Laurie's Blogs.

This week, I just want to share some crazy cases with you.  Some I’ve seen as a second opinion within my clinic.  Some that have been sent to me specifically by vets I know.  Some that are long time clients.  But all weird, or complicated, or challenging!  They’re the kind of cases that a wee part of you thinks, “Man, I wish I could just pass this case off to someone else.” or “Why me??”  or “OMG, I have what am I going to do!?”

We’ve all seen them.  The goal is to breath and look at the case with an open mind, allow your creativity to flow, let the answers slowly filter in.  Okay, here are my recent stumper cases… and they’re still in progress, but the point of this blog is the thought processing.  Which makes this another blog about CLINICAL REASONING. 

Case 1 – Australian Shepherd with a tumour removed from his ear canal.  Offending parts removed… how much, I don’t know, the vet referral didn’t mention it!  Ear sewn shut.  Case closed, except the head tilt and some balance issues.  He has seen another therapist who presented the case for discussion amongst our staff – our first thought was deep inner ear infection – refer back to vet.  The response back was, “No infection.” 

This case I just saw last week – he’s had manual therapies to his upper cervical spine… but he’s sort of status quo with the head tilt and balance.  So, when I see him, I think, what has been looked into and what can be left to look into. 

Mechanical reason for head tilt – check.  It’s fine.

Idiopathic Geriatric Vestibulitis? – No nystagmus.  No apparent nausea.  He shakes willingly.  Can follow treat with eyes.  Doesn’t make sense.

While I couldn’t come up with a presumed diagnosis, I can test for dysfunctions and treat what I find.  I figured, let’s test his vestibular system.  I blind folded him and we had him move while following a treat.  Getting from sitting to standing, he lost balance and bumped into the wall beside him.  Walking to follow the treat was not too bad.  Free movement was less predictable.

Okay… so problem 1:  Issues with balance attributable to the vestibular system - better with scent-following movement than free movement; vertical movement more provoking of dysfunction than turning.  I could muse about why this could be (Saccule problem – did they remove the inner ear?  Over compensation by the contralateral inner ear parts? Issue affecting cranial nerve 8)… but it doesn’t change the treatment plan – work on vestibular system retraining.  So, the owner is to do blind folded exercises with the dog – getting up, lying down, following a treat.

My treatment ideas going forward… what if I tried to treat cranial nerve 8 (vestibulococclear nerve).  I’m thinking of lasering the occiput / brainstem region.  I’ve done this in the past with some interesting results.  Maybe swimming – blind folded as well.  (We had another little dog where we tried this in the past and it helped with her balance issues.)   

Case 2 – A 12-year-old Doodle with a history of falling of the bed and hind limb disuse x 5 months.  The dog is quite stiff when walking and tends to circumduct the offending limb while holding it very straight.  He was seeing another therapist that requested a radiograph of the hip, which revealed nothing.  That therapist can also elicit a soft (non-painful) click with a maneuver that looks to be a bit like an ‘outer hip quadrant test’ (i.e. abduction, external rotation).  She notes that the dog has had on and off bouts of pain with hip abduction, and occasionally some stifle discomfort.  The dog is a puzzle and a second brain is requested.

This case, I also saw last week.  Before seeing the dog, and in talking with the other therapist, I wondered about a labrum tear… mostly based on the other therapist’s description.  Sadly, if this is the case, I don’t know who would / could do anything about it – surgically.  There is next to nothing on PubMed when you type in ‘canine hip labrum’.

Fast forward to me getting my hands on the dog.  There was pain at the right SIJ and piriformis muscle and pain to palpate the deep gluteal and pectineus muscles as well.  The dog would not allow full hip flexion (that’s extremely unusual) and the SIJ didn’t move (no glides, no rotations, no translations…).  I also found a slight discomfort to palpate the posteromedial joint line sulcus at the stifle, but this joint had full ROM and no drawer sign and no pain on testing for drawer.  For now, I decided to put the stifle into a ‘we’ll come back to you later’ category.

The other therapist was in with me for my assessment of her patient, and she showed me the hip click.  I don’t know that I would have come up with or thought of the testing she used in order to find it, so I was impressed by that.  It also solidified my thoughts about the potential of a labrum tear.

Problem 1:  SIJ is immobile.  Goal:  Get it moving.

Problem 2:  Hip is painful, could be labrum.  Owner not wanting surgery even if there was a surgeon willing to attempt it.  Goal: Treat the hip conservatively to reduce pain, increase blood flow, encourage passive, active, and accessory motion, and facilitate use of the limb.

Treatment that day consisted of Radial shockwave to the deep gluteal and lateral borders of the hip as well as to the Sacroiliac joint and mobilizations of the SIJ (gapping, rotations, and thigh thrust techniques).  That evening, the owner felt the dog was moving better, but she had stiffened up again by the next morning.  Three days later, at a follow up appointment, the other therapist felt that the SIJ was moving better and the dog was walking better (less circumduction) as well.

Plans:  We need to do thigh circumference measurements, take stance analyzer measurements, and continue to treat the SIJ and hip.  See what happens and modify from there.

THOUGHTS

I think both of these cases are interesting from two standpoints.

1.      Clinical reasoning and thinking outside of the box are important in coming up with strategies for what to test and what to try.

2.      A definitive diagnosis isn’t always necessary in order to treat a problem.

If this stirs up some questions or conversation in your head, shoot me a line to discuss (or write me a blog to highlight an interesting case where you used clinical reasoning to formulate a plan!

Cheers!  Laurie

P.S.  Stay tuned for Part 2 Next week... more crazy clinical cases.