What is the best treatment approach for a patient with hyperlaxity (hypermobility) and chronic lower back and hip pain?

Treatment of Hyperlaxity with Lower Back and Hip Pain

For patients with hyperlaxity (hypermobility) and chronic lower back and hip pain, prioritize intensive multidisciplinary rehabilitation combining physical therapy with cognitive-behavioral therapy, while strictly avoiding opioids and emphasizing structured exercise programs. 1

Initial Assessment Priorities

When evaluating hyperlaxity with lower back and hip pain, specifically assess for:

• Beighton score ≥4/9 to confirm generalized hypermobility (knees, elbows, wrists, metacarpophalangeal joints, and ankles most commonly affected) 2
• Pelvic floor dysfunction and rectal hyposensitivity, which are highly prevalent in hypermobile patients and contribute to lower back symptoms 1
• Comorbid autonomic dysfunction (POTS) or mast cell activation syndrome, as these frequently co-occur and require specific management 1
• Psychological distress and anxiety, which are increased in hypermobility patients and mediated by autonomic dysfunction 1

First-Line Treatment Strategy

Non-Pharmacologic Interventions (Primary Approach)

Intensive multidisciplinary rehabilitation (>100 hours, daily sessions) is moderately superior to usual care for both short-term (3-4 months) and long-term (60 months) functional status and pain outcomes. 1 This approach should include:

• Structured exercise therapy as the cornerstone, which reduces pain and improves function with sustained benefits for 2-6 months 1
• Cognitive-behavioral therapy (CBT) integrated with physical treatments, as functional restoration with a cognitive-behavioral component is more effective than usual care for reducing disability 1
• Psychological support using brain-gut behavioral therapies to address anxiety and psychological distress common in hypermobility 1

Pharmacologic Management

Nonopioid pharmacologic therapy should be combined with nonpharmacologic approaches: 1

• Acetaminophen or NSAIDs for initial pain control in lower back and hip pain 1
• Tricyclic antidepressants or SNRIs (duloxetine) for chronic pain, particularly if neuropathic features are present 1
• Gabapentin or pregabalin for neuropathic pain components, though evidence for radiculopathy is limited to small short-term benefits 1, 3
• Neuromodulators (SSRIs, SNRIs) can be considered depending on pain location, type, and frequency 1

Critical Management Principles

What to Avoid

Opioids must be avoided or ceased in patients with pain-predominant features, as they should not be used specifically to treat musculoskeletal pain in hypermobility disorders. 1 This is particularly important given the multisystemic nature of these conditions.

Less intensive interdisciplinary rehabilitation (<100 hours) is no better than usual care, so if pursuing multidisciplinary treatment, ensure adequate intensity. 1

Addressing Comorbidities

If autonomic dysfunction (POTS) is present:

• Lifestyle modifications first: increased salt/fluid intake, compression garments, physical counter-pressure maneuvers, exercise training 4
• Pyridostigmine as second-line or adjunctive therapy if refractory to other treatments, with the advantage of not causing supine hypertension 4
• Fludrocortisone, midodrine, or droxidopa before pyridostigmine 4

Imaging and Diagnostic Testing

Radiographs of the pelvis and hip should be the first imaging test ordered. 1

MRI hip without IV contrast is appropriate when radiographs are negative or equivocal and there is suspicion for extra-articular soft tissue abnormalities such as tendonitis. 1

Anorectal manometry, balloon expulsion test, or defecography should be considered given the high prevalence of pelvic floor dysfunction in hypermobile patients with lower back and hip symptoms. 1

Functional Restoration Approach

For chronic symptoms, functional restoration must include:

• Daily intensive sessions to achieve the moderate effect sizes demonstrated in higher-quality trials (standardized mean differences of -0.40 to -0.90 for functional status) 1
• Workplace-focused interventions if occupational disability is present 1
• Progressive exercise programs rather than passive modalities, as remaining active is more effective than bed rest 5, 6

Common Pitfalls to Avoid

Delayed diagnosis is common (average 2-3 year delay from symptom onset to diagnosis in hypermobility), resulting in poor pain control and disruption of normal activities. 2 Early recognition and intervention are critical.

Do not rely on passive treatments alone. Interferential therapy, low-level laser therapy, and lumbar supports show inconsistent or minimal benefits compared to active rehabilitation strategies. 1

Avoid systemic corticosteroids, as they have not been shown more effective than placebo for low back pain with or without radicular symptoms. 5, 3

Long-Term Management

Teach self-management techniques including exercises and ergonomic spine protection once pain is controlled. 6 Evidence increasingly supports exercise programs, though optimal regimens may vary between patients. 6

Address the multisystemic nature of hypermobility disorders with integrated care focusing on musculoskeletal, autonomic, and psychological components simultaneously. 1