Hi Laurie
I am seeing quite a number of cavalier/Xs with really sore backs at the moment. I feel I am missing something in treating them so I was wondering if you could please give me your thoughts?
I have xrayed most of them, and some of them have mild HD but nothing radiographically visible on their spines, of course. Obviously the HD is causing them to overload their lumbar spine so they will be predisposed to a sore back, but radiographically and clinically I would call it mild (little pain on hip extension and none of the typical bunny hopping/limping/stiffness etc).
I have been treating with manual therapy, standing and side lying spine mobes, treating the ribs, STM. Some I have sent home with the 'Back Pain' protocol by Sasha Foster (standing with good posture, front legs on box, play bows, side stepping on box etc). Generally I send them home with gabapentin as well, sometimes NSAIDs if I think they need it. At the end of the consult the back pain/spasm has gone, but it is always back by the next visit (1-4weeks depending on dog). What am I missing? I am very new to rehab and do not have any toys yet, we are working on trying to convince management to let us get a laser.
Thanks!
Kriszty
Back Pain
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David Lane
- Posts: 164
- Joined: Mon Oct 24, 2016 10:51 pm
Re: Back Pain
First off, good on you for not being satisfied by very temporary resolution of the problem. Far too many therapists would instead accept that as normal, and simply fill their appointment books with recheck assessments.
If, by the end of the appointment, all evidence of pain or restricted vertebral mobility is gone, then you have succeeded in accomplishing your short-term goals. Step B is to convert that short-term improvement into long term resolution. FWIW, I have 2 thoughts:
Thought 1:
If possible, combine modalities. Back in the day, I started with training in manipulations, and did horses as well as dogs. It was standard that after a 1st equine chiro appt, I would recheck in a week because 90% needed that recheck. Then I added acupuncture on top of chiro. Suddenly, on those 1 week equine rechecks, I found that 90% of the time I didn’t need to be there because the horses were still doing well. Similarly, with my dog patients, I was immediately able to drop the frequency of my rechecks (currently, a standard situation for me is to see the dog for an initial assessment, recheck in a week, then in a month, then prn). Even for my polyarthritic, paretic, 3-legged, horribly dysfunctional chronic repeat geriatric cases, I can get treatment to last a month just by combining manual therapy with acu and laser. Keep nagging your boss for a laser.
To learn acupuncture, I took the full IVAS course, and today only use about 2% of what the course covered (the neurophysiology of acupuncture, and maybe 20 different acupoints). Over time, I find myself focusing more and more on palpating trigger points, and then stabbing them right in the eyeball. (I think professionals call that dry needling or IMS, but I like my description better). Rick Wall would be the one to talk to about acquiring that skill. He does a weekend course that I have never taken, but I suspect it would get you where you need to be faster than the IVAS route.
Thought 2:
Therapeutic exercise and strength training is your best tool for long term resolution. These dogs, who likely have sacrificed their lower spines in order to maintain pain free coxofemoral joints, have been practicing how to walk, trot, sit, etc. abnormally. As I type this, I realize it probably ties in nicely with Laurie’s blog on motor timing (which I haven’t read yet, but I’m guessing it would).
After the manual therapy treatment, you have the dogs returning to more normal function, but they are out of shape to do so. Muscles that used to spasm all day are stronger and more reactive, ready to spasm again at the slightest perceived insult. Other muscles that faced early retirement because the spasming muscles took over their jobs, are suddenly returned to active duty and aren’t in shape to take on that responsibility. The body needs to practice moving normally, and get fit at doing so. Once you achieve that goal through targeted therapeutic exercise, you should find the time between appointments widening nicely. If there is underlying OA or anatomic defects, then you will never return to 100% normal function, so some degree of repeat tune ups will always be required.
Does that help?
David Lane DVM
ACVSMR
If, by the end of the appointment, all evidence of pain or restricted vertebral mobility is gone, then you have succeeded in accomplishing your short-term goals. Step B is to convert that short-term improvement into long term resolution. FWIW, I have 2 thoughts:
Thought 1:
If possible, combine modalities. Back in the day, I started with training in manipulations, and did horses as well as dogs. It was standard that after a 1st equine chiro appt, I would recheck in a week because 90% needed that recheck. Then I added acupuncture on top of chiro. Suddenly, on those 1 week equine rechecks, I found that 90% of the time I didn’t need to be there because the horses were still doing well. Similarly, with my dog patients, I was immediately able to drop the frequency of my rechecks (currently, a standard situation for me is to see the dog for an initial assessment, recheck in a week, then in a month, then prn). Even for my polyarthritic, paretic, 3-legged, horribly dysfunctional chronic repeat geriatric cases, I can get treatment to last a month just by combining manual therapy with acu and laser. Keep nagging your boss for a laser.
To learn acupuncture, I took the full IVAS course, and today only use about 2% of what the course covered (the neurophysiology of acupuncture, and maybe 20 different acupoints). Over time, I find myself focusing more and more on palpating trigger points, and then stabbing them right in the eyeball. (I think professionals call that dry needling or IMS, but I like my description better). Rick Wall would be the one to talk to about acquiring that skill. He does a weekend course that I have never taken, but I suspect it would get you where you need to be faster than the IVAS route.
Thought 2:
Therapeutic exercise and strength training is your best tool for long term resolution. These dogs, who likely have sacrificed their lower spines in order to maintain pain free coxofemoral joints, have been practicing how to walk, trot, sit, etc. abnormally. As I type this, I realize it probably ties in nicely with Laurie’s blog on motor timing (which I haven’t read yet, but I’m guessing it would).
After the manual therapy treatment, you have the dogs returning to more normal function, but they are out of shape to do so. Muscles that used to spasm all day are stronger and more reactive, ready to spasm again at the slightest perceived insult. Other muscles that faced early retirement because the spasming muscles took over their jobs, are suddenly returned to active duty and aren’t in shape to take on that responsibility. The body needs to practice moving normally, and get fit at doing so. Once you achieve that goal through targeted therapeutic exercise, you should find the time between appointments widening nicely. If there is underlying OA or anatomic defects, then you will never return to 100% normal function, so some degree of repeat tune ups will always be required.
Does that help?
David Lane DVM
ACVSMR
David Lane DVM
ACVSMR, CVA, CVSMT, CCRP
ACVSMR, CVA, CVSMT, CCRP
Re: Back Pain
Thank you for the reply, and your thoughts David!
Hopefully we get a laser soon. I am in Australia so unfortunately Dr Wall's course is probably not going to happen soon. I have looked for a trigger point course here but not found anything yet. My own dogs get trigger point therapy by Dr Liz Frank, who is very experienced. I find them very difficult to feel, but will keep trying.
Re therapeutic exercise, I was hoping thats what the Back Pain protocol would do, but I have not seen a difference in the dogs that I put on that. I guess I need something more targeted for the specific dog rather than a generalised/cookie cutter approach?
Kriszty
Hopefully we get a laser soon. I am in Australia so unfortunately Dr Wall's course is probably not going to happen soon. I have looked for a trigger point course here but not found anything yet. My own dogs get trigger point therapy by Dr Liz Frank, who is very experienced. I find them very difficult to feel, but will keep trying.
Re therapeutic exercise, I was hoping thats what the Back Pain protocol would do, but I have not seen a difference in the dogs that I put on that. I guess I need something more targeted for the specific dog rather than a generalised/cookie cutter approach?
Kriszty
Re: Back Pain
Hey Kriszty,
David's comments are great, and I would concur that I like to multi-modal these guys a ton! I'm just going to throw out thoughts in random order, and hope they lands somewhere intelligibly!
Hips - Don't be a VOMIT (victim of medical imagine technology). i.e. don't assume anything about the hips unless you assess them to be painful. I like pressure just infront of the greater trochanter into the deep gluteal (or Gall Bladder 29 if you prefer). IF THAT is painful, then the hips are painful, and you might gain some ground by treating hips (strengthening glutes, massage / trigger point releases to the deep gluteal(s), and/or generalized stretches / fascial work. If you find pain, perhaps that IS your missing link.
Pelvis - Just because I love a good SIJ case. Be sure to check there. Strum the piriformis and over the Dorsal SIJ ligs. If pain, then there is something there. Treat accordingly, and look at Motor Control and timing (see that training video, and test control with facilitation of glutes or abdominals.)
Lumbar Spine - What mobs are you doing? For lumbar spine, I prefer a transverse pressure on the side of the spinous process while in flexion, or flexion mobs. OPEN OPEN OPEN the facets. Add tail pulls to the home program, and do some massage, fascial drags, and skin rolling over the area & rump to work muscles, fascia and the nervous system.
Motor Control & Timing: Again, check out the FourLeg Training Video on that. Slow slide of a rear leg off the ground and watch to see if the dog can maintain a straight topline or if it sinks & follows the leg. Then add abdominal tickles / pokes / squeezes and try the exercise again. If that works, then THAT becomes the home exercise, and in clinic, you can do the same exercise timed with e-stim of the abdominals.
Back Pain protocol. Hmmm. I'm not sure those would be my exercises of choice. Often times pain is due to the 'loss of the bowstring construct' (i.e. the facet joints bash each other in extension.) So I am not quick to ask a dog to go into extension. I don't mind the play bow, and I don't mind a bridge / plank exercise - slowing stretching the dog out while facilitating / poking the dogs abdominals to get them to fire. I would do some simple ROM - i.e. cookies at the hips. I'd also get the owners doing skin rolling and tail pulls - as mentioned above.
Multi-modality. I would agree with David, that I love to throw everything I've got at these guys. I too love laser and acupuncture as an adjunct. (And I make up points to suit me from a neuroanatomical standpoint). But without those tools spend a bit more time working fascia and muscles in the region in addition to the motor control & timing exercises.
All the best!
Laurie
David's comments are great, and I would concur that I like to multi-modal these guys a ton! I'm just going to throw out thoughts in random order, and hope they lands somewhere intelligibly!
Hips - Don't be a VOMIT (victim of medical imagine technology). i.e. don't assume anything about the hips unless you assess them to be painful. I like pressure just infront of the greater trochanter into the deep gluteal (or Gall Bladder 29 if you prefer). IF THAT is painful, then the hips are painful, and you might gain some ground by treating hips (strengthening glutes, massage / trigger point releases to the deep gluteal(s), and/or generalized stretches / fascial work. If you find pain, perhaps that IS your missing link.
Pelvis - Just because I love a good SIJ case. Be sure to check there. Strum the piriformis and over the Dorsal SIJ ligs. If pain, then there is something there. Treat accordingly, and look at Motor Control and timing (see that training video, and test control with facilitation of glutes or abdominals.)
Lumbar Spine - What mobs are you doing? For lumbar spine, I prefer a transverse pressure on the side of the spinous process while in flexion, or flexion mobs. OPEN OPEN OPEN the facets. Add tail pulls to the home program, and do some massage, fascial drags, and skin rolling over the area & rump to work muscles, fascia and the nervous system.
Motor Control & Timing: Again, check out the FourLeg Training Video on that. Slow slide of a rear leg off the ground and watch to see if the dog can maintain a straight topline or if it sinks & follows the leg. Then add abdominal tickles / pokes / squeezes and try the exercise again. If that works, then THAT becomes the home exercise, and in clinic, you can do the same exercise timed with e-stim of the abdominals.
Back Pain protocol. Hmmm. I'm not sure those would be my exercises of choice. Often times pain is due to the 'loss of the bowstring construct' (i.e. the facet joints bash each other in extension.) So I am not quick to ask a dog to go into extension. I don't mind the play bow, and I don't mind a bridge / plank exercise - slowing stretching the dog out while facilitating / poking the dogs abdominals to get them to fire. I would do some simple ROM - i.e. cookies at the hips. I'd also get the owners doing skin rolling and tail pulls - as mentioned above.
Multi-modality. I would agree with David, that I love to throw everything I've got at these guys. I too love laser and acupuncture as an adjunct. (And I make up points to suit me from a neuroanatomical standpoint). But without those tools spend a bit more time working fascia and muscles in the region in addition to the motor control & timing exercises.
All the best!
Laurie
LAURIE EDGE-HUGHES
Re: Back Pain
Thanks, Laurie!
I do a combination of standing DV and flexion lumbar spine (transverse processes), also like that one you taught in side lying where you lift the underneath back leg and neck. Yep doing skin rolling and tail pulls at home. Will add in ROM exercises and check motor control and timing. I had someone at my house checking my sport dogs yesterday, and she was assessing their ability to move their pelvis into extension and flexion whilst lying down, standing, and with 1 rear leg up on a target, as her functional exam. Interestingly all 3 dogs failed, even though all 3 of them passed the motor control and timing with sliding the back feet back with no dropping. So are the 2 exercises testing different things then?
I will change the exercises I send them home with.
Thanks again
Kriszty
I do a combination of standing DV and flexion lumbar spine (transverse processes), also like that one you taught in side lying where you lift the underneath back leg and neck. Yep doing skin rolling and tail pulls at home. Will add in ROM exercises and check motor control and timing. I had someone at my house checking my sport dogs yesterday, and she was assessing their ability to move their pelvis into extension and flexion whilst lying down, standing, and with 1 rear leg up on a target, as her functional exam. Interestingly all 3 dogs failed, even though all 3 of them passed the motor control and timing with sliding the back feet back with no dropping. So are the 2 exercises testing different things then?
I will change the exercises I send them home with.
Thanks again
Kriszty
Re: Back Pain
I've never heard of the testing you described - the ability to move their pelvis into flexion-extension in different positions. I'd love a video.
Part of me wonders if your dogs failed because they didn't know what was being asked... and what is being tested is a learned response / action vs a test of actual function...
Laurie
Part of me wonders if your dogs failed because they didn't know what was being asked... and what is being tested is a learned response / action vs a test of actual function...
Laurie
LAURIE EDGE-HUGHES
Re: Back Pain
Thank you for this. It is what I had envisioned.
I do think it is a good back exercise...
I do something similar for myself in sitting when my back is sore.
...but I'm not sure I would use it in a functional exam.
I might need to think on it a bit longer, to decide what I think of it as an 'exam'.
Laurie
I do think it is a good back exercise...
I do something similar for myself in sitting when my back is sore.
...but I'm not sure I would use it in a functional exam.
I might need to think on it a bit longer, to decide what I think of it as an 'exam'.
Laurie
LAURIE EDGE-HUGHES
Re: Back Pain
What do you think is the significance of a dog that can do one side really well (flat pelvis with elevated leg) and who struggles with the other side (unable to maintain flat pelvis despite practicing for awhile). Would you look for pathology on the struggling side?
Thanks
Kriszty
Thanks
Kriszty
Re: Back Pain
That is where my head would go... and I think I'd check the SIJ...
L
L
LAURIE EDGE-HUGHES