For individuals living with Hypermobility Spectrum Disorder (HSD) and hypermobile Ehlers-Danlos Syndrome (hEDS), land-based exercise is often a paradoxical challenge: movement is necessary for stability, yet gravity and load often trigger pain, fatigue, and injury. Hydrotherapy (aquatic therapy) offers a vital bridge, leveraging the unique properties of water to create a low-impact, supportive, and proprioceptively rich environment for rehabilitation.

For physical therapists, incorporating aquatic therapy protocols can significantly reduce the “fear of movement” (kinesiophobia) and facilitate earlier, safer progression of stabilization exercises.

The Unique Benefits of Water for Hypermobility

Water addresses the three primary obstacles faced by hypermobile clients during terrestrial exercise: pain, instability, and poor proprioception.

1. Buoyancy: Managing Gravity and Load

The upward thrust of water counteracts the effect of gravity, reducing the compressive load on the joints.

• Pain Reduction: When immersed up to the neck, body weight is reduced by approximately 90%. This allows clients to exercise with significantly less pain, especially in weight-bearing joints like the hips, knees, and spine, which often struggle with sustained upright postures.
• Early Weight-Bearing: Clients with functional instability or recurrent subluxations can practice standing, gait training, and closed-chain exercises in the pool much earlier than on land, without the risk of high impact.

2. Hydrostatic Pressure: Controlling Edema and Autonomic Function

The pressure exerted by the water on the submerged body offers systemic benefits.

• Edema Control: Hydrostatic pressure assists venous return, helping to reduce peripheral edema (swelling) common in lower limbs.
• Autonomic Regulation: For clients with Postural Orthostatic Tachycardia Syndrome (POTS), the pressure helps shunt blood back toward the heart, assisting with circulation and potentially alleviating symptoms of orthostatic intolerance (dizziness upon standing) during exercise.

3. Viscosity and Turbulence: Enhanced Proprioception

The water’s resistance (viscosity) and movement (turbulence) provide rich, multi-directional sensory feedback that is ideal for correcting proprioceptive deficits.

• Rhythmic Stabilization: The uniform resistance provided by water acts as a gentle, 360-degree force against movement. The client is forced to use their stabilizing muscles (core and girdle) to maintain posture, teaching the body where the joints are in space.
• Motor Control: Slow, controlled movements against viscosity enhance motor learning and joint position sense better than rapid, uncontrolled movements on land.

Practical Hydrotherapy Protocols

Aquatic therapy for HSD/hEDS should follow the same hierarchy as land-based exercise: establish central stability, train proprioception, and then add functional movement. Warm water (around $32-34^\circ\text{C}$ or $90-93^\circ\text{F}$) is often preferred to promote muscular relaxation.

Phase 1: Core and Proprioception Focus

Focus on activation of the inner core unit (TA, PF, Diaphragm) in non-weight-bearing positions.

• Deep Water Suspension: Using flotation belts, the client performs rhythmic stabilization exercises while suspended vertically in deep water. The Joint hypermobility physiotherapist Gold Coast creates gentle turbulence, forcing the core to stabilize the trunk against multi-directional movement.
• Single-Limb Proprioception: Standing in chest-deep water (minimizing gravitational load), the client performs single-leg stance. The water’s resistance slows the inevitable sway, allowing the nervous system time to correct the movement. Progress by closing the eyes.

Phase 2: Girdle Strengthening and Endurance

Integrate the core with the hip and shoulder stabilizers, utilizing flotation equipment for resistance.

• Water Walking/Gait Training: Focus on slow, deliberate gait in waist-deep water. Use exaggerated hip flexion to activate the glutes and hip flexors against the water’s resistance.
• Scapular Stability: Use water paddles or buoyant dumbbells in chest-deep water for slow, controlled movements (e.g., T’s and Y’s) through the shoulder’s safe mid-range. The resistance is provided by the equipment and the water, minimizing joint strain.

Phase 3: Functional Integration and Pacing

Introduce more dynamic, functional movements while strictly adhering to pacing principles.

• Transitional Movements: Practice pool-edge activities that mimic daily life, such as getting in and out of a chair or climbing stairs (using pool steps).
• Endurance Swimming: If tolerated, use low-impact strokes (e.g., backstroke or modified breaststroke) for cardiovascular conditioning, focusing on maintaining alignment and avoiding end-range hyper-extension.