Just sat here thinking about work during my time off and what I realised is how many of my clients are hyperlax, hypermobile or have hypermobility syndrome. Shockingly, 90% of these clients are not aware of this underlying condition and have never had it diagnosed by a fellow healthcare professional.
This article is to highlight how to assess and diagnose hypermobility during clinical assessments. There is a significant need for more awareness of these conditions, for the patient to understand their body and for clinicians to factor this into their rehab.
What is the Hypermobility Syndrome?
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.
The Hypermobility Syndrome is said to exist when symptoms are produced, a state of affairs that may affect only a minority of hypermobile people. It is probably more correct to refer to Hypermobility Syndromes (in the plural) as a family of related genetically-based conditions which differ not only in the particular protein affected, but also in the degree of difference of formation. Thus at one end of the spectrum are the diseases with the potentially serious complications such as Marfan Syndrome or Ehlers-Danlos Syndrome Vascular Type (formally EDS IV). At the other end are what is now called on good evidence Benign Joint Hypermobility Syndrome (BJHS) and Ehlers-Danlos Hypermobile Type (formerly EDS III), which may be one and the same
Hypermobility or Hypermobility Symdrome?
Hypermobility and hypermobility sydrome (HMS) can be diagnosed by a set of tests called the Beighton Score, and then tested against the criteria for HMS which is called the Brighton Score:
The Beighton modification of the Carter & Wilkinson scoring system has been used for many years as an indicator of widesparead hypermobility. A high Beighton score by itself does not mean that an individual has HMS. It simply means that the individual has widespread hypermobility. Diagnosis of Hypermobility Syndrome or HMS should be made using the Brighton Criteria.
The Beighton score is calculated as follows:
||Score one point if you can bend and place you hands flat on the floor without bending you knees.
|Score one point for each knee that will bend backwards.
||Score one point for each elbow that will bend backwards.
|Score one point for each thumb that will bend backwards to touch the forearm.
||Score one point for each hand when you can bend the little finger back beyond 90°.
If you are able to perform all of above manouevres then you have a maximum score of 9 points.
An important landmark was passed in July 2000 with the publication in the Journal of Rheumatology (2000; 27: 1777-1779) of the Brighton Diagnostic criteria for the Benign Joint Hypermobility Syndrome (BJHS).
The actual criteria have been reproduced (as published) below.
- A Beighton score of 4/9 or greater (either currently or historically)
- Arthralgia for longer than 3 months in 4 or more joints
- A Beighton score of 1, 2 or 3/9 (0, 1, 2 or 3 if aged 50+)
- Arthralgia (> 3 months) in one to three joints or back pain (> 3 months), spondylosis, spondylolysis/spondylolisthesis.
- Dislocation/subluxation in more than one joint, or in one joint on more than one occasion.
- Soft tissue rheumatism. > 3 lesions (e.g. epicondylitis, tenosynovitis, bursitis).
- Marfanoid habitus (tall, slim, span/height ratio >1.03, upper: lower segment ratio less than 0.89, arachnodactyly [positive Steinberg/wrist signs].
- Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring.
- Eye signs: drooping eyelids or myopia or antimongoloid slant.
- Varicose veins or hernia or uterine/rectal prolapse.
The BJHS is diagnosed in the presence two major criteria, or one major and two minor criteria, or four minor criteria. Two minor criteria will suffice where there is an unequivocally affected first-degree relative.
BJHS is excluded by presence of Marfan or Ehlers-Danlos syndromes (other than the EDS Hypermobility type (formerly EDS III) as defined by the Ghent 1996 (8) and the Villefranche 1998 (9) criteria respectively). Criteria Major 1 and Minor 1 are mutually exclusive as are Major 2 and Minor 2.
The Subjective Give Away.
During your subjective assessment you should look for comments made by clients about their flexibility.
Clients may report that they feel a disconnection to their movements whilst partaking in sport. They may report numerous episodes of tripping for no reason, theymay alos report a long history of ankle problems. Ankle instability is well documented in HM and HMS sufferers as they have the flexibility in the ankle ligaments for them to stretch wihtou causing damage.
It is also well documented that dancers have exceptional flexibility, and most commonly ballet dancers, so their past times or activiteis may include dancing.
Such comments as, ‘I’ve always been very flexible’, ‘I’ve sprained my ankle loads of times’, ‘I used to do a lot of dancing’ are a sign for you to investigate further.
Start with the Beighton Score and then consider the Brighton Score is you suspect more. Always provide as much information to clients about HM or HMS, if you are unsure then direct them to a good source of information. The website below is excellent.
Thank you for reading this article.
Information regarding HMS and HM is available at www.hypermobility.org