442- How TLF Thickness Correlates with Chronic Low Back Pain in Idiopathic Scoliosis

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode we are back with more research. Brand new study and a great one highly applicable to chiropractic practices around the world. This is around Thoracolumbar fascia, chronic low back pain in idiopathic lumbar scoliosis. Using ultrasound to determine what's going on. And there's a lot of key facts and findings from this study. As always, we'll drop a link down below in the show notes. But before we get I want to say a few words about Patient Pilot by the smart Chiropractor. If you have more than 500 inactive patients and you're not consistently communicating with them, you're just missing out on a massive opportunity. Probably spending too much on new patients, not focusing on those most valuable people, the people who already know, like and trust you. The people who have already said yes and experienced your care. Those people are sitting in your ehr. Patient pilot can help the patient navigate more of them back to your practice. If you'd like to kick up your patient reactivations, head over to the smartchiropractor.com, schedule a patient pilot demo. But as I said at the top, today's episode's all around research European Spine Journal title of the study Thoracolumbar Fascia and chronic Low Back pain in idiopathic lumbar. An ultrasonographic study. I don't think I've ever said that word before, but there you go. Let's start by defining what is idiopathic scoliosis. It is a three dimensional spinal deformity and it's characterized by a few things. One lateral deviation. We all know that, but there also is do not forget that when there is a lateral deviation, concurrently with that often is a rotational component. And this is often seen with a reduction in the normal kyphotic curvature. So do not forget about the rotational aspects whenever you're seeing that lateral deviation. Now, we also know that individuals who have scoliosis, they do have biomechanical and morphological variations. It's highly prevalent and this manifests in a variety of different ways. There can be discrepancies in limb trunk symmetry. There can be postural malalignments, misalignment, so to speak. There can be Compensatory motion patterns, of course, alterations in morphology of the rib, pelvis, arm, skull, you name it, and an overall reduction in body stability and mobility. And this is one of those things where it's when we see a structural abnormality, there is a lot of upstream reasons why that occurred and many downstream effects of those changes. Important to keep that in mind because we are dynamic beings. So this can result in postural deformities, of course. And the big deal with that is, as we like to say, as I like to say, time and gravity are undefeated. So as people age, AKA under load gravity, over time, chronic repetitive asymmetrical stress can wreak havoc. Now, just because you have an idiopathic scoliosis, does that mean you are destined for a life of pain later on in life? Not necessarily, but it certainly increases the likelihood that you're going to experience some pain as a result of time load stress and repetitive asymmetrical stress specifically. So important to keep all these things in mind when you, as you evaluate people that have scoliosis. And these can manifest these imbalances, asymmetrical stresses, you can have muscle imbalances, you can have functional limitations, you can have low back pain and a variety of other aspects that affect our well being. So idiopathic scoliosis has been identified as a potential risk factor for the development of chronic low back pain, specifically in adolescents, with prevalence rates ranging from about 28% to 72% in adolescents with scoliosis. So chronic low back pain affects over a quarter, up to three quarters of adolescents with scoliosis. So is that a big deal? Yes, it is a big deal because we know how much chronic low back pain, especially that's the key word there, chronic low back pain can really have negative ramifications as time marches on. So how does chronic low back pain start? A few different ways, mechanisms, opportunities. One is asymmetrical facet loading. This is a big deal because we can see facet hypertrophy on X ray. We see it all the time on mri, of course, on CT as well. But asymmetrical loading of the facets is a really, really big deal. We've talked about it many, many times. But the instantaneous axis of rotation migrates posteriorly as we age. That is normal facet loading occurs as increased facet loading. That is normal. So when you have asymmetry, asymmetrical loading and that migration and that increased load over time, that's where you start to end up with big time challenges. So we also can see muscular pain due to eccentric load. And we can also see disc issues. Again, imbalanced load on a disc over time, wedging, so to speak, can absolutely cause challenges. So the thoracolumbar fascia, they're referring to that as the TLF in this study is dense connective tissue in layers in and throughout the lumbar region, and it unites around the spinal muscles. This TLF plays a really, really pivotal role in alignment, stability and movement of the spinal column. And there is a lot of evidence, growing evidence, that highlights how the TLF is interplays, so to speak, with individuals that have chronic low back pain. And, for example, they highlight the TLF to be thicker in subjects with chronic low back pain. Why? Probably good due to stress and load. Right. So the hypothesis of this study was that there could be a relationship between chronic low back pain and the TLF with individuals specifically that have scoliosis, and the thickening might be affecting trunk motion and flexibility. So that's the hypothesis they were looking at. They had 60 individuals in this study, and they broke them up into three separate groups. One was a painful group of individuals who had pain for more than three months with a VAS of three or higher. The non painful group, no pain, obviously, and the healthy group that had no spinal pathology and no pain. So people with idiopathic scoliosis above the age of 10 were included if they had a left lumbar curve with a Cobb angle of more than 15 degrees. So more than 15 degrees. And it did not need to be extreme. That's important to consider. These were not every individual on the verge of surgical intervention. Fifteen degrees, you know, if you go above that, 16, 17, 18, that's pretty mild to moderate in my mind in terms of what we see day in and day out. And that's important to keep in mind. It doesn't have to be a scoliotic deformity that is massive to potentially create challenges. Important for us to keep in mind. So thickness of the TLF was measured in this study at L3. So the apex, so to speak, of the lumbar curve using ultrasound and bilateral measurements in millimeters were taken as people rested in a prone position. And active trunk range of motion was assessed during flexion, extension, rotation, lateral flexion, and that was assessed using a goniometer. And flexibility of the trunk was evaluated using the situation and reach test. So that is what they measured. Now the results start to get interesting as we've highlighted, let's recap a few items. One, taking a look at how fascia interplays with chronic low back pain for individuals adolescent specifically with scoliosis. Measurements didn't have to be that big and this was about 60 people. So they discovered there was the relationship between TLF thickness, trunk motion, flexibility and pain. There was no correlation in either the non painful or the healthy group. So that makes sense. In the painful group, moderate and negative correlations were found between right thickness and trunk flexion, trunk extension and left rotation. We'll highlight what that means in a few moments, but it kind of is in line with what their hypothesis was. So this study revealed that TLF thickness was greater on either side of the curve in individuals with left sided lumbar scoliosis versus their healthy peers. Additionally, between individuals with scoliosis, those who had chronic low back pain had greater fascial thickness on the concave side when compared to non painful individuals. And finally, TLF thickness was found to be positively correlated. This big take home positively correlated with pain. There's no association between thickness and trunk motion in healthy or non painful thickness idiopathic scoliosis subjects. So what do we take away from this? What we take away from this is that without scoliosis and without pain, thickness, curvature, everything looked just pretty good is overall is the easiest way to say it. However, when there was scoliosis and when there were pain, that's when we started to see some ramifications, which makes total sense. So in my mind, this study really confirms what's obvious. But what's obvious isn't always true, right? So looking at this study, you could have probably guessed that's what the results would have been. However, this study did a really great job actually doing the work to showcase, yes, what we believe to be true, what would make sense is actually what's happening. So their conclusion was, quote, this study showed that when comparing individuals with idiopathic scoliosis to healthy counterparts, the thickness of the TLF exhibits a notable increase. Additionally, in individuals with chronic low back pain, the fascia in the concave region is found to be thicker than that in the non painful peers. TLF thickness is also associated with limitation of trunk motion in the sagittal horizontal planes in painful individuals. And last but not least, as I highlight to our best guess, our study is the first to have investigated the TLF in individuals with scoliosis and examined its relationship with pain. And future research should investigate the cause and effect relationship of the findings in a wider group. So really great study highlights and I think, let me rephrase that. The takeaway messages in my mind for this study are keep an eye on this. When you see adolescents, when you see pre adolescents with idiopathic scoliosis of a degree more than 15 degrees, take a keen eye on that and really coach and guide them. Now, obviously getting in there, delivering spinal adjustments so that the mobility of those individual segments is as optimal as possible. Totally critical. Good luck having good regional and whole body motion. If you have segmental anomalies, you'll just be compensating all over the place and eventually that's going to catch up to you. So really important to get in there and ensure segmentally everything is moving in the best manner possible. Absolutely critical. Next step is what can you do? Whether it is, and this is depending upon your approach, quite frankly, whether it is at home exercise, whether it is traction, whatever it might be for your combination of how can you approach that scoliosis to try to minimize it as quickly as possible before skeletal maturity so that you give every patient that is a pre adolescent, adolescent, young adult the opportunity to get into adulthood at less than that. 15°. 15° is not a magic number, but you want to minimize that as much as possible so that your load is as symmetrical as their load ultimately is as symmetrical as possible for as long as possible. Because the asymmetries will create additional stress that has ramifications to the musculature, to the neuromusculoskeletal system, of course, and all the way down to the fascia. And as you start to see thickening of things, thickening, just like a muscle that's due to load and stress, the muscle gets bigger. It appears as though a lot of the same thing which makes sense happens within the fascia. And there is something to be said as far as loading and the benefits of loading. But asymmetrical loading over a long period of time with compromised biomechanics, now we start to get into territory that can, as this study showed, result in chronic pain long term. So fascinating study, really, really great findings and good important messaging for us to understand, take hold, internalize and then put into action with our patients in each and every week. So I'll drop a link to this study down in the show notes, you can check it out. Additionally, before we wrap up, if you are into objective assessments of the cervical spine, you have to check out Neckcare, neckcare.com, i'll drop a link down below. Reliable assessments and exercises of the cervical spine for neuromusculoskeletal control, proprioception, range of motion, sensory motor integration. Potentially the most technology driven awesome tool I have seen for cervical assessments, maybe in my career. Neckcare.com, check it out and if you are looking to bring Shockwave into your practice, I can't recommend stemwave enough. It's what I use in the practice that I own. Gostemwave.com the evidence based Chiropractor I'll drop that link down below. Have a conversation with them. As a listener to this podcast, they're willing to hook you up with their best offer, best deal so they support this podcast. You should support them. If you're thinking about bringing Shockwave in, have a conversation with stemwave. Go stemwave.com the evidence basedchiropractor Again, I will drop that that link down in the show. Notes if you have not left a reading or review for this podcast, I would greatly appreciate it if you took a moment and do so. That helps more and more docs find out about it and if you have any feedback, I'm always available. Jeff the evidencebasedchiropractor.com I hope you have a fantastic week in practice and I will talk to you soon.

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