hypermobility/instability - exam 1

Question 1

what are the 4 variables of stabilization?

Answer 1

joint integrity (i.e, cartilage)
passive stiffness (i.e. ligaments)
neural input
muscle function

Question 2

abnormal movement resulting in P! changes what?

Answer 2

instantaneous axis of motion

Question 3

what is functional instability? can PT help this?

Answer 3

instability that can be stabilized with muscle activity and/or positioning
PT can help

Question 4

what is mechanical instability? can PT help this?

Answer 4

instability that cannot be completely stabilized with muscle activity or positioning
PT cannot help - not a good outcome

Question 5

what are causes of hypermobility?

Answer 5

traumatic or recurrent sprains (i.e IDD)
age related disc changes
repetitive extension activities
creep due to poor posture
adjacent joint hypomobility
connective tissue disorder (generalized hypermobility)

Question 6

what is the most common site for hypermobility?

Answer 6

L4-S1

Question 7

what are the “tests” to assess for benign joint hypermobility syndrome?

Answer 7

stand and touch palms to floor
each knee that hyperextends
each elbow that hyperextends
each thumb that touches the forearm
each little finger with 90 MCP hyperextension

Question 8

Confirmed BJHS if:

Answer 8

2 major criteria present
1 major and 2 minor criteria present
4 minor criteria present

Question 9

what would a patient tell you if they have functional instability?

Answer 9

predictable pain (every time i do ..)
spine and referred pain, possibly paresthesias from nociplastic pain
decreased pain positional changes and support
increased pain with prolonged positions, looking up, sudden and strenuous ADLs, impact activities
catching (randomly moving into position that creates pain)
easy self manipulation (cracking back)

Question 10

what would a PT find in a scan for functional instability?

Hx?
ROM?
combined motion?

Answer 10

Hx: < 40 years old

ROM:
if acute, limited with aberrant motion. primarily limited and painful with extension bc of increased anterior vertebral shearing followed by SB. Flexion - may be limited with Gower’s sign (UE assistance returning from FB)
PROM > AROM particularly in nonWB vs WB
if NOT acute - often WNL or excessive except for ext that may still be limited with creasing
greater flexibility including generalized hypermobility conditions

CM: inconsistent block

Question 11

what are signs of aberrant AROM? how many make a positive?

Answer 11

painful arc of motion primarily in sagittal plane
uncoordinated motion, primarily in sagittal plane
Gower’s sign (UE use to stand from FB)
LE/pelvis compensations
positive if > 1 present

Question 12

what would a PT find in a scan for functional instability?

resisted/MMT?
neuro?
stress tests?

Answer 12

resisted:
if acute, may be P!ful
most often strong and painless bc global muscles are not affected

neuro:
(-) except possibly a hyperesthesia with pinwheel during sensation testing

stress:
(+) PA pressures
mixed findings w distraction depending on severity

Question 13

what would a PT find in a biomechanical exam for functional hypermobility

accessory motion?
special tests?
what about local muscles?

Answer 13

AM:
possible hypomobility if hypermobile joint is stuck (drawer example)
possible adjacent hypomobility
– T10-12 rotation
– SI jt motion
– hip hyperextension

special tests:
possible (+) prone LE ext. test
likely (+) linear stability
– most often excessive anterior shearing
– LBP can lead to an excessively recruited Psoas
– can be stabilized by muscle activation or positioning
possible (+) ASLR

inhibited local muscles

Question 14

why can LBP lead to an excessively recruited Psoas?

Answer 14

psoas maintains lordosis in standing
can further add to the hyperextension and anterior shearing most often occurring with lumber hypermobility/instability

Question 15

what does ASLR test? describe the test

Answer 15

tests local muscles
supine SLR to 6 inches
scoring:
– 1 pt for each:
– tremor, P!, ipsilateral pelvic rot to raised LE, slow motion, unable to raise LE
– (+) if > 1/5
may resist w weight of hand
repeat with manual or orthotic pelvic support or local muscle activation for any improvements

Question 16

what are mechanical instability symptoms?

Answer 16

same as functional instability except worse and with:
- unpredictable pattern of provoking activities
- worsening symptoms with more frequent episodes
- increased pain with even trivial and lesser ADLs

Question 17

what are mechanical instability signs?

Answer 17

same as functional instability except worse and with:
+ stability tests that wont stabilize fully with repositioning or muscle activity

even in closed pack position, the joint will move

Question 18

will functional instability always show up on a radiograph?

Answer 18

no - can exist without radiological evidence

Question 19

what do stress radiographs look at?

Answer 19

comparing vertebral position in various positions for mechanical instability

may also be a spondylolisthesis

Question 20

what could be done for mechanical instability?

Answer 20

prolotherapy for stabilization into iliolumbar ligaments along with PT
spinal fusion:
– for mechanical instability
– similar long term results to multi disciplinary PT
– higher costs and greater risks

Question 21

what should a PT prescribe for hypermobility?

Answer 21

Rx like ligamentous laxity
POLICED
postural education to activate local muscles and for chair support
JM - increase adjacent joint hypomobility
bracing/taping
MET
– emphasis on stabilization of local mm
– addition of hip exercises provided greater pain and disability improvements
– hyperextension contraindicated