Common Vertebral Joint Problems PDF
Preview Common Vertebral Joint Problems
COMMON VERTEBRAL JOINT PROBLEMS GregorPy. G rieve FCS!' DipT !' HonorarFye lloowf t heC harterSeodc ieotfyP hysiotherapy Post-RegistTruattoiroD,ne partmeonftR heumatoloagnyd RehabilitaNtoirofno,la kn dN orwicHho spital FormeSru pervisanodrC linicTault orS,p inaTlr eatmeUnnti t, RoyaNla tional OrthoHpoasepdiitcLa oln,d on Fo,.ewob,y. d PHILIPH . NEWMAN CBE DSO MC FRCS LatclCyo nsultaOnrtt hopaedic SurtgheeoM ni ddtloe sex Hospitaanld,C onsultant Su10r tgheeoR no yaNla tional Orthopaedic HoasnpdIi ntsatli touftO er thopaedics, London PasPtr esideonftt h eB ritiOsrht hopaeAdsisco ciatainodn formerClhya irmaonf t heB ritiCsohu nciolfM anagemenotf theJ ournoaflB onea ndJ oinStu rgery �c::J� c::Jc::Jc::J c::Jc::Jc::J L7 CHURCHILL LIVINGSTONE EDINBURGH LONDON MELBOURNE AND NEW YORK 1981 http://avaxhome.ws/blogs/ChrisRedfield CHURCHILL LIVINGSTONE MedicaDli visioofnL ongmanG roupL imited DiSlribuitnet hde U niteSdt ateosfA mericbay Churchill Livingstone Inc.1,9 W est4 4thS treeNte,w YorkN,. 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Common venebrjaoli nptr oblems. 1.S pine-Diseases 1.T itle 617'375 RC400 LIbraorfyC ongreCua talCoagr dN umber8 1-67465 PrintiendG reat Bribtya Biunt le&r T anneLrt d.F romea ndL ondon Foreword Moderand vanicnpe r evenatnidot nr eatmheanset l imitorocfhp lanntihncegu rricaunldup mro gredsesvievel op natoerdb rouguhntd ecro ntmraonloy f t hsee veirlel nesmseensto ft hea nnucaolu rsdeusr itnhge e ighets pecially whicahg ,e neraotris ooa ng oa,ffl ictmeadn T.h em edicaflo rmatyievaer1 s9,6 t8o 1 975. profesnsoiwho angs r eaotpepro rtutnopi atyayt tenttoi onD urintgh is Gtriimeevd ee lvdeede pilnyt o vtahset thceh alloefnc gher oanritc hraintdti hsee ff ecotfts r aumal,i tertahtauhtra aesc cumuloantt ehdis su bjeTchtev. a riety streasnsds traainndw eaarn dt caorft hmeu sculoskealnedet xatle onftt hifise lidsa ptleyxp resisnte hdi bso ok: system, 'Thmeo untaoifln i teroants uprienp aalt holiosmg ays sive Thep opulaotfit ohneW estewronr lodft odaiyt,as v enougthoh avbee comaelt lh intgoas l mle n.T'h ibso ok eraagge ea ndd emanfdo prh ysical gcroamdfuoairlntl yl isntols e stsh a1n4 0r0e fereanncdie ttsse xitsa stoundingly creaspirnegs,e annte sx pandainndeg x acting pIrno rbelveme.rt eotn htge a laoxfoy p iniaonndcs o nclusainodtn hse hospiptraalc ttiocw eh,i cthh em ored ifficuclats e3fsC conflichtyipnogt htehsaettsh ey contain. referirtie sdt ,h ec onsulwthaone tx aminiensv,e stigaDteersa,n gemoeftn htev ertecborlaulm insc overienad l l attemtpodt isa gnaonsdpe r escrtirbeeast maenndht a vinigt ass peacntdsi ts oobne comoebsv iotuhsat th vea luoef excluads eedr icoauusos ret hnee efdo irn pattireenatt metnhtim so nograipsuh n iquIetu. n foltdhsen atuorfet he mayr eftehrpe a titeont th dee partmoefpn hty simceadli problaesms eebny a p erswohno h ass penmtu cht ime cinfeo sru perviasnidco anr Teh.e t herawphiosc ta rriceosm municawtiitanhng da ctively treaTthienrg e patients. outt heisnes trucstpieonnmdsus c ht imwei tthh pea tieinstm ucht ol eabront fhr oam d iagnoasntdti hce rapeutic andl earnfirnogme xperideenvceel aonpu sn parallaenlgewldhe i cihsn ofto unidnt hmea nyt extboworkist btye n understaonftd hinena gt uorfse k eleptaailn . theme dicparlo fession. GregG riehvaes d edicahtiepsdr ofessliioftneoaa ln Thiisas c ompreheangsgirveeg aotfti howenh olseu bject extenssitvuedo yf t hese phpyrsoibclaelam nsd h as butt heirsen othipnegd estirnii tatsne achiItni gsp. r ov devoteda thtiesn itnip oanr tictuotl haemr u ltispylne ocatainvdde o ubtltehsmeso rceo nservraetaidvweeor u ld dromeasr isifnrgo mt hei nterveratnedbs raaclr oilnioawac n da gaicna tchhi bsr eath. joints. Abovaeli lpt r ovisdteism ulfaottrih oonu gohnat s ubject Soi mpreswsaeshd e b yt hweo rokf M enneMlalr, linw,h icihsa ptto b eb oggdeodw nb yt radiatnido nh ampered CyriaSxt,o ddaanrddo thetrhsah tee nergetbieccaalmleby y i nterdiscciopnltiennatriyo n. involwvietdoh,t hCehra rteprheyds iotheirnfa opuinsdts,I ti sa bravaen db rilleinadneta vtoout rr anstlhaet e inags chooofil n struicntt ihobena ssicci enacsae psp liejda rgooftn h vea risocuhso ionltsa ol anguwaigteah s cien tot hes pinaen do ft hep robleomfds e rangeamnednt to tifibca siIstc. a nnfoatti ola ppetaoal l tlh oisnet ereisnt ed trapihny siotheirnta hpaeir sottf st reatmbeymn atn iputhvee ncbcroallu mwnh atever their clinical status. latiFoonl.l owtihniegn itcioaulr sweist,oh t hetre achers, betwe1e9n6 a5n d1 96h7e w ast hpei onewehroc arrtiheedA ldeburSguhf,f o1l9k8 1 P.H.N. Preface Ist heraen ythiwnhgc rcofmiaty b es aid',S ect,h iissn ew?I th ath froamd eepuenrd erstaonftd hinena gt uorfte h fuen ctional beena lreaodfyo ld timwehsi,c hw asb eforues .('E cclesiia,s taesb normality ciotin ssc uerrenleyd ,a xtihoaamtba ntoirc 10) malitoifte hsme u sculoskseylsettaearmmlc o reeff ectively Theries) junteewi nt hibso okon,l ayd ifferveonitsc aey intgr eatwehde nt hen atuorfet hea bnormmaolv emeinst theo ldt hinygestg, a thetroegde tihnea r f orwmh cih Iu nderstsoiondbc,oe d imloyv emeinstt hef unctcioonn hopwei lbleu seftuoml y c olleagues. cerneTdh.e riesn othiinngc ongrourou unsa ccepitna ble A commonelxyp resrseegdro cftt h erapwihsost tsr itvo ea pplyitnhigbs a silca wo fp rogressitohne raipne utics improtvhee hiarn dloifnc go mmojno ipnrto bleimsts h ate qualtloty h et reatmoefdn its eaosfte hseb loofdo,ir n somoef t howsheo sper erogiatits it ovd ei agnaonsdpe r esstancaen,dd egenerajtoiivndeti seaosfte h ev ertebral criabtet imeasp petaorh avoen layl imictoendc epotfi ocno lumn. thec apabiloift imeosd ern thSeurcaihp sti hsest pse.e d Tot remauts culoskpealiwenht,ea tlh beymr a nipulation, witwhh icthht ee chnoalnodcg ayp abiolfial tdli iessc iplaicnuepsu ncthuyrder,o cortiinsjoencet tiroann,s cutaneous hasr isctnh,ic si rcumstparnocbea nbolwya ppltioeas l ln ervset imulatthi'eob na,sc ckh oorle'l,a xatteicohnn iques, interdiscriepllaitniaornys hips. exerciusletsr,a sooruw nhda tevweirt,h ofiurtsm ta kinag Sincieti si ncumbuepnotnu st ok eeopu ro wnh ousec ompreheantstievmetp out n dersttahnecd l inincaatlu re ino rdetrh,e rapmiussttds o s omethaibnogut th eoiwrn oft hem usculoskaeblneotramla alsii ttya ffecetasc h situatWieo mnu.s t provide oppoorutrpu eneirtpsia etsi eifnstot hr,re o atdo E rewhon. andc olleatgoku neosw a bouotu rw orka,s piraatnido nsT heb asipch ysiecxaalm inaotfic oonm movne rtebral capabilities. andp eriphjeoriacnlot n dithiaonsno swb eedne velotpoe d Ina nyc asieti, s r ealnlomy o rteh aenn lightseenleftdh set aogfaem odertne chnolaongdgy i,v tehni assi ncreas interteocs otm prehaesmn udc ha sw ec aanb outthc eo ntexti ngsltya ndparradc ttihcseet ,e aadcyc umulaotffi uornt her ofo urw orbke cauisfwe ed on oti,tv sa launed o urw orthk nowleidsgc ee rtaWiint.h otuhti bsa silso,wb acpka in, wilfla lalw ayW.r ighatn dH opki(n1s9 7"" 8)h aveem fibrosimtuissc,u lpaari nssc,i ataincdta e nsihoena dache, phasitsheasdto m3e0 p ecre notfp hysiothetriampieis s ettscw'.i ,lr le macilna ssiacsaslolcyiw aittpehad t emnetd icine devotteord h eumaatnidoc r thopaceodnidci tions.a dvertisermuebnitfsa,c ient guenncetriaolenixsse,er d Ih avaet tempttofe odr mulaag tuei daev ,o cabuolfa rcyi seost,h e'rs hot-rgeugni'ml eiskg ee neralriesleadx ation basic infofromrta htoissoepn e ndimnugc ho ft hed ay orw hatepvieeroc fge l eamcihnrgo mium-pmlaactheidn ery handlvienrgt ejboriacnlot n ditiAosan fso.u ndaftoiroh na ppecnusr retnot libynev o guTeh.e riesn othisnagd der improvoiunkrgn owlewdegm eu sktn oswo methoiftnhgi st hayne stermdaacyh'iSn e. iwfe a spitrobe e comceo mpetientn htce o nservtarteiavteW hilwee m aken or eaelff orttou ndersttahnmedy riad menotf c ommovne rtejboriapnlrt o bleamnsdt, ok nowi n clinipcraels entaotfji ooinansbt n ormality, troublesome whicdhi recotuirko nno wlemdugsebt e e xpanded. joipnati nwsil tlh undoenru nabated. Thee asiployr takbnlaep sack-andi-nbfeodrrmoaltliS oinn tchele e voeful s eful knionwt lhweeod rgleid n creases and rule-ocfl-itnhmiuecmtabhl oodfst imepsa satr neo horrendoiunsdliyv,i hdauvagelr se daitffi cuilntk ye eping longeenro ugTho.d ayw'osr kemruss gta thkenro wledugpew itahd vanicnet sh eoiwrn s malslph erteh;ea rrete h e from mfiaenlyd asn,dt ratihne msetlova epsp liytq uicklpyr obloefma ss similaantdei sopne cioarlglayn isoaftt hieo n anda ccurawtheelnay s sestshimen ugl titouffd aec otbs availianbfloer maIth iaovnhe.a di nm indt hne eefdo ar tainbeyda g oocdl ineixcaamli nation. news tructfurraamle woprekr,h aspesr viansag s keleton Ast hmeo rseu ccestsrfeualt moefrn ets piranteorrvyo,ua sr ouwnhdi cihn creasingly bestutcecre-siwsnioflrolsr med andm etabodliisce afsoeer,x amphlaesn, a tureavlollyv ebdu iyledmt o rmee att,hw eh olree mainoirngga niisnte hde viiPiR EFACE sensteh atth es keleftraalm ewoirsnk e velro sftr omo thetrhsaw te l eatronm akie nventionso wnop,fa rour sight. ticulianrr elgya trocd l ineixcaamli naptrioocne daunrde s Thev olumoefi nformarteiqounit rheamsta nyc ontrtireatmteencth niques. butoarrsne eedeadn,dt hiism plimeys h opteh aott hersW hilpeh ysiothesrhaopuinlsodatt ns e mp[Qtw rictoem wilslh arienf ormulastuicncge eadnidnb ge nefro rmosf prehensoinvp erloyb leomfds i agnoosrti hsde,i sciplines thitse xUtn.l etshse bye m onstoefro sm nisciienndciev,oi fp atholmoegdyi,c isnuer,g enreyu,r olroagdyi,o alnogdy dualwsh os inglehanadtetdelmtypow t r itoent hem anye pidemioeltocgp.ye,,r haipnts h ed evotoifoa np rofes andd ivearsspee ocftv se rtejboriacnlot n ditmiuosndtse als ionlailf ettiotm heifi se lodfm inoorr thopaoendemi acys witsho maes peacbtosu wth icthh ehya vlei totrln eofi rsthavaec quitrhecedo mpetetnotc oeu cuhp otnh edsies cip hankdn owledge. linaesst hecyo ncetrhneg rouopfc ondituinodnesdr i s Withoduitv idnies pensoanteio'owsnn v ieowf w haits cussion here. importcaanntn bOeta ccepttaobm loer et haanh andfulW,h en stuadpepnrtosta hcehti rra iniin'n cgl inciocnal andf ort hirse asaolno nIew ,o ulbde v ergyr ateffourld itioansds i's eaosfte hsve a riosuyss tetmhsce,o nditions informaatbioounot m issicoonnst,r adiacntdia omnbsi tentdoa ssuams eo rotfs ocipaelc kionrgd ienrt hemiirn ds. guitsiuegsg;e sftiroolnmis k e-micnodleldew aoguelshd e lpR egretttahblela yr,gb eelnyi agnndh umblreh eumadtiisc tom akea mores uitabbolneyf ramewofrokrt hen ew ordehrasv aeh aboiftb einrge legtaott ehdle o weorr ders meaatn dh eltpoe raditchaietn ee vitdaebfleeoc fta sfi rsta ndb oring peatshaihnsit esr aorfIcb heyl.i tehviets ob e attempt. ap rofoumnids taskien,bc yem eticulous exaanmdi nation Onec oulhda vwer itteennt iroen'l Mya nipulayteiteo nnl'i,g htaesnseeds semaecnohtn eo ft he' ol(da nydo ung) thipsr esupptohsametas n ipuliastt ihpoern i mairnyt erensetc.ka sn db ackbse'c omaense xcitdientge csttiOvorefy Thiissn osto -thmeo rwee u nderstaabnodutt h gee nesaibss orbiinntge arnesdatm plrye paiynsf oramnedad c curate oft hese contdhitete imopnesr,a amnedln itf e-hoaftb hiett sr eatmwehnitcn,he endo tb ev igoroorua sg gresTshiev e. patieinnwt hso mt heayr oec currainndmg o rees peciaalmlpylr ee paymleinetis nt hep urpel easoufrr ee lieving thien finviatrei oeftp yr esentfartoipmoa nt iteonp ta tiencth,r onaincdo ftdeins abplaiinangn do thseyrm ptoamnsd thbee ttweerh eltph em';m anipuliasbt uitoo nne'o fo ur ino nes'lso wilnyc reaaswianrge noefts hsie n finviatrei ety treatmeanltbsea,is tu bjienci tt self. ofw ayisnw hicmho vement-abnoorfmt ahvleei rttieebsr al Thet exitsa ddrestsote hdem emberosfn op articucloalru mcna np resent. discipoltihnteehr alni ke-mipnrdoefde sscioolnlaela guDeesg,e nerajtoiidvniets eoafst eh es piniesp erhabpess t byw hateavceard emriocu tteh emya yh avdee veloapne dr egaradsaef da miolfpy h ysiological ageing processes, with interients htec onservtarteiavtem oeftn hteu biquitopuast,h olocghiacnagilen st ervesnoionnoger rl ataesar c on frustraantdid negp ressspiinngja oli pnrto blesmusf ferseeqdu entceh,pe r ocebsesi nign fluenbcyed di reacntdi ndi bys ucmhu ltitoufdp eeso ple. recttr auomras treasnsdc, o exisdtiesnetaP saet.i ents rarely Ih avneo ta ttempttoce adt egoorrie slea,b oornat,th ee a ttebnedc autshee sipri naerseu ndergogirnagd uaanld patholaongdsy y ndroomfce osm momnu sculoskaeblestiallde engte nerwaittighor na dudailm inuotfim oonv ement, normaloitthiteehrsa inna g eneralf owtrah ye,es xec ellbeuntbt e cautsheeh ya vpea iann do thterro ublessyommpe reasons: tomisn a s peciafireedaa n,d s ometitmweoos r t hree. 'Theirsie n m edicain naet ulraawtlh aatn ys ingle man 1.I a lrekandoyow f a tl eatshtr deieff erseonltu ttioto hnes ifestastuibojne,c otrio vbej ectmiavyhe a,v bee hiintda probloefms yndrocmlea ssificwahtiiciohsan h ,i ghly multiploifoc rigtayn ciacu sejsu,sa tsa nys ingplaet ho artifibcuisailn aensys,w ay. logiecvaelni tsb ountdo p roject itasn eulmfb eorif n to 2. Thiesnr oest p afcoesr u cahf udlils sertsahtoiuoIln d, differcelnitn miacnailf est(aSttieoinns1d'9l 6e2r),. 1i1s7 1 It bec ompetteonp tr oviidtie,ft heirsea lstoob es ome conventioue sngete neratlriesaetdmp ernotc edfuor'ret sh e generaatlt enttoit orne atmteencth niques. arthroosr'i tshs'ep ondylaosts hiebs a's ic rfeoatrsh oen 3. Knowledogfte h es ubjeicset x pandainndcg h anging patienatt'tse ndaynectea ,l waymso rer ewardtion g witshu cshp eetdh aatt exptu rporttoib neug p -to-date broadaenun n derstaonftd hiienn gfi nviatrei oeftw ya yisn andw ritbtyee nv etnh bee satu thorhiatlsii etsct hlaen ce whicpha tiecnatnbs e t roubalneddt ryt op ercetihvee ofm eetisnugc ahc laim. natuorfte h cea usaensdt oa dapttr eatmfeotnrht ue n ique Hencper,i nciopnllaeyrs ic m portaannddt o,n octh angfeo rimn w hicthh edi sease eaaffcoehnc et.s witthh yee arIsnT. h eH istoroyfI mpressionisRmelnOo29i rW itrhe gatroda ffectiooftn hsec ranniearlv feoser,x isq uotaesdo bserv'i. n.tg.h, o ugohne s houtladk cea rea mplBer,o d(a1l9 6h5a)sp ointoeudtt h aitti ss omewhat nott or emaiimnp risoinnte hdfe o rmwse h avien herituendr,e litaoab tltee mfipttt iang gi vseenr ioefss y mptotmos ones hounledi thtehrr,o ulgohvo efp rogriemsasg,i tnhea to neo ft hem anys yndrodmeessc risbiendtc,he e ssey n onec and etaocnhe sceolmfp leftreolpmya scte nturiedsr.o'm ersa reolcyc uirnt ypifcoarlmT .h es ame applies to Furthiefwr e,l ootkoo uerx periweenfi cnedt haitti s b y migraoinfce o,u r(spe2. 1 8a)n,de specisaotl oal lycl l inical thoroughly faomuirlsiealwrviietstshih niegn ventoifo nprse sentoafmt uisocnu loskjeolipenrttoa bll ems. PREFACEi x Attemtpote sr aditchaiatsne n oyuinntgi dibnyes sese,k ito,rt hfea cilfiothrie elaspr neo at sa dequaastd ee sired, intgo i mpose arotridfieacrni dra elg ulawrhietryne,o net hpea tiiesgn itv eafn e wg eneraelxiesrecdai nsdte osl tdo cany eetx isatrf,eo oliPslha.ot bos ertvheadmt a nn ever' liwviet iht T'h.e riest hep aradtohxa wth ilmeu sculo legisbluadtte esst,i anniadec sc idheanptpse niinan lgSl o rtssk eletal abnaorrtemh aeml oistftir eesq uceanutso efd e ofw aylse,g isilnaa lstloe r otfws a y(ss epe.2 05T)h.e raer e pressaicnhgea sn dp aintsh,et ye ntdo b er egaradset dh e tomoa nyf actors invmoalvneyod ft; h sevo e-rcyat lylpedl earsetw ardtiotn rge aantd t humsa yb et hew orsptr o icsayln droamrescsu rprisingly Tuhnicbsoe mcmoomnev.si ded-Tfhoerr u.n -of-tshtea-nmdioalfcrl ld i neixcaamli n morea ppariennd ti rercetl atiotnots hheic po mpreheantioonft hes'eu ninterceosntdiintgii'so p nesr hanpost sivenoefhs iss tory-itnaiktieinxagal,m inaatnidco anr efaullw aayssp ainstaaksii tmn igg hbte a,n dt hep atieonfc e palpation. patieinsat tts i muensb elievTaheba lmeo.u ntr eoanfle ed Becautshee raep peatrobs e a grosism balaanmcoen gi sc alamitaonudts h,ce l inwihcearle wittoch oaplwe i tiht thwee igohflt i teroantd uergee nercahtainvgieen t, h atth ee thickanlolwyl,e dgeeaffbelcyt,ia vnedwl iyt ahm inimum lumbadri shca sc ornearf eads hionaanbdrl ied iculooufvs ilgyo huars,b eesna dtlhyi onn t hger ound. larsghea roefa nemioInh ,a vdee votmeodr es pacteh an Fort hirse astohnee,n ergaetttiacwc iktl hi mimteeadn s mayb ec ustomtaoar ryt hroasnidts os, e eminlgelsys -voints hiem portlaunmtb sapri pnreo blbeymt sh Seo cifeotry iteddi stroiftc htvese rtecborlaulm Tnh.es ubjeocfvt esr BacPka in Resweialdrlomc uhc hg oodt;hc ee rvirceagli on tebrtarla ctainodtn h sea crojioliihnaatcv ael sboe egni veno ft hev ertecborlaulm ann,dt heub iquiptrooubsl eomfs rathmeorr sep acsei,nt chee cyu rreantttlryca ocnts idercaebrlveis cpaoln dylhoasviaesl ,sr oe ceiavnei dn creavsoilng interest. umeo fe xpearttt en1t 1ia1 nodnt, o getwhietrth h aed vances Theo pposeintdoe ft hsep inient, h feo romf t herapyi nft ohreu nderstaonfdp ianibgne havitooudra,yc 'lsi nical headacahler,e asduyff erfsr oma ne mbarrassosfm ewnotr kearrsic m measurbaebtlteyeq ru ipptehdat nh osoef riches-acdaedbeamotiveces mr i grabienceo mmeo reer utwod ecadaegsoI .tm ayb et hatth weo r'dm anipulation' ditaen dt hder ugmso reex otwiicta hni ncreabsailnlg- anwdilclo njuirnte h em indosf m anyt he' rogue-elephant' chaipna rapheronfa lsiiad e-effects. manipulbaatnogri,an wga iyn a v igormoaunsn eartw hat A vergyr eadte amlo rei sb einlge arnaebdo uwth ate vejro icnotn ditmiaoynp reseintts eiltmf a;y a lsboe appeatroas c lintihcearla tpoi sbiten m, a nyc aseosfl, i tttlhea (th appais lmya ll) mionfao urtihtowyri sta hm anipu shopflocolri nviaclaulae n,dw ew istfhuolplteyh amto rel atibveen tw,h oh avaec quiaruetdh oritvaotiicavene d timwei lbled evotteocd o mprehenesxiavmeilnyai nndg r esponsiobvietlrhi eyt eya rhsa,v tee ndteoda lientahtee palpatthibeni gtt h ahto ldtshh ee adaucph-et hcee rvicmaold eratmeilnyd ebdy a nh abitsutaylol feu nbuttoned spianned t hcer aniovertebral junctionr.h etoarnidnc o issye lf-aggrandisement. Witrhe gatropd a tholocghiacnaglie ths a,sb eenne cesIq uotFe.D udleHya rt''': sartyor estdriiscctu stsoti hoonas sep ewchtisc ahr oef first importiannt chefie e lodfm usculoskjeolipenrttoa bll emsI;nm edicitneh ea uthoriitnty h ep asfto rs omet heoroyf a e wherceo nventiode ons tor ,e feraesni csnee cesissamar dye tiologyd rourga ctioornp athologoircp ahly siologpircoacle ss waso ftesno me( oftepnr ofessorGioadl-)l ikfieg urea ndw as int he' Clinpirceasle ntasteicotnir'oa tnh tehra inn t he sometimbeass eodn p recioluist telvei denbcuet,i tw asa ccepted more detsaeicltoeindo' nP atholcohgaincga(elcs af'n. k y ast rubee cau(sle)i ts eemetdo e xplatihni ngnsi cealnyd o ften losisnpgo ndylitis). (2) relativseilmyp layn d theg entlemwahno saiodr w rotiet Wherieth a sse emtedom ea pproprIih aatvneeo hte si wasa greaatu thor.i.t.y.T he God-likpeh ysiciparno,v en tatteocd rotshsse o mewh'awta tertight'b oduenscrrieppetaitevrdeilg yh itn t hep asta ndv enerataendd r espectaecd darioefas e tiolpoagtyh,o laongdcy l infiecaatlu froetrsh ,e cordingclaynh, o ldb ackf ory earasf terwamreddsi cparl ogress more effective opfri emspeonrttaaastnpiteo icnntp sa rtibya n. ..u tteranbcaes eodn i nadequaetvei den.c.e. .I ti ss o cular srpeigniaoeln. sgi,.n t hes ectoino' nw hipliansh'm uche asifeorru sa ltlo b elieivnes omebodrye putabtlhea nt o juritehsed, i scusosfis ounr gipcraolb leimnts h es ectiowno rki to utf oro urselavnedss eei fh ew asr igh.t...M osto fu s onb iomechaonfti hccese rviccoaraldn dm eningaensd, perforomu rm edicadlu tieasc tinogn workinhgy potheses the discoufss osftitio sns cuhea nges. rathetrh ano n fixedb eliebfust,i ti sv erye asyf ort heo ne graduaalnldyv eriyn sidio[u0s bleyc omteh eo thepra,r ticularly Bourdi(l1l9o7n3 e)x'p"r esass eadl ifeenatt oufrs ep inal ifo nei st eachianngdl ecturiWnhga.tI s ayt hretei meisst rue, musculoskperloebtlaelm s: ist ruei,sv eryt rue. The pauciotfyc linisciagln asn dt hed iversoifts yy mptoms Havintrga vetlhlleeo dn g frroaocdmo cksiugrneo rance producbeyds pinjaoli dni(s ordceornsf ustehdem edicparlo fes tot houghutnfcuelr taIia nmtm yi,n dfouftl h per imnee ed sio[nQ sucha ne xtentth atth ewye ren ota lwayrse cogniasse d fotrh yeo ungcelri nwiocarlk etrods e veltohpe viorc abu havintgh eiorr igiinns pinal joints. laroyf a natomiicnaflo rmaatnidot nh eicra paciftoire s Occasionbaelclayut,sh eec linical mtahyeo rnalpyia ssts essmbeencta,us suep erficial dceornicvflerudos mi ons partiaaplplrye cwihaattteh p ea tiiescn otm plaining caabsouuaotlb,ls ye rved phaernneoo matel nwaa ys juTshtei fied. orf ulalpyp reciitba uttde osc nso ktn oww hatto d oa boutf actth amto sstt rip-aculduibesn acresesa itdoc omprise x PREFACE baldheaodledmde ns hounlodtl eatdoa ' logiccoanlc'l utheo cculnta turoef m anyv iscerlaels ionmsu;c h effort is siotnh alto okiantlg a diweist hoauntyc lotohnems a kes requir[e0d e ncouraagleml e dicaclo lleagtuoee sx aminjeo ints thhea ifra olult . proper.l.y. Thep atiwehnotp reseans't jsu asnto thoeldrdi slce sion' Ith as bseuegng esttheabdte cautshece o nundroufm mayh avaep aibne haviaonudmr o rseu btcllei nsiicganls rheumataoritdh rwiitlpilrs o babblesy o lvweidt htihne whicohn lrye vetahle mseolnvc easr eefxualm ination. decadreh,e umatomluosgltyo otkon ewfi eladnsd s hould Thosweh oh avteh ew ita ndt hes tamitnoaa d optth e turint msa ine nergtioeb sa ckacThoeg.e thweirtt hh ese attitoufid net ellectual extphlaoonrp etrifsnog,ar n r laotghieacrna drl e asonoabbsleer vaitsii nocnlsu ded: easiaenrds afpeart hwaaspy a ssrievcei pioefon rttsh odox knowledwgielgl,e mto rien teraensdft u no utof t hper o Sufferers whoa res ufficienatllayr mebdy t heisry mptomasn d whospea inasr cs evewriel sle ehke lps,o mef romf amildyo ctors ceedianngdws i lfiln dt hweo rmko raeb sorbtihnoegv ;e rall ands omef romh eterodhoexa lertsh,eo steopatchhsi,r oprac profietx ceetdhpsea ibnya h andsommaer giFno.rm yself, tormsa,n ipulatpihnygs iotheraupniqsutasl,i fied boneosre tters oneo ft hhea rdetshitn Igh sa dt ol eawransc oncentration otherosft heh osdte scribaes'd f rinmgeed icine'. ont reattihnesg i gannsd s ymptoamnsdn Otu nwittingly tryitnogt retahteX -raayp pearatnhcete e,x tbotohke,T hew ritoefsr u cphh rasaebso uett hiacnadcl o mpetent dogmoar m echaniccoanlc eopftw sh awta sb elietvoe dp aramedwiocraklei rnts h hee alctahrt ee acmo ulndmh ave havoec curriemdp,o rttahnotu gthh reoeft hesmea yb e.m orpel aibnalrye hdi dse eapn xietTiheosswe.h op rofess I pleatdh atth em edicaanld p hysiothsecrhaopoylt osh andtlheve e rtecborlaulmm nu sbte a wak[eQa lals pects mighdte vomtuec hm oraet tenttoit ohnte e achoifvn egr ata ltli mePsr.o bleamf se,wo ft hem hidgihslcyo ncerting, tebraanla toamnyd t hec omprehensive moafn ahgaevameh e anbtoi ftl oomisnugd deannldyt hmeo rseo a so ne beniagrnt icpualtahro lotghyes poifn caoll umbne caussel,i diensta one asfya milioafhr aintdyl aifntgae ' rr outine' likteh ec ommocno ldt,h erae 'lsoo tf i ta bouatn di tsh istory-Tthaekp ionsgs.i boifls ietryi poautsh olaongdy , depredaitnitoenrswf ietroheu rec onoamnidcs ociaaffla irsso mlei memsa lignahnacnygo,sv earl lc linipcraels enta toa s ade xteTnhti.is sa p itbye,c auast er urleym arkatbiloeon fsv ertebraTlh apwtah iinc.ph r eseansta ss i mple amounotft hpeo pulatmioonne'sysy phointss ienltfro e joipnrto blceamnb et hes eemingly ianungoucroeyfn t searocfoh n ek inadn da nothaenrdi ti sp latihna atm inors omethmionrgse i nisNtoetor f.t ebnu,ot f teenno ugFho.r proporotfii tom ni ghatc quciornes idecroasbtl-ee ffectthiirvsee asaolno nteh,te h erampuissbtte s oundalnydc om nesbsy b eincgh anneilnltetode achvienrgmy a nym orep rehensively infoarwmaekaden, d a lawlaweyacsyo s clinicainadtn hse raphioswtt sor ecognainsdte r ebayt nomiciantl h ues oef v igoTuhre.r iesn oo thweary t oa void relatsiivmeplmlyee a ntsh eea rplayi nful manioffe ssetraitooiruoc sna st astrmoapnhiipcu laatcicoind ents. vertedbergaeln erjaotiidnvites ease. Shoultdh erbeea m essaignet hibso oki,tl ieisnt he A summary (W1o9o8"d0',)" o ft hep roceedoifna g sse ctioonan sss essmIcnin ttcs.o ordinaactteidva indtu ys c Workshoonpu ndergraedduuactaet iinro hne umatoloofsg tyo,r peadt tetrhnmesi nidsl ikage r ouopfp rimmeo vers suggetshtaswt h ilteh em usculoskseylsettieasmol n eo f and syncrgica ndmiu tsascb lieltsio tg yr asspo,r atn d them ajosry stemtsh ebo ofd yi,t sst atiusos n liyn freorganiinsfeo rmactainro ena cahna rtiasstp reyr faesca tn quentrleyc oridnep da tiecnatsse'n otes. outfielldeearfp'o sarb ack-hcaantdcI hnh. i ess soanyS ir IsaNaecw toJn.M, . K eyndeess crtihbmeei sn d-muassc le Althougcho nsiderapbrloeg rehsass b eene vidensti ncteh e muchl ikael entsh;ea biltiotg ya thuenrr elabtietds of 1971su rvenye)v erthetlheesrswe e res tiglrlo undfso rc oncernk nowleidnga ne e wp attvearrni ferso m petrops eorns on. aboutt hea dequacoyf rheumatologtiecaaclh iinng m any Thiasb iliista yne ssenqtuiaallif totyrh ea ccuraantde undergradumaetdei cal schtoohless ji tuatiinor ne gartdo detaialsesde ssomfej noti pnrto bleAmnsa.t omiicnaflo r rehabilitiaslt ieossnsa tisfactory. matiopna,i nstackliinngmi ectahlo adn db asicsailmlpyl e Undert heh eadinogf' Educatioonbajle ctiivses su'g gestetd hindgosn cea refulwleyl alra meno dr iem porttahnattnh e thef osteroifna gna ttitoufd' ec ooperatiinor ne gartdot hec on facaiclqeu isoifte ixoontmi acn ipultaetcihonni qSuiensc.e tributitohnacsta nb em adeb yv ariohuesa ltphr ofessioannadl s wet enadt,t imetsot, a koeu rselmvuecsht osOe rioIu sly othemre mberso ft het eam'. hopteh mei lidr reverheenracen edt heirnet htee xdto es notm akem ym orseo becro lleatgouuoen sh appy. Thes ummarayl soob sertvheast : Thel atSei Wri nstCohnu rchoinlclse a itdh asth ort ..t.h ep ersistnienggl eocftt hem usculoskeslyesttaelim sc ausew ordwse rbee tttehral no nogn easn dt hoel wdo rdwse re fors eriocuosn cerann,dt endtsob ee ncouragbeytd h ef actth atb esotfa llIh. o pteh earren eo tt ooma nyl onwgo rds. patienatrseu sualalwya reo ft heiprro blem,i nc ontratsot G.P.G. Acknowledgments Wec limobnt hseh ouldoeftr hso wsheo h avgeo nbee forNee,w manM,r H .P hillDirpW s.,G .W enleayn dD rB .D . andt howsheo f ollwoiwlc ll imobnO Uf ownw;e a lsloe anW ykef okri ndlloyo kaintsg e ctiooftn hste e xatn da dvising on tshheo uldoefcr osl leaagnudIee sx prweistsph l easumrce;f aulwthsi crhe maairnme y o wno,f c ourse. ad ebotfg ratittouj doeh Cno nwa(yf rowmh omI learntD rA .B urneelnlt'hsu shiaabsse me anc onsteanncto ur mucha boutth vea loufet reatpiantgi einn(t hsse i de-lyaignegm etnotp hysiothearnadwp ieos wtesm ucht oD rJ . positiaonndj) o ej ean(sw hosfer ienbdultyi ncessaCnytr iawxh,ob rougshotm eo rdetrot hee xaminaotfi on demandtsh aIt p roduac beo okh avneo wb eenme t),m usculoskperloebtlaealmn sdu ponw hosweo rkf urther alsFor eddPiree asrBnreiraE,nd wardPse,t eErd gclowd,e velopmheanvtbese ebna seAdl.s too M r W.j .G uest, MarjoBrlioeo Sru,e A damsF,r eddKya ltenbBoerrny,lP rinciopfat lh eW estM iddlesHeoxs pitSaclh ooolf GravelSiuneBg a,r keSrh,e lPihai lbrCohorkiC,so xh ead,P hysiothheircsaa ppya;c fiotdryo inggo oudn obtrusively andj iGluly mer. habse nefiptheyds iothmeorrateph yai ntk nowasn dIt ake Iw isthoa cknowltehdfegr eu iwtofrukli rnegl ationpslheiapsi unpr ueb lircelcyo rdmiyna gp precioafht iieson n betweGeeno ffrMeayi tlaannddm yselefx,t endoivnegr c ouragemaenndts uppoorftt heC SP Manipulation eightyeeeanra sn dd atifnrgo hmi vsi stiotS tT homasC' oursients h eea rdlayy asn,d o fm yseolvfe 3r0 y eaorfs HospiitnaL lo ndodnu ri1n9g6 1W.e havbeo thha dt hep rofessaisosnoacli ation. priviolfde egvee lotphiuens goc fm obilisaantdmi aonni Memberosft hMea nipulaAtsisoonc iaotfCi hoanr lered pulation tebcyph hnyisqiuoetsh eirnoa uprri esstpse ctPihvyes iothehraavpbeie semtnos s fto rtutnoae tnej oayc cess countrainedts h,fe r eeex chaonfgi en formaatnidio dne atso t hger eaantd i mportvaonltu moefc ontinmeendtiacla l betweueshn a sa fformdeep dl easauswr eel alsp rofit.l iteriatntu hrisesp ecifiaelliasdnt,d f otrh iasr ien m ajor Figur2e.s1 8, a2n.d21 .92a 0r rce produfcreoVdme rtedebtto t hem ultilienrguudailt oifmo yn classmoaft e bralM alliplIla(l4iEob)lyl k inpde rmissoifGo eno ffreyye arnso ws adlpya sMtr, H.j .C .C oopearn,dt oh is MaitlaAnVdA, F CSPM APA,a ndM essBrust terworutnhf,a iling w(iQl bluirnntg hneme isdsn igohitol n o ur London. behawlift Fhr ench, Gaenrdmi afnn e edb eR ussian Theriesa ne specpilaalci enm y regafrodMr r P.H . translations. Newmani,nw hosTeu esdcalyi naittc hsRe o yaNla tionaIlt i sa p leastuorr eec omrydd eb(tQt htee chnsikcialll s OrthopaHeodsipci Itl aela rsnomt u cha bouotr thopaeodfDi rcj ohnG raveosft heG raveAsu dioviMseudailc al patieHnet sg.r acioluesnlhtyi si mmenstec achaiungL ibraMriys,Vs t aB oundMye,d icPahlo togratpoth heer thortiott yh e1 9731,9 7a4n d1 97C5S PM anipulatIinosnt iotfOu rtteh opaeLdoincdso,Mn r,j ohTny demaonf Coursaensdh, a vse rkyi ndhloyn ourmeebd y w rittihnegt hDee partmeMnetd ioclfal llustrNaotrifooanln,kdN or forewtoort dh ibso ok. wicHho spitalt,oA nagnldPi hao tograHpahliecssw,o rth; Altlh erapwiisljtlos im ne i nr ecordoiunrcg o nsidertahbelhyea vdee votmeudc hc araen dt echnisckiatllol t he debttoP rofesRs.Eo .Mr .B owdeDnr,D .A .B rewertiolnl,u strations. Mr R.C ampbeCloln nolDlryj ,.E bbetMtrs A,. W .F . To thosweh op atienmtoldye lldeudr intgh el ong LettDirnR ,. O .M urraDyr,A .S toddaDrrdj ,.D .G . andt ediopuhso tograspehsisci voinzst.,h el atMeo ira TrouPpr,o fesPs.Do .rW alaln dD rB .D .W ykeT.o o ur Pakenham-WSaalrsaKhhe, y j,e niHfoerrs fKaaltlh,l een debIta ddm y warmp ersotnhaaln kasl,st ooD rB asi\'\Ili nteDre,n iPsoeu ltannedyF ionPae rciJv aamlv ,e ry ChrisDtriI ea,Cn u rwcDnr,D esmonNde wtoann dM r grateful. HughP hilltihpehsya; v meo rteh aonn cgeu idmeydw an To MrsM . MooreL,i braroifat nh eN orfoalnkd dering notions. NorwiIcnhs tiotfuM teed icEadlu catainondt, oM r C. Ia mg ratetfoPu rlo fesDs.oL r.H ambleMnr, P .H . DavenpaonrdtM r P.S mitrhe,s pecttihvepe rleyv ious xiiA CKNOWLEDGMENTS andp reseLnitb raroifat nhseI nstiotfuO tret hopaedailclso,wm eedt or eprodvuecrmeya nyfi guraensdp assages LondoIng ,r atefauclklnyo wltehdeegffi ec iehnetlI ph avef rommy w ritiinnPg hsy siotherIat phy.a nMkr B .H olden beegni ven. ofC artLetrdsM ,r N .P eteorfTs h eT ru-ECzoeI. n ca.n d It hanMkr G .T .F .B raddofcogkre neropursolvyi diMnrg J .M aleoyf t heC hattanooga PChoa.rf moarc al photograepvhiidce nocfa e u niqueex perimwehnitc,h p romptsleyn dimnegt hiel lustrIah taidro enqsu ested. raismeydi nterwehsetnd escriabnedfd o,ar l lowmient go Evercya rhea sb eetna ketnom aket hec ustomaacry publiisth. knowledgtmohe onltd oefrc so pyribguhittaf ,n cyo pyright ProfesPseotreR r.D aviheassb eeens pecigaelnleyr omuast erhiaaisln advertbeenent lyuw sietdh oduutep ermis witahd viocnee xpresosfim oang nituidnSe -sIu n its.s ioonr a cknowledgampeonlto,ga ireeos ff eretdot hose MrsJ .W hitehoTuhseeC ,S PJ ournEadli thoarks,i ndlcyo ncerned.
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