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on the 12th rib. Breathing and hip motions will be particularly relevant. CONSIDERATIONS When properly applied, the work described here is safe and effective; however, some important considerations apply. • In side-lying work, be mindful of the ends of the floating ribs and the transverse processes of the vertebrae, which are sensitive and could be injured by incautious work. • These techniques are most effective with mild to moderate chronic back pain. Recent back injuries or surgery are contraindications until the tissues have healed (though with care, experienced practitioners can adapt these ideas for clients with recent back injuries). Older, healed injuries and surgeries often respond favorably to these techniques. • Strong low-back pain of sudden or frequent onset warrants referral to rehabilitation or complementary specialists, since such pain may need more care than most manual therapists typically provide. • Intervertebral disc issues (bulging, herniation, and degeneration) were long the favored explanation for many types of low-back pain. Recent research has shown this to be a relatively uncommon cause of pain; nevertheless, I do not recommend using these techniques on a client with disc issues until you are very familiar with their application and can reliably gauge pressure, duration, and response. One danger in working with disc issues is that those issues could be aggravated by releasing the client's compensatory muscular and fascial tension too quickly or in an unbalanced way. Refer these clients to a specialist or work under a specialist's close supervision until you've gained enough experience to competently address these issues. CONCLUSION At the beginning of this column, we listed some of the many mechanisms that have been thought to be responsible for back pain through the ages. While these factors may contribute to low- back pain, and their treatments may provide relief in individual cases, none of these theories has proven to be consistently effective with a majority of low-back pain sufferers. Our increased understanding of the TLF's sensitivity and its role in back pain is a significant addition to our knowledge base, and it gives manual therapists new tools to help many clients' back pain that has not responded to other treatments. Notes 1. J. D. Frymoyer, "Back Pain and Sciatica," New England Journal of Medicine 318 (1988): 291– I t p a y s t o b e A B M P C e r t i f i e d : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 117 300; Institute for Health Metrics and Evaluation, "2010 Global Burden of Disease Study." 2. R. DonTigney, "The Sacroiliac Joint," accessed July 2014, www.thelowback.com/history.htm; G. K. Lutz, M. Butzlaff, U. Schultz-Venrath, "Looking Back on Back Pain: Trial and Error of Diagnoses in the 20th Century," Spine 28, no. 16 (2003): 1,899–905; D. C. Maharty, "The History of Lower Back Pain: A Look Back Through the Centuries," Primary Care 39, no 3 (September 2012): 463– 70; P. W. Hodges, C. A. Richardson, "Inefficient Muscular Stabilisation of the Lumbar Spine Associated with Low Back Pain: a Motor Control Evaluation of Transversus Abdominis," Spine 21, no. 22 (1996): 2,640–50; L. A. Danneels et al., "CT Imaging of Trunk Muscles in Chronic Low Back Pain Patients and Healthy Control Subjects," European Spine Journal 9, no. 4 (2000): 266–72. 3. R. Deyo and J. Weinstein, "Low Back Pain," New England Journal of Medicine 344 (2001): 363–70. 4. H. M. Langevin et al., "Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low Back Pain," BMC Musculoskeletal Disorders 10 (2009): 151. 5. H. M. Langevin et al., "Reduced Thoracolumbar Fascia Shear Strain in Human Chronic Low Back Pain," BMC Musculoskeletal Disorders 12 (2011): 203;. A. D. Furlan et al., "Massage for Low-Back Pain," Cochrane Database of Systematic Reviews 4 (2008): CD001929. 6. P. Nickelston, "Thoracolumbar Fascia: The Chronic Pain Linchpin," Dynamic Chiropractic 31, no. 21 (2013); T. Myers, Anatomy Trains (Churchill Livingstone, 2009). 7. R. Schleip, "Fascial Plasticity—A New Neurobiological Explanation, Part I," Journal of Bodywork and Movement Therapies 7, no. 1 (2003): 14. Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is a Certified Advanced Rolfer and originator of the Advanced Myofascial Techniques approach. Contact him via info@advanced-trainings.com and Advanced-Trainings.com's Facebook page. Watch Til Luchau's technique videos and read his past Myofascial Techniques articles in Massage & Bodywork's digital edition. Image 9: Careful use of the thumbs is one option when working with the deep quadratus lumborum layer. Keep your two thumbs together, avoid hyperextending any joints, and check with your client about comfort. Adding breath and slow movement can increase effectiveness of this and other TLF techniques. Image courtesy Advanced-Trainings.com. 9