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ACTIVE CONTRACTION OF THE THORACOLUMBAR FASCIA - INDICATIONS OF A NEW FACTOR IN LOW BACK PAIN RESEARCH WITH IMPLICATIONS FOR MANUAL THERAPY

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5th Interdisciplinary World Congress on Low Back & Pelvic Pain
Melbourne, November 2004 www.worldcongresslbp.com
ACTIVE CONTRACTION OF THE THORACOLUMBAR
FASCIA - INDICATIONS OF A NEW FACTOR IN LOW
BACK PAIN RESEARCH WITH IMPLICATIONS FOR
MANUAL THERAPY
Robert Schleip, Werner Klingler MD, Frank Lehmann-Horn PhD
Applied Physiology, Ulm University, Germany
Email: robert.schleip@medizin.uni-ulm.de
INTRODUCTION
The fascia and ligaments are usually considered to be a passive element in the neuro-myofascial
dynamics of joint stability. The presence of contractile connective tissue cells and the ability of
fascia to contract on its own suggests that fascia may play a more active role in joint dynamics and
regulation.
BACKGROUND AND PURPOSE
Tensile transmission across the thoracolumbar fascia (TLF) serves as an important element for
back stability(1). Previous viscoelastic examinations of the TLF exposed to in vitro isometric
stretch demonstrated an unexpected ability for autonomous fascial contraction within several
minutes (2). Since the musculature of visceral organs exhibits a similar capacity, a histological
examination of the TLF for intrafascial cells with smooth muscle like contractility had been
suggested (2,3). Contractile cells containing smooth muscle actin have been found not only in
wound healing and pathologically contracted fascia (Morbus Dupuytren, club foot, frozen
shoulder) but also in normal ligaments (4,5), tendons (6) and fascia (7,3). The current study
therefore examines the existence of cells containing contractile smooth muscle actin in the TLF.
Additionally some of the possible variables influencing TLF active contraction are investigated.
Figure1. Left side: tissue section of lumbar fascia from a man of 19 yrs with dense population of
cells staining positively for alpha smooth muscle actin (here in black) and with high degree of
collagen crimp. Right side: section from man of 76 yrs. with hardly any collagen crimping and no
positively stained cells in this area.
5th Interdisciplinary World Congress on Low Back & Pelvic Pain
Melbourne, November 2004 www.worldcongresslbp.com
MATERIAL AND METHODS
Immunohistochemistry: 39 tissue samples of the superficial lamina of the posterior layer of the
TLF at the level of L2 and L4 from 11 human cadavers of 3 different age groups were taken
(Group A: 19-26 yrs, 4 males. Group B: 54-56 yrs, 1 female, 2 male. Group C: 71-76 yrs, 1
female, 3 male). Samples were analyzed by immunohistochemistry for cells containing alpha
smooth muscle actin using a monoclonal antibody,
In vitro contraction tests: Test pieces of fresh porcine lumbar fascia (size 30 mm x 2 mm x 2 mm)
were dissected along the main longitudinal fiber direction. The samples were fixed at either end
and oriented vertically in an organ bath containing Krebs-Ringer solution (pH buffered, supplied
with 95% O2 and 5% CO2) at 35o C. Samples were prestretched with a constant 5% isometric
strain. Force registrations were performed after an adaptation period of at least 30 minutes to
ensure steady state conditions. The tension force of the tissue was recorded by a computer over a
testing period of 15 min., during which the tissue was either challenged with electrical stimulation
or with chemical stressors, thereby testing for a possible response to acetylcholine, caffeine, the
NO-donator glyceroltrinitrate, and a potassium enriched solution.
RESULTS
Immunohistochemistry: Cells containing alpha smooth muscle actin were found in all tissue
samples. Mean density of these cells in longitudinal sections was 128/mm2 (± 51/mm2) in group A
(<32 yrs), 13/mm2 (±8/mm2) in group B (54-56 yrs) and 12/mm2 (± 3/mm2) in group C (<70 yrs).
Mean average density of contractile cells was 79/mm2, with an average cellular diameter of 4.2 µm
and a length of 18.1 µm. Density seemed to be related to the degree of collagen crimping, which
had a mean amplitude of 8 µm (± 1.5µm) in the youngest group, 4.4 µm (± 0.7µm) in the middle
group, and 3.9 µm (± 0.6µm) in the eldest group. The youngest group showed significantly more
contractile cells (p<0.002) and higher crimp amplitude (p>0.0005) compared with any of the two
other groups.
In vitro contraction tests: Caffeine in concentrations up to 50 mM did not result in reproducible
significant tension increase or decrease, neither did acetylcholine (10-8 to 10-6 M) or a potassium
enriched solution of up to 80 mM. Yet electrical stimulation of 5 Hz (7 V, 2 ms) tends to increase
the force (mean increase 2.1%, ± 1.7%, n=12), a 20 Hz stimulation (7V, 2 ms) tends to decrease it
(by 1.6%, ±1.4%, n=10), and the NO-donator glyceroltrinitrate tends to decrease the force as well
(by 1.2%, ± 1.5%, with 2 mg/ml, n=9). Because of the small number of repetitions for each tested
variable, these in vitro results still require further verification.
CONCLUSION
Contractile cells containing smooth muscle actin are commonly present in the posterior layer of the
thoracolumbar fascia. The density of these cells is higher in younger people and correlates
positively with the amplitude of crimp in collagen fiber arrangement. Assuming the known
potential force of smooth muscle cells or contractile myofibroblasts, the amount of cells could be
sufficient to result in significant fascial contractions such as in compartment syndrome.
Using in vitro testing of fresh porcine lumbar fascia, a transient temporary contraction or release
can be triggered by electrical as well as chemical stimulation. We suggest that these preliminary
results support the possibility that active contraction of intrafascial smooth muscle like cells could
play a contributing role in temporary or chronic changes in force transmission of the thoracolumbar
5th Interdisciplinary World Congress on Low Back & Pelvic Pain
Melbourne, November 2004 www.worldcongresslbp.com
fascia. Further studies including antibodies specific for smooth muscle cells and in vitro tests with
human samples are needed to get a more specific understanding of fascial contraction. If verified
by future research, active fascial contractility could offer new insights for the understanding of low
back stability, compartment syndromes, and myofascial release therapies.
128
13 12
80
44 39
<32 yrs 54-56 yrs >71 yrs
Contractile Cells / mm2 Collagen Crimp (amplitude in 0.1 µm)
Figure 2. Comparison of density of intrafascial contractile cells and amount of collagen crimp
between 3 age groups
REFERENCES
1. Barker P J, Briggs C A, Bogeski G 2004 Tensile transmission across the lumbar fascia in
unembalmed cadavers: effects of tension to various muscular attachements. Spine 29(2): 129-
138
2. Yahia H, Pigeon P, DesRoisiers E A 1993 Viscoelastic properties of the human lumbodorsal
fascia. J Biomech Eng 15: 425-29
3. Schleip R 2003 Fascial plasticity - A new neurobiological explanation – Part 2. Journal of
Bodywork and Movement Therapies 7(2): 104-16
5th Interdisciplinary World Congress on Low Back & Pelvic Pain
Melbourne, November 2004 www.worldcongresslbp.com
4. Murray M M, Spector M 1999 Fibroblast distribution in the anteromedial bundle of the
human anterior cruciate ligament: the presence of alpha-smooth muscle actin-positive cells. J
Orthop Res 17(1): 18-27
5. Wilson C T, Dahners L E 1988 An examination of the mechanism of ligament contracture.
Clinic Orthop 227(2): 286-91
6. Ralphs J R, Waggett A D, Benjamin M 2002 Actin stress fibres and cell-cell adhesion
molecules in tendons. Matrix Biology 21: 67-74
7. Staubesand J, Li Y 1996 Zum Feinbau der Fascia cruris mit besonderer Berücksichtigung
epi- und intrafaszialer Nerven. Manuelle Medizin 34: 196-200
Citation:
Schleip R, Klingler W, Lehmann-Horn F: Active contraction of the thoracolumbar fascia - Indications of a new factor
in low back pain research with implications for manual therapy. In: The proceedings of the Fifth interdisciplinary
world congress on low back and pelvic pain. Melbourne. Editors: Vleeming A, Mooney V, Hodges P. 2004; ISBN 90-
802551-4-9
... Their smooth muscle-like contractile kinetics make myofibroblasts well suited for long lasting isometric contractions, and their contraction plays a major role in wound healing as well as in pathological fascial contractures such as Dupuytren disease, plantar fibromatosis, or frozen shoulder [11]. The presence of myofibroblasts in normal (nonpathological ) fascia has already been demon- strated121314. Unfortunately, no quantitative histological examination has yet been published examining possible differences in myofibroblast density between the epi-, peri-and endomysial fascial layers. ...
... The smooth muscle relaxing substances nifedipine and EDTA as well as the microtubule disrupting substance cytochalasin-D exhibited a relaxing effect . A relaxing response in porcine lumbar fascia to the substance glyceryltrinitrate (a NO donor and smooth muscle relaxant) has been reported by Schleip et al. [12]. Malata found that mepyramine-induced contractions in rat subcutaneous fascia were enhanced by previous incubation with heparin [25] . ...
... Malata found that mepyramine-induced contractions in rat subcutaneous fascia were enhanced by previous incubation with heparin [25] . Using an immunohistochemical analysis of 39 tissue samples from the thoracolumbar fascia of 11 human donors (ages 19–76 years), Schleip et al. [12] demonstrated the widespread presence of myofibroblasts in all samples, with an average density of 79 cells/mm 2 in his longitudinal sections. Taken together, these findings confirm that fascial tissues can actively contract, and that their contractility appears to be driven by myofibroblasts . ...
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The article introduces the hypothesis that intramuscular connective tissue, in particular the fascial layer known as the perimysium, may be capable of active contraction and consequently influence passive muscle stiffness, especially in tonic muscles. Passive muscle stiffness is also referred to as passive elasticity, passive muscular compliance, passive extensibility, resting tension, or passive muscle tone. Evidence for the hypothesis is based on five indications: (1) tonic muscles contain more perimysium and are therefore stiffer than phasic muscles; (2) the specific collagen arrangement of the perimysium is designed to fit a load-bearing function; (3) morphological considerations as well as histological observations in our laboratory suggest that the perimysium is characterized by a high density of myofibroblasts, a class of fibroblasts with smooth muscle-like contractile kinetics; (4) in vitro contraction tests with fascia have demonstrated that fascia, due to the presence of myofibroblasts, is able to actively contract, and that the resulting contraction forces may be strong enough to influence musculoskeletal dynamics; (5) the pronounced increase of the perimysium in muscle immobilization and in the surgical treatment of distraction osteogenesis indicates that perimysial stiffness adapts to mechanical stimulation and hence influences passive muscle stiffness. In conclusion, the perimysium seems capable of response to mechanostimulation with a myofibroblast facilitated active tissue contraction, thereby adapting passive muscle stiffness to increased tensional demands, especially in tonic musculature. If verified, this new concept may lead to novel pharmaceutical or mechanical approaches to complement existing treatments of pathologies which are accompanied by an increase or decrease of passive muscle stiffness (e.g., muscle fibroses such as torticollis, peri-partum pelvic pain due to pelvic instability, and many others). Methods for testing this new concept are suggested, including histological examinations and specific in vitro contraction tests.
... Their smooth muscle-like contractile kinetics make myofibroblasts well suited for long lasting isometric contractions, and their contraction plays a major role in wound healing as well as in pathological fascial contractures such as Dupuytren disease, plantar fibromatosis, or frozen shoulder [11]. The presence of myofibroblasts in normal (nonpathological ) fascia has already been demon- strated121314. Unfortunately, no quantitative histological examination has yet been published examining possible differences in myofibroblast density between the epi-, peri-and endomysial fascial layers. ...
... The smooth muscle relaxing substances nifedipine and EDTA as well as the microtubule disrupting substance cytochalasin-D exhibited a relaxing effect . A relaxing response in porcine lumbar fascia to the substance glyceryltrinitrate (a NO donor and smooth muscle relaxant) has been reported by Schleip et al. [12]. Malata found that mepyramine-induced contractions in rat subcutaneous fascia were enhanced by previous incubation with heparin [25] . ...
... Malata found that mepyramine-induced contractions in rat subcutaneous fascia were enhanced by previous incubation with heparin [25] . Using an immunohistochemical analysis of 39 tissue samples from the thoracolumbar fascia of 11 human donors (ages 19–76 years), Schleip et al. [12] demonstrated the widespread presence of myofibroblasts in all samples, with an average density of 79 cells/mm 2 in his longitudinal sections. Taken together, these findings confirm that fascial tissues can actively contract, and that their contractility appears to be driven by myofibroblasts . ...
... This connective tissue is considered to serve a passive role in biomechanical dynamics, transmitting mechanical tension. However, recent data from animal studies suggest that fascial tissue might have contractile properties [6, 7]. Several neuromuscular diseases are associated with increasing amounts of connective tissue, and an above average coincidence of clinical MH-suspicion and disorders of connective tissue as well as musculoskeletal disorders has been suggested [8, 9]. ...
... Contracture curves were displayed and recorded with a computer-based data evaluation program. For further details, see Ording et al. [6]. In the quantitative analysis of histological data, a Mann–Whitney test (U-test) was used to test significant differences between samples from different individuals . ...
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Malignant hyperthermia is a dreaded complication of general anaesthesia. Predisposed individuals can be identified using the standardised caffeine/halothane in-vitro contracture test on a surgically dissected skeletal muscle specimen. Skeletal muscle is composed of muscle fibres and interwoven fascial components. Several malignant hyperthermia-associated neuromuscular diseases are associated with an altered connective tissue composition. We analysed adjacent fascial components of skeletal muscle histologically and physiologically. We investigated whether the fascial tissue is sensitive to electrical or pharmacological stimulation in a way similar to the in-vitro contracture test for diagnosing malignant hyperthermia. Using immunohistochemical staining, α-smooth muscle actin-positive cells (myofibroblasts) were detected in the epi-, endo- and perimysium of human fascial tissue. Force measurements on isolated fascial strips after pharmacological challenge with mepyramin revealed that myofascial tissue is actively regulated by myofibroblasts, thereby influencing the biomechanical properties of skeletal muscle. Absence of electrical reactivity and insensitivity to caffeine and halothane suggests that, reassuringly, the malignant hyperthermia diagnostic in-vitro contracture test is not influenced by the muscular fascial tissue.
... As the TLF plays a key role in generation, dispersal of forces and stabilization, it is important to consider its role in back pain for evaluation and developing intervention strategies. Above stated reasons have lead research to investigate TLF as a potential pain generating structure in the back [Stevens et al., 2010;Langevin et al., 2011;Schleip, 2004]. One study showed increased thickness and echogenicity of the TLF in patients with chronic low back [Stevens et al., 2010]. ...
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Objective The purpose of the study was to assess the length of TLF and to evaluate the strength of muscles attached to it in subjects with and without nonspecific low back pain (NSLBP). Methods 31 patients with NSLBP and 31 healthy individuals were included in the study. In each subject the TLF length was assessed by quantifying lumbar rotation using Back range of motion (BROM-II) instrument. The endurance of transverses abdominis was assessed using the pressure biofeedback unit while the strength of Latissimus dorsi, internal and external oblique's were assessed using MMT. Outcome measure such as Range of Motion (ROM) was compared across the group using independent sample T-test. While the muscle strength of Latissimus dorsi and oblique's were compared across the group using Man-whitney U- test. Transverse abdominis endurance was tested using chi-square test. Results There was statistically significant difference in the length of TLF of subjects with NSLBP when compared with subjects without NSLBP. When the strength of Latissimus dorsi muscle, transverses abdominis muscle and internal and external oblique's muscle was assessed no significant (p value > 0.05) difference was found in either group. Conclusions There was statistically significant reduction in length of TLF but there was no difference in the strength of Latissimus dorsi, internal and external oblique's or endurance of transverses abdominus attached to the TLF in individuals with NSLBP and without low back pain. This study will help in determining the inclusion of TLF and the associated structures in evaluation and management of subjects with NSLBP.
... They showed that lumbar fascia, plantar fascia, and the fascia lata contain myofibroblast cells that stain for a-smoothmuscle actin. 50 Further in vitro research showed that smooth muscle-like contractions can be both induced and inhibited pharmacologically. 51 Schleip and colleagues recognized that *The terms, myotomes, dermatomes and sclerotomes refer to tissues that develop from particular masses of embryonic mesoderm. ...
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Zum Feinbau der Fascia cruris mit besonderer Berücksichtigung epi-und intrafaszialer Nerven
  • J Staubesand
  • Y Li
Staubesand J, Li Y 1996 Zum Feinbau der Fascia cruris mit besonderer Berücksichtigung epi-und intrafaszialer Nerven. Manuelle Medizin 34: 196-200