Can ultrasound imaging be used to detect adaptations in the thoracolumbar fascia of people with lower back pain?

Chronic non-specific lower back pain (LBP) is a widespread, multi-faceted condition which affects over 80% of the population in their lifetime. Moreover, LBP has been rated as the highest cause of worldwide disability, costing the NHS over £1632 million each year. There are many treatment methods used for the management of LBP with exercise widely recommended as the most effective and cost-effective method, however the mechanism by which exercise can reduce LBP symptoms is still equivocal. Over the past 30 years, the thoracolumbar fascia has become an area of research interest in the aetiology of LBP. Using ultrasound imaging, in-vivo evidence has shown morphological differences in the thoracolumbar fascia of those with and without LBP. The study in Chapter 4 presents the perceptions, preferences, and knowledge of the thoracolumbar fascia of clinicians and practitioners working with patients with LBP. There was an agreement between practitioner groups to treat LBP patients with one-to-one rehabilitation exercises but a lack of consensus around the role of the thoracolumbar fascia which is perhaps in part due to lack of coverage on fascia in educational courses, with over 85% of participants expressing that fascia was not included in their initial anatomy training. Moreover, less than 20% of participants were aware of research on the thoracolumbar fascia and LBP despite a growing literature base in this area. The study reported in Chapter 5 assessed the inter- and intra- rater reliability of a novice and expert rater to use ultrasound imaging to capture and analyse the thoracolumbar fascia. The two raters captured and analysed images from 27 participants, 16 with chronic LBP. Results for inter-rater reliability between the novice and expert rater reported ICCs ranging from 0.91-0.99 coupled with small SEMs ranging from 0.01-0.02 for echogenicity and 0.14-0.43 mm for thickness measurements. For intra-rater reliability, the novice rater reported very high reliability for the subcutaneous and combined thoracolumbar fascia thickness and moderate for the perimuscular thickness. For echogenicity intra-rater reliability was reported as high for all zones. The study presented in Chapter 6 used ultrasound imaging to investigate morphological differences of the thoracolumbar fascia in individuals with and without LBP. A total of 33 participants were recruited (17 with LBP), however no significant differences between the thickness and echogenicity of the perimuscular thoracolumbar fascia layer of people with and without LBP. The final study reported in chapter 7 was an investigation into the impact of a 6-month movement and exercise intervention on the thickness and echogenicity of thoracolumbar fascia of people with chronic LBP. A total of 45 participants self-reporting with LBP took part in the study and were randomly allocated to one of three groups: an exercise intervention group, a movement prompt intervention and a control group. This study found that a 6-month remote multi-modal exercise programme and a movement prompt intervention had no significant effect on the thickness or echogenicity of the thoracolumbar fascia compared to a control. In conclusion, ultrasound imaging can be used to reliably measure the morphology of the thoracolumbar fascia by both novice and expert raters alike. However, differences in thickness and echogenicity may not be enough to measure adaptations due to LBP. The exercise and movement prompt randomised controlled trial in this thesis found no significant adaptations of the thoracolumbar fascia. However, as this study is the first intervention of this type and duration, evaluating the impact on the thoracolumbar fascia in those with LBP, the findings have provided important insights into the need for further and potentially interventions of longer duration of this kind. The perceptions of fitness professionals and physical therapists study advocates for the inclusion of fascial anatomy in the curricula of physical therapists and those in the health and fitness industry.