The Pilates client on the hypermobility spectrum
2017; Elsevier BV; Volume: 22; Issue: 1 Linguagem: Inglês
10.1016/j.jbmt.2017.12.013
ISSN1532-9283
AutoresWarrick McNeill, Sally Jones, S. Barton,
Tópico(s)Musculoskeletal pain and rehabilitation
ResumoThe diversity of human movement quality and range that a Pilates Teacher sees on a daily basis can extend from the muscle-bound and significantly joint-restricted individual to those who are waif-like, with whole kinetic chain, contortionist-level, joint flexibility, and, often appearing in the same group class. What an individual also brings into an exercise studio is not just their physical (biological) self but also the sum total of their whole life; their beliefs, experience, current mood and psychological set point (Diener et al., 2006Diener E. Lucas R.E. Scollon Christie N. Beyond the hedonic treadmill: revising the adaptation theory of well-being.Am. Psychol. 2006; 61: 305-314Crossref PubMed Scopus (1026) Google Scholar) created by their physical, psychological and social history. Inter-relationships between their biology, psychology and social factors can create differing outcomes following treatment interventions, of which exercise is one. The biopsychosocial model, very much the focus of current physical therapies research (Nijs et al., 2013Nijs J. Roussel N. Paul van Wilgen C. Köke A. Smeets R. Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment.Man. Ther. Apr. 2013; 18: 96-102Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, Singla et al., 2015Singla M. Jones M. Edwards I. Kumar S. Physiotherapists' assessment of patients' psychosocial status: are we standing on thin ice? A qualitative descriptive study.Man. Ther. 2015; 20: 328-334Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar), has relevance within the rehabilitation space in the Pilates management of movement. When a Pilates Teacher surveys a new class or individual in front of them, they are automatically assessing the client. Hypermobile range and its control will be one of the first things visible. Hypermobility has never been rare in a Pilates context, particularly as the discipline has always attracted those from movement backgrounds, particularly dance and gymnastics in which hypermobility may almost be the norm. It could be said that Dancers and Gymnasts ‘self-select’ from the hypermobile population due to their innate physical attributes. Dancers' attraction to Pilates has a long history as early development of his ideas were cross-fertilised with his contacts with dancers such as Rudolph van Laban and Ted Shawn (of the Denishawn Dance Company) and later Ron Fletcher, Martha Graham and George Balanchine. From the 1940's onwards a mainstay of Joseph Pilates' clientele were dancers, having earned his reputation for efficiently returning them to the stage after injury (Latey, 2001Latey P. The Pilates Method: history and philosophy.J. Bodyw. Mov. Ther. 2001; 5: 275-282Abstract Full Text PDF Scopus (122) Google Scholar). Such clients are used to movement, they have learned how to ‘learn’ movement and are trained to be highly body aware, having nurtured their movement control neuromuscular pathways from a young age. Dancers build muscular support and strength at a vital time of their development, moreover, they train their kinetic system to hold their joints to near optimal functional alignment. What is obvious today is that many individuals with hypermobile joint signs present to Pilates late in life. It is quite likely that these individuals have not experienced the potential positives an early life movement background can provide, or they may be further along the hypermobility spectrum, meaning they are in a risk group in which problems can develop regardless of any preventative behaviours consciously or unconsciously adopted early in life. If in the dance, gymnastics and Pilates worlds, hypermobility appears to be common, what is its true frequency? In a Primary care triage clinic Connelly et al., 2015Connelly E. Hakim A. Davenport S. Simmonds J. A study exploring the prevalence of joint hypermobility syndrome in patients attending a musculoskeletal triage clinic.Physiother. Pract. Res. 2015; 36: 43-53Google Scholar reported that 30% of attendees of the clinic had symptomatic joint hypermobility. Hakim and Grahame, 2003Hakim A. Grahame R. Joint hypermobility.Best Pract. Res. Clin. Rheumatol. 2003; 17: 989-1004Abstract Full Text Full Text PDF PubMed Scopus (238) Google Scholar in their Joint Hypermobility paper, identified that the presence of joint hypermobility is influenced by age, gender and ethnicity; they reported in studies of younger people up to 35% of males and 57% of females show polyarticular hypermobility, and, a prevalence in the general population of 10%–20%. Clarke and Simmonds, 2011Clarke C. Simmonds J.V. An exploration of the prevalence of hypermobility syndrome in Omani women attending an outpatient department.Muscoskel. Care. 2011; 9: 1-10Crossref PubMed Scopus (29) Google Scholar reported 55% of Omani women, between 18 and 50 years old attending a hospital physiotherapy service had evidence of Joint Hypermobility Syndrome (JHS). The prevalence is greater in the female population and those of African and Asian descent (Simmonds and Keer, 2007Simmonds J.V. Keer R.J. Hypermobility and the hypermobility syndrome.Man. Ther. 2007; 12: 298-309Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar). There has long been awareness of the presence of hypermobility within the human population and that it is a heritable condition. There is no cure for heritable conditions, just management of the signs and symptoms. Currently, it is believed that the best management is provided by a multidisciplinary, holistic approach that is patient centred. It has pacing and physiotherapy, especially exercise, at its centre. Outside of specialist centres, it is a spectrum still not well understood or managed at present (Simmonds and Keer, 2007Simmonds J.V. Keer R.J. Hypermobility and the hypermobility syndrome.Man. Ther. 2007; 12: 298-309Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, Palmer et al., 2017Palmer S. Manns S. Cramp F. Lewis R. Clark E.M. Test-retest reliability and smallest detectable change of the Bristol Impact of Hypermobility (BIoH) questionnaire.Musculoskeletal Sci. Pract. 2017; 32: 64-69Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, Engelbert et al., 2017Engelbert R.H. Juul-Kristensen B. Pacey V. de Wandele I. Smeenk S. Woinarosky N. Sabo S. Scheper M.C. Russek L. Simmonds J.V. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos syndrome.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 158-167Crossref Scopus (73) Google Scholar). Expert opinion identifies that exercise is the key intervention but best practice of its delivery has yet to be proven by high-powered RCT's (randomised controlled trial's) (Palmer et al., 2014Palmer S. Bailey S. Barker L. Barney L. Elliott A. The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review.Physiotherapy. 2014; 100: 220-227Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, Web source 1, 2017Simmonds J. Physiotherapy management of hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome.in: HMSA Conference Lecture 1.10.17. 27 November 2017Date accessed: December 8, 2017Google Scholar). There are suggestions (Palmer et al., 2016bPalmer S. Cramp F. Clark E. Lewis R. Brookes S. Hollingworth W. Welton N. Thom H. Terry R. Rimes K.S. Horwood J. The feasibility of a randomised controlled trial of physiotherapy for adults with joint hypermobility syndrome.Health Technol. Assess. 2016; 20Crossref Scopus (16) Google Scholar) that the effectiveness of therapy includes education and (physiotherapy led) exercise. It is therefore in the interests of the Pilates Teacher to have a basic understanding of the hypermobility spectrum. A Pilates Teacher should be able to provide some level of education and care to those attending their classes who exhibit generalised joint hypermobility (GJH). They should be able to recognise those further a long the hypermobility spectrum who may present with a potentially undiagnosed, and perhaps rarer form of heritable Ehlers Danlos Syndrome (EDS). A Pilates Teacher might advise their hypermobile clients to seek a referral for specialist assessment, but always deliver appropriate exercise supervision within the remit of their experience and training. The development of the understanding of the hypermobility spectrum is a classic example of an area of interest that in its early study developed a nomenclature littered with acronyms, current and past, but that may still be in use. A lot of the study of the hypermobility spectrum is in the diagnostic arena, and the information delivered can be both technical and tautologic which can be confusing to a practitioner or an individual with the condition. In 1988, 1998, and 2017 reclassifications of Ehlers-Danlos syndromes (EDS) have occurred to standardise terminology due to advances in genetic testing, and future reclassifications are highly likely, especially as revision meetings are planned every 2 years. A Pilates Teacher should have familiarity with some of the terms used, historic and current, within the spectrum but be mindful of the current classifications. For example, the largest subset of the Ehlers Danlos syndromes (EDS) has most recently been termed Hypermobile-EDS (hEDS) whereas it has previously been known as EDS Type III, or EDS Hypermobility Type (Tinkle et al., 2017Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. Levy H. Hypermobile Ehlers–Danlos syndrome (a.k.a. Ehlers–Danlos syndrome Type III and Ehlers–Danlos syndrome hypermobility type): clinical description and natural history.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 48-69Crossref Scopus (207) Google Scholar). Tinkle, on behalf of an International group of experts also proposes the combination of the clinical diagnoses of hEDS and JHS (Joint hypermobility syndrome) as they are often clinically indistinguishable from each other (see Table 1). Both are heritable connective tissue disorders (HCTD) and since they do not have a current genetic test, diagnosis can only be based on a clinical description (Tinkle et al., 2017Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. Levy H. Hypermobile Ehlers–Danlos syndrome (a.k.a. Ehlers–Danlos syndrome Type III and Ehlers–Danlos syndrome hypermobility type): clinical description and natural history.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 48-69Crossref Scopus (207) Google Scholar).Table 1Abbreviations within the hypermobility arena. On the left side of the table acronyms without syndrome or disorder indicate the asymptomatic end of the hypermobility spectrum, the term syndrome or disorder denotes that symptoms are present associated within their part of the spectrum. Note the 2017 classification identifies over 20 types of EDS, 13 are named here, it is not within the scope of this piece to describe them. hEDS comprises over 80% of the EDS's (Tinkle et al., 2017Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. Levy H. Hypermobile Ehlers–Danlos syndrome (a.k.a. Ehlers–Danlos syndrome Type III and Ehlers–Danlos syndrome hypermobility type): clinical description and natural history.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 48-69Crossref Scopus (207) Google Scholar).TerminologyAlso known asJHJoint hypermobilityGJHGeneralised joint hypermobilityAsymptomatic generalised joint hypermobilityPJH(Asymptomatic) peripheral joint hypermobilityLJH(Asymptomatic) localised joint hypermobilityGJH(Asymptomatic) generalised joint hypermobilityJHSJoint hypermobility syndromeHSHypermobility syndromeBJHSBenign joint hypermobility syndromeFrom 2017aTinkle et al. (2017) proposes the combination of the two undifferentiated syndromes hEDS and JHS.hEDSHypermobile Ehlers-Danlos syndromeHCTDHeritable connective tissue disorderHSDHypermobility spectrum disorderL-HSDLocalised-Hypermobility spectrum disorderG-HSDGeneralised-Hypermobility spectrum disorderP-HSDPeripheral-Hypermobility spectrum disorderH-HSDHistorical-Hypermobility spectrum disorderEDSEhlers-Danlos syndromehEDSHypermobile Ehlers-Danlos syndromeEDS-Hypermobile typeEhlers-Danlos syndrome-Hypermobile typeEDS-Type IIIEhlers-Danlos syndrome Type 3From 2017aTinkle et al. (2017) proposes the combination of the two undifferentiated syndromes hEDS and JHS.JHScEDSClassical Ehlers-Danlos syndromevEDSVascular Ehlers-Danlos syndromeclEDSClassical like Ehlers-Danlos syndromecvEDSCardiac-valvular Ehlers-Danlos syndromeaEDSArthrochalasia Ehlers-Danlos syndromedEDSDermaosparaxis Ehlers-Danlos syndromekEDSKyphoscoliotic Ehlers-Danlos syndromespEDSSpondylodysplastic Ehlers-Danlos syndromemcEDSMusculocontractural Ehlers-Danlos syndromemEDSMyopathic Ehlers-Danlos syndromepEDSPeridontal Ehlers-Danlos syndromeBCSBrittle cornea syndromePoTSPostural orthostatic tachycardia syndromeFGDFunctional gastrointestinal disordera Tinkle et al., 2017Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. Levy H. Hypermobile Ehlers–Danlos syndrome (a.k.a. Ehlers–Danlos syndrome Type III and Ehlers–Danlos syndrome hypermobility type): clinical description and natural history.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 48-69Crossref Scopus (207) Google Scholar proposes the combination of the two undifferentiated syndromes hEDS and JHS. Open table in a new tab According to Cathy Collier, Healthcare Information Officer for Ehlers-Danlos Support UK, the 2017 reclassification is particularly useful as for the first time Management and Care Guidelines have been put forward (Collier, 2017Collier C. A Summary of the 2017 EDS International Classification. Fragile Links, EDS UK2017Google Scholar) at the same time as the reclassification. The hypermobility spectrum described in Castori et al., 2017Castori M. Tinkle B. Levy H. Grahame R. Malfait F. Hakim A. A framework for the classification of joint hypermobility and related conditions.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 148-157Crossref Scopus (235) Google Scholar, starts with a simple explanation, that Joint Hypermobility (JH) also known as joint laxity or double-jointedness can be defined as the capability that a joint can have to move beyond normal limits. JH can present with no other signs or symptoms. It can be localised (LJH) usually affecting fewer than 5 joints, inherited, or the result of trauma, disease or training. Generalised joint hypermobility (GJH) can involve all 4 limbs and the spine. The Beighton score, first described in 1973, is a reliable and commonly utilised tool particularly to find generalised joint hypermobility (GJH) (See Fig. 1.). Criticism that the Beighton score does not assess joints such as the shoulders, hips and ankle that are often involved in JH is also valid, but its frequent use over decades means that it has been kept as a current tool, partially to aid future research comparisons (Engelbert et al., 2017Engelbert R.H. Juul-Kristensen B. Pacey V. de Wandele I. Smeenk S. Woinarosky N. Sabo S. Scheper M.C. Russek L. Simmonds J.V. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos syndrome.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 158-167Crossref Scopus (73) Google Scholar). The Beighton score can add up to 9 points and interpretation of the results is age-dependent with children and adolescents being identified as having GJH if they score 6 or above, adults under 50 if they score 5 or above, and those over 50 only need to score 4. A further 5 point questionnaire can assist in identifying GJH if an individual is 1 point off the cut off. (See Fig. 2). (Collier, 2017Collier C. A Summary of the 2017 EDS International Classification. Fragile Links, EDS UK2017Google Scholar).Fig. 2Hypermobility Questionnaire.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The Beighton score does not identify those individuals that present with symptoms and this is where the hypermobility spectrum starts adding the words ‘disorder’ or ‘syndrome’. The Hypermobility Spectrum Disorders (HSD's) include; Generalised Hypermobility Spectrum Disorder (G-HSD), Peripheral, Localised and Historical subgroups. In the hEDS grouping the syndromic and disorder classifications present when systemic manifestations of more generalised connective tissue disorders are identified. These features can include:•Soft or velvety skin•Mild skin hyperextensibility•Unexplained striae (stretchmarks in the absence of weight change)•Piezogenic heel papules (fatty extruding bumps at the heel)•Abdominal hernia's•Widened scars•Pelvic floor, rectal or uterine prolapse•Dental crowding with a high or narrow palate•Arachnodachtyly (abnormally long fingers or toes)•Longer arm span than height•Heart issues - mitral valve, aorta dilatation Symptoms along the spectrum can also include chronic pain, recurrent joint dislocations, including non-traumatic dislocations (frank joint instability). Some specific findings such as significant skin fragility, congenital hip dislocations, arterial rupture, other cardiac valve issues, or low muscular tone, among other symptoms may be found. Specific symptoms help in the diagnosis of other EDS groupings, but they are all part of the mild to severe symptomatic end of the spectrum. Comorbidities are disorders that run concurrently with a primary disorder. In the Hypermobility Spectrum Disorders (HSD's) these can be key features that may be used by a Pilates Teacher to flag up an individual who may have a more symptomatic hypermobility that needs careful handling, and a slower progression of exercise. The Pilates Teacher might consider asking the individual whether they have linked their Hypermobility symptoms to their comorbidity. Often it is the weight of linked features that can help someone affected by an HSD realise that there may be a combined story to explain a lifetime of seemingly random issues. Especially when the western medicine model has created specialisms that appear to have resulted in highly trained Consultants who find it difficult to step back in order to see the bigger picture that an HSD can present as. A key comorbidity is PoTS (postural tachycardia syndrome), a condition that can present with headaches, fatigue, palpitations, sweating, nausea, fainting and dizziness. These symptoms are related to the inability of the body to adjust to postural (orthostatic) change especially from lying down to standing up causing the heart rate to increase significantly. It is related to the autonomic nervous system, the sub-conscious body system regulation controller, and is linked to the chemicals of the stress, ‘fight or flight’, response. (Web source 2, 2015Web source 2 What is Pots?.1 February 2015http://www.potsuk.org/what_is_pots2Date accessed: December 8, 2017Google Scholar). Another possible comorbidity involves functional gastrointestinal disorders (FGD's), that may involve symptoms of abdominal pain, bloating, nausea, diarrhoea, and constipation. FGD's are becoming increasingly recognised as being commonly associated with joint hypermobility (Fikree et al., 2017Fikree A. Chelimsky G. Collins H. Kovacic K. Aziz Q. Gastrointestinal involvement in the Ehlers–Danlos syndromes.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 181-187Crossref Scopus (72) Google Scholar), especially in children (Kovacic et al., 2014Kovacic K. Chelimsky T.C. Sood M.R. Simpson P. Nugent M. Gisela Chelimsky G. Joint hypermobility: a common association with complex functional gastrointestinal disorders.J. Pediatr. 2014; 165: 973-978Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar). Other autonomic related comorbidities include Chronic Fatigue that may be directly related to the effects of the disease burden associated with autonomic symptoms (De Wandele et al., 2014De Wandele I. Calders P. Peersman W. Rimbaut S. De Backer T. Malfait F. De Paepe A. Rombaut R. Autonomic symptom burden in the hypermobility type of Ehlers–Danlos syndrome: a comparative study with two other EDS types, fibromyalgia, and healthy controls.Semin. Arthritis Rheum. 2014; 44: 353-361Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar). GJH is more common in individuals with Chronic Fatigue syndrome and Fibromyalgia, overlapping disorders, though diagnostically different, compared with healthy volunteers. (Nijs, 2005Nijs J. Generalized joint hypermobility: an issue in fibromyalgia and chronic fatigue syndrome?.J. Bodyw. Mov. Ther. 2005; 9: 310-317Abstract Full Text Full Text PDF Scopus (14) Google Scholar). Anxiety, panic disorder/agoraphobia was linked in a (Bianchi Sanches et al., 2012Bianchi Sanches S.H. de Lima Osório F. Marc Udina M. Martín-Santos R. José Alexandre S. Crippa J.A.S. Anxiety and joint hypermobility association: a systematic review.Rev. Bras. Psiquiatr. 2012; 34: S53-S68Crossref PubMed Google Scholar) systematic review with JH, though the underlying aetiology was reported as being controversial. Psychological and psychiatric involvement in HSD's are well described and in neuroimaging of subjects with hEDS increased activity in emotional processing areas has been observed which may explain the levels of anxiety reported in this group (Bulbena et al., 2017Bulbena A. Baeza-Velasco C. Bulbena-Cabre A. Pailhez G. Critchley H. Chopra P. Mallorqu ı-Bague N. Frank C. Porges S. Psychiatric and psychological aspects in the Ehlers–Danlos syndromes.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 237-245Crossref Scopus (82) Google Scholar). An important set of symptoms in HSD's are related to the fact that hypermobility itself can create secondary musculoskeletal manifestations.•Trauma - divided into macrotrauma, involving dislocations and subluxations and injuries to the soft tissues surrounding the joints, and microtrauma's the effects of which are more cumulative, perhaps resulting over time in osteoarthritic, recurrent or persistent pain•Chronic pain - which could be related to increased sensitivity to pain (hyperalgesia) or neuropathies•Disturbed proprioception - is a well observed phenomenon within the hypermobility spectrum, creating a mismatch between the perception of somatic inputs and the cognitive effort required for output, and may be a cause of the hyper-vigilance that hypermobile individuals are constantly demonstrating in movement situations•Flexible flat feet•Cumulative bony mal-alignments of great toes and elbows•Spinal curvature alterations including scoliosis, both increased thoracic kyphosis and lumbar lordosis, or flexible reverses of the normal curvature in postures such as sitting Dr. Jane Simmonds, an Australian Physiotherapist working in the UK, and Chair of the International Ehlers Danlos Syndrome Physical Therapy Clinical Guidelines working group, helps to clarify the management of the hypermobility spectrum in her presentation at the Ehlers-Danlos Support UK and the Hypermobility Syndromes Association joint conference in October 2017 (Web source 1, 2017Simmonds J. Physiotherapy management of hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome.in: HMSA Conference Lecture 1.10.17. 27 November 2017Date accessed: December 8, 2017Google Scholar). She is very cognisant of the fact that members of the Physiotherapy profession are often uninformed both in the recognition of the hypermobility spectrum and its management. This has contributed to some poor reporting of the effectiveness of physiotherapy, which at worst has exacerbated symptoms, resulting in some physiotherapy practitioners being noted by hypermobility spectrum patients to,•display a lack of understanding•not listen•not treat the whole person•provide boring exercise/treatment•be too vigorous and/or progress too quickly•be over cautious or hands off (Web source 1, 2017Simmonds J. Physiotherapy management of hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome.in: HMSA Conference Lecture 1.10.17. 27 November 2017Date accessed: December 8, 2017Google Scholar, Palmer et al., 2016aPalmer S. Terry R. Rimes K.A. Clark C. Simmonds J. Horwood J. Physiotherapy management of joint hypermobility syndrome - a focus group study of patient and health professional perspectives.Physiotherapy. 2016; 102: 93-102Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar). Simmonds advocates the biopsychosocial model in the management of the hypermobility spectrum which includes a Holistic, Compassionate, Empowering and Evidence based approach - HOPE. It should include Education and Reassurance, and should direct those on the Hypermobility spectrum towards support groups. Therapy should be individualised, based on assessing the problems as presented by the individual, involving a problem solving, clinically reasoned, goal directed functional restoration program. Exercise interventions have to be carefully implemented. The therapist should understand how to manage recurrent subluxations/dislocation with a ‘Dislocation plan’ acute management, with a ‘Do Not Panic’ headline, incorporating joint support, pain management - including pain killers and icing - time, and avoidance of prolonged immobilisation. Assessing gait, posture, basic movements such as sit-to-stand, balance, coordination, joint repositioning drills, muscle engagement (slow motor unit dominant cognitive control) and cardiovascular/fitness assessment, allows the judicious application of remedial tactics. Simmonds' co-authored 2017 paper with first author Raoul Englebert is an important and up-to-date resource for any Physical therapy practitioner, including Pilates Teachers interested in working with Hypermobile clients (websource 1, Engelbert et al., 2017Engelbert R.H. Juul-Kristensen B. Pacey V. de Wandele I. Smeenk S. Woinarosky N. Sabo S. Scheper M.C. Russek L. Simmonds J.V. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers Danlos syndrome.Am. J. Med. Genet. Part C Semin. Med. Genet. 2017; 175C: 158-167Crossref Scopus (73) Google Scholar). Simmonds and Keer, 2007Simmonds J.V. Keer R.J. Hypermobility and the hypermobility syndrome.Man. Ther. 2007; 12: 298-309Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, Simmonds and Keer, 2008Simmonds J.V. Keer R.J. Hypermobility and the hypermobility syndrome, Part 2: assessment and management of hypermobility syndrome: illustrated via case studies.Man. Ther. 2008; (13 2 e1–e11)Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar provide expert opinion on management. From a Pilates perspective, slowly progressed graded exercise, cognitively addressing uncontrolled movements (UCM's) (Comerford and Mottram, 2012Comerford M. Mottram S. Kinetic Control: the Management of Uncontrolled Movement. Elsevier, Churchill Livingstone2012Google Scholar) through the full range of movement available, is important. The principles of centre, breath, concentration, control, precision, and (aiming for) flow seems to have been designed particularly for the management of those on the hypermobile spectrum. Pilates narrow focus on the assessment, exercise choice and delivery of exercise supervision, with its large back catalogue of exercises and an understanding of the gentle application of exercise, means it is well placed to be an adjunct to the multi-disciplinary team treating acute hypermobility-related problems. It is unlikely to be ‘boring’, no matter how gentle the exercise requirement, but comes into its own once problems become sub-acute or maintenance, or gently strengthening led. It is likely that a Pilates Teacher could be the only professional an individual on the Hypermobility spectrum may see year on year, all going well. But the Pilates Teacher must be a member of The Team, and refer onwards when necessary, and accept referrals to further the therapeutic goals. When Pilates is the primary contact for someone with perhaps relatively light or no symptoms on the hypermobility spectrum it is important to remember that increasingly, hypermobile clients from non-movement backgrounds are presenting in a Pilates setting. They may have varying degrees of hypermobile issues, they may not have been diagnosed, have possibly been misdiagnosed and their hypermobility may be increasingly symptomatic, which may have been a driver to attend Pilates classes. Pilates Teachers first task is to make a functional movement diagnosis. When working with hypermobility the primary interest is to understand where the client's hypermobility sits within the spectrum, which will help determine appropriate movement strategies, management and exercise choices. How important are the classifications? Does it make a difference? While important from a medical management perspective, in a Pilates setting, classifications may be relatively irrelevant. Whether a client has a diagnosis, is seeking diagnosis or remains undiagnosed, for Pilates Teachers the issue is much more about how the client's hypermobility presents. What are their movement behaviours and how does their individual hypermobility manifest under movement instruction? What might be expected? What questions should a Pilates Teacher ask? What's in their toolkit of practical functional movement for that individual? Assessing a Pilates client's hypermobility. To recap: while the Beighton Score is the most widel
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