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Concept: Straight leg raise


BACKGROUND: Leg pain associated with low back pain (LBP) is recognized as a risk factor for a poor prognosis, and is included as a component in most LBP classification systems. The location of leg pain relative to the knee and the presence of a positive straight leg raise test have been suggested to have clinical implications. To understand differences between such leg pain subgroups, and whether differences include potentially modifiable characteristics, the purpose of this paper was to describe characteristics of patients classified into the Quebec Task Force (QTF) subgroups of: 1) LBP only, 2) LBP and pain above the knee, 3) LBP and pain below the knee, and 4) LBP and signs of nerve root involvement. METHODS: Analysis of routine clinical data from an outpatient department. Based on patient reported data and clinical findings, patients were allocated to the QTF subgroups and described according to the domains of pain, activity limitation, work participation, psychology, general health and clinical examination findings. RESULTS: A total of 2,673 patients aged 18–95 years (median 47) who were referred for assessment of LBP were included. Increasing severity was consistently observed across the subgroups from LBP only to LBP with signs of nerve root involvement although subgroup differences were small. LBP patients with leg pain differed from those with LBP only on a wide variety of parameters, and patients with signs of nerve root involvement had a more severe profile on almost all measures compared with other patients with back-related leg pain. CONCLUSION: LBP patients with pain referral to the legs were more severely affected than those with local LBP, and patients with signs of nerve root involvement were the ones most severily affected. These findings underpin the concurrent validity of the Quebec Task Force Classification. However, the small size of many between-subgroup differences amid the large variability in this sample of cross-sectional data also underlines that the heterogeneity of patients with LBP is more complex than that which can be explained by leg pain patterns alone. The implications of the observed differences also require investigation in longitudinal studies.

Concepts: Longitudinal study, Epidemiology, Spinal disc herniation, Low back pain, Cross-sectional study, Cross-sectional analysis, Straight leg raise, Cyclic group


Chronic fatigue syndrome (CFS) is a complex, multisystem disorder that can be disabling. CFS symptoms can be provoked by increased physical or cognitive activity, and by orthostatic stress. In preliminary work, we noted that CFS symptoms also could be provoked by application of longitudinal neural and soft tissue strain to the limbs and spine of affected individuals. In this study we measured the responses to a straight leg raise neuromuscular strain maneuver in individuals with CFS and healthy controls. We randomly assigned 60 individuals with CFS and 20 healthy controls to either a 15 minute period of passive supine straight leg raise (true neuromuscular strain) or a sham straight leg raise. The primary outcome measure was the symptom intensity difference between the scores during and 24 hours after the study maneuver compared to baseline. Fatigue, body pain, lightheadedness, concentration difficulties, and headache scores were measured individually on a 0-10 scale, and summed to create a composite symptom score. Compared to individuals with CFS in the sham strain group, those with CFS in the true strain group reported significantly increased body pain (P = 0.04) and concentration difficulties (P = 0.02) as well as increased composite symptom scores (all P = 0.03) during the maneuver. After 24 hours, the symptom intensity differences were significantly greater for the CFS true strain group for the individual symptom of lightheadedness (P = 0.001) and for the composite symptom score (P = 0.005). During and 24 hours after the exposure to the true strain maneuver, those with CFS had significantly higher individual and composite symptom intensity changes compared to the healthy controls. We conclude that a longitudinal strain applied to the nerves and soft tissues of the lower limb is capable of increasing symptom intensity in individuals with CFS for up to 24 hours. These findings support our preliminary observations that increased mechanical sensitivity may be a contributor to the provocation of symptoms in this disorder.

Concepts: Symptoms, Symptom, Tissues, Soft tissue, Fatigue, Post-concussion syndrome, Chronic fatigue syndrome, Straight leg raise


Restless Legs Syndrome (RLS) is estimated to affect 5-15 percent of the U.S. population. There are few studies investigating non-pharmacological treatments for RLS, such as physical therapy and/or peripheral neural mobilization. The traction straight leg raise (tSLR) technique is one such mobilization that may affect central and peripheral neural pathways and reduce RLS symptoms. The purpose of this study is to determine the effects of a tSLR on the symptoms associated with RLS. A cohort of fifteen people was enrolled. Thirteen subjects (11 female) between the ages of 32-64 completed the study. Subjects completed two questionnaires to quantify their severity of RLS before treatment was initiated and at the final session. These measures included: the Restless Legs Syndrome Rating Scale (RLSRS) 0-40, an RLS Ordinal Scale, and a Global Rating of Change (GROC) assessments (-7, 0, +7). Patients were treated with tSLR bilaterally for four total visits on days 1, 3, 8, and 15. Results indicated an RLSRS pre-treatment average of 24.8 (severe) and post-treatment average of 9.2 (mild), representing a 63% improvement from baseline (p < 0.05). Ten of 13 subjects reported a GROC of +4 or higher at the final session, indicating at least a moderate improvement in patient status from baseline. Our results indicate that following a series of tSLR treatments symptoms were reduced in individuals with idiopathic RLS. A prospective, randomized controlled trial is necessary to evaluate the potential for a tSLR to effectively manage idiopathic RLS symptoms.

Concepts: Patient, Randomized controlled trial, Evaluation methods, Syndromes, The Final, Dopamine, Restless legs syndrome, Straight leg raise


The purpose of this study was to establish the reliability of a frame-by-frame cross correlation method of assessing longitudinal sciatic nerve excursion motion using real time ultrasound imaging during a modified passive straight leg raise (SLR) test. Eighteen asymptomatic participants (age range 19-68 years) lay on their sides on a purpose made jig and the sciatic nerve in the posterior thigh was imaged during knee extension at 30° and then 60° of hip flexion (HF). Participants were re-tested ≥48 h later. The ultrasound images were analysed off-line using cross correlation software. Results demonstrated excellent repeatability of in vivo sciatic nerve excursion during a modified SLR (HF30° ICC 0.92, CI 0.79-0.97, SEM 0.69; HF60° ICC 0.96, CI 0.89-0.99, SEM 0.87). The authors also identify points of good practise to ensure an accurate as possible measurement of nerve excursion using this method. These include breaking down larger movements into sub-components, visually tracking the moving nerve during the tracking procedure, and ensuring the optimal image is captured prior to analysis. The use of ultrasound imaging in lower limb nerve dysfunction will enhance the understanding of how nerves move in vivo during neurodynamic testing, as well as being able to identify possible alteration to nerve movements in patients with neuropathic pain states.

Concepts: Spinal disc herniation, Measurement, Psychometrics, IMAGE, Extension, Human leg, Straight leg raise, Posterior compartment of thigh


PURPOSE: To compare the short-term effects of a neurodynamic sliding technique versus control condition on hamstring flexibility in healthy, asymptomatic male soccer players. SUBJECTS: Twenty-eight young male soccer players from Palencia, Spain (mean age 20.7 yrs ± 1.0, range 19-22) with decreased hamstring muscle flexibility. METHODS: Subjects were randomly assigned to one of two groups: neurodynamic sliding intervention or no intervention control. Each subject’s dominant leg was measured for straight leg raise (SLR) range of motion (ROM) pre- and post-intervention. Subjects received interventions as per group allocation over a 1 week period. Data were analyzed with a 2 (intervention: neurodynamic and control) × 2 (time: pre and post) factorial ANOVA with repeated measures and appropriate post-hoc analyses. RESULTS: A significant interaction was observed between intervention and time for hamstring extensibility, F(1,26) = 159.187, p < .0005. There was no difference between the groups at the start, p = .743; however, at the end of the study, the groups were significantly different with more range of motion in the group that received neurodynamic interventions, p = .001. The group that received neurodynamic interventions improved significantly over time (p < .001), whereas the control group did not (p = .684). CONCLUSION: Findings suggest that a neurodynamic sliding technique can increase hamstring flexibility in healthy, male soccer players.

Concepts: Time, Scientific method, Experimental design, Design of experiments, Analysis of variance, Straight leg raise, Tukey's range test


STRUCTURED ABSTRACT:: Study Design. Case report.Objective. To present a case of primary hydatid cyst in the lombar subcutaneous tissue affecting posterior paravertebral muscle and mimicking disc herniation.Summary of Background Data. Cystic Hydatid Disease is a rare but significant parasitic disease in endemic areas. Musculoskeletal or soft tissue hydatidosis accounts for about 0,5-5% of all echinococcal infections in endemic areas and is almost secondary to the hepatic or pulmonary disease. Primary lomber subcutaneous hydatid cyst affecting paravertebral muscle and extending to neural foramina is a very rare condition even in endemic areas.Methods. A 25 year-old female patient was admitted with swelling and pain in the right lumbar region for three months. The pain was reflecting in the right gluteal region and the right leg. Lumbar extension and right lateral flexion was painful and straight leg raising test was positive at right side. There was a mild hypoesthesia at L5 dermatome. According to the magnetic resonance imaging which the clinician requested for initial diagnosis of lumbar disc herniation we find multi-cystic masses located at the right paravertebral muscle at the level of L3-5 and extends to L4-5 neural foramina and at subcutaneous tissue at the riht gluteal region.Results. The patient was operated for the purpose of removal of cysts. Postoperatively, diagnosis of hydatid cyst was confirmed by histopathology.Conclusion. By this case, we emphasize that cystic hydatid disease should be taken into consideration in the differential diagnosis of low back pain and could mimic disc herniation.

Concepts: Spinal disc herniation, Low back pain, Back pain, Medical terms, Magnetic resonance imaging, Cyst, Straight leg raise, Lumbar


Study Design. A case report by Kara Krajewski and Jan Regelsberger.Objective. To demonstrate a case of intradural lumbar disc herniation including imaging studies, intraoperative imaging and an intraoperative video.Summary of Background Data. The first case of lumbar intradural disc herniation was reported as early as 1942; since then over 150 cases have been reported, mostly in the lumbar spine. Gadolinium-enhanced MRI is considered the gold standard for diagnosing this entity, though it is rarely peformed routinely in lumbar disc disease and diagnosis is often made intraoperatively.Methods. A 70-year-old man presented to the emergency department as a referral complaining of lower back pain, loss of sensation in the right thigh and difficulty walking. On examination, he showed uneven gait, right-sided foot drop (1/5), hypesthesias in the right inguinal area and ventral thigh and a positive straight leg raise test on the right. Anal sphincter tone was within normal limits. An MRI of the lumbar spine showed a large mediolateral herniated disc at L3/4, with caudal displacement and unclear signal changes intradurally.Results. Intraoperatively, the herniated disc was found upon opening the dural sac.Conclusion. Intradural disc herniations are a rare entity. The opening and inspection of the dural sack should be considered when the correct spinal level can be confirmed and insufficient herniated disc material can be visualized extradurally.

Concepts: Spinal disc herniation, Low back pain, Back pain, Vertebral column, Hernia, Degenerative disc disease, Intervertebral disc, Straight leg raise


STUDY DESIGN: Test - retest interrater reliability. OBJECTIVES: 1. Examine the interrater reliability of an existing clinical prediction rule (CPR) for predicting success with lumbar stabilization exercises (LSE). 2. Examine the interrater reliability of 4 clinical tests that may be useful in determining the need for LSE. BACKGROUND: Lumbar stabilization exercises are commonly used by physical therapists in the management of patients with low back pain (LBP). The clinical efficacy of LSE is unclear. A clinical prediction rule (CPR) has been previously suggested to identify patients most likely to benefit from LSE. The passive lumbar extension test (PLET), lumbar extension load test (LELT), active straight leg raise test (ASLR) and active hip abduction test (AHAbd) are 4 clinical tests that may also suggest the need for LSE. The reliability of these tests has not been established sufficiently. METHODS: Thirty patients with LBP participating in a large randomized clinical trial (RCT) underwent all tests by 2 independent examiners. Kappa (қ) coefficients with 95% confidence intervals (95% CI) were calculated to establish the interrater reliability of the tests. RESULTS: The interrater reliability of the CPR was excellent (қ=0.86, 95% CI, 0.65 - 1.00). The interrater reliability of the individual items making up the CPR, as well as that of the PLET was substantial (қ=0.64-0.73 and қ=0.76, 95% CI: 0.46 -1.00, respectively). The interrater reliability of the ASLR and LELT was moderate (қ =0.53, 95% CI: 0.20 - 0.84, and қ=0.47, 95% CI: 0.14 - 0.78, respectively). The interrater reliability of the AHAbd was poor (қ=-0.09, 95% CI, -0.35 - 0.27). CONCLUSION: With the exception of the AHAbd, all other clinical tests can be considered sufficiently reliable for clinical use. The relatively small sample size likely contributed to the fairly wide confidence intervals around some of the reliability indices.J Orthop Sports Phys Ther. Epub 14 January 2013. doi:10.2519/jospt.2013.4310.

Concepts: Scientific method, Clinical trial, Spinal disc herniation, Sample size, Randomized controlled trial, Prediction, Clinical prediction rule, Straight leg raise


The purpose of this study was to investigate whether the functional movement screen (FMS) could predict running injuries in competitive runners. Eighty-four competitive male runners (average age = 20.0 ± 1.1 years) participated. Each subject performed the FMS, which consisted of 7 movement tests (each score range: 0-3, total score range: 0-21), during the pre-season. The incidence of running injuries (time lost due to injury ≤4 weeks) was investigated through a follow-up survey during the 6-month season. Mann-Whitney U tests were used to investigate which movement tests were significantly associated with running injuries. The receiver-operator characteristic (ROC) analysis was used to determine the cut-off. The mean FMS composite score was 14.1 ± 2.3. The ROC analysis determined the cut-off at 14/15 (sensitivity = 0.73, specificity = 0.54), suggesting that the composite score had a low predictability for running injuries. However, the total score (0-6) from the deep squat (DS) and active straight leg raise (ASLR) tests (DS & ASLR), which were significant with the U test, had relatively high predictability at the cut-off of ¾ (sensitivity = 0.73, specificity = 0.74). Furthermore, the multivariate logistic regression analysis revealed that the DS & ASLR scores of ≤3 significantly influenced the incidence of running injuries after adjusting for subjects' characteristics (OR = 9.7, 95%CI [2.1 to 44.4]). Thus, the current study identified the DS & ASLR score as a more effective method than the composite score to screen the risk of running injuries in competitive male runners.

Concepts: Regression analysis, Logistic regression, Statistics, Prediction, Mann–Whitney U, Receiver operating characteristic, Binary classification, Straight leg raise


BACKGROUND: The purpose of this study was to examine the association between functional movement and overweight and obesity in British children. METHODS: Data were obtained from 90, 7–10 year old children (38 boys and 52 girls). Body mass (kg) and height (m) were assessed from which body mass index (BMI) was determined and children were classified as normal weight, overweight or obese according to international cut offs. Functional movement was assessed using the functional movement screen. RESULTS: Total functional movement score was significantly, negatively correlated with BMI (P = .0001). Functional movement scores were also significantly higher for normal weight children compared to obese children (P = .0001). Normal weight children performed significantly better on all individual tests within the functional movement screen compared to their obese peers (P <0.05) and significantly better than overweight children for the deep squat (P = .0001) and shoulder mobility tests (P = .04). Overweight children scored significantly better than obese in the hurdle step (P = .0001), in line lunge (P = .05), shoulder mobility (P = .04) and active straight leg raise (P = .016).Functional movement scores were not significantly different between boys and girls (P > .05) when considered as total scores. However, girls performed significantly better than boys on the hurdle step (P = .03) and straight leg raise (P = .004) but poorer than boys on the trunk stability push-up (P = .014). CONCLUSIONS: This study highlights that overweight and obesity are significantly associated with poorer functional movement in children and that girls outperform boys in functional movements.

Concepts: Cancer, Nutrition, Obesity, Mass, Body mass index, Body shape, Childhood obesity, Straight leg raise