Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.

Background

Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.

Image from Pilates Suffolk click for larger view

Clinical Pilates vs Pilates

Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.

In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.

Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery. 

The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.

Peripheral injuries

When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries. 

Spinal Injuries

Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.

In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.

Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.

In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.

If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt. 

The benefits of Pilates
 
•    General fitness and body awareness greater strength and muscle tone
•    Improved flexibility
•    A flatter stomach
•    Improved efficiency of the respiratory, lymphatic and circulatory systems
•    Better posture and awareness
•    Less incidence of back pain
•    Increased joint mobility
•    Lower stress level

Which clients would benefit from Pilates?

•    Males and females
•    Pregnant: Pre and post natal
•    Athletes and dancers
•    Amputee and stroke rehabilitation clients
•    Elderly
•    Children 12 years-old +

Clinical pilates therefore  targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.

If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!

Pilates and Physiotherapy is a post from: Musculoskeletal Consumer Review

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Stability of Pelvic Girdle / Sacroiliac Joints

The pelvis consist of the sacrum (triangular base of the spine) and 2 iliums and they are connected to one another via the sacroiliac (SI) joints. The SI joints need to be stable for the pelvis to function normally, so that they can act as shock absorbers between the lower limbs and spine, and to act as a proprioceptive feedback mechanism for coordinated movement and control between trunk and lower limbs. The SI joints (pelvic girdle) achieve stability via:

Form Closure: The shape, structure and congruency of the sacroiliac bones and associated sacral ligaments provide the passive stability (i.e. 2 lego pieces fitted together).

Force Closure: External forces exerted by muscle systems, through their attachment into connective tissue (ligaments and fascia), to compress and stabilize the sacroiliac joints and hence the pelvic girdle. Adequate force closure is vital to allow for movement of the sacrum during activities such as, walking, transferring, stair use, and bending.

The combination of form and force closure is known as the “self-bracing” or “self-locking mechanism” of the SI joint. Form and force closure should be balanced. If a person lacks form closure, perhaps because genetics or anatomy, they will require more stability from muscles that assist in force closure. This is where myofascial slings come into play.

Myofascial Slings

The ‘slings’ that provide force closure and stability in the pelvic girdle include the anterior oblique, posterior oblique and the posterior longitudinal slings.

Anterior Oblique Sling

Anterior Oblique Sling includes the pectorals, external and internal obliques and transverse abdominis. When this group of muscles contract, it provides stability by acting like an abdominal binder, compressing the entire pelvic girdle, especially the front, securing the symphysis pubis.

Posterior Oblique Sling

Posterior Oblique Sling includes the latissimus dorsi,the contralateral/ opposite gluteus maximus and biceps femoris. This sling provides stability by simultaneous contraction of the latissimus dorsi and contralateral gluteus maximus. They also act on the sacrotuberous ligaments thereby compressing the SI joint.

Longitudinal Sling includes the deep multifidus muscles (attached to the sacrum), the deep layer of the thoracolumbar fascia and the sacrotuberous ligament via the long head of the biceps femoris muscle. Contraction of the deep multifidus muscle will rotate the sacrum forward thereby increasing the tension of the ligaments surrounding the sacroiliac joints, and ‘lock the joints in”, thus increasing its stability. Also, as with the contraction of the deep multifidus muscles, the tension of the thoracolumbar fascia increases, giving rise to a “pumping up” phenomenon which in turn increases the compression of SI joints.

Failure of any of the myofascial slings to secure pelvic stability can lead to lumbo-pelvic pains and dysfunctions. This is especially apparent in expectant women and women following childbirth in whom posterior pelvic pain (PPP) and symphysis pubis dysfunction (SPD) are common. Athletes involved in high-impact activities who have lumbo-pelvic pains from walking, lunging and landing from jumps, often suffer from dysfunction of these myofascial slings. This is due to overloading of the ligaments of the pelvis and/or lumbo-pelvic junction (including the sacroliliac joints) during activities in which loads have to be transferred between legs and trunk, thereby injuring the lower back and pelvis.

References

1. Liebenson, C.The relationship of the sacroiliac joint, stabilization musculature, and lumbo-pelvic instability Journal of Bodywork and Movement Therapies (2004) 8, 43–45.
2. O’Sullivan, P.B., Beales, D.J., Beetham, J.A., Cripps, J., Graf, F., Lin, I.B., Tucker, B., Avery, A., 2002. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine 27, E1–E8.
3. Pool-Goudzwaard, A., Vleeming, A., Stoeckart, C., Snijders, C.J., Mens, M.A., 1998. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to ‘‘a-specific’’ low back pain. Manual Therapy 3, 12–20.
4. Snijders, C.J., Vleeming, A., Stoeckart, R.. Transfer of lumbosacral load to iliac bones and legs. Part I: biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise. Clinical Biomechanics 8, 285–294 (1993).

We’ve Heard So Much of the ‘CORE’, What About the ‘SLINGS’? is a post from: Musculoskeletal Consumer Review

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An unstable Sacro-illiac Joint (SIJ) can cause pain in the lower back and pelvic region. This happens when the core muscles surrounding it are too weak to support the SIJ. A sacroiliac support belt can help to provide support and stability to the joints during the initial stages of core stability training.

What is the Com-Pressor belt?

A popular sacroilliac support belt is “The Com-Pressor^TM” by Diane Lee, a leading physiotherapist in the field of SIJ disorders. The Com-Pressor belt consists of a belt which is worn around the pelvis and separate individual elastic straps that are velcro-ed onto it. The elastic straps with Velcro strips allow for specific tension to increase the amount of support. Do take note that the belt should not be worn on a long-term basis so as to prevent your body from over relying on it for support.

How does the Com-Pressor works?

The Com-Pressor belt does 2 things. Firstly, it stabilises the injured SIJ with a compressive force. Secondly, to provide cues (propioceptive feedback) to the brain, reminding it to contract muscles that stabilises the SIJ.

The individual straps allow for specific areas of the pelvis to be tightened for more compression or to provide cues for specific muscles to contract.

If you can recall your early experiences on a bicycle, someone will be holding on to your bicycle as you pedal to prevent you from falling over. If you keep leaning to your left, the person will push you towards the right to stop you from falling to the left. Once you pick up the skill of pedalling and balancing on two wheels, you would not need any help to stabilise. This is how the belt works; as a specific stabilising force while the body learns how and when to contract the appropriate muscles to stabilise itself.

When the core muscles are strong enough to contract appropriately, the use of belt will be weaned off progressively. A word of caution, extensive use of the belt can have a reverse effect when the muscles become lazy and over-reliant. Instead of strengthening, the core muscles will learn to “switch off” since the belt is taking over the role of the muscles.

Belt Up Your Unstable SIJ is a post from: Musculoskeletal Consumer Review

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While pain may begin at any time during pregnancy, PPP on average begins in the 18th week of pregnancy and becomes more intense as the pregnancy progresses. The pain usually spontaneously resolves within 3 months post delivery. But in some cases it can become chronic and disabling.

What are the Sacroiliac joints?

The sacroiliac joints (SIJ) are formed between the sacrum, a triangular-shaped bone in the lower portion of the spine, and the right and left ilium of the pelvis. The SIJ is a strong and stable weight-bearing joint that permits very little movement due to its natural structure. The main role of the SIJ is to allow forces to be transmitted effectively through the body, absorbing impact from the legs to the spine during activities such as walking, running and jumping.

The SIJ is kept stable through two mechanisms:

1. Firstly, the rough, groove-like connecting surfaces of the sacrum and ilium interlock and help stabilise the joint, like two pieces of Lego together.
2. Secondly, the SIJ is further strengthened by a complex mesh of ligaments and muscles such as the core stabilizers. These core muscles, such as the transversus abdominis and multifidus which surround the SIJ, act as active stabilizers by actively contracting to create a compressive force over the SIJ, gripping the joint firmly together. They act as a natural corset by providing that compression around the lower back and pelvic region -much like wrapping your fingers around the two Lego pieces, keeping them firm and tight.

Posterior pelvic pain arises from sacroiliac joint dysfunction, in other words, when the stability of SIJ is compromised.

Why does it happen?

During pregnancy, mechanisms stabilising the SIJ is affected. This instability allows for increased motion, stressing the SIJ.

1. Hormones released during pregnancy relax the ligaments of the body to allow the pelvis to enlarge, in preparation for childbirth
2. Due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened.

Moreover, the additional weight and altered walking pattern associated with pregnancy can cause significant mechanical strain on the sacroiliac joints, which may result in SIJ inflammation, giving a deep ache in the posterior pelvis.

What are the symptoms?

Of all the back pains experienced during pregnancy, posterior pelvic pain is the most common – you are four times more likely to experience PPP than lumbar pain.

You may have posterior pelvic pain / sacroiliac joint dysfunction if you have:

• Deep, boring pain in the back of the pelvis (around the sacroiliac joints)
• Pain may occasionally radiate to the groin and thighs.
• The pain is typically worse with standing, walking, climbing stairs, resting on one leg, getting in and out of a low chair, rolling over and twisting in bed, and lifting. The pain improved when lying down.
• If there is inflammation and arthritis in the SI joint, you may experience stiffness and a burning sensation in the pelvis.

Diagnosing Sacroiliac Joint Dysfunction in pregnancy

Your doctor and/or physiotherapist will conduct a thorough history and physical examination to determine the underlying disorders for your pain. That includes your description of symptoms, a series of tests designed to look at the stability, movement, and pain in the sacroiliac joints and surrounding structures. Imaging, such as computed tomography (CT) scan and X-ray may also help in the diagnosis. Another reliable diagnostic method involves injecting an anesthetic agent into the SI joint, guided by an X-ray machine, numbing the irritated area, thereby identifying the pain source. However, due to the concerns of fetal exposure to radiation, diagnostic procedures involving radiation is generally avoided.

Treatment and Management

The first-line treatment of pregnancy-related sacroiliac joint dysfunction is physiotherapy and exercises that focuses on core stability of the trunk and pelvic girdle. Sometimes, a sacro-iliac belt is prescribed to complement the core stability exercises and to give quick pain relief. Exercises will form a large part of the treatment and in some cases, mobilisation (a gentler form of manipulation) of your hip, back or pelvis may be used to correct any underlying movement dysfunction. Other manual techniques include muscle energy technique (MET) and myofascial release. It is vital to engage a physiotherapist who is skilled in treating pregnancy-related pain as she is aware of the studies that support the use of specific stabilizing exercises and other treatment techniques, thereby preventing the dysfunction from escalating into a chronic condition.
Other alternative treatments include anesthetic and steroidal injections into the SIJ that can help in pain relief, which lasts from one day or much more long-term. Oral anti-inflammatory medications are often effective in pain relief as well. However, these two treatments may be contra-indicated during pregnancy.

Posterior Pelvic Pain Home Advice

Here are some tips for expectant women with posterior pelvic pain..

Lying down

• Avoid lying on your back for long periods of time, particularly after the 19th week of your pregnancy.
• Try lying on your side (preferably your left) with a pillow placed between your knees and another under your tummy.
• If your waist sags down into the bed, try placing a small rolled up towel under your waist.

Turning over in bed

• To turn to your right while lying on your back, arch your lower back, tighten your pelvic floor muscles and lower abdominal muscles and bend both knees one by one.
• Turn your head to the right and take your left arm over to the right of your body. Hold onto the side of your bed if you can.
• To turn, pull with your left hand and take both knees over to the right so that you roll to the right. As soon as possible, bend your knees up as high as they will go – this helps to lock out your pelvis and lessen pain.
• Reverse this to turn to the left.

Getting out of bed

• Roll onto your side with your knees bent up, move your feet over the edge of the bed and push yourself up sideways with your arms.
• Reverse the process when you lie down.

Standing from a sitting position.

• Sit on the edge of the chair.
• Keeping your knees apart slightly and lean forwards till your head is directly over your knees, keeping your back straight.
• Stand up by pushing up with your arms, with your back straight and tummy tucked in. This helps to hold your pelvic joints in their most stable position and may reduce your pain significantly.

Reference:

1. Fitzgerald CM and Le J. Back pain in pregnancy requires practitioner creativity. Biomechanics. 2007 November 
2. Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine. 1991; 16:549-552.
3. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994; 19:894-900.
4. http://www.sidysfunction.com/articles/lumbarbackandposteriorpelvicpain.html

    

Posterior Pelvic Pain (Sacroiliac Joint Pain) in Pregnant Women is a post from: Musculoskeletal Consumer Review

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WHAT IS THE SIJ?

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The main role of the SIJ is to allow forces to be transmitted vertically through the body. The SIJ acts like a very tough suspension that absorbs the impact from the legs to the spine during activities like walking, running and jumping.

The SIJ is an inherently strong and stable joint that permits very little movement due to its natural construction. This structural strength provides passive stability or form closure. The rough, groove-like connecting surfaces of the iliac bones and sacrum interlock and help stabilise the joint; like fixing two Lego pieces together. In addition, strong and tight ligaments hold the SIJ firmly together.

Another feature that stabilises the SIJ is described as the active stabilisers or force closure. Imagine wrapping your fingers around the two Lego pieces. This is similar to your muscles surrounding the SIJ, actively contracting to create a compressive force over the SIJ, gripping the joint firmly together. These muscles are also known as the core muscles. They act as a natural corset by providing that compression around the lower back and pelvic region.

Source: Gray's Anatomy 20th ed
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WHAT CAUSES AN UNSTABLE SIJ??

Passive instability can be compromised when the ligaments joining the SIJ becomes loose or lax. This happens when you fall and land on to the buttocks, or miss a step. The impact going through the SIJ overstretches the ligaments causing it to become loose or lax.

Another cause of SIJ instability is pregnancy. Hormones released during pregnancy relax the ligaments of the body to allow the pelvis to enlarge. At the same time, muscles around the pelvis get overstretched and weakened. This contributes to the loss of form and force closure.

TREATMENT

The only way to improve on the stability of the SIJ would be to increase the system of force closure. Thus, core stability exercises are recommended for an unstable SIJ to increase the compressive force. Sometimes, a sacro-iliac belt is prescribed to complement the core stability exercises.

The unstable SIJ is a post from: Musculoskeletal Consumer Review

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Image: onlynick

The study pooled results to include a total of 170,991 women with nearly 3,000 hip fractures and a total of 68,606 men with 214 hip fractures. These studies suggest that calcium intake is not appreciably associated with hip fracture risk in women or men. That means the researchers did not find that a higher calcium intake reduced the incidence of hip fractures.

Hip fractures are the most frequent and severe fractures among the elderly. Increased calcium intake is still commonly recommended as a single fracture prevention strategy, although the researchers wrote that considerable uncertainty exists regarding optimal intakes of calcium. For example, for adults over age 50, the recommended calcium intake is 700 milligrams (mg) daily in the United Kingdom, but 1,200 mg daily in the United States. In Singapore, according local studies³, the average calcium intake is in the region of 400mg daily, far below the recommended intakes

Dr. Dawson-Hughes and her colleagues concluded that the findings do not support an overall benefit from greater-than-average calcium intake.

Future studies of fracture prevention should focus on the best combination of calcium plus vitamin D, rather than on calcium supplementation alone. Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. It is also produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Bioactive vitamin D or calcitriol is a steroid hormone that helps regulate the body’s levels of calcium and phosphorus, and in mineralization of bone.

Reference:

1. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials, American Journal of Clinical Nutrition, Vol. 86, No. 6, 1780-1790, December 2007
2. USDA/ Agricultural Research Service (2008, June 11). Calcium Alone Does Not Reduce Hip Fracture Risk.
3. Bone Mineral Density Measurements Using The Hologic QD2000 In 175 Singaporean Women Aged 20-80, K H Leong, P H Feng, Singapore Medical Journal, 1997 Jan;38(1):25-6.
4. Dietary Supplement Fact Sheet: Vitamin D, National Institutes of Health

Supplement Calcium Pills with Some Sun is a post from: Musculoskeletal Consumer Review

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Causes my back and pelvic pains

As your pregnancy advances, your back experiences more strain from three key changes – a shift in your centre of gravity, hormonal changes and abdominal muscles changes.

Centre of Gravity Shift

Your centre of gravity shifts forward due to the growing bump. This accentuates the curvature of the spine and adds stress to the spinal joints, contributing to the tightening of your spinal muscles. The growing bump also adds extra load on joints, and that means more work for the back muscles, which is why your back pain may worsen as the day progresses as they tire.

Hormonal Changes 

Relaxin, a hormone produced during pregnancy, acts on ligaments making them suppler. The ligaments that hold the pelvis bones together gradually loosen to prepare you for labour and birth. Unfortunately, this compromises joint stability of the pelvis. Making you feel less steady and cause pain when you sit for long periods, stand, walk, roll over in bed, get out of a low chair, bend, and lift.  

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Abdominal Muscles Changes 

The expanding size of the uterus stretches the abdominal muscles reducing support for the spine. Diastasis recti, a pregnancy-induced condition, is the separation of the rectus abdominis muscles in the middle, reducing the ability of the abdominal muscles to support the pelvis and spine¹.

Common areas of back pain during pregnancy

Expecting mother most typically experience low back (lumbar pain) and posterior pelvic or sacroiliac back pain.

With low back pain, you feel it across the lower spine, near or at the level of your waist. Prolonged sitting or standing usually makes it worse, so does wearing high heels. It tends to be more intense towards the end of the day.

Posterior pelvic pain is typically felt at or near the 2 dimples at the back of your pelvis (hip). You feel the pain deep inside the buttocks or in the back of your thighs on one or both sides. Activities that aggravate the pain include walking, climbing stairs, resting on one leg, getting in and out of a low chair, rolling over and twisting in bed, and lifting.

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What can I do to prevent back pain?

If you have a history of back pain, you are more likely to get it again. You are also prone to back pains if you lead a sedentary lifestyle and have weak back and abdominal muscles with poor flexibility.

To prevent recurrence, start on an exercise program to stretch and strengthen muscles that support the back, which include your abdominals. Remember first to get clearance from your doctor before you start any exercise program.  

Adopt good postures in your daily life will do wonders for your back. 

• Standing. Stand up straight. This gets harder to do as pregnancy progresses, but try to keep your chin tucked in, drawing your shoulders back and down with the tummy and bottom tucked in. Expectant women tend to slump their shoulders and arch their backs as their bumps grow, which puts more strain on the spine.  

• Sitting. Try to avoid prolong sitting and get up take frequent breaks. Support your feet with a footstool can help reduce back pain, and using small pillow to support your lower back helps too.  

• Lifting. Bend at your knees, keeping your back straight and lift using the strong thigh muscles instead of the small muscles of the back. Do not twist as you are lifting. Get help for heavy objects.  

• Sleeping. To rest better at night, sleep on your side with one or both knees bent and a pillow between your legs. As your pregnancy advances, use a rolled up towel or small pillow to support your tummy.  

Finally yet importantly, pay attention to your body. If you find that a particular activity or exercise aggravates your pain, stop doing it. Ask your doctor or physiotherapist whenever in doubt!

Reference

1. Kisner C and Colby L.A. Therapeutic Exercise: Foundations and Techniques (4^th Edition).  
2. Pennick VE, Young G. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001139
3. Young G, Jewell D. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev 2002;(1): CD001139                             

Pregnancy – Changes and Aches is a post from: Musculoskeletal Consumer Review

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