Hypermobility and Dance: A Review

Abstract

Joint hypermobility is defined as an excessive range of motion. Although the dance profession has often promoted hypermobility for aesthetic reasons, there is a belief amongst health professionals that potential risks associated with the condition may have been overlooked. The aims of this review were to examine the epidemiology of joint hypermobility in dancers; the effects on fatigue and bone health; the injury profile of hypermobile dancers; and the use of the Beighton score as a diagnostic tool. Depending on the criteria used, epidemiological studies suggest that hypermobility among dancers can be as high as 44%, especially in students. As hypermobility has been linked to fatigue in the general population, the hypermobile dancer should be careful given the association between fatigue and aetiology of injury in dance. Similarly, in light of research encouraging dancers to become fitter, this recommendation may not be appropriate for hypermobile dancers. In addition, the Beighton score used in most dance related studies may not be an appropriate measure of hypermobility in these populations. More research is necessary into this area to ascertain the reasons for the attrition rate from student to soloist/principal level and whether it is linked to dance health and injury issues.

Key words

benign joint hypermobility syndrome - osteopenia - Beighton criteria - fatigue - injury - health

References

• 1 Acasuso-Díaz M, Collantes-Estéez E. Joint hypermobility in patients with fibromyalgia syndrome.  Arthritis Care Res. 1998;  11 39-42
• 2 Adam MU, Brassington GS, Matheson GO. Psychological factors associated with performance-limiting injuries in professional ballet dancers.  J Dance Med Sci. 2004;  8 43-46
• 3 Akhtar MA, Robinson CM. Generalised ligament laxity and shoulder dislocations after sports injuries.  Br J Sports Med. 2010;  44 i3
• 4 Aktas I, Ofluoglu D, Albay T. The relationship between benign joint hypermobility syndrome and carpal tunnel syndrome.  Clin Rheumatol. 2008;  27 1283-1287
• 5 Al-Rawi ZS, Al-Aszawi AJ, Al-Chalabi T. Joint hypermobility among university students in Iraq.  Br J Rheumatol. 1985;  24 326-331
• 6 Allen N, Wyon M. Dance medicine: artist or athlete?.  SportEX Medicine. 2008;  35 6-9
• 7 Angioi M, Metsios G, Koutedakis Y, Wyon MA. Fitness in contemporary dance: a systematic review.  Int J Sports Med. 2009;  30 475-484
• 8 Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome.  J Bone Joint Surg. 1969;  51B 444-453
• 9 Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population.  Ann Rheum Dis. 1973;  32 413-418
• 10 Birrell FN, Adebajo AO, Hazleman BL, Silman AJ. High prevalence of joint laxity in West Africans.  Rheumatology. 1994;  33 56-59
• 11 Bravo JF, Wolff C. Clinical study of hereditary disorders of connective tissues in a Chilean population.  Arthritis Rheum. 2006;  54 515-523
• 12 Briggs J, McCormack M, Hakim AJ, Grahame R. Injury and joint hypermobility syndrome in ballet dancers – a 5-year follow-up.  Rheumatology. 2009;  48 1613-1614
• 13 Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip.  J Bone Joint Surg. 1964;  46-B 40-45
• 14 Collinge R, Simmonds JV. Hypermobility, injury rate and rehabilitation in a professional football squad – A preliminary study.  Phys Ther Sport. 2009;  10 91-96
• 15 Deighan MA. Flexibility in dance.  J Dance Med Sci. 2005;  9 13-17
• 16 Didia BC, Dapper DVB, Boboye SB. Joint hypermobility syndrome among undergraduate students.  East Afr Med J. 2002;  79 80-81
• 17 Dolan AL, Hart DJ, Doyle DV, Grahame R, Spector TD. The relationship of joint hypermobility, bone mineral density, and osteoarthritis in the general population: the Chingford Study.  J Rheumatol. 2003;  30 799-803
• 18 Eyigor S, Ozdedeli S, Durmaz B. The prevalence of generalized soft tissue rheumatic conditions in Turkish medical students.  J Clin Rheumatol. 2008;  14 65-68
• 19 Ferrell WR, Tennant N, Sturrock RD, Ashton L, Creed G, Brydson G, Rafferty D. Amelioration of symptoms by enhancement of proprioception in patients with joint hypermobility syndrome.  Arthritis Rheum. 2004;  50 3323-3328
• 20 Forleo LH, Hilario MO, Peixoto AL, Naspitz C, Goldenberg J. Articular hypermobility in school children in Sao Paulo, Brazil.  J Rheumatol. 1993;  20 916-917
• 21 Foss KDB, Ford KR, Myer GD, Hewett TE. Generalized joint laxity associated with increased medial foot loading in female athletes.  J Athl Train. 2009;  44 356-362
• 22 Gannon LM, Bird HA. The quantification of joint laxity in dancers and gymnasts.  J Sports Sci. 1999;  17 743-750
• 23 Gazit Y, Nahir AM, Grahame R, Jacob G. Dysautonomia in the joint hypermobility syndrome.  Am J Med. 2003;  115 33-40
• 24 Gedalia A, Person DA, Brewer Jr EJ, Giannini EH. Hypermobility of the joints in juvenile episodic arthritis/arthralgia.  J Pediatr. 1985;  107 873-876
• 25 Gedalia A, Press J, Klein M, Buskila D. Joint hypermobility and fibromyalgia in schoolchildren.  Ann Rheum Dis. 1993;  52 494-496
• 26 Grahame R. Joint hypermobility and genetic collagen disorders: are they related?.  Arch Dis Child. 1999;  80 188-191
• 27 Grahame R. Joint hypermobility is a liability for the performing artist.. In:, Williamson A,, Coimbra D, (eds). Proceedings of the International Symposium on Performance Science. Porto, Portugal: European Association of Conservatoires, Utrecht, The Netherlands; 2007: 281-285
• 28 Grahame R. The need to take a fresh look at criteria for hypermobility.  J Rheumatol. 2007;  34 664-665
• 29 Grahame R, Bird H. British consultant rheumatologists’ perceptions about the hypermobility syndrome: a national survey.  Rheumatology. 2001;  40 559-562
• 30 Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS).  J Rheumatol. 2000;  27 1777-1779
• 31 Grahame R, Jenkins JM. Joint hypermobility – asset or liability? A study of joint mobility in ballet dancers.  Ann Rheum Dis. 1972;  31 109-111
• 32 Gratacòs M, Nadal M, MartIn-Santos R, Pujana MA, Gago J, Peral B, Armengol L, Ponsa I, Miró R, Bulbena A, Estivill X. A polymorphic genomic duplication on human chromosome 15 is a susceptibility factor for panic and phobic disorders.  Cell. 2001;  106 367-379
• 33 Gulbahar S, Sahin E, Baydar M, Bircan C, Kizil R, Manisali M, Akalin E, Peker O. Hypermobility syndrome increases the risk for low bone mass.  Clin Rheumatol. 2006;  25 511-514
• 34 Hakim AJ, Grahame R. Non-musculoskeletal symptoms in joint hypermobility syndrome. Indirect evidence for autonomic dysfunction?.  Rheumatology. 2004;  43 1194-1195
• 35 Hakim AJ, Grahame R, Norris P, Hopper C. Local anaesthetic failure in joint hypermobility syndrome.  J R Soc Med. 2005;  98 84-85
• 36 Hamilton WG, Hamilton LH, Marshall P, Molnar M. A profile of the musculoskeletal characteristics of elite professional ballet dancers.  Am J Sports Med. 1992;  20 267-273
• 37 Hardin JA, Voight ML, Blackburn TA, Canner GC, Soffer SR. The effects of “decelerated” rehabilitation following anterior cruciate ligament reconstruction on a hyperelastic female adolescent: a case study.  J Orthop Sports Phys Ther. 1997;  26 29-34
• 38 Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes.  Am J Sports Med. 2006;  34 299-311
• 39 Hincapie CA, Morton EJ, Cassidy JD. Musculoskeletal injuries and pain in dancers: a systematic review.  Arch Phys Med Rehabil. 2008;  89 1819-1829
• 40 Holt LE, Pelham TW, Holt J. Sports, Fitness, and Dance Applications.. In: Flexibility: A Concise Guide. New Jersey: Humana Press; 2008: 61-66
• 41 Juul-Kristensen B, Rogind H, Jensen DV, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome.  Rheumatology. 2007;  46 1835-1841
• 42 Karaaslan Y, Haznedaroglu S, Ozturk M. Joint hypermobility and primary fibromyalgia: a clinical enigma.  J Rheumatol. 2000;  27 1774-1776
• 43 Keay N, Fogelman I, Blake G. Bone mineral density in professional female dancers.  Br J Sports Med. 1997;  31 143-147
• 44 Kenne E, Unnithan VB. Knee and ankle strength and lower extremity power in adolescent female ballet dancers.  J Dance Med Sci. 2008;  12 59-65
• 45 Kirk JA, Ansell BM, Bywaters EG. The hypermobility syndrome. Musculoskeletal complaints associated with generalized joint hypermobility.  Ann Rheum Dis. 1967;  26 419-425
• 46 Klemp P, Chalton D. Articular mobility in ballet dancers: a follow-up study after four years.  Am J Sports Med. 1989;  17 72-75
• 47 Klemp P, Learmonth ID. Hypermobility and injuries in a professional ballet company.  Br J Sports Med. 1984;  18 143-148
• 48 Klemp P, Stevens JE, Isaacs S. A hypermobility study in ballet dancers.  J Rheumatol. 1984;  11 692-696
• 49 Klemp P, Williams SM, Stansfield SA. Articular mobility in Maori and European New Zealanders.  Rheumatology. 2002;  41 554-557
• 50 Koutedakis Y. Burnout in dance: the physiological viewpoint.  J Dance Med Sci. 2000;  4 122-127
• 51 Koutedakis Y, Jamurtas A. The dancer as a performing athlete: physiological considerations.  Sports Med. 2004;  34 651-661
• 52 Koutedakis Y, Owolabi EO, Apostolos M. Dance biomechanics: a tool for controlling health, fitness, and training.  J Dance Med Sci. 2008;  12 83-90
• 53 Koutedakis Y, Stavropoulos-Kalinoglou A, Metsios G. The significance of muscular strength in dance.  J Dance Med Sci. 2005;  9 29-34
• 54 Lamari NM, Chueire AG, Cordeiro JA. Analysis of joint mobility patterns among preschool children.  Sao Paulo Med J. 2005;  123 119-123
• 55 Larsson L-G, Baum J, Mudholkar GS. Hypermobility: features and differential incidence between the sexes.  Arthritis Rheum. 1987;  30 1426-1430
• 56 Liederbach M, Compagno JM. Psychological aspects of fatigue-related injuries in dancers.  J Dance Med Sci. 2001;  5 116-120
• 57 Mallik AK, Ferrell WR, McDonald AG, Sturrock RD. Impaired proprioceptive acuity at the proximal interphalangeal joint in patients with the hypermobility syndrome.  Br J Rheumatol. 1994;  33 631-637
• 58 Martin-Santos R, Bulbena A, Porta M, Gago J, Molina L, Duro JC. Association between joint hypermobility syndrome and panic disorder.  Am J Psychiatry. 1998;  155 1578-1583
• 59 McCormack M, Briggs J, Hakim A, Grahame R. Joint laxity and the benign joint hypermobility syndrome in student and professional ballet dancers.  J Rheumatol. 2004;  31 173-178
• 60 Nijs J, Van Essche E, De Munck M, Dequeker J. Ultrasonographic, axial, and peripheral measurements in female patients with benign hypermobility syndrome.  Calcif Tissue Int. 2000;  67 37-40
• 61 Nilsson C, Wykman A, Leanderson J. Spinal sagittal mobility and joint laxity in young ballet dancers.  Knee Surg Sports Traumatol Arthrosc. 1993;  1 206-208
• 62 Popat VB, Calis KA, Vanderhoof VH, Cizza G, Reynolds JC, Sebring N, Troendle JF, Nelson LM. Bone mineral density in estrogen-deficient young women.  J Clin Endocrinol Metab. 2009;  94 2277-2283
• 63 Pountain G. Musculoskeletal pain in Omanis, and the relationship to joint mobility and body mass index.  Rheumatology. 1992;  31 81-85
• 64 Pyeritz RE. Heritable disorders of connective tissue.. In:, Klippel JH,, Crofford LJ,, Stone JH,, Weyand CM, (eds). Primer on Rheumatic Diseases. Atlanta, Georgia: Arthritis Foundation; 2001: 483-492
• 65 Remvig L, Ellis R. Awareness of the hypermobility syndrome among delegates at the 13^th FIMM Congress, Chicago, 2001.  J Orthop Med. 2001;  23 108-111
• 66 Remvig L, Jensen DV, Ward RC. Are diagnostic criteria for general joint hypermobility and benign joint hypermobility syndrome based on reproducible and valid tests? A review of the literature.  J Rheumatol. 2007;  34 798-803
• 67 Remvig L, Jensen DV, Ward RC. Epidemiology of general joint hypermobility and basis for the proposed criteria for benign joint hypermobility syndrome: review of the literature.  J Rheumatol. 2007;  34 804-809
• 68 Rikken-Bultman DGA, Wellink L, van Dongen PWJ. Hypermobility in two Dutch school populations.  Eur J Obstet Gynecol Reprod Biol. 1997;  73 189-192
• 69 Roussel NA, Nijs J, Mottram S, Van Moorsel A, Truijen S, Stassijns G. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers. A prospective study.  Man Ther. 2009;  14 630-635
• 70 Rozen TD, Roth JM, Denenberg N. Cervical spine joint hypermobility: a possible predisposing factor for new daily persistent headache.  Cephalalgia. 2006;  26 1182-1185
• 71 Sacheti A, Szemere J, Bernstein B, Tafas T, Schechter N, Tsipouras P. Chronic pain is a manifestation of the Ehlers-Danlos syndrome.  J Pain Symptom Manage. 1997;  14 88-93
• 72 Schievink WI, Gordon OK, Tourje J. Connective tissue disorders with spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension: a prospective study.  Neurosurgery. 2004;  54 65-71
• 73 Seçkin Ü, Tur BS, Yılmaz Ö, Yagı I, Bodur H, Arasıl T. The prevalence of joint hypermobility among high school students.  Rheumatology Int. 2005;  25 260-263
• 74 Seow CC, Chow PK, Khong KS. A study of joint mobility in a normal population.  Ann Acad Med Singapore. 1999;  28 231-236
• 75 Sporton G. Natural selection and the audition process: dance science in context.  Research in Dance Education. 2010;  11 139-142
• 76 Subramanyam V, Janaki KV. Joint hypermobility in South Indian children.  Indian Pediatr. 1996;  33 771-772
• 77 Tofts LJ, Elliott EJ, Munns C, Pacey V, Sillence DO. The differential diagnosis of children with joint hypermobility: a review of the literature.  Pediatr Rheumatol Online J. 2009;  7 10.1186/1546-0096-1187-1181
• 78 Verbraecken J, Declerck A, Van de Heyning P, De Backer W, Wouters EFM. Evaluation for sleep apnea in patients with Ehlers-Danlos syndrome and Marfan: a questionnaire study.  Clin Genet. 2001;  60 360-365
• 79 Voermans NC, Knoop H, van de Kamp N, Hamel BC, Bleijenberg G, van Engelen BG. Fatigue is a frequent and clinically relevant problem in Ehlers-Danlos Syndrome.  Semin Arthritis Rheum. 2010;  40 (3) 267-274
• 80 Vougiouka O, Moustaki M, Tsanaktsi M. Benign hypermobility syndrome in Greek schoolchildren.  Eur J Pediatr. 2000;  159 628
• 81 Warren MP, Brooks-Gunn J, Fox RP, Holderness CC, Hyle EP, Hamilton WG, Hamilton L. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study.  Fertil Steril. 2003;  80 398-404
• 82 Wood PH. Is hypermobility a discrete entity?.  Proc R Soc Med. 1971;  64 690-692
• 83 Wyon MA, Deighan MA, Nevill AM, Doherty M, Morrison SL, Allen N, Jobson SJ, George S. The cardiorespiratory, anthropometric, and performance characteristics of an international/national touring ballet company.  J Strength Cond Res. 2007;  21 389-393
• 84 Zarate N, Farmer AD, Grahame R, Mohammed SD, Knowles CH, Scott SM, Aziz Q. Unexplained gastrointestinal symptoms and joint hypermobility: is connective tissue the missing link?.  Neurogastroenterol Motil. 2010;  22 e252-e278

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