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The origin and relief of common pain

Article  in  Journal of Back and Musculoskeletal Rehabilitation · February 1998

DOI: 10.1016/S1053-8127(98)00027-X · Source: PubMed

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 Central Annals of Musculoskeletal Disorders
Research Article *Corresponding author
Robert Irvin, Adjunct Clinical Associate Professor,

Disequilibrium of Department of Osteopathic Manipulative Medicine,

Oklahoma State University Center for Health Sciences,
1111 West 17th Street, Tulsa, Oklahoma, 6620 Bryant Irvin

Posture as Root Cause for Road, Suite 100, Fort Worth, Texas 76132, USA, Tel: 817-
346-6656; Fax: 817-346-8305; Email:

Preponderance of Chronic
Submitted: 13 June 2017
Accepted: 12 October 2017
Published: 16 July 2018

Neuromusculoskeletal Pain Copyright

© 2018 Irvin

Robert Irvin* OPEN ACCESS

Department of Osteopathic Manipulative Medicine, Oklahoma State University, USA

Keywords
• Chronic pain of nonspecific cause
Abstract • Postural imbalance
• Custom foot orthotics
Chronic musculoskeletal pain is one of the largest unsolved problems in medicine, as measured
• Heel lift
by incidence and cost. Current concepts of specific mechanical causation of musculoskeletal
• Ischial lift
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.

ABBREVIATIONS from cardiovascular and cancer. Overall 27.7% or about 17.3

RMD: Rheumatic and Musculoskeletal Disease; NMS:
Neuromusculoskeletal; MSD: Musculoskeletal Disease; CFO:
Custom Foot Orthotics; Nl: Normal; CNS: Central Nervous System;
FSS: Functional Somatic Syndrome
INTRODUCTION
Chronic 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
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

Cite this article: Irvin R (2018) Disequilibrium of Posture as Root Cause for Preponderance of Chronic Neuromusculoskeletal Pain. Ann Musc Disord 2(1):
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Figure 1 The proportion of musculoskeletal conditions far exceeds those for all
other conditions observed at the level of primary care.
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
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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
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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
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 modernity
Note the tree trunk for the Roman reproduction, necessary for postural balance of this imitation.
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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
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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
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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
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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
Figure 5 Professor Benno Nigg, bio mechanist from Calgary University who
the obliquity of the sacral base is previously or concurrently exhaustively studied foot orthotics as they might relate to alleviation of any
corrected, effects from correction of the feet can be expressed clinical condition, with limited success.
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 Figure 6 (A): The transverse line of eburnation that reflects the attitude of the
patients with chronic neuraxis pain of unknown cause, and for sacral base.
MSD’s otherwise resistant to improvement. (B): Method for measuring unlevelness of the sacral base with respect to the
lateral position of the femoral heads.
Our usual understanding of mechanical cause is that it is (C): Pelvic obliquity of 45 mm measured as unlevel sacral base, standing and
temporally antecedent and spatially contiguous to pain [27]. in the coronal plane, with compensatory lateral angularity of 16 degrees of the
Where cause is not contiguous to pain, pain can instead be due lumbar spine.
to a mechanical chain of causes and effects involving structures (D): The sacral base is leveled incrementally by bi-weekly 1.6 mm augmentation
proximate or neighboring, which incite chronic pain. An example of a heel lift to 40 mm, and re-filmed with this lift in place. The sacral base is level
is restriction of the subscapularis, which, in turn, can increase and the lateral angularity of the lumbar spine is straightened.

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.
Figure 7 (A): Pes planovalgus, Pre- and
3. The central nervous system is the uppermost boundary of (B): Post custom foot orthotics.
posture, which interplays constructively with posture and the
frame of the entire nervous system, given the initial conditions of
disorder has a various names. Current terminology in the
the feet, ankles, and sacral base.
Diagnostic and Statistical Manual of Mental Disorders, 5th edition
Fortunately, the CNS/upper boundary of posture is usually [29], includes somatic symptom disorder, conversion disorder, and
anatomically intact, so that most treatment is directed toward illness anxiety disorder. A term preferred for reason of greater
the configuration of the feet/ankles and the attitude of the sacral patient acceptance is functional somatic syndrome (FSS), used to
base. describe a combination of symptoms that may include chronic
pain, not fully explained by pathologic conditions or diseases that
There is causation between cognitive dysfunction in terms of
cause impairment or disruption of everyday activities, without
unresolved conflicts and chronic pain. This psychophysiological
evidence of the patient substantially feigning their symptoms

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[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
A)
their central location for their respective frame of reference, the B) C)

boundaries of posture have direct operational linkage with all of

D)
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- Figure 8 (A): In the sagittal plane, measurement of the angle of the sacral base
factorial reduction of postural imbalance. Variance of posture (sacral angle) relative to horizontal (Nl< 41 deg.).
from ideal configuration of these fundamental constituents can (B and C): Measurement of the position of load of the lumbar spine relative to the
generate a cascade of mechanical causations, from centric to sacral base (ideally passes thru the anterior 1/3rd of the sacral base).
(D): The therapeutic posture “Book ‘N’ Towel”, practiced 20 minutes daily
mechanical chain to contiguous.
throughout the course of treatment, is reductive of lumbopelvic lordosis.
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 Figure 9 (A): Pre-treatment the lumbopelvis is lordosed (sacral angle > 41
4 rather than 3 constituents, they would not be each, least like degrees), with anterior displacement of the line of sacral load.
(B): Post treatment the sacral angle is reduced from 47 degrees (A) to 40
the other, as the fourth line segment could not be perpendicular
degrees, and the sacral load is repositioned to the anterior 1/3rd of the sacral
to the other three. If there were 2 rather than 3 constituents
base (ideal).
grouped, there would be incompleteness with exclusion of an
implied constituent. This archetypal constraint both includes and
exhausts the observable fundamental constituents for postural contemporary practices treating chronic neuromusculoskeletal
systematics at this resolution. pain.

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
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

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

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.
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 11 Taxonomy of postural systematics.

absorbing than corrective). Figure 12 Lateral angularity of the lumbar spine is measured by method of
Initially, subjects were interviewed and asked for each of Ferguson.
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
Figure 13 Graphic results for (A) leveling of the sacral base, and (B) reduction
therapy was used. On the basis of the large reduction of chronic of lateral angularity of the lumbar spine.
discomfort for this population, methodology for reduction of

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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.
RESULTS
Initially, 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.

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.

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

between the unlevelness of the sacral base, delineated by the

line of eburnation across the base of the sacrum, compared with Figure 17 (A): For a pre-treatment radiograph of the lumbopelvis in the
difference in the heights of the iliac crests or the femoral heads. sagittal plane, the sacral angle is lordosed at 52 degrees (Nl < 41 degrees).
(B) Post treatment, the sacral angle is reduced to 35 degrees.
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 Figure 18 Graphic representation of incidence of chronic regional pain, pre-
and post leveling of the sacral base, standing.
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.
Ideal-posture (A) Pre-treatment (B) Post-treatment (C)
Independent investigation where unlevelness and correction
of the sacral base is estimated by physical exam, combined with Figure 19 (A): Compared to ideal posture
custom foot orthotics, also shows positive relief of chronic low (B): Pre-treatment subject demonstrates sub-optimal posture.
back pain [35-39]. (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
DISCUSSION of the sacral base, standing, 3) an ischial lift to correct pelvic obliquity, seated,
Imbalance of the middle and lower centric regions mediates and 4) physical therapy to reduce accumulated restriction and misalignment of
arthrodial tissues reflective of prior postural imbalance.
“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 of leg lengths or unlevelness of iliac crests, did not use the
more severe cases of MSD after postural balancing. This suggests radiographically measured unlevelness of the sacral base as
that postural imbalance is the root cause for both chronic pain reference for pelvic obliquity.
of nonspecific cause, and for the preponderance of MSDs not
associated with metabolic cause. Where MSD is severe, surgical Considerations for the configuration of foot orthotics
intervention may be indicated. and pelvic lifts
Absent the concept of centric causation, the fact that a single Foot orthotics for non-diabetic population are of two forms:
intervention (leveling the sacral base, combined with physical 1) symmetric, being equal in the respective amplitudes, right
therapy) has significant effects throughout the body is surprising, and left, and modest in the extent of correction; 2) custom, being
as no known intervention has done so. Previous studies where a configured to the individual foot and its extent of pes planovalgus.
single intervention modified a postural aspect, such as disparity

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

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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
Ann Musc Disord 2(1): 1006 (2018)
Irvin (2018)
Email:
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.
CONCLUSION
The 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
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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.
Ann Musc Disord 2(1): 1006 (2018)
Irvin (2018)
Email:
Future study will continue to test the theory of centric
causation in the treatment of populations with chronic pain
secondary to postural imbalance.
ACKNOWLEDGEMENTS
Appreciation 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.
REFERENCES
1. 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.
11/12

Central
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.
Cite this article
Irvin R (2018) Disequilibrium of Posture as Root Cause for Preponderance of Chronic Neuromusculoskeletal Pain. Ann Musc Disord 2(1): 1006.
Ann Musc Disord 2(1): 1006 (2018)
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Irvin (2018)
Email:
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.
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