title: Proprioceptive acuity into knee hypermobile range in children with joint hypermobility syndrome.
abstract: BACKGROUND
  Children with Joint Hypermobility Syndrome (JHS) have reduced knee joint proprioceptive acuity compared to peers. Altered proprioception at end of range in individuals with JHS is hypothesised to contribute to recurrent joint injuries and instability. This study aims to provide the first objective comparison of functional knee joint proprioceptive acuity in hyperextension range compared to early flexion range in children with JHS.
  
  
  METHODS
  Active, weight-bearing knee joint proprioceptive acuity in both hyperextension and early flexion range was tested with a purpose-built device. Proprioceptive acuity was measured using the psychophysical method of constant stimuli to determine ability to discriminate between the extents of paired active movements made to physical stops. The smallest difference in knee range of motion that the child is able to correctly judge on at least 75% of occasions, the Just Noticeable Difference (JND), was calculated using Probit analysis. Knee pain, muscle strength, amount of physical activity and patient demographic data were collected.
  
  
  RESULTS
  Twenty children aged 8-16 years with JHS and hypermobile knees participated. Eleven children demonstrated better proprioceptive acuity in flexion, and 9 in hyperextension (z = 0.45, p = 0.63). Matched pairs t-test found no significant difference in children's ability to discriminate between the same extents of movement in the hyperextension or flexion directions (mean JND difference 0.11°, 95% CI -0.26° - 0.47°, p = 0.545). However, 3 children could not discriminate movements in hyperextension better than chance. Proprioceptive acuity scores were positively correlated between the two directions of movement (r = 0.55, p = 0.02), with no significant correlations found between proprioceptive acuity and age, degree of hypermobility, muscle strength, pain level, amount of physical activity or body mass index centile (r = -0.35 to -0.03, all p ≥ 0.13).
  
  
  CONCLUSIONS
  For a group of children with JHS involving hypermobile knees, there was no significant difference between knee joint proprioceptive acuity in early flexion and in hypermobile range when measured by a functional, active, weight-bearing test. Therefore, when implementing a proprioceptive training programme, clinicians should focus training throughout knee range, including into hyperextension. Further research is needed to determine factors contributing to pain and instability in hypermobile range.
authors.affiliation: Physiotherapy Department, The Children's Hospital at Westmead, Sydney, Australia ; Kids Rehab, The Children's Hospital at Westmead, Sydney, Australia ; Discipline of Biomedical Sciences, The University of Sydney, Sydney, Australia.
authors.forename: Verity
authors.initials: V
authors.lastname: Pacey
authors.affiliation: Discipline of Physiotherapy, The University of Sydney, Sydney, Australia.
authors.forename: Roger D
authors.initials: RD
authors.lastname: Adams
authors.affiliation: Kids Rehab, The Children's Hospital at Westmead, Sydney, Australia ; Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia.
authors.forename: Louise
authors.initials: L
authors.lastname: Tofts
authors.affiliation: Department of Endocrinology, The Children's Hospital at Westmead, Sydney, Australia ; Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia.
authors.forename: Craig F
authors.initials: CF
authors.lastname: Munns
authors.affiliation: Kids Rehab, The Children's Hospital at Westmead, Sydney, Australia ; Discipline of Biomedical Sciences, The University of Sydney, Sydney, Australia.
authors.forename: Leslie L
authors.initials: LL
authors.lastname: Nicholson
mesh_terms: D000293:Adolescent; D000367:Age Factors; D018771:Arthralgia / Q000453:epidemiology; D002648:Child; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000503:physiopathology* / Q000628:therapy; D007719:Knee Joint / Q000503:physiopathology*; D008297:Male; D053580:Muscle Strength / Q000502:physiology; D026741:Physical Therapy Modalities; D015995:Prevalence; D011434:Proprioception / Q000502:physiology*; D016059:Range of Motion, Articular / Q000502:physiology*; D016474:Weight-Bearing / Q000502:physiology
keywords: Ehlers-Danlos syndrome; Hyperextension; Hypermobility; Joint hypermobility syndrome; Knee; Proprioception; Range of motion