Patrick Calders

Musculoskeletal complaints, physical activity and health-related quality of life among patients with the Ehlers–Danlos syndrome hypermobility type

Purpose. To investigate the musculoskeletal complaints, physical activity (PA) and health-related quality of life (HRQoL) in patients with the Ehlers–Danlos syndrome hypermobility type (EDS-HT). Methods. Thirty-two female EDS-HT patients as defined by the Villefranche criteria and 32 gender- and age-matched healthy control subjects participated in the study. Data about musculoskeletal complaints were collected from a specific form developed for the study. Daily PA and HRQoL were evaluated by the Baecke questionnaire and the RAND 36-Item Health Survey (distributed by RAND), respectively. Results. A significant presence of joint pain, joint dislocations, muscle cramps, tendinitis, fatigue and headache were revealed in the EDS-HT patient group. Joint pain was reported as the most frequent and most severe symptom. The habitual PA level was diminished in the patient group. Specifically, EDS-HT subjects had significantly lower sport participation, but a comparable leisure time excluding sports compared to the healthy control subjects. All eight HRQoL dimensions of the RAND-36 and both physical and emotional summary scores were significantly impaired in EDS-HT. Conclusions. EDS-HT is characterised by various severe musculoskeletal complaints and has a detrimental effect on the habitual level of PA and HRQoL, in both physical and psychosocial dimension. An appropriate treatment and management in healthcare is needed.

Influence of combined exercise training on indices of obesity, diabetes and cardiovascular risk in type 2 diabetes patients

Objective: To investigate the influence of combined exercise training on indices of obesity, diabetes and cardiovascular risk in type 2 diabetes patients. Design: A double-blind randomized controlled trial with patients receiving either combination (COM), endurance (END) or no training (C). Setting: Sint-Jozef hospital (Belgium), general practice (Holland). Subjects: Forty-six type 2 diabetes patients (17 female, 29 male). Interventions: COM versus END and C. Patients exercised for three months, three times a week for 1 hour. Main measures: Six-minute walk test (6MW T), peak Vo2, strength in upper and lower limbs, sit-to-stand, height, weight, body mass index, fat mass, glycosylated haemoglobin (HbA1c), glycaemia, triglycerides, high-density lipoprotein (HDL), total cholesterol and quality of life (General Health Survey Short Form (SF-36)). Results: COM had significant better results on sit-to-stand (P<0.05), 6MW T (P<0.01), strength in upper (P<0.001) and lower limbs (P<0.001) compared with C. A different evolution among COM and C was found for HbA1c (P<0.05) and cholesterol (P<0.01), both decreased in COM and increased in C. HDL increased in COM and decreased in C (P<0.01). END had significant higher results on the 6MW T (P<0.01) compared with C. Compared with END, COM had significantly higher results on strength in upper (P<0.01) and lower limbs (P<0.01). The evolution of SF-36 items was not significantly different between the three groups. Conclusion: In diabetes type 2 patients, COM had significant better effects on indices of physical condition, diabetes and cardiovascular risk compared with C. Compared with END, COM gave a tendency towards better results, however more research with a larger number of participants is needed.

Heart rate variability in patients with fibromyalgia and patients with chronic fatigue syndrome: a systematic review

OBJECTIVE The goal of this systematic literature review is to determine whether there are differences and similarities in heart rate variability (HRV) between adult patients with fibromyalgia (FM), chronic fatigue syndrome (CFS), and healthy pain-free control subjects. METHODS To obtain relevant articles, PubMed and Web of Knowledge were searched for case-control studies. Selection of the literature was based on selection criteria ascertaining studies with adult human patient groups comparing HRV. Risk of bias and levels of evidence were determined. RESULTS Sixteen case-control studies were included, 10 comparing FM patients to controls and 6 comparing CFS patients to controls. Methodological quality was moderate to good. Both time domain and frequency domain measurements were used. The majority of the researchers observed lower HRV in FM patients compared to healthy control persons, as well as increased sympathetic activity and a blunted autonomic response to stressors. Resistance training improved HRV in FM patients. In CFS patients HRV was only reduced during sleep. CONCLUSION FM patients show more HRV aberrances and indices of increased sympathetic activity. Increased sympathetic activity is only present in CFS patients at night. Since direct comparisons are lacking and some confounders have to be taken into account, further research is warranted. The role of pain and causality can be subject of further research, as well as therapy studies directed to reduced HRV.

Dysautonomia and its underlying mechanisms in the hypermobility type of Ehlers–Danlos syndrome

OBJECTIVES Many non-musculoskeletal complaints in EDS-HT may be related to dysautonomia. This study therefore aims to investigate whether dysautonomia is present and to explore the underlying mechanisms. METHODS A total of 39 females with EDS-HT and 35 age-matched controls underwent autonomic function testing. Resting autonomic tone was assessed using heart rate variability (frequency domain) and baroreflex sensitivity analysis (cross correlation). Autonomic reactivity was assessed using the Autonomic Reflex Screen test battery. Factors suspected to contribute to dysautonomia, e.g., neuropathy, medication use, decreased physical activity, depression, pain-induced sympathetic arousal, and connective tissue laxity, were quantified using validated questionnaires, the Beighton score, and measurement of skin extensibility. RESULTS The EDS-HT group showed autonomic deregulation with increased sympathetic activity at rest and reduced sympathetic reactivity to stimuli. Increased resting activity was indicated by a higher LF/HF ratio compared to controls (1.7 ± 1.23 vs 0.9 ± 0.75, p = 0.002); decreased reactivity by a greater BP fall during valsalva (-19 ± 12 vs -8 ± 10, p < 0.001), and a smaller initial diastolic BP increase during tilt (7% vs 14%, p = 0.032). Orthostatic intolerance was significantly more prevalent in EDS-HT than controls (74% vs 34%) and was most frequently expressed as postural orthostatic tachycardia. Lowered QSART responses suggest that sympathetic neurogenic dysfunction is common in patients (p < 0.013), which may explain the dysautonomia in EDS-HT. Further, connective tissue laxity and vasoactive medication use were identified as important factors in aggravating dysautonomia (p < 0.035). CONCLUSION Dysautonomia consisting of cardiovascular and sudomotor dysfunction is present in EDS-HT. Neuropathy, connective tissue laxity, and vasoactive medication probably play a role in its development.

The evidence-base for basic physical therapy techniques targeting lower limb function in children with cerebral palsy : a systematic review using the International Classification of Functioning, Disability and Health as a conceptual framework

OBJECTIVE This systematic review provides an overview of the effectiveness of basic techniques used in lower limb physical therapy of children with cerebral palsy. It aims to support the development of clinical guidelines for evidence-based physical therapy planning for these children. DATA SOURCES AND STUDY SELECTION A literature search in 5 electronic databases extracted literature published between January 1995 and December 2009. Studies were evaluated using the framework recommended by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), which classifies outcomes according to the International Classification of Functioning, Disability and Health. DATA EXTRACTION Three independent evaluators rated the strength of evidence of the effects according to the AACPDM levels of evidence classification, and the quality of the studies according to the AACPDM conduct score system. DATA SYNTHESIS A total of 83 studies was selected and divided into categories (stretching, massage, strengthening, electrical stimulation, weight-bearing, balance-, treadmill- and endurance training). Interventions targeting problems at body function and structure level generally influenced this level without significant overflow to activity level and vice versa. CONCLUSION The more recent studies evaluating strength training mainly demonstrated level II evidence for improved gait and gross motor function. There was limited evidence for specific information on intensity, duration and frequency of training.

Joint position sense and vibratory perception sense in patients with Ehlers–Danlos syndrome type III (hypermobility type)

Neurophysiological deficits could make patients with Ehlers–Danlos syndrome (EDS) type III (hypermobility type) more vulnerable to musculoskeletal problems, particularly to joint instability. The purpose of this study was to investigate whether joint position sense (JPS) and vibratory perception sense (VPS) in EDS type III patients in the knee and shoulder joints are impaired. Thirty-two female EDS type III patients as defined by the Villefranche criteria and 32 individually gender- and age-matched healthy control subjects were included in the study. Range of motion was determined using a goniometer, passive and active JPS were assessed with an isokinetic dynamometer system, and the VPS was measured by a biothesiometer. Daily physical activity was evaluated by the Baecke questionnaire. The EDS type III group showed significantly larger ranges of movement (P < 0.05) and lower levels of sport physical activity (SPA) compared to the control group (P = 0.023). Considering SPA as covariate, the EDS type III group demonstrated a significant impairment in knee joint reposition compared to the control group (P = 0.018). No significant differences were found for shoulder JPS. The VPS was not significantly different in the EDS type III group compared to the control group. In addition, no significant correlation was found between JPS and VPS, neither at the knee nor at the shoulder joint. This is the first study examining proprioception deficits in EDS type III patients as defined by the Villefranche criteria. Further research on the neurophysiological dysfunctions and mechanisms in this pathologic entity is needed.

Influence of combined aerobic and resistance training on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes: a randomized controlled trial

Objective: To evaluate the effect of combined exercise training on metabolic control, physical fitness and quality of life in adolescents with type 1 diabetes. Design: A double-blind randomized controlled trial with patients receiving combined aerobic and strength or no training. Setting: University Hospital Ghent (Belgium). Subjects: Sixteen children with type 1 diabetes were randomized into a control group (n = 8) and an intervention group (n = 8). Interventions: Patients participated twice a week for 20 weeks in the combined aerobic and strength group. The control group continued their normal daily activities. Main measures: Before and after the intervention anthropometric variables (weight, length, BMI, body composition), metabolic control (glycaemia, HbA1c, daily insulin injected), aerobic capacity (peak V o 2, peak power, peak heart rate, 6-minute walk distance), strength (1 repetition maximum of upper and lower limb, hand grip strength, muscle fatigue resistance, sit-to-stand) and quality of life (SF-36) were assessed. Results: At baseline, none of the measured parameters differed significantly between the two groups. There was no significant evolution in the groups concerning anthropometric indices, glycaemia and HbA1c. However, the daily doses of insulin injected were significantly lowered in the training group (0.96 IU/kg.day pre versus 0.90 IU/kg.day post; P < 0,05), while it was increased in the control group. Physical fitness increased significantly in the training group. General health, vitality and role emotional had a tendency to improve. Conclusion: Combined exercise training seemed to lower daily insulin requirement and improve physical fitness, together with better well-being.

Balance, gait, falls, and fear of falling in women with the hypermobility type of Ehlers-Danlos syndrome

To investigate balance, gait, falls, and fear of falling in patients with the hypermobility type of Ehlers‐Danlos syndrome (EDS‐HT).

Understanding the relationship between type 2 diabetes mellitus and falls in older adults: a prospective cohort study.

Background Older adults with type 2 Diabetes Mellitus are at increased risk of falling. The current study aims to identify risk factors that mediate the relationship between diabetes and falls. Methods 199 older adults (104 with diabetes and 95 healthy controls) underwent a medical screening. Gait (GAITRite®), balance (AccuGait® force plate), grip strength (Jamar®), and cognitive status (Mini-Mental State Examination and Clock Drawing Test) were assessed. Falls were prospectively recorded during a 12-month follow-up period using monthly calendars. Results Compared to controls, diabetes participants scored worse on all physical and cognitive measures. Sixty-four participants (42 diabetes vs. 22 controls) reported at least one injurious fall or two non-injurious falls (“fallers”). Univariate logistic regression identified diabetes as a risk factor for future falls (Odds Ratio 2.25, 95%CI 1.21–4.15, p = 0.010). Stepwise multiple regressions defined diabetes and poor balance as independent risk factors for falling. Taking more medications, slower walking speed, shorter stride length and poor cognitive performance were mediators that reduced the Odds Ratio of the relationship between diabetes and faller status relationship the most followed by reduced grip strength and increased stride length variability. Conclusions Diabetes is a major risk factor for falling, even after controlling for poor balance. Taking more medications, poorer walking performance and reduced cognitive functioning were mediators of the relationship between diabetes and falls. Tailored preventive programs including systematic medication reviews, specific balance exercises and cognitive training might be beneficial in reducing fall risk in older adults suffering from diabetes.

Medication, Surgery, and Physiotherapy Among Patients With the Hypermobility Type of Ehlers-Danlos Syndrome

OBJECTIVES To describe medication use, surgery, and physiotherapy, and to examine the effect of these treatment modalities on functional impairment and amount of complaints among patients with the hypermobility type of Ehlers-Danlos syndrome (EDS-HT). DESIGN Cross-sectional study. SETTING Physical and rehabilitation medicine department and center for medical genetics. PARTICIPANTS Patients with EDS-HT (N=79; 8 men, 71 women) were recruited for this study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patients filled out questionnaires regarding type of complaints, medication use, surgery, physiotherapy, and outcome of treatment. Functional impairment in daily life was measured by the Sickness Impact Profile. Pain severity was assessed with visual analog scales. RESULTS Patients reported a large number of complaints, a considerable presence of severe pain, and a clinically significant impact of disease on daily functioning. Most patients (92.4%) used medications, among which analgesics were the most prevalent. Fifty-six patients (70.9%) underwent surgery, including mainly interventions of the extremities and abdomen. Forty-one patients (51.9%) are currently enrolled in a physical therapy program, mainly comprising neuromuscular exercises, massage, and electrotherapy. Patients with a high consumption of analgesics, who visited the physiotherapist, or who underwent surgery had a higher dysfunction in daily life. Only 33.9% of the patients who underwent surgery and 63.4% of patients in physical therapy reported a positive outcome. CONCLUSIONS Patients with EDS-HT have numerous complaints and an impaired functional status that strongly determine their high rate of treatment consumption. The outcome of surgical and physiotherapy treatment is disappointing in a large percentage, which illustrates a strong need for evidence-based therapy.