Overview of Orthopedic Rehabilitation
Rehabilitation assessment of orthopedic conditions involves capturing subjective data from the client, including history of present condition and the client’s goals for their animal. The therapist must also obtain a thorough medical history from the referring veterinarian and capture objective data including posture, gait, functional activities, strength, palpation, passive range of motion (PROM), muscle flexibility, joint play, and special tests. Findings from each of these areas are placed on the problem list and are critically analyzed by the therapist to develop a working rehabilitation diagnosis. The working rehabilitation diagnosis is an expansion of the primary orthopedic diagnosis and includes the sequelae of the primary diagnosis as well as other underlying physical limitations that may not be associated with the orthopedic condition. The problem list is then prioritized based on the client’s goals for the patient, and a treatment plan is developed for the prioritized findings based on anatomical, biomechanical, and physiological principles. The rehabilitation plan, including a home exercise program, is completed following principle-based frequency, intensity, and duration for each treatment. Treatment efficacy is reassessed frequently in the rehabilitation process, allowing for intervention modifications within a session and over a course of treatment to ensure treatment effectiveness. When assessment reveals that the patient has reached their rehabilitation goal, they are discharged to a health maintenance program.
Sequencing the Orthopedic Assessment
Proper sequencing of objective data collection promotes a lasting therapeutic relationship with the patient. At the initial meeting, the therapist should greet the client in a warm and friendly manner, taking breed-specific preferences for patient interaction into consideration, initially avoiding direct eye contact and physical interaction with fearful and dominant patients. The therapist then leads the client and patient into the therapy room, allowing the patient the freedom to become familiar with the new setting. As the patient explores the environment, the therapist interviews the client, capturing subjective data and medical history. The objective evaluation begins with the hands-off elements including posture, gait, and functional activities. If the patient is provided with rewards in the form of food or toys during the initial phases of the assessment, they may be more agreeable during the manual portions of the exam which include palpation, flexibility, PROM, joint play, and special tests. Patient preference for body position (standing, sitting, or lying) and order of manual exam elements is respected. To avoid pain and fear responses early in the examination, the involved limb is typically evaluated last.
Forelimb Assessment
Consideration of anatomy, osteokinematics, and arthrokinematics during each objective test will guide the therapist to a deeper understanding of the injury location and tissue type. A thorough assessment includes observation of muscle origins and insertions and their impact on normal osteokinematic movement including scapular protraction (scapula moves away from midline) and retraction (scapula moves toward midline); glenohumeral flexion, extension, abduction, adduction, internal and external rotation; elbow flexion and extension; and carpal flexion, extension, supination, and pronation. Normal osteokinematics demands normalized arthrokinematics at each joint which include glenohumeral joint cranial, caudal, medial, lateral, internal, and external rotation glides; elbow cranial and caudal glides; and carpal cranial, caudal, medial, and lateral glides. Each of these arthrokinematics requires joint capsule stability, which is maintained via the inherent integrity of the joint capsule as well as ligamentous stability providing additional resistance to external forces. Ligamentous stability in the forelimb includes the medial collateral ligament of the glenohumeral joint, which prevents excessive medial glide of the humerus in the glenoid fossa, and the medial and lateral collateral ligaments of the elbow and carpus, which counteract varus or valgus forces through each of these joints. Keen observation of anatomy, osteokinematics and arthrokinematics in each of the following objective tests will assist with development of the rehabilitation diagnoses.
Posture
The purpose of postural objective data is to determine positional inequities that may lead the therapist to further assessment of a particular area of the body. Posture is assessed with the patient in a natural static standing position observed from the front, side, back, and top. The therapist first takes into consideration head position relative to back height and midline. Due to a number of multijoint muscles including brachiocephalicus and omotransversarius, primary or compensatory injuries of the front limb can affect neck posture which in turn can affect the posture of the entire body, predisposing the front limbs, back, and pelvic limbs to compensatory injuries. Position of the scapulae on the thorax should then be reviewed, taking into consideration breed-specific angulation (visit www.akc.org for breed-specific angulation). Inequities in scapular position can indicate tightness, weakness, or injury to the muscles that attach the scapula to the thorax including serratus ventralis cranial and caudal fibers, rhomboids, and cranial and caudal heads of trapezius. Standing angle of the glenohumeral, elbow, and carpal joints relative to the contralateral limb and relative to each other are captured. Abnormal standing angles or inequities from side to side can indicate a primary injury such as increased elbow flexion due to osteoarthritis or a compensatory strategy such as elbow hyperextension due to carpal flexor strain. Compare Figure 13.1 of a young, injury-free dog to Figure 13.2 of a geriatric patient.
Figure 13.1 Postural assessment from the side and front of a young, injury-free dog. A. Side view. B. Front view. Note the position of the scapula on the thorax, the angulation of the front limb joints, and the position of the head and top line in comparison to those of the geriatric patient in Figure 13.2.
Figure 13.2 Postural assessment from the side and front of a geriatric patient with a medical diagnosis of hip osteoarthritis. A. Side view. B. Front view. Physical therapy postural assessment reveals scapulae dorsally positioned on thorax, extension of shoulder and elbow joints, and hyperextension of carpal joints (likely to utilize the passive tension of flexor carpi ulnaris), all of which help maintain a passive energy-efficient standing position. Head and topline positions indicate offloading of the pelvic limbs, increasing weight through the front limbs.
Gait
Gait assessment is used to capture data regarding kinematic quality. Decreased quality of movement including gross lameness, decreased weight bearing, and unequal stride length provide observational data that guide the therapist to an in-depth evaluation of specific areas. For example, observation of right front limb decreased stride length may lead the therapist to a detailed assessment of the cervical spine, bilateral front limbs, and thoracolumbar spine. See Chapter 2.
Function
The purpose of the functional assessment is critical analysis of movement inequities that may indicate primary or secondary physical limitations. Functional assessment should, at a minimum, include lateral recumbency-to-sit, sternal-to-sit, sit-to-stand (Figure 13.3), stand-to-sit, and movement on curbs, ramps, stairs, and into and out of the client’s primary vehicle. Movement abnormalities during each of these functional tests can provide important information regarding injury location. For example, refusal to assume and maintain a sternal recumbent position may indicate decreased glenohumeral or elbow joint flexion. Further evaluation of both of these joints is indicated to determine arthrokinematic quality, osteokinematic quality, and muscle extensibility. Glenohumeral joint hypomobility, as is seen with biceps tendinosis, or hypermobility, as is seen with medial shoulder instability (MSI), and elbow joint hypomobility, as is seen with osteoarthritis, may impact the patient’s ability to comfortably assume and maintain a sternal recumbent position.
Figure 13.3 Functional assessment of the front limb requires observation of the primary functional activities needed for daily living. Here a dog is attempting to stand by first (A) swinging the head in preparation for standing and (B) struggling to extend the pelvic limbs and elevate the pelvis. As this geriatric patient with a medical diagnosis of hip osteoarthritis moves from sit to stand, the cranial placement of the paws and the extended position of the elbows indicate likely caudal shoulder muscle concentric contraction pulling the body to stand. This posturing decreases the need to actively flex the shoulder and elbow joints indicating possible arthrokinematic issues that need to be assessed in the evaluation.
(Images derived from video.)
Strength
Skeletal muscle provides strength to maintain posture and move joints while absorbing external forces and distributing loads (Hill, 1950). The purpose of strength testing is to determine baseline force-producing capacity of a particular skeletal muscle group and to analyze, in the problem list, whether more strength is required to meet the goals for the patient. Prior to strength testing, quality of muscle bulk must be observed to determine if atrophy is present. If atrophy is noted, limb circumference is measured with a Gulick tape measure, taking particular note of the area measured to allow for valid remeasurements. Limb circumference is assessed throughout the course of treatment to determine if muscle bulk is returning within an expected time frame. Muscle strength must be tested separately as muscle circumference is not directly correlated with muscle torque (Stevens et al., 2004). See Chapter 5 for detailed description of Gulick measurements.
In human physical therapy, strength has been determined with a manual muscle test (MMT), a 1–5 rating scale requiring volitional open-chain muscle contraction through full joint range of motion (Perry et al., 2004). In the canine patient, the traditional MMT cannot be utilized. To test strength in the canine patient, closed-chain contractions must be observed in a functional standing position and the data captured using the canine manual muscle test (C-MMT). The C-MMT is used by the author (SF) as a repeatable objective measure. It requires repeated testing to assure validity. Three categories of strength are defined in this test: <3/5 (poor), the muscle group is unable to provide the force required to maintain a static standing position; 3/5 (fair), the muscle group is able to provide the force required to maintain a static standing position; 3+/5 (good), the muscle group is able to provide more force than is required to maintain a static standing position.
For C-MMT strength testing, a stifle height box or step is required (Figure 13.4). Initially, the dog is asked to stand on the floor. The limb opposite the limb to be tested is lifted into a non-weight-bearing position, and the therapist observes the testing limb. If the limb is unable to maintain the position as observed by increased dorsal glide of the scapula (weakness of serratus ventralis), increased shoulder flexion (weakness of biceps and supraspinatus), increased elbow flexion (weakness of triceps), increased carpal extension (weakness of carpal flexors), or any combination of these or other signs of weakness, the strength score is <3/5. The test is then completed on the opposite side. If the dog is able to maintain an upright position without compensatory movements, the score is at least 3/5, and the limb can then be tested to determine whether the strength is >3/5. To do this, the patient’s pelvic limbs are placed on a box or a step, increasing the weight on the front limbs. The test is repeated with the therapist observing if the limb is able to maintain the position. If the patient is unable to maintain the position, the strength score is 3/5. If the patient is able to maintain the position, the strength score is 3+/5. When completing the C-MMT, attention must be given to musculoskeletal issues that may interfere with the test like facet joint dysfunction that would prevent the patient from comfortably placing the pelvic paws on the box.
Figure 13.4 The canine manual muscle test (C-MMT) allows the therapist to determine baseline isometric strength in this case of the right forelimb in a functional standing position. A. The patient is placed in a standing position, and the contralateral limb is lifted into a non-weight-bearing position. The therapist observes changes in the position of the scapula on the thorax and changes in joint angle as the contralateral limb is lifted. Inability to maintain scapular and joint angles indicates a strength score of <3/5. If the patient is able to maintain the position, further testing ensues as described in B. B. The patient is placed in a standing position with the pelvic limbs on a box, thus increasing weight-bearing on the front limbs. The contralateral limb is lifted into a non-weight-bearing position. The therapist observes changes in the position of the scapula on the thorax and changes in joint angle as the contralateral limb is lifted. Inability to maintain scapular position and joint angles indicates a strength score of 3/5. Ability to maintain the position indicates a strength score of 3+/5.
More objective strength test scores may be obtained with surface electrode electromyography (EMG). Clinical limitations include time constraints, the need to shave each muscle group, and the paucity of research directly correlating canine EMG measures and muscle force production. Further studies are required to develop canine objective strength measures that are valid as well as interrater and intrarater reliable.
Palpation
By manually challenging the tissues, palpation assessment provides the therapist with information regarding the specific tissue type that is involved and the location of edema, heat, pain, tone, and tightness. Palpation findings help specify the anatomical structure and chronicity of a primary or secondary orthopedic injury. For example, during evaluation of the front limb, palpation assessment of the latissimus dorsi requires pressing the fingertips into the muscle tissue along the ventral boarder of the muscle from origin to insertion and through the muscle belly from the proximal caudal border of the humerus into the thoracodorsal fascia (Figure 13.5). A positive response to palpation, including the subjective feeling of edema, heat, and tone, as well as visible pain or muscle spasm, leads the therapist to further assess the scapulothoracic, glenohumeral joint, and thoracolumbar areas. Thorough objective palpation includes all joints, muscles (Table 13.1), and bony landmarks of the front limb.
Figure 13.5 A. Manual palpation of the latissimus dorsi muscle challenges the muscle tissues along the ventral border of the muscle from origin to insertion feeling for tissue changes including edema, heat, tone, pain, and muscle spasm. B. Manual palpation of the latissimus dorsi also challenges tissues in the central portion of the muscle belly paying particular attention to areas of pain and tightness that may indicate trigger points.
Table 13.1 Muscle open-chain actions from an anatomically neutral position
| Muscle | Actions |
| Rhomboids | Scapular dorsal glide |
| Trapezius, cranial head | Scapular dorsocranial glide |
| Trapezius, caudal head | Scapular dorsocaudal glide |
| Omotransversarius | Scapular cranial glide + cervical spine side bending |
| Subscapularis | Glenohumeral adduction + flexion |
| Serratus ventralis, cranial fibers | Scapular ventrocranial glide |
| Serratus ventralis, caudal fibers | Scapular ventrocaudal glide |
| Supraspinatus | Glenohumeral extension |
| Infraspinatus | Glenohumeral abduction |
| Biceps brachii | Glenohumeral extension + elbow flexion |
| Brachiocephalicus | Cervical spine side bending + glenohumeral extension + elbow flexion |
| Deltoids | Glenohumeral flexion + abduction |
| Latissimus dorsi | Glenohumeral internal rotation and flexion |
| Superficial pectoral | Glenohumeral adduction |
| Deep pectoral | Glenohumeral flexion + internal rotation |
| Teres major | Glenohumeral flexion + internal rotation |
| Triceps | Elbow extension + shoulder flexion |
| Brachialis | Elbow flexion |
| Carpal flexor muscle group | Carpal and digit flexion |
| Carpal extensor muscle group | Carpal and digit extension |
Passive Range of Motion (PROM)
Objective assessment of PROM guides a therapist to a deeper understanding of primary or secondary injuries of the articular surfaces and joint capsule. For the highest quality measurements, the nonaffected side is measured first. The joint is gently moved into the range of motion, and overpressure is applied to assess for pain and capsular restriction. Overpressure should not be applied to a joint that is hypermobile or has an empty (painful) end-feel. When end range is determined, the goniometer is placed over the joint with the stationary arm on the proximal bony landmark, the point of rotation over the joint, and the movable arm on the distal bony landmark (Figure 13.6). The measurement is recorded. It is important to be sure that all muscles surrounding the joint are on slack ensuring a valid joint measurement. Some single-joint muscles may still affect range of motion measurements, as is the case with glenohumeral joint flexion, which stretches the supraspinatus, and glenohumeral joint abduction (with the joint in extension), which stretches the subscapularis. Range of motion testing takes into consideration possible muscular involvement—decreased range of motion caused by adaptive shortening of the muscle unit or increased range of motion caused by a muscle strain.
Figure 13.6 A. When completing the goniometric measurement for flexion of the glenohumeral joint, the therapist must keep in mind that range of motion limitations may be due to joint capsule involvement, joint play restrictions, or musculotendinous involvement. B. When completing the goniometric measurement for glenohumeral joint extension, the therapist carefully stabilizes the scapula to ensure assessment of joint end-feel. Without stabilization, the scapula glides on the thorax creating a false-positive hypermobility measurement. C. When completing the goniometric measurement for glenohumeral joint abduction, the therapist carefully stabilizes the scapula against the thorax to prevent a false-positive hypermobility measurement. The therapist also is careful to prevent unintentional external rotation of the joint, which may involve subscapularis tendon.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
