An investigation into the effects of a virtual reality system on phantom limb pain: a pilot study.

BACKGROUND: There is no first-line treatment available for phantom limb pain (PLP). For some years, there has been interest in the use of mirrors and other techniques based on visual feedback. Unfortunately, up until now, all published studies have had methodological weaknesses with two recent systematic reviews concluding that therapies of this kind need more evidence to support their use. AIM: To evaluate the effects of a virtual reality (VR) activity on PLP. METHODS: This was a prospective pilot study of upper limb amputees using questionnaires to evaluate a VR system. Eleven participants were recruited, with nine completing all three sessions of VR. Participants undertook three sessions of VR, one a month for 3 months. Outcome measures were PLP pain intensity using an 11-point numerical rating scale (NRS), number of PLP episodes and duration of the PLP episodes. All participants were also asked for their judgement of change. Open-ended questions captured the qualitative experience of all aspects of the VR experience. RESULTS: The mean PLP pain score following three VR sessions reduced (6.11 v 3.56) but this was not a statistical difference (t = 2.1, df = 8, p = 0.07). No statistical difference was found for the number of PLP episodes (Pearson chi-square = 3.43, df = 2, p = 0.18) or the duration of each PLP episode (Pearson chi-square = 22.50, df = 16, p = 0.13). Three groups emerged: those whose pain reduced (the majority), those whose pain remained the same (small number) and one those whose pain increased slightly. DISCUSSION: There is insufficient evidence from these results to identify an effect of VR on PLP; however, this is a small group and qualitatively most were content with the treatment and wanted a longer trial.

Exploring the Role of Cortical Reorganization in Postamputation Phantom Phenomena, Including Phantom Limb Pain in Lower Limb Amputees: A Cross-Sectional Study of the Patterns of Referral of Sensations into the Phantom.

BACKGROUND: Cortical reorganization and pain memory are theories to explain phantom limb pain and other postamputation phantom phenomena. This study was undertaken to identify evidence of cortical reorganization in lower limb amputees and to find evidence for the pain memory theory. METHODS: This was a qualitative interview study using structured questionnaires with lower limb amputees. Participants were asked to identify body areas and activities that stimulate postamputation phantom phenomena to confirm the cortical reorganization theory. We tested the pain memory theory by comparing traumatic amputees with surgical amputees. RESULTS: A total of 122 participants (response rate 42%) were recruited. Prevalence of postamputation phantom phenomena was similar to previous studies with phantom pain reported as 84%. Twenty (16.3%) identified body regions that could stimulate postamputation phantom phenomena and 32 (26%) identified activities that could stimulate postamputation phantom phenomena. Not all body areas or activities were related to somatotopic regions adjacent to the leg on the sensory homunculus. Overall, 47 (38.2%) exhibited attributes suggestive of cortical reorganization into areas adjacent to the leg. No associations were found between presence of pain or length of time in pain before amputation and the presence of phantom pain (p = .1-1.0). No statistical difference was found between surgical and traumatic amputees for any postamputation phantom phenomena (p = .3-1.0). CONCLUSIONS: The cortical reorganization and pain memory theories for the development and maintenance of postamputation phantom phenomena have only limited support from our data. Taking this into account, it may be worth reopening the debate on the mechanism for postamputation phantom phenomena, including phantom limb pain. The cortical reorganization theory and memory theory for the mechanism of phantom limb pain are questioned by these results. Both may play a role, but neither can explain the presence of postamputation phantom phenomena on their own.

A review of the management of phantom limb pain: challenges and solutions.

BACKGROUND: Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment. OBJECTIVES: To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain. METHOD: MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system. RESULTS: Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use. CONCLUSION: No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.

Fluctuating residual limb volume accommodated with an adjustable, modular socket design: A novel case report.

BACKGROUND: This novel case report describes the problems of prescribing a prosthetic socket in a left transfemoral amputee secondary to chronic patellofemoral instability compounded by complex regional pain syndrome. Case Description and Methods: Following the amputation, complex regional pain syndrome symptoms recurred in the residual limb, presenting mainly with oedema. Due to extreme daily volume fluctuations of the residual limb, a conventional, laminated thermoplastic socket fitting was not feasible. Findings and Outcomes: An adjustable, modular socket design was trialled. The residual limb volume fluctuations were accommodated within the socket. Amputee rehabilitation could be continued, and the rehabilitation goals were achieved. The patient was able to wear the prosthesis for 8 h daily and to walk unaided indoors and outdoors. CONCLUSION: An adjustable, modular socket design accommodated the daily residual limb volume fluctuations and provided a successful outcome in this case. It demonstrates the complexities of socket fitting and design with volume fluctuations. Clinical relevance Ongoing complex regional pain syndrome symptoms within the residual limb can lead to fitting difficulties in a conventional, laminated thermoplastic socket due to volume fluctuations. An adjustable, modular socket design can accommodate this and provide a successful outcome.

A Clinical Evaluation of Postamputation Phenomena Including Phantom Limb Pain after Lower Limb Amputation in Dysvascular Patients.

To explore the effects of phantom phenomena on a group of dysvascular lower limb amputees. This was a cross-sectional study of dysvascular lower limb amputees. A modified version of the phantom phenomena questionnaire was used to measure the prevalence of phantom phenomena and the effects of those phenomena on daily life. Eighty-nine amputees were recruited. The majority were inpatients (72%) and male (72%). Most had pain before amputation (83%). Sixty-three percent had phantom limb pain. No associations were found between phantom limb pain and preamputation pain (p = .397). Phantom limb pain was present immediately on waking from amputation in 23%. Phantom limb pain is highly fluctuant. It is more likely that phantom limb pain was present with more time passed since amputation (p = .002). Outpatients with unhealed wounds were less likely to have phantom limb pain (p = .007). The effects of postamputation phenomena include sleep loss and social restrictions. These results challenge the belief that phantom limb pain reduces over time as more outpatients reported phantom limb pain than inpatients. Preamputation pain is not linked to the presence of phantom limb pain. The fluctuant nature of phantom limb pain makes its treatment complex. Some may wish intensity to reduce, whereas others may prefer to reduce the number of episodes or duration of each episode instead. More research is needed to clarify the needs of amputees in relation to the postamputation phenomena.

Bariatric amputee: A growing problem?

BACKGROUND: This study reviewed prevalence of patients with lower limb amputations with above normal weight profile, with body mass index over 25, in seven disablement services centres managing their amputee rehabilitation in the United Kingdom. OBJECTIVES: To review two clinical standards of practice in amputee rehabilitation. Ambulant lower limb amputees should have their body weight recorded on an electronic information system, with identification of cohort with body weight >100 kg. Lower limb amputees to be provided with suitable weight-rated prosthesis. STUDY DESIGN: Observational study of clinical practice. METHODS: Data were collected from the Clinical Information Management Systems. Inclusion criteria--subjects were ambulant prosthetic users with some prosthetic intervention in the last 5 years and had at least one lower limb amputation. RESULTS: In 96% of patients, the weight record profile was maintained. In addition, 86% were under 100 kg, which is the most common weight limit of prosthetic componentry. Of 15,204 amputation levels, there were 1830 transfemoral and transtibial sites in users with body weight over 100 kg. In 60 cases, the prosthetic limb build was rated to be below the user body weight. CONCLUSIONS: In 96% of our patients, body weight was documented, and in 97%, the prosthetic limb builds were within stated body weight limits, but this may not be the case in all the other disablement services centres in the United Kingdom. Also, the incidence of obesity in the United Kingdom is a growing problem, and the health issues associated with obesity are further compounded in the amputee population. CLINICAL RELEVANCE: Prosthetic componentry has distinct weight limits which must be considered during prescription. As people with amputation approach the limits of specific components, clinicians are faced with the challenge of continued provision in a safe and suitable manner. This article reviews the amputee population and the current national profile to consider trends in provision and the incidence of these challenges.

Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle.

Most clinically available prosthetic feet have a rigid attachment or incorporate an "ankle" device allowing elastic articulation during stance, with the foot returning to a "neutral" position at toe-off. We investigated whether using a foot with a hydraulically controlled articulating ankle that allows the foot to be relatively dorsiflexed at toe-off and throughout swing would increase minimum toe clearance (MTC). Twenty-one people with unilateral transtibial amputation completed overground walking trials using their habitual prosthetic foot with rigid or elastic articulating attachment and a foot with a hydraulic ankle attachment (hyA-F). MTC and other kinematic variables were assessed across multiple trials. When using the hyA-F, mean MTC increased on both limbs (p = 0.03). On the prosthetic limb this was partly due to the device being in its fully dorsiflexed position at toe-off, which reduced the "toes down" foot angle throughout swing (p = 0.01). Walking speed also increased when using the hyA-F (p = 0.001) and was associated with greater swing-limb hip flexion on the prosthetic side (p = 0.04), which may have contributed to the increase in mean MTC. Variability in MTC increased on the prosthetic side when using the hyA-F (p = 0.03), but this did not increase risk of tripping.

Impact on the biomechanics of overground gait of using an 'Echelon' hydraulic ankle-foot device in unilateral trans-tibial and trans-femoral amputees.

BACKGROUND: If a prosthetic foot creates resistance to forwards shank rotation as it deforms during loading, it will exert a braking effect on centre of mass progression. The present study determines whether the centre of mass braking effect exerted by an amputee's habitual rigid 'ankle' foot was reduced when they switched to using an 'Echelon' hydraulic ankle-foot device. METHODS: Nineteen lower limb amputees (eight trans-femoral, eleven trans-tibial) walked overground using their habitual dynamic-response foot with rigid 'ankle' or 'Echelon' hydraulic ankle-foot device. Analysis determined changes in how the centre of mass was transferred onto and above the prosthetic-foot, freely chosen walking speed, and spatio-temporal parameters of gait. FINDINGS: When using the hydraulic device both groups had a smoother/more rapid progression of the centre of pressure beneath the prosthetic hindfoot (p≤0.001), and a smaller reduction in centre of mass velocity during prosthetic-stance (p<0.001). As a result freely chosen walking speed was higher in both groups when using the device (p≤0.005). In both groups stance and swing times and cadence were unaffected by foot condition whereas step length tended (p<0.07) to increase bilaterally when using the hydraulic device. Effect size differences between foot types were comparable across groups. INTERPRETATION: Use of a hydraulic ankle-foot device reduced the foot's braking effect for both amputee groups. Findings suggest that attenuation of the braking effect from the foot in early stance may be more important to prosthetic-foot function than its ability to return energy in late stance.

Visuomotor behaviours when using a myoelectric prosthesis.

BACKGROUND: A recent study showed that the gaze patterns of amputee users of myoelectric prostheses differ markedly from those seen in anatomically intact subjects. Gaze behaviour is a promising outcome measures for prosthesis designers, as it appears to reflect the strategies adopted by amputees to compensate for the absence of proprioceptive feedback and uncertainty/delays in the control system, factors believed to be central to the difficulty in using prostheses. The primary aim of our study was to characterise visuomotor behaviours over learning to use a trans-radial myoelectric prosthesis. Secondly, as there are logistical advantages to using anatomically intact subjects in prosthesis evaluation studies, we investigated similarities in visuomotor behaviours between anatomically intact users of a trans-radial prosthesis simulator and experienced trans-radial myoelectric prosthesis users. METHODS: In part 1 of the study, we investigated visuomotor behaviours during performance of a functional task (reaching, grasping and manipulating a carton) in a group of seven anatomically intact subjects over learning to use a trans-radial myoelectric prosthesis simulator (Dataset 1). Secondly, we compared their patterns of visuomotor behaviour with those of four experienced trans-radial myoelectric prosthesis users (Dataset 2). We recorded task movement time, performance on the SHAP test of hand function and gaze behaviour. RESULTS: Dataset 1 showed that while reaching and grasping the object, anatomically intact subjects using the prosthesis simulator devoted around 90% of their visual attention to either the hand or the area of the object to be grasped. This pattern of behaviour did not change with training, and similar patterns were seen in Dataset 2. Anatomically intact subjects exhibited significant increases in task duration at their first attempts to use the prosthesis simulator. At the end of training, the values had decreased and were similar to those seen in Dataset 2. CONCLUSIONS: The study provides the first functional description of the gaze behaviours seen during use of a myoelectric prosthesis. Gaze behaviours were found to be relatively insensitive to practice. In addition, encouraging similarities were seen between the amputee group and the prosthesis simulator group.

Functional goal achievement in post-stroke spasticity patients: the BOTOX® Economic Spasticity Trial (BEST).

OBJECTIVE: Evaluate changes in active and passive function with onabotulinumtoxinA + standard of care within goal-oriented rehabilitation programmes in adults with focal post-stroke spasticity. METHODS: Prospective, 24-week double-blind study with an open-label extension. Subjects were randomized to onabotulinumtoxinA + standard of care or placebo + standard of care, at baseline and at 12 weeks, if judged appropriate, with follow-up to 52 weeks. The primary endpoint was the number of patients achieving their principal active functional goal at 24 weeks (or 10 weeks after an optional second injection). Secondary endpoints included achievement of a different active or a passive goal at this timepoint. RESULTS: The intent-to-treat population comprised 273 patients. The proportion of patients achieving their principal active functional goal and secondary active functional goal with onabotulinumtoxinA + standard of care was not statistically different from placebo + standard of care. Significantly more patients achieved their secondary passive goal with onabotulinumtoxinA + standard of care (60.0%) vs. placebo + standard of care (38.6%) (odds ratio, 2.46; 95% confidence interval, 1.18-5.14) as well as higher Goal Attainment Scaling levels for upper limb and ankle flexor subgroups. CONCLUSIONS: Addition of onabotulinumtoxinA to standard of care as part of goal-oriented rehabilitation in post-stroke spasticity patients significantly increased passive goal achievement and was associated with higher levels of active function.

Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic 'ankle' damping.

BACKGROUND: Passive prosthetic devices are set up to provide optimal function at customary walking speed and thus may function less effectively at other speeds. This partly explains why joint kinetic adaptations become more apparent in lower-limb amputees when walking at speeds other than customary. The present study determined whether a trans-tibial prosthesis incorporating a dynamic-response foot that was attached to the shank via an articulating hydraulic device (hyA-F) lessened speed-related adaptations in joint kinetics compared to when the foot was attached via a rigid, non-articulating attachment (rigF). METHODS: Eight active unilateral trans-tibial amputees completed walking trials at their customary walking speed, and at speeds they deemed to be slow-comfortable and fast-comfortable whilst using each type of foot attachment. Moments and powers at the distal end of the prosthetic shank and at the intact joints of both limbs were compared between attachment conditions. RESULTS: There was no change in the amount of intact-limb ankle work across speed or attachment conditions. As speed level increased there was an increase on both limbs in the amount of hip and knee joint work done, and increases on the prosthetic side were greater when using the hyA-F. However, because all walking speed levels were higher when using the hyA-F, the intact-limb ankle and combined joints work per meter travelled were significantly lower; particularly so at the customary speed level. This was the case despite the hyA-F dissipating more energy during stance. In addition, the amount of eccentric work done per meter travelled became increased at the residual knee when using the hyA-F, with increases again greatest at customary speed. CONCLUSIONS: Findings indicate that a trans-tibial prosthesis incorporating a dynamic-response foot reduced speed-related changes in compensatory intact-limb joint kinetics when the foot was attached via an articulating hydraulic device compared to rigid attachment. As differences between attachment conditions were greatest at customary speed, findings indicate a hydraulic ankle-foot device is most effectual at the speed it is set-up for.

Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment.

BACKGROUND: Disruptions to the progress of the centre-of-pressure trajectory beneath prosthetic feet have been reported previously. These disruptions reflect how body weight is transferred over the prosthetic limb and are governed by the compliance of the prosthetic foot device and its ability to simulate ankle function. This study investigated whether using an articulating hydraulic ankle attachment attenuates centre-of-pressure trajectory fluctuations under the prosthetic foot compared to a fixed attachment. METHODS: Twenty active unilateral trans-tibial amputees completed walking trials at their freely-selected, comfortable walking speed using both their habitual foot with either a rigid or elastic articulating attachment and a foot with a hydraulic ankle attachment. Centre-of-pressure displacement and velocity fluctuations beneath the prosthetic foot, prosthetic shank angular velocity during stance, and walking speed were compared between foot conditions. FINDINGS: Use of the hydraulic device eliminated or reduced the magnitude of posteriorly directed centre-of-pressure displacements, reduced centre-of-pressure velocity variability across single-support, increased mean forward angular velocity of the shank during early stance, and increased freely chosen comfortable walking speed (P ≤ 0.002). INTERPRETATION: The attenuation of centre-of-pressure trajectory fluctuations when using the hydraulic device indicated bodyweight was transferred onto the prosthetic limb in a smoother, less faltering manner which allowed the centre of mass to translate more quickly over the foot.

Role of myofascial trigger points in post-amputation pain: causation and management.

BACKGROUND: Post-amputation pain is a multifactorial issue and thus necessitates multiple treatment strategies. Myofascial trigger points-related pain remains under diagnosed and hence not addressed. This study investigates causation and management. OBJECTIVES: To identify the presence and role of myofascial trigger points in post amputation pain. STUDY DESIGN: Post-amputation pain clinic review and recruitment. METHODS: Twenty one identified patients in the post-amputation pain clinic with myofascial trigger points were recruited, of which 13 were transtibial and eight transfemoral and all had phantom limb pain and stump pain. The trigger points were identified and injected with long-acting local anaesthetic on a weekly basis and patients were followed up on an ongoing basis. RESULTS: There was significant resolution of pain on the Visual Analogue Scale in the majority of these patients within five weeks, though some of the transtibial cohort needed further eight injections on a weekly basis for resolution of the pain. CONCLUSION: Identification of myofascial trigger points in amputation stumps and their role in post-amputation pain, followed by appropriate intervention is an important facet of management of this complex chronic pain. Clinical relevance Myofascial trigger points in amputation stumps can lead to ongoing chronic post-amputation pain and our results indicate that identification and intervention of these trigger points does lead to notable resolution of this pain.

Prevalence and characteristics of painful diabetic neuropathy in a large community-based diabetic population in the U.K.

OBJECTIVE: To assess, in the general diabetic population, 1) the prevalence of painful neuropathic symptoms; 2) the relationship between symptoms and clinical severity of neuropathy; and 3) the role of diabetes type, sex, and ethnicity in painful neuropathy. RESEARCH DESIGN AND METHODS: Observational study of a large cohort of diabetic patients receiving community-based health care in northwest England (n = 15,692). Painful diabetic neuropathy (PDN) was assessed using neuropathy symptom score (NSS) and neuropathy disability score (NDS). RESULTS: Prevalence of painful symptoms (NSS ≥5) and PDN (NSS ≥5 and NDS ≥3) was 34 and 21%, respectively. Painful symptoms occurred in 26% of patients without neuropathy (NDS ≤2) and 60% of patients with severe neuropathy (NDS >8). Adjusted risk of painful neuropathic symptoms in type 2 diabetes was double that of type 1 diabetes (odds ratio [OR] = 2.1 [95% CI 1.7-2.4], P < 0.001) and not affected by severity of neuropathy, insulin use, foot deformities, smoking, or alcohol. Women had 50% increased adjusted risk of painful symptoms compared with men (OR = 1.5 [1.4-1.6], P < 0.0001). Despite less neuropathy in South Asians (14%) than Europeans (22%) and African Caribbeans (21%) (P < 0.0001), painful symptoms were greater in South Asians (38 vs. 34 vs. 32%, P < 0.0001). South Asians without neuropathy maintained a 50% increased risk of painful neuropathy symptoms compared with other ethnic groups (P < 0.0001). CONCLUSIONS: One-third of all community-based diabetic patients have painful neuropathy symptoms, regardless of their neuropathic deficit. PDN was more prevalent in patients with type 2 diabetes, women, and people of South Asian origin. This highlights a significant morbidity due to painful neuropathy and identifies key groups who warrant screening for PDN.

Rationale and design of a multicentre, double-blind, prospective, randomized, European and Canadian study: evaluating patient outcomes and costs of managing adults with post-stroke focal spasticity.

OBJECTIVE: This report describes the design of a study aiming to provide evidence for the extended use of botulinum toxin A in focal post-stroke upper and lower limb spasticity and to evaluate the impact of incorporating botulinum toxin treatment into the rehabilitation of patients with spasticity. DESIGN: International, prospective, randomized, double-blind, placebo-controlled study with an open-label extension. METHODS: Approximately 300 adults with a stroke occurring ≥ 3 months before screening, presenting with symptoms and signs of an upper motor neuron syndrome and focal spasticity-related functional impairment, were randomized to botulinum toxin (BOTOX®, Allergan Inc.) + standard care or placebo + standard care. Study medication was administered at baseline and again at Week 12 if required, with follow-up to 52 weeks. The primary endpoint was the number of patients who achieved their investigator-rated principal active functional goal (as measured by Goal Attainment Scaling), at 10 weeks after the second injection (Weeks 22-34) or at the 24-week visit if no second injection was administered. Secondary endpoints included changes from baseline in level of goal achievement, health-related quality of life and resource utilization. CONCLUSION: Botulinum toxin A Economic Spasticity Trial (BEST) will provide information regarding clinical and cost-effectiveness of botulinum toxin + standard care vs standard care alone in patients with upper and/or lower limb post-stroke spasticity typically seen in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov number NCT-00549783.

The treatment of phantom limb pain using immersive virtual reality: three case studies.

PURPOSE: This paper describes the design and implementation of a case study based investigation using immersive virtual reality as a treatment for phantom limb pain. METHOD: Three participants who experienced phantom limb pain (two with an upper-limb amputation, and one with a lower-limb amputation) took part in between 2 and 5 immersive virtual reality (IVR) sessions over a 3-week period. The movements of participants' anatomical limbs were transposed into the movements of a virtual limb, presented in the phenomenal space of their phantom limb. RESULTS: Preliminary qualitative findings are reported here to assess proof of principle for this IVR equipment. All participants reported the transferal of sensations into the muscles and joints of the phantom limb, and all participants reported a decrease in phantom pain during at least one of the sessions. CONCLUSION: The authors suggest the need for further research using control trials.

Association between hypermobility and congenital limb deficiencies.

OBJECTIVE: To determine the prevalence of hypermobility in individuals with congenital limb deficiencies and whether congenital limb loss is associated with increased laxity in the remaining joints. STUDY DESIGN: All data were collected during the individuals' visits to the prosthetic clinic. SETTING: The subjects were evaluated at the Subregional Disablement Services Centre at University Hospital of South Manchester, UK. SUBJECTS: Forty-five individuals with congenital limb deficiencies were studied (male/female 27 :18; ages 6-31 years). OUTCOME MEASURE: A modified version of the nine-point Beighton Score for hypermobility was used, using the presently accepted criteria for diagnosing hypermobility. Any individual who scored 3 or more points was considered to have joint hypermobility. RESULT: Of the 45 individuals with congenital limb deficiencies, 71% had at least one hypermobile joint, whereas 38% had three or more features of hypermobility, with female/male ratio of 2.75:1. CONCLUSION: Our results show an increase in joint hypermobility (laxity) in individuals born with congenital limb deficiencies compared with the prevalence of this condition in the general population. As joint hypermobility may predispose individuals to low back pain, joint effusion, recurrent joint dislocation and ligament rupture, it is useful to identify those individuals with hypermobility.