Knee joint instability is frequently reported by patients with knee osteoarthritis (KOA). Objective metrics to assess knee joint instability are lacking, making it difficult to target therapies aiming to improve stability. Therefore, the aim of this study was to compare responses in neuromechanics to perturbations during gait in patients with self-reported knee joint instability (KOA-I) versus patients reporting stable knees (KOA-S) and healthy control subjects.Forty patients (20 KOA-I and 20 KOA-S) and 20 healthy controls were measured during perturbed treadmill walking. Knee joint angles and muscle activation patterns were compared using statistical parametric mapping and discrete gait parameters. Furthermore, subgroups (moderate versus severe KOA) based on Kellgren and Lawrence classification were evaluated.Patients with KOA-I generally had greater knee flexion angles compared to controls during terminal stance and during swing of perturbed gait. In response to deceleration perturbations the patients with moderate KOA-I increased their knee flexion angles during terminal stance and pre-swing. Knee muscle activation patterns were overall similar between the groups. In response to sway medial perturbations the patients with severe KOA-I increased the co-contraction of the quadriceps versus hamstrings muscles during terminal stance.Patients with KOA-I respond to different gait perturbations by increasing knee flexion angles, co-contraction of muscles or both during terminal stance. These alterations in neuromechanics could assist in the assessment of knee joint instability in patients, to provide treatment options accordingly. Furthermore, longitudinal studies are needed to investigate the consequences of altered neuromechanics due to knee joint instability on the development of KOA.
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BACKGROUND: Instability of the knee joint during gait is frequently reported by patients with knee osteoarthritis or an anterior cruciate ligament rupture. The assessment of instability in clinical practice and clinical research studies mainly relies on self-reporting. Alternatively, parameters measured with gait analysis have been explored as suitable objective indicators of dynamic knee (in)stability.RESEARCH QUESTION: This literature review aimed to establish an inventory of objective parameters of knee stability during gait.METHODS: Five electronic databases (Pubmed, Embase, Cochrane, Cinahl and SPORTDiscuss) were systematically searched, with keywords concerning knee, stability and gait. Eligible studies used an objective parameter(s) to assess knee (in)stability during gait, being stated in the introduction or methods section. Out of 10717 studies, 89 studies were considered eligible.RESULTS: Fourteen different patient populations were investigated with kinematic, kinetic and/or electromyography measurements during (challenged) gait. Thirty-three possible objective parameters were identified for knee stability, of which the majority was based on kinematic (14 parameters) or electromyography (12 parameters) measurements. Thirty-nine studies used challenged gait (i.e. external perturbations, downhill walking) to provoke knee joint instability. Limited or conflicting results were reported on the validity of the 33 parameters.SIGNIFICANCE: In conclusion, a large number of different candidates for an objective knee stability gait parameter were found in literature, all without compelling evidence. A clear conceptual definition for dynamic knee joint stability is lacking, for which we suggest : "The capacity to respond to a challenge during gait within the natural boundaries of the knee". Furthermore biomechanical gait laboratory protocols should be harmonized, to enable future developments on clinically relevant measure(s) of knee stability during gait.
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Purpose: Instability of the knee joint is reported by a majority (>65%) of patients with knee osteoarthritis (KOA) and is hypothesized to play a crucial role in the initiation and progression of KOA. A generally accepted objective metric of knee joint stability is lacking, making development of diagnostics and treatment options for knee joint instability more difficult. Such a metric should be based on how gait biomechanics and muscle activation in the unstable knee joint differ from those in a stable knee joint. To challenge knee joint instability, external perturbations during gait are needed to replicate the situations in daily life that require stability of the knee joint. Therefore, the aim of this study was to compare the responses in knee biomechanics and muscle activation patterns to different types of external perturbations during gait of patients with self-reported knee joint instability (KOA-I) versus patients reporting stable knees (KOA-S) and healthy control subjects.Methods: Forty patients (60% female) were included in this study with a mean age of 66 years (range: 52-82), body mass index of 26 (range: 19-32) and Kellgren and Lawrence grade of 2.5 (range 0-4). Patients were dichotomized in a KOA-I group (n=20) and KOA-S group (n=20) based on if they had perceived an episode of knee joint instability in the past four weeks. Furthermore, twenty age-, gender- and BMI-matched healthy control subjects were measured. The participants walked on a dual-belt instrumented treadmill while different external perturbations were applied, triggered by heel strike of the most affected leg (figure 1). The external perturbations consisted of sway left (SL) or sway right (SR) translations (4 cm) or accelerations (AC) or decelerations (DC) of one belt (1.6 m/s walking speed change in 0.23 seconds). Knee kinematics and muscle activation patterns of the perturbed gait cycles were collected using a motion capture system and surface electromyography. The three groups were compared using statistical parametric mapping (SPM) and discrete values by analysis of variance. The discrete values of the knee angles (initial contact, peak and range of motion (ROM) values) and muscle activation patterns (peak, mean and co-contraction index (CCI) values) were corrected for walking speed.Results: The SPM analysis results (example provided in figure 2) showed that in response to the SL perturbations the KOA-I group walked with greater knee flexion angles (KFA) during pre-swing compared to the control group (SPM, p<0.01) and during mid-swing compared to the KOA-S group and control group (SPM, p<0.01). Moreover, during the SR perturbed gait cycles the KOA-I group had greater KFA during mid-swing compared to the KOA-S group (SPM, p=0.01). In response to the AC perturbations the KOA-I group walked with a greater KFA during late terminal stance compared to the control group (SPM, p<0.01). Furthermore, the KOA-I group had greater KFA during the pre-swing phase of the DC perturbed gait cycles compared to the control group (SPM, p<0.01). The significant results from the comparison of the discrete values are presented in table 1. The KOA-I group had greater peak KFA during the swing phase of all perturbed gait cycles (independent of perturbation type) compared to the KOA-S group and control group (p<0.01). Moreover, during both sway perturbations (SL, SR) higher KFA ROM were observed in the KOA-I group compared to the KOA-S group (p<0.05). Besides this, the KOA-I group presented higher CCI of the medial muscles (vastus medialis and medial hamstring) compared to the KOA-S group during the DC perturbation (p=0.03). Furthermore, changes in vastus medialis and gluteus medius muscle activation in response to different external perturbations were observed in the KOA-S group compared to the control group and the KOA-I group (p<0.05).Conclusions: Patients with KOA-I walked with greater knee flexion angles during peak stance, late-terminal stance, pre-swing and mid-swing in response to different external perturbations, which could be a distinctive strategy of these patients to maintain stability of the knee joint during these phases of gait. Besides this, only few alterations were observed in the knee muscle activation patterns between the groups. This could be explained by the large variation between subjects in the muscle activations patterns which might indicate different neuromuscular strategies to respond to the external perturbations. Future studies with larger sample sizes are required to test the reliability and validity of the knee flexion angle as a candidate for the objective measurement of knee joint stability and to further investigate neuromuscular control of the unstable osteoarthritic knee.
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Study Type – Aetiology (individual cohort)Level of Evidence 2bWhat's known on the subject? and What does the study add?Recent studies have already shown associations between generalized joint hypermobility (GJH) and voiding and defecation dysfunction and/or slow transit constipation. Changes in extracellular matrix composition in vesico‐ureteric junction of vesico‐ureteral reflux (VUR) patients were also observed previously.This study is the first to assess joint mobility as a parameter for connective tissue composition in vesico‐ureteral reflux. We convincingly demonstrate that VUR patients have significantly more hypermobile joints compared to controls and this provides a new angle to the intriguing subjects of development of VUR and susceptibility to VUR.OBJECTIVE•To assess whether there is an increased prevalence of joint hypermobility in patients with vesico‐ureteric reflux (VUR).MATERIALS AND METHODS•We studied 50 patients with primary VUR and matched controls drawn from a reference population.•Joint mobility was assessed using the Bulbena hypermobility score.RESULTS•We identified significantly more patients with VUR with generalized joint hypermobility than controls (24% vs 6.7%, P= 0.007).CONCLUSION•Our findings confirm our clinical observation of an increased rate of joint hypermobility in patients with VUR. We speculate that an altered composition of the connective tissue may contribute to the severity of the (pre‐existing) VUR phenotype.
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BACKGROUND: Chronic musculoskeletal pain (CMP), Generalized Joint Hypermobility (GJH) and pain-related fear have influence on physical functioning in adolescents.AIM: to evaluate differences in physical functioning between adolescents with CMP, GJH or the combination of both, and in addition evaluate the potential contribution of pain-related fear.DESIGN: The design of this study was observational and cross-sectional.SETTING: The adolescents with CMP were recruited by a physician in rehabilitation medicine and measured in the university outpatient rehabilitation clinic (Adelante/Maastricht University Medical Center+, the Netherlands). The adolescents without CMP were recruited in the Southern area of the Netherlands and measured in the university outpatient rehabilitation clinic (Adelante/Maastricht University Medical Center+, the Netherlands).POPULATION: Four subgroups of adolescents were included; 21 adolescents with CMP without GJH, 9 adolescents with CMP and GJH, 51 adolescents without CMP without GJH, and 11 adolescents without CMP with GJH.METHODS: Outcome measures were muscle strength and endurance, motor performance, physical activity level, and pain-related fear. Hierarchical regression analyses were used to study differences in physical functioning and the contribution of pain-related fear in adolescents with/without CMP as well as with/without GJH.RESULTS: Adolescents with CMP had decreased muscle strength (P=0.01), endurance (P=0.02), and lower motor performance (P<0.01) compared to adolescents without CMP. Higher levels of pain-related fear were related to decreased muscle strength (P=0.01), endurance (P<0.01), and motor performance (P<0.01). No differences in physical functioning and pain-related fear between hypermobile and non-hypermobile adolescents with CMP were found.CONCLUSIONS: Adolescents with CMP had decreased muscle strength and motor performance associated with increased levels of pain-related fear compared to adolescents without CMP. The association of being hypermobile with physical functioning is not more pronounced in adolescents with CMP.CLINICAL REHABILITATION IMPACT: No differences were found in physical functioning and pain-related fear between hypermobile adolescents with CMP compared to non-hypermobile adolescents with CMP. Future rehabilitation treatment in hypermobile adolescents with CMP should also focus on psychological components, such as pain-related fear.
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INTRODUCTION: To provide a state of the art on diagnostics, clinical characteristics, and treatment of paediatric generalised joint hypermobility (GJH) and joint hypermobility syndrome (JHS).METHOD: A narrative review was performed regarding diagnostics and clinical characteristics. Effectiveness of treatment was evaluated by systematic review. Searches of Medline and Central were performed and included nonsymptomatic and symptomatic forms of GJH (JHS, collagen diseases).RESULTS: In the last decade, scientific research has accumulated on all domains of the ICF. GJH/JHS can be considered as a clinical entity, which can have serious effects during all stages of life. However research regarding the pathological mechanism has resulted in new potential opportunities for treatment. When regarding the effectiveness of current treatments, the search identified 1318 studies, from which three were included (JHS: n = 2, Osteogenesis Imperfecta: n = 1). According to the best evidence synthesis, there was strong evidence that enhancing physical fitness is an effective treatment for children with JHS. However this was based on only two studies.CONCLUSION: Based on the sparsely available knowledge on intervention studies, future longitudinal studies should focus on the effect of physical activity, fitness, and joint stabilisation. In JHS and chronic pain, the effectiveness of a multidisciplinary approach should be investigated.
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BACKGROUND: Generalized Joint Hypermobility (GJH) has been found to be associated with musculoskeletal complaints and disability. For others GJH is seen as a prerequisite in order to excel in certain sports like dance. However, it remains unclear what the role is of GJH in human performance. Therefore, the purpose of the study was to establish the association between GJH and functional status and to explore the contribution of physical fitness and musculoskeletal complaints to this association.METHODS: A total of 72 female participants (mean age (SD; range): 19.6 (2.2; 17-24)) were recruited among students from the Amsterdam School of Health Professions (ASHP) (n = 36) and the Amsterdam School of Arts (ASA), Academy for dance and theater (n = 36) in Amsterdam, The Netherlands. From each participant the following data was collected: Functional status performance (self-reported Physical activity level) and capacity (walking distance and jumping capacity: side hop (SH) and square hop (SQH)), presence of GJH (Beighton score ≥4), muscle strength, musculoskeletal complaints (pain and fatigue) and demographic characteristics (age and BMI).RESULTS: GJH was negatively associated with all capacity measures of functional status. Subjects with GJH had a reduced walking distance (B(SE):-75.5(10.5), p = <.0001) and jumping capacity (SH: B(SE):-10.10(5.0), p = .048, and SQH: B(SE):-11.2(5.1), p = .024) in comparison to subjects without GJH, when controlling for confounding: age, BMI and musculoskeletal complaints. In participants with GJH, functional status was not associated with performance measures.CONCLUSION: GJH was independently associated with lower walking and jumping capacity, potentially due to the compromised structural integrity of connective tissue. However, pain, fatigue and muscle strength were also important contributors to functional status.
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OBJECTIVE: To determine the prevalence of generalized joint hypermobility (GJH) in Dutch children aged 5.5 years, and to examine the association between GJH and motor performance and development over time.STUDY DESIGN: A prospective cohort of 249 children was recruited. GJH was assessed with the Beighton test at age 5.5 years. Motor performance was evaluated at age 2.0 years using the Bayley Scales of Infant Development, Second Edition and at age 5.5 years using the Movement Assessment Battery for Children-Second Edition (subscore categories: manual dexterity, aiming and catching, and static and dynamic balance).RESULTS: In 249 children, the prevalence of GJH, defined by the Beighton test score, was 34.1% for a score ≥ 4, 22.5% for a score ≥ 5, and 16.5% for a score ≥ 6. No significant association was found between GJH and total motor performance. Manual dexterity in girls (Beighton score ≥ 4) was positively associated with higher level of motor performance (β [SE] = 0.38 [0.17]; P = .028), ranging from +0.04 SD to +0.72 SD, even after correction for covariates. A significant interaction between GJH and body mass index (BMI) growth was found, indicating that the effect of GJH on the rate of development of motor performance declines with increasing BMI growth (β = 0.05 [0.02]; P = .031).CONCLUSION: In this healthy pediatric cohort, GJH was present in one-third of the sample, and no significant association was found between GJH and total motor performance. The effect of GJH on the rate of development of motor performance appears to decline with increasing BMI growth. Longitudinal prospective studies are recommended to detect influences of GJH on motor performance over time, as well as the influence of body composition and Beighton cutoff points.
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OBJECTIVE: To study the impact of generalized joint hypermobility (GJH) in professional dancers on physical fitness, musculoskeletal complaints and psychological distress.METHODS: Thirty-six professional dancers were recruited and compared with control subjects (mean age 20.1, range 17-27). Height, weight, Beighton score, physical fitness (walking distance, muscle strength, estimated VO2max), musculoskeletal complaints (pain, fatigue) and psychological distress (anxiety, depression) were measured.RESULTS: Univariate analysis revealed, in between-group analysis, that dancers (with and without GJH) had higher physical fitness [the six-minute walk test (6MWT): ΔD = +8.4%, P = 0.001; VO2max: ΔD = +12.8%, P = 0.01], fatigue (checklist individual strength: ΔD = +80.3%, P < 0.0001) and greater psychological distress (Hospital Anxiety and Depression Scale: ΔD = +115.0%, P < 0.0001). When comparing dancers and control subjects with GJH to those without GJH, lower levels of physical fitness (muscle strength: ΔD = -11.3%, P < 0.0001; 6MWT: ΔD = -9.9%, P < 0.0001), more fatigue (checklist individual strength: ΔD = +84.4%, P < 0.0001) and greater psychological distress (Hospital Anxiety and Depression Scale: ΔD = +79.6%, P < 0.0001) were observed in subjects with GJH. Multivariate analysis showed that dancers have higher levels of physical fitness (6MWT, P = 0.001; VO2max, P = 0.020); however, when taking GJH into account, this advantage disappeared, indicating lower levels of physical fitness in comparison with control subjects (6MWT, P = 0.001; muscle strength, P < 0.0001; VO2max, P = 0.040). Dancers experienced more fatigue (P = 0.001) and psychological distress (P < 0.0001). This was associated with even more fatigue (P = 0.010) and psychological distress (P = 0.040) when GJH was present.CONCLUSION: Dancers with GJH seem more vulnerable to musculoskeletal and psychological complaints. In addition, GJH was also associated with lower physical fitness, despite training. Caregivers for professional dancers should monitor closely the physical capabilities and the amount of psychological strain.
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A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability. Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability. It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism. In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.
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