Annals of Musculoskeletal Disorders

Cite this article: Irvin R (2018) Disequilibrium of Posture as Root Cause for Preponderance of Chronic Neuromusculoskeletal Pain. Ann Musc Disord 2(1): 1006.

Central

*Corresponding authorRobert Irvin, Adjunct Clinical Associate Professor, Department of Osteopathic Manipulative Medicine, Oklahoma State University Center for Health Sciences, 1111 West 17th Street, Tulsa, Oklahoma, 6620 Bryant Irvin Road, Suite 100, Fort Worth, Texas 76132, USA, Tel: 817-346-6656; Fax: 817-346-8305; Email:

Submitted: 13 June 2017

Accepted: 12 October 2017

Published: 16 July 2018

Copyright© 2018 Irvin

OPEN ACCESS

Keywords•Chronicpainofnonspecificcause•Postural imbalance•Custom foot orthotics•Heel lift•Ischial lift

Research Article

Disequilibrium of Posture as Root Cause for Preponderance of Chronic Neuromusculoskeletal PainRobert Irvin*Department of Osteopathic Manipulative Medicine, Oklahoma State University, USA

Abstract

Chronic musculoskeletal pain is one of the largest unsolved problems in medicine, as measured by incidence and cost. Current concepts of specific mechanical causation of musculoskeletal pain often overlook one very important root cause-disequilibrium of posture. This includes the imbalance of forces that necessitate additional force to maintain stability. Causation for postural disequilibrium is multifactorial, thus studies addressing only single factor observation or intervention have had inconclusive results. These outcomes have led to the premature conclusion that posture is not a significant player in the genesis of chronic pain.

Studies show that the preponderance of chronic pain and disease of the musculoskeletal system is mediated by mechanical stress. Origins of chronic musculoskeletal pain have been thought as being either contiguous with or, by mechanical chain, neighboring to the painful site. I propose a third etiology, “centric” causation, as a treatable origin for chronic musculoskeletal pain.

Three regions of the body have a large, pan corporeal influence on posture and related chronic pain, previously thought to be of non-specific cause: the central nervous system (CNS), the sacral base, and the feet/ankles. This relies on the concepts that the CNS is central anatomically with respect to the neurologic system, the sacral base is central with respect to the geometry of the outstretched human body, and the feet/ankles are central with respect to ground support, gravity, and total body load.

Custom orthotics, which aligns these regions of the body while sitting or standing with respect to gravitation, can significantly reduce mechanical stress as a pain generator. Synchronous correction of the “attitudes” of the feet and ankles, and the unlevel sacral base, simultaneously reduce mechanical stress and chronic pain throughout the body. Improved postural symmetry with pain reduction is outlined in the illustrations and case presentations in this paper. Outcomes are very favorable, and “centric” causation of chronic musculoskeletal pain should be considered so that early treatment can be initiated.

ABBREVIATIONSRMD: Rheumatic and Musculoskeletal Disease; NMS:

Neuromusculoskeletal; MSD: Musculoskeletal Disease; CFO: Custom Foot Orthotics; Nl: Normal; CNS: Central Nervous System; FSS: Functional Somatic Syndrome

INTRODUCTIONChronic musculoskeletal pain has the highest incidence

of all medical diseases. The annual aggregate cost in the U.S., both direct and indirect, is estimated at $873.8 billion per year. This is more than the yearly costs for cancer, heart disease and diabetes combined [1] (Figure 1). Persons with chronic wide spread pain experience excess mortality risk [2], including death

from cardiovascular and cancer. Overall 27.7% or about 17.3 million people (95% Cl 26.9-28.4%) report having rheumatic and musculoskeletal disease (RMD) [3]. The most prevalent RMDs were low back pain (12.5%, 12.1-13.1) and osteoarthritis (12.3%, 11.8-12.7).

This paper introduces centric cause as a new hypothesis of causation for most chronic neuromusculoskeletal (NMS) pain that is mediated by mechanical stress secondary to postural imbalance.

Chronic musculoskeletal pain is attributed to either MSDs or “nonspecific” cause. MSDs represent injuries or pain to the body’s joints, ligaments, muscles, nerves, tendons, or structures that support the limbs, neck or back [4]. MSDs can arise from sudden

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 2/12

Central

exertion (e.g., lifting a heavy object), repetitive motions, or from repeated exposure to force, vibration, or awkward posture [5]. Physical factors can interact with ergonomic, psychological, social, and occupational factors to increase symptoms [6].

There are problems with both experimental design and conclusions drawn from prior studies regarding posture and pain. A systematic review of the literature fails to find a consistent connection between awkward posture and low back pain [7]. Prior studies, which concluded a lack of correlation for postural imbalance and chronic pain, did not correct the multiple and pivotal factors that mediate postural imbalance [8,9]. For example, where an orthotic device (instrument to correct or straighten) such as a heel lift to reduce pelvic obliquity was studied in isolation, pain from postural imbalance was not significantly changed.

There is also no observed correlation between pelvic obliquity/asymmetry and lower back pain [10-13]. One of the arguments in favor of an association between leg length differences and low back pain is the reported success of heel lifts in reducing back pain [14-19].

However, all these studies failed to include controls or sham heel lift (such as inefficient soft foam lift). There are problems with insistence on control group or sham treatment in the particular case of postural imbalance. A population controlled by withholding treatment is difficult to collect. A soft foam heel lift or a foot orthotic with minimal amplitudes would not be credible to the patient. Placement of a heel lift on the wrong side could cause pain, with participant rejection. The insistence for control group or sham treatment, else disregard of outcomes, has led one investigator to conclude that there is no evidence for a causal relation between postural imbalance and chronic pain [20].

Furthermore, most studies did not use the radiographically measured attitude of the sacral base as a reference for observation or intervention of pelvic obliquity. Instead, references such as leg lengths or iliac crest measurements were used, as the importance of the sacral base for postural balance was not well understood. Thus, the causality for chronic pain from postural imbalance was not adequately tested.

Another problem with prior studies of posture and chronic pain is the presumption that if there is no observable aspects of postural imbalance that correlate with chronic pain, this fact

exhausts the possibility of causation. There are three classes of causation [21], with the latter two not being adequately tested as follows

1. Observational causality: Where one sees an entity A, one regularly sees a second entity, B.

Both early and subsequent studies [8,9] found that postural imbalance assessed by any reference (entity A) has no predictive value for chronic pain (entity B).

2. Manipulable causality: Change A, B changes.

I propose that by use of orthotics and physical therapy to minimize multi-factorial imbalance of posture, chronic and multiregional pain of otherwise “non-specific” cause is greatly alleviated. Hence, there is manipulable causality for minimization of postural imbalance and chronic pain.

3. Postulational causality: Given a postulate, where one sees A, one is not surprised to see B.

Postulational causality has several features that distinguish it from observational or manipulable causalities. The leading feature of a postulational explanatory theory of causality is that it introduces a new domain of entities. An example of successful medical postulates is Koch’s Postulates for Infectious Disease.

Koch’s postulates are four criteria designed to establish a causal relationship between a microbe (a hypothetical entity at that time) and a disease. The postulates were formulated by Robert Koch and Friedrich Loeffler in 1876 [22] and refined and published by Koch in 1890. They serve as an excellent example of innovative medical postulation.

Centric causation is a postulate for this new domain of entity for the cause of chronic pain. By virtue of this centricity, one is not surprised when balancing the posture relieves chronic pain throughout the body, throughout the body, and lack of surprise represents postulational causality.

Biological literature does not offer much knowledge with respect to posture and chronic pain. Interestingly, the field of art is well developed in the practical aspects of posture, being chiefly concerned with esthetics, ideal human form, and the mechanical stability of statues in terms of postural balance. The historical advances of this artistic knowledge of posture led to the discovery of centric causation.

The greatest advance in statuary posture occurred during the Golden Era of classical Greek sculpture (~500-300 BC). The discovery of the ideal mathematical proportions for the human form was attributed to Myron (480-440 BCE). His student was Polykleitos of Argos, a renowned Greek bronze sculptor who flourished between 450 and 420 BCE [23]. His treatise, entitled the Kanon (or Canon, translated as “measure” or “rule”), exemplified what he considered to be the perfectly harmonious and balanced proportions of the human body in the sculptured form. These proportions transformed classical statuary, endowing it with both esthetic appeal and postural balance. The latter enabled the statues to balance upright, without the need for extrinsic bracing.

Pre-Classical statuary (c. 600 B.C.) depicted the human form as having perfect symmetry, right to left. An example is the

Figure 1 The proportion of musculoskeletal conditions far exceeds those for all other conditions observed at the level of primary care.

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 3/12

Central

lost to modernity, this proportionality enabled sculpture’s work to be both esthetically pleasing, posturally balanced, and with the appearance of being dynamically lifelike. As for a living human, the statue could stand unbraced with one knee bent, the pelvis unlevel, torso side bent, head turned and arms in different positions (Figure 3B).

Approximately 320 years later, Romans recovered several classical statues of ancient Greece, and imitated them using calipers to make approximate measurements. For reason of imperfect postural balance, these statues necessitated some form of extrinsic brace to sustain balance (Figure 3C). This imbalance illustrates that even subtle variance of posture from ideal can result in disequilibrium.

This theory is contrary to the modern view, which argues that copies of the bronze statues made from marble must have increased support because of the weight of the stone itself. Thus, we see light, hollow bronze statues like Antikythera Youth (c. 340 BC) without lateral support, in contrast to the heavy, supported, marble sculptures [42]. This modern interpretation is problematic since 1) total mass has no effect on stability, within the limits of material strength and ground support, 2) lateral support relates directly to equilibrium, defined as balance of total forces, both intrinsic and extrinsic to the body, and 3) lateral support contributes little to compressive support.

Leonardo da Vinci later illustrated certain interregional proportions in the supine outstretched human figure, which is an icon of modern medicine, known as the “Vitruvian Man, or the “Universal Man” (c. 1490). Vitruvius (c. 1st century BC) was an architect/civil engineer/military engineer who was assigned by the Roman emperor Augustus (27 BCE-14 CE) to study the classical architecture and statues of ancient Greece, so that the Roman sculptors and architects could emulate these structures. This classicism of architecture was based on the proportionality of the human form, hence the phrase “Man is the measure of all

A B

Figure 2 (A) A schematic that illustrates the equivalent right-left symmetry of the (B) Kouros statuary, commonly present in the cemeteries of ancient Greece, c. 600 B.C.

Figure 3 (A): Interregional proportionality of the hand to the forearm, in accord with the Golden Mean. (B): Youth of Antikythera (c. 340 BC), regulated by interregional proportionality, stands unbraced.(C): Roman imitation of Discus Thrower by Myron (480-440 BCE), obtained by caliper measurements of the original Greek version, lost to modernityNote the tree trunk for the Roman reproduction, necessary for postural balance of this imitation.

Kouros statue, often used in Greek cemeteries (Figure 2). While posturally balanced, a limitation of this symmetry is that it did not appear lifelike nor dynamic, but rather static in appearance. Myron overcame this limitation by discovery of “interregional proportionality”, based in part on the Golden Mean (Figure 3A).

While the full canon for anatomic proportionality has been

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 4/12

Central

Figure 4 (A): The illustration of the Vitruvian Man by Leonardo da Vinci did not strictly follow the description by Vitruvius of the proportionate man, whereby the human figure is fully outstretched with both the feet and hands extended. Where the feet and hands are extended, the geometric center is the sacral base. (B): Instead, Leonardo depicts the feet as flat, rendering the geometric center the navel.

things”. Inspection of these writings by Vitruvius reveals a flaw that points to the navel as the geometric center of the human frame.

As written by Vitruvius in his The ten books on architecture [24]

“Similarly, in the members of a temple there ought to be the greatest harmony in the symmetrical relations of the different [p73] parts to the general magnitude of the whole. Then again, in the human body the central point is naturally the navel. For if a man be placed flat on his back, with his hands and feet extended, and a pair of compasses centered at his navel, the fingers and toes of his two hands and feet will touch the circumference of a circle described there from. And just as the human body yields a circular outline, so to a square figure may be found from it. For if we measure the distance from the soles of the feet to the top of the head, and then apply that measure to the outstretched arms, the breadth will be found to be the same as the height, as in the case of plane surfaces which are perfectly square.”

This description by Vitruvius illustrates that the navel is central only if the ankles are extended (Figure 4B). Leonardo could not render the navel central where the feet were extended, and still have proper anatomic proportions. He reconciled this inconsistency by rendering the feet flat, and thereby the navel central. The received and modern view of this image and its inconsistency with Vitruvius’ writings seems to have gone unnoticed. Where the feet are extended, true to Vitruvius’ description, the approximate geometric center of man is not the navel, but the sacral base [25] (Figure 4A).

This flaw in the description by Vitruvius may be attributed

to his having studied the classic proportions of ancient Greek architecture some 100 years after the fall of Greece (146 BC), and long after the Polyclitus Canons of Human Proportion had been all but lost, save for the Golden Mean.

Charitably, without the advantage of radiography, the navel is an attractive candidate for geometric centrality. However, the sacral base is the key, as the attitude of the sacral base figures causally to both overall posture and chronic pain throughout the body.

The feet and ankles also play an important role in chronic musculoskeletal pain. Custom foot orthotics (CFO) have been used to improve posture and alleviate pain. Implementation of orthotics alone to relieve chronic musculoskeletal pain is controversial, whereas multi-modal therapy proves more effective.

Professor Benno Nigg, a well published bio mechanist in orthotics and footwear at Calgary University (Ret.) concluded that [26] (Figure 5).

“There is no reliable, significant predictive value for foot orthotics and relief from any clinical condition. I recommend that you try them, and see if you like them.”

Early in my career, I took a one-month leave. On my return, the locum tenens physician suggested that I prescribe CFOs to more of my patients with pes planovalgus. Since many of the patients with corrected sacral obliquity (Figure 6) had pes planovalgus (Figure 7), my involvement with CFOs increased. Greater clinical improvements occurred when sacral obliquity and pes planovalgus were both addressed. Still better outcomes occurred when lumbopelvic lordosis was treated with the

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 5/12

Central

therapeutic posture “Book ‘N’ Towel” (Figures 8,9).

A contrasting feature between Dr. Nigg’s subject populations and mine is that he examined the effects of foot orthotics alone, whereas my subjects had the obliquity of their sacral base corrected prior to implementation of the foot orthotics. Were postural stability directly dependent on two regions of the body, correcting only one region (the feet) would leave the other region (the normally oblique sacral base) still in play to effect imbalanced superincumbent loading of the feet and ankles, and disequilibrium of overall posture. However, where the obliquity of the sacral base is previously or concurrently corrected, effects from correction of the feet can be expressed without sacral interference. Stated otherwise, the large and multi-regional benefits from CFOs have been obscured by an overriding interference from the normally oblique sacral base (avg. obliquity is ¼-inch). The outcomes point to multi-factorial conditions for postural balance.

Imbalance of posture is a normal feature of developmental variance, although it can occur to an abnormal extent; whereas MSDs are an abnormal feature. The ubiquity of postural imbalance represents an untapped potential for treatment of patients with chronic neuraxis pain of unknown cause, and for MSD’s otherwise resistant to improvement.

Our usual understanding of mechanical cause is that it is temporally antecedent and spatially contiguous to pain [27]. Where cause is not contiguous to pain, pain can instead be due to a mechanical chain of causes and effects involving structures proximate or neighboring, which incite chronic pain. An example is restriction of the subscapularis, which, in turn, can increase tension/recruit musculature that connects the scapula with the occiput. Thus, a mechanical chain of causation can exist between the restricted subscapularis and the cervical paraspinous muscles that are contiguous to the pain.

I assert that there are three centric boundaries for posture. The respective frames of reference for the three centric boundaries are as follows [28] (Figure 10).

1. The configuration of the feet and ankles is the lowermost boundary of posture, which is central to the frame of reference that includes ground support, gravitation, and total body mass.

2. The attitude of the sacral base in the coronal and sagittal planes, measured radiographically in the upright and seated positions, is the middle boundary of posture, which is geometrically central to the frame of reference that is the outstretched human frame in the coronal plane.

3. The central nervous system is the uppermost boundary of posture, which interplays constructively with posture and the frame of the entire nervous system, given the initial conditions of the feet, ankles, and sacral base.

Fortunately, the CNS/upper boundary of posture is usually anatomically intact, so that most treatment is directed toward the configuration of the feet/ankles and the attitude of the sacral base.

There is causation between cognitive dysfunction in terms of unresolved conflicts and chronic pain. This psychophysiological

Figure 5 Professor Benno Nigg, bio mechanist from Calgary University who exhaustively studied foot orthotics as they might relate to alleviation of any clinical condition, with limited success.

Figure 6 (A): The transverse line of eburnation that reflects the attitude of the sacral base. (B): Method for measuring unlevelness of the sacral base with respect to the lateral position of the femoral heads. (C): Pelvic obliquity of 45 mm measured as unlevel sacral base, standing and in the coronal plane, with compensatory lateral angularity of 16 degrees of the lumbar spine. (D): The sacral base is leveled incrementally by bi-weekly 1.6 mm augmentation of a heel lift to 40 mm, and re-filmed with this lift in place. The sacral base is level and the lateral angularity of the lumbar spine is straightened.

Figure 7 (A): Pes planovalgus, Pre- and (B): Post custom foot orthotics.

disorder has a various names. Current terminology in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition [29], includes somatic symptom disorder, conversion disorder, and illness anxiety disorder. A term preferred for reason of greater patient acceptance is functional somatic syndrome (FSS), used to describe a combination of symptoms that may include chronic pain, not fully explained by pathologic conditions or diseases that cause impairment or disruption of everyday activities, without evidence of the patient substantially feigning their symptoms

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 6/12

Central

[30]. FSS is not suggested as formal diagnostic terminology. Cognitive dysfunction is a condition that is remediable by professional counseling, resulting in relief of chronic pain of the NMS [31].

In what way do the centric boundaries of posture differ from the spatial character of mechanical causes that are 1) contiguous with or 2) mechanically chained to painful effects? By virtue of their central location for their respective frame of reference, the boundaries of posture have direct operational linkage with all of the NMS, regardless of distance of a symptomatic region from the centric regions.

The fundamental constituents of posture can be modeled taxonomically [25] (Figure 11).

A utility of this taxonomic model is that each of the fundamental constituents of posture present manipulable avenues for multi-factorial reduction of postural imbalance. Variance of posture from ideal configuration of these fundamental constituents can generate a cascade of mechanical causations, from centric to mechanical chain to contiguous.

Modeling the fundamental constituents of posture revealed a surprising symmetry that lends itself to groupings and operational linkages that perfectly fit into a complex of branching Cartesian matrices. Inferred from this symmetry is that, in principle, these constituents are each least like the other, operationally linked, and necessary to complete the picture of postural systematics at this resolution.

To describe this inference, each line segment represents either one or two constituents, the latter where the line segment on each side of the origin represents a constituent. That these constituents are each, least like the other is represented by the 1) perpendicular intersection of the line segments for each grouped constituents, and 2) mutual opposition of two constituents along a common line segment divided by the origin. The intersection of these line segments at origin represents that the constituents are operationally linked. The number of the perpendicular line segments through a common origin implies a limitation to either 3 or 6 for the number of fundamental constituents for each matrix of postural systematics; no more, no less. If there were 4 rather than 3 constituents, they would not be each, least like the other, as the fourth line segment could not be perpendicular to the other three. If there were 2 rather than 3 constituents grouped, there would be incompleteness with exclusion of an implied constituent. This archetypal constraint both includes and exhausts the observable fundamental constituents for postural systematics at this resolution.

The work that follows describes the centric conditions for postural balance, and the clinical consequences where imbalanced. By the use of orthotics (devices to correct or align), one can successfully predict increased postural symmetry and significant, large, and enduring alleviation of chronic pain [25,28,32-39].

The intended readership for this paper is the health care provider, who would benefit from this evolutionary advance in the understanding and therapeutics for chronic musculoskeletal pain. The reader will discover the existence of a relatively new form of mechanical causation, and a different approach than

A) B) C)

D)

Figure 8 (A): In the sagittal plane, measurement of the angle of the sacral base (sacral angle) relative to horizontal (Nl< 41 deg.). (B and C): Measurement of the position of load of the lumbar spine relative to the sacral base (ideally passes thru the anterior 1/3rd of the sacral base).(D): The therapeutic posture “Book ‘N’ Towel”, practiced 20 minutes daily throughout the course of treatment, is reductive of lumbopelvic lordosis.

Figure 9 (A): Pre-treatment the lumbopelvis is lordosed (sacral angle > 41 degrees), with anterior displacement of the line of sacral load. (B): Post treatment the sacral angle is reduced from 47 degrees (A) to 40 degrees, and the sacral load is repositioned to the anterior 1/3rd of the sacral base (ideal).

contemporary practices treating chronic neuromusculoskeletal pain.

MATERIALS AND METHODS

The human subjects research board approved participation in this study

Subjects for this study were recruited from those adults presenting with multi-regional chronic pain (>3 months duration, average number of painful regions 3-4) for which pain was without apparent cause.

Not included in this study population were subjects who had been diagnosed with fibromyalgia and diabetics (who may have requirement for accommodative orthotics that are more pressure

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 7/12

Central

absorbing than corrective).

Initially, subjects were interviewed and asked for each of 8 regions whether they had chronic (> 3 months) discomfort at least once biweekly, typically: foot, leg, knee, thigh, pelvis, lumbosacral, thorax, or head/neck. This interview was repeated at the conclusion of their course of treatment, and compared with the responses from the initial interview.

Pre-treatment, unlevelness of the sacral base was measured radiographically, using the stratified line of eburnation to delineate the sacral base (Figure 6). Also, lateral angularity of the lumbar spine was measured by method of Ferguson (Figure 12). These measurements were repeated at the conclusion of treatment.

For the data collected regarding incidence of regional, chronic discomforts, for unlevelness of the sacral base, and for lateral angularity of the lumbar spine, only heel lift and physical therapy was used. On the basis of the large reduction of chronic discomfort for this population, methodology for reduction of

postural imbalance was further developed [25,28,34].

1. Custom foot orthotics (CFOs) to correct pes planovalgus (flattened arches and angled ankles) (Figure 7).

2. A pelvic lift is placed beneath one heel to lift the low side of the pelvis while standing to correct pelvic obliquity > 1.6 mm, using the radiographic attitude of the sacral base as reference [25,28,32,34] (Figures 6,13,14). This reduces the lateral angularity of the lumbar spine that is compensatory to the pelvic obliquity (Figures 6, 13,14). The initial lift can be 1/8-inch, for those with unlevelness ≥ 1/8-inch, with incremental augmentation by 1/16-inch each two weeks [32]. Greater amount or frequency of augmentation can cause transient pain.

3. A pelvic lift beneath one ischium applied while seated to correct pelvic obliquity ≥ 3 mm, using the radiographic attitude of the sacral base as reference. This also reduces the lateral angularity of the lumbar spine that is compensatory to the pelvic obliquity (Figures 15,16) [25,28,34]. (data not shown).

4. A therapeutic posture “Book ‘N’ Towel is practiced 20 minutes daily in the recumbent position on a firm floor throughout the course of treatment to reduce lumbopelvic lordosis, when present [25,28,34] (Figures 8,9,17,19).

Figure 10 Illustration of 3 central boundaries of posture, each central to its respective frame of reference.The frame of reference for the central nervous system is the nervous system. The frame of reference for the geometric center is the outstretched skeleton in the coronal plane. The frame of reference for the center of gravitational interaction is the conjunction of opposing vectors, at the feet and ankles, of the ground support and the net mass of the body, in the context of gravitation.

Figure 11 Taxonomy of postural systematics.

Figure 12 Lateral angularity of the lumbar spine is measured by method of Ferguson.

Figure 13 Graphic results for (A) leveling of the sacral base, and (B) reduction of lateral angularity of the lumbar spine.

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 8/12

Central

Figure 14 (A): Pre-treatment radiograph of the lumbopelvis in the coronal plane, standing, the sacral base was 18 mm low on the left, and the lumbar scoliosis measured 13 degrees.(B): Post treatment, with a 25 mm heel lift and CFOs in place, the sacral base is level, and the lateral angularity of the lumbar spine is reduced to 9 degrees.

Figure 15 (A): Postural radiography, seated on a firm, horizontal bench. (B): Method for measurement of obliquity of the sacral base with respect to the lateral position of the angle of the ischia. (C): Pelvic obliquity, seated, with compensatory lateral angularity of the lumbar spine. (D): The sacral base is leveled by a lift beneath one ischium, with straightened lateral angularity of the lumbar spine.

Figure 16 (A): Pre-treatment, a radiograph of the lumbopelvis, seated and in the coronal plane, reveals the sacral base is low 29 mm on the left, and the lumbar spine is laterally angled 22 degrees.(B): Post treatment, and with a 26 mm left pelvic lift in place, beneath the ischium, the sacral base is level, and the lateral angularity of the lumbar spine is reduced to 10 degrees.

This employs a 1-inch thick paperback book positioned transversely beneath the sacrum, and a towel rolled tightly to 3-3 1/2 inches diameter that is placed along the vertebral spine from T-12 to above the occiput.

5. Physical therapy with each increase in thickness of the heel lift, to reduce accumulated arthrodial restrictions and misalignments that are resistive to the symmetrizing effects of the lift. This establishes physical therapy as a necessary compliment for postural balancing.

RESULTSInitially, the average number of regions with chronic

discomfort was 3-4, or 43% of eight regions. At conclusion of treatment to level the sacral base, the number of regions with chronic discomfort was reduced by 70%, to 13% [25,28,34] (Figure 18). For seven of eight regions, the number of patients for whom previously recurrent discomforts became absent was statistically significant (P < .01 for each). For those regions that remained symptomatic, anecdotally, there was moderate to marked reduction of pain. Also anecdotally, and for other populations with similar inclusion criteria where the full method described herein is applied, results were greatly improved for chronic pain of non-specific cause, and for pain attributed to MSDs of a less than severe extent.

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 9/12

Central

Initially, unlevelness of the sacral base ranged from 2 to 17mm, with a mean of 6.7 + 1.0mm. By completion of this study, this unlevelness was significantly reduced to 2.6 + 0.4mm (t = 6.6, P <.001) [32] (Figure 13). Under correction was far more common than overcorrection.

Prior to the incorporation of the heel lift, the lateral angularity ranged from 2-19 degrees, with an average of 7.5 degrees. After leveling of the sacral base, the angle was significantly reduced to a mean of 5.3 + 0.8 degrees (t =3.3, P < .01) (Figure 13), [32].

On a case-by-case basis, agreement varied considerably between the unlevelness of the sacral base, delineated by the line of eburnation across the base of the sacrum, compared with difference in the heights of the iliac crests or the femoral heads.

For the seated radiography of the lumbopelvis, data was not collected. The initial unlevelness was replaced with an ischial lift of thickness 1 mm less than the unlevelness measured, so as to avoid possible over correction.

For the same subject photographic and radiographic studies were compared, pre- and post treatment, standing (Figures 14,17,19) and seated (Figure 15). These studies show clearly the large improvement in posture where these multi-factorial therapeutic methods are fully applied.

For a second patient with multi-regional and chronic pain, initial imbalance of posture is evident photographically. Within a three-month period undergoing multi-factorial therapeutics for postural imbalance, ideal posture was attained, with complete alleviation of pain (Figure 20) by conclusion of treatment.

Where both the middle and lower central boundaries of posture are corrected by orthoses, virtually all chronic pain of nonspecific cause is routinely alleviated. Anecdotally, if a MSD is not severe, postural balancing similarly relieves associated pain.

Anecdotally and with another population with autoimmune disease such as rheumatoid or psoriatic arthritis, chronic pain is reduced by about 50% by balancing the posture. This benefit is attributed to reduction of mechanical stress of hyperirritable joints.

Independent investigation where unlevelness and correction of the sacral base is estimated by physical exam, combined with custom foot orthotics, also shows positive relief of chronic low back pain [35-39].

DISCUSSION Imbalance of the middle and lower centric regions mediates

“nonspecific cause” of chronic pain, and hypothetically predisposes development of secondary and specific causes of chronic pain from MSDs. I have found pain is relieved in all but the more severe cases of MSD after postural balancing. This suggests that postural imbalance is the root cause for both chronic pain of nonspecific cause, and for the preponderance of MSDs not associated with metabolic cause. Where MSD is severe, surgical intervention may be indicated.

Absent the concept of centric causation, the fact that a single intervention (leveling the sacral base, combined with physical therapy) has significant effects throughout the body is surprising, as no known intervention has done so. Previous studies where a single intervention modified a postural aspect, such as disparity

Post-treatment (B)Pre-treatment (A)

Figure 17 (A): For a pre-treatment radiograph of the lumbopelvis in the sagittal plane, the sacral angle is lordosed at 52 degrees (Nl < 41 degrees). (B) Post treatment, the sacral angle is reduced to 35 degrees.

Figure 18 Graphic representation of incidence of chronic regional pain, pre- and post leveling of the sacral base, standing.

Ideal-posture (A) Pre-treatment (B) Post-treatment (C)

Figure 19 (A): Compared to ideal posture(B): Pre-treatment subject demonstrates sub-optimal posture. (C): Posture is optimized by the combined effects of 1) CFOs for correction of pes planovalgus, combined with 2) a pelvic orthotic (heel lift) to correct the obliquity of the sacral base, standing, 3) an ischial lift to correct pelvic obliquity, seated, and 4) physical therapy to reduce accumulated restriction and misalignment of arthrodial tissues reflective of prior postural imbalance.

of leg lengths or unlevelness of iliac crests, did not use the radiographically measured unlevelness of the sacral base as reference for pelvic obliquity.

Considerations for the configuration of foot orthotics and pelvic lifts

Foot orthotics for non-diabetic population are of two forms: 1) symmetric, being equal in the respective amplitudes, right and left, and modest in the extent of correction; 2) custom, being configured to the individual foot and its extent of pes planovalgus.

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 10/12

Central

range from 20-80% correction, without increasing likelihood of supination. For the present study, the amplitudes were elevated to a higher extent than is typical for the industry, with correction of approximately 70% of the pes planovalgus.

Women, with their more varied style and somewhat more confining footwear, may require orthotics that are less robust, not only in amplitude of the arches but the thickness of the orthotic base, typically comprised of thin carbon fiber. A second, more corrective set may also be prescribed, for use where practical, typically with tie-shoes such as tennis shoes.

Women also wear varying heel heights. The most up-to-date epidemiological review provides clear evidence of an association between high heel wear and hallux valgus, musculoskeletal pain, and first-party injury. The body of biomechanical reviews provides clear evidence of increased risk for these outcomes, as well as osteoarthritis [40]. Interestingly, the higher is the heel, the less involved are the arches of the feet. Taken to an extreme, a ballerina en pointe is standing on a column comprised by the metatarsal and mid-foot bones, rather than an arch. Thus, the benefit of a custom orthotic diminishes where the forward pitch of the foot exceeds 45 degrees.

With respect to the heel lift, there is a limit for most shoes as to the thickness of lift than can be comfortably worn without the heel coming out of the shoe. This limit is about 3/8-inch. If need for more lift is indicated, the initial lift can be moved to the underside of the heel of the shoe by a cobbler doing an augmentation (Figure 21). For an augmented shoe, the heel and sole may be augmented to different extents, in order to avoid excessive stiffness of the shoe, while minimizing the pitch of the augmented shoe by partial augmentation of the sole. Otherwise, the contrasting pitch of the feet can generate torque throughout the body, with potential for further dysfunction. As a rule-of-thumb, there should be no more than 3/8-inch difference between the augmented heel and sole.

For the ischial lift, and for <10mm of unlevelness of the sacral base while seated, the entirety of the un levelness can be corrected at once, minus 1 mm to protect from over correction. For greater extents of unlevelness, the additional lift can be augmented by up to 5 mm monthly, without discomfort.

CONCLUSIONThe preponderance of chronic pain and disease of the

musculoskeletal system is mediated by mechanical stress. Current concepts of causation for such pain suggest that specific causation is either 1) bordering/contiguous or 2) linked as a mechanical chain proximate/neighboring to painful effects. Remaining pain is of “nonspecific cause”. Absent is a root cause for chronic pain of “nonspecific origin”.

Introduced here is a third etiology for pain production, centric causation, mediated by mechanical stress from postural imbalance. As postural imbalance is a multi-factor condition, efforts to test a single variable (with the exception of the sacral base) for predictive value previously precluded the ability to demonstrate the operational linkage between postural imbalance and chronic pain. Treatment methods now directed towards the correction of postural disequilibrium can successfully

Figure 20 (A): Ideal posture in the sagittal plane is (B) compared to that presented by a subject with chronic, multiregional pain. As pes planovalgus and pelvic obliquity are corrected by orthoses, and over a 3-month period, the subject transforms to ideal posture.

Figure 21 Introduction and incremental augmentation of the heel/sole lift. (A) Of interest is the elevation of the calcaneus. (B) A heel lift can be placed inside the shoe, and augmented incrementally biweekly to an approximate maximum of 5/16-inch. (C) This amount of lift can be moved to the outside of the shoe, and lifting resumed inside the shoe, where indicated. (D) The sole is finally augmented where thickness of the heel lift exceeds 3/8-inch, so as to limit the difference between the augmentation of the heel and sole to < 3/8-inch. Intent is to limit the difference in pitch between the augmented shoe and the other shoe. (Kuchera ML Treatment of gravitational strain pathophysiology. In Vleeming et al: Movement, Stability and Low Back Pain. Edinburgh: Churchill Livingston, 1997:477-499.)

For both forms, and for the industry of foot orthoses, there can be a wide variance of robustness to the amplitude of the arch pads, with the more robust being more corrective. Clinical response relates directly to the amplitude of the arch pads relative to the extent of pes planovalgus. The extent of amplitudes can

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 11/12

Central

treat chronic pain of previous nonspecific etiology. Combining experimental and anecdotal observations, correction of the middle and lower centric boundaries for postural balance can be a safe, effective way to treat chronic pain and MSDs of a less than severe extent.

A limitation of this study is that the experimental outcomes are from an open pilot study, without controls. A practical example of a lack of need for controls is the significant reduction of lumbar scoliosis by use of a pelvic lift to level the sacral base [32]. For a representative population, scoliosis is known not to significantly reduce spontaneously, or by any non-surgical method, other than by leveling the sacral base. Hence, a control population of scoliotics for whom treatment was withheld would add no confidence to the observation of significant reduction of scoliosis following leveling the sacral base. In the case of postural imbalance and chronic pain, in a representative population, spontaneous symmetrization of posture with alleviation of chronic multi-regional pain is also not known to occur.

To take this argument to an extreme, if one were to evidence that a particular treatment returns the long dead back to life, it would add no confidence to the experimental outcome to assemble a control population of corpses for which treatment was withheld.

A second limitation is that the study population did not include subjects with known contiguous or mechanically linked cause of chronic pain, only of “nonspecific cause”. The generalization of centric causation as root cause for the two classes of specific cause due to mechanical stress, in addition to that of nonspecific cause, is plausible. This generalization is supported by anecdotal observation that patients with less than severe MSD respond similarly to those with nonspecific cause.

In terms of risk-benefit-cost, these non-pharmacological therapeutics, aimed to maximally balance posture are safe, of large benefit for the chronic pain population, and a good cost value. The average course of treatment for the usual 5-6 treatments comes to a net cost of approximately $2,000-$2,500, including physician time, radiography, physical therapy, foot orthotics and pelvic lifts.

Implementation of these advances requires education of the healthcare provider, and public awareness of the therapeutic treatments. The techniques represent a non-invasive, non-pharmacologic alternative for the treatment of chronic musculoskeletal pain mediated by mechanical stress. This treatment direction has increased in importance in the current milieu of opioid abuse and, commonly, death [41]. The crisis of opiate use and abuse for pain control is real, with undesirable effects for the patient, family, and society. Effective conservative treatment for chronic pain should always take precedence over narcotics.

Practically, patients who are steadily improving request less analgesia. Those who are on opiates prior to initiation of postural correction can reduce their dosage progressively, and most cease entirely by conclusion of treatment. This reduction does not generally meet with patient resistance, as decreasing pain reduces the desire for analgesia. Exception is where there is addiction, which requires more specific guidelines.

Future study will continue to test the theory of centric causation in the treatment of populations with chronic pain secondary to postural imbalance.

ACKNOWLEDGEMENTSAppreciation is expressed to Barry S. Rodgers D.O. for

discussion contributing to clarification of the concept of centric causation, and to Alan M. Rubin M.D for editing this manuscript.

This work was supported in part by American Osteopthic Association Research grants No. 85-11-190 and 86-11-190; Texas College of Osteopathic Medicine Organized Research grant 3400; and Health Science Center of Oklahoma State University Intramural Grant.

REFERENCES1. The Burden of Musculoskeletal Diseases in the United States. 3rd edn.

Rosemont: United States Bone and Joint Initiative. 2014.

2. Macfarlane GJ, Barnish MS, Jones GT. Persons with chronic widespread pain experience excess mortality: longitudinal results from UK Biobank and meta-analysis. Ann Rheum Dis. 2017; 76: 1815-1822.

3. Palazzo C, Ravaud JF, Papelard A, Ravaud P, Poiraudeau S. The Burden of Musculoskeletal Conditions. PLoS One. 2014; 9: e90633.

4. https://www.cdc.gov/niosh/programs/msd/default.html

5. https://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf

6. Gatchel RJ, Kishino N. Pain musculoskeletal injuries, and return to work. In: Quick JC, Tetrick LE, editors. Handbook of Occupational Health Psychology. Washington: American Psychological Association.2011.

7. Roffey DM, Wai EK, Bishop P, Kwon BK, Dagenais S. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine J. 2010; 1: 89-99.

8. Grundy PF, Roberts CJ. Does unequal leg length cause back pain? A case-control study. Lancet. 1984; 8397:256-258.

9. Dieck GS, Kelsey JL, Goel VK, Panjabe MM, Walter SD, et al. An epidemiological study of the relationship between postural asymmetry in the teen years and subsequent back and neck pain. Spine. 1985; 10:872-877.

10. Levangie PK. The association between static pelvic asymmetry and low back pain. Spine. 1999; 24:1234-1242.

11. Levangie PK. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther. 1999; 79: 1043-1057.

12. Fann AV. The prevalence of postural asymmetry in people with and without chronic low back pain. Arch Phys Med Rehabil. 2002; 83: 1736-1738.

13. Knutson GA. Incidence of foot rotation, pelvic crest unleveling, and supine leg length alignment asymmetry, and their relationship to self-reported back pain. J Manipulative PhysiolTher. 2002; 25: 110E.

14. Giles LG, Taylor JR. Low-back pain associated with leg length inequality. Spine (Phila Pa. 1976). 19881; 6: 510-521.

15. Gofton JP. Persistent low back pain and leg length disparity. J Rheumatol. 1985; 12: 747-750.

16. Helliwell M. Leg length inequality and low back pain. Practitioner. 1985; 483-485.

17. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. 1983; Spine. 1983; 643-651.

Irvin (2018)Email:

Ann Musc Disord 2(1): 1006 (2018) 12/12

Central

Irvin R (2018) Disequilibrium of Posture as Root Cause for Preponderance of Chronic Neuromusculoskeletal Pain. Ann Musc Disord 2(1): 1006.

Cite this article

18. Friberg O.Results of radiologic measurements of leg length inequality (LLI). Spine (Phila Pa. 1976). 1992; 17: 458-460.

19. Brady RJ, Dean JB, Skinner TM, Gross MT. Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther. 2003; 221-234.

20. Lederman E.The fall of the postural-structural-biomechanicalmodel in manual and physical therapies: Exemplified by lower back pain. 2010; 1-14.

21. Rapoport A. Operational Philosophy: Integrating Knowledge and Action. New York: Harper & Brothers Publishers. 1954;57-64.

22. Koch R. The etiology of anthrax, based on the life history of Bacillus anthracis.PDF). Cohns Beitrage zur Biologie der Pflanzen (in German),1876;2: 277-310.

23. Stokstad M. Art: A Brief History. 3rd edn. Pearson Education. 2007.

24. Vitruvius Pollio, The ten books on architecture. Chapter I: On Symmetry: In Temples and in the Human Body. Morris Hicky Morgan, Ed. Cambridge: Harvard University Press. 1914;73.

25. Irvin RE. Why and How to Optimize Posture. In: Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement Stability and Lumbopelvic Pain. 2nd edn. Edinburgh: Elsevier. 2007; 239-251.

26. Hume P, Hopkins W, Rome Keith, Nigg B, Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Med. 2008; 38: 759-779.

27. Hume D. A Treatise of Human Nature. Norton DF & Norton MJ. Oxford University Press. 2002:54.

28. Irvin RE. The origin and relief of common pain. JBMR. 1998; 11:89-130.

29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn. Arlington VA. American Psychiatric Publishing. 2013.

30. Graves CJ. Functional somatic syndrome: assessment and management. J Am Osteopath Assoc. 2017;117:511-519.

31. Sarno JE, Healing Back Pain. Warner Books. New York. 1991.

32. Irvin RE. Reduction of lumbar scoliosis by use of a heel lift to level the sacral base. J Am Osteopath Assoc. 1991;91:37-44.

33. Hoffman KS, Hoffman LL. Effects of adding sacral base leveling to osteopathic manipulative treatment of back pain: a pilot study. J Am Osteopath Assoc. 1994; 3: 217.

34. Irvin RE. Enduring relief of chronic pain, using orthotics to correct postural imbalance. In: Dalton E, editor. Dynamic Body: Exploring Form, Expanding Function. Freedom Pain Institute. 2011; 62-84.

35. Lipton JA, Brooks JS, Hickey MJ, Drew BG, Eggleston MT, GemmerCH. Lift treatment in naval special warfare personnel: a retrospective study. AAOJ. 2000; 10:31-37.

36. Lipton JA, Flowers-Johnson J, Bunnell MT, Carter L. The use of heel lifts and custom orthotics in reducing self-reported chronic musculoskeletal pain scores. AAOJ. 2009; 19:15-20.

37. Lipton JA. The use of orthotics in the reduction of self-reported pain scores in a veteran affairs population: a retrospective study. AAOJ. 2013; 23:9-12.

38. Lipton JA, Mitchell LJ. Orthotic correction of postural unleveling in a patient with ankylosing spondylitis. J Am Osteopath Assoc. 2014; 114:125-128.

39. Lipton JA, Vasquez JA. Use of orthotics to treat persistent low back pain after left sacroiliac joint fixation: a case report. AAOJ. 2016; 26: 7-11.

40. Barnish M, Morgan HM, Barnish J. The 2016 HIGh Heels: Health effects and psychosexual Benefits (HIGH HABITS) study: systematic review of reviews and additional primary studies. BMC Public Health. 2017; 18: 37.

41. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156:569-576.

42. Clarke JR. Personal communication. Annie Laurie Howard Regents Professor. Department of Art & Art History. The University of Texas at Austin, 2301 San Jacinto Blvd, Stop D1300, Austin, TX 78712-1421. 2018.