1 / 33

Clinic Case

Clinic Case. Alev Wilk, MD Primary Care Conference 4/28/04. No conflict of interest. Cases. 49 y.o. AA woman seen with a h/o multiple musculoskeletal symptoms Pain in lower back & neck, bilateral elbows & shoulders for months to years

ronny
Télécharger la présentation

Clinic Case

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinic Case Alev Wilk, MD Primary Care Conference 4/28/04

  2. No conflict of interest

  3. Cases • 49 y.o. AA woman seen with a h/o multiple musculoskeletal symptoms • Pain in lower back & neck, bilateral elbows & shoulders for months to years • PMH: Mild scoliosis, OA, lateral epicondylitis, TMJ dysfunction, left shoulder tendonitis, fibromyalgia • SH: Postal worker 5 yrs.; military service 9 yrs. • FH: possible Ehler-Danlos syndrome • PE: Musculoskeletal findings: hyperextension of MCP’s and thumbs; diffuse tenderness • Radiologic: osteoarthritic changes of the spine

  4. Cases • 39 y.o. woman seen for intermittent low back pain: • 10-20 year h/o low back pain worse with prolonged sitting & standing • PMH: de Quervain’s tenosynovitis, olecranon bursitis, fibromyalgia, umbilical hernia • SH: cashier; gymnast as a teenager • FH: noncontributory • PE: musculoskeletal findings: marked elbow, knee, back extension, thumb apposition • Radiologic: retrolisthesis at L3-4, mild DJD

  5. Cases • 27 y.o. woman seen for recurrent subluxation of her left shoulder • Several year h/o of left shoulder pain with recurrent subluxations • PMH: right wrist and shoulder tendonitis • SH: school teacher; rock climbing • FH: sister with repeated shoulder subluxations • PE: musculoskeletal: hyperextension at elbows and knees. Tenderness over supraspinatus tendon. Skin: striae, hyperextensibility

  6. Case summary • Joint Hypermobility • Soft tissue injuries • Chronic pain • Osteoarthritis

  7. Objectives • Presentation, diagnosis, prevalence of joint hypermobility syndrome • Relationship to associated conditions (soft tissue injury, chronic pain, osteoarthritis) • Treatment of associated conditions when present

  8. Presentation • Musculoskeletal symptoms in presence of joint laxity • Heritable disorder of connective tissue • Identical to the hypermobility type of Ehler-Danlos syndrome (EDS type III) • Mechanism of injury: Increased ligamentous laxity; decreased joint proprioception

  9. Diagnosis • Nine-Point Beighton hypermobility score* • Passive dorsiflexion of the metacarpophalangeal joint to 90 degrees • Apposition of the thumb to the flexor aspect of the forearm • Hyperextension of the elbow to > 10 degrees • Hyperextension of the knee to > 10 degrees • Forward trunk flexion with hands flat on the floor and with knees extended *Ann Rheum Dis 1973;32:413-7

  10. Revised diagnostic criteria • Major criteria • Beighton score of 4/9 or greater • Arthralgia for longer than 3 months in 4 or more joints • Minor criteria • Beighton score of 1,2 or 3/9 • Arthralgia (>3 mo) in 1-3 joints, or back pain, spondylosis, spondylolysis/listhesis • Dislocation/subluxation in more than one joint, or in one joint on more than one occasion • Soft tissue rheumatism > 3 lesions

  11. Revised diagnostic criteria • Minor criteria continued • Maranoid habitus (tall, slim, span/height > 1.03, arachnodactyly) • Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring • Eye signs: drooping eyelids or myopia or antimongoloid slant • Varicose veins or hernia or uterine/rectal prolapse 2 major criteria or one major and 2 minor criteria; 4 minor criteria or 2 minor and an affected first-degree relative

  12. Prevalence • 5-13% in childhood • 4-5% in the general population • 13-15% in rheumatology clinics • Higher rates reported in women • Higher rates reported in West Africans & Middle-Eastern women

  13. Benign Condition? • Heritable Disorder of Connective Tissue • Hypermobility syndrome • Benign Joint Hypermobility Syndrome • Mechanisms • Increased ligamentous laxity may lead to soft tissue pain/ligamentous injury • Decreased proprioception of hypermobile joints

  14. Associated conditions • Tendency towards dislocation • Traumatic synovitis • Chronic joint pain • Fibromyalgia and depression • Premature osteoarthritis

  15. Bridges AJ et al. Joint hypermobility in adults referred to rheumatology clinics. • 130 adult patients referred to a rheumatology clinic with musculoskeletal problems • 97 women, 33 men • Beigton score > 5 out of 9 • Exclusion criteria: signs of Ehler-Danlos syndrome (EDS) Annals of the Rheumatic Diseases 1992;51:793-796

  16. Bridges AJ et al.Results • 15% had joint hypermobility • Average Beighton score of 8; average age of 50; hypermobile features since childhood • All cases of hypermobility were women • 65% had a FH of joint hypermobility in a first degree relative • Trunk hypermobility was noted in younger patients (average age of 37 y.o.)

  17. Bridges AJ et al. • 50% had hypermobility of the fingers & ankles, 35% of the hips. • 85% flat feet • 35% scolioisis • 40% soft tissue injury • 60% OA • 30% fibromyalgia

  18. Hudson N et al* Diagnostic associations with hypermobility in rheumatology patients. • 378 consecutive referrals to a rheumatology clinic • Beighton score of four or greater out of nine. • Assessed by physical exam and physical activity, leisure and work Brit J of Rheumatology 1995;34:1157-61

  19. Hudson et al. • 13.2% fulfilled criteria for hypermobility • 94% of the patients were women (73% in the control group); average age 45 y.o. • 26% had tendonitis, bursitis or fasciitis (17% in the control group) • 30% fit diagnositic criteria for fibromyalgia syndrome, the most frequent diagnosis (8% in the control group)

  20. Hudson et al. • 15% with axial or spinal complaints (15% in the control group) • 7% with OA (19% in the control group) • 4% with inflammatory arthropathy (32% in the control group)

  21. Hudson et al. • Pain breakdown: • Widespread in 44% • Multiple localized sites in 44% • Single site in 13% • Spinal-neck in 37% • Spinal-midthoracic & low back in 80% • Tendonitis (previous and present) in 63%

  22. Living with Hypermobility* • Everyday activities carry the price of pain • ADL’s • Repetitive movement • Absenteeism from work • Adverse effects on family and relationships • Depression & isolation from pain and disability *Rheumatology 2001;40:487-489

  23. Barriers to diagnosis and management • Patients generally look well and present uniquely • Under-recognized and under-estimated • Lack of a clear cause-and-effect relationship • Non-specialized physical therapy can exacerbate symptoms

  24. Treatment • Specialized physiotherapy • Stabilizing lax joints with exercise to increase stability, reduce pain and diminish hypermobility • Improving proprioceptive acuity • Drug therapy • Cognitive-behavioral therapy • Patient support groups

  25. Summary • Joint hypermobility appears to be associated with multiple soft tissue injuries, fibromyalgia and osteoarthritis • Joint hypermobility is relatively common in populations with & without musculoskeletal symptoms. • Joint hypermobility syndrome may be a true entity but like fibromyalgia is difficult to assess and treat.

  26. References • Hudson N. Fitzcharles MA. Cohen M. Starr MR. Esdaile JM. The association of soft-tissue rheumatism and hypermobility. British Journal of Rheumatology. 37(4):382-6, 1998 Apr. • Acasuso-Diaz M. Collantes-Estevez E. Joint hypermobility in patients with fibromyalgia syndrome. Arthritis Care & Research. 11(1):39-42, 1998 Feb. • Hudson N, Starr MR, Esdaile JM, Fitzcharles MA. Diagnostic association hypermobility in Rheumatology Patients. British J of Rheumatology 1995;34:1157-1161. • Bridges AJ, Smith E, Reid J. Joint hypermobility in adults referred to rheumatology clinics. Annals of the Rheumatic Diseases 1992;51:793-796.

  27. References • Gurley-Green S. Living with the hypermobility syndrome. Rheumatology 2001;40:487-489. • Grahame R, et al. The Revised (Brighton 1998) Criteria for the Diagnosis of Benign Joint Hypermobility Syndrome (BJHS). J of Rheumatology 2000;27:7. • Mishra MB, Ryan P, Atkinson P, et al. Extra-articular feature of benign joint hypermobility syndrome. Br J Rheumatol 1996;35:861-6. • Larsson LG, Mudholkar GS, Baum J, Srivastava DK. Benefits and liabilities of hypermobility in the back pain disorders of industrial workers. Journal of Internal Medicine 1995;238:461-467.

  28. References • Larsson LG, Baum J, Mudholkar GS, Kollia GD. Benefits and disadvantages of joint hypermobility among musicians. N Engl J Med 1993;329:1079-81. • Fitzcharles MA. Is Hypermobility a Factor in Fibromyalgia. J of Rheumatology 2000;27:7. • Al-Rawi ZS, Al-Aszawi AJ, Al-Chalabi T. Joint mobility among university students in Iraq. Br J Rheumatol 1985;24:326-31. • Birrell FN, Adebajo AO et al. High prevalence of joint laxity in West Africans. Br J Rheumatol 1994;33:56-9.

More Related