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Subedited by Phil Tucak
The use of multimodal treatment modalities is becoming more common in veterinary practice, and the successful management of many conditions can be significantly improved with this approach. The following case highlights how combining rehabilitation and hydrotherapy with traditional western veterinary diagnostics and medicine can assist in improving patient quality of life and subsequently potentially reduce the need for invasive surgical techniques.
Kora, a six-month-old female kelpie-cross puppy, presented to her regular veterinarians at around 14 weeks of age with an acute onset of an unusual hind limb gait. At this time, she was up to date with routine vaccinations and parasite control, and was on a raw-meat based diet.
Kora had been a stray puppy found three weeks prior, and video footage taken of her shortly after showed that she had ‘bunny-hopped’ with her gait even then. However, on this particular weekend her owners noted that she was holding her back legs at an abnormal angle and had developed an unusual and slightly uncoordinated gait.
On initial examination with her regular veterinarian, Kora was found to have severe bilateral pelvic gait abnormalities, bilateral coxo-femoral joint pain, with the right being more painful than the left, hyper-extension of the left hock and a mild decrease in proprioception on the left hind leg. A complete blood and serum biochemistry panel was performed (Idexx) and a borderline elevation in ALT (89) (RR 8-75) was noted, with no other changes of diagnostic significance.
The next day, a series of pelvic limb radiographs were performed which did not reveal any overtly obvious changes. At this stage, Canine Hip Dysplasia (CHD) was suspected and she was referred for advanced imaging and specialist orthopaedic assessment. Examination of the puppy at the veterinary specialty centre confirmed a bunny-hopping gait with a popping sensation when she walked, and CHD was still considered the most likely diagnosis.
On that basis, advanced imaging was performed. The CT scan revealed normal anatomical structures, and examination of the coxo-femoral joints under general anaesthesia revealed minimal subluxation, a negative Ortolani sign, and minimal joint effusion. At this stage, CHD seemed less likely and a soft tissue injury was suspected.
Kora presented to our team about 10 days later, by which stage her gait had worsened and she had progressively weakened and developed severe muscle atrophy in both hind legs and along the spine.
Examination at this stage revealed a ‘cow-hocked’ stance with mild effusion on both hocks, severe hyper-extension of the right hock and severe bilateral muscle atrophy in both hind legs. She had difficulty standing unaided, her back was arched, and when placed in a standing position, she would hold her stifles and hocks medially, with the lower limbs abducted.
Kora was weak, particularly on the left hind limb, yet at the same time there was a rigidity to her limbs rather than flaccid weakness. If placed in position, she would shift her right hind centrally to take weight off the left hind leg, and she exhibited hyper-extension of the right hock in this position. There were no proprioceptive deficits obvious at this examination. There was minimal discomfort on examination, so at this stage a presumed neurological cause was suspected rather than an orthopaedic condition.
Since our practice works both as a primary care as well as a referral practice, we often work together as a team with owners and their regular vets where this is the client’s preference. In this case, Kora’s owners were keen to continue her veterinary care with their regular GP veterinarian and to utilise our services for rehabilitation. As such, we referred her back to her GP veterinarian for further workup, scheduled a full rehabilitation assessment and, in the meantime, demonstrated some basic therapeutic exercises for her owners to perform at home.
Kora’s serology testing returned with a diagnosis confirming infectious neurological disease, neosporosis. Neospora Caninum IFAT Titre was 1:256 (with >1:16 being seropositive). Toxoplasma IgG and IgM titres and Cryptococcus antigen titres were normal. The results also showed an elevated CRP due to inflammation as well as mild muscle damage, likely due to secondary myopathy.
Kora was immediately started on Trimethoprim-sulfa, Clindamycin and Prednisolone. She returned for a physical therapy assessment 24 hours after commencing these medications, at which point she had severe laxity bilaterally in the stifles and hocks, with both back legs crossing over each other when attempting to walk. She had marked muscle atrophy dorsally and on both hind legs, hyper-extension bilaterally on the hocks, and mild oedema on the left hock. Her ability to stand and to walk, however, was improved from the previous visit four days earlier, despite having only been on medications for just over 24 hours.
There were two main concerns at this stage. These were the need to prevent soft tissue contracture for long term mobility, and the possible need for bilateral arthrodesis on the tarsal joints if the stability of these did not significantly improve.
Since one of the biggest complications with neosporosis is soft tissue contracture causing permanent, lifelong gait abnormalities which, in turn, can lead to ongoing issues with overcompensation and pain in the remaining limbs, Kora’s owners were shown how to regularly perform a range of therapeutic exercises at home to assist in her recovery.
These exercises consisted of a passive range of motion and stretches for each of the hind limb joints, heat therapy, assisted standing exercises, side lying oblique stretches, and stimulation of the nerves in the feet and toes to induce an active range of motion exercise as well.
Braces for the tarsal joints were also organised to assist in stabilising the tarsal joints since the instability of both hocks had markedly worsened. Use of a brace must be carefully considered, since over-reliance on these can lead to further muscle atrophy and weakness if not careful. For this reason, a structured plan was created to ensure the braces were removed for some of the time to perform therapeutic exercises, and then replaced for some of the time to allow for stability, improved pain management and to encourage more normal gait patterning.
We continued to see Kora weekly for four weeks. During these sessions she commenced hydrotherapy in a heated underwater treadmill, therapeutic exercises which were altered regularly to include strengthening exercises, acupuncture, and received Chinese herbs. She also had regular measurements taken to track her progress.
While it is still too early to be sure what the final outcome will be, Kora has shown much improvement in strength, mobility and comfort levels. The hyper-extension on the right tarsus has significantly reduced, although it remains problematic on the left. She has recently completed her course of medications and continues to visit us for hydrotherapy and rehabilitative exercise. The improvements already seen in the reduction of hyper-extension of the tarsal joints bilaterally leads us to hope that she may be able to avoid tarsal arthrodesis, at least in the right hind, and hopefully in both legs.
In this particular case, Kora would not have had such a successful outcome had traditional veterinary medical practice been used alone, or if rehabilitative physio and acupuncture modalities had been used alone. The successful outcome for this puppy is due to western veterinary diagnostics and medicines being combined with rehabilitation, therapeutic exercise, hydrotherapy and acupuncture, as well as the outstanding dedication of her owners and team of veterinarians.
In addition to our team at Vogue Vets & Wellness Centre, we would like to acknowledge the other veterinarians involved in Kora’s care including the team at The Vet Connection in Fremantle, and Dr Fiona Haining at Rivergum Referral Services.
Dr Fran Pagnacco BSc BVMS, Vogue Vets & Wellness Centre
Dr Fran Pagnacco graduated from Murdoch University in 1999 and has spent most of her career working in Perth apart from having spent two years working in the United Kingdom as a small animal practitioner.
In 2011, Dr Pagnacco opened Vogue Vets in Joondanna. In 2019 she expanded their services to include animal rehabilitation and physiotherapy, hydrotherapy, acupuncture, traditional Chinese medicine and traditional western medicine at the Wellness Centre in Stirling.
Dr Pagnacco has undertaken further training to achieve Certificates in Canine Sports Medicine, Post-operative Cruciate Rehabilitation, Introduction to Canine Rehabilitation (University of Tennessee), Therapeutic Handling for Canine Rehabilitation, Canine Aqua Therapies, and completed units Canine II and III in Canine Rehabilitation through the University of Tennessee.