A randomized comparative trial of generalized vs targeted physiotherapy in the management of childhood hypermobility.

OBJECTIVE Joint hypermobility, common in childhood, can be associated with severe pain and significant morbidity. Physiotherapy, the mainstay of treatment, lacks a robust evidence base. This study is aimed at determining the best physiotherapy intervention in managing childhood hypermobility. METHODS A prospective randomized comparative trial (RCT) compared a 6-week generalized programme, improving muscular strength and fitness, with a targeted programme aimed at correcting motion control of symptomatic joints. Patients were assessed on symptom scores (pain/global-impact), function, muscle strength and fitness. RESULTS Fifty-seven children, aged 7-16 years with symptomatic hypermobility, were randomly assign to receive a targeted (T; n = 30) or generalized (G; n = 27) programme. Statistically significant improvements were demonstrated in both the children's and parental pain scores across both the randomized groups between baseline and follow-up assessments (P < 0.05). However, the difference in improvement between the groups was not statistically significant. Child's assessment of change in pain score: mean difference (95% CI) T - G, 3.97 (-15.59, 20.85) at the end of treatment and 9.41 at 3-month follow-up (-17.42, 36.24). At the end of treatment, parental assessment of change in pain score, T - G was: -0.27 (-15.05, 14.50) and at 3-month follow-up it was: -9.48 (-26.40, 7.43). Change in parental global assessment was statistically significant, in favour of targeted physiotherapy at final assessment: -21.29 (-40.03, -2.55). CONCLUSION This is the first physiotherapy RCT for treating hypermobility. It demonstrated significant and sustained reduction in pain when both groups were combined, but did not detect any difference between the groups. This study provides normative and methodological data for future studies of hypermobility. TRIAL REGISTRATION Current Controlled Trials, www.controlled-trials.com, ISRCTN58523390.

[1]  S. Klepper,et al.  Exercise in pediatric rheumatic diseases , 2008, Current opinion in rheumatology.

[2]  R. Keer,et al.  Hypermobility and the hypermobility syndrome, part 2: assessment and management of hypermobility syndrome: illustrated via case studies. , 2008, Manual therapy.

[3]  J. Schomacher.  Response to: Brandt, C., Sole, G., Krause, M.W., Nel, M., 2007. An evidence-based review on the validity of the Kaltenborn rule as applied to the glenohumeral joint. Manual Therapy 12 (1), 3-11. , 2008, Manual therapy.

[4]  R. Keer,et al.  Hypermobility and the hypermobility syndrome. , 2007, Manual therapy.

[5]  O. Bar-or,et al.  The effects of vigorous exercise training on physical function in children with arthritis: a randomized, controlled, single-blinded trial. , 2007, Arthritis and rheumatism.

[6]  R. Grahame,et al.  Joint hypermobility syndrome in childhood. A not so benign multisystem disorder? , 2005, Rheumatology.

[7]  H. Bird.  Joint hypermobility in children. , 2005, Rheumatology.

[8]  R. Saurenmann,et al.  A randomized trial of parenteral methotrexate comparing an intermediate dose with a higher dose in children with juvenile idiopathic arthritis who failed to respond to standard doses of methotrexate. , 2004, Arthritis and rheumatism.

[9]  R. Hinman,et al.  Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial , 2003, BMJ : British Medical Journal.

[10]  S. Klepper.  Exercise and fitness in children with arthritis: evidence of benefits for exercise and physical activity. , 2003, Arthritis and rheumatism.

[11]  P. Lachenbruch,et al.  Defining Clinical Improvement in Adult and Juvenile Myositis. , 2003, The Journal of rheumatology.

[12]  B. Feldman,et al.  Minimal difference in pain associated with change in quality of life in children with rheumatic disease. , 2002, Arthritis and rheumatism.

[13]  A. Ramanan,et al.  Nitrous oxide analgesia during intra-articular injection for juvenile idiopathic arthritis , 2002, Archives of disease in childhood.

[14]  S. Sawhney,et al.  The British version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ). , 2001, Clinical and experimental rheumatology.

[15]  P. Woo,et al.  Benign joint hypermobility in childhood. , 2001, Rheumatology.

[16]  R. Grahame,et al.  Time to take hypermobility seriously (in adults and children). , 2001, Rheumatology.

[17]  S. Gurley-Green.  Living with the hypermobility syndrome. , 2001, Rheumatology.

[18]  S. Mottram,et al.  Functional stability re-training: principles and strategies for managing mechanical dysfunction. , 2001, Manual therapy.

[19]  S. Mottram,et al.  Movement and stability dysfunction--contemporary developments. , 2001, Manual therapy.

[20]  R. Grahame,et al.  The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). , 2000, The Journal of rheumatology.

[21]  Fitzcharles Ma,et al.  Is hypermobility a factor in fibromyalgia , 2000 .

[22]  C. Greenberg,et al.  Pain assessment in infants and children. , 2000, Pediatric clinics of North America.

[23]  L. Russek.  Examination and treatment of a patient with hypermobility syndrome. , 2000, Physical therapy.

[24]  R. Grahame.  Joint hypermobility and genetic collagen disorders: are they related? , 1999, Archives of disease in childhood.

[25]  S. Klepper.  Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis. , 1999, Arthritis care and research : the official journal of the Arthritis Health Professions Association.

[26]  J. Esdaile,et al.  The association of soft-tissue rheumatism and hypermobility. , 1998, British journal of rheumatology.

[27]  D. Felson,et al.  Preliminary definition of improvement in juvenile arthritis. , 1997, Arthritis and rheumatism.

[28]  J. Esdaile,et al.  Diagnostic associations with hypermobility in rheumatology patients. , 1995, British journal of rheumatology.

[29]  J. Fries,et al.  Measurement of health status in children with juvenile rheumatoid arthritis. , 1994, Arthritis and rheumatism.

[30]  M. Panjabi.  The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. , 1992, Journal of spinal disorders.

[31]  R L Lamb,et al.  Reliability of goniometric measurements and visual estimates of knee range of motion obtained in a clinical setting. , 1991, Physical therapy.

[32]  D H Nielsen,et al.  Intrarater reliability of manual muscle testing and hand-held dynametric muscle testing. , 1987, Physical therapy.

[33]  A. Kirsner,et al.  The hypermobility syndrome. , 1982, Postgraduate medicine.

[34]  H. Bird.  Joint hypermobility. , 2007, Musculoskeletal care.

[35]  J. Theodosakis.  A randomized, double blind, placebo controlled trial of a topical cream containing glucosamine sulfate, chondroitin sulfate, and camphor for osteoarthritis of the knee. , 2004, The Journal of rheumatology.

[36]  G. Murrell,et al.  Reliability of five methods for assessing shoulder range of motion. , 2001, The Australian journal of physiotherapy.

[37]  M. Fitzcharles.  Is hypermobility a factor in fibromyalgia? , 2000, The Journal of rheumatology.