Exercise in children with joint hypermobility syndrome and knee pain: a randomised controlled trial comparing exercise into hypermobile versus neutral knee extension

Abstract

BackgroundKnee pain in children with Joint Hypermobility Syndrome (JHS) is traditionally managed with exercise, however the supporting evidence for this is scarce. No trial has previously examined whether exercising to neutral or into the hypermobile range affects outcomes. This study aimed to (i) determine if a physiotherapist-prescribed exercise programme focused on knee joint strength and control is effective in reducing knee pain in children with JHS compared to no treatment, and (ii) whether the range in which these exercises are performed affects outcomes.MethodsA prospective, parallel-group, randomised controlled trial conducted in a tertiary hospital in Sydney, Australia compared an 8 week exercise programme performed into either the full hypermobile range or only to neutral knee extension, following a minimum 2 week baseline period without treatment. Randomisation was computer-generated, with allocation concealed by sequentially numbered opaque sealed envelopes. Knee pain was the primary outcome. Quality of life, thigh muscle strength, and function were also measured at (i) initial assessment, (ii) following the baseline period and (iii) post treatment. Assessors were blinded to the participants’ treatment allocation and participants blinded to the difference in the treatments.ResultsChildren with JHS and knee pain (n=26) aged 7-16 years were randomly assigned to the hypermobile (n=12) or neutral (n=14) treatment group. Significant improvements in child-reported maximal knee pain were found following treatment, regardless of group allocation with a mean 14.5 mm reduction on the visual analogue scale (95% CI 5.2 – 23.8 mm, p=0.003). Significant differences between treatment groups were noted for parent-reported overall psychosocial health (p=0.009), specifically self-esteem (p=0.034), mental health (p=0.001) and behaviour (p=0.019), in favour of exercising into the hypermobile range (n=11) compared to neutral only (n=14). Conversely, parent-reported overall physical health significantly favoured exercising only to neutral (p=0.037). No other differences were found between groups and no adverse events occurred.ConclusionsParents perceive improved child psychosocial health when children exercise into the hypermobile range, while exercising to neutral only is perceived to favour the child’s physical health. A physiotherapist prescribed, supervised, individualised and progressed exercise programme effectively reduces knee pain in children with JHS.Trial registrationAustralia & New Zealand Clinical Trials Registry; ACTRN12606000109505.

Quality of life prediction in children with joint hypermobility syndrome

“…Previous authors have hypothesised that treatments achieving pain reduction for children with JHS would result in substantial improvements in HRQOL. Randomised controlled trials with this patient population have demonstrated a 30–40% reduction in pain following a 6‐ to 8‐week physiotherapy programme with significant improvements in parent‐perceived HRQOL subsequently achieved . However, neither of these trials included child‐reported HRQOL or fatigue as an outcome measure.…”

The feasibility of a randomised controlled trial of physiotherapy for adults with joint hypermobility syndrome

“…The only other controlled studies were conducted with children and employed different types of exercise as comparator groups. 37,38 So, there is an argument that the existing research evidence (or lack thereof) supports a notion of clinical equipoise in terms of if physiotherapy is better than advice or indeed doing nothing. The qualitative data seems to support the notion that this was largely understood by patients and physiotherapists in the present study.…”

“…Another systematic review of occupational therapy and physiotherapy interventions for JHS 34 independently identified a high risk of bias in the study by Sahin et al 26 and did not identify any additional RCTs of physiotherapy in this area. Also of note is that three of the five studies 26,35,38 focused on the knee joint in what is a multiple-joint condition and all assessed a relatively brief intervention of ≤ 8 weeks. So, the true effectiveness of physiotherapy (including exercise) in JHS remains unknown.…”

“…Based on a review of titles and abstracts we found six papers 35,38,[91][92][93][94] reporting generic health-related quality of life in patients with JHS (Table 31). These studies typically were cross-sectional surveys with small numbers of patients with JHS (range 20-115).…”

“…38 It also compared two different types of exercise: one using exercise to neutral knee extension (n = 14) and one using exercise into the full hypermobile range (n = 12). Exercises were performed for 8 weeks.…”