Application of Veterinary Spinal Manipulation Therapy (VSMT) or Chiropractic in Animal Healing

Application of Veterinary Spinal Manipulation Therapy (VSMT) or Chiropractic in Animal Healing

Manual Manipulation Therapy (Chiropractic) in animals

Chiropractic is a holistic and alternative therapy commonly used for treating misaligned joints.Chiropractic adjustment for animals has been around since the late 1980s. The treatment involves spinal manipulation or manual therapy. Canine chiropractors use low force to manually move parts of your dog’s spinal column, joints, and other vertebrae.Almost any animal species can safely get chiropractic adjustment from certified chiropractors. In fact, horses are common patients for many certified animal chiropractors.

The chiropractic principles used to treat dogs and other animals are almost identical to those used in treating humans. The main difference is, of course, applying the techniques together with their knowledge of animal anatomy. Animal Chiropractic care is a manual therapy, which can be used for many health and performance problems. It focuses on the biomechanical dysfunction of the spine and its effect on the entire nervous system throughout the body. Animal Chiropractic treatment does not replace traditional veterinary medicine; however, it can provide additional means of diagnosis and treatment options for spinal problems as well as biomechanical related musculoskeletal disorders. Animal Chiropractic can often eliminate the source of acute or chronic pain syndromes.

What is chiropractic?

“Chiropractic refers to the practice of manipulating the spine to treat disease.”

The term chiropractic comes from the Greek words “cheir” which means ‘hand’ and “praxis” which means ‘practice’ or ‘done by’, and refers to the practice of manipulating the spine to treat disease. Chiropractors base their theories of disease on the connections between various body structures and the nervous system via the spinal column, and on the role of the spine in biomechanics and movement. Therapy is directed at the spine in order to modify the progression of disease.

Veterinary Spinal Manipulation Therapy (VSMT) also known as “animal chiropractic” is a gentle and non-invasive integrative manual therapy that may help with symptoms associated with dysfunction of the musculoskeletal and neurologic systems.

Spinal manipulation has been practiced for centuries in many cultures, including the early Chinese and Greeks. However, there is a distinct lack of historical documentation of its early use in animal species. In its modern form, chiropractic theory and practice have developed within the last century. Early practitioners of modern chiropractic investigated its use in various animal species. As a distinct practice specialty, veterinary chiropractic is a young profession that is undergoing rapid growth and evolution.

Chiropractic manipulation is frequently performed on horses, dogs, and cats, but can theoretically be performed on any vertebrate species.

An adjustment includes gentle range of motion, traction and joint mobilization techniques and specific adjustments to restricted joints, resulting in the restoration of normal motion and alleviation of pain. It has been observed that various conditions not responding to conventional therapy have responded to spinal manipulation. This is thought to be due to the somato/visceral connection, or the connection of the nervous and musculoskeletal system to the organ system of the body. Nerves that leave the spinal cord exit the spine and eventually communicate with muscles, joints, and even internal organs. If there is a restriction in mobility anywhere along that pathway, it is possible it may affect the way that muscle, joint, or organ functions.

CONDITIONS/ DIAGNOSES THAT BENEFIT FROM A SPINAL MANIPULATION CONSULTATION:

• Neurologic conditions
  • Prevention of and conservative management of intervertebral disk disease
  • Wobbler’s disease
  • Chronic back and neck pain
• Orthopedic conditions
  • Arthritis
  • Hip dysplasia
  • Spondylosis
  • Musculoskeletal weakness or pain
• Incontinence (fecal or urinary)
• Maintenance of healthy mobility
• Maintenance of top athletic performance
• Various conditions not responding to conventional medical care

After a thorough initial examination, the doctor will determine if your pet is a good candidate for spinal manipulation and will make appropriate recommendations and adjustments. Veterinarians  will only recommend spinal manipulation therapy if it is safe for your pet.

HOW IT WORKS

The goal of an animal chiropractor is to restore function and mobility to the compromised or ‘stuck’ vertebra to re-store proper motion to the joint, this allows the body to perform at its optimum potential. An animal chiropractor will use their hands to identify areas of restriction; and once identified, apply a precise, high velocity, low amplitude (fast and shallow) thrust specific to the anatomy of the joint. This treatment is intended to restore normal motion of the vertebra. By working in conjunction with veterinarians, animal chiropractors aid in restoring your pet’s optimal health. Animal Chiropractic is NOT intended to assume the primary health care responsibility of animals or replace veterinary medicine.

SIGNS AND SYMPTOMS

Because our animals communicate in a language other than words, they must rely on your capacity to observe and distinguish the subtle changes in their behavior which might indicate a warning sign for health concerns.  Since not all behavioral changes are cause for concern, the following list of Signs and Symptoms will help you identify what to watch for to protect your animals and ensure a healthy and vigorous life.

Dogs & Cats:

• Pain or flinching when being touched, pet, or lifted
• Reluctance or difficulty when climbing stairs or jumping
• Difficulty when getting up after lying down or laying only on one side
• Negative changes in attitude or behavior
• Constantly licking or chewing paws
• Lameness or changes in gait
• Changes in performance
• Being less active than normal or disinterest in usual play activities

Horses:

• Pain, flinching, or stiffness when moving or being touched
• Reduced performance
• Negative changes in behavior or attitude
• Abnormal gait, shortened stride or lameness
• Inability or difficulty in taking a lead
• Bucking
• Difficulty or inability to collect
• Pinning ears or snapping when being cinched
• Difficulty flexing at poll
• Changes in posture
• Resistance to being ridden

It should be emphasized that this list is a basic overview, and does not cover every sign and symptom an animal may exhibit. The purpose is to highlight the most commonly seen signs and symptoms in the hope of offering guidelines to help the pet owner to recognize potential disorders. This is in no way an attempt to diagnose and/or treat any specific disease or condition. If a pet is demonstrating any unusual symptoms or behaviors, the owner should consult a qualified veterinarian without delay!

Chiropractors who work on animals must have specific training in both chiropractic theories and animal anatomy so that they are knowledgeable about the differences in biomechanics and neuromusculoskeletal function between humans and animals. Conditions with a neurologic or biomechanical origin are amenable to chiropractic manipulation. These conditions include degenerative joint diseases such as hip dysplasia and spondylosis; cervical instability; acute neck pain; intervertebral disk disease; autonomic nervous system problems such as urinary and fecal incontinence; musculoskeletal weakness or pain that resists conventional diagnosis and treatment; and chronic back and neck pain.

Chiropractic therapy is often combined with other forms of traditional and alternative veterinary medicine. There appears to be a particularly strong synergy between acupuncture and chiropractic. When multiple types of treatments are used, it may be difficult to determine the efficacy of a chiropractic treatment, unless the treatments are performed at different times. Certified veterinary chiropractors have the knowledge and skill to understand the interactions between different forms of treatment and to interpret the patient’s response to therapy. If your pet is receiving chiropractic treatment from a practitioner other than your regular veterinarian, it is imperative that both individuals are kept updated about the ongoing treatment in order to provide coordinated care of your pet, to allow proper evaluation of treatment and to minimize any avoidable interactions or interferences.

The Role of Physical Manipulation (Chiropractic) in Canine Rehabilitation

The spine is a central stabilizing structure in any mammal. All appendages are connected to it via bony or soft tissue attachment. Chiropractic, or spinal manipulative therapy (SMT), can be a powerful tool in restoring the body to its proper mechanical and neurophysiologic state after injury or disease, and can assist with maintainance of health of canine patients. This chapter reviews the history, theory, and terminology of animal chiropractic; gives a general overview of adjustment and techniques; reviews common indications and precautions; discusses anatomy, biomechanics, and functional neurology; and finally, discusses educational opportunities and legal issues. Although manipulative therapy can be applied to any accessible joint in the body, the focus of this chapter will be on the spine.

Animal Chiropractic History

Early History

Chiropractic originated with D.D. Palmer in 1895. Believing that the spine was the key to all disease and disorders, he used chiropractic as an entire system of medicine, and started the first school of chiropractic, now known as the Palmer School of Chiropractic. His son, B.J. Palmer, took over the school and promoted the newly developed profession. He was reputed to have treated animals as well as people at the school. Many individuals trained by the Palmers went on to develop their own theories and techniques.

In the 1980s, the field of animal chiropractic came into being when Sharon Willoughby, DVM, began to apply this medical system to her patients. After practicing general medicine for several years, she enrolled at the Palmer School and studied the differences between human and animal anatomy. Tom Offen, DC, mentored her work adapting chiropractic to animal patients, and she went on to finish her Doctor of Chiropractic (DC) degree. Dr. Willoughby established the first course in animal chiropractic and founded the American Veterinary Chiropractic Association in 1989.

Animal Chiropractic as a Profession

Animal chiropractic is not legally recognized as a unique profession. Both veterinarians and chiropractors have opportunities for advanced training and certification. Much progress has been made with respect to understanding biomechanics and neurophysiology, resulting in a more scientific and evidence-based modality. To distinguish it from practice on humans, the term veterinary spinal manipulative therapy (VSMT) is used.

Chiropractic Theory

Evolution of Chiropractic Theory

As the profession grew, so did the desire for a more thorough understanding of the process by which dysfunction occurs and why manual therapy is effective. Today, many theories are being investigated, including nerve compression, spinal cord compression, axoplasmic aberration, somatoautonomic dysfunction, and facilitation (Leach & Phillips, 1986). Central to these theories is the concept of subluxation.

Evolution of subluxation theory. Subluxation theory has grown and developed since the early days of chiropractic, reflecting a more thorough understanding of complexity in both pathophysiology and treatment.

Segmental Spinal Dysfunction or Subluxation

The word chiropractic is derived from the Greek roots, cheir (the hands) and praxis (to practice). Initially, D.D. Palmer believed that a bone out of place was the cause of a number of clinical signs in his patients. He termed this abnormal rela­tionship between two adjacent vertebrae a sub­luxation. The signs that he attributed to the subluxation were metabolic and neurologic as well as musculoskeletal.

The term subluxation is the hallmark of chiropractic theory and practice. Many individuals have sought to define it, leading to over 100 synonymous terms (Gatterman, 1995). The Consortium for Chiropractic Research defines it as “a motion segment in which alignment, movement integrity, and/or physiologic function are altered though contact between the joint surfaces remains intact” (Gatterman, 1995).

Subluxation and Other Chiropractic Terminology

To better understand the concept of subluxation, it is important to be familiar with basic chiropractic terminology

Chiropractic terminology

Term	Definition
Subluxation	Dysrelationship between two vertebral segments; may be anatomic but is often a subtle, functional dysrelationship.
Motion segment	Two adjacent vertebra and all of the associated structures (muscles, ligaments, vessels, and the contents of the intervertebral foramen).
Intervertebral foramen	Space between vertebrae through which the spinal nerves and associated structures pass.
Adjustment	High velocity, low amplitude manipulation (thrust) delivered to a specific hypomobile motion segment using a specific force and depth. Used to restore mobility to that segment.
Contact point	The part of the chiropractor’s hand that is used to deliver the adjustment. There are many possible contact points, but most often the “v-trough” (between the thumb and second metacarpal) or supported thumb is used.
Segmental contact point	The part of the vertebra that the chiropractor uses to adjust the segment. Contact points vary with spinal regions as well as extremities. The points typically used include spinous processes, transverse processes, mammillary processes, lamina, and other bony prominences (tuber sacrale).
Line of correction	The direction of the manipulative thrust, along the plane of the zygapophysial joint which is restricted. Subtleties vary from segment to segment, as with joint mobilization.
Zygapophysial joint (Z joint)	Joint formed by the cranial and caudal articular processes of adjacent vertebrae. Also known as a facet joint. See anatomy section for detailed description.
Static palpation	Assessment of positional symmetry or dysrelationships without regard to mobility.
Motion palpation	Assessment of functional mobility without regard to static position.

The Motion Segment

The motion segment  is generally accepted as the smallest unit of motion in the spine and is composed of two adjacent vertebrae and all of the associated structures. These structures include muscles, tendons and ligaments, joints, nerves and vessels, and the contents of the in­­tervertebral foramen (IVF). The relationship be­­tween the two vertebrae is anatomically and neurologically complex. When there is a minute alteration in this relationship, the body responds with numerous mechanisms designed to maintain homeostasis.

The motion segment consists of two adjacent vertebrae and all associated structures. A. Dorsal spinous processes. B. Vertebral bodies. C. Transverse processes. D. Articular facets. E. Supraspinous ligament. F. Interspinous ligament. G. Ligamentum flavum. H. Dorsal longitudinal ligament. I. Ventral longitudinal ligament. J. Joint capsule. K. Intervertebral disk. L. Intervertebral foramen.

The IVF

The IVF is the communication portal of the nervous system (Willoughby, 1998). Foramina are found at each spinal segment from C2 through the sacrum. The boundaries of the IVF include the vertebral notches and facet joint capsules on either side, intervertebral disk (IVD) ventrally, and ligamentum flavum dorsally. The primary content is the spinal nerve, surrounded by the cerebrospinal fluid (CSF) and supported by a dural extension that eventually blends with the epineurium, the recurrent meningeal nerve that supplies the IVD (and other areas), the dorsal longitudinal ligament, meninges, spinal artery, intervertebral veins, lymphatics, and connective tissue that serves as a shock absorber to protect the delicate structures within.

The Vertebral Subluxation Complex (VSC)

The VSC is a model used to describe the interrelationship of clinical signs associated with segmental dysfunction in the spine. Rather than defining a distinct subluxation, it describes a more general view of the complexity of alteration in spinal motion. The VSC consists of nine components of pathology that can occur individually, but more often collectively, when a vertebral subluxation occurs, with kinesiopathology as the central factor around which all other changes occur .

The vertebral subluxation complex model. Muscles, nerves, vessels, and connective tissue (all part of the motion segment) are intimately involved in development of kinesiopathology and incur pathologic changes as a result. The sequela to this pathology is inflammation eventually leading to tissue damage.

Adapted from Lantz (1995).

Clinical Procedure

The Chiropractic Examination

The chiropractic examination is not significantly different from a thorough rehabilitation evaluation. It begins with attaining a signalment and thorough history followed by assessment of general physical health. Particular emphasis is placed on posture and gait analysis as well as palpation of the spine and extremities.

A. Normal posture. Note the squarely placed limbs, level topline, and smooth muscle outlines in this dog. B. Abnormal posture. This geriatric canine exhibits pelvic limbs held forward under her body and a slightly kyphotic topline. There is some loss of the secondary curvature in the lower cervical spine, resulting in low head carriage.

Abnormalities in static alignment, muscle tone/strength/symmetry, and range of motion are noted for each vertebral segment, each extremity joint, the temporomandibular joint (TMJ), and often the ribs, sternum, and tail. Symmetry in the bones and soft tissue of the cranium is also noted .. Any signs of segmental dysfunction (pain, excessive tightening or spasm of muscles, heat, and reduced or increased mobility) are noted. Neurologic assessment is completed to establish a baseline, and radiographic evaluation is performed as indicated.

A Papillon is examined for symmetry in the head, static alignment, and anterior/posterior motion of the atlas.

Adjustment or Spinal Manipulation

An adjustment is defined as a high velocity, low amplitude thrust directed at a specific spinal segment with a specific force and depth. It is synonymous with a grade 5 joint mobilization. Grades 1–4 joint mobilizations deliver intervention via low velocity motion with increasing amplitude (lowest for grade 1, highest for grade 4) within the passive range of motion. Initial models described an adjustment as going beyond normal passive range of motion into a paraphysiologic space. This is where the spring occurs with overpressure in a normal joint. Manipulations are performed only on hypomobile joints. Vernon proposed a new model that more rationally describes the adjustment as occurring within the clinical physiological range, slightly before the end limit of this range  (Vernon & Mrozek, 2005). This results in restoration of full range of motion after manipulation .

Model of mobility in a dysfunctional joint. AC = active range of motion. P = passive range of motion. PH = “paraphysiologic space.”

Model of mobility in manipulation. AC = active range of motion. P = passive range of motion. PH = “paraphysiologic space.”

The setup involves finding the line of correction across the plane of the joint and placing the contact point of the therapist’s hand (most frequently the supported thumb) on the segmental contact point (muscles over a bony prominence, most often dorsal spinous, transverse, or mammillary process in the thoracolumbar spine, lamina/pedicle junction in the cervical spine, and various contact points in the pelvis and extremities).

Initially, the joint is taken to tension (developing a preload force). A rapid thrust is applied in a specific direction (line of correction) along the plane of the hypomobile joint to provide gapping in the joint. This may produce an audible sound due to fluid cavitation (Brodeur, 1995) although other mechanisms have been proposed.

Follow-up is generally recommended based on the degree of pathology and the likelihood of the patient holding the adjustment for a particular length of time. For patients with significant pathology, a second adjustment may be recommended in 2–3 days. For those with many compensatory issues, repetition may initially be done weekly. Therapy is tapered as the patient improves. For maintenance of health, intervals from monthly to every few months may be appropriate. Sporting dogs at major competitions may be treated daily to optimize performance.

Commonly Used Techniques

Because philosophies differ regarding the primary or root issue contributing to dysfunction, over 100 different techniques have been developed to address spinal subluxations, including

• Gonstead
• Diversified
• Logan basic
• Sacro-occipital
• Applied kinesiology
• Activator
• Network

Directional and Anatomical Descriptions, Listings

The language that is used when recording findings and documenting therapy is relative to human anatomy (e.g., anterior, superior) . This is referred to as a listing and is written in the form of an abbreviation. Because motion tends to be complex, the listing is based on the predominant restriction.

Directional and anatomic abbreviations and terms

Abbreviation	Human term	Veterinary term
P	Posterior	Dorsal
A	Anterior	Ventral
S	Superior	Cranial
I	Inferior	Caudal
PSIS	Posterior superior iliac spine	Tuber sacrale
ASIS	Anterior superior iliac spine	Tuber coxae
TMJ	Temporomandibular joint	Temporomandibular joint

Indications and Precautions

Indications

Any disorder that results in abnormal musculoskeletal or neurologic function is an indication for application of chiropractic. This includes an almost exhaustive list of problems when considering the complexity of the nervous system and potential for modulation. Many studies have established efficacy of chiropractic in humans, principally related to back and neck pain (Bronfort et al., 2004).

Primary Spinal or Joint Disorders

With the exception of treating contraindicated areas (such as painful intervertebral disk disease [IVDD]), manipulative therapy can improve mobility, assist neurologic healing, and rebalance muscle tone and function while reducing pain.

Indications for chiropractic intervention

Primary spinal and peripheral joint disorders
Spondylosis
Facet joint osteoarthritis
Intervertebral disk disease
Fibrocartilagenous embolus
Lumbosacral stenosis
Cervical vertebral instability/stenosis
Discospondylitis
Degenerative myelopathy
Muscle pathology in the lumbar spine (iliopsoas strain)
Spine and neck trauma (only when stability present)
Temporomandibular joint pain
Rib injuries
Osteoarthritis
Fibrosis/adhesion

Nonprimary Problems Resulting in Spinal Hypomobility

Many other musculoskeletal diseases result in abnormalities in spinal mobility as a result of increased stress or imbalance in the body. Chronic lameness typically results in abnormal position of the spine at rest and/or in motion. Muscle tightness and spasm can result in segmental dysfunction and pain. Immobility from enforced rest (crating) or nonspinal paresis (i.e., Coonhound paralysis, diabetic neuropathy) can lead to significant dysfunction and loss of segmental mobility. Overuse injury can contribute to subluxation, with athletic patients at higher risk. This is especially true of those who undergo chronic repetitive patterns of stress, such as working dogs and those competing in flyball and agility.

Precautions and Risks

The benefits of chiropractic can be profound, but the risks also must be taken into account. The most notable risks in humans include cauda equine syndrome resulting from lumbar manipulation (Shekelle et al., 1992) and verte­brobasilar accidents following cervical manip­ulation (Hurwitz et al., 1996). The incidence of complications remains quite small (1 per 100 million and 5–10 per 10 million adjustments, respectively) compared to procedures that we consider routine, such as vaccination (38.2 per 10,000 dogs vaccinated; Moore et al., 2005). Chiropractic must be performed by only well-trained professionals.

Pain

Although muscle spasm and hypertonicity of an intrinsic spinal muscle can cause significant pain, it is important to determine whether the degree of pain is appropriate to the clinical signs. Abnormal stresses on joint capsule, tendons, and ligaments can generate pain, and it can be referred from other areas (several segments above and below). Addressing muscle spasm and pain in the course of therapy may result in complete resolution and may restore functional biomechanics and neurologic input. Adjusting an area of reduced mobility where other pathology (IVDD, disco­spondylitis) exists could result in damage to the surrounding tissues. The prudent therapist manipulates a painful area only when the source of pain can be confidently determined.

Acute Injury/Postsurgical Areas/Instability

In the acute phase of injury, there is often considerable edema and inflammation (and possibly hemorrhage), so an area that is actually unstable may appear to be hypomobile. Any area that is unstable and any adjacent areas should not be adjusted due to the risk of creating further instability and tissue damage. Once the affected area has stabilized, it may be manipulated, beginning with gentle procedures and progressing as needed based on the stage of healing and tissue pliability.

Neoplasia

Extreme caution must be used when manipulating patients with neoplasia. Neoplastic tissue is abnormal and reactive by nature, and caution must be used to avoid increasing blood flow and resultant circulation of neurotransmitters that may be stimulatory to cancer cells. Areas adjacent to cancerous tumors should not be adjusted due to concerns for pain and inflammation, potential instability, and the potential to stimulate metastasis.

Infection/Fever

Spinal manipulation has the potential to increase circulation and lymphatic flow to and from a site of infection. If the infection is local, this may result in dissemination.

Anatomy and Biomechanics

The Canine Vertebral Column

The canine spine articulates in a manner that promotes proper stability as well as mobility in the body. It functions to protect the spinal cord and nerves and serves as a central axis of stability as well as motion for the body.

Typical Vertebra

Canine vertebrae are considered irregular bones, defined by their prominent protuberances where tendons and ligaments attach.

A typical vertebra has a distinct structure related to its function. The body is the main bony structure with a cranial (convex) and caudal (concave) articular surface. A vertebral arch consisting of a lamina (dorsal) and pedicle (lateral) on each side lies dorsal to the body. This forms a protective housing for the spine, with the opening known as the vertebral foramen. Collectively, these foramina are known as the vertebral canal.

Typical vertebral structure, L1. Note that the accessory process is typically found only from T11–12 to L4–5.

Veterinary Chiropractic FAQ

What is Veterinary Spinal Manipulative Therapy (VSMT)?

VMST, often referred to as animal chiropractic care, is a hands-on therapy designed to find and relieve areas of abnormal or restricted movement of the joints and spine. These restricted or abnormal movements affect the nervous system, which, in turn, affects the entire body. The doctor applies small, quick thrusts to specific joints to help restore proper movement. This allows the body to function at its healthiest level and realize its maximum potential.

Can chiropractic adjustments be used to treat my pet?

Chiropractic adjustments can be very helpful for many clinical conditions, including:

• Back, neck, leg, or tail pain (including chronic pain)
• TMJ problems
• Sports injuries
• Muscle spasms
• Nerve problems
• Incontinence
• Senior pain or stiffness

How long will a treatment take?

The initial consultation and first treatment tends to take longer than subsequent visits (usually between 30 – 60 minutes), because a detailed case history, examination, and goal assessment is undertaken. Subsequent treatments are usually shorter (between 20 – 40 minutes), depending on the veterinary chiropractor’s findings.

Do chiropractic adjustments hurt?

Most pets find chiropractic adjustments relatively painless. During an adjustment, your pet may experience discomfort for a brief moment, but most pets are very relaxed and comfortable throughout the treatment.  Occasionally, after a treatment, a pet may be mildly sore for a day or two, as we are after a good workout. Afterwards, their movement and gait are improved.

How many treatments are necessary?

The number of recommended treatments will vary for different patients. In most cases, a single treatment is not enough to eliminate a problem. Most animals show significant improvement after 1 – 4 treatments. Chronic problems usually take longer to resolve, requiring more chiropractic treatment; whereas animals with acute problems often respond more quickly. Wellness adjustments are often done every 3 months to help maintain spinal health.

The goal of VSMT and chiropractic treatment is to address neurological dysfunction in the spine and restore mobility. The muscles and ligaments need to learn to support the spine and maintain this newly realigned position.An animal chiropractor will adjust and correct the animal a number of times, until the body accepts the new position of the spine as normal and the muscles and ligaments can support and maintain this position.

How does chiropractic care compare to traditional veterinary care?

 Veterinary chiropractic treatment does not replace traditional veterinary medicine; however, it can be an integrative approach to provide additional diagnostics and treatments for spinal and musculoskeletal disorders.    

COMPILED & EDITED BY-DR NIRBHAY KR. SINGH, ASST. PROF. BVC,BASU,PATNA

REFERENCE-ON REQUEST.

https://www.pashudhanpraharee.com/application-of-physiotherapy-in-veterinary-practice/

https://www.copetownvet.com/uploads/1/2/0/8/120807248/vsmt_info_for_website.pdf