Hypermobility: The Hidden Caseload in Every Clinic 

Hypermobility: The Hidden Caseload in Every Clinic 

By Jeannie Di Bon, MA, MSc : Hypermobility Specialist, Educator, Author. 

 

Ask most movement professionals about hypermobility and the Ehlers-Danlos Syndromes and the conversation tends to go in one direction: rare condition, specialist territory, someone else's patient. The reality on the ground looks quite different. Joint hypermobility is estimated to affect 5 to 20 percent of women and around 1 percent of men, and the symptomatic forms – hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD) – are widely acknowledged in the literature to be under-recognised. The patients are not elsewhere. They are already on our caseloads, often quietly sitting inside the recurrent-sprain, the "non-specific" low back pain, the chronic-pain referral that has not progressed the way we'd hoped. 

Recognising them matters, because their bodies respond differently to movement than the textbook assumes. The connective-tissue picture is not just about loose joints; it shapes proprioception, fatigue, autonomic regulation and the way the nervous system interprets threat. A patient who looks unremarkable on a first assessment may have spent years compensating in ways that are invisible until you know what to look for – and they may arrive in our clinics carrying a long history of being told their pain is unexplained. 

The screening cues are simple enough to apply in any first session. The Beighton score remains the most familiar starting point, and the five-part questionnaire developed by Hakim and Grahame is quick to administer and well validated, although these should not be used in isolation to diagnose a patient. The 2017 Diagnostic Criteria is currently the most up to date way to assess a patient if you suspect a connective tissue issue. A history of recurrent subluxations, easy bruising, marked fatigue, dizziness on standing, and a sense that the patient has "always been bendy" together build a picture worth investigating further. None of this requires a specialist diagnosis to act on; it simply changes how we approach the rehabilitation plan. 

This is where the profession is genuinely still catching up – and where, I'd argue, there's an opportunity for every clinician reading this. The published evidence on rehabilitation experiences in this group is sobering in places. Bovet and colleagues (2016) documented that a meaningful proportion of patients with symptomatic hypermobility report being made worse by well-intentioned physical therapy. Halverson and colleagues (2021) heard similar accounts: patients prescribed exercises that overextended joints already prone to instability, with progress measured in setbacks rather than gains. These findings are not a verdict on the profession. They reflect the fact that the standard rehabilitation model – built around progressive loading, repetitions, and intensity – was developed for bodies that respond predictably to those inputs. The hypermobile body often does not. 

A different starting point helps. The Integral Movement Method (IMM), which I developed over eighteen years of clinical practice and which underpins the peer-reviewed work published by Russek and colleagues in the Journal of Bodywork and Movement Therapies (2025) and the Journal of Multidisciplinary Healthcare (2026), builds safety before strength. That means regulating the nervous system first – through breath, relaxation and proprioceptive work – before introducing the stability and load that conventional rehabilitation reaches for early. The pain-science rationale is straightforward: a hyper-vigilant nervous system, common in this group, will resist stability work until it feels safe. Try to outmuscle that, and you reinforce the very fear-of-movement pattern you're trying to resolve. 

The evidence is encouraging. In our pragmatic clinical trial of 420 participants, my online programme built on these principles produced statistically significant improvements in hypermobility impact, body awareness and fear of movement – improvements that held at six months. Patients consistently named four things that made the work succeed: exercises designed for hypermobility, a sense of safety, an instructor who understood the condition, and accessibility on their own schedule. 

None of which makes hypermobility easy to treat. It does, however, suggest that recognising this hidden caseload, and adjusting the starting point of rehabilitation accordingly, is one of the higher-leverage changes a movement professional can make. I'll be exploring this in more depth in my Therapy Expo session in November. I hope to see you there. 

 

References  

Bovet et al. (2016) | Bovet C, Carlson M, Taylor M. Quality of life, unmet needs, and iatrogenic injuries in rehabilitation of patients with Ehlers–Danlos Syndrome hypermobility type/Joint Hypermobility Syndrome. American Journal of Medical Genetics Part A. 2016;170(8):2044–2051. doi:10.1002/ajmg.a.37774 

Halverson et al. (2021) | Halverson CME, Clayton EW, Garcia Sierra A, Francomano C. Patients with Ehlers–Danlos syndrome on the diagnostic odyssey: Rethinking complexity and difficulty as a hero's journey. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2021;187C(4):416–424. doi:10.1002/ajmg.c.31935 

Russek et al. – Journal of Bodywork and Movement Therapies (2025) | Russek LN, Di Bon J, Simmonds J, Nation CS, Zion Higgins CV, Jandrew T. A qualitative study exploring participants' feelings about an online Pilates program designed for people with hypermobility disorders. Journal of Bodywork & Movement Therapies. 2025;42:1148–1158. doi:10.1016/j.jbmt.2025.03.002 

Russek et al. – Journal of Multidisciplinary Healthcare (2026) | Russek LN, Di Bon J, Herbland A, Higgins C, Jandrew TR, Adams AM, Simmonds J. An Online Pilates Program for People with Hypermobility: A Pragmatic Clinical Trial Looking at Function, Interoception, Kinesiophobia, and Physical Activity Levels. Journal of Multidisciplinary Healthcare. 2026;19. doi:10.2147/JMDH.S564972 

 

Beighton score | Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Annals of the Rheumatic Diseases. 1973;32(5):413–418. doi:10.1136/ard.32.5.413 

Hakim and Grahame five-part questionnaire | Hakim AJ, Grahame R. A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain. International Journal of Clinical Practice. 2003;57(3):163–166. 

2017 International Classification (hEDS diagnostic criteria) | Malfait F, Francomano C, Byers P, Belmont J, Berglund B, Black J, et al. The 2017 international classification of the Ehlers–Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017;175(1):8–26. doi:10.1002/ajmg.c.31552