Papers by Stephan Milosavljevic
Clinical Biomechanics, Aug 1, 2020
Background: Frequent falls while walking among individuals with incomplete spinal cord injury may... more Background: Frequent falls while walking among individuals with incomplete spinal cord injury may suggest impairments in reactive balance control; however, reactive balance control during walking has not been studied in this population. The objective was to compare reactive balance control with respect to changes in margin of stability, onset of arm and heel responses, and onset and magnitude of muscle activity following an unexpected slip perturbation in individuals with incomplete spinal cord injury and able-bodied individuals. Methods: Kinematic and electromyography data were obtained during normal walking and one unexpected slip. Changes in margin of stability following a compensatory or aborted step, onset of arms and trail heel responses, and onset and magnitude of activation of the tibialis anterior, soleus and gluteus medius were calculated. Multivariate analyses compared responses between incomplete spinal cord injury and able-bodied groups. Findings: Data from 16 participants with incomplete spinal cord injury (all American Spinal Injury Association Impairment Scale Grade D, 8 with tetraplegia) and 13 age-and-sex matched able-bodied individuals were included. Individuals with incomplete spinal cord injury demonstrated limited ability to increase margin of stability in the lateral direction during a compensatory or aborted step, and a smaller magnitude of soleus activity compared to able-bodied individuals. Interpretation: There are limitations in reactive balance control of individuals with incomplete spinal cord injury, which may be a reason for the high frequency of falls in this population. Reactive balance assessment should be included as a component of routine balance assessment and fall avoidance strategies in this population.
Anonymized data from 174 participants taking part in a randomized controlled trial exploring for ... more Anonymized data from 174 participants taking part in a randomized controlled trial exploring for the effectiveness of a clinician guided walking programme to manage Chronic Low Back Pain.
PubMed, Jun 1, 2015
Background: There is evidence that applying a pelvic compression belt (PCB) can decrease hamstrin... more Background: There is evidence that applying a pelvic compression belt (PCB) can decrease hamstring and lumbar muscle electromyographic activity and increase gluteus maximus activity in healthy women during walking. Increased isokinetic eccentric hamstring strength in the terminal range (25 ° - 5 °) of knee extension has been reported with the use of such a belt in sportsmen with and without hamstring injuries. However, it is unknown whether wearing a pelvic belt alters activity of the hamstrings in sportsmen during walking. Purpose: To examine the effects of wearing a PCB on electromyographic activity of the hamstring and lumbopelvic muscles during walking in sportsmen with and without hamstring injuries. Study design: Randomised crossover, cross-sectional study. Methods: Thirty uninjured sportsmen (23.53 ± 3.68 years) and 20 sportsmen with hamstring injuries (22.00 ± 1.45 years) sustained within the previous 12 months participated in this study. Electromyographic amplitudes of the hamstrings, gluteus maximus, gluteus medius and lumbar multifidus were monitored during defined phases of walking and normalised to maximum voluntary isometric contraction. Within-group comparisons [PCB vs. no PCB] for the normalised electromyographic amplitudes were performed for each muscle group using paired t tests. Electromyographic change scores [belt - no belt] were calculated and compared between the two groups with independent t tests. Results: No significant change was evident in hamstring activity for either group while walking with the PCB (p > 0.050). However, with the PCB, gluteus medius activity (p ≤ 0.028) increased in both groups, while gluteus maximus activity increased (p = 0.025) and multifidus activity decreased (p < 0.001) in the control group. The magnitude of change induced by the PCB in gluteus medius activity was similar between groups (p = 0.760). No statistically significant baseline differences in no belt scores were evident between groups for the investigated muscles (p ≥ 0.050). Conclusion: Application of a PCB had individual-specific effects on electromyographic activity of injured and uninjured hamstrings during walking, resulting in no significant changes within or between the two groups. Future studies investigating effects of the PCB on hamstring activity in participants with acute injury and during a more demanding functional activity such as running are warranted. Level of evidence: Level 3.
PubMed, Aug 1, 2015
Background: Clinical investigation of shoulder injuries commonly utilizes visual evaluation of sc... more Background: Clinical investigation of shoulder injuries commonly utilizes visual evaluation of scapular movement to determine if abnormal or asymmetrical movements are related to the injury. To date, the intrarater reliability and diagnostic accuracy of visual evaluation of scapular movement among physical therapists are not known. Purpose: The aims of this study were to determine the clinical reliability and diagnostic accuracy of physical therapists visual evaluation of scapulohumeral movements when used to diagnose shoulder impairment. Study design: University based laboratory and an internet based survey. Methods: Thirty-three physical therapists and 12 patient participants participated in this study. Reliability was measured as percent agreement and using the free marginal kappa statistic (κ) and Cronbach's alpha (α) for interrater and intrarater reliability respectively. Diagnostic accuracy variables such as sensitivity, specificity, likelihood ratios were calculated from contingency table analysis. Results: Visual evaluation yielded the following (95% CI): diagnostic accuracy 49.5%, specificity 60% (56 - 64), and sensitivity 35% (29 - 41), positive and negative likelihood ratios were 0.87 (0.66 - 1.14) and 1.09 (0.92 - 1.27) respectively. Percent agreements of evaluation findings between sessions for static and dynamic symmetry were 69% and 68%, respectively. The alpha statistics for static and dynamic symmetry were both 0.51. Percentage agreement in determining the injured shoulder was 59%, with an alpha statistic of 0.35. Conclusion: Visual evaluation of scapular movements, without additional clinical information, demonstrated a poor to fair reliability and poor to fair diagnostic accuracy. Clinical relevance: The clinical utility of the use of isolated visual scapular evaluation is cautioned. More reliable and valid objective measures are needed for diagnosing shoulder impairment. Level of evidence: 2b, Exploratory cohort study.
International Journal of Rheumatic Diseases, May 27, 2019
Aim: Magnetic resonance imaging (MRI) can be used to identify sacroiliac joint (SIJ) inflammation... more Aim: Magnetic resonance imaging (MRI) can be used to identify sacroiliac joint (SIJ) inflammation and provide an earlier diagnosis of nonradiographic axial spondyloarthritis (nrAxSpA). However, MRI is frequently a resource-limited examination. Our aim was to assess if a set of physical clinical tests can identify SIJ inflammation in patients with nrAxSpA. Methods: Twenty participants with nrAxSpA underwent two functional tests (active straight leg raise, and stork test on the support side) and four pain provocation tests (Gaenslen's, posterior pelvic pain provocation, Patrick's Faber and palpation of the long dorsal SIJ ligament) for the SIJ, and then proceeded to a contemporaneous reference standard MRI. The Spondyloarthritis Research Consortium of Canada scoring system (SPARCC) was used to score MRI. Specificity, sensitivity, and likelihood ratios (LR) were calculated for individual clinical tests, and for the composite of tests. Results: Pain provocation tests were superior to functional tests, which showed poor accuracy. The Patrick's Faber test was the best performing procedure (sensitivity 71%, specificity 75%, positive LR 2.9, negative LR 0.4). When combining the provocation tests, a positive test in one out of two tests demonstrated the strongest predictive value (sensitivity 86%, specificity 62%, positive LR 2.2, negative LR 0.2). Conclusions: Sacroiliac joint pain provocation tests correlate modestly with inflammation. The Patrick's Faber test showed the greater LR to identify SIJ inflammation in patients with nrAxSpA. SIJ pain provocation tests may offer a simple and cost-effective way of identifying patients with nrAxSpA who are most likely to have MRI evidence of inflammation.
Clinical Biomechanics, 2015
The purpose of the study was to examine the muscle activity and hip-spine kinematics in a group o... more The purpose of the study was to examine the muscle activity and hip-spine kinematics in a group of individuals diagnosed with posterior pelvic girdle pain and confirmed postural muscle delay during a repeated fast hip flexion task. Twenty-four (12 pain and 12 control) age and sex matched participants performed a repeated fast hip flexion task to auditory signal. Surface EMG activity in the external and internal oblique, the multifidus, the gluteus maximus and biceps femoris in the stance-limb was examined for onset timing and EMG integral. Sagittal plane hip (swing limb) and spine kinematics were examined for group and side differences over the repeated trials. While the pain group lacked significant feedforward muscle activity they displayed higher muscle activity at movement onset in the biceps femoris bilaterally (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) as well as the external oblique (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) during motion of the symptomatic side. Furthermore, the pain group experienced asymmetrical spinal range of motion with increased motion on the contralateral side (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) and reduced flexion velocity on the symptomatic side (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The findings support previous hypotheses regarding the effect of increased biceps activity on pelvic control during lumbo-pelvic rotation. Further, there appears to be a symptom led strategy for bracing the innominate through opposing tension in the biceps and external oblique during movement of the painful side. Such asymmetrical pelvic girdle bracing may be a strategy to increase the stability of the pelvis in light of the failed load transfer mechanism. Putatively, this strategy may increase the mechanical stress on the sacroiliac joint exacerbating pain complaints.
Journal of Occupational Rehabilitation, Dec 4, 2010
Many New Zealand rural workers have repeated low back pain (LBP) episodes yet continue to work. W... more Many New Zealand rural workers have repeated low back pain (LBP) episodes yet continue to work. We wanted to find out why, given that other manual workers with LBP often end up on long term sick leave or permanently disabled. Our primarily qualitative approach used mixed methods to investigate rural workers with non-specific LBP. Participants (n = 33) were surveyed for demographic data, the Brief Illness Perception Questionnaire and the General Self Efficacy Scale followed by one-to-one semi-structured interviews. Analysis ranged from descriptive content to detailed qualitative Interpretative Phenomenological Analysis. Participants had high self efficacy scores, positive perceptions about LBP but strong beliefs that LBP is lifelong. Four distinct themes emerged. &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Thinking with my head before my back&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Knowing the risks&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; described participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; innovation regarding job modifications. &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Just carry on&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Love of the land&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; related to stoical resilience and commitment to something more than employment. This rural workforce adopts a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;can do&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; attitude to work, managing LBP within the context of having job control and flexible work practices. Rehabilitation interventions promoting job control and targeting positive attitudes towards getting on with work, whilst accepting LBP as part of everyday life, may have merit for other workers with LBP.
Journal of Orthopaedic & Sports Physical Therapy, May 1, 2011
Physical Therapy Reviews, Jul 3, 2020
Background: Decreased shoulder function is frequently experienced by breast cancer survivors foll... more Background: Decreased shoulder function is frequently experienced by breast cancer survivors following surgery, and it is associated with both decreased ability to perform daily living tasks and decreased overall quality of life, even several years post-surgery. Shoulder function is often measured with self-reported questionnaires. If objective measurements are taken, they are frequently restricted to range of motion measurement in the cardinal planes of movement. It is not known to what extent shoulder motion in more functional tasks has been investigated. Objectives: This review aims to determine what is known about the objectively evaluated shoulder function following breast cancer and to determine what are the most frequently used methods for evaluation. Methods: This protocol outlines the steps that will be taken to conduct a high quality scoping review on the objective measurement of shoulder function in breast cancer survivors. A comprehensive search of several databases will be performed to identify all relevant research. All identified studies will be screened and those including the objective measurement of shoulder function of breast cancer survivors post-surgery will be included. Data will be extracted by two reviewers and results will be consolidated and presented in narrative form as well as tables and figures. Conclusion: The resulting synthesis of the literature will provide a comprehensive overview of the current methods of evaluating shoulder function in breast cancer survivors. This review will elucidate gaps in knowledge regarding objective measurement of shoulder function and help to develop future research questions.
Footwear Science, Jun 17, 2014
ABSTRACT Background: Debate over footwear design and prescription is currently shaped by two oppo... more ABSTRACT Background: Debate over footwear design and prescription is currently shaped by two opposing paradigms to which the clinician or researcher subscribes. Human structure is considered either ‘poor’ requiring intervention or ‘well-adapted’. The interventionist paradigm directs research on the effect of changing mediolateral footwear bias either within the shoe design or using inserts. However, the mediolateral condition of shoes worn by individuals has seldom been considered or measured. Objective: To describe a clinical assessment tool to measure outer-, mid- and innersole footwear components and report on patterns of mediolateral heel asymmetry in a sample of commonly used footwear. Main Outcome Measure: Total mediolateral asymmetry that includes the difference between medial and lateral outersole (mm), innersoles (mm) and mid- and innersole stiffness (Asker C). Results: A total of 212 shoes provided by 106 participants were assessed, with average shoe age 11.9 months (SD 11.4) and mean use 4.6 hrs.d �1 (SD 3.9). Shoe drop between 1.0 and 3.0 cm was measured in 87.8% of shoes. Zero or symmetrical wear was observed for 41.5% of shoes while 57.6% of shoes had 1 to 5 mm lateral heel degradation. The most frequent was 1 mm (30.2%) followed by 2 mm (12.3%) and 15.1% had 3 to 5 mm. Only 0.9% (2/212) had 1 mm of medial degradation. Asymmetry of wear was influenced by the reported age of the shoe, and females were likely to have greater lateral wear than men. Conclusions: Lateral heel degradation was the most frequently measured mediolateral asymmetry. Mediolateral asymmetry by design and/or degradation was measured in the outer-, mid- and innersoles. These results may be important for related footwear research on aberrant ankle and knee joint function. Keywords: footwear; mediolateral; asymmetry; degradation; assessment
BMJ Open, 2017
Introduction: Low back pain (LBP) is the most common, costly and disabling musculoskeletal disord... more Introduction: Low back pain (LBP) is the most common, costly and disabling musculoskeletal disorder worldwide, and is prevalent in healthcare workers. Posture is a modifiable risk factor for LBP shown to reduce the prevalence of LBP. Our feasibility research suggests that postural feedback might help healthcare workers avoid hazardous postures. The Effectiveness of Lumbopelvic Feedback (ELF) trial will investigate the extent to which postural monitor and feedback (PMF) can reduce exposure to hazardous posture associated with LBP. Methods: This is a participant-blinded, randomised controlled trial with blocked cluster random allocation. Participants will include volunteer healthcare workers recruited from aged care institutions and hospitals. A postural monitoring and feedback device will monitor and record lumbopelvic forward bending posture, and provide audio feedback whenever the user sustains a lumbopelvic forward bending posture that exceeds predefined thresholds. The primary outcome measure will be postural behaviour (exceeding thresholds). Secondary outcome measures will be incidence of LBP, participant-reported disability and adherence. Following baseline assessment, we will randomly assign participants to 1 of 2 intervention arms: a feedback group and a no-feedback control group. We will compare between-group differences of changes in postural behaviour by using a repeated measures mixed-effect model analysis of covariance (ANCOVA) at 6 weeks. Postural behaviour baseline scores, workrelated psychosocial factors and disability scores will be input as covariates into the statistical models. We will use logistic mixed model analysis and Cox's proportional hazards for assessing the effect of a PMF on LBP incidence between groups. Discussion: Posture is a modifiable risk factor for low back disorders. Findings from the ELF trial will inform the design of future clinical trials assessing the effectiveness of wearable technology on minimising hazardous posture during daily living activities in patients with low back disorders.
Physical Therapy Reviews, Apr 1, 2008
Hamstring injuries are common in running and sprinting sports and have a high recurrence rate. Pr... more Hamstring injuries are common in running and sprinting sports and have a high recurrence rate. Prevention and management of these injuries has focused on traditional outcomes of strength, flexibility and endurance. The aim of this review is to explore the stabilising function of the hamstring muscle group, described as increasing the stiffness of the sacro-iliac and the knee joints during weight acceptance of stance. Loss of stability of segments proximal or distal to the hamstring muscles may lead to altered muscle recruitment, potentially increasing the loading of this muscle group and, thereby, posing an increased injury risk. Intrinsic risk factors to be considered are previous knee, groin or lumbopelvic injuries; extrinsic factors include footwear and training surfaces. The effect of physiotherapy interventions on the stabilising function of the hamstrings needs to be investigated. Such research will contribute to a clearer understanding of the reasons for the high injury recurrence rate of this muscle group.
Clinical Biomechanics, Dec 1, 2019
Background: Breast cancer survivors may encounter upper limb morbidities post-surgery. It is curr... more Background: Breast cancer survivors may encounter upper limb morbidities post-surgery. It is currently unclear how these impairments affect arm kinematics, particularly during functional task performance. This investigation examined upper body kinematics during functional tasks for breast cancer survivors and an age-matched control group. Methods: Fifty women (aged 35-65) participated: 25 breast cancer survivors who had undergone mastectomy and 25 age-range matched controls. Following basic clinical evaluation, including shoulder impingement tests, motion of the torso and upper limbs were tracked during six upper limb-focused functional tasks from which torso, scapular, and thoracohumeral angles were calculated. Between-group differences were evaluated with independent t-tests (p < .05). The breast cancer group was then divided based upon impingement tests and differences between the three new groups were tested with one-way ANOVAs (p < .05). Findings: Breast cancer survivors had higher disability scores, lower range of motion, and lower performance scores. The largest kinematic differences existed between the breast cancer survivors with impingement pain and the two non-pain groups. During overhead tasks, right peak scapular upward rotation was significantly reduced (d = 0.80-1.11) in the breast cancer survivors with impingement pain. This group also demonstrated trends of decreased peak humeral abduction and internal rotation at extreme postures (d = 0.54-0.78). These alterations are consistent with kinematics considered high risk for rotator cuff injury development. Interpretation: Impingement pain in breast cancer survivors influences functional task performance and may be more important to consider than self-reported disability when evaluating pain and potential injury development.
Journal of Orthopaedic & Sports Physical Therapy, Sep 1, 2014
The Journal of Rheumatology, Nov 15, 2014
Objective. To examine the level of evidence for criterion-concurrent validity of spinal mobility ... more Objective. To examine the level of evidence for criterion-concurrent validity of spinal mobility assessments in patients with ankylosing spondylitis (AS). Methods. Guidelines proposed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used to undertake a search strategy involving 3 sets of keywords: accura*, truth, valid*; ankylosing spondylitis, spondyloarthritis, spondyloarthropathy, spondylarthritis; mobility, spinal measure*, (a further 16 keywords with similar meaning were used). Seven databases were searched from their inception to February 2014: AMED, Embase, ProQuest, PubMed, Science Direct, Scopus, and Web of Science. The Quality Assessment of Diagnostic Accuracy Studies (with modifications) was used to assess the quality of articles reviewed. An article was considered high quality when it received "yes" in at least 9 of the 13 items. Results. From the 741 records initially identified, 10 articles were retained for our systematic review. Only 1 article was classified as high quality, and this article suggests that 3 variants of the Schober test (original, modified, and modified-modified) poorly reflect lumbar range of motion where radiographs were used as the reference standard. Conclusion. The level of evidence considering criterion-concurrent validity of clinical tests used to assess spinal mobility in patients with AS is low. Clinicians should be aware that current practice when measuring spinal mobility in AS may not accurately reflect true spinal mobility.
Journal of Science and Medicine in Sport, May 1, 2015
Effects of external pelvic compression on isokinetic strength of the thigh muscles in sportsmen w... more Effects of external pelvic compression on isokinetic strength of the thigh muscles in sportsmen with and without hamstring injuries
Manual Therapy, Oct 1, 2009
The objective of the study was to evaluate sex differences in the pattern of innominate motion ab... more The objective of the study was to evaluate sex differences in the pattern of innominate motion about the sacroiliac joint (SIJ) during hip movement. Although the magnitude of intrinsic SIJ motion is influenced by joint congruence and ligament elasticity sex differences in pelvic joint kinematics are under-investigated. Forty healthy and active males and females between the ages of 18 and 35 were recruited. 3D motion of the innominate bones and femur were recorded with a magnetic tracking device as the hips were loaded in standardised increments of 10 in 3 positions-external rotation (ER), abduction (AB), and combined external rotation and abduction (AB þ ER). While females had greater overall innominate motion, two distinct sex dominant patterns emerged. Patterns of innominate motion also differed when load was applied to the dominant rather than non-dominant limb. As the main motion within the pelvis is intrinsic, the results of the present study point to a differing viscoelastic response and different movement strategies to passive load between the sexes. In addition, careful attention to limb dominance should be considered when testing SIJ motion.
Clinical Rheumatology, Sep 4, 2015
The study aimed to determine, using systematic review and meta-analysis, the level of evidence su... more The study aimed to determine, using systematic review and meta-analysis, the level of evidence supporting the construct validity of spinal mobility tests for assessing patients with ankylosing spondylitis. Following the guidelines proposed in the Preferred Reporting Items for Systematic reviews and Meta-Analyses, three sets of keywords were used for data searching: (i) ankylosing spondylitis, spondyloarthritis, spondyloarthropathy, spondylarthritis; (ii) accuracy, association, construct, correlation, Outcome Measures in Rheumatoid Arthritis Clinical Trials, OMERACT, truth, validity; (iii) mobility, Bath Ankylosing Spondylitis Metrology Index-BASMI, radiography, spinal measures, cervical rotation, Schober (a further 19 keywords were used). Initially, 2558 records were identified, and from these, 21 studies were retained. Fourteen of these studies were considered high level of evidence. Compound indexes of spinal mobility showed mostly substantial to excellent levels of agreement with global structural damage. Individual mobility tests for the cervico-thoracic spine showed only moderate agreements with cervical structural damage, and considering structural damage at the lumbar spine, the original Schober was the only test that presented consistently substantial levels of agreement. Three studies assessed the construct validity of mobility measures for inflammation and low to fair levels of agreement were observed. Two meta-analyses were conducted, with assessment of agreement between BASMI and two radiological indexes of global structural damage. The spinal mobility indexes and the original Schober test show acceptable construct validity for inferring the extent of structural damage when assessing patients with ankylosing spondylitis. Spinal mobility measures do not reflect levels of inflammation at either the sacroiliac joints and/or the spine.
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Papers by Stephan Milosavljevic