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Pediatric Generalized Joint Hypermobility With and Without Musculoskeletal Complaints: A Localized or Systemic Disorder?

Raoul H. H. Engelbert, PhD, PT^*, Ruud A. Bank, PhD^,, Ralph J. B. Sakkers, MD, PhD^||, Paul J. M. Helders, PhD, PT^*, Frits A. Beemer, MD, PhD^¶ and Cuno S. P. M. Uiterwaal, MD, PhD^#

^* Department of Pediatric Physical Therapy, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, the Netherlands
Gaubius Laboratory, TNO Prevention and Health, Leiden, the Netherlands
Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
^|| Department of Pediatric Orthopedics, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, the Netherlands
^¶ Department of Medical Genetics, Division of Biomedical Genetics, University Medical Center, Utrecht, the Netherlands
^# Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands

--> Objectives. Children with generalized hypermobility of the joints and musculoskeletal complaints frequently visit pediatric clinics, but many show no currently known collagen or other possibly related diseases. Whether the symptoms are confined to the musculoskeletal system is unknown. We assessed whether such children have detectable differences in laxity of connective tissue present in organ systems other than joints. We also assessed whether children with generalized joint hypermobility and musculoskeletal complaints have more profound systemic changes in connective tissue of various organ systems as compared with children with generalized joint hypermobility without musculoskeletal complaints.

Methods. Anthropometrics, range of joint motion, muscle strength, skin extensibility, blood pressure, quantitative ultrasound measurements of bone, and degradation products of collagen were studied in 15 prepubertal children with generalized joint hypermobility and musculoskeletal complaints and compared with a population-based reference group of 95 nonsymptomatic prepubertal children. Symptomatic hypermobile children were also compared with children of the population-based reference group who had asymptomatic hypermobility of the joints (n = 16).

Results. Children with symptomatic generalized joint hypermobility had significantly higher skin extensibility (5.6 mm/15 kPa, 95% confidence interval [CI]: 4.0–7.1), lower quantitative ultrasound measurements (speed of sound: -26.8 m/s; 95% CI: -41.1 to -12.6) in bone, and lower systolic and diastolic blood pressure (-8.0 mmHg, 95% CI: -13.3 to -2.8; and -6.0 mmHg, 95% CI: -10.0 to -2.2, respectively) as compared with the total reference group. Also, they had significantly lower excretion of urinary hydroxylysylpyridinoline cross-links (mean difference: -51.3 µmol/mmol; 95% CI: -92.2 to -10.4) as well as lysylpyridinoline cross-links (-18.7 µmol/mmol; 95% CI: -36.9 to -0.5). Age, gender, body weight, height, and particularly cross-links excretion did not explain group differences in clinical and bone characteristics. After adjustment for age, gender, body weight, and height, children with symptomatic generalized joint hypermobility (n = 15) had significantly higher total range of joint motion (117.8 degrees; 95% CI: 77.7–158.0), skin extensibility (3.5 mm/15 kPa; 95% CI: 1.6–5.3), lower quantitative ultrasound measurements in bone (speed of sound: -27.9 m/s; 95% CI: -48.4 to -7.5), borderline lower diastolic blood pressure (-4.9 mmHg; 95% CI: -10.7–0.9), and significantly higher degradation products in urine (hydroxyproline/creatinine: 21.2 µmol/mmol; 95% CI: 2.3–40.1) as compared with asymptomatic hypermobile children of the total reference group (n = 16). After adjustment for possible confounders, children with generalized joint hypermobility without musculoskeletal complaints had a significantly higher total range of joint motion and more profound skin extensibility, as compared with the reference group (n = 79).

Conclusions. Clinically manifested symptoms in otherwise healthy children with generalized joint hypermobility are accompanied by increases in the laxity of other body tissues. Thus, generalized joint hypermobility with musculoskeletal symptoms does not seem to be restricted to joint tissues. In symptomatic hypermobile children, a more systemic derangement was also present as compared with asymptomatic hypermobile children.

Key Words: joint hypermobility • collagen • skin extensibility • blood pressure • bone density • quantitative ultrasound measurements • functional ability

Abbreviations: SOS, speed of sound Hyp, hydroxyproline • HP hydroxylysylpyridinoline • LP, lysylpyridinoline • CI, confidence interval

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