Hip Hinging: What, Why and How?

Hip hinging is a very powerful movement that our bodies can do, that allows us to bend, lift, squat, and even climb up stairs and hills. Learning what a hip hinge is and how to do it well helps us to move more efficiently, minimize pain and injury, and enhance our fitness routine.

What is a hip hinge?

A hip hinge is essentially any movement that involves… well, hinging at the hips! Typically, it refers to a movement in the sagittal plane (forward and back plane) that allows the flexing at the hips (creasing the fronts of the hips), and subsequently extending the hips (opening the fronts of the hips). Rather than the movement being initiated at the spine, knees, or elsewhere, the movement pattern is initiated at the hips.

The hips are a ball and socket joint, as the joint is the union between the socket provided from the pelvis (acetabulum) and the ball from the thigh bone (head of the femur). So hip hinging must involve motion relative to the ball and socket, typically the socket of the pelvis rolling forward and back over the ball from the thigh bone.

Examples:

Many daily movement patterns, as well as exercises that one might perform, involve hip hinging. Here are some examples of hip hinging:

• Sit to stand: The act of getting up and down from the chair involves hinging at the hips, as to sit, the hips must flex, and to stand, the hips must extend.  

• Deadlift: Lifting and lowering a weight from the ground using a hip hinge

• Squat: Sitting the hips back and down as knees bend, standing back up by thrusting hips up and forward

• Step up: Single leg hip hinge involving putting one foot onto a step or platform which hinges the hip, and stepping up by extending through the hip/knee. 

• Kettlebell swing: Holding a kettlebell with both hands, hinging at the hips to send the kettlebell back and down, extending powerfully through the hips to send the kettlebell out in front 

• Sun salutations in yoga: A yoga practice is full of hip hinging. A traditional sun salutation, that involves going into a forward fold, lifting half way up, coming up to standing, etc involves a lot of hinging of the hips.

Why is it important?

Hip hinging uses the strongest, most powerful muscles in the body. This includes the gluteals, the hamstrings, the erector spinae, and the abdominals. Powerful coupling between these muscle groups helps create high levels of force, allowing us to move ourselves efficiently and lift heavy objects without injury. For this reason, getting to know how to hip hinge, and using hip hinges very often during daily activities and within a fitness regimen is an excellent way to stay strong and powerful.

Try these at home:

Here are several common cues that I use to teach people how to hip hinge-

• “Buns in the oven”:  Stand about 6 or so inches in front of a wall, facing away from the wall. Pretend the wall is an oven. Send your buns into the oven by sending your bottom back to touch the wall (hips go back, or hips are flexing, as your upper body leans forward. Once your bottom can feel the wall, pause. You are in a hinged position. Come back to standing by taking your buns out of the oven (hips go forward, hips are extending).

• “Roll the roller”:  Stand with a foam roller against your upper thighs. Roll the roller down your thighs by sending bottom back. Come back to starting position.

• In kneeling: “Sit back towards your heels”: Knees on a kneeling pad, sit hips back towards heels as hands reach forward. Return to starting position.

• Step ups: “Pull the thigh back”: Put one foot on a step or stool. Lean forward slightly. Step up, pulling the thigh back. Lower back down to starting position.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Images:

https://orthoinfo.aaos.org/link/6e0531e00f714f43a2cb1f93fae0e762.aspx

Trouble Committing to your PT “Homework”? You’re not Alone!

The benefits of physical therapy can be immense, but only when one is an active part of the healing process. The learnings, lifestyle suggestions, and exercises taught by the provider are not confined to the clinic, but must seep into the rhythms of one’s day to day life. Otherwise, the time spent in physical therapy can be fruitless, or at least not as effective as it otherwise might be. Afterall, the time in the clinic only makes up a small fraction of one’s life. What one does outside of the clinic is up to the individual.

Why do so many have trouble bringing these practices home? The most common reasons are lack of time, lack of confidence in one’s own abilities (known as self-efficacy), lack of understanding of or agreement with the recommendations from the PT, the PT giving “too much” homework, forgetfulness, or simply being stuck in one’s habits with difficulty inviting changes to a fixed routine. Additionally, the desire for a “quick fix” to one’s pain or injuries, and subsequent disappointment with the realization that PT is an ongoing process and not an instant cure, can often set up a substantial barrier.

How do we address these barriers?

Establish a Commitment to Oneself

In order for PT to be effective, one must fully commit. The commitment goes beyond simply showing up for scheduled appointments. The commitment must involve willingness to have an open-mind, take on an active role in one’s healing, learn new things, willingness to invite in the new and to say goodbye to what is no longer serving.

Before scheduling a first appointment, one might ask themselves, “Am I willing to fully commit to this? Why or why not?”

A Strong Therapeutic Relationship

As PT is a two-way street, a strong relationship between provider and patient is necessary. This means the ability to engage in deep communication: active listening and responding. As a patient, one must communicate their needs, and be open to suggestions provided by the therapist. 

If the patient feels that their needs are not being met, or if they are not understanding the suggestions provided by the therapist, they must make this very clear. For example, if one feels that their PT is giving them too much or too little homework, the patient must communicate this. That way, the two can work together to find a program that best fits the needs of the patient.

It is critical that a patient feels a sense of trust and connection with their therapist. Without this, the therapy is built upon a weak foundation, and it will likely be ineffective. Without trust, the patient will not trust the therapist’s suggestions, and probably will not follow through.

Check out our previous blog post to learn more about what goes into a strong therapeutic relationship.

Self-reflection

Throughout the process of PT, the therapist will help guide the patient towards desired goals. The patient must also continuously engage in a process of self-reflection to ensure they are continuing to commit to an active role in therapy.

Here are some questions a patient could ask themselves throughout the process:

• How and when am I going to do it?
  - ”It” refers to the suggestions and exercises from the PT
  - Establish a firm time and place to carry out the homework

• Why am I doing this?
  - Focus on the “why” can help provide motivation. Why is this worth doing?
  - Remind yourself that you are doing it to better yourself, your health, well-being, comfort, etc. Or to become a better person for those that you love.
  - Remember your goals for PT, and write them down

• What is going to get in my way?
  - What are the barriers? Is it time, space, commitments to other people?
  - How can you address those barriers?
  - If it is forgetfulness or lack of understanding, work with your therapist to find what helps you with this. This might be the PT sending reminder emails, taking detailed videos of the exercises, or it could be self-reminders by putting sticky notes up at home or in the office, keeping track of your exercises in a journal, or creating events/reminders in your calendar. 

When challenges are faced, it is important to be kind to oneself. Every moment of every day is a chance to begin again, re-focus, and re-prioritize this commitment to oneself.

Having a “PT journal” is a helpful tool to keep track of one’s commitment, intentions, progress, as well as for keeping a record of exercises completed and other provided interventions. This could be a very casual notebook, scratch paper, or the “notes app” on one’s phone. 

Here is an example of a tool that someone might use. Start by printing out several blank templates of the days of the week, perhaps divided into AM and PM. You could write what you intend to do in each blank, and give it a ✅ upon completion (or only write in the log once you have completed the activity).

After the initial effort of implementing a new practice into one’s routine, after around three weeks, one might find that it no longer takes as much discipline, and one might even look forward to these practices as the benefits become more clear. New habits take a while to fully form. Many have heard from pop psychology that new habits take 21 days to form. However, evidence shows that this is a myth, because the formation of habits is dependent on MANY factors. Generally, the most “simple” an activity is, and the more obvious the reward is (e.g. like drinking water every day), the quicker that habit will form.

On average, habits take about 66 days to form, after which they become “second-nature” or effortless.¹

The best way to create this new habit? Have an external cue (e.g. a sticky note) to perform an activity in a consistent context (e.g. a space in your home), and repeat it. Again and again and again. Perhaps the same time every day. Eventually it will become automatic.

At The Wellness Station, we aim to create a close, trusting therapeutic alliance. We seek to provide learning experiences, so the patient feels “on-board” with the process. We recognize the inherent challenges in this process, and are compassionate towards those who are having difficulty. Through close communication, your therapist will help to address any barriers throughout the therapeutic process, and together you and your therapist will steer the ship in the direction of your choosing.

Summary/Key Points

• Physical therapy is a process that is guided by your therapist, but requires the patient to have an extremely active role

• This involves a commitment from the patient to follow the suggestions from the provider, and to work together with the provider to address any barriers that come up relative to home practice 

• The working relationship between the provider and patient must be built on trust and deep communication. 

• As a patient, one should ensure they are fully committed by asking themselves why they are doing PT, what might get in their way, and how they will respond to these challenges along the way. 

• Strategies to help improve participation in the home program might include having a PT Journal for self-reflection as well as for a log of exercises.

• Additionally, have an external cue, such as sticky note reminders around the home or office, which provide visual cues to practice exercises. Or perhaps creating calendar events to practice could also be a solid reminder system. 

• After consistent practice of an activity in a particular environment, the habit will become automatic and effortless, which takes an average of 66 days (though could be much sooner or later). 

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505409/

Takeaways from Glucose Revolution

For anyone who has not yet read Glucose Revolution: The life-changing power of balancing your blood sugar, it is most definitely worth the read. It was written by a French biochemist, Jessie Inchauspé, and is the holy grail for anyone hoping to learn a little more about nutritional biochemistry.

Inchauspé provides background information about how what we eat and when we eat it can trigger glucose spikes, in which the amount of sugar in our blood goes up very quickly. Over time, many glucose spikes can be taxing on our organs, our mental and physical health, and can put us on the road towards serious health issues. Even if we have not been diagnosed with diabetes or prediabetes, chronic spiking of glucose can negatively impact our health, well-being and our waistlines.

The chronic spiking of glucose can lead to insulin resistance, chronic inflammation, atherosclerosis (and related heart events), as well as weight gain.

The book does not suggest dieting, as going on diets is often unsustainable. If we choose to restrict what we eat, we will often experience the “yo-yo effect”, in which we temporarily deprive ourselves only to drain our will-power and eventually return to our old ways.

Rather than dieting, if we are hoping to improve our health for the long-term, we must change the relationship we have with nutrition and exercise to be evidence-based, more enjoyable, and strategic.

How does this relate to physical therapy?

More glucose spikes means more inflammation. More inflammation means more irritated tissues, which leads to more pain. Excess weight also leads to inflammation, as well as increased biomechanical forces on joints, both of which contribute to pain. So, by improving our relationship to nutrition, we decrease inflammation, maintain a healthy weight, thereby making us less vulnerable to pain and unwanted strain on our tissues.

Takeaways

Here are the four takeaways that have stuck with me the most, and that I tend to recommend most often to clients who are hoping to enhance their blood sugar regulation.

Don’t “Diet”

If you’re on a “diet”, it is likely unsustainable. Consider asking yourself the following question: “Is the way I’m eating now sustainable?” Or “Could I see myself eating like this for the rest of my life?” If the answer is no, you probably would benefit from adjusting your mindset relative to what you are eating. Restricting calories or certain foods is likely temporary, and as soon as you stop doing it, your weight will likely bounce back to what it was before the restriction.

It is helpful to consider more the relationship you have to food and nutrition. To learn how to make decisions about food based on the best available information. To not deprive yourself of calories, but rather focus on nourishing your body with healthy, whole foods. Move away from counting calories, and towards counting how many different fruits and vegetables you eat in a week.

Seriously, try it. Over the course of a week, write down every single fruit and vegetable you eat. If you eat a banana seven times, this only counts as one, as I am referring to different fruits and veggies. At the end of the week, what is your number? Aiming for 20-30 per week is a great place to be. If you’re nowhere close to that, no worries! Try again next week.

“Dress” your Carbs

Ever wonder why taking medicine on an empty stomach might not be a great thing? Or perhaps drinking alcohol? When the stomach is empty, there is no buffer, and whatever you ingest has a quicker, stronger effect on your cells. Same thing with carbs: if you eat something that is high in carbs, particularly refined carbs (e.g. white bread, pasta, rice) or sugar (desserts) on an empty stomach, this will lead to a very high glucose spike.

Consider a green starter to each meal, which means having a vegetable before the carb. Or “dress” your carbs with fats, proteins, and fiber. The glucose spike from eating two pieces of white bread would be far higher than a sandwich with two pieces of white bread with avocado, greens, tomatoes, and a protein source in between. Better yet, choose whole wheat bread, as the fiber will also slow down the glucose spike.

Move After Eating

In the post-meal state, when the glucose is first starting to spike, your body is trying to figure out what to do with it. Is it going to go to the liver for long term storage? Is it going to go into the fat cells? How about the muscles? If you move a bit after eating, your muscles will start to soak up the sugar to use as energy, rather than going into fat cells. 

This doesn’t have to be intense exercise. Simply walking for five or ten minutes after a meal will help to decrease the glucose spike by sending the glucose into the muscles instead of the fat, which can be very helpful for weight management over time.

Apple Cider Vinegar (ACV) is your Friend

Vinegar can help decrease glucose spikes. This is particularly helpful if the vinegar is taken about 20 minutes before consuming something that could potentially spike glucose. It is important to only have a small amount, 1 - 2 tablespoons, and to dilute it.

As the taste of vinegar can be vile, I like to make an ACV tonic, which I drink a couple times per week. Here is the recipe:

• 1 - 2 tablespoons organic raw ACV (maybe start with 1)

• Liquid stevia to taste, or other natural zero-calorie sweetener (no sugar, as this will negate the effects!)

• 1/4 tsp cinnamon (or keep cinnamon sticks in the bottle of ACV)

• Big squeeze of lemon

• 8 oz water

• Mix it up, apple sliced and/or lemon wedge optional for garnish

Enjoy!

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Befriending Your Unwanted Habits

If we didn’t have habits, life would be really difficult. All of us have developed patterns of moving, thinking, and behaving that become deeply ingrained in our nervous systems, like well-carved out ski slopes during peak season. These patterns are represented in our brains as neural networks, or interconnected brain cells that fire together to create our ways of being. The brain creates these networks to ensure efficiency. Without these networks, we would have to start from scratch every single day with clean slates, no skills, and no purposeful movements available to us, like a newborn baby.

As we go through our development, we learn a heck of a lot. In fact, by the time we are adults, our 100 billion neurons can form over 100 trillion synaptic connections! We continue to learn as we grow older, although our brain does go through certain critical periods, making it more or less responsive to learning certain types of information throughout various parts of our lives. This is why it is so much easier to learn a new language as a child, as early childhood is the critical period for language development. Our youth is also a time where we develop many of the neurological patterns that define who we are, what we do, and how we think.

When it comes to movement, our repertoire tends to shrink as we grow older, and we are more likely to move in a less variable, more confined way, which gives rise to challenges with mobility in our later years. We are more likely to fall back on the same patterns again and again, and less likely to expand our horizons.

While the learning process is extremely adaptive and helpful for our ability to engage in life, our learning can also lead to undesirable habits and patterns. For example, imagine that you grew up in the north with a very questionable heating system. Whenever winter would come along, you might bundle up in a few coats, and find yourself shivering and hiking your shoulders up towards your ears more often than you might like.

The more time you spend generating tension in your shoulders, the more of a habit it might become. So later on, even if you move down south, you might have the learned habit of tensing up the shoulders, particularly during times of increased stress. This can impede the natural movement and flow of your body, and might contribute to strain on the tissues and chronic discomfort.

We all have our bodily habits. Whether it’s hiking up the shoulders, clenching the jaw, craning our necks forward during computer work, tensing the pelvic floor, holding our breath during exercise, only crossing the same leg on top while sitting, or countless others. What these habits have in common are that they are learned, persistent, and undesirable- and, they may have served us some helpful purpose in the past. That’s why they exist.

Sometimes we don’t even notice these habits until someone else points them out- a family member, a friend, a physical therapist. Sometimes the habit is completely innocuous and may or may not be associated with something undesirable. If in fact the habit is truly undesirable, e.g. it relates to unwanted strain on a tissue, is associated with discomfort, etc., then we are likely trying to change the habit. How do we do this?

Building Awareness

The first step of creating change is awareness. If you do the habitual behavior 100 times per day, and only notice it one time, this is not enough. Performing mind-body practices regularly such as Feldenkrais lessons, yoga, tai-chi, mindfulness meditation, etc. will help to develop the ability to become more aware.

In everyday life, a reminder system must be developed. One must become aware of the situations and environments in which the undesired habit is most likely. Does the habit show up the most frequently at the computer? While driving? In the kitchen? Wherever the habit is likely to show up, consider bringing a visual cue into the area, such as a brightly colored sticky note. The sticky note could be blank, have a small symbol to remind you to cease the habit, or a few words or short phrase, such as “exhale”, “relax your shoulders”, “smile”, etc.

During the activities that are most likely to trigger the habit, consider a very short body scan, perhaps right before starting the activity, sometime during, and immediately after. Say that you are going to do desk work for one hour. Right before you begin, sit down, get comfortable. Close your eyes. Ask yourself if you are comfortable. Ensure that your breathing is nice and relaxed. Scan your attention throughout your whole body, particularly the area where the habit might show up. Maybe this takes 15-30 seconds. Continue on with your task, but do the same thing half way through, and again after finishing the task.

Respond with Kindness

When you inevitably notice that the habit is happening, change how you respond to it. It is very easy to become frustrated with yourself- “What’s wrong with you, why can’t you stop doing that!”. This is an unhelpful strategy, as it creates unnecessary frustration and suffering around the habit. Instead, have a chuckle. “There you go, tensing your shoulders again like it’s freezing! No need- you are safe and comfortable.” This is making friends with your habit. Your habit is there for a reason, and by being kind to yourself, you are more likely to develop a better relationship with it.

Purposefully Move the Involved Tissues

And finally, when you notice the habit arising, perform some movement that helps to relax and change the tension in the area. For example, if the habit is hiking your shoulders up, here is a movement sequence you can try. Start by raising and lowering both shoulders, towards and away from your ears, as if your shoulders are two rising elevators. Then, let one shoulder shrug up as the other goes down, like two elevators going in opposite directions. Finally, begin to circle both shoulders up, back, down and around. This can become both shoulders making circles, but at opposite phases of the circle, so as one shoulder is up the other is down (like two ferris wheels going side by side). Perhaps you spend no more than a minute on these movements, and then return to whatever task you were engaging in.

By implementing these you will begin to create more instances of noticing the habit, and changing how you respond to it to be that of kindness, as well as an active movement-based strategy to change how your nervous system communicates with the involved muscles.

These strategies can greatly decrease the frequency and impact of the habit, and can facilitate the creation of new habits! The nervous system will begin to choose less stressful and more efficient movement patterns, which can eventually replace or minimize the influence of long-term, inefficient movement patterns. Over time, the new patterns can become automatic. While the old habits may never disappear completely, you will find it comes up less often, you will notice when it happens more often, and it will lead to overall less distress and discomfort.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Images:

https://online-learning-college.com/wp-content/uploads/2022/04/Neurons-and-synapses-scaled.jpg 

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Jill’s Journey Through Back Pain: A Case Study Part II

In the previous blog post, we introduced Jill and described her journey with back pain. Now we will discuss more specifically the approach we used to help her navigate this complex situation. 

As the Wellness Station is a holistic practice, Jill’s plan of care was based on the biopsychosocial approach. This means that our care integrates factors related to biological/tissue structure and function, as well as psychological and social factors. Our approach is inspired by the Feldenkrais Method of somatic education, as well as therapeutic yoga, mindfulness, and traditional physical therapy.

(For further understanding of the biopsychosocial approach to pain, check out the following two previous blog posts: Does How You Think About Your Pain Affect Your Pain? & A Holistic Approach to Pain Science)

Bio

In collaboration with Jill’s referring provider, we made sure that Jill was managing pain most effectively with the lowest possible therapeutic doses of medications with the least potential for adverse effects. Jill’s goal was to get off medications for good, as she did not want to rely on them over the long term for pain management. 

We also ensured that Jill was consuming a nutritious, whole-food diet to support an internal environment conducive to healing (she adopted an anti-inflammatory diet similar to the Mediterranean diet). 

The bulk of our treatment approach focused on movement patterns that were likely putting additional strain on the injured tissues. Jill was extremely sensitive to bending movements, as well as prolonged sitting. Using biomechanical principles, we broke down patterns of spinal flexion and extension necessary to bending and lifting, and provided opportunities for neuromuscular learning- new strategies of bending that felt more comfortable, efficient, and less stressful on Jill’s back. This generally involved keeping Jill’s center of gravity over her base of support, sending her hips back to counterbalance her reach, and lifting objects with the strongest muscles of her core and legs.

Jill began to practice picking objects up in her daily life using new techniques, and eventually picked up her two year-old granddaughter in her new and improved way! 

We also provided education about posture and the importance of changing position throughout the day, especially during prolonged sitting. Jill found that a children’s ball placed behind her back in her chair was incredibly helpful for back support, as well as performing small, regular movements of her pelvis, hips, and spine known as the pelvic clock. 

See How Your Spine Moves Part I and How Your Spine Moves Part II for some ideas on what Jill learned here.

Psycho

Psychologically-informed care was necessary for Jill’s treatment approach. The grief from the loss of her husband was affecting her more than she cared to admit. She also recognized that a fear of aging and loss of confidence in her own body’s resilience contributed to a sense of hopelessness. Addressing these factors allowed Jill to further align with her goals, and she was able to instill a sense of self-compassion into the rhythms of her day. Combined with education on the psychology and neuroscience of chronic pain, as well as a daily practice of mindfulness meditation, Jill was able to insert a mindful influence on her pain. She recognized that by shifting the way she thought about her pain, her back, and the active role she could have in her own healing, she was able to take control of the situation more effectively. This helped her body and mind to begin to function more as one.

See Mindfulness and Movement for more of an idea on how we integrated mindfulness and self-compassion into Jill’s therapeutic care.

Social

Without others, we are lost. By creating a strong therapeutic alliance, Jill and I were able to work together on an even playing field. Unlike previous therapies she had been to in which an authoritarian figure prescribed what she should do for her back, Jill and I collaborated as a team, along with her physician. This feeling of support improved Jill’s confidence in her providers, as well as in herself as a necessary member of the team.

See Enhancing the Therapeutic Alliance for more information on the importance of the relationship between the patient and the provider.

We also addressed Jill’s social life and relationships with others. We encouraged her to seek support from her daughters and her friends. Jill began to feel more comfortable asking for help. She also began to go on regular walks with her friends, which she realized was very helpful for her back and much more enjoyable than walking alone. 

A Whole New Jill

Clearly, Jill’s issues were not just in the tissues. The tissues in the back are part of a living, breathing, thinking, feeling, moving organism. Any persistent pain or mobility challenge is multifactorial. Throughout the healing process, the biopsychosocial approach was taken in order to holistically Jill’s issues.

As mentioned previously, Jill is now back to rowing, walking with her friends, strength training with weights, and playing on the floor with her grandchildren!  This has further motivated her to continue to stay active and improve her life and her movement capabilities. She feels that she has gotten her life back!

“In the last eight months, I have shared my experiences with friends and shown them some of the simple movements. I have traveled, concerned I would re-herniate a disc. Not. That truly felt like success. I now know that this process takes time and patience but it is well worth the investment.”

Jill will occasionally experience instances of increased pain. However, these instances are drastically different from the flare ups of the past. They are far less frequent and less severe, and do not bother Jill as much emotionally. She also has much more clarity as to why the flare ups are happening, based on what she has or has not been doing.

Jill no longer sees pain as the enemy, but rather as an informant that helps to guide her actions. She recognizes that pain is inevitable for us all, but how we believe and behave relative to our pain can make all the difference.

Jill has the tools to manage and diagnose how to treat her pain, and she still does a monthly check in at The Wellness Station for support and for a review of movements and techniques.

Jill had an extremely active role in her healing journey, which will be a gift that keeps on giving for the rest of her life.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Images: 

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