Joint protection is a very important aspect of managing hypermobility.
- Sitting in slumped position
- Sitting cross-legged, legs entwined around each other or in the ‘W’ position (bottom on the floor, knees forward, feet backward and to the side),
- Sustained standing with the knees pushed back i.e. hyperextended, or
- Holding your weight on one hip when standing.
An ergonomic assessment involves a review of the tasks and the environment in which an individual works. It will involve assessing and adapting tasks (including lifting etc.), the work-station and the layout of the environment, the timetable and demands of the working day, and also the structures of teams, supervision and the nature of the resources available.
Suitable adjustments to furniture and equipment at school, in the home and at work are examples of things that may help to reduce unnecessary strain and help to improve performance. Advice on time management, planning and pacing may also be helpful (Mangharam, 2003).
In the learning environment (click Here to go to more detail on School/College/University) other examples include:
- The use of electronic devices to collect information, including recording lectures / seminars etc.
- Extensions to deadlines to allow more time to complete project work / essays,
- A review of the terms or courses programme to try and even out the workload where possible,
- Rest breaks as required,
- A % extension to exams.
For those returning to work after injury or a period of ill-health, suitable adjustments to both the physical work environment and workload may be necessary. Physiotherapists can advise and monitor a graded return to activity in liaison with your GP and occupational health teams (Mangharam, 2003).
Splints, Supports, and Orthotics
Occasionally it is helpful to splint a hypermobile joint. In general though splints should be used judiciously to avoid over dependence and muscle deconditioning.
- Finger and hand splints can be very helpful for specific activities, for example practicing a musical instrument and prolonged periods of typing.
- Lycra gloves and arm garments are often more comfortable than rigid plastic splints and can provide support while allowing improved hand function.
- Back supports and knee braces may be required during acute periods of pain and during rehabilitation and re-entry to work or sport.
- Tape can also be beneficial to help support a vulnerable joint and also to help improve awareness of joint position (proprioception) and control of posture (Keer and Simmonds, 2011).
A combination of poor coordination of muscles and joints (motor control), weak muscles, poor proprioception, reduced stamina, and mechanical changes and forces through the joints (biomechanics) can affect the way a persons or runs walk (gait), and stands (Fatoye et al, 2010; Murray, 2006). To correct this, the causes of the abnormalities need to be identified and where possible corrected.
Hypermobile individuals commonly present with over flatfooted-ness. The heel is often turned outward (pronated hind foot), the arch of the foot flat, and occasionally the muscles that hold the arch are weak (Tibialis Posterior muscle dysfunction). This may lead to an altered walking pattern and subsequent pain.
In many cases correcting the biomechanics of the ankle/foot complex with supportive footwear (McCulloch et al., 2011) improves function and reduces pain. In cases where the ankle is very unstable or the foot very flexible, orthotics may be recommended (McCulloch et al, 2011). “Off the shelf” orthotics provided by a physiotherapist are often a good starting point and where more complex ankle and foot issues are present, an assessment and custom made orthotics are recommended.
Education is an important aspect of gait re-training and it is important that the hypermobile individual recognizes the abnormalities in their gait and where possible learns to correct them. The use of video recording and a mirror can aid this and give the individual helpful visual feedback.
The provision of walking and mobility aids such as crutches and wheelchairs requires careful consideration and discussion between the hypermobile individual and medical team.
The aim of these devices is to facilitate independence, participation, and quality of life. Each case needs to be individually assessed and carers and hypermobile individuals require education to ensure appropriate use.
Carefully planned exercise programmes are required when improving control of the joints and muscle strength during activities. These should help to minimize trauma to joints and reduce pain. For individuals already in pain, exercise may need to be very gentle to start with before progressing to dynamic and resisted work using equipment such as elastic strengthening bands and weights. Exercise in water is often also helpful (Simmonds and Keer 2007)
Dr Jane Simmonds MCSP, MMACP, FHEA
Professional Lead Physiotherapy, University of Hertfordshire. Clinical Specialist, Hypermobility Unit, Hospital of St John and St Elizabeth, London. Medical advisor HMSA and EDS Support UK
Written January 2014. Reviewed by Dr A Hakim. Planned date of review January 2017
Fatoye F, Palmer, S Macmillan F, Rowe P , van der Linden M. Pain intensity and quality of life perception in children with hypermobility syndrome, Rheumatology International. 2010; 32, 5; 1277–1284.
Keer R, Simmonds, J. Joint protection and physical rehabilitation of the adult with hypermobility syndrome, Current Opinion in Rheumatology. 2011; 23, 2: 131–136.
McCulloch RS, Redmond A & Keer R (2011) The Hypermobile Foot. In Eds Hakim, A., Keer, R. Grahame, R. Hypermobility, Fibromyalgia and Chronic Pain. Churchill Livingstone: Edinburgh
Mangharam J (2003) Joint hypermobility and work related musculoskeletal disorders (WRMSD). In Hypermobility Syndrome, Recognition and Management for Physiotherapists. Butterworth Heinemann: Edinburgh.
Murray K J. Hypermobility disorders in children and adolescents. Best Practice & Research Clinical Rheumatology. 2006; 20(2): 329-351.
Simmonds JV, Keer R (2007) Hypermobility and the Hypermobility Syndrome Masterclass. Manual Therapy. 2007; 13: 492-495.