Conservative management of hand impairment in children and adolescents with heritable disorders of connective tissue: A scoping review.

AIMS: To synthesize and critically appraise available interventions in the conservative management of hand impairment for children and adolescents with heritable disorders of connective tissue (HDCT). METHODS: A search of peer-reviewed literature and online platforms were included with data regarding hand impairment and function, conservative management and outcome measures extracted and appraised. Levels of evidence were applied to published literature. RESULTS: Ten peer-reviewed papers, eleven webpages and YouTube videos met the inclusion criteria. Reported interventions included: strengthening, orthoses, assistive equipment, education and pacing. Evidence of intervention effectiveness and evidence-based guidance on dosage were absent, with no consistency of outcome measures monitoring intervention effectiveness. Online platforms posted by health professionals predominantly provided advice for families without clinical detail of interventions. CONCLUSIONS: There is a consistent suite of interventions identified in both peer-reviewed literature and online platforms used by clinicians and families to manage hand impairment for children and adolescents with HDCT. Clear dosage parameters and outcome measures are needed in future intervention studies to determine the effectiveness of interventions and guide clinicians in how best to treat hand impairment. Increasing accountability and quality of online resources posted by health professionals for families is warranted to ensure dosage details and precautions are provided.

Reference values of four measures of craniocervical stability using upright dynamic magnetic resonance imaging.

PURPOSE: To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures. MATERIALS AND METHODS: Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb-Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position. RESULTS: The revised measurement protocol produced inter-rater reliability indices of 0.69-0.97 (moderate-excellent). Fifty adults' (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found. CONCLUSIONS: This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported.

Online pain management programs for chronic, widespread musculoskeletal conditions: A systematic review with meta-analysis.

Face-to-face pain management programs demonstrate positive clinical outcomes in the chronic pain population by improving pain intensity and attitudes, depression, and functional disability scores. The effects of this modality carried out online is less known, particularly in subgroups of chronic pain. This systematic review assessed the effects of online pain management programs in chronic, widespread musculoskeletal conditions on pain measurements (intensity, interference, coping, and catastrophizing), health-related quality of life, depression, and anxiety scores immediately post-intervention. Five electronic databases (Embase, Medline, CINAHL, Scopus, and PEDro) were searched with 3546 studies identified. Eighteen randomized controlled trials fulfilled the inclusion criteria. Included studies had moderate methodological quality (using the Effective Public Health Practice Project (EPHPP) quality assessment tool) but high risk of bias (using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2)). There were significant improvements in pain intensity (11 studies, 1397 participants, SMD -0.30, 95% CI -0.50 to -0.10, p = 0.004), health-related quality of life (eight studies, 1054 participants, SMD 0.41, 95% CI 0.08 to 0.75, p = 0.02), and depression (nine studies, 1283 participants, SMD -0.32, 95% CI -0.55 to -0.08, p = 0.008). However, effect sizes were small and did not meet their respective measure's minimal clinically important change score. Guided interventions (regular interaction with an instructor) appeared to be superior to self-completed interventions. Future research should standardize outcome measures for assessing pain, use active control groups, and analyze other outcome measures such as cost and long-term effects. This study was registered with Prospero on August 15, 2021 (CRD42021267565).

Hand Impairment and Function in Children and Adolescents With Heritable Disorders of Connective Tissue.

IMPORTANCE: Heritable disorders of connective tissue (HDCTs) affect hand function and participation in daily activities for children and adolescents. OBJECTIVE: To describe hand impairment and function and determine the extent to which hand impairment and function explain the variation in self-reported functional performance. DESIGN: Cross-sectional observational study. SETTING: Specialist tertiary hospital. PARTICIPANTS: Children and adolescents ages 8-18 yr with HDCTs (N = 73). INTERVENTION: None. OUTCOMES AND MEASURES: Hand function outcomes included grip strength (digital dynamometer), manipulation and dexterity (Functional Dexterity Test, Nine-Hole Peg Test), and fine motor skills (Bruininks-Oseretsky Test of Motor Proficiency). Upper limb hypermobility was assessed using the Upper Limb Hypermobility Assessment Tool. Hand pain and fatigue were recorded for a timed button test and 3- and 9-min handwriting tasks. Functional performance was measured using the Childhood Health Assessment Questionnaire. RESULTS: Scores on all hand function measures were below expected norms. Pain and fatigue were significantly worse after the writing tasks (p < .001) but not the button test (p > .40). Secondary students had significantly lower handwriting scores than primary students (p = .03) but similar grip strength z scores (p = .95). Variation in self-reported functional performance was explained by grip strength (6%) and upper limb hypermobility and dexterity (16%). CONCLUSIONS AND RELEVANCE: Young people with HDCTs have poor hand function attributable to poor grip strength and hand pain and fatigue. Comprehensive upper limb evaluation and ongoing monitoring throughout the school years are warranted to inform timely intervention. What This Article Adds: Children and adolescents with heritable disorders of connective tissue have difficulty with hand function that affect their participation in daily activities. The results of this study can help clinicians identify, assess, and monitor daily activities, performance skills, and symptoms of children and adolescents with HDCTs to promote their participation in all aspects of daily life.

International Perspectives on Joint Hypermobility: A Synthesis of Current Science to Guide Clinical and Research Directions.

ABSTRACT: There is exponential clinical and research interest in joint hypermobility due to recognition of the complexity of identification, assessment, and its appropriate referral pathways, ultimately impacting management. This state-of-the-science review provides an international, multidisciplinary perspective on the presentation, etiology, and assessment of joint hypermobility, as it presents in those with and without a systemic condition. We synthesize the literature, propose standardizing the use of terminology and outcome measures, and suggest potential management directions. The major topics covered are (i) historical perspectives; (ii) current definitions of hypermobility, laxity, and instability; (iii) inheritance and acquisition of hypermobility; (iv) traditional and novel assessments; (v) strengths and limitations of current assessment tools; (vi) age, sex, and racial considerations; (vii) phenotypic presentations; (viii) generalized hypermobility spectrum disorder and hypermobility Ehlers-Danlos syndrome; and (ix) clinical implications and research directions. A thorough understanding of these topics will equip the reader seeking to manage individuals presenting with joint hypermobility, while mindful of its etiology. Management of generalized joint hypermobility in the context of a complex, multisystem condition will differ from that of acquired hypermobility commonly seen in performing artists, specific athletic populations, posttrauma, and so on. In addition, people with symptomatic hypermobility present predominantly with musculoskeletal symptoms and sometimes systemic symptoms including fatigue, orthostatic intolerance, and gastrointestinal or genitourinary issues. Some also display skeletal deformities, tissue and skin fragility, and structural vascular or cardiac differences, and these warrant further medical follow-up. This comprehensive review on the full spectrum of joint hypermobility will assist clinicians, coaches/sports trainers, educators, and/or researchers in this area.

Identifying lower limb specific and generalised joint hypermobility in adults: validation of the Lower Limb Assessment Score.

BACKGROUND: The Lower Limb Assessment Score (LLAS) has only been validated in a paediatric population. The aim of this study was to validate the use of the LLAS in an adult population by: i) evaluating its ability to discriminate between different extents of lower limb hypermobility, ii) establishing a cut-off score to identify lower limb hypermobility, and iii) determining if the LLAS is able to identify Generalised Joint Hypermobility (GJH). METHODS: Participants were recruited across three groups representing varying degrees of hypermobility. They were assessed using the LLAS, Beighton score and clinical opinion. Pearson's correlation coefficient and MANOVA were used to assess between-group differences in the LLAS. The cut-off score was determined using median and inter-quartile ranges and the Receiver Operator Characteristic Curve. The ability of the LLAS to identify GJH was assessed using percent agreement with clinical opinion. RESULTS: One hundred twelve participants aged 18-40 years were recruited. The LLAS distinguished the control from the likely hypermobile and known hypermobile cohorts (both p < 0.001), as well as the likely hypermobile from the known hypermobile cohort (p = 0.003). The LLAS cut-off score for identifying lower limb hypermobility was ≥7/12 with a specificity of 86% and sensitivity of 68%. The LLAS accurately identified those with GJH with high percentage agreement compared to clinical opinion across all cohorts (69-98%). CONCLUSIONS: The LLAS is a valid tool for identifying lower limb specific hypermobility and GJH in adults at a cut-off score of ≥7/12. It demonstrates excellent specificity and moderate sensitivity, and discriminates well between extents of hypermobility.

An interactive, multi-modal Anatomy workshop improves academic performance in the health sciences: a cohort study.

BACKGROUND: Students often strategically adopt surface approaches to learning anatomy in order to pass this necessarily content-heavy subject. The consequence of this approach, without understanding and contextualisation, limits transfer of anatomical knowledge to clinical applications. Encouraging deep approaches to learning is challenging in the current environment of lectures and laboratory-based practica. A novel interactive anatomy workshop was proposed in an attempt to address this issue. METHODS: This workshop comprised of body painting, clay modelling, white-boarding and quizzes, and was undertaken by 66 health science students utilising their preferred learning styles. Performance was measured prior to the workshop at the mid-semester examination and after the workshop at the end-semester examination. Differences between mid- and end-semester performances were calculated and compared between workshop attendees and non-attendees. Baseline, post-workshop and follow-up surveys were administered to identify learning styles, goals for attendance, useful aspects of the workshop and self-confidence ratings. RESULTS: Workshop attendees significantly improved their performance compared to non-attendees (p = 0.001) despite a difference at baseline (p = 0.05). Increased self-confidence was reported by the attendees (p < 0.001). To optimise their learning, 97% of attendees reported utilising multi-modal learning styles. Five main goals for participating in the workshop included: understanding, strategic engagement, examination preparation, memorisation and increasing self-confidence. All attendees reported achieving these goals. The most useful components of the workshop were body painting and clay modelling. CONCLUSIONS: This interactive workshop improved attendees' examination performance and promoted engaged-enquiry and deeper learning. This tool accommodates varied learning styles and improves self-confidence, which may be a valuable supplement to traditional anatomy teaching.

Quality of life prediction in children with joint hypermobility syndrome.

AIMS: To assess the child- and parent-reported health-related quality of life (HRQOL) of children with joint hypermobility syndrome (JHS), to compare these with other chronic paediatric conditions and to determine whether symptoms experienced by children with JHS can predict their HRQOL. METHODS: Eighty-nine children with JHS and one of their parents completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale, the Multidimensional Fatigue Scale and the Pediatric Pain Questionnaire. Anthropometric measures and reported symptoms were recorded. Child-reported HRQOL scores were compared with parent report, and both child- and parent-reported HRQOL scores of children with JHS were compared with those of children with other chronic conditions. Stepwise multiple regression was undertaken to determine whether any combination of measures could predict HRQOL. RESULTS: Parent- and child-reported HRQOL scores were strongly correlated (r = 0.6-0.84, all P < 0.001); however, parents of children with JHS perceived lower overall HRQOL (mean difference = 4.44, P = 0.001), physical (mean difference = 7.11, P < 0.0001) and emotional functioning (mean difference = 5.24, P = 0.011) than their children. When considered together with previously reported HRQOL scores for children with other chronic conditions, parent and child scores were similarly strongly correlated (r = 0.93, P = 0.001). Multiple regression revealed that 75% of the variance in child-reported HRQOL scores was accounted for by a child's level of pain and fatigue, and presence of stress incontinence symptoms (P < 0.0001). CONCLUSION: Children with JHS experience poor HRQOL and disabling fatigue, with parent scores providing a good proxy. Pain, fatigue and the presence of stress incontinence symptoms have the greatest impact on their HRQOL.

Diagnostic accuracy of clinical tests for ankle syndesmosis injury.

OBJECTIVE: Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests. DESIGN: Cross-sectional diagnostic accuracy study. SETTING: 9 clinics in two Australian cities. PARTICIPANTS: 87 participants (78% male) with an ankle sprain injury presenting to participating clinics within 2 weeks of injury were enrolled. METHODS: Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with MRI results (read by a blinded radiologist) as a reference standard. Tests were evaluated using diagnostic accuracy, sensitivity, specificity and likelihood ratios (LRs). A backwards stepwise Cox regression model determined the combined value of the clinical tests. RESULTS: The clinical presentation of an inability to perform a single leg hop had the highest sensitivity (89%) with a negative LR of 0.37 (95% CI 0.13 to 1.03). Specificity was highest for pain out of proportion to the apparent injury (79%) with a positive LR of 3.05(95% CI 1.68 to 5.55). Of the clinical tests, the squeeze test had the highest specificity (88%) with a positive LR of 2.15 (95% CI 0.86 to 5.39). Syndesmosis ligament tenderness (92%) and the dorsiflexion-external rotation stress test (71%) had the highest sensitivity values and negative LR of 0.28 (95% CI 0.09 to 0.89) and 0.46 (95% CI 0.27 to 0.79), respectively. Syndesmosis injury was four times more likely to be present with positive syndesmosis ligament tenderness (OR 4.04, p=0.048) or a positive dorsiflexion/external rotation stress test (OR 3.9, p=0.004). CONCLUSIONS: Although no single test is sufficiently accurate for diagnosis, we recommend a combination of sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness and the dorsiflexion-external rotation stress test (sensitive) may be combined with pain out of proportion to injury and the squeeze test (specific).

An online pain management program for people with hypermobile Ehlers-Danlos Syndrome or hypermobility spectrum disorder: a three-staged development process.

PURPOSE: Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs. MATERIALS AND METHODS: A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS). RESULTS: 396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability". CONCLUSIONS: A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

Pain is one of the most common and impactful symptom affecting those with Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD).Online pain management programs are effective in other chronic conditions such as Fibromyalgia and Rheumatoid Arthritis, but there are no programs specific for hEDS/HSD.People with hEDS or HSD and healthcare professionals with experience in these conditions feel that an online pain management program specific to their condition is important; consensus revealed thirty-five key topics important to these stakeholders.The first hEDS/HSD-specific online pain management program, called HOPE, was developed with stakeholder input and usability tested, ready for clinical trial testing.

The Effectiveness of Dance Interventions on Psychological and Cognitive Health Outcomes Compared with Other Forms of Physical Activity: A Systematic Review with Meta-analysis.

BACKGROUND: Physical activity is known to improve psychological and cognitive outcomes. Learning dance sequences may challenge cognition, partnered or group dance may benefit social interactions, and the artistic aspect may improve psychological wellbeing. Dance is an equally effective form of physical activity compared with other structured physical activities to improve physical health, but it is unclear how effective dance could be for psychological and cognitive outcome measures. OBJECTIVE: To systematically review the literature on the effectiveness of structured dance interventions, compared with structured exercise programmes, on psychological and cognitive outcomes across the lifespan. METHODS: Eight databases were searched from earliest records to July 2022. Studies investigating a dance intervention lasting ≥ 4 weeks, including psychological and/or cognitive health outcomes, and having a structured exercise comparison group were included. Screening and data extraction were performed by two independent reviewers at all stages. All reviewer disagreements were resolved by the primary author. Where appropriate, meta-analysis was performed, or an effect size estimate generated. RESULTS: Of 21,737 records identified, 27 studies met the inclusion criteria. Total sample size of included studies was 1392 (944 females, 418 males, 30 unreported). Dance was equally as effective as other physical activity interventions in improving quality of life for people with Parkinson's disease [mean difference 3.09; 95% confidence interval (CI) - 2.13 to 8.30; p = 0.25], reducing anxiety (standardised mean difference 2.26; 95% CI - 2.37 to 6.90; p = 0.34), and improving depressive symptoms (standardised mean difference 0.78; 95% CI - 0.92 to 2.48; p = 0.37). Preliminary evidence found dance to be superior to other physical activity interventions to improve motivation, aspects of memory, and social cognition and to reduce distress. Preliminary evidence found dance to be inferior to other physical activity interventions to improve stress, self-efficacy and language fluency. CONCLUSION: Undertaking structured dance of any genre is generally equally and occasionally more effective than other types of structured exercise for improving a range of psychological and cognitive outcomes. TRIAL REGISTRATION: PROSPERO: CRD42018099637.

Prognosis and prognostic factors for patients with persistent wrist pain who proceed to wrist arthroscopy.

UNLABELLED: Wrist pain is common. People with persistent pain commonly undergo arthroscopic investigation. Little is known about the prognosis or prognostic factors for these patients. The purpose of the study was to evaluate prognosis and prognostic factors for pain and functional disability in patients with persistent wrist pain who proceed to arthroscopic investigation. The study design used was a prospective cohort study. One hundred and five consecutive participants who underwent arthroscopic investigation for undiagnosed wrist pain for at least four-week duration were recruited. Patient-rated wrist and hand evaluation (PRWHE) scores were determined at baseline (before arthroscopy) and one year after arthroscopy. One-year follow-up data were obtained for 97 (92%) of 105 participants. Mean PRWHE total score declined from 49 of 100 (standard deviation [SD] 18.5) at baseline to 26 of 100 (SD 20.4) at one year. Two prognostic factors were identified: baseline PRWHE and duration of symptoms. These factors explained 19% and 5% of the variability in the final PRWHE score, respectively. Results of provocative wrist tests and arthroscopic findings did not significantly contribute to prognosis in this cohort. This study provides the first robust evidence of the prognosis of persistent wrist pain. Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability. Duration of pain and PRWHE at baseline explained 24% of the one-year PRWHE score. LEVEL OF EVIDENCE: Level 2.

Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations.

Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.

More Than a Game: Musculoskeletal Injuries and a Key Role for the Physical Therapist in Esports.

SYNOPSIS: The esports industry is growing exponentially: more viewers, more support, more money, and more players. Esports competitors require high-level cognitive function and dexterity. There is an increasing demand for physical therapists to manage esports-related musculoskeletal injuries across all levels of play (amateur, semi-professional, professional). Clinicians have relied on general musculoskeletal principles and extrapolating research findings from other populations, including athletes, office workers, air traffic controllers, and musicians, to inform an evidence-based practice approach to assessing and managing injury in esports competitors. The physical demands of esports competitors are triple those of office workers, varying across esports games, platforms (computer, console, mobile), and levels of performance. We highlight the role of physical therapy in esports, the need for best-practice guidelines for musculoskeletal health care, the current research evidence, and the large research gaps in the field. J Orthop Sports Phys Ther 2021;51(9):415-417. doi:10.2519/jospt.2021.0109.

Is there a relationship between sagittal cervical spine mobility and generalised joint hypermobility? A cross-sectional study of 1000 healthy Australians.

OBJECTIVES: The primary aim was to determine the association between sagittal cervical mobility and the presence and extent of GJH across the lifespan. Secondary aims were to determine which features explain variability in cervical range of motion (CROM) and to establish the sagittal cervical hypermobile range in both genders across the lifespan. DESIGN: Cross-sectional observational study. Spearman's rho determined the relationship between presence and extent of GJH and CROM, age, gender and ethnicity. Multiple regression identified the factors explaining variability in CROM. The hypermobile CROM was identified as the upper 5% of flexion, extension and combined ranges for age and gender. SETTING: University laboratory in Sydney Australia. PARTICIPANTS: One thousand healthy individuals, aged 3-101 years. OUTCOME MEASURES: Cervical active range of motion was assessed using an inclinometer, extent of and presence of generalised joint hypermobility were assessed using the Beighton scoring system and age- and gender-specific criteria respectively. RESULTS: CROM correlated positively with GJH (Beighton score as a continuous or dichotomous age and gender specific variable) (rho=0.12-0.50; p < 0.001) and negatively with age (rho=0.54; p < 0.001). Age, gender and extent of GJH (Beighton as a continuous score) accounted for 19 to 51% of variability in CROM. Cut-offs for cervical hypermobility were calculated across the lifespan. CONCLUSIONS: Increased sagittal CROM was observed in individuals identified with GJH. Extension CROM decreased with age more than flexion; the greatest loss in the second and third decades. CROM screening is warranted for patients identified with GJH and for rehabilitation goal-setting.

Joint hypermobility and its association with self-reported knee health: A cross-sectional study of healthy Australian adults.

AIM: The primary aim of this study was to determine the association between generalized joint hypermobility (GJH), knee-specific hypermobility (KSH) and self-reported knee health in an Australian population. Secondary aims included elucidating ethnic/gender differences in GJH/KSH prevalence and knee health, and identifying KSH using a novel knee extension range of motion cut-off method. METHOD: Knee extension range, Beighton score, and 5 domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected from adults aged 18-101 years self-identifying as healthy, and were grouped by ethnicity and gender. Two established Beighton score criteria and 1 novel knee extension range cut-off method were used to determine GJH and KSH respectively. Point-biserial correlation tested the associations between GJH/KSH and KOOS. Differences in GJH/KSH prevalence and knee health between ethnic/gender groups were determined with the Chi-squared test. RESULTS: Of 732 participants (50% male), 80.3% were Caucasian. No correlations were found between GJH and KOOS while a very weak correlation was found between KSH and 1 KOOS domain (r > -.30; P = .04). Prevalence of GJH was higher in non-Caucasians (17.4% vs 5.6%, P < .001) and females (4.4% vs 1.1%, P = .007). Prevalence of KSH between ethnic and gender groups was not significantly different (P = .50 and P = .69 respectively). Non-Caucasians scored higher (better) in all KOOS domains than Caucasians (all P < .05). CONCLUSION: Those who met the age- and gender-specific criteria for GJH/KSH did not report worse knee health than their non-hypermobile counterparts. Clinicians can assure individuals who exhibit GJH/KSH that these are not associated with lower knee health and function.

Prevalence and unique patterns of lower limb hypermobility in elite ballet dancers.

OBJECTIVES: Determine the prevalence of lower limb hypermobility in elite dancers and secondarily to describe the patterns of mobility. DESIGN: Cross sectional. SETTING: Self-report questionnaires and physical assessments were undertaken at a tertiary dance institution and a professional ballet company. PARTICIPANTS: Fifty-seven pre-professional and 29 professional ballet dancers (21±4years, 64% female, mean 13.7years training) were recruited. MAIN OUTCOME MEASURES: Lower Limb Assessment Score (LLAS) was used to assess hypermobility. Prevalence was determined by descriptive statistics, between-leg and -group comparisons were analysed using the chi-square statistic and the pattern of mobility by cluster analyses. RESULTS: The right leg was significantly more hypermobile than the left for the whole cohort (44% vs 40% meeting ≥7/12 for the LLAS; LLAS mean/12(SD): right:5.0(2.4) and 7.6(1.9); left:4.8(2.1) and 6.7(2.0) in pre-professionals and professionals respectively (p = 0.02)). Subtalar pronation (p < 0.001) and hip abduction/external rotation (left:p = 0.01; right:p < 0.001) were significantly more hypermobile bilaterally in professionals. Three hypermobility profiles on the left and four on the right lower limb were identified. CONCLUSIONS: This paper presents unique lower limb hypermobility profiles identified in elite dancers.

Sports participation and humeral torsion.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To examine differences between arms in humeral torsion in adult and adolescent throwing and nonthrowing athletes, and nonathletic adults. BACKGROUND: It is hypothesized that humeral retrotorsion develops by, and is beneficial for, throwing. Thus throwers should demonstrate greater retrotorsion in their dominant arm relative to their nondominant arm and have more side-to-side retrotorsion difference than nonthrowing groups. In addition, adult throwers should have a greater side-to-side retrotorsion difference than adolescent throwers, and swimmers should not demonstrate a retrotorsion difference. METHODS AND MEASURES: Using ultrasound to standardize the location of the bicipital groove, the amount of humeral torsion was measured in both arms of male baseball players (85 adult, 35 adolescent), female softball players (16 adult, 37 adolescent), 29 elite adolescent swimmers (19 female), and 16 nonathletic adults (8 female). RESULTS: More retrotorsion was found in the dominant arm of almost all throwing athletes, irrespective of their gender or whether they were adults or adolescents (mean+/-SD side-to-side difference, 11.9 degrees+/-10.5 degrees). This difference was less for swimmers (6.4 degrees+/-9.9 degrees) and nonathletic adults (1.3 degrees+/-8.9 degrees). CONCLUSION: Greater dominant armhumeral retrotorsion is observed contingent with participation in throwing sports.

Prevalence and frequency of self-perceived systemic features in people with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type.

Some commonly reported systemic features of joint hypermobility syndrome (JHS)/Ehlers-Danlos syndrome hypermobility type (EDS-HT) are absent from nosologies due to insufficient validity. The primary aim was to examine the hypothesised high prevalence and frequency of orthostatic intolerance, easy bruising, and urinary incontinence in adults with JHS/EDS-HT and secondarily to determine the association between extent of generalised joint hypermobility (GJH) and these systemic features. A cross-sectional cohort study was conducted via online recruitment of medically diagnosed JHS/EDS-HT patients. A survey collected demographic data and clinical history. A subgroup of participants underwent physical testing of GJH using the Beighton score and Lower Limb Assessment Score (LLAS). Descriptive analysis was performed on demographic data and self-reported non-musculoskeletal systemic features. Correlation of GJH scores and systemic features were performed using Spearman's rank correlation. The survey was completed by 116 individuals (95% female; 16-68 years) with 57 (93% female) also participating in the physical assessment. The most prevalent systemic feature was orthostatic intolerance (98%), followed by easy bruising and urinary incontinence (97% and 84% respectively). Of those reporting symptoms of orthostatic intolerance, easy bruising, and urinary incontinence, 58%, 40%, and 18% described them as very highly frequent respectively (frequency > 75%). No significant correlations were found between the extent of systemic features and GJH scores as measured by either the Beighton score or the LLAS. The high prevalence and frequency of the systemic features found in this study, which are omitted in diagnostic classification criteria, suggest that further research on their diagnostic accuracy is warranted.

Proprioceptive acuity in active rotation movements in healthy knees.

OBJECTIVES: To investigate the ability of asymptomatic participants to discriminate between active knee rotation movements of different magnitude and to determine whether proprioceptive acuity of active knee rotation differs between limbs (dominant and nondominant and right and left). DESIGN: Cross-sectional study. SETTING: Laboratory in an Australian university. PARTICIPANTS: Healthy volunteers (N=30) without previous cruciate ligament injury or surgery, previous fracture of the lower limbs, or other lower-limb disorders in the last 3 months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Knee rotation proprioceptive acuity was determined by using our custom-designed device. The measure of proprioceptive acuity used in this study was the just-noticeable difference (JND). Participants actively rotated the knee (internal or external rotation) to 1 of 4 movement blocks and judged the magnitude of the permitted motion. Proprioceptive acuity scores, representing a participant's ability to detect small differences in magnitude of active knee rotation movements, were then calculated. RESULTS: The means of the JND for proprioceptive acuity of internal rotation (1.37 degrees +/-.11 degrees ) were significantly (P=.04) lower than for external rotation (1.6 degrees +/-.14 degrees ) regardless of side (right, left) or dominance. No significant difference was found between the mean JND for left and right knee rotations (P=.84) or between the mean JND for dominant and nondominant knee rotation (P=.69). CONCLUSIONS: Participants perceived smaller differences between active internal rotation movements than external rotation. No significant difference was found between the dominant and nondominant leg or between the left and right leg; therefore, clinicians can establish whether a proprioceptive deficit exists after unilateral injury and can use acuity of the uninjured knee as a normal status for rehabilitation.