Tag: Lumbar Spine

Importance of the Hip Hinge

Hip-Hinge-Graphic

Previously, I wrote about how bending down towards the floor is commonly used during daily movement and somehow mistakenly has also been utilized as a self-stretch. Hopefully the last article I wrote helped you appreciate how, when done repeatedly, bending down towards your toes can lead to lumbar symptoms. (You can find that article : here). I offered a suggestion regarding how performing a hip hinge is an appropriate substitute for bending through your back, and also mentioned how there are more safe ways to stretch as well. Below, I am going to describe the hip hinge and how to correctly perform the movement. As for the previous comment about more safe ways to stretch, more on that later.

I like the hip hinge for several reasons. The hip hinge is purely a sagittal plane movement through the hip joint which helps engage the posterior chain (glutes and hamstrings), which often is weaker due to anterior chain dominance (i.e. quads). Best and perhaps most importantly of all, the movement spares the spine and prepares you for several activities of daily living and is a good precursor/injury prevention tool for more athletic movements. We already know that the typical low back patient moves excessively through their low back during daily activities; but learning how to hip hinge effectively is a movement pattern that can assist the cervical spine patient who looks down too often, the anterior knee pain patient with inhibited glutes and hamstrings, and our elderly patients who need help transitioning from sit-to-stand.

Physical therapists and patients alike will tell you, learning how to correctly perform a hip hinge and then incorporating it into daily activities is easier said then done. Because most people have already trained their body to move a certain way, often times re-programming to move a different way, even though it’s more beneficial, is a foreign concept.

I have found that the most effective way to coach this movement is with the proprioceptive input gained from using a dowel rod. Having the dowel to help learn the movement provides the patient with the neural feedback to assess the movement and be more aware of inconsistencies when practicing correct form.

Here are the coaching tools I use to teach the hip hinge:

hip-hinge-with-stickStep 1: Utilize the stick to create 3 points of contact: 1)Occiput, 2)Thoracic Spine, 3)Sacrum

Step 2: Keep a slight bend in the knees with feet slightly wider than shoulder width apart

Step 3: Engage your transverse abdominis and gluteal region (teaching points on how to do these actions will have already been instructed)

Step 4: Hinge forward—push butt back and keep chest up

The spine should remain neutral throughout the entire movement and the knee should not bend excessively either. 

Hip Hinge to Save Your Spine

Somewhere along the way, bending down to touch your toes became a criteria for demonstrating appropriate levels of flexibility and also an essential movement for avoiding back pain in the mind of many individuals.

Often times when taking a subjective history of a patient, I have heard the phrase, “touch my toes” and whether they can, can’t, or have had a change in their ability to do that particular task.

back

I realize that being flexible is essential to being able to move through ranges of motion unrestricted and pain-free. And maybe because people seem to think it is ok to bend down and touch their toes as a form of stretching, it is also ok to perform this movement, repeatedly, to complete their daily activities. This isn’t the case. There are safer ways to stretch and safer ways to perform specific activities. (More on both of those in the coming weeks).

Yes, sometimes I have patients bend down in the clinic. Bending down to touch your toes, when used for assessment purposes, can help identify movement impairments. Gray Cook introduced The Selective Functional Movement Assessment (SFMA) and this movement based diagnostic system utilizes multi-segmental flexion (toe touching) as a movement pattern for those with known musculoskeletal pain. So that is not to say that we avoid the movement in the clinic completely. However, we must make it clear that assessment is not exercise and prescribing (or failure to correct) faulty movement can only lead to further injury.

So what about bending down (lumbar forward flexion) is undesirable? To reference Stuart McGill, lumbar forward flexion, even in the absence of moderate load will lead to discogenic troubles. A fully flexed position leads to strained posterior passive tissues and high shearing forces on the lumbar spine (from both reaction shear on the upper body and interspinous ligament strain). His lab work has shown this to be a good way to cause disc herniations.  I read an analogy of lumbar flexion and a credit card that helps illustrate the point. If you take a credit card and bend it back and forth repeatedly, it would eventually damage and/or break. That damage doesn’t occur from a single bend, but rather a series of bends over and over.

Now consider the various activities throughout our day that might tempt us to bend through our back. There are plenty— such as wearing shoes/socks or bending down to pick an object up from the floor.

A safe alternative that I think is essential in helping to avoid injury is a hip hinge. By bending at our hips (rather than the spine), we are able to keep the spine neutral and avoid the risks of repetitive bending done daily.

Correctly performing a hip hinge, however, is easier said that done. It takes more effort, can be more time consuming, and often requires coaching and cuing to be done correctly. In my next post, I will give a short description on how to perform a hip hinge.

Do This, Not That!

Have you seen those, “Eat this, not that!” articles as it relates to nutrition, weight loss tips, and health news?

Let’s apply that principle to exercises.

How many physical therapists, personal trainers, or coaches have had their athletes do the Superman exercise? How many of us do this exercise ourselves?

The “Superman” exercise is one that I remember doing well before I started PT school in 2008. I still see it done at the gym on a frequent basis. I remember being told it is a great way to exercise the muscles that support the spine, so I understand why many people still do the exercise. At the time, I didn’t think about what biomechanically is going on with the exercise and whether it was safe to do.

The Superman exercise is when you lie on your stomach and lifts both arms and legs up to train the spinal extensors, gluteal muscles, and secondary muscles as wellsuperman-core-exercise. According to Stuart McGill, who is an expert on low back disorders, the Superman exercise creates nearly 6000 N of compression to a hyperextended spine, transfers the load to your facets, and crushes the interspinous ligaments (You can see all his work in his book: Low Back Disorders: Prevention and Rehabilitation). Simply put, it’s really bad for your back when done repeatedly. For perspective, the National Institute for Occupational Safety and Health (NIOSH) did research and testing regarding the maximum disc compression levels that your back can safely tolerate. They found that level to be 3425 N, or about 770 pounds of force.

If we do some simple conversions knowing that 1 newton = 0.22 pounds, than we see that the Superman exercise at 6000 Newtons is equal to 1349 pounds of force to the lumbar spine. That exercise exceeds the safety guidelines by nearly 600 pounds of force!

So what to do? A core exercise that I think is challenging, but also more safe is the forearm plank.

ab-plank-2x3

Although I haven’t seen research on the levels of compression during a plank, Dr. McGill has found that the side plank creates a force of about 581 pounds to the lumbar spine, and being in a push-up position leads to 413 pounds of force. The more traditional plank is listed under one of his advancements of the side plank exercise, so I am inclined to believe it is still well below the 770 pounds of force noted by the NIOSH to correlate with risk of back injury.