In the management of Joint Hypermobility Spectrum Disorder (HSD) and hypermobile Ehlers-Danlos Syndrome (hEDS), traditional strengthening often falls short because it fails to address the faulty sensory feedback loop—the proprioceptive deficit. Proprioceptive training is the neurological re-education necessary to teach the muscles to react quickly and appropriately, protecting the loose joints from injury.
Effective proprioceptive training for the hypermobile client must be systematic, patient, and adhere to a strict progression from simple, stable inputs to complex, dynamic challenges.
The Foundation: The Stable and Calm System
Before any complex movement begins, the patient must establish stability and baseline nervous system regulation. The goal is to maximize the quality of sensory input (proprioception) while minimizing inhibitory factors (pain, anxiety).
1. Breathing and Pelvic Control
The diaphragm is a primary core stabilizer. Hyper-vigilant hypermobile clients often shallow-breathe, contributing to nervous system overdrive.
- Exercise: Diaphragmatic Breathing in Hook-Lying: Focus on achieving quiet, slow abdominal expansion (three-dimensional breathing). This is paired with gentle cues to activate the deep abdominal and pelvic floor muscles (the “inner core”) at the end of exhalation. This establishes central stability before limb movement begins.
2. Closed-Chain Activation
Closed-chain exercises are performed where the hand or foot is fixed, providing maximal compressive and tactile sensory feedback to the joint mechanoreceptors.
- Exercise: Wall Slides (Knees and Shoulders): The patient uses the wall to create external stability. For the knee, a gentle isometric squat with the feet fixed; for the shoulder, a controlled arm slide on the wall, focusing on smooth scapular control. The emphasis is on feeling the joint position and maintaining smooth movement, not muscle fatigue.
The Progression: Sensory Manipulation
Once stability is established on a stable surface, the physical therapist must systematically remove external input, forcing the reliance on proprioception.
1. Removing Visual Input (Eyes Closed)
The hypermobile client often over-relies on vision. Removing this input immediately demands higher internal awareness.
- Exercise: Eyes-Closed Single-Leg Stance: Begin with a stable, wide base, progressing to single-leg stance. Once stable (e.g., holding 30 seconds), repeat the exercise with eyes closed. This is a powerful, low-load diagnostic and therapeutic tool.
2. Modifying the Surface (Altering Tactile Input)
Introducing unstable surfaces challenges the body’s equilibrium and forces constant micro-adjustments from the stabilizing muscles.
- Exercise: Single-Leg Stance on Foam/Balance Disc: The patient repeats the single-leg stance while standing on a compliant surface. Start with eyes open and advance to eyes closed. Crucially, ensure the client is in a controlled, safe environment (near a wall or parallel bars) to prevent falls.
- Exercise: Wobble Board/Mini-Trampoline: Use these tools to introduce dynamic instability while performing static holds or gentle weight shifts.
3. Introducing Perturbation (Reactive Training)
This is the highest level of proprioceptive training, designed to train the muscles to react quickly to unexpected forces—mimicking real-life threats like tripping or catching a falling object.
- Exercise: Rhythmic Stabilization: The Joint hypermobility physiotherapist Gold Coast applies small, gentle, unpredictable manual pressures to the patient’s shoulder, hip, or trunk while they maintain a stable position (e.g., seated on a stability ball, standing in a partial squat). The client must counteract the force without losing their posture or allowing the joint to sublux.
- Exercise: Catch-and-Throw Drills: Perform simple catch-and-throw exercises with a light ball while the patient is standing on an unstable surface or holding a static pose. The unexpected movement of the ball demands rapid core and limb stabilization.
Clinical Takeaways for PTs
- Quality Over Quantity: For hypermobile patients, ten high-quality, controlled repetitions performed with maximum sensory focus are infinitely better than 50 rushed, sloppy reps. Stop before fatigue compromises form.
- Avoid the End Range: Proprioceptive exercises must be performed in the mid-range of stability—never challenging the hypermobile joint’s anatomical end range, as this only risks further ligament strain.
- Progression is Sacred: Do not rush the progression. A client must master eyes-closed stability on a stable floor before moving to an unstable surface. This layered approach ensures the new, functional motor patterns are hardwired into the nervous system.
