hEDS: Pacing the Strengthening Work Around PEM
For the real subgroup of hypermobile EDS patients who also have ME/CFS, POTS, or post-exertional malaise (PEM), Dr. Linda Bluestein's joint-protective strengthening work stays inside your energy envelope: screen honestly for a delayed crash after exertion, and if PEM is present, sessions get shorter, less frequent, and stop at the first sign of a crash the next day, never pushed through. Pacing always outranks strengthening when PEM is present.
Ask: does exertion cause a delayed crash (worsening hours to days later), not just immediate fatigue that resolves with rest? n/a, self-assessment, confirm with your clinician
PEM is the defining feature that changes everything below; a delayed crash pattern means pacing rules apply first, not a strengthening schedule.
Closed-chain, low-range proprioceptive strengthening as already described in this site's hEDS strengthening protocol, 2-3x/week with a PT familiar with hEDS 2-3x/week, PT-guided
Without PEM, the existing strengthening approach applies as published: build stability without adding range past what can be controlled.
Keep strengthening sessions shorter and less frequent than a non-PEM hEDS patient would use, and treat any sign of a crash the following day as the stop signal to scale back further Individualized, well under your known energy envelope; stop and scale back at the first sign of delayed worsening
This is the exact reconciliation point between 'build stability' and 'never push through PEM.' A crash the next day is not a sign to push harder, it is the stop signal.
Apply kinesiology tape to unstable joints for proprioceptive feedback, either way As needed, taught by a PT familiar with your joint pattern
Taping gives sensory feedback that supports joint-position awareness, independent of the pacing question above.
Joint-protective strengthening (closed-chain, low-range, proprioceptive work) is genuinely helpful for hEDS joint stability.
View sources
Strategies for POTS Relief with Dr. Satish Raj (Bendy Bodies ep 125)
About Dr. Linda Bluestein
Not medical advice. This page is for education only and is not a substitute for professional medical care. Consult a qualified clinician before changing your health routine.
Independent curation. YourProtocol is an independent platform. This protocol is based on the publicly available work of Linda Bluestein, MD and is not created, reviewed, endorsed by, or affiliated with Linda Bluestein, MD or Hypermobility MD / Bendy Bodies.
Is this for you
- Hypermobile EDS patients who also have ME/CFS, POTS, or PEM
- Anyone told to just 'build strength' who crashed after trying to follow a standard exercise plan
- Not for a fixed, escalating exercise program of any kind if PEM is present
Cautions
- Informational only, alongside a physical therapist familiar with hEDS and, if PEM is present, a clinician who understands post-exertional malaise
- Never a fixed, escalating exercise schedule if ME/CFS, POTS-related PEM, or any PEM presentation is present
- A crash the day after exertion is the stop signal to scale back, never a sign to push through
- Educational only, not medical advice
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