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I find the term "hypermobility" or "hypermobile" to be unacceptable terms. Since "hypermobility" is a word meaning "excess motion" but is used to clinically describe the load vs deformation characteristics of a joint/joints within the body, the word has no meaning for the biomechanical characteristics it is being used to describe. Would you say that a bicycle frame, a golf club shaft or an automobile shock absorber is "hypermobile" when you are attempting to describe the ability of the bicycle frame, golf club or shock absorber to resist deformation upon externally applied loading forces?! I hope not. But, for some reasons, podiatrists are still using "hypermobility" or "hypermobile" to describe how easily a joint rotates under load, when in fact, the term they are using has no provision for the magnitude of applied load and only has a provision of "excess motion".
Stiffness or compliance are the proper terms that should be used to describe the load-deformation characteristics of any joint of the foot and lower extrmity since they are more definable, precise, quantifiable and unambiguous terms that are standardly used within the international biomechanics community. "Hypermobility" has none of these qualities. "Hypermobility" and "hypermobile" does not have a good definition, is not mathematically quantifiable, is ambiguous and if any word needs to be banned within podiatry, "hypermobile" or "hypermobility" should be the first ones to go since their continued use by biomechanics professors and teachers is holding back the profession from truly understanding the biomechanics of the foot and lower extremity.
Ah, I'd forgotten Dave's rather beautiful version of Romeo and Julliet
Quote:
Kevin K.--- Speaking to 1st ray--
It is only your name that offends me;--
you are yourself (a collection of bones and joints), not a name such as hypermobile.
What's hypermobile? It is neither hand, nor foot,
nor arm, nor face, nor any other part belonging to Modern Biomechanics.
Please, (for the sake of precise communication) use some other name!
What's in a name? you are still you, 1st ray, whatever name you are called.(you won't change)
so even though you where not called hypermobile you would still be our old friend, the 1st ray.
And retain the qualities we love you for
even without that title---hypermobile 1st ray:, so cast off that name;
And in place of that name, which really is not right for you,
Accept my more precise terminology. (1st Ray decreased dorsiflexion stiffness)
1st Ray.---to Kevin K
I understand your reasoning:
Please, rename me, "1st ray Decreased dorsiflexion stiffness", and I will be reborn in the true light
Never again will I be hypermobile.
Genius.
However. In defence of Hypermobile, and because I hang around with too many physio's.
Global hypermobility is a defined and recognised term in paediatrics, defined by the score on the Beighton scale.
The LLAS is rather more specific to podiatry and again refers to a score on a series of tests.
For starters, is it acceptable in thine eyes to refer to hypermobile in context of these criteria?
Your 4 criteria are definable, precise, quantifiable and unambiguous. I'd say that the LLAS meets all 4.
I agree. However, if we are to talk in terms of load/ deformation we need methods and instruments to reliably quantify these. How might the quantification of load/deformation characteristics of the foot and lower extremity impact on treatment strategies?
While the Beighton scale may define global "hypermobility", Kevin was talking about the use of the term hypermobility in association with the first ray of the foot. As far as I can recall, the Beighton scale does not use the 1st ray within it's criteria. Moreover, as far as I can recall, the Beighton scale uses among other factors the extended position of the knees and elbows. As such it doesn't really test the mobility of these joints at all, the knees might be "hyper-extended" yet have zero degrees of mobility from this position under physiologic loading; what about the flexion at these joints? What if these joints extend many degrees beyond zero, but only flex by 1 degree?
And does this measure the range of motion of the first ray? Moreover, does it standardise the loading applied to the joints to determine their deformation under this load?
To paraphrase what you said that I said in another thread: if I use a high velocity ram to extend your knee, I bet I could get 180 degrees of extension. It might smart a little.
Like you Robert, I too have spent a lot of time around physios who have a real fondness for "hypermobility", the word and the diagnosis. I must confess that I find it's usage as a diagnosis, as in "Benign Joint Hypermobility Syndrome" is every bit as irritating as pes planus. However, as inaccurate as it is, it undeniably serves a purpose in conveying an impression of a certain presentation between health professionals, as does pes planus.
If I am writing a letter of referral to a foot ankle consultant I always want to describe specific biomechanical issues as I see them. However, as they are quite good friends of mine, they have no problem telling me that they are not interested in my mumbo jumbo - "just give it to me in terms I can understand"
Terms like pes planus and hypermobile.
Does that mean that we should stop being accurate? No, we should always endeavour to move the profession forward. But should we do it at the risk of alienating ourselves from our fellow professionals who are comfortable with less accurate terminology?
Lets just say that I still give them the long winded, detailed, biomechanically more accurate version. Otherwise known as "******* in the wind"
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So,and I am only seeking knowledge , I can tell when a foot moves so easily as to be Hypermobile in the same way as I can feel if a foot is weak in say resisted dorsiflexion , how should i describe this ?
So,and I am only seeking knowledge , I can tell when a foot moves so easily as to be Hypermobile in the same way as I can feel if a foot is weak in say resisted dorsiflexion , how should i describe this ?
i would say in terms of stiffness in a direction.
Ie jacks test - dorsiflexion stiffness at the 1st MTPJ. Ideally in newtons but a sliding scale from more stiff to less stiff will work.
The other thing to consider is a mobile foot/joint non-weightbearing maybe unmobile or have increased stiffness weightbearing and of course have various degrees of stiffness during different stages of gait.
And does this measure the range of motion of the first ray? Moreover, does it standardise the loading applied to the joints to determine their deformation under this load?
To paraphrase what you said that I said in another thread: if I use a high velocity ram to extend your knee, I bet I could get 180 degrees of extension. It might smart a little.
No. But to be fair Kevin did not mention the first ray in the op...
I think that there is some repeatabilty data for LLAS...
To the best of my knowledge, wasn't the Beighton scale first originally developed as an epidemiological measure and not really a clinical assessment tool. In this case there was a convenient assumption made about normal end range of joint mobility. (statisticians love convenience and simple assumptions as it makes the statistical analysis work so much better even though the results may not really reflect any useful truth in terms of clinical importance) Therefore any significant motion past that, pre assumed, end range was called hypermobility. The force applied was generally only that which the subject themselves would apply during the prescribed action, i.e. extending knees and elbows, extending the thumb to the radius with a flexed wrist - well this chart describes it best
Therefore hypermobility was a convenient statistically efficient term never meant for clinical use (my reasoned conclusion )
Dave Smith
__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
To the best of my knowledge, wasn't the Beighton scale first originally developed as an epidemiological measure and not really a clinical assessment tool. In this case there was a convenient assumption made about normal end range of joint mobility. (statisticians love convenience and simple assumptions as it makes the statistical analysis work so much better even though the results may not really reflect any useful truth in terms of clinical importance) Therefore any significant motion past that, pre assumed, end range was called hypermobility. The force applied was generally only that which the subject themselves would apply during the prescribed action, i.e. extending knees and elbows, extending the thumb to the radius with a flexed wrist - well this chart describes it best
Therefore hypermobility was a convenient statistically efficient term never meant for clinical use (my reasoned conclusion )
Dear Dave
Hi, I beg to differ.
the 9 point flexibility scale is very useful.
when assessing joint motion one has to know where they lie in the 9 point scale.
0-1 is hypomobile, 2-3 is normal, greater than 4 is hypermobiles.
eg, if you have afootball front rower and he has a 9 point flexibility scale of zero and i was testing his external rotation of a shoulder where in normal people is 90 degrees.
if he demonstrated about 80 to 85 degrees that would be fine, it would be an aim in rehab to get to about this ROM
but
if we have a 9 out of 9 person say a dancer and they demonstrated only 80 degrees i woul be stretching them aiming for 95 or so. I would regard 95 as normal for them.
this is where it comes in handy.
This can be used in all joint examination and rehabilitation.
maybe instead of "hypermobility" we should discuss "ligamentous laxity"?
And this can be measured by the levels and severity of its effect on the soft tissues/ connective tissues.
Some types may be trauma induced and only affect specific areas. Others may be linked to diseases, for example, Ehlers- Danlos syndrome which affect the whole body.
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Dear Dave
Hi, I beg to differ.
the 9 point flexibility scale is very useful.
when assessing joint motion one has to know where they lie in the 9 point scale.
0-1 is hypomobile, 2-3 is normal, greater than 4 is hypermobiles.
eg, if you have afootball front rower and he has a 9 point flexibility scale of zero and i was testing his external rotation of a shoulder where in normal people is 90 degrees.
if he demonstrated about 80 to 85 degrees that would be fine, it would be an aim in rehab to get to about this ROM
but
if we have a 9 out of 9 person say a dancer and they demonstrated only 80 degrees i woul be stretching them aiming for 95 or so. I would regard 95 as normal for them.
this is where it comes in handy.
This can be used in all joint examination and rehabilitation.
Regards
Paul Conneely
[url]www.musmed.com.au
Paul, I don't deny it can be a useful tool if adapted in the right way but the epidemiological study only sought to establish the magnitude and distribution pattern of people with a certain compliance to their joints and not to apply any clinical significance to that compliance. Therefore the definition of hypermobile was used as a cut off point for inclusion/exclusion criteria and not as a definition of a pathological condition. The intent of the statistical study may have been to understand who and where and when in the population the clinical need might arise and this might lead people to think that there is a link between the pathology and hypermobility as defined in those terms. This I think would be a kind of logical fallacy - Robert!! get on the end of this one please.
In your example you have assigned a clinical significance to the scale and applied it in a useful way, which, by my guess, was likely to never have been intended by the designers but is still useful none the less.
Regards Dave
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Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
Last edited by David Smith : 12th July 2011 at 10:44 AM.
Reason: clarity
'Hypermobility' and 'ligamentous laxity' are well known and accepted terms that all medical/health disciplines understand ... why fix something that's not broken?
'Hypermobility' and 'ligamentous laxity' are well known and accepted terms that all medical/health disciplines understand ... why fix something that's not broken?
Lusnan:
If the term "hypermobility" is so well known and accepted by all health professions, then it should also have a definition that has a precise mechanical meaning which is useful for the podiatrist and clinician. What, then is your best definition for "hypermobility"? Let's make it even more simple, please define "first ray hypermobility".
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
If the term "hypermobility" is so well known and accepted by all health professions, then it should also have a definition that has a precise mechanical meaning which is useful for the podiatrist and clinician.
Like pes planus?...
Quote:
Let's make it even more simple, please define "first ray hypermobility".
Off the top of my head, I'd say decreased first ray dorsiflexion stiffness
If the term "hypermobility" is so well known and accepted by all health professions, then it should also have a definition that has a precise mechanical meaning which is useful for the podiatrist and clinician. What, then is your best definition for "hypermobility"? Let's make it even more simple, please define "first ray hypermobility".
Kevin
This all comes down to what you want ...
Do you want a terminology that most medical / health professionals can access?
Or, do you want a terminology that only podiatrists (and similar disciplines) can access?
Then again, do you want a terminology that is more physics/mechanics based?
If you want a terminology that the majority of people understand, then hypermobility is a good term IMHO.
Using terminology that a large section of medical/health professionals can not access is not the way forward.
I personally see hypermobility as a general term and that it's a large/excessive ROM of a joint; outside the ROM normally expected for that joint.
Do you want a terminology that most medical / health professionals can access?
Or, do you want a terminology that only podiatrists (and similar disciplines) can access?
Then again, do you want a terminology that is more physics/mechanics based?
If you want a terminology that the majority of people understand, then hypermobility is a good term IMHO.
Using terminology that a large section of medical/health professionals can not access is not the way forward.
I personally see hypermobility as a general term and that it's a large/excessive ROM of a joint; outside the ROM normally expected for that joint.
Lusnan:
As far as what I want, I want podiatry to be on the cutting edge of biomechanics.... not stuck back behind everyone else. Using your logic, I suppose we should still be talking about the oblique and longitudinal axes of the midtarsal joint also and that all posterior tibial tendon swelling is "posterior tibial tenosynovitis" rather than "posterior tibial tendon dysfunction" since we don't want to confuse anybody.
It seems to be your opinion, then, that we should we place a freeze on all new terminology since the majority of clinicians wouldn't understand a term if we made a change in terminology? I really could care less what other health practitioners think about the terminology...if the terminology does not the adequately describe the mechanical process occurring and can't be quantified, then, as far as I'm concerned, we should consider replacing it with terminology that can adequately describe the mechanical process and can be quantified. This is how progress is made in science and medicine.....by change!
As far as standard terminology, since when have the engineers, biomechanists and bioengineers used the term "hypermobility" to describe the load-deformation characteristics of joints? Maybe 15 to 20 years ago?? Why don't you just look at what the standard biomechanics terminology used for load-deformation characteristics over the last decade in the Journal of Biomechanics, Clinical Biomechanics, etc to see if they use "hypermobility" or rather use the term "stiffness" to describe this mechanical characteristic of all joints.
I like to be taking the lead down the best path, rather than waiting behind others content to follow the leader. Maybe your personality is different than mine.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I like to be taking the lead down the best path, rather than waiting behind others content to follow the leader. Maybe your personality is different than mine.
Ouch! If I was following the leader I wouldn't be challenging you, would I?
Correct me if I'm wrong (as I'm sure you will ), the title of this thread is 'Is 'hypermobile' an acceptable term?'
I understand your line of argument ... and agree with it, to some extent. However, we don't live in an ideal world (e.g. not everyone understands 'biomech speak') and, as we have to communicate with other professionals (so we can collaboratively treat patients), I'm sure you'll agree that it's a good idea to 'speak the same language'?
If this thread asked 'Is 'hypermobile' accurate terminology?' then I would agree with you wholeheartedly. It's all about semantics ...
Ouch! If I was following the leader I wouldn't be challenging you, would I?
Correct me if I'm wrong (as I'm sure you will ), the title of this thread is 'Is 'hypermobile' an acceptable term?'
I understand your line of argument ... and agree with it, to some extent. However, we don't live in an ideal world (e.g. not everyone understands 'biomech speak') and, as we have to communicate with other professionals (so we can collaboratively treat patients), I'm sure you'll agree that it's a good idea to 'speak the same language'?
If this thread asked 'Is 'hypermobile' accurate terminology?' then I would agree with you wholeheartedly. It's all about semantics ...
I still use the term "hypermobile" when I speak to podiatrists about the way the foot works mechanically. However, I point out that the term "hypermobile" is vague and ambiguous and doesn't clearly describe the load vs deformation characteristics of any of the joints of the lower extremity.
Therefore, I am trying to educate others as I gradually explain to them why they should ease themselves away from the the poor terminology to the more accurate and meaningful terminology using "stiffness". I believe this gradual replacement of "hypermobility" with "stiffness" will occur over time. In addition, I firmly believe that this terminology change will be for the overall good of the podiatry profession .....especially long after I am gone from this world.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Is there then a quantified definition for "stiffness" as opposed to "hypermobility"?
As we don't want Podiatry to stagnate, but do not want to see change merely for the sake of change.
PS- Isaacs & Spooner.. "stiffness" as relating to the feet. Though I am sure you have a long list of alternative terminology and measurements :)
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Is there then a quantified definition for "stiffness" as opposed to "hypermobility"?
As we don't want Podiatry to stagnate, but do not want to see change merely for the sake of change.
PS- Isaacs & Spooner.. "stiffness" as relating to the feet. Though I am sure you have a long list of alternative terminology and measurements :)
The point is, and this is the point I was making in my earlier posts here, we do not have base-line data for stiffness characteristics of the foot. So to talk about "reduced stiffness" or "increased stiffness" is a bit of a nonsense at the moment.
we do not have base-line data for stiffness characteristics of the foot.
Exactly!! So as we dont have a baseline, dispite a physic's definition and calculations, we cannot currently quantify the level of "stiffness" present. Just as we have no baseline for "hypermobility".
The question is, will there ever be a study carried out on an adequate number of participants, using acceptable methods, to set such a baseline?
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Duct tape is like The Force. It has a light side, a dark side, and it holds the universe together.
Exactly!! So as we dont have a baseline, dispite a physic's definition and calculations, we cannot currently quantify the level of "stiffness" present. Just as we have no baseline for "hypermobility".
The question is, will there ever be a study carried out on an adequate number of participants, using acceptable methods, to set such a baseline?
As I recall, Craig studied dorsiflexion stiffness of the hallux. I'm currently engaged in a study which, among other things, measures medial longitudinal arch stiffness. So, we can currently quantify levels of stiffness and future studies will provide baseline characteristics.
Is "hypermobile" acceptable terminology?
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), the title of this thread is 'Is 'hypermobile' an acceptable term?' 
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