Charlie – 6 year old Male Sprocker Spaniel

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History of the Case 

  • Dog’s lifestyle/occupation: Companion Animal; will sometimes go to work with owner. 
  • Brief history of dog’s family history (i.e. adopted from Humane Society, owner has owned since puppy, etc): Has had Charlie since a puppy. Has been an intact male, until recently (this past Christmas had neuter procedure performed) and believes that Charlie’s soundness has really not been the same since 
  • Brief history of problem in which dog is referred for (i.e. date of injury or onset of problem, how owners’ noticed a problem, type of problem noticed): 
    • Charlie presented to the SMART Veterinary Clinic for evaluation and physiotherapy for an undetermined cause of a chronic right forelimb lameness. 
    • Five to six months ago, Charlie began to limp and hesitate to bear weight on his right forelimb. Initially Charlie responded well to strict rest and NSAID therapy, but after returning to a mild exercise routine he would become lame again and sometimes demonstrate shifting lameness of other limbs or would freeze and be unable to move. Charlie’s walks have been cut down significantly and he no longer runs after a ball (originally Charlie’s favourite activity). 
    • With deterioration and lack of resolution of Charlie’s discomfort he was referred to Weighbridge Referral Centre for radiographs and evaluation of his right forelimb and cervical spine. A small osteophyte was found along the caudal border of the humeral head and there was evidence of remodeling of the medial coronoid process which could be indicative of a degree of elbow dysplasia; however, these findings did not necessarily explain the degree of pain that Charlie has been experiencing clinically. The owner reported that this week prior to our evaluation had been particularly painful for Charlie. He is currently on Metacam, but the owner does not believe that it is helping as much as it did when Charlie was initially placed on the medication. 
  • Interventions (i.e. medication, restrictions, exercise, rest, etc.):
    • Metacam Oral Suspension: Give 15kg dose per os every 24hours
    • Strict Rest—no running or jumping or offleash activity (owner struggled with this as Charlie is a very exuberant dog) 
  • Referring veterinarian’s diagnosis: Chronic right forelimb lameness—definitive cause open 
  • Test Results (please include a photograph or digital picture of the appropriate test): None reported 
  • Radiographs: 
  • Laboratory results: N/A 
  • CT Scan/MRI: N/A 
  • Surgery (if appropriate): N/A 

• Past medical history: Of note Charlie had corrective cranial cruciate ligament repair surgery of the left stifle in 2016 and had not previously presented with signs of orthopaedic pain since recovering from that procedure. 

Evaluation 

  • •Observation/Gait Analysis/PROM—Initial Assessment April 12, 2019
    • On gait analysis Charlie was Grade 3/6 lame at the walk with a notable head bob that would rise up with weight placement in the right forelimb. He was moderately short strided in the front, being unable to fully extend the right forelimb during the caudal stance phase of the walk. He lacked flexibility and a fluid shoulder glide in his forelimb movement. Charlie would also abduct both of his elbows laterally at the walk and while at rest attempted to shift his weight caudally. In the back he hinged in the thorcolumbar junction and presented with a moderate pendulous swing in his hips most likely secondary to an overall lack of core and pelvic limb stability. He tended to circumduct the left hip and lacked appropriate hip flexion or stifle extension, also shortening the stride of his pelvic limbs at the walk. At rest Charlie would shift and offload the right forelimb to the left side. When challenged to complete a circle, Charlie could not complete a circle to the right loosing stability and stumbling on the right forelimb. When attempting the left sided circle his stride and extension on the right forelimb shortened further. At the end of the gait evaluation Charlie was fatigued. 
    • On physical exam, Charlie’s body condition score was a 6/9. Anatomically he was base wide in the front and narrow in the back. He had mild muscle wasting and sluggish tone in the right forelimb, particularly in the triceps, and deltoid muscle groups. Charlie resented manipulation of the right forelimb, and vocalized in pain and withdrew the limb when the right biceps tendon was stretched. He resisted elbow and shoulder flexion and extension. Charlie was stiff in his shoulder glide and resented left sided traction of the scapula (most likely secondary to compensatory movement). Charlie was reactive and tight on deep palpation bilaterally of his cervical trapezius, and in his latissimus dorsi muscle groups just behind the shoulder blades. He was also reactive in his right superficial pectoral, biceps, triceps and intercostal muscles. He lacked spinal flexibility, but did not seem to demonstrate signs of discomfort when manipulated or palpated along his paraspinal epaxial muscles. He had a moderate reaction with deep palpation bilaterally of his hip flexor muscle groups, with the most significant noxious response to the right iliopsoas. There was no obvious signs of nerve root pain appreciated at this time. His stifle joints were able to be put through appropriate range of motion and no pain or effusion was found. Neurologically, Charlie was within normal limits. 
  • Pain assessment [0-10] (using pain assessment scale from, Matthews, K.A., Pain assessment and general approach to management, Management of Pain, The Veterinary Clinics of North America, Small Animal Practice, July 2000, p. 729-755): 7-8/10 on deep palpation along biceps tendon & hip flexor muscle groups
  • Assessment:
    • Problems: 
      • Primary diagnosis of Charlie’s chronic pain is open given the multiple muscle groups that are painful and reactive leading to a compensatory gait pattern that has further spiraled Charlie’s overall discomfort. 
      • Suspect the initial cause of Charlie’s lameness, in lieu of not having a definitive orthopaedic cause found on radiographs, stems from a possible right biceps tendinopathy 
    • Goals: 
      • Focus on lowering Charlie’s pain scores with a multimodal approach, and relieve muscle spasm. 
      • Find a definitive diagnosis for chronic lameness—offered diagnostic ultrasound of the right biceps tendon with SMART Clinic; was declined by owner, elects to go forward with physiotherapy and evaluate response before going forward with any further diagnostics 
  • Treatment Plan:
    • Home exercise program: 
      • Initial home exercise plan: Warm compress applied over lower back, and groin region ~7-10min every 8-12hours; followed by square standing exercises hold for 5-10sec and attempt to encourage appropriate paw placement; further exercises to be reviewed after response of today’s treatment, warm compress therapy and response to Amantadine 
      • We recommend he continue Metacam at this time and have also started Charlie on Amantadine 25mg 2 tablets per os every 24hours. Introduced “Figure of 8” head collar to help encourage slow walking without pulling 
        • Short frequent walks encouraged outside ~5-10min every 8hours 
    • Program within clinic or hospital: Will look to have Charlie in for weekly hourly sessions and adjust based upon clinical status. 

Actual History of Treatment 

  • • 04/18/2019
    • Subjective: Owner believes that Charlie is still depressed and not comfortable; he is not liking restriction to activity. Did have a few good days initially after treatment, but did get over excited a few days ago and may have re-injured himself. 
    • Objective:
      • BARH 
      • Gait: Improved control of gait pattern with head collar; head bob still present but not as frequent; abducts out left forelimb; short strided in right; Grade 3/6 lameness right forelimb 
      • PE: Muscularly much more comfortable—spasm reduced; less reactive over palpation over the cervical trapezius, pectorals, intercostals and thoracolumbar paraspinal muscle groups.Still reactive and pain on biceps tendon stretch 
    • Treatment and parameters 
      • Neuromotor gait training in UWT; some initial assistance required to help encourage right forelimb extension; Charlie fatigued quickly on the right forelimb, so session was kept short 
      • Acupuncture: GB21; Bld11, 13, 17, 25, 57, 60; GB29,30 
      • Exercises: Square standing exercise review w/owner; proprioceptive track walking and continued warm compress over lower back 
    • Measurable outcomes: Still Grade 3/6 lameness on right forelimb w/headbob 
    • Assessment:
      • Progress: Some resolution in muscle spasm from assumed compensatory gait pattern; Charlie walks much better with a headcollar so believe that home walking program will be more easily managed by owner 
      • Deficits remaining from initial plan: still painful w/deep palaption of biceps tendon despite Amantadine therapy not fully effective in helping to manage discomfort 
      • Remaining problems and goals: See deficits; adjusting Amantadine dosing therapy to twice daily and evaluate response to change. Owner compliance—discussed with owner importance of keeping Charlie from running in the garden, that this could lead to further injury of the affected limb. 
    • Plan – plan of care for next visits: 1hour appointment next week 
  • • 04/25/2019
    • Subjective: Had ups and downs last week. Initially after therapy, was tired and seemed sore. On Saturday was unwilling to get up or move and would not bear weight through the right forelimb. Discontinued the Amantadine, did not think it was helping. Only on Metacam right now. Sunday-Tues steadily improved and was able to put weight completely on right front with no head bob. Had a “frenzy” episode and now seems sore again. 
    • Objective:
      • BARH 
      • Gait: Consistent from last eval 
      • PE: Tightness/reactivity through cervical trapezius has loosened off; very tight through thoracolumbar paraspinals; still moderate to severe reaction in right illopsoas…suspect irritation of obturator nerve root. 
      • Neurologically: Appropriate. 
    • Treatment and parameters
      • Neuromotor gait training in UWT 
      • Acupuncture: GB21; Bld11, 13, 17, 25, 57, 60; GB29,30 + Elect 
      • Soft tissue work over neck, and thorocaolumbar paraspinals 
    • Measurable outcomes: Still Grade 3/6 lameness on right forelimb w/headbob persists 
    • Assessment:
      • Progress: Stymied with continued re-injury from frenzy episodes and d/c of medication from owner 
      • Deficits remaining from initial plan: still painful w/deep palaption of biceps tendon though improved comfort in other muscle groups 
      • Remaining problems and goals: See deficits; adjusting treatment plan to have Charlie as a day patient to really focus on painful loci and gait training 
    • Owner education: Continue to try to limit Charlie’s activity. Concerned he continues to re-irritate biceps tendon and illopsoas. Cont warm compress over affected areas. Attempt square standing exercises with head turns. Rec inpatient treatment to try to get ontop of nerve root discomfort; STM; Accup + Elect. Will D/C Amantadine. Consider Diazapam as a muscle relaxant in future if persists. Considering laser therapy over biceps tendon in clinic. 
    • Plan – plan of care for next visits: Inpatient next week
      • Owner education follow up next day: Client Communication: TTO, Charlie is doing well today. Slept well after yesterday’s treatment. Taking Charlie on a walk today and will re-eval comfort level and keep us posted on his progress at home with current treatment plan. 
  • •05/02/2019
    • Subjective: Shown some signs of improvement at home–mood/demeanor has brightened. Did have a “zoomies” event earlier this week but seemed to recover better than last time. Performing head/neck stretches, heat pack. Walks 10min 2x day. Was performing head turns, but this was difficult. 
    • Objective:
      • BARH 
      • Gait: Reduced head bob; better right forelimb extension with improved confidence in weight bearing and placement; elbows turned more medially/appropriately towards midline 
      • PE: Improved comfort through neck and less restrictive through shoulders. Still modest tightness/reactivity through paraspinals with discomfort on deep palpation of the right ilopsoas. 
    • Treatment and parameters 
      • STM over paraspinals, Acup + Elec (performed twice today—AM and PM after last TM session), Warm compress, Neuromotor gait training (3x UWT gait training) 
      • Exercise review: square standing with gentle forward stretches to help extend groin/hip flexors and thoracolumbar paraspinals; look at “give paw” exercise to encourage forelimb extension 
      • Continue with short frequent walks; leash walks only!!!!!!! 
    • Plan–plan of care for next visits: Inpatient next week 
  • •05/10/2019
    • Subjective: Was better for longer last week. Was walking wonderfully at the end of his treatment last week through Monday. In the garden had a “zoomies” event and then started to be lame after this episode. Charlie did bounce back faster than previously. Unsuccessful at getting Charlie to perform static exercises. 
    • Objective: BARH 
      • Gait: Head bob absent today; better right forelimb extension with improved confidence in weight bearing and placement; elbows turned more medially/appropriately towards midline–improved neuromotor gait training and self initiating right forelimb extension 
      • PE: Improved comfort through neck and less restrictive through shoulders. More relaxed paraspinals and reduced spasm in right illopsoas 
    • Treatment and parameters 
      • STM, Acup + Elec, laser therapy (Class IIIA laser probe) treatment applied over right biceps tendon; Neuromotor gait training in UWT 3x 
      • Exercise review, and discussed possibly keeping Charlie on a long lead in the garden so as to try to prevent a zoomies outburst. 
    • Plan–plan of care for next visits: Inpatient next week—intensive treatments very well tolerated 
  • •05/16/2019
    • Subjective: No history shared—Charlie dropped off by family member who was not aware of how Charlie was doing—assumed that he has been fine. 
    • Objective: BARH 
      • Gait: Grade 0/6–No appreciable lameness in clinic today! No appreciable headbob 
      • PE: Improved ROM in shoulder and extension better tolerated, no appreciable discomfort or restriction on neck ROM today; no pain with deep palpation over biceps tendon 
    • Treatment and parameters
      • Repeat of last treatment session: Acup + Elec, laser therapy (Class IIIA laser probe) treatment applied over right biceps tendon; Neuromotor gait training in UWT 3x—improved forelimb activation; no lameness with challenge of TM training w/improved duration of walking/increased endurance 
    • Owner education: Discharge Notes TGH w/family member: 
      • “Charlie has done well in the clinic today. Charlie continues to improve during neuromotor training and physiotherapy sessions showing an appreciable improvement in endurance and range of movement. Please continue Charlie’s head turning exercises at home now that he is more comfortable. Continue short controlled walks lead walks on his figure of 8 headcollar. We would like to see Charlie again next week. Please don’t hesitate to contact us with any questions.” 
    • Plan – plan of care for next visits: Inpatient next week—very positive outcome 
  • •05/23/2019
    • Subjective: Owner reports Charlie doing well at home. Did well after last weeks session. Was recently stiff in AM, and slow on return part of walk. 
    • Objective:
      • Gait: Grade 0/6–No appreciable lameness in clinic today. No appreciable headbob 
      • Has maintained relaxed resting muscle tone and is comfortable on palpation. Good RoM in RF, shoulders and elbow, and no discomfort evident on movement of neck or along deep palpation of biceps 
    • Treatment and parameters
      • Repeat of last treatment session: Acup + Elec, laser therapy (Class IIIA laser probe) treatment applied over right biceps tendon; Neuromotor gait training in UWT 3x—continued improvement in endurance 
        • Further improvement in endurance (wonder if reluctance at end of walk at home is due to not wanting to finish rather than fatigue?) 
      • Palp moderate spasm and tension at cranial scapulae through caudal traps and paraspinals stemming from T2-T6 
        • Soft tissue massage to affected muscle groups! Exercise review: Walking 15 mins BID, mix of on and off lead per owner.• 
          • Look into adding pole work to encourage further forelimb stepping/tracking; place 3-4poles ~1metre to 1 1⁄2 metre apart and encourage Charlie to walk/step over slowly 3-4x; repeat 2-3x a day 
    • Plan – plan of care for next visits: Inpatient next week—very positive outcome 
  • •05/30/2019
    • Subjective: Owner reports Charlie walks10-15mins SID currently, still a little stiff in mornings. Finds getting Charlie to walk over poles to be very difficult and Charlie no longer interested in head turn stretches. 
    • Objective: BAR; Further improvement in comfort levels, comfortable in psoas today, no FL lameness appreciable, reduced lateral stability R stifle as fatigues 
    • Treatment and parameters 
      • Neuromotor gait training in UWT 3x 
      • Acupuncture: GB21; Bld11, 13, 17, 25, 57, 60; GB29,30 + Elect 
      • Soft tissue work over neck, and thorocaolumbar paraspinals 
      • D/C laser treatment this week 
      • Ex Review: instead of pole work, tried walking Charlie in Fig of 8 pattern; set up three cones and walked Charlie slowly in serpentine fashion; repeat 3-4 times; perform 2-3x daily 
    • Owner education: Cont his exercises (poles, head turns, figures of 8). Evaluate comfort level with increased duration in between visits 
    • Plan – plan of care for next visits: Inpatient; extend to two weeks 
  • •06/12/2019
    • Subjective: Discussed with family member who dropped Charlie off; based on previous descriptions improved coordination and stride length all four limbs, increased willingness to stay standing!
    • Objective:
      • Gait: Ambulatory; no appreciable lameness today 
      • PE: Tight ventral fascial line towards sternum/including diaphragmatic arch. High tone through left iliopsoas with one large trigger point, reluctant to allow stifle to come out from medial rotation/groin shortening in a stand. Mild pain on palpation of body of biceps brachii, but very tight upon stretching. 
    • Treatment and parameters
      • Repeat of Acup + Elec, laser therapy (Class IIIA laser probe) treatment applied over right biceps tendon and left illopsoas; Neuromotor gait training in UWT reduced to 2x due to soreness
        • High tone in psosoas did reduce through the day’s treatment 
      • Fascial release applied along sternum 
      • Thoughts: Restrictions responded well to treatment; will try another 2 week increase in between treatments and eval if we need to go back to weekly 
  • 06/26/2019 
    • Subjective: Sadly no drop off info given by family member; family member believes Charlie has done well since last visit. Nothing ill to report. 
    • Objective: Incr resting tone in ce mm, extending into pectorals bilaterally. Mildly reactive. More comfortable in psoas today. 
    • Treatment and parameters 
      • STM: massaged and fascial release left thoracic trapezius, left iliopsoas with good response, tissues relaxed following with minimal reactivity. 
      • Repeat of Acup + Elec, laser therapy (Class IIIA laser probe) treatment applied over right biceps tendon and left illopsoas; Neuromotor gait training in UWT reduced to 2x due to soreness 
    • Owner education: Disc with o at discharge; struggles with hands on exercises – Charlie remains uncooperative.For this fortnight focus on SLOW lead walking in the evening and serpentine walk at start and end of each walk.At next visit look at expanding dynamic exercises – try fig 8 and poles, panned poles etc. OR did try early on but Charlie wouldn’t do them very well. 
    • Plan – plan of care for next visits: Inpatient in a fortnight 
  • •07/12/2019
    • Subjective: Has done well at home. Sitting better and lighter on his feet. Currently performing serpentines; walking 10min on leash, 10min off; 30min walks split into AM and PM. Well tolerated 
    • Objective: BARH; gained weight 6-7/9BCS
      • Gait: no visible signs of lameness or head bob; improved limb extension and flexion; improved endurance during neuromotor gait training
      • PE: Comfortable overall for palpation; some mild to modest restriction over right gluteal and hip flexor but responded well to treatment 
    • Treatment and parameters
      • STM, Acup, Neuromotor gait training 
        • Fascial release over the cervical trapezius/brachiocephalicus; general massage over thoracolumbar epaxials; relaxed quite nicely.Nutrition Review–weight loss plan—owner will be in touch with feeding routine so we can eval kcal to prevent further weight gain 
    • Owner education: Continue dynamic exercises (static ones owner finds difficult); rec cont walking at current duration and add gentle slopes to walking routine; cont serpentines/figure of 8’s very pleased with Charlie’s progress 

Discussion 

  • •How many visits?
    • 12 visits and still continuing treatment 
  • Veterinarian feedback
    • Referring veterinarian is pleased with Charlie’s progress.
    • Revisit with orthopedic surgeon still pending, but based upon positive clinical response to therapy, biceps tendinopathy/soft tissue injury most likely at this time and recovery has been positive without surgical intervention. 
  • Owner compliance:
    • Charlie is a very happy, energetic and happy spaniel. We knew in the beginning of treatment that keeping Charlie calm and quiet would be a challenge. The owner particularly had that difficulty in helping Charlie perform any type of static exercise so we changed to more dynamic exercises in attempts to achieve similar stretches and strengthening exercises 
    • The owner really had trouble with keeping Charlie on a leash, even though he did well with his figure of 8 headcollar. Charlie’s zoomies would often occur in the yard without his leash, which led to set backs in Charlie’s condition 
  • How do you feel physical therapy made a difference in this particular case? 
    • I do believe we’ve made a difference in Charlie with physical therapy. Even though we were unable to confirm diagnostically my suspicions of Charlie’s biceps tendinopathy, we were able to help relieve pain in discomfort in the affected areas with a multimodal approach, relieve compensatory muscle spasm and achieve a functional gait pattern. He is now able to be more active and less likely to injure himself, especially with his tendency to have a “spaniel funny 5minutes.” 
  • What is your speculation of the case if the patient did not receive physical therapy? 
    • I think given Charlie’s high energy level and without physiotherapy treatments he would have lost muscle conditioning in his shoulder and forelimb muscle groups. I fear he would have continued to be painful and that chronic re-injury could lead to fibrosis/shortening of the tendon or that a complete rupture could have occurred. 
  • What could have been altered in the physical therapy care of this case? Were there any barriers to the outcome of the case 
    • Ideally diagnostic ultrasound of the biceps tendon
    • Started laser therapy on the tendon sooner
    • Ideally for static exercises to have been performed at home; compliance was very difficult to achieve, but I believe that Charlie’s response to treatment in clinic and management of Charlie’s lifestyle/walking routine as well as a multimodal approach to pain management helped us to be successful despite these barriers to our ideal treatment plan. 
  • How was billing performed in this case?
    • Billed for time—hourly appointment slots; inpatient day patient 
Skills

Posted on

June 3, 2021

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