Hypomobility/Hypermobility
In this discussion of different body types, I am not referring to the three basic body types, which are Ectomorphic, Mesomorphic and Endomorphic. Rather, I am speaking of different body types based on connective tissue types. This is a very brief general article.
Different Body Types Require a Different Approach
Hypermobility
One extreme is Hypermobility Syndrome in which the connective tissue is very slack. There are several types of collagen, a protein that makes up our connective tissue such as tendon, ligaments, fascia, etc.. An excessive amount of elastin, a more "stretchy" connective tissue affects hypermobility. Hypermobility Syndrome is sometimes referred to as Erlos-Danlos Syndrome. People with general laxity have excessive motion in their joints. their posture may reflect this with hyperextension of the knees and elbows, excessive valgus of the elbows and knees, hyperextended hip joints, etc.. Passive motion testing will reveal greater than normal mobility at all (or nearly all) joints. for example, the typical person can extend their 5th metacarpo-phalaneal joint 45 to 60 degrees, the hypermobile can go 90 degrees and beyond. these body types are wonderful for circus acrobatics and gymnastics, because of the profound flexibility. They are able to protect themselves because they work out daily and have incredible strength and endurance.
When treating a person with hypermobility, there are several considerations. It is important to screen for Fibromyalgia as there does seem to be a correlation. A complete biomechanical evaluation should be performed to determine if there are any underlying problems, and they can have dysfunctional stiff, hypomobile joints secondary to trauma, posture, muscle imbalance, etc.. It may sound paradoxical, yet indeed, they can present with joint that is hypomobile. Will it be symptomatic? Typically not, it is usually the joint above or below, or the joint that reflexively compensates/adapts. Alternately, an excessively hypermobile joint can move to its end-range and become stuck. Therapy is directed at restoring motion, and then, very importantly; constraining motion. General strengthening, avoiding end-range is important. although there is very little data to support that teaching proper body mechanics is helpful in reducing reinjury and reducing symptoms, I submit that we have a moral obligitation to do so, and to do so thoroughly. I proudly teach a few "extras" which are not the norm, yet in my opinion; very relevant. Please see relevant section in my workbook. anything and everything that can be done to enhance biomechanical function should be considered. An example: the typical foot orthotics may be inadequate, wheras the type that are casted in greater supination (includes greater arch support)may be more helpful. stretching is rarely indicated, but when utilized it must be done gently, and for shorter times than is typical. More often than not, sustained end-range is to be avoided. These clients can easily hurt themselves performing passive stretches. More will be added to this topic in time.
When treating a person with hypermobility, there are several considerations. It is important to screen for Fibromyalgia as there does seem to be a correlation. A complete biomechanical evaluation should be performed to determine if there are any underlying problems, and they can have dysfunctional stiff, hypomobile joints secondary to trauma, posture, muscle imbalance, etc.. It may sound paradoxical, yet indeed, they can present with joint that is hypomobile. Will it be symptomatic? Typically not, it is usually the joint above or below, or the joint that reflexively compensates/adapts. Alternately, an excessively hypermobile joint can move to its end-range and become stuck. Therapy is directed at restoring motion, and then, very importantly; constraining motion. General strengthening, avoiding end-range is important. although there is very little data to support that teaching proper body mechanics is helpful in reducing reinjury and reducing symptoms, I submit that we have a moral obligitation to do so, and to do so thoroughly. I proudly teach a few "extras" which are not the norm, yet in my opinion; very relevant. Please see relevant section in my workbook. anything and everything that can be done to enhance biomechanical function should be considered. An example: the typical foot orthotics may be inadequate, wheras the type that are casted in greater supination (includes greater arch support)may be more helpful. stretching is rarely indicated, but when utilized it must be done gently, and for shorter times than is typical. More often than not, sustained end-range is to be avoided. These clients can easily hurt themselves performing passive stretches. More will be added to this topic in time.
Hypomobility
That describes me! I have very dense, very stiff connective tissue. When I stretch I often have to use a fulcrum and I have to sustain the stretch for a long time, typically 2-5 minutes and sometimes much longer! I will elaborate more in time. Hypomobility of the 3RD Rib, and Relation with the Thoracic 2-3 facet Joint Example:
One example, is the discovery of a very stiff rib (costovertebral) joint. The 3rd rib lacked anterior glide and anteromedial glide. I used a fulcrum, but had to be very cautious about body position. Logic would tell me to lie supine on a firm ball, such as solid rubber 2-3" (5-7.5cm) diameter. however, this would give a limited response due to discomfort with muscle guarding. Therefore, treatment position was sitting with the lateral portion of the rib (just lateral to thoracic spinous process) agains an outside corner of the wall. Applying a posterior-anterior force lifted the rib anteriorly in a loose-pack position and I remained for 3 minutes. I then applied a vector at a 45 degree angle to move the rib anteriorly and medially, in essence, closing the rib at the costo-transverse and costo-corporal joints for 3 minutes.
After that I felt much freer, rotation of the thoracic spine and even extension was greater and easier. Furthermore, self manipulation of the 3-4 thoracic facet joint was much easier and much more lasting. I hope this serves as a good example. As a rule, I always consider the rib joints whenever I perform a thoracic manipulation. sometimes the rib acts as a long lever and controls the thoracic segment, necessitating a rib mobilization first. Othertimes, the rib is secondary, and after mobilizing the thoracic segment the rib restriction becomes more apparent, perhaps as a permutation. The rib is then mobilized. Of course I then check the rest of the body for compensations and adaptations. Please see seperate section on "Regional Dependence".
It is noteworthy that the 3rd costovertebral joint is remarkably close to the thoracic 2-3 facet joint, and joint dysfunction can at times be confusing if only one of them is implicated. Always evaluate and treat (as indicated) the thoracic joint AND the rib joint. I marvel at published case studies and research articles that treat the thoracic spine using manipulation with no mention at all of the relevant relationship with the costotransverse and costovertebral joints. These joints are rather dense with losts of connective tissue and of cours have a variable angle segment to segment. The intercostal muscles (one of 2) angle at least 45 degrees away from the angle of the joint. The take home message: it takes creep (deformation over time) to properly mobilize these joints. Therefore, I take 3-5 minutes whenever I mobilizea rib joint and I do not believe that a grade 5 thrust is adequate. by design, the anatomy mandates creep.
One example, is the discovery of a very stiff rib (costovertebral) joint. The 3rd rib lacked anterior glide and anteromedial glide. I used a fulcrum, but had to be very cautious about body position. Logic would tell me to lie supine on a firm ball, such as solid rubber 2-3" (5-7.5cm) diameter. however, this would give a limited response due to discomfort with muscle guarding. Therefore, treatment position was sitting with the lateral portion of the rib (just lateral to thoracic spinous process) agains an outside corner of the wall. Applying a posterior-anterior force lifted the rib anteriorly in a loose-pack position and I remained for 3 minutes. I then applied a vector at a 45 degree angle to move the rib anteriorly and medially, in essence, closing the rib at the costo-transverse and costo-corporal joints for 3 minutes.
After that I felt much freer, rotation of the thoracic spine and even extension was greater and easier. Furthermore, self manipulation of the 3-4 thoracic facet joint was much easier and much more lasting. I hope this serves as a good example. As a rule, I always consider the rib joints whenever I perform a thoracic manipulation. sometimes the rib acts as a long lever and controls the thoracic segment, necessitating a rib mobilization first. Othertimes, the rib is secondary, and after mobilizing the thoracic segment the rib restriction becomes more apparent, perhaps as a permutation. The rib is then mobilized. Of course I then check the rest of the body for compensations and adaptations. Please see seperate section on "Regional Dependence".
It is noteworthy that the 3rd costovertebral joint is remarkably close to the thoracic 2-3 facet joint, and joint dysfunction can at times be confusing if only one of them is implicated. Always evaluate and treat (as indicated) the thoracic joint AND the rib joint. I marvel at published case studies and research articles that treat the thoracic spine using manipulation with no mention at all of the relevant relationship with the costotransverse and costovertebral joints. These joints are rather dense with losts of connective tissue and of cours have a variable angle segment to segment. The intercostal muscles (one of 2) angle at least 45 degrees away from the angle of the joint. The take home message: it takes creep (deformation over time) to properly mobilize these joints. Therefore, I take 3-5 minutes whenever I mobilizea rib joint and I do not believe that a grade 5 thrust is adequate. by design, the anatomy mandates creep.
A Combination of Hypermobility & Hypomobility
The average person is a mixture of both hypermobile and hypomobile. evaluating the whole body will reveal those structures that need to be treated form the perspective of a hypermobile structure and which need to be treated from the perspective of a hypomobile structure. There are several reflexes that can come into play and make treatment challenging. An example would be a hypomobile craniocervical junction that is only partially responsive to soft tissue work, stretching, and joint mobilization. What is missing? Something below is influencing the occulopelvic reflex (also has other names) such as a transverse plane rotation of the pelvis (so called sacroiliac joint dysfunction). the same is true for hip rotation due to muscle spasm or shortening, and anterior talus, a rib dysfunction enhancing trunk rotation, etc.. again, a whole body screen is essential. To focus only on what hurts for example, is to be somewhat incomplete with regards to how the body functions.