Manual Therapy xxx (2015) 1e7

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Increased sliding of transverse abdominis during contraction after

myofascial release in patients with chronic low back pain
Yen-Hua Chen a, Huei-Ming Chai b, c, Yio-Wha Shau d, Chung-Li Wang e, **,
Shwu-Fen Wang b, *
a
Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Hsin-Chu Branch, HsinChu,
Taiwan
b
School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
c
Center of Physical Therapy, National Taiwan University Hospital, Taipei, Taiwan
d
Institute of Applied Mechanics, College of Engineering, National Taiwan University, Taipei, Taiwan
e
Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Recent evidence suggested the significance of integrity of the tension balance of the muscle-
Received 27 October 2014 fascia corset system in spinal stability, particularly the posterior musculofascial junction which is adja-
Received in revised form cent to dorsal located paraspinal muscles joining each other at lateral raphe (LR). The purpose of this
17 October 2015
study was to compare the contraction of the transversus abdominis (TrA) at both anterior and posterior
Accepted 19 October 2015
musculofascial muscle-fascia junctions in patients with low back pain (LBP) and asymptomatic partici-
pants before and immediately after a sustained manual pressure to LR.
Keywords:
Methods: The present observational cohort study used a single-instance, test-retest design. The outcome
Abdominal drawing-in maneuver
Transversus abdominis
variables included the resting thickness (Tr), the thickness during contraction (Tc), change in thickness
Musculofascial junction (DT), sliding of musculofascial junction (DX), muscle length at rest (L) and displacement pattern (DD) of
Tensegrity the TrA using ultrasonography. Vertical tolerable pressure at the LR was applied manual for 1 min. Tr, Tc,
Lateral raphe DT, and DX were analyzed by three-way ANOVA (musculofascial junction sites*group* pre-post manual
release). DL and DD were analyzed by two-way ANOVA (group* pre-post manual release).
Results: Participants with LBP revealed less Tc, DT and DX at both sites (p < 0.005). After myofascial
release, LBP group demonstrated a positive DD of the musculofascial junctions at both end (p < 0.001).
Nevertheless, both groups increased the DT and DX at both sites (p < 0.001 and 0.001, respectively).
Conclusion: The result indicated immediately effect of sustained manual pressure on musculofascial
junction of TrA and supported the concept that the possible imbalanced tension of the myofascia corset
of TrA in patients with LBP.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction
Transversus abdominis (TrA) and thoracolumbar fascia (TLF)
form the musculofascial sling. The TrA is attached dorsally to the
middle layer of the TLF (Barker et al., 2007) and the transverse
* Corresponding author. School and Graduate Institute of Physical Therapy, Col-
lege of Medicine, National Taiwan University, Floor 3, No.17, Xuzhou Road,
Zhongzheng Distinct, Taipei 100, Taiwan.
** Corresponding author. School and Graduate Institute of Physical Therapy, Col-
lege of Medicine, National Taiwan University, Floor 3, No.17, Xuzhou Road,
Zhongzheng Distinct, Taipei 100, Taiwan.
E-mail addresses: chungli@ntu.edu.tw (C.-L. Wang), sfwang@ntu.edu.tw
(S.-F. Wang).
process of the spine via the lateral raphe (LR) (Willard et al., 2012).
These deep muscles and fascia of the trunk form a continuous
musculofascial corset-like system (Barker and Briggs, 1999; Barker
et al., 2004, 2006; Gatton et al., 2010). Based on the musculofascial
corset concept, tension is balance in different segments. The fascial
system is considered as a “tensegrity” or tensional integrity struc-
ture to manage the balance between tension and compression
around the organs, joints and muscles.
During chronic LBP, deep muscles show dysfunction as their
attaching fascia structures are changed (Gatton et al., 2010). Pa-
tients with low back pain (LBP) (Hides et al., 2011) demonstrate
delayed contractions of the TrA (Ferreira et al., 2004) and attenu-
ated thickness changes in patients with chronic LBP (Critchley and

http://dx.doi.org/10.1016/j.math.2015.10.004
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Please cite this article in press as: Chen Y-H, et al., Increased sliding of transverse abdominis during contraction after myofascial release in
patients with chronic low back pain, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.004
2 Y.-H. Chen et al. / Manual Therapy xxx (2015) 1e7
Coutts, 2002; Ferreira et al., 2004; Teyhen et al., 2009). Degenera-
tive changes in the TLF (Bednar et al., 1995) and increased thickness
of the perimuscular connective back muscles tissues have also been
observed in individuals with chronic LBP (Langevin et al., 2009).
The muscle function of the TrA in the corset sling may be
compromised by imbalanced tension with different stiffness
properties at the two ends of fascia attachment. Furthermore, pa-
tients with chronic LBP demonstrate decreased activation of deep
muscles such as the TrA and multifidus, and overactivation of su-
perficial muscles such as the erector spinae (Hides et al., 1996;
Hodges and Richardson, 1996; Hodges, 2001; Ferreira et al., 2004;
Hides et al., 2008, 2009). This may be a potential source of myo-
fascial tension imbalance, because these mentioned muscles con-
nected via different layers of thoracolumbar fascia at LR.
Clinically, sustained manual pressure on the LR has been used to
release muscle tightness in patients with LBP. Sustained manual
pressure is applied to the location of the LR, which is a junction
between the layers of the TLF and abdominal muscles (Willard
et al., 2012). Sustained pressure on the LR frequently results in
the release of tightness and positive subjective responses in pa-
tients with LBP. However, the effect of this manual technique on
specific tissues, such as the length, change of thickness of TrA,
muscle-fascia sliding of TrA, has not been identified objectively
during in vivo studies. Ultrasound imaging is a non-invasive and
reliable instrument to examine the morphological change during
activation of abdominal muscles (Critchley and Coutts, 2002;
McMeeken et al., 2004; Hides et al., 2007; Koppenhaver et al.,
2009). Thus, US images could be used to visualize in vivo tissue
changes after manual techniques and then quantify the changes.
The purpose of this study was to compare the contraction of the
transversus abdominis (TrA) at both anterior and posterior mus-
culofascial junctions in patients with LBP and asymptomatic par-
ticipants before and immediately after a sustained manual pressure
to LR using ultrasound imaging. The hypotheses were: (1) there
would be differences in resting and contractile tissue properties of
muscle-fascia junctions of TrA (Tr, Tc, DT, and DX) between LBP
patients and asymptomatic participants; (2) resting tissue proper-
ties of the TrA (muscle length (L) and displacement pattern of TrA
(DD)) would be difference between LBP patients and asymptomatic
participants; (3) sustained manual pressure to the LR would alter
resting and contractile tissue properties of muscle-fascia junctions
of TrA and the resting tissue properties of the TrA; and (4) these
alterations would be different between LBP patients and asymp-
tomatic participants.
Using ultrasound imaging, we measured the resting and con-
tractile tissue properties of anterior and posterior muscle-fascia
junctions of TrA; and the resting tissue properties of the TrA, in
LBP patients and asymptomatic participants, at pre-post sustained
manual pressure to LR.
2. Methods
2.1. Participants
The advertisement for participant recruitment was posted on
the Internet and at a rehabilitation center. Twenty asymptomatic
participants and twenty participants aged from 20 to 40 years old
with recurrent LBP during non-pain period were recruited. In order
to eliminate the influence of pain, all participants were without
pain. The definition of recurrent LBP is pain that occurred more
than once per day during the last three months. Other exclusion
criteria were pregnancy, neoplasm, system disease, significant
lumbar abnormities, previous surgery or injury of the lumbar spine
or abdomen, and elite athletes or people that had engaged in spinal
stabilization exercise before. After enrollment, all participants were
Please cite this article in press as: Chen Y-H, et al., Increased sliding of transverse abdominis during contraction after myofascial release in
patients with chronic low back pain, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.004
assessed by a physical therapist for eligibility to make sure that the
patients are in a remission period with minimal pain. To eliminate
the influence of pain, all participants were without pain while the
examination was taking place. Participants provided informed
written consent before commencing the baseline assessment.
2.2. Instrument
A real-time ultrasonography apparatus (HDI 5000 system, Phi-
lips/ATL, Bothell, WA, USA) with a 5e12-MHz 38-mm linear
transducer was used in the study.
2.3. Procedure
2.3.1. Screening
The present observational cross-sectional study used a single-
instance, test-retest design. The purpose and procedures of the
study, which were approved by the local ethics committee, were
explained to the participants, after which they signed a written
consent form. The participants completed a questionnaire related
to their basic personal information and the Oswestry Disability
Index (ODI) questionnaire.
2.3.2. Initial evaluation
The participants were positioned in a supine crook-lying posi-
tion (Fig. 1), with their arms crossed over their chest; both the
anterior and posterior sites of the TrA were examined in random
order. Previous studies considered the dorsal attachment side to be
the fixed end (Hodges et al., 2003) and focused on the anterior
morphological change and sliding of the anterior abdominal fascia.
However, our previous study demonstrated that the measurement
of morphological changes in the posterior musculofascial junction
of the TrA is also reliable. Our pilot study demonstrated good reli-
ability [ICC(3,3) ¼ 0.888e0.978] in measuring the thickness and
sliding of the posterior musculofascial junction of the TrA. The
correlation of measurements between the anterior and posterior
sites of the TrA were moderate to good [Pearson correlation
(r) ¼ 0.41e0.74]. Thus, measurement of both the anterior and
posterior musculofascial junctions of the TrAeTLF may reveal the
possible mechanism of LBP in relation to the change of the inte-
grated musculofascial corset-like system.
The transducer was placed on the anterior or posterolateral
abdomen at the same level as the umbilicus at the inferior angle of
the rib cage. An echo-absorptive material was attached on the
participant's abdomen with Sellotape in order to generate a refer-
ence line on the US image as an internal marker for measuring the
sliding of the musculofascial junction of TrA (Jhu et al., 2010)
(Fig. 1). To measure the muscle length in the resting state, a
panorama scan (extended field-of-view ultrasonography) was used
to obtain the extended view of the TrA from its anterior to the
posterior site. For measuring the contraction of the TrA, the par-
ticipants were instructed to practice the abdominal drawing-in
maneuver.
2.3.3. Sustained manual pressure on the LR
After the initial evaluation, the participants changed to the side-
lying position for the evaluation of the opposite site. The middle
point of the LR of the TLF between the posterior musculofascial
junction of the TrA and the erector spinae muscle was identified by
US. Vertical manual pressure was applied on the middle point of the
TLF for 1 min according to the technique in “The myofascial release
manual,” page 13e19 (Fig. 2) (Manheim, 2001). The pressure was
maintained steady at a level that the participant could tolerate. The
subjective discomfort level was scored by the participants using a
verbal rate scoring method (score: 0e10). If any intolerable pain
 Y.-H. Chen et al. / Manual Therapy xxx (2015) 1e7 3

Fig. 1. The experimental setup of the anterior (A) and posterior (B) muscle-fascia junction of the Transverse Abodominis (TrA). Ultrasound probe position and the attachment of the
ultrasound-absorbable Sellotape functioning as internal markers while measuring the performance of the TrA. (A) anterior region, (B) posterior region.

used in our previous research for analysis of US images (Jhu et al.,

Fig. 2. Sustained manual pressure to lateral raphe. Position of the participant during
sustained manual pressure to lateral raphe. The arrow (/) indicates the force location
and direction of the therapist. Inset: Location of applying manual release: the middle
point of 12th rib and iliac crest on the junction of the thoracolumbar fascia (TLF) of the
erector spinae and posterior muscle-fascia junction of the TrA. TrA transverse
abdominis, IO and EO internal and external oblique, ALF, MLF, PLF anterior, middle and
posterior layers of lumbar fascia.
(verbal rate score: 10) occurred, the manual pressure would stop
immediately. The average pain or soreness perception was
3.88 ± 1.77.
2010). The calculation principle was stated in our previous publi-
cation (Jhu et al., 2010). The accuracy of the measurement by the
written program is tested by measuring a known-size object with a
Vernier caliper. The difference between the measurement by a
Vernier caliper and by the written program is 0.06 ± 0.05 mm. The
thickness of the TrA was defined as the distance between the upper
and lower borders of the fascia of the TrA. The percentage change in
thickness was calculated using the following formula:


DT
%DT ¼  100
Tr
The distance between the internal marker and the muscu-
lofascial junction of TrA at rest (Xrest) and maximum contraction
(Xcontract) was measured (Fig. 3). The difference between these two
conditions was defined as the lateral sliding of the musculofascial
junction (DX).
DX ¼ jXcontract  Xrest j
The muscle length of the TrA at rest was estimated by first
determining the anterior (a) and posterior (b) musculofascial

2.3.4. Second evaluation after releasing the TLF

After receiving sustained manual pressure on the middle point
of the LR of the TLF, the participants returned to the crook-lying
position, and measurements were performed using the previ-
ously described protocol.

2.4. Measurements

The outcome measurements in this study included the

following: 1) thickness of the TrA at rest (Tr); 2) the contraction
conditions (Tc); 3) change in thickness (DT); 4) percentage change
in thickness (%DT); 5) sliding of the anterior and posterior mus-
culofascial junctions (DX) of the TrA when performing the
abdominal draw-in maneuver (ADIM); 6) muscle length at rest (L);
and 7) the displacement pattern of the musculofascial junctions of
TrA after sustained manual pressure on the LR (DD). The unit of
measurement is in millimeters (mm). Fig. 3. Illustration of the calculation of the sliding (DX) of muscle-fascia junctions in
relation to the internal markers at anterior and posterior muscle-fascia junction of the
2.5. Data analysis TrA. The TrA is indicated in dotted line at rest, and gray area during contraction.
Xrest_a: resting position of the anterior muscle-fascia junction of the TrA. Xcontract_a:
position of the anterior muscle-fascia junction of the TrA after contraction. Xrest_p:
US images were analyzed off-line by a customized program resting position of the posterior muscle-fascia junction of the TrA. Xcontract_p: posi-
written using MATLAB. This customized written program has been tion of the posterior muscle-fascia junction of the TrA after contraction.

Please cite this article in press as: Chen Y-H, et al., Increased sliding of transverse abdominis during contraction after myofascial release in
patients with chronic low back pain, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.004
4 Y.-H. Chen et al. / Manual Therapy xxx (2015) 1e7

of the musculofascial junctions in relation to the internal markers

was defined as the displacement of the TrA (DD, Fig. 5). To deter-
mine whether the resting musculofascial junction of TrA moved
anteriorly or posteriorly, the spinal column was defined as the
origin of a reference coordinate system. A positive difference in the
distance between the musculofascial junctions and the spinal col-
umn after sustained manual pressure indicated anterior shifting of
the musculofascial corset system, i.e., the musculofascial junction
of TrA moved toward the umbilicus.

DD ¼ r Xrest  Xrest

2.6. Statistical analysis

Fig. 4. Effect of release on the two muscle-fascia junctions for individual site. *:p-
value < 0.008 in group comparison. þ: p-value < 0.008 after sustained manual
pressure.
junctions of the TrA and plotting the muscle length digitally. The F
(Langevin et al., 2009) was then fit into the following equation for
calculating the arc length to indicate the muscle length:
Zb qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
1 þ ½f ðxÞ2 dx
0
Arc length ¼
a sites  2 conditions). The significance level was set at a ¼ 0.05.
where “a” and “b” represent the x coordinates of the anterior and
posterior musculofascial junctions of TrA, respectively.
To examine whether the TrA has shifted or not, internal markers
were used, which were created by two US echo-absorptive mate-
rials placed over the skin at the anterior and posterior muscu-
lofascial junctions as references. Thus, the distances between the
internal marker and the musculofascial junctions of TrA at rest both
before (Xrest) and after sustained manual pressure application
(r_Xrest) could be calculated. The difference in the resting position
A statistical software package (SPSS version 11.0, SPSS. Inc.) was
used for data analysis. Independent t test and chi-square analyses
were used to compare the basic demographic data including
gender, age, body weight, body height, and duration of sitting be-
tween the asymptomatic group and the LBP group.
Three-way mixed analysis of variance (ANOVA) was used to
identify the differences in Tr, Tc, DT and DX of the TrA between the
two groups of participants before and after manual pressure
application in the anterior and posterior regions (2 groups  2
If interactions existed in three-way ANOVA, the post-hoc com-
parison would be processed. The significance level was adjusted to
a ¼ 0.025 using the Bonferroni adjustment for two-way ANOVA (2
sites  2 conditions or 2 groups  2 conditions). The significance
level was further adjusted to a ¼ 0.012 if interactions still existed in
two-way ANOVA.
To compare the muscle length between the groups before and
after sustained manual pressure, two-way ANOVA was used (2
groups  2 conditions) to determine the difference. The signifi-
cance level was set at a ¼ 0.05.

Fig. 5. The position of the TrA of asymptomatic participants (A) and patients with low back pain (B) before (areas indicated by dotted lines) and after sustained manual pressure
(indicated by areas with patterns). : The position of the TrA of asymptomatic participants after sustained manual pressure. Note: no significant shift of the TrA after sustained
manual pressure. : The position of the TrA of patients with low back pain after sustained manual pressure. Note: significant anterior shift of the TrA after sustained manual
pressure in patients with low back pain. Xrest_a: resting position of the anterior muscle-fascia junction of the TrA. r_Xrest_a: resting position of the anterior muscle-fascia junction
of the TrA after manual release. Xrest_p: resting position of the posterior muscle-fascia junction of the TrA. r_Xrest_p: resting position of the posterior muscle-fascia junction of the
TrA after manual release.

Please cite this article in press as: Chen Y-H, et al., Increased sliding of transverse abdominis during contraction after myofascial release in
patients with chronic low back pain, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.004
 Y.-H. Chen et al. / Manual Therapy xxx (2015) 1e7 5

Table 1 3.2. Group effect

Descriptive data of the participants.

Mean (±SD) Sig. The LBP group had less Tc, DT, and %DT than the asymptomatic
Asymptomatic (n ¼ 20) LBP (n ¼ 20)
group (Tc, mean difference: 0.76 ± 0.23 mm, p < 0.05, power ¼ 0.90;
DT, mean difference: 0.76 ± 0.12 mm, p < 0.001, power ¼ 1.00; %DT,
Age 25.4 ± 4.2 25.4 ± 4.2 1.00
mean difference: 30.2% ± 4.1%, p < 0.001, power ¼ 1.00, Table 2).
Gender (M/W) 12/8 13/7 0.48
Height 168.3 ± 6.8 170.5 ± 7.3 0.32 Furthermore, the LBP group demonstrated less DX at the ante-
Weight 60.0 ± 9.2 63.5 ± 7.1 0.19 rior and posterior sites than the asymptomatic group (DX at the
BMI 21.1 ± 2.1 21.8 ± 2.0 0.26 anterior site, mean difference: 4.30 ± 0.56 mm, p < 0.001,
6.9 ± 3.1 7.0 ± 2.9
Sitting time/day (hour) 0.90
power ¼ 0.97; DX at the posterior site, mean difference:
Abbreviation: M, man; W, woman; BMI, body mass index. 4.31 ± 0.55 mm, p < 0.001, power ¼ 1.00, Table 2, Fig. 4).

Two-way mixed ANOVA was used to identify the difference
between the two groups in the DD of the anterior and posterior
musculofascial junctions of TrA after sustained manual pressure (2
sites  2 groups). The significance level was set at a ¼ 0.05.
3. Results
The descriptive data of the participants were listed in Table 1
and demonstrated no significant difference between groups. The
recording of sitting time/day could indicate the life style of the
participants to be in sedentary style. Three-way ANOVA indicated
no significant three-way nor two-way interaction, and significant
main effect for Tr, Tc, DT, and %DT. For DX, significant three-way
interaction was noted. Furthermore, the post-hoc two-way
ANOVA demonstrated significant interaction for anterior site, and
for poster site.
3.3. Release effect
Both groups demonstrated increased Tc, DT, and %DT at the
anterior and posterior sites of TrA after sustained manual pressure
(Tc, mean difference: 0.36 ± 0.06 mm, p < 0.001, power ¼ 1.00; DT,
mean difference: 0.40 ± 0.05 mm, p < 0.001, power ¼ 1.00; %DT,
6.24% ± 3.0%, p < 0.001, power ¼ 1.00, Table 2). Both patient and
asymptomatic groups demonstrated significant increased DX after
release (p < 0.001, Table 2, Fig. 4). Furthermore, the release effect of
DX on the LBP group was more significant than the asymptomatic
group at the anterior site and the posterior site (p < 0.001 and 0.017,
respectively, Table 2, Fig. 4).
The muscle length (L) before or after sustained manual pressure
was not statistically significant between the groups (p ¼ 0.43,
power ¼ 1.00, Table 2). Regarding the DD after sustained manual
pressure, only the LBP group demonstrated an anterior-shifting
pattern (shifting toward the umbilicus) (p < 0.001, power ¼ 1.00,
Table 3, Fig. 5).

3.1. Site effect
The Tr, Tc, and %DT at the anterior site were greater than those at
the posterior site (Tr, mean difference: 0.21 ± 0.07 mm, p < 0.05,
power ¼ 0.8; Tc, mean difference: 0.17 ± 0.08 mm, p < 0.05,
power ¼ 0.56; %DT, mean difference: 16.8% ± 2.3%, p < 0.05,
power ¼ 0.52, Table 2).
4. Discussion
The primary findings of the present study are the significant
greater anterior shift of the muscle-fascial junction of TrA of both
anterior and posterior sites in patients with chronic LBP compared
to those with asymptomatic group. In addition, both groups
demonstrated greater DT and DX after release. The secondary
findings are the significant less DT and DX in patients with chronic

Table 2
The measurements of the TrA by ultrasonography before and after sustained manual pressure to lateral raphe (mm).

Variable Asymptomatic (n ¼ 20) LBP (n ¼ 20)

Anterior Tr# Before 2.69 ± 0.53 2.66 ± 0.34

After 2.68 ± 0.53 2.68 ± 0.43
Tc# Before 4.43 ± 0.73*y 3.50 ± 0.52*y
After 4.63 ± 0.87*y 3.98 ± 0.69*y
DT Before 1.62 ± 0.46*y 0.83 ± 0.27*y
After 1.95 ± 0.49*y 1.31 ± 0.54*y
DX# Before 10.24 ± 2.17*y 5.94 ± 1.26*y
After 12.07 ± 1.85y 10.29 ± 2.82y
%DT# Before 62.42 ± 21.84*y 31.39 ± 10.19*y
After 74.04 ± 18.96*y 49.89 ± 23.97*y
Posterior Tr# Before 2.52 ± 0.54 2.48 ± 0.56
After 2.40 ± 0.59 2.46 ± 0.59
Tc# Before 4.23 ± 0.92* 3.31 ± 0.71*
After 4.43 ± 1.07* 3.76 ± 0.74*
DT Before 1.71 ± 0.53*y 0.82 ± 0.28*y
After 2.02 ± 0.62*y 1.29 ± 0.35*y
DX# Before 8.43 ± 2.49*y 3.64 ± 1.05*y
After 10.00 ± 2.13*y 6.17 ± 1.28*y
%DT# Before 68.69 ± 18.79*y 34.13 ± 11.19*y
After 85.40 ± 22.83*y 54.50 ± 15.77*y
L Before 71.58 ± 13.28 73.83 ± 11.30
After 70.88 ± 12.30 74.41 ± 9.44

Tr, thickness at rest; Tc, Thickness during contraction; DT, change in thickness; DX, sliding of muscle-fascia junction; L, muscle length; #:significant difference between
anterior and posterior sites, p < 0.05; *: significant difference between groups, p < 0.05; y:significant difference after sustained manual pressure, p < 0.05.

Please cite this article in press as: Chen Y-H, et al., Increased sliding of transverse abdominis during contraction after myofascial release in
patients with chronic low back pain, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.004
6 Y.-H. Chen et al. / Manual Therapy xxx (2015) 1e7
Table 3
Displacement pattern of TrA in asymptomatic group and LBP group after myofascial
release (mm).
Asymptomatic LBP
DD Anterior site 0.32 ± 1.31 2.49 ± 3.34a
Posterior site 0.23 ± 1.28 3.00 ± 2.32a
DD, displacement pattern. A positive value indicates shift to anterior (toward the
umbilicus).
a
Main effect of group, p < 0.001.
LBP compared to those of the asymptomatic group, while the
muscle length is not different between groups.
The manual pressure technique on the LR resulted in an anterior
shift at both the anterior and posterior musculofascial junctions of
the TrA and no change in the muscle length, which may indicate a
change in the properties of the posterior TrA musculofascial junc-
tion. Thus, we reasoned that before sustained manual pressure was
applied on the LR in patients with chronic LBP, the TrA and its
musculofascial corset were located at a posterior positon, probably
because of an adhesive and/or tight posterior fascia.
Significant improvement in thickness during contraction and
the change in the thickness of the TrA support that the major effect
is on the fascia after sustained manual pressure. However, the in-
crease in thickness during contraction and the change in thickness
were close to the MDD value (ICC ¼ 0.88, MDD ¼ 0.78) (Chen et al.,
2015). This result implies a statistically significant improvement
with limited clinical implication and should be interpreted with
caution.
The sliding of the two musculofascial junctions of the TrA
significantly increased (the DX of the anterior site before and after
release are 10.24 ± 2.17 mm and 12.07 ± 1.85 mm, respectively; the
DX of the posterior site before and after release are 8.43 ± 2.49 mm
and 10.00 ± 2.13 mm, respectively, Table 2), beyond the minimal
detectable difference (MDD) calculated according to the present
and previous reliability studies (anterior TrA: ICC ¼ 0.98,
MDD ¼ 1.2 mm; posterior TrA: ICC ¼ 0.948, MDD ¼ 1.79 mm) (Jhu
et al., 2010; Chen et al., 2015), indicating a meaningful difference in
the amount of sliding after sustained manual pressure. The change
in both thickness and sliding of the musculofascial junctions of the
TrA after release of pressure on the LR may have resulted from
tension redistribution of the musculofascial corset system.
The anterior shift of the musculofascial corset system may be
due to the change in the elastic property (K) of the fascia, but not
due to the change in the muscle length of the TrA. The myofascial
stiffness of the posterior musculofascial junction of TrA is deter-
mined by the elastic property (K) of the fascia in the musculofascial
corset system. Smaller K value indicated less stiffness. During
muscle contraction, force (F) is generated to increase myofascial
tension. The release of the posterior musculofascial junction
resulted in anterior shifting of the musculofascial junction of the
TrA, and greater sliding of the fascia (DX). When muscle contraction
force (F) is generated after release, which is considered to be the
same as before release, greater sliding of the fascia (DX) indicate
smaller K value of elastic property, and less myofascial stiffness.
Thus, the present results support that the area of the LR, the
junction of different layers of the TLF (Willard et al., 2012) forming
musculofascial corsets, is a site of possible effective intervention to
improve sliding of musculofascial junctions of TrA and decrease the
stiffness of the fascia.
Tensegrity structures are characterized by use of continuous
tension and local compression; architecture and pre-stress (inter-
nal stress prior to application of external force) play the most
critical roles in terms of determining their mechanical stability
(Chen and Ingber, 1999). The concept of tensegrity regards the
Please cite this article in press as: Chen Y-H, et al., Increased sliding of transverse abdominis during contraction after myofascial release in
patients with chronic low back pain, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.004
fascia as a force transduction network rather than local passive
structures (Chen and Ingber, 1999; Ingber and Tensegrity, 2003).
Consequently, the phenomenon of posterior location of the TrA is
considered, as it makes the TrA and surrounding connective tissue
unable to slide or glide, thus impairing functional efficiency. The
effect of release with manual pressure applied on the LR was
examined by ultrasonography in the present study, providing dy-
namic tissue information.
The majority of previous studies regarding the effect of manual
pressure treatment have reported on the general performance of
the patients, such as the range of motion and pain status or uti-
lized data from functional questionnaires as the outcome mea-
surements (Threlkeld, 1992; Barnes, 1997). In contrast,
ultrasonography could be used to identify the target tissue and
provide quantified measurement of the effect. The present study
suggests tension imbalance in the musculofascial corset system of
the TrA and the surrounding connective tissue in individuals with
LBP. The findings of the anterior-shifting pattern of the muscu-
lofascial junction of the TrA in patients with LBP after sustained
manual pressure indicates increased pre-existing tension/adhe-
sion in the area of the LR.
However, the length of the TrA measured by US in our study was
shorter when compared with those reported by previous cadaveric
studies. Previous cadaveric studies have reported the length of the
TrA to range from 95 to 113 mm (Urquhart et al., 2005; Brown et al.,
2010). The shorter length reported in the present study may be due
to different locations of length measurement or the muscle tone
existing in vivo.
Using ultrasonography, the present study demonstrated that
sliding and the changes in thickness were smaller at the posterior
site of the TrA in patients with LBP when compared to the
asymptomatic group. The implication of the result indicate that
patients unable to increase the intra-abdominal pressure by sliding
to increase the tension of musculofascial junction of TrA. This is
complementary to previous studies which using ultrasonography
to investigate the anterior site of TrA that reported a similar
decrease of thickness at the anterior site (Critchley and Coutts,
2002; Ferreira et al., 2004; Hodges et al., 2003; O'Sullivan et al.,
1997; Teyhen et al., 2009). The decreases of muscle activation
from the present study of the posterior musculofascial junction;
and previous findings from anterior musculofascial junction of TrA
(Critchley and Coutts, 2002; Ferreira et al., 2004; Hodges et al.,
2003; O'Sullivan et al., 1997; Teyhen et al., 2009) provided more
comprehensive understanding the change of TrA in patients the
change in motor control of TrA in patients with LBP. Furthermore,
previous studies using MRI demonstrated that elite athletic par-
ticipants with LBP (Hides et al., 2011) were less able to decrease the
cross session area of the trunk during ADIM were decreased
compared with that of athletic players without LBP. The patients
either elite athletic participants with LBP (Hides et al., 2011) or
middle aged patients with LBP in the present study might be unable
to decrease the cross-sectional area of the trunk, or decreased
sliding ability, and consequently are unable to increase the intra-
abdominal pressure by increasing the tension of muscle-fascia,
which is related to spinal instability suggested by Hides et al.
(2011).
The percentage change in the thickness at the posterior mus-
culofascial junction of TrA in asymptomatic participants in the
present study was similar to the percentage change in the anterior
musculofascial junction reported in previous studies. The per-
centage change in thickness at the anterior site has been reported
to range from 49.7% to 65.5% in asymptomatic individuals and from
19.2% to 44.6% in patients with LBP when performing the ADIM,
which is comparable to the results obtained in the present study
(62.4% vs. 31.4%) (Critchley and Coutts, 2002; Teyhen et al., 2009).
 Y.-H. Chen et al. / Manual Therapy xxx (2015) 1e7
The posterior musculofascial junction of TrA also presented a
similar pattern of percentage change in thickness (68.7% vs. 34.1%).
The results could be further investigated by directly measuring
the tension of the fascia at two ends of the TrA by elastography.
Considering that the role of the fascial component (Gracovetsky,
2008) is not well described in the current model of spinal stabil-
ity proposed by Panjabi (1992), more scientific studies of the me-
chanical properties of the fascia and the effect of manual treatment
on connective tissues are needed in future study.
4.1. Limitation
The changes occurred at anterior and posterior sites of muscu-
lofascial junction of the TrA could not be measured simultaneously
by ultrasound image due to the limitation of the transducer. The
immediate effect of myofascial release was investigated in the
present study. The long-term effect of release need to be further
examined. The present study investigated only the immediate ef-
fect of myofascial release; the long-term effects require further
investigation. Furthermore, the application of the present study is
limited to population of participants who is during pain remission
and in non-athlete population.
5. Conclusion
The musculofascial corset was shifted anteriorly in patients with
LBP after release of manual pressure applied on the LR. Both
asymptomatic participants and patients with LBP demonstrated an
increase in the DT and DX of the TrA after manual release. After
sustained pressure on the LR, both the anterior and posterior
musculofascial junctions shifted toward the ventral site (anterior)
in the LBP group, indicating pre-existing tightness and/or adhesion
in the posterior junction of TrA. The manual release technique on
the TLF is efficient at facilitating change in the musculofascial corset
system, as the sliding of the musculofascial junctions of the TrA is
improved beyond the MDD.
Key points
Findings: This study provides evidence of the effect of sustained
manual pressure on changing the location of the musculofascial
corset system, and the change in the thickness and sliding of the
musculofascial junctions of the TrA, which may result from tension
redistribution in the musculofascial corset system.
Implications: The results of the present study support the
concept that the TrA and the surrounding connective tissue may be
restricted at a more posterior position. Adjustment of the tension at
the posterior site through sustained pressure on the LR resulted in
an anterior shift of the TrA in patients with LBP. Thus, restoration of
the tensional integrity and optimal muscle function of the deep
musculofascial corset system may play a role in providing stability.
Caution: The present study investigated only the immediate
effect of myofascial release; the long-term effects require further
investigation.
Acknowledgment
The research is supported by NHRI-EX100-10042EI, NHRI-
EX101-10042EI and MOST 103-2314-B-002-022.
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