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The purpose of the current study was to determine whether auditory prepulse inhibition (PPI) and/or prepulse facilitation (PPF) were altered in people with fibromyalgia (FM) when compared with controls. Eyeblink responses were recorded from 29 females with FM and 27 controls, while they listened to 3 blocks of auditory stimuli that delivered pulses with either PPI or PPF. Using a linear mixed model, our main findings were that there was a GROUP*CONDITION interaction (F4, 1084 = 4.01, P= .0031) indicating that the difference in amplitude between FM group and control group changed depending on the condition (PPI or PPF). Post hoc tests revealed no differences between the groups in response to PPI. The FM group showed a greater reactivity of response to the PPF conditioned stimulus than the control group did (t(39.7) = 2.03, P= .0494). Augmentation of PPF, as demonstrated by the FM group is thought to be linked to alterations in information processing mediated by an autonomically driven general orienting process. Activities that decrease autonomic drive or rebalance autonomic and parasympathetic tone such as vagal stimulation might be pursued as effective interventions for people with FM. Perspective This article presents evidence of preservation of neural circuitry that underpins response suppression and evidence of neural circuit disturbance mediated by autonomic drive-in people with FM. These results are important because intact circuitry underpins the effectiveness of therapies and may be harnessed, and rebalancing autonomic drive may be indicated.

Refereed/Peer-reviewed

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome—hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

Three studies examined humor and adjustment to stressful events. In Study 1, patients with fibromyalgia syndrome ( N = 22) reported on mental and physical adjustment, social interaction, and reappraisal of their illness. Dispositional humor was associated with reduced distress and fewer physical symptoms. Study 2 ( N = 109) examined undergraduates’ reports of stressful events. Dispositional, self-enhancing, affiliative, and self-defeating humor showed direct effects on distress, which were mediated by social interaction and reappraisal. Moreover, dispositional and aggressive humor showed stress-buffering effects. Study 3 ( N = 105) examined undergraduates’ adjustment to the September 11, 2001, attacks at 1 and 3 months postattack. At T1, affiliative humor showed a stress-buffering effect on distress. Social interaction mediated the relation of self-enhancing humor with reduced T1 distress, and mediated relations of aggressive and self-defeating humor with greater distress. Relations of T1 dispositional and self-defeating humor to changes in T2 distress were mediated by reappraisal.

Background Bodily self-consciousness depends on the coherent integration of sensory information. In addition to visual and somatosensory information processing, vestibular contributions have been proposed and investigated. Vestibular information seems especially important for self-location, but remains difficult to study. Methods This randomised controlled experiment used the MIRAGE multisensory illusion box to induce a conflict between the visually- and proprioceptively-encoded position of one hand. Over time, the perceived location of the hand slowly shifts, due to the fact that proprioceptive input is progressively weighted more heavily than the visual input. We hypothesised that left cold caloric vestibular stimulation (CVS) augments this shift in hand localisation. Results The results from 24 healthy participants do not support our hypothesis: CVS had no effect on the estimations with which the perceived position of the hand shifted from the visually- to the proprioceptively-encoded position. Participants were more likely to report that their hand was ‘no longer there’ after CVS. Taken together, neither the physical nor the subjective data provide evidence for vestibular enhanced self-location.

BackgroundThe pain threshold is traditionally conceptualised as a boundary that lies between painful and non-painful events, suggesting a reasonably stable relationship between stimulus and response. In two previous experiments, participants received laser stimuli of various intensities and rated each stimulus on the Sensation and Pain Rating Scale (SPARS), which includes ranges for rating painful and non-painful events and clearly defines the presumed boundary between them. In the second experiment, participants also provided ratings on the conventional 0-100 Numerical Rating Scale for pain (NRS) and a new rating scale for non-painful events. Those data showed the SPARS to have a curvilinear stimulus-response relationship, reflecting that several different intensities may be rated as painful and non-painful in different trials. This suggests that participants were uncertain about painfulness over a range of intensities and calls into question the idea of a boundary between non-painful and painful events. The current study aimed to determine the number of different stimulus intensities across which each participant provided ‘painful’ and ‘non-painful’ reports in different trials.MethodsWe undertook novel exploratory analyses on data from the aforementioned two experiments (n = 19, 11 female, 18-31 years old; n = 7, 5 female, 21-30 years old). We used the binomial test to formally determine the width of this ‘zone of uncertainty’ about painfulness, using ratings on the SPARS and the comparator scales, and data visualisation to assess whether trial-to-trial change in stimulus intensity influences ratings.ResultsWe found that the width of the zone of uncertainty varied notably between individuals and that the zone was non-continuous for most participants. Plots of group-level data concealed the inter-individual variability apparent in the individual plots, but still showed a wide zone of uncertainty on both the SPARS and the NRS, but a narrow zone on the scale for non-painful events. There was no evidence that trial-to-trial change in stimulus intensity influenced ratings.ConclusionsThe variability revealed by this study has important design implications for experiments that include initial calibration of repeatedly delivered stimuli. The variability also stands to inflate the size of sample that is required for adequate statistical powering of experiments, and provides rationale for the use of statistical approaches that account for individual variability in studies of pain. Finally, the high variability implies that, if experimental stimuli are to be used in clinical phenotyping, many trials may be required to obtain results that represent a single patient’s actual response profile.

In experiments on pain, participants are frequently exposed to nonpainful and painful stimuli; however, the conventional pain-rating scales lack a nonpainful range and a clear point of transition from nonpainful to painful events. The Sensation and Pain Rating Scale (SPARS) assesses the full stimulus intensity range, extending from no sensation (rating: –50) to worst pain imaginable (rating: +50), and it explicitly identifies pain threshold (rating: 0). Here, we tested the SPARS in 2 experiments by using laser heat stimuli to establish its stimulus–response characteristics (Experiment 1, N = 19, 13 stimulus intensities applied 26 times each across a 1–4 J range), and compared it to 0 to 100 scales that assess nonpainful (0: no sensation, 100: pain) and painful (0: no pain, 100: worst pain imaginable) events (Experiment 2, N = 7, 9 stimulus intensities applied 36 times each across a 1.5–4.5 J range). Despite high inter- and intraindividual variations, we found a reasonably consistent curvilinear stimulus–response relationship (the curve flattens around pain threshold), with stable response characteristics across the range of the scale. The SPARS ratings transformed to a 0 to 100 range tended to be lower than the 0 to 100 pain rating scale in the noxious stimulus intensity range and greater than the 0 to 100 nonpainful sensation scale in the non-noxious stimulus range, likely reflecting differences in scale dimensionality. The SPARS overcomes limitations in scale range inherent to conventional pain rating scales. As such, it is well suited to experimental studies that must quantify a wider range of perceptual intensity or distinguish between painful and nonpainful events. Perspective This article presents the stimulus–response characteristics of a new scale designed to allow participants to rate a range of nonpainful and painful stimuli. The scale could be useful for research that involves exposing participants to a range of stimulation intensities or requires a clear distinction between nonpainful and painful events.

A classical conditioning framework is often used for clinical reasoning about pain that persists after tissue healing. However, experimental studies demonstrating classically conditioned pain in humans are lacking. The current study tested whether non-nociceptive somatosensory stimuli can come to modulate pain threshold after being paired with painful nociceptive stimuli in healthy humans. We used a differential simultaneous conditioning paradigm in which one non-painful vibrotactile conditioned stimulus (CS+) was simultaneously paired with an unconditioned painful laser stimulus (US), while another vibrotactile stimulus (CS-) was paired with a non-painful laser stimulus. After acquisition, at-pain-threshold laser stimuli were delivered simultaneously with a CS+ or CS- vibrotactile stimulus. The primary outcome was the percentage of at-threshold laser stimuli that were reported as painful. The results were as expected: after conditioning, at-threshold laser trials paired with the CS+ were reported as painful more often, as more intense, and as more unpleasant than those paired with the CS-. This study provides new evidence that pain thresholds can be modulated via classical conditioning, even when the stimulus used to test the threshold can not be anticipated. As such, it lays a critical foundation for further investigations of classical conditioning as a possible driver of persistent pain. publisher: Elsevier articletitle: Pain by Association? Experimental Modulation of Human Pain Thresholds Using Classical Conditioning journaltitle: The Journal of Pain articlelink: http://dx.doi.org/10.1016/j.jpain.2016.06.012 content_type: article copyright: © 2016 by the American Pain Society ispartof: The Journal of Pain vol:17 issue:10 pages:1105-1115 ispartof: location:United States status: published

Generalized joint hypermobility (GJH) and joint hypermobility syndrome (JHS) are gaining increased attention as potential sources of pain and injury. The aims of this study were to evaluate prevalence of GJH and JHS and to determine whether musculoskeletal injuries and symptoms commonly attributed to GJH and JHS were more common within a "healthy" college student population. The study involved a convenience sample of 267 college and graduate students, aged 17-26. GJH was assessed using the Beighton score with a cutoff of 5/9, while JHS was assessed using the Brighton criteria. Injury history and symptoms were assessed by recall. Prevalence of GJH was 26.2 % overall (females 36.7 %, males 13.7 %). Prevalence of JHS was 19.5 % overall (females 24.5 %, males 13.7 %). Injury rates were not significantly different for individuals who had GJH vs. those who did not have GJH. Individuals with JHS were significantly more likely to have had sprains, back pain, and stress fractures. Symptoms were no different between those with GJH and those who did not have GJH. However, individuals with JHS were significantly more likely to report clumsiness, easy bruising, and balance problems than those who did not have JHS. GJH and JHS were relatively common in this healthy college student population; GJH was not associated with increased incidence of injury or symptoms commonly attributed to JHS, but JHS was associated with increased incidence of some injuries and symptoms.

OBJECTIVE : Associative learning has been proposed as a mechanism behind the persistence of pain after tissue healing. The simultaneous occurrence of nociceptive and non-nociceptive input during acute injury mimics the pairings thought to drive classical conditioning effects. However, empirical evidence for classically conditioned allodynia is lacking. We aimed to manipulate pain thresholds with a classical conditioning procedure that used non-nociceptive somatosensory stimuli as conditioned stimuli (CS) and nociceptive stimuli as unconditioned stimuli. We also explored the influence of gender, depression, anxiety, negative affect, and pain catastrophizing on the main manipulation. DESIGN : Thirty-four healthy humans participated in a differential classical conditioning procedure that used vibrotactile stimulations at two different locations as CS. In an acquisition phase, CS+ was paired with painful thermal stimulation, and CS- with nonpainful thermal stimulation. Heat pain threshold was assessed during paired heat-CS trials before and after acquisition. A 2 (time: 1 and 2) x 2 (condition: CS+ and CS-) repeated-measures analysis of variance compared pain thresholds before and after acquisition. Exploratory analyses explored the influence of gender, depression, anxiety, negative affect, and pain catastrophizing. Postexperiment questions investigated participants' awareness of the contingencies employed. RESULTS : The classical conditioning procedure did not alter pain thresholds. Exploratory analyses did not reveal any influence of individual differences. Thirty of the 34 participants were unaware of the contingencies between stimuli. CONCLUSIONS : The results of this study provide no evidence that allodynia can be induced in healthy humans using a classical conditioning procedure with simultaneous timing.

New insights into the phenotype of Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome-hypermobile type (hEDS) have raised many issues in relation to classification, diagnosis, assessment, and treatment. Within the multidisciplinary team, physical therapy plays a central role in management of individuals with hypermobility related disorders. However, many physical therapists are not familiar with the diagnostic criteria, prevalence, common clinical presentation, and management. This guideline aims to provide practitioners with the state of the art regarding the assessment and management of children, adolescents, and adults with JHS/hEDS. Due to the complexity of the symptoms in the profile of JHS/hEDS, the International Classification of Functioning, Disability and Health (ICF) is adopted as a central framework whereby the umbrella term of disability is used to encompass functions, activities and participation, as well as environmental and personal factors. The current evidence-based literature regarding the management of JHS/hEDS is limited in size and quality and there is insufficient research exploring the clinical outcomes of a number of interventions. Multicenter randomized controlled trials are warranted to assess the clinical and cost-effectiveness of interventions for children and adults. Until further multicenter trials are conducted, clinical decision-making should be based on theoretical and the current limited research evidence. For all individuals diagnosed with JHS/hEDS, international consensus and combined efforts to identify risk profiles would create a better understanding of the pathological mechanisms and the potential for optimizing health care for affected individuals. (C) 2017 Wiley Periodicals, Inc

Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration.Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure).We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was 'non-informative' (pooled AUC = 0.59 (0.55-0.63), n = 1153) and 'acceptable' for discriminating disability outcomes (pooled AUC = 0.74 (0.66-0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was 'poor' for discriminating pain outcomes (pooled AUC = 0.69 (0.62-0.76), n = 360), 'acceptable' for disability outcomes (pooled AUC = 0.75 (0.69-0.82), n = 512), and 'excellent' for absenteeism outcomes (pooled AUC = 0.83 (0.75-0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only.LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict.PROSPERO international prospective register of systematic reviews registration number CRD42015015778 .

Background Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration. Methods Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure). Results We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was ‘non-informative’ (pooled AUC = 0.59 (0.55–0.63), n = 1153) and ‘acceptable’ for discriminating disability outcomes (pooled AUC = 0.74 (0.66–0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was ‘poor’ for discriminating pain outcomes (pooled AUC = 0.69 (0.62–0.76), n = 360), ‘acceptable’ for disability outcomes (pooled AUC = 0.75 (0.69–0.82), n = 512), and ‘excellent’ for absenteeism outcomes (pooled AUC = 0.83 (0.75–0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only. Conclusions LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict. Systematic review registration PROSPERO international prospective register of systematic reviews registration number CRD42015015778. Electronic supplementary material The online version of this article (doi:10.1186/s12916-016-0774-4) contains supplementary material, which is available to authorized users.

Background Joint hypermobility syndrome (JHS) is one of the most common inherited connective tissue disorders. It causes significant pain and disability for all age groups, ranging from developmental delay among children to widespread chronic pain in adults. Experts in JHS assert that the condition is under-recognized and poorly managed. Purpose The aim of this study was to assess US physical therapists' knowledge about JHS compared with other causes of widespread pain and activity limitations: fibromyalgia, juvenile rheumatoid arthritis and adult rheumatoid arthritis. Methods Cross-sectional, Internet-based survey of randomly selected members of the American Physical Therapy Association and descriptive statistics were used to explore physical therapists' knowledge about JHS, fibromyalgia, juvenile rheumatoid arthritis and adult rheumatoid arthritis, and chi square was used to compare knowledge about the different conditions. Results The response rate was 15.5% (496). Although 36% recognized the Beighton Scale for assessing joint hypermobility, only 26.8% of respondents were familiar with the Brighton Criteria for diagnosing JHS. Few respondents (11–19%) realized that JHS has extra-articular features such as anxiety disorder, fatigue, headache, delayed motor development, easy bruising and sleep disturbance. Physical therapists working in environments most likely to see patients with JHS underestimated the likely prevalence in their patient population. Conclusions The results suggest that many physical therapists in the United States are not familiar with the diagnostic criteria, prevalence or common clinical presentation of JHS. Copyright © 2014 John Wiley & Sons, Ltd.

Fear of movement may contribute to functional limitations and loss of well-being among individuals with fibromyalgia (FM). The objectives of this study were to assess factors contributing to movement-related fear and to explore relationships among these factors, function and wellness, in a widespread population of people with FM. This was an internet survey of individuals with FM. Respondents completed a battery of surveys including the Fibromyalgia Impact Questionnaire--Revised (FIQR), Tampa Scale of Kinesiophobia (TSK), Activities-Specific Balance Confidence Scale (ABC), Primary Care Posttraumatic Stress Disorder screen (PC-PTSD), Vertigo Symptom Scale (VSS-SF), a joint hypermobility syndrome screen (JHS), and screening questions related to obsessive-compulsive personality disorder (OCPD), physical activity, work status, and demographics. Analysis included descriptive statistics, Pearson product-moment correlations, and linear regression. Over a 2-year period, 1,125 people (97.6 % female) completed the survey battery. Kinesiophobia was present in 72.9 % of the respondents, balance confidence was compromised in 74.8 %, PTSD likely in 60.4 %, joint hypermobility syndrome likely in 46.6 %, and OCPD tendencies in 26.8 %. The total FIQR and FIQR perceived function subscores were highly correlated (p 0.0005, r 0.4) with pain, kinesiophobia, balance confidence, and vertigo. Reported activity level had poor correlation (r 0.25) with all measured variables. Pain, ABC, VSS, and TSK predicted FIQR and FIQR-pf, explaining 65 and 48 % of the variance, respectively. Kinesiophobia, balance complaints, vertigo, PTSD, and joint hypermobility were common in this population of people with FM. Sources of movement-related fear correlated to overall wellness and perceived function as measured by the FIQR and FIQR-pf.

Factors contributing to movement-related fear were assessed by Russek, et al. 2014 for subjects with Fibromyalgia (FM) based on the collected data by a national internet survey of community-based individuals. The study focused on the variables, Activities-Specific Balance Confidence scale (ABC), Primary Care Post-Traumatic Stress Disorder screen (PC-PTSD), Tampa Scale of Kinesiophobia (TSK), a Joint Hypermobility Syndrome screen (JHS), Vertigo Symptom Scale (VSS-SF), Obsessive-Compulsive Personality Disorder (OCPD), Pain, work status and physical activity dependent from the “Revised Fibromyalgia Impact Questionnaire” (FIQR). The study presented in this paper revisits same data with a Bayesian analysis where appropriate priors were introduced for variables selected in the Russek’s paper.

It is now well understood that to make effective decisions based on patient data physical therapists need to know the psychometric properties of the clinical measurements they use. What may not be as well understood is that the calculation of various reliability coefficients often reported in the literature are not all based on the same statistical concepts. This technical note explores how variability among subjects affects interpretation of various reliability coefficients and how different coefficients, used with the same data, can lead to paradoxical interpretation. J Orthop Sports Phys Ther. 2004; 34(6):341–349. doi:10.2519/jospt.2004.0797

Background and Purpose. Clinical databases will gain importance as physical therapists need to determine the effectiveness and justify the expense of treatment. Obstacles impeding participation in standardized data collection need to be identified and addressed to construct high-quality databases. Subjects. Subjects were clinicians involved in patient care in a multisite physical therapy/occupational therapy practice that had initiated a standardized data collection program. Methods. Questionnaires, asking about participation in the data collection project, were distributed to participating clinics. Factor analysis identified attitudes toward standardized data collection. Relationships between efforts to learn standardized methods, attitudes, clinic and clinician characteristics, and levels of participation in the project were investigated. Results. Most respondents (66%) had made some effort to learn the standardized procedures. Five attitudes were identified: inconvenience, acceptance of operational definitions, automation, paperwork, and training. Conclusion and Discussion. Inconvenience of data collection and training in standardized methods need to be addressed to construct large, high-quality databases.

Joint hypermobility syndrome (JHS) is one of the most common inherited connective tissue disorders. It causes significant pain and disability for all age groups, ranging from developmental delay among children to widespread chronic pain in adults. Experts in JHS assert that the condition is under-recognized and poorly managed.The aim of this study was to assess US physical therapists' knowledge about JHS compared with other causes of widespread pain and activity limitations: fibromyalgia, juvenile rheumatoid arthritis and adult rheumatoid arthritis.Cross-sectional, Internet-based survey of randomly selected members of the American Physical Therapy Association and descriptive statistics were used to explore physical therapists' knowledge about JHS, fibromyalgia, juvenile rheumatoid arthritis and adult rheumatoid arthritis, and chi square was used to compare knowledge about the different conditions.The response rate was 15.5% (496). Although 36% recognized the Beighton Scale for assessing joint hypermobility, only 26.8% of respondents were familiar with the Brighton Criteria for diagnosing JHS. Few respondents (11-19%) realized that JHS has extra-articular features such as anxiety disorder, fatigue, headache, delayed motor development, easy bruising and sleep disturbance. Physical therapists working in environments most likely to see patients with JHS underestimated the likely prevalence in their patient population.The results suggest that many physical therapists in the United States are not familiar with the diagnostic criteria, prevalence or common clinical presentation of JHS.

The purpose of current study was to assess postural control and balance self-efficacy in people with fibro-myalgia syndrome [FMS]. Thirty-two females with FMS completed the Activity-specific Balance Confidence Scale, Berg Balance test, NeuroCom Balance Master sensory-organization test, and limits of stability. There was a high prevalence of reported falls and a low mean score on the Activity-specific Balance Confidence Scale. A significant number of subjects scored below the population norm fifth percentile score on the sensory-organization test composite, visual, and vestibular sections. Preliminary evidence suggests that women with FMS may present with deficits in postural control, sensory organization, and balance self-efficacy.

Background and Purpose. The purpose of this case report is to present the examination, evaluation/diagnosis/prognosis, intervention, and outcome of a patient with hypermobility syndrome (HMS). Hypermobility syndrome has been widely recognized in the rheumatology literature, but it has seldom been discussed in the orthopedic literature and has only recently been described in the physical therapy literature. The signs and symptoms of HMS are common among patients seen in orthopedic physical therapy clinics; however, the HMS may be overlooked while treating individual joints or tissues causing pain. Case Description. The patient was a 28-year-old woman with complaints of chronic, multiple-joint pain. After years without a diagnosis, a rheumatologist had recently diagnosed her as having HMS. Outcomes. Following intervention that emphasized patient education and activity modification, the patient's complaints decreased. Discussion. Recognition of HMS underlying common orthopedic problems may facilitate appropriate patient education and management.

Established cell lines are now widely used in experiments concerning vascular smooth muscle (VSM) function; however, considerable evidence suggests that cultured VSM cells are functionally different from VSM cells in intact blood vessels. In order to test the hypothesis that calcium signaling mechanisms are comparable in these two preparations, we developed a new method for high resolution 45Ca efflux studies in A7r5 cells. Briefly, this method involves plating cells in the lumen of a tubular glass efflux chamber and, after loading the cells with 45Ca, perfusing the chamber with a physiological saline solution and collecting the effluent. Using this method we found that the plasma membrane in cultured cells is not rate limiting for calcium efflux, since the efflux curves from both permeabilized and intact cells are kinetically the same. We also found the plasma membrane is not rate limiting in whole aortic segments by using a depolarizing solution followed by dihydropyridine solution. Thus, we demonstrated that the data obtained from cells or tissues with intact membranes reveal information about the intracellular stores (sarcoplasmic reticulum and mitochondria). Combining efflux data with a detailed kinetic model of cellular Ca transport allows least-squares estimation of the rate constants for release and uptake of Ca2+ by intracellular stores with a high degree of confidence (CV < 25%) as well as the Ca2+ contents and transmembrane fluxes associated with these stores. Quantitative comparison of results obtained from A7r5 cells with those we previously obtained for rabbit aortic segments reveals marked similarities and suggests that A7r5 cells serve as excellent model experiments for VSM cell Ca2+ homeostasis.

Examination and treatment of a patient with hypermobility syndrome [Physical Therapy 2000;80(4):386-98]

Several lines of evidence, including the reported ability of calcium channel blockers to prevent atherogenesis in cholesterol-fed rabbits, suggest that calcium mediates one or more of the pathologic changes in atherosclerosis. Moreover, it has long been known that calcium accumulates in atherosclerotic blood vessels. To test the hypothesis that a substantial fraction of this accumulated calcium is intracellular and to identify possible causes of this accumulation, calcium fluxes and contents were determined in aortic segments from cholesterol-fed rabbits and age-matched controls. A new method, based on 45Ca efflux experiments and computer-assisted kinetic analysis, was used to measure intracellular and extracellular calcium contents (nmol calcium/g wet wt tissue) and fluxes. Total intracellular calcium increased from 269 +/- 11.6 to 1,300 +/- 352 nmol/g in cholesterol-fed animals compared with controls (p less than 0.01). This change was sufficient to account for the observed increase in total tissue calcium from 4,190 +/- 211 to 5,240 +/- 477 nmol/g (p less than 0.05). Thus, the fraction of tissue calcium that is intracellular increased significantly from 0.065 +/- 0.006 to 0.223 +/- 0.048 (p less than 0.01) in experimental atherosclerosis. In addition, the data were quantitatively consistent with the hypothesis that these changes are brought about by a 4.8-fold increase in the plasma membrane calcium permeability of aortic smooth muscle cells. These results provide evidence that increased intracellular calcium is a possible mediator of cholesterol-induced atherogenesis.