PHYSICAL THERAPY AS AN ADJUNCTIVE TREATMENT FOR SEVERE OSTEOARTHRITIS IN A KOMODO DRAGON (VARANUS KOMODOENSIS) Author(s): Tammy Culpepper Wolfe, D.P.T., P.T., C.C.R.P., G.C.F.P., Elizabeth Stringer, D.V.M., Dipl. A.C.Z.M., Sue Krauss, and Tim Trout, B.S. Source: Journal of Zoo and Wildlife Medicine, 46(1):164-166. Published By: American Association of Zoo Veterinarians DOI: http://dx.doi.org/10.1638/2014-0103R.1 URL: http://www.bioone.org/doi/full/10.1638/2014-0103R.1

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Journal of Zoo and Wildlife Medicine 46(1): 164–166, 2015 Copyright 2015 by American Association of Zoo Veterinarians

PHYSICAL THERAPY AS AN ADJUNCTIVE TREATMENT FOR SEVERE OSTEOARTHRITIS IN A KOMODO DRAGON (VARANUS KOMODOENSIS) Tammy Culpepper Wolfe, D.P.T., P.T., C.C.R.P., G.C.F.P., Elizabeth Stringer, D.V.M., Dipl. A.C.Z.M., Sue Krauss, and Tim Trout, B.S.

Abstract: This case report describes a new physical therapy technique, specifically the Wolfe Kinetic TechniqueTM, as adjunctive therapy in the treatment of severe osteoarthritis in a 20-yr-old Komodo dragon (Varanus komodoensis). This animal was managed with oral analgesics for 3 yr with fair to minimal response over time. Due to worsening of lameness and mobility, physical therapy was initiated. Ten treatment sessions were administered at 1-wk intervals. Within 1 mo the Komodo dragon exhibited marked improvement in gait and function, increased responsiveness to his environment, and increased mobility which continued to improve over the subsequent sessions. Although outcomes could not be measured by standardized objective measures, this study provides a reference for treatment of future cases and a foundation for future research substantiating treatment practices in animal physical therapy. Key words: Komodo dragon, osteoarthritis, physical therapy, Varanus komodoensis, Wolfe Kinetic Technique.

BRIEF COMMUNICATION Lameness, although not a common clinical presentation in reptiles, can be caused by trauma, luxation, septic arthritis, and idiopathic causes.5 Komodo dragons (Varanus komodoensis) are the largest species of lizard, growing to over 3 m in length, weighing up to 90 kg, and living over 20 yr in captivity.6,8 Although there are anecdotal reports of musculoskeletal disorders, there is little published literature on the treatment of osteoarthritis in captive varanids.1,2 A femoral head and neck excision was performed to treat a chronic coxofemoral luxation in a white-throated monitor (Varanus albigularis), with minimal success.1 There are few reports on the use of physical therapy in Komodo dragons, including an animal with neurologic dysfunction. That animal showed initial improvement in exercise tolerance, range of motion, and abdominal muscle tone. However, that individual developed several wasting, and improvement plateaued after 5 mo of treatment.7 Neurologic disease was confirmed on necropsy. A captive-born, 20-yr-old Komodo dragon presented for rear leg lameness in the summer of 2009. The animal was stationed on a radiograph plate, and dorsoventral radiographs were taken of

From the K9 Body Shop, PC, 12500 W 58th Avenue, Suite 100, Arvada, Colorado 80002, USA (Wolfe); and the Denver Zoological Foundation, 2300 Steele Street, Denver, Colorado 80205, USA (Stringer, Krauss, Trout). Correspondence should be directed to Dr. Stringer ([email protected]).

the pelvis, coxofemoral joints, stifles, and distal hind limbs. Osteoarthritis was diagnosed in both stifles, worse on the right limb. Blood was collected from the ventral tail vein (lateral approach), while the animal was stationed in a restraint box with tail exposure, and showed no significant abnormalities on a complete blood cell count or plasma biochemistry panel. The animal was started on treatment with oral meloxicam (Boehringer Ingelheim Vetmedica, Inc., St. Joseph, Missouri 64506, USA; 10.5 mg s.i.d.) and chondroitin-glucosamine supplementation (Nutramax Laboratories Inc., Lancaster, South Carolina 29720, USA; 800 mg chondroitin, 1,000 mg glucosamine s.i.d.). This resulted in improvement in the animal’s body posture, strength, and ambulation. All medications were administered in capelin or a small rodent and were readily accepted. Chondroitin-glucosamine was continued indefinitely, and meloxicam was discontinued after several weeks. Lameness recurred approximately 1 yr later, so meloxicam was started again and tramadol (Amneal Phamceuticals, Hauppauge, New York 11788, USA; initial dose of 150 mg s.i.d.) was added to the treatment regimen. These treatments again produced a clinical improvement in body posture and gait. The animal’s discomfort was monitored, and radiographs and blood work were rechecked every 3–12 mo as needed. The tramadol dose and frequency were adjusted to find a balance between acceptable analgesia and minimizing sedation side effects. Ultimately, 75 mg orally once per day was found to be most

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Figure 1. Komodo dragon (Varanus komodoensis) receiving a physical therapy treatment.

effective. Three years after initial presentation, gabapentin (Amneal Phamceuticals; initial dose of 300 mg s.i.d., increased to 600 mg s.i.d. after several months) was added to the treatment regimen due to perceived worsening of lameness and mobility. Meloxicam was discontinued due to the potential side-effect risks of long-term therapy despite normal uric acid values. In the fall of 2013, the animal continued to be intermittently lame despite analgesic treatments, so physical therapy was initiated. Due to the severity of pain and the success of utilizing the technique with canines,9 the physical therapist chose to utilize the Wolfe Kinetic TechniqueTM (WKT). The WKT is a very-gentle manual technique that is performed with the intent of changing movement patterns in a way that spreads out the work load of the body when the patient performs functional activities. The WKT operates under the premise that the performance of the spine and core dictates the movement patterns of the extremities and that the spine and core must move normally in order for the extremities to move normally. Because of that premise, the majority of the manual therapy is focused initially on the spine, ribs, and pelvis and then connected to extremity movement. By manually performing micromovements that harmonize with the patient’s habitual movement patterns, the practitioner attempts to spread the workload throughout the body so that there is an appropriate, proportional amount of work being

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done as the body moves in functional patterns. There is never a manual movement performed that causes resistance from the patient or the tissues. There is, rather, movement assistance that enriches and redirects motions that are easy for the patient and which takes those motions to new levels of differentiation. In theory, the technique works in conjunction with the plasticity of the nervous system. The central nervous system (CNS) has the capacity to adapt and alter its structure and function in response to a variety of internal and external pressures. This neural plasticity is the mechanism by which the CNS encodes experience and learns new behaviors. It is also the mechanism by which the damaged CNS relearns lost behavior in response to rehabilitation.3 Activity-dependent plasticity occurs in response to afferent (sensory) input, causing adaptive neuronal changes. The mechanisms of activity-dependent plasticity appear to involve functional and structural changes at all levels of the CNS.4 It is on this level of activity-dependent plasticity that physical therapy intervention is important, and choosing interventions that will develop the CNS in ways that will return normal function is of premium importance. In this Komodo dragon, initial treatment was on the thoracic spine, branching out into the scapular stabilizers, lumbar spine, and pelvis (Fig. 1). At initial evaluation, the pelvis was almost immobile in any plane of motion. Minimal thoracic, rib, and lumbar mobility was appreciated. Twice-per-week treatments would have been ideal, but due to limited availability of the therapist, the initial plan was to perform physical therapy on a weekly basis and evaluate progress after four visits. After the initial treatment, keepers reported no change in the animal’s status. Treatment then focused on spinal connections to the pelvis, ribs, and scapulae. Keepers were instructed to perform daily, gentle, manual lateral rocking of the pelvis for 3–5 min. On the third visit, keepers reported increased movement around the exhibit and decreased time in the pool. They reported that the animal was brighter and that he was more responsive to his environment. The WKT was performed, connecting the hind limb gait pattern movement to the torso and pelvis. On the fourth visit, keepers reported additional improvement in the animal’s activity level. During treatment the animal changed to various positions, which enabled more variety in movement patterns to be performed. Due to a positive response, weekly physical therapy sessions were continued.

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During the fifth visit, WKT was performed with increased head movement and positional changes. The keepers pointed out that the animal had been moving around the exhibit in many different patterns, as evidenced by tail-dragging patterns in the exhibit’s substrate. Keepers were instructed to add daily rib rotational rocking to the lateral pelvic rocking. By the sixth visit, keepers reported that the animal’s extremities were underneath him during ambulation and his spine was moving nearly normally. The WKT was extended from the core into the hind limbs and tail. Along with WKT, keepers were instructed in massage to the right hind limb. On the eighth visit, the focus of treatment was on lateral weight-shifting during head movement. During the ninth visit, keepers reported that the animal had been running, and WKT was performed with a focus on turning and weightshifting in all planes. At the tenth visit, keepers reported that the animal was able to easily negotiate a 12-inch step in-between the exhibits, an action which had not been observed for several years. The animal’s gait, activity level, and responsiveness to his environment continued to improve. Physical therapy frequency was then reduced to every other week with no appreciable worsening of the animal’s condition. At the time of this writing, the animal had been receiving physical therapy treatment for 11 mo in addition to keepers administering daily rocking and massage treatments. For a short period in the summer of 2014, physical therapy treatments were reduced to every 3 wk, but there was an appreciable worsening in the animal’s gait and activity level. Therefore, every-other-week sessions will be continued for the foreseeable future. Analgesic treatments have been decreased during this timeframe, with tramadol discontinued after 3 mo and gabapentin reduced from 600 mg to 300 mg after 6 mo of physical therapy. Glucosamine-chondroitin supplementation continues indefinitely. The animal continues to be sound despite no radiographic improvement. This case demonstrates that physical therapy, specifically the Wolfe Kinetic Technique, is a viable treatment option for osteoarthritis in a Komodo dragon. While it is impossible to know what changes took place structurally and chemically in the CNS during the physical therapy intervention, it is possible to observe the func-

tional outcomes. The intention of physical therapy is to gradually increase activity and exercise based on the patient’s physical limitations and pain level. In this Komodo dragon, observations included increased activity level, mobility and gait mechanics, and responsiveness. It is highly probable that these changes were due to the physical therapy treatment, especially as analgesics were reduced due to clinical improvement during this time period. More research is needed to validate these changes, both in a long-term follow-up basis and with other individuals and species. Reliable outcome measures are also needed to morecompletely assess functional changes and improvement in the quality of life for affected Komodo dragons.

LITERATURE CITED 1. Barten SL. Treatment of a chronic coxofemoral luxation by femoral head and neck excision arthroplasty in a white-throated monitor (Varanus albigularis). Bull Assoc Rept Amphib Vet. 1996;6:10–13. 2. Garner MM. A retrospective study of disease in monitor lizards (Varanus spp.) In: Proc AAZV ARAV Joint Conf; 2008. p. 1–2. 3. Kleim J, Jones TA. Principles of experiencedependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;S1:S225–S239. 4. Lynskey JV, Belander A, Jung R. Activity dependent plasticity in spinal cord injury. J Rehabil Res Dev. 2008;45:229–240. 5. Mader DR, Bennett RA. 2006. Surgery. In: Mader DR (ed.). Reptile medicine and surgery, 2nd ed. St. Louis (MO): Saunders Elsevier. p. 581–630. 6. Schumacher J. Lacertilia (lizards, skinks, geckos) and amphisbaenids (worm lizards). In: Fowler ME, Miller RE (eds.). Zoo and wild animal medicine, 5th ed. Philadelphia (PA): W. B. Saunders Co; 2003. p. 73–81. 7. Unwin S, Sanderson S, Chantrey J. Physiotherapy treatment and outcome of a neurologic dysfunction in a komodo dragon (Varanus komodoensis). Proc. AAZV ARAV Joint Conf. 2008; p. 237–239. 8. Walsh T, Visser G, Lewis R. Komodo dragon husbandry manual, 3rd ed. AZA/SSP and EAZA/EEP. 2004; p. 2. 9. Wolfe TC. Application of the neuroplasticity theory through the use of the Feldenkrais method with a canine with traumatic spinal cord injury: a case study. Orthoped. Physical Therapy Practice 2012;24:237–241. Received for publication 29 May 2014

Physical therapy as an adjunctive treatment for severe osteoarthritis in a Komodo dragon (Varanus komodoensis).

This case report describes a new physical therapy technique, specifically the Wolfe Kinetic Technique, as adjunctive therapy in the treatment of sever...
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