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Orthopedic RehabilitationDr. Dianne Dunning, DVM, MS, DrPH, DACVSNC State University, College of Veterinary MedicinePatient Assessment and Outcome MeasurementPrior to beginning any rehabilitation program, one must first fully assess the animal to establ<strong>is</strong>h a problem l<strong>is</strong>tand baseline from which to evaluate the success or failure of the program. Since most cases presenting to arehabilitation facility are usually orthopedic or neurologic in origin, a large part of a rehabilitation assessmententails a full orthopedic and neurologic exam.Orthopedic examA good examination begins with a thorough h<strong>is</strong>tory and general physical examination. The animal should beobserved off the leash within the room for body composition, conformation, lameness, joint alignment andmuscle asymmetry. A great deal of information can be obtained by intentional observation.Gait analys<strong>is</strong>In addition to <strong>not</strong>ing which limb or limbs are affected, all lameness should be graded. There are many lamenessscales in ex<strong>is</strong>tence, each with its own merit. Most lameness scales are numeric with the lameness being gradedon a 0 to 5 or 0 to 10 scale (see the tables below). Others are simpler and more descriptive in nature, with thelameness quantitated as mild, moderate, or severe. In any case, it <strong>is</strong> important to post the lameness score systemin an easily v<strong>is</strong>ible area, so that a practitioner can refer to it when performing gait analys<strong>is</strong> to limitintra/interobserver variability.Tables 2 and 3. Numeric lameness scoring systemsNUMERIC DESCRIPTIONGRADE0 Normal, no lameness1 Off weight bearing at a stance, no lameness <strong>not</strong>ed at a walk/trot2 Mild lameness at a trot, none at a walk3 Moderate lameness at a walk/trot4 Places foot when standing, intermittently carries limb when trotting5 Non-weight bearing lamenessNUMERIC DESCRIPTIONGRADE0 Sound1 Occasionally shift weight2 Mild lameness at a slow trot, none at a walk3 Mild lameness while walking4 Obvious lameness while walking, but places the foot when standing5 Degrees of severity6 Degrees of severity7 Degrees of severity8 Degrees of severity9 Places toe when standing, carries limb when trotting10 Unable to put the foot on the ground(Tables modified from Sumner-Smith, G: Gait Analys<strong>is</strong> and Orthopedic Examination. In Textbook of SmallAnimal Surgery, 2 nd ed.1993, p. 1578.

Once graded, all lameness should also be described. Abnormalities such as a shortened stride, toeing-in or out,limb circumduction, ataxia, head bobs, should be included in the record. A video data base also <strong>is</strong> useful whencomparing an animal’s lameness over time. In addition, animals with intermittent or exerc<strong>is</strong>e induced lamenessmay need to be run on a treadmill or exerted prior to the gait analys<strong>is</strong> examination to fully reveal the lameness.PalpationOnce the lameness has been confirmed, palpate the animal fully. At our facility, we palpate the animal severaltimes to ensure repeatability of the findings. Initially, we start with a standing palpation where we evaluate theanimal for muscle atrophy, body asymmetry and joint swelling. Then we place the animal in lateralrecumbency, with the affected limb placed on the “down” or floor side. Each joint and bone <strong>is</strong> manipulatedindividually and checked for pain, stability, range of motion (which can be measured with a goniometer), andend feels characterized. After we feel confident in our unsedated musculoskeletal examination findings, we willusually sedate the animal, repeat the palpation, and radiograph as necessary.Neurological examOnce the musculoskeletal examination <strong>is</strong> completed, a neurological exam should be performed. During gaitanalys<strong>is</strong>, observe the animal for ataxia and weakness. During the musculoskeletal examination, the pads,toenails, and webbing of all four feet should be observed for aberrant wear. There are essentially threecomponents to any neurological evaluation: 1) determination of the level of dysfunction and loss ofneurological function, 2) neuroanatomical localization of the lesion through evaluation of the spinal ormyotactic reflexes, and 3) determination of pain on epaxial palpation. See the attached neurological evaluationform for specific details regarding the exam.Orthopedic and Rehabilitation Exam Findings:A rehabilitation exam <strong>is</strong> really just a good assessment of body condition and fitness and it should <strong>not</strong> besurpr<strong>is</strong>ing that it strongly correlates with the animal’s functional ability. In our clinic we use joint goniometry,muscle girth, body condition scoring, d<strong>is</strong>ability indexing, force plate analys<strong>is</strong>, pressure mat analys<strong>is</strong>, and dualenergy x-ray absorptiometry (DEXA) analys<strong>is</strong> for form a baseline of animal’s ability and function. Incombination with the physical, orthopedic, and neurologic exam findings, <strong>th<strong>is</strong></strong> forms the bas<strong>is</strong> upon which weconstruct all our therapy regimes.GoniometryGoniometry may be defined as the objective measurement of a joint angle and <strong>is</strong> also referred to as jointalgometry. At a minimum, all joints should be measured in both flexion and extension. Normal angles ofmeasure have been reported for the Labrador Retriever, however measurements will vary with breed and bodysize and should be taken in context of the whole animal (See the table below). 1 A goniometer or medicalprotractor <strong>is</strong> used to measure the angles of motion. Always measure both the affected and unaffected limb. It <strong>is</strong>also important that you are familiar with the anatomic landmarks of the <strong>is</strong>ometric centers of motion to limit yourvariability of measurement.Table 4. Publ<strong>is</strong>hed normal values for the forelimb*JOINT POSITION NORMAL RANGES ( O )SHOULDER Flexion 30-40Extension 160-170Abduction 40-50Adduction 40-50Internal rotation 40-50External rotation 40-50ELBOW Flexion 20-402

Extension 160-170RADIOULNAR Pronation 40-50Supination 80-90CARPUS Flexion 20-35Extension (hyper) 190-200Varus (medial) 5-15Valgus (lateral) 10-20*Table modified from Mill<strong>is</strong> D, et al. Canine Rehabilitation and Physical Therapy. Philadelphia: Saunders,2004, 441.Table 5. Publ<strong>is</strong>h normal values for the rearlimb*JOINT POSITION NORMAL RANGES ( O )HIP Flexion 55Extension 160-165STIFLE Flexion 45Extension 160-170TARSUS Flexion 40Extension 170*Table modified from Mill<strong>is</strong> D, et al. Canine Rehabilitation and Physical Therapy. Philadelphia: Saunders,2004, 441.Goniometric measurement technique pointers:• A second person <strong>is</strong> always helpful for restraint and recording data.• Goniometric measurement will be more accurate if the animal <strong>is</strong> relaxed and compliant.• Always perform in the same positiono Lateral recumbency preferred• Relative measurement as normal range of motion will vary with breedo Use opposite (unaffected) limb as a compar<strong>is</strong>on• Variation in measuremento Interobserver variation (between people)• Helpful to have the same person performing the measurement each timeo Intraobserver (within one person)• Decreases with practice• Cons<strong>is</strong>tency of techniqueEnd FeelsAn end feel may be defined as the type of res<strong>is</strong>tance felt by an examiner at either extreme of flexion orextension of a PROM exerc<strong>is</strong>e. It <strong>is</strong> a subjective assessment that <strong>is</strong> diagnostic, as it characterizes the movementof a joint, and it guides PROM therapy on the animal. An end feel may be normal and pathologic, dependentupon the joint being palpated (i.e. ball in socket/hip or composite hinged cubital/elbow), the movementd<strong>is</strong>cerned (normal, lax, or restricted), and where in the range of motion that they are felt (end or middle).Table 6. End Feels classification system (Cyriax)CLASS NAME WHAT IS FELT INDICATIVE OFBone on bone Abrupt stop to the movement Can <strong>not</strong> change or alter withPROMCan be associated with a poorprognos<strong>is</strong> (end stage DJD) ornormal (elbow extended)3

CapsularT<strong>is</strong>sueapproximationFeeling of immediate stop ofmovement with some giveMost common of the endfeelsLimb segment can<strong>not</strong> bemoved further because thesoft t<strong>is</strong>sues surrounding thejoint can<strong>not</strong> be furtherCan be normal or associated withchronic fibros<strong>is</strong>Dependent on degree of ROMCan be normal ( stifle flexion) orassociated with postoperativehemarthros<strong>is</strong> and soft t<strong>is</strong>sueswelling and edemacompressedEmpty No end palpated Pain or res<strong>is</strong>tance to themovementSpringy blockA rebound <strong>is</strong> felt at the endof the rangeJoint derangement or laxitySpasm Muscle shaking or tremors An involuntary and abnormalmuscular contraction during thepassive movementMuscle GirthGirth measurement may be defined as the measurement of circumference of a body part (limb, thorax, orabdomen). It <strong>is</strong> an accurate estimate of lean body mass and body condition scoring. Muscle girth, however, <strong>is</strong> arelative measurement, <strong>not</strong> an absolute number. There are no “normals” publ<strong>is</strong>hed and <strong>there</strong> <strong>is</strong> extremeindividual variation from animal to animal. When performing muscle girth on an animal, use opposite(unaffected) limb as a compar<strong>is</strong>on if possible. Muscle girth <strong>is</strong> also affected by multiple parameters such as:• Hair coat• Obesity/Body condition score• Sedation• Limb position: flexion or extension• Point of measurement on limb• Body position: standing vs. laterally recumbentCons<strong>is</strong>tency <strong>is</strong> very important when obtaining the measurement. To limit incons<strong>is</strong>tencies in measurement, thesame person should perform the measurement each animal (if possible), the limb should be at the same positioneach time when measured (usually a standing or functional angle), the animal <strong>is</strong> positioned in lateralrecumbency, and a second person <strong>is</strong> helpful for restraint and recording data. We also use a permanent sharpiemarker to make a small mark on the inner surface of the limb to ass<strong>is</strong>t in reproducibility of measurement.Table 7. Anatomic landmarks for appendicular muscle and abdominal girth measurement.LIMBLANDMARKProximal rearlimb 1/4th the d<strong>is</strong>tance between the greater trochanter to the patellaD<strong>is</strong>tal rearlimbProximal forelimbAt the tibial tuberosity1/4th the d<strong>is</strong>tance from the tibial plateau to the medial and lateralmalleoli3/4th the d<strong>is</strong>tance from the greater tubercle to the olecranon4

D<strong>is</strong>tal forelimbThoraxAbdomen1/4th the d<strong>is</strong>tance from the epicondyles to the medial and lateralstyloid processesXiphoid processMidway between 13 th thoracic vertebra and wing of the ileumBody Condition ScoringBody condition scoring (BCS) <strong>is</strong> a classification system used to determine relative fitness and <strong>is</strong> a subjectivemeasure of body fat stores. Publ<strong>is</strong>hed scales are numeric and range from 1-5 and 1-9, with 1 = cachetic and 5 or9 = obese. Scales are usually based upon rib palpation and degree of fat cover and are strongly correlated toDEXA analys<strong>is</strong> which quantitated lean body mass, percent fat and bone density. Excellent publ<strong>is</strong>hed bodycondition charts are available (and free of charge) through many of the pet food companies.Therapeutic Exerc<strong>is</strong>e and Proprioceptive ActivityTherapeutic exerc<strong>is</strong>e <strong>is</strong> a key component of a rehabilitation program for a variety of impairments. Therapeuticexerc<strong>is</strong>e may be the bas<strong>is</strong> of the intervention, such as with animals that are obese, or more commonly, may be acomponent of the total plan. Therapeutic exerc<strong>is</strong>e includes activities and techniques to improve physicalfunction and health status resulting from the primary d<strong>is</strong>ease. When structuring an exerc<strong>is</strong>e program, it <strong>is</strong>helpful to first identify and create a problem l<strong>is</strong>t stemming from the primary problem. From <strong>th<strong>is</strong></strong>, <strong>there</strong>habilitation practitioner can identify specific performance goals that will allow an animal to function at ahigher level. Success of any therapeutic program <strong>is</strong> based upon taking into consideration the owner’sexpectations of the animal, the owner’s commitment to continuing the work at home, and the underlyingcondition being treated.When developing an effective, efficient therapeutic exerc<strong>is</strong>e program, it <strong>is</strong> helpful to answer the followingquestions regarding your animal patient:• Which elements of the musculoskeletal system need to be addressed to restore function?• Which activities or techniques can be chosen to achieve a functional outcome?o Include in <strong>th<strong>is</strong></strong> the sequence and duration necessary within a given exerc<strong>is</strong>e session• What <strong>is</strong> the purpose of each specific activity or technique chosen?• What posture and movement must the animal be able to perform to fully achieve the activity?It <strong>is</strong> also important to realize that, unlike in people; you can<strong>not</strong> push animals into an activity or overexert arecovering animal. If you hurt a rehabilitation patient, it <strong>is</strong> likely that either the animal or the owner willbecome rapidly noncompliant with your program.What type of problems do therapeutic exerc<strong>is</strong>e programs commonly address?• Decreased ROM• Pain• Muscle atrophy• Neurologic deficits• Obesity• Loss of function/decreased quality of life• Therapeutic exerc<strong>is</strong>e may also be used to improve ex<strong>is</strong>ting normal function, such as in the agility animalor working dog.5

Therapeutic Exerc<strong>is</strong>e ModalitiesLand treadmillA land treadmill <strong>is</strong> very useful for patterning gait and encouraging early use of limb. It requires decreasedbraking and propulsion ground reaction forces when compared to normal walking, trotting, or running on land.A land treadmill <strong>is</strong> also very good at encouraging early limb usage in the postoperative patient. It also has thebenefit of being able to use it immediately post-operatively - unlike the underwater treadmill, where <strong>there</strong> <strong>is</strong>some concern for inc<strong>is</strong>ional infection during the initial phase of wound healing. When used appropriately it <strong>is</strong>very safe, widely available form of activity. Most models come with a variable speed/timer and anincline/decline mode. The altered incline may be used to reduce stress on forelimbs/hindlimbs or to increasedifficulty of an activity.Underwater treadmill and aquatic therapyWater <strong>is</strong> a unique environment for an animal to rehabilitate in. The inherent properties of water can bemanipulated in a variety of ways to achieve many therapy goals. When used correctly, water’s buoyancyprovides a safe environment for animals to exerc<strong>is</strong>e. However, the increased v<strong>is</strong>cosity may cause early fatiguein some animals. Due to the increase res<strong>is</strong>tance, balance <strong>is</strong> challenged with every active movement.Hydrostatic pressure of immersion also reduces edema and improves peripheral blood flow from theappendicular skeleton.Cavaletti railsCaveletti rails are rails or poles space apart on the ground. They are commonly used in orthopedics to lengthenstride, encourage limb use, and allow for greater active flexion and extension of joints. In dogs or cats withneurologic d<strong>is</strong>ease, caveletti rails are used with ambulatory but ataxic patients to increased body awareness andcoordination and will maintain and improve balance and coordination.Balance trainingThe benefits of balance training or proprioceptive activity are many: They enhance proprioception andfacilitated body awareness, in addition to allow for gradual gains in muscle strength and balance. In people,ass<strong>is</strong>ted weight shifting <strong>is</strong> believed to be a better more efficient activity in the elderly than strength trainingalone. Forms of balance training include ass<strong>is</strong>ted standing, facilitated walking with slings and carts, weightshifting, balance boards, and physioballs (d<strong>is</strong>cussed in the next section).PhysioballsPhysioball activity <strong>is</strong> an excellent and inexpensive method of therapeutic exerc<strong>is</strong>e. Physioball based exerc<strong>is</strong>ecan be used to improve balance, improve weight shifting forces weight bearing activity, enhance musclecontraction in a control loading environment, and increase animal confidence in weight bearing.TunnelsTunnels are readily available, very inexpensive and come in a variety of sizes. We frequently use tunnels inhighly functional agility animals to keep the animal interested (they are fun!). Tunnels work forces the animalto change in the active range of motion of the appendicular skeleton, as animal must squat to correctly navigateand run through the tunnel.WeightsWeights are used to add additional res<strong>is</strong>tance to a limb or torso. Extra weight on weak limb usually encouragesweight bearing and also provides an extra challenge in athletes.Soft pliable weights are easiest to use to most animals.6

Res<strong>is</strong>tance bandsRes<strong>is</strong>tance bands come in many different sizes and may be cut to length for individual sizing. Res<strong>is</strong>tance bandsmay be used to advance an animal’s foot in gait patterning, to strengthen ab/adductor muscles, as an aversiontechnique to increase stride length and force usage, and to provide additional res<strong>is</strong>tance to a limb.Sit to stand/down activitySit to stand/down activity encourages active flexion and extension of affected joints with absolutely noequipment! In the rearlimbs, it strengthens gluteal, quadriceps, semitendinosus and semimembranosus muscles.In the forelimbs, it may be used to condition the biceps/triceps muscle groups.Hoops and advanced activitiesHoops are used in athletic and agility conditioning/training regimes. It <strong>is</strong> usually employed as an advancedactivity for athletes/working/agility dogs. Hoop jumping requires an intense burst of muscle use and <strong>is</strong> a<strong>not</strong>herfun exerc<strong>is</strong>e to keep animal’s interest. Other therapeutic exerc<strong>is</strong>es including trotting, running, and controlledfetching can be used to provide an additional challenge for the highly functional animal. Wheelbarrow/dancing,exerc<strong>is</strong>e on a grade, toy batting (especially for the dog with forelimb neurological deficits), and controlled play(great for cats, puppies, young dogs) have specific indications and benefits for the rehabilitation animal.Outpatient programsOutpatient programs are important component of improving function in an animal that has a prolonged orlengthy recovery. Owners can be taught to perform rehabilitation regimes at home. To improve complianceand ensure that the activities are being performed appropriately, periodic rechecks should be scheduled. Norehabilitation program <strong>is</strong> ever static, and most will need adjustment to cope with an animal’s changing needs.Owners also should be taught to be creative in their use of the environment as a rehabilitation facility.Children's play areas and parks, bicycle racks (weaving), sand pits/sand boxes (footing changes, proprioceptivefeedback), curbs/ditches (hill climbing), railroad ties (for cavaletti rails), and public stairs/ramps are all usefuland easily accessible devices to implement in any program.Electrical stimulation and ultrasoundElectrical stimulation and ultrasound are adjunct therapies that are now commonly employed in mostrehabilitation facilities. A complete d<strong>is</strong>cussion of these two modalities <strong>is</strong> outside of the scope of <strong>th<strong>is</strong></strong> basiclecture.Electrical stimulationElectrical stimulation in its most fundamental form <strong>is</strong> the application of an electrical current to a t<strong>is</strong>sue. It <strong>is</strong>commonly used for three purposes: 1) to enhance muscle contraction, 2) to reduce pain, and 3) to reduceedema. General contraindications for electrical stimulation include: Animals with seizures d<strong>is</strong>orders,peripheral vascular d<strong>is</strong>ease, or thromboembolic d<strong>is</strong>ease. In addition, one should never apply electricalstimulation directly over a neoplastic mass, infected t<strong>is</strong>sue, or an abdomen, particularly if the animal <strong>is</strong>pregnant. There are various types of electrical stimulation units/programs available, to perform specific tasks,but they basically fall into two groups: the transcutaneous electrical nerve stimulators (TENS) andneuromuscular electrical stimulation (NMES) units. Some electrical stimulation units have the capacity toperform both, others do <strong>not</strong>. It <strong>is</strong> worth your while to test and sample various units available to find one thatserves your practice needs and caseload.TENSHas widely been used to identify stimulators that modify pain, but in actuality, all forms electrical stimulationare TENS units. Electrical stimulation to alter pain sensation involves the application of an electrical current toa sensory nerve. There are various speculated mechan<strong>is</strong>ms of action to the altered pain sensation which include:the gate control theory which involves the increased activity of the sensory afferents causing pre-synaptic7

inhibition of pain transm<strong>is</strong>sion, an endogenous opiate release, the counter irritant theory, and the placebo effect.Altered pain sensation via TENS <strong>is</strong> probably due in part to all of the above mechan<strong>is</strong>ms; however, TENS shouldbe only considered an adjunctive pain management modality, as it by no means replaces normal traditionalmultimodal pain management techniques.TENS general technique tipsThere <strong>is</strong> no set requirement of pad placement for TENS. Pads may be positioned over the sites of pain, alongacupuncture/pressure sites, along dermatomes, and over trigger points. For pain control using interferentialelectrical stimulation over a painful joint, such as the shoulder with bicipital tenosynovit<strong>is</strong> try the followingtechnique:• Use of 2 channels of electrical stimulation that are controlled by a common source of generation• The two channels mark the area to be treated in an “X”‣ Channels of current interfere with one a<strong>not</strong>her‣ At the intersection of the “X” <strong>there</strong> <strong>is</strong> a summation of the electrical stimulation effect (see thepicture below)• By increasing the d<strong>is</strong>tance between the electrodes• Stimulate deeper t<strong>is</strong>sues• By varying the intensity of the two channels• Move the summation pointBAABNMESNMES <strong>is</strong> indicated in cases that necessitates prolonged joint immobility or fractures with neurologicalimpairment. Neuromuscular stimulation prevents d<strong>is</strong>use atrophy and improves limb performance by recruitingcontracting fibers and increasing maximum contractible force of affected muscles. The electrical stimulationdevice cons<strong>is</strong>ts of a pulse generator and electrodes, which are placed over selected weakened or paralyzedmuscle groups to create an artificial contraction. Pulse amplitude, rate and cycle length may be varied to suit the8

comfort of the patient. Reduction of muscular pain and edema due to improved blood flow also occurs.Combining neuromuscular stimulation with PROM exerc<strong>is</strong>es improves joint range of motion and preventsmuscle contracture and <strong>is</strong> particularly indicated in fractures of the d<strong>is</strong>tal femur of the young dog. Furthermore,neuromuscular stimulation has also been proven to be effective in promoting muscle re-education after aprolonged d<strong>is</strong>use.NMES general technique tips and definitions• Find the motor point of the muscle, which <strong>is</strong> generally around the midpoint of the muscle belly• Select a waveform for NMES– Symmetrical biphasic– Russian stimulation• Pulse duration– Usually preset at 200-300 µsec– Creates a strong muscle contraction• Frequency– Can vary but usually set at 30-50 pulse/sec (pps)• Duty cycle (on:off time)– Muscle strengthening• 1:3 – 1:5– Muscle endurance• 1:1 – 1:2• Ramp– R<strong>is</strong>e and decay time of electrical current– Increase the ramp to increase comfort• Reusable and d<strong>is</strong>posable electrodes are available. Electrode size will dictate animal comfort…butalways try it out on yourself first before putting an electrode on an animal. Generally, it <strong>is</strong> <strong>not</strong> a goodidea to cut electrode pads, as <strong>th<strong>is</strong></strong> concentrates the current in a small area and decreases the comfort ofthe therapy, but in some cases (small dogs and cats) <strong>th<strong>is</strong></strong> <strong>is</strong> difficult to avoid.• Therapeutic regimes can vary, but most are 2-3 times/week for 10-20 minutes/sessionCheat sheet for electrical stimulation unit use:Indication Amplitude Pulse duration Frequency ModeAcute Pain LFC Sensory 2-50 usec 50-100 pps contChronic pain LFC Sensory >150 usec 2-4 pps contStrengthening Motor 100-400 usec 30-50 pps interruptedEdema Motor 100-400 usec 30-50 pps interruptedTherapeutic ultrasound:Therapeutic ultrasound <strong>is</strong> based upon the delivery of acoustic vibrations to produce the deepest form ofphysiological heat and cellular inflammation. The physiologic effects of ultrasound may be divided into twocategories: thermal and non-thermal. The thermal effects of ultrasound increase connective t<strong>is</strong>sue extensibilityand vascularity, and provide a form of temporary nerve blockage, thus promoting muscular relaxation and painrelief. Non thermal effects of ultrasound include the acceleration and compressing of the inflammatory phase ofhealing, an increase in the local circulation, a decrease in edema, a mechanical release of endorphins,9

enkephalins, and serotonin for pain control, and the stimulation of collagen synthes<strong>is</strong>, and the stimulation ofbone growth.The indications for ultrasound are somewhat limited in the acute fracture patient or any cases where <strong>there</strong> <strong>is</strong> anexcessive amount of inflammation present. Before ultrasonography <strong>is</strong> used, a complete working <strong>know</strong>ledge of<strong>th<strong>is</strong></strong> therapeutic mode must be undertaken as <strong>there</strong> <strong>is</strong> a wide variety of continuous or pulsed wave deliverymodes, wave intensities, and therapy regimes to choose from. Accordingly, complications of therapeuticultrasound mostly relate to operator inexperience or error due to inappropriate dosages producing excessiveheat, free radical production, and subsequent t<strong>is</strong>sue destruction. However, ultrasound may be of use in thetreatment of chronic scar t<strong>is</strong>sue and adhesions associated with fracture trauma and fixation and for the palliationof muscle spasms and to improve organized and rapid tendon bone healing.Therapeutic ultrasound general technique tips and definitionsAgain clip, clean and prepare the skin prior to applying the probe.Terms that you should be familiar with:• Frequency <strong>is</strong> usually preset at either 1 or 3.3 MHz.o 1 mHz <strong>is</strong> used to penetrate t<strong>is</strong>sues 2-5 cm deepo 3.3 mHz penetrates 0-3 cm and <strong>is</strong> use on more superficial t<strong>is</strong>sues• Mode can either be set on continuous or pulse and refers to the on:off cycle of the ultrasound waveso Continuous mode theoretically has more thermal effectso Pulse mode <strong>is</strong> more commonly applied for mild heating or non-thermal effects• 20% duty cycle• 50% duty cycle• Intensity <strong>is</strong> the rate at which energy <strong>is</strong> delivered/unit area and <strong>is</strong> expressed as Watts/cm 2 and ranges from0.5-2.0 W/Cm 2o 1.0-2.0 Watts/cm 2 <strong>is</strong> used in areas where <strong>there</strong> <strong>is</strong> moderate to large amounts of soft t<strong>is</strong>sue• Caudal aspect of the stifle• Hipo 0.5-1.0 W/cm 2 <strong>is</strong> used in areas with little soft t<strong>is</strong>sue• Dorsal aspect of the carpus• Caudal aspect of the elbow• Sound head sizeo Most units come in 2, 5, & 10 cm2o 5 cm <strong>is</strong> the most commonly used in companion animal rehabilitation• Coupling agent <strong>is</strong> necessary to conduct the ultrasound waves to the t<strong>is</strong>sueso Gelo WaterTherapeutic U/S treatment technique tips• Pass the probe slowly and steadily over the defined treatment area‣ In general, the treatment area should be no bigger than 2-3 times that of the size of the effectiveradiated area of the head of the U/S probe• General rule of thumb for duration of treatment‣ 5 -10 minutes of U/S time per treatment area for effective heating‣ Desired temperature increase10

Rehabilitation Services Available at the College of Veterinary MedicineThe NC State University Rehabilitation and Mobility Service offers a wide range of rehabilitative, fitness andpain management services to treat dogs, cats, and other small animals. Some of the treatment modalities weoffer include:• Acupuncture and pain management• Cryotherapy and heat therapy• Gait training• Land and underwater treadmill activity• Massage and passive range of motion activity• Neuromuscular electrical stimulation• Therapeutic exerc<strong>is</strong>e• Therapeutic ultrasound• Ass<strong>is</strong>tive devices and prostheticsSome of the most common conditions we treat include:• Postoperative cases (e.g. total hip replacement, cranial cruciate ligament repair, spinal surgery)• Neurological conditions (e.g. degenerative myelopathy, fibrocartilagenous embol<strong>is</strong>m (FCE), spinal cordinjury)• Traumatic injuries and intensive care cases• Wound healing• Geriatric conditions• Obesity• Osteoarthrit<strong>is</strong>• Pain managementService Faculty and Staff:Dianne Dunning, DVM, MS, DrPH, DACVSClinical Associate ProfessorNatasha Olby,VetMB, PhD, DACVIM (neurology)Professor, NeurologyDuncan Lascelles, BSc, BVSc, PhD, CertVA, DSAS (ST), DECVS, DACVSProfessor, Small Animal SurgeryDen<strong>is</strong> Marcellin-Little, DEDV, DECVS, DACVS, DACVSMRProfessor, OrthopedicsJoanne Leicester, MSc, BSc, AS, RVT, CCRPClinical TechnicianContact InformationReferrals and questions can be directed to the Rehabilitation and Mobility service at 919 513 617711

NC State University Rehabilitation Service Neurological Evaluation FormD<strong>is</strong>ability Index:Ambulatory Parapares<strong>is</strong>Non-ambulatory Parapares<strong>is</strong>ParaplegiaAmbulatory Tetrapares<strong>is</strong>Non-ambulatory Tetrapares<strong>is</strong>TetraplegiaAmbulatory Hemipares<strong>is</strong>Non-ambulatory Hemipares<strong>is</strong>HemiplegiaAmbulatory Monopares<strong>is</strong>Non-ambulatory Monopares<strong>is</strong>MonoplegiaMental status:Cranial nerve exam:Conscious Proprioception: (2 normal, 1 reduced, 0 absent)ForelimbHindlimbHopping: (2 normal, 1 reduced, 0 absent)ForelimbHindlimbLeftLeftRightRightReflexes: (0 Absent, +1 Decreased, +2 = Normal, +3 = Exaggerated, +4 = Very exaggerated or clonic)Forelimb withdrawalPatellarSciaticHindlimb withdrawalCrossed extensor (FL)Crossed extensor (HL)Mass reflexCutaneous Trunci reflex (level)Perineal reflexLeftRight12

Muscle tone: (0 absent, 1 decreased, 2 normal 3 increased (spastic))ForelimbHindlimbLeftRightMuscle atrophy: l<strong>is</strong>t muscles involved, <strong>not</strong>e contracturesForelimbHindlimbLeftRightSensory:Nociception (0 absent, 1 reduced, 2 normal)UrinationDefecationForelimbHindlimbTailUrinates on own all timeDoes <strong>not</strong> empty completelyUnable to urinateLeaks urineAware of defecationUnaware ofdefecationLeftRightParaparetic/plegica) Gait AssessmentStage 1- Paralys<strong>is</strong> with no voluntary limb movement0 No limb movement and absent deep pain1 No limb movement and present deep pain2 No pelvic limb movement but voluntary tail movementStage 2 – Non-weight-bearing voluntary limb movements3 Minimal non-weight-bearing activity of one limb (one joint)4 Non-weight-bearing activity in more than one joint 50% of the timeStage 3 – Voluntary limb movement with occasional weight bearing6 Weight-bearing activity of the limb 50% of the time13

Stage 4 – Weight-bearing movements with decreased motor strength9 Weight-bearing activity 100% of the time with reduced strength ofpelvic and m<strong>is</strong>takes > 90% of the time (eg, crossing of limbs,knuckling of paws,standing on dorsum of foot, falling)10 Weight-bearing activity 100% of the time but with reduced strength. M<strong>is</strong>takes made 50to 90% of the time11 Weight-bearing activity 100% of the time but with reduced strength. M<strong>is</strong>takes made 50% ofthe time (eg, lack of coordination with thoracic limb, crossing of pelviclimbs, skipping steps, bunny-hopping, knuckling of paws)13 Ataxic gait with normal strength, but m<strong>is</strong>takes made