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Tuesday, June 6, 2023

IASTM: Thoracolumbar Fascia (Low Back)

Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

IASTM: Thoracolumbar Fascia

By Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Thoracolumbar Fascia (20:05)

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The thoracolumbar fascia (TLF) is likely the most well researched fascial structure. Much of the research cited on the potential of fascial tissue to contribute to movement, dysfunction and/or pain seems to be based on research performed on the TLF (6, 326-328, 335, 352, 354, 357-360, 366-367). The TLF can be described as a 3 layer system, with the posterior layer having a deep and superficial laminae (layers), and the anterior layer often being omitted from movement analysis because it is thought to be too thin to contribute to lumbar stability (192, 337). (The anterior layer may be continuous with the posterior abdominal fascia). The division of the TLF into 3 layers (or 4 if counting the two layers of the posterior layer separately), is often described as a 2 layer system in research, combining the two laminae of the posterior layer and omitting the anterior layer all together. The 3 layer system is used in this article.

Anatomy - The superficial laminae of the posterior layer is continuous with the latissimus dorsi , serratus posterior inferior, gluteus maximus , as well as part of the external obliques and lower trapezius (6, 192, 330 - 334). Medially, the majority of the superficial layer is bordered by the supraspinous ligament and spinous process cranial to L4, but fibers do cross to attach to the contralateral sacrum, PSIS and iliac crest (6). Some fibers of the TLF, arising from the gluteus maximus , also cross the mid-line attaching to the opposite sacrum, PSIS or lateral raphe (6, 192, 333). The deep laminae of the posterior layer runs continuous from the splenius capitis and cervicis, superficial rhomboids , envelops the erector spinae (acting as a retinaculum), and is continuous with the sacrotuberous ligament and potentially the biceps femoris (192, 334, 337). The middle layer of the TLF extends from the transverse processes, between the quadratus lumborum and erector spinae , and runs continuous with the aponeurosis of the transverse abdominis and internal obliques (192, 330-334). The deep laminae of the posterior layer and middle layer fuse to form the lateral raphe, which may be thought of as a thickening of the middle layer to reinforce the attachment of the abdominal tourniquet muscles (192, 337). As mentioned above, the anterior layer is generally given little attention; the thinnest of the 3 layers it likely does not contribute much to lumbar stability or force transmission between muscles (192, 337), but may be continuous with the posterior abdominal fascia, abutting the transverse fascia and perotineum.

Summary

By Anatomist90 – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17900177; Thoracolumbar fascia. Notice the lighter colored band of tissue. This is the fascia.

Stability - Several studies have implicated the TLF as instrumental to lumbar spine and sacroiliac joint (SIJ) stability (191, 201, 208, 337 - 346). Some of these studies imply the significance of the role of the TLF indirectly; that is, via the attachment of the transverse abdominis and internal obliques and their contribution to lumbar and SIJ stability (191, 201, 208, 338). Other studies have directly tested increased tension in the TLF and its impact on lumbar rigidity using cadavers (334, 339 - 340). A model proposed by Vleeming et al. further supports the importance of the TLF (and investing musculature) to SIJ stability, suggesting that the bumps, ridges and friction coefficient of the intra-articular surfaces of the SIJ (form closure) are insufficient to stabilize the joint without additional compression from muscles and connective tissue (force closure) (340, 341). Studies by Cisco et al., Vleeming et al. and Richardson et al. reinforced this assertion, demonstrating increased SIJ stability with muscle activity and form closure (191, 194, 342). Additional evidence for the importance of the TLF's role in stability of the LPHC is the review of muscle behavior discussed in this article, and how many of these muscles would not directly impact the lumbar spine, SIJ or pelvis if not for their investment in the TLF (including the sacrum and sacrotuberous ligament).

Contribution to motion - The TLF was originally thought to aid in lumbar extension, but further research refuted this hypothesis (343 - 347). However, several studies have noted that the TLF may aid in resisting lumbar flexion (aid in eccentric deceleration) by increasing in length while decreasing in width (192, 334, 347). "Traction studies" (studies in which force is applied to the TLF in a similar way to a particular set of muscle fibers would pull on the TLF), aids in understanding the ability of the TLF to communicate or transfer force. The amount of displacement of fascial tissue and the distance displacement of fascial tissue occurs away from the site of traction are indicators of the ability of fascia to communicate force from one muscle to another structure. Several studies have demonstrated displacement, especially when replicating the force from the latissimus dorsi , gluteus maximus (superficial posterior layer of TLF), transverse abdominis and internal obliques (middle layer of TLF) (162, 327, 335, 348).

Results from Vleeming et al. (348):

  • Traction of trapezius muscle - ipsilateral displacement up to 2 cm
  • Traction to the cranial muscle fibers of the latissimus dorsi  - ipsilateral displacement up to 2–4 cm
  • Traction to the caudal part of the latissimus dorsi - ipsilateral displacement 8 - 10 cm up to the midline
    • Between L4–L5 and S1–S2 levels, the displacement spread to the contralateral side.
  • Traction to the gluteus maximus ipsilateral and contralateral displacement up to 4 to 7 cm.

Additionally, studies have demonstrated similar recruitment between muscles linked by the TLF. Kim et al. demonstrated contralateral muscle activity of the latissimus dorsi and gluteus maximus during gait, which increased when speed increased or weights were held (348). Hodges et al. demonstrated a relationship between increased arm speed and recruitment of ipsilateral and contralateral trunk musculature (tourniquet/middle layer TLF) (201). Stevens et al. demonstrated the co-contraction of various muscles investing in the TLF during a "quadruped" exercise (349). Last, DeRiddler et al. demonstrated the recruitment of muscles investing in the deep posterior layer of the TLF during an extension exercise (350). An interesting study by Schuenke et al. demonstrates the complexity and necessity for intramuscular coordination of muscles investing in the TLF (356). In this study, inflation of the deep posterior layer by extensor muscles altered the moment arm and load angle of muscles investing in the superficial posterior layer and middle layer of the TLF (356). This could imply that the force, action and function of individual muscles could be altered when the order of muscle recruitment is altered (as seen in those with low back pain). Further, Huskins et al. proposed a model that demonstrated that the deep laminae (extensor retinaculum) could aid in increasing the force output of the erector spinae by up to about 30%, by restricting its radial expansion (364).

Sensory Innervation - Various studies and texts have implicated fascia, and the TLF specifically, as a sensory organ closely tied to neurmuscular reflex, motion, dysfunction and pain. The presence of corpuscular receptors in the posterior layer of the TLF is commonly described by the older studies - such as Golgi, Pacini and Ruffini endings which imply a role in proprioception (352-354). Interestingly, the most recent study (using modern methods) by Tesarz et al. failed to find such corpuscular endings, with the exception of possible Ruffini endings (354). If the TLF does plays a role in proprioception it would likely be indirect through forces imparted on the supraspinous, interspinous and iliolumbar ligaments, which are abundantly innervated by Pacinian receptors and Ruffini endings (352, 361). However, additional studies show that these receptors may only be stimulated at end range as limit detectors which implies they have less of a role in mid-range (362-363).

The study by Tesarz et al. did find that the TLF was especially dense in free nerve endings, presumably nociceptors, in the posterior layer (354). These findings are supported by several studies as research in this area has increased in recent years (355, 557 - 559). Although these findings do not support the notion of the TLF as a proprioceptive organ, they do support the hypothesis that micro-trauma and inflammation of the TLF may contribute to low back pain. There is additional evidence to suggest that an increase in sympathetic activity, and/or inflammation may "sensitize" the posterior layer of the TLF contributing to an increase in nociception (357-359). The role of the TLF in low back pain was originally discussed by Hirsh in 1963 (352), revisited as a potential mechanism for chronic low back pain by Punjabi in 2oo6 (356), and beautifully summarized in the quote below by Vleeming (192):

Quote from Vleeming et al. (192):

  • To summarize, the sensory innervation of the TLF suggests (may imply) at least three different mechanisms for fascia-based low back pain sensation: (1) microinjuries and resulting irritation of nociceptive nerve endings in the TLF may lead directly to back pain; (2) tissue deformations due to injury, immobility or excessive loading could also impair proprioceptive signaling, which by itself could lead to an increase in pain sensitivity via an activity-dependent sensitization of wide dynamic range neurons; and finally (3) irritation in other tissues innervated by the same spinal segment could lead to increased sensitivity of the TLF, which would then respond with nociceptive signaling, even to gentle stimulation.

Fascial Mobility, SIJ Stability and Practice -

As mentioned above a study by Levangin et al. compares shear strain (movement between fascial planes) of the TLF in those with and without a history of low back pain (367). It was proposed that mal-adpative cross-bridging in response to tissue damage and inflammation may have reduced movement between layers. The Brookbush Institute does recommend IASTM techniques with the intent of disrupting these cross-bridges; however, careful consideration must be given to the irritability of the patient and the receptor density of the TLF.

Perhaps the most obvious application of TLF research is a focus on activation and strengthening of investing musculature with the goal of increased stability of the lumbar spine and SIJ. Mooney et al. showed the effectiveness of rotary exercises for the treatment of SIJ dysfunction (368), and many of the previously mentioned studies by Richardson et al., Hides et al, Hodges et. al. and Morris et al. have demonstrated the efficacy of transverse abdominis and internal oblique  activation/strengthening for stabilization of the lumbar spine and SIJ, and treatment of low back pain (157-159, 194-196).

In conclusion, mobility and/or activation techniques may result in positive changes. Current studies suggest that manual therapy and other myofascial modalities may increase TLF stiffness, while increasing shear (movement) between layers, effect tone of fibroblasts and investing musculature, while activation and strengthening of investing musculature may improve stability of the lumbar spine and SIJ. Care should be taken in addressing these tissues directly, as there is evidence to suggest that the TLF could be a source of nociceptive input for those suffering from chronic low back pain. The Brookbush Institute does recommend IASTM techniques and Posterior Oblique Subsystem Integration (POS) (discussed below) based on these findings.

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