This study solicited feedback from Deerhound breeders and owners in a search for answers and commonalities that could direct future research into etiology, diagnosis and treatment of neck pain in Scottish Deerhounds.

Deerhound Neck

by David J. Brunarski, DC, MSc, FCCS(C)^1,2

¹Brunarski Chiropractic. Simcoe, Ontario, Canada. ²McMaster University Chiropractic Working Group, Hamilton, Ontario, Canada

 ABSTRACT

Study Design: Questionnaire survey.

Background: “Deerhound neck” is a term coined by owners and breeders of Scottish Deerhounds to describe a syndrome characterized by the sudden onset of pain in the cervical region.

Dogs with Deerhound neck often endure episodes of pain behavior that may occur when the dog’s head is lifted or turned; either actively or passively. The dog may prefer to lie in a sphinx like position rather than curled up nose to tail. There may or may not be a history of trauma, fever, loss of appetite, gait disturbance, lameness, paralysis or other neurological problems. Current practice does not agree on the diagnosis and treatment for dogs suffering with a complaint of non-specific (idiopathic) neck pain.

Objective: This study solicited feedback from Deerhound breeders and owners in a search for answers and commonalities that could direct future research into etiology, diagnosis and treatment of neck pain in Scottish Deerhounds.

Methods: A 14-item survey was administered to approximately 500 subscribers to the Scottish Deerhound discussion list that enquired about demographic variables, important components of neck pain symptoms, assessment, diagnoses, treatment response and outcomes.

Results: 47 Deerhound owners and breeders completed a survey on 63 animals (35 males and 28 females) for a response rate of 9.4%. The majority (more than 62%) of respondents attributed the onset of neck pain to a singular traumatic incident such as a slip, fall or collision with another animal or object. Symptoms in males generally began after they reached four years of age whereas in females symptoms began before they were three years old. 60% of all animals recovered within six weeks and 54% of all afflicted dogs lived more than four years beyond onset of neck pain.

Examinations were performed and often duplicated by the following healthcare professionals: veterinarian (91.3%), chiropractor (64 %), acupuncturist (63%), osteopath (54.3%), registered massage therapist (52.2 %), and naturopath (50%). Examination typically included palpation, active and passive range of motion testing, blood tests, and cervical spine radiographs. No diagnosis was provided in 27 animals (42.9%) and no specific anatomical structure ( muscle, tendon, joint, ligament or nerve) was identified as the source/site of the pain. The next most frequently reported diagnoses were strained neck muscles (23.8%), and “Deerhound Neck” (11.1%). Although treatments were often combined, the primary treatments included prescription medication (36.5%), acupuncture (14.3%), chiropractic manipulation (12.7%), rest (4.8%), and soft tissue massage (1.6%). Gradual return to exercise was recommended in all cases. Recurrences were common but less severe and most often occurred within months of the initial event.

Conclusions: Despite failing to identify a precise structure-specific diagnosis, Scottish Deerhounds suffering with non-specific neck pain appear to respond to multimodal conservative care including non-steroidal anti-inflammatory drugs (NSAIDs), acupuncture, chiropractic manipulation, rest, soft tissue massage and gradual return to exercise.

Deerhound Neck warrants continued study in terms of tracking and reporting symptoms, progress and outcomes to specific examinations and treatments that adhere to precise inclusion/exclusion criteria and reproducible measures of treatment success or failure. Improved availability and access to advanced diagnostic techniques such as arthroscopy, ultrasonography, computer assisted tomography (CT) or magnetic resonance imaging (MRI), could help establish a definitive diagnosis and therefore guide appropriate treatment and follow-up care.

Key Words: canine neck pain, cervical spine, Deerhound neck, degenerative joint disease, myofasciitis, radiculitis

I first became acquainted with the term “Deerhound Neck” during a visit to Fernhill Deerhounds. It was their annual walking stick event for Deerhound owners and breeders. When I was introduced as a chiropractor and clinical researcher, I was immediately asked what I knew about the disorder: “Not enough” was apparently an inappropriate answer! It was suggested that I find out. So Barbara Heidenreich and Richard Hawkins provided me with direction, background material, and the available research to date. We decided to survey members on Deerhound-L, a listserv for Deerhound owners. Thank you all who responded to the survey and those who wish to help in the future. My hope is that the responses and results provided in the following paper will guide future research and clinical treatment. I am most thankful for the continuing support and advice that I have received from the Health and Genetics Committee of the Scottish Deerhound Club of America, particularly Dr. John Dillberger for his painstaking and most helpful editorial review. Also, Richard Hawkins and Barbara Heidenreich for gently nudging me along the writing process. D.B.

BACKGROUND

“Deerhound neck” is a term coined by owners and breeders of Scottish Deerhounds to describe a syndrome characterized by the sudden onset of pain the cervical region. Deerhound neck is highly prevalent condition with an incidence of 8% in male Deerhounds and 5% in females.¹ Dogs with Deerhound neck often endure episodes of pain behavior that may occur when the dog’s head is lifted or turned; either actively or passively. The dog may prefer to lie in a sphinx like position rather than curled up nose to tail. There may or may not be a history of trauma, fever, loss of appetite, gait disturbance, lameness, paralysis or other neurological problems.

Determining the best course of management for dogs with Deerhound neck is complicated by a lack of consistent diagnostic criteria that reliably distinguish serious from self-limiting disorders. Some Deerhound owners pursue every possible avenue of diagnosis and treatment in an effort to relieve their animal’s suffering. Deerhounds can be stoic but they also can be prone to the dramatic in terms of vocalizations, exaggerated postures and movements if they feel pain or anticipate pain. Even simple manual physical examinations can be overly stressful for the dog, the owner and the healthcare provider. Research published to date has not established agreement on a diagnosis or treatment for Scottish Deerhounds suffering with a complaint of non-specific (idiopathic) neck pain although several case series have been described and theories proposed.^2-9

OBJECTIVE

This study solicited feedback from Deerhound breeders and owners in a search for answers and commonalities that could direct future research.

METHODS

Questionnaire Development and Administration

Between April 18 and August 04, 2010 a 14-item questionnaire about neck pain was administered to approximately 500 subscribers of the Scottish Deerhound discussion list (LISTSERV@APPLE.EASE.LSOFT.COM located on the http://deerhound.org web site). The questions enquired about demographic variables, important components of neck pain symptoms, assessment, diagnoses, treatment response and outcomes. It was decided that an online survey would best facilitate timely data collection and increase responsiveness. SurveyMonkey was used. (http://www.surveymonkey.com/).

RESULTS 

47 Deerhound owners completed the survey on 63 animals. Question 1 asked if any of their dogs experienced “Deerhound neck. 47 answered yes for a response rate of 9.4%.

Question 2 enquired how many were males versus females with their ages at onset. There were 63 animals (35 males and 28 females). This sex ratio is similar to that reported previously for the breed.¹ Onset in males occurred most frequently between 4 to 7 years of age (57.1%); less often between 1 and 3 years (20%) and at 8 years or older (14.3%) or less than 1 year old (8.6%). Onset in females clustered more closely between 1 to 3 years old (50%) and 4 to 7 years old (42.8%). Females younger than 1 year or older than 8 years were affected equally (3.6%).

Question 3 asked how long each dog lived after the onset of “Deerhound neck “. Out of a total of 63 animals, 34 (54 %) lived more than four years: 20 (57.1 %) of the males and 14 (50 %) of the females. 15 (42.9%) males and 13 (46.4%) of females lived between 1 and 4 years beyond onset. Dividing this past group further produced 2 groups of 14 animals: 8 males (12.7 % of the total animals) and 6 females (9.5%) lived between 2 and four more years after onset. 7 out of 63 recent onset males (11%) and 5 recent onset females (7.9%) were still alive within one year of survey. Two outliers, 3 and 7 year old females presenting with neck pain, quickly followed by paralysis, were euthanized within 48 hours of onset. Fibrocartilaginous embolism was confirmed by post-mortem examinations.

In reply to Question 4, more than 62% of respondents attributed the onset of neck pain to be a singular traumatic incident such as a slip, fall or collision with another animal or object. There is a breed predilection to “the crazy zoomies” and “body slamming” (described in historic accounts as deer hunting technique often ending in forceful collisions). 48% reported an unknown origin and 24% said onset was spontaneous. (Figure 1)

Figure 1

Question 5 asked if “symptoms were ever associated with a rise in body temperature. 97.9 % answered no. When asked “which parts of the body were found to be most sensitive to touch” in Question 6: the neck, closest to the shoulders (26.7%) and the neck, closest to the skull (18.6%) were reported most often. The least sensitive areas were the top of the head (2.9%); side of head (2.8%); either shoulder (2.6%) or under the chin (0.0%) respectively. When asked in Question 7, if “the dog was taken to see anyone for treatment or consultation, 89.6% answered yes. The responses to Question 8 about which healthcare professional was most helpful produced the following results: Acupuncturist (41.3%), Veterinarian ( 40.9%), Chiropractor (28.1%), Naturopath (8.7%), Registered Massage Therapist and Osteopath (equally at 4%). Question 9 requested what diagnostic tests if any were performed and if they were considered relevant. The top five included palpation, active and passive range of motion testing, blood tests, and cervical spine radiographs.

Question 10 asked if a diagnosis was provided. The answer was no for 27 animals (42.9%); neck strain in 15 (23.8%); “Deerhound Neck” in 7 (11.1%); arthritis in 4 (6.3%); shoulder strain in 4 (6.3%); herniated intervertebral disc in 2 (3.2%); fibrocartilaginous embolism in 2 (3.3%) The remaining 2 diagnoses included single cases of neuropathic pain and vasculitis.

Question 11 enquired if treatment was provided and if there was a positive impact. Treatments were often combined. Prescription of medication was recommended in 23 cases (36.5%). Non-steroidal anti-inflammatory drugs (NSAIDS) represented 47.8% of the primary prescriptions; steroids 21.7%; analgesics 13%; muscle relaxants 8.7%; and antibiotics 4.3%. Acupuncture was delivered in 9 cases (14.3%); chiropractic manipulation in 8 cases (12.7%); rest advised in 3 cases (4.8%); and soft tissue massage in 1 case (1.6%). Gradual return to exercise was encouraged in all cases.

Question 12 wanted to find out how long symptoms lasted. 23 cases (36.5%) resolved within 1 week. 15 cases (23.8%) took up to 6 weeks to recover. 10 cases (15.9%) went a few months or longer and 7 cases (11.1%) were still active at one year. 8 cases (34.8%) remained chronic past 18 months. 2 of these cases were diagnosed as vertebral disc herniation; another case was determined to be chronic arthritis in a ten year old male; one case diagnosed with vasculitis and the last case was as a result of a very violent collision with another dog.   Three cases remained chronic but no diagnosis established. Question 13 found that recurrences were very common (50.8%) but less severe and most often occurred within months of the initial event. Age or sex of the animal did not seem to correlate with duration of symptoms, recurrence rate or severity.

Question 14 was reserved for comments and when answered were used to amplify previous responses.

DISCUSSION

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.¹⁰

Pain can be categorized by type (superficial somatic, deep somatic or visceral); mechanism  (inflammatory, neuropathic or both); severity (mild, moderate or severe) and duration. Forequarter and forelimb pain can all originate from lesions of the cervical spine.¹¹ Fifty-six percent of 179 dogs examined at an emergency service at a veterinary teaching hospital presented with acute pain of moderate severity and primary hypersensitivity to manual examination. Most dogs had deep somatic pain. Inflammation was the most common mechanism. Analgesic treatment was considered successful in seventy-three percent of the dogs.¹²

Pain distribution is similar whether the cause is traumatic or degenerative. Nociceptive fibers are present in many cervical spine structures including the disc annulus, facet joint capsules, muscle, meninges, arteries, nerve roots and dorsal root ganglia.¹³

Cervical disc disease in dogs was first reported in the literature in 1973 by Parker¹⁴ and male Scottish Deerhounds may be prone to arthrosis of the C2/C3 articular facet joints.^15,16 The Scottish Deerhound Club of America had its first extensive description of “neck pain” in an individual male with tragic resolution in the October-November 1973 issue of the Club publication “Deerhound Newsletter”.¹⁷ This elicited a response in the next issue (“Christmas 1973”) from a Club member with a similar experience that had been well resolved with the help of a chiropractor. ¹⁸

There is compelling evidence of an association between chronic neck pain and impaired cervical flexor muscle performance. Muscle pain stimulates pain receptors that cause an immediate reorganization of neck flexor muscle activity.¹⁹

Myofascial (trigger) points are defined as: “localized, hyperirritable nodules nested within a palpable taut band of skeletal muscle or fascia”.²⁰ They are found in both humans and animals. Stimulation, irritation or some perturbation of myofascial trigger points in neck and shoulder muscles might contribute to neck pain perception.²¹ Another study showed that pain immediately affects the activity of both deep and superficial cervical extensor muscle layers.²² Therefore, the presence of pain leads to an inhibition or altered timing of activation of muscles and muscle groups, which may cause alterations in neuromuscular patterns of motor activity during functional movement. The implication is that the deep cervical flexors lose their endurance capacity in individuals with neck pain thereby altering the levels of activity in the superficial neck flexors.²³

The forelimb of Deerhounds perform a tremendous amount of locomotor work to better absorb rising impact forces with the ground as evidenced by increased excitation and a short oscillation period in the pectoralis profundus, transversus and descendens muscles while accelerating. Likewise, the cleidobrachialis and cervical serratus ventralis muscles spike excitation to stabilize the forelimb during impact with the ground.²⁴

The shoulder joint is one of the most mobile of all main limb joints and sprains or strains of all supporting structures of the canine shoulder have now been reported.²⁵   Over time, muscle stiffness increases and atrophy and fat accumulation occur leading to significant pain and disability.^{26,27,28,29,30}

Acupuncture points are anatomically unique in possessing a greater density of large, myelinated fibers compared with normal tissue. When compared for spatial distribution and pain referral patterns, research has demonstrated a remarkable seventy-one percent correlation between trigger points and acupuncture points leading researchers to believe that they may be identical physiologic phenomena governed by similar neurophysiologic mechanisms. Dry needle stimulation to a single trigger point (sensitive locus) evokes short-term segmental anti-nociceptive effects by modulating segmental mechanisms which may be important in the management of myofascial pain.³¹

Electro-acupuncture can trigger powerful opioid and non-opioid analgesic mechanisms.³²

Extracorporeal shockwave therapy produces transient pressure oscillation (wave) energy in soft tissues with anti-inflammatory effects and relieves pain through hyper-stimulation analgesia.³³ (See Mills 2016 for a relevant individual report.)³⁴

CONCLUSIONS    

This survey found that “Deerhound Neck” afflicted more males (55.5%) than females (44.4). Onset in the majority of males occurred after four years of age but within the first few years of life in females and in both sexes the majority of animals lived more than four years after onset of neck pain.

62% of respondents reported that the most likely trigger was a single traumatic incident and despite failing to identify a precise structure-specific diagnosis in 42.9% of the cases in this survey, 60% of the dogs recovered within 6 weeks of onset.

Professional treatment was sought in all cases. Acupuncture, veterinary medicine and chiropractic represented the top three healthcare professions consulted and treatments were often combined.

Prescription medication was recommended in 36.5% of cases and non-steroidal anti-inflammatory drugs (NSAIDS) comprised the largest proportion of these (47.8%).

Although Scottish Deerhound owners generally do not agree upon a consistent set of treatments for dogs suffering with a complaint of deerhound neck.

The neck (and shoulder) pain of “Deerhound Neck” appears to be self-limiting and responsive to multimodal conservative care including acupuncture, chiropractic manipulation, extracorporeal shock wave therapy, soft tissue massage, non-steroidal anti-inflammatory medication and exercise.^35,36,37,38

Improved availability and access to advanced diagnostic techniques such as arthroscopy, ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI), could help establish a definitive diagnosis ^39,40 and rule out disorders such as: cervical spinal cord compression, cervical spondylosis, cervical spondylolisthesis, canine wobbler syndrome, caudal cervical subluxation, cervical vertebral instability, cervical spondylopathy caudal cervical malformation-malarticulation, cervical vertebral stenosis, cervical myelopathy, cervical spondylotic myelopathy, caudal cervical sponylomyelopathy or dynamic compression of the cervical spinal cord, or steroid responsive meningitis-arteritis (SRMA).^41,42

Acknowledgements:   The author wishes to thank Richard Hawkins and Barbara Heidenreich of Fernhill Deerhounds for case history and reference discussion (http://fernhill.com). Kristy Hiltz DVM, Rachael Jones DVM, and Britt Mills DVM for veterinary clinical contact and discussion of current therapy. Special thanks to John E. Dillberger DVM, Ph.D, DACVP, DABT, FIATP and Fiona James DVM for editorial review and the Health and Genetics Committee of the Scottish Deerhound Club of America for their review.

Conflict of Interest: The author declares that there is no conflict of interest regarding the publication of this report.

Funding: No funds were received for the research and preparation of this report.

For more information on Deerhound Neck, see these earlier articles. Ed.

REFERENCES

¹Dillberger JE. 2011 Deerhound Health Survey. Claymore May/June 2012:13.

²Trotter EJJ. Canine Wobbler Syndrome. In: Textbook of Small Animal Orthopaedics, CD Newton and DM Nunamaker (Eds.) Publisher: International Information Services, Ithaca, New York, U.S.A. 1985.

³De Decker S, Bhatti S, Gielen I, Van Ham L. Diagnosis, treatment and prognosis of disc associated Wobbler syndrome in dogs. Vlaams Diergeneeskundig Tijdschrift 2008;78:139-46.

⁴da Costa RC, Parent JM, Holmberg DL, Sinclair D, Monteith G. Outcome of medical and surgical treatment of dogs with cervical spondylomyelopathy: 104 cases (1988-2004), J Am Vet Med Assoc 2008 Oct 15;233(8):1284-90.

⁵da Costa RC. Cervical spondylomyelopathy (wobbler syndrome) in dogs. Vet Clin North Am Small Anim Pract 2010 Sep;40(5):881-913.6

⁶De Decker S, Bhatti SF, Duchateau ZL, Martie VA, Van Soens I, Van Meervenne SA, Saunder JH, Van Ham LM. Clinical evaluation of 51 dogs treated conservatively for disc-associated wobbler syndrome. J Small Anim Pract 2009 Mar;50(3):136-42.

⁷Dillberger JE. Neck Pain. Claymore 1997 November/December:47-52.

⁸Dillberger JE. Neck pain by a new name: steroid-responsive meningitis-arteritis (SRMA). Claymore 2010 March/April:15-18.

⁹Tipold A, Schatzberg SJ. An update on steroid responsive meningitis-arteritis. J Small Animal Practice 2010;51:150-4.

¹⁰International Association for the Study of Pain Taxonomy. http://iasp-pain.org/AM/Template.cfm?Section=Pain_Definitions

¹¹Webb AA. Potential sources of neck and back pain in clinical conditions in dogs and cats: a review. Veterinary Journal May 2003;165(3):192-213.

¹²Wiese AJ, Muir WW 3^rd, Wittum TE. Characteristics of pain and response to analgesic treatment in dogs and cats examined at a veterinary teaching hospital emergency service.      J Am Vet Med Assoc 2005 Jun 15;226(12):2004-9.

¹³Taylor JR, Finch P. Acute injury of the neck: anatomical and pathological basis of pain. Ann Acad Med Singapore 1993 Mar;22(2):187-92.

¹⁴Parker AJ, Park RD, Henry JD Jr. Cervical instability associated with cervical disk disease in two dogs. J Am Vet Med Assoc 1973 Dec 15;163(12):1369-71.

¹⁵Kinzel S, Hein S, Buecker A, Kromback GA, Kuepper W. Diagnosis and treatment of arthrosis of cervical articular facet joints in Scottish Deerhounds: 9 cases (1998-2002). Am Vet Med Assoc Nov 1,2003;223(9):1311-15.

¹⁶Dillberger JE. Claymore 2010 May/June.

¹⁷Liebold P. Deerhound Newsletter. Medical PuzzlesTurn into Tragedy. Scottish Deerhound Club of America 1973 (Oct-Nov):11-12.

¹⁸Atkinson F. The Adventures of Bash. Deerhound Newsletter. Scottich Deerhound Club of Amercia 1973 (Dec):6, 9-20.

¹⁹Cagnie B, Dirks R, Schouten M, Parlevliet T, Cambier D, Danneels L. Functional reorganization of cervical flexor activity because of induced muscle pain evaluated by    muscle functional resonance imaging. Man Ther 2011 Oct;16(5):470-5.

²⁰Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol 2004;14:95-107.

²¹Fernandez-de-Las-Penas C, Simons D, Cuadrado ML, Pareja J. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain           Headache Rep 2007 Oct;11(5):365-72.

²²Cagnie B, O’Leary S, Elliott J, Peeters I, Parlevliet T, Danneels L. Pain-induced changes in the activity of the cervical extensor muscles evaluated by muscle functional magnetic resonance imaging. Clin J Pain 2011 Jun;27(5):392-7.

²³Sterling M, Jull G, Wright A. Cervical mobilization: concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther 2001;6(2):72-81.

²⁴Deban SM, Schilling N, Carrier DR. Activity of extrinsic limb muscles in dogs at walk, trot and gallop. J Exp Biol 2012;215:287-300.

²⁵Marcellin-Little DJ, Levine D, Canapp SO Jr. The canine shoulder: selected disorders       and their management with physical therapy. Clin Tech Small Anim Pract 2007 Nov;22(4):171-82.

²⁶Derwin KA, Baker AR, Codsi MJ, Plannotti J. Assessment of the canine model of rotator cuff injury and repair. J Shoulder Elbow Surg 2007;16(5 Suppl):S140-S148.

²⁷Carrier DR, Deban Sm, Fischbein T. Locomotor function of forelimb protractor and retractor muscles of dogs: evidence of strut-like behavior at the shoulder. J Exp Biol 2008 Jan,2(Pt 1):150-62.

²⁸Williams SB, Wilson AM, Daynes J, Peckham K, Payne RC. Functional anatomy and   muscle moment arms of the thoracic limb of an elite sprinting athlete: the racing         greyhound (Canis familiaris). J Anat 2008 Oct;213(4):378-82.

²⁹Angle TC, Gillette RL, Weimar WH. Caudal paw displacement during movement initiation and its implications for possible injury mechanisms. Vet Comp Orthop Traumatol 2012 Jun 13;25(5):397-401.

³⁰Angle T, Gillette R, Weimar W. Kinematic analysis of maximal movement initiation in Greyhounds. Aust Vet J 2012 Mar:90(3):60-8.

³¹Srbely JZ, Dickey JP, Lee D, Lowerison M. Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. J Rehabil Med 2010;42:463-68.

³²Staud R. Mechanisms of acupuncture analgesia: effective therapy for musculoskeletal pain? Current Rheumatology Reports 2007;9:473-81.

³³Notamicola A, Moretti B. The biological effects of extracorporeal shock wave therapy (eswt) on tendon tissue. Muscles Ligaments Tendons J 2012(Jan-Mar);2(1):33-7.

³⁴Mills Britt, DVM. Extracorporeal shockwave therapy in a Scottish Deerhound with neck pain. Mills Veterinary Services (personal communication 2016). “A 4.5 year old Scottish Deerhound was presented to the clinic with persistent neck pain causing neck stiffness and yelping. Previous treatments with non-steroidal anti-inflammatories, chiropractic adjustments and acupuncture (including electro-acupuncture) had resulted in temporary improvement but the dog relapsed. Extracorporeal shockwave therapy (Masterpuls vetMP50) was initiated because of its pain relieving effects in other syndromes. The dog was not sedated during therapy and    appeared to enjoy the treatments. Intensity was gradually increased to 3 bar for 2000         pulses using the largest massage head over the neck region where most of the pain and stiffness was elicited. There was an immediate and dramatic pain reduction, which lasted for weeks. The dog underwent a second treatment two weeks later and has been pain free since. Radial pressure wave therapy may be a non-invasive and effective therapy for neck pain common in this breed.”

³⁵Millan M, Leboeuf-Yde C, Budgell B, Amorim M-A. The effect of spinal manipulative therapy on experimentally induced pain: a systematic literature review. Chiropractic & Manual Therapies 2012 Aug 10;20(1):26. Doi: 10.1186/2045-709X-20-26.

³⁶Coronado RA, Gay CW, Bialosky JE, Carnaby GD, Bishop MD, George SZ. Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis. J Electromyogr Kinesiol 2012 Oct;22(5):752-67.

³⁷Hurwitz EL, Carragee EJ, van der Velde G, et al,….Treatment of neck pain: non-invasive interventions. Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. Spine 2008;33(Suppl):S153-169.

³⁸Corti, L Nonpharmaceutical approaches to pain management. Topics in Compan An Med 2014;29:24-8.

³⁹Kunkel KA, Rochat MC. A review of lameness attributable to the shoulder in the dog: Part one. J Am Anim Hosp Assoc 2008 Jul-Aug;44(4):156-62.

⁴⁰Kunkel KA, Rochat MC. A review of lameness attributable to the shoulder in the dog, part two. J Am Anim Hosp Assoc 2008 Jul-Aug;44(4):163-70.

⁴¹Forterre F, Casoni D, Tomek A, Karli P, Howard J, Precht C. Congenital cervical kyphosis in two young sighthounds. Vet Comp Orthop Traumatol 2015;28. http://dx.doi.org/10.3415/VCOT-14-08-0116

⁴²Lowrie M, Penderis J, McLaughlin M, Eckersal PD, Anderson TJ. Steroid responsive meningitis-arteritis: a prospective study of potential disease markers, prednisolone treatment, and long-term outcome in 20 dogs (2006-2008). J Vet Intern Med 2009;23:862-870.