A Walking Cure and Back Pain Loss

From the Times Online

From The Times
September 26, 2009
Back pain: the walking cure
Almost half the British population suffers back pain. A new treatment promises to ease their suffering. Will it?
Simon Crompton
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My walk has never been subject to so much scrutiny. Frankly, it’s embarrassing. “Mmm, definitely hyperlaxic,” one physiotherapist mutters to another as they watch me march up and down the room, my steps measured by 14,000 pressure sensors on a beige carpet running down the centre of the gym. I pick up worrying words: “Bracing right side ... pronation ... arm not swinging,” but they urge me to ignore them. Everyone’s gait has peculiarities. Yeah, right.

It turns out to be a couple of the most revelatory hours I’ve spent — at least as far as my bones and joints are concerned. I’m trying out a new “breakthrough” analysis and treatment technique for lower back and knee pain being launched in the UK by Bupa. If it really works, and becomes widely available, it could revolutionise the treatment of these conditions — Bupa claims that there is evidence that it can eliminate the need for prescription pain relief in seven people out of ten suffering from back pain. Research by Bupa suggests that 45 per cent of British adults suffered back pain in the past year, and that 25 per cent suffered knee pain.

The system is called APOS — All Phases of Step Cycle — and combines a computerised assessment of the way you walk with a treatment consisting of wearing a specially tailored pair of shoes. The shoes treat you as you walk, realigning the body and making you slightly unstable so that your muscles find new ways of stabilising joints.

The principle is this. For many of us — whether because of injury or abnormality — the body gets into the habit of working asymmetrically, with some muscles braced and overworked, others underdeveloped. As a result, strains, aches and pains become established. That’s why a pain in the foot can result eventually in a pain in the back — it sets up a domino effect of pain-inducing imbalances as your body tries to compensate.

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Amit Mor, the doctor from Israel who jointly invented the APOS system with Dr Avi Elbaz, says that such imbalances underlie many chronic knee, back and hip conditions, including osteoarthritis.

“Conditions such as arthritis are a glimpse of a much bigger problem with neuromuscular control,” he says. APOS is about getting your body to relearn a more efficient way of moving, to prevent damage and pain setting in. Mor joins the physiotherapists to study my evidently intriguing walk. The computer read-outs, measuring my step length, walking speed, in/out-toeing, and time spent on each foot, confirm what Mor says he could tell from my posture as soon as he saw me: I have a problem with hyperlaxity.

It sounds like an accusation of laziness, but it means that, like 10 per cent of the population, I have loose joints with an unusually large range of motion. Because they move too freely, they don’t produce the forces that would normally result in muscle-building around them and so become more easily damaged. This probably accounts for the intermittent exercise-related pains I get in the ankles, hips and lower back, and my strange tendency to brace the right side of my body while walking.

It’s a fascinating insight for me, because it explains so much about the pains in hips and back I’ve been having for 25 years that doctors never adequately got to grips with.

Mor says that his analysis technique has similarly managed to put the finger on the problem of thousands of back and knee-pain sufferers in his clinic in Israel, and since January in the UK. He shows me some extremely impressive “before and after” videos of people first hobbling with long-term knee pain, and then walking freely after a few months’ treatment with specially tailored APOS Walkright shoes.

He explains that what his treatment is doing is getting the body back in alignment by inducing a sense of instability. This gives a jolt to the body’s biofeedback system (which tells us where we are in space) and demands that subconsciously we reassess old ways of standing and walking. The instability is administered through the Walkright shoes, which have two large rubber domes on the soles, specially balanced to the individual to change weight distribution too. Worn for periods of increasing duration for a three-month period, they provide therapy over thousands of repetitions during daily activities.

Mor admits that the Walkrights are not unlike MBTs and Fit-Flops, sold as “healthy shoes”, which also induce “natural instability”. The difference, he says, is that his shoes are tailored after a detailed assessment, and are worn in a controlled and supervised programme (APOS patients are invited back for regular reassessments).

So does it work? That’s a bit important since the full treatment costs an eye-watering £2,925 (£3,250 if spread over six months). APOS is available free to those with some types of Bupa health cover — but only if the source of their problem is the knee, not the back. If it’s your back, Bupa members pay for at least some of the cost.

The fact is that Bupa is showing a surprising act of faith in offering the treatment and publicising its benefits, particularly for back pain. APOS was first offered in 2005, in the Assaf Harofeh Medical Centre, Tel Aviv. Since then it has been immensely popular in Israel, with 12,000 people receiving treatment (mainly for knee problems), and four medical insurance companies covering it, but inevitably there has been little time for comprehensive, independent trials.

A small study conducted by Mor and published in the journal Spine in July showed that 19 patients with chronic low-back pain increased their step length, walked faster and became less asymmetrical after 12 weeks of using the tailored shoes. Another as yet unpublished study by Mor showed that of 57 people with knee osteoarthritis 69 per cent showed improved function after eight weeks of treatment, and 70 per cent experienced less pain.

Bupa admits that the research base behind the treatment is still developing, but says that it is part of its mission to offer innovative treatments to members. After its horizon-scanning group heard about APOS, a fact- finding team was sent to Israel.

“They’re getting exciting results,” said Peter Mace, the deputy medical director of Bupa. “Normally we would look with considerable care at the published research before offering a treatment, and it’s true that with this treatment we’ve looked more at anecdotal findings and the information provided by the APOS team in Israel, who have a lot of very impressive data on the efficacy of the treatment.” There was, he added, more evidence for the effectiveness of APOS in treating knees rather than backs. There were also indications that APOS could prevent the need for knee surgery in patients — which made its provision to this group more of a priority.

Did it work for this patient? It’s too early to say. I’m a month into wearing my wobbly Walkrights around the house — at the moment for an hour a day, but by the end of six weeks it’ll be 90 minutes, some of the time outside. Then I go back for a re-assessment to adjust my shoes and exercise prescription as necessary. It’s no great inconvenience wearing the shoes, although it’s no great fashion statement either, and you do get used to them.

Got to timesonline.co.uk/health to see how the APOS treatment worked out for me

For more on Back Pain goto backpainloss.com