3. rehabilitation in hindlimb - lvmaò nsaids, tramadol, gabapentin ò ò acupuncture, laser, us,...

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Rehabilitation in Hindlimb Conditions What’s all the fuss about?

Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT

[email protected]

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


Primary problem



internal rotation










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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


Primary problem



internal rotation










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!


Primary problem

Functions: •  Flex •  Adduct •  External rotate •  Core stabilization




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


Primary problem




•  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


Primary problem




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  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  NSAIDs, Tramadol, Gabapentin


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  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  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  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  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  Laser – relieve pain, reduce swollen

ò  Heat or Cold

ò  PROM – maintain joint health

ò  Joint compressions – improve propioception


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  Laser – relieve pain, reduce swollen

ò  Heat or Cold

ò  PROM – maintain joint health

ò  Joint compressions – improve propioception


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, wheelchairs, 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  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 ?

[email protected]

3. rehabilitation in hindlimb - lvmaò nsaids, tramadol, gabapentin ò ò acupuncture, laser, us,...

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