The hip joint is vulnerable in people with physical disabilities, but varied movement and activation of the muscles around the hip joint can be beneficial from an early age. Here are lots of suggestions for great things you can do, with particular emphasis on the hips.
We’re delighted to welcome the two Swedish physiotherapists Malin Larsson and Hanna Bengtson, as guest bloggers on the subject of hips. They’ll be addressing the following topics in a three-part series of articles:
- Part 1 – Why do hip problems occur, and can they be prevented?
- Part 2 – The hip is slipping out of place – so what do we do?
- Part 3 – Things we can do to benefit hip joint development
Malin Larsson and Hanna Bengtson run the weyoume.se website, an information site for parents of children with disabilities.
Here comes our third and final article from our guest bloggers in our series about hips.
Things we can do to benefit hip joint development
So, now we’re back to the hip joint. And back to our insights into how the health and function of the hip joint are affected by the pelvis, the shape of the acetabulum, the angle and appearance of the femoral neck and the pull of the muscles around the hip joint. We’ll also be reminding ourselves of common strategies for preventing hip problems, such as postural positioning, axial compression, medication and surgery. The aim with all intervention is to influence the position of the joint and reducing tension in the muscles that cause the femoral head to move close to the outer position. But how can you help create varied movement across the joint from an early age? How do you activate the muscles that give the hip joint stability? And why is this important?
Functional motor skills
The most commonly suggested strategies aim to extend tense muscles, avoid the outer position and deal with the shape of the acetabulum and the angle between the femoral neck and the acetabulum. But how do we get the muscles that influence the development of the hips to work out? How do we activate the muscles that stretch and rotate the hip - these are the muscles needed to counteract the muscles that pull the legs forward and inward? The strategies for this are not clearly defined in healthcare, and interventions therefore varies widely depending on who’s giving the advice.
To answer the questions above, we need to look at basic motor development. Why? Simply because development of motor skills is so much more than just reaching milestones. These skills lay the foundation for our movement. Each new position the child masters means that the senses, joints and muscles receive new impressions and send signals to the brain about how the body works in relation to its surroundings. The connection between the body and the brain (and not the actual muscles in the body) is particularly strengthened during childhood, laying the foundation for good body awareness and control. It is what we offer of surroundings that determines what impressions the child can process and how the body responds to the challenge. Considering the motor challenges of basic development is what we refer to as Functional Motor Skills, and this is our tool for freely analysing abilities and deciding how to support the part of the body that’s primarily holding up progress. It also gives us the opportunity to find the right tasks for children with motor disabilities who have passed motor development milestone in terms of age but are struggling to progress in their physical learning. In the same way, we can work out which pieces of the motor skills puzzle are needed to prevent secondary complication, such as hip problems.
Muscles around the hip joint
When we refer to functional muscles around the hip joint, there are two things we need to think about: regulation and strength. These are like two sides of the same coin: regulation controls the use of joint mobility and its stability. This is because the muscles nearest to the joint work together beautifully to determine when to tense and relax. We often refer to tense muscles at the front and inside of the hip joint, but rarely highlight the fact that lack of engagement of the muscles at the back and outside of the hip is another factor. Instead, developing strength around the hip joint is about being able to perform large movements and being able to lift or balance the weight of the body against gravity. We mean large movements here, moving around and often a partnership between muscles above and below the hip joint.
Positions that challenge regulation
So, regulation is very much about being able to use the full range of motion of the joint with control, and the hip is a joint with the ability to move in many directions. Below we describe a number of positions that provide opportunities to challenge and develop movement control in positions important to good hip health.
Supine leg lift
In the supine position, the child is able to find movement control by bending the hip joint forwards and twisting it outwards. If this challenge is too great at first, placing a wedge or towel under the child’s bottom can place them in a position that allows them to explore and gives them something to kick against and turn the challenge into a fun game.
Direction: forwards + outwards.
Pushing away in a supine position
Young children are experts at finding things to kick their feet against, and it’s not uncommon to find them at the top end of the cot in the morning, with their head against the edge. This is a great way to challenge their hip extensors and the back of the body. This challenge is suitable even if they find it difficult to support themselves on their legs. Pushing themselves away on a skateboard or a woollen blanket on parquet flooring can be turned into a fun game.
Making scooting movements or pushing away from the ground in the prone position gives the child the opportunity to develop control by twisting the hip joint outwards and extending it fully. Simply, this control is what usually presents a challenge in people with hip problems.
Direction: outwards + backwards.
Sitting cross-legged/sitting in a saddle/sitting to one side
The position of the hip is also affected by how we sit. There’s plenty of opportunity for the hip joint to challenge movement control when twisting outwards when we sit cross-legged or move into and out of a sitting position. Sitting astride a roller, a parent’s leg or a saddle chair makes it possible for the child to find control over outward movement of the legs, and, as a bonus, places the femoral head in a good position in the joint.
Positions that challenge strength
When we refer to the strength of the hip joint in people with disabilities, we’re mainly referring to the power to defy gravity. We also need enough strength to counteract the force in the muscles that pull forwards and inwards. The gluteal muscle is mainly responsible for extending the torso upwards against gravity and moving the hip joint backwards and outwards, and this is a muscle usually tricky for children with challenged motor skills to activate. The following positions provide good conditions for activating the seat.
Crawling presents a useful challenge for the gluteal muscle in a position that doesn’t require much balance. That said, it also presents a great challenge for the muscles of the torso. Crawling up a flight of stairs is a perfect task for anyone who doesn’t have the balance needed for activity when standing but where crawling on flat ground is too heavy. Obstacle courses that involve crawling over cushions or other objects can also give the torso the small amount of support needed to present the seat with a decent challenge.
We’ve talked about axial compression in previous sections; that is, straightening the load through the hip joint by standing upright. Kneeling play is a great alternative to more passive standing support and also gives the seat a chance to balance for longer and parry the movements of the torso. If this position is too challenging due to lack of strength or balance, supporting the body with the arms against a table may be an intermediate step. The important thing is to stretch the body straight up and not let your bottom sag down towards the feet.
Standing up/sitting down
Strength is all about large movements or moving around. The gluteal muscle is involved in all movements where we push off with our legs and raise the body towards an upright standing position. Moving to and from low stools presents a good challenge for the leg muscles and the seat and often helps to achieve a more stable gait in the long run. An additional challenge is presented by standing from kneeling on one leg, where more of the load is on the leg at the front.
Regulatory assistive devices
Exopulse Mollii Suit
The Exopulse Mollii Suit, formerly known as the Mollii Suit, is a medical device that has small electrodes sewn into a jacket and a pair of trousers. The settings are programmed by certified personnel according to the user’s individual needs. The Exopulse Mollii Suit is based on the principle of reciprocal inhibition and makes it possible to reduce tension in spastic muscles while also creating the conditions for activation of weak muscles, such as the gluteal muscles and the muscles that move the hip outwards. The Exopulse Mollii Suit is non-invasive and non-pharmacological and has few side effects compared to the invasive measures currently available. Positive effects have been observed in clinical studies on range of motion, balance, hand and arm functions and gait. However, the product has not been studied extensively in scientific studies, so there is little scientific evidence. On the other hand, we’ve personally seen great effects in practice for the children we’ve met who use the product as an assistive device. Its use is recommended for an hour every other day.
Saddle chairs creates a favourable position for the hip joint. Regular use can prevent further loss of range of motion when moving the legs apart, often caused by great tension in the muscles that bring the legs together. This is part of the 24-hour positioning that you can find out more about in last week’s article.
Standing and walking aids
Standing and walking aids focus on weight-bearing and axial compression. See last week’s article for more information on this. Made for Movement’s Innowalk product is currently undergoing some fascinating research, comparing dynamic standing (where the legs are moving) with static standing (where the legs are stationary).
Relevant scientific articles are summarised here:
- Static or Dynamic standing? New study reveals interesting data
- New study - Activity has positive effect on lactate in people with CP
TheraTogs are soft orthotic undergarments and strapping products made of a compressive stretch material. They come in a range of designs and sizes. TheraTogs are designed on the basis of the theory that increased postural control (posture) creates more of an ability to control the arms and legs. The increased postural control is created by the body awareness increased by the compressive material. The material is also stretchy, which means that different amounts of input can be sent to the brain to activate the muscles, depending on how the TheraTogs are put on. The products designed for hips and thighs can be used to create greater awareness of the muscles which people with problems with hips often have difficulty activating, the gluteal muscles and the muscles that move the leg outwards.
However, is stimulation of Functional Motor Skills the solution to all our problems? And does that mean that life should be all about exercise? Of course not. Looking at regulation and strength in respect of the hip joint is another piece of the puzzle that can help people with motor disabilities to cope with the next stage in their development while also helping to prevent hip problems. And of course, this is always combined with all the great strategies we described previously for movement and weight-bearing that we take for granted. By Clarifying how we can concretely support people with motor disabilities from a functional perspective, we equip families and assistants with helpful tools. This helps them to understand why and how to assist development and health in a structured way on a daily basis.
We hope this also contributes towards new approaches and innovation so as to provide everyone with the opportunity for motor stimulation by means of assistive devices that focus on activity and function in varied positions.
But that said, focusing on functional motor skills doesn’t mean family members should be locked into the role of on-call physiotherapist. It should rather help the family to easier incorporate meaningful tasks with the right purpose into play and day-to-day life by understanding WHAT is important, HOW can we influence it and what DIRECTION we need to guide the body in.
In this series of articles, we have focused on hips from a number of perspectives. We’ve shared our thoughts on how to prevent, support and treat a hip at risk of dislocation. We’re passionate about the Functional Motor Skills perspective, and we’re so grateful that you’re helping us to highlight this important piece of the puzzle and what it can achieve! This piece of the puzzle adds value for both the individual and the family and gives those of us around the individual a way of being part of their development in a meaningful way. Through understanding and presence. In play. In practice.
Malin Larsson is a physiotherapist and has a background in sports medicine. Her daughter was born with a disability in 2011, and this inspired her to work with young children and people with disabilities. She’s focused on this field ever since. She began to look at the world through new eyes thanks to her strong little girl facing some major challenges. Malin has been curious to understand basic motor development in depth because of this little girl and her two siblings. She’s gained an insight into just how many people are needed to bring things together to help a child with challenges, and she’s aware that everyone involved needs to have this information presented in different ways if they’re to be able to play their part. Hanna is strongly committed to children’s right to development, to the fact that they should ALL be offered the opportunity to achieve their maximum potential. She’s worked in rehabilitation for more than a decade, working with both children and, adults and has experience of lots of different diagnoses, both congenital and acquired. Taking Functional Motor Skills as her starting point, she wants to get involved and help the network to understand the child’s needs and requirements to help them make progress.
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