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This blog is a compilation of fun and functional facts about the muscles which control and move the hip. Presented here are concepts around anatomy, muscle synergies and changes to muscle function which occur with pathology, specifically OA. There is also a review of the current knowledge and details that drive our decision making around exercise prescription for retraining hip strength, particularly hip extension, abduction and external rotation strength. 

A REVIEW OF THE ANATOMY

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MUSCLES WORK IN SYNERGY GROUPS

NOT ONLY ABOUT THE GLUTES!

An article was recently published by Benn, et al (2018) talking about the functional anatomy of adductor magnus. This article highlights that hip extension is not all about GMax and BF and that AddM might play an important role in stabilisation and counter forces at the hip. They describe two functionally specific portions. 
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  1. The upper portion is involved in hip extension and adduction and some ER.
  2. The lower portion is involved in hip extension, adduction and internal rotation.
  3. Both loose adduction force production as hip flexion increases.
Many studies looking at hip extension muscle moments only talk about gluteus maximus and bicep femoris. Hardly ever is adductor magnus a clinical consideration. 

CHANGES IN MUSCLE SIZE WITH PATHOLOGY

There are 2 Grimaldi articles talking about muscle changes in hip OA and provoking us to think about functional units within the muscles. These articles tell us about which muscles are likely to be affected by hip OA and where we can target our treatments. 

CHOOSING EXERCISE POSITIONS BASED ON MUSCLE BIAS

Bridges are used to strengthen hip extension and are important for bed mobility and preceed functional tasks such as sit-to-stand and kneeling. Kang, Choung & Jeon (2016) found that as hip abduction angle increases from 0 to 15 to 30 degree, there is an increase in GMax activation and reduction in anterior pelvic tilting and erector spinae muscle activity. Bridge with increasing hip abduction increases GM and decreases BF and ES (kang, Choung & Jeon., 2016). 
Prone hip extension (PHE) is often used to assess hip extension strength and provided as a rehabilitation exercise.
  • Jeon and colleagues (2016) found that when PHE is performed off the edge of a table with the moving leg held at 90 degrees knee flexion, GMax activation is promoted over biceps femoris.
  • Kang et al (2013) found that as hip abduction angle increases in PHE (0 to 15 to 30 degrees) increases, there is an increase in GMax activation over biceps femoris.  Therefore, if you want to increase hamstring muscle strength in this exercise, 0 degrees abduction is recommended, whereas if you want to increase GM activity, then 30 degrees abduction is recommended. 
  • Chance-Larsen, Littlewood & Garth (2010) found that knee angle during the PHE changes muscle activation i.e. with the knee extended the hamstrings are far more likely to activate before and more than GMax. 
Clams are used to target GMax and strengthen hip external rotation. Koh, Park & Jung (2016) found that providing visual feedback in the form of watching the ASIS of the topside hip allows for patients to perform the clam movement without pelvic rotation, which increases gluteal activation and accuracy of performance. 
Hopefully this blog has provoked you to think a little more about the tests we used for hip strength (bridges, side lying abduction, clams) and which muscles they are truely targeting. When teaching these movements, remember to ask your patient where they feel the muscle contraction to ensure they are feeling the correct location. 


Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams.

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REFERENCES

Benn, M. L., Pizzari, T., Rath, L., Tucker, K., & Semciw, A. I. (2018). Adductor magnus: An EMG investigation into proximal and distal portions and direction specific action. Clinical Anatomy.
Chance-Larsen, K., Littlewood, C., & Garth, A. (2010). Prone hip extension with lower abdominal hollowing improves the relative timing of gluteus maximus activation in relation to biceps femoris. Manual Therapy, 15(1), 61-65.
Crossley, K. M., Zhang, W.-J., Schache, A. G., Bryant, A., & Cowan, S. M. (2011). Performance on the single-leg squat task indicates hip abductor muscle function. The American journal of sports medicine, 39(4), 866-873.
Grimaldi, A., Richardson, C., Stanton, W., Durbridge, G., Donnelly, W., & Hides, J. (2009). The association between degenerative hip joint pathology and size of the gluteus medius, gluteus minimus and piriformis muscles. Manual therapy, 14(6), 605-610.
Grimaldi, A., Richardson, C., Durbridge, G., Donnelly, W., Darnell, R., & Hides, J. (2009). The association between degenerative hip joint pathology and size of the gluteus maximus and tensor fascia lata muscles. Manual therapy, 14(6), 611-617.
Grimaldi, A. (2011). Assessing lateral stability of the hip and pelvis. Manual Therapy, 16(1), 26-32.
Jeon, I. C., Hwang, U. J., Jung, S. H., & Kwon, O. Y. (2016). Comparison of gluteus maximus and hamstring electromyographic activity and lumbopelvic motion during three different prone hip extension exercises in healthy volunteers. Physical Therapy in Sport, 22, 35-40.
Kang, S. Y., Jeon, H. S., Kwon, O., Cynn, H. S., & Choi, B. (2013). Activation of the gluteus maximus and hamstring muscles during prone hip extension with knee flexion in three hip abduction positions. Manual therapy, 18(4), 303-307.
Kang, S. Y., Choung, S. D., & Jeon, H. S. (2016). Modifying the hip abduction angle during bridging exercise can facilitate gluteus maximus activity. Manual therapy, 22, 211-215.
Koh, E. K., Park, K. N., & Jung, D. Y. (2016). Effect of feedback techniques for lower back pain on gluteus maximus and oblique abdominal muscle activity and angle of pelvic rotation during the clam exercise. Physical Therapy in Sport, 22, 6-10.
Retchford, T. H., Crossley, K. M., Grimaldi, A., Kemp, J. L., & Cowan, S. M. (2013). Can local muscles augment stability in the hip? A narrative literature review. J Musculoskelet Neuronal Interact, 13(1), 1-12.
Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther, 43(2), 54-64.

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Another great infographic from Brad Beer on instagram. Helpful to share for your runners or athletes who may be overtraining. 
View this post on Instagram

[STRESS FRACTURES] ๐Ÿ‘ฃ⚡️ _ ‼️Bone stress fractures are not to be missed ‼️ _ ๐Ÿ‘‰๐ŸปThere can be a high recurrence rate (ie tibial stress fractures have a 600% risk of recurrence) and some forms of lower limb bone stress injuries can be dangerous and very serious (eg femoral neck) ๐Ÿ– ๐Ÿƒ‍♂️๐Ÿƒ‍♀️ - ๐Ÿ‘‰๐ŸปSometimes runners with bony stress injuries present late for physio – sometimes weeks after the onset of their pain and symptoms ๐Ÿ˜ฉ _ ๐Ÿ‘‰๐ŸปI hope this post can improve awareness of when a runner may have a stress injury that can become (or might already be) a stress fracture๐Ÿ‘Ÿ _ ๐Ÿ‘‰๐ŸปHere’s 5 signs that you may have a bony stress injury or stress fracture _ ๐Ÿ“ŒTAKE HOME: if you suspect a bone stress injury of your lower limb be wise and get it checked by a health professional ๐Ÿƒ‍♀️๐Ÿƒ‍♂️ _ ‼️If you know a runner this can help please tag them in ✋๐Ÿป _ ❓Q’s are welcome . . . #physio #physicaltherapy #run #running #runner #rehabilitation #run #runner #running #sportsscience #marathon #marathontraining #tendontuesday #triathlon #ultrarunning #trailrunning #trackandfield

A post shared by Brad_Beer Running.Physio ๐Ÿƒ‍♂️ (@brad_beer) on




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Keeping it Eclectic...

Reidar Lystad and colleagues in 2011 published a critical systematic review entitled, “Manual Therapy with and without Vestibular Rehabilitation for Cervicogenic Dizziness: A Systematic Review”.  I say it is critical because of the following conclusion,
There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potential synergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.
I highlighted a particular important outcome of the systematic review in bold above.  Basically, just 7 years ago (at time of writing this blog), we do not have the highest level of evidence telling us we should perform vestibular rehabilitation on patients diagnosed with Cervicogenic Dizziness!
In the era of evidence-based practice, we know this is just one leg to Sackett’s stool; but can’t deny the power of a systematic review!
One thing we point out in our Cervicogenic Dizziness Course is if you delve into this review, you will note that there are no studies that indicate use of Vestibular Rehabilitation in Cervicogenic Dizziness, therefore, of course the evidence is lacking!

Cervicogenic Dizziness, Cervical Vertigo
http://www.iccseminars.com

Over the years as medicine and practice knowledge grew, we have been able to add onto this statement with a Randomized Control Trial, a Retrospective Chart Review and an Exploratory Study  Even though only three articles, this is better than none back in 2011!  This was exposed in a recent article in 2018 entitled,“Vestibular Rehabilitation Therapy Improves Perceived Disability Associated with Dizziness Post-Concussion” to express there is level 2 and level 3 evidence supporting the use of vestibular rehabilitation to treat patients suffering from dizziness post-concussion.
I would also add, even though not specific to post-concussion, Jaroshevskyi’s work in 2017 finding the following conclusion:
The multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability.
The last study is one I want to bring to light and expose that ultimately, to achieve maximal therapeutic benefit, we CAN’T limit ourselves to just performing manual therapies OR vestibular rehabilitation for a complex disorder such as Post-Concussion Dizziness, Cervical Vertigo or Cervicogenic Dizziness.
We should, and need to, continue to blend the two specialities so patients can achieve the best of the best treatments to maximize recovery, decrease symptoms, and return to sport.
This is why Drs. Vaughan created the Physio Blend for treatment of Cervicogenic Dizziness — it is the most researched and skillful approach to tailor to these complex cases.
If you are a Vestibular Therapist wanting to learn specific manual therapies or a Manual Therapist wanting to learn vestibular rehabilitation for your patients, this is the course for you.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

- Via In Touch PT Blog

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...


How often do you challenge your patients with heavy lifts? What about if your patient is pediatric? Do you have them lift heavy things? Why wouldn't you?


 
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Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Andrew Rothschild at Modern Patient Education.


Keeping it Eclectic...


The Motion Guidance is one of my favorite tools for rehab. Using visual feedback on the grid or with some of their newer tools is a great way to restore motor control.


If an insurance company can find a way to deny a claim, they will. If another carrier should be paying for the claim, it will most likely be denied, forget medical necessity! What happens when a worker's compensation claim patient, gets hit by a motor vehicle while at work? The Worker's comp, motor vehicle insurance by the driver, plus the private insurance of the patient - all the same company!

Subscribe to Untold Physio Stories
Search for Untold Physio Stories on your favorite music/podcast apps!  

Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Andrew Rothschild at Modern Patient Education.

Keeping it Eclectic...



____Start of thought experiment:

Imagine, for the sake of a thought experiment, that you could instantly clone your body as an exact replica, where you would then have version A and version B of yourself. In this world you can also rewind time, and create a version B of a person, at the moment before something bad happens to them (although the rules are A has to continue and meet their fate).
You have a patient with right knee pain. It is severe, and started 7 months ago. The patient subjective notes they had started increasing their daily walking a little in preparation for some travel about 7 months ago, and this is around the time the knee started to bother them. They endured their travel, but the pain only worsened after 2-3 months. The deep medial knee pain started to be felt with almost all activities, and the tissue was even tender to touch all around the area.
The patient received imaging noting radiographic knee OA, limited medial space and osteophyte formation. The patient is now seeking help as the pain is not getting better, and the prognosis does not sound great. But they would like to avoid surgery. They also saw a prior therapist, and they brought in a few evaluation papers. The previous therapist jotted a long list of things, but the sum of it revealed that their gait catered to the stresses of the medial knee, that they had a weaker glut medius, and that the right L1/2/3 facets were “stiff” 
Because this story takes place in the aforementioned world, we decide to create a version patient B at 9 months ago, a few months prior to pain onset. At the time of replication, we instruct them that their other self (patient A) was about to acquire severe knee pain over the next 9 months. We talk to patient B about a strategy to avoid this. This includes a more careful increase in walking as to help the knee adapt to changes in load and frequency, additional strength exercises to toughen the tissues, and some unloaded light aerobic exercise (cycling) for joint health and circulation.
Return to the present and patient A and patient B are now sitting together in the same room, for a consult.
The pathway that patient B took was successful. Patient B’s knee was doing just fine. Patient A is on the brink of surgery. At this moment it seems especially relevant, in light of patient B’s condition, to ponder of patient A, what is the cause of their pain?
 Is it the tissue morphological change at the medial condyles? Was it the travelling, and the walking? Is it “bad knees” or genetics? Was it that gait and those shoes? Or possibly the health of the L2/3 nerve root under it’s “stiff” environment? Is it a structural problem? Is it a tissue problem?
The only true answer must accommodate the existence of patient B, sitting there in the same room in no visible discomfort, who hadn’t given a thought to their right knee in the last 9 months. In fact, patient B reported that his left knee was aching a little bit! It could have been the cycling last week, they mused.
 _________ End of thought experiment.
 It is recommended that patients receive a diagnosis. The suffering is in the not knowing why the pain is there. We need to be able to answer the question why is my (enter body part here) hurting like this. And, it has also been recommended that the patient can describe this explanation to their family as well.
 Can we give an answer that accommodates for a previous version of that patient, in a different iteration, having the same body part without a complaint of pain? Lots of findings can be, and are relevant to pain. But it is difficult to say that they’re causative. And which findings are still present for patient B, at that awkward cloned patient consult? Picture anything you say to patient A, patient B chiming in “hey I have that too, why doesn’t my knee hurt???” That may leave you fumbling for explanations.
Even if the findings of Patient A that do differ from Patient B, (likely non structural) for all we know all the “findings” that are revealed after examination of patient A may just be how they are presenting because of the pain, and because of the last 7 months of pain. Not causative, but simply related to a limb functioning under the influence of pain.
If we can tie the onset of pain to a series of events that have to do with all sorts of tissue response (how tissue responds to load, strain, stress, sleep deprivation, overtraining, undertraining etc.)… we can view the pain as a phenomenon that happens when X amount of variables are met. We don’t have a patient B to act as an example, as a “see, its possible to exist in a better state, under the majority of your individual circumstances.” How the tissue is acting, isn’t necessarily reflective of how the tissue is, how it can be, or how it could have been otherwise.
Regarding causes, patients will get loads of answers from loads of professionals. Many of these professionals might get the same person better with their best approach to “their answers,” while many may fail to get the same person better.
The example above used knee pain, but I think this type of experiment and thought processes are even more relevant toward something like back pain. Something I’ve thought of recently is, how can I best frame an explanation and plan for said pain problem, that doesn’t take a strictly deterministic approach and that leaves the door open to returning to their “patient B” state while having the patient take an active approach in rehab to return to their pain-free version of themselves. Part of this is viewing pain as a reaction to a specific set of variables in the environment, and not necessary a product of its environment. In this sense, pain is a more fluid phenomenon, and is malleable for better or for worse under any set of conditions (this applies to tissue of great integrity and tissue of poor integrity). Through the course of rehab, laying out the variables and influences on pain, as well as options to address these variables and revert them to their best condition (patient B), might be a good way to frame it.
Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...