Thoracolumbar Fascia and Low Back Pain

Research Review: Thoracolumbar Fascia and Low Back Pain

By Erik Korzen, DC, NASM CES

Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Langevin, H., Fox, R., Koptiuch, C., Badger, G., Greenan-Nauman, A., Bouffard, N., Konofagou, E., Lee, W., Triano, J., Henry, S. (2011) Reduced thoracolumbar fascia shear strain in human low back pain. BMC Musculoskeletal Disorders. 12: 203. ARTICLE

Thoracolumbar Fascia - https://upload.wikimedia.org/wikipedia/commons/1/17/Thoracolumbar_fascia.JPG

Why is this relevant?: The thoracolumbar fascia (TLF) is a complex fascial structure, comprised of multiple layers with attachments to the lumbar and thoracic spine, pelvis and various muscles (latissimus dorsi , gluteus maximus , transverse abdominis , internal obliques , external obliques , erector spinae , multifidus and psoas ). Due to this complex relationship with core muscles and joints the TLF is often cited as having a role in Lumbo-Pelvic-Hip Complex Dysfunction, and has become the focus of many discussions and research studies pertaining to the function of fascia and connective tissue. The affect low back pain (LBP) has on the TLF may provide information that enhances the treatment of low back pain, and further, may highlight maladaptive processes of fascial structures in response to pathology.

Study Summary

Study Design	Case-control study
Level of Evidence	IIA: controlled study without randomization
Subject Demographics	121 subjects Gender: 62 Males, 59 Females Characteristics:50 without low back pain (LBP), 71 with LBP Inclusion Criteria: History (Hx) of chronic/recurrent LBP for 12 months or longer for the LBP group. No Hx of LBP or pain that limited ADLs, and a current pain index score of 0.5 or less on a 0-10 visual analog scale (VAS). Exclusion Criteria: Hx of severe back or lower extremity injury; major struc- tural spinal deformity (scoliosis, kyphosis, stenosis) or spine surgery; ankylosing spondylitis or rheumatoid arthritis; spinal fracture, tumor or infection; clinical neurological deficit suggesting nerve root compression; neurological or major psychiatric disorder; bleeding disorders; corticosteroid medication or corticosteroid injection at L2-3 level of the back; pregnancy; worker’s compensation or disability case; litigation for LBP; acute systemic infection.
Outcome Measures	Primary: Ultrasound (US) imaging to determine tissue displacement during passive prone flexion Patient positioned prone on passive flexion table Hinge point of table at L4-5 interspace US transducer placed 2cm lateral to midline at L2-3 interspace Table underwent 5 cycles (0.5Hz) with range of 15° excursion, US sampling rate was 25 MHz Testers were blinded to subject’s group (LBP vs non-LBP) US data collection “Displacement” defined as: the axial or lateral motion of the tissue between two successively acquired ultrasound frames (i. e. after 40 ms have elapsed). Tissue lateral displacement was computed for each successive pair of ultrasound frames in a 1 × 1.5 cm region of interest (ROI) centered laterally on the midpoint of the image and axially on the thoracolumbar fascia Shear strain calculation was repeated after shifting both sub-ROIs 0.5 mm superficially, then 0.5 mm deep to the original position. The maximum shear strain among the three positions was taken as the outcome measure for the right and left sides. The average of the two sides was used for statistical analysis. Secondary: Physical performance measures and ROM evaluations Trunk ROM using inclinometers for Flexion/Extension/Lat flexion Repeated trunk flexion task, 5 cycles, timed Repeated sit to stand task, 5 cycles, timed 50 foot walk task, fast and self selected speeds Sorrensons test, without dropping below 10degrees to horizontal, timed
Results	Shear strain was 62% among all subjects tested T/L fascia shear strain was 20% lower in subjects with LBP compared with non-LBP subjects No significant differences between LBP and non-LBP groups for age, BMI, activity levels No significant differences between groups for age, BMI, activity levels within male/female Flexion/Extension ROM, Sorrensons test decreased in LBP group Perimuscular connective tissue echogenicity, repeated trunk flexion test, repeated sit to stand task and 50 foot walk test duration all increased in LBP group
Conclusions	Thoracolumbar fascia shear strain was reduced by approximately 20% in subjects with chronic LBP. In subjects without LBP, thoracolumbar fascia layers appear to move independently. In subjects with low back pain thoracolumbar fascia layers demonstrates less differential motion between layers
Conclusions of the Researchers	Thoracolumbar fascia shear strain was reduced in a group of human subjects with LBP of greater than 12 months duration compared to a control group with No-LBP

Layers of the thoracolumbar fascia - http://www.anatomy-physiotherapy.com/online-courses/online-courses/images/articles/p3/f208/original.jpg

Review & Commentary:

This study is unique in that it quantifies changes in fascial shearing as result of (or perhaps cause of) low back pain, using ultrasound imaging. This study provides evidence that low back pain is correlated with a reduction in the gliding motion of fascial layers independent of one another.

By using machine imparted passive motion, the researchers constructed a reliable protocol for examining the TLF independent of muscular involvement. The use of ultrasound allowed for the visualization and measure of various fascial layers in vivo, providing evidence on motion pertinent to low back pain patients. Although dissection of anatomical structures is essential to our understanding of the human movement system, the influence of post-mortem changes may confound results.

Although this study used a strong and reliable methodology, the lack of information comparing relative reduction in shear to the extent of low back injury, or relating how these changes in shear altered the transfer of force from attached muscles to the spine, pelvis and other muscles, leaves many unanswered questions. Specifically, questions pertaining to how this study can be used to refine intervention, alter exercise selection, or influence the changes noted in TLF shear in low back pain subjects. These questions should be explored in future research.

Why is this study important?

This study contributes to a growing body of evidence that alterations in fascial tissue may influence human movement and play a role in dysfunction and pathology. Furthermore, it demonstrates a correlation between individuals with chronic LBP and fascial changes. The results of this study provides evidence for the hypothesis that fascial layers may become bound as a cause, or result of dysfunction.

How does it affect practice?

This study suggests that those individuals with LBP of 12 months or greater duration have reduced motion throughout the thoracolumbar fascia (TLF). This may imply that motion of the TLF should be considered when creating rehabilitation and performance enhancement routines in this population. Two modalities related to this structure are worth further consideration. Fascial release techniques - including manual techniques, self-administered static techniques and self-administered fascial mobilizations, and core integration techniques including - intrinsic stabilization subsystem activation , core conditioning , and posterior oblique subsystem integration .

How does it relate to Brookbush Institute Content?

The Brookbush Institute basis intervention on a foundation of functional anatomy, and the thoracolumbar fascia is an important anatomical structure relative to chronic LBP and the Lumbo Pelvic Hip Complex. This structure is discussed in great detail in the articles pertaining to the muscles invested in this structure (latissimus dorsi , gluteus maximus , transverse abdominis , internal obliques , external obliques , erector spinae , multifidus and psoas ). Further, knowledge of this structure has influenced the techniques covered in the articles - fascial release techniques , intrinsic stabilization subsystem activation , core conditioning , and posterior oblique subsystem integration . Below are several videos that specifically address neuromuscular control of the intrinsic stabilization subsystem and and posterior obliques subsystem - synergies that rely on the thoracolumbar fascia for communication and transfer of force between structures.

Quadruped

Quadruped and Glute Max Activation Progressions

Hardest Quadruped Ever Challenge

Posterior Oblique Subsystem Integration Playlist:

Questions, comments, and criticisms are welcomed and encouraged -

Thoracolumbar Fascia and Low Back Pain

Research Review: Thoracolumbar Fascia and Low Back Pain

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