"I am a recent mother. And I have been breastfeeding my 3-month old baby daughter. Since about 2 months ago, I have started have neck aches and around my upper back. I think this is related to my breastfeeding posture. Is there anything I can do about it? Thanks in advance! - Melinda Q."

Dear Melinda,

International Breastfeeding Symbol

Some things you can try out:

• Make sure you sit well supported, preferably with a high back chair or using pillows to support behind your back (place pillow vertically).
• A footstool to raise your lap, if your feet is not resting firmly on the floor and the baby is not high enough to feed. 
• Place a pillow or two on your lap to support your baby (so baby lay at chest level), draw your shoulder blades back and keep your chin in as you bring your baby towards you for nursing. Experiment with the placing of pillows to achieve the most comfort. Alternatively,there are several "nursing" pillows on the market that help raise baby to a comfortable height and position. Whatever position you choose to nurse in, make sure you have a good posture and feel comfortable.
• Have frequent short breaks (about 30s) while breastfeeding to stretch your neck.
• Place hot packs around neck and upper back for about 20 minutes each time.  Alternatively, try showering with warm water over the neck and upper back where it is sore. 

If your neck pain does not resolve within 3 months, it is best you seek a women’s health physiotherapist to help assess and manage your pains.

Low back pain is one of the most common reasons for consulting a physician. Despite little supporting scientific evidence, bed rest was considered the primary treatment for low back pain from the late 19th century. What has changed now is how back pain is understood and managed.

How Bed Rest Started as the Recommended Approach for Back Pain

Source: flickr amanky

Their theory of injury leading to an inflammatory response that requires rest to heal the body had a huge influence throughout the field of medicine even though their works revolves around only on inflammation and wounds. Physicians all over the world started to use rest as a treatment for a wide range of conditions, from myocardial infarction to normal childbirth.

TThroughout the 19th century, the orthopaedic principle of rest became dominant. The rationale of rest for back pain started from the idea that pain was due to injury. With injury, inflammation occurs and thus rest was essential for healing. If the primary injury was not properly treated with rest, chronic pain would develop. It was believed that movements, physical activities and repeated back injuries during the inflammatory phase may increase pain and so must be harmful, and thus should be avoided. This thinking was later applied in the treatment of a ruptured disc, where the disc "comes out". The idea was that with bed rest, i.e. lying down, disc pressure is the lowest and the disc will somehow "go back". Unfortunately, there was no scientific evidence back then to support bed rest as treatment. Orthopaedic doctors just followed with what was taught to them, i.e. bed rest. By 1900, a standard orthopaedic text was published and recommended two to six weeks of bed rest for acute back pain.

Doubts Began to Form in Approach to Back Pain

Although some doctors during the 19th century did question the use of bed rest, it was not until the 1980s that its efficacy as a treatment for back pain began to be seriously questioned. However, many then still felt that some rest was necessary, and initial studies only questioned the amount of rest that was needed rather than whether it was needed at all

In 1986, Deyo et al were the first few to investigate the use of bed rest in low back pain. The study compared the functional status and symptoms of a group that received 7 days of bed rest with a second group that received 2 days of bed rest. No difference was found between the two groups in terms of the functional status and symptoms. This later formed the basis for several guidelines that advise no more than 2 days of rest for patients with acute low back pain

Over the years, studies have emerged showing that bed rest of any duration is not effective for low back pain and that it often delays recovery. In fact, other than delayed recovery, prolonged bed rest can also have detrimental effects on the body. Patients with prolonged bed rest may end up with osteoporosis (bone calcium loss), muscle wasting due to muscle protein loss, deep vein thrombosis and undesirable psychological effects

Current Approach to Back Pain

So the question now is, if bed rest has been shown to be detrimental and ineffective in the treatment of low back pain, would early activity be better?

Several studies have looked at the effects of advice to stay active in the treatment of acute low back pain and found that advice to stay active was better or similar to advice to rest in bed. In an update of a 2004 Cochrane Review of trials on bed rest for acute low back pain and sciatica, it was found that for patients with acute pain, advice to rest in bed was less effective in reducing pain and improving an individual’s ability to perform every day activities than advice to stay active. For patients with sciatica, there was little or no difference between advice to rest in bed and advice to stay active.

For chronic back pain sufferers, exercise therapy has been supported by good evidence to reducing time taken to return to work and improving functional status. Patients prescribed with graded exercises have been shown to return to work sooner, have less disability, and have fewer pain complaints than patients treated with medications and bed rest.

No More than Two Days Bed Rest

Given the extensive research done in recent years on back pain and rest, there is rising evidence to point towards avoidance of bed rest for the management of back pain. Advice on early, progressive activity, with no more than 2 days of bed rest, will serve as the current approach to the management of back pain.

References

1. Allan, David B. and Waddell, Gordon(1989). A historical perspective on low back pain and disability, Acta Orthopaedica,60:3,1-23.

2. Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? The New England Journal of Medicine 1986; 315:1064-1070.

3. Gorden Waddell. The Back Pain Revolution, Churchill Livingstone, New York. 1999.

4. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001254.

5. Lindstrom I, Ohlund C, Eek C, et al.Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain: a randomized prospective clinical study with a behavioral therapy approach. Spine 1992; 17:641-652.

6. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavorial approach. Physical Therapy 1992; 72:279-293.

Ever wondered how a belly-dancer is able to move and control her hips effortlessly to the rhythm? She will need to have good control of her lower spine, pelvis and its supporting muscles systems, in particular the “myofascial slings".

Stability of Pelvic Girdle / Sacroiliac Joints

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

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

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

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

Myofascial Slings

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

Anterior Oblique Sling

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

Posterior Oblique Sling

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

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

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

References

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

Spasmodic torticollis (ST) is also called cervical dystonia. Dystonia is a neurological movement disorder characterised by involuntary muscle spasms and sustained muscle contractions. Dystonia can affect just one muscle or a group of muscles or all of your muscles. In the case of ST, the muscles in the neck go into involuntary contractions. These sustained muscle contractions result in twisting, turning or tilting of the head and neck, and sometimes jerky head movements. Pain can also accompany the involuntary muscle contractions in the neck.

Although it is said that ST occurs as a result of a dysfunction of the brain, the exact cause to how the nervous system of the brain goes awry remains unknown. ST can resemble other disorders such as Parkinson’s disease, epilepsy, muscular dystrophy and wry neck. In order to exclude these conditions, various diagnostic tools are utilised by the physician. The electromyography (EMG) is used to help assess and diagnose muscle and nerve disorders. It can help to confirm whether the patient is having ST or another condition. A Magnetic resonance imaging (MRI) may be used to rule out ST and identify the presence of tumour or stroke whereas a blood test will reveal the presence of toxins.

ST usually occurs between the ages of 25 to 55 years old, with a higher incidence in women than in men. There also seems to be a genetic link, with 3 percent of patients reporting at least one relative with ST, and 50 percent of patients with a family history of tremors in the hand or head.

The symptoms associated with ST always occur slowly or intermittently, reaching a plateau in 2 to 5 years. The pain that is normally associated with ST is always focused on one place. Frequently, the pain is noted at the side of the neck or at the back of the shoulders.

To date, there is no cure for ST. However, there are a number of treatments that have been shown to provide some relieve. These include botulinum toxin injection, stress reduction techniques and physiotherapy. If all these intervention fail, patients will have two choices of surgical procedures, either deep brain stimulation or denervation surgery. A deep brain surgery is where a thin insulated wire is inserted into the brain via a small hole cut into the skull. This wire will then send electrical pulses to the brain to block the nerve signals that caused your head to twist. On the other hand, a denervation surgery involves cutting the nerves or the muscles that are responsible for the contorted posture associated with ST.

Do you stand or walk like a limbo rocker? If yes, you may have sway back. Apart from slouching, sway back is another common bad posture that leads to back pain. Like most posture problems, it is easily correctable by treating and preventing its contributing factors.

What is SWAY BACK?

source: flickr kaliya

What contributes to SWAY BACK?

Typically, sway back posture arise from a combination of these four factors:

1. Weak abdominal muscles
2. Tight hamstrings and back muscles
3. Stiff spine and/or pelvis
4. Ligaments laxity or overstretching of your back and pelvis

One of the basic functions of abdominal muscles is to pull the upper part of the body forward, like when you do sit-ups. When they are weak, they are unable to pull the spine forward enough to a straight or neutral position. As with most bad postures, the back muscles tend to work harder than they should, causing them to tighten up. In this case, the back muscles and hamstrings tigthen up, pulling the back of the legs and upper back towards the buttocks. Overtime, causing the sway back posture to become more pronounced. Sway back is not an optimal posture; the weight borne by the spine is not evenly distributed. Instead, joints and ligaments are strained with additional weight. Strained joints stiffen up up over time. Making it difficult for them to return to their neutral, relaxed position even when no weight is bearing down on them. Ligaments, on the other hand, when strained over time become stretched. When the ligaments are loose, the spinal column becomes ‘loose’ and less stable. Perversely, it makes for sense for the body to return to the sway back position and rest on the joints as it is more stable, although bad in the long run. These four contributing factors that disturb the stability of the spine can cause the lower back to be more susceptible to injuries.

Treatments

Correcting back pains as a result of sway essentially requires us to treat and correct the four contributing factors.

1. Strengthening the abdominal muscles to better support the spine.
2. Release the the tight hamstrings and back muscles muscles either through deep tissue massage or myofascial release.
3. Increasing the flexiblity of the spinal joints with manual therapy techniques such as mobilisation or spinal manipulation to restore normal joint movements.
4. Unfortunately, nothing can be done to ‘un-stretch’ ligaments. Ligaments are very tough tissues that don’t stretch to hold bones together and don’t bounce back when stretched. To compensate for the instablity caused by the loose ligaments, specific spinal muscles have to be trained to better support the spine. These are your postural muscles found deep within the body.

Prevention

Like with most body pains, it would have been better if we never had to fix it in the first place. We can prevent sway back with the four simple tips below.

1. Good posture – Having a good posture by being conscious of your body. Tuck in your chin, stand up tall without slouching, your shoulder should be aligned with the hip to prevent excessive back arching. And lastly. stand evenly on both feet.
2. Abdominal muscles (Rectus Abdominis) strengthening – It is important to start training your Rectus Abdominis muscles to better support your spine, relieving strain off the spinal joints, ligaments and back muscles.It can be done with a simple exercise at home - Lie face up, bend both of your knees and hips on a firm surface. Rock your pelvis towards forward and upward and feel your lower back flattening on the firm surface. Hold in the position for 5 seconds then relax, then repeat this exercise for 3 sets of 10 repetitions.
3. Hamstring stretch – Lie face up. Straighten the knee. Hook a towel around the leg near the ankle and pull the leg gently towards the body. Feel the stretch at the back of the thigh and hold it for 20-30 seconds. Repeat it for 3 sets.
4. Back muscles stretch - Lie face up and with your knees bent. Twist your body to the side and feel the stretch on your back. If you cannot feel the stretch, turn the knees to the opposite side. Hold the stretch for 20-30 seconds. Repeat it on the other side and continue for another 3 sets.

Sometimes its difficult to imagine all the muscles, nerves and ligaments that your therapist mentions, even when drawn out. Below is a great video filmed at the Body World exhibition in Canada. The video explains how the restrictions in the structures of your low back, core, and lower extremities can cause low back pain and a wide array of other problems. Learn how releasing restrictions throughout this kinetic chain can provide a resolution to your low back problems. 

If you have a broadband connection, click on the "HQ" button at the bottom of the video, to watch the video in High Quality.

 "Hi, I am suffering from pain in my lower back. It has been going on for some time now, about 6 weeks of so. Hot packs and heat rubs don’t seem to be working as before. And it seems to be getting worse. I heard that Pilates and Tai Chi is great for preventing back pain, so I was thinking one of them.  Which would you recommend? Thanks!" - Pauline Shi

Hi Pauline,

Sorry to hear about your back but first things first - prevention is not cure. Prevention is great before your have your problem. When you have a problem, what you need is a cure, not prevention.  If you are injured in a car accident, you don’t try to heal your self by wearing a seat-belt in bed. Nor will drinking more milk help your bone fracture heal right.

Flickr: Steve Rhodes

So the first thing I would recommend is that you seek proper medical advice for your low back pain. Doing Pilates or any other form of exercises at this stage is not likely to help and may even aggravate it.

Once the pain is gone or properly managed, you can then look at either Pilates or Tai Chi to prevent the pain from coming back. As to which is better, both have a great foundation in core stability and strength. If done right, these exercises can go a long way in helping you strengthen the right muscles that’s required to support your spine. Yoga is another exercise you might want to consider.

But do look for a reputable instructor, these muscles are located deep within your abdominal area and are hard to activate. More so, for people with a history of back pain. Good instructors will know if you are doing the exercises right.

Here are some past MCR articles that you might find useful.

1. Confused Over Core
2. Multifidus - Smallest Yet Most Powerful Muscle
3. Why does my back hurt?

Good luck.

The Swiss ball has been with us for a long while, since 1963 to be exact. It was invented by Aquilino Cosani, an Italian plastics manufacturer. Swiss balls today are almost de-riguer in gyms and it is not unusual to spot one in place of a chair at work or at home. But with so many choices available, buying one can be a daunting. So how does one go about choosing a Swiss ball?

The two most important criteria in picking the right Swiss ball (also known as Gym Balls, Fit Balls and Exercise Balls) are the Size and the ball Material.

Size Matters

First on Size, Swiss balls often come in several standard sizes - 45cm, 55cm, 65cm and 75cm in diameters. The most common method of choosing the right-sized ball to fit a person is the ‘Sit on the Ball’ test. Sit on a properly inflated Swiss ball with your feet flat on the ground and your knees should end up just below your thigh. If your knees are at a level higher than your thigh, the ball is too small for you.

It is possible to inflate or deflate the ball a little more or less than its recommended size but not too much. Because,

• If over inflated, you run the risk of the ball bursting at the worse possible moment.
• If under inflated, it becomes less wobbly, losing its ‘unstable surface’ properties that make the ball a great stability exercise tool. An under inflated ball also presses against the back of your thigh when sitting down. This can restrict blood circulation during prolonged sitting.

If you intend to use the ball for other exercises other than sitting, you should test the ball size to see if your posture or form is right performing those particular exercises.

Substance Counts Too

One thing that you will notice almost immediately is that the cheaper Swiss ball tends to be quite stretchy. Avoid these materials if possible as their stretchy properties make it harder to properly size a ball to fit you. Sitting on a 65-cm ball can quickly squish it down to a height of a regular 55cm ball. Stretchy materials also tend not to be anti-burst.

Anti-burst will be a common selling feature when you shop for Swiss balls. But what does it mean? Well, it doesn’t mean that your ball will never break or puncture. What it does mean is that when you get a puncture and if you happen to be sitting on it, it will deflate slowly giving you time to get off or if not, fall more gently to the floor.  When a regular Swiss ball is punctured, they pop like balloons - that is very quick, leading to injuries. Anti-burst Swiss ball material tends to be more rigid but not all rigid material is anti-burst. If unsure, ask your therapist or personal fitness trainer for advice. A good Swiss ball should last you for several years.

One of the most popular questions we get is, “How do we treat back pain?” Understandably, if you are suffering any sort of pain, anyone would want to know how to get rid of it. But it is not the best first question. A better first question is, “How do we figure what’s causing the pain?

What is the difference?

Back pain like other sorts of pain is only a symptom. It is a sign that something is wrong. It is not a problem in itself. Unfortunately, it is one of a handful of symptoms that we have that is shared by thousands of conditions. We can trace from a specific condition to how it causes pain. But it is not as simple to trace back from pain to the specific condition. It is like watching someone climb up a mountain to the top. We know where they will end up. But just by observing someone standing at the top of the mountain, we cannot determine from which side of the mountain that person came up from. Take for example, some forms of internal organ problems (eg: kidney) cause back pain. If you were just treating the pain at the back without realizing that it is your kidney that’s the cause of it, you can imagine the result if the kidney was left untreated. While at the same time, there are some chest pains that are caused by issues with the muscles at the chest and not the heart.

Solution meets problem

It is only when we have a complete diagnosis, we can then treat. Otherwise, it is pretty much hit-and-miss. This is the reason why you often hear two persons having very different results with the same back pain treatment. That is because they actually have two different problems but share a common symptom – back pain.

Source: SkiNet

How does back pain get diagnosed?

In most cases, back (or neck) pain has its roots in the body’s musculoskeletal system. This system comprises of your bones, joints, ligaments, tendons, muscles, nerves and the nervous system. A competent medical professional will be able to rule out other causes quite quickly and refer to you to the appropriate specialists. If a musculoskeletal specialist determines that the pain might be a result of bone cancer instead of a problem with the musculoskeletal system, the patient will be referred to a cancer specialist. When diagnosing a patient, a musculoskeletal specialist will rely on 4 things:

1. The patient’s history of the pain.
2. A visual observation of the patient movements.
3. Feel of the affected and surrounding areas.
4. Specific movement diagnostic test to confirm or eliminate probable causes.

An example of a movement diagnostic test is the Thomas Test. In a simple example of Snapping Hip, a condition where a popping sound is heard and pain felt when the leg is moved forward or backward at the hip. To determine if it is an Internal Snapping Hip caused by tight iliopsoas, a muscle deep inside the thigh and pelvis or an External Snapping Hip caused by ITB tightness, a taut band running along the outer side of your thigh. The Thomas Test is a movement that helps us isolated a specific muscle; in this case, the iliopsoas to determine if the Snapping Hip condition is arising from the either two possible causes.

What about machine testing?

Diagnostic tests using machines of late have become controversial in some areas of medicine. In some areas like cancer treatments, detecting specific genetic markers have helped medical practitioners to quickly and accurately, pin-point the exact type of cancer; thereby enabling them to prescribe the most appropriate and effective drug. In the past, cancer treatment employed a cocktail of drugs with the hope that one of them works. Even when successful, the patient suffers a range of undesirable side-effects. Today, success rates are much higher with fewer side effects. Unfortunately in the area of musculoskeletal conditions today, the strength of machine testing is also its weakness. Machines such as Magnetic Resonance Imaging (MRIs) are capable to producing a significant amount of information with a great level of precision. If not properly directed, scanning the entire body will produce a tremendous amount of information. Even when scanning a specific part of the body, the direction and angle of the scan matters. That is only possible if we have some idea of what we are looking for; a probable diagnosis. Another thing that confounds the machine’s precision is our body’s amazing ability to adapt and compensate. There are certain types of conditions within our spine that we know cause pain such as bulging or herniated discs. But not all instances of bulging discs cause pain. It may eventually cause pain in the future but for the moment, something else is causing it.

After childbirth with an epidural, one may experience short-term back soreness at the catheter site where the medication was injected. As such, most women tend to associate labour epidural analgesia with chronic or long-term back pain. But is there really a connection between labour epidural and chronic backache?

In some retrospective studies conducted, there were suggestions that there is mild association between epidural analgesia during labour and low back pain 6 months post delivery. However, such studies were flawed by recall bias or reporting bias as they relied heavily on the respondent’s memory of past events. If the surveys were performed months and years post delivery, as in the case of such retrospective studies, the results may be inaccurate.

Source: The Martha Jefferson Hospital

In sum, based on studies conducted, there is no connection between back pain and epidural usage, and the epidural pain relief during delivery do not increase the risk of long-term back pain. Back pain post delivery is more likely attributed to the pre-existing prenatal backaches due to mechanical and structural changes in the spine which are a result of normal physiological changes during pregnancy.

So what can I do if I have back pain post delivery?

Seek advice from your Doctor. Mothers should be informed about back care and how best to nurse the newborn baby with appropriate care and attention to posture. This should help resolve the back pain. Oral analgesics may sometimes be required. However, should symptoms persist for more than 6 weeks, your doctor will refer you to a physiotherapist specialized in women’s health. Meanwhile, some back care advice for postnatal mummies:

• Make sure your posture is correct in all working and resting positions
• Ensure work surfaces are of the correct height to prevent stooping (especially when changing nappies for your baby!)
• Tighten your abdominals and pelvic floor muscles before changing positions or performing activities.
• Get out of bed by bending knees, rolling over on to side keeping knees together
• Avoid exercises such as curl-ups or sit-ups if your back hurts
• Avoid heavy lifting if possible but if it is unavoidable, use correct lifting/handling techniques.
• Sit in a chair with good back support, with a rolled up towel behind the lower back (if necessary) and feet resting firmly on the floor.
• Have frequent rest breaks in between tasks

• Avoid wearing high heels

Reference

1. Alison Macarthur, Colin Macarthur, and Sally Weeks. Epidural anaesthesia and low back pain after delivery: a prospective cohort studyBMJ 1995 311: 1336-1339
2. Howell CJ, Dean T, Lucking L, et al. Randomised study of long term outcome after epidural versus non-epidural analgesia during labour. BMJ 2002; 325:357. Erratum in: BMJ 2002; 325:580
3. Loughnan BA, Carli F, Romney M, Dore J, Gordon H. Epidural analgesia and backache: a randomized controlled comparison with intramuscular meperidine for analgesia during labour.Br J Anaesth 2002; 89:466-72
4. Russell, R., Reynolds, F. Back pain, pregnancy, and childbirth.BMJ 314: 1062-1062
5. Young G, Jewell D. Interventions for preventing and treating pelvic and back pain in pregnancy.Cochrane Database Syst Rev 2002;(1): CD001139