I have a pain clinic but patient come to my clinic with discopathy and sciatica or other disease without involvement of fascia then i focouse on their problem not neglect fascia . I think role of fascia is not clear on discopathy or other lumbar disease

regards, reza shakerighadi . Physiatrist .

The role of Thoracolumbar fascia is covering the muscle of posterior back. so almost every research in finite model might be thought that muscle contain the fascial power.

There indeed is research on the thoracolumbar fascia. I refer to the book 'the spinal engine' of serge gracovetsky. The studies of robert schleipp and the recent study of frank willard. Over all i think the role of the fascia is underestimated and therrfore neglected in many studies. This is a problem because the fascia has a signoficant role in support of the spine!!

Thank you very much for your comments. I am familiar with the very nice contributions of Drs Gracovetsky, Farfan and Schliep; I am talking about usual biomechanical models (particularly those using finite elements methods). Despite its significant role, fascia is often missing.

Good idea, it has 2 roles: first as a passive lamina that stretches and relaxes and as a container for muscle compartment, enhancing its power

Dear alberto,

I am afraid you are doing the fascia no justice. It is not just some passive structure that contains the muscles. Actually, from the perspective of evolution fascia is older than muscle or bone. It is the fundamental tissue that forms the basic hull of biologic tissue. Any motion is possible because of the fascial tissue's. We always focus on the spine and try to understand how we control the spine. In fact we should look the other way around. We could consider the human body as a giant cell, mainly formed by fascial tissue. It is the role of the bones {the spine , pelvis and rib cage} to provide room within the fascial sheets for our organs etc. From this viewpoint we should not look at our body as a bunch of bones held together by muscle: we should consider our body as a very balanced and subtle pressure system. Controlled by muscle, but where the fascia plays a major role since it provides the containing system to build up pressure. To give one example: We know that the intra abdominal pressure by itself is not sufficient to support the spine {gracovetsky and others} However, due to this pressure we create tension on the fascial system {abdominal wall and thoracolumbar fascia}. This wall tension gives stability not only to the abdominal region, but to the back region as well. To create this abdominal pressure the pelvic floor and diaphragm are essential to. This can explain why many people with spine or pelvic problems also can have pelvic floor of breathing problems. When the support system of the spine is deregulated the subject tries to find other ways to create stability. One way can be to increase intra abdominal pressure by tensing the pelvic floor and/or diaphragm.

Regrettably this way of thinking i so new that there are {to my knowledge} no finite element models constructed. This is a pity because I think this way of looking at spine controll has great potential to clarify many spine problems

Hi. I'm a Portuguese Physiotherapist specialized in Postural Reeducation by Mézières Method. Actually I'm doing my PhD on Biomedical Engineering, more specifically in Biomechanics of the spine. In my PhD thesis I intend to simulate with Finite Element Model the Spine, its muscles, ligaments, fascias (including the thoracolumbar) and understand its role in the sagittal balance of the spine. It will help to understand, when it is in a wrong lenght (shortened or lenghtened) what it will cause in the adjacent structures (alignment of muscles, ligaments and spine and pathological forces imposed to the intervertebral disc).

While not beeing an expert on finite modelling I have an additional question on this topic: How would the thoracolumbar fascia be included in FM? If constructors of fm do not have any idea of the importance of this structure and its biomechanical role, how could/would they include the structure in their models? In other words fundamental to the FM question is how we consider the function of the fascia! Can anyone give some views on this?

Thoracolumbar fascia plays a pivotal role in the spine mechanics, especially in its stability. There are many studies covering the biomechanics of facia. Some efforts to integrate the facia model to the biomechanics of the spine also are seen in the literature. See the following links for details.

http://www.ncbi.nlm.nih.gov/pubmed/20709320

http://www.barralinstitute.com/articles/docs/3D_recostruction.pdf

http://www.biomedcentral.com/1471-2474/12/203

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213554/

http://www.ncbi.nlm.nih.gov/pubmed/17383659

http://fasciacongress.org/abstracts_2012.php

As discussed by many others below the TL fascia plays a vital clinical role in spine and pelvis stability. To my knowledge, it is the only "low back" structure that has both anterior and posterior muscle group attachments. It serves as a "force transfer link" from the pelvis to the thorax and vice versa. From a functional anatomic perspective, it is an complex structure with integrated functional relationships with many other regional structures. It contains both nociceptive and mechanoreceptive neural structures and so is also involved in complex neuromuscular feedback loops relating to spine and pelvis stability. So I think this complexity makes FE modeling difficult but something that should be considered when discussing spine and pelvis modeling.

I agree with previous comments. The function of the TL fascia is poorly understood.

According to me, the TLF can not be dissociated from attached muscles. First the TLF is able to generate axial tension (via attachments to the vertebral processes) explaining trunk relaxation in flexion. Secondly, as previously underlined, the TLF is linked to the shoulder girdle, the pelvis and the lower limbs (via the fascia lata). Therefore the TLF is able to transfer load between upper and lower parts of the body but also across the midline for example during walking as limb extend and trunk rotate. Moreover, we have found a relationship between transversus abdominis and leg stiffness (soon published in the Journal of strength and conditioning research) underpinning the functional role of the TLF. Thirdly, considering the obliquely oriented fibers, the tension generated is maximal in the transverse plane and likely potentializes the force produced by superficial muscles attached to the TLF (abdominals or latissimus dorsi) and deep muscles enclosed in the TLF (multifidus). The "hydraulic amplifier" effect is supposed to increase the efficiency of paraspinal muscles by up to 30% (Huskins 1990).

The TLF is probably more than a segmental controler of the spine. So modeling is necessary for better understanding of lumbar stability and more generally of human locomotion.

Hi, I agree fascia is not placed into many models, it maybe because it is difficult to model and the hoop stressors from multiple muscles of varying activity adds complexity to their role. One aspect that is also difficult to model is that fascia cross multiple segments/ muscles having local and distance influence on the transfer for forces. Many FEM models act on a smaller volume than many of the fascia connections i.e. Sacrotub lig upto the spine but also anterior into the deep abdominal muscles rectus sheath. regards GTA

Intriguing. We all agree the thoracolumbar fascia is important, but because it is to difficult we leave it out or implement only a limited piece? What does that do for the quality, reliability and predictability of the fm models of the back? This in regard of biological systems where small differences already can give huge changes.

There´is no single element governs spine stability . In practice, there are several aetiologies that should be considered such as intirinsic bone disorders, myogenic, neurogenic, hormonal and othres. Connective tissue disorders, particularly these correlated with ligamentous hyperlaxity and hypermobility disoders do consist of al long list of serious disorders which play essentail role in spine stability. Variants of skeletal disorders and syndromic complexes is a vast area of aetiological importance and these are frequent rather than raret

Dear Ali,

You are right that there are many disorders. The intriguing question is whether these disorders are 'stand alone' or whether disorders are in some way related|. For example, is disc degeneration some weak spot in the human body or does motorcontrol play a role? In this respect the thoracolumbar fascia may be of importance too. For example: the fascia supports the spine but can only do so when tensed. Tension of the fascia can be augmented by abdominal muscle, rector muscle and (submaximal) flexion of the spine. As a consequence use of the fascia requires adequate motorcontrol. According to old studies by floyd and Silver and also by Sihvohnen the EMG of the erector shuts of during flexion. At that moment it is assumed that lumbar support is largely taken over by the passive structures like the thoracolumbar fascia. It is known that back pain patients use other motion patterns possibly leaving the fascia less or ineffective and putting larger strain/pressure on the discs. This could be a factor in disc pathology. (this is a bit short fetched, the mechanism is more complex, but is is only as an example of interaction of disorders)

Dear Jan-Paul,

Happy for your comment, though there is another element that should not ommitted. We observed that senile hyperostosis is not restricted to old age group patients. It is also seen in pediatric patients, particularly those with congenital spine malformations e.g. hemivertberae or bilateral failure of segementation. The problem appears early and we use to label it as early senile hyperostosis resembeling DISH of old age. The process of spine hyperostosis is serious since bony ankylosis, osteoporosis and possibly fractures might ensue. DISH is not uncommon disorder, and possibly the thoraco-lumbar fascia might get involved in this process. As you said, the mechanism is more complex and every patient should be documented individually. Generalizations should be avoided.

Dear Ali,

If we talk about excessive formation of bone like in DISH, do we talk about regular biologic responses in a system that is mechanically abnormally loaded (or has a motorcontrol problem), or do we talk about deregulated systemic responses like in rheumatoid arthritis, where normal loading also leads to abbarant reactions?

Dear Jan-Paul, excessive ectopic bone formation is not restricted to DISH, the variants of sclerosing bone disorders in asymptomatic patients is another issue of concern. Rheumatoid arthritis (-like), is a symptom-complex in a long list of skeletal dysplasias and their asymptomatic long list of variants. We stress on the necessity of proper and targeted clinical documentation of every spine patient.

Dear Colleagues,

Thank you for all your interesting comments. I think that one of the major reason is that the classical biomechanics approach is based on Newtonian mechanics and often study the components of the spine separately as isolated or closed systems. There no holistic approach in the spine biomechanics.

Dear colleagues, this is a very engaging conversation. My personal thought is that the TLF should be included in any biomechanical models of the spine to get the full story. Furthermore, I wish to highlight that this topic is well suited for a forthcoming congress (http://fasciacongress.org) which I had the pleasure of inviting Prof. Yahia as a speaker and encourage others to submit their papers related to the biomechanics of fascia and the TLF.

I, too have found this discussion very stimulating. I will introduce another, completely different take on this problem.

I am reminded of the fact that most back pain tends to be found associated with this region and may actually be due to problems with the TLF. I am referring here to a way to look at it as more than just a biomechanical construct, despite its importance in that place. After all, it can help lower back muscles be more effective in their contraction because of hydrostatic forces. But, the more I think about anatomy beyond its identification/mechanical model aspect, the more I understand many other physiological processes.

I have been practicing mindfulness to help the brain learn how to remove many toxins. The liver only breaks down organic toxins. There are many chemical elements that are really dangerous when let loose within the body and we have no truly adequate method of detox. After all, look at all the problems with getting rid of mercury. At some point after strong chelation therapy of all types and monitoring blood, urine, saliva, etc, we keep discovering it seems to "come back." Many have theorized that it stays hidden somewhere else. [Maybe because they assume that the blood sample will show all, but that is not necessarily the case].

I found that toxins tend to run with the movement of qi (chi) as described by qigong practitioners, up the back and down the front of the body. When I first heard of this thought imagery in 2009, I thought it was interesting and may be helpful in achieving the stress-free state that practitioners wanted with qigong, but I could not imagine how. But after a great deal of "Socratic" thinking (asking myself a lot of questions and searching for suggested answers) I realized there may be something to that "flow." Chi has been very loosely translated as meaning "energy," giving rise to a lot of research on and development of theory/techniqes in "energy" medicine. But few have even made an attempt to explain it, other than pointing to quantum mechanics, which I did not satisfy me at all.

With a lot of practice using mindfulness techniques that allowed me to focus in on sensations, no matter how tiny, I taught my brain to warn me when toxins were moving and where. This eventually led me to realize that chi could be energy as an important part of the path of nutrients getting to the cells (more on that below). As I focused onto parts of the body in a predictable sequence, my own brainstem "learned" to enhance the sensations of pain in areas where the toxins were particularly strong, and thus confirming my suspicion. The sensation can be one of pin-pricks, often only one, which disappears when I have to focus on other things..

As I traveled along the body this way, I discovered that the acupuncture meridians may well be "channels" that transport interstitial fluids around the body, extravascularly. These fluids carry the nutrients dumped into it by capillaries, and thus can supply the "energy" that cells need. Transport of these fluids has not been widely studied, nor thought to be possible other than as a very "local," passive response (see more below) to the exchange of metabolites and nutrients between capillaries and cells. No one has found vessels or nerves along the meridians, but I strongly suspect that they ignored other possible mechanisms.That is another, very long story that I have been working on as a theoretical model.

At any rate, very often with lower back pain, I found pooled toxins, probably within pockets formed by this fusion of layers of c.t. [Anatomists can do tox analyses of this region to see if my theory is confirmed]. The body does have what I call, "local" responses to toxins and metabolic activities of cells in particular areas, in a holistic way. "Local" means that, although there is some neural control, there are some other kinds of control that appear automatically, e.g. the inflammatory response chain of events, that tends to be more limited spatially.Another example is wound healing or responses to a mosquito bite.

One mechanism that appears to be such a local response to the presence of toxins or foreign material is something that orthopaedic surgeons have discovered when they implant anything--encapsulation. The body tends to surround the foreign material with epithelium and/or connective tissue. It is probably also occurring as a mechanism to remove toxins from disrupting normal cellular responses as ithey move within the interstitial fluid in these meridians. The presence of heavy metals in bone was discovered with the discovery of x-rays. I suspect they got there because of this "local" response, as well.

Pooling of toxic metals such as aluminum, zinc, tin, platinum, lead, mercury, cadmium, etc.(just about everywhere in the industrial world in air, water and soil), will occur in various places inside the body. This is probably due to their interaction with "biological" ions in the interstitial fluid, causing a slowing down or end to movement of interstitial fluids. [It seems that massage therapists have also discovered the importance of this movement, too].

I follow the tox literature. There is an extremely long list of foods, water and soil samples, air pollution tests that support the extremely high likelihood that all of us have this stuff freely moving inside of us in the interstitial fluids. So far, every toxicologist I have met or read about who has bothered to look at their own bodies has discovered them inside, usually to their own shock.

Everyone who has taken graduate level (and some undergrad) courses in physiology with a laboratory exercise in separating out nerves in an animal's body, learns that they cannot use metal probes to do this. It stands to reason that many of the symptoms people have of pain, itch, tenderness, etc may be due to the presence of these metal particles in ionic form in the interstitial fluids. Exercise gets those fluids moving again, as it is a way to get extravascular calcium and phosphate to the muscles quickly, in addition to blood flow (which is always moving, anyway in comparison).

I have tracked toxins that have pooled in my feet (pain there suddenly) going to the top of my head (tenderness, itching, pain when scratched) within 2.5 min after getting up and moving around on my feet. That is much slower than blood flow, but it matters when you think about how cells have to get their nutrients by diffusion. There has to be a way to set up diffusion gradients. The meridian channels may be that way.

The evidence I have found in the peer-reviewed articles backs up my arguments for this toxic flow very well, even though the authors have not even considered this mechanism as having anything to do with their discoveries.

I am in agreement with Prof. Yahia's note of  Sept. 23  where he states, “one of the major reason is that the classical biomechanics approach is based on Newtonian mechanics and often study the components of the spine separately as isolated or closed systems “, but he then states that “there is no holistic approach in the spine biomechanics”. I would point to my Researchgate webpage, https://www.researchgate.net/profile/Stephen_Levin, where I have several papers that describe just that, in particular, THE TENSEGRITY-TRUSS AS A MODEL FOR SPINE MECHANICS: BIOTENSEGlRITY, Journal of Mechanics in Medicine and Biology 2(3&4):375-378 · January 2002.

Thank you very much Dr Levin for your comment and especially the references to your work on biotensegrity. This is a very interesting approach, but one that is off the beaten path, particularly from classical biomechanics. Moreover, I find it strange that biotensegriity can not convince colleagues in conventional biomechanics! Do you know why ? Did you published your work in any Biomechanics or Bioingenneering Journal ?

@

“Why?” Is a question better answered by you than I. Any departure from an existing paradigm meets strong resistance and for a variety of reasons. My question is, "Why have so many not questioned the existing paradigm when it fraught with so many inconsistencies and paradoxes?" I do have articles in several biomechanics and engineering journals and I have presented at several national and international biomechanics' conferences. I can provide you with a list but that may be better answered in a private communication. I would be happy to discuss this with you further and in depth. Thank you for taking the time to read my articles. smlevin[at]biotensegrity.com.

Dear dr Levin,

Could you comment on the relation between tensegrity and hydrostatic pressure?

I have read some articles on tensegrity, and was very interested in the suble, elegant interaction between pulling and compressive forces within structures. However from my perspective this model still focusses on the interplay between bony structures and ligaments (or muscle), with a lot of empty space in between.

Specific property of biological creatures is that they consist of 3D filled space, surrounded by tissue and not just ropes.

Is there any of this incorporated in the tensegrity model? (I know there are the shadescreen constructions, but that differs from hydrostatic pressure).

I must add to this discussion by emphasizing that biotensegrity theory recognizes that the tension and compressional forces are active at every heterarchical level within the organism. So, although bones, muscles and ligaments are frequently offered as examples, tension 'elements' also include the fascia, extra-cellular matrix, collagen and the attractive forces between atoms at the molecular scale, while compression 'elements' also include the width across a muscle, fascial compartments, cells and proteoglycans etc. The compression elements are then considered as 3D space generators with complex multi-level tensegrity-configured sub-structures that are mechanically interacting to produce what has been labelled as 'hydrostatic', so that it fits in with conventional mechanical protocols, but I suggest that it is a misnomer because they are not fluid-filled bags in the way that a balloon or central heating radiator is.

Dear Graham,

Thank you for your input. Can you explain why you consider 'hydrostatic' a misnomer? Hydrostatic pressure is not static in the sense that it can change. Affecting hydrostatic pressure in fact could be considered an essential consequence of tensegrity principles. However I have not yet seen models describing this.

I concur with Graham.The biotensegrity theory is multi-scalar and heterarchical. There are no empty spaces in the conception, it just appears that way when we present a model the represents an higher order structure. The “empty spaces” are filled with tensegrities at the next scale down - ad infinitum. Hydrostatics applies to fluids and pressures created by fluids. Although the body gels may, at times, behave as fluids they are gels that usually have restricted parameters and do not spill out from their containers as would water from a hose. Many biologic gels are, if anything, oncotic and would pull water into it and make it part of its structure rather than exert pressure out. ( An expanding gel might exert pressure on its surroundings but this is structural, it just takes up more space, not hydrostatic as the inbibed water is no longer "fluid"). As a surgeon, the only tissues or compartments that I found to be pressurized by fluid forces are the arterial system, spinal fluid, intra-ocular, and the bladder. Other tissues retract when cut or entered, even synovial joints are not pressurized as I have entered many of them and, as long as there is not a pathological joint effusion, nothing squirts out. The so-called “muscular hydrostats”, worms and the like, are also mislabeled. As a fisherman, I have cut into hundreds of worms and they do not squirt out fluids, the two halves contract and go their own way.

Dear dr Levin,

Thank you for your reply. I wonder whether there is a problem with 'static' in hydrostatic. Your example of the knee is under narcose. So there is no muscle tension. What i assume is that motoractivity enables 'shrinking' of fluid containers like the abdomen or fascia. This mechanism might increase hydrolic pressure.

And about the worm: it is not a single cell bursted by your knife. There will be compartiments allowing the worm to survive. ....

Dear dr. Van Wingerden,

Thank you for your response to my posting. I am more than happy to continue this discussion but we seem to be straying from the original posting about the thoracolumbar fascia and it fitting onto a single whole systems architectural model. If Dr H'Yahia would like, I can continue here or, If I may, I will contact you directly.

I agree dr levin. It is not anymore about finite elements anymore.....however this could be interesting concering the role of fascia......

Dear all, I very much appreciate your perspectives and assume you will be in Berlin next week at the Fascia Congress. Let us continue this chat in person. I look forward to seeing you.

Kind regards,

Mark