Download ppt - SYMPHYSIS PUBIS DYSFUNCTION

SYMPHYSIS PUBIS SYMPHYSIS PUBIS DYSFUNCTIONDYSFUNCTION

Beyond Category 2Beyond Category 2

Antwerp 19Antwerp 19thth-21-21stst September 2008 September 2008

Dr Eric Pierotti DC. DO. Ch.D (Adel) DIBAKDr Eric Pierotti DC. DO. Ch.D (Adel) DIBAK

IntroductionIntroduction

• Increasing number of patients Increasing number of patients presenting with pain to lower presenting with pain to lower back and or sacroiliac joint area back and or sacroiliac joint area

• No obvious pattern of pain or No obvious pattern of pain or aetiological incidenceaetiological incidence

• Many also had pain of left or Many also had pain of left or right lower abdominal quadrant right lower abdominal quadrant (s) and or groin pain(s) and or groin pain


• Therapy localisation and Therapy localisation and challenge of lumbars, pelvic challenge of lumbars, pelvic bones and joints all negativebones and joints all negative

• No visceral fixations or mal-No visceral fixations or mal-positioning positioning

• Postural analysis essentially Postural analysis essentially normal exceptnormal except for;for;

IntroductionIntroduction• Minor loss of lumbar lordosis with Minor loss of lumbar lordosis with

associated posterior pelvic tiltassociated posterior pelvic tilt

• Standard quadriceps and rectus Standard quadriceps and rectus femoris test negative femoris test negative

• Beardall’s test showed marked Beardall’s test showed marked inhibition of quadriceps groupinhibition of quadriceps group

• Occasionally functionally inhibited Occasionally functionally inhibited abdominals, adductors and abdominals, adductors and piriformis muscles unilaterally or piriformis muscles unilaterally or bilaterallybilaterally


• Therapy localisation to all Therapy localisation to all factors of the IVF failed to factors of the IVF failed to isolate one common reflex which isolate one common reflex which facilitated the inhibitionfacilitated the inhibition

• Possible association with pubic Possible association with pubic symphysis dysfunction was symphysis dysfunction was recognised after examining a recognised after examining a patient postpartum patient postpartum

Case historyCase history• 32 year old female 8 weeks 32 year old female 8 weeks

postpartum second child postpartum second child • Presenting symptoms of general Presenting symptoms of general

lumbar spine pain and acute lumbar spine pain and acute bilateral groin and pubic painbilateral groin and pubic pain

• Particularly difficult pregnancy Particularly difficult pregnancy and instrument assisted delivery and instrument assisted delivery

• Difficult walking and erecting Difficult walking and erecting after sitting or lyingafter sitting or lying

• No previous history of spinal No previous history of spinal related problems related problems

Case historyCase history• Examination elicited normal Examination elicited normal

ranges of motion of the lumbar ranges of motion of the lumbar spine and sacroiliac joints spine and sacroiliac joints

• Exquisite tenderness at the pubic Exquisite tenderness at the pubic tubercles, medial joint and tubercles, medial joint and inferior ramus bilaterallyinferior ramus bilaterally

• Palpatory widening of symphysis Palpatory widening of symphysis • Bilateral weakness of quadriceps Bilateral weakness of quadriceps

(Beardall’s) and rectus abdominus (Beardall’s) and rectus abdominus • Negative TL and challenge to all Negative TL and challenge to all

lumbars, SIJ’s and innominateslumbars, SIJ’s and innominates

Case historyCase history• TL to pubis negated muscle TL to pubis negated muscle

weaknessweakness

• Diagnosis; symphysis pubis Diagnosis; symphysis pubis diastasis associated with diastasis associated with ligamentous compromiseligamentous compromise

Case historyCase history

• Correction of pubic subluxation Correction of pubic subluxation using activator and blocking using activator and blocking techniques techniques

• 95% reduction of lumbar and 95% reduction of lumbar and pubic pain immediately after first pubic pain immediately after first correction correction

• Correction and remedial Correction and remedial exercises over 2 weeks exercises over 2 weeks completely resolved all symptoms completely resolved all symptoms and findingsand findings

Normal AnatomyNormal Anatomy

• A fibrocartilaginous joint with a A fibrocartilaginous joint with a cleft at the confluence of the two cleft at the confluence of the two pubic bonespubic bones

• A thick intra pubic A thick intra pubic fibrocartilaginous disc is fibrocartilaginous disc is sandwiched between thin layers sandwiched between thin layers of hyaline cartilageof hyaline cartilage

Normal AnatomyNormal Anatomy• Major stability is Major stability is

provided by the provided by the inferior pubic inferior pubic (arcuate) ligament(arcuate) ligament

• The superior pubic The superior pubic ligament connects ligament connects the bones from the bones from above and above and provides superior provides superior support and support and stabilitystability

Normal AnatomyNormal Anatomy

• Further support is Further support is provided by an provided by an aponeurosis created aponeurosis created by the tendons of by the tendons of the rectus abdominis the rectus abdominis above and the above and the gracilis and adductor gracilis and adductor longus below giving longus below giving anterior and inferior anterior and inferior support where they support where they merge with the merge with the acuate ligament acuate ligament

BiomechanicsBiomechanics

• Little in literature regarding Little in literature regarding biomechanics of the symphysis biomechanics of the symphysis pubispubis

• Gray’s Anatomy states Gray’s Anatomy states – ““angulation, rotation and displacement angulation, rotation and displacement

are possible but slight, and are likely are possible but slight, and are likely in activities at the sacroiliac joints. in activities at the sacroiliac joints. Some separation is held to occur late Some separation is held to occur late in gestation and child birthin gestation and child birth””


• More recent authors in keeping More recent authors in keeping with early research(1937) have with early research(1937) have stated quite categorically that;stated quite categorically that;– ““Pelvic biomechanics should be Pelvic biomechanics should be

viewed from the perspective of the viewed from the perspective of the symphysis pubis”symphysis pubis”

P.E. P.E. GreenmanGreenman

• Movement at the symphysis Movement at the symphysis pubis consists of two movementspubis consists of two movements


•No.1No.1– A superior to inferior translatory A superior to inferior translatory

movement that occurs during one movement that occurs during one legged standing (Chamberlain)legged standing (Chamberlain)

– On prolonged one legged standing, On prolonged one legged standing, the ipsilateral pubes moves cephaladthe ipsilateral pubes moves cephalad

– This should return to normal on This should return to normal on standing on the opposite leg or on standing on the opposite leg or on prolonged two-legged standingprolonged two-legged standing


•No.2No.2

– As an axis of rotation for the As an axis of rotation for the alternating anterior to posterior alternating anterior to posterior rotation of the right and left rotation of the right and left innominate bones during gait innominate bones during gait (Pitkin and Pheasant et al)(Pitkin and Pheasant et al)

Patho-mechanicsPatho-mechanics• Habitual one legged stances may Habitual one legged stances may

result in muscle imbalances between result in muscle imbalances between the abdominals and the adductors the abdominals and the adductors with the resultant restriction of the with the resultant restriction of the pubic bone in aberrant relationship pubic bone in aberrant relationship with its partnerwith its partner

• A leg length discrepancy of 1cm or A leg length discrepancy of 1cm or more causes torsion to occur in the more causes torsion to occur in the pelvic girdle resulting in changes in pelvic girdle resulting in changes in the sacrum and pubis which the sacrum and pubis which frequently results in sacroiliac pain frequently results in sacroiliac pain (Bellamy et al)(Bellamy et al)

BiomechanicsBiomechanics•““the most reliable clinical sign the most reliable clinical sign

of instability of the sacroiliac of instability of the sacroiliac joints is disruption of normal joints is disruption of normal function at the symphysis pubis function at the symphysis pubis resulting in increased mobility resulting in increased mobility when alternate weight bearing when alternate weight bearing on either leg”on either leg”

P.E.GreenmanP.E.Greenman

BiomechanicsBiomechanics• It appears that the symphysis;It appears that the symphysis;

– Provides an axis of rotation during Provides an axis of rotation during normal gait patterns via both normal gait patterns via both interosseous and reciprocal flexing interosseous and reciprocal flexing around the joint without actual around the joint without actual separation or translatory shearseparation or translatory shear

– As long as this bound but flexible As long as this bound but flexible union is maintained, normal union is maintained, normal biomechanics of the innominates biomechanics of the innominates and sacrum can occur without undue and sacrum can occur without undue strain placed upon their jointsstrain placed upon their joints

BiomechanicsBiomechanics• When this firmly bound union fails or When this firmly bound union fails or

becomes hypermobile;becomes hypermobile;– It allows the normal synchronous It allows the normal synchronous

forward and backward motion of forward and backward motion of the innominates and combined the innominates and combined lumbar side bending and rotation lumbar side bending and rotation during gait, during gait, to move beyond their to move beyond their normal range (usually unilateral)normal range (usually unilateral)

– Causing undue and repetitive Causing undue and repetitive strain on the ligamentous supports strain on the ligamentous supports of the spine and SIJ’sof the spine and SIJ’s

Aetiology of Aetiology of DysfunctionDysfunction• There appears many and diverse There appears many and diverse

reasons for dysfunction of pubic reasons for dysfunction of pubic symphysissymphysis

• 1. Pregnancy1. Pregnancy– Normal widening of the symphysis due to Normal widening of the symphysis due to

laxity of connective tissue under laxity of connective tissue under hormonal (relaxin, oestrogen) control hormonal (relaxin, oestrogen) control which peaks at around 38 weeks which peaks at around 38 weeks

– Separation usually occurs around 20 Separation usually occurs around 20 weeks with gradual progression to its weeks with gradual progression to its maximum at around 30-35 weeks maximum at around 30-35 weeks gestation (Pierotti)gestation (Pierotti)

Aetiology of Aetiology of DysfunctionDysfunction• The normal The normal

spacing 0.5-5 mm spacing 0.5-5 mm

• Pregnancy: 9.0-Pregnancy: 9.0-12mm12mm

• Abnormal : 1 cm Abnormal : 1 cm and above and above

Aetiology of Aetiology of DysfunctionDysfunction– If widening is If widening is

excessive or too excessive or too rapid, instability rapid, instability results with results with increased increased ranges of ranges of motion at one or motion at one or both SIJ’s both SIJ’s causing a causing a repetitive type repetitive type strain with strain with resultant pain resultant pain and usually and usually inflammationinflammation

Male Soccer Player

Aetiology of Aetiology of DysfunctionDysfunction

•Post partum 28 year old female, Post partum 28 year old female, 33rdrd child child


– According to the Office of According to the Office of National Statistics: National Statistics:

•In 2002 there were 594,634 In 2002 there were 594,634 pregnancies in the UKpregnancies in the UK

•Figures from Manchester Figures from Manchester University and Leeds Royal University and Leeds Royal Infirmatory showed that 1:36 of Infirmatory showed that 1:36 of those women did or would suffer those women did or would suffer pelvic dysfunction pelvic dysfunction


• 2. Failure of symphysis to close 2. Failure of symphysis to close after deliveryafter delivery

– During delivery as the baby’s head During delivery as the baby’s head breaches the pelvic rim, a further breaches the pelvic rim, a further slight separation occurs at the slight separation occurs at the symphysissymphysis

– Which in some sort of body logic Which in some sort of body logic effects a “rebound” type motion effects a “rebound” type motion closing the symphysis over the next closing the symphysis over the next 24-26 hours24-26 hours

Aetiology of Aetiology of DysfunctionDysfunction• 2. Failure of symphysis to close 2. Failure of symphysis to close

after deliveryafter delivery– Within 24 hours of parturition blood Within 24 hours of parturition blood

levels of relaxin markedly reduce levels of relaxin markedly reduce and ligaments begin to tighten and ligaments begin to tighten regardless of joint positionregardless of joint position

– Failure to elicit this “rebound” in Failure to elicit this “rebound” in the presence of reducing relaxin the presence of reducing relaxin levels contribute to maintaining the levels contribute to maintaining the joint in a separated or dysfunctional joint in a separated or dysfunctional positionposition


• Failure to separate can be as Failure to separate can be as counterproductive as excessive counterproductive as excessive widening as; widening as; – Separation provides extra space in the Separation provides extra space in the

birth canal for the baby’s head to birth canal for the baby’s head to breach the bony pelvic rim breach the bony pelvic rim

– Failure of separation requires the Failure of separation requires the sacroiliac joints to compensate to a sacroiliac joints to compensate to a greater degree than normalgreater degree than normal

– Causing both instability and pain Causing both instability and pain especially during the last trimesterespecially during the last trimester


• This condition is This condition is responsible in part, responsible in part, for long and for long and difficult labours difficult labours and in many cases and in many cases responsible for responsible for failure of the cervix failure of the cervix to adequately to adequately dilate resulting in dilate resulting in many emergency many emergency caesarean sectionscaesarean sections

(Pierotti)(Pierotti)

Failure to separate

Aetiology of Aetiology of DysfunctionDysfunction• 3. Direct Trauma such as;3. Direct Trauma such as;

– Falling in split leg position Sports Falling in split leg position Sports and activities such ballet, dance or and activities such ballet, dance or callisthenics requiring the “splits”callisthenics requiring the “splits”

• 4. Postural Strain4. Postural Strain– Standing stationary for extended Standing stationary for extended

periods of time (hairdressers, sales periods of time (hairdressers, sales assistants, production workers)assistants, production workers)

– Secondary to positions of coitusSecondary to positions of coitus


• During prolonged During prolonged standing there is a standing there is a natural tendency natural tendency to gravitate to one to gravitate to one leg to relieve the leg to relieve the stress. Resultant stress. Resultant muscle imbalances muscle imbalances effect the shearing effect the shearing type subluxationtype subluxation

Shearing Subluxation


• This is This is particularly more particularly more relevant around relevant around the time of the time of menses with menses with resultant resultant ligament laxity ligament laxity due to due to fluctuations in fluctuations in hormone levels hormone levels

Shearing Subluxation

Aetiology of Aetiology of DysfunctionDysfunction•5. Repetitive Strain5. Repetitive Strain

– Faulty gait mechanics associated Faulty gait mechanics associated with asymmetrical stride length with asymmetrical stride length can cause a specific torque can cause a specific torque pattern to the side of short pattern to the side of short stride not dissimilar to a dural stride not dissimilar to a dural torque pattern but resulting in a torque pattern but resulting in a pubic subluxationpubic subluxation

Aetiology of Aetiology of DysfunctionDysfunction• Recent spate of Recent spate of

osteitis pubis in osteitis pubis in AFL players is as AFL players is as a result of strong a result of strong repetitive torque repetitive torque of the symphysis of the symphysis during the follow during the follow through in the through in the action required action required to kick the ball in to kick the ball in excess of 50 excess of 50 metres metres


•TraumaticallTraumatically induced as y induced as a result of a result of sporting sporting incidences incidences

Signs and SymptomsSigns and Symptoms

•Can range from; Can range from; – Acute pain at the pubes or groinAcute pain at the pubes or groin– Medial aspect of the thigh Medial aspect of the thigh

unilaterally or bilaterallyunilaterally or bilaterally– Supra pubic painSupra pubic pain– Pain on weight bearing activities Pain on weight bearing activities

(walking, negotiating stairs)(walking, negotiating stairs)


– Parting the legs or turning over Parting the legs or turning over in bedin bed

– Dysfunction of the urogenital Dysfunction of the urogenital diaphragm (frequency and diaphragm (frequency and stress incontinence)stress incontinence)

– Dyspareunia Dyspareunia – Exquisite palpatory tenderness Exquisite palpatory tenderness

around the pubis on around the pubis on examinationexamination


•A large percentage of A large percentage of patients present with this patients present with this subluxation but are not subluxation but are not aware of any symptoms other aware of any symptoms other than vague or diffuse lumbar than vague or diffuse lumbar spine painspine pain

Postural ExaminationPostural Examination

• Main postural Main postural feature in most feature in most but not all but not all cases is a hypo-cases is a hypo-lordosis of the lordosis of the lumbar spine lumbar spine and posterior and posterior tilt of the pelvistilt of the pelvis


• Note the subtle Note the subtle anterior pelvic anterior pelvic tilt (24 year old tilt (24 year old hockey player hockey player nulliparous) nulliparous)


• Pubis separation Pubis separation widens the pelvis widens the pelvis causing an causing an increase in Q increase in Q angle which angle which gives rise to gives rise to knee symptoms knee symptoms and instability and instability

Postural ExaminationPostural ExaminationPre Correction Post Correction


RadiologicalRadiological

• Weight Weight bearing X-bearing X-rays in a rays in a “Flamingo” “Flamingo” stance best stance best illustrates illustrates symphysis symphysis instabilityinstability

Muscle WeaknessMuscle Weakness

• There is a specific and recurrent There is a specific and recurrent bilateral muscle weakness now bilateral muscle weakness now correlated in well over 1000 correlated in well over 1000 patientspatients

• That is a bilateral quadriceps That is a bilateral quadriceps muscle weakness tested as a muscle weakness tested as a group but only on Beardall’s testgroup but only on Beardall’s test

• This weakness is classically This weakness is classically accompanied by hypertonic accompanied by hypertonic hamstrings hamstrings

Muscle WeaknessMuscle Weakness

• Beardall’s TestBeardall’s Test– Patient supine, Patient supine,

flex the leg to 45˚ flex the leg to 45˚ from the table from the table with the knee in with the knee in full extension. The full extension. The opposite leg opposite leg remains fully remains fully extended on the extended on the examination tableexamination table

Note inability to fully extend the legs

from hypertonic hamstrings

Biomechanics of Muscle Biomechanics of Muscle WeaknessWeakness

• Hypothetically; contraction of say the Hypothetically; contraction of say the right quadriceps in the supine position right quadriceps in the supine position performing a resisted muscle test performing a resisted muscle test requires,requires,– The left ilium to be forced posteriorly The left ilium to be forced posteriorly

into the examination table to stabilize into the examination table to stabilize the pelvis and provide a fulcrum point the pelvis and provide a fulcrum point for the muscle to maintain an isometric for the muscle to maintain an isometric contractioncontraction

– This torque motion is centred around This torque motion is centred around an intact symphysisan intact symphysis


• If the symphysis fails and the resulting If the symphysis fails and the resulting translatory motion is too great, translatory motion is too great, general pelvic instability occurs and general pelvic instability occurs and inhibition of the test muscle resultsinhibition of the test muscle results

• This is bourn out by having the patient This is bourn out by having the patient flex the opposite knee with the foot flex the opposite knee with the foot flat on the tableflat on the table

• This now provides the missing This now provides the missing stabilizer and the positive test is stabilizer and the positive test is negated negated


• This test will show This test will show a significant a significant percentage of percentage of pubic symphysis pubic symphysis subluxationssubluxations

• When suspected When suspected but Beardall’s test but Beardall’s test is negative, is negative, incorporating 10-incorporating 10-20˚ of external leg 20˚ of external leg rotation will show rotation will show the rest the rest

Therapy LocalisationTherapy Localisation

• TL to the pubis TL to the pubis will negate the will negate the weakness of the weakness of the associated associated quadricepsquadriceps

• TL will weaken a TL will weaken a previous normal previous normal facilitated facilitated indicator muscle indicator muscle

ChallengeChallenge•Challenge is directed to the Challenge is directed to the

ramus of the pubis with a ramus of the pubis with a thenar contact in either caudal, thenar contact in either caudal, medial, lateral or cephalad or medial, lateral or cephalad or combination of thesecombination of these

•For separation dysfunction use For separation dysfunction use a double hand contact to the a double hand contact to the lateral aspects of the ramus in lateral aspects of the ramus in a compressive rebound fashiona compressive rebound fashion

ChallengeChallenge

• Most frequent Most frequent subluxation found subluxation found is the shearing or is the shearing or translatory type translatory type with one pubis with one pubis superior and the superior and the other in an inferior other in an inferior configuration configuration along the coronal along the coronal plane or Y axisplane or Y axis

Respiratory Respiratory ChallengeChallenge

• During inhalationDuring inhalation– The innominates The innominates

move anteriorly in move anteriorly in a rotation motion a rotation motion around the Y axis around the Y axis

– The bony arch The bony arch separates and separates and moves inferiorlymoves inferiorly

– The opposite The opposite occurs on occurs on exhalationexhalation

Respiratory Respiratory ChallengeChallenge• Respiratory challenge only seems Respiratory challenge only seems

valid in facilitating the inhibited valid in facilitating the inhibited quadriceps when the pubis is quadriceps when the pubis is either separated or compressed, either separated or compressed, that is; that is;

• Strong inhalation will facilitate the Strong inhalation will facilitate the inhibited quadriceps when the inhibited quadriceps when the pubis is compressedpubis is compressed

• Strong exhalation will facilitate the Strong exhalation will facilitate the quadriceps when the pubis is quadriceps when the pubis is separated separated

CorrectionCorrection

• Correction is Correction is performed in the performed in the opposite opposite direction to the direction to the positive manual positive manual challenge by challenge by eithereither;;– Using an impact Using an impact

instrument instrument (activator)(activator)

Correction right inferior pubis (on exhalation)


• Activator Activator correction for correction for left superior left superior pubis (on pubis (on inspiration)inspiration)


•Manual correctionManual correction• Bring patient’s right leg into Bring patient’s right leg into

flexion, abduction and external flexion, abduction and external rotation with the sole of the foot rotation with the sole of the foot to the medial thigh left legto the medial thigh left leg

• Right thenar contact to left pubic Right thenar contact to left pubic tubercle, left hand grasps tubercle, left hand grasps patient’s right knee patient’s right knee

CorrectionCorrection• Manual Manual

correctioncorrection

• At point of At point of maximal stretch maximal stretch apply a short apply a short sharp low sharp low amplitude thrust amplitude thrust in an inferior in an inferior lateral directionlateral direction Correction for left superior

pubis


• Manual correctionManual correction• Repeat the Repeat the

procedure on the procedure on the opposite side opposite side contacting more contacting more inferiorly on the inferiorly on the right tubercle and right tubercle and thrust in a thrust in a cephalad and cephalad and lateral directionlateral direction Correction right inferior

pubis

CorrectionCorrection• Separation Separation

subluxations subluxations requires both requires both manual and manual and activator activator correctioncorrection

• Patient supine Patient supine place DeJarnette place DeJarnette blocks under blocks under each hip joint at each hip joint at 90˚ to the spine 90˚ to the spine


• Take a bilateral Take a bilateral thenar contact to thenar contact to the lateral aspect of the lateral aspect of pubic tuberclespubic tubercles

• As patient exhales As patient exhales apply a compressive apply a compressive force in a medial force in a medial direction increasing direction increasing the force towards the force towards the end of the the end of the exhalation exhalation Correction separation

subluxation

Pre-correctionPre-correction

Post-correctionPost-correction

Pre and Post Pre and Post CorrectionCorrection

Pre-correction Post-correction

Pre and Post Pre and Post CorrectionCorrection

RehabilitationRehabilitation

• There appears little in way of There appears little in way of remedial exercise as we are remedial exercise as we are essentially dealing with a ligament essentially dealing with a ligament laxity regardless of originlaxity regardless of origin

• One procedure has proven useful in One procedure has proven useful in at least creating some stability to the at least creating some stability to the symphysis in these casessymphysis in these cases

• But, requires an assistant to gain the But, requires an assistant to gain the best benefitbest benefit

RehabilitationRehabilitation• Patient supine, Patient supine,

knees flexed to knees flexed to 90˚ heels together 90˚ heels together and soles of feet and soles of feet flat on the tableflat on the table

• Assistant contacts Assistant contacts lateral aspect of lateral aspect of knees and knees and provides provides resistance to the resistance to the patient abducting patient abducting the knees to 45˚the knees to 45˚

• Repeat twice Repeat twice First Contact

RehabilitationRehabilitation

• With the knees in With the knees in 45˚ abduction 45˚ abduction assistant assistant contacts the contacts the medial aspect of medial aspect of the knees and the knees and resists the resists the patient’s patient’s adduction to the adduction to the neutral positionneutral position

• Repeat twiceRepeat twice Second contact

ConclusionConclusion

• Corrective techniques shown have Corrective techniques shown have addressed the joint predominantly, addressed the joint predominantly, be aware that the secondary support be aware that the secondary support structure of the adductors, gracilis structure of the adductors, gracilis and abdominals can in many cases be and abdominals can in many cases be dysfunctional as a result of micro dysfunctional as a result of micro avulsion of these musclesavulsion of these muscles

• Addressing this problem is beyond Addressing this problem is beyond the time constraints of this the time constraints of this presentation, just be aware that;presentation, just be aware that;


• This condition can and is multi factorialThis condition can and is multi factorial• Applied kinesiology teaches us the Applied kinesiology teaches us the

triad of health and the importance of triad of health and the importance of looking at every patient from the point looking at every patient from the point of view of structure, chemical and of view of structure, chemical and emotional implicationsemotional implications

• This technique makes the assumption This technique makes the assumption that all facets of the triad have been that all facets of the triad have been assessed and any dysfunction corrected assessed and any dysfunction corrected before embarking on this coursebefore embarking on this course


• Treating this condition as part of Treating this condition as part of a holistic approach will ensure a a holistic approach will ensure a positive and lasting resultpositive and lasting result

Thanks for your Thanks for your AttentionAttention