Copyright, All Rights Reserved 199
by
Brian A. Rothbart, D.P.M.,Ph.D.
Kevin Hansen, P.T.
Paul Liley, D.D.S.
M. Kathleen Yerratt, R.N.
This manuscript may not be used in part/whole for any other reason without the primary author written authorization.
Low back pain is one of the most common complaints seen by health care providers. the patient's complaints are most often vague and unrelated to any specific cause or injury. These people have often been to any number of physicians for symptomatic relief, only to find that the pain returns when therapy is terminated. Is there a way to better help these people?
PREMISE:
One of the leading causes of low back pain, unrelated
to disease or trauma, is poor posture alignment associated with
gait abnormalities. The specific gait problem is
hyperpronation
[inward collapse of the foot] often associated with forefoot
varum deformity. Clinically, the patient is assessed
'biomechanically' rather than 'medically' from head to toe.
GOOD ALIGNMENT:
The biomechanical approach focuses on the
patient's posture and walking pattern. The manner in which the
patient stands and walks [postural mechanics] is compared to
the
anatomical neutral model. This neutral model is the classic
concept of "perfect posture". A straight line can be drawn
from the head through the torso down through the ankle ending
at
the ground [see figure 2]. The shoulders, pelvis, and ankle
joints are 'level', side to side. The student of kinetics
would describe the body's center of gravity as being in the
anatomically correct position or, more eloquently, as being at
equilibrium. Visually, the patient stands perfectly straight.
As this patient walks, the same straight lines are maintained.
Dynamically, the 'perfect' anatomical model has a smooth,
quiet,
walking pattern. There is no excessive motion, e.g., no
ungainly, asymmetrical lurges.
HYPERPRONATOR:
In contrast to good postural mechanics, poor
postural mechanics is ungainly, uneven, asymmetrical.
Visually, there is some degree of inward rotation of both feet.
This inward collapse of the feet affect all the weight bearing
joints above, e.g., the superstructure [See Figure 2]. The
knees may come closer together, the low back may appeared
'swayed' [rotated forward], and the head and shoulders may
shift forward ['chicken neck' with hunched shoulders]. In
addition, it is common to hear that the patient has been
diagnosed with a leg length difference or muscular tightness.
As these patients walk, they appear to limp. They walk heavy
footed. The shoulders and arms have a more limited motion and
appear 'tight' With each step, this patient is putting stress
through the entire musculoskeletal structure.
LOW BACK PAIN STUDY:
Treating with Orthoses. In varying degrees, removing the stress from the skeleton and muscles, is the most effective treatment. That is, the foot is supported to maintain a correct posture without muscular exertion [an engineer would describe this as fortifying the foundation of a building to stabilize the roof]. When symmetry is reintroduced , the stress on the musculoskeletal structure is reduced and significant healing occurs.
A four year study of 208 patients with back pain was conducted at the Bellevue Foot and Ankle Center. All 208 patients were hyperpronators. Prior to this study, all of these patients had been treated with various modalities including anti inflammatory medication, physical therapy, injections, and in some cases surgery. All these patients were, to some degree, disappointed with their outcomes. They were committed to permanent relief and an improved quality of life.
In this study these patients were treated with orthoses ranging from arch support devices to sophisticated Postural Control Orthotics [PCO Trademark by PCO, Inc.]. Orthoses treatment is dependent upon the pattern of hyperpronation [heel contact vs. midstance], the severity of the low back pain, and the patient's objective goals in therapy. Mild, early stance phase hyperpronation patterns associated with relatively mild low back pain were treated with traditional arch support orthoses. More severe midstance hyperpronation patterns associated with moderate to severe low back pain were treated with precise Postural Control Orthoses. One year after therapy was completed, the following subjective outcomes were reported: [1] 139 reported improvement of 70% or greater, [2] 31 reported improvement of 50 to 60 percent, [3] 24 reported improvement of 10 to 40 percent, [4] 6 reported no improvement, and [5] 3 reported that their low back symptoms increased.
CONCLUSION:
Although patient stated outcomes are not based on
pure scientific protocol, if the patient does not feel better
after treatment is concluded, the effectiveness of that
treatment must be questioned. Over 90% of the patients
participating in the above Low Back Study, improved in a
conservative orthoses treatment plan.
Biomechanics from the ground up is a concept that is
easily
understand, i.e., a weak foundation affects the entire
structure. The above study strongly suggests that orthoses
therapy in the presence of hyperpronation is effective in
reducing low back pain. The authors encourage comment on this
preliminary position paper.
The End.