For many individuals with Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (hEDS), chronic pain is the most disabling symptom. This pain is often intensified and sustained by psychological factors, namely pain catastrophizing (an exaggerated negative orientation toward pain) and kinesiophobia (the irrational fear of movement due to the belief that it will cause re-injury).
The physical therapist, operating within a biopsychosocial framework, is uniquely positioned to address these cognitive and emotional barriers. Effective treatment must combine physical stabilization with cognitive restructuring to break the cycle of fear, avoidance, and pain.
Understanding the Fear-Avoidance Cycle
In hypermobility, the link between movement and pain is often direct (a subluxation, a micro-strain). This reinforces the belief that movement is dangerous.
- Injury/Pain Signal: The patient experiences pain or joint instability.
- Catastrophizing: The patient interprets the pain as a sign of imminent, severe, or irreparable damage (“My joint is falling apart,” “This pain will never end”).
- Fear/Anxiety: This catastrophic thinking generates high levels of fear (kinesiophobia).
- Avoidance: The patient restricts activity (walking, lifting, exercising) to avoid the perceived threat.
- Deconditioning/Increased Sensitivity: Avoidance leads to muscular weakness, stiffening, and central nervous system sensitization, which lowers the pain threshold.
- Worse Pain/Re-Injury: When movement is attempted, the deconditioned body is more prone to injury, confirming the patient’s catastrophic belief and restarting the cycle.
Phase 1: Cognitive Restructuring (Addressing Catastrophizing)
The initial step is validating the patient’s pain while challenging their interpretation of it.
1. Pain Neuroscience Education (PNE)
PNE is foundational. Explain that chronic pain is often not purely a measure of tissue damage, but an output from a highly sensitive nervous system.
- Key Message: “Your pain is real, but it doesn’t mean your body is currently being damaged. The ligaments are lax, but the alarm system (the CNS) is set too high.”
- Hypermobility Context: Link the pain alarm to the systemic nature of the condition (dysautonomia, sensory overload). Explain that the nervous system is often globally hypersensitive, leading to heightened pain responses.
2. Normalizing and Externalizing Pain
Use metaphors (like the Spoon Theory for fatigue, or a Hyper-Vigilant Guard Dog for the pain alarm) to help the patient externalize and objectify their pain experience.
- Targeting Catastrophizing: When a patient uses catastrophic language (“I can’t lift that, I will dislocate”), gently reframe it: “I hear that your protective system is sounding a high alarm. Let’s find a way to test that hypothesis safely, at a very low volume.”
Phase 2: Exposure and Graded Activity (Combating Kinesiophobia)
The clinical treatment for kinesiophobia is graded exposure—systematically and safely reintroducing feared movements below the threshold of pain and subluxation. This retrains the brain to perceive movement as safe.
1. Identify the Fear Hierarchy
Collaboratively create a list of feared activities (e.g., walking for 30 minutes, carrying a gallon of milk, bending over). Rank them from 1 (least feared) to 10 (most feared).
2. Start at the Lowest Rung
Begin therapy with the lowest-ranked fear activity, using the principles of Pacing and Proximal Stability.
- Rule of Halves: If the patient fears walking for 30 minutes, start with two 5-minute walks on separate days. This is an intentional reduction to ensure success and build confidence.
- Successful Exposure: The session is successful if the patient experiences minimal or no pain and the anticipated “catastrophe” does not occur. This evidence directly contradicts the catastrophic belief.
3. Introduce Proprioception as Safety
Link the success of graded exposure directly to the simultaneous stabilization training.
- Key Message: “We are not just moving; we are moving safely by activating your inner core first. Your muscles are now providing the stability your ligaments cannot.”
- Focus on Sensation: During graded activity, cue the patient to focus on the sensation of muscle activation (proprioception) rather than the sensation of pain. This redirects attention away from the “alarm” and toward the “protective action.”
By integrating these psychosocial strategies—validating the patient’s experience while challenging their cognitive barriers to movement- Joint hypermobility physiotherapist Gold Coast empower hypermobile clients to dismantle the debilitating fear-avoidance cycle, making physical rehabilitation effective and sustainable.
