To Do · 2018-04-02 · Regional interdependence “With respect to musculoskeletal problems, regional interdependence refers to the concept that seemingly unrelated impairments in

4/19/2016

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“Why do the cervical and lumbar

spine get all the glory?” Rehab concepts for the thoracic spine

and sacroiliac joints

Hugo Klaers, PT, DPT

&

Shannon Kelly, PT, DPT

Objectives

• Define the concept of regional interdependence as it applies to spinal pathology and treatment

• Describe the treatment of thoracic spine as it relates to cervical, shoulder, and lumbar dysfunctions

• Review the physical therapy examination of the thoracic spine and SIJ

• Demonstrate manual therapy techniques for the thoracic spine and the SIJ

• Describe application and progression of exercises for the thoracic spine and SIJ

• Apply “sling stabilization” concepts to the SIJ

Incidence of thoracic conditions

• Thoracic spine dysfunction: rare

compared to cervical and lumbar

• Thoracic spine

dysfunction is treated

effectively with manual

therapy techniques

Incidence of thoracic conditions

• Often looked at as an isolated structure

• However, the role of

the thoracic spine is

not typically recognized

in cases of cervical,

shoulder, or lumbar

dysfunction

Regional interdependence

“With respect to musculoskeletal problems, regional

interdependence refers to the concept that seemingly

unrelated impairments in a remote anatomical region

may contribute to, or be associated with, the patient’s

primary complaint.”

~Robert Wainner, PT, PhD, FAAOMPT

Wainner et al, 2007

What it is NOT…

• Treating the source of

radiating/referred pain

• Ignoring the primary

region of complaint

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What it IS…

• Looking up & down the

kinematic chain

• For neck, shoulder,

and back complaints:

Consider contributions

from the thoracic spine

Regional interdependence

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Biomechanics of t-spine and cervical motion

• Cervical rotation includes segmental

motion through T4 (Sizer et al, 2007)

• T1-4 demonstrate primarily axial rotation (White et al, 1990)

• Same coupling pattern as lower C-spine (White et al, 1990)

• Unilateral sagittal and scapular plane

shoulder elevation (Theodoridis & Ruston, 2002)

• T2-7 segments demonstrated: • Ipsilateral sidebend and rotation coupling

• Extension

• Bilateral shoulder elevation includes thoracic

extension (Edmondston, 2012)

• Bilateral elevation 12.8° thoracic ext

from T3-T11

Biomechanics of t-spine and shoulder motion

• Thoracolumbar junction shows blended

anatomy

• T11-12 demonstrate primarily flexion-

extension, same coupling pattern as L-spine (White et al, 1990)

• Thoracolumbar spine: “principal load-

bearing structure of the body”(Resnick et al, 1997)

Biomechanics of t-spine and lumbar motion

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Examination

Examination

• Posture

Examination

• Posture

• Mobility

•AROM, segmental

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Segmental Mobility Examination

• Posture

• Mobility

• AROM, segmental

•Layers

•Osseous

–Kemp’s test

Examination

• Posture

• Mobility

• AROM, segmental

•Layers

•Osseous

• Inert

–Neural tension, disc,

capsule, ligamentous

Examination

• Posture

• Mobility

• AROM, segmental

•Layers

•Osseous

• Inert

•Contractile

–Resisted isometrics

–Strength

Particular emphasis on

mid/low trap

Core

Examination

• Posture

• Mobility

• AROM, segmental

•Layers

•Osseous

• Inert

•Contractile

•Neuro-mechanical

THE SACROILIAC JOINT

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The Plan… • Rings: remember the anatomy of the pelvis is

a ring, engage the ligaments via the muscles

• Slings: Utilize the muscular slings to improve the stability of the SI joint

• Other things: Address joint and soft tissue issues via manipulations and mobilizations

In 200 patients with low back pain complaints: • 10 found to have solely SIJ pathology • 29 found to have SIJ involvement in

combination with lumbar &/or hip

PT Eval: Consider the Lumbar Spine

• Differential diagnoses for the low back: Posterior facet joint, nerve root irritation, discogenic pain, spondylolisthesis

Lumbar Screen:

Range of motion

Repeated motions into flexion/extension

PT Eval: Consider the Hip

• Morgan et al. 2013 – 76% of subjects

presenting with SIJ pain also had radiographic evidence of FAI

• Cibulka et al. 2002 – Evaluated hip ROM in

patients with LBP

– Hip ER/IR ROM values differed in those with SIJ involvement

– A hip screen can help rule in SIJ involvement

Physical Therapy Examination

Looking for the pattern • Subjective:

– Unilateral pain

– Inferior to PSIS

– Pain into the buttock

– Preceded by sudden episodic joint stress/trauma

OR

– Preceded by cumulative/repetitive joint stresses

• Objective:

– Provocation testing to reproduce patient’s primary pain and indicate the SIJ as the pain generator

– Strength

– Motor control assessment

Palpation Based Testing

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Active Straight Leg Raise Pain Provocation Testing

Clinical Prediction Rule

• Laslett et al. 2008

• Patients with LBP have >70% probability of having primary SIJ pain involvement with the presence of:

– Three or more positive SIJ provocation tests

– Centralization of pain is not achieved during a McKenzie evaluation of repeated movements and sustained positions

At the End of the Evaluation…

• Lumbar Spine Involvement: RULED OUT

• Hip Involvement: RULED OUT

• POSITIVE SIJ Provocation Tests

NOW WHAT??

LAB

Treatment Approach

Manual Therapy

Therapeutic Exercise

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Thoracic Rx for Cervical Dysfunction

• Manipulation group better on NDI and NPRS (50.5% and 58.5%) vs. mob group (12.8% and 12.6%)

• C1-2 PROM and craniocervical flexor performance also better in thrust group

• NNT = 1.8-2.3

Dunning et al, 2012

n = 107


• Experimental group significantly better on NPRS and NDI

• 31/33 (94%) vs. 11/31 (35%) had GROC of +4 or higher

• NNT = 2

Masaracchio et al, 2013

n = 64


1.) Sx’s <30 days

2.) No sx’s distal to shoulder

3.) Looking up does not aggravate

4.) FABQ-PA <12

5.) Diminished upper thoracic kyphosis (T3-T5)

6.) Cervical extension ROM <30°

3/6 present increased probability of success from 54% to 86%

Cleland et al, 2007

Thoracic Rx for Shoulder Dysfunction

• 14% increase in manipulation group vs. 3% in placebo group

• Low trap inhibition secondary to extension limitations T8-T12 (Flynn, 2006)

Cleland et al, 2004

n = 40


• Less pain during: – Neer

– Hawkin’s-Kennedy

– Resisted empty can, ER, IR

– Active ABD

• Improved SPADI

Boyles et al, 2009

n = 56


• No changes in ROM or scap kinematics

• EMG: small, significant increase in middle trap activity

• ***Less pain with impingement tests & flexion AROM

• ***Improved shoulder function

Muth et al, 2012

n = 30

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Thoracic Rx for Lumbar Dysfunction

• Both groups improved NPRS, no sig diff

between groups

• T-manipulation group improved PPT

significantly

Fernando de Oliveira et al, 2013

n = 148

- NDI, NPRS improve with addition of thoracic manipulation to cervical mobilizations

- Manipulation shows better improvements that mobilization

- Can also improve C1-C2 PROM and craniocervical flexor performance

- Thoracic manipulation results in:

• Increased activation of low and mid trap

• Decreased pain with Neer, HK, resisted empty can/ER/IR, active ABD and flexion

• Improved SPADI scores

- Similar decrease in pain regardless of whether lumbar manipulation or thoracic manipulation is performed

- Thoracic manipulation increases pain pressure threshold

Why does manipulation work?

• Biomechanical: Regional interdependence (Wainner et al, 2007; Cleland et al, 2005)

• Neurophysiological

• Stimulation of descending inhibitory

mechanisms (Sparks et al, 2013; Cleland et al, 2005)

• Change in pain modulation via biochemical

response (Plaza-Manzano et al, 2014)

• Stimulation of ANS/DRG’s???

• Placebo??? (Kardouni et al, 2014)

Two Key Elements


Manual Therapy


Mobility Strength

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Thoracic Ex’s - Mobility

Egan et al, 2011

Mobility

Egan et al, 2011

Mobility Mobility

Mobility Mobility

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Mobility Mobility

Mobility Mobility

Thoracic Ex’s - Strength Strength

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Strength Strength

Mobility & Strength Mobility & Strength

Mobility & Strength Mobility & Strength

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LAB

THE SACROILIAC JOINT: RINGS

Anatomy: Bones

• Part of three different mechanical chains – LE Chain: sacrum,

innominate, lower extremity

– Spine Chain: L4/L5/Sacrum

– Pelvic Chain:

• Picture to demonstrate

Innominate/Sacrum/Innominate

• Form closure

Anatomy: Anterior Ligaments

• Sacrospinous ligament – Blends into the hamstrings

• Iliolumbar ligament

– Blends into quadratus lumborum, erector spinae and multifidi

• Anterior sacroiliac ligament

Anatomy: Posterior Ligaments

• Sacrotuberous ligament – Blends into the hamstrings

• Long dorsal ligament

• Posterior sacroiliac ligaments

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A Common Question: Does it Move?

• Minute amounts of rotation and translation – Goode A. et al. Three-Dimensional Movements of the Sacroiliac Joint:

A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther.2008, 16(1):25-38

• The SI joint adapts throughout the life span – Bowen V, Cassidy, JD. Macroscopic anatomy of the sacroiliac joint from

embryonic life until the eighth decade. Spine. 1981, 6: 620-628

• Ossification of ligaments leading to increased stiffness – Rosatelli AL, Agur AM, Chhaya S. Anatomy of the Interosseous Reigon

of the Sacroiliac Joint. J Orthop Sports Phys Ther. April 2006; 36(4):200-208

THE SACROILIAC JOINT: SLINGS

• Form closure

• Force closure

Anatomy Review: Anterior Muscles

Anatomy Review: Posterior Muscles

• Two muscle systems that influence the sacroiliac joint

– Deep muscle system

– Superficial muscle system

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Deep Muscle System • These are the muscle that are most commonly

thought of as stabilizing muscle

• This is the cylinder:

– Top: Diaphragm

– Bottom: Pelvic Floor

– Sides: TrA, IO, Multifidi (Snijders et al, Liebenson et al)

Deep Muscle System

• Supine

• Hooklying

• Prone

• Quadruped

Superficial Muscle System

1. Posterior oblique sling

2. Anterior oblique sling

3. Longitudinal sling

4. Lateral sling

#1 Posterior oblique sling • Muscles involved:

– Latissimus Dorsi – Contralateral Gluteus

Maximus • Mooney et al. (2001)

– 15 healthy subjects: reciprocal relationship between latissimus and glut max.

– Patients with SI pain showed increased activity of the gluteus on the involved side

Posterior Oblique Sling Exercises Posterior Oblique Sling Exercises

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#2 Anterior Oblique Sling

• Muscles involved:

– External oblique

– Transverse abdominus

– Contralateral internal oblique

– Contralateral adductors

• Attach through the abdominal sheath on the anterior aspect

Anterior Oblique Sling Exercises

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Anterior Oblique Sling Exercises Anterior Oblique Sling Exercises

Anterior Oblique Sling Exercises

#3 Longitudinal Sling


– Thoracolumbar fascia

– Erector spinae

– Multifidi

– Hamstrings

Longitudinal Sling Exercises Longitudinal Sling Exercises

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#4 Lateral Sling


– Hip abductors

– Internal Oblique

– Contralateral quadratus lumborum

Lateral Sling Exercises

Lateral Sling Exercises Lateral Sling Exercises

ADD FULL SIDE PLANK PIC

Combinations

• At this point in working the different slings, you are only limited by your imagination

• Combine different movements to activate different slings and different muscle groups

• Train muscles to work together and in unison

Tensioning the ligaments

• Utilizing the ligaments to increase the stability of the joints

• Done via the muscular and fascial attachments

– Sacrotuberous and Biceps Femoris

• Van Wingerden et al. (1993)

– Long Dorsal Ligament and Erector Spinae and TLF

• Vleeming et al. (1996)

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OTHER THINGS

The Hamstrings & Gluteus Maximus

• Vleeming et al (2012) discussed the hamstrings’ pull on the pelvis

• Arab et al (2011) investigated the relationship between hamstring length and gluteal muscle strength

– Tightness in the hamstrings seen in conjunction with gluteal weakness

– Clinical takeaway: don’t stretch the hamstrings without strengthening the gluteals

The Hamstrings & Gluteus Maximus

• Hungerford et al (2003) used EMG to record hip and trunk muscles activation in those with SIJ pain compared to those without

– Clinical takeaway: timing is key for stability, getting the right muscles to fire at the right time

• Hoissen and Nokes (2008) identified poor gluteus activation during gait in a subject with SIJ pain

MANIPULATIONS

MOBILIZATIONS

SOFT TISSUE

MANUAL THERAPY

• Tullberg et al (1998) showed that a manipulation did not alter the position of the joint

– The subjects did report decreased pain

• Kamali and Shorkri (2011) provided lumbar and SIJ manipulations and showed decreased pain

• Cibulka et al (1988) created bilateral innominate rotation with a manipulative technique

– Pain was not assessed in these subjects

Is SIJ Manipulation Beneficial? Sacroiliac Joint Manipulation

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Sacroiliac Joint Mobilizations

Soft Tissue Manual Therapy

• Iliopsoas

• Piriformis

• Tensor fascia lata

• Lumbar paraspinals Adductors

• Gluteus medius

• Quadratus lumborum

STABILIZATION BELTS

TAPING TECHNIQUES

ALTERNATIVE OPTIONS

Stabilization Belts

• Recommended wear time will vary from patient to patient

• Can perform stabilization exercises with the belt on

Taping Techniques

• Kinesiotape

• Leukotape

LAB

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Summary

Principles of PT Management

Summary thoughts • Rings: remember the anatomy of the pelvis as

a ring, engage the ligaments via the muscles

• Slings: Utilize the muscular slings to improve the stability of the SI joint

• Other things: Address joint and soft tissue issues via manipulations and mobilizations


• REGION SPECIFIC TREATMENTS!!!

Cervical

๏Manual traction

๏Segmental mobility

๏Cervical flexor endurance

๏STM

Lumbar

๏Directional preference

๏Axial separation

๏Core stab





• Manual therapy techniques - manipulation,

mobilization

• Neuromuscular re-ed

• Emphasis on thoracic extension and rotation

• Strengthen

• Periscapular & postural musculature

• Heavy emphasis on mid/low trap!!!

Thoracic References

1. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in

the treatment of musculoskeletal pain: a comprehensive model. Manual Ther. 2008;doi:10.1016/j.math.2008.09.001.

2. Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, et al. The short-term effects of

thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Ther.

2009;14:375-380.

3. Cleland J, Selleck B, Stowell T, Browne L, Alberini S, St. Cyr H, et al. Short-term effects of thoracic

manipulation on lower trapezius muscle strength. J Man Manip Ther. 2004;12:82-90.

4. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in

patients with neck pain: a randomized controlled trial. Manual Ther. 2005;10:127-135.

5. Cleland JA, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of

patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys

Ther. 2007; 87:9-23.

6. Dunning JR, Cleland JA, Waldrop MA, Arnot C, Young I, Turner M, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a

multicenter randomized controlled trial. J Orthop Sports Phys Ther. 2012;42:5-18.

4/19/2016

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Thoracic References

7.Edmondston S, Ferguson A, Ippersiel P, Ronningen L, Sodeland S, Barclay L. Clinical and

radiological investigation of thoracic spine extension motion during bilateral arm elevation. J Orthop Sports Phys Ther. 2012;42:861-869.

8.Egan W, Burns S, Flynn TW, Ojha H. The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence. In: Hughes C, ed. Current Concepts of Orthopaedic

Physical Therapy, 3rd edition. La Crosse, Wisc: Orthopaedic Section, APTA; 2011:1-33.

9.Fernando de Oliveira R, Liebano RE, da Cunha Menezes Costa L, Rissato LL, Costa LOP.

Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients

with chronic low back pain: a randomized controlled trial. Phys Ther. 2013;93:748-756.

10.Flynn TW. Thoracic spine and rib cage dysfunction. In: Placzek JD, Boyce DA, eds. Orthopaedic

Physical Therapy Secrets. St. Louis, Mo: Elsevier Mosby; 2006: 484.

11.Kardouni JR, Shaffer SW, Pidcoe PE, Finucane SD, Cheatham SA, Michener LA. Immediate

changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with

subacromial impingement syndrome: a randomized controlled study. Manual Ther. 2014;xxx:1-7.

12.Masarrachio M, Cleland J, Hellman M, Hagins M. Short-term combined effects of thoracic spine

thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2013;43:118-127.

13.Muth S, Barbe MF, Lauer R, McClure P. The effects of thoracic spine manipulation in subjects with

signs of rotator cuff tendinopathy. J Orthop Sports Phys Ther. 2012;42:1005-1016.

Thoracic References

14.Plaza-Manzano G, Molina F, Lomas-Vega R, Martínez-Amat A, Achalandabaso A, Hita-Contreras F.

Changes in biomechanical markers of pain perception and stress response after spinal manipulation. J Orthop Sports Phys Ther. 2014;44:231-239.

15.Resnick DK, Well SJ, Benzel EC. Biomechanics of the thoracolumbar spine. Neurosurg Clin N Am. 1997;8:455.

16.Sizer PS, Brismée JM, Cook CE. Coupling behavior of the thoracic spine: a systematic review of the

literature. J Manipulative Physiol Ther. 2007;30:390-399.

17.Sparks C, Cleland JA, Elliott JM, Zagardo M, Liu WC. Using functional magnetic resonance imaging

to determine if cerebral hemodynamic responses to pain change following thoracic spine thrust

manipulation in healthy individuals. J Orthop Sports Phys Ther. 2013;43:340-348.

18.Theodoridis D, Ruston S. The effect of shoulder movements on thoracic spine 3D motion. Clin

Biomech. 2002;17:418-421.

19.Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal

examination model whose time has come. J Orthop Sports Phys Ther. 2007;37:658-660.

20.White AA, Panjabi MM. Clinical Biomechanics of the Spine, 2nd Ed. Philadelphia, Pa: JB Lippincott;

1990.

SIJ References • Arab A, Nourbakhsh M, Mohammad A. The relationship between hamstring length and gluteal

muscle strength in individuals with sacroiliac joint dysfunction. Jour Man Manip Ther. 2011 19(1).

• Bowen V, Cassidy, JD. Macroscopic anatomy of the sacroiliac joint from embryonic life until the eighth decade. Spine. 1981, 6: 620-628

• Breyen, P. Sacroiliac Joint Conference Presentation, September 2014.

• Goode A. et al. Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther.2008, 16(1):25-38

• Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the present of SIJ pain. SPINE. 2003, 23.

• Hoissen M, Nokes LDM. A Biomechanical Model of Sacroiliac Joint Dysfunction. J Bone Joint Surg BR B, 2008

• Laslett M et al. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy. 2005. 10.

• Laslett M. Evidence based Diagnosis and Treatment of the Painful Sacroiliac joint. Jour Man Manip Ther. 2008: 16(3).

• Liebenson C. The relationship of the sacroiliac joint stabilization musculature and lumbo-pelvic instability. Journal of bodywork and movement therapies. 2004. 8(43-45).

• Mens, J.M.A., Vleeming, A., Snijders, C.J., et al., 1999. The active straight leg raising test and mobility of the pelvic joints. European Spine Journal 8, 468–473.

• Mooney V, Pozos R, Vleeming A, et al. (2001) Exercise treatment for sacroiliac pain. Orthopedics 24, 29–32.

• Morgan P, Anderson A, Swinontkowski, M. Symptomaptic Sacroiliac joint disease and radiographic evidence of femoral acetabular impingement. Hip int. 2013:23(212-217).

SIJ References • Prather H. Repetitive motion can create sacroiliac joint dysfunction in female athletes. Advance

Newsmagazine. 2014.

• Potter NA, Rothstein JM. Intertester Reliability for Selected Clinical Tests of the Sacrolilac Joint. Phys Ther. 1985; 65:1671-1675.

• Prather H. Sacroiliac Joint Pain: Practical Management. Clin J Sports Med. 2003. 13(4).

• Rosatelli AL, Agur AM, Chhaya S. Anatomy of the Interosseous Reigon of the Sacroiliac Joint. J Orthop Sports Phys Ther. April 2006; 36(4):200-208

• Shaffrey CI, Smith JS. Nonoperative care to manage the sacroiliac joint. J Neurosurg Spine. 2014. 20:351-353.

• Snijders, CJ et al. EMG recodings of abdominal and back muscles in various standing postures: validation of a biomechanical model on sacroiliac joint stability. Journal of EMG and Kines. 1998 (205-214).

• Van Wingerden, JP, Vleeming, A, Snijders CJ et al. A functional-anatomical approach to the spine-pelvis mechanism: interaction between the biceps femoris muscle and the sacrotuberous ligament. Eur Spine J, 1993 Octl 2(3): 140-4

• Vleeming, A et al. The posterior layer of the thoracolumbar fascia: its function in load transfer from spine to legs. Spine. 1995, (753-758).

• Vleeming, A. (2012). The sacroiliac joint: An overview of its anatomy, function and potential clinical implications. Journal of Anatomy, 221(6), 537–567-537–567.

• Vleeming, A. (2012). The sacroiliac joint: An overview of its anatomy, function and potential clinical implications. Journal of Anatomy, 221(6), 537–567-537–567.

• Vleeming et al. The function of the long dorsal sacroiliac ligament. Spine. 1996. 21(5), 556-562

To Do · 2018-04-02 · Regional interdependence “With respect to musculoskeletal problems, regional interdependence refers to the concept that seemingly unrelated impairments in

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