Chapter 1.5 explains how leakages occur from the core to the annulus and how that can lead to extra stress in the fibres of the annulus. These leaks can impede the movement of the disc and cause stiffness.
The purpose of this test is to determine whether the disc can move “freely”, or whether there are potential leaks in the annulus. The test can give an indication of where these are in the annulus.
A combination of two exercises described in the book is used (Figures 70 and 71). The test must be performed twice: First, with one shoulder against the wall, then with the other. If there is pain in the back or leg, start with the least painful side against the wall.
Stand as shown in Figure 88. Legs crossed: inner leg outwards and the inner arm on the other shoulder. Move the hip towards the wall as far as it goes and push it sideways.
When the hip touches the wall, move the hip forward along the wall (see Figure 89). Push into the back with your hand.
Explanation step 1
By crossing the legs, the pelvis on the wall side drops down. The pelvis is crooked, and there is a lateral curvature created in the lower back. As a result, the intervertebral discs are “squeezed out” to the side (towards the wall).
Explanation step 2
By moving the pelvis forward, the lower back is more concave. The result is that the intervertebral discs are now also “squeezed out” forwards. The leaks are typically inclined towards the rear in the annulus (for more information, see chapter 11.3).
Assessment and follow up
Four test outcomes can be distinguished.
1. The end range has not been reached and the patient feels more pain or extra resistance:
→ Test is positive
2. The end range has been reached and the patient feels more pain or extra
→ Test is positive
3. The end range has been reached and the patient feels no pain or extra
→ Test is negative
4. The end range can not be reached and the patient feels no pain or extra
→ Test is unclear *
For patients it is not always easy to determine whether the end range reached is their natural end range. In case of doubt, one may continue pressing on at their assumed end range, to see if one can extend the end range farther or if pain and/or resistance occurs. Otherwise, a consultation of a therapist specialized in this matter may be helpful.
* There may be another reason than internal disc leakage why the movement is restricted. Only when the end position has been reached without pain or extra resistance, the test is negative. When the end position can not be reached and the patient feels no pain or extra resistance, the outcome of the test remains unclear.
With a negative outcome (no impediments) no further exercises need to be done. If the outcome is positive, exercise in the direction that is restricted. Use the same steps 1 and 2 as in the Ipel test, but then:
- Hang gently outward and press with your hand on your back, so you move forward slowly, or
- Repeat gently, pressing your hand on your back so that you move slowly.
An immediate improvement (the back is loosened up within a few minutes and pain is reduced) indicates a leakage from the disc as cause. The exercise has reduced/reversed (some) leakage and the disc can move more smoothly. These exercises may be a bit painful, which is often unavoidable. If there is no rapid improvement, then consult chapter 11.4 for more information.
Please note: There may be abnormalities, such as a stenosis, that prevent the exercise from being performed properly. This can manifest itself in a sharp pain, or pulling the pain further into the leg. That is why you should stop the exercise if:
- The pain during the exercise draws to the leg or pulls further into the leg.
- The pain clearly increases
In addition, the following advice applies:
If the pain after the exercise is worse than before, this may also be caused by leakages to the front of the annulus instead of the rear side. In that case, exercises in the bending direction might be helpful. See Addendum V for more information.
Right and left
The exercise with the left shoulder against the wall can reduce leaks located at the right rear of the annulus.
The exercise with the right shoulder against the wall can reduce leaks that are located at the rear left of the annulus.
By positioning the feet closer to the wall or farther away from it, the squeezing direction changes slightly. This way an exercise can be optimized per person (see chapter 11). Exercise in the direction that provides the most best results.
The Ipel test may work effectively as a preventive tool. This is possible in two ways:
- Test daily whether the back is still OK. If yes, no action is needed. If the back
can not move smoothly, start with the exercise in the limited direction.
- Don’t test daily as a routine, but start testing as soon as the back becomes sensitive / stiff / painful again.
Serious damage can be prevented by reducing leaks at an early stage.
This test uses, and builds on, the insights about end range exercises described by Robin McKenzie (see Addendum IV). The first step of this test can be seen as a modification of an exercise that this author described to treat a pelvic shift (crooked lower back). The 2nd step can be seen as a modification of an extension exercies of the back.
Yet there are four important differences with McKenzie’s work:
1. Crossed leg
McKenzie does the sideways exercise against the wall with legs stretched, limiting the pelvis on the wall side in lowering. The lateral bend in the lower back is smaller and the end range in this direction can be achieved less quickly. In the Ipel test, the inner leg is placed over the other leg, which means that the pelvis can sink downwards. The lateral bending in the lower back increases and the squeezing effect can be greater.
2. Combination forwards and sideways
After steps 1 + 2, there is at the same time squeezing in the lateral and in the forward direction. As a result, leaks that are located at the back of the annulus can be optimally pushed back to the core. McKenzie only uses the sideways effect in his corrective maneuver against the wall. In other positions he does exercise in the direction of stretching, but the direction of pushing back is different from the combined movement.
3. Other Methodology
McKenzie performs diagnostic research based on movements in various directions, looking at which exercises have a positive or negative effect on the patient’s symptoms. The Ipel Test examines whether the disc can move freely: does the spine move smoothly up to an end point or not?
According to McKenzie, the often remarkably quick effect of end range exercises can be explained by a displacement of the disc, which may lead to less tension on the bands or other tissues outside the disc. However, such a displacement has never been proven. In this book, the effect is attributed to a reduction of the amount of core content being leaked to the annulus. This is a process that takes place within the disc, whereby the leaked core content is forced back from the annulus to the core. This has become plausible after several studies and is described in detail in the book ‘Lower Back Pain, Hernia, Acute Lumbago. How to get rid of it’.
The name Ipel
The test was developed by the authors of this book and the name Ipel is the combination of the first letters of both surnames. It is the authors’ experience that many limitations can be detected and remedied with this test. Scientific research must show to what extent this is the case and how valid the test is