Original articleSlump stretching in the management of non-radicular low back pain: A pilot clinical trial☆
Introduction
Disability associated with low back pain (LBP) continues to rise, contributing to a substantial economic burden that exceeds nearly 50 billion annually in the United States alone (Frymoyer, 1992). Health care expenditures among individuals with LBP are also 60% greater than those without LBP (Luo et al., 2004) with 37% of the costs a direct result of physical therapy services (Maniadakis and Gray, 2000).
Physical therapists utilize a wide range of interventions in the management of LBP; however, evidence for the effectiveness of these interventions is limited (Philadelphia Panel, 2001). Given that LBP is a heterogeneous condition, it does not seem reasonable to expect that all patients will benefit from a single treatment approach. Rather, the key is to identify subgroups of patients with a high probability of achieving a successful outcome with a particular intervention. Evidence suggests that short- and longer-term outcomes are improved when a classification-based approach is used compared to decision-making based on clinical practice guidelines (Fritz et al., 2003). To date, evidence for several subgroups of LBP exist, such as patients likely to benefit from manipulation (Childs et al., 2004; Flynn et al., 2002), lumbar stabilization (O’Sullivan et al., 1997), and specific directional exercise (Long et al., 2004).
One subgroup that has not been readily examined is patients with more distal symptoms whose symptoms are not improved with specific directional exercises (i.e. flexion- or extension-oriented exercise). These patients are commonly thought to be experiencing altered neurodynamics, the interaction between nervous system mechanics and physiology (Shacklock, 1995a, Shacklock, 1995b). A number of neurodynamic tests have been purported to assess the mechanosensitivity of neurogenic structures (Cyriax, 1942; Kenneally et al., 1988; Maitland, 1985). Cyriax (1942) originally used neurodynamic testing, specifically the straight-leg-raise (SLR), to identify the presence of perineuritis. Maitland (1985) further refined the technique and described the slump test, which incorporated cervical flexion and ankle dorsiflexion which was believed to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal.
Studies (Adams and Logue, 1971; Breig, 1978; Goddard and Reid, 1965) have supported the claims of Cyriax (1942) and Maitland (1985) by demonstrating that in the cadaver model, spinal flexion resulted in tension of the nerve roots and dural sleeve (Breig, 1978). Although it has often been stated that neurodynamic tests have limited diagnostic utility in the differentiation between neural and non-neural structures (Di Fabio, 2001), recent evidence demonstrated that pain of nonneural origin (experimentally induced) was not exacerbated by slump stretching (Coppieters et al., 2005). The authors suggested that the results of their study support the use of neurodynamic tests (including the slump) in the identification of altered neurodynamics.
Since Maitland (1985) described the slump test it has been used as an assessment tool for the identification of possible altered neurodynamics and more recently has been suggested as a possible treatment technique (Butler, 2000). However, limited evidence exists to support the effectiveness of using the slump test as a treatment approach and has only been presented in the form of case reports or case studies (Cleland et al., 2004; Cleland and McRae, 2002; George, 2000, George, 2002).
George (2002) recently described the outcomes in a subgroup of 6 patients hypothesized to respond favorably to slump stretching. Treatment was limited to those whose symptoms did not worsen or improve with lumbar flexion and extension movements and who exhibited a positive slump test in the absence of radicular signs. Although favorable outcomes were reported, the design of this study being a case series precludes establishing a cause and effect relationship. Therefore, the purpose of this study was to determine whether slump stretching is beneficial for the subgroup of patients hypothesized to benefit from this form of treatment. We hypothesized that patients who received slump stretching plus lumbar spine mobilization and exercise would experience greater improvements in disability, pain, and centralization of symptoms than patients who received lumbar spine mobilization and exercise only.
Section snippets
Methods
Participants were consecutive patients in primary care between 18 and 60 years of age with a chief complaint of LBP referred to physical therapy. Patients were required to have symptoms that referred distal to the buttocks, reproduction of the patient's symptoms with slump testing, no change in symptoms with lumbar flexion or extension, and a baseline Oswestry score greater than 10%. Patients with “red flags” for a serious spinal condition (e.g. infection, tumors, osteoporosis, spinal fracture,
Results
One hundred and seventeen patients were screened for eligibility during an 18-month period from January 2002 to June 2003. Eighty-one patients (69%) did not satisfy the inclusion and exclusion criteria for the study. The high rate of ineligibility was due to the stringent inclusion criteria requiring symptoms distal to the buttock, a positive slump test, and the exclusion of patients with a positive straight leg raise. Six patients (5%) refused participation because they did not desire to be
Discussion
The results of our study confirm our hypotheses that slump stretching may be beneficial in the management of patients with non-radicular LBP. Slump stretching in addition to lumbar spine mobilization and exercise was beneficial in reducing short-term disability and improving pain and promoting centralization of symptoms in this subgroup of patients. Our results are similar to those of George (2002) who reported that a subgroup of patients with LBP might exist who have distal symptoms but whose
Conclusion
Slump stretching is beneficial for improving short-term disability, decreasing pain, and centralization of symptoms compared to treatment without slump stretching in a subgroup of patients hypothesized to benefit from this form of treatment. These data provide preliminary evidence supporting the notion that patients with distal symptoms who are unable to centralize their symptoms may be a distinct subgroup of patients with LBP that benefit from slump stretching exercise. Future studies should
References (40)
- et al.
The centralization phenomenon of spinal symptoms—a systematic review
Manual Therapy
(2004) - et al.
The impact of neurodynamic testing on the perception of experimentally induced muscle pain
Manual Therapy
(2005) - et al.
Effectiveness of manipulative physiotherapy for the treatment of neurogenic pain syndrome: a single case study—experimental design
Manual Therapy
(2002) - et al.
Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability
Pain
(1999) - et al.
Low back pain: reliability of a set of pain measurement tools
Archives of Physical Medicine and Rehabilitation
(2001) - et al.
What is the maximum number of levels needed in pain intensity measurement?
Pain
(1994) The slump test: examination and treatment
The Australian Journal of Physiotherapy
(1985)- et al.
The economic burden of back pain in the UK
Pain
(2000) - et al.
The inter-therapist reliability of the slump test
The Australian Journal of Physiotherapy
(1989) Neurodynamics
Physiotherapy
(1995)
Fear-avoidance beliefs questionnaire and the role of fear-avoidance beliefs in chronic low back pain and disability
Pain
Studies in cervical spondylitic myelopathy: movement of the cervical roots, dura and cord, and their relation to the course of the extrathecal roots
Brain
Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up
Spine
Adverse mechanical tension in the central nervous system: an analysis of cause and effect
The sensitive nervous system
A clinical prediction rule to identify patients likely to benefit from spinal manipulation: a validation study
Annals of Internal Medicine
Effectiveness of neural mobilization in the treatment of a patient with lower extremity neurogenic pain: a single-case design
Journal of Manual and Manipulative Therapy
Complex regional pain syndrome I: management through the use of vertebral and sympathetic trunk mobilization
Journal of Manual and Manipulative Therapy
Perineuritis
British Medical Journal
Neural mobilization: the impossible
Journal of Orthopaedic and Sports Physical Therapy
Cited by (87)
The effectiveness of slider and tensioner neural mobilization techniques in the management of upper quadrant pain: A systematic review of randomized controlled trials
2022, Journal of Bodywork and Movement TherapiesNeurodynamic exercises provide no additional benefit to extension-oriented exercises in people with chronic low back-related leg pain and a directional preference: A randomized clinical trial
2022, Journal of Bodywork and Movement TherapiesValidation of a sham novel neural mobilization technique in patients with non-specific low back pain: A randomized, placebo-controlled trial
2021, Musculoskeletal Science and Practice
- ☆
Work should be attributed to the Physical Therapy Program, Franklin Pierce College, Concord, NH 03301.