Janet B. Van Dyke, DVM, DACVSMR
The physiotherapeutic approach to patient evaluation places an emphasis upon proper and thorough soft tissue diagnosis. Problem solving is emphasized as are creating and meeting goals that are functional for the patient. As veterinarians, we have been trained to evaluate our patients, using imaging to help us evaluate bones and joints. When a dog presents with a lameness and the radiographs are negative, what can we do? This is where the skills used daily by physiotherapists can assist us. Determining specific soft tissue pathologies allows us to apply focused treatments to patients previously treated with “R&R” (Rest & Rimadyl).
Veterinarians have traditionally used “S.O.A.P. notes to record their thought processes on evaluating patients. Physiotherapists use a similar approach. Subjective data from the client/pet owner is combined with the medical history from the referring veterinarian as well as the objective data obtained through the physical examination. A detailed problem list is then created. From this list, an assessment is written. This is a narrative of the problem list. From this narrative, a list of functional goals is created. A detailed treatment plan is then written. As the treatment plan is pursued, the patient is reassessed to determine if goals were met. The treatment plan is then altered as necessary. The objective data collected includes the usual veterinary physical exam plus the following: Posture, function, strength, gait, PROM/AROM, flexibility, joint play, and special tests. Treatment plan development requires that the problem list be prioritized. The acuity and the primary tissue(s) of the injury are determined, leading to proper decision making regarding manual therapies, physical modalities, and therapeutic exercises. Treatments are then carried out, and the results evaluated before planning the next step. Determining the acuity of the injury requires understanding the tissue responses during acute, subacute, and chronic phases of healing. In the acute phase, there is initial tissue damage and an inflammatory response. Our treatment goals at this time are to decrease the acute pain, prevent exacerbation of the pain, and prevent resultant compensatory dysfunction. The subacute phase of healing begins when the inflammatory response has resolved. The injured tissues are still at high risk of reinjury and return to the acute phase. Treatment goals during the subacute phase include enhancing tissue healing, resolving compensatory pain, and preventing exacerbation of the underlying injury. In the chronic phase, tissues are beginning to heal, scarring is taking place, but healing is incomplete. Here, the treatment goals are to complete the resolution of the underlying injury, recondition the tissues associated with the injury, and begin reconditioning of the entire body. As a review: The rehabilitation therapist gathers the subjective data, prior medical history, performs the evaluation, obtaining the objective data, and then creates a problem list. This problem list is translated into an assessment, from which functional goals are created. The treatment plan is developed, addressing each item on the problem list and working toward meeting the functional goals. Treatment choices are determined by the type of tissues that have been injured and the acuity of this injury. Treatment plan options fall into three categories: manual therapies, therapeutic exercises, and physical modalities. Manual therapies include stretching and joint mobilizations. Therapeutic exercises are chosen based upon the weight-bearing status of the patient. All exercise programs include work on proprioception and balance, strength, flexibility, and endurance. The type of exercise in each area is determined by weight- bearing status, which is defined as progressing from non-weight-bearing to partial weight-bearing to full weight bearing. Once an animal is fully weight-bearing on a limb, the types of exercises are changed from functional weight-bearing exercises to functional strengthening exercises. The patient’s strength is then progressed from “<3 out 5” to “3 out of 5” to “5 out of 5.” The goals of the therapeutic exercise program are determined by the goals of the client, but all prgrams will include work on proprioception/balance, strength, flexibility, and endurance. The parameters for each physical modality are chosen based upon the acuity of the injury. Physical modalities are generally used to prepare the tissues for manual therapies and therapeutic exercises. Most modality treatments can be carried out by a rehabilitation-trained veterinary nurse. Some manual therapies and therapeutic exercises must be done by the rehabilitation therapist (veterinarian or physiotherapist).
Physiotherapy brings a new set of terminology to the veterinary field. Some terms have been used regularly in veterinary practice, but others are new, and even the ‘old’ terms need to be more clearly defined. Range of motion (ROM) is determined by both osteokinematics and arthrokinematics and includes both active range of motion (AROM) and passive range of motion (PROM). Osteokinematics is defined as the movement of bony segments around a bony axis. There are two kinds of osteokinematics: AROM and PROM. Assessment of both AROM and PROM is an important component of the rehabilitation evaluation. Active range of motion (AROM) is carried out by the patient and is best assessed using slow motion video. Passive range of motion (PROM) is carried out by the therapist with no muscular effort on the part of the patient. This is measured using a goniometer aligned with specific bony landmarks. The goniometer has a stationary arm, a fulcrum, and a moving arm. The stationary arm is generally aligned with the proximal landmark. The fulcrum is aligned with the center of rotation of the joint, and the moving arm is aligned with the distal landmark. For example, in measuring elbow range of motion, the stationary arm is aligned with the greater tubercle, the fulcrum is placed over the lateral humeral epicondyle, and the moving arm is aligned with the lateral styloid process. Apps are available on mobile devices to measure goniometric angles on stop action video clips. AROM and PROM are used clinically to help tease out the source of impairment. For example, if a patient presents with limited AROM in shoulder extension with evidence of pain when moving into extension, but on PROM testing, full non-painful shoulder extension is achieved, what is your differential diagnosis? Pain on AROM with no pain on PROM leads to a diagnosis of muscle or muscle/tendon impairment. In this case, the primary differentials would be biceps or supraspinatus tendinopathy. Limited PROM can be the result of issues in muscle, tendon, intra-articular lesions, joint capsule shortening or swelling. Flexibility is different from ROM. Flexibility refers to muscle distensibility rather than joint arthrokinematics. To determine the source of loss of PROM, the therapist assesses end feels: the sensation or feeling in the therapist’s hands when the joint is at the end of its available range. Arthrokinematics is the study of the movement of joint surfaces on one another. Normal arthrokinematics are essential before normal osteokinematics can occur. The two basic movements in all joints are roll and glide. Abnormal shortening of the joint capsule or associated ligaments will result in loss of normal arthrokinematics. The solution for this is joint mobilization that lengthens the shortened tissues. Joint mobilization is used to assess and treat limited arthrokinematics, and has the added advantage of modulating mechanoreceptors thereby reducing pain nociception.