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Rehabilitation in Hindlimb Conditions What’s all the fuss about?
Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT
Assistant Professor, Integrative Medicine
School of Veterinary Medicine Louisianan State University
Overview
1. Introduction to Rehabilitation
2. Goals for Hindlimb Rehab
3. Rehab Exam in Hindlimb
4. Objective Outcome Measurements
5. Rehab Plan:
ò CHD, Iliopsoas, CCLR, IVDD
Rehabilitation
ò Growing specialty in vet med
ò “Physical Therapy” and “Physiotherapy” are protected terms
ò DVM/ VMD / VT / PT / PTA / OT / OTA
ò Canine Rehabilitation Institute (CCRT or CCRA)
ò University of Tennessee (CCRP)
ò Am Col of Veterinary Sports Medicine and Rehabilitation
ò DACVSMR, Approved by ABVS in 2010
ò All rehab patients need to be evaluated by a veterinarian
Veterinarians Veterinary Technicians
Physical Therapists Physical Therapist Assistants
Occupational Therapists Students in one of the accepted
professions*
ò Approved by ABVS in 2010
Rehabilitation in Hindlimb
ò CHD, CCL, MPL, OA, tendinopathy, IVDD, DM
ò Pain relieve and maximize function
ò Rehab techniques address the following conditions:
ò Pain and inflammation
ò Hypomobility or hypermobility
ò Flexibility
ò Weakness
ò Muscle atrophy
ò Goals of rehabilitation are:
ò To restore, maintain and promote optimal function, fitness, wellness and quality of life as they relate to movement disorders and general physical health.
What is involved?
ò Assessment of the patient
ò Physical exam
ò Orthopedic exam
ò Neurologic exam
ò Rehabilitation exam
ò Diagnostic imaging
General health Concurrent problems
Primary problem
Dogs with OCD in the shoulder joint will have pain when:
A. extend the shoulder B. flex the shoulder with some
internal rotation
Check for bicep tendonsynovitis: Flex the shoulder, and extend
the elbow, this would cause full tension to the biceps as it crosses the humerus and
inserted at the proximal antebrachium.
If pain is noted, go back and
palpated the region of bicipital groove where the biceps runs
along it ( just medial to the greater tubercle), look for pain .
Kent Allen: “In the absence of a diagnosis,
Surgery is trauma, Medicine is poison, and
Alternative Therapy is witchcraft.
DIAGNOSIS!!
Ortho Exam Tips – DO
ò Put on your detective hat
ò Ask clients to provide video
ò Take rectal temp after exam
ò Use treats
ò Evaluate functional mobility and transitions
ò Do exam on good grip floor
ò Leave the “limb of interest” for last
ò Leave the feet for last but DON’T forget
General health Concurrent problems
Primary problem
Dogs with OCD in the shoulder joint will have pain when:
A. extend the shoulder B. flex the shoulder with some
internal rotation
Check for bicep tendonsynovitis: Flex the shoulder, and extend
the elbow, this would cause full tension to the biceps as it crosses the humerus and
inserted at the proximal antebrachium.
If pain is noted, go back and
palpated the region of bicipital groove where the biceps runs
along it ( just medial to the greater tubercle), look for pain .
Kent Allen: “In the absence of a diagnosis,
Surgery is trauma, Medicine is poison, and
Alternative Therapy is witchcraft.
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Ortho Exam Tips – DON’T
• Do exam on a stainless-steel table
• Forget the soft tissues
• Forget front limbs and neck
• Forget that neuro disease
• Assume the only indication of pain is crying out, turning, or pulling back
• Pin the scared animal to the ground and expect to feel cranial drawer or other subtle signs of discomfort
General health Concurrent problems
Primary problem
Dogs with OCD in the shoulder joint will have pain when:
A. extend the shoulder B. flex the shoulder with some
internal rotation
Check for bicep tendonsynovitis: Flex the shoulder, and extend
the elbow, this would cause full tension to the biceps as it crosses the humerus and
inserted at the proximal antebrachium.
If pain is noted, go back and
palpated the region of bicipital groove where the biceps runs
along it ( just medial to the greater tubercle), look for pain .
Kent Allen: “In the absence of a diagnosis,
Surgery is trauma, Medicine is poison, and
Alternative Therapy is witchcraft.
ò Soft tissue palpation
ò Goniometer ò Measures joint angles
ò Compare both sides
ò Gulick: ò Specialized tape (4oz tension)
ò Measures muscle girth
ò High up in the thigh, cross tape at greater trochanter
ò Compare both sides
Rehabilitation Exam
Rehabilitation Exam
ò Gait Analysis
ò Stance
ò Gait ò Walk, Trot, Pace, Gallop
Some breeds, particularly herding breeds, have pelvic limbs with internally rotated tarsi,
sometimes referred to as being “cow hocked.”
This may actually be an adaptation for herding; having
this type of rear conformation is thought to provide improved
stability for lying down and standing up and to reduce the
rear leg motion required in turning. Herding dogs frequently lie down to reduce the pressure
on moving sheep and have to turn very sharply to cut off
sheep that attempt to bolt from the flock.
Rehabilitation Exam
ò Gait analysis tools ò Stance analyzer
ò Kinematic analysis system
ò Temporal analysis system
ò Set goals ò Pain management
ò Rehab Plan
ò Patient compliance
ò Owner compliance and finances
ò Owner expectations
Formulate a Treatment Plan Hip Dysplasia or OA
Common findings:
ò Tenderness or pain
ò Decreased ROM
ò Atrophy
ò Slow rise, hip sway, “bunny” hop
ò “tight skirt” syndrome
ò Overactive or decreased flexibility of pectineus and iliopsoas m
ò Using the forelimbs to pull themselves into the standing position
ò Presentation
ò Painful on hip extension +/- LS pain
ò Reduced hip ROM
ò Reluctant to go up stairs, jump on furniture or into car
ò Difficult/slow to rise/lie down
ò Bunny hop gait
ò Lameness worse after exercise
ò Diagnosis
ò Positive Ortolani sign
ò Radiographs
Treatment goals
ò Decrease pain
ò Maintain/improve ROM
ò Increase muscle mass and strength
ò Decrease hypertonicity of pectineus and iliopsoas
ò Increase flexibility of iliopsoas and pectineus
ò Improve core stabilization
ò Manage weight
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Hip Dysplasia or OA
Treatment goals
ò Decrease pain
ò Maintain/improve ROM
ò Increase muscle mass and strength
ò Decrease hypertonicity of pectineus and iliopsoas
ò Increase flexibility of iliopsoas and pectineus
ò Improve core stabilization
ò Manage weight
ò Pain management
ò NSAIDs, Gabapentin, Tramadol, etc
ò Acupuncture, Laser, US, Adequan
ò Massage: adductors, iliopsoas, lumbar spine, shoulders
ò Ice: acute injury, post-op, after exercise
ò Heat: chronic injury, before exercise
ò Stretching: hip, pectineus, iliopsoas, quads
ò Joint Mobilization: traction, compression, gliding
ò OFA, glucosamine, chondroitin, MSM, HA, GLM, protandim
Hip Dysplasia Treatment Plan
compression
Non-slip Floor
ò Ground
ò Grass
ò Carpet
ò Sand
ò Mat
IMPORTANT!! We should first realize the larger picture. Dogs walk on their toes like a horse, not on their pads or the “soles” of their feet like a human. So this puts weight dispersion and balance of the dog’s entire mass on a very small center of impact absorption (especially if they are also overweight). If they feel pain in a toe or a nail, they will then have to rock back on their heels and extend the ligaments of their larger pad and the back of their ankles to try to ease the pain in their toes. This puts them at a tremendous risk of injuring their ankles, elbows, hocks, shoulder and hips, as well as their connective tissues such as ACLs. Everything in one’s musculoskeletal system is connected with every other part of the body. Overgrown nails are also one of the leading causes of obesity. Left: proper nail length allows dog to stand on its toes Right: overgrown nails causing lengthening of toes and pain So, simple overgrown nails can be the root of not only much discomfort, but much financial expense in the long run… We as people can address to our own needs and vocalize when we have pain to someone who can help. For dogs, they rely on their caregivers to take notice and give them relief. So, it is my belief that proper care and maintenance of a dog’s toenails is one of the most important jobs and skills a groomer needs to have.
Extended & lengthened
• Pain • Weight distribution • Physical issues
Harness
Comfortable Sturdy
Good ROM Easy to put on
• Premier Sure Fit Harness • Four Paws Safety Seat Harness
Hip Dysplasia or OA
Physical Therapy
ò Sit-to- stands
ò Cavaletti rails / weave poles
ò Balancing board
ò UWTM vs. swimming
ò G. trochanter or stifle level
ò Steps/stairs, walking up hill
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Hip Dysplasia or OA
Home Exercises:
ò Ice or Heat
ò Slow walking
ò Stretching:
ò flexion, extension, abduction ò Cookie stretch
ò Swaying/Shifting
ò Stepping
ò Sit-to-Stand
ò Swimming?
The Forgotten – Iliopsoas Muscle
ò Often under-diagnosed
ò Origin at L2-L7, insert at lesser trochanter
ò Primary or Secondary
ò Signs similar to hip problems
ò No pain on hip joint palpation (X-ray normal)
ò Hip become painful when extend the hip
ò Dx: Iliopsoas Exam, US or MRI
ò If hip pain not better on NSAID, think ILIOP!
General health Concurrent problems
Primary problem
Functions: • Flex • Adduct • External rotate • Core stabilization
Kent Allen: “In the absence of a diagnosis,
Surgery is trauma, Medicine is poison, and
Alternative Therapy is witchcraft.
Iliopsoas O: Transverse processes of the second and third lumbar vertebra and by means of the ventral aponeurosis to the third and fourth lumbar vertebrae, and finally on the ventral and lateral surfaces of the fourth to seventh lumbar vertebrae. I: Along with the iliacus muscle to the lesser trochanter of the femur. A: To draw the pelvic limb forward by flexion of the hip joint; when the femur is fixed in position, flexion and fixation of the vertebral column; when the leg is extended backward, it draws the trunk backward. N: Branches of the rami ventrales of the lumbar nerve.
Iliopsoas Exam
General health Concurrent problems
Primary problem
Kent Allen: “In the absence of a diagnosis,
Surgery is trauma, Medicine is poison, and
Alternative Therapy is witchcraft.
• Abduct, internal rotate, extend the hip
• Palpate it’s origin (L2-L7) and insertion (lesser trochanter)
• Compare both sides
Iliopsoas Muscle Strain
ò Treatment
ò Conservative!
ò Pain meds not always helping
ò Add muscle relaxant
ò Rehab is similar to CHD
ò Lots of acupuncture + US + stretch
ò Take longer time to recover (>8wks)
ò May consider tenectomy
General health Concurrent problems
Primary problem
Kent Allen: “In the absence of a diagnosis,
Surgery is trauma, Medicine is poison, and
Alternative Therapy is witchcraft.
Cranial Cruciate Ligament Rupture
Common findings:
ò Grade I-II sprain (partial tear) vs. Grade III (complete tear)
ò NWB–PWB gait
ò Abnormal sitting posture
ò Swelling in stifle
ò + cranial drawer ± cranial tibial thrust test
ò Painful at end range stifle flexion and extension
ò Meniscal “click”
ò Muscle atrophy in affected disuse limb
ò Presentation
ò Either acute or gradual onset of lameness
ò Intermittent to non-weight bearing lameness
ò Medial buttress if chronic
ò Spastic and painful sartorius and quadriceps
ò Atrophied hamstrings
ò +/- Referred back pain
ò Diagnosis
ò Cranial drawer and tibial thrust
ò Radiographs
Cranial Cruciate Ligament Rupture
Treatment goals:
ò Decrease pain and swelling
ò Normalize ROM
ò Normalize flexibility
ò Achieve FWB gait
ò Strengthen quadriceps, hamstrings, gluteals
ò Promote core stabilization
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ò Pain management
ò Acupuncture, Adequan, NSAIDs, tramadol
ò No running, jumping, or quick side turns
ò Massage
ò Quads, hamstrings, sartorius
ò Exercises
ò Leash walks
ò Sit to stands
ò 3 leg stance (2 leg stance if bilateral CCRL)
ò Steps/stairs
ò Walking up hill
ò Walking in sand/shallow water or UWTM
CCLR Treatment Plan
Grade I or II sprains:
ò Pain management
ò NSAIDs, Tramadol, Gabapentin
ò Acupuncture, Laser, US, Adequan
ò Rest and No running, jumping, or quick side turns
ò Ice or Heat
ò PROM: until WB
ò Massage and Stretching: quads, hamstrings, sartorius
ò Joint Mobilization: traction, compression, gliding
ò Start physical exercises once pain and inflammation are relieved
Grade III sprains (complete tears): ò Pot Pain management
ò Acupuncture, Adequan, NSAIDs, tramadol
ò No running, jumping, or quick side turns
ò Massage ò Quads, hamstrings, sartorius
ò Exercises
ò Leash walks
ò Sit to stands
ò 3 leg stance (2 leg stance if bilateral CCRL)
ò Steps/stairs
ò Walking up hill
ò Walking in sand/shallow water or UWTM
CCLR Treatment Plan
Grade III sprains:
ò Post-Op pain management
ò NSAIDs, Tramadol, Gabapentin
ò Acupuncture, Laser, US, Adequan
ò Rest and No running, jumping, or quick side turns
ò Ice or Heat
ò PROM: until WB
ò Massage and Stretching: quads, hamstrings, sartorius
ò Joint Mobilization: traction, compression, gliding
ò Start physical exercises once pain and inflammation are relieved
CCLR Treatment Plan
Physical Exercises (non-surgical and 2-4 weeks postop)
ò Balancing board
ò Cavaletti rails / weave poles
ò Sit-to- stands
ò UWTM (stifle level) – Postop: not until suture removed
ò 3 legged standing (PWB or FWB)
ò Steps/stairs, walking up hill (>4 week)
ò Brace? Orthopet, Animalorthocare
CCLR Treatment Plan
Home Exercises:
ò Ice or Heat
ò Slow walking (2-3 months)
ò Stretching:
ò Flexion, extension, abduction
ò Cookie stretch at shoulder, hip, toe
ò Swaying/Shifting
ò Stepping
ò Sit-to-Stand
Common Neurological Conditions Affect Hindlimb
ò Spondylosis, IVDD, trauma, cancer, DM, FCE, Wobbler’s
ò Pain
ò Slow or unable to rise
ò Using the forelimbs to pull themselves up
ò Delayed or absent CP
ò Muscle atrophy
ò Pressure sores
ò Incontinences
ò UTI
ò Loss deep pain
Anxiety
Neurological Disorders
Treatment goals:
ò Decrease pain
ò Improve nerve function
ò Maintain/improve joint health
ò Prevent muscle loss
ò Improve muscle tone & strength
ò Increase proprioception
ò Treat anxiety!
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ò Pain management – steroids/NSAIDs, tramadol, gabapentin, etc
ò Acupuncture – relieve pain, regenerate nerves
ò Laser – relieve pain, reduce swollen, wound healing
ò Cage rest (6-8 weeks)
ò No running or jumping
ò Cold or Heat
ò NMES – prevent muscle atrophy
IVDD Treatment Plan Rehab
ò Acupuncture – relieve pain, regenerate nerves
ò Laser – relieve pain, reduce swollen
ò Heat or Cold
ò PROM – maintain joint health
ò Joint compressions – improve propioception
ò NMES – prevent muscle atrophy
ò Foot protection, sling/harness
ò Physical Exercises
ò Massage – paraspinal muscles and limbs
ò PROM and toe pinches
ò Ear scratches
ò Joint compressions – improve proprioception
ò Assisted standing
ò Assisted sit to stands
ò UWTM : 2 weeks after injury/postop
IVDD Treatment Plan Rehab
ò Acupuncture – relieve pain, regenerate nerves
ò Laser – relieve pain, reduce swollen
ò Heat or Cold
ò PROM – maintain joint health
ò Joint compressions – improve propioception
ò NMES – prevent muscle atrophy
Assisted Standing
ò After injury or postop
ò Sling is good, BUT…
• Core strength • Useful in stretching • Body weight support
• Strengthen hip and stifle extensors and start re-educating muscles needed for balance and proprioception
• Often improve attitude
• Assistive devices such as slings, physioRolls, wheel- chairs, or Hoyer lifts
• Only on a non-slip or textured surface
• Static standing and sit-to-stand exercises.
canineexercise.com
A good time to correct the stance is meal times. Although the patient is occupied with eating,
gently correct the stance to a normal position (Figure 34-2). Repeat this as needed to maintain
a proper stance.
Underwater Treadmill
ò Great for non-ambulatory paraparesis or paralysis
ò G. Trochanter level, then stifle level
ò Helps with gait re-training and proprioception
IVDD Treatment Plan
Home Exercises:
ò PROM & Massage
ò Slow walking
ò Stretching:
ò cookie stretch to shoulder, hip and toe
ò Swaying/Shifting
ò Stepping
ò Sit-to-Stand
PROVIDE ASSISTANCE IF
NEEDED
Toe Up Sling
ò Dorsiflexion assist
ò Felicitate cranial swing
ò Proprioceptive input/stimulation
ò IVDD, Spondylosis, FCE, DM
Orthopet
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Wheelchairs
ò Ideal for certain patients…maybe not large dogs
ò Most dogs that end up in cart are “end-stage” CAREFUL!
ò MUCH more work than you expect…
ò Measurements and fitting are important!
ò Can get into trouble loose in a cart!!
Active Therapeutic Exercises
ò No one exercise fits all!
ò Exercise should be PAIN FREE
ò Good TRACTION floor!
ò Choose only 2-4 exercises per session, BID-TID
ò Doing all exercises may result in lameness and pain
ò Rate of progression is based on response and progress
If the patient appears to have increased stiffness, lameness,
or pain after a therapy session, the activity level may need to be
decreased The rehabilitation program
should proceed with the patient being as pain free as possible
Summary
ò Growing specialty
ò Benefit any MSK or neurological in hindlimb
ò Goals: ò Pain relieve
ò Minimize disuse changes
ò Return to normal activities
ò Multi-modalities
ò Individualized treatment - No one size fits all
ò 5‘S’ home exercises
ò Should see improvements every week
Question ?