Indian Journal of Physiotherapy and Occupational Therapy

Dongre Alpana¹, Sharma Sanjeev²

¹Professor, ²Assistant Professor, Ravi Nair Physiotherapy College, DMIMS Sawangi Wardha India 442002
alpanapt(at)yahoo.co.in

Study Design: Randomized controlled single blinded clinical trial.
Objective: To identify prevalence of thoraco-lumbar dysfunction (TLD) and analyze the role of latissimus dorsi in it.
Summary of background data: 30% of chronic mechanical back pains are reported to be due to TLD. The thoracolumbar muscles control the dynamic and postural stability of the lower spine. Though core stabilization exercises are widely recommended for low back pain, but no reports are available for exercises specific to thoraco-lumbar dysfunction.
Methods: 30 subjects in age group of 25 to 40 years with non traumatic, chronic mechanical low back pain were identified for study and randomly divided into two groups. Group-A (n=15): only core stabilization exercises and Group-B (n=15): latissimus dorsi strengthening and core stabilization exercises. Primary outcome measure was pain intensity (VAS score). Secondary outcome measures were general health (SF-36) and back pain disability (Aberdeen back pain disability score). Outcome measurement scores were compared using unpaired student t-test.
Results: 42 % of all subjects had back pain of TLD origin.88 % of TLD subjects had latissimus dorsi strength < 4. Highly significant improvement in general health (p <0.0001), and significant improvement in disability score (p= 0.0017) was observed in the Group-B subjects. Re-assessment after 3 and 6-months reflected better scores in Group-B subjects. Conclusion: Identification of TLD as a cause of low back pain is recommended in all non-traumatic, chronic, mechanical low back pains. Strengthening of latissimus dorsi relieves thoraco-lumbar related back pain.
Key words: low back pain, thoraco-lumbar dysfunction, latissimus dorsi strengthening, dorso-lumbar fascia.
Key points: 42% of non-traumatic chronic low back pains are due to thoraco-lumbar dysfunctions. Contractions of latissimus dorsi with lumbar stabilizers act towards thoracolumbar stabilization. It leads to early pain relief, improvement in general health and reduction of back pain disability.

Introduction

Back pain is a primary reason to seek medical advice. Considering 80% of people suffering with back pain, we can say it is a universal epidemic requiring attention. Sources of back pain are numerous, usually sought in as lesions of disc or facet joints at L4-L5 and L5-S1 levels¹.

Robert Maigne described thoraco-lumbar dysfunction (TLD) as pain originating in thoraco-lumbar region, but reported by patients in either the low back or upper buttocks. These pains are mostly chronic in nature and constitute 30% of all low back pains^2,18.

Thoraco-lumbar fascia is used for load transfer3. The superficial lamina gets tensed by contraction of various muscles, such as the latissimus dorsi, gluteus maximus and erector muscle³.

Many rehabilitation techniques for LBP are proposed. Several researchers have used different stabilizing exercise, strengthening the muscles of the trunk and back emphasizing the correct timing and co-contraction^4-8. Their aims are short time pain decrease, muscular strengthening, and increased hip and lumbar spine mobility, increased lumbar and pelvic proprioceptive sensibility⁹.

Core strengthening has become a major trend in rehabilitation. It is in essence a description of the muscular control required around the lumbar spine to maintain functional stability¹⁰.

The core contraction alone is logically presumed ineffective in producing required forces for the stabilization of thoracolumbar junction. The extensive and thick attachments to the superior part of thoraco-lumbar fascia have a definite role to play in the stability of this junction. In our opinion, circumstances where thoraco-lumbar dysfunction is found to be the cause of low back pain, concentric strengthening of latissimus dorsi with core stabilization exercises will produce the required tensile forces at the thoraco-lumbar region and contribute towards its functional stability.

The patients we cater in our physiotherapy clinic are from rural area, where compliance to institution based treatment by patients is poor. We wanted to design a home-based self performed exercise program that can be reviewed periodically.

The study was designed to a) identify the cases of low back pain with TLD, b) ascertain whether lumbo-pelvic stabilization exercises are alone effective in low back pain with TLD and c) analyze the association between latissimus dorsi and low back pain due to TLD.

Material and Methods

The study was approved by the college ethical committee. All subjects were informed of procedures and an informed consent was obtained. Subjects who reported to physiotherapy clinic with complaint of low back pain were clinically assessed for signs of TLD. Patients with TLD were identified by the:

1) positive ‘iliac crest point’ test,
2) positive skin roll test,
3)localized tenderness over spinous process at the thoraco-lumbar junction (T11 to L2), and
4) tenderness over involved apophyseal joint at the thoracolumbar junction1¹.

Subjects with positive signs of TLD were included in the study. Those with associated lumbar radiculopathy, sacroilliac joint dysfunction or history of trauma or surgery to lumbar spine were excluded. Radiculopathy was clinically assessed by Lassegue’s test. Sacroilliac joint dysfunction was confirmed by striding tests. Latissimus dorsi muscle strength was tested using manual muscle testing as described by Kendall and colleagues¹². All subjects identified for the study were also evaluated using back pain disability score (Aberdeen low back pain disability score) intensity of pain (visual analogue score) and general health score (SF-36), 100 subjects in the age group of 25 to 40 years with low back pain were assessed for clinical signs of TLD. 18 (18%) subjects tested positive for lumbar radiculopathy, and 10 (10%) subjects had sacroilliac joint dysfunction (2 subjects had associated signs of lumbar radiculopathy). Following the exclusion criteria, 72 (72%) subjects were then evaluated for TLD of which 30 (42%) tested positive.

These 30 subjects included 12 (40%) females and 18 (60%) males. They were randomly assigned to two groups. Group -A received only core muscle stabilization exercises in supine and quadruped positions. Group-B received latissimus dorsi muscle strengthening exercises using theraband along with core muscle contractions. Subjects with muscle spasm were given moist heat therapy before exercises.

To ensure that the subjects do not go wrong with the required muscle contractions, they were instructed to attend hospital based treatment 1-week. Later, they continued the exercises at home for 1-month. SF-36, Aberdeen low back pain disability score and VAS score were then re-evaluated. Follow-up assessment was done at a 3-month and 6-month interval using all the three outcome measures.

Results

Mean age of Group-A subjects was 33.73 ± 12.6 and of Group-B was 34.4 ± 7.058. . All subjects (100%) presented with complaints of pain in anterior and lateral part of thigh. 56.6% (n=30) complained of pain in upper glutei and 86.6% (n=30) reported lower lumbar pain. Only 46.6 % of all subjects reported with pain in thoraco-lumbar region (Figure 1). Latissimus dorsi muscle strength was found to be < 4 in 88% (n=30) subjects (Figure 2).

The different outcome measures were analyzed using unpaired student’s t-test. Following the 1-month exercises, highly significant improvement in general health (t= 3.4695, p<0.0001), very significant reduction in back pain related disability (t=5.1999, p=0.0017) and significant reduction in pain (t=2.1767, p=0.0381) was observed in subjects who received latissimus dorsi strengthening along with core stabilization exercises (Table 1).

Follow-up assessment at 3-month interval was witnessed with no change in the scores of either SF-36, Back pain disability or VAS. After 6-month interval, the average SF- 36 scores alone increased by 5% but individuals reported better social and family relations and less frequency of pains.

Discussion

Thoraco-lumbar dysfunction as a cause of back pain in 42% of subjects with low back pain is suggestive of the need to regularly check its presence in all cases of low back pains. The patients may have radiological evidence of lumbar pathology. Also the thoraco-lumbar junction may / may not have radiological signs of involvement, but the importance of clinical assessment of the thoraco-lumbar junction cannot be under-estimated. Posterior layer of thoraco-lumbar fascia has two laminae. The superficial lamina is formed by the aponeurosis of latissimus dorsi¹³. Tensile transmission across the thoraco-lumbar fascia (TLF) serves as an important element for back stability¹⁴. The thoracolumbar muscles control the dynamic and postural stability of the lower spine¹³. Both superficial and deep laminae of the posterior layer are more extensive superiorly. Contractions of latissimus dorsi produce a superior and laterally directed tension on the superior aspect of thoracolumbar fascia. This is likely to have implications on the stability of thoraco-lumbar junction. The thickness of the superior attachments is also variable¹⁵. Functional instability is defined as a relative increased range of the neutral zone16. Active stability can be achieved through muscular cocontraction, akin to tightening the guys of a tent to unload the center pole¹⁶.

Table 1: Unpaired t-test analysis of the improvement of the different parameters between two groups

	% of change in SF-36 scores		% of change in Aberdeen back pain related disability score		Difference in VAS score
	Group-A	Group-B	Group-A	Group-B	Group-A	Group-B
Mean and SD	42.5 ± 19.005	72.62 ± 27.74	65.52 ± 16.43	90.151 ± 8.156	56.16 ± 9.69	65.18 ± 11.90
t-value	3.4695		5.1999		2.2737
Df	28		28		28
p-value	<0.0001		=0.0017		=0.0309
	Highly significant		Very significant		Significant

In one of the research studies, lumbo-pelvic stabilization exercises were found to be non-effective in abdominal or back muscle activity and pain or functional disability indices¹⁷. We feel that the subjects with latissimus dorsi muscle weakness in the presence of thoraco-lumbar dysfunction will not respond positively to lumbo-pelvic stabilization exercises alone. The core stabilization exercise increase tension in the thoraco-lumbar fascia, more in its inferior part. If the subjects have latissimus dorsi muscle weakness, then there will be slackness in the superior portion of the fascia. This slackness is adjusted by thoracic kyphosis and instability at the thoraco-lumbar junction. This concept also seems to be the basis of resolving the sacroilliac pain by fixation of thoraco-lumbar junction using joint manipulations¹⁸.

Fig. 1: Graph showing the distribution of pain in 30 subjects with thoracolumbar dysfunction (TLD).

Fig. 2: Percentage of 30 subjects with thoraco-lumbar dysfunction and MMT grades of their latissimus dorsi muscle.

The posterior rami of the T-12 and L-1 nerve roots innervate the superior gluteal regions and the inferior subcutaneous tissues. The anterior rami innervate the inferior abdomen and groin. A lateral cutaneous branch innervates the trochanteric region. Our observation of 100% subjects reporting with anterior/lateral thigh pain can be explained well with this. Concentric contractions of the latissimus dorsi and core stabilization exercises together will reduce the compression forces over the facet joints of T10 to L1 levels. This will reduce the irritation to the posterior, anterior and lateral primary rami of the T12 and L1 nerve roots.

The importance of examining the thoraco-lumbar junction even in the presence of clinically evident lumbar pathology cannot be under-estimated. Core stabilization exercises alone are ineffective in cases where low back pain is associated with thoraco-lumbar dysfunction. Concentric strengthening of latissimus dorsi and core stabilization exercises together are very effective in relief of back pain. Also, it produces an improvement of general health, improved social and family relations. The effects were lasting even after 6-months of supervised care.

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