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/

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: 

https://onlinelibrary.wiley.com/cms/asset/fb4cbd45-725d-45ae-a745-df734fa89f6b/jabr12125-fig-0002-m.jpg

https://images.everydayhealth.com/images/diet-nutrition/mediterranean-diet/mediterranean-diet-food-list-meal-plan-722x406.jpg 

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

Who Is Jill?

When Jill first presented to the Wellness Station, she described her life as “a mess” and felt skeptical that another attempt at physical therapy would make any kind of difference. Jill is 75 years old and had stayed generally active with outdoor rowing and exercising with weights. However, Jill has experienced recurrent bouts of debilitating back pain over the last 15 years, which tended to set her back for quite some time. She had been to physical therapy several times, which never made any long-lasting difference for her.

Jill was having an extremely challenging year. She had become more sedentary during the pandemic, as she did not feel as comfortable working out with her personal trainer. She lost her husband, her lifelong best friend. On top of this, her sister also lost her husband around the same time.

While at her sister’s house to support her both emotionally and physically and to re-organize their house, Jill suffered a severe back injury. A herniated disc in her lumbar spine became sequestered, and the sequestered disc fragment led to nerve compression. Jill began to experience severe back and leg pain, which was constant and severe. She had herniated several discs in the past, and she described this pain as far worse.

Jill went through a course of traditional physical therapy and described it as follows:

““It was very modest stuff. I felt like there wasn’t much of a progression, and it wasn’t as individualized as I would have hoped. They might have used the same printable exercises as any other old lady with back pain!” ”

Jill Finds The Wellness Station

Jill was referred to the Wellness Station four months after her sequestration injury, and was still experiencing constant, debilitating pain. In coming to the Wellness Station, Jill hoped for improvement but wasn’t sure what to expect. Her goals were to improve her fitness and build her core strength in order to be active, independent, and play with her grandchildren- however, she was beginning to lose hope that any of this would be possible.

““In the first session, I found Jacob Tyson to be an exceptional listener as I outlined my back pain history, the recent event and goals. The room was calm as was his demeanor that set a relaxed tone.””

““I still was puzzled in the first few sessions that focused on just a few movements or exercises to establish what is called the pelvic clock. But at each weekly session, the new movements built on the previous week, a method I could appreciate as a former newswriting instructor, teaching the basic journalism language and incorporating more concepts and practices as students learned newswriting style.” ”

Jill Turns the Corner, & Beyond! 

As we worked together over the course of weeks to months to a year, we gradually progressed Jill’s home exercise program by introducing new movements, slightly more challenging than the week before. We continued to layer on educational and lifestyle components that were related to Jill’s life, including concepts of biomechanics, anatomy, exercise physiology, psychology, mindfulness, pain neuroscience, and more.  As Jill continued to learn and build her strength and confidence, she has been able to do more demanding physical tasks without any increase of pain.

“ “Through the sessions, I learned how to stand up and walk in new ways, to use my legs and tailbone to shift weight, to improve the flexibility of my entire spine—all aimed at relieving the pressure and weight on the lumbar part of my spine. We also did relaxation and simple meditation to promote mind-body connection. After each session, I received an email, summarizing our activity. I have compiled all those exercises and support into a file that I can use to refresh my memory of exercises—and to see my progress.” ”

““The knowledge and movements I learned gave me a feeling of accomplishment and control over the mechanics of my body. Usually an exercise or stretch would relieve the pain, and I did not take any medication. A triumph!” ”

Jill is doing much better today, and feels that she has gotten her life back. She no longer feels limited by her pain, and feels empowered to stay active and engaged in life. She is now back to rowing (weather-permitting!), going to the gym twice per week, and having no trouble lifting her quickly growing grandchildren!

Jill also improved on the Modified Oswestry Disability Index (a survey used to measure the impact that back pain has on quality of life) from a 58% to a 12% over a period of six months, which is over four times the threshold of clinically significant improvement. 

Stay tuned in to see our next blog post, which will break down more specifically what we addressed with Jill biologically, psychologically, and socially.

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

Images:

https://www.safetyandhealthmagazine.com/ext/resources/images/2019/10-oct/back-pain.jpg?t=1568903562&width=768

http://balanced-movement.com/2019/02/17/controlling-pelvis-hips/

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Yoga: Like Flossing for your Joints!

For our whole lives, we participate in a daily practice to ensure the health of our teeth, as it is obvious that tooth decay is extremely undesirable. Neglecting dental hygiene can lead to issues far beyond affecting that beautiful smile on your face, including infection, as well as compromised gut and heart health. In order to ensure dental health, we brush and floss daily, and visit the dentist two times per year. We have accepted this as the gold standard practice, and dental hygiene becomes almost an unconscious part of our lives.

What about our joints? We have over 200 of them in our body, and without them, we would be unable to move. Each of these joints desperately need movement, compression, and relaxation in order to stay healthy, mobile, and well-lubricated. Unfortunately, we have an epidemic of poor joint health that is on the rise. In fact, around a quarter of US citizens have arthritis (an inflammatory disease of the joints), and the prevalence of knee osteoarthritis has actually doubled since the mid-20th century.1 This is contributing to extreme rises in healthcare costs, risky surgeries, chronic disability, and unnecessary pain and suffering. Poor joint health is also associated with many other health conditions- depression, cardiovascular disease, stroke, and metabolic conditions such as diabetes.2 There are many theories as to why the incidence of this disease is so high- increasing weight, sedentary behavior, as well as the overall aging of our population. However, there is little discussion about how to address the root cause of this disease through education and prevention.

Why is there not more education about how to keep our joints healthy as we go through our lives? My main takeaways from gym class growing up were pretty much as follows: how many sit ups and chin ups can I do in a minute in order to "perform well" on the presidential fitness test, as well as how quickly can I run a mile in order not to embarrass myself around my peers? However, there was absolutely no discussion of joint health in any of my education up until physical therapy school.

What joints need is movement- movement that goes behind repetitive gym exercises, walking, and running. As joints do not have great blood supply, they are completely reliant on us moving our bodies through our given ranges of motion in order to distribute the lubricating synovial fluid around the joint space. As we move and load our joints through their given ranges of motion, we develop an improved mind-body awareness that helps us control the force we put through each joint through our body's posturing and muscle recruitment/relaxation. By regularly moving each joint, we also build up our injury resistance to both chronic and acute injuries. For example, if you never practice moving your ankle inwards, and then you accidentally trip over a root during a hike that forces your ankle into an inward position, you will be far more likely to sprain this joint compared to someone who regularly practices moving and loading their ankle in this position.

One might be thinking…."Are you telling me that in order to have to have healthy joints, I have to move each and every one of them every single day?? This sounds like a lot of work… I already have enough on my plate, especially with how often I am supposed to floss my teeth!"

Luckily, even a brief mindful movement practice such as yoga can help ensure your joint health! A yoga practice has the potential to move every joint and engage every muscle in your body in a relatively short, continuous sequence. And, you will naturally start to use what you learn on the mat in your daily life as well, perhaps without even meaning to! Rather than a chore, a yoga practice can be fun, and make you feel more comfortable and strong in your body. Yoga can be an excellent supplement to whatever else is in your fitness routine that can actually improve your performance in other athletic endeavors as well.

Written by: Jacob Tyson, DPT - Physical Therapist and Yoga Instructor

References:

1. https://www.pnas.org/content/114/35/9332

2. https://pubmed.ncbi.nlm.nih.gov/31207113/#:~:text=The%20key%20comorbidities%20associated%20with,to%20have%20other%20chronic%20conditions.