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EVIDENCE INFORMED PRACTICE
shortened muscles and lines can be traced. One can therefore develop strategies about which part of the fascial tissue has to be worked on in order to decrease and normalise mechanical tension and/or muscle tone and hence return to a healthy, efficient and pain free posture and movement.
NON-SPECIFIC LOW BACK PAIN This section will explain the myofascial pain syndrome in low back pain (LBP) with injured and non-injured fascia. LBP has become a major health problem worldwide (12). This type of back pain does not originate in the bony structures of the spine, facet joints or from alterations in the discs (13,14) but in the lumbar soft tissue or the thoracolumbar fascia, respectively (1,15). The thoracolumbar fascia is richly innervated with sensory fibres of encapsulated free nerve endings working as mechanoreceptors and nociceptors (16).
Panjabi (2) and Schleip et al. (17) explain the mechanism of LBP by ‘sub-failure injuries’: single trauma or cumulative micro-injuries that lead to nociceptive signalling.
Due to an inflammation process (micro-injury) and pain, the reflexive muscle tone will be increased, which will increase tension even more. This, in turn, can lead to re-injuring old or lead
to new micro-injuries. Langevin et al. (18) show that the
posterior layer of the thoracolumbar fascia is thickened in patients with chronic LBP. This can be explained by incomplete wound healing with the proliferation of fibres and continuous re-injury of the old and new fibres again and again. The myofascial tension will be higher once the fascia is shortened, injured or contains scar tissue. Therefore, the free nerve endings in the fascia are stimulated earlier and more than usual, especially during movement and when stretching occurs in the direction of the fibre as illustrated in Figure 1. To stop the ‘dysfunctional
myofascial pain loop’, fascia-specific treatment is needed. The myofascial release will be created by a mechanical shift of the fascial tissue that will result in both a mechanical and neurological decrease (tone) of the myofascial tension.
Fascial force transmission of the superficial backline Tension and kinematic pull can be transferred to any part of the body by the myofascial web, especially along the Anatomy Trains. When the goal is to reduce tension in the low back, one must also take a look at the hamstrings, as demonstrated
TABLE 1: PARAMETERS THAT CHANGE FASCIA AND THE MYOFASCIAL SYSTEM
1. Fascia changes depending on the demand and load (20) 2. Habits (also emotional) (4) 3. Sustaining mechanical forces (21) 4. Gravity (21) 5. Injury (22)
6. Chemical substances in the body (23) 7. Direct cell signals (24)
by Franklyn-Miller et al. (6). When a straight leg raise is performed with fresh cadavers, the fascial tension of the ipsilateral lumbar fascia has 145% more tension than the hamstrings.
Figure 1: The blue line in (A) and (B) depicts the superficial back line. (B) The fascia is relatively loose, as in standing position. Even though micro-injuries are present it is often not painful. (A) The fascia is tensioned with nociceptive signalling from the free nerve endings.