Hello everybody and welcome to today's webinar brought to you by the webinar event. Now, my name is Doctor John Waterhouse and I'll be your presenter today for part two of the Introvertible disc disease webinar series. And so today we're gonna be talking about how to perform a physical examination on an introvertible disc disease patient.
But before we get into that, just a little bit about my background, if you didn't catch me on part one. So I'm a licenced Australian veterinarian that came out to the United States back in, oh God, 2010 to undertake a fellowship in pain management under the Tillis of Doctor Jamie Gaynor. Once that finished, I then went on and completed my canine rehab practitioner certification at the University of Tennessee.
And then I came back to Colorado Springs and consulted on the development of a 1500 square foot rehab facility for six orthopaedic surgeons. Since 2014, I started veterinary teaching academy to produce online educational materials, and I speak on topics of canine rehab, sports medicine, laser therapy around the world. So just a little bit about my background, if you're new and you haven't heard any of my other webinars in the webinar vet membership archives, or you missed last month's part one webinar.
So that's enough about me, let's get on to what we're really here for, and that's about talking about indivertible disc disease, and I apologise for last month's webinar, I went, Really quickly or Because there was so much information that I had to cram into a 15 minute presentation, because this is a 3 hour topic, that I talk about for my students. So therefore, the lovely people at Webinarett came back and there were a lot of questions that people asking, Can I go back and talk about physical examination because I briefly mention it in part one, or part one webinar, and so that's what we're here today to go back and really do the part one. Very physical examination first where we talked about the treatment modalities and options in last month's webinar.
So what we're gonna talk about today is what are the clinical signs and symptoms of an invertible disc disease patient. We briefly talked about that in last month's webinar. Then we're gonna talk about tips on how to perform a physical examination on an invertible disc disease patient.
How to perform a pain examination, a lot of people ask that question because they talk about pain examination and what I do. What to look for in a gay examination of an indivertible disc disease patient, and then we're gonna talk about diagnostic tests to perform to confirm a diagnosis of indivertebral disc disease. So hopefully you have your pens and paper ready.
I'm not going to be going as quickly as I went last time because I don't have as much volume of information to get in in 50 minutes, but still we'll be moving at a pace and strap your seats, your belts on and let's go. So let's talk about physical examination. So, we need to talk about what is an acute injury and what is a chronic injury, which will go into a lot of detail in the first webinar, but acute injury, Usually pain levels that are mild to moderate or can be severe.
And I classify acute injuries as something that lasts up to a month. And it's usually related to some traumatic injury, surgery or medical problem, and it resolves when that underlying condition resolves. Chronic injuries are recurrent repetitive clinic have repetitive clinical science what we're gonna talk about with indivertebral disc disease patients.
Their long-term conditions lasting greater 3 months. They usually are progressive in nature and have multiple acute injuries sustained over a long period of time, so this could be indivertible disc disease degeneration. We could use this for osteoarthritis patients, cruciate ligament patients, we have micro tears, micro tears, micro tears in that ligament, and finally it goes.
And the original stimulus is usually absent. So what are some of the clinical signs for intervertebral disc disease patients, we have pain on palpation of the cervical neck region. So then we have hyperposia of the neck and front limbs.
We usually see spasm of the neck muscles if it's in the cervical neck area. We have ataxia of the hind limbs that can progress to quadriplegic paralysis of actually all the limbs, acute onset paralysis or quadriplegic paralysis and a different, this disease has multiple faces and multiple different. Ways it can present, so that's the big catchphrase is, it can be very mild to severe, and chronic slow progression of clinical signs become worse over time, really is one of the catchphrases for this disease.
So in the cervical region, I said this pain is the hallmark of cervical individual disc protrusion and maybe constant or intermittent. Most of the pain is of a rate. Of a nerve root origin, some may be associated with medingial integration of the, Of discogenic pain, so we have, when we're thinking of cervical lesions, we think of pain in that cervical area, and this is different when we talk about the thoracol lumbar region area.
So as I said, clinical signs now of the raccolumbar region, we have severe severe pain, we have vocalisation, reluctance to move, these guys just don't want to get up. Protective when going to touch or going near that area, we'll talk about why that's important with your physical examination in the next couple of slides, and they can have aggressive behaviour to protect that area. So let's talk about observations.
So tips, this is one of my tips, we're gonna have tips as we go through, observe the patient in the waiting room. See how they are, even before you, you, when you come out your consult door, even before you call the their their owner's name, look to see how the patient's sitting, are they lying, are they pacing, are they restless, what they're doing, because this gives you a good key to what that, Presenting problem because we're now in, we're still in a stressful environment of a waiting room, but we haven't got them into a closed confined area of the consultation room. And so we can pick up subtle hints and then watching them walk towards the consultation room, you can pick up subtle hints of what might be going on even before you get them into the consultation room.
So as the patient rises, look for weakness, limb trembling, full weight bearing or non full weight bearing on one or multiple limbs, panting and any signs of lameness when they're walking towards you and the consultation room. Common clinical signs we see for indivertebral disc disease patients, shortness of stride, trouble getting up, usually they have a stiff gait, partial or complete lameness, but this is a really cloak and dagger disease because if they've got bilateral just slight any type A attack yet, they might look normal because it's on both sides and it's normal. Decreased range of motion and neurological deficits.
So here's a little guy, he came in, he had a really short, stride, we'll see if the video works. So you can see he's pulled under his carriage, he's not wanting to walk. He's taking really minimal, microsteps, and he's really painful.
And this guy was really painful in the Isola area, but I just want to show this was walking towards the consultation room, and you go, Wow, OK. Instantly, something's going on here that's not right, and you, your cogs in your head, we'll start turning about what your differential diagnosis could be. So let's talk about orthopaedic examination.
I want to say firstly, I'm not an orthopaedic surgeon, so this is what I do, what I've learned over years in practise, working with orthopaedic surgeons. This is how I do my examinations, but I'm the first to say that no, I'm not an orthopaedic surgeon, but this is how I do it. So we have invertible disc disease regions and so the classifications of disc rupture is generally grouped into larger regions.
And I've learned this because you can then hallmark it to regions and makes it very easy to, when you refer out for decompressing surgery or ventral slight surgery, then you can give a good guide to the surgeon for where the lesion is. So here is a breakdown of the different areas that we break into the lesions for talking or documenting where a potential invertible disc disease lesion is. So, orthopaedic examination, so we do an active range of motion, a passive range of motion.
I take measurements of joint angles, muscle girth, and I assess joint function every patient that I see. So tips, with your examination, this is where it comes back to the painful route. Leave the painful sight, if you see an acute injury, say if they're hit by a car, or you just see ataxia, in the hind limbs or their non-weight bearing on one leg, leave that area to last.
Don't go straight for it because we know that we're going, that's gonna be the painful area when we pull, we probe, we bend, we twist, we're gonna actually set them up, they're gonna become more painful, so it will cloud your other exam because things that we're gonna do and you'll see with the pain exam and manipulation is very subtle. And if they're already hypersensitive to what we're doing, we may get wrong readings or misguidance or missing. So I always leave the painful area of the area, my rule of thumb, the area that they come in, that the client presents, this is the reason I'm bringing my pet to you, I leave for last.
But also this is a tip. Don't be afraid to muzzle. I deal with, I used to deal with all the Colorado Springs, police dogs and the the military dogs, and so they would come in and except for two of the working, police dogs, they would come in muzzled.
And if you at all feel that you're gonna get bitten, it's not worth it. We can have your staff bitten, have the client bitten, that's even worse, or have you yourself bitten. So I will routinely for these guys to come in and have any type of ataxia or neurological deficits, I'll ask that we put a muzzle on them, and it'll be a.
Soft cage muzzle like this, so it's, not too stressful for the dog, not it's too stressful for the client, because that's a big thing for clients to understand and get over. But I will ask that we muzzle the dog just to keep everyone safe and even keep the dog safe too, during the physical examination. So other tips, when they're in the consulting room, and you're talking, I never touch the, you know, the patient when they walk into the room first.
I talk to the clients. And that gives me a good 10 to 20 seconds to 30 seconds just to watch how the patient reacts in the consult room before we even address. So I'll look for stance abnormalities, changes in gait, any structural deformations and any neurological deficits while I'm having a chat with the owners like, hey, how are you going, What's, what are you presenting for, what are you thinking?
I'm always watching the patient while they're telling me just to pick up these subtle hints before I put my hands on the patient. So let's talk about visual examination. So I'm looking for, as I said, any signs of lameness of various degree.
Any signs of muscle attribute, muscle or muscle development, because if they've got a hind limb problem, they're losing function of hind limbs, they become really big in the shoulders. Become really developed with their muscles in that forelimb because they're now using the fore limbs to pull themselves along. Any decreased activity, decreased range of motion of joints, swelling of or around joints, because we can see this with chronic nature, any pain and stiffness on passive range of motion.
So, it's important to watch the patients walk to see what level the lameness is. And I've got some really great videos for you, later on. This can be done by having the patients walk over different surfaces.
So I try and get them to go up and down stairs if they can do it safely. If they walk into the consult room, they're a taxi and they're flopping around, I don't ask them to walk stairs. I do this for the, Pretty much normal patients or the patients that you just think, OK, I think there's something going on here, I will walk them up the stairs and I'll film them walking up the stairs, up and down the stairs.
Going over on an even surface. So here's a picture of a little obstacle course we have set up at the clinic, and if you don't have access to stairs or a pre-built obstacle course, go into the car park and get them to walk up and down gutters over, different trains. So on the ash belt, the concrete, on grass, I mean, if you have sand or little bushes, something that they have to step up and over, just to see how they, how they ambulatory or amgate over those structures.
So tips, with bilateral lameness, you may not see any signs of lameness. And this we can see with patients with indivertible disc disease, also patients with hip dysplasia, and patients with, say, bilateral cranial cruciate ligament rupture, you might not see any lateness because they're lame on both sides. When we're dealing with.
Invertible disc disease patients, we have a neurological component because we have compression of that spinal cord. We now have, ataxia and loss of, proprioception and feeling. All those things are happening to both limbs sometimes at the same rate.
So they may not be clinically lame when they come in, but there is lameness, . To the disease that that patient is experiencing, so this could be a trick or something that can catch you, and so I always look, even if I see a dog that's sound, I suck. I always think, oh, are they lame as a bilateral.
So measurements we talked about, measurements we want to have a muscle girth measurement, we wanna do goometry angles of the joints, we wanna do a muscle strength test, and we want to do free movement tests. We'll talk about those tests now. So girth measurements, so for the front limb, we have the humerus, and so I go 2/3 proximal up the humerus for my measurement.
On the hind limb, I go, I take the measurement, 2/3 up the grade or to 1/3 down or, on the 2/3 up from the condyle on the femur, as you can see here in the diagram. And so these are great landmarks, and I'll actually put, if it's a white dog, I'll take a Sharpie or a black ink pen, permanent marker, and make a dot there, if it's a white, black dog, I will use some, White pen or white out, just put them up, or if they're going into surgery that I put a little clip and I'll just click a little spot and that's now a landmark that I can keep going back. So as they come back through for treatment or post-surgery, I can then always just quickly do a quick measurement at that spot, and we can track how that muscle mass is doing.
Is it getting bigger? Is it getting smaller, or what's going on with it? So that's just a, another tip.
So, what do we usually see? So we see muscle actually usually noted on the affected limb. And so if usually if it's bilateral, there may be one side that's worse than the other, and that's common with hip dysplasia, elbow dysplasia, or cranno cruciate ligament disease.
But with invertebral disc disease, they may be bilaterally lame or ataxic, and so you'll have equal muscle. Pendry issues, their front limbs or their front carriage will get bigger if they have ataxia or neurological deficits in the hind limb. So these patients, as you're measuring, if they're getting bigger at the front and you don't have any, Lameness that you can note on the hind limb, that's another warning sign that I, not clinical sign that I go, OK, something's going on with the hind limb because we're getting bigger muscles, more developed muscles on the front limb.
That means they're shifting their way forward, they're pulling with their front limbs, that means something's going on with the back limbs and it's another diagnostic test. So I can't over, Exaggerate how important even for all your general physical examinations, just, even if you just took girth measurements of the muscles, and it takes 30 seconds, and put that into your record, it is a great diagnostic tool to compare against over the years, as a baseline to see if things are going on with your patients in regards to muscle mass, because that's can be a really early indicator of something going on. So gynaometry, we look at joint or the affected joint or all joint and measure the joint angle, and use that as a reference.
And while I'm doing gometry, I'm also looking at joint biomechanics. Is there any repitation in that joint? And is there any pain during the movement?
Is there any swelling or edoema in that joint? So while I'm doing the joint angles, it's a great opportunity to check that joint out at the same time. So joint angles, we measure all the affected joints, so we do front limb and hind limb.
Usually angles will be less on an affected limb than a non-affected limb. But this is, that's classic for in vertebral disc disease, oh no, so classic for arthritis, any type of joint disease, but with inadvertent. Well this disease, this can be a red herring.
And they can actually have greater joint ankles because they've lost propriception, muscle tone, and innervation sometimes in the high limbs or all the limbs. And so you might get greater joint angles because there's nothing stopping that end point. You can go beyond that end point because there's no muscle tension.
So this is where you can get get tripped up a little bit, but it's important that you still do it, and it builds your confidence with joints because they give, it gives a really good diagnostic picture to follow over time as well. Muscle strength testing, so we talked about, a lot of people ask me how I do this, I, it's either the paper pull test or the pullus test. So I put a little bit of paper under the hind limbs and I just pull it backwards, and usually if they're weight shifting, they should be 60% of their weight on the front limbs, 20 or 40% of their weight on the hind limbs, and then as the normal weight distribution that diagram I produced there shows, it should be 20.
20. So if you're pulling back really easily on one side and really hard on the other side, you know the weight shifting onto the harder side, and they're not putting as much weight onto the limb that's easy to pull back on that piece of paper. With the front limbs, it's just the same.
You put your little, you put your fingers behind the carpets and just push them back and forth and see how easy it is, and you'll really get an easy picture or a quick picture of where their weight is and where their weight distribution is. So tips with strength testing. You'll see the loss of strength in the affected limb.
So here's on the right-hand side, as I said before, the normal, 60 on the front, 40 on the back, and then you see on the injured side, and this is for a front limb injury, you see the weight shift so you'll then have 10%, And then 50% of the weight will be shifted to the other side, from the left-hand side to the right-hand side and the front foreling, and so, This can be a really easy and it's just cheap, it's your finger or a piece of paper, so you actually get some diagnostic information without all the bells and whistles that we'll talk about. Free movement, as I said, we do passive range of motion, but we also, while we're doing that, feeling for crepitus, pain, any swelling around the joint, or any abnormal changes to the joint anatomy. Structural palpation of the joint and so a lot of people are saying, do we, And so this, it depends what disease.
If you think that this dog is an invertible disc disease dog, I don't because we're, we're now wanting to check the spinal nerves, see how they're going, they're doing their, these tests, but if we're looking at arthritis, we're looking at cranio cruciate ligament disease, we're looking at other or. Orthopaedic joint diseases, then there are sometimes you want to sedate and sometimes you don't. But for anything that I subject or think about that's gonna be neurological or have a invertible disc disease component, I do not sedate for any of my passive range of motion, flexibility tests, mobility tests or strengthening tests.
So let's talk about palpation, but this is really important and it has to be, and it's one of those areas that needs to be done correctly when you're dealing with an invertebral disc disease patient. So the goals of palpation is to determine what's causing the joint limitation. Is it pain, is it inflammation?
Is it swelling, is it degenerative joint disease, is it near lagia, or is there a neurological component? So let's talk about the spines, that's what we're all here about for intervertebral disc disease patients. So I break the spine down into really 4 areas, the cervical, the thoracic, the lumbar, and then I don't have here the sacral area.
So with spine, palpation, we have to be really gentle. If we all think about, these guys, a patient comes in, you think it's indivertebral disc disease or it's, got any type of neurological deficits. I'm very, very careful with my spinal palpation.
If I think that this is just a young, healthy dog with hip dysplasia, elbows displaced. Like an OCD lesion or something like, or, kind of cruciate ligament disease in an older dog. And I'm then a little bit more, I won't say aggressive, but I'm a bit more firm in my spinal, segment manipulation.
But when I think it's a neurological patient, I'm really cautious, and if they're really ataxy, if it's a dash out or something that I know that's going to be a chondrodysplastic breed, I sometimes will not palpate the spine at all till I then get radiograshed and everything just to see what's going on, just because you know, multiple discs are in, in, play in that. But if it's a non-chondro dysplastic dog like a German Shepherd, things like that, I'm a little bit more confident, to do a little bit of, spinal segment moving, just trying to work out what's going on. So it's very important to respect pain and restrictions.
Hypermobility often exists for a reason, so trust that. If you see pain, if they, they don't want you to touch that part of the back, where you're getting extra hyper mobility, respect that. Don't go and force on it and try and get the chiro like my trainer or one of the orthopaedic surgeons says, I'm not there to be a chiropractor, I'm there to be an examiner.
And so we want to just examine very subtly as we go down, and I find the more subtle you are, the more, less pressure you are, the more diagnostic you get. And we'll talk about this in the pain examination. Mobility tests, so we're testing the movement of the scapula, the spinal facet or facets in the cervical spine, thoracic spine, lumbar spine, and we're also looking at the sacral spine area as well.
So with our palpation, we want to palpate. And have a good recognition of what normal movement is, so when we find abnormal movement, we know what that is. Most mobile mobile area in the body is the thoracca lumbar region as we come off the rib cage, that's really a box that doesn't move in the thoracic area, but then when it goes thoracic lumbar, we now have all this free movement of the spine till it gets to the hips, that's in the box.
And that's where we traditionally see 75% of all lesions is in that thoracolumbar region for indivertible disc disease. And the areas will increase or decrease along the spine with areas of mobility, and different ages and breeds will have more or less different movements. So, by just doing this on different breeds, you start to feel what a muscular greyhound will feel like compared to a, chihuahua or a A Labrador retriever or different dogs that do different things with different muscle structure and conformations will have different palpation and mobility in their spine.
So underlying orthopaedic diseases that can affect this is hip dysplasia, stifle disease, lumbosacral disease, and these conditions cause areas of the spine to tighten up, or actually soft tissue area around the spine to tighten up, because I know we've all pulled our back and all of a sudden everything freezes, your whole back locks up like it's in concrete, you can't bend over. Tie your shoes. It's quite an amazing thing what the body does to protect itself and, from, and allow itself to heal.
And the same thing with this. So any underlying orthopaedic injuries to the spine or the hips, or the stifle can trigger this soft tissue locking up response that will show you when we do, pain evaluation. So tips, ileosoas muscle is the, the biggest issue of the non-issued causes out there.
A lot of people don't know about the ileos, and so the ileos can also mask a lot of things. So you can see a lot of back pain actually can be ileos sous pain. So what is ileosois pain, so it's pain with stretching of the hips into extension or internal rotation, pain with stretching of the hips into abductions, and then pain and spasm in the groyne region and the lumbar region.
So a lot of our gilli dogs, working dogs, and you'll see in my pain video we have a cholera. Police dog Vader, and you'll see really some great a great example of what ileosois, pain is. But this can actually be very debilitating pain, but it can mask itself as back pain, and you think, oh, the dog's got back pain, and no, it's in the muscle strain.
So tips to work out if it's ileosoms, so patients will exhibit pain especially when in motion, involving hip extender or lumbar extensors, so. Activity dogs, they won't jump and they'll knock bars over. Frisbee dogs, they won't be able to get high, they'll actually vocalise when they try and jump.
They'll have decreased activity level, decreased jumping performance, and these, when I'm doing my physical or verbal history with clients, and I'm asking all these questions, and if it's a gilly dog or working dog, I have a different list of questions, and we talk a few about the questions before, in last month's webinar, but, When they say things, oh they're knocking down bars, they're vocalising when they're jumping, they're not getting that hype, I start to think about ilo sized muscle injury. So let's talk about a little bit about neurological examination. And so we need to perform and determine the presence or absence of any or a neurological lesion and we present to determine its location and the probable extent of damage to the nervous system.
So we're not going to go into how to perform a neurological examination, we just don't have time for that. And, but I really encourage everyone to do, start from the top and do a full neurological examination on any dog that's you assume may have invertible disc disease or any neurological function. So what we do, we look at the cranial nerves, and they can have Involvement, yes and no, postural reactions, we're doing wheelbarrows, hemi standing, hemi walking and hopping.
Conscience proprioception of tendons, the tendon flexors, the biceps, the triceps, the craniotibualis, and the gastronemius and the patella. We're doing sensory perception, bladder function, and anal reflex tests when we're doing our ne neural examination. Here's a great chart that I've used for years, and I thought I'd put it up here.
So when I do my neurological examination, I have a little check piece and I check off, yes, normal, no. I then go back to this table and you can come back and review this, and it's a great way to see if they've got positive or negative, neurological function, you can actually work out with this table and get a better idea of where potentially a lesion will be. So People then ask, what is the paniculus reflex?
And so paniculus reflex is one of the cornerstones I, reflexes I use when I'm dealing with a neurological dog or dog with inhibit or disc disease and I'm trying to work out where the lesion is. And this is a reflex iced by applying a noxious stimulus to the skin that stimulates the superficial spinal nerves, inverting it, Innovating a particular region of the autonoma zone or the dermazone of the dermisone lists the motor response, which is seen as a muscle twitch. And so, A deficit in the cutaneous trunchi response at a specific location indicates a spinal cord lesion, and this is really cool, that's approximately two vertebrate bodies cranial to where you elicit the response.
So I get a pen. Some people use a blunted needle, they file down the points and just start the point, but I just use a pinpoint, and you go up the back slowly between each invertible disc on either side, about 2, I do like 2 inches or 6 centimetres on the inside of the spinal cord and just go up and you just poke with the pen, and their muscles will fasciculate, fasciculate, and as you're coming down the spine, so you're going down the spine fascia and then it'll stop. And then you won't get any muscle fasciculation anywhere below that point.
I put my finger on that point, go along to the spine, fill that invertible crest, and then move two spaces up, and that's where the lesion's going to be. So it's a pretty cool test. Pain examination.
So with my pain examination, the tip, be systematic, do the same regime every time because it teaches you good habits. Perform on every patient, so I do it as a standing examination to start with if they can. If they can't, then I try and modify it for the floor, .
As I said here, a recumbent examination is secondary and based on issues that are determined, or if they can't stand with a neurological patient, they come in, they are toxic and have great deficits, then I try and do it on the floor. But you're now getting a modified exam, but then your, your results aren't as objective as if they're standing, but still something's better than nothing. So pain, I break the spine down into, three areas for this.
I do the cervical, the thoracic, the lumbar, and the iliasoas muscle regions. So this is a soft tissue examination, not an orthopaedic examination. So, you'll see how, how we do this, and it's a very gentle light probing, not what you'll do for an orthopaedic examination.
So what we're looking for, we're looking for signs of muscle tremor, muscle for circulation's licking your lips, and they turn and look at you, whimpering or whining, pulling away, growling, mouthing you and trying to bite you. So if you think the dog's gonna try and bite you or it's an aggressive dog. Feel comfortable with, please muzzle, like I said with that earlier tip.
It all, it's not worth getting bitten, or your staff getting bitten or clients getting bitten because it just sucks. And, for a bit of, and I call it ego, and when I started, I said, oh, I don't need to, muzzle anything. And then once you get and most dogs will mouth you and say, oh, I don't like that, and I go, thank you very much, but some dogs don't have that in their communication vocabulary and they just bite.
And so it's just not worth it. So now I explained to owners, I don't, like, this is for the sake of your dog, and for all of us, we're going to do this examination, and it can be painful. It's a pain examination.
Do you mind if we just put a cage muzzle, a soft cage muzzle on your dog? I show them, they hold it, they say, oh yeah, that's fine. Usually 100% of nearly all owners will say, yes, no problems, and then everyone's protected.
So here's a video. This is Vader, he's just come in from, a police bus. He took down a suspect and in the, we'll call it the fight, the suspect jammed him up and so that's a, a terminology where as the dogs, they're biting, there's, The spinal area, like the dog's hanging in the air, they get shaken around, the suspect fights and these dogs get beat up, and so I had a really, a policy and truly, I really encourage you if there's a canine unit in your area, reach out to them and offer them support.
I had an open door policy, anytime any dog was injured, they would call and I'd get them in before consultation in the morning in my lunchtime break after night and afternoons and sometimes I'd come in on weekends or even at nighttime just to get these guys back and away. So I'm gonna play this video, and I apologise as a black dog, but you can see the shininess of his coat and you'll see the muscle faciculations really well. So as I said, I start at the top and I just work my way down, I work between each of the set and I slowly push it and I like you're pushing onto a testing a tomato.
So that's as much pressure as you want to go and push in and you're just going down, you're looking for the and here we go iliao, whoa, OK, so you can see that fasciculation, so it's really sore in the ileosois region and so then we go back and we just retest and you can see those very slight little fasciculations. And so this is one of the only police dogs that I would trust not. To be muzzled.
And so that gives you a good idea, and so it's as much pressure as you place if you were testing the ripeness of a tomato. And it's on about 2 inches or 6 centimetres on either side of the vertebrae, and you'll just go down the muscle belly, very lightly touching, and you'll see the sciculation where they're sore, and that gives a great example of where they're paid for. Here's another example.
This guy came in, he was a sled dog pulling, had neurological signs. I'm gonna play the whole video because he's a cheeky bugger, and when I start, he then runs away because you'll see how painful he is. And so I start, you see the fasciculations there, and I'm just there and he runs away.
He vocalises. He then comes back and we grab him, and he's, and like Huskies, he's a lovely cheeky, cheeky bugger. And then we, we start again.
And so you'll see here when I get down into the lumbar, sacral area, and then bang, he collapses, and he collapses, and he's just really painful. And so he had a, a disc issue and that. I can't remember which area, the track of lumbar area, but he then went off and we had medical management and he did great, but that's how I do my pain examinations.
Flexibility testing, we're looking for stiffness on the affected area, muscle tightness over the spine, so if it's a front limb, area, we have cervical thoracic spine region area. If it's a hind limb pain area we have lumb or thoracic lumbar pain area and tightness. Pain on palpation, so be muscle palpation, be systematic.
Think about the actions of the muscle group. If pain on palpation, perform the opposite action of that muscle, and then palpate, make sure you palpate the entire muscle. So gate So, physical examination, what we usually see, so visually, we, I like to see when they come in, how they're sitting, is the affected limb sticking out.
So here's a photo of a limb sticking out, this is an abnormal sitting position. So if you see that, you go, oh, instantly there's something going on on with the hind leg leg. Is there a head bob when walking and the shorter stride length usually is shown on the affected limb.
Decrease extension. Circumduction or an outward walking gait, and you'll see this in the video, decreased power and pushing off as the condition worses may be non-weight bearing or partial weight bearing, or you can't tell if it's bilateral weight-bearing because it's a neurological disease affecting both limbs. I'll ask the, when I go into the consultation room, I ask the patient just to stand there for 10 seconds while I'm talking to clients, I'm watching, seeing if they can stand for 10 seconds.
Here's an artificial, photo of my dog for one of the photo shoots, and he's just standing there and he's standing weird. You can see the right, hind limb is sticking out abnormally. That is a subtle thing that something might be going on, and that just gives me an idea when they're standing.
If they can't stand for 10 seconds, every dog should be able to stand for 10 seconds. I know that there's something wrong. Gate analysis, what we're looking for, we're looking for head bobbing, and they'll head bob or not, any signs of laying the stride shortening we've talked about, weight shifting, neurological deficits.
Watch for various angles, front, back, and the side. Walk them if they can, it'll walk and try if they can, and videotape everything because we have this thing called great slow motions. Here's the dog, we couldn't work out why it was lame, we put it under the underwater treadmill and then look at that carless collapse.
And so we video. They taped it, played it back in slow motion, you see the front left limb. Here we go, it's coming down and collapsed.
And so this dog was out, and was running in a field. They heard a yelp, and it, it supposedly put its front for limb down a rabbit hole, and it then tore the collateral ligaments in the carpus. Here's an examination or example of ataxic dog that came in, and this dog has invertible disc disease, but you can see, OK, they're toxic, they're wobbling everywhere, they're crossing, they're not neurologically sound, this is a great, if you see that come through your consult room says there's a side view, here's a hind view.
You go, OK, there's something going on here. So that's peg-legged, you know, circumducting out to the sidewalk. The other on the left-hand side's a little bit straighter, but they're all over the shop, they're crossing, they're collapsing.
These are the neurological signs you'll see with an indivertible distipation. So this is quite a, a, severe case, some of them are more subtle. Important to watch the patient, as I said, walking over an obstacles, uneven ground, and this can be done by having them over an obstacle course, or you just saw there we were in the street, and I didn't have to walk, have her walk over the gutters to show that she had a neurological issue.
But remember, record, record, record, because if they're always stepping up with one limb on the stairs, they're always bleeding with a limb on the hind limb or the front limb. And they're never alternating that means the lead limb is the strong limb and the second limb or the lag limb is the weak or the affected limb. As I said before, going up and down stairs, uneven surfaces, and if you don't have access to those things, go to the car park.
Gait analysis, lay this is this is another Colorado Springs dog, this was TJ and TJ injured himself, jumping through a window. And so this is, as I said, really important we give back to our community. So front limb, hind limb, I've said before, 60% on the front limb, 40% on the hind limb.
Number one rule, don't walk your patient yourself. Train a technician to walk the patient on a loose lead and never have the owner walk the patient. Pacing, pacing can be normal in dogs and actually can be induced, well, I'll just quickly show you a study in the next slide.
So my German Shepherd is always aced, so when I'm doing my history, if I see in the lameness, Walk that the, the patient is pacing, I then ask the clients, have they always paced or have they not paced, and if they say, always paced, I'm not so concerned, if they say, oh, he just started doing this in the last couple of weeks or last couple of months, I start to put, And that little light goes off in the back of my head, something's going on here. So we can also induce pacing, so this was a great paper that said we can artificially induce pacing by not being trained or having trained people walking their dogs every time. So I won't go into this payment, but that's just a quick reference for you to go back and have a look at.
So have a person, have them trained, always do the analysis analysis in a distraction free environment. So this is a room that the CAS at VOSM in Baltimore. In the United States have just do their evaluation.
They're probably one of the biggest and probably the best orthopaedic hospitals in the United States or if not the world. And so they have this whole gym room just to do their gate evaluations because it's free a distraction. This is the clinic guy built in Colorado Springs, and we built a purpose corridor with no distractions, and we'll talk about this mat on the left-hand side, called the gate right mat in a bit, but there was a, Door at the end, and I had glass entrusted in, there was a window at the other end, and that's, you can see the sliding door, on the right hand side is where the patron come in, you slide that door and there's no distractions when they're running up and down this century map.
Or you can use your hallway, so this is the consultation hallway, you close your consultation doors and you run them up and down the hallway, and that's usually a great distraction free environment. Another diagnostic test is wet paws on concrete, quick, you dip their paws in water and get them to walk across concrete or asphalt, and you can see the paw prints and then you get coloured chalk and you circle which pore goes to which, so I had a whole colour chart system and then you can measure with a quick tape measure to measure stride length to make sure that all the stride lengths are the same. We started this off, we had a great idea, Doctor Jamie Gaynor and myself, we rolled our butcher's paper in a roll down the hallway at the consultation between the consultation rooms, and we dipped each pouring ink.
I can already hear you guys moaning out there. But it was great while the dog was on paper, but then someone came out of. Consultation room, the dog saw another dog, bolted into that consultation room and left 4 different coloured inkalpis through the vet hospital.
So we went, realised that didn't work real well to start with, and then we went out into the car park and did it on the concrete. Do, diagnostic devices, so this is a stances analyse and really it's just a glorified 4 scales connected to a computer and you scan the patient on the scale, each limb or core is on a different scale, and it measures weight distribution. You can actually do this yourself.
With just 4 electronic scales in your clinic. When I go and have my chiropractic examination, they make you stand on scales just to make sure the weight distribution for us is the same, same principle for our patients, but this only works in one dimension. We then have, as I said, the gate right or gate for dogs, and this is a map with 30,000 sensors in it, and it measures now stride length, motion, velocity, weight distribution, and so we will go out to events and here's a photo of myself in a trailer.
Doctor Jerry Gaynor and I would roll the man out and then we would walk the dogs up and down for agility events and show events, find out where they were laying, laser them and get them in the ring and they would run pain-free, and the owners were amazed, and we were booked most weekends doing this. Below is my German Shepherd on, they now have it in a treadmill, so he's practising and is a dummy on the stands or the gate right in a treadmill, so no longer you need the 30 ft mat, you put them on the treadmill, they walk on the treadmill, and you get your diagnostic information. And this is what the diagnostic printout looks like.
So this is my dog Nahlo, another, shepherd, and so this is what the printout looks out. And then this is a great diagnostic piece. The client clients love it, because you can give it to them, and then every time they come in, you run them all across the mat and you get a diagnostic readout.
Are they getting better? Are they getting worse? And it's really subjective clinical data that you can use.
As I said, videoing, have the owners videotape their pets. Everyone now has a smartphone with video slow motion, get the owners to videotape and then they come and show you the videotape, send it to you, you can then put in slow motion and have them do multi-views. Front limb lameness is more challenging than high limb lameness to diagnose, and so, and it's also harder than high limb to treat, more difficult to manage clients expectations.
When we have a a front limb injury compared to a hind limb injury. In front limb lads will be a head bob, and the head will go up and down when the patient plays weight on the sound front limb. Up and when, and there they'll go up.
So think about you walking on, you've sprain your ankle every time you go younger. Oh, and you lift up. Same with the dogs, a head bob, the head goes up when they place pressure on the injured leg.
High limb lameness, a lot easier to observe than front limb lameness. We're looking for hip movements, we have a hip hike, same thing, when they put weight on the affected limb, the hip rotates away, and the effect from the affected limb as the patient shifts onto the unaffectiveness so you get a little hip hip hike, and this is really important when you're videotaping in slow motion, you see this. You might not see it when they're walking, but when you slow it down, you can really pick out the hip rotation, the hip hike.
Can we see, so hind limb lameness, we can see reduced flexion extension in the hind limb and the affected limb may appear stiff, leg may swing in and out, and the peg leg have a peg leg experience or ataxia. So here's the little guy, we'll see if the video runs, and you can see we've. Well done treatment for him.
He's now, we're a couple of weeks into treatment. We see a big change, but we still have that little shortness of underneath stride. He was bilateral, and so, but you can see a big improvement in him.
But that's what we're looking for, little subtle changes that you've seen. And I apologise we're going fast because we're coming up to time and I've still got a few more slides to go. Our combined force of high limb and front limb lameness, so very hard to assess which limb is the primary cause and which is the compensatory cause.
And this is for a neurological or invertible disc disease patients. So they're more likely to be primary for imb if they have a head bob when they'll hip hike, head bob without forward weight shifting, persistent head bob at a walking, or no changes in stride length in the hind limbs. So diagnostic modalities.
So people ask how do we work these guys up. So we have incredible diagnostic modalities for these guys. We have radiographs, soft tissue ultrasound, thermal imaging, CT scans, MRI, bone scans, and PET CT.
So what do these modalities do? So it's radiographs they're great for osseous disease and soft tissue calcification. Thermal imaging is great for acute soft tissue disease and osseous disease.
CT scans are best for osseous detail, bone scans find lesion locations. Soft tissue ultrasounds, better for soft tissue structures like muscles, tendons, and ligaments, MRI for soft tissue injuries, and PET CT scans, the new thing on the market, a great bone scans and metabolic activity. So our radiographs, as I said, show osteo structures really well, but don't show soft tissue structures very well.
So what we're looking for is, in our bone, they're great for diagnosing bone, osseous disease and for pulses calculus location for intervertical disc disease patients. So we're looking for offsets in the spine, we're looking for collapsed in a vertebral disc spaces, we're looking for minimalization of that The invertible disc, we're looking for hard tissue signs and that's what we're using our, our radiographs for. So as I said, radiographs won't show up the rupture of the indivertebral disc, but will show the overall position of other structures plus any mineralization or otolytic changes.
So here on the right hand side, we have a normal spine, and on the, oh sorry, on the left-hand side, on the right-hand side image, we then have an abnormal spine you see compression of those in the verbal disease spaces, and you see lithic changes and isolytic growth on the corners of the innervertebral discs. Radiograph evaluation of the invertebral column is performed with an animal in a general plane of anaesthesia. Especially these guys, we don't want them to be fighting, we want to either they're sedated or they're they're they're put under.
It's really important we don't be macho and fight with these guys on the table. I sedate them as a minimum, gently put them on the table, and then we take our views. And this eliminates any problem of motion, the facets or moving in the animal, but also some of these animals are struggling because neurologically, they're fine in their head, but things are going on back there that they can't control, they get worried, they get anxious, and some of these guys, will fight.
And so just giving them a little bit of sedation that can be reversed, is the easiest and most safe way for everyone in the room when doing radiographs. Cervical invertible disc disease routine for radiographs for animals with suspected cervical indivertebral disc disease should include lateral and ventral dorsal views of the entire cervical spine, and survey lateral radiographs of the serrao lumbar region. And so I really I I concentrate on the cervical area, but I do radiographs of the rest of the spine to see if anything else is going on, especially with our chododysplastic breeds.
Common radio radiographic findings in the cervical region and narrowing of the inner vertical distor space. Increased density into into vertebral foramen, and so this is will be above the intervertebral disc disease lesion, and what can you, can see mineralization or not in the spinal canal. And so the big tip is to look between C2 and C3 and C3 and C4 because this is where the majority of cervical lesions are, and cervical lesions make up around 18% of all invertebr disc disease lesions.
Thoracic invertible disc disease lesions, so with suspected thoracic invertebral disc disease, the lateral and ventral dorsal views of the thoraccolumbar and lower lumbar regions are taken, and survey and lateral radiographs of the cervical spine are routine, so we just reverse. And so you spend all you do all sides in the thraollumbar area and just do a survey radiograph of the cervical region, just to make sure things aren't happening up there as well. Thoracolumbar view with the cervical indivertebral disc disease patient and the cervical view of the tracolumbar indivertebral disc disease patient are indicated because multiple indivertebral disc diseases aren't infrequent.
So if I always think if there's 1, there's 2. And if it's a condo dysplastic breed, I always think if there's 1, there's 3 or 4. If it's a non-condo dyspastic breed, I still always think if there's 1, potentially there's another one.
Or when you fix the 1, you always then have potentiality for the next one down the chain to start to degenerate. Single radiographs of the entire spine are avoided because you have. Inadequate detail can have been not obtained because of the collimation issues of a radiograph, so we do multiple radiographs, multiple different places of the spine is the gold standard.
Myelographs, this is where we injected contrast material dye into the spinal column around the cord, able to visualise the spinal cord in any subarachnoids in the subarachnoid space. Due to the potential spi effects, I only recommend this if the animal's going to surgery and it's a pre-surgical case, just because, we have side effects and we want to minimise the side effects for this procedure, but if they're going into surgery and the surgeon wants it, then we do it. How to use a diagnose, so used to be diagnosed herniated discs, spinal cord tumours, infection or inflammation of spinal cord, spinal stenosis, the degeneration of bones and the tissues around the spinal cord, can cause narrowing of the spinal canal.
Ankyloidosis spinalosis or bone spurs, osteoarthritis, cysts, and injuries to the spinal nerve roots can all be seen in myelograms. Soft tissue ultrasound, I'll skip around this quickly, but this doesn't do osteo structures very well, but that soft tissue structures really well, but everything we're looking at soft tissue is encased in bone, so we don't do much with soft tissue ultrasound. Thermal imaging is great, so it doesn't do osteo structures well, but that soft tissue structures really well.
When we have disc lesions, so soft tissue injuries, tumours, infections, or nec necrotic osseous diseases, those areas get inflamed, inflamed and they light up like as you can see, here's a right-handed hip dysplasia. That area lights up and it's really cheap, diagnostic tests that you can do that just pinpoints areas of inflammation. Diagnostic imaging CT scan shows osteostructures very well, not soft tissue structures aren't so well, but you can build a 3D reconstruction, so diagnostic use for bone, osseous disease, muscle and tendon calcification, and very good for joints.
MRI shows osteo structure is not so well as CT soft tissue structure shows really well, so this is our go to. If you can get an MRI and it evaluates evaluates the entire organ, and diagnostic issues for neurological issues, soft tissue disease, muscle and tendons and ligament injuries, and also very good for the joints. Bone scans, this is another modality that's out there but not used much and so this is does osteo structures very well and soft tissue structures very well, but you need to inject a agent that can be tracked and, We don't do that much with invertible disc disease patients.
Big kid on the block, the new thing is PT, CT scans. There's, I think, two in the country here in the United States, one's just up the road at Fort Collins Veterinary School. This does obviously structures very well, soft tissue structures very well, and you can build a 3D model of what's going on, and incorporates nuclear medicine and metabolic and biochemical uptakes you can inject isotopes, and that's the word I was thinking for the bone scans, isotopes, nuclear medicine really map things really well and, Diagnostic use of bone scans and metabolic activity.
So here's a quick synopsis. X-rays are great for all joints and bone. CT scans are great for OCD lesions, complete joints and complete fractures.
Soft tissue ultrasound is great for soft tissue ligaments and tendons. MRI is great for neurologic and complete joints, bone scans for osteo problems, metabolic disease and infections. PET and CT is osseous problems and soft tissue problems.
So there we are, I think I've done that in the hour, and I want to thank you for listening to me. If you have questions, I'm sure that our friends at the webinar vet will take those and they can pass those on, and we may have another webinar to deal with the questions. I can then answer those, and I'm sure that they, the lovely people at our webinar met will get those answers to you.
But I want to thank you. I know your time's important. I hope you've got something out of this webinar, and I look forward to, speaking for you again in the future.
Bye-bye.