1994; 74:548-560.PHYS THER. Michael J Koury and Elizabeth ScarpelliRoot IrritationTreatment of a Patient With a Chronic Lumbar Nerve A Manual Therapy Approach to Evaluation and

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Case Report

A Manual Therapy Approach to Evaluation and Treatment of a Patient With a Chronic Lumbar Nerve Root Irritation

The purpose of this case report is to familiarize the reader with the basic principles of the approach to manual therapy evaluation and treatment pioneered by Mait- land, an Australian physical therapist. This approach involves a complete subjec- tive examination to detemzine the severity, irritability, nature, and stage of the patient's complaints. In this way, the therapist may reach conclusions as to the amount and vigor of the physical examination and proceed with treatment in an analytical' manner. Methodical reassessment is used to justzh treatment progres- sion. Comprehensive treatment and the rationale for this approach are discussed. Though most physical therapists are familiar with the straight-leg-raising test as a means of assessing low back pain and chronic lumbar nerve root irritation, they are ofien not familiar with other tests that examine neural tissues, such as the slump test. The proposed anatomical and biomechanical bases for these tests are discussed. The patient in this case study was a 5O-year-old man with a physician's diagnosis of a chronic lumbar nerve root irritation. The patient was evaluated and treated in eght visits using techniques designed to evaluate neural tissues. Reassessment indicated signiJicant symptom reduction, and the treatment was modz$ed accordingly. Patient management, including home exercises, is dis- cussed [Koury MJ; Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Phys Ther. I 994; 74:548-560.1

Key Words: Manual therapy, Mobilization, Slump test

Michael J Koury Elizabeth Scarpelll

An Australian approach to manual Maitland2 uses the term "subjective itself, o r extraneous characteristics of therapy, pioneered by Maitland,' pro- examination" to represent the thera- the patient. Maitland's use of the term vides a framework for evaluation and pist's interpretation of the patient's also differs from how the term is treatment of musculoskeletal disor- perceptions of his o r her symptoms. ders. We used this approach in the Maitland's use of the term differs from evaluation and treatment of a 50-year- that of Jette,3 who states that a subjec- old man with chronic lumbar nerve tive test or measure is one that is root irritation. influenced by the examiner, the test

MJ Koury, F'T, 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.

routinely used in measurement science.4

The data collected from the patient interview assists the therapist in iden- tifylng the strategies and techniques to be used in the physical examination, which Maitland2 calls the "objective examination." He uses this term dif- ferently than it is commonly defined. The American Physical Therapy Asso-

E Scarpelli, PT, OCS, is Senior Clinical Faculty, Kaiser-Hayward Physical Therapy Residency Pro- ciation's Task Force on Standards for gram in Advanced Orthopedic Manual Therapy, and Private Practitioner, Scarpelli and Kakahashi Physical Therapy, 4200 18th St, Ste 102, San Francisco, CA 94114.

Measurement in Physical Therapy, for example, defines an objective exami-

This article was submitted Februaty 27, 1 9 2 , and was accepced December 21, 1993.

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rzation as an examination used to obtain measurements that are not affected by some aspect of the person obtaining the measurements."p595)

A key concept in the Maitland evalua- tion strategy is SINS? an acronym for "severity, irritability, nature, and stage" that is used to determine the vigor and extent of the physical exam- ination and treatment. Severit?, refers to the intensity of the patient's symp- toms 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 pa- tient, the symptoms are generally considered severe (eg, a patient has stopped using his or her arm for dressing or is unable to find a com- fortable sleeping position due to the intensity of the symptoms). Irritabilit~, refers to the relationship among the amount of activity required to pro- voke a patient's symptoms, the magni- tude 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 rais- ing the arm once or twice increases the patient's symptoms and the symp- toms 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 repre- sents the therapist's perception of the possible pathology; the patient's per- sonality and character, pain tolerance, and ethnic or social background; and the familial o r 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: based on the therapist's assessment of the severity, irritability, nature, area of the symptoms, stage, history, and any special tests (radiogra-

phy, 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 behav- ior 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 symp- toms, the therapist develops a work- ing hypothesis as to the most proba- ble cause of the patient's c ~ m p l a i n t . ~ , ~ Continual assessment of the SINS during the examination and treatment is supposed to assist the therapist in modlfylng the worlung hypothesis.2.9

Once the working hypothesis is for- mulated 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 o r precautions taken dur- ing the examination. For example, if the therapist considers the symptoms to be severe or irritable o r considers the condition to be unstable, the plan would be to limit the examination to a few tests. If the therapist's assess- ment of the SINS does not indicate limitations, the goal of the examina- tion is to reproduce all of the symp- toms. The plan of the examination should be geared toward confirming o r disproving the working hypothesis. The therapist should also postulate which components of the problem he o r she will treat: pain, stiffness, sen- sory changes, involuntary muscle activity (as opposed to muscular guarding), weakness, incoordination, or a combination of these cornponents.2.9

The examination has two major pur- poses: (I) to determine the structures responsible for symptoms and (2) to determine which physical factors lead to the predisposition of the impair- ment2 (ie, short limb, tight iliopsoas muscle, and so on). The components of the examination may include ob- servation of the patient's posture, passive and active movements, soft tissue palpation, passive accessory

movements, neurological examina- tion, neural tissue tests, and any spe- cial tests that are indicated from the interview.2.79 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. P@siological movements are those that we believe can be performed by the patient vol- untarily.2J0J1 Passive accesso?y move- ments are those movements in a joint that we believe a patient cannot per- form actively or in isolation, but that are performed by another person and are necessary for normal movement at that j~ in t .~ JOJ~ For example, the head of the humerus needs to glide inferiorly and slightly backward in the glenoid fossa during shoulder flex- ion2 We believe these specific glides cannot be performed actively (in isolation) and are therefore consid- ered accessory movements.

The term "adverse neural tissue ten- sion" (ANTI') 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 o r be stretched. These tests are designed to examine the integrity and the mobility of neuronal structures. Examples of AN'IT tests are passive straight leg raising (SLR) and the slump t e ~ t . ~ , ~ These tests and the rationale for their use will be de- scribed 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 Mait- land.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 inter- preted to form a feasible working

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ntermittent

ntermittent- ~umbness/~ingling

Figure I. ~ o d y chart of patient's vnlptoms

hypothesis. New information must be interpreted as it emerges and the working hypothesis modified as necessary.

Maitland2 argues that analytical assess- ment is the cornerstone of the treat- ment. This assessment includes (1) relating the interview and history to the onset of the disorder and how it affects the patient's function, (2) en- suring that all the findings of the examination are compatible with each other and with the patient's impair- ment, (3) investigating why certain signs and symptoms have improved as a result of the treatment techniques and why others have not, o r (4) inves- tigating why the treatment goals have not beer1 a~hieved .~

Case Report

Background

The patient in this case report com- plained 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,l2%lJ zyg- apophyseal joints,l"l5 nerve roots,lG23 sacroiliac joints,24 and so forth. Differ- entiating 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, Maitland25 described the slump test, a procedure that is a com- bination of knee extension, dorsiflex- ion, slouched sitting, and neck flex- ion. 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 studies17'*6 and at the time of s ~ r g e r y ~ ~ ~ 2 1 ~ * 3 ~ ~ ~ . * 8 is well dwu- mented. Although there are numerous theories regarding adhesion forma- tion, it is generally accepted that stretching of adhered neural tissues can cause symptoms such as pain, burning, numbness, and tin- gling.1~*l~2J~25,27 FahrniZl describes three patients in which surgical re- leases of nerve root adherence com- pletely abolished symptoms. This finding provides evidence that adher- ence 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 hy- droxide into the cord substance), Breig29 concluded that adhesions that restrict the mobility of the dura and nerve root may result in a local in- crease in tension, producing symp- toms 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 recre- ational 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 tro- chanter. 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 symp- toms were related. He stated that his symptoms started in his buttocks and radiated down his leg. This informa- tion regarding the relationship be-

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tween the symptoms was used to determine whether we were dealing with one or more problems. Deter- mining 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 derrnat0me.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 sit- ting. 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 shav- ing, 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 but- tock. Within the week, the patient started chiropractic treatments, which consisted of general rotational lumbar manipulations to the left and ultra- sound to the low back, four times a week for 2 weeks. The low back pain was relieved, but the leg pain gradu- ally worsened. One week later, the patient saw a physician/acupuncturist for acupuncture treatments. The pa- tient received 12 treatments within 1

month and felt there was minimal change in the symptoms. His symp- toms 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 hypothe- sized 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 der- matomal pattern. The patient's diffi- culty getting out of a car (requiring neck flexion) and his pain while driv- ing (using the clutch involves extend- ing 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 AN'IT. 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 contin- ued ambulation tended to exacerbate the symptoms by repeatedly stretch- ing 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 hernia- tions are usually said to be worse with flexion activities (eg, sitting) and better with extension activities (eg, walking).l3 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 sympt0ms.3~ The patient's history,l5 difficulty with extension activities,'* and pain referral might have suggested a zygapophyseal or facet impingement.15 The symptom behavior and the dermatomal distri- bution 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)" 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). Symp- toms that contributed to the initial working hypothesis after the interview are summarized in Table 1.

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 com- plaints by active or passive movement or any demonstration of an abnormal- ity 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 in- cluded 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

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Table 1. sjmptoms That Contribute to Initial Working Hypothesis AJer the Patient Interview

Symptom Working Hypothesls

Symptoms in the L-5 dermatome L-5 chronic nerve root irritation

Symptoms were nonirritable and moderately severe

Stage of the pathology was chronic and stationary

Pain with getting in and out of car (neck flexion component) Adverse neural tissue tension

Worsening of symptoms with the use of his clutch (knee component

extensiorl component)

Pain on the initiation of ambulation that dissipated quickly and returned later

Difficulty with extension activities (ie, walking and standing) Extension dysfunction

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 exten- sion during the slump test were mea- sured with a goniometer.

In our opinion, the patient demon- strated a slight decrease in his lordo- tic lumbar curve in standing when viewed from the front, back, and side. Lumbar flexion with fingertips ap- proximately 15 cm (6 in) from the floor increased the burning pain in the patient's left lateral thigh. The symptoms increased with over- pressure. Over-presrure is slight oscil- latory movement at the end of active range of motion (ROM) to detect end-feel and joint ROM and/or to reproduce symptoms.2 Lumbar exten- sion was observed to be approxi- mately 10 degrees, with little move- ment at the low lumbar segments. This information was gathered by observing where the movement oc- curred; 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 bum- ing 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 flex- ion, and rotation to the same side) bilaterally in an effort to determine whether they reproduced the numb- ness 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 posi- tion, there was increased left leg pain. The neurological examination con- sisted of deep tendon reflexes (gas- trocnemius, quadriceps femoris muscles), manual muscle testing (ab- dominal, gastrocnemius, illiopsoas, quadriceps femoris, tibialis anterior, extensor hallucis longus, extensor digitorum brevis, peroneal, flexor digitorum brevis, hamstring, and glu- teal muscles), and sensation (to pin- wheel) in both lower extremities. Manual muscle test grades, reflexes, and sensation were symmetrical, but there was mild bilateral weakness in the abdominal, gluteal, and quadri- ceps femoris muscles. Passive neck flexion, prone knee bending, and sacroiliac compression/distraction tests demonstrated full ROM and were all pain-free. Passive hip flexion, me- dial (internal) rotation, and a com-

bined 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 de- grees because the patient complained of hamstring muscle tightness. Reli- ability 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 re- vealed soft tissue thickening. The patient reported tenderness to the left of the fourth and fifth lumbar verte- brae. Left unilateral posteroanterior (PA) pressure at L-5 reproduced the left buttock pain. Unilateral PA pres- sures 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 movemen t.2

The slump test procedure is designed to examine the mobility of the neural tissues by incorporating the move- ments 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 (mea- surements) 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 possi- ble, producing full irunk flexion; the examiner applied firm over- pressure to bow the subject's back,

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extension on the right side was full and painless in the slump position.

Flgure 2. Slump position with components of neck flexion and dorsijlexion.

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.

tend the knee. The effect of releas- ing 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.

5. Dorsiflexion is then added to knee In this patient, the slump test repro- extension. The slump position with duced the hurning pain and numb- the components of neck flexion ness that radiated into the foot at 20 and dorsiflexion is shown in degrees from full left knee extension. Figure 2. Neck extension decreased the sensa-

tion of burning pain and numbness 6. Neck flexion is then released, and and enabled the patient to extend his

the subject is asked to further ex- knee an additional 5 degrees. Knee

Maitland2 defines a positive response to the slump test as an asymmetrical limitation in movement and/or repro- duction 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 pa- tient'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 exten- sion in the lumbar spine. Active ex- tension with over-pressure and stand- ing for 15 minutes increased the buttock pain. We also considered the slump test position to mimic the posi- tion 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 con- firmed that tension on neuronal struc- tures was causing symptoms. Because the patient complained of symptoms in the L-5 dermatome, had positive SLR and slump tests, and experienced reproduction bf symptoms with left L-5 unilateral PA pressure, a hypothe- sis of a L-5 dysfunction and chronic L-5 nerve root irritation was gener- ated. This hypothesis supported our initial working hypothesis from the interview. Signs and symptoms that lead to the confirmation of the work- ing hypothesis after the physical ex- amination are summarized in Table 2.

Treatment and Results

The treatment objective was to de- crease o r eliminate all of the patient's symptoms so he could return to play- ing golf. Initial treatment consisted of three 45-second bouts of left L-5 uni- lateral 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

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Figure 3. Efect of releasing neckjexion component (decreasirzg tension on the neural t1ssues.s) on the knee extension comporzent

was most comparable, (2) the prob- the examiner encountered resistance lem was one of resistance greater prior to any complaints of symptoms, than pain because on passive testing (3) there were n o contraindications to - Table 2. Additional Sgns and Symptoms rlfter the Physical Examination That Lead to Confilmation of the Working Hypothesis

Worklng Hypothesis

Reproduction of symptoms with tests that stretch the nerve L-5 chronic nerve root irritation (straight leg raising and slump)

Positive slump and straight leg raising Adverse neural tissue tension

Right side bending increased burning pain component

Extension with over-pressure reproduced buttocks pain Extension dysfunction

L-5 unilaleral posteroanterior increased buttocks pain

compressing the involved joint sur- faces o r structures, (4) PA mobiliza- tion helps to restore extension, and (5) unilateral problems respond bet- ter to unilateral techniques.*-jz 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 o r 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 experi- enced buttock pain and was able to walk longer (15 minutes) before the burning pain commenced. Active o r sustained extension o r left lumbar quadrant positioning with over- pressure for 10 seconds did not re- produce 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 o r pressure) were performed because of the favorable results obtained after the first treat- ment 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, bridg- ing, and squatting. We also instructed the patient in proper body mechanics and posture. The patient left without any change in his signs and symp- toms. No other treatment was imple- mented at this time because we intro- duced exercise and increased the vigor of the unilateral PA mobiliza- tions. 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, with- out any change in the patient's flex-

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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 ANTI was the primary source of the remaining symptoms and needed attention. Three bouts of SLR in ap- proximately 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 posi- tioning 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 mus- cles 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

Flgure 4. Therapist demonstrating lumbar rotation technique. Rotationalforce is upplied b y therapist's left hand, with the right hand acting only as a stabilizer.

ion, right side bending, SLR, or slump test. Because the PA mobilizations were not changing the flexion, side bending away (right side bending), o r A N T I 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 ipsilat- era1 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 ex- tremity is then filly 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 hu- merus 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 rota- tional force is applied by therapist's left hand, with the right hand acting only as a stabilizer (Fig. 4). The pa- tient's lumbar flexion increased 7.6 cm (3 in) after the third treatment session (based on fingertip-to-floor meamrement), but no change was noted in right side bending, SLR, or slump test.

During the fourth visit, 3 days afier the third visit, the patient reported a decrease in the intensity of the burn- ing 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 tender- ness or thickening to the left of L-4 and L-5. Left L-5 unilateral PA pres- sures had a normal feel compared with the right side, without reproduc- tion of pain. There was no change in the AN'IT.

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 ANTI 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, stretch- ing the SLR in some degree of abduc- tion will, in theory, decrease the ten- sion on the lumbosacral nerve roots.'? Because there was no change in flex- ion, right side bending, SLR, or slump test and the condition was nonirrita- ble, we decided to progress treatment in a "tension" position, which repro-

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duced the patient's symptoms. We felt we could relax the hamstring muscles sufficiently through a hold-relax tech- nique 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, stretch- ing these structures too vigorously at first can produce some deleterious results. Because of our experience, we felt comfortable enough to go from treating the A N T in a painless position to a painful position without 24-hour reassessment.

We be1ie:ved that it was safe to repro- duce 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, o r sensa- tion changes), (3) the radiating symp- toms were minor, (4) no sustained or combinr:d examination movements would reproduce his peripheral symptonls, (5) movements during the ANTT were restricted by stiffness rather than pain, and (6) he exhibited no lateral shift2

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 buming pain decreased. Flexion (fingertips to floor) with over-pressure and SLR at 75 degrees of neck flexion and dorsi- flexion reproduced minimal burning pain. No change was detected in the slump test; however, right side bend- ing was full and painless with over- pressure:. 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 sec- onds. The patient was also instructed in a home SLR stretching program. He was told to raise his leg as far as pos- sible with his knee slightly bent while holding a towel around the bottom of his foot to hold the dorsiflexion com- ponent and then to actively extend his knee. Our objective was to reproduce at least some of his symptoms, but only if (hey 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 exer- cises 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 de- grees 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 intol- erable numbness during the proce- dure, which resolved on release of the slump position.

Because performing the SLR while the patient experienced buming pain produced favorable results without any deleterious effects, we felt it rela- tively safe and necessary to reproduce the patient's numbness to change this symptom. We believe that it was nec- essary 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 dorsi- flexion.8 In this patient, repeated flexion in standing followed by exten- sion 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 nenre root irritations, un- stable diskogenic conditions, o r circu- latory disturbances, as well as when symptoms d o not subside quickly." direct contraindication is when the neurological signs worsen or when the test produces any signs and symp- toms suggestive of cauda equina com- pression or cord involvement: dizzi- ness, o r headache (unless using the slump test for the treatment of headaches) .35

When the patient returned 5 days later for the seventh visit, he com- plained of increased soreness, com- pared 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 experi- enced numbness on two instances since the treatment (both while walk- ing 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 ex- tension, and dorsiflexion. The posi- tion for the slump test with the above-mentioned components was held for 1 minute as a treatment. This position replicated the patient's symp- toms, but they stopped when the patient moved out of the position.

The patient returned 2 weeks later and reported 1 day of increased sore- ness 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.

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Dlscusslon/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 to- gether; SLR was tested without a pil- low 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 ~sed.2~8 Treatment must be based on the patient's clinical presentation (signs, symptoms, and history) rather than the diagnosis o r 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 con- firms or disproves the working hy- pothesis. By obtaining a comparable sign for each working hypothesis, we were able to show the relationships between the hypotheses and progres- sion of treatment. For example, the unilateral PA mobilizations seemed to eliminate the extension dysfunction but did not improve the flexion or A N T component (objective signs related to the AN'IT tests [ie, SLR, slump]). The rotational mobilizations seemed to improve the flexion but did little to change the ANT compo- nent. At this stage, our hypotheses were reranked. The A N T component was identified as the primary cause of

the symptoms. Assessments need to be continually made after the inter- view and the physical examination, during the treatments, at the begin- ning and end of each treatment ses- sion, and at the time of discharge.2 Treatment, reassessment of signs, and reranking of the working hypothesis are summarized in Table 3.

In this case study, unilateral PA and rotational mobilizations were chosen first because Maitland2,25 feels it is safest and more effective to treat the joints before attempting to treat the ANT component. The AN'IT compo- nent (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 ANT ~igns.~<35

When palpation signs at the L-5 apo- physeal joint were equal to the other side with little change in the patient's complaints, we hypothesized the AN'IT component was the primary source of the remaining symptoms and needed attention. Though the slump technique is generally more effective in treating the A N T compo- nent, SLR was implemented first be- cause of the logical progression from a gentle to a more vigorous tech- n i q ~ e . ~ The concept of a gentle to vigorous progression permeates the approach we used.2,"en 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 ANT component may be the probable cause of the patient's symptoms.

The idea of reproducing the symp- toms with treatment may make some clinicians apprehensive. If symptoms are reproduced under the right cir- cumstances, however, we believe this approach not only will be safe, but also may hasten the patient's recovery. Maitland2 believes that stressing tis- sues 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. Maitland2 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) AN'IT tests are re- stricted by stiffness and not pain, and (7) protective-type deformities when corrected do not cause any referred symptoms.

Reproducing the symptoms with treat- ment of the ANT 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 recov- ery without the risks of worsening the patient's condition. The most provoca- tive movement is the movement that most readily reproduces the patient's complaint. For example, if the dorsi- flexion 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 ten- sion." 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,3" lateral (external) rotation,'' 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 struc- tures as the signs and symptoms dictate.8

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Table 3. Summaq of Treatment

Flndlngs Treatment

~ -

Reassessment Worklng Hypothesls

Initial evaluation (day 1)

Extension with over-pressure increased buttocks pain

Lefl lumbar quadrant test increased thigh pain

Right side bending with over-pressure reproduced thigh burning

Flexion - 15 cm (-6 in) from fingertips to floor reproduced leg pain

Straight lug raising (SLR) to 65" reproduced burning pain

Slump test at - 15" of knee extension reproduced numbness and tingling

Day 2

Flexion -15 cm from fingert~ps to floor iqcreased leg pain

SLR to 65" reproduced burning pain

Slump test at - 15" of knee extension reproduced numbness and tingling

Extensior and quadrant tests were full range of motion (ROM) and painless to over-pressure

Day 3

Flexion -15 cm from fingertips to floor increased leg pain

SLR to 65" reproduced burning pain

Slump test of -15" of knee extension reproduced numbness and tingling

Right side bending with over-pressure reproduced thigh burning

Day 4

Flexion -7.6 cm from fingertips to floor increased leg pain

SLR to 65" reproduced burning pain

Slump test at -15" of knee extension reproduced numbness and tingling

Day 5

Flexion full, but with over-pressure increased leg symptoms

Left L-5 unilateral posteroanterior Extension with over-pressure Extension dysfunction (PA) mobilizations (three normal bouts)

Lefl lumbar quadrant test L-5 chronic nerve root irritation increased ROM

Flexion, right side bending, SLR, Adverse neural tissue tension test and slump unchanged (ANT) component

Left L-5 unilateral PA No change in remaining mobilizations (three bouts) with comparable signs increased vigor

Exercise program for abdominal, gluteal, and quadriceps femoris muscles

L-5 chronic nerve root irritation

A N T component

Lefl L-5 unilateral PA 7.6-cm (3-in) increase in flexion L-5 chronic nerve root irritation mobilizations (three bouts)

Three general lumbar rotations to No change noted in right side A N T component the lefl bending, SLR, or slump

Lefl L-5 unilateral PA Fingertips to floor increased leg L-5 chronic nerve root irritation mobilizations (three bouts) pain

Three general lumbar rotations to SLR to 75" increased leg A N T component the left symptoms

Hold-relax SLR Slump test increased numbness and tingling at -10" of knee extension

Three bouts of left L-5 unilateral All active movements and SLR A N T component PA mobilizations were full ROM and painless to

over-pressure (continued)

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- Table 3. Continued

Findings Treatment Reassessment Working Hypothesis

Day 5

SLR to 75" with neck flexion (NF) and dorsiflexion (DF) components increased burning sensation

Slump test at - 10" of knee extension reproduced numbness and tingling

Right side bending was full ROM and painless to over-pressure

Day 6

Slump test at -5" of knee extension reproduced numbness and tingling

All other tests negative

Day 7

Three general lumbar rotations to Slump test at -5" of knee L-5 chronic nerve root irritation the left extension reproduced

numbness and tingling

Three bouts (45 s) of SLR at 75"

Slump test with the components Slump reproduced numbness A N T component of NF and DF at -5" of knee and tingling with the extension components of NF and DF

L-5 chronic nerve root irritation

Slump test with components of Slump test with the components Slump test normal stretch Resolving nerve root NF, DF, and hip flexion of NF, DF, and hip flexion reproduced numbness and tingling

Minimal A N T component

Day 8

No objective signs noted Reviewed home exercise No physical signs Discharged to home exercise program, no longer experienced any symptoms or physical slgns and was not limited functionally

Conclusions

Pain in the lower extremities can be referred from a variety of sources. This case study demonstrated a man- ual therapy approach in a patient with a chronic lumbar nerve root irritation. The basic principles of this approach and the theoretical basis of ANTr were discussed and implemented in the case study. The process of contin- ual assessment was utilized through- out the case study to confirm a work- ing hypothesis and to assist in clinical reasoning. This detailed form of as- sessment, by systematically reproduc- ing the patient's symptoms during treatment, allowed for safe and effec- tive treatment progression.

The use of ANIT as a treatment tech- nique appeared to contribute to alle- viating the patient's symptoms and allowing him to return to his recre-

ational activities. Therefore, we be- lieve the mobility of these neural tissues should be examined in pa- tients whose low back pain is of pos- sible ANIT origin.

Acknowledgments

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

References

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1994; 74:548-560.PHYS THER. Michael J Koury and Elizabeth ScarpelliRoot IrritationTreatment of a Patient With a Chronic Lumbar Nerve A Manual Therapy Approach to Evaluation and

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