Pediatric Hypermobility and Physical Therapy

When Physical Therapy is targeted to the specific needs and responses of the child and adolescent, beneficial outcomes result. The ideal approach is holistic, patient centered, specific, and aimed at giving the child the tools needed (Birt 2013, Barton 1996, Simmonds 2007). Therefore, it is incumbent upon therapists to understand those specific needs and be equipped to effectively provide services to this population. Beginning in childhood, a proactive approach for joint protection, stabilization training, and body awareness can facilitate management of symptoms and be preventative in nature (Celletti 2013). 

Treatment Strategies

According to the Cincinnati Children’s Hospital Evidence-Based Care Guidelines

1. Ideal treatment progression should begin at a low intensity and progress in a slow manner. 
2. Therapists should use careful handling for patient with joint hypermobility, bearing in mind the fragility of the connective tissue and the increased vulnerability to associated trauma and overuse problems. 
3. Therapeutic exercises should target postural awareness, joint stability, joint protection and restoration of muscular balance.
4. Symptoms of pain and fatigue should be assessed throughout each visit, and all exercises should be modified to ensure proper technique and/or minimize pain symptoms based upon each child’s needs.
5. Home exercise programs should be continuous, progressive, and performed as part of a daily routine to achieve maximum benefit.
6. Once children learn to recruit stability muscles in static positions, therapists should encourage activation during dynamic tasks and daily activities. After the child is able to activate and sustain contraction of stabilizing muscles, therapists should slowly advance training.
7. Incorporation of proprioceptive exercises and neuromuscular re-education will help improve postural control, improve functional status and decrease compensatory movement patterns.
8. Children with joint hypermobility have displayed benefits from habitual physical activities that facilitate neuromuscular control, are enjoyable and pain free. Examples include: swimming, Pilates, tai chi, modified yoga, dance, and biking. Be mindful of the impact of the physical activity by limiting high impact activities and repetitive tasks.

All treatment plans should be specified based on the unique needs of each child. Some examples of exercises to address joint hyper mobility include:

Hamstring Stretching

In long sitting position on firm surface, with low back up against an upright support, maintain knee straight and ankle in dorsiflexion to at least neutral. Can use a towel roll under knees to partially relieve stretch for increased tolerance.

Standing with one heel elevated on a step, maintain knee straight, ankle dorsiflexed to at least neutral and trunk in upright. Be sure child keeps hips facing straight ahead avoiding compensatory rotation to either side.

Heel Cord Stretching

Wall calf stretch with attention to keeping feet pointed straight ahead, heels flat on floor and back knee kept straight. If indicated, be sure child is in supportive shoes and orthotics to avoid over stretch through the medial longitudinal arch of the foot.

Abdominal Isometric

In hook lying, encourage child to draw ‘belly button into spine’, and maintain for 5-10 second hold count. Be sure child is not holding their breath and that they maintain contraction throughout the entire hold count. Progress by increasing hold count.

Posterior Pelvic Tilt

In hook lying, tighten stomach muscles and flatten back to the ground by rolling pelvis downward. Progress this exercise to bridge (pictured below).

Bridging

In hook lying, initiate with posterior pelvic tilt, then lift hips upward into neutral hip extension. Keep knees apart or use towel roll between them, depending on stability. Verbal and manual cueing provided to encourage posterior pelvic tilt, proper breathing techniques, and to avoid excessive lumbar lordosis or hip hyperextension.

Hip Adduction Isometrics

In hook lying, squeeze ball or towel roll between knees for 5 seconds.

Progress this exercise first by increasing hold count. Next combine this exercise with bridge (pictured above).

Mini Wall Squatting

Perform partial wall squats for lower extremity strength & postural stability by controlling eccentric lowering into modified range (30 to 45 degrees) and concentric rising within range. Use verbal cueing for control during lowering and return to starting position. 

Scapular Squeezes

Seated scapular retraction for 5 to 10 second hold. Use verbal and tactile cueing to promote shoulder depression, scapular retraction and upright posture during exercise. Also provide cues to limit shoulder shrugging and or exaggeration of lumbar lordosis.

Modified Heel Raises

Static partial heel rises for increased ankle stability and proprioception. Use verbal and tactile cueing to avoid locking out ankles into full plantarflexion and to sustain neutral eversion/inversion while holding for 5-10 counts.

All treatment and interventions should be performed under the care of a qualified and experienced Pediatric Physical Therapist. 

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References:

1. Barton,L.,and Bird,H.:Improving pain by the stabilization of hyperlax joints. Journal of Orthopaedic Rheumatology, 9: 46-51, 1996.
2. Bathen,T.,Hangmann,A.B.,Hoff,M.,Andersen,L. O.; and Rand-Hendriksen, S.: Multidisciplinary treatment of disability in ehlers-danlos syndrome hypermobility type/hypermobility syndrome: A pilot study using a combination of physical and cognitive- behavioral therapy on 12 women. Am J Med Genet A, 2013.
3. Celletti,C.,Castori,M.,LaTorre,G.,and Camerota, F.: Evaluation of kinesiophobia and its correlations with pain and fatigue in joint hypermobility syndrome/Ehlers- Danlos syndrome hypermobility type. Biomed Res Int, 2013.
4. Cincinnati Children’s Hospital Medical Center Joint Hypermobility Team 2014. “Evidence-basedclinicalcareguidelinefor Identification and Management of Pediatric Joint Hypermobility” CCHMC EBDM Website Guideline 43 pages 1-22.
5. Engelbert RHH, Juul-Kristensen B, Pacey V, De Vandele I, Smeenk S, Woinarosky N, Sabo S, Scheper MC, Russek L, Simmonds JV. The Evidence-based rationale for physical therapy treatment of children, adolescents and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos Syndrome. Am J Med Genet C Semin Med Genet, 2017: 175(1):158-167.
6. Kemp,S.,Gamble,C.,Wilkinson,S.,Davidson,J.E.,Baildam, E. M.,Cleary, A. G.,McCann, L. J.,Beresford, M. W., and Roberts, I.: A randomized comparative trial of generalized vs targeted physiotherapy in the management of childhood hypermobility. Rheumatology, 2010: 49(2): 315-325.
7. Pacey, V., Nicholson, L. L., Adams, R. D., Munn, J., and Munns, C. F.: Generalized joint hypermobility and risk of lower limb joint injury during sport: a systematic review with meta-analysis. Am J Sports Med, 2010: 38(7): 1487-97.
8. Simmonds, J. V., and Keer, R. J.: Hypermobility and the hypermobility syndrome. Man Ther, 2007: 12(4): 298-309.