Joint hypermobility Syndrome in water

By Lynda Keane PGc, MSc, BSc (Hons), ATRIC, AEA, mSMA

Joint Hypermobility Syndrome (JHS)/ Elhers-Danlos Syndrome Hypermobility Type (HEDS) formerly EDS III aka JHS/ Benign JHS (BJHS) is a barely recognised and often poorly managed multi systemic Hereditary Connective Tissue Disorder (HCTD). It is known that approximately 20-30% of individuals are affected by hypermobility to some degree (HMSA 2012) and can affect a person either focally, regionally or cause widespread mechanical injury (Hakim et al. 2010. p3). A vast majority of individuals with JHS are asymptomatic with no medical conditions or diagnosis. However, the individuals who are symptomatic can have life changing symptoms and altered function. The pain associated with this can become widespread and persistent and any joint within the body can be affected. Hypermobile individuals can injure joints, ligaments, tendons and other ‘soft tissues’ around the joints (Keer and Butler 2010). Though these injuries may cause immediate ‘acute’ pain they can often lead to longer-term ‘chronic’ pain. It is quite common for a person with JHS to repeatedly injure parts of their body and bruise from insignificant injuries. These injuries tend to heal more slowly than normal (Levy 2012). Individuals will often explain they are ‘clumsy’, have poor balance or that they are uncoordinated. This ‘clumsiness’, lack of balance and poor coordination can be explained by the diminished proprioception in individuals with this condition (Mallik et al. 1994; Hall et al. 1995). When planning an aquatic programme all the symptoms that may be affecting the individual and what results the individual may be looking for need to be considered. Water therapy/exercise can enhance retraining in the chronic, long standing and recurrent physically deconditioned hypermobile individual. It is imperative that the aquatic professional who instructs a class or individual understands the condition and is confident in joint ranges of motion. Hakim (2012) states that for some, rehabilitation would be ineffective (up to 20%). However, in my experience as an aquatic professional, the average period of retraining in the pool takes between 12-24 months from initial inception, this could be due to the deconditioned nature of the individual.

Maintenance of wellbeing is lifelong for these individuals and as such it is common that once an individual has found water exercise, the benefits are substantial and they choose to continue such exercise as a lifestyle. In Sahin et al’s. (2008) study they found that decreased muscle tone, tensile power of tendons and degeneration of ligaments contribute to functional impairment by causing abnormal motor control and proprioceptive feedback loss. For some hypermobile individuals maintaining a standing and sitting posture for any period of time can be a challenge because their postural muscles are unused to holding joints in a neutral position. As water gives support in a non-gravity environment, joint loading is decreased allowing effective and efficient joint control without pain. In a group exercise situation, for example it is by performing isolation exercises on one leg, then adding oppositional dynamic exercises with the other that muscle balance and strength can start to be regained. Worth noting is that bracing and rigid movement strategies are common tactics used in hypermobile individuals (Keer and Butler 2011 p.152). Initial rehabilitation training should ideally be in a minimal weight bearing environment using closed kinetic chain as recommended by Keer and Simmonds (2007); Keer and Butler in Hakim et al. (2011 p153). This will have a beneficial effect on the rest of the kinetic chain as well as on positional awareness. It is by using the limbs in an effective way that a hypermobile individual will reduce pain, improve proprioception, muscle strength and improve quality of life (Ferrell et al. 2004). It is evident that aquatic therapy has many benefits to the hypermobile individual as a lack of proprioception can result in poor gait, frequent falls, and general clumsiness often resulting in injury. As a consequence it is common for the hypermobile individual to suffer from anxiety and Kinesiophobia which has a profound effect on the individual’s quality of living and contribute to a repetitive injury cycle of pain, non-movement and rehabilitation.

Lynda has a CPD course on Hypermobility that can be accessed on the AREA website.

Reference:

Hakim, A.J., Keer, R., Grahame, R., (2010). Hypermobility, Fibromyalgia and Chronic Pain. Churchill Livingstone: China.

Ferrell,W.R., Tennant,N., Sturrock,R.D., Ashton,L., Creed, G., Brydson,G. and Rafferty,D., (2004). Ameloration of symptoms by enhancement of proprioception in patients with joint hypermobility syndrome. Arthritis and Rheumatism. 50.(10). 3323-3328.

Keer, R. and Butler, K., (2010). Physiotherapy and occupational therapy in the hypermobile adult. In Hakim, A., Keer, R. and Grahame,R. (Eds). Hypermobility, Fibromyalgia and Chronic Pain. (p143-153). Churchill Livingstone: China.

Keer,R. and Simmonds, J.V. (2007). Hypermobility and the hypermobility syndrome. Manual Therapy. 12. 298-309.

Levy, H.P., (2012). Ehlers-danlos syndrome, hypermobility type. Gene Reviews. [Accessed 20th January 2014]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1279/

Mallik, A. K., Ferrell, W.R., McDonald, A.G., Sturrock, R.D., (1994). Impaired proprioceptive acuity at the proximal interphalangeal joint in patients with the hypermobility syndrome. British Journal of Rheumatology. 33.(7). 631-637.

Sahin,N., Baskent, A., Cakmak, A., Salli,A., Ugurlu, H. and Berker, E., (2008). Evaluation of knee proprioception and effects of proprioception exercise in patients with begnin joint hypermobility syndrome. Rheumatology International. 28. 995-