aptaregis2017 - · pdf file4 palpation * make note of: muscle deﬁnition atrophy *soft...

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Assessment&ManualPhysicalTherapyfortheSportingDog

RiaAcciani,MPT,CCRPAdvancedCanineRehabilitation

DOGPT.COM

Copyright © 2017 by Animal Rehabilitation SIG, Orthopaedic Section, APTA All rights reserved. The material used in this course or any portion thereof may not be reproduced or used in any manner

whatsoever without the express written permission of the publisher.

AssessmentofSportsInjuries*  ComponentsofEvaluation:* History* Stance/Gait* Palpation* Musclestrength* ROM

*  Girth*  Mobility*  Flexibility*  NeuroScreen*  SpecialTests

© 2017 Animal Rehabilitation SIG, Orthopaedic Section, APTA. All Rights Reserved.

AssessmentObjectives

*  Focuswillbeonforlimbandhindlimbassessment*  SpecialTests*  Flexibility*  Palpation*  Strength


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•  Tomakeassessmentofsofttissueinjuryoneneeds:

•  ExcellentPalpationskillsknowledgeofAnatomy

AssessmentofInjury


History

*  Livingsituation,inside,outside,stairs,surfaces.*  Otheranimals/humans(puppy/child)*  playing/exercise*  Bedding/Crate*  Jumping(car,bed,ottoman)

* DailyRoutine* TypeofSport


History

*  Typeofexercise,frequency,duration.*  Leash/free*  Playingwithotherdogs*  Collar/harness*  Toysorchaseanimals


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Observation/Gait

*  Stance-WB,posture,Atrophy,wideornarrowbased,weight.Anydeviationfromnormshouldbenoted.*  Gait-fluidityofmovement,transitions(lyingtostand),symmetry,WB,walk,trot,circles.Onleadorofflead?*  Observefromdifferentangles.


Palpation

*  Takecautionwhilepalpatingpainfuldogs*  Painresponsecanbetobite*  Watchfor:pupildilation,headturning

* Lickinglips* Panting* Whining/vocalization


Palpation

*  Standingorlateralrecumbency*  Workproximaltodistalonthelimbsandheadtotailforthespine*  Useaflathandfirstwithlightpressurethenprogresstodigitalpalpationofspecificmuscles.


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Palpation* MakeNoteof:

* Muscledefinition* Atrophy* Softtissueswelling* Bonyanomalies* Temperatureandpainresponse* Comparesides


Flexibility/MuscleLengthTest

*  Veryimportant!!*  Musclelengthcandeterminethedifferencebetweenmuscleandligamentinjury*  Determinemuscleimbalance


Flexibility

*  Shouldbedoneinlateralrecumbency*  Canalsobedoneinstanding/sitting*  Dogshouldberelaxed

*  Movementintoendrangeshouldbeslow*  Observeanytwitching*  NEVERforcethelimb*  Stopatpointofdiscomfort*  Comparebothsides


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Flexibility

*  Totestflexibilityofamuscleyoumustputthemuscleinalengthenedposition*  Originandinsertionofmuscleshouldbelengthenedawayfromoneanother


*  Checkmusclelengthofforelimb,hindlimb,&spine.*  Forlimb:

*  Shoulderflexion&extension*  ShoulderIR&ER*  ShoulderAbduction/Adduction*  Elbowextention/flexion*  CarpusExtension/flexion*  Carpussupination/pronation*  Toes

Flexibility


Flexibility

*  Hindlimb:*  Hipextension/flexion/

abd/add*  HipIR/ER*  StifleFlexion/extension*  Hockflexion/extension

* Toes


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Flexibility:

SpineCS/TS/LSLateralflexionExtensionFlexionRotation


Muscle strain: •  Tender to palpation (deep cross-fiber) •  Combined with specific irritability upon

stretch to that same tender muscle. Ligament injuries are assessed using direct palpation and ligamentous stress/provocation tests.

Assessmentofstrainedmuscle&ligamentinjuries

Donethroughmusclelengthandspecialtests


*  Valgus/VarusStressTest:*  Testsintegrityofmed/latcollateralligaments*  LateralRecumbency*  Applymedialandlateralstresswithstifleinneutralandvariousdegreesofflexion/extensionextension

SpecialTests/ProvocationStifle


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*  AnteriorDrawTest:*  TestsintegrityofCCL*  Flexstifle120o*  Graspdistalfemurwiththumblockedbehindlateralfemoralcondyle*  Otherhandgraspsproximaltibiathumbbehindlateraltibialcondyleandindexfingeratjointlinetopalpatejointmovement.

*  Applycranialpressureontibiauponthefemur,thisexertsacranialtranslationofthetibiatostresstheCCL.

StifleSpecialTest


ANTERIORDRAWCranialtranslationofthetibiauponthefemur.


PatellarTesting*  Usedformobilitytestingandstabilityofpatella(luxatingpatella)*  Grasppatellabetweenindexandthumb

*  Mobilitytestpatellamedial,lateral,dorsalandventral*  COMPAREbothsidestodeterminetranslation/luxation*  Testinvariousdegreesofflexion/extension

© 2017 Animal Rehabilitation SIG, Orthopaedic Section, APTA. All Rights Reserved. Luxating Patella Test

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*  Determinesstabilityofthehock*  Testerplacesindexfingerandthumbonhock<dogisinstanding(limbmustbeWB)*  Pressureisplacedinacranialdirection*  Hockshould“bounce”backifstabilityisgood*  Hockwillstayforwardandtarsuswill“slip”forwardifunstable

“Slipped”Hock


MeasuringAbductionAngle

*  Lateralrecumbencyorsitting*  Goniometer:onearmparalleltospineofthescapandtheotheralongthehumerus*  Elbow/shoulderinextension*  Stabilizescapula*  Thenabducttotissuelimit


PalpationofIliopsoas*  Palpation:oftheIliopsoasm.canbeverytender(lessertrochantermedialthigh),otherareasoftenderness:paraspinals,quadratuslumborum,sartorious,quads,piriformis,gracilis.*  POSITIVEsignistendernessatinsertionoflessertrochanter


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IliopsoasSpecialTest*  DeterminesstrainofIliopsoas*  Extend,IRhiptoendrangeortopointofdiscomfort,thenextendspine* POSITIVEsignispullingforward,painresponse,&decreasedm.length


LABQuickdemoofeval/assessment

PerformspecialtestsIftimethenreviewmusclelength

SubjectivecomplaintsforMSI

*  Historyisvariable*  Maybesubtletoseverecomplaints*  “Hemissedhisweavepole

entry”*  “Hejustwillnotturntothe

right”*  “Sheisdeadlame”*  Chronicconditionsc/o*  “Ihaverestedhimfor8wks

andhestillcomesuplameafterworking”

*  “Werestedhimfor6wksandhewasonNSAIDS,whyisn’thebetter?”© 2017 Animal Rehabilitation SIG, Orthopaedic

Section, APTA. All Rights Reserved.

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Objectivefindings

*  Gait:mildshortenedstridelengthatbothwalkandtrotorsignificantlameness.*  Girthmeasurementdeficits*  VisibleAtrophy*  DecreasedROM:shoulderextension*  IncreasedAbductionangle*  Withseverecasessubluxationcanbefeltduringabduction*  Flexibility:biceps,supraspinatusandsubscapulariscanbeinvolved,decreasedflexibilitycanbenoted.


Objectivefindings:cont.

*  Abductionangle*  3categories:*  Mild-35-45degrees(conservativemanagement)*  Moderate-45-60degrees(arthroscopicsx)*  Severe>65degrees(sx)


MeasuringAbductionAngle

*  Lateralrecumbencyorsitting*  Goniometer:onearmparalleltospineofthescapandtheotheralongthehumerus*  Elbow/shoulderinextension*  Thenabducttotissuelimit


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Objective:cont.

* Palpation:*  tendernessisusuallynotedalongthesubscapularis

tendonandmuscle,somethickeningofthetendon*  Teresmajortendernessuponpalpation*  Bicepsandtricepsdiscomfort/triggerpoints*  CS,TSandLS


OBJ.cont.*  Mobility*  Decreasedposterior(caudal)glideofGHjt.*  IncreasedmedialglideoftheGHjt.*  LowerCS&upperTSdecreasedmobility*  Decreasedscapularmobility


IlopsoasStrain

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SubjectivecomplaintsforIliopsoasStrain

*  “Mydogisknockingbarsandheneverdoesthat”*  “Hemissedhisweavepoleentryandsometimespopsout”*  “Hera-frameisslowandshemissedhercontact”*  “SheisnotshowingmuchbutIknowthereissomethingwrong”


Objectivefindings

* Gait:Shortenedstridelength,stancephase,effectedlimb.Hiphikingorhopduringleadchangesorgaittransitions(walktotrot).* ROM:Decreasedhipextension*  Flexibility:Decreasedfelxibilitycanbenotedintheiliopsoas(hipextension,abduction,IR,&lumbarext.),quads,sartorious,piriformis,hamstrings,adductors(gracilis),andgastroc.


Objectivecont.

*  GirthMeasurements:Canvarydependingonacuteorchroniccondition.Atrophycanbeseenalongglutregion.*  Palpation:oftheIliopsoasm.canbeverytender(lessertrochanterinsidethigh),tenderparaspinals,quadratuslumborum,sartorious,quads,piriformis,gracilis.Oppositefrontteresmj,lats,traps,infraspinatusandsupraspinatus.


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Objectivecont.

*  Flexibility&Mobility:Decreasedmobilityisusuallynotedinthepelvis,hipcapsule(cranially/medially),patella(ventrally),LS,TS.*  FlexibilityisdecreasedintoextensionandIRofhip.Sartoriousandgracilismayhavesomedecreasedflexibilityaswell.


GoalSettingandRehabPlanning

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Acute Stage: (week 1-3) •  Decrease pain and inflammation Increase Joint

ROM •  Increase tissue healing •  Preserve muscle mass •  Prevent compensatory dysfunction

GoalSetting&RehabPlanforEachStageofHealing


GS&RPcont.Owner education- reduce risk of injury, stress lifestyle changes and precautions. On lead walks for 5 min and up to 10 min by end of 3rd week. Inflammation management- modalities (US, Laser, PEMF pulsed electromagnetic field, Cryotherapy, NMES. ROM exercises- PROM (increase circulation/proprioception & ROM) AROM (easy WB/weight shifting activities, verbal commands) Proprioception- Grade 1 mobilizations/Jt. compression, massage, weight shifting activities, NMES with functional movement. Compensatory Dysfunction- address all restrictions found when evaluating whole animal. Especially, spinal/pelvic dysfunction. Mobility, flexibility, ROM, soft tissue dysfunction.


GS&RPcont.

Sub-Acute(4-6weeks)Strengthening-

•  Buildmuscularstrength/supportofaffectedjoint

•  Utilizeclosedandopen-chainexercises,beginslowlyandprogressastolerated.Nosignsoflameness,decreasedpainuponpalpation,swelling,painwithstretchingormobilizations.

•  Weightbearing&stabilizationexercisesbegin

•  Muscularenduranceisalsoincreasedie,increasewalkingtimesto20min.UseofUWTMorPoolcanbeutilizedatthispointifindicated.

•  SofttissuestretchingandROMProprioception-

•  Increasedifficulty.balanceboards,un-evensurfaces,walkingoverobstacles(ladder,grass,cones)Manualperturbationsisprogressed.


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GS&RPcont.Mid-Stage(7-9weeks)Strengthening&Proprioception-Increaseduration,time,distanceandspeed.Terrainchangeswithwalks.Hills,Stairs,trottingcouldbeutilizedatthistime.Compensatorymanagement-shouldbedecreasingatthistime.Mobilizationsandsofttissuetreatmentstillnecessarybutonlyasneeded.Corestabilization-Ball,disc,pad,balanceboard,narrowplanks.Progressslowly,startatbeginnerslevel.


GS&RPcont.* End-Stage(10weeksplus)

* StrengtheningandProprioception-Ifprogresshasbeennormalthenyoumayprogresstoadvancedstrengtheningtechniques.Endurance/cardiovasculartrainingincreases30+min,walking/trotting,UWTM,swimming.Initiateoffleadhikesafter12weeks.Jumping14weeks.

* OwnerEducation-nofrisbee,ballplaying,properwarm-upandcool-down.Maintainnon-slipsurfacesinhomeifnecessary.


GS&RPcont.Return to Sports (14 weeks+) Advanced training and rehab is essential. Endurance Plyometrics/Jumping agility training (tunnels, A-frames, dog walks, tires, tables, broad jumps) sport-specific training sprints lateral training (pivot, figure of 8, turning/cutting) advanced trunk stabilization strength training


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RehabProtocolPost-opMSIAcute Stage: (week 1-3) Conservative management is critical to maintain integrity of tightened structures Contraindications: No sh. ROM! No laser over jt. capsule Modalities: Laser (except over shoulder Jt.) Cryotherapy

2-3x’s/day for the first 3 days then done as needed and post-rx. NMES. Exercise choices should be geared towards stabilization of the shoulder complex All exercises are done in Hobbles except ROM Treatment: PROM, Jt. compressions, Jt. mobilizations (avoid shoulder), and manual treatment to reduce compensatory effects of sx and Hobble use. HEP: Lateral raises, PROM, 3x’s/day and CS stretches. Torso stabilization and slow leash walks. Owner Education!


MSIProtocolCont.. Sub-Acute Stage: (4-6 weeks) Continue to protect healing structures Contraindications: Avoid ER, ABD, & EXT of the shoulder. No laser, No UWTM. All exercises done in hobbles Increase leash walks by 3-5min every 3-5days work up to 30min, stabilization exercises of shoulder and torso. Treatment: Manual Rx., Stretching, Jt. mobilizations, begin GENTLE Flexion PROM of involved shoulder. Jt. Compressions if needed, jt. mobilizations, PNF. Modalities: Laser, not over surgical site. NMES, Ice, US. HEP: PROM 2-3x’s/day, All 4’s rocking, 3 leg stand, sit-stand, lying to stand.


MSIProtocolCont.Sub-Acute Stage: (4-6 weeks) Continue to protect healing structures Contraindications: Avoid ER, ABD, & EXT of the shoulder. No laser, No UWTM. All exercises done in hobbles Increase leash walks by 3-5min every 3-5days work up to 30min, stabilization exercises of shoulder and torso. Treatment: Manual Rx., Stretching, Jt. mobilizations, begin GENTLE Flexion PROM of involved shoulder. Jt. Compressions if needed, jt. mobilizations, PNF. Modalities: Laser, not over surgical site. NMES, Ice, US. HEP: PROM 2-3x’s/day, All 4’s rocking, 3 leg stand, sit-stand, lying to stand.


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MSIProtocolCont.End-stage (10-12 weeks) Increase all exercises as tolerated by patient. Endurance, proprioception, strength (eccentric and concentric), endurance and speed should be addressed. Full ROM of Shoulder, no palpable tenderness of surrounding soft tissue, prepare for return to normal activities. UWTM & swimming can be introduced. Hobbles still in use during daily activities, begin exercises without hobbles. Modalities: Laser unlimited, NMES, US. Treatment: continues as necessary


MSIProtocolCont* Return-to-Sports(14-16weeks)

* Thisstagecanbeginifnormalhealingtimeswereconsistentandprogresswithineachstagewaswithoutcomplication

* Limbcircumference/musclemassshouldbeequalorwithin1/2cmofeachlimb.ConfirmationoffullhealingfromSurgeon,minimaltonosofttissuedysfunctions,fullflexibility,normalgait.

* Thisstageisessentialtosafelyreturntosportduetothemanystressesplacedontheshouldercomplexwithspecificsports.Eachprogramshouldbespecializedtotheparticularsportbeingreturnedto.


ElbowTreatmentPlan*  PhaseIImmediateMotionstage(week1-3)Goals:ImproveROMDecreasepainandinflammationRestoreWBandretardmuscleatrophyContraindications:nostairs,unevensurfaces,orslipperysurfaces


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ElbowPhaseI*  Exercises:*  1.ManualTherapy-PROM,stretching,jt.mobilizations(grade1-2),softtissuemobilization/massage*  2.Therapeuticexercise-leashwalking,rhythmicstabilizationandWBexercises*  3.Modalities-cryotherapy,lasertherapy,US,TENS-electricalstimulation,andwhirlpool


ElbowPhaseII*  PhaseIIIntermediatestage(week4-6)InitiateoncefullROM,minimalpain/tenderness,andimprovedlamenesshavebeenobtainedGoals:NormalizemotionImprovemuscularstrengthandendurance


ElbowPhaseII

*  Exercises-*  1.StretchingtojointsoftheentireforelimbandCS*  2.Longerleashwalks-includeup/downhills,steppingoverobjectsandunevensurfaces,circlesandfigure8’s,ladder,wheelbarrow,playbow.*  3.Hydrotherapy-UWTMorswimmingmaybeinitiatedifcriteriaismet.*  4.Proprioceptiveexercisesbeginforneuromusc.Controlandstabilization.PNF.


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ElbowPhaseIII

*  PhaseIIIAdvancedStrengtheningstage(wk7-11)Initiatewhenfullnon-painfulROM,nopainortenderness,andstrengthandmusclemassthatis70%ofthecontralateralforelimb.Goals:Increasestrength,power,andenduranceIncreaseneuromuscularcontrolPrepareforgradualreturntosport


ElbowPhaseIII*  Exercises-*  1.Advancedstrengtheningemphasizinghighspeed,eccentriccontraction,therabandandplyometricexercises*  2.Leashwalksincludeincreasetime,distance,speedandterrain.Theadditionofsteeperhillsandstairworkaidinstrengthening.*  3.Advancedproprioceptionandstabilizationexercises.


ElbowPhaseIV

*  PhaseIVReturntoActivityStage(week12+)Initiatewhenequalforelimbmusclesymmetry,nolamenessatwalkortrot,orcircles/tightturnsareperformed.Satisfactoryclinicalexam.Goals:Returnprogressivelytofulloff-leadactivityandcompetition.


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ElbowPhaseIV*  Exercises:*  1.Gradualoffleadactivities*  2.Longerwalking/trottingsessionstoincreaseendurance*  3.Advancementofdurationandputurbationsofstabilizationexercises*  4.Sprinting,jumping,andadvancedplyometrictraining.Sportsspecifictrainingbegins.


HipTreatmentPlan

*  PhaseIweek1-3*  Goals:*  Decreasepainandinflammation*  Ifchronicthenbreakupscartissuetoinitiatehealing*  IncreaseROMifnecessary.


HipPhaseI*  Treatment:*  ManualTherapy-PROM,gentlelightstretchingifappropriate(Strain/sprainshouldavoidstretchingforthefirst2weeks).Jt.Mobilizations(grd.1-2),softtissuemobilizationandmassage.*  Modalities-Laser,Heat,US,NMES,whirlpool.*  Exercise:Leashwalking,static/rhythmicstabilizationexercises,Extensionexercisesonthestairs,sit/standex.Hillslengthwiseattheendofweek2.


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HipPhaseII*  PhaseIIIntermediateStage(Week4-6)InitiateoncefullROMorpainhasdecreasedwithflexibilityandpalpation.Decreasedlamenessscoreduringwalk/trot.Goals:IncreaseflexibilityandmobilityNormalizemotionDecreasepain


HipPhaseII*  Treatment:1.  ManualTherapy-Jt.Mobilizations(grade2-3),Manual

stretching,myofacialrelease,softtissuemobilization.Makesuretoaddressallcompensatoryissues,VERYIMPORTANT.

2.  Modalties:ContinueasneededfromPhaseI


HipPhaseII*  Exercises:*  Longerleashwalks,acrosshills,up/downhills,largecircles,playbow,increasedifficultyofstabilizationexbutmaintainevensurfaces.*  Hydrotherapy:NOTforIliopsoasstrain!!AnyotherhipissuesmaybeginUWTMorswimmingifappropriate.


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HipPhaseIII*  PhaseIIIAdvancedStrengtheningStage(wk7-11)Initiatewhennopaintopalpation,fullflexibilityandnopainendrange.JointmobilityandalignmentisWNL.Musclemassis70%-80%ofcontralaterallimb.Goals:IncreaseStrengthandpower/enduranceIncreaseproprioceptionandtrunkstrengthPrepareforgradualreturntosport


HipPhaseIII*  Treatment:*  Continueappropriatejt.Mobilizations,stretching,softtissuetechniques.*  Modalities:Utilizeasappropriate*  Exercises:*  Beginhigherlevelactivities,BOSU,Wobbleboard,eccentricactivities,Lateralmovementexercises(sidestepping,circlesondisc,steephills,lumbarstabilization,peanut/doughnutwork.


HipPhaseIV*  PhaseIVReturntoSport/Activity(week12+)Initiatewhenequallimbcircumference,NOlamenessduringgait.Bodyalignmentissatisfactory,NopainendrangeROMorflexibility.Goals:Returntofullfunction.


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HipPhaseIV

*  Exercises:*  Offleashactivities,gradualreturn*  Longerwalking/trotting*  Stabilizationexercises*  Speed,plyometrics*  Sportsspecifictraining


ReturntoSport

*  TissuehealingfromTrauma/surgerycanresultinproprioceptivedeficitsthatcaneffectneuromuscularcontrol.

*  Thisstageofadvancedtrainingisimperativeforathletestosafelyreturntosport.


ReturntoSport*  AgilitySpecific:*  Hills:Varyingsteepness,off-leadsprints,trot/walkintervaltraining.Hillsup/down,zig/zag.Weightedvestsandweights.*  Gait:Differentsurfaces(tallgrass,sand,dirt)*  Jumping:Differentdirections(pinwheel,serpentine,threadles,figure8’s,circles,straightlinebouncejumpsandjumpgrids)


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*  Eccentrics:12”tunnelwork,reversesquats,pushups,backwardwalkingandupstairs,hindlimbawarenessexercises,ladderwithweights*  Concentrics:Weights,theraband,pullingwithharness,swimming,treadmill,hiking,ladder*  Endurance:Walk,trot,run,intervaltraining,UWTM,increaseintensity,andduration.

ReturntoSport


ReturntoSport

*  Balance/Proprioception:Physioball/Peanut/Doughnut/Discs/PodsBOSU,minitrampoline,narrowplankswithdiscunderplank.See-saw,&weavepoles.

*  Flexibility:Continuestretchingatleast2-3x’s/weektomaintainflexibility/mobility/optimumfunctionandperformance


LabDemomanualtechniquesHands-onforparticipants

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References Hall C, Body L: Therapeutic exercise: moving toward function. Philadelphia: Lippincott; 1999. Williams N: Wound Healing: tendons, ligaments, bone, muscles, and cartilage. In: Taylor R, editor. Canine Rehabilitation and Physical Therapy. St. Louis, MO: WB Saunders; 2004. p 100-12. Edge-Hughes, L.M. 2002, Therapeutic exercise for the Canine patient. In: Proceedings of the 2nd International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine. Knoxville, TN, USA, pp. 59-62. Maitland, G.D. 1966 Manipulation-Mobilisation. Physiotherapy 52(11): 382-384. Marcellin-Little, D.J., Levine, D., Taylor, R. 2005,


Rehabilitation for the orthopaedic patient. Vet Clin Small Anim. Pract. 35(6): 1357-1388. Millis DL, Schwartz P, Hicks DA, et al, Kinematic assessment of selected therapeutic exercises in dogs. In: Proceedings of the third International Symposium on Physical Therapy and Rehabilitation in Veterinary Medicine. Raleigh(NC): North Carolina State College of Veterinary Medicine; 2004. p 215. Jackson AM, Stevens M, Barnett S. Joint Kinematics during underwater treadmill activity. In: Proceedings of the second International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine. Knoxville(TN): Univ. of Tennessee College of Veterinary Medicine; 2002. p 191. McGowan, C., Goff, L., Stubbs, N., Animal Physiotherapy: assessment, treatment and rehabilitation of animals. Blackwell Publishing; 2007. p 207-235. Bordelon, J.T., Reaugh, F., Rochat, M.C., 2005, Traumatic Luxations of the Appendicular Skeleton. Vet Clin Small Anim. Pract. 35(5): p 1169-1194. Bardet JF. Diagnosis of shoulder instability in dogs and cats: retrospective study. J Am Anim Hosp Assoc 34:42; 54, 1998. Cook JL, Renfro D, Tomlinson JT, et al. Measurement of angles of abduction for diagnosis of shoulder instability in dogs using goniometry and digital image analysis. 34:463-468, 2005. Cook JL, Tomlinson JT, Fox DB, et al. Treatment of digs with medial shoulder instability using radiofrequency-induced thermal capsulorrhaphy. 34:469-475, 2005


aptaregis2017 - · pdf file4 palpation * make note of: *muscle deﬁnition *atrophy *soft...

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aptaregis2017 - · pdf file4 palpation * make note of: muscle deﬁnition atrophy *soft...