Joint Hypermobility, Anxiety and Yoga

 

Overall

I feel like anyone with anxiety and pain who does yoga yet still “feels tight” has a really good chance of being hypermobile. It’s actually quite deceiving because the bulk of the people I see in physical therapy who say they are really tight, are actually really flexible when I measure them. I was talking about reactive muscle spasms with regards to neck and back pain and noticed people were saying the same thing about their hips. Danielle was a new tech at my office at the time and when I was talking about muscle spasms in relation to the hips, she said she had “hypermobility” and she had read this article about it on the web by Alan Pocinki, MD. It isn’t a research article, but it’s very complete, written in a very readable manner for laymen. It begins like this:

“Many people have flexible or loose joints. They’re the people, maybe like you, who did gymnastics or ballet when they were young and are “good” at yoga…”

My comments:

The entire article is quote-worthy so I’d suggest you just read it for yourself. Dr. Pocinki doesn’t cite research, but thus far everything I have looked up has checked out, which led me to a number of the studies I found below. So far everyone I have talked to about the link between hypermobility, anxiety, and yoga, if they have it, have been able to relate immediately. Rather than denial they were like, “oh shit.” Several said they cried when they read the article because it made sense out of so much.  Talking with Danielle afterwards, I said though I first developed Spinal Flow™ for neck and back pain, if you asked me to develop a home exercise program specifically for hypermobility it would be identical to Spinal Flow Yoga™. A total body exercise program anyone can do at home, or in a yoga class environment without equipment, that keeps the spine neutral and increases total body strength, endurance, and aerobic conditioning – with other joints worked through a full normal, but not hypermobile range of motion. If I ever change that assessment I’ll modify my program and post here on SpinalFlowYoga.com.


HYPERMOBILTY INCREASES RISK OF DISC HERNIATION, AND SLIGHTLY IMPEDES RECOVERY THEREAFTER

Generalized Joint Laxity is Associated with Primary Occurrence and Treatment Outcome of Lumbar Disc Herniation. Han WJ, Kim HB, Lee GW, Choi JH, Jo WJ, Lee SM. Korean J Fam Med. 2015 May;36(3):141-5. (free full text)

My comments:

What’s interesting about this paper is they looked only at men (three times as many women have hypermobility) who herniated discs that were relatively young (average age 24.3). They had herniated lumbar discs 13.2% and had a Beighton index score of at least 4/9. While in an age and weight matched control group without disc herniations only 5.1% were hypermobile. After they did their match controlling for other variables they concluded that hypermobility elevated your risk of disc herniation 3.54 times.

They said those with herniated discs got physical therapy for which the type was not described and recovery was about the same in the short term with pain decreasing from 7ish/10 to 2ish/10 after treatment, but the hypermobile group was slightly (about half a point) worse off 1-2 years after treatment.

I think the pessimistic way to look at this is to think “I’m hypermobile, I’m screwed”, but a better way to look at it is “I’m hypermobile, I just need to watch my posture more and take care to increase core and hip strength and endurance, and maybe bend my spine less even though I’m good at it.” While they didn’t look at genetic sequences in this paper, other research on genetics and disc degeneration found that both genetic and environment act synergistically to mess up the spine. If you went out of your way to avoid known spine stressors you had a much better chance of avoiding injury. It’s also got me thinking that in the genetics papers I don’t think they discussed physical manifestations of those genes, like if they were associated with increased or decreased range of motion, BMI, or muscle strength. It would be nice to know ahead of time if you are at risk for damage, and it looks like a score of 4 or more on the Beighton index is a way of knowing.


LESS MUSCLE STRENGTH IN THOSE WITH GENERALIZED JOINT HYPERMOBILITY

Generalized joint hypermobility, muscle strength and physical function in healthy adolescents and young adults. Scheper M, de Vries J, Beelen A, de Vos R, Nollet F, Engelbert R. Curr Rheumatol Rev. 2014;10(2):117-25.

“GJH was associated with reduced muscle strength for all muscle groups…”

“Individuals with GJH have reduced muscle strength and tend to avoid dynamic activities and prefer more stable activities, like cycling. This may indicate that individuals with GJH adapt their behaviour to prevent musculoskeletal complaints and functional decline.”

The above quote summed up the study findings really well. They looked at males and females and the reduced strength was universal. They performed the study on those who did NOT have pain complaints, which presumably those with pain would be weaker still. Interestingly those with hypermobility played less sports but spent more time cycling, indicating a self selection of activities. What they couldn’t tell was how much of the reduced strength was due to hypermobility itself and how much was due to disuse or lesser activity, but it’s likely both and bidirectional as they said:

“Overuse injuries, occur with minimal provocation and may lead to inactivity impairment in order to preserve joints. This results in ‘pay later’ behavior for participants in certain activities, characterized by over-activity followed by underactivity to recover. Consequently, there is a downward spiral of less activity due to fear of more pain with less provocation, leading to deconditioning.”

While I think the above condition happens frequently, talking to those with hypermobility, there’s also the feeling that some sports/activities are more difficult for them, and because they don’t do as well they don’t like them as much. Which can lead to another type of downward spiral where you avoid the more difficult activities that would improve strength and aerobic conditioning that help the condition, and instead focus on that which they are “good at” like stretch-oriented yoga, which is the last thing a hypermobile person needs.


STRENGTH TRAINING IMPROVES EVERYTHING TESTED IN EVEN EXTREME HYPERMOBILITY

Functional adaptation of tendon and skeletal muscle to resistance training in three patients with genetically verified classic Ehlers Danlos Syndrome. Møller MB, Kjær M, Svensson RB, Andersen JL, Magnusson SP, Nielsen RH. Muscles Ligaments Tendons J. 2014 Nov 17;4(3):315-23.

METHODS:
subjects underwent strength training 3 times a week for 4 months and were tested before and after intervention in regards to muscle strength, tendon mechanical properties, and muscle function.

RESULTS:
three subjects completed the scheduled 48 sessions and had no major adverse events. Mean isometric leg extension force and leg extensor power both increased by 8 and 11% respectively (358 to 397 N, and 117 to 123 W). The tendon stiffness was tested and an average increase in response to physical training, from 1795 to 2519 N/mm was found. On average, the training loads both in upper and lower body exercises increased by around 30% over the training period. When testing balance, the average sway-area of the participants decreased by 26% (0.144 to 0.108 m(2)). On the subscale of CIS20 the participants lowered their average subjective fatigue score from 33 to 25.

“The specific exercises were: leg extension, leg curl, leg press, resisted calf raises, chest press, seated rows, abdominal crunch and lower back extension.”

“The intensity was self-chosen and without progression. The upper body protocol always consisted of 4 exercises, 3 sets per exercise and aimed at a mean of 10 repetitions per set.”

“The authors can conclude that heavy resistance training was both feasible and safe in three patients with genetically verified connective tissue defects (classic Ehlers Danlos Syndrome). The participants demonstrated improved musculo-tendinous function, and somewhat lower fatigue as a result of the training.”

(d) The quotes from the article pretty much say it all. Ehlers Danlos Syndome (EDS) is considered one of the more severe forms of hypermobility. In years of reading research on strength training, and reading research where strength training has performed on almost any population known to man, almost everyone gets stronger and increases function, so the EDS subjects increasing strength didn’t surprise me at all. However, what I thought was interesting was that their connective tissue (tendons) increased in stiffness a full 40%, which is remarkable and, given their condition, is exactly what you would hope would happen. Also interesting is they did all machine exercises, which I wouldn’t think would train balance and stability to the same extent free weight training, yet balance still improved 26%. For what it’s worth, when I was developing Spinal Flow™ I was doing so with an intent to mimic free weight training effects as much as possible, and it turned out the balance component was more difficult than free weight training. It is still yoga after all.


SALT TABLETS AND HYPOTENSION

Plasma volume restoration with salt tablets and water after bed rest prevents orthostatic hypotension and changes in supine hemodynamic and endocrine variables. Waters WW, Platts SH, Mitchell BM, Whitson PA, Meck JV. Am J Physiol Heart Circ Physiol. 2005 Feb;288(2):H839-47. [FREE FULL TEXT]

“On day 13 of bed rest, subjects followed the standard fluid-loading procedure used by the astronauts on landing day, i.e., within a 2-h period, oral consumption of one 1.0-g salt tablet per 125 ml of water, with a total volume of 15 ml/kg body wt.”

“Despite the normovolemia after bed rest, 2-adrenoreceptors were upregulated, and heart rate, epinephrine, and plasma renin responses to tilt were augmented; these changes represent primary effects of bed rest. Collectively, these findings offer insight regarding separation of primary effects of bed rest from secondary effects caused by hypovolemia.”

“We report that oral fluid loading after bed rest restored plasma volume and resulted in 0% presyncope.”

“Use of this protocol on day 13 of bed rest restored plasma volume in all our subjects from an average 8% loss on day 12.”

“The changes in the heart rate, epinephrine, and plasma renin responses to tilt after bed rest represent primary effects of bed rest that are independent of hypovolemia and may reflect 1) a heightened acute stress response, 2) a disruption in the central integration of baroreceptor input, and/or 3) an enhancement of -adrenergic sympathetic responsiveness.”

My comments:

I looked up this paper after the one on vegan diets decreasing fibromyalgia symptoms, but also cutting urinary salt excretion by 2/3. So it made me wonder if the lesser salt intake of a vegan diet could at some point become too much of a good thing and lessen blood pressure or volume, resulting in orthostatic hypotension or tachycardia. This paper might suggest that’s the case, with the potential answer being not to eat meat again, but rather to salt your food. Interestingly they noted that even with blood volume restored, bed rest caused an increased stress response which makes me wonder how much of generalized anxiety disorder is diet and exercise related, rather than just a mental phenomenon. Anxiety tests are often looking to determine how much of a person’s anxiety is state (meaning in relation to what’s going on in their environment) and trait (meaning just how you are). But this makes me think that insufficiencies of diet and exercise might show up as “trait” anxiety when it’s still an unappreciated “state” that is treatable in a way that’s overall healthy for you anyways.


MORE ON SALT AND STRESS

Dietary sodium influences the effect of mental stress on heart rate variability: a randomized trial in healthy adults. Allen AR1, Gullixson LR, Wolhart SC, Kost SL, Schroeder DR, Eisenach JH. J Hypertens. 2014 Feb;32(2):374-82. 

“…70 normotensive healthy young adults (F/M: 44/26, aged 18-38 years) consumed a 5-day low (10 mmol/day), normal (150 mmol), and high (400 mmol) sodium diet…”

“Diet did not affect resting blood pressure, but heart rate (HR) (mean ± SE) was 66 ± 1, 64 ± 1, and 63 ± 1 bpm in low, normal, and high sodium conditions, respectively…”

“The response to low sodium was most marked and consistent with sympathetic activation and reduced vagal activity…”

“The interactions signify that sodium restriction evoked an increase in resting sympathetic activity and reduced vagal activity to the extent that mental stress caused modest additional disruptions in autonomic balance. Conversely, normal and high sodium evoked a reduction in resting sympathetic activity and incremental increase in resting vagal activity, which were disrupted to a greater extent during mental stress compared to low sodium.”

My comments:

This was another paper that looked at lessened salt intake and anxiety symptoms. I had to do some conversions but low sodium worked out to 0.58 grams of salt, normal 8.9 grams and high 23 grams of salt per day. There are 5 grams in a teaspoon. Blood pressure was not affected by low, medium or high salt intake, but resting heart rate decreased incrementally with the higher salt intake. Combined with increased sympathetic tone and decreased parasympathetic tone during rest that seem to be made worse with stress, it makes me think that too low of salt intake could contribute to “state” anxiety. It makes me think a person gets all involved in yoga because of anxiety, which gets them into a healthy diet, that perhaps with regards to salt is “too healthy” for their own good.


Vegan Diet, Salt and Fibromyalgia

Vegan diet alleviates fibromyalgia symptoms. Kaartinen K, Lammi K, Hypen M, Nenonen M, Hanninen O, Rauma AL.Scand J Rheumatol. 2000;29(5):308-13.

My comments:

This was the study I was referring to above about vegan diets really decreasing salt intake. It was a fairly strict “living food” vegan diet where all foods were eaten uncooked. Caloric intake averaged 1829 per day and they stayed on the diet for 3 months. There were a number of interesting findings, most of which were good.

  • Body mass index dropped from 28 (overweight) to 24 (normal weight)
  • Pain at rest dropped from 6/10 to just 3/10
  • Quality of sleep improved
  • Beck Depression Inventory dropped from approximately a 9 to a 4
  • Urine sodium dropped from about 65 mmol/l to 20-25ish

In spite of what looks like rather dramatic heath improvements, which I expect were driven most by the drop in BMI, they reported almost everyone went back to normal diets after the study, with all their biomarkers returning near to baseline, including increased weight, increased pain, and increased depression. They commented that they thought the diet was too severe for most people to continue to follow in the long term.

However, this was the paper that got me thinking about the connection with salt, hypermobility, and anxiety. Because I was talking to a friend on the phone and she said she was just at a bar, stood up, then “had a panic attack and had to get out of there.” I think she’ll eat one of her own chicken’s eggs every now and then, but otherwise she’s pretty vegan and definitely into whole foods, is very healthy and looks fantastic, yadda yadda. So I asked her, “did you have a panic attack, stand up and leave, or did you stand up, then have the panic attack?” She said, “I stood up first, then felt weird.” And I said, “orthostatic tachycardia, not enough salt in your whole foods plants based diet, maybe!” The connection was actually quite relieving to her. She thought she was going crazy, and it was perhaps just a physiological response secondary to a dietary insufficiency.


Two Types of Anxiety?

Sympathetic activation in broadly defined generalized anxiety disorder. Roth WT, Doberenz S, Dietel A, Conrad A, Mueller A, Wollburg E, Meuret AE, Barr Taylor C, Kim S. J Psychiatr Res. 2008 Feb;42(3):205-12. [FREE FULL TEXT] 

“The definition of generalized anxiety disorder (GAD) has been narrowed in successive editions of DSM by emphasizing intrusive worry and deemphasizing somatic symptoms of hyperarousal.”

“Thus, the tense group showed a failure to periodically reduce sympathetic tone, presumably a corollary of failure to relax. We conclude that broader GAD criteria include a substantial number of chronically anxious and hyperaroused patients who do not fall within standard criteria. Such patients deserve attention by clinicians and researchers.”

“…the tense group rated themselves as more worried, under more stress, more depressed, and having poorer sleep than the calm group. Their worry on the Penn State Worry Questionnaire was less than expected for people meeting GAD criteria…”

“For some, worry was not a salient symptom, which is understandable considering that human emotions such as anxiety are expressed in three general ways: motoric-behavioral (e.g., avoidance), verbal-cognitive (e.g., worrying), and physiological (e.g., sympathetic activation) (Lang, 1988).”

“We could create new categories or subcategories such as “Generalized Worry Disorder” and “Generalized Tension Disorder,” although the boundaries between categories like these might be difficult to set.”

My comments:

My earlier reading about anxiety certainly implicated rumination (basically worry) as a primary cause, and the evidence I have read definitely seems to suggest that is true. However, this paper brings up another factor that I think fits in well with the hypermobility anxiety theme, where you might still worry about your various pains more than you maybe should, but that there is also a real increased stress response that makes you feel tense. That could be because of the pain, or the lessened blood volume, or the heart stroke volume, that increases heart rate, and makes you feel anxious. All of which could cause more to ruminate/worry about. A yoga class that provided community, got you out of your head for the time, but significantly increased fitness rather than flexibility (they are different) might be an ideal, which is exactly what Spinal Flow™ is meant to be.


Exercise and Postural Orthostatic Tachycardia

Exercise in the postural orthostatic tachycardia syndrome. Fu Q, Levine BD. Auton Neurosci. 2015 Mar;188:86-9. [FREE FULL TEXT]

My comments:

This was a fascinating paper! The researchers noted that postural orthostatic tachycardia syndrome (POTS) was most prevalent in women. They didn’t make a link to hypermobility or anxiety, but they did suggest that it was perhaps due to women’s smaller heart size (I knew it) and how their smaller heart would have to beat faster to pump sufficient blood to the brain when they stood up. They also noted that aerobic exercise increases blood volume and increases stroke volume (the amount of blood the heart can eject in one beat). They said the reduced blood volume and stroke volume coupled together could cause “reflex tachycardia” when people with tachycardia during exercise; basically freaking them out by simulating a panic attack during exercise.

So what they tested as treatment for the condition was aerobic exercise, started in a recumbent (like a recumbent bike) position 3 times per week for 20-30 minutes with a target heart rate of 75% of max. As the subjects got more in shape they progressed to standing exercise, usually the 2nd or 3rd month. They also started strength training once weekly for 15-20 minutes and progressed to two times per week for 30 minutes.

Results were:

  • left ventricular mass increased 12%
  • end diastolic volume increased 8%
  • blood volume increased 6%
  • autonomic circulatory control and arterial-cardiac baroreflex function were improved “increased vagal reactivation and decreased sympathetic tone”
  • 53% of subjects no longer had tachycardia

They noted that patients with more severe tachycardia were the ones less likely to be cured and they thought 3 months of training just wasn’t enough time for them to fully normalize.

Though they weren’t talking about hypermobility and anxiety, it seems likely to me that the connection here is that hypermobility leads to joint instability and thus increased effort, and likely more pain, for the child during sports activity. So they don’t participate in sports as much and their heart size doesn’t fully develop. So when they stand up quickly, the heart races simulating a panic attack. And the same happens when they try aerobic exercise, “they don’t like running.” But they do like yoga where their hypermobility makes them a star pupil, but doesn’t so much address their strength and cardiovascular deficits. Which makes me think the more aggressive strength training I incorporated into Spinal Flow Yoga™, combined with the semi-circuit training type arrangement to increase aerobic conditioning is ideal for their deficits, even if they can’t show off their hypermobility to the same degree, which I think is for the best as well.

 

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