Benignes Gelenkhypermobilitätssyndrom: Klinik, Diagnostik, physikalische Therapiemöglichkeiten

Zusammenfassung

Das benigne Gelenkhypermobilitätssyndrom (BGHS) repräsentiert ein gutartiges Overlap-Syndrom von nicht lebensbedrohlichen Komponenten der seltenen und besser definierten kongenitalen mesodermalen Dysplasien: Marfan-Syndrom, Ehlers-Danlos-Syndromen und Osteogenesis imperfecta. BGHS-Patienten leiden vorwiegend an Arthralgien, Kreuzschmerzen, weichteilrheumatischen Symptomen, rezidivierenden Gelenkluxationen und extraartikulären Manifestationen wie Angst, Stress, kutanen Striae, erhöhter Blutungsneigung, Mitralklappenprolaps, Spontanpneumothorax, Harninkontinenz, Beckenbodeninsuffizienz etc. Die BGHS simuliert oftmals chronisch entzündlich-rheumatische Erkrankungen. Am Beginn der Therapie steht die richtige Diagnosestellung. Die Patienten müssen wissen, dass der Arzt ihr Leiden erkannt hat und versteht. Lebensumstände, welche die Symptome verschlechtern, sollten nach Möglichkeit ausgeschaltet werden, da dies die Patienten vor unnötigen, potenziell schädlichen Therapien schützt. Jüngst wurden Arbeiten veröffentlicht, die Prolotherapie als wirksam in der Behandlung nachwiesen. Physikalische Therapie gilt als eine tragende Säule, evidenzbasierte Empfehlungen können derzeit infolge des Fehlens von Daten nur durch Anwendung von Analogieschlüssen gegeben werden. Die unterschiedlichen Ansatzpunkte der physikalischen Therapie werden umrissen.

Abstract

The benign joint hypermobility syndrome (BJHS) is a hereditary benign overlap disorder of connective tissue, which incorporates features seen in the Marfan syndrom, Ehlers-Danlos syndroms and osteogenesis imperfecta. Patients with BJHS usually present arthralgia, back pain, overuse soft tissue lesions, recurrent joint dislocation or subluxation and even extraarticular features, e. g. anxiety, stress, skin striae, easy bruising, mitral valve prolapse, pneumothorax, urinary incontinence and pelvic floor prolapse. The BJHS often simulates chronic inflammatory rheumatic diseases. There are many ways in which BJHS patients can be helped: Getting the diagnosis right is a start. Patients need to know that they have a condition that physicians recognize and understand. They should be encouraged to seek out factors in their daily activities that seem to provoke or aggravate their symptoms to prevent patients from treatment with unnecessary, potentially harmful treatment modalities. There are recent trials showing Prolotherapy to be an effective treatment. Physical therapy is said to be a mainstay of treatment, but currently evidence based recommendations can be given only based on conclusions by analogy. There are different levels of physical intervention, which are outlined in this paper.

Schlüsselwörter

Rheumatische Erkrankungen - Gelenkhypermobilität - Physikalische Therapie - Beratung

Key words

Rheumatic diseases - hypermobility - joint - physical therapy techniques - medical history taking - punctures

Literatur

• 1 Kirk J H, Ansell B M, Bywaters E GL. The hypermobility syndrome.  Ann Rheum Dis. 1967;  26 419-425
• 2 Beighton P, Grahame R, Bird H. Hypermobility of Joints (3rd ed.). London; Springer 1999
• 3 Mishra M B, Ryan P, Atkinson P, Taylor H, Bell J, Calver D, Fogelman I, Child A, Jackson G, Chambers J B, Grahame R. Extra-articular features of benign joint hypermobility syndrome.  Brit J Rheumatol. 1996;  35 861-866
• 4 Larsson L G, Baum J, Mudhokar G S. Hypermobility: features and differential incidence between the sexes.  Arthr Rheumat. 1987;  30 1426-1430
• 5 Beighton P B, Solomon L, Soskolne C L. Articular mobility in an African population.  Ann Rheum Dis. 1973;  32 413-418
• 6 Duro J C, Vega E. Prevalence of articular hypermobility in schoolchildren: a one-district study in Barcelona.  Rheumatology. 2000;  39 1153
• 7 Giessen L J van der, Liekens D, Rutgers K J, Hartman A, Mulder P G, Oranje A P. Validation of Beighton score and prevalence of connective tissue signs in 773 Dutch children.  J Rheumatol. 2001;  28 2726-2730
• 8 El Garf A K, Mahmoud G A, Mahgoub E H. Hypermobility among Egyptian children: prevalence and features.  J Rheumatol. 1998;  25 1003-1005
• 9 Al-Rawi Z S, Al A szawi, Al C halabi. Joint mobility among university students in Iraq.  Brit J Rheumatol. 1985;  24 326-331
• 10 Graham R. Hypermobility syndrome in the elderly. In: Rovensky J (ed) Proceedings of the 1st Central European Congress of Rheumtology. Piestany, Slovakia; Časlekčes 1996
• 11 Bridges A J, Smith E, Reid J. Joint hypermobility in adults referred to rheumatology clinics.  Ann Rheum Dis. 1992;  51 793-796
• 12 Child A H. Joint hypermobility syndrome inherited disorder of collagen synthesis.  J Rheumatol. 1986;  13 239-243
• 13 Grahame R. Joint hypermobility and genetic collagen disorders: are they related?.  Arch Dis Child. 1999;  80 188-191
• 14 Bird H A, Calguneri M, Wright V. Changes in joint laxity occurring during pregnancy.  Ann Rheum Dis. 1981;  40 209-214
• 15 Bluestone R, Bywaters E G, Hartog M, Holt P JL, Hide S. Acromegalic arthropathy.  Ann Rheum Dis. 1971;  30 243-258
• 16 Rillo O L, Babini S M, Basnak A, Wainer E, Balbachan E, Cocco J AM. Tendinous and ligamentous hyperlaxity in patients receiving long-term hemodialysis.  J Rheumatol. 1991;  18 1227-1231
• 17 Harpe A L De la, Brighton S W. The effect of long-term corticosteroid therapy on joint mobility.  Clin Exp Rheumatol. 1989;  7 79-80
• 18 Carlsson C, Rundgren A. Hypermobility of joints in women alcoholics.  J Stud Alcohol. 1980;  41 78-82
• 19 Klemp P, Stevens J E, Issacs S. A hypermobility study in ballet dancers.  J Rheumatol. 1984;  11 692-696
• 20 Graham R. Joint hypermobility and the performing musicans.  NEJM. 1993;  329 1120-1121
• 21 Barton L M, Bird H A, Lindsay M, Newton J, Wright V. The quantification of joint hyperlaxity in athletes.  J Orthop Rheumatol. 1995;  8 79-86
• 22 Hull R G. Articular hypermobility presenting after „aerobic” exercise.  Clin Exp Rheumatol. 1985;  3 359-364
• 23 Hudson N, Fitzcharles M A, Cohen M, Starr M R, Esdaile J M. The association of soft-tissue rheumatism and hypermobility.  Brit J Rheumatol. 1998;  37 382-386
• 24 Acasuso Diaz M, Collantes-Estevez E. Joint hypermobility in patients with fibromyalgia syndrome.  Arthr Care & Res. 1998;  11 39-42
• 25 Adair S M, Hecht C. Association of generalized joint hypermobility with history, signs, and symptoms of temporomandibular joint dysfunction in children.  Paediatr Dent. 1993;  15 323-326
• 26 Binns M. Joint laxity in idiopathic adolescent scoliosis.  J Bone Joint Surg. 1988;  70 420-422
• 27 Larsson L G, Mudholkar G S, Baum J, Srivastava D K. Benefits and liabilities of hypermobility in the back pain disorders of industrial workers.  J Intern Med. 1995;  238 461-467
• 28 Kaalund S, Hogsaa B, Grevy C. Coxa saltans in patients with Ehlers-Danlos syndrome, type III.  Scand J Rheumatol. 1988;  17 229-230
• 29 Al-Rawi Z, Nessan A H. Joint hypermobility in patients with chondromalacia patellae.  Brit J Rheumatol. 1997;  36 1324-1327
• 30 Bird H A, Tribe C R, Bacon P A. Joint hypermobility leading to osteoarthrosis and chondrocalcinosis.  Ann Rheum Dis. 1978;  37 203-211
• 31 Jonsson H, Valtysdottir S T, Kjartansson O, Brekkan A. Hypermobility associated with osteoarthritis of the thumb base: a clinical and radiological subset of hand osteoarthritis.  Ann Rheum Dis. 1996;  55 540-543
• 32 Woodward E G, Morris M T. Joint hypermobility in keratoconus.  Ophthal Physiol Opt. 1990;  10 360-362
• 33 Haberhauer G, Feyertag J, Hanusch-Enserer U. Joint hypermobility syndrome and bilateral occlusion of the ulnar arteries presenting as Raynaud's phenomenon.  Clin Exp Rheum. 2000;  18 270-271
• 34 Handler C E, Child A, Light N D, Dorrance D E. Mitral valve prolapse, aortic compliance, and skin collagen in joint hypermobility syndrome.  Brit Heart J. 1985;  54 501-508
• 35 Morgan A W, Pearson S B, Bird H A. Respiratory symptoms in Ehlers-Danlos syndrome and the benign joint hypermobility syndrome.  Arthr Rheum. 1996;  39 136
• 36 Marshman D, Percy J, Fielding I, Delbridge L. Rectal prolaps: relationship with joint mobility.  Aust NZ J Surg. 1987;  57 827-829
• 37 Al-Rawi Z S, Al-Rawi Z T. Joint hypermobility in women with genital prolapse.  Lancet. 1982;  24 1439-1441
• 38 Martin-Santos R, Bulbena A, Porta M, Gago J, Molina L, Duro J C. Association between joint hypermobility syndrome and panic disorder.  Am J Psychiatry. 1998;  155 1578-1583
• 39 Beighton P H, Solomon L, Soskolne C L. Articular mobility in an African population.  Ann Rheum Dis. 1973;  32 413-418
• 40 Graham R, Bird H A, Child A, Dolan L, Edwards-Fowler A, Ferrell W, Gurley-Green S, Keer R, Mansi E, Murray K J, Smith E. The revised (Beighton 1998) criteria for the diagnosis of benign joint hypermobility syndrom (BJHS).  J Rheumatol. 2000;  27 1777-1779
• 41 Karaaslan Y, Haznedaroglu S, Öztürk M. Joint hypermobility and primary fibromyalgia. A clinical enigma.  J Rheumatol. 2000;  27 1774-1776
• 42 Bird H A, Wright V. Joint hypermobility mimicking pauci-articular juvenile polyarthitis.  Brit Med J. 1978;  2 402-403
• 43 Scharty Y, Nahir A M. Hypermobility syndrome mimicking juvenile chronic arthritis.  Rheumatol Rehab. 1982;  21 78-80
• 44 Lewkonia R M, Ansell B M. Articular hypermobility simulating chronic rheumatic disease.  Arch Dis Child. 1983;  58 988-992
• 45 Gedalia A, Person D A, Giannini E H, Brewer E J. Joint hypermobility in juvenile episodic arthritis/arthralgia.  J Rheumatol. 1984;  11 716
• 46 Bridges A J, Smith E, Reid J. Joint hypermobility in adults referred to rheumatology clinics.  Ann Rheum Dis. 1992;  51 793-796
• 47 Guma M, Olive A, Roca J, Forcada J, Duro J C, Holgado S, Casado E, Mezquiriz X, Tena X. Association of systemic lupus erythematosus and hypermobility.  Ann Rheum Dis. 2002;  61 1024-1026
• 48 Garnero P, Piperno M, Gineyts E, Chrisgau S, Delmas P D, Vignon E. Cross sectional evaluation of biochemical markers of bone, cartilage, and synovial tissue metabolism in patients with knee osteoarthritis: relations with disease activity and joint damage.  Ann Rheum Dis. 2001;  60 619-626
• 49 Murphy E, FitzGerald O, Saxne T, Bresnihan B. Increased serum cartilage oligomeric matrix protein levels and decreased patellar bone mineral density in patients with chondromalacia patellae.  Ann Rheum Dis. 2002;  61 981-985
• 50 Shashikirian U, Rastogi A, Gupta R P, Sabir M. Ehlers-Danlos syndrome type VI variant presenting with recurrent respiratory infections and responding to high dose vitamin C.  J Assoc Physicians India. 1999;  47 554-555
• 51 Sastry P S. Matrixmetalloproteinase inhibitor therapy to prevent complications as well as therapy for Ehlers-Danlos syndrome.  Med Hypotheses. 2002;  59 314-315
• 52 Russek L N. Examination and treatment of a patient with hypermobility syndrome.  Phys Ther. 2000;  80/4 386-389
• 53 Russek L N. Hypermobility Syndrome.  Phys Ther. 1999;  79 591-599
• 54 Graham R. Hypermobility Syndrome in Rheumatology (eds: Klippel JH, Dieppe PA). London; Mosby 1994: 181-186
• 55 Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard C H. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow.  J Bone Joint Surg (B). 1992;  74 646-651
• 56 Balint M. Der Arzt, sein Patient und die Krankheit. Stuttgart; Klett 1965
• 57 Sachse J, Hinzmann J L, Janda V, Ruhm B. Normuntersuchung der Beweglichkeit junger Erwachsener.  Phys Rehab Kur Med. 2002;  12 325-329
• 58 Pountain G. Musculoskeletal pain in Omanis, and the relationship to joint mobility and body mass index.  Br J Rheumatol. 1992;  31 81-85
• 59 Konrad K. Joint hypermobility: frequent cause of low back pain. (Hungarian).  Orvosi Hetilap. 1996;  137/30 1643-1646
• 60 Müller K, Kreutzfeldt A, Schwesig R, Müller-Pfeil J, Bandemer-Geulich U, Schreiber B, Bahrke U, Fikentscher E. Hypermobilität und chronischer Rückenschmerz.  Orthop Praxis. 2002;  38 716-721
• 61 Baquie P. An investigation into the potential relationship between intervertebral joint hypermobility and pain response in ballet dancers suffering lower back pain (abstract).  Aust J Physiother. 1986;  32/3 204-205
• 62 Grob K R, Kuster M S, Higgins S A, Lloyd D G, Yata H. Lack of correlation between different measurements of proprioception in the knee.  J Bone Joint Surg Br. 2002;  84 614-618
• 63 Mallik A K, Ferrell W R, McDonald A G, Sturrock R D. Impaired proprioceptive acuity at the proximal interphalangeal joint in patients with the hypermobility syndrome.  Br J Rheumatol. 1994;  33 631-637
• 64 Hall M G, Ferrell W R, Sturrock R D, Hamblen D L, Baxendale R H. The effect of the hypermobility syndrome on knee joint proprioception.  Br J Rheumatol. 1995;  34 121-125
• 65 Barrett D S, Cobb A G, Bentley G. Joint proprioception in normal, osteoarthritic and replaced knees.  J Bone Joint Surg Br. 1991;  73 53-56
• 66 Marks R, Quinney H A, Wessel J. Proprioceptive sensibility in women with normal and osteoarthritic knee joints.  Clin Rheumatol. 1993;  12 170-175
• 67 Pai Y C, Rymer W Z, Chang R W, Sharma L. Effect of age and osteoarthritis on knee proprioception.  Arthritis Rheum. 1997;  40 2260-2265
• 68 Koralewicz L M, Engh G A. Comparison of proprioception in arthritic and age-matched normal knees.  J Bone Joint Surg Am. 2000;  82 1582-1588
• 69 Sharma L, Pai Y C, Holtkamp K, Rymer W Z. Is knee joint proprioception worse in the arthritic knee versus the unaffected knee in unilateral knee osteoarthritis?.  Arthritis Rheum. 1997;  40 1518-1525
• 70 Hewitt B A, Refshauge K M, Kilbreath S L. Kinesthesia at the knee: the effect of osteoarthritis and bandage application.  Arthritis Rheum. 2002;  47 479-483
• 71 Sharma L, Pai Y C. Impaired proprioception and osteoarthritis.  Curr Opin Rheumatol. 1997;  9 253-258
• 72 Richie D H. Functional instability of the ankle and the role of neuromuscular control: a comprehensive review.  J Foot Ankle Surg. 2001;  40 240-251
• 73 Lofvenberg R, Karrholm J, Sundelin G. Proprioceptive reaction in the healthy and chronically unstable ankle joint.  Sportverletz Sportschaden. 1996;  10 (4) 79-83
• 74 Jerosch J, Prymka M. Knee joint proprioception in patients with posttraumatic recurrent patella dislocation.  Knee Surg Sports Traumatol Arthrosc. 1996;  4 (1) 14-18
• 75 Parkhurst T M, Burnett C N. Injury and proprioception in the lower back.  J Orthop Sports Phys Ther. 1994;  19 282-295
• 76 Ramsay J R, Riddoch M J. Position-matching in the upper limb: professional ballet dancers perform with outstanding accuracy.  Clin Rehabil. 2001;  15 324-330
• 77 Hurley M V, Scott D L. Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime.  Br J Rheumatol. 1998;  37 1181-1187
• 78 Jerosch J, Pfaff G, Thorwesten L, Schoppe R. Effects of a proprioceptive training program on sensorimotor capacities of the lower extremity in patients with anterior cruciate ligament instability.  Sportverletz Sportschaden. 1998;  12 (4) 121-130
• 79 Beard D J, Dodd C A, Trundle H R, Simpson A H. Proprioception enhancement for anterior cruciate ligament deficiency. A prospective randomised trial of two physiotherapy regimes.  J Bone Joint Surg Br. 1994;  76 654-659
• 80 Bartlett M J, Warren P J. Effect of warming up on knee proprioception before sporting activity.  Br J Sports Med. 2002;  36 132-134
• 81 Perlau R, Frank C, Fick G. The effect of elastic bandages on human knee proprioception in the uninjured population.  Am J Sports Med. 1995;  23 251-255
• 82 Walker H L, Schreck R C. Relationship of hyperextended gait pattern to chondromalacia patellae.  Physiotherapy. 1978;  1 1-9
• 83 Young A. Current issues in arthrogenous inhibition.  Ann Rheum Dis. 1993;  52 829-834
• 84 Gedney H Earl. Hypermobile Joint (a preliminary report).  Osteopathic Profession. 1937;  4 9
• 85 Dechow E, Davies R K, Carr A J, Thomson P W. A randomized controlled trial of sclerosing injections in patients with chronic low back pain.  Rheumatology. 1999;  38 1255-1259
• 86 Klein R G, Eek B C, DeLong W B, Mooney V. A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain.  J Spinal Disord. 1993;  6 23-33
• 87 Reeves K D, Hassanein K. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy.  J Altern Complement Med. 2000;  6 311-320
• 88 Reeves K D, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity.  Altern Ther Health Med. 2000;  6 68-74
• 89 Klemp B. Hypermobility: (Editorial).  Annals of the Rheumatic Diseases. 1997;  56 573-575
• 90 Diaz M A, Estevez E C, Guyjo Sanchez P. Jolint hyperlaxity and musculoligamentous lesions: study of a population of homogeneous age, sex, and physical exertion.  Br J Rheumatol. 1993;  32 120-122
• 91 March L, Silman A. Joint hyperlaxity: is there a case for screening?.  Br J Rheumatol. 1993;  32 91-92
• 92 MacIntyre D L, Reid W D, Lyster D M, Szasz I J, McKenzie D C. Presence of WBC, decreased strength, and delayed soreness in muscle after eccentric exercise.  J Appl Physiol. 1996;  80 1006-1013
• 93 Tokmakidis S P, Kokkinidis E A, Smilios I, Douda H. The effects of Ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise.  J Strength Cond Res. 2003;  17 53-59
• 94 Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors.  Sports Med. 2003;  33 145-164
• 95 Eston R G, Finney S, Baker S, Baltzopoulos V. Muscle tenderness and peak torque changes after downhill running following a prior bout of isokinetic eccentric exercise.  J Sports Sci. 1996;  14 291-299
• 96 Prou E, Guevel A, Benezet P, Marini J F. Exercise-induced muscle damage: absence of adaptive effect after a single session of eccentric isokinetic heavy resistance exercise.  J Sports Med Phys Fitness. 1999;  39 226-232
• 97 Brockett C L, Morgan D L, Proske U. Human hamstring muscles adapt to eccentric exercise by changing optimum length.  Med Sci Sports Exerc. 2001;  33 (5) 783-790
• 98 Dannecker E A, Koltyn K F, Riley J L, Robinson M E. The influence of endurance exercise on delayed onset muscle soreness.  J Sports Med Phys Fitness. 2002;  42 458-465
• 99 Graham R, Bird H. British consultant rheumatologists' perceptions about the hypermobility syndrome: a national survey.  Rheumatology (Oxford). 2001;  40 559-562
• 100 http://www3.who.int/icf/ . 
• 101 Semark A, Noakes T D, St Clair Gibson A, Lambert M I. The effect of a prophylactic dose of flurbiprofen on muscle soreness and sprinting performance in trained subjects.  J Sports Sci. 1999;  17 197-203
• 102 Bourgeois J, MacDougall D, MacDonald J, Tarnopolsky M. Naproxen does not alter indices of muscle damage in resistance-exercise trained men.  Med Sci Sports Exerc. 1999;  31 4-9
• 103 Craig J A, Cunningham M B, Walsh D M, Baxter G D, Allen J M. Lack of effect of transcutaneous electrical nerve stimulation upon experimentally induced delayed onset muscle soreness in humans.  Pain. 1996;  67 (2 - 3) 285-289
• 104 Smith L L, Keating M N, Holbert D, Spratt D J, McCammon M R, Smith S S, Israel R G. The effects of athletic massage on delayed onset muscle soreness, creatine kinase, and neutrophil count: a preliminary report.  J Orthop Sports Phys Ther. 1994;  19 93-99
• 105 Hasson S M, Wible C L, Reich M, Barnes W S, Williams J H. Dexamethasone iontophoresis: effect on delayed muscle soreness and muscle function.  Can J Sport Sci. 1992;  17 8-13
• 106 Ernst E. Does post-exercise massage treatment reduce delayed onset muscle soreness? A systematic review.  Br J Sports Med. 1998;  32 212-214
• 107 Craig J A, Bradley J, Walsh D M, Baxter G D, Allen J M. Delayed onset muscle soreness: lack of effect of therapeutic ultrasound in humans.  Arch Phys Med Rehabil. 1999;  80 318-323
• 108 Minder P M, Noble J G, Alves-Guerreiro J, Hill I D, Lowe A S, Walsh D M, Baxter G D. Interferential therapy: lack of effect upon experimentally induced delayed onset muscle soreness.  Clin Physiol Funct Imaging. 2002;  22 339-347
• 109 Kraemer W J, Bush J A, Wickham R B, Denegar C R, Gomez A L, Gotshalk L A, Duncan N D, Volek J S, Putukian M, Sebastianelli W J. Influence of compression therapy on symptoms following soft tissue injury from maximal eccentric exercise.  J Orthop Sports Phys Ther. 2001;  31 282-290
• 110 Karjalainen K A, Malmivaara A O, Tulder M W van, Roine R P, Jauhiainen S, Hurri H O, Koes B W. Biopsychosocial rehabilitation for repetitive-strain injuries among working-age adults.  Scand J Work Environ Health. 2000;  26 373-381
• 111 Moore L E, Wiesner S L. Hypnotically-induced vasodilation in the treatment of repetitive strain injuries.  Am J Clin Hypn. 1996;  39 97-104
• 112 Torkki M, Malmivaara A, Reivonen N, Seitsalo S, Laippalo P, Hoikka V. Individually fitted sports shoes for overuse injuries among newspaper carriers.  Scand J Work Environ Health. 2002;  28 176-183
• 113 Tittiranonda P, Rempel D, Armstrong T, Burastero S. Effect of four computer keyboards in computer users with upper extremity musculoskeletal disorders.  Am J Ind Med. 1999;  35 647-661
• 114 Rempel D, Tittiranonda P, Burastero S, Hudes M, So Y. Effect of keyboard keyswitch design on hand pain.  J Occup Environ Med. 1999;  41 111-119
• 115 Giombini A, Cesare A Di, Casciello G, Sorrenti D, Dragoni S, Gabriele P. Hyperthermia at 434 MHz in the treatment of overuse sporttendinopathies: a randomised controlled clinical trial.  Int J Sports Med. 2002;  23 207-211
• 116 Melhorn J M. A prospective study for upper-extremity cumulative trauma disorders of workers in aircraft manufacturing.  J occup Environ Med. 1996;  38 1264-1271