4 F I S I O T E R A P I E MAART 1980 M OVEMENT O F PAIN SENSITIVE STRUCTURES IN TH E V E R T E B R A L CANAL IN A GROUP OF PHYSIOTHERAPY S T U D E N T S G . D . M A IT L A N D * , A. U . A ., F.C .S.P., F .A .C .P ., M .A .P.A ., M.S.A.S.P., M .T.A .A . SU M M A R Y A study was set up to relate the general degree o f m o b ility o f the pain sensitive structures in the vertebral canal to the m o v e m e n t o f the vertebral colum n. I t was fo u n d th a t pain in area o f the ham strings or behind the knees on fu l l extension o f the knee, d orsiflexion o f the fo o t and fu ll fle x io n o f the trunk, disappears w hen the neck fle x io n co m p o n en t is lost. I t appears th a t ham string or posterior knee pain a n d the c o n co m ita n t decrease in range o f m o v e m e n t are not caused by shortened ham ­ strings, b u t apparently by decreased m o v e m e n t o f the structures betw een the sacrum and th e skull. These structures are th u s the pain sensitive structures w ithin the vertebral canal. E v ery o n e w ho has been involved in th e treatm en t o f p a tie n ts hav in g p a in arisin g fro m th e v erteb ral colum n w ill h av e read a b o u t ‘d u ra l p a in ’. M o st texts on m a n ip u la tio n w ill m ak e referen ce to th is d u ral p a in and som e au th o rs m ake reference to th e m echanism . I t is also believed th a t th e d u ral sh eath o r nerve ro o t sleeve can also be resp o n sib le f o r p a in b u t th e p a in in these circum stances w ill be a re fe rre d p ain . I t is com m on p ractice fo r m ed ical p ra c titio n e rs and p h y sio th erap ists to m easure th e ranges o f m ovem ent tak in g place a t jo in ts u n d e r e x a m in a tio n w hile a t the sam e tim e relatin g any p a in w hich m ay b e p rovoked b y these m ovem ents. A n e v a lu a tio n is m a d e as to w h eth er th e ran g e an d th e p a in p ro v o k ed is n o rm al o r n o t, based u p o n a com p ariso n w ith 0 th e sam e m o v em en t in th e jo in t on th e opposite side o f th e b ody w here possible; # th e sam e m ovem ent in th e jo in t above an d th e jo in t below , i f the v e rte b ra l colum n is being exam ined; # th a t w hich is believed to be n o rm a l fo r th a t m o v em en t in th a t jo in t in a p erso n w ith th a t b o d y ty p e u n d er th e existing conditions. A lth o u g h p ap ers have been pub lish ed giving details o f th e m ean d iam eter o f th e v e rte b ra l canal a t different levels o f th e spine, now here has it been p u b lish ed th a t th e p a in sensitive stru ctu res in th e v e rte b ra l canal, such as the d u ra, th e n e rv e ro o t sleeve an d th e nerve ro o t, m ay h av e a m ean ran g e o f ex ten sib ility related to th e m ovem ents o f th e spine. I t w as f o r th is reason th a t th e in v estig atio n re p o rte d on in th is p a p e r was un d ertak en . I t seem ed necessary to know w h a t one could expect to be n o rm al so as to h av e a m e a su re fro m w hich to judge th e ab norm al. * S en io r L e c tu re r and C lin ical T u to r fo r th e G ra d u a te D ip lo m a o f A dvanced M an ip u la tiv e T h e ra p y , School o f P h y sio th erap y , S o u th A u stra lia n In stitu te o f T ech ­ nology. t R e a d a t th e In a u g u ra l C ongress o f th e M a n ip u lativ e T h e ra p ists A sso ciatio n o f A u stralia, O ctober 1978 and p rin te d by k in d p erm ission o f the M an ip u lativ e T h e ra ­ p ists’ A ssociation o f A u stralia. R eceived 5 S ep tem b er 1979. OPSOM M ING 'n Studie is geloods om die algem ene graad van lenig- heid van die p y n sensitiewe strukture in die vertebrate kanaal in verw antskap m et die bewegings van die wer- w elko lo m te bring. Daar is gevind dat p yn w at in die area van die ham pese o f agter die kniee gevoel word wanneer voile ekstensie van die knie, dorsifleksie van die voet en voile ro m p fleksie gedoen word, verdw yn as die n e k-fleksie-ko m p o n en t verloor word. D it b ly k d ^ ‘... ham pees- o f posterior kniepyn en die gelyktydige korting van om vang van beweging nie die gevolg van verkorte ham pese is nie, m aar blykbaar inkorting van beweging van die strukture tussen die sakrum en die skedel is. H ierdie strukture m o et dus die p yn sensitiewe strukture binne die vertebrale kanaal wees. T h e re w ere two o th e r facto rs w hich p ro m ted the in itial thoughts regarding carrying o u t such an in ­ vestigation. T h e first o f these w as th a t it seem ed to the a u th o r th a t no one h ad suggested any physical ex am in atio n p rocedure w hich satisfactorily tested the m ovem ents o f these canal structures to such a degree th a t follow ing e x am in atio n the exam iner w ould be able to say w h eth er th e m ovem ent of th e p a in sensitive structures in the v erteb ral canal and in terv erteb ral fo ram en w ere n o rm al o r not. I t is agreed th a t L a sig u e ’s test an d p ro n e lying h ip extension w ith knee flexion are tests fo r m ovem ents o f th e related nerve ro o ts and presum ably th e ir nerve ro o t sleeves. I t has also been described that, w ith a p a tie n t lying su p in e an d th e exam iner then passively flexing h is head and neck so th a t his chin ap p ro x im ates h is chest, test fo r dural involvem ent p a rtic u la rly in relatio n to low lum bar pain. H ow ever, th is test seem s to b e incom plete, espe­ cially w hen it is n o t uncom m on to find th a t a p a tie n t w ith b ack p a in w ill say th a t he has difficulty b en d in e his head dow n w hile getting into a car because o f ̂ back p ain w hich this neck flexion produces, y et k,a ex am in atio n th e su p in e lying neck flexion test is found to be negative. H ow ever, if, u n d er these circum stances, th e p atien t is asked to sit in a slum ped p o sitio n and to then p u t h is chin onto h is chest, i t will be fo u n d th a t th e range is lim ited by p ain w hich is reproduced in his low er back. I t th erefo re seem ed necessary to develop a test w hich could adequately d eterm ine w hether a p a tie n t’s sym ptom s b o re any relatio n to a lim ited range o f m ovem ent w ithin th e vertebral canal and in terv erteb ral foram en ra th e r th an due to m ovem ent o f an in terv erteb ral joint. T h e second facto r w hich in itia te d th e th o u g h t o f conducting a survey to determ ine th e ‘n o rm als’ was the p u b licatio n o f an article by M acnab (1971) in w hich h e describes five sources o f nerve ro o t tension w hich include nerve ro o t kin k in g b y the pedicle, artic u la r process im pingem ent o n th e nerve ro o t and spinal stenosis. O th er au th o rs including F a h rn i (1966) m ake reference to nerve ro o t adhesions sim ulating disc p ro ­ trusion. T h e tests o f straig h t leg raising, p ro n e knee flexion and supine neck flexion w ere also in ad eq u ate in this instance to test fu lly th e n o rm al excursion o f cephalad and cau d ad m ovem ent of th e p a in sensitive R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M A R C H 1980 P H Y S I O T H E R A P Y 5 s l r u c t u r e s in I h e v e r t e b r a l c a n a l a n d i n l e r v e r t e b r a l f o r a ­ m e n . A s a re su l t o f t h is i n a d e q u a c y a test w i t h t h e p a t i e n t i n a s l u m p s i t t i n g p o s i t i o n o n a n e x a m i n a t i o n c o u c h w a s u se d to test t h e s e m o v e m e n t s b y v a r i o u s l y a d d i n g a n d s u b t r a c t i n g k n e e e x t e n s i o n ( s i m u l a t i n g s t r a i g h t leg r a i s i n g ) , a n k l e d o r s i f l e x i o n , h e a d a n d n e c k f lex io n a n d , i f t h i s t o t a l c o m b i n e d p o s i t i o n c o u l d b e a d o p t e d w i t h o u t r e s t r i c t i o n o r p a i n , t h e t r u n k w a s f u r t h e r fl exed o n t h e f e m u r (i.e. h i p f le x i o n ) w h i c h it w a s h o p e d w o u l d p l a c e t h e c a n a l s t r u c t u r e s o n full s t r e t c h . A s t h e s e tes ts f o r c a n a l m o v e m e n t w e r e u se d in p a t i e n t s w h o h a d v e r t e b r a l d i s o r d e r s , i t w a s r e a l i s e d t h a t it w a s n e c e s s a r y to h a v e s o m e i d e a o f w h a t t h e n o r m a l e x c u r s i o n s h o u l d b e i n t h e n o r m a l a v e r a g e i n d i v i d u a l w h o h a s n o p a i n . T h e r e f o r e it w a s d e c i d e d to u n d e r t a k e a s u r v e y o n a g r o u p o f n o r m a l s , w h o , in t h i s c as e, w e r e p h y s i o t h e r a p y s t u d e n t s . It w a s h o p e d a l s o t h a t t h e r e s u l t s o f t h e s u r v e y w o u l d p r o v i d e s o m e f u r t h e r i n f o r m a t i o n in r e l a t i o n to / • e u s e o f s t r a i g h t leg r a i s i n g as a t r e a t m e n t t e c h n i q u e , V ^ . i d , t h e c o n c e p t o f l i g h t h a m s t r i n g s . Tt is o f t e n s u g ­ g e s t e d t h a t w h e n a p a t i e n t fe el s p a i n in h i s h a m s t r i n g a r e a d u r i n g s t r a i g h t leg r a i s i n g , t h e t e c h n i q u e is o n l y s t r e t c h i n g t i g h t h a m s t r i n g s . H o w e v e r , t h i s d o e s no t se e m to fit t h e c l i n i c a l s i t u a t i o n s w h i c h a r e s e en a n d w h i c h r e s p o n d to s t r a i g h t leg r a i s i n g a s a t r e a t m e n t p r o c e d u r e . P h a l e n a n d D i c k s o n (1 961), i n d i c a t e v e r y c l e a r l y a set o f c i r c u m s t a n c e s w h e r e s o m e p e o p l e m a y c o n s i d e r t h a t p a t i e n t s h a v e t i g h t h a m s t r i n g s . H o w e v e r , f o l l o w i n g c o r r e c t i v e s u r g e r y f o r t h e s p o n d y l o l i s t h e s i s t h e h a m s t r i n g t i g h t n e s s d i s a p p e a r e d , i n d i c a t i n g t h a t t h e a p p a r e n t t i g h t n e s s o f h a m s t r i n g s h a d its o r i g i n in s o m e f a u l t o f t h e l u m b a r s p i n e r a t h e r t h a n in t h e h a m s t r i n g s t h e m s e lv e s . M E T H O D F o r t y - n i n e p h y s i o t h e r a p y s t u d e n t s w e r e e x a m i n e d to test w h a t w a s p r e s u m e d to b e t h e r a n g e o f m o v e m e n t o f t h e p a i n s e n s i t i v e s t r u c t u r e s in ( h e v e r t e b r a l c a n a l . O f t h e f o r t y - n i n e s t u d e n t s e x a m i n e d , t w e n t y - f o u r h a v e b e e n e x c l u d e d f r o m t h i s s u r v e y o f ' n o r m a l s ’. O f t h e t w e n t y - f o u r w h o w e r e e x c l u d e d t w e n t y - t w o w e r e e x ­ c l u d e d b e c a u s e o f b a c k s y m p t o m s a n d t w o w e r e e x ­ c l u d e d b e c a u s e o f sc o l io s i s . T w e n t y - f i v e ‘n o r m a l s ' r e ­ m a i n e d o f w h o m s e v e n w e r e m a l e a n d e i g h t e e n w e r e f e m a l e . T h e a v e r a g e a g e o f t h e m a l e s w a s 21, v a r y i n g ^ i r o m 2 0 - 23. T h e a v e r a g e a g e o f t h e f e m a l e s w a s 20. C~<*th a n a g e s p a n b e t w e e n 19 a n d 24. N o s i g n i f i c a n t ^ d i f f e r e n c e s c o u l d b e e s t a b l i s h e d in t h e t es ts w h i c h c o u l d b e a t t r i b u t e d to t h e a g e . sex , b o d \ h p e or d i f f e r ­ e n c e in h e i g h t . Test M ovem enls F o r t y - n i n e p h y s i o t h e r a p y s t u d e n t s w e r e a s k e d to fill in a q u e s t i o n n a i r e a n d t h e a n s w e r s w e r e v e r i fi e d , p a r t i ­ c u l a r l y in r e l a t i o n to a n y s y m p t o m s w h i c h m a y h a v e b e e n felt in t h e s p i n e , p a r t i c u l a r l y f r o m t h e m i d d l e t h o r a c i c s p i n e to t h e l o w l u m b a r s p i n e . All f o r t y - n i n e s t u d e n t s w e r e t a k e n t h r o u g h t h e t o t a l e x a m i n a t i o n r o u t i n e . E a c h s t u d e n t w a s a s s e s s e d d u r i n g t h e test m o v e ­ m e n t s f o r p a i n ( t h is i n c l u d e d d i s c o m f o r t , s t r e t c h i n g f e e l i n g s , o r a n y a w a r e n e s s o f a d i f f e r e n t f e e l i n g p r o ­ v o k e d by t h e te st m o v e m e n t ) a n d t h e r a n g e o f m o v e ­ m e n t . T h e s t u d e n t s w e r e t a k e n t h r o u g h t h e test r o u t i n e d e s c r i b e d b e l o w , a n d w il l b e r e f e r r e d to as b e i n g f e m a l e . 1. Standing: 1.1 S h e w a s a s k e d to r e p o r t i f s h e f e l t a n y d i s ­ c o m f o r t . N o o n e h a d a n y d i s c o m f o r t in s t a n d i n g . 1.2 S h e w a s a s k e d t o flex h e r t r u n k as f a r as p o s s i b l e a n d t o r e m a i n in t h a t p o s i t i o n so t h a t t h e r a n g e c o u l d b e r e c o r d e d . A n a s s e s s m e n t w a s s i m u l t a n e o u s l y m a d e o f ( h e c o n t o u r o f ( h e s p i n e . S h e w a s a s k e d to r e p o r t w h e r e s h e felt a n y p a i n o r d i s c o m f o r t etc. 1.3 I n t h i s f u l l y flexe d p o s i t i o n w h e r e t h e s a m e d e g r e e o f f l e x i o n o f ( h e t h o r a c i c a n d l u m b a r s p i n e s a n d t h e h i p s w a s r e t a i n e d , .she w a s a s k e d t o flex h e r c h i n o n t o h e r c h e s t as f a r a s p o s s i b l e a n d to r e p o r t a n y c h a n g e s in s y m p t o m s , o r n e w s y m p t o m s . O v e r - p r e s s u r e w a s a l s o a p p l i e d to t h e n e c k f l e x i o n b y t h e e x a m i n e r a n d t h e r a n g e o f m o v e m e n t w a s a s se s se d . 1.4 O n r e s u m i n g t h e s t a n d i n g p o s i t i o n s h e w a s a s k e d if s h e c o n s i d e r e d t h a t h e r r a n g e o f f l e x i o n w a s h e r n o r m a l r a n g e , a n d w h e t h e r i t h a d c h a n g e d in r e c e n t m o n t h s . T h e f i n d i n g s w e r e r e c o r d e d in S e c t i o n A, T a b l e T. 2 . S i l l i n g on e x a m i n a t i o n c o t t c li : 2.1 S h e w a s a s k e d to si t w e l l b a c k u n t i l ( h e p o s t e r i o r k n e e a r e a w a s w e d g e d a g a i n s t t h e e d g e o f t h e e x a m i ­ n a t i o n c o u c h so t h a t u n i f o r m i t y o f ( h e test p o s i t i o n w o u l d b e m a i n t a i n e d . 2.2 In t h i s e r e c t s i t t i n g p o s i t i o n s h e w a s a s k e d to r e p o r t a n y p a i n o r d i s c o m f o r t . N o n e o f t h e s t u d e n t s r e p o r t e d a n y d i s c o m f o r t . 2.3 S h e w a s t h e n a s k e d t o l e t h e r b a c k s l u m p t h r o u g h its f u l l r a n g e o f t h o r a c i c a n d l u m b a r f le xi on w h i l e at t h e s a m e l i m e n o t a l l o w i n g h e r h e a d a n d n e c k to d r o p i n t o fl ex i o n . O n c c in t h i s p o s i t i o n f irm o v e r ­ p r e s s u r e w a s a p p l i e d b y t h e e x a m i n e r to t h e s h o u l d e r a r e a so as to f u l l y s t r e t c h t h e t h o r a c i c a n d l u m b a r s p i n e s i nt o f u l l f le x io n ( F i g . 1). All t h e s t u d e n t s w e r e s y m p ­ t o m free. F ig . 1. ‘S lu m p -sittin g ’ w ilh over-pressure R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 F I S I O T E R A P I E MAART 1980 T A B L E I. C A N A L M O V E M E N T S A S T A N D IN G F L E X IO N R an g e ................................... P a in ........................................ Is it u su al range? ............. H a s it changed recently? . R ange N F L u m b ar C urve A dd N F O P. B S IT T IN G (T1 Sit, P a in ...... Pain — Pelvis) N A M E : ..................................... N o rm al ........ Stiff ............... H y p erm o b ile I N o rm al ......... Stiff .............. H y p erm o b ile Slum p (T1 — Pelvis) R an g e T h R ange L .. P ain .......... Slum p w ith O.P. 1. M id P o sitio n P ain 2. w ith h ip F ’d P ain 3. w ith h ip E ’d Pain C N F C O M P O N E N T Slum p (m id) + N F j R an g e P a in .. D SL R C O M P O N E N T Slum p (m id) ‘N F -to -p elv is’ R ange .......................................................................... f R ange P a in .............................................................................. I Pain .. (D o n ’t allow H ip E) A D D SLR N F effect release N F P a in ........................ N ew SL R R ange N ew Pain ........... P a in ........................ N ew SLR R ange N ew P ain ........... E D F C om p o n en t Slum p (m id) + N F + SL R (Lacks ........................................................... °K n.E. (H O L D )) A D D D F \ R" Ee ........................................... J R*W ........... I P a in .............................................................................. I P ain ........................ 1. N F E ffect P a in .................................................................... (a) release N F H O L D SLR (b) N E W SLR fro m N O D F Pain N ew D F ran g e ................................................... N ew D F range N ew pain ........................................................... N ew p a in ....... P a in ........................................................................ P ain N ew D F range New D F range N ew p ain ........................... ................................ N ew pain R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 2 4 S h e w a s t es te d f o r a n \ p a i n r e s p o n s e w h i c h m a y h a v e o c c u r r e d if t h e t r u n k , w h i l e b e i n g h el d f ir m ly in full fl ex i o n , w a s flexe d o r e x t e n d e d o n t h e f e m o r a N o n e o f t h e s t u d e n t s r e p o r t e d a n \ s y m p t o m s T h e f i n d in g s w e r e r e c o r d e d in S e c t i o n B. T a b l e i. 2.5 T h e m e t h o d o f m a i n t a i n i n g t h e o v e r - p r e s s u r e to th e s l u m p e d s p i n e w a s c h a n g e d so t h a t t h e e x a m i n e r h a d a f r e e h a n d ( F i g 2). W i t h t h e c h a n g e d p o s i t i o n it w a s c o n f i r m e d t h a t t h e r e w a s n o c h a n g e in th e s t r e n g t h o f o v e r - p r e s s u r e o r th e o n s e t o f a n y s y m p ­ to m s . M A R C H 1980 P H Y S I O T Fig. 2. ‘S lum p-sitting' w ith over-pressure 2.6 S h e w a s a s k e d to f u l l y flex h e r h e a d a n d n e c k , a p p r o x i m a t i n g h e r c h i n to h e r s t e r n u m , a n d o v e r ­ p r e s s u r e w a s a p p l i e d by t he e x a m i n e r to t h i s nec k fl e x i o n p o s i t i o n . O n c e s h e h a d r e p o r t e d a n y d i s c o m f o r t felt w i t h th e s u p e r i m p o s e d n e c k fle xi on , t h e o v e r - p r e s s u r e o n h e r h e a d w a s r e t a i n e d b y t h e e x a m i n e r ' s c h i n t h u s l e a v i n g hi s r i g h t h a n d f r e e ( F i g u r e 3). T h e p o s i t i o n o f t h e e x a m i n e r ' s c h i n o n h e r h e a d h a d to be su c h t h a t t h e e x a m i n e r w a s a b l e to see h e r k n e e s a n d feet w h e n s h e w a s l a t e r a s k e d to e x t e n d h e r k n e e a n d d o r s i f l e x h e r foot.- T h e f i n d in g s w e r e r e c o r d e d in S e c t i o n C'. T a b l e I T h e s e f in d in g s a r e r e f e r r e d to l a t e r in t h e s e c t i o n on R e su l t s. 2.7 2.7.1 W i t h t h e w h o l e s p i n e m a i n t a i n e d in f le xi on wi th F ig . 3. ‘S lu m p -sittin g ’ w ith superim posed real flexion and over-pressure. o v e r - p r e s s u r e , s h e w a s a s k e d to e x t e n d h e r left k n e e as f a r as p o s s i b l e , a n d w h i l e h o l d i n g it in th i s p o s i t i o n the r a n g e w a s n o t e d a n d s h e w a s a s k e d to r e p o r t a n y c h a n g e to e x i s t i n g s y m p t o m s a n d a l s o to r e p o r t a n \ new s y m p t o m s ( F i g u r e 4). 2.7.2 W h i l e t h e n ec k fl e x i o n to k n e e e x t e n s i o n p o s i t i o n w'as b e i n g m a i n t a i n e d a n d b e i n g s u r e t h a t t h e s y m p ­ t o m s w e r e s t a b l e a n d c o n s i s t e n t , t h e e x a m i n e r r e t a i n e d t h e s a m e o v e r - p r e s s u i e t o t h o r a c i c a n d l u m b a r f l e x i o n w h i l e at t h e s a m e t i m e r e l e a s i n g t h e n ec k f le xi on t h u s a l l o w i n g h e r h e a d to b e r a i s e d to t h e n e u t r a l p o s i t i o n . In t h is new' p o s i t i o n s h e w a s a s k e d to c l e a r l y s t a t e w'hat h a d h a p p e n e d to a n y o f t h e s y m p t o m s T h e s e c h a n g e s w e r e r e c o r d e d in S e c t i o n D , T a b l e I. In t h e f u l l y s l u m p e d p o s i t i o n t h e s t u d e n t m a y or m a y n o t h a v e h a d a f u l l t a n g e o f k n e e ex te n si o n .. 2 8 W h e n a s t u d e n t w a s u n a b l e to f u l l y e x t e n d h e r k n e e (2.7.1), s h e w a s t h e n a s k e d , w h e n n e c k f le xi on w a s r e l e a s e d (2.7 2). if s h e c o u l d e x t e n d h e r lef t k n e e f u r t h e r a n d in t h i s n e w p o s i t i o n t h e r a n g e w a s n o t e d a n d a n y p a i n r e s p o n s e r e p o r t e d . A l l t h e s t u d e n t s w e r e a b l e to a c h i e v e full k n e e e x t e n s i o n T h e s e f in d in g s w e r e r e c o r d e d in S e c t i o n D . T a b l e f 2 9 2.9.1 W h e n a s t u d e n t w a s a b l e to f u l l y e x t e n d t h e k n e e (2 7.1) s h e w a s t h e n a s k e d to d o r s i f l e x h er a n k l e as f a r as p o s s i b l e . T h e r a n g e w a s n o t e d a n d t h e p a i n r e s p o n s e r e p o r t e d . 2.9.2 W h i l e t h e p o s i t i o n ( e s p e c i a l l y t h e d o r s i f l e x i o n p o s i t i o n ) w a s b e i n g h e l d , a n d k n o w i n g t h a t t h e s y m p ­ t o m s w e r e r e m a i n i n g c o n s t a n t , t h e n e c k f l e x i o n w a s r e l e a s e d as d e s c r i b e d in t h e p r e v i o u s s e c t i o n a n d t h e c h a n g e in p a i n w a s r e c o r d e d in S e c t i o n F . T a b l e I. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 8 F I S I O T E R A P I E MAART 1980 F ig. 4. ‘Slump-sitting — real flexion’ with superimposed knee extension (range o f knee extension and pain response assessed). In the fu lly slum ped position the student m a y or m ay n o t have had a full-range o f dorsiflexion. 2.9.3 W hen a student was un ab le to fully dorsiflex h er ankle she was then asked, when the neck flexion was released, if she could dorsiflex h e r a n k le fu rth e r, and the new range and its pain response w ere rep o rted and recorded in Section E, T ab le I. N o t all the students w ere ab le to fully dorsiflex the ankle even at th is stage. 2.10 W hen a stu d en t was un ab le to fully extend h e r knee two tests w ere carried out. 2.10.1 F irs t she w as asked to dorsiflex h e r a n k le w hile her knee extension rem ained at the range av a il­ ab le in the fully slum ped position. T h e ran g e and p ain response w as recorded in Section E , T a b le I. 2.10.2 Second, the neu tral neck flexion p o sitio n was retained and she was then asked to fully extend h e r knee. In this position she was then asked to attem pt fu rth e r dorsiflexion so that its new range and changes in pain could be recorded in Section E, T ab le I. 2.11 W ith the student sitting u p rig h t and w ith her knee fully extended, the norm al full range of d o rsi­ flexion and the pain response was assessed. RESULTS A N D DISCUSSIO N Standing (Table II) O f th e seven males and eighteen fem ales (total twenty-five) exam ined, only tw o (one m ale and one fem ale) could be considered to be stiff. T h e rem ain d er w ere at least able to touch th e ir toes. T h e two students who w ere stiff also had a lim itatio n o f neck flexion T A B L E II. Std. F . Std. F. + N F R A N G E 7 M ales 18 F em ales 6 1 17 1 td 1 td N F V N F 1 td N F V N F 1 td 17 Std. F . Pain 4 p o ste rio r knees 1 p o sterio r knees + ham string area 1 calf area 1 calf area 12 p o sterio r knees 2 posterior knees & ham string area 1 ham string area only 1 calve 1 ham string area & calf area 1 p o ste rio r knee B ehaviour o f P ain when N F superim posed 2 t 2 f + buttock pain 1 t both 1 unchanged 1 t 9 t 2 f + T10 pain 1 f -I- centre low back area 2 t both areas & sprea ham s higher l T l T 1 t b o th areas 1 t R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M ARCH 1980 P H Y S I O T H E R A P Y 9 w hen standing w ith th e tru n k fully flexed. T h e ir pain responses will be seen to have no special significance w hen com pared w ith those students having a n orm al range o f movem ent. W hen tested in standing th e m ajo rity o f students (tw enty-one) felt pain behind th e ir knees on touching th e ir toes and it is interesting to n o te th a t by su p e r­ im posing neck flexion on the tru n k flexion th is p ain behind th e knees increased in intensity. It is im p o rtan t to consider w hy this p o sterio r knee pain should be increased in intensity w hen no ex tra strain o r stretch is placed on the ham strings o r p o ste rio r knee soft tissue structures. O ne m ale and two fem ale students had p ain both behind the knees and in the ham strin g m uscle area. Each had- th e ir pain increased by th e superim position o f neck flexion. O ne fem ale and two males had pain in the calf area, and o f these three, th e pain o f tw o was increased by th e sup erim p o sitio n of neck flexion while th e pain o f the th ird rem ained unchanged. One ^ m a l e and one fem ale had p ain in both the ham string ^ a r e a and the calf a rea and both students had an increase ”^ in both areas of pain w hen neck flexion was su p erim ­ posed. Sitting, Slum p Sitting, Superim posed N eck F lex io n (Table TII) N o n e of th e twenty-five students had sym ptom s on sitting, e ith er in th e straig h t p osition o r in the slum p- sitting p osition (Figures 1 & 2). N e ith e r was th ere any restriction o f range o f neck flexion w hen th is was superim posed on the slumped sitting position. H ow ever, the pain response on superim posing th e neck flexion turned o u t to be interesting in th at th e findings w ere unexpected. T h e results are listed in T ab le III. Only five o f the twenty-five students felt no discom fort w hatsoever. O f the rem aining tw enty, seventeen felt sym ptom s centrally in the th o racic spine area at a p ­ proxim ately T9. Sixteen felt the pain only in th e centre o f th e T9 a rea w hilst one also felt slight d is­ com fort centrally in the lum bosacral area. T h e re m a in ­ ing th ree had atypical responses; one felt sym ptom s on the sides ad jac en t to th e centre o f the T9 area, ra th e r than centrally, an o th er had sym ptom s in a sim ilar distrib u tio n but extending down as fa r as the iliac crest, and th e th ird felt sym ptom s in the right low er rib cage well laterally fro m the m idline. Tt w ould be interesting if the student w ho had central lum bosacral pain and the student w ho had rig h t low er rib cage sym ptom s could be follow ed u p over the next ten to tw enty years to see w h eth er they develop sym p­ tom s in these areas. If they w ere to develop sym p­ tom s in these areas it w ould th en be interesting to note w hether the ‘superim posed neck flexion sign’ becam e m ore positive, th a t is, w h eth er the av ailab le range of neck flexion w ere lessened o r the intensity o f p ain so provoked, w ere increased. I t seems fro m the above tests th at pro v o k in g o f sym p­ toms in th e T9 a rea can be classed as being w ith in no rm al lim its, and th at, in fact, only a sm all p e r­ centage will have a painless full range in th is position.- Slum p Sitting plus N eck F lexion, Superim posing K nee E xtension and R eleasin g N eck F le x io n (T able IV) T h e p o sitio n show n in F ig u re 3 is adopted, w here th e exam iner holds th e stu d e n t’s head and neck in full flexion w ith h is ow n chin, and his hands are fre e to encourage th e stu d e n t’s knee extension and he is at the sam e tim e still ab le to ob serv e the range o f knee extension. T h e student is now asked to extend h e r knee as far as possible and to re p o r t w here sym ptom s are felt while the exam iner assesses th e range o f knee extension (Figure 4). T h e range and p ain response are show n in T ab le IV. W hile th e ex am in er ensures th a t th e stu d en t’s knee rem ains in th e sam e degree o f extension, and also ensures th at th e th o racic an d lu m b a r sp in e is held in the fully slum ped p o sitio n , th e student is p erm itted to return the head and neck to the n e u tra l positio n . T h e change in sym ptom s on releasing the neck flexion is recorded in th e th ird p a rt o f T ab le IV. Also, if knee extension w as lim ited w hen in the p o sitio n show n in F ig u re 4, once th e neck flexion was released the student was asked to en d eav o u r to extend th e knee fu rth e r and the resulting new ran g e o f knee extension and any discom fort p rovoked by th is new range w ere listed in the th ird p a rt o f T a b le TV. O f th e tw enty-five students included in th e survey, seventeen had a full range o f knee extension w ith both left and rig h t knees, tw o h ad a lim ita tio n o f knee ex­ tension in the rig h t knee w hilst the left knee had full range, and the rem ain in g five students had a degree of bilaterally equal lim ita tio n in each knee varying from th ree to th irty degrees, approxim ately. O f th e seventeen students w ho had full knee ex­ tension only th re e had no p ain w hen each knee was extended. O f th ese th ree, tw o had no pain in slum p sitting w ith full neck flexion and also h ad only slight pain behind th e ir knees on standing w ith full tru n k flexion w hich w as only slightly increased when neck flexion w as added. T h e th ird had very slight pain a t the centre, T 9 level and h ad calf p ain on standing w ith full tru n k flexion w hich increased w hen neck flexion was added. By review ing th e w hole o f T ab le TV it w ould seem th a t at one ex trem e o f th e range o f norm als, 3 students have p ain free full slum p sitting w ith neck flexion and knee extension superim posed. T h e biggest m a jo rity had th e ir T 9 pain increased when adding knee extension. Also, w ith the ad d itio n o f th e knee extension, th e m ajo rity h ad p o sterio r knee pain provoked if they h ad this in the standing position. O thers w ho h ad different areas o f pain in th e stan d ­ ing tests h ad these p rovoked once th e knee w as ex­ tended. T h o se w ho had calf p a in in standing proved 25 16 1 1 1 1 T ABLE m . Slum p-Sit S uperim posed N F N um bers Sit (Figs 1 & 2) R ange P ain 2 Fem ale V V V V 3 M ale 12 Fem ale V V V t T 9 a rea 4 M ale 1 F em ale V V V sides o f ra th e r th a n t 1 F em ale V V V sides from T9 — iliac crest 1 Fem ale V V V R low er rib s laterally 1 F em ale V V V t T 9 a re a plus slight central f = c e n tr e 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 10 F I S I O T E R A P I E MAART 1980 T A B L E IV F R O M SL U M P -SIT + N .F . P O S IT IO N R eleasing N F C hange A dding K nee E xt Effect possib S tudent P ain felt in on to Kn« N o. standing test R ange P ain p ain Ext. 2 P o st K nee V V V5 V T + P o st K n 6 V + P ost K n V 8 - 2 0 ° T T9 + Post K n V V 9 L ", V T9 T + Post K n V R - 3° T9 T + Post K n V R V 10 - 5° T9 t + P ost K n N o L/S V V 11 V T9 t + Post K n V 13 V V V V14 - 3 0 ° T 9 t + P ost K n 15 V T 9 ISQ no Post K n V 16 V T 9 t + B utt to P ost K n V 17 V Sides T9 to L u ISQ + post K n V 18 V T 9 + | post K n V 19 L ” ” V T 9 ISQ + post K n + L B utt V R V „ + R B utt V 21 - 5° H am s V V 22 V T9 t + Post K n + low B utt V 24 V N o T9 post K n V 12 L P ost K nee H am s V T T9 + H am s V VR - 1 0 ° f T 9 + R B utt V 1 ” ” ” V T9 + Post K n + M id H am s V V23 - 1 5 ° SI T9 T H am s no K n V 3 H am s ly V T 9 T + Low H am s V 7 H am s, Calves V T 9 T + Post K n no H am s or V C alf V V20 Calves - 3° N o T9 si H am s 25 V N o T9 (or Sit) post K n V 4 *» V S it T8 K nee Ext. p ost K n si post K n si post K n si post K n V si H am s + post K n V v si H am s to be an exception to th is rule, but this only related to th ree students. T h e m ost im p o rta n t to arise o u t o f this p a rt o f the test .was th a t every student, w hen «neck flexion was released, com pletely lost all the sym ptom s w hich had previously been provoked. I t w ould th erefo re seem th a t these sym ptom s were provoked by tension having been applied to th e p ain sensitive structures in the vertebral canal, because it is only these stru ctu res w hich are altered on releasing the neck flexion position. It is also im p o rtan t to n o te th a t those students who had a lim itatio n o f knee extension w ere ab le to have full range o f knee extension once th e neck flexion was re­ leased. In all th e students b u t one, the only sym ptom s provoked by th e im proved range of knee extension was discom fort behind th e knee. Superimposing Dorsiflexion of the Ankle W hen dorsiflexion is added to straig h t leg raising (B ragard’s test) as a n exam ination p rocedure fo r nerve ro o t com pression, it w ould seem reasonable to assume th a t it is only o f value when the range of dorsi­ flexion is lim ited, coupled w ith rep ro d u ctio n o f a p a tie n t’s p ain , p rovided th is pain is not eith er in the calf o r behind th e knee. It is o f interest to note the results o f this survey o f a selected gro u p o f so-called norm als in relation to the range of dorsiflexion and th e areas o f p a in so produced. Because o f the com­ p lexity o f trying to relate both range and pain w ith the o th er tests carried ou t on each student it is p e r­ haps b etter to present different aspects o f th e findings ra th e r th a n to describe th e results fo r each student as is set o u t in the final (T able V III).* F ull Range Dorsiflexion (Table V) O nly nine students had a full range o f dorsiflexion and, w ith the exception o f one student who had very slightly lim ited knee extension, they all h a d a full range of knee extension. T h ere w as only o ne student who h ad no pain w ith the full range o f dorsiflexion. T h e rem aining eight students h ad som e p ain w ith/ dorsiflexion. I t is im p o rtan t to note th a t w ith the re ­ lease o f neck flexion all p a in caused by the d o rsi­ flexion disappeared. T his finding was valid fo r all the students. Symmetrical Limitation o f D orsiflexion (T able V I) T en students had a lim itatio n o f dorsiflexion w ith full flexion o f the spine and m axim um knee extension. O f these ten, six had full range o f knee extension, and the rem aining fo u r w ith lim ited dorsiflexion also had lim itatio n o f knee extension. F o r all ten students the lim itatio n o f dorsiflexion and extension w here ap p li­ cable, was the sam e fo r both left and rig h t legs. Asymmetrical Limitation o f D orsiflexion (T able V II) T h e six rem aining students had lim ited dorsiflexion w hich w as different when com paring the left leg w ith th e right. T h ree of these h ad full range of knee extension. Two o f the o th e r th ree had a m atching * C an be obtained from a u th o r at 175 W ard Street, A delaide, South A ustralia 5600. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M ARCH 1980 P H Y S I O T H E R A P Y 11 T A B L E V. F U L L R A N G E O F D O R S IF L E X IO N Student Slum p-sit + N F Slum p-sit + N F + K nee Ext. A dding D orsiflexion Effect on Releasing N o. R ange Pain R ange P ain R ange Pain N F 2 V V V V V 13 V V V V V post K n V 19 V T9 V T9 + ISQ B u tt + Post K n V t B utt K n V (T9 ISQ) 4 V T9 V T9 ISQ V T T9 V 5 V T9 V T9 t + post K n V T9 ISQ post k n | V 6 V R lat low V ribs ISQ post K n V R ibs ISQ V ribs post k n f 7 V T9 V T9 t + P ° st K n (no ham s, V si T T9 + V calves) calf, ham s 15 V T9 V T 9 ISQ no K n p V T9 ISQ + V P ost K n 20 V T9 V. si. ltd. H am s V T9 ISQ T ham s V TABLE VI. SYM M ETRICAL LIM ITATION OF D O R SIFLEX IO N R ange of R ange of knee lent No. dorsiflexion extension P ain felt w ith the D .F. 3 - 2 5 ° V H am s 11 - 1 5 ° V post kn T9 hams 16 - 2 0 ° V T9 Butt, to post K n. 17 - 1 0 ° V post kn. 18 —20° V post kn. 24 - 1 0 ° V post kn. 8 - 5 0 ° - 2 0 ° post kn. 14 - 3 0 ° - 3 0 ° post kn. 21 - 3 0 ° - 5° H am s, calves, post kns. 23 - 1 0 ° - 1 5 ° H am s TABLE VII. ASYM M ETRICAL LIM ITATION OF D O R SIFLE X IO N R ange of R ange of knee lent No. dorsiflexion extension Pain felt w ith th e D.F. 1 L - 2 5 ° V Pcist kn, H am s & T9 R - 1 0 ° V 22 L - 5° V T9, B utt & C alves R - 2° V 25 L - 3 0 ° V L C alf & L Butt. R - 2 5 ° V R C alf & H am s 9 L - 2 5 ° V - 3° Post knees R - 4 0 ° 12 L - 1 5 ° V - 1 0 ° L H am s R - 3 5 ° R B utt + + 10 L - 3 0 ° - 5° Post knees and H am s R - 2 0 ° - 5° lim itatio n to th e ir range o f knee extension w hilst one had a b ilaterally equal lim itatio n o f knee extension as com pared w ith the asym m etrical lim itatio n of the dorsiflexion. Pain Patterns T he v ariatio n in p attern s o f p ain p roduced by the various test m ovem ents was interesting to follow. In re la tio n to the dorsiflexion m ovem ent the p a in re ­ sponses w ere as follow s: 1. Increased pain in the T9 a rea in six o f the students. Tw elve of the students who had T9 area pain w hile in the sitting neck flexion position, how ever, did n o t have this pain increased by the dorsiflexion despite the fact th a t the T9 p ain was increased w ith the knee extension movem ent. 2. In tro d u ctio n o r increased ham string area p a in o r buttock pain in ten o f the twenty-five students. If student No. 4 is included, because dorsiflexion increased p ain in the T9 area, then eleven o u t o f twenty-five students had p a in provoked or in tro ­ duced in areas o th e r than in the calf o r behind the knee. It is useful to follow thro u g h th e twelve unusual p a in responses which occurred. R eference to T ab le V III* will serve to clarify the follow ing statem ents: 1. S tudent No. 4 had calf pain on standing w ith full tru n k flexion. T his pain was n o t reproduced a t any o th er stage o f the test. * C an be obtained from a u th o r at 175 W ard Street, A delaide, South A u stralia 5600. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 12 F I S I O T E R A P I E MAART 1980 2. S tudent N o . 6 h ad right low er rib pain felt laterally o n sitting neck flexion. T h is p ain was n o t pro v o k ed fu rth e r by the rem aining test m ove­ ments. 3. S tudent N o. 7 h ad ham string and calf p a in on standing flexion, w hich was increased by neck flexion in standing. T his was n o t affected by knee extension in sitting yet rep roduced calf and ham string p a in w ith dorsiflexion. 4. S tudent N o. 10 h ad lum bosacral pain when neck flexion was added to standing full tru n k flexion. T h is pain was n o t reproduced in an y o th er test position. T h is student did, how ever, have lim it­ atio n o f knee extension and dorsiflexion greater than nearly all o f the o th e r students. 5. S tudent N o. 12 follow ed the com m on p attern w ith the in itial tests u n til knee extension was introduced. A t this p o in t, the rig h t m ovem ent show ed restrictio n in range and m ark ed increase o f rig h t b u tto ck pain. I t could p ro v e interest­ ing if this student w ere able to be follow ed over a period o f tw enty or th irty years to see if she develops back, rig h t buttock o r rig h t sciatic pain fo r an y reason. 6. S tudent 16 was one of tw o students to feel T9 area p ain in flexion in standing w hen h e r neck was flexed. W hen knee extension was in tro ­ duced in to the test, not only did th e T9 area p a in increase b u t p a in was also felt in the b u t­ tocks and ham string a rea to behind the knees. T h is p ain was fu rth e r provoked by dorsiflexion w hich w as lim ited. F ollow -up in this case w ould be interesting. 7. S tudent N o . 17 h a d a m uch w ider distrib u tio n o f pain during the sitting neck flexion test but as no o th e r test m ovem ent was significant it is assum ed th a t th e w ider a rea o f p a in is n o t sig­ nificant. 8. S tudent N o. 18 was the o th er student to present w ith p ain in the T9 area standing tru n k flexion plus neck flexion. T here was n o th in g of fu rth er significance in h e r test m ovem ents. 9. Student 19 h ad bu tto ck pain w hen neck flexion w as added to the standing tru n k flexion position. T his p ain was reproduced by both knee ex­ tension and dorsiflexion. F ollow -up could again be of interest. 10. S tudent N o. 20 h a d very lim ited tru n k flexion in standing w hich provoked calf pain th at in­ creased w ith neck flexion. I t is also o f interest th at the neck flexion range was lim ited by this calf pain. D espite this ex am in atio n finding none o f the o th e r test m ovem ents seem ed to bear any relatio n to the findings on standing. 11. S tudent N o. 22 h ad buttock pain reproduced in standing full flexion when neck flexion was added. T his p ain in the buttocks w as fu rth e r rep ro ­ duced by knee extension an d dorsiflexion. Again, a follow -up study could prove enlightening. 12. S tudent N o. 25 had calf p ain on standing full flexion w hich was reproduced by dorsiflexion in an asym m etrical m anner. T his is an o th er exam ple w here follow -up could prove useful. T h e com m ents in the above section hav e related basic­ ally to p a in response. C om parisons regarding range o f m ovem ent can be m ade by reference to colum ns 10 and 14 w ith colum ns 17, 22 and 24. C om paring colum ns 10 and 17 it will be seen th a t they m atch m uch as one w ould anticipate, and when follow ing this com parison thro u g h to colum n 22 in p a rtic u la r but also to colum n 24 w here applicable, the figures do m atch in a p re ­ dictable m anner. SU M M A R Y H av in g tabulated the results o f this survey o f twenty- five supposed norm als it is obvious that it can only be considered as a pilot study. T h e study needs to include a larger num ber of candidates. I t should be expanded to test th e norm als in tw o other age groups, 1 1 -1 3 years an d 35 - 45 years. Possibly, if m ore scrupulous care were taken w ith the questioning o f p ain response to the test m ovem ents, som e of- the m in o r discrepancies in this survey m ight n o t have occurred. F o r exam ple, the n u m b e r o f tim es when 't'9 area p a in was n o t recorded as having been increased by the ad d itio n o f knee ex­ tension. T h e n orm al test fo r straig h t leg raisin g should also be added to the test m ovem ents. F u rth erm o re, fro m this survey the follow ing can be considered norm al: 1. T 9 area pain w ith tru n k an d neck flexion. i 2. P a in behind th e knees, an d in som e cases, in th l. ham strin g area. 3. R elease o f pain, p rovoked when knee extension and dorsiflexion are added to th e neck and tru n k flexion position, when flexion is released. 4. F u ll range knee extension w ith full tru n k flexion in all but a very small percentage o f examples. 5. F ull range of dorsiflexion w hich was previously lim ited when neck flexion is released fro m its fully flexed p osition in the m a jo rity o f examples. 6. P a in w ith som e of the test m ovem ents in this slum ped position. O nly one o f the twenty-five students h a d a full p ain-free range. T h e m ost significant finding fro m this survey is, how ever, the fa c t th a t pain felt in the area o f the ham strings or b ehind th e knees w hen th e knee is fu lly extended and the fo o t dorsiflexed w hile the tru n k is fully flexed, disappears when the neck flexion com ­ ponent is released. T herefore, it seems logical to b e­ lieve th a t the ham string o r p o ste rio r knee pain and its concurrent lim itatio n o f m ovem ent is due, n o t to ‘tig h t h am strin g s’ but ra th e r to the lim itatio n o f m ove­ m ent o f structures betw een the sacrum and the skull. These stru ctu res m ust be the pain sensitive structures w ithin the vertebral canal. A cknow ledgem ents I w ould lik e to express m y sincere thanks to M iss” * M. J. H am m o n d the H ead o f th e School o f P hysio­ th erap y in South A ustralia, to M rs M. M em itz who organised the exam inations o f the students and also to th an k the students them selves fo r being w illing to take p a rt in this survey. I w ould also lik e to express my thanks to M r D avid T hom pson, M r N eil M erkel and M iss M arg aret Sim m onds fo r th e visual aids w hich they have produced. F in a lly I m ust express m y thanks to M rs H elen Allen fo r struggling so success­ fully to reproduce the T ables, especially T ab le V III. References F ah rn i, W. H . (1966). O bservations on straig h t leg raising w ith special reference to nerve ro o t a d ­ hesions. Can. J. Surg.. 9, 44. M acnab, I. (1971). N egative disc exp/oration. A n a n a ­ lysis of the causes o f nerve ro o t involvem ent in 68 patients. /. B one & Jt. Surg., 53A, 891. P halen, G. S. an d D ickson, J. A. (1961): Spondylolisthe­ sis and tight hamstrings, J. B one & Jt. Surg., 43A, 505. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )