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.



Radiographic Evaluation of Weight-bearing Orthotics and Their Effect on Flexible Pes Planus

 D. Robert Kuhn, DC,a  Nofa J. Shibley, DC,b William M. Austin, DC,c  and Terry R. Yochum, DCd



Objective: To determine whether any positive change in the alignment of the bones of the feet occur with the use of custom-made flexible orthotics, cast by weight bearing, in individuals having flexible pes planus. Methods: Anteroposterior and lateral radiographs were obtained with and without orthotics in place. The anteroposterior and lateral talocalcaneal angles and the lateral pitch of both the left and right foot were assessed.

Results: The t test values and P values derived from the radiographic measurements indicated statistically significant improvements in weight-bearing foot alignment.

Discussion: Biomechanical faults in the pedal foundation can adversely affect any of the joints and structures of the foot/ankle complex, lower extremities, pelvis, and spine.

Conclusion: This study supports the use of a custom-made flexible orthotic for the improvement of pedal structural alignment. (J Manipulative Physiol Ther 1999;22:221-6)



Orthotic Insole Use and Patient Satisfaction in an Outpatient Chiropractic Clinic

Manuel A. Duarte, D.C., M.S., D.A.B.C.O., D.A.C.B.S.P, and Jerrilyn A. Cambron, D.C., M.P.H., National University of Health Sciences


The effectiveness of foot orthotics is a controversial and often debated topic. Some authors suggest significant clinical advantages, mainly based on studies with heterogenous samples. However, reviews of the literature assessing the benefit of orthotics for more specific disorders demonstrate equivocal results. Prevention of back and lower extremity disorders through the use of orthotics has also demonstrated equivocal results. Even though data are lacking on specific therapeutic efficacy of foot orthotics, there appears to be a high level of satisfaction with use. However, there are no data on patient satisfaction of foot orthotics in a general population. Furthermore, there are no data on the reasons for use within a chiropractic population. The purpose of this study was to survey the reasons for foot orthotic use and the resultant level of satisfaction within a chiropractic outpatient clinic.


Subjects were randomly sampled from a list of patients who previously purchased Foot Levelers orthotics at a chiropractic teaching clinic. A three-page, IRE-approved survey was either mailed or personally presented to each selected subject. The survey consisted of 19 questions including the subject's chief complaint when_ initially presenting to the clinic, the reason orthotics were recommended, and the subject's overall satisfaction with their orthotics. All patients were fitted for orthotics in the manner described and taught by Foot Levelers, Inc. Prior to use, patients were instructed to wear the orthotics for progressively longer periods of time each day in order for the body to accommodate, until the orthotics could be comfortably worn as needed. Data collected from the survey were collapsed descriptively. Variables significantly associated with level of satisfaction were determined using multivariate modeling.



The Effect of Custom Orthotics on the Vertical leap of Athletes in a Sport Demanding Jumping

William M. Austin, D.C,, C.C.S.P., C.C.R.D., Foot Levelers, Inc., Dennis Nosco, Ph.D., Nosco Consulting, and Jeffrey D. Olsen, D.C., Foot Levelers, Inc.


The chiropractic literature is almost devoid of any studies related to vertical leap. In fact, scientific literature, in general, is devoid of any reference to orthotics affecting vertical leap. A number of companies have attempted to produce non-custom shoe insoles or shoe-related devices designed to improve vertical leap in jumping sports (i.e., basketball, volleyball, track and field jumping events). The current pilot project attempts to gather the first data on whether the use of custom orthotics in athletic shoes of a jump sport team can positively affect the vertical leap in a controlled, blinded study.


Eleven female high-school-age volleyball players from a local elite club team were recruited into this pilot study. Parental informed consent was obtained. The subjects, who were blinded to the end point of the study, were fitted for custom orthotics supplied by Foot Levelers, Inc. Standing (first session) and three-step approach vertical reach were measured on separate days with and without orthotics to minimize complicating fatigue factors. Testing was done at almost the same time of day and at the same point in practice at both test sessions. The order (with orthotics and without orthotics) was randomized for each girl and each measurement date. Vertical leap measurements were made using a Vertec® vertical leap measurement device to minimize measurement bias. This device measures to the nearest half-inch. Vertical leap was determined as the best of three attempts for each of the four measurement conditions (i.e., standing vertical with and without orthotics, and approach vertical with and without orthotics). Statistical analysis was done using descriptive statistics and linear regression.


The mean increase in vertical leap using orthotics in the first testing session was 0.14 inch and in the second testing session was 0.23 inch. In the first test session, five subjects showed improvement, two stayed the same, and four showed a decrease in vertical leap after putting in orthotics. At the second testing session, five subjects showed an increase, four stayed the same, and two showed a decrease in vertical leap after wearing orthotics. Linear regression indicated a high correlation (r2 = .-896 for the first testing session and .950 for the second session) for vertical leap values before and after orthotics' within one testing session but not for vertical leap changes (r2 = .05) for individuals between test sessions.



Radiographic Evaluation of the Effect of Orthotics on the Unlevel Pelvis

D. Robert Kuhn, D.C., D.A.C.B.R., Sarah Smasal, D.C., Alethea Pappas, D.C., and Dennis Nosco. Ph.D., Logan College of Chiropractic


The purpose of this study was to determine if there was an effect on pelvic unleveling with the use of custom­made flexible orthotics in subjects with asymmetrical flexible pes planus.

1st-trimester students with pelvic unleveling of at least 4 mm and asymmetrical pes planus were identified and signed informed consent. Anteroposterior (AP) and lateral full­spine radiographs were taken on the subjects without the orthotics in place. The subjects then wore their orthotics for a minimum of 2 weeks. After this interval, the subjects under­went a second radiographic examination consisting of AP and lateral full-spine views. Iliac crest height measurements were obtained from the first and second AP radiographic exami­nations. The researchers then analyzed the percentage of the subject population that improved, were unchanged, and those whose measurements worsened. A comparison of the results was also performed using a t test analysis.


The use of custom-made orthotics demonstrated a normal­izing effect on pelvic measurements in 20/35 subjects. In 10/35 the values remained the same and worsened in 5/35. The average unleveling before the insertion of the orthotics was 10 mm and the average unleveling after the insertion of the orthotics was 8.9 mm. Of the subject population who improved, there was a preorthotic measurement average of 8.8 mm and a postorthotic measurement average of 6.5 mm. The t test did not reach statistical significance (p = .09).



Motor Learning and Drop Jump Techniques

Effects of Orthotic Intervention on Neuromuscular Adaptations and Performance Gains

Jeanmarie R. Burke, Ph.D., and M. Owen Papuga, M.S ., New York Chiropractic College


Stretch shortening cycle (SSC) exercises, such as drop jumps, are known to improve the mechanical output of muscles. The primary neural factor contributing to the increased mechanical output of the muscle during SSC exer­cises is the stretch reflex response (SRR). An understanding of the plasticity of the SRR provides insights on the adaptive capacity of the neuromuscular system. However, there are limited data on training adaptations to SRR during SSC exercises. Adaptations of the SRR may be more evident during motor learning than following exercise training, because of the concept of task specificity and the contributions of movement coordination to skilled human performance. In addition, an optimal orthotic, which improves footwear comfort, may improve human performance by enhancing neuromuscular efficiency. Specifically, effective dampening of soft tissue vibration by orthotics may reduce muscle activity, minimize fatigue, and increase comfort perception. The potential conse­quences of undamped soft tissue vibrations are impairments to neuromuscular efficiency. The purpose of the study was to establish that motor learning occurred during SSC exercises and to determine the effects of orthotic intervention on neuromuscular adaptations and performance gains during motor learning.



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)




A Correlation to Spinal Biomechanics

D. Robert Kuhn, D.C., D.A.C.B.R., Michael Tremba, D.C., Logan College of Chiropractic, and Dennis Nosco, Ph.D., Nosco Consulting


This student research project was designed to take the first steps toward determining whether any positive changes on spinal gravity lines can be detected after a trial of flexible orthotic devices on subjects who exhibit asymmetric flexible pes pianos and spinal towering.


This study was approved by an IRB at Logan College of Chiropractic. Seven students who passed all entry criteria and gave, in writing, informed consent to participate were enrolled in the study. Study subjects were fitted with orthotics that they wore for 2 weeks. Anteroposterior full-spine radio­graphs were obtained both pretrial and posttrial, with the posttrial radiographs taken with orthotics in place. A spinal gravity line (plumb line) was constructed in both pre- and postorthotic radiographs that ran from the level of the apex of the odontoid process and intersected with the second sacral tubercle. The right or left deviation of the odontoid versus the plumb line intersecting with the second sacral tubercle was measured on all radiographs. Data analysis consisted of descriptive statistics and a two-tailed t test.



Methodology to Describe the Regulation of Sensory Feedback Mechanisms

Jeanmarie R. Burke, Ph.D., New York Chiropractic College


Neuromuscular concepts underlying the benefits of orthotics suggest that improvements in sensorimotor integration may contribute to the reduction in muscle activity and the resultant increase in comfort perception. Sensorimotor inte­gration refers to the modulation of motor outputs via modi­fying sensory feedback signals. Modifications to H-reflex amplitudes that occur as a function of changes in motor task demands, postural orientations, and background muscle activity are considered functional indices of sensorimotor integration. It is hypothesized that sensory feedback mecha­nisms are impaired in patients with chronic low back pain. Clinical efficacy of orthotic interventions in patients with chronic low back pain may involve improvements to the regulation of sensory feedback mechanisms.


The purpose of this research is to determine the effects of Foot Leveler's orthotics on the recruitment profiles of the tibial nerve H-reflex response in chronic low back patients during quiet standing as compared to lying prone on a table.



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