6.1

This is the shortest section of this text, not because it is less important but because the field is the least developed. Given the paucity of evidence on palpation, the first chapter presents a method of assessment which could form the basis for a standardized and then testable palpatory technique for fascial disorders. Spinal palpatory findings differ between examiners, showing low to moderate reliability in the review by Seffinger and colleagues (2004); pain provocation tests were more reliable than soft tissue palpation, which is of course precisely what manual therapists consider to be most important. Inclusion of the clinical context rather than blind assessment of the patient improved reliability in upper extremity examinations (Hickey et al. 2007; Smith et al. 2010). Both Cibere et al. (2008) and Brunse et al. (2010) showed that test standardization improved those examination signs with poor rater agreement. Newer examination tools such as musculoskeletal provide such an opportunity, but Kim et al. (2007) found that they were able to identify structural problems but the results were unfortunately independent of the physical exam or the pain symptoms. Once a standardized assessment is developed, it can be improved into a psychometrically more sound test (Hunt et al. 2009). As Seffinger (Seffinger et al. 2004) concludes:

Chapter 6.2 addresses another vexing problem, hypermobility (HM). While there are multiple techniques for the management of people who have decreased range of motion, there are far fewer options for those with increased range. The British Medical Journal has begun a series of articles for physicians on conditions often missed, and the recent one by Ross & Grahame (2011) is highly recommended for your interactions with traditional medical practitioners. It lists a number of clues (besides joint mobility) that suggest the joint hypermobility syndrome, which in adults may include symptoms of pain, arthritis, autonomic dysfunction, gastrointestinal disorders. A somewhat different set of symptoms are found in children and adolescents, including late walking, ankle sprains, decreased coordination, and widespread pain.

There is not enough research on psychological aspects of fascial disorders to devote a whole chapter to this, but there are some intriguing findings regarding hypermobility. A strong association between hypermobility and anxiety and panic disorder was noted in a case control study by Martin-Santos and colleagues (1998), with 68% of persons with a diagnosis of anxiety showing hypermobility, compared to 10% of persons with medical or psychiatric diagnoses. That group has continued to find this association in the general population, with increased scores measuring trait anxiety in persons with hypermobility (Bulbena et al. 2004) in a general medical clinic, and increased scores measuring fear in a general population sample with hypermobility, compared to those without (Bulbena et al. 2006). Recently they have reported a 15-year follow-up of a general population recruited at ages 16 to 20 (Bulbena et al. 2011); in this population 20% have hypermobility, similar to the population rate in many other places. In the 15 years since entry into their study, an astounding 41% of the persons with hypermobility have developed panic disorder, compared to only 2% of the persons with normal mobility. There was also a significant increase of social phobia (6×), simple phobia (3×), and anxiolytic drug use (4×) in persons with hypermobility.

These findings have been replicated by two other groups: Ercolani et al. (2008) found increased anxiety and somatic symptoms in a case control study, compared to normal persons and another group of persons with fibromyalgia. Garcia-Campayo et al. (2010) found a similar 20-fold increase in panic disorders in persons with hypermobility (61% compared to only 10% in the general population) and noted a direct correlation (r = 0.52) between the Beighton hypermobility score and the Panic and Agoraphobia Scale. For a recent review of the association between anxiety and hypermobility, see Garcia-Campayo et al. (2011).

The parallel between increased anxiety and panic disorder in HM and in persons with gastrointestinal (GI) disorders was noted by Zarate et al. (2010), who looked more closely at the correspondence between HM and GI disturbances. They found that 50% of new patients in a GI clinic had hypermobility, and hypothesize a change in the connective tissue and passive mechanical properties of the gut wall or concurrent changes in the autonomic nervous system as possible etiologies. The same group (Mohammed et al. 2010) looked at persons with rectal evacuation dysfunction, and found 32% reported hypermobility symptoms on a simple five question screening test, compared to 14% of controls. Vounotrypidis et al. (2009) looked at specific types of GI disorders and found joint hypermobility in 70% of clinic patients with Crohn’s disease, 35% with ulcerative colitis, compared to 25% of controls.

In all of these studies, patients are given a hypermobility score based on specific numbers of joints involved, without specifying a specific pattern of increased mobility. In my clinical practice I have noticed patients who have distal hypermobility particularly in the arms, some with excessive but some with reduced straight leg raise. Voermans et al. (2009) nicely categorize the pattern of joint hypermobility found in persons with myopathies, and their findings are instructive as we continue to explore the issue of hypermobility in general. While they list findings by muscle disease, their joint findings can be categorized by the effect on joints in a fashion of more use to studies of fascia:

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