DACVSMR, CCRT, CVPP, CVMA

Transcription

1 Physical Medicine I: Having a Therapeutic Exercise Game Plan Tara Edwards, DVM, DACVSMR, CCRT, CVPP, CVMA Lake Country Veterinary Specialist Hospital Kelowna, BC, Canada Physical medicine focuses on supporting the body to heal and restoring functional ability. A successful rehabilitation program begins with a thorough mobility evaluation. This allows the tailoring of an exercise program to meet the needs of your patient. It is important to acknowledge your patient s limitations and determine what areas need improvement to appropriately set short/long term goals and develop a game plan. Regardless of the injury or surgery, the rehabilitation program will need to be broken down into different stages and the therapist needs to appreciate that each patient will move through these phases at different speeds. The acute inflammatory stage is the period immediately after surgery or following an injury. Goals at this stage include reducing pain and inflammation while preserving joint health. Cryotherapy and passive range of motion can usually be initiated. Patient safety is imperative and often requires restricting activity and adjusting the home environment. In these early stages, identify patients that are overweight or at risk of gaining weight and address caloric intake while their activity level is being restricted. In the early recovery stage, primarily goals still include reducing pain and inflammation while enhancing range of motion. Continue with passive range of motion while beginning active range of motion. Controlled low impact aerobic activity like leash walking and targeted therapeutic exercise can assist with proprioception, joint health, muscle strengthening, and promoting normal weight bearing. In the middle recovery stage, goals include restoring normal range of motion. Continue passive and active range of motion while increasing the challenge of therapeutic exercises and aerobic conditioning. Cryotherapy can continue after activity if required to target post-therapy inflammation. Late recovery stage is focused on advanced land based activities to encourage return to normal activities of daily life. This is a great time to engage in functional activities that will likely be encountered following recovery such as zigging, zagging, accelerations, decelerations, pivoting, and jumping. This stage is preparing the patient for off-leash activity, ball play, and interactions with other animals. When assessing a patient for a rehabilitation program, areas that need improvement could include: controlling pain and inflammation, joint health, range of motion, flexibility, muscle strength, weight bearing, core strength, postural control, proprioception, and weight management. Therapeutic exercises use movement to restore normal function and are the cornerstone of a structured rehabilitation program. An ideal program identifies the patient s weaknesses as exercises need to be specific and targeted to achieve results. Adequate range of motion is required for normal function and restrictions may be secondary to pain, weakness, joint dysfunction, swelling, and a lack of flexibility. Lack of adequate range of motion can lead to stress and discomfort elsewhere in the body. Passive range of motion is moving a joint through flexion and extension without muscle contraction. It can be beneficial in preventing joint contracture, enhancing blood flow, increasing synovial fluid production, promoting joint health, and improving mobility. Providing passive range of motion is indicated in any patient with altered mobility and can include those with arthritis, injuries, weakness, neurological abnormaltities, and following surgery. Common exercises to target active front limb range of motion may include: High 5 s or shake a paw Sit-down-sit Play bow Incline/decline hills, steps, ramps Tunnels/crawling Aquatic therapy Common exercises to target active hind limb range of motion may include: Sit-to-stands or squats Walking in tall grass or water Incline/decline hills, steps, ramps Tunnels or crawling Aquatic therapy Stretching is different than range of motion in that you are providing a small amount of pressure at the end of available range of motion and encouraging elongation of tissues. Stretching should not be painful and should be provided within a patient s comfort range. Knowing anatomy and muscle function is required to determine which muscles need to be stretched and how. Stretching helps to improve the flexibility of muscles, tendons, and joints. It is indicated when there is a lack of flexibility and can guide healing following an injury. Regular stretching programs in humans have been shown to improve flexibility and help with reducing the risk of 491

2 micro-tear injuries. Active stretching through targeted fitness exercises allows dogs to self-regulate and reduces the risk of overstretching. Weight bearing is an important contributor to normal muscle, bone, and cartilage health. Weight bearing helps to increase synovial fluid production, distributes joint nutrients, increases proteoglycan production, and promotes overall joint health. There are many reasons for lack of weight bearing including but not limited to pain, weakness, soft tissue or joint dysfunction, and surgical complications. Common exercises to improve weight bearing may include: 4-leg standing & 3-leg standing Weight shifting Cookie stretches Leash walking Assistive devices harness & foot wear Leash Walking Circles / Figure 8 s Inclines/declines hills, steps, ramps Aquatic therapy Maintaining muscle mass is important as it is the major support structure for joints and is required for proper joint stability and function. Muscle atrophy is not a benign process it involves a change in muscle structure and function. Atrophied muscles have strength deficits and are quicker to fatigue which contributes to an abnormal gait following an injury or surgery. Conditioning, including endurance and strength training, are required for return to normal function following muscle atrophy. Muscles change with age and geriatric deconditioning or sarcopenia involves a loss of muscle mass. Weakness and frailty in our geriatric population is common and preventing muscle atrophy should be a goal when dealing with senior patients. Common exercises to target limb muscle strength may include: 4-leg standing & 3-leg standing Weight shifting Sit-to-stands Curb work Incline/decline hills, steps, ramps Destination jumping Tunnels/crawling Pulling weight Aquatic therapy Core muscles include the muscles along the back and abdomen. These muscles are important at stabilizing the body during movement. Without adequate core strength, the spine is not appropriately supported. Improving core strength and muscle tone can assist with posture, reduce stress on the back, and potentially decrease the risk for injury. Common therapeutic exercises to improve core strength may include: 4-leg standing & 3-leg standing Weight shifting Cross leg standing Cookie stretches o Side crunches o Sternal stretch o Sitting stretch Sit-beg posture Plank standing Tunnels/crawling Proprioception is the ability to sense movement and to acknowledge where joints and limbs are in space. This spatial awareness is required for every day functioning and needs to be focused on during recovery. Elements of proprioception or balance work should be incorporated into a program not only for neurological cases, but also puppies, geriatrics, and athletes as it has effects on coordination, stability, balance, agility, and reducing the risk of future injury. Common therapeutic exercises that target proprioception may include: Working on a variety of ground surface 4-leg standing & 3-leg standing Weight shifting Cross leg standing 492

3 Cookie stretches Weaves Wobble boards & air cushions Prolonged bed rest in people has been associated with significant changes to the muscle and joints of the lower limbs. Patients that are unable to stand and ambulate require intervention to encourage assisted-standing. Getting these patients in a standing posture can assist with weight bearing, limb strengthening, postural muscle activation, cardiovascular and lung function, skin health, and sensory stimulation. Inexpensive and easily accessible equipment to assist with therapeutic exercises includes inflatables and cavalettis. Common inflatable equipment that can be used during therapeutic exercises includes physio-rolls, balls, and air cushions. These can target limb strength, core strength, weight bearing, balance, and proprioception by providing an unstable surface. Cavalettis or obstacle course items encourage a patient to repeatedly step over objects and can target weight bearing, limb strengthening, core strength, range of motion, balance, and proprioception. The distance between, the height, and the configuration of the items can all be varied pending treatment goals. Step standing or elevated standing is a common therapeutic exercise that promotes limb strength, core strength, weight bearing, balance, and range of motion. A variety of different objects or items can be used for step standing and cavalettis. It is important to start exercises based on the patient s current physical fitness, limitations, and comfort zone with the concept of slowly increasing and challenging the body over time based on the goals of treatment. When therapeutic exercises are preformed regularly, they can progress as an animal is healing by adjusting frequency, increasing repetitions or duration, speed, and difficulty by varying the terrain, adding a balance component, or unstable surface. It is important to allow for adequate rest, monitor for fatigue, and focus on quality vs quantity. Pain levels should be appropriately and frequently assessed during all stages of a rehabilitation program as adequate pain management is required for patients to be actively engaged in a successful rehabilitation program. References available upon request 493

4 Physical Medicine II: Modalities in the Rehabilitation Tool Box Tara Edwards, DVM, DACVSMR, CCRT, CVPP, CVMA Lake Country Veterinary Specialist Hospital Kelowna, BC, Canada Physical medicine focuses on supporting the body to heal and restoring functional ability. An interesting paper published as early as 1961 in JAVMA by Jadeson, demonstrated that a combination of modalities can be used to achieve optimal recovery during the rehabilitation of dogs with interverbal disk lesions. Modalities can play a role in assisting with recovery but also have the ability to provide pain relief by targeting many areas along the pain pathways. Currently, there are several modalities available to provide physical medicine including but not limited to thermotherapy, cryotherapy, electrical muscle stimulation (EMS), transcutaneous electrical nerve stimulation (TENS), shockwave therapy, laser therapy, and acupuncture. Thermotherapy is the application of local heat to help manage pain, reduce muscle spasms, and increase circulation. Heat causes vasodilation which results in an increased local blood flow allowing for tissue oxygenation and nutrient delivery. Application of heat can reduce the intensity of pain by blocking the stimulus from peripheral sensors. Thermotherapy can also decrease the firing of muscle spindles thereby helping to reduce muscle guarding and spasms. Heat increases the extensibility of soft issue which is desirable prior to range of motion or stretching exercises. It is generally recommended to start the application of thermotherapy 72 hours after acute inflammation, otherwise, the premature application of heat can result in additional swelling and edema. Heat application has the greatest effects occurring at 1-2 cm deep and options regarding application include heating pads, microwavable bags, and hydrocollator packs which are maintained at a constant temperature and provide moist heat. Cryotherapy is the application of cold to help manage pain and inflammation following acute injuries and chronic conditions. Cryotherapy results in a constriction of blood vessels which assists in decreasing swelling and edema. Application of cold slows tissue metabolism and inhibits inflammatory mediators thereby decreasing inflammation. Lowering tissue temperature provides pain relief by reducing sensory nerve conduction and increasing pain thresholds. Via the gate control theory, peripheral stimulation of sensory or A-delta nerves with cold application interferes with the processing of incoming pain signals. To prevent cold induced trauma, do not apply ice directly to the skin surface and be cognizant regarding the duration and location of cold application. Cryotherapy can provide tissue cooling 2-4 cm deep and options regarding application include alcohol/water combinations in sealable bags, flexible gel packs, and direct ice massage. The addition of compression with icing has been demonstrated to improve success of managing post-operative swelling. Electrical muscle stimulation (EMS) uses an electrical current to cause depolarization of nerve or muscles cells which can be utilized to stimulate and facilitate muscle contractions. EMS is often used to minimize muscle atrophy, restore muscle strength, and provide muscle re-education leading to improved functional muscle use. Electrical stimulation recruits muscle fibers differently than a normal voluntary contraction in that type II muscle fibers are activated prior to type I muscle fibers. Muscles often fatigue faster and the contraction strength is only 80% compared to voluntary muscle contraction. When possible, active exercises are usually more desirable. Due to the resistance for an electrical current to pass, ultrasound gel is required and certain hair coats may require clipping. Treatment parameters to consider include electrode size, anatomical placement, amplitude (ma), pulse duration (us), frequency (Hz), and duration of treatment. Patient are often started in a relaxed position and once they are comfortable with electrical muscle stimulation, functional positions such as standing can be incorporated An important treatment objective with the application of an external electrical current is to stimulate motor nerves and not evoke pain signals via A-delta fibers. Unlike electrical muscle stimulation, transcutaneous electrical nerve stimulation (TENS) is the use of an electrical current at different settings (pulse duration, Hz) to provide sensory level stimulation and not recruit muscle contractions. Use of TENS over an area of pain provides pain relief during while the stimulus is applied. This modality provides pain relief via the gate control theory where peripheral stimulation of sensory or A-delta nerves interferes with the processing of incoming pain signals. Sensory nerve stimulation can also result in the release of endogenous B-endorphins and activation of descending pain control pathways. Hydrotherapy or aquatic therapy has become a popular form of exercise and is often provided in the form of swimming or underwater treadmills. The benefits of hydrotherapy can include providing a buoyant environment which is less stressful on joints, improving range of motion, encouraging muscle strengthening with resistance, and enhancing sensory awareness. Hydrotherapy can provide a positive environment where the buoyancy supports easier movement, however, the increase in resistance requires patients to work harder and therapists need to be aware and able to identify early signs of fatigue. Hydrotherapy may be indicated for soft tissue injuries, orthopedic or neurological conditions, arthritis, and for generalized conditioning and fitness programs. Contraindications for hydrotherapy include urinary catheters, diarrhea, open or infected wounds, bleeding, unstable fractures, and a generalized fear of a water environment. Precautions could include any cardiac or respiratory compromised patients. Certain breeds 494

5 with respiratory challenges, such as brachycephalics, need to be monitored closely when exercising due to increased physiological stress in a potentially warm and humid environment. The underwater treadmill is a controlled environment that can be ideal for post-operative, arthritic, and neurological conditions. Treatment parameters to consider include walking speed, distance/duration, and depth of the water. Adjusting the height of the water dictates the amount of buoyancy and resistance provided for the patient. When the water is at the level of the greater trochanter, patients are approximately bearing 38% of their body weight on dry land compared to 91% when water is at the level of the lateral malleolus. The buoyancy reduces weight bearing on joints and allows a potentially weak and painful patient to exercise with more support, comfort, and confidence. Hydrotherapy s impact on joint kinematics needs to be considered when developing a patient s treatment plan. Pending water depth, the underwater treadmill in general encourages a more full range of motion with respect to both flexion and extension. In contrast, due to the effects of buoyancy, swimming encourages overall joint flexion. Swimming is a less controlled form of exercise compared to activity in an underwater treadmill but can provide a great opportunity for mental stimulation, cross training, and improving core strength and endurance. The 100% buoyant environment often encourages initial movements in non-ambulatory patients suffering from severe paresis or paralysis. Precautions may include but are not limited to patients with unstable fractures, certain IVDD cases, and patients at risk for aspiration. Patient safety regarding water entry and exit needs to be evaluated and monitored. Flotation devices can be utilized to assist with handling safety and improving patient comfort and confidence Hydrotherapy and land based treadmills can be utilized to enhance a dog s physical fitness in regards to the cardiovascular system and musculoskeletal system. Both these modalities can be incorporated as part of a fitness and weight loss program. Low intensity exercise can be beneficial to our patients by supporting the loss of fat vs muscle, increasing oxygen capacity and energy expenditure, improving fatigue resistance, encouraging joint and muscle function, enhancing fatigue resistance, promoting endorphin release, reducing lameness scores, and improving mental health. With respect to a conditioning program for aerobic training, a land based treadmill can stimulate a high level of intensity in a short period of time. However, due to the use of different muscle and alterations in biomechanics, they should not be relied on as the sole means for endurance training. The preferred gait for endurance training is the trot because it is symmetrical and exercises both sides of the body equally. Both underwater or land based treadmills can be an important component for neurological recovery due to the repetitive nature and ability to work on gait training. These patients often need assistance because of weakness and neurological deficits in the form of manual gait patterning in order to assist with correct movement and encourage a normal gait. With respect to both hydrotherapy and land based therapies, the duration of an activity will be based on the patient s current physical fitness and limitations with the concept of slowly increasing and challenging the body over time based on the goals of treatment. Pain levels should be appropriately and frequently assessed during all stages of a rehabilitation program as adequate pain management is required for patients to be actively engaged in a successful rehabilitation program. References available upon request 495

6 Physical Medicine III: Low Level Laser Therapy and Medical Acupuncture Tara Edwards, DVM, DACVSMR, CCRT, CVPP, CVMA Lake Country Veterinary Specialist Hospital Kelowna, BC, Canada Physical medicine focuses on supporting the body to heal and restoring functional ability. Low level laser therapy and medical acupuncture are both unique and complementary physical medicine modalities that can modulate and influence healing within the body. Critical thinking is required to provide a tailored treatment approach with these modalities and success improves when they are utilized as part of a multimodal pain management or rehabilitation strategy. LASER stands for Light Amplification by Stimulated Emission Radiation and was first recognized by Albert Einstein in Despite the recent surge of interest in veterinary medicine, the use of laser therapy in various fields in human medicine has been well established. Therapeutic laser therapy has several synonymous terms that include but are not limited to cold laser therapy, low intensity laser therapy, low level laser therapy, light therapy, phototherapy, and bio-stimulation laser therapy. Included in the electromagnetic spectrum is both visible light ( nm) and non-visible or infrared light (>800nm). The light from a laser diode is unique in that it is monochromatic, coherent, and collimated. A lasers emits energy in the form of photons which have the ability to promote both biochemical and physiological effects. Laser can have primary effects on cells with secondary effects systemically. In general, laser therapy stimulates and accelerates the healing of inflamed, injured, and diseased tissue. The light energy can reflect, scatter, absorb, or penetrate deeper into a target tissue. Different components of tissues can preferentially absorb different wavelengths of light. Overall, lower wavelengths result in less penetration while longer wavelengths result in deeper penetration. Wavelengths of 810nm are considered optimal for the treatment of musculoskeletal conditions due to the ability to penetrate into deeper tissues within the body. Once the energy enters the target tissue, it is absorbed by chromophores. Cytochrome C oxidase, within the electron transport chain, is a common chromophore that is stimulated within the mitochondria. Once light is absorbed, electrons become excited and cellular respiration is stimulated. Biostimulation is the term that refers to this process of light energy being converted into chemical energy. The resulting increase in ATP provides the cells with energy and allows them to preform specific cell-related tasks. From a cellular level, there is an increase in metabolism which stimulates various genes, growth factors, and cytokines resulting in cellular proliferation and migration. Laser therapy can stimulate a variety of cells including macrophages, lymphocytes, fibroblasts, keratinocytes, and endothelial cells which can improve tissue function by assisting with tissue repair and healing. Laser therapy also improves oxygen binding which displaces nitric oxide (NO) from cytochrome C oxidase. This release in nitric oxide relaxes endothelial cells and encourages vasodilation. Increase blood flow to an area can encourage nutrient and oxygen delivery thereby accelerate healing. Laser therapy is also a valuable modality for managing pain and inflammation. Laser therapy has the ability to modulate the inflammatory response, suppress nerve condition, and stimulate endogenous opioid analgesia. The increased blood flow to an area can also assist with the removal of inflammatory mediators which often sensitize nociceptors. The primary safety concern with providing low level laser therapy is retinal damage. Those involved with laser treatments need to consider appropriate eye protection for the therapist, owners, and potentially the patient. If not used correctly the potential for skin hazards or thermal injury exists for higher power units especially for sedated or anesthetized patients who cannot provide feedback regarding discomfort. Current contraindications include direct application of laser therapy over known malignancy, the eye, active hemorrhage, reproductive organs, active growth plates, and repetitive dosing over the thyroid gland. The potential indications for laser therapy are rapidly increasing from managing wounds and dermatological conditions to treating arthritis, soft tissue injuries, and neurological disease. New areas are being investigated such as the management of kidney, bladder, and pancreatic diseases to increase oxygenation and blood flow while reducing pain and inflammation. Many clinics are incorporating the use of laser therapy for the perioperative management of discomfort and tissue healing for surgical and dental procedures. The efficacy of laser therapy relies upon using the correct light source, the appropriate wavelength of light to penetrate, and delivery of the required dose to the target tissue. Power refers to the rate at which the energy is delivered and is reported as W=J/sec while dose is considered the density of energy delivered to the target tissue and is often reported as J/cm2. There is a lack of consensus on protocols or standard treatment doses but current suggestions can be found on the World Association for Laser Therapy website ( Adjustment of dose or treatment parameters often needs to be considered based on depth and location of the target tissue, hair thickness, coat or skin color, dermal thickness, body condition score, specific disease process (acute, chronic, complex), and individual patient response or sensitivity. If using computer based programs, understanding the programs or pre-set protocols is imperative as knowing how to adjust or modify your treatments will improve your laser therapy skills and clinical results. A significant amount of energy is lost to reflection, scattering, and absorption. Therefore, the dose delivered at the skin surface needs to be greater than the therapeutic dose required at the depths of the target tissue. The amount of energy lost between the fur and 496

7 the laser probe can be significant. Pending probe design and manufacturer s recommendations, direct contact with the skin and the laser probe is ideal for allowing maximum energy transmission as less energy is lost to reflection or absorption. When possible, part and separate the fur and deliver directly on to the skin surface. Contact treatment with the probe held at 90 degrees to the surface and with the application of light pressure compresses the tissue thereby reducing the distance between the probe and target tissue. This increases energy penetration depth by blanching the skin and reducing the amount of energy lost to absorption by hemoglobin. Acupuncture is the insertion of small needles into the skin, subcutaneous tissue, fascia, and muscles. Medical acupuncture focuses on the relationship between acupuncture points with neuroanatomical landmarks such as nerves, muscles, sensitive fascia, and blood vessels. Needles can act as an important biological mediator in that stimulation of the nervous system can result in analgesia, impact the immune system, enhance normal nerve function, and support normal physiological functions such as gastrointestinal motility by balancing sympathetic and parasympathetic systems. Acupuncture s impact on the body can be described as local, segmental, and systemic. 1. Insertion of a needle directly impacts the nervous system with stimulation of A-delta nerve fibers. Local effects of acupuncture include mechanical traction of the surrounding tissue which results in the local release of neurotransmitters, cytokines, and substances such as growth factors which often improves local circulation, reduces muscle tension, and facilitates soft tissue and wound healing. 2. Acupuncture results in segmental analgesia via the Gate Control Theory. The sensory information from the needles interferes with other ascending pain signals from chronic arthritis or an acute injury. This allows for modulation of the transmission of pain signals in the spinal cord by inhibiting or depressing information in the dorsal horn. Placement of needles along the dorsal paraspinals stimulates specific spinal cord segments and allows for targeted treatment of visceral and somatic conditions. 3. Acupuncture can also have a generalized effect on the body via the endogenous production of B-endorphins within the cerebrospinal fluid. These can modulate the nervous system activity over time and result in activation of the periaqueductal grey (PAG) which is the control center for descending inhibition of pain. A large variety of needles exists differences include packaging, coating, and gauge. Needle selection is often based on depth and location of target tissue, body condition score, and individual patient response or sensitivity. Electroacupuncture is the use of an electrical current through acupuncture needles to provide more stimulation which can be useful for the management of pain and neurological conditions. Different frequencies are used depending on the treatment goals for pain relief. The location and number of needles placed in a patient needs to be accounted for a well as safe disposal in an appropriate sharps container. Critical thinking is required for effective low level laser therapy or medical acupuncture as their application is dependent upon a complete myofascial, neurological, and orthopedic examination. Appropriate patient assessment allows for a tailored treatment plan that addresses both the direct pathology and compensatory components. A thorough understanding of your patient s needs allows you to modify your treatment strategy to achieve optimal results. When treating arthritis, we are targeting the underlying inflammatory joint pathology, the secondary myofascial problems due to altered biomechanics, and the central components of pain. Both modalities can modify the inflammatory cascade, reduce degenerative changes, manage muscle dysfunction, address peripheral pain receptors in the skin, modulate pain signals in the central nervous system, and improve endogenous analgesia. Many common acupuncture points for treating elbow, hip, and stifle disease overlap with recommended treatment areas for laser therapy application. Acupuncture and laser therapy can be incorporated into peri-operative treatment planning to assist with reducing nociceptor stimulation, increasing circulation of endogenous opioids, addressing tissue trauma, reducing swelling, and promoting tissue healing. The primary goal when treating neurological conditions is to minimize the impact of the initial injury and improve functional outcomes. Utilizing laser therapy and acupuncture can enhance recovery by encouraging spinal cord or peripheral nerve health, providing analgesia, increasing local blood flow, reducing inflammation, reducing muscle tension, and limiting pathology by addressing the secondary biochemical changes that can occur following a nerve or spinal cord injury. Laser therapy and acupuncture often start with multiple treatments during an induction phase followed by gradually adjusting treatment frequency to maintain the primary goals of treatment ie. finding the lowest effective dose or treatment frequency. Chronic conditions often require continued treatments to maintain improvements. The full benefits of physical medicine often take time and pain levels should be appropriately and frequently assessed during appointments. Pharmaceutical intervention should be utilized when required as adequate pain management is required for patients to be actively engaged in a successful rehabilitation program. It is ideal to provide a stress-free environment during acupuncture and laser therapy. Treatments should focus on minimizing traffic, limiting auditory and visual distractions, utilizing pheromone products, providing comfortable bedding, limiting restraint, and offering positive reinforcement. References are available upon request. 497

8 Chronic Pain: Struggling With Arthritis and Obesity Tara Edwards, DVM, DACVSMR, CCRT, CVPP, CVMA Lake Country Veterinary Specialist Hospital Kelowna, BC, Canada As our pets live longer, there is an increased risk they will experience discomfort and pain. Arthritis is quoted to affect 20% the pet population. Since many of our patients suffer in silence, this is likely a conservative estimate. Arthritis and obesity limit movement, impact cartilage health, contribute to muscle atrophy, result in weakness, and alter normal biomechanics. Both these diseases are significant contributors to chronic pain in our companion animals. Arthritis is a multi-dimensional disease beginning with joint dysfunction and leading to changes in movement. We need to acknowledge that pain is often present before visible changes in mobility. Arthritis is a progressive disease; any change in function is often due to an increase in pain. We can improve arthritis patient care by focusing on the prevention of pain and disability. This requires earlier arthritis identification and the implementation of multi-modal arthritis strategies. In humans, pain is often unrecognized and inadequately treated. With non-verbal patients, we have an even bigger challenge in veterinary medicine. We need to excel at our history taking and our physical examinations. Because we rely on pet owners, we need to advocate for education. Educating clients about the clinical signs of arthritis, the progressive nature of the disease, and the impact of contributing factors such as obesity all encourage earlier identification and compliance with our recommended treatments. Understanding the difference between acute and chronic pain becomes imperative when trying to raise the bar for patient care. While acute pain may not be a pleasant experience, it is protective in nature. Like an alarm system, it is a helpful reminder for the body to rest and promotes the healing of injured tissue. Compared to acute pain, chronic pain does not serve a purpose and can become debilitating. Long term exposure to pain signals results in altered pain physiology: decreased pain thresholds, spontaneous electrical activity, activation of pain pathways, loss of descending pain inhibition or suppression, and exaggerated responses to stimuli. These changes in the spinal cord can result in altered structure and function of the nervous system leading to central sensitization, hyperalgesia, and allodynia. Chronic pain, or maladaptive pain, can become a separate disease process and is difficult to treat. Every patient should be assessed for pain. Assessing for acute pain has become an expected standard of care for our trauma, medical, and surgical patients. Assessing for chronic pain is more difficult as the symptoms are difficult to recognize and our patients often don t complain. Instead, our patients slowly adapt and change their activity patterns. Owner s observations are required for chronic pain and mobility assessments. Their feedback can help to identify these slow adaptions or subtle behavior changes and provide clues as to how their pets are functioning at home. Good online resources for helping to assess chronic pain include the Helsinki Chronic Pain Index, the Canine Brief Pain Inventory, and the ACVS Canine Orthopedic Index. Mobility evaluations start with a thorough history followed by observing the patient standing, sitting, moving into different positions and a detailed palpation. An overlooked source of discomfort in our veterinary patients is muscle pain or myalgia. The chronic changes to posture, weight bearing, and gait from obesity and arthritis can lead to activation of pain sensing pathways which contributes to secondary muscle pain. In people, myalgia is often described as aching or cramping and the chronic activation of muscle pain sensors can activate areas in the brain which are associated with depression. The prevalence of arthritis in our feline patients is alarming. A retrospective study revealed that 22% of cats over one year of age and 90% of cats over twelve years of age had radiographic evidence of degenerative joint disease. History taking is even more imperative for our feline patients as they are often suffering in silence and may only exhibit subtle and gradual behavior changes. Things to discuss with clients include monitoring for reduced activity, difficulty jumping, increased grumpiness, changes in sleep patterns, dislike for grooming, avoiding interactions, appetite fluctuations, weight changes, and potential variabilities to litter box habits. Arthritis treatment goals include improving the ability to function and improving quality of life. These can be achieved by controlling pain and inflammation, slowing down the progression of arthritis, improving joint function, maintaining muscle strength, preventing injury, and promoting physical fitness and independence. Arthritis management is life-long and therefore requires good client communication and support. Treatment plans need to be individualized and based on thorough examinations. Due to the progressive nature of the disease, frequent re-evaluations are required throughout the life of the pet. A common cause for failure with arthritis management is neglecting to adjust treatment plans over time. As with many areas of practice, managing arthritis becomes more successful with the involvement of the entire veterinary team. Chronic pain involves multiple pathways and once central sensitization has occurred, a multi-modal treatment strategy is required that targets different pain pathways. Pharmaceuticals, nutrition, disease modifying agents and rehabilitation can all provide different components of a management plan. Pharmaceuticals play an important role in reducing pain and inflammation. The most commonly used medications for managing pain in arthritic patients include non-steroidal anti-inflammatories (NSAIDs), gabapentin, and amantadine. NSAIDs are the hallmark of initial therapy since arthritis is an inflammatory disease process. NSAIDs can help to 498

9 increase activity, maintain muscle mass, and assist with weight loss. The addition of gabapentin and amantadine are good options for chronic or maladaptive pain. Tramadol is considered questionable as an appropriate choice for the management of chronic pain patients. Our goal with multi-modal pain management is to maximize our treatment success while minimizing side effects. Identifying or determining the lowest effective dose is ideal, however, it may be an unrealistic goal to discontinue pharmaceuticals in maladaptive pain patients. Remember, it takes time to change central sensitization and patients should be re-evaluated prior to adjusting medications. Despite pharmaceuticals targeting inflammation, providing pain relief, and modulating neurophysiology, we cannot forget about the importance of slowing down the progression of arthritis. Disease modifying agents can help to protect and promote cartilage health. The earlier we initiate the use of supplements the better chance we have at modulating cartilage damage. These products should be used as part of a multi-modal treatment plan and not as a replacement for appropriate pain-relieving medications or modalities. Common disease modifying agents include but are not limited to glucosamine, chondroitin, omega 3 fatty acids, green lipped muscles, avocado soybean unsaponifiables (ASU), and injectable chondroprotectants such as Adequan and Cartrophen. Arthritis is an inflammatory disease by nature and obesity is also a source of chronic inflammation. Adipocytes release a variety of hormones that have effects both locally and systemically. Increased body condition scores are associated with an increase in inflammatory markers which means that overweight and obese patients are in a constant state of inflammation. Obesity contributes to a pro-inflammatory state which activates pain sensors, increases pain perception, and aggravates joint degeneration by encouraging destructive enzymes. Obesity and arthritis exacerbate each other and it is a constant struggle of arthritic patients becoming overweight because of reduced mobility and overweight patients developing arthritis at faster rates due to systemic inflammation and mechanical joint stress. There is a lack of recognition of obesity amongst pet owners and the veterinary health care team. Despite obesity being easily recognizable and the most common nutritional disease, it is often a difficult conversation with owners. Obesity is spreading like an epidemic - we need to remove emotion and focus on the health risks. Obesity compromises mobility, compounds arthritis, and contributes to pain. More importantly, it affects quality and quantity of life which impacts the human-animal bond. Obesity in companion animals is a human disease often a combination of overfeeding and lack of exercise. Weight loss is the single most important factor to assist with reducing pain in overweight and arthritic patients. Achieving ideal body weight is also critical for maintaining joint health and slowing down the progression of arthritis. Estimating the current body condition score allows for determination of the ideal body weight, this is integral for calculating the appropriate dose of calories. Simply reducing the current volume of food is not always ideal for long term balanced nutrition. It is also important to choose a diet that is appropriate for weight loss versus weight maintenance or obesity prevention. How we feed our patients during a weight loss or weight maintenance program is equally important for long term success. Consider the use of gram scales to improve measurement accuracy when dosing calories and food puzzles or games to encourage mental stimulation. Successful weight loss patients are less likely to rebound or gain weight when the weight loss diet is continued but adjusted for a caloric intake that is appropriate for weight maintenance. A tailored rehabilitation program can focus on reducing pain and inflammation, improving joint health and mobility, maintaining and improving muscle mass, encouraging proprioception to reduce the risk of injury, and stimulating overall mental health and physical fitness. Several physical medicine options are available including cryotherapy, thermotherapy, laser therapy, acupuncture, land based treadmills, hydrotherapy, and targeted therapeutic exercises. In humans, exercise has been shown to be effective at managing chronic pain from conditions such as arthritis and obesity. Low intensity exercise can be equally beneficial to our patients by supporting the loss of fat versus muscle, increasing oxygen capacity and energy expenditure, improving fatigue resistance, encouraging joint and muscle function, enhancing fatigue resistance, promoting endorphin release, reducing lameness scores, and improving mental health. Controlled and structured leash walks are preferred over uncontrolled off-leash activity for the arthritic and obese patient. With respect to any exercise program, the duration of an activity will be based on the patient s current physical fitness and limitations with the concept of slowly increasing and challenging the body over time based on the goals of treatment. Pain levels should be appropriately and frequently assessed during all stages of a rehabilitation program as adequate pain management is required for patients to be actively engaged in a successful rehabilitation program. Improving arthritis patient care requires a focus on high risk individuals. This may include certain breeds, age, athletic lifestyles, and patients with previously diagnosed orthopedic conditions. Providing the arthritic patient with extra tender-loving-care (TLC) in the clinic can go a long way for patient comfort. Increase traction on slippery clinic floors, use mats for orthopedic examinations, remember sore joints during handling for catheters, nail trims, and with positioning of sedated patients for dentistry and radiographs. Clients can also provide their pets with extra TLC at home by focusing on appropriate nail care, comfortable bedding, elevated feeding dishes, and increasing traction in high traffic areas. Our overall goals when treating this patient population is to minimize pain while maximizing mobility. References are available upon request. 499

10 Mobility Evaluations: Finding the Hurt Tara Edwards, DVM, DACVSMR, CCRT, CVPP, CVMA Lake Country Veterinary Specialist Hospital Kelowna, BC, Canada As veterinarians, we always want an anatomical diagnosis. However, we can have two patients with the same diagnosis that have drastically different levels of pain or disability. From a rehabilitation perspective, it is the level of pain and disability that dictates our treatment plans. We are often focusing on the physical impairments, the alterations in gait, and the secondary or compensatory changes due to altered biomechanics. Like any other appointment, the first step for a mobility evaluation includes taking a thorough history. Information regarding a specific lameness, previous injury, current activity level, progression of the problem, previous response to medications, aggravating factors, weight fluctuations, and changes to daily habits can all provide clues as to how a pet is functioning. Knowing information with respect to daily activities, levels of exercise, and the household environment is also helpful. Client based questionnaires can assist with obtaining feedback regarding subtle behaviour changes that may be occurring at home. Gait analysis is an important component of a mobility evaluation. Goals include evaluating how efficiently an animal moves and looking for the quality of movement. It is ideal to evaluate in an area with good space and appropriate traction. Videotaping allows for analyzing movement in slow motion and can serve as a base line to compare with at a later date. It is best to evaluate during symmetrical gaits such as a walk or trot. Animals can be viewed moving from both sides, towards, and away from the evaluator. A challenging lameness can often be exaggerated with circling, stairs, or jumping onto a higher surface. Changes to gait can occur during stance phase when the leg is weight bearing and during swing phase when the limb is advancing forward. Changes in gait may be secondary to joint discomfort, inadequate range of motion, weakness, or soft tissue dysfunction resulting in pain or a lack of flexibility. Clues to look for regarding a thoracic limb lameness include the classic head bob and clues for pelvic limb lameness include a swagger or exaggerated lateral pelvic movement during ambulation. It is helpful to adopt a lameness scoring system within the clinic to assist with tracking improvement or deterioration in medical records. Observing patients while they are standing allows for assessment of general symmetry, body condition with respect to weight and muscle, conformation, posture, weakness, cranial weight shifting, limb placement, digit positioning, and general nail care. Assessing the position of limbs during resting postures can provide information regarding restrictions or discomfort. Observing patients while they are transitioning into different positions such as a sit posture can also provide information regarding joint comfort, strength, and coordination. A thorough mobility evaluation includes a myofascial examination which evaluates the muscles for symmetry, atrophy, and pain. An overlooked source of discomfort in our veterinary patients is muscle pain or myalgia. Any injury, arthritis, and even surgery can result in changes to posture, weight bearing, and gait which can lead to activation of pain sensing pathways contributing to myofascial dysfunction and secondary muscle pain. Palpating a patient while they are standing allows for examination of overall symmetry, body condition score, muscle tone, swelling, and soreness prior to the movement of limbs and joints. General palpation of the cervical muscles and vertebrae for tenderness can precede assessment of active cervical range of motion. Palpate over each scapula to appreciate muscle atrophy as prominence of the scapular spine becomes evident with thoracic limb dysfunction. Palpation and reactivity over latissimus dorsi muscle is often to due chronic cranial weight shifting or inappropriate transitioning from a sit to a stand. Palpation along the epaxials for sensitivity prior to dorsal/ventral palpation along each vertebra can occur while the patient is standing. Evaluation of the lumbosacral area should be included with any mobility assessment as lumbosacral disease is a common condition in the senior and large breed population. For a true assessment of this region, it is recommended to evaluate the lumbo-sacral joint prior to hip extension. Direct palpation with dorsal/ventral pressure, gentle tail elevation, or pelvic extension are all methods for assessing the lumbo-sacral region. Discomfort in this region may be due lumbosacral disease (an all-encompassing term for a variety of different diseases), myofascial discomfort secondary to abnormal posture or movement, or secondary to wind-up or central sensitization from a pelvic or pelvic limb condition. The following muscles can be assessed while the patient is standing: iliocostalis lomborum, iliopsoas, sartorius, tensor fascia latae, rectus femoris, gracilis, pectineus, semimembranosus, and semitendinosus. Any changes to weight bearing or abnormal movement can lead to inappropriate use of muscles, affect joint movement, promote further weakness, and contribute to pain and dysfunction. While standing, the patient can be assessed for: hip range of motion, patellar laxity, presence of a medial buttress, digit positioning while weight bearing, abnormal weight bearing, neurological reflexes such as conscious proprioception or appropriate limb placement with hopping, and measuring thigh muscles for circumference or muscle atrophy. Examining a patient in lateral recumbancy allows for more specific palpation and evaluation of muscles, joints, tendons, ligaments, range of motion, and instability or laxity. Good landmarks for the shoulder include the scapular spine, acromion, and greater tubercle. The myofascial examination assesses for general tone and should include examination of the biceps, supraspinatus, and triceps as these are common muscles involved with injury and overuse conditions. These soft tissue structures can be evaluated with direct 500