SLUMP TESTOrthopaedic testMaitland's lumbar SLUMP TEST effectively puts the sciatic nerve under increasing dural tension to test for possible entrapment. The standard sciatic nerve stretch test was originally credited to Charles Lasègue more than 150 years ago. Applied together with the Braggard manoeuvre it has been the gold standard for more than a century. The Slump test spine is to my mind not necessarily better, but just different, and easier to apply. It also adds further dimensions of stretch to Lasègue's original test. The two tests together, along with Braggards, complement each other and sometimes produce baffling contradictions for the clinician.
FROM THE CHIROPRACTIC COALFACEI have just had a patient with the typical signs of small low lumbar LEFT POSTERO-MEDIAL herniation, fortunately with no leg pain.As expected, Slump 2 RIGHT > Left LBP. And Slump 2 LEFT was negative. But bizarre, SLR right was negative, and SLR left was positive! In any case, he'll get better, despite not quite understanding the biomechanics. I love PM discs. They get better much quicker. 
Slump 1: slump the lumbar spine.The patient with low back and/or leg pain sits in an ordinary upright chair, or on an examination table, it makes no difference. S/he then adopts the slightly slumped (kyphotic) lumbar spine posture, without flexing the whole body forwards. Does it hurt? Where?In practice, I personally move immediately to Slump 2, finding that Slump 1 yields little useful information.
Slump 2: extend the knee.The clinician then extends the patient's knee, first of the non-painful leg, to establish a normal muscle stretch, and then followed by extension of the knee of the painful leg.Aside: I have not seen research comparing active and passive extension of the knee. Both seem to produce much the same result, perhaps with subtle differences that a good research study could elucidate. In an acute sciatica, Slump 2 will almost always produce an immediate reaction. Questions: Does it hurt ... 1. When I raise your non-painful leg? Where? In the low back? Right, left, centre, both sides? In the non-painful leg? Ominously, does it hurt in the opposite leg (the leg with the suspected nerve-type pain)? 2. Now, when I straight your naughty leg, where does it hurt? In your back, both sides? right? left?, in your leg? where in your leg, tingling in the toes? which toes? ...
Slump 'Ouch' sign. The crossed sign.When passive extension of the patient's 'good' leg, reproduces the pain in the painful leg, in my experience, the clinician is always faced with a conundrum. What I call the 'Ouch sign' is not frequently positive, but when it is ...! Usually it is only in the opposite thigh that pain is experienced, but very occasionally in the lower leg too.The challenge of whether to use
gives the thinking Chiropractor a plethora of clinical options making for a very challenging and complex situation. Aside: An interesting study would be to evaluate how many patients in the Chiropractic clinic with an Ouch sign end up within one year in surgery. I suspect it's quite high. I always take the Ouch sign very seriously, and ensure the patient does too. Slump 3: add ankle dorsi-flexionProgressive stretch is now added to the sciatic nerve, always comparing first the non-painful leg with the painful leg, to distinguish between a tight hamstring, piriformis, calf muscle on the one hand, and true sciatica on the other.In Slump 3, the ankle is dorsi-flexed. (equivalent to Braggards) In my notes, I might write, for example: Slump 3 + right. (R LBP and R posterior thigh stretch/tingle/pain ..) or: 1. Slump 3 + right (L posterior thigh pain), and 2. Slump 3 +++ left (Left LBP, buttock and posterior thigh pain)
Slump 4: add medial hip rotation.With the lumbar spine slumped, the knee extended, the ankle dorsiflexed, the clinician now medially rotates the whole lower limb, using the ankle (rather than the foot as shown above in the graphic) as a lever.If Slump 3 was negative, but medial rotation reproduces the pain in the leg, then the patient has a Slump 4 (I always write where the patient experiences the pain. It's extremely useful to come back later and be able to compare.) Tip. Doing Slump is hard on the Chiropractor's own back. I go down on one knee, and place the patient's leg on my other knee whilst adding ankle dorsiflexion and hip medial rotation.
Slump 5: add head and neck flexion
In a typical Lhermitte type manoeuvre, flexing the head and neck SLOWLY adds further traction to the dura, even drawing the whole cord cephalad, and tractioning the lumbar nerve root up against the pedicle. In my notes, Slump 5 R+ (R lateral ankle pain) would mean that Slump 4 was negative, but flexing the head caused pain (not in the neck) but in the low back or leg (specify for future reference to track the patient's progress). Thought. Has anyone tried doing a Straight Leg Raise on a patient with an acute brachial neuralgia, to pull the cord in a caudad direction?
Slump 6: add ValsalvaSometimes Slump 5 may be negative, but adding a Valsalva manoeuvre may elicit the pain.I always test Valsalva and Lhermitte before starting on the Slump test, so the patient already knows how to do a Valsalva. And finally ...
A Slump 7 done vigorously like this could only be done on a completely normal patient! Slump 7: add CoughAdding a cough SHOULD BE EXTREMELY GENTLY DONE. With the sciatic nerve now under extreme stretch, any vigorous cough or sneeze could be disastrous, but in the presence of a negative Slump 6, it does occasionally conclusively convince the clinician of the presence of a disc lesion.
INTERPRETATIONThe interpretation of the Slump test is extremely complex, and I suspect clinicians would argue vigorously about it.What adds to the confusion is that sometimes the Slump test is strongly positive, whilst the Straight Leg Raise is negative, though rarely vice versa. Piriformis syndrome? SI-sydrome? Thought: At the WFC congress in Portugal in 2007, a group of Danish researchers persuaded a group of about 40 chiropractors to workshop the Lumbar facet syndrome. It proved to be an extremely interesting exercise, and could be repeated perhaps on the Slump Test at a subsequent congress?
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