Motor Learning for Hypermobility: How Your Nervous System Actually Builds Reliable Movement

About
Latest Posts

Adam Foster is the founder of The Fibro Guy and one of the leading voices in hypermobility, EDS, and chronic pain rehabilitation. A former Reconnaissance Soldier, he developed chronic pain after an IED blast in Afghanistan and built his approach from the ground up when the medical system had no answers. Since 2009 he has worked with thousands of people across eight countries, drawing on pain neuroscience, motor learning, and sensorimotor rehabilitation. He co-authored "No Pain, No Pain" with trauma psychologist Dr Mairi Harper, directed the documentary "Invisible Monster," and has been featured in Forbes, BBC Radio 4, ITV News, LiveScience, and The Telegraph.

What Motor Learning Actually Is

Motor learning is the set of changes that practice makes to how well you move, the ones that are still there when you come back tomorrow. That last clause is the whole definition, and it’s the bit that gets skipped.

It isn’t a single mechanism. There are at least four different things your nervous system is doing while you practise, and they run together rather than taking turns [1][2].

The first is learning from the gap. You predict what a movement is going to feel like, you do it, and the difference between the prediction and what actually arrived is what gets used to update the next attempt. The second is learning from what worked, which is a reward system rather than an error system, and it biases you towards the solutions that came off. The third is the plainest one, as simply having done something a lot makes you more likely to do it that way again, whether it was any good or not. And the fourth is you, consciously having a think about it and coming up with a strategy.

That last one is not a minor player. A fair chunk of what looks like quick, clever learning in the first few attempts is really the explicit, thinking part of you doing the work [3].

Now, the part that matters most for a hypermobile body, and it’s easy to miss. Practice doesn’t only change the moving, it changes the sensing. Practise a movement and the way you feel your own body shifts along with it, so the system you’re learning with is being rebuilt while you use it [4]. Which means the noisy signal we spent all of Part 2 on isn’t a fixed ceiling you have to work under. It’s one of the things that moves.

A Hundred Years Of People Changing Their Minds

This always makes me laugh, because every bit of advice you’ve ever been handed came out of one of these eras, and a lot of it came out of an era that has since been corrected.

The early answer was a loop. You build a memory of how a movement ought to feel, then you compare what you’re feeling against that stored copy, and you steer towards it [5]. It makes sense, and it explains a lot about slow, careful movement where you have time to check. It also has two problems it never really solved. You’d need a separate saved copy of every movement you might ever make, which is an awful lot of filing. And it can’t explain how you do something you have honestly never done before, which people do all day long.

Round about the same era, a Soviet physiologist called Nikolai Bernstein was working on the other half of it from Moscow. His question was how the brain coordinates a body with that many joints and that many muscles into one smooth action, which he called the degrees of freedom problem. His answer, which is the one line worth carrying out of all of this, was that a skilled movement is never repeated identically. The goal stays the same and the solution shifts slightly every time, and that shifting isn’t sloppiness, it’s the actually point of it all. Part 1 goes through this side of it in more detail if you want it.

Then in the late sixties, two American researchers, Fitts and Posner, described learning as three stages, from thinking about every step, to refining it, to it running on its own [6]. That model is nearly sixty years old and it is still the one most physios and most coaching courses teach, mostly because it’s genuinely useful for talking to somebody about where they are.

The idea that changed rehab the most arrived in 1975, when Schmidt argued that your brain doesn’t save movements at all. It saves a rule, plus the learned knack of setting the speed, the force and the limb to suit the situation in front of you [7]. Which is why you can sign your name on a whiteboard having only ever signed it on paper. The prediction that fell out of it was that practising a spread of versions should build a better rule than drilling one of them, and that is where the whole “vary it” idea in modern rehab came from.

That prediction has had a rougher time than the confident version lets on. Somebody went back over decades of experiments testing it and the support came out limited rather than strong, with a fair few of those experiments not really built to test it anyway [8]. Later work comparing different amounts of variation found that varying it did beat not varying it, while the gap between the various amounts came to nothing much [9]. And a separate line of work pushed the other way, showing that what you learn can get more tied to the exact conditions you practised in, not less, so take somebody’s vision away after they’ve trained and the whole thing falls over [10].

The maths side got sharper at the same time. By the mid nineties it was shown that when you learn to move against an unfamiliar force, your brain builds a working model of that force, and you can prove it, because take the force away and the movement goes wrong in exactly the direction the model says it should [11]. Then came the finding that short term learning runs as two processes at once. A fast one that learns hard from a mistake and forgets almost as quickly, and a slow one that barely notices anything and keeps what it gets [12]. Which is a decent description of why a session can feel brilliant one day, and not so much the next day.

Where it has landed now is messier and a good deal more honest. The current version is that learning a movement is built out of three things: working out a solution, polishing it with practice, and then pulling up the right one for the situation you’re in [13]. Sitting next to that is the idea that your brain isn’t updating one memory at all. It’s working out which situation it’s in, and fetching the memory that belongs to it [14]. And the old stage models get treated as a decent map rather than an explanation, useful for teaching somebody where they are, too neat and tidy to be true [15].

Which is the actual reason to know any of this though?. There is no single settled theory of motor learning, so anybody selling you the definitive method, built on the one true model, is at least thirty years ahead of the evidence.

The Stages, And What They Feel Like From The Inside

Take the three stage version first, as it’s the one you can actually locate yourself in.

In the first stage everything needs thinking about. The movement is clunky, you make a lot of errors, and it’s exhausting in a way that has nothing to do with how heavy it is. This is where nearly all rehab happens, and it is supposed to feel effortful, so don’t read the effort as a bad sign.

In the second, it starts to make sense. The errors get smaller, you can feel yourself correcting mid movement, and it stops eating your whole afternoon. Most people spend a lot longer here than they expect to, which is fine, and considerably better than the alternative.

In the third it runs on its own. You can do it tired, do it talking, do it when the floor turns out to be wet, and the pattern holds. Owned is the word we use for it, and it’s the thing we look for before adding anything.

The tradition that grew out of Bernstein’s question describes the same arc from the mechanical end, and that version is the more useful one for a hypermobile body. First you freeze, locking down as many joints as you can and moving as one stiff unit, because reducing the number of things you have to manage is the safest strategy available when you’ve no good model yet. Then you free, as neighbouring joints start cooperating and the movement smooths out. Then you exploit, letting your own tissue, your momentum and the forces coming back at you do some of the work for you, which is what skilled movement actually is.

Now, the wrinkle. A lot of those with hypermobility turn up already frozen, and have been for years. Gripping through the hips, jaw clenched before breakfast, shoulders up somewhere near the ears. That isn’t stage one of learning something, it’s a coping strategy that got installed a long time ago and never came back off, and Part 3 goes through why your nervous system put it there. Telling those two apart is most of the skill in the first few sessions, as they look identical and they need opposite things.

It also explains something that genuinely worries people. When the freezing starts to come off, you feel wobblier, not steadier. The rigid version had been passing for control, so losing it feels like going backwards. It usually isn’t.

Recalibrating Is Not The Same As Learning Something New

This distinction is quietly one of the most useful things in the whole field, and it hardly ever gets made outside of a lab.

Adaptation is when you already have a movement and the world changes under you, so the system recalibrates to get back to where it was. Learning a skill is different, as you’re building something you didn’t have, and getting better than your own baseline rather than back to it [16][17]. Different processes, different timescales, and they respond to different things, which is part of why the research can look like it contradicts itself. Half of it is about one and half is about the other.

Why that matters to you is the good news buried in it. In Ehlers Danlos syndrome, the precision of your sense of where a limb is comes out genuinely poorer, as the estimate scatters more widely around roughly the right answer [18]. But give somebody with EDS a task where what they can see has been deliberately shifted away from where their hand really is, and they recalibrate perfectly normally [19].

So the learning machinery is intact. What’s arriving at it is noisier. That’s a completely different problem from a system that can’t learn, and it’s the one sentence I’d want anybody to take away from this section, as it’s the difference between a ceiling and a workload.

The knock on is that how well you can locate a joint changes what your strength is actually worth. In the hypermobile type of EDS, strength does relate to what somebody can manage in daily life, as you’d expect, and for some of the things that make a day hard the relationship gets muddled once the accuracy of joint position sense is taken into account [20]. Not for everything, which is worth saying. Still, force you can’t aim isn’t much use to you.

Explore the course

Learning Runs On About Five Different Clocks

None of this runs on one clock, and that is most of why week six feels like a waste of everybody’s time.

The fastest clock runs in seconds, and it runs in the gaps. Most of what you gain early in a practice session turns out to arrive during the short rests between goes, rather than during the goes themselves [21]. Which is a strange thing to read, and it means the standing about between sets is doing work rather than wasting your afternoon.

Then there’s the minutes and hours clock, which is the fast and slow business from earlier, where one part of you grabs everything and drops it and another part quietly holds on [12]. Then there’s overnight, where what you did gets bedded in while you sleep, and how much you gain in a session and how much of it survives the night turn out to be two separate things that don’t track each other at all [22].

Then the long one, weeks into months, which hardly anybody studies because it’s a nightmare to run. When somebody finally did, using a huge pile of gaming data across a hundred days, people kept getting better the whole way through, and piling on more practice in any one day bought less and less [23]. Slow, steady, and not helped much by hammering it.

Underneath all of that sits the reason your mirror lies to you for the first couple of months. Early strength gains come from your nervous system getting better at driving the muscle you already have, by switching on more of it, wasting less of it on the muscles pulling the other way, and getting the timing right [24]. The muscle actually getting bigger comes later, and the two overlap rather than handing over neatly [25].

Put that together and the first six to eight weeks of a well built programme look like nothing much from the outside, as what’s changing is the quality of the information and the way the movement is put together, not the size of anything. That’s the stage where nearly everybody quits, and it’s the stage that decides everything after it.

The Rule, Not The Recording

Everything above points the same way for how a session should actually be built, and it’s the thing most programmes get backwards.

If your brain is building a rule rather than saving a recording, then doing the identical rep, at the identical speed, on the identical mat, three hundred times, teaches it that exact situation and not a great deal else. Change the surface, the speed, the direction, the load, the shoes, whether your head is turned, and the system has to work out what all of those attempts had in common. That common thread is the rule, and the rule is the bit that turns up for you in a situation you’ve never rehearsed.

There’s a tidy demonstration of it where people trained on a task that kept changing at random. Rather than getting confused they pulled out the thing all the versions had in common, then learned faster inside it and started exploring along it [26]. That’s the rule idea doing more or less exactly what it says it should.

Keep it deliberate and keep it modest though, as more variety is not automatically more learning and the evidence on how much is genuinely unimpressive [8][9]. Same movement, one or two things changed, something left the same to hang on to. Not a new exercise every fortnight, which is a different problem with a different name.

And this matters more in a body running off a vague signal, not less, as a rule built out of variety copes far better with a bad reading on any given day than one rehearsed pattern does.

Where You Point Your Attention

For about twenty years the line was that you should always aim a cue outwards. Push the floor, reach for the mug, and never mention the muscle, on the grounds that watching your own body gets in the way of the automatic control that would otherwise run the movement for you. It got folded into a bigger theory that added two more ingredients, expecting to do well, and having some say in your own training [27]. Add the studies up and the case looked strong, as pointing attention outwards came out ahead on how well people moved, on what they kept, on how it carried over to new tasks, and on how little wasted muscle work it took [28].

Then somebody went back over all of it and did the sums properly, allowing for the fact that studies which find nothing tend not to get published. Corrected for that, the average benefit came out at roughly nothing at all (happens more than you would think)[29]. The same group did the same to the other two ingredients and found those had been hyped up as well [30]. None of that says attention doesn’t matter. It says the effect jumps about wildly from study to study, for reasons nobody has worked out, and the confident version you were given was never really there.

And it isn’t a one way street either. Where the job genuinely depends on feeling your own body, aiming attention inwards has come out better [31], which stops being surprising the moment you treat it as a question rather than a rule. What seems to matter is whether the cue points you at something the task actually needs, not whether it points inside or outside your skin [32].

So, the practical version. The cue is free, it’s easy to change, and it’s worth changing on purpose. For balance and control, pointing outwards is a sensible default, and in the one study done in hypermobile people it helped, which Part 1 goes through properly. For producing force, a clear instruction of either sort beat no instruction at all. What you shouldn’t do is build a programme on it, or decide your rehab failed because somebody used the wrong words.

What Pain Does To Learning

Pain doesn’t switch muscles off (despite someone on instagram saying so). What it does do, however, is change who does what, and the change looks fairly protective. [33].

The awkward question, in whether pain actually stops you learning, is genuinely unsettled. Pull the experimental pain studies together and there’s no consensus on whether it changes how much skill you acquire or how much you keep [34]. What does turn up repeatedly is that people who trained in pain kept the altered movement strategy afterwards, once the pain had gone. So the learning happened. It’s what got learned that’s the problem.

That’s the bit worth wrapping your noggin around, as a protective strategy is a sensible short term solution with a long term bill attached, and the bill is that you have now practised it [35]. A year of training in pain isn’t a neutral year in which not much happened. It’s a year of teaching a pattern you didn’t want, quite efficiently, to a system that learns whether you meant it to or not.

The response varies a lot between people too, and not in the direction you’d guess. Put a group into sustained muscle pain and some of them get more variable in how they move while others get less, and which way somebody goes relates to what’s happening in the line from brain to muscle [36]. So there isn’t one pain response to design around, which is most of the argument for individualising anything.

The guarding itself is more than stiffness. When experienced physios watched people with long term back pain move, what they were reading in the guarding was caution and worry about the movement, alongside a separate quality they called flow, meaning how natural and continuous the movement still looked despite everything it was working around [37]. Which fits the wider work on fear, where pain related fear and avoidance are themselves learned, can spread well beyond the movement that originally hurt, and contribute to disability in their own right [38]. If you want that half on its own, our piece on fear of movement in hypermobility and EDS goes through it.

There’s a measurable change in the motor system too!

Across chronic pain conditions, the movement part of the brain loses some of its own braking, and the clearest pooled findings are in nerve pain groups rather than in everybody [39]. In fibromyalgia specifically, motor cortex activity came out lower alongside slower performance on a rapid finger tapping task [40]. Small study, one lab, and it lines up with what people describe.

And the single most practical finding in this whole area is in Part 2, so I’ll only point at it here. In work on learning a new walking pattern, pain during the training left performance on the day completely intact and wrecked how much of it was still there the following morning. You can practise in pain, do it well, and keep none of it, which is why the honest measure of a session is tomorrow rather than today.

Watching Somebody Else Do It Counts For Something

This one is genuinely useful on the days when doing the thing isn’t on the table.

The plain version of the science first, as it’s been badly oversold. Mirror neurons are cells that fire both when you do something and when you watch somebody else do it, and finding them was a genuinely big deal [41]. What they don’t do is explain copying, empathy, autism and the other dozen things they got attached to over thirty years, and most of those bigger claims have since been dropped [42][43].

What survives is smaller and a lot more useful. Watching a movement switches on your own movement system, and using that on purpose can help people move better and relearn a pattern, which is why watching the movement is now a real part of rehab after a stroke [44].

The bit that matters here is that it still works in a body that hurts. In fibromyalgia, watching somebody move still lit up the same movement networks it lights up in anyone else, so learning by watching isn’t one of the things long term pain takes off you [45]. Handy to know on a bad week, as watching the thing properly, and running it through in your head, is not the same as doing nothing at all.

The staged version of that, where you start by telling left hands from right hands in photos, then move to imagining movement, then to mirrors, does bring pain down in long standing complex regional pain syndrome, and nobody can properly tell you why yet [46]. Which is about the right amount of confidence to have. It does something, and the reason is still an open question.

If You Were Also The Clumsy Kid

Hypermobility keeps company with ADHD, autism, and the clumsiness that used to get called dyspraxia, and that overlap is well enough described now that it belongs in any talk about learning movement [47].

The clearest evidence is in the children who get called clumsy, and it’s good news. They do learn movement skills, including the sort of learning that happens without you noticing it happen. It’s slower though, and messier, and it leans much more heavily on the practice being set up to suit them [48][49]. So the ceiling isn’t the problem. The setup is.

ADHD looks different again. Put the studies together and there’s no real difference in the kind of learning where you pick up a sequence without trying [50]. What did turn up though, in one small study, was a timing effect. Young adults with ADHD kept very little overnight after practising in the morning, and held on to it perfectly well when they practised in the evening instead [51]. One study, one task, so don’t build your week on it. If you have ADHD and your practice keeps vanishing by morning though, the time of day is worth a try.

Which is the point that keeps coming back. None of this says you can’t learn. It says the amount, the timing and the setup have to fit the person doing it, and a programme written for somebody with a tidy attention span and a joint they can find will do less for you, for reasons that have nothing at all to do with effort.

Two Things That Stop A Session Working Before It Starts

Both of these are worth knowing because they get mistaken for not trying hard enough, and neither is.

The first happens around a joint that has been upset. When a joint is swollen or sore, the odd signal coming out of it puts a reflex brake on the muscle around it, so you simply cannot switch all of that muscle on. It isn’t a choice, it isn’t a confidence thing, and you can’t beat it by wanting it more [52]. The joint doesn’t have to look swollen either, and being lax is itself on the list of things that can change that signal [52]. So loading a freshly upset joint doesn’t do what the plan says it will, as some of the muscle you were aiming at isn’t available and the joint takes the stress instead. Settle it, then load it.

The second one takes out the whole system. When your immune system is busy, the chemicals it uses to talk to itself act straight on the brain, and what comes out is a set package of tiredness, aching, no motivation and a head full of fog [53]. That’s a biological programme, not a character flaw, and training through it doesn’t buy you what training is supposed to buy you. It buys you more fatigue, and a rehearsal of whatever movement you can manage while feeling like that.

Which isn’t permission to stop training. It’s permission to stop pretending every session is the same session. Some days the system is online and ready to learn, and some days it’s busy.

What We’d Actually Do With All That

This is how we sequence it, and it’s our read rather than a settled finding. Nobody has run the study that compares doing it in this order against doing it the other way round.

– Sort the signal out before you add load. If the information arriving at your brain is vague, adding weight to a joint nobody can locate accurately mostly adds consequences. Skin contact, textures, different floors and tape all help here, and our piece on KT tape for hypermobility and Ehlers Danlos syndrome walks through what tactile cueing actually looks like.

– Short and often, rather than long and occasional. Learning consolidates in the gaps, in the seconds between attempts and in the night between sessions [21][22]. Twenty attentive minutes four times a week will generally do more than one long session at the weekend after work, and it happens to be a much more achievable target on a rough day.

– Treat attention as the thing that runs out, because it is. Once the last few reps of a set look nothing like the first few, the set stopped teaching you anything a while ago. Stop it, rest properly, and come back with fewer.

– Vary the conditions, not the exercise list. Same action, different speed, surface, direction, head position or shoes, with one or two things changed at a time and an anchor left in place [8][9]. You’re building a rule for a situation you haven’t met yet.

– Judge the session by tomorrow. Not by how it felt, not by what you lifted. Whether the thing is still there the next morning is the honest measure, and changing that one scoring rule reorganises an entire programme.

– Work out which sort of freezing you’re dealing with. Gripping that’s part of learning something new comes off as the pattern improves. Gripping that’s been a coping strategy for fifteen years needs the reason for it removed first, and Part 3 covers what that reason usually is.

– Use the cue, don’t lean on it. Point the attention outwards for balance and control, inwards when the task genuinely needs body information, and stop treating it as the mechanism [29][31].

– Leave the joint alone when it’s irritated, and leave the session alone when you’re ill. Neither is going to teach you anything [52][53]. Watching the movement attentively and rehearsing it in your head is a reasonable use of those days [45].

– Expect the first stretch to look like nothing. What’s changing early on is the quality of the information and the organisation of the movement, not the size of anything [24][25]. That’s the stage where most people quit.

What Nobody Knows Yet

Almost nobody has studied how hypermobile adults learn movement. Nearly everything above is borrowed, from general motor learning work, from other chronic pain groups, and from children with coordination difficulties, and the rehab research in hEDS and HSD is small, mixed and short on the sort of trials that would settle anything [54]. Somebody has measured how precisely you can find your own knee. Somebody has measured whether you can recalibrate. Nobody has really measured the learning.

Whether long term pain harms the learning itself, rather than changing what gets learned, is still open. The lab work disagrees with itself and the fair summary is that nobody knows [34].

How much to do is a complete unknown. Sets, reps, how often and how fast to build are all guesses in this group, and anybody handing you a precise number is handing you their preference [54].

And our order of operations is unproven. Information before load is our read, built on the mechanisms and on watching a great many people go through it in the studios. The head to head study doesn’t exist. If it turns up and says we had it the wrong way round, we’ll say so and teach the other thing.

The Fibro Guy

References

[1] Therrien, A.S. and Wong, A.L. (2022) ‘Mechanisms of Human Motor Learning Do Not Function Independently’, Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2021.785992

[2] Spampinato, D. and Celnik, P. (2020) ‘Multiple Motor Learning Processes in Humans: Defining Their Neurophysiological Bases’, The Neuroscientist. https://doi.org/10.1177/1073858420939552

[3] Taylor, J.A., Krakauer, J.W. and Ivry, R.B. (2014) ‘Explicit and Implicit Contributions to Learning in a Sensorimotor Adaptation Task’, The Journal of Neuroscience. https://doi.org/10.1523/jneurosci.3619-13.2014

[4] Ostry, D.J. and Gribble, P.L. (2016) ‘Sensory Plasticity in Human Motor Learning’, Trends in Neurosciences. https://doi.org/10.1016/j.tins.2015.12.006

[5] Adams, J.A. (1971) ‘A closed-loop theory of motor learning’, Journal of Motor Behavior. https://doi.org/10.1080/00222895.1971.10734898

[6] Salehi, S.K., Tahmasebi, F. and Talebrokni, F.S. (2021) ‘A different look at featured motor learning models: comparison exam of Gallahue’s, Fitts and Posner’s and Ann Gentile’s motor learning models’, Movement and Sport Sciences. https://doi.org/10.1051/sm/2021012

[7] Schmidt, R.A. (1975) ‘A schema theory of discrete motor skill learning’, Psychological Review. https://doi.org/10.1037/h0076770

[8] Van Rossum, J.H.A. (1990) ‘Schmidt’s schema theory: the empirical base of the variability of practice hypothesis’, Human Movement Science. https://doi.org/10.1016/0167-9457(90)90010-b

[9] Schmidt, M., Kemena, M. and Jaitner, T. (2021) ‘Null Effects of Different Amounts of Task Variation in Both Contextual Interference and Differential Learning Paradigms’, Perceptual and Motor Skills. https://doi.org/10.1177/00315125211022302

[10] Proteau, L., Marteniuk, R.G. and Levesque, L. (1992) ‘A Sensorimotor Basis for Motor Learning: Evidence Indicating Specificity of Practice’, Quarterly Journal of Experimental Psychology. https://doi.org/10.1080/14640749208401298

[11] Shadmehr, R. and Mussa-Ivaldi, F.A. (1994) ‘Adaptive representation of dynamics during learning of a motor task’, The Journal of Neuroscience. https://doi.org/10.1523/jneurosci.14-05-03208.1994

[12] Smith, M.A., Ghazizadeh, A. and Shadmehr, R. (2006) ‘Interacting Adaptive Processes with Different Timescales Underlie Short-Term Motor Learning’, PLoS Biology. https://doi.org/10.1371/journal.pbio.0040179

[13] Tsay, J.S., Kim, H.E., McDougle, S.D., Taylor, J.A., Haith, A., Avraham, G. et al. (2024) ‘Fundamental processes in sensorimotor learning: Reasoning, refinement, and retrieval’, eLife. https://doi.org/10.7554/elife.91839

[14] Heald, J.B., Lengyel, M. and Wolpert, D.M. (2020) ‘Contextual inference underlies the learning of sensorimotor repertoires’, Nature. https://doi.org/10.1038/s41586-021-04129-3

[15] Schollhorn, W.I., Rizzi, N., Slapsinskaite-Dackeviciene, A. and Leite, N. (2022) ‘Always Pay Attention to Which Model of Motor Learning You Are Using’, International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph19020711

[16] Krakauer, J.W. and Mazzoni, P. (2011) ‘Human sensorimotor learning: adaptation, skill, and beyond’, Current Opinion in Neurobiology. https://doi.org/10.1016/j.conb.2011.06.012

[17] Diedrichsen, J. and Kornysheva, K. (2015) ‘Motor skill learning between selection and execution’, Trends in Cognitive Sciences. https://doi.org/10.1016/j.tics.2015.02.003

[18] Clayton, H.A., Jones, S.A.H. and Henriques, D.Y.P. (2015) ‘Proprioceptive precision is impaired in Ehlers-Danlos syndrome’, SpringerPlus. https://doi.org/10.1186/s40064-015-1089-1

[19] Clayton, H.A., Cressman, E.K. and Henriques, D.Y.P. (2013) ‘Proprioceptive sensitivity in Ehlers-Danlos syndrome patients’, Experimental Brain Research. https://doi.org/10.1007/s00221-013-3656-4

[20] Scheper, M., Rombaut, L., de Vries, J., De Wandele, I., van der Esch, M., Visser, B. et al. (2017) ‘The association between muscle strength and activity limitations in patients with the hypermobility type of Ehlers-Danlos syndrome: the impact of proprioception’, Disability and Rehabilitation. https://doi.org/10.1080/09638288.2016.1196396

[21] Bonstrup, M., Iturrate, I., Thompson, R., Cruciani, G., Censor, N. and Cohen, L.G. (2019) ‘A Rapid Form of Offline Consolidation in Skill Learning’, Current Biology. https://doi.org/10.1016/j.cub.2019.02.049

[22] Beck, M.M., Kristensen, F.T., Abrahamsen, G., Spedden, M.E., Christensen, M.S. and Lundbye-Jensen, J. (2024) ‘Distinct mechanisms for online and offline motor skill learning across human development’, Developmental Science. https://doi.org/10.1111/desc.13536

[23] Listman, J.B., Tsay, J.S., Kim, H.E., Mackey, W.E. and Heeger, D.J. (2021) ‘Long-Term Motor Learning in the Wild With High Volume Video Game Data’, Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2021.777779

[24] Sale, D.G. (1988) ‘Neural adaptation to resistance training’, Medicine and Science in Sports and Exercise. https://doi.org/10.1249/00005768-198810001-00009

[25] Folland, J.P. and Williams, A.G. (2007) ‘Morphological and Neurological Contributions to Increased Strength’, Sports Medicine. https://doi.org/10.2165/00007256-200737020-00004

[26] Braun, D.A., Aertsen, A., Wolpert, D.M. and Mehring, C. (2009) ‘Motor Task Variation Induces Structural Learning’, Current Biology. https://doi.org/10.1016/j.cub.2009.01.036

[27] Wulf, G. and Lewthwaite, R. (2016) ‘Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning’, Psychonomic Bulletin and Review. https://doi.org/10.3758/s13423-015-0999-9

[28] Chua, L.K., Jimenez-Diaz, J., Lewthwaite, R., Kim, T. and Wulf, G. (2021) ‘Superiority of external attentional focus for motor performance and learning: Systematic reviews and meta-analyses’, Psychological Bulletin. https://doi.org/10.1037/bul0000335

[29] McKay, B., Corson, A.E., Seedu, J., De Faveri, C.S., Hasan, H., Arnold, K. et al. (2024) ‘Reporting bias, not external focus: A robust Bayesian meta-analysis and systematic review of the external focus of attention literature’, Psychological Bulletin. https://doi.org/10.1037/bul0000451

[30] McKay, B., Bacelar, M.F.B., Parma, J.O., Miller, M.W. and Carter, M.J. (2023) ‘The combination of reporting bias and underpowered study designs has substantially exaggerated the motor learning benefits of self-controlled practice and enhanced expectancies: a meta-analysis’, International Review of Sport and Exercise Psychology. https://doi.org/10.1080/1750984x.2023.2207255

[31] Gottwald, V.M., Owen, R., Lawrence, G.P. and McNevin, N. (2020) ‘An internal focus of attention is optimal when congruent with afferent proprioceptive task information’, Psychology of Sport and Exercise. https://doi.org/10.1016/j.psychsport.2019.101634

[32] Herrebroden, H. (2022) ‘Motor Performers Need Task-relevant Information: Proposing an Alternative Mechanism for the Attentional Focus Effect’, Journal of Motor Behavior. https://doi.org/10.1080/00222895.2022.2122920

[33] Hodges, P.W. (2011) ‘Pain and motor control: From the laboratory to rehabilitation’, Journal of Electromyography and Kinesiology. https://doi.org/10.1016/j.jelekin.2011.01.002

[34] Izadi, M., Franklin, S., Bellafiore, M. and Franklin, D.W. (2021) ‘Motor Learning in Response to Different Experimental Pain Models Among Healthy Individuals: A Systematic Review’, Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2022.863741

[35] van Dieen, J.H., Flor, H. and Hodges, P.W. (2017) ‘Low-Back Pain Patients Learn to Adapt Motor Behavior With Adverse Secondary Consequences’, Exercise and Sport Sciences Reviews. https://doi.org/10.1249/jes.0000000000000121

[36] Summers, S.J., Chipchase, L.S., Hirata, R., Graven-Nielsen, T., Cavaleri, R. and Schabrun, S.M. (2019) ‘Motor adaptation varies between individuals in the transition to sustained pain’, Pain. https://doi.org/10.1097/j.pain.0000000000001604

[37] Williams, A.C. de C., Buono, R., Gold, N.E., Olugbade, T.A. and Bianchi-Berthouze, N. (2023) ‘Guarding and flow in the movements of people with chronic pain: A qualitative study of physiotherapists’ observations’, European Journal of Pain. https://doi.org/10.1002/ejp.2195

[38] Meulders, A. (2019) ‘From fear of movement-related pain and avoidance to chronic pain disability: a state-of-the-art review’, Current Opinion in Behavioral Sciences. https://doi.org/10.1016/j.cobeha.2018.12.007

[39] Parker, R.S., Lewis, G.N., Rice, D.A. and McNair, P.J. (2016) ‘Is Motor Cortical Excitability Altered in People with Chronic Pain? A Systematic Review and Meta-Analysis’, Brain Stimulation. https://doi.org/10.1016/j.brs.2016.03.020

[40] Gentile, E., Brunetti, A., Ricci, K., Delussi, M., Bevilacqua, V. and de Tommaso, M. (2020) ‘Mutual interaction between motor cortex activation and pain in fibromyalgia: EEG-fNIRS study’, PLoS ONE. https://doi.org/10.1371/journal.pone.0228158

[41] Rizzolatti, G. and Craighero, L. (2004) ‘The mirror-neuron system’, Annual Review of Neuroscience. https://doi.org/10.1146/annurev.neuro.27.070203.144230

[42] Bonini, L., Rotunno, C., Arcuri, E. and Gallese, V. (2022) ‘Mirror neurons 30 years later: implications and applications’, Trends in Cognitive Sciences. https://doi.org/10.1016/j.tics.2022.06.003

[43] Heyes, C. and Catmur, C. (2020) ‘What Happened to Mirror Neurons?’, Perspectives on Psychological Science. https://doi.org/10.1177/1745691621990638

[44] Ciullo, G., Bozzetti, F., Ziccarelli, S., Fogassi, L. and Errante, A. (2025) ‘Neurophysiological Mechanisms Underlying Action Observation Treatment for Upper Limb Stroke Rehabilitation: A mini-review’, Neuroscience and Biobehavioral Reviews. https://doi.org/10.1016/j.neubiorev.2025.106484

[45] Gentile, E., Brunetti, A., Ricci, K., Bevilacqua, V., Craighero, L. and de Tommaso, M. (2022) ‘Movement observation activates motor cortex in fibromyalgia patients: a fNIRS study’, Scientific Reports. https://doi.org/10.1038/s41598-022-08578-2

[46] Moseley, G.L. (2004) ‘Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial’, Pain. https://doi.org/10.1016/j.pain.2004.01.006

[47] Baeza-Velasco, C. (2021) ‘Neurodevelopmental atypisms in the context of joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes’, American Journal of Medical Genetics Part C. https://doi.org/10.1002/ajmg.c.31946

[48] Subara-Zukic, E., Cole, M.H., McGuckian, T.B., Steenbergen, B., Green, D., Smits-Engelsman, B.C. et al. (2022) ‘Behavioral and Neuroimaging Research on Developmental Coordination Disorder: A Combined Systematic Review and Meta-Analysis of Recent Findings’, Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2022.809455

[49] Warlop, G., Nijhof, A.D., Cracco, E., Wiersema, J.R. and Deconinck, F.J.A. (2025) ‘Neural underpinnings of visuomotor adaptation and retention after a night of sleep in children with DCD’, Research in Developmental Disabilities. https://doi.org/10.1016/j.ridd.2025.105170

[50] Sanjeevan, T., Cardy, R.E. and Anagnostou, E. (2020) ‘Procedural Sequence Learning in Attention Deficit Hyperactivity Disorder: A Meta-Analysis’, Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2020.560064

[51] Korman, M., Levy, I. and Karni, A. (2017) ‘Procedural Memory Consolidation in Attention-Deficit/Hyperactivity Disorder Is Promoted by Scheduling of Practice to Evening Hours’, Frontiers in Psychiatry. https://doi.org/10.3389/fpsyt.2017.00140

[52] Rice, D.A. and McNair, P.J. (2010) ‘Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives’, Seminars in Arthritis and Rheumatism. https://doi.org/10.1016/j.semarthrit.2009.10.001

[53] Dantzer, R. and Kelley, K.W. (2007) ‘Twenty years of research on cytokine-induced sickness behavior’, Brain, Behavior, and Immunity. https://doi.org/10.1016/j.bbi.2006.09.006

[54] Flanagan, S.C., Foreman, L.N. and Teran-Wodzinski, P. (2023) ‘Physical therapy interventions in generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome: a scoping review’, Disability and Rehabilitation. https://doi.org/10.1080/09638288.2023.2216028