Download 3. Rehabilitation in Hindlimb.pptx

Overview
Rehabilitation in
Hindlimb Conditions
1.  Introduction to Rehabilitation
for Hindlimb
What’s 2. 
all Goals
the fuss
about? Rehab
3.  Rehab Exam in Hindlimb
4.  Objective Outcome Measurements
Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT
[email protected]
5.  Rehab Plan:
ò  CHD, Iliopsoas, CCLR, IVDD
Assistant Professor, Integrative Medicine
School of Veterinary Medicine
Louisianan State University
Rehabilitation
ò  Goals of rehabilitation are:
ò  To restore, maintain and promote optimal function,
fitness, wellness and quality of life as they relate to
disorders and
general physical
ò  “Physical Therapy”movement
and “Physiotherapy”
are protected
terms health.
ò  Growing specialty in vet med
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  Physical exam
: “In the absence of a
diagnosis,
s trauma, Medicine is
poison, and
Alternative Therapy is
witchcraft.
ò  Orthopedic exam
ò  Neurologic exam
ò  Rehabilitation exam
ò  Diagnostic imaging
DIAGNOSIS!!
Veterinarians
ò  Pain relieve and maximize function
Veterinary Technicians
ò Physical
Rehab techniques
address the following conditions:
Therapists
Physical Therapist Assistants
ò  Pain and inflammation
Occupational Therapists
ò  ofHypomobility
or hypermobility
Students in one
the accepted
professions*
ò  Flexibility
in 2010
What is involved?
General health
Concurrent problems
Primary problem
ò  CHD, CCL, MPL, OA, tendinopathy, IVDD, DM
ò  Weakness
ò  Approved
ò  ABVS
Muscle atrophy
by
ò  All rehab patients need to be evaluated
by a veterinarian
ò  Assessment of the patient
Rehabilitation in Hindlimb
Ortho Exam Tips – DO
ò  Put on your detective hat
Ask in
clients
provide video
Dogs withò OCD
the to
shoulder
jointò willTake
have
pain
when:
General health
rectal temp after exam
A. extend the shoulder
Concurrent problems
ò  shoulder
Use treats with some
B. flex the
Primary problem
internal
rotation
ò  Evaluate
functional
mobility and transitions
Kent Allen: “In the absence of a
ò  Dotendonsynovitis:
exam on good grip floor
Check
for
bicep
diagnosis,
shoulder,
extend
Surgery is trauma, Medicine is Flex theò 
Leave theand
“limb
of interest” for last
poison, andthe elbow, this would cause full
ò  Leave the feet for last but DON’T forget
tension to the biceps as it
Alternative Therapy is
crosses the humerus and
witchcraft.
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 .
Dogs with OCD in th
joint will have p
A. extend th
B. flex the shoulder
intern
Check for bicep tendo
Flex the shoulder, a
the elbow, this would
tension to the b
crosses the hum
inserted at th
ante
If pain is noted, go
palpated the region
groove where the b
along it ( just me
greater tubercle), loo
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Ortho Exam Tips – DON’T
ò  Soft tissue palpation
•  Do exam on a stainless-steel table
•  Forget the soft tissues
General health
Concurrent problems
Primary problem
: “In the absence of a
diagnosis,
s trauma, Medicine is
poison, and
Alternative Therapy is
witchcraft.
Rehabilitation Exam
•  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
Dogs withò 
OCD
in the shoulder
Goniometer
joint willò have
painjoint
when:
Measures
angles
A. extend
the shoulder
ò  Compare both sides
B. flex the shoulder with some
internal rotation
ò  Gulick:
ò  Specialized tape (4oz tension)
Check for bicep tendonsynovitis:
ò  Measures muscle girth
Flex the shoulder, and extend
ò  would
High up
in the full
thigh,
the elbow, this
cause
cross tape at greater trochanter
tension to the biceps as it
ò  Compare both sides
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 .
Rehabilitation Exam
ò  Stance
ò  Gait
ò  Walk, Trot, Pace, Gallop
Formulate
a Treatment Plan
ò  Presentation
ò  Radiographs
Hip Dysplasia or OA
+/- LS pain
ò  Set goals
ò  Reduced hip ROM
ò  Pain management
ò  Reluctant to go up stairs, jump on furniture or into car
ò  Rehab Plan
ò  Difficult/slow to rise/lie down
ò ò Patient
compliance
Bunny hop gait
ò ò Owner
compliance
andexercise
finances
Lameness
worse after
Owner expectations
ò ò Diagnosis
ò  Positive Ortolani sign
Rehabilitation Exam
This may actually be an
adaptation for herding; having
Gait
analysis tools
this type ofò rear
conformation
is
Stance improved
analyzer
thought toò 
provide
ò  lying
Kinematic
analysis
stability for
down
and system
standing up ò 
andTemporal
to reduce
the system
analysis
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.
ò Gait Analysis
ò  Painful on hip extension
Some breeds, particularly herding breeds, have
pelvic limbs with internally rotated tarsi,
sometimes referred to as being “cow hocked.”
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
Treatment goals
ò  Decrease pain
ò  Maintain/improve
ò  Increase muscle m
ò  Decrease hyperton
ò  Increase flexibility
ò  Improve core stabi
ò  Manage weight
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Hip Dysplasia or OA
Hip Dysplasia Treatment Plan
ò  Pain management
Treatment goals
ò  NSAIDs, Gabapentin, Tramadol, etc
ò  Decrease pain
ò  Acupuncture, Laser, US, Adequan
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  Massage: adductors, iliopsoas, lumbar spine, shoulders
ò  Ice: acute injury, post-op, after exercise
ò  Heat: chronic injury, before exercise
compression
ò  Stretching: hip, pectineus, iliopsoas, quads
ò  Joint Mobilization: traction, compression, gliding
ò  OFA, glucosamine, chondroitin, MSM, HA, GLM, protandim
Non-slip Floor
IMPORTANT!!
We should first realize the lar
not on their pads or the “sole
dispersion and balance of the
impact absorption (especially
toe or a nail, they will then ha
ligaments of their larger pad
in their toes. This puts them a
elbows, hocks, shoulder and
ACLs. Everything in one’s mu
other part of the body. Overg
obesity.
ò  Ground
ò  Grass
ò  Carpet
ò  Sand
ò  Mat
•  Pain
•  Weight distribution
•  Physical issues
Left: proper nail length allows
Right: overgrown nails causin
overgrown nails can be the ro
expense in the long run… We
vocalize when we have pain
their caregivers to take notice
proper care and maintenance
jobs and skills a groomer nee
Extended & lengthened
Harness
Comfortable
Sturdy
Good ROM
Easy to put on
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
•  Premier Sure Fit Harness
•  Four Paws Safety Seat Harness
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Hip Dysplasia or OA
Home Exercises:
ò  Often under-diagnosed
ò  Ice or Heat
ò  Origin at L2-L7, insert at lesser trochanter
General health
Concurrent problems
Primary problem
ò  Slow walking
ò  Stretching:
ò  flexion, extension, abduction
ò  Cookie stretch
ò  Swaying/Shifting
ò  Stepping
ò  Sit-to-Stand
ò  Swimming?
Kent Allen: “In the absence of a
diagnosis,
Surgery is trauma, Medicine is
poison, and
Alternative Therapy is
witchcraft.
Iliopsoas Exam
ness
meness
driceps
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!
ò  Conservative!
•  Compare both sides
ò  Pain meds not always helping
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
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
Cranial Cruciate Ligament Rupture
Common findings:
Treatment goals:
ò  Grade I-II sprain (partial tear) vs. Grade III (complete tear)
ò  Decrease pain and swelling
ò  NWB–PWB gait
ò  Normalize ROM
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”
Functions:
•  Flex
•  Adduct
•  External rotate
•  Core stabilization
ò  Treatment
•  Palpate it’s origin (L2-L7) and insertion (lesser trochanter)
: “In the absence of a
diagnosis,
s trauma, Medicine is
poison, and
Alternative Therapy is
witchcraft.
Iliopsoas
O: Transverse processes of the second a
vertebra and by means of the ventral apo
and fourth lumbar vertebrae, and finally o
surfaces of the fourth to seventh lumbar
I: Along with the iliacus muscle to the les
femur.
A: To draw the pelvic limb forward by flex
when the femur is fixed in position, flexio
vertebral column; when the leg is extend
the trunk backward.
N: Branches of the rami ventrales of the
Iliopsoas Muscle Strain
•  Abduct, internal rotate, extend the hip
General health
Concurrent problems
Primary problem
The Forgotten – Iliopsoas Muscle
ò  Normalize flexibility
ò  Achieve FWB gait
ò  Strengthen quadriceps, hamstrings, gluteals
ò  Promote core stabilization
ò  Muscle atrophy in affected disuse limb
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CCLR Treatment Plan
Grade I or II sprains:
CCLR Treatment Plan
ò 
Pain management
ò 
ò  Post-Op
management
No running,
jumping,pain
or quick
side turns
ò 
ò  NSAIDs, Tramadol, Gabapentin
Massage
ò  Acupuncture, Laser, US, Adequan
ò 
ò  Pain management
ò  NSAIDs, Tramadol, Gabapentin
ò  Acupuncture, Laser, US, Adequan
ò 
ò  Rest and No running, jumping, or quick side turns
Grade III sprains (complete te
Grade III sprains:
Acupuncture, Adequan, NSAIDs, tramadol
ò  Ice or Heat
ò 
ò  walks
Ice or
Leash
ò  PROM: until WB
ò 
Sit
ò to stands
PROM:
ò  Massage and Stretching: quads, hamstrings, sartorius
ò 
ò  Massage
Steps/stairs
ò 
Walking
up hillMobilization:
ò  Joint
ò  Joint Mobilization: traction, compression, gliding
ò  Start physical exercises once pain and inflammation are relieved
CCLR Treatment Plan
ò 
Heat
until WB
3 leg stance (2 leg stance if bilateral CCRL)
and Stretching: quads, hamstrings, sartorius
traction, compression, gliding
Walking in sand/shallow water or UWTM
Pot Pain management
ò 
ò 
ò 
Quads, hamstrings, sartorius
ò  Rest and No running, jumping, or quick side turns
ò  Exercises
ò 
ò 
Massage
ò 
ò 
Acupuncture, Adequan, N
No running, jumping, or qui
Quads, hamstrings, sartori
Exercises
ò 
Leash walks
ò 
Sit to stands
ò 
3 leg stance (2 leg stance if
ò 
Steps/stairs
ò 
Walking up hill
ò 
Walking in sand/shallow w
ò  Start physical exercises once pain and inflammation are relieved
CCLR Treatment Plan
Physical Exercises (non-surgical and 2-4 weeks postop)
Home Exercises:
ò  Balancing board
ò  Ice or Heat
ò  Cavaletti rails / weave poles
ò  Slow walking (2-3 months)
ò  Sit-to- stands
ò  Stretching:
ò  Flexion, extension, abduction
ò  UWTM (stifle level) – Postop: not until suture removed
ò  Cookie stretch at shoulder, hip, toe
ò  3 legged standing (PWB or FWB)
ò  Swaying/Shifting
ò  Steps/stairs, walking up hill (>4 week)
ò  Stepping
ò  Brace? Orthopet, Animalorthocare
ò  Sit-to-Stand
Common Neurological Conditions
Affect Hindlimb
ò  Spondylosis, IVDD, trauma, cancer, DM, FCE, Wobbler’s
ò  Pain
ò  Improve nerve function
ò  Using the forelimbs to pull themselves up
ò  Muscle atrophy
Treatment goals:
ò  Decrease pain
ò  Slow or unable to rise
ò  Delayed or absent CP
Neurological Disorders
ò  Maintain/improve joint health
Anxiety
ò  Prevent muscle loss
ò  Pressure sores
ò  Improve muscle tone & strength
ò  Incontinences
ò  Increase proprioception
ò  UTI
ò  Loss deep pain
ò  Treat anxiety!
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nsors and start rebalance and
IVDD Treatment Plan
IVDD Treatment Plan
Rehab
ò  Pain management – steroids/NSAIDs, tramadol, gabapentin, etc
ò  Foot protection, sling/harness
ò  Acupuncture – relie
ò  Laser – relieve pain, reduce swollen
ò  Massage – paraspinal muscles and limbs
ò  Heat or Cold
ò  PROM and toe pinches
ò  PROM – maintain joint health
ò  Ear scratches
ò  Laser – relieve pain
ò  Joint compressions
– improve propioception
ò  Joint compressions
– improve proprioception
ò  Joint compressions
Assisted
standing
ò  NMES –ò prevent
muscle
atrophy
ò  NMES – prevent m
ò  Physical Exercises
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
Rehab
ò  Acupuncture – relieve pain, regenerate nerves
ò  Heat or Cold
ò  PROM – maintain j
ò  Assisted sit to stands
ò  UWTM : 2 weeks after injury/postop
Assisted Standing
Underwater Treadmill
ò  Great for non-ambulatory paraparesis or paralysis
ò  After injury or postop
ò  G. Trochanter level, then stifle level
ò  Sling is good, BUT…
ò  Helps with gait re-training and proprioception
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.
gs, physioRolls,
d surface
d exercises.
canineexercise.com
•  Core strength
•  Useful in stretching
•  Body weight support
IVDD Treatment Plan
Toe Up Sling
ò  Dorsiflexion assist
Home Exercises:
ò  Felicitate cranial swing
ò  PROM & Massage
ò  Proprioceptive input/stimulation
ò  Slow walking
ò  IVDD, Spondylosis, FCE, DM
ò  Stretching:
ò  cookie stretch to shoulder, hip and toe
ò  Swaying/Shifting
ò  Stepping
ò  Sit-to-Stand
PROVIDE
ASSISTANCE IF
NEEDED
Orthopet
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Wheelchairs
Active Therapeutic Exercises
ò  Ideal for certain patients…maybe not large dogs
ò  No one exercise fits all!
ò  Most dogs that end up in cart are “end-stage” CAREFUL!
ò  Exercise should be PAIN FREE
If the patient appears to have
ò  MUCH more work than you expect… increased stiffness, lameness,
or pain after a therapy session,
ò  Measurements and fitting are important!
the activity level may need to be
decreased
ò  Can get into trouble loose in a cart!!
The rehabilitation program
should proceed with the patient
being as pain free as possible
Summary
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
Question ?
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
[email protected]
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