Case Studies

CASE STUDY HYDROTHERAPY

Subject
'Demi', a 14 year old, neutered female, Labrador Retriever

Introduction
Demi was first seen on 24th September 2008, showing lameness and pain in the right hind leg (RH). Clinical examination revealed thickening of the inside of the R knee joint, as well as joint laxity (looseness). X-rays showed changes compatible with Cranial Cruciate Ligament failure, as well as spondylosis (spine changes), Hip Dysplasia and secondary osteo-arthritis. Surgery was not advised in this case, due to a combination of factors, such as age and the presence of multiple other problems.
Demi was given a Cartrophen injection (to aid joint health) and Rimadyl tablets (pain killers). The owner was also advised that Demi could benefit from physiotherapy, and, more specifically, hydrotherapy.

Physiotherapy / Pre-hydro assessment
Demi was toe-touching on the RH. There was reduced flexion (bending) on the R knee joint, with some heat and swelling. There was evidence of muscle wasting. There was also some tenderness of the spine at the level of T7 (chest area of the spine). Demi was weight bearing through the entire left side of her body, more than on the right side. At this time Demi was unable to walk up stairs / steps, or jump into the car. The owner was advised on how to perform physiotherapeutic exercises at home. At this stage Demi was reported to be quite 'depressed'. Demi received physiotherapeutic treatment and was referred to our hydrotherapist.

Initial hydrotherapy session
Water height was at the level of the knee joint.
Demi had three 1 minute sessions of slow walking only. Weight shifting exercises and soft tissue massage were performed.
Gait assessment showed a lack of bending of the R knee and both hips and a shortened stride length ('step') of the front legs. Demi stumbled on the RH occasionally. She was very willing, but tired very quickly.

Further hydrotherapy sessions
For the next three weeks we did twice weekly sessions, during which we slowly lowered the water level. We continued the weight shifting exercises and massage. We also started passive range of motion exercises (PROM) in high water. Gradually the speed and duration were increased, to a total of 18 minutes walking in water. We also decreased the rest periods in between walking periods.
We could see reduction of swelling and heat in the affected joint, and Demi's stride length improved in all limbs. She also showed increased endurance and was putting more weight through her RH leg. The owner reported that Demi was looking more comfortable at home.

Set back
Demi had a sudden set back, with increased lameness in her RH after overdoing it at home. She was toe-touching again, with increased heat and swelling in the R knee joint. The owner reported that Demi was 'depressed' again. She was given a Cartrophen and a Rimadyl injection.

Further follow-up hydrotherapy sessions
We now kept the water height high again and reduced the speed and duration, to a maximum of 10 minutes. We also allowed longer rest breaks between walking. We continued the weight shifting exercises, as well as massage and PROM. The owner was advised to restrict Demi's exercise at home, especially regarding steps etc.
After 6 more sessions Demi was improved sufficiently to increase walking times to 18 minutes again.

Continuation
After a total of 14 sessions we had established an improved flexion and extension (straightening) of knee and hip joints, with increased stride length of all limbs. Demi was now able to walk for 20 minutes, in decreasing water heights. We decreased the session frequency to once weekly. We started to use a float on the LH to increase the stance phase '(time on the floor') of the RH. The owner reported that Demi was very lively and had started playing with toys again.

Ongoing
Demi continued to come for hydrotherapy sessions on a fortnightly basis, walked for 20 minutes in ever decreasing water heights. At standstill she would, occasionally, toe-touch, but she would fully weight bear when walking, both on land and in the water. There was no swelling, nor heat, in the RH knee joint. There was almost full ROM in the R knee, as well as flexion and extension in both hip joints. Demi was able to hop on steps and get into and out of the car with little assistance. The owner reported Demi to be much happier, able to walk for longer periods, not as stiff and coping better with stairs etc.

Final result
Unfortunately, Demi had a massive set back some weeks later. She was unable to use her hind legs properly, seemed to be in discomfort, uncoordinated and imbalanced. We suspected the onset of CDRM (a degenerative spinal cord condition), as well as an acute worsening of the arthritic symptoms. The owner and her vet decided on euthanasia, on welfare grounds.

Owner's declaration
Demi's owner, who had initially been quite sceptical about hydrotherapy, told us that she was extremely happy that we had been able to give Demi many months of good quality life, which otherwise might not have been possible. She was very impressed with both the results of this new complementary therapy, as well as the service received at our veterinary practice. The owner has kindly given us permission to use Demi's case for this case study, to honour her memory.

Conclusion
This case clearly demonstrates that with the right equipment and with staff possessing the relevant and specific knowledge and expertise, it is possible to improve the quality and longevity of life for our four legged patients.

Pete van Dongen, Drs.(Utrecht), Cert.V.R., M.R.C.V.S., Veterinary Surgeon, Pennard Veterinary Group
Samantha Maynard, LCGI, Hydrotherapist, Pennard Veterinary Group