Laurie's Blogs.

This week’s blog is really just a compilation of thoughts as they relate to a workshop I’m doing at the STAAR Conference in New Jersey in April (www.staarconference.com).  Now, I’m going to admit, I’m a little bit competitive, so when information comes out saying “XX number of spots available” in one of my seminars, I want my numbers to be really low.  In other words, I want everyone going to want to be in my classes!!!  So one of my motivations with this blog is to get my webinars all filled up!  The other motivation is to elaborate on why I chose to do one of my sessions on the topic of case management.

I get buckets and boat loads of e-mails asking for my assistance & thoughts on various cases that have presented themselves to members & friends of FourLeg.com from all over the world.  And there is a common thread in many of these e-mails.  There is a gap in systematic problem solving or individualization of treatment planning.  For example, there might be a case of a geriatric dog with some hind end weakness and some generalized back pain.  The plan up until contacting me has been to do underwater treadmill therapy, ( and maybe e-stim, ROM & massage) and check back in with the treatment planner in 4 weeks.  And then I’m asked, Laurie, what more should I be doing?  Or perhaps the issue is an iliopsoas strain (and I mean a real one, not just a facilitation of the muscle secondary to back pain or overuse due to compensations for a different injury), and the plan has been rest and stretching (or UWT and stretching), and the question is ‘how long should the dog be walking now?’  So I am seeing a bit disconnect in the problem solving and treatment planning, because there is more that each of these dogs should be doing if one were to a) understand the pathology behind the issue, b) understand how tissue heals, and c) have an algorithm for goal setting & treatment planning.

I recently came across some of my old notes from university on goal setting, and I though it would be worthwhile to share.  When creating a problem list, you are either looking at INADEQUATE strength, ROM, coordination, endurance, balance, or function or the PRESENCE of pain, muscle spasm, abnormal muscle tone, edema, postural deviations, gait deviations, abnormal sensory feedback, contractures / deformities, or inappropriate mood or behaviours.  (This list is not exhaustive, but I thought it was pretty darn good.)  So these are your problems and as such your goals would be to increase, maintain, prevent regression of, or decrease whatever was on the problem list, as appropriate.  Simple, right?  Maybe not.

I have always taught assessment and treatment planning in a way so as to get people to think about 1) What is the root of the problem & 2) What are the secondary signs & symptoms.  So let’s go to the old dog with weakness and back pain.  Root of the problem, I’d guess to be disc degeneration and/or stenosis.  I’d say check the neck and treat the neck pro-actively (go back to Video Training 131 or search the blog for ataxic geriatric dog.)  I’d have that dog coming weekly for ‘physio’ hands-on sessions plus laser and/or acupuncture, and maybe alpha stim & PEMF as I was doing the other therapies.  But the manual therapy would be my priority to treat the root of the problem and see if I could make a difference.  The weakness is a secondary sign… so in my head, that’s part of what the home program could address (maybe some easy hill walking to gain some strength), along with exercises to target the spine (tail pulls, chest lifts, cookies at the hip or shoulder, or neck traction).  In this way I have addressed the root of the issue, the secondary issues, and I have built in client retention, and increased my chance of success with this patient.

Let’s talk about goal setting a bit more.  Here’s another way to think of things.  When I was teaching people just starting out in canine rehab, I would have them think through different case scenarios and set goals that tapped into the following categories:

• Home & Lifestyle Management 
• Supplements?
• Education
• Manage inflammation and/or pain
• Support?
• ROM
• Muscle Flexibility
• Strengthening
• Proprioception
• Return to activity advice

If the participants / students thought about these things, then their problem solving & treatment planning was easier.  The same goes for the list of  “increase… decrease… maintain or prevent regression of…”

Okay, so lets think about that iliopsoas strain.  First off, is it a true strain?  Are both sides affected?  (If yes, then it’s not likely a strain.)  Was it slow onset? (Again, not likely a strain.)  Was there a history of injury or sudden onset with lots of pain on palpation?  (Then sure, we can talk iliopsoas strain.)  What’s the pathology?  Answer: Micro and macro tearing of the muscle or tendinous fibres.  Fibres will heal by the laying down of inelastic collagen fibres.  The fibres lay down in a disorganized mess.  So right off the bat, if this is acute, then we need relative rest (not zero, just some rest), we want to promote laying down of the collagen fibres, and we want to promote the fibres to orient themselves in a way that is best to withstand the stresses normally put on that structure.  So acutely, I’d pick modalities to stimulate healing, easy active or passive stretches, and easy concentric or isometric exercise.  Does this dog need to go into the UWT?  No, in fact, I’d say it’s not indicated.  It’s not specific enough.  I can accomplish more with specific exercises to target iliopsoas and leave walking to be a home activity on leash.  Maybe find a small hill or a flight of stairs to work the fibres a bit more by getting more hip extension (up hill) or eccentric control (down hill).  And if it’s a chronic condition… you need to start with those more challenging targeted exercises.

So these are just two examples, but if you break down any case put before you into problem list, goal list, & treatment plan.  Then you can be a mastermind in the rehab world!  This is how physical therapists were trained to think.  It took years to get us into that mind-set.  It may seem simple, but it accomplishes a lot!  So, on that note, I’m going to suggest that all of you non-physiotherapists sign up for my Interactive Case Management workshop at STAAR.  Hope to see you there!  Cheers!  Laurie