Innervation of the thoracolumbar fascia

Effects of Fascial Manipulation® on urinary symptoms: A case report

BACKGROUND

Pelvic floor dysfunction (PFD) is prevalent post-childbirth, with urinary incontinence (UI) affecting approximately 30 % of women. Although pelvic floor muscle training is widely recognized as the first-line treatment for UI, emerging research underscores the significance of fascial tissue on pelvic floor muscle function. The fascia surrounding the pelvic diaphragm shares an intrinsic relationship with the abdomen, pelvis, lumbar region, and lower limb. In this sense, fascial restrictions in any of these segments may contribute to the development of UI. Fascial Manipulation® (FM®), is a method targeting fascial restrictions across the body and has shown promise in treating musculoskeletal and pelvic conditions. Given the potential influence of fascial dysfunction in PFD, this case explores the application of FM® to address UI symptoms.

CASE PRESENTATION

A Japanese 36-year-old woman with UI symptoms that worsen six months post-partum. Two weeks after a vaginal delivery, she consulted a urologist due to increased urinary frequency and urgency, which was disrupting her sleep. At that time, she underwent a five-week program of pelvic floor muscle training, with no improvement in UI symptoms, prompting her to seek alternative treatment. A 72-h bladder diary was used to assess patient's voiding pattern, including daytime and nighttime urine frequency. Symptom severity and her distress symptoms were evaluated using the Overactive Bladder Symptom Score (OABSS) and Core Lower Urinary Tract Symptom Score (CLSS) questionnaires, respectively. Pelvic floor displacement was measured via ultrasound imaging. Additionally, movement specific tests and palpation, based on Stecco's Fascial Manipulation® (FM®) method, identified points of tissue densification. Pain intensity was measured using the 10-point Visual Analogue Scale (VAS). During the specific movement tests assessment, the patient complained about right knee pain and restricted dorsiflexion of the right ankle. Palpation revealed tissue densifications in the medial ankle and knee, posterior knee, right hip, bilateral pelvic region, and the area of the lower abdominal muscles. The patient underwent a single session of the FM® method, involving deep friction of the identified densification points. Follow-up assessments included a reassessment of the 72-h bladder diary, OABSS, and CLSS questionnaires one month after the intervention. Ultrasound images and the specific movement tests, with VAS score, were performed immediately after intervention and one month later.

RESULTS

One month after the treatment, the 72-h Bladder Diary indicated a reduction in urination frequency from 10 to 13 times/day to 6 times/day, and nighttime frequency from 2 to 3 times/night to 1 time/night. Questionnaire scores reflected significant improvement, with OABSS severity decreasing from 7 to 1, and CLSS distress reducing from 6 to 1. Immediately after the treatment the ultrasound imaging showed an increase in pelvic floor muscle elevation from 4 to 7 mm., which was maintained, at 7 mm., one month later. The patient reported an improvement in the specific movement tests, being able to squat without pain in the right knee, with zero on the VAS scale. One month later, the patient could sit upright without pain (VAS from 6 to 0) in the right knee.

CONCLUSION

Fascial Manipulation may reduce urinary frequency and urgency by releasing abnormal tension on the bladder via the internal fascia. Recognizing fascial influences on the whole body could be an effective strategy for treating these symptoms.

Association between thoracolumbar fascia injury and residual back pain following percutaneous vertebral augmentation: a systematic review and meta-analysis

Objective

To evaluate the association between a thoracolumbar fascia injury (TLFI) and the development of residual back pain (RBP) following percutaneous vertebral augmentation (PVA).

Background

Osteoporotic vertebral compression fractures (OVCF) commonly affect elderly individuals and those with osteoporosis, leading to pain and limited mobility. Percutaneous vertebral augmentation provides immediate pain relief and stabilization of the fractures. However, some patients experience residual pain after the treatment. Although recent studies have suggested a potential association, the role of TLFI in RBP remains inconclusive. The aim of this meta-analysis was to evaluate this association.

Methods

A thorough search was performed across the PubMed, Medline, Embase, Web of Science, and Cochrane Library databases from inception to 31 December 2024 to identify studies examining the link between TLFI and RBP following PVA. A random-effects model was used to combine the outcome data to account for the potential heterogeneity among the included studies.

Results

This meta-analysis included 13 studies with a total of 4,542 participants and a TLFI incidence rate of 28%. Univariate analysis indicated that patients with a TLFI were significantly more likely to develop RBP compared to those without a TLFI, with an odds ratio (OR) of 4.19 (95% CI: 2.49 to 7.05, I² = 76.9%). The sensitivity analysis identified two studies as significant influential outliers that contributed to the majority of the observed heterogeneity. Excluding these studies resulted in an OR of 4.62 (95% CI: 3.61 to 5.92, I² = 0%). The multivariate analysis confirmed a strong association between TLFI and RBP after adjusting for confounders and other risk factors, with an OR of 4.57 (95% CI: 3.28 to 6.37, I² = 81.5%). The sensitivity analysis identified three studies as significant influential outliers, and excluding them resulted in an OR of 4.79 (95% CI: 3.76 to 6.11, I² = 0%) with no heterogeneity. This finding further confirms the association with a more homogenous overall effect estimate.

Conclusion

The pooled effect size of both univariate and multivariate analyses consistently demonstrated that a TLFI significantly increased the risk of developing RBP after PVA regardless of other related risk factors. Recognizing fascia injury as a potential source of postoperative pain in clinical practice could enhance the care of these patients and mitigate postoperative pain.

Research progress on the role of fascia in skin wound healing

The skin, the human body's largest organ, is perpetually exposed to environmental factors, rendering it vulnerable to potential injuries. Fascia, a vital connective tissue that is extensively distributed throughout the body, fulfils multiple functions, including support, compartmentalization, and force transmission. The role of fascia in skin wound healing has recently attracted considerable attention. In addition to providing mechanical support, fascia significantly contributes to intercellular signalling and tissue repair, establishing itself as a crucial participant in wound healing. This review synthesises the latest advancements in fascia research and its implications for skin wound healing.

Rapid weight loss and combat athletes: a study on psychological resilience and mechanical hyperalgesia

Introduction

The study investigates the effects of Rapid Weight Loss (RWL) on the levels of psychological resilience and mechanical pain sensitivity in elite kickboxers. The primary aim was to examine changes in psychological resilience subdimensions and pressure pain threshold (PPT) values in the thoracolumbar region before and after a one-month RWL period leading up to competition. Hypotheses included expectations of significant reductions in PPT values due to biomechanical and physiological changes during RWL, along with improvements in psychological resilience subdimensions due to structured routines and social support.

Methods

Thirty-seven elite male athletes (age: 22.94 ± 1.98) participated in the study. Psychological resilience was assessed using the Psychological Resilience Scale for Adults, and mechanical pain sensitivity was evaluated through Pressure Pain Threshold (PPT) measurements. Measurements were conducted before and after the RWL period, spanning one month prior to competition.

Results

The results revealed significant PPT values across all thoracolumbar segments after RWL (p < 0.001). Cohen's d values indicated large effect sizes for these changes (d = 2.10-2.36). The L5 segment exhibited the largest PPT decrease (t = -10.45, d = 2.36), while the Th1 segment showed the smallest decrease (t = -8.23, d = 2.10). Measurements taken at 4 cm from the spine midline also demonstrated significant PPT reductions (p < 0.001), with the highest change recorded in the L5 segment (t = -9.78, d = 2.30). Psychological resilience subdimensions, including "structured style," "social competence," "future orientation," and "social resources," improved significantly after RWL (p < 0.05), while "family cohesion" and "personal strength" did not show significant changes. Athletes who previously ranked in tournaments exhibited higher psychological resilience, potentially due to enhanced self-confidence.

Discussion

These findings align with literature suggesting that competitive success and optimism play crucial roles in resilience development. Personality traits and perceived social support further contributed to the observed resilience levels. This study highlights the multidimensional impact of RWL, emphasizing its detrimental effects on pain sensitivity and its mixed outcomes on psychological resilience. RWL-associated increases in mechanical hyperalgesia, especially in the lumbar region, were attributed to biomechanical and neurophysiological factors. Enhanced psychological resilience observed in certain subdimensions underscores the importance of structured and social support systems in mitigating RWL-induced stress. Future research should explore interventions to optimize resilience and manage pain during RWL periods, focusing on individualized support strategies for athletes. These findings contribute to understanding the interplay between psychological and physiological factors during RWL, practical insights for athletic training.

The Use and Benefits of Focused Shockwaves for the Diagnosis of Myofascial Pain Syndrome by Examining Myofascial Trigger Points in Low Back Pain

Background/Objectives: Low back pain (LBP) is a widespread public health issue, with myofascial pain syndrome (MPS) being a common cause, affecting 67-100% of patients. However, there are significant challenges in the diagnostic process due to the subjective and unreliable nature of manual palpation. Focused Extracorporeal Shockwave Therapy (F-ESWT), traditionally used for MPS treatment, offers a reproducible and non-invasive mechanical stimulus, making it a potential diagnostic tool. This study evaluated F-ESWT's diagnostic efficiency in chronic LBP patients by focusing on "recognition" and "referral" of pain. Methods: twenty-eight participants were screened for myofascial trigger points (MTrPs) in the lumbar, gluteal, and thigh regions. Identified MTrPs were stimulated using F-ESWT, and patient feedback was recorded. Results: data showed high diagnostic accuracy for muscles such as the quadratus lumborum, gluteus medius, and gluteus minimus muscles, achieving "referral" rates of 96%, 95%, and 92% and "recognition" rates of 84%, 86%, and 85%, respectively. Other structures like adductors, iliopsoas, erector spinae, and biceps femoris muscle showed consistent but lower diagnostic rates. Conclusions: the study's findings indicate that F-ESWT effectively reproduces pain patterns, offering a precise, reproducible, and non-invasive diagnostic approach for MPS in chronic LBP. However, they also highlight the necessity for detailed diagnostic criteria in managing myofascial pain.

Relations between daily stressful events, exertion, heart rate variability, and thoracolumbar fascia deformability: a case report

BACKGROUND

The posture of performance-oriented sport climbers adapts in a way that likely promotes the development of low back pain. The thoracolumbar fascia, while also contributing to performance, seems to be involved in that process. Furthermore, there has been evidence of the stiffening of the fascial structures in disorders associated with negative affectivity. The study aims to investigate the relationship between the autonomic nervous system and the deformability of the thoracolumbar fascia in a sport climber in a natural setting.

CASE PRESENTATION

Over a 30 day period, a 50-year-old German male reported daily morning resting heart rate variability and daily inventory of stressful events. The thoracolumbar fascia deformation was measured daily using ultrasound in a manual therapy clinic. A time series analysis was performed to detect possible time-delayed relationships between the variables. A cluster analyses revealed two distinguishable heart rate variability clusters (heart rate variability clusters 1 and 2). Both clusters were correlated with thoracolumbar fascia deformation and daily inventory of stressful events. Higher heart rate variability cluster 1 immediately caused lower thoracolumbar fascia deformation. Heart rate variability cluster 1 parameters mediated the effect of daily inventory of stressful events on a decrease in thoracolumbar fascia deformation with a 2-day delay. One heart rate variability cluster 2 parameter mediated the effect of daily inventory of stressful events on an increase in thoracolumbar fascia deformation with a 7-day delay.

CONCLUSION

Heart rate variability cluster 1 values, which probably indicate sympathetic nervous system activity, are directly related to thoracolumbar fascia. Presumably, the sympathetic nervous system mediated the effect of daily inventory of stressful events on a lower thoracolumbar fascia deformation with a 2-day delay, followed by a supercompensation, most likely parasympathetically mediated. Coaches and trainers should be aware of these mechanisms and consider monitoring during training to minimize potential additional risk factors for impaired performance and health.

Addressing gaps in pain research from an integrated whole person perspective

ABSTRACT

While our understanding of pain is rapidly growing, some areas of pain research are lagging behind. This article discusses two current and inter-related gaps in knowledge that are in need of addressing: first, the connections between "brain" and "body" components of pain; and second, the process of endogenous pain resolution. Historical reasons for these research gaps are discussed and solutions are outlined based on an integrative, whole person research approach. These include comprehensive mapping of the mechanosensory and nociceptive innervation of deep tissues; developing objective, non-invasive measurements to quantify the metabolic, structural and mechanical components of the peripheral tissue environment; integrating our understanding of pain pathophysiology, across whole organs and whole body, as well as across bio-psycho-social domains; and understanding the interplay of nervous system and peripheral tissue mechanisms that promote the endogenous resolution of pain and prevent its acute-to-chronic transition. Current NIH-led efforts in these areas are outlined, including several studies within the NIH HEAL (or Help End Addition Long Term) initiative and the National Center for Complementary and Integrative Health's strategic priorities in whole person research.

Epimuscular myofascial force transmission between nerve and myotendinous unit: A shear-wave elastography study

INTRODUCTION

Epimuscular myofascial force transmission can occur bidirectionally between muscles and nerves through a connecting neurovascular tract. The purpose of this study was to determine whether a neurodynamic stress test produces stiffness changes in the adjacent myotendinous complex. The authors also assessed which anatomical variables had an impact on elasticity changes provoked by the maneuver.

METHODS

A convenience sample of healthy adults (n = 39) recruited from a university population who met the inclusion criteria participated voluntarily in this study. Using Shear-Wave elastography, stiffness data were obtained for the ulnar nerve, flexor carpi ulnaris tendon and muscle before and after a neural tensioning maneuver.

RESULTS

Following an ulnar nerve stretch, statistically significant differences were obtained in neural stiffness increase in nerve (p < 0.001), tendon (p < 0.001) and muscle (p = 0.046), with a moderate (d = 0.538), small (d = 0.485) and small (d = 0.224) effect sizes, respectively. The changes obtained were greater in those individuals with a smaller anatomical distance between nerve and tendon.

CONCLUSIONS

Alterations in peripheral neural tissue tension involves elasticity changes in adjacent musculoskeletal tissue mediated by the neurovascular tract. Collateral force transmission was determined by the individual anatomical differences of each subject. Future research should assess whether the observed increase in myotendinous stiffness due exclusively to the passive transmission of force through the connective bridges between the two tissues studied or if there is a "neuroprotective" muscle contraction following neural stress.

Effects of a Manual Treatment on Lumbar Microcirculation and Tissue Stiffness Following Submaximal Eccentric Trunk Extensor Exercise: A Randomized Controlled Trial

Recent studies have shown that the extramuscular connective tissue (ECT) is thickened and stiffened in delayed onset muscle soreness (DOMS). However, contrarily to the normal population, severe DOMS is rare in athletes or highly trained individuals. The present randomized, controlled trial therefore aimed to investigate pain as well as microcirculation and stiffness of the ECT and the erector spinae muscle following submaximal eccentric trunk extension exercise not causing DOMS. The effect of manual treatment by a therapist (myofascial release; MFR) on these parameters was to be studied. Trained healthy participants (n = 21; 31.3 ± 9.6 years; > 4 h exercise per week) performed submaximal eccentric exercise of the trunk extensors. One group was manually treated (n = 11), while the other group (n = 10) received placebo treatment with sham laser therapy. Stiffness of the ECT and the erector spinae muscle (shear wave elastography), microcirculation (white light and laser Doppler spectroscopy), palpation pain (100 mm visual analogue scale, VAS) and pressure pain threshold (indentometry, PPT) were assessed before (t0), 24 h (t24) and 48 h (t48) after conditions. Erector spinae muscle stiffness increased after eccentric exercise from t0 to t24 (0.875 m/s) and from t0 to t48 (0.869 m/s). After MFR, erector spinae muscle stiffness decreased in contrast to placebo treatment at t24 (-0.66 m/s), while ECT stiffness remained unchanged. Oxygen saturation increased (17-20.93%) and relative haemoglobin decreased (-9.1 - -12.76 AU) after eccentric exercise and MFR differed from placebo treatment at t48 (-3.71 AU). PPT differed after MFR from placebo treatment at t48 (20.69 N/mm), while VAS remained unchanged. Multiple linear regression showed that ECT stiffness and group membership predicted erector spinae muscle stiffness. MFR could have a positive effect on pain, microcirculation and muscle stiffness after submaximal eccentric exercise, suggesting better recovery, which needs to be confirmed by future work.

Quantifying thoracolumbar fascia deformation to discriminate acute low back pain patients and healthy individuals using ultrasound

Reduced shear strain and deformability of the thoracolumbar fascia has been linked to low back pain. A number of ultrasound examination methods have been developed for laboratory rather than clinical practice. The aim of this study was to examine the reliability and discriminative validity (patients vs. healthy individuals) of an ultrasound (US) measurement method for the quantification of thoracolumbar fascia deformation (TLFD). A cross-sectional study with US assessment and rater blinding was conducted in a manual therapy clinic and a university laboratory. 16 acute low back pain (aLBP) patients and 15 healthy individuals performed a standardized trunk extension task. US measurements of TLFD were carried out independently by two raters by imaging the TLF in the starting and ending positions of the movement. Intra-rater and inter-rater reliability were calculated using intraclass correlation coefficients (ICCs) and minimal detectable changes (MDC) were calculated. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off for TLFD to discriminate the study groups. Kappa statistics were performed to assess rater agreement in discrimination. Intra-rater reliability was excellent (ICC: .92, MDC: 5.54 mm, p < .001) and inter-rater reliability was good (ICC: .78, MDC: 8.70 mm, p < .001). The cut-off for TLFD was 6 mm with a sensitivity of 100% and a specificity of 93.75% and the raters agreed moderately (κ = 0.74, p < .001) when distinguishing patients and controls. The reliability of the US method for assessing TLFD is moderate to excellent, and the ability to discriminate aLBP patients from healthy individuals is moderate. The method could be used to capture an additional parameter in morphological aLBP screenings.

Effect of thoracolumbar fascia injury on reported outcomes after percutaneous vertebroplasty

Purpose

Thoracolumbar fascia injury is often associated with poor early pain relief after percutaneous vertebroplasty (PVP). This study will evaluate the effects of thoracolumbar fascia injury on early pain relief and time to get out of bed after PVP.

Methods

A total of 132 patients treated with PVP for osteoporotic vertebral compression fractures (OVCF) were included and divided into injured group (52 cases) and non-injured group (80 cases) according to the existence of thoracolumbar fascia injury. Before surgery, 1 day, 3 days, 1 week, 1 month, and 3 months after surgery, and at the last follow-up, the primary patient-reported outcome measures (PROMs) were the visual analogue scale (VAS) of pain while rolling over and standing, and the secondary PROMs was the Oswestry disability index (ODI). Meanwhile, the achieved rate of minimal clinically important differences (MCID) and patient acceptable symptom states (PASS) of the above measures in both groups was evaluated at the last follow-up.

Results

Except for the postoperative 3 months and the last follow-up, there were statistically significant differences in VAS-standing and ODI between the two groups at other time points after surgery (P < 0.05), and the non-injured group was significantly better than the injured group. At the last follow-up, there was no statistically significant difference in the MCID and PASS achievement rates of the above measures between the two groups (P > 0.05). In addition, the proportion of patients who got out of bed 1 and 3 days after surgery in the non-injury group was significantly higher than that in the injury group (P = 0.000 for both).

Conclusion

Thoracolumbar fascia injury significantly affected early pain relief and extended time of getting out of bed after PVP. Attention should be paid to preoperative evaluation of thoracolumbar fascial injury in order to better predict the postoperative efficacy of PVP.

Short-Term Benefits from Manual Therapy as an Adjunct Treatment for Persistent Postural-Perceptual Dizziness Symptoms: A Preliminary Prospective Case Series

Persistent dizziness and balance deficits are common, often with unknown etiology. Persistent Postural-Perceptual Dizziness (3PD) is a relatively new diagnosis with symptoms that may include dizziness, unsteadiness, or non-vertiginous dizziness and be persistent the majority of time over a minimum of 90 days. The purpose of this case series was to investigate short-term outcomes of reducing dizziness symptoms using a manual therapy intervention focused on restoring mobility in the fascia using a pragmatically applied biomechanical approach, the Fascial Manipulation® method (FM®), in patients with 3PD. The preliminary prospective case series consisted of twelve (n = 12) patients with persistent complaints of dizziness who received systematic application of manual therapy to improve fascial mobility after previously receiving vestibular rehabilitation. The manual therapy consisted of strategic assessment and palpation based on the model proposed in the FM® Stecco Method. This model utilizes tangential oscillations directed toward the deep fascia at strategic points. Six males (n = 6) and females (n = 6) were included with a mean age of 68.3 ± 19.3 years. The average number of interventions was 4.5 ± 0.5. Nonparametric paired sample t-tests were performed. Significant improvements were observed toward the resolution of symptoms and improved outcomes. The metrics included the Dizziness Handicap Inventory and static and dynamic balance measures. The Dizziness Handicap Inventory scores decreased (i.e., improved) by 43.6 points (z = -3.1 and p = 0.002). The timed up and go scores decreased (i.e., improved) by 3.2 s (z = -2.8 and p = 0.005). The tandem left increased (i.e., improved) by 8.7 s (z = 2.8 and p = 0.005) and the tandem right increased (i.e., improved) by 7.5 s (z = 2.8 and p = 0.005). Four to five manual therapy treatment sessions appear to be effective for short-term improvements in dizziness complaints and balance in those with 3PD. These results should be interpreted with caution as future research using rigorous methods and a control group must be conducted.

Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome

INTRODUCTION

Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option.

RESULTS

This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome.

CONCLUSION

This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Pain quality patterns in delayed onset muscle soreness of the lower back suggest sensitization of fascia rather than muscle afferents: a secondary analysis study

Delayed onset muscle soreness (DOMS) of the lower back is considered a surrogate for acute low back pain (aLBP) in experimental studies. Of note, it is often unquestioningly assumed to be muscle pain. To date, there has not been a study analyzing lumbar DOMS in terms of its pain origin, which was the aim of this study. Sixteen healthy individuals (L-DOMS) were enrolled for the present study and matched to participants from a previous study (n = 16, L-PAIN) who had undergone selective electrical stimulation of the thoracolumbar fascia and the multifidus muscle. DOMS was induced in the lower back of the L-DOMS group using eccentric trunk extensions performed until exhaustion. On subsequent days, pain on palpation (100-mm analogue scale), pressure pain threshold (PPT), and the Pain Sensation Scale (SES) were used to examine the sensory characteristics of DOMS. Pain on palpation showed a significant increase 24 and 48 h after eccentric training, whereas PPT was not affected (p > 0.05). Factor analysis of L-DOMS and L-PAIN sensory descriptors (SES) yielded a stable three-factor solution distinguishing superficial thermal ("heat pain ") from superficial mechanical pain ("sharp pain") and "deep pain." "Heat pain " and "deep pain" in L-DOMS were almost identical to sensory descriptors from electrical stimulation of fascial tissue (L-PAIN, all p > 0.679) but significantly different from muscle pain (all p < 0.029). The differences in sensory description patterns as well as in PPT and self-reported DOMS for palpation pain scores suggest that DOMS has a fascial rather than a muscular origin.

MRI T2 mapping and shear wave elastography for identifying main pain generator in delayed-onset muscle soreness: muscle or fascia?

INTRODUCTION

The main generator of delayed onset muscle soreness (DOMS) is still unknown. This study aimed to clarify the main generator of DOMS.

METHODS

Twelve participants performed eccentric exercise (EE) on lower legs. MRI and ultrasound were used to assess changes of calf muscle and deep fascia before and after EE. These results were then compared to the muscle pain level.

RESULTS

Compared to baseline, muscle pain peaked at 24-48 h after EE (downstairs 22.25 ± 6.196, 57.917 ± 9.298, F = 291.168, p < 0.01; resting 5.833 ± 1.899, 5.083 ± 2.429, F = 51.678, p < 0.01). Shear wave speed (SWE) of the deep fascia and T2 values of the gastrocnemius muscle and deep fascia all increased and peaked at 48 h after EE (1.960 ± 0.130, F = 22.293; 50.237 ± 2.963, F = 73.172; 66.328 ± 2.968, F = 231.719, respectively, p < 0.01). These measurements were positively correlated with DOMS (downstairs: r = 0.46, 0.76, 0.87, respectively, p < 0.001; resting: r = 0.42, 0.70, 0.77, respectively, p < 0.001). There was a significant positive correlation between SWE and T2 values of deep fascia (r = 0.54, p < 0.01).

CONCLUSION

DOMS is a common result of muscle and fascia injuries. Deep fascia edema and stiffness play a crucial role in DOMS, which can be effectively evaluated MR-T2 and SWE.

CRITICAL RELEVANCE STATEMENT

Delayed-onset muscle soreness is a common result of muscle and deep fascia injuries, in which the edema and stiffness of the deep fascia play a crucial role. Both MRI and shear wave elastography can be effectively used to evaluate soft tissue injuries.

KEY POINTS

• The deep fascia is the major pain generator of delayed-onset muscle soreness. • There is a significant correlation between fascia injury and delayed-onset muscle soreness. • MRI and shear wave elastography are preferred methods for assessing fascia injuries.

Fascial Signal Change on the Cervical MRI of a Patient with Systemic Lupus Erythematosus

Here, we present a case of a 53-year-old female patient with chronic neck pain and systemic inflammation who was ultimately diagnosed with systemic lupus erythematosus. Notably, applying fat-suppressed T2-weighted MRI sequences was pivotal in detecting structural fascial changes commonly associated with systemic inflammatory diseases. PET-CT scans further revealed systemic inflammation around multiple joints, providing valuable insights into MRI signal alterations. This case underscores the importance of considering systemic autoimmune pathology as a potential underlying cause of chronic musculoskeletal pain. It also highlights the clinical utility of MRI with fat suppression sequences in identifying inflammation-related fascial changes. This case emphasizes the significance of a comprehensive evaluation, particularly in situations where clinical features overlap between autoimmune and degenerative skeletal pathologies. Fat-suppressed MRI can provide information about fascial pathology related to systemic inflammatory diseases. In this context, it is worth noting that PET-CT and fat suppression MRI complement each other by providing complementary information about inflammation and the underlying causes of a patient's pain.

A New Player in the Mechanobiology of Deep Fascia: Yes-Associated Protein (YAP)

Recent studies have demonstrated that fascial fibroblasts are susceptible to mechanical stimuli, leading to the remodeling of the extracellular matrix (ECM). Moreover, the extensive literature on Yes-associated protein (YAP) has shown its role in cell mechanics, linking cell properties, such as shape, adhesion, and size, to the expression of specific genes. The aim of this study was to investigate the presence of YAP in deep fascia and its activation after a mechanical stimulus was induced via a focal extracorporeal shockwave (fESW) treatment. Thoracolumbar fascia (TLF) samples were collected from eight patients (age: 30-70 years; four males and four females) who had undergone spine elective surgical procedures at the Orthopedic Clinic of University of Padova. YAP was measured in both tissue and TLF-derived fibroblasts through immunoblotting. COL1A1 and HABP2 gene expression were also evaluated in fibroblasts 2, 24, and 48 h after the fESW treatment. YAP was expressed in all the examined tissues. The ratio between the active/inactive forms (YAP/p-YAP) of the protein significantly increased in fascial fibroblasts after mechanical stimulation compared to untreated cells (p = 0.0022). Furthermore, COL1A1 and HABP2 gene expression levels were increased upon treatment. These findings demonstrate that YAP is expressed in the deep fascia of the thoracolumbar region, suggesting its involvement in fascial mechanotransduction processes, remodeling, regeneration, and fibrogenesis. This study indicates, for the first time, that YAP is a "new player" in the mechanobiology of deep fascia.

A model for personalized diagnostics for non-specific low back pain: the role of the myofascial unit

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Effects of Maximal Eccentric Trunk Extensor Exercise on Lumbar Extramuscular Connective Tissue: A Matched-Pairs Ultrasound Study

Recently, it has been shown that the extramuscular connective tissue (ECT) is likely involved in delayed onset muscle soreness (DOMS). Therefore, the aim of the present study was to investigate the effects of maximal trunk extension eccentric exercise (EE) on ECT thickness, self-reported DOMS, ECT stiffness, skin temperature, and possible correlations between these outcomes. Healthy adults (n = 16, 29.34 ± 9.87 years) performed fatiguing EE of the trunk. A group of highly active individuals (TR, n = 8, > 14 h of sport per week) was compared with a group of less active individuals (UTR, n = 8, < 2 h of sport per week). Ultrasound measurements of ECT thickness, stiffness with MyotonPro and IndentoPro, skin temperature with infrared thermography, and pain on palpation (100 mm visual analog scale, VAS) as a surrogate for DOMS were recorded before (t0), immediately (t1), 24 h (t24), and 48 h (t48) after EE. ECT thickness increased after EE from t0 to t24 (5.96 mm to 7.10 mm, p = 0.007) and from t0 to t48 (5.96 mm to 7.21 mm, p < 0.001). VAS also increased from t0 to t24 (15.6 mm to 23.8 mm, p < 0.001) and from t0 to t48 (15.6 mm to 22.8 mm, p < 0.001). Skin temperature increased from t1 to t24 (31.6° Celsius to 32.7° Celsius, p = 0.032) and t1 to t48 (31.6° Celsius to 32.9° Celsius, p = 0.003), while stiffness remained unchanged (p > 0.05). Correlation analysis revealed no linear relationship between the outcomes within the 48-hour measurement period. The results may confirm previous findings of possible ECT involvement in the genesis of DOMS in the extremities also for the paraspinal ECT of trunk extensors. Subsequent work should focus on possible interventions targeting the ECT to prevent or reduce DOMS after strenuous muscle EE.

Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group

ABSTRACT

Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.

Global Status and Future Trends of Fascia and Pain Research in 2013-2022: Bibliometric Analysis Based on CiteSpace and VOSviewer

Background

Fascial pathological pain is the main type of chronic pain in older adults today, and studying the relationship between fascia and pain can help in the clinical search for effective treatments. However, in the face of the vast amount of research findings, there is no systematic assessment of the relationship between fascia and pain in a bibliometric analysis. Therefore, the purpose of this study is to analyze studies on fascia and pain using CiteSpace and VOSviewer to identify research hotspots and future directions.

Materials and Methods

A total of 744 papers related to fascia and pain from 2013 to 2022 were collected from the core collection database of Web of Science, and the authors, countries, institutions, keyword co-occurrence, keyword clustering, and keyword emergence were analyzed by CiteSpace and VOSviewer to construct a knowledge map.

Results

Literature publication has shown an overall upward trend over the past decade, but there have been some fluctuations. Carmelo Pirri, Caterina Fede, and Raffaele De Caro are the top three authors with the most articles. The United States, China, and Spain are major contributors to fascial and pain research. The University of Padua, Universidad Complutense and Harvard Medical School are leading institutions in this field. However, it is noteworthy that the collaboration between authors, countries and institutions is not active. Keyword analysis showed that hot spots and trends in research on fascia and pain focused on hot diseases, major interventions, and mechanism exploration.

Conclusion

This analysis identifies the most influential authors, institutions, and countries in the field of fascial and pain research and provides a reference for assessing their academic impact. The analysis of keywords and co-cited literature is useful for analyzing research hotspots and their evolution, as well as for predicting future trends.

Ultrasound Imaging of Thoracolumbar Fascia Thickness: Chronic Non-Specific Lower Back Pain versus Healthy Subjects; A Sign of a "Frozen Back"?

The thoracolumbar fascia (TLF) plays an important role in lower back pain (LBP). Recent studies have revealed an association between increases in TLF thickness and reduced TLF gliding in patients with LBP. The purpose of this study was to measure and compare by ultrasound (US) imaging the thickness of the TLF at the bilateral L3 level of the lumbar spine in the longitudinal and transverse axes in chronic non-specific LBP and in healthy subjects. A cross-sectional study was performed using US imaging to measure the longitudinal and transverse axes with a new protocol in a sample of 92 subjects: 46 chronic non-specific LBP patients and 46 healthy participants. The findings for TLF thickness revealed statistically significant differences (p < 0.05) in the longitudinal and transverse axes between the two groups. Moreover, in the healthy group, a statistically significant difference was found between the longitudinal and transverse axes (p = 0.001 for left and p = 0.02 for right), which was not evident in the LBP patients. These findings suggest that the LBP patients lost anisotropy of the TLF, with it becoming homogeneously thicker and losing adaptability in the transversal direction. The US imaging evaluation suggests that TLF thickness behavior points out altered fascial remodelling compared to healthy subjects, a sort of "frozen back".

Effects of a Myofascial Technique on the Stiffness and Thickness of the Thoracolumbar Fascia and Lumbar Erector Spinae Muscles in Adults with Chronic Low Back Pain: A Randomized before-and-after Experimental Study

The thoracolumbar fascia (TLF) may be a pain generator, given its rich innervation. Structural and biomechanical changes have also been documented in adults with chronic non-specific low back pain (LBP). Myofascial techniques (MFTs) are commonly used in manual therapy and are hypothesized to reduce tissue stiffness and pain. However, evidence for these effects is limited. The objective of this study was to evaluate the immediate effects of a standardized MFT compared to a simulated MFT on: (1) the stiffness of the TLF and erector spinae muscles (shear-wave sonoelastography), (2) the thickness of the TLF (B-mode ultrasound), and (3) pain intensity (numerical rating scale). Forty-nine participants with chronic non-specific LBP were included in a randomized before-and-after experimental study. Outcome measures were collected before (T0) and immediately after the intervention (T1). Pain intensity was also assessed on day two (T2) and seven (T7). The MFT group showed a significant decrease in left erector spinae muscle stiffness and left TLF thickness compared to the simulated group. In addition, there was a significant reduction in pain intensity in the MFT group compared to the simulated group at T1 and T2. The results of this study suggest that MFT results in immediate tissue changes and transient pain reduction in patients with LBP.

From Muscle to the Myofascial Unit: Current Evidence and Future Perspectives

The "motor unit" or the "muscle" has long been considered the quantal element in the control of movement. However, in recent years new research has proved the strong interaction between muscle fibers and intramuscular connective tissue, and between muscles and fasciae, suggesting that the muscles can no longer be considered the only elements that organize movement. In addition, innervation and vascularization of muscle is strongly connected with intramuscular connective tissue. This awareness induced Luigi Stecco, in 2002, to create a new term, the "myofascial unit", to describe the bilateral dependent relationship, both anatomical and functional, that occurs between fascia, muscle and accessory elements. The aim of this narrative review is to understand the scientific support for this new term, and whether it is actually correct to consider the myofascial unit the physiological basic element for peripheral motor control.

Immediate Effects of Myofascial Release Treatment on Lumbar Microcirculation: A Randomized, Placebo-Controlled Trial

(1) Background: Inflammatory processes in the thoracolumbar fascia (TLF) lead to thickening, compaction, and fibrosis and are thought to contribute to the development of nonspecific low back pain (nLBP). The blood flow (BF) of fascial tissue may play a critical role in this process, as it may promote hypoxia-induced inflammation. The primary objective of the study was to examine the immediate effects of a set of myofascial release (MFR) techniques on the BF of lumbar myofascial tissue. The secondary objectives were to evaluate the influence of TLF morphology (TLFM), physical activity (PA), and body mass index (BMI) on these parameters and their correlations with each other. (2) Methods: This study was a single-blind, randomized, placebo-controlled trial. Thirty pain-free subjects (40.5 ± 14.1 years) were randomly assigned to two groups treated with MFR or a placebo intervention. Correlations between PA, BMI, and TLFM were calculated at baseline. The effects of MFR and TLFM on BF (measured with white light and laser Doppler spectroscopy) were determined. (3) Results: The MFR group had a significant increase in BF after treatment (31.6%) and at follow-up (48.7%) compared with the placebo group. BF was significantly different between disorganized and organized TLFM (p < 0.0001). There were strong correlations between PA (r = -0.648), PA (d = 0.681), BMI (r = -0.798), and TLFM. (4) Conclusions: Impaired blood flow could lead to hypoxia-induced inflammation, possibly resulting in pain and impaired proprioceptive function, thereby likely contributing to the development of nLBP. Fascial restrictions of blood vessels and free nerve endings, which are likely associated with TLFM, could be positively affected by the intervention in this study.

Immediate Effects of Instrument-Assisted Soft Tissue Mobilization on Hydration Content in Lumbar Myofascial Tissues: A Quasi-Experiment

BACKGROUND

Instrument-assisted soft tissue mobilization (IASTM) is thought to alter fluid dynamics in human soft tissue. The aim of this study was to investigate the influence of IASTM on the thoracolumbar fascia (TLF) on the water content of the lumbar myofascial tissue.

METHODS

In total, 21 healthy volunteers were treated with IASTM. Before and after the procedure and 5 and 10 min later, lumbar bioimpedance was measured by bioimpedance analysis (BIA) and TLF stiffness was measured by indentometry. Tissue temperature was recorded at the measurement time points using an infrared thermometer.

RESULTS

Bioimpedance increased significantly from 58.3 to 60.4 Ω (p < 0.001) at 10-min follow-up after the treatment. Temperature increased significantly from 36.3 to 36.6 °C from 5 to 10 min after treatment (p = 0.029), while lumbar myofascial stiffness did not change significantly (p = 0.84).

CONCLUSIONS

After the IASTM intervention, there was a significant increase in bioimpedance, which was likely due to a decrease in water content in myofascial lumbar tissue. Further studies in a randomized control trial design are needed to extrapolate the results in healthy subjects to a symptomatic population as well and to confirm the reliability of BIA in myofascial tissue.

Ultrasound evidence of altered lumbar fascia in patients with low back pain

Different hypotheses have been proposed about the role of lumbar connective tissue in low back pain (LBP). However, none of the previous studies have examined the change in the elastic behavior of lumbar fascia in patients with LBP. The present study aimed to evaluate the changes in the elastic behavior of lumbar fascia in patients with chronic non-specific LBP based on ultrasound imaging. The sonographic strain imaging assessed the thoracolumbar fascia (TLF) of 131 human subjects (68 LBP and 63 non-LBP). Assessments were done at L2-L3 and L4-L5 levels bilaterally. The points were located 2 cm lateral to the midpoint of the interspinous ligament. There were no significant differences in age, sex, and BMI between LBP and healthy individuals. There is a strong inverse relationship between pain severity (r = -0.76, n = 68, p = 0.004) and the TLF elastic modulus coefficient. No significant relationship were observed between age (r = 0.053, n = 68, p = 0.600), BMI (r = -0.45, n = 68, p = 0.092), and gender (r = -0.09, n = 68, p = 0.231) with the TLF elasticity coefficient. The LBP group had a 25%-30% lower TLF elastic modulus coefficient than healthy individuals. The present study is the first to evaluate the elastic coefficient of TLF using the ultrasound imaging method. The study results showed that the TLF elastic coefficient in patients with LBP was reduced compared to healthy individuals and directly related to LBP severity.

The Relationship Between Acute Exercise-Induced Changes in Extramuscular Connective Tissue Thickness and Delayed Onset Muscle Soreness in Healthy Participants: A Randomized Controlled Crossover Trial

Background

The extramuscular connective tissue (ECT) has been shown to play a significant role in mechanical force transmission between musculoskeletal structures. Due to this and owing to its tight connection with the underlying muscle, the ECT may be vulnerable to excessive loading. The present study aimed to investigate the effect of eccentric elbow flexor exercise on the morphology of the biceps brachii ECT. In view of the high nociceptive capacity of the ECT, an additional objective was to elucidate the potential relationship between ECT damage and the occurrence of delayed onset muscle soreness (DOMS).

Methods

Eleven healthy participants (♂ = 7; 24 ± 2 years) performed fatiguing dumbbell elbow flexor eccentric exercise (EE) for one arm and concentric exercise (CE) for the other arm in random order and with random arm allocation. Before, immediately after and 24–96 h post-exercise, maximal voluntary isometric contraction torque of the elbow flexors (dynamometer), pressure pain (algometer), palpation pain (100 mm visual analog scale), biceps brachii ECT thickness and ECT/muscle mobility during passive movement (both high-resolution ultrasound) were examined.

Results

Palpation pain, suggestive of DOMS, was greater after EE than CE, and maximal voluntary isometric contraction torque decreased greater after EE than CE (p < .05). Relative to CE, EE increased ECT thickness at 48 (+ 17%), 72 (+ 14%) and 96 (+ 15%) hours post-exercise (p < .05). At 96 h post-EE, the increase in ECT thickness correlated with palpation pain (r = .68; p < .05). ECT mobility was not different between conditions, but compared to CE, muscle displacement increased at 24 (+ 31%), 72 (+ 31%) and 96 (+ 41%) hours post-EE (p < .05).

Conclusion

Collectively, these results suggest an involvement of the ECT changes in delayed onset muscle soreness.

The Influence of a Single Instrument-Assisted Manual Therapy (IAMT) for the Lower Back on the Structural and Functional Properties of the Dorsal Myofascial Chain in Female Soccer Players: A Randomised, Placebo-Controlled Trial

Background: Instrument-assisted manual therapy (IAMT) is indicated to improve flexibility, reduce pain, and induce hyperaemia locally and along myofascial chains. The underlying effects are largely unclear. This randomised, placebo-controlled pilot study aimed to gain first insights into these effects, primarily on the structural level, through ultrasonography. Methods: 67 healthy female soccer players aged 20.9 (±3.9) years were examined after right lumbar intervention (IAMT: intervention group (IG), heat application: comparison group (CG), pressure-less placebo: placebo group (PG)). Ultrasonography (absolute movement and shear motion), flexibility tests (passive straight leg raise test (PSLR), lumbar and thoracic double inclinometry), and superficial skin temperature were recorded before (t0), immediately (t1) and 45 min after the intervention (t2). Results: IAMT decreased the absolute mobility of the superficial lamina and its shear motion to the superficial fascia compared with the PG (t1; p < 0.05). PSLR improved in the IG compared with the CG (t2) and PG (t1, t2; p < 0.05). The temperature increased in the IG and CG compared with the PG (t1, t2) and in the CG compared with the IG (t1; p < 0.05). Conclusion: IAMT of the lumbar back briefly reduces absolute mobility of the superficial lamina and its shear motion to the superficial fascia, improves flexibility, and increases the temperature.

Associations between Deformation of the Thoracolumbar Fascia and Activation of the Erector Spinae and Multifidus Muscle in Patients with Acute Low Back Pain and Healthy Controls: A Matched Pair Case-Control Study

Background: The thoracolumbar fascia (TLF) is thought to play a role in the development of LBP, but it is not yet clear which factor of TLF changes is a cause and which is an effect. Therefore, some studies used the cross-correlation function (CCR) to reveal time-dependent relationships between biomechanical and neuromotor factors. Methods: Ten patients with acute low back pain (aLBP) were matched to healthy controls. Simultaneous recording of surface electromyography (sEMG) of the erector spinae and multifidus muscle (ESM) and dynamic ultrasound (US) images of TLF deformation were performed during trunk extension. CCR functions and Granger causality (GC) were used to describe the relationship between the two measures. Results: CCR time lags were significant higher in the aLBP group (p = 0.04). GC showed a direct effect of TLF deformation on ESM activation only in the aLBP group (p < 0.03). Conclusions: The results suggest that in aLBP, ESM activity is significantly affected by TLF, whereas this relationship is completely random in healthy subjects studied with CCR and GC comparisons of dynamic US imaging and sEMG data signals. Fascia-related disturbances in neuromotor control, particularly due to altered muscle spindle functions, are suspected as a possible mechanism behind this.

Evidence of in-vivo myofascial force transfer in humans- a systematic scoping review

BACKGROUND

The fascial system not only enables the body to operate in an integrated manner but modifies its tension in response to the stress on it. Recent animal, cadaveric and in-vitro trials have shown that "myofascial force transmission" (MFT) can play a major role in homeostasis, musculoskeletal function and pain. Human evidence for the in-vivo existence of MFT is scarce.

OBJECTIVE

This scoping review attempts to gather and interpret the available evidence of the in-vivo existence of MFT in humans, its role in homeostasis, and musculoskeletal function.

METHOD

A search of major databases using the keywords 'myofascial force transmission' and 'epimuscular force transmission' yielded 247 articles as of November 2021. For the final analysis, only original in-vivo human studies were considered. In-vitro human studies, cadaveric or animal studies, reviews, and similar studies were excluded. A qualitative analysis of the studies was conducted after rating it with the Oxford's Center for Evidence -based Medicine (CEBM) scale.

RESULT

Twenty studies ranging from randomized controlled trials (RCTs) to case studies covering 405 patients have been included in this review. The analysed trials were highly heterogeneous and of lower methodological quality meddling with the quantitative analysis. The majority of the appraised studies demonstrated a higher probability of MFT existence, while two studies revealed a lower probability.

CONCLUSION

Our search for proof of the in vivo existence of MFT in humans has led us to support such an existence, albeit prudently. Previous research on animals and human cadavers reinforces our finding. We are optimistic that the forthcoming studies on the topic will pave the way for the unraveling of several musculoskeletal riddles that are currently unknown or less well-known.

Pressure pain threshold map of thoracolumbar paraspinal muscles after lengthening contractions in young male asymptomatic volunteers

This study aimed to characterise topographic distribution of pressure pain thresholds (PPTs) of thoracolumbar paraspinal muscles and its change after lengthening contractions (LCs) of the back muscles. Using young male asymptomatic participants in Experiment 1, we systematically examined the distribution of PPTs bilaterally in the range of Th1–L5 at measurement points 2 and 4 cm from the midline. PPTs were found to be higher in the lumbar segments of the paraspinal muscles than in the thoracic segments, and in muscles closer to the vertebrae (2 vs. 4 cm from the midline). The PPTs did not differ between the left and right sides in each segment. In Experiment 2, LC was applied by asking a part of participants recruited in Experiment 1 to fall their trunk from a starting position (parallel to the floor) to 40° flexed position, and then made it back as quickly as possible to the starting position. This cycle was repeated until participants could not keep contractions (30 times/set, 25.4 ± 10.6 sets). PPTs of the LC group decreased prominently in the lower thoracic and lumbar segments, and the decrease was more evident 24 h after LC compared to that 48 h after. In contrast, PPTs in the control group without LC remained unchanged. These results provided broad topographic images of PPTs in the thoracolumbar paraspinal muscles of young male participants with and without LC, and the obtained PPT maps could be a useful guide for better treatment of exercise-induced myofascial pain in the lower back.

Innervation of human superficial fascia

The superficial fascia has only recently been recognized as a specific anatomical structure. Furthermore, whereas it is actually recognized that the innervation of the deep/muscular fascia plays a key role in proprioception and nociception, there are very few studies that have analyzed these characteristics in the superficial fascia. In this work, our group analyzed two different anatomical districts (abdomen and thigh), from volunteer patients, undergoing surgery procedures. Each sample was processed for histological analysis by Hematoxylin&amp;Eosin, and by immunohistochemistry stainings (in 5-micron-paraffin embedded section and in cryosectioned free floating samples), with antibodies specific for nerve fibers: S100 antibody for myelinating and non-myelinating Schwann cells, PGP9.5 antibody as pan-neuronal marker, tyrosine hydroxylase for autonomic innervation. The results revealed a huge innervation: the nervous structures were found above all around blood vessels and close to adipocytes, but they penetrated also in the connective tissue itself and are found in the midst of fibro-adipose tissue. The tissue is pervaded by both thin (mean diameter of 4.8 ± 2.6 μm) and large nerve fiber bundles of greater diameter (21.1 ± 12.2 μm). The ratio S100/TH positivity was equal to 2.96, with a relative percentage of autonomic innervation with of 33.82%. In the light of these findings is evident that the superficial fasciae have a clear and distinct anatomical identity and a specific innervation, which should be considered to better understand their role in thermoregulation, exteroception and pain perception. The knowledge of the superficial fascia may improve grading and developing of different manual approach for treatments of fascial dysfunctions, and the understanding of how some factors like temperature or manual therapies can have an impact on sensitivity of the fascia.

Fascial Innervation: A Systematic Review of the Literature

Currently, myofascial pain has become one of the main problems in healthcare systems. Research into its causes and the structures related to it may help to improve its management. Until some years ago, all the studies were focused on muscle alterations, as trigger points, but recently, fasciae are starting to be considered a new, possible source of pain. This systematic review has been conducted for the purpose of analyze the current evidence of the muscular/deep fasciae innervation from a histological and/or immunohistochemical point of view. A literature search published between 2000 and 2021 was made in PubMed and Google Scholar. Search terms included a combination of fascia, innervation, immunohistochemical, and different immunohistochemical markers. Of the 23 total studies included in the review, five studies were performed in rats, four in mice, two in horses, ten in humans, and two in both humans and rats. There were a great variety of immunohistochemical markers used to detect the innervation of the fasciae; the most used were Protein Gene Marker 9.5 (used in twelve studies), Calcitonin Gene-Related Peptide (ten studies), S100 (ten studies), substance P (seven studies), and tyrosine hydroxylase (six studies). Various areas have been studied, with the thoracolumbar fascia being the most observed. Besides, the papers highlighted diversity in the density and type of innervation in the various fasciae, going from free nerve endings to Pacini and Ruffini corpuscles. Finally, it has been observed that the innervation is increased in the pathological fasciae. From this review, it is evident that fasciae are well innerved, their innervation have a particular distribution and precise localization and is composed especially by proprioceptors and nociceptors, the latter being more numerous in pathological situations. This could contribute to a better comprehension and management of pain.

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy.

The Deep Fascia and its Role in Chronic Pain & Pathological Conditions: A Review

INTRODUCTION

The deep fascia is a three-dimensional continuum of connective tissue surrounding the bones, muscles, nerves and blood vessels throughout our body. Its importance in chronically debilitating conditions has recently been brought to light. This work investigates changes in these tissues in pathological settings.

MATERIALS AND METHODS

A state-of-the-art review was conducted in PubMed and Google Scholar following a two-stage process. A first search was performed to identify main types of deep fasciae. A second search was performed to identify studies considering a deep fascia, common pathologies of this deep fascia and the associated alterations in tissue anatomy.

RESULTS

We find that five main deep fasciae pathologies are chronic low back pain, chronic neck pain, Dupuytren's disease, plantar fasciitis and iliotibial band syndrome. The corresponding fasciae are respectively the thoracolumbar fascia, the cervical fascia, the palmar fascia, the plantar fascia and the iliotibial tract. Pathological fascia is characterized by increased tissue stiffness along with alterations in myofibroblast activity and the extra-cellular matrix, both in terms of collagen and Matrix Metalloproteases (MMP) levels. Innervation changes such as increased density and sensitization of nociceptive nerve fibers are observed. Additionally, markers of inflammation such as pro-inflammatory cytokines and immune cells are documented. Pain originating from the deep fascia likely results from a combination of increased nerve density, sensitization and chronic nociceptive stimulation, whether physical or chemical.

CONCLUSIONS

The pathological fascia is characterized by changes in innervation, immunology and tissue contracture. Further investigation is required to best benefit both research opportunities and patient care.

Exploring the Effects of Standardized Soft Tissue Mobilization on the Viscoelastic Properties, Pressure Pain Thresholds, and Tactile Pressure Thresholds of the Cesarean Section Scar

Background:

Objectives of soft tissue mobilization applied to cesarean section (C-section) scars are to decrease stiffness and to reduce pain. Research investigating these effects is lacking.

Materials and methods:

The authors conducted a descriptive, exploratory, proof-of-concept clinical study. Women aged 18 to 40 years who had undergone at least one C-section were recruited. A trained osteopath performed standardized mobilization of the C-section scar once a week for 2 weeks. Scar quality and pain characteristics, viscoelastic properties, pressure pain thresholds, and tactile pressure thresholds were measured before and after each session. Paired Student's t-tests and Friedman's test with Dunn–Bonferroni adjustment were performed to assess the immediate and short-term effects of mobilizations. Kendall's W and Cohen's d were calculated to determine effect sizes over the short term. Simple bootstrapped bias-corrected and accelerated 95% median confidence intervals were computed.

Results:

Thirty-two participants completed the study. The Patient and Observer Scar Assessment Scale questionnaire revealed differences with small and moderate effects for stiffness (p = 0.021, d = 0.43), relief (p < 0.001, d = 0.28), surface area (p = 0.040, d = 0.36), flexibility (p = 0.007, d = 0.52), and participant opinion (p = 0.001, d = 0.62). Mobilizations increased elasticity (p < 0.001, W = 0.11), decreased stiffness (p < 0.001, W = 0.30), and improved pressure pain thresholds (p < 0.001, W = 0.10) of the C-section, with small to moderate effects. The results also showed decreased tone and mechanical stress relaxation time, as well as increased tactile pressure thresholds at the different measurement times (p < 0.05), but trivial effect sizes (W < 0.10). Creep showed trivial effect and no significant difference (p = 0.09).

Conclusion:

This study showed that two sessions of mobilization of C-section scar might have a beneficial effect on some viscoelastic properties of the C-section as well as on pain. Some variables of interest useful for future empirical studies are highlighted.

ClinicalTrial. Gov NCT04320355.

Dose-Dependent Pain and Pain Radiation after Chemical Stimulation of the Thoracolumbar Fascia and Multifidus Muscle: A Single-Blinded, Cross-Over Study Revealing a Higher Impact of Fascia Stimulation

Acute low back pain can be experimentally induced by injections of hypertonic saline into deep tissues of the back, such as fascia and muscle. The current study investigated the dose-dependency of peak-pain and spatial extent of concomitant radiating pain following 50, 200 and 800 μL bolus injections of hypertonic saline (5.8%) into the thoracolumbar fascia and multifidus muscle, since data on dose-dependency is lacking in humans. Sixteen healthy subjects rated (11 female, 5 male; 23.3 ± 3.1 years, mean ± SD) intensity and spatial extent of pain. Injections into the fascia resulted in significantly higher peak-pain (+86%, p < 0.001), longer pain durations (p < 0.05), and larger pain areas (+65%, p < 0.02) and were less variable than intramuscular injections. Peak-pain ratings and pain areas were 2−3-fold higher/larger for 200 μL vs. 50 μL. In contrast, peak pain increased only marginally at 800 μL by additional 20%, while pain areas did not increase further at all in both, fascia and muscle. Thus, higher injection volumes did also not compensate the lower sensitivity of muscle. Peak-pain ratings and pain areas correlated between fascia and muscle (r = 0.530, p < 0.001 and r = 0.337, p < 0.02, respectively). Peak-pain ratings and pain areas correlated overall (r = 0.490, p < 0.0001), but a weak correlation remained when the impact of between-tissue differences and different injection volumes were singled out (partial r = 0.261, p < 0.01). This study shows dose-dependent pain responses of deep tissues where an injection volume of 200 μL of hypertonic saline is deemed an adequate stimulus for tissue differentiation. We suggest that pain radiation is not simply an effect of increased peripheral input but may afford an individual disposition for the pain radiation response. Substantially higher pain-sensitivity and wider pain areas support fascia as an important contributor to non-specific low back pain.

Effects of Isometric Plantar-Flexion on the Lower Limb Muscle and Lumbar Tissue Stiffness

Purpose: This study investigated the effects of isometric plantar-flexion against different resistances on the thoracolumbar fascia (TLF), erector spinae (ES), and gastrocnemius stiffness by shear wave elastography (SWE). The purpose was to explore the interaction between the lower limb muscle and lumbar tissue in the myofascial tensegrity network.

Methods: Twenty healthy young female were recruited in this study. The stiffness of the TLF, ES, medial gastrocnemius (MG), and lateral gastrocnemius (LG) was measured by SWE under four isometric plantar-flexion resistance conditions. The resistance conditions involved 0% maximum voluntary isometric contraction (MVIC), 20% MVIC, 40% MVIC, and 60% MVIC.

Results: There was a strong correlation between the stiffness change of MG and that of TLF (r = 0.768–0.943, p &lt; 0.001) and ES (r = 0.743–0.930, p &lt; 0.001), while it was moderate to strong correlation between MG and that of LG (r = 0.588–0.800, p &lt; 0.001). There was no significant difference in the stiffness between the nondominant and dominant sides of TLF and ES under the resting position (p &gt; 0.05). The increase in stiffness of the TLF, ES, MG, and LG, with MVIC percentage (p &lt; 0.05), and the stiffness of TLF and ES on the nondominant side is much higher than that on the dominant side.

Conclusions: Our data shows that isometric plantar-flexion has a significant effect on the stiffness of the lumbar soft tissue and gastrocnemius. The gastrocnemius has a strong correlation with the stiffness changes of TLF and ES, which provides preliminary evidence for exploring the myofascial tensegrity network between the dorsal side of the lower limb muscle and lumbar tissue.

Myofascial points treatment with focused extracorporeal shock wave therapy (f-ESWT) for plantar fasciitis: an open label randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common cause of heel pain. Among the several conservative treatment options, extracorporeal shock wave therapy (ESWT) is considered the standard treatment. However, recent studies suggest that PF may be sustained by a myofascial impairment proximal to the pain area with a biomechanical disequilibrium of the entire limb and pelvis.

AIM

By combining the concepts of fascial manipulation and ESWT, the purpose of this study was to evaluate the effectiveness of the ESWT on myofascial points in a sample of subjects with PF.

DESIGN

Open label randomized controlled clinical trial.

SETTING

Outpatient clinic.

POPULATION

Patients with PF were randomly assigned to an experimental treatment group (EG), treated with focused ESWT on myofascial points, and a control group (CG), treated with the focused ESWT traditional approach on the medial calcaneal tubercle.

METHODS

Every patient underwent a 3-session program and follow-up after 1 and 4 months. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and the Italian Foot Functional Index (17-iFFI).

RESULTS

Thirty patients were enrolled in the study. Four patients of the CG dropped out the study, therefore twenty-six patients were included in the final analysis. Improvement in 17-iFFI and FAOS scores was observed in both groups starting from the third treatment and confirmed at the 1-month and 4-month follow-ups, with earlier improvement in the score values observed in the EG.

CONCLUSIONS

Treatment of the myofascial points with ESWT in subjects suffering from plantar fasciitis could be an effective treatment option. It fosters the hypothesis that a global biomechanical re-equilibrium of the body would be necessary to completely solve the pathology.

CLINICAL REHABILITATION IMPACT

ESWT on myofascial points could provide an interesting alternative with better outcomes in terms of time needed for recovery compared to traditional ESWT for the conservative management of PF.

Evaluating the Effectiveness of Soft Tissue Therapy in the Treatment of Disorders and Postoperative Conditions of the Knee Joint-A Systematic Review

The term "soft tissue therapy" (STT) refers to mechanical methods of treatment involving passive kneading, pressing and stretching of pathologically tense tissues in supporting the process of recovery after surgery or trauma to the musculoskeletal system. The objective of this study was to review current scientific reports evaluating the effectiveness of the use of STT in patients with diseases or after surgical procedures of the knee joint. A systematic search of the popular scientific databases PubMed, Scopus and Embase was performed from inception to 15 October 2021. Eight articles met eligibility criteria and were included in the review. Six papers were related to disorders of the knee joint, while the remaining two studies were related to dysfunctions associated with the conditions after surgical intervention. The findings presented confirmed the effectiveness of STT in orthopaedic patients who showed an increase in lower limb functional parameters. The research has shown that the use of various methods of STT has a significant impact on increasing muscle activity and flexibility as well as increasing the range of motion in the knee joint. The physiotherapeutic methods used had a significant impact on reducing pain and increasing physical function and quality of life. The techniques used reduced the time to descend stairs in patients with knee osteoarthritis. This review summarises the effectiveness of STT as an important form of treatment for orthopaedic patients with various knee joint dysfunctions.

Fascial thickness and stiffness in hypermobile Ehlers-Danlos syndrome

There is a high prevalence of myofascial pain in people with hypermobile Ehlers-Danlos Syndrome (hEDS). The fascial origin of pain may correspond to changes in the extracellular matrix. The objective of this study was to investigate structural changes in fascia in hEDS. A series of 65 patients were examined prospectively-26 with hEDS, and 39 subjects with chronic neck, knee, or back pain without hEDS. The deep fascia of the sternocleidomastoid, iliotibial tract, and iliac fascia were examined with B-mode ultrasound and strain elastography, and the thicknesses were measured. Stiffness (strain index) was measured semi-quantitatively using elastography comparing fascia to muscle. Differences between groups were compared using one-way analysis of variance. hEDS subjects had a higher mean thickness in the deep fascia of the sternocleidomastoid compared with non-hEDS subjects. There was no significant difference in thickness of the iliac fascia and iliotibial tract between groups. Non-hEDS subjects with pain had a higher strain index (more softening of the fascia with relative stiffening of the muscle) compared with hEDS subjects and non-hEDS subjects without back or knee pain. In myofascial pain, softening of the fascia may occur from increase in extracellular matrix content and relative increase in stiffness of the muscle; this change is not as pronounced in hEDS.

Anastomoses (Superficial Cervical Ansa) Between the Cervical Plexus and Peripheral Facial Nerve Branches: Implications for Regional Anesthesia in Carotid Endarterectomies - Anatomical Study

Purpose

Sensory innervation in the carotid triangle involves the cervical plexus, cranial nerves, and the sympathetic trunk. This innervation also applies to skin incision, including various anatomical structures with potentially different innervation, such as the skin (dermatomes), the platysma (myotomes), and the superficial layer of the cervical fascia (fasciotomes), as well as retromandibular retractor insertion (co-innervation: V, VII). The aim of this anatomical study was to develop an injection technique for carotid endarterectomies to additionally block anastomoses between the transverse cervical nerve (TCN), the cervical branch VII (CB VII), and the marginal mandibular branch VII (MMB VII). These anastomoses are also termed superficial cervical ansa (SCA).

Materials and Methods

Preparations (n=16) were performed on unembalmed donor cadavers (n=8). Subplatysmal injections (each using 5 mL of Alcian blue) were performed cranially within the carotid triangle between the anterior margin of the sternocleidomastoid muscle and the submandibular gland.

Results

Anastomoses between the TCN, CB VII, and MMB VII were stained in all preparations (n=16).

Conclusion

This anatomical study presents an ultrasound-guided subplatysmal SCA block to optimize, in addition to a cervical plexus block, the quality of anesthesia for carotid endarterectomies.

Potential Nociceptive Role of the Thoracolumbar Fascia: A Scope Review Involving In Vivo and Ex Vivo Studies

Nociceptive innervation of the thoracolumbar fascia (TLF) has been investigated over the past few decades; however, these studies have not been compiled or collectively appraised. The purpose of this scoping review was to assess current knowledge regarding nociceptive innervation of the TLF to better inform future mechanistic and clinical TLF research targeting lower back pain (LBP) treatment. PubMed, ScienceDirect, Cochrane, and Embase databases were searched in January 2021 using relevant descriptors encompassing fascia and pain. Eligible studies satisfied the following: (a) published in English; (b) preclinical and clinical (in vivo and ex vivo) studies; (c) original data; (d) included quantification of at least one TLF nociceptive component. Two-phase screening procedures were conducted by a pair of independent reviewers, after which data were extracted and summarized from eligible studies. The search resulted in 257 articles of which 10 met the inclusion criteria. Studies showed histological evidence of nociceptive nerve fibers terminating in lower back fascia, suggesting a TLF contribution to LBP. Noxious chemical injection or electrical stimulation into fascia resulted in longer pain duration and higher pain intensities than injections into subcutaneous tissue or muscle. Pre-clinical and clinical research provides histological and functional evidence of nociceptive innervation of TLF. Additional knowledge of fascial neurological components could impact LBP treatment.

Effectiveness of external myofascial mobilisation in the management of male chronic pelvic pain of muscle spastic type: A retrospective study

Objective

To evaluate the outcome of men with muscle spastic chronic pelvic pain syndrome (CPPS) who underwent a comprehensive five-session fascial connectivity based external myofascial mobilisation (EMM) approach.

Patients and methods

A retrospective chart review of patients who underwent EMM for CPPS at the Pelvic Pain Unit of Hamad Medical Corporation, Qatar between January 2019 and October 2020 was conducted. Patient's symptoms were measured with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) scale and the numerical rating scale (NRS) before and after the completion of the sessions. The patients were given five EMM sessions as a 'once-a-week' programme.

Results

A total of 31 patients who completed all the EMM sessions were included. The mean (range) age of patients was 38 (20-54) years. The mean (SD) NIH-CPSI score at initial evaluation was 29.41 (8.3) and decreased to 9.14 (3.45) after the fifth visit. All the patients in the study group had a reduction of >6 points in the NIH-CPSI score, indicating a robust treatment response. The NRS reading also revealed significant improvement in pain (P < 0.001).

Conclusions

: An EMM approach based on fascial connectivity led to significant symptom improvement in all the studied patients. EMM may be an effective treatment option for muscle spastic type of CPPS. Future high-quality studies with control groups are needed to confirm the present findings. Durability and long-term results are yet to be determined.

ABBREVIATIONS

CP/CPPS: chronic prostatitis/chronic pelvic pain syndrome; EMM: external myofascial mobilisation; EO: external oblique; FM: fascial manipulation; GMx: gluteus maximus; HAC: hip adductor complex; HMC: Hamad Medical Corporation; IO: internal oblique; LD: latissimus dorsi; MFR: myofascial release; MM: myofascial mobilisation; NIH-CPSI: National Institute of Health-Chronic Prostatitis Symptom Index; NRS: numerical rating scale; PFPT: pelvic floor physical therapy; QoL, quality of life; TLF: thoracolumbar fascia; UPOINT: urinary (U), psychosocial (P), organ-specific (O), infection (I), neurological/systemic (N) and tenderness of pelvic floor skeletal muscles (T).

Analysis of Muscle Activity Following the Application of Myofascial Release Techniques for Low-Back Pain-A Randomized-Controlled Trial

Introduction. Lumbosacral dysfunctions and the resulting pain syndromes, such as low-back pain (LBP), are one of the most common musculoskeletal problems being faced by society around the world. So far, a contributory role of thoracolumbar fascia (TLF) dysfunction in some cases of LBP has been suggested. Research also confirms that muscle resting activity level in the TLF area is increased in people with LBP. Myofascial release (MFR) is a therapeutic option offered to patients with chronic low-back pain (CLBP). The therapy aims to improve flexibility and sliding between layers of soft tissue, and thus decrease muscle activity, reduce pain intensity, and improve functional performance. Objective. This study aims to assess changes in resting activity of selected muscles within the TLF in a group of patients with CLBP immediately after a single MFR treatment and one month after the intervention. Methods. A total of 113 patients with CLBP completed the study. Simple randomization was applied to assign subjects to study groups. The experimental group (n = 59) underwent a single session of MFR therapy. No therapeutic intervention was applied to the control group (n = 54). Surface electromyography was used to evaluate positive treatment effects in patients immediately after receiving the therapy (experimental group) and after one month (experimental and control group). Results. A statistically reliable decrease in the activity of erector spinae (ES) and multifidus muscles (MF) was observed after a single session of MFR therapy. Effects of the treatment were present immediately after receiving the therapy and one month after the intervention. Conclusions. A single MFR treatment in patients with CLBP immediately reduces the resting activity levels of ES and MF. Results of measurements carried out one month after the treatment confirm that the therapeutic effects were maintained.

Is "Delayed Onset Muscle Soreness" a False Friend? The Potential Implication of the Fascial Connective Tissue in Post-Exercise Discomfort

Strenuous and unaccustomed exercise frequently lead to what has been coined “delayed onset muscle soreness” (DOMS). As implied by this term, it has been proposed that the associated pain and stiffness stem from micro-lesions, inflammation, or metabolite accumulation within the skeletal muscle. However, recent research points towards a strong involvement of the connective tissue. First, according to anatomical studies, the deep fascia displays an intimate structural relationship with the underlying skeletal muscle and may therefore be damaged during excessive loading. Second, histological and experimental studies suggest a rich supply of algogenic nociceptors whose stimulation evokes stronger pain responses than muscle irritation. Taken together, the findings support the hypothesis that DOMS originates in the muscle-associated connective tissue rather than in the muscle itself. Sports and fitness professionals designing exercise programs should hence consider fascia-oriented methods and techniques (e.g., foam rolling, collagen supplementation) when aiming to treat or prevent DOMS.

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.

Immediate Effects of Myofascial Release on the Thoracolumbar Fascia and Osteopathic Treatment for Acute Low Back Pain on Spine Shape Parameters: A Randomized, Placebo-Controlled Trial

BACKGROUND

Spine shape parameters, such as leg length and kyphotic or lordotic angle, are influenced by low back pain. There is also evidence that the thoracolumbar fascia plays a role in such pathologies. This study examined the immediate effects of a myofascial release (MFR) technique on the thoracolumbar fascia and of an osteopathic treatment (OMT) on postural parameters in patients with acute low back pain (aLBP).

METHODS

This study was a single-blind randomized placebo-controlled trial. Seventy-one subjects (43.8 ± 10.5 years) suffering from aLBP were randomly and blindedly assigned to three groups to be treated with MFR, OMT, or a placebo intervention. Spinal shape parameters (functional leg length discrepancy (fLLD), kyphotic angle, and lordotic angle) were measured before and after the intervention using video raster stereography.

RESULTS

Within the MFR group, fLLD reduced by 5.2 mm, p < 0.001 and kyphotic angle by 8.2 degrees, p < 0.001. Within the OMT group, fLLD reduced by 4.5 mm, p < 0.001, and kyphotic angle by 8.4°, p = 0.007.

CONCLUSION

MFR and OMT have an influence on fLLD and the kyphotic angle in aLBP patients. The interventions could have a regulating effect on the impaired neuromotor control of the lumbar muscles.