A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation.

[Koury MJ, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Phys Ther. 1994;74:548-560.]

Key Words: Manual therapy, Mobilization, Slump test.

An Australian approach to manual therapy, pioneered by Maitland,[1] provides a framework for evaluation and treatment of musculoskeletal disorders. We used this approach in the evaluation and treatment of a 50-year-old man with chronic lumbar nerve root irritation. Maitland[2] uses the term "subjective examination" to represent the therapist's interpretation of the patient's perceptions of his or her symptoms. Maitland's use of the term differs from that of Jette,[3] who states that a subjective test or measure is one that is influenced by the examiner, the test itself, or extraneous characteristics of the patient. Maitland's use of the term also differs from how the term is routinely used in measurement science.[4]

The data collected from the patient interview assists the therapist in identifying the strategies and techniques to be used in the physical examination, which Maitland[2] calls the "objective examination." He uses this term differently than it is commonly defined. The American Physical Therapy Association's Task Force on Standards for Measurement in Physical Therapy, for example, defines an objective examination as an examination used to obtain measurements that are not affected by some aspect of the person obtaining the measurements.[4(p595)]

A key concept in the Maitland evaluation strategy is SINS,[2] an acronym for "severity, irritability, nature, and stage" that is used to determine the vigor and extent of the physical examination and treatment. Severity refers to the intensity of the patient's symptoms and is based on the patient's perception of the symptoms and how much the symptoms limit the patient's activities. If the symptoms limit the patient's activities or awaken the patient, the symptoms are generally considered severe (eg, a patient has stopped using his or her arm for dressing or is unable to find a comfortable sleeping position due to the intensity of the symptoms). Irritability refers to the relationship among the amount of activity required to provoke !a patient's symptoms, the magnitude of those symptoms, and the time it takes for the symptoms to subside. Irritable conditions are those easily made worse and take a considerable time to subside. For example, if raising the arm once or twice increases the patient's symptoms and the symptoms take 30 minutes to subside, the condition is considered irritable, If the shoulder symptoms dissipate immediately on return from flexion, however, this would be considered a nonirritable condition. Nature represents the therapist's perception of the possible pathology; the patient's personality and character, pain tolerance, and ethnic or social background; and the familial or genetic components of the disorder.

The stage refers to the progression and stability of the pathology. The therapist may decide that a condition is improving, stable (staying the same), or unstable (deteriorating). The stage can also be expressed in terms of acute, subacute, and chronic, referring to length of time the impairment is present and its presentation. According to Maitland,[2] based on the therapist's assessment of the severity, irritability, nature, area of the symptoms, stage, history, and any special tests (radiography, magnetic resonance imaging, computer tomography), the therapist develops a working hypothesis as to the most probable cause(s) of the patient's complaint(s). Symptom behavior refers to how the symptoms react during certain activities (eg, patients with spinal stenosis frequently have difficulty with prolonged standing).[5,6]

Having determined the SINS from the patient's report of his or her symptoms, the therapist develops a working hypothesis as to the most probable cause of the patient's complaint.[7,8] Continual assessment of the SINS during the examination and treatment is supposed to assist the therapist in modifying the working hypothesis.[2,9]

Once the working hypothesis is formulated and an assessment of the SINS is made, the therapist plans for how vigorously to proceed during the physical examination. The therapist decides whether there should be any limitations or precautions taken during the examination. For example, if the therapist considers the symptoms to be severe or irritable or considers the condition to be unstable, the plan would be to limit the examination to a few tests. If the therapist's assessment of the SINS does not indicate limitations, the goal of the examination is to reproduce all of the symptoms. The plan of the examination should be geared toward confirming or disproving the working hypothesis. The therapist should also postulate which components of the problem he or she will treat: pain, stiffness, sensory changes, involuntary muscle activity (as opposed to muscular guarding), weakness, incoordination, or a combination of these components.[2,9]

The examination has two major purposes: (1) to determine the structures responsible for symptoms and (2) to determine which physical factors lead to the predisposition of the impairment[2] (ie, short limb, tight iliopsoas muscle, and so on). The components of the examination may include observation of the patient's posture, passive and active movements, soft tissue palpation, passive accessory movements, neurological examination, neural tissue tests, and any special tests that are indicated from the interview.[2,7,9] Passive movements are movements performed on a patient by another person, with no active role from the patient.[2,10,11] These can be classified as either physiological or accessory movements. Physiological movements are those that we believe can be performed by the patient voluntarily.[2,10,11] Passive accessory movements are those movements in a joint that we believe a patient cannot perform actively or in isolation, but that are performed by another person and are necessary for normal movement at that joint.[2,10,11] For example, the head of the humerus needs to glide inferiorly and slightly backward in the glenoid fossa during shoulder flexion.[2] We believe these specific glides cannot be performed actively (in isolation) and are therefore considered accessory movements.

The term "adverse neural tissue tension" (ANTT) is used to describe any abnormal physiological or mechanical responses from the nervous system that are thought to limit movement of neural tissue that should otherwise be free to move or be stretched. These tests are designed to examine the integrity and the mobility of neuronal structures. Examples of ANTT tests are passive straight leg raising (SLR) and the slump test.[2,8] These tests and the rationale for their use will be described in subsequent sections.

Structures that underlie the area of the symptoms and structures that can potentially refer pain to the area of symptoms must be examined and their role as possible sources of the symptoms clarified, according to Maitland.[2] There are specific tests for each joint, which must be examined to determine that the joint does not contribute to the patient's complaint.

The examination should help confirm the therapist's assessment of the SINS made during the interview, as well as the working hypothesis. Thus, the interview and examination are interpreted to form a feasible working hypothesis. New information must be interpreted as it emerges and the working hypothesis modified as necessary.

Maitland[2] argues that analytical assessment is the cornerstone of the treatment. This assessment includes (1) relating the interview and history to the onset of the disorder and how it affects the patient's function, (2) ensuring that all the findings of the examination are compatible with each other and with the patient's impairment, (3) investigating why certain signs and symptoms have improved as a result of the treatment techniques and why others have not, or (4) investigating why the treatment goals have not been achieved.[2]

Case Report

Background

The patient in this case report complained of pain radiating into the lower extremity, a common complaint of patients seeking physical therapy. In theory, leg pain may be caused by irritation or inflammation of a variety of structures such as disks,[12,13] zygapophyseal joints,[14,15] nerve roots,[16-23] sacroiliac joints,[24] and so forth. Differentiating the sources of the symptoms by, in theory, selectively stressing specific tissues or components of the tissue may implicate the structures involved and enables the therapist to better direct treatment. For example, in 1979, Maitland[25] described the slump test, a procedure that is a combination of knee extension, dorsiflexion, slouched sitting, and neck flexion. Maitland postulated that this position stretches the peripheral nerves of the lower extremity and the neural structures of the intervertebral foramen and the spinal canal.

Evidence of adhesion of neural tissues (dura, dural sleeve, and nerve root) in cadaveric studies[17,26] and at the time of surgery[20,21,23,27,28] is well documented, Although there are numerous theories regarding adhesion formation, it is generally accepted that stretching of adhered neural tissues can cause symptoms such as pain, burning, numbness, and tingling.[16-21,23,25,27] Fahrni[21] describes three patients in which surgical releases of nerve root adherence completely abolished symptoms. This finding provides evidence that adherence of neural tissues may produce pain. Based on studying cadavers with artificially induced pathological changes (eg, by corroding the cord's surface or by injecting sodium hydroxide into the cord substance), Breig[29] concluded that adhesions that restrict the mobility of the dura and nerve root may result in a local increase in tension, producing symptoms distal to the adhesion.

Interview Data

The patient we are reporting on was a 50-year-old, married, male Caucasian who was a retired real estate agent. He was referred to physical therapy with a diagnosis of left lumbar nerve root irritation. The patient's recreational activities included playing golf five times a week. Due to the patient's symptoms, he had not been able to play golf during the 3 months before we saw him. The patient complained of an intermittent deep ache in the left buttock, with a deep burning pain just posterior to the greater trochanter. This pain radiated down the lateral aspect of his leg to the knee, with some numbness and tingling in the posterolateral aspect of the calf and across the dorsum of the foot. A body chart with the patient's area of symptoms is shown in Figure 1. The patient believed that all of his symptoms were related. He stated that his symptoms started in his buttocks and radiated down his leg. This information regarding the relationship between the symptoms was used to determine whether we were dealing with one or more problems. Determining the area in which the pain is most severe may provide insight as to the stage of the disorder. Symptoms of acute nerve root irritation are said to be worse in the distal portion of the dermatome.[2,30]

The patient's greatest complaint was the intermittent burning pain in the lateral thigh, which was made worse by walking longer than 10 minutes. After 10 minutes of walking, he started to notice the numbness and tingling, and after approximately 30 minutes, the burning pain forced him to sit. These symptoms were relieved after 10 minutes of sitting. Standing for 15 minutes increased left buttock pain, which was relieved in 5 minutes of sitting. Driving in traffic for 30 minutes increased his burning pain. The pain was much less bothersome on the freeway, and the patient did not complain of difficulty when sitting. Although the patient had no difficulty getting out of bed or a chair, he noticed burning pain in the lateral aspect of his thigh when getting in or out of his car and on initiation of walking. This pain dissipated after the first few steps. This burning pain also appeared after 5 minutes of sustained forward bending with knees straight, a position commonly used for shaving, but dissipated immediately when standing erect.

The patient reported the problem commenced 3 months prior to his initial visit to our clinic while he was swinging a golf club (rotating his upper torso to the left). He felt a snap" in his low back. He continued to play golf, but noticed soreness in the low back radiating into his buttock. Within the week, the patient started chiropractic treatments, which consisted of general rotational lumbar manipulations to the left and ultrasound to the low back, four times a week for 2 weeks. The low back pain was relieved, but the leg pain gradually worsened. One week later, the patient saw a physician/acupuncturist for acupuncture treatments. The patient received 12 treatments within 1 month and felt there was minimal change in the symptoms. His symptoms had not changed the month prior to our initial evaluation. The patient had a previous episode with a similar problem in the right lower extremity 3 years previous to this episode that was relieved after he visited an acupuncturist for 3 treatments.

Based on the interview, we hypothesized that the patient's symptoms were moderately severe (he had to stop after 30 minutes of walking and was unable to play golf due to his symptoms) and that the condition was nonirritable (pain dissipated within 10 minutes after walking for 30 minutes). The stage appeared to be chronic and stable because the pain was the same as during the past month. The nature of the problem was more difficult to discern. The pain was in a dermatomal pattern. The patient's difficulty getting out of a car (requiring neck flexion) and his pain while driving (using the clutch involves extending the left leg) suggested to us the pain was caused in a position similar to a slump position. Pain during the first few steps of walking may also have indicated ANTT. Theoretically, if the neural tissues are being stretched, they may loosen sufficiently after the first few steps to be asymptomatic on subsequent steps. As seen with this patient, however, we believe continued ambulation tended to exacerbate the symptoms by repeatedly stretching the involved tissues. In our view, the probability of other structures (ie, disk, sacroiliac joint) causing the symptoms appeared less realistic.

The behavior of the symptoms did not seem to indicate a disk herniation or derangement pattern, according to McKenzie's classification criteria.[13] Patients' symptoms with disk herniations are usually said to be worse with flexion activities (eg, sitting) and better with extension activities (eg, walking).[13] This patient reported the opposite. The sacroiliac joint region did not appear to be a source of pain because the symptoms were in a dermatomal distribution and rising to standing and crossing legs did not increase the symptoms.[31] The patient's history,[15] difficulty with extension activities,[14] and pain referral might have suggested a zygapophyseal or facet impingement.[15] The symptom behavior and the dermatomal distribution of symptoms, however, seemed to be more indicative of a nerve root irritation with ANTT. The local symptoms appeared to be from a dysfunction (adaptively shortened tissues)[13] rather than an impingement. Therefore, our working hypothesis was a chronic L-5 nerve root irritation with ANTT and possible extension dysfunction (loss of extension due to adaptively shortened tissues). Symptoms that contributed to the initial working hypothesis after the interview are summarized in Table 1.

[TABULAR DATA 1 OMITTED]

Physical Examination Data

The goals of the physical examination were to find a comparable sign for each of the patient's complaints and to confirm or disprove our working hypothesis. A comparable sign is any reproduction of the patient's complaints by active or passive movement or any demonstration of an abnormality in a structure that is capable of reproducing the patient's complaints (eg, lumbar flexion increases the symptoms or limitation of ipsilateral SLR due to tightness). Our assessment of the SINS indicated no reason to limit the examination. The plan included a neurological examination and examination of the lumbar spine, sacroiliac joint, ankle, hip, knee, and muscles under the area of symptoms, because they were possible sources of the symptoms. We postulated the physical examination might have to be quite vigorous to reproduce all of the symptoms, because the patient needed to do a significant amount of activity before all of his symptoms were reproduced.

The patient was asked to stand with both of his feet together and his knees straight so there would be a consistent and reproducible starting position for the active movement tests. The resting symptoms were reassessed. The patient performed a series of active movement tests while maintaining his knees straight and reporting any change in symptoms. Measurements were performed through visual inspection, except for lumbar flexion, which was measured fingertips to floor to the nearest inch. Straight leg raising and knee extension during the slump test were measured with a goniometer.

In our opinion, the patient demonstrated a slight decrease in his lordotic lumbar curve in standing when viewed from the front, back, and side. Lumbar flexion with fingertips approximately 15 cm (6 in) from the floor increased the burning pain in the patient's left lateral thigh. The symptoms increased with overpressure. Over-pressure is slight oscillatory movement at the end of active range of motion (ROM) to detect end-feel and joint ROM and/or to reproduce Symptoms.[2] Lumbar extension was observed to be approximately 10 degrees, with little movement at the low lumbar segments. This information was gathered by observing where the movement occurred; there was a smooth curve above L-3, with a crease or "hinge" at the L3-4 interspace and minimal movement below. Over-pressure into extension reproduced the left buttock pain. In left side bending, the patient was able to reach with his fingertips to the tibia-fibula joint line. In right side bending, he was able to reach 5.08 cm (2 in) above the tibia-femoral joint line. In the latter case, there was a slight reproduction of the left burning sensation with the addition of over-pressure.

Lumbar rotations were equal on both sides and painless with over-pressure. The patient was asked to move into lumbar quadrant positions (combined movements of extension, lateral flexion, and rotation to the same side) bilaterally in an effort to determine whether they reproduced the numbness in the calf and foot. By visual inspection, the left lumbar quadrant position was limited approximately 20% compared with the right lumbar quadrant position. When the patient was in the left lumbar quadrant position, there was increased left leg pain. The neurological examination consisted of deep tendon reflexes (gastrocnemius, quadriceps femoris muscles), manual muscle testing (abdominal, gastrocnemius, illiopsoas, quadriceps femoris, tibialis anterior, extensor hallucis longus, extensor digitorum brevis, peroneal, flexor digitorum brevis, hamstring, and gluteal muscles), and sensation (to pinwheel) in both lower extremities. Manual muscle test grades, reflexes, and sensation were symmetrical, but there was mild bilateral weakness in the abdominal, gluteal, and quadriceps femoris muscles. Passive neck flexion, prone knee bending, and sacroiliac compression/distraction tests demonstrated full ROM and were all pain-free. Passive hip flexion, medial (internal) rotation, and a combined movement of flexion-adduction under compression; passive knee flexion, extension, and combined movements of extension-adduction and extension-abduction; and passive ankle plantar flexion and dorsiflexion all appeared to demonstrate full ROM and were painless with over-pressure. Reliability of these measurements has not been established.

Right SLR, measured with a standard goniometer, was limited to 85 degrees because the patient complained of hamstring muscle tightness. Reliability of the goniometric measure was not established. Adding neck flexion and dorsiflexion increased the complaints of tightness in the right calf Left SLR reproduced the burning pain in the lateral thigh at 65 degrees. Adding neck flexion and dorsiflexion increased the burning sensation. We believe that lumbar palpation revealed soft tissue thickening. The patient reported tenderness to the left of the fourth and fifth lumbar vertebrae. Left unilateral posteroanterior (PA) pressure at L-5 reproduced the left buttock pain, Unilateral PA pressures or mobilization was performed by the therapist placing his thumbs over the area of the L5-S1 facet with his shoulders above his hands in order to produce an oscillatory movement.[2]

The slump test procedure is designed to examine the mobility of the neural tissues by incorporating the movements of spinal flexion, neck flexion, knee extension, and dorsiflexion. It is a sequential test requiring assessment of the signs and symptoms when adding or deleting components (measurements) and is performed as follows:

1. The subject sits up straight with arms behind back, legs together, and the posterior aspect of the knees against the edge of the couch.

2. The subject slumps as far as possible, producing full trunk flexion; the examiner applied firm overpressure to bow the subject's back, being careful to keep the sacrum vertical.

3. The subject is asked to flex his or her head, and over-pressure is then added to the neck flexion.

4. While maintaining full spinal and neck flexion with over-pressure, the examiner asks the subject to extend the knee.

5. Dorsiflexion is then added to knee extension. The slump position with the components of neck flexion and dorsiflexion is shown in Figure 2.

6. Neck flexion is then released, and the subject is asked to further extend the knee. The effect of releasing the neck flexion component (decreasing tension on the neural tissues) on the knee extension component is shown in Figure 3.

7. Dorsiflexion and knee extension are released, and neck flexion is resumed. The subject is then asked to perform steps 4 through 6 with the other leg.

In this patient, the slump test reproduced the burning pain and numbness that radiated into the foot at 20 degrees from full left knee extension. Neck extension decreased the sensation of burning pain and numbness and enabled the patient to extend his knee an additional 5 degrees. Knee extension on the right side was full and painless in the slump position. Maitland[2] defines a positive response to the slump test as an asymmetrical limitation in movement and/or reproduction of the patient's symptoms. The slump test and SLR test were therefore considered positive. The slump test was attempted during the initial evaluation because we had not found a test that reproduced the patient's numbness and the patient was considered to have a nonirritable and stable condition.

The features of the examination were consistent with the complaints noted in the interview. We believe that standing is an activity that requires sustained extension and walking is an activity that requires repeated extension in the lumbar spine. Active extension with over-pressure and standing for 15 minutes increased the buttock pain. We also considered the slump test position to mimic the position needed to get in and out of a car. Both the slump test position and getting in and out of a car caused the patient's symptoms. In our opinion, the positive SLR and slump tests confirmed that tension on neuronal structures was causing symptoms. Because the patient complained of symptoms in the L-5 dermatome, had positive SLR and slump tests, and experienced reproduction of symptoms with left L-5 unilateral PA pressure, a hypothesis of a L-5 dysfunction and chronic L-5 nerve root irritation was generated. This hypothesis supported our initial working hypothesis from the interview. Signs and symptoms that lead to the confirmation of the working hypothesis after the physical examination are summarized in Table 2.

[TABULAR DATA 2 OMITTED]

Treatment and Results

The treatment objective was to decrease or eliminate all of the patient's symptoms so he could return to playing golf Initial treatment consisted of three 45-second bouts of left L-5 unilateral PA mobilizations, as described by Maitland.[2] We chose this treatment approach because we believe (1) the patient had a local joint dysfunction to which a left L-5 unilateral PA pressure was most comparable, (2) the problem was one of resistance greater than pain because on passive testing the examiner encountered resistance prior to any complaints of symptoms, (3) there were no contraindications to compressing the involved joint surfaces or structures, (4) PA mobilization helps to restore extension, and (5) unilateral problems respond better to unilateral techniques.[2,32] On reassessment after this treatment, the patient's extension was 15 degrees, with more movement at lower lumbar levels (detected through observation). Over-pressure into extension and lumbar quadrant positioning no longer produced any buttock pain or leg symptoms. Flexion, right side bending, SLR, and slump test were unchanged.

The patient returned 3 days later for his second visit. He no longer experienced buttock pain and was able to walk longer (15 minutes) before the burning pain commenced. Active or sustained extension or left lumbar quadrant positioning with overpressure for 10 seconds did not reproduce the buttock or leg symptoms. The leg pain and numbness reported at the initial evaluation persisted. Left L-5 unilateral PA mobilizations (with increasing vigor or pressure) were performed because of the favorable results obtained after the first treatment session. Exercises to strengthen the patient's abdominal, gluteal, and quadriceps femoris muscles were added because, based on manual muscle testing, we thought these muscle groups were weak. These exercises included abdominal crunches, abdominal bicycling, bridging, and squatting. We also instructed the patient in proper body mechanics and posture. The patient left without any change in his signs and symptoms. No other treatment was implemented at this time because we introduced exercise and increased the vigor of the unilateral PA mobilizations. We felt adding more treatments would make it difficult to assess which element was responsible for a change, especially if the patient's condition worsened.

During the third visit, 3 days after the second visit, the patient's signs and symptoms were the same as during the second visit. Left L-5 unilateral PA mobilizations were again used, without any change in the patient's flexion, right side bending, SLR, or slump test. Because the PA mobilizations were not changing the flexion, side bending away (right side bending), or ANTT components, we felt the need to implement a new treatment. Three bouts of general lumbar rotational mobilizations to the left were added to the unilateral PA mobilizations.

Lumbar rotation is a technique that is supposed to gap or open the ipsilateral apophyseal joints (eg, left rotation gaps the left apophyseal joints). This technique can therefore theoretically stretch the structures surrounding or within the foramina of the apophyseal joint. The technique is performed by first positioning the patient on his or her right side. The right lower extremity is then fully extended, with the patient's toes over the tabletop, and the left lower extremity is flexed at the hip and knee so the medial femoral condyle is over the edge of the table to allow for the rotation. The therapist grasps the proximal humerus of the patient's right arm from the front and gently pulls until full rotation of the lumbar spine occurs. The therapist then stands behind the patient with the right hand on the patient's left shoulder and the left hand on the patient's ilium. The rotational force is applied by therapist's left hand, with the right hand acting only as a stabilizer (Fig. 4). The patient's lumbar flexion increased 7.6 cm (3 in) after the third treatment session (based on fingertip-to-floor measurement), but no change was noted in right side bending, SLR, or slump test.

During the fourth visit, 3 days after the third visit, the patient reported a decrease in the intensity of the burning pain in his lateral thigh but felt the frequency of occurrence of the pain was the same. There was no change in the numbness and tingling. The same treatment as that performed on the third visit was performed with increased vigor, but there were no changes in the signs and symptoms. Reassessment of the soft tissues led us to conclude that there was no tenderness or thickening to the left of L-4 and L-5. Left L-5 unilateral PA pressures had a normal feel compared with the right side, without reproduction of pain. There was no change in the ANTT.

Once the normal movement at the left L-5 apophyseal joint had been restored with little change in the patient's complaints, we hypothesized the ANTT was the primary source of the remaining symptoms and needed attention. Three bouts of SLR in approximately 10 degrees of abduction with the components of neck flexion and dorsiflexion were performed for a duration of 1 minute each. The SLR procedure was performed by positioning the patient's neck in flexion on a pillow and passively raising his leg in 10 degrees of abduction and dorsiflexion until resistance was felt. No pain was felt with this procedure, only a stretch in the hamstring muscles. Reassessment after this technique showed no changes in right side bending, SLR, or slump test. A hold-relax SLR procedure in the sagittal plane at 70 degrees in combination with neck flexion and dorsiflexion was performed for 30 seconds.[33] The patient complained of burning pain during the technique. Reassessment after the hold-relax SLR revealed the patient could touch his fingertips to the floor in flexion before the onset of the burning pain. The patient's SLR was 75 degrees. The patient was warned about possible exacerbation of symptoms or soreness anywhere along the path or stretch.

During this treatment session, we chose to start stretching the ANTT in a pain-free ROM. It has been suggested that stretch occur and be stopped before the onset of pain to avoid any latent responses.[34] A latent response is an increase in symptoms after the technique is stopped or after there is movement from a position. The time it takes for the symptoms to increase can vary from a few seconds to hours. We believe avoiding a latent response may be accomplished by stretching the hamstring muscles in a position "out of tension." For example, stretching the SLR in some degree of abduction will, in theory, decrease the tension on the lumbosacral nerve roots.[17] Because there was no change in flexion, right side bending, SLR, or slump test and the condition was nonirritable, we decided to progress treatment in a "tension" position, which reproduced the patient's symptoms. We felt we could relax the hamstring muscles sufficiently through a hold-relax technique to gain increased ROM to the point at which symptoms would be reproduced. We have often found that tight hamstring muscles appear to be used reflexively to protect tight neural structures. In our experience, stretching these structures too vigorously at first can produce some deleterious results. Because of our experience, we felt comfortable enough to go from treating the ANTT in a painless position to a painful position without 24-hour reassessment.

We believed that it was safe to reproduce this patient's symptoms because (1) the condition was stable, (2) there were no unstable neurological signs such as signs of nerve compression or fluctuating or recent neurological signs (eg, strength, reflexes, or sensation changes), (3) the radiating symptoms were minor, (4) no sustained or combined examination movements would reproduce his peripheral symptoms, (5) movements during the ANTT were restricted by stiffness rather than pain, and (6) he exhibited no lateral shift.[2]

During the fifth visit, 4 days later, the patient reported that soreness in the buttocks was increased for 1 hour after treatment, but that the burning pain decreased. Flexion (fingertips to floor) with over-pressure and SLR at 75 degrees of neck flexion and dorsiflexion reproduced minimal burning pain. No change was detected in the slump test; however, right side bending was full and painless with overpressure. The patient was treated as he was during the previous visit, but with three bouts of the SLR at 75 degrees with the components of neck flexion and dorsiflexion for 45 seconds. The patient was also instructed in a home SLR stretching program. He was told to raise his leg as far as possible with his knee slightly bent while holding a towel around the bottom of his foot to hold the dorsiflexion component and then to actively extend his knee. Our objective was to reproduce at least some of his symptoms, but only if they dissipated immediately on release of the stretch and did not provoke soreness later. He was asked to hold each stretch for 20 seconds and perform the stretch only two times the first day to ensure the exercises were not a detriment to his condition. He was then asked to slowly increase the frequency and duration of the exercise to five times a day for 2 to 3 minutes. He was instructed to start the exercise the next day so the response to that day's treatment could be more accurately assessed.

The patient returned 5 days later for the sixth visit and stated he was no longer experiencing any burning pain. He still, however, experienced occasional numbness in his foot and calf after long periods of walking (greater than 30 minutes). His active movements were all full and painless to over-pressure. His SLR was 85 degrees and appeared to be limited only by hamstring muscle tightness. The only test that could reproduce the numbness was the slump test with full neck flexion and 5 degrees from full left knee extension with dorsiflexion. The patient held this position for 30 seconds as a treatment technique. The patient complained of an almost intolerable numbness during the procedure, which resolved on release of the slump position.

Because performing the SLR while the patient experienced burning pain produced favorable results without any deleterious effects, we felt it relatively safe and necessary to reproduce the patient's numbness to change this symptom. We believe that it was necessary to reproduce the symptoms when using the slump test, but that the symptoms should stop when the tension position is released. A normal response is pain in the T-9 region with neck flexion and pain behind the knee with knee extension and dorsiflexion.[8] In this patient, repeated flexion in standing followed by extension in standing without any decrease in the patient's movement or increase in symptoms indicated his condition was stable enough to be treated using the slump test.

We believe that although going from SLR to slump test techniques is a logical progression from a gentler to a more vigorous technique, caution still must be exercised when using the slump test. Because the slump test is vigorous, we feel it has certain contraindications. Caution is required when treating elderly patients and those with nerve root irritations, unstable diskogenic conditions, or circulatory disturbances, as well as when symptoms do not subside quickly.[8] A direct contraindication is when the neurological signs worsen or when the test produces any signs and symptoms suggestive of cauda equina compression or cord involvement,[8] dizziness, or headache (unless using the slump test for the treatment of headaches).[35]

When the patient returned 5 days later for the seventh visit, he complained of increased soreness, compared with before the treatment, for 1 hour in the left leg and of a residual ache in the leg for 1 day after the prior treatment. He had only experienced numbness on two instances since the treatment (both while walking greater than 30 minutes).

Retesting with use of the slump test led to a report of numbness if the component of slight hip flexion was added to full neck flexion, knee extension, and dorsiflexion. The position for the slump test with the above-mentioned components was held for 1 minute as a treatment. This position replicated the patient's symptoms, but they stopped when the patient moved out of the position.

The patient returned 2 weeks later and reported 1 day of increased soreness after the last treatment, but he also reported that he had played 18 holes of golf five times since the last treatment, without symptoms. The patient was discharged from treatment because he no longer experienced any symptoms, presented no signs, and stated he was not limited functionally.

Discussion/Treatment Rationale

This case study was presented to show the progression of a manual therapy technique that is widely used in Australia for patients with chronic lumbar nerve root irritations. One of the major elements of this approach to evaluation is the importance of the examination, as seen in this patient case.

With the exception of flexion, SLR, and the slump test, the measurements were obtained by visual inspection. Flexion was determined with the use of a tape measure (fingertips to floor) and measured to the closest inch. A standard goniometer was used to measure the angle of SLR and the knee extension component of the slump test. Care was taken to begin each test or measurement at the same starting position. For example, active lumbar movements were tested with the knees straight and the feet together; SLR was tested without a pillow and with the leg was raised in as close to the sagittal plane as could be determined by visual inspection.

The process of proving the value of each technique is essential in the approach we used.2,8 Treatment must be based on the patient's clinical presentation (signs, symptoms, and history) rather than the diagnosis or hypothesis. As evidenced in the case study, there is consistent reassessment of the signs after each technique is applied. This not only indicates the value of each technique but also confirms or disproves the working hypothesis. By obtaining a comparable sign for each working hypothesis, we were able to show the relationships between the hypotheses and progression of treatment. For example, the unilateral PA mobilizations seemed to eliminate the extension dysfunction but did not improve the flexion or ANTT component (objective signs related to the ANTT tests [ie, SLR, slump]). The rotational mobilizations seemed to improve the flexion but did little to change the ANTT component. At this stage, our hypotheses were reranked. The ANTT component was identified as the primary cause of the symptoms. Assessments need to be continually made after the interview and the physical examination, during the treatments, at the beginning and end of each treatment session, and at the time of discharge.[2] Treatment, reassessment of signs, and reranking of the working hypothesis are summarized in Table 3.

[TABULAR DATA 3 OMITTED]

In this case study, unilateral PA and rotational mobilizations were chosen first because Maitland[2,25] feels it is safest and more effective to treat the joints before attempting to treat the ANTT component. The ANTT component (passive neck flexion, prone knee bending, SLR, and slump test) should be treated when restoration of normal passive movement at the joint produces little or no change in the ANTT signs.[2,35]

When palpation signs at the L-5 apophyseal joint were equal to the other side with little change in the patient's complaints, we hypothesized the ANTT component was the primary source of the remaining symptoms and needed attention. Though the slump technique is generally more effective in treating the ANTT component, SLR was implemented first because of the logical progression from a gentle to a more vigorous technique.[2] The concept of a gentle to vigorous progression permeates the approach we used.[2,8] When SLR was no longer producing any change in the patient's signs and symptoms, the slump test was initiated. After a few treatments of slump test, the patient's symptoms cleared, thus providing evidence that the ANTT component may be the probable cause of the patient's symptoms.

The idea of reproducing the symptoms with treatment may make some clinicians apprehensive. If symptoms are reproduced under the right circumstances, however, we believe this approach not only will be safe, but also may hasten the patient's recovery, Maitland[2] believes that stressing tissues in a controlled manner during the appropriate stage may help the remodeling of those tissues in much the same way that bone remodels in response to the mechanical demands placed on it. Maitland[2] feels it is safe to reproduce the referred symptoms if the following criteria are met: (1) The history is in a safe and stable phase (eg, no deterioration or recent fluctuation of the patient's condition), (2) behavior of the symptoms shows the present stage is stable, (3) no fluctuating or unstable neurological signs are observed, (4) referred pain is only minor and does not restrict activity, (5) only movement tests with firm over-pressure or tests that are sustained reproduce the referred symptoms, (6) ANTT tests are restricted by stiffness and not pain, and (7) protective-type deformities when corrected do not cause any referred symptoms.

Reproducing the symptoms with treatment of the ANTT component must be done cautiously. It is safest to start in a painless manner.[34] This is due to the possibility of latent symptoms associated with overstretching neural tissue.8 We have found that treating the most provocative movement "out of tension" seems to hasten the recovery without the risks of worsening the patient's condition. The most provocative movement is the movement that most readily reproduces the patient's complaint. For example, if the dorsiflexion component of SLR increases the symptoms more than the other components (most provocative) of the SLR, it would be best to start with mobilizing dorsiflexion "out of tension." This can be accomplished by moving the SLR with dorsiflexion to the point of symptom reproduction, then altering the other components--lateral flexion of trunk and/or neck toward the side of SLR, abduction,[36] lateral (external) rotation,[17] and knee flexion--to decrease the tension in the neural tissues and relieve the symptoms while still producing a stretch in the muscles. By changing from a position of known increased tension to a position that decreases the tension, you are moving "out of tension." You progress by changing the other components to a position of increased tension on the neural structures as the signs and symptoms dictate.[8]

Conclusions

Pain in the lower extremities can be referred from a variety of sources. This case study demonstrated a manual therapy approach in a patient with a chronic lumbar nerve root irritation. The basic principles of this approach and the theoretical basis of ANTT were discussed and implemented in the case study. The process of continual assessment was utilized throughout the case study to confirm a working hypothesis and to assist in clinical reasoning. This detailed form of assessment, by systematically reproducing the patient's symptoms during treatment, allowed for safe and effective treatment progression.

The use of ANTT as a treatment technique appeared to contribute to alleviating the patient's symptoms and allowing him to return to his recreational activities. Therefore, we believe the mobility of these neural tissues should be examined in patients whose low back pain is of possible ANTT origin.

Acknowledgments

We thank Carol Jo Tichenor, PT, for her support and assistance in editing this case report. We also acknowledge Maggie Fillmore, PT, for her suggestions,

References

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MJ Koury, Pr, is Clinical Faculty, Kaiser-Hayward Physical Therapy Residency Program in Advanced Orthopedic Manual Therapy, Kaiser Permanente Medical Center, 27400 Hesperian Blvd, Hayward, CA 94541, and Private Practitioner, Redwood Orthopaedic Physical Therapy Inc, 20211 Patio Dr, Ste 205, Castro Valley, CA 94546 (USA). Address all correspondence to Mr Koury.

E Scarpelli, PT, OCS, is Senior Clinical Faculty, Kaiser-Hayward Physical Therapy Residency Progra in Advanced Orthopedic Manual Therapy, and Private Practitioner, Scarpelli and Kakahashi Physical Therapy, 4200 18th St, Ste 102, San Francisco, CA 94114.