Hypermobility on the mat: some pointers for teaching yoga to hypermobile people

hypermobilityThese suggestions for working with hypermobile students1 are written in response to the many requests for help and advice I receive from yoga teachers. Im not a doctor, a scientist or a hypermobility expert. I am a yoga teacher and therapist who has been practising yoga with Ehlers-Danlos Hypermobility Type since 1981. When I started teaching, in 2003, it was a rare teacher who didn’t respond, What’s that? to a disclosure of hypermobility. I did at least have an awareness of the territory in my own body, and hypermobile students started to approach me in search of a teacher with some sense of how to work with them in a helpful way. Together, over the years, we have emerged a body of experience.

There is no list of postures that are helpful / contra-indicated for hypermobility. Each hypermobile person is an individual with unique biomechanics and has to be evaluated as such. Hypermobility is complex to work with. It goes without saying that if you are a relatively new teacher and feel out of your depth, always refer your hypermobile student to a suitably experienced colleague. That said, any sound principle for functional movement and structural integrity you have learnt is potentially a useful tool for hypermobile students. Many of the principles for teaching hypermobile people are also best practice for working with all students and so are good material to incorporate into a general group class. Particular techniques for particular postures are outside the scope of this writing, but the following are some general possibilities to explore.

• Many beginning students share the popular view of yoga in our culture as stretching, and even experienced students are often overly focused on flexibility. Frame physical practice as a movement towards balance and integrity. For some students this will mean working primarily on strength, stamina and stability; for others it will mean working on mobility and extensibility. This approach will also serve your stiffer students, who may feel that they are ‘bad’ at yoga because they are not flexible.

• Work towards stability by encouraging hypermobile students to practise within end range of motion and engage postural muscles to support themselves structurally.

• 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 rather than ‘hanging’ in their joints – or dumping all their weight there.

• Introduce hypermobile students to the dynamic of spiral and counter-spiral. This can be an accessible way to create more muscular engagement and counteract the tendency to hyper-extend the joints.

• Guide students to draw their limbs into the sockets. The general principle is to relate back to the centre rather than pulling towards the extremities. If you teach a vinyasa style, bandha-s are key here – and generally very helpful for hypermobile people.

• When teaching bandha be aware that a hypermobile person may tend to grip muscles globally and hang onto them for dear life, so present bandha is a subtle art, offering lots of opportunities for somatic exploration. Inviting the student to imagine the bandha rather than actually engage it can help to mitigate over-engagement everywhere.

• Frame the discreet bandha-s articulated in many yoga systems – mula, uddiyana and jalandhara – as part of a much broader system of bandha which extends throughout and stabilises the whole body.

• 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 letting go or releasing in the tight places (myofascial techniques can be helpful here) 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) 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, neurotic 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 capacity, 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 or two verbal / physical adjustments 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 engage muscles and 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 helps the hypermobile student find the structure of the posture so that they can embody it.

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

Dyspraxia.
Dyslexia.
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, hEDS / HSD / MS are genetic conditions 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, hEDS / HSD / 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 are hypermobile, it may be helpful to let them know that you cannot diagnose, but that you think they may have hEDS / HSD / MF. 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 – selectively and in a sensible way. 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 Ehlers-Danlos, the blood vessels, gut wall and uterus are fragile and at risk of rupture (which may be life-threatening). Prevention of trauma to the skin (eg bruising) is 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 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 (which 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 hEDS / HSD are unaware that they are hypermobile, those with Marfan Syndrome are most often already diagnosed. This is because 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 ashtanga 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 students with hEDS / HSD / MF on their physical performance. A hypermobile 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, bring great sensitivity and highly creative ways of apprehending and describing their physical experience, and are a joy to teach. Trust your instincts, honour the unique embodiment of your student, and enjoy this opportunity to explore together.

Notes
1. Those with hypermobile Ehlers-Danlos Syndrome, Hypermobility Spectrum Disorder and Marfan Syndrome (hEDS, HSD and MS).

I offer occasional workshop days on hEDS / HSD / MS for yoga teachers (both hypermobile and not) and for hypermobile yoga practitioners. For more information see www.embodyyogadance.co.uk or email jess@embodyyogadance.co.uk.