patients with JHS having pelvic organ prolapse compared with 9.6% of controls. Other symptoms include cardiovascular, pulmonary, gastrointestinal, and autonomic disorders; slow wound healing; skin changes; joint injuries; and changes in the eyes. Clearly many of the patients seen by a PT with special training have these conditions and therapists are wise to look at the overall patient for comprehensive, successful treatments.
Chapter 3 includes a good review of the pathology of pain, although other recent texts cover this topic in more detail. In chapter 4 the relationship of JHS and anxiety disorders is discussed. The text does an excellent job of drawing contrast and comparison of JHS with fibromyalgia in chapter 5. The similarities are striking. Chapter 6 is divided into 3 sections covering the cardiovascular and autonomic characteristics, bowel dysfunction, and proprioceptive changes of JHS and fibromyalgia. The chapter on bowel disorders is very interesting as it highlights the difficulty of diagnosing functional gastrointestinal disorders and also covers the theory of abnormal pain processing and the importance of central processing in these patients. The authors note increased incidence of fecal incontinence, slow transit constipation, obstructed defecation due to rectal prolapse, and hiatal hernias in patients with JHS. The section on proprioceptive dysfunction is also very well done and gives some specifics of treatment.
Section 2 starts with a detailed look at pharmacotherapy in fibromyalgia and JHS. Chapter 8 covers pain management and cognitive behavioral therapy. The authors do point out the importance of a complete training in this modality. However, the chapter also includes one of the most complete explanations I have seen on the theory behind cognitive behavioral therapy and ideas on treatment of sleep disturbances in these patients. This chapter also includes very specific ideas on how to pace activities, avoid the boom and bust pattern, and gradually stabilize and even increase activity tolerance. Chapter 9 provides comprehensive explanation of physical therapy and occupational therapy treatment of the adult with JHS. This section does a very good job at providing specifics of treatment plan development and progression. Chapters 10 and 11 cover similar topics for the adolescent and child with JHS.
Chapter 12 provides individual sections on the specifics of the joints of the shoulder, hand, hip, knee, and foot, pregnancy and the pelvis, thoracic and lumbar spine, cervical, jaw, and temporomandibular joint. All chapters are well done. The hand section gives very clear and practical suggestions, which can be applied to all joints. The authors also discuss the importance of hand joint protection in the PT with JHS. This section has information about joint protection in musicians. The hip section is written by 2 orthopedic surgeons and includes very little information about conservative management. The pregnancy section points out the increased incidence of premature rupture of membranes, incompetent cervix, shorter labor, stress urinary incontinence, pelvic organ prolapse, and issues of the sacroiliac joint. Some evaluation and treatment is discussed. Chapter 13 proposes to cover "sports and fitness"; however, it is mostly geared to the adult recreational fitness participant with very little specific information about the athlete. This is better covered in chapter 9.
I would agree with the quote on page 245 of the text "It behooves all those who are responsible for the care of women in pregnancy to be aware of these conditions and alert to their occurrence so that risks to the mother and child may be minimized." Overall, the text is an excellent reference and will be clinically useful for pelvic PTs. I highly recommend it.
Beth Shelly, PT, DPT, WCS, BCB-PMD
Moline, Illinois