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Hypermobility vs Physical Therapy

Why traditional physical therapy approaches often don't "work" for hypermobile adults

When we look at the adult US population as a whole, a large portion of them are "hypo mobile" or stiff. This can range from a geriatric population who is significantly limited, to a younger population who works a desk job and doesn't get enough exercise. When they do get injured or have pain, the formula can be rather simple. Start local with the painful joint and surrounding areas - mobilize what it stiff, strengthen what is weak, and eventually involve the other joints for a "return to functional movement."

I started my career largely working with this population and we would start on the table or in a chair with specific exercises for the joint at play and then expand to involve the others as things got better. (In reality, there can be a lot of complexities here as well, I am making it sound a lot more simple then it is but you get the point).

However, as I moved into treating the hypermobile population, I realized this approach often did not lead to a decrease in pain and sometimes made people feel worse. As I began to study this population more and more, I realized why. People who have hypermobile joints, and even more so in people who have widespread hypermobility and Ehlers Danlos Syndrome tend to lack proprioception - or the ability to know where their joints were in space. So - when we did table single joint - focused exercises things would go ok, but as soon as we started to get more functional that ankle that we worked so hard to strengthen would be facing the wrong way, or the shoulder blade would be sticking 2 inches out from the ribcage, and now the exercises were not only ineffective, they were painful. When I would tell the client "foot forward" or "shoulder blades tucked" they would look like a lost puppy trying to realign things. Therefore, progress would be stalled.

In other scenarios, we couldn't even get to that point because I felt we weren't progressing enough on the simple stuff. A gripping exercise that I expected a patient to be able to do 100 of would fatigue them so much by 15 or 20 reps that pain would set in and they would have to stop. Or after 5 calf raises they would have to sit down. How were we ever going to get to jumping and lifting and carrying if we couldn't get through this simple stuff? This time, it wasn't proprioception, but rather communication that was the issue. And funny enough, I realized this shaking a patients hand after a session.

I had put my hand on the gentleman's shoulder while shaking hands, and recognized the absence of really any muscle contraction in the shoulder. Although I had never realized the presence of it before, the absence was loud. This prompted me to research, test, research and test some more and I found that so many of my hypermobile clients REALLY isolate the muscles they are using, and don't communicate with some of the larger muscles closer to the spine to take any of the load off. Therefore, they were using only the small local muscles in some of the exercises, working harder than they need to. No wonder they would fatigue so easily. Our larger muscles and our core are meant to stabilize our body so the small muscles have to do the small movements. In this population, many people are using the small local muscles for EVERYTHING. Of course there is going to be pain and fatigue.

So, what did I change? Well, I pretty much flipped my treatment approach for people with hyermobility upside down and inside out. Instead of working from individual joints to whole body, we need to work from the center of the body out to improve communication. We need to start with some loading (bands, light weights, etc ) and PROGRESS to unloaded activity to improve proprioception. All of a sudden I was able to get my clients back to what they wanted to do. We weren't stalling anymore, just taking a new approach.

Of course again, it is not that simple and there are a lot more complexities and individual needs, but correcting these two areas, and differing from my treatment scheme for my "normo-mobile" or hypo mobile clients made a huge difference. Unfortunately, in many PT clinics treatment is done more with a rigid mindset or a cookie cutter approach. Therapists are juggling many clients at once and don't have time to tell the aide to do exercises in a different order. There are other people using the equipment so they have to modify and sometimes these hypermobile clients get lost in the sea with others and end up in the same approach where they get stuck or even worse, worse.

That is why at Perfect Ten I decided to treat all clients one on one, we can work through problems together and do things in any order we need to to improve proprioception, communication and any other issues that you have. If you are hypermobile and feel like you would benefit from this approach, click here and provide me with some information so we can talk on the phone about your needs and goals and how to reach them!

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