05 Jan

The Importance of Physical Therapy for Hypermobility Syndrome

What is Hypermobility Syndrome?

Hypermobility is a description given to joint movement outside of its normal range. Connective tissue is a scaffolding that supports the body and consists of tendons, ligaments, and fascia. Hypermobility Syndrome (HMS) is a group of disorders which involve connective tissue in multiple joints throughout the body. This includes joint hypermobility syndrome, hypermobility spectrum disorder, and Ehlers Danlos Syndrome. There exists a group of signs and symptoms that guide diagnosis of this syndrome. The prevalence is difficult to determine due to under diagnosis. In Wales and the UK, one paper found a prevalence of 194.2 per 100 000 in 2016/2017 or roughly 10 cases in a medical practice of 5000 patients. 

People with HMS usually do have more perceived flexibility which can be used to their advantage for certain activities and sports such as dance, jiu jitsu and gymnastics. Oftentimes this ‘flexibility’ is actually extra motion in the connective tissue of the joints rather than a lengthening of muscles and fascia. This creates higher risk of injury due to poor distribution of forces through the biomechanical structure. More on this later.

People with HMS can experience pain, fatigue, frequent injuries such as dislocations, subluxations, sprains, and microtraumas. They also may appear to be clumsy due to decreased proprioception (this is the body’s sense of its location in space.) Underlying issues of the bladder, bowel, and pelvic floor may be present, as well as impact on the autonomic nervous system (this is the nervous system that runs in the background and helps with bodily regulation) potentially causing fainting or dizziness.

People with hypermobility often have chronic daily pain due to extra abnormal movement within a joint causing microtrauma, wear and tear and inflammation. Injuries can result from frequent, repeated use of muscles, tendons, ligaments, joints, and bones which would not normally bother someone without HMS. Repetitive microtrauma may present as pain due to small tears within the connective tissue of the muscles as well as sprained ligaments, strained muscles, and overstretched tendons. Over time inflammation and microtrauma lead to degenerative type changes also known as arthritis.

Stiffness can, and very often does kick in as we age. Hypermobile adults may not exhibit the same hypermobility they did in their youth. They still fall under the hypermobile spectrum and now present with years of wear and tear experienced as pain and stiffness.

Another component that may lead to pain is the loss of proprioception. Receptors within joints, tendons, and fascia, rely on position and movement to give the body its sense of where it is in space. This information is critical, as the body and brain coordinate movement to obtain a desired position. Often this information does not match up well and persons with HMS are mistaken for being clumsy.

 

What is best: Stretch, Strengthen, or Stabilize? 

The answer is all of the above, however, stabilization will benefit the body more thoroughly for functional activities. One of the backbone treatment techniques used in Functional Manual Therapy that works marvelously for people with HMS is Proprioceptive Neuromuscular Facilitation (PNF.) PNF is the most efficient way to tap into the body’s natural stabilization system of tonic muscle fibers. Research suggests most people in general do well with consistent physical activity. This cannot be more true for those with HMS. Inactivity often triggers symptoms, therefore a regimen of physical therapy is indicated to guide a person back to regular exercise. This is especially true for anyone who wants to participate in sports. An active lifestyle can stave off much of the complaints of hypermobility due to the stabilization required to complete the skills required in sport. It is smart to train specifically for any activity and having a physical therapist who understands your specific needs is key. 

How to pick a Physical Therapist who will work well with hypermobility needs?  

Any physical therapist is well versed in the ‘normal’ ranges of joint mobility. A Physical Therapist should not be, however, preoccupied with the severity of your hypermobility. It is important your PT learn the history of your body and any possible diagnosis. Your functional activities, including any sport skills, will need to be viewed from a number of angles to assess movement strategies. This will allow your therapist to guide you through obtaining efficiency; reducing compensations which may be potential for injury. Part of caring for your body is learning the difference between muscle discomfort due to training and pain due to microtrauma. The term “no pain no gain” does not apply when you have HMS. Pushing past your point of pain or to joint fatigue can create injury. The primary emphasis of physical therapy should be on stabilization and improving motor control. Exercises should be performed in a way that does not over-work any one area, while also emphasizing appropriate body mechanics and movement habits. Progression of exercises need to be slower than standard protocols to allow strength, coordination and mobility changes to occur gradually without injury.

 

In summary, if you suspect you are a person with hypermobility, having an evaluation by a knowledgeable Physical Therapist is a great starting point in helping you understand your condition and how to manage daily aches and pains. Your PT will also help you navigate activity goals that will keep you mobile, as well as any sport skills and performance goals with less risk of injury and pain. It is not uncommon, in fact to your benefit, to have a Physical Therapist that works with you regularly any time you need help to get through a pain flare up or a small injury which will occur.  

For more information on hypermobility disorders please reference below. They were great resources for this blog.

Simmonds, J.V., Masterclass: Hypermobility and hypermobility related disorders, Musculoskeletal Science and Practice, http://doi.org/10.1016/j.msksp.2021.102465

https://www.hypermobility.org

Joanne C Demmler, Mark D Atkinson, Emma J Reinhold, Ernest Choy, Ronan A Lyons, Sinead T Brophy Diagnosed prevalence of Ehlers-Danlos syndrome and hypermobility spectrum disorder in Wales, UK: a national electronic cohort study and case–control comparison. BMJ Open. 2019; 9(11): e031365. Published online 2019 Nov 4. doi: 10.1136/bmjopen-2019-031365

About the Author

jessicaworkman

Jessica Workman received her B.S in Physiology and Neuroscience at the University of California, San Diego in 2009, and her Doctorate in Physical Therapy from University of St. Augustine for Health Sciences, San Marcos in 2012. She started her career in an outpatient orthopedic clinical residency program in Thousand Oaks, CA. In March 2014, she moved to a mixed outpatient ortho/neuro practice specializing in vestibular disorders. Jessica has been treating patients with complex neurological and vestibular diagnoses as well as chronic orthopedic conditions while studying and practicing Functional Manual Therapy® techniques and philosophies. In August 2021, she passed her Certification in Functional Manual Therapy® (CFMT) through the Institute of Physical Art (IPA) with Honors (>90% cumulative average), and is currently training in the Functional Manual Therapy Fellowship Program offered through IPA Physio Orange County. Her philosophy is centered around evaluation of the whole person; working as a team with her patients to ensure they return to the activities which bring them joy.