STA185 ‘Thoracolumbar Fascia and Lower Back Pain' with special guest Claire Boucher

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
You're listening to the Sports Therapy Association podcast, putting evidence
back into soft tissue therapy.
Music.

(00:20):
Welcome to episode 185 of the Sports Therapy Association podcast.
My name is Matt Phillips, creator of OneChatLive.com. and
as always this episode is being recorded live on
a tuesday at o'clock on the sports therapy association youtube
channel and also on the sports therapy association
facebook page and the facebook group so plenty of

(00:41):
ways to join us if you're honest in the podcast and you do want to join us
live so you can ask the actual guest questions directly or
just hang out with other like-minded soft tissue therapists then that's
what you have to do just eight o'clock head to one of
those sources so very shortly in this episode thoracolumbar
fascia and lower back pain my special guest is going to be claire
oucher lecturer of sports therapy rehabilitation at country

(01:03):
christ church university and phd researcher
at university of kent but first as always i
want to give a massive thank you to last week's guests plural
uh last week because it's the first tuesday of the
month we had our regular series ask us anything
and some of the questions on that included further education
for myself's therapist sports therapist or physio we had

(01:26):
rebranding renaming my business which logo how do
you keep things fresh in your clinics nutrition consultation alongside
sports massage any recommended courses and also
a question about hiring an additional therapist is the subcontracting model
effective what's a fair hourly rate and commission split therapist so all of
the answers to that were provided very graciously by our sta panel who in this

(01:48):
episode were made up by daniel peters director of body health gatwick also we
had in in the studio, Mark Bleasdale.
Sports massage therapist in Langdala, or apparently in Wales it's pronounced Shandilaw.
Penny DeMoss, the Soma sports massage therapy. I can't wait for emails about that pronunciation.
Yeah, Penny DeMoss, the Soma sports massage therapy was also with us on the panel.

(02:09):
And then last, oh, Sarah Clatworthy was here as well. Sarah Clatworthy, sports therapy.
And then last but not least, founder of the STA, Gary Benson.
And so, yes, like I say, if you do want to listen to episode 184,
and it's available as always on all popular podcast apps and on YouTube and
of course at the STA website which is thesta.co.uk.

(02:32):
Also if you are an STA member and you'd like to be part of the STA panel on
the next first Tuesday of the month, so using my math that will be the first Tuesday of March,
then you can email me matt at thesta.co.uk and if you fancy being on the panel
and not an SDA member, then look into becoming an SDA member. Remarkably cheap.

(02:53):
Particularly effective and welcoming and warm and supportive
so there you go right then by the way
if you are joining us via the facebook open group and you'd
like to ask a question or leave a comment then you do
need to give facebook permission for your
image and logo to appear on the
screen there is a link in the comments but

(03:13):
if you are watching this live and i'm
going to put the link up here on the bottom of the screen there now you
can see that just there it literally is
you just just have to go to the website b.live
forward slash comments hyphen issue you do it once and
it's just a facebook security thing so there you go and if
you do join us live then obviously you can ask our guests questions

(03:34):
directly and you can share your feelings
you can just hang out with each other for example in the live lounge at the moment
we've got glenn murphy hey glenn let's this evening playmates
back to the 80s glenn murphy thanks glenn
good to see you here as always ways gary benson
found at the sda so sorry i'm late to the party gosh everyone's
painting quite a picture of merriman tonight i hope our

(03:54):
guest realizes that that it's going to be entertaining as well
as educating uh cecily hisslop has joined us
as well hey cecily how you doing good to see you we've got.
A facebook user now facebook user just to
point out the reason we can't see your beautiful face and all
your name is because you just need to click that link which is
in the show show notes not in the show notes it's in the comments for the

(04:15):
open the facebook open group or so you
can see it at the bottom of the screen once i get your comment or maybe you
want to remain anonymous and haunt our guests the rest of their lives without
knowing who you are it's fine it's 2024 it's what we do so there we go thanks
for joining us people live so i think it's about time i've left her for long
enough down in the lobby as i say tonight it's going to be thoracolumbar fascia, lower back pain.

(04:39):
So I shall bring up my special guest Claire Boucher.
Music.
Hey Claire, how are you? Hey guys. Now I'm a bit unnerved by the party vibe that's going on.
There's so much to be worried about. We've got a stalker in there.

(05:03):
You'll never know who they are.
And yeah, we're expecting balloons and whistles. So there you go.
But thank you anyway for joining us. I hope you don't run away.
No, yeah. No, I won't. I mean, I did think I could bring out some party pockets.
It's my birthday on Thursday, so it kind of fits, you know. Oh,
seriously? I have a birthday for Thursday.
Thank you very much. And I hear you've had a busy day today, yeah?
Yeah. Yeah, seven hours of teaching today, back to back without a break.

(05:26):
So I am a little bit flat, but the party vibe is obviously waking me up a bit.
So I apologise if I'm a bit slow.
Well, that's a wonderful segue into telling us about where you are in the country
and what you've been teaching. That'd be great.
Yeah, so I'm down in Canterbury, so southeast of England, basically.
I am currently working at Canterbury Christchurch University.

(05:46):
I have also worked at the University of Kent over the past kind of five years.
I've sort of jump between the two which there's
a big rivalry between the two universities so it's quite
comical that I'm that person between them both basically
so I'll give you my background really I suppose please I well started off with
I was working as an exercise referral instructor in health and fitness industry

(06:09):
for about well coming up 10 years really I've been in now a different role and
I found that I was working a lot with people with lower back pain and we weren't really kind of,
understanding the kind of what was going on there.
I mean, there's what, 82% of the population with non-specific back pain,
and we don't really know what's going on there.
So that was always a big driver, I suppose, in me and kind of gaining further education.

(06:35):
I then went back into education, did a sports science degree,
and then ended up with a PhD kind of in sports therapy. So my.
Kind of sidestep into there was a bit comical really. I was lying on the sofa
with back pain, with my legs in the air, scrolling through Twitter and I saw
this PhD application come up for thoracolumbar fascia and lower back pain.

(06:59):
And I thought, what the hell is the thoracolumbar fascia? Why have I never heard
of this in my 10 years of work and education?
I need to know more. So I reached out to my, well now supervisor and amazing researcher, Dr.
Kira DeConnick and said, hi, I'm keen, but I know nothing.
What do you want? Are you interested? Can I apply?

(07:21):
And then it kind of went from there, really. So I started my PhD and I started
lecturing, lecturing in sports massage, a lot of kind of muscles,
gleeful anatomy, various different rehab modules and biomechanics and anything
they could chuck me at, really.
And now I'm still doing a bit of everything.
But today I was teaching exercise referral this morning

(07:43):
and then introduction to kinesiology and msk
and after me this afternoon so that's that's the
whistle stopped all to me really i think you've
got a lot of people on your side now because it's beautiful the story of not
how easy it is to get into these things so obviously you've got to do your work
but how yeah you're lying in pain with your back and you're looking through

(08:03):
like people just swiping away scrolling scrolling the doom and then suddenly
wow that looks interesting I can do that.
Yeah, and here you are. Brilliant. Very cool.
So the research, that is the title of today's episode. I'm just going to share
this for people who have joined us live and put it on the screen.
It's the second publication you've had so far to this date.

(08:24):
And it's that it's on the screen now just go to research gate
in normal places and you will be able to find what's going on but
yes we're talking about tracheal pain relationship between
the tracheal fascia and lower back pain how
long ago was this written wasn't that long ago was it no so
that was my first or second phd
study so it's only yeah i've only i've literally only just finished my phd

(08:46):
i passed my bible two weeks ago so i'm in
the process of thank you writing writing everything
up to get more and more things published basically but
yeah that was kind of the first thing i talked about so the data was collected
2021 2022 for that one excellent
and that's gonna we're gonna be talking about that tonight before we
do just to mention you're also very much involved i love looking

(09:07):
you up on linkedin actually we've got information about
you there it's exciting to hear and that you're also
working part-time i don't know how you find all the
energy but a lot of times they need triathlon coach yeah
yeah yeah that's my weekend job so yeah I
can't really I fell into that as well it seems to be a habit
with me I was teaching spin class and they

(09:28):
needed cover for the triathlon class afterwards I was like but
at the time I couldn't really swim I mean I could swim to survive
but I couldn't triathlon swim and
I said I can't do that and they yeah chucked me in
last minute and I love it I love it I've
got a little little whatsapp group we've been chatting today there's about 40 of
us in there about going up to london to watch one of the british olympic

(09:48):
get swim games and yeah i love it it's my little side hustle.
With sea swimming and triathlon i can't stop.
I have enough work yeah i'm getting that pressure i think it's a few episodes
this podcast you need to look into about taking time off yes how to say no yeah
yeah doing my spinning class well not teaching and then suddenly the the opportunity

(10:09):
came up to be a triathlon league coach. Yeah. Wonderful.
Okay. Right. So a lot of passion and interest there. So we're looking forward
to listening to this. So let's get straight into it. If it's okay with you.
A lot of our listeners will be familiar with fascia by now. It's been through
different waves of popularity.
It's been credited, maybe over-credited sometimes, and then discredited too

(10:32):
much. And it's kind of been very rocky.
I'm interested, first of all, just in theory, it should be the same.
But can you give us a little definition about fascia and its role in the body
that we'd like to start with?
Yeah. So basically, our whole body is covered in fascia.
And it's an area of connective tissue, really, that encompasses think

(10:52):
of it like a second another organ really it's underneath our skin
and it covers all of our muscles our whole body and what
we used to think of it if we go back to you know 40 plus years ago is that this
tissue was purely there as like packing material and it meant nothing so you'd
see lots of research and evidence of surgeons going well we cut through that
that's not doesn't matter and then we just get to what interesting underneath

(11:15):
you know the bones the the muscles, the tendons.
And then we started to kind of go, well, actually, wait a minute,
there's something here. We won't just have all this much packing material.
It's got to have a purpose. We've started looking at the kind of the chemical
makeup of it, the kind of what's going on with the extracellular makeup,
what's going on in terms of different nerve fibers.

(11:36):
And we know that the thoracolumbar fascia, which is on the lower back between
your isthmus dorsi and your glute,
has more nociceptors than muscle so
there's more ability to feel pain
in this than anywhere else kind of in our body so
how can it not be linked with back pain and that was kind of my main kind of
burning question so what we've had I suppose in in and around recent years of

(12:02):
people going this is the this is what's causing everything this is the answer
and we've not quite managed to quantify that in the research yet.
I'd argue there's certainly still something at play there, but it's what exactly,
is it the connective tissue and the dense and the loose layers,
or is it the extracellular matrix?
How is it, you know, we don't know chicken or the egg, what's causing what kind
of thing, but there's something definitely going on there, in my opinion,

(12:26):
that I think warrants further research from research perspective and further kind of, I suppose,
trial and error with different practices and manipulations to
try and improve that clinically because yeah I'm kind
of on both sides here I want I want to do the research but
I want to know how to treat the patient because ultimately what's the
point otherwise if we're just finding all these numbers

(12:46):
but if they don't help someone it doesn't really matter to me shouldn't say
that as a researcher no that's a really wonderful beautiful modern interpretation
of research is because historically has been a little bit kind of academia separated
from shop floor and that's why it's taken so long for souls to come through.
13 18 years depending where you look and now people like

(13:08):
yourself it's very exciting we've had we've had other researchers who
have turned into clinical or spoken directly to
the shop floor like dr karen inshore is a good example some of
those trying to connect the research with the reality
it's a very kind of modern idea and before it would have been poo.
Poo say no you're either academic i know you
know it's kind of like but now there's people like yourself who are like brilliant.

(13:29):
You're kind of thinking oh this is ridiculous it's the same we need.
To be together yeah well so now it's very exciting and
a woman as well which i wasn't going to bring up but you are and that
is that exciting for you have you noticed that that's because i've
had a lot of guests who said that one of the problems with
the research it's traditionally it's been done by men
on men yeah a lot of differences

(13:49):
are coming up depending on what you're working on but are you aware that you
are a woman working research and that's something quite modern and good i
mean i suppose so in that there's there are less
women in my universities that i've worked at than men but
on the flip side of all the BASIA researchers I
know I think I actually know more female researchers that
are working with BASIA specifically so perhaps we're

(14:10):
navigating our way there for some reason I'm not
really sure but yeah I haven't really thought
about it to be honest because I just I've got my goals and
my aspirations with research and training and
all the rest of it and it doesn't really matter to me that I'm female because
I'm gonna do it anyway it's probably a very
healthy answer oh stubborn i didn't say

(14:31):
that by the way right so let's bring up for again we've
probably got mixed people um listening and joining us
live so we're just going to pick up an image here it's if
you listen to the podcast and want to see the images then you can always hop
off the podcast and go to youtube and obviously you'll see the recording there
or you can go to the sta.co.uk and you can you can connect to the recording
there so i'll bring this up on the full page this is the area we're talking

(14:53):
about yeah give us an idea about what in particular of the fashion in this area
does and why it's an area of great interest for you?
Yeah. So, I mean, what we've got there is kind of, it's a nice image.
I think it's from Grey's Anatomy. I won't know, which is beautiful imagery.
So we've got the kind of green oval that's showing you kind of the whole general
area of the thoracolumbar fascia there.

(15:14):
So it's connecting, say, all the way up between the glutes and the latissimus dorsi.
Where I've been particularly interested is the little square.
And that's not just on that side.
I have looked on both sides of the spine, which is basically between L1 and
L2, looking at that kind into this space and we look two centimeters to the
left and to the right of the spine.

(15:35):
So we pick this area partly because, I mean, it's the lumbar spine.
We know we get a lot of specific lower back pain in this area.
But also, so we can try, and it's because I'm using ultrasound imaging,
I'm trying to find an area of the thoracolumbar fascia that's relatively.
Unaffected by the underlying tissue, be that the kind of curvature
of the body as we go around the trunk or be that as

(15:56):
we get lower with the glutes coming in or the vertebrae and all the rest
of it so that's kind of the one of the flattest parts
for me when measuring which makes it easier for
me to take the scans if i'm honest but it's also mimicked
after helene langevin who was what is a really
really big fascia researcher arguably the pioneer
here if i'm honest and that's where she started doing her studies and you'll

(16:19):
see quite a lot of us are like yes that's where we're looking that works and
it makes some really nice images so yeah you can can really see some nice healthy
fascia and people with perhaps maladaptive fascia as well at that's.
Fantastic and i'm interested you mentioned on the paper which
is freely accessible as a lovely pdf will include the link in the show notes

(16:40):
but you make a point of reiterating our lower back pain is like the leading
worldwide cause of years lost to disability i mean you gave a statistic i think
84 percent of the given population will experience lower back pain which is incredible really yeah.
Obviously it's probably multifactorial it might be the fact we
can't see it that might have something to do with it you know you know
headache just rub it with the back it's kind of like i can't see what's going on but do

(17:03):
you think maybe the fascia in this area is is something
which is to do with it do you think that makes a standout yeah i
do i suppose that's that's my
opinion in a way because you know there's lots of evidence now and i've recently
started reasoning about kind of that nociplastic and nociceptive pain kind of
for back pain coming from the cns basically but i i think i do think it's multifactorial

(17:24):
i don't think i will ever be able to go yes it's just fascia 100 but i I think it plays a role there.
I think fascia is adapting and we can see differences with people with pain
and without pain, whether that's
a cause of the back pain or caused by maladaptive movement patterns.
We all know if we're in pain, we hold ourselves differently.

(17:45):
We're probably more likely to be sitting or lying down. I certainly was.
We're not doing that regular movement physical activity.
So I think it's got to play a role. If it's got that many pain receptors, how is it not?
And we also know that it's connecting everything so when we
get back pain we very rarely go oh yes it's exactly this
one point it's more this kind of overarching kind of numbness perhaps tingling

(18:06):
sensation that covers a lot of ground it's like toothache you generally don't
feel it in one spot it radiates doesn't it and that makes me think with the
back anyway that maybe that's back here because it's it's just so all-encompassing kind of pain.
Wonderful and and we're going
to get onto what your study ceased to to
prove or look at and demonstrate but essentially

(18:29):
some of what you were looking for looking for had been shown before to do with
the thickness and so if you could like kind of talk to us a little about what
you thought you were going to find and then we can go into what you actually
find yeah so i mean again started off with that helene langevin so she had a
few studies 2009 2011 if you're interested in fascia look her up and go read
them because she'll blow your mind.

(18:49):
But she basically found it was a 25% increase in thoracolumbar fascia thickness in those with pain.
I think it was around a 20% reduction in echogenicity.
She also looked at shear strain, which is the gliding capabilities of fascia.
So as we move, they glide.
I didn't have good enough equipment, unfortunately, to measure that one.

(19:09):
So I stuck with the two kind of single images.
But I was sort of hoping, I suppose, and finding and and hoping to find that
same kind of pattern, that significant difference, that 20 plus percent kind of variety.
But it hasn't been found by anyone else, not at that significance level.
We're seeing trends, but we haven't been able to recreate that.

(19:30):
And, I mean, I didn't either. I found a difference, but it wasn't anywhere near that.
I think it was about 11% of it. I can't remember the life of me,
right? You'd think I'd know it by heart by now, but I don't.
But, yeah, it wasn't significant.
So there are differences, but why are they not?
I'd argue that's potentially populations. I looked at sedentary,

(19:53):
not physically active, you know, and relatively low levels of pain.
So my participants, I would say, were, and that's for all of my three ultrasound
studies, I think all three of them were very, what I would describe as kind
of a typical population with pain.
So, you know, we've all, all 80-something percent have this low level of pain.

(20:13):
Perhaps it's going on for a long time with that chronic, perhaps it's recurrent,
but it's not enough to stop us from functioning. And that, I suppose, is what I was looking at.
I wonder, and this is my theory, I think perhaps we start seeing those significant
differences if we look at people with very high levels of PEP.
It's going to be much harder for me to recruit them because you're in a lot of pain
you probably don't want to come into my lab so i can scan you and

(20:35):
do some exercise and movements with you and see any differences and
yeah i mean that's what i basically that was the
outcome of my phd that i need to do more to find more with different pain levels
that just keep going the whole time but yeah i think that's that's these few
results of anyone who does i've never done recess but everyone we talk to on
the show seem to think and our conclusion was more studies need to be done It pretty much is.

(21:00):
I can see a message from Nikki in the chat saying, you know,
the Langevin study was really pivotal for finding these differences.
But yeah, couldn't conclude the chicken or the egg. We still don't know. We still don't.
We don't at all. I did the one of my studies was a six month exercise intervention, which was long.
I won't lie. So I did have 45 participants. We split into different groups for the control.

(21:24):
Role and we did two 55 minute
exercise classes with me instructing twice a
week every week for six months which was
a lot keeping these people active we enjoyed it
we've had great fun actually I made some proper friends with
these people with all with pain and we did ultrasound at the
beginning three months in six months at the end and

(21:44):
then six weeks post and I thought well this surely
will tell us something you know something significant about
this because six months of difference and again we
saw changes and certainly a trend towards a reduction
thickness and a change in echo but it wasn't
significant so we still don't know what's causing
what and I think for that we need studies

(22:05):
really looking at kind of before that onset of pain we
need a lot more like that and following them on which takes time and money I
know Carla Secko has been doing a lot of work looking at a really really early
I think like pre-birth kind of stages and looking at what is is going on with
the development of FASIA and perhaps that's something we can then track.

(22:26):
That's going to be a long time coming because it's not just go and do a quick
one study or a six month study. It's going to be years and years over time.
And I think there's certainly interest in it.
I know my mom, I'm going to keep going on about my supervisor,
Kira, because she's amazing.
But I really scan some of the same people she scans.
So I think she's hoping to kind of see if we can get the research to put those

(22:47):
together, because some of those have been like 10 years in between.
Do we have any differences? Have we seen any kind of changes in their pain statuses?
But it's really hard to kind of knuckle that down and quantify,
I suppose, that research when, you know, life happens in between.
So how can we... Spin classes and triathlon coaching. Yeah, it's tricky.
It's so healthy though. It's so interesting hearing. I don't know.

(23:09):
I don't want to go on too much about the modern researcher, but it sounds like,
you know, you're constantly critically kind of thinking, oh,
but challenging yourself, challenging your expectations and not kind of doing
kind of study where you're looking for this.
And therefore hey guess what you're finding this and that seems to
be a kind of a modern take and a little bit more realistic because

(23:30):
in the past yeah i mean researchers have been guilty of that
they've been looking for something and they found it because they were looking for it so
sounds really healthy which is essentially what clinicians need to
be doing as well if they if they do a course on i don't
know this and that and then suddenly the next 100 patients are going to
have this and that what a surprise they're looking for but that's how
it's gone with research though if we look at kind of back

(23:50):
pain in general when we first started being able to to use
x-rays suddenly all the back pain was to do with the bone to do
with the spine then we started looking and being able to image the
muscles and like okay it's all to do with the muscles now we're
using ultrasound and we're looking at a path here you know we it's kind of I
think human nature to have that sort of degree and I think we just need to kind
of remember that whatever we're doing is building on something and I don't think

(24:13):
I sound a bit preachy there but it kind of is you know it's all I don't think
we could it's really difficult to find something I think nowadays it's like,
this is that, you know, it's more likely to be this big picture and how can
it all interplay, I suppose.
That's great. And that's so, like I say, that's so similar to what should be
happening in things, you know, we probably might not find the exact cause of

(24:35):
your pain, but we're going to address these factors, you know, it could be a factor.
And hey, if we keep doing a little bit of this, a little bit of this,
guess what, you're not in pain anymore. Do we know what fixed it exactly?
No, but we're getting there. But it works. it works you know yeah
so yeah really interesting um i wanted um
i was in i think it'd be interesting for listeners again i'm sorry podcast
listeners you can't see this image but i just want to bring up these images

(24:56):
which are on the pdf and we will put a pdf in the
show notes and let's put that on a solo it just kind of shows the participant
demographics and how did how i'm interested how did you choose what sample size
to have how did you sort that sort of thing out yeah so we We did some power
equations to work out kind of the minimum we'd need for each of these studies.

(25:18):
And we also looked at what's existing elsewhere.
This study was actually started the day of the lockdown. So I had all my labs booking.
I had all of my participants lined up and then, nope, we're not allowed to do
that. We can't get face to face.
So it was all changed, all cancelled, started again, started again post all

(25:38):
the lockdowns. I then got a chest infection halfway through,
so I had to move it around.
And, yeah, if anyone here is
thinking of doing a PhD, expect a roller coaster. It really is like that.
Even without the pandemic, I swear, this is just how it goes.
But, yeah, and then it was looking for participants.
So some of the participants with the No Back Pain Group in this were my colleagues at the university.

(26:00):
For the Low Back Pain Group, I actually recruited from local residence chats.
So I have the Canterbury Residence Group. there was Whitstable Herne Bay the
neighbouring town and I put out a nice poster and just like hey I'm interested in back pain.
Do you want to take part kind of thing and it was actually I
mean I sent out about 400 emails and I'm not exaggerating in that but I got

(26:22):
a nice chunk of people back that were really interested really keen and just
I mean I can't thank them enough like I bought them all chocolate when I finished
but I'm on a research budget so it wasn't very much chocolate but it was like
thank you thank you have something so yeah it's
I like recruiting it's something I think is
one of one of my favorite things of research which perhaps

(26:43):
is a bit strange but I like I suppose because I'm working with people with pain
I want to be able to try and give them something to kind of interesting something
to learn because so often with well with something that's chronic and going
on we're just kind of told well you've got to live with it now and it's like
well actually I think people inherently want want to learn and want to.
Even if it's still not equivocal we still don't know thank you Anne next time

(27:08):
I'll let you know but yeah we don't always we don't always have the answer and
the research isn't always going to give us it in that clear-cut manner but it,
gives us something to think about something to investigate
and i think we're inherently nosy aren't we as people we
want to learn something we want to investigate ourselves and yeah
it means i get to talk to people about that yeah so that was that was really

(27:28):
cool i think it's um i don't
know but i know what how i'm feeling but i think for our listeners as
well it's encouraging to hear how how research
truly works as again it takes researchers off
the pedestal we imagine it's everyday people like
yourself having to send out emails call people make friends
say please can i not please you know and then suddenly it's out

(27:48):
of the world pandemic which kind of puts you know it's i think
it makes this we definitely need more research done but.
It makes it more accessible to people thinking maybe i could never
do research that's for the clever clogs but i'm not saying you're not clever clogs
but it just it means it is accessible if you've got
a passion for something and you want to do this then you know
it's it's hopefully it will encourage people people to do it especially

(28:08):
clinicians you know especially people who maybe fear academia
and think i could never do that you can't do it yeah get
involved like get involved in a research study you
know obviously i'm down in kent but there are multiple universities
that run sport therapy courses now but are doing similar
stuff i think we're the only fascia team down in kent and
literally the kent fascia team is our new name but

(28:30):
but people are doing research take part start see what's
going on and ask how you can get involved there's always usually some
sort of internships going on in summers you could always
do a master's you know we have masters by research you could
go and investigate that yourself and come and join our team you know we'd love
it we want you know we want to know well certainly i do and so does my supervisor
well what are you seeing in clinic that we don't know about because we all know

(28:55):
from working with people you see something over and over again and actually
you're like why is no one doing anything about this because they they don't know.
How do you link those two off? And that, I think, is a really,
a big thing is research dissemination, but not just from researchers to clinician,
but back, clinicians to researchers. Clinicians can give us such.

(29:16):
Eye-opening experience as to what they're seeing what's working
for them what treatments are working because otherwise there's too
much there's too much to cover and give us direction i think
certainly i do i always want to hear from clinicians and
what's working or not working for them so we can.
Kind of quantify that in research yeah very
encouraging wonderful right so it is going to get a

(29:38):
little bit geeky now because we're going to show images of ultrasound with
that which again i'm excited that you're here to comment on that
because i think it's something else which again we've talked
so many times about non-physios basically whether
it's a sports therapist sports massage therapist but having a
bit of imposter syndrome and i think maybe reading an
ultrasound is something which strikes the fear into into.

(30:00):
Any non-alert health professional because it's like oh my god that's a world i
can't do and if a patient says i could bring in my ultrasound if you
want all sorts of excuses come up out of sports medicine
oh that's okay i don't want and so
i'm excited it's obviously your whole thing about ultrasound let's
bring up some images of what you found and then
maybe you can talk us through the significance of the yeah so

(30:22):
i'll prefix it with i do not have
a formal qualification in msk ultrasound my
supervisor does actually a 12-month course
i think it was southampton don't quote that somewhere somewhere
with self and basically she trained me in how
to measure ultrasound so I had like-for-like training and
how to use this methodical on the fascia so I am I'm not

(30:44):
an expert I you told me to scan your elbow I could manage it but I couldn't
guarantee what I'd be looking at but in terms of fascia I kind of I understand
the methodology behind it and I can well we did a reliability study and I could
scan as reliably as my supervisor so we know I can do it it's just uh yeah in
my little area of ultrasound.
But yeah, so what I did was basically I took ultrasound images of the lower

(31:09):
back, say between L2 and L3, two centimeters to the left or the right.
And we did this on people with and without pain. So I'm kind of guessing at that image.
I know that's one of my analysis software there, but I can tell you that's definitely
someone with pain from looking at it.
So what we've got is basically that's a MATLAB script.
So if you're freaked out by ultrasound, this will make it even worse.

(31:29):
So basically, we analyze the scans using a piece of software called MATLAB,
which uses literal code.
So I think developers, computer people to make this code.
And I won't lie, my boyfriend helped me with it because he's a web developer.
So he helped me make the scope work. Oh, yeah, it was very convenient.
And what that could do was basically what I've done on that image there,

(31:52):
and that's the kind of section in the middle of a full ultrasound scan at the
back, is I could kind of sort out the zones that I was interested in, really.
So I think if you can all see, I'm looking from the top there.
So the kind of the red line that's going across the top, and between the red
and the green line is looking at the kind of subcutaneous zone.
So on some people, this is going to be really, really small. some people

(32:14):
it's going to be larger depending on where you're holding your
kind of adipose tissue okay and that's shown by
kind of the darkest so when an ultrasound is going down and
bouncing those kind of beams back up to you if it's kind of liquid or fat it's
going to show as black okay so that's what we're seeing there I then have the
zones between the green line and the blue line and that that's what I'm interested

(32:36):
in that's the thoracolumbar fascia here okay so underneath that You can see
there's an additional kind of white line, kind of pale white.
That's the kind of covering the muscle. And actually, you can't quite see it
on there, but underneath there is all the muscle and you can see all the kind
of the striations there.
So what I'm looking at in that kind of between the green and the blue is the
kind of, oh, I've got a funny sound. Can you hear me OK?

(32:58):
I can hear you fine. Yeah, cool. It's the kind of the lines,
which are the dense connected tissue and the loose connected tissue kind of lining up.
They look very neat and tidy at this angle because of where I'm slicing through with the scanner.
But in reality, they're more honeycombed up.
And looking at the darkness between those lines at the extracellular matrix,
so the kind of the fluid that's between these layers, which allow them to glide.

(33:20):
And actually you can kind of see something I found
in that image so we haven't managed to quantify
this but it's something I mean I certainly want to look
into and if you're at home zoom in pause the screen
and zoom in later you can see there's kind of two little pockets
of kind of really dark areas inside that fascia
can you see what I mean where it's kind of a bit bigger it's

(33:40):
kind of they're kind of this kind of shape in there slightly
up in the blue yeah so I have a
of theory on this and it's very much theory but basically
what we were seeing in people with pain is they
had more of these kind of pockets of this fluid and what
I think that is is evidence that we've got reduction in shear strength so reduction
in that movement between the layers and I'm going to do it with my hands because

(34:04):
otherwise I can't explain it so if we imagine the kind of dense connective tissue
layers are like logs and they're in a gel kind of water so they're moving around
happily, the fluid's moving, everything's good.
If we then get kind of adhesions or it's just getting stuck or whatever,
and I imagine it's got a sticking between the two, you kind of get this kind of ballooning behind.
Does that make sense? So that's what I think is happening. And I didn't measure

(34:28):
shear strain, so I don't know if that's true, but I think we'll see these pockets
when we've got that sticking because it's going to pull on the other side.
And that kind of makes sense to me. So that's what I think is happening.
And certainly what I'd like to go on and study would be
to get away to measure that shear strain look at it have
we got those pockets are they moving are they not

(34:48):
because we certainly saw them in people with pain and
we saw less of them after a while so running theory needs some work we need
some samples taken out of there i think katarina fede does a few samples and
that down in italy but why because you can see it right you can see that there's
something there and what why is it like that maybe it's just random maybe maybe

(35:08):
there is something going on.
So that's kind of, yeah, that's kind of me. And yeah, my MATLAB script,
basically I put in those layers and it gives me some computational kind of numbers
which work out the depth.
So how deep it is from the skin, how thick it is effectively,
and then those brightness.
So I can look at how bright are the white lines compared to darkness and kind
of, is that different? People with pain and no pain.

(35:30):
I think I answered that. I may have got excited. No, that's wonderful.
It's really easy to understand you, I promise. It's great.
And I'm hoping, again, if you listen to the podcast, then go along to YouTube.
We're approximately at 39 minutes in or something, and you'll see the image come up.
And, yeah, you can pause it, zoom in, and have a little look yourself.

(35:51):
But, yeah, no, fascinating.
I was interested in the results you found.
There was a there was something which you said was different or
in contrast to other studies where you mentioned echogenicity yeah
i know i say thracolumbar different than you you
said beautifully but i i probably won't i think i learned it in spain where
it's kind of thracolumbar it might not be you it might no no it's me it's me

(36:15):
i'm sure it has been all my life but but yeah so i'm reading out from here you
said the echogenicity of the thracolumbar fascia in in those who the LVP was
significantly lower when compared to control,
is in contrast to other studies where the ecogenicity was higher.
What's the significance of that and why do you think that was the case?
I would argue potentially that that pain level, and that's my running theory,

(36:37):
is perhaps people with higher pain levels have a difference in ecogenicity and
perhaps on the low-level pains, perhaps that's slower to change.
Because the ecogenicity would generally look at how dense those connective tissue layers are.
If we look at an ultrasound, the sound things coming back kind of
brightish white are the most dense and hardest to
get through so kind of think about the kind of the fascia and

(36:58):
the connection because you're covering bone you see the kind of the outline
that's the brightest you're going to see so potentially if it is an adaptation
to fascia and kind of the injury comes first the fascia change comes second
then perhaps that takes a bit longer perhaps that takes higher pain levels that
those change but but I don't know.

(37:19):
I don't know. It's the honest answer. I don't know. That's my theory.
You're hearing inside my brain now.
This is great. We're going deep into it, Claire. We're about to break.
So echogenicity sounds like a complicated word, but essentially we're just talking
about the ability of the tissue to reflect, which is how kind of sound waves work. The brightness.
Okay, fantastic. And by the difference in visual, you can then kind of contrast

(37:43):
between different types of tissue.
You and in your case you can see whether fascia has increased or decreased
in people would accept the idea of it yeah yeah pretty
much and i mean i haven't i haven't
got an image of this there but obviously i did over over 200 scans you know
over the kind of time of my phd and and some people obviously you've seen the
kind of poster i've got there i've used the nice ones haven't i because you're

(38:05):
not going to show the ones that are difficult to read that's not that's not
what what we'd do as researchers or clinicians,
but some of the scans we looked at, and this wasn't just me,
Kira found the same, and my external examiner and Professor Natalie Godreau
in Canada, who also does some brilliant work here.
Were they always that easy to scan? Or did you find some that were an absolute nightmare?

(38:26):
And you're like, yeah, some of them honestly look like cotton wool.
They look like candy floss.
And you're looking at this going, what am I looking at? You know, where are these layers?
They're so messed up, for lack of a better word.
And why? Why are they like this? You know, why is that connective tissue just
not showing those nice lines?
And if we look at someone without pain, we generally see, you know, it's thinner,

(38:49):
but they look far more regimented, far more kind of tightly
packed and they look really neat they look beautiful you can
literally go oh lovely and then on the
flip side of that you've got the cotton wool and you go well well i'm not surprised you
have pain because what is happening you know that's not
what we want to see we want to see these nice lines but
i don't have i'd show you if i had one in front of me and go look no cotton

(39:10):
wool but i don't unfortunately nikki mansell's come up the question here you
mean pockets of interstitial fluid kind of getting damned by tissue sticking
i wonder if the possible Pressure buildup there might cause a nociceptive response
where it pushes out on the fascia. Yeah, another theory.
So I think there's something got to be happening there, isn't it?
We know certainly evidence is showing that reduction in shear strain is definitely

(39:32):
seen in people with pain and also animal studies.
There was a big, big animal study by Bishop in 2018, don't quote that.
And they basically immobilized a leg on a pig and they also,
it's more multiple, and they injured one side of the fascia.
And noticed the massive, massive changes in shear strain kind of on the opposite
sides of where I was kind of trying to manage all of this.

(39:55):
So there's certainly lots of evidence to say that shear strain reduces in pain.
But what is causing that, whether it's the connective tissue,
whether it's the fluid, we don't know.
And I think, yeah, sticking and causing that kind of a dam is kind of a good idea of how to work that.
Yeah, I wouldn't be surprised if that does cause more pain because it's,
I mean, if anything, if something's getting stuck, we know if we've had someone

(40:18):
come in with a muscle injury, if they've got kind of stickiness,
let's say, around the IT band, it hurts, doesn't it?
So we need to manipulate, we need to massage, we need to get them moving to
move that and it alleviates that pain most of the time.
So I think, yeah, but I can't back that up with quantified evidence, unfortunately. Yeah.
That's a great segue. great you've just given me the perfect segway

(40:41):
to my next question so okay so the the your
research has congratulations for being second paper
which has shown this i think because you said before there was only one it's a
great note too yeah you just said
oh so you know something's stuck and we need to be able to move it
and get it moving and stuff like that so what is the significance of
this do you think for clinicians yeah so

(41:02):
yeah so the answer is i
tried to do a big six month study to say yes this type of
exercise cures it and i found nothing significant so
i don't have a clear answer for you but
i did see a trend okay so i found with all that exercise
and basically what i did in that was there are
some studies coming out with kind of specific manual therapies and stretching

(41:23):
but i looked at the exercise kind of angle and that returning to
movement and that kind of rehabilitation approach in that respect
and we did say those hour classes had a mixture
of kind of typical gentle aerobic of course
i'm with a population with pain and then that kind of alternate
movement so if you think about one arm going one the leg going the other trying
to move that fascia in as many directions as possible and then some kind of

(41:45):
core strengthening work okay so i went with that because it's the most typically
used people with pack pain you know it's the most safe it's the most effective
if you look at kind of reducing pain levels so So that was the argument behind it.
And we saw a proper trend towards a reduction in that thickness.
So what I need to do is do, I think, probably a longer study.

(42:07):
I think fascia takes a very, very long time to change.
There's been sort of some hypothesis around this.
If you look at Robert Sleip, he was, I think, one of the first to say,
we're looking at six months plus, you know, maybe 24 months for these changes.
If we look at connective tissue in other types, so tendon,
if we look at ligament, and if we look at just how that fast

(42:28):
that turning over we are looking at over six months
so i think whatever we're doing i think
i think exercise will be able to adapt faster i
think manual therapy will be able to adapt
faster but i think it's going to take a long
time i don't think it's going to be oh we'll bring you in for four sessions
then we'll fix it i think it's going to be a case of us working with these kind

(42:50):
of treatment plans and stuff these clients can do do at home because I don't
want to have someone keep coming back to me every single week for the rest of
their life potentially I want them to be able to take something back and learn
from it and do it themselves,
But I think we've got somewhere to go to kind of find out what exactly is the answer.
I think I'm very confident that we will find this target fascia which helps back pain.

(43:16):
But yeah, we've got a lot to do there to actually quantify that.
And I'm sure some of the listeners here would probably actually agree that,
you know, well, they've done X treatment and it worked or perhaps it's back
pain, perhaps there's other injuries.
But there might not be that nice stamp of a pupil with the nice guidelines or
World Health Organization that says definitely do this.

(43:38):
Yeah. But I think, yeah, we've just got to keep trial and error.
We've got to keep doing it. We've got to keep researching and bringing out these
big studies, because as often with research, I'm not sure how many researchers you have on.
It's often an acute study. Someone comes in and does one session with a personal
trainer or whatever that is, or it's four weeks.
Whereas actually we're looking at chronic health we need to kind of

(43:59):
look at longer duration studies and see how it's
going to work in the long term and maybe if i scan all
my participants again 12 months later and see if see if they
kept up the uh the routine they have got youtube videos of
what to do so maybe i'll see that to get some
more ethics in yes sounds like a good idea
do you think either is there any
particular exercise or manual therapy which affects

(44:22):
the fashion more which we which we can do
that on purpose than other tissues in
the body or is it just a case of any movement will affect the fascia and the
muscle at the same time because you can't separate it so what yeah it is all
connected and i think that that term connected is kind of what i would say is
your take home here so we know that the fascia is covering the whole body so the most.

(44:46):
Movement and manipulations and massage we can do that target multiple kind of
body sites following you look at body slings, you know, following it or the
whole posterior chain, I think that will be far more likely to target fascia.
If we look at doing rehab exercises and even myofascial release and everything,
which is going, your body's going one way, we're going the other.
Keeping those direction changes, I think would certainly have more of an impact here.

(45:10):
And that's been discussed in a few different books, but again, not fully quantified.
But you know, that is where I think the research is going.
That is what I would expect to see coming out is that multi-directional kind of treatments.
And I think most of us are doing that anyway. You know, we don't just.
Treat a muscle in the same way all the time do we we try and bring

(45:30):
in the movement whether it's active whether it's passive and trying
to put it all together so i think naturally we're
gravitating that way and i think the evidence is gonna it
will back that up it's just a case of when what
do you think of the idea that kind of
maps of fascia and and and following that
and doing movements which follow those maps is that something which

(45:52):
you're into as well or do you think it's a little bit pinpointing it
too much or telling them too much potentially too much
and i have and i might not get friends for this
but i've seen a lot of the whole kind of people coming out with
specific fascia training you know you have to do this you have to do that and
you'll work on fascia and i think that that's jumping a bit i don't think we're

(46:13):
there yet to tell you exactly what training method exactly what manual therapy
treatment you know i don't think we're there i think I think we've got hints
of what we think it will be,
but ultimately they're all people like me going, I think it's this.
I might be wrong. People have been wrong over the years. I mean,
they thought fascia was packing material, which we know it definitely isn't
now, but we're constantly learning and building upon who's been there before

(46:38):
us and who's kind of built something else.
So every single research paper that comes out from FASIA is hitching us more and more and more.
We've got more journals taking notice. I know the Journal of Bodywork and Movement
Therapy are creating a FASIA special issue right now.
So we've got a whole issue coming out to do with FASIA.
You guys are talking to me about FASIA, which, I mean, it's my first podcast.

(47:00):
So you're risking it and I'm risking it here. But, you know,
we're talking about it, aren't we?
And I think, you know, there's the conferences. I'm one of the board of directors
for the FASIA Research Society, which, again, I got into because I need to know more.
And, you know, there's more and more and more building, I think,
globally, probably more so than nationally.
I think there's not many of us FASIA researchers in the UK, but we're trying.

(47:24):
We're trying to build and we're trying to learn and understand as much as possible
so that we can really kind of understand this and give everyone who's working
in these populations a nice guide.
That's what we want. I want to find something where I can go,
this works, pass this on and get this working in clinics.
Because otherwise, yeah, it's pointless. It's absolutely pointless if I don't

(47:45):
pass that down and we don't find what works because, yeah.
Brilliant love you it's great you know it sounds like we're lucky to
have you on the board and and it's got
a great question here i'll read out if that's okay with you and cochrane says very interesting
work there have you looked at the work by mcclellan mstr effects
on fascia scars and correlations to such things for example as back pain
from c-section wouldn't it have been great also scans of

(48:07):
your square box yeah so i've seen a little
very little but yeah certainly well we've got
to do some sort of collaboration don't we i mean kira and i and
now she's got a master's student tracy meller as well so there's kind
of three of us over here with these huge number of
scans now so we've we've got these scans we need to do
something with it and yeah make it a bit bigger and make it a bit

(48:27):
more accessible and there's talks let's put it that way we're talking we're
trying we're trying to kind of collaborate and get more out there because we're
only small everyone's there's such a nuanced and kind of new area we all need
to jump together and and share this research and get it out there and that it's happening.
Marvelous. Okay, thanks for the question, Anne. Great question.

(48:50):
Right, well, look, it's already 8.52.
If people want further information on this, obviously they can have a look at
your studies, but is there any particular sources which you would recommend
or website that they go to?
So check out the FASIA Research Society. Definitely, you know,
they're always talking about FASIA.
They run webinars and all sorts. You can obviously join as a member,
but you can also pay to view them them separately and i'm not on

(49:12):
commission i'm a volunteer i promise so but there are things like
that that's happening yeah on google
scholar get looking at what journals exist following those
new articles follow me on linkedin and twitter and i will share everything obsessively
that i find out and we'll kind of go from there really but it's i think talking

(49:32):
about it you know there's there's been evidence evidence is the wrong word there's
been researchers now starting to talk about that that need for that collaboration
and talking with the clinicians.
So we're really, I think at the kind of beginning of that at the moment,
which perhaps is a bit far behind, but we want to collaborate.
We want to talk. We want to get that discussion going on between clinicians

(49:54):
and researchers. So I think that.
Keep your eyes peeled really i suppose is the
outcome from that wonderful so we'll
make sure again these links obviously go into show notes but fascia research
society is that a dot com i think it's dot
all is it a dot all there we go make sure that
goes in there and also you mentioned on twitter your
clarem voucher is that right yeah pretty sure it's

(50:17):
a c-l-a-i-r-e-m-b-o-u-c-h-e-r and
then you mentioned instagram as well yeah i mean yeah
i didn't say the instagram you can look at my instagram no i said linkedin
oh linkedin sorry my instagram is mostly me
doing fun activities i mean you can watch it but
it's not not gonna be as informative no
might be loads of spinning picks and and yeah yeah

(50:40):
there's a lot of open water stuff on there and suddenly a kayak comes and
you're like what's she talking about okay so linkedin
then yeah i mean i've got so much information linkedin that'd be great and yeah
people to go to that yeah i've been told i'm a bit obsessive with my linkedin
i'm constantly posting stuff but everyone's like my god she's on it and i'm
like but it is you know how people say with instagram it's the kind of the highlights

(51:01):
reel linkedin is my highlights reel of research so but it's not been as nice
and clear-cut as that there has been drama.
And fantastic we're looking up now on linkedin and nicky mansfield says cb i'm
presuming that's Cleo Batch.
Yes, CB is my new favourite researcher. Oh, thank you.
A genuine passion for the subject and for clinical applicants.

(51:21):
Akin to Schleip's, there we go,
Who's part of Fresh Research? Yeah, our founding director. There you go, founding director.
So that's great. So you work with him directly then?
So I have had the pleasure. I haven't worked with him on academic work or research
work, but yeah, he's on the board with me.
I spoke to him last night, in fact. There you go. Wow. There you go.

(51:43):
Excellent. We'll see if he's free to show. That'd be nice to get him on at some
point. But Alan, brilliant.
I'll tell you what, he probably wouldn't do a better job than you because you
managed to break this down the same way as many people try
to break down fashion with their elbow it's been wonderful you've made
it very clear and um and really infectious as well your passion shines
through so i really thank you for that thank you um i'm

(52:03):
especially if you've had a very busy day um so
i appreciate you coming along thank you very much no i really appreciate
it and i i don't think i said anything stupid so first
podcast nothing not even slightly slightly
right great so thank you everybody who
joined us in the live lounge obviously i'm sure that was
interesting entertaining for you if you listen to podcasts

(52:25):
and thank you very much for listening do please if you did enjoy this
then please leave a rating and review on your
app particularly on apple because it just helps it
get found easier on google it's as simple as that and
the good word of our amazing guests like claire boucher will
appear high end results and that's the way to disseminate this information okay.
It's not a money thing it's just more people who rate it the

(52:46):
more it gets out it's like true advice or something when we've talked to
top so please take two minutes to do that we will
be back next week oh yes right important stuff coming
up so if you listen to the podcast or you're listening to the live lounge next
tuesday at eight o'clock we're going to start a three-part series called something
like how to set up a massage therapy business and we're going to do three parts

(53:08):
first one's going to be at your home so including people are thinking or already
doing it and coming in a room garage or building a purpose wheelchair we're
also going to have part two which will be episode 187 a week later which is
in a rented room so we're going to.
The gym or something or talk about that and part
three will be in events now when i say we we're going to have a panel again
so we're looking for volunteers from the sda who would like to be part of
that panel share their experiences share their wisdom and help

(53:31):
members and non-members learn so if you're interested
in being part of that panel and even if you're scared but
kind of interested then talk to me i'm friendly i won't
shout at you or anything just email me matt at the sda.co.uk and
i'll help build up your confidence it's essentially just talking about what
you do on the camera here the same as claire has
been okay it's not has it been scary claire it

(53:52):
was before i started but at the party vibe you guys
fixed it exactly so yeah i'll read
you well so there you go you will be scared before you start that you soon ease
into it so yeah if you're interested in being part of that panel just to help us
share um your experience because members love annual
members tissue therapists love hearing about each other's
work and it's a great way of learning as well so yeah matt's at the

(54:12):
stf.uk and right that's it
thanks everyone who joined on this live like i said to our special guest this episode claire
boucher everything we're going to share notes for links and have a follow claire
and if you are interested in joining us live then tuesday eight o'clock either
on youtube or facebook sports therapy association page or group and in the meantime

(54:34):
thank you very much and take care of each other.
Music.

All Episodes

Episode Transcript

Popular Podcasts

Dateline NBC

Stuff You Should Know

The Nikki Glaser Podcast

.css-15opob5{left:0;position:absolute;top:0.8rem;} All Episodes

.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}STA185 ‘Thoracolumbar Fascia and Lower Back Pain' with special guest Claire Boucher

Episode Transcript

Popular Podcasts

.css-r6mb8g{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:1;overflow:hidden;}Dateline NBC

Stuff You Should Know

The Nikki Glaser Podcast

All Episodes

STA185 ‘Thoracolumbar Fascia and Lower Back Pain' with special guest Claire Boucher

Dateline NBC