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Immediate effects of myofascial release treatment on lumbar microcirculation: a randomized, placebo-controlled trial

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Abstract

Immediate effects of myofascial release treatment on lumbar microcirculation: a randomized, placebo controlled trial
Immediate effects of myofascial release treatment on lumbar
microcirculation: a randomized, placebo-controlled trial
Andreas Brandl 1,2,3,*; Christoph Egner 3; Rüdiger Reer 1, Tobias Schmidt 4,5, Robert Schleip 3,6
Inflammatory processes in the thoracolumbar
fascia (TLF) lead to thickening, compaction,
and fibrosis and are thought to contribute to
the development of nonspecific low back
pain1. The blood flow (BF) of fascial tissue may play a
critical role in this process, as it may promote hypoxia-
induced inflammation. In osteopathic myofascial release
(MFR) treatment, mechanical shearing motion
(combination of compression and stretching) is applied
with low force and slow speed2. This is thought to result
in a lasting change in the morphology of the fascia and
also its hydration, because fascial tissue response to
balanced, sustained stretching is more likely than to
intermittent, uneven loads3.
The primary objective of the study was to
examine the immediate effects of a set of MFR
techniques and a sham treatment on the BF of
lumbar myofascial tissue. The secondary ob-
jectives were to evaluate the influence of TLF mor-
phology (TLFM), physical activity (PA), and body mass
index (BMI) on these parameters and their correlations
with each other.
Introduction
1University of Hamburg, 2Vienna School of Osteopathy, 3DIPLOMA Hochschule, 4Osteopathieschule Deutschland, 5Medical School Hamburg, 6Technical University of Munich; * correspondence: andreas.brandl@wso.at
Keywords Microcirculation; thoracolumbar fascia; fascia morphology; physical activity; myofascial release; osteopathy
Methodology
Objectives
Ethics Committee: DIPLOMA Hochschule (Nr. 1014/2021,27.10.2021).
Registration: German Clinical Trials Register (DRKS00028780)
This study was a single-blind, randomized,
placebo-controlled trial. Thirty pain-free subjects
(40.5 ±14.1 years) were randomly assigned to two
groups treated with a single set of MFR
techniques or a placebo intervention. Correlations between
PA, BMI, and TLFM were calculated at baseline. The effects
of MFR and TLFM on BF (measured with white light and laser
Doppler spectroscopy) were determined. A detailed descript-
tion of the MFR techniques can be found in Figure 1.
Results
Mense5described mechanosensitive varicosities (axonal wide-
nings storing neuropeptides and neurotrophins) in free nerve
endings of TLF innervating their arterioles. Mechanical stimuli
release these contents, leading to vasodilation of adjacent
arterioles and an increase in BF. The TLF is rhombically pervaded by this
dense nerve network.
Discussion/Conclusion
Original title available at DOI: 10.3390/jcm12041248
Figure 1. Myofascial release and placebo treatment at the
TLF. A. Sustained manual pressure to the lateral raphe. B.
Lateral stretching of the TLF. C. Longitudinal glide along the
lumbar paravertebral muscles. D. Longitudinal stretch of
the TLF. E. Unilateral longitudinal stretch of the TLF. Blue
arrows show the direction of tissue stretching in the
myofascial release treatment. In the placebo treatment, the
hands were instead left in place with minimal pressure.
Ultrasound images of the TLF were taken and the TLFM was divided into 4 groups
according to De Coninck et al.4: group 1: very disorganized, group 2: somewhat
disorganized, group 3: somewhat organized, group 4: very organized.
The MFR group had a significant increase in BF after treatment
(31.6%) and at 40-minute follow-up (48.7%) compared with the
placebo group (p < 0.001).
BF was significantly different and up to 2.5 fold higher in organized
than in disorganized TLFM (p < 0.001).
There was a strong positive correlation between PA and TFLM
(r = 0.648; p < 0.001), and a strong negative correlation between, BMI
and TLFM (r = 0.798; p < 0.001).
The differences between MFR and placebo groups are shown in Figure 2.
The differences between TLFM groups are shown in excerpts in Table 1.
Figure 2. Relative changes in percent compared to baseline
measurement. For better readability, the error bars are only
shown on one side and represent the standard deviation. t0,
baseline measurement; t1, measurement after treatment; t2,
measurement 40 minutes after treatment; SO2, oxygen
saturation; rHb, relative hemoglobin. Group differences,
significant at the level * < 0.05,** < 0.01,**** < 0.001.
TLF groups Mean (AU; 95% CI) p (adj.)
1 (n=5) 3 (n=9) 31.0 (4.7 57.3) 0.0167
1 (n=5) 4 (n=9) 75.2 (48.9 102) < 0.001
2 (n=5) 4 (n=9) 74.3 (50.5 98.1) < 0.001
Table 1. Influence of thoracolumbar fascia morphology on blood flow. AU,
arbitrary units; n, number, adj., Bonferroni adjusted.
Impaired blood flow
could lead to hyp-
oxia-induced inflam-
mation, possibly re-
sulting in pain and
impaired proprioce-
ptive function, there-
by likely contributing
to the development
of nonspecific low
back pain. Fascial re-
strictions of blood
vessels and free ner-
ve endings, which
are likely associated
with TLFM, could be
positively affected
by the osteopathic
intervention in this
study (Figure 3).
Figure 3. Thoracolumbar fascia of a patient with acute lumbar back pain. The red
circles show adhesions 24 hours after lumbago, likely causing the posterior layer to
take on an undulating shape (a). 10 days after myofascial release treatment, the
adhesions disappeared and the pain subsided completely. The fascia was then rated
as 'very organized' (b). *DER, dermis; *SAT, subcutaneous adipose tissue; *TFL,
thoracolumbar fascia; *ES, erector spinae; ROI, region of interest, zones rated.
References: 1. Willard, F.H. et al.The Thoracolumbar Fascia: Anatomy, Function and Clinical Considerations. J. Anat. 2012,221
2. Ajimsha, M.S. et al. Effectiveness of Myofascial Release: Systematic Review of RCT. J. Bodyw. Mov. Ther. 2015,19
3. Schleip, R.; et al. Strain Hardening of Fascia. J. Bodyw. Mov. Ther. 2012,16
4. De Coninck et al. Measuring the Morphological Characteristics of Thoracolumbar Fascia in Ultrasound Images.
BMC Musculoskelet. Disord. 2018, 19,
5. Mense, S. Innervation of the Thoracolumbar Fascia. Eur J Transl Myol 2019, 29
ORI Poster Award 2023
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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.
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Introduction Myofascial release (MFR) is a form of manual therapy that involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function. Anecdotal evidence shows great promise for MFR as a treatment for various conditions. However, research to support the anecdotal evidence is lacking. Objective To critically analyze published randomized controlled trials (RCTs) to determine the effectiveness of MFR as a treatment option for different conditions Data sources Electronic databases: MEDLINE, CINAHL, Academic Search Premier, Cochrane library, and Physiotherapy Evidence Database (PEDro), with key words myofascial release and myofascial release therapy. No date limitations were applied to the searches Study selection Articles were selected based upon the use of the term myofascial release in the abstract or key words. The final selection was made by applying the inclusion and exclusion criteria to the full text. Studies were included if they were English-language, peer-reviewed RCTs on MFR for various conditions and pain Data extraction Data collected were number of participants, condition being treated, treatment used, control group, outcome measures and results. Studies were analyzed using the PEDro scale and the Center for Evidence-Based Medicine's Levels of Evidence scale. Conclusions The literature regarding the effectiveness of MFR was mixed in both quality and results. Although the quality of the RCT studies varied greatly, the result of the studies was encouraging, particularly with the recently published studies. MFR is emerging as a strategy with a solid evidence base and tremendous potential. The studies in this review may help as a respectable base for the future trials.
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In this overview, new and existent material on the organization and composition of the thoracolumbar fascia (TLF) will be evaluated in respect to its anatomy, innervation biomechanics and clinical relevance. The integration of the passive connective tissues of the TLF and active muscular structures surrounding this structure are discussed, and the relevance of their mutual interactions in relation to low back and pelvic pain reviewed. The TLF is a girdling structure consisting of several aponeurotic and fascial layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall. The superficial lamina of the posterior layer of the TLF (PLF) is dominated by the aponeuroses of the latissimus dorsi and the serratus posterior inferior. The deeper lamina of the PLF forms an encapsulating retinacular sheath around the paraspinal muscles. The middle layer of the TLF (MLF) appears to derive from an intermuscular septum that developmentally separates the epaxial from the hypaxial musculature. This septum forms during the fifth and sixth weeks of gestation. The paraspinal retinacular sheath (PRS) is in a key position to act as a 'hydraulic amplifier', assisting the paraspinal muscles in supporting the lumbosacral spine. This sheath forms a lumbar interfascial triangle (LIFT) with the MLF and PLF. Along the lateral border of the PRS, a raphe forms where the sheath meets the aponeurosis of the transversus abdominis. This lateral raphe is a thickened complex of dense connective tissue marked by the presence of the LIFT, and represents the junction of the hypaxial myofascial compartment (the abdominal muscles) with the paraspinal sheath of the epaxial muscles. The lateral raphe is in a position to distribute tension from the surrounding hypaxial and extremity muscles into the layers of the TLF. At the base of the lumbar spine all of the layers of the TLF fuse together into a thick composite that attaches firmly to the posterior superior iliac spine and the sacrotuberous ligament. This thoracolumbar composite (TLC) is in a position to assist in maintaining the integrity of the lower lumbar spine and the sacroiliac joint. The three-dimensional structure of the TLF and its caudally positioned composite will be analyzed in light of recent studies concerning the cellular organization of fascia, as well as its innervation. Finally, the concept of a TLC will be used to reassess biomechanical models of lumbopelvic stability, static posture and movement.
Strain Hardening of Fascia
  • R Schleip
Schleip, R.; et al. Strain Hardening of Fascia. J. Bodyw. Mov. Ther. 2012, 16