Sensory innervation of human thoracolumbar fascia. An immunohistochemical study

Additional Effect of Interfascial Hydrodissection With Dextrose on Shoulder and Neck Function in Patients With Myofascial Pain Syndrome: A Randomized Control Trial

OBJECTIVE

The aim of the study is to evaluate whether the application of an interfascial injection with dextrose water could result in reduced pain and improved shoulder function and range of motion.

DESIGN

This is a double-blind randomized controlled trial. Thirty-five patients with chronic shoulder pain were randomly assigned to receive either an interfascial injection of 10 mL of 10% dextrose water guided by ultrasound or a sham injection of 0.5 mL of 10% dextrose water into the subcutaneous layer. All patients received education on a home program of self-massage and self-stretching. Shoulder pain, shoulder range of motion, and neck and shoulder function were measured before injection and at 4 and 12 wks after injection.

RESULTS

Both groups showed significant improvements in visual analog scale scores at 12-wk follow-up. The interfascial injection group exhibited a significant pain reduction compared with the sham group at the 12-wks follow-up. No between-group differences were observed in shoulder range of motion, pain threshold, and neck and shoulder function.

CONCLUSIONS

Interfascial injection is effective in decreasing pain in patients with myofascial pain syndrome.

Comparison of three concentrations of ropivacaine in posterior quadratus lumborum block: A randomized clinical trial

Background

A conclusive evidence regarding the optimal concentration and volume of local anesthetic for quadratus lumborum block is lacking.

Methods

In this single-center, prospective, randomized, controlled study, 60 patients scheduled for laparoscopic colorectal surgery were randomly assigned to 3 different combinations of volume and concentration of ropivacaine (3 mg/kg) - Group 0.25%, Group 0.375% and Group 0.5%. All subjects received ultrasound-guided posterior quadratus lumborum block prior to the induction. The primary outcome was the complete sensory block rate of surgical site measured at 30 min after quadratus lumborum block, after extubation, at 12, 24, and 48 h after operation. Secondary outcomes were the changes in hemodynamic parameters before and after incision (ΔSBP, ΔDBP and ΔHR), postoperative pain score, the sufentanil consumption after surgery, length of stay and adverse reactions.

Results

The sensory block rate of surgical site at 5 time points differed significantly among the three groups (P < 0.001). Both Group 0.375% (P < 0.001) and Group 0.5% (P < 0.001) had a higher sensory block rate than Group 0.25%, but no significant difference was observed between the former two. Group 0.375% and Group 0.5% had lower postoperative pain scores, lower sufentanil consumption after surgery and shorter length of stay. No statistical difference was observed in ΔSBP, ΔDBP, ΔHR and the incidence of adverse reactions.

Conclusions

0.375% and 0.5% ropivacaine in posterior quadratus lumborum block provide better sensory block of surgical site when compared to 0.25% in laparoscopic colorectal surgery.

Trial registration number

Chinese Clinical Trials Registry (ChiCTR2100043949).

Ultrasound-guided quadratus lumborum block: Posterior versus anterior approach in paediatrics undergoing laparoscopic inguinal hernia repair

Background and Aims

Regional anaesthesia has gained popularity in managing post-operative pain in paediatric patients. Quadratus lumborum block (QLB) is recognised as one of the peri-operative pain management techniques used during abdominal surgeries. However, no consensus about the best approach has been reached.

Material and Methods

Sixty paediatric patients with ages ranging from 1 to 6 as well as classification I and II of the American Society of Anesthesiologists, scheduled for laparoscopic inguinal hernia, were allocated to receive either a posterior approach (Group I) or an anterior approach (Group II) QLB. Twenty four-hour morphine consumption, the face, legs, activity, cry, and consolability (FLACC) score, duration of analgesia, performance time, and block-related complications were recorded.

Results

Group II showed significantly lower morphine consumption as well as a longer duration of analgesia (P = 0.039*, 0.020*, respectively), with an equivalent period for block performance being reported in the two groups (P = 0.080). At 2, 4, 6, and 12 hours post-operatively, the FLACC scores were substantially diminished in Group II compared to Group I (P = 0.001*, 0.012*, 0.002*, 0.028*, respectively). However, at twenty-four hours, comparable pain scores were observed between both groups (P = 0.626). In addition, there were no block-related complications.

Conclusions

In paediatric patients scheduled for laparoscopic inguinal hernia repair, the ultra-sound-guided anterior approach of the QLB was associated with significantly reduced post-operative morphine consumption, a lower FLACC score, and a longer analgesia duration when compared to the posterior approach.

Efficacy of ultrasound-guided infiltration with levobupivacaine and triamcinolone for myofascial pain syndrome of the quadratus lumborum: a retrospective observational study

INTRODUCTION AND OBJECTIVES

Myofascial Pain Syndrome (MPS) of the Quadratus Lumborum muscle (QL) is a frequent cause of chronic low back pain. With this study, we aimed to assess the efficacy of ultrasound-guided infiltration with 0.25% levobupivacaine and 40.ßmg triamcinolone for MPS of the QL.

METHODS

Observational and retrospective study of participants submitted to ultrasound-guided infiltration of the QL muscle from January 1, 2015 to June 31, 2019. Pain intensity was assessed using the five-point pain Numeric Rating Scale (NRS): pre-intervention, at 72.ßhours, 1 month, 3 months and 6 months post-intervention. Additional data collected were demographic characteristics, opioid consumption, and adverse effects.

RESULTS

We assessed 90 participants with mean age of 55.2 years. Sixty-eight percent of participants were female. Compared to the pre-intervention assessment, there was an improvement in pain at 72.ßhours (Mean Difference [MD.ß=.ß3.085]; 95% CI: 2.200...3.970, p.ß<.ß0.05), at the 1st month (MD.ß=.ß2.644; 95% CI: 1.667...3.621, p.ß<.ß 0.05), at the 3rdmonth (MD.ß=.ß2.017; 95% CI: 0.202...2.729, p.ß<.ß0.05) and at the 6th month (MD.ß=.ß1.339; 95% CI 0.378...2.300, p.ß<.ß0.05), post-intervention. No statistically significant differences in opioid consumption were observed. No adverse effects associated with the technique were reported.

CONCLUSIONS

Ultrasound-guided infiltration of the QL muscle is a safe and effective procedure for the treatment of pain in the QL MPS within 6 months post-intervention.

Intra- and inter-session reliability of electrical detection and pain thresholds of cutaneous and muscle primary afferents in the lower back of healthy individuals

To advance evidence-based practice and targeted treatments of low back pain (LBP), a better pathophysiological understanding and reliable outcome measures are required. The processing of nociceptive information from deeper somatic structures (e.g., muscle, fascia) might play an essential role in the pathophysiology of LBP. In this study, we measured the intra- and inter-session reliability of electrical detection and pain thresholds of cutaneous and muscle primary afferents of the lower back. Twenty healthy participants attended two study visits separated by 27.7 ± 1.7 days. To determine the location-specific electrical detection threshold (EDT) and pain threshold (EPT), needle electrodes were inserted in the epidermal layer over, and in the lumbar erector spinae muscle. Additionally, established quantitative sensory testing (QST) parameters were assessed. Reliability was determined by differences between measurements, intraclass correlation coefficients (ICC2,1), Bland-Altman plots, and standard error of measurement (SEM). Correspondence between QST parameters and electrical thresholds was assessed using Pearson's correlation. Except for cutaneous EPT, no significant (p ≤ 0.05) intra- and inter-session differences were observed. Excellent intra-session reliability was shown for cutaneous and intramuscular electrical stimulations and all QST parameters (ICC: 0.76-0.93). Inter-session reliabilities were good (ICC: 0.74-0.75) except for electrical stimulations (ICC: 0.08-0.36). Limits of agreement and SEM were higher for inter-session than intra-session. A medium to strong relationship was found between electrical and mechanical/pressure pain thresholds. In conclusion, cutaneous and intramuscular electrical stimulation will potentially close an important diagnostic gap regarding the selective examination of deep tissue afferents and provide location-specific information for the excitability of non-nociceptive and nociceptive afferents.

Low-Intensity Resistance Exercise Based on Myofascial Chains Alters the Lower-Limb Tension and Improves Health Status in Female Individuals With Knee Osteoarthritis

BACKGROUND

Low-intensity resistance exercise therapy (LIRET) based on myofascial chains, applied to both affected and nonlocal joints, is an effective method for knee osteoarthritis (OA) rehabilitation. This study applied LIRET in a comparison of prevalues and postvalues of lower-limb tension in female patients with knee OA and asymptomatic participants.

METHODS

Twenty-four female participants with knee OA and 20 asymptomatic women took part in a 3-month long application of LIRET. Participants' ankle passive torque and ankle range of motion in the sagittal plane were assessed with an isokinetic dynamometer. The collected values were used to estimate the sagittal-plane lower-limb tension.

RESULTS

Compared with the asymptomatic group, participants with knee OA presented decreased maximum ankle dorsiflexion (P < .001), decreased ankle plantar flexion range (P = .023), ankle resting position more inclined to dorsiflexion (P = .017), increased ankle dorsiflexion stiffness (P = .005), and lower ankle plantar flexion stiffness (P = .034). After exercise intervention, the knee OA group self-reported less knee pain (P < .001), improved physical function (P < .001), increased maximum dorsiflexion (P = .021), and increased plantar flexion range (P < .001). While plantar flexion stiffness increased (P = .037), dorsiflexion stiffness decreased (P = .015) and ankle resting position moved toward dorsiflexion (P = .002). Results suggest possible decreased anterior leg tension and possible increased posterior leg tension in patients with knee OA.

CONCLUSIONS

The results supported that knee OA patients present imbalanced myofascial tension of lower limbs. LIRET based on myofascial chains appears to decrease pain, and stiffness, and improve physical function of patients with knee OA and change their lower-limb tension.

Effect of Remote Myofascial Release on Lumbar Elasticity and Pain in Patients With Chronic Nonspecific Low Back Pain: A Randomized Clinical Trial

Objective

The purpose of this study was to evaluate the effects of myofascial release technique of a remote area on lumbar elasticity and low back pain (LBP) in patients with chronic nonspecific LBP.

Methods

For this clinical trial, 32 participants with nonspecific LBP were assigned to a myofascial release group (n = 16) or a remote release group (n = 16). Participants in the myofascial release group received 4 sessions of myofascial release to the lumbar region. The remote release group received 4 myofascial release sessions to the crural and hamstring fascia of the lower limbs. Low back pain severity and elastic modulus of the lumbar myofascial tissue were assessed before and after treatment by the Numeric Pain Scale and ultrasonography examinations.

Results

The mean pain and elastic coefficient in each group before and after myofascial release interventions were significantly different (P ≤ .0005). The results showed that the changes in mean pain and elastic coefficient of the 2 groups after myofascial release interventions were not significantly different from each other (F1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 = 1.48, P = .230, 95% confidence interval) (effect size = 0.22).

Conclusion

The improvements in the outcome measures for both groups suggest that remote myofascial release was effective in patients with chronic nonspecific LBP. The remote myofascial release of the lower limbs reduced the elastic modulus of the lumbar fascia and LBP.

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.

Elevated serum TLR4 level as a potential marker for postsurgical chronic pain in pediatric patients with different approaches to analgesia

Introduction

The perioperative period of any surgery is accompanied by immune suppression. The level of Toll-like receptor 4 (TLR4) is known to increase in inflammation and after nerve injury and contributes to the development of neuropathic pain. The interaction of TLRs in response to the effect of opioids results in paradoxical hyperalgesia. Regional anesthesia techniques are the standard of care for perioperative pain management in children.

Aim

The aim of the study was to determine and evaluate the indicators of TLR4 for different methods of pain relief in anesthetic management of hernia repair in children and their effect on pain chronification.

Materials and methods

There were examined 60 children with inguinal hernia during 2020-2022. Children were divided into 3 groups: Group I included 20 children who underwent surgery under general anesthesia using the block of the anterior abdominal wall-transversalis fascia plane block (TFPB), combined with the quadratus lumborum block (QLB-4) via a single intramuscular injection; Group II included 20 children who underwent surgery under general anesthesia using the TFPB; Group III comprised 20 children who underwent surgery under general anesthesia using opioid analgesics. The levels of TLR4 were evaluated at a discharge from the hospital, 3 and 6 months after surgery.

Results

There was no difference in age and body weight among all groups. In Group II, boys prevailed. In Group III, the length of hospital stay was the longest (3.28 ± 0.24 days, p < 0.05, t = 4.09) as compared to children of Group II and Group I (3.0 ± 0.30 (p < 0.05, t = 2.647) and 2.1 ± 0.16 days, respectively). While staying in the surgical department, children of Group III demonstrated significantly higher FLACC and VAS scores. The prevalence of chronic pain was the highest among children of Group III (35%) as compared to those in Group II and Group I (20 and 15%, respectively). The highest increase in the level of TLR4 was found in the group of opioid analgesia on the third and sixth months after surgery (68.86 + 10.31 pg/ml and 143.15 + 18.77 pg/ml (p < 0.05, t = 6.33), respectively) as compared to patients who received regional anesthesia.

Conclusions

There were confirmed the following advantages of the transversalis fascia plane block combined with the quadratus lumborum block (QLB + TFPB) via a single intramuscular injection: ease of use; adequate perioperative pain control as evidenced by the FLACC and VAS pain assessment scales; reduced perioperative use of opioid analgesics; shortening the length of hospital stay.

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.

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.

Unilateral rhomboid intercostal and subserratus plane block application for analgesia after laparoscopic cholecystectomy surgery :a quasi-experimental study

Background

Interfascial plane block applications can be used for postoperative pain after laparoscopic surgery. We aimed to investigate the effect of ultrasound-guided unilateral rhomboid intercostal and subserratus plane (RISS) block after laparoscopic cholecystectomy operations on the amount of analgesic use.

Methods

50 patients underwent laparoscopic cholecystectomy were included in the quasi-experimental study. Patients meeting the criteria were analyzed in two groups as experimental group (RISS block with 20 ml %0.25 bupivacaine+intravenous patient-controlled analgesia (IV-PCA) tramadol ; n = 25) and group Control (IV-PCA tramadol; n = 25).The primary outcome was the total amount of tramadol used over 24 hours.Secondary outcomes included the side effects, additional analgesic use and postoperative pain (during rest and activity) was at the 2nd, 6th, 12th, and 24th hours using the NRS scores .

Results

Postoperative tramadol consumption at the 24 hours was significantly lower in the Group RISS than the Group Control (p<0.001). The resting NRS scores at the 2nd and 6th hours were statistically significantly low in the Grup RISS. The NRS scores during movement in Grup RISS were significantly low at the postoperative 2nd, 6th, and 12th hours.There was no statistically significant difference in the rate of side effects and additional analgesic use between the groups (p>0.05).

Conclusions

In conclusion, unilateral RISS block is an effective method for pain management after laparoscopic cholecystectomy and can be used as a part of multimodal analgesia.

Anatomical basis of fascial plane blocks

Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space ("plane") between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.

The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function

Purpose

There is growing evidence that vertebral column function and dysfunction play a vital role in neuromuscular control. This invited review summarises the evidence about how vertebral column dysfunction, known as a central segmental motor control (CSMC) problem, alters neuromuscular function and how spinal adjustments (high-velocity, low-amplitude or HVLA thrusts directed at a CSMC problem) and spinal manipulation (HVLA thrusts directed at segments of the vertebral column that may not have clinical indicators of a CSMC problem) alters neuromuscular function.

Methods

The current review elucidates the peripheral mechanisms by which CSMC problems, the spinal adjustment or spinal manipulation alter the afferent input from the paravertebral tissues. It summarises the contemporary model that provides a biologically plausible explanation for CSMC problems, the manipulable spinal lesion. This review also summarises the contemporary, biologically plausible understanding about how spinal adjustments enable more efficient production of muscular force. The evidence showing how spinal dysfunction, spinal manipulation and spinal adjustments alter central multimodal integration and motor control centres will be covered in a second invited review.

Results

Many studies have shown spinal adjustments increase voluntary force and prevent fatigue, which mainly occurs due to altered supraspinal excitability and multimodal integration. The literature suggests physical injury, pain, inflammation, and acute or chronic physiological or psychological stress can alter the vertebral column’s central neural motor control, leading to a CSMC problem. The many gaps in the literature have been identified, along with suggestions for future studies.

Conclusion

Spinal adjustments of CSMC problems impact motor control in a variety of ways. These include increasing muscle force and preventing fatigue. These changes in neuromuscular function most likely occur due to changes in supraspinal excitability. The current contemporary model of the CSMC problem, and our understanding of the mechanisms of spinal adjustments, provide a biologically plausible explanation for how the vertebral column’s central neural motor control can dysfunction, can lead to a self-perpetuating central segmental motor control problem, and how HVLA spinal adjustments can improve neuromuscular function.

Evidence of a new hidden neural network into deep fasciae

It is recognized that different fasciae have different type of innervation, but actually nothing is known about the specific innervation of the two types of deep fascia, aponeurotic and epymisial fascia. In this work the aponeurotic thoracolumbar fascia and the epymisial gluteal fascia of seven adult C57-BL mice were analysed by Transmission Electron Microscopy and floating immunohistochemistry with the aim to study the organization of nerve fibers, the presence of nerve corpuscles and the amount of autonomic innervation. The antibodies used were Anti-S100, Anti-Tyrosine Hydroxylase and Anti-PGP, specific for the Schwann cells forming myelin, the sympathetic nerve fibers, and the peripheral nerve fibers, respectively. The results showed that the fascial tissue is pervaded by a rhomboid and dense network of nerves. The innervation was statistically significantly lower in the gluteal fascia (2.78 ± 0.6% of positive area, 140.3 ± 31.6/mm² branching points, nerves with 3.2 ± 0.6 mm length and 4.9 ± 0.2 µm thickness) with respect to the thoracolumbar fascia (9.01 ± 0.98% of innervated area, 500.9 ± 43.1 branching points/mm², length of 87.1 ± 1.0 mm, thickness of 5.8 ± 0.2 µm). Both fasciae revealed the same density of autonomic nerve fibers (0.08%). Lastly, corpuscles were not found in thoracolumbar fascia. Based on these results, it is suggested that the two fasciae have different roles in proprioception and pain perception: the free nerve endings inside thoracolumbar fascia may function as proprioceptors, regulating the tensions coming from associated muscles and having a role in nonspecific low back pain, whereas the epymisial fasciae works to coordinate the actions of the various motor units of the underlying muscle.

Quadratus Lumborum Blocks in Nephrectomy: A Narrative Review

The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. It is used for caesarean sections, hip arthroplasty, gynecologic surgery, colectomy, and recently nephrectomy. To date, there are no reviews that outline the efficacy and performance of the quadratus lumborum blocks in patients receiving laparoscopic nephrectomy. The objective of this project was to outline the current available data from both clinical trials along with case series and reports regarding the methods and utility of quadratus lumborum blocks for analgesia in patients receiving nephrectomy. For this literature review, we searched Pubmed, Embase, and Web of Science from their inception until 5/31/2020. Our search terms were as follows: “(nephrectomy OR laparoscopic nephrectomy) AND (QL block OR Quadratus Lumborum block OR QL OR TQL OR Thoracolumbar fascia block).” We analyzed all relevant clinical trials for quality using the Jadad scale. Our search yielded a total of 30 articles, 23 of which we ultimately reviewed for this manuscript. The qualitative sum of these data show that patients receiving quadratus lumborum block for nephrectomies have reduced opioid requirements, reduced pain scores, and improved side-effects relative to other analgesic modalities like epidurals. Based on these findings, we conclude that the quadratus lumborum block is a useful analgesic for patients undergoing nephrectomy.

Immediate effects of myofascial release on neuromechanical characteristics in female and male patients with low back pain and healthy controls as assessed by tensiomyography. A controlled matched-pair study

BACKGROUND

Low back pain (LBP) is a major health issue in most industrialised countries. Lumbodorsal fascia has been advocated as a potential source of pain in the lumbopelvic region. Myofascial release constitutes a manual therapeutic approach focussing on the restoration of altered soft tissue function. No previous study has focused on quantifying neuromechanical effects of myofascial release on LBP patients through tensiomyography. The purpose of this study was to quantify immediate neuromechanical alterations of myofascial release on patients with LBP and healthy controls through tensiomyography parameters.

METHODS

The participants' (n = 30) bilateral lumbar erector spinae muscles were assessed via tensiomyography before and after a 6-min myofascial release treatment of the lumbodorsal fascia to evaluate the muscles' mechanical characteristics. Subjects with LBP (n = 15) were eligible to partake if they reported having had LBP for most days in the past 12 weeks. Muscle displacement (Dm [mm]), velocity of contraction (Vc [mm/s]), and lateral symmetry (Ls [%]) were assessed through tensiomyography testing.

FINDINGS

Statistical analyses revealed a significant increase for velocity of contraction in the right (p = .021) and left (p = .041) lumbar erector spinae for the subjects with LBP but not for the healthy controls (both p > .14).

INTERPRETATION

We suggested that myofascial release alters neuromechanical characteristics in subjects with LBP. Tensiomyography may be implemented in clinical settings to monitor intervention effects of the myofascial system, especially the tensiomyography parameter velocity of contraction.

Analgesic efficacy of two approaches of ultrasound-guided quadratus lumborum block for laparoscopic renal surgery: A randomised controlled trial

BACKGROUND

Moderate-to-severe pain exists in the early postoperative period after laparoscopic renal surgery.

OBJECTIVE

We investigated the analgesic effect of quadratus lumborum block (QLB) via two approaches in patients undergoing laparoscopic renal nephrectomy.

DESIGN

A randomised controlled trial.

SETTING

An academic tertiary care hospital in Beijing, China.

PARTICIPANTS

Ninety-six patients aged 18 to 70 years who were scheduled for elective laparoscopic radical or partial nephrectomy.

INTERVENTIONS

Eligible patients were allocated randomly to a control group (no block), lateral QLB group or posterior QLB group. Ultrasound-guided QLB was performed via either the lateral or posterior approach with 30 ml of 0.4% ropivacaine before surgery.

MAIN OUTCOME MEASURES

The primary outcome was sufentanil equivalent consumption within 24 h. Among secondary outcomes, somatic and visceral pain intensity at rest and on coughing were assessed with a numerical rating scale (where 0 = no pain and 10 = the worst pain) until 24 h postoperatively.

RESULTS

Sufentanil equivalent consumption did not differ among the three groups (118 ± 36 μg in the control group, 115 ± 47 μg in the lateral QLB group and 119 ± 40 μg in the posterior QLB group; P = 0.955). However, both somatic (lateral QLB vs. control, median difference -1, P < 0.001 at rest and -2 to -1, P < 0.001 on coughing; posterior QLB vs. control, -1, P < 0.001 at rest and -2 to -1, P < 0.001 on coughing) and visceral pain scores (lateral QLB vs. control, -1 to 0, P < 0.001 at rest and -1, P < 0.001 on coughing; posterior QLB vs. control, -1 to 0, P < 0.001 at rest and -2 to -1, P < 0.001 on coughing) were significantly lower in the two QLB groups than in the control group.

CONCLUSION

For patients undergoing laparoscopic renal surgery, a pre-operative single-shot QLB via the lateral or posterior approach did not decrease opioid consumption, but improved analgesia for up to 24 h after surgery.

TRIAL REGISTRATION

www.chictr.org.cn identifier: ChiCTR1800019883.

The morphological and microscopical characteristics of posterior layer of human thoracolumbar fascia; A potential source of low back pain

BACKGROUND

Posterior layer of thoracolumbar fascia (PTLF) is the deep fascia of back of the trunk, which connects the trunk, upper limb and lower limb muscles. Very few cadaveric studies of posterior layer of thoracolumbar fascia (PTLF) are found in the literature, which mention the presence of nerve receptors in it but, quantification of the nerve receptors where not found. Providing the morphological and morphometrical data of PTLF may help the exercise physiologists, sports physicians, occupational health assistants and, physiotherapists to modify or invent new protocol of treatment to help the society.

METHODS

In this study, twenty formalin embalmed human cadavers were used and we have documented the orientation of the PTLF and quantified the number of peripheral nerve endings at the different vertebral levels.

RESULTS

Mean distance of PTLF from vertebral spines to the musculofascial junction was at thoracic region 3.38cm and 3.34cm; at lumbar region, it was 7.4cm and 7.36cm and at sacral region it was 2.98cm and 2.96cm on right and left side, respectively. The angulation of PTLF varies from 18-110 degrees at different vertebral levels. The microscopic data shows the thickness of PTLF and number of nerve endings in the sacral level is increased compared to that of thoracic vertebral levels.

CONCLUSIONS

We have contributed the novel morphological and microscopical details to the limited existing data on PTLF. We also have provided the quantitative data of nerve fibers, which are possible nociceptors of PTLF.

Analgesic Effect of Ultrasound-Guided Preoperative Unilateral Lateral Quadratus Lumborum Block for Laparoscopic Nephrectomy: A Randomized, Double-Blinded, Controlled Trial

Purpose

The quadratus lumborum block (QLB) is a relatively new regional analgesic technique that could provide analgesia to the abdominal wall and reduce postoperative opioid consumption. We investigated the opioid-sparing effect of a unilateral lateral QLB in laparoscopic nephrectomy.

Patients and Methods

A total of 60 patients undergoing laparoscopic nephrectomy were included in the study. Patients were randomized into two groups as QLB and control group. QLB group received QLB with 25mL 0.25% ropivacaine, and the control group received 25mL 0.9% saline at anterolateral border of quadratus lumborum muscle preoperatively. Opioid consumption and the pain intensity at rest and on movement were measured at 2nd, 6th, 24th, and 48th hour postoperatively. We also assessed the time to first flatus to measure the extent of paralytic ileus and the quality of recovery-15 (QoR-15) questionnaire.

Results

Postoperative opioid consumption was significantly lower in the QLB group than in the control group at 6, 24, and 48h after surgery (P < 0.05). The pain intensity at rest and on movement was significantly lower in the QLB group than in the control group during the first 24 hours after surgery (P < 0.05). The incidence of postoperative nausea and vomiting, time to first flatus, and QoR-15 score did not show significant differences.

Conclusion

Preoperative unilateral QLB successfully decreased postoperative pain and opioid consumption after laparoscopic nephrectomy and could be an option for analgesia after laparoscopic nephrectomy.

Clinical Assessment and Thickness Changes of the Oblique and Multifidus Muscles Using a Novel Screening Tool and Exercise Program: A Randomized Controlled Trial

CONTEXT

Training and assessment of the abdominal and trunk muscles are widely used in the clinical setting. However, it is unknown what types of exercises are most effective in activation of both the global and local stabilizers in these regions.

OBJECTIVE

The purpose of this study was to establish the reliability of a novel clinical screening tool (sling screen) to assess the muscles of the abdomen and trunk. The second aim was to use the clinical screening tool and musculoskeletal ultrasound to compare the effects of a rotary-based exercise program that targets both the global and local muscles to the effects of a traditional exercise program on the activation of the abdominal and trunk muscles.

DESIGN

Double-blind, randomized controlled trial.

SETTING

Sports medicine facility.

PARTICIPANTS AND INTERVENTIONS

Thirty-one healthy participants were randomly allocated to receive a single-session rotary-based or traditional "core" exercise program.

MAIN OUTCOME MEASURES

The participants were assessed at the baseline and immediately postintervention. The primary outcome measures were muscle thickness examined by musculoskeletal ultrasound and clinical examination of muscle activation using a screening tool. The data were collected by blind assessors. Reliability and validity of a clinical screening tool (sling screen) were also assessed.

RESULTS

The analysis of the covariance tests showed a significant increase in oblique thickness for the rotary exercise group. All participants displayed a significant increase in multifidus thickness. The Wilcoxon signed-rank tests revealed a significant increase in clinical assessment scores in the rotary exercise group but not the traditional exercise group. Reliability of the sling screen ranged from moderate to good.

CONCLUSION

This clinical trial provides evidence that a rotary-based exercise program may be more effective in producing increases in oblique muscle thickness than traditional "core" exercises in young, healthy adults. The sling screen tool was able to identify these muscle thickness changes. Future studies should investigate how these results correlate to injury risk, other populations, and also how to implement the sling screen into clinical practice.

Integrating mental imagery and fascial tissue: A conceptualization for research into movement and cognition

Mental imagery (MI) research has mainly focused to date on mechanisms of effect and performance gains associated with muscle and neural tissues. MI's potential to affect fascia has rarely been considered. This paper conceptualizes ways in which MI might mutually interact with fascial tissue to support performance and cognitive functions. Such ways acknowledge, among others, MI's positive effect on proprioception, body schema, and pain. Drawing on cellular, physiological, and functional similarities and associations between muscle and fascial tissues, we propose that MI has the potential to affect and be affected by fascial tissue. We suggest that fascia-targeted MI (fascial mental imagery; FMI) can therefore be a useful approach for scientific as well as clinical purposes. We use the example of fascial dynamic neuro-cognitive imagery (FDNI) as a codified FMI method available for scientific and therapeutic explorations into rehabilitation and prevention of fascia-related disabling conditions.

The feasibility and impact of instrument-assisted manual therapy (IAMT) for the lower back on the structural and functional properties of the lumbar area in female soccer players: a randomised, placebo-controlled pilot study design

BACKGROUND

Myofascial (self-)treatments, such as foam rollers to therapeutic instruments in manual therapy, are utilized increasingly in prevention and therapy in healthy people, athletes, and patients suffering from chronic back pain. However, there is limited knowledge about the effectiveness of treatment and the underlying mechanisms of myofascial therapies, especially for instrument-assisted manual therapy (IAMT). Therefore, this pilot study will investigate the feasibility and impact of IAMT for the lumbar area compared with heat application and placebo treatment as a basis for calculating the sample size for further full studies. The primary outcomes will be a critical analysis of the feasibility of the measurement protocol in terms of time economy and expressiveness and of the short- and long-term effects on shear motion of the single tissue layers of the lower back obtained through ultrasound imaging. Secondary outcomes will include thickness and compressibility of the lumbar structures and flexibility of the dorsal structures, indentometry, and superficial skin temperature.

METHODS

A minimum of 60 healthy, competitive 15-35-year-old female soccer players will be recruited and randomised into three groups. Short-term effects of IAMT on thoracolumbar structures will be compared with heat application and pressure-less placebo treatment. Long-term effects in the IAMT group will be tested after nine further interventions over a 5-week period (2×/week) and compared with the placebo group, which will not receive further treatments but will serve as a control. Intermediate and final testing of both groups will occur in weeks three and five.

DISCUSSION

This pilot study will assess the feasibility and the impact of IAMT for the lower back particularly by examining the structural and functional properties of myofascial tissue using diagnostic ultrasound. These outcomes could evaluate the feasibility of the measurements used, shall build a basis for sample size calculation of further full studies, and might generate a greater understanding of myofascial therapies, especially IAMT, for the lower back and its benefits. If this approach proves to be practicable, next steps will be further full studies with soccer players, other sports, and patients with low back pain.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00012252) 20.06.2018; retrospectively registered.

T1ρ-Mapping for Musculoskeletal Pain Diagnosis: Case Series of Variation of Water Bound Glycosaminoglycans Quantification before and after Fascial Manipulation® in Subjects with Elbow Pain

Diagnosis and management of musculoskeletal pain is a major clinical challenge. Following this need, the first aim of our study was to provide an innovative magnetic resonance technique called T_1ρ to quantify possible alterations in elbow pain, a common musculoskeletal pain syndrome that has not a clear etiology. Five patients were recruited presenting chronic elbow pain (>3 months), with an age between 30 and 70 years old. Patients underwent two T_1ρ-mapping evaluations, one before and one after the series of Fascial Manipulation^® (FM) treatments. After the first MRI evaluation, a Disability of the Arm, Shoulder and Hand (DASH) questionnaire was administered to quantify the symptoms and pain intensity. Patients then received three sessions of FM, once a week for 40 min each. A statistically significant difference was found between bound and unbound water concentration before and after FM treatment. Our preliminary data suggest that the application of the manual method seems to decrease the concentration of unbound water inside the deep fascia in the most chronic patients. This could explain the change in viscosity perceived by many practitioners as well as the decrease of symptoms due to the restoration of the normal property of the loose connective tissue. Being able to identify an altered deep fascial area may better guide therapies, contributing to a more nuanced view of the mechanisms of pain.

Biomechanical model of swimming rehabilitation after hip and knee surgery

As a low-to-moderate intensity rehabilitation exercise after hip and knee surgery, we propose a dynamical model of the legs motion through the water medium in freestyle and backstroke swimming. We formulate a general Kirchhoff-Lagrangian dynamics model of the legs-propulsion through the water in post-surgical rehabilitation swimming. We start by defining the two-leg-propulsion configuration manifold. This is composed of eight Euclidean groups of rigid motions in 3D space for each of the four leg segments. Next, we define Newton-Euler dynamics for each segment. This single segmental dynamics is further generalized into Lagrangian dynamics for the whole leg-propulsion system. Finally, the water effects are added in the form of Kirchhoff's vector cross-products. In agreement with orthopaedic recommendations for post-surgical rehabilitation, numerical simulation is performed on a simplified version of the full Kirchhoff-Lagrangian dynamics model, which we call the "robotic swimming leg" - with intentionally reduced number of (microscopic, non-sagittal) degrees-of-freedom. The purpose of this development is both qualitative, for medical and physiotherapist practitioners to study, and quantitative, for biomechanics experts to analyze and further develop.

Innervation of the thoracolumbar fascia

The aim of the study was to obtain information on the sensory functions of the thoracolumbar fascia (TLF). The types of nerve fibres present in the TLF were visualized with specific antibodies to neuropeptides and sympathetic fibres. Most data were obtained from the TLF in rats, but some findings from the human fascia are also included. The only receptive nerve ending found was the free nerve ending, i.e. no corpuscular receptors existed in our specimen. An exclusive innervation with free nerve endings speaks for a nociceptive function, but the TLF may also fulfill proprioceptive functions, since many of the free nerve endings have a low mechanical threshold. Most of the fibres could be visualized with antibodies to CGRP [calcitonin gene- related peptide (CGRP)] and SP [substance P (SP)]. The latter ones most likely were nociceptors. The TLF contained a great proportion of postganglionic sympathetic fibres, which may be vasoconstrictors. A comparison between an inflamed and intact fascia showed an increase of the CGRP- and SP-positive fibres in the inflamed TLF. This finding could be one explanation for the low back pain of many patients, since practically all lesions of the fascia are accompanied by a sterile inflammation.

Quadratus Lumborum Block: Anatomical Concepts, Mechanisms, and Techniques

A review of anatomy, potential mechanisms of action, and techniques and summary of clinical evidence for quadratus lumborum block.

Resolution of a Greater Than 50-year History of Severe, Chronic Low Back Pain Following an Ultrasound-guided Platelet-rich Plasma Infiltration of the Thoracolumbar Fascia

The diagnosis of chronic low back pain is a scourge of society that does not take into account the pathoanatomical cause of pain. This case describes a six-year search for the pinpoint pathoanatomical diagnosis of a patient's 50-plus year history of debilitating chronic low back pain after he failed the standard nonoperative and operative treatment modalities. Ultrasound-guided diagnostic blocks identified a potential space within the thoracolumbar fascia. This was treated with platelet-rich plasma, yielding a complete resolution of his pain and a full return to normal activities of daily living for three years since the procedure.

Measuring the morphological characteristics of thoracolumbar fascia in ultrasound images: an inter-rater reliability study

Background

Chronic lower back pain is still regarded as a poorly understood multifactorial condition. Recently, the thoracolumbar fascia complex has been found to be a contributing factor. Ultrasound imaging has shown that people with chronic lower back pain demonstrate both a significant decrease in shear strain, and a 25% increase in thickness of the thoracolumbar fascia. There is sparse data on whether medical practitioners agree on the level of disorganisation in ultrasound images of thoracolumbar fascia. The purpose of this study was to establish inter-rater reliability of the ranking of architectural disorganisation of thoracolumbar fascia on a scale from ‘very disorganised’ to ‘very organised’.

Methods

An exploratory analysis was performed using a fully crossed design of inter-rater reliability. Thirty observers were recruited, consisting of 21 medical doctors, 7 physiotherapists and 2 radiologists, with an average of 13.03 ± 9.6 years of clinical experience. All 30 observers independently rated the architectural disorganisation of the thoracolumbar fascia in 30 ultrasound scans, on a Likert-type scale with rankings from 1 = very disorganised to 10 = very organised. Internal consistency was assessed using Cronbach’s alpha. Krippendorff’s alpha was used to calculate the overall inter-rater reliability.

Results

The Krippendorf’s alpha was .61, indicating a modest degree of agreement between observers on the different morphologies of thoracolumbar fascia.The Cronbach’s alpha (0.98), indicated that there was a high degree of consistency between observers. Experience in ultrasound image analysis did not affect constancy between observers (Cronbach’s range between experienced and inexperienced raters: 0.95 and 0.96 respectively).

Conclusions

Medical practitioners agree on morphological features such as levels of organisation and disorganisation in ultrasound images of thoracolumbar fascia, regardless of experience. Further analysis by an expert panel is required to develop specific classification criteria for thoracolumbar fascia.

Hand fasciae innervation: The palmar aponeurosis

There are few data in the scientific literature about the innervation of fasciae of the hand. The present study first elucidates the density and location of nervous structures in the palmar aponeurosis and, for comparison, in the flexor retinaculum (both can be considered specializations of the deep fascia of the upper limbs). Second, it compares nonpathological with pathological palmar aponeurosis. Samples of nonpathological fascia were taken from the flexor retinaculum and palmar aponeurosis of 16 upper limbs of unembalmed cadavers. Samples of pathological palmar aponeurosis were taken from seven patients with Dupuytren's disease. All samples were stained immunohistochemically with anti-S100 and anti-tubulin antibodies, and analyzed quantitatively and qualitatively by microscopy. The palmar aponeurosis showed higher median density than the retinacula of free nerve endings (22 and 20 elements/cm² , respectively), Pacinian corpuscles (2 and 0 elements/cm² ) and Golgi-Mazzoni corpuscles (1.0 and 0.5 element/cm² ). Some corpuscles were located at the intersections of the fibers in the three directions. Free nerve endings were denser in pathological palmar aponeurosis (38 elements/cm² ). The results indicate that the palmar aponeurosis is central to proprioception of the hand and that surgery should therefore avoid injuring it. The higher density of free nerve endings in pathological samples indicates that the nervous structures are implicated in the amplified fibrosis of Dupuytren's disease. Clin. Anat. 31:677-683, 2018. © 2018 Wiley Periodicals, Inc.

Fetal Development of Fasciae around the Arm and Thigh Muscles: A Study Using Late Stage Fetuses

To obtain a better understanding of multi-laminar deep fascia covering skeletal muscles, we examined nondecalcified histological sections of the arm and thigh of 20 human fetuses aged 25-33 weeks. Morphologies of the fasciae varied between sites and specimens, but the initial morphology was most likely to be a thin and loose sheet on the external surface of the muscles (fascia-1 or F1). When the F1 became wavy, thick and tight, it was detached from the muscle surface. Beneath the F1, the second lamina of fascia (F2) appeared on the muscle surface and it was also detached. In this manner at 25-33 weeks' gestation, fasciae covering the triceps and vastus lateralis muscles had a three-layered configuration (F1, F2, and F3). Due to significant individual variations, this process was not correlated to the ages and sizes of specimens. Muscle contractions might facilitate the detachment. In these muscles, the intramuscular tendon joined the F2 or F3 and the latter became thick and aponeurotic. Along the finally developed lamina, muscle fibers carried a desmin-positive spot for insertion. Increased laminae were accompanied by a reduced number of CD68-positive macrophages and, nerves were absent, near the developing fascia. In contrast to skin ligaments or superficial fasciae showing de novo development in loose tissue, a deep or muscle-covering fascia seemed to originate from the skeletal muscle itself at the surface, and this process was repeated to produce multi-layered fascia. Depending on sites, collagen fibers were added by the intramuscular tendon. Anat Rec, 301:1235-1243, 2018. © 2018 Wiley Periodicals, Inc.

Effect of lumbar fasciae on the stability of the lower lumbar spine

The biomechanical effect of tensioning the lumbar fasciae (LF) on the stability of the spine during sagittal plane motion was analysed using a validated finite element model of the normal lumbosacral spine (L4-S1). To apply the tension in the LF along the direction of the fibres, a local coordinate was allocated using dummy rigid beam elements that originated from the spinous process. Up to 10 Nm of flexion and 7.5 Nm of extension moment was applied with and without 20 N of lateral tension in the LF. A follower load of 400 N was additionally applied along the curvature of the spine. To identify how the magnitude of LF tension related to the stability of the spine, the tensioning on the fasciae was increased up to 40 N with an interval of 10 N under 7.5 Nm of flexion/extension moment. A fascial tension of 20 N produced a 59% decrease in angular motion at 2.5 Nm of flexion moment while there was a 12.3% decrease at 10 Nm in the L5-S1 segment. Its decrement was 53 and 9.6% at 2.5 Nm and 10 Nm, respectively, in the L4-L5 segment. Anterior translation was reduced by 12.1 and 39.0% at the L4-L5 and L5-S1 segments under 10 Nm of flexion moment, respectively. The flexion stiffness shows an almost linear increment with the increase in fascial tension. The results of this study showed that the effect of the LF on the stability of the spine is significant.

The Lumbodorsal Fascia as a Potential Source of Low Back Pain: A Narrative Review

The lumbodorsal fascia (LF) has been proposed to represent a possible source of idiopathic low back pain. In fact, histological studies have demonstrated the presence of nociceptive free nerve endings within the LF, which, furthermore, appear to exhibit morphological changes in patients with chronic low back pain. However, it is unclear how these characteristics relate to the aetiology of the pain. In vivo elicitation of back pain via experimental stimulation of the LF suggests that dorsal horn neurons react by increasing their excitability. Such sensitization of fascia-related dorsal horn neurons, in turn, could be related to microinjuries and/or inflammation in the LF. Despite available data point towards a significant role of the LF in low back pain, further studies are needed to better understand the involved neurophysiological dynamics.

Morphological features of fascia lata in relation to fascia diseases

Fascia lata is an important element of the fascial system, which forms the continuum of connective tissue throughout the body. This deep fascia envelops the entire thigh and hip area and its main function is to transmit mechanical forces generated by the musculoskeletal system of the lower extremities. Fascia lata is also known as a useful and easily harvested graft material. Despite its crucial role in lower extremity biomechanics and wide-ranging applications in plastic and reconstructive surgery, both the structure of fascia lata and particularly the cells populating this tissue are relatively unexplored and therefore poorly understood. The aim of this study was to characterize the main cell populations encountered within human fascia lata and to try to understand their role in health and diseases. Pathologically unchanged human fascia lata was obtained post mortem from adult males. The specimens were analyzed under light, electron, and confocal microscopy. On the basis of different visualization techniques, we were able to characterize in detail the cells populating human fascia lata. The main cells found were fibroblasts, fibrocytes, mast cells, cells showing myoid differentiation, nerve cells, and most interestingly, telocytes. Our results supplement the formerly inadequate information in the literature regarding the cellular components of deep fascial structure, may contribute to a better understanding of the pathogenesis of fascial disorders and improve fascia lata application as a graft material.

Intermuscular force transmission along myofascial chains: a systematic review

The present review aims to provide a systematic overview on tensile transmission along myofascial chains based on anatomical dissection studies and in vivo experiments. Evidence for the existence of myofascial chains is growing, and the capability of force transmission via myofascial chains has been hypothesized. However, there is still a lack of evidence concerning the functional significance and capability for force transfer. A systematic literature research was conducted using MEDLINE (Pubmed), ScienceDirect and Google Scholar. Studied myofascial chains encompassed the superficial backline (SBL), the back functional line (BFL) and the front functional line (FFL). Peer-reviewed human dissection studies as well as in vivo experiments reporting intermuscular tension transfer between the constituents of a myofascial chain were included. To assess methodic quality, two independent investigators rated studies by means of validated assessment tools (QUACS and PEDro Scale). The literature research identified 1022 articles. Nine studies (moderate to excellent methodological quality) were included. Concerning the SBL and the BFL, there is moderate evidence for force transfer at all three transitions (based on six studies), and one of two transitions (three studies). One study yields moderate evidence for a slight, but not significant force transfer at one transition in the FFL. The findings of the present study indicate that tension can be transferred between some of the examined adjacent structures. Force transfer might have an impact in overuse conditions as well as on sports performance. However, different methods of force application and measurement hinder the comparability of results. Considering anatomical variations in the degree of continuity and histological differences of the linking structures is crucial for interpretation. Future studies should focus on the in vivo function of myofascial continuity during isolated active or passive tissue tensioning.

Evidence for the existence of nociceptors in rat thoracolumbar fascia

Recently, the existence of nociceptive fibers in fascia tissue has attracted much interest. Fascia can be a source of pain in several disorders such as fasciitis and non-specific low back pain. However, little is known about the properties of fascia nociceptors and possible changes of the fascia innervation by nociceptors under pathological circumstances. In this histologic study, the density of presumably nociceptive fibers and free nerve endings was determined in the three layers of the rat TLF: inner layer (IL, covering the multifidus muscle), middle layer (ML) and outer layer (OL). As markers for nociceptive fibers, antibodies to the neuropeptides CGRP and SP as well as to the transient receptor potential vanilloid 1 (TRPV1) were used. As a pathological state, inflammation of the TLF was induced with injection of complete Freund's adjuvant. The density of CGRP- and SP-positive fibers was significantly increased in the inner and outer layer of the inflamed fascia. In the thick middle layer, no inflammation-induced change occurred. In additional experiments, a neurogenic inflammation was induced in the fascia by electrical stimulation of dorsal roots. In these experiments, plasma extravasation was visible in the TLF, which is clear functional evidence for the existence of fascia nociceptors. The presence of nociceptors in the TLF and the increased density of presumably nociceptive fibers under chronic painful circumstances may explain the pain from a pathologically altered fascia. The fascia nociceptors probably contribute also to the pain in non-specific low back pain.

Ultrasound Evaluation of the Combined Effects of Thoracolumbar Fascia Injury and Movement Restriction in a Porcine Model

The persistence of back pain following acute back "sprains" is a serious public health problem with poorly understood pathophysiology. The recent finding that human subjects with chronic low back pain (LBP) have increased thickness and decreased mobility of the thoracolumbar fascia measured with ultrasound suggest that the fasciae of the back may be involved in LBP pathophysiology. This study used a porcine model to test the hypothesis that similar ultrasound findings can be produced experimentally in a porcine model by combining a local injury of fascia with movement restriction using a "hobble" device linking one foot to a chest harness for 8 weeks. Ultrasound measurements of thoracolumbar fascia thickness and shear plane mobility (shear strain) during passive hip flexion were made at the 8 week time point on the non-intervention side (injury and/or hobble). Injury alone caused both an increase in fascia thickness (p = .007) and a decrease in fascia shear strain on the non-injured side (p = .027). Movement restriction alone did not change fascia thickness but did decrease shear strain on the non-hobble side (p = .024). The combination of injury plus movement restriction had additive effects on reducing fascia mobility with a 52% reduction in shear strain compared with controls and a 28% reduction compared to movement restriction alone. These results suggest that a back injury involving fascia, even when healed, can affect the relative mobility of fascia layers away from the injured area, especially when movement is also restricted.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial

BACKGROUND

The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation® associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone.

METHODS

24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured.

RESULTS

Patients receiving Fascial Manipulation® showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term.

CONCLUSION

Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial

BACKGROUND

The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation® associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone.

METHODS

24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured.

RESULTS

Patients receiving Fascial Manipulation® showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term.

CONCLUSION

Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.

[Ageing and restricted mobility. Frailty from the perspective of myofascial structural models]

BACKGROUND

Decreasing physical mobility largely defines our idea of ageing. Frailty is generally considered to be a degenerative but normal age-related condition in elder people. A detailed analysis of this somatic process and the development of intervention strategies, however, require a differentiation of so-called normal mobility which does not focus on average values, but on functional connections.

METHODS

Myofascial structural models provide such a perspective, in which muscles, tendons, and connective tissue are not regarded as isolated tissue parts but as an integrated functional network.

RESULTS

Within these models, the key to an adequate understanding of physical frailty is the extracellular matrix, which tends to dehydrate in inactive or strained body regions and to store additional collagen. Thus tractive forces are reduced but at the cost of reduced elasticity. As the connective tissue is interspersed with mechanoreceptors that are sensitive to pressure induced externally, affected structures are accessible for prophylactic and therapeutic intervention.

Upper Limb Motor Impairment After Stroke

Understanding poststroke upper limb impairment is essential to planning therapeutic efforts to restore function. However, determining which upper limb impairment to treat and how is complex because the impairments are not static and multiple impairments may be present simultaneously. How impairments contribute to upper limb dysfunction may be understood by examining them from the perspective of their functional consequences. There are 3 main functional consequences of impairments on upper limb function: (1) learned nonuse, (2) learned bad use, and (3) forgetting as determined by behavioral analysis of tasks. The impairments that contribute to each of these functional limitations are described.

Innervation changes induced by inflammation of the rat thoracolumbar fascia

Recently, the fascia innervation has become an important issue, particularly the existence of nociceptive fibers. Fascia can be a source of pain in several disorders such as fasciitis and non-specific low back pain. However, nothing is known about possible changes of the fascia innervation under pathological circumstances. This question is important, because theoretically pain from the fascia cannot only be due to increased nociceptor discharges, but also to a denser innervation of the fascia by nociceptive endings. In this histological study, an inflammation was induced in the thoracolumbar fascia (TLF) of rats and the innervation by various fiber types compared between the inflamed and intact TLF. Although the TLF is generally considered to have proprioceptive functions, no corpuscular proprioceptors (Pacini and Ruffini corpuscles) were found. To obtain quantitative data, the length of fibers and free nerve endings were determined in the three layers of the rat TLF: inner layer (IL, adjacent to the multifidus muscle), middle layer (ML) and outer layer (OL). The main results were that the overall innervation density showed little change; however, there were significant changes in some of the layers. The innervation density was significantly decreased in the OL, but this change was partly compensated for by an increase in the IL. The density of substance P (SP)-positive - presumably nociceptive - fibers was significantly increased. In contrast, the postganglionic sympathetic fibers were significantly decreased. In conclusion, the inflamed TLF showed an increase of presumably nociceptive fibers, which may explain the pain from a pathologically altered fascia. The meaning of the decreased innervation by sympathetic fibers is obscure at present. The lack of proprioceptive corpuscular receptors within the TLF does not preclude its role as a proprioceptive structure, because some of the free nerve endings may function as proprioceptors.