How to be a wellness superhero in 5 minutes or less
Wellness visits are precious because they are chances to keep a healthy patient healthy. We are used to discussing dental health and performing laboratory profiles to screen for subclinical disease, but what about mobility?
Rarely does a wellness visit uncover subclinical mobility issues. In general practice, we do not routinely screen for these issues. Because most orthopedic and neurological issues begin with subtle signs, by the time most clients are bringing up a concern, the problem is already significant. In my rehabilitation practice, many clients who bring their dog for treatment of a seriously debilitating disease reflect on the history and express guilt that they did not recognize the problem sooner. What if we had a better way of recognizing mobility issues sooner?
Let’s discuss how you can be on the lookout (BOLO) for mobility issues during a routine wellness visit. We begin with when a mobility assessment should be done, note how it can easily be done within a wellness visit, and discuss what you can do when you determine that a mobility issue may be present.
Every new patient should have a mobility assessment, regardless of age. Even young puppies may begin to show signs of developmental orthopedic disease (DOD) at a very young age. The earlier we catch these issues, the greater our opportunity to intervene and help these patients.
Every patient should receive a mobility assessment at annual and semiannual wellness visits. Musculoskeletal and neurologic health should be treated no differently from renal or hepatic disease—it is far better to detect an issue through a screening test before clinical signs develop. This is also not limited to dogs, because cats can also show subtle signs of discomfort or weakness that are either missed or attributed to other conditions.
A mobility assessment doesn’t take as much time as you might think. The assessment begins with the signalment and a thorough history. Giving extra attention to detail with breeds at risk for orthopedic conditions is a must. Labrador retrievers, golden retrievers, German shepherds, and Rottweilers are some of the most popular breeds that have increased prevalence of DOD such as hip and elbow dysplasia, as well as cranial cruciate ligament (CCL) disease.
Small breeds such as Chihuahuas, Pomeranians, and Yorkshire terriers have a greater tendency to have patellar luxation, and neutered animals along with senior pets also having increased incidence of joint disease.1 Chondrodystrophic dogs such as dachshunds, pugs, and French bulldogs have a higher prevalence of intervertebral disk disease, which often goes unnoticed until severe. Certain breeds are at higher risk of developing neurodegenerative conditions as well; for example, German shepherds, boxers, and Welsh corgis have a higher risk of degenerative myelopathy. Retrievers are overrepresented with geriatric onset laryngeal paralysis polyneuropathy.
Asking the right questions in the right manner can provide so much information, even from a client who is completely unaware that their pet has mobility issues. We can ask a few specific questions that will drive a conversation and generate more clues that a mobility issue is present. These can be included in a wellness visit intake. Even better, have clients fill out a questionnaire prior to their visit. Another option is having an assistant or technician review this with the client and flag any responses that raise concern.
The following are examples of questions that can be useful to detect subtle signs of a mobility issue. If the client answers “yes” to any of the questions below, ask them to provide details about when they see this happening, what they’re seeing, if it’s getting better or worse, and how long have they observed it.
Figure 1: Balanced stand position. Note the “4 pillar” limbs, balance, and symmetry (there is a very slight lift in the left rear heel as the dog is about to move).
Figure 2: Proper sit position. Note the balance and the rear toes directly under the stifles and tarsi directly under the hips.
Figure 3: Deviations in stand position. Note forelimbs behind shoulders (forward weight shift); left metatarsals are perpendicular to the ground but the limb is in front of the ischium. There is also external rotation and abduction with reduced weight bearing. This patient has a left CCL rupture.
Figure 4: Deviations in stand position. Note forelimb fairly upright, very slightly behind shoulder. Metatarsals angled forward vs perpendicular, held forward under body (rearward weight shift). This patient has carpal osteoarthritis.
Next come your observations. Even without red flags in the signalment and history, you may pick up some more subtle signs of a mobility issue. While you are listening to your client, BOLO!
There are several things that you can take note of in 1 minute or less:
Figure 5: This patient shows an offset vs square stance, but note the proper position of right forelimb and right hind limb. Both are perpendicular to the floor, with the front foot directly below the shoulder and the metatarsals upright and caudal to the pelvis (structure dictates how far caudal the rear limb should be, but the metatarsal should always be at least as far back as the ischium).
Figure 6: Common sit posture deviation. Note the “puppy sit” with weight shifted to 1 hip.
Figure 7: Common subtle sit posture deviation. Note the asymmetry. This patient has her weight centered over the left rear and right front limbs, while the left front limb is slightly abducted and externally rotated and the right rear limb is slightly abducted and externally rotated.
Figure 8: Common subtle sit posture deviation. This dog has weight shifted into her pelvis instead of on her feet (a proper sit is the equivalent of a deep squat in a human). Note the toes coming off the floor, the rear feet well in front of the stifles, and the tarsi well in front of the hips.
Figure 9: Subtle deviation in sit position. This dog has her rear feet slightly wide. They should be directly under the stifles. Also note slight asymmetry (right rear foot slightly more abducted than left). This patient is still recovering from type 3 intervertebral disc disease T12-T13.
Figure 10: Proper sphinx down. Note symmetry and tarsi under hips and rear feet under stifles.
You should always palpate muscles for tone and tension and palpate the spine to assess comfort and motion. A general range of motion on each limb should also be assessed.
If you suspect an issue, you can home in on the area in question and briefly check to assess more common issues. If weakness is suspected, lift each limb for a few seconds and note difficulty and ability. You may find that 1 or 2 limbs are more difficult for the patient to lift and/ or maintain, so there may be an issue with balance and stability in one of the supporting limbs (or both).
Check the placement reflexes (“conscious proprioception”) in all senior dogs and any dog with a suspicion of neurologic disease. Perform a more thorough palpation of the hips to check for laxity and discomfort at end range extension and abduction. Check for a medial buttress, and if CCL disease is suspected, palpate the anterior stifle while the dog is standing. You may pick up subtle effusion. With practice, cranial tibial thrust can also be assessed quickly with the dog standing and is quite well tolerated.
Lastly, don’t forget to palpate the toes. Quickly flexing and extending the digits and metacarpophalangeal joints may uncover discomfort or limited range of motion, which is an early sign of osteoarthritis.
Once your exam is complete, you may have identified 1 or 2 key problem areas that need imaging. You may also have a diagnosis and plan to manage the patient with pharmaceuticals, nutraceuticals, photobiomodulation therapy, or even surgery.
You may not always determine a diagnosis for a subtle issue during a wellness visit. It is absolutely reasonable to quickly scan the patient for obvious issues and recommend a follow-up visit so that you can do a more thorough musculoskeletal and/or neurological exam. You can also refer the patient to a rehabilitation practitioner, orthopedic surgeon, or neurologist. Most importantly, communicate your concerns to the client and explain why further workup and management is in their pet’s best interest.
Early detection can mean the difference between seeing that patient in great condition for years to come or tumbling down the slippery slope of pain and muscle loss that often lead to euthanasia. In a United Kingdom study involving euthanasia in general practice that had data from more than 100,000 canines, the top 3 reasons for a patient presenting for this service were neoplasia, musculoskeletal conditions, and neurologic conditions.1
With a small change in your wellness exam routine, you can take your visits to the next level and be a wellness superhero. Detecting these issues earlier can lead to a better quality of life and longevity for your patients.
Imagine how many lives you can make better in just 1 month.
Christine Jurek, DVM, CCRT, CAC, CVA, received her doctor of veterinary medicine degree from Purdue University and spent 6 years in general practice before joining the staff at Thrive Pet Healthcare partner TOPS Veterinary Rehabilitation in Grayslake, Illinois. She has been practicing full-time canine rehabilitation for more than 21 years. Jurek has numerous published works on rehabilitation and integrative medicine and is currently pursuing a master’s degree in integrative veterinary medicine (MSIVM-canine) at Chi University in Reddick, Florida.