Background & Aims
It has been shown that chronic pain contributes to the persistence of chronic local connective tissue inflammation, which results in fibrosis, connective tissue adhesions, and decreased mobility of the thoracolumbar fascia (TLF) in patients with chronic low back pain (CLBP) (1,2,3,4).
Also, the evidence showed that the increase in TLF thickness due to possible structural changes in the connective tissue is associated with pain severity (5).
Stretching of the fascia is an important component of manual and movement therapies (6,7). However, evidence is limited for the effect of TLF stretching on CLBP patients.
The objective of this study was to investigate the effect of TLF stretching on pain characteristics; pain intensity, pressure pain threshold (PPT), temporal summation, pain sensitivity, and the effects of pain on activity in CLBP.
Keywords: thoracolumbar fascia, stretching, pain threshold, temporal summation, low back pain.
Methods
30 participants with nonspecific CLBP aged 20-60 years, participated in this study which was conducted from November 2023 to January 2024. The subjects were randomized into two groups: the study (n?=?15; 7 men, 8 female) and the control group (n?=?15; 7 men, 8 female).
The study group received a 4-week TLF fascial stretching exercise (10 times per day) in addition to the conventional physiotherapy program, while the control group only received a conventional physiotherapy program. Outcomes measures recorded before and after the interventions included pain intensity measured with 10?point numerical rating scale (NRS) (8), pressure pain threshold (PPT) (9), and temporal summation by an algometer (from TLF levels of lumbar 1 and 3 vertebrae (L1, L3) and 12th costa )(10) as primary outcomes. Secondary outcomes comprised pain sensitivity assessed by the Pain Sensitivity Scale (PSS)(11) and the effects of pain on activity measured by the Brief Pain Inventory (BPI)(12).
Results
The primary outcome measures of the study; pain threshold at the level L1, L3, and 12th costa showed significant differences in the experimental group in post-treatment threshold by getting higher compared to pre-treatment threshold (p<0.001, ?p2=0.61, ?p2=n.67, ?p2=0.74,). Temporal summation showed no significant difference in both groups' pre-post treatment results (p>0.05). Pain sensitivity and effects of pain also showed significant differences between the study and control groups with statistically significant improvement in terms of PSC and BPI scores (p< 0.05).
Conclusions
The results of our study showed that TLF stretching appears to be more effective than conventional low back pain exercises for improving pain intensity, pain threshold, pain sensitivity symptoms, and the effects of pain on activity in individuals with nonspecific chronic LBP. While we know non-specific LBP is a condition with a multifactorial etiology, fascia is one of the increasingly suspected factors to be involved in the problem. We believe that having the aspect of fascia in LBP treatment can be beneficial for both patients and clinicians.
References
1.Langevin H.M., Stevens-Tuttle D., Fox J.R., Badger G.J., Bouffard N.A., Krag M.H., Wu J., Henry S.M. Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low Back Pain. BMC Musculoskelet. Disord. 2009;10:151. doi: 10.1186/1471-2474-10-151. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
2.Langevin H.M., Fox J.R., Koptiuch C., Badger G.J., Greenan- Naumann A.C., Bouffard N.A., Konofagou E.E., Lee W.-N., Triano J.J., Henry S.M. Reduced Thoracolumbar Fascia Shear Strain in Human Chronic Low Back Pain. BMC Musculoskelet. Disord. 2011;12:203. doi: 10.1186/1471-2474-12-203. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
3. Wilke J., Schleip R., Klingler W., Stecco C. The Lumbodorsal Fascia as a Potential Source of Low Back Pain: A Narrative Review. BioMed Res. Int. 2017;2017:5349620. doi: 10.1155/2017/5349620. [PMC free article][PubMed] [CrossRef] [Google Scholar]
4.Yang ZM, Ma LJ, Xu JF, Lin RZ. Clinical application of TCM therapy for pain based on fascia theory. Chin Manipul Rehabil Med. 2022;13 (10):61–63. doi:10.19787/j.issn.1008-1879.2022.10.018
5.Yahia L, Rhalmi S, Newman N, Isler M. Sensory innervation of human thoracolumbar fascia. An immunohistochemical study. Acta Orthop Scand. 1992 Apr;63(2):195-7. doi: 10.3109/17453679209154822. PMID: 1590057.
6. Langevin HM, Bishop J, Maple R, Badger GJ, Fox JR. Effect of Stretching on Thoracolumbar Fascia Injury and Movement Restriction in a Porcine Model. Am J Phys Med Rehabil. 2018 Mar;97(3):187-191. doi: 10.1097/PHM.0000000000000824. PMID: 28901961; PMCID: PMC7411307.
7.Ruiz, Juan Javier Bru, Perez-Cruzado, David, and Llanes, Raúl Pérez. ‘Immediate Effects of Lumbar Fascia Stretching on Hamstring Flexibility: A Randomized Clinical Trial’. 1 Jan. 2023 : 619 – 627.
8.Chiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB. Measurement Properties of Visual Analogue Scale, Numeric Rating Scale, and Pain Severity Subscale of the Brief Pain Inventory in Patients With Low Back Pain: A Systematic Review. J Pain. 2019 Mar;20(3):245-263. doi: 10.1016/j.jpain.2018.07.009. Epub 2018 Aug 10. PMID: 30099210.
9.Fischer AA: Pressure threshold measurement for diagnosis of myofascial pain and evaluation of treatment results. Clin J Pain 1986;2:207
10.Sanjana F, Chaudhry H, Findley T. Effect of MELT method on thoracolumbar connective tissue: The full study. J Bodyw Mov Ther. 2017 Jan;21(1):179-185. doi: 10.1016/j.jbmt.2016.05.010. Epub 2016 Jun 3. PMID: 28167175.
11.Ruscheweyh R,Vermeuer B,Dany K,et al.Validation of the pain sensitivity questionnaire in chronic pain patients.Pain2012;153:1210e8
12.Yildirim Y, Parlar K?l?ç S, Eyigor S, Eyigor C, Yildirim Y, Karaman E, Oyur Çelik G, Uyar M. Validity and reliability of Turkish version of the Brief Pain Inventory-Short Form for patients with chronic nonmalignant pain. Agri. 2019 Nov;31(4):195-201. English. doi: 10.14744/agri.2019.25901. PMID: 31741339.
Presenting Author
Naime Ulu?
Poster Authors
Topics
- Specific Pain Conditions/Pain in Specific Populations: Low Back Pain