Hypermobility, pelvic pain, and pelvic organ prolapse: a cluster of symptoms

Joint hypermobility syndrome (JHS) describes an abnormal increase in the range of movement in different joints of the body. JHS is a hereditary condition and people often experience recurrence of sprains, strains, bruising, and/or dislocations as a result. Those who have the condition often notice its effects in their fingers, knees, or elbows. When the soft tissues are more lax and mobile, however, the same pliability applies to the skin and the support system of our internal organs. Furthermore, Ehlers-Danlos syndrome (EDS) refers to the group of disorders that consequently affect the different organs. The only proper way to diagnose EDS is to be evaluated in an extensive history-taking and physical examination that includes orthopedic, neurologic, and dermatologic analysis, to name a few.

In their article, Colombi, Dordoni, Chiarelli, and Ritelli (2015) discuss the clinical spectrum of JHS and EDS. The spectrum expands to include the skin, joints (including flat footedness, ability to do the splits, bending the thumb to the forearm, bending and touching hands to the floor), muscles, gastrointestinal system, urogenital system, cardiovascular system and neuropsychiatric symtoms (fatigue, disturbed sleep, anxiety, etc.).

In addition to understanding the breadth of the disease, recognizing the co-mobilities is beneficial to properly diagnosing JHS and/or EDS.

There have been several studies that show the correlation between hypermobility and gastrointestinal symptoms, including irritable bowel syndrome (IBS). One study found that those who suffer from the constipation sub-type of IBS show much higher symptoms of JHS. This could be due to the biomechanics of the connective tissue that lead to slower transit, or, movement, in the colon, also known as colonic inertia (Zweig, Schindler, Becker, van Maren, Pohl, 2018).

In another study by Castori, Morlino, Pascolini, Blundo, and Grammatico (2015), the gastrointestinal indicators of JHS/EDS were broken into structural anomalies (hernias, organ prolapse, intestinal intussusceptions) and functional alterations (recurrent abdominal pain, constipation/diarrhea, reflux).  

Postural tachycardia syndrome (POTS) and other cardiovascular conditions both at rest and sudden positions changes (orthostatic) has been shown to be more prevalent in those with EDS (Roma, Marden, Wandele, Fancomano, Rowe, 2018).

As with many others who have chronic conditions, recognizing the psychosocial function of a patient with JHS/EDS is highly important because people with these conditions generally do not respond to typical biomedical approaches (Baeza-Velasco, Bulbena, Polanco-Carrasco, Jussaud, 2018).

There is evidence that women with JHS could be more prone to pelvic organ prolapse. Pelvic organ prolapse occurs when one or more pelvic organs, which includes the bladder, urethra, uterus, vagina, rectum, and small bowel, droop or descend into the vaginal opening. Additionally, many women with JHS/EDS tend to suffer from pelvic floor muscle tightness and shortening, causing pain with the use of tampons, intercourse and/or in a pelvic exam. This could be explained by the fact that hypermobility in other parts of body causes the pelvic muscles to tense up for better postural support.

The physical therapists who specialize in pelvic floor rehabilitation have the expertise to perform a complete evaluation of the mechanical and musculoskeletal systems, enabling them to better understand complex diagnoses for conditions like JHS and EDS. Their skills allow them to create a sustainable, effective treatment plan that aims to make everyday life more functional and pain more manageable.

Diastasis of Rectus Abdominis Muscles

Diastasis of the rectus abdominis muscles (DRA), or separation of the abdominal wall, is different from abdominal or umbilical hernia.  The linea alba, or the connective tissue that connects the rectus abdominis (8 packs), thins which leads to laxity of the abdominal muscles.

It is seen in men and women and despite the lack of supportive evidence, it is considered to be a significant contributor to chronic back pain .  In the study by Doubkova et al.(2018), 77% men and 45% of women with DRA had experienced low back pain.

Also, pelvic related issues, such as incontinence, pain and organ prolapse, have also been shown to be related to poor abdominal support.  In this article more than 66% of women (average age of 52) who presented with DRA also had support related pelvic floor dysfunction.

When the abdominal muscles function optimally, they support the abdominal organs, maintain proper posture and create stability for the pelvis and spine.  This perfect design achieves the proper abdominal pressure that is needed to maintain bowel/bladder function and preserve continence with higher impact tasks such as lifting, jogging, coughing, sneezing and laughing.   While there is conflicting reports and minimal scientific support of the direct connection between DRA and low back pain and pelvic issues, clinically and functionally speaking, these symptoms are often seen along with the presence of DRA.

DRA is most commonly associated with pregnancy and some believe that up to 100% of pregnant women experience some degree of abdominal separation during pregnancy.   Even though most women show improvement in their pelvic related issues in the early postpartum phase, one third of women who experienced urinary incontinence immediately postpartum and improved, experience urinary incontinence 5-7 years later.  This was explained to be related to poor movement strategies that they adapt to due to poor abdominal support.  Read more here.

In recent years, there has been a flood of information (not all correct) on what to do about the abdominal bulging that many men and women experience with movement and/or activities that increases the abdominal pressure.   There have been many exercise regiments that mainly focus on closure or approximation of the DRA.

In this study available treatment methods were analyzed and it was concluded that there is not one method that showed significant change in the signs and symptoms of DRA.   Tension of the linea alba is needed to transfer force across the abdominal muscles in presence of tasks that increased intra-abdominal pressure (i.e. jogging, lifting, coughing, or sneezing). Ultrasound imaging has shown that when the deepest layer of abdominal muscles activate before a task is done, the proper tension is created and therefore less stress is transferred to low back and pelvic organs.  This translates to improvement in symptoms of low back pain, pelvic pain, incontinence and pelvic organ prolapse.

Many experienced pelvic floor physical therapists utilize their musculoskeletal expertise along with state of the art technology (real time ultrasound) to train men and women  who suffer from pelvic related issues or those who may not have responded to traditional low back rehab protocols.