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 1 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 2 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. 3 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. 4 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. 5 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 6 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% 7 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? 8 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? 9 10 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: .