Beyond the Joints: Screening for Autonomic and Gastrointestinal Comorbidities in HSD Patients
For decades, Joint Hypermobility Syndrome (JHS) was viewed primarily as a musculoskeletal issue characterized by loose joints and chronic pain. However, with the recognition of Hypermobility Spectrum Disorders (HSD) and hypermobile Ehlers-Danlos Syndrome (hEDS), we now understand these conditions are complex, multi-systemic connective tissue disorders.
For physical therapists, this shift in understanding is critical. The chronic pain, fatigue, and poor recovery seen in our hypermobile patients are often driven not by isolated joint instability, but by systemic issues like dysautonomia (Autonomic Nervous System dysfunction) and gastrointestinal (GI) distress. Ignoring these comorbidities severely limits the success of traditional stabilization exercises.
The Autonomic Challenge: Screening for POTS
One of the most common and functionally limiting comorbidities in the HSD/hEDS population is Dysautonomia, a blanket term for disorders of the Autonomic Nervous System (ANS). The ANS regulates involuntary functions like heart rate, blood pressure, digestion, and temperature control. A specific, frequent presentation is Postural Orthostatic Tachycardia Syndrome (POTS).
In patients with POTS, standing up causes an excessive increase in heart rate without a significant drop in blood pressure. This results in symptoms that are highly relevant to rehabilitation:
- Dizziness or Lightheadedness: Especially when transitioning from sitting/lying to standing.
- Chronic Fatigue: Often debilitating and unresponsive to rest.
- Tachycardia: A racing heart, particularly upon upright posture.
- “Brain Fog”: Difficulty concentrating.
Essential Screening Questions for POTS:
A PT should incorporate these questions into the initial intake:
- Do you often feel dizzy or lightheaded when you stand up quickly? Have you ever fainted or nearly fainted?
- Do you experience a rapid or pounding heart rate (palpitations) when you are standing still?
- How often do you feel completely exhausted, even after sleeping?
While only a cardiologist can diagnose POTS, the physical therapist can perform a simple Standing Heart Rate Test (or a brief “Poor Man’s Tilt Table Test”). Assess resting heart rate (HR) and blood pressure (BP) in supine, then immediately upon standing, and again after two, five, and ten minutes. An increase in HR of 30 bpm or more (or 40 bpm in adolescents) from supine to standing, sustained after 10 minutes, warrants referral.
The Gut Connection: Screening for GI Issues
The same faulty collagen and connective tissue that causes joint laxity affects the lining and motility of the gastrointestinal tract. This can lead to a host of functional GI problems that directly influence pain, inflammation, and energy levels, making exercise intolerance worse.
Common GI symptoms include:
- Reflux/GERD: Due to laxity of the esophageal sphincter.
- Gastroparesis: Delayed stomach emptying, causing nausea and early satiety.
- Irritable Bowel Syndrome (IBS): Chronic constipation, diarrhea, or alternating patterns.
Essential Screening Questions for GI Distress:
- Do you experience frequent acid reflux, nausea, or vomiting?
- Do you suffer from chronic constipation or diarrhea that is not resolved by diet changes?
- Are there many foods you cannot tolerate, or do you feel full after only a few bites?
Identifying these symptoms helps the therapist modify the treatment plan. High-impact exercises can exacerbate GI symptoms, and deep, stabilizing core work may be difficult if the patient is experiencing chronic abdominal discomfort or bloating.
The PT’s Role: Recognizing and Referring
A Joint hypermobility physiotherapist Gold Coast role is not to diagnose these internal medical conditions, but to recognize the pattern and facilitate the right referral. Recognizing these symptoms allows the PT to:
- Modify Exercise: Substitute high-impact activities with recumbent exercises (cycling, swimming) to manage orthostatic intolerance.
- Prioritize Relaxation: Implement diaphragmatic breathing and nervous system regulation exercises before starting intensive stability work, helping to calm the overactive ANS.
- Validate Symptoms: Acknowledging the multi-system nature of the condition validates the patient’s experience, which is crucial for building trust and improving compliance with rehabilitation.
