Holistic healthcare is an alternative to the conventional approach which focuses on the illness and not so much the patient. It is important for patients to do their own research and decide what they believe, and to also involve a healthcare provider who is open to trying different methods of care. A foot and ankle surgeon is a good place to start. Consider the options that comprise integrative care; using or combining different techniques or therapies of healing and managing to aid a patient. Change is never easy, but try to view pain as a chance to take a fresh approach to your health. By seeking appropriate treatment and care, often patients can expedite their own recovery. Often a visit to a health professional is not necessary and done so out of habit. Think back to your preventive care and ask yourself, “Did I do everything that I could to help myself?” The answer is often ‘no’ but the truth of the matter is, wellness is your birthright and achieving it is within your power (even with chronic foot and ankle pain!). This can be the start of a journey to learn, understand, and implement a new path of health and healing. Often said, the hardest part is taking the first step!
Understanding foot and ankle pain can be incredibly challenging. Injuries are often accompanied by tissue damage that is difficult to visualize, and many chronic pain syndromes involve complex changes to the way the nervous system processes information from painful stimuli. Understanding the cause of the pain is crucial in order to treat it effectively. Equally important is the understanding that effective treatment may need more than one single approach.
Understanding Foot and Ankle Pain
Understanding foot and ankle pain will be essential to facilitating effective treatment. The development of a classification system for acute musculoskeletal injury has provided a framework for predicting time of recovery, optimal treatments, and outcomes. A common language will also facilitate communication with patients, the multidisciplinary healthcare team, and researchers. The following section will examine the primary trajectories of musculoskeletal injury related to variations in the mechanism of injury, tissue affected, and clinical presentation. Common conditions affecting the foot and ankle will be used to illustrate points. They will be loosely grouped into acute injury, chronic overload, and episodic overload. The use of a biopsychosocial model for each condition will also be demonstrated, as it is considered to be the best approach for understanding pain and injury.
Importance of Holistic Approaches
An understanding of holistic care and treatments for specific conditions can be used to inform and involve the patient in self-management and prevention of further disability. This knowledge and self-management could result in less reliance on other healthcare services, and further education could prevent musculoskeletal conditions from occurring in future generations.
The configuration of holistic care and the best holistic treatments for musculoskeletal conditions will vary greatly depending on the condition and the individual person. Therefore, it is important that research into this approach is condition-specific and is able to measure the change in the condition and the person’s overall quality of life throughout treatment.
Holistic healthcare models have been common practice since ancient times, in societies where it was understood that wellness was a state of balance between the physical, psychological, and social states of being, and that curing a disease was not the same as restoring health. However, the idea of using holistic care to consider musculoskeletal conditions is relatively new, and there is little understanding and evidence of how this approach can be applied.
Based on the work done in other areas of healthcare, it is proposed that holistic care for musculoskeletal conditions should involve treatments that consider the positive and negative effects of the body, mind, and social state on overall health, use minimally invasive treatments in preference to surgery, and take into account both the short and long-term effects of the condition on a person’s quality of life.
While most people are aware of the term holistic care, and it is, of course, important to consider the whole person when treating any condition, there is little understanding of what holistic care actually involves and how it can be applied to specific musculoskeletal conditions. There is currently no consensus amongst medical practitioners and therapists on what holistic care involves beyond considering the psychological and social aspects of a condition.
Orthopaedic medicine should take a more integrated approach where the understanding and treatment of musculoskeletal conditions takes into account the physical, psychological, and social aspects of the condition on the person’s life, with the aim of preventing further disability and improving overall quality of life. This shift towards a biopsychosocial approach to musculoskeletal medicine has led to an increase in research using holistic methodologies and models of care, and an understanding between musculoskeletal pain and pathology and its effect on a person’s quality of life.
More recent research shows that the outcomes of orthopaedic surgery may not always be a cure for the problem, and in some cases, may provide little difference to the natural history of the condition. This has led to a rethink in how musculoskeletal conditions are understood and managed, with calls for less invasive and more conservative treatments, which consider the wider effects of pain and pathology on a person’s life.
In orthopaedic medicine, there has traditionally been a very biomechanical approach to understanding and treating lower limb pain and pathology. This approach is based on mechanical principles and assumes that the body can be understood and treated like a machine. While the benefits of taking this reductionist approach to understanding musculoskeletal pain are that it can provide a clear diagnosis and a direct treatment pathway, in some cases, it can lead to oversimplified understandings of complex problems and treatments, which may provide short-term benefits only.
Holistic care refers to care that takes into account the whole person and focuses on overall wellness, rather than just treating a disease or condition. In recent years, it has become a more common way of thinking in healthcare, and with that, there has been an increase in research looking into ways to apply this approach to treating musculoskeletal conditions.
Holistic Approaches to Foot Pain Management
Physical therapy treatments to improve gait and strength of foot musculature will lead to reduced pain and lowered risk of future foot injury. Although physical therapy treatment is often slow to give pain relief, it should be considered when wanting to return to high function and activity lifestyle.
In a recent study, 65 people who suffer from rheumatoid arthritis (a disease often resulting in chronic foot pain) were treated with physical therapy only, drug therapy only, or a mix of the two therapies. After 12 weeks of treatment, the group receiving combination therapy had significant improvement in pain and footsteps per day, as well as increased physical function.
When considering methods to approach foot pain, one of the most effective methods is physical therapy. Physical therapy has been proven to aid in pain relief, as well as strengthening the muscles and increasing joint movement. An improvement in these areas will enable people who experience foot pain to return to regular activity and improve performance in everyday activity.
Physical Therapy and Rehabilitation
Overall, these interventions are designed to prolong the time before onset of foot and ankle pain and improve functional standing in individuals with musculoskeletal conditions. High-level athletes with sprains or other minor injuries can expect a similar progression to more intense therapeutic exercises and eventually prevention strategies to decrease the risk of re-injury.
Aerobic and sport-specific activity are often what patients most relate to their quality of life and therefore providing a means to participate in these activities is a common goal in treatment progression. It is important that a progressive transition is made from simple strength or endurance exercises to more complex and functional activities. This will often help to bridge the gap between impairment and disability.
More recently, there has been an increased focus on the role of weight bearing and aerobic activity. This is indicative of a global transition in practice of physical therapy for foot and ankle pain, from traditional impairment-based strategies to contemporary disablement-oriented prevention and management of musculoskeletal conditions. This approach is justified by evidence that has demonstrated the chronic nature of foot and ankle pain and its associated functional limitations.
In regards to musculoskeletal conditions, the etiology is often related to some form of muscle weakness or imbalance. Exercise is effective for foot and ankle pain, but the type of exercise prescribed will depend on the nature of the condition. Therapeutic functional exercise includes a wide range of activities that can be performed at home or in a gym and is designed to promote strength, power, endurance, and flexibility in patients.
A large and growing body of research has demonstrated that exercise is a safe and effective conservative treatment for a variety of musculoskeletal conditions, including musculoskeletal foot and ankle pain. In general, exercise is beneficial in the management of lower extremity pain. Exercise also plays an important role in preventing both lower extremity and foot and ankle injuries. It does this by addressing the underlying etiology of many functional problems.
Acupuncture and Traditional Chinese Medicine
In a study, 15,000 patients from around the world were treated with acupuncture and the reports showed that 70-90% experienced relief from symptoms such as nausea, vomiting, dry mouth, and drowsiness. Later studies have shown that acupuncture is effective for cancer-related and postoperative pain. Acupuncture also has a large effect on relaxation and at the same time increases the precise and coordinated movements of the body. This has been proven with MRI evidence showing changes in brain activity and the release of endorphins and serotonin.
Acupuncture is a therapy that has been practiced in China and other Asian countries for more than 2,000 years. It is based on the belief that living beings have a vital energy, called “qi”, that circulates through twelve invisible energy lines known as meridians on the body. Each meridian is associated with a different organ system. An interruption in the flow of qi is believed to be the cause of all disease. Acupuncturists insert needles into specified points along these meridians to affect the flow of qi.
Massage Therapy and Reflexology
Reflexology is a bodywork modality based on the theory that there are specific areas on the feet (or hands) that are energetically connected to other areas of the body. Through manipulation of these reflex points, using special hand, thumb, and finger techniques, it is believed that one can improve health throughout the body. The theory is that when the body is in a state of dis-ease, the corresponding reflex will often become tender, indicating congestion or imbalance in the corresponding area. By working the reflex, this tenderness will decrease, and over time healing can occur throughout the body. Reflexology can be a relaxing and noninvasive modality that is often utilized to create a state of deep relaxation and to optimize the body’s ability to regenerate and heal itself. When addressing foot pain, this can be an alternative method of care for individuals unable to tolerate direct work on their feet, and it can potentially have systemic effects by addressing reflexes specific to locations of pain and dysfunction.
Massage therapy and reflexology are two modalities that can be used to address foot pain. Massage therapy is a manual technique involving manipulation of soft tissue using a variety of different styles and techniques. Through applying structured pressure, tension, motion, or vibration to the various parts of the body, massage assists in increasing circulation and promoting relaxation, helping the body to facilitate its own healing process. It is used to decrease tension in muscles, reduce stress, and create a sense of relaxation. Poor gait mechanics and traumatic foot injuries tend to lead to excessive tension in the musculature surrounding the foot and ankle complex. Massage may provide a therapeutic environment to help increase flexibility of involved tissues and relieve pain. This modality can be useful in addressing muscle pain syndromes and is often used in conjunction with other methods of care. A trained massage therapist can also utilize a technique called myofascial release, believed to be beneficial in freeing constricted or tightened fascia due to injury. Regular session duration, frequency, and level of benefit will vary between individuals, but massage therapy can have a role in a comprehensive plan of care for foot pain.
Holistic Approaches to Ankle Pain Management
Holistic therapy’s purpose is to treat pain and the person as a whole. Options include identifying stress and/or other psychological contributors to the pain, attempting to eliminate or reduce these stresses, and utilizing a wide array of non-drug, non-surgical interventions and techniques to address the biomechanical, structural, and physiological imbalances, as well as the injury or complaint. By nature, holistic therapies rarely have side effects of consequence and have an excellent safety record. Holistic care shines when used as a prevention and can serve as ongoing “maintenance” for the patient. This form of holistic therapy frequently takes a patient so far out of the pain “syndrome” that they will not need to address the problem with the same therapy. An example would be so far improving one’s nutritional status or learning to swim instead of run for exercise. The most important principle of holistic care is always taking into consideration the whole person. In the case of an athlete with a foot or ankle problem, the dynamic nature and high demands of the foot/ankle complex require the body to be in as best balance and function as possible, and that the patient’s activity level and desire to return to it are highly considered for the most satisfactory result. This may be a lot to ask for someone with a chronic problem, but strong holistic care may allow an arthritic patient to no longer need his/her cane.
Chiropractic Care and Spinal Alignment
Due to some differences in approach and philosophy between chiropractors and podiatrists, as well as the fact that the two professions do not commonly engage in formal referral systems to each other, there is not a large body of published research on the results of concurrent treatment of foot pain with the use of spinal manipulation. Anecdotal evidence, however, shows that in cases where a patient seeks both podiatric and chiropractic care, coordination of treatments to the holistic benefit of the patient can have appreciable results.
Acknowledging the fact that most mechanical maladies to the lower extremity have some impact on the biomechanics of the pelvis and the spinal column, it is reasonable to suppose that treatment of the pain in the context of the patient’s total body physiology will have the most comprehensive results. This approach is quite congruent with holistic podiatric treatment aimed at improving not only foot function but total body gait mechanics.
Chiropractic philosophy dictates that mechanical lesions to the body’s spinal column and the limbs can be a primary factor in many diseases and that the resultant physiological and pathological changes in the body can affect many different health outcomes. Theoretical ideologies aside, there are many cases in the treatment of pain in the lower extremity where a podiatric patient has sought chiropractic care and orthotic therapy for a musculoskeletal ailment.
In the case of podiatric pain, a mechanistic view of compensatory foot function (i.e. limping) leading to spinal and pelvic pathology resulting in further pain and dysfunction can lead us in many cases to quite an effective mode of treatment often referred to as a “domino effect”. Chiropractic care is founded on the above-mentioned principle of causality in mechanical disturbance to the body resulting in pain and loss of physiological function.
From the traditional perspective, the ailments of the human body are often attributed to abnormalities and misalignments of its musculoskeletal structure. This mechanistic view hinges on the premise that the body can be treated as a conglomeration of its separate parts, an ideology that has come to shape modern medical practices.
Herbal Remedies and Supplements
The use of herbal remedies is perhaps the oldest form of medicine. Archaeological evidence suggests that herbs were used to treat wounds and illness as far back as the Neanderthal period. Much later, the ancient Egyptians, Indians, Chinese, Greeks, and Romans used herbs in their healing ceremonies. This has been documented in historical documents, such as the Ebers Papyrus (an ancient Egyptian medical document), which contains more than 700 compounds and prescriptions for countless illnesses collected from several different cultures. The Native American Indians have an incredibly extensive knowledge of herbal medicine, and many of the remedies they used have been proven to be effective by modern science.
What is the difference between herbal medicine and a pharmaceutical drug? The primary difference is that plant medicines are made up of a whole host of chemicals, not just one active ingredient. Because of this, herbal medicines are able to create a range of effects on the body. For example, the same herb can be used to treat two patients with the same disease but with different underlying causes. This is vastly different from a pharmaceutical drug, which usually just treats the cause and not the individual.
Herbal medicine, also called botanical medicine or phytomedicine, refers to using a plant’s seeds, berries, roots, leaves, bark, or flowers for medicinal purposes. Herbalism has a long tradition of use outside of conventional medicine. It is becoming more mainstream as improvements in analysis and quality control, along with advances in clinical research, show the value of herbal medicine in treating and preventing disease.
Mind-Body Techniques and Stress Reduction
Stress management techniques can be part of a treatment plan with a professional therapist or an approach an individual can take on their own. They are safe, have no side effects, and can give a patient a sense of control in managing their condition.
A study examining the relationship between depression and arthritis showed that those who were depressed were more likely to use analgesics, nonsteroidal anti-inflammatory drugs, opioids, and alternative therapy in addition to traditional treatment for their arthritis. They were also more likely to visit a medical doctor, physical or occupational therapist, and orthopaedic surgeon. They also had a higher rate of joint replacement. This underlines the importance of dealing with these issues effectively in any patient with a chronic musculoskeletal condition.
This is an integral part of holistic care, with extensive scientific study of its impact on health. It involves evidence-based use of mind-body interactions designed to influence physical functioning and promote emotional and physical well-being. There are many techniques used, but those which have relevance to an orthopaedic patient include relaxation, visual imagery, hypnosis, and cognitive-behavioural therapies. These have been shown to reduce pain perception through direct effects on the brain, producing an altered state of consciousness and brain wave pattern. Simple relaxation exercises may increase parasympathetic autonomic activity and reduce muscle tension. All can have an impact on anxiety, depression, and sleep, which are common co-morbidities in those with chronic orthopaedic conditions.
Integrative Care Strategies for Foot and Ankle Pain
The implementation of multidisciplinary care for musculoskeletal problems is superior to a single modality approach. This has been shown through evidence in the management of low back pain, and the same should be applied for foot and ankle pain. The combination of physiotherapy and podiatric medicine has demonstrated greater improvements in pain and functional limitations for patients with foot and ankle osteoarthritis. The study concluded that this approach was safe and feasible, and a larger trial would prove more definitive results. This is but one example of how a combined effort from practitioners of differing modalities could help to improve patient outcomes. Interface with other medical practitioners such as dieticians/nutritionists and traditional Chinese medicine practitioners will provide an opportunity for case discussion and collaborative decisions on patient management.
Integrative care is a current trend in healthcare. It has been defined as the combination of practices and methods from complementary and alternative medicine with conventional Western medical techniques. Trials have suggested that the combination of alternative therapies with established medical practice results in an overall improved quality of life and, therefore, should be considered as a treatment option. To facilitate the best possible outcomes, patients must be educated and encouraged to make well-informed decisions regarding potential treatment options. Physicians should give sound explanations about the risks and benefits of conventional treatments, as well as any alternative therapies. It is highly recommended that access to information for patients is in an easy-to-understand format. If patients choose to proceed with alternative therapies, referrals to certified practitioners with knowledge and experience in the given technique should be given. Open lines of communication between practitioners of differing disciplines are vital for a coordinated approach to patient care.
Multidisciplinary Treatment Approaches
The patient presented with an acute injury or potentially reversible pathology may be best managed within the uniplanar care pathway. For the protracted pain or complex clinical presentation, this may not be the best means to a successful treatment outcome. An example of such a case would be the young athlete with undiagnosed spondyloarthropathy, presenting with inflammatory heel pain and early sacroiliac joint discomfort. Another example might be an elderly individual with complex regional pain syndrome overlaying a background of inflammatory osteoarthritis, involving the entire foot and ankle complex. In such cases, the ultimate treatment goal would be to treat the systemic or spine-related pathology in conjunction with the peripheral pain complaint, aiming to improve function and reduce pain levels. This type of treatment goal is difficult to achieve within the constraints of public healthcare service and funding for private healthcare rebates, i.e. one injury, one pathology, one rebate.
The complex nature of foot and ankle pain conditions often involves a near intimate relationship between structural abnormalities, biomechanical faults, referred pain, and primary or concomitant pain from internal or systemic disorders. There are times when the initial or singular specialty specific management has failed to adequately deal with the patient’s pain and disability. This type of scenario often lends itself to a multidisciplinary treatment approach. In general terms, multidisciplinary care involves input by professionals from a range of medical and allied health care disciplines, aimed at achieving a unified treatment goal. This approach can be contrasted to the traditional uniplanar pathway of care provided by a single specialist within a single professional discipline.
Nutritional Counseling and Diet Modification
For many patients with chronic pain, adopting healthy eating practices and altering body composition will require assistance from a qualified nutrition professional. In the UK, the title “dietitian” is protected, and only those who have met approved professional standards and are registered with the health professions council may practice under this title. The title “nutritionist” is not protected, and while many excellent nutrition professionals may use this title, some with limited qualifications may also use it. To ensure an evidence-based and safe practice for management of painful conditions, it is advised that patients seek a dietitian who is experienced in the relevant field.
This understanding suggests that weight management and dietary interventions to reduce systemic inflammation may be of benefit to patients with chronic pain. At present, there is limited evidence of effective nutritional interventions for specific painful conditions. However, in conditions associated with inflammatory arthritis or crystal deposition, it is reasonable to suggest that patients should avoid pro-inflammatory diets.
Apart from the mechanical effect of increased weight causing or contributing to foot pain, there is now evidence of systemic inflammation associated with adiposity. Adipose tissue acts as an endocrine organ, releasing adipokines which are linked to inflammation of musculoskeletal tissue, and elevated levels of inflammatory markers. Inflammatory arthritis and other systemic inflammatory conditions are adversely affected by obesity, and a pro-inflammatory diet. Inflammation is an underlying mechanism for many painful conditions, and systemic inflammatory load can exacerbate localized inflammation at tendons and joint capsules.
It is anticipated that patients with painful conditions are commonly overweight. In a study using NHANES data, the prevalence of obesity in those with chronic pain was found to be 39.4%, compared with 24.3% in those without chronic pain.
In the past two decades, the role of nutrition in health and management of disease has become a major topic. It is now widely recognized that a well-balanced diet and appropriate weight control are vital elements in maintaining health and in the management of various chronic conditions. Nutritional practices that are good for the general population are believed to be appropriate for individuals with painful conditions; however, this may not be true for those with chronic pain.
Alternative Therapies and Complementary Medicine
Dr. L has also compiled an excellent list of positive interview questions for the patient to clarify the potential usefulness of various alternative therapies and complementary medicine for foot and ankle pain as well as to assess the importance of these modalities to the patient. This can help the patient to be more open-minded as well as provide useful information for the clinician regarding the direction of treatment. An open-ended approach will yield the most insightful information. An understanding of the nature and potential effects of various alternative treatments is required to know which resources to recommend and how resources can best be accessed. Finally, an ongoing reassessment of the patient’s preferences and what is actually available to them will shape the context of treatment over time.
Dr. L, of the Jefferson School of Health Professions, has additional suggestions. “When considering alternative therapies and complementary medicine for chronic foot and ankle pain, it is important to be open. The patient has already been suffering for a very long time and may have tried many things. The clinician should first be supportive and explore what the patient has already tried. At this point, the patient may have a negative impression of these treatment modalities, so it is important to explore what they have previously tried and why it was not successful for them.” Dr. L recommends the clinician be careful not to sound negative about these treatment modalities as this could harm the patient-clinician relationship.
