Cleland JA, Childs JD, Palmer JA, Sarah Eberhart S. Slump stretching in the management of non-radicular low back pain: A pilot clinical trial. Manual Therapy 11 (2006) 279-286
This study was performed to assess the additive effect of slump stretching on patients with low back and leg pain, with the idea that patients who received slump stretching in addition to a standard physical therapy plan would have greater improvements in disability, pain, and centralization of symptoms than patients who received standard care only. Subject were 30 people between 18 and 60 years of age with a chief complaint of LBP referred to physical therapy. Patients were required to have symptoms that referred distal to the buttocks, reproduction of the patient’s symptoms with slump testing, no change in symptoms with lumbar flexion or extension, and a baseline Oswestry score greater than 10%. Exclusion criteria included positive neurologic signs or symptoms suggestive of nerve root involvement (diminished upper or lower extremity reflexes, sensation to sharp and dull, or strength), osteoporosis, or a straight leg raise (SLR) test of less than 45 degrees. Eighty-one patients (69%) did not satisfy the inclusion and exclusion criteria for the study.
All patients completed several self-report measures including a body diagram, numeric pain rating scale (NPRS), and the modified Oswestry Disability Index (ODI). Fourteen patients were randomized to receive lumbar spine mobilization and exercise, and 16 received lumbar spine mobilization, exercise, and slump stretching. All patients were treated in physical therapy twice weekly for 3 weeks for a total of 6 visits.
Slump stretching was performed with the patient in the long sitting position with the patient’s feet against the wall to assure the ankle remained in 0 degrees of dorsiflexion. The therapist applied over pressure into cervical spine flexion to the point where the patient’s symptoms were reproduced (Fig. 2). The position was held for 30 s. A total of 5 repetitions were completed.
At discharge, patients who received slump stretching demonstrated significantly greater improvements in disability (9.7 points on the ODI), pain (.93 points on the NPRS), and centralization of symptoms than patients who did not. The results suggest that slump stretching is beneficial for improving short-term disability, pain, and centralization of symptoms.
I absolutely love this study. It represents a lot of what I like about some of Josh Cleland’s work – it asks a straightforward clinical question that has been generally accepted but not formally tested in the physical therapy world, and then sets up a trial that involves treatments with strong external validity. Many studies answer such specific questions that it is hard to take the information straight to the clinic. This study is different, because if you have a patient who fits the criteria outlined above – leg pain, not changing with lumbar flexion and extension, no neurologic symptoms and, generally, fairly well-controlled symptoms – you may be missing something if you are not adding slump stretching to that patient’s treatment. I found it especially interesting that the authors found increased centralization over time, as I had not read of or seen that previously in relation to slump stretching.
The one problem that I have with this study comes from my background in McKenzie training, and is an issue that often comes up with the type of repeated motion testing performed in this study and those carried out by Cleland, Childs and others. The patient group that was treated here would be analogous in diagnosis and treatment to McKenzie’s adherent nerve root – intermittent leg pain, produced with tension on the nerve, but otherwise painfree in the leg. This diagnosis is only arrived at after exhaustive repeated motion testing, and is probably found in 2-5% of patients, versus the 31% of patients in the current study. Given that the repeated motion testing was not specifically described in this paper, it would be interesting to see if more subjects would have been excluded with different repeated motion testing. Perhaps the results would have been even stronger.
Orthopedic Physical Therapy Research 