Recommendations
for the treatment of the Joint Hypermobility Syndrome (JHS)
(Written in a
language for patients)
It
is necessary that the patients with JHS know that this is a common condition
(15% worldwide and 40% in Chile and probably in other Latin countries) and is
usually not diagnosed. In spite that it can cause acute and chronic pain that
can be disabling, it does not have the possible serious complications of the
other types of Hereditary Diseases of the Connective Tissues (HDCT) such as the
vascular type of Ehlers-Danlos Syndrome (VEDS), formerly called EDS type IV;
the Marfan Syndrome (MFS); or the Osteogenesis Imperfecta (OI). Women are more
hypermobile than men and children more than adults, since laxity decreases with
age.
The problem
lies in that the joints are too lax, which makes them unstable and painful, due
to the extreme mobility. In general, there is more problem with hyperextension
than hyper-flexion of the joints. Due to this, these patients are prone to
recurrent traumatic lesions such as sprains and subluxations, which are painful
and at times require immobilization.
It is
necessary to avoid extension of the joints, especially lax joints, for example
when putting weight on the hand it is better to put the weight on a full fist
rather than on the palm of the hand. When standing it is necessary to avoid the
knees from going backwards (genu recurvatum), for this, the patient needs to
stand with mild flexion of the knees and to use a strong 3 cm shoe heel. We recommend children not to show others how
lax they are (not to do “party tricks”), since every time that they extend too
much the joints they are damaging them, which in the long run will result in
osteoarthritis (joint wear and tear). If possible, it is better not “to crack
the joints” on purpose.
In order to
prevent ankle sprains it is necessary not to wear high heels. Falls should be
prevented, since fractures can happen, because these patients frequently have
osteoporosis (22%) and more importantly it is to realize that in JHS patients
younger than 30 years old, the frequency is 19% in both sexes, as we have found
in our recent study of 1,000 JHS patients.
We recommend
these patients to avoid been overweight to prevent osteoarthritis of the knees
and hips.
It is
necessary to do exercises carefully to strengthen the tendons, ligaments and
muscles. Most JHS patients awake with muscular rigidity and for them stretching
and local heat are useful. They should not stretch too much, since they usually
get leg cramps. Stretching before sports or exercises is even more necessary in
these patients, than for people without hypermobility.
Violent
sports, such as: karate, box, rugby, skating, etc. should be avoided. Also
contact sports such as volleyball and basketball are harmful to patients with
lax fingers, because they develop frequent sprains and tendinitis. In general
swimming, cycling, Yoga, Tai Chi, and Pilates are recommended. Each person
needs to determine which sport gives them problems as to avoid them, and some
may not be able to practice soccer, tennis or other sports. This also depends which joint is affected,
if the hands or wrists, the person will not be able to be a goalkeeper or to
play volleyball. If someone has knee or ankle problems he/she may be unable to
play some sports. If a patient wants to play a sport anyways, he should protect
the weak joints, using elastic bandages, splints, etc., and to consider
quitting the sport if problems are recurrent.
Due to mark
agility, some adolescents begin Ballet classes or Gymnastics, but a warning is
necessary, since some may not be able to continue and may have to quit because
of articular problems. They need to start slowly and evaluate the situation and
if they start having musculo-skeletal problems, they need to see a physician or
retire from that activity.
Elastic
bandages and splints with metallic reinforcement are useful. In offices or
industry, it is important to evaluate working conditions, to prevent problems
such as neck or back pain, carpal tunnel syndrome, sprains, tendinitis,
bursitis, subluxations, etc.
In cases of
capillary fragility and ecchymoses, Duo CVP and Vitamin C are beneficial,
besides avoiding contusions. The use of Glucosamine alone or with Condroitin
Sulphate, in optimal doses and taken for a prolonged period of time, are useful
to prevent progression of Osteoarthritis, that can appear early in these
patients. It is necessary to look for Osteoporosis that can appear even in
young men and to treat it as early as possible.
Chronic
Fatigue, which at times is associated with dizziness or even syncope, causes
poor quality of life and is frequently misdiagnosed as Fibromyalgia or
Depression, with which it is usually confused. Every day we see patients that
have seen many physicians, had many tests, and have been having a very poor quality
of life for years and that the proper diagnosis has not been made. Dysautonomia
is very frequent in JHS, as we have seen in our recent study, where we found
that in patients younger than 30 years old, it affects 64% of the women and 40%
of the men. The good news, though, is that it can be treated effectively.
A good measure
is to take short periods of rest and not to stay for hours in the same job,
without changing body positions. It is necessary to advise music students about
which instrument to prefer. School children should not carry heavy back packs,
because this is a frequent cause of back pain. It is advisable to have school
accident insurance, since JHS children are prone to recurrent
musculo-skeletal injuries, such as sprains, subluxations, tendinitis, etc.
Treatment of
the acute phase. The
immobilization of the affected joint is of paramount importance. The use of
splints or casts is at time indicated. Short periods of immobilizations are
better than very prolonged ones. Hot or cold packs are beneficial. At the house
a pack of frozen peas, covered by a towel, can be used effectively. Hot
compresses or hot baths reduce pain and muscle contraction. Physical therapy is
recommended, including massage, ultrasound, ultratermia, etc. It is necessary
to avoid the repetitive activity that caused the acute problem. Medications
such as Tylenol or anti-inflammatory, for short periods, are useful. Muscle
relaxants reduce pain, but if the pain is intense, then Tylenol with Codeine or
Tramadol is suggested. Topic analgesics or anti-inflammatory creams can be
used. If the problem persists, it will be necessary to see a Rheumatologist or
an Orthopedist, to study the cause of the problem. Occasionally an infiltration
with steroids and lydocaine is needed to treat a tendinitis or a bursitis. This
procedure is very efficacious and painless, since a local anesthetic is
applied.
I recommend to
see in my Web Site the following articles:
The
Joint Hypermobility Syndrome (JHS).
Dysautonomia (Chronic Fatigue, dizziness and syncope).
Importance
of JHS diagnosis (in Spanish).
Osteoporosis
in JHS (in Spanish).
www.reumatologia-dr-bravo.cl
An easy way to
find information, that I have written in my Web Site, is to use the
“Search”, that is found at the beginning of the Web Site.
Jaime F.
Bravo, MD
Rheumatology-Osteoporosis
Revised: March 30, 2007