Canine IV Packet

Dear Canine IV participant:

We hope you are looking forward to the upcoming Canine IV course as much as we are. We have prepared an exciting, stimulating and informative course.

As you are aware, the course is designed to assist in the development of skills necessary to design and implement a comprehensive rehabilitation program for dogs with commonly seen orthopedic and neurologic conditions. A problem-based learning approach will be used to facilitate the learning process and foster interaction with instructors and participants. You will work hard, probably be tired at the end, and will do most of the problem solving while interacting with others.

The success of problem-based learning is based on the interaction of participants with each other to work through a series of learning issues associated with actual cases. Each group will have members with various backgrounds and professional affiliations. Please take advantage of each member’s professional training and strengths. A number of cases will be presented that have unique needs regarding physical rehabilitation. For each case, all participants will be briefed regarding the case. Participants will then separate into their individual groups to further discuss the case. Groups may wish to have members volunteer for various duties, including a reader, a recorder, a process person to be certain that the group stays on task and does not stray too far from the issues at hand (although some free-flow of thoughts is encouraged), and a group spokesperson. Flip charts, markers, and tape will be provided for taking notes. Specific items that groups may wish to consider writing on the charts are 1) known facts regarding the case, 2) additional information that the group would like to know regarding the case, 3) learning issues to review, 4) ideas and plans, 5) any other “brainstorming” thoughts. Groups will have between 30 and 60 minutes to discuss and work through each case (this sounds like a lot of time, but it really isn’t because participants will need to discuss some specific material to address the learning issues). At the end of that time, all of the groups will convene and the spokesperson of each group may be asked to present their group’s findings, answer the questions, or to add additional thoughts to another group’s responses. The instructors will also emphasize certain points, review important concepts, and summarize the main issues regarding each case.

We are providing you with the general topics for the cases that will be presented. It is important that you take some time prior to the course to review the cases and begin thinking of various rehabilitation considerations, goals, and ideas. Other information, Protocol Development and a Sample Elbow Fracture case (#7), are included to help guide the process of problem solving. In addition, we would like you to bring your previous course notes, and any other books or study guides that you feel may be beneficial.

We look forward to seeing you!

Sincerely,

Denis Marcellin-Little, DVM, DACVSMR, DACVS, CCRP David Levine, PT, PhD, DPT, CCRP Deborah Gross Torraca, DPT, MSPT, OCS, CCRP, Board-Certified Orthopedic Clinical Specialist Emeritus Darryl Millis, MS, DVM, DACVSMR, DAVCS, CCRP

Canine IV Course Problem Based Learning Exercises

Schedule - Day One

1:00-5:00 Case 1, Case 2, Case 3A and B

Day Two

8:30 - 5:00 Case 4, Case 5a, 5b, 5c, Case 6

General Topics for Cases These are provided to give you a basis for review of material prior to the course. Questions follow each case to guide the case study. Case 7, attached at the end of this packet is a guide for case study and review.

Case 1 Older patient with multiple arthritic joints Examine aquatic therapy, home care, pharmacological management, nutraceuticals, and rehabilitation plan

Case 2 Intervertebral Disk Disease Examine management of the down dog, lower motor neuron conditions, upper motor neuron conditions, rehabilitation plan

Case 3 Puppy with fracture Examine differences in healing between mature animals and those with open growth plates, joint contracture and its management, therapeutic ultrasound, common fracture fixation techniques, prevention of joint immobility, encouraging use of limb, ethical issues regarding certain fracture treatments, bandaging and splinting, rehabilitation plan

Case 4 Rehabilitation business start-up Examine: Equipment and facilities -- how to get started Set up professional staff – who and how to hire, roles of various members, day-to-day activities Approach other practices regarding referrals, professional communication, marketing, fee generation

Case 5 Cranial cruciate ligament rupture Examine pathophysiology, risk factors, differences between human and canine cruciate rupture, perioperative considerations, neuromuscular electrical stimulation, therapeutic exercises, different surgical techniques and how these may affect a postoperative rehabilitation program, rehabilitation plan.

Case 6 Bilateral pelvic fractures with hip luxation and radial nerve paralysis - with complications Examine management of the recovering recumbent dog, various fracture fixation techniques for pelvic fractures, combined surgical and rehabilitation management of difficult patients, neurological assessment, orthopedic assessment, balancing and proprioception activities, functional neuromuscular electrical stimulation, rehabilitation plan.

Case 1

Maggie

Signalment: 11 year-old female spayed Golden Retriever

Chief Complaint: Bilateral Stifle Degenerative Joint Disease, worse in Left

History:

Had medially luxating patella noted at 6 months of age. Had extensive surgical correction on both stifles in Texas at about 1 year of age. Had 2 surgeries performed on both stifle joints.

12/08 Receiving carpprofen (Rimadyl) for lameness

3/08 Owner concerned about Rimadyl; chemistry panel performed. ALT slightly elevated Rimadyl discontinued, began Cosequin (orally) and Adequan injections, 1 cc IM weekly

7/08 Diagnosed with hypothyroidism, began on Soloxine

11/08 Limping badly in LH, owner gave Aspirin buffered in Maddox Limping severely, radiographs taken at that time; indicated severe DJD of both stifles, hardware seen from previous surgery, possible avulsion fracture of left patella. Nonweight-bearing lameness of LH, painful with stifle flexion, stifle is thickened, no cranial drawer palpated. Does not warm out of lameness. 11/08 Consultation with a surgeon indicated possible lysis in the joint, but patella is intact. Begin NSAID for 2 weeks Increased Adequan frequency

1/08 Began therapeutic laser treatments 3 times per week

1/08 Owner feels laser treatments helping. Will walk on LH, but intermittently nonweight-bearing. Also on Glycoflex, Adequan twice weekly.

2/08 Will walk briefly after laser on limb, but then holds it up again after treatment. Vomited while on etodolac (Etogesic), discontinued. Refer for rehabilitation.

3/08 Presented to UTCVM

Physical Examination Findings 85 lbs

Erythematous ears

Abdomen: Cystic fluid filled mass in L inguinal area, which RDVM has previously drained and performed cytology

M-S L stifle- severe crepitus, very little flexion of stifle, painful R stifle - flexes slightly more, crepitus, but less than R stifle Weight shift toward the front (camped under posture)

Radiographs R stifle Extensive subchondral erosions associated with femoropatellar and femorotibial joint spaces. Articular margins are markedly irregular. Mineral dense opacities associated with the distal aspect of the patella. Pin and wire seen in tibial crest. Osteophytes of the tibial plateau, fabellae, and medial and lateral femoral condyles. Intracapsular increased soft tissue opacity suggestive of joint effusion or fibrosis.

L stifle Marked articular irregularity of the femorotibial and femoropatellar joint spaces. Bony fragment in the cranial aspect of the L stifle which appears to be part of the tibial crest. Muscle atrophy of the quadriceps muscles.

Diagnostic Impression: Severe and advanced DJD of both stifle joints. Marked muscle atrophy of thigh muscles.

Plan

Owner not interested in more surgery unless has an excellent chance of helping. PT evaluation, initiate PT

Rehabilitation Evaluation ROM R Stifle 145° ext, 70° flex, R hock 165° ext 85° flex L Stifle 130° ext, 65° flex, L hock 165° ext 75° flex

Thigh circumference L 32 cm R 36 cm

Lameness more obvious on L than R, L limb internally rotates during gait Both rear limb quiver and shake with standing, L worse than R

Force Plate Evaluations

Static Trot LH RH LH RH 3/28 11.9% 26.7% Would not trot

4/16 11.8% 26.9% Would not trot

5/9 17.2% 24.4% Would not trot

6/11 12.9% 23% 55.3% 67.8%

7/26 17.4% 22.8% 60.3% 67.6%

9/10 14.4% 26.9% 71.1% 71.9%

1. What treatment considerations do you have regarding Maggie?

2. What are common medications for treating osteoarthritis? What are common side effects of some of these medications?

3. What are some common nutraceuticals that are used? How beneficial are they?

4. What therapeutic modalities will you consider?

5. Discuss aquatic therapy. What are the main principles of aquatic therapy? What would your plan be for the use of aquatic therapy in Maggie?

6. What will your specific rehabilitation plan be? Consider time of trt, frequency of trt, reps, etc. of all of the treatments you would consider.

7. What will you re-evaluate on Maggie, and how often?

8. What criteria will you use to increase, or decrease, activity level?

9. What will you instruct the owner to do at home? Are there any specific instructions you would give the owner regarding Maggie's care at home?

10. What medications or other treatments will you recommend?

11. What are your goals for Maggie?

12. What prognosis will you give the owner for Maggie?

After discussing this case, all groups will reconvene and discuss the various aspects of this case. Then we'll hear... the rest of Maggie's story.

Case 2 Scooter Signalment: 12 year old neutered male Daschund . Chief Complaint: August 2014: acute onset of severe pain Conscious proprioception and motor present on right hind Complete loss of conscious proprioception, motor present on left hind Deep pain present bilaterally History: . Chronic back pain . Mild chronic kidney disease . Overweight

Physical Examination: . Mild prolapse of C2

. Disk herniation on L1-L2, L2-L3 . Hemilaminectomy . Methadone, fentanyl patch, and carprofen for post-op pain control

Post-op Assessment: . No motor function present . Deep pain sensation present . Not able to urinate without manual assistance . Discontinued NSAIDs . Discharged with: fentanyl 25mg delivered transdermally gabapentin 100mg by mouth prazosin 1mg by mouth every 12 hours

Rehabilitation evaluation Owners: . disheartened . unable to express urinary bladder . considering euthanasia Scooter: . depressed, not eating . non-ambulatory . swelling around surgery site . deep pain . no motor function . urinary bladder was small and difficult to express . voluntary tail wagging . anal tone present . crepitus on flexion of right stifle

1. Design a rehabilitation program for the early post-operative period (first week).

2. Discuss prognosis and factors affecting the prognosis.

3. What sort of home exercise program would you begin Scooter on?

4. How will you progress the rehabilitation program over the next month, and what are precautions?

5. What will you do to help Scooter develop balance and proprioception?

6. How would you explain the return of function after the damage to the spinal cord?

7. If deep pain sensation was not present after surgery, how would it affect his prognosis and anticipated progression and outcome?

8. If you were to use ultrasound, describe the procedure including the parameters.

Case 3A

Jeb

Signalment 8-month-old female intact Labrador Retriever

Chief Complaint Hit by car, acutely nonweight-bearing in right hind limb

History Was hit by a car the evening prior to admission Patient presented in shock and was given supportive care over night

Physical Examination Findings Nonweight-bearing in right hind limb Open wound (5 mm in size) over right caudal thigh with moderate amount of hemorrhage from wound Originally had hematuria which cleared over night

Radiographs Extensive soft tissue swelling from the pelvis to the middiaphysis of the right tibia. Irregularly shaped gas opacities can be seen within the soft tissues. There is a comminuted fracture of the distal femoral physis with marked lateral and cranial displacement. The main configuration of the fracture is that of a Salter-Harris Type II fracture. There is marked overriding with the distal femoral segment lying at the level of the midfemoral diaphysis.

Plan Surgical repair consisted of an open arthrotomy with inspection of the fracture site. Hemarthrosis was present with considerable swelling of the thigh musculature. The fracture was reduced and stabilized using 4 pins placed in cross pin fashion. Swabs were taken for culture and sensitivity. The joint capsule was closed and a Jackson Pratt continuous suction drain was placed in the soft tissues and the tissues were closed.

The culture indicated 3 colonies of Enterococcus sp. and 1 colony of an unidentified Gram negative rod (not Pseudomonas). The Enterococcus was resistant to ciprofloxacin, penicillin, tetracycline, and was sensitive to vancomycin, moderately sensitive to gentamicin.

Postoperative radiographs indicated reduction of the fracture and adequate placement of the pins.

Rehabilitation Evaluation After surgery there was swelling and edema of the limb. Range of motion exercises and cold packs were initiated since the morning after surgery. Four days postoperatively, a consultation with the rehabilitation service was sought because of continued swelling and edema postoperatively and markedly decreased range of motion of the right stifle.

Initial evaluation indicated severe lameness at a walk and toe touching at a stance. The drain was still in place. Right stifle flexion was 78°, and extension was 150°. The dog was painful with stifle flexion. Moderate swelling was present in the thigh near the injury, with minimal swelling in the proximal thigh and distal tibia.

1. Review the differences in expected healing time of fractures in mature animals versus those with open growth plates. Also consider healing of surrounding tissues.

2. What considerations should be evaluated in this patient when forming the treatment plan?

3. How will you manage the edema and soft tissue swelling? Consider several different modalities.

4. How stable is this type of fracture repair?

5. What is fracture disease, what is quadriceps contracture, and over what time course do they occur? What is occurring at the tissue level? Discuss strategies to prevent this condition.

6. How will you manage the drain while doing rehabilitation?

7. What types of external coaptation devices are appropriate in the management of this fracture? What forms of external coaptation are not appropriate?

8. Discuss your SPECIFIC treatment plan for this patient.

Case 3B

Trevi

Signalment 2 year old female Italian Greyhound

Chief Complaint Poor use of limb following fracture repair

History At 2 years of age, had a fracture of the R radius and ulna on Christmas day that was treated by the RDVM with a splint. Radiographs made 2 weeks later indicated malalignment of the fracture. A figure-of-8 cerclage wire was placed surgically and a splint was applied. Removed splint 5 weeks after injury when it appeared solid, but it refractured. Placed splint again for an additional 3 months, at which time a nonunion fracture was diagnosed and the dog was referred.

Physical Examination Palpable instability at fracture site. When splint is removed, can toe-touch with the limb

Radiographs Chronic nonunion fractures of the right radius and ulna with evidence of poor bone mineralization.

Plan Surgical fixation with a bone plate, reaming of medullary canals, and placement of an autogenous cancellous bone graft.

The dog was discharged from the hospital 3 days after surgery with instructions for the owner to restrict activity to leash walks only, with confinement in between walks. The owner was also instructed to gently massage the leg and gently flex and extend her leg for a short amount of time several times each day.

Follow-up The dog returned to the hospital 1 week after surgery with an open wound over the surgical site (over the plate) as a result of licking at the incision. At that time, it was also noted that there was carpal contracture. The carpus was painful during extension, flexion was limited to 90°, and the dog was not using the leg. The dog was also noted to be timid and a bit of a “baby”.

1. Discuss the issues associated with the early management of this fracture, concentrating on the professional communication and how you might handle the communication with the RDVM. What if this case originally came to you for rehabilitation, rather than surgery? What would you do?

2. Discuss the manner of instruction of the owner to do physical therapy at home. How might this have been improved?

3. Discuss the management of joint contracture in this case.

4. Discuss the use of heat for the carpal contracture in this case. How will you apply it? If using US what frequency will you use? How will you maximize contact? How long will you treat, and what power will you use? What do you hope to accomplish? Discuss stretching and when to apply the stretch.

5. What therapeutic exercises would you recommend in this patient to encourage use of the limb, especially since it has not used the limb in 5 months?

6. What tissues have been involved with the disuse and immobilization, and how might this affect bone healing and recovery? What complications would you expect in dogs, such as Italian Greyhounds, with distal radius and ulna fractures and why?

Case 4

You have elected to enter this fascinating business of small animal physical rehabilitation. The task in this problem is to write a business plan for a rehabilitation business start-up to present to your business colleagues and the bank. You should consider:

1. Equipment and facilities -- design the facility, determine exactly what equipment you will need, what equipment would be nice to own or lease, and how much will these items cost?

2. Organize the professional staff – who to hire, how to hire them, roles of various members, how will you pay them, what will their day-to-day activities be?

3. How will you approach other practices regarding referrals, professional communication?

4. How will you market the rehabilitation practice, and who will you market to?

5. How will you determine fees, and what will you charge for services?

Case 5A Miss DJ Signalment 8 year old female spayed mixed breed dog Chief Complaint Acute nonweight-bearing lameness of the RH History Miss DJ was doing well the day prior to presentation Was out running and playing and came back holding the right rear limb up Physical Examination Findings Nonweight-bearing lameness of the right hind limb Moderate effusion of the right stifle joint Positive cranial drawer test

Radiographs Mild degenerative changes of the right stifle, including osteophytes along the medical and lateral trochlear ridges, distal patella, medical and lateral fabellae, intracapsular swelling with cranial displacement of the fat pad. Plan Surgical stabilization followed by physical rehabilitation Surgery Surgical exploration revealed a complete tear of the cranial cruciate ligament and caudal horn of the medical meniscus. Joint was debrided and a partial meniscectomy of the medical meniscus was performed. The stifle was stabilized using a modified retinacular imbrication technique

1. What, if any, presurgical evaluation will you perform?

2. What is the pathophysiology of cranial cruciate ligament rupture in the dog? Compare this to human beings.

3. What risk factors exist for cruciate disease in the dog?

4. What facts that exist in the stifle may affect the prognosis and your rehabilitation plan?

5. What are the common things that occur to tissues prior to and following CCLR surgery? Think in terms of disuse of tissues, including other ligaments, muscle, bone, joint capsule, and articular cartilage. Discuss the magnitude and timing of changes.

7. What will you do immediately post-operatively? 8. How will you assess and treat pain postoperatively? During the rehabilitation period?

9. How will you progress the animal during rehabilitation? What will you use to help guide this progress?

10. What types of evaluations will you perform and how often?

11. Discuss neuromuscular electrical stimulation and how it might be used in this case. What muscle groups will you target? Where will the electrodes be placed? How will you prepare the patient for NMES? What type of current will you use? What features are available on common NMES units? Describe the pattern of muscle fiber recruitment during NMES. How is this similar or different from a normal muscle contraction? How will you set up the machine (what settings will you use)? What are indications and contraindications to the use of NMES?

12. What therapeutic exercises will you consider using, and at what state? Are there contraindications to any particular activities?

13. When would you expect the dog to begin toe-touching? Walking with significant weight on the limbs? Trotting on the limb? Achieve near normal function?

14. What will you do if the dog does not reach the milestones regarding limb use that you set in the question above?

15. What instructions would you give the owner for home care?

16. What prognosis would you give the owner?

17. What will you expect to happen to the joint 6-12 months after the surgery? Long-term?

18. What complications are possible with post-operative cranial cruciate ligament surgery patients? How are these recognized?

19. What about the contralateral limb?

Case 5B

Signalment Male castrated dog

Chief Complaing Acute nonweight-bearing lameness of the RH

History

Physical Examinations Findings Nonweight-bearing lameness of the right hind limb Moderate effusion of the right stifle joint Positive cranial drawer test

Plan Surgical stabilization followed by physical rehabilitation

Surgery Surgical exploration revealed a complete tear of the cranial cruciate ligament and caudal horn of the medial meiscus. Joint was debrided A partial meniscectomy of the medical meniscus was performed. A tibial plateau leveling osteotomy was performed

1. How does the TPLO work to provide stability to the stifle?

2. How are the biochemical stresses altered on the periarticular tissues and how do these affect the rehabilitation program?

3. Design a SPECIFIC post-operative rehabilitation program for this patient.

4. What complications will you watch for, and how will you recognize them?

5. What are the advantages and the disadvantages of the TPLO versus the modified retinacular imbrication technique?

6. What other common techniques are used for stifle stabilization surgery for cranial cruciate ligament surgery? What specific alterations would you consider in your rehabilitation program and why? Think of the specific tissues involved and the changes in strength with tissue healing.

Case 5C

Signalment 138lb 8 year old female spayed Golden Retriever dog

Chief Complaint Chronic nonweight-bearing lameness of both rear limbs

History Has been progressively getting worse in both limbs over the past 5 months, but seemed to start and progress to a greater extent in the left rear limb. Has been virtually nonambulatory for one month prior to admission. The owners were told that the dog had spinal cord disease and was referred to a neurologist.

Physical Examination Findings Morbidly obese Unwilling to rise and support weight on the rear limbs Severe effusion of both stifle joints Positive cranial drawer test in both stifles, but does not have a great deal of laxity Has firm swelling on the medical aspect of the distal femur on both sides Becomes very winded when aided to a standing position and supported to stand Neurological evaluation is normal

Radiographs Moderate to severe degenerative changes of both stifles, including osetophytes along the medial lateral trochlear ridges, distal patella, medial and lateral fabellae, intracapsular swelling with cranial displacement of the fat pad.

1. What general medical conditions are you concerned about in this patient?

2. What nutritional concerns do you have for this patient and how will you address these with the owner?

3. Would you recommend surgery immediately in this patient? Will you recommend surgery in both stifles simultaneously? If you will stage the procedures, how long will you wait between surgeries? What type of rehabilitation program will you institute in either case?

4. How ill you manage a recumbent obese dog?

5. On the other hand, would you institute a preoperative rehabilitation plan in this case? Why or why not? What types of activities would you recommend? What will be your goals, and how will you decide when to do surgery?

Case 6

Corbin

Signalment 4 year old male castrated mixed breed dog

Chief Complaint Hit by car

History Corbin was hit by a car one day prior to admission. At that time, the dog was unable to walk and the veterinarian diagnosed multiple pelvic fractures, a right hip luxation, pneumothorax, and a broken right maxillary canine tooth. In addition, there were contusions of the right hock, right medial elbow, and left carpus. Anisocoria was present upon admission.

Physical Examination Findings Upon admission, the broken tooth and conditions were noted. The dog was not ambulatory. Pupillary light reflexes were present, although anisocoria was present. The dog had an apparent partial brachial plexus injury with no deep pain present in the left forelimb. A rectal exam indicated pelvic fractures. The dog weighed 73lbs, had a pulse rate of 140 / minute, a respiratory rate of 20 / minute , and a temperature of 100.1°F.

Radiographs Thorax A pneumothorax was present. There was a mild increase in pulmonary opacity in the right middle lung lobe consistent with pulmonary contusions. Pelvis Fractures associated with the left cranial ischium and pelvic floor were noted. In addition, there was a cranial dorsal luxation of the right coxofemoral joint.

Plan Surgical repair of the luxation was performed using a capsulorraphy and triple pelvic osteotomy technique

Rehabilitation Evaluation Physical rehabilitation was begun the day following surgery. The dog was unable to stand unassisted. In addition, the dog was painful with any movement. The dog had decreased range of motion in the right hip, a flaccid left forelimb, a urinary catheter in place, and muscle guarding with any movement including passive range of motion.

1. Which pelvic fractures should be managed surgically, and which may be managed conservatively? How are pelvic fractures commonly repaired? What are the advantages and disadvantages of managing pelvic fractures conservatively or surgically? How would you approach physical rehabilitation of patients with pelvic fractures?

2. In the case of Corbin, what additional considerations do you have?

3. What complications may occur in long-term recumbent patients? What preventative measures would you take to help reduce the risk of complications secondary to decumbency?

4. What activities would you consider in helping an animal regain strength, balance, and proprioception functioning?

5. Discuss the differences between upper motor neuron and lower motor neuron conditions. How will your rehabilitation program be altered by whether in injury is an upper motor neuron or a lower motor neuron injury? Discuss functional neuromuscular electrical stimulation and the goals for the patient.

6. What is the expected recovery time for each of the injuries that Corbin has sustained?

7. How will you balance the rehabilitation program for each of Corbin’s injuries? What precautions must you take for each injury to prevent complications? What complications might be expected and how will you monitor for them?

Complications The hip was reluxated at some point following surgery. Nine days after the initial surgical repair, the hip was restabilized using a toggle pin and a figure of 8 anti-rotational suture. Physical rehabilitation had begun the day following surgery and consisted of standing activity and whirlpool treatment. The dog was unable to stand unassisted at that time.

8. Do you feel that rehabilitation may have contributed to relaxation of the hip? What other factors have contributed to reluxation?

Following the second surgery to reduce and stabilize the hip, rehabilitation was reinstated. During the next three weeks, Corbin became increasingly improved, the right side (coxofemoral luxation side), but became more painful and the left hip region. The dog was placed on amitriptyline, an antidepressant, and carprofen for pain. He continued to have note the pain in his left forelimb and has minimal ability to bear weight on the rear limbs.

A reevaluation by the neurologist indicated monoplegia, absent reflexes, and hypotonia on the left forelimb. In addition, pain perception was absent along the radial, median, and ulnar nerve

distributions. A partial Homer’s syndrome was present in the left eye and the cutaneous trunci reflex was reduced on the left side. The left pelvic limb had intact pain perception and spinal reflexes but pain was evident on palpation of the coxofemoral joint. The assessment was a C6-T2 nerve root injury and it was felt that these deficits were likely permanent. The pain in the left pelvic region may be a result of instability of the ischial fracture site and sciatic nerve compression. Surgical exploration of this area to evaluate the nerve was recommended. This was performed to approximately one month after the initial injury.

At that time, the sciatic nerve was found to be entrapped in the decreased space between the tuber ischium and the greater trochanter. The ischium was displaced cranially as a result of the fracture. There was much fibrous tissue deep to the nerve which was displacing the nerve superficially and laterally. The entrapping tissue was removed and the tuber ischium was transposed caudally to help allow more room for the nerve. After removal of the purse string suture from the anus, a small mass just inside the rectum was noted and was removed and submitted for biopsy. The histologic diagnosis was a carcinoma in situ.

9. What is the expected recovery from pain in trauma patients following surgery? What complications may result in ongoing pain during the rehabilitation period in trauma patients?

10. What is the prognosis for Corbin?

PROTOCOL DEVELOPMENT

David Levine, PhD, PT, Diplomate ABPTS Darryl Millis, MS, DVM, Diplomate, ACVS Robert Taylor, MS, DVM, Diplomate, ACVS

A protocol is simply a treatment plan developed to reflect the rehabilitation needs of the patient. While many patients receive similar injuries and surgical repairs, slightly different needs produce changes in the protocol.

One might ask why bother with protocol development and implementation? Using an established protocol helps create standardization of treatment, allows for several people to provide the therapy and to avoid omissions to a standard treatment plan. It is vital to develop a protocol based on the nature of the injury, type of surgical repair, anticipated end result and sound knowledge of the temporal aspects of wound healing.

The following factors all influence protocol development and are discussed individually in the following text:

1. Nature of the injury 2. Type of surgical repair 3. Anticipated end result and prognosis 4. Wound healing and tissue repair 5. Equipment available 6. Personnel available and level of training 7. Patient/owner compliance

1. Nature of the Injury An acute injury will have a different protocol; there is more inflammation and tissue damage than a long-standing chronic repetitive injury.

2. Type of Surgical repair Fortunately, the surgical team has options to consider when faced with the repair of most orthopedic injuries or problems. An 8-year old Labrador retriever with a torn cranial cruciate ligament might have the knee stabilized with one of several different techniques. These may include extracapsular stabilization with large gauge polypropylene sutures, intracapsular repair using either autograft, allograft or synthetic materials, a tibial plateau leveling osteotomy (TPLO) or in some cases no surgical repair. Each of the procedures progress through wound healing differently, while influencing the stability of the knee. With an extracapsular repair, once the inflammation produced by the surgical procedure itself is resolved, the knee is stable and can undergo early rehabilitation. Intracapsu]ar auto or allografting requires stress protection

during graft incorporation.

The rehabilitation plan or protocol will be different based on the actual procedure used by the surgeon. In many cases there will be one protocol for TPLO recovery and a separate one for extracapsular stabilization. Both plans will share many aspects, but will be different based on the actual procedure.

3. Anticipated End Results and Prognosis A different protocol or treatment plan might be developed for a field trial competitor as compared with a house companion animal. One case involves rehabilitation of a competitive athlete and the other a more sedentary individual. The prognosis for a particular injury and its surgical repair is based on the surgeon’s skill, type of injury and the ability of the tissue to heal. For example: a midshaft closed tibia fracture treated with external fixation has a better prognosis for full recovery than a complete tear of the cranial cruciate ligament.

4. Wound healing and tissue repair It is vital that wound healing be optimized and that the protocol development team understand wound healing. Of equal importance is being able to integrate the temporal aspects of tissue repair into the treatment protocol. In the case of a common calcaneal tendon (Achilles) disruption three to four weeks is allowed before stress is applied to the repair. Following TPLO surgery the tibial osteotomy must heal before a great deal of muscle strengthening actually can be done.

5. Equipment Developing protocols must be done with the equipment and facilities that are available in mind. While there is more flexibility with a well-equipped facility with aquatic therapy capability, acceptable results may be obtained with minimal equipment and facilities.

6. Personnel available and level of training It is desirable to have a well-organized staff to provide appropriate physical rehabilitation services. The veterinarian must direct the care of the patient. It is highly desirable to have a physical therapist on staff, either in a day-to-day functional capacity as a primary caregiver or as a consultant to evaluate patients and direct treatment. Physical therapist assistants and veterinary technicians are also vital members of the team and will perform many of the rehabilitation activities.

7. Patient and owner handler compliance While it is difficult to provide rehabilitation to an adult polar bear it can be equally challenging to rehabilitate an aggressive chow-chow or deal with an owner-handler with unrealistic expectations or demands. In most cases a rehabilitation plan can be designed for even the most demanding patient and

client.

The Five-Step Method for Protocol Development

Using this method one will be able to develop a protocol customized to a particular patient, surgical repair and unique features of the practice and resources available.

Step 1. Develop a sense of your “statistics of repair.” If you surgically repair 10 cranial cruciate deficient knees, how do they do? Where are these patients at 1 week, 6 weeks, 12 weeks and one year? What prognosis do you offer the owner-handler? In developing Step 1 it is important to objectively evaluate the various types of orthopedic procedures you do and what is your anticipated result. While published recovery statistics of others can be useful it is important to objectively and dispassionately examine your own results. This will help identify areas of concern and help define the treatment plan for your patient. (Figure 1)

Step 2. Establish outcome goals: Based on the injury, type of repair and follow-up available establish outcome goals for the procedures performed in your hospital. For example: we want our TPLO patients to be fully rehabilitated and ready for competition by 12 weeks postop, or our patients with midshaft closed tibial fractures should be clinically normal and released from therapy by 12-14 weeks.

Step 3. Examination of capabilities and resources: In this step we examine and develop the rehabilitation team. We identify who will provide the therapy (physical therapist, physical therapy aid, veterinarian, or veterinarian technician.) What resources can be committed to the effort? Can an electrical stimulation unit or therapeutic ultrasound be used? Is there a therapy pool or treadmill available? The first and most important resource commitment is of the person performing the therapy.

This person needs to have the training and desire to provide animal rehabilitation. The person should have the time provided for this service and not become burdened with other duties that interfere with rehabilitation. Having a dedicated person(s), space and modalities available will ensure that a credible and regular program be developed and implemented. For example: using a veterinary technician when he/she is not busy in surgery to provide physical therapy will not work well. One can begin most aspects of physical therapy and rehabilitation with a dedicated person (PT, PTA, DVM, Vet Tech) and add equipment and modalities as the effort grows.

Step 4. Patient Assessment

This is an extremely important step and is reflective of the uniqueness of each patient undergoing the same procedure. The steps in patient assessment are listed and discussed below:

A. Nature of injury and surgical repair. There are different rehabilitation demands for extracapular CCL stabilization when compared to the TPLO procedure. The person(s) providing the rehabilitation must be aware of the repair method for each patient.

B. Physical examination: The patient’s general health status is important. A 24-lb. obese diabetic inactive Schnauzer may have a greater incidence of postoperative problems and delayed wound healing.

C. Limb evaluation: One should use goniometry, limb circumference, scar assessment, range of motion and gait analysis to assess the patient. This level of assessment is important because it creates objectivity and helps the therapist develop and chart patient progress. This level of assessment also helps eliminate treatment failure and missed diagnosis. Most dogs with an extracapular stabilization of the knee following cruciate disruption have a near normal gait at 6 weeks following surgery. If this is not the case for an individual animal at 6 weeks following surgery one should be suspicious of treatment failure (sutures broken or dislodged) or missed diagnosis (multiple myeloma).

D. Documentation: Each part of the patient assessment and protocol implementation deserves documentation. This provides for proof of therapy, progress or lack of, allows for more than one-person to provide the rehabilitation and offers medicolegal security.

Step 5. Patient/Procedure Specific Protocol

Utilizing the information previously developed we can design and implement a custom protocol for each of our patients:

1. Procedure and patient: 7-year-old hunting/athletic female Labrador retriever procedure of choice TPLO anticipated surgical results - healed osteotomy 7-9 weeks

2. Outcome goal: This dog is a candidate for Master Hunter with an anticipated return to competition in 12 weeks

3. Your capabilities/resources: You currently have a job dedicated veterinary technician and a physical therapist available for consultation. You have heat/cold capabilities, an exercise area and recently purchased a neuromuscular stimulator.

4. Patient Assessment: 7-year-old healthy female Labrador limb assessment 1st week, PROM, 4 cm limb circumference difference, painful scar, and mild effusion. Apparent muscle atrophy of the semimembranous, semitendonosis and quadriceps muscle groups.

5. Your Protocol 1st week: Anti-inflammatory protocol- PROM and ice packs to peri incisional area tid gentle massage of limb tid short leash walk on a flat surface tid

2nd week: + ice packs and PROM -scar massage neuromuscular stimulation of the hamstring/quad groups, leash walks - 10 minutes bid or tid. Begin sit/stands/wall sits

3rd week: Reassess patient - may begin transition from Phase I to Phase II. Neuromuscular stimulation may continue. Achilles stretch, wall sits, leash walks 20-40 minutes + use of leg weights.

4th and 5th week: Continued muscle/strengthening development wall sits/short trotting leashwalks - 20-40 minutes bid proprioception redevelopment (unbalance while walking)

6th week: reassessment of stability of limb, begin/continue muscle specific therapeutic exercise: incline or stairs, swimming, figure of eights, wheelbarrowing

10-12 weeks: reassessment and release from rehabilitation program

Figure 1

Protocol Development. Step 1

Procedure:______

Patient population:______

Numbers/years:______

Patient assessment Presurgical Suture removal 1 month 3 month 6 month 1 year

For example: Step 1 Procedure: extracapular stabilization with large gauge polypropylene Patient population: 80% medium to large breeds 20% small breeds Numbers: 100/year

Patient assessment: Presurgical acute vs. chronic injury Suture removal - toe touching with ambulation 1 month - grade 2 weight-bearing lameness 3 months - full use of leg - grade 1 lameness upon arising in the am. 6 months- full use of leg - pain with hyperextension of knee. Grade 1 lameness 1 year - palpable DJD - full use of leg grade 0-1 lameness

Case 7 Overview Elbow Fractures

Anatomy Review Radius, Ulna, Humerus, Joint Capsule, Supporting Collateral Ligaments, Annular Ligament The radius bears the majority of the weight The head of the radius articulates with the humeral capitulum, lateral to the humeral condyle

Fracture types of the elbow joint In immature dogs the most common type of elbow fracture is a lateral condylar fracture of the lower part of the humerus. This is generally a Salter-Harris type IV fracture.

In mature dogs, Spaniel breeds are predisposed to developing this fracture with some type of trauma such as jumping off of a high place. In these breeds, the fracture line commonly occurs along a soft line of cartilage matrix, due to incomplete ossification of the humeral condyle.

The T- or Y-shaped fracture is less common, but is a complex fracture that is difficult to repair and obtain good results with.

Special Considerations with Elbow Fractures If not repaired quickly, fibrous tissue and fracture callus can develop which may prevent the surgeon from optimally reducing the fracture. The fracture should be repaired so that the joint surfaces align as precisely as possible. If an elbow fracture is not repaired, decreased limb function results. If the elbow is not flexed and extended soon after surgery, fibrosis and scar tissue will stiffen the joint and the limb could become essentially non-functional as well.

Arthritis of the elbow joint is expected to develop long-term commonly causing some degree of lameness. In order to surgically approach the elbow joint in dogs (with a Y- fracture) over 8 months of age, the olecranon usually must be cut in order to open the elbow joint; on occasion, the fixation may fail resulting in distraction of the bone. The radial nerve wraps around the distal humerus and could get damaged by the fracture fragments or surgery.

In the young dog, Salter-Harris type IV fractures are commonly seen as a result of trauma. In the cocker spaniel breed, it is not uncommon for mature animals to present with articular fractures with minimal evidence or history of trauma. With any articular fracture, loss of ROM, and destruction of articular cartilage are often sequelae of an

articular fracture. In addition, in Salter-Harris fractures, joint congruency may be altered, especially if the fracture occurs at a very young age.

Surgical Repair Lateral condylar fractures are usually repaired using a screw and pin. The T- or Y-shaped fractures are usually repaired with a screw and bone plates; in some cases these fractures are repaired using intramedullary pins rather than plates.

Potential Complications Non-union or mal-union of the fracture site Non-union of the olecranon Excessive fibrosis (or scar tissue deposition) in and around the joint making it stiff and less functional Failure of the metal screws/pins/plates Arthritis of the elbow joint resulting in stiffness Infection Radial nerve damage

Case # 7 cont.

A 3-year-old male Bloodhound sustained a Y fracture of the elbow with surgical repair 48 hours later.

Rehabilitation General Considerations The goal of the early post-operative period is to maintain joint viability, ROM, and allow time for adequate bone healing in order to support more active weight-bearing exercises. After adequate healing has occurred, physical rehabilitation consists of continued ROM exercises with stretching if needed, and active weight-bearing exercises such as progressive leash walking and aquatic therapy.

Immediate Postoperative Therapy Immediately following surgery, cryotherapy should be administered. Ice packs or other commercial cryotherapy devices may be used around the elbow joint for 15 to 30 minutes. Either during this time, or prior to cryotherapy it is also beneficial to perform slow, continuous passive range of motion to the elbow. It is important to feel the tissues to ensure that the limb will not be excessively cooled. Following removal of the cold pack, a pressure wrap should be placed to limit swelling and edema. The wrap should be placed so that the limb is in a functional walking position and may be a modified Robert Jones bandage or an Ace-type bandage (as long as it is not placed too tightly). Appropriate analgesic/anti-inflammatory medication should be administered so that the patient is comfortable.

Step 1- Day 1 Post-Op until Toe-touching

Goals include edema control, improving elbow range of motion, limiting muscle atrophy, and providing pain control.

Anti-inflammatory medication (ie, carprofen or other) should be administered 30-60 minutes prior to the first session of the day. Remove the pressure bandage. Begin the session with gentle massage of the area, concentrating on edema resolution, muscle relaxation, and mobilization of soft tissues near the incision. Passive range of motion/stretching exercises should follow massage, performing 10-20 repetitions. Follow with cryotherapy and pressure bandage.

Most dogs will have a reduced comfortable range of motion (ROM) during the first couple of days after surgery. Patients should have ROM performed 2-3 times daily, followed by cryotherapy and Ace bandage. In patients with greatly reduced ROM, exercises should be performed 3-5 times daily. If the patient is exceptionally painful, the

clinician should be contacted to determine if there is a post-operative complication. Dogs in this category may require opioid analgesia.

In general, dogs will hold the leg in an over-flexed position for 5-7 days after surgery (in some cases, up to 2 weeks). Continue step 1 procedures during this initial painful period. It is extremely important during this early recovery phase that the dog not be overworked and become more painful following therapy sessions. Particular attention should be paid to analgesic medication.

The patient should be leash-walked very slowly to encourage weight-bearing. When the dog begins to carry the limb in a more extended position, but is still non-weight bearing, this is an indication that the dog is about to begin toe-touching. Step 2 may begin at this point.

Step 2 - Early Weight-Bearing

Goals include continued pain control, management of edema, returning range of motion to a more normal state, and beginning toe-touching gait.

Anti-inflammatory therapy may continue as long as there are no contraindications, such as bloody stool or vomiting. As long as acute inflammation has subsided, the session may begin with ultrasound therapy (typically 3 MHz in the elbow, .5-1.5W/cm2 depending on the size of the dog and the amount of soft tissue). If some swelling is still present, pulsed ultrasound may be utilized. Heat packs to warm up the tissues may also be used. ROM exercises may continue if full flexion (40°) and full extension (165-170°) have not been achieved. In young dogs, it is important to continue ROM for 4 weeks even if normal ROM has been achieved.

Toe-touching should be encouraged by gently shifting the dog off balance so that the affected leg begins to touch the ground for balance. Dogs should be leash walked for 5- 10 minutes very slowly to allow an opportunity for weight-bearing. Dogs may also begin work on the land treadmill. Depending on the prior condition and fitness of the dog, the first rehabilitation/training session should last 1.5 to 2.5 minutes, at 0.5 mph, with a 1.5 grade. Most dogs will begin to toe-touch within the first few seconds, but others may need support and encouragement. It is important to provide support when first starting the treadmill to prevent stumbling. Occasionally a dog will resist toe-touching; this may be encouraged by lifting the affected foot and advancing it and placing it on the ground during a normal gait cycle. Most dogs will catch on fairly quickly and begin to use the limb. In some dogs, it is beneficial to gently push the dog off balance during the gait cycle to encourage greater weight-bearing. Ankle weights, syringe caps, or other objects may be placed on the unaffected limb to increase use of the affected limb. Treadmill

activity may be performed 1 - 2 times per day. Cryotherapy may be administered following a session.

Sessions may be preceded by ROM, massage, or other warm-up activities. To help prevent muscle atrophy, NMES may also be performed every other day. Following this, the dog should be leash walked very slowly for 5-10 minutes to encourage weight- bearing. Cryotherapy may follow the session.

Aquatic therapy may also be used following suture removal (day 8-14 after surgery). Sessions may be performed in the whirlpool tub. Water temperature should be approximately 85° F.

As long as the dog continues to increase weight-bearing activity on the limb, treadmill time may be increased 15 to 30 seconds to a minute per day, and the grade increased by 0.5 degrees every other day. Leash walks may be increased in length and speed as weight-bearing improves. In addition, walking down inclines or hills is beneficial to encourage forelimb activity and extension of joints. A reasonable goal is 10 to 15 minutes of leash-walking, to include 5 to 10 repetitions down an inclined surface.

By the end of Step 2, the dog should be consistently using the limb during every stride at a walk, although lameness will still be apparent. The dog may be intermittently or consistently toe-touching at a trot. Step 3 procedures should now begin.

Step 3- Consistent Weight-Bearing

Goals include improving joint ROM, improving weight-bearing at a walk and trot. Radiographs should be made prior to increasing activity to be certain that normal fracture healing is occurring and there are no fracture healing complications.

If normal ROM has not yet been achieved, continue passive ROM/stretching exercises. It may be most beneficial to perform ultrasound therapy while simultaneously stretching if tissues seem to be tight or have lost extensibility. Also perform ROM/stretching if the dog does not fully or nearly fully extend the elbow during walking and trotting.

Following a warmup activity of leash walking at a moderate pace for five minutes, the dog should be walked down inclines or hills for 5-10 minutes. When the dog is comfortable going down an inclined surface, the dog may be walked down a flight of steps. Care should be taken to go slowly and encourage full weight bearing and use with the affected limb.

During one session per day, the dog may jog slowly for 2 minutes. If available, swimming in a pool, lake, or pond for two to five minutes daily or every other day will be very beneficial. When the dog is bearing significant weight on the affected limb at a trot, step 4 activities should begin.

Step 4 - Consistent Weight-Bearing at a Trot

Goals include improving ability to use the limb with some speed, improving muscle mass and strength, and improving stamina and endurance. Radiographs should be made prior to increasing activity to be certain that normal fracture healing is occurring and there are no fracture healing complications. Significant increases in activity should not be allowed until there is evidence of bridging fracture callus.

At this point, the dog should be using the limb consistently at a trot. Some mild lameness may be apparent, and prolonged activity may result in worsening of lameness. If lameness worsens following activity, anti-inflammatory medication should be administered and the dog should be rested for 1 to 2 days, followed by a return to a reduced level of activity (activity should be 50% of what it was just prior to lameness). Trotting activities should initially be encouraged for 5 to 10 minute sessions, two times daily. The speed, length and frequency of jogging should be gradually increased to 15 to 25 minutes three times daily. At least part of this time should be spent jogging up hills. Stair climbing should continue. If possible, swimming should be offered several times per week, for 10 to 20 minutes depending on the fitness of the dog. Controlled playing with a ball at a fast trot may be substituted for jogging several times per week for 5 to 10 minutes. Step 4 should be continued until the dog willingly trots quickly and with minimal or no lameness.

Step 5 - Trotting at Speed with Minimal to No Lameness

Goals include improving speed at a lope and slow gallop, improving muscle mass and strength, improving stamina and endurance, and returning to as normal activity as possible. At this time, the fracture should be healed with no evidence of implant complications.

Dogs may run up and down hills, inclines, and trot up steps. Swimming may continue for 15 to 20 minute exercise periods several times per week if possible. Ball playing may be encouraged with the dog running at a lope for 5 minutes initially, working up to 15 to 20 minutes daily. Dogs may jog for prolonged distances. It is important that the level of activity be relatively consistent from day to day, rather than allow vigorous activity for 1 to 2 days per week with little activity for the remainder of the week.

Important During all of the five steps, particular attention should be paid to any deterioration in the dog's progress. Specifically, attention should be focused on lameness or stiffness following activity. If the patient appears to have stiffness or increased lameness at any time after a therapy session, the level of activity should be decreased and a slower rate of progression should be instituted. It is very important that dogs be as comfortable and pain-free as possible during the rehabilitation period.