A Practical Approach to the Orthopaedic Patient Consultation Room

A Practical Approach to the Orthopaedic Patient in the Consultation Room Andrew Tomlinson BVSc CertAVP (GSAS) DipECVS FHEA MRCVS EBVS™ European Specialist in Small Animal Surgery Aims of this session: v Generate a relevant capsule history v Implement a logical therapeutic strategy v Assess long-...

A Practical Approach to the Orthopaedic Patient in the Consultation Room Andrew Tomlinson BVSc CertAVP (GSAS) DipECVS FHEA MRCVS EBVS™ European Specialist in Small Animal Surgery Aims of this session: v Generate a relevant capsule history v Implement a logical therapeutic strategy v Assess long-term efficacy of your therapeutic strategy CLINICAL METROLOGY INSTRUMENTS Liverpool Osteoarthritis in Dogs (LOAD) Canine Brief Pain Inventory (CBPI) CLINICAL METROLOGY INSTRUMENTS Feline Musculoskeletal Pain Index (FMPI) Questionnaire with 17 questions: • Generates a score out of 68 Or: • Generates a FMPI % Possible score APPROACH TO THE ORTHOPAEDIC PATIENT Clinical History Be logical and methodical Ask questions which generate a baseline information: • Facilitates implementation of a bespoke management plan • Establishes data that future assessment can be compared to APPROACH TO THE ORTHOPAEDIC PATIENT Dynamic Assessment Subjective gait assessment: • VAS • NRS • Descriptive Objective gait analysis: • Force plate • Pressure sensitive walkway NRS 0 - 5 Description NRS 0 - 10 0 No Lameness 0 1 Barely detectable lameness 1 2 Mild lameness 2-3 3 Moderate lameness 4-6 4 Severe lameness 7– 9 5 Non-weight bearing lameness 10 APPROACH TO THE ORTHOPAEDIC PATIENT Dynamic Assessment Most likely to use NRS or Descriptive methods NRS 0 - 5 Description NRS 0 - 10 0 No Lameness 0 1 Barely detectable lameness 1 2 Mild lameness 2–3 3 Moderate lameness 4–6 4 Severe lameness 7– 9 5 Non-weight bearing lameness 10 Be consistent : • Use the same assessment method • Use the same assessor What about cats? Use Smartphone to record lameness APPROACH TO THE ORTHOPAEDIC PATIENT NRS 0 - 5 Description NRS 0 - 10 0 No Lameness 0 1 Barely detectable lameness 1 2 Mild lameness 2–3 3 Moderate lameness 4–6 4 Severe lameness 7– 9 5 Non-weight bearing lameness 10 APPROACH TO THE ORTHOPAEDIC PATIENT NRS 0 - 5 Description NRS 0 - 10 0 No Lameness 0 1 Barely detectable lameness 1 2 Mild lameness 2–3 3 Moderate lameness 4–6 4 Severe lameness 7– 9 5 Non-weight bearing lameness 10 APPROACH TO THE ORTHOPAEDIC PATIENT Physical Examination Be methodical and consistent 1. Assess Soft Tissue • Muscle mass and symmetry • Joint effusions • Tendinous insertions 2. Palpate Long-Bones Examine the normal leg(s) first 3. Assess Joints • Range of motion • Periarticular thickening • Crepitus Record examination findings accurately! THERAPEUTIC STRATEGY Decreased Lameness Exercise Modification Increased Exercise Tolerance Physiotherapy Analgesia Increased ROM Increased Muscle Mass Weight Management Decrease Analgesia Requirement ANALGESIA My standard analgesic therapy: NSAID Paracetamol Surgery May be required to facilitate better control of certain disease processes • Cranial cruciate ligament disease • Carpal hyperextension Additional analgesia • Amantadine • Gabapentin EXERCISE MODIFICATION Aim: To establish a baseline level of exercise that the patient can tolerate without exacerbation of their clinical signs “Rest Benji for a few weeks and see how he goes” “Here’s a structure eight-week exercise plan for Benji” Lead-Restricted exercise • Reduce to ~25% of a typical walk • two – three times daily Increase length of each walk by 5 minutes every 7 – 14 days • Aim for a maximum duration • Typically 40 mins The same rules apply to the garden! Continuously reassesses and modify your plan Introduce off-lead work when lead-restricted target achieved • Usually introduce at the end of each walk ASSESSING THERAPEUTIC SUCCESS Exercise Modification Physiotherapy Analgesia Weight Management ASSESSING THERAPEUTIC SUCCESS Initially reassessment performed after 6 – 8 weeks When stable review every 6 months Gait analysis CMI’s Weight loss/reduction in BCS Increased Range of Motion Improved Muscle mass CONCLUSION v Use your time taking a clinical history to generate a database of useful and clinically relevant information. v Provide the owners with a specific and realistic therapeutic plan v Don’t underestimate the importance of good weight management v Continuously review and modify your management strategy