Physiotherapy with 7 basic lower back stretching for flexibility and release pain

Ref: https://www.dnaindia.com/cricket/

             Low back pain or lumbar region pain is one one the most cause of daily function limitations. There are risk factors including weakness, stiffness, trauma, degenerative, overuse, or poor posture.

        Biomechanically, the joint flexibility is also determined by the resistance

caused by the tissues surrounding them and can be reduced due to adaptive

shortening of the soft tissues. This shortening can be caused by immobilization,

sedentary lifestyle, and the aging process of collagen, which leads to less

elasticity of the fasciae near the spine.

        Changes in the connective tissue involving tendons, ligaments, and muscle

fasciae caused by factors that directly influence the range of motion (ROM) of a

joint (aging, work, immobilization, injuries, metabolism disorders, or nutritional

deficiencies) can predispose an individual to low back pain (LBP). In addition, low

levels of flexibility of passive muscle structures (tendons, ligaments, and fasciae)

may be associated with LBP. In conditions of LBP, the muscles become spasmodic

even at rest and the accumulation of metabolites can cause irritation in the nerve

endings of the area, generating reflex spasm and increased pain. 

Ref:https://cck-law.com/

        The treatment for chronic LBP may involve physical exercises, medication,

injections, physical therapy treatment, and, as a last resort, surgical intervention.

Regarding the use of physical exercises, despite the lack of clinical trials, there is

theoretical support that suggests stretching exercises are an effective alternative

for the treatment of chronic LBP.

        Despite the multifactorial etiology, physical therapies that result in analgesic

effects, such as stretching exercises, could be viable alternatives as

non-pharmacological therapies for reducing pain intensity in individuals with LBP

through biomechanical and neurophysiological mechanisms, besides improving

body posture, musculoskeletal disorders, and muscle pain.

Ref: https://www.verywellhealth.com/

        Stretching is possible to reduce low back pain after performing stretching

exercises. Such exercises can be performed with different possible organizations

regarding the stretching techniques used, mainly passive-static, passive-dynamic,

active-dynamic, and proprioceptive neuromuscular facilitation (PNF). 

Tight low back muscles cause an anterior tilt of the pelvis and hold the lower back in a position of lordosis.

        The principle to stretch this muscle is the same as the others: stretch to the

point where “tightness with pain” or “noticeable tension without pain” will hold at

the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Ref: https://www.freepik.com/

The 7 basic options to stretch lower back muscle

Exercise #1: Supine double knees to chest

Exercise #2: Supine single knee to chest

Exercise #3: Longed sitting bending: Sit against the wall then bend torso forward with keep sacrum

at the wall.

Exercise #4: Cat pose: hump lumbar spine. Do not hump thoracic spine.

Exercise #5: Child pose

Exercise #6: Prone on ball: Ball is under lumbar and hip level.

Exercise #7: Seat pelvic posterior tilt: Do lumbar spine, not thoracic spine.

              Anatomy of back muscles are organized in layers and divided into intrinsic

muscles and extrinsic muscles categories: 

(1) The extrinsic muscles (latissimus dorsi and serratus muscles) cover the

intrinsic muscles and are mostly responsible for limb motion that we do not

discuss in this article. 

Latissimus dorsi & serratus anterior muscles as extrinsic muscles
(Ref: https://www.acropt.com/)

        (2) The intrinsic muscles regulate the tonus and motion of the spine. Intrinsic

muscles are divided in three groups and represent a muscular column with a

cross-sectional area of approximately 10 cm2 to 25 cm2: a deep layer (rotatores,

interspinalis and intertransversarii muscles), a middle layer (multifidus muscle) and

a superficial layer (sacrospinalis muscle formed by the longissimus and iliocostal

muscles). 

        The deep layer muscles are short and small that refer to their location. The

Intertransversarii and interspinalis muscles connect to the transverse and spinous

processes, respectively, of two adjacent vertebrae. They can be considered as

proprioceptive transducers helping in spinal positioning. The Rotatores muscles

connect transverse processes and laminae of two adjacent vertebrae. 

Rotators & interspinalis & intertransversarii muscles
(Ref: https://www.chegg.com/)

        The erector spinae and multifidus muscles are the primary muscle groups

responsible for controlling lumbar motion and forward inclination of the trunk. It is

estimated that the erector spinae and multifidus contribute up to 85–95% of extensor

moment during manual handling tasks, with these muscles playing an important role

in resisting anterior shear forces during lifting and lowering.

        The erector spinae and multifidus muscles are thought to play an important role

in the prevention of back injuries, and these muscles are often targeted during the

rehabilitation of patients with such injuries. For example, during vocational activities

such as lifting, the erector spinae and multifidus muscles are the major contributors

to the extensor moment and serve to resist anterior shear forces acting on the

lumbar spine.

Multifidus muscles
(Ref: https://learnmuscles.com/)

        The multifidus muscles are installed in the middle layer. The multifidus consists

of multiple overlapping layers of fibers that can be clearly divided into five bands.

        Each fascicle arises from a common tendon attached to the spinous process of

individual lumbar vertebrae with fascicles attaching to the mamillary process of the

inferior vertebrae, the iliac crest and the sacrum. Fascicles of multifidus arise from a

common tendon and create a force vector that acts vertical and perpendicular to the

spinous process. This orientation and the segmental innervation of fiber bands not

only allows the multifidus to control lumbar curvature at a segmental level but

provides good mechanical advantage when applying an anti-flexion (extension)

moment.

Muscle activity study of erector spinae (ES) and multifidus (MF)
(Ref: https://www.mdpi.com/2077-0383/10/18/4039/htm)

           The multifidus exerts a relatively small horizontal force vector when compared

to the lower erector spinae and the obliquity of its fascicles varies between segments.

However, the net effect of its fascicle arrangement in upright standing is to produce anterior

shear on the L5–S1 segment. The multifidus has twice the physiological cross-sectional

area of other erector spinae muscles, despite having a similar mass. This relatively large

cross-sectional area, in combination with its short fiber length, enables the multifidus to

produce large forces over a short range of motion. These properties make the multifidus

better suited to intersegmental stabilization, as opposed to generating large amounts of

lumbar motion.

    Erector spinae muscle is a vast musculotendinous mass formed by two muscular

groups: the longissimus muscle, medially, and the iliocostal muscle, laterally. Longissimus

muscle fibers arise from the lumbar and inferior thoracic transverse processes, while

iliocostalis muscle fibers arise from the angles of the lower ribs and from the lateral one

quarter of the lumbar transverse processes. In the lumbar region, both muscle fibers

attach to a robust aponeurosis, the erector spinae aponeurosis, attached to the medial

sacral crest, lumbar spinous processes and ilium. During flexion, the erector spinae muscle

controls rather than produces motion and prevents excessive motion. During lateral bending

and twisting, the erector spinae muscle both controls and produces motion.

Erector spinae muscles group
(Ref: https://yogamedicine.com/)

            The erector spinae muscles consist of the iliocostalis muscle (lateral column

extending from the ilius to the ribs), the longissimus dorsi (intermediate column extending

from the sacrum to transverse processes), and the spinalis, a medial group that courses

along the spinous processes. The multifidi are an extensive group of smaller muscles that

extends along the spinous processes from the sacrum to the axis. 

Longissimus muscles are divided into 3 parts as thoracis & cervicis & capitis
(Ref: https://www.getbodysmart.com/)

                The upper erector spinae consist of the thoracic fibers of longissimus and

iliocostalis lumborum. Its muscle fascicles arise from the thoracic transverse processes

and lower seven ribs and span the entire lumbar spine forming the erector spinae

aponeurosis. The erector spinae aponeurosis has no direct attachment to the lumbar

vertebrae and connects to the posterior pelvis and sacrum. In upright standing, the upper

erector spinae has the greatest moment arm of all the lumbar extensors muscles which

allows it to generate a large extensor moment at a relatively low compressive cost. As the

upper erector spinae fibers run almost parallel to the long axis of the lumbar spine, they

have limited influence on shear forces.

Spinalis muscle consists of capitis & cervicis & thoracic part
(Ref: https://www.kenhub.com/en/)

            The lower erector spinae consist of the lumbar fascicles of longissimus thoracis

and iliocostalis lumborum. The lower erector spinae has two distinct architectural

differences that differentiate it from the upper erector spinae. First, it connects to the

lumbar vertebra and this enables the fascicles to directly exert forces on the vertebrae to

which they attach. Second, the lower erector spinae are more obliquely oriented than the

upper erector spinae and therefore are better suited to generating forces that oppose

anterior shear. Lower erector spinae obliquity is more pronounced at the level of L4 and L5,

and in this region the fascicles of the muscle are capable of generating 40–49% of their total

resultant force in the posterior direction.

The iliocostalis consists of cervicis & thoracic & lumbar part
Ref: https://bodybuilding-wizard.com/

      

              A number of low back intervention programs have been developed to improve the

strength and function of the erector spinae and multifidus muscles. However, a limitation

often associated with these programs is that they assume the erector spinae to be a single

muscle that extends the length of the lumbar spine and ignore the biomechanical role played

by the different divisions of the erector spinae and the multifidus muscle.

Reference: 

https://www.researchgate.net/publication/358014814_Mechanisms_of_muscle_stretching_

exercises_for_reduction_of_low_back_pain_narrative_review 

https://www.researchgate.net/publication/276425136_Lumbar_posture_biomechanics_

and_its_influence_on_the_functional_anatomy_of_the_erector_spinae_and_multifidus 

https://www.researchgate.net/publication/5387495_Disorders_of_paravertebral_lumbar_

muscles_From_pathology_to_cross-sectional_imaging 

https://www.ajronline.org/doi/pdf/10.2214/ajr.138.1.93 

https://www.jospt.org/doi/10.2519/jospt.2019.8827 

https://www.researchgate.net/publication/306146670_Iliocostalis_Thoracis-Lumborum_

Myofascial_Pain_Reviewing_a_Subgroup_of_a_Prospective_Randomized_Blinded_Trial_

A_Challenging_Diagnosis_with_Clinical_Implications

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1256533/ 

Physiotherapy on thoracolumbar fascia release in shoulder and low back pain

 

Parivrtta Baddha Parsvakonasana which can stretch related TL fascia muscles
(Ref: https://doctorlib.info/anatomy/yoga-anatomy/7.htm)

Thoracolumbar fascia (TLF) is a strong aponeurosis of a large, roughly diamond - shaped area of connective tissue constituted by the thoracic and lumbar parts of the deep fascia enclosing the intrinsic back muscles. Moreover, the superficial part separates the paraspinal muscles from the muscles of the posterior abdominal wall and serves as an attachment site for various muscles of the back.  

Many muscles connected to TLF include multifidus, erector spinae, latissimus dorsi, transverse abdominis, gluteus maximus, biceps femoris of hamstring, and trapezius that can be related with shoulder problems and lower back problems.

TL fascia and connected muscles
(Ref: https://www.greatbigcanvas.com/)

Some studies stated TLF release was effective in reducing shoulder pain. The results of this study can be applied in clinical practice for TLF release performed to reduce shoulder pain. According to some studies addressed TLF release can help to improve low back pain as well. The TLF release technique was recommended in the terms of manual fascia release and foam rolling. 

In my opinion, the manual fascia release must be run by practitioners that cannot do home base exercise. Foam rolling and stretching has the potential to do the self TLF release that I would like to present in this article.

Manual TL fascia release 
(Ref: https://www.researchgate.net/publication/
282410517_The_clinical_efficacy_of_thoracolumbar_fascia_release_for_shoulder_pain)

Conclusion of thoracolumbar fascia release (Please stop and see physiotherapist in case of strong worse pain, radiation of numbness or pain to leg, dizziness. Moreover, patients with disc herniation must consult physiotherapist before start this instruction.)

Exercise #1: Foam rolling: roll around pelvic bone including sacrum and iliac crest, and lumbar area.

Exercise #2: Tennis ball massage: roll around pelvic bone including sacrum and iliac crest, and lumbar area.

Exercise #3: Multifidus and Erector spinae stretch: bend torso to opposite side of target muscle.

Exercise #4: Latissimus dorsi stretch: do this exercise on the floor for more stability.

Exercise #5: Gluteus maximus stretch: move the knee to opposite shoulder.

Exercise #6: Hamstring stretch: keep knee and lower back straight.

Exercise #7: Trapezius stretch: this is modified stretching pose that need bend over with following of bend head forward. Patients with disc herniation or dizziness problems must do it carefully and consult physiotherapist before start stretching.

Exercise #8: Torso rotation stretch: move both knee to opposite target muscle. During stretching need keep both knees together with keep ribs and thoracic spine on the floor.

Additionally, to improve TLF imbalance and pain does not need only stretching but also strengthening all muscles which attach to TLF. 

Anatomically, TLF covers lower thoracic spine, lumbar spine, and sacrum level. This configuration creates a previously undescribed fat-filled lumbar interfascial triangle situated along the lateral border of the paraspinal muscles from the 12th rib to the iliac crest. This triangle results in the unification of different fascial sheaths along the lateral border of the TLF, creating a ridged-union of dense connective tissue that has been termed "the lateral raphe". 

The lateral raphe (LIFT)
(Ref: Schuenke MD, et al. A description of the lumbar interfascial triangle and its relation with the lateral raphe: anatomical constituents of load transfer through the lateral margin of the thoracolumbar fascia. J Anat. 2012 Dec;221(6):568-76.)

This complex structure becomes especially notable at the caudal end of the lumbar spine where multiple layers of aponeurotic tissue unite and blend to form a thickened brace between the two posterior superior iliac spines (PSIS) and extending caudalward to reach the ischial tuberosities. Various myofascial structures with differing elastic moduli contribute to the formation of this thoracolumbar composite (TLC).

Dimples are the surface anatomy landmark of posterior superior iliac spine
(Ref: https://www.stalbanstherapyclinic.co.uk/sacroiliac-joint-pain) 

 Numerous descriptions of this structure have presented either a two-layered model or a three-layered model. Both models will be summarized, and a consensus approach will be attempted to present a summary diagram illustrating the two- vs. three-layered model of the TLF.

The two-layered model presents a posterior layer that attaches to the tips of the spinous processes of the lumbar vertebrae as well as the supraspinous ligament, and wraps around the paraspinal muscles reaching a raphe on their lateral border. The posterior layer is typically described as being composed of two sheets, a deep lamina that invests the paraspinal muscles and a superficial lamina that joins the deep lamina in the lower lumbar region. In the cervical region, the deep lamina of the posterior layer continues to cover the paraspinal muscles (all the muscles innervated by the posterior primary ramus) including the splenius capitis, as it blends with surrounding cervical fascias; eventually this paraspinal fascial sheath fuses to the cranial base. 

The two - layered model of TL fascia
(Ref: https://www.physio-pedia.com/Thoracolumbar_Fascia)

The three-layered model has strong similarities with the previously described model containing two layers. It is the most commonly used model in most research studies that is the reason why I wrote in the QL stretching article previously. The posterior layer consists of two laminae: superficial (the aponeurosis of the Latissimus Dorsi); and deep lamina. In between these laminae above the L4 level, the aponeurosis of the Serratus Posterior Inferior is present. The Middle Layer of TLF is the fascial band that passes between the paraspinal muscles and the QL. The anterior layer is defined as passing anterior to the QL and ending by turning posterior to pass between the QL and the psoas. The anterior layer has been described as being an extension of the transversalis fascia. As previously stated, typically authors using the two-layered model refer to the fascia anterior to the QL simply as transversalis fascia and exclude it from the model.

The three - layered model of TL fascia
(Ref: https://ittcs.wordpress.com/tag/thoracolumbar-fascia/)

The TLF envelops the back muscles from the sacral region, through the thoracic region, and is composed of anterior (ALF), middle (MLF), and posterior (PLF) layers. Of these, the PLF consists of superficial and deep laminae. The superficial lamina of the PLF is continuous with the latissimus dorsi (LD), and partially continuous with the gluteus maximus, external abdominal oblique (EO) and trapezius and contribution from the serratus posterior inferior (SPI). The deep lamina of the PLF has contributions from the SPI, lumbosacral attachments to interspinous ligaments, the long dorsal sacroiliac ligament, and the iliac crest and cranial attachments extending into the cervical paraspinal region. Along the lateral border of the PRS, a complex interaction occurs between the attachments of the abdominal muscles. The blending of the aponeurotic sheaths of the transversus abdominis (TA) and internal oblique (IO) muscles along with the lateral margin of the TLF gives rise to a ridged-union of dense connective tissue. This area of fascial fusion exists just lateral to the paraspinal muscles through much of the lumbar region, and was coined the lateral raphe (LR). The LR extends from the iliac crest caudally to the 12th rib cranially. Thus, the raphe is formed at the location where abdominal myofascial structures join the fascial structures surrounding the paraspinal muscles. Since Bogduk and MacIntosh’s original use of the phrase ‘lateral raphe’, several articles. 

TL fascia layer and muscles
(Ref: https://id.pinterest.com/pin/703898616752662141/)

TLF plays a multi role including enveloping posterior and lateral torso muscles, stability of spine and posture, movement of limbs and spine, transmission force between upper and lower limbs.

The lumbosacral spine plays a central role in sustaining the postural stability of the body; however, the lumbar spine alone is not capable of sustaining the normal loads that it carries daily. To stabilize the lumbar vertebrae on the sacral base requires the assistance of a complex myofascial and aponeurotic girdle surrounding the torso. On the posterior body wall, the central point of this girdling structure is the thoracolumbar fascia (TLF), a blending of aponeurotic and fascial planes that forms the retinaculum around the paraspinal muscles of the lower back and sacral region 

Stabilizer function of TL fascia
(Ref: https://www.researchgate.net/publication/
51654116_Reduced_thoracolumbar_fascia_shear_strain_in_human_chronic_low_back_pain/
download)

Movement and stability of the lumbosacral region is contingent on the balance of forces distributed through the myofascial planes associated with the thoracolumbar fascia (TLF). This structure is located at the common intersection of several extremity muscles (e.g. latissimus dorsi and gluteus maximus), as well as hypaxial (e.g. ventral trunk muscles) and epaxial (paraspinal) muscles. The mechanical properties of the fascial constituents establish the parameters guiding the dynamic interaction of muscle groups that stabilize the lumbosacral spine.

Ref: https://onlinelibrary.wiley.com/doi/10.1111/j.1469-7580.2012.01511.x

There is bilateral force transmission from gluteus maximus to the latissimus dorsi and lower trapezius muscles. These muscles are connected by the fascial network of the back. The gluteus maximus and latissimus dorsi share the origin from the aponeurotic posterior layer of the thoracolumbar fascia (PTLF). In conditions like idiopathic back pain, radiating pain, etc., instead of focusing on single structures like a muscle or a fascia, more holistic approaches seem appropriate. In pathological conditions, the connection through PTLF may contribute to altered biomechanics of the back of the trunk. 

Force transmission tarjectory to opposite side obliquely (Ref: https://openhealthclinic.com/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference: 

https://www.uni-ulm.de/fileadmin/website_uni_ulm/med.herti/Forschungsprojekte/Publikationen/2012_Thoracolumbal_Fascia_Anatomy_J_Anat.pdf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512280/ 

https://kmbase.medric.or.kr/Fulltext/10120/2015-4-1/55-59.pdf

https://www.mskscienceandpractice.com/article/S1356-689X(16)30756-1/pdf

http://www.mltj.online/role-of-posterior-layer-of-thoracolumbar-fascia-in-epimuscular-myofascial-force-transmission-from-gluteus-maximus-to-latissimus-dorsi-and-lower-trapezius/ 

https://www.researchgate.net/publication/284278045_Do_exercises_with_the_foam_roll_short_impact_on_the_thoracolumbar_fascia_A_randomized_controlled_trial

https://www.kenhub.com/en/library/anatomy/thoracolumbar-fascia