HISTORY OF TREATMENT

Hank Ferguson is a 5-year old neutered male Border collie, who presented in physical therapy for an evaluation on 4-21-09; with a diagnosis of Bridging Spondylosis at L7-S1. Hank’s normal activity level was competitive herding, along with herding sheep and cattle two times a week. On days he was not herding, he usually ran loose in an open space for one to two hours as his owner walked. His owner reported that he had been lame in his right hind limb for approximately six weeks and that the lameness was progressively getting worse; additionally reporting that he was always non-weight bearing on his Right Hind Limb (RHL) after resting/sleeping. He had seen two DVM’s, and both had recommended an MRI and possibly a Dorsal Laminectomy. The owners preferred to try physical therapy. Radiograph results were normal for bilateral stifle and the hip joints. His owner refused NSAIDS because of previous GI upset with medications. Hanks prior medical history included bi-lateral shoulder OCD surgery done on 10-19-04 and probable L-S IVDD diagnosed on 11-28-06. At that time he was treated with rest and acupuncture for several weeks.

On initial evaluation, Hank presented, in standing, with Toe Touch Weight Bearing (TTWB) to Partial Weight Bearing (PWB) of the RHL. At a walk and a trot, he presented with shortened strides bilaterally in the hind limbs, TTWB to PWB of the RHL, and a lameness score of 3/5. Moderate atrophy was palpable and observed in the right gluteals, quads, and hamstrings. Moderate muscle spasms were palpable bilaterally in the epaxial musculature T9 to the pelvis. Moderately decreased vertebral mobility was palpable, especially into extension, from L1 to S1. Hank would not allow hip extension in side lying or standing. Neurological tests were normal. L7 nerve root mobility was 50% on the left and 25% of normal motion on the right. Cervical and thoracic limb passive range of motion was normal and painless. Bilateral stifle and tarsus mobility was normal and painless.

On the initial visit, Hank was treated with manual segmental traction from T13-S1. His owner was instructed to limit his exercise activities to one hour per day, including herding activities; and to massage the epaxial musculature sid to bid for ten to fifteen minutes. Hanks owner observed and demonstrated correctly a “tail pull,” also to be done bid for two to five minutes. The plan of care was to see Hank for physical therapy BIW, gradually working towards core strengthening as tolerated and decreasing to QIW visits.

Hank returned for his second physical therapy visit on 4-24-09. His owner reported that Hank loved his massages and that she had begun his “tail pull.” She stated that the first time she pulled his tail; Hank turned around and started biting at his right leg and the base of his tail. She continued his “tail pull” with increased tolerance from Hank. She reported he had not been “three legged” since the first time she pulled his tail. The second treatment session included Functional Integration™ (FI) to improve RHL weight bearing. Segmental traction was performed from T13-pelvis; bilateral L7 nerve root mobilization was also performed. Hank still did not allow any hip extension during treatment.

Hank’s third visit on 4-28-09 consisted of soft tissue release techniques in the right abdominal oblique, hip flexors, and epaxials. FI was performed to further integrate spinal motion to RHL weight bearing and extension. L7 nerve mobilization was performed, along with segmental manual traction from T11-pelvis. Upon completion of the visit, Hank’s L7 nerve mobilization had improved to 100% with no pain response.

Hank returned on 4-30-09 for a fourth visit. His owner reported that she had taken him for an hour and a half romp in the open space the previous day, and, for the first time since his injury, Hank did not limp after taking a nap. Treatment consisted of manual segmental traction from T11-pelvis. FI was done in sitting and left side lying, with focus on integrating the four limbs with the thoracic spine with weight shifting.

Hank was re-evaluated on his fifth visit on 5-04-09. His lameness score had improved to 15 with partial weight bearing and full strides on the RHL. He was allowing 120 degrees of bi-lateral hip extension passively during treatment. L7 nerve mobilizations were normal bi-laterally, as were L5 and L6 nerve mobilizations. His owner reported that he was running faster and able to run for longer periods of time without rest. She was noticing a limp that was off and on, depending upon Hanks activity level. Treatment continued to be manual therapy, including FI to integrate weight shifting through the four limbs during all gait activities. Soft tissue release techniques were also being used in the epaxial and the oblique musculature.

Hank participated in a herding competition the weekend before his sixth visit on 05-07-09. His owner did not notice any limping during or after the competition. She also reported he was limping three to five minutes after a short rest or after sleeping overnight. She was not noticing any gate abnormalities during the day. Visits six and seven (05-12-09) were similar to visit five above, with the focus being FI for more efficient and pain-free gait.

Hank returned to his eighth visit on 05-14-09. His owner had reported that he had been about the same that week; however, she had noticed that Hank was beginning to stand with his right leg behind the left. On evaluation, his right ilium was caudally displaced. MET was performed in standing position to correct the displacement. FI was performed to integrate weight bearing with spine and pelvic extension. Hank’s owner was instructed to decrease his runs in the open space to 30 minutes and begin swimming for 15 minutes, TIW. Swimming was added primarily for core strengthening and energy release. His owner was given precautions and told to watch for increased pain possibly due to increased spinal extension during swimming. She was also instructed to begin gym ball core exercises BIW to TIW. Physical therapy appointments where decreased to QIW.

Hank returned for his ninth visit on 05-19-09. His owner reported that she had not had any adverse side affects from swimming. He had also won a herding competition over the weekend. She reported that he still had a mild limp upon rising from sleeping; but estimated that the limp only continued for 30 to 60 seconds after rising. Treatment on that visit included FI for weight shifting and hip extension. Segmental traction T11-pelvis was also performed; and L5, 6 and 7 nerve mobilizations continued to be normal and painless. His owner was instructed to increase Hanks swimming time from 15 minutes to 20 minutes.

Upon presentation of his tenth visit on 05-26-09, Hanks owner reported that she had not seen Hank limping at all since his previous visit on 05-19-09. She had increased the swimming time from 15 minutes to 20 minutes three times a week; she had increased his running time to two hours since his last visit. On evaluation, Hanks gate was normal at a walk and a trot. Hip extension had increased to 145 degrees bi-laterally in side lying. Spinal and pelvic extensions were still mildly decreased. Treatment included FI for spinal, pelvic and hind limb extension.

On 06-02-09, Hank returned for his eleventh visit. On evaluation, his gate was normal at a walk and trot; range of motion through the spine and hind limbs was normal; and nerve mobility was normal. Treatment consisted of FI to integrate the entire body in running and trotting gates.

Hank was seen for his final re-check appointment on 06-16-09. His owner reported that he had been working hard and more frequently and was not noticing any limping or stiffness. He had returned to full activity and was continuing to swim two to three times a week. She was continuing to do massage and core strengthening with the gym ball two to three times a week. Evaluation was normal. Hank was discharged with all goals met.

DISCUSSION

It is probable that Hank would have reached his goals in fewer than 12 treatments if his total activity level would have been limited further from the beginning of treatment. However, it was of utmost importance to his owners that he continued working and exercising as much as possible throughout the course of treatment. In addition, swimming may have been beneficial to add earlier in his home program for energy release and core strengthening. Hank’s limited hip and spinal extension was the determining factor in waiting until the eighth visit to begin swimming. Infrared or laser may have been beneficial in decreasing pain and inflammation early on in the rehabilitation process. However, the client’s financial limitations were a restraining factor throughout treatment, so treatment techniques were kept to a minimum cost to them. If Hank had not been improving consistently, the treatment program would have been adjusted significantly and included more modalities for that purpose.