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Manual therapy (MT) is a core component of physical therapy, but its application must be drastically altered when treating clients with Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (hEDS). The primary danger is that aggressive mobilization or manipulation can further strain already fragile connective tissue, potentially destabilizing joints or triggering a pain flare.

The role of manual therapy in hypermobility shifts entirely: it is not about mobilizing lax joints, but about treating the protective muscle spasms and compensating restrictions that arise due to the underlying instability.

🛑 The Golden Rule: Avoid Aggressive Mobilization

The most critical principle is: Do not mobilize or manipulate hypermobile joints.

Many hypermobile individuals present with a high Beighton score, meaning their joints inherently have excess passive range of motion. Pushing this range further is counterproductive and harmful. Even if a hypermobile joint feels “stiff,” this stiffness is often protective, muscular tightening (spasm) intended to prevent subluxation or pain.

Safe Manual Therapy Techniques: Focus on Soft Tissue and Regulation

The most effective manual techniques focus on two goals: calming the hypersensitive nervous system and releasing the compensatory muscular tension surrounding a loose joint.

1. Low-Grade Joint Mobilization and Oscillations

While high-velocity thrust (HVT) manipulation is contraindicated, low-grade (Grades I and II) joint oscillations can be highly therapeutic, provided they are applied to hypomobile segments that are restricted due to compensation.

• Application: Apply gentle, rhythmic, non-thrust oscillations to an obviously restricted, hypomobile joint (e.g., a thoracic spine segment stiffened by compensatory postural holding). The goal is to modulate pain and relax the surrounding musculature, not to increase the range of motion.
• Safety Check: Always monitor the patient’s comfort and heart rate. If the technique increases anxiety, stop immediately and pivot to a gentler approach.

2. Soft Tissue and Myofascial Release

This is often the most beneficial application of manual therapy in the hypermobile population. Protective muscle spasms (e.g., in the upper trapezius, paraspinals, or hip flexors) are common responses to core and girdle instability.

• Techniques: Use slow, sustained pressure via myofascial release, trigger point therapy, or gentle effleurage. The Joint hypermobility physiotherapist Gold Coast should focus on pressure that facilitates tissue relaxation and blood flow, rather than deep, painful stripping.
• Goal: Decrease pain, improve local circulation, and provide a window of reduced spasm, allowing the patient to immediately engage their stabilizing muscles (the core and deep stabilizers) without the spasm fighting them.

3. Muscle Energy Techniques (METs)

METs are an excellent method for gently restoring balance and resting length to restricted muscles without forcing a joint into a hypermobile range.

• Application: METs use the patient’s own muscle contractions (isometrics) followed by stretching. This is a safer alternative to passive stretching, as the muscle relaxation that follows the contraction is internally mediated and less likely to trigger a protective spasm.
• Example: To relax a tight hamstring, gently resist the patient’s isometric push into hip extension, followed by a slight, controlled increase in hip flexion range (never pushing into the hypermobile end range).

Integrating Manual Therapy with Active Care

Manual therapy should never be a standalone treatment for hypermobility; it must serve as a precursor to active stabilization.

1. Prep the Muscle: Use MT (e.g., soft tissue release) to quiet a hypertonic muscle (e.g., the upper trap or multifidus spasm).
2. Activate the Stabilizer: Immediately follow the manual technique by guiding the patient into an active stabilizing exercise (e.g., core engagement or deep neck flexor activation). The relaxed muscle is now inhibited, allowing the correct, deep stabilizer to fire more easily.
3. Reinforce the Pattern: The patient then practices this correct motor pattern (e.g., deep core activation) multiple times to consolidate the neurological learning.

Clinical Considerations for Safety

• Establish Baseline: Always inquire about a history of adverse reactions to previous manual therapy (e.g., post-treatment pain flares that last for days).
• Pressure Gauge: Start with the lightest pressure possible. Hypermobile clients often have highly sensitive skin and nervous systems. Ask the patient to grade the pressure (e.g., “5/10 is my maximum comfortable pressure”) and strictly adhere to their limit.
• Acknowledge Autonomic Issues: If the patient has POTS, avoid sudden positional changes on the plinth and ensure they are comfortable. Manual work that is too intense can trigger an autonomic response, increasing heart rate and anxiety.