Hypermobility on the mat: some pointers for teaching yoga to people with Ehlers Danlos / Joint Hypermobility Syndrome and Marfan Syndrome

hypermobilityThese suggestions for working with yoga students with Ehlers Danlos / Joint Hypermobility Syndrome and with Marfan Syndrome (EDS / JHS / MS) are written in response to the many requests for help and advice I receive from teachers of hypermobile students. They are neither exhaustive nor gospel. They are the result of personal experience rather than expertise. I have been practising yoga with Ehlers Danlos (Hypermobility Type) since 1981 and have experienced many different attitudes and approaches from teachers. In the last decade-and-some, I have also been fortunate enough to teach many students with hypermobility.

While teachers with a normal mobility range are sometimes, understandably, anxious about how to work with hypermobile students in a beneficial way, most of the principles for teaching hypermobile people are also good practice for working with all students, so hypermobile people are easy to integrate into a general yoga class. Individual techniques for individual postures are outside the scope of this writing, but pretty much any principle for alignment and physical integrity you have learnt is potentially a great tool for hypermobile students. The following are some general possibilities to explore.

• Many beginning students share the popular view of yoga in our culture as the cultivation of flexibility. Frame physical practice as a movement towards balance and integrity. For some students this will mean working on strength and stamina; for others it will mean focusing on loosening restrictions in fascia and muscle. This approach will also serve your stiffer students, who may feel that they are ‘bad’ at yoga because they are not flexible.

• Guide hypermobile students to release (micro-bend) the insides of their elbows and the backs of their knees so that they are using postural muscles to support themselves rather than ‘hanging’ in their joints.

• If you are familiar with spirals, use them to guide alignment – as far as I can tell, it is impossible to both spiral and hyper-extend knees / elbows at the same time.

• Guide students to draw their limbs gently into the sockets rather than pulling them out, and to feel into the spaces for movement within the joint. The general principle is to relate back to the centre rather than pulling towards the extremities. If you teach a vinyasa style, bandhas are key here – and generally very helpful for hypermobile people.

• When teaching bandha be aware that a hypermobile person may tend to grip everything and hang onto it for dear life, so emphasise that bandha is a subtle art, offering lots of opportunities for somatic exploration.

• In a hypermobile body, overworked and very flexible muscles often compensate for tight, contracted ones. Look out for this and suggest ways in which the student might rebalance, by stretching or letting go in the tight places and strengthening the over-extended ones.

• Hypermobile people, by definition, have difficulties with proprioception, the ability to sense 1) the position of one’s own body in space, 2) the orientation of one body part to another, 3) the range of movement in a body part, 4) the degree of effort involved in carrying out a movement, and 5) which muscles need to be switched on and which switched off in order for a movement to be made in the most economical way. At the same time, many hypermobile people (particularly those – a significant number of us – who are autistic too) also have heightened interoception – awareness of stimuli arising within the body – and so may be receiving an overload of other sensory information. Be mindful of the potential for labelling sensation-sensitive students as hypochondriac or self-dramatising because they are registering somatic experience in a range that for the teacher is under the radar.

• A hypermobile student may find it helpful to have something to push into or resist against – this provides greater proprioceptive feedback and de-emphasises extending the joint as the main action. For example: ‘Press your elbows into my hands’ (to work with hyper-extending elbows in downdog), or ‘Press your shin up into your hand’ (to work with a hyper-extending knee in utthita trikonasana).

• Educate students about edge as a range of possibilities. Because of the limitations in their proprioceptive ability, hypermobile people may need guidance to be able to feel the softer edges on the spectrum. If a hypermobile student consistently chooses a hard edge, be aware that this may be because it’s the only edge they can feel, rather than concluding that they are an aggressive practitioner.

• Be prepared to adjust the hypermobile student’s alignment, in the same place, in the same way, again and again. Because of the proprioceptive deficit that is integral to hypermobility, most hypermobile students will need to feel the new alignment many more times than a non-hypermobile student in order to embody it.

• Offer only one verbal / physical adjustment at a time, even if there are many things in an asana that you feel need attention. Proprioceptive challenges, together with interoceptive overload (which can act as a kind of interference), make it difficult for hypermobile students to integrate multiple or complex changes into their body and they will quickly get overwhelmed by too much information.

• Refer students to the internal – energetic, somatic, psychological – dimensions of yoga. Remind them that the intention of physical practice is to create a simulacrum for life, in which our habitual patterns (samskhara-s), so naturalised as to be transparent to us, can become opaque, and once visible may be worked with consciously. Physical practice is simply an opportunity in which yoga may occur; it is not itself yoga.

• In making physical adjustments, focus on helping the student to feel the dynamics of the posture rather than increasing the amount of stretch in it. Adjustment focused on stretch puts hypermobile students at high risk of injury. A good adjustment holds the structure of the posture for the hypermobile student so that they can embody it.

• Be aware that wide range of motion is only one aspect of hypermobility and that EDS / JHS / MS is one of a group of overlapping conditions. A hypermobile student may also be experiencing:

Dyscalculia (difficulty with numbers and sequences).
Dysautonomia / POTS (disregulation of the autonomic nervous system: so they may feel faint coming up from head-down postures, and dizzy in head-back postures).
Fibromyalgia / chronic pain.
Chronic fatigue / general need for more rest than usual.
Irritable Bowel Syndrome.
Eating disorders / self-harm.
Higher than usual rates of anxiety / a sensitive nervous system that easily gets stuck in fight, flight, freeze / low-level PTSD / OCD.
Austism / Asperger’s Syndrome.

• Be aware that while developing strength is desirable for hypermobile people, EDS / JHS / MS is a genetic condition of the collagen. While muscle strength can compensate to some degree for lack of tensility in the fascia, it can never create the kind of stability that is inherently present for non-hypermobile people (i.e. people with normally coded collagen). This compensatory form of stability is not automatic and must be consciously turned on and maintained. For this reason stabilising their body can be physically and mentally exhausting for hypermobile people.

• Know that yoga is very often not easy for hypermobile people. In fact, EDS / JHS / MS presents many additional challenges in asana work. These may include chronic pain, difficulty in stabilising the body due to lack of fascial support, limitations in proprioception (which, together with stability issues can make balance very difficult), dysautonomia (which may cause faintness, dizziness, a racing heart and unusual fluctuations in body temperature), frequent dislocations and injuries (which may require a longer healing time in a hypermobile body), and difficulty in building muscle mass.

• Avoid framing the holding of a posture as a feat of endurance. A hypermobile student may lack the fascial tensility to hold a standing posture for what would be a normal period of time for other students, even when they have good muscle strength. Holding beyond their comfort range may not increase the student’s stamina but cause muscles to go into spasm, and tendons, ligaments and fascia to become inflamed and over-stretched.

• If you teach a yin style, be aware that for some hypermobile people an optimal yin stretch may be one to two minutes, and extending the hold time may result in damage to tissues. The appropriate duration will vary from person to person, and for the same person in different postures. Encourage students to track their own edge and emphasise that it is always OK to come out of a posture. The optimal hold time is not five minutes but when you feel ‘cooked’. I have written specifically about yin yoga and hypermobility here.

• Be extra-mindful of your own projections. Hypermobile students sometimes receive projections related to the teacher’s own desire to be flexible, and may be inappropriately praised or criticised as a result. Remember that hypermobility is not something that the student is doing; it is something they are being. There is no choice or agency involved in being hypermobile; it is simply a genetic condition.

• If you are teaching a student who regularly dislocates (and may also be able easily to put themselves back in joint), keep teaching towards structural integrity and avoid communicating any sense of fear or horror you experience in response. Be aware that this kind of dislocation is an everyday occurence for some hypermobile people and for them may not be a big deal.

• If your student is not aware that they have EDS / JHS/ MS, it may be helpful to let them know that you cannot diagnose, but that you think they may be hypermobile. Many beginning hypermobile students struggle enormously with balance and stability, and may be having other unexplained health problems. It can be very useful for them to know that there is a reason for this. Explain simply and without drama, and offer as much information as they want to receive. For some students this will be a lot, for others little.

• Offer help to stabilise, strengthen and align the student’s extension rather than asking them to pull back out of it (or not to go so far). This way you are offering them something more rather than taking something away. Most students will be responsive to this approach.

• Be aware that for all sorts of reasons, hypermobile people do need to stretch. We all do. Unstressed tissues are degenerating tissues, and many hypermobile people have some muscles in a state of chronic contraction.

• Be aware that in people with the, less common, vascular type of EDS the blood vessels, gut wall and uterus are very fragile and at risk of rupture (which may be life-threatening). Prevention of trauma to the skin (eg bruising) is very important. A person with vascular EDS may need to pad vulnerable areas of their body and avoid any postures that might cause them to fall. Be very careful of their skin if you make any physical adjustments.

• If you teach an aerobic form of yoga, be aware that for people with Marfan Syndrome (a form of hypermobility that also affects the heart and circulatory system), aerobic exercise is usually contraindicated because it can place too much stress on fragile tissues in the heart, veins and arteries and may lead to heart attack. Whereas many people with EDS / JHS are unaware that they are hypermobile, those with Marfan Syndrome are most often already diagnosed. This is because EDS/ JHS / MS runs genetically true to type, so it is likely that there have been instances in their family of early heart attack without the usual indicators of coronary disease (for example, a relative with low blood pressure, low cholesterol and a normal weight who had a heart attack in their forties). It is recommended that people with Marfan Syndrome do regular low-intensity, low-impact activities in which their heart rate does not go above 100 bpm. They should work at about 50 per cent of maximum effort. A strenuous yoga class may not be appropriate for them. You can download a guide to Marfan Syndrome and physical exercise here.

• If your student is an experienced yogi, by all means offer suggestions for change, but be mindful not to sweep in and reconfigure their practice for them. Remember that the practice is the student’s. Because of the proprioceptive deficits involved in hypermobility, most hypermobile people receive limited information about where they are in space and where their body ends. As a result, control over their own body may be an issue for them and they may feel threatened by any suggestion that you are trying to take over. If your student appears resistant to your suggestions, consider this as a possibility and explore how you could work with them more collaboratively. A style that supports what they already know and adds value to how they already practise will generally be well received. Be aware, too, that hypermobility sometimes attracts a surfeit of technical imput. You may or may not be giving the experienced student something new. Enquire and offer rather than impose.

• Some people with EDS / JHS / MS are housebound wheelchair-users, others are elite dancers, gymnasts and circus performers. In a yoga class, some hypermobile people will easily be able to enter physically challenging postures and will travel swiftly through progressive yoga practices such as astanga vinyasa, becoming adept practitioners of advanced series. Others will be dogged by injury and chronic pain. One possible reason for this disparity is that hypermobility is in fact not one but a group of many different genetic variations in the collagen. As genetic testing becomes cheaper and easier to carry out, more of these variations are being identified. Avoid evaluating hypermobile students on their physical performance. An EDS / JHS / MS student who is often injured may not be weaker or more pushy or more inconsistent in their practice than another who sails easily through increasingly more challenging sequences of asana. They may simply each have a different genetic variation in their collagen.

In general, hypermobile students try really, really hard, love working with their body and are a joy to teach. Trust your instincts, and honour and enjoy this opportunity to explore together.

I offer occasional workshop days on EDS / JHS / MS for (non-hypermobile) yoga teachers and for hypermobile yoga practitioners. For more information see www.movingprayer.co.uk or email jess@movingprayer.co.uk.

Articles about yoga and hypermobility
‘Six Tips for Teaching Yoga to Hypermobile Students’ – very good article by yoga teacher and physiotherapist Ariele Foster.

Hypermobility and Yin Yoga – another article by me.

General information about  EDS / HMS
A Guide to Living with Hypermobility Syndrome, Isobel Knight, Singing Dragon, 2011.

Teaser for a documentary on ED / HMS by Lara Bloom – a really good five-minute introduction.

The Hypermobility Syndrome Association (UK).

Ehlers Danlos Support UK.

The Ehlers Danlos Foundation.

Ehlers Danlos Syndrome Network CARES Foundation (US).

The National Marfan Foundation (US).

Postural Othostatic Tachycardia Syndrome (POTS)

Useful article on POTS in the British Journal of General Practice.

Dyspraxia Foundation.

The National Autistic Society.

Autism Womens Network.