1. An increase in tension can be produced in the interneural component, where tension is being applied from both ends, so to speak, as in the ‘slump’ test.
2. Increased tension can be produced in the extraneural component, which then produces the maximum movement of the nerve in relation to its mechanical interface (such as in SLR) with the likelihood of restrictions showing up at ‘tension points’.
3. Movement of extraneural tissuesin another plane can be engineered.
Before beginning the exercises below, look at Box 7.1, which gives some general precautions and contraindications for their use.
Box 7.1 General precautions and contraindications for Exercises 7.1–7.5
1. Take care of the spine during the ‘slump test’ if disc problems are involved or if the neck is sensitive (or the patient is prone to dizziness).
2. Take care not to be excessive in side-bending of the neck during ULTT.
3. If any area is sensitive, take care not to aggravate existing conditions during performance of tests (arm is more likely than leg to be ‘stirred up’).
4. If obvious neurological problems exist, take special care not to exacerbate by vigorous or strong stretching.
5. Similar precautions apply to diabetic, MS or recent surgical patients or where the area being tested is much affected by circulatory deficit.
6. Do not use the tests if there has been recent onset or worsening of neurological signs or if there is any cauda equina or
cord lesion.
EXERCISE 7.1: STRAIGHT LEG RAISING (SLR) TEST
Time suggested: 3–4 minutes for each ‘sensitising’ addition
It is suggested that this test should be used in all vertebral disorders, all lower limb disorders and some upper limb disorders to establish the possibility of AMT in the nervous system in the lower back or lower limb.
See the text relating to hamstring test (for shortness) in Chapter 5 (Exercise 5.17A) and its accompanying figure (5.25).
The leg is raised in the sagittal plane, with the knee extended, until a barrier or resistance is noted or symptoms are reported.
Sensitising additions might include:
ankle dorsiflexion (this stresses the tibial component of the sciatic nerve)
ankle plantarflexion plus inversion (this stresses the common peroneal nerve, which may be useful with anterior shin and dorsal foot symptoms)
passive neck flexion
increased medial hip rotation increased hip adduction
altered spinal position (the example is given of left SLR being ‘sensitised’ by lateral flexion to the right of the spine).
Perform the SLR test and incorporate each sensitising addition, in order to assess changes in symptoms, new symptoms, restrictions, etc.
Can the leg be raised as far as it should normally go (approximately 80°), and as easily, without force and without symptoms (new or old) appearing when the sensitising additions are incorporated?
Notes on SLR test
On SLR there is caudad movement of the lumbosacral nerve roots in relation to interfacing tissue (which is why there is a
‘positive’ indication – pain and limitation of leg-raising potential – from SLR if a prolapsed intervertebral disc exists).
Less well known is the fact that the tibial nerve, proximal to the knee, moves cuadad (in relation to the mechanical interface) during SLR, whereas distal to the knee it moves cranially. There is no movement of the tibial nerve behind the knee itself, which is therefore known as a ‘tension point’.
The common peroneal nerve is attached firmly to the head of the fibula (another ‘tension point’).
EXERCISE 7.2: PRONE KNEE BEND (PKB) TEST
Time suggested: 3–4 minutes for each ‘sensitising’ addition in each position (1 and 2) Method 1
Your palpation partner should be prone. You flex the knee, taking the heel towards the buttock, in order to assess reproduction of existing symptoms or other abnormal symptoms or altered range of movement (heel should approximate buttock easily).
During the test the knee is flexed while the hip and thigh are stabilised and this moves the nerves and roots from L2, 3, 4 and, particularly, the femoral nerve and its branches.
Method 2
If, however, the test is conducted with the person side-lying, the hip should be maintained in extension during the test (this alternative position is thought more appropriate for identifying entrapped lateral femoral cutaneous nerve problems).
The PKB test stretches rectus femoris and rotates the pelvis anteriorly, thus extending the lumbar spine, which can confuse interpretation of nerve impingement symptoms.
Reliance on sensitising manoeuvres helps with such interpretation. These include (in either prone or side-lying use of the test)
the addition of:
cervical flexion
adopting the ‘slump’ position (Exercise 7.3) – but only in the side-lying variation of the test variations of hip abduction, adduction, rotation.
Can the knee easily be fully flexed, without force and without symptoms (new or old) appearing, when the sensitising additions are incorporated?
EXERCISE 7.3: THE 'SLUMP TEST'
Time suggested: 3–4 minutes for each ‘sensitising’ addition
This is regarded by Butler as the most important test in this series. It links neural and connective tissue components from the pons to the feet and requires care in performance and interpretation (see Fig. 7.1).
This test is suggested for use in all spinal disorders, most lower limb disorders and some upper limb disorders (especially those which seem to involve the nervous system).
The test involves your palpation partner introducing the following sequence of movements.
Thoracic and then lumbar flexion, followed by Cervical flexion
Knee extension Ankle dorsiflexion
Sometimes also with hip flexion (produced by either bringing the trunk forwards on the hips or by increasing SLR) Sensitising manoeuvres during ‘slump testing’ are achieved as a rule by changes in the terminal positions of joints. Butler gives examples:
Should the ‘slump position’ reproduce (for example) lumbar and radiating thigh pain, a change in head position – say away from full neck flexion – could result in total relief of these symptoms.
A change in ankle and knee positions could significantly change cervical, thoracic or head pain.
In both instances this would confirm that AMT was operating, although the site would remain obscure.
Additional sensitising movements, with the person in the slump position, might involve the addition of trunk side-bending and rotation or even extension, hip adduction, abduction or rotation and varying neck positions.
The ‘slump test’ involves tensionon the nervous system rather than motion.
Notes on ‘slump’ position
Cadaver studies demonstrate that neuromeningeal movement occurs in various directions, with C6, T6 and L4 intervertebral levels being regions of constant state (i.e. no movement, therefore ‘tension points’).
Butler reports that many restrictions, identified during the ‘slump’ test, may only be corrected by appropriate spinal manipulation and that SLR is more likely to pick up neural tension in the lumbosacral region.
Fig 7.1 The slump test position stretches the entire neural network from pons to feet. Note the direction of stretch of the dura mater and nerve roots. As the leg straightens, the movement of the tibial nerve in relation to the tibia and femur is indicated by
arrows. No neural movement occurs behind the knees or at levels C6, T6 or L4 (these are 'tension' points).
It is possible for SLR to be positive (e.g. symptoms are reproduced) and ‘slump’ negative (no symptom reproduction) and vice versa, so both tests should always be performed.
The following findings have been reported in research using the ‘slump test’.
1. Mid-thoracic to T9 are painful on trunk and neck flexion in 50% of ‘normal’ individuals.
2. The following are considered normal if they are symmetrical:
hamstring and posterior knee pain, occurring with trunk and neck flexion, when the knees are extended and increasing with ankle dorsiflexion
restrictions in ankle dorsiflexion during trunk/neck flexion, while the knee is in extension
there is a common decrease in pain and an increase in range of knee extension or ankle dorsiflexion on release of neck flexion.
If the patient’s symptoms are reproduced by the slump position and can be relieved by sensitising manoeuvres, you have a positive test.
This is further emphasised if, as well as symptom reproduction, there is a symmetrical decrease in the range of motion which does not happen when tension is absent. For example, bilateral ankle dorsiflexion is restricted during slump, but disappears when the neck is not flexed.
In some instances, anomalous reactions are observed in which, for example, pain increases when the neck is taken out of flexion or when trunk on hip flexion decreases symptoms. Mechanical interface (MI) pathology may account for this.
EXERCISE 7.4: PASSIVE NECK FLEXION (PNF) TEST Time suggested: 1–2 minutes for each variation
As with SLR, this test takes up slack from one end only. It allows movement of neuromeningeal tissues in relation to the spinal canal, which is its mechanical interface (MI).
Twenty two percent of patients with back pain were shown to have a positive PNF test in an industrial survey.
The head and neck are supported by your hands as you take the chin toward the chest. In a normal neck the chin should approximate the sternum without force or symptoms.
Variations such as neck extension, lateral flexion and PNF, in combination with other tests, should be used for screening purposes for AMT.
EXERCISE 7.5: UPPER LIMB TENSION TESTS (ULTT 1 AND 2)
Time suggested: 3–4 minutes for each ‘sensitising’ addition to each version of the test ULTT 1
Your palpation partner should be supine. Place the tested arm into abduction, extension and lateral rotation of the glenohumeral joint. Once these positions are established supination of the forearm is introduced together with elbow extension. This is followed by addition of passive wrist and finger extension.
If pain is experienced at any stage during placement of the person into the test position or during addition of sensitisation manoeuvres (below), particularly reproduction of neck, shoulder or arm symptoms previously reported, the test is positive and confirms a degree of mechanical interference affecting neural structures.
Additional sensitisation is performed by:
adding cervical lateral flexion away from the side being tested introduction of ULTT 1 on the other arm simultaneously the simultaneous use of straight leg raising, bi- or unilaterally introduction of pronation rather than supination of the wrist.
Notes on ULTT 1
A great deal of nerve movement occurs during this test. In cadavers, up to 2cm movement of the median nerve in relation to its mechanical interface has been observed during neck and wrist movement.
‘Tension points’ in the upper limb are found at the shoulder and elbow.
ULTT 2
Butler developed this test and finds it more sensitive than ULTT 1.
He maintains that it replicates the working posture involved in many instances of upper limb repetition disorders (‘overuse syndrome’).
In using ULTT 2, comparison is always made with the other arm.
Example of right-side ULTT 2:
For a right side test the person lies close to the right side of the table, so that the scapula is free of the surface. The trunk and legs are angled towards the left foot of the bed so that the patient feels secure.
The practitioner stands to the side of the person’s head, facing the feet with the practitioner’s left thigh depressing the shoulder girdle (see Fig. 7.2).
The person’s fully flexed right arm is supported at both elbow and wrist, by the practitioner’s hands.
Slight variations in the degree and angle of shoulder depression (‘lifted’ towards ceiling, held towards floor) may be used, by alteration of thigh contact.
Holding the shoulder depressed, the practitioner’s right hand grasps the patient’s right wrist while the upper arm is held by the practitioner’s left hand.
With these contacts sensitisation manoeuvres can be introduced to the tested arm – see below:
shoulder internal or external rotation
elbow flexion or extension forearm supination or pronation.
The practitioner then slides his right hand down onto the open hand and introduces supination or pronation or stretching of fingers/thumb or radial and ulnar deviations.
Further sensitisation may involve:
neck movement (side-bend away from tested side, for example), or altered shoulder position, such as increased abduction or extension.
A combination of shoulder internal rotation, elbow extension and forearm pronation (with shoulder constantly depressed) is considered to offer the most sensitive test position.
Notes
Cervical lateral flexion away from the tested side causes increased arm symptoms in 93% of people and cervical lateral flexion towards the tested side increases symptoms in 70% of cases (Butler & Gifford 1991).
Butler & Gifford report that ULTT mobilises the cervical dural theca in a transverse direction, whereas the ‘slump’ mobilises the dural theca in an anteroposterior direction as well as longitudinally.
Fig 7.2 Upper limb tension test (2). Note the practitioner's thigh depresses the shoulder as sensitising manoeuvres are carried out.