People struggling with HSD and hEDS are often told that to feel better they need to get stronger. Though this advice is not all wrong, it often leads to a cycle of frustration, pain, fatigue and debilitation. It’s little wonder that patients throw their hands up and decide that getting stronger just doesn’t work.
The reality is that people who are hypermobile can and should get stronger, but they need to exercise differently than people without hypermobility disorders.
One of the first things to consider is PROPRIOCEPTION.
This is how a person’s brain knows where each part of their body is during a movement. The brain is trained by repetition to know how much movement will occur at each joint as the body performs tasks. For example, in a non-hypermobile person, the brain can count on previous data to know how much movement will occur at the shoulder, elbow and wrist as a person reaches for something. In hypermobile patients, the amount of movement at each joint is different every time due to the ligamentous laxity of the joints as well as the way the movement is initiated (more on that below!). Therefore, the brain cannot rely on that information and has trouble sensing where each joint is in space throughout the movement. This makes simple movements difficult and often painful.
Second, the central, stabilizing muscles are not working properly. For example, in non-hypermobile people, the central, stabilizing muscles of the core and shoulder girdle will contract a millisecond before a person raises their arm to create a stable base from which the arm can work. This is called ZONE 1 movement. Proximal joints are driving the movement. In hypermobile patients, this does not happen effectively. Thus, the same movement is driven by distal joints pulling the extremity. The core and shoulder girdle muscles have not engaged. This is called ZONE 3 movement. It is a recipe for disaster with lax ligaments at the shoulder that can just keep going and going as they are pulled by the distal joints in the arm. Add to this ZONE 3 movement poor proprioception as well as loose ligamentous structures, and the simple movement of lifting the arm can produce, pain, muscle guarding, chronically poor biomechanics and muscle contraction patterns as well as possible subluxation. Therefore, it is essential to train proprioception and central stability before loading joints with weight. Asking the body to tolerate a weighted movement at the end of a long lever arm without central stability and improved proprioception will result in pain and poor movement patterns.
Finally, pain is a complicated sensation.
Many different things make up a person’s sensation and experience with pain. Stress, sleep, social support, fatigue can all contribute to pain as well as muscle guarding and biomechanical muscle firing patterns that can affect joint positions. Therefore, managing pain can involve a variety of strategies. When preparing to exercise with a hypermobility diagnosis, a person may benefit from manual work like myofascial release, massage, dry needling, Dolphin therapy, and muscle energy techniques to help to quiet pain and the autonomic nervous system before starting exercise.
Every patient with HSD/hEDS has a bit of a different story, and that is where a physical therapist can be helpful. Determining where you are in the process and finding the right starting point is key. You may need to start by calming your autonomic nervous system with relaxation techniques and /or manual therapies. Most times it is beneficial to start the exercise continuum with breathing to eliminate pathological patterns with accessory breathing muscles that can cause head, neck and shoulder pain. Second, follow the breath work with pelvis, SI joint, core and hip stability. Third, practice proprioceptive drills with variation to give the brain as much information as possible. Doing exercises through limited range and focusing on the mind to muscle connection can help build stability as well as proprioception. Monitoring fatigue as a response to exercise and making the necessary modifications also builds confidence and helps to ensure success. Most patients keep some semblance of a basic stability/proprioceptive routine as a warm up before strengthening workouts and use the same principles that they learned with breathing and proprioceptive work when they start weighted exercises to make their journey to get stronger more successful.
If you are hypermobile and are finding yourself caught in the frustrating loop of fatigue and pain when trying to exercise, physical therapy may be able to help!
