Journal Article Review: Amelioration of Symptoms by Enhancement of Proprioception in Patients with Joint Hypermobility Syndrome (Ferrell et al.)
This article explored in-depth the previously observed relationship between joint hypermobility syndrome and impaired proprioception in affected patients by designing and testing a home exercise plan to improve proprioception. Similar in presentation to Ehlers-Danlos syndrome hypermobility type, joint hypermobility syndrome is underdiagnosed in the general population. The primary symptoms of this disorder are hypermobility of the joints and musculoskeletal pain without inflammation (as would be seen in diseases such as rheumatoid arthritis). Another recognized symptom of joint hypermobility syndrome is poor proprioception as described by Ferrell et al. Currently, joint hypermobility syndrome has no true treatment, though physical therapy is recommended to manage the condition.
The major goal of this study was to understand whether or not a home exercise plan could benefit patients with joint hypermobility syndrome through measurable improvements in their symptoms, especially in impaired proprioception. Previously, the impact of physical therapy on impaired proprioception had not been studied. To accomplish this goal, Ferrell et al. recruited twenty patients diagnosed with joint hypermobility syndrome, both through the Brighton criteria and the Contompasis system, from the Glasgow Royal Infirmary. Through additional screening for knee pain and patient withdrawal from the study, they established a cohort of eighteen patients. First, they performed a test of proprioception by rotating the more painful knee using a stepper motor and allowing the patient to determine the direction of its displacement. Then, they developed a balance board to test the patients’ balance, used a dynamometer to measure both their highest and average muscle strength in the hamstrings and the quadriceps, and determined
The word count of this assignment is 1,165 words.
1 December 2017 BIOL 216 – Kuemerle Rudrapatna, Akshata (anr51)
their mental and physical health using a health perception questionnaire (the SF-36 questionnaire). An additional assessment, the visual analog scale, was used to gauge the level of joint pain in the knees. Finally, they designed an eight-week set of physical therapy closed kinetic chain exercises (which includes exercises such as lunges, bridges, and squats, among others) for the patients. These were conducted at home, with the patients recording their daily exercises in a notebook, and the number of exercises increased weekly. Once the exercise program was complete, all tests were conducted once again as mentioned before. All data received from these experiments were statistically analyzed with a paired t-test (for data demonstrating a normal distribution), and a Wilcoxon signed rank test (for the SF-36 and the dynamometer data).
The researchers found that proprioception improved in sixteen out of eighteen patients after the physical therapy was completed, though there was variability in initial proprioceptive abilities among the patients (as would likely be expected). Specifically, proprioception tended to improve the most in the subjects who had the greatest deficits in proprioception initially, though the correlation between these two was reported as 0.45. This trend was similar to the one seen in the balance assessments where balance improved dramatically among the patients in general, though those with the worst balance initially improved the most. In general, both the highest and average muscle strength improved moderately among the patients in both the hamstring and quadriceps muscles. As well, patients experienced improvements in physical function and mental well-being after the course of physical therapy as measured through the SF-35 questionnaire; there was also a reduction of pain among the patients, correlating to a lower observed visual
The word count of this assignment is 1,165 words.
1 December 2017 BIOL 216 – Kuemerle Rudrapatna, Akshata (anr51)
analog scale score. All experiments included a successful test of reproducibility, since no control group was present, and p-values were given for all results.
Through this study, it was found that physical therapy improves the proprioceptive and balance abilities of patients with joint hypermobility syndrome to the point where they resemble those with normal proprioception and balance. In fact, the authors suggested that early diagnosis of joint hypermobility syndrome with an implemented exercise program could help reduce the burden of the disease on patients. Because the criteria for entry into the study was limiting, it was not possible to include a control, non-exercise group. For this reason, the reliability measurements taken throughout the study were of critical importance in determining the significance of the results. In addition, it was difficult to say that the augmented proprioceptive abilities directly caused the improvement of symptoms. The patients experienced less pain and had greater muscle strength after they completed the exercises, but these were likely not the direct causes of improved proprioception since it was previously found that there was no association between increased proprioceptive abilities and increased muscle strength or increased proprioceptive abilities and pain management. The positive benefits of the exercises on the participants of the study signified that the exercises should be continued, since it was observed that patients who discontinued the exercises experienced symptoms once again.
This paper was written extremely well, in a manner that explained all concepts thoroughly and with data that supported the conclusions drawn. The figures and tables in the data section were very understandable and the authors described all procedures conducted in-detail. While no control group was included, the authors included tests of reliability before, during, and/ or after each experiment. The experiments were appropriate for the study. P-values were
The word count of this assignment is 1,165 words.
1 December 2017 BIOL 216 – Kuemerle Rudrapatna, Akshata (anr51)
calculated for all experimental data to ensure significance of the results. However, the correlation values were not strongly indicative of specific trends and there was little discussion in the article about how it was determined that the patients were adhering to the exercise plan throughout the full eight weeks (apart from their word and a single follow-up appointment), since this would directly impact the results. Most limitations were discussed throughout the discussion section of the paper. I find the analysis and conclusions drawn from this study very credible and thus agree with them, as they do support the use of physical therapy for patients with joint hypermobility syndrome and notes that certain results, such as the decrease in pain among patients after physical therapy, are supported by previous research conducted in this field. However, it may have helped the researchers to recruit patients with this condition from other hospitals in the United Kingdom so that they had the opportunity to understand the impact of exercise with a control group. This would have then aided their experimental design greatly and added to the importance of their findings. In addition, it would have allowed them to understand the impact of exercise on gender (since this group was heavily skewed towards females).
I accept this article with minor revisions. These minor revisions would include greater discussion of how patients were kept accountable for completing the exercises throughout the study. Otherwise, the researchers present their data in a lucid manner and provide all necessary information to determine the conclusions of their study. In addition, they remark on the patients who did not see improvement during the study, discuss the limitations of their work and possible future research goals, and explore a treatment that could potentially help many patients with joint hypermobility syndrome.
The word count of this assignment is 1,165 words.