Learn the anatomy, kinetic chain, and effective treatment plan to care for posterior lumbar fascia complaints

Treatment of the fascia has long been considered integral in the treatment of soft tissue injuries. In recent years, several anatomical studies, including ones by Barker and Briggs,¹ have been performed to determine fascial attachments throughout the body and have aided clinicians in the treatment of the kinetic chain.

Fascia has several important functions. It serves as a facilitating structure in the movement between adjacent structures reducing pressure and friction. It also transmits tension from the lower extremities to the pelvis, spine, and upper extremities.

Fascia Anatomy
Superficial fascia is subcutaneous and immediately deep to the dermis. It contains the near-terminal branches of subcutaneous nerves and vessels and serves to increase skin mobility and acts as a thermal insulator. It is generally composed of loose areolar tissue, colloidal gel, and fat cells.

Deep fascia is more compact and regular in arrangement. This layer lies immediately on the muscles separating individual muscles and muscle groups and sends septa between the muscle groups. Intermuscular septa serve to compartmentalize muscles of similar function and nerve supply. Deep fascia serves to facilitate movement and provide mobility and stability of the musculoskeletal system.

The neurosensory input of fascia is extensive. The stretch receptors of muscles account for only 25% of the sensory innervation with the other 75% consisting of free endings in the fascia of muscles, between muscles, and in the walls of blood vessels and tendons.²

The posterior lumbar fascia (PLF) is the thickest of the three layers and the only layer that extends into the thoracic region. This layer serves to divide paraspinal musculature from extrinsic musculature of the back. The PLF serves as an attachment site for extrinsic back muscles and covers the paraspinal musculature. It also acts as an attachment site for muscles of the shoulder girdle and abdominal wall.

The PLF consists of two laminae, the superficial and deep. The superficial lamina extends superiorly becoming continuous with the latissimus dorsi at T6, and the rhomboids extend as high as the cervical splenii. The superficial lamina attaches inferiorly to the gluteus medius and maximus and has bony attachments to the sacrum and ilium.

The deep lamina consists of bands that pass laterally from the spinous process of L2–L5. It becomes continuous inferiorly with the sacrotuberal ligament and the biceps femoris. Superiorly, the deep lamina attaches to the serratus posterior inferior. It blends with the transversus abdominis, internal oblique, and surrounds muscles, including the multifidus.^1,3

The PLF has several important functions. The primary function of this layer of fascia is to aid the extension movement while lifting, which is accomplished by assisting in the transfer of loads between the limbs and the trunk. This is done through the posterior layer’s ability to increase lumbar contraction by limiting radial expansion of the associated musculature. By limiting radial expansion, axial stress increases (hydraulic amplification), It has been demonstrated that hydraulic amplification can improve the effectiveness of the lumbar paraspinal musculature by 17%–30%.^1,3

A secondary role is within the kinetic chain. The PLF has the ability to transfer tension and force loads from the lower extremities to the pelvis and lumbar spine into the upper spine and upper extremities because of its anatomical connections, which are critical for treating throwing and overhead athletes. Since there is anatomical evidence showing connections of the PLF throughout the entire spine and the upper and lower extremities, there are anatomical mechanisms for positive neural/meningeal tension tests, such as a slump test.

In summary, the PLF acts as a middleman in the transfer of force between the upper and lower limbs, the left and right sides of the body, and the abdomen and spine.¹

A third role of the PLF involves protection and stabilization of the weaker spinal elements, including the discs. Since it has attachments to several important muscles involved in spinal stabilization, including the transversus abdominis, and deep fibers of the multifidus, the PLF serves as an important link in spinal protection. Both of these muscles demonstrate earlier contraction than the muscles of the limbs in order to control intersegmental motion, thus influence disc pressure.^1,3,4

The PLF itself has the ability to adapt to stresses placed on it via its viscoelastic properties. With selective and successive loading (such as exercise rehabilitation), the PLF will demonstrate thickening. This selective thickening serves to resist flexion moments and potential injury from axial rotational forces, which the annulus of the disc is least adapted to tolerate.^1,2

Dysfunction of PLF can lead to myriad injuries, including repetitive wearing of the discs and other spinal elements. The myofascial system is placed under great stress with adhesion or stiffening of the PLF. Under repetitive microtrauma or stress, fascial thickening can occur. In chronic cases of these insults, a lumbar compartment syndrome can develop. This leads to a lower excitability threshold of the muscles and decreased flexibility and may lead to impaired circulation resulting in ischemia and degeneration.¹

Kinetic Chain Reaction
In this article, the kinetic chain will be considered as the focal point of discussion. With fascial restriction, muscles lose their ability to elongate within their fascial sheaths. This is often thought of simply as a stretching manner. If stretch is limited from fascial restriction, the ability for the muscle to contract will also be affected. Therefore, 3-D elongation of the muscle group will be affected.⁵

If the central point of the kinetic chain is disrupted, force transference will not occur correctly. This can lead to repetitive stress to all the components of the kinetic chain by altering normal biomechanics. Continuous strain from altered biomechanics will eventually lead to repetitive strain injuries within the kinetic chain. Thus, it is PLF restriction that can eventually lead to lower and upper extremity and spinal injuries.¹

When assessing and treating the lumbar spine, several methods can be used to determine the presence of a restriction. Palpation is a method to determine tissue texture and assist in the localization of restriction.

However, a shortcoming of our hands is due to compression of our fat pads on deep palpation. It becomes impossible to truly feel interfiber relationships. As our fat pads flatten, the ability to separate tissue fibers, and therefore tissue adhesions decreases. Importantly, our fingers do not necessarily tell us the direction of restriction. Direction is of vital importance with PLF because of the complex lattice work of fibers overlapping one another at several different angles.²

Instrument assisted assessment. This type of soft tissue mobilization assessment is preferred when localizing and treating fascial restriction. The stainless steel instruments enhance the ability to detect fascial restriction and accurately determines the direction of adhesions. An unscientific description of the sensation is that it feels like the instrument is moving across gravel, fine sand, or ridges. The weight of steel promotes deeper penetration of the instrument without the application of additional force. The clinician can focus on the finesse, skill, and sensitivity of the palpation exam and treatment application instead of applying adequate pressure to reach deeper structures.²

Passive motion assessment. This second method of assessment of the lumbar spine is accomplished with the patient in a seated position. While controlling the shoulders with your arms, bring the patient in flexion, lateral flexion, rotation, and extension. At the end range of each motion, produce a slight overpressure. You should be able to ascertain directions of restriction. Once simple, unidirectional motions have been assessed, use coupled motions to further localize directions of restriction. When areas of restriction have been determined, the patient is held in the specific direction (or couple motion) and is treated in the direction of adhesions. After a few treatment passes, the motion pattern is repeated to assess progress or a possible new area of restriction.

Functional assessment. This may be the most important of all examination procedures. Often, patients say that a particular action or movement produces symptoms or is limited due to injury.

When treating patients with specific functional activity restrictions, it is critical to have them perform their limited functional activity to better isolate symptoms and demonstrate progress, preferably three to four times during the course of a single treatment to assist in the localization of symptoms.

Finally, we can use certain rehabilitation protocols that use the kinetic chain in the treatment of PLF restriction. Use alternating arm and leg extensions (often referred to as swimmers or prone crossed extension) to assist in treatment on fascial restriction (Figure 1).

Figure 1: Incorporate muscular contraction and relaxation to assist in treatment of fascial adhesions, such as the swimmers or prone crossed extension.

True tissue healing does not occur from breaking down adhesions and scar tissue alone. Soft tissue treatments will cause a proliferation of fibroblasts, but stretching and exercise promote remodeling. Stretching exercises encourage proper realignment of newly forming collagen. Endurance strengthening exercises (high repetition; low resistance) are introduced to impart adaptive stress to the structures to increase its strength, promote proper alignment, and tissue remodeling.⁶ If clinicians are performing only a soft tissue technique, two thirds of the equation in true soft tissue healing is missing. CP

Gregory Henry Doerr, DC, CCSP, has been in practice for 6 years at Health One in Ridgefield, NJ. He is a credentialed Active Release technique provider and an instructor for Graston technique. Doerr is currently the president of the NJ Chiropractic Sports Council. He can be contacted via email: gregory.doerr@verizon.net.  

References
1. Barker PJ, Briggs, CA. Attachments of the posterior layer of lumbar fascia. Spine. 1999;24(17):1757–1764.
2. Danto JB. Review of integrated neuromusculoskeletal release and the novel application of a segmental anterior/posterior approach in the thoracic, lumbar, and sacral regions. JAOA. 2003;103(12):583–596.
3. Barker PJ, Briggs CA, Bogeski GB. Tensile transmission across the lumbar fasciae in unembalmed cadavers: effects of tension to various muscular attachments. Spine. 2004;29(2):129–138.
4. Moseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine. 2002;27(2):29–36.
5. Calliet R. Hand Pain and Impairment. 4th ed. Philadelphia: FA Davis Co; 1994:74.
6. Carey-Loghmani MT. Graston Technique Instruction Manual. 2nd ed. Indianapolis: TherapyCare Resources Inc; 2001.