When McGraw Hill first approached me (Tony Mosconi) to write a neuroanatomical and neurophysiological text aimed at students of physical therapy, I was both intrigued and intimidated. Despite many years’ experience teaching neuroanatomy and neurophysiology to these students, I was no clinician. Knowing a bit about the psychology of clinically oriented students, I recognized this as a major impediment to my ability to compose such a text.
At this time of grim self-reflection, I recalled the time my colleague, a physical therapist, accosted me in the hall between our offices, grilling me on the presentation of patients with a lesion of the hypoglossal nerve. It was the first time for either of us to directly compare differences in basic scientific and clinical descriptions of neuroscience and pathology. It was the beginning of a beautiful friendship (and collaboration).
We spent a long time discussing how we could combine disciplines to create a format that was different from the current texts in the field. It became clear that the available texts were aimed at the educational needs of medical students, who would be using the information for medical differential diagnosis, and lacked the basic science that forms the foundation of modern rehabilitative health care. Herein, we tried to find a common clinical-scientific ground, emphasizing the science necessary to conceptualize the conditions that physical therapists see in their practices. Further, we wanted it to be readable and stimulating, mindful not to lose our reading audience in the often dry and unfamiliar material.
We decided that a consistent chapter format would benefit the flow so that students understood what kind of material was about to be presented and where to find the information that they needed. Each chapter begins with a case study of a real patient assessed and interviewed on camera by Vicky Graham. The case studies establish a conceptual framework for the rest of the chapter.
A short Overview of Concepts introduces the basic content of the chapter and is followed by the details of the topic or system. We built up the neuroanatomical framework of the system with descriptions that are presented in language comprehensible to novices and still sophisticated enough for students familiar with the concepts. This is not always an easy synthesis, and we hope we struck the right balance.
After “building” the neurological systems, we broke them, discussing the physiologic processes of damage and clinical presentation, including observable behaviors after injury or disease. We also recognized that the often dense presentation of information could benefit from short interesting interludes, so we introduced a scattering of boxes that expand on issues relating to Neuroplasticity, Response to Injury, and Frontiers in Research, that hopefully are informative and interesting.
Chapter organization of the text begins traditionally, with an Overview chapter and a chapter on Nervous System Development. These generate an anatomical scaffold on which the rest of the book is built. Understanding fetal development helps students understand the complex structure and connectivity found in the developing, mature, and recovering brain.
We have noticed that most physical therapy students have minimal understanding of cell biology. We felt that it was important for students to understand the cytology of the components of the nervous system, especially some of the basic molecular biology. Much of neuronal function is driven by the expression of various proteins, their insertion into the cell membrane, and their release into extracellular space. This information facilitates student understanding of neurophysiological concepts presented in the following chapter. We felt that this level of detail was important in light of the way that numerous injuries and degenerative diseases alter cellular and intercellular functions. This was an expression of our underlying desire to assist students to gain a deeper understanding of the mechanisms of function, injury, and recovery that their patients will undergo.
Both of us, as well as most of our colleagues, teach the functional nervous system from the “bottom up,” that is, starting with the spinal cord, ascending through the brainstem and diencephalon, up to the cerebral cortex. Many texts are organized from the top down, beginning with the cortex. We felt that our organization would be as beneficial to the professors as to the students. So we started in the spinal cord and ascended to the cortex. Of course, we still faced the challenge of integrating clinical and scientific information in a way that was manageable for students, so we inserted patient presentations from a student-centric perspective. We anticipate that after studying our chapters, students will be prepared to apply neuroscience principles during subsequent clinical application courses as well as during patient care of this population.
For our chapter on the brainstem and cranial nerves, we recruited Maryke Neiberg, a neuro-optometrist, for assistance in preparing the portions on the sensorimotor features of the visual system. We knew we’d found a kindred spirit and creative collaborator when we heard her speak eloquently at a conference, memorably describing the circle of Willis as “a little devil.” She was also a major contributor to the sections in the cerebral cortex related to visual processing for perception and association. We felt this of particular interest because of the enormous diagnostic value in assessment of vision and extrinsic and intrinsic motor function of the eyes.
After each chapter, there is a discussion of the outcomes of the introductory case study. These sections are often very intimate and in some cases include discussions from the patients themselves. We feel that this personalizes the patients and leads students away from thinking about the disease or injury and toward viewing patients as the people they will spend the rest of their working lives helping.
Each chapter ends with ten Review Questions to help students think about the information in a way that prepares them for further study for board exams. Additional materials include a Glossary to collect terminology that might be difficult to remember when seen in subsequent parts of the book. We have also developed Appendices that present more detailed pathology and that lead students through a complete neurological evaluation. To make these sections more impressive on student learning, many videos are available that demonstrate these conditions in actual patients and observations on students. Videos are available by subscription to McGraw-Hill’s AccessPhysiotherapy site (accessphysiotherapy.mhmedical.com).
We are optimistic that the present work will make the enormous, but critically important, subjects of neuroscience accessible, understandable, and engaging to our students. We have created it out of our fascination with the form and function of the nervous system, from development through senescence and during recovery from injury. We created it with students in mind because we love them and want only the best for the development of their individual brilliance. Finally, we hope that this book will inform students in a way that will ultimately guide their professional selves to creatively and compassionately assist people in need.
Victoria Graham, PT, DPT, OCS, NCS