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Educational Chiropractic Resource Articles

Proven to reduce low back pain

The Effects of Orthotic Intervention and 9 Holes of Simulated Golf on Gait in Experienced Golfers

Methodological Considerations

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



Background: This investigation evaluated the effects of orthotic intervention on gait patterns and fatigue associated with 9 holes of simulated golf among a group of experienced golfers.
Setting: Northwestern Health Sciences University, Bloomington, Minn.

Participants: Twelve experienced golfers.

Method: By means of video freeze-frame analysis, gait was assessed in each subject before and after 9 holes of simulated golf. Subjects wore custom-made, flexible orthotics daily for 6 weeks, and gait was then reassessed through use of the same objective measurement parameters. Fatigue was introduced by having participants complete 9-hole rounds of simulated golf before and after wearing custom-made, flexible orthotics for 6 weeks.

Main Outcome Measure: Parameters associated with gait (ie, stride length and pelvic rotation) were measured in all subjects before and after they used custom-fit, flexible orthotics for 6 weeks and before and after they completed 9 holes of simulated golf.

Results: The data indicate that for experienced golfers, wearing the custom-fit, flexible orthotics used in this study for 6 weeks influenced the parameters associated with gait and reduced the effects of fatigue associated with 9 holes of simulated golf.

Conclusion: The use of custom-fit, flexible orthotics in this study had a significant influence on the elements of gait measured in the investigation—specifically, pelvic rotation and stride length. There was an average increase in pelvic rotation of between 29% and 36%, and there were concomitant changes in stride length after subjects had used the orthotics for 6 weeks. In addition, use of these custom orthoses reduced the effects of fatigue associated with playing 9 holes of simulated golf; they could thus improve the likelihood of more consistent performance, possibly as a result of a more efficient gait pattern. (J Manipulative Physiol Ther 2001;24:279-87)



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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.



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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).



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Immediate Changes in the Quadriceps Femoris Angle After Insertion of an Orthotic Device

D. Robert Kuhn, DC,a Terry R. Yochum, DC,b Anton R. Cherry,c and Sean S. Rodgersc



Objective: To measure changes in the quadriceps femoris angle (Q-angle) after the insertion of full-length flexible orthotics.

Setting: Outpatient health center of Logan College of Chiropractic.

Subjects: A total of 40 male subjects were included in the study population. The selected population all demonstrated bilateral pes planus or hyperpronation syndrome.

Design: Before-after trial. Method: A cohort demonstrating bilateral hyperpronation was recruited. The subjects were cast according to standard protocols provided by the manufacturer. Subject right and left Q-angles were measured with and without the orthotic in place. The landmarks used were marked with a permanent marker, and great care was taken to accurately assess the angles formed. The evaluator was not told whether the measure was before or after orthotic insertion. A modified quailcraft goniometer was used.

Data Analysis: The data set was collected and assessed by the t test.

Results: Thirty-nine of 40 test subjects showed reduced Q-angle, which was in the direction of correction. A 2-tailed matched sample showed statistically significant mean reduction in Q-angle measures. There was a minority of patients who showed asymmetrical Q-angle measures. Within this group there was greater symmetry of Q-angle measures after placement of the orthotic.

Conclusion: Insertion of full-length, flexible orthotic devices significantly improves the Q-angle in hyperpronating male subjects. If the literature accurately links an increase in the Q-angle with a predisposition for knee injury, then the possibility of long-term benefits following the use of flexible orthotics exists. More research is required to determine whether these biomechanical changes are maintained after use of these orthotics. (J Manipulative Physiol Ther 2002;25:465-70)



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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.



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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)



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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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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.



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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.



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