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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 1 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 2 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 3 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 4 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! 5 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 6 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] 7