Biomechanical changes in the gastrocnemius medius–Achilles tendon complex in people with hypermobility spectrum disorders:A cross-sectional compression sonoelastography study

OBJECTIVE: This study aimed to assess the biomechanical impact of Hypermobility Spectrum Disorders (HSD) on the elasticity of the gastrocnemius medius-Achilles tendon (GM-AT) complex. METHODS: Using a cross-sectional design, the GM-AT complex elasticity was compared using sonoelastography (SEG) in an HSD group and healthy controls during rest and maximal isometric plantar flexion contraction. RESULTS: The HSD group comprised 28 patients (26 women); mean ± SD age 28.7 ± 8.4 years, compared to 28 controls (26 women); 31.5 ± 8.7 years. During rest, greater elasticity was identified in HSD relative to controls at the GM-AT musculotendinous junction (strain ratio 2.05 ± 1.31 vs. 1.48 ± 0.49), mid-AT (3.60 ± 1.97 vs. 2.66 ± 1.00), and distal AT (4.57 ± 2.69 vs. 3.22 ± 1.94) (all p 0.05). No significant differences were found between groups in the GM strain ratio during rest (4.05 ± 1.43 vs. 3.62 ± 0.78), or contraction (4.23 ± 1.29 vs. 4.19 ± 1.31). Exploratory Receiver Operator Characteristics curve analysis suggested low sensitivity and specificity of the strain ratio for the diagnosis of HSD. CONCLUSION: People with HSD have greater GM-AT complex elasticity. Although statistically significant group differences were identified, further research is required to establish the diagnostic, clinical, and research utility of strain ratio measurements

Understanding the psychosocial impact of Joint Hypermobility and Ehlers-Danlos Syndrome

AbstractIntroduction: Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome Hypermobility Type (EDS-HT) are heritable disorders affecting connective tissue. Existing research has predominately focused on biological features such as joint range of movement and pain, while less consideration has been given to psychosocial and behavioural factors.Methods: This multiphase mixed-methods design explored the lived experience of adults with JHS and EDS in three studies. Firstly, a systematic review of the literature appraised and analysed ten papers using thematic synthesis. Secondly, semi-structured telephone interviews with a purposive sample of 17 adults (14 women, 3 men), considered participants’ lived experiences and the psychosocial, cognitive and behavioural impact of JHS/EDS-HT on their lives. In the final study, these results were mapped to the Theoretical Domains Framework and COM-B model in a behavioural analysis to identify potential behaviour change interventions. Intervention options were presented to focus group participants (n=9, all women) with JHS/EDS-HT to gain consensus on priorities in a modified nominal group technique (NGT).Results: Results from the systematic review showed that people with JHS and EDS experience difficulties being understood by others in society, have limited participation in social activities, and often depend on their families for help. Similarly, results from interviews indicated a general lack of awareness of JHS/EDS-HT, fears regarding injuries or decline in ability, and a range of positive coping strategies including physiotherapy. The behavioural analysis prioritised a number of different behaviour change interventions.Conclusion: The psychosocial impact of JHS/EDS-HT on adults is substantial, and there are a number of unmet areas of care and support for this population. Novel findings have been linked to potential intervention recommendations. The findingsare discussed and triangulated in relation to existing literature and implications for future research

The feasibility of using sonoelastography to identify the effect of joint hypermobility syndrome on elasticity of gastrocnemius muscle

Background: Joint hypermobility syndrome (JHS) is a heritable connective tissue disorder in which multiple synovial joints demonstrate a painful and extraordinary range of motion. Genetically there are abnormal changes in the connective tissue matrix in people with JHS, and that may alter the viscoelasticity of their muscular tissue. Sonoelastography (SEG) is a new technology in musculoskeletal practice for assessing tissue elasticity. This study aimed to determine the feasibility of using SEG to distinguish between those with and without a diagnosis of JHS. Gastrocnemius muscle (GM) elasticity was examined, as it is essential for balance and walking.Methods: Twenty participants were examined in a cross-sectional feasibility study: 10 participants diagnosed with JHS and 10 age- and gender-matched healthy controls. The dominant GM was scanned three times using SEG. The colours of the SEG images indicate soft (red), intermediate (green) and hard (blue) tissues. ImageJ software was used to analyse the images by identifying the mean percentage of pixels of each colour.Results: For the JHS group, nine females and one male were examined, with a mean age of 38.9 years (S.D. 15.53). Similarly, for the non-JHS group, nine females and one male were examined, with a mean age of 38.9 years (S.D. 12.37). The groups were comparable in terms of age, gender and BMI (P = 1.00, 1.00, and 0.77, respectively).The JHS group had a significantly higher percentage of blue (hard tissue) pixels when compared with the control group (P = 0.035). No significant differences were found in the mean percentage of green (intermediate) and red (soft) pixels (P = 0.55 and P = 0.051, respectively).SEG required a reasonable amount of training for clinicians with sufficient background in musculoskeletal anatomy, 4 h of observation and practical training. The examination was completed in < 5 min, so it may be reasonable for use in clinical practice, and it was well tolerated by patients. The SEG image was analysed in < 5 minutes.Conclusion: The results indicate that the GM in people with JHS had more areas of hard tissue when compared with the control group, contradicting the expected results. However, GM hyperactivity has been identified during walking in people with JHS, and increased muscle tone might therefore explain the findings. The findings need to be verified in a much larger future study. The SEG seems a feasible tool for quantifying muscular tissue elasticity in JHS

Problems, solutions, and strategies reported by users of TENS for chronic musculoskeletal pain: A qualitative exploration using patient interviews

BACKGROUND: Transcutaneous Electrical Nerve Stimulation (TENS) could offer a non-drug form of pain relief, but there is no consensus regarding its effectiveness for chronic musculoskeletal pain or chronic low back pain. A recent review of previous trial methodology identified significant problems with low treatment fidelity. There is little information available to inform the development of a pragmatic implementation design for a TENS evaluation.OBJECTIVES: To explore the experiences of secondary care Pain Clinic patients with expertise in using TENS to manage chronic musculoskeletal pain. These key informants were selected as they had the potential to generate knowledge which could inform research design and clinical practice.DESIGN: A qualitative method using individual semi- Structured interviews with open questions was selected for its capacity to generate rich data.METHODS: Semi-structured interviews were conducted with nine patients (6 women). Thematic analysis was used as the primary data analysis method, and this was enhanced by a case level analysis of the context and processes of TENS use of each individual.FINDINGS: Data analysis indicated that patients learned to address a range of problems in order to optimise TENS use. Patients may need to personalise the positioning of electrodes, and the TENS settings, and to re-adjust these over time. Patients learned to use TENS in a strategic manner, and the outcomes of each strategy varied.CONCLUSIONS: The findings indicated that a pragmatic TENS evaluation may need to incorporate a learning phase to allow patients to optimise this complex pattern of TENS usage, and evaluation may need to be sensitive to the outcomes of strategic use. These findings also have implications for clinical practice

Foundational research could improve future transcutaneous electrical nerve stimulation evaluations

Background and objectives: There is a lack of good quality evidence regarding the effectiveness of transcutaneous electrical nerve stimulation (TENS) for chronic musculoskeletal pain, including chronic low back pain. High quality randomised controlled trials (RCTs) have been called for to establish effectiveness over and above placebo and some guidance has already been offered regarding the design of such trials. This article expands the discussion regarding the design of future TENS trials. There is qualitative evidence of the complexity of TENS as an intervention which should be considered in future TENS evaluations. This complexity includes multiple benefits reported by patients, depending on their chosen contexts of TENS use. The ideal content and delivery of support for patients to optimise TENS use also lacks consensus. There is no evidence that a TENS education package has been designed to support the complex set of behaviours and choices which experienced users suggest are required to optimise TENS benefits. Finally, clinical and research outcomes have not been contextualised and related to the specific strategies of use. Conclusions: We suggest that research is required to develop consensus about the content and delivery of training in TENS use for patients who live with pain, informed by the experience of patients, clinicians, and researchers. Once a consensus about the content of TENS training has been reached, there is then a need to develop a TENS training course (TTC) based on this content. An effective and acceptable TTC is needed to develop the knowledge and skills required to optimise TENS use, supporting patients to build confidence in using TENS in everyday life situations with the aim of reducing the impact of chronic pain on function and quality of life. Further research is required to extend the evidence base regarding appropriate, contextualised TENS patient-reported outcomes

Epidemiology of Generalized Joint Laxity (Hypermobility) in Fourteen-Year-Old Children From the UK: A Population-Based Evaluation

Objective Although diagnostic criteria for generalized ligamentous laxity (hypermobility) in children are widely used, their validity may be limited, due to the lack of robust descriptive epidemiologic data on this condition. The present study was undertaken to describe the point prevalence and pattern of hypermobility in 14-year-old children from a population-based cohort. Methods We performed a cross-sectional analysis using the Avon Longitudinal Study of Parents and Children, a large population-based birth cohort. Hypermobility among children in the cohort (mean age 13.8 years) was measured using the Beighton scoring system. Objective measures of physical activity were ascertained by accelerometry. Data on other variables, including puberty and socioeconomic status, were collected. Simple prevalence rates were calculated. Chi-square tests and logistic regression analyses were used to assess associations of specific variables with hypermobility. Results Among the 6,022 children evaluated, the prevalence of hypermobility (defined as a Beighton score of ≥4 [i.e., ≥4 joints affected]) in girls and boys age 13.8 years was 27.5% and 10.6%, respectively. Forty-five percent of girls and 29% of boys had hypermobile fingers. There was a suggestion of a positive association between hypermobility in girls and variables including physical activity, body mass index, and maternal education. No associations were seen in boys. Conclusion We have shown that the prevalence of hypermobility in UK children is high, possibly suggesting that the Beighton score cutoff of ≥4 is too low or that this scoring is not appropriate for use in subjects whose musculoskeletal system is still developing. These results provide a platform to evaluate the relationships between the Beighton criteria and key clinical features (including pain), thereby testing the clinical validity of this scoring system in the pediatric population. Copyright © 2011 by the American College of Rheumatology

Arabic translation, cultural adaptation, and validation of the Bristol Impact of Hypermobility questionnaire

Background: The Bristol Impact of Hypermobility questionnaire (BIoH) is the first condition-specific patient reported outcome measure for people with hypermobility-related conditions. The BIoH original version is in English, which limits its use for patients who speak other languages. The study aimed to translate and culturally adapt the BIoH into Arabic and determine its concurrent validity, reliability, internal consistency and smallest detectable change. Methods: Forward-backward translation and cross-sectional designs were used. The Ethics Committee of Kuwait Ministry of Health approved the study. Spearman correlation coefficient, intraclass correlation coefficient (ICC), and Cronbach’s α were used for statistical analysis. Patients with hypermobility spectrum disorders (HSD) were included, diagnosed using the 2017 classification framework. Results: 55 HSD patients were included, aged 26.0 (18.0) years old; median (IQR), and 85.5% were women. The BIoH showed very good concurrent validity when correlated with the SF-12 total and physical component scores; r = -0.743 and − 0.740, respectively (p < 0.05). Good correlation was identified between the BIoH and the SF-12 mental component score; r = -0.496 (p < 0.05). The BIoH demonstrated excellent test-retest reliability; ICC = 0.934 (0.749–0.983 95% CI) (p < 0.05), and high internal consistency (Cronbach’s α = 0.933). The smallest detectable change was 30.90 points, representing 19.8% of the mean baseline score. Conclusions: The study successfully translated the BIoH into Arabic and demonstrated high psychometric properties. The translated score can help Arabic patients with HSD in their clinical evaluation process. Future research needs to determine the responsiveness of the Arabic version and translate the BIoH to other languages

Pilot study: Is a long‐term follow‐up service beneficial for patients undergoing revision hip replacement surgery?

PurposeTotal hip arthroplasty (THA) is highly successful but some patients will require later revision surgery. This pilot study evaluates the effects of long‐term follow‐up for patients undergoing revision hip replacement.MethodsConsecutive patients undergoing aseptic revision of THA were recruited from a large orthopaedic unit to a single centre, observational study. Primary outcomes were changes in patient‐reported scores from pre‐revision to 12 months post‐surgery. Secondary outcomes were costs during hospital stay up to 6 months post‐revision. Participants were retrospectively allocated to two groups—those with regular orthopaedic review prior to revision (Planned revision) or those without (Unplanned revision).Resultspatients were recruited, 7 were unrevised, one incomplete baseline questionnaires. There were 25 planned and 19 unplanned revisions with no significant differences between groups at baseline. At 12 months, 34 complete data sets were available for analysis, 17 in each group. Change scores were analysed with Mann–Whitney U test; none reached statistical significance. There was a significant difference for length of stay: Planned group 5 days (2–22), Unplanned 11 days (3–86) (Mann–Whitney U test, p = 0.023). No significant differences found for theatre time or component costs. Resource costs post‐revision surgery are presented.ConclusionThis pilot study indicates that some change in methods would be required for future work. The results show that there may be some financial benefit from providing long‐term follow‐up of THA but a larger study is needed to explore these findings and to discuss the impact on recommended guidelines