Articles written by Dr. Glen Bobker

As a chiropractic physician practicing for over 30 years, I have treated thousands of painful conditions to all regions of the muscle- skeletal system. Regardless of the cause and location of pain (i.e. low back, neck, whiplash , sprain, strains,etc.) a question that is often asked and or is often misunderstood is whether to apply ice (cryotherapy) or heat (thermotherapy) to relieve pain and promote healing. The fact is both ice and heat can be useful therapeutic modalities in the war against pain. Both can even provide a powerful and safe alternative/substitute to potentially harmful over-the- counter and prescription medications. However, it must be noted that each modality has its own benefits and risks. The risks and benefits of heat and ice therapy can be attributed to the unique biological (physiological) effects each provides. Thus patients must be informed and cautioned as to their appropriate application. When used correctly, under the right health circumstances, home compresses of ice and heat can be very effective at the job of treating and managing common muscle- skeletal pain. This column is devoted to clarifying the debate of when the use ice vs. heat is appropriate.

Heat is hot. Ice is cold. (How profound!). Their opposite temperature properties account for their opposing therapeutic effects. The cold of ice therapy (cryotherapy), has a localized anti-inflammatory (slowing and decreasing blood flow) effect while the heat of heat therapy (thermotherapy) increases blood flow (circulation) encouraging more inflammation. When an injury or musculoskeletal pain is new or fresh ( i.e. sprain/strain) the resultant inflammation needs to be reduced and ice therapy is best applied; acting as an inexpensive drugless anti-inflammatory. Heat therapy works best for old and or dull (chronic) musculoskeletal pain ( i.e., non-inflammatory degenerative arthritis/osteoarthritis, fibromyalgia, muscle spasm/tightness, old injuries,etc) when increased blood flow to the area involved would be most soothing. If heat is erroneously applied to a new injury it will cause excessive inflammation (tissue congestion) and impede the healing process often ensuring greater damage or harm. In addition, cryotherapy works as a safe and effective drugless pain killer (analgesic) as cold has a numbing effect on the local pain nerves.

Both therapies are easily applied to the body in the form of readily available soft gel packs. Soft gel packs of different sizes can be stored in the freezer for ice therapy. Most gel packs on the market are microwavable (follow the instructions written on them) allowing them to be used as well for heat therapy. I often recommend that patients purchase a bag of frozen peas to be used for home cryotherapy. Moist heat is more therapeutic than dry heat as it is more penetrating to sooth deep muscles. Never apply the ice or heat directly to the skin. Rather to avoid injuring the skin surface, use a thin insulating dish towel, tee shirt or cloth to avoid direct skin contact. Both therapies work best when compressed against the area of pain/injury. For low back application I recommend that the patient lies on their side with knees slightly bent (fetal position), pillow supporting neck and between knees with the pack belted or tied to the back. For both ice/heat therapy application time is 15-20 minutes with 2 hour intervals between applications (20min. every 2hrs.). During the 15-20 cryotherapy application aside from the initial feeling of cold it is expected to be followed by the sensations of burning, achy pain, then numbness. Caution must be taken not to make heat compress to hot as to burn oneself. At risk of harm, never leave the ice or heat compress on for greater than 20 minutes.

Ice and heat therapy should not be used (contraindicated) under the following circumstances:

1) region of nerve damage (i.e. peripheral / diabetic neuropathy)

2) region of impaired circulation (i.e. peripheral vascular disease, deep vein thrombosis, blood clots, and arterial sclerosis)

3) over open wounds

4) heat should never be used over a sunburn

5) hypersensitivity to cold or heat

6) malignancy

As a clinician on the front lines of treating musculoskeletal pain/injury it is common for patients to mistakenly apply home heat when ice therapy would be more appropriate to use. This seductive almost instinctive impulse to choose the warm soothing allure of heat can be difficult to resist and or break. It is often exasperating to discover that a patient's worsening condition can be attributed to their inappropriate use of home heat therapy. It is even more disturbing to learn that such erroneous usage of heat therapy was prescribed by the previous obviously ill informed physician (often at the emergency room). I contend that when it comes to the home treatment of most musculoskeletal pain/injury ice therapy should be applied first, as while it may not always help, it will not harm. In contrast, heat therapy can run the risk of harming the healing process. My motto to patients in pain who are uncertain as to whether to apply ice or heat is "when in doubt use ice first, as while it may not help it won't do harm". Think of the injured athlete on the sidelines at a sporting event who has an ice pack compressed over the site of injury.

The following are practical guidelines as to when and how to use ice and heat to treat muscle-skeletal pain/injury: 

1) When the injury is new, inflamed, or fresh (< 72hours old) or when the pain is sharp (acute) always apply ice first.

2) When the injury is old, chronic (> 72hours old) or when the pain is dull, heat may be applied.

3) If indecisive as to what stage of pain or injury you may be in and thus uncertain as to which therapy to apply or if you can't accept my preference for ice as previously noted, I recommend you do the following self test. First, apply an ice compress for 20 minutes (using the correct previously mentioned procedure) to the injured/painful area and wait 2hours. During the 2 hr. waiting period, take note as how you feel in the site of concern. Immediately after the 2 hr. interval, apply a heat compress for 20 minutes to the same injured area and again note how you feel for a 2 hr. interval. Whichever therapy causes the most relief or improvement of symptoms during the 2 hr no therapy waiting period is the one you should continue to use exclusively. Be sure to base your decision on how you feel during the 2 hr. non application interval, (not the 20 minute application period) as what is most important is the therapeutic effect of the therapy. Heat can feel good while on but not have beneficial effects while off. If both have beneficial effects the alternating applications of ice and heat, may offer a positive therapeutic benefit. The key to the success of this method of choosing between ice and heat therapy is listening to what your body tells you.

Authored by,

Dr. Glen Bobker, Chiropractic Physician

Life on earth evolved to thrive in natural environments. It is becoming more and more apparent that a wide range of human physical and emotional ailments result from our disconnection from the power of nature. One can say that our genes are most compatible with the natural environment. The term "nature-deficit disorder", ( coined by the author, Richard Louv), is used here to explain the fact that in modern society our dissociation and alienation from things natural has negative health consequences. This relevant and important health concern is slow to be recognized or accepted by the medical community.

Here are some scientifically accepted examples of how deviation from nature in our modern environment is unhealthy to human health:

1) The overconsumption of industrially altered processed (loaded with salt, high fructose corn syrup, preservatives, pesticides, hormones, and antibiotics) foods which are cumulatively unhealthy to our bodies.

2) Lack of exposure to natural sunlight, which results in deficiency of vitamin D, a nutrient of vital importance for bone , brain, and immune health.

The lack of exposure to natural light during the day and overexposure to artificial light at night will disrupt biorhythms (circadian rhythms) interfering with our sleep, moods, and energy.

3) An increasingly altered from nature water supply loaded with dissolved man-made pollutants (including prescription drugs) are cumulatively toxic to our health.

4) A lack of direct physical contact with the earth in our post-industrial modern society. We are no longer tied to the earth. With our computers, iPads, smart phones we do not need to go outside anymore. We are surrounded by concrete, steel, pavement, drive automobiles and walk in shoes. All of which serves to deprive us of proper exposure to earth's pulsed electromagnetic field (PEMF), a biologically vital component to the health and wellness of all 75 trillion cells of our bodies .The importance of the earth's PEMF in health and wellness is scientifically established and gaining more prominence as technical devices and equipment that emulate this natural energy are clinically used to treat the body. As a chiropractic physician utilizing this vital energy medicine in practice, I can attest to its powerful pain reducing, healing and wellness impact.

Here are some health tips for our modern lives:

1) Consume foods that are as close to nature as possible! Go with organic ,unprocessed whole (nutrient-rich) foods. They are a healthier match for our biology. 

2) Drink water that is as close to nature as possible. Modern tap water is loaded with harmful chemicals and thus consider purchasing a water purification system that closely duplicates earth's best spring (mineral-rich) water. 

3) Spend more time outside in nature and in natural light. More time spent in natural light will improve our sleep, energy and moods as well as our vital natural vitamin D stores. In our modern lives we rarely go outside anymore. While skin cancer in sunny climates is a concern, one can still be covered up and benefit from natural light exposure.

4) Get a daily dose of health in the form the earth's pulsed electromagnetic field (PEMF). Lay down on the grass, beach or stand barefoot on the earth daily for approximately 1 hr. twice a day. This behavior will serve to charge all the cells of the body with energy provided by the earth's natural energizing force field. If this prescription is too impractical to apply there are quality high-tech devices available that emulate the earth's PEMF. The value and importance of exposure to earth's PEMF for our health and well-being has been studied and verified by NASA, the Russian space program, as well as the world scientific community. In fact, all space suits and space capsules are equipped with a high-tech device that supplies this vital health enhancing energy in biologically friendly frequencies/intensities that match the earth's. My patients, my family, and I have found this revolutionary high-tech "energy medicine", now available for clinical and home use, to be invaluable at improving wellness. To learn more visit: www.ienergymedicine.com

In summary, as Albert Einstein said- "Look Deep Into Nature and Understand Everything Else Better". As modern human beings, we tend to forget that we are tied to nature and that our health and well-being are compatible and interdependent with it.

Active Isolated Stretching: Massage Therapy to Stretch Away Pain & Optimize Health

Just like cats and dogs, humans innately feel the urge to release joint stiffness and discomfort by stretching. One just has to point to the popularity and devoted following of body lengthening fitness techniques like Yoga and Pilates to justify nature’s drive to stretch. The need to stretch and be elastic is so important that the lack of flexibility may be considered a health liability. Being inflexible leaves us more susceptible to pain, injury and disability. Gentle stretching to improve flexibility serves to nurture joint health by promoting the flow of blood and lymph. While the importance of body elasticity as a measure of fitness is well established, many people still neglect to include stretching in their workouts. Fortunately for stretching slackers, a gentle body lengthening technique exists, called Active Isolated Stretching (AIS) for achieving optimum flexibility and joint health. 

After all, people are mechanical in nature. Structurally we are made up of bones which act as levers, joints which form fulcrums for movement and soft supporting tissues (i.e., muscles, tendons, ligaments, fasciae) which serve as pulleys. All joints contain specialized nerve receptors called proprioceptors which allow us to automatically sense joint position/movement, a process known as proprioception. Flexibility is a vital measure of health as it effects movement, balance, coordination, posture, athletic performance, circulation and ultimately susceptibility to musculoskeletal pain/injury.

Active Isolated Stretching (AIS) is a safe and powerfully effective body lengthening technique for optimizing health. Specially-trained massage therapists, chiropractic physicians, physical therapists, athletic trainers and sports medicine doctors apply AIS therapeutically to treat pain and improve joint function. AIS is commonly applied to rehabilitate joint pain/surgery, enhance athletic performance or just to optimize wellness. AIS is a unique stretching skill because it incorporates the principles of both musculoskeletal anatomy (isolating specific muscles) and neuroscience (the stretch reflex) to maximize myofascial release, improve flexibility and enhance circulation. Unlike the more commonly utilized “static stretching” which can be painful and counterproductive, AIS is specific, gentle (non-bouncing) and incremental in nature; making for a softer, safer and ultimately more rewarding stretch. AIS can restore flexibility and soft tissue aeration in such a gentle manner that it is used to effectively treat/rehabilitate recent sprains/strains, arthritis, heel/elbow tendinitis, frozen shoulder, plantar fasciitis, whiplash, Lumbar & Cervical Disc problems, post-operative joint pain, etc. Professional and non-professional athletes are devoted enthusiasts due to its ability to improve athletic performance and treat/prevent joint injuries. Patients of all types and all ages can benefit from AIS’s ability to improve and optimize health. Discover the therapeutic benefits of Active Isolated Stretching and make it a regular part of your fitness/wellness routine.

Dr. Glen Bobker, Chiropractic Physician

The Downtown Chiropractic & Orthotic Center

If you would like to reproduce this article, please contact Dr. Bobker at info@ftlaudchiro.com

As a recreational runner for over 30 years I can attest to the stress relieving and posture enhancing impact of custom foot orthotics. I credit these shoe inserts for alleviating my chronic heel pain (Achilles tendinitis), improving my athletic performance and for being instrumental in allowing me to be like the Energizer Bunny, “still going…” As a Chiropractic Physician, the profound personal benefit I have experienced wearing Custom Foot Orthotics have made me a passionate proponent of their use; encouraging me to develop an expertise in their proper use. My profession is uniquely qualified in understanding the relationship of how faulty foot mechanics impact the entire body. We commonly prescribe Custom Foot Orthotics as an effective pain remedy for people who suffer from metatarsalgia, foot neuromas, plantar fasciitis, heel spurs, Achilles tendinitis, shin splints, reoccurring knee, hip, back or neck pain. Athletes of all types have long understood their performance enhancing impact. For the past 17 years I have successfully assisted hundreds of patients to achieve a more pain-free lifestyle from the ground up through the application of Custom Foot Orthotics.

From my experience most people are in the dark when it comes to choosing the foot orthotics that will work best for them. Most are blind to the fact that there is a science and art to prescribing, fitting and dispensing corrective foot appliances. Those seeking the improved comfort and support provided by orthotics may be overwhelmed and confused by the diversity of types and prices. The seemingly endless variety can range from prefabricated off-shelf inserts purchasable at local retail store kiosks to laboratory created “custom” versions prescribed by clinicians. This article was written to shed light and aide those consumers searching for foot orthotics to make a more informed decision about which version would best suit their health needs.

Custom foot orthotics work on feet the way braces work on teeth; exerting gentle pressure to mechanically reposition the foot muscles, joints, and ankle into a more ideal alignment. They are purposely applied to the body’s foundation to minimize stress forces (excessive pronation or supination), improve structural support (fallen arches) and balance weight distribution from the ground up; ultimately serving to improve whole-body posture and relieve pain. Unlike the prefabricated store bought inserts, Custom Foot Orthotics must be prescribed by a clinician. The most accurate custom foot orthotics should be meticulously crafted in a laboratory from a mold of each foot. To create the most corrective custom appliance available, the prescribing doctor provides the orthotic lab with a cast (impression) of each foot, taken with the feet held in the most ideal foot-ankle alignment. This casting method called Non Weight Bearing Sub-talar Neutral, corrects for the negative foot-ankle postural effect of gravity and body weight. Orthotics made in this way provide the most therapeutic benefit because they are posted (pitched or tilted) a few degrees to correctively align each foot at the ankle (neutral alignment). By supporting a more ideal alignment of the body’s foundation these custom foot appliances have the broadest impact.

It should be noted that many clinicians fit custom foot orthotics by using a less precise casting method, known as Step-In-A-Box. This method requires that the standing patient step each gravitationally misaligned (non-neutral) ankle-foot into a box of foam. Next, these weight bearing foot impressions are sent to a laboratory where the orthotics are usually hand-picked from a collection of pre-made off-shelf templates. The step-in-a-box variety of custom foot orthotics are less precise (not truly custom) because they are not formed directly from a mold of each foot and depend upon guess work regarding contour and corrective posting. With foot orthotics of this nature, the right and left inserts are commonly just mirror images, thus not accounting for the unique requirements of each foot. Prefabricated “custom” foot orthotics, whether chosen off-shelf from a store kiosk or selected from a batch of pre-manufactured models in a lab should not qualify as “truly” custom foot orthotics. Unfortunately, in this manner many unsuspecting consumers may waste money as they are deceived into purchasing overpriced “custom” orthotics that in reality may not provide the best therapeutic result.

The standard of care for prescribing, fitting and ultimately creating the most efficacious Custom Foot Orthotics is all about the clinician taking the necessary time to attain the most therapeutically wearable cost-effective inserts. Practical and utilitarian concerns such as the size and types of footwear (i.e., sport, dress, heel height) typically worn should be addressed. Unfortunately, many people are misguided into wastefully purchasing orthotics that are mismatched or ill fitted to their footwear; often “throwing away good money after bad.” In my practice we request orthotic candidates to report with a shopping bag of their typically worn shoes to best ensure the inserts chosen are a qualified match. Consideration must be given to those who possess sensitive feet. In my practice we weed out the “princess and the pea” types by allowing those who may be potentially sensitive, to test drive sample inserts. A thorough health history (i.e., diabetes, joint pains, etc.), foot exam (i.e., Achilles/ heel problems, hammer toes, bunions, foot arches, calluses, etc.), shoe preferences (i.e., dress or sport varieties) and postural distortions (i.e., unleveled hips, scoliosis, etc.) are important considerations for choosing the style and specifications for orthotic construction. In order to achieve optimal comfort and utility, customization also includes determining the orthotics’ length (i.e., 1/2, 3/4, or full), firmness of construction material (i.e., EVA, Plastazote, Leather & Cork, Polypropylene Thermoplastics, etc.), type of cover (i.e., Spenco), and heel cupping (flanging). Other accommodations such as metatarsal padding, neuroma bar, Morton’s extensions, heel lifts, heel spur hole-pad, etc. may be added as needed. Attention to these details often requires a close working relationship with the laboratory pedorthist (a licensed professional, trained to manufacture foot orthotics). We even consult with the lab pedorthist about each cast and provide him with a video of the patient’s foot alignment and gait to ensure even more accuracy and comfort. A custom orthotic clinic should be questioned about the laboratory practices and processes involved in their manufacture. Because of the clinical decision making and meticulous steps involved in creating the best custom appliances one can expect them to be priced from $400.00 to $500.00 per pair.

In summary, corrective insoles can be transformational in their ability to improve posture and alleviate pain throughout the body. However, it is important to understand that just like feet, not all foot orthotics are created equal. Those seeking the health benefits of appliances which so intimately hug and support our feet are advised to make a knowledgeable decision. In order to achieve the best outcome, my advice is to become an educated consumer and consult with a skilled foot orthotic clinician.

The Downtown Chiropractic & Orthotic Center