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Surviving Veterinary Medicine

How To See A Dog

Surviving Veterinary Medicine. Be smart, be bold, be creative and be your own boss. At the very least, find a practice where you can do what you do in the most positive way that gives you the space to practice medicine as you see fit. Because at SVM we set a higher standard for medicine than what you learned in school.

Hi, everybody, this is Dr. Narda Robinson, President, Founder and CEO of CuraCore Vet and CuraCore Med.

Today’s podcast on Surviving Veterinary Medicine is talking about how to see a dog and do a better job at diagnosing. What is going on with them? Are they painful? How are they restricted in their movement? What is the source of that? What is the cause of their pain? Where is it located? And how pervasive and widespread is it?

This kind of stuff isn’t taught in school, typically. If there is any kind of look at movement, oftentimes, it’s just trying to see is there a lameness? So, not seeing the animal as a whole, but just focusing on the lower limbs. And this happens a lot in equine medicine. So, large animal medicine, especially.

But what I’m going to talk to you today about is how to view the entire patient, so that you are a better veterinarian, you have a more complete understanding of what’s going on with that patient.

And then a better diagnosis that’s more accurate and more comprehensive is going to give you more, not only precision, but more information about what would be the best approach moving forward. Is it going to be (hopefully not) just drugs and surgery, but more a spectrum of science-based integrative medicine and the type of integrative rehabilitation that we’re also teaching at CuraCore Vet, which is going to include not only modalities, but also a deeper assessment of the neurological state of the patient and the connective tissue involvement and recruitment of dysfunction and just the whole thing. Because we want to really get a good, solid treatment and recommendations that will help that animal feel better not only now, but in the long run.

So, veterinarians, like their human counterparts, receive extremely little exposure to pain medicine as a rule. So, resultantly, they graduate from their professional educational programs, really unable to adequately determine why and where animals or their patients (if it’s a human patient) might be hurting through fear free, comprehensive physical examinations.

You can see various articles in the medical literature about the lost art of the physical exam, and that’s part of what we’re seeing here. New graduates find themselves poorly prepared to discuss with clients the rational and evidential basis of medical acupuncture, massage, photomedicine, botanical approaches and rehabilitation. But they also find themselves inadequately experienced in determining where and why animals are hurting because they’re just not taught what are the manifestations, what can I see visually, what can I feel with my hands?

Given these gaps in veterinary education, what we’re doing here at CureCore Vet is helping to restore confidence and trust in the practice of veterinary medicine. We’re doing that by reintroducing veterinarians to the lost art of that physical examination. Also, we’re teaching them the joy of taking a thorough history.

And what I see as both an osteopathic physician and a veterinarian is that veterinarians aren’t told about the whole complexity of social, trauma, medical, surgical, the whole long list of information that if the client has been with that animal for quite a while, that we should be getting that information and recording that in that patient’s history, because then we can better understand the mechanism of injury or the mechanism of this disease or what’s the origins of it, and is it physical, mental, social, environmental or combination of the above?

So, what happens when there’s a rushed, or as we say, perfunctory assessment that leads to an incomplete diagnosis based on the tunnel vision that we’ve been encouraged to adopt and acquire in vet school, along with a non-integrative medicine mindset, all those together lead to the state that we’re seeing now, which is why vets and clients are pretty unhappy a lot of times with just what’s going on. Because there’s unnecessary drugs being prescribed, needless surgery when something else could have done, perhaps a better job. Then we have unaddressed problems, unrecognized and unmitigated pain, which leads to untold suffering for the whole family.

And one thing I’ve been talking about a lot lately in my lectures is, especially if you’re a veterinarian or even a human physician, but whoever is diagnosing; do you remember while you were in training and you were so excited about learning the art of the differential diagnosis and coming up with just a whole list of possible reasons why your patient is having the problem that he or she is?

And you might have mentioned something that’s not run-of-the-mill, every day. And you might have been quite proud to think of it, because after all, you’ve been sitting in class maybe for that first two years, just soaking all this information in. And then you get into the clinic third year, or on your way to fourth year (hopefully its third year) and your doctor that you’re rounding with is saying, “Okay, what could be the problem?” And you come up with one of those rather not run-of -the-mill expressions of, “This could be it.”

And this is what kills intellectual curiosity along the way; when you start from your idealistic first year and soon, by the time you get the second or third year, a lot of people have lost that enthusiasm for now their new profession. Because you make that recommendation and then somebody says, “You know what? When you hear hoofbeats, think of horses. We don’t think of zebras.”

And I remember hearing that several times in medical school, perhaps a little less in veterinary school, because people would actually be thinking of maybe horses or if they were in exotics, maybe zebras, but still, the emphasis was still the same.

Because, for example, with cruciate disease, I mean, as I’ve talked about the dreaded TPLO a number of times on webcasts and podcasts and all that, we’re taught that if a dog has a pelvic limb lameness, then that’s cruciate injury until proven otherwise.

And the gold standard approach for that is a TPLO where they’re going to saw your leg bone apart and tibia (for those of you in the field) and then plate it again. And then you have a 40 times more risk of developing osteosarcoma and so on.

So, what I like to do is to encourage the rejuvenation of that intellectual curiosity that was many times probably just kind of squelched as you were in training. Because if you’re too knowledgeable, if you’re a bit of an upstart, then you’re going to make your teacher nervous and they might not be able to keep up with you. So, better that you be quiet and you follow the rules.

What’s the solution? Observe, enquire, palpate, differentiate and diagnose.

  • Observe: Know what to look for and why. And that’s what we’re doing here with How to See a Dog
  • Inquire: Ask more in-depth questions, which means you have to have enough time to do a thorough history and a thorough exam. And if you’re in a job that’s not going to let you do that, then are you happy with how you’re practicing medicine?
  • Palpate: Master the fear-free myofascial evaluation. Everything that I teach is designed to be not anxiety producing and to be just calming and partner-building with the patient and the client.

Once we have that information that we’ve gathered by observation, inquiry and palpation, then we can start to develop our differential list. So, we’re going to squelch our tunnel vision and consider the differentials for the problems that we see.

Don’t just jump to what you’ve been told to think and then prescribe a whole round of treatment based on something that’s not the case. Really consider what about that vascular, inflammatory, neoplastic, degenerative, iatrogenic and so on and all the whole differentials list; whether you’re using the acronym Vindicate the Myofascial or something else.

And then when you have all this; you’ve observed, inquired, palpated and differentiated, then you can be more confident about your diagnosis and you’re going to base your assessment on a comprehensive evaluation, not just a bunch of tests.

Specifics on the first step, which is observation:

  • Be thorough: Watch your patients move, outside of the exam room, even outside of the clinic, if you have a safe and protected place to do so.
  • Learn what to see: When we’re observing, we can see the posture, ease of movement, and the rhythm of movements speak volumes.

So, we’re going to view the movement from at least two directions. You’re going to watch them walk at a slow pace (not a trot) from right to left, looking at them. They’re going to go right to left and then left to right. Ideally, three times if the animal can do it.

Watching the animal go in front of you, going from left to right and then right to left, you’re going to see the head bobs, you’re going to see postural abnormalities, and we’re going to see alterations in limb strike involving the amplitude of the excursion of the limb, the rhythm of the advancement and possible proprioceptive deficits.

Then you’re going to ask the client or your technician or whoever to walk with the animal again at a slow pace, moving away from you and then back towards you. So, you’re more facing them coming at you and then they’re walking away from you, also two to three times.

And this will allow you to identify asymmetries in the axial spinal mechanics, as well as truncal soft tissue tone and bulk, and appendicular offsets in weight bearing. So, are they lame? Are they lame in multiple limbs?

But mostly as we’re starting to watch them move, I want you to have a systematic approach. So, I want you to challenge yourself to assess the posture, ease and rhythm of movement as systematically as possible. This is like what you learn to do when you are interpreting a radiograph.

Do not, as you learned with radiographs, do not zero-in on the problem right away, or you could miss significant findings that could be contributing to or coexisting with the complaint.

So, if somebody came in and said, “My dog has hip problems,” don’t just watch the hip, watch everything else, and that’s where you’re going to go from head to tail and topline to toe. What’s the position of their head and neck? Is the head and neck area ventroflexed, so bent down. This could indicate neck pain, myofascial restriction in that suboccipital region and (or) ventral neck soft tissue restriction or possibly caudal cervical compressive myelopathy, if it’s associated with an asynchronous gait.

If you don’t know what an asynchronous gait is, search for it, know what it is, don’t ever miss it.

So, head and neck ventroflexion, combined with various other signs that you should be noting could indicate neck pain, myofascial restriction in the suboccipital region or in the ventral neck soft tissues.

What are the signs you’re seeing from the whole face and the soft tissues? Look again at the eyes, the nose, the mouth. Are the eyes wide open? Are they alert? Is there fear? Is there stress? Are they partially closed, connoting head pain, fatigue, exhaustion, or something else? Is the dog relaxed and friendly or fearful and in pain? Do they not want to be there? What’s just going on? Are they stressed? How much muscle tension is in their face as well?

And then what is the impact of the collar and leash or the harness or other device that’s being used that the client brought in to help you watch the animal walk? Do you know what kyphotic means? Do you know what lordotic means? So, kyphotic is like you might be doing right now with your upper back If you’re hunched over; that’s kyphotic. So, you’re flex forward.

If you’re kind of sticking out your chest and have your hands on your hip and you’re doing, “What are you doing that for? Blah, blah, blah.”

The opposite of kyphotic is lordotic. So, that’s where when we talk about sway back, that’s where the spine is in extension.

So, these are important terms to understand because every section of the axial spine (So, that’s the neck and back and sort of the pelvis in there and also the tail, but mostly the neck and back down to LS junction and the sacrum itself). Where are the bends in the back and neck?

So, for the neck, is there a curvature? Is it extended or is it flexed? If the cervical spine is displaying unusual curvature in the cranial (middle or caudal portion) then try to determine why. And this will be something that you will investigate further in your myofascial evaluation.

Dogs with cranial cervical kyphosis could be experiencing headaches; just think of you with the tension underneath your occiput that you have and gives you that tension headache that can radiate to your forehead.

This can be from suboccipital muscle restriction or again, something going on with the discs, with the nerves, all kinds of compression, maybe a mishmash of all of it with some fascial restriction as well, and tightening.

Now, beside looking just at curvatures, look at the movement, is there ease in flexion, extension, rotation and side bending?

So, we never, ever recommend or endorse that forced passive range of motion that you probably saw done in school and you may have learned how to do it, and you maybe you still do it. So, you’re moving the neck around till they scream and that’s like, “Oh, okay, that must be hurting them. Now let’s move it to the other side and see how far they can move.” That is archaic and barbaric in my book. There’s no need for it.

So, active range of motion, if they’re following a biscuit or treat and(or) as you’re watching the animal’s head and neck movement during ambulation, that should tell you a lot. That’s just about everything you need along with your palpation. That’s what you need to know about the comfort and mobility of that neck region.

So, the myofascial evaluation that follows this observational exercise will fill in the missing parts when you search and denote tenderness to palpation, stiffness, atrophy, hypertonicity, hypotonicity, texture, and temperature changes, and asymmetries.

So, let’s move on down to the thoracic spinal curvature. If it’s abnormal, is it kyphotic or lordotic? Again, where and why do you think that is? So, we’re going from the cervical thoracic to the thoracolumbar junction.

If the thoracic spine and(or) that thoracolumbar junction display abnormal curvatures, then we can start to think about what is the differential diagnosis for this? What is the pain source? Is this musculoskeletal? Is it myofascial? Is it neurologic? And could there be a visceral problem that is causing viscerosomatic reflexes and affecting the back, secondarily?

Another thing we’re going to look for are haircoat changes, and this is really fundamental. Look for haircoat changes such as flattening, changes of direction, just changes in the quality of the haircoat that are identifying areas of fascial adhesion.

So, when the fascia is all kind of battened down, that’s going to impact nerve communication and just the health of the tissue, the nourishment through circulation. And when you think about the hair coat flattening that is affecting the erector pili muscles; the little muscles that would put your hair on end or at least just have it in the normal position.

So, that is key. And that is something also to talk to your clients about and to show them, so that they can know to monitor not only for the movement changes, but also the haircoat changes. And if you’re doing a round of a science-based integrative medicine rehab kind of approach and treatment, and then you’re to the point of maintenance, this is what you can tell the clients to watch for, as well as areas of heat; anywhere from the head, on the neck, the back, the limbs, anything.

Show them how to feel for those subtle temperature changes and how to watch for the haircoat changes. And so that if they are doing some kind of maybe massage or photomedicine at home as maintenance, if you’ve taught them that, then when it’s not really responding that well, then that’s when they need to come back in.

So, plan to palpate that entire trunk circumferentially, including the thorax and abdomen, searching for sources of somatic dysfunction once you move into your myofascial evaluation.

So, moving down from the thoracolumbar junction down to the lumbosacral junction, we have the lumbar spinal curvature; is that kyphotic or lordotic? What’s going on from a protective standpoint? Is it moving? Is there, with the whole spine, what is the movement? Again, flexion, extension, side bending, rotation.

It’s your job to find out why there are abnormal curvatures or restricted areas of the spine that’s just not moving well. It could be also that they are off-loading weight on one of the limbs or one or more of the limbs.

So, you’re going to continue to document these changes and again palpate circumferentially. We’re coming down to the same sacral caudal junction, and this is where we’re going to take into account tail position and its curvature.

What’s going on where it attaches to the pelvis? Is there some kind of haircoat change and abnormality there? Is the tail moving correctly? Is it moving in a position of ease? Is it just limp? Does it look pinned on and not confluent with the rest of the axial skeleton? Or if it’s wagging, is it wagging symmetrically? What expressions is it conveying? What emotions is it conveying, as well as neurologic capacity? Are there kinks or haircoat changes?

Ensure that the tail appears on the list of your upcoming myofascial assessment to evaluate more closely. Determine, as you would anywhere else, ideally, where is the problem in the tail; is it in the joints, is in the vertebrae itself, is it a composite, is it in fascia, is it in muscles, is in the nerves, et cetera?

And then even if there was a lameness coming in, it’s only after you look at everything else that you’re going to then, “Okay, I can look at the limbs now.” Thoracic limbs; is there a head bob? How’s the movement going? Is there weighting or unweighting of the limb?

And for the movement, how many of the joints are actually moving? And if they aren’t, then is the weight being shifted onto the contralateral limb? Or if it’s a hind leg, is the animal bearing more weight on the thoracic limbs?

You’re still going to systematically take a good look at the mobility and normality or lack of movement in every joint of that thoracic limb.

And then look at the muscle tone and bulk; are there proprioceptive deficits? Is there a wide based or a narrow stance in those thoracic limbs? Are they circumducting? And is the limb being held close to the body or further away than normal? Similar with the pelvic limbs, are they weighting or unweighting?

We’re not going to jump to a diagnosis. We’re going to assess tone and bulk. And especially, think of animals that you’ve seen with a suspected cruciate or other problem in the limb. Which joint aren’t they moving?

It’s striking how many veterinarians will say, “Oh, I didn’t see that before.” when you point something out because again, we haven’t been taught this in school. You should have been, but we’re trying to do our best to fill that gap.

And now, we can listen and look to the rhythm of the movement, to the actual sight of the movement, the sounds of stress, or abnormal neurologic states.

So, when we’re listening, what do you hear? Do you hear scuffing of the dorsum of one or more paws? Do you hear labored respiration, or panting, or agitation? These are all things to attune to.

So, if you’re in a really noisy environment, that’s just stressful for everybody, so you should do something else.

Are the thoracic and pelvic limbs moving synchronously? If not, would you call this an asynchronous gait? Some people call it a two-engine gait, so that the thoracic limbs are moving forward in a straight and more quick succession than the pelvic limbs, which may be exhibiting proprioceptive deficits; they’re going slower. That doesn’t mean it’s a T3 to L3 myelopathy. This could well be a caudal cervical compressive myelopathy.

So, with all these taken into account, what I would like you to do is to obtain the How to See A Dog handout, so that you can see the pictures that I’m going to be describing.

And for that, you can go to our website or put this in your search bar, in your, you know, go to this site. So, it’s curacore.org./vet/how-to-see-a-dog.

I’m going to do it right now, just to show myself that I would get there, and there it is. So, you’re going to enter your email address and then download. That will give you the ability to download the PDF.

In the handout that we have, I have the two images that are going from a lateral perspective and then a more frontal perspective. So, even if you have a dog right now and he or she is ambulating about as you’re listening to this podcast, or if you’re taking a run or something and you’re seeing all these animals on the street with their people.

So, here’s a warning, is that once you get accustomed to evaluating for pain and lameness, it gets really hard to see animals out. I find, like when I’m riding my bike and I go by animals and I’ll tell my partner, my biking partner, “Yeah, right hind limb lameness,” or “That dog really has neck pain,” because so many of them do.

In this handout, I show you a dog from the side and we look at the thoracolumbar lordosis, hypertrophic cervical region, kyphotic cervical curve. And then when we’re going to the lumbar sacral region, there’s kyphosis, there’s a little discontinuity in the tail region, from the sacrum to the tail, and the tail lacks tone.

And then looking from the front, we’re seeing a head carriage that’s lower than normal. We would expect it higher, but we’re already seeing that there’s a lot of neck restriction that you can see. You can see this muscle tone shortening.

The other things we’d be doing in a live session would be the rhythm of the foot strike; we’d be listening for that sound or evidence of scuffing. A deeper look at haircoat changes, because in a picture, it can be hard to tell, but in the live animal, you can see that. You can see how the light strikes the fur differently.

Then we could be evaluating for neurologic abnormalities, not only by observation, but also with a neurological exam that most people tend to forget to do, or just don’t do, or don’t feel like they have time to, or really never understood once they get out and practice. And that’s very, very sad.

So, we emphasize knowing the basics of your neuro exam, especially if you’re seeing — if you’re not an ophthalmologist, I guess if you are anyways, but if you’re treating animals, you should know; do they have a lower motor neuron lesion? Do they have an upper motor neuron lesion? Do they have peripheral neuropathy? This is very basic stuff.

But there’s so much more. The observation gives you a much more encyclopedic understanding of who this boy, girl, whatever; this level of observation gives you so much more than you’ve probably been picking up. And you’re going to be a better doctor for knowing this.

So, write to me if you have any questions, info@curacore.org or write to me directly, narda@curacore.org and take some classes from us in how to look at this and how to treat without drugs or with fewer drugs, without surgery or with less surgery.

If you’d like to learn integrative medicine from a scientific perspective, visit us at curacore.org. Thanks for listening to another installment of Surviving Veterinary Medicine.