Laurie's Blogs.

Hi there!

I had contacted you several months ago regarding my first rehab patient. It was a dog with MSI of the left shoulder with biceps and supraspinatus tendinopathy. He had been lame for over 2 years before I saw him. 

Since we last spoke a lot has happened! He had been doing pretty well with Laser and rehab (still lame but showing definite signs of improvement) and we had started using the Ace bandage hobble system. The owner then graduated to the Dog Leggs system because she didn't like the Ace bandage and this seems to be working well for him. His abduction angle has improved from 40 to 26 but the lameness is no different. He also has profound OA and dysplasia of the hips and literally has no joint to speak of on the left side. You can feel immense cracking and laxity in that hip and stifle whenever he shifts weight. 

She brought him the the University with the hopes to enrol him in a stem cell study but he was denied into the study. They suggested he see their integrative medicine department and since then I feel like we've lost ground. They did 3 sessions of shock wave on him. After each session they took him off his NSAIDs and the owner said he would just lay there and cry and not move. He is highly depending on the NSAID's for function.  There was no improvement noted with the shock wave (this was done to the left shoulder). 

He returned to them and the did triamcinolone injections into his left elbow and left hip and PRP into the left biceps tendon. That was 2 wk ago and so far he has not improved and actually seems less active since then. 

My issues are that every time he has a new therapy we back slide on his rehab because he's too uncomfortable to exercise. The other issue is that I feel any exercise I try to do for the shoulder makes the hip worse and vice versa. And the last problem is he has simply out smarted me! He is VERY stubborn and not food motivated so it's a constant battle to get him to do things. I'm trying to be creative but I feel like I'm making minimal progress. I've spoken to her about possible FHO of the left hip but I'm not sure if she's going to do it. To date, my ther ex with him has been trying 3 legged stands and diagonals, sit to stands, rocker board/wobble board weight shifting and cookie stretches, C-poles and yesterday I tied therabands in a figure 8 from the LF to the LR limbs and walked him because that's all he would do and I figured it was at least providing some resistance and strengthening. He gets Laser once weekly and joint glides/manual therapy once weekly. He is just now re-starting his inclines/declines walking (he was too painful to do those after shock wave so we had to stop those). The owners have a pool and would like him to swim but he doesn't know how to swim for one...and I'm worried about abduction at the shoulder with swimming. 

I just feel like I hit a wall with this case and I'm not sure where to go next or what exercises to try with him. We were on such a good path and now I feel like we're back to square one :(

Any help would be appreciated!!

Thanks so much-

S.

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Hey S.,

Sorry for my tardy reply.  ( I start every e-mail that way these days!)

So, I'm thinking that in this case... at this point, it sounds like you have to go back to ground zero and focus on pain management... with the exercise just being simple walking for now.

•Incorporate massage - and show the owners the same 

•Laser the living daylights out of the dog - High doses (i.e. 10 J/cm2 at the target tissue... so more than that at the surface), and cover every square inch of 'hurt' on the poor boy! 

•Joint mobilizations and ROM... but not trying to make gains in movement - maybe just a grade 2 - for pain relief

•Acupuncture or acupressure if there is access to this

•E-stim, low frequency (i.e. 4pps) for muscle memory as well as pain management... and I'd just use it passively at this point.

Maybe the best you hope for is improvement and not 'soundness'.  Maybe (and actually, more than maybe, change that to Likely) what this dog needs is maintenance rehab as pain management.  It's a change of mindset from 'fix the dog', to 'help the dog feel better'... on a regular basis.  Sometimes when I get to that point, it feels like I may have failed... but when I bring it up with clients, they are usually more than happy to agree on some kind of a maintenance schedule.  And then we 'play' a bit to see what sort of frequency works best.

All in all, I'd suggest not worrying about the exercises and go to all passive pain management... and then see where you get with that program after a few weeks.

Best of luck!

Cheers,

Laurie