Physical Therapy Management of the Hypermobile Patient
This presentation by Mr. Terry Olson, PT, MHS, FAAOMPT at the 2005 EDNF Conference in Los Angeles is accompanied by a Power Point presentation. Don't have Power Point? Click Here
Terry Olson, PT, MHS, FAAOMPT, received his physical therapy
training at the University of Iowa and he has an interest in the manual
treatment of the muscular skeletal problems. He subsequently received
his Masters Degree in orthopedic physical therapy and he developed a
post graduate program in exercise and manipulative therapy. Mr. Olson
is a fellow of the American Academy of the Orthopedic Manual Therapists
and we would like you to welcome Mr. Terry Olson.
I am going to present
this from the standpoint of looking at hypermobility. We are going to
look at a definition of hypermobility, its relationship to EDS, then talk about
the role of exercise and joint protection, and a short case study that I
thought I would present.
Okay, what is
hypermobility? There are quite a few definitions, but the one that seemed
to be the simplest was that it is a connective tissue disease, where connective
tissue proteins, such as collagen, which give the bodies its intrinsic
toughness, are differently formed; the results are mainly felt in the “moving
parts”, that being the muscles, joints, tendons, ligaments, which now are
more fragile than is the case for most people. The result is joint laxity
with hypermobility and with it comes vulnerability to the effects of injury.
The young girl presented here is the one on which I did the case presentation.
Quick review of the categories.
- Classical: Looking at skin hyperextensibility,
tissue fragility and joint hypermobility.
- Hypermobility: again, joint hypermobility is
the dominant characteristic, may have joint subluxation and dislocation,
limb and joint pain.
- Kyphoscoliosis: generalized joint laxity and
severe muscle hypotonia, scoliosis, tissue and organ fragility.
- Arthrochalasia: congenital hip dislocation,
severe generalized joint hypermobility, recurrent subluxations, tissue
fragility, and muscle hypotonia.
- Vascular: organ fragility with the possibility
of arterial or organ rupture, tendon or muscle rupture, joint
hypermobility primarily in the digits.
- Dermatosparaxis: severe skin rigidity, skin
soft and doughy and may have large hernias.
Of all of those
categories, the dominant feature from a physical therapy perspective is
hypermobility and joint laxity, so those are the primary considerations for a
therapist when treating patients with EDS; and that means that treatment needs
to focus on joint protection and dynamic stabilization of those joint
Muscle stiffness is a
term that is used to describe the spring-like quality of muscle. When a
muscle has high stiffness, increased force is required to cause lengthening of
that muscle or to perturb it. Muscle stiffness has been described in the
biomechanical and neurophysiological literature as one of the most crucial
variables in joint stabilization; and in the knee a link has been established
between receptors in the ligaments of the joint and muscle stiffness. The slide
includes a few of the references for that.
In the residency process
(I went through post-graduate residency training in manipulative and manual
therapy) you are primarily moving joints that are stiff. Switching to talking
about joints that are not stiff, which is the case here, takes a bit of a
shift. One of the things taught in the residency process was that you
cannot distinguish a problem as being a joint problem or a muscle problem.
The structures are so closely interrelated that the feedback between the two is
critical to the integrity of that joint. If you have problems within the joint;
because the joint provides feedback to the muscles, you are going to have
muscular weakness. If you have muscle weakness, again through association
with the joint structure, you are going to have impact on the stability of the
joint. Thus, any treatment needs to be directed at all of those structures.
It is possible that the
sensory properties of structures within joints can be modified by the
contraction of the local, stabilizing muscles, and this is usually the proximal
muscle groups. If you are looking at the shoulder, you are talking about
the scapular cervico-thoracic muscles and the large shoulder muscles
themselves. If you are talking about ankles and knees, you are looking at the
muscles in the trunk and the pelvic girdle.
mechanical stability to the joints, these muscles can contribute to the sensory
feedback mechanisms associated in the joint structures themselves. A
study done by Blazier, Carpenter, and
showed that tightening of the joint structures with active muscle contraction
increases the acuity of that shoulder joint. That means if the muscles are
functioning properly, then they are going to provide feedback to the joint
which, in turn, makes a more stable situation for that joint and the joint has
the ability to have feedback as to where it should be positioned.
“Dynamic stabilization”, or the use of exercise to promote joint stabilization, occurs when
tonic (postural and slow twitch muscle units), are activated. These tonic
motor units are activated during tonic continuous low load activation of
muscle, maximizing muscle stiffness. What we are talking about here is asking
the muscle to contract gently, not maximally, and to be able to sustain that
contraction for a period of time. This can be influenced by the speed of
the activity or exercise, as well as the type of muscle contraction you are
trying to acquire. Muscle contractions that are performed in the
shortened range of the muscle length are going to be critical in establishing
the sensitivity and optimal functional capacity of the sensory feedback system
in the muscle.
All that says is that
when you are exercising - for folks that are afraid to exercise, for folks that
have an inherent increase in mobility - exercise needs to be done in a very
small controlled range of motion. Dr. Unger and I have had discussions
about patients that we might see commonly as well as the patients I have seen
from Dr. Mark LaVallee. One of the things that I have seen somewhat
consistently is that the patients who are stretching don't need to stretch.
They will tell me about being stiff and they will take their leg and wrap it
around their head and it is just difficult to relate to that as being stiff.
Now you can have a feeling of stiffness, if the muscles are fatigued or
overworked, which to me then relates back to weakness.
co-activation of muscle groups provides the biomechanical forces for joint
stabilizing and protection, especially if they are performed in mid-range or
neutral joint positions. Every joint, in its ability to move through range, is
going to have positions that are inherently more stable because you have joint
surfaces that have better contact with each other. You also have a point in
that range where the muscle has mechanical advantage. If I am bending my elbow,
the biceps will do that. When the bicep is in its lengthened range (elbow
fully straight), I am going to be much weaker than when I get to a point (elbow
fully bent) when things are going to shorten or come closer together.
Mechanically this is much stronger. And, so, when you exercise EDS
patients, you need to make sure you attend to placing them in those
mechanically advantaged positions to work and exercise.
This is not just with
EDS, but with many of the patients I see that have weakness or hypermobility.
They do not exercise their full range of motion, they do not have the control
to do so, and building the ability to exercise to the greater range is the
goal. So, you start where the patient can perform in a pain-free and
stable manner. Closed chain exercise is superior for muscle protection of
the joint, although open chain exercise is also beneficial and necessary,
especially again if it is performed in the protected range of motion.
When we are talking
about open chain exercise/closed chain exercise we mean the following. Open
Chain Exercise: if I want to exercise my quadriceps, that is the muscle that
straightens my knee out, that is open chain, just moving my leg through range
of motion. Closed Chain Exercise: if I stand here and do a squat, I am
still working that quadriceps muscle, but by virtue of contact with the floor,
we now have other muscles that act to provide increased stability. So a lot of
times, starting these patients with exercises that are more closed chain,
enhances that ability to stabilize muscles around the joint.
We take a body chart
that the patient marks when they come in - and again, typically, when I get a
body chart on a patient from Dr. LaVallee, that whole body chart may be colored
in - it looks like they have a suit on.
As a therapist, where do
you start with that - you cannot treat everything. In this case here, the
young girl, the primary complaint was the mid lower back, and the other
complaints were part of her overall problem; but in this case not the primary
reason for presenting to therapy. Primarily, it was because of back and
hip trouble. She had a diagnosis of lumbar back pain, left hip pain, and
EDS multiple areas of pain complaint and again those were most notable in back
and hip. She described pain complaints of an 8 out of 0-10, (0 being no
pain, 10 being like a wild animal tearing your leg off).
She described her pain
at her worst as being an 8 on that scale with standing for more than one hour
being a provocative activity, as well as her activities of daily living.
One of the things that were important at that time was that she had a baby, and
that holding her baby was enough to provoke a lot of these pain complaints.
She had objective signs of multiple joint hypermobility with back pain
In her case, initial emphasis
was on symptom alleviation using modalities (heat and cold, TENS units,
electrical stimuli), gentle joint mobilizationand biomechanical correction, as
well as performing assisted exercise in protected asymptomatic range of motion.
We also provided biomechanic counseling on joint protection, as well as back
care education regarding lifting, sitting, and performance of her activities of
Over the course of
treatment, as her symptoms decreased, we progressed into more dynamic exercise,
dynamic stabilization, and that become the crux of her home program.
One of the things that
we can use in the setting that I work in, at least in the acute phases, is
equipment designed to start exercising folks at less than full limb loading. If
you have someone that has an injury or problems with - as in this case - knee
and hip, and those problems occur when they are weight bearing, then the idea
is that exercise has value because if we exercise, we have the ability to
increase blood flow and circulation, increase oxygen, all of the things that
are essential for healing, as well as building blocks for laying down stronger
tissue. The problem is bringing that load to an acceptable level for that
So, in this case, this
patient is just doing a bilateral squat activity and the slide board allows
her/him to exercise anywhere from less than 20% of body weight taking it all
the way up to 70% of body weight and then we know how to graduate that into a
gym exercise. We try to exercise people as functional as we can, so if
people have complaints of “when I stand too long or when I walk too long, when
I bend is when I have my complaints,” I am
going to try to set my exercise program up so that they are standing, walking,
bending, but using the equipment to again decrease gravity, or their body
weight, so that they are exercising with less body weight on those joints.
In this case, with
walking, we use a treadmill system that has an overhead pneumatic assist and
that harness allows us to hoist someone up. We can take that person, take
as much as 70% of body weight (essentially the weight of the trunk - you go any
higher than that and you are like Peter Pan and you are unstable, and you are
ready to fly) then you are still getting input into the joints, but not full
I had a discussion with
one of the participants who asked me about Pilates - I am going to beat people
to the punch - I don't know. Pilates makes sense to me that it can be of
value, but I don't know enough about it and I might make an idiot of myself
trying to tell you the value of it.
Not for purpose of this
talk, but if it gives any rationale to why; the approach that we use is a
system called "medical exercise training". That approach is
based on specific tissue exercise, and so we work from a standpoint that muscle
requires a different muscle stimulus than does tendon, than does cartilage,
than does disc. All of those structures have a different metabolic
requirement, so those exercises have to be different, and when you are working
with folks who have tendonitis, we try to work out an exercise program that
allows that person to go through anywhere from 150 to 200 repetitions - because
that seems to be the adequate number of repetitions to get an adequate increased
blood flow to the area to promote a healing response. When trying to
address structures such as ligament, cartilage, disc, those structures require
upwards of 1,000 to 1,500 reps. The problem is taking someone who hurts and
tell them you are going to put them on an exercise program of 1,500 repetitions
and then say I will come back in an hour and see how you are doing. So to do
that, you need to take load off, and the purpose of the equipment is to assist
that part so that person can perform repetitions without pain. And then
as the structure begins to heal, we gradually put load back on.
So this was the initial
phase. In addition, we started to work on trunk. With Pilates or with
other approaches, their value is core strengthening of the trunk - because your
arms and legs attach to your trunk and if your trunk is not stable, then it is
difficult to promote stability into those joints. Oftentimes the trunk is the
most logical place to start, and is probably the easiest because everything
else has to function off of it.
A simple leg raise will
require activation of the transverse abdominal muscles if they are activated
and used. The fact that her back is arched and she is unable to keep it
from arching is indicative of the fact that a good exercise becomes a very poor
one because she doesn't exhibit the ability to recruit enough trunk muscles to
actually handle the weight. Here, she is able to keep the trunk stable
(you don't see that hollow) and so she is performing that exercise actually
really well with good trunk control.
Exercise is controlled
trauma. When we exercise someone, we are inflicting trauma - the idea is
to control it. If you exercise adequately, you are going to break down
tissue, then let it rest and in this phase it recovers and lays down stronger
tissue - if you adequately stress it. If you overstress it, then a good
exercise becomes a bad exercise pretty quickly. All day long I see patients
come in who are failures at exercise programs and it is not because exercise is
not a benefit to them, they have just not been trained to do it with good form
and to work in a range where they have control. You need to understand
what is safe.
I had actually treated
Erika about 9 months ago and she did well. I asked her to come back to see how
she was doing but also to take some photos for this presentation and it was a
good chance to take her upstairs and see if she was doing what we had
instructed her to do 9 months ago. She demonstrates incredible form. Her
elbows are going the wrong way and you would think that would make sense, but
when we first went over her exercises and she did things, a lot of the things
she was performing, a lot of work was in an unstable range and it was causing a
lot of pain. It was just a matter of again making certain that her trunk was
active and then worked in the range that she could exhibit control.
The exercise doesn't
matter - when I set exercises for people, it doesn't matter, pushing up,
pulling down, pushing away, pulling into them, I do a variety because life is
made up of that. You need to be able to do all sorts of things but in a stable
manner. The exercises need to be changed and modified as long as the
patient understands stabilizing well, good trunk improvement, and that the
joints are working in a range where they were stable.
I saw Erika for 9 visits
over a 5 week period. Initial treatments consisted of gentle treatment to
relieve symptoms coupled with assisted exercise utilizing the assisted
treadmill walking and total gym. The patient then progressed to a
stabilization and progressive strengthening exercise program. Her
symptoms decreased, her discharge pain complaints were decreased, and she was
able to stand and sit for more than two hours without symptoms, as well as lift
her baby without increase in symptoms.
The final slide provides
some excellent overall points in your therapy process. All of these things can
be used in treatment and pain reduction. What I have seen with pain
reduction, if you are heating people or icing them or electric stimuli, you are
doing things that are temporary. Long lasting change is only going to
come with making a change in the body, to the extent that you can. So,
exercise with emphasis on controlled range of motion or working within a range
of control. Pool therapy is beneficial and we use a pool at our facility
also. Pool therapy takes the body weight off much the way the harness
mentioned above does. Massage certainly has value, but again I think you need
to be careful about monitoring skin integrity, especially if you are doing
friction massage which is one of the therapy modalities often used in treating
tendonitis. Use of splints or bracing - those are done supportively.
Annual therapy, manipulative therapy, chiropractic therapy - it is not
contraindicated, but you need to make sure you are addressing treatment to a
joint that needs to be moved, not the joints that already move excessively.
As a general rule, you want to be cautious of vigorous stretching secondary to
inherent hypermobility. Again, I don't teach people to stretch, but they
do need to strengthen because they have all of this range of motion that they
don't have control of and that is painful. A lot of patient
education, regarding ergonomics, joint protection, body mechanics, is required.