Imaging can show plenty of things that are not related to people’s complaints. You need to move people to understand their problem. I am not against imaging when used under the appropriate circumstances. But imaging people’s spines (who have no red flags) before moving them to arrive at a diagnosis is plain wrong. Stenosis is quite normal with aging and is present on images of people with zero pain. Therefore, we know stenosis is not an automatic pain generator. If you have complaints and imaging shows stenosis, it holds that something else could be causing your pain. We don’t know until we move you. In my experience, the large majority of patients who have come to me saying another clinician diagnosed them with stenosis have done very well with therapy. In most of those cases, therefore, something else was causing their symptoms and their initial diagnosis was incorrect.
Scenario one. Your image shows stenosis. We move your spine and, despite the bony stenosis your image shows, you respond well to movement(s) and your symptoms resolve. [majority of cases in my experience]
Scenario two. Your image shows stenosis and, after we move you for several visits, it becomes clear that the stenosis is related to your symptoms. We discuss how we need just a couple weeks of specific movement to see if we can change any correlated soft tissue stenosis and impact your symptoms. We know that there is bony stenosis on the image but we still don’t know if bone or soft tissue is the real issue. Soft tissue we can usually change with movement, bones we cannot. After a few weeks your symptoms decrease or resolve so that no further intervention is desired/needed. [fewer cases]
Scenario three. Same as number two except, after the couple weeks of specific movement, your symptoms are unchanged. At this point we can integrate different strategies in therapy with goals of minimal to moderate overall improvement of symptoms - or you can have a surgical consult with the goal of more significant improvement. [fewer cases]
The point is we don't know which scenario applies to you until we move you. -- Laura
I recently treated a patient who is emblematic of a slew of patients, especially baby boomers. She came to me with an MRI showing severe spinal stenosis - and several other spinal irregularities. She had been referred to a surgeon, but, luckily, as the idea of surgery at age 83 did not appeal to her, ended up coming to me instead. As we talked during the evaluation, it was clear that she already had two strong impressions. One, the stenosis was the cause of her symptoms. And, two, her stenosis was an irreversible disorder that would possibly get worse without surgical intervention. She had met a former patient of mine and had called me on the off chance physical therapy could help.
Stenosis refers to the narrowing of an opening. In the spine, stenosis commonly refers to narrowing of the opening through which nerves pass secondary to either bony overgrowth (eg osteophytes) or disc height loss. These changes in the spine are quite prevalent. Can stenosis be symptomatic? Yes. Irreversible without surgery? Yes.
But ... can stenosis (true, bony stenosis) be apparent on imaging and not be the cause of the patient's symptoms? An even louder yes. Very commonly.
In this patient's case, other spinal irregularities were observed on imaging as well. However, she had left her doctor's office believing that the stenosis was producing her symptoms. How was that determined? Diagnosing stenosis on imaging alone is not enough. A patient deserves a thorough physical examination to determine the cause of her symptoms, and then deserves a treatment plan specifically targeting that cause. Upon moving my patient's spine in different directions during her physical evaluation - I use the McKenzie method of mechanical diagnosis and therapy - I noted a favorable response to spine extension. In her case, over the course of four visits, she responded very well to sustained extension in prone. -- Laura
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