Systematic reviewThe effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review
Introduction
Joint hypermobility syndrome (JHS) has been defined as a “heritable disorder of the connective tissues characterised by hypermobility, often affecting multiple joints, and musculoskeletal pains in the absence of systemic inflammatory joint disease such as rheumatoid arthritis” [1]. Variation in diagnostic criteria makes interpretation of published literature difficult but the revised Brighton Criteria [2] are now widely used. JHS is generally accepted to be more prevalent in children, in females and in some ethnic groups. Approximately 5% of women and less than 1% of men experience symptomatic joint hypermobility [3].
Joint pain in JHS is thought to be caused by excessive movement increasing stress on joint surfaces, ligaments and neighbouring structures [3]. Pain may cause muscle inhibition, leading to atrophy and reduced joint control [4]. Proprioceptive acuity may also be adversely affected [5], [6], perhaps due to joint mechanoreceptor damage [7]. The inability to acknowledge extreme joint ranges may create an even more unstable joint by further stretching supporting structures. JHS can be accompanied by fatigue [8], anxiety and depression, impacting negatively on social function [9] and thereby having a substantial impact on individuals.
Acute pain episodes may be managed using taping, bracing or splinting [4] or with non-steroidal anti-inflammatory drugs [3]. However education [10], [11] and therapeutic exercise [12] are the mainstays of long term management. Encouraging an active lifestyle may improve function and enhance quality of life [13].
Strengthening exercises targeting stabilising muscles around hypermobile joints might enhance joint support throughout movement and reduce pain [14], [15]. Closed chain exercises may reduce strain on injured ligaments [16], enhance proprioceptive feedback [4], and optimise muscle action [17]. Coordination and balance exercises such as wobble board training may improve proprioception [18], [19]. Neural pathways and movement patterns consisting of muscle pair co-contractions are reinforced [20]. This can encourage compensation reactions [21], preventing joints moving into extreme ranges and avoiding further injury [3].
In contrast to specific muscle training, a generalised exercise approach can also be taken, addressing cardio-respiratory, musculoskeletal and neurological aspects of movement [22] and reducing general deconditioning [23]. Hydrotherapy can be a successful medium in which to perform such exercises [22], challenging balance and core strength within a supportive environment, with water resistance and buoyancy increasing exercise variability [24].
Although exercise is widely regarded as a core component of JHS management [4], [12], there is no clear consensus about its effectiveness. There is generally a lack of high quality research which might contribute to the prescription of inappropriate interventions [25] and negative experiences of physiotherapy [1]. It is timely that the available evidence for exercise should be systematically evaluated.
This systematic review aimed to establish the effectiveness of therapeutic exercise for JHS. Due to the small number of studies identified in initial scoping work, it was decided not to prescribe the specific type of exercise or the clinical outcomes.
Section snippets
Methods
This review has been reported in accordance with PRISMA recommendations [26].
Study selection
The process of study selection is summarised in Supplemental Information, Figure A. After duplicates were removed a total of 2001 potentially relevant articles were identified (1967 from the electronic search, two from the hand search and 32 from snowballing). Successive application of the inclusion criteria to the titles, abstracts and full texts left four articles for inclusion within the review (three from the electronic and hand search and one from snowballing).
Study characteristics
Table 1 provides a synopsis
Summary of evidence
This review identified one randomised comparative trial in children [29], and one randomised controlled trial [30] and two cohort studies in adults [1], [31]. The evidence suggests that people with JHS who undertake exercise improve over time in a range of patient (and parent) reported outcomes (including pain, global assessment of the impact of hypermobility, maximum distance walked and quality of life) and objective outcomes (including proprioception, balance, strength and range of movement).
Conclusions
Overall, the available evidence suggests that patients who received an exercise intervention improved over time and no adverse effects were reported. However, there was no convincing evidence that generalised exercise was any better than joint-specific exercise [29] or that knee exercises were any better than a control condition [30]. Clear cause-effect relationships for exercise have therefore not been demonstrated. The methodological quality of the included studies was generally lacking,
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