Ms. D. came to my office with an interesting symptom presentation. She had intermittent back pain for two years, with occasional echoes of mild pain down the back of her leg. She also had some occasional hip issues. The pain she had was more annoying than disabling.
She could only walk for short periods before the pain got worse and caused her to sit down or lie down.
Ms. D. outlined the numerous practitioners she had seen and what the diagnoses had been. Her primary care doctor thought it to be some sort of disc issue, but did not do any follow-up or imaging. Anti-inflammatory drugs made only a marginal improvement. One physical therapist suggested an approach using prolonged passive extension, which made things worse.
She asked to see another PT, who surmised that the problem was a hamstring issue (which is reasonable). An aggressive stretching routine was prescribed, which made things much worse.
She switched therapists yet again. The new physical therapist concluded that the problem was an issue with the sacroiliac (SI) joint. Numerous manipulations were performed and some homework was assigned for Ms. D. The results were underwhelming.
As she began describing her next foray with another practitioner, this time a chiropractor, I found myself involuntarily glancing at her legs. As Ms. D.—a pretty woman in a rather short skirt—sat facing me, my eyes kept drifting downward. I tried to pay attention, but I missed many details.
Something was amiss, but what? At some extremely embarrassing moment, she stopped talking, because she was aware of my gaze, and I was aware that I had just been busted (for a crime I didn’t exactly commit).
“Excuse me, was I staring?” I said.
Just then, I had an epiphany. “I am sorry to be distracted, but I’m drawn to something. Have you noticed that your legs are not the same size?”
The look of surprise on her face said it all. “If you don’t mind,” I said, “may I take some measurements?”
We moved from the chairs to having her lie supine on my treatment table. I retrieved a tape measure from my desk and wrapped it around the mid-thigh of her left leg. Being careful to measure at the same place on the right leg, the difference in girth was six centimeters, significant for someone her size. She was stunned and sat up to look at her legs, comparing them visually. We could both see the difference.
Reviewing the diagnoses she had, what was the relevance of the leg girth differential? Would a hamstring issue cause this? Not likely. An SI joint problem? No. Piriformis issue? As we went through the possible reasons, the only one that made sense was some sort of nerve root involvement that would create a slight atrophy on one leg.
“Wait,” I said. “What did you say about your low back?”
Ms. D. repeated that her chiropractor had remarked she was losing some of the curve in her low back. She had seen the chiropractor intermittently and this person noticed that the lordotic curve was slowly decreasing. Even though she tried to counteract it by passive extension, it was just more comfortable to sit and stand in a flexed position. The extension, which was supposed to feel good if the problem was a disc issue, made the pain worse.
“I think you need to go back to your physician and request an MRI. I think it likely that he was correct all along: it is a neural issue, but not what he thought.”
Ms. D. returned to my office for a chat three weeks later. She had the MRI, which showed exactly what I thought: stenosis in her lower spine. This explained her pain pattern and why she had been losing the curve in her low back. Flattening of the lumbar curve actually creates greater room in the foramen, something her body did instinctively to counteract the stenosis. Her doctor was impressed a massage therapist weighed in with such important information. The surgery went flawlessly.
For me, it was a lesson in what neuroscientists call thin-slicing: the ability to extract, in an instant, multiple sets of data faster than the cognitive brain can process it (or explain it!).
Douglas Nelson is the founder and principle instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore
the science behind this work. Visit
www.nmtmidwest.com or e-mail him
at doug@nmtmidwest.com.