Day from hell

I just am SO wiped out still from yesterday and have this horrid headache now for four days and I'm sure it's all stress.

I spoke to Dr. P yesterday and he said after consulting with some colleagues they agreed that I should have a blood workup to make sure I don't have any underlying blood conditions. The reasoning for this is that because my vessels and tissues are so friable, they don't want me to form a haematoma whilst doing the spinal epidural, as then I would be paralyzed. I appreciate the caution, but it also delays everything. His assistant gave me a list of 3 haematologists but said that I needed to blood taken first so I could bring that with me and to go to my PCP as soon as possible. It didn't make sense to go to the PCP for blood when she had nothing to do with it, but the assistant sounded so sure I said ok. Being brain dead, I just do what I'm told. I rang up Dr. Rosen and her office said to come in. Which I did. And then I sat and waited for over an hour to see her. And whilst she's normally very understanding and accommodating, she was uncomfortable taking blood that she wasn't interpreting and not really knowing what was needed. Which I have to say I agree with. It didn't make sense to me and I did ask Dr. P's assistant over and over if she was sure that's what I should do. So I left and was quite disheartened. I picked up some food on the way back to the office as it was about half two at this point. When I got back I rang the first haematologist on the list from Dr. P. That dude was retired so the put me on to another dr. Of course my luck was that the person answering the phone was on her first day and knew nothing. She said she would have the other girl ring me back when she returned. In the meantime I rang Dr. P's office after finally inhaling my food, and filled them in. I then rang the next haematologist on the list, a Dr. Wu. Thankfully he was able to see me at 16.15!

Now you have to understand that throughout all of this I was under the impression I'd have some blood drawn, wait a couple of days and all would be groovy and I could go get the epidural. You have to imagine my surprise when Dr. Wu, after asking me a ton of questions about bleeding, explained the procedures. He first takes some blood and then sends it off for (I could have this backwards so excuse me) I believe the coagulation studies, which take a WEEK!!! THEN, after those results, he has to send me to a special lab at Beth Israel where they take more blood and do some sort of platelet study, which takes a couple of days. Whilst hearing all of this all my head is doing is calculating how soon I am actually going to be able to get this epidural. And it's not till after the 4th of July weekend by my calculations. All of this make me a very unhappy person.

So after I leave Dr. Wu's office, I ring Dr. P and get to speak to him. I was sort of flipping because no one had warned me about the length of time. He said he has to make sure about this and I do appreciate it because the worst cast scenario is that I bleed and get a haematoma on my spinal cord which would paralyse me. I don't really want that, but at the same time I am losing my mind from the pain. I'm at the point that I'm actually trying to convince myself it's all in my head and I'm imagining the pain. If only! So I ask Dr. P about Dr. Rosen's suggestion on trying neurontin, which he says is similar to Lyrica. I have been SO afraid of Lyrica because I've heard such horror stories. So he said sure he'll ring in a script for me. Groovy.

During the bus ride home though I was debating about it and when I got home I decided to go online and look up more info before I picked up the prescription. Very contradictory reports but some positive about nerve pain (the weight gain totally freaks me out) but in the end I decide to go ahead and try it. Ha, like anything is easy at this point. I get to the chemists and he tells me the doctor requested a specific number of pills, but the insurance co will only fill a lesser number. I said that is fine, as I am only going to try it for a week or two until I get an injection. He says ok, and puts it into the computer, which of course comes back saying that the doctor has to ring the insurance company for prior approval, and that can take 2-5 days. At this point I don't know how I didn't just fall on the ground and start wailing. I think I was too tired.
I rang my mother and ranted for a while, because everything that should just be simple isn't. I hate insurance companies and I really hope the President gets his public health care option, because we really do need to level the playing field here.

So that was my day from hell. I've emailed Dr. P today about the prescription problem, and I'm sure the pharmacist has rung him as well. So now it's a waiting game to see if I will get any relief or I will jump off a building waiting for some.

Venting for the day:
And if I hear one more person whinge about having a cold or the sniffles I just might kill them. Someone on FB yesterday went on and on about having a little cold and how he was sent home from work and was devastated. PERSPECTIVE PEOPLE. I know I'm not as bad as some people, but come on, a bloody cold!?!?!? Get over yourself!

EDS

Was reading another blog by an EDS sufferer and thought she described it as basic and easily as possible, so wanted to copy it because it's exactly the same for me. For her complete blog check here.

"Due to the EDS, every collagen cell in my body is faulty and is programmed to be too stretchy and ultimately becomes like an old stretched out rubber band. Normal rubber bands are tight and when you stretch them they bounce right back to their previous shape. EDS sufferers have collagen that is already over-stretched, so when you stretch it out again, it does not bounce back to its original shape, but stays lax and loose. Therefore, we’re super-flexible…but pushing our joints to their limits (as with stretching, yoga, Pilates, heavy-lifting) does long-term irreversible damage.

Practically speaking, this means that my joints are all incredibly unstable and frequently dislocate. Some of my joints bend completely backwards (I can do neat party tricks like bending all of my fingers to touch the back of my hand) while other joints like my wrists and knees bend about 5-10 degrees backwards. The muscles around every single joint also tend to tighten way up, to do the job that my tendons and ligaments aren’t doing: keeping my skeleton in one piece. Dislocations and always-tight muscles = whole body chronic pain...

Think of EDS like extreme rheumatoid arthritis in every single joint, with the addition of random dislocations. And “every single joint” means just that: fingers, wrists, elbows, shoulders, ribs, vertebrae , hips, knees, ankles, toes, etc. People with Ehlers-Danlos Syndrome experience acute chronic pain in some or all of their joints and experience neuropathic (nerve) pain in some or all parts of their body, and some even have heart defects that can cause sudden death. Most of us have additional problems with vision, digestion, migraines, pregnancy, and our jaws and teeth. It's an all-encompassing disorder. I have the "Hypermobility Type" of EDS, and my most serious symptoms are in my entire spine, hands, wrists, ribs, knees, and hips. Thankfully, I do not have the "Vascular Type" of EDS, which can cause sudden and early death."

Needles

Saw Dr. Panagos yesterday and he feels it's a shoulder & a neck issue. Of course, why should it only be one? Anyway, we agreed to do a cortisone injection into my shoulder and a trigger point injection into the muscle near my neck. He said one of his patients had a similiarish situation and they did this and it worked. He's quite weary about an epidural for my spine because of the HEDS (Hypermobility Ehlers Danlos Syndrome) as he says that the tissues in the body have easy friability and he doesn't want to make things worse in the long run.

I asked him what we could do if this works to prevent it from happening again. He said that he wants me to strengthen but no flexibility. He suggested Pilates, and I told him my hip surgeon told me not do that, but he said just do the strenghthening bits. When I feel better I will get out my old Pilates disc and see what's there to work with. I also asked him that what if the injection helps my shoulder but not my neck, and he said last resort would be the spine injection if I am still in agony. Fun stuff!

Dr. P also asked if I have been able to find out any biological information on my birth family. He said it would be very good to know what their health situations are. I told him that there is a group in NY fighting for our records to be open, and G-d willing it will pass on the floor this year, so perhaps in a year I will have some information. If you care to help, please get the information here, and help contact the key reps and senators in NY and say you support senate bill S5269. We need our bio/medical info - especially people like me!

Today I rang my chiro to update him and I will be going to see him next Thursday. He wants me to give everything a chance to work in and settle down. I am praying SO hard that this will work. Next Wednesday I have an appointment with my hand surgeon to see about my right hand/wrist. ARGH! It never ends!

Going on week no. 3

with the neck and shoulder pain. It's not gotten better at all. Last week the physiatrist gave me a taper pack of prednisone. Did absolutely nothing. Nil. Nada. Zippo.
I spent the wkend at my parents trying to not move b/c when I move it hurt more. I tried the shoulder sling but couldn't really tell if it made much of a difference or not.
Monday I rang the physiatrist and made an appt for next Tues, the 16th. It was the first available. Tuesday I was still dying so I rang back and got his nurse - yay a live person. She was very understanding and helpful and said she would talk to him and get back to me. She did in a couple of hours and asked about the pain, if it was the same as back in Dec. I said no it's worse, so she said the dr wants me to have another MRI of my neck. I asked if we should do my shoulder but she said he's pretty sure the pain is originating from the spine, so that's what we'll do. It's scheduled that for this Saturday. In the meantime he gave me Valium to take so I can sleep. I took one last night at 21.00 and ended up waking up at 5 this morning. When I got up to take a shower I was loopy and walking into doors and dizzy and thought I'd fall down in the shower. How can people enjoy this feeling? If it at least got rid of the pain, then I might not mind as much. Anyway I hope the MRI results are quick and that there is something the dr can do on Tuesday to get rid of this major pain because I can't take much more of it, mentally, emotionally or physically. Once we (hopefully) sort the pain out then we have to figure out what to do next. It's one thing having stenosis, but it's another when you have HEDS thrown into the mix. None of the normal options seem available.

Today I have to do the prep for the colonoscopy tmrw. I am pretty nervous since just sitting kills my neck and back and I know I'll spend most of the evening in the loo. Oh well, at least I'll get it over with. I have to say though reading about this HalfLytely stuff does put one off, it sounds so gross. I had to do this once before but it was about 15 yrs ago.

Nothing changes

Unfortunately I was in agony all weekend. I was back at the chiro yesterday and today. Yesterday he suggested contacting my physiatrist because even though we've loosened up the muscles, the pain has not gotten any better. I was able to speak to Dr. Panagos today and he put be on Prednisone for a few days. You take 6 the first day, then 5, then 4, etc. I drove the pharmacist lady nuts because I kept ringing to see if the script had been called in. Finally it was about 15.30 so I went across the street and picked it up. I took 6 pills around 16.00 and so far nothing. I read online sometimes it can work v. fast, which is what my dr said, but he also said it could take days. I don't have days! I am so worn out from no sleep and all this pain that I just want to scream (I've been doing the almost daily crying meltdowns already).

I asked him about an injection like I had in my hips, and he said something similiar could be done but since it's the spine it would be in at least two joints, as opposed to the one. He said if the Prednisone doesn't work (G-d forbid!!!) then that would be the next step.

Please please please let this work and quickly. I am truly at my wits end!

So You Think You Might Have EDS?

After reading this I was amazed how many things add up. Before my diagnosis I was made to think I just had tons of random things wrong with me, but when I look at this, it all fits together like a puzzle. But if you do have many of these, or even some, you must get diagnosed by a genetic doctor. If you need a referral for one in NYC I have a great one.

By Sue Jenkins RN with contributions from Liza Sauls (from www.ednf.org)

It has been the experience of many of our members that a final diagnosis of EDS is the result of 'connecting the dots' of a person's history and a comprehensive review of the constellation of all symptoms; and includes, for many, thorough review of the medical histories of their families as well. Finally getting the diagnosis can be a relief to know that the symptoms are real and have a name; however limitations occur here as well. There is no cure, no 'fix', simply because the collection of experiences and symptoms now has a name and identity. But it does allow the patient and their families to know what they may be facing and allow them to become educated and proactive about the care they seek and require.

Based on the accumulated experiences of our members, the following essay is an overview of many of the symptoms and conditions that can be associated with EDS. It is not meant as a substitute for thorough medical review and care and supervision, but to help to view some aspects of EDS. Not every patient will have every symptom, as you will see, EDS can manifest in many different ways.

The challenge of EDS is not to be able to identify each symptom, but to be able to see a pattern among several.Early diagnosis and intervention are the keys to living the best life possible. With the recent TV programs on Ehlers-Danlos Syndrome, many people are coming to this website with questions about having EDS. Here is a list to help you determine if you need to see a geneticist who can correctly diagnose you.

Caution: If after reading the following article, you think you may have EDS, be sure to seek medical advice.

Please do not rely solely on this article or end your search with a self- diagnosis. EDS is a genetic syndrome and is diagnosed by a specialist, usually a geneticist or rheumatologist with extensive knowledge about EDS and its types:

• Classical
• Hypermobile
• Vascular
• Kyphoscoliosis
• Arthrochalasia
• Dermatosparaxis

Ehlers-Danlos Syndrome is a group of disorders that affect connective tissues, which are tissues that support the skin, bones, blood vessels, eyes and other organs. Defects in connective tissues cause the signs and symptoms of Ehlers-Danlos Syndrome, which vary from mildly loose joints to life-threatening complications related to tissue structure and fragility.

A physical examination is required, including taking an extensive family history and using the Beighton scale, which measures Hypermobility. Depending on which type of EDS the physician believes you have, eithera blood test or muscle biopsy will be taken.

How You Get It:
EDS is a genetic disorder, a mutation of one or several genes that make different types of collagen in your body, producing a defective tissue. A mutation in a gene on one of the first 22 nonsex chromosomes can lead to an autosomal disorder. Genes come in pairs.

Some types of EDS are autosomal dominant and others are autosomal recessive. Differing types of EDS affect different types of collagen.

• If a disease is autosomal dominant, it means you only need to get the abnormal gene from one parent in order for you to inherit the disease. One of the parents may often have the disease. Each child has a 50/50 chance of inheriting this disease.

• Recessive inheritance means both genes in a pair must be defective to cause disease. People with only one defective gene in the pair are considered carriers. However, they can pass the abnormal gene to their children.

Wrong Diagnoses:
Most people diagnosed with EDS have come the same long road where it seemed that nobody knew what was really wrong with you. Diagnoses of

• osteoarthritis
• fibromyalgia
• lupus
• rheumatoid arthritis
• rheumatic fever
• multiple sclerosis
• “growing pains”
• and “it’s all in your head” are just some of them

Often people get several misdiagnoses before finally being correctly diagnosed with EDS.

Symptoms of EDS:
Although all types of Ehlers-Danlos syndrome affect the joints and many also affect the skin, features vary by type and severity. An unusually large range of joint movement, hypermobility, occurs with most forms of Ehlers-Danlos syndrome, particularly the HEDS (hypermobility) and CEDS (Classical) types.

Below is a listing of symptoms that persons with EDS often have. These symptoms are broken down according to body systems. This list is not all-inclusive, but include those most frequently encountered.

Not everyone with EDS has them all and if you have some of them you may still not have Ehlers-Danlos Syndrome.

Joints:
• Different types of EDS have differing degrees of joint problems. Joint dislocation and incomplete dislocation called subluxation is common and recurrent.
• Spontaneous easy reduction or replacement of the finger digits and shoulders occurs.
• Hypermobile joints cause pain, and sometimes the "cracking" or "popping" of them feels like it relieves the pressure.
• ‘Pes planus’ or being flatfooted is common and feet can flatten even more as one ages.
• EDSers can develop osteoarthritis earlier than typical, and they often have difficulty or pain walking. They can appear klutzy.
• Some EDSers’ hands collapse from the pressure of a simple handshake. It is difficult to write, and often finger splints help a great deal.
• Cervical (neck) instability occurs in some types, and some people may have trouble holding up their head.
• Another frequent joint problem is fluid effusions into the knees, ankles and elbows, primarily in Classical or Kyphoscoliosis types. (effusion: The escape of fluid from the blood vessels or lymphatics into the tissues or a cavity)
• In the Kyphoscoliosis type, many infants have severe muscle hypotonia (floppy babies), generalized joint laxity and scoliosis at birth, or develop a progressive scoliosis (a curvature of the spine) within their first year of life.
• With Vascular EDS, joint hypermobility may be limited to the small joints of the feet and hands or may be very lax all over. As with other types, VEDS patients often are first diagnosed as hypermobile, only later learning that they have VEDS!

The range of hypermobility differs greatly among EDSers, even within types. The loose joints throughout life are unstable, prone to subluxation and dislocation, cause chronic pain and early-onset arthritis. Some people are only mildly affected by their EDS; others are completely debilitated.

Orthopedic procedures to stabilize or improve the joint's function sometimes put more than expected strain and stress on adjacent joints, leaving many EDSrs disappointed with the results.

So your back, hips, shoulders, knees, elbows, and other joints go out more often than you do, you might have EDS.

Skin: General EDS skin traits include:
• Easy bruising, delayed wound healing, differing types of scarring.
• Thinner skin than normal, especially in the Vascular type.
• Those with VEDS have translucent skin where the blood vessels below are clearly visible.
• Soft, velvety skin that is fragile and sometimes highly elastic (stretchy) is found, especially in the Classical type.
• Classical type EDS may experience wounds that split open with little bleeding and leave scars that widen over time to create characteristic shallow "cigarette paper" scars.
• Surgical incisions may present problems with healing, with stitching EDS skin sometimes described as "like sewing butter." Often requiring sutures being closer together and left in for a longer time than usual.
• With severe CEDS, even just leaning on the table with your elbows can cause the skin to split or may have molluscoid pseudotumors on elbows and knees. (molluscoid pseudotumors are small, spongy tumors consisting of fat surrounded by a fibrous capsule found over scars and pressure points).
• Skin that sags and wrinkles is characteristic of the Dermatosparaxis type of EDS. Extra (redundant) folds of skin may be present as affected children get older.
• Skin hyperextensibility to some degree occurs in all types of EDS except Vascular.

So your skin has so many bruises people think you earn your living as a boxer, you might have EDS.

Cardiovascular:
• People with EDS tend to have low body temperatures, may have trouble controlling their body temperatures when exposed to heat or cold, and many have blood pressure problems.
• Some have dilated aortic roots, incompetent heart valves, and autonomic dystonia or POTS (a syndrome where you have wide and serious blood pressure swings with position changes).
• Many people with EDS bruise very easily and often severely. It can be difficult for a medical professional to "feel" their pulse.
• Mitral valve prolapse is not a sign of EDS, though someone with EDS may have MVP; it is not diagnostic for this syndrome.

In some types, arteries including the aortas are very fragile and can rupture causing a medical emergency.
Note: IV (intravenous) access and even sometimes simply drawing blood for testing may require multiple attempts; using a "butterfly" needle and syringe is much more successful than the use of a vaccutainer which draws the blood rapidly by the use of suction. People with this concern must use extreme care and inform their healthcare providers of these possibilities.

Neurological Symptoms:
• Poor balance, severe headaches including migraines .
• Decreased deep tendon reflexes.
• Intracranial vascular abnormalities.
• Brain "fog", a sense of not being present; absence of focus or a lack of clarity
• Spinal stenosis (narrowing of spinal column) and/or scoliosis.
• Chiari malformation (the brain tonsils protrude down through the forum at the base of the brain) occurs in some EDS patients.

So you had a school report card that said you were fidgety, uncoordinated, lazy, under-developed, and a complainer, you might have EDS.

Dental:
• Half of all EDS patients have a hypermobile tongue, and are able to touch at least the end of their nose with it easily.
• A high palate and crowded baby and adult teeth are common, even though many EDS patients have smaller than normal teeth. The high palate and smaller teeth can make fitting dentures very difficult even when explained to the dentist prior to the dentures being made.
• Pre-molar and molar teeth often have high cusps and deep fissures with root problems, and enamel hypoplasia can cause decay and possible early extractions. Sometimes teeth actually crumble when losing the enamel.
• Patients with Classical type offer suffer with juvenile periodontal disease. All EDSers are cavity prone, and have increased bleeding from anywhere in the oral cavity due to the fragility of tissues. Braces can cause problems as they can damage the gums and tongue while moving teeth quickly.
• TMJ (tempomandibular joint) pain and clicking occur in about 30% of the general population, and about the same incidence occurs in EDSers. Often if in a dental chair with your mouth open for an extended period of time, the joint will repeatedly sublux. Taking a pillow so you can prop your hand up to support your jaw during the procedure will prevent it from happening and also reduce your pain level from TMJ.
• Studies have proven that lidocaine (a local anesthetic used during dental procedures) often works poorly or not at all with EDS patients.
• Some people with EDS complain of always feeling like there is a lump in their throat when swallowing, and often have other swallowing and voice problems.

So a dentist ever gave you so much Novocain that his thumb was numb, and you could still feel everything, you might have EDS!

GI system:
Gastrointestinal complications of EDS run literally from one end to the other. Frequently EDSers suffer from reflux and GERD, stemming from an incompetent esophageal sphincter that allows stomach acid to backflow up the esophagus and cause burns in it. Diverticula have been seen throughout the G.I. tract.
• Tissue extensibility and laxity can also cause lack of contraction of the stomach, causing food to not move down into the intestines.
• Megacolon and rectal prolapse may also occur, primarily in childhood but megacolon is also seen in adults. (Megacolon is an abnormal dilatation of the colon (a part of the large intestines) that is not caused by mechanical obstruction. The dilatation is often accompanied by a paralysis of the peristaltic movements of the bowel.)
• Irritable bowel syndrome is a common co-diagnosis. Constipation can result from the flaccidity of the large bowel, more water being pulled from the stool the longer it remains in the colon, and from pain medications.

So your favorite foods are your digestive system’s LEAST favorite foods, you might have EDS.

Eyes:
An EDSer may have many different eye problems depending on the type of Ehlers-Danlos they have including blue sclera, microcornea (very small cornea), epicanthic folds, and wide-spaced eyes. Other common problems are:
• Many EDSers are photophobic, some squint causing an "angry" appearance and angiod streaks.
• Loose tendons and ligaments around the eye create hard working muscles that get tired. Strabismus is the medical terms for eye conditions commonly called by these various names: eye turns, crossed eyes, cross-eyed, wall-eyes, wandering eyes, deviating eye.
• Myopia (near-sightedness), astigmatism, and early presbyopia (a vision condition in which the crystalline lens of your eye loses its flexibility, making it difficult to focus on close objects.) occur often in EDS patients.
• Dry eyes are a common and uncomfortable problem.
• Other EDS related problems are detached retinas and ectopia (displaced) lenses.
• Persons with Ehlers-Danlos syndrome should see an Ophthalmologist annually so the internal eye can be checked for retinal and lens problems among other things. This is not an O.D, a Doctor of Optometry, but an MD with a specialty in eye issues.

Even during an eye exam, the exam itself can cause vertigo, nausea and headache feeling much like carsickness in some people.

* So you change your eyeglass prescription more often than your wardrobe, you might have EDS!

Pain: Pain with Ehlers-Danlos syndrome can range from none to chronic debilitating pain. It is subjective, individual, and different for each of us. For many patients, this is the worst symptom of all!Causes of this pain can be repeated trauma of constant instability from recent subluxations and dislocations as well as degenerative joint disease. Sometimes poor posture brought on by lax ligaments and weak abdominal muscles cause increased pressure on the spinal joints. Some with EDS do not have pain; others develop it later in life, and others begin to suffer severe pain as children.
• Many things are useful in treating EDS pain such as heated pools (92-94 degrees), gentle stretching, walking (if your joints allow), and emotional support that recognizes the degree of your pain and is non-judgmental.
• Occupational Therapists who make splints and assess what you may need may help to make daily life easier. Heat and cold packs help a lot. Always use cold for the first 24 hours after an injury to decrease swelling and limit bleeding into the area, and then switch to heat.
• Other possibly helpful things are yoga, relaxation therapy, massage, acupuncture or acupressure, diversion, TENS units and chiropractic maneuvers by a knowledgeable chiropractor.
• Common pain management problems are related to medications either in a too low a dose or prescribing the wrong medication, overemphasizing risks, using a "cookbook" approach, patients refusing helpful medications because they worry about addiction, and doctors afraid of prescribing because of their misunderstanding of the DEA laws.
• Often pain is undertreated in children, the elderly, and minorities. Less than 2% of all chronic pain patients (not just EDS patients) using pain medications correctly for pain become addicted. One can become dependent, but can be easily weaned off narcotics in a short amount of time.
• Medications often used with EDS are: muscle relaxants, NSAIDS, steroids, lidocaine patches, antidepressants, narcotic and nonnarcotic pain medications. Remember that over 4,000 mg. of Tylenol daily causes liver damage. Different combinations of medications work for each individual.
• Pain can be completely debilitating and keep you from needed sleep. Often family and friends don't believe you ... the worst part of all.

So you have days when you need a nap to rest up from the effort of getting out of bed in the morning, you might have EDS.

Emotional Effects of EDS:
Should either physical disability or chronic debilitating pain make your life feel destroyed, feelings of worthlessness and profound depression may set in; often talking to a counselor or medical professional will help. Regrettably, a tragedy occurs when we not only have to contend with no longer being able to do the things that we have loved doing, but also has to battle for family and friends' belief, respect and understanding. It appears that everyone with an invisible disability sadly experiences this.

While someone with EDS is mourning their loss of ability and freedom, others often accuse them of just being lazy, malingering, or becoming an addict to the pain medications that allow them to live their life. Because of this, we should not confuse their endeavors to live life and be positive with assuming they are feeling well or doing better.

Knowing you have EDS doesn't suddenly make things worse for you physically, but may allow for better physical management, and ideally allow for the prevention of any real problems, even if none exist currently. So knowing you have it is not necessarily a bad thing.

Personal doubt about one's mental and physical abilities can add to the fear that others can't possibly believe or understand what you're going through. Inability to cope with daily tasks or mental confusion can have a demoralizing effect.

But there is hope and help. You can join EDNF and learn how to help yourself, your doctor and your future. You are not alone.

So you are searching for knowledge, learning about EDS and educating others, you might have EDS!

www.ednf.org

Physical Therapy Management of the Hypermobile Patient

Terry Olson, PT, MHS, FAAOMPT, received his physical therapy training at the University of Iowa and he has an interest in the manual treatment of the muscular skeletal problems. He subsequently received his Masters Degree in orthopedic physical therapy and he developed a post graduate program in exercise and manipulative therapy. Mr. Olson is a fellow of the American Academy of the Orthopedic Manual Therapists and we would like you to welcome Mr. Terry Olson.

I am going to present this from the standpoint of looking at hypermobility. We are going to look at a definition of hypermobility, its relationship to EDS, then talk about the role of exercise and joint protection, and a short case study that I thought I would present.

Okay, what is hypermobility? There are quite a few definitions, but the one that seemed to be the simplest was that it is a connective tissue disease, where connective tissue proteins, such as collagen, which give the bodies its intrinsic toughness, are differently formed; the results are mainly felt in the moving parts, that being the muscles, joints, tendons, ligaments, which now are more fragile than is the case for most people. The result is joint laxity with hypermobility and with it comes vulnerability to the effects of injury. The young girl presented here is the one on which I did the case presentation.

Quick review of the categories.

*
Classical: Looking at skin hyperextensibility, tissue fragility and joint hypermobility.
*
Hypermobility: again, joint hypermobility is the dominant characteristic, may have joint subluxation and dislocation, limb and joint pain.
*
Kyphoscoliosis: generalized joint laxity and severe muscle hypotonia, scoliosis, tissue and organ fragility.
*
Arthrochalasia: congenital hip dislocation, severe generalized joint hypermobility, recurrent subluxations, tissue fragility, and muscle hypotonia.
*
Vascular: organ fragility with the possibility of arterial or organ rupture, tendon or muscle rupture, joint hypermobility primarily in the digits.
*
Dermatosparaxis: severe skin rigidity, skin soft and doughy and may have large hernias.

Of all of those categories, the dominant feature from a physical therapy perspective is hypermobility and joint laxity, so those are the primary considerations for a therapist when treating patients with EDS; and that means that treatment needs to focus on joint protection and dynamic stabilization of those joint structures.

Muscle stiffness is a term that is used to describe the spring-like quality of muscle. When a muscle has high stiffness, increased force is required to cause lengthening of that muscle or to perturb it. Muscle stiffness has been described in the biomechanical and neurophysiological literature as one of the most crucial variables in joint stabilization; and in the knee a link has been established between receptors in the ligaments of the joint and muscle stiffness. The slide includes a few of the references for that.

In the residency process (I went through post-graduate residency training in manipulative and manual therapy) you are primarily moving joints that are stiff. Switching to talking about joints that are not stiff, which is the case here, takes a bit of a shift. One of the things taught in the residency process was that you cannot distinguish a problem as being a joint problem or a muscle problem. The structures are so closely interrelated that the feedback between the two is critical to the integrity of that joint. If you have problems within the joint; because the joint provides feedback to the muscles, you are going to have muscular weakness. If you have muscle weakness, again through association with the joint structure, you are going to have impact on the stability of the joint. Thus, any treatment needs to be directed at all of those structures.

It is possible that the sensory properties of structures within joints can be modified by the contraction of the local, stabilizing muscles, and this is usually the proximal muscle groups. If you are looking at the shoulder, you are talking about the scapular cervico-thoracic muscles and the large shoulder muscles themselves. If you are talking about ankles and knees, you are looking at the muscles in the trunk and the pelvic girdle.

Besides providing mechanical stability to the joints, these muscles can contribute to the sensory feedback mechanisms associated in the joint structures themselves. A study done by Blazier, Carpenter, and Houston showed that tightening of the joint structures with active muscle contraction increases the acuity of that shoulder joint. That means if the muscles are functioning properly, then they are going to provide feedback to the joint which, in turn, makes a more stable situation for that joint and the joint has the ability to have feedback as to where it should be positioned.

Dynamic stabilization, or the use of exercise to promote joint stabilization, occurs when tonic (postural and slow twitch muscle units), are activated. These tonic motor units are activated during tonic continuous low load activation of muscle, maximizing muscle stiffness. What we are talking about here is asking the muscle to contract gently, not maximally, and to be able to sustain that contraction for a period of time. This can be influenced by the speed of the activity or exercise, as well as the type of muscle contraction you are trying to acquire. Muscle contractions that are performed in the shortened range of the muscle length are going to be critical in establishing the sensitivity and optimal functional capacity of the sensory feedback system in the muscle.

All that says is that when you are exercising - for folks that are afraid to exercise, for folks that have an inherent increase in mobility - exercise needs to be done in a very small controlled range of motion. Dr. Unger and I have had discussions about patients that we might see commonly as well as the patients I have seen from Dr. Mark LaVallee. One of the things that I have seen somewhat consistently is that the patients who are stretching don't need to stretch. They will tell me about being stiff and they will take their leg and wrap it around their head and it is just difficult to relate to that as being stiff. Now you can have a feeling of stiffness, if the muscles are fatigued or overworked, which to me then relates back to weakness.

Co-contraction and co-activation of muscle groups provides the biomechanical forces for joint stabilizing and protection, especially if they are performed in mid-range or neutral joint positions. Every joint, in its ability to move through range, is going to have positions that are inherently more stable because you have joint surfaces that have better contact with each other. You also have a point in that range where the muscle has mechanical advantage. If I am bending my elbow, the biceps will do that. When the bicep is in its lengthened range (elbow fully straight), I am going to be much weaker than when I get to a point (elbow fully bent) when things are going to shorten or come closer together. Mechanically this is much stronger. And, so, when you exercise EDS patients, you need to make sure you attend to placing them in those mechanically advantaged positions to work and exercise.

This is not just with EDS, but with many of the patients I see that have weakness or hypermobility. They do not exercise their full range of motion, they do not have the control to do so, and building the ability to exercise to the greater range is the goal. So, you start where the patient can perform in a pain-free and stable manner. Closed chain exercise is superior for muscle protection of the joint, although open chain exercise is also beneficial and necessary, especially again if it is performed in the protected range of motion.

When we are talking about open chain exercise/closed chain exercise we mean the following. Open Chain Exercise: if I want to exercise my quadriceps, that is the muscle that straightens my knee out, that is open chain, just moving my leg through range of motion. Closed Chain Exercise: if I stand here and do a squat, I am still working that quadriceps muscle, but by virtue of contact with the floor, we now have other muscles that act to provide increased stability. So a lot of times, starting these patients with exercises that are more closed chain, enhances that ability to stabilize muscles around the joint.

Case presentation

We take a body chart that the patient marks when they come in - and again, typically, when I get a body chart on a patient from Dr. LaVallee, that whole body chart may be colored in - it looks like they have a suit on.

As a therapist, where do you start with that - you cannot treat everything. In this case here, the young girl, the primary complaint was the mid lower back, and the other complaints were part of her overall problem; but in this case not the primary reason for presenting to therapy. Primarily, it was because of back and hip trouble. She had a diagnosis of lumbar back pain, left hip pain, and EDS multiple areas of pain complaint and again those were most notable in back and hip. She described pain complaints of an 8 out of 0-10, (0 being no pain, 10 being like a wild animal tearing your leg off).

She described her pain at her worst as being an 8 on that scale with standing for more than one hour being a provocative activity, as well as her activities of daily living. One of the things that were important at that time was that she had a baby, and that holding her baby was enough to provoke a lot of these pain complaints. She had objective signs of multiple joint hypermobility with back pain reproduction.

In her case, initial emphasis was on symptom alleviation using modalities (heat and cold, TENS units, electrical stimuli), gentle joint mobilizationand biomechanical correction, as well as performing assisted exercise in protected asymptomatic range of motion. We also provided biomechanic counseling on joint protection, as well as back care education regarding lifting, sitting, and performance of her activities of daily living.

Over the course of treatment, as her symptoms decreased, we progressed into more dynamic exercise, dynamic stabilization, and that become the crux of her home program.

One of the things that we can use in the setting that I work in, at least in the acute phases, is equipment designed to start exercising folks at less than full limb loading. If you have someone that has an injury or problems with - as in this case - knee and hip, and those problems occur when they are weight bearing, then the idea is that exercise has value because if we exercise, we have the ability to increase blood flow and circulation, increase oxygen, all of the things that are essential for healing, as well as building blocks for laying down stronger tissue. The problem is bringing that load to an acceptable level for that person.

So, in this case, this patient is just doing a bilateral squat activity and the slide board allows her/him to exercise anywhere from less than 20% of body weight taking it all the way up to 70% of body weight and then we know how to graduate that into a gym exercise. We try to exercise people as functional as we can, so if people have complaints of “when I stand too long or when I walk too long, when I bend is when I have my complaints,� I am going to try to set my exercise program up so that they are standing, walking, bending, but using the equipment to again decrease gravity, or their body weight, so that they are exercising with less body weight on those joints.

In this case, with walking, we use a treadmill system that has an overhead pneumatic assist and that harness allows us to hoist someone up. We can take that person, take as much as 70% of body weight (essentially the weight of the trunk - you go any higher than that and you are like Peter Pan and you are unstable, and you are ready to fly) then you are still getting input into the joints, but not full load.

I had a discussion with one of the participants who asked me about Pilates - I am going to beat people to the punch - I don't know. Pilates makes sense to me that it can be of value, but I don't know enough about it and I might make an idiot of myself trying to tell you the value of it.

Not for purpose of this talk, but if it gives any rationale to why; the approach that we use is a system called "medical exercise training". That approach is based on specific tissue exercise, and so we work from a standpoint that muscle requires a different muscle stimulus than does tendon, than does cartilage, than does disc. All of those structures have a different metabolic requirement, so those exercises have to be different, and when you are working with folks who have tendonitis, we try to work out an exercise program that allows that person to go through anywhere from 150 to 200 repetitions - because that seems to be the adequate number of repetitions to get an adequate increased blood flow to the area to promote a healing response. When trying to address structures such as ligament, cartilage, disc, those structures require upwards of 1,000 to 1,500 reps. The problem is taking someone who hurts and tell them you are going to put them on an exercise program of 1,500 repetitions and then say I will come back in an hour and see how you are doing. So to do that, you need to take load off, and the purpose of the equipment is to assist that part so that person can perform repetitions without pain. And then as the structure begins to heal, we gradually put load back on.

So this was the initial phase. In addition, we started to work on trunk. With Pilates or with other approaches, their value is core strengthening of the trunk - because your arms and legs attach to your trunk and if your trunk is not stable, then it is difficult to promote stability into those joints. Oftentimes the trunk is the most logical place to start, and is probably the easiest because everything else has to function off of it.

A simple leg raise will require activation of the transverse abdominal muscles if they are activated and used. The fact that her back is arched and she is unable to keep it from arching is indicative of the fact that a good exercise becomes a very poor one because she doesn't exhibit the ability to recruit enough trunk muscles to actually handle the weight. Here, she is able to keep the trunk stable (you don't see that hollow) and so she is performing that exercise actually really well with good trunk control.

Exercise is controlled trauma. When we exercise someone, we are inflicting trauma - the idea is to control it. If you exercise adequately, you are going to break down tissue, then let it rest and in this phase it recovers and lays down stronger tissue - if you adequately stress it. If you overstress it, then a good exercise becomes a bad exercise pretty quickly. All day long I see patients come in who are failures at exercise programs and it is not because exercise is not a benefit to them, they have just not been trained to do it with good form and to work in a range where they have control. You need to understand what is safe.

I had actually treated Erika about 9 months ago and she did well. I asked her to come back to see how she was doing but also to take some photos for this presentation and it was a good chance to take her upstairs and see if she was doing what we had instructed her to do 9 months ago. She demonstrates incredible form. Her elbows are going the wrong way and you would think that would make sense, but when we first went over her exercises and she did things, a lot of the things she was performing, a lot of work was in an unstable range and it was causing a lot of pain. It was just a matter of again making certain that her trunk was active and then worked in the range that she could exhibit control.

The exercise doesn't matter - when I set exercises for people, it doesn't matter, pushing up, pulling down, pushing away, pulling into them, I do a variety because life is made up of that. You need to be able to do all sorts of things but in a stable manner. The exercises need to be changed and modified as long as the patient understands stabilizing well, good trunk improvement, and that the joints are working in a range where they were stable.

I saw Erika for 9 visits over a 5 week period. Initial treatments consisted of gentle treatment to relieve symptoms coupled with assisted exercise utilizing the assisted treadmill walking and total gym. The patient then progressed to a stabilization and progressive strengthening exercise program. Her symptoms decreased, her discharge pain complaints were decreased, and she was able to stand and sit for more than two hours without symptoms, as well as lift her baby without increase in symptoms.

The final slide provides some excellent overall points in your therapy process. All of these things can be used in treatment and pain reduction. What I have seen with pain reduction, if you are heating people or icing them or electric stimuli, you are doing things that are temporary. Long lasting change is only going to come with making a change in the body, to the extent that you can. So, exercise with emphasis on controlled range of motion or working within a range of control. Pool therapy is beneficial and we use a pool at our facility also. Pool therapy takes the body weight off much the way the harness mentioned above does. Massage certainly has value, but again I think you need to be careful about monitoring skin integrity, especially if you are doing friction massage which is one of the therapy modalities often used in treating tendonitis. Use of splints or bracing - those are done supportively. Annual therapy, manipulative therapy, chiropractic therapy - it is not contraindicated, but you need to make sure you are addressing treatment to a joint that needs to be moved, not the joints that already move excessively. As a general rule, you want to be cautious of vigorous stretching secondary to inherent hypermobility. Again, I don't teach people to stretch, but they do need to strengthen because they have all of this range of motion that they don't have control of and that is painful. A lot of patient education, regarding ergonomics, joint protection, body mechanics, is required.

There are six major types of EDS. The different types of EDS are classified according to the signs and symptoms that are manifested. Each type of EDS is a distinct disorder that "runs true" in a family. This means that an individual with Vascular Type EDS will not have a child with Classical Type EDS. More detailed information can be found in our Medical Professionals Section.

General Frequently Asked Questions
Hypermobility (Formerly EDS Type III)

Joint hypermobility is the dominant clinical manifestation. Generalized joint hypermobility that affects large (elbows, knees)and small (fingers and toes) joints is evident in the Hypermobility Type. Recurring joint subluxations and dislocations are common occurrences. Certain joints, such as the shoulder, patella, and temporomandibular joint dislocate frequently. The skin involvement (hyperextensibility and/or smooth velvety skin) as well as bruising tendencies in the Hypermobility Type are present but variable in severity.

Chronic joint and limb pain is a common complaint amongst individuals with the Hypermobility Type. Skeletal X-rays are normal. Musculoskeletal pain is early onset, chronic and may be debilitating. The anatomical distribution is wide and tender points can sometimes be elicited.

To date, no distinctive biochemical collagen finding has been identified by researchers. The Hypermobility Type of EDS is inherited in an autosomal dominant manner.

(from EDS National Foundation site)

What is EDS?
Individuals with EDS have a defect in their connective tissue, the tissue that provides support to many body parts such as the skin, muscles and ligaments. The fragile skin and unstable joints found in EDS are the result of faulty collagen. Collagen is a protein, which acts as a "glue" in the body, adding strength and elasticity to connective tissue.

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of heritable connective tissue disorders, characterized by articular (joint) hypermobility, skin extensibility and tissue fragility. There are six major types of EDS. The different types of EDS are classified according to their manifestations of signs and symptoms. Each type of EDS is a distinct disorder that "runs true" in a family. This means that an individual with Vascular Type EDS will not have a child with Classical Type EDS.

What are the symptoms of EDS?
Clinical manifestations of EDS are most often joint and skin related and may include:

Joints: joint hypermobility; loose/unstable joints which are prone to frequent dislocations and/or subluxations; joint pain; hyperextensible joints (they move beyond the joint's normal range); early onset of osteoarthritis.

Skin: soft velvetâ-like skin; variable skin hyper-extensibility; fragile skin that tears or bruises easily (bruising may be severe); severe scarring; slow and poor wound healing; development of molluscoid pseudo tumors (fleshy lesions associated with scars over pressure areas).

Miscellaneous/Less Common: chronic, early onset, debilitating musculoskeletal pain (usually associated with the Hypermobility Type); arterial/intestinal/uterine fragility or rupture (usually associated with the Vascular Type); Scoliosis at birth and scleral fragility (associated with the Kyphoscoliosis Type); poor muscle tone (associated with the Arthrochalasia Type); mitral valve prolapse; and gum disease.
What are the types of EDS?
There are six major types of EDS. The different types of EDS are classified according to the signs and symptoms that are manifested. Each type of EDS is a distinct disorder that "runs true" in a family. An individual with Vascular Type EDS will not have a child with Classical Type EDS. Learn more about the different types of EDS.
How is EDS diagnosed?

The categorization of the Ehlers-Danlos syndromes began in the late 1960's and was formalized in the Berlin nosology. Over time, it became apparent that the diagnostic criteria established and published in 1988 did not discriminate adequately between the different types of the Ehlers-Danlos syndrome or between the Ehlers-Danlos syndrome and other phenotypically related conditions. Learn more about the EDS nosology and how EDS is diagnosed.
How prevalent is EDS?
At this time, research statistics of EDS show the prevalence as 1 in 5,000. It is known to affect both males and females of all racial and ethnic backgrounds.
How is EDS inherited?
The two known inheritance patterns for EDS include autosomal dominant and autosomal recessive. Specifics regarding genetic inheritance may be found by following the link below. Regardless of the inheritance pattern, we have no choice in which genes we pass on to our children. Read more about hereditary patterns.
What is the prognosis of someone with EDS?
The prognosis of EDS depends on the specific type. Life expectancy can be shortened with the Vascular Type of EDS due to the possibility of organ and vessel rupture. Life expectancy is usually not affected in the other types.
What can I do now?
The defining trait of those affected by EDS is the search for information. The rise in Internet usage in the last few years has delivered a significant benefit to families affected by EDS. EDNF members are sharing information on-line and learning from each other in ways that were impossible a decade ago. Learn more about the benefits of EDNF membership.

posts from ednf.com

About EDS
Funny, You Don't Look Sick

By Claire Forst
Reprinted from Loose Connections Vol X Number 1

People who have chronic illnesses are in two distinct categories: those who look sick and get all kinds of sympathy (wanted and unwanted), and those who, no matter how they feel, just don't look "sick". How do we classify "looking sick"? Well if someone is looking pale and wan, or seems to be in pain, we ask them how they are feeling and if we can do anything for them. On the other side, is the person who may very well be in constant pain or at least discomfort, but is able to walk and talk and carry on with their daily activities, no matter what the cost is to their physical or emotional health. These people are almost never asked how they are feeling because if they look "well", we assume that they are fine. Most times, they aren't fine, however, and it's about time we acknowledge this.

Our daughter has an unknown type of EDS. She is always in pain, yet as a child, she is always striving to keep up with her peers so as not to be different. To look at her, you would not say she is a child with a medical problem, unless you see her when the pain overwhelms her and she cries on her bed. Even her doctor, a kind and caring person, was not tuned into the degree of discomfort she endures each day until he heard her scream in pain one morning. He was shocked. Not because he doesn't care or didn't believe her, but because she "doesn't look sick". Recently, she has gone through a bad time with her legs, and I sent her in alone to talk to her doctor. We are grateful that she is a very articulate 8-year-old who can make her position known in no uncertain terms. They were in the office for quite a while, and when they came out, his whole attitude was changed. No longer was there the "how can she be in such pain when she gets around and looks OK". What we saw, was a true understanding of the life our child leads and how hard she works to be a "regular" kid.

The same principle applies to everyone, no matter what age. When we look sick, we may be accepted with all of our limitations. If we are bent over, someone may rush to help us. If you are visibly handicapped, people may look away, but most people would offer necessary assistance. Most people with EDS look just like everyone else. They may limp, or have visible skin changes. But many people have scars, and that doesn't make them sick.

We must make the general public and members of the medical community aware that the way we look is only "skin deep". The way we "feel", both emotionally and physically, is the bottom line. So the next time you ask someone, "how are you", please take a moment and really listen to the answer; you can be sure that your concern and caring will be appreciated.


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Learning To Manage Fibromyalgia Syndrome

Darlene A. Clarke, R.N., M.S.N.

President & Founder of the Northeast Ohio Branch of the EDNF. Darlene has Hypermobility Type EDS and Fibromyalgia Syndrome.

Individuals with EDS are often also diagnosed with Fibromyalgia syndrome. Fibromyalgia is a common and often disabling disorder whose cause remains obscure. Fibromyalgia frequently resembles other disorders such as rheumatoid arthritis and lupus. Individuals commonly complain of widespread muscle pain and tenderness, as well as fatigue and exhaustion after minimal exertion. A characteristically high “tender point� is evident. For individuals diagnosed with Fibromyalgia, learning to effectively cope with this disorder is essential to one’s emotional and physical health.

It's morning and as you awake you realize you are exhausted and you haven't even left the bed yet. The thought crosses your mind that for as tired as you are, you may as well have never gone to bed. You barely have enough energy to get out of bed and care for yourself, let alone being able to care for the children, or go to work or school. As you struggle to get out of bed, you realize that your body aches all over and you feel as if you are a 100 years old. You are stiff and can hardly move. What is wrong with you? After seeking one or more medical evaluations, you finally get the answer. Your physician informs you that you have Fibromyalgia syndrome. Such a big word that sounds ominous and must mean you have some dreaded problem. You have never even heard the term before.

So, what is Fibromyalgia syndrome?

Fibromyalgia syndrome is a common form of chronic, generalized muscular pain and fatigue. In some cases, the pain is so intense that it can be incapacitating.

1 Despite that Fibromyalgia does not result in serious, long-term target organ damage; it does have a negative impact on the quality of life similar to that of rheumatoid arthritis.

2 To effectively manage and cope with Fibromyalgia syndrome, it is imperative that one has a clear understanding of Fibromyalgia, its signs and symptoms, triggering factors and how it is treated and managed.

The term "Fibromyalgia" can be broken down into fibro (fibrous tissue), my (muscles), and algia (pain and tenderness). In Fibromyalgia there is pain in the muscles and fibrous connective tissues which comprise ligaments and tendons. Therefore, while Fibromyalgia feels like a joint disease, it affects muscles and their attachments to bone and joint deformity does not ensue.

3 Fibromyalgia can run in families, possibly suggesting an inherited predisposition. To date, the cause of Fibromyalgia is not known. It may lie dormant until it is triggered by an injury/trauma, stress, or a sleep disturbance. There are other theories as to what triggers Fibromyalgia. One theory is that the syndrome is caused by an infectious agent such as the influenza virus. Other suspected causes include extreme physical deconditioning of the nervous system brought on by a lack of exercise, and changes in muscle metabolism that can result in decreased blood flow to the muscles with fatigue and decreased strength the end results.

4 More recent research points to two key chemicals of the Central Nervous System that facilitate the regulation of pain messages transmitted to our brain. These two chemicals are substance P and serotonin. Substance P begins the pain–signal process following tissue injury. Serotonin reduces the intensity of pain signals in the transmission of pain and is very important in sleep regulation. Low levels of serotonin and elevated levels of substance P have been found in individuals with Fibromyalgia. These findings support the theories that individuals with Fibromyalgia have unusually high pain intensity messages transmitted to their brain as well as deficiencies in the inhibition of pain.

5 One clear fact remains: more research is needed on Fibromyalgia. Despite not being able to identify the exact cause of Fibromyalgia, individuals present with similar signs and symptoms.

Signs and Symptoms

Probably the most frustrating aspect of having Fibromyalgia syndrome, as in EDS, is that you "look healthy." Compounded by the fact that test results are normal, it is difficult to convince others that something is wrong with you. Every X–ray and blood test your physician ordered has come back within normal limits. You embark down the path of self doubt and frustration - is this pain real, or is it all in my head? Why is it so difficult to put a label to the signs and symptoms of Fibromyalgia?

Fibromyalgia is frequently misunderstood and confusing because the symptoms seen in this syndrome are also found in other conditions such as rheumatoid arthritis and lupus. Women are affected more than men and the symptoms usually occur first when an individual is between 20 and 40 years old.1 However, it must be noted that Fibromyalgia can sometimes affect children and the elderly.4 Recent research studies have established guidelines for diagnosing Fibromyalgia based on the presence of certain signs and symptoms.


Pain

The most common complaint from patients with Fibromyalgia is that they have diffuse pain all over, almost like the flu. Although in rarer cases, the pain is quite severe and disabling. More often, the symptoms often begin insidiously and may wax and wane in severity. In almost all cases, individuals complain of some degree of pain continuously. The pain is most often worse at tender points specifically located on the body. Fibromyalgia type pain generally is worse in the morning and late evening and often is associated with stiffness. Muscle groups that are used repetitively result in an increase in the level of pain you experience.

Fatigue and Sleep Disturbances

Have you ever awaked after sleeping and felt refreshed and rejuvenated? Most likely your answer would be Immense fatigue is frequently the debilitating aspect of Fibromyalgia. The fatigue may be exhibited as an overall tiredness and lack of energy, or as muscular fatigue and a lack of endurance. In either case, it can be difficult to perform activities of daily living such as caring for self or others, performing household chores, going shopping, or to function effectively at work. Keep in mind that it takes a tremendous amount of energy to deal with having chronic pain and this too can contribute to an individual's fatigue.

Approximately 90% of individuals with Fibromyalgia complain of moderate to severe fatigue coupled with a lack of energy or the type of exhaustion that is found with a lack of sleep. In most cases, individuals wake up feeling tired even after sleeping all night. While their minds may be rested, their bodies feel as if they never went to sleep. Many are aware that their sleep has become lighter with frequent awakenings throughout the night. Scientific studies reveal that individuals with Fibromyalgia have abnormal sleep patterns and are deficient in Stage 4 sleep - the deepest stage.1,3,5 It is important to note that a secondary Fibromyalgia syndrome can occur with any connective tissue disease (EDS included) and may not necessarily be related to sleep disturbances.6

Central Nervous System Symptoms

As in other chronic illnesses, mood and mental changes can occur in individuals with Fibromyalgia. Many individuals feel down, although only about 25% are clinically depressed. In most cases, depression and/or anxiety tends to follow the onset of Fibromyalgia symptoms and may be the result of Fibromyalgia and not the cause of it.3

People with Fibromyalgia may also experience numbness and tingling in their hands, arms, face, feet and legs. These symptoms can also be found in other disorders and usually require numerous tests before the diagnosis of Fibromyalgia is reached by a physician.

Other Problems

Muscular as well as migraine headaches are common in Fibromyalgia. Abdominal bloating, pain, alternating diarrhea and constipation are also commonly seen. They resemble irritable bowel syndrome or spastic colon in nature. Similar bladder spasms and irritability results in urinary urgency and frequency. The skin and circulatory system are sensitive to moisture and temperature changes resulting in temporary changes in skin color.2,3

Clinical Diagnosis

Currently, no definitive laboratory tests exist to make the diagnosis of Fibromyalgia. Rather, the diagnosis is made by a physician after obtaining the individual's medical history and performing a complete physical examination.

A hallmark of Fibromyalgia syndrome is reduced pain thresholds at designated tender points, demonstrated upon palpation.2 According to the American College of Rheumatology, the diagnostic criteria for Fibromyalgia includes: a). widespread diffuse pain that has been present for at least three months and b). pain that is present in 11 of the 18 bilateral tender point sites (see figure 1) when 4 kg of force is applied by digital palpation.1,2,7 Recall your response the first time your physician palpated these 18 tender points. Did you say ouch, flinch, make a facial grimace, and attempt to withdraw away from your doctor or even jump? These are the usual responses elicited by an individual with Fibromyalgia. Frequently, patients are shocked by the level of pain they experience when these areas are palpated. Now that you know how Fibromyalgia is diagnosed, let's look at the common triggering factors of Fibromyalgia.

Common Triggers of Fibromyalgia

Three common factors seem to trigger a flare in Fibromyalgia symptoms, physical factors, emotional factors and environmental factors. Keep in mind that your Fibromyalgia can become aggravated by these factors alone or any combination of these factors.

Physical Factors

Several physical factors can aggravate your Fibromyalgia. Infections are one type of physical factor that can produce the most profound exacerbation of Fibromyalgia symptoms. The second type of physical factors deal with ergonomics. The positions we maintain our bodies in has a direct correlation to the pain associated in Fibromyalgia. For instance, do you have a job that requires you use repetitive movements all day? Are you required to work in one spot with your arms elevated above your work surface? Do you need to remain in one position (i.e., standing, sitting or driving) for prolonged amounts time? If you answered yes to any of the above questions, you will be able to relate to the pain that results from maintaining your muscles in a sustained isometric position for any length of time. Ergonomics also plays an important role at home. It's often difficult for someone with Fibromyalgia to push a vacuum cleaner, wash walls, paint or prepare meals. These tasks require the use of shoulder muscles to maintain arms in extension at some level in front of our body. What generally happens is that an ache begins in the neck, shoulders and upper back. The ache rapidly turns into pain that elevates in intensity as it slowly radiates up and down the back. You feel as if you can't maintain your arms in this position any longer, and you quickly return your arms to your sides as you wait for the pain to slowly ebb away. Most, if not all of you, can relate to this all too familiar type of pain.
Emotional Factors

Stress is something that each of us has to deal with on a daily basis. Unfortunately, emotional stress is a prominent factor aggravating Fibromyalgia. We are faced with stressful situations at home, work, school, driving your car on the highway etc. It isn't difficult to identify situations that aggravate your Fibromyalgia symptoms that's the easy part of the equation. The trick is to avoid or attempt to modify any stressful situation.

It is extremely difficult to deal with those situations in which any stressor is unrelenting. These types of situations can present themselves in the home with family members or in the workplace with coworkers or supervisors. In these situations, one must look at not only the circumstance, but how you react to the stressor. Ultimately, it comes down to dividing these stressful situations into two categories: those that you have control over and those you have absolutely no control over. In circumstances that you have no control over, it is imperative that you learn to alter your response to those particular situations. Save your energy for those battles that you can emerge victorious.

Environmental Factors

How many times have you been able to predict the approaching weather without having looked at a weather map? Probably too numerous to count. You feel like you are a human barometer with the ability to predict weather changes before they occur. Most likely you have found that when the barometric pressure drops, it is followed by rain, cold, snow, and fog - all of which aggravate your symptoms.

Many individuals with Fibromyalgia report that certain types of artificial lighting, cold drafts or irritating noises often result in a flare of their muscle pain. When was the last time that you were able to enter a pool that wasn't heated? Just a guess, but it was probably many years ago. Most individuals with Fibromyalgia do not tolerate swimming in cold or cool water. We are usually found in the heated pools that others say are too hot to swim in or in hot tubs. The goal is to determine what factors aggravate your Fibromyalgia and either eliminate them if possible or at least modify them. Now that you know what factors can trigger your Fibromyalgia, let's look at how it is treated and managed.

Treatment and Management

Since Fibromyalgia's definitive cause is not known, current treatments are focused on relieving painful symptoms, not necessarily curing them. Additionally, the treatment program prescribed by your physician will be individualized to address your specific needs.

Numerous treatments have been employed over the years for Fibromyalgia. No one method has been entirely successful, but several methods will be prescribed by your physician in an attempt to control your symptoms. A sense of overwhelming relief comes with the validation of your symptoms and a diagnosis. Just knowing the name of your condition will not be enough though. Your physician and healthcare team will educate you and your family about Fibromyalgia. Specifically, you'll be informed about your prognosis, possible causative factors, the aspects of treatment and specific body mechanics techniques. This education will prove invaluable to you. If you are taught about what to expect and how to deal with flare-ups, you will be able to control your Fibromyalgia. The goal of education is to moderate the effects of Fibromyalgia on your life. Only then will Fibromyalgia not become your entire life.

Medications may be prescribed by your physician to control pain and improve deep Stage 4 sleep. If pain is prominent, your doctor may prescribe a low dose of an analgesic or nonsteroidal anti-inflammatory drug, although most nonsteroidal anti-inflammatory drugs are marginally beneficial and carry the risk of side effects that outweigh their benefits. Therefore, you will be most likely instructed to use over the counter medications such as acetaminophen, aspirin or ibuprofen to relieve pain and reduce stiffness. If you are currently on a nonsteroidal anti-inflammatory drug to help manage your EDS, your physician will likely instruct you to take acetaminophen, not ibuprofen or aspirin, to control your pain.

To improve Stage 4 sleep, your physician may prescribe low doses of tricyclic antidepressants (Elavil, Sinequan) or the muscle relaxant cyclobenzaprine (Flexeril). These drugs are structurally similar and they block the uptake of the neurotransmitters that regulate deep Stage 4 sleep.3,8. These medications carry the risk of potential side-effects which include: drowsiness, weight gain, dry mouth and constipation to name a few. Do not be discouraged if you do not respond to the first medication(s) prescribed. Your doctor may need to adjust dosages or change drugs to achieve an improvement.
Individuals with Fibromyalgia should practice good sleep hygiene to promote sleep. Bedtime rituals can relax you in preparation of sleep. These bedtime rituals can include: taking a warm bath or shower, reading a novel, watching a relaxing television program or listening to soothing music which can promote sleep. Attempt to follow a regular sleep schedule and go to bed at the same time each day. Sleep eight hours nightly if possible. Avoid alcohol, caffeine and tobacco before retiring they will disturb your sleep. Also abstain from taking midday naps.

Exercise is a key element in Fibromyalgia management. Your physician will recommend that you slowly increase your aerobic fitness with structured, low impact activities such as swimming, water aerobics, walking, or riding a stationary bicycle.2,3,7,8 Research has indicated that aerobic exercise improves sleep, enhances endorphin release and has antidepressant effects.2 It is important to check with your physician to ensure that the exercise program you have chosen is not contraindicated in your specific type of EDS. Remember to always stretch your muscles before engaging in any aerobic activity. Increase your exercise program gradually to reduce the chance of injury. As you continue to exercise, you'll notice that you feel better, have more endurance and experience a reduction in Fibromyalgia symptoms. It's worth the possible pain and fatigue felt initially to achieve these end results.

Always practice proper body mechanics and apply ergonomic principles at home, work and at rest. These techniques will prevent injury and reduce flare-ups of Fibromyalgia symptoms. Your doctor may prescribe various physical therapy treatments.

Possible treatments include: massage, heat or ice applications, ultrasound or whirlpool therapy and microvoltage electrical stimulation. These are all passive physical therapy techniques with varying results from individual to individual. These treatments are usually prescribed for flare-ups and are employed for short periods of time.3,8

Taking Control of Fibromyalgia

You can engage in several actions that will help you gain control of your Fibromyalgia. First and foremost, listen to your body. Identify those triggers that aggravate your symptoms and then avoid or at least minimize them. Get your stress level under control by practicing relaxation techniques. Relaxation techniques are primarily effective for chronic pain and have many benefits. Relaxation techniques enable you to reduce anxiety, pain and stress, reduce muscle tension pain and relieve the helplessness and depression associated with chronic pain. Despite having chronic pain and fatigue, learn to develop a positive attitude. Remember that if you have a constant negative attitude, your Fibromyalgia symptoms will exacerbate. Look for the good in every situation out there, but you may need to look closely.

Eat healthy and avoid fat in your diet. Excess weight is detrimental to your body and can aggravate your symptoms. Eating properly also maintains your health and avoids illness. Keep in mind that an illness (i.e., cold, flu, bacterial infection etc.) can be a triggering factor for your symptoms.

Educate yourself, family and healthcare providers about Fibromyalgia syndrome. Remember that knowledge is a powerful weapon in coping with any chronic illness. Knowledge also helps you to take control of your Fibromyalgia and reduce the exacerbation of its symptoms.

Lastly, seek support from others with Fibromyalgia. Check with your physician, healthcare institution, and within your local community for a Fibromyalgia support group. It is extremely beneficial to receive support and understanding from others who have the same type of problems from Fibromyalgia as you do. Connecting with a support group also helps you and your family to cope with having a chronic illness. And who knows, maybe someday you will have the opportunity to offer support to someone else just diagnosed with Fibromyalgia. I guarantee it will be one of the most gratifying and fulfilling experiences of your life.

Conclusion

Receiving a diagnosis of Fibromyalgia syndrome is an important first step in managing this condition. It is not the last step though! It is imperative that you have a clear understanding of Fibromyalgia, its signs and symptoms, triggering factors and treatments. Learning to effectively cope with this disorder is essential to one's emotional and physical health. It is only then that you will be able to manage your Fibromyalgia and prevent it from becoming your whole life. While there isn't a cure for Fibromyalgia, there are treatments that are effective in managing its symptoms. There is life after finding out you have Fibromyalgia. Tomorrow will be better and holds the possibility of a cure!

References

1 Fan, P.T., & Blanton, M.E. (1992). Clinical features and diagnosis of Fibromyalgia. Journal of Musculoskeletal Medicine, 9(4), 24-42.

2 Wilke, W.S. (1996). Fibromyalgia: Recognizing and addressing the multiple interrelated factors. Postgraduate Medicine, 100(1), 153-“170.

3 Arthritis Foundation, Inc. (1995) Fibromyalgia Syndromes, 1-12.

4 Dunkin, M.A. (1993, September–October). Fibromyalgia: Out of the Closet. Arthritis Today, pp. 24-28.

5 Dunkin, M.A. (1997, September–October). Fibromyalgia: Syndrome of the 90s. Arthritis Today, pp. 41-47.

6 Ignatavicius, D.D., Workman, M.L., & Mishler, M.A. (1995). Medical & Surgical Nursing (2nd ed.). Philadelphia: W.B. Saunders Company.

7 Goldberg, D.L. (1990) Fibromyalgia and chronic fatigue syndrome: Are they the same? Journal of Musculoskeletal Medicine, 7(5), 19-28.

8 Sherman, C. (1992) Managing fibromyalgia with exercise. The Physician and Sports Medicine, 20(10), 166-172.

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EDS Physical Therapy Management of the Hypermobile Patient

This presentation by Mr. Terry Olson, PT, MHS, FAAOMPT at the 2005 EDNF Conference in Los Angeles is accompanied by a Power Point presentation. Don't have Power Point? Click Here


Terry Olson, PT, MHS, FAAOMPT, received his physical therapy training at the University of Iowa and he has an interest in the manual treatment of the muscular skeletal problems. He subsequently received his Masters Degree in orthopedic physical therapy and he developed a post graduate program in exercise and manipulative therapy. Mr. Olson is a fellow of the American Academy of the Orthopedic Manual Therapists and we would like you to welcome Mr. Terry Olson.

I am going to present this from the standpoint of looking at hypermobility. We are going to look at a definition of hypermobility, its relationship to EDS, then talk about the role of exercise and joint protection, and a short case study that I thought I would present.

Okay, what is hypermobility? There are quite a few definitions, but the one that seemed to be the simplest was that it is a connective tissue disease, where connective tissue proteins, such as collagen, which give the bodies its intrinsic toughness, are differently formed; the results are mainly felt in the “moving parts�, that being the muscles, joints, tendons, ligaments, which now are more fragile than is the case for most people. The result is joint laxity with hypermobility and with it comes vulnerability to the effects of injury. The young girl presented here is the one on which I did the case presentation.

Quick review of the categories.

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Classical: Looking at skin hyperextensibility, tissue fragility and joint hypermobility.
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Hypermobility: again, joint hypermobility is the dominant characteristic, may have joint subluxation and dislocation, limb and joint pain.
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Kyphoscoliosis: generalized joint laxity and severe muscle hypotonia, scoliosis, tissue and organ fragility.
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Arthrochalasia: congenital hip dislocation, severe generalized joint hypermobility, recurrent subluxations, tissue fragility, and muscle hypotonia.
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Vascular: organ fragility with the possibility of arterial or organ rupture, tendon or muscle rupture, joint hypermobility primarily in the digits.
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Dermatosparaxis: severe skin rigidity, skin soft and doughy and may have large hernias.

Of all of those categories, the dominant feature from a physical therapy perspective is hypermobility and joint laxity, so those are the primary considerations for a therapist when treating patients with EDS; and that means that treatment needs to focus on joint protection and dynamic stabilization of those joint structures.

Muscle stiffness is a term that is used to describe the spring-like quality of muscle. When a muscle has high stiffness, increased force is required to cause lengthening of that muscle or to perturb it. Muscle stiffness has been described in the biomechanical and neurophysiological literature as one of the most crucial variables in joint stabilization; and in the knee a link has been established between receptors in the ligaments of the joint and muscle stiffness. The slide includes a few of the references for that.

In the residency process (I went through post-graduate residency training in manipulative and manual therapy) you are primarily moving joints that are stiff. Switching to talking about joints that are not stiff, which is the case here, takes a bit of a shift. One of the things taught in the residency process was that you cannot distinguish a problem as being a joint problem or a muscle problem. The structures are so closely interrelated that the feedback between the two is critical to the integrity of that joint. If you have problems within the joint; because the joint provides feedback to the muscles, you are going to have muscular weakness. If you have muscle weakness, again through association with the joint structure, you are going to have impact on the stability of the joint. Thus, any treatment needs to be directed at all of those structures.

It is possible that the sensory properties of structures within joints can be modified by the contraction of the local, stabilizing muscles, and this is usually the proximal muscle groups. If you are looking at the shoulder, you are talking about the scapular cervico-thoracic muscles and the large shoulder muscles themselves. If you are talking about ankles and knees, you are looking at the muscles in the trunk and the pelvic girdle.

Besides providing mechanical stability to the joints, these muscles can contribute to the sensory feedback mechanisms associated in the joint structures themselves. A study done by Blazier, Carpenter, and Houston showed that tightening of the joint structures with active muscle contraction increases the acuity of that shoulder joint. That means if the muscles are functioning properly, then they are going to provide feedback to the joint which, in turn, makes a more stable situation for that joint and the joint has the ability to have feedback as to where it should be positioned.

“Dynamic stabilization�, or the use of exercise to promote joint stabilization, occurs when tonic (postural and slow twitch muscle units), are activated. These tonic motor units are activated during tonic continuous low load activation of muscle, maximizing muscle stiffness. What we are talking about here is asking the muscle to contract gently, not maximally, and to be able to sustain that contraction for a period of time. This can be influenced by the speed of the activity or exercise, as well as the type of muscle contraction you are trying to acquire. Muscle contractions that are performed in the shortened range of the muscle length are going to be critical in establishing the sensitivity and optimal functional capacity of the sensory feedback system in the muscle.

All that says is that when you are exercising - for folks that are afraid to exercise, for folks that have an inherent increase in mobility - exercise needs to be done in a very small controlled range of motion. Dr. Unger and I have had discussions about patients that we might see commonly as well as the patients I have seen from Dr. Mark LaVallee. One of the things that I have seen somewhat consistently is that the patients who are stretching don't need to stretch. They will tell me about being stiff and they will take their leg and wrap it around their head and it is just difficult to relate to that as being stiff. Now you can have a feeling of stiffness, if the muscles are fatigued or overworked, which to me then relates back to weakness.

Co-contraction and co-activation of muscle groups provides the biomechanical forces for joint stabilizing and protection, especially if they are performed in mid-range or neutral joint positions. Every joint, in its ability to move through range, is going to have positions that are inherently more stable because you have joint surfaces that have better contact with each other. You also have a point in that range where the muscle has mechanical advantage. If I am bending my elbow, the biceps will do that. When the bicep is in its lengthened range (elbow fully straight), I am going to be much weaker than when I get to a point (elbow fully bent) when things are going to shorten or come closer together. Mechanically this is much stronger. And, so, when you exercise EDS patients, you need to make sure you attend to placing them in those mechanically advantaged positions to work and exercise.

This is not just with EDS, but with many of the patients I see that have weakness or hypermobility. They do not exercise their full range of motion, they do not have the control to do so, and building the ability to exercise to the greater range is the goal. So, you start where the patient can perform in a pain-free and stable manner. Closed chain exercise is superior for muscle protection of the joint, although open chain exercise is also beneficial and necessary, especially again if it is performed in the protected range of motion.

When we are talking about open chain exercise/closed chain exercise we mean the following. Open Chain Exercise: if I want to exercise my quadriceps, that is the muscle that straightens my knee out, that is open chain, just moving my leg through range of motion. Closed Chain Exercise: if I stand here and do a squat, I am still working that quadriceps muscle, but by virtue of contact with the floor, we now have other muscles that act to provide increased stability. So a lot of times, starting these patients with exercises that are more closed chain, enhances that ability to stabilize muscles around the joint.

Case presentation

We take a body chart that the patient marks when they come in - and again, typically, when I get a body chart on a patient from Dr. LaVallee, that whole body chart may be colored in - it looks like they have a suit on.

As a therapist, where do you start with that - you cannot treat everything. In this case here, the young girl, the primary complaint was the mid lower back, and the other complaints were part of her overall problem; but in this case not the primary reason for presenting to therapy. Primarily, it was because of back and hip trouble. She had a diagnosis of lumbar back pain, left hip pain, and EDS multiple areas of pain complaint and again those were most notable in back and hip. She described pain complaints of an 8 out of 0-10, (0 being no pain, 10 being like a wild animal tearing your leg off).

She described her pain at her worst as being an 8 on that scale with standing for more than one hour being a provocative activity, as well as her activities of daily living. One of the things that were important at that time was that she had a baby, and that holding her baby was enough to provoke a lot of these pain complaints. She had objective signs of multiple joint hypermobility with back pain reproduction.

In her case, initial emphasis was on symptom alleviation using modalities (heat and cold, TENS units, electrical stimuli), gentle joint mobilizationand biomechanical correction, as well as performing assisted exercise in protected asymptomatic range of motion. We also provided biomechanic counseling on joint protection, as well as back care education regarding lifting, sitting, and performance of her activities of daily living.

Over the course of treatment, as her symptoms decreased, we progressed into more dynamic exercise, dynamic stabilization, and that become the crux of her home program.

One of the things that we can use in the setting that I work in, at least in the acute phases, is equipment designed to start exercising folks at less than full limb loading. If you have someone that has an injury or problems with - as in this case - knee and hip, and those problems occur when they are weight bearing, then the idea is that exercise has value because if we exercise, we have the ability to increase blood flow and circulation, increase oxygen, all of the things that are essential for healing, as well as building blocks for laying down stronger tissue. The problem is bringing that load to an acceptable level for that person.

So, in this case, this patient is just doing a bilateral squat activity and the slide board allows her/him to exercise anywhere from less than 20% of body weight taking it all the way up to 70% of body weight and then we know how to graduate that into a gym exercise. We try to exercise people as functional as we can, so if people have complaints of “when I stand too long or when I walk too long, when I bend is when I have my complaints,� I am going to try to set my exercise program up so that they are standing, walking, bending, but using the equipment to again decrease gravity, or their body weight, so that they are exercising with less body weight on those joints.

In this case, with walking, we use a treadmill system that has an overhead pneumatic assist and that harness allows us to hoist someone up. We can take that person, take as much as 70% of body weight (essentially the weight of the trunk - you go any higher than that and you are like Peter Pan and you are unstable, and you are ready to fly) then you are still getting input into the joints, but not full load.

I had a discussion with one of the participants who asked me about Pilates - I am going to beat people to the punch - I don't know. Pilates makes sense to me that it can be of value, but I don't know enough about it and I might make an idiot of myself trying to tell you the value of it.

Not for purpose of this talk, but if it gives any rationale to why; the approach that we use is a system called "medical exercise training". That approach is based on specific tissue exercise, and so we work from a standpoint that muscle requires a different muscle stimulus than does tendon, than does cartilage, than does disc. All of those structures have a different metabolic requirement, so those exercises have to be different, and when you are working with folks who have tendonitis, we try to work out an exercise program that allows that person to go through anywhere from 150 to 200 repetitions - because that seems to be the adequate number of repetitions to get an adequate increased blood flow to the area to promote a healing response. When trying to address structures such as ligament, cartilage, disc, those structures require upwards of 1,000 to 1,500 reps. The problem is taking someone who hurts and tell them you are going to put them on an exercise program of 1,500 repetitions and then say I will come back in an hour and see how you are doing. So to do that, you need to take load off, and the purpose of the equipment is to assist that part so that person can perform repetitions without pain. And then as the structure begins to heal, we gradually put load back on.

So this was the initial phase. In addition, we started to work on trunk. With Pilates or with other approaches, their value is core strengthening of the trunk - because your arms and legs attach to your trunk and if your trunk is not stable, then it is difficult to promote stability into those joints. Oftentimes the trunk is the most logical place to start, and is probably the easiest because everything else has to function off of it.

A simple leg raise will require activation of the transverse abdominal muscles if they are activated and used. The fact that her back is arched and she is unable to keep it from arching is indicative of the fact that a good exercise becomes a very poor one because she doesn't exhibit the ability to recruit enough trunk muscles to actually handle the weight. Here, she is able to keep the trunk stable (you don't see that hollow) and so she is performing that exercise actually really well with good trunk control.

Exercise is controlled trauma. When we exercise someone, we are inflicting trauma - the idea is to control it. If you exercise adequately, you are going to break down tissue, then let it rest and in this phase it recovers and lays down stronger tissue - if you adequately stress it. If you overstress it, then a good exercise becomes a bad exercise pretty quickly. All day long I see patients come in who are failures at exercise programs and it is not because exercise is not a benefit to them, they have just not been trained to do it with good form and to work in a range where they have control. You need to understand what is safe.

I had actually treated Erika about 9 months ago and she did well. I asked her to come back to see how she was doing but also to take some photos for this presentation and it was a good chance to take her upstairs and see if she was doing what we had instructed her to do 9 months ago. She demonstrates incredible form. Her elbows are going the wrong way and you would think that would make sense, but when we first went over her exercises and she did things, a lot of the things she was performing, a lot of work was in an unstable range and it was causing a lot of pain. It was just a matter of again making certain that her trunk was active and then worked in the range that she could exhibit control.

The exercise doesn't matter - when I set exercises for people, it doesn't matter, pushing up, pulling down, pushing away, pulling into them, I do a variety because life is made up of that. You need to be able to do all sorts of things but in a stable manner. The exercises need to be changed and modified as long as the patient understands stabilizing well, good trunk improvement, and that the joints are working in a range where they were stable.

I saw Erika for 9 visits over a 5 week period. Initial treatments consisted of gentle treatment to relieve symptoms coupled with assisted exercise utilizing the assisted treadmill walking and total gym. The patient then progressed to a stabilization and progressive strengthening exercise program. Her symptoms decreased, her discharge pain complaints were decreased, and she was able to stand and sit for more than two hours without symptoms, as well as lift her baby without increase in symptoms.

The final slide provides some excellent overall points in your therapy process. All of these things can be used in treatment and pain reduction. What I have seen with pain reduction, if you are heating people or icing them or electric stimuli, you are doing things that are temporary. Long lasting change is only going to come with making a change in the body, to the extent that you can. So, exercise with emphasis on controlled range of motion or working within a range of control. Pool therapy is beneficial and we use a pool at our facility also. Pool therapy takes the body weight off much the way the harness mentioned above does. Massage certainly has value, but again I think you need to be careful about monitoring skin integrity, especially if you are doing friction massage which is one of the therapy modalities often used in treating tendonitis. Use of splints or bracing - those are done supportively. Annual therapy, manipulative therapy, chiropractic therapy - it is not contraindicated, but you need to make sure you are addressing treatment to a joint that needs to be moved, not the joints that already move excessively. As a general rule, you want to be cautious of vigorous stretching secondary to inherent hypermobility. Again, I don't teach people to stretch, but they do need to strengthen because they have all of this range of motion that they don't have control of and that is painful. A lot of patient education, regarding ergonomics, joint protection, body mechanics, is required.

Thank you

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Water Training and Ehlers Danlos Syndrome
by Lynda Huey, M.S. & Linda Neumann-Potash, R.N., M.N.

In recent years, water training has become the basic building block of therapeutic and conditioning programs for a wide range of people: athletes, dancers, fitness, fitness enthusiasts, post surgical patients, and those with arthritis and Ehlers-Danlos Syndrome (EDS). In water, you can walk, run, jump and kick without any trauma to your weight-bearing joints. The moment you slide into the water for a workout, you feel significantly better. Pain is reduced; mobility is regained. Where you sensed helplessness, now there is hope. For in water, you can perform movements that seem but a dream on land.

I have Ehlers-Danlos Syndrome type III. I started exercising in water with Linda Huey as an alternative to physical therapy in May of 1990. I have problems with many of my joints, and was looking for a form of exercise and rehabilitation that could help me strengthen the muscles around my joints to increase stability. Further, I wanted to prevent dislocations in currently non-affected joints. Having been a runner and a volleyball player during my high school and college days, I missed being active and feeling fit. Besides finding a way to preserve my joints and decrease pain, another of my motivations was to find a way to get in shape. Running, fitness walking, and bicycling were not options because of arthritis and my frequent patella dislocations. I contacted Lynda. I was the first person she had met with Ehlers-Danlos Syndrome, and she was eager to work with me. The program she set up for me includes a cardiovascular workout and isolated exercises for my upper and lower extremities.

You can build a Water Healing Workout that protects the injured body part form further harm, while the rest of the body continues to train. Standing in chest-deep water, you weigh only 10% of your normal body weight, so every exercise is low impact. If no impact is required, you can put on a flotation device and train while suspended in water. Injury areas are immobilized to prevent aggravation either with tape, slings, braces, or waterproof casts. If you don't normally wear braces, you probably won't need them in the pool. If you do wear braces, check with the manufacturer about using them in water and make sure that you rinse them out well after the workout.

Because of joint instability, I have found it necessary to wear protective devices in the water. Deciding which braces I needed was done by trial and error. I had patella (knee cap) dislocations and ankle instability in my left leg if I did not wear knee and ankle braces into the water. I use the CTI Brace (from Innovation Sports) for my knee and a standard ankle brace with a figure-8 wrap around my ankle. Because of multiple hand surgeries, I must also wear a right hand splint for protection. Whenever I have problems with shoulder dislocations, I also wear a shoulder immobilizer. This sounds like a lot to wear during a workout, but it allows me to safely exercise without injury. If I shrug off one of more of the protective devices, I usually experience pain, instability, and/or dislocations.

You may not have exercised in months or even years, yet you can enter the water and begin immediately. Most EDS patients should begin with the Deep Waterpower Workout, in which there is absolutely no weight bearing. You don't even need to know how to swim, for you will be wearing a flotation device that will hold you in a comfortable upright position for exercising. Choose a Wet Vest ($130), a Wet Belt ($40), an Aqua Jogger ($50), or use a standard water ski flotation belt ($10-$20) -- whatever best fits your body and your pocketbook.

Once outfitted, take to the water and slowly begin water running. Keep in mind your specific limitations. You may feel terrific floating along the surface of the water, but remember to try any movement, particularly ones that involve your affected joints, with caution. Move slowly through a narrow range of motion. If such movements cause no pain, gradually reach for a wider range of motion. Add speed last and with care. EDS patients should use the resistance of the water only; don't apply undue stress to the joints by adding any of the new resistance equipment devices.

Water Running. Keep your chest and head erect. Shoulders are relaxed and down. Knees lift to 90 degrees while the arms pull forward and back with no lateral movement. Hands are relaxed with the thumbs towards the sky. Pull the elbows back, each in its turn, and touch each hand into an imaginary pocket. Don't lean too far forward, or you'll be a dog paddling. Simply lift the knee, and then push the foot straight down behind you. Don't lean to far back or you will have a tendency to kick forward into a bicycling motion. Move around the pool for five minutes as you warm up. (If the pool is small, or if you need to stay in one place because the pool is crowded, use a Perry band ($50) or StretchCordz ShortBelt ($35) to tether yourself to the side of the pool.)

I noticed results right away. I expected to be sore, but I wasn't. I had less pain in my joints after the first workout. More important was the sense of accomplishment I felt. Wow! I could actually exercise without joint dislocation; something I hadn't been able to do in years. Over the months of water training, I have noticed that my joints are getting stronger and even though I continue to have dislocations, they are not as traumatic and not as frequent. The water offers me a soothing affect after any dislocation, and helps lessen the pain. I am now in better shape. I've lost 20 pounds and I seem to have more energy during the day. After years of focusing on what I can't do, I now focus on what I can do. It’s great to be able to run in the water. I feel like a runner again!

Water Walking. Start by establishing an "opposite positions". Hold your right arm forward and extend your left forward at the same time. Begin walking, keeping both your arms and legs straight. Visually check your elbows and knees. Most people think these joints are straight when they are not. Stay upright; don't lean forward or back. Water walk for three to five minutes, or until you become confident of the movement. Insist on opposition: right arm with left leg are left arm with right leg.

Having learned water running and water walking, you can now build a training program by altering those two skills and challenging your muscular strength and aerobic skills.

I've had several interruptions in my water rehabilitation program because of joint surgery, casts, and skin and healing problems. Since I have problems with healing and am prone to infections, I wait until my incisions are completely healed, and I always check with my physician for clearance before rushing quickly back to the water. Occasionally, Lynda and I have figured out ways to keep me active during what normally would have been an interruption. After a thumb injury that required casting, I asked my doctor to use a new waterproof gortex cast padding so I could continue water training. Since I had no open wounds, he agreed and we continued. Other times, we taped my arm into a plastic bag and elevated it above water level on flotation devices.

Water running and water walking are the two key exercises in a deep-water training program. However, other deep-water exercises specifically for the abdominals, arms and legs can be added over time. If you'd like a copy of the Deep Waterpower Workout booklet, due out in early 1992, or any of the equipment listed above please contact:

Huey's Athletic Network
3014 Arizona Avenue
Santa Monica, CA 90404
(310) 829-5622
Fax: (310) 828-5401

Exercise can be very important for patients with Ehlers-Danlos Syndrome, but finding the right form of safe exercise is the hardest part. Although EDS affects all of us differently, I feel that everyone can benefit from some form of water exercise. Just check with your physician before beginning this or any exercise program

Water training has made a big difference in my life. It has helped me strengthen my joints, increase stability and stamina, lose weight, and feel better both physically and emotionally.

Lynda Huey, M.S., has water trained dozens of Olympic and professional athletes as well as worked with many pre-surgical and post-surgical patients. In 1986, she published The Waterpower Workout (New American Library) and is finishing her next book Water Healing Workout: From Rehabilitation to Gold Medals.