by Alan Gardner PgD A. Phys, MDip, DipMgmt, IAAT, ASSVAP
In the winter, spring and summer 2017 editions of Animal Therapy Magazine, we outlined typical physiotherapy, strengthening and McTimoney chiropractic treatment protocols in the canine patient.I will now introduce some case studies that incorporate some of these (protocols). Cases chosen to highlight a specific aspect with the aim to offer a critical evaluation why I chose those respective treatment programs.
In the case of Jade, it is to present the use of therapeutic ultrasound, stretching through extension of the hind limb and client introduction to strengthening exercises. I will place emphasis on these 3 modalities while also referencing other treatments to give the reader the full program. Where applicable I will reference articles from the magazine editions above and encourage the reader to refer to them for further explanation.
Links to all 3 of the articles can be found at www.smartpawsphysio.com.
Jade was displaying reduced hip extension on the right side with corresponding reduction in weight bearing on the right hind limb. Radiographs show marked hip dysplasia on the right side and disc disease at the at the lumbo-sacral area.
Additionally, hip extension became painful around 45 degrees of extension. The Iliopsoas appeared painful and the muscle were swollen with corresponding mild reduction of gluteal muscles on the right. After a period of rest, subsequent evaluations demonstrated a continued reluctance to extend hips / bilateral reduced ROM.
Weekly physiotherapy was recommended to relieve the iliopsoas myopathy for an initial period of six weeks, before subsequent revaluation of the underlying orthopaedic condition.
The gait analysis on the Gait4Life (fitfurlife) treadmill is summarised in the GLS score (see figure 2). From this we can see offloading of both right hind (expected, see diagnosis above) and left fore. Explanation of the latter was aided by the visual analysis during treadmill evaluation and by compensatory injuries suggested by Hourdebaigt (1998)³.
During gait analysis, Jade walked with her head held to the right-hand side, resulting in a corresponding shift of her centre of gravity. This was to help maintain her stability due to the weight shift from the (painful) rear hind to the left hind (Transversal compensation), seen in Image 1 as a higher GLS score.
Additionally, Hourdebaigt explains
lumbo-sacral luxation…would cause muscular compensatory tension to develop on either side of the body.
Further data is provided in Table 1, where is can be seen that the limbs with the higher GLS score are covering some 8% more distance and taking >10% more weight per stride.
The 2 most notable factors from the physical evaluation where:
- Confirmation of limited extension of the right hind limb
- Muscle tension in the left bicep femoris
- Muscle tension around L4-5 area (left hand side)
To guide the treatment program, I use a modification of the rehabilitation pyramid (figure 3) to guide the appropriate use of physiotherapy based treatments. Although treatment programs are not linear in nature, the pyramid can be broadly broken into 5 (overlapping) phases with the options described in table 2. Additionally, supportive treatments to the physiotherapy program such as hydrotherapy and chiropractic care may be used throughout all the phases*.
*see note of caution in the section on strengthening
Springer at al list 6 factors which influence choosing an EPA, of which research, efficacy and operational issues are the most relevant to our discussion. Referring to the diagnosis, there were 3 issues that were arguably causing discomfort:
1. Painful / swollen Iliopsoas on the right side
6 sessions of long wave therapeutic ultrasound (TUS) was administered to reduce pain, help break down scar tissue and re-orientate collagen fibres. We began with a setting of 500 mW/cm3 and noted that after the second session that the scar tissue was more pronounced, probably because of the increased blood flow and remodelling of the tissue. At that stage, we continued for another 4 sessions at 100 mW/ cm3 until the scar tissues was almost imperceptible and hip extension had improved.
Longwave was chosen due to its excellent penetration ability (>10 cm), thus ensuring that the treatment reached into deep laying tissue. Alternatives to TUS include (i) LLLT (LASER) and (ii) NMES. I chose TUS over these to ensure the depth of penetration into the muscle coupled with its simplicity in administration and the wealth of published data to support the treatment aims.
2. Disc disease at the lumbo-sacral area
To help overcome the muscle tension around L4-5 LLLT was employed. TUS could have also been used in the case, but using LLLT with comb attachment meant we did not need to shave the area (which wasn’t such an issue with the relatively hairless groin area).
3. Hip dysplasia on the right side
For similar reasons to that above, coupled with the evidence for LLLT in pain control for both acute and chronic conditions of osteoarthritis , this modality was also applied during the initial consultation sessions.
Following treatments of TUS, we would use passive stretching of the quadricep, iliopsoas, gluteal and hamstring muscles with the dog in recumbency. Additionally, the owner would carry out daily complementary Range of Movement (ROM) exercises on the hind limbs.
At this stage of treatment, these 2 modalities are employed to help with gait pattern retraining, recover joint ROM and improve flexibility by stimulating tissue adaptation. How important are these treatments during the improvement stage? A paper by Woo reports “that passive mobilization places tensile forces and motion on the repair site which appears to accelerate the repair strength”.
As our initial aim was to re-start the healing process by using TUS, we can reasonably assume (from this quoted study) that ROM helps strengthen the targeted tissue.
It should be noted that a limitation of stretching for the canine patient is that for static stretches only passive stretching is applicable. Additionally, benefits of stretching can be considered as personal to the individual involved.
The primary aims during the restoration process are to continue the increase in muscle flexibility / decrease tightness. Table 3 outlines the recommended exercises and desired outcomes for this case. For a more in-depth review of this stage, the reader is encouraged to read Canine Groin Muscles – Rehabilitation and Strengthening. In that article, Bobbie Lyons, suggests 3 key elements to aid success at this stage of the program:
- Quality over quantity is a crucial factor in the initial stages of strengthening following muscular injury.
- Focus on the core muscle group which needs to be strong and flexible before returning to full activity. When the “core” is weak, movement will cause the dog to overuse the Iliopsoas (and other muscles).
- Avoid swimming until the area is almost completely healed. Swimming focuses more on flexion than walking in water, and initially, too much flexion will aggravate the healing area.
I explained to the client the importance of the initial 2 points, starting with foundation exercises (which worked core muscles) and the importance of how to carry them out while maintaining the dogs correct posture.
After Jade had showed good stability when performing the initial exercises, we introduced her to the land treadmill, building up from 5 minutes to full 20-minute sessions. As well as aiding to help build muscle tone and helping to restore the patients normal gait pattern, the dog’s weight is more evenly distributed (on the treadmill), therefore reducing stress on joints. At this stage, we also moved to the more advanced variations of the exercises outlined in table 3.
For Jade, return to normal activities meant being able to enjoy her lovely country surroundings with plenty of hills to run up and down again! Building up her activities daily was recommended.
The use of physiotherapy is becoming more widespread for the treatment of soft tissue injuries and as possible conservative treatments of orthopaedic. This case incorporated both factors, an underlying issue of hip dysplasia aggravated by a strain to the iliopsoas muscle.
Using the gait analysis, we objectively analysed both the extent of the initial injury and possible compensatory factors, allowing a holistic approach to the subsequent rehabilitation and strengthening program. For this (program) I like to use the rehabilitation pyramid to help apply the best modalities for the particularly patient treatment stage. These stages can be broken down as acute, improvements, restoration, normal movement and return.
Typically, a treatment program begins with an appropriate EPA, before introducing more manual therapies such as massage and stretching to continue the improvements. Evidence supports this protocol, although actual benefits may vary from patient to patient. Strengthening involves choosing the best exercises for the case with an emphasis on quality and targeting the core stabilising muscles. To complete the program gait repatterning and a slow careful introduction into normal activities was recommended.
¹ In the interests of veterinary and client confidentiality, this has been simplified to give the reader an overview without the substantial details from the original report
² Animal Therapy Spring 2017 p44
³ Hourdebaigt, J. 1998, CANINE MUSCULAR COMPENSATION, Massage Awareness, Inc
 GLS score is designed to show a grade for ‘off’ loading and ‘over’ loading of a limb. A perfect score is 100. Numbers below 100 can indicate a level an offloading of a limb i.e. lameness. Numbers above 100 indicate over loading of a limb (compensation)
 The reader is encouraged to reference Fischer, M.S. Karin, L.E. (2014) Dogs in Motion, VDH Service GmbH, Dortmund, Germany for an explanation of some of these terms.
 Cabon, Q. & Bollinger, C. (2013) Iliopsoas Muscle Injury in Dogs, Compendium: Continuing education for Veterinarians. Vetlearn.com 2013  Rehabilitation pyramid (from Hertel, Deneger: A rehabilitation paradigm for restoring neuromuscular control following injury. Athl Ther Today, 3:12–16; 1998)  Or ‘initial’. In the case of chronic tissue injuries consideration is often given to returning the injury to the ‘acute’ stage, see Sharma, P. Maffulli, N. (2006) Biology of tendon injury: healing, modelling and remodelling J Musculoskelet Neuronal Interact 2006; 6(2):181-190
 Shmuel Springer, corresponding author Yocheved Laufer, and Michal Elboim-Gabyzon, Clinical decision making for using electro-physical agents by physiotherapists, an Israeli survey (2015) Isr J Health Policy Res. 2015; 4: 14. Published online 2015 Jun 15. doi: 10.1186/s13584-015-0015-x PMCID: PMC4466804
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Alan Gardner PgD A. Phys, MDip, DipMgmt, IAAT, ASSVAP.
Alan is an animal physiotherapist and practices at Hawksmoor, Nuneaton and Dunton Veterinary Clinic in the UK. He specializes in rehabilitation of performance dogs and improving gait post-surgery. At the Hawksmoor practice, there is a GAIT4DOG gait analysis treadmill which is exceptionally good for evaluating imbalances in pressure distribution of the canine limbs. This evaluation can quickly demonstrate compensatory patterns.