By Alan Pocinki, MD
George Washington University Hospital
Joint laxity, or hypermobility, is a common feature of chronic fatigue syndrome (CFS). In fact, I believe that it is a characteristic feature of CFS. Peter Rowe and his colleagues at Johns Hopkins first reported the association of CFS with orthostatic intolerance and joint hypermobility in 1999 , and since then, I have not seen a single CFS patient who was not hypermobile, not one. Most hypermobile patients don’t look sick and, as a result, friends, colleagues and even doctors can be unsympathetic. Furthermore, they may spend years unsuccessfully searching for the cause of their chronic pain and other symptoms because many doctors are unfamiliar with hypermobility syndrome and its complex set of symptoms. Sound familiar?
The Beighton score is used to measure a person’s degree of hypermobility. One point is assigned for the ability to accomplish each of the following movements:
- bending your fifth finger back further than 90 degrees (1 point each side);
- bending your thumb forward to touch your forearm (1 point each side);
- hyper-extending your elbows and knees, that is, bending them beyond a straight line (1 point each joint, each side); and
- putting your palms flat on the floor without bending your knees (1 point).
Joint hypermobility syndrome (JHS) is defined primarily by the presence of painful lax joints (a Beighton score of four or more). The soft tissues (muscles and tendons) around lax joints are under constant strain from trying to stabilize the joints, and, inherently weak and lax themselves, are prone to tearing and spasm, leading to pain and stiffness of joints. Many such painful sites correspond to the tender points of fibromyalgia, and joint hypermobility is, in fact, known to predispose to the development of fibromyalgia.
The association of CFS with JHS is not surprising, if one considers the typical features of joint hypermobility syndrome (now considered identical to the hypermobile type of Ehlers-Danlos syndrome, or EDS): fatigue; muscle and joint pain; non-restorative sleep; and autonomic nervous system dysfunction, including orthostatic intolerance and post-exertional malaise. Like CFS patients, hypermobile patients are predisposed to more than a half-dozen different types of headaches. Like the acute onset of many cases of CFS, many hypermobility patients tolerate their symptoms well until an acute stress suddenly causes a significant decline in function. In CFS, the acute stress is often a viral infection, hence the association of sore throats and swollen glands with some cases of CFS. Cognitive impairment in hypermobility patients is likely the result of years of chronic pain, poor sleep and/or poor circulation, much as it is in CFS patients. CFS patients often have other symptoms, such as cold hands and feet, easy bruising and migraine headaches, which are typical of the hypermobility syndromes.
In recent years, I have found that the sleep studies of CFS patients and EDS patients are indistinguishable, both being primarily characterized by an increased number of sleep disruptions and a reduced amount of deep sleep. Autonomic nervous system testing shows virtually identical patterns of dysfunction in CFS patients and hypermobile EDS patients.
A basic treatment program for restoring autonomic balance in both groups of patients is:
- better sleep – reducing arousals and increasing deep sleep;
- adequate – really – pain control, including appropriate exercise,
- physical therapy;
- adequate salt and fluid;
- minimize emotional stresses; and
- conserve energy, rest when needed and don’t “push through” fatigue.
I think the most convincing argument of all that CFS is, in most patients, a hypermobility-associated dysauotnomia is that, despite very low published recovery rates, this treatment approach makes the majority of my CFS patients see some improvement!
 Rowe PC, Barron DF, Calkins H, Maumenee IH, Tong PY, Geraghty MT. Orthostatic intolerance and CFS associated with Ehlers-Danlos Syndrome. Journal of Pediatrics. Oct. 1999; 135(4):494-9. Link to abstract: http://www.ncbi.nlm.nih.gov/pubmed/10518084.
Dr. Pocinki graciously shared his guide to Joint Hypermobility and Joint Hypermobility Syndrome, which he wrote for patients to read and share with their own healthcare providers as a way of introducing the topic into the CFS conversation.
Dr. Pocinki is a general internist at George Washington University Hospital. His special interests include CFS and related conditions such as joint hypermobility and dysautonomia, as well as general preventive medicine. Dr. Pocinki is a clinical associate professor at George Washington University Medical Center and a fellow of the American College of Physicians. He has served the D.C. Medical Society in a variety of capacities, including as a member of its board of trustees, and was recently honored by the Medical Society with its Distinguished Service Award. He has also served as the president of the D.C. Society of Internal Medicine and was named the national Young Internist of the Year by the American Society of Internal Medicine in 1997. His patients recently voted him one of the “Top Primary Care Doctors in Washington” in a leading consumer magazine, and his peers have similarly voted him one of Washingtonian magazine’s “Top Doctors.”