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research report
LAWRENCE M. URBAN, PT, MSc1 • BRIAN J. MACNEIL, PT, PhD1

Diagnostic Accuracy of the

Slump Test for Identifying Neuropathic
Pain in the Lower Limb

T
he International Association for the Study of Pain has Given that NeP requires treatment
defined neuropathic pain (NeP) as “pain caused by a lesion distinct from that for nonneuropathic
pain, accurate diagnosis is critical to di-
or disease of the somatosensory system.”24 It has been
recting patients toward appropriate in-
estimated that 2% to 4% of the general population have terventions.16,29,32 The diagnosis of NeP
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

some form of NeP, with substantially higher rates in those with typically consists of a thorough history
chronic low back pain (LBP).7,17,25,34,35,46 Importantly, the presence of and an extensive neurosensory examina-
NeP has been linked with poor recovery, along with higher health tion to identify both positive (exagger-
care costs and lower quality of life.26,27,37,43,44 ated responses to stimulation, such as
allodynia) and negative (various sensory
and motor losses) signs.3 The neurosen-
TTSTUDY DESIGN: Diagnostic accuracy study having NeP. The slump test displayed high sensitiv-
with nonconsecutive enrollment.
sory examination is usually performed
ity (0.91), moderate specificity (0.70), a positive
by a specialist, requires a lot of time to
TTOBJECTIVES: To assess the diagnostic accu- likelihood ratio of 3.03, and a negative likelihood
ratio of 0.13. Adding the criterion of pain below complete, and in many regions involves a
racy of the slump test for neuropathic pain (NeP)
Journal of Orthopaedic & Sports Physical Therapy®

in those with low to moderate levels of chronic
low back pain (LBP), and to determine whether
accuracy of the slump test improves by adding
anatomical or qualitative pain descriptors.
TTBACKGROUND: Neuropathic pain has
been linked with poor outcomes, likely due to
inadequate diagnosis, which precludes treatment
specific for NeP. Current diagnostic approaches
are time consuming or lack accuracy.
TTMETHODS: A convenience sample of 21
individuals with LBP, with or without radiating leg
pain, was recruited. A standardized neurosensory
examination was used to determine the reference
diagnosis for NeP. Afterward, the slump test was
administered to all participants. Reports of pain
location and quality produced during the slump
test were recorded.
TTRESULTS: The neurosensory examination desig-
nated 11 of the 21 participants with LBP/sciatica as
the knee significantly increased specificity to
1.00 (positive likelihood ratio = 11.9). Pain-quality
descriptors did not improve diagnostic accuracy.
TTCONCLUSION: The slump test was highly sensi-
tive in identifying NeP within the study sample.
Adding a pain-location criterion improved specific-
ity. Combining the diagnostic outcomes was very
effective in identifying all those without NeP and
half of those with NeP. Limitations arising from the
small and narrow spectrum of participants with
LBP/sciatica sampled within the study prevent ap-
plication of the findings to a wider population.
TTLEVEL OF EVIDENCE: Diagnosis, level 4–.
J Orthop Sports Phys Ther 2015;45(8):596-603.
Epub 24 Jun 2015. doi:10.2519/jospt.2015.5414
TTKEY WORDS: neurodynamic testing, sensitivity,
specificity
long waiting period for the consultation.
Screening tools have been developed
in an attempt to facilitate the diagnosis
of NeP. Most of these tools consist of self-
report surveys of pain-quality descrip-
tors (eg, self-reported Leeds Assessment
of Neuropathic Symptoms and Signs
pain scale,4 Douleur Neuropathique en
4 Questions,5 painDETECT20), although
some also include a limited number of
physical findings.2,6 While useful, these
tools have an estimated sensitivity and
specificity of approximately 80%, and
therefore fail to identify 20% of those
with NeP and falsely identify 20% as hav-
ing NeP. Further, many of these estimates
have been derived from study samples of
individuals previously diagnosed with

Department of Physical Therapy, College of Rehabilitation Sciences, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada. All procedures received
1

ethical approval from the Human Research Ethics Board of the University of Manitoba (H2010:126). This study was funded in part by the Manitoba Public Insurance Corporation.
The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials
discussed in the article. Address correspondence to Lawrence M. Urban, Department of Physical Therapy, College of Rehabilitation Sciences, Faculty of Health Sciences,
University of Manitoba, Room 106, 771 McDermot Avenue, Winnipeg, Manitoba R3E 0T6 Canada. E-mail: Laurie.Urban@umanitoba.ca t Copyright ©2015 Journal of Orthopaedic
& Sports Physical Therapy®

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Recruitment by poster and word of mouth

TABLE 1 Exclusionary Diagnoses
• LBP/sciatica, n = 24

Category Diagnoses
Physical injury Neuropathy secondary to tumor infiltration, complex regional pain Screening for inclusion/exclusion criteria
syndrome II • Excluded, n = 0
Metabolic Diabetes mellitus, renal or hepatic dysfunction Appointment made for study
• Voluntary withdrawal, n = 3
Infectious/parainfectious Trigeminal neuralgia, postherpetic neuralgia, human immunodeficiency
virus
Toxic Chemotherapy-induced neuropathy, alcoholism
Nutritional deficiencies Vitamin B12 deficiency (also B1 and B6) Assessment and diagnosis, n = 21
• Designated NeP, n = 11
Vasculitis Rheumatoid arthritis
• Designated NNeP, n = 10
Immune related Paraneoplastic, paraproteinemia
Central nervous system Spinal cord compression/injury pain, multiple sclerosis, poststroke
*Modified from Nash.30
Slump test administered, n = 21
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

NeP or obtained in clinical settings that
are more likely to include those with
NeP, either of which may bias toward
more favorable estimates of diagnostic
function.28,33
Neurodynamic tests are a series of
multijoint movements of the limbs and/
or trunk that produce mechanical and
physiological events in the nervous sys-
Journal of Orthopaedic & Sports Physical Therapy®
of the slump test accurately identified pa-
tients with upper/mid-lumbar nerve root
compression.47 Last, the SLR test demon-
strated 100% specificity in patients clini-
cally diagnosed with NeP.36 While these
studies support the use of neurodynamic
tests to identify NeP, a key limitation is
that the study samples had more severe
pain or were prediagnosed with NeP. The
FIGURE 1. Flow diagram illustrating the progress
of participants through the study. Abbreviations:
LBP, low back pain; NeP, neuropathic pain; NNeP,
nonneuropathic pain.
an outpatient orthopaedic medical clinic
and a private physical therapy clinic. Par-
ticipants were recruited over an 8-month
period (June 2010-January 2011). All
participants were at least 25 years of age,

tem.12,31,38 One of these mechanical events
is an increase in tension in the nerve
being tested.8-10,13,19,21,41 The straight leg
raise (SLR) test is the most commonly
used neurodynamic test for the lower
extremity. The slump test is another neu-
rodynamic test and differs from the SLR
test in that it incorporates spinal flexion
and can therefore potentially generate
greater overall neural tension. The slump
test also incorporates knee extension as a
sensitizing maneuver, which can be used
to modulate the mechanical strain on
the nervous system,12 thereby confirming
nervous tissue as the source of symptoms
during the test. Accepting that neurody-
namic tests increase tension in nerves
and that NeP is associated with lowered
mechanical thresholds,2,5,36 it would be
ability of a neurodynamic test to inde-
pendently detect NeP in a nondiagnosed
population with less severe pain has not
been investigated.
The primary aim of this study was to
compare the diagnostic accuracy of the
slump test to a standardized neurosenso-
ry examination in identifying those with
and without NeP. Specifically, the slump
test was assessed in a small undiagnosed
sample of those with low to moderate lev-
els of chronic LBP. A second aim was to
determine whether the diagnostic func-
tion of the slump test could be improved
with the addition of qualitative and/or
anatomical pain-location descriptors.
METHODS
able to understand English, and able to
undergo a complete neurosensory ex-
amination and a slump test. This study
was designed to include participants with
LBP due to musculoskeletal pathology
who had only received conservative treat-
ment prior to recruitment. Therefore,
those with any history of back surgery
or existing systemic or central condition
(eg, cancer, diabetes, multiple sclerosis,
stroke) that might produce radiculopathy
were excluded from the study (TABLE 1).
Participants were screened by a clinic
administrator for inclusion/exclusion
criteria. Those willing to provide in-
formed consent were then scheduled
to return for testing (mean  SD time
between intake and testing, 11.1  7.6
days). Three voluntary withdrawals oc-

expected that a positive outcome on a
neurodynamic test would be highly asso-
ciated with NeP. Indeed, the rate of NeP
was more than 14-fold higher in those
with a positive SLR test,40 and a variation
A
convenience sample of partici-
pants with LBP, with or without
radiating leg pain (eg, radiculitis,
sciatica, radiculopathy), was recruited
by poster and by clinician referral from
curred prior to testing, due to scheduling
conflicts (FIGURE 1). The study sample in-
cluded 21 ambulatory participants with
nonacute LBP, with and without radi-
ating leg pain. The participants were 11

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TABLE 2
Test
Neurosensory examination
Slump test
Slump test plus pain location
Slump test plus pain quality
Slump test plus pain location plus pain quality
women and 10 men, with a mean  SD
age of 44.0  14.9 years, current pain
on a numeric pain-rating scale of 2.4 
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
1.9 (range, 0-7), and a median symptom
duration of 24 months (interquartile
range, 3-57 months; minimum dura-
tion, 4 weeks). Of the 21 participants,
14% had LBP only; 5% had buttock pain
only; 5% had LBP and buttock pain;
67% had LBP, buttock, and leg pain; and
9% had leg pain only. All procedures re-
ceived ethical approval from the Human
Journal of Orthopaedic & Sports Physical Therapy®
Research Ethics Board at the University
of Manitoba (H2010:126).
The testing procedure began with par-
ticipants undergoing a neurosensory ex-
amination, which provided the reference
diagnosis for the presence or absence of
NeP. The examinations were conducted
by 1 of 2 experienced orthopaedic man-
ual physical therapists. A standardized
assessment form (APPENDIX, available at
www.jospt.org) was created based on
previous studies of NeP.2,6,15,20,36,48 Key
components of the clinical exam included
pain (location, behavior, quality), motor
function (strength/weakness, reflexes),
sensory function (mechanical/thermal
sensation), autonomic function (sweat-
ing, hypotension), and the SLR test. The
slump test was excluded from the neuro-
sensory exam.
Based on the clinical findings, the ex-
aminer used an established algorithm to
designate a diagnosis of NeP as unlikely,
possible, probable, or definite.49 Briefly,
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45-08 Urban.indd 598
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research report
Summary of Criteria for Test Outcomes
Negative Diagnosis of Neuropathic Pain
Unlikely/possible
Pain not reduced with neck extension OR less than a 10° differ-
ence in knee extension and no difference in pain distribution
between limbs
Positive slump test but pain restricted to above the knee
Positive slump test with aching, deep, or burning descriptors
Positive slump test with negative pain location or negative pain
descriptors
the designation of unlikely NeP was as-
signed in the absence of (1) a plausible
neuroanatomical pain distribution con-
sistent with injury/lesion/disease of a
spinal nerve root or peripheral nerve,
or (2) a history that would indicate a le-
sion or disease of the nervous system (eg,
low back strain, disc protrusion, spinal
stenosis). Those with a pain distribu-
tion and history consistent with NeP but
lacking any objective clinical findings of
NeP were categorized as possible NeP.
Probable NeP was assigned when objec-
tive sensory signs (APPENDIX, available at
www.jospt.org) were present within the
neuroanatomical territory of the nerve
suspected to be injured. A rating of defi-
nite NeP was assigned when the results
of radiographs or magnetic resonance
imaging tests were available and indi-
cated the presence of a lesion consistent
with the other clinical findings. Partici-
pants were classified as “reference test
negative” (disease absent) if they were in
either the unlikely or possible NeP cate-
gory. Those with possible NeP were clas-
sified as reference test negative due to the
relatively weak criteria for pain distribu-
tion and history in the context of LBP.
Classifying this group as “reference test
positive” would be expected to strongly
bias the outcomes toward high sensitiv-
ity and low specificity. Those classified as
“reference test positive” (disease present)
were in the probable or definite NeP cate-
gory. Excluding those with probable NeP
Positive Diagnosis of Neuropathic Pain
Probable/definite
Pain reduced with neck extension AND either more than a 10°
difference in knee extension or difference in pain distribu-
tion between limbs
Positive slump test with pain extending below the knee
Positive slump test with burning, electric, shooting, or jabbing
descriptors
Positive slump test with positive pain location and positive
pain descriptors
from the reference positive category due
to the lack of diagnostic imaging would
likely have biased the findings toward
low sensitivity and high specificity. A
further justification for classifying those
with probable NeP as reference test posi-
tive is that, in clinical practice, attaining
a rating of probable is often considered
sufficient to establish a diagnosis of NeP,
with confirmatory diagnostic testing re-
served for inconclusive cases.22,49
Immediately following the diagnos-
tic clinical examination, the participant
moved to a separate area of the clinic,
where he or she was administered the
slump test by another experienced cli-
nician with additional postgraduate
training in neurodynamic testing and
interpretation, who was blinded to the
diagnosis from the clinical examination.
The slump test procedure was performed
as described by Butler.11,12 Briefly, the
participant was seated on a treatment
plinth, with the posterior aspect of the
knees just touching the plinth and the
examiner seated beside the participant.
The participant was instructed to place
the hands behind the back and to move
into the slump position by relaxing the
spine to permit maximal passive flexion
of the trunk. Any reproduction of pain
or prior sensations, such as paresthesia
or a burning sensation, in this position
was noted. The participant was then
instructed to flex the neck, with the ex-
aminer maintaining cervical flexion with
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TABLE 3
of the Slump Test Variations*
Slump
Sensitivity 0.91 (0.62, 0.98)
Specificity 0.70 (0.40, 0.89)
PPV 0.77 (0.50, 0.92)
NPV 0.88 (0.53, 0.98)
+LR 3.03 (1.15, 7.95)
–LR 0.13 (0.02, 0.88)
Abbreviations: L, pain location; LQ, pain location and pain quality; –LR, negative likelihood ratio;
+LR, positive likelihood ratio; NPV, negative predictive value; PPV, positive predictive value; Q, pain
quality.
*All diagnostic calculations use the clinical examination as the reference test. Values in parentheses
are 95% confidence interval.
†
Significantly different from corresponding value for slump (P<.05).
gentle pressure applied with the forearm
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
and hand. Any pain or sensations due to
the addition of cervical flexion were re-
corded. The participant was then asked
to dorsiflex the right ankle and then to
extend the right knee. Again, the par-
ticipant was asked if the addition of
this component reproduced any pain or
sensations. The angle of maximum knee
extension was recorded from a digital
Journal of Orthopaedic & Sports Physical Therapy®
inclinometer (DJO, LLC, Vista, CA) at-
tached to the shin. The participant was
then asked to extend the neck, and any
effect on sensations or pain was noted.
The participant then relaxed the right leg
and returned to the initial slump posi-
tion, and the same procedure was then
repeated for the left side. Differences
between right and left knee extension
were obtained from the inclinometer
readings.
The slump test was designated as
positive if the following conditions were
met: (1) pain or sensations were reduced
with neck extension, and (2) there was a
right-to-left difference in pain distribu-
tion or there was a difference between
right and left knee extension.12 To deter-
mine a suitable threshold for a difference
in knee extension, a group of pain-free
comparison participants (n = 24; mean
 SD age, 44.2  12.8 years; 14 women,
10 men) were recruited and underwent
slump testing in the same manner as
45-08 Urban.indd 599
Diagnostic Outcomes
Slump + L Slump + Q Slump + LQ
0.55 (0.28, 0.79) †
0.64 (0.35, 0.85) 0.46 (0.21, 0.72)†
1.00 (0.72, 1.00) †
0.70 (0.40, 0.89) 1.00 (0.72, 1.00)†
1.00 (0.61, 1.00) 0.70 (0.40, 0.89) 1.00 (0.57, 1.00)
0.67 (0.42, 0.85)† 0.64 (0.35, 0.85)† 0.63 (0.39, 0.82)†
11.9 (0.76, 187.8) 2.12 (0.75, 6.04) 10.08 (0.63, 162.1)
0.48 (0.26, 0.90)† 0.52 (0.22, 1.25)† 0.57 (0.33, 0.97)†
the participants with LBP. The mean 
SD difference in knee extension in the
comparison group was 4.1°  2.7°, with
a maximal value of 9°. From these data,
a difference of 10° or more was used to
indicate a positive slump test component.
Knee angle as an outcome of the slump
test has been reported to have very good
intrarater reliability (r = 0.88; standard
error of measurement, 1.8°).23
The ability of descriptors of pain loca-
tion and pain quality to improve the di-
agnostic function of the slump test was
also evaluated. Pain location was incor-
porated into the definition of a positive
slump test by asking if any part of the
test caused pain or sensations to extend
beyond the knee. Pain-quality descrip-
tors were evaluated by asking partici-
pants which of the following groups of
words best described any pain or sensa-
tions produced by the test: (1) pulling,
stretching, tight; (2) deep, aching, burn-
ing; or (3) electric, shock like, burning,
shooting, jabbing. In the analysis of the
diagnostic outcomes, the variations of
the slump test were identified as follows:
slump test (slump), slump test plus pain
below the knee (slump + L), slump test
plus pain qualities commonly associated
with NeP (slump + Q), slump test plus
pain below the knee and pain qualities
(slump + LQ).
journal of orthopaedic & sports physical therapy | volume 45 | number 8 | august 2015 |
Data Analysis
Sensitivity, specificity, predictive values,
and likelihood ratios were calculated for
all variations of the slump test. The neu-
rosensory examination was used as the
reference test for all calculations. The cri-
teria for defining test outcomes as posi-
tive or negative are summarized in TABLE
2. For each comparison, a 2-by-2 contin-
gency table was constructed and sensitiv-
ity, specificity, positive predictive value
(PPV), negative predictive value (NPV),
positive likelihood ratio (+LR), and nega-
tive likelihood ratio (–LR) and their 95%
confidence intervals (CIs) were calculat-
ed.1 Confidence intervals for sensitivity,
specificity, PPV, and NPV were calculated
using the Wilson method, whereas those
for likelihood ratios were calculated using
the log method.1,39 Where zero values oc-
curred, likelihood ratios were estimated
by adding 0.5 to each cell value.1,39
RESULTS
O
f the 10 participants with LBP
designated as having nonneuro-
pathic pain (disease absent), 8 were
classified as unlikely NeP and 2 as pos-
sible NeP. Within the 11 participants with
LBP designated as having NeP (disease
present), 7 were classified as probable
and 4 as definite. The slump test dis-
played high sensitivity (0.91; PPV, 0.77)
and moderate specificity (0.70; NPV,
0.88) in identifying NeP relative to the
neurosensory exam (TABLE 3). These val-
ues were associated with a +LR of 3.03
and a –LR of 0.13. Adding the criterion of
pain below the knee (slump + L) signifi-
cantly (P<.05 for both) reduced sensitiv-
ity (0.55) and increased specificity (1.00).
The corresponding increase in +LR from
3.03 to 11.9 did not reach statistical sig-
nificance due to the wide 95% CI associ-
ated with the estimate for the slump + L
test. The addition of verbal descriptors of
NeP to the slump test (slump + Q) also
reduced sensitivity without significantly
changing specificity. Combining ana-
tomical location and verbal pain-quality
descriptors with the slump test (slump +
599
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research report
LQ) did not improve diagnostic function would now be associated with a post-
beyond that already seen with the slump test probability of 5% if the outcome on 0.1 99
+ L test (TABLE 3). the slump test is negative (FIGURE 2). The 0.2 98
greater diagnostic utility of the slump test
DISCUSSION when the outcome is negative is also re- 0.5 95

flected in the higher NPV compared to 1 1000 90

T
500
he data from this study demon- the PPV and the more effective –LR com- 2 200 80
strate that the slump test was sensi- pared to the +LR. 100
50 70
tive and specific in identifying NeP The second aim of this study was to 5
20 60
in individuals with LBP within the lim- determine if diagnostic function could 10 50

Posttest Probability, %
Pretest Probability, %
10
5 40
ited study sample. The specificity of the be improved by adding pain-location and 20 2 30
1
slump test was improved if the definition pain-quality criteria to the definition of a 30 0.5 20
of a positive slump test was made more positive slump test. Addition of the pain- 40 0.2
50 0.1 10
stringent by requiring that pain experi- location criterion (pain produced dur- 60 0.05
5
enced during the slump test extend be- ing the slump test extending below the 70 0.02
0.01
low the knee. While encouraging, these knee) significantly reduced the sensitivity 80 0.005 2
findings must be viewed with caution of the slump test; however, the specific- 90
0.002
0.001 1
due to the small sample size. Further, the ity was increased to an optimal value of
95 0.5
use of convenience sampling might have 1.0. Although this version of the slump Likelihood
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

introduced spectrum bias; therefore, the
application of the findings is most ap-
propriate to similar patients and clinical
settings. Lastly, there was no established
objective test to serve as a reference diag-
nosis for NeP22; accordingly, the current
accepted gold standard of a thorough
neurosensory examination49 was utilized.
Accepting these limitations, the slump
Journal of Orthopaedic & Sports Physical Therapy®
test (slump + L) misclassified almost half
of those with NeP, all 6 patients with
positive slump + L tests were true posi-
tive cases (PPV, 100%). Using the prior
example of 30% pretest probability, the
posttest probability is 84% (FIGURE 2) if
pain extends below the knee during the
slump test, in contrast to a posttest prob-
ability of 56% if the pain-location criteri-
Ratio
98 0.2
99 0.1
FIGURE 2. A likelihood ratio nomogram adapted from
Fagan.18 The pretest probability of neuropathic pain
in a population of individuals with chronic low back
pain is placed at 30%. The negative likelihood ratio
of 0.13 for the slump test is indicated, along with the
corresponding posttest probability of 5% (blue line).

test may have clinical utility in facilitating
the identification of an NeP component
in those with LBP.
The primary aim of this study was
to assess the diagnostic accuracy of the
slump test in identifying those with an
NeP component in an otherwise un-
diagnosed population with LBP. The
slump test, as used conventionally, dem-
onstrated high sensitivity and moder-
ate specificity relative to a standardized
neurosensory examination. Although the
slump test identified true positive cases
at a high rate, it also yielded a substan-
tial rate of false positives, which limits
the utility of the test to diagnose NeP.
Utilizing the resulting +LR, a pretest
probability of 30% would be associated
with an indeterminate posttest prob-
ability of 56%. In contrast, the low rate
of false negatives (9%) makes for a much
stronger interpretation if a negative out-
come on the slump test is obtained. The
same pretest probability example of 30%
on is omitted (slump). Thus, the addition
of a pain-location criterion to the slump
test shifted the diagnostic utility in favor
of a positive outcome rather than a nega-
tive outcome, as seen without the pain-
location criterion.
Greater diagnostic function may be
achieved when the 2 tests are combined,
as would be expected during a clinical
assessment. If the slump test yields a
negative outcome, NeP can potentially be
ruled out based on the low rate of false
negatives (9%), the small –LR (0.13),
and the reasonable NPV (87.5%). If a
positive result is obtained on the slump
test, it does not provide much indication
that NeP is present, due to the high rate
of false positives (30%). However, if it is
reported that pain extends below the knee
during the slump test, then NeP can po-
tentially be ruled in, based on the absence
of false positives and the high +LR (11.9)
and PPV (100%). Despite the relative con-
fidence of ruling out NeP if the slump test
The positive likelihood ratio of 11.9 for the slump
test plus pain reproduced below the knee criterion
is indicated, along with the corresponding posttest
probability of 84% (orange line). This nomogram
illustrates the usefulness of combining a negative
outcome on the slump test with a positive outcome
on the slump test with pain reproduced below the
knee to effectively rule out or rule in neuropathic pain,
respectively.
is negative and ruling in NeP if the slump
+ L test is positive, very little can be inter-
preted when the slump test is positive but
the pain does not extend below the knee.
This uncertainty stems from the high rate
of false positives on the slump test and the
high rate of false negatives on the slump
+ L test. Clinicians would have to rely on
other components of the examination
or additional diagnostic tests to resolve
these cases. Despite this diagnostic gap,
combining these tests provided a highly
efficient means of identifying all those
without NeP and approximately 50% of
those with NeP in the study sample.

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A prominent limitation of the cur-
rent study was the small sample size and
the ensuing wide CIs. This impacted the
study findings in 2 ways. First, it compro-
mised the ability to achieve statistically
significant outcomes. Although some
outcomes were statistically significant,
such as the increase in specificity follow-
ing addition of the pain-location criteri-
on, the large absolute increase in the +LR
for the slump + L test was not statistically
significant. Second, the strong outcomes
for some of the tests should be consid-
ered in context with the wide CIs. For
example, the slump test had a low false-
negative rate of 9%, but the associated
CI indicates a range of 2% to 38% (NPV
value ranges from 53% to 98%), which
compromises the ability of the slump test
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
to rule out NeP when the test outcome is
negative. Similarly, despite the absolute
specificity (1.0) of the slump + L test,
the false-positive rate ranges from 0% to
28%, which diminishes the ability to di-
agnose the presence of NeP if the slump +
L test is positive. Obtaining more precise
diagnostic indices will require studies
with larger sample sizes.
Journal of Orthopaedic & Sports Physical Therapy®
The narrow range of the clinical
spectrum of LBP captured by the study
sample must also be factored into data
interpretation. This study sought to as-
sess the diagnostic utility of the slump
test in a specific LBP population, name-
ly, those with low to moderate nonacute
pain of musculoskeletal origin. Further,
the sample was narrowed to those who
had only received conservative treat-
ment prior to recruitment. For this, a
convenience sample was recruited from
a publicly funded outpatient orthopae-
dic medical practice and a private physi-
cal therapy clinic. The referral sources
for participants were family physicians,
sports medicine physicians, and physical
therapists. The study sample, although
narrow and specific, did not appear to
be biased toward a high NeP prevalence,
because participants were not recruited
on the basis of having radiating leg pain
or a moderate to high pain-intensity rat-
ing. Further, those in the disease-free cat-
journal of orthopaedic & sports physical therapy | volume 45 | number 8 | august 2015 |
45-08 Urban.indd 601
egory (negative for NeP on the reference
test) also had LBP. These factors helped
to create diagnostic uncertainty within
the study sample and to diminish exag-
geration of diagnostic outcomes. Despite
these positive aspects, the findings from
the present study are most appropriately
applied to a similar patient population
and clinical setting.
A final caveat relates to the use of the
neurosensory examination as the refer-
ence diagnostic test. Although the neu-
rosensory examination is commonly used
as a reference test (eg, in the derivation
of NeP screening tools2,6,20,36), it is widely
acknowledged that there is no true gold
standard for diagnosing NeP. Objective
tests such as diagnostic imaging and elec-
trophysiological assessment can indicate
the presence of a lesion, but whether
these lesions are painful can only be de-
termined through clinical examination.22
The diagnostic algorithm utilized in the
current study relies on elements of the
history and presentation to derive a rat-
ing of possible NeP, with the presence of
sensory abnormalities elevating the rat-
ing to probable.49 Indeed, clinical diagno-
sis often concludes at this stage without
seeking confirmation through additional
diagnostic procedures.14,45 Regardless,
uncertainty in the reference test can bias
results, although detecting the direction
of the bias is challenging.28,33 Resolving
these issues is beyond the scope of the
present study, but these limitations are
noted nonetheless.
This study is important in that it is the
first study, to our knowledge, to specifi-
cally examine the slump test in a sample
with no prior diagnosis of NeP. The slump
test is currently used to qualitatively dif-
ferentiate pain and dysfunction arising
from neural tissue versus nonneural tis-
sue. This study is, to our knowledge, the
first to provide a quantitative estimate of
the diagnostic accuracy of the slump test
for identifying NeP in the lower limb. The
poor prognosis for those with NeP26,42
highlights the need for efficient and effec-
tive tools to assist in directing treatment
to the appropriate individuals.
CONCLUSION
I
n a small and specific sample of in-
dividuals with LBP, with and without
radiating leg pain, this study dem-
onstrated that the slump test is a use-
ful tool to identify the presence of NeP.
The slump test was highly sensitive, but
moderately specific, in identifying those
with NeP. The addition of a pain-location
criterion for a positive test (pain repro-
duced below the knee) significantly in-
creased the specificity. The sequential
combination of the 2 tests provided an
effective means of ruling out those with-
out NeP and ruling in a large proportion
of those with NeP. Limitations arising
from the size of the study sample limit
the confidence in these results until con-
firmed through larger studies. Last, it is
unknown whether the slump test would
provide similar diagnostic function in a
broader spectrum of patients with LBP. t
KEY POINTS
FINDINGS: The slump test displayed high
sensitivity within the study sample of in-
dividuals with LBP. Conversely, adding
the criterion of pain distal to the knee
during the slump test yielded very high
specificity.
IMPLICATIONS: Combining the 2 versions
of the slump test generated a simple tool
that performed well in the study sample.
Specifically, all cases without NeP and a
large proportion of those with NeP were
accurately identified. Thus, the slump
test may greatly facilitate the identifica-
tion of those who need additional as-
sessment and/or treatment for NeP.
CAUTION: The wide CIs for the diagnostic
parameters mean that the true values
may be much larger or smaller than the
estimates reported. Further, the study
findings may not apply to individuals
who are markedly different from those
included in the study sample.
ACKNOWLEDGEMENTS: The authors acknowl-
edge physical therapists Mark Beatty and Sam
Steinfeld, who served as blinded examiners for
the standardized diagnostic examination.
601
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sion: a pilot study. Physiotherapy. 2011;97:59-64.
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48. Treede RD, Baron R. How to detect a sensory ab- WWW.JOSPT.ORG

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APPENDIX

SLUMP TEST STUDY NEUROSENSORY EXAMINATION TEMPLATE

Study number________
Date_______
Examiner________________________
History
General, including past history
A. Sudden versus insidious?
1. Date? Time course
2. Past history?
3. Severity of pain matches severity of injury?
B. Has the condition been diagnosed already?
1. What is the diagnosis?
2. Is the diagnosis on the list?
C. Treatment up to now?
History of serious illness?
Pain
Is your pain connected with any of the following conditions or diagnoses (indicate any of these with a check mark)?
Yes
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Peripheral nervous system

Physical injury
Nerve entrapment (eg, carpal tunnel)
Root compression (eg, lateral stenosis,
disc protrusion)
Postsurgical (eg, mastectomy, thoracotomy,
discectomy)
Neuropathy secondary to tumor infiltration
Complex regional pain syndrome II
Journal of Orthopaedic & Sports Physical Therapy®

Metabolic
Diabetes mellitus
Renal or hepatic dysfunction
Infectious/parinfectious
Trigeminal neuralgia
Postherpetic neuralgia
Human immunodeficiency virus
Toxic
Chemotherapy-induced neuropathy
Alcoholism
Nutritional deficiencies
Vitamin B12, B1, and B6
Vasculitis
Rheumatoid arthritis
Immune mediated
Paraneoplastic
Paraproteinemia
Central nervous system
Spinal cord compression/injury pain
Multiple sclerosis
Poststroke

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APPENDIX

Are you experiencing any pain at present?

□ Yes
□ No
Pain intensity___/10 (visual analog scale or numeric pain scale)
Pain out of proportion to injury?
□ Yes
□ No
Pain stimulus dependent?
□ Yes
Elicited by what?
□ Mechanical
□ Thermal
□ Chemical
□ No
Stimulus independent (spontaneous)?
□ Yes
□ No
Indicate the following on the body diagram: pain (xxx), hypoalgesia (nn), hypoalgesia to cold (cn), allodynia (Al), paresthesia (oo),
hyperalgesia (HH), cold hyperalgesia (CH), autonomic abnormalities (AA), heat hypoalgesia (HO), heat hyperalgesia (HYP)
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

3
Journal of Orthopaedic & Sports Physical Therapy®

ara arb alc ald ple plf prg prh

What is the quality of the pain? Do any of the examples on this form match the patient’s pain?
Do any of the following words describe your pain?
□ Continuous
□ Paroxysmal
□ Stabbing
□ Burst like
□ Shooting
□ Electric shock like
Hyperalgesia: does your pain feel exaggerated?
□ Yes
□ No
Allodynia: does light touch or brushing hurt your skin?
□ Yes
□ No
Spread: has your pain spread to a larger area?
□ Yes
□ No

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APPENDIX

Spread: has your pain spread to the opposite side of your body?
□ Yes
□ No
Other: does your pain wake you up at night?
□ Yes
□ No
Inflammation: how is your pain in the morning?
□ Better
□ Worse
□ Same
Irritability: does it hurt when you cough or sneeze?
□ Yes
□ No
Negative symptoms: have you noticed any numbness?
□ Yes
□ No
Positive symptoms: have you noticed any other unpleasant sensations?
□ Yes
□ Pins and needles
□ Tingling
□ Itching
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

□ No
Autonomic sensations: have you noticed any of the following?
□ Unusual sweating
□ Orthostatic hypotension
□ Gastrointestinal symptoms
Imaging tests
□ X-ray
□ CAT scan
□ MRI
□ Other
Journal of Orthopaedic & Sports Physical Therapy®

Results
Bowel and bladder dysfunction suggestive of neurological injury or dysfunction?
□ Yes
□ No
Medications (list)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

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APPENDIX

Physical Examination

Lumbar Spine AROM

Flexion

Extension

Neurodynamic Tests
Do only straight leg raise. Record range of motion and where pain is felt.
Straight leg raise positive (reproduction of pain, difference from side to side, pain worsened with neck flexion)
□ Yes
□ No
Range of motion
□ Left
□ Right
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Negative Signs
Myotomes
L3 L4 L5 S1
□ Left □ Left □ Left □
Left
□ Right □ Right □ Right □
Right
Reflexes
L3 S1
□ Left □ Left
□ Right □ Right
Journal of Orthopaedic & Sports Physical Therapy®

Hypoalgesia to pinprick present?

□ Yes
□ No
Hypoalgesia to 1-g monofilament (mark nnn on body diagram)?
□ Yes
□ No
Hypoalgesia to 10-g monofilament?
□ Yes
□ No
Hypoalgesia to cold (mark cn on body diagram)?
□ Yes
□ No
Hypoalgesia to heat (mark HO on body diagram)?
□ Yes
□ No

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APPENDIX

Positive Signs
Indicate on body diagram as stated
Allodynia present (cotton ball)?
□ Yes
□ No
Hyperalgesia to pinprick?
□ Yes
□ No
Hyperalgesia present (monofilament)?
□ Yes
□ No
Cold hyperalgesia present?
□ Yes
□ No
Heat hyperalgesia present?
□ Yes
□ No
Focal autonomic abnormalities present?
□ Yes
□ No
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

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