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/

Back Away From Knee Pain and Balance Issues: Walk Backwards!

Most of us are aware of the benefits of walking for a plethora of physical and mental health conditions. Walking is a necessary part of life for most people, and is what allows us to engage with the world around us. Walking allows us to explore our environment, is an excellent opportunity to spend time outdoors with our loved ones, and allows us to maintain healthy bones, muscles, hearts, lungs, and brains. 

When we think about walking, we are unlikely to consider walking backwards. However, walking backwards comes with a host of additional benefits, as it allows us to use our bodies and minds in a different way.

Here are some ways that backwards walking might help you:

May Help with Knee Pain

When you move backwards, whether it is walking, running, or going down the stairs, it reduces the compressive stress at the patella-femoral joint (the knee cap) as compared with moving forwards. This is based on the biomechanics of the movement . You might notice that when you go down stairs forwards, especially if you have a sore knee, that the increased bending of the knee required to go down the stairs forwards could further aggravate an irritated knee. Go down the stairs backwards, and this completely changes the forces on the knee!

Be sure to do this only after practicing on the first 2 lowest stairs, becoming very confident and comfortable with what can be quite disorienting at first.

Many clientele might enjoy going on walks, but notice that the further they walk, the more it bothers their knees. Especially when walking down hills. For these individuals, walking backwards might allow them to walk further and more comfortably!

Be absolutely sure of the terrain as you walk backwards, appreciate that this is challenging to your neuromuscular system at first)

A six-week study comparing a forwards and backwards walking program for individuals with knee osteoarthritis demonstrated that the backwards walking group had significantly reduced knee pain, increased quadriceps (front of thigh muscle) strength, and physical performance compared to the forwards walking group.

Improved Balance

Walking backwards has been shown to improve stability and improve balance performance for those at increased risk of falling. Why might this be? Practicing backwards walking may help to improve posture for those that have difficulties standing more upright. 

Additionally, our balance is controlled by many systems of the body, including vision, the vestibular system (inner ear), and the somatosensory system (sensory nerves). When we are walking backwards, we rely less on our vision (unless we have eyes in the back of our head!), and more on the other senses.

We must pay closer attention to the sensations from our feet on up in order to walk backwards, rather than relying on looking with our eyes at the ground with each step. If you alternate taking a step forward, and then backwards, compare the sensations in your feet – quite intriguing!

This can improve our spatial awareness and coordination, which enhances our balance and reduces our risk of falling.

Mindfulness and Awareness

Walking backwards is a practice in mindfulness and self-awareness. When we walk forwards, we are much more likely to go into auto-pilot, which in neuroscience is referred to as the default mode network. The little person in the control room (our brains) could be” reading a magazine” while we walk forwards, as we have been doing this our whole lives and it has become very automatic.

Walking backwards allows you to become more present with every step, rooting your attention in the here and now. This can be helpful for anxiety, as it produces a state of calm and presence. By shifting out of auto-pilot, we create new neural pathways and are more likely to experience learning and cognitive enhancements.

It is a neurophysiological fact that when we reverse a common function, we improve the skill level of that particular activity!

How To Implement Safely

When beginning to walk backwards, the most important thing is safety. Start at the kitchen counter: keep a soft hold on the counter, and practice switching between walking forwards and backwards.

Next, one could try walking throughout a room in the house, free of clutter.

Walking backwards on a treadmill is also an often. It is important to turn the speed down to the minimum, and hold on to the handrails to ensure safety. Try alternating between a minute of forward and a minute of backward walking, repeated in sets for as long as desired.

Walking backwards outside is also an option, but caution must be taken. One might start by only trying this when walking with someone else, who can serve as your eyes. Make sure you are in a clear path, free of oncoming traffic and obstacles!

The whole walk need not be backwards. One could mainly walk normally, but could try intervals of backwards walking (e.g. a minute at a time, 40 steps at a time, etc.) There is one area of my neighborhood walk that is about two blocks long, rarely has any cars, and has ample sidewalk and grassy areas. Whenever I get to this, I switch to walking backwards, which has become quite an enjoyable experience.

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

References:

https://pubmed.ncbi.nlm.nih.gov/30967128/

https://www.sciencedirect.com/science/article/abs/pii/S0966636218312906 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213492/

Images:

1. https://domf5oio6qrcr.cloudfront.net/medialibrary/5549/c0e7e791-3078-4cc0-8ded-2dbdf50c8cc8.jpg

2. https://content.health.harvard.edu/wp-content/uploads/2021/08/2fce081c-32bc-41e6-8f41-e85c78546c84.jpg

3. https://www.researchgate.net/publication/304906544/figure/fig4/AS:1086726726524941@1636107250352/Estimation-a-and-performance-b-of-the-walking-backwards-balance-task_Q320.jpg

4. https://media.wired.com/photos/59d6b0874dec4e4689be1b32/master/pass/mindfullness-FA.jpg 

Balance Part II: Strategies for Improvement

Last month, we discussed factors that control and impact our balance. Consideration of these factors can help us become more aware of what to do to stay safe and prevent falls, as well as targeted exercises to improve our balance that are based on scientific principles.

How do we improve our balance and prevent falling?

If we recognize the influence that the physiological, psychological, and environmental factors have on our balance, we can be strategic in how we improve our balance and decrease our risk of falling.

• Stay active, making sure you are keeping your muscles strong and healthy for life. Have a movement practice that incorporates functional strengthening and balance challenges.

• Enhance your somatosensory system by regularly stimulating your feet. Think of your feet like antennas that provide messages to your brain about your balance. Massaging your feet with balance pods are a great way to keep the nerve endings responsive. 

  Consider more time spent barefoot, especially during balance exercises. This will allow your feet to feel the ground and your toes to spread out, creating wider points of contact with the ground. In daily life, consider shoes with a thinner, more flexible sole, and a wide toe box.

• Ensure you are taking care of your eyes and vision by regularly visiting an ophthalmologist. Make sure you use a nightlight when going to the bathroom at night, and remove any trip hazards from your path.

You could also consider the role of vision to challenge your balance during exercises. Notice that keeping your gaze stable on an object in front of you helps your balance. Moving your eyes around will make balance more challenging. Closing your eyes will make it the most challenging!

Recall in Balance Part I, we discussed how being overly reliant on vision can contribute to a stooped posture, as many people will look down to the ground with their whole body rather than just with their eyes. When walking, practice looking down with just your eyeballs as needed to see the ground in front of you, rather than with your whole self. If you had a light shining from the tip of your nose, and a light from your chest bone, you should be able to maintain these lights at the level of the horizon while walking, rather than keeping the lights cast downwards. 

• Make sure your vestibular system is healthy, and recognize the impact that vertigo, seasickness, and certain medications can have on your balance.

Likewise, you can progress your balance exercises by introducing changes in your vestibular system. If standing on one leg has become easy, can you do it while slowly turning your head from side to side, or up and down? 

• Optimize your environment: Make sure your environment is conducive to not falling! If icy sidewalks, crowds, or uneven trails are not for you, make sure you modify appropriately, perhaps bringing an assistive device or a loved one to help you stay steady.

You can also use the environment to improve your balance, by intentionally walking on trails and standing on uneven or “squishy” surfaces.

• Train your balance… but don’t overshoot it! A mistake many people make while training their balance is going past their edge. If standing on one leg consistently leads to excessive wiggles, wobbles, and you are unable to find your steadiness, then you are simply practicing being unsteady, rather than practicing finding steadiness. You want to be close to your edge, without going over it!

Find an exercise that feels moderately challenging, but you are able to find steadiness and ease with practice. If not, modify the activity to make it more or less challenging. Standing at the kitchen sink, by the counter, in the corner of a room, or in a door frame are excellent places to practice balance, as you have the option of supporting yourself with your arms as needed. 

By finding this edge and achieving success with practice, not only can we improve the physiological components of balance, but we can also improve the confidence we have in ourselves, thereby decreasing our fear of falling and subsequent risk of actually falling!

Follow along with this video, which incorporates seven balance exercises and strategies, “Feldenkrais style”! It instructs in balance challenges including standing and walking with a narrow base of support, closing the eyes, getting up and down from the floor, dynamic weight shifting, and practice with “falling”. Best to do this video near something to hold on to as needed. 

At the Wellness Station, we can help you recognize and make changes in the factors that could be impacting your balance. We will provide you with individualized recommendations and movement lessons to help you improve your balance, your confidence in yourself, and your ability to continue to do what you love.

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

Exercise and Chronic Pain: A Guide

It is well known that exercise is an extremely beneficial activity that can elicit substantial improvements in many different measures of health, well-being and fitness.

Exercise is a broad category, as there are many different types and manners in which exercise can be carried out. (See Movement, Physical Activity, & Exercise blog for more information.)

There are many factors to consider when determining what kind of exercise might be best for an individual. These individual considerations might include health conditions, fitness level and experience with exercise, injuries, goals, cultural factors, socioeconomic status, access to safe spaces to exercise, personality, and the existence of chronic pain. One size does not fit all when it comes to exercise.

At the Wellness Station, we provide holistic care based on the biopsychosocial model, which takes these differences into account to create individualized movement programs.

 Can Exercise Help with Pain?

Pain is an extremely complex, subjective experience, it is difficult to apply generalizations to this topic. That being said, exercise can be extremely helpful for individuals with chronic pain for several reasons.

• However, individuals with chronic pain may become more physically inactive which may be due to fear-avoidant behavior (they may avoid movement for fear of triggering their pain), depression, or many other reasons.

• Inactivity can make chronic pain worse, as the tissues of the body will become deconditioned, inflammatory processes may increase, and weakened tissues may become more likely to be irritated and strained from acute stressors.

• Exercise, when performed appropriately, can have tremendous health benefits for all individuals, those with chronic pain included. Engaging in intentional exercise can help improve metabolic, cardiorespiratory, and musculoskeletal functioning, and also triggers the release of endogenous hormones (endorphins) that help us to feel good and decrease our sensitivity to pain.

• Exercise can improve the confidence we have in ourselves and in our painful body parts, which can also help with our experience of pain. This confidence helps us feel empowered to make positive changes, and less limited by fear of movement.

• Targeted exercise can help to nourish tissues with fresh blood and nutrients and  improve tissue strength and resilience.

It is clear that exercise is helpful for pain both directly and indirectly, but one must consider how exercise might be applied differently for someone experiencing chronic pain compared to an individual using exercise solely for fitness gains.

An Exercise Program with Chronic Pain: Factors to Consider

 The interventions chosen at the Wellness Station are highly individualized, as the intervention will depend on the unique characteristics of the individual.

• The individual will be encouraged to be generally more active in physical activities that are enjoyable and do not trigger pain.

• If the activities (such as walking) do trigger pain, it is a matter of changing the movement patterns involved in the activity. Often, people with chronic pain experience a pain pattern during specific activities because they have adopted compensatory, stressful and inefficient movement patterns. Unless these patterns of movement change, the pain cycle may continue. It is our job at the Wellness Station to identify these movement patterns and help you to change them.

• In addition to changing movement patterns, we can also make changes in the parameters of the activity (including the frequency, intensity, or duration of the activity). For example, engaging in several shorter walks throughout the day rather than a longer walk, if long walks trigger pain.

• The individual will learn not to push into pain, as this oftentimes will reinforce the pain pattern, contributing to flare ups. Rather than pushing into pain, the individual should learn how to listen and respond to the pain, as pain is your body’s way of communicating information to you. Contrary to the popular mentality of “no pain no gain”, “it’s got to hurt to be effective” when it comes to exercise, if you want exercise to be helpful for your pain you must take a different path.

• The movement program should also include specific, intentional practices that directly and/or indirectly involve the affected body area. If low back pain is the problem, the movement program will most likely involve the low back, whether that is performing movements that improve mobility, strength and control of the low back, or perhaps improving the movement capacity of a related body area (e.g. mid back or hips) to help spread out the forces of movement over more of the body. Engaging with the involved body part in this way is helpful not just biomechanically, but also psychologically, as it will improve the confidence you have in this area.

• The movement program for an individual with chronic pain will likely be progressive, meaning it will increase in complexity over time, but the progressions will often be much more gradual than a program that is more oriented towards fitness gains. The parameters of the program and the decision to progress will be based on evidence of neuromuscular learning, comfort, and effect on the pain pattern. By contrast, progressions for a program solely for fitness would likely be based more on the subjective challenge of the activity (e.g. it begins to feel too easy).

Enhance your Fitness for a Better Life

Physical fitness can be described as the ability for all body systems to work together in order for us to maintain health, and perform daily tasks with ease. Strength, balance, agility, cardiorespiratory endurance, and body composition are all components of fitness. It is extremely important for all of us, including those of us with chronic pain, to maintain our fitness through exercise. As we age, it becomes harder to maintain our fitness, as our muscle mass and bone density begin to fade unless we regularly strengthen ourselves. Maintaining and enhancing our fitness will help us stay independent, active and involved in the activities we love, while helping us avoid falls, fractures, metabolic diseases, and more. Pain is often a huge barrier that discourages people from exercising, so addressing the pain as described above can contribute to improvements in fitness overtime.

At the Wellness Station, we use movement to empower people with and without chronic pain to take control in order to live happier, healthier lives.

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

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461882/ 

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491894/ 

Images:

1. https://www.google.com/url?sa=i&url=https%3A%2F%2Finfo.totalwellnesshealth.com%2Fblog%2Fhealth-benefits-of-exercise&psig=AOvVaw0KPsdxcnvlolwFghH6x8EG&ust=1684769413131000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCKCqnqXdhv8CFQAAAAAdAAAAABAE
   

2. https://www.google.com/url?sa=i&url=https%3A%2F%2Fideas.ted.com%2Fwhy-does-running-give-you-a-high-heres-the-science%2F&psig=AOvVaw0h_TBiHHi9tLdGwBevnH9O&ust=1684769936466000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCIDL357fhv8CFQAAAAAdAAAAABAE

3. https://www.google.com/imgres?imgurl=https%3A%2F%2Ffivepointswashington.org%2Fwp-content%2Fuploads%2F2020%2F09%2Fseniorfitness.jpg&tbnid=yQpghkq9LHrOSM&vet=12ahUKEwi07LL534b_AhWxcTABHXGjAm0QMygTegUIARCTAg..i&imgrefurl=https%3A%2F%2Ffivepointswashington.org%2Ffitness%2Fsenior-fitness%2F&docid=xr2IfmIC2ir36M&w=500&h=334&q=senior%20fit&ved=2ahUKEwi07LL534b_AhWxcTABHXGjAm0QMygTegUIARCTAg