Extension for Spinal Stenosis

[00:00:00] Welcome back to Untold Physio Stories Podcast. I'm your host, Dr. E with Modern Manual Therapy and Edge Mobility System. And with me is Dr. Aleka Tromanis, right?

[00:00:11] You got it.

[00:00:12] All right, great. She posted on LinkedIn recently a case that I think everyone should hear, particularly if you treat elderly individuals or low back pain, and that's probably most of you. So you want to give a quick intro and background and then tell your story?

[00:00:29] Sure. Thanks for having me, Dr. E. My name is Dr. Aleka Tromanis, and I'm a physical therapist and owner of Versatile Physical Therapy and Wellness based in Boston, Massachusetts. I also offer online services through my app, which I can share more about later.

[00:00:51] I'm really excited to share more information on this case. A client who came to me who was scheduled for a multi-level lumbar fusion in September and was diagnosed with spinal stenosis through imaging and placed into a flexion-based protocol for several years.

[00:01:18] And so I want to share.

[00:01:22] It's the third year that makes a difference. You know, it's that third year is the charm, they say.

[00:01:26] It was six years that she had seen various PTs and just placed into flexion, flexion, flexion, very compliant with her flexion protocol.

[00:01:38] And so I'll share some details on how we were able to get her to cancel her surgery, which was really exciting for both of us, mostly for her.

[00:01:50] But I'll talk a little bit about loading strategies we used, challenges we encountered, and the successes we were able to have, including obviously having her cancel her surgery.

[00:02:06] So when she came to me, she's 83 years old, by the way, and she's had multiple MRIs, x-rays, injections, the whole nine yards, lots of physical therapy, never had a mechanical diagnosis and therapy treatment or assessment.

[00:02:31] And so when she came to me, she was pretty certain that flexion is what makes her feel better.

[00:02:41] But in diving into it further, we found that flexion actually peripheralized her symptoms and made her worse.

[00:02:50] So it felt like a nice stretch in her lower back, but she was getting cramping, pain, numbness, tingling throughout her legs.

[00:03:01] So, and varying degrees of that.

[00:03:05] So we started the movement assessment, of course, with flexion just to build that therapeutic alliance.

[00:03:11] And then we noticed she was getting worse.

[00:03:16] So I figured, well, let's put her into extension.

[00:03:19] So we got her prone.

[00:03:21] And she started to report that, oh, my legs feel better.

[00:03:27] My back hurts.

[00:03:29] I'm like, okay, this is good.

[00:03:31] Is prone flat?

[00:03:33] Yes, that's all we could really do was prone flat.

[00:03:38] Then I had her get up onto her forearms, which if you look at that LinkedIn post, that's that first picture there on the top.

[00:03:48] And that's as far as she could go.

[00:03:50] And she could only hold it for 10 seconds.

[00:03:53] And then she had to come back down.

[00:03:55] So range of motion there was really limited.

[00:04:01] And as we worked through it, we were able to find that she could now hold it for three minutes.

[00:04:10] And then she was able to perform extension over the kitchen counter and then with the forearms against the wall.

[00:04:19] So we had to find those various loading strategies that would work for her.

[00:04:26] But she wasn't fully understanding, okay, this is when I need to do extension.

[00:04:34] Or if I'm sitting for more than an hour, my legs hurt.

[00:04:39] And it just, it wasn't carrying over as well as I wanted it to, even though we were seeing improvements when we were together.

[00:04:50] So then we did get to a point where she started to perform extension more and sit less.

[00:05:00] And she noticed a difference.

[00:05:02] As she started to feel better, she stopped doing the exercises as often.

[00:05:08] And using those strategies of, okay, after 20, 30 minutes, I need a stand.

[00:05:17] She still works.

[00:05:18] So she takes a lot of Zoom calls and phone calls.

[00:05:22] And so she's an entrepreneur.

[00:05:26] She's a businesswoman.

[00:05:28] Oh, great.

[00:05:29] Good for her.

[00:05:30] So she, yeah, she's awesome.

[00:05:33] Very inspiring.

[00:05:36] And so she gets caught up in her work, sits a lot.

[00:05:42] And it was filling that cup and overflowing that cup.

[00:05:46] So we actually used that.

[00:05:48] I kind of drew it out for her and really started to make sense, which was great.

[00:05:54] And then she ended up having the flu for three weeks.

[00:05:59] So completely fell off with consistency.

[00:06:04] And her pain got significantly worse.

[00:06:08] So at that point, we, it wasn't really starting from scratch, but we had to reintroduce all those strategies.

[00:06:17] Again, get her back into a routine.

[00:06:21] And with extension, because she, it took a while to break the, oh, I should be moving into flexion, because that's what she had believed for so long.

[00:06:32] So that was probably one of the biggest challenges.

[00:06:38] And we were able to decrease the pain again.

[00:06:41] But in order for her to really understand how to manage her symptoms, you know, I tried so many strategies.

[00:06:51] I created a roadmap for her where it's like, okay, if you have this, go here.

[00:06:56] If this is happening, go here.

[00:06:58] And it really kind of laid it out.

[00:07:01] Follow-up calls in between our sessions, lengthy emails, and nothing was really sticking.

[00:07:10] So then one day she asked me, she's like, well, do you have one of those body diagrams?

[00:07:16] I'm like, oh, never thought of that.

[00:07:21] So I took, I always had one in my backpack.

[00:07:24] So I took one out, and she made several copies.

[00:07:29] And over the course of two weeks, she would date each page, and she would use different colors to draw out her symptoms.

[00:07:37] And as you flip through it, you can actually see that each day there are less and less markings and colors on the body diagram.

[00:07:48] And that really helped her to visualize and see, oh, this is what's working.

[00:07:54] This is what's not.

[00:07:56] And that was also helpful for me, because now she was more independent with managing her symptoms.

[00:08:04] And she would explain to me, okay, when I get up in the morning, I walk around a little bit, lie down flat on my back.

[00:08:13] Then I flip over onto my stomach, press up a little bit, and then walk around a little bit more, extend over the kitchen counter, place my forearms against the wall.

[00:08:26] And just, she would explain to me how she would ease into extension.

[00:08:33] And she was so obstructed initially that anytime we tried the press up, she just couldn't do it.

[00:08:43] But with continued practice of extension, we gave it another go.

[00:08:48] And that was the second photo that you see on LinkedIn.

[00:08:52] She just pressed right up into extension.

[00:08:56] Oh, she's going to pull press up, right?

[00:08:57] Yeah.

[00:08:57] Yeah.

[00:08:58] Yeah.

[00:08:59] Yeah.

[00:08:59] And that was really cool to see.

[00:09:02] And I actually now have a video.

[00:09:05] It was just still photos that I posted on LinkedIn.

[00:09:07] But I have a little video that I put together of her doing the modified press up on her forearms in the beginning several weeks ago.

[00:09:18] And then repeated press ups into full extension.

[00:09:22] And so I'll post that video as well because it's pretty cool.

[00:09:28] But not only do we see that mechanical improvement, but now she's walking up and down the long hallway.

[00:09:37] She was able to walk to the salon, right?

[00:09:40] And get your hair done, feel really good.

[00:09:43] I mean, that's all part of her progress.

[00:09:46] She's able to go up and down the stairs.

[00:09:49] There's, I mean, her O2 was dropping into the 80s prior to us starting together.

[00:09:55] And now she stays above 97% when she's walking.

[00:10:01] So she's able to attain that extended position.

[00:10:05] Oh, do you think that's because you said that last time we tried to record this?

[00:10:09] So this is the second go.

[00:10:11] But I didn't quite, I don't remember asking why.

[00:10:15] Do you think it's because she was flexed and she wasn't like, you know, her lungs weren't expanding as much?

[00:10:20] She was so flexed.

[00:10:22] And it was so, she was so obstructed into extension that she just, she couldn't allow those lungs to really fully open.

[00:10:34] To expand.

[00:10:35] That's awesome.

[00:10:36] Well, I think there's several.

[00:10:37] She was cleared from a, you know, cardiac pulmonary standpoint.

[00:10:41] Yeah.

[00:10:42] Yeah.

[00:10:42] Not like any kind of disease process going on.

[00:10:45] Yeah.

[00:10:45] Yeah.

[00:10:46] I mean, there's several great things about this case.

[00:10:48] I mean, first of all, it's just obviously, I can't believe that people would even do the same thing for like six years.

[00:10:54] And then like if somewhat, maybe it could be the patient's fault too, right?

[00:10:58] Because we don't, we sometimes easily blame other PTs, but like if the patient doesn't tell the PT like, oh, I tried flexion and it's not working.

[00:11:06] Although I guess she thought it was working.

[00:11:08] You know what I mean?

[00:11:08] But I mean, if I was a PT, it was like, I always ask, well, what have you been doing?

[00:11:12] And it's usually, it's usually some sort of thing that's exactly the opposite of what I would do.

[00:11:17] Which is, which is, you know, the rest of the, there's MDT world and there's like every other rehab clinician.

[00:11:23] It's often like you just get faster results when you do the opposites.

[00:11:27] But I mean, six years of flexion is a long time.

[00:11:30] It's a long time.

[00:11:31] Yeah.

[00:11:32] And, and I, I guess to your point, when you are having all this imaging and MRIs and you're being told by multiple providers, this is what you need based on.

[00:11:46] The fact that we're seeing spinal stenosis in your imaging, you really start to believe, okay, this is what I need.

[00:11:54] And it becomes a lot.

[00:11:57] Not to interrupt you.

[00:11:57] People often feel like flexion makes them feel better.

[00:12:00] And just like you said, it's because it's a stretch, right?

[00:12:02] Oh, this is a great stretch my back.

[00:12:04] But then, then they, then they get up and then they peripheralize, but they don't realize it's because they've been flexed so long.

[00:12:10] Because flexion may not immediately overflow the cup, but it's the, it's the static, prolonged flexion.

[00:12:16] It slowly starts to fill up the cup and you go to stand up and you think, oh, you know, being upright and loading is worse.

[00:12:22] And that's often like the, the stenosis pattern, but it's really just because they were flexed so long that they can't extend.

[00:12:31] Exactly.

[00:12:31] Yeah.

[00:12:32] Exactly.

[00:12:32] And, and that was, that's part of, cause it, it can trick you, you know?

[00:12:38] For sure.

[00:12:39] And so you just have to stick with it and look for those symptomatic mechanical improvements and continue to go with it.

[00:12:49] And then eventually it's like, okay, we're definitely on the right track.

[00:12:53] You can't, she would always say, you can't argue with success.

[00:12:57] She's like, it seems too good to be true, but I can't argue with the fact that I just canceled my surgery.

[00:13:05] Yeah, that's great.

[00:13:06] You know, instead of going in for surgery, she's walking to the salon to get her hair done and feel good.

[00:13:14] Yeah.

[00:13:14] The other interesting thing, and again, something I haven't done in like, I don't know, 20 years is a body diagram.

[00:13:20] Like one of the first, when I went digital, the first thing I removed from my evals and even before I went digital, the first thing I removed was the body diagram because it's like, you see all kinds of crazy things.

[00:13:29] Like people are drawing lightning bolts on it or we draw little flames underneath their foot.

[00:13:33] Like, wow, is that really happening?

[00:13:34] You know?

[00:13:35] Yeah.

[00:13:36] You know, you get a body diagram.

[00:13:38] It's like script says shoulder and the whole thing's colored in and you're like, oh man, it's going to be one of those days.

[00:13:43] But, you know, I think that'd be interesting also for you to post is like the progression.

[00:13:50] Yes.

[00:13:51] Improvement from the color to just the area.

[00:13:54] And again, it's not something we don't use.

[00:13:57] We use the body diagram once, but we don't, you don't repeatedly go use it over and over and over again.

[00:14:03] Like what's the use of using it once?

[00:14:05] It'd be like taking range of motion once.

[00:14:07] That's Western score once, you know, and you don't ever, you don't ever compare.

[00:14:12] Exactly.

[00:14:13] And so I actually, during our last session, I forgot to take pictures of them, but I will definitely get a hold of those because the first page is just filled.

[00:14:28] And then the last page has like a couple X's on her lower back.

[00:14:34] That's great.

[00:14:38] Well, thanks for coming on again.

[00:14:39] I appreciate your patience since this is our second, second go, but I think it's going to go great.

[00:14:43] And a lot of people are going to learn from this.

[00:14:45] So, so where can people find you, Aleka?

[00:14:49] People can find, I'm not a huge social media person, but because I have my own business, I do use Instagram a fair amount.

[00:14:57] So you can find me on Instagram at versatile.pt and then my website, versatilept.com.

[00:15:07] And there you can contact me through social media or email phone.

[00:15:15] All right.

[00:15:16] Great.

[00:15:17] Hey, if you guys have any comments, questions for Aleka or myself about this case, or you want to learn more about MDT, just reach out.

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[00:15:31] And as always, you guys have a great day.