Hi Laurie,
I have a couple of patient groups that I have been reflecting over case management with in order to improve my practice. I would really appreciate your thoughts/wisdom/suggestions here.
THJR - I have seen a few patients with complications following this procedure. For some of these patients it is a surgical issue, such as infection or implant failure. Those that fall into the category of physiotherapy management are: a) Sciatic nerve compromise, B) neurodynamic issues?, C) patients with muscle atrophy and weakness, or just slow to develop muscle mass (especially biceps femoris, vastus lateralis).
Strategies that I have been adopting for sciatic nerve compromise include:
* toe-up splint if affected hindpaw is knuckling
* sensory activation strategies: massage/stroking or flicking the skin surface to activate muscles and sensory receptors/touching the limb with different materials of varying sensations - to both the affected limb and paw
* proprioception activation strategies - electric toothbrush to affected paw as vibration to activate proprioceptors, walking over cavaletti to encourage joint proprioceptors, gentle hip joint compressions
* Laser: I have a SpectraVet laser Class 3B with both multi-probe and deep tissue probe. I have been applying laser at several points along the sciatic nerve tract in these patients and would be interested in your thoughts here in terms of points that you would choose, frequency of treatment. Often these patients are not referred to me until minimum 2 - 4 weeks post-operatively.
* Sciatic nerve excursion: I have been using sciatic nerve stretching where indicated (where hip flexion and combined stifle extension ROM is limited or resented). Normally I would recommend 5 - 10 reps pending on patient tolerance 2 x per day.
Patients with poor muscle activation, atrophy and weakness:
* NMES - often this is to biceps femoris and middle gluteals
* Kinesio-taping to activate muscles - although I do find this does not stay on so well with dogs
* Isometric contraction exercises
I am also wondering if there is a pain component that I am missing, and whether TENS would be a useful adjunct to some of those patients who appear to be poorly controlled with pain despite being on gabapentin +/- meloxicam.
Please advise if there is anything that I am missing.
Kindest Regards,
KG
THR questions
Re: THR questions
Hi K,
So first off, it sounds to me like you are really doing right by these dogs. Not sure I can add a whole lot more! But, let me see what I can come up with (???).
THJR - I’ve decided, I’m not a big fan of this as a surgery. I get it… but so many complications!
So, “thumbs up” to everything you are doing.
As for laser stimulation, I would focus more heavily on the area in the sciatic notch (between gr. Trochanter and ischial tuberosity) AND the nerve roots L6, 7, S1.
Honestly, it’s a crap shoot. We don’t know how much of the sciatic nerve was damaged during surgery… So, anything you can do it likely good.
Because of that, I’m a bit cautious about the sciatic Nerve glides… Okay if the surgical damage resulted in just a neuropraxia… but if the damage was more severe and an Axonotmesis, then perhaps nerve glides would be detrimental. (I don’t actually know for sure, but it would be my only caution.)
Pain Control… why not… however your laser is doing double duty. AND if you thought there was pain, then TENS around the hip and nerve roots might help. Maybe pre-exercise, in order to minimize any muscle inhibition. (??)
I would wonder, is it surgical pain? Is it windup pain from years of pain before the surgery? OR, is it not pain, and rather, learned non-use? I would think that your physical exam is likely the best guidepost!
Okay, as for papers - sorry, I’ve not actually done a deep dive into the THR research. We don’t see tons of these, so it’s not a subject that has peaked my interest enough to spend time on Pubmed. Sorry!
Okay, there you go!
Happy Monday!
Cheers,
Laurie
So first off, it sounds to me like you are really doing right by these dogs. Not sure I can add a whole lot more! But, let me see what I can come up with (???).
THJR - I’ve decided, I’m not a big fan of this as a surgery. I get it… but so many complications!
So, “thumbs up” to everything you are doing.
As for laser stimulation, I would focus more heavily on the area in the sciatic notch (between gr. Trochanter and ischial tuberosity) AND the nerve roots L6, 7, S1.
Honestly, it’s a crap shoot. We don’t know how much of the sciatic nerve was damaged during surgery… So, anything you can do it likely good.
Because of that, I’m a bit cautious about the sciatic Nerve glides… Okay if the surgical damage resulted in just a neuropraxia… but if the damage was more severe and an Axonotmesis, then perhaps nerve glides would be detrimental. (I don’t actually know for sure, but it would be my only caution.)
Pain Control… why not… however your laser is doing double duty. AND if you thought there was pain, then TENS around the hip and nerve roots might help. Maybe pre-exercise, in order to minimize any muscle inhibition. (??)
I would wonder, is it surgical pain? Is it windup pain from years of pain before the surgery? OR, is it not pain, and rather, learned non-use? I would think that your physical exam is likely the best guidepost!
Okay, as for papers - sorry, I’ve not actually done a deep dive into the THR research. We don’t see tons of these, so it’s not a subject that has peaked my interest enough to spend time on Pubmed. Sorry!
Okay, there you go!
Happy Monday!
Cheers,
Laurie
LAURIE EDGE-HUGHES