Physiotherapist Equine and Canine Physiotherapy - Initial Clinical Notes Template
Equine and canine physiotherapy notes document the assessment and treatment of musculoskeletal and neurological conditions in horses and dogs, including gait analysis, joint mobility, muscle palpation, and specific therapeutic interventions designed for quadruped anatomy.
These specialized veterinary records maintain compliance with animal health practitioner standards while providing defensible documentation of clinical reasoning and treatment progression for both professional accountability and potential insurance claims.
They support comprehensive rehabilitation of animal patients by tracking objective measures of movement quality, performance parameters, and functional improvements across treatment sessions, allowing for precise modification of therapeutic approaches based on the animal's response.
Why Are Equine and Canine Physiotherapy Notes Important?
Comprehensive physiotherapy notes facilitate clear communication between veterinarians, handlers, and other animal healthcare professionals involved in the care plan.
Well-documented initial assessments ensure compliance with veterinary practice standards and animal welfare regulations.
Detailed clinical notes establish baseline measurements that enable accurate tracking of rehabilitation progress and functional improvements in equine and canine patients.
How to Write Equine and Canine Physiotherapy Notes
Begin with a thorough history including owner concerns, previous treatments, and referral information from the veterinarian.
Document observable gait patterns, posture, muscle symmetry, and reaction to palpation using consistent terminology and measurement techniques.
Conclude with a clear assessment, proposed treatment plan, and measurable goals that are specific to the animal's function and performance requirements.
Key Components of Equine and Canine Physiotherapy Notes
The subjective section should capture owner observations, animal behavior patterns, and performance history relevant to the presenting condition.
The objective assessment must include detailed musculoskeletal evaluation, movement analysis, and functional testing appropriate to the species and discipline.
The treatment plan should outline modalities selected (such as manual therapy, therapeutic exercise, or electrotherapy), with clear justification linked to the assessment findings.
Tips for Writing Effective Equine and Canine Physiotherapy Notes
Use anatomical terminology specific to quadrupeds while ensuring the language remains accessible to handlers and owners who will implement home care programs.
Maintain client confidentiality while documenting all communications with referring veterinarians to ensure continuity of care within the legal framework.
Incorporate digital photography or diagrams to document posture, asymmetries, and gait abnormalities for more accurate progress tracking over multiple sessions.
Automating Equine and Canine Physiotherapy Notes
Digital templates with species-specific anatomical charts can significantly reduce documentation time while improving assessment consistency across different practitioners.
Implement mobile applications that allow for field-based documentation with voice-to-text features suitable for barn or stable environments.
3 Common Questions About Equine and Canine Physiotherapy Notes
How detailed should initial gait analysis be in my documentation?
Initial gait analysis should include observations from multiple angles, on different surfaces, and under various conditions relevant to the animal's normal activities, with numerical scoring where possible to facilitate objective progress measurement.
How do I document owner compliance with home exercise programs?
Create a dedicated section in your template to record specific instructions given, demonstrate understanding through return demonstrations, and track reported adherence at follow-up appointments.
What terminology should I use when documenting manual therapy techniques for animals?
Use established veterinary physiotherapy terminology that specifies the technique, anatomical location, direction of force, and the animal's response, noting any adaptations made to standard techniques due to species-specific anatomy.
Final Thoughts on Equine and Canine Physiotherapy Notes
Well-structured initial assessment notes serve as the foundation for successful rehabilitation outcomes in equine and canine patients, establishing clear baselines and treatment pathways.
Investing time in creating comprehensive, standardized templates tailored to different disciplines (such as sport horses, working dogs, or geriatric patients) will enhance both clinical efficiency and treatment effectiveness.
Canine and Equine Physiotherapy - Initial Clinical Notes
Presenting Complaint:
• Canine: The dog is presenting with lameness in the left hind limb, exhibiting difficulty walking, especially after longer periods of activity or during post-exercise cool-downs. The owner noticed the dog has become increasingly hesitant to jump onto furniture or climb stairs. There has been noticeable limping after outdoor play or walks.
• Equine: The horse is displaying stiffness and a hesitant gait when walking, particularly on the right front leg. The horse appears reluctant to trot and is stiff during lateral movement. The owner reports that the horse has been slower to warm up during rides and is exhibiting signs of discomfort during grooming, particularly around the right forelimb.
History of Presenting Condition:
• Canine:
• Age: 7 years
• Breed: Labrador Retriever
• The symptoms of limping began about 3 months ago. Initially, the owner attributed the behavior to the dog having played too much, but after the symptoms persisted, they sought physiotherapy. The dog has been diagnosed with hip dysplasia and mild arthritis in the left hip.
• Previous treatments include NSAIDs (meloxicam) for pain relief, but they have been ineffective in managing discomfort. No prior surgeries have been conducted, and the dog has never had any fractures.
• The dog is generally overweight (currently 5-10 kg above ideal weight) and has a low activity level at home. The dog’s diet is commercial dry food with regular treats, and it has access to a large yard for play but is not consistently exercised.
• Equine:
• Age: 10 years
• Breed: Warmblood
• The horse has shown signs of hindlimb stiffness over the past 6 weeks, with a noted decline in performance during training. The horse has been diagnosed with mild osteoarthritis in the right front joint.
• The horse has undergone joint injections in the right forelimb for arthritis two months ago, with temporary relief. However, the stiffness returned, especially during lateral movement.
• The horse is in regular training, but the owner notes that the horse’s warm-up routine is becoming increasingly slower. It has access to a large paddock, and its diet is a mix of high-quality forage and supplements aimed at joint health.
Aggravating and Easing Factors:
• Canine:
• Aggravating Factors: Walking long distances, climbing stairs, and jumping worsen the limping and discomfort. Cold, wet weather also seems to exacerbate the symptoms.
• Easing Factors: Resting, particularly when lying down, and use of soft bedding seem to help reduce discomfort. Application of heat packs on the affected hip also provides temporary relief.
• Equine:
• Aggravating Factors: Trotting and cantering appear to exacerbate stiffness, particularly after several days of intensive training or when the horse is not properly warmed up.
• Easing Factors: Walking and gentle stretching during grooming seem to alleviate some discomfort. The horse responds well to cold therapy after exercise, especially on the affected leg.
Medications:
• Canine:
• Meloxicam (NSAID) for pain relief (once daily)
• Joint supplements (glucosamine and chondroitin sulfate) for arthritis
• Equine:
• Adequan (polysulfated glycosaminoglycan) injections for joint health (every 4 weeks)
• Bute (phenylbutazone) as needed for inflammation (10 mg, once daily for 2-3 days post-exercise)
24-hour Symptom Behavior:
• Canine:
• The dog’s symptoms are worse in the morning, particularly after getting up from a long period of rest, and improve with moderate movement or a short walk. The dog limps more noticeably after 30 minutes of play or on colder days.
• Equine:
• The horse’s symptoms are worse after prolonged exercise or on days following intense training. There is increased stiffness in the morning, but it loosens up slightly after walking and light exercise. The stiffness becomes more pronounced after 1-2 hours of work or during lateral movements.
Objective Information:
• Canine:
• Physical Examination Findings:
• Gait: The dog exhibits a left-sided limp with a reduced stride length in the left hind limb.
• Palpation: The left hip joint is mildly painful on palpation, with noticeable discomfort upon flexion.
• Range of Motion: Limited hip flexion (60 degrees), with pain noted at the end of the range. Normal extension (150 degrees).
• Muscle Condition: Mild atrophy of the left gluteals and quadriceps compared to the right side.
• Equine:
• Physical Examination Findings:
• Gait: The horse exhibits stiffness during the trot, particularly on the right forelimb. Uneven stride and noticeable hesitation when transitioning into a canter.
• Palpation: Mild pain and muscle tightness over the right forelimb, particularly around the carpal joint and the shoulder region.
• Range of Motion: Carpal joint shows decreased extension (~160 degrees), but flexion remains normal (45 degrees).
• Muscle Condition: Mild muscle tightness in the shoulder area, with reduced elasticity on palpation.
Assessment:
• Canine:
• The dog’s hip dysplasia and mild arthritis are contributing to the ongoing discomfort in the left hind limb. The limited range of motion and muscle atrophy indicate reduced activity levels, which have worsened the symptoms.
• Equine:
• The horse’s symptoms are consistent with osteoarthritis in the right forelimb, exacerbated by exercise and training intensity. Joint injections provided temporary relief, but the return of symptoms indicates further management is required, particularly in reducing joint stress during training.
Treatment Plan:
• Canine:
• Manual Therapy: Focus on gentle hip mobilizations to improve range of motion and reduce pain.
• Exercise Therapy: Start with low-impact exercise (e.g., swimming or walking on soft surfaces), gradually increasing intensity to improve joint mobility.
• Assistive Devices: Consider the use of a supportive harness for stairs or walks.
• Weight Management: Recommend adjusting the diet to promote weight loss and relieve strain on the hip joint.
• Equine:
• Manual Therapy: Apply carpal joint mobilizations to improve range of motion and reduce stiffness. Use soft tissue therapy around the shoulder and forelimb to address tightness.
• Exercise Therapy: Introduce gradual warm-ups and cool-downs to the horse’s training routine. Implement low-impact exercises such as walking and slow trotting.
• Cold Therapy: Apply cold compresses post-training to reduce inflammation.
• Joint Care: Continue Adequan injections and consider additional joint support supplements.
Owner Education and Home Care Instructions:
• Canine:
• Instruct the owner on the importance of moderate exercise to maintain mobility without exacerbating symptoms. Discuss the need for weight management to reduce strain on the affected joint.
• Recommend heat packs for the dog’s hips and joint supplements for long-term management.
• Equine:
• Explain the importance of a consistent warm-up and cool-down routine to prevent exacerbation of stiffness.
• Educate the owner about joint care supplements and the cold therapy post-exercise.
Additional Notes:
• Canine: Encourage environmental modifications such as non-slippery flooring to reduce the dog’s risk of falling. Monitor for signs of increased pain or difficulty with walking.
• Equine: Suggest regular monitoring of the horse’s gait and performance, particularly after intensive training sessions. Adjust training intensity based on observed discomfort.
Follow-Up Plan:
• Canine: Schedule a follow-up in 2 weeks to reassess progress, particularly focusing on range of motion, gait, and overall mobility.
• Equine: Plan a 3-week follow-up for reassessment of pain levels, mobility, and adjustment to the training program. Consider additional joint therapy or re-evaluation of the need for further injections.
It’s your turn to create PatientNotes
