Reason for referral:
Road traffic accident (RTA) 19/12/06. Paralysis of right fore limb and cervical pain. Provisional diagnosis - brachial plexus injury
Medical history:
19/12/06 - Seen by own vets and hospitalised post RTA. Given intravenous fluids, pain relief and treatment for shock. Cranial nerve function ok. Painful right shoulder, elbows and dorsal rib area. No obvious signs of internal injury detected.
20/12/06 - Non weight bearing 24 hours post incident. Radiographs performed and nothing abnormal detected. Diagnosis: probable muscle damage and soft tissue injury.
21/12/06 - Neurological exam: Right fore (RF) paralysis and negative sensory and motor function at all levels. No deep or superficial pain RF. Suspect brachial plexus avulsion. Sent home and for re-evaluation in 2 weeks.
2/1/07 - Referral for physiotherapy assessment. RF ongoing paralysis and yelped when moving at times.
Physiotherapy Examination:
Non weight bearing (NWB) right fore limb. Loss of full carpal extension. Muscle atrophy RF scapular and shoulder area. Loss of deep pain and withdrawal reflex. Slight muscle twitch of biceps and triceps, so possible proximal nerve recovery. No distal nerve recovery at present.
Physiotherapy Treatment:
Began muscle stimulation of triceps and biceps + dynamic forelimb stretches on physio ball with assistance. Advised owner re corrective limb placement/weight bearing position.
Follow up: To continue with home exercise programme and refer for veterinary rehabilitation programme and acupuncture.
Veterinary examination:
3/1/07 - Cervical pain C7-T1 and reluctance to move head and neck laterally, especially to right. Associated cervical paraspinal muscle spasm and pain referral pattern right shoulder and neck. Taut muscle band under cranial scapula. NWB right fore and pain especially right shoulder. Has deep pain and very weak withdrawal reflex and superficial pain response. Proprioception negative. Muscle atrophy infraspinatus, supraspinatus, biceps and triceps.
Treatment:
Acupuncture of cervical points: BL11, CV14, and various trigger points neck and shoulder area. LI15, TH14, SI9, LI11, TH5, BL60. Needling of deep cervical and subscapular acupuncture points initially painful, but Harvey soon relaxed and analgesic effect obviously demonstrated after approximately 5 minutes. Electroacupuncture for 5 minutes from BL11 TH14/LI15.
Physiotherapist demonstrated muscle stimulator and physio ball exercises again and owners to continue at home to slow muscle atrophy.
4/1/07 - Owners phoned to say dog much more comfortable after treatment and definite movement of shoulder after acupuncture treatment. Dog seemed to be dragging the limb less.
9/1/07 - Much improved limb placement. Harvey able to hold his limb straight when sitting. Good superficial and deep pain response, and limb withdrawal stronger. Definite proximal limb response but distally still a poor response. Poor proprioception RF limb. Still NWB but holding limb higher when walking. Neck pain resolved, and he was much more comfortable with lateral movement of head and neck. Repeated electro-acupuncture.
Began hydrotherapy treadmill exercise but due to C7-T1 focus of pain, care re over-extension of RF shoulder and dorsiflexion of head/neck (free swimming not appropriate at this stage.) Did 3x2 minute sessions initially with support, to encourage proprioception. Harvey attempted to compensate with other 3 legs and tired easily.
16/1/07 -Repeated treadmill session of proprioceptive work with assistance 3 x 2 minutes. Concern regarding the muscle atrophy and owners having trouble with exercises. Given large peanut ball as dog is reluctant to use physio ball.
Harvey developed lick granuloma on the dorsum of his right fore paw, so applied a light dressing and prescribed antibiotics.
18/1/07 - Improved generally although still muscle atrophy++. Slow 2 minute warm up on treadmill, then proprioceptive work with assistance 2 x 3 minutes. Tried swimming in treadmill, however although he showed some ability to advance the RF limb he tired easily after 2 minutes. Discussed splinting, although difficult at present, as inability to advance the limb, due to muscle weakness.
23/1/07 - Aquatic treadmill and assisted proprioceptive work 3x3 mins after warm up. 3 minutes free swimming with life jacket supporting dog, enjoyed this although tired quickly. Arranged to book free swimming session weekly along with weekly treadmill and acupuncture sessions.
25/01/07 - Good proximal forelimb activity when free swimming and assisted proprioceptive and limb weight bearing / placement on treadmill. Tried floats to encourage weight bearing on RF limb, as Harvey had developed a compensatory gait pattern. Continued work on a peanut ball to improve distal limb function and muscle strength.
Plan:
Harvey is to continue an intensive 6-8 week rehabilitation programme with swimming, aquatic treadmill and regular acupuncture sessions. We aim to see an improvement in limb proprioception over the next 2-3 weeks and to maintain or improve muscle strength and bulk during this time. We may splint the limb using an Ortho-vet splint once the lick granuloma on Harvey’s paw has resolved.
The owners are to carry on with progressive exercise programme at home using peanut ball and muscle stimulator initially. Owner compliance is essential in these cases and we do find they really need our advice and guidance with these long term rehabilitation cases, especially when there is a plateau in the animal’s progression.
Although we hope Harvey will regain use of his right fore, a full recovery of total limb function may not be possible in this case. It is important that the owners are informed of this and have a realistic view of the likely outcome.
Monday 26 October 2009
Bella - Neutered Female Border Collie with Hip Dysplasia
The owner reported Bella had demonstrated recurrent lameness post agility and also noticed a failure to extend her hindlimbs over jumps. She had an increased tendency to sit afterwards, and tended to “pull” herself with her front legs rather than use her back end (as demonstrated in photo). She was originally prescribed rest and non-steriodal anti-inflammatories (Metacam). Bella’s problems continued however, and x-rays were performed by her referring vet.
Bella was diagnosed with Hip Dysplasia October 2003. Her right hip was worse and there was pain particularly on extension of R hip. Her vet advised use of Metacam with hydrotherapy and restricted land based exercise. Her prognosis with regard’s to her agility prospects was questionable, so her owner took the responsible decision to retire this very talented performer. She began Seraquin joint supplement, to help maintain her existing joint function.
Bella was referred to The Linhay during July 2006 as although retired from agility, she still demonstrated intermittent lameness and discomfort after exercise.
On examination, Bella had reduced extension and flexion of both hips, although the right hip was worse. She resented any manipulation and demonstrated a considerable pain response ie became very grumpy! Hip extensor muscles were very tight and there was also paraspinal spasm of the lumbar muscles (lower back).
There was considerable muscle wastage around the hips on both sides. Bella had discomfort associated with mobility changes and muscle weakness - a common, vicious cycle of events with hip dysplasia and arthritis.
On gait analysis, Bella had a typical compensatory gait pattern, using her forelimbs and throwing herself onto her forehand, to avoid using her hindlimbs. She avoided any hip extension and generally had a very short and stilted gait.
We started acupuncture weekly for 3 weeks, and she had a response after only two treatments. Acupuncture is excellent for helping with chronic pain associated with hip dysplasia and osteoarthritis. We also began hydrotherapy using a combination of pool and aquatic treadmill. Bella was much less grumpy on manipulation of the hips, and began to move more freely on land. Once we had adequate control of Bella’s chronic pain state, we were able to work on building up the muscle strength and endurance in her hindlimbs. If the soft tissues supporting the joint are strengthened in this way, the ball-and-socket hip joint then becomes more stable and more mobile. Sessions were bi-weekly initially then weekly for the first month. We continued to see an improvement in Bella’s gait and general ability to exercise on land, without stiffness afterwards. Bella's owner reported that Bella was much happier in herself and wanting to do agility again (although not allowed too!).
Bella, 6 months later, looks sound on land and during gait analysis on the aquatic treadmill. She has 4-6 weekly acupuncture and hydrotherapy sessions to maintain her much improved quality of life and happy retirement!
Piki - 12 Year Old with Osteoarthritis of Hips and Elbows
Reason for Referral:
Geriatric dog with osteoarthritis of hips and elbows. Bilateral hip dysplasia diagnosed as 7 year old.
Medical history:
October 2003: Given Cartrophen injections 4 weekly then annual top ups. This helped initially.
November 2005: Worsening of symptoms and reluctance to walk. Prescribed Rimadyl (non-steriodal anti-inflammatory) and Seraquin (neutraceutical joint supplement), which did improve her mobility, although she still struggled in cold/damp weather.
November 2006: Progressive worsening of mobility and reluctance to walk. Dog very dull and depressed, especially in cold and damp conditions.
Veterinary examination:
Generalised osteoarthritis and severe pain and reduced ROM bilateral hips and elbows. Piki was very uncomfortable and generally restless.
Moderate to severe muscle atrophy of gluteals, hamstrings and quadriceps, and hindlimb weakness generally. Difficulty sit-stand and owners report dog reluctant to rise without assistance. Very stiff and stilted action as lame forelimbs and hindlimbs. Acupuncture point SP12 reactive which may indicate sciatic pain L>R. Acupuncture performed bilateral, local elbow points LI11,TH10, LU5 and bilateral hip points BL54, GB20/30. Also BL23, BL40, BL60, ST36/SP6, lumbar Ba Hui.
30/11/06 - Much improved and owners reported Piki “bounding around like a 2yo!”
Dog much happier and very much improved mobility-excellent response after only 24 hours post acupuncture treatment. Repeat acupuncture using similar points repeat acupuncture 1 week.
4/1/06 - Acupuncture repeated using same points and dog wanting to go for walks at home and demeanour much more like she used to be.
9/1/07 - Begin bi-weekly aquatic treadmill sessions to strengthen hindlimb muscles and improve joint ROM in elbows and hips. Initially 2min warm up then 2x 3mins, 2 min warm down and coped very well.
Bi-weekly treadmill for 4 weeks and excellent improvement in muscle strength and cardiovascular fitness.
Discussion with referring vet. Reduced Rimadyl dose to half, and maintain on joint supplement.
Plan:
Reduce treadmill to once weekly for 3-4 weeks then owner very keen to carry on with 2 weekly maintenance sessions as there has been such an improvement in Piki’s willingness and ability to exercise.
Acupuncture sessions 4-6 weekly to maintain relief from chronic pain.
Progressive home exercise programme with small frequent walks 4-6 x daily.
Prince - Obese 8 Year Old Neutered Male Labrador
Prince first came to us at the beginning of November 2006. His caring owners were seeking advice & support to help Prince lose weight.
At 75.15 kg he weighed more than double his healthy weight. This was exacerbating an existing problem he has with both his stifle (knee) joints, as well as predisposing him to other problems such as heart disease.
After ruling out a thyroid condition & assessing his lifestyle, we decided with his owners to hospitalise him on an individual diet & exercise plan.
His daily food ration is divided into 4 meals, to help him burn off the energy over the day. He is also fasted for 1 day a week – a situation that is quite natural for dogs, & one that Prince accepts well.
Prince has regular sessions on our hydrotherapy treadmill as well as going for walks in surrounding fields. The hydrotherapy treadmill has enabled us to build Prince’s exercise up slowly, as he was extremely unfit to begin with. The warm water also helps to support his joints, & gives him gentle resistance to work against.To help with the pain in his joints Prince receives acupuncture treatments. He began with twice weekly treatments for 4 weeks, reducing to weekly treatments at present. This has helped his ability to exercise, & has enabled us to stop his anti-inflammatory medication.
Initially Prince managed 4 minutes at a time on the treadmill & couldn’t walk far.
Five weeks later, Prince weighs 64.8kg. He loves his treadmill sessions & can manage 20 minutes each time.
By February 2007, Prince weighs 53kg, having lost over 20kg in weight. He is doing very well & can already enjoy a new lease of life, playing with a ball & going for fun walks.
Popi - Agility Collie
The inner thigh muscles of the hind limb that Popi keeps re-injuring are the Gracilis and Adductor muscles. These muscles attach from the pelvis to femur and tibia bones. Their action is to draw the hind leg in and under the body, bend the knee, and extend the knee and hock. They can easily be overstretched and injured in agility work, and are at risk when they are not well developed and exercised sufficiently.
In July o6 Popi attended the Linhay for an assessment. She was in full work and competing, but the owner was concerned she may re-injure and wanted advice on an exercise program to prevent re-occurrence. The owner did not allow Popi to work off lead very often; most free exercise work was done at training sessions 2 times a week. It became apparent that Popi was not doing enough specific muscle training work to achieve suitable strength and muscle support and balance of the hind limbs particularly and she could generally improve on overall muscle development to work at top agility level safely and injury free.
On examination Popi was sound on a straight line but on a left circle a mild shortened stride of the right hind was apparent. There was some muscle wastage of the right thigh circumference and an obvious muscle imbalance with more muscle definition of the front and back thigh muscles i.e. quadriceps and hamstrings in comparison to less defined inner and outer thigh muscles i.e. adductors and abductors respectively. On palpation a taut right adductor muscle band and tendon insertion was felt. A mild soft tissue strain was diagnosed.
The soft tissues were treated with veterinary acupuncture and manual physiotherapy. Advice was given on an exercise/reconditioning program, stretching pre/post exercise, combining straight line controlled work with lateral, circle, weaving work to achieve a good muscle balance of the hind limbs. Popi also started fitness and gait training on the hydrotherapy treadmill; free swimming could also be introduced to assist strengthening of the thigh muscles with circles, figure of 8, sharp turns working against the resistance of the water and using jets to increase the work load. Popi remained in full training and competing.
Unfortunately she was still episodically becoming sore after competition. She re-injured the LH adductors at the World Championships in October 2006. Treatment with acupuncture and physiotherapy was administered and water treadmill exercise. An ultrasound scan of the adductor region was advised at this stage to determine the degree of muscle/tendon damage; this is a very useful tool in human sports medicine to help determine a prognosis regarding continued sport. Unfortunately we are still waiting for this scan to be done.
With treatment and exercise Popi continued to become symptom free, a scan would be now be more useful in the acute stage of injury. Since the end of October Popi has continued weekly water treadmill sessions and re-examinations of the musculo-skeletal system. She has continued to put muscle on generally and now has a minimal difference in muscle circumference right to left hind. Popi continues with a daily regime of controlled exercise, gradients/hills, walk, trot, transition changes, physioball/balance exercises, alternate days of circles, figure of 8, weaving, free running, normal agility training sessions.Popi had one recent episode of stiffening up after training, the owner was not able to warm her down sufficiently as she was too excitable, then she travelled home for 2 hours in the car and was stiff on return home. The owner was advised in future to leave the training site, warm the dog down for 15 minutes, use a warm dog coat and special dog thermal pack under the car blanket, then a short walk on return home.
Now in February 2007 Popi has remained sound is in full work and competing. This rehabilitation program takes dedication from the owner to perform the home exercises and general exercise regime. Unfortunately with Popi’s chronic injury history it will no doubt mean she is susceptible to re-injury. The scar tissue that keeps developing post strain is non-functional and the muscle-tendon area each side of the scar is put under greater stress during exercise. If the owner continues to work hard on a daily program and with a combined team approach at the Linhay, we will endeavour to keep Popi competing at top level.
In July o6 Popi attended the Linhay for an assessment. She was in full work and competing, but the owner was concerned she may re-injure and wanted advice on an exercise program to prevent re-occurrence. The owner did not allow Popi to work off lead very often; most free exercise work was done at training sessions 2 times a week. It became apparent that Popi was not doing enough specific muscle training work to achieve suitable strength and muscle support and balance of the hind limbs particularly and she could generally improve on overall muscle development to work at top agility level safely and injury free.
On examination Popi was sound on a straight line but on a left circle a mild shortened stride of the right hind was apparent. There was some muscle wastage of the right thigh circumference and an obvious muscle imbalance with more muscle definition of the front and back thigh muscles i.e. quadriceps and hamstrings in comparison to less defined inner and outer thigh muscles i.e. adductors and abductors respectively. On palpation a taut right adductor muscle band and tendon insertion was felt. A mild soft tissue strain was diagnosed.
The soft tissues were treated with veterinary acupuncture and manual physiotherapy. Advice was given on an exercise/reconditioning program, stretching pre/post exercise, combining straight line controlled work with lateral, circle, weaving work to achieve a good muscle balance of the hind limbs. Popi also started fitness and gait training on the hydrotherapy treadmill; free swimming could also be introduced to assist strengthening of the thigh muscles with circles, figure of 8, sharp turns working against the resistance of the water and using jets to increase the work load. Popi remained in full training and competing.
Unfortunately she was still episodically becoming sore after competition. She re-injured the LH adductors at the World Championships in October 2006. Treatment with acupuncture and physiotherapy was administered and water treadmill exercise. An ultrasound scan of the adductor region was advised at this stage to determine the degree of muscle/tendon damage; this is a very useful tool in human sports medicine to help determine a prognosis regarding continued sport. Unfortunately we are still waiting for this scan to be done.
With treatment and exercise Popi continued to become symptom free, a scan would be now be more useful in the acute stage of injury. Since the end of October Popi has continued weekly water treadmill sessions and re-examinations of the musculo-skeletal system. She has continued to put muscle on generally and now has a minimal difference in muscle circumference right to left hind. Popi continues with a daily regime of controlled exercise, gradients/hills, walk, trot, transition changes, physioball/balance exercises, alternate days of circles, figure of 8, weaving, free running, normal agility training sessions.Popi had one recent episode of stiffening up after training, the owner was not able to warm her down sufficiently as she was too excitable, then she travelled home for 2 hours in the car and was stiff on return home. The owner was advised in future to leave the training site, warm the dog down for 15 minutes, use a warm dog coat and special dog thermal pack under the car blanket, then a short walk on return home.
Now in February 2007 Popi has remained sound is in full work and competing. This rehabilitation program takes dedication from the owner to perform the home exercises and general exercise regime. Unfortunately with Popi’s chronic injury history it will no doubt mean she is susceptible to re-injury. The scar tissue that keeps developing post strain is non-functional and the muscle-tendon area each side of the scar is put under greater stress during exercise. If the owner continues to work hard on a daily program and with a combined team approach at the Linhay, we will endeavour to keep Popi competing at top level.
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