Accepted Manuscript

Fascia – The unsung hero of spine biomechanics

P. Mark Driscoll

PII: S1360-8592(17)30319-4
DOI: 10.1016/j.jbmt.2017.10.014
Reference: YJBMT 1626

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 21 October 2017

Revised Date: 23 October 2017
Accepted Date: 24 October 2017

Please cite this article as: Mark Driscoll, P., Fascia – The unsung hero of spine biomechanics, Journal of
Bodywork & Movement Therapies (2017), doi: 10.1016/j.jbmt.2017.10.014.

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 ACCEPTED MANUSCRIPT

EDITORIAL FOR FASCIA SECTION OF JBMT ISSUE 22(1)

Fascia – The Unsung Hero of Spine Biomechanics

Mark Driscoll P.Eng., PhD.

Assistant Professor
Department of Mechanical Engineering,
Musculoskletal Biomechanics Research Laboratory

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McGill University, 817 Sherbrooke Street West,
Montreal, QC, H3A 0C3, Macdonald Eng. Bldg. office #153
mark.driscoll@mcgill.ca

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Biomechanics has come a long way since the days of Borelli who applied mechanical levers to
anatomical joints by way of a plume in hand. Today, a plethora of experiential tools are at the

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disposal of researchers which enables one to more accurately gather data and explore the ever-
evasive road map towards knowing what governs the biomechanics of the musculoskeletal
system. This journey has led to two marking manifestations, amongst others. First, researchers in

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biomechanics have made novel and valuable discoveries. Second, the same researchers are now
presented with more questions than before because of these data.
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Fascia and its implication in biomechanics is both victor and victim of the experimental tools and
experimental data of today.
Musculoskeletal biomechanics is field faced with many redundancies when seeking to perform
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mechanical analyses. This occurs provided several muscles may, technically and theoretically,
accomplish the same task. In order for such biomechanical analyses to be solvable, one must
make several simplifications. This often results by tossing fascia aside, so to speak, perhaps
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analogous to how anatomist did so during dissections. Nevertheless, over the last decade fascia
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has gained acknowledgement as a player in biomechanics by way of conveying mechanical

forces directly or indirectly. Directly, it is somewhat evident that the endo- peri- and epi-mysium
that infiltrates our muscles are responsible for transferring forces to and from attachments. In
addition to this, substantial inter-muscular and extra-muscular force transmission have been
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shown to exist and may have a dependence on local fascia as the conduit of such transmission
(Maas and Sandercock, 2010). Indirectly, the implications of fascia are less evident but of equal
importance. The enveloping or containment of intra-muscular pressure in a contracting muscle
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has been shown to have a positive role, compared to a fasciotomy section, in the muscle’s ability
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to transfer force (Garfin et al., 1981). Interestingly, when this envelop is intact and surrounded
by others, inter-muscular pressure or adjacent transverse loading may work against an individual
muscle’s force transmission (Reinhardt et al., 2016). However, it is conceivable that such
pressures, afforded by the enveloping fascia, may be beneficial for dynamic loading and
providing support or stability of neighbouring structures such as in the spine, for example.
The spine is a biomechanical marvel in regards to its intricate control and performance.
However, because of such complexities many things can go wrong, perhaps why the spine is
responsible for plaguing so many with pain. The role of fascia in spinal stability has yet to be
fully understood but several novel and valuable discoveries have been made. Clinically, many
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researchers have shown and alluded to the role of the thoracolumbar fascia (TLF) in spine
stability. The TLF is believed to play a role in transferring forces during coordinated activities
and, consequently, such important function may be coupled with pathologies and clinical
observations of TLF dysfunction (Willard et al., 2012). Mechanically, the tension in the TLF is
regulated by many muscular attachments spanning the spino-pelvic region (Vleeming et al.,
1995; Barker et al., 2004) and by the intra-abdominal and muscular pressures (Hodges and

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Gandevia, 2000; Tesh et al., 1987; Gracovetsky et al., 1985). These notions further complicate
the task of rehabilitation practitioners who attempt to decipher the culprit(s) when TLF related
pain or spinal stability issues are present.

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How is this then studied in the lab or what are the experimental tools often utilized? Many telling
patient based or in vivo studies support the role of the TLF in spinal stability. Irrespective of
whether augmented intra-abdominal pressure unloads the spine, it is a consensus that intra-

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abdominal pressure increases with trunk flexion (McGill and Norman, 1987; Nachemson et al.,
1986; Andersson et al., 1977) while this pressure and TLF tension appears to be physically
linked (Tesh et al., 1987; Vleeming et al., 2014). To further objectively explore spinal stability,

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many have attempted to create an analogue or ex vivo spine models but fail in the model’s ability
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to support physiological magnitudes of loading without collapse. The general accord is that one
must adopt a follower type load (Patwardhan et al., 1999) in order for the analogue spine model
to support any considerate loading. This loading type accounts for the fact that spinal stability is
best achieved when the resultant force of local segmental loading of the spine is maintained
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tangential to the spinal profile. This means that all forces and pressures from muscles and fascia
should lead to loading the spine in a manner that is beneficial to its stability, should this loading
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profile be followed. Thus, the posterior direction of forces from the TLF becomes quite
important as it works with muscular tension in its attempts to stabilize against the axial loads
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from gravity. Subsequently, such loading theorems have been applied to virtual or in silico
models of the spine. This in silico type tool is frequently used by biomedical engineers and
researchers which, to put it simply, uses computerized simulations to explore biomechanics using
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finite element method by reducing biological volumes of our bodies into small computational
regions and uses Newtonian mechanics to execute analyses. The above mentioned spinal
follower type loading has been applied to the spine with success with the motive of conceiving
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improved treatments of spinal instability (Driscoll et al., 2011; Driscoll et al., 2009) while others,
via rigid body models, explored the role of intra-abdominal pressure and inversely tied in the
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TLF and its potential function (Stokes et al., 2011; Stokes et al., 2010). Nevertheless, objective
analyses of the biomechanical impact of the TLF have yet to be fully elaborated in the above
experimental tools and platforms despite its apparent importance.
From a rehabilitation or treatment approach, the aforementioned biomechanical role of fascia
offers an option upon which to plan and treat musculoskeletal disorders. However, one’s path to
dysfunction and consequential disability varies from patient to patient and is also poorly
understood biomechanically. Further, once a dysfunction sets it, regardless of its onset etiology,
compensatory patterns may worsen by way of the novel biomechanical notion of physiological
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stress shielding. This concept defines how when a bias or difference in tissue quality (mechanical
properties) is present, this can inherently offset how loads are distributed within our bodies when
engaging in activities and thus potentially advancing the underlying disorder (Driscoll, 2008;
Driscoll et al., 2009; Driscoll and Blyum, 2011).
Thus where, when, and how to rehabilitate is a difficult task for any, and an even more
challenging task is to systematically present a turnkey rehabilitation program to alleviate

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symptoms such as back pain. What can we do to improve this? Such an objective takes us full
circle back to the experimental tools and research methods at our disposal. Undoubtedly, we
know more than we did 10 or 20 years ago but whether we apply it or not is another question.

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Researchers continue to drive data, interpretations and findings all the while rehabilitation
practitioners continue to sharpen their methods.
It is the collaborations of these two groups which is critical to take our knowledge of

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musculoskeletal biomechanics to the next level while filtering current and future data with the
underlying purpose of improving patient treatment and outcomes. A platform devised to achieve
just this is the Fascia Research Congress which since 2007 has been governed by such a

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mandate. The forthcoming congress in 2018 at the historical Urania Center in Berlin will
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continue to bring together scientist, researchers, engineers, clinicians, and rehabilitation
practitioners under one roof to advance this field and to pay well deserved praise to the unsung
hero that is fascia.
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