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Headaches & orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markleigh, Dec 10, 2007.

  1. markleigh

    markleigh Active Member

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    I have just reviewed an orthotic patient 2 weeks post dispense. For the 2 weeks, she has been sufffering quite severe headaches. Her foot has also been uncomfortable particularly where the metatarsal dome was positioned. When she removed the orthoses from her shoes, her headaches went away almost immediately & returned when she put them back in. She is a fairly sensible lady, 34 years of age & otherwsie healthy. Her initial presenting complaint was knee related & which I had initially trialled a low dye strapping. That had given positive benefit so I prescribed appropriate orthoses. And this happens. BIZARRE! I have removed the met dome (PPT) & they immediately felt more comfortable. I can't explain the connection but I said I would just ask around. Interestingly (but maybe not connected) she said she has suffered sinus problems in the past & massaging her thena emanance on her hand relieves her sinus problems. Is she sensitive to pressure points?
  2. pgcarter

    pgcarter Well-Known Member

    I've had one guy who presented self diagnosed as head aches that went away with orthoses. Long hx of head aches, shopped himself around, ended up with a lot of tx from chiros and osteos before one of them said "hey your pretty pronated, get some orthoses," he bought some OTC jobs and had significant improvement, then decided he wanted "the podiatry version"....according to him.."turned them off like a tap"
    regards Phill Carter
  3. markleigh

    markleigh Active Member

    Thanks Phil. I just find it amazing that such a small change can make such a difference. And such a long distance difference. It highlights to me that we still have a long way to go to understand how it works. And that maybe it is more connected than what we give it credit for.
  4. Daniel Bagnall

    Daniel Bagnall Active Member

    If she had good results, like you said she did, from the low-dye strapping and didn't receive any adverse affects from it, then you are correct in removing the met dome. BTW, did she have forefoot pathology? Or was the dome to improve something else?

    The beauty I find with low-dye strapping, is that it is so versatile compared to an orthotic. Pts can wear the strapping with just about anything (even without shoes) and receive therapeutic benefits.

    Did you check to see what footwear she was wearing the orthoses with?


    Last edited: Dec 11, 2007
  5. Well there are several possibilities.

    It could be that our friend Brian is onto something.

    However i prefer to beleive that the mechanism at work was more along the lines of that observed by :-

    Mei Capuano et al in Topiramate in migraine prophylaxis: a randomised double-blind versus placebo study
    which observed a reduction in migraine attacks from 6.17±1.80 SD to 2.57±0.80. in the placebo group

    Winner, ROthner et al in A Randomized, Double-Blind, Placebo-Controlled Study of Sumatriptan Nasal Spray in the Treatment of Acute Migraine in Adolescents
    Which observed a 53% improvement in symptoms 2 hours after a placebo dose. (compared to 63% in the active group)

    There are many more studies which show high improvement rates in placebo vs active trials. It is harder to find studies which compare placebos to no treatment groups unless you count all the homeopathic studies as placebo studies:rolleyes:. However it seems clear that good results can be acheived via placebo.

    Migraine and headaches are one of those things so multifactorial in origin that it is a struggle to come up with any firm answers of effective treatments or prophalaxis as anyone who suffers with migraine (like me) will attest to their sorrow. It is therefore unsurprising that placebos show a pretty solid success rate which even the most effective drugs do not exceed by much.

    It is entirely possible that the headaches with mechanical triggers are affected in some way by orthotics but this seems to me to be the lesser of the possibilities.

    Put it down to Robert being a cynical unbeleiver who won't accept it is raining without a 2 hour process of data gathering if you like but thats just my view.

    Consider, if you have the time and inclination, the nature of heuristics and the texas sharpshooter fallacy. A study of this fascinating field is well worth it for anyone engaged in any kind of science and indeed in everyday life.

    Last edited: Dec 11, 2007
  6. trudi powell

    trudi powell Active Member

    My most obvious case of helping a migraine, was a young new father, who for the life of me I can't remember why, had a significant difference between his left and right MTJ. ( Too many years ago )

    After just 3 weeks of wearing corrective orthotics he was actually able to return from work and play Daddy instead of going straight to bed each afternoon with a posturally induced migraine.

    Once again correct the postural symmetry and the body / spine can be better alligned. So did your patient have an assymetry of the feet/ knees or hips ?? Or did your orthotics cause an assymetry and thereby cause the headaches ?? Or was her knee pain only one sided and she had slowly adjusted to an assymetry over time and it may take a while, and a few sports massages, to 're-balance' her to where you want her to be ??

  7. Dananberg

    Dananberg Active Member

    Many headaches are cervicogenic. Repositioning the head (ie, decrease forward head posture) can relax the upper back musculature and relieve many of the referred pain type headaches. The trick to head repositioning has everything to do with sagittal plane function.

    Look at your patient w/ and w/out orthotics...and use a side view. Note head position. Also watch for symmetry or asymmetry in arm swing motion. One of the common problems with orthotic design is missing the need for a heel lift. If you control foot position, but do not account for LLD, then cervical tightness may result as the body is trying to splint the neck as it lost its ability to level the posture at the foot level. As a general rule (nothing's perfect), the arm on the shorter side tends to swing more than the arm on the longer side. It a very helpful observation that can alter the way you review orthotic effectiveness.

    One last comment. Too much rearfoot posting can restrict internal hip rotation and this alter spinal function. I am very, very, very, careful with RF posting...and usually avoid it excepting for PT rupture cases.

  8. At the risk of being a buzzkill i'm really not sure we can make such claims. So far as i know (and i'd love for somebody to correct me) there are no studies showing a correlation between orthotics and headaches. There might be a working model as Howard describes, however a model based on an observation of a side view of a patient in static WB is not exactly watertight!

    I am reminded of another working model related to the retroversion of the innominates and its effect on circulation to the uterus. I'm not so sure about that one either.

    I think we must be very careful in making claims such as these, especially given the high effectivness of placebos in the treatment of headaches (over 50% in some studies). This makes us particularly vunerable to the texas sharpshooter fallacy and this can corrupt our thinking if we build further theories / ideas on that foundation.

    I think we should be sure our feet are on the ground (sorry, accidental pun) before we build castles in the sky!

  9. Craig Payne

    Craig Payne Moderator

    Robert, you are right.

    All we have are:
    1. Some hypothetical models, that do have some biological plausibility and theoretical coherence to them (but theoretical models do not constitute evidence)
    2. Anecdotes (and we all probably have one or more)
    3. Crank pots
  10. davidh

    davidh Podiatry Arena Veteran

    I've "cured" the odd headache with orthoses too.

    I'm with Robert and Craig on this one, otherwise the observations that "orthoses cured the migraine" are really no different to Prof Rothbarts claims about the effectiveness of his orthoses, just made in a less self-promotional way.

    My view is that if orthoses do something beneficial for the patient in addition to what they were being treated for by me in the first place, I'm delighted (but not particularly excited).

    The placebo effect really is a phenomenon much more powerful than we acknowledge (I believe:p).

  11. pgcarter

    pgcarter Well-Known Member

    Very happy to have the placebo effect on my side....as long as I'm not making claims of treating all sorts of stuff like this I'm happy when the patient feels a whole lot better about their quality of life, head, feet, knees, back whatever...as long as it's better. When I take responsiblity for a situation where the treatment does not work and give some one a refund(because it's my fault)....is it my fault when it does work?
  12. MuShu

    MuShu Member

    Hi, first sorry about my english ;)

    I only want to make a coment.... there aren´t about headaches but i seemed interesting.
    One day i received a patient that she refered a little fascial pain, but the problem is that she had a lot of pain in a zone of the heel than in podiatry hasn´t importance, besides the pain was in one foot.
    I have read a lot of reflexotherapy and i asked her (curiosity) if she had / has any problem with her ovaries (her pain zone in reflexology is the ovaries), and she asked me, very surprised that she has suffered a hysterectomy and a removal of the ovarie corresponding to the pain foot. I had some cases similary and i think that there are something that we escapes, or that we don´t see because there is much coincidence. (I don´t know if exists studies that demonstrate if its true or false).
    I agree with you that the origin of headache will be mechanic, but i find very interesting things about this... Do you know the posturology? its very interesting...

    Thanks, sorry about my english again
  13. Mushu
    Full respect to you for having a crack, which a lot of people with english as their first language won't do.

    So far as your observation, can i invite you to read this thread http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=5896 on the scientific method which, i think, provides an point to consider. Come to think of it its quite relevant to this whole thread!

    Mr Carter

    The placebo effect is indeed a powerful thing... but also a dangerous one. It is well and good to be pleased by positive results we may not expect. However it is highly perilous to start looking for a rationale to fit the a pattern based entirly on an availibility heuristic. The risk we must guard against is, to paraphrase CS lewis, "to become infected with our own propaganda".

    It is a short journey from enjoying a placebo effect to seeking a placebo effect. It is a shorter journey still to seeking to rationalise a gunslinger pattern (for the purposes of enhancing the placebo) and thence to beleiving our own rationalisation.

    The scientific method is, as i have previously observed, heavily counterintuative. We face a constant effort to swim against that currant.

    Agreed! It is incredibly powerful and often underestimated. It is also, IMHO hugely perilous, and that too is underestimated.

    Born again sceptic
  14. pgcarter

    pgcarter Well-Known Member

    Hi Robert,
    I usually have my currants in buns....when diving I swim against currents. Please forgive the humour. I agree with you completely about the trap of thinking that what we do is always understood or in fact the reason why people get better. I don't have that kind of intellectual arrogance....(I have a different kind).I know there is lots of stuff I don't know, and lots of stuff I don't know I don't know...to carry on a bit. But while I'm happy to recognize the strength of the placebo effect, and not to play or seek for it, I think it's OK when it happens to contribute to a total picture of clinical improvement. It's not intrinsically a bad thing.
    regards Phill Carter
  15. scottma

    scottma Member

    Dear markleigh:
    Headache is closely associated with temporomandibular dysfunction( TMD).The most important etiological factor is occlusion (bite ). In my experience, over90% of patients had more than 90% pain relief after temporomandibular orthosis therapy ( occlusal appliance therapy, splint therapy). In addition, forward head posture is also improved by TMJ orthosis.
    One patient developed occipital headache arter thumb pressure on first metatarsal shaft, just proximal to the ball area. Tmj orthosis does nothing but establing a perfected occlusion. However, the orthosis is removable. If the patient removes the orthosis, the occlusion returns to the original status. Hope it helps.
    scott ma
  16. This has a depressingly familier ring to it.

    I don't suppose you could give any evidence of any of your contestations there?

    Bearing in mind that "we've been having great results" And a few before and after photos do not constitute evidence.

    Because otherwise your observations are worthless. And a 90% in 90% from someone we don't know is a meaningless number.

    I might as well say "long hair causes orthotics".

    So no it does'nt help at all.

  17. Shane Toohey

    Shane Toohey Active Member

    I just hope Xmas shopping isn't getting neglected be the Arena junkies!:eek:

    You wrote Mark:

    It's funny how some simple things get folks off on tangents.
    No headaches then intervention of orthoses = headaches
    Remove intervention (orthoses) = no headaches
    Apply intervention again = headaches
    Orthoses when worn are uncomfortable
    It all seems fairly logical: the orthoses cause the headaches one way or another because there is something not tolerated about them causing MSK dysfunction proximally. Doesn't even matter exactly where: do no harm: remove/modify orthoses.
    This doesn't mean that orthoses are not appropriate for this patient and we better get off and do some more drastic treatment but that despite the orthoses being indicated by the symptoms being reduced by low dye strapping the orthoses are in error.
    Personally, I regard low dye strapping as a very useful treatment option but do not regard it as being particularly useful in giving me much information about orthotic prescription other than the fact that mechanical intervention may be helpful.

    Cheery Xmas to all:santa2:
  18. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Could this be "snake oil", suggesting an orthotic can relieve headaches? Or could this be what Posturologists have talked about for years, the connection between the feet and the rest of the body.

    I see many patients in my practice that have been referred to me specifically for intractable, chronic headaches. Using the appropriate proprioceptive insoles, many times the headaches are eliminated or greated reduced (both in severity and frequency). I agree with Howards post that headaches can result from a forward head position. By repositioning the head over the spine, the hypertonic trapezius (and other neck muscles) relax, the headaches attenuates.

    I must admit, I am very surprised that you have not labeled this thread as SNAKEOIL!!!

    Prof B Rothbart

    I DID!!!!! :deadhorse::craig:

    As i observed before there is NO EVIDENCE of the mechanism suggested or the outcomes. Success rates for placebos for headaches run at around 50%!!! So yes it will work a lot of the time whether you use a proprioceptive insole, a polyprop orthotic or a pork pie in the shoe!

    So whats the difference between Brians claims of curing infertility which (no offence mate) most of us find silly and those made here about treating headaches? We're quick to jump down his throat (and rightly so) but when its something more people "buy" we become all open minded and new age.

    Both can claim a rational
    Neither have any evidence.

    Could be. Its possible. Or it could be a placebo effect. Or a selection bias. Without at least SOME evidence (and like i say before and after photos are not evidence and "data" is NOT repeat NOT the plural of anecdote) we cannot make ANY claims with more substance than those made for crystal healing, reiki faith healing or reflexology.:bang:

    Sorry. Its my first day back at work, i've got a headache and i'm in a foul mood.

    PS love the new smillies. Especially like that the one with the hair being pulled out appears in the text as : craig :.
  20. Maybe Rhubarb could contact Antony Gormley and see if his "technology" would work on No 21 at Another Place! Discerning patrons of the fine arts, pods and no doubt even posturologists, will have noticed that the sculpture closest to the sea wall at Crosby has a medially deviated STJ - as well as a barnacle-encrusted willy. Posture Control Insoles may not be of much use for the former but I'm sure they would help repel those nasty crusty creatures. :sinking:

    Attached Files:

  21. CEM

    CEM Active Member

    I think pressure points all over the body have various effects on various things, everybody is different.... several years back an italian world cup skier [debora companioni] was having problems with her training...she had not changed skis or boots since the previous season when she was winning everything , her ciropractor started with some pressure point tests and discovered that a scar she had on her head from a fall when she was 5 years old was to blame, the foam from companioni's new helmet was pressing on the scar tissue and causing a proprioceptive weakness on one side of her body, remove pressure from the scar tissue [quick cut of the padding with a knife] and the problem went away, she won the overall world cup alpine slalom that year

    strange but true
  22. :craig:.....
  23. W J Liggins

    W J Liggins Well-Known Member

    Anecdote after anecdote after anecdote.

    I recall a patient who received a carefully measured (according to Root theory) pair of rohadur orthoses. She fell into my hands and enthusiastically praised the wonderous affect the devices had had upon her foot pain and her life in general. When I examined these superb devices I discovered that she had been wearing them in the wrong shoes.

    Robert is right. Anecdote and patient feedback does not constitute scientific evidence. If something does no harm and makes a patient feel better - good - but we, above all, must not get trapped into the 'well it works for me so that's proved it' scenario.

    All the best

  24. :good::drinks

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