I want to follow up on last week’s blog with a couple of additional cases that have made me scratch my head! In my opinion sound clinical reasoning is a foundational piece of physiotherapy and an area that I would love to see fostered and strengthened in animal rehab. It’s my thinking that the more we talk about it and provide examples, the more it strengthens and elevates this area of animal health care.
Case 3 – A tiny little Maltese x Something, about 10 years old or so that I was asked to see with another therapist at my clinic for ideas on a justifiably overwhelming case. This little one has front end issues and back end issues. Both carpi hyperextend dramatically and one has a significant medial deviation as well. In the back end, it would appear that both stifles are problematic, and the surgeon that evaluated the dog offered bilateral cruciate repairs.
On evaluation, I will admit, this was one of those cases where my inside voice was say, “Oh my goodness, this is horrible case – who can we send it to!?!” Then I realized that I WAS the second opinion (3rd actually) … so, “Figure it out, Laurie!”
The carpal joints were a mess, the laxity and crepitus in the joints were astounding. I stopped part way through in doing a full evaluation of the stifles, because it was obvious that the dog was using them successfully, they did not seem painful with function, and that the back legs were not as problematic as the fronts. (So, why do surgery on the functional set of limbs!?!)
The owner had purchased an over-the-counter foot/carpus splint, but it was too big.
Problem 1: carpal ligamentous laxity bilaterally on a teeny tiny older dog.
Problem 2: we can come back to the stifles at a later date.
Goal: Stabilize… but with what?
So, the problem with a dog where all 4 limbs are compromised is that if you make any one of the problem areas too immobile… that dog just might not sue the limb at all, and can shift weight elsewhere, subsequently having a negative impact on the other problem areas. I also remember listening to Ilaria Borghese of Therapaw during a splinting and bracing course say, “I always tell people to do a ‘Mock-Up’ first to see how the dog responds.”
Maybe we will need a rigid brace. Maybe we will need a customized soft brace. However, let’s see how the dog will move with any kind of wrap on the carpal joints. So, we fabricated vet-wrap wraps with bits of extra support to hinder the laxity and the owner was shown how to do the wraps. We’ll see how she’s made out soon.
In the meantime, I’ve created some wraps using neoprene and Velcro. The next appointment will be about testing these and then seeing if thermoplastics might also play a role. Where do we go from there?
If the wraps work, great! That’s the solution.
If thermoplastics are needed and they solve the problem; Great.
If the dog is willing to walk with the wraps +/- thermoplastics BUT they don’t support the joints enough, then we can look at custom wraps or a custom rigid brace.
But the message here is to test before spending big money on an unknown outcome.
Case 4: A little Chihuahua mix Mexican rescue dog with a medial shoulder instability. This dog is owned by family. So, I’ve seen this dog on and off for various things over the years. This time she’s been on and off lame on that leg. I’ve prescribed exercises and she was improving. However, the owners decided that perhaps an x-ray was in order, so they took her in for that. She was evaluated and x-rayed under sedation (she’s fairly ‘spunky’ and ‘toothy’ when it comes to evaluations), and since that time she’s not used the leg at all! (P.S. Nothing was found on x-ray and no diagnosis was given. The owners were offered a referral for a surgical consultation.)
So, on evaluation, I found nothing new, just the medial shoulder hypermobility and pain at the supraspinatus tendon. Now, I have to admit I don’t tend to ever have to recommend hobbles. I’ve found that exercises with or without an elastic bandage wrap for proprioceptive support is all that is ever needed for these cases. However, in this instance, given the temperament of the dog (I think she rules the household), and the fact that the kids might not be as diligent with the “Don’t do this” list that goes along with medial shoulder hypermobility management… we’ve ordered some hobbles.
Problem: Medial shoulder hypermobility, compounded by the dog’s temperament, and living in a house with children, requires more than Active Management of the situation. Passive strategy would benefit as well.
What is the lesson here? While my clinical experience says that this can be managed without an adaptive device, my knowledge of the “Social history” (as we call it in the human field) led me to approach this case differently than I would with my other cases. So, we’re adding Hobbles to the regimen for about 2 months in addition to the exercises.
While part of the stories above highlight CLINICAL REASONING, they also highlight the need to provide options, to problem solve, to test, to take into account multiple factors, and be willing to go down different paths depending upon how a patient responds to an intervention. I guess I’ll have to see how these two dogs make out, but I thought their cases were fairly interesting and worthy of sharing!