Articles - Ask Dr. P - The Pain Doc

The Dangers of Using Opioid Drugs to Treat Pain

by Pain Doc | Sep 25, 2012 | Uncategorized

Opioids are strong drugs that are typically prescribed for cases of acute pain such as that from major trauma or post-surgery, and also for patients experiencing severe, chronic, debilitating pain; primarily from terminal cancer and rheumatoid arthritis. Opioids chemically bind to receptors in the central and peripheral nervous system and produce an analgesic effect via decreased pain perception, decreased reaction to pain, and increased pain tolerance.

Morphine and codeine are opioid drugs derived from natural opiates of the opium poppy plant; hydromorphone, hydrocodone, oxycodone, oxymorphone, ethylmorphine and buprenorphine are semi-synthetic and created from either natural opiates or from morphine esters; fentanyl, pethidine, levorphanol, methadone, tramadol and dextropropoxyphene are fully synthetic opioids.

Doctors usually prescribe opioids with caution because of their side effects and propensity of addiction. Known side effects include nausea and vomiting, drowsiness, itching, dry mouth, miosis, and constipation. More potent doses can result in respiratory depression, confusion, hallucinations, itching, hypothermia, bradycardia/tachycardia (abnormally slow/fast heart rate), orthostatic hypotension, dizziness, headaches, urinary retention, ureteric or biliary spasm, muscle rigidity, myoclonus (involuntary muscle twitches) and flushing of the skin. If the dose is not closely monitored and adjusted appropriately to the patient, side effects can often lead to serious consequences. There is a troubling trend where

opioid drugs are increasingly being prescribed for less serious forms of pain such as back pain. Not surprisingly, the number of documented cases of adverse drug reactions has risen accordingly.

When patients are not properly informed about how to take opioid painkillers or are prescribed too high a dose of these drugs, or too long a course of treatment, serious and potentially fatal side effects may result, including respiratory depression (reduced respiration or breathing). If left untreated, patients who develop respiratory depression as a result of a painkiller overdose may die from a lack of oxygen due to shallow breathing caused by the medication.

Thousands of patients die each year as a result of a prescription painkiller overdose.

The CDC reports that prescription painkiller overdoses were responsible for more than 15,500 deaths in 2009. While all prescription painkillers have contributed to an increase in overdose deaths over the last decade, methadone has played a central role in the epidemic. More than 30% of prescription painkiller deaths involve methadone, even though only 2% of painkiller prescriptions are for this drug. Six times as many people died of methadone overdoses in 2009 than a decade before.

When these deaths are the result of patients who were given excessive doses of pain medications, improperly warned about the side effects of the drug, or prescribed more potent drugs than were necessary, the doctors or hospital that prescribed these medications may be at fault. The law firm of Heygood, Orr & Pearson is one of many in the country that offer legal assistance to those injured or damaged by taking prescription drugs. The firm recently launched a website, Painkiller Overdose Lawyers . The site will serve as a resource with the latest news and legal information for patients who believe they were injured after using a prescription opioid painkiller.

Do this simple thing to add years to your life

by Pain Doc | Aug 18, 2012 | Uncategorized

No, it’s not quit smoking, exercising more, or eating a healthy diet I’m talking about; although these things can add years to your life.

You know what it is? Answer: stop sitting too much!

We are living in a society that encourages sitting, thanks to computers. Many jobs require it. Using the computer at home to surf the web, check bank accounts, shop, etc. require it. School requires it. Going to restaurants and coffee shops require sitting. Evidence is showing that prolonged sitting promotes disease, malady and death in epidemic proportions.

The latest study examining the relationship to prolonged sitting and morbidity tracked over 50,000 men and 69,000 women over the course of 13 years. Study participants indicated if they sat less than 3 hours per day total or over six hours per day, total. The results showed that women who sat the most were 37% likely to die, and for men who sat the most, they were 18% more likely to die than the rest of the study participants. The association remained virtually unchanged after adjusting for physical activity level; meaning, a woman who sat for more than six hours a day who exercised regularly still had the same chance of dying than a woman who sat for more than six hours per day and did not exercise regularly.

Numerous other studies done in the past show that prolonged time spent sitting, independent of physical activity, affects metabolism and may influence things like triglycerides, high density lipoprotein (HDL cholesterol, the good cholesterol) fasting plasma glucose, resting blood pressure, and leptin, which are biomarkers of obesity and cardiovascular and other chronic diseases.

It is clear by now that prolonged sitting, which can be defined as over four hours per day, is a threat to your health. There needs to be more public health announcements on this. Imagine the billions of dollars in health care costs that we as a country can realize if everyone knew not to sit too long, as well as all the lives that can be saved.

If you are in a job that requires prolonged sitting, I suggest that you print out the study (link below) and show it to your supervisor. Tell him or her that you take this seriously, and you must be allowed to stand up and walk at least once an hour, for 15 minutes. Or, stand up and walk every 15 minutes of sitting, for about five minutes.

Reference: “Leisure Time Spent Sitting in Relation to Total Mortality in a Prospective Cohort of US Adults.” Alpa V. Patel, et al.

New Study Shows Qigong Helps Relieve Fibromyalgia

by Pain Doc | Aug 13, 2012 | Fibromyalgia

Qigong, sometimes spelled Chi gung, is a form of exercise that originated in China some 4,000 years ago. Literally translated to “life energy cultivation” it involves aligning breath, movement, and awareness for exercise, healing, and meditation for the purpose of balancing the body’s energy meridians and enhancing the intrinsic capacity of the body to heal. Qigong is considered a part of Traditional Chinese Medicine, or TCM, along with acupuncture and Chinese herbology.

Basically, in TCM it is believed that there are “energy meridians” or lines that cover the body from head to toe. Health is dependent on the “flow” of this energy, or chi. Whenever there is an “obstruction” in one or several meridians, the body experiences disease. Qigong works to improve this energy flow by focused breathing, meditation, and gentle movements. Whether the benefits of Qigong are derived from improved energy flow, or by better breathing and exercise is uncertain.

Fibromyalgia is a condition that involves diffuse, muscular pain in multiple parts of the body. It is more of a syndrome; meaning, it is described in terms of symptoms rather than objective findings such as offered by an X-ray or MRI. Fibromyalgia is also often associated with chronic fatigue syndrome. It is a difficult musculoskeletal disorder to diagnose and treat because it usually lacks a causative event. Some believe that it may be related to a virus, or abnormal central nervous system response.

A recent study investigating the effectiveness of qigong on fibromyalgia was published August 3rd. The randomized, controlled study involved 100 fibromyalgia patients, divided into a control group and test group. Outcomes were pain, impact, sleep, physical function and mental function, and these were recorded at baseline, 8 weeks, 4 months and 6 months using standardized pain questionnaires (10 point and 100 point). The test group participated in a one-hour practice session once weekly for 8 weeks and were asked to practice the movements and exercises at home every day for six months for 45 to 60 minutes. After the first 8 weeks of practice, the investigators reported the following results:

Based on a 10-point scale, patients in the qigong group had a 1.55 point reduction in pain compared with only 0.02 points in controls
Based on the 100-point Fibromyalgia Impact Questionnaire, individuals who participated in qigong reported a decrease of 18.45 points compared with 0.93 points in controls. This questionnaire rates pain, sleep, function, and psychological distress
Quality of sleep also improved during the 8-week treatment period based on a sleep quality index of 3.29 points
Psychologically, patients in the 8-week treatment group showed an improvement of 5.29 points on a questionnaire

Following the initial 8-week treatment period, the patients said they practiced for a mean of 4.9 hours per week, which declined to 2.9 and 2.7 hours by months 4 and 6, respectively. However, the 52% of patients who practiced at home the most (5 hours per week) enjoyed the most benefits in a number of areas.

Individuals who participated in the delayed treatment also showed improvements similar to those in patients who took part in the immediate qigong sessions and practice in all areas. When the authors combined the results of the two groups, the results revealed sustained effect of qigong on pain at both 4 and 6 months, and benefits persisted through 6 months for impact scores, sleep, and physical and mental well-being.

Bottom line: this is one of several studies that suggest the Chinese system of qigong exercise can be helpful in reducing, or at least managing chronic pain. If you have FM and have not tried it yet, it is worth investigating.

Functional Exercises to Strengthen the Core and Back

by Pain Doc | Aug 12, 2012 | Uncategorized

Functional exercises, in my opinion, are the “best” kind of exercises in that you get the most “overall benefit” per unit time doing them. This is especially true for those who don’t have that much time to dedicate to exercise.

Basically, functional exercises are those that engage the whole body rather than one section at a time. They improve strength, coordination, and muscle stamina; and have cardiovascular benefits as well. For example, arm curls, bench pressing, and leg pressing are not considered functional exercises because they target just one area. An example of a functional exercise would be carrying a 30# sandbag on your shoulder and walking up a hill.

Most people group exercise as either cardio or strength. But coordination is often forgotten. You see, muscle groups need to have good coordination between them in order for your body to function at its peak and be the most resistant to injury. Muscle coordination is a neurological function as much as it is a muscular contraction function. The proper “firing sequence” of neurons to each muscle fiber must be fine tuned in order to have optimum muscle performance, and this is done by repetitious, combined movements of multiple groups. Functional exercises do just that. Do them often, and you will notice that common movements will be easier to do, such as walking up a long flight of stairs, or lifting something heavy and placing it on a higher level.

Delayed Onset Muscle Soreness Treatment

by Pain Doc | Jul 6, 2012 | Uncategorized

Delayed Onset Muscle Soreness, or DOMS is a condition where your muscles feel pain a day or two after hard or unfamiliar exercise. DOMS is thought to more likely be worse with exercises that emphasize eccentric muscle contraction, where the muscle lengthens as it contracts. Examples of eccentric contraction include negative weight lifting (like lowering a curling bar slowly, squatting, and lunges). It is believed to be the result of microscopic tears of muscle and fascia fibers and consequential inflammation. Pain from micro injury is generated by inflammatory biochemicals interacting with nociceptors (nerves that transmit pain signals). In DOMS, the injuries are so small that it takes 12-24 hours before the inflammatory response is enough to generate pain and stiffness.

The muscle pain from DOMS is different in nature than a typical muscle sprain/strain injury. It generally is more widespread, depending on the muscle groups that were worked out the most. Contracting the affected muscles will increase symptoms. For affected muscles that cross a joint such as the knee and shoulder, stiffness reduces joint range of motion.

DOMS, while it can be quite uncomfortable, usually self-resolves in about 7-10 days, with rest and a break from physical exertion. But for some people, that is too long.

So, what can one do to prevent and treat delayed onset muscle syndrome?

(1) Take it easy, tiger. If you do not exercise frequently and decide one day to make up for all the months you slacked off by going “all out” you are setting yourself up for pain, stiffness, and movement limitations. If you haven’t been exercising for months, your muscles won’t be acclimated to taking loads and repetitions and will likely incur microtears in the fascia, tendons, and muscle fibers. So, use the 10% rule, which basically is a scaling up of exercise over a week or two depending on how often you go, to re-acclimate your muscles to your normal, maxed workout. Let’s say you usually curl 40 pound dumbbells. Start day one with 5 pounds, day two with 10 pounds, day three with 15 pounds, until you get up to your max.

(2) Seek out a professional. A personal trainer can show you the right exercises to do for your goals, and the proper technique to get the most out of it, without injuring yourself.

(3) Warm up. Do about 15 minutes of cardio before you do strength or functional training like Boot Camp and similar, full body exercises. Jumping jacks, jump rope, treadmill with incline are good choices.

(4) Do some light stretching. Although recent studies showed that stretching before exercising did not significantly reduce injuries, stretching feels good and can put you in tune with your body.

(5) Hydrate 30 minutes before your workout, competition, or task that will involve heavy lifting (like helping a friend move out of his house). Most sports drinks are formulated to provide the major electrolytes (sodium, potassium, calcium) that muscle use to contract.

(6) Know your limitations. As you age, you lose muscle mass; and therefore strength. Adapt your workout routine accordingly: lighter weights, exercises that are easier on the joints; more rests in between sets.

Now, if you still get DOMS, congratulations, you weren’t cheating; way to go for it! But seriously… here are things you can do to minimize it:

(1) Get a Swedish style or lymphatic drainage massage (NOT a deep tissue or acupressure massage) from an experienced, skilled massage therapist. The long, light pressure strokes towards the heart will increase lymph circulation and help your body clear out the inflammatory products. If you can find a place in your town that does endermologie (cellulite treatment), that is even better. Endermologie is a type of negative pressure massage done with a special machine that can increase skin circulation by over 300%, for up to six hours.

(2) Rest, ice, compress, elevate (RICE). If your whole body is affected, try a cold water bath for 20 minutes. Epsom salts added to the water, and eucalyptus can be helpful.

(3) Do some light exercise– walking, stretching, yoga.

(4) Take fish oil supplements. This may reduce the inflammation somewhat.

(5) Get some protein in you: whey protein drinks, eggs, fish. This gives the body the amino acids it needs to rebuild torn muscle.

(6) Rest. Try to get at least an hour more sleep per day while you are recovering.

And of course, no smoking or over indulging in alcohol during DOMs. When you are ready to start up exercising again, work up to max gradually over a week.

Pain With No Apparent Cause

by Pain Doc | Jul 2, 2012 | Uncategorized

It’s strange, but you would think that for someone experiencing neck, back, shoulder or any other type of musculoskeletal pain in his body, he would know exactly when it started, and how.

But surprisingly, this is not the case for a majority of patients I have seen over the years. Most cases of pain I see are idiopathic; meaning, “with no apparent cause (at least in the eyes of the patient).”

A typical history of such a patient goes something like this:

Me: “Ok Sue, I understand you are experiencing pain in your upper back, right side. When did it start, and how, to your knowledge?”

Patient: “At least the past five or so years. I don’t know what started it; it just seemed to have appeared gradually. It is good some days, then bad, and lately it has been getting worse, so I decided to get it checked.”

At this point, I continue with the history by asking questions related to the patient’s occupational, social/recreational, and past medical history. Usually there is something in the history that can be linked to the complaint, like a past car accident, a particular sports activity during college, or something about the physical requirements of her occupation. But in some cases, there still is nothing in the history that can explain the pain.

But where there is a problem, there is an answer. It’s just that sometimes the answer requires some smart detective work.

If you suffer from pain that can’t seem to be traced to a specific cause, realize that musculoskeletal pain, aside from systemic related disorders such as rheumatoid arthritis, lupus, bone disease, and others, develops from some kind of mechanical breakdown in the musculoskeletal system. It can be something obvious like a hard fall that injures and misaligns a joint; something seemingly innocuous like sleeping on your right side for most of your adult life; or something very subtle, like a subluxated heel bone that does its damage via a drip effect.

So, your best bet is to find a practitioner who is very experienced in human biomechanics. Chiropractors or physical therapists such as Craig Liebenson, DC who emphasize body kinematics and targeted exercise rehabilitation will typically have a keen eye for abnormal or dysfunctional movement. The course of treatment will involve identifying and acknowledging the problem; aggressive rehabilitative exercise regimen, and lifestyle modifications. Manual therapies may be employed, such as spinal manipulation; and orthotics may be required, at least during the initial phase of treatment.

This applies to conditions including unilateral hip or knee pain, TMJ pain, neck pain with right or left rotation, rib or sternum pain, and many others. Oftentimes the condition is secondary to a primary cause, so the doctor should not jump to conclusions and direct all treatment to the site of pain. A thorough investigation and inspection is required.

Hamstring muscle strain from running

by Pain Doc | Jun 29, 2012 | Uncategorized

I have a patient who complains of acute pain right under the right butt cheek, and inner part of the thigh. It is a persistent pain that has been bothering him for weeks and also feels stiff. He is in his mid 50s, professional, and in good health other than “high” cholesterol, for which he takes Lipitor.

The pertinent history for this patient is that he is an avid runner, and has been running regularly since his 20s. He is one of those folks who enjoys the feeling of running, during and after. It is a form of stress relief for him. He also does Pilates using the reformer, and enjoys 3-4 glasses of wine on most nights.

The area in question is the biceps femoris tendon, which is part of the “hamstrings” of the leg. It functions as the major knee flexor of the leg (its agonist, opposing muscle is the quadriceps group). The biceps femoris muscle inserts into the ischial tuberosity, which is the bony part of the ischium (half of the pelvis) that we use to sit.

Without the benefit of an MRI or CT scan, and based mostly on the history and lack of other findings that would cause me to think otherwise, I diagnosed myofascial strain of the biceps femoris tendon, with possible tendinopathy (degradation of the tendon from overuse). Basically, something has happened to the muscle and tendon that is resulting in unrelenting pain.

Running is the repetitive, alternating contraction and relaxation of opposing muscles. The most stress occurs at the tendinous attachments to the anchor points on the bone. However, the spot where the tendon attaches to bone is stronger than the breaking point of the tendon itself, so when it is stressed, the body of the tendon will experience tearing (strain) first. It is rare for a tendon to separate from bone at the attachment site. This is the case for this patient, as his pain is described as about 2-3 inches from the attachment point on the ischial tuberosity.

I am treating his injury with a LiteCure deep tissue laser and have given him a nutritional prescription consisting of whey protein to provide the building blocks for repair; high potency fish oil and capsaicin to help reduce the inflammation, and bromelain supplements to serve as an enzyme to soften scar tissue formation. Today, I advised him to drink distilled water for 2-3 weeks. Distilled water may have a chelating-type of effect (binding) on dissolved, inorganic toxins or debris in tissues, which could help with the situation; it is often used for detox programs because of this quality. He was advised to rest, ice and compress the area for 3 days to help suppress the inflammatory reaction.

The case is a very interesting one that will hopefully have a good outcome. We should realize that a muscle is very much like an organ of the body, although it is rarely referred to as one. It has its own unique type of cells, blood supply, and plays an important function. As in all cases of disease of the body, a good strategy is to give it an edge in repairing itself. Diet modification, concentrated, high potency supplements, and non-pharmacological, manual therapy, when used in the right manner can oftentimes hasten recovery.

What Should You Do For Neck Pain?

by Pain Doc | Jan 8, 2012 | Neck Pain

A recent study in the Annals of Internal Medicine compared the effectiveness of chiropractic spinal manipulation, pain medications, and home exercise and advice in treating biomechanical neck pain.

The study participants were 272 people between the ages of 18 and 65 who complained of non-specific neck pain for 2-12 weeks. They were divided into three groups, one of which took medicine only; one which received spinal manipulation to the neck only, and a third group that was just given home exercises and self-care advice. Participants were asked to rate their pain at 2 weeks, 1 month, 2 months, 3 months, 6 months, and one year. The method the study used to grade the pain was subjective rating (probably using a visual pain scale between 0 to 10, with 0 being no pain and 10 being the worst pain) and a Health Status questionnaire asking them their level of ability to engage in certain activities.

The patients treated by a chiropractor experienced the highest rate of success with 32 percent saying they were pain free, compared to 30 percent of those who exercised. Only 13 percent of patients treated with medication said they no longer experienced pain.

The conclusion of the study was that for participants with acute (recent onset) and subacute (usually meaning lasting more than two weeks) neck pain, chiropractic spinal adjustments were more effective than medication in both the short and long term. However, a few instructional sessions of home exercises and advice resulted in similar outcomes at most time points.

My comments:

Biomechanical neck pain can lower the quality of life significantly. Imagine having to struggle to turn your neck all the time, and having to avoid exercise, sports and many recreational activities due to neck pain. According to the researchers, neck pain affects 70% of adults at one point in their lives.

From my experience, biomechanical neck pain typically arises from some type of past trauma, and it doesn’t have to be major. Examples include car accidents, sports injuries/impacts, horseplaying as kids; and hard impact generating activities such as running, horseback riding, parachuting, gymnastics, boxing, martial arts, and cheer leading.

A second, possible cause of biomechanical neck pain is ergonomic in nature; meaning, related to positioning of the body. Long hours of desk work keeps the head relatively stationary (static) in a single position, allowing gravity to pull down on the head, over time altering the weight distribution on the joint surfaces of the bones that make up the neck. Such an “activity” also promotes muscle deconditioning around the neck. The term “deconditioned” means that the muscle is slower to respond to nerve commands, so it loses some ability to support, guard and protect the cervical spine (neck).

The worst combination is someone who has a history of impact trauma to the neck who later gets a job that involves working at a desk for long hours at a time. The trauma history sets the stage for neck pain, and the static positioning of the head accelerates the process over time.

The pain in biomechanical neck pain frequently originates in the joint surfaces of one or several cervical vertebrae, commonly the posterior facet joints (also called the zygapophyseal joints). This is where most of the movement occurs when turning and bending the neck. Orthopedic surgeons sometimes prescribe a facet block for neck pain, which is an injection of pain medications directly into the joint, usually guided by video fluoroscopy. If the patient has degenerative disc disease, pain can emanate from the intervertebral discs, either as a disc herniation or internal tear of the disc. If this is the case, neck surgery is typically the last hope. The disc herniation may be able to be reduced by surgery, but if the surgeon feels that the disc is beyond repair, discectomy (total disc removal) with surgical fusion is usually performed. However, this is like trading one evil for another. Surgeons know that when you fuse two vertebrae together, the vertebrae above and below the fusion bear an increased burden of providing the movement lost by the two fused vertebrae. This will lead to accelerated degenerative changes to those areas as well, over time.

Neck pain can also emanate from the surrounding muscles and fascia. Myofascial trigger points are focal, tender spots along a muscle that are believed to develop from trauma or microtrauma. They may actually be a concentration of nerve endings on the muscle that developed following an injury. These are best handled through manual therapies such as chiropractic, massage, exercises and stretches.

Some people get inexplicable muscle spasms of the neck. This is usually accompanied with a migraine or tension headache. A muscle spasm occurs when the nerves that control the muscle misfire, causing the muscle to maintain a constant state of hypertonus (involuntary contraction). This results in muscle pain, fatigue and low grade inflammation. Sometimes the spasm can be so intense that anti-spasmodic medications, ice, heat, and rest have no effect. In cases like this, botox injections are sometimes used. Botox injections are comprised of a weakened strain of the Botox bacteria, which has the effect of muscle paralysis.

Lastly, it should be mentioned that a poor, nutrient-deficient diet and smoking can make neck pain worse by denying the body critical nutrients needed for repair and maintenance of muscles, ligaments, tendons, nerves and bones.

The study, while emphasizing that chiropractic manipulation was superior to medications in reducing neck pain among participants, also mentions that home exercises and advice were just as effective. It therefore seems natural that a combination of spinal manipulation and home exercises would be a good strategy to reduce or eliminate biomechanical neck pain.

If you are experiencing non-specific neck pain (don’t really know what caused it) for over two weeks and desire to try chiropractic, it’s important to choose a good, qualified chiropractor. Some of the signs of a good, reputable chiropractor are:

1. Doesn’t try to convince you to purchase a long-term treatment program involving multiple adjustments per week.

2. Asks you about your complaint: the nature of your symptoms, how they started, how long you’ve had these symptoms, how they affect your ability to do certain things; and questions regarding your general health.

3. Gives you his/her diagnosis and uses standard orthopedic terminology that is consistent with what you are coming in for (doesn’t go off subject). It meshes with the information you provided in #2 above. You feel that the chiropractor listened to you, and responded with a meaningful solution that is clear to you.

4. Gives you a treatment recommendation the same day: the type of treatment and a brief description of it (spinal adjustments, modalities, supports); what to expect from the treatment, and approximately how long it will take. The chiropractor should also disclose potential risks and side effects of the treatment. In my opinion, six treatments followed by a re-evaluation is a sensible treatment approach for most cases of subacute, musculoskeletal pain.

A chiropractor like this may or may not have a lot of reviews on the internet. Use your judgement, ask friends and co-workers for referrals, and by all means, don’t be afraid to change chiropractors if your first choice turned out to be bad.

Regarding home exercises and advice for treating biomechanical neck pain, stay tuned! I will be putting up an information-packed neck pain relief video on this topic shortly.

Questions to Ask Your Doctor About Neck Pain (everydayhealth.com)
Why Do I Have Neck Pain? (everydayhealth.com)

Can Custom Foot Orthotics Help Back Pain?

by Pain Doc | Dec 25, 2011 | Foot and Ankle Pain

Shoe orthotics are custom made shoe inserts that doctors (podiatrists, chiropractors and orthopedic MDs) use to help patients suffering from foot, ankle, knee, hip, or back pain. The concept is that, since the feet are literally the foundation of a standing human body, any problems in the foundation will translate to problems further up the body.

If you stop to consider this, it makes a lot of sense. You don’t have to have any special training to realize the connection. For example, if the foot rolls inwards when walking (called prontation) it can place twisting forces in the knee and hip. This will require more effort from the locomotor muscles, which are not only your leg muscles, but also your gluteus (buttock) muscles and psoas muscle (major hip flexor) which attaches itself to the lumbar (lower back) spine. This happens subconsciously behind the scenes, but you will definitely notice the effects: pain in the weight bearing joints, back stiffness, reduced mobility/agilitiy, and fatigue.

Take a moment to look at the soles of your shoes (find an old, heavy-used pair in your closet). Are they worn out a lot more on the inner edges? If so, chances are you are over-pronating. This is common with people who have flat feet, or “fallen arches.” If this is the case, a pair of shoe orthotics shaped in a way to counter the rolling-in action can be prescribed. They may be rigid or semi-rigid, depending on what the doctor thinks is more appropriate. If the rolling in can be minimized by the shoe orthotic, then there will be less twisting forces to the knee and hip, resulting in a more efficient gait (walking motion) and less strain to the lower back.

A May 2011 study in the Journal of Manipulative Physiological Therapeutics studied the effects of custom shoe orthotics on a test group of 50 people experiencing lower back pain. Some were treated for 12 weeks with the orthotics, some had no treatment, and some were treated for 6 weeks. It found that from 0-6 weeks of treatment, there was improvement in subjective scores for pain. From weeks 6-12, improvement was maintained, but did not continue to improve. The people who did not use orthotics continued to experience the same level of pain.

These findings suggest that there is a relationship between foot biomechanics and lower back pain, and that improvements can be effected by correcting imbalances in the foot. However, it also suggests that more studies are needed. What I take from it is that orthotics prescription is appropriate when indicated for treating lower back pain, but must be complemented with other types of interventions, depending on the case. This may include exercise rehabilitation, somatic exercises, nutrition, and spinal manipulation.

If you desire to get custom made foot orthotics, you can seek out the services of a podiatrist. Some chiropractors can prescribe orthotics as well. Two of the main brands chiropractors use are Amfit and FootLevelers. An off the shelf brand that I have found success with is the WalkFit orthotics. These come with a gel cushion for the heel and acupressure massage surfaces to help with blood circulation. If you wear sandals, which can pose a problem for traditional, doctor-prescribed orthotics, the come with sandal attachments. Plus, they are a lot less expensive; less than $20.

To Run Barefoot or Not?

by Pain Doc | Dec 9, 2011 | Foot and Ankle Pain

If you suffer from foot pain, knee pain, or lower back pain of unknown origin, then it might be related to your shoes: Scientists recently held a conference in England to debate shoe running vs. barefoot running. Over the last five years, the barefoot movement has gained a lot of recognition among runners and experts in human biomechanics. I wrote about the merits of going barefoot last year. The movement was apparently started by the book “Born to Run” by Christopher McDougall. In it, he tells of time spent with members of Mexico’s indigent Tarahumara tribe, who routinely run long distances barefoot, often very fast, apparently without suffering the injuries that plague many avid runners in the developed world.

The issue is whether or not putting on a pair of running shoes implicitly causes the person to run in an unnatural way; a way that goes against nature’s design, due to a “false sense of security” offered by the thick cushioning of the shoes, especially in the heel and arch.

In a study published in the scientific journal Nature last year, Daniel Lieberman, an evolutionary biology professor at Harvard University, sought to find out how our ancestors, who ran and hunted for millions of years in bare feet or simple moccasins, coped with the impact of the foot hitting the ground.

Lieberman and colleagues from Britain and Kenya studied runners who had always run barefoot, those who had always worn shoes, and runners who had abandoned shoes.

They found that barefoot endurance runners often land on the fore-foot (the ball of the foot) before bringing down the heel, while shoe runners mostly rear-foot (heel) strike, prompted by the raised and cushioned heels of modern running shoes.

The study further discovered that barefoot runners incur less collision forces on their feet compared to shoe runners, despite the heel cushioning of the shoe, and that they use their calf muscles more efficiently.

As of this date, there isn’t a large scale study that gives definitive data on what is better for the human body, going barefoot or wearing shoes. People are taking sides based on their beliefs, biases and experiences. Major athletic shoe companies generally are against the barefoot running idea, for obvious reasons; but some are experimenting with “minimalist” shoes to capture this growing market. These are shoes that offer protection to the feet but with the least amount of restriction.

My take on this: it makes a lot of sense to walk and run barefoot. It is a natural act, and it’s tough to argue against nature because it has its ways of cancelling out bad traits. Our human ancestors walked and ran barefoot for millions of years, and were fine. I believe that walking barefoot exercises the muscles and small joints of the foot and takes more of the load off the knees, hips and pelvis in doing so. On the contrary, wearing shoes binds the feet, prevents the foot joints from doing their job of distributing the body weight and cushioning the shock, and makes the leg and back muscles work in a less efficient manner. It is easy to see how this can result in lower back problems. So, walk barefoot more than you currently do– not just in the house, but on pavement, hilly terrain, and the nearest park. Then, when you feel that your feet have acclimated to the new sensations, give barefoot running a try!