Observations : Notice R/ stifle looks fairly even. She is back to her normal chirpy self. Notice bunny hopping when she jogs, but she has been very keen on her walks.

Assessment : Shorter reps today and 3+ minute breaks to allow Misty time to recover. Bilataral 31cm R/H mid thigh. Reluctant to flex R/ stifle initially, but allowed once gained confidence in therapist. Paraspinal discomfort and fasciculations around mid thoracic region – slightly lordotic and atrophied in her back too. Dynamically, good range of motion of forelimbs. Lots of breath holding during H/L PRoM so discontinued this.

Treatment Plan : Weekly hydrotherapy

Harness Size : X Large

Pre Showering Techniques : Paraspinal warmup, Forelimb Sweep, Hindlimb Sweep, Primary joint compression

Water Height : 16″ x 6

Speed: : L2.5 x 4, L3 x 2

Duration: : 1m

Repetitions: : 6

Rest Duration: : 2m

Rest Period Interventions: : Effleurage paraspinals PRoM H/L and F/L hindlimb retraction and protraction stretches

Movement Shaping Techniques : Misty did very good, mostly HAT used to prevent sway in spine.

Observations : Misty has been good this week – anal glands have been cleared, but she still is suddenly looking around at her rear end – could they have recompacted?

Assessment : She appeared much more forward today, although kept the same reps and time. O. feels hind limbs aren’t as even still, and notice the rotation still. Agree with owner that rotation still there, but muscle mass coverage has improved a lot, and in the treadmill (with therapist support), she doesn’t rotate the knee (believe it might be femoral).

Treatment Plan : Weekly hydrotherapy

Harness Size : X Large

Pre Showering Techniques : Paraspinal warmup, Forelimb Sweep, Hindlimb Sweep, Primary joint compression

Water Height : 16″ x 6

Speed: : L2.5

Duration: : 1m

Repetitions: : 6

Rest Duration: : 2m

Rest Period Interventions: : Effleurage paraspinals PRoM H/L and F/L hindlimb retraction and protraction stretches

Movement Shaping Techniques : Misty did very good, mostly HAT used to prevent sway in spine.

Assessment : Standing very well in the tank, the medial rotation is almost absent now. Good muscle tone just 1cm diff between right and left (31cm L/ and 30cm R/). Good stifle RoM. Can still favour L/H at times and weight shift is approx 60/40% to left

Treatment Plan : Weekly hydrotherapy

Harness Size : X Large

Pre Showering Techniques : Paraspinal warmup, Forelimb Sweep, Hindlimb Sweep, Primary joint compression

Water Height : 16″ x 6

Speed: : L3

Duration: : 1m x 3, 1m15 x 3

Repetitions: : 6

Rest Duration: : 2m

Rest Period Interventions: : Effleurage paraspinals PRoM H/L and F/L hindlimb retraction and protraction stretches

Movement Shaping Techniques : Misty did very good, mostly HAT used to prevent sway in spine.

Observations : Noticed leg still disused at times in stance. Rolling on her back, which is something she hasn’t done in ages! O. noticed that she was chewing her paws recently, unsure if this is a habit, or allergy.

Assessment : Posture much more improved, utilising R/H. Is still weak to isolate R/H with 3LS in L/H, but can tolerate 3LS with L/F lifted. Muscle mass and tone appears to have improved, main lingering weakness in lateral hamstring (bicep fem). Some painful TP paraspinals – some resolved with massage incl. cross fibre and skin rolling which Misty enjoyed. Good RoM of bilateral stifles, hock and hip.

Treatment Plan : Weekly hydrotherapy

Harness Size : X Large

Pre Showering Techniques : Paraspinal warmup, Forelimb Sweep, Hindlimb Sweep, Primary joint compression

Water Height : 13″ x 6

Speed: : L3

Duration: : 1m

Repetitions: : 6

Rest Duration: : 1m30

Rest Period Interventions: : Effleurage paraspinals PRoM H/L and F/L hindlimb retraction and protraction stretches

Movement Shaping Techniques : HAT to prevent lumbar sway Lower water height by 1 inch which Misty coped very well with! Evening striding out. May add scrunchies to stimulate more R/H

Observations : Been on holiday to the Cotswold. Really enjoyed it. Owners still believe rotation is there. She was running around at the Cotswold ! No concerns.

Assessment : Hip extension achievable to 120 degrees bilaterally, some resistance but good with distraction. Good stifle RoM bilaterally. Little resistant to forelimb RoM standing up in the water, despite it being higher water height. Does still overload her L/H but not particularly cranial loading now. Multiple Tp in paraspinals, non painful although some causing paraspinal global fasciculations, some resolved with massage through the session. Moderately restricted fascia dorsal thoracic region to lumbar. Hypertonic medial thigh mm L/H. Hock collapse no longer noticeable,

Harness Size : X Large

Pre Showering Techniques : Paraspinal warmup, Forelimb Sweep, Hindlimb Sweep, Primary joint compression

Water Height : 14” x 7

Speed: : L2.5

Duration: : 30s

Repetitions: : 7

Rest Duration: : 1m30

Rest Period Interventions: : Effleurage paraspinals PRoM H/L and F/L hindlimb retraction and protraction stretches

Movement Shaping Techniques : HAT to prevent lumbar sway,

Observations : Going well this week, vet appt next week to check with progress. Notice that she is offloading it still, however looks much more stable.

Assessment : Her limb appears much more stable during stance phase, and her overall balance has improved significantly. Hypertonic dorsal shoulder mm, but less tone and muscle mass through to mid thoracic region, where TP are mostly located through to her pelvis, these are quite uncomfortable for her. Tender on flexion of L/ carpus, and repeatable crepitus observed. Good stifle ROM bilaterally, and hock RoM, although slightly tender on L/ hock flexion.

Manual Treatments Delivered : Gentle effleurage paraspinals, dorsal shoulder mm. Forelimb protraction stretch x 2 PRoM – carpus x 3, stifle b/l x 4 and hock x 4

Therapeutic Exercise Programme: In Clinic + Home Prescription : Added in clinic: POLES x 1, at level 2. She is quite food motivated to extend that she can become distracted so was knocking this pole. However, when focused, she walked very well over these – aim of poles is to improve balance and paw eye coordination. UNEVEN OBJECT FORELIMBS RAISED – on FitBone. Holding a stand for 3 seconds and releasing.

Electrotherapy Delivered : 4J x 2 R/ stifle, 2J per TP paraspinals, 4J per elbow and carpus B/L.

Treatment Plan : 2 weekly H/P. Continuation of exercises ADDED: Correct sit – with hind limbs tucked under, no slouched position with hind legs extended or sitting on bum. Ask her to hold for 5 seconds. Correct down – same as above in a down position, no side ways resting, both hinds tucked under in a correct down. Walking over legs – 5-10 reps back and forth to encourage equal stepping and balance of legs, try and prohibit any jumping!

Manual Pricing Adjustment : 0

Harness Size : X Large

Water Height : 14″ x 4, 11″ x 2

Speed: : L2.5 x 4, L2.2 x 2

Duration: : 45s x 4, 25s x 2

Repetitions: : 6

Rest Duration: : 2m

Movement Shaping Techniques : Gentle support of stifles bilaterally, encouraging weight bearing and limiting twisting of tibia. May require some HAT as minor lumbar/sacrum sway.

Observations : Misty has been great the past two days, now time to reduce to only 1x session a week and see how Misty goes. O. noticed her head carriage has improved, and overall posture.

Assessment : Standing much more willingly on the R/ stifle, however not completely equal. Forelimb ROM good today, little hesitant to extend B/L shoulders, but achievable. Repeatable crepitus bilateral carpus, but aware of arthritis in these joints. She is choosing to sit square, for about 10 seconds now, before falling into a sloppier sit. Was working on Sit, down sits today, which she can almost get, but quickly slops to the L/ hind. Although has preference to sit on R/ hind at times. Used resistance band, but unsuccessful.

Manual Treatments Delivered : Gentle effleurage paraspinals, dorsal shoulder mm. Forelimb protraction stretch x 2 PRoM – carpus x 3, stifle b/l x 4 and hock x 4

Therapeutic Exercise Programme: In Clinic + Home Prescription : Added in clinic: POLES x 1, at level 2. She is quite food motivated to extend that she can become distracted so was knocking this pole. However, when focused, she walked very well over these – aim of poles is to improve balance and paw eye coordination. UNEVEN OBJECT FORELIMBS RAISED – on FitBone. Holding a stand for 3 seconds and releasing.

Electrotherapy Delivered : 4J x 2 R/ stifle, 2J per TP paraspinals, 4J per elbow and carpus B/L.

Treatment Plan : 2 weekly H/P. Continuation of exercises ADDED: Correct sit – with hind limbs tucked under, no slouched position with hind legs extended or sitting on bum. Ask her to hold for 5 seconds. Correct down – same as above in a down position, no side ways resting, both hinds tucked under in a correct down. Walking over legs – 5-10 reps back and forth to encourage equal stepping and balance of legs, try and prohibit any jumping!

Manual Pricing Adjustment : 0

Harness Size : X Large

Water Height : 14″

Speed: : L2.5 x 5, L3 x 1

Duration: : 50s x 5, 30s x 1

Repetitions: : 6

Rest Duration: : 2m

Rest Period Interventions: : Lower water height and same speed for Misty today, first rep was a little sluggish, but soon warmed up and moved well.

Movement Shaping Techniques : Gentle support of stifles bilaterally, encouraging weight bearing and limiting twisting of tibia.

Assessment : Misty still requires more weight loading of the R/H till we can progress the exercises more to target the individual stabiliser muscles. However, she is improving each week, at week 4 post op, she is weight bearing and placing her paw completely on the ground 8/10x. Misty’s left hock appeared less over extended, and her overall posture has improved.

Manual Treatments Delivered : Gentle effleurage paraspinals, dorsal shoulder mm. Forelimb protraction stretch x 2 PRoM – carpus x 3, stifle b/l x 4 and hock x 4

Therapeutic Exercise Programme: In Clinic + Home Prescription : Added in clinic: POLES x 1, at level 2. She is quite food motivated to extend that she can become distracted so was knocking this pole. However, when focused, she walked very well over these – aim of poles is to improve balance and paw eye coordination. UNEVEN OBJECT FORELIMBS RAISED – on FitBone. Holding a stand for 3 seconds and releasing.

Electrotherapy Delivered : 4J x 2 R/ stifle, 2J per TP paraspinals, 4J per elbow and carpus B/L.

Treatment Plan : 2 weekly H/P. Continuation of exercises ADDED: Correct sit – with hind limbs tucked under, no slouched position with hind legs extended or sitting on bum. Ask her to hold for 5 seconds. Correct down – same as above in a down position, no side ways resting, both hinds tucked under in a correct down. Walking over legs – 5-10 reps back and forth to encourage equal stepping and balance of legs, try and prohibit any jumping!

Manual Pricing Adjustment : 0

Harness Size : X Large

Water Height : 16″ x 4, 14″ x 2

Speed: : L2 x 2, L2.5 x 4

Duration: : 35

Repetitions: : 6

Rest Duration: : 2m

Rest Period Interventions: : Misty has improved a lot between sessions, much more fluent and rhythmical in her movement, increased speed as she was stopping and starting with L2, L2.5 kept a more consistent forward walk.

Movement Shaping Techniques : Gentle support of stifles bilaterally, encouraging weight bearing and limiting twisting of tibia.

Observations : Misty was uncomfortable morning after Wednesday, however thereafter she was better than ever, and willing to walk further (however slow)! Going well with correct sit exercise, and correct down.

Assessment : Her posture and overall fluency of walking has improved significantly, the tibial twist is still present, however less than previously observed. Appears Misty is developing tone in her quadriceps enabling more stabilisation of the limb, next to focus on strengthening lateral thigh muscles including bicep fem.

Manual Treatments Delivered : Gentle effleurage paraspinals, dorsal shoulder mm. Forelimb protraction stretch x 2 PRoM – carpus x 3, stifle b/l x 4 and hock x 4

Therapeutic Exercise Programme: In Clinic + Home Prescription : Continuation of exercises prescribed 2 days ago.

Electrotherapy Delivered : 4J x 2 R/ stifle, 2J per TP paraspinals, 4J per elbow and carpus B/L.

Treatment Plan : 2 weekly H/P. Continuation of exercises ADDED: Correct sit – with hind limbs tucked under, no slouched position with hind legs extended or sitting on bum. Ask her to hold for 5 seconds. Correct down – same as above in a down position, no side ways resting, both hinds tucked under in a correct down. Walking over legs – 5-10 reps back and forth to encourage equal stepping and balance of legs, try and prohibit any jumping!

Manual Pricing Adjustment : 0

Harness Size : X Large

Water Height : 18″

Speed: : L2

Duration: : 30s

Repetitions: : 5

Rest Duration: : 3m

Rest Period Interventions: : RoM of joints with extra buoyancy. Will reduce water next week to encourage more static weight bearing during rest periods, as leg becomes buoyant.

Movement Shaping Techniques : Gentle support of stifles bilaterally, encouraging weight bearing and limiting twisting of tibia.

Observations : Have been good with exercises, keeping her walking slow on walks, and utilising the blocks to load her R/H while eating, with the addition to spinal stretches.

Assessment : Discomfort in lumbar region towards sacrum of paraspinals, was guarded of R/H, has preference to lay on this limb however on rising, she is very stiff and more reluctant to weight bearing in R/H. L/ hock very collapsed, not much flexion in the joint itself. R/ stifle RoM feels good at this level of healing, slightly reluctant to full extend, however due to some swelling around the joint (no heat observed) the inflamed soft tissues may be causing joint restrictions. Allowed some forelimb joint RoM, digits appear okay, carpus slightly restricted on extension, was more guarded on R/ forelimb.

Manual Treatments Delivered : Gentle effleurage paraspinals, dorsal shoulder mm. Forelimb protraction stretch x 2 PRoM – carpus x 3, stifle b/l x 4 and hock x 4

Therapeutic Exercise Programme: In Clinic + Home Prescription : Continuation of exercises prescribed 2 days ago.

Electrotherapy Delivered : 4J x 2 R/ stifle, 2J per TP paraspinals, 4J per elbow and carpus B/L.

Treatment Plan : 2 weekly H/P.

Manual Pricing Adjustment : 540

Harness Size : X Large

Water Height : 19″

Speed: : L0.5

Duration: : 10s

Repetitions: : 3

Rest Duration: : 3m

Rest Period Interventions: : RoM of joints with extra buoyancy.

Movement Shaping Techniques : Gentle support of stifles bilaterally, encouraging weight bearing and limiting twisting of tibia.

Chief Complaint / Areas of Concern : 5 weeks ago tore R/ cruciate ligament, TPLO

Date of diagnosis : 20/03/2024

Owner’s Goal : Restore gait patterning, reduce pain and improve quality of life

Previous clinical history : 12 years old Labrador Retriever. Started limping bilateral forelimbs, vet diagnosed with arthritis, on Metacam for a couple of weeks, blood test after usage, however liver showed increase in protein that could cause issue so not recommended long term use of Metacam. Injury occurred on a walk, played with another dog and ruptured her R/ cruciate ligament. Tibial twist, it does not need surgery, Vet recommended intensive physiotherapy and the tibial twist should resolve on it’s own without interference of surgery. Vet currently recommended 10 mins 3x day first week, adding 5 minutes each week.. Diagnosed with arthritis diagnosed in her forelimb carpus, and in her stifles.

Medication history : Pain relief post surgery 20 days. Some metacam when she needs it. Paracetamol post surgery.

Supplement history : YuMove and salmon oil

Veterinarian follow up : Nothing scheduled, Vet mentioned 6 weeks post physiotherapy

Patient Specific Aggravations : Would settle but couldn’t get comfy. Would sit out in the garden to find comfort. Groans when laying down. H

Subjective Outcome Measures : No longer able to jump, Stiffness getting up, Limping, Lack of excitement for exercise, Repetitive licking, Lethargic/ tired, Excessive panting

Home Environment : Access to downstairs kitchen and lounge. At night she is locked in the living room. Can’t get on furniture. 2 days ago has had access on/off the sofa via a split step. Step getting in/out of garden. Bed in lounge. Can no longer jump in and out the car, so she’s lifted.

Daily Activity : 15 minutes 3x a day. 20- 30 mins, she’d never refuse to walk prior to the injury, off lead, not been to the beach as not a huge fan. 5 minute walks to garzen salts nature reserve or cricket pitch. Morning is good, she is quite keen for a walk, in the afternoon she’d refuse to walk

Behavioural notices : Friendly

Demeanour on arrival : Inquisitive

Body Condition Score : #7 – Too heavy

Static Observations : Uncomfortable standing for a long period of time. Cranial loading. Toe touching R/H. Pivot shift on stance phase of walking. L/ fore wrist collapse. Tremor noted in R/ hind.

Observational Gait Analysis : Excessive loading L/ hind. Short swing phase of R / hind

Palpation Assessment : Very tender and multiple TP through paraspinals. Would not allow touch of forelimbs, and no RoM at all, very uncomfortable in forelimbs. Allowed touch of shoulder mm., hypertonic dorsal spinal musculature, fascial restrictions all through epaxials, with multiple adhesions and nodules. Fatty lumps located around body. Thickening of carpus bilaterally. L/ stifle appeared thickening in palpation. L/ hock extremely overextended through significant weight bearing. Appears quite unbalanced through L/ hind also, lost her balance a few times during our session.

Range of motion : Reluctant to allow any forelimb RoM. Good right stifle RoM, limited in extension.

Short Term : Improve weight bearing, reduce tibial twist. Improve gait patterning. Improve scar and soft tissue quality. HEP and home management.

Long Term : Improve weight bearing, soft tissue extensibility, and compensations. Reduce pain in forelimbs through cranial loading by improving posture and weight bearing.

Treatment Plan : WALKS: Very slow lead walking, with her head up – to prevent cranial loading and even weight bearing. HEP: Weight shifting with R/H and F/L raised to encourage weight bearing and lengthening of the soft tissue. SPINAL STRETCHES ICING AFTER WALKS 5 minutes after walk Weight loss diet needed NEXT TIME: Measure H/L muscle mass, video gait analysis of pivot shift. 2 x weekly H/P for 2 weeks

• Sit to Stand
• Hill Walk (Incline)
• 3 leg standing