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Beighton's Criteria For Ligamentous Laxity

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Em3, Aug 18, 2008.

  1. Em3

    Em3 Member


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    Hi there,

    I've recently had a very lively and informative thread about the dynamic Hick's test and I was wondering if I could get some help about another question of mine.

    I've been reading about ligamentous laxity and the related dysfunction, disorders and such.
    What I'm curious about is "Beighton's 9-point criteria".
    How often is this used in practice? It seems like a sound enough theory that if a person has x-number of hypermobile joints then they have ligamentous laxity but is the test really necessary or of much value when conducting a biomechanical evaluation of a patient?

    I very much look forward to some responses!

    Emma
     
    Last edited by a moderator: Aug 18, 2008
  2. DaVinci

    DaVinci Well-Known Member

    I do not know of anyone that uses Beightons clinically. It is a widely accepted norm for assessing the hypermobility syndromes and I do understand a number of people who have problems with it, but I not sure what those problems are.

    Even though I do not use the scale, I do use aspects of it if hypermobility is suspected (eg the test with the thumb)
     
  3. Admin2

    Admin2 Administrator Staff Member

    Attached Files:

  4. I use the Beighton scale routinely in Paediatrics. It is a useful objective benchmark and useful for assessing whether hypermobility in the feet / ankles is local or part of a global condition.

    I also use a modified version for assessing lower limb hypermobility.

    Like any such assessment tool it is flawed, however it does provide a more objective and in a gross sense, repeatable assessment tool which can be easily used by any other practitioner.

    Oh and just to clarify admins post, its one point per side. So if the right knee is hyperextendable and the left not thats one point.

    Regards
    Robert
     
  5. David Smith

    David Smith Well-Known Member

    Emma

    You wrote
    In my opinion
    If you were looking to classify a certain person into a certain group for the purposes of categorization and filing then this may be useful. Especially in large organizations like the NHS. This may be for juvenilles that may require monitoring for disease progression thru life for example. The screening process of test score classification would enable targeted intervention protocols and resources.

    However, in terms of physical treatment that might be given by the podiatrist, if someone has hypermobile joints, where the term hypermobile means joint ligament laxity and a certain range and quality of motion that is beyond that which is considered normal, but causes them no problem but due to having the required number of lax joints they are included in the group termed Joint Hypermobility Syndrome, what does that achieve. If however a person has one joint that is hypermobile and that joint causes pain then even tho they do not come into the classification JHS, they still need help.

    Perhaps a scoring system like the Beighton or the newer Brighton score might help the clinician to focus on who and where to refer a patient. And of course has the benifit of being recordable and justifiable.

    Dave Smith
     
  6. Ella Hurrell

    Ella Hurrell Active Member

    Like Robert, I use the Beighton scale for paeds and occasionally adults also. It gives me an idea of whether the patient has global laxity/hypermobility. It obviously has it's limitations ie. no foot and ankle tests in the criteria etc, so I do not use it to classify/diagnose patients - just to record an overall picture of mobility.
     
  7. Em3

    Em3 Member

    Thank you everybody, I believe I have more questions now than I even started with!

    So would it be recommended to apply the tests for each paed case? And what exactly are the implications for children with benign ligamentous laxity, I mean to say no underlying syndrome or disease?
    Would it be possible for you to elaborate on the modified version for the lower limb assessment?

    So as an overall global-type assessment it might be useful, say on the initial consult to test, should you be suspicious of a hypermobility issue?

    If the Brighton score is more specified to reaching a conclusion or diagnosis, how exactly would you determine which patients you would want to test?
    And what tests are used with the Brighton score? I've found several mentions of the criteria, but not what they actually are.

    Which aspects do you find to be most relevant to either diagnosis or treatment?
     
  8. Ella Hurrell

    Ella Hurrell Active Member

    Yes, that's exactly how I use it. It gives me a numerical, repeatable value to record in the records.
     
  9. David Smith

    David Smith Well-Known Member

    Emma

    I don't use either, this is because in private practice I would just refer on when necessary and not become involved in medical conditions. Most children I have seen have first been thru the NHS and classified and categorised as required.
    Lax ligaments alone would not really ring alarm bells for me unless there were significant familial history where there were also problems.

    Here's an extract from the HMSA web site

    The Brighton Score - The New Diagnostic Criteria for HMS
    An important landmark was passed in July 2000 with the publication in the Journal of Rheumatology (2000; 27: 1777-1779) of the Brighton Diagnostic criteria for the Benign Joint Hypermobility Syndrome (BJHS).

    WHY IS IT IMPORTANT TO HAVE SUCH A SET OF CRITERIA FOR THE BJHS?
    Hitherto, there has been no consensus view on how the BJHS should be defined. Without generally agreed criteria for the diagnosis, it is very much a hit and miss affair and doctors confronted with an affected patient may come to very different conclusions regarding whether BJHS is present. We know that that happens quite a lot. To take one example, doctors differ considerably in the number of hypermobile joints they require to be present before they accept the diagnosis on hypermobility syndrome. In a recent survey out of 319 consultant rheumatologists 185 required a Beighton score of 5 while 92 required 3, 3 required 1, while 35 preferred not commit themselves.

    WHY ARE THE BRIGHTON CRITERIA REPLACING THE WELL TRIED BEIGHTON SCORE?
    The answer is that they are not. The Beighton scoring system has been used for over 30 years and have withstood the test of time. But as Professor Beighton has pointed out they were never designed for assisting in diagnosis in the clinical situation. They were in fact developed for epidemiological studies and for this they were invaluable.

    They are not adequate for diagnosis for two reasons. Firstly, they only cover a sample of joints in the body, and reliance on them may lead to hypermobility being missed in other joints: those not covered in the Beighton 9-point score. Secondly, as we always knew, hypermobility syndrome means hypermobility + symptoms, and we now know there other features in BJHS (changes in skin – increase skin stretchiness, thin scar formation, marfanoid body shape) so that a measurement of joint hypermobility alone is no longer enough. The new criteria include symptoms and these other features. The Beighton score remains an integral component. It is not being abandoned!

    HOW RELIABLE ARE THE NEW BRIGHTON CRITERIA?
    The new criteria have been validated in adults but not yet in children below the age of 16 years. The process of validation requires the criteria to be “tested” among a group of BJHS patients and also among a group of volunteers who have not got the syndrome. For criteria to declared valid they have to show that they are capable of picking up the condition in the majority who have it (sensitivity), but also of ruling out the condition in the majority of people who do not (specificity). In the case of the Brighton criteria the sensitivity and specificity were both very high (93% each).

    HOW WILL THEY HELP?
    Doctors and research workers can use the criteria in their work. If a person fulfils the criteria, then, for all intents and purposes they may be confidently considered to have the BJHS. We therefore now have a reliable benchmark that we did not have before. It is anticipated that they will be widely used in future research. Indeed, since their publication they have already been incorporated into research protocols. For example, they will constitute an important linchpin in the gene-mapping project reported elsewhere in the website.

    WHAT DO THE BRIGHTON CRITERIA CONSIST OF?
    The actual criteria have been reproduced (as published) below.

    REVISED DIAGNOSTIC CRITERIA FOR THE BENIGN JOINT HYPERMOBILITY SYNDROME (BJHS)
    Major Criteria

    A Beighton score of 4/9 or greater (either currently or historically)
    Arthralgia for longer than 3 months in 4 or more joints
    Minor Criteria

    A Beighton score of 1, 2 or 3/9 (0, 1, 2 or 3 if aged 50+)
    Arthralgia (> 3 months) in one to three joints or back pain (> 3 months), spondylosis, spondylolysis/spondylolisthesis.
    Dislocation/subluxation in more than one joint, or in one joint on more than one occasion.
    Soft tissue rheumatism. > 3 lesions (e.g. epicondylitis, tenosynovitis, bursitis).
    Marfanoid habitus (tall, slim, span/height ratio >1.03, upper: lower segment ratio less than 0.89, arachnodactily [positive Steinberg/wrist signs].
    Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring.
    Eye signs: drooping eyelids or myopia or antimongoloid slant.
    Varicose veins or hernia or uterine/rectal prolapse.
    The BJHS is diagnosed in the presence two major criteria, or one major and two minor criteria, or four minor criteria. Two minor criteria will suffice where there is an unequivocally affected first-degree relative.

    BJHS is excluded by presence of Marfan or Ehlers-Danlos syndromes (other than the EDS Hypermobility type (formerly EDS III) as defined by the Ghent 1996 (8) and the Villefranche 1998 (9) criteria respectively). Criteria Major 1 and Minor 1 are mutually exclusive as are Major 2 and Minor 2.

    Professor Rodney Grahame

    Dave
     
  10. Em3

    Em3 Member

    Thanks Dave, that's exactly the website I stumbled across when I first heard of the Brighton criteria...
    So the Brighton criteria uses the Beighton, arthralgia >3months in 4+ joints etc?
    And I'd more than likely not want to incorporate it into a biomechanical analysis then either?

    Fantastic, thanks everyone, this is helping a lot :)
     
  11. Great source Dave, thanks for sharing that one.

    One of the reasons i like the beighton score, and i'm not sure this is present in the Brighton score, is its ease of use. I can do most of a beighton score on a non compliant 7 year old autistic kid who is screaming the place down within about 30 seconds.

    You will, like all of us, decide for yourself what makes it into your standard assessment. Personally i like to do the score for all paeds, like i say it takes almost no time to do. Its quick, dirty and sound.

    The implications are rather beyond what i can really go into here. In broad strokes however, it tells you if a hypermobility is local or global. this can inform prognosis, treatment and crucially, managing parents expectations.

    The lower limb score i use is as follows

    The points total is not so important to me here. However each of these factors give me a crude measure of what the patient is doing.

    Peadiatric assessment is sometimes a rather different animal to adult, especially if you work with children with learning difficulties, CP, Autism etc. I find little use for measurements such as rcsp, ncsp etc in these cases. Its not particularly repeatable in compliant adults let alone children. These, however, i find useable, if somewhat crude.

    Regards
    Robert
     
  12. davidh

    davidh Podiatry Arena Veteran

    Dave,
    You said:
    "But as Professor Beighton has pointed out they were never designed for assisting in diagnosis in the clinical situation. They were in fact developed for epidemiological studies and for this they were invaluable."

    This was my understanding too. Thanks for pointing that out.

    Cheers,
     
  13. pgcarter

    pgcarter Well-Known Member

    Hi Em3,
    The most relevant things to handling a particular person is what ever is actually their issues. It's less productive to try and make a rigid analysis algorithm than it is to focus on the detailed individual characteristics of the individual. I used to tell my students that most of us are good at recognising repeating patterns in the population. What makes a better practitioner is the increasingly sophisticated ability to recognize increasingly smaller differences between patients so that you can make the treatment more and more specific to their particular issues.
    Just a general over view that I think helps in the long run.
    regards Phill Carter
     
  14. Jorisds

    Jorisds Member

    Dear Robert,

    I was just wondering what kind of "modified version" you use ?

    Thanks in advance.
    Regards,
    Joris
     
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