and Prosthetics
Martin W. Kaufmann and Patrice M. Mich
The historical record of the field of human orthotics and prosthetics (H-OP) dates back to 2700 and 1500 BC, respectively (Seymour, 2002). Modern H-OP has been advanced by experiences gained from treating catastrophic wartime injury, sports injury, complica-tions of diabetes, and congenital limb deformities.
Today the use of mechanical appliances to improve function and to manage pain associated with mobility is no longer solely the purview of human medicine. The techniques and materials used in H-OP are now being utilized in veterinary medicine. Veterinary-OP (V-OP) has made great strides in the past decade from the sim-ple adaptation of PVC pipes, aluminum rods, thermoplastics, and fiberglass or plaster casting to the use of veterinary specific hinges, vacuum-molded composite high-temperature plastics, titanium, and carbon fiber, alongside a growing understanding of the intricacies of quadruped mobility and biomechanics (Adamson et al., 2005).
The advantages afforded by custom orthoses and prostheses include prevention of cast-related wounds and resultant pain; management of primary pain generators associated with functional impairments;
improvement of biomechanics, allowing for greater activity and a significant decrease in secondary pain; earlier return to active lifestyle, resulting in decreased obesity and associated comorbidi-ties; improvement in quality of life and functional independence, possibly preventing a premature decision to euthanize; and the availability of treatment options where none existed before.
PRIMARY AND SECONDARY PAIN GENERATORS ASSOCIATED WITH LIMB DYSFUNCTION OR ABSENCE
Primary pain generators are those directly and specifically caused by an injury. For example, hyperextension injury of an osteoarthritic carpus during weight bearing produces pain stimuli above and beyond the pain associated with osteoarthritis in the resting state.
The former, evoked pain, and the latter, spontaneous pain, can be significant sources of primary pain and subsequent loss of mobility.
In both instances the peripheral nociceptors are activated, resulting in the perception of localized pain.
Secondary pain generators are those arising from compensa-tion for pain or mechanical or funccompensa-tional impairment. Secondary pain compounds discomfort and can become a greater strain on the quality of life than the original injury. In the example above, decreased weight bearing through the affected carpus will result in a weight shift to the contralateral thoracic limb and potentially an increase in pelvic limb weight bearing. The contralateral triceps brachii, latissimus dorsi, and pectoral muscles will be excessively loaded and strained, resulting in myofascial trigger points within these muscle bellies. Additionally, the cervical, epaxial, and core muscles may be similarly affected due to a loss of homeostasis in structural supports. Lastly, increased weight bearing and com-pensatory gait shifting may exacerbate any concomitant ligament or joint pathology in the remaining limbs or trunk. The alert pain management clinician will carefully assess for gait and postural changes secondary to the presenting complaint. Common compen-satory adjustments include ventral displacement of the head and neck, head bobbing, “hip hiking,” pelvic tilt, spinal kyphosis or scoliosis, medially displaced limbs, and wide-based stance, among others (DeCamp, 1997; Renberg, 2001; Burton et al., 2008; Gomez Alvarez et al., 2008; Weishaupt, 2008).
THE ROLE OF CUSTOM EXTERNAL COAPTATION IN PAIN MANAGEMENT
Orthoses
Orthoses are any medical device attached to the body to support, align, position, immobilize, prevent or correct deformity, assist weak muscles, or improve function (Deshales, 2002) (Figure 13.1).
Goals of orthotic use may include reduction of pain and/or swelling, prevention of contractures, or provision of joint stability (Melvin, 1989). Human medical conditions partly or wholly managed with orthoses include: rheumatoid arthritis (Egan et al., 2003), mild-to-moderate carpal tunnel syndrome (De Angelis et al., 2009); lateral epicondylitis (tennis elbow) (Jafarian et al., 2009); osteoarthritis of the digits (e.g., halicus limitus) and midfoot region (Kruizinga
Pain Management in Veterinary Practice, First Edition. Edited by Christine M. Egger, Lydia Love and Tom Doherty.
C2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc.
155
156 Section 3 / Nonpharmacological Pain Therapy
Figure 13.1. Articulating carpal device for carpal
hyperextension injury; allows freedom of motion in flexion while providing hyperextension stop for “arthrodesis on demand.”
et al., 2002; Rao et al., 2009; Ibuki et al., 2010); plantar fasciitis;
mild-to-moderate lateral collateral ligament sprains of the ankle;
mild-to-moderate Achilles tendon sprain (Petersen et al., 2007;
Knobloch et al., 2008); and medial compartment syndrome of the osteoarthritic knee (Hewett et al., 1998; Barnes et al., 2002; Finger
& Paulos, 2002; Pollo et al., 2002; Dennis et al., 2006; Ramsey et al., 2007). Patients with osteoarthritis may benefit from orthoses used to unload, support, or protect the joint (Seymour, 2002). Additionally, orthoses may be used preoperatively or as a protective supplement to surgical repair. These devices may also be used as an alternative to surgery or when no surgical option exists.
Surgical management of many orthopedic conditions in veteri-nary species remains the standard of care and the preferred thera-peutic choice. Custom external coaptation can be used to provide security before and after the surgical repair and help prevent wounds or surgical failures caused by splinting, wet bandages, splint mate-rial fatigue/breakdown, and lack of patient tolerance of a support splint. The term coaptation refers to approximation and involves transmitting compressive or corrective forces through skin to the boney structures beneath. As a general rule, molded external coap-tation devices are more efficient stabilizers of bones and joints than premade ones (Piermattei et al., 2006). The advantages of custom-fitted devices are that, in closely approximating the patient’s indi-vidual topography and dispersing corrective forces over a larger surface area, fewer soft tissue problems arise and devices are better tolerated (Piermattei et al., 2006).
A good example is the surgical repair of an avulsed gastrocne-mius tendon. Once repaired, rigid fixation of the tarsus in extension
greater than 165◦ is maintained for approximately 8 weeks, with transition to a gradual reloading of the tendon over an additional 4–8 weeks. Painful complications may arise when a traditional caudolateral or lateral rigid splint is used and followed by serial padded bandages including: maceration of skin and contamination of surgical incisions (Piermattei et al., 2006); moist dermatitis of the interdigital space; tape associated dermatitis; pressure wounds usually associated with the lateral metatarsal head (fifth metatarsal bone), the lateral malleolus, and/or the calcaneal tuberosity; pres-sure wounds from splint edges; and with an insufficiently rigid splint, flexion of the tarsus resulting in premature tendon loading at best, and surgical failure at worst. The use of a custom orthosis can obviate these complications because it can be altered from a rigid device, used during the initial tendon healing phase, to a dynam-ically articulating device which allows gradual controlled load-ing of the tendon as it heals (Figure 13.2). Ultimately, this device can be adapted to a sports brace as the patient resumes normal
(a) (b) (c)
Figure 13.2. Progressively dynamic tarsus–paw orthosis for acute common calcaneal tendon injury used for postsurgical and nonsurgical support. (a) Articulating paw, nonarticulating tarsus configuration. Used during the healing phase. Large arrow indicates motion limiter in locked position; tarsus locked in extension 165–170◦. (b) Articulating paw, progressively articulating tarsus configuration. Used during early loading phase of
rehabilitation. The small arrow indicates adjustable motion limiter allowing variable flexion for controlled tendon loading as healing progresses. This device is set at 5◦of freedom articulation. (c). Sports brace. Used after healing and rehabilitation are complete. Paw segment removed for increased freedom of motion. Fully articulating tarsus with controlled flexion stop to prevent end range flexion trauma during high intensity activity. (Mich, P.M., Fair, L., &
Borghese, I. (2013) Assistive devices, orthotic, prosthetics, bandaging, inCanine Sports Medicine and Rehabilitation (eds M.C. Zink & J.B. VanDyke), Wiley-Blackwell.)
13 / Custom External Coaptation as a Pain Management Tool: Veterinary Orthotics and Prosthetics 157 Table 13.1. Orthopedic conditions amenable to
veterinary orthotic devices
Some common pathologies amenable to thoracic limb orthoses
Elbow instability (subluxation, osteoarthritis) Carpal hyperextension
Carpus bi or triplanar instability Carpal arthrodesis failure
Carpal support orthosis for contralateral thoracic limb amputation
Carpal instability secondary to contralateral amputation Paw injuries including tendon laceration and digit amputation Peripheral neuropathy
Brachial plexus distal neuropathy (carpus distad) Some common pathologies amenable to pelvic limb
orthoses
Cranial cruciate ligament rupture Patellar luxation (grades 1 and 2) Stifle collateral ligament injury Tarsal hyperextension
Tarsal collateral ligament injury Failed Achilles tendon repair Achilles tendon rupture or avulsion
Achilles tendon sprain without rupture or avulsion Sciatic neuropathy (tarsal collapse)
Paw injuries including tendon laceration and digit amputation Peripheral neuropathy: degenerative myelopathy
Sciatic nerve trauma secondary to pelvic fracture or repair IVDD, spinal canal stenosis, cervical spinal instability Fibrocartilagenous embolus (FCE)
Special conditions
Hoppy vest/“monoski”/“Can-do” wheels for bilateral forelimb amputee
Toe-up sciatic sling for peripheral neuropathy of hindlimbs Helmet as postcraniotomy protective device
activity. Although “off-the shelf” coaptation devices have been used in these cases, such devices cannot provide articulation or controlled, progressive reloading of tendon or bone; furthermore, the absence of customization often leads to soft tissue complica-tions.
A number of patients are not surgical candidates for a variety of reasons including financial, personal preference, advanced patient age, perceived increased anesthetic risk, comorbidities, or circum-stances requiring a delay of surgery. Until recently, veterinarians had no viable option for these patients. The development of V-OP has provided choices for applications using customized, articulated (as needed), external coaptation in the pre- or postoperative periods or in lieu of surgical intervention (Table 13.1).
Prosthetics
Biomechanical implications of agenesis of a limb segment (“con-genital amputation” or amelia) or limb amputation include remain-ing limb breakdown and the development of secondary pain gen-erators in myofascial tissue, joints, and spine by virtue of altered gait and structural support. Based on the significant consequences
of full limb amputation consideration of subtotal level amputation and application of prostheses becomes an attractive alternative. For perspective, consider human medical practice in which removal of normal proximal limb segments as a result of catastrophic injury to a distal limb segment is untenable.
The structural consequences of a missing or nonweight-bearing thoracic limb have not been fully elucidated, but conceivably are made more significant by virtue of the normal asymmetrical weight distribution of the quadruped. Normal weight distribution is approx-imately 60% to the thoracic limbs and 40% to the pelvic limbs.
Importantly, body condition becomes a critical factor because obe-sity affects the thoracic limbs to a greater extent than the pelvic limbs. With the loss of a single thoracic limb or limb segment, the following compensatory adjustments can be seen during ambula-tion: ventral displacement of the head and neck during the weight-bearing phase of the gait; propulsion of the cranial half of the body during the swing phase, requiring an explosive thrust of the neck, trunk, and remaining thoracic limb; medially displaced remaining thoracic limb, which supports a disproportionate percentage of body mass (>30%) and absorbs the full concussive force of landing; and kyphosis of the lumbar spine with associated ventral rotation of the pelvis about the sacrum as body mass is distributed over the remaining three limbs (Figure 13.3). Clinical signs associated with these compensatory conformational changes may include: pectoral, rhomboideus, latissimus dorsi, triceps, and cervical, thoracic, and lumbar epaxial muscle tension and pain and myofascial trigger point development; shortening of the iliopsoas with reduced pelvic limb extension range; pain on palpation of the cervical and lumbar spine due to abnormally hyper- and hypomobile segments (Wada et al., 1992; G´omez Alvarez et al., 2007); frontal and sagittal plane collapse of the remaining carpus; and splayed thoracic limb digits due to collapse of the transverse paw arch.
The structural consequences of a missing or non-weight-bearing pelvic limb are similar, with some unique aspects. In this case, the propulsive thrust of the caudal half of the body is dependent on a single pelvic limb. This increases the requirement for spinal and core effort in driving the body forward. Balance is maintained by limiting the range of tail movement and ventral placement of the head. The resulting conformation bears some resemblance to that of a kangaroo in motion, with an even greater majority of body mass shifted onto the forelimbs (>60%). Additionally, in most cases the pelvis is tilted to the side of the missing limb with concomitant rotation of the lumbar spine (Figure 13.4). This asymmetrically alters lumbar epaxial muscle tension. Hypermo-bility of the lumbar spine in the sagittal, frontal, and transverse planes may increase the potential for altered kinematics and back pain (Wada et al., 1992; Landman et al., 2004; Gomez Alvarez et al., 2008).
Whenever possible, it is advantageous to re-establish a normal quadruped structure. Fortunately, veterinary patients are amenable to prosthetic limbs and adapt rapidly. This means that with distal limb injury or tumor, careful surgical planning for a subtotal limb amputation as opposed to the traditional complete limb amputa-tion can enable the applicaamputa-tion of a custom prosthesis. The new paradigm is preservation of as much normal tissue as possible.
At the time of this writing, in order to suspend a prosthetic on the thoracic limb of a quadruped, preservation of 40% of the radius and ulna is required, and in the case of the pelvic limb, at minimum, 40% of the tibia and fibula is required (Syme’s ampu-tation (Shurr & Cook, 1990)). Technological advances, such as
158 Section 3 / Nonpharmacological Pain Therapy
(a)
(b)
Figure 13.3. Thoracic limb prosthesis. (a) Impact of right thoracic limb loss on biomechanics. Because propulsion of the thoracic half of the body is driven from the left thoracic limb and cervical or thoracic spine, head and neck are shifted ventrally to move the center of mass cranially, absorb a portion of ground reaction force, improve balance, and most importantly, absorb and store energy to provide a means for forward propulsion; left thoracic limb absorbs greater than normal 30% of body mass; pelvic limbs shifted forward beneath the trunk to provide further balance and decrease impact to the left thoracic limb;
subsequent kyphosis of the lumbar spine and ventral rotation of pelvis (transverse axis); pelvic limb stride length shortened in order to keep limbs beneath the trunk.
(b) Improved biomechanics with the addition of a right thoracic limb prosthesis. Propulsion of thoracic half of body no longer driven from left thoracic limb and cervical or thoracic spine alone; head and neck are properly elevated taking weight off of the left thoracic limb and decreasing repetitive strain on the cervical or thoracic spine; the back is more level from shoulders to pelvis;
lumbar kyphosis and pelvic rotation (transverse axis) are reduced; pelvic limbs are shifted into more normal position centered beneath the pelvis allowing normalization of stride length. The end result is decreased myofascial and orthopedic biomechanical strain. (Mich, P.M., Fair, L., &
Borghese, I. (2013) Assistive devices, orthotic, prosthetics, bandaging, inCanine Sports Medicine and Rehabilitation (eds M.C. Zink & J.B. VanDyke), Wiley-Blackwell.)
osteointegration and implantable bone topographical segments, may alter these level limits in the near future. The tremendous variability in veterinary patients requires adaptability in socket design, componentry, and prosthetic limb mechanics to accom-modate differences in the degree of injury, body type and con-dition, species, breed, size, lifestyle, sport or activity, and terrain (Table 13.2).
(a)
(b)
Figure 13.4. Pelvic limb prosthesis. (a) Impact of left pelvic limb loss on biomechanics. Because propulsion of the pelvic half of the body is driven from the right pelvic limb and lumbar spine, the head and neck are shifted ventrally for balance and the body mass is shifted cranially away from the pelvic limbs; the thoracic limbs are positioned caudally for balance and support; ventral rotation of the pelvis (transverse axis), kyphosis of the lumbar spine, and shortened right pelvic-limb stride length provide a means for energy storage for propulsion; the right pelvic limb is shifted medially beneath the trunk to provide balance and decrease impact to the left thoracic limb; subsequent rotation of pelvis (craniocaudal axis) alters spinal and limb biomechanics; the tail is low and shifted to the right for balance. (b) Improved biomechanics with the addition of a pelvic limb prosthetic. Propulsion of the pelvic half of the body is no longer driven by the right pelvic limb and lumbar spine alone. The head and neck are elevated as the body mass is shifted caudally to the pelvic limbs; the back is more level from the shoulders to the pelvis; lumbar kyphosis and pelvic rotation (craniocaudal and transverse axis) are reduced; the right pelvic limb is shifted laterally away from the midline as the prosthetic limb shares in weight bearing; the tail is elevated and in motion. The end result is decreased myofascial and orthopedic
biomechanical strain. (Mich, P.M., Fair, L., & Borghese, I.
(2013) Assistive devices, orthotic, prosthetics, bandaging, inCanine Sports Medicine and Rehabilitation (eds M.C.
Zink & J.B. VanDyke), Wiley-Blackwell.)
PATIENT EVALUATION FROM A V-OP PERSPECTIVE:
DIAGNOSIS TO DEVICE
Patient evaluation for a V-OP device must be thorough and incor-porate at least five separate examinations in order to fully define the presenting deficit, characterize biomechanical implications, identify comorbidities and potential complicators, and diagnose all
13 / Custom External Coaptation as a Pain Management Tool: Veterinary Orthotics and Prosthetics 159 Table 13.2. Orthopedic conditions amenable to
veterinary prosthetic devices Thoracic limb prosthetics
Subtotal midshaft radius or ulna amputation (40%
antebrachium retention required) Subtotal radiocarpal disarticulation Subtotal intercarpal disarticulation Subtotal carpometacarpal disarticulation Amelia
Congenital limb derangements Traumatic limb amputation Pelvic limb prosthetics
Subtotal midshaft tibia or fibula amputation (40% crus retention required)
Subtotal tarsocrural disarticulation Subtotal level intertarsal disarticulation Subtotal level tarsometatarsal disarticulation Amelia
Congenital limb derangements Traumatic limb amputation
primary and secondary pain generators. These examinations include a general wellness examination, an orthopedic (joint) examination, a myofascial (muscle) examination, a biomechanical (how joints and muscles work together) examination, and a neurological exam-ination. The following issues must be identified and addressed:
the type of injury or deficit and the functional and mechani-cal impairment resulting from it; comorbidities or complicators, lifestyle, environment, family dynamic, sport or activity; the goals and desired outcome of the client, the veterinarian, and the V-OP professional; and the alignment of goals with orthotic or prosthetic device functionality.
Because V-OP is a hands-on specialty, care must be taken to manage the case through a team approach. The ideal team includes the owner, the family veterinarian, a V-OP specialist, and a certified rehabilitation therapist.
Once case evaluation is complete and design of the device has been determined, custom fabrication and fitting of the device can proceed. The patient’s primary and secondary pain generators must be re-evaluated in the device to assure that both functionality and quality of life goals have been addressed. Initiation of a professional rehabilitation and conditioning program is ideal when coupled with an appropriate device orientation program.
SUMMARY
Careful analysis of biomechanics challenges the long-held belief that quadrupeds are not adversely affected by a dysfunctional or missing limb. A new paradigm dictates that functional adaptability cannot be the only consideration. Custom orthoses provide a new alternative to static splinting and bandaging, minimizing associ-ated wounds and improving long-term outcomes over these tradi-tional techniques. Additradi-tionally, the use of veterinary prosthetics can significantly decrease chronic pain states and improve short
and long-term quality of life in patients missing a limb or requiring amputation.
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