More Than Just Bendy Joints: Understanding Voice and Swallowing in Hypermobile Ehlers-Danlos Syndrome
- SpeechAppeal
- 10 minutes ago
- 8 min read
When most people think about hypermobility, they think about joints.
They picture someone who can do the splits without trying, bend their thumb back toward their forearm, or place their hands flat on the floor without bending their knees.
In many cases, these abilities are treated as interesting party tricks or signs of being “double-jointed.” But for some people, these differences in flexibility are part of a broader pattern involving how their connective tissue supports the body.
One possible explanation is Hypermobile Ehlers-Danlos Syndrome (hEDS).
While hEDS is often recognized because of joint hypermobility, connective tissue is found throughout the entire body. It provides support and structure to many systems involved in movement, breathing, speaking, singing, and swallowing.
What often surprises people is that the same connective tissue allowing someone to touch the floor with ease also helps support the systems responsible for speaking, singing, and swallowing.
Hypermobility Is About More Than Flexibility
Collagen is one of the body’s primary structural proteins. It helps provide strength, support, and elasticity to connective tissues throughout the body.
In hEDS, connective tissue may be more flexible than expected. This can allow joints to move beyond their typical range, but the effects are not limited to the joints themselves.
When passive support from connective tissue changes, the muscles often take on more of the work of controlling movement, maintaining alignment, and providing the stability the body needs.
Sometimes these adaptations are incredibly effective.
Sometimes, over time, they can contribute to fatigue, discomfort, or movement patterns that require more effort than expected.
The voice is no exception.
Speaking is a highly coordinated process involving breathing, vocal fold vibration, resonance, articulation, posture, and timing. It does not depend on one muscle or one structure working alone.
When the system has to create stability differently, the muscles involved in voice production may also adapt. For some people, these adaptations allow the voice to function well. For others, they may contribute to a voice that feels more effortful, unpredictable, or tiring over time.
Hypermobility is often described as “having more flexibility,” but that only tells part of the story.
A more useful question is how the body creates stability.
When passive support changes, the body often responds by changing coordination. Sometimes these adaptations are helpful. Sometimes they become more effortful over time.
Voice and swallowing symptoms can be different expressions of the same system responding to different demands.
Why Speaking Can Feel More Effortful
One of the challenges with voice symptoms in hEDS is that the voice may sound completely typical to other people while feeling very different to the person using it.
Someone may find themselves thinking, “Why does talking feel exhausting when my voice sounds fine?”
Many people with hEDS describe feeling as though speaking requires more effort than it should. They may notice changes in endurance, vocal reliability, or how their voice feels after extended use.
The voice does not operate in isolation from the rest of the body.
Stress, illness, pain, sleep, fatigue, reflux, and overall physical demand can all influence how efficiently the voice functions.
For a body that already relies on increased muscular coordination to create stability, these additional demands may become more noticeable.
This does not mean the voice is failing.
It means the system is responding to changing conditions.
Common Voice Symptoms Associated With hEDS
Voice experiences vary from person to person, but some individuals with hEDS report symptoms such as:
Vocal fatigue after prolonged speaking
Reduced vocal endurance
Hoarseness or changes in vocal quality
A voice that feels weak, strained, or less reliable
Frequent throat clearing
Feeling like speaking requires extra effort
Changes in singing range or vocal flexibility
These symptoms can fluctuate. A person may notice their voice feels easier on some days and significantly more effortful on others.
Understanding these patterns can be an important part of assessment. Rather than looking at the voice as an isolated structure, clinicians consider how factors such as physical fatigue, pain, stress, respiratory patterns, and overall coordination may influence vocal function.
Swallowing Is Also a Coordinated System
Swallowing is another process that requires remarkable precision.
Every swallow involves timing between the muscles of the mouth, throat, airway, and esophagus. It depends on strength, sensation, coordination, and the ability of different structures to work together efficiently.
Because connective tissue contributes to the support and movement of these structures, some people with hEDS experience swallowing-related concerns.
Some individuals with hEDS also experience dysphagia (difficulty swallowing), which may present as food sticking, coughing during meals, or increased effort during swallowing.
Other experiences may include:
Difficulty initiating a swallow
Fatigue during meals
Coughing or throat clearing while eating or drinking
A sensation of a lump in the throat
These symptoms do not occur in everyone with hEDS, and they can have many possible contributing factors.
For some individuals, swallowing concerns may exist alongside other symptoms such as reflux, gastrointestinal difficulties, autonomic changes, or differences in muscle tension.
This is why looking at the whole person matters. A single symptom rarely tells the entire story.
When swallowing concerns occur, a Speech-Language Pathologist can help assess the different factors involved and determine what strategies may improve comfort, efficiency, and safety.
Therapy Is Not About Making the Body Work Harder
One of the biggest misconceptions about rehabilitation is that improvement always comes from strengthening or pushing harder.
For many people with hEDS, the goal is not simply to increase effort. The goal is to improve efficiency.
Voice therapy focuses on helping the different parts of the vocal system coordinate with less unnecessary effort. This may include exploring breathing patterns, resonance strategies, vocal fold coordination, and techniques that make speaking feel easier and more sustainable.
Approaches such as Resonant Voice Therapy, Flow Phonation, and Semi-Occluded Vocal Tract exercises can help some individuals explore more efficient ways of producing voice.
The goal is not to force the voice into a particular pattern. The goal is to understand how the system is currently working and identify opportunities for greater ease.
Swallowing therapy is similarly individualized. Depending on a person’s needs, therapy may focus on strategies that support swallowing coordination, pacing, posture, breathing patterns, or comfort during meals.
Because every person’s experience with hEDS is different, there is rarely a single approach that works for everyone.
Effective therapy considers the person’s symptoms, goals, communication demands, and daily life.
Singers and Professional Voice Users
For singers and professional voice users, changes in vocal efficiency may become noticeable sooner.
Teachers, performers, actors, healthcare professionals, lawyers, and other high-demand voice users rely on their voices for extended periods every day. Small changes that might go unnoticed during casual conversation can become much more apparent during professional use.
For singers, this relationship between flexibility and stability can be especially interesting.
Some singers with hEDS may have access to notes or vocal colours that others find difficult. They may experience characteristics that feel like a gift:
An unusually large vocal range
Exceptional vocal flexibility
Ease moving between registers
Unique vocal qualities
However, flexibility alone does not always equal stability. These same singers may still struggle with consistency, recovery, or endurance. The characteristics that allow for increased movement may also require greater coordination to maintain reliable vocal performance over time.
A singer may have the ability to access impressive vocal extremes while still experiencing fatigue, slower recovery, or inconsistent performance over longer periods of singing.
This can be especially frustrating for performers because their voice may feel unpredictable. A note that was effortless one day may require significantly more effort the next.
Voice therapy and voice training are not about limiting what the voice can do.
They are about helping someone understand their instrument, recognize patterns, and develop strategies that allow their voice to meet the demands placed on it in a sustainable way.
Singing voice therapy may involve improving awareness of vocal effort, exploring more efficient coordination, adjusting vocal load, and building confidence in what their voice can reliably do.
Connecting the Pieces
Because hEDS affects connective tissue throughout the body, many people benefit from a collaborative approach to care.
Depending on their symptoms and goals, individuals may work with physicians, physiotherapists, occupational therapists, dietitians, ENTs, and Speech-Language Pathologists. Each professional contributes a different perspective.
For voice and swallowing, an SLP can help explore how these differences are affecting communication, vocal function, swallowing, and daily activities.
Sometimes symptoms that seem unrelated begin to make more sense when viewed as different expressions of the same underlying system.
The goal is not to focus on one isolated symptom. It is to understand the relationship between the different systems involved and identify strategies that support greater comfort and function.
Final Thoughts
Hypermobility is often described by what the body can do.
But for many people with hEDS, the more important question is how the body manages that movement.
Voice and swallowing are both examples of highly coordinated systems. They rely on precise timing, stability, and communication between many different structures.
When connective tissue, stability, and muscle activity interact differently, these functions may also require different strategies.
Your voice is not separate from your body.
It is one of the many ways your body adapts, responds, and communicates.
Sometimes the goal isn’t changing your voice. It’s finally understanding why it has been working so hard in the first place.
At SpeechAppeal, we regularly assess complex voice and swallowing presentations and can help identify patterns that may be contributing to communication difficulties.
With the right support, speaking, singing, and swallowing can become more comfortable, sustainable, and aligned with the demands of everyday life.
SpeechAppeal
SpeechAppeal is a Canadian online voice & speech therapy clinic serving adults & older teens across Toronto & Ontario. To learn more about SpeechAppeal and the services we provide, visit www.speechappeal.ca
If you’re in Ontario and would like to explore more personalized options for improving your voice and communication, book a free Online Meet-and-Greet.
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References and Further Reading
Birchall, M. A., Lam, C. M., & Wood, G. (2021). Throat and voice problems in Ehlers-Danlos syndromes and hypermobility spectrum disorders. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 187(4), 527–532. https://doi.org/10.1002/ajmg.c.31956
Malfait, F., Francomano, C., Byers, P., Belmont, J., Berglund, B., Black, J., Bloom, L., Bowen, J. M., Brady, A. F., Burrows, N. P., Castori, M., Cohen, H., Colombi, M., De Backer, J., De Paepe, A., Fournel-Gigleux, S., Frank, M., Ghali, N., Giunta, C., Grahame, R., … Tinkle, B. (2017). The 2017 international classification of the Ehlers-Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), 8–26. https://doi.org/10.1002/ajmg.c.31552
Sharma, A., Bryson, P. C., & Adessa, M. (2024). Laryngological symptomatology in patients with Ehlers-Danlos syndrome. The Laryngoscope, 134(2), 894–896. https://doi.org/10.1002/lary.30852
Williams, H. R., Wood, G., Hakim, A. J., Birchall, M., & Hirani, S. P. (2023). Self-reported throat symptoms in Ehlers-Danlos syndromes and hypermobility spectrum disorders: A cross-sectional survey study. Laryngoscope Investigative Otolaryngology, 8(5), 1259–1264. https://doi.org/10.1002/lio2.1120
Yan, K., Hou, D., Bolden, L., Laing, J. R., & Berke, G. (2025). Laryngeal manifestations of Ehlers-Danlos syndrome. Journal of Voice, 39(3), 752–756. https://doi.org/10.1016/j.jvoice.2022.10.018
