brief introduction to rehabilitation in the 21st century ... · stimulates the nervous system...

1 | C o p y r i g h t ; H e a l i n g O a s i s W e l l n e s s C e n t e r 2 0 1 6

Brief introduction to Rehabilitation in the 21st Century

– “Manipulating the Neuro-Frontier”

Pedro Luis Rivera, DVM, FACFN, DACVSMR

Fellow of the American College of Functional Neurology

Diplomate of the American College of Veterinary Sports Medicine and Rehabilitation

Healing Oasis Wellness Center, Wisconsin, USA

[email protected]

www.healingoasis.edu

Topics and goals for this lecture series:

Basic neuro-anatomy pertinent to manual therapies – Keeping up with the

times! Segmental, peripheral and spinal cord neuro-anatomy will be

discussed. Emphasis on how this information can improve on our patient

performance will be provided.

TMJ and Hyoids. This anatomical region is sometimes described as “the

black box” that no one cares to tackle. Anatomy, basic neurology

(including the trigeminal system) and its effect on balance and

performance will be discussed. Several advanced techniques discussed

during the basic program will be reviewed. Clinical cases will be

presented throughout the lecture to help the attendees integrate the

information.

Occiput and Atlas – The “Black Box” of Quadrupeds. This is another

“black box” that brings frustration to those licensed practitioners that are

providing VSMT / AC as a service to their patients. Several techniques

will be presented, discussed and reviewed (movies) for the attendees.

Coupled adjustments of the cervical and thoracic region

Cranial cruciate ligaments – More than a lameness. Very brief description

of the condition will be presented, emphasizing the biomechanics of the

stifle and how VSMT or Animal Chiropractic can improve on the outcome.

Basic neuro-anatomy will be used to describe the importance or providing

integrative approaches for these patients. Some techniques will be

discussed throughout the presentation.

mailto:[email protected]

http://www.healingoasis.edu/


Adjunct modalities to improve on treatment outcomes. Improving on

athlete performance is not just based on ONE health care modality, but

should be viewed in a “multimodal approach”. Nutrition, LASER and

PEMF are some of the modalities to be presented.

Hemisphericity – More than just suprasegmental health. This lecture will

discuss the basic brainstem and cortical anatomy, and how its integrative

health and function helps to not only modulate the motor neurons, but

improve on patient performance.

In the United States, Veterinary Massage and Rehabilitation Therapy has

become one of the most popular and abused rehabilitation therapy aids within

the last ten (10) years. Veterinary rehabilitation is not all “just about” the machine

that has been invested on or bought to provide the desired services. It is more

important to understand HOW the machine and health care modality works, than

just learning how to “turn on and off the machine”.

We know that manual therapy has been around since the ancient world. Manual

therapy, according to the National Institute of Health (NIH) includes chiropractic,

osteopathy, massage, and physical therapy among others. The NIH, the US

Agency for Health Care Policy & Research (AHCPR), the scientific community,

and the general public have come to realize that there is a WHAT, HOW, WHEN

AND WHERE for each of the rehabilitation health care modalities and further-

more, they should be considered a valid health care system.

It is always suggested for the licensed veterinarian and one (minimum) of the

licensed / certified veterinary technician of the office to be educated and trained

on the specific health care modality that they are looking into to provide at their

office. Licensed veterinarians must understand that even though they want or

are going to provide rehabilitation therapy at their office, they MUST keep in mind

differential diagnosis to better assess and decide if the specific health care

modality is indicated for the patient. All licensed health care providers should


and MUST think and provide at least five (5) differential diagnosis BEFORE

treatment is even provided. These differential diagnoses serve as a reminder of

our ultimate goal of providing not only good medicine, but being true to ourselves

and to our patients. Differential diagnosis and our thorough examination is what

helps us to determine IF treatment is indicated or FURTHER diagnostics are!

The biggest part of rehabilitation therapy (or of any manual therapy) is muscle

“conditioning and strengthening”. To achieve this goal, a thorough understanding

of the neurological connections from the periphery to the CNS and vice versa

must be understood. Without the proper facilitation of neurological connections,

conditioning and strengthening any part of or complete function or improvement

would be just about impossible.

Therapies can be divided into either passive or active. Passive therapy includes

those treatment modalities that do not require any energy expenditure on the part

of the patient. Rather, the modalities are applied to the patient while it lays

quietly on a therapy table or in our case the “good old” floor! Massage,

application of heat and cold, electrical stimulation, therapeutic ultrasound,

chiropractic, acupuncture, manual and mechanical traction are among some of

the examples. Even though they are considered “passive” to the patient, it still

stimulates the nervous system (central, peripheral and autonomic) with emphasis

on non-volitional (reflexogenic) systems. In fact, once you are able to

understand the functional aspect of the neuro-anatomy, then you can start

utilizing BOTH active and passive treatment to improve on you patient outcome!

Active therapy demands some “active” involvement on the part of the patient.

Exercise, neuro-muscular re-education and training are among some examples

of these “active therapies.” I personally like / prefer to describe the active

therapy as engaging both the “volitional and reflexogenic” systems. After all, it is

not that easy to tell the quadruped patient to maintain a posture while you are

providing therapy!


Basic neuro-embryology

The nervous system (NS) and the skin derives from the ectoderrmal layer (which

becomes the neuro-ectoderm) of the embryo which is formed around the 3rd

week of gestation. As the neural plate starts in-folding, there is a group or cluster

of cells that come together and migrate throughout the embryo; these are the

neural crest cells. These cells with the help of some specialized glial cells, will

migrate to different parts of the embryo to form the dorsal root ganglia, sensory

ganglia of cranial nerves, autonomic ganglia, SA/AV nodes of the heart,

neuroglial cells of the peripheral nerves and secretory cells of the adrenal

medulla (among others).

http://2.bp.blogspot.com/_EMVbNZzbRa8/S1NB8Dx4eoI/AAAAAAAAACs/nLG9Cw1r8pg/s400/neuralcrest.jpg

Embryologically, it does make sense to make all those receptors closer to the

midline an integral part for afferent input, reflexogenic immediate feed-back and

crucial to both spinal cord and central pattern generators. Remember that all

muscles closed to the midline that cross over ONE JOINT have so many

receptors that they are now being considered RECEPTOR ORGANS!


As the embryo is elongating and in-folding unto itself, the embryo is also

developing by “cephalization”. This later “cranial elongation” is how the brain

develops. Basically, the part of the embryo that is extending cephalad divides

into three (3) main vesicles (prosencephalon, mesenceaphalon and

rhombencephalon) with the ultimate goal of forming a total of five (5) vesicles

(telencephalon, diencephalon, mesencephalon, metencephalon and

myelencephalon).

Understanding of the basic neuro-anatomical division of these vesicle will make

our lives much easier and improve our diagnostic skill to identify the longitudinal

level of the lesion (LLL). The way to break down the above vesicles with its most

simple components is as follow:

Prosencephalon

Telencephalon

Cerebral hemispheres

Ventricles (lateral ventricles and interventricular foramen)

Cranial nerve I (CN-I) nuclei

Diencephalon

Thalamus, hypothalamus, epithalamus and perithalamus

Cranial nerve II (CN-II) nuclei

Third ventricle

Mesencephalon

Does not change much throughout development

Cerebral aqueduct of Sylvius

Cranial nerves III and IV (CNs III & IV) nuclei

Rhombencephalon

Metencephalon

Pons (pontine region)

o Cranial nerves V, VI, VII and part of VIII (CNs V, VI,

VII, and VIII) nuclei


o Fourth ventricle (cranial aspect)

Cerebellum

o With its three cerebellar peduncles

Brachium conjunctivum

Brachium pontis

Restiform body

Myelencephalon

Medulla oblongata

Cranial nerves IX, X, XI and XII (CNs IX, X, XI and XII)

nuclei

Caudal aspect of the fourth ventricle

http://www.guwsmedical.info/cerebral-artery/images/4507_10_35-embryology-brain.jpg

It would behoove the attendee to understand the above basic neuro-anatomical

differentiation as it would greatly enhance their diagnostic skill(s) and ultimately

with their patient treatment outcome.

Basic description of the nervous system (NS)

The NS has three overlapping functions:


It uses its millions of sensory receptors to monitor changes

occurring both inside and outside the body

It processes and interprets the sensory input and makes decisions

about what should be done at each moment (integration)

It elicits a response by activating muscles or glands; this response

is called motor output. Please note that efferent output includes

both efferent information originating from the ventral horn cells and

the efferent information originating from the intermedio-lateral cell

column (autonomic influence).

Bottom line as it pertains to the NS:

1. The nervous system is stimulated and influenced by exterocerptors and

interoceptors

2. The nervous system is also stimulated and influenced by the amygdala

and limbic system. More so in quadrupeds as the olfactory nerve directly

stimulates both of these systems and the thalamus.

3. There are only two outputs that can be used to evaluated the nervous

system. These latter two outputs are: the autonomic and the somatic

system. The good thing about these later two, is that they are inter-related

(you cannot affect one without affecting the other).

The motor portion of the PNS can be further subdivided depending on the type of

tissue being innervated. Somatic efferent, are those neurons that innervate

voluntary, striated, skeletal muscle. Visceral efferent, are those neurons that

supply involuntary, smooth muscle of viscera, blood vessels, cardiac muscle and

glands. Due to time constraints, we will keep this lecture basic and to the point.


Exteroceptors Interoceptors Amygdala Nervous / Limbic System System Somatic system Autonomic system

How to assess the nervous system (NS) to avoid pushing the patient too

much?

For those of us that have decided to get trained and practice either acupuncture

(AP) or veterinary spinal manipulation (VSMT)/ animal chiropractic (AC), or any

type of manual therapies (rehabilitation and massage included) we will encounter

not only enjoyment but also happiness in treating our patients and watching them

improve and regain some if not all of their “energy” and overall function /

performance. However, we will also encounter those cases that even though we

have followed and used every single tool that we have been taught and trained

with and still don’t get the improvement or get the response that was expected

but instead, they get worse. That is a risk that we as practitioners take every

time we work with any patient.

There are several factors that we have to take into consideration when providing

any type of manual therapies. Three of these factors are as follows:

Age and condition of the patient

As doctors, we cannot forget of the basics, starting with a GOOD case

intake! We can’t forget that as the patient gets older, their vital force or its

inherent healing process (recovery) is slowed down and becomes very

susceptible to changes, specially to those that will increase the metabolic


rate and function of the nervous system. We also have to keep in mind

the condition or disease process that the patient is currently being

“challenged” with. We can be presented with a four year-old, Golden

Retriever that has been diagnosed with generalized lymphoma and could

have the same “energy level” as a 10 year old, Golden Retriever with

kidney problems. Bottom line, they both have to be independently

evaluated and treated very carefully because BOTH of the patients

“energy” level are very critical and fragile.

Nutrition: We can offer and have the best equipment to treat a patient,

but if they are not getting a good nutrition or not absorbing proper

concentrations of nutrients, then recovery will be not only slow, but it could

also further complicate the case.

Sharpen our observation skills: When stimulating the NS (either directly

or indirectly), we have to understand that we are stimulating hundreds if

not thousands of different receptors of the patient that is being treated.

All cells (neurons being emphasized) maintain its health primarily by receiving

stimulation by its pre-synaptic neuron, by receiving good concentration of

oxygen and last but not least a good source of nutrition, in this case glucose.

We will not be discussing neurotrophic factors.

As with any cell, neurons have its own metabolic rate that will limit the response

to its stimulation or response to therapy. Basically, the neuronal health is based

on how well the sodium – potassium pump (Na:K ) is working. This pump (which

energy dependent) is what keeps the electrical gradient at optimum and

maintains the sodium (Na) concentration higher outside of the cell, hence

avoiding swelling of the cell and its demise. So, if we stimulate a nerve ending

(receptor) and the nutrition and oxygen tissue perfusion is not the best, then the

energy production by the mitochondria in the neuronal cytoplasm will decrease,

causing the malfunction of the Na:K pump and the diffusion of water into the cell,

changing the entire cellular biomechanics, function and efficacy. It would be like


a person deciding to run a mile without training or conditioning its body; fatigue

settles in! Fatigability will pre-dispose to further damage and cellular / system

failure. Please note that the number one cause of re-injury is fatigability! As

doctors, you should always strive to find out the WHY of this re-occurrence!

To avoid “pushing the body” (and all of its cells) into anaerobic metabolism and

increasing the possibilities of causing more weakness in the patient, the doctor

should always monitor several parameters that he / she could quantitate

accurately throughout the therapy. Some of these examples include:

Heart rate / pulse

Respiration

Blood pressure

Assessing fatigability of the pupils through the pupillary light reflex

TMJ and Hyoids

What can we say about the TMJ?

The TMJ is the articulation between the mandible and the cranium. The joint

itself is created by the mandibular condyle (condyloid process) and its

attachments to the articular disc which lies in the mandibular fossa of the

temporal bone.

The TMJ is a compound synovial joint with fibrocartilagenous surfaces and an

intra-articular disc. The latter has been described to me as a fibro-cartilagenous

disc. The joint capsule is very thick and broad, and is incorporated to stabilize

the disc. It should make sense to have developed such “stability” since the TMJ

does have multiple types of motion. The intra-articular disc compensates for the

lack of congruence between the articulating surfaces. To my understanding and

what I have seen from dissecting many TMJ’s, the way that this joint is stabilized

does allow for resistance to compressive forces among others (like translation).


As described previously, the joint has two independent compartments, with the

dorsal providing lateral excursion and the ventral providing flexion and extension.

Please understand that both of them do also provide motion for translation.

Anatomically and developmentally, the body provides stability on the caudal

aspect of the TMJ with the retro-articular process.

As you might imagine, the TMJ region is rich with nerves. Ranging from Cranial

Nerves in close proximity to the joint itself (CN’s 7 [in equines], 9, 10, 11 and 12)

but also cranial sympathetic (cervical) ganglia, carotid arteries, other nerves

along the hyoid musculature and ALL of the cervical spinal nerves (including

cervical plexus) that feed the sub-occipital muscles (and then some) with all of

the above afferent information being able to affect the trigeminal nuclei.

Some of the muscles that influence this joint include (but are not limited to):

Muscle Innervation

Muscles of mastication CN V – 3rd branch (some by CN 7)

Sublingual and lingual CN IX and XII

Hyoid muscles CN IX

Fascial muscles CN VII

Splenius / Scalenus Cervical spinal nerves – segmental (cervical

plexus)

Pectorals Cranial and caudal pectoral

Trapezius, sternocephalicus CN XI

Omotransversarius CN XI

Rectus capitis muscle group Cranial cervical plexus (C1-2)

Multifus Segmental***

Rotatores breves / longus Segmental***

***Denotes those that anatomists are considering as “sensory organs” due

to the number receptors that they contain and how they influence non-

volitional control


The above list of muscles and innervations are specific to the stomatognathic

system but it should be emphasized that said system can be influenced by

changes on different regions of the musculoskeletal system not to mention the

central integrative state of the nervous system.

https://www.bing.com/images/search?q=canine+hyoid+radiograph&view=detailv2&&id=364FA27F7507FAAEE56ECF92F

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How about ligaments that influence the TMJ region?

Although the above list that has been provided contains many ligaments, I would

like to bring your attention to the periodontal ligament. This tiny (in size) ligament

as compared to others, does affect hundreds of sensory receptors that can

directly or indirectly affect the afferent information that is sent to the dorsal horn

and affects the non-volitional aspect of balance. Now imagine, these small

ligaments also affecting the “integration” of other nerves including cranial nerves!

As you might imagine, the afferent information that is being sent parietal sensory

cortex would increase by several folds (not %, but by folds)!

How about changes on dental occlusions?

To my understanding, dental occlusion strike stimulates the dental alveolar

afferents and reflexively attenuates jaw muscle activity. This is important


especially in uneven tooth eruption or wear in horses, with premature first strike

diminishing the effectiveness of the chew cycle. Pain also is transmitted through

small myelinated and unmyelinated afferent fibers that project through the

trigeminal ganglion to the trigeminal brain stem sensory nuclear complex. In fact,

nociceptive stimulus from malocclusion can reflexively guide the mandible away

from bite. These muscle changes may also cause a change in the pattern of

firing of the equilibrium proprioceptors of the head and neck. This can then lead

to alterations in posture and balance, fixation, tension in the dura of the spine

and subsequent changes in coordination of the whole body.

It has also been documented that malocclusions can also affect the postural

“reflexogenic balance”. This will be discussed during class.

To summarize, all of the afferent input that affects balance into the

“Stomatognathic System”:

1. Vestibular Apparatus

Sensory input to the inner ear canals tells us where the head is in

relation to gravity.

2. Vision

Vision input tells us where the head is in relation to the horizon.

Brain prioritizes having eyes level with the horizon. The body will

contort to maintain level eyes in the face of an imbalance accident.

In quadrupeds, this relates more to the front end.

3. Cervical spine

Mechanoreceptive input will relay information regarding head

position in relation to the body. This information is also active and

applies during motion. Swiveling a person on a chair while

stabilizing the head will create or worsen dizziness if a lesion is

cervicogenic versus vestibular.


4. Mandible

Movement of the jaw relative to the head provides information

regarding position of the skull compared to gravity while the head

and neck are in motion.

5. Hyoid Apparatus

The hyoid system is made up of many bones that are suspended in

a muscular sling and therefore moves with movement. I personally

look at the hyoid system as a gyroscope compass that provides

information regarding where the head is in relation to the body, and

where the head is in relation to the horizon in movement (therefore

where the body is in relation to space).

What about the Stomatognathic System as it applies to manual therapies?

The stomatognathic system is influenced by a very complex cascade of neuro-

anatomical and biomechanical connections. In a simple way, this important

system is composed of the dento-alveolar ligament, the teeth, jaw, temporo-

mandibular (manidular and maxillary component) joint, skull (with C0-1-2

complex), hyoid apparatus, sternum, cervical vertebrae, and all of the muscles

and ligaments that connects within these regions. Brachio-cephalicus, omo-

transversarius, pectorals, sterno-cepahlicus, sterno-thyro-hyoidius are among

some of the muscles that directly and indirectly affect this important system. It

has been very well documented how changes on the TMJ angles can affect /

influence the afferent neurological system causing aberration on stances and

overall interpretation of the afferent information.

All the muscles that were briefly discussed previously are part of this system.

Although it might seem redundant, I will like to list the components of the

stomatognathic system.

1. Mandible

a. condylar process


b. coronoid process

c. angular process

d. ramus

e. mental foramina

2. Cranium

a. zygomatic arch

b. mandibular fossa of temporal bone

c. many cranial sutures.

3. Hyoid Apparatus

a. Tympanohyoid

b. Stylohyoid

c. Epihyoid

d. Keratohyoid

e. Basihyoid

f. Thyrohyoid

g. lingual process of basihyoid (this latter one only found on horses)

4. Sternum

a. Manubrium

b. First rib

c. Shoulder blade

5. Cervical region

a. C0-7

b. Articular facets

c. Transverse processes

d. Demi-facets

e. Trigeminal nucleus

6. Muscles

a. Masseter

b. Temporalis

c. Digastricus

d. Pterygoids


e. Sublingual and lingual

f. Hyoid muscles

g. Facial muscles

h. Splenius

i. Scalenus

j. Pectorals

k. Trapezius

l. Rhomboideus

m. Sternocephalicus, sterno-thyrohyodideus

n. Rectus capitis group

o. Inter-transversiri muscle

p. Multifidus

q. Rotatores breves and longus

7. Ligaments / tendons

a. Joint capsule

b. Transforaminal ligaments

c. Ligamentum nuchae

d. Supraspinous

e. Interspinous

f. Inter-transverse

g. Dorsal longitudinal ligament

h. Ventral longitudinal ligament

i. Rotatorius brevis and longus

What is the importance of the neck and the trigeminal system?

It has been very well documented in humans, the relationship of afferent

stimulation arising from the first 4-5 spinal nerves causing very complicated “pain

referrals” to not only the head, neck but also causing moderate to severe

muscular changes. One of the main reasons for the “vast” presentation of

symptoms / signs is due to its mixed nerve components. The “simple

explanation” of the trigeminal ganglia is its division of into the mesencephalic


nucleus (found within the rostral aspect of the mesencephalon to rostral pons);

the principal sensory nucleus (extends from the rostral pons to the end of the

rostral aspect of the spinal trigeminal nucleus); and lastly, the spinal trigeminal

nucleus (extends from the cranial medullary region to the C4/5 cervical dorsal

horn cell region). As the trigeminal system is derived from the first pharyngeal

arch, it would suffice to say that it will also influence the incus and malleus of the

middle ear (affecting not only hearing but balance as well)!

As described previously, the trigeminal nucleus extends from the demarcation of

the mesencephalon / pons all the way to the dorsal horn of the first 4 (sometimes

5) cervical spinal nerves. Latter part of the CNV-nucleus is called the “nucleus

caudalis” or “spinal trigeminal nucleus”. So, it is very important to understand

that referred pain can occur in either direction (cranial or caudal). As you know,

the upper 3 – 4 cervical spinal nerves innevates the muscles, ligaments and

joints (including IVD, arteries), and dura of upper cervical spinal cord. The

second order neurons found within the dorsal horn (which projects cranially or

cephalad to the brain) receive afferent from pain generators (from the previously

listed structures) and potentially from pain generators innervated by the lower

cervical nerves whose central processes have ascended in the dorso-lateral tract

of Lissauer. Additionally, the second order neurons also receive input from pain

generators innervated by CN V primary afferents. When the brain receives all

this “mish-mash” of information, the brain will misinterpret the input as coming

http://teachmeanatomy.info/wp-content/uploads/Anatomy-of-the-Origin-of-the-Trigeminal-Nerve-Nuclei-and-Ganglia.jpg


from a familiar site, but in true reality the stimulation is coming from a completely

different site.

It humans, neck pain with headache (or cervicogenic headache) alone accounts

for most of the complaints described by patients when they go to their primary

physician. About 70 – 75% of the patients seen for cervicogenic headaches also

presented with related tension, or sustained flexion during activities of daily living

or as experienced by the younger “human generation” suffering of “i-neck” (i-

phone neck compensatory changes).

Please keep in mind that afferent information that originates from the cervical

region (from C8 cranial or cephalad) can and will affect the information that is

being carried by the tecto and cuneocerebellar tracts as well as the trigeminal

system.

Cranial Cruciate Ligament Injuries

Cranial cruciate ligament (CCL) disease in dogs has more than doubled on its

diagnosis since graduating in veterinary school in 1986. As of yet, there is no

technique that has been found to be “better than another”. It is all based on

surgeon’s preference.

This common condition, I feel, should be viewed as being caused by many

factors and not “just one”. I believe that emphasis should be given to the causes

of joint instability and muscle fatigability. Needless to say, once the joint is

unstable, the gravitational, compressive and rotational forces will cause uneven

weight distribution and ultimately osteo-arthritis.

Joint instability can be caused by many factors. Some of them would include:

Fatigue

Ventral horn motor neuron problems (alpha – gamma gain disparities)


Decrease (or aberrant) afferent sensory input into the dorsal horn (and

spinal cord)

Muscle congenital problems

Neuro-transmitter production / release issues

Supra-segmental influences (or modulation) on the ventral horn cells (or

motor neurons)

Others

According to Adrian CP (et al) 2013, the canine stifle consists of structures which

functions to resist cranial tibial translation relative to the distal femur. Please

keep in mind that the canine stifle is normally at about 120-140° during stance.

This latter range will maintain the knee and all of its intra-articular and peri-

articular components under constant pressure and stimulation.

When addressing a patient that has been diagnosed with CCL, close attention

should be provided to the quadriceps, biceps femoris, and gastrocnemius muscle

groups. Furthermore, the doctor / therapist should understand that the

coordination of said muscles cannot be correctly provided if there are sources of

undiagnosed discomfort (pain), peripheral nerve entrapment issues, lumbo-sacral

or sacro-pelvic degenerative changes or hypomobility changes of one or more

motion unit(s).

Further discussion of the importance of the locomotor system! (As it

pertains to CCL).

The locomotor system can be described as an intimate symbiotic relationship

between the skeletal (articular aspect included as well), muscular, connective,

vascular and nervous systems. It is like a symphony orchestra. The orchestra is

made up of individual musicians with different instruments. Each musician might

sound okay by himself but when the orchestra is brought together, and each

plays his part at the right time and in a specific sequence, it provides the

audience with a flawless and enjoyable sound called music. The same goes for


the entire locomotor system, with the end result culminating in a coordinated and

purposeful motion (or “music”).

When the above components of the locomotor system are brought together, they

provide the patient with:

Information necessary to maintain muscle tone and to fire each individual

muscle or group of muscles in correct sequence. This latter information

provides further and crucial joint stability.

Balance*

The correct distribution of compression or distraction of the connective

system.

The ability of the skeletal & articular system to grow and adapt correctly to

both internal and external forces now and in the future.

A nervous system that can benefit from the afferent / efferent stimulation

which facilitates the nourishment by the proper stimulation of the

autonomic nervous system.

An end result of stimulation of the cortex.

*= Although balance is influenced by the vestibular system, visual system,

musculo-skeletal system (including the temporo-mandibular joint and

peripheral feed-back), spinothalamic (trigeminal system included) and

cerebellum. We will only be addressing briefly the “peripheral feed-back” for

the sake of simplicity.

Once the above cascade provides motion to the patient or pet, that motion itself

will provide constant and necessary feedback to create a controlled, appropriate,

purposeful and accurate efferent (motoric) response. This latter response

(efferent motoric) is the ultimate expression that the nervous system can offer in

response to a stimulation (be it internal, external, reflexogenic or limbic). When

this efferent control / modulation is not provided at the correct time, then injuries

will be more than likely to occur.


The attendee cannot forget that afferent information is as crucial / important to

prevent injuries as supra-segmental modulation and influences. A very good

understanding of how information that originates from peripheral receptors will

influence not only segmental, regional, spinal and ultimately suprasegmental

areas must be achieved.

http://classconnection.s3.amazonaws.com/548/flashcards/1531548/jpg/golgi1336592364639.jpg

For example; one response that is not frequently discussed is how the afferent

information that originates from the joint mechanoreceptors, golgi tendon organs,

and muscle spindle cells will influence some of the areas of the central nervous

system (CNS) that modulate or control motoric responses. In other words,

providing continuous feedback to the “main computer which delivers the constant

information that allows us to determine if we are ON- or OFF-course on the motor

task at hand.


http://www.malab.se.ritsumei.ac.jp/en/wp-content/uploads/2011/09/snake_cpg_02.jpg

Information that provides constant feedback to the CNS on a moment-to-moment

basis enters the spinal cord with local, cerebellar and cortical influence.

Some of this feedback information will:

Influence the local spinal cord pattern generators

Send information to the cerebellum. The information that must reach the

cerebellum must do so as fast as possible, which is why the spino-

cerebellar tracts have a two- neuron connection.

Send information to the primary sensory cortex, thalamus, and brain stem,

utilizing the dorsal columns (medial lemniscus) and the spino-thalamic

tracts. These latter two tracts transmit through a three-neuron connection.

As mentioned previously, it is important to understand that the ultimate

modulation of all of the lower motor neurons (hence providing flawless loco-

motion) occurs through the function of the cortex.

Manual therapies provide a safe and efficient way to allow that peripheral afferent

feedback to enter the spinal cord and send accurate information to the “computer

centers” used for balance. By allowing these computer centers to receive

accurate information, the chances for the patient to be injured (during a field trial

for example) will be minimal.

Please note that canine CCL also contains mechanoreceptors that influence

alpha motor neuron activation. I personally like to emphasize how this afferent

input (from joint mechanoreceptors, muscle spindle cells and golgi tendon

organs) influences overall stability.

By now you might be thinking: How can we use this information to improve on the

orthopedic procedure that has been done to a specific patient. Based on my

experience, the most common orthopedic procedure that is done in Veterinary


Medicine is the “Cranial Cruciate Ligament (CCL) Repair” (Anterior Cruciate

Ligament or ACL). So, let us dissect this procedure to the best of our ability.

First ask yourself; Why would this patient be prone to developing a tear or

rupture of the CCL? The easiest answer would be to say: “that is the way the

cookie crumbles” and “there is nothing we can do about it”. But what if, it is not

that way? It is the job of the licensed veterinarian to ask her or himself the

question: Why is that? (In other words – Why did this injury happen?). Let us

discuss several scenarios that will lead to a full blown “ACL” or “CCL”.

First scenario:

What if the muscles that stabilize the knee are weak or have undergone paresis

(weakness) altering the afferent input originating from the receptors within the

muscle fibers (muscle spindle cell, golgi tendon organ and or joint mechano-

receptors) or any of the agonistic / homologus muscles that allows them to have

sensitivity and help to determine if the joints are being put through an aberrant

range of motion (ROM)? The latter would definitely alter the afferent input,

integration and interpretation of said information (which occurs at the cerebral

cortex) and last but not least the output through the motor unit hence altering the

response to the skewed information!

Second scenario:

For this scenario, we will identify the affected knee (ACL or CCL) as the LEFT

leg. What if the muscles that stabilize the contra-lateral knee (right knee) are

increasing their rate of firing (maybe causing spasms) hence causing weakness

of the muscles on the left knee via reciprocal or cross-cord inhibition? Again, the

problem is on the RIGHT knee but the orthopedic changes are being felt and

developed on the LEFT knee.

Third scenario:

What if, there is femoral nerve (innervates Quad’s and Sartorius muscles),

cranial gluteal nerve (innervates the Tensor fascia lata) or sciatic nerve


(innervates several hamstring muscles) problems? If that is the case, then it

would be important for the doctor to understand the location / origin of the spinal

nerve segments that make up that specific nerve that is being affected (i.e. deep

understanding of the Lumbo-Sacral Plexus).

Fourth scenario:

What if you have scar tissue contracture affecting the blood supply to that

transverse the epineurium, perineurium and endoneurium? As you might

imagine, it would affect the nutrients and oxygenation of the peripheral nerve

fibers that make up the specific nerve. It is important to remember that

peripheral nerves contain not only sensory and motoric fibers but autonomic as

well. How would you explain the ethiopathogenesis of this scenario?

Both human medical and chiropractic treatments have significantly and

exponentially expanded with the advent of radiology, computed tomography,

magnetic resonance and functional imaging; not to mention the integration of

functional neurology (how the nervous system works and exerts its influence)

correlating to anatomical and biomechanical changes as they apply to the body

(both local and supra-segmental levels [cortical & brainstem region]).

Chiropractic and rehabilitation (massage included) are both classified as “Manual

Therapies” under the National Institute of Health (NIH) definitions. Although

chiropractic care has become a very respected albeit misunderstood health care

by some professionals that are still holding on to the “old unscientific theories”

(described above) and that do not care to educate themselves on this specific

health care system.

Adjunct Therapies to Be Considered

Laser


LASER stands for “Light Amplification by Stimulated Emission Radiation”.

Laser technology has been in existence since late 1950’s / early 1960’s, in fact it

has been described as “photorethatpy”. The “light” aspect of the acronym

includes electromagnetic radiation of any frequency, not only visible light. One

crucial difference between lasers and any other light source, is that the light

emitted is COHERENT and COLLIMATED. Lasers can be classified as either

“cold” (low level laser therapy) or “hot” (surgical lasers). We will be emphasizing

LLLT during this short presentation.

Laser therapy has many effects on the body, but it is primarily used for its

photobio-stimulation benefits. Some of the benefits rely on its ability to modulate

various biologic processes, such as ATP synthesis and hence, mitochondrial

respiration. By providing a steady “supply” of ATP, the body is able to use it to

accelerate wound healing (either soft tissue or joint) and to promote cellular

regeneration among others. Basically, laser functions to activate photothermic,

photomechanical and photochemical effects. These latter 3 reactions are

considered to the primary biological effects of lasers. Other benefits from laser

therapy include DNA production, cell proliferation and regeneration (as

mentioned above), analgesic, anti-inflammatory, and provides / produces

vascular changes.

Although the complete scientific mode of action (MOA) is out of the scope for this

lecture it would suffice to explain (in a simplistic way) that when an electron

absorbs energy and becomes excited, for it to be able to go back to its original

state, it would have to emit energy through what is called "spontaneous

emission". This emission comes out as a “light” which is collimated and

transferred to the treatment area. “Light” as a hole, can interact with the body by

either being reflected from it, transmitted, scattered or absorbed. When light is

absorbed, it stimulates what are called “chromophores”. Some of the

chromophores that will be stimulated include melanin, proteins (and amino

acids), hemoglobin, water and mitochondria (cytochrome C system in specifics).


The benefits of laser therapy are broad and they can be provided to patients in

our everyday veterinary practice. Examples include (but not limited to):

Improving energy production

Wound healing by stimulating fibroblasts production, collagen formation

and angiogenesis with the latter improving blood supply to affected areas

Anti-inflammatory effects (either post-surgical or post-traumatic or post-

injury) secondary to decreasing prostaglandin E2 (PGE2) and

cyclooxygenase-2 (COX2) concentrations

Nerve recovery by improving myelination, increase axonal sprouting and

increasing growth hormones

Inhibiting nociception by increasing release of endorphins and enkephalins

and decreasing production of substance P

Degenerative joint disease (by decreasing inflammation, pain / discomfort

/ pro-inflammatory enzymes and improving fibrous healing).

As with any therapy, there are some parameters that should be followed to

improve treatment outcomes when utilizing laser therapy:

Hair should be clipped on treatment area (as protein is a chromophore) to

improve penetration properties

Dark skin patients should have total dosage increase for ¼

Isolate and identify treatment area.

Maintain direct contact with hand piece and keep it at 90 degrees (to

minimize scattered energy)

Be sure to use and wear appropriate eye protection

Maintain appropriate and accurate health records and improvement

Keep in mind the following CONTRAINDICATIONS or PRECAUTIONS

o Cancer

o Open fontanels or skull injuries

o Stay away from growth plates

o Keep away from the eyes


o Do not laser over gravid uterus

o Do not laser over sensitive skin (either de-nervated or

photosensitized)

ULTRASOUND

Ultrasound therapy is considered to be a deep heat modality. Ultrasonic waves

(of high frequency and not audible to the human ear) are produced in the hand

piece through stimulation of crystals. This vibratory response with its energy,

enters the tissue that is being treated causing both thermal and non-thermal

effects.

The practitioner must always keep in mind that thermal effects can be beneficial

or detrimental depending on how the treatment is being provided. Some benefits

of the thermal effects can include increase blood supply to the treatment area;

and increase pliability of the treatment area. Some of the non-thermal benefits

include decrease discomfort / pain; allow for better healing by optimizing the pro-

inflammatory response; improving and maximizing cell proliferation; increase

protein synthesis; improving scar tissue and making it more of a “functional scar”.

Massage, transverse frictional massage and ROM will be facilitated post-

ultrasound therapy (if indicated).

As will laser therapy, for this modality to be maximized you would have to shave

the treatment region and utilize a coupling gel to improve sound wave

penetration.

Some of the conditions that have shown good response to therapeutic ultrasound

include:

Trigger points / Myositis

Tendinitis

Bursitis

Edema


Others

Frequency, duty cycle, intensity and treatment area are some of the settings /

parameters that will be discussed during lecture. ALWAYS remember that once

the machine is emitting sound waves, the hand piece should always be IN

MOTION. One of the biggest mistakes that I have seen if when the therapist

gets distracted and they stop moving the hand piece causing periosteal burning.

Contraindications of ultrasound are similar to laser contraindications: malignancy,

metal implants below the area being treated, local acute infection, vascular

abnormalities, and directly on the abdomen of pregnant women. It is also

contraindicated to apply ultrasound directly over active epiphyseal regions

(growth plates) in children, over the spinal cord in the area of a laminectomy, or

over the eyes, skull, or testes.

So, you and your practice decides to buy a laser or therapeutic ultrasound

therapy machine…now what??? How can you as the certified / licensed or

registered veterinary technician (VT) help your practice get a good return on

investment? First and foremost, get trained! Second, understand the therapy

and the machine. Third, offer free services / evaluations to pets owned by

practice employees / owners; and Fourth, start making appointments!

Nutrition

My goal for this section is not to open a “can of worms” as every professional has

her / his own opinion about nutrition. I will try to provide you with my no non-

sense approach.

As we know, proper nutrition is necessary to maintain requirements for daily

living, proper healing and to allow for proper function of all organs! The primary

goal of nutrition is to provide the appropriate energy (ATP) production for the

athlete (either canine, equine or human). There are several sources that you can

utilize to produce energy. Depending on what the athlete is being used for, will

determine the kind of energy source that you will utilize.


There are several equations that a therapist can utilize to calculate the energy

requirements for a particular patient. First, I calculate the resting energy

requirement (RER): RER = (30 X Body weight in Kgs) + 70. Once I calculate the

RER, then I can use a factor ranging from 2-5 to calculate the active

maintenance requirement (AMR). This latter equation would like: AMR = (Factor)

X RER.

We as professionals also need to learn to read “nutrition lables”. For example,

some labels utilize the following descriptions:

Nutritionally complete = which means that all required nutrients are

present in the food in adequate levels or quantities.

Complete and balance = which means that all required nutrients are

present in proper proportions as well as in adequate quantities.

Both of the above descriptions are sometimes (and erroneously) considered to

be synonymous.

To provide a proper nutrition, you must spend time with the owner and determine

several factors: what they do for work, how often they work, and for HOW LONG

they are worked / exercised per session, their body score condition and lastly,

the environmental conditions that they work under.

We will provide several examples throughout this presentation.

Hemisphericity

Hemisphericity is defined as “which part of your nervous system is either weak or

working overtime” and how we can either increase stimulation or dampening of

said areas. By providing the latter, we would improve on patient outcome.

As rehabilitation practitioners, we have to keep in mind that the nervous system

needs four things to be kept healthy and functioning in a proper and orderly

fashion. Nutrients (glucose is the primary source), oxygen, neurotrophic factors


and frequency of firing of the pre-synaptic pool to the neuron in question. These

latter requirements, are crucial to maintain the nervous system healthy (by not

exceeding its metabolic rate) and being able to work efficiently. Hence, this is

one of the reasons I feel that the Supreme Being linked the skin to be

embryologically related to the nervous system and the importance for GRAVITY

which (both of them together) maintain constant stimulation to the central

nervous system (CNS).

Once a cell has been activated (or stimulated as described previously) several

things occur at the basic cellular level which will either allow the continuous

existence or the demise of the cell. Stimulation will cause action potential

changes and the production of cellular messengers (cAMP or Ca+ as examples)

which helps to prime the cellular organelles for what the nucleus will be

demanding from them (to be produced to). As you might imagine, the

mitochondria is important for the production of ATP (efficient energy production

under aerobic conditions), the endoplasmic reticulum is very important for the

production / synthesis of protein (like microtubules which will give support and

shape to the cell; or proteins that will be used as transmitters, or to repair

axoplasmic tubules, are some examples). To my understanding, these changes

will affect directly the AMPA and the NMDA receptors and efficiency of mRNA

translation. These cellular changes are also known as “Cellular Immediate Early

Gene Response” or CIEGR.

The skin, muscles and connective tissue contains thousands of receptors that

provides the body with constant and immediate information necessary to provide

a flawless motion or performance. Rehabilitation practitioners must understand

the basic function of receptors, what kind of information they carry, where they

take that information and how that information will be utilized. Receptor

stimulation (by manual therapies) not only starts the CIEGR cascade (as soon as

you start touching the patient) but it also allows the divergent afferent information

to start bombarding the dorsal horn of the spinal cord. As we know, receptor


based therapies have been documented to help decrease pain. Rehabilitation

has been documented to have other effects on the body (improve joint

movement, decrease inflammation, change parameter of the immune system, etc

among others) among others. We will not be discussing the latter functions at

this time, but ones that the attendee SHOULD get to know and feel comfortable

with.

Most afferent input (from the skin and other mechanoreceptors) comes via large

diameter fibers (Ia, Ib, II or A-alpha, A-beta, A-gamma; depending if they

originate from the muscles / joint mechanoreceptors or skin respectively). Pain

relief can be achieved by the stimulation of large diameter fibers, which will

stimulate inter-neurons with the primary function of modulating the information

that will be passed onto the secondary order pain neuron. This latter effect is

one of the ways that the second order neurons that deals with pain can be

dampened at the dorsal horn level. Hence stimulation of non-nociceptive

receptors can inhibit the transmission of nociceptive signals in the dorsal horn;

that is, “nociceptive stimuli” can be “gated out” by counter-irritation using non-

painful stimuli. There are also several supra-segmental centers that when

stimulated will also help with the inhibition of pain (via ascending or descending

connections pathways) by the activation of inhibitory interneurons at specific

areas (laminae) of the dorsal horn. Some suprasegmental areas that help to

minimize pain includes the periaqueductal gray (releases beta-endorphins),

nucleus raphe magnus (releases serotonin), nucleus reticularis

paragigantocellularis (releases norepinephrine), and locus ceruleus (whichc

realeases nor-epinephrine).

All manual therapies help with the stimulation of (primarily) large diameter fibers

which invariably prevents the development of what is called “dysafferentation”.

This latter neuro-pathophysiological term describes and addresses the

neurological imbalance when there is less stimulation originating from large

diameter fibers as compared to small diameter fibers. If we allow the afferent


input coming from large diameter fibers to decrease, then we will allow the

nociceptors to continue to provide their afferent input (unopposed). Be allowing

the latter, we will ultimately allow the creation of plasticity and long term

potentiation of said pain pathways.

Rehabilitation therapy (including massage, which is an integral part of rehab) is

unique is that it is able to stimulate either muscle spindle cell or the golgi tendon

organs (GTO’s) which will help to either increase or decrease muscle tone where

needed. Please note that most if not all of the mechano-receptors / receptors

that will be stimulated with receptor based therapies will stimulate what is called

“non-volitional” or “reflexogenic” pathways. Latter pathways deal with information

traveling to the cerebellum and how that information is used to influence motoric

expression.

Nervous system – discussed previously

Peripheral nerves

Cranial nerves can be easily evaluated and they should be done in a regular

basis. Cranial nerves can be evaluated by performing the following tests:

Pupillary light reflex = evaluates CNs II and III

Palpebral reflex (medial canthus) = CNs V1 and VII

Palpebral reflex (lateral canthus) = CNs V2 and VII

Corneal reflex = CNs V1, VI and VII

Gagging or swallowing reflex = primarily CNs IX and X

Tongue extrusion = Cn XII

Flexion of the temporomandibular joint = CNs V3

Muscle tone of the brachiocephalicus, omotransversarius and trapezius

muscles = CN XI

Others


Plexuses to keep in mind

Cervical: This region of composed of cervical spinal nerves from C1 to C5(6).

Dural innervation, sub-occipital muscle innervation, spinal accessory nerve and

phrenic nerves are among some of the major region(s) that this plexus affects.

Brachial: This region which is composed of spinal nerves from C(5)6-T1(2). This

plexus provides not only stability to the secondary curvature of the quadruped,

but also the entire sensory and motoric innervation to the thoracic limb and

pectoral musculature. Specific reflexes and evaluations that the VT should be

comfortable with will be discussed during lecture.

Lumbo-sacral plexus: This region is composed of spinal nerves L4 – S2. This

plexus provides not only stability to the sacro-pelvic region but also the entire

sensory and motoric innervation to the pelvic limb. Specific reflexes and

evaluations that the VT should be comfortable with will be discussed during

lecture.

Common changes found with specific spinal cord lesions include:

Spinal cord region Clinical signs

C1 – C4 (5) Nerve root signs; tetraparesis and or UMN

C(5)6-T2 UMN signs / changes to pelvic extremities; LMN signs / changes to thoracic extremities

T3 – L3 Normal thoracic extremities; UMN signs to pelvic extremities

L4 – S3 LMN sign to pelvic extremities with the possibility of bladder changes

Coccygeals Referred pain to LS region, others


Occiput Techniques to Consider

Occiput Bilateral Superior - Canine

Dorsal View: Observe the stabilization from C1-5 Dorsal View: Observe the bilateral contact

point

Provided by the doctors

Lateral View: Observe the LOC of slight dorsal to ventral with a “caudal scooping”

Listing: Occiput superior (unable to EXTEND at the poll) DP: In front of the patient facing the head SC: Bilateral thumb contact on the occipital ridge and broad contact along the

zygomatic arch and ramus of the mandible CP: Thumb, web and fingers LOC: After bringing the joint into tension (by extending the C1 – Occiput) the

LOC will be dorso to ventral with a caudal scooping coming primarily from the thumbs following the C0-1 motion

Stab: C1-5 bilaterally REFERENCE POINT: OCCIPITAL RIDGE / PROTUBERANCE Notes:


Occiput Bilateral Inferior - Canine

Listing: Occiput Inferior (unable to BEND at the poll) DP: In front of the patient facing the head SC: Bilateral broad contact on the parietal bone and along the zygomatic arch

and ramus of the mandible with both thenar regions resting on the nasal bone

CP: Thumb, web, thenar and fingers of both hands (i.e. broad contact point) LOC: After bringing the joint into tension (by flexing the C1 – Occiput) the LOC

will be dorso to ventral bringing the nose “ventral & inferior” in a scooping motion

Stab: C1-5 bilaterally REFERENCE POINT: OCCIPITAL PROTUBERANCE / RIDGE Notes:


References:

1. Animal Chiropractic Statue; SF #3683, 4th Engrossment 85th Legislative

Session (2007-08) from the State of Minnesota

2. Arkuszewski Z., The Efficacy of Manual Treatment in Low Back Pain: A

clinical Trial. Manual Med 1986;2:68-71

3. Boline PD., et al., Spinal Manipulation vs. Amitriptyline for the Treatment

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4. Bromm B. Treede R.D. Withdrawal reflex skin resistance reaction and pain

ratings due to electrical stimulation in man. Pain 1980;9: 339-354.

5. Carrick Institute, Lecture Notes for the Diplomat Chiropractic Neurology

Boards, Modules 1,3,7

6. Cassidy JD., et al.,The Immediate Effect of Manipulation versus

Mobilization on Pain and Range of Motion in the Cervical Spine: A

Randomized Controlled Trial. J Manip Physiol Ther 1992;15:570-75

7. Carnes, DT., et al., Man Ther. Adverse events and manual therapy: A

systematic review, Man Ther (2010), doi:10.1016/j.math.2009.12.006.

8. Cassidy JD., et al., Risk of Vertebrobasilar Stroke and Chiropractic Care:

Results of a Population Based Case–Control and Case–Crossover Study.

Spine (2008) 33, 4S;s176-183

9. Cho ZH, Wong EK, Fallon J; Neuro-Acupuncture – Scientific evidence of

acupuncture revealed; 2001, Q-Puncture Inc, California

10. Cramer, G., et al., Basic Science Research Related to Chiropractic Spinal

Adjusting: The State of the Art And Recommendations Revisited. JMPT

2006;29:726-761

11. Cramer, G., The Clinical Anatomy of Spinal Manipulative Therapy.

Proceedings presented at the National University of Health Sciences and

Healing Oasis Wellness Center – Basic Veterinary Spinal Manipulative

Therapy Certification program (2010-11)

12. Cramer GD, Darby SA, Basic and Clinical Anatomy of the Spine, Spinal

Cord and ANS; 1995, Mosby, St. Louis, Missouri


13. Dyce KM, et al.; Textbook of Veterinary Anatomy, WB Saunders, PA;

1987

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cervical spine. Medical Clinics of North America 1978; 62: 533-544.

15. Fields Rd, et al.; Regulation of gene expression by action potentials:

dependence on complexity in cellular information processing. Novartis

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review., Spine 2009 May 15:34(11)E405-13

17. Hurwitz EL., et al.,Manipulation and Mobilization of the Cervical Spine.

Spine 1996;21:1746-60

18. Kandel E., et al., Principles of Neural Science 4th, Ed., McGraw Hill, 2000

19. Kiernan JA, The Human Nervous System – An anatomical viewpoint. 7th

Ed;1998; Lippincott-Raven, PA

20. Kosterlitz, H.W.; Terenuis, L.Y. (eds) Pain and Society. Dahlem

Kongerenzen Weinheim, Verlag Chemie Gmb H. 1980.

21. Manga P., et. al., The Effectiveness and Cost-Effectiveness of

Chiropractic Management of Low-Back Pain; Ontario Ministry of Health

1993

22. Lederer, F.L. Tenta, L.T. Tardy, M.E. Otorhinolaryngologic aspects of

headache and head pains. Headache 1971;11: 19-30.

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26. Rees, S. Relaxation therapy in migraine and chronic tension headaches.

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27. Nolte J, The Human Brain – An introduction to its functional anatomy; 5th

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Disk Herniations: A systematic Review and Risk Assessment; JMPT

2004;27:197-210

29. Pasquini, C., et al., Anatomy of Domestic Animals – Systemic and

Regional Approach, 8th Ed., SUDZ, TX., 1989

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31. Robinson, N., Tui Na: Chinese massage or something else?, VPN 2009

32. Seaman DR, Winterstein JF; Dysafferentation: A Novel Term to Describe

the Neuropathophysiological Effects of Joint Complex Dysfunction. A

Look at Likely Mechanisms of Symptom Generation; JMPT 21(4);May

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Books to consider: a. Basic and Clinical Anatomy of the Spine, Spinal Cord and ANS; by

Cramer G., Darby S., Elsevier/Mosby, 3rd Ed. b. Canine Rehabilitation and Physical Therapy; Millis DL, Levine D., 2nd

Ed., Elsevier 2014 c. Canine Sports Medicine and Rehabilitation; Zink MC, Van Dyke JB.,

Wiley-Blackwell 2013. d. Functional Neurology for Practitioners of Manual Therapy; Beck R.,

Elsevier 2008; ISBN 9780443102202. New edition will be publish shortly. e. Fundamentals of Veterinary Clinical Neurology; Bagley R., Blackwell

2005; ISBN 0813828430 f. Neuroanatomy through Clinical Cases; Blumenfeld H., Sinauer 2002

ISBN 9780878930609 g. Neuroscience; by Purves et al.; ISBN 0878937250 3rd Ed; Sinauer). Buy

the 4th Edition h. Textbook of Veterinary Anatomy by Dyce; Sack and Wensing;

Saunders ISBN #0-7216-1332-2 (it has both Canine and Equine species). i. The Human Brain – An Introduction to its functional anatomy; Nolte,

John; Sixth Ed; Mosby. SEVENTH edition should be available shortly.

brief introduction to rehabilitation in the 21st century ... · stimulates the nervous system...

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