Foot orthotics for low back pain: The state of our understanding and recommendations for future research

Effect of Customized Insoles on Gait in Post-Stroke Hemiparetic Individuals: A Randomized Controlled Trial

Background: Insoles have been widely applied to many diseases, but stroke involves complex problems and there is a paucity of research on the application of insoles in stroke patients. Aim: To evaluate the effect of customized insoles on gait in patients with hemiplegia. Design: A randomized controlled trial. Setting: Rehabilitation department of a hospital. Population: A total of 50 stroke patients were randomized into an experimental group (n = 25) or a control group (n = 25). Methods: Both groups received conventional gait training, which was conducted five times a week, every 40 min for four weeks and patients in the experimental group were required to wear customized insoles for at least 1 h per day for four weeks. The primary outcome measure was the Tinetti Gait Scale (TGS) and the secondary outcome measures were the plantar pressure test, 6-min walking test (6MWT), lower extremity Fugl-Meyer assessment (FMA-LE), Berg Balance Scale (BBS), and the modified Barthel index (MBI). Results: Compared to the control group, there were significant increases in the experimental group after four weeks (p = 0.014) and at the four week follow-up (p = 0.001) in the change in TGS, weight-bearing on the involved side (p = 0.012) or forefoot (p = 0.028) when standing, weight-bearing on the involved side (p = 0.01 6) or forefoot (p = 0.043) when walking, early stance phase (p = 0.023) and mid stance phase (p = 0.013) on the involved side, FMA-LE (p = 0.029), BBS (p = 0.005), and MBI (p = 0.009), but there were no differences in the late stance phase (p = 0.472) on the involved side when walking or in the 6MWT (p = 0.069). Conclusions: Customized insoles had great efficacy in enhancing gait performance in stroke patients.

Custom-Made Foot Orthoses as Non-Specific Chronic Low Back Pain and Pronated Foot Treatment

Excessive foot pronation has been reported as being related to chronic low back pain symptoms and risk factors in sports-specific pathologies. Compensating custom-made foot orthotics treatment has not been entirely explored as an effective therapy for chronic low back pain (CLBP). This study aims to observe the effects of custom-made foot orthoses, in subjects with foot pronation suffering from CLBP. A total of 101 patients with nonspecific CLBP and a pronated foot posture index (FPI) were studied. They were randomized in two groups: an experimental one (n = 53) used custom-made foot orthotics, and the control group (n = 48) were treated with non-biomechanical effect orthoses. The CLBP was measured using the Oswestry Disability Index (ODI) Questionnaire and a visual analogue scale (VAS), both for lower back pain. The symptoms were evaluated twice, at first when the subject was included in the study, and later, after 4 weeks of treatment. The analysis of outcomes showed a significant decrease in CLBP in the custom-made foot orthoses participants group (p < 0.001 ODI; p < 0.001 VAS). These findings suggest that controlling excessive foot pronation by using custom-made foot orthoses may significantly contribute to improving CLBP.

The biopsychosocial-digital continuum of foot orthosis practice and research: the VALUATOR model

Foot orthoses have been used for decades despite uncertainty surrunding their therapeutic efficacy. Orthoses have been used exclusively to affect neuro-biomechanical input and outcome variables, however, there is emerging evidence that therapeutic efficacy may be affected by a psychological stimulus. Critical appraisal of the literature highlights that there is no holistic model upon which foot orthosis practice is taught, practised nor investigated. This paper introduces a conceptual model of foot orthosis practice (Value Based Foot Orthosis Practice (VALUATOR) model) that embraces a broader range of factors that are pertinent to orthosis practice, incorporating contemporary health service behaviours and values into orthosis practice for the first time.Within the VALUATOR model, foot orthosis design and clinical value is considered along a bio-psycho-social-digital continuum that reflects the reality of foot orthosis practice. The model contextualises the variable outcomes that are observed in research and practice within 6 key areas: 1) value, 2) person-centered approach, 3) zone of optimal bio-psycho-social stress, 4) bio-psycho-social assessment, 5) monitoring, 6) primary and secondary clinical strategies.The VALUATOR model is targeted at students, lecturers, scientists and practitioners and includes carefully chosen terminology to support a robust basis for educational and scientific discussion. It is believed that it provides a contemporary viewpoint and a structured conceptual metaphor that builds on existing evidence from a wide range of sources, invites constructive intellectual debate, and is anchored in the experiences of practitioners too. Stress testing the VALUATOR model will help determine its model and support further developments and evolution of orthotic practice in a evidence based way.

Using a texture analyser to objectively quantify foot orthoses

BACKGROUND AND AIM

Foot orthoses alter the kinematics and kinetics in gait. With the increasing importance of evidence based practice and with the permanent development of subtractive manufacturing and introduction of additive manufacturing, there is a growing need for quantification of orthoses parameters. We describe a measurement method and protocol to quantify different parameters of a foot orthosis.

TECHNIQUE

A texture analyser is used to impose a displacement of the surface of the orthosis, while the applied force is measured. The measured points are determined based on the location of anatomical landmarks on the foot. Out of the measured data, parameters are calculated representing the stiffness, compression set and shape.

DISCUSSION

To illustrate the proposed technique, five different parameters are extracted from three example orthoses. Results show the added value of the proposed technique as the parameters are not only defined by the material but also by the shape.

Trunk kinematic, kinetic, and neuro-muscular response to foot center of pressure translation along the medio-lateral foot axis during gait

Footwear devices that shift foot center of pressure (COP), thereby impacting lower-limb biomechanics to produce clinical benefit, have been studied regarding degenerative diseases of knee and hip joints, exhibiting evidence of clinical success. Ability to purposefully affect trunk biomechanics has not been investigated for this type of footwear. Fifteen healthy young male subjects underwent gait and electromyography analysis using a biomechanical device that shifts COP via moveable convex elements attached to the shoe sole. Analyses were performed in three COP configurations for pairwise comparison: (1) neutral (control) (2) laterally deviated, and (3) medially deviated. Sagittal and frontal-plane pelvis and spine kinematics, external oblique activity, and frontal and transverse-plane lumbar moments were affected by medio-lateral COP shift. Transverse-plane trunk kinematics, activity of the lumbar longissimus, latissimus dorsi, rectus abdominus, and quadratus lumborum, and sagittal-plane lumbar moment, were not significantly impacted. Two linear mixed effects models assessed predictive impact of (I) COP location, and (II) trunk kinematics and neuromuscular activity, on the significant lumbar moment parameters. The COP was a significant predictor of all modeled frontal and transverse-plane lumbar moment parameters, while pelvic and spine rotation, and lumbar longissimus activity were significant predictors of one frontal-plane lumbar moment parameter. Model results suggest that, although trunk biomechanics and muscle activity were altered by COP shift, COP offset influences lumbar kinetics directly, or via lower-limb changes not assessed in this study, but not by means of alteration of trunk kinematics or muscle activity. Further study may reveal implications in treatment of low back pain.

Footwear-Generated Dynamic Biomechanical Manipulation and Perturbation Training for Chronic Nonspecific Low Back Pain

BACKGROUND

Home-based therapy optimizing biomechanics and neuromuscular control is increasingly recognized as a treatment option for chronic nonspecific low back pain (CNSLBP). However, its impact on pain, function, and gait is limited among patients in a metropolitan area.

OBJECTIVE

To evaluate the change of pain, function, and gait parameters with home-based therapy with the use of footwear-generated biomechanical manipulation and perturbation training in a population with CNSLBP in a metropolitan area.

DESIGN

Prospective observational study.

SETTING

Outpatient rehabilitation clinic at an academic teaching hospital.

PARTICIPANTS

One hundred sixteen patients with CNSLBP for more than 6 months.

INTERVENTION

Six months of home-based therapy with a biomechanical device using 4 modular elements attached to a foot-worn platform.

MAIN OUTCOME MEASURES

Instrumental gait analysis (gait velocity, step length, single limb support phase % of gait cycle), Numeric Rating Scale for pain, and Oswestry Disability Questionnaire Index for pain and function.

RESULTS

Only 43 patients (37.1%) completed the study. Among 43 patients, mean gait velocity increased from 86.6 ± 20.7 to 99.7 ± 22.1 cm/s (P < .0001) in 6 months. Mean left step length increased from 51.1 ± 8.4 to 54.8 ± 9.8 cm (P < .0001). Mean right step length increased from 51.0 ± 7.9 to 55.4 ± 9.0 cm (P < .0001). Mean single limb support increased from 36.4 ± 2.8 to 37.2 ± 2.5%, (P = .208) in the right side and from 36.6 ± 3.0 to 37.8 ± 4.4%, (P = .019) in the left side. Median Oswestry Disability Questionnaire Index score improved from 28 (18-44; interquartile range) to 17 (10-35) (P = .045). Mean Numeric Rating Scale for back pain improved from 7.7 ± 1.8 to 3.3 ± 3.1 (P < .0001).

CONCLUSION

At 6 months, patients with CNSLBP undergoing home-based therapy with footwear-generated biomechanical manipulation and perturbation training demonstrated significant improvement of objective gait parameters, pain, and function.

LEVEL OF EVIDENCE

IV.

Muscle activity and kinetics of lower limbs during walking in pronated feet individuals with and without low back pain

The objectives of this study were to investigate whether excessive feet pronation alters the joints' kinematics, kinetics and the activity of involved muscles during gait in low back pain patients.

METHODS

The lower limb joints' motion, moment and power, as well as the activity of involved muscles during walking were measured in a control group, and two experimental groups including a group with excessive feet pronation only, and another group of low back pain patients with excessive feet pronation.

RESULTS

In both experimental groups, ankle inversion, knee flexion and internal rotation, hip internal rotation, plantar flexors' moment, hip flexors' moment, and peak positive ankle power were lower than those in control group (p < .05). Besides, in patients, higher activity of gastrocnemius medialis, gluteus medius, erector spinae, and internal oblique muscles, and lower negative power at the ankle and peak positive power at the knee were observed (p < .05). In conclusion, pronated feet with low back pain was associated with less ankle inversion and knee flexion, higher knee and hip internal rotation, higher muscle activity, less energy absorption at the ankle, and reduced positive power at the knee. This study reveals that strengthening of the muscles especially knee extensors are of great importance in low back pain patients with feet pronation.

Influence of custom foot orthoses on venous status: A quasi-experimental study

BACKGROUND

Customized foot orthoses (CFO) have been widely accepted to reduce the frequency of foot problems and postural disorders. The purpose of the research was to compare the influence of CFO utilization on the venous status among healthy females and males.

METHODS

This was a quasi-experimental study (NCT03329430), which included 20 healthy subjects that completed all the stages of the process. The subjects showed an age mean of 20.00 ± 1.62 years and were recruited in a foot and ankle specialist center. Self-reported data were medical records and venous function which were evaluated by plethysmography with or without utilization of CFO.

RESULTS

A sample of 40 feet was studied, showing statistically significant differences between venous filling time (P < 0.001) and in the ejection fraction (P < 0.001) with CFO utilization versus without use of CFO.

CONCLUSIONS

Healthy people who utilize CFO evidenced an increased venous return in the feet.

National profile of foot orthotic provision in the United Kingdom, part 1: practitioners and scope of practice

Background

Foot orthoses have been advocated in the management of a wide range of clinical foot and lower limb problems and are within the scope of podiatry, orthotic and physiotherapy practice. Previous reports into the provision of orthoses have consistently identified significant issues with services and devices, but data were never specific to foot orthoses. The aim of this first of a series of papers was to report the first ever national multi professional profile of foot orthosis provision in the United Kingdom.

Methods

Quantitative and qualitative data were collected from podiatrists, orthotists and physiotherapists via an online questionnaire. The topics, questions and answers were developed through a series of pilot phases. The professions were targeted through electronic and printed materials. Data were captured over a 10 month period in 2016.

Results

A total of 499 responses were included in analysis, including 357 podiatrists, 93 orthotists and 49 physiotherapists. The results reveal wide ranging practices across podiatrists, orthotists and physiotherapists, provision of orthoses through different health care departments (uni and multidisciplinary), for different health conditions (acute and chronic), and involving different types of orthoses (prefabricated and customised).

Conclusion

Foot orthoses in the United Kingdom are provided in areas of well recognised health and rehabilitation priorities. A wide range of orthotic devices and practices are employed and different professions provide foot orthoses in different ways.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-017-0215-4) contains supplementary material, which is available to authorized users.

Restriction in lateral bending range of motion, lumbar lordosis, and hamstring flexibility predicts the development of low back pain: a systematic review of prospective cohort studies

Background

Low back pain (LBP) is an increasingly common condition worldwide with significant costs associated with its management. Identification of musculoskeletal risk factors that can be treated clinically before the development of LBP could reduce costs and improve the quality of life of individuals. Therefore the aim was to systematically review prospective cohort studies investigating lower back and / or lower limb musculoskeletal risk factors in the development of LBP.

Methods

MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus, and the Cochrane Library were searched from inception to February 2016. No age, gender or occupational restrictions of participants were applied. Articles had to be published in English and have a 12 month follow-up period. Musculoskeletal risk factors were defined as any osseous, ligamentous, or muscular structure that was quantifiably measured at baseline. Studies were excluded if participants were pregnant, diagnosed with cancer, or had previous low back surgery. Two authors independently reviewed and selected relevant articles. Methodological quality was evaluated independently by two reviewers using a generic tool for observational studies.

Results

Twelve articles which evaluated musculoskeletal risk factors for the development of low back pain in 5459 participants were included. Individual meta-analyses were conducted based on risk factors common between studies. Meta-analysis revealed that reduced lateral flexion range of motion (OR = 0.41, 95% CI 0.24-0.73, p = 0.002), limited lumbar lordosis (OR = 0.73, 95% CI 0.55-0.98, p = 0.034), and restricted hamstring range of motion (OR = 0.96, 95% CI 0.94-0.98, p = 0.001) were significantly associated with the development of low back pain. Meta-analyses on lumbar extension range of motion, quadriceps flexibility, fingertip to floor distance, lumbar flexion range of motion, back muscle strength, back muscle endurance, abdominal strength, erector spinae cross sectional area, and quadratus lumborum cross sectional area showed non-significant results.

Conclusion

In summary, we found that a restriction in lateral flexion and hamstring range of motion as well as limited lumbar lordosis were associated with an increased risk of developing LBP. Future research should aim to measure additional lower limb musculoskeletal risk factors, have follow up periods of 6-12 months, adopt a standardised definition of LBP, and only include participants who have no history of LBP.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1534-0) contains supplementary material, which is available to authorized users.

Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial

OBJECTIVES

To investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment.

DESIGN

Randomized controlled trial.

SETTING

Integrative medicine teaching clinic at a university.

PARTICIPANTS

Adult subjects (N=225) with symptomatic low back pain of ≥3 months were recruited from a volunteer sample.

INTERVENTIONS

Subjects were randomized into 1 of 3 treatment groups (shoe orthotic, plus, and waitlist groups). The shoe orthotic group received custom-made shoe orthotics. The plus group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage. The waitlist group received no care.

MAIN OUTCOME MEASURES

The primary outcome measures were change in perceived back pain (numerical pain rating scale) and functional health status (Oswestry Disability Index) after 6 weeks of study participation. Outcomes were also assessed after 12 weeks and then after an additional 3, 6, and 12 months.

RESULTS

After 6 weeks, all 3 groups demonstrated significant within-group improvement in average back pain, but only the shoe orthotic and plus groups had significant within-group improvement in function. When compared with the waitlist group, the shoe orthotic group demonstrated significantly greater improvements in pain (P<.0001) and function (P=.0068). The addition of chiropractic to orthotics treatment demonstrated significantly greater improvements in function (P=.0278) when compared with orthotics alone, but no significant difference in pain (P=.3431). Group differences at 12 weeks and later were not significant.

CONCLUSIONS

Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment. The addition of chiropractic care led to higher improvements in function.