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Reduced thoracolumbar fascia shear strain in human chronic low back pain

Article in BMC Musculoskeletal Disorders · September 2011

DOI: 10.1186/1471-2474-12-203 · Source: PubMed

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RESEARCH ARTICLE Open Access

Reduced thoracolumbar fascia shear strain in

human chronic low back pain
Helene M Langevin1,2*, James R Fox1, Cathryn Koptiuch1, Gary J Badger3, Ann C Greenan- Naumann4,
Nicole A Bouffard1, Elisa E Konofagou5, Wei-Ning Lee5, John J Triano6 and Sharon M Henry7

Abstract
Background: The role played by the thoracolumbar fascia in chronic low back pain (LBP) is poorly understood.
The thoracolumbar fascia is composed of dense connective tissue layers separated by layers of loose connective
tissue that normally allow the dense layers to glide past one another during trunk motion. The goal of this study
was to quantify shear plane motion within the thoracolumbar fascia using ultrasound elasticity imaging in human
subjects with and without chronic low back pain (LBP).
Methods: We tested 121 human subjects, 50 without LBP and 71 with LBP of greater than 12 months duration. In
each subject, an ultrasound cine-recording was acquired on the right and left sides of the back during passive
trunk flexion using a motorized articulated table with the hinge point of the table at L4-5 and the ultrasound
probe located longitudinally 2 cm lateral to the midline at the level of the L2-3 interspace. Tissue displacement
within the thoracolumbar fascia was calculated using cross correlation techniques and shear strain was derived
from this displacement data. Additional measures included standard range of motion and physical performance
evaluations as well as ultrasound measurement of perimuscular connective tissue thickness and echogenicity.
Results: Thoracolumbar fascia shear strain was reduced in the LBP group compared with the No-LBP group (56.4%
± 3.1% vs. 70.2% ± 3.6% respectively, p < .01). There was no evidence that this difference was sex-specific (group
by sex interaction p = .09), although overall, males had significantly lower shear strain than females (p = .02).
Significant correlations were found in male subjects between thoracolumbar fascia shear strain and the following
variables: perimuscular connective tissue thickness (r = -0.45, p <.001), echogenicity (r = -0.28, p < .05), trunk flexion
range of motion (r = 0.36, p < .01), trunk extension range of motion (r = 0.41, p < .01), repeated forward bend task
duration (r = -0.54, p < .0001) and repeated sit-to-stand task duration (r = -0.45, p < .001).
Conclusion: Thoracolumbar fascia shear strain was ~20% lower in human subjects with chronic low back pain. This
reduction of shear plane motion may be due to 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.

Background adjacent connective tissue layers is particularly relevant

The thoracolumbar fascia plays an important role in in structures such as the thoracolumbar fascia in which
transferring forces among trunk muscles and the spine the dense layers correspond to the aponeuroses of mus-
[1]. An important feature of this complex fascial struc- cles with different directions of pull: in this case, longi-
ture is that it is composed of several layers of dense tudinal (for latissimus dorsi, serratus posterior and
connective tissue separated by layers of “loose” areolar erector spinae) vs. transverse (for internal/external obli-
connective tissue that allow adjacent dense layers to ques and latissimus dorsi).
glide past one another [2]. Independent motion of Although the thoracolumbar fascia has been the sub-
ject of recent attention as a potential pain-generating
structure in the back [3-6], its role in low back pain
* Correspondence: [email protected]
1
Department of Neurology, University of Vermont, Burlington VT, USA
(LBP) pathophysiology is poorly understood. In a pre-
Full list of author information is available at the end of the article vious study using ultrasound, we found that human
© 2011 Langevin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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subjects with chronic LBP of more than 12 months Scale). Additional exclusion criteria based on a sub-
duration had increased thickness and echogenicity of ject’s self report for both groups were: previous severe
the perimuscular connective tissues forming the thora- back or low extremity injury or surgery; major struc-
columbar fascia in the low back [6]. Abnormal connec- tural spinal deformity (scoliosis, kyphosis, stenosis) or
tive tissue structure may be a predisposing factor for spine surgery; ankylosing spondylitis or rheumatoid
LBP, or a consequence of injury and/or changes in arthritis; spinal fracture, tumor or infection; clinical
movement patterns occurring as a result of chronic neurological deficit suggesting nerve root compression;
pain. A potentially important consequence of injury may neurological or major psychiatric disorder; bleeding
be fibrosis and adhesions, causing loss of independent disorders; corticosteroid medication or corticosteroid
motion of adjacent connective tissue layers which could injection at L2-3 level of the back; pregnancy; worker’s
further restrict body movements. Therefore, quantifica- compensation or disability case; litigation for LBP;
tion of tissue mobility within the thoracolumbar fascia acute systemic infection. Subjects in the LBP group
would be an important next step to investigate connec- completed the McGill Pain questionnaire [9], the
tive tissue pathophysiological alterations that may play a Oswestry Disability Scale questionnaire [10], as well as
role in LBP. a custom-designed questionnaire about the onset, his-
Ultrasound elasticity imaging is a computational tech- tory and duration of their LBP. In addition, both
nique utilizing cross correlation methods to quantify tis- groups completed the Baecke physical activity level
sue motion based on a series of ultrasound images questionnaire [11]. The Tampa Scale for Kinesiophobia
acquired in rapid succession. In this study, we used a was used to determine LBP subjects’ level of fear
novel application of ultrasound elastography in which toward movement in the presence of recurrent or
the relative mobility of layers within the thoracolumbar chronic pain, with higher scores indicating heightened
fascia was quantified in humans during passive trunk fear [12]. The Medical Outcomes Survey (MOS) was
flexion induced by a motorized articulated table. Based used as a general health, physical and mental quality of
on our previous findings of abnormal connective tissue life measure for all subjects, with higher scores corre-
structure in chronic LBP [6], we hypothesized that this lating with better health [13]. Subjects with No-LBP
relative motion would be reduced on average in a group were frequency-matched to subjects with LBP for age,
of human subjects with chronic LBP of greater than 12 sex and body mass index (BMI) in order for the two
months duration compared with control subjects with- groups to be balanced for these characteristics.
out low back pain (No-LBP). In addition, we compared Testing protocol
thoracolumbar connective tissue motion to clinical tests We tested 121 subjects, 71 with LBP and 50 with No-
commonly used during physical therapy to evaluate LBP. Each subject underwent a single testing session
trunk range of motion and physical performance in LBP during which he/she was placed prone-lying on a
assessment. motorized articulated table (Figure 1A). Use of a motor-
ized table to passively move the trunk has the advantage
Methods of creating a reproducible rate and amplitude of input
Subjects and testing protocol motion which is difficult to achieve with active trunk
Human subject recruitment and selection criteria flexion. In addition, the prone position of the subject
The study was approved by the University of Vermont facilitated stabilization of the ultrasound probe on the
Institutional Review Board (CHRMS 07-025) and in skin. The subject was positioned such that the hinge
compliance with the Helsinki Declaration. All subjects point of the table was at the L4-5 interspace and the
provided informed consent. Subjects were recruited by ultrasound transducer head was placed longitudinally 2
advertisements at the University of Vermont and asso- cm lateral to the midline at the level of the L2-3 inter-
ciated facilities. The inclusion criterion for the LBP space (Figure 1B). The rostral end of the transducer was
group was a history of recurrent or chronic LBP for at fixed to the subject’s skin using surgical tape, and the
least 12 months as defined by Von Korff [7,8]. Recur- transducer was lightly stabilized by hand taking great
rent LBP was defined as low back pain present on less care not to compress the tissues at any time during
than half the days in a 12-month period, occurring in table motion. Lack of attachment at the caudal end
multiple episodes over a year. Chronic LBP was allowed the skin to slide caudally during trunk flexion,
defined as back pain present on at least half the days while fixation at the rostral end prevented overall lateral
in a 12-month period. Inclusion criteria for No-LBP and rostral translation of the ultrasound probe, which
subjects were the absence of a history of low back pain was verified during post processing. We used an ultra-
or any other chronic pain that had limited activities of sound image field depth of 4 cm and a single ultrasound
daily living or work and a numerical current pain beam focal zone that was focused on the thoracolumbar
index of less than 0.5 (on an 10 point Visual Analogue fascia. This procedure was performed separately on the
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Figure 1 Ultrasound image acquisition method. A: Motorized articulated table capable of moving in the sagittal plane 15° at a rate of 0.5 Hz.
The subject is positioned prone on the table with the hinge point at the L4-5 level. B: Location of ultrasound transducer (posterior view).

right and left sides of the back, with the order of testing the displacement within the ROI for each pair of ultra-
randomized. sound frames. Corresponding cumulative lateral displace-
The motorized table underwent five cycles (0.5 Hz) of ment maps were obtained by summing tissue
flexion with a range of 15° excursion for each cycle. displacements over time. Cumulative lateral shear strain
During this table motion, we collected an ultrasound maps were further generated by outputting the off-diago-
cine-loop (25 Hz) over a 10 second period using a Tera- nal component in the Lagrangian finite strain tensor,
son 3000 ultrasound machine equipped with a 10 MHz which is obtained based on the displacement gradient [16].
(12L5) linear array transducer. The ultrasound sampling Quantification of thoracolumbar shear strain at
rate was 25 MHz. The investigators performing the test- standardized location
ing and ultrasound data analyses were blind to the sub- To calculate the magnitude of shear deformation at a
jects condition (LBP vs. No-LBP). standardized location in human subjects with and

Ultrasound measures
Ultrasound data post processing and thoracolumbar fascia
tissue displacement calculation
Ultrasound data from right and left sides were processed
with a custom program written in Matlab (Natick, MA).
Tissue displacements between successive ultrasound
frames were estimated from the “raw” ultrasonic radio
frequency (RF) data using cross-correlation techniques
[14,15] with a 1 mm window incremented with a 90%
overlap. The term “ultrasound frame” refers to the RF
data acquired at each time point in the cine-loop. The
terms “axial” and “lateral” indicate directions of tissue
motion that are, respectively, along and perpendicular to
the propagation of the ultrasound beam in the plane of
the ultrasound image (Figure 2). The term “displace-
ment” refers to the axial or lateral motion of the tissue
between two successively acquired ultrasound frames (i.
e. after 40 ms have elapsed). Tissue lateral displacement Figure 2 Ultrasound elasticity imaging method. White box
was computed for each successive pair of ultrasound indicates the region of interest (ROI) within the ultrasound image
frames in a 1 × 1.5 cm region of interest (ROI) centered that was processed using cross correlation analyses. Arrows indicate
laterally on the midpoint of the image and axially on the reference axes within the ultrasound image: axial and lateral axes
thoracolumbar fascia (Figure 2). indicate directions parallel and perpendicular to the ultrasound
beam respectively, in the plane of the ultrasound image. Elevational
Thoracolumbar displacement and shear strain mapping
axis indicates direction perpendicular to the ultrasound image
In order to visually document the presence of a shear plane. Axial, lateral and elevational directions in the ultrasound
plane within the thoracolumbar fascia, we generated suc- image correspond to antero-posterior, rostro-caudal and medio-
cessive displacement maps as a spatial representation of lateral anatomical directions respectively.
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Figure 3 Ultrasound imaging of thoracolumbar fascia. A: Illustration of layers composing the thoracolumbar fascia corresponding to
aponeuroses of back and abdominal wall muscles. Arrows indicate directions of pull for individual muscles. B-C: ultrasound image of
thoracolumbar fascia in longitudinal (B) and transverse (C) planes showing echogenic (dense connective tissue) and echolucent (loose
connective tissue) layers within the thoracolumbar fascia. A distinct echolucent plane (red line) is visible within the thoracolumbar fascia in the
longitudinal image corresponding to the loose connective tissue layer located between the aponeurosis of the erector spinae muscles and the
combined aponeuroses of the abdominal wall muscles, serratus posterior and latissimus dorsi.

without LBP, we used as a reference the echolucent (based on three separate measurements of six randomly
plane separating the echogenic sheet closest to the erec- selected images) was 0.98.
tor spinae muscle (seen in longitudinal images as Band The cumulative lateral strain between superficial and
1 in Figure 3B) from the more complex echogenic struc- deep sub-ROIs was calculated throughout one flexion
ture immediately superficial to it (Band 2 in Figure 3B). cycle (shaded area in Figure 4B). P1 and P2 in Figure 4B
With B-scan ultrasound, Band 1 is consistently visible represent the mean tissue displacement in the deep and
as a thin echogenic line that moves with the underlying superficial Sub-ROIs respectively at each time point.
muscle and can thus be identified as the aponeurosis of Shear strain between the sub-ROIs was calculated as the
the erector spinae muscle. In contrast, Band 2 is more absolute difference in lateral motion between the super-
variable in thickness, and sometimes contains one or ficial and deep sub-ROIs (|P2-P1| in Figure 4C) divided
more echogenic sub-bands which may correspond to by the distance (2 mm) between the centers of the two
the different aponeuroses that merge together to form sub-ROIs (D in Figure 4C) and expressed as a percen-
the remainder of the thoracolumbar fascia (although tage. We used the absolute difference in lateral motion
this cannot be directly confirmed based solely on ultra- in order to quantify the total amount of shear strain
sound). To calculate the magnitude of shear deforma- deformation (both positive and negative) that occurs
tion at a standardized location in human subjects with within the thoracolumbar fascia in response to passive
and without LBP, we used as a reference the echolucent trunk flexion. This shear strain calculation was repeated
line separating Band 1 and Band 2 to define sub-regions after shifting both sub-ROIs 0.5 mm superficially, then
of interest (sub-ROIs) each 2 mm × 10 mm (Figure 4A). 0.5 mm deep to the original position. The maximum
The same blinded investigator identified the echogenic shear strain among the three positions was taken as the
line in all images. Intra class correlation corresponding outcome measure for the right and left sides. The aver-
to intra-rater reliability for shear strain calculations age of the two sides was used for statistical analysis.
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Figure 4 Ultrasound data processing method. A: Location of sub-ROIs (yellow and orange boxes) used for quantification of lateral tissue
motion. B: Plot of lateral tissue displacement over time. Positive displacement in B corresponds to tissue movement toward the right (rostral, red
arrows in A). Negative displacement in B corresponds to tissue movement toward the left (caudal, blue arrows in A). Yellow and orange lines in
B respectively correspond to deep and superficial sub-ROIs in A. C: Shear strain model and calculation method. P1 and P2 represent the mean
tissue displacement in the deep (yellow) and superficial (orange) Sub-ROIs respectively at each time point as shown in B. Shear strain between
the sub-ROIs was calculated as the absolute difference in lateral motion between the superficial and deep sub-ROIs divided by the distance
between the centers of the two sub-ROIs (2 mm) and expressed as a percentage.

Correction for axial tissue movement Clinical measures

Although the predominant thoracolumbar fascia tissue Range of motion and physical performance measures
motion during passive trunk flexion is lateral (in the A number of clinical tests commonly used during physi-
direction or red and blue arrows in Figure 4A), a small cal therapy LBP assessments were performed to evaluate
amount of axial tissue motion can also occur. In order trunk range of motion and physical performance. These
to correct for any axial displacement, we used an auto- measures may be affected by both tissue abnormalities
mated tracking system that first determines the axial (e.g. increased stiffness) and pain; therefore, these mea-
displacement map for each ultrasound frame pair. The sures were used in this study to 1) begin to understand
location of the ROI at each time point was adjusted the impact of connective tissue abnormalities on overall
based on the mean axial displacement of the tissue rela- function and 2) plan future studies that combine func-
tive to its starting position. The corrected sub-ROI posi- tional assessment with more specific measurements of
tions were then used for determining lateral tissue behavior during active and passive trunk motion.
displacement. In the physical performance measures, subjects per-
Measurement of perimuscular connective tissue thickness formed active trunk movements and tasks; the time
and echogenicity necessary to perform these tasks was recorded in sec-
The thickness and echogenicity of the perimuscular con- onds using a stop watch. Given that these tests were
nective tissues at the L2-3 level within the ROI was secondary outcome measures, the number of tests was
measured bilaterally by a blinded investigator as pre- kept to a minimum in order to avoid excessive fatigue
viously described [6]. Because the superficial border of or soreness prior to ultrasound testing; the subject was
the thoracolumbar fascia can merge with additional also instructed not to move into ranges of motion that
layers of subcutaneous connective tissue, this method caused increased discomfort in the low back region.
uses operationally defined criteria based on the ultra- Range of motion tests were performed first, followed by
sound intensity profile. First, perimuscular connective performance tests.
tissue thickness was defined as the thickness of the Trunk range of motion (ROM) measurements
echogenic layered structure located closest to the muscle We used the double inclinometer technique for mea-
and separated from the nearest, more superficial echo- surement of lumbar flexion [17], extension and lateral
genic layer by more than 2 mm. Second, perimuscular flexion [18] ROM. While the subject stood erect, an
connective tissue echogenicity was defined as the area inclinometer (a circular, fluid-filled instrument with a
under the curve of the ultrasound intensity profile weighted needle that indicates the number of degrees
within the portion of the ROI delineated by the peri- on a protractor scale) was placed on the dorsal midline
muscular thickness measurements. Ultrasound measure- at the level of L1-2 interspinous space (upper) and at
ments were made on images reconstituted from raw the level of the posterior superior iliac crests (PSIS)
ultrasonic data in Matlab software (The MathWorks, (lower). The inclinometers were “zeroed” and the sub-
Natick, MA) using a Hilbert transformation without ject was instructed to flex his/her trunk forward as far
additional image enhancements. as he/she could without bending the knees. The
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examiner recorded the number of degrees on both the Least Square Difference (LSD) procedure. The associa-
upper and lower inclinometers. The amount of motion tions between shear strain and other outcomes were
of the lower inclinometer was subtracted from the evaluated using Spearman’s rank correlations. All statis-
upper inclinometer to derive the total lumbar spine flex- tical analyses were performed using SAS Statistical Soft-
ion (lumbar flexion ROM). A similar procedure was ware Version 9.2 (SAS Institute, Cary, NC). For those
used to record the lumbar extension ROM. For males outcomes measured bilaterally (thoracolumbar fascia
and females respectively, the normal ROM is 65.0 and shear strain, perimuscular connective tissue thickness,
64.4 degrees for trunk flexion and the normal ROM is perimuscular connective tissue echogenicity, lateral
26.6 and 27.3 degrees for trunk extension [19]. For lat- trunk flexion ROM), analyses reported represent the
eral flexion ROM (performed bilaterally), the inclin- average of the right and left sides. Results of analyses
ometers were placed in the same locations and oriented performed within right and left sides paralleled the over-
in the frontal plane (rather than the sagittal plane for all findings. The type 1 error rate was set at a = .05 on
measuring flexion/extension). The same subtraction of a comparison wise basis.
the upper minus lower inclinometer readings provided
the total lumbar lateral flexion ROM. The normal ROM Results
for lateral flexion is 24 degrees [18]. The percentage of male subjects in the LBP and No-LBP
Functional measures (task duration) groups was 53% and 48% respectively (chi square = 0.36,
Repeated Trunk Flexion test From a neutral standing p = .55). There were no significant differences between
position, the subject maximally flexed his/her trunk for- LBP and No-LBP groups for age, (44.6 ± 1.8 vs. 41.8 ±
ward and returned to the upright position as fast as 2.3, p = .35), BMI (26.0 ± 0.5 vs. 26.1 ± 0.6, p = .76),
comfortably tolerated. The total time (sec) to complete and activity levels measured by the Baecke Activity
five repetitions of trunk flexion/extension was recorded. index (8.0 ± 0.3 vs. 7.7 ± 0.5, p = .61). There also were
Repeated sit-to-stand test From a standardized seated no significant differences between groups for age, BMI
position, the subject rose to standing and returned to and activity level within either males or females. Indices
sitting as quickly as possible five times. The total time of symptom severity and disability in subjects with LBP
(sec) taken to complete five repetitions was recorded. are shown in Table 1.
50-ft walk test Subjects walked 50 feet, first as fast as The following two video clips show examples of thora-
they could and then at their preferred walking speed. columbar fascia motion during passive trunk flexion in a
The total time (sec) to complete the fast and self human subject with No-LBP (Additional file 1) and a
selected walk was recorded. subject with LBP (Additional file 2). In the subject with
Sorrensen’s test To assess trunk muscle strength and No-LBP, the layers within the thoracolumbar fascia can
endurance, subjects were positioned prone on a table be seen to move independently with some adjacent
such that only their lower limbs and pelvis were sup- layers moving in opposite directions. In contrast, in the
ported on the table top. While their lower body was sta- subject with LBP, there is less apparent differential
bilized by the examiner, the subject was asked to motion between the adjacent layers.
contract his/her trunk extension muscles to maintain a The next two video clips (Additional file 3 and Addi-
horizontal trunk position against gravity while unsup- tional file 4) respectively show cumulative lateral displa-
ported. The total time (sec) holding the trunk horizontal cement and corresponding shear strain maps within the
without dropping below 10 degrees to the horizontal ROI during one flexion cycle of the table. In both
was recorded. movies, red indicates tissue displacement or shear strain
toward the right (rostral) and blue indicates tissue dis-
Statistical methods placement or shear strain toward the left (caudal). Fig-
A chi square test was used to compare LBP and No-LBP ures 5A, B and 5C respectively show B-scan, cumulative
groups on the distribution of males and females. Two- displacement and cumulative shear strain maps at the
way analyses of variance and covariance were used to end of one flexion cycle of the motorized table demon-
compare LBP and No-LBP groups on continuous out- strating the presence of shear plane deformation within
comes with sex as the additional factor in the model. the thoracolumbar fascia as illustrated in Figure 5D.
For outcomes in which BMI was a significant predictor, When shear strain was calculated using anatomically
significance levels were based on analyses of covariance defined locations as shown in Figure 4, average shear
with corresponding means representing least square strain was 62% (SD = 27.2%) among all subjects tested.
means adjusted for the covariate. If there was evidence On average, thoracolumbar fascia shear strain was 20%
that group comparisons were different across males and lower in subjects with LBP compared with subjects
female (i.e. group by sex interaction, p-value < .10), without LBP. For the LBP vs. No-LBP groups, thoraco-
group comparisons within sex were based on Fisher’s lumbar fascia shear strain was (mean±SE) 56.4% ± 3.1%
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Table 1 Indices of symptom severity and disability in subjects with LBP

Males Females p-value
McGill pain questionnaire 7.1 ± 0.5 8.2 ± 0.9 p = .31
(# of words circled)
Duration of pain (years) 12.9 ± 1.7 13.5 ± 2.5 p = .83
Pain level (0-10 Scale) 2.8 ± 0.4 3.5 ± 0.4 p = .24
Current pain intensity on day of testing (0-10 scale) 1.5 ± 0.3 2.5 ± 0.4 p = .053
Exacerbation intensity (0-10 scale) 6.1 ± 0.4 5.2 ± 0.4 p = .17
Exacerbation frequency (%) Yearly 23 3 p = .01
Monthly 20 32
Weekly 14 39
Daily 43 26
Exacerbation duration (days) 50.1 ± 21.5 39. 9 ± 20.9 p = .73
Initial injury (%) 33 48 p = .20
Oswestry Mild (0-20) 71 58 p = .56
disability Moderate (21-40) 26 39
scale (%) Severe (>40) 3 3
TAMPA kinesiophobia scale 39.9 ± 0.9 35.1 ± 1.0 p < .001
Von Korff (%) Recurrent 42 45 p = .77
Chronic 58 55
Note. All measures were reported via take-home questionnaires except the current pain intensity measure which was reported on the day of testing. Values
represent Mean ± SE unless otherwise indicated.

Figure 5 Cumulative lateral tissue displacement and shear strain maps. A: B-scan ultrasound image ROI. B: Sum of tissue displacement over
time (cumulative displacement) during one flexion cycle of the table within the ultrasound image ROI. Red indicates tissue displacement toward
the right (rostral) and blue indicates tissue displacement toward the left (caudal). C: Cumulative shear strain within the ultrasound image ROI.
Red and blue indicate positive (toward the right) and negative (toward the left) shear strain respectively. (B) and (C) respectively correspond to
cumulative tissue displacement and shear strain at the end of one flexion cycle of the motorized table. D: Diagram illustrating positive and
negative shear strains which represent sliding or deformation of an object in different directions. The shear component is obtained by taking the
gradient of lateral displacement (Ux) along the positive axial direction (+y). The x-y coordinates are defined corresponding to the ultrasound
imaging configuration (see axes in Figure 2).
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vs. 70.2% ± 3.6% respectively, p < .01) (Figure 6). There perimuscular connective tissue thickness (r = -0.45, p <
was no evidence that this difference was sex-specific .001), echogenicity (r = -0.28, p < .05), trunk flexion
(group by sex interaction p = .09) although overall, range of motion (r = 0.36, p < .01), trunk extension
males had significantly lower shear strain than females range of motion (r = 0.41, p < .01), repeated forward
(p = .02). There were no significant overall correlations bend task duration (r = -0.54, p < .0001) and repeated
between thoracolumbar fascia shear strain and either sit-to-stand task duration (r = -0.45, p < .001). No sig-
age (r = -0.18, p = .06), BMI (r = -0.13, p = .16) or nificant correlations were found in females between
activity level (r = -0.09, p = .34). Additionally, in sub- thoracolumbar fascia shear strain and any of these out-
jects with LBP, there were no significant correlations come measures. There were also no significant correla-
between thoracolumbar fascia shear strain and responses tions in either males or females between thoracolumbar
to McGill pain questionnaire (r = 0.03, p = .84), pain fascia shear strain and measures of anxiety, cognitive
level (r = 0.03, p = .81), pain intensity on day of testing function, mental health or psychological distress (MOS
(r = 0.01, p = .93) or Oswestry disability scale (r = 0.12. questionnaire) or kinesiophobia (Tampa questionnaire).
p = .34). However, thoracolumbar fascia shear strain
was negatively correlated with pain duration in males Discussion
with LBP (r = -0.46, p < .0004) but not in females (r = This study reports the first quantitative evaluation of
-0.07, p = .67). shear strain within the thoracolumbar fascia in humans.
Results of testing for perimuscular connective tissue Mapping of shear strain using elastography, as well as
thickness and echogenicity, trunk range of motion and computation of shear strain using anatomically defined
functional measures for male and female subjects are sub-ROIs demonstrated the presence of a prominent
shown in Table 2. Significant differences were found shear plane at the first echolucent plane superficial to
between the two groups for several outcome measures: the muscle/fascia interface. We found that, during a
flexion range of motion, extension range of motion and standardized passive flexion test, shear strain was
Sorrensen’s endurance test were decreased in the LBP reduced by ~20% in a group of human subjects with
group while perimuscular connective tissue echogenicity, chronic LBP.
repeated trunk flexion task duration, repeated sit to The lack of correlation between thoracolumbar fascia
stand task duration and 50 foot walk task duration (reg- shear strain and subjective psychosocial outcome mea-
ular and fast pace) were increased in the LBP group. sures (including pain level) suggests that reduced shear
Some of the outcome measures (perimuscular connec- strain may not correlate with pain symptoms over time.
tive tissue thickness, extension range of motion, However, thoracolumbar fascia shear strain may never-
repeated sit-to-stand task duration and Sorrensen’s theless be a useful biomarker for pathophysiological pro-
endurance test) were gender-specific (see letter super- cesses that may predispose to chronic LBP or may
scripts in Table 2). influence its long term trajectory including the increased
Significant correlations were found in male subjects likelihood of recurrence, especially in males in whom we
between thoracolumbar fascia shear strain and found a moderate positive correlation between shear
strain and LBP duration. This, and the additional male-
specific moderate correlations with connective tissue
thickness and echogenicity, range of motion and physi-
cal function, could be related to body composition, fat
distribution pattern, hormonal factors, or to structural
and/or movement pattern differences between males
and females. The latter explanation is supported by pre-
vious reports of specific lumbopelvic movement impair-
ment in males with low back pain [20,21]. In the
current study, we found that differences in perimuscular
connective tissue thickness between LBP and No-LBP
were only significant in males. In our prior report [22],
we did not have evidence that this difference was sex-
specific, although we had observed a greater difference
between LBP and No-LBP in males. We did however
Figure 6 Thoracolumbar shear strain in human subjects with confirm our previous finding that perimuscular connec-
and without LBP. Thoracolumbar shear strain was ~20% lower in tive tissue echogenicity is greater in LBP in both males
human subjects with chronic LBP compared with No-LBP. *indicates and females. If differences in connective tissue thickness
p < .01. N = 121 subjects. Error bars represent standard errors.
are indeed limited to males, this could be related to
Langevin et al. BMC Musculoskeletal Disorders 2011, 12:203 Page 9 of 11
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Table 2 Outcome Measures for Male and Female Subjects with and without Low Back Pain
Males Females
Outcomes No-LBP LBP No-LBP LBP Group Sex Group by
(n = 24) (n = 38) (n = 26) (n = 33) p-value p-value Sex
p-value
Percent Shear Strain 64.70 ± 5.17 50.88 ± 3.77 75.36 ± 5.02 62.73 ± 5.18 .007 .02 .90
Perimuscular 0.37 ± 0.04a 0.49 ± 0.03b 0.41 ± 0.03a 0.41 ± 0.03a .07 .50 .09
Thickness*
Perimuscular 0.13 ± 0.01 0.16 ± 0.01 0.14 ± 0.01 0.15 ± .01 .007 .92 .30
Echogenicity*
Flexion Range 53.90 ± 1.88 46.38 ± 2.27 53.58 ± 1.84 52.13 ± 1.78 .03 .19 .15
of Motion
Extension Range 16.90 ± 1.89a 9.74 ± 0.86b 16.89 ± 1.55a 16.28 ± 1.92a .02 .04 .04
of Motion
Lateral Flexion 19.51 ± 0.68a 17.07 ± 0.61b 18.02 ± 0.67a 18.23 ± 0.61a .09 .80 .04
Repeated Trunk 7.97 ± 0.52 9.88 ± 0.41 8.27 ± 0.45 9.64 ± 0.41 <.001 .94 .56
Flexion*
Repeated Sit to 10.71 ± 0.43a 13.42 ± 0.62b 11.90 ± 0.54a 12.67 ± 0.41a .002 .69 .08
Stand
50 Foot Walk 10.64 ± 0.35 11.58 ± 0.27 11.19 ± 0.30 11.97 ± 0.28 .005 .12 .80
Regular Speed*
50 Foot Walk 6.82 ± 0.26 7.56 ± 0.20 7.25 ± 0.22 8.24 ± 0.21 <.001 .71 .57
Fast Speed*
Sorensen’s* 126.5 ± 10.1a 104.9 ± 7.9a 139.2 ± 8.9a 85.7 ± 8.1b <.001 .71 .08
Note: tabled values are mean ± SE unless otherwise indicated. Variables denoted by an asterisk indicate values are least square mean ± SE, which are adjusted
for BMI. For those variables in which there was evidence that differences between LBP and No LBP were dependent on sex (i.e. group by sex interaction p <.10),
group comparisons were performed within males and females. Superscripts a and b indicate that group means not sharing a common letter are significantly
different within each sex (Fisher’s LSD, p <.05).

some of the other male-specific findings observed in this recruitment patterns could lead to altered forces being
study such as decreased range of motion and functional transferred to the connective tissues, which could cause
measures. remodeling as can occur in other types of connective
A limitation of this study is that measurements of tissues such as ligaments and joint capsules [27-33].
thoracolumbar fascia shear strain were made only at the Over time, the altered movement patterns could worsen
L2-3 level. This was chosen in this initial study because, connective tissue adhesions resulting in increased move-
at this location, the skin surface is relatively flat and the ment restriction, especially in the presence of pain and
thoracolumbar fascia is relatively parallel to the skin, inflammation. A third possibility is that reduction of
which simplifies calculation of lateral displacement. shear strain could be due to intrinsic connective tissue
Applying this technique to more caudal low back seg- pathology (e.g. chronic inflammation, fibrosis) resulting
ments, as well as other body regions where restricted from direct injury to the connective tissue. Concurrent
mobility between adjacent connective tissue planes may measurement of shear strain and electromyographic
be present, could potentially contribute to a more gen- measurement of muscle activity will be an important
eral understanding of the role of connective tissue in next step to further understand these potentially impor-
chronic pain pathophysiology [23]. This measurement tant pathophysiological mechanisms. Such studies may
method could also be adapted to active, as opposed to lead to defining a subgroup of patients with decreased
passive, body movements although this would pose shear plane motion predominantly due to abnormal
additional challenges for stabilization of the ultrasound movement strategy who may benefit from movement
probe. reeducation, versus a subgroup with decreased shear
Given that the dense connective tissue layers within plane mobility due to fibrosed connective tissue layers
the thoracolumbar fascia are aponeuroses connected to who may benefit from direct connective tissue
dorsal and ventral trunk muscles, one plausible explana- manipulation.
tion for our findings is that reduced shear strain results
from impaired neuromuscular control and recruitment Conclusions
patterns of these muscles during trunk movements In summary, thoracolumbar fascia shear strain was
which has been shown to be associated with chronic reduced in a group of human subjects with LBP of
LBP [24-26]. Alternatively, the altered muscle greater than 12 months duration compared to a control
Langevin et al. BMC Musculoskeletal Disorders 2011, 12:203 Page 10 of 11
http://www.biomedcentral.com/1471-2474/12/203

group with No-LBP. Although differences in thoraco- subjects and manuscript preparation; AGN performed physical therapy
assessments and SMH, EEK and JJT participated in study design. All authors
lumbar fascia shear strain between LBP and No-LBP read, edited and approved the final manuscript.
were found in both sexes, shear strain was lower in
males overall, and significant correlations with trunk Competing interests
The authors declare that they have no competing interests.
flexibility, functional measures and connective tissue
structure were found in males only. Possible explana- Received: 20 May 2011 Accepted: 19 September 2011
tions for reduced thoracolumbar fascia shear strain dur- Published: 19 September 2011
ing passive trunk flexion in LBP include abnormal
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doi:10.1186/1471-2474-12-203
Cite this article as: Langevin et al.: Reduced thoracolumbar fascia shear
strain in human chronic low back pain. BMC Musculoskeletal Disorders
2011 12:203.

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