Hooray for hips

Posted by Nurse Linda in Life After Paralysis on March 11, 2020 # Health

HipA person’s hips are typically not a body part that we think much about. They are just there on our bodies. They don’t require any unusual care. They work when they are needed. However, let’s take just a moment to think about them as special as they are.

The hips, one on each side of the body, are considered differently by people. Some think about their hips as an area of skin, others think about the hip’s bones and muscles. Indeed, the hips are all these things. The hips are the starting point to the legs. Engaging the hip joint can keep us from falling when alerted by the brain. They are quite important.

After spinal cord injury, the hips movements are typically unaffected. The bones still move, muscles still work, circulation is still pumping. The issue is messages cannot get through the area of the injury to or from the brain. The body below the level of injury still works, even if brain engagement of the hips is challenged.

Therefore, a person might neglect this part of their body. The hip joint can develop issues if attention is not paid to it. This is not a massive job but one that should not be neglected. You can care for your hips in your usual daily routine without much additional effort.

Hip Bones
The hip bones are a ball and socket joint which means the top of the femur or long bone of the thigh, has a ball end which fits into a cup like area of the pelvis, the socket. Thinking about a socket wrench, the hips move mostly forward, less backwards and sideways. This flexibility allows our bodies to move in a variety of directions.

Good positioning in bed or when seated is important to maintain the structure of the hips. Most people with SCI sit in their chairs and when in bed, use the incline feature. This puts the hip in a flexed position most of the day and night. If you are able, try to lay flat or occasionally, extend your hip a tiny bit toward the back when on your side in bed or straight if you are able to be positioned on your stomach. This will stretch out your flexor hip muscles to avoid a muscle contraction. When doing range of motion exercises, be sure to stretch the hip back just a tiny a bit when on your side in bed. This will help to keep the flexing hip muscles longer and pliable.

When anyone is positioned on their back in bed, their feet will start to turn out from their body due to gravity. You can see this as the feet each point to the outer side instead of correct back positioning when the toes point straight up. This slow droop of the toes affects all of the leg muscles right up to the hips. The weight of the pull of the feet will start to affect the hip joint.

To avoid this, many individuals with SCI will have positioning boots to keep their feet in alignment at night and sometimes in the day as well. The same positioning can be done when on the back by rolling a bath towel and placing it along the length of the leg, from the upper thigh to just above the ankle. The towel should not be placed under the hip bone or ankle to avoid pressure injury. Others might use a pair of high-top athletic shoes to keep their feet upright which protects both the foot position as well as the hips.

Other diseases can affect your hip joints as well. This includes arthritis, an inflammation of the joints, and bursitis, an inflammation between the tissues of the hips or other body joints. Both of these inflammations can develop at anytime but after SCI, they usually appear when the limbs have been consistently tossed instead of carefully placed when changing positions or during transfers.

Hip fractures can occur after SCI, either from mishandling the body or from loss of bone density, an all too common issue. A hip fracture may not be accompanied by pain if your sensation is challenged. You may have symptoms of autonomic dysreflexia, or when positioned on your back in bed, you might notice one of your legs being a bit longer than the other and the foot turned out on the side of the hip fracture. Swelling can also occur in the area of the hip.

Bone density tests are very important to assess the health of your bone health. Early detection can help you get treatment to avoid a hip and other bone fractures. If your bones are healthy, ask your healthcare professional about obtaining a standing frame. In the standing frame, your body has some tension on the tendons that attach to the bones which will assist in keeping your bones in shape. Also, performing range of motion exercises will cause the tendons to pull on the bones. Be sure to follow the explicit instructions of your healthcare professional and physical therapist so as not to overwork your body.

Another revealing outcome of bone density testing is if you have too much bone growth. A complication of spinal cord injury can be Heterotophic Ossification (H.O.) Sometimes, the bone grows too thickly and out into muscle tissue. This can cause the joint to be unable to articulate or move. If H.O. is in the hip, it can prevent you from sitting. Sometimes H.O. is confused with a contracture so you need to have a CT scan, MRI or X-ray for diagnosis. This condition is treatable with medication if caught early. Surgery to remove the bone overgrowth is needed in extreme situations.

Hip Vasculature or Blood Vessels
The blood vessels of the hip can become compressed. Blocking the flow of the blood vessels can lead to blood clots which can become dislodged and travel to the heart, lungs or brain. The feet are the furthest part of your body from your heart. You want your blood to be freely circulating to your toes. Therefore, any constriction will hamper your ability to get the blood flowing.

Be sure to keep the circulation flowing by moving your body, performing skin care releases and wearing clothes that do not constrict the inside of the hips where they bend when you sit. With the style of ‘skinny’ pants, many people want the look but don’t think about the consequences. Pants that are too tight in the groin or back of the knees can affect your circulation.

Other diagnoses can affect your circulation. These include high blood pressure and heart disease, diabetes, smoking, poor diet, and a sedentary lifestyle. Providing movement to your body can improve the consequences of these situations. Improvement in diet and smoking cessation is necessary.

Hip Skin
The skin around the hips is full of areas for pressure injury. The sacrum (end of the tail bone), the ischium (sitting bones) and the top of the femur (long bone of the leg) are key pressure injury areas. These locations need to be monitored frequently for pressure injury which may appear as a dark, purple or ashy area in darkly pigmented individuals and as a red or purple spot for lightly pigmented individuals.

The skin where your legs meet your body that gets folded when sitting can also have a skin injury from vascular issues mentioned above. Monitor all of your skin to ensure it is healthy.

The boney areas of the hips are frequent locations for pressure injury development because of the heavy use when sitting or when in bed. A combination of these locations is under pressure 24 hours a day. It is extremely important to use pressure dispersing measures to keep your circulation unrestricted. Use medical grade equipment to assist in reduction of pressure. Since there is no equipment that can completely eliminate pressure, you still need to perform pressure releases and turning to ensure a safe and healthy skin.

If you see a spot on your skin, stay off it. The spot you see on the surface of your skin is less of an injury than what is happening below the skin where you cannot see. Do not become complacent in this activity. Even if you have not had a skin injury, your body will change as you age which puts you at higher risk. Keep your skin dispersing equipment in good shape and replace when worn.

Pediatric Consideration:
Infants have a hip examination shortly after birth. This is to make sure the hips are in alignment and not mispositioned. With neurological diseases or spinal cord injury, the hips are typically checked by a healthcare professional to ensure they are still in alignment prior to beginning therapy. As the child ages, the muscles become stronger leading to less risk for displacement, but they should still be checked.

Children’s bones are not as firm as adults. If there is a fracture, it is usually what is called a ‘greenstick’ meaning the bones is like a branch of a young tree where the bone is broken but not pulled apart. Severe fractures can be through the bone, like adult bones. Children’s bones are typically mature at ages 15 for girls and 17 for boys.

Consequences of spinal cord injury can happen to children, even though they are younger and not yet with mature bones. Heterotophic Ossification (H.O.) and decreased bone density can occur. Therefore, children should be evaluated for these conditions.

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.