Q&A Time! Repeated Loading and Hypermobility/Hypomobility | Modern Manual Therapy Blog

Q&A Time! Repeated Loading and Hypermobility/Hypomobility

An online mentee recently asked me this question.

"What is your criteria for determining Hypermobilty versus Hypomobility in a patient?  Is there proven research on this through Mckenzie or other framework?  I can use the Rowe test or thumb to radius as a clinical pattern that then allows me to devise a more "motor control" protocol for the client ... I ask this because slow responders are usually Hypermobile.  Again hyper mobility is subjective as an "end feel " but not a real objective finding."

That is a good question, but I tend to throw out a lot of the more conventional thinking and treatments like hypermobility needs stabilization and hypomobility needs mobilization. The nervous system needs threat mitigation and novel movement strategies, plus manual therapies to decrease stretch/pain perception during self limiting movements.

McKenzie had said it for decades, repeated loading strategies DO NOT promote hypermobility, any more than mobilizations do. Someone who is 8-9/9 on the Breighton hypermobility scale - systemically hypermobile, right? Ever met a patient who is systemically hypermobile in all areas, except their involved shoulder? Me either! You are born that lax, and any motion loss is usually neurologic lockdown from perceived threat or motor control issues. Most of my caseload for a better part of a decade were TMD patients, most ectomorphic hypermobile females, and getting them to repeatedly load in the directional preference just meant they had to go farther typically than someone who is not lax.

Conversely, for a patient that has high tone all over, or tends to have less than stellar mobility in all areas, is actually easier to use repeated loading strategies with, since they are easier to get to end range, thus having the same effect as mobilizations. The same goes for manipulations or mobilizations, it's easier to do a grade 4 or 5 thrust on someone who is hypomobile versus hypermobile, but if you have ever used any manual therapy, STM, mobilization, manipulation, PNF, etc, on a hypermobile patient, then you would use repeated loading as well.

Don't believe the old school manual therapy hype, before you dismiss repeated loading strategies for hypermobile patients, ask yourself
  • would I use mobilizations/manipulation on an area of less mobility even if the patient was hypermobile elsewhere?
  • have I ever done this before?
If the answer is yes, and I am betting it is, then repeated loading strategies are also indicated any time there is pain and/or loss of motion, regardless if the rest of the body is a bit lax. Most patients regardless of their body type are rapid responders, or what MDT calls Derangement Syndrome. I would also say, that most DO NOT need stabilization, as once pain and movement thresholds are reset, motor control and movement returns. They may need endurance or strengthening depending so their capacity is up to par, but stabilization is just a strategy I have not regularly prescribed in many years.

Keeping it Eclectic....


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