As a physical therapist (or physiotherapist, for those outside of the USA), this is how I most frequently work with patients with Ehlers-Danlos Syndrome (EDS): In addition to skilled hands-on techniques to improve boney alignment and specific muscle fiber recruitment, I prescribe very specific strengthening exercises that stabilize joints, and I teach patients self-myofascial release.
An ongoing combo of self-myofascial release followed by joint stabilization through exercise is often key to reducing the kind of chronic, daily pain that can accompany generalized hypermobility.
Physical therapy exercises are usually progressed over time, and part of teaching ANY patient (not just those with EDS or hypermobility) is teaching them how to recognize fatigue, compensatory effort during exercises and daily activities or the warning signs that pain may come later (also, don’t push through pain) — essentially the kind of mindfulness that we also practice with yoga asana.
How do we do find a similar therapeutic approach in the context of teaching group classes? How do we maintain the safety of a yoga student with known hypermobility?
The best case scenario for a potential yoga student with hypermobility or EDS is to do the following pre-yoga class activities:
- First deeply study their condition, so that they know the risks. There are quite a few benign and not-so-benign conditions that can cause localized or general hypermobility. Many don’t know, and go in blind.
- Second, if they haven’t had physical therapy to address pain or joint instability issues, they should. Physical therapy can conclude with providing individualized guidance on what moves to avoid, and what moves to encourage.
- Third, bring that specific guidance from your physical therapist to an experienced and skilled (not just any) yoga teacher for a private lesson. During that lesson, the instructor can translate what the physical therapist has recommended into specific advice for common yoga asana or transitions during a group yoga class. For example, if someone has a repeatedly dislocated shoulder, they want to be very careful even during the simple act of abducting the arm to 90 degrees. This occurs in virabhadrasana II, and trikonasana, two commonly practiced poses.
As a group yoga instructor with a student with hypermobility (revealed or observed):
- Begin class with intentional mindfulness. This may come in the form of meditation, verbal reminders to avoid competitive behavior and to listen to our own “internal teachers” or discussion of what one’s “edge” exactly is.
- Avoid cues like “Feel the stretch”. This cue is exceedingly common, but the reality is that the sensation of stretch is hugely variable (some won’t feel a thing), not necessarily a mark of a “good pose”, and frequently masks unsafe range of motion by encouraging intense sensation. For someone with hypermobility (this includes more yoga practitioners than you might guess), the cue can be downright dangerous as their proprioceptive capacity is limited.
- Encourage holds that cause (a reasonable amount of) shaking (in reasonable poses). For example, in tree pose or Warrior III, the ankles wobble. This is the stuff of essential muscle strengthening. With navasana (boat pose), on the other hand, please don’t encourage long shaking holds because, unlike standing on one foot, it is not a functional movement done multiple times a day.
- Look out for locked joints. There’s a fine line between discouraging saggy elbows during downward facing dog and seeing double jointed arms that look like a medieval bowstring. Locking out joints (especially hypermobile one) and hanging in the joints is a big no-no for hypermobile folks. Your task as an instructor is to teach everyone in the room, which means different cues for the hypermobile set versus the set that has sub-normal range of motion, not one blanket cue. This is the refined and individualized stuff of experienced teaching, but even if you are brand-new, or feeling lost, give it a try.
- Repeat and Refine. I once read this statement from yoga teacher Jason Crandall: students want poses repeated much more than teachers want to repeat teaching them. If you as a teacher wish to teach the bind in, say, trikonasana, consider teaching it two or three times as a warm-up without the bind first, and teach components of the bind before the “full pose”. Peak poses and / or intelligent, building block sequencing can make all the difference in creating stability in less than stable joints.
- On fascial release and group yoga classes. Fascia responds to long sustained holds. Muscle stretch can occur in much shorter time frame (30-60 seconds or with repetition). Know that the two body systems are intimately connected, hence the term “myofascial”. That said, realistically fascial release is not the end result of most asana outside of a yin practice. And a yin practice (long, 4 minute holds) is not necessarily therapeutic. In fact, Yin Yoga can be quite dangerous for hypermobile students and can exacerbate underlying body asymmetries for others. For the hypermobile students who need targeted fascial release, our humble opinion here at Yoga Anatomy Academy is that they must seek that outside of a standard yoga class. And so should yoga instructors and others. There are skilled myofascial release massage therapists in every city. There are great resources like our 2 hour “Way of the Happy Fascia” audio workshop that guides you in self-myofascial release with tennis balls. And there are DVDs like those offered by Yoga Tune-Up for self-myofascial release.
BONUS TIP 🙂
Teachers, please be careful not to glorify flexibility. If a student can touch their foot to their head, recognize that although it might be “beautiful”, it is not a functional goal, and it sets them up for potential joint damage. Refrain from overly praising such acts while in the seat of a teacher in yoga class. Instead, glorify the big breakthroughs that have lifelong meaning: for example, the fact that everyone showed up to yoga class for self-care and mindful movement.
Join the discussion on Facebook!
There is a new Facebook group DEDICATED to sharing best practices around this exact topic, “Yoga for Hypermobility and Ehlers-Danlos”. It can be found here. This group is intended to be a crowd-sourced, evidence-based information resource for those with hypermobility (officially diagnosed or not) and the yoga teachers who teach them. Please join the group, invite your friends, ask questions, and share what elements of yoga have helped your hypermobility, as well as recommendations on what to avoid. https://www.facebook.com/groups/YogaforHypermobility
As always, we’d love to read your comments and questions below.