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Physiotherapy 97 (2011) 59–64

Reliability and diagnostic validity of the slump knee bend neurodynamic


test for upper/mid lumbar nerve root compression: a pilot study
Kate Trainor a,b,∗ , Mark A. Pinnington a
a Directorate of Physiotherapy, School of Health Sciences, University of Liverpool, Liverpool, UK
b Aintree University Hospitals NHS Foundation Trust, Physiotherapy Department, University Hospital Aintree, Liverpool, UK

Abstract
Objectives It has been proposed that neurodynamic examination can assist differential diagnosis of upper/mid lumbar nerve root compression;
however, the diagnostic validity of many of these tests has yet to be established. This pilot study aimed to establish the diagnostic validity of
the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression in subjects with suspected lumbosacral radicular pain.
Design Two independent examiners performed the slump knee bend test on subjects with radicular leg pain. Inter-tester reliability was
calculated using the kappa coefficient. Slump knee bend test results were compared with magnetic resonance imaging findings, and diagnostic
accuracy measures were calculated including sensitivity, specificity, predictive values and likelihood ratios.
Setting Orthopaedic spinal clinic, secondary care.
Participants Sixteen patients with radicular leg pain.
Results All four subjects with mid lumbar nerve root compression on magnetic resonance imaging were correctly identified with the slump
knee bend test; however, it was falsely positive in two individuals without the condition. Inter-tester reliability for the slump knee bend test
using the kappa coefficient was 0.71 (95% confidence interval 0.33 to 1.0). Diagnostic validity calculations for the slump knee bend test (95%
confidence intervals) were: sensitivity, 100% (40 to 100%); specificity, 83% (52 to 98%); positive predictive value, 67% (22 to 96%); negative
predictive value, 100% (69 to 100%); positive likelihood ratio, 6.0 (1.58 to 19.4); and negative likelihood ratio, 0 (0 to 0.6).
Conclusions Results indicate good inter-tester reliability and suggest that the slump knee bend test has potential to be a useful clinical test
for identifying patients with mid lumbar nerve root compression. Further investigation is needed on larger numbers of patients to confirm
these findings.
© 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

MeSH terms: Nerve compression syndromes; Radiculopathy; Physical examination

Keywords: Slump knee bend; Diagnostic accuracy; Neurodynamics

Introduction of spinal nerve/nerve root compression remains unclear, and


this has implications for all clinicians who use it to assist with
Accurate clinical diagnosis of upper/mid lumbar nerve differential diagnosis.
root compression (L2 to L4) is highly desirable to ensure that The slump knee bend test [1] or femoral slump test [2]
appropriate surgical candidates are identified and referred on is an extension of the standard prone knee bend test [1] or
for diagnostic imaging. The slump knee bend neurodynamic femoral nerve stretch test [3]. The prone knee bend test has
test is not pathognomonic but is suggested to be useful in the been shown to place a load on the upper/mid lumbar nerve
diagnosis of lumbar radicular pain among other pathologies roots (L2 to L4) via movement of the femoral nerve during
[1,2]. The diagnostic validity of this test for specific levels knee flexion [3]. The slump knee bend test differs from the
prone knee bend test in that it is performed in side lying,
∗ Correspondence: Directorate of Physiotherapy, School of Health Sci-
and combines knee flexion and hip extension with thoracic
ences, Thompson Yates Building, University of Liverpool, Brownlow Hill,
and cervical flexion to further load the nervous system [1].
Liverpool L69 3GB, UK. Tel.: +44 0151 794 5742; fax: +44 0151 794 5740. Cervical extension is used when symptoms are reproduced
E-mail address: K.L.Trainor@liverpool.ac.uk (K. Trainor). to ‘unload’ the nervous system and assist with structural dif-

0031-9406/$ – see front matter © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.physio.2010.05.004
60 K. Trainor, M.A. Pinnington / Physiotherapy 97 (2011) 59–64

ferentiation [1]. The addition of a spinal flexion component MRI of this region. Exclusion criteria included pain in the
to the slump knee bend test gives it suggested superiority cervical or thoracic region likely to be exacerbated by spinal
over the standard prone knee bend test in differentiation slump, a history of central nervous system pathology, sys-
between symptoms arising from neural and non-neural tis- temic illness or symptoms indicating possible serious spinal
sues [1]. The prone knee bend and slump knee bend tests are pathology or ‘red flags’ [15]. The neurodynamic test per-
thought to be particularly useful to evoke symptoms in mid- formed in the study is presumed to load the nervous system;
dle and upper lumbar radiculopathy, but it is also suggested for this reason, the presence of any of these characteristics
that they may have a role in the assessment of sensitive lower may have subjected the study participants to an unacceptable
lumbar radiculopathy [1]. Both tests are also advocated to level of risk. Patients with recent quadriceps injury (in the
assist in the differential diagnosis of other disorders including last 6 months) and participants unable to lie in the test posi-
femoral-nerve-related pathologies [2]. tion were also excluded. Finally, participants were excluded
An electronic search was performed of AMED (1985 to if the anticipated wait for MRI was more than 6 weeks or if
2008), CINAHL (1982 to 2008), EMBASE (1980 to 2008), their previous MRI was obtained more than 6 weeks previ-
Medline (1980 to 2008) and PEDro (1980 to 2008). The ously.
search terms used were deliberately kept broad to allow Informed consent was obtained from suitable participants
for the lack of literature relating to neurodynamic testing, who were then screened for the presence of serious spinal
and were as follows: prone knee bend, crossed prone knee pathology or ‘red flags’ [15]. Any participants found to
bend, femoral nerve stretch test, slump knee bend, straight have signs of widespread neurology or other red flags were
leg raise, neurodynamics, adverse neural tension, thora- highlighted to the medical team and withdrawn from the
columbar radiculopathy, lumbar radiculopathy and lumbar study.
nerve root compression. The search was further refined by The slump knee bend test was performed once on
adding additional terms including ‘and Physiotherapy’, ‘and each participant by two investigators, both experienced
Physi*therapy’, ‘and validity’, ‘and reliability’ and ‘and diag- physiotherapists who had been working in the field of mus-
nosis’. The prone knee bend test [4–8] and crossed prone knee culoskeletal physiotherapy for over 10 years. The first author
bend test [9,10] have been investigated in relation to their was named as the principal investigator. Tests were performed
ability to diagnose upper/mid lumbar disc herniation, low with random examiner order. Repeated movement of a joint
thoracic disc herniation and upper/mid lumbar radiculopa- to the end of its range during serial measurement may itself
thy (L2 to L4 spinal levels), but these papers are descriptive change the range of movement available at that joint; for
and do not report calculations of diagnostic accuracy. To the this reason, each neurodynamic test was only carried out
authors’ knowledge, no published studies have investigated once by each investigator. Any interval between repeated
the diagnostic validity of the slump knee bend test. testing was kept deliberately small (a few minutes), and indi-
This paper reports the diagnostic validity of the slump vidual investigators were blinded to each other’s findings.
knee bend test for the diagnosis of L4 nerve root compression Investigators were also blinded to any previous MRI scan
in conjunction with other levels of nerve root compromise results to avoid any conscious or subconscious ascertain-
in patients with radicular pain. Magnetic resonance imaging ment bias. The slump knee bend test protocol was adapted
(MRI) was used as the gold standard for diagnosis [11–14]. from a previously described protocol [1] and is shown in
The inter-tester reliability of the slump knee bend test is also Figs. 1 and 2. The slump knee bend test was performed in
reported. an attempt to reproduce symptoms or to identify any changes
occurring in existing symptoms. Unnecessary pain provoca-
tion was avoided by using sensitising manoeuvres to reduce
Methods rather than increase symptoms [2]. Each test was determined
to be either normal (negative) or abnormal (positive) for
Convenience sampling was used to recruit 16 patients each subject. No adequate criteria were found in the liter-
from an orthopaedic spinal clinic in an acute National Health ature to describe normal or abnormal participant responses
Service trust over a 6-month period. to the slump knee bend test using the specific end-test mea-
Participants were included if they had symptoms synony- sures chosen in this study, so criteria were established by the
mous with lumbosacral radicular pain, defined as having the authors. These criteria are shown in Boxes 1 and 2 and were
following features: based on the suggestions of experts in the field of neurody-
namics [1,2]. The point of evoked symptoms, submaximal
• intermittent or constant pain radiating into one or both legs
pain or the onset of firm resistance (R1) were used as end-
distal to the groin or gluteal crease; or
test measures. The reliability of these end-test measures has
• distribution of pain in all or part of the dermatomal area
not been investigated previously for the slump knee bend
of one or two adjacent lumbosacral nerve roots (L1 to S2
test.
levels).
Following neurodynamic testing, participants underwent
Participants were only recruited if they were awaiting MRI MRI if this had not been performed previously. All MRI scans
of the lumbar spine or returning to the spinal clinic following were evaluated routinely by hospital radiologists, and these
K. Trainor, M.A. Pinnington / Physiotherapy 97 (2011) 59–64 61

Box 1: Classification of a normal response (negative


result) to the slump knee bend neurodynamic test.
• Symptoms of stretching or discomfort on the side
being tested.
• These symptoms may be felt in the anterior thigh area.
• These normal symptoms may either decrease in inten-
sity or remain the same when cervical extension is
performed.
• Range of movement and normal symptom response
is the same on both sides.

Box 2: Classification of an abnormal response (pos-


itive result) to the slump knee bend neurodynamic
test.
• All or part of the subject’s reported symptoms are
reproduced or increased during the test procedure
(when testing on either or both sides). The symptoms
Fig. 1. Protocol for the slump knee bend neurodynamic test. Adapted from: should be the same usually experienced by the subject
[1].
(e.g. pain, paraesthesia previously reported). The pro-
voked symptoms should diminish when the subject’s
cervical spine is extended.
OR
• Associated symptoms (but not the subject’s reported
symptoms) are reproduced during the test procedure.
If the associated symptoms are not in a normal dis-
tribution and symptoms diminish when the subject’s
cervical spine is extended, this can be considered
a positive test. If the associated symptoms are in
a normal distribution, there must be evidence of
asymmetry between sides, and the symptoms should
diminish when extending the subject’s cervical spine.
OR
• The onset of firm resistance is perceived to occur ear-
lier in range during the testing procedure when one
side is tested compared with the other. This may or
may not be accompanied by symptom reproduction
or associated symptom production. There should be
a decrease in perceived resistance at the hip when
Fig. 2. The slump knee bend neurodynamic test. Reproduced with per-
mission from Claire Molyneux, Senior Physiotherapist, Aintree University extending the subject’s cervical spine.
Hospitals NHS Foundation Trust.

written reports were reviewed to establish:


sion is suspected. It is a reliable and valid tool for diagnosing
• the presence of any spinal nerve/nerve root compression
lumbosacral nerve root compression and intervertebral disc
and the level(s) it occurred in the lumbosacral spine; and
injury [11,12], and determination of nerve root compromise
• the type of pathology present causing the spinal
by MRI appears to be well correlated with surgical findings
nerve/nerve root compromise.
[13]. The sensitivity, specificity, accuracy, and positive and
The radiologists evaluating the scans were not aware that a negative predictive values for standard MRI and nerve root
research project was taking place. MRI was chosen as the gold compression have been shown to be 81%, 100%, 82%, 100%
standard for diagnosis and is routinely ordered in the spinal and 25%, respectively, when following the protocol used in
clinic where this study was undertaken if nerve root compres- this study [14].
62 K. Trainor, M.A. Pinnington / Physiotherapy 97 (2011) 59–64

Data analysis knee bend test (95% confidence intervals) were: sensitivity,
100% (40 to 100%); specificity, 83% (52 to 98%); positive
Inter-tester reliability for the slump knee bend neurody- predictive value, 67% (22 to 96%); negative predictive value,
namic test was calculated using the kappa coefficient [16–18]. 100% (69 to 100%); positive likelihood ratio, 6.0 (1.58 to
Strength of agreement was ascertained using standards pro- 19.4); and negative likelihood ratio, 0 (0 to 0.6).
posed by Brennan and Silman [19]. The diagnostic validity
of the slump knee bend test was established for upper/mid
lumbar nerve root compression (L2 to L4) by calculating Discussion
sensitivity, specificity, and positive and negative predictive
values. Positive and negative likelihood ratios were also cal- Inter-tester reliability was found to be ‘good’ for the slump
culated, defined as how many times more (or less) likely knee bend test using the kappa coefficient. This suggests
patients with the disease are to have a particular result than that clinicians can reliably agree on the findings of this test
patients who do not have the disease [20]. using the operational definitions described. All subjects with
All diagnostic accuracy measurements were calculated mid lumbar nerve root compression confirmed on MRI had
using data collected by the principal investigator, and 95% a positive slump knee bend test, and over 80% of partici-
confidence intervals were calculated for each value to estab- pants without the disorder had a negative test. The slump
lish the precision of the estimates [21,22]. knee bend test had some clinical value in predicting the dis-
order, and was found to be excellent at negating the disorder.
The rate of MRI-confirmed cases being correctly diagnosed
Results with a positive slump knee bend test was found to be six
times greater than that of negative MRI cases being incor-
The study sample was taken from an area of the North rectly diagnosed with a positive slump knee bend test. The
West of the UK. Of the 16 patients approached, all agreed to lower confidence interval of the positive likelihood ratio for
participate. Nine females (56%) and seven males (44%) were the slump knee bend test is greater than 1 (1.6), so it can
recruited, aged between 35 and 72 years with a mean age of therefore be suggested with 95% confidence that a patient
49 years (standard deviation 12.6). Symptom duration was classified with a positive slump knee bend test is more likely
reported as subacute (between 3 weeks and 3 months) for 11 to have mid lumbar nerve root compression than to be falsely
participants (69%) and chronic (more than 3 months) for the positive for the disorder.
remaining five participants (31%). The authors were unable to find any published literature
investigating the diagnostic validity of the slump knee bend
Reliability testing test in relation to any pathology; for this reason, no direct
comparison can be made with other work in this particu-
For the slump knee bend test, kappa was 0.71 (95% con- lar area. The only work previously undertaken in this area
fidence interval 0.33 to 1.0). This indicates that the strength has been in relation to the standard [4–8] and crossed [9,10]
of agreement using the kappa coefficient was ‘good’ for this versions of the prone knee bend/femoral nerve stretch tests.
test (between 0.61 and 0.8) using guidelines suggested by Only one paper was found that reported the diagnostic valid-
Brennan and Silman [19]. ity of these tests for L2 to L4 nerve root compression rather
than disc pathology [10]. This paper cannot be used for com-
MRI results parison with the present research as it only details two case
studies, and the data presented were insufficient for the cal-
MRI findings can be found in Table 1. Four of the 16 culation of sensitivity, specificity or predictive values for
participants had mid lumbar nerve compression on MRI, with diagnostic accuracy.
only two of these participants showing L4 compression in Bias can potentially limit diagnostic validity studies, so
isolation. attempts were made to eliminate this where possible. Inter-
pretation biases, which can occur when the results of the test
Diagnostic validity of the slump knee bend test for under investigation are known when the diagnosis is made
upper/mid lumbar nerve root compression using the gold standard (diagnostic review bias) or vice versa
(test review bias) [23], were eliminated by the blinding of
Neurodynamic test findings were reported as either posi- investigators. Observer variability bias [23], which can have
tive or negative, and all positive tests reproduced symptoms an adverse effect on external validity if not adequately con-
or associated symptoms in test participants (Boxes 1 and 2). trolled, was controlled for using a highly experienced tester
These findings were compared with MRI findings as the gold using standardised protocols for all neurodynamic testing.
standard, and the results are shown in Table 2. The slump Similarly, potential bias arising from the order in which the
knee bend test correctly confirmed or negated the presence tests were performed was controlled for by the random test-
of mid lumbar nerve root compression in 14 of the 16 partic- ing procedure. As the participants in this study were patients
ipants (88%). Diagnostic validity calculations for the slump referred to a spinal clinic due to the suspicion of lumbosacral
K. Trainor, M.A. Pinnington / Physiotherapy 97 (2011) 59–64 63

Table 1
Magnetic resonance imaging results indicating level and cause of spinal nerve/nerve root compression.
Subject Levels of SN/NR compression evident with MRI Significant pathology present causing spinal
SN/NR compression
1 No SN/NR compression N/A
2 No SN/NR compression N/A
3 Compression of the left L4 and L5 nerve roots Disc herniation
4 Compression of the left L5 nerve root Degenerative disc disease with herniation
5 Compression of the left L5 nerve root Disc herniation
6 Compression of the right L5 nerve root Disc herniation
7 L4 nerve root compression L3/L4 disc bulge, L4/L5 right lateral recess
stenosis and narrowing of the left
neuroforamina
8 No SN/NR compression N/A
9 Compression of the right S1 nerve root Narrowing of the L4/L5 and L5/S1 discs,
and small disc prolapse at L5/S1
10 No SN/NR compression N/A
11 No SN/NR compression N/A
12 Compression of the left S1 nerve root Disc herniation
13 No SN/NR compression N/A
14 Compression of the left L4 and L5 nerve roots L3/L4 disc dehydration. Posterior and lateral
disc bulging together with facet joint
hypertrophy causing a degree of
anteroposterior and transverse canal stenosis
and narrowing of the lateral recess exit
foramina. Minor disc bulge at L4/L5
impinging on the left exit foramina
15 Compression of the L4 nerve root Disc degeneration and bulging
16 Compression of the S1 nerve root Disc herniation
SN/NR, spinal nerve/nerve root; MRI, magnetic resonance imaging; N/A, not applicable.

nerve root compression, an element of patient cohort bias may validity [24]. All positive slump knee bend tests in this study
have been present (in particular, population bias). The authors reproduced symptoms or associated symptoms; for this rea-
acknowledge that this homogenous sample may affect the son, the use of R1 would not have affected the internal validity
external validity of the findings to the general population, but of the study findings. The use of M1, the onset of reflex mus-
suggest that the findings remain valid for individuals who cle activity, may be a more valid end-test measure for future
would be likely to undergo these tests in clinical practice (i.e. neurodynamic research. However, it remains unclear whether
patients with suspected radicular pain). clinicians can ascertain M1 reliably during clinical testing.
Clinicians should be aware that predictive values are Longer time intervals between repeated tests on individuals
dependent on the prevalence of disease in a study population, would have allowed any symptoms and potential biomechan-
whereas sensitivity and specificity findings are not. Increas- ical effects on tissues to settle, as this could have affected the
ing prevalence of disease makes it more likely that a person validity of the results. Both intra- and inter-tester reliabil-
with a positive test result has the disease, and less likely that a ity could also have been established for the individual test
positive result is a false positive. It should therefore be empha- measures used within the protocols.
sised that clinicians may not be able to apply these predictive The wide confidence intervals presented for the slump
test values directly to their own patient populations unless knee bend test mean that further data are needed from a larger
disease prevalence is similar. sample in order to clarify the usefulness of the test for this dis-
Other limitations to the study are in relation to the opera- order. In particular, more patients with upper lumbar nerve
tional definitions and protocol for the slump knee bend test. root compression (L2 to L3) would have strengthened the
The use of R1 as an end-test measure is contentious in the neu- conclusions, as this study has only shown the slump knee
rodynamic literature, both in relation to its reliability and its bend test to be valid for L4 spinal nerve/nerve root compres-

Table 2
Accuracy of the slump knee bend test for the diagnosis of L2 to L4 spinal nerve/nerve root compression using data collected by the principal investigator.
L2 to L4 SN/NR compression L2 to L4 SN/NR compression Total number of subjects
confirmed with MRI negated with MRI
Slump knee bend positive 4 True positives 2 False positives 6
Slump knee bend negative 0 False negatives 10 True negatives 10
Total number of subjects 4 12 16
SN/NR, spinal nerve/nerve root; MRI, magnetic resonance imaging.
64 K. Trainor, M.A. Pinnington / Physiotherapy 97 (2011) 59–64

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