Congratulations PTSMC Graduates and New DPT Students!

Brianna Annunziato

Branford PT Aide

Graduated from the University of Hartford (UHART) with a BS in Health Science. She will be attending UHART’s DPT Program.

Maddie Archangelo

Fair eld PT Aide

Graduated from Sacred Heart University (SHU) with a BS in Exercise Science. She will be attending SHU’s DPT program.

West Hartford PCC

Graduated from Central Connecticut State University (CCSU) with a BS in Exercise Science.

Caidan Galovich

East Hampton PT Aide

Graduated from East Hampton High School. She will be attending the University of Delaware for Nursing.

Lauren Granato

Glastonbury PT Aide

Graduated from the University of Connecticut (UCONN) with a BS in Allied Health Sciences and a minor in Spanish. She will be attending Boston University’s DPT program.

Graduated from UCONN with an MS in Public Policy.

Isabella Matarazzo

Wallingford PT Aide

Graduated from CCSU with an BS in Exercise Science.

Nikki Matarazzo Wallingford PSC

Graduated from SHU with an AS in Radiography.

Graduated from CCSU with an MS in Accounting.

Ashley Cato, PT Aide Windsor, UHART

Anna Donato, PSC Essex, Belmont University

Aarohi Patel, PSC Avon, UHART

Alex Rostenberg, PT Aide Avon, UCONN

Amanda Warner, PT Aide Plainville, UHART

Bri Boulerice, PT, DPT - Waterbury PT

Brittany Kearney, PT, DPT - Westbrook PT

Elena Masiello, PT, DPT - Wallingford PT

PICO Question: In adults ages 18-65 with hypermobility spectrum disorder (HSD) or Ehlers Danlos hypermobility subtype, what is the e ectiveness and safety of high intensity exercise compared to low or moderate intensity exercise on stability and self-perceived function?

Population: Adults age 18-65 with Ehlers Danlos syndrome (hypermobility subtype) or Hypermobility Spectrum Disorder (HSD). There are multiple subtypes of Ehlers Danlos syndromes (EDS) with di erent genetic presentations. EDS hypermobility is the most common. Common symptoms include increased joint range of motion, unstable joints, joint pain, and fatigue. This can often lead to joint subluxations and dislocations. See below for a list of EDS subtypes.4

Intervention:

Databases: CINAHL, PubMed, PEDro, Cochrane Database of Systematic Reviews, MEDLINE Complete, SPORTDiscus with Full Text Medline search strategy: [“Physical Therapy” or “exercise” or “high intensity”] AND ["Ehlers Danlos" or "EDS" or "Hypermobility Spectrum Disorder" or "HSD"]

Filters: past 10 years, all text, English Abstract Available

In order to ensure the most up to date research, we limited our search to only the past 10 years. In addition, due to the relatively limited number of studies available addressing this question, we used general search terms and all-text elds in order to capture as many relevant studies as possible.

Comparison: See conclusion below.

Outcome: A meta-analysis of randomized controlled trials, a systematic review or a single randomized control trial (RCT) would best address this question. The RCT study design allows for control of extraneous variables through the use of an experimental and a control group that are statistically homogeneous prior to the application of an intervention in order to conclude that any changes observed between the two groups is due to the independent variable. When analyzing a report of original research, it is important to analyze threats to internal validity including randomization, blinding, heterogeneity at baseline, adequate follow up, intention to treat with reason given for drop-outs, instrument calibration techniques, and standardized data collection protocols. Additionally, it is important to analyze external validity to determine if your patient case is represented in the study population.

Sub-types of Ehlers Danlos: classical EDS, classical-like EDS, cardiac-valvular EDS, vascular EDS, arthrochalasia EDS, dermatosparaxis EDS, kyphoscoliotic EDS, brittle cornea syndrome spondylodysplastic EDS, musculocontractural EDS, myopathic EDS, periodontal EDS.4

Liaghat B, Skou ST, Søndergaard J, Boyle E, Søgaard K, Juul-Kristensen B. Short-term e ectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial. Br J Sports Med. 2022 Jun 1;56(22):1269–76. doi: 10.1136/bjsports-2021-105223. Epub ahead of print. PMID: 35649707; PMCID: PMC9626913.

A randomized controlled trial performed in 2022 by Liaghat, et al. investigated the short-term e ectiveness of high- versus low-load strengthening exercises on self-reported function in 100 patients ages 18-65 with hypermobility spectrum disorder (HSD), particularly involving the shoulder joint. There is currently no clinical practice guideline for advising loading patterns for this population and thus clinicians tend to be wary of prescribing higher load exercise programs for fear that this may result in safety concerns for the patient. Liaghat, et al. (2022) found that patients with HSD (Beighton score ≥ 4 for men of all ages and women ≥ 50 years, and≥ 5 for women < 50) could tolerate a 16-week high-load shoulder strengthening program, and this resulted in higher self-reports of shoulder functionality. Groups were randomized using a computer-generated system with block randomization set up by an external data manager, thus blinding the assessors, however it was di cult to blind the subjects or therapists due to the nature of this study. Visit the original study above for links to speci c intervention outlines provided to therapists.

The HEAVY intervention group received one-on-one treatment twice per week and were encouraged to train once per week at home. Patients were brought through a ve minute warm-up involving unloaded exercises. Five exercises were then used for scapular and RTC training: side-lying external rotation in neutral, prone horizontal abduction, prone external rotation at 90° shoulder abduction, supine scapular protraction and seated scaption. Loads were based on patients’ ve-repetition maximum to replicate a similar load for each participant. The rst three weeks of the study served to familiarize patients with the program and consisted of the following: 3 sets of 10, week 1 at 50% of 10 RM, week 2 at 70% of 10 RM, week 3 at 90% of 10 RM. Weeks 4-9 included 3 sets of 10 RM, weeks 10-15 included 4 sets of 8 RM, and week 16 was used as a taper period to allow anabolic response to occur prior to retesting.

The LIGHT intervention group (comparator) was designed to be a “typical” course of PT treatment for this condition in Denmark, including primarily self-training exercises performed 3x/week. Patients received individual training initially to orient to the exercise program and then again at weeks 5 and 11 when new exercises were introduced. Exercises included nine shoulder exercises: “phase 1 (isometric), posture correction; phase 2 (isometric), shoulder abduction, shoulder internal and external rotation with 90° exion at the elbow joint against a wall, and standing weight-bearing in the shoulders against a table; and phase 3 (dynamic with a yellow Theraband), shoulder abduction, shoulder internal and external rotation at 90° exion at the elbow joint and four-point kneeling with single-arm raising.”

Self-reported function was assessed using the following outcome measures / questionnaires: WOSI, COOP/WONCA, Tampa Scale of Kinesiophobia, European Quality of Life Scale, EQ-VAS, GPE, etc.. A statistically signi cant relationship (8/3% greater) was found between higher intensity exercise and self-reported function versus the light intensity group at 16-week follow-up. Patients in HEAVY were also found to have a less positive shoulder rotation, indicating improved stability of the shoulder joint.

This RCT yielded a PEDro score of 8/10, indicating good validity. [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind subjects: No; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been con rmed*.

Daman, M., Shiravani, F., Hemmati, L., & Taghizadeh, S. (2019). The e ect of combined exercise therapy on knee proprioception, pain intensity and quality of life in patients with hypermobility syndrome: A randomized clinical trial. Journal of Bodywork and Movement Therapies, 23(1), 202–205. https://doi.org/10.1016/j.jbmt.2017.12.012 https://doi.org/10.1186/s13102-021-00238-8

A randomized clinical trial was performed in 2019 by Daman, et al. examining the e ect of combined exercise therapy on knee proprioception, pain intensity and quality of life in patients with hypermobility syndrome. This single blind study placed 24 participants into two groups, intervention (exercise therapy) or control group (no intervention). The exercise therapy group included closed kinetic chain exercises and proprioception exercises. Exercise sessions were completed three days a week for four weeks. Measurements of knee proprioception, pain intensity and quality of life were taken before and after the intervention. The study concluded that combined exercise therapy led to a signi cant improvement in all three categories when compared to the control group. The study included 24 women 18-30 years old diagnosed with hypermobility syndrome and who all attended associated physical therapy clinics. A computer randomly placed the patients into the two groups. Exclusion criteria included: women who already exercised three times a week or more, history of knee trauma, history or RA or knee OA, knee ligament injury, knee arthroplasty, neuromuscular or musculoskeletal disorder. Data was not recorded when any of the patients were at the beginning of their menstrual cycle due to increased hormone release which can increase joint laxity. Pain intensity, quality of life and proprioception were measured using the VAS, SF-36 and a goniometer. One physical therapist supervised all the patients and another blinded therapist evaluated them.

Exercise therapy was completed three times a week for four weeks. The rst week included squatting, bridging and plie one set of ve each, 30 seconds each of walking backwards, heel walking, walking on toes, walking with eyes closed, standing on one leg, and bending back and forth on one leg with eyes closed and then with eyes open. The second week included squatting, bridging, plie one set of ten, front and side lunges one set of ve, ten sit to stands and all of the walking and standing exercises from week one for 30 seconds each. Week three included everything from week two in addition to slow eight exercises (slow walk broad circle, fast walk broad circle, slow walk narrow circle, fast walk narrow circle) ve times each. The last week included squats, bridges, and plies two sets of 15, front and side lunges two sets of ten, ten sit to stands, ve sets of the fast eight exercises and 30 seconds each of backwards walking, heel walking, toe walking, walking with eyes closed, standing on one leg, bending back and forth on one leg with eyes closed and eyes opened.

Power analyses were performed to determine sample size for each group which was 12 women based on an 0.05 alpha value, 80% power and 0.2 beta value. The Shapiro-Wilk test was used to assess data normality and found data was normally distributed other than joint angle repositioning in weight bearing so this was assessed using nonparametric tests. The Mann- Whitney was used to compare angle error and paired t-tests and independent sample t-tests were used for within group and between group di erences of pain intensity, quality of life and joint angle repositioning in non weight bearing. This article scored a 5/10 PEDro score due to not including concealed allocation, blind subjects, blind therapists, an adequate follow up or intention to treat analysis.

Previous studies have looked at exercise over eight weeks and had similar results. This study showed that combined exercise in four weeks leads to improvement in proprioception which has a crucial role in joint stability, decreased pain intensity, and increased quality of life.

Luder, G., Aeberli, D., Mebes, C.M. et al. E ect of resistance training on muscle properties and function in women with generalized joint hypermobility: a single-blind pragmatic randomized controlled trial. BMC Sports Sci Med Rehabil 13, 10 (2021).

This randomized control trial included 51 women between the ages of 20 and 40 with generalized joint hypermobility. This was operationally de ned by the authors as a Beighton score of at least 6/9. The subjects were randomly allocated to a 12-week resistance training group or a no lifestyle change group. The resistance training group program was mainly self-guided and completed two times per week. Inclusion criteria included: score of at least 6/9 points on the Beighton score (with right knee hyperextension being mandatory), body mass index between 18 and 30 kg/m2, and ability to understand German questionnaires. Exclusion criteria included: women who had surgery of the lower extremities or spine in the last two years, women with acute back pain or lower extremity pain, women who regularly undertook more than four hours per week of exercise, pregnant women, women less than one year postpartum, and women with known inherited diseases of the connective tissues (except Ehlers-Danlos hypermobility type). Participants were randomized using a computer-generated list. The assessor and statistician were blinded to the randomization list.