Ehlers–Danlos Syndrome—Hypermobility Type: A Much Neglected Multisystemic Disorder

Ehlers–Danlos syndrome (EDS)—hypermobility type (HT) is considered to be the most common subtype of EDS and the least severe one; EDS-HT is considered to be identical to the joint hypermobility syndrome and manifests with musculoskeletal complaints, joint instability, and soft tissue overuse injury. Musculoskeletal complaints manifest with joint pain of non-inflammatory origin and/or spinal pain. Joint instability leads to dislocation or subluxation and involves peripheral joints as well as central joints, including the temporomandibular joints, sacroiliac joints, and hip joints. Soft tissue overuse injury may lead to tendonitis and bursitis without joint inflammation in most cases. Ehlers–Danlos syndrome-HT carries a high potential for disability due to recurrent dislocations and subluxations and chronic pain. Throughout the years, extra-articular manifestations have been described, including cardiovascular, autonomic nervous system, gastrointestinal, hematologic, ocular, gynecologic, neurologic, and psychiatric manifestations, emphasizing the multisystemic nature of EDS-HT. Unfortunately, EDS-HT is under-recognized and inadequately managed, leading to neglect of these patients, which may lead to severe disability that almost certainly could have been avoided. In this review article we will describe the known manifestations of the extra-articular systems.


GENERAL CHARACTERIST ICS AND MANIFESTATIONS
Joint hy permobility (JH), defined as an ex cessiv e range of joint mov ement taking into consideration age, gender, and ethnic background, is inherited 40,41 and may pose no problem. Acquired hy permobility may also result from changes in connective tissue in other diseases such as sy stemic lupus ery thematosus. 42 Joint hy permobility is recognized by the nine-point Beighton score 43 ( Figure 1) and includes passiv e dorsiflexion of each fifth finger greater than 90°, passiv e apposition of each thumb to the flexor surface of the forearm, hy perex tension of each elbow greater than 10°, hyperextension of each knee greater than 1 0°, and ability to place the palms flat on the floor with the knees fully ex tended.
Ehlers-Danlos sy ndrome-HT, now considered to be indistinguishable if not identical to the joint hy permobility sy ndrome (JHS), 44 is a clinical condition of JH with sy mptoms of joint instability, arthralgia, myalgia, soft tissue injuries, and arthritis. 45,46 Diagnosis relies on the Brighton criteria (Table 1 ). 47 ,48 The predominant presenting complaint is pain, which is often widespread and longstanding, with patients reporting pain ranging from 1 5 days to 45 years. 39,49 Chronic pain may start in adolescence (with 7 5% of hy permobile adolescents reporting symptoms by the age of 1 5) or even as late as the fifth or six th decade of life. 3,39,45 Sev erity sometimes correlates with the degree of joint instability. 3,15 Fatigue and sleep disturbance, most probably secondary to sev ere chronic pain, sublux ations, and dislocations while changing posture during sleep, are frequently associated. 3,11,12,1 5 Affected individuals are often misdiagnosed with chronic fatigue syndrome, fibromyalgia, depression, hy pochondriasis, and/or malingering prior to recognition of joint laxity and establishment of the correct underly ing diagnosis. 3 Ov er the last three decades it has become apparent that EDS-HT has a widespread distribution and is not manifested solely in the joints ( Table 2). The Beighton score is calc ulated as follows: 1. One point if while standing forward bending you can place palms on the ground with legs straight 2. One point for each elbow that bends backwards 3. One point for each knee that bends backwards 4. One point for each thumb that touches the forearm when bent backwards 5. One point for each little finger that bends backwards beyond 90 degrees Taken with permission from the Hypermobility Syndrome s Association (HM SA) site (http://hypermobility.org/helpadvice/hypermobility-syndromes/beighton-score/). JHS is diagnosed in the presence two major criteria, or one major and two minor criteria, or four minor criteria. Two minor criteria will suffice where there is an unequivocally affected first -degree relative.

Cardiov ascular and Autonomic Nervous Sy stem Manifestations
A mild degree of aortic root dilatation has been found in up to one-third of EDS-HT patients, 20,21,22 necessitating echocardiographic evaluation and surv eillance. Raynaud phenomenon was found in 38% of EDS-HT patients. 19 Patients with EDS-HT may suffer from palpitations, chest pain, dizziness, presy ncope, and syncope, 17 which has been attributed in the past to mitral valve prolapse (MVP). Mitral valve prolapse was originally included in the earlier v ersion of the Brighton criteria in 1 986. 47 With more modern ev aluation techniques clinically significant MV P has not been found to be more prev alent among EDS-HT patients. 21 ,22,50,51 For this reason MV P was remov ed from the Brighton criteria in 1 998. 48 The frequency of MV P among EDS-HT patients was found to be 28%-67 % in more recent studies, 52,53 but its clinical significance is not clear. Sy mptoms formerly attributed to MV P are now considered to be related to autonomic dy sfunction, which was found to be highly prevalent among EDS-HT patients. [16][17][18] Gastrointestinal Manifestations Gastroesophageal reflux was found in 57 % of EDS-HT patients. 19,23 Chronic gastrointestinal discomfort was reported in 86% of patients with EDS-HT, attributed to dy spepsia, gastritis, or gastroesophageal reflux . Irritable bowel sy ndrome was found among 62% of patients. Early satiety and delay ed gastric emptying are reported and ex acerbated by opioids. 3

Hem atologic Manifestations
Easy bruising and bleeding tendency is common in all EDS ty pes, including EDS-HT. 25 It manifests with prolonged bleeding time, 24,26 oral mucosa fragility with mucosal bruises, 9 and menometrorrhagia. 54 Since coagulation tests are normal, 24-26 the underly ing cause is presumed to be mechanically impaired collagen too weak to afford adequate protection t o the capillaries. It is important to note that small and large arterial dissections have not been reported in EDS-HT.

Ocular Manifestations
My opia has been found in up to 50% of EDS-HT patients, 54 and high my opia of more than -6.0 diopters was found in 1 6% of patients compared with 0% in the control group. 3,27 Strabismus was found in 7 % of EDS-HT pediatric patients 55 (as opposed to only 2%-4% of the general pediatric population), and it is often refractory to surgical

Gy necologic Manifestations
Dy smenorrhea and menorrhagia are common 1 9,28,29,54,56 and thought to be due to muscle contractions occurring with greater force giv en the loose connectiv e tissue. Dy spareunia was found among 30%-57 % of EDS-HT women, 28,29,58 thought to be caused by small tears in the v aginal surface and lack of appropriate vaginal secretions. 56 Pelvic organ prolapse is common, 1 9,28,29,56,59-62 including uterine prolapse which was found in almost 40% of women with EDS-HT. 49

Urologic Manifestations
In children with hy permobility constipation and fecal soiling were found to be more common in boys, and urinary tract infection and urinary incontinence more common among girls. 63 In another pediatric series 1 3% of girls and 6% of boy s suffered from urinary tract infections. 64 Stress urinary incontinence was found in 40 %-7 0% of women with EDS-HT, 28,58,65 often earlier in life, thought to be due to a weakened pelvic floor, which may be worsened to bladder prolapse. 56 Fecal incontinence was found in up to almost 1 5% of EDS-HT patients, as compared to only 2.2% of the general population. 65 Rectal prolapse may also be found among EDS-HT patients. 66 Furthermore, Dordoni et al. reported on two EDS-HT family members who suffered from v isceroptosis, including bilateral kidney prolapse, gastric ptosis, liver prolapse, and ovarian and heart prolapse. 67

Obstetric Manifestations
While labor and deliv ery might be rapid (shorter than 4 hours), 19,29 and premature rupture of membranes is common, 54,68,69 pregnancy in women with EDS-HT is generally normal with good maternal and neonatal outcome. 30,7 0 Howev er, joint lax ity and pain may increase during pregnancy. 3,29,30,54,70 Pelvic pain and instability necessitate the use of pelvic belt, crutches, and/or bed rest in 26% of women with EDS, the majority being EDS-HT (compared to only 7 % among non-affected women). 56,70 Varicose veins in the legs and the v ulva are more common among pregnant women with EDS-HT. 56 Dy sautonomia, characterized by lightheadedness, dizziness, fainting, etc., may worsen during pregnancy, 56 and when postural orthostatic tachycardia sy ndrome (POTS) is present a blood pressure fall was reported. 71 Women with EDS-HT are more prone to postpartum hemorrhage (1 9% v ersus 7 %) and complicated perineal wounds (8% v ersus none). 70 Premature delivery was found to be more related to EDS-HT of the infant (40%), and was less prevalent if the mother had EDS-HT (21 %). 70

Neurologic Manifestations
A total of 40% of children with EDS-HT 72 and 50% of adults 14 suffer from headaches, characterized as chronic recurrent headaches in the absence of structural, congenital, or acquired central nervous sy stem lesions that correlate with their symptoms. 73 Many complain of headaches related to the neck or facial pain that might be related to jaw or TMJ problems. 56 Headaches may also be part of dysautonomia, which was found in 7 8% of EDS-HT patients v ersus 10% of controls, 17 characterized by dizziness/ lightheadedness and pre-syncopal episodes, which were found in 88% and 83% of patients, respectiv ely. Partial or complete failure of local anesthesia was described during biopsies and dental or obstetric procedures. 74,75 Hakim and Grahame found local anesthesia resistance in 58% of EDS-HT patients v ersus 21% of controls. 32 Proprioceptive acuity has been found to be impaired among EDS-HT adult patients 76,77 and pediatric patients. 78 Postural instability and balance and gait impairment, resulting in increased frequency of falls, were found among EDS-HT patients as compared to matched healthy controls. 79 Impaired proprioceptive acuity is thought to influence muscle strength. Therefore, improving muscle strength on the basis of proprio ceptiv e impairment may be more important for reducing activ ity limitations than just improv ing muscle strength. 80 Chiari 1 malformation type 1 was found in 4.7 % of EDS-HT patients 19 and may be associated with cranio-cervical instability and/or the tethered cord sy ndrome.

Psy chiatric Manifestations
Fear of joint pain and/or instability may lead to av oidance behavior (kinesiophobia) and exacerbate dy sfunction and disability. 3,7 Depression and anxiety are more common among EDS-HT patients 7,19,34 and are ex acerbated by fatigue and pain. 1 1 ,1 5

GENERAL REMARKS
The multisy stemic nature of EDS-HT results in patients having difficulty coping with the syndrome, as well as medical personnel failing to understand the true nature of the condition. This may adversely affect the therapeutic relationship, giv ing rise to skepticism, resentment, distrust, and hostility on the part of the patient. 3,7 Although EDS-HT is the most common type and the least sev ere ty pe of EDS, it tends to be underdiagnosed and mistreated, sometimes leading to sev ere disability that may have been preventable if diagnosed and treated properly . 64,81 ,82 A surv ey among phy siotherapists in the UK found that only 32% of respondents receiv ed formal training in EDS-HT management. 83 Patients perceive a lack of awareness of the sy ndrome among health professionals and describe delays in diagnosis and access to appropriate health care services. 84 Many patients reported lengthy diagnosis trajectories and treatment for indiv idual symptoms rather than EDS-HT as a whole. Receiving a correct diagnosis is necessary in order to access appropriate care pathway s, for ex ample, referral for physiotherapy for EDS-HT rather than for an acute single joint problem. 84 A study conducted among military personnel found misdiagnosis of EDS-HT has a disabling impact on military personnel with EDS-HT who are exposed to strenuous physical activ ities. 85 Significant neuromuscular and motor development problems hav e been found among a pediatric population, and delay in diagnosis resulted in poor control of pain and disruption of normal home life, schooling, and phy sical activities. 64 Furthermore, they conclude that knowledge of the diagnosis and appropriate interv entions are likely to be highly e ffectiv e in reducing the morbidity and cost to the health and social serv ices. 64

DIAGNOSIS
Diagnosis relies on the revised Brighton criteria, but it is important to rule out other connectiv e tissue disorders, especially Marfan sy ndrome and other ty pes of EDS. Unfortunately, no genetic defect has been found, and for such a prev alent and complex genetic disorder multiple genes might be involved.

MEDICAL MANAGEMENT
Treatment requires multidisciplinary co-operation and consulting with a cardiologist with echocardiogram monitoring ev ery 2-5 y ears, orthopedic surgeon with a follow-up once a y ear, oral and max illofacial surgeon for temporomandibular joint inv olv ement, gastroenterologist when gastrointestinal manifestations are present, ophthalmologist to rule out other connectiv e tissue diseases and when ocular manifestations are present, urologist and urogy necologist when urologic manifestations are suspected, neurologist and neurosurgeon when prolonged headache is present to rule out Chiari 1, and psy chiatry when anxiety and/or depression are suspected. Allergologic consultation may also be needed when there are multiple drug reactions and/or food allergies. A n autonomic nervous system specialist should be consulted when signs and sy mptoms of POTS or other autonomic nerv ous sy stem manifestations are present. Management includes physiotherapy and hy drotherapy aimed at sy mmetric and generalized muscle strengthening and proprioception acuity improvement, including deep connective tissue manipulations after each session, occupational therapy when wrists and fingers are inv olved, and cognitive behavioral therapy for proper adjustment to the chronic nature of the condition. Nutrition has an important role in treating EDS-HT, and nutritional deficiencies should be sought out and treated.

CONCLUSION
Ehlers-Danlos sy ndrome-HT is a complex hereditary disorder which is multisystemic, probably due to the prev alence of connectiv e tissue in all body sy stems. Its gene defect has y et to be found and might be of multigenetic nature, but until then we hav e to think about the possibility of EDS-HT in ev ery chronic pain patient, and look for joint hypermobility as well as other multisystemic manifestations of this prev alent sy ndrome.