Active Straight leg raise : Load test

The active straight leg raise test (ASLR) is a loading test . It is use to assess pain provocation and the ability to load the pelvis through the limb. This test performed in lying and the patient is instructed to lift the leg 20cm off the bed .

A positive response is a complete inability to lift the leg off the bed, however this response can vary from person to person and its difference in heaviness to complete inability.

Mens and colleagues use a six-point scale to rate the level of difficulty: “not difficult at all = 0; minimally difficult = 1; somewhat difficult = 2; fairly difficult = 3; very difficult = 4; unable to do = 5. 

Palpation check point during assessment: 

1.Lumbar spine

2.Femoral head .

HOW CAN YOU MODIFIED THE ASLR TEST

•  Add compression – over the lumbar spine, anterior abdominal wall, pelvic ring or hip joints

•  Increase muscle activation of contralateral shoulder (to engage the ipsilateral abdominal wall).

•  you can add a cervical flexion, change the posture of the thoracic spine  

•  Trial of myofascial release : post hip capsule or iliacus anteriorly followed by reassessment.

NORMAL RESPONSE during ASLR:

•   Ipsilateral chest wall activation and abdominal to the ASLR.

•  No change in breathing patterns or IAP 

•  pelvic floor position should be minimal alteration to the position. 

The role of psoas in the ASLR test. Hip flexion will cause a forward pull on the innominate, which was previously thought to be counteracted by the contralateral bicep femoris and ipsilateral lateral abdominals, to press the innominate towards the sacrum for increased force

•   Problems with the ASLR may reflect problems with force .

• Forward rotation of the innominate  counter balances by Abdominal wall

•   Contralateral Biceps femoris activity which causes horizontal plane rotation of the pelvis which is often visualised as an upward movement of the contralateral ASIS. Such type of movement is counteracted by the ipsilateral Transverse abdomins and Internal oblique. 

•   On the moving side Iliacus, rectus femoris and adductor longus are active to perform hip flexion on the moving side.

What is AN ABNORMAL RESPONSE:

•  [restrict]Abdominal wall over working bilaterally.

•  In asymptomatics side there was no pelvic floor descent, no loss of diaphragmatic excursion. 

•  On the symptomatic side, there was increased intra-abdominal pressure and pelvic floor depression and increased minute ventilation. This demonstrate that patient adopt bracing strategies during a low load task. Hu et al, also noticed the effect of these bracing strategies. These bracing strategies identify with manual pelvic compression and found adverse bracing strategies were reversed. 

Summary : 

The ASLR is not a pure hinge test. However,it gives us a lot of information to drive decision making. if we consider it to the hinge. It looks at three things:

“1) Adequate extension of the down leg

2) Adequate mobility and flexibility of the elevated leg

3) Appropriate pelvic stabilization prior to and during the leg raise”

The anterior tilt, on one side or both, will hold the hamstring(s) in a lengthened position(resting), which is potentially causing the inability to raise the leg without compensation. Not because hamstring is tight, but because of it`s elongated position whihc is held in. This will have an strong impact on stabilize our hips. gradually it will devlope to an issue into our back. Again, it’s more than likely not due to a tight hamstring, but rather a core strength, or hip position. In addition to that that is a big deal when it comes to hing movement.

The ASLR allows us to evaluate the raw materials for identification of hing problem hinge before putting someone into a hinge issue.

The ASLR is a raw materials test. does a person have the hip/core strength and stability to hinge well? Can they synchronize core stability with hip mobility ? If not, it’s likely that they can’t do SLR when gravity acts on that movement.

From Movement perspective:

The hips are a window to the core. Hip strength is usually weak in the same direction that spine stability is poor. When hip flexion strength is weak, we see spine problems associated with poor anterior or flexion stability [Look for at active flexion]. When hip extension is weak, there will be spine problems associated with poor posterior or extension stability [all matters for the hinge]

What is our approach ?
Work on hip mobility, core stability, and retraining the hinge pattern. Progressively work to full range of motion loaded hinging as we clear the test.

REFERENCES

Hu, H., Meijer, O. G., van Dieën, J. H., Hodges, P. W., Bruijn, S. M., Strijers, R. L., … & Xia, C. (2011). Is the psoas a hip flexor in the active straight leg raise?. European Spine Journal, 20(5), 759-765.

Mens, J. M., Vleeming, A., Snijders, C. J., Koes, B. W., & Stam, H. J. (2001). Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine, 26(10), 1167-1171.

Laslett, M., Aprill, C. N., McDonald, B., & Young, S. B. (2005). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual therapy, 10(3), 207-218.

Roussel, N. A., Nijs, J., Truijen, S., Smeuninx, L., & Stassijns, G. (2007). Low back pain: clinimetric properties of the Trendelenburg test, active straight leg raise test, and breathing pattern during active straight leg raising. Journal of manipulative and physiological therapeutics, 30(4), 270-278.

O’Sullivan, P. B., Beales, D. J., Beetham, J. A., Cripps, J., Graf, F., Lin, I. B., … & Avery, A. (2002). Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine, 27(1), E1-E8.

Hu, H., Meijer, O. G., Hodges, P. W., Bruijn, S. M., Strijers, R. L., Nanayakkara, P. W., … & van Dieën, J. H. (2012). Understanding the Active Straight Leg Raise (ASLR): An electromyographic study in healthy subjects.Manual therapy, 17(6), 531-537.

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