New Perspectives on Back Pain: Does the Thoracolumbar Fascia (TLF) Hold the Key to Healing?
If you’ve ever had an aching low back, you’re keenly familiar with how painful it can be. Though we often point to tight muscles or disc problems as the source of pain, new insights into the fascia are revolutionizing how we think about back pain. This is great news for the 20-30% of us suffering from low back pain at any given time.
Low back pain affects over 80% of people in their lifetime. It is the 5th leading cause of physician visits in the United States, and one of the leading causes of chronic pain and disability. In many cases the origin of back pain remains a mystery.
Research from published in the prestigious scientific journal Pain suggests that there may be another dimension to low back pain that was not previously understood. Specifically, focus is turning to the role of thoraculumbar fascia (TLF), which may play a key role in the experience of chronic back pain.
The fascia, also referred to as connective tissue, has previously been regarded as the inert ‘wrapping’ material of the body. But increasingly, researchers are recognizing its role in a wide range of body functions, in particular structural health and balance.
“Fascia is the biological fabric that holds us together,” says Tom Myers, author of Anatomy Trains, a book that explores the fascia lines of the body. “You are about 70 trillion cells all humming in relative harmony; fascia is the 3-D spider web of fibrous, gluey, and wet proteins that hold them all together in their proper placement.”
Fascia surrounds most structures of the body including nerves, blood vessels, muscle fibers, and muscles, and it forms a complex, interconnected web throughout the body.
Much like a sweater, a “pull” in one section of fascia fiber can radiate to other regions of the body. This has far reaching implications for how we think of low back pain.
The Thoracolumbar Fascia and Low Back Pain
As researchers are discovering more and more about the role fascia has to play in bodily functions, one of the areas of focus is the role of the thoracolumbar fascia in back pain.
The thoracolumbar fascia (TLF) is a specialized form of fascia known as an aponeurosis. An aponeurosis is a broad sheet of dense fibrous connective tissue that covers and forms the endpoints and attachments of several muscles. You can think of it as a flat sheet of tendons merged together.
Low back pain is easier to understand when you consider it in terms of the thoracolumbar fascia. Often pain in the low back feels as though it originates in the muscles of the low back, but many times structures like the hamstrings, piriformis, and gluteus (buttocks) muscles, or joints like the sacroiliac (SI) joint are also involved. Back pain can often radiate from the low back to the upper back and shoulders. These are all structures that are connected by the TLF.
In fact, many of the major muscles of the back, trunk, and legs intersect with the TLF. On the back, it connects the latissimus dorsi, trapezius, rhomboid major, and quadratus lumborum muscles, as well as the spinal erectors and multifidi. For the trunk, it connects the external obliques to the back, and it forms the attachment point for the gluteus maximus and the hamstrings. The dense fibers of fascia also attach to many key bony structures of the spine and back, including the thoracic spinous processes, the sacrum, ribs, and hips (iliac crest).
Given this degree of interconnectedness, it’s not hard to see that imbalances in parts of the muscles attached to the TLF often are communicated as sheer stress to the TLF. This is born out by new research, which finds that the TLF contains numerous nocioreceptors, making it a capable of sending out pain signals to the brain. In Part II of this article we will review a new study that finds that the TLF is even more sensitive to pain than muscles and other connective tissues (tendons and ligaments).
The Thoracolumbar Fascia in Movement
The TLF is central to movements like walking, sitting and standing. When weight is transferred from one leg to another, the mechanical loads of the body are transferred from the low back, pelvis and hips across the TLF to the upper back, arms and shoulders. The force transfers diagonally in an x-axis right through the center of the TLF at the lower back.
This means that the TLF is responsible for managing a considerable amount of weight and force through the low back. This is also occurs when you’re twisting your spine. If you’re climbing up a hill or a flight of stairs, or carrying any weight on your back or shoulders, this force is magnified considerably.
Why haven’t we been thinking of low back pain in terms of the TLF until now? First off, up until recently, fascia has only been viewed as inert wrapping material. In addition, unlike muscles and bones, the TLF is not easily seen with current imaging techniques like ex-rays and MRIs (magnetic resonance imaging). That means that even though doctors can see the TLF in an image, they cannot see it clearly enough to diagnose a problem.
Preventing Low Back Pain
Understanding how your back works can be a good first step in preventing low back pain. Be mindful of how you move, and consider your posture when moving or lifting heavy objects. In addition to mindful movement there are a number of other steps to consider.
Get rid of excess weight – When you consider the biomechanics of movement it becomes clear that the more you weigh, the greater force you place on your low back, spine, hips, and TLF, all of which are implicated in low back pain.
Watch your posture – Be mindful of how you sit, stand and move. The alignment of your back and hips can have a great deal to do with the force that your lower back absorbs, and the strain that is placed on it.
Get up and move – Believe it or not, sitting puts 4 times the amount of mechanical force and stress on your back than standing. Your low back is the recipient of a lot of this stress. Stand up, walk around, and get into a routine of moving.
Strengthen your spine – Whether through gentle yoga or more active exercise and strengthening programs, make sure to pay attention to your spine and your abdominal muscles. Core strengthening exercises found in yoga and Pilates can be ideal.
B Grace Bullock, PhD, E-RYT 500 is a psychologist, research scientist, educator, yoga and mindfulness expert and author of Mindful Relationships: Seven Skills for Success - Integrating the Science of Mind, Body and Brain. Her mission is to reduce stress, increase health and well-being and improve the quality of relationships. She offers classes, workshops, writing and research that combine the wisdom of applied neuroscience, psychophysiology, psychology and contemplative science and practice. Her goal is to empower individuals, groups, leaders and organizations to reduce chronic stress and increase awareness, attention, compassion, mindfulness and effective communication to strengthen relationships, release dysfunctional patterns and unlock new and healthy ways of being. Dr. Bullock is also the Founding Director and Principal Consultant of the International Science & Education Alliance, an organization devoted to exceptional research, program evaluation, assessment design, strategic planning and capacity building to support equity, programmatic diversity and scientific integrity, and promote effective leadership, decision-making and social change. Bullock is a Certified Viniyoga Therapist and Faculty at the Integrated Health Yoga Therapy (IHYT) Training program. She is the former Senior Research Scientist at the Mind & Life Institute and former Editor-in-Chief of the International Journal of Yoga Therapy. For more information see www.bgracebullock.com.
Myers, T.W. (2009). Anatomy Trains: Myofascial Meridians for Manual Movement Therapists, 2nd Edition. Churchill Livingston Elsevier: New York.
Schilder, A., Hoheisel, U., Magerl, W., Benrath, J., Klein, T., & Treede, R. (2014). Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain, 155, 222-231.