Please see an interview with Dr. Norman Marcus and Jay Gill, discussing the use of low dose naltrexone for treating chronic pain related to Ehlers-Danlos Syndrome (EDS).

Ehlers Danlos Syndrome (EDS) is a connective tissue disorder that affects skin and joints between bones. The most common type of EDS is hEDS or hypermobility EDS. People with hEDS are usually more flexible or bendy than the average person. Being able to do a split, being able to bend your thumb back so it touches your wrist, and stretchy skin are three common signs of joint hypermobility. On the surface, these symptoms don’t seem too problematic, but hEDS can cause widespread pain in the body and many other problems.

There is growing research on the link between hEDS and another condition called called Mast Cell Activation Syndrome (MCAS). One recent study done by Song et al. in 2020 identified that 24% of a group of EDS patients also had MCAS.  This is a very exciting finding for EDS researchers because as of now, the genetic causes of EDS are unknown. Therefore, studying MCAS may provide an avenue for exploring the origins of EDS in the body.

Both of these conditions share many different symptoms including skin hives, skin flushing, itchy skin, nasal or sinus congestion, asthma, gastrointestinal disorders like irritable bowel disorder or celiac disease, and many more. Research connecting these two conditions is a new and exciting field for researchers trying to get to the bottom of the physiology of Ehler’s Danlos Syndrome.

If you know you have EDS or hypermobility, and also experience pain and allergy symptoms like hives, coughing, wheezing, or redness in the skin, it’s possible you also have Mast Cell Activation Syndrome.

Ehler’s Danlos Syndrome (EDS) is a condition that affects the connective tissues of the body. There are 13 types of EDS, and the most common one is hEDS or hypermobility EDS, which affects approximately 1 of 3,100-5,000 people. EDS can be inherited genetically.

The three most common symptoms in people with hEDS are joint hypermobility, skin hyperextensibility, and tissue fragility.

Can you do a split? Or does your thumb bend backwards so far that it can touch your wrist? Those are two examples of joint hypermobility. Joints are the pieces of connective tissue that are between our bones. Joint hypermobility can be a problem because it makes people more likely to be injured through dislocations, sprains, or other joint problems.

Skin hyperextensibility means excessively stretchy skin. A common test for this is putting your hand flat on a table, and gently pinching and pulling the skin on the back of your hand.

Tissue fragility can also be a problem for people with EDS. Medically speaking, tissues are like the armor of our bodily organs. For example, our skin is a type of tissue (epithelial), but there is also nervous tissue, connective tissue and muscle tissue. Tissue fragility can be a problematic part of EDS because it leaves our organs more vulnerable to damage and injury. Because tissue is in all parts of our bodies, tissue fragility can pose a wide range of other symptoms, from bruising to gum disease.

Because EDS symptoms can vary so widely, there is no one mainstay of treatment for EDS patients. Rather, treatment plans are based on the individual. EDS patients should seek a care team of specialists from multiple disciplines to ensure that all of their symptoms are being treated differently and professionally.

Do you have widespread pain? Do you also have allergy symptoms like itching, hives, or wheezing? You may have gone a long time thinking pain and allergy symptoms were unrelated, but you could have Mast Cell Activation Syndrome (MCAS), a condition that causes both.

If you have never heard of MCAS, that’s because MCAS is a condition that is only gaining recognition in the past decade or so. There are many doctors who are not familiar with MCAS. It was once thought to be a rare condition, but current estimates are that it could affect up to 17% of the general population. It’s important that such a common condition be understood.

MCAS is hard for doctors to diagnose for a few reasons. The main reason is that it is an under researched condition, despite being likely very prevalent. Furthermore, MCAS has a lot of symptoms that aren’t frequently associated with each other. Mainly, pain symptoms and allergy symptoms. In fact, a MCAS diagnosis requires that symptoms occur in two organ systems, for example, the skin (hives), and the gastrointestinal system (stomach pain). The two other most common organ systems affected by MCAS are the cardiovascular system, and the respiratory system. Cardiovascular symptoms include low blood pressure and fainting. Respiratory symptoms include shortness of breath, congestion, sneezing, or wheezing.

MCAS can be a confusing condition due to the vast range of symptoms that a person with MCAS can experience. A person with MCAS could go to a pain doctor and an allergist separately to seek answers for their two different symptoms. They might not bring up their stuffy nose and skin hives with the pain doctor, and they might skip the pain conversation with the allergist. As a result, the pain doctor and allergist might diagnose this patient with something completely different. Without a full picture of a person’s overall symptoms, it is tough to diagnose MCAS, which is why it is important for doctors to learn more about this condition.

If you have allergies and pain symptoms, you may have never thought about how these two seemingly unrelated symptoms might be a sign of a single condition. To learn more about a potential MCAS diagnosis, visit the link below and find out about a clinical trial on a medication for MCAS that may ease allergy and pain symptoms.

Mast cells are important cells in our immune systems that help us fight off sickness, infections, and allergies. Although these cells are vital to protecting our bodies, some peoples’ mast cells can be too active for no good reason. In these cases, the mast cells might cause more harm than good. When Mast Cells are overly active, Mast Cell Activation Syndrome (MCAS) may sometimes be diagnosed. In MCAS, Mast Cells release excessive chemicals into the bloodstream. This reaction can cause swelling, hives, coughing, and pain.

There are three main types of MCAS that are recognized:

1. Primary
2. Secondary
3. Idiopathic.

Primary MCAS is when the bodies’ mast cells clone themselves excessively. In these cases, mast cells gather in organ tissues in excessive numbers. Symptoms of primary MCAS can occur in pretty much any organ in the body. Common symptoms are allergy-like. For example, skin rashes, hives, and abdominal pain. Especially serious cases of primary MCAS can be called mastocytosis, a life-threatening condition that can cause serious allergic reactions called anaphylaxis.

Even though you may have not heard of it, you are probably familiar with secondary MCAS. Do you have any allergies? If so, you may have secondary MCAS. Secondary MCAS may be diagnosed when a person experiences allergic reactions, for example, to nuts or shellfish. Unlike in primary MCAS, mast cells do not clone themselves abnormally in second MCAS. In fact, people with secondary MCAS have a perfectly normal amount of mast cells. However, these mast cells are overactive and release excessive chemicals into the bloodstream (such as histamine), which cause allergic like reactions. Some examples of environmental triggers can include pollen, food, and alcohol.

Idiopathic MCAS is an interesting condition that can be frustrating for patients who have it. This is because these patients experience allergy-like symptoms, but they are not allergic to anything. In other words, idiopathic MCAS can cause seemingly allergic reactions for no reason at all. For MCAS to fall into the idiopathic category, there must be no evidence of an excessive amount of mast cells (primary MCAS), and the allergy-like symptoms must not be triggered by an actual allergy. For someone to be diagnosed with idiopathic MCAS, the doctor must make sure that they rule out all potential causes of the allergy symptoms.  Although not typically, patients with idiopathic MCAS may still have serious reactions (anaphylaxis).MCAS in all its forms is treatable through different strategies. Helpful interventions for primary, secondary and idiopathic MCAS may include antihistamines to calm allergy symptoms. For cases of secondary MCAS where the allergic trigger is known, lifestyle changes can go a long way in calming down mast cells.

Are your “allergic symptoms” and pain related to idiopathic Mast Cell Activation Syndrome (MCAS)?

Hives, rashes, itching, problems breathing, and pain in your stomach or other parts of your body may all be related to allergies. Your doctor may have tested you, but did not find what you might be specifically allergic to, for example types of foods or substances surrounding us like pollen, dust, and mold. If you didn’t have evidence of an allergy to any or only a few of these substances, then what is causing your symptoms?

Your symptoms may be caused by excessive activity in a special cell in your body called the Mast Cell (MC) which is stimulated whenever you experience any irritation. The MC helps to fight off infections and help repair damaged tissue by producing many different powerful substances. However, when it is overactive, these substances may be produced by the MC after exposure to ordinary stimuli including a hot shower, sunlight, perfumes, cleaning solutions, and a variety of foods. Overactive MCs may cause diffuse pain in various parts of your body.

Doctors have been aware that increased numbers of MCs can cause serious symptoms in different organs. When there are too many MCs the diagnosis is often Mastocytosis, which requires specialized treatment. When the number of MCs is normal and the MCs are just overactive, the diagnosis, which is a relatively new discovery, is often idiopathic Mast Cell Activation Syndrome (MCAS) and can be diagnosed with several blood and urine tests. However, if you have symptoms in 2 or more organ systems, for example skin rashes, heart burn, asthma like symptoms, and your symptoms improve with an anti-histamine, you may be diagnosed with idiopathic MCAS without complicated testing.

Our body makes a substance that can down-regulate the activity of the MC. It is called palmitoylethanolamide (PEA). It is in the family of substances, called cannabinoids, and is related to the molecules that are present in marijuana. Other substances can down regulate the MC such as Cromolyn Sodium. Since one of the main substances produced by the MC is histamine, medications that block histamine. such as antihistamines used for allergies and histamine antagonists used for heart burn, may be helpful in reducing the symptoms of overactive MCs.

If you have diffuse pain and other symptoms, like the ones above, that have been difficult to diagnose and treat, you may have MC problems that can be treated.

How do we test new medicines before they are released to the public?

Let’s say for the sake of this example that there’s a new drug that is potentially effective at treating people with muscle pain. The process to test that treatment is called clinical trials. To test the medicine, clinical trials occur in different stages, called phases. Phase I testing is done on healthy volunteers without muscle pain. If the drug is found have unsafe side effects, it would fail phase 1 and be withdrawn from further testing. If the drug passes Phase 1, it goes on to Phase 2 which studies a small group of patients with muscle pain to see if the new drug is effective in treating the condition without producing serious side effects. If the drug passes Phase 2 it goes on to Phase 3 which tests a larger group of patients with muscle pain to confirm the effectiveness and safety found in Phase 2.

There are strict guidelines that researchers must follow when conducting clinical trials to ensure the safety of their human subjects. Regulatory bodies such as the FDA monitor clinical trials to ensure that all guidelines are being followed. If the physicians in charge of a new drug trial are found to not follow the guidelines, they are removed from their trial and may lose their ability to participate in any future trials.

Participation in a new drug study can be an exciting experience–especially when it results in a decrease or elimination of your symptoms. Before a patient begins a clinical trial, all the possible risks that may occur during the study are spelled out in a document called the consent form. The consent form is signed by the participant before they start treatment. The consent form makes it clear that declining to participate in a study will not affect the participant’s future care, and that they may withdraw from the study at any time for any reason.

A drug study is an experiment. To ensure that enthusiasm about the new drug doesn’t influence the outcome–for example hoping that the treatment is going to work will make you believe that it works–some participants will receive an inactive drug called a placebo. Whenever possible, the physician administering the drug will not know if they are giving you the real drug or the placebo. This type of study, where the physician and the study participant do not know which medication they receive, is called a double-blind study. Participants are informed at the end of the study if they received the active drug or the placebo.

Some drug trials provide financial compensation for time and participation. Some trials will only compensate you for any expenses that you incur in the process of participating in the study. Participation in a study may or may not benefit you directly but will potentially benefit many patients in need of new effective treatments.

A recent study done in Turkey took a look at the walking patterns of chronic pain patients- ideopathic neck pain, to be specific. They based their hypothesis around previous studies that have shown that people with chronic ideopathic neck pain (CINP) had abnormal walking patterns (known as gait), whether it be in the physical pattern or in the timing of their walks.

The scientists recruited 20 individuals with CINP as well as 20 healthy individuals without CINP to perform 10 minute walking tests with pressure sensitive insoles inserted into their shoes. They performed three different tests: Preferred walking, preferred walking with head rotation, and walking at maximum speed.

The study showed that individuals with CINP had a slower gait speed in all three walking conditions compared to the control groups. The gait was also found to be asymmetric in individuals with CINP in two out of three of the different test groups. This is important because gait asymmetry has the potential to load your entire body unequally, causing unbalanced strain on your muscles, joints, and other problem areas. These can lead to other musculoskeletal problems in the future.

Here at Norman Marcus Pain Institute, we see many patients with chronic pain everywhere, not just in the neck. We also often see collapsed arches in patients’ feet as well as uneven strides that can be magnifying discomfort on one side of the body vs the other. Recently we have started recommending special orthotics designed to strengthen and correct imbalances and weak arches. We occasionally recommend that our patients see a professional gait analyst to find ways to correct these imbalances to relieve some of the strain that their muscles may be experiencing.

In May 2017, there were several changes in the criteria for the diagnosis of what used to be Ehlers-Danlos Syndrome Type III, hypermobility type. First, the name has been changed to hypermobile Ehler-Danlos Syndrome or hEDS. Instead of six types, there are now 13 types.

hEDS continues to have no obvious known genetic testing and is only diagnosed through clinical testing.

As mentioned earlier, the Beighton scale is used to determine if a person is hypermobile. This continues to be an important determinant for hypermobility. A 5/9 score in adults is needed in order to meet this requisite. However, because age has an effect on flexibility (ie with age, you tend to become stiffer), there is a Five Point Questionnaire that determines if there is a history of hypermobility. The five points are the following:

• Can you now (or could you ever) place your hands flat on the floor without bending your knees?
• Can you now (or could you ever) bend your thumb to touch your forearm?
• As a child, did you amuse your friends by contorting your body into strange shapes or could you do a split?
• As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?
• Did you consider yourself “double-jointed”?

If you answer yes to two or more questions, then you have met the criteria for hypermobility (with 80-85% sensitivity and 80-90% specificity).

The Beighton Scale and Five Point Questionnaire are the first part of three criteria that need to be met in order to qualify for the diagnosis of hEDS. This criterion also meets the diagnosis of hypermobility (you can have generalized joint hypermobility without a diagnosis of hEDS).

The second criterion has three parts (A, B, and C), of which two must be met to qualify. Part A is a series of 12 symptoms, of which five must be met in order to quality:

• Unusually velvety skin
• Mild skin hyperextensibility
• Unexplained striae on back, groins, thighs, breast or abdomen in adolescents, men or prepubeteral women without a history of significant gain/loss or weight.
• Bilateral piezogenic papules of the heel
• Recurrent or multiple abdominal hernias (umbilical, inguinal, crural)
• Atrophic scarring with papyraceous or meosideric scars
• Pelvic floor, rectal and/or uterine prolapse in children, men or nulliparous women without a history of morbid obesity or other known predisposing medical conditions.
• Dental crowding or high or narrow palate
• Arachnodactyly (fingers & toes, long and slender), Steinberg Sign (thumb beyond palm), Walker-Murdoch sign (thumb overlapping fifth finger around wrist)
• Arm span to height ≥ 1.05
• MVP
• Aortic root dilation

Part B is a positive family history of one or more first degree relatives, independently meeting the criteria of hEDS.

Part C is musculoskeletal complaints; a patient must have at least one to qualify:

• Daily musculoskeletal pain at least three months in two or more limbs
• Chronic widespread pain for more than 3 months.
• Recurrent joint dislocation or frank instability in the absence of trauma (A or B)
  • 3 or more atraumatic joint dislocations in the same joint or two or more atraumatic dislocations in two different joints occurring at two different times.
  • Medical confirmation of joint (2 or more) instability

The third criterion contains three pre-requisites, all of which must be met:

1. Absence of unusual skin fragility which should prompt consideration of other types of EDS.
2. Exclusion of other heritable and acquired connective tissue disorder with autoimmune connective tissue disorder (ie Lupus, RA).
3. Exclusion of alternative diagnoses that may also include joint hypermobility by means of hypotonia and/or CT laxity. Alternative diagnoses and diagnostic categories include, but not limited to, neuromuscular diseases, myopathic EDS, Bethlem myopathy, or HCTD (ie other types of EDS), Loeys-Dietz Syndrome (Marfan), and skeletal dysplasias (ie OI).

References

American Journal of Medical Genetics, Part C. (Seminars in Medical Genetics), March 2017.