ACPAT 2015 FourFront Journal

CONTENTS

Editorial

The Equine Hydrotherapy Treadmill used as an adjunct to Veterinary Physiotherapy following a carpal injury: A Case Study Maruska Aylward MSc BSc MCSP HCPC ACPAT A The use of dynamic mobilisation exercises (baited stretches) in the management of neuromusculoskeletal injuries in the equine patient: A Review Olivia France PgDip BSc MCSP HCPC ACPAT A

Delayed physiotherapy intervention following a Femoral Head and Neck Excision surgery: A Case Study Nycky Edleston MCSP ACPAT A

An overview of neurological physiotherapy concepts and their application to create a postoperative rehabilitation guide for thoracolumbar hemilaminectomy.

Melanie Haines Chartered Veterinary and Human Physiotherapist MSc Vet Physio, BSc (Hons) Physiotherapy MCSP, ACPAT cat A

In interview with ACPAT’s new Chairman Stephanie Brighton MSc BSc (Hons) MCSP HCPC ACPAT A

Light Therapy in Veterinary and Animal Therapy Practice Marietjie Venter National Diploma in Physiotherapy, BA Social Sciences

The successful use of veterinary physiotherapy in the management and rehabilitation of surgically corrected over-riding dorsal spinous processes: A case report Faith Fisher-Atack HCPC CSP ACPSM ACPAT CAT A

Research Digest Kate Davy MCSP ACPAT Cat A; Stephanie Brighton MSc BSc (Hons) MCSP HCPC ACPAT A; Daisy Collins BSc, ACPAT Cat B

Diary of events Course reviews Book reviews Journals of Interest Recent news Writing for Four Front

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Designed by Intaglio - 07810 300730 www.intaglio-pms.co.uk

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EDITORIAL

Maruska Aylward, Stephanie Brindley and Daisy Collins welcome you to our sixth edition of FourFront and the third under our guidance. We hope that you enjoyed our last edition and found it a useful spend of your CPD time. This year’s journal we hope will be as informative and educational for you all. Please do send us your comments regarding our content this year either via a ‘letter to the editor’ or by emailing journal@acpat.org. The more that the membership are involved in the development of this journal the better it will be for our readers.

Please do also remember that our on-line Newsletter also exists for other informative material that is not necessarily evidence-based to be submitted for reading by the membership. We hope that this provides another route for submission of material for those members wishing to submit articles that are not subjected to the peer review system. Please do utilise this avenue for the sharing of information.

That aside, the last two FourFront journals were recently submitted to be assessed for Medline review. Unfortunately, they were not successful and currently Medline does not wish to have FourFront within its library listings. The ACPAT editors expected this outcome however, and submission was made in order to receive comments about the journal’s current academic level. Once we have received the comments we will relay these to the membership.

Our current plan is to continue along this line and we will await further membership comments regarding our efforts.

Before we continue, we welcome Kim Sheader as our next ACPAT Chairman and say a thank you to Louise Carson, who stepped down in February 2015. The committee has further said farewell to some other members such as Megan Rees, Rachel Greetham and Amy Barton. We wish you both well and thank you for your hard work to date.

As many of you are aware, the ACPAT editors have strived to raise the bar on the standard of FourFront, ultimately with the aim of perhaps one day achieving Medline status. We have carried this out by way of having a peer review system, evidence-based articles and the research digest section. We are aware this has meant authors have been expected to write articles to a higher standard. ACPAT feels this is necessary in order to maintain the standard of the journal and to reach the status we aim for. We also feel this is imperative in order to be regarded as one of the leading organisations at the forefront of the Veterinary Physiotherapy Profession.. We do however welcome comments from the membership regarding this issue. This journal represents you, and if you do not feel that it achieves that, the editorial team would like to hear from you. Are you happy with the standard of the journal?

So, in the meantime, please keep sending your articles, case studies, literature reviews and research projects through. We are aware of the time writing articles takes, but this is who we are, Physiotherapists’ love a good article, don’t they?!

We thank you all so far for your support and hard work, so please keep it up. As editors we are happy to support authors in raising the standard of their articles in order to reach publication, so please utilise us. ACPAT will reimburse you for your time, so please do contact us for more information.

Thank you again Your ever dedicated Your Editorial Team

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The Equine Hydrotherapy Treadmill used as an adjunct to Veterinary Physiotherapy following a carpal injury: A Case Study Maruska Aylward MSc BSc MCSP HCPC ACPAT Bridgefield Physiotherapy Ltd Website: www.bridgefieldphysio.co.uk Email: ma@bridgefieldphyaio.co.uk Tel: 07879 031974 Summary A 14 year old Cob cross Irish Sports Horse was referred to Bridgefield Physiotherapy for veterinary physiotherapy one month following an injury to the left thoracic limb common digital extensor tendon proximal to the carpal joint. A full Physiotherapy assessment by a Chartered ACPAT A Veterinary Physiotherapist identified appropriate exercises aimed at reducing pain, and improving joint range of motion and function. Carpal flexion at the initial assessment was 90º. Further referral to a hydrotherapy centre was used as an adjunct to physiotherapy.

The carpal flexion range of motion improved significantly after 13 consecutive treadmill walking sessions, 9 of which were above the tarsal joint. This case study was a good example of where multidisciplinary working yielded a successful outcome for the patient returning them to full function and improving their carpal range of motion to 150º of flexion.

Key Words: veterinary physiotherapy, carpus, common digital extensor (CDE), hydrotherapy treadmill, range of motion.

Introduction Horses are highly efficient athletes placing significant demands on their musculoskeletal system during different disciplines (Singer, et al., 2008). Various injuries, most of which occur at the carpus, have been reported during British Eventing and racing competitions (Singer, et al., 2008; Murray, et al.,

2004; Hill, 2003; Field and Zaruby, 1994). Additionally, osteochondral fractures involving the equine radio- or intercarpal joint are the most common high speed injuries involving the carpal bones (Bailey, et al., 1984). Such injuries can cause increased periarticular fibrous tissue, swelling and pain resulting in reduced carpal flexion (Bailey, et al., 1984), subsequently restricting overall joint function (Porter, 2005).

As Chartered Veterinary Physiotherapists we are skilled in treating the restrictions in joint ranges of motion following any joint injury in humans and can therefore apply these techniques to our equine athletes. These techniques may include passive joint mobilisations, accessory joint glides, deep friction massage, specific exercise prescription or hydrotherapy for example (Artz, et al., 2015; Loew, et al., 2014; Valdes, et al., 2014; Brantingham, et al., 2013; Pozzi, et al., 2013; Bruder, et al., 2012).

The hydrotherapy treadmill is becoming more popular in the equine rehabilitation world both for it’s desired effects to aid restoration of lower limb ranges of movement post injury (Mendez-Angulo, et al.,2013) and for it’s proposed effects on muscular conditioning of the hindlimb (Scott, et al., 2010).

However, the research into it’s clinical effects on the equine system is relatively under researched and only a handful of studies exist to date evaluating it’s effects on peripheral (Mendez-Angulo, et al., 2013; Scott, et al., 2010; Tokuriki, et al., 1999) and spinal biomechanics

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(Mooij, et al., 2013). In comparison, in human physiotherapy, there is a plethora of research evaluating it’s physiological effects (Zamunér, et al., 2015) and uses post injury for increasing joint ranges of motion and function (Gibson and Shields, 2015) and in reducing pain (Mazloum, et al., 2014). Beneficial effects have also been noted in postoperative limb function in dogs (Marsolais, et al., 2003; Monk, et al., 2006).

This case report looks at a case study where the hydrotherapy treadmill was used as an adjunct to Physiotherapy intervention to treat an equine patient following an injury affecting the carpus.

The Case Study The equine patient was a 14 year old Cob x Irish Sports Horse. Veterinary Consent was gained prior to the Veterinary Physiotherapy Assessment.

The history was that of an external injury to the left thoracic limb (LTL) one month previously. The patient had sustained an injury to the common digital extensor (CDE) tendon of the LTL in the field which had resulted in an inability to allow sufficient carpal flexion for activities of daily living such as lying down, rolling, and hoof picking out of the LTL only. A recent veterinary assessment had deemed the patient sound and the owners were advised to carry out left carpal flexion passive stretches daily. The passive stretches were not tolerated and resulted in the patient rearing.

Veterinary advice was to maintain the patient in light hacking ridden

work with the aim of this improving his carpal range of motion. The owners felt that there had been minimal improvement with this regime after one month and they therefore self-referred the patient for a veterinary physiotherapy assessment.

A full initial physiotherapy assessment noted the following: Observation On Observation in standing and full weight bearing the patient presented with a thickened LTL CDE tendon which was 4cm in length and 3cm dorsal to the radiocarpal joint (see figure 1) as measured using a tape measure.

Figure 1. Lateral view of left thoracic limb (LTL) with red arrow showing region of CDE tendon injury

Passive range of motion testing

feels’ given their anatomical location.

The ‘normal’ carpal end feel of the RTL into passive physiological flexion was characterised by a soft tissue approximation between the caudal antebrachium flexors and palmer distal limb flexor tendons.

Goniometry testing revealed this normal range to be 160º of carpal flexion. Figure 2 demonstrates the joint angle measured. The centre point of the goniometer was positioned over the joint centre of rotation (COR) on the lateral aspect of the limb. The joint COR was determined as being dorsal to the radio-carpal joint and full carpal flexion was determined when the palmer aspect of the metacarpophalangeal joint (MCPJ) reached the olecranon or a normal end feel was reached. The two moveable arms were positioned with one along the long axis of the metacarpal bones III (McIII) and IV and the other along the long axis of the antebrachium. The latter was defined as the line joining the lateral styloid process of the radius to the lateral epicondyle of the humerus.

Passive range of motion (PROM) testing of the right thoracic limb (RTL) revealed full carpal range with a normal end feel. ‘End feel’ is defined as the limitation of movement due to ligament, articular surface contact, muscle or tendon extensibility or soft tissue apposition (Petty and Moore, 2001). All joints are characterised by specific ‘end

During carpal assessment the elbow was freely allowed to flex as shown in Figure 2, the author refers to this elbow position as ‘elbow neutral’.

When passively assessing the LTL the patient was extremely apprehensive about having the LTL raised from the ground. Furthermore, the patient would not allow any carpal flexion testing with the elbow

Palpation Palpation over the injury site revealed no heat or soft swelling. A fibrotic and thickened CDE tendon however could clearly be felt at the injury site which was abnormal when compared to the right thoracic limb. No pain response however was elicited during palpation in the weight bearing position, where a pain response was regarded as any indication of the patient retracting the limb away from palpation (McGowan, et al., 2007). Palpation over the injury site however with the carpus flexed to the available end range position did however reveal a painful response from the patient. This was characterised by a retraction of the limb away from the Physiotherapist handling the limb (McGowan, et al., 2007). There were no other significant findings on palpation.

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neutral position. The CDE originates from the lateral epicondyle of the humerous and proximolateral surface of the radius and attaches on to the extensor processes of the distal and middle phalanx and the dorsal surface of the proximal phalanx (Gronberg, 2002) (Figure 3).

Using the knowledge of this anatomy, and being aware that this muscle and associated tendon cross the cranial and dorsal surfaces of three joints, the LTL carpus was tested with the elbow being immediately placed into flexion so that the antebrachium was positioned parallel to the floor. This aided removal of any excessive tension on the CDE muscle and associated tendon. The patient was able to tolerate this position which allowed for carpal flexion testing. In this position, the carpus was measured to have 90º of carpal range using goniometry (as described above). The end feel was that of a ‘spasm end feel’, where a spasm end feel is defined as a ‘sudden hard end feel due to muscle spasm’ and characterised by an inability of the examiner to reach a normal anatomical limitation of movement (Petty and Moore, 2001).

The pain response of the patient at this spasm end feel position was that of an ‘abrupt retraction’ of the limb away from the author. The end feel through range however between 50-90º was that of a ‘capsular feel’ (firm soft tissue stretch), essentially this was regarded by the author as an abnormal end feel as when compared to that of the RTL which in comparison revealed no resistance through range (Petty and Moore, 2001). The patient showed no pain response to this. Further flexion of the MCPJ of the distal limb in this position elicited a similar pain response which confirmed the diagnosis of a CDE injury and relative shortening. Had the injury been to the extensor carpi radialis muscle for example, this further pain response would not have been expected.

Gait analysis revealed that the patient was sound on the LTL and had functional range for the swing phase of walk and trot when compared to the RTL.

Figure 2: Diagram demonstrating full carpal flexion and the angle measured.

Note the red arrow showing the free movement of the elbow into flexion ‘elbow neutral’

Problem No

Problem

1

Reduced left carpal range of motion to 90º

2

Pain on LTL carpal flexion; spasm end feel

3

Unable to maintain left fore foot hygiene safely

4

Avoiding functional activities such as lying down for rolling; possible disruption of sleep pattern

5

Carpal joint and other surrounding joints such as the elbow and MCPJ and soft tissues such as the extensor carpi radialis and lateral digital extensor also at risk of further contracture into flexion range

Table 1: The problem list identified after the initial physiotherapy assessment for the patient.

Problem No

Treatment Plan

1

Deep friction massage to the injury site Specific LTL CDE tendon stretches Passive Physiological Carpal Flexion Hydrotherapy treadmill referral

2

As above

3

Teaching the owner and grooms at the yard a technique for raising the LTL from the floor so as to place minimal stretch on the CDE.

4

The owners and yard grooms were asked to monitor this subjective marker during the treatment process

5

Issuing passive physiological movement for the left elbow and metacarpophalangeal (MCP) joints were difficult due to the stretch this placed on the CDE muscle/tension complex. Passive physiological left elbow and fetlock movements were issued

Table 2: The treatment plan aimed to address the problem list.

Goal Problem No Short Term goal 1

Goal

Time Frame

Owners able to safely lift the LTL for foot hygiene

After initial assessment

Figure 3: Diagram showing path of common digital extensor in an equine left thoracic limb

Short Term goal 2

After initial assessment

The Problem List, Treatment Plan and Goals

Mid Term goal 1

Owners able to carry out carpal stretches and deep friction massage safely Reduced pain with carpal range testing, reduced spasm end feel to capsular end feel

Mid Term goal 2

Carpal range into flexion increased by 30º

Two weeks

Mid Term goal 3

Showing signs of lying down/ rolling

Two weeks – 1 month

Long Term goal 1

Full functional carpal range of motion, ≥150º carpal flexion.

1 month

The Problem list identified following the initial assessment is detailed in Table 1 and the treatment plan is outline in Table 2. The short, mid and long term goals are outlined in Table 3 and Table 4 outlines the specific treatments that were carried out and the home exercise programme that was issued in order facilitate a carry-over effect of treatment for the patient.

Two weeks

Table 3: The short and long term goals for the patient outlined after the initial assessment

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Problem No 1 and 2

Treatment Applied, Home Exercises Issued (in italics) and Goals achieved Deep friction massage to the injury site The left carpus was positioned in approximately 50º flexion and stabilised at the caudal aspect with the elbow flexed and the antebrachium positioned parallel to the floor. Specific soft tissue glides were applied transversely to the CDE from lateral to medial mobilising in to the resistance of the tendon.

The owners were taught this technique safely and advised to carry it out 3 times a day for 5 minutes each time.

Short term goal 2 achieved

1

Specific LTL CDE tendon stretches The left carpus was held in 90º flexion and stabilised at its caudal aspect with the antebrachium positioned parallel to the floor, the MCPJ was then supported on the dorsal surface and slowly passively flexed from the proximal phalanx until a capsular end feel could be felt in the CDE. Care was advised not to increase this range into a spasm end feel however as range improved and the spasm end feel reduced over days the stretch could be advanced into a capsular end feel.

The owners were taught this technique safely and advised to carry it out 3 times a day, for 3 repetitions at a time for a total of 1 minute.

Short term goal 2 achieved

1

Passive Physiological Carpal Flexion The left carpus was held in 90º flexion and stabilised at its caudal aspect with the antebrachium positioned parallel to the floor. The canon bone was then supported at its dorsal surface and approximated slowly towards the radius to passively flex the carpal joint. This was continued until just before the spasm end feel was reached, the limb was then held in this end position for approximately 2 seconds and then mobilised out of this position and back again repeatedly, slowly.

The owners were taught this technique safely and advised to carry it out 3 times a day, for 10 repetitions at a time, slowly.

Short term goal 2 achieved

1 and 2

Hydrotherapy Treadmill referral Communication was made to the veterinary surgeon to communicate clinical reasoning for the referral.

Further communication was then made with Equine Aqua Training regarding the patient’s history and current LTL carpal range of motion.

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For day to day foot hygiene the yard grooms and owners were taught how to lift the LTL to minimise stress on the CDE tendon. They achieved this by ensuring immediate elbow flexion and shoulder extension on lifting of the limb and maintaining this position whilst flexing the MCPJ in order to reach the sole of the foot.

Short term goal 1 achieved

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This required additional communication with the yard staff regarding monitoring this subjective marker. In particular any morning staff were asked to make a log of whether the patient had shown signs of lying down and rolling and feed this information back to the owners

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For the elbow: The owners were taught to passively move the elbow through the full available passive range possible whilst placing minimal stretch on the CDE tendon. For flexion the owners were taught to stabilise the LTL behind the carpus and approximate the dorsal aspect of the radius towards the humerus; for extension they were taught to maintain the carpus in approximately 50º of flexion and to stabilise the limb on the dorsal surface of the radius and dorsal mid-cannon region and gently retract the elbow caudally, due to the pull of the CDE tendon this movement created some carpal extension during the movement.

The owners were taught this technique safely advised to carry it out for 10 repetitions, 3 times a day with no hold in the end position.

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5 (cont)

For the MCPJ: Extension was achieved by the load bearing position.

For flexion the elbow was stabilised caudal to the carpus and held in full available flexion as described above, the carpus was maintained in approximately 50º flexion, the MCPJ was then flexed to the full available comfortable range and then returned to the original position. Full passive MCPJ flexion could not be achieved due to the restriction in the CDE tendon.

The owners were taught his technique safely and advised to carry it out 10 times, 3 times a day with no hold in the end position.

Short term goal 2 achieved

Table 4: The specific treatments carried out on the patient following the initial assessment along with the exercises issued to the owners and goals achieved

The owners were advised to begin and continue this regime outlined in table 4 until their appointment was booked for the hydrotherapy treadmill. Within 5 days of starting the exercises at home their treadmill session was booked. Following this the patient was reassessed (see Table 6). The author liaised with the treadmill staff regarding the history of the patient and current assessment findings. It was decided to begin the water height low at hoof height to allow for the patient to acclimatize to the treadmill. No significant changes in joint angles have been noted at this height and it has been used as a control (Scott, et al., 2010) or baseline (MendezAngulo, 2013) for water height comparison studies. It was therefore considered appropriate in order to allow the patient to acclimatize to the treadmill. The first session used the settings noted in Table 5. The treadmill belt speed was chosen by treadmill staff observing the speed at which the patient appeared most relaxed in their head and neck posture.

The client was then reassessed by the author 10 days after the initial assessment (see Table 6) Table 6 illustrates that the short term goals 1 and 2 and mid-term goal 1 had been achieved. Midterm goal 2 had only partially been achieved, and mid-term goal 3 had not been achieved. The increase in carpal range was felt to have most likely been attributable to the physiotherapy exercise programme as opposed to the treadmill session on the basis of previous research noting no significant

Date

Gait

Time

Water Height

Speed

14/11/13

Walk

15 minutes

Hoof

5.6 km/hr

Table 5: Treadmill settings chosen for the patient’s first treadmill session on an Activo-Med Hydrotherapy Treadmill at Equine Aqua Training. Abbreviations: km/hr (kilometres per hour)

Problem number reassessed 1

Outcome measured

2

No spasm end feel or associated ‘abrupt retraction’ of the limb pain response. The further capsular end feel position did not result in the patient’s ‘abrupt retraction‘ of the limb but instead a slower flexor withdrawal response suggesting the pain the patient experienced from the CDE tendon during carpal flexion was reduced The owners and grooms were confident and safe in carrying out foot hygiene tasks and the patient showed no pain response during the task

Carpal flexion was measured to be 100º

3

4

The owners and grooms had not noticed any change in the patient’s rolling and lying behaviour

Table 6: The findings of reassessment one after 10 days

effects on joint angles at this water height (Mendez-Angulo, 2013).

Despite the owners and grooms being aware of the improvements with the physiotherapy exercises they reported carrying out the exercises three times a day difficult to maintain on a regular basis. As an alternative treatment approach, it was therefore suggested to try daily treadmill sessions. Research reports that steady state gait or habituation is achieved after 4-6 sessions (Scott, et al. 2010). Therefore, this required achieving before any training or clinical effects of the treadmill could be expected.

Furthermore, from a physiotherapy perspective, treatmentprescription and dose is vital in order to gain a significant

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carry over effect of treatment (Brody, 2012). For the current injury, the author was keen to ensure daily mobilisation of the patient’s carpus, the justification for the treadmill being that if this was unlikely to be achievable with daily manual therapy it could alternatively be achieved with daily treadmill exercise therapy.

Table 7 outlines the programme that was carried out on the treadmill.

No physiotherapy exercises were issued to be carried out whilst at the treadmill so that maximum carry over effect of the treadmill could be determined. During the treadmill stay, the patient was stabled during the night and turned out during the day.

A reassessment was booked for after five days of the treadmill sessions.

Date (2014)

Gait

Time (mins)

Water

Speed (km/hr)

23/11

Walk

15

Fetlock towards mid cannon

5.6 km/hr

24/11

Walk

15

Carpal

5.5 km/hr

25/11

Walk

18

Above carpal

5.6 km/hr

26/11

Walk

18

Above scar tissue

5.0 km/hr hard work

27/11

Walk

20

Above tarsus

5.1

28/11

Walk

2

Above tarsus

5.4-6.2 owners viewing

29/11

Walk

25

Above tarsus

5.4 km/hr

Physiotherapy Reassessment Two 30/11

Carpal range into flexion measured as 120º using goniometry before reaching a capsular end feel in the ‘elbow neutral’ position, see Figure 4. No flexor withdrawal pain response in end range position.

The scar tissue length was measured as 2 cm in length.

As there was a clear improvement in the carpus range and reduction in a pain response with testing, the treadmill regime was continued and no additional exercises were issued.

Mid Term goal 2 achieved.

30/11

Walk

25

Above tarsus

5.5 owners viewing

1/12

Walk

20

Dry treadmill

6 LF filled with some scabs/ mud fever type

2/12

Walk

25

Above tarsus

6 still some filling in front

3/12

Walk

25

Above tarsus

5.6 fore legs down no filling

4/12

Walk

25

Above tarsus

6.0

5/12

Walk

25

Above tarsus

5.8

Table 7: The treadmill settings chosen by Equine Aqua Training for the patient’s inpatient stay with mid-way Physiotherapy reassessment two.

Abbreviations: km/hr (kilometres per hour); Mins (Minutes) LF (Left fore) 10

Figure 4. Picture showing the carpal flexion measured as 120º at a reassessment after 5 days of daily hydrotherapy treadmilling at Equine Aqua Training; scar tissue length measured as 2cm in length; No flexor withdrawal pain response was present.

Problem number reassessed 1 and 5

Outcome measured

Carpal flexion was measured to be 150º and the end feel was that of a capsular end feel in the ‘elbow neutral position’ (see Figure 5). All other joints appeared to have normal ranges that were equal to that of the right thoracic limb Long term goal achieved

2

There was no flexor withdrawal response from the patient when the carpus was flexed beyond the capsular end feel position suggesting no pain could be experienced by the patient

3

The owners and groom could resume normal foot hygiene tasks with no need for careful limb handling

4

The owners and grooms had noticed the patient resuming normal rolling and lying behaviour Mid term goal 3 achieved

Table 8: The findings of reassessment three after the treadmill stay

After the stay at the treadmill the patient was reassessed at their yard, see table 8.

The author also noted that the thickened area of CDE tissue at the one month follow-up had also reduced from 4cm in length to 0.5cm in length when compared to when assessed at reassessment two, see Figures 6 and 7.

All goals at reassessment 3 had been

achieved. Although the final range of motion was not 160º of flexion as on the RTL the patient was able to carry out all activities of daily living with the LTL and was fully functional on the LTL. The owners at this point were therefore advised to resume normal ridden work. They were advised to check the LTL carpal joint range daily when performing foot hygiene tasks as this seemed a sensible time to check the carpal range on a daily basis.

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Figure 5. The LTL showing 150º of carpal flexion 1 month after referral. No pain response was elicited in the end range position, note the elbow neutral position now being feely adopted.

It is worth also noting however that on a full spinal palpatory assessment the patient was noted to have developed some myofascial trigger points in the thoracolumbar region of the paraspinals. The patient also resented any ventroflexion of the thoracic region. This area was further treated with physiotherapeutic modalities and did improve, the details of which are beyond the scope of this case study. Although the research is limited, the hydrotherapy treadmill has been found to have a significant effects on spinal biomechanics (Mooij, et al., 2013). It is therefore important to always assess the whole horse before, during and after hydrotherapy treadmill stays to ensure any changes are detected before ridden exercise is resumed.

Discussion This case study demonstrates an example of where multidisciplinary team working between a veterinary physiotherapy practice and hydrotherapy referral centre was successful in treating an equine carpal injury. In this instance, the physiotherapy assessment was vital in order to establish the patient’s main

problems and in order to formulate a treatment plan with realistic goals and measurable outcomes. Some improvements in pain and range of movement were made after the initial assessment however most significant improvements were made after hydrotherapy referral for this case.

The hydrotherapy Treadmill The referral was made to the hydrotherapy treadmill as it was anticipated that this would facilitate a greater amount of carpal flexion during walk when compared to over land walking and mobilise the CDE tendon and carpal joint effectively.

Kinematics of the Water Treadmill

Figure 6. Picture showing area of thickened CDE 8 days after treadmill sessions began; the scar measured 2cm in length.

Scott, et al. (2010) found in their study that horses walking in water at carpal or ulna height resulted in a lower stride frequency and greater stride length. This was thought to be achieved through the buoyancy effects of the water in assisting vertical limb movement; horses also assume the path of least resistance during the swing phase of the stride by increasing their flight arc. These effects were mirrored in another recent study by Mendez-Angulo, et al. (2013) where with increasing water height, the percentage stance duration decreased and the percentage swing phase increased.

Mendez-Angulo, et al. (2013) found that increased water heights resulted in greater amounts of fetlock, carpal and tarsal joint flexion when compared to baseline conditions walking at hoof height in 9 clinically normal horses. In particular, the most relevant finding relating to this case was that carpal range of motion (ROM) increased the most at tarsal water height. At this height the mean maximum amount of flexion for the carpus increased by 20ยบ when compared to baseline values. This is a finding that suggests why the water height selected for this patient (table 7) resulted in a positive treatment outcome and an overall increase in carpal range of motion. Specific mobilisation and targeting of the

Figure 7. Picture showing area where thickened CDE was most obvious, note minimal thickening appears evident cranially over the carpus; the scar measured 0.5cm in length.

CDE tendon was further expected following findings noted in a study

by Tokuriki, et al. (1999). In this study, the most intense electromyographic (EMG) activity was noted in the extensor digitorum communis at walk and trot on a water treadmill

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when compared to overland walking and swimming. Perhaps the treadmill was effective at mobilising the musculotendinous junction which may have affected the scar tissue formation.

Water Temperature The temperature of the water is also important to consider. The author is only aware of one study considering the effects to lower limb tendon injuries of cold spa therapy in horses (Hunt, 2001). Although a cold spa therapy is different to a hydrotherapy treadmill, in this study the temperature was maintained between 5-9 ºC which is similar to that of the Equine Aqua Training treadmill (5ºC).

Furthermore, the massaging effects of the spa can in principle be likened to the turbulence effects of the water in a moving hydrotherapy treadmill.

This study found that horses with a mixture of tendon injuries had markedly improved echogenicity and fibre realignment of injured tissues after ten minutes three times a week of spa therapy. These effects were believed to occur from cold agitated water being denser than that of warm motionless water, and the pressure of the water creating a hydrostatic effect to the injured tissues aiding fluid dispersal. There may also have been further cryogenic pain relieving effects that are well documented for treating equine injuries (McGowan, et al, 2007).

Physiotherapy Exercise Prescription and Change of Treatment Plan The patient had made a small improvement in carpal ROM at reassessment one. This was thought to be as a result of the stretches issued after the initial assessment.

This exercise programme was chosen by the author as it was felt to be an appropriate treatment choice and dose given the assessment findings. As the injury had occurred one month before the initial assessment the healing tissue was thought to be within the regeneration phase of the healing process which can last for up to 15 weeks post-injury (McGowan, et al.

2007). The restricted carpal range was considered to be originating from the formation of type III collagen fibres being laid down from tenoblastic activity within the CDE tendon. Introduction of stretching

and deep friction massage aimed to place correct tensile loads through the injured tissue during this repair phase and was considered vital to ensure the fibre alignment was organised and to promote type I collagen production (Riboh, et al, 2008). Passive stretching of repaired flexor digitorum profundus tendons has also shown to be an effective therapy to lessen adhesions and improve strength in a canine model (McGowan, et al., 200&; Zhao, et al., 2002). Positive results have also been found in the canine model when applying a passive stretch for 10 seconds, 10 times twice daily in a group of Labradors suffering from osteoarthritis (Crook, et al., 2007).

The patient had demonstrated a reduction in pain response which perhaps could have been attributable to the stretches having had a positive effect on fibre orientation and therefore the resistance that could be determined during the passive physiological carpal flexion test. Despite this reduction in pain there had however been relatively little improvement in the LTL range of carpal movement or function at reassessment one.

Intra-rater reliability of goniometry measurement has been found to be reliable when compared to visual estimations (Jones and Curran, 2012; Kim, et al., 2011).

The increase of 10º of carpal flexion that had been achieved with physiotherapy exercises alone and one treadmill session (Table 6) was therefore felt to be a reliable measurement finding but insufficient to significantly improve the patient’s lying down behaviour. Referral to the hydrotherapy treadmill therefore seemed to be an appropriate treatment of choice as an adjunct to manual physiotherapy intervention.

Furthermore, the owners of this case study reported finding the home exercise programme difficult to maintain three times daily. It is possible that application of the stretches twice daily as applied in the study by Crook, et al. (2007) may have yielded better compliance with the owners and perhaps more favourable results.

The clinical reasoning behind referral

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to the hydrotherapy treadmill as discussed above was justified. It has further been suggested that in order for effective habituation to the treadmill to occur at walk, more than two sessions are required (Scott, et al, 2010; Buchner, et al., 1994). More regular sessions therefore seemed a sensible consideration to allow for this habituation period and then for a training or treatment effect to occur.

A more significant carry over effect was hoped for, but a reassessment was essential to determine this.

Alternative rehabilitation options of raised pole exercises were discussed with the owners in order to help with the carry over effect of the physiotherapy exercises, as this too has recently been shown to result in an increase in lower limb flexion during trot and the increased activity of the flexor muscles (Brown, et al. 2015). The owners however reported that the patient was unsafe with pole work and therefore preferred not to pursue this treatment choice. Furthermore, where Tokuriki, et al. (1999) showed an increase in EMG activity of the extensor digitorum communis during walking on a water treadmill compared to walking over land or at trot on the water treadmill, this could be considered a more appropriate treatment option for this patient as he also required increased activity of the extensor muscle groups to support the strengthening phase of rehabilitation for the injured tissue (McGowan, et al. 2007). .

Treadmill Speed It is worth noting however that the main differences with the hydrotherapy studies mentioned and with the current patient’s treadmill regime, is that the speeds used I previous studies were much slower.

The speed of the treadmill belt in the aforementioned studies ranged from 0.8m/s (Mooji, et al., 2013) to 0.9m/s (Mendez-Angulo, et al., 2013; Scott, et al., 2010) to 1.34m/s (Tokuriki, et al., 1999). 0/9m/s is the equivalent of 3.24km/hr which is considerably slower than the speeds used for the current patient. This is not necessarily a concern for the current patient as data was not being

recorded from the patient and these times have been used across these studies so that data can be comparable. In the study

by Scott, et al. (2010) however, it was anecdotally noted that head and neck displacement is considerably larger in speeds over 1m/s resulting in a more extended thoracolumbar posture. It is not known what effect faster speeds have on lower limb mechanics as such in a water treadmill and to the authors knowledge this has never been studied. In the case of the current patient, it did not appear to be detrimental and the patient did appear to be walking at a comfortable speed. The question however does need to be raised as to why the thoracolumbar tension developed. Perhaps this would not have been the case had the treadmill belt speed been slower. Having said that, the carpal range may not have improved as significantly.

Future studies should be directed towards assessing the changes in distal limb kinematics at various speeds on the water treadmill. It would also be useful to determine EMG activity of the paraspinals at these speeds and at various water heights and to relate this to muscle tone changes before and after treadmill activity. This may then help to develop safe and effective treatment protocols for patients with multiple peripheral and spinal conditions, which is what is more commonly encountered in the clinical setting.

The patient at the final assessment was found to have achieved all of their goals and at a year follow up was noted to be fully functional with full carpal range of motion.

Conclusion The current study was a good example of how a carpal injury that had resulted in a loss of carpal flexion benefitted from walking in a water treadmill at mostly tarsal height to improve ROM and function. This showed the importance of multidisciplinary team working and where

communication with alternative therapy providers can be vital in the management of equine patients.

Perhaps more immediate application of the manual physiotherapy exercises would have yielded a faster recovery and return to function with the application of electrotherapy modalities, or even earlier hydrotherapy and physiotherapy referral combined.

It is also clear that assessment of the whole horse is vital, particularly in the case of peripheral limb conditions, a full spinal assessment must also be carried out and monitored for any changes. The use of the hydrotherapy treadmill could further be considered for carpal injures that occur to equine athletes such as carpal chip fractures that result in a loss of carpal range.

This case study further highlights the importance of Physiotherapy assessment and reassessments for directing a clinically reasoned treatment plan and where a sound knowledge of current evidence-base is vital to ensure the best and most up-to-date treatment for equine cases.

Bridgefield Physiotherapy wishes to thank the owners for the use of this patient for the purpose of this case study and Equine Aqua Training for their collaboration with this case.

References Artz, N., Elvers, K.T., Lowe, C.M., Sackley, C., Jepson, P., Beswick, A.D., 2015. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and metaanalysis. BMC Musculoskeletal Disorders, Feb 7, 16:15.

Bailey, J.V., Barber, P.B., Fretz, P.B. and Jacobs, K.A., 1984. Subluxation of the carpus in thirteen horses. Canadian Veterinary Journal, 25, pp.311-314.

Brantingham, J.W., Cassa, T.K., Bonnefin, D., Pribicevic. M., Robb, A., Pollard, H., Tong, V., Korporaal, C., 2013. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Journal of Manipulative Physiological Therapeutics, 36(3), pp.143-201.

Brody, L.T., 2012. Effective therapeutic exercise prescription: the right exercise at the right dose.

Journal of Hand Therapy, 25 (2), pp.220-31.

Brown, S., Stubbs, N.C., Kaiser, L.J., Lavagnino,

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M., Clayton, H.M., 2015. Swing phase kinematics of horses trotting over poles.

Equine Veterinary Journal, 47(1), pp.107-12.

Bruder, A.M., Taylor, N.F., Dodd, K.J., Shields, N., 2012. Physiotherapy intervention practice patterns used in rehabilitation after distal radial fracture. Physiotherapy, 99(3), pp.233-40.

Buchner, H. H. F., Savelberg, H. H. C. M., Schamhardt, H. C., Merkens H. W., Barneveld, A., 1994. Habituation of horses to treadmill locomotion. Equine Veterinary Journal, 26(S17), pp. 13–15.

Crook, T., McGowan, C., Pead, M., 2007. Effect of passive stretching on the range of motion of osteoarthritic joints in 10 labrador retrievers.

Veterinary Record, 21, 160(16), pp.545-7.

Field J.R. and Zaruby J.F. 1994. Repair of a fracture of the fourth carpal bone in a yearling Standardbred horse. Canadian Veterinary Journal, Jun, 35, pp.371-372.

Gibson, A.J., Shields, N., 2015. Effects of Aquatic Therapy and Land-Based Therapy versus LandBased Therapy Alone on Range of Motion, Edema, and Function after Hip or Knee Replacement: A Systematic Review and Metaanalysis. Physiotherapy Canada, 67(2), pp.133-41.

Gronberg, P., 2002. ABC of the Horse: Anatomy biomechanics conditioning. Finland: Otava Book Printing Ltd. Hill, W.T., 2003. Survey of injuries in Thoroughbreds at the New York Racing Association Clinical Techniques in Equine Practise, Dec 2(4), pp. 323-328.

Hunt, E.R., 2001. Response to twenty-seven horses with lower leg injuries to cold spa bath hydrotherapy. Journal of Equine Veterinary Science, 21 (4), pp.188-193.

Jones, A.M., Curran, S.A., 2012. Intrarater and interrater reliability of first metatarsophalangeal joint dorsiflexion: goniometry versus visual estimation. Journal of the American Podiatric Medical Association, 102 (4), pp.290-8.

Kim, P.J., Peace, R., Mieras, J.,Thoms,T., Freeman, D., Page, J., 2011. Interrater and intrarater reliability in the measurement of ankle joint dorsiflexion is independent of examiner experience and technique used. Journal of the American Podiatric Medical Association, 101 (5), pp.407-14.

Loew, L.M., Brosseau, L., Tugwell, P., Wells, G.A., Welch, V., Shea, B., Poitras, S., De Angelis, G., Rahman, P., 2014. Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. The Cochrane Database of Systematic Reviews Nov 8, 11, CD003528.

Marsolais, G.S., McLean, S., Derrick, T., Conzemius, M.G.J., 2003. Kinematic analysis of the hind limb during swimming and walking in healthy dogs and dogs with surgically corrected cranial cruciate ligament rupture.

Journal of the American Veterinary Medical Association, Mar 15, 222(6), pp.739-43.

Monk, M.L., Preston, C.A., McGowan, C.M., 2006. Effects of early intensive postoperative physiotherapy on limb function after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament.

American Journal of Veterinary Research, Mar 67, (3), pp.529-36.

Mazloum, V., Rahnama, N., Khayambashi, K., 2014. Effects of therapeutic exercise and hydrotherapy on pain severity and knee range of motion in patients with hemophilia: a randomized controlled trial. International Journal of Preventative Medicine, 5(1), pp.83-8.

McGowan, C., Goff, L., Stubbs, N., 2007. Animal Physiotherapy: Assessment, Treatment and Rehabilitation of animals. 1st Edition. Oxford: Blackwell Publishing.

Mendez-Angulo, J.L., Firshman, A.M., Groschen, D.M., Kieffer, P.J., Trumble, T.N., 2013. Effect of water depth on amount of flexion and extension of joints of the distal aspects of the limbs in healthy horses walking on an underwater treadmill. American Journal of Veterinary Research, 74(4), pp. 557-66.

Valdes, K., Naughton, N., Michlovitz, S., 2014.

Therapist supervised clinic-based therapy versus instruction in a home program following distal radius fracture: a systematic review.

Journal of Hand Therapy, 27(3), pp.165-73.

Voss, B., Mohr, E., Krzywanek, H., 2002. Effects of Aqua-treadmill exercise on selected blood parameters and on heart rate variability.

Journal of the American Veterinary Medical Association, 49, pp.137-143.

ZamunĂŠr, A.R., Andrade, C.P.,Forti, M., Marchi, A., Milan, J., Avila, M.A., Catai, A.M., Porta, A., Silva, E., 2015. Effects of a hydrotherapy programme on symbolic and complexity dynamics of heart rate variability and aerobic capacity in fibromyalgia patients. Clinical and Experimental Rheumatoly, 33(1 Suppl 88), S73-81.

Zhao, C., Amadio, .P.C., Zobitz, M.E., Momose, T., Couvreur, P., An K.N., 2002. Effect of synergistic motion on flexor digitorum profundus tendon excursion. Clinical Orthopaedics and Related Research, Mar, (396), pp.223-30.

Mooij M.J.W., Jans,W., den Heijer, G.J., de Pater, M., Back,W., 2013. Biomechanical responses of the back of riding horses to water treadmill exercise. Veterinary Journal, 198(S1), pp120123.

Murray, J.K., Singer, E.R., Saxby, F. and French, N.P., 2004 Factors influencing risk of injury to horses falling during eventing. The Veterinary Record, Feb 14, pp. 207-208.

Petty, N.J., Moore, A.P., 2001. Neuromuscular examination and assessment: A handbook for therapists. 2nd ed. London: Churchill Livingstone.

Porter, M., 2005. Equine Rehabilitation Therapy for Joint Disease. Veterinary Clinics in Equine Practise, 21, pp.599-607.

Pozzi, F., Snyder-Mackler, .L, Zeni, J., 2013.

Physical exercise after knee arthroplasty: a systematic review of controlled trials.

Europeon Journal of Physical and Rehabilitation Medicine, 49(6), pp.877-92.

Riboh, J., Chong, A.K., Pham, H., Longaker, M., Jacobs, C., Chang, J., 2008. Optimization of flexor tendon tissue engineering with a cyclic strain bioreactor. The Journal of Hand Surgery, 33 (8), pp.1388-96.

Singer, E.R., Barnes, J., Saxby F. and Murray J.K., 2008. Injuries in the event horse: training versus competition Veterinary Journal (London, England: 1997), Jan, 175(1), pp.76-81.

Scott, R., Nankervis, K., Stringer, C., Westcott, K., Marlin, D., 2010. The effect of water height on stride frequency, stride length and heart rate during water treadmill exercise. Equine Veterinary Journal, 42 (Suppl.38). pp. 662-664.

Tokuriki, M., Ohtsuki, R., Kai, M., Higara, A., Oki, H., Miyahara, Y., Aoki, O., 1999. EMG activity pf the muscles of the neck and forelimbs during different forms of locomotion. Equine Veterinary Journal Supplement, 30, pp. 231-234.

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The use of dynamic mobilisation exercises (baited stretches) in the management of neuromusculoskeletal injuries in the equine patient: A Review Olivia France PgDip BSc MCSP HCPC ACPAT A Bridgefield Physiotherapy Ltd Website: www.bridgefieldphysio.co.uk Tel: 07795 262554 Email: of@bridgefieldphysio.co.uk Introduction Both veterinarians and physiotherapists use clinical reasoning based on academic knowledge and clinical experience to justify the use of dynamic mobilisation exercises in the management of back pain.

Often used as an adjunct to manual therapy, specific exercise prescription can improve strength, flexibility and decrease back pain in the human (Gladwell, et al., 2006; Rydeard, et al., 2006) and equine species (Clayton, 2012; Stubbs and Clayton, 2008).

However, little consideration has been given to the existing evidence that supports the use of such exercises in the equine field.

Equine dynamic mobilisation exercises are described by Stubbs and Clayton, (2008) as baited stretches in which the horse is trained to move the chin to a specific position by following a piece of carrot. They can be used for both assessment and therapeutic purposes in equine physiotherapy for back and neck dysfunction. These exercises are active movements of the neck and trunk with the aim of assessing and/ or increasing flexion, extension, lateral flexion or rotation of the axial skeleton (Haussler, 2010). Also, it is proposed that they recruit and strengthen the musculature that moves and stabilises the spine (Stubbs, et al., 2011).

Clayton, (2012) highlighted similarities between horses and humans in causes and treatment of back pain. Therapeutic exercises

such as dynamic mobilisation exercises can be effective in the treatment and prevention of equine back pain. It has been suggested that this is a result of the movements produced during the exercises stimulating co-contraction of multifidus and abdominal muscles (Stubbs and Clayton, 2008).

Dynamic mobilisation exercises could potentially also be beneficial for equine neck pain.

Exercises to strengthen cervical flexor muscles (Falla, 2004) using directional movements (Taimela, et al, 2000) have been advocated in the management of human neck pain (Moffett and McLean, 2006).

Application of this evidence to the equine species suggests dynamic mobilisation exercises in horses could improve cervical range of movement, strength and stability following injury and arthritis.

This review discusses the effects and uses of dynamic mobilisation exercises for musculoskeletal dysfunction and pain of the equine spine.

Discussion Range of movement Evidence shows changes in spinal segmental angles along the length of the entire equine spine during dynamic mobilisation exercises. A small study of eight subjects by Clayton, et al. (2010) used skin markers to investigate angular changes of the vertebral joints in three different positions; chin-tochest, chin-between-carpi and chinbetween-fetlocks. In a comparison with cervical flexion with a neutral

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position, results showed cervical vertebral level (C) 2-5 flexion increased by 9-11º, and thoracolumbar flexion increased by 3-7º. Angular changes from C6-1 increased in magnitude from caudal to cranial intervertebral joints as the head was lowered. There were significant increases in flexion of thoracic intersegmental angles; the authors suggested that this was a result of the nuchal ligament attachments and pulling on the supraspinous ligament. However, the method of measurement was poor as the accuracy of skin surface markers has been questioned and only proven at mid thoracic and lumbar levels (Faber, et al., 2001).

Furthermore, conformational differences lessened the reliability of these thoracic results.

Lumbar spine angles did not change with the different positions described above, although a more recent study found the introduction of cervical lateral flexion induced lumbar kinematic changes (Clayton, et al., 2012). This latter trial used chin-to-girth, chin-to-hip and chinto-tarsus mobilisation exercises.

Chin-to-girth gave the largest angular change at C1, and as the horse’s chin moved more caudally, C6 and thoraco-lumbar segmental changes were larger. These two trials have identified angular changes in the different positions, but not the effects of an exercise programme. They do, however, suggest that lowering of the horse’s head and increasing lateral flexion can effectively maintain range of movement at C6 when the exercises are used regularly. This finding concurs with that of other

researchers, Blignault, (2003) who suggested that caudal cervical lateral bending stretches elongate soft tissues and mobilise the cervicothoracic spine, which can be useful in the treatment of neck pain and arthritis.

The conclusions drawn from these studies are important in musculoskeletal management and physiotherapy exercise rehabilitation. If lunging or Pessoa exercise is prescribed, they should be done with the horse’s head in a lowered position to facilitate vertebral movement at C6 and to facilitate thoraco-lumbar flexion.

The effects of thoracic flexion and separation of the spinous processes of the thoracic spine during the exercises may be beneficial in horses with poorly fitting saddles and impinging or over-riding dorsal spinous processes (kissing spines) (Paulekas and Haussler, 2009). However, at present, there is a lack evidence in the use of dynamic mobilisation exercises for kissing spines. Two studies have used similar ‘suppling exercises’ but have failed to describe exact methods. The first study incorporated these exercises into the conservative management to improve symptoms of kissing spines, but was unsuccessful (Petterrson et al., 1987). The second, however, used ‘suppling exercises’ successfully as part of a post-operative protocol alongside electrotherapy and massage (Walmsley et al., 2002). A recent study, Coomer, et al. (2012), also had successful results after interspinous ligament desmotomy when dynamic mobilisation exercises were used in the postoperative rehabilitation programme.

Core strengthening Dynamic mobilisation exercises are active movements produced by concentric contraction of muscles to alter position. The abdominal, epaxial and pelvic muscles act isometrically, concentrically and/ or eccentrically to stabilise the trunk/back and limbs.

Dynamic mobilisation exercises have both a

mobilisation effect on the cervical and thoracolumbar spine and also a strengthening effect on the epaxial and core muscles such as the abdominals and multifidus (Stubbs and Clayton, 2008).

Horses appear to follow the same pathophysiological pattern as humans in response to back pain. Dysfunction and atrophy of the multifidus muscle has been found at the same spinal level as osseous pathology (McGowan, et al., 2007; Stubbs, et al., 2010). In humans, the multifidus muscle does not spontaneously resume it’s normal activity and function without physiotherapy exercises (Hides, et al., 1996), and as a result spinal stability decreases (Kavcic, et al., 2004). Multifidus is also thought to have a stabilising role in horses because spinal kinematics change after an injection of local anaesthetic into the multifidus muscle of sound horses (Holm, et al., 2006). The structure of the multifidus muscle enables it to stabilise intervertebral joints (Stubbs, et al., 2006). In humans instability and micro motion of intervertebral joints predisposes to further injury (Hides, et al., 1996), particularly arthritic changes. It may therefore be proposed that multifidus strengthening could reduce equine back pain and potentially delays the onset of arthritis. This delay is important for the management of musculoskeletal injuries in which secondary arthritis may develop (McIlwraith, 1996).

Arthritic changes can occur in the injured joint as well as other joints (including spinal joints) through compensatory mechanisms or offloading of a limb.

Stubbs, et al. (2011) used ultrasonography, a reliable and repeatable measure (McGowan, et al., 2007; Stubbs, et al., 2010), to determine changes in multifidus cross sectional area following three months of dynamic mobilisation exercises. Three cervical flexion (chin-to chest, chin-between-carpi, chin-between-fetlocks), one cervical extension and three lateral flexion exercises (chin-to-girth, chin-to-

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tuber coxae, chin-to-tarsus) were repeated five times five days per week resulting in hypertrophy and improved symmetry.

Despite a good measurement protocol, the subjects were withdrawn from their normal exercise and there was no control group making the results less reliable. It is difficult to conclude whether continued work would have improved multifidus activation or caused inhibition if the horse was suffering from back pain. However, Tabor, et al. (2012) recorded similar results among racehorses in training. All their treated subjects had the same training regime and the group that performed dynamic mobilisation exercises showed multifidus hypertrophy after six weeks while no significant changes were found in the control group.

Neither study directly measured back pain or multifidus activation. However, based on the human literature and back pain model, hypertrophy of multifidus, a spinal stabiliser, may be interpreted as being beneficial in recovering spinal function and reducing back pain. In addition, multifidus strengthening has been shown to be associated with a reduction in the incidence of back pain recurrence in humans (Hides, et al., 2001).

Therapeutic exercises that reduce musculoskeletal back pain also have potential applications in restoration of locomotor function. In horses there is a strong association between lameness and back pain, (Landman, et al., 2004; Dyson, 2005) and between induced back pain and limb kinematics (Gómez Álvarez, et al., 2007). Therefore dynamic mobilisation exercises that strengthen the core muscles and stimulate spinal movement may be appropriate in equine rehabilitation following injury to not only the neck (Dyson, 2003) and back, but also the limbs. Compensations arising from lameness can be prevented with these exercises to maintain a healthy functional back.

Dynamic mobilisation exercises are particularly useful in young horses to prepare them for ridden work.

Activation and strengthening of the core musculature increases spinal stability, thus enabling the horse to better carry a rider and avoid excessive extension caused by the additional weight (De Cocq, et al., 2004). They may also be a means of maintaining core strength in horses on box rest or off work.

Although core strength and spinal stability is increased with the exercises, the movements only stimulate a brief muscle contraction and are performed with the horse stationary and weight bearing on all four limbs. This may facilitate recruitment of the thoracic sling muscles, abdominal muscles, gluteus medius and multifidus but the horse’s ability to recruit these muscle contractions may not carry over into dynamic work when they serve different functions and require endurance for repeated contractions.

The stabilising spinal muscles have to work harder during locomotion to oppose displacement of the spine (Licka, et al., 2009) and even more so at higher speeds and inclines (Robert, et al., 2001). For example, there is increased activity of longissimus dorsi (Robert, et al., 2001) and rectus abdominis (Zsoldos, et al., 2010) at trot to stabilise the spine preventing lateral movement that would waste energy. It is therefore arguable that, if the horse is in work, functional exercises such as hill or pole work would be more effective for core strengthening. This might also require some muscular endurance, which would assist the horse to maintain a good posture.

There is no evidence to suggest any increased core muscle activity with functional exercises or even jumping, only that rectus abdominis activity is higher in trot than walk (Zsoldos, et al., 2010) and a case study showed increased longissimus dorsi activity in jumping (St George and Williams, 2013). Further research is needed to detect any increases in multifidus and core muscle activity with hill and pole work, and whether or not their effects are similar to, better or worse than dynamic mobilisation exercises.

As in all exercise prescription, there is a significant reliance on client compliance and competence to

achieve the full benefits of dynamic mobilisation exercises. The exercises are easy to perform and can be executed by most owners without a need for expensive equipment or highly skilled professionals. However, undesired positions and movements, such as head tilting or snatching, may render them less effective.

According to Stubbs, et al., (2011) and Tabor, et al., (2012), the exercises are effective when performed with five repetitions of each exercise approximately five days per week.

The positions were also held for a few seconds (Stubbs, et al., 2011) because historically in humans, exercises combining dynamic and static phases i.e. active movement with a static hold, are most effective in restoring multifidus size (Danneels, et al., 2001). Overall this can be very time consuming, but if owners do not adhere to this high frequency and sustained positioning optimal effects may not be achievable.

Stretching Shortening and increased muscle activity of the ipsilateral longissimus dorsi has been identified during active lateral flexion (Peham, et al., 2001; Groesel, et al., 2010).

However, there are no studies that have investigated changes on the contralateral side. The right and left longissimus muscles have an agonist-antagonist relationship, so it can be concluded that as the ipsilateral longissimus dorsi muscle contracts and shortens during lateral flexion, the contralateral longissimus muscle relaxes and lengthens. This theory is supported by a knowledge of the longissimus dorsi muscle attachments (Henson, 2009) and movement demonstrated in the spine (Clayton et al, 2010).

Therefore, combined flexion and lateral flexion during a dynamic mobilisation exercise stretches the contralateral longissimus dorsi. Equine research shows a relationship between longissimus dorsi dysfunction and back pain (Wennerstrand, et al., 2004), and stretching assists with pain relief through centrally mediated effects (Frick, 2010).

It may therefore be suggested that stretching of

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the longissimus muscles during bilateral dynamic mobilisation exercises might reduce muscle tightness and potentially alleviate equine musculoskeletal back pain.

Unfortunately, at present there is little evidence to directly support this hypothesis.

Further research Current studies have tended to use dynamic mobilisation exercises five days per week, but peripheral joint range of movement increases with a three day per week exercise programme (Rose, et al., 2009) and this might also be adequate for multifidus strengthening. Therefore, future research is required to determine the minimum frequency and duration of performing the exercises.

In practice, dynamic mobilisation exercises are commonly used to achieve increased range of movement and soft tissue stretching to maintain effects of treatments such as reflex inhibition or spinal mobilisations. As yet, there is no evidence to support such use. There is a need to investigate whether a programme of exercises can increase intervertebral range of movement, reduce longissimus muscle tightness or reduce back pain Conclusion Dynamic mobilisation exercises are generally believed to have numerous benefits including stretching, mobilisation of the cervical and thoraco-lumbar spine, and strengthening of the core musculature. They may be useful in the management of equine back pain, in postoperative kissing spine, and reduction of the risk of arthritic changes. They may also help the horse support the weight of the rider. There is some evidence to support their therapeutic use but studies are still required to determine whether dynamic mobilisation exercises can increase spinal range of movement, stretch longissimus dorsi, preserve neck and back treatment effects and if they are any better than functional exercises.

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Holm, K. R.,Wennerstrand, J., Lagerquist, U., Eksell, P., & Johnston, C. 2006. Effect of local analgesia on movement of the equine back. Equine veterinary journal, 38(1), pp.65-69.

Kavcic, N., Grenier, S. and McGill, S. M., 2004.

Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine, 29, pp. 1254-1265.

Landman, M. A., de Blaauw, J. A., van Weeren, P. R., Hofland, L. J., 2004. Field study of the prevalence of lameness in horses with back problems.

Veterinary Record, 155(6), pp.165-168.

Licka, T., Frey, A. and Peham, C., 2009.

Electromyographic activity of the longissimus dorsi muscles in horses when walking on a treadmill.The Veterinary Journal, 180(1), pp.71-76.

McGowan, C., Stubbs, M. N., Hodges, P., Jeffcott, L., 2007. Back Pain in Horses.

McIlwraith, C.W., 1996. General pathobiology of the joint in response to injury. In: Joint Disease in the Horse. Eds: C.W. McIlwraith & G.W. Trotter, W.B. Saunders Co, Philadelphia, USA. Moffett, J. and McLean, S., 2006. The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatology, 45(4), pp.

371-378.

Paulekas, R. and Haussler, K. K., 2009. Principles and practice of therapeutic exercise for horses.

Journal of Equine Veterinary Science, 29(12), pp.

870-893.

Peham, C., Frey, A., Licka, T. and Scheidl, M., 2001.

Evaluation of the EMG activity of the long back muscle during induced back movements at stance.

Equine Veterinary Journal, 33(S33), pp. 165-168.

Pettersson, H., Strömberg, B. and Myrin, I., 1987.

Das thorkolumbale, interspinale Syndrom (TLI) des Reitpferdes - Retriospektiver Vergleich konservativ und chirurgisch behandelter Fälle.

Pferdeheilkunde 3, pp. 313-319.

Robert, C., Valette, J. P. and Denoix, J. M., 2001.

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Rydeard, R., Leger A., Smith, D., 2006. Pilatesbased therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability:A randomised controlled trial.

The Journal of Orthopaedic and Sports Physical Therapy, 26(7), pp.472-484.

St. George, L., and Williams, J. M., 2013.

Electromyographic evaluation of approach stride, jump stride and intermediate stride in selected superficial muscles of the jumping horse: a preliminary study. Comparative Exercise Physiology, 9(1), pp. 23-32.

Stubbs, N. C., Hodges, P.W., Jeffcott, L. B., Cowin, G., Hodgson, D. R., McGowan, C. M., 2006. Functional anatomy of the caudal thoracolumbar and lumbosacral spine in the horse. Equine Veterinary Journal, 38(S36), pp. 393-399.

Stubbs, N.C. and Clayton, H.M., 2008. Activate your horse’s core: unmounted exercises for dynamic mobility, strength and balance. Sport Horse Publications, Mason (MI).

Stubbs, N. C., Riggs, C. M., Clayton, H. M., Hodges, P. W., Jeffcott, L. B., and McGowan, C. M., 2010. Spinal pathology and epaxial muscle ultrasonography in Thoroughbred racehorses. Equine Veterinary Journal, 38, pp. 654-661.

Stubbs, N. C., Kaiser, L. J., Hauptman, J. and Clayton, H. M., 2011. Dynamic mobilisation exercises increase cross sectional area of musculus multifidus. Equine Veterinary Journal, 43(5), pp.

522-529.

Tabor, G.F., Johansson, C., Randle, H., 2012. The effects of dynamic mobilization exercises on the multifidus muscle in thoroughbred racehorses. In: Randle, H.,Waran, N. and Williams, J. (eds.) The road ahead, proceedings 8th international equitation science conference, Edinburgh, UK, pp. 64.

Taimela, S., Takala, E.-P., Asklöf, T., Seppälä, K., Parviainen, S., 2000. Active treatment of chronic neck pain.A prospective randomized intervention.

Spine, 25, pp. 1021-1027.

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Wennerstrand, J., Johnston, C., RoethlisbergerHolm, K., Erichsen, C., Eskell, P., Drevemo, S., 2004.

Kinematic evaluation of the back in the sport horse with back pain. Equine Veterinary Journal, 36(8), pp.

707–711.

Zsoldos, R. R., Kotschwar, A., Kotschwar, A. B., Rodriguez, C. P., Peham, C., Licka,T., 2010.Activity of the equine rectus abdominis and oblique external abdominal muscles measured by surface EMG during walk and trot on the treadmill.

Equine Veterinary Journal, 42(s38), pp. 523-9.

Delayed physiotherapy intervention following a Femoral Head and Neck Excision surgery A Case Study Nycky Edleston MCSP ACPAT A Email: Edleston@hotmail.com Website: http://classicphysiotherapy.co.uk Tel: 07767 455168 Summary A young Labrador (Patient A) had a Femoral Head and Neck Excision of the right pelvic limb (RPL) after a femoral fracture repair, which later necrosed. Eight weeks postoperatively he was referred for Physiotherapy because he was not using the limb functionally and he had developed some muscle atrophy. After a physiotherapy assessment, a regular therapy program was implemented, initially concentrating on proprioception and initiating use of the limb and then later on improving functional use and strength. A home therapy program was provided so that Patient A received daily therapy during his daily activities. 18 weeks post-operatively he had gained full functional use of the limb along with a gain in muscle mass.

Keywords: Femoral Head and Neck Excision (FHNE); femoral fracture necrosis; post-operative canine physiotherapy; canine proprioception; Introduction Femoral head and neck excision (FHNE) may be indicated for hip dysplasia, traumatic hip dislocation and irreparable fractures of the hip joint (Johnson, 2010). A fibrous joint is expected to form at the hip following a FHNE. A study on 66 dogs and 15 cats in 2010 found that FHNE resulted in limb shortening (84%); muscle atrophy (75%); reduced hip extension and abduction range of motion (74%); pain (32%) (Off and Matis, 2010).

Dogs weighing more than 15kg showed less hip extension and

compensated with more tarsal extension (Off and Matis, 2010).

An earlier study found functional restrictions in larger breeds of difficulty climbing stairs or jumping up (Duff and Campbell, 1977). Both studies noted that most owners were satisfied with the outcomes.

In these studies no rehabilitation protocols were mentioned nor any mention of hydrotherapy or physiotherapy.

able to practice with guidance from the physiotherapist so that they are confident in providing the appropriate home program.

A rehabilitation program that is incorrectly applied will not benefit the rehabilitation of the animal.

Physiotherapists are able to select a therapy that the owner can carry out depending on the unique circumstances of the owner and animal.

Physiotherapy rehabilitation for post orthopaedic surgery in people is linked to faster recovery and better functional outcomes (Kehlet, 1997; Ibrahim, et al., 2013; ERAS, 2014).

Referring pets for post-operative rehabilitation is becoming more prevalent within the small animal veterinary field with early postoperative rehabilitation the gold standard (Marsolais, et al., 2002; Davidson, et al., 2005; Monk, et al., 2006; Millis and Levine, 2014).

Physiotherapy rehabilitation aims to maximize the functional recovery of the dog (Edge-Hughes and Nicholson, 2007).

Proprioceptive deficit is a key issue with joints and soft tissues that have been injured (Friemert, et al., 2006; Lin, et al., 2011; Millis and Levine, 2014). Proprioceptive sensations are derived from mechanoreceptors in muscle spindles, golgi tendon organs at the origin and insertion of muscles, Ruffini and Pacinian receptors in ligaments and from joint capsular receptors (Jerosch and Prymka, 1996; Millis and Levine, 2014). Proprioception is likely to be impaired following FHNE since both joint capsule and local muscles of the hip are incised and sutured and the ligament of the femoral head is completely transected (Off and Matis, 2010; Berzon, et al., 1980). As a result, poor proprioception may result in muscle atrophy, reduced function and learned non-use of a limb (van der Esch, 2007; Lentell, et al., 1995).

Land-based therapy is an important part of any rehabilitation process as physiotherapists can show owners therapy that can be carried out regularly at home.

This means the animal receives ongoing rehabilitation each day, as opposed to just when the dog is having hydrotherapy or physiotherapy by a qualified professional.

In my own and other veterinary physiotherapists’ experiences, it is important that the specialist rehabilitation therapy is shown by the physiotherapist to the owner and the owner is

20

In this case study, a FHNE was performed due to failed fracture repair of the neck of femur and physiotherapy rehabilitation was not provided until 3 months post injury.

Case History An 18 month male neutered Labrador (Patient A) experienced a

traumatic fractured neck of femur to the right pelvic limb (RPL).

The fracture was plated but unfortunately over the next 4 weeks resorption of the bone of the femur occurred likely due to a poor blood supply. An alternative surgical management resulted in the dog having a femoral head and neck excision. Patient A received no rehabilitation immediately following either surgery.

Eight weeks later Patient A presented to the surgeon with no functional use of the limb and restricted hip and stifle passive range of movement. The owner was offered and declined limb amputation and patient A was referred for physiotherapy in an attempt to prevent amputation.

Following a thorough physiotherapy assessment, Patient A’s main

physiotherapy problems were noted in Table 1.

Following the physiotherapy assessment, specific, measurable, achievable, realistic and timed goals were identified, see Table 2.

Over the next 5 weeks, the therapy program in Table 3 was used where problems 1-7 (Table 1) were addressed therapeutically.

Proprioceptive techniques including differing types of sensory stimulation/handling, a proprioceptive wrap and weight transfer exercises were used.

There were ongoing adaptations to the therapy as Patient A slowly progressed. The most noticeable progression was improvements in problem 1, where the stance phase of the RPL improved during slow walking, reducing Patient A’s lameness score to 6-7/10.

The muscle atrophy (problem 6) was slow to change due to the insufficient and inconsistent right hind limb use. Hydrotherapy was unavailable to the patient. Patient A received physiotherapy from the physiotherapist (the author) every 7-10 days and the owner was shown a home therapy program to perform 2 to 3 times a day. Financial restrictions had to be balanced with effective physiotherapy intervention.

Table 4 shows the home exercise programme that was performed twice a day but with any part of it performed intermittently whenever possible during any 24 hour period.

Following the home exercise programme and initial physiotherapy treatments the short term goal outcomes were reviewed, see table 5:

Problem No

Problem identified

1

Gait – Walk – occasional toe touch RPL (9/10 lame);Trot – Non-weight bearing on right hind (10/10 lame).

2

Orthopaedic Proprioceptive deficit (no other neurological findings were present however on the knuckling test, the placing reflex was delayed to 4 seconds which the author considered to be related to a lack of proprioception from the injured tissue and from lack of use of the limb, weakness and pain)

3

Poor functional use of the RPL with the left pelvic limb being placed in the midline of body for function of the hindquarters.

4

Increased paraspinal muscle tension and tenderness from T5 to S3, bilaterally.

5

Minimal fur re-growth over operation site.

6

Significant muscle atrophy of the RPL musculature

Table 1: Physiotherapy problem list of Patient A noted after a thorough initial physiotherapy assessment

Goal

Specific Goal

Time Frame

Outcome Measure

Short Term Goal

Improved orthopeadic proprioceptive deficit

5-8 weeks

Reduce knuckling test to a 1 sec delay.

Reduce lameness score to 5-6/10

Short Term Goal

Improved functional use

5-8 weeks

Reduced medial placement of left hind limb when walking during visual gait analysis

Long Term Goal

Improve lameness score

12 weeks

Reduce lameness score to 1- 2/10 at walk; 3-4/10 at trot

Long Term Goal

Improve quality of limb use

12-18 weeks

Improved hind limb posture and control during functional tasks i.e. sit-stand

Table 2: Short and Long Term Goals Identified following identification of the main problems

21

Problem No

Problem being addressed

Treatment used

1 and 3

Gait and Functional limb use.

Snail pace walk with a two point harness control (‘two-point control’ was application of a collar and a harness with a lead attached to each). This prevented the patient leaning onto their forelimbs. Shallow loops and circles with a diameter of approximately 10m to encourage weight transfer to RPL.

2 and 3

Orthopaedic Proprioceptive Deficit/ Poor functional limb use

Application of a ‘Proprioceptive Wrap’, a bandage placed in a figure of 8 across the chest and crossing in the mid-thoracic areas and loosely tied above each stifle. This was used for all therapy and walks.

2 and 3

Orthopaedic Proprioceptive Deficit /Functional limb use

‘Weight transfer exercises’ in standing; Wobble cushion used as a variance to static exercise on flat surface. Exercise facilitated by passively moving the left pelvic limb one paw width from midline of his body and rocking him from chest and left hip towards right pelvic limb to facilitate RPL quadriceps, hamstring and gluteal contraction.

2 and 3

Orthopaedic Proprioceptive Deficit/ Functional limb use

‘Sit Transitions’ with assistance- Passively move the left pelvic limb one paw width from the midline of the body, place hands on left hip to encourage weight transfer to RPL, then command the sit.

2 and 5

Orthopaedic Proprioceptive Deficit/ Minimal fur regrowth over the operation site

Different touch techniques on the RPL including brushing with fingers, a comb and a dog brush in circles and against the coat along with finger tapping.

4

spinal muscle tenderness and tension

Pulsed magnetic therapy (200HZ, Constant,15 minutes using a Westville Therapies Biomag 2 unit) and soft tissue work of massage and myofascial release on paraspinal muscles at spinal levels T5 to S3 bilaterally.

6

Significant right pelvic limb muscle atrophy

Expected to improve by addressing problems 1-4

Table 3: Initial Physiotherapy Treatments (week 1 through to 5)

Problem No

Home exercise

2 and 3

Use of a ‘Proprioceptive Track’ made up using different surfaces in a row consisting of: a rubber mat, cardboard, carpet, foam square and a shaggy rug. Performed at a slow walk with 5 repeats. Non-slip boots applied to both hind limbs when patient A had access to wooden floors.

3 and 4

Prevention of free running access in the house and garden to limit abnormal right hindlimb use and resultant paraspinal compensatory muscle tension.

3

‘Snail’s pace’ walking on a ‘two-point control’ for 10 minutes; Application of a ‘Proprioceptive Wrap’ worn during walks.

2 and 3

Weight transfer exercises in standing for 3 minutes

3

Practising quality sits with hands on facilitation by passively placing the left pelvic limb one paw width from the midline of the body, applying hands on the left hip to a encourage weight transfer to the RPL and then commanding the sit. Repeated 5 times.

2 and 5

Touch and massage techniques (effleurage) on the limb with a variety of stimulating surfaces, speeds of application and pressure; Stroking down the limb and applying some pressure with the hand to place the toes passively on the floor. Repeated 5 minutes.

Table 4: Home Therapy program

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Goal

Specific Goal

Time Frame Achieved

Outcome Measured

Outcome

Short Term Goal

To Improve Orthopaedic Proprioceptive Deficit

8 weeks

Reduce knuckling test to 1 sec delay

Replacing right metatarsus after 1 sec.

Consistently weight bearing on RPL during slow walk, (6/10).

Short Term Goal

Improved functional use

8 weeks

Less medial placement of left hindlimb during visual gait analysis

More sagittal placement of left pelvic limb during gait.

Improved use of RPL during functional tasks i.e. sit-stand, lie-stand.

Table 5: Short term goal outcomes

Following achievement of the short term goals the exercise programme was progressed. Exercises often remained the same however, they were progressed in order to challenge patient A’s proprioception and strength by either reducing

their base of support and/or increasing the degree of load being placed through the RPL. Progression was also dependant on the owner’s ability to carry out the exercise progressions effectively whilst also preventing any compensatory

Weeks since physio commenced

Re-Assessment

Treatment

5 weeks

•

•

• •

• •

Consistently partial weight-bearing at ‘snails pace’ walk, 5-6/10 lame.

Using the RPL in weight transfer exercises.

Began use of the RPL during the sit transition but required symmetrical passive placement of the hindlimbs to start the exercise correctly.

Improved in remaining in a quality sit position without hands on assistance during the exercise.

Poor hindlimb symmetry during sit if sat independently.

• •

• •

23

movements (See Table 6). By 18 weeks post physiotherapy intervention (7 months post injury) the dog was using the limb correctly in all of his daily activities.

Introduction of a neoprene hock splint on the nonoperated leg. The splint had tensioned elastic across the joint to increase flexion of the joint as it started the swing phase – this encouraged RPL to take more weight and hold a longer stance phase.

‘Sit Transitions’ and the ‘Weight Transfer Exercises’ (see Table 4) - assisting the position of the left pelvic limb away from midline.

Once achieved, progressed to placing forelimbs on a low step or a wobble cushion or a peanut ball during ‘The Weight Transfer’ exercises to encourage loading of the hindlimbs.

These were carried out until patient A reached fatigue on the RPL which was approximately 2-3 mins per exercise.

Home exercises: same program but advanced to use step and household cushions for weight transfer exercises.

6 to 7 weeks

Continued slow improvements with all of the above.

•

•

Walking over 5 poles placed approximately 1.5ft apart (broom handles) - Displayed poor skill initially however this improved after 5 repeats, with a full RPL stride before and after each pole, once achieved, 3 more good quality repeats would be carried out.

‘The Weight Transfer’ exercises were repeated as above and progressed to a large (80cm) wobble cushion.

Home exercise programme: continued as previously;

Added in hill walking and walking over broom handles.

8 weeks

•

• • •

• •

13 weeks

• •

•

18 weeks

• •

He was consistently weight bearing during a slow and up to half pace walk (4-5/10) – any increase of pace over this and he would go 10/10 lame every 3rd to 5th stride.

In stand - an estimated less than 50% of expected weight bearing on the operated limb.

He could 3-legged stand (i.e. lifting left hind limb) for 3-5 seconds comfortably.

He was functionally weight bearing through the RPL 80% of the time including around the house (previously mobilising around the house is when patient A would consistently tend to go 10/10 lame).

The sit the exercise could now be carried out with quality and without assistance.

The fur had started growing back over the whole site.

Some holiday time slowed his progress a little.

He had however continued to improve in the quality of his paces and he was consistency weight bearing through the RPL at normal walking pace, 2/10 lame.

His fur had grown back over the operated site during the last few weeks.

7 months post injury, he was discharged from physiotherapy.

All short and long term goals had been achieved.

• •

Large wobble cushion (80cm) with all four limbs standing on it and doing weight transfer and balance exercises.

Walking on and off curbs, 90 ° turns, inter changing paces during walk i.e. from a snail pace - slow pace – normal pace- snail pace etc; Introducing trot (ensuring a stance phase during trot but slowing to a walk if patient A went 10/10 on the RPL)

Home exercise programme: Varying walk paces and

including trot as above; Walking on and off curbs ( see Figure 1); Continuation of circles, shallow loops on the walk and started 90 ° turns.

•

•

Introduction of an obstacle course including walking and trotting over raised poles, walking over and stopping on small and large wobble cushions and boards, walking up and down multiple steps (performed three times).

Quicker changes of direction between 90° &180°.

Home exercises: Longer walks up hills; walking up steps and over raised poles; walking at faster paces and changes of direction on the lead; running.

By week 16 allowing some off the lead exercise for short doses interspersed with rest on the lead.

All aimed at gradually increasing his muscle strength and endurance.

No further physiotherapy required.

Table 6: Further physiotherapy re-assessments and treatments from week 5 when the RPL had commenced weight bearing more consistently.

24

weight

transfer

exercises

and

Figure 1: Controlled walking on and off Kerbs to encourage RPL use

Discussion This case was successful because an initial physiotherapy assessment identified the patient’s main functional problems and these were addressed with a progressing therapy program.

A strong focus was placed on the patient A’s poor proprioceptive function. Proprioceptive receptors deep within joints and in ligamentous and muscle tissue provide the body with precise information about where their limbs are located in space (Dhillon, et al., 2011; Millis and Levine, 2014).

Patient A’s poor proprioceptive function was thought to have arisen from the lack of limb weight bearing over time and learnt non-use of the limb. In veterinary medicine, proprioception is generally assessed in relation to patients with a neurological dysfunction, however in the human field, there is much evidence in support of the use of proprioceptive rehabilitation following orthopaedic injury and the inability for this to return without rehabilitation (Friemert, et al., 2006; Lin, et al., 2011; Dhillon, et al., 2011).

In relation to patient A, this does not suggest reduced proprioception is always related to a neurological dysfunction. Therefore with this patient, to improve proprioception in the early stages of rehabilitation,

sensory stimulation to skin, muscles and joints were used (Edge-Hughes and Nicholson, 2007; Millis and Levine, 2014). In the later stages of rehabilitation, proprioception was improved further with the use of balance boards and cushions, perturbations and balance exercises (Edge-Hughes and Nicholson, 2007; Millis and Levine, 2014).

Although this owner had been given instructions by her veterinary surgeon to walk the dog slowly on the lead, she was unable to comply to a level that was therapeutic to the operated limb due to the dog pulling on the lead and offloading the RPL in the process. This is a common mistake that may lead to poor use or dis-use in a limb postoperatively but one that can be prevented with a physiotherapy rehabilitation program (Millis and Levine, 2014). For patient A, I used a harness and two leads, one on the collar and one on the harness and trained the owner how to use this two point control to provide a therapeutic walking exercise. Functional use of the limb was achieved by extremely slow walking with some weight transfer movements using circles and shallow curves during the walking.

Once the dog was starting to use the limb in slow walking I enhanced this by putting a neoprene splint

25

over the hock of the opposite hind leg which had the effect of increasing the stance time required by the operated limb. The splint did this by having elastic on tension across the hock joint which assisted in increasing flexion in the hock of the non-operated limb which increased the time it spent during swing phase (Millis and Levine, 2014).

Muscles strengthen with active use and this is best achieved using functional movements (Millis and Levine, 2014). Patient A in this case was initially unable to perform the sit and sit-to-stand exercises independently in a manner that would strengthen the muscles as they had adapted to using the nonoperated limb to lower and raise the hindquarters. By providing the expertise on how to facilitate Patient A to perform an active sit that had therapeutic value, I was able to utilise this exercise for this dog. The owner was also trained on how to facilitate the exercise, which with guidance and training from myself, she was able to achieve to a satisfactory level. A home exercise program needs to be bespoke for the patient and owner in order for it to be effective for the patient’s rehabilitation.

Once Patient A was using the operated limb at walk, functions that would increase the stance phase of the RPL and therefore the muscle strength were incorporated into the therapy. This included walking up and down hills, on and off kerbs, up and down steps and eventually running and playing (Millis and Levine, 2014) Conclusion Early intervention is routinely applied in the human field post orthopaedic surgery to help minimise mobility problems. In the authors opinion this should also be the case in the veterinary field.

Chartered Veterinary Physiotherapists understand the stages of healing and that tissues need controlled stresses to be applied at specific times to facilitate

effective recovery. This case highlights the importance of early physiotherapeutic intervention following a FHNE operation.

In the authors opinion, Patient A’s problems could have been significantly reduced if immediate post-operative physiotherapy had taken place.

Nevertheless, following a thorough physiotherapy assessment with identification of the main physiotherapy problems a positive outcome was achieved for Patient A. References Berzon, J., Howard, P., Covell, S., Trotter, E., Dueland, R., 1980. A retrospective study of the efficacy of femoral head and neck excisions in 94 dogs and cats. Veterinary Surgery, 9(3), pp.

88-92.

Davidson, J., Kerwin, S.c., Millis, D.L., 2005.

Rehabilitation for the orthopaedic patient. Vet Clin North Am Small Anim Pract. 35(6), pp.

1357-88.

Dhillon, M.S., Bali, K., Prabhakar, S., 2011.

Proprioception in anterior cruciate ligament deficient knees and its relevance in anterior cruciate ligament reconstruction. Indian J Orthop. 45(4), pp. 294–300.

Duff, R., Campbell, J.R., 1977. Long term results of excision arthroplasty of the canine hip. Vet Rec, 101, pp. 181–184.

Edge-Hughes, L., Nicholson, H., 2007. Chapter 13 - Canine Treatment and Rehabilitation. In Mcgowan C, Goff L & Stubbs N. Ed Animal Physiotherapy – Assessment, Treatment and Rehabilitation of Animals. Oxford, UK , Blackwells Publishing, pp. 207 – 237.

Johnson, J.M., Johnson, A.L., 1993. Cranial cruciate ligament rupture. Pathogenesis, diagnosis, and postoperative rehabilitation.

Vet Clin North Am Small Anim Pract, 23(4), pp. 717-33.

Kehlet, H., 1997. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br. J. Anaest,. 78 (5), pp. 606-617.

Lentell, G., Baas, B., Lopez, D., McGuire, L., Sarrels, M., Snyder, P., 1995. The Contributions of Proprioceptive Deficits, Muscle Function, and Anatomic Laxity to Functional Instability of the Ankle. Journal of Orthopaedic & Sports Physical Therapy, 21(4), pp. 206-215 Lin, C., Lee, I., Liao, J., Wu, H., Su, F. 2011.

Comparison of Postural Stability Between Injured and Uninjured Ballet Dancers. Am J Sports Med, 39(6), pp. 1324-1331.

Marsolais, G., Dvorak, G., Conzemius, M.G., 2002. Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs. JAVMA. 220(9), pp. 1325-1330.

Millis, D., Levine, D., 2014. Section V – Therapeutic Exercise and Manual Therapy in Canine Rehabilitation and Physical Therapy.

Second edition. Saunders. pp 401-542.

Monk, M.L., Preston, C.A., McGowan, C.M., 2006. Effects of early intensive postoperative physiotherapy on limb function after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament.

American Journal of Veterinary Research, 67(3), pp. 529-536.

Van der Esch, M., Steultjens, M., Harlaar, J., Knol, D., Lems, W., Dekker, J. 2007. Joint proprioception, muscle strength, and functional ability in patients with osteoarthritis of the knee. Arthritis Care & Research, 57(5), pp. 787–793.

ERAS( 2014) Enhanced recovery after surgery Society The ERAS Protocol. Available at <http://www.erassociety.org/index.php/erascare-system/eras-protocol>. [Accessed on 15th June 2014].

Friemert, B., Bach, C., Schwarz, W., Gerngross, H., Schmidt, R., 2006. Benefits of active motion for joint position sense. Knee Surgery, Sports Traumatology, Arthroscopy, 14 (6), pp. 564-570.

Ibrahim, M.S, Twaij, H., Giebaly , D.E, Nizam, I., Haddad, F.S., 2013. Enhanced recovery in total hip replacement. Bone Joint J, 95-B(12), pp. 1587-1594.

Jerosch, J., Prymka, M., 1996. Proprioception and Joint Stability. Knee Surgery, Sports Traumatology, Arthroscopy, 4(3), pp. 171-179 Johnson, K. 2010. Editorial - Outcome of femoral head ostectomy in dogs and cats. Vet Comp Orthop Traumatol, 23(5 ), III-IV.

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An overview of Neurological Physiotherapy Concepts and their application to create a post-operative rehabilitation guide for Thorocolumber Hemilaminectomy Melanie Haines Chartered Veterinary and Human Physiotherapist MSc Vet Physio, BSc (HONS) Physiotherapy MCSP,ACPAT cat A Email: Melvetphysio@yahoo.co.uk Website: www.physio4animals.co.uk Tel: 07931 850475 Following the article in the previous Four Front (Haines, 2014) reviewing the evidence for the treatment of intervertebral disc disease (IVDD) with thoracolumbar hemilaminectomy this article is a discussion of the neurological physiotherapy concepts and how they can be applied in practice.

This is followed by post-operative veterinary and physiotherapy guidelines for thoracolumbar hemilaminectomy patients.

Neurological Physiotherapy Recent advances in the scientific understanding of both motor control, functional reorganisation and recovery of the central nervous system (CNS) following injury (neuroplasticity) have led to vast changes in human neurorehabilitation. There has been a shift within physiotherapy treatment following spinal cord injury to use a more science based, activity dependant approach to improve walking based recovery (Behrman 2006). These concepts are now being used to successfully rehabilitate animals.

Rehabilitation of the neurological canine patient is case specific.

Not only is it dependent on the presenting pathology, veterinary and surgical intervention, but also on the symptoms presented by each case. This makes prescribing specific post-operative protocols for physiotherapy difficult. Postoperative guidelines based on sound clinical reasoning are therefore more appropriate.

Each case requires a physiotherapy assessment of motor function, muscle tone,

pain, behaviour and nursing needs.

From this, an individualâ&#x20AC;&#x2122;s problem list and treatment goals can be identified whilst working within the constraints of the surgery. It is vital that the veterinary surgeonâ&#x20AC;&#x2122;s constraints for the animal are known for each case.

Neurological Physiotherapy Theoretical approaches Neurological physiotherapy for people has been well documented with various treatment concepts / approaches existing, see Table 1.

dependant training and through this recovery (Behrman, et al., 2006). The therapeutic aim of all treatment is to work with the dog to reach the functional rehabilitation goals.

The rehabilitation goals are to regain normal neuromuscular functions of ambulation. The aims of treatments are:Normalising muscle tone Normalising spinal reflexes Facilitating normal movement patterns

Bobath

A problem solving approach to optimise the individuals motor performance through facilitation of normal postural control and selective movement to produce independent function (Raine, et al., 2009).

Motor Relearning (Carr and Shepherd)

Non-Hierarchical, functional, task based rehabilitation without focus on underlying impairment. Based on modern motor learning concepts (Carr and Shepherd, 2011).

Rood

Sensory stimulation for inhibition and facilitation.

Neurodevelopmental sequence (Stokes, 1998).

Proprioceptive Neuromuscular facilitation (PNF)

Uses specific proprioceptive stimulation to re-educate the neuromuscular system (Knott, et al., 1985). Mostly known for working in diagonal patterns.

Motor Control

A problem solving approach based on up to date theories of motor learning specifically the systems model described by Shumway-Cook and Wollacott (2007).

Table 1: A summary of Neurological Physiotherapy theoretical approaches.

In clinical practice, a combination of all of these approaches is often used.

This optimises rehabilitation and compensates for a dogâ&#x20AC;&#x2122;s inability to cognitively understand commands, speak and perform various key components of movements on command. The spinal cord has been shown to respond to activity-

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Giving patients a sensation of normal postural control.

Improving proprioception Preventing muscle contractures Improving the dogs involvement/ motivation with functional tasks Preventing pressure areas and other complications of being non ambulatory

Treatment of post-surgical pain These goals can be achieved through a rehabilitation program that incorporates exercises, functional activities and therapeutic modalities.

Application of the theoretical approaches in practice Facilitation of normal postures and transitions Using the Bobath theory of normal movement facilitation and a sensation of normal movement, a sequence can be applied to dogs by working through postural sets and transitions e.g. side lying to sternal lying to sit to stand to walk (Figure 1). Although this is displayed as a sequence, each individualâ&#x20AC;&#x2122;s problems and treatment goals should be assessed. Through careful clinical reasoning it should be decided where you start in the sequence and whether you work up or down the sequence. For example, for a low toned dog rehabilitation should involve going into standing as early in treatment as possible.

The treatment should be lead through side lying to sternal and through sitting to get to stand but the goals of treatment would be to stand ASAP. This would improve postural control, stimulate normal balance reactions, vestibular system and activate the Ascending Reticular Activating System (reticular formation) governing arousal. Dogs should be encouraged to rest in a variety of normal postures that have the desired effect on tone and function. The aim of reducing abnormal tone and placing the dogâ&#x20AC;&#x2122;s limbs in a normal posture will prepare the dog for the progression of movement as well as preventing muscle shortening.

For example, when the dog is in sternal lying and the hind limbs (HL) are positioned into a normal squat position, sensory feedback from the plantar surface of their pads will be facilitated and will aid in preparation for standing.

Extensor tone, although useful to enable the dog to bear weight in

standing, is undesirable in function, as normal movements such as sitting and stepping require downgrading of extension and recruitment of flexion i.e. reciprocal innervation.

Therefore, increased extensor tone should be discouraged through appropriate handling techniques and positioning. Nurses and owners should be educated to prevent extensor tone patterns whilst the dog is resting e.g. rest in a natural/ flexion based posture with limb not being allowed to rest in full extension.

Sit to stand should be facilitated through a normal sequence of joint movements to recruit active participation and postural control, rather than lifting the dogs and passively placing them into standing.

It may be necessary to work certain dogs in standing first to recruit appropriate postural control and then ask for a graded sit e.g. onto your lap and then immediately facilitate a stand on the background of better postural control. If the dog is unable to cope with a full sit to stand, due to the effect on its tone, it may be necessary to work first with postural sets in a large base of support such as sternal or side lying or standing over a wedge or ball. Key point handling will reduce tone and mobilise tight areas of muscle as well as locate and treat underlying lack of stability, which may then allow you to progress

Figure 1. A diagram showing postural sets.

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to a sit to stand by the end of the treatment session. As mentioned earlier, the postural sets below can be progressed through forward or backwards and for some dogs who find static standing challenging you may start with facilitated gait and work backwards to a static stand.

Standing practice is vital to give sensation of normal joint position, upright posture, muscle function, reduction of abnormal reflex reactions and to either increase or decrease tone. In addition, standing increases arousal and stimulates automatic balance reactions. In standing, passive ROM of alternate limbs, withdrawal reflex stimulation, weight transfers, bouncing and rhythmic stabilisation and baited movements can be carried out.

Simple turning of the head or reaching forwards for a treat is enough to stimulate normal trunk and pelvic control. If the dog is unable to bear weight then the use of standing in water can be very beneficial due to the buoyancy and proprioceptive input of the water.

This can be achieved either in an underwater treadmill or if the dog is small enough, in a tub table (see Figure 2). An alternative way to support the dog is through the use of a gym ball or rolled towel under their abdomen. Although care should be taken when using a gym ball to make sure the desired effect on their tone and posture

Figure 2. A photo showing a filled tub table being used as a delivery method of water based therapy with a post operative spinal patient.

is achieved. In cases of low tone, if a dog is given a large base of support, their tone remains low and unchanged therefore failing to achieve the goal normalising tone, despite them being in a more functional posture of standing.

Therapeutic handling through key points is vital during any facilitation of movement and standing practise, which is aimed at restoring normal neuromuscular function. Key points of control refer to parts of the body that are advantageous when facilitating or inhibiting movement/ posture (Raine, et al., 2013). For example, if trying to overcome high tone, avoid placing your hands on the plantar surface of the dog’s pads, as this may elicit an extensor reflex. Instead, by placing gentle pressure behind the stifle, the extensor tone in the hamstrings can be relaxed or by leading into the movement through flexion of the digits the muscle tone may reduce and allow flexion. In low tone dogs, by handling with your thumbs under their ischial tuberosities and your fingers over the cranial stifle, you can facilitate hip and stifle extension to encourage gluteal and quadriceps action in weight bearing (see Figure 3 and 4). Extensor spasm usually comes about through increased effort and muscle shortening or stimulation of hypersensitive areas (e.g. ball of foot in human, pads in dogs).

bouncing whilst in standing (lifting the pelvis slightly until the HL’s are just touching the floor and then lowering them) can be used to elicit the extensor reflex and therefore aid in weight bearing. The application of proprioceptive neuromuscular facilitation (PNF) through rhythmic stabilisations in standing works well to raise tone and facilitate muscle activity, and therefore is good for use in cases presenting with low tone. This can be done whilst on a proprioceptively rich surface e.g. a rough side of a wobble cushion.

Constant evaluation of the dog and clinical reasoning whilst using any of these techniques is vital to make sure you are gaining the desired proximal activity in the trunk, pelvis and limbs and not just achieving an increase in non-normal muscle tone.

Functional Tasks

Figure 3. Photograph one of two showing a start position of a facilitated sit to stand, showing handling of the HL’s with thumb under their ischial tuberosites and fingers over cranial stifle.

Figure 4. Photograph two or two; the handling of sit to stand through facilitated stifle and hip extension.

Use of Spinal Reflexes to facilitate function and rehabilitation Using reflex stimulation in a functional position e.g. standing or walking, can help when treating dogs with low tone by gaining proximal activity in the trunk, pelvis and limbs.

You can elicit the withdrawal reflex in the hind limb to initiate stifle and tarsal flexion, thereby encouraging normal tone and function. Also

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The act of using functional tasks brings the motor relearning theories of Carr and Shepherd (2011) into the treatment session. Giving a sit command will encourage the relaxation of tone to allow HL joint flexion as well as connecting the dog with its HL control. Using treats or a ball to encourage a sit often works as a high number of dogs are taught to sit for a biscuit, therefore this activates their normal neural pathways by potentially tapping into the dogs automatic spinal circuits (Central Pattern Generator). Care must be taken that the excitement of food or a ball does not have a negative effect of the dog’s tone and if so alternative application of stimulation should be used.

Quyang, et al., (2014) found that early sitting, standing and walking in conjunction with a contemporary Bobath approach improved lower extremity mobility and balance in people after a stroke. Brock, et al., (2011) found that physiotherapy focused on structured task practice alone produced less improvement in gait than physiotherapy based on the Bobath concept with structured task practice in people following a stroke. Therefore, it is important to use a combination of functional

tasks with normalisation of tone and movement approach of Bobath during a treatment session.

Sensory facilitation Roods techniques of sensory stimulation (Stokes, 1998) can be applied whilst carrying out the above functional tasks/movements or in a side lying position to inhibit or facilitate muscles and movement.

Brushing, stroking, tapping, vibration, ice, pressure and joint compressions are all techniques that can be easily applied to the canine patient. The speed and method of application will differ depending on whether treatment is aimed at facilitating or inhibiting muscles e.g. using techniques in a fast, brisk and against the hair stroke will facilitate muscle tone whilst using the techniques in a slow, sustained, gentle way will inhibit muscle tone. Neuromuscular Electrical Stimulation (NMES) could also be used to provide both sensory and motor stimulation.

Owners can easily be taught these techniques to apply at home and often in large dogs with elderly owners who cannot cope with the facilitation of transitions and functional tasks. This is a good basis of a home exercise program.

proprioception, postural control and muscle control, e.g. obstacles, different surfaces, transitions and turns. At this point core stability work can be added through baited stretches and facilitating a leg away into three leg standing, progressing onto two leg lifts and working on an unstable surface over the following months (see Figure 5). Again it is vital that there is constant evaluation of the effect of these techniques on the dog’s postural control and compensations and clinical reasoning along with good handling and use of key points are used to make sure treatment goals are being met. There is a risk that these techniques if not facilitated well may encourage inappropriate compensation or weight transfer.

prevent these complications actively rather than passively.

Post-operative veterinary guidelines for a thoracolumbar hemilaminectomy It is commonly accepted amongst veterinary surgeons that due to tissue healing it takes 6 weeks for the disc structure to heal from the surgery, therefore the forces through the disc must be kept to a minimum to prevent further complications. This must be clearly explained to owners – if their dog is ambulatory day 1 post-operatively, they often allow the dog to over exercise, causing potentially serious setbacks, which

Ambulation In practice with dogs the author finds facilitated gait through placement of HL’s for the dog can have a great effect on stimulating the automatic movement pathways and aid in the motivation of the dog by allowing them to feel more ‘normal’ (Carr and Shephard, 2011). Again handling is key whilst facilitating gait and must constantly be assessed to maximise the facilitation/inhibition that is desired to get the most out of every treatment session. The only occasions when walking a patient would not be beneficial is if they do not have enough components of movement present so they have to use strong compensatory strategies which would negate any treatment gains.

Once the dog is ambulatory work should progress onto maximising

Figure 5. A dog carrying out an obstacle course to improve proprioception.

Prevention of complications of non-ambulation In dogs that take longer to progress to ambulation prevention of muscle contractures and muscle atrophy becomes an important consideration. PROM, massage, stretches and NMES can all be used to prevent theses complications.

However, if ambulation is regained quickly, less importance is placed upon these techniques with rehabilitation concentrated towards active movement patterns and functional tasks, as this works to

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may require further surgery. Below is the post-operative guidelines that the surgeons the author works with provide. These guidelines may vary between surgeons and so obtaining this direction from the individual surgeon of each case is important.

Cage Rest 0-2 weeks strict cage rest; sling supported lead walks for toileting 3-4 times a day.

2- 6 weeks cage rest but can come out if supervised for small periods of time in a small room and if out

iof the cage in the house the dog must be on a lead at all times.

No running, jumping, stairs or playing, until advised by the veterinary surgeon (earliest is 6 weeks post-op).

Walks/ Exercise Levels 0-2 weeks - toileting in garden only.

2-4 weeks - if able, start 5 minutes lead walks on a suitable surface (grass) 3 times a day.

4-6 weeks - progress to a maximum of 5-10 minutes lead walks 3 times a day.

6 weeks - post-operative review with veterinary surgeon.

6-12 weeks - stop cage rest and gradually increase freedom around the house but still avoid stairs.

Gradually increase walks by 5 minutes per week up until the dog is back to normal walking distance pre-onset.

Consider long term prevention of stairs, play, high-speed off-lead activity, jumping on/off furniture, depending on condition of other discs.

Post-operative physiotherapy guidelines for a thoracolumbar hemilaminectomy Some dogs will be ambulatory at the first day post-operatively in comparison to those dogs with a higher neurological grade (Haines, 2014), depending on manipulation of the spinal cord during surgery or if any surgical trauma to the spinal cord has occurred. Postoperative inpatient physiotherapy can commence on day 1 with the aims of: Normalising muscle tone Facilitating normal movement patterns Giving patients a sensation of normal position, normal movement Improving proprioception Pain relief and reducing post op swelling It is normally delivered in 10-15 minute sessions, 3-4 times a day, alongside the dogsâ&#x20AC;&#x2122; nursing needs, i.e. feeding, toileting, etc., as dogs fatigue quickly in the early stages

panic easily which will have a negative effect on their muscle tone.

Therefore, it is imperative to gain their trust and make them feel safe.

If not, their muscle tone increases further and their co-operation decreases. Ensure the environment for physiotherapy is appropriate â&#x20AC;&#x201C; quiet, calm, appropriate flooring. All this will facilitate the effectiveness of the treatment sessions.

Re-assessment is essential at every session, particularly within the first few days, as during this time these dogs can make marked improvement. Specific, Measurable, Assignable, Realistic and Time related (SMART) goals should be set and treatment must be progressed accordingly to ensure the best outcome of each session. The neurological tests such as deep pain, knuckle test, hop test and paper slide test can also be used to re assess the dogsâ&#x20AC;&#x2122; progress.

Dogs with hind limb paresis often

Normalise muscle tone

Ambulatory post- operative dog

Non Ambulatory post-operative dog with High tone (AIM TO INHIBITE TONE AND SPINAL REFLEXS)

Non Ambulatory post operative dog with Low tone (AIM TO STIMULATE TONE AND SPINAL REFLEXS)

Massage

Massage

Massage

PROM

PROM

PROM

Functional tasks

Postural sets with large base of support such as sternal or side lying or standing over a wedge or ball.

Roods techniques (sensory input).

Key point handling to reduce tone and mobilise tight areas of muscle Locate and treat underlying lack of stability Assisted functional task e.g. sit to stand to let go of tone Compression e.g. thunder shirts or Tuba grip.

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Postural sets with small base of support antigravity postures e.g. sitting, standing or modified standing.

Key point handling to recruit muscle activity Assisted functional tasks on stimulating surfaces e.g. wobble cushion or a surface that challenges proprioception

Promote normal movement patterns and postures/ functional activities

Sit to standing to vocal command Lie to stand to vocal command Walking on different surfaces Simple obstacles Normal toileting postures

Postural set and accepting base on support e.g. sternal lying or normal HL posture in sit

Postural sets and supporting dog with blocks and blankets to stay in that posture

Sit to stand with facilitation through key points and with vocal command

Facilitation of weight bearing with key point handling rather than sling.

Normal eating posture e.g. standing to eat

Normal eating postures Support normal toileting postures

Support normal toileting posture

Facilitation of sit to stand, stepping and gait.

Facilitated stepping and walking if ready Improve proprioception

Pain

Nursing needs

Roods technique

Roods Technique

Roods Technique

Obstacles

Joint PROM

Joint PROM

Joint PROM

Bouncing in standing

Toe tickling

Sensory stimulation to the paws encourage flexion and relaxation of tone

Pharmaceutical pain relief

Pharmaceutical pain relief

Pharmaceutical pain relief

Massage

Massage

Massage- effleurage and stroking

Care of dragging toes and so causing sores

Care of dragging toes and so causing sores

Care of dragging toes

Monitor urination and skin cleanliness to prevent urine scald

Pressure sore management Monitor if able to urinate and if not may need catheterization of bladder

Eating and drinking post operatively.

Stability

Standing and transitions on an unstable surface.

Leg lifts Rhythmic stabilisations Baited stretches

Encourage eating and drinking Practice Rhythmic stabilisations whilst dog has large base of support on a stable surface Baited stretches in sternal lying

Sensory stimulation of the paw to increase muscle tone.

Monitor if has no bladder control as potential of skin sores.

Pressure sore management Encourage eating and drinking.

Standing and transitions on an unstable surface.

Rhythmic stabilisations Baited stretches

Table 2: A summary of post-operative physiotherapy techniques for Post thoracolumbar hemilaminectomy with levels of ambulation and muscle tone.This is by no means a complete list of physiotherapy techniques that can be used on these cases but rather the core basics.

It is important that owners are taught the appropriate handling techniques and physiotherapy exercises to continue at home. In order to achieve this we carry out a joint veterinary and physiotherapy session with owners on discharge from the hospital. We advise clients to do 3 to 4 10-15 minute sessions of physiotherapy a day due to the

negative effects of on movement patterns and muscle tone if they fatigue (Olby, 2005).

It has been shown that the central nervous system after injury is malleable and can learn. This neuro plasticity of the the spinal cord has been shown to be activity dependant. (Behrman, et al., 2006;

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Quayang, et al., 2014; Brock, et al., 2011; Olby, 2005). Therefore, owners are also encouraged to combine physiotherapy sessions with a functional task whenever possible. For example mobilising in the garden for toileting or during feeding times or lying in a normal postural set to eat or standing to eat if able.

The importance of owners’ understanding post-operative guidelines can never be underestimated.

We must remember that disc healing times are the same for all dogs regardless of their rate of progression to ambulation.

A dog progressing quicker (neurologically) must not be given too much freedom by their owners.

Physiotherapy progression is case dependent, which includes consideration of the owners’ ability to comply and carry out the protocols. The aims remain the same throughout the rehabilitation, but they must stay within the post-operative guidelines.

We aim to jointly see all our cases back at 2 weeks post-operatively although in some cases they have a physiotherapy session after 1 week if progress is slow.

If the wound is healed, our surgeons allow the use of the underwater treadmill from 2 weeks postoperatively and dogs must be fully assisted. I find the water treadmill very beneficial to facilitate recovery of normal movement patterns. Gandini, et al. (2003) used underwater treadmill treatment as part of their physiotherapy program and it was shown to have a major influence on recovery rate following fibrocartilaginous embolism. With the aid of water providing enhanced proprioception and buoyancy, as well as utilising key points, I find this an invaluable tool in rehabilitation. Also utilised are T-Touch wraps, taping and elastic braces to further facilitate normal movement patterns either on-land or in the water treadmill (Tellington-Jones, 2012; Jaraczewaska and Long, 2006). Free swimming is not favourable and not advised by our vets, for at least 6 weeks postoperatively, due to the potential increase of spinal motion of free swimming in the pool (Gandini, et al., 2003; Olby, 2005). Hesse, et al.

(1995) found that treadmill training with partial body weight support in human stroke patients was more effective in respective to gait ability and waking velocity compared

with physiotherapy based on the Bobath concept. This partial weight support could be compared to the support given by the water and therefore transferred to the use of an underwater treadmill.

Frequency of physiotherapy input is dependent on the dog’s progression, the owner’s geographical location, funding and compliance. The nonambulatory dogs have a higher frequency of physiotherapy and hydrotherapy input than the ambulatory dogs that can be set active home exercise programs with their owners. At 6 weeks, a joint session is carried out to check the progress and discuss the long term management of these cases and encourage to continuation of stability work long term involving controlled baited stretches, use of unstable surfaces and varied obstacles.

Further Research There is a need for further physiotherapy specific research to be carried out to investigate the effectiveness of the treatment ideas discussed above. Some interesting questions that could be investigated are: Does the speed of recovery and percentage of cases which recover ambulation for dogs with loss of deep pain, improve with physiotherapy?

What are the best physiotherapy treatments for low tone and for high tone?

Does owner compliance with postoperative guidelines improve with physiotherapy input and therefore affect the rates of post-operative complications?

Does the use of the underwater treadmill during the first 12 weeks of recovery influence the quality of the ambulation and endurance gained by theses dogs?

Is there a decreased risk of future discs herniation if the owner carries stability exercises out long term?

And if so, could high risk dogs be identified prior to IVDH and work to prevent these cases? Levine, et al. (2006) have published a paper

33

looking at association between anatomical physical factors and acute thoracolumbar IVDH in dachshunds to identify risk factors of IVDH prior to episodes.

Summary Prognosis of recovery from hemilaminectomy surgery varies depending on the pre-operative neurological grading. The frequent re-assessment and clinical reasoning during every physiotherapy session will maximise the dog’s recovery potential.

Physiotherapy must encourage the return of normal movements but physiotherapy must remain within the veterinary surgeon’s post-operative protocols.

But as professionals we also need to on be able to input on these protocols and challenge practice where we have good reason to do so and apply our have specialist knowledge. The frequency of physiotherapy sessions will be determined by the progression of the dog and the compliance of the owners.

Glossary Hierarchical approach - theory that the performance of a motor activity is initiated, co-ordinated and controlled by central mechanisms that act on a hierarchical basis.

Facilitation - the enhancement or reinforcement of any action or function so that it can be performed more easily.

Inhibition - when increased tone is proving to be an obstacle to the achievement of normal movement a specific inhibitory technique may be used to reduce the raised muscle tone.

Muscle tone - is the continuous and passive partial contraction of the muscles, or the muscle’s resistance to passive stretch during a resting state.

Proprioception - is the sense of the relative position of neighbouring parts of the body and strength of effort being employed in movement.

It is provided by proprioceptors in skeletal striated muscles and in joints. The brain integrates information from proprioception and from the vestibular system into its overall sense of body position, movement, and acceleration.

body e.g. joint position, muscle length, muscle stretch.

Proprioceptive Stimulation stimulation through the bodies proprioceptive sensors within the

Proprioceptive neuromuscular facilitation (PNF) - a neuromuscular treatment method for restoring

Sensory stimulation - stimulation through touch, pressure, temperature, vibration and other sensory experiences.

References Behrman, A., Bowden, M. and Nair, P. 2006.

Neuroplasticity after spinal cord injury and Training: An Emerging Paradigm Shift in Rehabilitation and walking recovery. Physical Therapy, 86, pp. 14061425.

patients with serve motor deficits.Topics in stroke rehabilitation, 21(2), pp. 120-127

Brock, K., Hesse, G., Rothacher, G., Cotton, S. 2011.

Does Physiotherapy based on the Bobath Concept, in conjunction with a task practice achieve greater improvement in walking ability in people with stroke compared to physiotherapy focused on structured task practice alone? A pilot randomized controlled trial. Clinical Rehabilitation, 25(10), pp.

903-912.

Sawner, K. A. and LaVigne, J. M. 1992 Brunnstorms Movement Therapy in Hemiplegia. 2nd ed.

Lippincott, Philadelphia.

Carr, J. and Shepherd, R. 2011. Neurological Rehabilitation, Optimizing performance, 2nd Ed.Elsevier, London.

Raine, S., Meadows, L., Lynch-Ellerington, M., 2013.

Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation. Willey-Blackwell, Chichester.

Gandini, G., Cizinauskas, S., Lang, J., Fatzer, R., Jaggy, A,. 2003 Fibrocartilaginous embolism in 75 dogs: clinical findings and factors influencing the recovery rate. Journal of Small Animal Practice, 44(2), pp. 7680.

Stokes, M. 1998 Neurological Physiotherapy. Mosby international, London.

Shumway-Cook, A., Wollacott, M., 2007 Motor Control:Translating Research into Clinical Practice.

Third Edition. Lippincott Williams &Wilkins, Pennsylvania, USA.

Tellington-Jones, L., 2012. Getting in TTouch with your Dog: A gentle Approach to influencing behaviour, Health and performance. 2nd Ed. Trafalgar Square Publishing,Vermont.

Haines, M. 2014:Thoracolumbar hemilaminectomy for the treatment of intervetertebral disc herniation/extrustion: The evidence reviewed as a precursor to a post operative physiotherapy protocol. Four Front: The Magazine of the Professionals in Animal Therapy, 5, pp. 28-30.

Hesse, S., Bertelt, C., Jahnke, M. T., Schaffrin, A., Baake, P., Malezic, M. and Mauritz, H., 1995.

Treadmill Training with partial body weight support compared with Physiotherapy in Non ambulatory Hemiparetic Patients. Stroke. 26, pp. 976-981.

Jaraczewaska, E., Long, C., 2006. KinesioÂŽ Taping in Stroke: Improving Functional Use of the Upper Extremity in Hemiplegia. Topics in Stroke Rehabilitation, 13(3), pp. 31â&#x20AC;&#x201C;42 Knott, M., Voss, I., Myers, J. and Voss, D., (1985) Proprioceptive Neuromuscular Facilitation: Patterns and Techniques. Harper and Ross, Philadelphia.

Olby, N., Halling, K., Glick,T. R., 2005. Rehabilitation of the Neurological patient.Veterinary Clinics, Small Animal Practice, 35, pp. 1389-1409.

Quayang, M., Zhan, C., Qinqin, P., Lixiang, W., 2014.

Early sitting, Standing and Walking in conjunction with Contemporary Bobath Approach for Stroke

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movement and mobility using sensory inputs to direct motions in diagonal patterns; it emphasizes that movements must be specific and directed toward a goal.

Postural control - Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity.

An interview with Kim Sheader, ACPAT Chairman Stephanie Brighton MSc BSc MCSP HCPC ACPAT A Brief background I qualified from the University of Hertfordshire in 2000 with the intent of being a sports physio (in my wildest dreams, for a F1 team!!).

I did consider animal physiotherapy at this time too, but you were required to have two years of experience in the human field, so I started my junior rotations at Wexham Park Hospital in Slough and discovered that outpatients was not as much fun as working on ITU. I did a wide range of rotations there including working on SCBU which was equally heart breaking and wonderful.

After 2.5 years there (with 6 months acting Senior 2 on acute medical) I moved to Hillingdon Hospital in Uxbridge for Senior 2 inpatient rotations in medical, orthopaedics and surgery. I spent 4.5 years there where I learnt many things, taught many students and developed an award winning breathlessness clinic for COPD patients who were deemed too severe for pulmonary rehabilitation. During my time there I acted up into the Band 7 cardiac rehabilitation rotation for 10 months covering maternity leave.

From here, I was lucky enough to get a job at The Royal London as a Band 7 heading the medical respiratory team. Here I became the physiotherapist on the Tracheostomy Team. I learned to remove and change tracheostomy tubes as well as lead weaning of tracheostomy patients throughout the hospital along with teaching other physiotherapists how to decannulate patients. I worked here for just over 2 years when I had a small injury to my hand which made me realise the stress of the NHS was no longer for me. I handed in my notice and applied for the RVC course which I was lucky enough secure a place on.

I worked for Maidenhead RFU as the Physiotherapist for their second team while I completed my PG Dip at the RVC. I qualified in March 2012 and was lucky enough to begin by working at Davies Veterinary Specialists, covering the maternity leave of Di Messum in the May. I was asked to stay on after her return and together we have provided a full time physiotherapy service for the last 3 years.

On the days I do not work at Davies, I am lucky enough to have a thriving private practice providing domiciliary visits within my local area and West London.

Why did you want to take on ACPAT chair?

I am a firm believer in you cannot complain if you do not try and solve the problem; that was one of the main reasons I joined the committee in the first place. When the chair position became available, I initially didn’t want it as I didn’t think I would have the time to give to the position that it needed and deserved, but my personal situation changed slightly and I was able to reconsider. I would like our organisation to continue to flourish as it has done in previous years under other Chairs and I will try my best to do this.

What are your aims for the group ACPAT going forwards? Where do you see ACPAT in the next 5 years?

I am closely involved in some work with Sonya Nightingale in the regulation of all animal physiotherapists in the future and would like to see this continue to progress. Ultimately, the whole reason I think we are all working with animals is to improve their welfare and I would like to see this at the heart of any changes to the veterinary paraprofessional area as a whole. I would like ACPAT to be

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at the forefront of any changes as I believe we are one of the most appropriate groups to be helping to guide this. We are familiar with professional regulation from our human careers and are perhaps more aware of potential pitfalls when setting up something so overarching because of this.

Besides this, I would like to see higher level courses being provided, a better, more user friendly website and better education to the veterinary surgeons we work with as to what we as animal physiotherapists can do to help their clients.

In 5 years’ time, I would like to see ACPAT working much more alongside and in conjunction with the veterinary associations, particularly BSAVA and BEVA, and for physiotherapy to be recognised as an essential part to recovery and maintenance of certain conditions, just as it is in the human field.

I would also like to see an ACPAT and CSP recognised BSc course in animal physiotherapy in the future of ACPAT. It is perhaps controversial but I think we need to look to see if there is a way to offer this as well as our current routes so we can realistically hope to compete with the other animal physiotherapy qualifications currently available.

Do you have any personal goals/achievements you would like to achieve for ACPAT? To achieve protection of title for us as Veterinary Physiotherapists and to establish us as the gold standard within the profession. I feel that by the benefit of us learning our skills on human patients initially, whom can give us verbal feedback as well, we are best placed to deliver the best possible care to non-verbal animals of all kinds. My greatest wish for ACPAT would be for our

members to be autonomous as we are when treating humans.

What are your strengths and weaknesses that you bring to ACPAT? Now I feel like I’m at a job interview! Strengths I think I have: I like to consider all the options I can see before deciding on an outcome, but then I am quite definite about what is needed and my decision; I am open to hearing different points of view and will change my opinion if the evidence is clear that I am wrong; I’m also not afraid to ask for help if I don’t feel I’m an expert in the subject and someone else is and I’m more than happy to delegate a task if it will be done better that way!

Weaknesses are mainly procrastination and time management! It’s not that I’m awful at either of these but I do tend to put off things until I absolutely have to do them. Having said that, I am improving, since becoming Chair I’ve learnt the benefit of free wifi at Starbucks and my favourite coffee is great motivation to get work done!

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Light Therapy in Veterinary & Animal Therapy Practice Marietjie Venter National Diploma in Physiotherapy (University of Pretoria, ZA 1982), BA Social Sciences UNISA 1990 Marietjie Venter Physiotherapists, Mayville, Pretoria, South Africa Many veterinary clinicians around the world are having great success using light therapy on small animals, wildlife, horses and livestock (see figure 1) following numerous positive studies on people however more are needed on animals.

Today, many vets and animal physiotherapists are turning to the healing benefits of light therapy to speed up healing (Mester, 1985), minimise scar tissue and proud flesh formation (Barolet, et al., 2010), reducing swelling and bruising (Fakuda, et al., 2012; Meneguzzo, et al., 2012; Xavier, et al., 2010) and to offer a non-invasive, safe and natural approach to pain control (Pozza, et al., 2008; Chow, et al., 2005; Ferreira, et al., 2004).

of the most popular of these will be the Light Emitting Diode (LED) light therapy based devices. As with all new things, this has caused much uncertainty and confusion amidst clinicians. Marketing from manufacturing companies also compounds the issue.

Both Laser and LED based devices will be beneficial towards the clinical effects in the treatment of living tissue (animals and humans) (Abreu Chaves, et al., 2014). Research has mostly been done with laser-based devices (TunĂŠr and Hode, 2010), as it has been available for many years before the introduction of LED light therapy.

Light (either Laser or LED based) wavelengths between 600nm and 100nm is absorbed by receptors in cells; this energy is transformed by the cell to a bio stimulus (will be discussed later in the article). Direct radiation of cells in these ranges of wavelengths will have some primary and secondary effects that will have beneficial clinical outcomes (Karu, 1999).

There are however some differences in the way the light is delivered:

Figure 1. A simple treatment with a modern LED device

Therapeutic light therapy devices currently available in the clinical field Most clinicians and Vets will be familiar with devices termed low level laser therapy or laserbased light therapy as it has been available for many years, where laser translates to Light Amplification by Stimulated Emission of Radiation.

Advantages in technology have brought new types of light therapy devices to the market as light therapy treatment options. One

1. Laser based devices have a collimated or coherent beam and LED based devices have an un-collimated divergent or noncoherent beam.

2. Coherency causes speckle formation in tissues, and according to the popular belief, when all treatment parameters are equal, this forms the reason that laser based devices are thought to top the therapeutic outcome Each type of light therapy device has itâ&#x20AC;&#x2122;s own benefits:

1. Laser based devices will be more suitable for acupuncture point treatment (pin point beam); whereas LED based with its divergent beam has a wider cover area to treat bigger problem areas.

2. LED based device diodes have a longer life span (20 000-50 000 hours) without the loss of output power, whereas Laser based devices have up to 2000 to 3000 hours, with loss of output power over time (always buy a lased based device with an output meter).

3. Laser based device diodes are heat sensitive (although advances in technology has reduced this), whereas LED are less sensitive towards overheating, thus output power may be pushed higher. LED diodes are also cheaper to manufacture, thus prices of LED based devices are lower than those of Laser based devices.

4. Protective eyewear is needed with Laser based treatments because of the collimated beam. Laser based devices are categorized in risk of eye damage, for example class 3B or 4A (output power ratings). The divergent LED beam post no eye damage risks.

Advantages/Disadvantages of Light Therapy Devices LED or Laser Clinicians and Vets will be familiar with devices termed low level laser therapy or laser-based light therapy.

Lasers, however, have some inherent characteristics that make their use in a clinical setting problematic, mainly limitations in beam width, heat generation, high cost, and fragility (Eells, et al., 2003).

The size of wounds and areas that

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can be treated is limited because of time constraints. Heat production from the laser light itself can damage tissue, and the pinpoint beam of laser light will damage the eye if used inappropriately therefore protective eyewear must be worn by the patient and therapist.

The modern LED based light therapy devices offer an effective alternative to lasers. These diodes can be configured to produce suitable wavelengths that produce a more diffuse light so that larger areas can be treated at a time. The diodes are very robust, lightweight, and produce virtually no heat.

Understanding Coherent and Incoherent Light – Laser vs LED There are two forms of light used in therapy – coherent (pinpoint) and incoherent (spread out). Most visible light on Earth and in the universe is incoherent. This means that photons (light particles) randomly spread out as soon as they are emitted from a light source.

Incoherent sources include the sun and light from incandescent fluorescent and LED sources.

Lasers are the only manufactured form of light therapy that does not spread out, but stays tightly collimated (coherent).

An LED is a silicon microchip with various added substances each of which releases a different wavelength (colour) of light when electrically stimulated. LEDs were previously used mainly as lowpower indicator lights for electronic devices however, with great improvements in LED technology, device manufacturers are now developing LED devices with higher intensities and a greater range of available colours and designs.

Literature and studies seem clear that the therapeutic effects to monochromatic (a single colour)

light relate more to wavelength than the source of light. In other words, the source does not have to be a laser in order to produce a therapeutic effect, but rather appropriate doses of light in the range of 600-1000nm, which contemporary reports continue to show (Sommer, et al., 2001).

Terms and Parameters in Light Therapy (Tunér and Hode, 2010) Optimum or effective dose This refers to a practical, effective dose of light therapy where a desired response will take place, taking into account many variables, such as (but not only) light parameters, patient parameters and environmental parameters.

Light Parameters Treatment dose This is the most important parameter in light therapy and is the same as energy density. Dosage refers to the amount of energy per area applied to the tissue surface or cell culture surface, typically measured as J/cm². Most often clinicians will ask: How long do I have to treat?

Light therapy devices have a set output power and wavelength.

Selected devices have variable pulsed frequencies that are to be set to different treatment objectives.

In most instances clinicians need to know how long they have to treat to administer a given dose. This equation is most often used: t(sec) = D(J/cm²) X A(cm²)/ Output power(W) Where, t = Time (seconds) D = Dose, measured in Joules (J) per cm²

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A = Area to be treated, measured in cm² Average output power – The amount of energy emitted from the light source measured in Watts or Milliwatts. Higher output power does influence penetration depth, and well as treatment time.

Power density – is the same as the ‘intensity’ of the light and is measured in Watts or Milliwatts per cm².

Energy density – is the same as ‘Dose’. The difference between power density and energy density is simply the time.

Pulsed Light (Frequency) and Continuous Light Emission A light source usually emits light at a constant intensity. This is known as continuous wave emission. It is however possible to make light therapy devices with varying intensity. Usually the light source is pulsed electronically or mechanically and has a duty cycle of 50%. Many studies have shown that there are different effects when pulsing light is used, as opposed to continuously emitting light (Al-Watban and Zhang, 2004; Korolev and Zagorskaia, 1996). Pulsed emission affects the output power and thus the average output power and this must be taken into consideration when calculating treatment time or dose. When all or part of a light therapy dose is in the form of pulsed light emission, it results in longer treatment time compared to continuous emission in order to administer the desired dose.

Patient And Treatment Parameters Patient parameters also refer to the many variations in tissue and individual responses to light therapy treatment, see Table 1.

Treatment Area

Surface area to be treated as well as depth below skin surface

Treatment Intervals

General guideline: Acute conditions need shorter treatment intervals than chronic conditions. Best results occur if treated as quickly as possible after injury/trauma or start of condition Light therapy has little effect on healthy tissue but due to activation of a variety of processes, e.g. production of singlet oxygen species, tissues may be in a more favourable state if trauma occurs immediately after treating Local – irradiate affected area Systemic (Indirect) – acupuncture points, trigger points, spinal processes and dermatomes, blood and lymph nodes Light therapy can be used alongside: Medication (antibiotics, NSAID’s) Heat Ultrasound Topical wound treatments

Pre- or Post-Operative

Treatment Method Combination Treatments

Table 1 – Patient and Treatment Parameters (Tunér and Hode, 2010)

OTHER FACTORS Divergence As LED based light is divergent, power density will be negatively affected the greater the distance the probe is held from the surface of the skin or affected area.

Depth of Penetration Penetration of light into tissue is no easy or exact answer! It mostly depends on the wavelength used (longer wavelengths penetrate deeper), output power, type of tissues treated, treatment technique used, and others. Direct irradiation of cells will be in between 0.5cm to proximally 5cm or deeper. A good example is to shine a visible (600-680nm beam) through your hand. The biological effect however will be much wider and deeper, with even systemic effects with low dosages. This will be caused by the absorption of photon or light energy by the blood and surrounding light reflection and scattering (Hode, 2005), see figure 2.

The depth of penetration of photonic emissions depends on wavelength (longer wavelengths have a slightly deeper penetration, output power and treatment technique (Stolik, et al., 2000; Hudson, et al., 2013). There are also other factors that can influence depth of penetration:

Figure. 2 - Penetration of Light into living tissue (Hode, 2005)

a. Different tissues absorb light to different degrees, e.g. adipose tissue is more transparent than muscle tissue. b. Highly vascularized tissue (such as muscles) absorb more light than less vascularized tissue (such as tendons/types of connective tissues). c. Dirty skin and dark, pigmented skin reduces penetration. d. Light penetrates bone and different types of bone absorb light to different degrees. It is not the hardness that is important, but the absorption coefficient.

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e. Reflection can be differentiated into surface reflection and backscatter reflection. When treating in direct contact with the skin, reflection can be reduced by 80%. f. Tissue compression involves the light pressure of the emitting probe on the skin, to mechanically remove the blood, as blood is responsible for most of the absorption of light, this ensures deeper penetration.

Photons are absorbed as they penetrate tissue, so less photon energy is available to be absorbed the deeper the tissue. The depth of

the target area must be taken into account. The greatest active depth refers to where the intensity is so low that no biological light effect can be registered. This is the case for the direct effect on cells and not the systemic effects that light therapy has.

Tissue and Cell Condition

wavelength, such as laser versus LED devices.

angiogenesis capillaries).

Numerous studies have shown there is a ‘Therapeutic Window’ of dosing e.g. 0.1 J/ cm2 to 10J/cm2 (see figure 3), with proven bio-stimulatory effects in tissues (Tunér and Hode, 2010).

The treatment dose is the most important parameter in successful

Wound and tissue healing has three phases: first, a substrate is laid down, second, cells proliferate, and third, there is remodelling of tissue.

Studies published so far suggest that light bio stimulation produces it’s primary effect during the cell proliferation phase of the healing

(formation

of

new

The more deteriorated or compromised the condition of cells, tissue and organs, the greater the bio stimulatory effect from the energy delivered from light therapy.

This has been shown in clinical and experimental experience where the redox status of the cell is shifted to a reduced state.

In Vitro and In Vivo Studies Many peer-reviewed light therapy studies have been done in vitro.

Dosages in these cases must be taken with caution, as dosages used in these studies are difficult to implement into a clinical setting. In a clinical setting, there is no single cell effect. Every cell in the body is part of a system and influenced by a very complex cascade of processes at each particular moment.

Therapeutic Window of Dosing The application of light therapy in veterinary care in the world is relatively new, but is now increasing steadily as more veterinary clinicians from a number of countries are learning about the advantages of it’s use and efficacy with the correct dosage when treating patients.

Guidelines and recommended dosages have been set for low level laser therapy (LLLT) treatment

by WALT (World Association of Laser Therapy) which will help guide practitioners to work out an effective dose if they are using devices that require the user to set up the treatment parameters. It is acceptable to extrapolate from these LLLT studies, as studies have now shown that the wavelength is the factor that causes the biological response in a cell (Karu, 2002) and not the way of delivering that

Figure. 3 -Therapeutic Window of Dosing in Light Therapy (Tunér and Hode, 2010)

treatment of pathological conditions.

So how does Light Therapy work?

Light therapy (laser and LED based) stimulates the basic energy processes in the mitochondria (energy compartments) of each cell (see figure 4), particularly when near-infrared light is used to activate the wavelength sensitive constituents inside (chromophores) (Wong-Riley, et al., 2003).

Optimal light wavelengths (proven in studies of laser and LED light) to speed wound healing rate lie in the range between 600 nanometers and 1000 nanometers (Sommer, et al., 2001). LED-based devices can now produce these wavelengths accurately.

Light therapy provides lowenergy stimulation of tissues by lasers or LED-based light therapy devices, which results in increased cellular activity during wound and tissue healing.

These activities include collagen production and

41

process (Whelan, et al., 2003; Karu, 1999; Karu, 1989).

Processes such as fibroblast proliferation, attachment and synthesis of collagen and procollagen, growth factor production (including keratinocyte growth factor [KGF]), transforming growth factor [TGF], and platelet-derived growth factor [PDGF]), macrophage stimulation, lymphocyte stimulation, and greater rate of extracellular matrix production have been reported with light treatment (Pozza, et al., 2008; Sommer, et al., 2001; Whelan, et al., 2001; Whelan, et al., 2000) Light therapy can also be regarded as a complementary/ extra treatment modality that will greatly enhance the effectiveness of conventional treatment used in practice.

Light therapy complements traditional treatment in both acute and chronic conditions with the following effects (see table 2).

Effect

Relevant Reference

Stimulation/regulation of DNA and RNA production

Karu, 1999; Karu, 1989;Whelan, et al., 2003

Stimulation/regulation of the immune system

Novoselova, et al., 2006; Safavi, et al., 2007

Analgesic effect (acute and chronic)

Pozza, et al., 2008; Chow, et al., 2005; Ferreira, et al., 2004

Anti-inflammatory effect

Fukuda, et al., 2012; Meneguzzo, et al., 2012; Xavier, et al., 2010

Reduced scar/proud flesh formation

Barolet et al, 2010

Cell repair if treated within 4-6 hours of injury

Wong-Riley, et al., 2004; Eells, et al., 2003

Regeneration of skin, nerve, muscle, and bone cells, etc.

Reduced muscle spasms and trigger point release

Ekizer, et al., 2012; Ferraresi, et al., 2012; Bayat, et al., 2009; Rochkind, 2007; Rochkind, et al., 2007 Chen, et al., 1996

Increased blood supply

Ihsan, 2005; Maegawa, et al., 2000

Increased lymph vessel diameter

Lievens, 1988

Table 2 - Effects of light therapy for acute & chronic conditions

The following illustrations demonstrate the use of a Photizo LED Light Therapy device (Wavelengths 625nm and 850nm)

being the primary underlying cause of the pain and subsequent licking of the affected area (see figure 7).

Case One - Chronic wound on lateral metatarsal area

Note the drastic change in appearance of the wound after one light therapy treatment before medication started and without wound dressings. A collar was not required as the patient stopped licking the wound. The patient was sent home with anti-inflammatory medication.

Patient: 6 year old male GSD presented with a chronic open wound on the medial metatarsal area (see figure 4). The owner was unsure of the cause and had been treating the wound for the 10 days with topical ointments. According to the owner, the wound was not healing at all and the dog was starting to lick the affected area.

phototherapy session. had been given

No medication

Outcome:

Figure. 6 - 3 days and 3 phototherapy sessions later

Treatment: Phototherapy was applied for 5 minutes (dose 2J/cm2 for acute wounds) held over wound area, once per day for 7 days. Improvement could be seen 12 hours after initial light therapy treatment (see figure 5).

Medication commenced (concurrent Cephalexin antibiotics and antiinflammatories) 2 days after light therapy treatment had started (see figure 6). X-rays revealed an underlying instability, with ankylosis of the joint starting to form, as

Figure. 4 - Presenting wound

Figure. 7 - X-ray of affected area showing underlying instability and ankylosis formation Figure. 5 - 12 hours after the first

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(Case study by Mayville Animal Clinic, Pretoria)

Case One - Chronic wound on lateral metatarsal area Patient: A miniature horse presented with a large, deep wound extending onto the bone (see figure 8).

Treatment:

References

Phototherapy was administered once per day (dose 2joules/cm2 for acute wounds) and bandaged. No medication was used.

Abergel, R.P., Lyons, R.F., Castel, J.C., 1987.

Biostimulation of wound healing by lasers: experimental approaches in animal models and in fibroblast cultures. The Journal of Dermatologic Surgery and Oncology, 13, pp.127–133.

Outcome:

Abreu Chaves, M.E. de. Araújo, A.R. de. Piancastelli, A.C.C., Pinotti, M., 2014. Effects of low-power light therapy on wound healing: LASER x LED. Anais Brasileiros de Dermatologia, 89(4), pp.616-623.

The wound healed without any proud flesh formation.

Good granulation tissue and epithelial tissue progressed (see figure 9) leaving almost no scar tissue behind.

The horse recovered sooner than expected (within 2 weeks) with no complications (see figure 10).

Akai, M., Usuba, M., Maeshima,T., Shirasaki,Y.,Yasuoka, S., 1997. Laser’s effect on bone and cartilage change induced by joint immobilization: An experiment with animal model. Lasers in Surgery and Medicine, 21, pp.480-484.

Al-Watban, F.A., Zhang, X.Y., 2004.The comparison of effects between pulsed and CW lasers on wound healing. Journal of Clinical Laser Medicine and Surgery, Feb 22, (1), pp.15-8.

Al-Watban, F.A., 1997. Laser acceleration of open skin wound closure in rats and its dosimetric dependence. Lasers in Life Science, 7, pp.237–247.

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Barolet D, Boucher A., 2010. Prophylactic low-level light therapy for the treatment of hypertrophic scars and keloids: a case series. Lasers in Surgery and Medicine,Aug 42, (6), pp.597-601.

Bayat, M., Abdi, S., Javadieh, F., Mohsenifar, Z., Rashid, M.R., 2009.The effects of low-level laser therapy on bone in diabetic and nondiabetic rats.Photomedicine and Laser Surgery, 27(4), pp.641-646.

Figure. 8 - Presenting wound

Figure. 10 - After less than 2 weeks of daily phototherapy, wound almost healed with minimal scar tissue

(Case study by Mayville Animal Clinic, Pretoria) Summary

Figure. 9 - Wound healing with good granulation tissue

LED Light therapy devices offer a great complementary, effective treatment option.

Scientifically proven, non-invasive, safe and practical, light therapy is a very effective treatment option for a wide array of pathologies. The availability of devices with pre-programmed evidence-based dose settings and affordability enables the benefits of this great treatment modality to be in the hands of every veterinary clinician or animal therapist.

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Bibikova, A., and Oron, U., 1995. Regeneration in denervated toad [Bufo viridis] gastrocnemius muscle and the promotion of the process by low energy laser irradiation. The Anatomical Record, 241, pp.123–128.

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Chow, R.T., David, M.A., Armati, P.J., 2005. 830 nm laser irradiation induces varicosity formation, reduces mitochondrial membrane potential and blocks fast axonal flow in small and medium diameter rat dorsal root ganglion neurons: implications for the analgesic effects of 830 nm laser. Photomedicine and Laser Surgery, 23(1), 60-5.

Eells, J.T., Henry, M.M., Summerfelt, P., WongRiley, M. T. T., Buchmann, E. V., Kane, M., Whelan, N. T., and Whelan, H. T., 2003. Therapeutic photobiomodulation for methanol-induced retinal toxicity. Proceedings of the National Academy of Sciences of the United States of America, 100(6), pp.3439–3444

Ekizer, A., Uysal, T., Güray, E.,Yüksel,Y., 2013. Lightemitting diode photobiomodulation: effect on bone formation in orthopedically expanded suture in rats-early bone changes. Lasers in Medical Science, Sep 28(5), 1263-70.

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Ferraresi, C., Hamblin, M.R., Parizotto, N.A, 2012 Low-level laser (light) therapy (LLLT) on muscle tissue: performance, fatigue and repair benefited by the power of light. Photonics and Lasers in Medicine, Nov 1, 1(4), pp.267-286.

Fernandes, K.P.,Alves,A.N., Nunes, F.D., Souza, N.H., Silva, J.A. Jr., Bussadori, S.K., Ferrari, R.A., 2013. Effect of photobiomodulation on expression of IL-1ß in skeletal muscle following acute injury. Lasers in Medical Science, May, 28(3), pp.1043-6.

Ferreira, D.M., Zângaro, RA, Villaverde A.B., Cury, Y., Frigo, L., Piccolo, G., Longo, I., Barbosa, D.G., 2004. Analgesic effect of He-Ne (632.8 nm) lowlevel laser therapy on acute inflammatory pain.

Photomedicine and Laser Surgery, 22(4), pp.306-11.

Fukuda, T.Y., Tanji, M.M., Silva, S.R., Sato, M.N., Plapler, H. 2013. Infrared low-level diode laser on inflammatory process modulation in mice: proand anti-inflammatory cytokines. Lasers in Medical Science, Sep 28(5), pp.1305-1.

Hode, L., 2005.The importance of the Coherency.

Photomedicine and Laser Surgery, 23(4), pp.431434.

Hudson, D.E., Hudson, D.O., Wininger, J.M., Richardson, B.D. 2013. Penetration of laser light at 8008 and 980nm in bovine tissue samples.

Photomedicine and Laser Surgery, (4), pp.163-8.

Ihsan, F.R., 2005. Low-level laser therapy accelerates collateral circulation and enhances microcirculation.

Photomedicine and Laser Surgery, June, 23(3), pp.289-294.

Prevention and treatment of mice paw edema by near-infrared low-level laser therapy on lymph nodes. Lasers in Medical Science, 27(3), pp.585-591.

Effect of NASA light- emitting diode irradiation on wound healing. J. Clin. Laser Med. Surg, 19, pp.305– 314.

Mester, E., Mester, A.F., Mester, A., 1985. The biomedical effects of laser application. Lasers in Surgery and Medicine, 5, pp.31-39.

Whelan, H.T., Houle, J.M., Whelan, N.T., 2000. The NASA light-emitting diode medical program— progress in space flight and terrestrial applications.

Space Tech.Appl. Int. Forum, 504, pp.3–15.

Novoselova, E.G., Glushkova, O.V., Cherenkov, D.A., Chudnovsky,V.M., Fesenko, E.E., 2006. Effects of lowpower laser radiation on mice immunity. Biofizika, 51(3), pp.509-518.

Pozza, D.H., Fregapani, P.W.,Weber, J.B., de Oliveira, M.G., de Oliveira, M.A., Ribeiro Neto, N., de Macedo Sobrinho, J.B., 2008. Analgesic action of laser therapy (LLLT) in an animal model. Medicina Oral, Patologia, Oral y Cirugia Bucal , Oct 1, 13(10), pp. E648-52.

Rochkind, S., 2007. Phototherapy in peripheral nerve regeneration: From basic science to clinical study. Photomedicine and Laser Surgery, 25(5), pp.436-442.

Rochkind,S.,Drory,V.,Alon,M.,Nissan,M.,Ouaknine, G.E., 2007. Laser phototherapy (780 nm), a new modality in treatment of long-term incomplete peripheral nerve injury: a randomized double-blind placebo-controlled study. Photomedicine and Laser Surgery, 25(3), pp. 137-143.

Sommer, A.P., Pinheiro, A.L.B., Mester, A.R., Franke, R.P., and Whelan, H.T., 2001. Biostimulatory windows in low-intensity laser activation: lasers, scanners and NASA’s light-emitting diode array system. Journal of Clinical Laser Medicine and Surgery, 19, pp.29–34.

Safavi, S.M., Kazemi, B., Esmaeili, M., Fallah, A., Modarresi,A., Mir, M., 2007. Effects of low-level HeNe laser irradiation on the gene expression of IL1beta,TNF-alpha, IFN-gamma,TGF-beta, bFGF, and PDGF in rat’s gingiva. Lasers in Medical Science, Jul, 23(3), pp.331-5.

Karu,T.,1989.Laser biostimulation:a photobiological phenomenon. Journal of Photochemistry and Photobiology. B.Biology..Aug 3(4), pp.638-40.

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Karu, T.I., 2002. Low power laser therapy. In: CRC Biomedical Photonics Handbook Korolev, I.uN, Zagorskaia, N.Z., 1996.The effect of infrared laser radiation of different frequencies on the healing of skin wounds. Voprosy Kurortologii Fizioterapii i Lechebnoi Fizicheskoi Kultury, MayJun, (3), pp.8-10.

Lievens, P. 1988. Effects of Laser treatments on Laser treatments on the Lymphatic system and Wound Healing. Laser Journal Uer. Medical Laser Assessment, 1 (2), pp.12-15.

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Whelan, H.T., Buchmann, E.V., Dhokalia, A., Kane, M.P., Whelan, N.T., Wong-Riley, M.T.T., Eells, J.T., Gould, L.J., Hammamieh, R., Das, R., and Jett, M., 2003. Effect of NASA Light-Emitting Diode irradiation on molecular changes for wound healing in diabetic mice. Journal of Clinical Laser Medicine and Surgery, 32, pp.67-74.

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Whelan, H.T., Smits, R.L., Buchmann, E.V., 2001.

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Wong-Riley, Margaret T.T., H. L. L., Eells, J.T., Chance, B., Henry, M.M., Buchmann, M., Kane, E., WhelanH.T., 2004. Photobiomodulation Directly Benefits Primary Neurons Functionally Inactivated

by Toxins. Role of Cytochrome c Oxidase. The Journal of Biological Chemistry, 280 (6), pp.4761– 4771.

Xavier M, David DR, de Souza RA, Arrieiro AN, Miranda H, Santana ET, Silva JA Jr, Salgado MA, Aimbire F, Albertini R., 2010. Anti-inflammatory effects of low-level light emitting diode therapy on Achilles tendinitis in rats. Lasers in Surgery and Medicine, 42(6), pp.577-583.

Evidenced-based

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The successful use of Veterinary Physiotherapy in the management and rehabilitation of surgically corrected over-riding dorsal spinous processes. A case report Faith Fisher-Atack HCPC CSP ACPSM ACPAT CAT Email: equinephysioservices@hotmail.co.uk Website: www.equinephysioservices.co.uk Tel: 07729 945746 Summary A 17-year-old thoroughbred mare presented for resection of overriding dorsal spinous processes (ODSP’s) diagnosed on radiographic examination. Surgery involved the complete removal of the spinous processes of three vertebrae.

Referral to veterinary physiotherapy was made at two weeks postsurgery. After a full physiotherapy assessment, a problem list was drawn up. The list was then used

to influence the use of a 16-week rehabilitation program that included the use of electrotherapy, manual soft tissue therapy and progressive exercise. This program is presented as an example of how progressive exercise rehabilitation can be applied in the management of postoperative surgically corrected overriding dorsal spinous processes.

Keywords: veterinary physiotherapy, over-riding dorsal spinous processes (ORDSP’s), kissing spines, exercise

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rehabilitation, neuromuscular electrical stimulation.

Introduction Overriding dorsal spinous processes, commonly referred to as ‘kissing spines’, are noted to be the most common anatomical abnormality reported in the horse with back pain (Henson and Kidd, 2009; Jeffcott, 1980; Walmsley, et al., 2002). Impinging or over riding dorsal spinous processes (ORDSP’s),

describes the loss of space between adjacent dorsal spinous processes (DSPs) within the equine spine.

There is currently much debate over the actual causes of pain, as the presence of ORDSPâ&#x20AC;&#x2122;s have being found in many athletic horses with little or no clinical signs of back pain on post mortem examination (Townsend, et al., 1986; Haussler, et al., 1999). Risk factors include sustained dorsal flexion, breed and lack of core stability (Henson, 2009). In the thoroughbred, the incidence of ORDSPâ&#x20AC;&#x2122;s is common (Zimmerman, et al., 2012). Reasons for this may be attributable in part or combined with; premature training loads associated with racing, the shape of the summits of the dorsal processes (Henson, 2009), or the use of half tree saddles used commonly in the racing industry (Head, 2009).

Current management In many diagnosed cases, surgical removal of the impinging dorsal spinous processes is performed, leading to the need for appropriate post-operative management strategies. In a study evaluating the management of the condition, surgical intervention in 215 horses was presented. Ridden work commenced at 3-6 months postsurgery in all successful cases (Walmsley, et al., 2002). At present there is limited evidence and lack of guidance in the management of post-operative kissing spine surgery.

As physiotherapists in human practice, many routine operations are supplemented by postoperative protocols that guide appropriate rehabilitation based on the presentation of the patient. Currently, these are generally lacking in the veterinary physiotherapy profession.

Case History We present a case history of one thoroughbred mare referred

to a Chartered Veterinary Physiotherapist following surgical removal of identified ORDSPâ&#x20AC;&#x2122;s.

On presentation at the referral hospital, radiographic examination revealed one impinging DSP between thoracic vertebrae (T)14 and T15, with T13 and T14, and T15 and T16 being closely opposing and over-riding. Based on radiographic examination it was proposed that the dorsal processes of T13 and T15 were to be removed under standing sedation and local anaesthesia.

During surgery it became apparent that the T14 dorsal spinous process was not going to withstand being the remaining process in this region of the thoracic spine and so this was removed in its entirety creating a space between T12 and T16.

mobilisations of the cervical spine increase cross sectional area of spinal stabilisers when using a specified number of sets and repetitions over a period of three months (Stubbs, et al., 2011).

Post-operative advice regarding the rehabilitation and aftercare consisted of initial box rest and in-hand walking for 15 minutes daily for the initial 4 weeks. The owner was requested to turn the mare out in a small paddock for a further 4 weeks after this period (40 by 40 square feet).

At 8 weeks, complete turn out in her normal paddock could be introduced, at which point lunging exercise could to begin, assuming there was adequate healing of the incision sight. Recommendations were made to use a pessoa when lunging to encourage spinal stability.

This was described to aid in rehabilitation of the musculature of the thoracoloumbar spinal region (Walker, et al., 2013).

Physiotherapy assessment took place 5 weeks post surgery and a full subjective history noted the previous details. Subjective assessment consisted of static and dynamic visual observation of posture, muscle assymetry and gait, palpation, joint mobilisation, reflex assessment and specific pain provocation testing.

Ridden exercise was advised to commence 12 weeks following surgery once a repeat assessment by the referring Veterinary Surgeon had taken place. In addition, the owner was told to perform spinal stretches in to lateral flexion to the left and right for two weeks following suture removal to encourage flexibility in the back.

There was no further detail or advice offered regarding the number of sets and repetitions. Dynamic

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It was the intention of the Chartered Veterinary Physiotherapist to continue with the outlined plan set out by the Veterinary Surgeon.

However, by employing evidence based sets, repetitions, time frames, progressive exercises and goals the Physiotherapist aimed to enhance this plan and educate the owner in the anticipation of greater compliance.

Assessment Findings

Postural Observatio Postural observation showed the mare had adopted a sway backed posture and a lordotic lumbar spine.

There was moderate atrophy of the longissimus over the surgical site bilaterally between T12-16.

Observation of the gait at walk showed the hind limb stride length was reduced bilaterally and the mare showed no ability to over track.

Palpatio Palpation of soft tissue, using the physiotherapists hands, was performed both parallel and perpendicular to the orientation of the cervical, epaxial and superficial gluteal muscle fibres. Muscle spasm of the longissimus and bilateral superficial gluteals was identfied.

Palpation of the thorocolumbar fascia identified localised myofascial trigger points, bilaterally, at the level of the thorocolumbar junction.

Guarded muscle spasm of right and left omotransversarius and splenius muscles were identifed when palpating the cervical spine.

Joint Mobilisatio Mobilisation of the cervical vertebrae was performed using Maitland oscilations to the vertebral bodies in a transverse direction.

Stiffness between the C3/4 and C5/6 facet joints was identified.

Costovertebral joints were assessed using grade I-II Maitland oscillations performed in a dorsal direction and identified resistance at ribs 13-16 bilaterally.

Pain Provocatio The behaviour and reactions of the mare towards assessment procedures were consistantly monitored for pain reaction and adherance to certain pressure.

Pressure over the tuber sacrale and tuber coxae was further performed to test for pain reaction (Hesse, et al., 2010) Problem List • •

•

•

Epaxial muscle atrophy between T12-T16 Bilateral muscle spasm of omotransversarius, longissimus, thorocolumbar fascia and superficial gluteals Facet joint stiffness C3/4 and C5/6 and costovertebral stiffness at ribs 13-16 Lordotic/ sway back posture

A list of goals were set based on the problem list and to influence the treatment plan

longissimus, thorocolumbar fascia and superficial gluteals Increase cervical facet joint mobility at C3/4 and C5/6 Increase costovertebral joint mobility at ribs 13-16 Strengthen abdominal musculature/ facilitate abdominal control

et al., 2009). Joint mobilisation using Maitland oscillations at progressive grades were used at the cervical spine from the beginning of the rehabilitation program.

Costovertebral joints mobilisations took place at week 7 at grade I, increasing the grade of mobilisation over the following weeks.

Table 1 (over) demonstrates the treatments that were carried out based on the problems list and goals.

Discussion

A combination of acupressure and reflex inhibition therapy was applied to the longissimus dorsi (Wakeling, et al., 2006), superficial gluteals and omotransversarius at the start of rehabilitation.

• • •

Neuro-muscular Electrical stimulation (NMES) In human studies, the use of NMES results in increasing circulation and subsequent oxygen supply which can enhance the rate of healing of soft tissues to which it is applied (McDonough, et al., 2002).

Unfortunately, there is little evidence to evaluate it’s use in equine practice.

However, the application for this case study aimed to increase muscle development of the longissimus muscle at the surgical site and aid in facilitating neuromuscular control. The application was well tolerated by the mare. The frequency of application was twice weekly. This was due to the availability of both the owner and the Chartered Veterinary Physiotherapist.

Long reining Studies in to the effect of lunging on longissimus activity have shown that movement on a circle produces 2-3 times more activity of the muscle on the inside of the turn than on the outside (Cottrial, et al., 2008). The Chartered Veterinary Physiotherapist felt that asymmetrical muscle activity during the early phases of the rehabilitation program may encourage asymmetrical development of spinal stabilisers. During the proliferation of tissue healing, asymmetrical forces placed on healing tissue may risk further injury if repair is not adequate (Paulekas, et al., 2009).

Baited Cervical Stretches Dynamic cervical stretches of the neck have been proven to increase cross sectional area of spinal stabilising muscles when performed over 3 months. (Stubbs, et al., 2011). The Chartered Veterinary Physiotherapist advised to the owner on the number of sets, repetitions and direction of movement in accordance with current evidence (Stubbs, et al., 2011)

Figure. 1 - Long reigning in the arena

Manual Mobilisation • •

Restore muscle mass of longissimus between T12-T16 Restore resting muscle length of omotransversarius,

Excessive or repetitive forces can compromise tissue healing in the proliferation phase (Paulekas,

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Figure. 2 - Outdoor long reining on an incline/ altered terrain.

Weeks Post Surgery

Home Exercises

Physiotherapy Treatment Performed twice weekly

5-6

Long rein exercises 4 x 20 minutes walking in a roller with hock strap in controlled arena setting

Neuromuscular Electrical Stimulation (NMES) Use of the ‘NeuroTrac™ Neuromuscular Electro Stimulator’ machine was applied via 2 electrodes to the motor points of the longissimus muscles, trapezius muscles and superficial gluteal muscles. Motor points were identified using palpation carried out by the physiotherapist.

Treatment time: 20 minutes per side

Baited cervical stretches performed 5 times for each exercise and held for approximately 30 seconds • Left lateral Flexion at the level of the girth • Right lateral Flexion at the level of the girth • Left lateral Flexion at the level of the fetlock • Right lateral Flexion at the level of the fetlock • Bilateral cervical flexion chin to manubrium 7-8

Long reining • 20 minutes walking in a roller with hock strap over alternating surfaces outside of the previous arena setting.

• 3 x per week Baited cervical stretches (as previously described) Pessoa Lunging • Performed on a 20 meter circle, 5 min walk right/ 5 min walk left, 3 min trot right/ 3 left, 5 min walk right/ 5 min walk left • 2 x per week

9-12

Long Reining • Session 1 30 minutes ascending and descending hill/ alternating terrain.

• Session 2 30 minutes arena setting over straight line poles placed 1 metre apart.

Baited cervical stretches (as previously described) •

Pessoa Lunging Performed on a 20 meter circle, 5 min walk right/ 5 min walk left, 5 min trot right/ 5 left, 5 min walk right/ 5 min walk left

• C2, C3, C4, C5, C6 transverse glides, 3 x 10, Grade II Myofascial Trigger point release Sustained pressure for 20 seconds was placed with the therapists thumb over identified myofascial trigger points of the superficial gluteals, longissimus dorsi and omotransversarius bilaterally.

NMES Use of the ‘NeuroTrac™ Neuromuscular Electro Stimulator’ machine was applied via 2 electrodes to the motor points of the longissimus muscles, trapezius muscles and superficial gluteal muscles. Motor points were identified using palpation carried out by the physiotherapist.

Treatment time: 20 minutes per side Cervical Joint mobilisations • C2, C3, C4, C5, C6 transverse glides, 3 x 10, Grade II Myofascial Trigger point release Sustained pressure for 20 seconds was placed with the therapists thumb over identified myofascial trigger points of the superficial gluteals and longissimus dorsi bilaterally.

Costovertebral joint mobilisations Performed at ribs 13-16 performed in a dorsal direction at grade I, 3 x 10 oscillations.

NMES Electrodes placed over motor points located at longissimus, trapezius and superficial gluteal.

Cervical Joint mobilisations • C2, C3, C4, C5, C6 transverse glides, 3 x 10, Grade III Myofascial Trigger point release Sustained pressure for 20 seconds was placed with the therapists thumb over identified myofascial trigger points of the superficial gluteals and longissimus dorsi bilaterally.

Costovertebral joint mobilisations Performed at ribs 13-16 performed in a dorsal direction at grade II, 3 x 10 oscillations.

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12-14

• 2 x per week Owner included poles placed on the circle at ‘12’, ‘3’, ‘6’ and ‘9’ positions (as on a clock face).

Reflex Inhibition Applied unilaterally to palpable areas of increased tone and muscle spasm at the cervical spine.

Applied contralateral to areas of increased tone and muscle spasm at the thoracic and lumbar spine.

Locations of spasm were located via parallel and perpendicular palpation of the cervical, epaxial and gluteal musculature.

Long Reining Session 1 • 30 minutes ascending and descending hill/ alternating terrain.

Session 2 • 30 minutes arena setting over straight line poles placed 1.5 human strides apart.

Session 3 • 20 minutes arena setting over straight line poles placed 1 metre apart and raised approximately 30 centimetres on alternate sides.

NMES Cervical Joint mobilisations Myofascial Trigger point release Costovertebral joint mobilisations Reflex Inhibition (Treatments performed as previously described)

Baited cervical stretches (as previously described) Pessoa Lunging • Performed on a 20 meter circle, 5 min walk right/ 5 min walk left, 5 min trot right/ 5 left, 5 min walk right/ 5 min walk left • 2 x per week Owner included poles placed on the circle at ‘12’, ‘3’, ‘6’ and ‘9’ positions (as on a clock face).

14-16

•

Baited cervical stretches Performed 5 times for each exercise and held for approximately 30 seconds

Pessoa Lunging Session 1 • Performed on a 20 meter circle, 5 min walk right/ 5 min walk left, 5 min trot right/ 5 left, 5 min walk right/ 5 min walk left • 2 x per week Owner included poles placed on the circle at ‘12’, ‘3’, ‘6’ and ‘9’ positions (as on a clock face).

Session 2 • Performed on a 20 meter circle, 5 min walk right/ 5 min walk left, 5 min trot right/ 5 left, 5 min walk right/ 5 min walk left • 2 x per week Raised cavelletti poles placed at a height of approximately 20 centimetres were placed 1 metre apart. This

NMES Cervical Joint mobilisations Myofascial Trigger point release Costovertebral joint mobilisations Reflex Inhibition (Treatments performed as previously described).

49

sequence was performed at trot for approximately 10 repetitions on each rein.

Saddle Fitting The owner owned two saddles that were both assessed by a master saddle fitter. These were then re-flocked to fit according to the specific assessment.

This was then followed up after 12 weeks to reassess and identify changes in muscle size and symmetry.

Ridden work commenced and progressed over a further 4 weeks that included pole work and incline progressions.

Table 1 - Table demonstrating the treatments carried out on the patient based on the problem list and goals

Long reining was proposed as a method of facilitating postural control without causing continuous side flexion of the back and thus encouraging asymmetrical development. There is very limited evidence on the effect of long reining on the spinal stabilisers. However, by using this modality the owner was able to facilitate exercises that challenged proprioception, abdominal control and spinal stabilisation through the use of incline and decline walking (Robert, et al., 2001), ground pole placement and alternating surfaces (Paulekas, et al., 2009).

Initial training was performed in the enclosed environment of the arena (Figure 1), followed by progressive incline and decline work over hills, (Figure 2).

Subjective Measures Subjective measures included repeated palpation and observation of muscle symmetry, spinal posture, stride length and joint mobility. This was carried out twice weekly during physiotherapy visits.

Objective Measures This study was limited with objective measurement.

The Chartered Veterinary Physiotherapist could have

utilised equipment to measure stride length, spinal position and muscle resistance but this was unavailable at the time of treatment. Unfortunately, due to limited access to objective assessment measures the Chartered Veterinary Physiotherapist cannot prove nor disprove alleviation of problems identified at the start of treatment. However, following completion of the program, the mare did return to her preoperative level of work. This consisted of three 40 minute hacks per week that included incline, decline and pole work.

Schooling now takes place three times a week in the arena lasting approximately 30 minutes and the mare has successfully competed in unaffiliated dressage.

After Care The owner continues to perform cervical baited stretches once a day for a total of five repetitions.

This consists of left and right lateral flexion towards the girth, left and right flexion to the level of the fetlock joints and flexion at the level of the carpus. Thoracic lifts are performed three times per week to maintain thoracic mobility in a ventral direction. This is achieved with pressure applied in a ventral direction to the sternum with the pads of the

50

fingertips until a lift of the thoracic spine is observed.

Physiotherapy reassessments take place every 12 weeks in which stride length, muscle tone, symmetry and joint mobility are assessed and treated accordingly.

Conclusion The effectiveness of specific training modalities on core recruitment and ultimately recovery are not easily objectively measured in the field setting. However, this outlined case study demonstrates how progressive exercise can be clinically reasoned and applied to a post-operative treatment plan in the management of postoperative, surgically corrected overriding dorsal spinous processes.

References Cottrial, S., Ritruechai, P., Wakeling, J., 2008. The effects of training aids on the longissimus dorsi muscle in the equine back. Comparative Exercise Physiology, 5(3-4), pp. 111-114.

Haussler, K., Stover, S. and Willits, N., 1999.

Pathologic changes in the lumbosacral vertebrae and pelvis in thoroughbred racehorses. American Journal of Veterinary Research, 60 (1), pp. 143-153 Head, M.J., 2009. Racehorses. In: Henson, F. Equine Back Pathology: Diagnosis and Treatment. Oxford: Wiley-Blackwell, pp. 213-223.

Henson, F. and Kidd, J., 2009. Overriding dorsal spinous processes. In: Henson, F. Equine Back Pathology: Diagnosis and Treatment, Oxford,WileyBlackwell, pp. 147-157.

Henson, F., 2009. Equine Back Pathology: Diagnosis and Treatment. Oxford,Wiley-Blackwell.

Hesse, K.,Verheyen, K., 2010.Associations between physiotherapy findings and subsequent diagnosis of pelvic or hindlimb fracture in racingThoroughbreds.

Equine Veterinary Journal, 42 (3), pp. 234-239.

Jeffcott, L., 1980. Disorders of the thorocolumbar spine of the horse - a survey of 443 cases. Equine Veterinary Journal, 12, pp. 197-210.

McDonough,S.and Kitchen,S.,2002.Electrotherapy: Evidence Based Practice: 11th Edition, London, Churchill-Livingston.

Paulekas, R., Houssler, K., 2009. Principles and

practice ofTherapeutic Exercise for Horses. Journal of Equine Veterinary Science, 29 (12), pp. 870-893.

longissimus dorsi in the equine back. Equine and Comparative Exercise Physiology, 3(3), pp. 153-160.

Robert, C. Valette, J. Denoix, J., 2001. The effect of treadmill inclination and speed on the activity of three trunk muscles in the trotting horse. Equine Veterinary Journal, 33 (5), pp. 466-472.

Walker, V., Dyson, S., Murray, R., 2013. Effect of Passoa training aid on temporal, linear and angular variables of the working trot. The Veterinary Journal, 198, pp. 404-411.

Stubbs, N., Kaiser, L., Hauptman, Clayton, H., 2011.

Dynamic mobilisation exercises increase cross sectional area of musculus multifidus. Equine Veterinary Journal, 43, (5), pp. 522-529.

Walmsley, J., Pettersson, H.,Winberg, F. and McEvoy, F., 2002. Impingement of the dorsal spinous processes in two hundred and fifteen horses: Case selection, surgical technique and results. Equine veterinary Journal, 34, pp. 23-28.

Townsend, H., Leach, D., Doige, C. and KirkaldyWillis, W., 1986. Relationship between spinal biomechanics and pathological changes in the equine thoracolumbar spine. Equine veterinary Journal, 18, pp. 107-112.

Wakeling, M., Barnett, K., Price, S., Nankervis, K., 2006. Effects of manipulative therapy on the

Zimmerman, M., Dyson, S. and Murray, R., 2012.

Close, impinging and overriding spinous processes in the thoracolumbar spine: The relationship between radiological and scintigraphic findings and clinical signs. Equine veterinary Journal. 44(2), pp.

178-184.

Equine Research Digest Biomechanical Responses of the Back of Riding Horses to Water Treadmill Mooij M.J.W., Jans W., den Heijer G.J.L., de Pater M. and Back W. The water treadmill is widely used as part of rehabilitation for equines, and provides a good mechanism of increasing joint range of movement, muscle strength and cardiovascular fitness. However, there is little research into its influence on the kinematics of the equine spinal column. The aim of the study was to establish the influence of water height on spinal kinematics, specifically looking at axial rotation, lateral flexion and pelvic flexion.

What they did Twelve riding horses with no previous treadmill experience were evaluated over a ten-day period.

Skin markers were attached to seven bony landmarks over the thoracolumbar spine, tuber sacrale, tuber coxae and tail base. Water level was taken at hoof height as a control then raised to the level of fetlock, carpus, elbow and shoulder, all at a speed of 0.8m/s.

What they found

Significant differences were found in the kinematic variables in all movements assessed. Relative to hoof depth, axial rotation increased at each level, demonstrating the greatest increase in movement with water at the level of the carpus (5.9cm ± 0.3cm). Lateral bending displayed the greatest increase in range of movement with water at hoof height (9.1cm ± 0.5cm) with a subsequent decrease in lateral movement. Pelvic flexion increased with water height and demonstrated the greatest degree of movement with water at shoulder height (17.7cm ± 0.6cm).

Take-home message The article reviews the influence of water height on spinal and pelvic movement, with water height at the elbow and carpus producing significant differences. The authors recognise that over a 10-day period there were no statistical differences between the range of movement recorded at the beginning and end of the trial. However, the author’s mechanism of recruitment does not state horses were clinically sound which could influence the validity of this study.

The Veterinary Journal 2013: (198) 120 – 123

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DOI: 10.1016/j.tvjl.2013.09.045 Daisy Collins BSc, ACPAT Cat B The interrelationship of lameness, saddle slip and back shape in the general sports horse population Greve L. and Dyson S.J. Anecdotally saddle slip is a common problem and is usually blamed on saddle fit, a crooked rider or the horses shape. Recently it has been demonstrated that it may reflect hind limb (HL) lameness with horses with a wider back shape at T13 in comparison to T8 and T18 in a referral population. This study aimed to quantify the frequency of saddle slip, lameness, thoracolumbar asymmetries, ill-fitting saddles and crooked riders in the general sports horse population.

What they did A non-random cross-sectional study of 506 sports horses in normal work was carried out.

Thoracolumbar shape and symmetry were measured at predetermined sites, the presence of lameness, rider crookedness and saddle slip was recorded from in hand trotting and ridden work at

trot and canter, in straight lines and 10 and 20m circles. Saddle fit was also assessed.

Equine Veterinary 2014; (46): 687-694

Journal

DOI: I0.IIII/evj. 12222 What they found The frequency of lameness (included in this was quadrilaterally reduced cranial phase of the stride or a stiff stilted canter) was 45.7%, the frequency of saddle slip was 12.3%, left to right thoracolumbar shape asymmetries 0.6% and rider crookedness 37.3%.

There was a strong positive association between saddle slip and HL lameness alone (P<0.001) and between saddle slip and HL lameness with coexistent forelimb (FL) lameness (P<0.001). The associations between saddle slip and non-lame horses (P<0.001) and between saddle slip and horses with FL lameness (P=0.05) were negative. 19 (30.6%) horses with saddle slip had no detectable HL lameness; however 14 of those 19 horses (73.7%) showed some form of HL gait abnormality, particularly in canter.

Multivariable analysis found saddle slip was significantly associated with HL lameness and gait abnormalities, saddles fitted with even contact and uniform flocking, riders sitting crookedly, a well-balanced saddle and large back shape ratio at T18.

Take-home message The results cannot prove any causal relationships but do increase the understanding of saddle slip and quantify the relative contribution of risk factors in a general sports horse population. Saddle slip may be associated with asymmetry of the horses back and rider crookedness but these associations are less common than HL lameness. As many horses with HL and or FL lameness go unrecognised and saddle slip may be a sign of this, detecting it may provide an opportunity for owners, trainers and veterinarians to detect subclinical lameness.

Kate Davy MCSP ACPAT Cat A The effects of three month oral supplementation with a nutraceutical and exercise on the locomotor pattern of aged horses Higler M.H., Brommer H., Lâ&#x20AC;&#x2122;Ami J.J., de Grauw J.C., Nielen,M., van Weeren P.R., Laverty S., Barneveld A. and Back W.

No significant difference was found between stride length in either group between the beginning and end of the trial. At the outset carpal flexion was not significantly different between the groups but the control group showed significant improvement in carpal flexion regardless of gait (P<0.05). Maximal fore fetlock extension increased over the time period in both groups, more so in trot than walk (P<0.05) Tarsal joint range of motion was not significantly different between treatment and control groups.

Take home message

Pain and inflammation due to osteoarthritis is often thought to be a cause of stiff joints in geriatric horses. Anti-inflammatory compounds with minimal toxicity could potentially improve joint motion and in vitro studies on joint cells suggest that glucosamine and chondroitin sulphate may possess anti-inflammatory effects. Little is known of their clinical effects in vivo as equine clinical studies assessing joint supplements are scarce and limited to field studies using subjective outcome measures.

The of this study was to assess the clinical effects of a mixed supplement on the improvement of a stiff gait in aged horses.

No significant response of the locomotor apparatus of geriatric horses to supplementation with GS/CS/MSM could be shown. There appeared to be a positive effect on locomotion during the time lapse between the two assessments which may be explained by habituation to the treadmill or could be due to an exercise effect. It is unclear why the control group alone showed this effect with carpal flexion. The study cannot support the use of GS/ CS/MSM as a means to decrease joint inflammation with a clinical locomotor effect but may indicate the usefulness of exercise regimes in older horses.

What they did

Equine Veterinary Journal 2014; (46): 611-617

24 geriatric horses took part in a randomised, blinded, placebo controlled study. The treatment group received 3 months oral supplement containing glucosamine (GS), chondroitin sulphate (CS), and methyl sulfonyl methane (MSM).

Objective measurement of limb locomotion was performed pre and post intervention. Kinematic gait analysis was used to measure stride length, carpal flexion, fore fetlock extension and tarsal range of motion on a treadmill at walk and trot.

What they found

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DOI: I0.IIII/evj. 12182 Kate Davy MCSP ACPAT Cat A

Canine Research Digest Rehabilitation and Physical Therapy for the Neurological Veterinary Patient Sims C, Waldron R, Marcellin-Little D.L. Neurological patients are often severely compromised and rehabilitation therapy includes nursing and supportive care

to protect the patient from complications and preserve tissue strength and function during the recovery period as well as exercises to promote and restore function.

The authors discuss the different mechanisms of spinal cord injury, initial assessment indicators / markers and all aspects of supportive care including hoisting, harness, walking aids and toileting.

The article discusses the use of some basic exercises for the initial post op/event phase of the damage for ambulatory and non ambulatory patients. The authors look at electrotherapy modalities that they consider useful during the early / mid stage of rehabilitation which include NMES, U/S, TENS, acupuncture and massage.

This article also discusses the importance of client education and support for the patient at home.

Take home message A canine patient that has undergone a neurological event will require advice from the physiotherapist of postural and supportive care as well as techniques / exercises and treatment to maximise functional outcome. It is important that the client has a good understanding of the exercises to be performed and as the physiotherapist we have the most contact with the client and therefore a responsibility to support the client in all aspects of care.

The Veterinary Clinics of North America. Small Animal Practice 2015 (45): 123-143 DOI: 10.1016/j.cvsm.2014.09.007 Stephanie Brighton MSc Vet Phys, ACPAT A Therapeutic Laser in Veterinary Medicine Pryor B. and Millis D.L. Laser therapy or photobiomodulation is a fast growing modality; being noninvasive and a drug free treatment option make it a popular choice.

Development of products and

protocols has resulted in more consistent clinical outcomes and research into the field continues to increase with studies now focusing on particular conditions and its use in the clinical setting.

The mechanism of action is still questioned and it is most likely several mechanisms occur depending on the type of cell being modulated but the most published and recognised is that of the cytochrome c system. This is found in the inner cell membrane in the mitochondria and acts as a photoreceptor. Laser light allows cytochrome c oxidase to be produced at an optimal rate, this is critical to the production of ATP. ATP is essential for energy production in the cells and resulting in favourable biological responses or secondary mechanisms, including reduction of pain and inflammation and tissue healing.

The authors advise when reviewing published studies to note if the study was done in vivo or in vitro and the type and size of animal.

Dosages used in culture will be vastly different from those used to treat an animal and differ again depending on size of animal. Much greater doses being needed for a Siberian Husky compared to a feline patient. Depth of penetration is one of the most critical elements of laser treatment of musculoskeletal conditions. Dosages from 2 to 20 J/ cm2 applied to the surface appear to be an appropriate range for photobiomodulation. The patientâ&#x20AC;&#x2122;s size, body type, coat colour, skin colour, coat length and the depth of target tissue are the important parameters needed to calculate the correct dosage.

Common applications may be post-surgery, for conservative management of muscle, ligament or tendon injury, nerve damage, arthritis, otitis, lick granulomas, postsurgical incisions, wounds and inflammatory conditions. You should ensure hair and skin is clean, where possible clip the hair for optimal penetration. If wavelengths less than 900nm are being used be cautious not to overheat the coat or skin

53

when higher power (Watts) is used.

In these cases reduce the power and increase the dosage instead to deliver enough energy.

As it can be difficult to isolate a specific afflicted area it is recommended to have a broad area of treatment enabling effected areas and satellite areas of pain to be covered, treating from as many sides as possible is advised. There are typically two treatment techniques, lower powered lasers generally < 1Watt use a point to point method with dosage at each spot being delivered in approximately 30 seconds, depending on power and spot size. A second technique is to move the laser in a scanning fashion while treating; this is used with higher output powered laser.

Treatment may be applied in a contact or an off-contact mode, an on contact mode allowing compression of the tissue and deeper treatment.

Recommended frequency of treatment is dependent upon the nature of the condition, and access to the patient. Treating acute conditions every day is ideal, if not treat as often as is possible. For chronic conditions every other day with this phase continuing until a noticeable result is seen.

This change may occur earlier for acute conditions (2-3 treatments) than with chronic conditions (4-6 treatments).

Protective eyewear should be matched with the laser equipment because eye-wear is wave- length dependent. Specific laser eyewear for animals is available or the patientâ&#x20AC;&#x2122;s eyes can be directed away from the treatment or shielded with a dark cloth. It is possible to get potential heating with dark coloured skin and or hair and if you observe discomfort the treatment should be paused. Treatment is not recommended over open fontanels, pregnant uterus, malignancies and for patientâ&#x20AC;&#x2122;s taking photosensitive medications. Removal of leads and collars is advised and care should be taken close to metal surfaces that could reflect the light.

The Veterinary Clinics of North America. Small Animal Practice 2015 (45): 45-46 DOI: 10.1016/j.cvsm.2014.09.003 Kate Davy MCSP ACPAT Cat A Feline Rehabilitation Drum M.G., Bockstahler B., Levine D. and Marcellin-Little D.J. Feline patients are typically underrepresented in veterinary physiotherapy for a variety of reasons. They have fewer developmental orthopaedic diseases and injuries as a whole and less is known about these conditions in comparison to dogs. A significant problem is also the detection of osteoarthritic (OA) related disorders in cats due to the mismatch between radiographic prevalence of OA and clinical signs. Dogs with chronic pain show lameness whilst cats tend not to, instead reacting with changes in behaviour and lifestyle.

There is also a perception that cats are not treatable with most methods of physiotherapy due to their independent nature and low tolerance of handling.

Their species related behaviour may make them more difficult to handle but they do also have some unique characteristics that can be utilised in the development of a rehabilitation programme and orthopaedic problems that can be positively impacted by physiotherapy. This article summarises common physiotherapy methods tolerated by cats with suggestions of adaptations to the species and reviews common injuries and surgeries where physiotherapy input may be most beneficial.

Massage can be well tolerated in cats, if given time to acclimatise and restraint is kept to a minimum. Heat either in the form of hot packs or infra-red lamps can be tolerated, infra-red lamps are often liked by cats and owners may be able to hold cats or allow them to lie in their lap whilst a hot pack is applied.

Cold may also be tolerated but cryomassage may be preferred over cold pack application.

Therapeutic ultrasound is thought to be well tolerated in cats, a small head should be used to ensure best contact with the treatment and less soft tissue in cats means lower intensities will be required. Electrical stimulation may also be successfully used for both muscle strengthening and pain control. It is recommended to use smaller electrodes and lower intensities while overall treatment time may need to be shortened.

Therapeutic exercise plays a significant role in most rehabilitation programs and a cat’s impatience, boredom and reluctance to be restrained can make it difficult to perform this. If an exercise is successful it should be continued as long as it is tolerated but tolerance to it may end well before fatigue and or pain would end the session.

The article suggests the use of a pheromone spray may help during these sessions.

Passage range of movement can be trialled but cats are quickly bored, may dislike holding a limb position for a period time and resent manual manipulation. In these cases the therapist can use the cat’s body weight to perform the passive stretch for example hip extension in high standing using a harness and toy. Assisted exercises may be possible, such as assisted standing with either hands or a physio ball or rolled-up towels. Note that a cat’s claws can puncture physio balls and so they should be covered to prevent this. Weight shifting exercises on level surfaces with progression to unstable surfaces and wheel barrowing and dancing exercises may all be performed.

Motivating cats is best done by using their playing and hunting behaviours. Use light beams, feathers on a string or a toy mouse. Good footing such as carpet is important, the speed of movement induced through play and hunting should always be appropriate for the animal’s stage of recovery. Dangling a toy above will encourage a cat

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to sit on its hindlimbs and improve range of movement in the forelimbs as it reaches. Dragging a toy may induce a chase and pounce, good for encouraging use in all four limbs. Crawling through tunnels encourages flexion of all the joints and dragging a toy around chair legs encourages spinal bending.

Some cats will tolerate aquatic therapy in the form of underwater treadmill surprisingly well; Bengal, Serval and Savannah cats having a natural affinity to water. Whilst some cats may tolerate the water they may be hesitant to walk due to the moving belt. Having a physiotherapist in with them, allowing the cat to walk confidently before the belt is turned on and using very short sessions may all aid with building confidence. A life jacket is recommended for the first session and food motivation with salmon paste and shredded chicken can aid with positive reinforcement.

For underwater treadmill the authors advise initially supporting and encouraging the cat until they take 1 or 2 steps forward voluntarily, then the belt should be stopped immediately. This should be repeated 2 or 3 times before challenging the cat with a longer duration of up to a minute.

Many cats will tolerate only 1 or 2 minute intervals for several assisted sessions regardless of fitness or mobility levels. Begin with very slow speed, vary water level until the cat will voluntarily walk forward then increase slowly to the desired level.

Many cats will resist and float their hind limbs or try climbing out with higher water levels.

It is recommended to begin all cats in the underwater treadmill for acclimatisation, as swimming is more challenging and less well tolerated in cats. It is better to allow a cat to swim to a point and return to a rest spot than swim on the spot. Manual resistance and prolonged duration can be built up to but initially very short sessions of 2-5 minutes would be enough. It has been found many cats will tolerate the first couple of sessions but then become increasingly dismayed with swimming.

Specific injures and surgeries Traumatic Stifle Luxation- following removal of a transarticular pin or external fixator rehabilitation can be begun. Focus on flexion base activities and passive range before progressing to active extension.

Use of cavaletti rails, tunnels, stairs climbing, inclines, balance board and hydrotherapy can be effective in regaining functional ability.

Femoral fractures put cats at risk of quadriceps contractures and preventing loss of stifle flexion is the priority as restoring this once lost is extremely difficult. Even with internal fixation, quadriceps contracture can occur and so client education, early passive range of

motion and weight bearing are important in the management of these cases.

Femoral head and neck excision requires early weight bearing. Pain levels may be too high for them to tolerate passive range of movement but active range in conjunction with gentle passive range can be used. Sit to stand is a useful exercise and can be done at feeding time by allowing them to have a small feed and then moving the bowl forwards thus inducing them to stand and walk and then naturally sit or lie to eat again.

Cruciate ligament injury unlike in dogs is often traumatic in cats and seen in conjunction with other

ligament, tendon and soft-tissue injuries. Cats may use the affected limb more readily post-operatively than a dog following this surgery.

For this reason exercise restriction and client education in removing objects for them to jump from is very important. Joint stability, weight-bearing and stifle extension are important in the early phase post-operatively before moving onto muscle strengthening.

Vet Clin Small Animal 2015 (45): 185-201 DOI: 10.1016/j.cvsm.2014.09.010 Kate Davy MCSP ACPAT Cat A

DIARY OF EVENTS Date

Event

Location

7-10th September 2016

BEVA

Birmingham

14-15th November 2015

Your Horse Live

Stoneleigh Park, Warwickshire

19-20th November 2015

London Vet show

London

20-21st February 2016

ACPAT Seminar

Dunchurch Park Conference Centre, Rugby

10-13th March 2016

Crufts

Birmingham

June 2016

Animal Rehabiliation Expo

ExCel London

Please see www.acpat.org for further details

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Physiotherapy

The Association of Chartered Physiotherapists in Animal Therapy

The Professionals in Animal

ACPAT SEMINAR 2016 Saturday 20th & Sunday 21st February 2016 Dunchurch Park Hotel & Conference Centre, Rugby Road, Dunchurch, Rugby, Warwickshire CV22 6QW

Canine Day Saturday 20th February 2016 Topic

Presenter

Chronic pain: assessment, management and quality of life – how can the Physiotherapist help?

Louise Clark

Current research into Regenerative Medicine in the Canine

Greg McGarrell

Connective tissue and fascia – an essential update for Manual therapists

Michelle Watson

Physiotherapy management of the Feline patient

Polly Hutson

Orthopaedic management of stifle pathology

Christoph Stork

AGM

All ACPAT members

Equine Day Sunday 21st February 2016 Topic

Presenter

Current Research in Equine medicine - TBC

Cathy McGowan

Feedback and discussion of advanced Equine study days

TBC

Current research into Regenerative Medicine in the Equine

Greg McGarrell

Current research in Equine performance and its application in Saddlery

Mark Fisher

Further speakers TBC Programme may change at the discretion of ACPAT

Copyright © The Association of Chartered Physiotherapists in Animal Therapy (ACPAT) 2007 All rights are reserved. Unauthorised copying or use of this information is prohibited.

Email: secretary@acpat.org Website: www.acpat.org ACPAT is a Clinical Interest Group of the Chartered Society of Physiotherapy

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Course Reviews Advanced Manual Therapy for the Canine Spine Laurie Edge-Hughes, BScPT, MAnimSt(Animal Physio), CAFCI, CCRT

were reported to be a useful technique and particularly useful for older dogs with lumbar pain of a spondolytic nature. Other lumbar spine opening techniques were also taught (see picture 1) along with some rehabilitative techniques for encouraging abdominal activation, see picture 2.

March 22-24th 2015 This practical course was run at a north and south location and was run by Nycky Edleston who is part of the course organisation team on the ACPAT Committee.

Picture 2: Laurie demonstrates some abdominal tapping/facilitation techniques using manual stimulation alongside the use of a theraband in a retriever with transversus abdominal weakness

This course was run at Moulton College and was organised by Catherine Watts and Kate Galley who form part of the course organisers group on the ACPAT committee. The course was also run in November 2014 and was re-opened following a high demand for a second course. A total of 24 delegates attended this successful course in May 2015 which covered informative topics surrounding varying tree shapes and styles and other useful tips for assessing and fitting saddles along with when to appropriately refer to a qualified saddle fitter for a saddle alteration or check. The course covered both theory (picture 3) and practical (picture 4) aspects of saddle fitting.

ACPAT intend to run this course again please do refer to the ACPAT website, www.acpat.org, for more information on further courses.

This course certainly improved my confidence in applying manual therapy to my canine patients and I would be happy to attend another should it become available again.

Maruska Aylward MSc BSc MCSP HCPC ACPAT A Picture 1: Laurie demonstrates the use of some passive intervetertebral opening techniques in the lumbar spine

This course built on the ‘Basic Manual Therapy’ course that Laurie ran in February 2013. This course covered assessment and treatment techniques of the Canine cervical, thoracic and lumbar spine and of the sacroiliac joint. The provision of canine subjects to practise palpation techniques on was excellent and Laurie was an excellent tutor.

Interesting points covered included upper cervical instability testing for the cervical spine; for the thoracic spine facet joint ‘opening’ problems were suggested to be the more common dysfunction assessed and numerous opening techniques were covered; for the lumbar spine ‘global’ as opposed to specific passive physiological intervertebral joint rotations of the lumbar spine

Saddle Fitting Course Run by APCAT in conjunction with The Society of Master Saddlers 26th May 2015

Picture 3: The Saddle fitting course covered the theory of saddle fitting, and among other aspects considered the equine anatomy of the rib cage for example

Picture 4: The Saddle fitting course covered practical aspects of saddle fitting allowing for further group discussion on the topic

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Book Reviews Horse Movement: Structure, Function and Rehabilitation Gail Williams PhD Hardcover: 190 pages Publisher: J.A. Allen Language: English ISBN: 978-1-908809-11-7 RRP £30.00 This is book is a useful reference that provides a useful and simple overview of equine biomechanics and how the equine musculoskeletal system responds to injury. There is minimal ‘scientific’ language throughout the book which further suggests its more suitable audience should be the horse owner or under graduate student wishing to gain some insight into physiotherapy techniques as opposed to the higher institution student. It should be pointed out that the illustrations throughout the book of the equine skeleton and muscular system are excellent and a useful reference for any equine therapist. The chapters are clear and an easy read however unfortunately no references exist after each chapter rendering the more advanced reader unsure of the underlying evidence base to the suggested treatment techniques.

This is a useful book to have on your shelf and addition to any collection certainly.

The Dog Anatomy Workbook A guide to the Canine Body Andrew Gardiner Paperback: 212 pages Publisher: J A Allen Language: English ISBN: 978-0-85131-983-4 RRP £25.00 This is a useful book the content of which has been created by three clinical lecturers at the School of Veterinary Studies, University of Edinburgh. This book is designed to help readers with different styles of learning and allow them to learn mostly using colour throughout the book. A colouring anatomy book, every physiotherapists dream. Much of the content is of an undergraduate standard, however the illustrations are incredibly clear and there are some useful surface anatomy pictures and clinical notes throughout the book. I liken this to the ‘ABC of the horse’ by Pauli Gronberg, which was lacking in the canine sector. It has been designed with undergraduate veterinary surgeons in mind, nevertheless, I think this is a useful book for undergraduate veterinary physiotherapists.

Maruska Aylward MSc BSc HCPC MCSP ACPAT A

Maruska Aylward MSc BSc HCPC MCSP ACPAT A

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A Way of Life Healing Animals Mary Bromiley Paperback: 246 pages Publisher: Edward Gaskell Language: English ISBN: 978-1-906769-52-9 RRP £10.00 This is a delightful and insightful look at Mary’s life and her journey in getting animal physiotherapy recognised by the veterinary profession. There are many funny anecdotes of the trials, tribulations and successes of treating animals including the first animal she treated which was a squirrel, through the whole spectrum of animals that were lucky enough to come into Mary’s care and including some of the many racehorses.

The book is an easy read, the pages turn effortlessly and it will be enjoyed by all.

Stephanie Brighton MSc Vet Phys, ACPAT A

Recent Research Publications Here are some journal titles that may be of interest to you from the Equine Veterinary Journal and the Journal of Small Animal Practice.

All these articles are available online via www.onlinelibrary.wiley.com to all ACPAT members using the ACPAT Wiley username and password. If you require these details or have any questions regarding accessing these journals then please feel free to email me at physio@swanimalrehab. co.uk. In particular, ACPAT members please be encouraged to access the supplement of the more recent EVJ journal as accessing the supplement may provide a better idea of the focus of current research and what may be published.

Many Thanks Kate Davy MCSP ACPAT Cat A Research Officer EQUINE VETERINARY JOURNAL January 2015 Volume 47, Issue 1 Diagnosis and treatment of intrathecal tears of the accessory ligament of the superficial digital flexor (pages 48–53) G. J. Minshall and I. M. Wright Article first published online: 9 APR 2014 | DOI: 10.1111/evj.12240 Combined influence of expertise and fatigue on riding strategy and horse– rider coupling during the time course of endurance races (pages 78–82) S.Viry, J. B. De Graaf, J.-P. Frances, E. Berton, M. Laurent and C. Nicol Article first published online: 20 MAR 2014 | DOI: 10.1111/evj.12236 Water intake, faecal output and intestinal motility in

horses moved from pasture to a stabled management regime with controlled exercise (pages 96–100) S. Williams, J. Horner, E. Orton, M. Green, S. McMullen, A. Mobasheri and S. L. Freeman Article first published online: 20 MAR 2014 | DOI: 10.1111/evj.12238 Stance phase kinematics and kinetics of horses trotting over poles (pages 113–118) H. M. Clayton, N. C. Stubbs and M. Lavagnino Article first published online: 7 APR 2014 | DOI: 10.1111/evj.12251 March 2015 Volume 47, Issue 2 Science in brief: Recent advances into understanding tendon function and injury risk (pages 137–140) C. T. Thorpe, E. M. Spiesz, S. Chaudhry, H. R. C. Screen and P. D. Clegg Article first published online: 3 FEB 2015 | DOI: 10.1111/evj.12346 State of the art: Stem cells in equine regenerative medicine (pages 145–154) M. J. Lopez and J. Jarazo Article first published online: 10 SEP 2014 | DOI: 10.1111/evj.12311 Outcome of palmar/plantar digital neurectomy in horses with foot pain evaluated with magnetic resonance imaging: 50 cases (2005–2011) (pages 160–164) S. D. Gutierrez-Nibeyro, N. M. Werpy, N. A. White II, M. A. Mitchell, R. B. Edwards III, R. D. Mitchell, S. J. Gold and A. K. Allen Prevalence of exertional rhabdomyolysis in endurance horses in the Pacific Northwestern United States

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(pages 165–170) M. S. Wilberger, E. C. McKenzie, M. E. Payton, J. D. Rigas and S. J.Valberg Article first published online: 19 MAY 2014 | DOI: 10.1111/evj.12255 Posture and movement characteristics of forward and backward walking in horses with shivering and acquired bilateral stringhalt (pages 175–181) A. C. E. Draper, T. N. Trumble, A. M. Firshman, J. D. Baird, S. Reed, I. G. Mayhew, R. MacKay and S. J.Valberg Article first published online: 20 APR 2014 | DOI: 10.1111/evj.12259 Epidemiology of shivering (shivers) in horses (pages 182–187) A. C. E. Draper, J. B. Bender, A. M. Firshman, J. D. Baird, S. Reed, I. G. Mayhew and S. J.Valberg Article first published online: 3 JUN 2014 | DOI: 10.1111/evj.12296 Prevalence of and risk factors for equine obesity in Great Britain based on owner-reported body condition scores (pages 196–201) C. A. Robin, J. L. Ireland, C. E. Wylie, S. N. Collins, K. L. P.Verheyen and J. R. Newton Article first published online: 22 MAY 2014 | DOI: 10.1111/evj.12275 Management and horse-level risk factors for recurrent colic in the UK general equine practice population (pages 202–206) C. E. Scantlebury, D. C. Archer, C. J. Proudman and G. L. Pinchbeck Article first published online: 28 MAY 2014 | DOI: 10.1111/evj.12276 Effect of hoof orientation and ballast on acceleration and vibration in the hoof and distal forelimb following

simulated impacts ex vivo (pages 223–229) C. A. McCarty, J. J. Thomason, K. Gordon, T. Burkhart and W. Bignell Article first published online: 9 APR 2014 | DOI: 10.1111/evj.12252 JOURNAL OF SMALL ANIMAL PRACTISE December 2014 Volume 55, Issue 12 Evaluation of facial expression in acute pain in cats (pages 615–621) E. Holden, G. Calvo, M. Collins, A. Bell, J. Reid, E. M. Scott and A. M. Nolan Article first published online: 30 OCT 2014 | DOI: 10.1111/jsap.12283 Development of a behaviourbased measurement tool with defined intervention level for assessing acute pain in cats (pages 622–629) G. Calvo, E. Holden, J. Reid, E. M. Scott,

Recent News International Conference on Equine Exercise Physiology Sonya Nightingale MCSP ACPAT Cat A I was given the opportunity of attending ICEEP on your behalf and I now feel that I have to recommend it to you all. ICEEP is organised every four years and this, the 9th one, happened in Chester in midJune 2014. The format and ethos of the conference is not one I was familiar with at all, there are only two keynote lectures a day, the first at 8am and the other after lunch.

They introduce the topic for that half day and are followed by up to twenty five presentations varying in length from 5 to 15 minutes.

This carries on until about 6pm by which time your brain is slightly full!

Over 180 research projects were presented over the course of the week.

All the presentations are from

A. Firth, A. Bell, S. Robertson and A. M. Nolan Article first published online: 3 DEC 2014 | DOI: 10.1111/jsap.12280 Corrected by: CORRIGENDUM: Corrigendum Vol. 56, Issue 4, 293, Article first published online: 26 MAR 2015 February 2015 Volume 56, Issue 2 Vertical forces assessment according to radiographic hip grade in German shepherd dogs (pages 108–111) A. N. A. Souza, A. C. B. C. F. Pinto,V. Marvulle and J. M. Matera Article first published online: 14 NOV 2014 | DOI: 10.1111/jsap.12294

Extended proximal trochleoplasty for the correction of bidirectional patellar luxation in seven Pomeranian dogs (pages 130–133) research groups undertaking ground breaking research which has not yet been published. As a consequence there is tacit agreement from all attendees that no photos will be taken or filming done. In addition no direct reporting of presentations is allowed, as most of this work is owned by universities around the world and they retain the right to publish as and when they wish.

Therefore if you really want to know what is going on out there you have to attend in person and get to meet some of the nicest and most inspirational people I have ever met. They are a true international community who just wish to share their knowledge with each other and likeminded professionals, and trust that it will be treated with the respect it deserves. That does not mean that they are averse to criticising each other’s methodology and techniques, but it is done to enhance/improve further research programmes.

However to give you a taster this ICEEPs topics were- applied exercise

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C. Wangdee, H. A. W. Hazewinkel, J. Temwichitr and L. F. H. Theyse Article first published online: 10 JUL 2014 | DOI: 10.1111/jsap.12248 March 2015 Volume 56, Issue 3 A skeletal disorder in a dog resembling the Klippel–Feil Syndrome with Sprengel’s Deformity in humans (pages 213–217) G. Bertolini, M. Trotta and M. Caldin Article first published online: 5 SEP 2014 | DOI: 10.1111/jsap.12268 Chest wall reconstruction with latissimus dorsi and an autologous thoracolumbar fascia graft in a dog (pages 218–222) A. de Battisti, G. Polton, M. de Vries and E. Friend Article first published online: 16 SEP 2014 | DOI: 10.1111/jsap.12270

physiology, genetics of performance, performance horse nutrition/ biochemistry of exercise, muscle physiology/biochemistry, biomechanics of performance, cardiology and performance, functional biomechanics, physiotherapy/rehabilitation and performance. The physiotherapy session was actually the last one on the Friday, but, in spite of its timing, was extremely well attended. Narelle Stubbs presented the keynote and was, as usual, a fantastic and eloquent ambassador for our profession, we are lucky to have her working in this environment. Her summary of all her research projects and how they tie together to deepen our understanding of equine spinal biomechanics and how physiotherapy works inspired and humbled a mere practitioner!

I for one will be starting to save up now to attend as many of these as I can in the future wherever they happen in the world. 2018 happens to be in Lawns, Australia. A long way to go but what an experience that could be!

Acknowledgments The Four Front editorial team have been lucky to secure a new Peer Review panel this year and thank them all for their continued support to help generate such a high standard of articles for our readership.

Thank you for your time and continued support.

Canine articles Joanne Boddy BSc, MCSP, SRP, Category A ACPAT

Nigel Smith BVetMed CertSAS MRCVS Professor Tim Watson Equine articles Dr Tracy Crook Grad Dip Phys, MSc (B’ham & Lond), PhD Amanda Sutton MSc Vet Phys, MCSP, HCPC Berna Lindfield Chartered Veterinary Physiotherapist, Dip PT, Dip TP, Dip Vet Phys ACAPT A

Thank you also to all of our authors that have contributed this 6th Four Front edition.

Editors Maruska Aylward MSc BSc MCSP HCPC ACPAT A Bridgefield Physiotherapy Ltd Stephanie Brighton MSc BSc MCSP HCPC ACPAT A Daisy Collins BSc, ACPAT Cat B

Writing For Four Front

The Official Magazine Of The Association Of Chartered Physiotherapists In Animal Therapy Guidelines and Information for Authors The Editor would like to encourage ACPAT members to get involved in the magazine. If you are doing interesting clinical work, have a philosophical viewpoint that you would like to express, would like to share some research findings, have read a relevant book, article or attended an interesting course; please write something for the ACPAT magazine.

The aims of the magazine are to inform members about clinical, research and business developments that affect physiotherapists working with animals. It also provides a channel of communication between ACPAT members by informing and debating all aspects of animal physiotherapy.

We invite you to present material under the following sections:

Business Related topics Clinical Articles/Case reports Letters to the Editor Research Articles Useful addresses Conference / Course Reviews Small Adverts Product News Book Reviews

How to contact us If you have an article that you would like to submit for publication or you would like to discuss the outline of an article that you would like to write, please do not hesitate to contact ACPAT secretary who will pass on the information to the Journal Officer.

Post: M. Sharon Morgan Pembroke House Middle Lane Shotteswell OX17 1JQ

Email: secretary@acpat.org Editorial Product Reviews Literature Reviews

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Submitting an article Dates for Submission Research Articles – Oct 2015 Clinical Articles/Case – Oct 21015 Literature Reviews- Oct 2015 Product/Book/course/conference reviews – March 2016 Small adverts/Useful addresses/ useful tips – March 2016 Please send all text in electronic form (ideally in Microsoft Word) by attaching the file to an e-mail or on a disk, along with any original photographs to the editor.

We can accept articles up to 3,000 words and encourage the use of tables, illustrations and photographs.

If an article is longer please discuss with the editor.

There is no need to spend time adjusting fonts, columns etc, as we will adjust these to match the

current publishing style.

Where appropriate, articles must be supported by a reference list using the Harvard system. In the text quote the authors surname and year of publication. In your reference list please include the full reference, to include authors name, initials, year of publication, full title of the paper, name of the journal, volume number and the first and last page numbers.

Any identifiable photographs must be accompanied by written permission from the owner of the animal, otherwise the image will be obscured, so that recognition is not possible.

Please supply your full name, address, telephone number and e-mail address that you would like to be published with your article.

Format and structure of manuscripts Manuscripts should be headed with the full title of up to 15 words, which should describe accurately the subject matter. Authors should avoid including within the text: the name of the institution at which the work was performed, initials of the authors; and must remove institution names from illustrations in order to maintain anonymity for the review process.

Title Page A title page is needed for all manuscript types, it must contain the title of the paper, names and qualifications of all authors, affiliations and full mailing address including e-mail addresses, and contact telephone number of corresponding author. No author details are to be submitted in the manuscript. In addition details of any acknowledgements should be given on the title page.

Original Papers/Research Articles Each paper should comprise the following sections: Structured Summary - maximum of

200 words, divided, under separate headings, into Objectives, Methods, Results, Clinical Significance.

Keywords - maximum of five, for use as metadata for online searching.

Introduction - brief overview of the subject, statement of objectives and rationale.

Materials and Methods - clear description of experimental and statistical methods and procedures (in sufficient detail to allow others to reproduce the work).

Results - stated concisely, and in logical sequence, with tables or figures as appropriate.

Discussion - with emphasis on new and important implications of the results and how these relate to other studies.

Case Reports Full Case Report Reports of single or small numbers of cases will be considered for publication if the case(s) are particularly unusual or the report contributes materially to the literature. A case report should not exceed 1500 words and must comprise of: Summary (maximum 150 words); Keywords - for use as metadata for online searching Introduction - brief overview of the subject Case Histories - containing clinical detail Discussion describing the importance of the report and its novel findings To be considered for publication in a single case report must: - Exemplify best practice All papers and case reports are subject to peer review and publishing preference will be

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given to reports of original or retrospective studies.

Letters to The Editor Letters describing case reports or original material may be published and will be peer-reviewed prior to publication. Letters commenting on recently published papers will also be considered and the authors of the original paper will be invited to respond.

Style of manuscripts Writing should conform to UK English, and acceptable English usage must be presented within the manuscript. Where abbreviations are used, the word or phrase must be given in full on the first occasion.

All Manuscripts must be doublespaced for the purpose of peer reviewing.

All manuscripts must be numbered throughout for purpose of peer reviewing.

line the

All units of measurement should be given in the metric system or in SI units. Temperatures should be in °C. Drugs should be referred to by Recommended International NonProprietary Name, followed by proprietary name and manufacturer in brackets when first mentioned, eg, fenbendazole (Panacur; Intervet).

Anatomical terminology should conform to the nomenclature published in the Nomina Anatomica Veterinaria (1983) 3rd edn. Eds R. E. Habel, J. Frewein and W. O. Sack.

World Association of Veterinary Anatomists, Ithaca, New York.

Length The maximum length for research papers is 3000 words and for case reports is 1500 words. Review articles should not exceed 4000 words. All word limits include the summary but exclude the reference list. Authors should indicate the word count at the beginning of the manuscript.

Tables and Figures The minimum number of tables and figures necessary to clarify the text should be included and should contain only essential data.

Presentation of Book, Product and Course Reviews Book, Product and course reviews should be between 500 â&#x20AC;&#x201C; 700 words long. Book reviews should quote the title, publisher, ISBN number and price of the book.

Some points to consider before and during writing an article Try to produce a structured abstract and a list of key messages before you begin, this will help the article to be more focused and succinct and therefore more interesting for the reader.

Try to make the article as concise as possible, think hard what needs to be in the article to get the message across. Very few articles are longer than 2,000 words.

Try to ensure that references cited for tables and legends are done in sequence at the point where the table or figure is first mentioned in the text.

read and approved the manuscript.

Each author should give his or her name as well as the address and current e-mail for correspondence.

We now aim to publish the corresponding authorâ&#x20AC;&#x2122;s e-mail address in every article.

Copyright and exclusive licence Many publishers traditionally asked authors to assign their copyright as this allows them to tackle copyright infringement, to republish and reproduce on a website.

We however require all authors for an irrevocable licence so that we can reproduce articles on our website without the need to seek further permission.

All articles submitted to the editor are therefore accepted on the basis that all authors of the material agree to ACPAT acquiring this irrevocable license upon the publication of the article in any medium owned or controlled by ACPAT. Corrections

Finally check the final copy carefully.

We try hard not to make mistakes, but errors, both by authors and editors can creep into the journal.

We publish corrections when necessary. If you want to notify us about the need for a specific correction, please contact the editor.

Previous publication

Final note from the Editor

We do not have a strict policy on publishing material that has appeared elsewhere, but welcome authors to do so, especially where the subject is important to animal physiotherapists.

The Editorial Board reserves the right to edit all material submitted.

We may use material on the APCAT website, if you do not want us to publish information on the website, please explain this when you submit your work.

Terms and Conditions Material accepted for publication will be edited. All articles will be treated as though all authors have

The views expressed in Four Front are not necessarily those of ACPAT, the Editor or the Editorial Committee.

The inclusion of advertising does not imply any form of endorsement

by ACPAT. No article, drawing or photograph may be reproduced without prior permission of the Editor.

Four Front is an annual publication and aims to be published in the

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spring of each year.

We are looking forward to receiving articles from any member of ACPAT on any relevant topics that you wish to share with fellow members.

The success of the magazine and its benefit to members is ultimately dependent on the collective contributions that we receive, thank you, the Editors.