Download An Integrative Guide to Sacroiliac Joint Dysfunction

An Integrative Guide to
Sacroiliac Joint
Dysfunction:
UnderstandingYourLowBackandButtockPain
By,DavidMesnick,PT,OCS,cMDT
ContributionsbyTravisBarefoot,DPT
www.pt360atl.com
Overview
Themusculoskeletalsystemisanintricatenetwork
ofbones,muscles,andotherconnectivetissuethat
servestoprovideformandstructuretoourbodies,
toproducemovement,andtoprotectourinner
organs.“(Professionalsinthemedicalfield)use
manualmedicinetoexaminethisorgansystemina
muchbroadercontext,particularlyasanintegral
andinterrelatedpartofthetotalhuman
organism.”4
“SkilledPhysicalTherapistsareaninvaluablepartof
ateamofhealthprofessionalsprovidingspecialknowledgeandabilitiesthatcanenablethedeliveryof
aneffectiverehabilitationprocess,especiallyforpatientswithmusculoskeletaldysfunctions.”5The
informationprovidedinthispamphletservestobettereducateyouasapatientontheissuescausedby
thesacroiliacjoint,andhowPhysicalTherapistusecertainmethodstoexpeditetheprocessofrecovery.
Anatomy
Thesacroiliacjoint,abbreviatedas“SI”joint,isa
connectionoftwobonesjustbelowthelumbar
vertebrae(yourlowerback).Thisjointiscomposed
ofthesacrumandiliumbones.Justasthekeystone
inamasonryarchservestomaintainthestructural
integrityofdoorwaysandceilings,thesacrumisa
biologicalequivalenttothestructuralintegrityof
thepelvis.
Thereare2partstotheSIjoint;oneithersideofthesacrumwehave2iliums(placeyourhandsonyour
‘hips’andyou’refeelingthetopoftheilium)andbetweentheplacementsofyourhandsbeingonyour
hipslaysthesacrum.Thisisthe“SIjoint”.Previousschoolofthoughtbelievedthisjointtoberelatively
‘fixed’,orextremelystable.However,moreup-to-dateresearchoutlineshowthemobilityand
synchronicityofmovementatthisjointplaysanextremelyimportantroleinthenormalmotionofthe
humanbody.
Normalmovementofthesacruminrelationtotheiliumisdescribedas‘nutation’(andconversely,
‘counternutation’),whichcanbedefinedasoscillatorymovementoftheaxisofarotatingbody1.
Anotherwaytothinkofthisistoimaginethetopofthesacrummovingforwardanddowncomparedto
thebottom,andthentheoppositewouldthenbecounternutation.Thesemotionsoccurinconjunction
withothermovementslikewalking,bendingforward/backward,andevenbreathing!
Signsandsymptoms
WhenthereisadisturbanceinthenormalmovementoftheSIjoint,an
arrayofsignsandsymptomsmaybepresent.InaPhysicalTherapy
examination,thetherapistwillobservethemotionoftheSIjointand
otherinvolvedstructuresviaspecialteststhatareoutlinedinthis
handout.Althoughspecialtestsarepresenttoserveasabasisfor
examination,realizethateveryevaluationmayvaryfromtherapistto
therapist.“PeoplewithSIjointdysfunctionwillhavesymptomsranging
frompainatthejointitself,inthelowerback,orevendownthethigh
andgroin.Theremaybeapresenceofgeneralizedstiffnessorburning
sensationatthejoint”2.SometimesanSIdysfunctioncanactuallycause
painontheoppositesidefromwherethetrueproblemlies!3
Muscles
Piriformis
InnervatedbyS1andS2
WillbecomeoveractiveorfacilitatedwithanSIJD.
Tendernessisusuallyfeltinthemusclebelly(deepbuttockpain)orattheorigin(sacrum)orattachment
(atthegreatertrochanter)
BecomestheprimarystabilizeroftheSIJinthepresenceofSIJDwhichisafaultypattern
Cancompressthesciaticnerveandcancausepiriformissciatica(link)orpiriformissyndrome
Overstretchingoftenincreasesoveractivityorfacilitationandleadstoincreasedpainorsciatica.
Iliopsoas(iliacus+psoasmuscle)
iliacus:L2-L4(femoralnerve)psoas:L1-L3(anteriorbranchesoflumbarplexus)
DysfunctionatL2-3causeshypertonicityofthehipflexorgroupmuscles,whichcanmimicalabraltear
Hamstrings
Bicepfemoris:tibialnerve+commonperonealnerve,semitendinosus:tibialnerve,semimembranosus:
tibialnerve
Hamstringtearsareoftenaresultoftheinactivationofthegluteusmaximusduringathleticactivity.
Overactivation/facilitationofthehamstringscanbecausedbysacraldysfunctions,T-Ljunction
dysfunctions,andevenanklesprains.
Neuraltensionisanadditionalsymptomoftighthamstrings.Whenneuraltensionincreases,the
hamstringsbecomeshortenedtoprotectthenervesthatrundowntheleg(think:sciaticnerve).
QuadratusLumborum(QL)
T11-L2innervation
Mostfrequentmuscularcauseofbackpain
HypertonicityononesideassociatedwithFRSdysfunctionatT12-L1tothatside.
PossiblytheprimarystabilizeroftheL-spine
CommonwithonesidedsittersandstandersinSIJD
LumbarMultifidus
Innervatedbyposteriorbranchesoflumbarspinalnerves
Whenthereiscompromisetothedeeplayerofthespinalcolumn(vertebrae/discs/ligaments)the
multifidus,akeystabilizingmusclethatnormallyprotectstheinjuredspinaljoint,quicklyshrinksby25%
andfailstoactivatecorrectly.Thismeansthekeymusclesthatnormallykeepourbacksfunctioning
properlyandwithoutpaincannolongerdtheirjob.8(Jemmett)
SerratusAnterior
Innervation:C5-7(longthoracicnerve)
BecomesinhibitedasaresultsofERS(extension)dysfunctionsintheupperthoracicspine,orfroma
lossofinferior/posteriorglideoftheG-Hjoint
Asaresultofthedysfunction,scapularwingingcanoccur.Thisequatestopoorscapularstabilization,
cervicalpain,shoulderimpingement,anduppertrap/levatorscapulaetriggerpoints.
Internal&ExternalObliques
Innervation:intercostalnerves7-12,subcostalnerve
Innercostalnerve8-12,iliohypogastric,ilioinguinalnerves9
Triggerpointsintheexternal/internalobliquesandtransversusabdominusallhavesimilartriggerpoint
patternsintotheabdominalcavity.Referralpatternscanmimicheartburnandepigastricpain.
(www.bodyworks.com)
TransversusAbdominus
Innervation:T8-12
Thismuscle,likethemultifidus,isakeyplayerinspinal(core)stabilizationinthelowback.Injurytothe
deeplayerofthespinalcolumnresultsindecreasedcontractileabilityofthe“TrA”.Causesalsostem
fromThoraco-Lumbarjunctiondysfunctionsandlowerthoracicdysfunctions.
Thisleadstotight/overactivehamstrings,increasedneuraltension,andlowbackpain.
Onlyneed3-5%ofTrAcontractionforstability
Onlytrainaftermechanicaldysfunctioniscleared
RectusAbdominus
Innervation:7-12intercostalnerves
Acauseofdysfunctionofthismusclegroupisaninferiorpubicdysfunctiononthesamesideasthe
symptoms,whicharesamesideadductorpainandpubicpain(symphispubis).
Adductors
InnervationL2-L4
Arefunctionallyconnectedtotheabdominalobliqueslingofsupportfortheanteriorpelvis
Whenhypertonicthepulloftheadductorscanresultinaninferiorpubicshear(symphysispubis)
Diaphragm
InnervationisthephrenicnerveC3-C5
Thediaphragmfunctionsinbreathing.Duringinhalation,thediaphragmcontractsandmovesinthe
inferiordirection,thusenlargingthevolumeofthethoraciccavity(theexternalintercostalmusclesalso
participateinthisenlargement).Thisreducesintra-thoracicpressure:Inotherwords,enlargingthe
cavitycreatessuctionthatdrawsairintothelungs.
GluteusMaximus
InnervationL5,S1,S2
PrimaryStabilizeroftheSacroiliacjoint
CanbecomeunderactivewithaLeftonRightsacraltorsionorRightonLeftSacraltorsion,and
mechanicalproblematL4orL5onthesameside
UnderactivityoftenresultsinchronicHamstringtightnessorinjury.
GluteusMediusandMinimus
InnervationL4,L5,S1
Primarystabilizerofthehipandknee
BecomesunderactivewithaLeftonrightsacraltorsion,rightonleftsacraltorsion,andL4orL5
mechanicalproblemoftenontheoppositeside.
UnderactivityisacommoncauseofITBsyndromeorPatellarFemoralPainSyndrome
TensorFasciaLatae/Iliotibialband(TFL/ITB)
InnervationofTFLisL5-S1
UnderactivityoftheGluteusMediuscausetightnessintheITB/TFLwithchronictightness.
Pelvicgirdlemusclegroupsandslings
The‘pelvicgirdle’simplyreferstotheenclosedstructurethatisformedfromthecollectionofbones
thatmakeupthepelvis.Musclesthatattachtothepelvismakeupcomplimentarymusclegroupscalled
“slings”.Thesemusclegroupsallowforeithertheproductionofmovementorstabilizationtoreduce
movement.However,theseslingscansometimesbecompromisedduetostructuralmisalignmentinthe
SIjoint.15
Theanteriorobliqueslingthatiscomposedoftheserratusanterior,externalandinternalobliques,
rectusabdominus,transversusabdominus,andlowerlimbadductors“providesstabilitybyactinglikean
abdominalbinder,compressingtheentirepelvicgirdle,especiallythefront,securingthesymphysis
pubis”.6
Whentheadductorsofthelegbecomeoveractive(hypertonic),theycandistortthepositionoftheir
attachmentatthepelvisandcauseaninferiorshearatthepubicsymphysis.
Thelateralslingthatismadeofthegluteusmedius,andadductorsononesideofthebody,aswellas
thequadratumlumborum(QL)ontheothersideprovideslateralstabilitywhenwalking.7Usually,the
gluteusmediuscanbecomeunderactiveorhypotonic,resultinginabnormalpositioningofthepelvis
withambulation.
Theposteriorobliqueslingiscomposedofthelatissimusdorsi,thoracolumbarfascia,andgluteus
maximus(onthecontralateralsidefromthelatissimusdorsi).
“Theactionofthesemusclesalongwiththefascialsystemisthoughttobothfighttherotationofthe
pelvisthatwouldoccurduringgaitaswellasstoreenergytocreatemoreefficientmovement.”7Muscle
activityofthearmsorlegsinfluenceeachotherviatheLumbarspine
Thedeeplongitudinalslingisformedfromtheerectorspinaemusclegroup,thoracolumbarfascia,and
bicepfemoris(portionofthehamstring).“TheDLSusesboththethoracolumbarfasciaandparaspinal
systemtocreatekineticenergyabovethepelvis,whilethebicepsfemorisactsasarelaybetweenthe
pelvisandleg.Thisslinghelpstocreatestabilityandhelpbuildaswellasreleasekineticenergytohelp
moreefficientmovement.”7
Types of SIJD
HypermobileorLooseSIJ
HistoryofTraumaorhormonalchange
Waddlinggait
Secondarytolumbarpathology
Difficultybendingforwardandstandingononeleg(+forwardflexiontestandstorktestonthesame
side)
ActivestraightlegwillbeeasierwithcompressionandSIbelt/coresshortsmayhelpwithstability(link)
Responsetomobilization,manipulation,taping,corestabilitywhenjointmechanicsareimproved,and
prolotherapy(link)13
Excessivecompressionwithligamentouslaxity
Traumaoverashortperiodoftimeorrepetitivetraumaoveralongperiodoftime
Difficultybendingforwardandstandingononeleg(+forwardflexiontestandstorktestonthesame
side)
ActivestraightlegraisewillnotbeeasierwithcompressionandSIbeltandcoreshortswillnothelp.
RespondstoMyofascialrelease,dryneedling,mobilization,manipulation,taping,corestabilitywhen
jointmechanicsareimproved,andprolotherapy(link)13
HypomobileSIJ
Compressedjointduetomuscleimbalance
Paincanswitchsides
Painisintermittent-cangoawayandreturn
Oftenananteriorrotationwithleftonrightorrightonleftsacraltorsionisobserved
Overactivepiriformiscausestoeoutgait(link)andpiriformissciatica(link)onthesameside.
Abletostandononeleg
AbletoliftbothlegswithoutcompensationwiththeActiveStraightlegtest
TreatmentiscorestabilizationandMyofascialrelease/dryneedling13
TypesofhypomobileSIJD
AbsentCore
CanresultfromPost-partum
Butt-gripper(showpic)
UnderactiveTransversusabdominus(core)andpubococcygeus(anteriorpelvicfloor-andmaycause
incontinencelinktopic)
Overactivepiriformisbothsides,multifidusanderectorspinae(lowbackmuscles,andposteriorpelvic
floor-maycausecoccydnia13
TwistedCore
Theresultofaunilateral(onesided)lumbarspineorSIjointdysfunction
ResultsinanAnteriorlyrotatediliumandLeftsacraltorsion
UnderactiveunilateralTransversusabdominus(core),and/ormultifidusandanteriorpelvicfloor
Overactiveunilateralpiriformisandposteriorpelvicfloor
InvertedCore
Overactivemultifidusanderectorspinaemusclesbothsides13
StiffJoint
ThejointdoesnotmovesecondarytoAnkylosingspondylitis,capsularfibrosis,orjointfusionsecondary
toadvancedage.
Treatmentismobilizationandflexionexercises
TheSIJjointhasahardendfeelwhenmobilized13
Diagnostic Testing and Physical Exam
SIJointProvocationTests
SIJtestingshouldbedoneonpatientswithbuttockpain,withorwithoutlumbarorLEsymptoms.Most
SIJisunilateralandaroundthePSIS.Forallprovocationtests,a+testisreproductionofsymptomsand–
testisnoreproductionofsymptoms.
DistractionTest:Thepatientissupinetheexaminerappliespressureto“spread”theASISs.
CompressionTest:Thepatientisinaside-lyingposition.Thetesterisbehindthepatientwithboth
handsapplyingadownwardpressurethroughtheanteriorportionoftheilum,spreadingtheSIJ.
ThighThrustTest:Thepatientissupineandthehipisflexedto90degreesandthekneeisbent.The
testerthenappliesaposteriorshearingforcetotheSIJthroughthefemur.Avoidexcessivelyadducting
duringthisexam.
Gaenslen’sTest(Right):Thepatientissupinelyingnearthesideoftable.Theexaminerstandsonsideof
patientsandplaceslegclosesttothemoffedgeoftable.Theexaminertheninstructsthepatientsto
activelyflextheoppositelegtotheirchestandhold.Theexaminerthenappliespressuretotheleg
handingoffedgeoftableforcingthehipintoextension.
SacralThrustTest:Thepatientisproneandtheexaminerappliesananteriorpressurethroughthe
sacrum.
2outof4provocationtests(distraction,compression,thighthrustorsacralthrust)havesensitivityof.88
andspecificityof.78.+Likelihoodratio(LR)of4.00and–LRof.16forSIJpathology.
3outofall6provocationhavesensitivityof.94andspecificityof.78.+LRof4.29and–LRof.80forSIJ
pathology.
LaslettM,AprillCN,McDonaldB,YoungSB.DiagnosisofSacroiliacJointPain:ValidityofIndividualTests
andCompositesofTests.ManualTherapy.2005:10;207-18.
SIJDysfunctionGoldStandardTesting
Thecurrent‘goldstandard’fordiagnosingsacroiliacpathologiesisadiagnosticnerveblock,whereby
anaestheticisinsertedintotheSIJ,underfluoroscopyguidance.Someauthorsarguethatifthepatient
achieves50-75%painrelief,on2occasionswithshortandlongactingnerveblock,adiagnosisofSIJ
dysfunctioncanbemade,butwithcaution(vanderWurffetal2006,Berthelot(citedMaigneetal).
FortinFingertest
SimplyplaceyourfingerdirectlyontheareaofyourpainwithONEFINGERtwotimes.
Accordingtotheresultsofthisstudy,ifyoupointtotheexactspotwherethesacroiliacjointislocated
(rightorleft)eachtime,yourpainislikelycomingfromtheSIjoint.Seediagrambelowforlocationof
sacroiliacjoints.
TheSIjointsarelocatedimmediatelybelowandtotheinsideoftheposteriorsuperioriliacspines(PSIS),
whichfeellikesmallboneybumpsoneachsideofyourlowerback.Eithersidecanbepainful
StandingFlexiontest
Thepatientisinstructedtobendforwardfromastandingpositionandthefeethipwidthapart,
attemptingtotouchthefloorwhilethetherapistfollowsthePSIS’stoseewhetheroneappearstomove
moretowardsthehead.IfoneofthePSIS’smovestowardstheheadthetestisconsideredpositive.A
positivetestissuggestiveofaSIJDonthepositiveside.
Storktest
TheexaminerplacesonethumbjustbelowthePSISandtheotherthumbonthesacralsulcus.Withthe
patientinstandingandarmsunsupported,thepatientisinstructedtoliftthetestedsidekneetowards
theceilinguntilhehasreached>90degreesofhipflexion.Ifpositive,thereisastrongindicationofSIJD
presentonthatside.Normally,thePSISshouldbegintodropdown(inferiorly)after90degreesofhip
flexion.ThistestisconsideredpositiveifthePSISdoesnotmoveormovesupward(superiorly)3.
Longsittest
Theexaminergraspsthepatient’slegsabovetheanklesandfullyflexesthem,thenextendsthem.The
examinerthencomparesthetwomedialmalleolitoseeifadifferenceinpositionispresent.Havethe
patientsitup,whilekeepingthelegsextended.Comparethepositionofthemedialmalleoliagaintosee
ifthereisachange.Ifthereisaposteriorinnominate,thelegthatappearedshorterwilllengthenwith
thesitup(Orwillgofromshorttolong).Ifthereisananteriorinnominate,thelegthatappearedlonger
willshortenwiththesitup.(Orgofromlongtoshort).Theaffectedsideislabelbasedonwhichsidethe
examinernoticedapositiveseated,standing,and/orstorktest.Thistestcanhelpindifferentiating
betweenatrueleglengthdiscrepancyandafunctionalleglengthdiscrepancyduetoasacroiliac
dysfunction.
Leglengthmeasurement
AleglengthmeasurementcanbemadewiththepatientinsupinestartingfromunderneaththeASIS
andendingunderneaththemedialmalleolusonthesameside.Anydifferencenotedwillbeatrueleg
lengthdiscrepancyandmaybereasontointroduceaheelliftororthotic.
Seatedflexiontest
Thepatientisseatedwiththefeetontheground,armsbetweentheknees,andthekneesapart.The
examinerplaceshisthumbsunderneaththePSIS’sonbothsidesandasksthepatienttobendforwardas
faraspossible.Ifonethumbmovesmoretowardstheheadthenthetestispositive.Apositivetestis
suggestiveofaSIJDonthatside.3
Pronehipextensiontest
Thepatientliesonherstomachandliftsonelegwiththekneestraightabout6inchesoffthetable.The
testisrepeatedontheoppositeside.Ifonesideseemsignificantlyhardertodoand/ortherewasa
significantdelayinthegluteusmaximuscontractionduringhipextensionthenthissideispositive.A
positivetestsuggestsgluteusmaximusunderactivityandmaybemeanthereissamesideSIJDora
lumbarfacetproblem.
SingleleggedSquattest
Thepatientstandsononelegwhiletheotherlegisliftedoffthegroundinfrontofthebodysothatthe
hipisflexedtoapproximately45°andthekneeofthenon-stancelegflexedtoapproximately90°.The
armsareheldstraightoutinfront,withthehandsclaspedtogether.Fromthisposition,squatdownuntil
about60°kneeflexion,andthenreturntothestartposition.Notethelegthatwastested.Iftheknee
bucklesinwardthanthetestispositiveforpoorhipstabilizationandweakGluteusmedius.
Treatment and Exercises
PhysicalTherapyandotherconservativetreatments
APhysicalTherapistusesavarietyofmanualtherapytechniques,stretching,exercises,andmodalities
toaddressthesourceofapatient’spain;theyalsoworktoalleviatetheaggravatingsymptomsthat
inhibitnormaldailyactivities.ThegoalofPhysicalTherapyisnotonlytohelpapatientreturntotheir
premorbidstatus,buttohelpincreasepatients’bodyawarenesssothattheywillbecomemore
independentinrecognizinghowtheycantreattheirownpainthroughspecifictreatmentstailoredto
individualneeds.
Dryneedling
AnadditionalserviceofferedbyPhysicalTherapistsforthetreatmentofSIjointandbackpain,dry
needlingisquicklybecomingago-totreatmentmethod.Withtheuseofaveryfinepointneedle,the
therapistwilllocatethepresenceofatriggerpoint,whichisatightlyboundgroupofmusclefibersthat
arehypersensitiveandoftencausepain,andinserttheneedleintothatarea.Thisprocessoftencauses
instantreliefoftensioninthemusclegroup/joint.
Botoxinjections
Traditionallythoughtofasatoolforcosmeticprocedures,Botoxtherapycanbeusedtoreducepainin
chronicallypainfulmuscles.“Theseinjectionsdecreasethespasmofmusclesthatcontributetoback
pain,reducethesympatheticresponsethatisresponsibleforthedeep-seated‘visceral’componentof
lowbackpain,andalsohelpreducetheinflammatoryresponseinandaroundthesiteofinjection.”
Steroidinjections
Inthehumanbody,painandinflammationgohandinhand.Theinflammatoryresponseofthebody,
althoughanaturalprocessdesignedforprotectionoftissuesandjoints,canoftenbeextremely
debilitating.Acortisoneinjectionisusedtoreduceinflammation(andthuslyreducepain).The
medicationtakeseffectrapidly,andishighlyeffectivecomparedtoanoralequivalent.
Prolotherapy
“Prolotherapyisaninjection-basedcomplementaryandalternativemedicaltherapyforchronic
musculoskeletalpain;overseveraltreatmentsessions,afairlysmallvolumeofanirritantorsclerosing
solutionisinjectedatsitesonpainfulligamentandtendoninsertionsandinadjacentjointspaceduring
severaltreatmentsessions.”11Thistreatmentkickstartsrepairtothedamagedtissue.
PRP
PlateletrichPlasma(PRP)involvesdrawing20cc’sofblood,spinningthebloodfor15minutesina
centrifuge,extracting3-4cc’sofPRP,andinjectingthePRPdirectlyintothesiteofinjuryusing
ultrasoundguidedimagery.Apepperedneedlingtechniqueisusedduringtheinjectiontoinvokean
inflammatoryresponse.Theplateletshavealotofgrowthfactorinthem,whichcausesstemcellsand
othergrowthfactorstocomeintothearea.Eventuallynewcollagenisformedandfillsinthetearinthe
tendon.ResearchshowsthatPRPinjectionsarenotasbeneficialascorticosteroidinjectionsinthefirst
12weeksfollowingtheinjection,butPRPinjectionsaremuchmorebeneficialafter12weeks.At2years
postinjectionthetendonactuallylooksnormalandshowsnosignsofinjuryonanMRI,whereasthe
corticosteroidsshowednolongtermbenefits.ResearchisongoingtoinvestigatetheaffectsofPRPfor
DDDandcartilagedefects.TherearecurrentlynostudiesonPRPandSIJD.ThecostofPRPvariesfrom
providerbutistypically$500-$1000/shot.
Reference-GosensT.PeerboomsJC.VanLaarW.DenOudstenBL.OngoingPositiveEffectsofPRPversus
CorticosteriodInjectioninLateralEpicondylitis:Adoubleblindrandomizedcontrolledtrialwith2-year
follow-up.AMJSportsMed201139:1200
PelvicClock
Directions:Lieonyourbackwithyourkneesbentandyourfeetplacedonthefloor.Imaginethatyou
haveaclockonyourstomachwiththefacepointingtowardstheceiling.Rollyourhipsbacktowards12
O’clockandflattenyourbackintothetable.Nowrollyourhipsforwardto6O’clockandarchyour
lowerback.Rollyourlefthipdowntowards3O’clockandthenyourrighthipdowntowards9
o’clock.Tofinishrollyourhipsaroundclockwiseuntilyou’vereachedeverynumberontheclock.
Evaluation:Rolltoeachindividualnumberontheclockanddecideinwhicharea(s)youaremost
restrictedand/orhavepain.Whenyoufindthenumber(s)intheclockthatarerestrictedfollowthe
treatmentguidelinesdescribedonthehandoutforeachnumberthatyouarehavingproblems
with.Alternatively,youcanholdyourpelvis6hoursacrossor180degreesacrossfromthenumber(s)in
theclockthatarerestrictedorpainfulfor1-2minutes.
Reassessment:Repeatthedirectionsabovetoseeifyouhaveclearedtherestrictedareas.Youmay
needtorepeattheexercisesagaintogetthebestresults.Youcanperformthepelvicclockexerciseas
manytimesadayasnecessary.
Thepelvicclockcanbeperformedinsitting.
Thenpelviccllockcanbeperformedinstanding.
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