Background: Jointhypermobilitysyndrome is an overarching term for a variety of disorders relating to abnormalities in tissue extensibility. Dry needling is an intervention that is growing in popularity to treat musculoskeletal pain often by targeting trigger points. The purpose of this case report is to present how dry needling techniques were used as part of the plan of care for an individual with knee pain complicated by hypermobilitysyndrome. Case Description: The patient was a middle-aged nurse with complaints of right knee pain, who presented with increased tone throughout her posterior lower
JointHypermobilitySyndrome (JHS) is characterised by chronic joint pain, instability and multi-system involve- ment. Following the exclusion of other heritable dis- orders of connective tissue, JHS is diagnosed using the Brighton criteria, as yet not validated in children . While the exact cause of pain and disability associated with JHS is unknown, reduced joint proprioception with associated sub-optimal motion control in the hyper- mobile range is hypothesised to be a contributing factor to symptoms associated with JHS, including poor motor co-ordination . The approach to physiotherapy ma- nagement of individuals with JHS published over the last 15 years has altered from advice to not move hypermo- bile joints into end-range , to advice to progress exer- cises so as to develop joint control in the hypermobile range, because this is where the joint is considered to be “less stable due to muscle weakness and altered proprio- ception” (p. e9) . While this treatment paradigm of exercising into the hypermobile range is the current expert recommendation, there have been no published reports investigating proprioceptive acuity in the hyper- mobile range in individuals with JHS.
JointHypermobilitySyndrome (JHS) is a heritable connective tissue disorder associated with excessive joint range of motion, often at multiple joints, in the presence of pain (Ferrell et al. 2004). JHS is reported to be under-recognised, poorly understood and poorly managed in clinical practice (Hakim and Grahame 2004, Grahame 2000). However it is a common source of musculoskeletal pain, with symptomatic jointhypermobility reported to affect approximately 5% of women and 0.6% of men (Simpson 2006). It should be acknowledged, however, that there is currently a lack of good quality epidemiological evidence for the true prevalence of JHS in the general population. When compared with healthy controls, JHS has been shown to have a significant impact on a wide range of outcomes such as exercise endurance, gait, pain, proprioception, strength, function and quality of life in both children (Engelbert et al. 2006, Fatoye et al. 2009, Fatoye et al. 2011, Fatoye et al. 2012) and adults (Hall et al. 1995, Mallik et al. 1994, Sahin et al. 2008a, Sahin et al. 2008b).
Musculoskeletal problems are common reasons for seeking primary health care (1). Jointhypermobilitysyndrome (JHS) is a hereditary connective tissue disorder, characterized by musculoskeletal pain and an excessive range of motion in joints (2). As there are no labo- ratory tests to indicate JHS (3), it is usually subjectively assessed using the Brighton criteria (4), which include the Beighton score (5) for jointhypermobility. It has been reported that symptomatic jointhypermobility affects around 5% of women and 0.6% of men (6). The prevalence of JHS amongst those attending rheumatology and physiotherapy clinics has been estimated to be between 30% and 60% and is higher in non-Caucasian populations (7,8). However, the diverse and fluctuating symptoms associated with JHS may easily be attributed to other causes and the true prevalence of JHS may be much higher than previously estimated. It has been suggested that many patients presenting with painful non-inflammatory musculo- skeletal problems may have unrecognized JHS (9).
A study which investigated the postures of patients with BJHS found significant differences between the pa- tients with BJHS and the control group with regard to posture scores and pain . All the clinical signs and symptoms evaluated under this study were significantly higher and New York posture rating test scores were significantly lower in patients with BJHS. Besides, such clinical features as joint pain, myalgia, shoulder impinge- ment and hyperkyphosis had a significant correlation with the joint laxity in these patients. Poor posture is significant in the management of BJHS, and its long term effects must be taken into account when planning a treatment for such patients. Reviewing the literature, we have not seen any study which evaluates the fre- quency of carpal tunnel syndrome, hyperkyphosis and hyperlordosis in patients with BJHS. Our findings sup- port the literature with reference to the joint pain and tendinopathy. On the other hand, we found lower values than those in the literature, particularly with regard to the values found for myalgia, pes planus and subluxa- tion. This might be attributed to the genetic variations and environmental factors.
Children with knee pain referred to The Children’s Hospital at Westmead’s Physiotherapy, Sports Medicine, Orthopaedic Knee, Connective Tissue Dysplasia and Rheumatology clinics between January 2007 and February 2011, were screened for eligibility by the treating clinician. Participants with a Beighton score  of ≥5/9 and >10° knee hyperextension were informed of the study. Any vol- unteers with a history of previous knee or patella disloca- tions, any current acute knee pathology or ligamentous insufficiency were excluded from participation. Partici- pants were initially eligible if aged 12-16 years, but follow- ing difficulties with recruitment, ethical approval was granted to increase the age range to 7-16 years. All out- come measures remained suitable for use with the youn- ger children, and their ability to undertake an exercise programme has been shown to be effective in the one pre- vious RCT with children with JHS . Thirty percent of children with JHS aged less than 10 years have chronic joint pain . The Human Ethics Committee of both the Children’ s Hospital at Westmead and The University of Sydney granted ethical approval for this study.
Specific joint exercises: hamstring curls in standing/prone, static hamstring in sitting, hip extensions in prone (knee extended/flexed), pelvic tilts, sit ups, chest press in supine, arm elevations in supine, resisted bicep curls, resisted bicep curls at 90degrees shoulder abduction, finger opposition, wrist flexion/extension, pronation/ supination, heel raises, alternate tiptoe-heel walking, ankle plantar/dorsiflexion, resisted ankle inversion/eversion
“It’s difficult to say because I can only reference it to my situation really. I think that it would’ve been useful – I think that comes from me, it would’ve been useful to look into the exercises in more precision, for me. But we did in the last session, but I think that’s only something I’ve really thought about in retrospect really. […] I think, maybe, my situation didn’t really help, going back to work and walking every day has knocked me back a few stages. I think if that hadn’t been the case I probably would’ve asked, we would’ve got more into the exercises and I would’ve then been able to ask more questions. …. I don’t know about other people with hypermobility, but for me specifically the exercises are about the finer points. Because sometimes I can do it, but just because I can doesn’t mean I should” [Patient 102].
Osteoarthritis (OA) is a common and debilitating dis- ease with a large public health burden in the United States and globally . OA development and progression can be influenced by biomechanical factors (e.g., joint in- jury, obesity) that change joint structures, alignment, motion, and loading, Jointhypermobility, broadly de- fined as range of motion of the joint that is greater than normal, may also influence OA development and pro- gression . The laxity of ligaments can contribute to increased range of motion, potentially leading to a hypermobile joint. Abnormalities in collagen and elastin may contribute to ligamentous laxity, with less severe defects occurring in isolated forms of jointhypermobilitysyndrome compared to heritable collagen diseases, such as Ehlers-Danlos syndrome . Hypermobility may con- tribute to joint injury  (microtraumas over time from stresses to joint structures at extremes of range of mo- tion or an increased susceptibility to a single major trau- matic event), pain , and damage to atypical contact areas of cartilage tissue . Due to this propensity for al- tered biomechanics and injury, jointhypermobility may be a unique risk factor for OA [7, 8].
The decreased range of joint motion is often pre- sented in different joint diseases and periarticular damages. Therefore, an increased joint mobility or hypermobility is still associated with some clinically irrelevant casuistry for the part of medical profes- sionals. Despite the fact of the simple palpability and detectability, a generalised joint hypermobil- ity (GJH) was recognised as a medical patholo- gy only in 1967 . Chronic pain related to jointhypermobility was was considered as one of the 5 most common conditions of chronic pain in pae- diatric rheumatology . In these cases, when GJH is associated with musculoskeletal symptoms in the absence of demonstrable systemic rheumatologic disease, a definition of jointhypermobilitysyndrome (JHS) is used .
We believe that the "benign" descriptor in "benign jointhypermobilitysyndrome" is misleading and unhelpful and prefer "JointHypermobilitySyndrome" to describe the combination of generalised jointhypermobility and func- tional symptoms. Consideration needs to be given to limit- ing diagnostic criteria to symptoms only rather than including a mixture of phenotypic features which are prob- ably more relevant to the underlying genetic diagnosis. Most authors now agree that children diagnosed as having Ehlers-Danlos syndrome (hypermobile type) or (benign) jointhypermobilitysyndrome represent the mild end of the spectrum of heritable disorders of connective tissue. Current research using this group is challenging because there is significant variability between individuals in this ill-defined population and some have features which overlap diagnostic groups. There is a need for descriptive studies of large cohorts of individuals with joint hypermo- bility to investigate the relationship between baseline clinical characteristics and adverse outcomes. In our expe- rience this condition can have a significant negative impact on an affected child's ability to function and par- ticipate in society and is much more disabling than gener- ally recognised. Accurate diagnosis of JointHypermobilitySyndrome facilitates early referral to an interdisciplinary team with appropriate clinical expertise in its manage- ment and avoids the use of ineffective measures, in partic- ular the over prescription of analgesia.
Ehlers Danlos Syndrome-Hypermobile Type) have been found to be associated with severely reduced HRQoL compared with NGJH [18, 44], which seems to support the current reduced HRQoL, especially in those with GJHS. Noteworthy and surprisingly, the EQ-5D-5 L’s physical activity dimension had the highest OR for de- creased HRQoL in participants with GJHS. This under- lines the high physical impact GJH and GJHS has on participants’ life. The current study found no associa- tions for GJH and GJHS with the mental-related dimen- sion of anxiety/depression, which has previously been reported in patients with Ehlers Danlos Syndrome, Hypermobile Type . However, a recent study did also find no significant association between patients with JointHypermobilitySyndrome/Ehlers Danlos Syndrome, Hypermobile Type and mental health, thereby support- ing the current results further . One of the reasons for the conflicting results of the impact GJH has on mental health  may be due to different methods of measuring mental health (the current one dimension of the EQ-5D-5 L versus the previously used four dimen- sions in SF-36).
OBJECTIVE: Because the criteria used for diagnosing between gener- alized jointhypermobility (GJH) and musculoskeletal complaints, as well as relations between GJH and an insufﬁcient motor development and/or a reduced physical activity level differ, the prevalence of GJH varies considerably. The aim of this study was to survey the prevalence of GJH deﬁned by a Beighton score at ⱖ 4, ⱖ 5, or ⱖ 6 positive tests of 9 and benign jointhypermobilitysyndrome (BJHS) in Danish primary school children at 8 years of age. A second aim was to compare chil- dren with and without GJH and BJHS regarding motor competence, self-reported physical activity, and incidence of musculoskeletal pain and injuries.
subtle symptoms such as musculoskeletal and neuropathic pain, joint instability, fatigue or anxiety [4, 5], but also cardiovascular autonomic diseases [6, 7] and bowel dis- turbance [8, 9] which are usually investigated and treated as distinct problems. JH and some of these features define the picture of the so-called jointhypermobilitysyndrome (JHS), a wide-spectrum clinical condition that is often hard to diagnose. It is a challenge to assess the frequency of JHS in the general population; the undefined signs, the lack of specific laboratory findings, but also the patients’ difficulty in describing their symptoms make it easy to underestimate or overlook this clinical picture. Moreover the syndrome is very similar – sometimes identical - to the more common variant of EDS hypermobility type (EDS-HT) (rev in [10–12]).
Generalized jointhypermobility (GJH) is a term used when most of the synovial joints in the body have an increased range of motion due to excessive connective tissue extensibility and/ or capsular or ligamentous laxity (1,2). GJH is a feature present in various rheumatologic diseases, including Marfan syndrome and Ehlers-Danlos syndrome, but it is known as a benign jointhypermobilitysyndrome that can also be present in the absence of rheumatologic diseases (3,4). GJH is most often seen in the females and among African and Asian descents, and its prevalence rate is reported from 5% to 43 % (5,6). Several studies have shown that the individuals with GJH have widespread joint pain and musculoskeletal and non- musculoskeletal complaints (1,,7-9). Approximately 3.3% of females suffering from GJH have tendency to develop pain in the legs and shoulder joint (10) . The result of Trudelle-Jackson and colleagues’ study showed that hypermobility appears to place women at increased risk of musculoskeletal injury while participating in physical
which would help to explain the association we found between this form of aggression and jointhypermobility. However, a weakness of the dataset was that the instructions for C-BARQ tell respondents not to complete the block of questions on familiar-dog aggression if there was no other dog in the household. Without other con- firmatory information, we could not determine whether respondents really had only one dog in the house, or had simply skipped that set of questions for some other reason. Also, aggression might be directed at familiar dogs that are not resident in the household, and the questionnaire, as it was completed, would miss this.
Among the weaknesses of this study are the limited data on clinical phenotypes such as symptoms and signs of disease of the Patient Registry. While the specificity of this register is high , especially for chronic disorders (including EDS or hypermobilitysyndrome), the sensitivity may be lower. Hence, we cannot ignore the possibility that some cases may have been missed. If such cases have less psychiatric comorbidity than individuals recorded with EDS or hypermobility in the Patient Registry, we may have overestimated the risk of psychiatric morbidity. However, considering the low prevalence of EDS or hypermobilitysyndrome in the general population (1/ 5000), false-negatives cases are unlikely to influence our estimates more than marginally.
This may be because hypermobile joints are unstable in nature due to their increased range of movement and subsequently reduced core stability. Subsequently, when impact occurs, they are not able to direct the force through the joint in a stable manner. In contact sports this causes joints to be in unstable positions due to their hypermobile nature, and when exposed to physical contact leads to injury. One may also hypothesise that JH may prevent injury in sports that require increased flexi- bility as there is less stress put through an already flexible joint. An example that highlights this is that if a runner misplaces their footing a flexible joint is able to move to the desired direction without sustaining injury. However, in a less flexible joint, an injury may occur. Hypermobile individuals may also be attracted to certain sports that require increased flexibility as certain movements are easier to perform, for example, hypermobility and being a gymnast. 7 It has also been suggested that training can
To consider alternative mechanisms that give rise to a refluxing uretero-vesical junction (UVJ), we hypothesized that children with a common heritable urinary tract defect, vesico- ureteric reflux (VUR), may have a defect in the extracellular matrix composition of the UVJ and other tissues that would be revealed by assessment of the peripheral joints. Several papers have reported that children with primary VUR are at higher risk for generalized jointhypermobility or “double jointedness” which raises the intriguing possibility that there are common defects in the extracellular matrix of the joint capsules and the UVJ that result in hypermobile joints and a refluxing UVJ. 6, 7 Indeed, we discovered two families with dominantly inherited VUR and joint