Hypermobility, Co-Occuring Conditions, & Bodywork

please pardon dead ends and other 🙄 on this page--it's under heavy construction but I'm not going to take it down while I tidy since I know a few people are using it!

Do you know about hypermobility?

The goals of this page are:

1) to help spark your interest in the broader context of current research and often missed health concerns relating to hypermobility spectrum disorders.

2) share some thoughts on what I have seen as helpful with respect to bodywork with hypermobility.

If you've arrived here without personal need of the information, please do read on a little. Hypermobility and related health challenges that arise even when the joints themselves are not much affected are so common that you probably know a few people who would benefit from collective greater awareness.

Hypermobility is a general term for conditions affecting the flexibility of joints and other soft tissues. It ranges from severe and rare to very common and hardly noticeable.

Both hypermobility itself and other health conditions relating to the same variability in collagen production can be highly impactful on the overall health picture, yet hypermobility is too little recognized as the sign that a body may need special kinds and degrees of care. Many people who are significantly hypermobile have sought diagnosis and effective care for years for a plethora of symptoms without any care provider realizing that their symptoms arise in relation to central causes relating to hypermobility--which would often be an easy way to screen for susceptibility to the rest of the cluster of concerns.

At the bottom of this page as well as here I've collected a few great links where you can seek further information.


Context

Because hypermobility profoundly impacts the ways in which daily strains, exercise, and injuries impact the body, and because it often increases the tendency to certain pain conditions I specialize in working with, I see a lot of people whom I suspect are somewhere on the hypermobility spectrum. It's a broad spectrum. I'm going to speak of this entire group here from a clinical perspective before moving on to what research says about hypermobility.

And first I'll say that as a massage therapist in New Mexico, USA, I have only around 800 hours of initial training. Massage therapists do not diagnose or treat. I can't identify my clients as definitely hypermobile. But it is essential to doing my work well to maintain awareness of the various qualities of the soft tissues that I work with and to apply my work differently depending on the available information--both the client's history as they report it and the information that comes through interacting with, observing visually, and feeling the tissues as we work.

And it's not an easy thing to send these clients for diagnosis. Awareness among health practitioners is improving in recent decades, but it is still poor. There are very few specialists for diagnosis of hypermobility spectrum disorders. Average time to diagnosis of EDS at the time of this writing is 12-14 years. Wait times at specialty clinics are the better part of a year at present, I hear from my few diagnosed clients and acquaintances plus many public figures in the EDS community. There is a great deal of debate at present as to what clinical criteria should be used to confirm EDS. Genetic markers have been identified for some forms but others are still clinical diagnoses. Some therapies exist, but they're all so far for management of symptoms. Some can be transformative for some small pieces of the picture, but none are corrective. 

Hopefully that's changing. New research highlights the possibility that B-vitamin (and at the same time histamine) metabolization might be a core piece of the puzzle; that would open the possibility of addressing hypermobility correctively through supplementation with more useful forms of certain vitamins.)

Regardless, I'm in the position of working as closely and informedly as I can with the phenoma of the body on the table, naming the likelihood of hypermobility for the sake of the client's need to engage in further diagnostics.

I study what seems to work well for whom. Over time, through experience, I come up with stories about why I think these techniques are useful for particular people with their particular body characteristics. In a relatively poorly documented but otherwise careful analog of science I develop my craft and endeavor to match and rematch evolving mental models to better understand the various categories relating to hypermobility that I feel I see on the table.

My model is based on the broader qualities of the body; since I'm not trained in sciences my model is loose. It doesn't stand much chance of mapping to what doctors define in the near term, I'm sure; we're looking through quite different lenses in general. But the benefit of adding this lens to the present available information is that:

Within the group that I see as likely hypermobile, sometimes the benefits of apparent hypermobility are more obvious than any obviously related challenges. Milder forms of hypermobility may not present much of a problem in themselves--in the joints--but I think I see in practice that they may still likely relate to a greater tendency than average to certain chronic pain, immune, gastrointestinal, sensory, mental health, and other challenges.

What is Hypermobility?

Most significantly hypermobile people know that they are "double-jointed," "bendy," exceptionally flexible, prone to joint dislocations. They often have a party trick or two, like putting their feet behind their ears. (Don't try it--even if you can easily do it, it may not be wise for your body!) 

Many hypermobile people realize from experience that they are at greater risk of dislocations than others. They may experience more pain and realize it's related to their extra flexible body. The may experience instability in their spine and related discomforts or even severe challenges. They may bruise easily.

On the other hand, many hypermobile people have a particularly forgiving body for what they've put it through. They may excel at dance, gymnastics, or yoga. They may generally avoid injury where others wouldn't by having extra flexibility available at the outset. They may seem exceptionally strong for their build, thanks to their tendency to high tone in the muscles and fascia.

Some have never given their high degree of flexibility a second thought. It's the norm for their family. Maybe they rely on it for getting by without stretching... or stretching in yoga class at a fairly capable level with little consistency in training.

Regardless of whether their hypermobility itself has appeared as a boon or a limitation, most hypermobile people that I see in my practice do not know that their hypermobility may cause or relate to numerous other health conditions. And in many cases they've been seeking diagnosis and effective care for years for a plethora of symptoms, commonly: gut issues, allergies or sensitivities, sensory differences, chronic faintness or fainting, heat or cold sensitivity, chronic headaches or migraines, dental issues, temporomandibular (TMJ) joint pain or dysfunction. At this point I'm surprised when I see clients who at any age have not had further health issues and are highly flexible.

In recent decades much has been done to learn and to show that autoimmunity, autism, autonomic dysregulation, and other health challenges often also occur in people who are hypermobile. And important internal challenges such as heart or vascular conditions can also result.

The most dangerous hypermobility diagnoses tend to be rare (on the order of one in a million). However, around a third of us are estimated to be hypermobile to some degree. I suspect on the basis of what I see in my practice that even mild hypermobility comes along with a greater predisposition to have or to develop common co-occuring conditions.

So what is hypermobility? There remains a lot of professional debate on that, in various ways. Some forms--all the most extreme and dangerous kinds of cases--have genetic markers identified. The largest group is not genetically diagnosable. Mild hypermobility is usually missed unless it causes problems and may affect a third of us. But there are also links with various other conditions, and the joints may not be any more flexible than normal but the soft tissue does to my view tend to share various certain qualities that are easily relatable at the gross observational level. Do we include these folk among the hypermobile? There's still a lot of sorting to be done.

Causes

Hypermobility can be caused by a variety of factors:

Classifications and Incidence

New and more precise classifications are likely to be found within the general classifier of Hypermobility Spectrum Disorder, which is used to diagnose individuals whom the current more precisely known classifications don't fit.

Some form of widespread hypermobility is thought to affect between 10 and 30 percent of people. Most hypermobile people go undiagnosed--especially common if their cases don't impact them greatly.

Some of the above classifications are easier to identify in principle if the right care provider is found--they may offer strong visual and clinical characteristics that make them easier to identify. Some are less visible. Some classifications and cases are less impactful than others altogether. All of them are often missed for years even in highly symptomatic cases, in part because they are relatively uncommon. Since the symptoms often impact areas throughout the body and any of those issues may be the primary concern which brings parties to the doctor, years may be spent trying to address those additional complaints as sole diagnoses without recognizing the common cause of genetic soft tissue variations.

Seeking Diagnosis

Diagnosis is important in some types of hypermobility to rule out dangerous health complications. Others may likely be benign. If you are seeking diagnosis, consider looking for a provider with the associations (listed above and here) for and of people diagnosed with relevant hypermobility conditions. These often list providers who take a special interest in or specialize in diagnosing or working with the conditions. These lists are a good place to start seeking diagnosis since many providers remain unfamiliar with or only superficially aware of the conditions.

For hypermobility in only one or a few particular joints that is impacting your health or quality of life, it may be worthwhile to find a provider who is familiar with the other forms of hypermobility, as many of their insights on therapeutics will apply. Physical therapists will likely be able to help in this case too, as they work often with joint instability from injuries.

Searching for answers when hypermobility or any of the co-occuring conditions are present can be like fighting a Hydra--the mythological monster that sprouted nine heads for every one that was lopped off. As you pursue answers in one area, if others are left unattended the challenges may remain.

These disorders are still poorly understood in many ways by researchers and little known by healthcare providers. Knowledge of their relationships and coincidence seem to still be the domain of researchers and specialists alone--they're likely not so well identified and understood as we'd hope. As you search for understanding and solutions you may have to do a lot more self-advocacy than most people will ever have to do. If you have the option of seeing a specialist who knows these areas, do consider it, as it may save you time, trouble, and money in the end.

If your energy or health are compromised you'll need to be wise about how you spend your effort. Here's some brief advice from experience.

Centers of Excellence for EDS care are identified here--they would be great places to get referred to.

Here's some information on local (and a few non-local) trusted providers who may be able to help. 

Bodywork and Hypermobility

Many people who are hypermobile benefit greatly from bodywork, but certain principles are important for hypermobile clients to keep in mind and for bodyworkers to know well in order to work both safely and effectively. For most people with significant hypermobility throughout their body or even in any particular area that is being worked, an average massage may be relaxing but will likely be of low value for pain relief and for correcting imbalances that lead to and perpetuate pain. Sometimes even a relaxing massage will actually cause significant problems, and more aggressive bodywork techniques can certainly be problematic if the therapist is not aware of hypermobility and how to work with it well.

This section is full of points that you may wish to know about if you're receiving any type of manual therapy, and you may wish to go over these points with any new therapist if you've had trouble finding effective care that doesn't cause further pain. Good bodyworkers will always be open to your feedback, concerns, and questions--if they know better than I do, that's awesome and they'll find ways to reassure you through both words and touch that they can be effective while keeping you safe. If they know better than you do and don't want to hear your upfront concerns or questions, I'd leave without the treatment, myself.

Some bodywork techniques are more useful for the various body types of hypermobility. Others are unnecessarily risky and/or ineffective. Different types of hypermobile presentations call for different techniques in bodywork to be most effective.

Massage therapists unfamiliar with the condition may either remark on how relaxed the body feels--The Type 1 body that I describe below reads that way on the surface--or on the other hand be astonished at how tight the muscles are even when the client is feeling pretty good. Type 2 tends to read the latter way--astonishingly tight. The Type 2 client usually needs quite deep work, yet the body often doesn't offer the kind of mechanical feedback that affirms and rewards efficacy under a bodyworker's hands--there has to be some experience and trust in the methods for the bodyworker.

Some bodywork techniques can present danger to a hypermobile body--most notably stretching, which can pull unstable joints out of place, injure delicate tissues, or cause spasms. Others techniques need special caution. Care with depth is needful especially in certain hypermobile body types and in certain areas. Pressure tolerance varies widely but tends to follow body type, but regardless of pressure tolerance, high specificity of work tends to have a lot of value for all the types... unless there are any of various issues creating too much tenderness to approach things pointedly.

While there is immense variety in what needs to be handled well with hypermobility, a skillful bodyworker who understands hypermobility will be able to apply techniques safely and sometimes profoundly reduce pain, tension, and other impacts.

An Effective General Strategy

My approach with bodywork for nearly everyone tends to begin with addressing pain as pointedly as will be effective, based on the qualities of the body on the table. With hypermobile clients, pointed work is typically quite effective so long as it's not overly deep or painful.

My first goal with hypermobile clients is often taking painful joints out of the grip of seized muscles whose longstanding and exhausting efforts to help stabilize also cause pain at their connection sites. If broader work is needed even initially so that these same more focused pain patterns are not immediately resuscitated by the broader pattern, that's where I'll start--as pointedly as will be effective to provide pain relief as quickly as possible. Quick pain relief gives clients the understanding that change is possible. Many haven't seen nearly enough successes in caring for their bodies to address pain. I explain the mechanics of the situation meanwhile with my clients on the table, to the degree that I understand it or with notes on my degree of conjecture, helping clients to understand the scope of the larger project.

From there, our work together generally involves relatively gentle and broad techniques tailored to serve the main priorities of:

Common Trouble Areas

The joints most likely to give trouble relating to hypermobility are those that are also more prone to it in the general population--shoulders, neck, and low back. These three are susceptible for different reasons.

The neck is often subject to accidents and injuries that can destabilize it. It is also subject in nearly all of us to muscle imbalances enforced and perpetuated by activities that, now doing them in the upright posture, we tend to do in front of ourselves and mostly looking down, often for much of the day: computing, cooking, driving, working at a desk. The combination of gravity itself and muscle imbalances put a lot of strain on that delicate structure over time.

The shoulders are susceptible because of their structure. They are not one joint made of two bones and a set of connecting tissues like other joints are, but a series of complex, soft-tissue braces that work together to provide all the kinds and degrees of movements needed. The extra-soft soft-tissue braces in a hypermobile person have to work really hard to hold everything together effectively--thus the tissues are frequently constantly fatigued, thus prone to local nutrient deficits and dehydration which cause pain. 

Constant pulling at attachment sites here (or anywhere in the body) by muscles and fascia working hard to stabilize joints can be another source of pain.

In general shoulders can easily be injured, but in hypermobile people where the soft tissue is softer, they have seemed in my experience more likely to experience dislocations and less likely to tear. Dislocations can result in scar tissue, which can result in tension and pain. Scar tissue can also impair lymphatic movement--this may or may not cause visible swelling, but is likely to contribute some degree of uncomfortable to painful stagnation in the tissues due to the inability to carry off metabolic byproducts and other irritants efficiently.

The low back is susceptible because as a site of change in the direction of curvature of the spine (just like the neck) it has to balance loads heading in a lot of different directions.

Techniques To Favor

Techniques that tend to work well for people who are hypermobile include:

Techniques to avoid:

Sensible cautions even more important to watch out for in hypermobile bodies than in others include:

There are further prioritizations to be made depending on the type of build the client presents.

Three Types of Hypermobile Body that Require Special Care

In clinical practice I see three relevant classifications of hypermobility--based solely on what I can see in practice since most of my clients are undiagnosed even where hypermobility in some form appears clearly to be a significant issue.

For lack of better indicators and for the sake of convenience, I'll name these categories the Watery Build, the Long-Boned Build, and the Combo Build.

I'm beginning to suspect that severity of hypermobility is a totally separate measure to these Types, although strictly from presentation and the current standards of diagnosis the first type seems to be more likely to be diagnosed with hEDS. I do see what appear to be severe hypermobility-cluster presentations in every other respect than joint hypermobility itself in both of the other types.

To my mind there is also no clear, single assignment into these categories for most clients. It is a matter of degrees to which the various are represented in any given client. However, I have observed that taking note of what traits and therefore what build is primary allows me to more sharply and quickly identify what therapeutic approaches are most likely to be helpful, what cautions to take, and what pace to go. So the typology isn't intended as science but as a set of handles by which to more quickly acclimate to working with individual clients and sort out how to work with them effectively.

A Short but Relevant Aside on My Typing Conventions

I've looked at fair length for decent terms to represent my three categories.

Conventional typologies such as endomorph, ectomorph, and mesomorph (corresponding pretty well to types 1, 2, and 3) would be convenient as they are familiar to many. On the other hand they are so familiar, so commonly used in an entirely superficial way, and so laden with the disrespect that western culture has for variety, that I just won't use them.

Certain medical descriptors would be quite fitting but less familiar to most people, and when they distracted themselves from more important things by taking the time to look them up they'd get the wrong picture--as those terms are overladen with our same ugly cultural biases about shape and weight and so on.

I would also be tempted to use the Ayurvedic Terms Kapha, Vata, and Pitta. In many ways they seem perfect as from the reading that I have done. They reflect a rich conceptual framework drawn from the same phenomena I'm here in my corner describing and interpreting. It would be a nice convenience to borrow from them. But it would be presumptive. If I decide in advance that what I see will need to fall neatly into those archetypes in order to keep my system together, I'm doing a disservice to both the bit of informal research that I do, and presumably to that rich system. I just don't have the training to use those terms without apology and high potential of naivete or error.

Also, I define one of my adopted roles in this bodywork world as the work of importing good things from the wide sphere of esoteric or unfamiliar, unstudied, promising work, seeing what I can find and prove value in, interpreting the goods, and translating for my own Western audience into my own English language. That role has long been of deep value to me--at least in my intellectual fantasies there's that possibility.

In the end the terms I use are not intended to matter much. They're intended to serve a job. They're to give easy and memorable handles into which to shape an image of the thing of which I mean to speak, to impart some experience through which clients can begin to share my observations looking at themselves and others. I demand only that the terms themselves reflect my intent to speak of the beautiful variety of our individual bodies respectfully and admiringly by importing nothing much or maybe something specifically aesthetic and limited.

I've changed my terms a number of times so far, looking for ones that are appropriately respectful and reflective of their objects. I've recently thought to use tree names.

Trees are beautiful in every shape and size, to my eye. Anyone who loves nature feels that innocent appreciation underlying whatever studied content or biases they may layer upon their experience of appreciation of a plant and of all plants in their variety. Trees are not quite so familiar to most people so perhaps they don't provide the headstart they might otherwise, but at least they are generally beloved if only in a distant way. That's one primary thing I want in a name. I think it's easier to access our non-judgmental, less culturally tainted curiosity for what is when using such a name to hold and handle it with while we explore the idea.

In choosing a few representative trees I mean to reference how form speaks of function, but don't read too much into my choices. Even that is kind of hard. Spending too much time determining just the right representatives for each type would be too much a distraction from the work I actually intend to try hard at this endeavor. Despite my better judgment it's hard to make a choice and move on, as a perfectionist. And despite my cautions in other areas, I find myself compelled for lack of better ideas yet to embrace the theatricality of referencing of a species I've never met, the Baobab. This is therefore the apology for my path--and the warning that I may yet change the monikers beneath you as better ones make themselves evident. I beg those who know trees far better than I do forgive any indiscretions in my metaphors.

For the rest of us, the bottom line suggestion is this: let's take the innocence of our appreciation of nature to loving our bodies as they are, learning where and how they each grow best, and learning to cultivate them for excellent health but respecting our vast variety and capacities.

Some hypermobile clients have a very watery, soft and smooth form of body with very soft, smooth skin. These are telling of the limited adhesion between superficial layers of tissue and the deeper layers. Many if not all joints will bend backward further than for most people as the soft tissues within the joints are looser.

This type of person tends to be gentle on their body, knowing well from lifelong experience the consequences of not doing so carefully enough. Caution is built in. Repeat, possibly widespread dislocations and other signs of hypermobility will likely show up in their history.

They often also have a high awareness of subtle internal sensations, while sometimes struggling with proprioception--knowing exactly where all of their body parts are at any given moment and coordinating movement sharply. They sometimes describe themselves as clumsy. Given their physical cautiousness combined with often not feeling as spatially aware as others, they'll frequently express an aversion to aggressive and contact sports and instead lean into dance, yoga, non-contact martial arts, etc.

Those of this type who are tall have long curves. Those who are shorter wear their softness more evidently. I point it out to help differentiate tall varieties from this type from the often taller, generally more linearly proportioned Type 2. The Type 2 will have lower levels of adipose tissue. I find that in a bodywork context I'm more likely to find success using techniques listed under this heading for the soft, tall builds. The higher the mixture of very high tone muscle and fascial tisues will call for more of the Type 2 techniques, moderated as much as necessary to respect the delicacy of the outer tissues of Type 1.

The skin is loose if pulled. It can be very delicate and easily injured. This is especially noticeable on the hands and feet where a lot of wear and tear occurs. Most people develop calluses to protect these areas. To a notable degree this person may not tend to.

Lymphatic movement is often impaired, leading to unusual tenderness, sometimes a tendency toward frequent illness. Sinus and ear issues are common.

Fingerprints are very subtle, sometimes creating difficulty in using fingerprint ID systems.

The outer ear sometimes feels stiff compared to that of other people's ears.

Chronic musculoskeletal pain, gut issues, immunological issues, fainting or faintness from POTS, heart palpitations or other symptoms from dysautonomia, sometimes vascular or heart issues, and mental health challenges tend to be significant burdens on health and quality of life. The burden is exacerbated by the difficulty of finding doctors who are at this time trained to see the particular big picture of hypermobility and related symptoms. (That is slowly changing--please call me for more info if you need a capable provider in Santa Fe--a group of is forming to help engage more providers with these issues, so there'll be more providers ready for you soon.) 

Once again this is the set of characteristics I observe on the table in a number of clients--it is not diagnostic of anything--but it does map pretty easily to the characteristics of Ehlers-Danlos Syndrome. If you recognize yourself in these characteristics, please speak with your doctor about whether evaluation for EDS would be appropriate.

Because of the severity of their joint related symptoms, this type is of the three I outline the most likely to have already received a formal hypermobility related diagnosis. However, many clients too arrive having searched for help with numerous health issues for twenty or more years without their having been recognized as possibly relating to hypermobility. These people likely know they're quite loose in the joints, but no doctor seems to have ever thought to ask or to make the connection among so many other more pressing complaints.

Diagnosis remains tricky for the largest group of people with EDS as a genetic marker has not yet been identified. The marker is being sought, and many therapeutic tools are being developed. If your primary care providers can't evaluate this possibility to your satisfaction, you may wish to seek evaluation from a specialist familiar with Ehlers-Danlos Syndrome. Centers of Excellence in EDS care are identified on the Ehlers-Danlos Syndrome Society website. These specialists will be more familiar than others with things that can be mistaken for EDS and may likely be useful even if EDS is not present.

Regardless of diagnosis, the body type just described speaks to the bodyworker in particular ways and should be addressed accordingly. Techniques that are most helpful with this kind of body tend to include:

A Case Narrative and a Pattern to Watch For

The following summary of a case offers an observation on one pattern of response to bodywork that I have been able so far to follow so closely only once but suspect might arise fairly often in this type of watery build. I'll be able to go into my notes to look at timelines and details more carefully at some point, but here is the general outline:

A female client in her late twenties had had regular episodes of cluster headaches with certain migraine qualities since childhood. Joint instability had been evident in many parts of the body, including multiple joints that had in the past frequently dislocated and others that showed signs of significant instability. These signs had not been picked up in medical appointments--many more troubling challenges were under focus. Numerous frequently co-occuring conditions had been diagnosed, including autoimmune and gastrointestinal conditions. Others (reproductive and dermatologic) were suspected and/or under investigation. The client had been in medical care for the other known diagnoses for many years without steady relief. Symptoms would wax and wane without good control. Some triggers were known and avoided, but much remains a mystery with respect to factors leading to exacerbations.

Previous bodywork had tended to create more pain and not help. The client had not had bodywork in quite some time.

In initial weeks of weekly bodywork it was necessary in certain areas of the body affected by instability to moderate the depth of our work very carefully. They were areas that were tender, sometimes even painful to touch. Other gentle sensations in those areas had at times caused pain, the client reported. Other areas welcomed moderate pressure.

Despite careful and gentle care at the tender areas they were initially painful for several days following our weekly bodywork sessions. However, the client felt the chronic pain was possibly improving meanwhile. She was encouraged to continue with bodywork by noticing that after those several painful days familiar pains were less present. The tender areas were gradually becoming less tender.

The client linked the pattern of tenderness to another unpleasant and unusual experience they typically faced with exercise. After exercise, with delayed onset, they would be in pain for several days. The client perceived this pain to be beyond regular, expected levels of soreness. It wasn't specifically in the muscles worked, but more generally throughout the body. It would come along with all the symptoms of coming down with the flu. After an overzealous workout it would take a week and a half or more to recover energy and to be past excessive soreness. The client had therefore for years felt that it was necessary to be cautious about exercise, which prevented full participation at certain periods in social events or outdoor opportunities despite the desire to do so. This pattern exacted a real weight on the client's life. Frustration and the hope of improving things would motivate her to work out. Before long, the routine would stop because of the unpredictability of energy levels and pain responses after exercise.

After some weeks of bodywork the client observed that there were no longer several days of pain in the affected specific areas following each session. Instead, those areas would be a little sore for about a day--just in the easy end of the range of what most people experience after deep bodywork.

We remained cautious but gradually deepened our work both in areas that were initially sore for days and those that responded more typically.

At this stage, working with this client now regularly (usually weekly) for about a year, we are now working at what I would consider a fairly deep level. We primarily use typical deep tissue, tone reduction oriented work. This gives us access to engage mechanoreceptors potently and help reduce the tendency of chronic spasm and resultant pain in certain muscles, collaterally moving lymph.

The upper cervical area is an exception in our generally deepening work. The craniocervical junction and the neck as a whole strike me as fairly unstable. This hasn't been clearly diagnosed or attended by the client's medical team. Amidst the client's ongoing efforts to bring to attention all the many open questions and concerns with regards to this possibility and to overall health, I opt to use caution here beyond what the rest of the body appears to need at this stage.

The suboccipitals remain quite tender--a good sign that they could use more specific work. The scalenes seem also to be strongly overcompensating for the apparent lack of upper cervical stability. Given how careful this local work may need to be and the progress we've continued to have with broader efforts, we've continued to maintain progress and experiment as described--choosing for some periods to intentionally avoid the cervical area to evaluate to what extent bodywork there might worsen symptoms.

Still unsure on that point, the client and I have chosen of late, unless specific symptoms are arising and sometimes despite them too, to lean away from direct work at this area. Pressure is moderate at most when we do work there. Instead of direct and deep work, I tend to aim to benefit the area in a downstream way with work at the large muscles that feed tension into it through biomechanical (postural and habit and activity based) strains. So far that seems to be helping a good deal.

Given this watery body's biomechanical picture, it makes sense that focusing on muscle balance and relief of the chronic strain induced by normal use seems to be helping so much.

In general the headaches or migraines occur less frequently. Clusters are less clusterlike and brief, in general. Pain levels are lower. Recovery is more complete much more quickly. In a recent episode, a regular dose of anti-inflammatories taken to abort an oncoming headache completely shut off the pain and related symptoms within half an hour instead of leaving difficulties with speech and recall present for hours or days as in the past.

It is clear that bodywork has helped the client to manage biomechanical strains contributing to migraine and headaches. It is hard to say to what degree the client's currently eased daily physical labors may be more responsible for the improvements in headache patterns than is bodywork. The client's lifestyle is for the present far less straining, with an anticipated return to busyness soon--one clear trigger.

However, clear benefits are evident with work around other joints--knees, sacrum, and hips--after single focused sessions.

There is one other very important way in which bodywork has had a clear and direct benefit with respect to the headaches and migraines. The client is able to observe certain patterns of relation between biomechanical, immune, and gastrointestinal symptoms and headache or migraine onset. The client is able thereby to modulate certain patterns better. In one instance so far, exercise of the right kind and at the right time seemed to turn around an oncoming headache. Other instances of trying the same methods made for significant improvements as well. This presents a new and encouraging set of possibilities for the client in managing her symptoms at home.

The thing I would most like to point out in this case history is the result of all this experimentation with respect to the pattern in which, in early weeks, work local to certain areas was painful at a certain depth in session and then painful for days after even extremely gentle work. Here are the notable changes:

The increase in exercise is leading to gradual strength gains, which we reasonably hope will gradually stabilize joints. We're currently working on muscle balance to ease the aches that are arising with training. We're able to work deeply everywhere but the neck in doing so, with no ill effect.

I feel that what likely was happening in early sessions was at least a flushing of lymphatic fluids that move inefficiently because of the clients watery, hypermobile build. The skin is quite lax. There is very little of the normal, structural adhesivity between layers of tissue and fascial compartments. Overall, the efficiency of the pumping action produced by movement throughout the soft tissues by the integrated fascial network running through and around all our parts has got to be much lower in this client. In several ways it makes sense to me that my clients of this build are generally impacted by this challenge. It also makes sense to me with this client's experience of delayed onset pain and a sense of illness for several days after exercise. 

It seems possible also that pain centralization was at play due to the chronic and long-running pain in certain areas, perhaps combined with the need to have been exceptionally vigilant with respect to seemingly normal activities and actions. In this proposed case, neural circuitry linked sensations in general from this area with the experience of pain, and that gentle touch gradually helped to retrain those circuits to perceive other kinds of experiences.

This client has been the most regular to receive care of all my clients of this build, and while I see certain signs in others that feel very similar to this one that I point out, I haven't been able to follow the pattern as closely. As I say, I suspect it might be fairly common.

Based on this case history and many others, I highly recommend that those of especially this body type who may experience chronic tenderness, pain, and exercise intolerance try working with a manual lymphatic drainage specialist. See what they observe and whether the work feels helpful. If you're local to Santa Fe, there are some listed here. Otherwise, I would suggest looking for providers listed through the Chikly Health Institute or through the International Association for Healthcare Educators.


These clients have a wiry, slender, lean, often tall build. The so-called long bones of the body appear long in proportion to those on other bodies. The torso can be long too. These clients often tend to be slender, but that's not always the case especially as people age. This is sometimes called a Marfanoid body type--similar in proportions to the body of a person with Marfan syndrome (but not at all an indication by itself that that diagnosis is present.)

Most of the clients I see who fit this description are only mildly hypermobile in the joints. The Beighton Criteria may or may not even capture them as hypermobile. Though hypermobility itself is often (not always) mild, these clients frequently share the neurological, immune, and/or gastrointestinal symptoms that are typical of Type 1 clients.

Low adhesion of different fascial compartments and layers of tissue is in common with both of the other Types I see. The mechanical consequences of low adhesivity seems to lead to various other soft tissue qualities and pain similar to those in clients who more strongly hit joint hypermobility criteria. There can frequently be a history of dislocations, though these may be cyclical (based on hormonal changes or seasons) or irregular (related to shifts in postural challenges related to habits and activities, perhaps other factors too) instead of quite the norm as with Type 1. Or the dislocations may come with slighter traumas than would tend to dislocate joints in other bodies. So to me, although joint hypermobility is often less the central challenge, it wouldn't be correct to say that this is a milder version of hypermobility; it's just different.

The longitudinal gesture of the cedar reflects the evident long quality in the Type 2 frame. Whether the person is short or tall, length is the defining aspect of their form. Like Type 2 body tissue, the wood of cedar has very low adhesion between rings grown in different seasons. Splitting cedar along those surfaces leaves a fine, hairy surface of connective fibers that held the surfaces of different seasons' growth together. This kind of interface with fine, delicate, and minimal connectivity between layers is evident in palpating a body like this.

The similar low adhesion of different fascial compartments and layers of tissues strongly impacts how these bodies function and when, why, and how they don't function well. It also very strongly informs the kinds of bodywork techniques I have learned to lean toward for this group, as with Type 1. The joints themselves are not as hypermobile, but the rest of the soft tissues share physical traits. Soft tissues don't adhere to each other. Postural muscles take a very high tone, making up for the lack of global adhesion.

These clients often appear to others to be unusually strong for their build, perhaps in part because constant high muscle tone trains the muscles to a degree. Too high a tone normally decreases strength, but without the adhesion of different layers the soft tissues remain more elastic than they would otherwise despite their high tone, allowing more application despite the high tone. But in part too we associate bulk with strength because the dense fascial cross connections of a bulkier build allow for efficient contributions of effort from muscles and fascia . So the strength of these clients without the bulk we usually associate with strength can be surprising.

Heights vary for this type, but people are often taller. Those who are shorter look have the same lengthened proportions. Whatever their height, this type tends to be quite lean.

Depending on early life activity levels and types of activities, fascial development may have helped to more or less permanently stabilize joints for this group. Most joints will hyperextend only a little if at all; the shoulders are generally an exception since larger soft tissue structure define the movement of that joint. The neck is usually problematic. In keeping with the lanky structure, the neck is most frequently long--further putting it at risk of injury whether from longstanding habits of posture or from accidents. Dislocations and other signs of hypermobility may show up in their health histories too, but joint hypermobility is a lesser problem than others that are likely associated--including gut issues, immunological issues, fainting/POTS or dysautonomia, and mental health challenges. All of these can be extremely impactful even where joint hypermobility is not a noticeable issue.

This type of person frequently needs deeper than average work for bodywork to be effective. That deeper work is welcomed, too. There is generally a higher than average pressure tolerance. They notice the relief of reduced tension in muscles that have been trying too hard without appropriate levels of aid from their antagonists to keep joints under control. Lymphatic movement is not generally impaired in a widespread way, though it can be in the vicinity of injuries, especially where superficial weblike fascial scarring (or reinforcement) has formed to help stabilize a joint--shoulders are especially susceptible, and this weblike scarring will be palpable just under the surface of the skin anterior to the glenohumeral joint and in the pectoral area and upper arm within a few inches of the glenohumeral joint. 

Techniques that are most helpful with this group include:

This build tends to look more typical in proportions than the other two. I know least how to deal with it's particular challenges--one good reason to write, sort out my observations, and lay open the idea for critique and addition by others.

The glaring visual signs of hypermobility are not necessarily present unless the person is hyperextending some joints out of habit or for fun. Joint hypermobility can be significant, however.

Adhesion between deeper and more superficial layers of tissue and between different fascial (sheathed) units is low. Therefore, there is a significant potential for instability globally. Yet, this third group easily builds muscle which can be protective against joint instability.

Long-bone proportions are moderate with respect to the human range. Facial features and distal points such as head, hands, and feet tend to be moderate or larger. A bit of watery softness may cover evident muscle unless some particular exercise and food regimen has made them lean.

High muscle tone and capable, often but not always larger musculature tends to control many joints adequately to prevent injury. Anywhere joint instability exists due to past injuries or inherent weakness, however, the issues can be severe. High muscle tone, if imbalanced, can add to the problem by continually pulling the joints out of proper alignment, leading to evident myofascial, joint, and dural pain, and frequently also neuropathic complaints. In this group as in Type 1, the tendency to have significant instability if not more severe issues such as spondylolistheses at the lumbar area or upper cervical area is strong. Balancing muscle groups and supporting maintenance of good posture is perhaps even more essential for this group than for either of the other two I describe. 

I'm still working out how to work most effectively with this group, but guided by the same physiological principles that prove useful in working with the other two groups, I tend to apply the same techniques piecemeal based on the body and body part and needs on the table. Deep work is generally welcome, and the overall session lands more in the direction of what I provide for those of Type 2 unless there is significant inflammation or some other cause of tenderness.

What Does It Look Like To Not Be Hypermobile?

A Sturdy Cottonwood, For Instance

For contrast, here is an image of another type of build that is very much not hypermobile:

Easy muscle growth. Average or husky proportions. Significant adhesion between all layers and types of tissue. Physical solidity, especially if there is or has been significant exercise.

Cottonwood has multitudes of transverse fibers that stretch from deeper rings of the trunk into newer ones, unlike many trees in which the layers of wood are quite discrete. Cottonwood is somewhat brittle at the limbs, but the trunk is a lot of work to split as it is so thoroughly tied together.

It hurts to pull or stretch the skin too aggressively because everything is so tied together. Some caution may be necessary in myofascial work to avoid that pain. However, beginning slowly, these techniques can be exceedingly helpful to reduce adhesion temporarily and help engage the body in learning, embracing new ranges of motion.

The body tends to stiffen without care, and regular stretching does a lot of good.

Joints are vulnerable to injuries especially as this person ages. Stiffness doesn't help, but the principle is that given the high degree of integration of tissues due to dense, interpenetrating fascial connection, forces land strongly at the joint, a bit of a weak link. Stretching is protective in part as it allows musculature and it's fascia to absorb more of the strains of activity. Stretching also keeps the soft tissues better hydrated and more resilient.

Percussion is useful for this body too, but because everything is tied together so densely it too is useful mainly to reduce tone temporarily in taut muscles so that better muscle balance can be taught. On its own percussion won't go far. Stretching and broad techniques to stretch the fascia in all directions should not be missed.

This person may well have an iron gut--no known sensitivities to anything. They can ride through physically difficult situations with ease--they're built for it. 

A Few General Points in Caring For a Hypermobile Body

Ergonomics

Many ergonomic factors contribute to the strain on a body, and for hypermobile people the consequences of not managing ergonomics well tend to be more severe than for others.

Most vehicles do not fit most humans well. Airplane seats are at least as bad. Chairs and couches frequently don't fit our individual bodies. Even if they do, the static posture is typically held for much of the day and doesn't offer us the opportunity to roundly develop our bodies in the way that we do just by being upright and actively moving, adapting. Standing to work is hard on soft, hypermobile joints. It also tends to leave strain on various parts of our body just the same as sitting would.

My favorite solution for hypermobile clients is to create an array of well situated places to work from--a chair and desk, a place to squat, a place to stand, a place to lie down. A healthy respect for the value of pacing or walking or moving one's body in other ways while working is also valuable, but in general I don't need to coach that. People in pain tend to be so uncomfortable staying still for as long as others do that they've generally developed habits of moving or changing places and positions anywhere there's the remote possibility to do so. Whatever array of working arrangements you can manage, set them all up with as much care as possible so that the body can find relative ease and neutrality for as many parts as possible while working in each, and give your body the opportunity as often as possible throughout the day to move freely and into positions opposing and helping to balance the workaday status quo.

Whether sitting or standing, the most-used segment of the monitor is in front of the eyes. Keyboards should be just below the elbow whether sitting or standing.

Avoid dual monitors if you can, and if you need them, try putting the primary one directly in front of you and using the other only incidentally. The secondary monitor could ideally be placed low, facing upward and the primary in the usual place just ahead of the eyes if glancing at the secondary is needed often. It's easier on most bodies to glance down here and there or to hang the head looking down for a bit than to maintain a forward facing seat while turning the neck to accomodate monitor position. Where the other suggestions are not possible and use of multiple monitors is extended, I highly recommend using a swivel chair with a keyboard tray or a desk setup that allow you to reposition your keyboard right in front of you and encourages you to face straight ahead whatever you're doing for the moment.

Practical challenges aside, please note that peering down at a laptop is far from ideal whether sitting or standing.

Laying in bed to work is popular among people with chronic pain who can do so--students for their homework sessions and remote workers, for instance. I caution you against sitting much at all with legs and arms out front to read or work at a keyboard. This posture is really hard on multiple areas of your body and will exacerbate any tendency to instability at the neck and perhaps low back as well as cause soft tissues to seize to try to control that risk. 

Feet should sit flat on the floor. Thighs should parallel the floor. For shorter people, the pressure of the edge of a too-high chair on the underside of the thigh is enough to cause pain at the pressure point or in the lower legs or feet.

Alternative to a regular desk chair, with some advantages, is the option of using a kneeling chair. If the knees are delicate this won't be a good option. For low backs and necks it's great so long as a way is provided to support the arms for typing or whatever activity is performed.

Hypermobile people frequently face a couple of special complications with respect to ergonomics. The arm bones are long, so tables, desks, and armrests tend to be a little high. Yet many hypermobile people are also on the tall side, and many have poor eyesight due to the same tissue qualities that make them hypermobile. All of this suggests the result we see--people managing an average working environment with their shoulders compressed to their ears as they hunch and peer downward at the table that is too far for their eyes and too near for their elbows.

In shared work environments, accommodating the various needs of multiple people let alone the various needs of any single person with pain is often not so freely possible. In these cases it is even more important to get up and move often and to do some sort of physical training that opposes the muscle imbalances. 

Economics and space often also limit what can be done to optimize workspace ergonomics. Prioritize it, but be ready to work around any limitations in the short term. Set up your environment as well as you're able, maybe create a space to keep some aids to accommodations when you come on shift if the space is yours for that period, but build forgiveness into your schedule or into other aspects of your life to manage the challenges better overall. Perfect never happens and it wouldn't help so much anyway to manage that kind of tight and stiff approach as it does to create more give, more options, and a smart general strategy of management. Awareness of the challenges is more valuable in the long run than the right solution, as over and over again you can practice getting more creative and capable with good management and feel your way gradually to solutions that really work well.

Adjunct Therapies

Because of their strong interoception, these clients often feel and incorporate well the immediate and widespread (perhaps fascia and immune mediated?) changes that acupuncture provides, accept it well, and express that they feel they benefit from it.

In cases where joints can frequently dislocate, it's very useful to have easy and/or regular access to a physical therapist, naprapath, or osteopath to help as soon as possible when joints are giving trouble. With an established relationship, these parties will be best able to help guide preventive measures and will know the body well enough to be of better service when trouble arises.

I do not recommend chiropractic involving high velocity, low amplitude (HVLA) techniques for these clients. HVLA and similarly jarring techniques frequently trigger spasms in soft tissues that are already working hard to keep joints stable. If clients already work with a chiropractor who works well with them, that's great--but many fear this kind of practice, intuiting that it's not the right fit for them.

I do specifically recommend practices such as naprapathy for hypermobile clients, in which manual techniques to pointedly release soft tissue tension to allow the bones to gently settle back into place. Specifically, seeking someone who employs Golgi Tendon Organ techniques well and pays attention to appropriate posture and function of the overall structure is likely to be a great resource. Paradoxically, in such a loose set of tissues, postural muscles frequently take on an intensely high tone to help hold the skeleton together. Balancing the tones of various muscle groups and training the posture to support balance between these groups can bring much pain relief.

Physical therapy and/or gentle, personally tailored strength training to help balance muscle strength and activation is immensely useful. Pilates, personal training, and dance are often a great fit so long as care is taken in technique--overstretching is a real risk, and strength work should be done patiently and with measure. Weekend warrior type training is risky.

Orofascial myologists, orthodontists, or others skilled in work with the temporomandibular joints of the jaw are often helpful.

Mental health support can be really helpful where navigating chronic pain or other health challenges is necessary. Hypermobile bodies are impacted in ways beyond the mechanical. Chemical factors present a nervous system that may need more care than most to stay balanced. Working with a therapist who knows hypermobility, chronic pain, or related conditions is ideal.

Nerve Compression

Nerve compression occurs particularly easily in hypermobile bodies. It can occur as a result of sleeping on a shoulder or hip habitually and causing the tissues upon which one rests to adhere to each other. Resting against something hard in a habitual way while at work can also easily create the same challenge. In many cases these compressions tend to be fairly easy to resolve because of the low adhesivity of tissues, especially if they haven't gone on long. The new adhesions are often easy to break with some simple myofascial techniques. You may be able to do a lot of good with these by yourself at home with a little coaching or research.

Nerve compression can also occur due to suboptimal posture. The extra range of movement available in a hypermobile body combined with the softness of the tissues and the lack of stiff protective fascial structuring allows for compression a little more easily than in other bodies. So care to find postures of ease is crucial for those who are hypermobile, particularly as one ages. Here is a favorite podcast that can be helpful in training posture not in a militaristic way but by finding ease and welcoming the body to embrace it.

Cyclical Dislocations

There are fascinating patterns to note in a clinical bodywork setting, but not always the infrastructure and numbers to validate them. I suspect that this group is especially susceptible to dislocations that could be linked to changes in weather and to hormonal factors, if not others.

In work with the general public I notice that as the weather cools in fall the bodies of my clients tighten. A series of predictable pain complaints progresses from neck and jaw, to shoulders and upper back, to low back and hips. More problematic for my Type 1 Watery clients is the spring thaw. As the weather warms, joints that already tend toward instability

Finances and Accommodations

Because nothing doesn't touch on money, let's talk about the career and financial implications of living in this type of body.

With few exceptions, my clients who have been highly hypermobile have had to be very thoughtful about their work and their schooling. Frequent illness, unpredictable bouts of temporary disability, chronic illness, and related health challenges all make living by an externally dictated schedule much more difficult than for others. This type of body may not be able to handle long hours in a chair like other bodies. Standing too can be painful. Any physically quiet activity is easier, but the repetitive motions and long-held static postures of desk work can easily be a source of pain too, especially when the ergonomic setup is not optimized. These folks look healthy, but often prefer to work from bed.

There are many specific things to be said about providing for good ergonomics while working from a soft, supportive setup. Sitting up in bed with the legs out in front and the neck craning forward is extremely common in people with chronic pain and may be exacerbating pain, I'm sorry to say--so be thoughtful and find help if you can to identify useful and helpful ergonomic arrangements. However, I'm for any and all helpful accommodations one can set up. Multiple well-designed setups are better than one. They allow the body to passively adapt to slightly different challenges and better distribute the strains of daily living.

Do negotiate for any and all accommodations that can be provided at your school or workplace. The world is a better place for your functioning at your top; you should be supported to do so. Do also consider the course you're setting for yourself if you're choosing a career or designing a career change. Try to find a path in which you'll have the room to make whatever accommodations will help you most and the money or benefits to keep up with higher costs of and needs for access to medical care.

Finding a Bodyworker Skilled with Hypermobility

Practitioners with high level training and a fair bit of experience in any modality are more likely than not to be more familiar than others with hypermobility and how to work with it well. Hypermobility is so common that any bodyworker has seen quite a lot of it. The ability to work with it well comes largely from clinical experience and investment in a strong understanding of physiological variability and the technicalities of bodywork. Beyond that, because certain conditions so often arrive along with hypermobility, certain specialties are in my opinion a bit more likely to come along with a technical, practical understanding of what works if not a theoretical one. Those include at least specialization in working with the following groups:

Poking around with the reference points below may help you find quality therapists. Trainings offered by these organizations and teachers tend to draw massage therapists and bodyworkers who are serious about their work and often have a fair bit of experience; many also draw other types of highly credentialed conventional medical healthcare providers as well who tend to work with a broad, holistic scope and open mindset by the time they're inspired to explore this far from the conventional mainstream.

Resources by Topic

A list of resources covering hypermobility and the various other areas of interest in which I serve: information in video and podcast form, articles, product and company webpages, support organizations, etc.

Hypermobility Meetup

This group is for anyone--diagnosed, undiagnosed, or just interested in the topic. Awareness is valuable to those who are struggling to find effective care. Some sessions may be reserved for those who face particular symptoms. The meetup is currently held in the north end of Santa Fe, roughly monthly, around the end of the month. Call for details.

Santa Fe & Albuquerque HSD/EDS Journal Club

A group of local providers is forming now (summer 2024) to further various purposes around improving care and awareness around hypermobility related health issues. This is the project of a local doctor, Katie Dewar at Method Physical Therapy. Specialties of providers aiming to take part vary widely among conventional and complementary modalities. Contact info for involved providers will be available soon. Please call Method Physical Therapy or me (at the info below) if you'd like the latest.

Migraine and Chronic Headache Resource Coming Soon

If you suffer from hypermobility, various other conditions such as migraine or chronic headache are more likely to be challenges for you than for others. I share strategies for reducing the frequency and pain of migraines and chronic headaches in my book, which I've committed to having available online in some form, tidy enough for consumption, by late December of 2024.

Contact Me

Please feel free to be in touch if you could benefit from guidance toward the right resources or help troubleshooting a specific bodywork and hypermobility related issue.