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Core Exercises for Hypermobility/EDS

Balancing rocks: Hypermobility core exercises
Adam Foster
Latest posts by Adam Foster (see all)

This article is part of our comprehensive guide to exercise and rehabilitation for hypermobility.

Every decade brings its own health and fitness trends. Some fade away quietly, and others dig their heels in. One that has managed to hang around far longer than it should have is the obsession with core exercises. And nowhere is this more apparent than in the world of hypermobility and Ehlers-Danlos syndrome.

Despite years of research painting a very different picture, the idea that a “weak core” is responsible for pain and injury still gets thrown around like fact [1]. It’s plastered across blogs, repeated in fitness studios, and prescribed by well-meaning professionals who may not be up to date with the evidence.

Now, I’ve called core stability a myth before, and I still stand by that. At least in the way it’s been marketed. Because when you start peeling back the layers and look at what the research actually says, you start to see a much more complicated and far less dramatic story. You might expect a theory that came out of the late 90s and was based on a few very small studies to have quietly disappeared by now. But no, it continues to thrive.

And that’s a problem. Because when it comes to people with hypermobility, this old idea of core weakness doesn’t just miss the mark, it can actually do harm. Not necessarily because the exercises themselves are bad, but because they’re often used in ways that increase fear, encourage bracing, and promote a one-size-fits-all model that just doesn’t work.

But let’s be clear. Core exercises aren’t the villain. There is a time and a place where they absolutely have value. The issue is when we lose sight of the bigger picture. We need to stop throwing the whole body into chaos just to chase control over one small part of it.

So in this blog, we’re going to take a proper look at core stability. What it is. What it isn’t. What the science says. And what all of this means for your hypermobile pelvic floor, your joints, and your pain.

The Issues around a hypermobility core stability

Let’s be honest, core stability is one of those terms that gets thrown around constantly but rarely with any real clarity. Most people hear it and immediately think of one muscle in particular, the transverse abdominis, or TVA. It’s the deepest of the abdominal muscles, and yes, it does have a role in stability. But the idea that it’s the single key to preventing pain or keeping everything in place doesn’t hold up.

Your core isn’t just one muscle. It’s a system made up of the pelvic floor, diaphragm, deep spinal muscles like the multifidus, and the TVA. These structures don’t work in isolation. They contract together and adapt based on what your body is doing. Standing still, walking, bending, reaching, or balancing all involve different recruitment patterns.

And most of it isn’t under conscious control. It’s driven by the nervous system. When your brain has a good map of your body and its position in space, it can call on the right muscles at the right time. That’s what real stability looks like. Not tensing your stomach. Not holding your breath. Not pulling your belly button in.

The whole idea that a weak TVA causes pain started from small studies back in the 90s [2]. Researchers noticed a tiny delay in TVA activation in people with back pain. The muscle still fired. It just happened a little slower. Somehow that delay turned into a belief that the TVA was weak, or dysfunctional, or needed to be fixed. But the more recent research paints a different picture [3]. It shows that while the TVA does play a role in stability, it’s part of a team. And that team’s effectiveness depends much more on coordination and timing than on strength alone.

This matters even more if you have hypermobility. With looser connective tissues, your body can’t rely on passive support like ligaments to hold things together. It has to rely more on active control, which means your brain and your muscles have to be in sync [4]. And that’s not something you get from just doing crunches or clamshells. It comes from movement that teaches the body to work as a unit.

So, if someone’s told you that your core is weak and that it’s the reason you’re in pain, it’s completely understandable to believe it. That message has been repeated for years. But the evidence tells us it’s not the whole story. In fact, it may not even be the right story at all.

This is one of the most common beliefs we hear from clients, and one of the most persistent myths in the health and fitness world. The idea that a weak core causes pain, particularly lower back pain, has been repeated so often that it’s rarely questioned. But when we stop and actually look at what the research says, the story is a lot more complex.

Let’s start with something often used to back up this claim: pregnancy. During pregnancy, the abdominal wall stretches significantly, hormone levels like relaxin rise, and core stability is temporarily reduced. You could argue that during this time, someone has the most unstable core they will ever have. Yet a large study that followed 869 postpartum women found that 635 of them recovered spontaneously from back pain within just one week of delivery, without any core-focused rehab at all [1][5].

Now, that doesn’t mean core strength isn’t important. But it does tell us that pain isn’t just about muscle strength. If it were, these women would all remain in pain, but they don’t.

We see similar patterns after certain surgeries. In breast reconstruction, for example, surgeons often use a portion of the rectus abdominis, removing part of the abdominal wall structure altogether. That’s a pretty substantial hit to the core. And yet, there’s still no strong link between this type of surgical weakness and chronic back pain [6]. Some people do experience discomfort or reduced function, but many don’t. Again, it’s not a simple cause and effect.

What the evidence shows is that core weakness can contribute to pain, particularly if it leads to more load being placed on passive structures like ligaments or spinal discs. But it’s not the sole cause, and it certainly isn’t the universal one it’s been made out to be.

In fact, much of the original theory behind core stability came from very small studies in the 1990s that noticed a tiny delay in transverse abdominis activation in people with back pain [2]. That delay, measured in milliseconds, was never about weakness. The muscle still worked. It just fired slightly later. And later studies found mixed results, with some showing no delay at all [7].

This matters especially in hypermobility. People with EDS or HSD often have poorer proprioception, reduced passive stability, and muscle fatigue [4]. Core training might help improve control and reduce strain, but not because the core is weak in the traditional sense. It’s more about restoring coordination and improving the body’s ability to respond to movement [8]. That’s a neurological process as much as it is a muscular one.

And let’s not forget the psychosocial side of pain. Things like job stress, fear of movement, sleep, and general wellbeing play just as much of a role in chronic pain as anything physical. Research shows that pain is one of the biggest blind spots in medical training. One study found that over 80% of medical graduates lacked basic competency in musculoskeletal medicine [9].

So, does a weak core cause pain?

Not by itself. It can contribute, especially in hypermobility where control matters more. But strengthening your core isn’t a guaranteed fix, and not having a perfect core doesn’t mean you’ll be in pain.

Pain is complex. Your approach to it should be too.

So why do people like core stability exercises?

So why do some people swear hypermobility core exercises work and why for some it does nothing?

As we mentioned before, pain is complex, and so is getting rid of it. And whilst a few studies do show that hypermobility core exercises can help with lower back pain [10], why don’t they work for everyone? What’s going on when we do core stability training?

Well, first off, we have the release of endorphins from exercises, we have noxious inhibitory control, we have the lessening of movement-related fear as you believe you are fixing an unstable core, and a multitude of other factors across the Biopsychosocial spectrum. When we look at the data, specific core stability exercises do seem to work marginally better for pain than just any old randomly selected exercise [11], and that’s most likely from intervening psychosocial factors such as breaking down the fear of movement and guarding.

However, there is no shortage of people out there, that through no fault of their own, core stability exercises have just not helped. Again, pain is complex and isn’t about just fixing one tiny thing. There are multitudes of factors that contribute to the creation of pain. Likewise, those with hypermobility likely don’t have a great sense of proprioception [4], and may not perform the movement correctly, leading to potential injury.

One issue I personally have with hypermobility rehab and indeed hypermobility core exercises, is that they promote segmenting the hypermobile body and focusing on solely one area. Many of the clients we see in the studio, all report the same systemic issues and the same treatment from health care professionals: they go for help with multiple dislocating joints, and at therapy, only one issue is addressed.

With Hypermobility rehab, these individuals need to relearn how to use the body as a unit again, and more of their rehab needs to lean toward the neurological side of things [8], not just joints and tissue. There is also the issue of these individuals being taught to brace and to contract their cores, which can lead to issues with the hypermobile pelvic floor.

Pelvic Floor Dysfunction and Hypermobility

There are many issues such as endometriosis, scoliosis, and especially pelvic floor dysfunction that rarely gets the attention it deserves when we talk about hypermobility and Ehlers-Danlos syndrome. Yet pelvic floor issues are incredibly common. In one study of over 1,300 women with EDS, more than half reported symptoms like stress incontinence, urgency, and even pelvic organ prolapse [12]. Compared to the general population, those numbers are alarmingly high.

So what’s happening?

References

  1. Lederman E (2010). The myth of core stability. Journal of Bodywork and Movement Therapies, 14(1), pp.84-98. doi: 10.1016/j.jbmt.2009.08.001
  2. Hodges PW, Richardson CA (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine, 21(22), pp.2640-2650. doi: 10.1097/00007632-199611150-00014
  3. Saragiotto BT, Maher CG, Yamato TP, et al. (2016). Motor control exercise for nonspecific low back pain: a Cochrane review. Spine, 41(16), pp.1284-1295. doi: 10.1097/BRS.0000000000001645
  4. Scheper MC, de Vries JE, Verbunt J, Engelbert RH (2017). Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome (hypermobility type): it is a challenge. Disability and Rehabilitation, 39(7), pp.668-677. doi: 10.1080/09638288.2016.1196396
  5. Bastiaenen CH, de Bie RA, Wolters PM, et al. (2008). Long term effectiveness and costs of a brief self-management intervention in women with pregnancy-related low back pain after delivery. BMC Pregnancy and Childbirth, 8:19. doi: 10.1186/1471-2393-8-19
  6. Erdmann-Sager J, Pusic AL, Wilkins EG, Kim HM, et al. (2017). Complications and patient-reported outcomes in abdominally based breast reconstruction: results of the Mastectomy Reconstruction Outcomes Consortium study. Plastic and Reconstructive Surgery, 140(5), pp.1391-1401. doi: 10.1097/PRS.0000000000004016
  7. Wong AY, Parent EC, Funabashi M, Kawchuk GN (2014). Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. The Journal of Pain, 15(4), pp.377.e1-377.e35. doi: 10.1016/j.jpain.2013.10.008
  8. Corrado B, Ciardi G (2018). Hypermobile Ehlers-Danlos syndrome and rehabilitation: taking stock of evidence-based medicine: a systematic review of the literature. Journal of Physical Therapy Science, 30(6), pp.847-856. doi: 10.1589/jpts.30.847
  9. Stockard AR, Allen TW (2006). Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. The Journal of the American Osteopathic Association, 106(6), pp.350-355. PMID: 16790542
  10. Coulombe BJ, Games KE, Neil ER, Eberman LE (2017). Core stability exercise versus general exercise for chronic low back pain. Journal of Athletic Training, 52(1), pp.71-72. doi: 10.4085/1062-6050-51.11.16
  11. Wang XQ, Zheng JJ, Yu ZW, et al. (2012). A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One, 7(12), p.e52082. doi: 10.1371/journal.pone.0052082
  12. Kciuk O, Li Q, Huszti E, McDermott C (2022). Pelvic floor symptoms in cisgender women with Ehlers-Danlos syndrome: an international survey study. International Urogynecology Journal, 33(11), pp.3185-3196. doi: 10.1007/s00192-022-05273-8
  13. Nipa SI, Sriboonreung T, Paungmali A, Phongnarisorn C (2022). The effects of pelvic floor muscle exercise combined with core stability exercise on women with stress urinary incontinence following the treatment of nonspecific chronic low back pain. Advances in Urology, 2022:2051374. doi: 10.1155/2022/2051374
  14. Embaby HM, Ahmed MM, Mohamed GI, et al. (2023). Impact of core stability exercises vs. interferential therapy on pelvic floor muscle strength in women with pelvic organ prolapse. European Review for Medical and Pharmacological Sciences, 27(4), pp.1255-1261. doi: 10.26355/eurrev_202302_31358
  15. Patel M, Khullar V (2021). Urogynaecology and Ehlers-Danlos syndrome. American Journal of Medical Genetics Part C, 187(4), pp.551-558. doi: 10.1002/ajmg.c.31959
  16. Allison GT (2012). Abdominal muscle feedforward activation in patients with chronic low back pain is largely unaffected by 8 weeks of core stability training. Journal of Physiotherapy, 58(3), p.200. doi: 10.1016/s1836-9553(12)70114-5
  17. Mannion AF, Caporaso F, Pulkovski N, Sprott H (2012). Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. European Spine Journal, 21(7), pp.1301-1310. doi: 10.1007/s00586-012-2155-9
  18. Steiger F, Wirth B, de Bruin ED, Mannion AF (2012). Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. European Spine Journal, 21(4), pp.575-598. doi: 10.1007/s00586-011-2045-6
  19. Smith BE, Littlewood C, May S (2014). An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskeletal Disorders, 15(1), p.416. doi: 10.1186/1471-2474-15-416
  20. Long M, Alexander CM, Kassam J, Kiru L, Strutton PH (2022). An investigation of the control of quadriceps in people who are hypermobile: a case control design. BMC Musculoskeletal Disorders, 23:600. doi: 10.1186/s12891-022-05540-1

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