10 years ago, I wrote a blog titled: Hypermobility – A Blessing or A Curse? Back then hypermobility was barely recognised, very misunderstood and often undiagnosed. Thankfully this has changed to a lot with still much room for improvement.
Whenever I bring up this topic in my workshops or trainings it turns into a big discussion because hypermobility is hugely over-represented in the yoga community (myself included). In the yoga subculture people with hypermobility are celebrated as if they are the ideal. This lionisation of flexibility can be problematic if hypermobility is not approached with a respectful, healthy attitude.
Hypermobility is when joints move beyond the expected range. What is confusing about this condition is the wide range of variability that it can express, hence the new diagnostic term of Hypermobility Spectrum Disorder. You can have generalised joint hypermobility, which does not cause pain or dysfunction, i.e., you have no symptoms other than very bendy joints. Whereas, at the other end of the spectrum, are those whose joints are so mobile that they need multiple surgeries to stabilise them and/or are so dysfunctional that they are bedridden and need a wheelchair to move. Everything in between these two poles is classified as Hypermobility Spectrum Disorder (HSD).
DIAGNOSIS
Unfortunately, there is no definitive diagnostic test for HSD. HSD is diagnosed by an extensive medical history, a physical exam and the elimination of other conditions. The primary feature is that people have symptomatic joint hypermobility but do not meet the criteria for other connective tissue disorders, such as Hypermobile Ehlers-Danlos Syndrome (hEDS). However, both are diagnosed by applying the 2017 Diagnostic Criteria.
If you suspect that you are on this spectrum, the Beighton’s scoring system is a quick screening tool. However, it is very incomplete. It only covers five joints in the body (albeit ones that are less disguised by muscle tension) and does not account for age-related changes in flexibility, i.e., children are naturally much more flexible than adults. Contentiously, it is one of the tripartite criteria used in the 2017 diagnostic criteria. You can read about the Beighton’s scale and the old Brighton Criteria that was used prior to 2017, to better understand the possible signs and symptoms of HSD and hEDS. (Go to 8 Limbs’ website’s blog page).
ALTERED PROPRIOCEPTION
I often say to students “If you’re stiff you have one problem: you’re stiff. But if you’re hypermobile you potentially have as many problems as you have joints.”
Aberrant protein synthesis and collagen production in HSD and hEDS leads to compromised structural integrity of ligaments, tendons, and other supportive tissues surrounding our joints. These weakened connective tissues result in altered proprioception (our innate sense of our body’s movement, orientation and position). This especially happens in extreme ranges of motion, which poses a higher risk for yogis who are often playing at that edge. The problem is that hypermobile people have less awareness and control in midrange, so they love to go to their end range as this is where they can actually feel something! An important role of proprioceptors is to help provide congruity and keep our joints well aligned. Excess mobility can be likened to wearing shoes that are too large. The loose fit means excess movement between your foot and shoe. This extra wear and tear is the reason for the increased susceptibility to osteoarthritis and it is a major cause of the frequent sprains, strains, instability, pain and, in severe forms, dislocations that happen in this population.
Any misalignment, imbalance or dysfunction of joints will cause the surrounding muscles to tighten in an attempt to stabilise and protect that area. However, muscles cannot fulfil the passive stability role of strong connective tissue and will tighten and spasm. This is why people with HSD and hEDS actually feel stiff and gain a lot of relief by stretching. Another reason for feeling stiff is the inappropriate inflammation that can accompany these conditions. This can lead to fibrosis or scaring which also results in the stiffening of tissues.
Additionally, with normal proprioception the body signals the brain a message as to where the joints are positioned. However, the aberrant proprioception of HSD and hEDS means that the body is constantly bombarding the brain with messages as to where the joints are positioned. This results in an overstimulation of the sympathetic nervous system which often induces a general sense of anxiety.
WHAT COMES WITH IT
As connective tissue is ubiquitous in our body, this condition can have wide-spread effects. Besides joint problems, those who are more severely on the spectrum of HSD and hEDS are prone to multi-organ co-morbidities, like gastrointestinal problems, headaches, migraines, menstrual pain, extreme low blood pressure, POTS (postural orthostatic tachycardia syndrome), an overactive nervous system, dysautonomia, Mast Cell Activation Syndrome (MCAS) chronic fatigue and more. HSD and hEDS are also associated with ADHD and autism. Many of these conditions contribute to the pain, fatigue and anxiety that often accompany this spectrum.
It is well established that this population has sensory sensitivity and enhanced empathy. We’re more sensitive to smells, sounds, bright lights, chemicals and even vibes! We do feel differently and may be described as “too sensitive“, “over dramatic”, “very fussy”, “too particular” or even “difficult to please”. But our sensitivity also enhances everything on the positive side of the rainbow of human experience. We have an enhanced potential to read people’s feelings, to appreciate scents and sounds and scenes and beautiful experiences.
THERAPY & A HEALING PERSEPCTIVE
The goals of therapy are to manage any symptoms, prevent joint injury and educate ourselves to reduce pain, improve function and enhance quality of life. Although it is usually considered that those with hEDS may face more severe and extensive multisystem involvement, someone with HSD can present with the same symptoms as someone with hEDS and so the management advice is the same for both and often requires a multidisciplinary approach.
If you are on this spectrum, physically you need to work on enhancing your proprioception, balance, stability and strength and not so much your flexibility. Many experts would say you should not even do yoga āsana, however, done with consideration of all of the above, yoga has too many benefits to abandon it. With hypermobility syndromes it is important to work the breadth of your mid-range of motion with awareness and control that you can build the extra strength that your joints need to be stable. At the same time, I would recommend that you avoid your final end range of motion, not hang off their joints or hold end ranges for long periods of time. Our connective tissue has less strong collagen and cannot support us in these positions. Instead, use stretching as a therapeutic tool rather than as an indiscriminate way to become even more flexible. What is needed is adequate strength surrounding the core of our joints. Muscle co-contraction and high resistance partial range training are excellent ways to achieve this.
Also, with HSD and hEDS, when you overstretch your joints you don’t feel it at the time, there is a delayed onset, and this makes correcting your practice to suit your body even more challenging. What is important is to develop body literacy, i.e., reading your body, understanding its signals and responding to its feedback by adjusting your practice to suit. One size does not fit all!
It is challenging and fun to be able to do all sorts of wonderful, if not weird things, with our body. However, if we damage ourselves at the same time we need to question our actions and especially our motives. It is a misconception to believe that every different body can or should be able to eventually perform all complex or flexibility-demanding postures with adequate practice. And if you already can, my question is: At what price? If you’re on the spectrum you are not as robust and when you overdo it you will pay more for it more than others and you will be less efficient at healing. The accurate saying goes: “God will forgive you but your body won’t”.
The excessive flexibility that many admire in the yoga world is often something people are born with and it is not always a blessing. Those not born with hypermobility, in an attempt to reach the same degree needed for extreme ranges of motion that some postures require, often destabilise their joints resulting in instability and injury. In my 40+ years of teaching I have seen that hypermobile yogis who push their limits, literally come apart at the seams. Educating yogis on how to stabilise their joints and work from a place of support and strength is the first part of the healing process of their bodies and our perception of yoga.
Excess flexibility is not an end in itself and certainly will never lead to lasting happiness let alone spiritual freedom! Practice yoga to sustain a healthy body by knowing your body type and working with awareness, sensitivity, respect, care, intrigue and always, with great appreciation for what we can do. Let’s readjust our lens and let yoga be the inside job that it is designed to be. Let’s not idolise a superficial trait that makes a circus out of a potentially deep and powerful transformative practice. And let’s not practise ableism* in yoga, a sacred practice that should be all inclusive.
Always with you on the mat
Monica
*to celebrate people just because they can do something that others can’t.