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CANINE SPORTS MEDICINE AND

REHABILITATION: WHAT YOUR CLIENTS EXPECT

Janet B. Van Dyke, DVM, Diplomate, American College of Veterinary Sports Medicine and Rehabilitation

Canine Rehabilitation Institute

CVMA Annual Conference

September 20 , 2013

MUSCULOSKELETAL DYSFUNTION:

n A Lameness Presents and the Radiographs Are Negative, Now What?

What is Veterinary Sports Medicine?

� It is not the same as Veterinary Orthopedics

� Canine Sports Medicine includes: � Anatomy and Biomechanics � Exercise Physiology � Conditioning and Retraining � Orthopedics � Internal Medicine � Pulmonology

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CANINE SPORTS MEDICINE IS:

� Cardiology

� Neurology

� Gerontology

� Nutrition

� Rehabilitation

� Complementary/Alternative Medicine

AMERICAN COLLEGE OF VETERINARY SPORTS MEDICINE

AND REHABILITATION

AMERICAN COLLEGE OF VETERINARY SPORTS MEDICINE

AND REHABILITATION �  Developed 2002-2010

�  Approved by AVMA and ABVS 2010

�  Residencies, Training Programs, Examination

�  Currently 85 Diplomates from 5 countries

�  7 Active Residencies �  3 Equine �  4 Canine

�  www.VSMR.org

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Why Add Sports Medicine to Your Practice?

� Opportunity to practice state-of-the-art rehabilitation medicine

� Work with highly educated clients who have significant financial and time investment in their dogs

� Healthy dogs are fun to work with

� Measurable success: Return to sport or work

CANINE SPORTS Non Breed Specific:

� Agility

� Obedience � Tracking

� Skijoring/Skatejoring

� Flyball � Disc Dog

� Dock Diving � Canine Puissance

Breed Specific: � Lure Coursing

� Herding � Field Trials/Hunt Tests

� Earth Dog Tests

� Coon Dog Tests � Schutzhund

� Mushing � Carting

ORGANIZED CANINE SPORTS

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Agility

FLYBALL

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Schutzhund

DOCK DIVING

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PUISSANCE

DISC DOG

SKIJORING/SKATEJORING

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PULLING/CARTING

WORKING DOGS � Search and rescue

(SAR)

� Bomb detection

� Police

� USDA Beagle Brigade

� Guide Dogs

� Assistance Dogs

� Mold detection

� Geese Police

Why Learn About These Sports?

� You injure your foot playing Soccer with your kids.

� You visit a physician who asks, “What is Soccer?” � Your comfort level with having him

treat you? � Your willingness to follow his plan of

care?

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What is Veterinary Rehabilitation?

� Definition:

� The treatment of physical injury or illness in an animal to decrease pain and restore function

What is Veterinary Rehabilitation? �  It is NOT all about the

Underwater Treadmill…Or

the LASER…

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EDUCATION " Physical Therapists � 4-5 year post graduate program � All graduate with a clinical doctorate degree " DPT

� Advanced Certification in clinical specialties " Orthopaedics, Neurology, Cardiopulmonary,

Sports Medicine " Animal Rehabilitation Special Interest Group

A ‘New’ Diagnostic Algorithm

� Kent Allen: “In the absence of a diagnosis, Surgery is trauma, Medicine is poison, and Alternative Therapy is witchcraft.”

� The physical therapist’s approach to the patient � Emphasis upon soft tissues � Special tests allowing determination of

specific tendinopathies and soft tissue impairments

Objective Outcome Measures

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REHABILITATION APPROACH

" Emphasis on a proper, thorough soft tissue diagnosis

" Emphasis on problem solving

" Emphasis on creating and meeting goals which are functional

REHABILITATION APPROACH

� Majority of therapeutics involve manual therapies and problem solving � Joint Mobilizations � Arthrokinematics VS Osteokinematics

� Therapeutic exercise � Concentric

VS Eccentric contractions � Modalities � Cryotherapy � Laser � E-Stim

� “I believe that in the near future, failing to refer a patient for physical therapy will amount to malpractice.”

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� “I believe that in the near future, failing to refer a patient for physical therapy will amount to malpractice.” -1959

H. A. Apfelbach, MD

Director of Orthopedics Rush Presbyterian Medical Center Chicago, IL

ANIMAL REHABILITATION �  WHAT IS DRIVING THIS NEW FIELD?

PUBLIC AWARENESS � Similar to Acupuncture in

the 1980’s � Client driven demand for

veterinary services

� Current Drivers for Canine Rehabilitation � Agility � 2012: >1 Million Entries � >1000 Sanctioned

Events in the US

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WHY SHOULD YOU ADD REHABILITATION TO YOUR

PRACTICE? " Increased awareness

" Client demand � Pain management � Return to sports � Improved geriatric

therapy � Weight management

SPORT-SPECIFIC AND JOB-SPECIFIC INJURIES COMMONLY

TREATED WITH REHABILITATION � Shoulder Insertionopathies

� Medial Shoulder Instability

� Teres Major Strain

� CCL Injuries

� Iliopsoas Strain

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REAHABILITATION OPTIONS FOR THE CCL PATIENT

� Treatment techniques address the following: � Pain � Inflammation

� Hypomobility � Hypermobility � Weakness � Altered muscle

recruitment

PAIN MANAGEMENT n Physical Therapists bring their skills to

the veterinary industry

n Determining specific soft tissue pathologies allows us to apply focused treatments to patients previously treated with “Rest and NSAID’s”

PAIN MANAGEMENT � Medical Management

� Physical Modalities

� Joint Mobilizations

� Stretches

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recruitment

RANGE OF MOTION n OSTEOKINEMATICS

Osteo = bone

Kinematic = motion

DEFINITION:

Bony segments moving around a joint axis

RANGE OF MOTION n Two kinds of Osteokinematic ROM

- Active Range of Motion (AROM)

- Passive Range of Motion (PROM)

n Assessment of AROM and PROM are important components of the rehabilitation evaluation

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ACTIVE RANGE OF MOTION n DEFINITION:

v Active motion performed by the patient

v Responsible for increasing strength

PASSIVE RANGE OF MOTION n DEFINITION: � The motion is performed

by the therapist � No muscular effort by the

patient

n Measured with a Goniometer � Specific bony landmarks

GONIOMETRY

Stable Arm

FULCRUM

Moving Arm

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GONIOMETRY Elbow Flexion:

Proximal Landmark:

Fulcrum:

Distal Landmark:


Proximal Landmark: Greater Tubercle

Fulcrum:

Distal Landmark:



Fulcrum: Lateral Epicondyle

Distal Landmark:

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Fulcrum: Lateral Epicondyle

Distal Landmark: Lateral Styloid Process

ACTIVE VS. PASSIVE ROM What Does It Tell Us?

Clinical Example: AROM: Shoulder Extension

1. Painful

2. AROM Limited

PROM: Shoulder Extension 1. No Pain

2. PROM Normal

ACTIVE VS. PASSIVE ROM What Does It Tell Us?

Clinical Example: AROM: Shoulder Extension

1. Painful

2. AROM Limited

PROM: Shoulder Extension 1. No Pain

2. PROM Normal DDx: Biceps or Supraspinatus Tendinopathy

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QUESTIONS?

LIMITED PROM? � WHAT CAN LIMIT ROM? o Muscle/Tendon – decreased flexibility

o  Intra-articular lesion (meniscus, bone)

o  Joint Capsule shortening

o  Pain

o  Swelling

How do we determine which of these structures is limiting PROM?

n Answer: END FEEL

n Definition:

The sensation or feeling (in your hands) when the joint is at the end of its available PROM

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END FEELS

n BONY

n SOFT-TISSUE APPROXIMATION

n FIRM

n SPRINGY BLOCK

n EMPTY

BONY END FEEL n SENSATION: � HARD (Abrupt)

n BLOCK: � BONE � PAINLESS

n Normal Example: � Elbow extension

BONY END FEEL n Pathological:

Hard end feel occurring BEFORE the normal end range of motion: often painful

n Abnormal Example:

Hip extension with osteoarthritis

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END FEELS n WHY DO WE CARE ABOUT

THEM? q Assists to identify the structure or the

tissue limiting PROM

q Allows focused treatment

ROM AND END FEELS n ROM

1. Active or Passive 2. Which motion? Flexion/Extension 3. Amount of motion

(Goniometer) 4. End Feel 5. Flexibility of 2 joint muscles

WHAT IS NEXT? n Assess: � Arthrokinematics � Accessory Joint Motions � Ligamentous Stability � Muscle Strength

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ARTHROKINEMATICS n DEFINITION:

� Movement that occurs between two joint surfaces

n Glide

n Roll

PATHOLOGY DUE TO POOR ARTHROKINEMATICS

n PURE GLIDE WITHOUT ROLL RESULTS IN IMPINGEMENT OF SOFT TISSUE OR CARTILAGE.

n Example: Drawer without stifle ‘roll’ results in Meniscal entrapment

PATHOLOGOY DUE TO POOR ARTHROKINEMATICS

n PURE ROLL WITHOUT GLIDE RESULTS IN JOINT DISLOCATION

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ARTHROKINEMATICS n Passive

n Involuntary

n “Accessory Joint Motion”

n Normal arthrokinematics are required for normal osteokinematics

QUESTIONS?




recruitment

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REHABILITATION SKILLS � Manual

Techniques

� Therapeutic Exercise

� Physical Modalities

REGULAR REASSESSMENT IS VITAL

� Determine Appropriate Blend of Manual Work, Modalities and Therapeutic Exercise

� Justify Each Element of the Treatment Plan � Based upon Patient Response to Prior

Treatment � Based upon Today’s Findings

� As Pain and Mobility Issues are Resolved, Therapeutic Exercise is the Focus

STIFLE SPECIFICS � Biology and Biomechanics are Key

Contributors to CCL Disease and Injury

� Biology is Addressed with Modalities and Manual Therapy � Decrease Pain � Promote Tissue Healing � Reduce Inflammation and Swelling

� Laser, Ice/Compression

� Grade I-II Joint Compressions

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STIFLE SPECIFICS � Biomechanics �  Instability

Addressed with Therapeutic Exercise � Strengthen

Dynamic Stabilizers of the Stifle and Core

� Proprioceptive Inputting to Prevent Reinjury

TREATMENT RATIONALE � Depends upon the type of surgery � Osteotomy requires activity modification

to ensure bone healing � Human research supports: � Early use of NMES to prevent muscle

atrophy and associated weakness �  Hasagawa, et al, 2011

� Early use of eccentric muscle contractions increase muscle mass and function

�  Gerber, et al., 2009

� Perturbation exercises to enhance coordinated muscle activity

�  Risberg et al., 2007, Chimielewski et al., 2005

Therapeutic Modalities !

� A device or application that delivers a physical agent to the body for therapeutic purposes!

Transfer of ENERGY for therapeutic purposes"

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TREATMENT RATIONALE � Canine research supports:

� Cold Compression Therapy: � Decreased signs of pain,

swelling, and lameness �  Increased stifle joint range of

motion in dogs during the first 24 hours after TPLO �  Drygas, et al. JAVMA, Vol 238, No. 10,

May 15, 2011 pg. 1284-1291

TREATMENT RATIONALE � LASER: � Wound healing: � Increase: fibroblast proliferation,

differentiation, collagen deposition, angiogenesis

� Decrease inflammation and edema: � Decrease: IL-1, PG. Improve WBC activity,

decrease vessel permeability � Decrease pain: � Increase B endorphins, decrease bradykinin,

block C fiber depolarization

Hawkins, DH 2006; Tuner J, 2007; Montesinos M, 1988; Wakabayashi H, 1993

TREATMENT RATIONALE � NMES:

� Canine CCL transection model � Decreased: � cartilage damage, radiographic OA,

crepitus, lameness

� Increased: �  thigh circumference

Johnson JM, Vet Res 1997

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Neuromuscular Electrical Stimulation

n NMES � “E-Stim” � Application of electrical

current to elicit a muscle contraction

� Reduce edema � Muscle re-education � Reversal of atrophy � Wound healing

Effects of Electrotherapy Ø CELLULAR LEVEL - Excitation of nerve cells

- Changes in cell membrane permeability

- Protein synthesis

- Stimulation of fibroblasts, osteoblasts

Electrotherapy

Wound healing

n Increased blood flow to the area

n Stimulates cell turnover

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Electrotherapy for Pain Control/Relief

Gate Theory � Severity of pain

sensation: � Balance of excitatory (C and A-Delta) and inhibitory (A-Beta) inputs to the T (transmission) cells in the spinal cord

Electrotherapy for Pain Control/Relief n TENS � Short-lived effect n One hour ?

� Uses: n Immediately PO n During therapy to

allow pain-free movement

THERAPEUTIC EXERCISE � Proprioception

� Balance

� Muscle Strengthening

� Endurance

� Gait Retraining

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THERAPEUTIC EXERCISE VARIABLES

� Frequency

�  Intensity

� Duration

� Environment

�  Impact

THERAPEUTIC EXERCISE EQUIPMENT

�  PHYSIOBALLS

�  THERABANDS

�  ROCKER BOARDS

�  CAVALETTI POLES

�  TREADMILL

THERAPEUTIC EXERCISE PATIENT CONSIDERATIONS

� Motivation

� Footing

� Assistive Devices

� Leash/Harness Control

OWNER HANDLER CONSIDERATIONS

� Body Mechanics

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PROPRIOCEPTION � Addressed daily to regain proper

balance and to prevent reinjury

� Cavaletti poles and Weave poles

� 

ECCENTRIC EXERCISES � ACL patient needs increased hamstring

strength

� Eccentric hamstring contraction: � Requires lengthening of the muscle while

contracted � Hip flexion � Stifle extension � Tarsus flexion

� Controlled Stand-to-Sit Exercise or Paws On The Counter

� Backward Walking

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PROGRESSION OF EXERCISES � Once proprioception circuits

and strength exercises completed:

� Sports-specific exercises added

� Endurance work progressed

� Cross-training program initiated

� Training calendar created for owner/handler

SUPRASPINATUS TENDINOPATHY � What is a “Tendinopathy”? � Overuse injury of the

tendon and surrounding tissues

� Requires lengthy treatment

� Historically poor results

SUPRASPINATUS TENDINOPATHY

� Unilateral forelimb lameness � Non-responsive to rest and

NSAID’s � Worse after exercise

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SUPRASPINATUS TENDINOPATHY � Anatomy: � Origin: Supraspinous

fossa � Insertion: Anterior

Greater Tubercle � Action: Stabilizer of the

joint; gleno-humeral extension

� Injury: Eccentric contraction during rapid elongation


� Physical Exam findings: � Supraspinatus atrophy � Pain on shoulder flexion � Especially with pressure on the insertion point


� Forelimb muscle girth diminished � Gulick Girthometer

� Decreased ROM Shoulder Flexion � Goniometer

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� Diagnostic Imaging � MRI confirms

presumptive diagnosis � Increased signal

intensity (inflammation vs. fibrosis) at insertion on Greater Tubercle

� May see nodules compressing Biceps tendon of origin


� Causes of injury � Jumping down onto

outstretched limb � Rapid shoulder flexion

with muscle contracted � Agility dismounts � Flyball contacts


� Classic history for tendinopathy:

� Repetitive eccentric contractions with the muscle on stretch

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SUPRASPINATUS TENDINOPATHY � Principal lesion in chronic human rotator

cuff injury

� Research with animal models: � Overuse activity leads to decreased

elasticity � Reduced stress-to-failure � Proliferative nodule at insertion with no

signs of inflammation � Calcification in chronic cases

J Shoulder Elbow Surg 2000


� Surgical management � Historically: Tendon debridement and

release � Poor results reported � JAVMA 1990 and 2005 � Vet Record 1996 � JAAHA 2000


� Extracorporeal Shock Wave Therapy � U of Wisconsin, CVM � Good results

�  Danova NA, Muir P: ESWT for supraspinatus calcifying tendinopathy in two dogs. Vet Rec 152:208-209, 2003

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SUPRASPINATUS TENDINOPATHY � Physical Therapy

techniques in human Supraspinatus Tendinopathy: � Manual Therapy � Ultrasound � LASER � Therapeutic exercise


� Manual Therapy techniques � Joint Mobilizations � Massage � Create brief inflammatory response to

encourage a resolution of chronic signs � Cross Friction Massage �  At tendon insertion �  At tendon-muscle interface �  With internal rotation of the humeral

head

SUPRASPINATUS TENDINOPATHY � Therapeutic Ultrasound � To warm tendon-muscle

interface � To reduce calcification in

tendon sheath

� Stretching after massage or Ultrasound � Shoulder flexion with

internal rotation of the humeral head

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� LASER Therapy � Treatment of choice today � Stimulation of myocyte and fibroblast

mitochondria � Shown to speed healing of

microfractures in soft tissue


� Therapeutic Exercise � Upon relief of any proliferative nodules,

therapeutic exercise is prescribed � Strength Work � Resistance Work � Proprioception Work � Retraining Techniques

SUPRASPINATUS TENDINOPATHY � Therapeutic Exercise � Strength Work � Start with

Concentric Exercise � No resistance � Shoulder extension � Physioball � Cavaletti Poles

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� Therapeutic Exercise--Strength Work � Progress to Concentric with Resistance � Therapy Bands � Water Walking


� Therapeutic Exercise--Strength Work

� Eccentric Exercise after Concentric � Shoulder Flexion with muscle contracted � Lie Down � Walk down stairs or ramp � Commando Crawl

SUPRASPINATUS TENDINOPATHY � Therapeutic Exercise � Proprioception Work

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SUPRASPINATUS TENDINOPATHY � Retraining Techniques � Agility

� Warm up protocol � Cool down protocol � Alter contact techniques

� Flyball � Swimmers’ Turn

� Cross Train

ILIOPSOAS STRAINS ILIOPSOAS (FUSION OF THE PSOAS

MAJOR AND ILIACUS)

§ O: 1) Iliacus: Cranioventral Ilium

2) Psoas Major: Ventral bodies and transverse processes of all Lumbar vertebrae and last 3-4 thoracic vertebrae

§  I: Lesser Trochanter

§ A: Flexion and external rotation of the Hip

Flexion of the Lumbar spine

ILIOPSOAS STRAINS

� Unilateral hind limb lameness

� Diminished extension of rear limbs in jumping

� Decreased use of the rear limbs in weave poles

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ILIOPSOAS STRAINS � Mild thigh girth atrophy � Pain on extension, internal

rotation, abduction of affected CF joint

� Pain on palpation of the region

�  Breur, GJ et al: Traumatic injury of the Iliopsoas muscle in three dogs;JAVMA 210:163-164, 1997

ILIOPSOAS STRAINS � Injury tends to be close to

the myotendinous junction

� Chronic injury results in mineralization of the tendon of insertion

� Diagnostic ultrasound will detect the lesion

� MR or CT are also used

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ILIOPSOAS STRAINS � Treatment for Acute: � Rest, muscle relaxants, ice, NSAIDs � Rehabilitation program for 6-9 weeks � Acupuncture for pain � Modalities: � Laser � Increase circulation � Decrease pain � Speed healing

� Therapeutic Ultrasound

ILIOPSOAS STRAINS � Manual Therapy � PROM without pain � No stretching in acute injury

� Therapeutic Exercise � Stabilization exercises with a gradual

increase in weight bearing � Progress to strength work and AROM � Cavaletti Poles � 2-leg standing (right or left) � Paws on Counter � Wobble Board

ILIOPSOAS STRAINS Treatment for Chronic Strains � Need to fire up the inflammatory process � No NSAIDs � Heat � Ultrasound � Laser � Massage

� Stretch after heat � Correct the mechanics of the lumbosacral spine

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Therapeutic Exercise For Chronic Iliopsoas Strains

� More challenging than treating acute cases

� Require slower return to function

� Long term: High risk of re-injury � Advise warm-up

and stretch routines

ILIOPSOAS STRAINS

� Cross training is important to avoid boredom and reinjury � Endurance (Treadmill) � Jumping � Balance � Plyometrics

� Time off between ‘seasons’ is essential

WHAT WOULD IT TAKE TO ADD SPORTS MEDICINE/REHABILIATATION TO YOUR

PRACTICE? " Training your team

" Minimal equipment list

" Minimal space dedication

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TRAINING THE REHAB TEAM

" Modules " Exams " Internships

IS VETERINARY REHABILITATION A VIABLE BUSINESS?

" Done correctly, YES!

" Business models that have worked the best: � Referral centers with surgery � Free standing rehab-only, referral-only

facilities � Specialty centers with emphasis on

Complementary Medicine and Pain Management

� General Practices that recognize the client-driven demand for Rehabilitation

CONCLUSION Know Your Patient’s Job And Expectations

� Great Diagnostics

� Anatomical Awareness

� Great Manual Skills

� Creative Problem Solving

� Awareness Of Current Techniques

� Excellent Pain Management

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Canine Sports Medicine and Rehabilitation

Edited By: M. Christine Zink Janet B. Van Dyke

ISBN 978-‐0-‐8138-‐1216-‐8 E-Book ISBN 978-‐1-‐118-‐54151-‐7 April 2013 $99.99 / £62.99 / CAN$109.99

Order online at www.wiley.com

QUESTIONS? Questions?

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