Assessment of the Canine Patient

Original Editor - Jess Bell Top Contributors - Jess Bell

Introduction

When assessing a canine patient, it is essential to determine the pet’s current functional level, its history, as well as specific challenges or deficits that need to be addressed. A detailed subjective and objective assessment is necessary to ensure that the animal physiotherapist can correctly identify each patient’s challenges / dysfunctions and, from there, develop an appropriate clinical plan in order to achieve the best outcomes for a patient.[1]

There are three key domains to consider when assessing an animal patient:[1]

  • Diagnosis
  • Client (i.e. owner)
  • Pet

Diagnosis

Animal physiotherapists will often receive referrals from a veterinarian that provide a specific diagnosis for the patient (e.g. cruciate ligament repair or spinal operation). This referral provides valuable information about the patient’s stage of healing, and prognostic expectations. It helps to guide the therapist's intervention. However, a thorough assessment is still necessary to ensure that all dysfunctions are identified and appropriately managed. [1]

Client

The majority of subjective information about an animal patient comes from the client or caregiver. Like conventional physiotherapy, important subjective questions include:[1][2]

  • When did symptoms start? Are they recent, chronic or recurring?
  • What treatments / care have been given so far?
  • What makes symptoms better or worse?
  • Have there been previous injuries to the area?

Other relevant information to obtain relates to the animal’s level of exercise, diet and nutrition and environment (i.e. is it a family pet or a sport or hunting dog? etc).[2] Insight into carers’ ability to handle their pets can also be gained during the subjective interview.[1]

Pet

The animal physiotherapist also has the opportunity to observe the pet while conducting the subjective interview. Prior to beginning the objective assessment, it is possible to observe:[1]

  • The pet's demeanour
  • The pet's willingness to be approached / touched by the animal therapist
  • The pet's confidence to be around the animal therapist

The pet may, however, behave differently in the clinic from how they behave at home. They may be over-excited and mask their symptoms or they may be nervous or insecure. It can, therefore, be difficult to obtain a clear picture of the pet’s normal behaviour during the initial consultation.[1]

Building a relationship with the pet

It is important that the animal physiotherapist builds a positive relationship with the patient from the first encounter. Using treats can help to achieve this.[1]

NB: always obtain the owner’s consent and ask about any allergies prior to offering treats to the pet.[1]

[3]

Red and Yellow Flags

During the initial subjective interview, you will gain insight into whether or not any red or yellow flags are present.

Like conventional physiotherapy, red flags tend to be associated with any rapid deterioration in symptoms. Dogs may also refuse food at home or lose their appetite. If the animal therapist notes the presence of red flags, the patient should be referred back to the veterinarian.[1]

Yellow flags can be client-related or pet-related.[1]

  • Client-related yellow flags may include pain catastrophising (associated with neuroticism),[4] negative expectations or a lack of understanding about the animal's condition[1]
  • Pet-related yellow flags, specifically for dogs, may include aggressive behaviour[1]

Assessing Pain

There are several validated tools for measuring pain and disability in dogs such as the Canine Brief Pain Inventory[5] and the Helsinki Chronic Pain Index.[6] However, these measures always rely on reports by the human observer,[7] which can impact their effectiveness. While the pain VAS, for instance, is considered valid and reliable in some contexts, it is not considered a useful measure for untrained owners to rate their pets’ pain levels as it has poor face validity.[8] Because the carer’s personal beliefs and anxieties about pain and disability can bias the physiotherapy consultation, the animal physiotherapist must gain an understanding of the owner's expectations and beliefs about the pet’s pain and diagnosis.[1]

Objective Assessment of the Canine Patient

Animal caregivers tend to bring their pets in for treatment based on a functional deficit (e.g. a dog can no longer climb the stairs, jump on the bed etc) rather than a specific impairment (e.g. loss of joint range of motion). Assessment and treatment should, therefore, be related to these functional deficits.[1]

Assessments that focus on body structure and function (such as joint range of motion) should always be used in conjunction with other validated measures of activity and participation (e.g. functional test batteries and health-related quality of life).[7]

Because animals are non-verbal, it is impossible to explain the assessment process to them. The therapist must attempt to maintain a positive relationship with the pet and counteract any painful tests with something positive for the animal (i.e. treats).[1]

Canine Gait Assessment

A thorough gait assessment is essential when assessing animal patients.[9] Gait assessments require the therapist to have access to a large, flat area as they need to observe the dog moving at different speeds (ie. walk, and trot) and in different directions.[1]

Certain features to look for:

  • At a walking speed, the dog will have two or three feet on the ground at a time[2][10]
  • A number of dogs may “pace” (i.e. ipsilateral legs move forward while the legs on the other side weight-bear). This is considered an incorrect and inefficient gait for all dogs and it may indicate paraspinal muscle dysfunction[2][10]

While the dog mobilises, the therapist checks for lameness (i.e. attempts to off-load painful areas). A dog may do this by:[1]

  • Changing speed
    • The dog may walk more slowly or it may change the speed at which the painful limb moves - i.e. it will try to minimise the amount of time that the painful limb is in contact with the ground. The contralateral limb will, therefore, move through the air more quickly, so that the uninjured or less painful limb can return to the ground more quickly[1]
  • Changing the amount of load placed through the limb
    • Typically, if the front limb is uncomfortable, the dog will raise its head when the painful limb strikes the ground. This shifts the weight more caudally, thus distributing some of the load to other body parts[1]
    • If the hind limb is painful, the dog shifts its weight cranially. The forelimbs tend to be positioned more caudally, with the head and neck extended and lowered to offset weight from the hind end.[10] The pelvis tends to rise when the painful hind limb strikes the ground, resulting in a hip hinge.[1] The hip on the unaffected side will appear lower than the lame side. The tail may also rise as the painful leg is in contact with the ground[10]

It is important to note that while visual gait analysis is often used in clinical assessments, it is not considered a reliable measure of gait analysis.[11] The gold standard for quantifying lameness requires an objective form of gait analysis, such as force plate analysis.[10]

Static Weight-Bearing

It can be beneficial to examine static weight-bearing, particularly in dogs who have had surgery for cranial cruciate ligament dysfunction.[11] It has been found that using bathroom scales provides an objective, reliable and quantitative measure to assess static weight bearing in dogs who have osteoarthritis of their hind limbs.[11][12]

Palpation

It is possible to identify areas of dysfunction while palpating an animal patient. You may find:[1]

  • Increased muscle tension
  • Areas of asymmetry
  • Muscle atrophy
  • Changes in coat texture or temperature
  • Sensitivity or anxiety about a specific area being touched

In relation to stifle problems, the subjective evaluation of thigh muscle asymmetry through palpation is considered a sensitive method to detect functional deficits.[11] However, results can be improved by also measuring the degree of atrophy with a tape measure.[11]

Functional Testing

Once areas of dysfunction are identified, it is possible to start functional testing. The functional assessment should include any activities of daily living identified as problematic by the client.[1][11] The aim of testing is to reproduce the patient's complaint.Traditional manual muscle testing is not possible, but certain information can be obtained from testing a pet’s ability to maintain equilibrium in standing.[1]

To perform this test, the therapist lifts one of the animal's legs and applies a slight balance perturbation (forwards, backwards and laterally). The aim of this test is to assess how effectively the dog counterbalances the perturbation. The therapist compares sides and checks both the front and hind limbs. A normal result is when the animal can easily counterbalance the therapist.[1] This test highlights an animal’s willingness to shift its weight onto its affected limb, as well as its motor control and ability to maintain the position (which provides an indication of strength).

Passive testing

When assessing a quadruped patient, it is important to assess all areas (limbs, cervical spine, thoracolumbar spine) to ensure that both primary and secondary dysfunctions are identified.[1]

With passive testing, the animal physiotherapist is looking at:[1][2]

  • Range of motion
  • Comfort throughout range
  • End feel (normal vs abnormal - bony (e.g. in hip), springy block, muscle spasm, capsular, empty)
  • Accessory joint movements

Goniometry is considered a valid tool for measuring range of motion in various breeds.[13][14] However, certain limitations have been identified when using range of motion as an objective measure. The impact of age on passive range in stifle patients is, for instance, unknown.[12]

During cervical spine testing, it is important to also check for any nystagmus or asymmetries in eye movement. These tests (passive flexion, extension and lateral flexion) can be assessed in sitting.[1]

Sifting tests can initially be performed in standing (fore-limbs: carpal flexion/extension, elbow flexion/extension shoulder flexion/extension; hind-limbs: hock flexion/extension, tarsal flexion/extension, stifle flexion, extension, hip extension/abduction/flexion), but if there are areas that appear painful, they can then be assessed in side-lying. When performing hip movements, it is important that the dog is well supported to prevent any loss of balance.[1]

[15]

Test Battery for Canine Stifle Functionality

A recent Finnish study attempted to create a testing battery to measure canine stifle functionality.[16] It was found to have a sensitivity and specificity of 90 percent and 90.5 percent, respectively. Cronbach’s alpha for internal reliability was 0.727.[16] The following active and passive domains were included in the battery of tests:[16]

  • Compensation in sitting and lying positions
  • Thrust symmetry of the hind limbs when getting up from sitting and lying
  • Manual assessment of muscle symmetry
  • Measurement of symmetry in static weight bearing between hindlimbs using bathroom scales
  • Measurement of stifle passive range of motion (flexion and extension) with a universal goniometer

Neurological Assessment of the Canine Patient

The animal physiotherapist may complete a full neurological assessment for dogs who:[1]

  • Have been referred for specific rehabilitation for known neurological conditions (e.g. intervertebral disc disease)
  • Have been referred for an orthopaedic condition, but who also appear to have an underlying neurological condition

If the animal physiotherapist suspects there is an undiagnosed neurological condition, this is considered a red flag. Patients should be referred back to the veterinarian.[1]

Specific symptoms that may be highlighted in the subjective interview that suggest neurological deficits include:[1]

  • Bladder and bowel changes
  • An observation that the dog is prone to licking / chewing certain parts of the body (this can indicate nerve pain)
  • Progression of symptoms that do not appear to be due to orthopaedic conditions

Objective Neurological Assessment

Mental Status

It is important first to assess the patient's mental status. It is recommended that animal patients be allowed to explore the examination room, so that the therapist can view the animal's reactions to the surroundings.[17] The patient's level of consciousness and content of consciousness should be assessed, and any abnormal behaviour (when compared to dogs of the same age and breed) should be identified.[17]

Attitude and Posture

The attitude of an animal is defined as the position of its head and eyes in relation to its body. An abnormal head position may appear as a head tilt or turn.[17] An abnormal posture, such as a wide base of support, is common in dogs with neurological dysfunction.[17]

Gait analysis

During a neurological gait analysis, it is important to identify any changes in gait that are not related to orthopaedic lameness (e.g. crossing of front or back legs, loss of balance, inability to effectively respond to disturbances in balance).[1]

Lameness in dogs is usually caused by orthopaedic dysfunction and, as discussed above, will often result in a reduced stride length on the painful limb.[17] If a single limb is painful, the animal tends to carry the limb. However, if there is neurological dysfunction (i.e. a paretic limb), the animal tends to drag the limb.[17] Animals with neurological issues may also present with an ataxic gait (i.e. an inability to walk in a normal, coordinated manner, or the presence of abnormal movements such as tremor).[17] There are three types of ataxia:

  1. Sensory or proprioceptive ataxia
  2. Cerebellar ataxia
  3. Vestibular ataxia

Palpatory Scan

When performing a palpatory scan, it is important to look specifically for atrophy, as well as changes in the quality of the coat or skin temperature. Check for any scuffing of the toes, toenails (especially the back feet). This may indicate that the dog is dragging its legs.[1]

It is important to also scan for orthopaedic issues in patients with known neurological conditions. Animal patients rarely present with just one dysfunction.[1]

Special neurological tests

These tests help to determine the location of the neurological lesion and severity of the dysfunction. Patients with upper motor neurological conditions are more likely to present with primitive reflexes such as the crossed extensor reflex (i.e. flexion of one limb causes an exaggerated extension of the contralateral limb).[1]

Placing reflex

This tests the dog's proprioception and its ability to correct its position appropriately when the foot is placed in a non-functional position.[1]

Pain withdrawal or flexor withdrawal reflex

Pressure is applied to one of the dog’s toes. The dog should try to pull the limb away. During testing, the therapist observes whether the dog moves away from the stimulus consciously or not. Because there is a pain withdrawal reflex at the spinal level, the dog may react, but not be aware of the pain sensation. If this occurs, there is a greater likelihood of a spinal lesion. If the dog turns to look at the therapist's hand or whines, it is demonstrating that it is aware of the stimulus.[1]

Panniculus reflex

A sensory stimulus is applied paravertebrally at each spinal level to help detect the lesion level.[1]

Myotatic reflexes

In a neurological examination, it is important to assess the:[1]

  • Biceps reflex
  • Patella reflex

Sensory evaluation

Testing for sensation is difficult as animal patients are unable to provide feedback about any differences in sensation. During a palpatory scan, it is possible to assess if the patient appears equally aware of touch across sides, but this is not a reliable test for sensation.[1]

Cranial nerve testing

Cranial nerves 3, 4, and 6 all contribute to strabismus (a condition where the eyes do not properly align with each other when looking at an object) and eye control dysfunction.[1] These can also occur with sensorimotor deficits of the cervical spine and benign paroxysmal vertigo. It is, therefore, important to be able to distinguish between pure musculoskeletal presentations that can affect balance, head position and eye movement and central lesions.[1]

Cranial nerves 7 (facial nerve) and 12 (hypoglossal nerve) affect facial symmetry.[1] The client may also note that the dog has difficulty eating, chewing food or has a tendency to choke.[1]

Cranial nerve 11 (the accessory nerve) supplies motor innervation to trapezius.[17] If there is atrophy of the cervical spine or lack of muscle control around the scapula, it is possible that cranial nerve 11 is involved.[1]

Cerebellar dysfunction

A key sign of cerebellar dysfunction is gait ataxia and intention tremor. This may be apparent during functional activities such as eating or drinking (i.e. the dog may be unable to judge the distance to its food or drink). The dog may also present with a loss of balance and a head tilt.[1]

Test Battery for Neurological Function in

The Finnish neurological function testing battery for dogs (FINFUN) was recently developed due to a growing demand for objective outcome measures in animal physiotherapy.[20] This battery of tests consists of 11 tasks:[20]

  • Lying
  • Standing up from lying
  • Sitting
  • Standing up from sitting
  • Standing
  • Proprioceptive positioning
  • Starting to walk
  • Walking
  • Trotting
  • Walking turns
  • Walking stairs

The FINFUN has been found to be an objective, valid and reliable tool that can be used on dogs post-spinal cord injury.[20]

Summary

This above approach to the assessment of the canine patient will provide the animal physiotherapist with knowledge of the animal’s:

  • Context (including any handling issues, anxieties)
  • Owner's expectations
  • Main functional challenges
  • Main contributors to loss of function (i.e. weakness, joint stiffness, neurological dysfunction)

From here, the animal physiotherapist can prioritise treatment goals, identify barriers, and optimal outcomes.

References

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