Educational Chiropractic Resource Articles

Proven to reduce low back pain

Bone Marrow Edema Caused by Altered Pedal Biomechanics

Terry R. Yochum, D.C.1 and Michael S. Barry, D.C.2


Objective: To review the magnetic resonance imaging (MRI) appearance of bone marrow edema (BME) and to discuss the applications of this imaging modality in the diagnosis of associated disorders. A case of BME in the foot is also provided to acquaint the reader with how MRI may assist in establishing a differential diagnosis in patients with normal radiographs and clinical findings that suggest osseous injury.

Clinical features: A 42-yr-old woman suffered from persistent pain along the dorsum of her foot that worsened with jogging. There was foot pronation and palpable pain and swelling at the third tarsometatarsal joint. An MRI was performed, but it was initially misinterpreted. A second review of the MRI examination established the presence of stress-induced BME adjacent to the articular margins of the third tarsometatarsal joint.

Intervention and outcome: Medical treatment consisted of a cortisone injection into the left third tarsometatarsal joint, which provided transient relief. Chiropractic treatment included flexible custom orthotics prescribed to specifically address her foot pronation. This was the only chiropractic treatment employed.

Conclusion: In the presented case, the sensitivity of MRI to stress-induced BME identified the cause of this patient's symptoms and, more importantly, directed management. Because of its ability to demonstrate anatomic and physiologic information, MRI is the ideal imaging modality for assessing suspected injury to the osseous tissues. In patients who relay historical information that suggests chronic or acute osseous injury but demonstrate no radiographic changes to support the clinical suspicion of bony abnormality, an MRI may be indicated to exclude occult injury.



Effects of Orthotic Intervention and Nine Holes of Simulated Golf on Club-Head Velocity in Experienced Golfers

 David E. Stude, DC,a  and Jeff Gullickson, DCb



Objective: This study was an initial investigation evaluating the effects of orthotic intervention on club-head velocity (CHV) among a group of experienced golfers before and after 9 holes of simulated golf.

Setting: Northwestern College of Chiropractic, Bloomington, Minnesota. Participants: Twelve experienced golfers were included in the study. Method: CHV was measured with a device used by many Professional Golf Association and Ladies Professional Golf Association teaching professionals before and after wearing orthotics and before and after completing 9 holes of simulated golf. Subjects wore custom-made, flexible orthotics daily for 6 weeks and then were retested with the same objective measurement parameters.

Outcome Measure: CHV (swing speed in miles per hour) was measured in all subjects before and after wearing custom-fit, flexible orthotics for 6 weeks and before and after completing 9 holes of simulated golf.

Results: There was an approximate increase in CHV of between 3 and 5 mph, or a relative increase in CHV by up to 7%, after subjects had worn custom-made, weight-bearing, flexible orthotics daily for 6 weeks. A 5-mph increase in CHV is equivalent to an approximate increase in golf ball travel distance of 15 yards, a significant increase for the tour player for whom small increases in performance can reflect large position changes on the roster board. In addition, the use of these custom orthoses eliminated the effects of fatigue associated with playing 9 holes of golf (relative to CHV) and therefore may improve the likelihood for more consistent golf performance.

Conclusion: The use of the custom-fit, flexible orthotics in this study had a positive influence on CHV in experienced golfers. (J Manipulative Physiol Ther 2000;23:168-74)

Key Indexing Terms: Biomechanics; Orthotic Devices; Golf; Sports



Effect of an orthotic intervention on sensorimotor integration mechanisms

In patients with musculoskeletal disorders

by Jeanmarie R. Burke

Biodynamics Laboratory, New York Chiropractic College Research, Seneca Falls, 2360 State Route 89, NY 13148, USA



Objective: The objective of this research was to determine the effect of an orthotic intervention on the recruitment profiles of the tibial nerve H-reflex response in patients with musculoskeletal disorders during quiet standing as compared to lying prone on a table. The amount of H-reflex inhibition between resting prone and quiet standing assesses the integrity of sensorimotor integration mechanisms.

Design: Cross-sectional with repeated measures on footwear conditions for patients with musculoskeletal disorders. Single-blind of investigator for footwear conditions.

Setting: Research Laboratory.

Methods: The participants were 12 asymptomatic individuals and 11 patients with musculoskeletal disorders. In the prone and standing positions, H/M recruitment profiles were generated with subjects wearing their aerobic shoes. The subjects rested prone on a treatment table with their feet resting on foot plates. During quiet standing trials, subjects balanced equally on both feet while maintaining a relaxed posture and lightly grasping a hand support at hip level to minimize the influence of postural sway and fatigue. The patients were tested with and without their orthotics inserted into their aerobic shoes. The tibial nerve H-reflex methodology was used to record M-wave and H-reflex responses from the gastrocnemius muscle of the right leg. The Hmax/Mmax ratio was calculated from the recruitment profile in each test position. Results: The amount of H-reflex inhibition for the prone position to quiet standing did not systematically increase with the orthotic intervention (12.7%) as compared to the patient’s normal shoe condition (13.2%). Regardless of footwear condition, the amount of H-reflex inhibition from the prone position to quiet standing was similar to the effect observed in the asymptomatic individuals (13.4%). Among the patients with musculoskeletal disorders, subject-specific variations in the amount of H-reflex inhibition from the prone position to quiet standing were significantly different from zero, between the two footwear conditions (5.7%; t10 = 4.54).

Conclusion: Altering sensory feedback signals from the plantar surface of the foot with an orthotic intervention modified sensorimotor integration mechanisms in a subject-specific manner. In agreement with biomechanics research and neuromuscular concepts for the benefits of orthotics, sensorimotor integration mechanisms may be different for each subject-shoe-insert condition.



Shoe Orthotics for the Treatment of Chronic Low Back Pain

A Randomized Controlled Trial

Jerrilyn A. Cambron, DC, MPH, PhD,a Jennifer M. Dexheimer, BS, LMT,a
Manuel Duarte, DC, MSAc, DABCO, DACBSP,b Sally Freels, MS, PhDc



Objectives: The purpose of this pilot study was to investigate the feasibility of a randomized clinical trial of shoe orthotics for chronic low back pain.

Methods: The study recruited 50 patients with chronic low back pain through media advertising in a midwestern suburban area. Medical history and a low back examination were completed at a chiropractic clinic. Subjects were randomized to either a treatment group receiving custom-made shoe orthotics or a wait-list control group. After 6 weeks, the wait-list control group also received custom-made orthotics. This study measured change in perceived pain levels (Visual Analog Scale) and functional health status (Oswestry Disability Index) in patients with chronic low back pain at the end of 6 weeks of orthotic treatment compared with no treatment and at the end of 12 weeks of orthotic treatment.

Results: This study showed changes in back pain and disability with the use of shoe orthotics for 6 weeks compared with a wait-list control group. It appears that improvement was maintained through the 12-week visit, but the subjects did not continue to improve during this time. Conclusions: This pilot study showed that the measurement of shoe orthotics to reduce low back pain and discomfort after 6 weeks of use is feasible. A larger clinical trial is needed to verify these results. (J Manipulative Physiol Ther 2011;34:254-260)



Custom-made Orthotics as an Adjunct to Chiropractic Care: The Patient's Perspective


William Austin, DC, CCSP, CCRD1, Dennis L. Nosco, PhD2, John C. Allen, PhD2

INTRODUCTION: Due to the lack of literature on the effectiveness of custom-made orthotics as an adjunct to chiropractic care, a study on this subject ,vas com-missioned by Foot Levelers, Inc. The goals of the study were (I) determine what % of patients considered orthotics an effective adjunct to chiropractic care and/or were satisfied with their orthotics and (2) determine if patient satisfaction varied with demographic category.

METHODS: Chiropractors were recruited through mail advertisements promising modest inducements ( one free pair of orthotics for every 10 questionnaires returned) to return completed questionnaires from consenting patients. Patient entry criteria were: age ≥18 years, patient verbal informed consent, wearing orthotics for ≥1 month, currently under chiropractic care. The type of chiropractic care was not captured, only the conditions for which the patients were being treated. Custom-made, flexible Spinal Pelvic Stabilizer (SPS) orthotics were used and fitted by scanning the feet or from foam impression casts. A 20-question questionnaire was completely sanitized before data entry to insure patient confidentiality. Data were analyzed for frequencies and means (where appropriate) using SPSS 10.0. Inter-variable analyses were conducted using SAS 8.02.

RESULTS: 527 questionnaires were received from 59 chiropractors. Demographic variables for the study are given in Table 4 and, sorted by gender, in Table 1 . Table 2 gives reported regions of responders pain and Table 3 gives reported chief patient complaints. Responders had worn orthotics for means of 2.6 months for 8.6 hours/day and indicated it took 4.4 days to become accustomed to their orthotics. In efficacy-indicating questions, 92.5% indicated satisfaction with their orthotics, 88.5% indicated their orthotics were a good adjunct to their chiropractic care, 55% said they were more active with their orthotics and 88% indicated they would recommend orthotics to a friend.



The Effectiveness of Custom Orthotics at Reducing Injuries in a College Football Team

Brian Jensen, DC1,William Austin1, DC, J. Nathan Wilder2, MS, ATC, CSCS, Brent A. Ungar3, DC, CCSP, John Zhang4, MD, PhD, Dennis L. Nosco5, PhD, Mark Mandell1, DC, MBA
1-Foot Levelers, 2- Waynesburg College, 3- Private Practice, 4- Logan College of Chiropractic, 5-Nosco Consulting
Contribution from Foot Levelers Inc., Roanoke, VA



INTRODUCTION: American football is a violent sport involving high velocity directional changes and high velocity impact. The sport is performed by athletes of above-average strength, speed and, in many cases, weight. Lower body half (defined as from the lumbar spine down) injuries are common in football. While a number of studies have been published discussing ankle, knee, neck and mouth injuries and devices to make football safer, the incorporation of custom-made orthotics into football shoes to help prevent lower body-half injuries has, of yet, not been studied. Therefore a study was conducted looking at the effect of custom-made orthotics on the injury rate for a college football team using the previous year’s injury rate as the control. Secondary indicators such as satisfaction with orthotics and injury self-reports for this and previous seasons were also captured.

MATERIALS AND METHODS: This study was approved through the Logan College Institutional Review Board. Players from the Waynesburg College football team (an NCAA Division III team) were recruited into the study. All participating players signed an informed consent form which described the study, the study risks and benefits and participant study responsibilities. Inclusion criteria for the study were as follows: a football player active on the team at the time of the start of the study, having read and signed informed consent document. Exclusion criteria included failing to complete the season on the football team and/or failing to wear their orthotics for at least two weeks. Study participants filled out a pre-study questionnaire.

Their feet were then scanned by a local chiropractor using the Associate scanner and the scans used to fit the players with Ultra Tough and Extreme XT custom-made orthotics from Foot Levelers Inc., the sponsor of this study. The players were instructed to wear the orthotics in their practice and game football shoes for the entire season and reminded they could stop their use of the orthotics and thus their participation in the study at any time. At the end of the study players were requested to fill out a post-study questionnaire. Data from the college injury database was gathered for the 2004 and 2005 seasons and data related to injuries of the lower body-half was extracted. The data were coded and analyzed by a 3rd party consultant. Statistical programs used included Microsoft Excel version 11.0 and SPSS, version 10.0.



Chiropractic Adjustments and Orthotics Reduced Symptoms for Standing Workers




Objective: This controlled study was designed to explore the effectiveness of foot orthotics in solving problems of the feet and other parts of the lower extremities and to reduce low back pain.

Methods: Thirty-two subjects (24 males) were recruited and randomly assigned into 3 study groups. There were 10 subjects in the chiropractic care plus orthotics group, 14 subjects in the orthotics group, and 8 in the control group. All subjects filled out a patient information sheet and pre-screening foot pain questionnaire. Foot orthotics information was collected and the data was sent to Foot Levelers, Inc. for orthotic fabrication. Chiropractic treatment was performed using Activator Technique.In-home exercise was prescribed to subjects receiving orthotics and chiropractic care.

Results: The control group did not experience much change during the testing period. The orthotics group showed improvement in symptoms (P 0.053), activities of daily living (P = 0.058), sport and recreation(P = 0.186) and quality of life (P = 0.085). While trends were apparent, the improvements did not reach statistically significant levels, In contrast, there was no trend with pain (P = 0.492). The orthotics plus chiropractic group showed improvement in the four conditions over the study period. Greater improvement was seen in quality of life (P < 0.05), symptoms (P< 0.05) and activities of daily living (P < 0.05), which were statistically significant. Improvement was also seen in sports and recreation but it did not reach statistical significant level (P = 0.097).

Conclusion: This study showed that a combination of chiropractic care and orthotics improved symptoms, activities of daily living, sport and recreation, and quality of life in workers whose job requires them to stand at least 6 hours daily. (J Chiropr Med 2005;4:177-181)



Effect of Exercise and Custom-Made Flexible Orthotics on Blood Pressure and Heart Rate Variability

 John Zhang, MD., Ph.D.,Logan College of Chiropractic, and William M. Austin, D.C., Foot Levelers, Inc.


The hypothesis for the study was that exercise and custom-made orthotics have a positive impact on the heart rate variability (HRV) and blood pressure(BP). The null hypothesis was that exercise and custom-made flexible orthotics would not induce positive changes in HRV and BP during the study period.


This study was reviewed and approved by the Institutional Review Board of Logan College of Chiropractic. All subjects were randomized into control and experimental groups by a randomization table. Both groups had the same exercise program and only the experimental group wore custom-made flexible orthotics. The exercise effects were compared before and after the training. Each subject must be a Ping-Pong club member for the last 5 years and be an active member in the club. The subject must also play no less than twice a week or no less than 6 hours a week. Heart rate variability was measured using Biocom's Heart Rhythm Scanner for HRV data collection. Blood pressure was determined by using Biopac blood pressure measurement equipment. Foot Leveler's custom-made flexible orthotics were factory-fitted to tennis shoes for the study.The study lasted 5 months with one data collection per month except for the 4th month. The baseline HRV and BP were recorded before the warm-up period. When one player had played with two other players in a non stop fashion, the data were collected again immediately after the second game. No rest was allowed for this data collection in order to detect the peak heart rate and blood pressure changes. The third data collection of HRV andBP was at the end of the playing period.



Effects of Foot Orthotics on Running Economy

Methodological Considerations

Jeanmarie R. Burke, PhD,a and M. Owen Papuga, PhDb



Objective: The purpose of the study was to collect preliminary data to address methodological considerations that may impact subject-specific reactions to foot orthotics during running.

Methods: Six endurance-trained recreational runners recruited from a chiropractic college campus wore their preferred running shoes and then inserted either their custom-made orthotics during 1 testing session or their shoe-fitted insoles during the other testing session. Comfort perception was measured for each footwear condition. Measurements of oxygen consumption (VO2) at several moderate exercise intensities, to mimic recreational running, generated an individual's economy-of-running line. Predicted running velocity at VO2max (vVO2max) was calculated as an index of endurance performance. Lower extremity muscle activity was recorded. Descriptive statistics, a repeated-measures analysis of variance model, and a paired t test were used to document any systematic changes in running economy, lower extremity muscle activities, and vVO2max within and across subjects as a function of footwear conditions.

Results: Decreases in VO2 at several moderate exercise intensities (F(1,5)footwear = 10.37, P = .023) and increases in vVO2max (t5 = 4.20, P = .008) occurred in all 6 subjects while wearing their orthotic intervention vs their shoe-fitted insoles. There were no consistent changes in lower extremity muscle activity.

Conclusions: Methodological decisions to use a sustained incremental exercise protocol at several moderate exercise intensities and to measure comfort perception of a custom-molded foot orthosis were effective at documenting systematic improvements in running economy among the 6 recreational runners tested. The development of a less physically demanding sustained exercise protocol is necessary to determine underlying neuromuscular mechanisms and/or clinical effectiveness of orthotic interventions. (J Manipulative Physiol Ther 2012;35:327-336)



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