The “New” guide to hypermobility – Part 2 – Everything changes, including you!
If everything changes, why would you be any different? The truth is you’re not! And when it comes to being hypermobile, it’s kind of important to realise what changes actually matter. Let’s start this part with a fact! Did you know a banana is around 74% water?
When you first came into the world all those years ago, you came in 1% wetter than a banana. So at around 75% water, you were pretty wet. However, in just 0ne year, you dropped down to about 65% water. By the time you entered adulthood you are around 60% if you are male or 55% if you are female. And by the time you become “officially” elderly, water will make up around half of your body. If one thing is certain in life, it’s that you are slowly drying, see what I did there :-). But, why does this matter? Because if you’re hypermobile, it’s going to affect you.
As a member of the human species, you are subject to the same eventual degeneration and drying out, just like everyone else. So, when you age and suffer from hyperlaxity, you are going to find yourself becoming less hypermobile over the years. Now while this may not sound too bad, you need to remember that for the last 30 years of your life, you have probably been instinctively subluxing your joints into the positions you needed, instead of using the muscle.
Those who are hypermobile tend to participate in exercises like stretching and yoga classes as they find it is generally an easier form of exercise and the harder poses come more naturally to them. The problem is when stretching (unless they have an unbelievable mind to muscle connection), an individual with hypermobile joints will subconsciously, either through subluxation or moving way past the normal range of motion, rearrange the joints to get around the tight tissue that would limit them. HM folk have incredibly tight and active muscles, a compensation method so to speak, designed to counter lax tendons. Just because you can keep your legs straight and touch your hands to the floor does not make you flexible (in this case), it makes you Hyper Lax.
Over time the brain and nervous system will re programme you to only ever use the tissue laxity to manipulate the joint, getting the desired range of motion. When this happens it creates weakened, over active, under active muscles and huge imbalances in the body which, (dependent on perception) may bring on pain. So, if you have spent many years moving in this fashion, as you grow older and your tissue isn’t as lax as it once was, you are going to experience a lot of restriction in moving.
3 stages of hypermobility
If you are HM you are going to move through 3 stages over the years. This for me is by far the most important take home message. Obviously, there is going to be some give in the age range and onset of pain, as remember, there is a lot more to pain than simply Pain=Damage.
Stage 1 (0-12) -Hypermobile with no joint pain (generally). This stage of hypermobility is where people generally find it useful, engaging in exercises such as gymnastics and dance, taking advantage of the tissue laxity.
Stage 2 (12-35) -Hypermobile with joint pain. Unfortunately, there isn’t a huge body of research on this or indeed as to why this part of life may cause so many problems for HM folk. However, as puberty starts, an increase in the hormone progesterone increases, which is known to have a loosening effect on collagen. This is partly why a lot of female HM sufferers become so much worse approaching their period. Usually, it is this stage that other conditions such as POTS start to manifest.
Stage 3 (35+) -HYPOmobile- Now these guys are the group of people who everyone seems to forget about. After years of bouncing off already lax ligaments, 1000’s of dislocations and years of pain, the body will stop spasming weak under-active muscle in hopes of bring the joints together and will instead, start to size up and, in some instances, fuse. Anyone reading this over the age of 40 and possibly even younger will attest to what I am saying. I normally see that the first places to size up are the thoracic spine and the pelvis. It’s completely understandable why anyone in such pain would want nothing more than to stay in bed dealing with their pain all day, but this, unfortunately, is one of the worse things you could do. Doing less in response to pain (not only at this stage) can start a downward spiral: symptoms worsen, stamina decreases, central sensitization can occur due to become so efficient in creating pain and the fatigue worsens. Much effort must be made to effectively learn to use the muscle, in the fashion it is supposed to be used. Muscle is used as the first call for stopping the joint at the end range of motion. It provides stability and stops you from hyper extending and stops you from “bouncing off ligament”.
Ligaments are not like muscles, they do not have the same elasticity. They cannot respond to a resistance load the same as a muscle, and if a muscle fails to stabilize a joint, the body will use the next best thing….Ligaments. Should this over time become ineffective the body will spasm the surrounding muscle of a joint as a last ditch attempt to pull the joint back together. It is very common in those with hypermobility, due to low muscle tone and other factors, to use lax ligament (attaches bone to bone) to get the body into the position they are after. This can cause many problems over the years. It can change how you move, making you less stable and forcing you to guard more. You may even find that due to the instability, you may hold your breath during harder parts of walking, which can cause an increase in the severity of things like POTS (something not uncommon to see in those with hypermobility). The repetitive hyperextension can leave you wide open to sustaining many injuries, damaging ligaments, cartilage and other important stabilizing structures.
The standard scenario for a lot of people is as follows;
You’re stood for lengthy periods of time, you zone out, your knees lock out, your hip shifts to one side to compensate the supporting load of your upper body and because of your inability to stabilise the knee joints using muscles, the ligaments act as the stopper. Over time, the repetitive force applied to the ligaments only makes matters worse, as they are now effectively carrying loads that were meant for muscles.
Same old bull sh*t
So, you’re probably wondering when we are actually going to start talking about what we can do to start reducing, and in some people cases, eliminate subluxs and dislocations! Well, it’s coming I promise! There is just so much of the same old crap all over the internet and so many myths that stop people succeeding before they actually get started. Some of the stuff around on hypermobility is incredibly useful. But, without proper application is pretty useless and not to mention its all really hyped!
Take for example muscle strength, something which is really glorified in many articles on hypermobility. Although increasing strength can be incredibly beneficial; it’s still just one part of a whole. If your proprioception is something to be desired, then it doesn’t really matter how strong you are, you can still sublux. Focusing on increasing muscle tone is a far more beneficial way to focus your energy and time.
Muscle strength is defined as the maximum amount of force that a muscle can exert against a form of resistance in a single effort.
Muscle tone, however, is the degree of muscle tension or resistance during rest or in response to passive stretching.
So let’s break that down. Muscle tone is pretty much the background tension within a muscle at rest. Think of it like this:
Your friend Linda calls you for a chat. You engage in conversation and pretty soon you start to relax and zone out. Due to the random activation of a small amount of muscle motor units, even when you’re stood and zoned out, you’re actually not really resting. While the conversation with Linda has your attention, your body is autonomically holding everything together; stabilizing that hip, knee or ankle joint. After a while, you may get uncomfortable standing up and you start to shift your weight. Your body is still running all the background programmes, working very hard to help re-balance itself every time you shift your weight on to one leg or when you hold yourself in strange and awkward positions, just as most of us do whilst on the phone. The problem for those with Hypermobility is that due to the low muscle tone, the muscles don’t engage, the force transfers and ultimately hangs off your ligaments. So, for those with limited energy, we definitely want to get the most bang for our buck when it comes to training, which remember, is just a small part of a big whole.
Proprioception – The unconscious perception of movement and spatial orientation arising from stimuli within the body itself. Proprioception is what you use when for example you drive anywhere. You drive around navigating the roads, you change gears and you know exactly where the gear stick is in relation to your body and the space around you. When you need to brake, your foot moves from the accelerator to the brake without you looking to see where the brake is. Proprioception is an unconscious perception of movement and spatial awareness from within the body. Proprioception (or lack of) plays a huge role in the reason we repeatedly injure the same body parts time and time again.
The good news, however, is that you can train to improve it and to be honest, it’s actually pretty easy. Creating a stronger proprioception feedback loop will give you greater protection against dislocations and subluxations. One of the most common things I hear from those with hypermobility is that they feel they are unaware of where their legs are and this all comes down to proprioception. Increasing muscle tone is important for those with HM. But, when you combine increased muscle tone, with increased proprioception, then we start to get somewhere. Lots of people with HM have impaired proprioception, which means they can easily hyper extend and never really know they are doing it. This obviously is going to cause a problem if we want to stop the repetitive hyperextension. Many articles I have seen online, focus far too much on muscle and fascia and the role they play in proprioception. There has been, is and will be, one part of you that if you focus your time on, will yield a huge improvement in proprioception…Skin! But, when we get to part 3 we can get into that 🙂
New fad on the block
In my industry and indeed many others, each decade has its fads, it’s new ways to create problems that don’t exist and ultimately cash in on. The new fad on the block at the moment seems to be fascia. People are spending £90+ on “Fascia blasters” or spending their time “releasing” their tight muscles with expensive foam rollers. Everything you do to your body is an input. Every input to your body creates an output. You may feel looser after rolling on a foam roller, but, you have not made the slightest bit of sustainable change to the actual tissue. Better off trying to stretch the tyres on your car….you would have more of a chance. All you have done is put an input into your nervous system and your brain created an output. Touch is an incredible important part of the human experience and is an input, an input that can create a pretty strong output. Remeber the flood of chemicals or euphoric feeling the first time you held a partners hand. or even how safe you felt whilst crossing the road holding a parents hand as a child.
We need to get out of this purely mechanical way of thinking. There are so many other factors that influence the physical from what you believe, your emotional state and what you perceive to name but a few.
Let’s do an experiment!
- Hold one arm out to the side, just like in the picture.
- Now get someone to put their hand on top of your hand.
- Don’t look at the other person; instead, focus on your hand.
- Ask the other person to pick a number between 1 and 10, but not to tell you.
- Ask them to count to that number in their head and when they reach it, try to push your arm down and I want you to resist.
- Keep your focus on your hand and tell the other person to start counting and resist them when they try to push your arm down.
Feel how strong you are? Now let’s make you instantly weaker!
You are going to do the experiment again, but, this time as your partner starts counting in their head, I want you to close your eyes. Feel how much weaker you are? Now you haven’t suddenly had a massive amount of muscle waste away. But, you did take a pretty important sense away that we use for assessing danger. You did slow down a lot of postural reflexes that provide you with a lot of stability. I see this kind of output change a lot in my 80-year-old clients. They come through the door and they always tell me the same thing “my muscles have wasted” and I say the same thing to everyone…”They haven’t, your body just won’t let you create that much force for protection”. In the UK, 1 in 3 accident and emergency visits for the elderly are due to a fall. This is something that is becoming increasingly worse. Most of my elderly clients come through the door and can not get down on the floor or they can, but they just can’t get back up. Normally, it takes about an hour before they can do it again.We don’t focus on strengthening their muscles, we don’t exercise, we start somewhere very simple. We spent most of the session on the floor getting rid of bad association’s. Ask anyone on the street what happens to an elderly person after a fall and you are greeted with pretty much the same response. “it’s usually downhill from there”. A fair assumption, to be honest, a lot of elderly folks do go down hill following a fall. A lot of elderly people have bad associations with the floor. They may have fallen before and took months to repair the damage that was done. Some feel weaker in their old age and fear falling and what it may lead to.
Ultimately though, the body will become protective. In the same way that you just became weaker without muscle wastage, elderly peoples ability to get up off the floor dials down to protect them. If the body doesn’t let them get up, they can’t fall and get damaged. So, before I even think about exercise for this type of client, bad associations need to be removed. We may spend half an hour on the floor, on our hands and knees, we may play a game down there, sometimes I like to go through the first couple of movements of getting up. Sometimes, I may even show someone a video of another 70+ client at the start of the session unable to get up and a video of the same person at the end of their session getting up. Most of the time you can help some one within an hour to be able to get up and down onto the floor, even after years of being unable to. Remeber, beliefs and perceptions create powerful outputs, be that the illusion of “poor posture” or how you perceive something. Focusing solely on the physical may get some people where they want to be, but, for most people its not enough!.
Your “weak” and “painful” core
Before we get to Parts 3 and 4 where we will start to discuss the things we need to be doing to help ourselves.There is just one more myth we need to talk about!
Over the years I’ve used the same assessment test to see if someone has a weak “core”. If they can walk through the door, their core is fine.
The “core stability” myth, is probably one of the biggest and in my opinion, damaging myths still going. Even despite the evidence to debunk it!
“I have a weak core”… No other words make me want to slam my face into a wall as much as these ones! If the next professional you see tells you that your pain is caused by a “weak core” then please, ask them to show you the evidence that a weak core causes back pain (There isn’t any). In fact, the very word “Core” is incredibly poorly defined. When you lift your arm up, muscles like your transverse abdominal fire automatically before hand. Through research, we find that it happens before you even lift your arm. One of the great joys of human movement is that postural reflexes (like TVA activation) are started in anticipation of movement and outside influences that affect balance. What an amazing thing the body is, movement, pre-programmed in to do everything important, automatically, in a form type of movement patterning. Have you ever played darts? If you have you will know there gets a point where you almost “will” the dart where to go. Through absorbing different sensory information, postural reflexes, repetition and many other factors, you programme your patterning movement until they become automatic and easy. Do you think a footballer makes sure that they have their stomach drawn in and their posture “correct” before they score a goal? Most certainly not. Practice makes perfect and the more you do something, the better you get. This can work for us or in the case of some hypermobility, against us. Just like how you have trained yourself to use the joint laxity to get to certain positions.
One tissue, in particular, gets preached in core stability, by pretty much every person living in the Jurrasic era of health care. The elusive “Transverse Abdominals (TVA)”. The TVA is the deepest of the abdominal muscles and while it does indeed play a part in spinal stability, it with works together with other muscles (including the back) that make up the “core”. The involvement of these muscles can even change depending on the task at hand. Spinal stability is a product of many systems including bone, ligament, muscle, and most important of all, neural control. Exercise addresses both the muscular and neural function. The very notion of a “weak” core, can cause some very serious problems for people. Believing your core is weak can lead to “Guarding” a protective response where in you create stiffness, change how you move and can begin to become more sensitised to potential danger. Guarding may lead more protection responses such as spasms after prolonged straining of the tissues.
If the human species was supposed to be infatuated with core training because the body was so inherently weak, then why is not every single obese, or pregnant, or breast cancer survivor or anyone who has ever had a hernia repair, not in terrible back pain?
During a breast reconstruction, one side of the rectus abdominals is used in the reconstruction. This ultimately leaves the patient with abdominal weakness. However, despite this, there is still no evidence linking this to back pain. Pregnant women go through huge body-wide changes during pregnancy including, truly impressive abdominal wall elongation. Even after 9 months of stretching the tissue, delivering a baby, waiting 8 weeks to regain pelvic stability and for the tissues to re-shorten, there would be a period of terrible spinal instability. Through studies done on this topic, there is still little evidence that spinal stability plays a part in lower back pain during pregnancy. In fact, researchers studying effects of cognitive-behavioural approach, compared with standard physiotherapy, found some interesting results. During the study of 869 women after child birth and during a period where the rectus abdominals had not re shortened. 635 of the woman had to be dropped from the study after making a sudden, unaided and unexpected recovery in the first week.
So, if you look at the evidence it just doesn’t add up to what we have all been told! A weak “core” does not cause pain. Constant drawing in of the stomach may actually do more harm than good. Whilst core stability exercises can help to ease back pain, they are no more effective than any other exercises. As im probably going to say a lot in this guide, Pain is complex, it’s not just a case of one simple cause and it’s most certainly not just Pain=Damage. Some people will have tried core stability exercises and had no improvement what so ever. Some will have seen a great improvement. It’s important to realise that a weak core does not cause pain. Simply returning to movement and understanding how inherently strong you are can yield massive results! In fact, Ill show you a client of mine who did no core training whatsoever and went from crutches, multiple subluxs and terrible pain to…well click here and you can see for your self. Or you can click here and see someone go from a wheel chair and a stick, to being able to run, all without ever doing a core exercise. You are an integrated unit, everything works together, the muscles in your trunk, the nervous system and the muscle and more importantly……Your beliefs and your limitations. Take a look at the evidence for yourself 🙂
As always, gentle hugs.
Coming in part 3- What we should be doing 🙂