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Slump Test: Effect of Contralateral Knee Extension on Response Sensations in Asymptomatic Subjects and Cadaver Study
Abstract
Study design:
Part 1: Randomized single blind study on the effect of contralateral knee extension on sensations produced by the slump test (ST) in asymptomatic subjects. Part 2: Cadaver study simulating the nerve root behavior of part 1.
Objective:
Part 1: Test if contralateral knee extension consistently reduces normal stretch sensations with the ST.Part 2: Ascertain in cadavers an explanation for the results.
Background:
In asymptomatic subjects, contralateral knee extension reduces stretch sensations with the ST. In sciatica patients, contralateral SLR also can temporarily reduce sciatica. We studied this methodically in asymptomatic subjects before considering a clinical population.
Methods:
Part 1: Sixty-one asymptomatic subjects were tested in either control (ST), sham, or intervention (contralateral ST) groups and their sensation response intensity compared.Part 2: Caudal tension was applied to the L5 nerve root of three cadavers and tension behavior of the contralateral neural tissue recorded visually.
Results:
Part 1: Reduction of stretch sensations occurred in the intervention group but not in control and sham groups (p ≤ .001).Part 2: Tension in the contralateral lumbar nerve roots and dura reduced in a manner consistent with the responses in the intervention (contralateral ST) group.
Conclusion:
Part 1: In asymptomatic subjects, normal thigh stretch sensations with the ST reduced consistently with the contralateral ST, showing that this is normal and may now be compared with patients with sciatica.Part 2: Contralateral reduction in lumbar neural tension with unilateral application of tension-producing movements also occurred in cadavers, supporting the proposed explanatory hypothesis.
... Recently a randomized clinical trial (20) assessed the effects of the contralateral mobilization in Slump position compared with a sham mobilization and no mobilization on asymptomatic subjects. The effects were measured using a Numerical Rating Scale that scored the tension sensation reported by the subjects in the posterior thigh region. ...
... The placebo manoeuvre ( Figure 3) consisted in mobilising the left ankle joint into dorsiflexion with the flexed knee until R2 was perceived. Although the dorsiflexion of the ankle is considered a neurodynamic movement, the mobilization of the ankle to endrange with the knee flexed to 90° should not be able to transmit tension along the sciatic nerve and reach the nerve roots lumbar (19,20). The ankle mobilization was performed with the same amount and frequency described above for the experimental condition. ...
... Recently, Shacklock, et al. (20) studied the contralateral mobilization in Slump position in asymptomatic subjects. They found a reduction of stretch sensation, assessed with a Numerical Rating Scale, in the posterior thigh in the intervention group (p≤.001), but no changes in the control and sham groups (p=.996). ...
Background and aim:
In the acute phase of neuropathic pain due to nerve root disorders, the neurodynamic approach proposes the mobilization of the contralateral limb to decrease the pain and increase the range of motion in the affected limb. The aim of this study was to evaluate the effect of the contralateral knee mobilization on the ipsilateral knee extension range of motion in Slump position in healthy adult subjects.
Methods:
Thirty-eight healthy subjects underwent a placebo, control and experimental manoeuvres that included a passive contralateral knee mobilization into extension. The knee, hip and cervical angles and distance between glabella and femoral condyle achieved in Slump test position were measured with an optoelectronic motion analysis system before and after each manoeuvre.
Results:
Experimental manoeuvre produced a statistically significant increase of the knee extension ROM when compared to the control (p=.017) and placebo (p=.007) manoeuvres. A significant increase of the hip angle and distance between glabella and femoral condyle was detected after the experimental manoeuvres (p<.001), but not after the placebo and control manoeuvres.
Conclusions:
The contralateral mobilization in Slump position increases the ipsilateral knee extension ROM. Further research is required to confirm that the knee increment ROM was due to the neural component.
... In the sitting and long-sitting positions, the spinal cord and sciatic nerve were tested by slump and Slump LS (Butler 2000, Herrington et al 2008, Shacklock 2016). ...
... In accordance with the PNF philosophy, the treatment began each time on the non-painful R side (Adler et al 2014, Shacklock 2016. This had the advantage for the patient to be able to perceive and integrate the movement while emphasizing conscious breathing with the aim to relax, which was quasi an indirect way to help decrease the pain level (Adler et al 2014, Butler 2000. ...
Introduction
Different approaches are used in physical therapy when treating patients with peripheral nerve paralysis and pain syndrome, such as neuro-mobilization techniques, manual therapy, muscle strengthening, active mobilization and relaxation techniques. Proprioceptive neuromuscular facilitation (PNF) seems to be a promising therapy for mobilizing the neurodynamic system. This case report illustrates the clinical reasoning and feasibility of applying PNF based neuromobilization to a patient not responsive to standard physical therapy.
Case description
A 66-year-old male was diagnosed with neurofibrosarcoma grade II, paravertebral L4-L5 left (L) side. After laminectomy of the transverse process L4 and L5 L side and stenting in the lumbar region, the patient presented pain and peripheral nerve paralysis. The patient’s complaints 13 years later were chronic lower back, buttock and leg pain and weakness in the L leg.
Patient management
Six treatment sessions with follow-up were provided during 3.5 months. The PNF-based-rehabilitation-approach applied the PNF philosophy, specific techniques, and facilitating principles and procedures using manual guidance in 3-dimensional PNF movement patterns in various positions, aiming to mobilize the neurodynamic system to decrease pain and achieve trunk and leg mobility.
Discussion and conclusion
The PNF-based-rehabilitation-approach led to improvement in pain, nerve mobility and balance beyond or close to clinical relevance. This approach had positive effects, by supplying oxygen to the nerves, increasing nerve mobility and decreasing pain, hence restoring altered movement patterns, which all improved the patient’s activities-of-daily-living. In a situation, where standard strengthening and mobilization techniques are not effective, PNF seems a feasible alternative to decrease chronic pain.
... Our data provide evidence that NDT prevents sensitization to normal mechanical stimuli that we observed by the significantly lowered mechanical threshold in the untreated rats on both sides, suggesting that NDT may activate metameric or systemic processes, avoiding nerve sensitization to mechanical stimuli. Even if some pain behaviours related to contralateral DRG changes after a nerve injury, as described in the literature [82,84,85,104], only a few clinical studies have shown in healthy subjects that NDT improves the mobility of the contralateral untreated limb [105,106]. We provide evidence that NDT administered before nerve injury modulates pain with a significant antiallodynic effect for mechanical stimuli 19 days after nerve injury, with no significant difference in TACAN gene expression in the ipsilateral and contralateral DRG assessed 24 days after the injury when compared to controls. ...
Background:
Somatic nerve injuries are a rising problem leading to disability associated with neuropathic pain commonly reported as mechanical allodynia (MA) and hyperalgesia. These symptoms are strongly dependent on specific processes in the dorsal root ganglia (DRG). Neurodynamic treatment (NDT), consisting of selective uniaxial nerve repeated tension protocols, effectively reduces pain and disability in neuropathic pain patients even though the biological mechanisms remain poorly characterized. We aimed to define, both in vivo and ex vivo, how NDT could promote nerve regeneration and modulate some processes in the DRG linked to MA and hyperalgesia.
Methods:
We examined in Wistar rats, after unilateral median and ulnar nerve crush, the therapeutic effects of NDT and the possible protective effects of NDT administered for 10 days before the injury. We adopted an ex vivo model of DRG organotypic explant subjected to NDT to explore the selective effects on DRG cells.
Results:
Behavioural tests, morphological and morphometrical analyses, and gene and protein expression analyses were performed, and these tests revealed that NDT promotes nerve regeneration processes, speeds up sensory motor recovery, and modulates mechanical pain by affecting, in the DRG, the expression of TACAN, a mechanosensitive receptor shared between humans and rats responsible for MA and hyperalgesia. The ex vivo experiments have shown that NDT increases neurite regrowth and confirmed the modulation of TACAN.
Conclusions:
The results obtained in this study on the biological and molecular mechanisms induced by NDT will allow the exploration, in future clinical trials, of its efficacy in different conditions of neuropathic pain.
... The SLR is the most applied physical test in evaluation of the sciatic and tibial nerve involvement in clinical practice (Boyd et al., 2009;Boyd and Villa, 2012;Capra et al., 2011;Cleland et al., 2006;Herrington et al., 2008;Ridehalgh et al., 2012Ridehalgh et al., , 2005Shacklock et al., 2016;Sierra-Silvestre et al., 2017). As in other tests designed to assess the mechanosensitivity and mechanical function of the neural system, in this context, ankle dorsiflexion has been proposed as necessary to make a differential diagnosis between muscle or nerve involvement (Bueno-Gracia et al., 2016;Butler, 2000;Herrington et al., 2008;Nee et al., 2012;Shacklock, 1995). ...
Background
A structural differentiation maneuver has been proposed to differentiate between muscle and nerve involvement during the straight leg raise test. However, to date, the mechanical specificity of this maneuver for the tibial nerve at the posterior knee has not been tested. The aim of this study was to investigate the specificity of ankle dorsiflexion as a differentiation maneuver between the tibial nerve and the biceps femoris muscle at the posterior knee during the straight leg raise in cadavers.
Methods
A cross-sectional study was carried out. In fresh frozen cadavers, with microstrain devices and Vernier calipers, strain and excursion in the tibial nerve and distal biceps femoris muscle were measured during ankle dorsiflexion at 0°, 30°, 60° and 90° of hip flexion of the straight leg raise.
Findings
Ankle dorsiflexion resulted in significant distal excursion and increased strain in the tibial nerve (p < 0.05) whilst the muscle was not affected by the dorsiflexion (p > 0.05) at all hip flexion angles.
Interpretation
Ankle dorsiflexion was mechanically specific between the tibial nerve and biceps femoris during the straight leg raise. This study adds to evidence that, in certain circumstances, dorsiflexion may be used in differentiation of nerve and muscle disorders in the posterior knee.
... Nineteen fulltext articles were screened for eligibility. One study included asymptomatic participants [36], five studies were review articles [17,19,20,22,23], and one had a pretest-post-test design [37]. Thus, 12 studies met the inclusion criteria and were included in this review. ...
Background
The slump test is a type of neurodynamic test that is believed to evaluate the mechanosensitivity of the neuromeningeal structures within the vertebral canal. The objective of this review was to investigate the effectiveness of slump stretching on back pain and disability in patients with low back pain (LBP).
Methods
We searched eight electronic databases (PubMed/Medline, Scopus, Ovid, CINAHL, Embase, PEDro, Google Scholar, CENTRAL). The publication language was restricted to English, and we searched the full time period available for each database, up to October 2017. Our primary outcomes were pain and disability, and the secondary outcome was range of motion (ROM).
Results
We identified 12 eligible studies with 515 LBP patients. All included studies reported short-term follow-up. A large effect size (standardized mean difference [SMD] = –2.15, 95% confidence interval [CI] = –3.35 to –0.95) and significant effect were determined, favoring the use of slump stretching to decrease pain in patients with LBP. In addition, large effect sizes and significant results were also found for the effect of slump stretching on disability improvement (SMD = –8.03, 95% CI = –11.59 to –4.47) in the LBP population. A qualitative synthesis of results showed that slump stretching can significantly increase straight leg raise and active knee extension ROM.
Conclusions
There is very low to moderate quality of evidence that slump stretching may have positive effects on pain in people with LBP. However, the quality of evidence for the benefits of slump stretching on disability was very low. Finally, it appears that patients with nonradicular LBP may benefit most from slump stretching compared with other types of LBP.
Keywords: Low Back Pain, Neurodynamic Technique, Slump Stretching, Review, Meta-analysis
... Neurodynamics is a clinical concept that uses movement (1) to assess increased mechanosensitivity of the nervous system; and (2) to restore the altered homeostasis in and around the nervous system (Coppieters and Nee, 2015). Anatomical and biomechanical studies support the biological plausibility of upper limb neurodynamic tests (ULNTs) (Nee et al., 2012) and common neurodynamic tests for the lower limb, such as the straight leg raise test (Coppieters et al., 2015a,b;Rade et al., 2017;Ridehalgh et al., 2015) and slump test (Coppieters et al., 2005;Ellis et al., 2016;Shacklock et al., 2016). There are however few biomechanical studies which evaluate the neurodynamic tests for the femoral nerve. ...
Background:
Neurodynamic assessment and management are advocated for femoral nerve pathology. Contrary to neurodynamic techniques for other nerves, there is limited research that quantifies femoral nerve biomechanics.
Objectives:
To quantify longitudinal and transverse excursion of the femoral nerve during knee and neck movements.
Design:
Single-group, experimental study, with within-participant comparisons.
Methods:
High-resolution ultrasound recordings of the femoral nerve were made in the proximal thigh/groin region in 30 asymptomatic participants. Scans were made during knee flexion in supine and a semi-seated position, and during neck flexion in side-lying slump (Slump FEMORAL). Healthy participants were assessed to reveal normal nerve biomechanics, not influenced by pathology. Data were analysed with one-sample and paired t-tests. Reliability was assessed with intraclass correlation coefficients (ICC).
Results:
Longitudinal and transverse excursion measurements were reliable (ICC≥0.87). With knee flexion, longitudinal femoral nerve excursion was significant and larger in supine than in sitting (supine (mean (SD)): 3.6 (2.0) mm; p < 0.001; sitting: 1.1 (1.6) mm; p = 0.001; comparison: p = 0.001). There was also excursion in a medial direction (supine: 1.4 (0.3) mm; p < 0.001; sitting: 0.7 (0.6) mm; p < 0.001) and anterior direction (supine: 0.2 (0.2) mm; p < 0.001; sitting: 0.1 (0.2) mm; p = 0.06). Neck flexion in Slump FEMORAL did not result in longitudinal (0.0 (0.3) mm; p = 0.55) or anteroposterior (0.0 (0.1) mm; p = 0.10) excursion, but resulted in medial excursion (1.1 (0.5) mm; p < 0.001).
Conclusion:
Although the femoral nerve terminates proximal to the knee, femoral nerve excursion in the proximal thigh occurred with knee flexion; Neck flexion in Slump FEMORAL resulted in medial excursion.
Background: The clinical examination is one of the best suitable methods for diagnosis of low backache. Backache is one disease that the signs, clinical examination finding, and the results on imaging modalities not always related. The straight leg raising (SLR) and slump tests, can be used for diagnosis of lumber disc herniation.
Objectives: To compare the result of the slump test and SLR test in the diagnosis of lumber disc herniation.
Subjects and Methods: A prospective comparative study conducts on 280 patients in Al-Kindy teaching and private clinics complaints of backache, aging between 18-70 years old with acute or recurrent backache, sciatica pain, or low back and sciatica pain for last 12 weeks, while patients with spinal surgery, sacroiliac joints pain, cervical dysfunction and hip and knee pathology, and chronic illness were excluded.
MRI of the lumbar region was done and clinically examine first by SLR test then Slump test on the next days by separated author. All the record collected patient’s data are interpreted with the MRI finding by the third doctor.
Results: The Slump test is significant than the SLR in the patients with disc herniation at L4-L5 and (L4-5 &L5S1) 93.1% versus 70%, while for L5S1 level no significant in both tests. Leg pain present in 74.1 %, low back and leg pain in 21.5%, and only 4.4% present with low back only.
Conclusion: The Slump test is more sensitive than the SLR test in diagnosis of lumber disc herniation.
Résumé
L’interrogatoire et l’examen neurologique ne suffisent souvent pas au diagnostic de sciatique radiculaire, lequel repose surtout sur la reproduction de la douleur par la mise en tension des racines. Celle-ci est réalisée d’ordinaire seulement par la manœuvre de Lasègue, dont le premier temps, jambe tendue, est dénommé straight-leg-raising (SLR). Le test de Lasègue n’est toutefois pas parfait, ni toujours bien réalisé et interprété. La dorsi-flexion de la cheville en fin de test (test de Braggard) peut être plus sensible. Toutefois ces deux tests peuvent être parfois faussement négatifs, si bien que d’autres tests de mise en tension radiculaire peuvent aider à poser le diagnostic positif d’une souffrance sciatique en présence de douleurs atypiques d’un membre inférieur. Il s’agit : 1- du signe de Christodoulides, qui correspond à la reproduction d’une douleur de topographie L5 lors de la réalisation d’un test de Léri (femoral strech test) ; 2-du signe de Slump, qui consiste sur un patient assis, à étendre la jambe douloureuse à l’horizontale puis à fléchir passivement le cou (ou l’inverse) ; 3-du signe de la corde de l’arc, qui consiste lors de la manœuvre de Lasègue, une fois le genou un peu fléchi après avoir atteint le degré maximal d’élévation passive du membre douloureux, à appuyer sur le trajet des nerfs péroniers et tibiaux dans le creux poplité pour reproduire ou non la douleur connue du patient. La combinaison de tous ces tests pourrait beaucoup améliorer tant la sensibilité que la spécificité de l’examen clinique des sciatiques.
Diagnosis of sciatica mainly relies on pain reproduction by stretching of the lumbar roots since neurological examination and medical history are usually not sufficient to guarantee diagnosis. The Lasègue test is the most popular method, which starts with the straight leg raising test (SLR). However it is not perfect, and is not always well performed or interpreted. Passive ankle dorsiflexion at the end of the SLR (Bragard test) is more sensitive, but can also remain normal in some cases of sciatica. Other stretching tests can help to recognize lumbar root damage in patients with poorly defined pain in a lower extremity: 1) the Christodoulides test, i.e. reproduction of L5 sciatic pain by a femoral stretch test; 2) the Slump test, performed on a patient in a sitting position, by slowly extending their painful leg then passively bending their neck (or the opposite); 3) the Bowstring test, which requires, at the end of the Lasègue test, once the knee has been slightly flexed, pressing on the course of the peroneal and/or tibial nerves in the popliteal fossea to try and reproduce the exact pain felt by the patient. The combination of all these tests takes less than 2 minutes, and could improve both the sensitivity and specificity of the physical examination for the diagnosis of sciatica. This article is a review of the limitations of the Lasègue/SLR tests and of the efficacy of these other tests for stretching the lumbar roots.
Background:
Neurodynamic tests (NDTs) have shown to be useful in evaluating neural tissue involvement. Peroneal nerve reaches high importance in ankle injuries. However, up to date, no study has documented the normal responses for this nerve.
Objectives:
The objective of this study was to document normal responses of the peroneal neurodynamic test (NDTPER) in asymptomatic subjects. Differences in sensory response depending on sex and leg dominance were also examined.
Design:
A cross-sectional study was designed.
Method:
Forty-four asymptomatic subjects with a total of 88 lower limbs were tested. The range of motion (ROM) at the point of first appearance of symptoms (S1) and the point of symptoms tolerance (S2), quality and distribution of sensory responses were recorded.
Results:
Hip flexion was significantly higher at S2 than S1 (mean difference, 27.22°; 95% CI: 25.29°, 29.14°; p < 0.001). However, it was not different between sex, nor dominance (p > 0.05). The descriptor of the quality of sensory responses more often used by subjects was stretching (90.9%) in the external foot (74.6%).
Conclusions:
This study provides the normal hip flexion angle and quality and distribution of sensory responses to the NDTPER in asymptomatic subjects. Responses were independent of the influence of sex or leg dominance.
Background:
Normal displacement of the conus medullaris with unilateral and bilateral SLR has been quantified and the "principle of linear dependence" has been described.
Purpose:
Explore whether previously recorded movements of conus medullaris with SLRs are i) primarily due to transmission of tensile forces transmitted through the neural tissues during SLR or ii) the result of reciprocal movements between vertebrae and nerves.
Study design:
Controlled radiologic study.
Methods:
Ten asymptomatic volunteers were scanned with a 1.5T magnetic resonance (MR) scanner using T2 weighted spc 3D scanning sequences and a device that permits greater ranges of SLR. Displacement of the conus medullaris during the unilateral and sham SLR was quantified reliably with a randomized procedure. Conus displacement in response to unilateral and sham SLRs was quantified and the results compared.
Results:
The conus displaced caudally in the spinal canal by 3.54±0.87 mm (mean±SD) with unilateral (p≤.001) and proximally by 0.32±1.6 mm with sham SLR (p≤.542). Pearson correlations were higher than 0.99 for both intra- and inter-observer reliability and the observed power was 1 for unilateral SLRs and 0.054 and 0.149 for left and right sham SLR respectively.
Conclusions:
Four relevant points emerge from the presented data: i) reciprocal movements between the spinal cord and the surrounding vertebrae are likely to occur during SLR in asymptomatic subjects, ii) conus medullaris displacement in the vertebral canal with SLR is primarily due to transmission of tensile forces through the neural tissues, iii) when tensile forces are transmitted through the neural system as in the clinical SLR, the magnitude of conus medullaris displacement prevails over the amount of bone adjustment.
The Slump Test is used as a fast, low-cost diagnostic tool in the evaluation of leg and back pain disorders. The purpose of this study was to identify the normative sensory responses to the Slump Test in asymptomatic subjects. Eighty-four subjects were tested using a standardized procedure by the same examiner to ensure consistency. Prevalence, intensity, location, and nature of responses at each stage of the Slump Test [Slumped Sitting (SS), Knee Extension (KE), Ankle Dorsiflexion (AD), and Cervical Extension (CE)] were recorded. Of the subjects, 97.6% reported a sensory response during the Slump Test. Prevalence of responses increased significantly from 29.8% at SS to 94% at KE and decreased significantly from 97.6% at AD to 65.5% at CE. Median intensity of responses increased significantly from 0/10 at SS, through 4/10 at KE, to 6/10 at AD, and then decreased significantly to 2/10 at CE. At SS, responses were located at the back or neck, but during the subsequent stages, responses were located most commonly in the posterior thigh, knee, and calf. In terms of nature, a number of different descriptors were used, the most common being "stretch," "tight," and "pull." Approximately 80% of subjects reporting a response had complete or partial relief of this response following cervical extension, indicating that the normal response to the Slump Test may be considered a neurogenic response. This normative data may be used as a reference point when using the Slump Test in the examination of leg and back pain disorders.
The slump test is a tool to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal. While some studies have investigated the reliability of aspects of this test within the same day, few have assessed the reliability across days. Therefore, the purpose of this pilot study was to investigate reliability when measuring active knee extension range of motion (AROM) in a modified slump test position within trials on a single day and across days. Ten male and ten female asymptomatic subjects, ages 20-49 (mean age 30.1, SD 6.4) participated in the study. Knee extension AROM in a modified slump position with the cervical spine in a flexed position and then in an extended position was measured via three trials on two separate days. Across three trials, knee extension AROM increased significantly with a mean magnitude of 2 degrees within days for both cervical spine positions (P>0.05). The findings showed that there was no statistically significant difference in knee extension AROM measurements across days (P>0.05). The intraclass correlation coefficients for the mean of the three trials across days were 0.96 (lower limit 95% CI: 0.90) with the cervical spine flexed and 0.93 (lower limit 95% CI: 0.83) with cervical extension. Measurement error was calculated by way of the typical error and 95% limits of agreement, and visually represented in Bland and Altman plots. The typical error for the cervical flexed and extended positions averaged across trials was 2.6 degrees and 3.3 degrees , respectively. The limits of agreement were narrow, and the Bland and Altman plots also showed minimal bias in the joint angles across days with a random distribution of errors across the range of measured angles. This study demonstrated that knee extension AROM could be reliably measured across days in subjects without pathology and that the measurement error was acceptable. Implications of variability over multiple trials are discussed. The modified set-up for the test using the Kincom dynamometer and elevated thigh position may be useful to clinical researchers in determining the mechanosensitivity of the nervous system.
An inferential cadaveric study.
To compare the displacement and strain of the lumbosacral nerve roots during different conditions of straight leg raise (SLR) with intact foraminal ligaments.
Clinicians use sensitizing movements such as dorsiflexion during neurodynamic testing, assuming that these prepositions influence the displacement or strain to the lumbosacral nerve roots. Little is known about the effect of these prepositions on neurodynamic behavior.
Lower limbs and associated nerve roots of 5 unembalmed cadavers (n = 10) were used to evaluate the displacement and strain of the L4, L5, and S1 roots during 2 different SLR conditions. Fluoroscopic images of intraneural metal markers were digitized to evaluate displacement and strain during SLR with no preposition (SLR NPP) of the ankle and SLR with dorsiflexion preposition (SLR DF) of the ankle, respectively.
SLR NPP produced larger distal displacement at L5 and S1, (P < 0.001) when compared with SLR DF. Displacement comparisons at L4 were nonsignificant (P = 0.051). While nonsignificant, medium to large effect sizes (0.60-0.96) suggest that SLR DF may produce more strain than the SLR NPP condition.
Prepositions of the SLR test alter the displacement and possibly the strain of the lumbosacral nerve roots in the lateral recess.
A descriptive cadaveric study incorporating a novel nerve root marking technique.
To describe the displacement and strain of the lumbosacral nerve roots in the lateral recess during straight leg raise (SLR) without disrupting the foraminal ligaments.
Previous studies document 2 to 8 mm of lumbosacral nerve root displacement during SLR. Prior dissection methods incorporated laminectomy and facetectomy.
Lower limbs and associated nerve roots of 5 unembalmed cadavers (n = 10) were studied. Metal markers were inserted intraneurally within the lateral recess of L4, L5, and S1 with a modified spinal needle. Fluoroscopic images were digitized to evaluate displacement and strain during SLR.
The lumbosacral nerve roots in the lateral recess moved less and experienced less strain during SLR than described in previously published reports. Statistically significant distal displacement occurred at hip positions greater than 60 degrees of flexion at all nerve root levels (P < 0.01).
The lumbosacral nerve roots (L4, L5, S1) moved less and underwent less strain during SLR testing than previously reported and may require hip motion greater than 60 degrees to produce substantive displacement in the lateral recess. Additional research is needed to examine the effects of prepositioning during SLR.
An accurate and specific diagnosis prevents the recurrences of low back pain and chronic spinal pain. The physical examination is the most useful tool to diagnosis. The examiner must aim to determine the exact tissue that pain arises from to make the specific diagnosis. Lumbar disc herniation is 1 disease that physical examination, symptoms, and findings on imaging technique do not always correlate with each other. The Straight Leg Raising (SLR) test has been used as the primary test to diagnosis lumbar disc herniations and found to have high correlation with findings on operation since its sensitivity is high in only disc herniations leading to root compression that may eventually need operation. More sensitive test, like the Slump, might be used in herniations in which the SLR is negative. The Slump test is really a variant of the SLR and the Lasègue's tests performed in the seated position and is a progressive series of maneuvers designed to place the sciatic nerve roots under increasing tension. At each step in the procedure, the patient informs the examiner what is being felt and whether radicular pain is produced. As a result, the Slump test applies traction to the nerve roots by incorporating spinal and hip joint flexion into the leg raising and would warn the examiner of the presence of nerve root compression when there is a negative SLR test.
This study measured the sensitivity and specificity of the Slump test and compare it with the SLR test in patients with and without lumbar disc herniations.
A prospective case control study of 75 patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department of a state teaching hospital. Seventy-five referred or self-admitted patients with low back, leg, or low back and leg pain who had results of magnetic resonance imaging (MRI) of the lumbar spine were included in the study. Thirty-eight patients had signs of herniation demonstrated by MRI. Control patients (n = 37) had no disc bulges or herniations on MRI. Both the Slump and SLR tests were performed during the assessment of all the patients by the second author. The MRI results were assessed and recorded by the first author.
The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. However, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83).
The Slump test might be used more frequently as a sensitive physical examination tool in patients with symptoms of lumbar disc herniations. In contrast, owing to its higher specificity, the SLR test may especially help identify patients who have herniations with root compression requiring surgery.
This book deals with a new field of neurology, namely the investigation into tension in txhe central nervous system generated by external or internal dynamic forces acting on the nervous tissue. The resulting deformation of the nerve cells and axons is ultimately responsible for familiar neurological symptoms. The forces in question may have their origin in a variety of pathological conditions and mechanical situations in different parts of the central nervous system and they therefore give rise to specific functional disorders. This chain of cause and effect has been analysed by the author on the basis of simple mechanical principles and the insight gained from this analysis has pointed to methods of eliminating the adverse tension and hence the deformation of tissue elements and the resulting neurological symptoms. Details of the mechanical analysis and the principles underlying the therapeutic methods aimed at the relaxation of the distended tissues are well illustrated with diagrams, photomicrographs and radiographs.
Twenty-four fresh cadavers were employed to study the vertebral canal and its contents during relative displacement ranging from hyperflexion to hyperextension. Changes in position were visualized by interpedicular bony landmarks associated with neuromeningeal markers positioned after laminectomy. The length of the vertebral canal increased by 5-9 cm in the transition from hyperextension to hyperflexion, thereby necessitating neuromeningeal adaptation. During hyperflexion the degree of neuromeningeal displacement varies with the level of the spinal column but converges toward the two regions of maximum mobility, usually C6 and L4. These movements produce stretching that is particularly forceful at three points: the C6 and L4 myelomeres and the roots of the cauda equina distal to the 4th lumbar roots.
Controlled radiologic study.
Verify (i) whether conus medullaris displacement varies with range of hip flexion ii) if the acquired data support the "principle of linear dependence".
We have previously quantified normal displacement of the conus with unilateral and bilateral SLR have and described the "principle of linear dependence". However, we have since effected methodological advances which have produced data that surpass previous studies.
Ten asymptomatic volunteers were scanned with a 1.5T magnetic resonance (MR) scanner using T2 weighted spc 3D scanning sequences and a device that permits greater ranges of SLR. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure.
Pearson's correlations were higher than 0.99 for both intra- and inter-observer reliability and the observed power was 1 for each tested manoeuvre. The conus displaced caudally in the spinal canal by 3.54±0.87 mm (μ±SD) with unilateral (p≤0.001) and 7.42±2.09 mm with bilateral SLR (p≤0.001).
To the authors' knowledge these are the first data on non-invasive, in vivo, normative measurement of spinal cord displacement with the SLR test at 60° of hip flexion. Conus medullaris displacement increased with hip flexion angle, while maintaining the relationship between magnitude of conus displacement and number of nerve roots involved into the movement, supporting the "principle of linear dependence". The use of T2 weighted spc 3D-sequence allows for better reliability testing which is important for future clinical utility.
It is common practice for those concerned with the treatment of patients with the many patterns of pain arising from the vertebral column to assess ranges of intervertebral joint movement and to associate with this assessment that of the behaviour of pain during the test movements. This clinical paper deals with the examination of movement of the pain sensitive structures in the vertebral canal (the dura mater and nerve root sleeves) and the clinical implications of restriction in range together with reproduction of the patient's pain. The possible clinical findings are considered in relation to low back pain, tethering of pain sensitive vertebral canal structures in pre and post laminectomy patients, the 'juvenile disc' patients and patients with headaches.
The Slump test is becoming more widely accepted as an examination and treatment procedure for all levels of the vertebral column. The test is essential for a fuller recognition of the factors contributing to some patients' disorders. This paper describes the test, the normal pain response, predictable findings on examination, and use of the test in treatment.
This study examined the inter-therapist reliability of the slump test. Six pairs of physiotherapists tested a total of 93 patients currently receiving treatment for lumbar and/or lower limb symptoms. Each pair performed two slump tests on patients during a normal clinical visit. The slump test was positive if the patients' symptoms were reproduced, and subsequently decreased with cervical extension. A second definition of positive slump required decreased symptoms and increased knee extension with cervical extension. The results indicated that the slump test has high inter-therapist reliability which is consistent with reliability findings for related clinical tests of pain.
Study design:
Controlled radiological study.
Objective:
To investigate noninvasively in vivo spinal cord displacement in the vertebral canal during the passive straight leg raise (SLR) in asymptomatic subjects. The basic assumption is that the cord follows L5 and S1 nerve roots displacement by similar magnitude and direction (principle of linear dependence).
Summary of background data:
It is generally accepted that the SLR produces some caudal movement mainly of L5 and S1 nerve roots, but the magnitude of this displacement is still a matter of debate.
Methods:
Sixteen asymptomatic volunteers were scanned with 1.5-T magnetic resonance scanner (Siemens Avanto, Erlangen, Germany) using T2-weighted turbo spin-echo fat-saturation sequence. The displacement of the medullar cone relative to the vertebral endplate of the adjacent vertebra during the passive SLR was quantified and compared with the position of the conus in the neutral (anatomic) position. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by 2 observers. Four practitioners performed the maneuvers in a random sequence to avoid series effects.
Results:
Compared with the neutral (anatomic) position, the medullar cone displaced caudally in the spinal canal by 2.31 ± 1.2 mm with right (P ≤ 0.001) and 2.35 ± 1.2 mm with left SLR (P ≤ 0.001). Spearman correlations proved higher than 0.99 for intra and interobserver reliability, as well as results reproducibility testing for each maneuver.
Conclusion:
The data show that the spinal cord in the thoracolumbar region slides distally in response to the clinically applied SLR test. The high correlation values in this study show that these movements are consistent and reproducible. Because of the neural continuum, the authors speculate that this movement might be directly proportional to the sliding of the L5 and S1 neural roots. This study offers baseline measurements on which further studies in diagnosis of lumbar disc protrusion and radiculopathy may be developed.
Study Design. Controlled radiologic study.Objective. Ascertain if a difference exists in the mechanical effects on the cord between the unilateral and bilateral SLR and to verify whether the effect on the spinal cord may be cumulative between the two.Summary of Background Data. To the author's knowledge these are the first data on non-invasive, in-vivo, normative measurement of spinal cord displacement with bilateral SLR test.Methods. Sixteen asymptomatic volunteers were scanned with 1.5T magnetic resonance scanner (Siemens Avanto, Erlangen, Germany) using T2 weighted turbo spin-echo fat-saturation sequence.The displacement of the medullar cone relative to the vertebral endplate of the adjacent vertebra during the passive bilateral SLR was quantified and compared with the position of the conus in the neutral (anatomic) position and with unilateral SLR. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by two observers. Four practitioners performed the maneuvers in a random sequence in order to avoid series effects.Results. Compared to the neutral (anatomic) position, the medullar cone displaced caudally in the spinal canal by 2.33±1.2mm (μ±SD) with unilateral (p≤0.001) and 4.58±1.48mm with bilateral SLR (p≤0.001). Statistical significance was also reached for bilateral versus unilateral SLR (p≤0.001).Spearman correlations proved higher than 0.99 for intra and inter-observer reliability, and 0.984 for results reproducibility in bilateral SLR.Conclusions. The caudal displacement of the medullar cone was significantly greater (almost double) with the bilateral compared to the unilateral SLR. We hypothesize that this greater movement may be because more force was transmitted to the cord through a larger number nerve roots with the bilateral than unilateral SLR.The high correlation values in this study show that these movements are consistent and reproducible.This study offers baseline measurements on which further studies in diagnosis and treatment of lumbar disc protrusion and radiculopathy may be developed.
Résumé A partir de 24 sujets anatomiques frais, non fixés, une étude dynamique a été réalisée pour apprécier les déplacements relatifs du canal vertébral et de son contenu entre des manœuvres d'hyperflexion et d'hyperextension. La mise en évidence des déplacements a été effectuée à partir de repères osseux interpédiculaires et des repères nerveux et méningés posés à partir d'une laminectomie. Le canal vertébral subit un allongement de 5 à 9 cm de l'hyperextension à l'hyperflexion ce qui implique une adaptation neuro-méningée. Les formations neuro-méningées subissent en hyperflexion des déplacements variables suivant les secteurs vertébraux c'est-à-dire qu'ils s'effectuent de telle sorte qu'ils convergent vers deux régions de grande mobilité: les vertèbres C6 et L4 le plus souvent. Au cours de ces déplacements, il se produit des phénomènes d'étirement particulièrement importants en trois points: les myélomères C6 et L4 et les racines de la queue de cheval à partir, dans le sens caudal, des 4e racines lombaires.
Objectives: Pre-season or pre-participation screening is commonly used to identify intrinsic risk factors for sports injury. Tests chosen are generally based on clinical experience due to the paucity of quality injury risk factor studies for sport and, often, the reliability of these clinical tests has not been established. The purpose of this study was to establish the reliability of eight, musculoskeletal screening tests, commonly used in the screening protocols of elite-level Australian football clubs.Methods: Fifteen participants (n=9 female, n=6 male) were tested by two raters on two occasions, 1 week apart to establish the inter-rater and test–retest reliability of the chosen measurement tools. The tests of interest were Sit and Reach, Active Knee Extension, Passive Straight Leg Raise, slump, active hip internal rotation range of movement (ROM), active hip external rotation ROM, lumbar spine extension ROM and the Modified Thomas Test.Results: All tests demonstrated very good to excellent (Intraclass correlation coefficient, ICC 0.88–0.97) inter-rater reliability. Test–retest reliability was also shown to be good for these tests (ICC 0.63–0.99).Conclusion: The findings suggest that these simple, clinical measures of flexibility and ROM are reliable and support their use as pre-participation screening tools for sports participants.
The purpose of the study was to assess the effect of structural differentiation or sensitising manoeuvres on responses of normal subjects to standard neurodynamic tests of straight leg raise (SLR) and slump test. Eighty-eight (39 males and 49 females) asymptomatic subjects were examined (aged 18-39 mean age 21.9+/-4.1 years). Knee flexion angle was measured using a goniometer during the slump test in two conditions cervical flexion and extension. Hip flexion angle was measured using a goniometer during SLR test in two conditions; ankle dorsi-flexion and neutral. The change in knee flexion, following addition of the structural differentiating manoeuvre to the slump test, was a significant increase in knee flexion angle for both males (change in knee angle; 6.6+/-4.7 degrees /18.7+/-17.5%, p<0.01) and females (change in knee angle 5.4+/-5.8 degrees /17.6+/-23.7%, p<0.01), though showed no difference between sides (p>0.05). During the SLR test, a significant reduction in hip flexion occurred following structural differentiation for both groups (change in hip angle; males = 9.5+/-8.3 degrees /21.5+/-18.8%, p<0.01; females = 15.2+/-9.5 degrees /25.9+/-13.9%, p<0.01), though showed no difference between sides (p>0.05). Structural differentiating manoeuvres have a significant effect on test response in terms of range of movement even in normal asymptomatic individuals. These responses should be taken into account during the assessment clinical reasoning process.
Studies of the sacral plexus have been made in six cadavers to demonstrate the increased tension due to medial hip rotation. A standard protocol was adopted for the straight-leg-raising test (SLR) and three qualifying tests--dorsiflexion of the ankle, medial hip rotation, and cervical flexion--when examining 442 patients. Positive signs on medial hip rotation were frequently associated with evidence of increased tension and neurologic dysfunction of lumbosacral roots. It is concluded that uncontrolled hip rotation reduces the value of the SLR is a useful qualifying test for increased root tension, and that the diagnostic value and repeatability of SLR would be improved by adopting a standardized protocol.
The slump test has been used routinely to differentiate low back pain due to involvement of neural structures from low back pain attributable to other factors. It is also said to differentiate between posterior thigh pain due to neural involvement from that due to hamstring injury. If changes in cervical position affect the hamstring muscles, differential diagnosis is confounded. Posterior thigh pain caused by the cervical component of the slump could then be caused either by increased tension on neural structures or increased tension in the hamstrings themselves. The aim of this study was to determine whether changing the cervical position during slump altered posterior thigh pain and/or the tension in the hamstring muscle. Asymptomatic subjects aged between 18 and 30 years were tested. A special fixation device was engineered to fix the trunk, pelvis and lower limb. Pain levels in cervical flexion and extension were assessed by visual analogue scale. Fixation was successful in that there were no significant differences in position of the pelvis or knee during changes in cervical position. Averaged over the group, there was a 40% decrease (P < 0.05) in posterior thigh pain with cervical extension. There were no significant differences in hamstring electromyographic readings during the cervical movements. This indicated that: (1) cervical movement did not change hamstring muscle tension, and (2) the change in experimentally induced pain during cervical flexion was not due to changes in the hamstring muscle. This conclusion supports the view that posterior thigh pain caused by the slump test and relieved by cervical extension arises from neural structures rather than the hamstring muscle. Copyright 1997 Harcourt Publishers Ltd.
There are reasons for believing that the spinal cord, in spite of its sheltered position within the vertebral column, is subject to stresses that change with posture. The changes in posture may involve the trunk or the limbs. In the trunk, flexion must necessarily stretch the cord, since the vertebral canal increases in length. Of postural changes in the limbs, those that put traction on the nerves may be expected to stretch the cord. This is suggested by the observation of Inman and Saunders (1) that the trunks of the lower lumbar nerves, located in the intervertebral foramina, move distally when the hip is flexed and the knee is kept in extension. The present study was undertaken to measure the changes in length and position of the individual spinal cord segments (a) when the trunk is flexed and (b) when the extremities are moved into positions which put traction on the peripheral nerves. Material and Method Normal rhesus monkeys (Macaca mulatta) were killed by anesthetization and evisceration. The left...
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