The Slump Test: Examination and Treatment

The Slump test is becoming more widely ac- GEOFFREY D. MAITLAND

cepted as an examination and treatment pro-
cedure for all levels of the vertebral column. Geoffrey Maitland, M.B.E., A.U.A., F.C.S.P., F.A.C.P.,
The test is essential for a fuller recognition of S.A.S.P., M.M.T.A.A., F.A.C.P. (Specialist Manipula-
the factors contributing to some patients' dis- tive Physiotherapist) is a Senior Lecturer Tutor and
Clinical Supervisor, 'Graduate Diploma of Advanced
orders. This paper describes the test, the normal ManipQlative Therapy', South Australian Institute of
pain response, predictable findings on exami- Technology. He is also a private practitioner in North
nation, and use of the test in treatment. Adelaide.

The Slump test is a spinal test which Step 1 Step 6

is aimed at determining the relationship Symptoms in the erect posture Symptom and range changes with re-
between the patient's symptoms and The patient sits erect and the symp- lease of cervical flexion
restriction of movement of the pain- toms in this position are defined (Fig- While the patient is held in this po-
sensitive structures within the vertsbral ure 1). sition of maximum stretch, the flexed
canal or intervertebral foramina'" (ey- Step 2 cervical spine component of the stretch
riax 1982). Physiotherapists are famil- Symptoms and range in slumped tho- is released and any change in the symp-
iar with the straight leg raising test racic and lumbar areas tom responses noted (Figure 6). In pa-
(SLR), together with superimposed an- The patient slumps and the physio- tients of the spontaneous-onset group,
kle dorsiflexion, as a test of movement therapist isolates the movement to full the common response on release of the
of the neural elements in the low lum- flexion of the thoracic and lumbar cervical flexion stretch is for the pain
bar spine. The SLR, on its own, is spines, preventing any flexion of the to lessen or to be completely relieved.
often insufficient to reveal a canal/ cervical spine (Figure 2). The symptom This response is proportional to the
foramen component. However, by us- response to the movement and to ap- amount of cervical flexion released.
ing the Slump test, the canal/foramen plied overpressure is determined. When the cervical flexion has been re-
structures are put on maximum stretch, Step 3 leased, the patient is usually able to
thus demonstrating their involvement. Symptoms and range in slumped cerv- extend the knee further before pain is
This is particularly so in the lumbar ical, thoracic and lumbar areas again produced.
area, and also applies to the thoracic The patient fully flexes the cervical Step 7
and cervical areas of the spine (Breig spine and overpressure is applied (Fig- Slump test with extension of both knees
1978). ure 3). Symptom responses are again and dorsiflexion of both ankles
determined. The test can be repeated using both
Method Step 4 legs (Figure 7). Again the pain re-
Symptoms and range in slumped spine sponses are determined. The cervical
The following description relates to and extension of one knee flexion is then released and the effect
the lumbar spine, with some reference The patient extends one knee and on symptoms and range of movement
to the cervical spine. The methods for the physiotherapist applies overpres- is assessed.
performing the test for the lower tho- sure while noting the symptom re- Step 8
racic area on the one hand and the sponses (Figure 4). A position of strength and control of
middle and upper areas on the other, Step 5 the full slump position with the patient
are not discussed as they are the same Symptoms and range in slumped po- in &long-sitting'
as those for the lumbar and cervical sition with knee extension and ankle A maximum stretch for the Slump
areas respectively. dorsiflexion added test can be performed with the patient
In the position of maximum knee in the 'long-sitting' position while the
Lumbar Area extension, the patient dorsiflexes the physiotherapist adopts a position on
Because the finer details of the Slump ankle of the raised leg and the physio- the examination couch such that the
test have been published elsewhere therapist applies overpressure (Figure firmness of the overpressure can be
(Maitland 1979), the following descrip- 5). The symptom responses are again controlled. The sternum is used to con-
tion will be brief. determined. trol the thoracic and lumbar flexion,

The Australian Journal of PhYSiotherapy. Vol. 31, No.6, 1985 215

The Slump Test

slowly into the flexed position. Changes

in the patient's sYmptoms and any re-
strictions of range are noted (Figure
10).
Step 3
Changes in symptoms and range with
extension of both knees and dorsiflex-
ion of both ankles
An alternative and quite different
approach is to extend both knees and
dorsiflex both ankles, without allowing
the thoracic and lumbar spine to slump
(Figure 11). Changes are again noted.
Patients on whom the Slump test is
assessed can be divided into two
groups. There are those whose history
Figure 1: The erect posture. involved trauma, and there are those
whose symptoms have come on 'more
or less' spontaneously. The latter Figure 3: Slumped cervical, thoracic and
lumbar areas.
group, referred to in Step 6 (above),
have a common symptom reponse at
the different stages of the test. To make
the description clearer, an example of
the chin controls cervical flexion, one the common symptom responses for a
hand stabilizes the knee extension and man with left buttock pain of lumbar
the other hand controls the dorsiflex- 'canal structures' origin would be as Step 3 (Figure 3)-Reproduces his left
ion (Figure 8). follows: buttock pain
Step 4 (Figure 4)-Left knee extension
Steps 1 and 2 (Figures 1 and 2)-No
Cervical Area lacks 10° and increases the intensity
pain
Patients may have symptoms arising of the buttock pain
from the cervical canal structures. The Step 5 (Figure 5)-Full range of dor-
Slump test is modified to test the struc- siflexion and no change in sYmptoms
tures in this area.
Step 6 (Figure 6)-Left buttock pain
Step 1 disappears and full range of left knee
Symptoms and range of cervical flex- extension is possible before slight left
ion while sitting in the erect position buttock pain returns
After first determining any symp- When endeavouring to evaluate the
toms in the erect sitting position (Fig- pain responses in the lower limb, it
ure 1), the patient flexes the cervical must be remembered that a pulling
spine, approximating the chin to the feeling or pain felt in the calf with
manubrium sterni. Overpressure is ap- dorsiflexion does not necessarily im-
pled, to reproduce symptoms if nec- plicate the canal structures as the cause,
essary. This overpressure must be such as it is a common response with the
that it flexes the whole cervical spine dorsiflexion part of the test (Figure 5).
(Figure 9). Also, it is notable that these calf sen-
Step 2 sations are not eased with the 'cervical
Changes in symptoms and range with flexion-release' part of the test (Figure
thoracic and lumbar flexion added 6).
This step requires great care to en- Pain felt at the T8 T9 area of the
sure stability of the patient's flexed spine during the stages of the test from
cervical spine while the patient allows Figure 2: Slumped thoracic and lumbar Figures 3, 4 and 7 is common and
the thoracic and lumbar spine to slump areas. normal (Maitland 1980).

216 The Australian Journal of PhySiotherapy. Vol. 31, No.6, 1985

 The Slump Test

When to Use the Slump Test

Even when a patient has lumbar
be taken a fraction further to deter-
mine the pattern of behaviour of the ,,"
symptoms only, the Slump test is man- radicular symptoms. No overpressure
datory. When the patient's symptoms should be added if radicular pain is
are only in the lower back or buttocks, reproduced.
strong overpressure should be used if In the thoracic and cervical area the
it is necessary to prove that the canal slump test need be used only when:
movements are normal. However, in (a) trauma is involved in the patient's
the presence of radicular symptoms, history;
each stage of the test movement should (b) there is reason to believe that the
be taken only to the point where pain structures within the canal may be
is first felt. Having stated this, it may involved or affected;
(c) it is necessary to prove that move-
ment of the canal structures is not
affected;
(d) if treatment of other faulty struc- Figure 6: Release of cervical flexion.
tures ceases to produce predicted
improvements.

When to Use the Slump Test

as a Treatment Procedure
The Slump test can be used as a
treatment technique in two basic ways:
1. When the canal structures are moved
through a large pain-free amplitude.
(This is indicated when pain is the
dominant feature of the patient's
disorder rather than restricted
range.)
2. When the aim is to stretch the struc-
Figure 4: Slumped spine with one knee tures strongly. There are gradations
extension. between the 'large painfree ampli-
tude' technique and the strong Figure 7: Extension of both knees and
stretch technique. dorsiflexion of both ankles.

~--

,.
"
I ,- - -
Figure 5: Slumped spine position with
knee extension and ankle dorsiflexion Figure 8: A position of strength and control of the full slump position with the
added. patient in 'long sitting'.

The Australian Journal of PhYSIOtherapy. Vol. 31, No.6, 1985 217

The Slump Test

The physiotherapist most commonly

sees the patient whose canal structures
are involved secondarily. But whether
the involvement of the canal structures
is primary or secondary, the faulty in-
tervertebral segment should be treated
before considering treating the canal
structures. This is the best and safest
way to determine the degree of primary
or secondary involvement of the canal
structures. If treatment of the interv-
ertebral segment restores normal move-
ment, yet the canal signs remain un-
changed or only slightly improved, then Figure 11: Cervical flexion with exten-
the canal structures should be treated ion of both knees and dorsiflexion of
by using techniques which move them. both ankles.
In other words, the only time when the
canal structures should be treated by
Figure 9: Cervical flexion while sitting
in the erect position. moving them is when it can be deter- course, that the physical examination
mined that the disorder of the canal has revealed a canal component).
structures is the primary reason for the
spinal movements being painful or lim- Techniques
ited in range. As an example, a pa- Lumbar
The pain sensitive structures in the
tient's lumbar flexion and left lateral Especially with low lumbar disorders
vertebral canal and intervertebral fOI-
flexion may be painfully limited due which have a canal component, one
amen may be implicated in the pa-
entirely to restricted movement of the usually has a choice between using
tient's symptoms either primarily or
canal structures rather than to any fault straight leg raising or a technique in
secondarily.
in the joint structures. the slump position. Slump techniques
The canal structures may be injured
In summary, treat the joint move- 'get at' the disorder more effectively
directly such as when a patient has been
ments first, and if they do not improve than straight leg raises, but they are
involved in a vehicular accident. This
the canal movement signs, then treat more awkward to perform.
is one example of primary involve-
the canal movements (assuming, of It is quite common, in patients who
ment. The canal structures may also
have episodic low back pain, to find
be involved primarily as a result of
that the cervical flexion component of
inflammation or infection, but such
the slump test (Figure 3) is restricted
patients are not discussed in this paper.
and reproduces the low back pain. As
In patients who have a history of
mentioned above, the lumbar inter-
spontaneous onset, the canal structures
vertebral joint component should be
may be involved secondarily. Being in-
treated first so as to eliminate its con-
volved secondarily means that there is
tribution to the patient's symptoms and
something else wrong with other parts
signs after which the canal moving
of the spine and that it is the faults in
techniques may be used. In this in-
these parts which hinder the move-
stance, the patient would be put into
ments of the canal structures thereby
the slump position but without the
causing pain. A common example of
cervical flexion, and the treatment
this is the patient who has episodic low
technique would be to perform cervical
back pain which later radiates into the
flexion in a chosen grade and rhythm.
leg. If examination using the Slump
The basis for choosing certain grades
test reveals a canal component, it may
and rhythms is the same as if the tech-
be that a herniating disc is irritating
nique were being applied to a joint.
the dura or nerve root sleeve; that is,
there is nothing wrong with the dura Thoracic
itself, as it is only because part of the The same principles apply to the tho-
disc is touching it that the Slump test Figure 10: Thoracic and lumbar flexion racic spine as have been described
is positive. added. above for the lumbar spine. However,

218 The Australian Journal of PhySiotherapy Vol. 31, No.6, 1985

 The Slump Test

the examination procedures for the up- A similar canal 'movement-without- being first positioned in lateral flexion
per thoracic spine match more closely pain' technique is to have the patient or rotation before adding each of the
those used for the cervical canal struc- sitting with his head in flexion while other components. This increases the
tures. he performs repeated double leg knee unilateral effect of the Slump test
extension as a swinging movement (see (Maitland 1984). These variations
Cervical Figure 11). should be remembered so that they can
The cervical area (and the upper tho- Using the slump position for treating be used when patients with the more
racic area) can be treated by two move- headache which has a canal component difficult disorders are being examined.
ment techniques which differ from has been fully described in an earlier
those used for the lumbar spine. On publication (Maitland 1979). However
examining the cervical movements, it there is one factor about the technique In Conclusion
may be found that neck flexion is re- which requires explanation. The tech- Differentiating symptoms of canal
stricted by reproduction of the pa- nique in the slump position must be origin from those arising from move-
tient's pain. When thoracic flexion is sustained at the limit of its range for ments of the joints is necessary if the
added to the fiXed position of cervical upwards of a minute or so before the physiotherapist is to be fully aware of
flexion as described above, there will headache may be reproduced. This dif- patients' problems and the Slump test
be an immediate marked increase in fers from the other slump tests or treat- is essential for this differentiation. Only
the pain if there is a canal restriction. ment techniques in that it is a sustained then can treatment be performed ap-
Under such circumstances, the first of position rather than a movement. propriately with a clear aim in mind.
the two treatment movements is cerv- Prognosis also becomes more mean-
ical flexion, either with the thoraofc ingful.
spine erect or with it flexed. The second Slump Test Variations
technique is to hold the neck flexion The tests described up to this stage
in a stable position, and use thoracic maintain the spine in the sagittal plane.
References
flexion as the treatment movement. Admittedly the extending of each leg Breig A (1978), Adverse Mechamcal TensIOn In
Another treatment technique applied separately brings in a unilateral com- the Central Nervous system, Almquist and Wik-
sell International, Stockholm.
to cervical canal disorders is as follows. ponent to the test, and it is an impor- Cyriax J (1982), Textbook of Orthopaedic Med-
The patient lies supine with the cervical tant component. It is especially im- Icme, Volume 1, Bailliere Tindall, London.
spine flexed to the pcint where pain portant in those patients who have a Maitland GD (1979), Negative dtsc exploration:
positive canal SIgnS, The Australran Journal of
starts to be reproduced. While this po- bias in either their symptoms or the PhYSIOtherapy, 25, 129-134.
sition is maintained by pillows, re- other examination findings. This uni- Maitland GD (1980), Movement of pain sensitive
peated straight leg raising is performed. lateral consideration introduces an- structures in the vertebral canal and interverte-
bral foramina in a group of physiotherapy stu-
Such a technique is not painful but it other aspect to the Slump test. The full dents, South Afncan Journal 0/ PhYSIOtherapy,
does move the canal structures, and in Slump test performed in the manner 36,4-12.
Maitland GD (1984), Canal Signs and their SIg-
moving them, it may improve the 'pain described in Figures 2 to 7 above can nificance in Treatment, Symposium: Low Back
and range response' to the canal test. be performed with the seated patient Pam, PreventIOn, Treatment, Research, in press.

The Australian Journal of PhYSiotherapy Vol 31, No.6, 1985 219