Guest guest Posted June 20, 2011 Report Share Posted June 20, 2011 Carpal hyperextension related to magnesium deficiency. I realize that is not rehab but all the best work can go south if the right nutrients are not present in the tissue. I have 3 patients with this; min poodle, dach, Italian greyhound. They have improved with nutrition (mag, calcium, etc…) and Alpha-Stim therapy @ home but none got back to perfect. I suspect some is because of the severe nutritional degenerative state by the time we see them. Ava Frick, DVM,CAC From: VetRehab [mailto:VetRehab ] On Behalf Of reneeshumwaySent: Sunday, June 19, 2011 2:19 PMTo: VetRehab Subject: Carpal Hyperextension A referring vet called us last week about a dachshund he would like to send to us. The dog has a history of polyarthitis and has carpal hyperextension bilaterally. He would like us to specifically work on strengthen the ligaments of the carpi. We spoke about bracing, which the owners are willing to do. The referring veterinarian would like to try rehab for a few weeks before bracing. I am unaware of rehab related modalities/exercise to help with carpal hyperextension and I don't want to waste the people's time and money (it sounds like they have invested quite a bit into the poor dog already). The veterinarian will be sending over records. I will be happy to give more information once it is available. Advice or suggestions?Thank you in advance, Shumway LVT, CCRP, CCRA Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 20, 2011 Report Share Posted June 20, 2011 Hi , Ligaplex 1 from Standard Process will help nutritionally support the tendons and ligaments that support the joints. You don't want to totally support the joint with a brace or you will actually weaken the ligaments. I recommend the Canine Icer carpal braces, but you if the legs are tiny you may need to custom order. As they have four different levels of support, use the one that allows the most motion without letting them go to their full hyperextension. Swimming (they may be able to do it in the bathtub as it is a small dog) and digging are my favorite exercises for this and rocker board with supports on would be next. Good to hear from you. Laurie > > A referring vet called us last week about a dachshund he would like to send to us. The dog has a history of polyarthitis and has carpal hyperextension bilaterally. He would like us to specifically work on strengthen the ligaments of the carpi. We spoke about bracing, which the owners are willing to do. The referring veterinarian would like to try rehab for a few weeks before bracing. I am unaware of rehab related modalities/exercise to help with carpal hyperextension and I don't want to waste the people's time and money (it sounds like they have invested quite a bit into the poor dog already). The veterinarian will be sending over records. I will be happy to give more information once it is available. > Advice or suggestions? > > Thank you in advance, > Shumway LVT, CCRP, CCRA > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 20, 2011 Report Share Posted June 20, 2011 Good morningI wanted to comment on carpal hyperextension and bracing. From an anatomical view chronic hyperextension cases (distinct from acute traumatic hyperextension) seem to be a combination of palmar fibrocartilage insufficiency and loss of the column of support provided by the flexors (stretch and fatigue). From the biomechanical view the issue is 1) a loss of the column of support which resists ground reaction force transmission to the limb and 2) a shift of the carpus (hinge between two segments) behind the weight bearing line. The result is 1) a bending moment transmitted to the carpus directed from cranial to caudal and 2) a downward (body mass/gravity force) directed from the shoulder to the paw pad/ground with the carpus caudal to this line.One option is surgical arthodesis. An alternative is bracing (orthosis) as a so called "arthrodesis on demand" such that the carpus can flex, but is limited in extension. When the shell of the orthosis "locks" at a preset extension, the result is 1) creation of a rigid segment from elbow to metacarpal heads and therefore 2) transmission of the bending force to the proximal antebrachium ( a nice, big surface area padded with lots of muscle).See attached imagesTwo caveats on design1) Patients with hyperextension beyond ~+40 degrees or with other planes of instability (frontal or transverse) cannot tolerate articulation and must have a non articulating device. Physics!2) Those patients with severe hyperextension, multiple planes of instability, or short little metacarpals will require a paw segment to increase the lever arm for force control (think about a teeter totter and whether you sit close to or far away from the fulcrum). Physics again! The paw segment can be articulated in many cases to allow greater freedom in ambulation.I am not aware of any therapeutic exercise that can improve the palmar fibrocartilage damage. I am interested to know if anyone has had success with strengthening/shortening stretched flexors?Patrice M. Mich DVM, MS, DABVP, DACVACanine Rehabilitation Institute FacultyOrthoPets, medical director and ownerDenver, CO USA 3 of 3 Photo(s) carpus mechanics.jpg Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 21, 2011 Report Share Posted June 21, 2011 Excellent point Laurie. I agree that a non articulating orthosis (totally supporting the carpus as you mentioned) will further weaken the flexors profoundly. To clarify, the dogs that end up with a non articulating orthosis should be only those dogs that cannot safely endure axial loading of the limb without risk of further collapse. I've found if the internal structures (flexors and palmar fibrocartilage) cannot and will never create an internal moment to resist the external bending moment produced by the paw contacting the ground, then fusing the joint surgically or externally is about all you can do in a lousy situation. I'm not sure if this little dachshund fits into this category or not....depends on the severity of sagittal plane collapse, if there is frontal or transverse plane instability, and the severity of pain induced by axially loading.If, on the other hand, hyperextension is not so severe as to require compete fusion of the joint then use of an articulating orthosis with a hyperextension stop provides the ability to use those flexors and I don't find this weakens them. The flexor carpi ulnaris can still be activated. Also if the paw segment is not necessary or can be articulated as well the superficial and deep digital flexors are still active. I prefer this to arthrodesis because that can always be done, but can't be undone. I have had several cases improve their mild to moderate hyperextension through the use of articulating orthoses.I am wondering if there are specific therapeutic exercises recommended to help strengthen the palmar fibrocartilage and flexors in these mild to moderate cases. PatsyPatrice M. Mich DVM, MS, DABVP, DACVA> Canine Rehabilitation Institute Faculty> OrthoPets, medical director and owner> Denver, CO USA Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2011 Report Share Posted June 22, 2011 Great thread! I agree bracing has a correlation with muscle atrophy. Through observation in both human and animal situations, I believe this point is grossly overstated. I feel that the basic correlation between the injury disuse and muscle atrophy far supersedes what the brace adds to the situation. AND if bracing is used in tandem with physical therapy (controlled exercise with out the brace) the bracing's share of the muscle atrophy is negligible. Sounds like a topic for a study to me? I agree with Dr. Mich's guidelines on differentiating between articulated and static bracing. Cheers Ben Ben Blecha, CPO www.aceorthosolutions.com > > Excellent point Laurie. I agree that a non articulating orthosis (totally supporting the carpus as you mentioned) will further weaken the flexors profoundly. To clarify, the dogs that end up with a non articulating orthosis should be only those dogs that cannot safely endure axial loading of the limb without risk of further collapse. I've found if the internal structures (flexors and palmar fibrocartilage) cannot and will never create an internal moment to resist the external bending moment produced by the paw contacting the ground, then fusing the joint surgically or externally is about all you can do in a lousy situation. I'm not sure if this little dachshund fits into this category or not....depends on the severity of sagittal plane collapse, if there is frontal or transverse plane instability, and the severity of pain induced by axially loading. > > If, on the other hand, hyperextension is not so severe as to require compete fusion of the joint then use of an articulating orthosis with a hyperextension stop provides the ability to use those flexors and I don't find this weakens them. The flexor carpi ulnaris can still be activated. Also if the paw segment is not necessary or can be articulated as well the superficial and deep digital flexors are still active. I prefer this to arthrodesis because that can always be done, but can't be undone. I have had several cases improve their mild to moderate hyperextension through the use of articulating orthoses. > I am wondering if there are specific therapeutic exercises recommended to help strengthen the palmar fibrocartilage and flexors in these mild to moderate cases. > Patsy > Patrice M. Mich DVM, MS, DABVP, DACVA > > Canine Rehabilitation Institute Faculty > > OrthoPets, medical director and owner > > > Denver, CO USA > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 23, 2011 Report Share Posted June 23, 2011 Hello Dr. Parchman, That is an interesting point about the articulating surfaces. The OA knee unloading braces can be very effective in mild to moderate cases of varus and valgus in humans. I have to say I have not studied the articulating surfaces between the Radius/Ulna and Carpi to see the cartilaginal wear. Following this hypothesis, we may not have to amputate. We could actually cast the leg in the hyperextended position and put a lift underneath the orthosis to even the shoulder girdle height. I do find it interesting about the dogs being more uncomfortable in a brace, were they custom made or off the shelf?? Oh and you are correct, hinged=articulating. Cheers Ben Ben Blecha, CPO www.aceorthosolutions.com > > Hi Patrice, > No I don't think that with joint collapse the dogs are now walking on a cartilage surface, I think that if you have an axial loaded joint that has two articular surfaces that have extensive cartilage loss with exposed hypersensitized nerve fibers in the subchondral bone that with luxation of the joint some dogs seem more comfortable because they are no longer axial loading the joint surfaces and in some cases they are not even articulating with a full luxation. Hence they are no longer experiencing the bone on bone scenario of pain. I have also experienced this myself to a certain extent in that in 1977 I unfortunately had a ACL tear (not replaced) and complete excision of my MMC resulting in extensive medial compartment OA. With a custom medial unloading hinged (articulating?) brace it is much more comfortable because of the drop in axial loading of my medial compartment that has extensive chondral loss. Of course none of the dogs that have gone on to luxate a carpus or > hock can talk, but it is just a subjective observation that they seem to be more comfortable luxated, and when I indeed did put them in a rigid brace they were less willing to try to walk and appeared more uncomfortable. The owners have also noted that. Perhaps with the luxation they are no longer having the subchondral component of joint pain. Another example is the dog with the inadequate FHO that suffers bone impingement at the caudal acetabulum, where you re-op and shave that area to alleviate the bone to bone contact and the pain goes away. Maybe we should reframe our view, leave them in the collapsed position and create an orthotic that elevates them to a normal standing height and acts as a pad for the distal end of the radius and ulna, or perhaps amputate at the carpus and replace it with a prosthetic. How's that for radical? Thoughts? > Many ideas seem to whirl around my brain. > Enjoy the entertainment! > Mark Parchman, DVM, DACVS, CVA, CCRT > > Re: Carpal Hyperextension > > > Interesting idea Mark with regard to walking on the luxated joints. > > Are you thinking that through luxation the dog is actually walking > > on a cartilage covered surface and this will improve comfort? One > > question is how long does the dog remain comfortable? What makes > > me think of this is the concern some have reported for TPLO > > patients and the impact of weight bearing on cartilage not intended > > to withstand axial loading. My understanding is these folks feel > > that there is premature loss of cartilage. > > > > In my practice, for those patients who absolutely will never go > > through surgery (arthrodesis), a non-articulating orthosis is as > > close to arthrodesis as we can get. Although the dog must still > > axially load through a trashed joint, it seems to me that we can > > reduce (though not eliminate) " extraneous " motion in all planes > > and thereby decrease some of the pain associated with articulation > > and instability. Admittedly it is likely not the ideal option > > (arthrodesis being likely preferred) and should be coupled with a > > comprehensive pain management plan. > > > > Happy first day of summer all. > > > > Patrice M. Mich DVM, MS, DABVP, DACVA > > Canine Rehabilitation Institute Faculty > > OrthoPets, medical director and owner > > Denver, CO USA > Quote Link to comment Share on other sites More sharing options...
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