Irene Acevedo, MS, PT, Cert MDT

Response to a reader's questions on cervical stenosis

A comment was posted to my blog on "Cervical Stenosis" with some very good questions:

"I am wondering which Mckenzie neck excercises did you perform? All 7? 8 times a day? I am concerned about doing #2 and #7. I am in the same situation that you were in: I started with pain in my right side-arm and leg all the way to figres and toes with no neck pain. Neurosurgeons found formainal and moderate central stenosis at C4-5 and C5-7. They want to perform cervical discectomy and fusion. I want to try other avnues first. Thanks for the information."

Stenosis is quite a tricky syndrome. Many people with their MRI reporting stenotic findings have no stenotic symptoms, while others have the symptoms but not the MRI indication. Within the group that have the symptoms and the confirming MRI, there is a number of them that can be treated conservatively, and there is a number that can only be managed surgically. The McKenzie method for the neck is not merely the 7 or 8 exercises, but a comprehensive systematic methodology to solve orthopedic problems. Stenosis, like many other mechanical problems in the spine, will require a thorough McKenzie assessment to determine the extensiveness, in order for the most precise and appropriate therapy to be prescribed. If I were you, with symptoms you presented, I would not perform any of the 7 exercises without a McKenzie assessment by an experienced certified McKenzie therapist or diplomat. The McKenzie method is able to determine whether the patient can benefit from it or not. If your problem is beyond what conservative approach can offer, you may not want to waste too much time there.

In the meantime, my first recommendation for you would be: Let the symptoms guide you. This is one of the McKenzie principles to treatment. My MRI was extremely alarming and depressing a year ago. However, my symptoms were not constant nor severe. I had strong tingling and numbness only if I extended my neck--i.e. a movement to look up, or to lift one's head up above neutral position. So I avoided the activities and positions that would aggrevate any symptom.

Furthermore, the component of the stenosis in my case was the severe herniation toward the back--the nerve roots and spinal cord. Therefore, I also avoided flexion--the movement that brings the head down or forward. Please keep in mind though--for severe stenotic symptoms, many times it is only flexion that can alleviate symptoms. So this may seem contradicting, but indeed it is not. The need to see a certified McKenzie professional is in this--knowing in what direction to exercise and how far to go to reduce the mechanical problem, but don't go too far to worsen the symptoms. In my case, I performed retraction hourly as long as it did not provoke symptoms. But I would not tell all my stenosis patients to do the same thing.

Without knowing all the aspect of your symptom behavior, I cannot, and should not, tell you which exercise to do. I would urge you to consult a certified McKenzie professional (www.McKenzieMDT.org) to get the right exercises to do at the right time and with the right amount of intensity. Hope this helps and best of luck to you!

Irene Acevedo, PT, Cert MDT

My Cervical Stenosis

I used to have periodic "pain in the neck", especially in the years of keeping my head in the books in college and graduate school. But since I was introduced to the McKenzie method and became certified in it, there has been hardly any episode of neck pain that I could recall.

One day last Spring as I squatted down to pet my dogs--the activities I do a million times a day--I suddenly felt tingling and numbness in my right forearm, then my right hand and the first few fingers. "This is not a good sign!" I thought to myself, "symptoms down my hand is quite alarming." I then began a series of evaluation on myself using the McKenzie method...and my conclusion was: cervical stenosis vs. tumor pressing on my spinal cord when I extend my neck.

Let me explain my consideration of the possibilities for just a little bit. As a principle, the further down the symptoms are, the more serious the derangement is in the neck, or back. For example, symptoms in the foot reveal a more serious condition of the back than if the symptoms are in the thigh. Therefore, if it is stenosis, it must be quite large, since my symptoms are all the way down to my fingers. But if it is a tumor, I had better find out as soon as possible.

A friend of mine is a physician and I discussed my situation with him. He was convinced that I should get a MRI. I took the MRI and the report came back stating that I had severe degeneration, herniation, stenosis, and bone spur in C4-5, C5-6, C6-7 with C5-6 being the worst. I was glad that it was not a tumor, but the severity did not give me a whole lot of relief. An old friend of mine is a successful neurosurgeon in Houston, TX and he read my MRI. He said to me, "Irene, your MRI warrants surgery--cervical fusion and diskectomy--ASAP, but do everything you can conservatively before you run out of options."

I have helped numerous patients recover from their spinal problems, so it was time to get my share of benefit from the McKenzie method. Still, I bore in mind that there was a possibility for a clinically significant stenosis, like mine, to be incurable conservatively. Therefore, everyday, and many times a day, I faithfully performed the McKenzie exercises, and kept my posture right at all times. I had my husband and coworkers help me in taping or watching my back for good posture. During the first week, I noticed a slight decrease in the symptom frequency. About 6 weeks later, the tingling and numbness anywhere in the arm all disappeared. Right now, as I am writing this on January 19, 2007, I have been symptom-free for the last 8 months.

At times, I still wonder why I, as a PT dealing with spinal problems everyday, would get such a problem, but I see now from personal experience that many severe symptoms can truly be hidden until they decide to surface without mercy. The fabulous fact I discovered in my experience is that even though severe spinal derangements can come unexpectedly, there is an enormous possibility that it can be resolved conservatively, indeed.

Weight Loss vs. Low Back Pain--which one to prioritize?

If you have low back pain and even have radiating symptoms from the lumbar spine, you need to FIRST take care of that before getting into all the other strengthening or cardio exercise for weight loss. Remember all mechanical problems in the back have a directional nature--i.e. while some movements make it better, some make it worse. If you get into all kinds of exercises indiscriminately, you can potentially worsen your underlying back problem. Many people take yoga and Pilates when they have disc herniation, and they end up not being able to even walk after their exercise.

AFTER the back problem is correctly identified with persistent progress, all radiating symptoms should be centralized in the lumbar region, and the low back pain becomes more and more infrequent. Then with proper instructions and precautions, you can gradually begin strengthening exercise, such as core training and Pilates, for injury prevention, as well as your cardio workout for weight loss.

Remember, there is a time for everything!

Spondylolisthesis

A wife of a patient asked me how to treat a spondylolisthesis. She said that she thinks her husband had spondylolisthesis and he responded to the exercises from the "Treat Your Own Back" (TYOB) by Robin McKenzie, but needed pointers to continue his progress... So I thought I would post a copy of my reply here for your reference.

"First and foremost, you need to make sure that your husband truly has a clinically significant spondylolisthesis ("spondy"). A true spondy is an anterior derangement, that is an obstruction, such as a protrusion, in front (anterior) of the vertebra. As opposed to an anterior derangement, a posterior derangement is an obstruction going towards the back (posterior) of the spine--for examples, common disc herniation, stenosis, etc. The symptom behavior as well as the treatment of an anterior derangement are almost opposite of that of posterior. The book "Treat Your Own Back" addresses the most typical lumbar spine disorders which are in the posterior aspect fo the spine, except for stenosis. Some of the reasons why posterior derangements are by far more common than anterior is that many people have developed slouch posture over the years, and moreover they bend their lumbar spine forward all the time, stretching their posterior disc wall again and again. All of these factors quite easily contribute to posterior derangement such as bulging disc at some point in their life.

If your husband responds to the exercises in the TYOB book, then he is likely to have a posterior derangement rather than an anterior one. Even though you may see spondy on a MRI, it may not be a symptomatic one. In the same way, many people with a symptomatic bulging disc may not see such on their MRI, since a MRI is only taken in 1 unloaded position and the person taking the MRI may not be having the symptoms at the time of taking the MRI.

Only if you have accurate diagnosis can there be targeting treatment. My advice for you and your husband is to first find out what he really has from a McK certified professional (http://www.mckenziemdt.org/). If his history, range of motions and movement testing...in their evaluation all point to a spondy, then a precise treatment plan can be established (and by the way, those therapeutic exercises are not in the TYOB book), and it usually does not take more than a few weeks to resolve a derangement. In the meantime, let his symptoms tell him what he needs to do. If he has positive response to the McK ex in the book, then continue them very faithfully. Only do the movements that help eliminate the symptoms, and do them every hour. And for the next several weeks, avoid doing things that cause the symptoms to sustain.

Lastly, if the right exercises are established with the right amount of force progression in the right direction, and your husband keeps the right precautions adequately, then as soft tissue takes about 2 weeks to heal, you husband can and should expect to recover within a few weeks as well.

Hope this helps!"

What is "Nerve Root Adhesion"?

There is the formation of fibrosed tissue (scar tissue) in the process of a derangement (bulging disc, herniation...) being reduced and healed in our spine. If there is nerve root involvement in the episode--i.e. radiating or referred symptoms occur, the scar tissue would likely to also involve the nerve, causing nerve root adhesion. A typical symptom behavior of a nerve root adhesion is that one would consistently experience radiating symptoms (anywhere down from the spine) whenever he reaches the limited end range of a certain movement--i.e. when the scar that is adhered to the nerve is stretched. Such symptoms is very consistent with repetitive movements reaching certain end range, and it immediately subsides as you return from end range. None of the radiating symptoms would become sustained, unless the range of motion is severely limited.

The way to eliminate this phenomenon is by stretching the scar tissue, and thus to elongate the fibrosis. Therefore one would need to stretch progressively and carefully beyond the limited end range once the derangement is completely healed. The reason why it is important to stretch in this way is that the scar tissue limiting range of motion of that spinal segment causes the neighboring spinal segments to compromise for the restriction. Therefore those levels become more susceptible to injury or derangement.

Stretching the nerve root adhesion should be done when the derangement is completely healed and with proper precautions. If it is performed appropriately, re-injury can be prevented and functional abilities can be greatly increased.

"Should I do hamstrings and piriformis stretches?"

Someone recently raised a question regarding numbness and weakness resulting from a low back pain episode. He recently had a low back injury from squatting and reaching down to pick up an object. After performing extension exercises according to the McKenzie principles his back pain has completely resolved within 8 to 9 days, but the numbness and weakness have persisted. Then he was told to perform hamstring and piriformis stretches... "Should I do them?" he asked.

It is true that numbness may take sometime to resolve, or it may never resolve if scar tissue is adhered to the nerve (unless you stretch it right). Unlike numbness, weakness however can be an indication that the motor nerve is still being interfered, unless it is from disuse atrophy. His injury occurred when he was squatting down and bending forward, and thus extensions (bending back) may likely be the most effective in resolving the rest of the problems. But if he performs hamstrings and piriformis stretches at this time--note that they are both bending forward movements--his problem may be worsened, or a potential relapse would be underway. This is, sadly, a very common phenomenon: clinicians prescibing exercises indiscriminately and patient's progress becomes very inconsistent. In order to allow soft tissues to heal and to elimiate relapse, all forward movements should be avoided--e.g. bending over, slouching, etc. It is crucial to know the directional preference of a mechanical derangement according to the symptom behaviors, and thereby perform the specific targeting reductive exercise. In this case, it is adviceable for the patient to perform extensions in standing hourly, and also try to perform press up with exhalation in the back extended position (when you come up on your hands) for more reductive pressure. Once he has no more weakness, gained full range in the back, no pain or stiffness for 2 weeks, he can begin stretches that require forward bending in mid-day before and after repeated entensions are performed.

When you do the right thing and proceed carefully, it only takes a couple of weeks to get rid of this kind of problems for good!

The NDT Neurological Rehabilitation

Effective neurological treatment is given by adequate knowledge base as well as much understanding in neuroscience. Normal movements require a fine control and balance between facilitating the right muscle group (agonist) while inhibiting other muscle group (antagonist).

If a patient suffers insult to one side or part of the brain, he or she is likely to exeperience weakness or even paralysis in one side of his body, it may be the right leg, arm, face, or eye. This is known as "hemiparesis." Weakness, or flaccidity, is due to lack of neuronal stimulation to facilitate the agonist muscle groups for a particular movement. A patient may also have abnormally high tone (hypertonicity/ spasticity), which is the over-stimulation of a certain muscle group, causing that group of muscles to be involuntarily tight, or spastic.

Based on human developmental sequence and movement science, the Neurodevelopmental Treatment (NDT) is developed as a logically and scientific approach to systematically regain proper balance between facilitation and inhibition of all muscular control of the body. It is the most effective treatment methodology for neurological dysfunctions, because it targets the root of the problem from the central nervous system to all the peripheral controls--the control of the trunk, arms, legs, etc. The post-graduate certification training process to become a certified NDT therapist is lengthy and extensive. This ensures the certified therapists to be competent in providing such rehabilitative process for their neurological patients. Most importantly, this enables patients with neurological deficits to improve their quality of life by achieving optimal movement control for all activities of daily living.

Mechanical Diagnosis and Therapy

This is to target spinal symptoms and all peripheral musculoskeletal injuries to achieve effective long-term outcome within minimal amount of visits. Expertise in mechanical symptomology for effective patient education is essential, because it empowers an individual to recognize symptoms, apply appropriate regimen immediately and prevent recurrence.

The Myth of Low Back Pain

While the traditional, unscientific approach of physical therapy and manipulative therapy fail to give long-term relief to low back pain patients, many people resort to think that they have to live with their low back pain (LBP) for the rest of their lives. Such myth has misled over milions of Americans to miss work, alter their quality of life, and even become addictive to pain-killer medications.

As a physical therapist (PT), I was in that midst for almost 5 years--applying hot or cold pack, electrical stimulation and/ or ultrasound, as well as some soft tissue or joint mobilization and giving exercises to my LBP patients, thinking that there was no certainty whether their symptoms would improve. Until one day I came across a PT who was partially trained in the McKenzie system, the ambiguity of the efficacy of traditional LBP regimen began to subside. It was surprising to see how his patients improved so quickly. They were so excited and grateful that they would bring him gifts again and again. Additionally, I was stunned by the fact that he could give logical answers to my questions in spinal analysis where none of my other colleagues in history could. Since learning is the primary motivation for me to stay in this profession, I began the series of courses in the McKenzie methodology in 2002.

The highlight of the McKenzie system is that it is entirely based on research and evidence-based principles. Therefore it is logical and effective. The consistent success in my practice using the McKenzie method brought me to become a certified credentialed practitioner. Not only was it a life-changing experience to me, but also to my colleagues and patients. At least a dozen of my fellow therapists began the McKenzie training, and some even reached certification. The average number of visits required for LBP treated by the McKenzie systems is 6 nationally, and 4 in my professional statistics. Most patients are painfree after 1-2 visits and began core training on the third or fourth visit to prevent recurrence. Based on research science and my experience, I testify that there is no such thing that everyone with LBP would have to "live with it for the rest of his life", although they would have to live with it for as long as they wait to seek effective help.