Common Vertebral Joint Problems

588 Pages·1981·38.586 MB·English

by  Gregory P. Grieve

COMMON VERTEBRAL
JOINT PROBLEMS
GregorPy. G rieve
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HonorarFye lloowf t heC harterSeodc ieotfyP hysiotherapy
Post-RegistTruattoiroD,ne partmeonftR heumatoloagnyd
RehabilitaNtoirofno,la kn dN orwicHho spital
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RoyaNla tional OrthoHpoasepdiitcLa oln,d on
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PHILIPH . NEWMAN
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LatclCyo nsultaOnrtt hopaedic SurtgheeoM ni ddtloe sex
Hospitaanld,C onsultant Su10r tgheeoR no yaNla tional
Orthopaedic HoasnpdIi ntsatli touftO er thopaedics,
London
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formerClhya irmaonf t heB ritiCsohu nciolfM anagemenotf
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CHURCHILL LIVINGSTONE
EDINBURGH LONDON MELBOURNE AND NEW YORK 1981
http://avaxhome.ws/blogs/ChrisRedfield
CHURCHILL LIVINGSTONE
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Inc.1,9 W est4 4thS treeNte,w YorkN,. Y.1 0036a,n db y associated
companiebsr,a nchaensd r epresematives thtrhoewu ogrhlodu.t
© LongmanG roupL imite1d9 81
Allr ighrtess ervNeod .p arotf t hipsu blicatmiaoynbe reproduced,
storeidna retriesvyaslt emor,t ransmititnea dn yf ormo rb y any
meanse,l ectromneicch,a nicpahlo,t ocopyirnegc,o rdionrog t herwise,
withoutth ep riopre rmissiooftn h ep ublish(eCrhsu rchill Livingstone,
RoberStt evensHoonu se1. -3Ba xter's PLleaictWeha, l k,E dinburgh,
EHI 3AF),
Firsplu blish1e9d8 1
ISBN 0 4430 21066
BritiLsihb raCrayt aloguiinPn ugb licatDiaotna
GrievGer.e gorPy.
Common venebrjaoli nptr oblems.
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LIbraorfyC ongreCua talCoagr dN umber8 1-67465
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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.