Most of the patients I see with excessive joint instability or joint hypermobility have already been diagnosed with Hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome. Having received this diagnosis the challenge to them now is to find an appropriate treatment.
In this article I will discuss stem cell therapy in treating hypermobile joints and spinal instability caused by hypermobility spectrum disorders. The information of this article will focus only on the musculoskeletal aspects and not the genetic aspect.
I see many patients with hypermobile, overly flexible or “double jointed,” knees, hips, shoulders, elbows, ankles and spines. Some were gymnasts or engaged in an activity where having hypermobile joints was considered a great benefit. That is until the chronic dislocations began and the accelerated osteoarthritis or bone on bone conditions started to develop. Now the benefit became a problem, a problem that became difficult to treat and difficult to understand.
Patients do not find a lot of resources or support for treatment
A paper published in the journal Disability and rehabilitation (1) wrote of “scant guidance for supporting patients. Patients, the study authors wrote: “indicated poor access to psychological support, occupational therapy and a lack of knowledge about Hypermobility spectrum disorders / hypermobile Ehlers-Danlos syndrome.” In our office patients tells us about the ineffectiveness of previous treatment and a general lack of understanding about long-term treatment goals beyond joint replacement and various joint and spinal fusions.
The problem can center on doctors relying too much on strategies that include physical therapy, chiropractic manipulation, muscle and core strengthening. Some of these strategies may put patients at greater risk for joint dislocation and joint injury.
Other aspects of treatment center on pain management. These include medications, counseling in cognitive behavioral therapy, and various electrostimulation devices.
Physical therapy
In June 2021, a paper published in the journal American journal of medical genetics. Part A. (2) suggested that physical therapy techniques are regularly prescribed for hypermobile type Ehlers-Danlos syndrome (hEDS) patients and that for the most part, PT is found to be helpful with the patient’s symptoms. One problem the researchers noted was that there was no consistency to the type of PT the patients were getting, however, “pain or proprioception demonstrated significant improvements in the intervention group regardless of the type of intervention.”
A February 2021 study (3) reported less than hoped for results. Here the study authors wrote that evidence for physiotherapy in Generalized joint hypermobility management is sparse and resistance training might be a possible intervention. To explore this option, the effects of a 12-week resistance-training program on muscle properties and function in women with generalized joint hypermobility were evaluated.
- In this single-blind randomized controlled trial women between 20 and 40 years with generalized joint hypermobility (Beighton score at least 6/9) were included. (As many of you are aware, the Beighton score is a means to determine extent of joint laxity and hypermobility. The Beighton score is a hypermobility scoring system measuring 0 – 9. The higher the scoring number the more significant the joint laxity.)
- The study participants were randomly assigned to a 12-week resistance training program twice weekly (experimental) or no lifestyle change (control). Resistance training focused on leg and trunk muscles.
What were the results between the two groups? “No improvement in strength or muscle mass by self-guided resistance training was found. Low resistance levels, as well as the choice of outcome measures were possible reasons. A more individualized and better guided training might be important. However, program adherence was good with few side effects or problems triggered by the resistance training.”
Platelet Rich Plasma Injections
While research is still exploring the role of regenerative injection therapies such as Platelet Rich Plasma and Stem Cell therapy, empirically and clinically, these treatments have demonstrated good results in relieving the symptoms of painful joint instability and hypermobility in patients with hEDS. One suggestion as to how these treatments work is that Ehlers-Danlos syndrome breaks down connective tissue. Regenerative medicine injections can help balance or overcome this breakdown and provide stability to spine and joint.
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.
If you are suffering from hEDS you know that the collagen in your ligaments and tendons may be compromised. These connective tissues which hold your bones to each other (by way of the ligaments) and your muscles to your bones (by way of the tendons) are made of of collagen. The compromised aspect of this connective tissue is that it is too elastic and as such cannot provide the strength of tissue needed to hold your joints and spine together.
PRP can help hEDS because the platelets contain growth factors crucial for the creation of collagen, fibrocartilage (the tough cartilage found in the discs of the spine and at the ligament and tendon attachments to the bone) and hyaline cartilage (the cartilage that covers the ends of the bones (articular cartilage)).
The platelets contain healing agents, or “growth factors” that help strengthen and tighten ligaments and tendons and rebuild cartilage. Let’s look at some of these growth factors and what they do:
- Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially fibroblasts (A vital cell that provides the framework for holding collagen together and smooth muscle cells
- Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
- Insulin-like growth factors which assist in building ligaments.
- Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
- Epidermal growth factor plays a key role in tissue repair mechanisms.
As was simply put in a paper published in the Clinical orthopaedics and related research (4) : “Platelet-derived growth factor, basic fibroblast growth factor, and insulin-like growth factor Type 1 have demonstrated chemotactic and mitogenic properties in vitro that could benefit healing ligaments.
More recently a December paper in the publication Tissue engineering. Part B, Reviews. (5) wrote: “Platelet-rich plasma is an autologous platelet concentrate prepared from the whole blood that is activated to release growth factors and cytokines and has been shown to have the potential capacity to reduce inflammation and improve tissue anabolism for regeneration. The use of PRP provides a potential for repair due to its abundant growth factors and cytokines, which are key in initiating and modulating regenerative microenvironments for soft and hard tissues.”
References
1 Bennett SE, Walsh N, Moss T, Palmer S. Developing a self-management intervention to manage hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS): an analysis informed by behaviour change theory. Disability and Rehabilitation. 2021 Jun 7:1-0.
2 Reychler G, De Backer MM, Piraux E, Poncin W, Caty G. Physical therapy treatment of hypermobile Ehlers–Danlos syndrome: A systematic review. American Journal of Medical Genetics Part A. 2021 Jun 19.
3 Luder G, Aeberli D, Mebes CM, Haupt-Bertschy B, Baeyens JP, Verra ML. Effect of resistance training on muscle properties and function in women with generalized joint hypermobility: a single-blind pragmatic randomized controlled trial. BMC Sports Science, Medicine and Rehabilitation. 2021 Dec;13(1):1-2.
4 Letson AK, Dahners LE. The effect of combinations of growth factors on ligament healing. Clinical orthopaedics and related research. 1994 Nov 1(308):207-12.
5 Fang J, Wang X, Jiang W, Zhu Y, Hu Y, Zhao Y, Song X, Zhao J, Zhang W, Peng J, Wang Y. Platelet-rich plasma therapy in the treatment of diseases associated with orthopedic injuries. Tissue Engineering Part B: Reviews. 2020 Dec 1;26(6):571-85.