Hypermobility has certain implications for the joint itself, as well as the surrounding ligaments, bones, joint capsules, muscles and tendons. It is important for a hypermobile client’s well being that they have effective neuromuscular control and active and passive systems that can support the joints in the body.

Hypermobile joints by definition are those “displaying a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual.”

Hypermobility Syndrome, also known as Joint Hypermobility Syndrome or Benign Hypermobility Syndrome, is defined as generalized joint laxity with associated musculoskeletal complaints in the absence of any systemic disease. It is an inherited form of a connective tissue disorder.

Those with Hypermobility Syndrome are believed to experience pain as a result of joint microtrauma, which has been caused by overuse and/or misuse of the tissues in which there is an inherent weakness in the collagen.

Common Features of Hypermobility

• Females are often more mobile than males.

• Mobility varies amongst ethnicity (Asian populations seem to be more affected than European populations).

• Mobility decreases with age.

• Hypermobility can be inherited or acquired i.e. repeated subluxation of the shoulder joint.

• Hypermobility syndrome is typically determined by the genetic make up of the individual, in particular the genes causing hypermobility are those that are responsible for the production of collagen, elastin, fibrillin and tenascin.

• Certain sports and activities (i.e., gymnastics, ballet dancing, swimming) have shown to have a greater number of individuals with hypermobility.

• Musculoskeletal regions commonly affected include the achilles tendon, patellofemoral joint, rotator cuff, carpal tunnel, cervical and lumbar spine (non specific lower back pain and medial and lateral epicondyles.

• Hypermobile individuals may suffer from clicking, spondylolithesis and pars fractures.

• Hypermobility is a risk factor for the development of early Osteoarthritis.

• Fibromyalgia is commonly diagnosed in individuals with Hypermobility Syndrome

Diagnosis

The Beigton Score System (below) is a 9 point scale originally introduced to recognize hypermobile patients within the population. Primary health care practitioners now use it as a common screening process to help determine whether an individual has hypermobility.

Activity	Left	Right
Passively dorsiflex 5th metacarpophalangeal joint to > 90 degrees
Passively take thumb to forearm, passive hyperextend the elbow to > 10 degrees
Passive hyperextend the elbow to > 10 degrees
Passively hyperextend the knee to > 10 degrees
Actively place hands flat on floor without bending the knees

There can be a total score of 9. The revised diagnostic criteria for hypermobility requires you to get a Beigton score of 4/9 and have arthralgia for longer than three months in more than four or more joints.

Other minor criteria that support the diagnosis of Hypermobility Syndrome include:

• Dislocation and/or subluxation in more than one joint and on one or more occasions.
• Abnormal skin: striae, thin skin, increased stretch of skin.
• Eye signs: drooping eyelid or myopia
• Varicose veins, hernia, or uterine/rectal problems
• Soft tissue rheumatism (i.e., epicondylitis, tenosynovitis, synovitis)

Hypermobility and Connective Tissue Disorders

Marfan’s Syndrome, Ehlers-Danlos Syndrome and Osteogenesis Imperfecta are each genetic disorders in which the connective tissue of the individual is affected. Each disorder is different in its epidemiology, incidence and clinical presentation. While it is beyond the realm of this article to discuss each of these conditions in detail, if you have a client with one of these disorders, you should conduct further reading in order to gain a better understanding of the disorder, its implications and how you can alter your training program to better suit your client. For further information, please refer to the list of resources at the end of this article or view the "related articles" at right.

Rehabilitation and Exercise Prescription

Management of your client will largely depend upon his/her age, current physical condition, hypermobility state and personal goals. The primary aim of dealing with any hypermobile client should be to reduce disability and increase function. This should incorporate a holistic approach that addresses not only the fitness components but also addresses dietary, work and other lifestyle components.

Hypermobility and Acute or Chronic Injury

The acute hypermobile client should be managed like any other acute musculoskeletal injury. During the acute stages, you should be aiming to reduce swelling, inflammation, pain and restrict any aggravating or maintaining factors. Always refer your client to a medical practitioner or hospital if you suspect anything serious. In the sub acute to chronic hypermobile client, the aim should be to restore normal function. This could range from prescribing an exercise program to referring your client for specific treatment from a GP, Physiotherapist, Osteopath or Podiatrist. Failing to correctly manage with your client’s subacute/chronic injury could result in the development of compensatory patterns, which in turn could lead to problems developing elsewhere.

Program Design

Training the hypermobile client requires special attention to certain training principles. You need to consider all joint, muscle and ligament actions when training, making sure that you train throughout the entire range of movement and training the muscles for isometric, isotonic, concentric and eccentric actions.

Stability of a joint is determined by the integrity of the musculoskeletal system (muscle, tendon, capsule, ligament and articular surfaces) and the neural control system (motor and sensory). It is important to address these aspects when devising a program in order to develop optimum function.

The key fitness components that need addressing in the hypermobile client include:

• Proprioception
• Balance
• Coordination
• Kinesthesia
• Core stability
• Endurance
• Strength
• Controlled flexibility
• Cardiovascular fitness

Each of these fitness components requires extra attention in clients with Hypermobility Syndrome. However, each program will differ considerably depending upon the client themselves (i.e., client age, current physical state, hypermobility and goals). Programs could range from being as simple as improving one's functional state (i.e., daily living activities such as walking, squatting, sitting up and down) to training elite athletes. Essentially, you will need to assess each case individually and design a program specific to the client's needs.

Your program should try to:

• Train function. Include functional activities such as push/pull, step up/down, squat, lunge and rotation exercises in your program.
• Strengthen muscles equally and ensure there is a balance among agonist, antagonist and synergistic muscles.
• Train movements rather than muscles, when possible.
• Progress from slow to fast, stable to unstable, simple to complex, non weight bearing to weight bearing, closed chain to open chain, one plane to multi plane.

In Part 2 of this article, I will be taking a more in depth look at the individual assessment of the hypermobile client and how we can deal with the common musculoskeletal issues one may have. The article has been divided into bodily regions, outlining what we should be looking for in the assessment, how this interacts with other regions of the body and how we can go about correcting these problems.

© Copyright Personal Training on the Net 1998 ­- 2006 All rights reserved

References:

1. Cook, G.  Athletic Body in Balance, Human Kinetics, USA, 2003.
2. Gray, G. Functional Video Digest Series
3. Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.
4. Janda, V. Muscle Function Testing, Butterworths, London, 1983.
5. Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.
6. Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.
7. Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.
8. Osar, E. Complete Hip & Lower Extremity Conditioning.
9. Osar, E. Complete Shoulder & Upper Extremity Conditioning.
10. Petty, N.J & Moore, A.P.  Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.
11. Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism.
12. Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

1. www.ehlers-danlos.org
2. www.hypermobility.org
3. www.marfan.org
4. www.marfanssyndrome.net
5. www.medicinenet.com/hypermobility_syndrome
6. http://medlineplus.gov/
7. www.oif.org (Osteogenesis Imperfecta)
8. www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html