26.8.

2016

Contralateralkneeextensionanewadvanceintheslumptest

Contralateralkneeextensionanewadvanceintheslump
test

ThisyearShacklocketal(2016)publishedafantasticstudyexploringtheimpactthatacontralateralknee
extensionhasonasymptomaticsubjectsduringtheslumptest(seeoriginalpaperhere).Thepurposeofthe
studywastounderstandwhatthenormalresponseisinasymptomaticsubjectswhenthisadditional
movementisperformed.
Theresultsofthisstudyhelpustounderstandfurtherthemechanicsofmovementofthelumbarnerveroots
duringneurodynamicmovements/testsandprovideclinicianswithnewinformationabouthowtointerpret
theresponseapatientfeelsduringtheslumptest.
Imsureweareallfamiliarwithperformingtheslumptestinclinicalpractice,asitisindicatedforpatients
withbothlowerbackandneckpain.OverthepastyearsIhavelearntfurtherdetailsabouthowtoperform
thistestreliablyandconsistentlyandthemainpurposeofthisblogisto:
Discusswhatthenormaltestproceduresisandwhatthenormalresponseisinasymptomaticpatients.
Sharethenewfindingsassociatedwiththeadditionofcontralateralkneeextensionattheendofthe
movement.

Slumptestaneurodynamicassessment
Useoftheslumptestisindicatedforpaininanyareaofthebody,butismostcommonlyusedinthe
assessmentoflowerbackpain.Itfallsunderthecategoryofneurodynamicassessment.Maitland(2005)
emphasisesthattheslumptestisapplicabletobothlumbarandcervicalspinedisordersandshouldbe
includedinthemusculoskeletalassessment.Forthelumbarspinespecifically,theslumptestisoftenusedto
testthemechanicsoflumbarneuraltissuesandidentifylumbardischerniations.
YoumayalsowonderwhyyouperformbothlumbarflexionAROMandaslumptestwhenbothproduce
spinalflexion.Theansweristhat...

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"Ifforwardflexionisrestricted,itmaybethattheintervertebraljointsarestifforitmaybethatthereisloss
ofmovementofthestructuresinthecanalorforamen.Theteststhatcanbeappliedtomovethe
structuresinthevertebralcanalwithoutalsomovingtheintervertebraljointsarefewinnumber"
(Maitland,etal.,2005,p.140).

Performingtheslumptest
Maitland(2005)&Shacklock(2005)instructtheprocessofaslumptestas:
1.Havethepatientsitontheedgeofthecouchwiththebackoftheirkneestouchingtheedgeofthecouch.
Askforrestingpain/symptoms.
2.Handsrestingonthecouchbehindthepatientsback.
3.Instructthepatienttoslumpthroughtheirupperandlowerback(withoutflexingthecervicalspine)and
thetherapistappliesagentleoverpressure(nottoendofrange).Agoodinstructionistoaskthepatient
toslumptheirshoulderstohipsanddropstraightdown.Theaimisfulllumbarandthoracicflexion.
Assessforanychangeofsymptoms.
4.Instructthepatienttotucktheirchintochestastheylookdownandafirmoverpressureisappliedbythe
therapisttomaintaincervical/thoracic/lumbarposition.Assessforanychangeinsymptoms.
5.Instructthepatienttoextendtheirkneeasfaraspossibleandnotetherangeofsymptomsorpain
response.Ask"Isthatyourpain?".
6.Theendpositionissustainedwhileneckflexionisreleasedandthechangeinpainresponseisnoted.
Also,ifthepatientisunabletoachievefullkneeextension,thenonceneckflexionisreleased,askthe
patienttotryextendtheirkneefurther.
7.Ankledorsiflexioncanbeaddedbeforeorafterkneeextensiontoincreasethestretchandassistwith
structuraldifferentiation.
8.Iffirmeroverpressureisrequired,repeatthetestinlongsitting.
9.Therapistsshouldalsodecide,basedonthepatienthistory,ifoverpressureisappropriateatall."The
therapistmusttakeintoaccountspecificinformation,suchasirritability,sensitivity,latencyand
contraindications"(Shacklock,2005,p.143).
BelowisthesequenceIusefortheslumptest.Ifthepatientissittingontheendoftheplinthasseenbelow
thenyoucanstandbesideyourpatient.Iftheyaresittinginthemiddleoftheplinthyouwillneedtoperchon
thetablenexttotheminordertopositionyourselfcorrectlytosustainedthethoracicpositionandhelpyour
clientmaintaintheirslumpwhiletheymovetheircervicalspine.

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Mostimportantlyremembertoaskforthepainresponse,painlocationandrelationshiptothepatient's
problem.Thenensuretoassessthechangeinpainresponsewithreleaseofcervicalflexion.
Positiveresponse:Boththeincreasedkneeextensionrangeandreductioninsymptomswithreleaseof
cervicalflexionwouldimplicateduralpainsensitisedstructuresoverhamstringmuscleextensibility,asthe
limitingfactortokneeextensionrangeofmovement.
Normalresponse(Maitland,2005Shacklock,2005):
Midthoracic(T9/10)pain/discomfortduringthoracicandlumbarflexion.
Apainfreelackof30degreesofkneeextensioncanbenormal.
Stretchingintheposteriorthighandknee,extendingintothecalf.
Ankledorsiflexionincreasestheposteriorthigh/kneepain.
Reductionofsymptomswithreleaseofcervicalflexion.
Awordofcaution
Maitlandalertstherapiststotheoftenunpredictableresponsethatpatientswithpainsensitivecanal
structuresandneuralstructuresmayhavetotheslumptestorslumpexercises."Therefore,whentheslump
testisusedasatechnique,caremustbetakenonthefirstdayandassessmentover24hoursisthen
necessarytodeterminewhetherthestrengthofthetechniqueneedstobechanged.Ifitisperformed
vigorously,anintervalof23daysshouldbeleftbetweentreatmentsforsorenesstosettlesoastomake
accuratereassessmentpossibletodeterminehowmuchhasbeengained"(2005,p.149).

Updatesinourunderstandingofa'normalresponse'
Whatdoweknowishappeningduringtheslumptest?
Shacklockandhisteamhavebeenstudyingthemovementofneuraltissuesformanyyearsinthehopeof
understandingthemechanismbehindtheseresponses.Comingbacktothestudyabove,Shacklocketal

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(2016)lookedatthechangeinpain(measuredonthenumericalratingofpainscale)whenthecontralateral
kneewasextended.
Whattheyfoundistheineverypatientwithintheinterventiongroup,the'evokedsensation'inthetestleg
wasreducedwhentheotherkneewasextended.
Infact,thechangeinsensationfollowingcontralateralkneeextensionintheinterventiongroupwason
average3.8onthenumericalratingscale(Shacklock,etal.,2016,p.E208).

(Shacklock,etal.,2016.,E207)
Firsttheymeasuredthephysicalimpactofthismovementandthentheystudieditoncadavers.Thesecond
partofthestudywastotestthemovementoflumbarneuraltissueswithmechanicaltractionincadavers.
Whattheyfoundisthatwhenamechanicaltractionwasappliedtothenerveroot(inthiscaseL5)ina
caudaldirection,allneuraltissuesontheoppositesidebecomelooser(Shacklock,etal.,2016,p.
E208).

(Shacklock,etal.,2016,p.E208)
Avideoofthismovementisavailabledirectlyfromthearticleundersupplementarydigitalimagesinthe
articleitselforyoucantryviewthemonthislink.

Howdoesthistranslatetoclinicalpractice?
Onofthemaintakehomemessagesfromthisarticleabouttheslumptestisthatmovingtheopposite
sidechangestensioninthelumbarneuraltissues.
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Whencontralateralkneeextensionisappliedthereislikelyacaudaltractionforceonthelumbarnerveroots
resultinginreducednerverootpressure.Thishelpsustounderstandalittlemorewhysomepatientswith
sciaticacanexperiencetemporaryreliefintheirsymptomsperformingthistest.Whileitmaylooklike
extendingbothlegsisastrongerslumptest,ifperformedinthecorrectsequence,itmayinfactbereducing
thepressure?!
ClinicallyIhaveseenthisworkandoftengivethismovementasaHEPforreducingpain.But,understanding
themechanismastohowthismovementworkshasnotuntilrecenttimesbeenfullyunderstood.

Howdoweknowthatitisn'tduetohamstringmuscletension?
Oneconfoundingfactorthatcouldresultinreductionofsymptomsistherelaxationofsofttissuestructures
inthethigh.Whentheevokedsensationinthetestinglegchangeswithareleaseofcervicalflexionand
thereisnochangeinmyoelectricactivityinthehamstrings,thechangeisthoughttobeassociatedwith
lumbarneuraltissues(Shacklock,etal.,2016).Basedonthisthinkingtheauthorsdesignedthestudyto
controlforanysofttissuechangesbyalsohavingacontrolandshamgroup.

Isthisjustinasymptomaticsubjects?
Thefirststageofthisresearchistoimproveourunderstandingofwhatnormallyhappensduringthese
movementsinasymptomaticindividuals.Fromhereresearcherscancontinuetostudyandunderstandthe
abnormalresponsetoo.You'veprobablyseenitbeforeandjustnotentirelyunderstoodwhatyouwere
lookingat.
IfirstcameacrosstheideaofmovementinthespinalcordwhenIwastaughtthecrossedSLRsign.The
crossedstraightlegraiseiswhenapatientwithLBPperformsanALSRtestandliftingthecontralateralleg
producesincreasedpain.IwastaughtthiswhenIfirststartedpracticingandhaveseenitmanytimes
before.
InitiallyIjustlookedforthissignbutdidn'tfullyunderstandwhatitmeant.NowIknowthatthecrossedSLR
signisanindicatoroflumbardischerniationandthesepatient'sweregenerallyslowertorecoverormore
trickytomanage.
Theresultsfromthisstudyhelpmetounderstandandconceptualisethemovementoflumbarneuraltissues
andwhythismightbethecase.Althoughfurtherresearchisstillrequiredtoprovideasoundexplanationfor
theseoutcomes,thereisgrowingevidencethatneurodynamictestssuchastheslumptestprovideuswith
invaluableinformationoftheneuralmechanicsofourpatients.Understandingmoreabouthowtheneural
tissuemoveinresponsetolimbmovementswillhelpustodevelopbettertreatmentsandhomeexercises
forourpatientswithbackpain.
Sian)
FollowneurodynamicupdatesfromMichaelShacklockdirectlyviaResearchGateandaccesstheoriginal
paperhere.
ForvariationsintheslumptestandpassivestraightlegraisetestrefertoMaitland'sbookVertebral
Manipulation,Shacklock'sbookClinicalNeurodynamics,andButlersbookTheNeurodynamictechniques
(Butler,2005Hengeveld&Banks,2005Shacklock,2005).
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References:
Hengeveld,E.,&Banks,K.(2005).Maitland'speripheralmanipulation:Elsevier/ButterworthHeinemann.
Shacklock,M.,Yee,B.,VanHoof,T.,Foley,R.,Boddie,K.,Lacey,E.,...&Airaksinen,O.(2016).SlumpTest:
EffectofContralateralKneeExtensiononResponseSensationsinAsymptomaticSubjectsandCadaver
Study.Spine,41(4),E205E210.
Shacklock,M.O.(2005).Clinicalneurodynamics:anewsystemofmusculoskeletaltreatment:Elsevier
HealthSciences.

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