Q & A with Mary Biancalana CMTPT

Mary Biancalana, CMTPT Mary Biancalana, CMTPT, Fibromyalgia Clinics of America, Chicago, Il has over 15 years experience as a certified personal trainer, and as a certified trigger point therapist, Mary specializes in myofascial therapy and self-care training for fibromyalgia patients.  Over the last three years Mary has fitted over 100 fibromyalgia patients with Posture Control Insoles® to remove a significant perpetuating factor, Rothbart's foot,  in fibromyalgia and myofascial pain. 
Do you only treat fibromyalgia patients?

We are fibromyalgia specialists.  Typically 70% of our patients have fibromyalgia and the remaining patients present with myofascial pain syndrome or a single muscle area episode of myofascial dysfunction.  We deal with long standing muscle pain as opposed to rehabilitation from car accidents or acute pain.

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What are the greatest challenges in treating FM patients?

The greatest challenges for fibromyalgia patients are retaining their ability to do activities of daily living within their family, work and social demands. It is very difficult to rehabilitate their muscles because their muscle physiology is so different from the average person’s muscles that it is a constant challenge to figure out what works for any particular case.

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Are fibromyalgia patients uniquely predisposed to trigger points?

Yes, absolutely.  Fibromyalgia patients probably develop trigger points more easily because of biochemical changes in their body.  They are more susceptible to hormone imbalances which again can lead to muscle tightening and inappropriate muscle contraction.  They suffer from both trigger and tender points.  According to doctor Devin Starlanyl the crossover between myofascial pain syndrome and Fibromyalgia can be as high as 80%.  So if a person has fibromyalgia, 80% of them has myofascial pain syndrome as a huge component to their muscular pain. 

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On average, among providers who deal with chronic pain, what would you say is the percentage of getting fibromyalgia patients pain free?

It is difficult to say.  But I do know that it will have a close relationship to eliminating perpetuating factors such as compensating for Morton’s foot structure.  This patient population is far more prone to have foot problems that will be affecting their head, neck, jaw and shoulders than the general population. 

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What happens if you do not address Morton’s or Rothbart’s foot structures in fibromyalgia patients?

Fibromyalgia patients have so much muscular dysfunction that they are using secondary movers to do the job of a primary mover.  I have found that from palpating hundreds and hundreds of people.  That is what unifies this population.  So if they are using strange accessory muscles while thinking they are stabilizing their unstable hyperpronated ankles, that dysfunction is going to be translated all the way into the lateral hip all the way up into the shoulder the jaws, the neck and head.

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Are many fibromyalgia patients using different muscles than other people? 

That’s right.  In layman’s language: They are using secondary movers where the primary movers are already so tired and so dysfunctional that that muscle has given up.  They literally use secondary movers to carry bags of groceries and they wonder why their arm hurts after carrying a bag of groceries for 20 feet from their trunk to their kitchen. 
They actually carry the bag with a different posture.  What I call mal-adaptation.  They have mal adapted their natural biomechanics to make the brain or their motor sensory system believe they are still doing things the usual way.  Then we give them the insoles, and their brain initially resists it because they think the mal-adaptation is normal and the new addition which is leading them toward normal posture is an intrusion.  It takes a while for them to process and to allow themselves to operate in a more neutral posture instead of being hunched over and imploded.  When we bring them back to natural posture, we start to employ the primary movers again. 

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Have you seen any changes in the patient’s feet as a result of wearing Posture Control Insoles for a 12 month or longer period? 

Absolutely.  We have arrested hammer toe developments, and reduced hammer toes.   We have removed horrible calluses on the medial toe and the first metatarsal head and on the medial ankle right under the heel.  With self-care training, new shoes and Posture Control Insoles those calluses did not return. 

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How about changes in the arch or ankle?

Absolutely.  Patients report far fewer episodes of twisting their ankle.  They report far less medial knee pain and significantly reduced or eliminated lateral hip pain because preventing the knee from rotating in, prevents deep lateral rotators that attach the hip and  to the pelvis from being over used and over stressed.  We have people who have literally changed completely the way they stand, the way they walk and the way they sit. 

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Before using Posture Control Insoles™ were you using anything to address your patients' posture issues?

We used to fabricate pads for the first metatarsal from felt and moleskin. It was a tedious job, and the result frankly didn’t look all that professional. Durability was a big problem too. Posture Control Insoles certainly last a lot longer, saves us time and are more anatomically correct.

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How did you go about integrating Posture Control Insoles™ into your practice?

It was very simple.  We did a one evening in-service for all the therapy and office staff.  We found the video to be very helpful, and Posture Dynamics arranging for a support teleconference gave us instant answers to our questions.  We were up and running the very next day. 

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What reasons do you give your patients for purchasing Posture Control Insoles™?

We are a muscle therapy clinic so we take time to educate our patients.  We even expect them to remember the name of some of their muscles and what they do.  We show our patients how important the feedback coming from the feet are to balancing the feet and posture and in effect sending signals to the rest of the stabilizing muscles especially the erector spinae group in the back that they need not work so hard.  We show them how the muscles receive feedback and how they adjust for your posture, so when leaning to the side, the feet will adjust, the legs will adjust, the glutes will adjust, the back will adjust, and so on.   
  
We often are asked what differentiates PCIs and orthotics.  PCIs allow the feet to work normally so the continuous feedback between posture, the feet and the various muscle groups are not interrupted as opposed to orthotics where the feet are stuck in one rigid position and not really able to provide those intrinsic signals needed to balance the system.  With PCIs the muscles that control the feet are allowed to work the way they were intended to do as opposed to laying there flaccid and tired because they really don’t need to do any work. 

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How about people who are accustomed to wearing arch supports?  Do you keep them in arch supports?

When a patient has been wearing rigid orthotics for several years, we will start them out with PCIs and #2 arch supports.   After several weeks we substitute more moderate, #1 arch supports.  We also give them foot exercises.  We have them walk barefoot in all different ways – sometimes starting with only a minute a day, but when they get up to 10-12 minutes a day, they redevelop the intrinsic muscles of the foot, and we can often remove their dependence on arch supports all together. 
I want to digress.  It is important that people do not wear old worn out shoes.  I check the outside wear as you recommend for medial or lateral wear, but I also check the inside of the shoes.  And, for people who show medial wear, I usually find a big divot underneath the first and second metatarsal head, and on people with lateral outside wear, I often see calluses on the top of their small toes because they grip so hard I can even feel the indentations of the top of their toes inside the shoe upper. 

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Do many of your patients wear orthotics?

Many of our patients present with those types of apparatus.  When asking them about their inserts, they often respond: “Oh yes, that’s my orthotics and I wear them every day.” They can barely walk and can’t do regular activities because their pain level is 7-8 or higher.  I often find they have been wearing them for 6-7 years and longer, and when I ask if they have been back for re-evaluation, they seldom have in spite of the fact that their pain may have gone from aches to burning pain and cramps.   Their intrinsic muscles of the foot and ankle are frequently hypotonic.  The rigid orthotics have immobilized and positioned the bones into a particular place.  In response, the muscles simply quit working.  They can barely walk barefoot.  They have horrible hyperpronation and virtual flat arches. 

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What has been your staff’s reaction to fitting Posture Control Insoles™?

Positive.  The Myofascial therapists determine which insoles will work best for a patient and if there will be a progression to higher technology or use of arches etc.  Our office staff usually trims the insoles and fits them into the patient’s shoes and make sure they are comfortable. 

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What were the challenges in learning how to fit Posture Control Insoles™?

There really were no challenges.  We follow the recommendations of Posture Dynamic to a “tee” but for one thing.  With fibromyalgia patients we extend the break-in period threefold.  So when PD recommends 2 hours the first day, we extend that to the first three days, and then they go to three hours a day for three days and so forth.  That eases their body into the proprioceptive changes that are going to be made in their biomechanics because they have a tendency to overreact to any other new stimuli.  The same thing goes for medications.  The doctors here ease them into medications starting with smaller doses as well.

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How do you determine which patients need to wear Posture Control Insoles™?

Since we started providing Posture Control Insoles several years ago, every patient after seeing the doctor, goes through a detailed initial myotherapist evaluation that takes an hour and a half.  We focus on identifying all perpetuating factors for myofascial pain. Hyperpronation, the status of their feet and first metatarsal deficit is always included.  It is imperative that all perpetuating factors are addressed to avoid the possibility of wasted therapy.  According to Dr. Travell, to really relieve muscular pain, all underlying perpetuating factors must be remediated.  A long second toe and first metatarsal deficit is a major perpetuating factor.  We try to correct it very quickly in our treatment program. 

With the event of PCIs, we can have staff or even the patient do the fitting based on our recommendations for amount of correction.

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Do you have a philosophy that predisposes you to use Posture Control Insoles™?

If the foot foundation of a fibromyalgia patient is not addressed for whatever reason, either because a patient is resistant or the patient is non-compliant, or they disagree and don’t want to use the insoles, we find that the ability for us to decrease their pain and increase their function is decreased exponentially.  Conversely if we quickly address their need for a long second toe correction their decrease in pain and increase in activities of daily living are wonderfully improved because we have gone right to their base, foundation first. 

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How have your patients responded to Posture Control Insoles™?

Nearly 70% of our patients are suffering from fibromyalgia.  With the combination of myofascial therapy, improved nutrition, exercise and Posture Control Insoles, many of them have pain reduction and some actually start to feel good.  Within our patient population that is great.  These are patients who receive myofascial therapy and actively participate in self care training as well as wearing PCIs.  The self care training has a big impact in reducing their muscle generated pain, and Posture Control Insoles are important in allowing their activity level to increase. 

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What are your patients’ objections to wearing Posture Control Insoles™?

We really do not hear any objections. 

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What is your patients’ first reaction when they see the Posture Control Insoles™?

Is that all there is? 

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Have there been any adverse reactions?

We have had no clinical adverse reactions, but because some of our patients can be hyper-sensitive, we have had less than a handful reject them.    Their sensitivity level has usually been so high that even clothing against the skin has been bothersome. 

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6 months from now, what percentage of your patients do you think will wear Posture Control Insoles™?

I really don’t expect it to change.  After working in this clinic for almost five years it is my personal observation that the prevalence of patients displaying a Morton’s foot structure as defined by a long appearing second toe who hyperpronate and have structural imbalances due to this foot structure is as high as 85%. 

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Do you have the patients fit their own insoles?

If they want to just take the insoles home and trim them for their shoes, we just tell them to be sure to trim the paper pattern first and make sure they have a good fit before they trim the insoles.  Sometimes when we transition them with an arch they say just give me what I need and I can do it myself.  It is really quite simple. 

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How would you describe the benefits of wearing Posture Control Insoles™? 

In very simple terms we tell them that it will decrease overall pain.  Posture Control Insoles will allow your muscles to stop being overworked especially if they are bracers.  That will decrease the amount of burning or cramping they have in the calf muscles and the hip.  And it will decrease the overreaction by your muscles to postural shifts – become less hypersensitive. 

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How did you decide to provide Posture Control Insoles™ to your patients?

Being familiar with Dr. Travell’s work I already knew about the impact of the first metatarsal in Morton’s foot structure.  The direct affiliation with Dr. Rothbart and his communications with Dr. Travell was a strong influence, and of course the ease with which we could make the first metatarsal correction.  The ease with which I could make a profound change for our patients was a big factor. 

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Can you recall a particular patient experience that stands out from the rest?

I can’t really because we have had so many patients that have found wonderful relief, but I can tell you about one of them.  This lady had been having back and shoulder pain.  She was an assistant to an endodontist, she was about 56 years old just slightly overweight, but nothing major.  She had two sons in college and really wanted to do everything she could  to support them, but she had so much pain in her life in general, her  back, her shoulder, her knees that it prevented her from seeing one of her sons last two years of high school football because she just couldn’t sit in the bleachers.  She was diagnosed with fibromyalgia before she came to our clinic.  She had a wonderful attitude, but terrible knee, hip, back, and shoulder pain.  Her posture was hunched over not only from the pain, but probably from her work as well.  She was able to work, but when she came home she was exhausted and had to lie down.  We evaluated her need for Posture Control Insoles.  She was a severe hyperpronator and actually needed 9mm insoles.  Her hyperpronation was unbelievable.  We started her out in a 3.5 mm.  She felt so much better she was able to start going to a Curves exercise center.  4-5 weeks later we took her up to a 6mm. pair.  By now her pain is decreasing rapidly.  She is barely at a 4-5.   She is able to do more.  She drove to visit her sons in college.  She went to their weekend games.  She was able to work and not get so tired.  By the time we got her into a 9 mm. pair and she had a follow up appointment with Dr. McNett he actually downgraded her to a non-fibromyalgia patient….downgraded by a fibromyalgia specialist.  He felt that it was unnecessary to continue treatment of her tender-points.  She did not even have 11 of 18 original tender-points.  She had almost complete resolution.  She was very active in the self care program and she took her exercises seriously.  She did not return to the clinic for more than 18 months and then she would just call me once in a while to check in.   

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