ACPAT FourFront Journal 2010

FourFront

September 2010

ACPAT Celebrates 25th Anniversary Association of Chartered Physiotherapists in Animal Therapy

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www.acpat.org

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25TH ANNIVERSARY GALA DINNER

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CONTENTS 4

Editorial

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ACPAT: The Beginning Mary Bromiley FCSP HPC

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Hind limb lameness in dogs: A Veterinary Surgeons Perspective Paul Freeman MA Vet MB Cert SAO MRCVS

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Can the knowledge of eccentric training in achilles tendinopathy be used to treat superficial digital flexor tendinopathies in the equine?

Denise Kesson MSC Veterinary Physiotherapy Student (RVC)

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Living thorough and surviving an economic sea change Sonya Nightingale MCSP ACPAT Cat A

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Sport specific rehabilitation of the dressage horse: straightness: a case study Hannah Nash MCSP ACPAT Cat A

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The successful use of veterinary physiotherapy in the management of intervertebral disc disease in an ataxic Cocker Spaniel Barbara Houlding MCSP ACPAT Cat A

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Dog of the year competition 2009: Inka Sonya Nightingale MCSP ACPAT Cat A

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Horse behaviour treatment from an equine professional: six steps to standing still Sue Brown MCSP ACPAT Cat A

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Diary of events

28

Course reviews

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Journal alert

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Guide to common abbreviations seen in the veterinary physiotherapy world

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Recent news

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Writing for Four Front

Front cover: Zara Phillips, Burghley

Author - Craig Carter - Creative Commons Attribution

Magazine designed by Three Hats Design - graphic and web design . www.threehatsdesign.com

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EDITORIAL Di Messum and Polly Hutson

Di Messum and Polly Hutson.

Welcome to Four Front the official magazine for chartered physiotherapists in animal therapy (ACPAT).

The aim of Four Front is to disseminate information to ACPAT physiotherapists and other animal related professionals.

A big thank you also goes out to all the authors who have provided us with the articles, without them we would not have even reached this point.

ACPAT celebrated its 25th Anniversary this year and a commemorative evening was held at the January We would like to make a special thank you to James seminar, this was well attended and we have included Grieson and Kathryn Nankervis who have kindly take the photographs from the evening. time out of their busy schedules to peer review all of the articles. With the ongoing demands for evidence based We hope this magazine is well received, but if you have practice we are striving to raise our profile hence the any comments positive or negative please contact us peer reviewing. via email journal@acpat.org.

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ACPAT: THE BEGINING Mary Bromiley FCSP HPC Chartered Physiotherapist

Forgive the somewhat personal note running through this article but ACPAT was formed as the direct result of personal experience. My father had qualified in Edinburgh, first as a Veterinary Surgeon then as a Doctor of Medicine, and practiced both professions simultaneously through his working life, so a career in the medical field was an obvious choice. Realising my scholastic achievements were unlikely to enable me to be accepted at either Medical or Vet school, I settled on Physiotherapy.

Shortly after qualifying at St. Thomas’s, I married and followed my doctor husband to Malaya where he had been sent to work as the first TB specialist to the Brigade of Ghurkas.

I was offered, and accepted, a job in the local Leper settlement. Plenty of interesting functional rehabilitation required – try two legless football teams and injury time being called when a leg was lost needing reattachment – a great learning curve. Our respective jobs did not make socialisation easy: ‘and what does your husband do dear?’, senior army wife, ‘he is a TB specialist’, step backward (I might be contaminated), ‘what are you doing to keep yourself amused?’, ‘I work at the Leper Colony’, departure of said wife. We were not sociably acceptable!

very rapidly when you hurt them.

I adopted the principles of the examination procedure taught me

by James Cyriax, a fanatic about observation; he considered you were a waste of space if you were not spot on, anatomically. ‘Watch the patient move; that tells you a lot’. ‘Know your muscles, their nerve supply and function’. ‘NEVER FORGET YOUR ANATOMY’. When I had, I hoped, identified the primary problem causing loss of performance or a clinical lameness, I incorporated massage, stretching and muscle strengthening. To my surprise, and to the astonishment of the Race Course Vets, not only did horses recover from muscle associated problems but actually raced again, many even winning.

On my return to England, no one seemed particularly interested in physiotherapy for animals despite my enthusiasm. Every-day life took over; work, children, ponies, dogs; animals variously came and went within the family. I treated any injuries using exactly the same principles, in so far as was possible, as I would for my human patients. Isolation of a single muscle group impossible, surely the antagonistic groups must be affected as well? Try weight on the limb in question.

Light relief needed, I turned to the local Turf Club and discovered I could buy injured racehorses for their slaughter value. I acquired some broken animals. I still vividly remember the day when a vet whom I was badgering, turned and said ‘you seem able to mend humans, why can’t you mend horses?’ Why not indeed?

Veterinary establishments usually had skeletons lying around – sometimes, in the case of cats and dogs, hanging on the walls in the waiting areas.

Thus, while I was not treating many animals, but finding comparative anatomy fascinating, I continued to read, look, learn and dissect. It was always possible to visit the local Hunt Kennels and work on fallen stock.

Anatomy, not quite as simple as the human model – relearn. No verbal communication, no chance of asking ‘where is the pain?’ To palpation skills, add speedy reflex withdrawal of examiner – animals let you know

I was shaken from lethargy into action when a patient I was treating announced she was attending a weekend course and would be, by the end of the weekend, an Animal Physiotherapist. I was irritated and

telephoned the CSP. They, too, were concerned – a Physiotherapist should be Chartered, trained – it was not a weekend job, even if she was only going to treat animals. They promised to investigate. No internet then, no ability to type in a name and learn intimate details!

Following my telephone call, enquiry

by Penelope Robinson working from CSP head office, revealed that a number of animal therapists were around. Few held any recognised qualification other than Charles Strong, Ros Boisseau and Penelope Richmond Watson, all three Chartered Physiotherapists.

Penelope approached the RVC and a working party was formed. Charles Strong seemed to be the only one of the trio recognised by a few Vets as being competent to work with animals – this, as a direct result of Royal Command. His rooms in Harley Street were not far from mine and I made an appointment to see him. He pointed out he had been Knighted for his efforts. This, he informed me, had not amused the CSP. ‘No’, he would not help form a group; ‘yes’, he would teach me all he could, but hands off his Royals!

I spent many informative hours watching him wield his Transeva, a very primitive form of muscle stimulator but designed with a much reduced skin sensation when compared to that delivered by the conventional Faradic machine. The machine, although large and cumbersome, was then a great breakthrough. I had recently attempted stimulating gluteal atrophy in a horse due to compete at Badminton using conventional Faradism, and had watched in horror as the patient departed his stable at the first current surge, towing the groom; luckily, the owner, ever unmoved, remarked ‘I always suspected he had a hidden turn of speed’.

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Negotiations with the RVC continued slowly over a three year period. At last, Chartered Physiotherapists given the all clear but with imposed limits; Veterinary permission to be obtained in every case, no direct referrals, not to diagnose, report back to the referring vet in every case.

A small group formed and spawned the specific interest group ACPAT. I had the honour of becoming the first Chair person. I really do not know how much help I was at the time as I was busy building Downs House. This purchase, a 30-box yard with paddocks and, at the time, use of Lambourn Valley Gallop, was the result of, as usual, chatting to a patient, a charming member of the Upper House. I was discussing possible ways forward for ACPAT. ‘Mend a horse and jockey, put them together and win a decent race’ was his advice, ‘then you had better do the same in the three day event and show jumping worlds.’ As an afterthought, ‘know anything about coursing?’ ‘yes’ ‘go for it, Waterloo Cup I should think’.

Sounded a good idea but where should I do this? Lambourn was the Valley of the Horse, Downs House was on the market.

After considerable family consultation, I borrowed a huge sum, calculating I could work four days a week in London to keep the bank happy and spend the other three at Downs House, leaving my luckless elder daughter to run the outfit in my absence. I converted a room to use as a human clinic in the house, built a straight swimming pool after consultation with Ray Hutchinson MRCVS (an Australian vet who was pro swimming), found a small inclined treadmill, put in an arena, a solarium, a Claydon six horse walker, and built four sand boxes large enough for turn out and safe rolling.

Bob Street riding Numismatist won a big race at York. Six months later, Mark Phillips conveniently hurt his Achilles tendon and his horse just before riding for Great Britain.

Paul Nunn brought a very broken show jumper, I was fairly certain we could not get it right, said so and

investigation proved this to be the case, rupture of the ventral ligament T14-L1, but at least we were honest.

A dog bred by Michael Forsyth Forrest, living in Lambourn, won the Waterloo Cup. Within a year, work was beginning to fill the boxes.

Over time, dogs arrived and I was requested to see a variety of animals ranging from domestic to exotic.

rather than success, lurks endlessly.

So what constitutes success?

I was very short of cash – the horse world are not good payers. Hilary Clayton had organised the first Equine Sports Medicine Conference, location Calgary. I needed to go, I must learn more. I do not bet, a £50 premium bond win was tempting . . .

Easy Come Easy Go, a horse of Jenny Pitman’s, romped in at 25 to 1. Fare and conference paid for, there was also enough left for my daughter to go to Portugal to learn the classical method of long reining.

I consider, to be successful, the therapist should know the discipline of their patient in depth. In Los Angeles, working with trotters, I felt I had to sit on a race cart to observe the action. No one had told me the harder you pulled the reins the faster you went! I think I probably broke the course record but between moments of extreme terror, I learned a lot. I have worked with the huskies at -400 when it became obvious their shoulder injuries were secondary to the effects of the unyielding pressure of nylon at those temperatures – seal skin harnesses caused no problems.

You should be able to converse with owner, trainer, stable lad, lass, head lad, kennel hand, farrier, farmer, zoo keeper, in their language, know what they require. Be honest, never be afraid to say you have been wrong; try standing alongside the open ditch at Newbury to see your NH horse jump, watch your agility dog compete, before you say your patient is ‘cured’!

As the years passed and those of us working with animals proved the idea was viable, ACPAT membership grew, the committee implemented various training routes. There was a time when, to be brutally honest, I regretted ever having suggested forming ACPAT. I felt people who came to ‘shadow’ seemed just to be looking for escape from the NHS. The underpinning knowledge of many, regarding animal disciplines, was, to the say the least, sketchy; illustrated by one, who, after examining a greyhound announced ‘it’s totally one sided, if I balance it up it will get better’. ‘Have you ever been to greyhound track, watched a race, and seen them train?’ ‘No, why?’

‘They always run anti-clockwise, this dog has a torn monkey muscle.

‘What’s that?’ Ideas come and go and will continue to do so, but the wheel cannot be reinvented, conformation is conformation. You may be able to improve posture but should you? In the long run, common sense should prevail.

I have been privileged to lecture to, and work under, some outstanding veterinarians in many countries, and to meet a huge variety of animals, each presenting with its own unique problem. There are no receipt books, every case varies.

Congratulations to those of you who have taken the plunge and, in the main, exchanged the human model for the animal. Never forget your anatomy, never hang up your L plates.

What is so exciting is there is always something new to learn. I mean, did you know the slime of the warty black slug, Arion Arter, reduces/ cures Sarcoids?

Mary Bromiley FCSP June 2010 Exmoor and the Smokey Mountains, NC, USA

The RVC Course is without parallel, a world best, how fortunate students are today. I have had to learn by trial and error; those of you who read this distribute know, if you are honest, there are no short cuts. It is a long hard slog and possible failure,

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HIND LIMB LAMENESS IN DOGS: A VETERINARY SURGEON’S PERSPECTIVE Paul Freeman MA VetMB CertSAO MRCVS The Veterinary Practice Millennium Way Braintree Essex CM7 3GX Introduction The following article includes an account of how I perform an investigation into hind limb lameness in dogs; it is not intended to be a definitive guide, but should provide an insight into the examinations and methods which can be utilised to arrive at a diagnosis.

Any discussion of the causes and treatments of hind limb lameness is greatly assisted by an understanding of the range of problems seen in different ages and breeds of dog. The old adage that “common things are common” should always be kept in mind, and the article provides a list of the more common conditions, although this is not intended to be exhaustive. Finally I have provided a brief overview of my current thoughts on one of the more common causes of hind limb lameness, cranial cruciate ligament disease.

The Lameness Investigation In making a diagnosis of the cause of lameness, I always like to begin with a careful history taking. This need not take very long, but requires the ability to listen and extract the useful information from the dog’s owner.

Owners often become side-tracked when discussing their dog’s problem, and sometimes will have decided what is wrong (or what cannot possibly be wrong), before seeking assistance.

Apart from ascertaining the age and breeding history, the important things are whether the lameness is acute or chronic, whether there was a known incident that precipitated the problem, whether it is progressive or static, and whether it is improved or exacerbated by rest and/or exercise.

The next step is to assess the dog moving; it is very common to be presented with a dog for lameness

examination of the wrong leg!

I always like to see the dog moving outside of the surgery at trot and walk; even when the problem appears severe and obvious, other things may be observed such as the existence of bilateral disease or a neurological problem. Once it is clear which leg(s) is/are affected, a thorough physical examination should be performed.

A systematic approach should always be taken in order to minimize the risk of missing an important feature.

I prefer to start with the foot and move proximally, except where I am very suspicious the problem is located in the foot, in which case I will begin proximally and leave the painful region till last. During the physical examination, it is important not to over interpret signs of pain or discomfort. Some dogs can be very fidgety, especially when handling their feet, and I always try to compare response to a similar examination of the contralateral limb. Once the painful region has been established, I also like to check that the response is repeatable.

The physical examination is vital, since multiple pathologies may be revealed by radiographs; it is particularly important to establish the location of the problem when surgical treatment may be proposed. As well as a pain reaction, palpation may reveal joint swelling, muscle wastage or the presence of an abnormal mass, all of which may be significant.

Once the location of the lameness has been established, further investigations may be proposed, including initially radiography and perhaps arthrocentesis. Radiography is still the main-stay of orthopaedic investigation, and good quality radiographs centred on the affected area are vital. Poor radiographs may suggest non-existent pathology

or miss the presence of subtle changes, and are a frequent cause of non diagnosis. Arthrocentesis is a relatively simple and minimally invasive technique which can normally be performed under sedation, and forms part of any examination into joint pathology (1). Samples of joint fluid can be taken from almost any joint, particularly if the joint is inflamed; cytology of this fluid can be performed quickly in a practice laboratory, and can be a sensitive way of confirming the location of intra-articular pathology, as well as diagnosing inflammatory and septic arthritis.

It is rare that further investigative techniques are required, but on occasions further imaging may be helpful. Computed Tomography (CT) scanning is especially useful in the diagnosis of elbow dysplasia in the fore limb; Magnetic Resonance Imaging (MRI) scanning is occasionally useful in diagnosing soft tissue tumours; and scintigraphy is a sensitive method for picking up subtle and difficult to detect lesions. More invasive techniques such as arthroscopy or even open arthrotomy are also sometimes necessary to reach a final diagnosis, particularly in cases of meniscal injury secondary to cruciate ligament disease. In cases of neurogical lameness such as lumbosacral disease and nerve tumours, MRI is probably the most accurate diagnostic method, but Electromyographic (EMG) changes may also be found which are highly suggestive of the source of the problem.

Differential Diagnoses Once the source of lameness has been established, a knowledge of the differential diagnoses becomes very helpful, and will aid the application of the appropriate investigative

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technique. The following list is by no means exhaustive, and there is much crossover between my differing categories, but it is meant to provide a simple guide to which are the most likely and unlikely causes of lameness in different ages and breeds of dog.

1. Hip/Proximal Limb Pain a. Immature Dogs Hip Dysplasia (HD) – Radiography – susceptible (larger) breeds.

Panosteitis – Radiography – German Shepherd Dog (GSD) especially prone.

Legg Perthes Disease (LPD) - Radiography – Small breeds especially West Highland White Terriers.

Proximal femoral physeal fracture – Radiography. b. Adult dogs Hip Osteoarthritis (OA) – secondary to HD or LPD. Radiographs and arthrocentesis.

Trauma e.g. fracture/luxation History.

Lumbosacral disease – larger breeds especially GSD. Neoplasia – bone or soft tissue.

2. Stifle Pain a. Immature dogs Distal femoral physeal fracture – History + Radiographs.

Tibial tuberosity avulsion (especially Staffs) – Radiographs, compare contralateral side to be sure.

Avulsion of the cranial cruciate ligament (CCL) - Radiographs.

Septic stifle arthritis Arthrocentesis.

Panosteitis - Radiographs.

Patella luxation – medial (small and toy breeds) or lateral (large breeds especially Flat Coated Retriever).

– Physical examination and radiography.

Inflammatory Polyarthritis Arthrocentesis. b. Adult Dogs CCL disease – see later – all breeds except Greyhound.

Inflammatory Polyarthritis Trauma.

Sepsis.

Patella luxation.

Stifle OA – suspect CCL disease (rarely primary).

Neoplasia – distal femur and proximal tibia are common sites for osteosarcoma.

3. Lower Limb a. Immature Dogs Hock Osteochondritis Dissecans (OCD) – Radiographs – Labrador.

Avulsion fractures – calcaneus and malleoli - Radiographs.

Toe injuries (trodden on!).

Trauma.

Inflammatory Polyarthritis. b. Adult Dogs Inflammatory Polyarthritis.

Plantar ligament breakdown/injury – Stressed Radiographs – Sheltie.

Hock OA – secondary to injury or OCD. Inter digital Foreign body – Spaniels and other working dogs.

Achilles injury / breakdown – Doberman Pinscher.

Corn – Greyhound.

Trauma.

Neoplasia.

Cruciate Disease The cranial cruciate ligament (CCL) functions to prevent cranial movement and inward rotation of the tibia during weight bearing. It is also believed to have a role in conscious proprioception of the hind limb.

Disease or injury to the CCL in dogs accounts for a very high proportion of hind limb lameness seen in veterinary practice, although unlike the human equivalent, the majority of canine CCL disease is not traumatic in origin. Occasionally we are presented with a dog that has obviously ruptured a CCL acutely in a traumatic incident such as running over a ploughed field; more often though the onset is insidious and chronic, with marked secondary OA already present at the time of diagnosis. Even many apparently acute ruptures can be shown to be acute episodes of a chronic disease, with careful history taking and radiographs demonstrating the true nature of the problem.

the affected limb when standing, and struggle to flex the stifle when sitting.

The stifle joint is usually thickened and painful, especially during forced extension and medial palpation, and sometimes a cranial drawer movement or tibial thrust may be palpated with the dog conscious. In these cases the diagnosis is easy to make, and the ligament is likely to be completely ruptured. Often a marked lameness can be caused by only partial CCL tearing however, and in such cases the diagnosis may be less obvious. Radiographs are likely to demonstrate a joint effusion and early OA; joint fluid should contain increased numbers of synoviocytes; a degree of cranial drawer can usually be palpated under sedation or general anaesthesia. In a small number of cases where the index of suspicion is high but no instability can be demonstrated, final diagnosis may only be confirmed at arthrotomy.

Care must also be taken in cases of bilateral CCL disease; these can present with the dog acutely unable to walk, and may be misdiagnosed as a spinal problem. Again a careful physical examination should reveal bilateral stifle pain and instability.

Once a diagnosis of CCL disease is made, treatment options must be discussed. Conservative treatment should always be considered in small dogs of 10kg and under (2).

This consists of a period of exercise restriction, usually accompanied by the use of non steroidal antiinflammatory drugs (NSAID’s).

Physical therapy techniques aimed at increasing quadriceps muscle bulk may also be helpful.

Where this is unsuccessful, and in larger dogs, surgical treatment should be considered. Currently most orthopaedic surgeons favour either an extra capsular stabilisation technique involving replacing the function of the CCL with a laterally placed nylon suture, or a tibial osteotomy procedure.

Dogs with CCL disease may have lameness varying from severe to slight. Characteristically they rest

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Lateral Suture Technique (3) This can be very successful in all sizes of dog, but is generally now recommended for lighter and older dogs. An arthrotomy or arthroscopy should always be performed concurrently to check for meniscal injury, since this may be a cause of persistent lameness following surgery (4). The stifle joint is stabilized by placing a nylon suture between the lateral fabella and the tibial tuberosity. Post-operatively, a gradually increasing regime of short, frequent lead walks over about 6-8 weeks is normally recommended.

Hydrotherapy twice weekly from 2 weeks post-op for 2-4 weeks also appears to be very beneficial.

Tibial Osteotomy Surgery A variety of techniques aimed at changing the angle of the proximal tibial plateau have now been shown to be effective in treating CCL disease (5). These procedures appear to be advantageous in particularly young large breed dogs, and in cases of bilateral disease. It is believed that an excessive caudal slope on the tibial plateau predisposes the CCL to fail, and that changing this in a pre-measured way can effectively eliminate the need for CCL stabilisation of the joint.The currently used techniques include:

suture technique, an arthrotomy is first performed in order to check for meniscal injury.

Post-operatively dogs are required to be rested strictly for the first month, before beginning a gradually increasing programme of lead walking and physical therapy. Hydrotherapy should be delayed until after a 6 week radiograph confirming osteotomy healing. Physiotherapy involving passive range of motion exercises may be employed from an early stage.

However, despite the popularity of these techniques, there is a shortage of evidence to support the belief that they provide an improved longterm function over other surgical techniques particularly lateral suture (10), and individual surgeons tend to develop protocols for management of CCL disease based on personal experience and largely anecdotal evidence.

References 1. BSAVA Manual of Small Animal Arthrology, Ed JEF Houlton and RF Collinson, 1994.

2.Vasseur PD: “Clinical results following nonoperative management for rupture of the cranial cruciate ligament in dogs”.Vet Surg 13, 243-246, 1984.

3. Flo GL: “Modification of the lateral retinacular imbrication technique for stabilizing cruciate ligament injuries.” J Am Anim Hosp Assoc 11, 570-576, 1975.

4. Flo GL: “Meniscal Injuries.” Vet Clin North Am Small Animal Practice 23: 831-843, 1993.

5. Kim SE, Pozzi A, Kowaleski MP, Lewis DD: “Tibial Osteotomies for cranial cruciate ligament insufficiency in dogs.” Vet Surg 37, 111-125, 2008.

6. Slocum B, Slocum TD: “Tibial Plateau Levelling Osteotomy for repair of cranial cruciate ligament rupture in the canine.” Vet Clin North Am Small Anim Pract 23: 777-795, 1993.

7. Slocum B, Devine T: “Cranial tibial wedge osteotomy: a technique for eliminating cranial tibial thrust in cranial cruciate ligament repair.” J Am Vet Med Assoc 184: 564-569, 1984.

The Tibial Plateau Levelling Operation (TPLO) (6)

8. Montavon PM, Damur DM, Tepic S: “Advancement of the tibial tuberosity for the treatment of cranial cruciate deficient canine stifle.” Proceedings of the 1st World Orthopedic Veterinary Congress, Munich, Germany, P.152, 2002 (abstract).

The Cranial Closing Wedge (7) The Tibial Tuberosity Advancement (TTA) of Tepic (8)

9. Bruce WJ, Rose A, Tuke J, Robins GM: “Evaluation of the Triple Tibial Osteotomy. A new technique for the management of canine cruciate deficient stifles.” VCOT 20, 159-168, 2007.

The Triple Tibial Osteotomy (TTO) of Bruce (9) A detailed account of the surgery involved is beyond the remit of this article, but any reader interested is recommended to see the Veterinary Instrumentation web site at www. veterinary-instumentation.co.uk for further information and videos of these procedures. As with the lateral

treatment options for CCL disease.

The references provided below will allow the reader to further explore this complex subject.

As stated at the beginning, this article is not intended to provide a complete guide to hindlimb lameness in dogs, but is intended to give a personal perspective on how an investigation of lameness can be performed, an outline of commonly seen conditions, and a brief overview of

10. Conzemius MG, Evans RB, Besancon MF: “Effect of surgical technique on limb function after surgery for rupture of the cranial cruciate ligament in dogs.” J Am Vet Med Assoc 226, 232-236, 2005.

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CAN THE KNOWLEDGE OF ECCENTRIC TRAINING IN ACHILLES TENDINOPATHY BE USED TO TREAT SUPERFICIAL DIGITAL FLEXOR TENDINOPATHIES IN THE EQUINE? Denise Kesson MCSP MSc Veterinary Physiotherapy Student Introduction Physiotherapy has been a valued component of health care in humans for over a century. The recognition of the benefits of Veterinary Physiotherapy in the injured animal has been relatively recent. The profile of the Veterinary Physiotherapist is rising in both the Veterinary world and with the general public. To increase the credibility of the profession it is important that interventions used are evidenced based.

The Equine Veterinary Journal published a review article by Buchner and Schildboeck (2006) on physiotherapy applied to the horse.

This review systematically analysed published research on the effect of the various physiotherapeutic modalities used in practice applying the evidence-based medicine approach (Mair and Cohen 2003).

Their findings were that there were insufficient good quality studies investigating the use of various physiotherapy treatments on horses to enable physiotherapists to work with an evidence based medicine approach to treatment.

The following year, in the same journal, McGowan et al (2007) built on this review stating that Buchner and Schildboeck had limited their review of evidence to veterinary literature. The feeling was that there are good quality studies performed in human literature that has led on from previous research performed on animals that can be applied to veterinary practice. McGowan et al emphasised how physiotherapy uses a range of treatment modalities for each individual patient after a formal assessment that will have led to a functional diagnosis. They therefore

believed that it was more beneficial to discuss both the science and evidence base behind current issues in key areas of physiotherapy and to look at how they can be applied to the performance horse, rather than reviewing the research done concerning each treatment modality.

surrounding the efficacy of eccentric exercises will be explored. The author will aim to draw from the literature evidence to justify the use of eccentric exercises in the management of superficial digital flexor tendinopathy in the equine.

Tendiniopathy Definition

Achilles tendon

The aim of this literature review is to follow on from McGowan et al’s article and to examine the relevance and application of eccentric exercise as an evidenced-based physiotherapeutic approach to treat superficial digital flexor tendinopathy in the equine.

Currently tendon problems affect both the human and equine athletes (Williams et al (2001), Maffulli et al (1999), Horshian et al (1998) and Moller et al (1996)). Management of Achilles tendinopathy in humans is predominantly conservative and physiotherapist led whereas the equivalent tendon in equines, the superficial digital flexor tendon, is managed by more invasive methods by the veterinary surgeon (Dyson (2004)).

Current literature exploring the definition of tendinopathy, its aetiology and the evidence

The term tendinopathy is used to describe tendon pathology in the sheath and or body itself arising from overuse (Benazzo and Maffulli (2000)). It has replaced the diagnosis of “tendonitis” and “tendinosis” which are only used if there is evidence of inflammation found after histopathological examination (Sharma and Maffulli, 2006). It has replaced the diagnosis of “tendonitis” and “tendinosis” which are only used if there is evidence of inflammation found after histopathological examination (Sharma and Maffulli, 2006).

Tendon structure

In both human and the equine, tendinopathies can occur from the influence of both intrinsic, for example poor foot conformation or biomechanics (Eliashar et al (2004) and Nigg (1994)), and extrinsic factors, such as excessive repetitive

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overloading of the tendon during vigorous training (Kvist (1994) and Kasashima (2004)). Selvanattie et al (1997) reports degeneration in the tendon is encouraged by the overloading of it during vigorous exercise. If the tendon is not able to regenerate as quickly as it is degenerating the end result is a tendinopathy. If intrinsic factors affect the overused tendon the risk of this process occurring increases.

Although it is widely recognised that tendon injuries are the most common in both human and equine athletes, little is understood about the aetiology of the conditions. At present tendinopathies are diagnosed once they become symptomatic and the ‘damage has been done’.

Arnoczky (2008) believes that if we understood the underlying causes of tendon injuries we would be able to identify the athletes at risk and begin injury prevention.

Current Theories in Causes of Tendinopathy The cause of tendinopathy is based mainly around several aetiological theories such as hypoxic or ischemic changes (vigorous exercise could lead to a reduction in oxygen delivery to the tendon and if this is prolonged, eventual tenocyte death), excessive apoptosis (normal programmed cell death is increased within the tendon), oxidative stress (ischemia occurs if the tendon is under increased load) and hyperthermia (when tendons are loaded heat is created.

If they are repeatedly loaded and the heat cannot escape, cells within the tendon can become damaged) (Sharma and Maffulli (2005), Yuan et al (2003), Bestwick and Maffulli (2000), Birch et al (1997) and Goodship et al (1994)). All of these theories are yet to have significant scientific backing (Fredburg and Stengaard-Pedersen, 2008). The predominant theory is that tendinopathies are caused by overuse which causes microtrauma and the tendon is not given enough time during training to recover (Kjaer et al (2006)). Following on from this, early degeneration occurs and the tendon is vulnerable to injury (Tallon et al (2001)).

It is known that, to have and maintain homeostasis within a tendon the tendon needs to be exposed to mechanical loading (Banes,et al (1995) and Wang and Ingber (1994)).

The magnitude, regularity and length of time the tendon should be loaded for to maintain homeostasis is unknown (Arnoczky (2007) and (2002)). There have been several studies performed looking into the effects of over stimulating tendons, in vitro, either by repetitive loading and stretching (Wang et al (2003), Archambault et al (2002) and (2001), Skutek et al (2001) and Banes et al (1999)). The studies showed that the mechanical loading they exposed to the tendons led to the release of inflammatory cytokines and degenerative enzymes. However the mechanical strains used to produce these responses where excessive of normal physiological movement in either the length of time the stress was applied, the magnitude of stress applied or the amount of repetitions applied. It is therefore not appropriate to base clinical reasoning for treating tendon degeneration solely on these studies.

Both human and equine athletes present with tendon problems once they become symptomatic.

By this time there is already a histological appearance of a failed healing response and the clinical diagnosis is tendinopathy. Therefore it is not the individual fibril damage caused by overloading of the tendons but the continued loading (or continued training) of the now inferior replacement collagen fibrils that leads to the progression of the pathological process.

Eccentric Exercises – the Evidence As the understanding behind tendinopathies increases, the aims of treatment of this condition has been seen to change within the human field and we are moving away from addressing the inflammatory process to become more exercise focused (Allison and Purdam, 2009). Over the last 10 years there has been a growing interest in the use of eccentric exercises to treat tendinopathies.

Eccentric exercise involves the muscle-tendon unit lengthening while it is loaded (Rees, 2008). This is the opposite of concentric exercises where the muscle-tendon unit shortens while it is loaded.

In 2005 Peers and Lysens proposed that eccentric exercises counteract the failed healing response of the tendon, encouraging the formation of cross links of the collagen fibres and facilitating the remodelling stage in healing. This theory was supported

by Jeffery et al (2005). Allison and Purdam (2009) progressed this theory further in their paper hypothesising that there may be several mechanisms at work that lead to the efficacy of eccentric exercises such as; 1) Correcting the heterogeneity of the visco-elastic properties of the tendon caused by tendinopathies and potentially affecting the tendons aponeurosis, elastic recoil and spinal reflex feedback loops improving lower limb function.

2) Correcting the imbalance of the elastic recoil timing and spinal reflex feedback in both short and long reflex loops and thus changing optimal functional ranges of the passive and active components of the muscle-tendon unit.

3) Reducing the vascularity of the tendon by causing shearing forces between the tendon and the paratendon.The increase in vascularity associated with tendinopathies is thought to be a source for the pain (Ohberg and Alfredson (2004).

4) Adapting the mechanotransduction signalling (the ability of living cells to sense mechanical stress and respond by remodelling) in the passive structures of the muscletendon unit.

A trial by Stanish et al (1986) found that in 200 patients diagnosed with Achilles tendonitis 44% became completely pain free and 43% had a “marked improvement” in their pain levels after performing an eccentric loading programme once a day for 6 weeks. Although these results were

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very promising there was no control group and, due to other weaknesses in the methodology, the results were grossly ignored by clinicians and eccentric exercises were not accepted as best practice.

It wasn’t until 1998 when Alfredson et al’s prospective randomised controlled trial confirmed the efficacy of eccentric exercises in Achilles tendinopathy. Although Alfredson et al’s methodology was considerably stronger than Stanish et al’s previous work; his prescribed dosage of eccentric exercises (15 repetitions of heel drops into discomfort twice a day for 12 weeks) was based on his clinical experience rather than any scientific reasoning.

Since Alfredson et al’s randomised controlled study, a lot more research has been dedicated to the efficacy of eccentric exercises using the exercise programme prescribed in Alfredson’s paper for Achilles tendinopathy.

Between 2001 and 2004, three randomised controlled trials took place (Roos et al (2004), Mafi et al (2001), Silbernagel et al (2001)).

They all used similar sample sizes of around 40 participants. Both Mafi et al and Silbernagel et al compared eccentric training with concentric training. Mafi used the eccentric overload training programme designed by Alfredson; Silberangel et al used a training method containing eccentric exercises as well as alongside other interventions (eg, stretching and applying ice). Roos et al also used Alfredson’s eccentric training programme along with night splints. By using two interventions the evidence of eccentric training as a standalone treatment is devalued.

The other variability noted between the trials was the use of outcome measures. Roos et al used the Foot and Ankle Outcome Measure (Roos et al (2001)) compared to the other two who used the Visual Analogue Scale (Wewers and Lowe (1990).

Aside from Alfredson et al (1998) and Stanish et al (1986) there are three controlled trials (Shalabi et al (2004), Alfredson et al (2003) and Fahlstrom et al (2003). All of these trials followed the prescribed eccentric

exercise routine of Alfredson et al (1998). Fahlstrom et al divided the participants into two groups, one for insertional Achilles pain and one for mid-portion Achilles pain finding eccentric exercises to be significantly more beneficial for mid-portion pain.

None of these three controlled trials used control groups.

All studies conducted so far have showed a reduction in pre-reported pain levels with eccentric training for Achilles tendinopathy and all except Mafi et al (2001) had a greater reduction in pain in the eccentric training compared with the control group. Unfortunately due to the various outcome measures used and the heterogeneity of the populations used it is not possible to pool the results to support a conclusion that there is a statistically significant effect of eccentric training. There is enough evidence to justify the use of eccentric exercises clinically for Achilles tendinopathy and to support further research into their affect on the tendon.

Discussion After reviewing the current literature supporting conservative management of Achilles tendinopathy by eccentric training, it is clear that the published work is only relevant to treating human tendons. It is also clear that the majority of our knowledge about the aetiology of tendinopathy and the effect on the tendons with exercise is based on the results from animal studies rather than the human population. Both the Achilles tendons and superficial digital flexor tendons are energy storing tendons designed to ensure propulsion is energy efficient. The knowledge gained about Achilles tendinopathy from studying animal tendons is used to support our treatment of the human tendons. Using this same reasoning, our knowledge of efficacy for tendinopathy treatment in humans could be transferred to the equine.

There is evidence to support the use of eccentric exercises clinically in the management of Achilles tendinopathy and that there is a

stronger efficacy for its use in midportion pain (Roos et al (2004) and Fahlstrom et al (2003)). Arnoczky (2008) reported that superficial digital flexor degenerative changes associated with tendinopathy occurs predominantly within the central core fibrils increasing the strength of justification for using eccentric exercises for rehabilitation. It is time to step away from the need of randomised controlled trials and to focus on the underlying science behind the interventions to justify our treatment.

Conclusion When evaluating the current literature supporting eccentric exercises it is important to bear in mind that the author who led the first randomised controlled trial proving the efficacy of the intervention has been involved in most of the research projects since. This could introduce bias into the literature body. Current findings are promising but there is a need to gain further insight into the mechanobiological mechanisms that may play a role in the cause of tendinopathy in both Achilles and superficial digital flexor tendons. It is important also to clarify the changes that occur within the tendon as a response to eccentric exercise training to either prove or disprove the current theories in the literature rather than measuring changes in pain levels. Lawson et al (2007) discuss the development of a technique to measure the strains that occur in equine tendons using a three dimensional lower limb mode and therefore there may be a possibility of using this technology to measure strain through tendons during eccentric loading.

This literature review continued on from McGowen et al’s (2007) paper and reviews the current literature surrounding tendinopathies and eccentric training. In the light of the findings, there is enough evidence available to justify supporting a more conservative approach to managing superficial digital flexor tendinopathy in the equine compared to more invasive methods. The author recommends development of an

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eccentric exercise programme suitable for the equine as well as exploring the possibility of using eccentric training to prevent tendinopathies in the future.

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11:196-499 Alfredson, H, Pietila, T, Jonsson, P and Larentzon, R (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine 26: 360-366 Allison, G and Purdam, C (2009). Eccentric loading for Achilles tendinopathy – strengthening or stretching. British Journal Sports Medicine 43: 276-279 Archambault, J, Tsuzaki, M and Herzog, W (2002). Stretch and interleukin -1beta induce matrix metalloproteinases in rabbit tendon cells in vitro. Journal of Orthopaedic Research 20 :36-39 Archambault, J, Tsuzaki, M and Herzog, W (2001). Response of rabbit Achilles tendon to chronic repetitive loading. Connective Tissue Research 42: 13-23 Arnoczky, S (2008). Role of mechanobiology in the pathogenesis of tendinopathy: Lessons learned from horses and humans. AAEP Proceedings 54: 470-474 Arnoczky, S, Lavagnino, M ,and Egerbacher, M (2007). The mechanobiological etiopathogenesis of tendinopathy: Is it the over-stimulation or the under-stimulation of tendon cells? International Journal of Experimental Pathology 88: 217-226 Arnoczky, S , Lavagnino, M, Whallon, J and Hoonjan (2002). In situ cell nucleus in cell deformation under tensile load: a morphologic analysis using confocal laser microscopy. Journal of Orthopaedic Research 20: 29-35 Banes, A, Horesovsky, G, Larson, Tsuzaki M, Judex S, Archambault J, Zernicke R, Herzog W, Kelley S and Miller L (1999). Mechanical load stimulates expression of novel genes in

vivo and in vitro in avian flexor tendon cells.

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Equine Veterinary Journal. 38(6) 574-580 Dyson, S (2004). Medical management of superficial digital flexor tendonitis: a comparative study in 219 horses (1992-2000).

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Relationship of foot conformation and force applied to the navicular bone of sound horses at the trot. Equine Veterinary Journal 36: 431-435 Fahlstrom, M, Jonsson, P, Larentzon, R and Alfredson, H (2003). Chronic Achilles tendon pain treated with eccentric calf muscle training. Knees Surgery, Sports Traumatology and Arthroscopy. 11: 327-333 Fredburg, U and Stengaard-Petersen, K (2008). Chronic tendonopathy tissue pathology, pain mechanisms and etiology with a specific focus on inflammation.

Scandanavian Journal of Medical Science in Sports 18: 3-15 Goodship, A, Birch, H, and Wilson A (1994).

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Jeffery, R, Cronin, J and Bressel, E (2005).

Eccentric strengthening: Clinical applications to Achilles tendinopathy. New Zealand Journal of Sports Medicine. 33: 22-30 Kasashima, y, Takahashi T, Smith RK, Goodship AE, Kuwano A, Ueno T, and Hirano S (2004). Prevelance of superficial digital flexor tendonitis and suspensory desmitis in Japanese Thoroughbred flat racehorses in 1999. Equine veterinary Journal 36(4): 346-350 Kivst, M (1994). Achilles tendon overuse injuries in athletes. Sports medicine 18: 173-208 Kjaer, M, Magnusson, P, Krogsgaard, M, Boysenm Moller, J, Olesen, J, Heinemeier, K, Hansen, M, Haraldsson, B, Koskinen, S, Esmarck. B and Langberg, H (2006).

Extracellular matrix adaption of tendon and skeletal muscle to exercise. Journal of Anatomy 208: 445-450 Lawson S, Chateau H, Pourcelot P, Denoix J-M, Crevier-Denoix N (2007). Sensitivity of an equine distal limb model to perturbations in tendon paths, origins and insertions Journal of Biomechanics 40 2510–2516 Maffulli, N, Barrass,V and Ewen, S (2000).

Light microscopic histology of Achilles tendon ruptures. A comparison with unruptured tendons. American Journal of Sports medicine. 28: 857-863 Maffulli N, Waterston SW, Squair J, et al (1999). Changing incidence of Achilles tendon rupture in Scotland: a 15-year study.

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Tallon C, Maffulli N and Ewen S (2001).

Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Medical Science in Sports Exercise 33: 1983-1990 Wang, N and Ingber, D (1994). Control of cytoskeletal mechanics by extracellular matrix, cell shape and mechanical tension.

Biophysiological Journal 66: 2181-2189 Wang, J, Jia F,Yang, G et al (2003). Cyclic mechanical stretching of human tendon fibroblasts increases the production of prostaglandin E2 and levels of cyclooxygenase expression; a novel in vitro model study.

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Moller A, Astron M and Westlin N (1996).

Increasing incidence of Achilles tendon rupture. Acta Orthop Scand 67:479–481 Nigg, BM (1994). The role of impact forces and foot pronation: a new paradigm. Clinicla Journal of Sports Medicine. 11: 2-9

Ohberg, L and Alfredson, H (2004). Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis. Knee Surgery Sports Traumatological and Arthroscopy. 12: 465-470 Peers, K and Lysens, R (2005). Patellar tendinopathy in atheletes: Current diagnosis and treatment recommendations. Sports medicine 35: 71-87 Rees, J, Litchtwark, G, Wolman, R and Wilson, A (2008). The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology.

47(10): 1493-1497 Roos, E, Engstrom, M, Lagerquist, A and Soderbers,B (2004). Clinical improvement after 6 weeks of eccentric exercises in patients with mid-portion Achilles tendinopathy – a randomised trialwith 1 year follow-up. Scandanavian Journal of Medical Science in Sports. 14: 286-295 Roos, E, Brandsson, S and Karlsson, J (2001).

Validation of the Foot and Ankle Outcome Score for Ankle Ligament Reconstruction.

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Selvanetti A, Cipolla M and Puddu G (1997).

Overuse tendon injuries: basic science and classification. Operative Techniques in Sports Medicine 5: 110-117 Shalabi, A, Kristoffersen-Wilberg, M, Svensson, L, Aspelin P and Movin T (2004). Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. American Journal of Sports medicine. 11: 1286-1296 Sharma, P and Maffulli, N (2006). Biology of tendon injury: healing, modelling and remodelling. Journal of Musculoskeletal Neuronal Interactions 6 (2): 181-190 Sharma, P and Maffulli, N (2005). Tendon injury and tendinopathy: healing and repair.

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87: 187-202 Silbernagel, K, Thomee, R, Thomee, P and Karlsson J (2001). Eccentric overload training for patients with Achilles tendon pain – a randomised controlled study with reliability testing of the evaluation methods.

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Wewers M.E. & Lowe N.K. (1990). A critical review of visual analogue scales in the measurement of clinical phenomena.

Research in Nursing and Health 13, 227-236 Williams R, Harkins L and Hammond C (2001). Racehorse injuries, clinical problems and fatalities recorded on British racecourses from flat racing and National Hunt racing during 1996, 1997and 1998. Equine Veterinary Journal 33:478–86 Yuan, J, Wang, M and Murrell, G (2003). Cell death and tendinopathy. Clinical Sports Medicine 22: 693-701 Achilles Tendon http://www.eorthopod.com/eorthopodV2/ index.php?ID=dbb85cd4171ee690cf f1b8cc7b0a57c6&disp_type=topic_ detail&area=20&topic_id=d46c40fda45e0a25 27a1ba3f5aa53cdd Tendon Structure http://mcr.coreconcepts.com.sg/tendondisorders-inflammation-and-degeneration/

Skutek, M, van Griensven, M, Zeichen, J and Brauer N, Bosch U (2001). Cyclic mechanical stretching enhances secretion of interleukin6 in human tendon fibroblasts. Knee Surgery, Sports Traumatology, Arthroscopy 9: 322-326 Stanish, W Rubinovich, R and Curwin, S (1986). Eccentric exercise in chronic tendonitis. Clinical Orthopaedic Related Research. 208: 65-68

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LIVING THROUGH AND SURVIVING AN ECONOMIC SEA CHANGE Sonya Nightingale MCSP ACPAT Cat A The last eighteen months have been an extremely challenging time for many of us. The economic climate has battered our clients and they in turn have sought to reduce their costs and outgoings. This has an obvious consequence for us as service providers. In addition many insurance companies are looking ever more closely at how much and to whom they pay out; they have their own battles with falling revenue and tighter margins.

With a dwindling pot of money the competition between practitioners sharpens and professionals will seek to protect their own income stream more fiercely.

Throwing your hands in the air and saying it’s not fair, or that you don’t like it will receive little or no sympathy, it is, after all, just change.

As practitioners we have to manage and adapt to this change and seek new opportunities while consolidating old ones. Very few people enjoy change but we adapt and change or sink without trace!

It also helps to try and consider the problem from all angles, in other words put yourself in the purchaser’s shoes. Why should they choose an ACPAT physiotherapist? Why should they choose you? What makes you the obvious choice, and make sure that you can justify it! We are actually very fortunate in the current situation. Physiotherapy for animals is very much the trendy option at the moment. Owners are keen on it and vets and insurance companies are waking up to this. From the owners and insurance companies’ point of view it is also often seen as a slightly ‘cheaper’ option with a high quality outcome. However from the vets point of view it could be seen as a severe threat to their own income, with little real evidence to back it up and a confusing variety of practitioners.

Many other sectors have already gone through many similar changes, accountants and lawyers are just two examples, private human physiotherapists are also facing similar challenges albeit without the confusion caused by lack of protection of title. It is no longer enough to put up your brass plaque and be good at what you do, although it helps, you must be astute, business minded and adaptable as well!

Business Fundamentals Each practice is unique therefore no solution is universal. This means following some basic business fundamentals and adapting them to individual market forces. The basic fundamentals are: Business Planning- creating a business plan and understanding how it works saves huge amounts of time and effort. The element of trial and error is greatly reduced so that a cost effective and efficient approach can be adopted.

Marketing- this is about understanding your customers and analysing them, not about slogans and pretty adverts.

Why do they choose you, what motivates them, how far do they travel, why your business and not another. Equally what is the competition up to and why do people choose them? Analysing this data allows you to plan and devise intelligent marketing strategies individual to you. These can then be tested, modified and refined until they succeed.

Organisation development - you may not think of yourself as an organisation, but in business terms you are, albeit a small one. Organisations grow and develop in very predictable ways and often face the same very predictable challenges. This process can be taught and once understood

makes adapting to market changes a much easier and less stressful process. This may include completely changing the way you work from being a small one man band to selling out to a large group practice. These changes can be good and bad for both sides but preparation reduces the chance of disaster.

Group Fundamentals ACPAT as an organisation is your group or trade association. This gives some power but also has its limitations from a business point of view. As an organisation we can support each other, compare notes and aid training. However there are rules enshrined in law that prevent united group action to reduce competition.

Think about it from the other side, if businesses from a particular sector were allowed to unite and coordinate their actions to see off competition, then competition and therefore consumer choice would be restricted, innovation would reduce and prices would rise. Can you imagine what would happen to food prices if Tesco, Sainsbury’s and ASDA decided to work together until all the small chains folded? British Airways got into severe trouble a couple of years ago for trying to attempt price fixing with Virgin.

In the UK this legislation is known as the Competition Act. There is no way around it, however much we may wish it. As a group the power comes from education and information to allow members to become more entrepreneurial and not from trying to kill off the competition.

The Future?

Now that is the question! Of course no one really knows but here are some well informed guesses.

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Well informed customers - both the clients themselves and ‘customers’ such as insurance companies and vets will become increasingly well informed about what we do. They will therefore feel much freer to scrutinise and challenge what we do.

This will mean that as professionals we will need to listen carefully and be able to respond in an informed and articulate way.

The internet- this will develop as an ever more sophisticated tool for advertising and marketing but will also be a challenge as customers seek a more rewarding and informative service. For instance customers may demand a more interactive on line service, the ability to question you prior to parting with any money! Practitioners may use other promotions such as Yellow Pages to direct customers to their website and this may become the preferred way for customers to assess whether or not your practice is the one for them. Your web presence or lack of it, and its sophistication could seriously affect your turnover.

Information gathering- gathering data for your business and in the form of research for clinical work may become imperative. Business data will allow you to evaluate your performance in relation to your competitors and enable you to justify your approach/prices by ‘giving’ this to your customers. Research data will be used similarly to evaluate and justify your place in the market and the quality of service which you provide. ‘Giving’ this research information to customers enables you to show that you are up to date. ‘Getting’ this information may be dependent on the amount you ‘give’ to professional organisations.

In an easy economic era with little competition it is easy to be apathetic but as the competition hots up ‘getting’ or achieving your aims may well only be possible by ‘giving’ information and participating.

Active professional involvement‘knowledge is power’ is an old adage but very applicable in a modern world. In a competitive market therefore organisations must guard

their knowledge and release it with care. Therefore members of organisations who participate more and ‘give’ knowledge will have better access to knowledge in return. It will no longer be enough just to be a member and expect to be ‘given’ all information freely, especially when an organisation is run by volunteers. This would give the false impression that it is the organisations ‘job’ to deliver and the members ‘job’ to receive.

Huge amounts of sector information runs through the committees who run professional organisations and access to this becomes an increasingly valuable resource. In the legal field they already have hotly contested elections to committee instead of arm twisting and ‘persuasion’. Also attendance at, and participation in, regional meetings should become an essential means of networking and gathering business information and data. Failure to regularly attend may well compromise knowledge and therefore business efficiency.

Practice, which has a huge business component, which may interest some of our members. Overall though the message is network, participate, join in, help and communicate. This will help you and your business to survive and thrive.

Acknowledgements: Many thanks to Eric Lewis MSc MCSP, whose article ‘Private Practitioner Market Place: living through a universal change’ In Touch Autumn Issue 2009 No. 128 was the inspiration for this, for his permission to use and adapt the original.

Conclusion These are not easy times and they won’t get any easier in the short term, however there are huge opportunities for those who put the effort in. Enrolment on business courses will become more necessary and ACPAT are already in the process of setting these up. Physio First has also started an MSc in Private

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SPORT SPECIFIC REHABILITATION OF THE DRESSAGE HORSE – STRAIGHTNESS: A CASE STUDY Hannah Nash ACPAT Cat A History Frisbee is an 8 yr old warmblood gelding who was purchased from Holland following a full 5 stage pre purchase veterinary examination for low level dressage in his 7th year. Conformationally, he is long in the body with high set neck typical of Dutch carriage horses. His full history is unknown. At the time of purchase he was working at basic preliminary dressage level and despite his conformation, showed no significant difficulty with progressive schooling towards elementary level over the next eight months. He was always reluctant to lower his head and neck and relax the topline when ridden or lunged and showed less suppleness on the left rein.

Eight months following purchase, he developed a sudden onset shortened stance phase on the left hind leg when ridden which was graded 1/10. Full lameness work up with nerve blocks revealed a resolution of the lameness with a tarsometatarsal (TMT) block to the left hock. Radiographs indicated possible minor degenerative changes to both distal TMT joints which was felt to be borderline significant.

Veterinary treatment consisted of bilateral Depo Medrone injections to the TMT joint space and a Tildren infusion. After ten days, a progressive walking programme was started in hand and under saddle. Six weeks post medication; there remained an intermittent uneven stride on the left hind on a left circle. Secondary referral to a specialist referral centre for Gamma Scintigraphy to the hind quarters showed no abnormality and a gradable lameness was not able to be reproduced on trot up, lunge or under saddle. A return to full work was advised.

In this case study, the horse was shod with a standard shoe on all four feet

and remedial alterations to support the veterinary treatment were not added.

Physiotherapy Assessment The main issue we noted with Frisbee’s movement was an intermittent irregular stride pattern.

On close assessment we noted poor muscular development of the hind quarters relative to the shoulder and he carried his head in an elevated outline but was unwilling to stretch his neck down and forward when lunged or ridden.

that would require rehabilitation.

On palpatory assessment, there was a moderate range of cervical side flexion and flexion equal bilaterally and spinal range of movement was within normal expectations. Left sided caudal longissimus spasm was elicited with pressure into resistance and mild increased tone in the lumbar insertion of the left middle gluteal. The middle gluteal and biceps femoris bulk was reduced on the left.

Treatment 0-4 weeks

On a right 10 m lunge circle, the right hind limb had a shortened cranial swing phase – possibly due to the extended stance phase and increased weight bearing on the right fore limb.

The left hind had a shortened stance phase with marked medial rotation through to the end of the caudal phase. The hind limbs travelled laterally left to the forelimbs with the right hind crossing under the body therefore travelling on four tracks. There was a lack of lower cervical side flexion and over activity of splenius during gait (not evident in stance).

The secondary lumbar and gluteal muscle spasm was addressed with reflex inhibition techniques and myofascial release. Reflex Inhibition Techniques have been demonstrated to temporarily reduce spasm in longissumus (Wakeling et al., 2006) which may be utilised to restore normal movement patters. In cases of long standing back pain it is suggested that the multifidus in the horse is inhibited (Clayton, Stubbs, 2010). Baited stretches have been proposed to help in the recruitment and hypertrophy of the multifidus in the horse (Clayton, 2010).

We hypothesised that the sudden onset of left hind limb lameness was due to the repetitive shearing and rotational forces through the tarsal and stifle joints as a result of the asymmetrical movement pattern.

We proposed that the shearing forces would have been increased as ridden work progressed at increased paces and more complex schooling patterns, a possible factor in the sudden onset of lameness.

The author proposes that the initial sudden onset of gradable lameness and a positive block suggested that hock pain was the initial problem.

The symptoms remaining post medication were suggestive of an underlying mechanical dysfunction

In this case we used daily lateral spinal flexion exercises biased to the lower cervical, thoracic and lumbar spines.

We added a combination of weight transfer and pelvic stability exercises to increase recruitment of the biceps femoris, particularly on the left. It is proposed that Biceps femoris is active throughout the stance phase of gait (Robert et al., 1999) and the deep fibres contain a higher percentage of type 1 fibres (Karlstrom et al 1994).

It has an important stabilising role in controlling the forces transmitted through the hock and stifle (Clayton, 2010). The stability exercises were started immediately and continued daily for 4 weeks along side a walking programme. The stability exercises

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Rehabilitation of a movement dysfunction of a horse using theraband and proprioceptive taping

are continued long term but we felt it was valuable to introduce a baseline level of control before progressing dynamic stability work.

Dynamic Control 2-6 weeks The goals of the dynamic exercise programme was to increase spinal stability and ability to relax over the topline, increase pelvic and hind limb stability, control and proprioception, improve and even out stride length and limb loading. Progress this to ridden work and competition dressage if possible.

Work began walking in hand in straight lines with no side reins.

We used proprioceptive taping (kinesiotape) over the left biceps femoris and bilaterally for transverse abdominis and the external obliques.

There are a significant number of papers suggesting the benefit of taping techniques for lower limb ligament injuries in humans but a lack of a satisfactory physiological explanation for its effect. Stubbs (2007) suggests that the tape provides sensory feedback to modulate performance

via a closed loop feedback system.

Facilitation the abdominal muscles was reasoned to aid an increase in stride length and control of spinal rotation. Facilitation of Biceps femoris was to aid pelvic stability and try to reduce shear and rotational forces travelling through the hock.

Short periods of trot work were added, avoiding tight turns and small diameter circles to begin with.

walk and progressing to trot as the exercises were consistently well achieved in walk. Proprioceptive effects were not limited to the school work but walk hacking over varied terrain was consciously added to maximise the development of strength, coordination and balance.

Periods of trot were introduced on hacks.

6-12 weeks

Proprioceptive rehabilitation was enhanced by varying the terrain the horse was walked over from sand to grass to gravel, deep and firm surfaces. At one stage we added a proprioceptive pastern chain but for this horse, the effect was evident for no more that two strides.

4-6 weeks Dynamic work progressed to pole exercises in variations of patterns.

Initially starting with individual poles and incorporating bend and raising one end of the pole. Different sequences were used to address abdominal recruitment, stride height and length and proprioception in

Through this early work developed improved range of movement, even stride length, reduced rotation at the hock and the horse was able to consistently work on two tracks.

(For this case study we did not have access to objective measures to show any improvements made. This could be a potential role for field based gait analysis systems). From 6 weeks we progressed the exercises over poles, increased hacking and added gentle slopes and short periods of canter (as this was potentially the most physically stressing gait, it was kept in short periods and only on straight lines). From the 6 week stage we introduced a specific ridden

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schooling programme.

Discipline Specific Training Progressing to the ridden school work provides a good opportunity to link with a trainer with a good understanding of equine biomechanics and training. I worked with classically trained dressage trainer Simon Battram who has a deep technical knowledge of dressage training and its evolution.

He has introduced the ridden exercises analysed below. It has been very interesting to apply the classical exercises and principles of dressage training to progression of sport specific rehabilitation. All the ridden exercises were first started in hand and then ridden in walk.

The exercises on each rein were specifically tailored to address the straightness and suppleness issues individual to each rein. All angles were introduced gradually.

Ridden Exercises Long and Low: When progressing to ridden work, the functional goal was for the horse to develop into a riding horse and to specifically compete in dressage.

The aim of this type of training is for the horse to push evenly from his hind legs into an even rein contact.

At this stage, the training should become functional and working towards a technically correct outline and contact for dressage is required if the rehabilitation is to be discipline specific.

The outline chosen to commence ridden work was a ‘long and low’ frame. The head carriage is low and the nose in front of the vertical. Studies into the benefits of different head positions in the ridden horse are not fully conclusive and are not directly transferrable to all training scenarios for example; a study by Rodin et al (2009) omits the ‘long and low’ (nose in front of the vertical) head position and uses high level trained dressage horses as the subjects. Comments on the training of dressage horses by Dr Gerd Heuschmann (2007) support the use of the long and low frame in the novice horse and are based

on an analysis of anatomy but are not supported by controlled studies.

The debate between dressage trainers is unresolved with a variety of experiences and hypotheses. In this case, long and low was chosen to encourage the horse to reach into a soft contact and relax over the epaxial muscles. This has been suggested to allow a greater cranial stride length and more even (straight) placement of the hind limbs. The horse is not held in this frame and periodic changes in head carriage are encouraged as the ridden exercises progress.

Riding a Square

Ridden exercises were initially aimed at biasing the propulsive role of the left hind leg. As increased symmetry was noted in the work on straight lines and circles, the exercises were introduced on both reins and degree of difficulty progressed.

We started off with some leg yield head to wall, encouraging the left hind, now on the outside, to swing forwards and through under the trunk of the horse. The leg yield does not require lateral bend and can be done at varying angles to increase or decrease the load on the hind legs. At a later stage, the exercise was progressed by adding lateral cervical and thoracic flexion to the right. This will prevent the excess weight transfer to the right fore, increasing the requirements for the horse to stabilise through the pelvis and spine effectively. Active force through the rein to move the neck into side flexion was avoided as this had the effect on reducing stride length and creating a strong muscle contraction in splenius. The process of working gradually into side flexion created a greater release through the right side of the neck.

Proposed Exercises for Developing Left Hind Leg Carrying Capacity: Left Rein ‘Giravolta’ The giravolta is an exercise whereby the horse is brought onto a 10m circle. The horse is then asked to bend towards the middle of the circle, the forelegs stay on the 10m path and the inside hind leg is asked to move forwards and under the horses mass. This exercise was initially done in hand and progressed to under saddle. The left hind steps under the trunk of the horse and through stance phase the limb moves through extension, abduction and a degree of lateral rotation. The muscle activity involves the middle gluteal, biceps femoris, illiopsoas and tensor fascia latae (Denoix, 2001).

The deep and cranial parts of biceps femoris have a greater percentage of type 1 fibres (Karlstrom et al., 1994) and so we can suggest one function of this exercise is to promote global pelvic stability.

This exercise does not fully address the transfer of weight onto the right shoulder so it is possible for the horse to escape the full potential of the exercise. In order to progress, the control of the right shoulder needs to be incorporated.

Left rein riding a square, enables the rider to gain a better control of the right shoulder which then in turn allows a better placement of the forehand in front of the hind quarters.

The shoulder-in as a continuation of this work places a larger work load to the left hind leg. The shoulder in has similar activity analysis to the giravolta and may increase or decrease the load on the left hind depending on the angle used.

Right Rein Leg Yield to Travers

Long Term Management More recently, we have progressed lateral exercises to work on both reins evenly and incorporated working on different terrains and slopes. The horse is working through a variety of hacking and schooling at elementary level at home and has successfully competed in dressage at novice level. The long term plan is for the horse to progress up the levels in dressage but the progression will be gradual in order to successfully achieve the suppleness and strength required at each level. High level dressage may not be achievable due to the increased loading placed on the hind limbs with collection.

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A Chartered Physiotherapist takes a holistic approach assessing both horse and rider

on the hind limbs with collection.

This will need to be monitored throughout the schooling programme and a wide variety of supplementary activities such as hacking and turn out would be advisable.

There are many thoughts and arguments about the correct training and rehabilitation of horses with little objective data available. This case study attempts to relate some of the pertinent literature in equine kinematics and rehabilitation to a specific case. However, the case itself lacks objective measures. This may be a future role for GPS based gait analysis systems in clinical practice.

References Clayton H., (2010).Posture Strength and Balance in Horse and Rider. Proceedings of the ACPAT Seminar. Unpublished data.

Denoix, J.M.,Pailloux, J.M. (2001), Physical Therapy and Massage for the Horse:

Biomechanics, Exercise and Treatment. 2nd edn. Manson Publishing.

Heuschmann, G. (2007) Tug of War: Classical versus Modern Dressage pg 71-73 JA Allen Karlstrom K., Essen-Gustavasson B., Lindholm A. (1994) Fiber type distribution, capilliarization and enzymatic profile of locomotor and nonlocomotor muscles of horses and steers. Acta Anat 151, 2:97-106.

elite dressage horse at trot. Equine Vet. J. 41(3) 274-279 Wakeling J.M., Barnett K., Price S., Nankervis K. (2006) Effects of Manipulative Therapy on the longissimus dorsa in the equine back.

Equine and Comparative Exercise Physiology 3:153-160.

McGowan C., Goff L., Stubbs N. (2007), Animal Physiotherapy: Assessment, treatment and Rehabilitation of Animals. Pg 243 Blackwell Publishing.

Robert C.,Valette J.P., Deguerce C., Denoix J.M. (1999) Correlation between Surface Electromyography and Kinematics of the Hind limb of Horses at Trot on a Treadmill.

Cells Tissues Organs 1999;165:113-122 Rodin,M.,Gomez Alvarez, CB.,Bystrom, A. ,Johnston, C.,van Weeren, P.R., Roepstorff, L.,Weishaupt, MA. (2009) The effect of different head and neck positions on the caudal back and hindlimb kinematics in the

A Neuromuscular Stimulator can be used to reduce muscle atrophy

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THE SUCCESSFUL USE OF VETERINARY PHYSIOTHERAPY IN THE MANAGEMENT OF INTERVERTEBRAL DISC DISEASE IN AN ATAXIC COCKER SPANIEL Barbara Houlding MScVetPhys MCSP FIRVAP Summary A 2 year old male Cocker Spaniel with pelvic limb ataxia was referred for veterinary physiotherapy and hydrotherapy following multiple intervertebral disc degenerations in the thoraco-lumbar region. Following a full veterinary physiotherapy assessment, a prioritized problem list led to treatment goal planning and agreement with the dog’s owners to commence a course of treatment including a range of land and water based treatment strategies. Functional outcome measures demonstrated a significant improvement in the dog’s core stability, pelvic limb strength and gait patterning in walk, trot and gallop.

Keywords: veterinary physiotherapy, aqua and hydrotherapy, intervertebral disc disease, pelvic limb ataxia, thoraco-lumbar IVDD Introduction Intervertebral disc disease (IVDD) is where herniated material that lies beneath or adjacent to the spinal cord extrudes or protrudes, resulting in compression of the spinal cord, leading to variable clinical signs that are dependent on lesion severity and location. Intervertebral disc protrusion (Hansen’s Type II IVDD) in the thoraco-lumbar region is a common neurological spinal disorder with clinical signs that include a slowly progressive pelvic limb weakness, reluctance to rise or jump and problems with climbing stairs.

Hyperaesthesia of the paraspinals may be present. Conservative management is indicated in dogs with early onset of Hansens Type II and mild neurological deficits.

Physiotherapy has a recognized key role in the effective management of neurological diseases in humans, as well as being central to minimizing and effectively addressing the problems of disuse, immobilisation and poor movement patterning of the musculo-skeletal system. This aims to maximize the functional recovery of the biped or quadruped.

However, the organization of canine motor patterning is very different to human motion, with the dog using quadruped biomechanics linked to form and function. Small animal veterinary physiotherapists are specialists able to effectively employ a range of assessment and treatment tools to deliver an individual programme, meeting the needs of their canine client and owner.

Case History A 2 year old male (entire) blue roan Cocker Spaniel presented to Dick White’s Referral Clinic from Wangford Veterinary Surgery for further investigation of acute pelvic limb ataxia with reluctance to walk, jump or climb stairs.

On presentation to the referral clinic, a full physical and neurological assessment was performed.

This revealed mild pelvic limb ataxia with mild thoraco-lumbar hyperaesethesia. Neuro-anatomical localization was consistent with a T3L3 myelopathy. Further investigations included hematology, biochemistry and electrolytes, with results being unremarkable. An MRI scan revealed multiple intervertebral disc degenerations with mild protrusion in the thoraco-lumbar area.

Conservative management was recommended with a view to surgical

decompression if there was a poor response to treatment. Management consisted of Gabapentin (Neurontin, Pfizer) 100mg – every eight hours (the dog weighed 13.2kg). Hydrotherapy at least once weekly was recommended along with instructions for rest initially consisting of 5 to 10 minutes lead walks for the first two weeks (then slowly increasing over the following two weeks) to four or five times a daily for toileting purposes.

Following this, lead exercise only was directed for four to eight weeks. Reexamination was arranged for four weeks or earlier in the case of any deterioration.

Wangford Veterinary Surgery then sent a referral to K9 Hydro Services.

A full veterinary physiotherapy assessment was performed. The history highlighted that the Spaniel slept curled up in a rigid plastic bed, was reluctant to climb stairs in the owners second home, could no longer jump into their 4 x 4 car and was exercised on an extendable lead, constantly leaning and pulling ahead of the owner at all times. His owners reported that his mentation had altered and he was withdrawn, quiet and depressed.

Observation at rest, functional transfers and gait identified that only a walk gait pattern in a straight line was achievable as the dog collapsed if attempted to trot, turn or circle.

In walk the nose was in contact with the ground at all times and the dorsum of the left pelvic limb scuffed consistently. Transfers showed poor core stability and dynamic control as the dog collapsed, using thoracic limbs to attain stance from sit, and sit from lying. In sitting posture the left pelvic limb was held cranial and abducted at all times.

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On palpation it was noted that the caudal epaxials had poor muscle tone with significant muscle atrophy of both Gluteal masses and Biceps Femoris, greater loss being noticed on the left pelvic limb. Increased muscle tone was identified in the caudal cervical muscle mass and right forequarter. He was reactive and uncomfortable on palpation of Trapezius and Rhomboids and had extreme tenderness at all levels of his lumbar spine.

Proprioceptive integrity tests including the knuckling over test, sliding paper test and pelvic limb static and dynamic balance tests to challenge the stability of the pelvichip complex, along with segmental core stability tests were used. This showed a significant loss in core stability and both pelvic limbs, left much greater than right.

The prioritized problem list identified the need to address the paraspinal hyperaesthesia, poor core and pelvic limb stability, muscle atrophy of the power muscle system, poor functional transfers and posture and limited movement and gait patterning. This led to goal planning and clinical reasoning to select a range of treatment strategies.

Initial land based approaches included a course of Biomag pulsed electromagnetic therapy to the paraspinals, Trapezius and Rhomboids applying two triple concentric pads set on 200HzC for 15 minutes. Two point control using a harness, collar and training lead was introduced to enable controlled and balanced movement over a proprioceptive track and achieve the graduated motor patterning land based programme. Two point control was demonstrated and directed as part of a home programme along with husbandry advice on a larger rectangular bed with sufficient bedding for the dog to lay out more comfortably and supported, reducing unnecessary spinal forces.

Water based treatment used included Aqua Pre Stim techniques prior to pool work (vibration, compression, touch, heat) to the Gluteals, Biceps

Barbara Houlding swimming a dog

Femoris, Trapezius and Rhomboids and caudal paraspinals). Pool work commenced with the dog fitted with a land harness and flat collar, no buoyancy aids were used. Access into the pool was by a gentle ramp and the veterinary physiotherapist in the pool provided an extensive range of aqua manual and graduated movement techniques and measured buoyancy. The dog’s key motivation was identified and assisted delivery of exercises in the warm water on submerged pods and ramps along with a variety of free reflexive swimming techniques. Centre of buoyancy and manually administered turbulence/ drag were the key hydrotherapy principles manipulated to progress the aqua work and enhance the dogs function, balance, co-ordination and motor patterning. Pool exit work to optimize the eccentric loading of the power muscle system and spinal reflexive towel work post hydro further enhanced the programme.

interactive. The Spaniel no longer moved with nose to ground and the left pelvic limb did not drag or scuff.

The dog had ceased pulling on the lead and engaged his rear power muscle system more appropriately.

He continued a weekly session for 5 weeks and achieved the initial treatment goals. The dog was then transferred onto a maintenance strengthening programme of modified hydrotherapy techniques, attending once every 4 to 6 weeks, with the dog returning to full function and activities after 5 more sessions.

Post treatment the outcome measures used included repeated functional sit to stand, re-palpation of paraspinals and observation of top line and gait assessment. A marked improvement was recorded after the first hydrotherapy session.

Brown, N.O., Helphrey N.L. and Prata R.G. (1977) Thoracolumbar disk disease in the dog: a retrospective analysis of 187 cases.

Journal of the American Hospital Association 13, 665-672

After the second session a week later the dog was reported and observed to use a trot gait pattern with increased propulsion, static and dynamic balance and was alert and

This single case study demonstrates that a physiotherapeutic package of specific water and land based assessment and treatment strategies is an important and significant part of the overall conservative management of thoraco-lumbar IVDD. References

S.R.Platt and N.J.Olby (2004) BSAVA Manual of Canine and Feline Neurology 3rd Ed, Blackwell Publishing K9 Hydro Services www.k9hydroservices.co.uk E-mail: fisio.care@hotmail.co.uk

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DOG OF THE YEAR COMPETITION 2009 – INKA Alison Williamson, 4th December 2009 (Re-printed with the kind permission of DTW) Healthwise, Inka, my GSD, has not been the luckiest of dogs. She was born in June 2001, and by the start of 2009, she had accumulated over £15,000 in veterinary fees. I bought her at six months old from a show kennel who had decided she was not of sufficient quality to breed from. Before I bought her I paid for her hips to be x-rayed – which were excellent at that time. I had received advice from many sources (including professional) that if a dog has good hips at that age they are unlikely to become very bad hips....

We had to work very hard together to overcome Inka’s nervousness caused by poor socialisation and exposure to ‘every day’ events during her early months. Then, when she was x-rayed/ scored at 2 ½ years old, I was shocked to discover her hip score was an appalling 81 (39:42), although thankfully her elbows were clear (0:0). Clinically, she exhibited no symptoms whatsoever, and veterinary advice was to ‘carry on as before’. So we continued with our lovely long walks, as well as obedience, agility and breed shows.

Sadly, Inka’s health was always causing set-backs. She had a nasty on-going skin complaint for many years, which largely ‘disappeared’ after she was spayed. She has also had several benign skin tumours. More seriously, in spring 2004 she very nearly died from splenic torsion – a rare and usually fatal condition. If that wasn’t enough, in summer 2007 Inka bloated three times in two months. Referral to specialist vets at Langford revealed chronic inflammation of the stomach wall caused by megaoesophagus. On further advice she had gastropexy surgery to ‘tack’ her stomach wall to prevent future torsion, and is now on a prescription tinned diet for life.

In 2008 we had a great year. Apart from two great walking holidays, she competed in the Special Prebeginner Stakes Final at Crufts, won

her Pre-Beginner and won one of her Beginners, had some great places in agility, and qualified for Crufts 2009 in breed!

We started off well in 2009.We went on another lovely walking holiday to North Wales in mid-March, and Inka had more successes in breed and agility shows. However, by the spring things were starting to go wrong.

Not only had I found out I was being made redundant, but it was also apparent that Inka’s hips were quite suddenly deteriorating. I had done everything I could to keep her fit and comfortable, but she was slowing significantly on walks, struggling with the stairs, could no longer jump full height at agility, and kept ‘clipping’ the back of the car as she jumped in.

The day she just looked in the car and looked back at me I knew I had to take her to the hip specialist.

Inka went to the specialist on 7th May. He concluded that she needed to have her right hip replaced ASAP. Since there was no real alternative, other than watch her suffer until she would have been PTS, I agreed and the vet operated that day. I picked her up the next day. She was very lame and confused, and so unsteady she needed help when rising, whilst she ate and to go to the toilet. She had to do four 10-minute walks a day, and right from the start she seemed to walk reasonably well, although would never weight-bear on her new hip when standing. The first weeks were a constant worry in case she slipped, tried to rush somewhere (such as if the doorbell rang) or tried to have a game with my other dog! I knew if she slipped in the first six weeks there was a very real risk of dislocation. I devised a system of ‘baby gates’ and room exclusions to try to minimise the risks, but suddenly life seemed fraught with potential dangers!

Five weeks after surgery she still wasn’t weight-bearing when standing, even though she was apparently

walking reasonably well. I took her back to my local vet who confirmed that he could feel vertical and lateral movement in the new joint on manipulation. I obtained an emergency appointment with the specialist the next day. He found that the metal pin was luxating in and out of the metal ball joint to which it should have been tightly secured. After it was fixed under further anaesthetic, Inka improved straightaway. There had been massive muscle loss during those five weeks, which now made her recovery and return to fitness much slower. However, six weeks later Inka was walking seven miles a day again. Following a further checkup Inka could start hydrotherapy, which we did twice a week for twelve weeks. This made a real difference to her overall strength. She also had physiotherapy to help release the locked muscles in her back and hips, which had gone into spasm to compensate for her joint problems.

In August we did our first Open Obedience Show of the year at Bath, where she won the Special GSD class – I was thrilled to bits! In September, knowing her passion for agility, I took her to my local Open Agility show, and ran her in the NFC anysize (micro height) class. To curb her speed and enthusiasm I just ambled along behind her. By jump four she realised I wasn’t ‘with her’ and looked around and gave me a very concerned look of “Oh well, if you’re not feeling too good, I’ll slow down and go at your pace then”. She happily ‘pottered’ around the rest of the course at a very steady pace, being very careful to measure her strides so as not to get ahead of me!

It was a truly touching moment and the memory will always be with me.

To prove her Bath obedience win wasn’t a fluke, she even managed a second at BAGSD Birmingham in late September. However, by then, erated hip. This was partly the result of excessive load-bearing and joint

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wear caused by the problems with her first hip replacement. Although only about 25% of dogs which have one hip replaced need both replacing, it looked as if Inka was going to be unlucky.

as re-start hydrotherapy – all of which should greatly speed up Inka’s recovery. I owe huge thanks to all the health professionals (vets, nurses, physiotherapists and hydrotherapists) who have helped (re-built?!) Inka.

In late October, having achieved maximum possible fitness, I took her back to the specialist. Although she moved/ gaited well, on examination he found she wasn’t putting much weight on her left hip, and that there was a lot of noise and ‘grinding’ within the joint. Although the optimum period for canine bilateral hip replacements is one to two years between surgeries, Inka needed surgery now. When he operated the vet discovered that the left hip was much worse than the right hip he had originally operated on, with several ‘joint mice’ apparent. These are small pieces of bone which had broken off the damaged joint and had become lodged between the femur head and socket. Here they were grinding away inside the joint causing pain and accelerating the deterioration. It was no wonder poor Inka had been much better on some days than others depending on where the joint mice were in her socket that day.

Throughout all her ordeals this year Inka has remained happy and playful.

She has been incredibly tolerant towards everyone and everything that has been asked of her. Her trust and faith in me has been entirely unmoveable, even when things weren’t going well. No matter what life throws at Inka, her truly lovely and loving character always shines through. She is a truly amazing dog.

This time Inka’s post-operative recovery was much quicker. Right from the start she was weight bearing on her new left hip, and even on the first day after surgery needed no help from me to steady her. Initially my biggest problem was trying to stop her from doing all the things she thought she should be doing!

Even this time though her recovery hasn’t been problem free. Three weeks after surgery, at the second attempt, she came off the pain-killers, but by five weeks she was so lame that we had to re-start them again.

I was very worried that something may have worked loose in the joint again. However, a further check–up and examination confirmed that she has been suffering from prolonged muscle pain where they have been in constant spasm. Thankfully, the joint is good, and hopefully she should be able to come off the pain killers in a couple more weeks. We can now increase exercise, as well

Postscript The above comprised Inka’s entry into the Dog Training Weekly’s (DTW) Dog of the Year 2009 Competition. This competition is for dogs working in competitive obedience who have shown courage and determination in adverse circumstances over the past year.

Inka won DTW Dog of the Year and on a very special and memorable day we were presented with our trophy in the main Obedience Ring at Crufts in March 2010. Below I provide a brief update since submission of our entry in December 2009.

We had re-started hydrotherapy on 8th December and if all had gone well, Inka would have come off the anti-inflammatory pain killers around mid-December 2009. However, despite twice weekly hydrotherapy sessions throughout December, it was clear that this alone could not unlock months of accumulated muscle spasm in her back and hips, and the on-going associated pain this was causing. Therefore, on 4th January 2010 I took Inka for a session of physiotherapy, which turned out to be the very best thing I could have done. The physiotherapist was appalled at the extent of muscle spasm in her back and hips, which required intensive physical manipulation to encourage release.

Inka struggled both to stand steadily or walk properly after the half hour session, and I momentarily doubted my wisdom in taking her. However,

within three hours she was moving more freely than she had for months, and within two weeks, following a rapid increase in exercise tolerance, she was once more walking seven miles a day. Inka had once weekly physiotherapy sessions throughout January which really turned her fortunes around, and by February she was completely free antiinflammatory drugs for the first time in about 2 ½ years.

She had another follow-up appointment with the hip specialist on 26th February, who confirmed she had finally made the recovery he had been expecting of a fit dog sometime previously. However, the very next day Inka pulled up lame on her front right leg whilst chasing my other dog! I put her back on anti-inflammatories, and when she wasn’t quite sound after five days, took her back to my local vet. He has detected a little arthritis/joint wear in her right elbow. In reality, this could have been developing for months or even years, and has been masked by the treatment for her hips. The good news is that the antiinflammatories are now controlling the elbow inflammation, although it seems unlikely that she will ever be totally independent of them!

Just a year ago, with the antiinflammatory drugs no longer controlling Inka’s hip pain, replacement hip surgery was the only remaining course of action. One year on, Inka’s range of movement in her hips has increased considerably, and she now has pain free joints. It is just five months since her second operation, and her strength continues to improve. Despite having to re-start the anti-inflammatories to control her elbow arthritis, importantly Inka is now once more leading a pain free, fulfilled and happy life.

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THE PHYSIOTHERAPIST Sonya Nightingale MCSP ACPAT Cat A Name: Inka Williamson DOB: 07/06/01 Breed: German Shepherd I will not repeat Inka’s main history here as it is included in the article above but merely outline her physiotherapy interventions.

Inka was referred in mid 2005 for mild thoraco lumbar pain on extreme exercise. On examination the only findings were a decreased range of passive movement at T11 and 12. This responded well to mobilisations and resolved the reported symptoms of early fatigue and tenderness, with an associated kyphotic stance. Over the next two years she was seen a further four times with similar symptoms but the picture was complicated by the development of her abdominal problems during this period.

By Dec 2007 the findings had changed

to a minor loss of proprioception and control of the pelvic limbs associated with a 20% loss of flexion in the left hip and extension in the right hip.

The proprioception and stability in the pelvic limbs improved with taping over the abdominal group and sartorious. However, in spite of mobilisations the ranges in the hip joints continued to deteriorate slowly. Between September 2008 and her first THR in May 2009 Inka experienced an increase in the frequency of her thoraco lumbar pain episodes and gradual loss of the stability in her pelvic limbs resulting in a ‘plaiting’ gait with increased sartorious spasm. She tolerated her treatment, consisting mainly of soft tissue mobilisations, well and improved each time, but the effects were not long lasting.

the article and was only allowed back for physiotherapy eleven weeks post op from her second THR. By this time her thoraco lumbar spine was extremely stiff and tender to palpation and the adductor muscle groups, quadriceps and sartorious were bilaterally in spasm. This resulted in a gait with very little spinal movement or swing phase in the hind limbs. Her treatment since then (Jan 10) has consisted mainly of spinal mobilisations and soft tissue work. She is now off her analgesia with no muscle spasm and only a slight drop to the right pelvis in trot.

I wish Inka well and congratulate her on gaining her dog of the year award. She has cheerfully put up with everything that has been thrown at her and is living proof that, with the right attitude, you can succeed.

Inka struggled with the recovery from her first THR as detailed in

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HORSE BEHAVIOUR – TREATMENT FROM AN EQUINE PROFESSIONAL SIX STEPS TO STANDING STILL Sue Palmer MSc Veterinary Physiotherapist (ACPAT Cat A) Intelligent Horsemanship Recommended Associate MCSP EBW BHSAI based in Stafford www.holistichorsehelp.com.

Picture the scene – the horse physio (substitute vet / dentist / farrier / saddler / other equine professional as appropriate) arrives to work with you and your horse. You’ve taken the morning off work, and kept him in his stable so that there’s no problems with not being able to catch him (you know that sometimes even a feed isn’t tempting enough if he’s only just been turned out!). He’s been carefully groomed so that the equine professional doesn’t get smothered in the dust that he’s so enjoyed collecting in the field, and he’s happily munching his way through a couple of sections of the best hay you can offer. His feet are picked out, his mane and tail combed through, his stable clean so that you don’t have to stand in his droppings whilst he’s being treated, and it’s clear that you love him dearly.

And then, after all the care and attention you’ve given him to make sure everything is just right, he lets you down – he won’t stand still.

The physio wants to see him stand on the yard so she can look at his conformation, but he keeps moving his feet. She wants to check how level his pelvis and shoulders are, but he won’t stand square. She tries to run her hands over his body to assess him, and he turns round to nip her, and waves a back leg in her direction when she finds a touchy spot, before squashing her against the wall, barging you out the way, then traipsing round his stable with you in tow on the end of the lead rope.

It’s a common problem – we spend so much time ‘doing’ with our horses that we forget to teach them about ‘not doing’. Where being with our horse should be our leisure time, all too often it gets squeezed into being a ‘duty’ that has to be done before

Sue Palmer

Photo Sue Brown . Copyright Simon Palmer, Into the Lens

we can get to work / get home to look after the kids / cook dinner for the husband, and any peace and tranquillity is lost. So it’s not surprising really that a lot of the horses I work with aren’t very good at keeping their feet still. It’s good to know, though, that there are some simple steps you can put into place that will make a big difference in just a few short sessions. Remember that the best reward you can offer your horse for getting it right is peace and quiet, keeping out of his space and just leaving him alone to be a horse.

Anything else that we train the horse to see as a reward (e.g. a stroke) is secondary to this.

is a good place to start), and ask your horse to stand still. Stand directly in front of him, square on to him with your toes pointing towards his toes, with a smile in the rope (i.e. a loop in the rope between your hand and the clip of the rope).

2) Take a step backwards away from him. If he moves his feet, immediately put them back to where they were originally, instantly release any pressure you used to do so, then take a step back again.

3) When he stands for 5 seconds, step towards him and give a gentle stroke as a reward, then step back again.

1) Pick an area to work in (the stable

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Sue Palmer assessing a horses back at a Monty Roberts demonstration

4) Progress to being able to step back to the end of a lunge line without your horse moving unless he’s asked to do so.

5) Before long he’ll realise that you’re asking him to stand still until asked to do something different, and more importantly, because you’re reacting to his actions, he will know that you are listening to him.

6) Practise this in different areas (in the stable, on the yard, in the field, on the track to the field), and soon you will have a horse who can willingly stand for treatment from his equine professional.

Teaching your horse to stand still when asked will have far reaching effects, not only affecting his attitude and manners on the ground, but also improving his ridden work. Horses don’t think like people, they think like horses, and it’s up to us to try to understand this before we try and influence it.

Photo Sue Brown – Copyright Simon Palmer, Into the Lens

DIARY OF EVENTS 8th-11th September 2010

BEVA Conference (BEVA Member rates for ACPAT members)

19 September 2010

British Veterinary Rehabilitation and Sports Medicine Association.

‘Rehabilitating the Veterinary Neurological Patient’

25th September 2010

Pilates in Horse Riders

23rd October 2010

WERC Pulse TMM Course

31st October 2010

Canine Sports Seminar

26/27th February 2011

ACPAT Annual Seminar

For Further details please see www.acpat.org

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COURSE REVIEWS ESMA Conference Equine Sports Massage Association Conference April 2010, The Diagnosis and Management of equine locomotor injuries, JeanMarie Denoix DVM, PhD, Agrege This was an excellent course as JeanMarie Denoix has an extraordinary knowledge of anatomy and presented the topics with enormous enthusiasm. The course covered tendon biomechanics, injuries and their management. He also went into great detail on the equine foot, it’s anatomy and injuries. Other topics covered included the neck, back and pelvis. I would fully recommend any course where Jean-Marie Denoix is speaking.

(Veterinary Surgeon) and Sonya Nightingale (Chartered Veterinary Physiotherapist) This was a day designed to pull together a few members of the multi-disciplinary team, the Vet, the Physiotherapist and the Farrier and their approach to treating distal limb pathologies. A concise day on the anatomy and function of the distal limb which included working with cadaver limbs, distal limb pathologies, viewing and analysing radiographs, gait assessment and foot balance from the Farriers perspective and rehabilitation techniques. This course is a great value for money allowing you to utilise the knowledge of the team for a multidisciplinary approach to these pathologies.

Diane Messum

Polly Hutson Equine MDT Workshop Brian Temple (Registered Farrier), Alice Sheldon

Posture, Strength and Balance in the Horse and Rider Dr Hilary Clayton BVMS, PhD, MRCVS

This was a day that concluded a fantastic 25th Anniversary Seminar weekend for ACPAT. We had the pleasure of Hilary’s wealth of knowledge in her presentation to us on the anatomy and function of the neck and back in the equine, core training in the horse, the effect of the bit in the mouth on the horses head and neck, her latest research on saddle fitting and function and the effects of different rug designs and saddle cloth fabrics on the horses back using an electronic pressure mat. It is emphasised to all of us in our practice, the importance of evidence based research to facilitate our clinical reasoning. It was a delight to hear how Hilary Clayton and the McPhail Centre at Michigan State University, USA are advancing research in our field. Hilary is an inspiring lecturer who will aim to encourage all you burning researchers out there to follow in her footsteps.

Diane Messum

SETTING UP JOURNAL ALERTS A journal alert is an automated email that will be sent to you, updating you of the titles of articles, within your chosen journals each time they are published.

Journal alerts can be set up directly with each journal provider, but you will need to register with each one separately. Or if you have an ATHENS account, if you work in the NHS or other organisations then this will be available, then a list of journals can be set up. Your work place intranet site may have further details. Please see below for further details to set up a journal list with an Athens username and password. Go to www.zetoc.mimas.ac.uk On this page select Zetoc Alert: to set up, modify and delete email alerts Click on Go for miscellaneous organisations Miscellaneous Organisations

Click on SearchZetoc Alert - Journal Selection Options Select journal names beginning with letter ABCDEFGHIJKLMNOPQRSTUVWXYZ

Select journal names containing a string

Enter string:

A list should appear of all Veterinary related journals. Click on Add next to the title if you would like a journal search alert for that journal. Each journal title that is selected will appear in your Alert list.

Enter your Athens username and password. Click on Add JournalsThe page below should appear. Type in a key word such as ‘veterinary’ for a list of all Veterinary related journal titles.

Suggestions: Journal of Small Animal Practice Equine Veterinary Journal Journal of Veterinary Science Veterinary Clinics of North America Equine Practice Veterinary Clinics of North America Small Animal Practice Veterinary Record

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ARTICLES 2010 VETERINARY RECORD VOL 166; NUMB 8; 2010 ISSN 0042-4900

EQUINE VETERINARY EDUCATION VOL 22; NUMB 2; 2010 ISSN 0957-7734

pp. 226-229 Review of the safety and efficacy of long-term NSAID use in the treatment of canine osteoarthritis.

Innes, J.F. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN266237647&field=zid

pp. 83-87 Cervical radiology.

Dimock, A.N.; Puchalski, S.M. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265841830&field=zid

EQUINE VETERINARY EDUCATION VOL 22; NUMB 3; 2010 ISSN 0957-7734

p. 88 Cervical arthropathy, myelopathy or just a pain in the neck?.

Martinelli, M.J.; Rantanen, N.W.; Grant, B.D. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265841842&field=zid

pp. 107-114 Conservative management of comminuted central tarsal bone fracture and joint instability in a horse.

Kearney, C.; McAllister, H.; Jenner, F. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267114091&field=zid

pp. 77-90 Qualitative assessment of corticosteroid cervical articular facet injection in symptomatic horses.

Birmingham, S.S.W.; Reed, S.M.; Mattoon, J.S.; Saville, W.J. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265841877&field=zid

pp. 112-120 Management of joint instability.

Smith, M.R.W. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267114132&field=zid

EQUINE VETERINARY JOURNAL VOL 42; NUMB 1; 2010 ISSN 0425-1644 pp. 5-9 Concurrent or sequential development of medial meniscal and subchondral cystic lesions within the medial femorotibial joint in horses (1996-2006).

Hendrix, S.M.; Baxter, G.M.; McIlwraith, C.W.; Hendrickson, D.A.; Goodrich, L.R.; Frisbie, D.D.; Trotter, G.W. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265652541&field=zid

pp. 141-145 Minimally invasive desmotomy of the accessory ligament of the deep digital flexor tendon in horses.

Tnibar, A.; Christophersen, M.T.; Lindegaard, C. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267114170&field=zid pp. 146-155 Ultrasonographic examination of the caudal structures of the distal antebrachium in the horse.

Jorgensen, J.S.; Stewart, A.A.; Stewart, M.C.; Genovese, R.L. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267114181&field=zid

pp. 10-17 Standing magnetic resonance imaging detection of bone marrow oedematype signal pattern associated with subcarpal pain in 8 racehorses: A prospective study.

Powell, S.E.; Ramzan, P.H.L.; Head, M.J.; Shepherd, M.C.; Baldwin, G.I.; Steven, W.N. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265652552&field=zid

EQUINE VETERINARY JOURNAL VOL 42; NUMB 2; 2010 ISSN 0425-1644 pp. 92-97 Repeatability of subjective evaluation of lameness in horses.

Keegan, K.G.; Dent, E.V.; Wilson, D.A.; Janicek, J.; Kramer, J.; Lacarrubba, A.; Walsh, D.M.; Cassells, M.W.; Esther, T.M.; Schiltz, P. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267124952&field=zid

pp. 18-22 Accuracy of ultrasound-guided injections of thoracolumbar articular process joints in horses: A cadaveric study.

Fuglbjerg,V.; Nielsen, J.V.; Thomsen, P.D.; Berg, L.C. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN26565256 6&field=zid

pp. 98-104 pp. 114-118 The effects of different saddle pads on forces and pressure distribution beneath a fitting saddle.

Kotschwar, A.B.; Baltacis, A.; Peham, C. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267124988&field=zid

pp. 86-89 Clinical update on the use of mesenchymal stem cells in equine orthopaedics.

Frisbie, D.D.; Smith, R.K.W. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265652692&field=zid

pp. 174-180 A review of tendon injury: Why is the equine superficial digital flexor tendon most at risk?.

Thorpe, C.T.; Clegg, P.D.; Birch, H.L. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN267125099&field=zid

JOURNAL OF SMALL ANIMAL PRACTICE VOL 51; NUMBER 2; 2010 ISSN 0022-4510 pp. 97-103 Management of concurrent patellar luxation and cranial cruciate ligament rupture using modified tibial plateau levelling.

Langenbach, A.; Marcellin-Little, D. J. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN265177657&field=zid

JOURNAL OF VETERINARY SCIENCE VOL 10; PART 4; 2009 ISSN 1229-845X pp. 365-367 Syringomyelia in three small breed dogs secondary to Chiari-like malformation: clinical and diagnostic findings.

Park, C.; Kang, B.-T.;Yoo, J.-H.; Park, H.-M. http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN266739107&field=zid

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GUIDE TO COMMON ABBREVIATIONS SEEN IN THE VETERINARY PHYSIOTHERAPYWORLD In no particular order: ACPAT

Association of Chartered Physiotherapists in Animal Therapy

CIG/ CIOG

Clinical Interest (and occupational) Group- of the CSP

CSP

Chartered Society of Physiotherapy

HPC

Health Professions Council

CHA

European School of Veterinary Postgraduate Studiesan organisation providing accreditation of CPD to Vets, VNs and now ACPAT members via its training arm Improve International

Canine Hydrotherapy Association-monitors canine hydrotherapy pools and provides training for their owners.

ESVPS

ESMA

Equine Sports Massage Association- started by Mary Bromiley to train equine masseurs.

IAAT

International Association of Animal Therapists- aims to provide one site for all complementary therapists.

TCAP

The College of Animal Physiotherapy- all its graduates become members of IAAT, no previous physio training required, based in Aylesbury.

ARD

Animal Rehabilitation Division. The newsletter of CHAP

CHAP

Canadian Horse and Animal Physical Therapists Association - the equivalent of ACPAT in Canada.

VDS

Veterinary Defence Society- advises vets on litigation

BVRSMA

British Veterinary Rehabilitation and Sports Medicine Association.

RVC

Royal Veterinary College

RCVS

Royal College of Veterinary Surgeons

BEVA

British Equine Veterinary Association

BSAVA

British Small Animal Veterinary Association

VN

Veterinary Nurse

CPD

Continuing Professional Development

NAVP

National Association of Veterinary Physiotherapiststrains animal physiotherapists at Harper Adams University. No previous physio training required.

IRVAP

Institute of Registered Veterinary and Animal Physiotherapists. Register for all trained animal physios of whatever background.

CEPT

Canine and Equine Physiotherapy Training. Trains animal physiotherapists in Nottingham, no previous physio training required.

RECENT NEWS Zara Philips, Tim Stockdale and Laura Bechtolsheimer are currently assisting ACPAT’s marketing campaign.

As part of ACPAT’s 25th anniversary Mary Bromiley’s contribution to ACPAT was recognised.

Mary was unfortunately unable to attend the seminar but wrote an amusing letter describing her early experiences in treating animals.

Kate Hesse was voted member of the year, for her high quality research and support of students.

to purchase in the near future.Water proof banners are also being made which will be available for member use. These will be posted out to members and members are then responsible for their return.

Members should contact Sharon Morgan for further information.

Tel : 01295 738204 Email: secretary@acpat.org Things change very quickly within ACPAT please keep up to date with further developments on the website www.acpat.org.

The PR team have been working hard to re vamp the ACPAT leaflets which will be available for members

Zara Phillips and Toytown, Badminton 2009.

Author - Henry Bucklow . Free Documentation License

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WRITING FOR FOUR FRONT THE OFFICIAL MAGAZINE OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN ANIMAL THERAPY Guidelines and Information for Authors The Editor would like to encourage ACPAT members to get involved in the magazine. If you are doing interesting clinical work, have a philosophical viewpoint that you would like to express, would like to share some research findings, have read a relevant book, article or attended an interesting course; please write something for the ACPAT magazine.

The aims of the magazine are to inform members about clinical, research and business developments that affect physiotherapists working with animals. It also provides a channel of communication between ACPAT members by informing and debating all aspects of animal physiotherapy.

We invite you to present material under the following sections: Editorial Product Reviews Literature Reviews Business Related topics Clinical Articles/Case reports Letters to the Editor Research Articles Useful Addresses Conference/Course Reviews Small Adverts Product News Book Reviews How to Contact us If you have an article that you would like to submit for publication or you would like to discuss the outline of an article that you would like to write, please do not hesitate to contact ACPAT secretary who will pass on the information to the Journal Officer.

Post: M. Sharon Morgan Pembroke House Middle Lane Shotteswell OX17 1JQ Email: secretary@acpat.org Submitting an Article Please send all text in electronic form (ideally in Microsoft Word) by attaching the file to an e-mail or on a disk, along with any original photographs to the editor.

We can accept articles up to 3,000 words and encourage the use of tables, illustrations and photographs.

If an article is longer please discuss with the Editor.

There is no need to spend time adjusting fonts, columns etc, as we will adjust these to match the current publishing style.

Where appropriate, articles must be supported by a reference list using the Harvard system. In the text quote the authors surname and year of publication. In your reference list please include the full reference, to include authors name, initials, year of publication, full title of the paper, name of the journal, volume number and the first and last page numbers.

Any identifiable photographs must be accompanied by written permission from the owner of the animal, otherwise the image will be obscured, so that recognition is not possible. Please submit photographs in jpeg format, at least 2000 pixels in size and at least 300 dpi (dots per inch - Resolution).

Please supply your full name, address, telephone number and e-mail address that you would like to be published with your article.

Format and Structure of Manuscripts Manuscripts should be headed with the full title of up to 15 words, which should describe accurately the subject matter. Authors should avoid including within the text: the name of the institution at which the work was performed, initials of the authors and must remove institution names from illustrations in order to maintain anonymity for the review process.

Title Page A title page is needed for all manuscript types, it must contain the title of the paper, names and qualifications of all authors, affiliations and full mailing address including e-mail addresses, and contact telephone number of corresponding author. No author details are to be submitted in the manuscript. In addition details of any acknowledgements should be given on the title page.

Original Papers/Research Articles Each paper should comprise the following sections: Structured Summary - maximum of 200 words, divided, under separate headings, into Objectives, Methods, Results, Clinical Significance.

Keywords - maximum of five, for use as metadata for online searching.

Introduction - brief overview of the subject, statement of objectives and rationale.

Materials and Methods - clear description of experimental and statistical methods and procedures (in sufficient detail to allow others to reproduce the work).

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A Chartered Physiotherapist utilising poles during a rehabilitation programme

Results - stated concisely, and in logical sequence, with tables or figures as appropriate.

Discussion describing the importance of the report and its novel findings.

Discussion - with emphasis on new and important implications of the results and how these relate to other studies.

To be considered for publication in a single case report must: - Exemplify best practice.

Case Reports Full Case Report Reports of single or small numbers of cases will be considered for publication if the case(s) are particularly unusual or the report contributes materially to the literature. A case report should not exceed 1500 words and must comprise of: Summary (maximum 150 words); Keywords - for use as metadata for online searching.

Introduction - brief overview of the subject.

Case Histories - containing clinical detail.

All papers and case reports are subject to peer review and publishing preference will be given to reports of original or retrospective studies.

Letters to The Editor Letters describing case reports or original material may be published and will be peer-reviewed prior to publication. Letters commenting on recently published papers will also be considered and the authors of the original paper will be invited to respond.

Style of Manuscripts Writing should conform to UK English, and acceptable English usage must be presented within the manuscript. Where abbreviations

are used, the word or phrase must be given in full on the first occasion.

All manuscripts must be doublespaced for the purpose of peer reviewing.

All manuscripts must be numbered throughout for purpose of peer reviewing.

line the

All units of measurement should be given in the metric system or in SI units. Temperatures should be in °C. Drugs should be referred to by Recommended International NonProprietary Name, followed by proprietary name and manufacturer in brackets when first mentioned, eg, fenbendazole (Panacur; Intervet).

Anatomical terminology should conform to the nomenclature published in the Nomina Anatomica Veterinaria (1983) 3rd edn. Eds R. E. Habel, J. Frewein and W. O. Sack.

World Association of Veterinary Anatomists, Ithaca, New York.

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Length

controlled by ACPAT.

The maximum length for research papers is 3000 words and for case reports is 1500 words. Review articles should not exceed 4000 words. All word limits include the summary but exclude the reference list. Authors should indicate the word count at the beginning of the manuscript.

Tables and Figures The minimum number of tables and figures necessary to clarify the text should be included and should contain only essential data.

Presentation of Book, Product and Course Reviews Book, Product and Course Reviews should be between 500 – 700 words long. Book reviews should quote the title, publisher, ISBN number and price of the book.

A Chartered Physiotherapist using ultrasound to assist healing

We may use material on the APCAT website, if you do not want us to publish information on the website, please explain this when you submit your work.

Terms and Conditions

Some Points to Consider Before and During Writing an Article: Try to produce a structured abstract and a list of key messages before you begin, this will help the article to be more focused and succinct and therefore more interesting for the reader.

Try to make the article as concise as possible, think hard what needs to be in the article to get the message across. Very few articles are longer than 2,000 words.

Try to ensure that references cited for tables and legends are done in sequence at the point where the table or figure is first mentioned in the text.

Material accepted for publication will be edited. All articles will be treated as though all authors have read and approved the manuscript.

Each author should give his or her name as well as the address and current e-mail for correspondence.

We now aim to publish the corresponding author’s e-mail address in every article.

Copyright and Exclusive Licence Many publishers traditionally asked authors to assign their copyright as this allows them to tackle copyright infringement, to republish and reproduce on a website.

Previous Publication

We however require all authors for an irrevocable licence so that we can reproduce articles on our website without the need to seek further permission.

We do not have a strict policy on publishing material that has appeared elsewhere, but welcome authors to do so, especially where the subject is important to animal physiotherapists.

All articles submitted to the editor are therefore accepted on the basis that all authors of the material agree to ACPAT acquiring this irrevocable license upon the publication of the article in any medium owned or

Finally check the final copy carefully.

Corrections We try hard not to make mistakes, but errors, both by authors and editors can creep into the journal. We publish corrections when necessary.

If you want to notify us about the need for a specific correction, please contact the Editor.

Final note from the Editor The Editorial Board reserves the right to edit all material submitted.

The views expressed in Four Front are not necessarily those of ACPAT, the Editor or the Editorial Committee.

The inclusion of advertising does not imply any form of endorsement by ACPAT. No article, drawing or photograph may be reproduced without prior permission of the Editor.

Four Front is an annual publication and aims to be published in the spring of each year.

We are looking forward to receiving articles from any member of ACPAT on any relevant topics that you wish to share with fellow members. The success of the magazine and its benefit to members is ultimately dependent on the collective contributions that we receive, thank you, The Editor.

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EXECUTIVE COMMITTEE MEMBERS 2010

Amy Barton Alison Bates Melanie Butler Tracy Crook Sarah Dalton Maeve Grant Victoria Henderson Polly Hutson Hannah Nash Sonya Nightingale Diane Messum Marjoleine Riezebos Samantha Rodwell Felicity Rodriguez Stephanie Wilson

Education Sub Committee CIG Sub Committee Courses Sub Committee Research Officer Course Organiser PR CIG Liaison Officer CPD Officer/ Diversity Officer/ Journal Sub Committee Vice Chair/Education Officer Chair Journal Editor/Regional Groups Co-opted - Education PR Category B Member Websire/IT Officer

ajbarton79@yahoo.co.uk bates842@btinternet.com melvetphysio@yahoo.co.uk research@acpat.org courses@acpat.org maevegrant@yahoo.co.uk cig@acpat.org cpd@acpat.org education@acpat.org chair@acpat.org journal@acpat.org regions@acpat.org marjoleine@vet-physio.com sam@countryphysio.co.uk flissspace@hotmail.co.uk webmaster@acpat.org it@ acpat.org

SECRETARY/TREASURER Sharon Morgan

Secretary

Andrea Walters

Treasurer

secretary@acpat.org secacpat@btinternet.com

M. Sharon Morgan Pembroke House Middle Lane Shotteswell OX17 1JQ secretary@acpat.org

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