Proceedings of the 9th international symposium on veterinary rehabilitation and physical therapy

Effect of acupuncture treatment for a canine with hip osteoarthritis : a study in single subject experimental design

Grading system Grade 0 = normal → Grade 4 = severe chondropathy Grade 1 = normal menisci → Grade 4 = degenerated menisci Normal = homogen green, organized matrix of collagen → Pathologic = disrupted, less organized, green matrix of collagen Grade 0 = minimal red staining → Grade 5 = strong red staining Fig. 1 Macroscopic examination of the medial menisci and of the articular cartilage surface on the medial tibial plateau of a "low" (a-c) and a "high chondropathy horse" (b-d). c, d 0-4: Chondropathy scores established following Ashraf and collaborators [4] Fig. 2 Classical coloration with Safranin-O, fast green and Weigert's iron hematoxylin of medial menisci belonging to a "low" (a-c) and a "high chondropathy horse" (b-d). *Cleft in the collagen matrix; the collagen networks of the menisci was abnormally disrupted in the "HCH" , which influences mechanics of the knee joint including the angle of the patellar ligament in the sagittal plane and constraint from trochlear ridges. Objectives: To fabricate four accurate replicas of a canine pelvic limb, perform three corrective osteotomies of the tibia: tibial plateau leveling osteotomy (TPLO), tibial tuberosity advancement (TTA), and triple tibial osteotomy (TTO), and measure the influence of the osteotomies on the PDPP. Materials and methods: CT scan and radiographs of the left pelvic limb of a Doberman Pinscher were used. 23 geometric markers were added to the tibia, femur, and patella to enhance the reproducibility of the physical models and assist in final assembly. The leg replicas were created using 3D printing, room temperature vulcanizing silicone molding, and casting. PDPP was measured in 5 joint positions (75°, 96°, 113°, 130°, and 148°) after removal of the CCL and after performing a TPLO, TTA, or TTO on leg replicas. Results: Mean (±SD) bone length was 246 ± 0.5 mm for 5 femoral replicas, 254 ± 0.7 mm for 5 tibial replicas, and 29.4 ± 0.2 mm for 8 patellar replicas. The pes measured 237 mm. The tibial plateau slope was 28°. The CCL measured 27 mm, the CaCL and LCL 33 mm, the LCL 48 mm, and the patellar ligament 59 mm. The intact model maintained a constant stifle and hock joint angle when loaded without mediolateral or craniocaudal subluxation. The CCLdeficient model also maintained a constant stifle and hock joint angle when loaded with a cranial thrust of 0.6 mm at 75°, 7.2 mm at 96°, 17.1 mm at 113°, 8.1 mm at 130°, and 7.1 mm at 148°. CCL removal induced a mean distal patellar displacement of 2.6 ± 5.7% of patellar length. The TPLO induced a proximal patellar displacement of 6.6 ± 2.2%. The TTA induced a distal patellar displacement 12.7 ± 5.3%. The TTO induced a proximal patellar displacement of 10.0 ± 6.1% (Fig. 4).

Conclusions:
The physical models accurately matched a canine pelvic limb, eliminated the variability present in cadaveric studies, and allowed the assessment of the effects of surgical procedures on the stability of the stifle joint and the motion of the patella. Tibial corrective osteomies lead to changes in patellar position: TTO and TPLO lead to proximal patellar displacement and TTA leads to distal patellar displacement.

Fig. 4
Articulated replica of a canine pelvic limb fabricated using 3D printing. The patellar ligament is made using braided silk. The leg is held up within a grame and the hip joint is loaded. Quadriceps femoris and gastrocnemius muscle tones are simulated using metal wires. The knee angle is assessed using an electrogoniometer Background: Canine osteoarthritis (OA) is a commonly seen problem in veterinary practice. There are different methods available to treat related pain, stiffness and lameness. A recently developed method is the treatment with nuclear magnetic resonance (NMR). In this method a permanent magnetic field is combined with an interfering field. Objectives: A double-blinded randomized trial was performed to evaluate if nuclear magnetic resonance treatment (MBST ® ) has a positive effect on the pre-treatment clinical signs of dogs suffering from osteoarthritis directly after the MBST ® treatment and 3 and 6 months after treatment.
30 dogs were included in the study. The inclusion criteria were a radiological confirmed osteoarthritis with clinical signs (pain during palpation and/or lameness) in the orthopedic examination. Fifteen dogs received NMR treatment (TG) and 15 received a placebo (PG) over a period of nine days. To describe the overall clinical success of the MBST ® intervention the following parameters were evaluated: symmetry indices of peak vertical force and vertical impulse, lameness and pain score, drop-out, additional pain medication or physical therapy during the course of the study. From these parameters an individual score was calculated for each dog to evaluate the overall treatment effectiveness (OTE) at the evaluation points. Results: In TG symmetry indices of vertical impulse and lameness score had significantly improved at 3 months after treatment. To compare the effect of the NMR treatment within the groups on the lameness and pain between day 0 and the subsequent measurements a Friedmann Test was used. To evaluate the changes in the GRF within the groups between day 0 and the subsequent measurements an ANOVA for repeated measurements was used. Differences in the overall score between groups were tested using a Mann-Whitney Test. P < 0.05 was considered statistically significant. Conclusions: Findings from this study suggested that NMR had potential positive effects regarding the clinical signs of OA in dogs at 3 months after therapy.
Background: Cervical dorsal to ventral (CDV) mobilizations are commonly used to treat pain and motion restrictions in the human cervical spine. These mobilizations may provide pain relief in dogs with cervical disease. Little is known about the motion of specific cervical vertebrae resulting from CDV mobilizations. Objectives: The objective of this study was to determine the effects of graded CDVs to the dorsal spinous process of cervical vertebrae 2-7. Materials and methods: Twenty healthy subjects (F = 14, M = 6) ranging from 21 to 32 years of age (median = 24), with no past cervical spine injury or pain in the last 6 months, and no contraindications for magnetic resonance imaging (MRI) or cervical mobilization were recruited. Subjects were positioned prone in an MRI scanner and spinal positions were scanned while a certified manual therapist performed grade II and III CDVs on each cervical vertebra (2-7). Appropriate hand placement on the spinous process was confirmed using MRI data prior to the mobilization. Sagittal plane cross sections were used to measure the position of each vertebra in the neutral position and during grade II and grade III CDVs. Movement of each vertebra was analyzed using image analysis software (OsiriX) to compare relative and absolute positions. Data were statistically analyzed using SPSS Version 19, (Armonk, NY). Results: All cervical vertebrae (C2-7) significantly changed from their resting position in the sagittal plane when grade II or III CDVs was performed on each cervical vertebra (P < 0.001; Fig. 5). Grade III CDVs produced greater anterior translation than grade II CDVs for each vertebra (P < 0.001). Grade II and III CDVs changed the position of each vertebra in relation to the vertebrae above and below (P < 0.001). Grade III CDVs on C7 resulted in the greatest relative translation of the lower cervical spine; grade III CDVs on C4 resulted in the greatest relative translation of the upper levels of the cervical spine. Grade III on C5 resulted in extension of C2-4 and extension of C6-7. Conclusions: Direct dorsal to ventral mobilization to each cervical vertebra (grade II or III) changed the position of that vertebra and the position of all cervical vertebrae. The amount of displacement is proportional to the mobilization grade. Isolating motion to a single cervical vertebral segment with graded mobilization in the cervical spine does not appear possible; segments above extend, while segments below flex; C5 mobilization was an exception to this pattern. Background: The goniometer is an objective and noninvasive tool for measuring joint positions in nonsedated animals. Measurement of front limb external rotation with goniometer in caninens has not yet been described.

Objectives:
The study aimed to develop a novel protocol for measuring the rotational angle of the canine front limb with a goniometer.

Materials and methods:
The study included 12 labrador retrievers, with a mean age of 3 ± 3 years and mean weight of 27 ± 4 kg. The rotation angle was measured in standing position with the goniometer's axis under the metacarpal pad, the arms parallel to the spine and the 3rd digit. The measurements were repeated three times by two measurers, and the combined data of the two was used for descriptive statistics. Means were compared with paired t test, with significance at P < 0.05.

Results:
The mean angle of external rotation was 15 °± 6° and the 95% confidence interval for the mean was 14-17°. There was no statistically significant difference between the left and right limb (P = 0.3) or between intra-tester measurements (P = 0.12). There was significant inter-tester variability (P = 0.005) with a mean difference of 3 °± 5° between measurers.

Conclusions:
The study reported normal values for antebrachial rotation in healthy labrador retrievers. The good intra-tester reliability and statistical inter-tester difference is consistent with goniometric measurement studies in humans [1].  Absolute is defined as the change in position of a vertebra from its resting position when a mobilization is applied. The horizontal axis represents the amount of PA motion of each vertebra and vertical axis represents the amount of superior to inferior motion of the vertebra. A negative number represents a flexion moment while a positive number represents an extension moment Background: Static weight distribution is considered to be a potential variable when lameness in dogs is evaluated. Instruments for this purpose, that are available in the market, lack research on their measurement properties. Objectives: The objective was to assess the degree of validity and reliability of 4Leg Check ® during standing in dogs. Materials and methods: 63 dogs participated. The scales criterion validity was controlled against control weights. The weight distribution was measured for all dogs with 4Leg Check ® during 3 s, three times in succession, followed by a manual assessment of the weight load of the fore and hind limbs pairwise. The relative reliability was calculated with Intraclass correlation coefficient (ICC) (2,1) and absolute reliability with Standard error of measurement (SEM and SEM%). Criterion validity, comparison of instrument and manual assessment, was calculated with Cohen's kappa (κ). Results: 4Leg Check ® showed 6.9-9.5 percent higher weight than control weights. The differences between weight sessions with control weights were consistent, ICC =  Fig. 7), but with a weak correlation between the two variables. The remaining variables were not considered to affect mobility. As expected, a strong correlation was found between size, height and body weight ( Table 2).

Conclusions:
The mobility of healthy dogs is not affected by individual size, weight, height, breed or body condition, with the exception of gender. The results of this study enhance robustness of the instrument, as the DMS was developed to detect changes in mobility caused by orthopaedic or neurological pathologies. Further studies are needed to evaluate the DMS as an instrument for such purpose. Background: Physical therapy goniometry is the measurement of the angles through which a joint is able to flex and extend, used to quantify joint range of motion, decide on appropriate treatment and evaluate the effectiveness of treatment. The aim of this study is to validate a goniometric measurements using a smartphone application. Objectives: Correlation of universal goniometer (UG), "DrGoniometer" (DrG) smartphone application (app) and radiographic measurements of metacarpophalangeal (MCP) angle. Materials and methods: Metacarpophalangeal angle measurements of thirty horses were taken using a UG, the photography-based DrG app and a lateral digital radiograph. For the first readings a cast was used to standardize the angle of the MCP and in the second the MCP was in full flexion. The examiner holding the limb was blinded to the readings while the other recorded the UG values, and took the photograph and radiograph. Radiographic angles were measured and the positioning of the markers for DrG photograph angle measurements were determined. Pearsons's correlations and ANOVA was performed on the data (P < 0.05). Background: Asymmetrical muscle development of the hindquarters of the racing Thoroughbred may result from one-leaded training and racing, possibly affecting future racing performance. Objectives: To identify the incidence of hindquarter asymmetry (both muscular width and tubera sacrale height) in Thoroughbred racehorses in a stable where constant one-leaded training and racing was performed.

Materials and methods:
The 25 Thoroughbred racehorses evaluated in this study were trained and raced on a left-leaded rein (clockwise). Caudal photographic images were taken of the hindquarters, while the horses stood square on a level cement surface. A transparent grid, placed on the screen of the camera was aligned in such a manner that the vertical line of the grid was directly aligned to the dorsal midline of the horse, while a horizontal line was aligned with the most dorsal part of the tubera sacrale. The images were printed and again a transparent grid was placed over them. Full and partially full grid blocks either side of the vertical line were counted to determine muscular asymmetry, and ventral to the horizontal line to determine tubera sacrale heights. The side on which the tubera sacrale was higher was termed the bony asymmetrical side, and the side with a larger muscular bulk (mostly the musculus biceps femoris) was termed the muscular asymmetrical side. Two authors (TK, AT) counted the grid blocks and compared their findings which were similar, but no inter-or intra-observer reliability was determined. An exact binomial test was performed on the data. Results: Of the 25 horses, 21 of the horses (84%) had asymmetric hindquarters. Of these 21 horses, 16 horses (76%) showed significant muscular asymmetry having larger left hindquarter muscular bulk. This was significantly larger than the expected number given equal probability of left and right muscular asymmetry (P = 0.039). Twenty percent showed both muscular and bony asymmetry, and none only bony asymmetry. Conclusions: It is suggested that training and racing to one side only, as in this stable's case where the horses worked mainly on a left-leaded rein, can possibly lead to hindquarter muscular asymmetry that could affect racing performance.  Background: Tendon fibroblast death has been reported to occur at 46 °C and since a six degree difference between skin and core temperature of the superficial digital flexor tendon (SDFT) in horses SDFT has been established [1], skin temperature can be used to approximate SDFT core temperature and can therefore assist in determining whether SDFT temperatures rise to injurious levels under certain perturbations.
Objectives: To determine palmar metacarpus three skin temperature (McTemp) of the equine forelimb on booted and non-booted limbs, at rest and post-exercise, and to determine rate of skin cooling after exercise. Materials and methods: Part 1:18 Thoroughbreds' McTemps were measured using a Benetech GM300 Infrared thermometer a before and 1 h after stabling, with one forelimb booted and the other unbooted. Part 2: 14 Thoroughbreds' McTemps were measured before and after 20 min lungeing at a trot, with one forelimb booted and the other bare; 1 min post cessation of exercise McTemp was again measured. Data were evaluated using paired t tests, with significance set at P < 0.05. No inter-or intra observer reliability evaluations were performed.

Results:
The temperature measuring technique used has been reported to be reliable [1]. Average McTemp of non-booted and booted legs is given in Table 3.

Conclusions:
The average skin temperature of the booted legs (26.2 ± 3.7 °C stabled time 0 and 32.8 ± 5.3 °C 20 min post-exercise) was higher than non-booted (26.7 ± 3.7 °C stabled time 0 and 30.8 ± 5.3 °C 20 min post-exercise) but did not reach the 40 °C level which could be indicative of overheating of the SDFT. Results: There was good correlation between the measurements of the two observers (Table 4).

Table 3 Average palmar metacarpal skin temperature in °C
The non-booted and booted legs cooled by 3-4 °C within 60 s of termination of exercise. The skin temperature of the booted leg was significantly higher than that of the non-booted legs both in the stable and immediately post-exercise (P < 0.001)  Background: A 6 year-old Great Dane female had undergone a partial hind limb amputation procedure due to osteosarcoma. Amputation was performed in the proximal third of the tibia. The titanium implant was introduced into the bone marrow cavity. The skin and muscles were attached to the implant. Objectives: The objective was to achieve full weight bearing of the affected limb using a custom designed bionic prosthesis. Materials and methods: The first goal was to minimize the muscle contraction caused by a two-week immobilization of the limb. Hot pack wraps were performed 2-3 times daily, followed by massaging of the thigh and stifle joint regions not involving skin of the operated region. The main interest was stretching contracted flexors and abductors of hip joint and flexors of the stifle joint. Afterwards, PROM exercises were introduced. Massage and PROM sessions were topped with passive extension 10 times for 30 s. The patient was then stimulated for weight bearing in standing position by pressing the temporary version of prosthesis to the implant and rocking the stern. This drove the dog to put the prosthesis on the ground. After obtaining correct positioning of operated limb, a four-stroke movement was introduced on the standard treadmill. All sessions were preceded by heat therapy, massage, and PROM. A few days of treadmill training showed great improvement in walking and controlled leash walks were introduced. In the same time, training of adaptation to normal functions like sitting, laying down, defecation, all using prosthesis were introduced. Results: After achieving stable gait heat therapy and PROM exercises were reduced. Regular walk trainings were maintained. Clinical examination and X-rays performed a few months post operation showed Background: Neurologic conditions produce structural, chemical and biophysical alterations in the muscle [1][2][3][4] and tend to alter weightbearing and limb use as a consequence of tissue atrophy [2,4]. Rehabilitation plays an important role in improving strength, condition and function of those tissues [5][6][7]. Case description: A 4-year-old intact male Golden Retriever with no past history of health problems presented to a Veterinary Hospital with hind limb paresis. After a computed tomography (CT) and myelography (Fig. 10), a Hensen II thoracolumbar Hernia was diagnosed between T11-T12. Because of the subtle nature of the lesion, medical treatment was chosen. During hospitalization, omeprazol, amoxicillin + clavulanic acid, enrofloxacin, robenacoxib were administered and cage rest was introduced. Three days after admission the dog regained function and proprioception of the left hind limb with no neurologic deficits but maintained no proprioception and diminished reflexes on the right hind limb. Ten days after initial presentation, the patient was discharged with oral medication and referenced to our rehabilitation centre. Discussion: At presentation the patient had no neurologic deficits on the left hind limb, reflexes were diminished and proprioception absent on the right hind limb, loss of muscle mass and strength was obvious.
On the first week a daily rehabilitation protocol was initiated, including thermotherapy (Fig. 11), PROM, flexor reflex stimulation, neuromuscular stimulation (NMES) (Fig. 12), bicycle movements with balance disc (Fig. 13), laser therapy (Fig. 14) and 15 days after presentation hydrotherapy with underwater treadmill (UWTM) (Fig. 15) [7]. On the second week of treatment the sessions occurred every other day (EOD) and by the end of this week the patient had regained almost normal proprioception and reflexes, although loss of muscle mass was still marked. By the third week the treatment suffered a set-back when the patient became lame from the right hind limb with no neurologic alterations. An orthopaedic problem was suspected and the patient referenced to the orthopaedic service who made the diagnosis of Grade D bilateral Hip Dysplasia (Fig. 16).  Conclusions: Although the patient never had any symptoms or other signs of hip dysplasia, it is likely that the changes in the hip were pre-existing. The abrupt loss of muscle mass and strength that can occur after limb disuse [3][4][5] due to the paresis episode and can led to a unstable hip. Starting rehabilitation as soon as a neurologic injury occurs is the only way minimize muscle, bone and articular losses, that ultimately can lead to permanent alterations [5][6][7].
Consent to publish: Written informed consent was acquired from the person in Fig. 13 Background: Laser therapy works by the application of electromagnetic radiation within the red and infrared spectrum over injuries and lesions to stimulate healing and pain relief through a process called photobiomodulation. Although its use continues to be controversial, Class IV Laser Therapy has been reported to be an adjunctive procedure for promoting healing of wounds through increased blood flow, release of growth factors, and by reducing inflammation without sideeffects when properly used. Case description: A 9 year-old neutered female canine underwent a cranial cruciate ligament surgery post rupture. One week after surgery the patient was referred for laser therapy treatment of deep dermatitis on the right hindlimb, due to prolonged recumbence in a surface with urine (Fig. 17). She had been treated with antibiotics (amoxicillin + clavulanic acid 12.5 mg/kg) and antiflammatory drugs (carprofen 4 mg/ kg) for 8 days.

Materials and methods:
Due to the painful nature of this lesion sedation with Propofol (4 mg/kg) was necessary. After sedation, the coat was trichotomized and the area cleaned with saline solution. For the laser therapy protocol a 10W class IV laser was used. The area to be treated was approximately 1000 cm 2 and dosage was of 4 J/cm 2 . The time of treatment was 7 min with a total of four sessions, one session per day during 3 days and a last session 4 days later. No other topic treatments were administered. Results: After the first treatment inflammation and redness of the skin tissue visibly decreased (Fig. 18). The lesions were measured at every laser therapy session (Figs. 19, 20, 21). By the second session of laser therapy the patient was no longer in pain and manipulation was possible with no sedation needed. After 1 week (four sessions) of laser  Background: Both horse and rider rely on muscle chain activation to perform dynamic work, featuring different biomechanics patterns that become one functional unit when performing together.
Objectives: Aim of this study was to determine if horse's and rider's postural systems and biomechanical efficiency are reciprocally influenced.

Materials and methods:
We postulated that the more the unbalanced rider unevenly loaded the horse's supporting muscle chains, the more the horse increased its own muscle load asymmetry, affecting movement dynamics of the horse-rider unit and further prompting rider's unevenness on the saddle: uneven load on seat and stirrups, overall balance and comfort, effectiveness of aids. We developed postural re-education and conditioning plans for both athletes, balancing their individual biomechanics before reworking together. Our work included: (1)   due to dental malocclusion affecting muscle tone of several muscle chains (Fig. 22). Postural analysis findings on the horse included hypertonic left appendicular muscle groups, caused by compensation of inconsistent left-to right forces applied by the rider while on saddle, due to her muscular and postural asymmetries (Figs. 22, 23). (2) Active separation of the horse-rider unit by formulation of individual protocols for both athletes, aiming at neutralisation of reciprocal compensational mechanisms: myofascial release, bodywork, Kinesiotaping ® (Fig. 24) for the horse (1 session/week for 6 weeks, then monthly sessions); dental bite device, postural gymnastics and yoga for the rider (2 sessions/week for 8 weeks, then weekly sessions). (3) Active reunion of the horse-rider unit, performing postural conditioning exercises under saddle. Results: Retests on rider after 4 months showed normotonic muscle chains, fatigue perception decrease and ROM increase. The horse also regained muscle symmetry and consistent bilateral muscle tone. Reintroducing mounted work and including maintenance sessions into their routine, both athletes maintained the acquired balance. Fig. 22 Rider's postural asymmetries and horse-rider unit adaptation  Conclusions: Horse and rider reciprocally affect their posture: treating and conditioning them both individually and as a whole, can improve and maintain comfort and effectiveness of the functional unit.

Declarations:
The authors have written informed consent from the rider. This is available upon request. Background: Integration of physical therapy and acupuncture for biomechanical issues and pain management shows increasing value in Veterinary Medicine. This combined approach has been chosen for treatment of a patient referred for PT and non-pharmacological management of his chronic spinal condition. Objectives: The objective was to use a conservative holistic approach on a 14 year old male Bolognese dog, diagnosed with lumbar arthritis (main radiographic lesion: L3-L4 osteophyte) (Fig. 25).

Materials and methods:
The patient received 10 weekly PT treatments integrated with 5 fortnightly acupuncture sessions, providing both biomechanical and energetic stimulation to control chronic pain and compensational postural issues. Initial findings included paraspinal muscles contracture and hind end muscle asymmetries. The patient was reluctant to voluntarily perform dynamic activities, showed kyphosis of lumbar-sacral region, fasciculation of right thigh muscles, uneven load of hind limbs. PT techniques applied during sessions included: myofascial release, pulsed-waves electromagnetic therapy, spike ball massage on muscle groups undergoing compensational mechanisms, dynamic gymnastics on poles, postural and proprioceptive exercises on a wobble pillow (Fig. 26). Acupuncture treatments included: organic stimulation points (Spleen, Kidney, Small Intestine, Governor Vessel meridians) for energetic reactivation of the patient, and extraordinary meridians to balance the load of the hind limbs. Loco-regional electroacupuncture in the area of the osteophyte has also been applied (Fig. 27). Results: Evaluations after the treatment cycle showed bilateral symmetry of appendicular muscles, and normotrophic/normotonic paraspinal muscle chains. Dynamic evaluation confirmed improvement of biomechanical efficiency, plus the dog demonstrated increased willingness to initiate movement. According to answers of pre-and post-treatment questionnaire administered to the owner, this patient elevated his life quality due to an improvement of his musculoskeletal condition (resolution of paraspinal muscle contracture and modification of thigh diameter from 21 cm left/25 cm right to bilateral 23 cm), supported by a higher level of energy and vitality (proper urination stance, increase in spontaneous physical activity, decrease of visible limb tremors, energetic and playful attitude). This dog continued maintenance sessions (PT every 20-30 days, acupuncture every 45-60 days) and followed up after 2 years without any relapse of symptoms. Conclusions: The chosen conservative approach to this case study, integrating non-invasive techniques addressing both physical and overall emotional condition of the patient, allowed him to regain positive and interactive disposition towards physical activity. Background: Three dimension accelerometers (3DA) have been validated for evaluating adult horses' behavior and locomotion [1,2]. However, there are no reports of using 3DAs for collecting information on foals. In adult horses the accelerometers were attached to a limb, which is not safe for a long-term observation of foals. We aimed to study the usability of 3DA attached to foals tails to quantify their gross motor behavior.  Background: Patella luxation (PL) is one of the most common orthopedic problems in dogs, occurring mostly as a consequence of developmental orthopedic diseases and trauma. Patellar luxation has been managed conservatively and via surgical procedures. The pathophysiology and management of patellar luxation has not been systematically reviewed. Objectives: The purpose of this systematic review was to identify and evaluate the evidence regarding the pathophysiology and management of canine patellar luxation by use of the FDA's evidence-based medicine scoring system. Materials and methods: A bibliographic search of online databases was performed through January 2016. Search terms included canine, dog, knee, stifle, dislocation, luxation, injuries, patella, patellar, patella and patellar dislocation, patella and patellar luxation, and Salvati. Articles that described the etiology, pathophysiology, diagnosis, management, and prognosis of patellar luxation in dogs were eligible for inclusion. Articles written in languages other than English were excluded. Articles describing patellar luxation in species other than dogs were excluded. The analysis consisted of study design rating, consistency rating, and cumulative strength of evidence ranking. Articles were then categorized based on their content and levels of evidence. Levels of evidence were graded using the Oxford Centre for Evidence-based Medicine scale. Articles were ranked under one or more of the following categories: etiology, pathophysiology, diagnosis, nonsurgical management, surgical management, and/or prognosis. Each category was graded on a scale of I (systematic review) through V (expert opinion). Reviews and prospective studies received lower numbered grades. Retrospective, case-series, and expert opinions received higher numbered grades.  Background: A 3 year-old male working Labrador (active at the local public utility K9 unit) with a recent history of 2-months front limb shifting-leg 2/5 lameness and with radiographic findings of bilateral sesamoidal fragmentation and distal metacarpal erosion (Fig. 29), was referred for physical therapy. Objectives: The goal for this clinical case was to exactly identify and consequently treat the biomechanical issues that caused the bilateral stress lesions in order to solve the lameness and allow the dog back to return to work after a proper reconditioning program. Materials and methods: The approach to this patient included:

A24 Tail as an accelerometer attachment site when measuring foals' motor behavior-a preliminary study
1. Initial static and dynamic evaluations and identification of the underlying biomechanical patterns that likely caused bone lesions and lameness. The dog showed the tendency of loading his front end more than his hind end (bilateral shoulder and pectoral muscles showing relative hypertrophy and hypertone); there was uneven left-to-right hind limb load; and varus deformity (Fig. 30). 2. A cycle of 10 weekly physical therapy sessions including spike ball massage, pulsed-waves electromagnetic therapy (MaRhyThe ® Matrix-Rhythmus-Therapie ® ), postural, wobble pillow (Fig. 31) and poles exercises, mainly aimed at postural correction, through reinforcement of paraspinal and hind limbs muscle chains, and relaxation of the anterior muscle groups, therefore prompting a shift of weight load onto the hind end. 3. In between sessions the dog followed a specific schedule of exercises (e.g. sit-to-stand and forward pulls) as well as a progressive reconditioning program, as the lameness grade consistently decreased.
Results: Along the treatment period, the patient constantly improved, lameness completely disappeared around the 3rd week of treatment, and then the dog was ready to progressively increase his conditioning program in order to go back to his regular training and working schedule. He went back to work at full regimen shortly after the 10-weeks treatment cycle, regularly receiving maintenance physical therapy treatments (monthly sessions, decreasing to one session every 45-60 days).

Conclusions:
After 1 year of soundness, regular work and maintenance treatment sessions, X-rays still show the same lesions as at day zero (Fig. 32), confirming that postural balance, proper conditioning and physical therapy aiming at control of conformational, compensational and biomechanical issues play a very relevant role for the effectiveness and comfort of movement. Fig. 29 Initial radiographic findings Background: Patients with complete spinal cord section at T3-L3 segments can develop spinal walking as a result from intricate dynamic interactions between a central program in the lower thoracolumbar spine and proprioceptive feedback from the hind limbs. Thanks to automatism developed at birth and crossed extensor reflex work, paraplegic deep pain negative patients can recover motion of the hind limbs by stimulation of hind limb reflexes. A specific training program is suggested to be performed along with the development of spinal walking in dogs and cats after a severe spinal injury. Objectives: To be an informative study without data collection and show the type of physical therapy we have been performing in paraplegic deep pain negative patients to help the development of a more controlled automatic gait or spinal walking. These animals will never recover deep pain sensation but do regain ambulation (with or without support), throughout a specific training and development of spinal walking. Materials and methods: This protocol was established in 15 small dogs (1-5 kg) with completed spinal cord sections between T3 and L3. These dogs were administered the same treatment plan, with the same number and duration of sessions. The proposed program lasts 6 months. It consists in repeated underwater treadmill and land treadmill exercises, proprioception training, and passive and active therapy. A 20% increase in weekly exercise load, with an end goal of 20 min sessions of underwater treadmill or land treadmill exercises, plus 15 min of active and proprioceptive exercises and, the 25 min of passive therapy have been performed in our patients arriving to our suggested sessions of 1 h three times a week. The use of a harness or wheelchair may be recommended for support during the sessions to maintain the correct standing position to be able to work properly. In-house sessions are combined with home exercises. Results: Most of the patients that received this specific protocol developed a spinal walking within 6 months. The patients re-learned the ability to walk in a straight line without losing their balance with or without the support of a wheelchair or harness for long walks, especially running, playing, or changing directions. Conclusions: Paraplegic deep pain negative patients with lesions localized between T3 and L3 segments receiving a specific rehabilitation program can develop spinal walking within 6 months. Further data collection is recommended for future study to obtain repetitive results and demonstrable benefits. Background: Therapeutic exercises have been proposed when planning a rehabilitation protocol [1]. However, few specific exercises have been reported to produce a functional improvement in horses [2,3]. In order to progress on the design of effective rehabilitation and conditioning plans, these exercises need to be assessed with objective methods in terms of muscle force and fatigue. Superficial electromyography (EMG) has demonstrated to be useful for this purpose in human research [4] but this type of tests needs to be standardized for horses. Objectives: To describe, prove and discuss three different protocols, using EMG as an objective functional test to measure muscle force and fatigue. Materials and methods: Contraction of the Rectus abdominis muscles was induced with three different protocols in five horses and EMG was recorded (Fig. 33). Test A: three consecutive contractions induced by manual stimulation of the sacral area (Fig. 34). Test B: a 20 s contraction induced by electrical muscle stimulation (Fig. 35). Test C: 10 P-waves electrically induced. Root Median Square was obtained from test A and B, peak to peak from test C and Median frequency from test A. Results: The uniformity of the EMG recording for tests B and C provided a more consistent measure of muscle force. All tests were useful for measuring muscle fatigue.  Background: The Dachshunds commonly suffer from intervertebral disc herniation (IVDH), which causes pain and neurological deficits [1]. In humans, IVDH is shown to cause back muscle atrophy where cross-sectional area (CSA) decreases and fat infiltration increases [2,  . Previous veterinary studies suggested similar findings when Dachshunds with IVDH were compared to dogs suffering from fibrocartilaginous embolism [4]. So far, no comparisons with healthy Dachshunds have been made. Objectives: The objective was to compare the epaxial muscle CSA and fat content between healthy and IVDH Dachshunds.

Materials and methods:
The magnetic resonance images of 10 healthy and 14 Dachshunds with thoracolumbar IVDH were evaluated retrospectively. One assessor used Osirix to analyze the CSA and fat content of the Multifidus and Longissimus dorsi muscles at the T12-L1 spinal segments. The assessor was blinded to the side, segment and background data of the dogs. The intra-rater reliability was tested with intra-class correlation coefficient. The difference between groups was analyzed with independent samples t test and Mann-Whitney U test. SPSS IBM statistics, version 23 was used, with level of significance set at 0.05.

Results:
The intra-rater reliability was excellent for all measurements (ICC 0.92-0.99). There was no difference in the Multifidus or Longissimus dorsi CSA between the two groups, but the fat content was greater in the IVDH Dachshunds than in controls (P < 0.0001) for the evaluated muscles.

Conclusions:
The increased fat content and non-affected CSA in the IVDH group agree with previous research [4], suggesting that fat tissue increases in the back muscles of Dachshunds with thoracolumbar IVDH.
Background: Diagnosing chronic pain and physical disability caused by osteoarthritis (OA) in cats is a challenge. Currently, the diagnosis is based on a combination of the cat´s medical history, information from the cat owner, clinical examination and radiography. However, the absence of radiographic signs indicating OA does not equal a joint free from pathological changes causing pain.

Objectives:
The objective was to compare the results from clinical examination with the radiographic findings in a group of cats with OA. Materials and methods: Nineteen cats were diagnosed as osteoarthritic based on their medical history, the owners´ information and findings from the clinical examination. The cats were sedated (medetomidine and butorphanol) and the joints that had pathological findings on the clinical examination were radiographed. The right elbow was radiographed as a reference. Results: On the clinical examination 63 joints out of 228 had pathological findings (Table 6). Of the 63 joints, 32 (51%) had radiographic findings of OA. Conclusions: Only every second joint that had pathological findings on clinical examination had radiographic findings indicating OA. This discrepancy is either caused by findings not detected by radiography, or by the cats experiencing discomfort during the clinical examination. There is need for improved diagnostic tools that can easily be used in a clinical setting.   Background: In treatment of nociceptive pain with opioids the full μ-agonists have highest efficacy. Methadone is a synthetic full μ-agonist and also an N-methyl-d-aspartate (NMDA) receptor antagonist used in horses. Opioids might also cause excitement in the horse and respiratory depression especially when used together with other drugs affecting the respiration. The α 2 -agonists are used in horses for sedation and analgesia both separately and in combination with opioids. A combination of methadone and the α 2 -agonist detomidine may be useful in pain management but may also cause effects on behaviour and respiratory rate. Objectives: The aims were to investigate the effects on behavior and respiratory rate after treatment with methadone IV or methadone IV in combination with detomidine IM in order to evaluate and possibly diminish adverse effects in the treatment of horses.

Materials and methods:
The study was randomized, blinded and placebo controlled with cross-over design. Eight Standardbred horses were treated with (1) methadone IV (0.2 mg/kg) in a total volume of 20 mL over 5 min together with placebo (saline) IM or (2) 20 mL methadone IV (0.1 mg/kg) over 5 min together with detomidine IM (0.01 mg/kg) or (3) equivalent volumes saline IV and IM. The effects on behavior and respiratory rate were examined. Results: After methadone administration the horses displayed behavioral changes such as staggering for a short period, head tremors and looking vigilantly around. The behaviors licking, nodding head, picking hay, tail flapping, skin twitching and scraping with front leg were more frequent after treatment with methadone compared to the control. There were no differences in respiratory rate between methadone and saline treatments. After methadone/detomidine administration the horses showed drowsiness, snored, stood with dropped head or head supported by the wall or the crib during the first one to three hours. In addition, a few horses were sweating. The respiratory rate was lowered between one and three hours after administration of the drug combination compared with placebo (P = 0.02). Conclusions: When the horses were treated with methadone they showed drug-related agitation which has been described in horses treated with different opioids. The combination of methadone/detomidine seems to prevent excitement caused by opioid exposure. A lowered respiratory rate is also a known non-wanted effect of opioids but in this study no such adverse effect was observed after solely methadone administration but the combination methadone/detomidine induced decreased respiratory rate.
Acknowledgements: Supported by The Swedish-Norwegian Foundation for Equine Research. Background: In pain management it is important to assess pain and pain relief in a robust way. Thermal threshold are experimentally used in pain assessment for several species including horses. Opioids such as methadone are effective in treatment of nociceptive pain but may also cause effects on traits used for assessing pain such as cortisol levels. Also alpha2-adrenoceptor agonists (α 2 -agonists) such as detomidine are commonly used for analgesia and sedation both separately and in combination with opioids. The possible influence of detomidine of the effects of methadone is not well studied in horses.

Objectives:
The aims of this study were to reveal possible drug effects on pain assessment tools and to optimize pain treatment in horses. The effects on plasma cortisol levels was examined and the analgesic effect was measured with a thermal threshold testing system adopted for horses was used after treatment with methadone IV or methadone IV in combination with detomidine IM.

Materials and methods:
The study was a randomized blinded placebo controlled with cross over design. Eight Standardbred horses were treated with (1) methadone IV (0.2 mg/kg) in a total volume of 20 mL over 5 min together with placebo (saline) IM or (2) 20 mL methadone IV (0.1 mg/kg) over 5 min together with detomidine IM (0.01 mg/kg) or (3) equivalent volumes placebo (saline) IV and IM. The cortisol levels and analgesia after administration of methadone alone and together with detomidine were examined. Blood samples were collected and the plasma concentrations of cortisol were quantified with a commercial cortisol ELISA kit validated in horses. Results: After both administration of methadone and the combination methadone/detomidine a rise in the plasma cortisol concentration compared to control (P < 0.05) occurred. The thermal threshold was elevated and analgesia was apparent for 1 h when treated with methadone compared to saline (P = 0.001) and for up to 2 h when combining methadone and detomidine (P = 0.02). Conclusions: Both methadone and the combination methadone/ detomidine induced the release of plasma cortisol in horses per se. Plasma cortisol concentration is not a useful tool to assess stress or pain in horses treated with methadone. The duration of the analgesic effect of methadone were short but when combined with detomidine the duration was prolonged. For extended analgesia a constant rate infusion of methadone could be used. Background: Accurate, repeatable and reliable pain recognition and quantification of analgesia are essential for development of effective analgesic protocols and necessary for adequate pain management. Thermal threshold testing techniques have valuable roles in both the identification of altered nociceptive function and the pre-clinical evaluation of analgesics in horses. When using test systems, definition of a clear cut end-point of stimulation, such as skin twitching, shaking or hoof withdrawal is crucial for reliable and repeatable determination of the nociceptive threshold. End-point behaviour might be reflex related or may represent conscious perception of pain but could also be influenced by the environment and the horse's willingness to show pain. Objectives: The overall aim was to optimise the reliability and repeatability of the testing procedures in a future study assessing analgesic treatment protocols. The optimal settings of the testing system was evaluated. Furthermore, the type of end-point behavior showed by different horses was investigated. Materials and methods: Fifteen Standardbred horses were evaluated using a thermal threshold testing system adopted for use in horses (Topcat Metrology). All horses were tested by heating with a thermal probe on skin at the withers until an end-point behaviour (threshold temperature) or a cut-out temperature (58 °C) was reached. The type of end-point behaviour, the willingness to wear the testing system and to show pain related behaviour was evaluated. Also the skin temperature before heating, the rate of heating (0.5 vs 1.0 °C/s) and repeatability was examined. The study was blinded with cross-over design.
Results: No differences in mean threshold temperature (49.5 and 50.7 °C, respectively) between the rates of heating of 0.5 vs 1.0 °C/s, nor in delta temperature (14.0 and 14.4 °C, respectively). There were individual differences in type of behaviour and easiness to observe their end-point behaviour and some horses did not produce an identifiable end-point behaviour before cut-out temperature. We identified and selected horses showing easy recognized skin twitch as end-point behavior to be included in our future study of analgesic treatments.

Conclusions:
Thermal threshold testing appears not to be an appropriate test technique in all individual horses. As higher cut-out temperatures could possibly damage the skin it is not appropriate to include more "stoic" horses. This implies that if pain is more easily identified in extrovert individuals the relationships between pain behavior and personality in horses should be clarified for better study design in pain management.

Background:
A number of studies with human patients support the importance of a robust day-night sleep rhythm in order to remain healthy. With the elderly, some symptoms such as alterations of the sleep, sensory and motor deficits can be related with disorders of the circadian rhythm. Few researches about dog's circadian system have been made, likely because it is difficult to evaluate under normal living conditions. Objectives: To compare the sleep-wake rhythm of older dogs pre and post physical rehabilitation.

Materials and methods:
The study was performed with seven healthy dogs (10-14 years old, 21.8 ± 8.9 kg) of different breeds. All dogs were examined and evaluated by physical rehabilitation. All dogs had characteristic symptoms of aging: poor mobility and a few points of chronic pain, but they did not have any significant pathology, nor took prescription medications. After the treatment (4-6 weeks) they were evaluated again to compare before and after the physical therapy. The life condition was the same during all treatment, like food, water or specific environment. The rehabilitation was individual and included physical therapy and kinesiotherapy, according to the need of each dog, twice a week. The circadian rhythm was measured per 3 days (day and night) by actimetry using a sensor of rest-activity (Hobo, Massachusetts, USA) and another of temperature (iButton Viewer 32). The sensors were positioned on the dog's collar. All dogs had a record card with historical and evaluation of pain and clinic status. The rhythm of temperature and activity were analyzed with the software "Circandianware" v7.1.1 and "Actiwatch" 2001, which allows both the parametric analysis and nonparametric analysis. Results: All seven dogs had better physical condition after the treatment. The circadian parameters like the sleep or awake time, sleep efficiency, fragmentation sleep index and acrophase, were all very similar pre and post treatment. On the other hand, the degree of regularity in the activity-rest pattern (interdaily stability) of the 24 h rhythm was increased after the rehabilitation. In addition, the Rayleigh test (a statistic test used to determine the pattern of a particular rhythm) was higher post rehabilitation and indicates the homogeneity of the daily phases. These results have a direct relationship with quality of life and could indicate a better sleep-wake rhythm after the treatment.

Conclusions:
The present study demonstrates that physical rehabilitation improves the sleep-wake rhythm in older dogs, suggesting a good way to maintain their quality of life. Background: Development of physiotherapy techniques and rehabilitation protocols is dependent on accurate measurements of outcome parameters [1]. Physiotherapists frequently focus on helping build muscle strength, yet few objective tests to evaluate the effectiveness of these treatments exists [1][2][3]. Maximum isometric force of a muscle correlates with its cross sectional area (CSA) [4]. Therefore, in situations where a muscle cannot be contracted voluntarily or strength measurements are inappropriate, changes in muscle size, [measured in CSA or thickness (MT)], are used as an indication of muscle strength [4,5].

Objectives:
The study was an operator-blind clinical trial of repeated ultrasonography (ULT) to determine a standardised method for MT measurement in the middle gluteal muscle of canines in the clinical setting. Materials and methods: ULT measurements were taken from ten healthy canines, by three operators (operator one inexperienced, operator two moderate experience, and operator three experienced), each following a protocol that evaluated three repeated measurements of both hind limbs to evaluate MT of cross-sectional (CS) and longitudinal (LT) views. Measurements were taken one-third of the distance between the origin on the wing of the ilium and the insertion onto the greater trochanter of the femur. Results: Good intra-rater reliability was found with MT measurements of both CS and LT views, with the operator variability for the right leg ranging from 0.09 to 0.23 cm 2 , and the left 0.27 to 0.41 cm 2 . There was significant difference between limbs using ANOVA, the left limb was considered not clinically reliable for all operators due to variability values being twice that of the right limb. No significant differences between the readings for the operators, determined that there was good inter-rater reliability for CS (P = 0.55, cv = 63.7%) and LT (P = 0.298, cv = 61.3%) measurements, tested using ANOVA oneway correlation coefficient testing. Table 8 shows between operator correlations, comparing these with Pearson's critical value of 0.6319 at P = 0.05 indicates: strong correlations between operators two and three, and moderate correlations between one and two, and one and three.
Conclusions: This study indicates that ULT for both CS and LT measurements appears to be a reliable tool for measuring MT in vivo in canines. The absence of scientifically proven and quantified measurements of MT means that no conclusions regarding the accuracy of measurements can be made. Further research is required to demonstrate that ULT is measuring the actual MT, to test the reliability of the CS verse LT measurements, and determine the reasoning behind the left limb results. The general objective of gait analysis is to identify deviations from normal gait patterns. Kinematic studies have identified differences in limb movement patterns between normal and distinctly lame dogs. Reassessment of gait at multiple time points during rehabilitation after surgical interventions, like TPLO or other cranial cruciate ligament surgery depends on accurate identification of limb landmarks for consistency of kinematic marker placement, and consistency of testing parameters, like walking/trotting velocity. Variability is inherent in gait, and changes occurring as a result of treatment must be greater than normal, within-session variability to be detected. Objectives: To investigate if basic gait variables can be used for detection of gait changes in dogs following cranial cruciate ligament surgery at two separate occasions during recovery >2 months after surgery. Materials and methods: Six dogs were recorded at walk on a treadmill at two different sessions one month apart. The first session was more than 2 months after surgery for unilateral cranial cruciate ligament rupture. Reflective markers were placed on palpable landmarks on all four limbs and along the back. Fourteen Qualisys infrared light emitting video cameras registered marker positional data at 500 Hz. Tracking was done in Qualisys Track Manager, while stride split into stance and swing phases and further calculations were done in a customized Matlab script. Variables used were stride time, stance time and relative stance time (duty factor); the sagittal angular displacement of carpal, elbow, tarsal and stifle joints, and the pro-and retraction angle of fore and hind limbs. Mean values for each variable per dog, per session, were calculated and statistically analysed with ANOVA, the mixed procedure. Results: Stifle joint angular displacement, for both surgically treated and contralateral hind limbs, increased (P < 0.1) between the first and second sessions. For the ipsi-lateral carpus, joint angular displacement was larger (P < 0.1) at the first session than the second. The protraction-retraction, i.e. the whole limb pendulum, was smaller in the surgical hind limb at both sessions. Stride time was longer in the second session. Stance time didn't differ either between limbs or sessions. However, relative stance time (duty factor) was shorter (P < 0.1) in the ipsilateral compared to the contralateral hind limb in both sessions.

Conclusions:
This pilot study showed that kinematic analysis can identify small differences through the late recovery period following cranial cruciate ligament surgery, although a full study with a larger sample size and kinematic variables needs to be performed.