The connection between hypermobility and “bad posture”

Estimated reading time: 10 minutesI’ve told the story many times of my first visit with a physiotherapist after the birth of my second son. I was experiencing terrible shoulder pain and loss of power down my left arm. He took one look at me and told me I was hanging off my joints and had a terrible posture. 

I had no idea what hanging off my joints meant back then. He recommended I start taking Pilates classes to improve my overall posture and stability. He was right. After embarking on Pilates classes and subsequently training in the method, my pain, posture, and stability all improved.

Of course, over time, I modified the Pilates to suit my body and the bodies of my clients with hypermobility and chronic pain. This led to the development of the Integral Movement Method, a hypermobility-suited modified Pilates.

But what is posture and why is it even more key if you have hypermobility? Posture refers to the way someone holds themselves when standing, sitting, or lying down. We can look at the alignment of the bony structures – the spine, feet, hips, knees, shoulders, and head and determine if these structures are sitting in an optimal position for balance and movement.

That all sounds rather static. I like to think of posture as dynamic. It needs to respond and change with our activities and environment.  A ‘good’ posture will help keep your body in balance and will use the least amount of muscular effort to do so. A ‘bad’ posture will put us out of alignment, may put additional stress on the soft tissues and joints, and could increase pain.

Having said that, I want to remove the terms “good posture” and “bad posture.” There is no such thing as bad posture.  

Wherever you are today, your body and mind are doing their very best to align your structure in the best way. If you’ve been told, or you believe, that you have a poor posture, how can we introduce your system to a new experience? A new way of holding yourself that, over time, will lead to a more aligned, optimal whole-body organization?

It does take time, and it is not about stacking or fixing yourself into a perfect posture.

Let’s explore this in more detail.

The research on hypermobility and posture

The literature surrounding hypermobility and posture is limited. Research in general about EDS/HSD is limited, so when we are looking at a specific topic of posture, you can imagine it is even more challenging.

Here are some published findings:

• Workers in a high-technology industry plant with hypermobility had more back pain than their non-hypermobile co-workers in static positions but less back pain in work that required changes in posture (1).
  • The details: Workers were assessed for hypermobility by being able to place their palms on the floor. The group was 47% female, 53% male, and between 18-65 years old. 144 (26%) of the 606 workers assessed had spinal hypermobility.
  • The numbers: For workers in static sitting or standing jobs, 40% of those with hypermobility had back pain, while 22% of the non-hypermobile group did. For those with jobs that involved changing postures 4.5% of the hypermobile group had back pain, while 12% of the non-hypermobile group had back pain.

• People in a small group diagnosed with “benign joint hypermobility syndrome” had significant deviations from “normal” posture and more pain (2).
  • The details: This was a small group of patients (n=35) reporting at a rheumatology clinic for pain – so there is potential for sampling bias in that they were only assessing the posture of hypermobile people who reported to a clinic for pain. They did have age-sex-matched controls – but it didn’t say where they were recruited. Benign joint hypermobility syndrome was a term used prior to the updated diagnostic criteria in 2017.
  • They used Reedco’s posture scoring system which assesses the alignment at different areas throughout the body, with a score of 100% being “good posture.”
  • The numbers: The average posture score for the joint hypermobility group was 55.3 and the average for the non-hypermobile group was 67. This difference was statistically significant.

• People with benign joint hypermobility (without pain) had different muscle activation patterns around the pelvis and low legs than non-hypermobile controls during standing and one-leg standing (3).
  • The details: This was a VERY small pilot study (meaning it was more of a proof of concept paving the way for a larger study) that compared muscle activation patterns during standing in 8 people who had benign joint hypermobility syndrome and eight controls without hypermobility. Remember, because this study is so small, it is not generalizable and should be verified with a larger study.
  • They used Electromyography to assess muscle activation of different muscles around the pelvis and legs.
  • The findings: There were significant differences in muscle activation with standing (both eyes open and eyes closed, one-legged and two-legged). For example, those with hypermobility had less erector spinae (a back muscle) activation with one-legged standing with closed eyes and greater lower leg contraction with standing.

• There are changes in the somatosensory and vestibular inputs in people with hEDS, and these may influence posture control. This can be helped by wearing somatosensory orthoses (4).
  • The details: The somatosensory system is how the body processes sensory information related to things like pressure and pain. Researchers hypothesized that his system may be impacted by variant connective tissue found in hEDS. More specifically, information arising from muscles, skin, and joints can impact perception, balance, and movement.
  • They assessed postural control with and without eyes closed in 6 hypermobile women and compared them to age and sex-matched controls. This is, again, a VERY small pilot study.
  • They found: The hEDS group had greater postural instability than the controls, and when their vision was removed, it was worse. They also found that wearing orthoses in the form of compression garments and proprioceptive insoles improved postural stability – especially with the eyes closed.

For the most part, these are very small studies that show some differences in hypermobile groups when it comes to postural control. More research is needed to make these findings generalizable.

Kenneth Hansraj, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

The consequences of poor posture

Everyone, regardless of whether they have hypermobility, can experience the consequences of less-than-ideal, or “poor posture”. I believe that with hypermobility, we are going to experience these things to a greater degree due to our laxity, reduced proprioception, and overall reduced body awareness, control, and stability.

It is important to remember that everyone is different – you may have a friend or family member with what would be considered ‘poor’ posture, and yet they experience no pain or discomfort.

The sensitivity that seems to come with hypermobility and EDS means we can be very prone to experiencing discomfort with the slightest adjustment or move. This is why I promote the “less is more” and “go low, go slow” approaches with any movement-related issue.

Issues that I find may be encountered with misaligned posture are:

• Back, neck, and shoulder pain: Let’s face it – we do spend a lot of time now on phones and computers. We are in that forward-flexed position a lot of our days. With our laxity, we may tend to ‘hang,’ as I was told many years ago. This can put extra strain on the spine and neck, leading to pain. I did a YouTube video on text neck that you might find helpful.
• Headaches: a forward head posture is going to put additional strain on the neck and upper back muscles. If you have cervical instability, it is even more important that we address head positioning.  My free neck class may give you some tips. Headaches are already a factor for many people with EDS/HSD, but alignment can help manage these
• Breathing issues: if we are slumped into a collapsed posture, it’s not just our muscular system that suffers. Our internal organs, including our lungs, will be getting increased pressure. This can make breathing more challenging, as the lungs cannot fully expand. It may even be painful and lead to a dysfunctional breathing pattern.
• Digestive issues: we are known to struggle with GI issues with EDS/HSD. Again, our posture could contribute to pressure on the digestive tract. Acid reflux and bloating could occur. Check with a gastrointestinal doctor or nutritional expert if you are experiencing issues here.
• Muscular imbalances: We’ve talked about the importance of balancing the whole-body structure. If I am out of alignment, I may start to have muscular imbalances. This means some muscles become too short and tight, while others are too long and stringy. A muscle will complain either way, presenting as sore or tight.
• Reduced mobility: Despite our hypermobility, we may experience decreased mobility and flexibility because as some things start to move too much, other areas will move less in an attempt to stabilize the whole structure. Ever feel tight AND loose? Check this video out about why this could be

The significance of proper posture

We’ve established that “proper posture” or “good posture” is more than just how we stand or trying to sit up straight. It is about supporting the whole-body alignment to reduce strain, improve overall function, and hopefully prevent injury.

For example, If the shoulders are introduced to a better positioning and have the strength to hold themselves in a better position, that is going to have a significant impact on our daily functional activities.

If you look at an illustration of a skeletal frame, you will see the arms are designed to fall at the sides of the body. The collarbones are long, allowing freedom of movement at the shoulder joint. However, for many of us, the arms sit in the front of the body, rounded forward. This is partly why I had so many shoulder issues that took me to the physiotherapist in the first place.  At the time, I did not even realise this was poor posture. It’s just how I held myself.

Finding balance throughout the whole body can be essential because it can help prevent injuries and improve our overall posture and how we feel. It can improve our movement patterns and encourage that all-important stability. When we are in balance, we start to have a more even distribution of force across all the joints and tissues, as opposed to the more mobile ones.

Remember – the body will always take the path of least resistance. So if my thoracic spine is stiff and in a flexed forward position, then the lumbar and cervical spines tend to become more mobile because the forces have to go somewhere.

Ever wondered why people have disc herniations in their lumbar and cervical spines and not the thoracic? In my 16-year career, I’ve only ever met one person with a thoracic disc herniation, and she had an underlying health condition outside of EDS.

Better balance in our structure can help alleviate pain and strain because there is the appropriate force being put through the joints and tissues, ensuring no muscle group is being overworked or compensating for weaknesses elsewhere in the body.

Reducing strain with better posture

While I mention the benefits of a more aligned posture, I also want to point out that posture cannot be forced. To force yourself into a perfect posture would likely cause you more strain and pain.  Posture, in my opinion, is something that emerges from all the work you’ve done.

Posture is the last principle in my Integral Movment Method (The IMM) for this reason. It comes after we have relaxed the tension, have improved our breathing, noticed our habits and tensions, and improved our proprioception and stability.

When learned this way, posture may change the nervous system’s response to movement, gravity, and your interaction with your environment.

Effective posture techniques

As I mentioned above, posture is not something we should force. This will just lead to more strain and pain. There are things that we can do that may support our journey towards a more balanced and comfortable posture.

Here are some tips:

• Start with the breath: This is the first principle in my IMM. I always start my clients and encourage members of The Zebra Club to start out by noticing the breath. I encourage you to start in a supine and relaxed position. Let those lungs and muscles expand with the inhale and relax with the exhale. It is an accessible way to start the process – you can try this video.
• Mindfulness: We can become more aware of how we stand or sit. For example, do you lock your knees while standing? If so, this will instantly change your pelvic position and could cause back pain. Do you wrap your legs around each other while sitting? I did! This is going to change my pelvic alignment. Start to notice these things without judging.   But if we become aware, we can make a change if needed.
• Overall stability is important: This is something we can work on slowly by starting movement and exercise supine gently building up from there.
• Take regular breaks from sitting if you work at a desk: Add in some movement snacks to get moving and hydrate your tissues. Close your eyes and take some deep breaths. This is a good practice for anytime you spend a lot of time in one position
• Ergonomic adjustments at work can be helpful to help your body feel supported while sitting.
• Posterior chain strength is key: These muscles than run the whole length of your back body are important for overall stability and posture. I’ve found over my 16 years of working with EDS patients that these muscles tend to be weaker, and our front bodies are super tight and dominant. We just released a posterior chain class into The Zebra Club specifically on this topic, you can find it in the Strength & Connect section of classes.
• Address gait and foot mechanics: Perhaps you need some orthotics to help your feet into better alignment.
• Compression garments: As we mentioned above, compression garments may be helpful in improving postural stability and proprioception (4).
• Sleep support: Many people subluxate or dislocate in their sleep. Can we help this with cushions and pillows? I believe that the overall muscle tone we achieve with movement therapy can help support us in our sleep when everything relaxes.
• Get help from a movement or physical therapist: Sometimes we need some one-to-one pointers and assessment to get started. I have a growing list of providers that I have trained in the IMM that I recommend.

Strategies for managing hypermobility

The management of hypermobility in general is going to be multi-faceted to address everything that can come along with symptomatic hypermobility and systemic connective tissue disorders. Hopefully, this will include a multi-disciplinary team on board.

In terms of movement practices to help manage hypermobility, I start with Breath and Relaxation always. Calming the nervous system and feeling safe is key. Working on proprioception and stability is super important. These are the foundations of what I have included in The Zebra Club app.

Overall, we are looking at strategies for joint stability and strengthening exercises over time. This can include finding a movement activity that you enjoy – whether it’s Pilates, swimming, or walking. I think when we learn body awareness and control and learn to focus on how we are doing the movement, we can do pretty much anything. Remember it’s often not the activity that is wrong, but our approach to the activity.

Also, let me remind you that less is more – please don’t be worried about or focus on the rate of progression. Small steps are all important when managing hypermobility.

This video shares some tips for standing that you may find helpful for becoming more aware of your patterns.

FAQ

Is walking bad for hypermobility?

No, walking is not bad for hypermobility. Many people find walking a very helpful form of daily exercise. You may need to address foot strength and gait patterns if walking is causing pain.

Can EDS cause bad posture?

I find that EDS can contribute to poor posture due to laxity, lack of stability, lack of strength, and decreased proprioception. These are all things that can be addressed and improved.

Do people with hypermobility sit weird?

People with hypermobility can adopt unique sitting positions like the W sit, for example.  They can also wrap their legs around each other which can be a subconscious attempt to increase pressure with conditions like POTS. You may find people with hypermobility find it hard to sit still.