1080 Map Functional Assessment

James at Back to Back is now offering an exciting new service called 1080MAP™. Developed in Norway and Sweden, it is a specialist assessment tool with software that is designed specifically for those committed to becoming more successful in their training and to improve their movement patterns. It is also a great tool to be used alongside rehabilitation protocols.

1080MAP™ assesses, analyses and optimises movement patterns to maximise your physical performance. There really is nothing like this in the world that assesses and maps out your movement patterns and using specialist software, it gives clear results to show how well your body moves! At the time of writing, there are only a couple of people with specialist training in London to do this and we have been lucky enough to be part of this.

This functional assessment is a unique, effective and accurate test system for determining a person’s fundamental ability to move and control movement. The system is based on combinations of full-body movement patterns that give results that will determine what may be needed to improve athletic ability or everyday function.

The first level of 1080 MAP covers mobility and stability as this is the foundation of any human movement and physical performance.

To measure full-body three dimensional movement patterns the 1080 MAT is an easy-to-use tool. It consists of a circular test area divided by vectors. Measurements in centimetres and degrees provide the input to the 1080 MAP database.

1080 MAP stands out as the only scientifically validated method that is repeatable for mobility and stability assessment.

Assessment

The measurement of movement patterns in standing positions to quantify function. Quantification of mobility, stability, strength, power, endurance and performance.

Analytics

The different tests are scored are then combined and directly linked to each other to create unique individual profiles. All profiles reflect physical performance, identify physical limitations and hidden potential.

Optimisation

1080MAP™ results in highly specific and individualised treatment and training programs that will optimise functional performance.

The picture below is the 1080Map of an elite athlete who was struggling with lower back pain for years. The graphic below shows some of the information we produced. It highlighted problems with her left hip (from left picture) and foot that had not been seen from previous assessments. The new and crucial information was then used in her treatment plan to target her left hip and foot. These were integrated into her movement patterns. She now is able to run really good distances and she is stronger with much less pain.

Test results are captured, analysis is done, and feedback is given from the 1080 MAP cloud based client management system. Here, each client’s results can be compared over time, on detailed level or by using a composite mobility score. Comparisons can also be done against the entire data base population based on gender, age, sport and performance level. Based on the analysis, feedback can be sent directly to the client.

If this could be something of interest to you, call the clinic on 020 8605 2323 and book into see James for a 1080 map assessment. Here is a link to more information. Our website also gives you information about the clinic.

-James Dodd

Biomechanics and REAL function

I have been an Osteopath since 1999 and part and parcel of being an osteopath is having a thorough understanding of anatomy, biomechanics as well as medicine and pathology.

This year I had the privilege of doing a mentorship with the Gray Institute called GIFT. This was a 40 week course working with the world legends Gary Gray and Dave Tiberio. They created ‘Applied Functional Science’ or AFS. This is the real science behind movement and not what is says in the anatomy books! Gary Gray has been a US physical therapist for more than 35 years and has been working with Dave Tiberio since then. They look at REAL function and how everything changes when your foot hits the floor.

Assessment and rehabilitation is all done in 3 planes and mostly standing, using the full impact of gravity and ground reaction! This uses correct neurological pathways as your proprioception is ‘switched on’ and so you are able to assess what the body is able to ‘functionally’ achieve. This is very different from feeling and seeing what a back, hip or knee does while lying on a table.

Very few people REALLY look at the body in the way they (or I do now) do. Some will look at the tri-plane movement of the foot and sub-talar joint, but they don’t link this to the hip or scapular or cervical spine in gait, hitting a golf ball or bowling. Gary Gray and Dave Tiberio teach all this to the extent of how your psoas affects your scapular or foot! Quite brilliant!

GIFT has been inspirational and an amazing journey and it has set me alight! It has given me more passion to further the osteopathic and functional model. GIFT is a huge investment both financially and in your time. But I looked at it as just that…. an investment. An investment in me and an investment in my patients. So worth it!

If anyone is interested in doing something like this, look at their website and if you cannot manage something so big as GIFT, look at one of their Chain Reaction courses or their online content.

Get Wise for CrossFit – and keep safe!

The first affiliated CrossFit (CF) gym was opened in Santa Cruz in 1995 and was founded and developed by the coach Greg Glassman.  Over his years of watching the fitness industry, his idea was to create versatile athletes (gymnastics and weightlifting) through primal movements and intense training.  It has since gained worldwide momentum and a huge following.

The typical workout or WOD may involve intense drills of weightlifting (squats, deadlifting and carrying odd objects or kettlebells etc) box jumps, burpees, sprinting and using gymnastic rings to name a few.  Most activities are all well and good and with a structured and progressive integration into your lifestyle and using the basic premise of not walking before your can crawl and not running before you walk.  This puts in place not just the neurological inputs that are needed to perform and function, but embeds some firm foundations of the chain reaction needed for movement and structural control.

I see and treat a fair amount of injuries sustained through CrossFit and whilst injury is often seen to be part of any intense exercise, I do feel some of these could be avoided.

CrossFit is massively intense and with that comes excitement and vigor and over time, a body that develops in power, coordination and agility.  But I feel that with this excitement and vigor often comes lack of care for ones self and the idea that if your push yourself harder, you get faster results.

Let me use the example of running again.  If we have a basic level of fitness, most of us assume we should be able to run.  Running is composed of lots of hops and leaps.  When treating/rehabbing athletes, I am often asked “am I ready to run yet?”…… and I ask them “can you repeatedly hop and leap?” and then depending on their answer we watch and see…… and we see if they can or if they fail.  That gives us the answer and often, they cannot hop and leap!  So surely, they should not run!

My point of this is much more about creating the foundations much deeper than you think you need.  To enable Mo Farah’s fabulous achievements at the 2012 Olympic Games, he would have run around those tracks hundreds if not thousands of times and known that if he gets a PB, it will probably be within a certain amount of time.

So doing 25 squats with 100kgs if you have only ever twice before would be foolish.  Doing 25 squats with 100kgs should ok if you are regularly doing 25 times 90kgs.

To enable good technique with power moves such as deadlifts and squats you don’t just need good technique, you really need good functional mechanics such as sufficient ankle, knee and hip movement and these need to be able to load the weight correctly.  If they cannot do this, somewhere else will take the hit….and this hit maybe your lower back, shoulder or neck!

Over the next few months I will be working with Tom and Harri Bold from CrossFit Bold and other coaches from Athletic Alliance to develop some easy strategies to enhance movement and control, which we will be sharing with all the members.  All with the idea injury avoidance!  But in the meantime, please be careful of your form and technique and keep your ego in check and don’t find yourself where you are trying to push your body to a place where it has not been before too quickly.

Ignore the figures but, think of it like an iceberg – 70% underneath and 30% on top…..

Functional Exercise and Training – The Why and the What!

Tri-Plane Movement and Functional Training, these are both current words used to describe movement and training by the personal training and allied health professions (osteopath, physiotherapist, exercise physiologist and chiropractor). The health and fitness industry is going through yet another change, just like the swiss ball was the man of the moment in the 90′s, pilates and the core were the trend of the early 2000′s, many trainers and health professionals are now focusing on training movement rather than muscle, training functional exercises rather than non functional exercises, training groups of muscles rather than muscles in isolation.

What this means in simplistic terms is that trainers and health professionals etc are now moving away from the body building approach to training and conditioning (that is isolated weight training) and moving towards training that integrates movement with resistance that mimics upright function such as gait and other movement patterns that we perform on a daily basis i.e. squat, sit to stand, step up and down, push, pull & rotate. Trying to use gravity as the driver by doing exercise on your feet or upright, rather than on your back or in a machine stimulates your proprioception much more effectively than fixing an area, therefore creating the correct chain reaction needed for full and appropriate muscle function.

This does not suggest that one training approach or philosophy is better than the other, it fundamentally comes down to what the specific individuals goal is. For a body builder looking to compete, then traditional weight lifting techniques that have been proven to produce muscle gain is required. For the olympic power lifter, olympic lifts are practiced. For the sporting indivdiual, there will be likely a combination of functional movement exercises as well as some strength, olympic and powerlifting techniques. For the individual wanting to improve their overall wellbeing, strength and mobility, there is also likely to be a combination of the above.

So what does Tri-plane movement, functional training etc etc mean. Tri-Plane movement simply refers to movement in the three planes (sagittal, frontal and transverse planes). If we look at the individual who is standing upright, the best way to describe movement in the sagittal plane is forwards and backwards movement. Movement in the the frontal plane refers to side to side movement (that is laterally stepping or performing a lateral lunge). Movement in the the transverse plane is when movement occurs with rotation. That is, whilst standing you twist and turn to move or lunge backwards and laterally. Everyday movement occurs in all three planes at a bone and joint level and this is why there is this growing change in the way that training is being carried out. Previously most gyms and training programs were focused on training muscles in machines and/or functional training was restricted to movement purely up and down i.e squat movement or forwards (anterior lunge). As our understanding of functional biomechanics and movement improves, so does our training approaches and philosophy. Now days we are seeing more and more clients perform movements that involve all three planes of movement, involving less equipment and with movements that mimic real life activity.

Functional Training is probably one of the biggest buzz words in the health and fitness industry at this particular moment. There are many indivdiuals out there claiming to provide functional training. Functional training is certaintly not something that is new, rather it has been around for many many years and simply relates to training that mimics how we function. How this training relates to how we function will depend totally upon what and why we are training. For an individual who sits for their job for their entire life and wants to improve this, then training should focus on improving their ability to sit whilst working. For those individuals who are wanting to improve their everyday movement, that is sit, stand, walk, step up and down, squat, lunge etc etc, then training should reflect this. For the sporting individual, the training should mimic the sporting requirements, movements or athletic components that are that sport. So functional training has many meanings and therefore can be interpreted in many different ways.

For the general public, when we look at the body and how it functions, the most common movements or positions we are in involve walking (gait), sitting, standing, squatting, lunging, stepping up and down, single leg balancing, pushing, pulling and twisting. All of these movements are impacted by gravity and ground reaction force and these are two other factors that should be taken into consideration when prescribing a program. Gravity is something that we are always working against to remain upright. Therefore gravity is something that can easily be used to increase or decrease the degree of difficulty of an exercise. Ground reaction force relates to Newton’s laws and how force in one direction results in an equal and opposite amount of force in the opposite direction. This can be related to jumping and landing on the ground whereby an amount of force is exerted downwards and then the force will be transferred back into the legs and must be either shifted or absorbed by the body. So when it comes to functional training and tri-plane movement training, hopefully now you will have a little bit more of an understanding of what, why and how this might be prescribed in relation to yours or anyone else’s training program.

In our opinion, functional exercise should be used more and more when rehabilitating injuries or with patients post surgery. The more you get patient’s bodies working proprioceptively and in 3 planes, their bodies can start to ‘switch on’ to allow them to recover better and stronger.

To find out more about changing your training program, making it a little bit more functional in relation to your specific goals, incorporating exercises that involve training in all three planes, then contact Back to Back – The Earlsfield Osteopath on 020 8605 2323 or click here

Gastrocnemius function – How it assists in knee extension

Gastrocnemius function – How it assists in knee extension

This attaches above the knee into the femur and into the achilles tendon. It acts in a similar way to soleus, but as it attaches to the femur, its influence on the proximal joints and structures is more significant.

Gastrocnemius decelerates internal rotation of the femur when the foot is on the ground, but it is lengthened at both ends. One end in the frontal plane, the other end in the transverse plane. In the sagittal plane, it controls ankle dorsiflexion.

The knee flexion is transformed into knee extension by a number of muscles along with mass and momentum. As the front leg in gait is moving through towards swing phase, the tibia is slowed down by eccentric lengthening of the gastrocnemius and a number of other calf muscles. This slowing along with the momentum of the body creates knee extension as it pulls back on the distal femur as ankle dorsiflexion is decelerated.

So in function and gait…. the Gastrocnemius are a powerful knee extensor!

Hypermobility part 2 (March 2012)

Hypermobility Syndrome – part 2

James Dodd

Part 1 of this article looked at giving readers a better understanding of Hypermobility Syndrome (HMS) and the implications it may have on the musculoskeletal system. Having a greater understanding of the common problems associated with hypermobility syndrome, how it is diagnosed and its relationship to other connective tissues disorders provides us with a solid base by which we can then go about developing a corrective exercise program. Part 2 aims to provide a more extensive look at assessing the hypermobile patient and taking a region specific approach to training. A detailed case history and screening process should alert you to any problematic areas or regions which may be predisposing, maintaining or aggravating your patient’s musculoskeletal problems. Static observation will help you to define any asymmetries in posture. Observation from all three views (frontal, lateral and posterior) will help you focus on areas of possible dysfunction. Functional testing in sagittal, frontal and transverse planes may highlight other areas of dysfunction

Muscle and Movement Testing

Carry out stretches and tests to identify weak, tight and shortened muscles. Take particular care in the hypermobile patient as range of movement may be much greater than expected. They are also good at ‘cheating’ to hide a dysfunctional area.

Assess functional activities such as gait, step up/down, lunge, squat, one leg stand and reach, anterior reach, posterior reach and push up for functional capability. Look for asymmetries, imbalances and glitches within the movement patterns to alert you to potential areas of dysfunction. Common causes of dysfunctional movements could be inhibited/over facilitated muscle activity in agonist/antagonist or synergistic muscles, tight and short or weak and lengthened muscles, hypo/hypermobile joints or body regions and balance, proprioception and coordination problems.

Always remember to seek advice from your patient’s general practitioner, osteopath or physiotherapist if you suspect any serious possible musculoskeletal problems or red flags.

A Regional Approach to Training the Hypermobile Patient

Common presenting features in the hypermobile patient include the following:

Shoulder, hip, neck, lower back, knee and foot pain

Poor body awareness, balance and proprioception

Flat, pronated feet

Hyperextended knees

Anterior pelvis

Clicking/popping joints

Hyperkyphotic or reduced movement in the thoracic spine. This could also be chronic muscle spasm

Tight and shortened hamstrings, gastrocnemius, iliotibial band, tensor fascia lata, pectoralis major/minor muscles

Weak anterior deep neck muscles, iliopsoas, core stabilizers and gluteals

Poor core stability

Upper rib breathing and poor diaphragmatic breathing

A good case history, observation and assessment should highlight any areas of dysfunction and will help you to focus on devising a program that will help restore optimal health and posture. Foam rollers, static stretching, active stretching and Muscle Energy Techniques (MET) are treatment strategies that can help stretch, activate and restore muscle balance. Remember to train the patient as a whole. The body works as one, and all systems are connected. Therefore, any one problem or area can predispose to a dysfunction elsewhere. The tissues are generally weaker and more vulnerable to injury than the non-hypermobile patient.

Hypermobility and the Lower Back

Poor overall functional stability is common among those individuals with lower back pain. In conjunction with poor stability, the hypermobile patient may also have poor kinesthesia and proprioception.

Focus training on:

Improving body awareness (anterior and posterior tilting of the pelvis)

Finding neutral spine

Teaching diaphragmatic breathing

Activating core muscles

Incorporating core muscle activation into functional activities

Balance, proprioception and coordination

Look for an ability to activate the core muscles:

Without co-contraction of more global muscles such as the rectus abdominis and external oblique muscles

Independently breathing

Diaphragmatic breathing? (often you will observe upper chest breathing)

Exercises that will be useful for the patient with core stability issues include:

Anterior and posterior tilting of the pelvis (standing, supine).

Core muscle activation (supine, prone, side-lying and four-point kneel).

Core muscle activation standing, seated.

Remember to isolate muscle activation and then integrate into functional activities.

Hypermobility and the Neck

Hypermobile patients may present with a history of neck complaints, ranging from the acute ‘wry’ neck to chronic neck pain. Individuals may present with an upper crossed syndrome pattern, which could be predisposed, maintained and aggravated by hypermobility, work and lifestyle postures such as sitting and slouching.

Look for:

Forward head posture (chin poking forwards)

Increased kyphosis (rounding) through the thoracic spine and Cervico-Thoracic C7/T1 region (base of the neck)

Reduced mobility through the thoracic and cervical spine

Tight upper trapezius, levator scapular, pectoral minor, sternocleidomastoid and scalene muscles

Weak rhomboids, lower trapezius and deep anterior neck flexors

Winging, elevated or protracted scapulars. Look for asymmetries in static

observation, movement and muscle weakness in shoulder stabilizers

Focus training on:

Lengthening short and tightened muscles

Strengthening weak muscles

Activating inhibited and de-facilitating over active muscles

Balance, proprioception and coordination

Exercises that will be useful for the patient with upper crossed syndrome and neck pain include:

Scapular retraction and setting

Ys and Ts exercise

Other useful exercises that aim to improve mobility of the neck, strengthen deep anterior neck flexors and increase body awareness include:

Chin tucks (similar to an emu neck movement)

Isometric neck flexion (using soft ball to push head against)

Isometric lateral neck flexion (using soft ball to push head against)

Pulling shoulder blades backwards and down, whilst lifting sternum to the roof

For more information on isometric neck exercises, see Paul Chek’s “How to Eat, Move and Be Healthy!”

Hypermobility and the Shoulder

The shoulder is the most unstable joint in the body, and often the hypermobile person will have a glenohumeral joint and/or scapulothoracic joint dysfunction. Problems may develop due to poor neuromuscular control, increased laxity of the capsule and rotator cuff weakness. Individuals may also present with subacromial impingement signs and symptoms. In some circumstances, your patient may require referral to an osteopath or physiotherapist to rehabilitate and teach correct scapulothoracic setting and glenohumeral positioning before commencing an exercise program. Focus training on:

Scapulothoracic setting

Rotator cuff strengthening

Stretching tight and shortened muscles i.e. pectoralis major and minor

Strengthening weak muscles i.e. serratus anterior, rhomboids, lower trapezius

Training functional exercises which address adjacent areas (cervical, thoracics, lumbars and hip/pelvis), muscular slings, synergistic and agonist/antagonist muscles

Hypermobility and the Hip

Like the shoulder, the hip is a ball and socket joint that has a large range of movement. It is essential that the neuromuscular, active and passive systems are working effectively to allow adequate movement and yet stabilize the region sufficiently. The hypermobile person is more likely to suffer from clicking/popping hip. The exact cause of this could vary from an intra to extra articular causes such as a tight iliopsoas to a labral tear or loose body. It may or may not be associated with pain. In those individuals presenting with extreme or constant pain, refer them off to the GP, sports medical doctor, osteopath or physiotherapist for further assessment. Typically, hypermobile patients will have poor control of their hip, pelvic and lumbar regions, and these often need to be addressed to correct any imbalances and prevent further problems developing.

Focus training on:

Lumbar (lower back) stability

Hip stability

Weak iliopsoas

Weak gluteus medius and maximus

Tight hamstrings, iliotibial band, tensor fascia lata

Balance, proprioception and coordination

Hypermobility and the Knee

Patellofemoral problems are common in hypermobile individuals. The cause of patellofemoral problems can be both structural and non-structural related. Common causes include a variable Q angle, genu varum, increased foot pronation and biomechanical and muscle imbalances.

Focus training on:

Tight iliotibial band, tensor fascia lata, hamstrings, gastrocnemius

Weak vastus medialis, gluteal muscles

Pronation and supination foot

Balance, coordination and proprioception

Exercises that will be useful for the client include:

Seated heel presses (helps to activate vastus medialis)

Foam rolling ITB and quadriceps muscles

Exercises that will be useful for the patient include:

Seated heel press (helps to activate vastus medialis)

Lunge – Forward

Lunge – Multiplanar

Squat – Against Wall with SB

Squat Touchdown – 1 Leg

Step Up to Balance – Frontal Plane

Hypermobility and the Foot

Pronated (flat) feet is common in the hypermobile patient. Over pronating can lead to problems with the subtalar joint, mid and forefoot, possibly causing plantar fasciitis and other problems up the biomechanical chain. Over pronation will cause internal rotation of the tibia and fibula, therefore potentially creating dysfunctions further up the chain at the knee, hip/pelvis and lower back. Individuals with flat feet may benefit from an exercise program or orthotics prescription.

Focus training on:

Tight plantar fascia, gastrocnemius and soleus muscles

Activation and control of tibialis anterior, peroneal muscles

Tight iliotibial band and weak gluteal muscles

Balance, coordination and proprioception

Exercises that will be useful for the patient include:

Active plantarflexion and dorsiflexion of the foot

Rolling feet inwards (pronation) and outwards (supination)

Single leg balance (stable to labile surface i.e. wobble board, bosu ball)

Swiss ball squat with ball between the knees finishing with standing on toes

Exercises that will be useful for the patient include:

Side to Side Hip Swing (Hip)

Balance Hold 1 Leg – Overhead Anterior Reach

Balance Hold 1 Leg – Overhead Posterior Reach

Hypermobility and Balance and Proprioception

Hypermobile individuals are likely to have poor balance, proprioception and kinesthesia. Exercises that challenge these components will translate over to improvement of general daily activities and reduce the likelihood of injury.

Exercises that will be useful for the patient include:

1 Leg Balance

1 Leg Balance Reach (anterior, posterior, lateral)

Balance Hold 1 Leg – Overhead Anterior Reach

Balance Hold 1 Leg – Overhead Lateral Reach

Step Up to Balance – Frontal Plane

Equipment such as wobble boards, Bosu Balls, cones, Airex Balance Pad, Swiss ball, Theraband, etc. can be added to further challenge balance and proprioception.

References:

Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.

Gray, G. Functional Video Digest Series

Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.

Janda, V. Muscle Function Testing, Butterworths, London, 1983.

Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.

Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.

Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.

Osar, E. Complete Hip & Lower Extremity Conditioning.

Osar, E. Complete Shoulder & Upper Extremity Conditioning.

Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.

Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism

Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

www.ehlers-danlos.org <http://www.ehlers-danlos.org>

www.hypermobility.org <http://www.hypermobility.org>

www.marfan.org <http://www.marfan.org>

www.marfanssyndrome.net <http://www.marfanssyndrome.net>

www.medicinenet.com/hypermobility_syndrome <http://www.medicinenet.com/hypermobility_syndrome>

http://medlineplus.gov/

www.oif.org <http://www.oif.org> (Osteogenesis Imperfecta)

www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http://www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html>

Important Disclaimer:

No express or implied warranty (whether of merchantability, fitness for a particular purpose, or otherwise) or other guaranty is made as to the accuracy or completeness of any of the information or content contained in any of the pages in this web site or otherwise provided by personal training on the net. No responsibility is accepted and all responsibility is hereby disclaimed for any loss or damage suffered as a result of the use or misuse of any information or content or any reliance thereon. It is the responsibility of all users of this website to satisfy themselves as to the medical and physical condition of themselves and their clients in determining whether or not to use or adapt the information or content provided in each circumstance. Notwithstanding the medical or physical condition of each user, no responsibility or liability is accepted and all responsibility and liability is hereby disclaimed for any loss or damage suffered by any person as a result of the use or misuse of any of the information or content in this website, and any and all liability for incidental and consequential damages is hereby expressly excluded.

Hypermobility pt 1 (January 2012)

Hypermobility Syndrome – part 1

James Dodd

There is Hypermobility and Hypermobility Syndrome (HMS). Hypermobility syndrome is the hypermobile patient with symptoms. Not all hypermobile patients are, or ever become symptomatic. HMS is a condition many individuals often experience their entire lives without ever having it diagnosed and managed correctly. Hypermobility has certain implications for the joint itself, as well as the surrounding ligaments, bones, joint capsules, muscles and tendons. It is important for a hypermobile patient’s well-being that they have effective neuromuscular control and active and passive systems that can support the joints in the body. Hypermobile joints by definition are those “displaying a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual.” Hypermobility Syndrome, also known as Joint Hypermobility Syndrome or Benign Hypermobility Syndrome, is defined as ‘generalized joint laxity with associated musculoskeletal complaints in the absence of any systemic disease’. HMS is an inherited form of a connective tissue disorder. Those with Hypermobility Syndrome are believed to experience pain as a result of joint microtrauma, which has been caused by overuse and/or misuse of the tissues in which there is an inherent weakness in the collagen.

It’s signs and symptoms are so often missed and so it goes undiagnosed and so is mismanaged. This means the suffering patient can go on suffering unnecessarily.

Common Features of Hypermobility

•Females are often more mobile than males.

•Mobility varies amongst ethnicity (Asian populations seem to be more affected than European populations).

•Mobility decreases with age.

•Hypermobility can be inherited or acquired i.e. repeated subluxation of the shoulder joint.

•Hypermobility Syndrome is typically determined by the genetic make up of the individual, in particular the genes causing hypermobility are those that are responsible for the production of collagen, elastin, fibrillin and tenascin.

•Certain sports and activities (i.e., gymnastics, ballet dancing, swimming) have shown to have a greater number of individuals with hypermobility.

•Musculoskeletal regions commonly affected include the achilles tendon, patellofemoral joint, rotator cuff, carpal tunnel, cervical and lumbar spine (non specific lower back pain and medial and lateral epicondyles.

•Hypermobile individuals may suffer from clicking, spondylolithesis and pars fractures.

•Hypermobility is a risk factor for the development of early Osteoarthritis.

•Fibromyalgia is commonly diagnosed in individuals with Hypermobility Syndrome

Diagnosis

The Beigton Score System (below) is a 9-point scale originally introduced to recognize hypermobile patients within the population. Primary health care practitioners now use it as a common screening process to help determine whether an individual has hypermobility.

•Passively dorsiflex 5th metacarpophalangeal joint to > 90 degrees (2 points)

•Passively take thumb to forearm (2 points)

•Passive hyperextend the elbow to > 10 degrees (2 points)

•Passively hyperextend the knee to > 10 degrees (2 points)

•Actively place hands flat on floor without bending the knees (1 point)

There can be a total score of 9. The revised diagnostic criteria for hypermobility requires you to get a Beigton score of 4/9 and have arthralgia (joint pain) for longer than three months in more than four or more joints.

There is also the Brighton Criteria that aids in the diagnosis of Hypermobility Syndrome. These include:

Dislocation and/or subluxation in more than one joint and on one or more occasions.

Abnormal skin: striae, thin skin, increased stretch of skin.

Eye signs: drooping eyelid or myopia

Varicose veins, hernia, or uterine/rectal problems

Soft tissue rheumatism (i.e., epicondylitis, tenosynovitis, synovitis)

Hypermobility and Connective Tissue Disorders

Marfan’s Syndrome, Ehlers-Danlos Syndrome and Osteogenesis Imperfecta are each genetic disorders in which the connective tissue of the individual is affected. Each disorder is different in its epidemiology, incidence and clinical presentation. While it is beyond the realm of this article to discuss each of these conditions in detail, if you have a patient with one of these disorders, you should conduct further reading in order to gain a better understanding of the disorder, its implications and how you can alter your training program to better suit your patient.

Rehabilitation and Exercise Prescription

Management of the patient will largely depend upon his/her age, current physical condition, hypermobility state and personal goals. The primary aim of dealing with any hypermobile patient should be to reduce disability and increase function. This should incorporate a holistic approach which addresses not only the fitness components but also addresses dietary, work and other lifestyle components.

Hypermobility and Acute or Chronic Injury

The acute hypermobile client should be managed like any other acute musculoskeletal injury. During the acute stages, you should be aiming to reduce swelling, inflammation, pain and restrict any aggravating or maintaining factors. Always refer your patient to a medical practitioner or hospital if you suspect anything serious. In the sub-acute or chronic hypermobile patient, the aim should be to restore normal function and reduce pain to a comfortable level. This could range from prescribing an exercise program to referring your patient for specific treatment from a GP, Physiotherapist, Osteopath or Podiatrist. It is always best to seek treatment from a practitioner that that works with and understands the implications of HMS. Failing to correctly manage with your client’s sub-acute/chronic injury could result in the development of compensatory patterns, which in turn could lead to problems developing elsewhere.

Program Design

Training the hypermobile patient requires special attention to certain training principles. You need to consider all joint, muscle and ligament actions when training, making sure that you train throughout the entire range of movement and training the muscles for isometric, isotonic, concentric and eccentric actions.

Stability of a joint is determined by the integrity of the musculoskeletal system (muscle, tendon, capsule, ligament and articular surfaces) and the neural control system (motor and sensory). It is important to address these aspects when devising a program in order to develop optimum function.

The key fitness components that need addressing in the hypermobile client include:

Proprioception

Balance

Coordination

Kinesthesia

Core stability

Endurance

Strength

Controlled flexibility

Cardiovascular fitness

Each of these fitness components requires extra attention in clients with Hypermobility Syndrome. However, each program will differ considerably depending upon each patient (i.e., client age, current physical state, hypermobility and goals). Programs could range from being as simple as improving one’s functional state (i.e., daily living activities such as walking, squatting, sitting up and down) to training elite athletes. Essentially, you will need to assess each case individually and design a program specific to the client’s needs.

Your program should try to:

Train function. Include functional activities such as push/pull, step up/down, squat, lunge and rotation exercises in your program.

Strengthen muscles equally and ensure there is a balance among agonist, antagonist and synergistic muscles.

Train movements rather than muscles, when possible.

Progress from slow to fast, stable to unstable, simple to complex, non weight bearing to weight bearing, closed chain to open chain, one plane to multi plane.

In Part 2 of this article, I will be taking a more in depth look at the individual assessment of the hypermobile patient and how we can deal with the common musculoskeletal issues one may have. The article has been divided into bodily regions, outlining what we should be looking for in the assessment, how this interacts with other regions of the body and how we can go about correcting these problems.

References:

Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.

Gray, G. Functional Video Digest Series <http:> </http:>

Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.

Janda, V. Muscle Function Testing, Butterworths, London, 1983.

Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.

Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.

Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.

Osar, E. Complete Hip & Lower Extremity Conditioning.

Osar, E. Complete Shoulder & Upper Extremity Conditioning.

Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.

Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism <http:> .</http:>

Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

www.ehlers-danlos.org <http:> </http:>

www.hypermobility.org <http:> </http:>

www.marfan.org <http:> </http:>

www.marfanssyndrome.net <http:> </http:>

www.medicinenet.com/hypermobility_syndrome <http:> </http:>

http://medlineplus.gov/

www.oif.org <http:> (Osteogenesis Imperfecta)</http:>

www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http:></http:>

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