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present after surgical interventions. Joint capsule pain can be addressed through Grade 1-2 joint mobilization. Laser can be used to address pain and cryotherapy can be applied after activity. Muscle atrophy is addressed through therapeutic exercises including cavaletti poles, physioball work, and training to complete ‘’High 5’s”. Elbow stabilizers can be strengthened via block work and proprioception exercises. Adaptive shortening around the elbow is treated via Grade 2-3 joint mobilizations and passive as well as active stretches focusing upon the biceps brachii and brachialis muscles. The most common cause of angular deformity in the radius and ulna is premature closure of the distal ulnar physis. This results in the distal radius having cranial- medial convexity and secondary elbow subluxation.
The age at the time of the injury and the time from
injury to therapy determine the degree of deformity. Angular deformity generally occurs before 4 months of age, with premature closure occurring 3-4 weeks post injury. The gross deformity happens 2-3 weeks later. Surgical options include CORA based procedures and proximal ulnar osteotomy. When these puppies present to rehabilitation immediately post operatively, treatment includes cryotherapy to decreases swelling, Grade 1 joint mobilizations of the carpus and elbow as well as laser to treat pain. The soft tissue impairments associated with angular deformities include loss of carpal ROM, elbow incongruity with pain, and adaptive shortening of the muscles associated with elbow and carpus movement. Loss of carpal ROM is addressed through manual therapies: Grade 1-2 joint mobilizations and stretches, especially of the flexor carpi ulnaris and digital flexors. Therapeutic exercises are aimed at early weight-bearing work, later moving to strength exercises. Ultrasound
is used to warm muscles prior to stretching, and laser
is applied to speed wound healing. Elbow incongruity with pain and adaptive shortening are treated via joint mobilizations, triceps stretches, therapeutic exercise moving from early weight-bearing to later elbow flexion work, and ultrasound and laser as above.In conclusion, the proper approach to rehabilitation therapy involves an emphasis on proper, thorough soft tissue diagnosis, an emphasis on problem solving and creating and meeting goals that are functional for our patients, and an emphasis on safety for our immature patients.
C. Mooney1
1University College Dublin, Small Animal Clinical Studies, Dublin 4, Ireland
Carmel T Mooney MVB MPhil PhD DipECVIM-CA MRCVS
Small Animal Clinical Studies, School of Veterinary Medicine, UCD, Belfield, Dublin 4, Ireland
Since trilostane was first used to manage hyperadrenocorticism in dogs, the ACTH stimulation test has been recommended to monitor treatment efficacy. Although therapeutic cut-offs have changed over time, most endocrinologists are comfortable with interpretation of results and advising on any necessary dose changes. Its limitations are recognised. Timing of the ACTH stimulation test is crucial and it should be carried out
2-4 hours after treatment1. It is known that results of stimulation tests started at 2 or 4 hours after trilostane can yield significantly different results2 and thus should be standardised for each individual dog. Additionally although considered excellent at identifying excessively controlled dogs, escape from inhibition can occur some hours later and therefore altering drug dosage may not be necessary3.
Several studies have investigated alternative means of monitoring trilostane therapy using the ACTH response test for comparison. Varying but usually limited success has been reported for baseline cortisol, endogenous ACTH, cortisol/ACTH ratio, acute phase proteins and the urine corticoid:creatinine ratio4-7. None have gained widespread acceptance. However, these reports
have been criticised for using the ACTH stimulation
test for comparison as it has been suggested that it
was never appropriately validated for the purpose of monitoring trilostane efficacy. Additionally, it has also been suggested that the results of the ACTH stimulation test correlate poorly with clinical control as assessed by owner questionnaire8. The recent problems with regard to availability of ACTH and its expense have highlighted the need for alternative monitoring strategies.One recent study evaluated the results of the ACTH stimulation test, baseline cortisol (3 hours post pill) and pre-trilostane cortisol (24 hours after trilostane administration for
once daily dosing or 12 hours for twice daily dosing)
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