a Structural Changes

In 2009, Langevin et al. performed an ultrasound-based comparison of perimuscular connective tissue structural variation in the lumbar region in a group of 60 human subjects with chronic or recurrent low back pain (LBP) compared to a group of 47 subjects without LBP. The study was set with good internal validity but with questionable external validity. The study was neither designed in a randomised format nor with blinding or concealing. The non- interventional format can be a justifiable answer to such arguments but no details of the possible biases were explained in the study. The authors were pointing out that this finding cannot be generalised to the patients who have had low back pain for less than twelve months and recommends future longitudinal studies. Nevertheless, this study concluded that LBP group had around 25% greater perimuscular thickness and echogenicity compared with the no- LBP group. In a similar quality study with one hundred and twenty one human subjects with and without LBP, Langevin et al. (2011) proved that thoracolumbar fascia (TLF) shear strain was almost 20% lower in human subjects with chronic low back pain. The authors were attributing this to the abnormal trunk movement patterns and/or intrinsic connective tissue pathology. There appears to be some sex-related differences in thoracolumbar fascia shear strain that may also play a role in altered connective tissue function. In a porcine model study, Bishop et al. (2016) has performed an ultrasound based evaluation of the combined effects of TLF injury and movement restriction and found that the combination of injury plus movement restriction had additive effects on reducing fascia mobility with a 52% reduction in shear strain compared to 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. Robust quality human subject research in this area may enlighten the role of fascia and fascial release in the low back pain.

In a conference proceeding, Blanquet et al. (2010) concluded that ultrasound evaluation could be used to measure and explain the changes in the TLF post MFR. The study was carried out to find out the effectiveness of fascial release in TLF on ten human subjects with chronic LBP with readings taken before, immediately after and 24 hours after the treatment. Release of the thoracolumbar fascia in patients with chronic LBP has shown an increase in thickness of fascial layers that remained for at least 24 hours. The authors implied that the findings of the study can be used to explain the fascial changes in response to treatments and ultrasound evaluation can be a better tool to reflect these changes. The structure of the conference abstract without details like randomization and blinding along with a low sample size restricts the study’s quality and generalisability. A study by Pohl (2010) has shown that ultrasound measurements applied immediately before and after manual intervention resulted significant differences in collagen fibre density and orientation in the structure of the matrix in the dermis, reflecting palpable differences in tension and regularity. Thirty patients were measured with high frequency ultrasound immediately before and after the first treatment in the area of pain or movement restriction. The result of the study is not foolproof due to the limitations associated with its validity and issues related to sampling. We need to conduct methodologically strong studies to ascertain such findings. All these findings are consistent with the assumption of re-organization and remodelling of collagen fibres, as suggested by Martin, (2009) explained as due to the breakdown of abnormal collagen cross-links and an increase in the matrix hydration which needs to be confirmed experimentally.

Wong et al. (2017) has conducted a cross sectional study with ten healthy participants to evaluate the mechanical deformation of TLF with myofascial release. An ultrasound evaluation was conducted before and after a press-down to maximal voluntary contraction

(MVC) in the prone position with three one minute procedure resembling to indirect Myofascial release techniques (IDTMFR). The study found that after MFR, the stiffness of the TLF decreased in healthy men. This was the first study to quantify fascial properties and deformation of the TLF and the effects of MFR on the TLF. The authors mentioned that they have conducted a pilot study with five participants in order to explore the reliability of each parameters and claims moderate to good reliability. A number of limitations were mentioned in the study including inability in the exclusion of isometric contraction and the measures taken for it, lack of control group, ultrasound image variability due to individual differences questioning test retest reliability and low sample size affecting generalisability. It cannot be possible to say that the TLF of healthy persons and one with chronic LBP behaves in a same way. It is doubtful whether one minute of IDTMFR is an ideal dosage to find a result as the minimum dosage used in this method is about three minutes. The data and limitations from this study can be used to design future methodologically robust randomised controlled studies on MFR. Future studies can analyse the effect of various forms of MFR with varying duration and frequency to ascertain and clarify these findings.