The Canine Orthopedic Index. Step 1: Devising the items

Development and validation of a questionnaire to assess owner and canine quality-of-life and treatment satisfaction in canine allergic dermatitis

BACKGROUND

Animal and owner quality-of-life (QoL) is pivotal in treatment decisions. Accurate measurement of owner-reported QoL and treatment satisfaction (TS) supports disease burden and treatment benefit evaluation.

OBJECTIVES

Develop and evaluate an owner-completed canine dermatitis QoL and TS questionnaire (CDQoL-TSQ) in allergic dogs.

MATERIALS AND METHODS

The CDQoL-TSQ was drafted following review of existing measures and expert input. Content validity was assessed through interviews with owners of allergic dogs. Psychometric properties of the QoL domains (Canine QoL, Owner QoL) were evaluated. Score interpretation was derived.

RESULTS

Twenty dog owners were interviewed. Item wording was amended following the first 10 interviews. Data from 211 owners were used in the psychometric evaluation. The Canine QoL domain demonstrated strong internal consistency (α = 0.89), test-retest reliability (ICC2,1 = 0.844), moderate convergent validity (r = 0.41) and moderate-high known-groups validity (effect size 0.37-0.64). The Owner QoL domain demonstrated strong internal consistency (α = 0.73), high convergent validity (r = 0.63) and moderate-high known-groups validity (0.43-0.63). Test-retest reliability approached moderate strength (ICC2,1 = 0.490). Group-level interpretation analysis showed minimal important difference of 7.0-13.6 points for dogs and 13.0-13.6 for owners. For individual dogs a change of 6.3 or 12.5 points for dogs, and 12.5 or 18.8 for owners indicates a response.

CONCLUSIONS AND CLINICAL RELEVANCE

The CDQOL-TSQ is a two-part assessment to evaluate QoL and TS in canine allergic dermatitis. The QoL questionnaire demonstrated validity and reliability, and interpretation of scores was derived, making it suitable for use in research and practice. The TS module is suitable for clinical setting use to improve owner-veterinarian communication.

Mobility, functionality and functional mobility: A review and application for canine veterinary patients

Mobility is an essential aspect of a dog's daily life. It is defined as the ability to move freely and easily and deviations from an animals' normal mobility capabilities are often an indicator of disease, injury or pain. When a dog's mobility is compromised, often functionality (ability to perform activities of daily living [ADL]), is also impeded, which can diminish an animal's quality of life. Given this, it is necessary to understand the extent to which conditions impact a dog's physiological ability to move around their environment to carry out ADL, a concept termed functional mobility. In contrast to human medicine, validated measures of canine functional mobility are currently limited. The aim of this review is to summarise the extent to which canine mobility and functionality are associated with various diseases and how mobility and functional mobility are currently assessed within veterinary medicine. Future work should focus on developing a standardised method of assessing functional mobility in dogs, which can contextualise how a wide range of conditions impact a dog's daily life. However, for a true functional mobility assessment to be developed, a greater understanding of what activities dogs do on a daily basis and movements underpinning these activities must first be established.

Humeral Condylar Fractures in French Bulldogs-Inciting Cause and Factors Influencing Complications of Internal Fixation in 136 Dogs

OBJECTIVE

 To report the inciting cause and configuration of humeral condylar fractures in French Bulldogs, and to identify risk factors for complications associated with their surgical stabilization, as well as their occurrence.

STUDY DESIGN

 Retrospective multicenter clinical cohort study.

ANIMALS

 French bulldogs (n = 136) with humeral condylar fracture.

METHODS

 Records from eight United Kingdom referral centers were reviewed for French bulldogs that underwent surgery for humeral condylar fracture between January 2017 and January 2021.

RESULTS

 Lateral fractures of the humeral condyle represented two-thirds of condylar fractures in this study (95 elbows; 69.8%); medial fractures of the humeral condyle and intracondylar Y or T fractures affected 22 (16.2%) and 19 (14%), respectively. A fall was the inciting cause for 60 elbows (45.6%), with stairs implicated in 27 (20.45%) elbows. Skeletal immaturity was significantly correlated with fracture. Complications affected 30 out of 132 dogs (136 elbows) (22%), of which 10 (33%) were major, and 20 (66%) were minor. Fixation method did not significantly impact complication rate for medial or lateral fractures of the humeral condyle (p = 0.87). Comminution increased the risk of complication for all humeral condylar fracture types (p = 0.02).

CLINICAL RELEVANCE

 Fixation method was not found to significantly impact the complication rate of surgically managed fractures of the humeral condyle in French bulldogs. Stair use, falling from low heights, and skeletal immaturity were common inciting reasons for humeral condylar fractures.

Long-term outcome in dogs with cranial cruciate ligament disease evaluated using the canine orthopaedic index

BACKGROUND

Cranial cruciate ligament disease (CCLD) is common in dogs, but studies on the long-term treatment outcome are scarce.

METHODS

The long-term outcome in a cohort of 71 dogs with CCLD treated with tibial plateau levelling osteotomy (TPLO, n = 18), tibial tuberosity advancement (TTA, n = 23) or lateral fabellotibial suture (LFS, n = 30) was evaluated using the canine orthopaedic index.

RESULTS

The risk of stiffness and lameness was increased in dogs treated with TPLO (stiffness: incidence rate ratio [IRR] 1.33, p = 0.015; lameness: IRR 1.34, p = 0.020) or TTA (stiffness: IRR 1.26, p = 0.035; lameness: IRR 1.31, p = 0.026) when compared to LFS at a median follow-up time of 4.6 years.

LIMITATIONS

No follow-up veterinary examination was performed. Data were collected from only two university animal hospitals, and thus, a referral bias towards more complicated cases is possible, which may limit the generalisability of the results.

CONCLUSION

Clinicians can use the results to inform dog owners about the expected long-term outcome in dogs with CCLD.

Long-term outcomes in dogs with elbow dysplasia, assessed using the canine orthopaedic index

BACKGROUND

Elbow dysplasia (ED) is an important cause of lameness in dogs. This study aimed to report long-term outcomes in dogs with elbow osteoarthritis.

METHODS

Demographic data, medical management, and scores from The American College of Veterinary Surgeons' Canine Orthopaedic Index (COI) were collected from owners of dogs radiographically screened for ED, graded as normal, mild, or moderate. Telephone interviews were performed in 2017 (Q1), followed by an email survey in 2020 (Q2). The association between ED grade and deterioration in COI scores over time was evaluated with logistic regression.

RESULTS

A total of 765 replies were collected for Q1 and 293 for Q2. At Q2, 222 dogs (76%) were alive, with a median age of 8 years (range 5-12 years). No association was found between ED and changes in COI score over time or between ED and survival (p = 0.071). Dogs with mild and moderate ED were treated with analgesic medications to a higher degree than dogs without ED (p < 0.05).

LIMITATIONS

Only owner-assed data were assessed; no clinical orthopaedic examination or follow-up radiographic evaluation was performed.

CONCLUSIONS

No association was found between the grade of ED and the worsening of clinical signs in dogs with elbow osteoarthritis.

Initial Psychometric Evaluation of the Portuguese Version of the Canine Orthopedic Index

OBJECTIVE

 The aim of this study was to perform the initial psychometric evaluation of the Portuguese version of the Canine Orthopaedic Index (COI).

STUDY DESIGN

 In a prospective, randomized study, a group of 50 police working dogs with bilateral hip osteoarthritis was assessed. A copy of the translated Portuguese version of the COI was completed by canine handlers, native Portuguese speakers. This result was compared with that of 50 sound dogs. Construct validity was determined by comparing sound dogs and dogs with osteoarthritis scores with the Mann-Whitney test. Additionally, the Kaiser-Meyer-Olin measure of sampling adequacy, eigenvalue, and scree-plot analysis were performed. Internal consistency was tested with Cronbach's α.

RESULTS

 A significant difference was observed between osteoarthritis and sound dogs in all dimensions of the COI (p < 0.01 for all), indicating construct validity. Two factors accounted for 87.8% of the total variance. Cronbach's α was 0.98, with a high interitem correlation, accounting for strong internal consistency.

CONCLUSION

 We presented criterion and construct validity of the Portuguese version of the COI. It is a step in providing clinicians with a validated and accessible tool to evaluate orthopaedic patients. Further studies are required.

Evaluation of the thermographic response of the lumbar region in dogs with bilateral hip osteoarthritis

Infrared thermography is suggested as a method of medical assistance for evaluating anatomical regions where there may be some inflammatory or painful condition that requires immediate medical attention. For this reason, this study aimed to characterize digital thermography of the lumbar region in police working dogs with hip osteoarthritis, 47 dogs with bilateral hip osteoarthritis were evaluated. A thermographic dorsoventral view of the dogs' backs were obtained, and mean and maximum temperatures were determined. In addition, results from the Canine Brief Pain Inventory, Liverpool Osteoarthritis in Dogs (LOAD), the Canine Orthopedic Index, and weight-bearing distribution evaluation were collected. Results were compared with an Independent Samples T-Test or ANOVA, followed by an LSD post hoc. Multiple regression was run to predict temperatures from age, sex, breed, body weight, and Orthopedic Foundation for Animals hip score and to predict clinical metrology scores and weight-bearing distribution results from temperature results. The sample included 28 males and 19 females, with a mean age of 6.3 ± 2.5 years and bodyweight of 26.9 ± 5.1 kg, with osteoarthritis hip scores of mild (70.2%), moderate (21.3%), and severe (8.5%). Significant differences were observed in mean temperatures between German Shepherd Dogs (GSD) and Labrador Retrievers (LR) (p < 0.01), and LR and Belgian Malinois (BM) (p=0.02). Mean temperature contributed to the prediction of LOAD and stiffness. LR showed significantly higher temperature values than GSD and BM. No differences were observed between osteoarthritis hip scores and mean temperature values contributed to LOAD scores' prediction. This relation needs to be addressed in further studies, involving a larger number of animals, and to determine changes in response to treatment.

Awareness and Use of Canine Quality of Life Assessment Tools in UK Veterinary Practice

The use of formal canine quality of life (QOL) assessment tools in veterinary practice has been recommended. An online survey investigated awareness, use and barriers to use of these tools in the UK. An anonymous 24-question survey was advertised through veterinary groups and social media. Ninety veterinary surgeons and twenty veterinary nurses responded. Thirty-two respondents (29.1%) were aware of the existence of formal canine QOL assessment tools. Of the three tools listed, current use was less than four per cent. No statistically significant influence of respondent age, role (veterinary surgeon or nurse) or possession of additional qualifications was found on the awareness of QOL tools (p > 0.05). Over half of respondents (55.5%) would 'certainly' or 'probably' be willing to use a QOL assessment tool. The main barrier to use was lack of time. Other barriers included a perceived resistance from owners. Although current use and awareness of canine QOL assessment tools in UK veterinary practice is low, veterinary professionals appear willing to use the tools within their daily practice. This discrepancy implies that QOL assessment tools are not well disseminated to veterinary surgeons and nurses in practice and that various barriers inhibit their use.

Evaluation of a small-bore needle arthroscope for diagnosis and treatment of medial coronoid disease in dogs: a pilot study with short-term assessment

CASE HISTORY

Dogs (n = 15) that were presented to a single veterinary teaching hospital with elbow dysplasia-associated lameness between September 2021 and May 2022, and were determined to require arthroscopy based on imaging results, were prospectively recruited into the study. The median duration of lameness was 4 (min 1, max 24) months.

CLINICAL FINDINGS

Various breeds were represented with a median body weight of 31.6 (min 15, max 46.4) kg and median age at presentation of 14 (min 8, max 83) months. Results of imaging modalities (CT) were consistent with medial coronoid disease with fissured or fragmented medial coronoid process in all dogs.

ARTHROSCOPIC FINDINGS

Feasibility of the needle arthroscopy (NA) procedure was firstly assessed in a preliminary cadaveric study in forelimbs (n = 10) collected from 10 adult dogs euthanised for reasons unrelated to the study. Elbow exploration was performed through a medial approach beginning with NA (1.9 mm 0° angle scope) followed by standard arthroscopy (SA; 2.4 mm 30° angle scope). The quality and extent of visualisation (scored through the number of anatomical structures visualised) were recorded and statistically compared. As the cadaver study indicated that NA allowed safe inspection of all structures in medial/caudal compartments, this procedure was then used in the dogs requiring treatment. In the clinical setting, elbow exploration was successful in all dogs and the treatment (removal of osteochondral fragments) was performed without requiring conversion into SA. One month after surgery, all dogs had an improvement in their lameness score (0-5) and 12/15 dogs were no longer lame. There was a reduction in Canine Orthopaedic Index scores measured a median of 99 (min 47, max 180) days after surgery (24 (IQR 19.5-31.5)) compared to the pre-operative period (49 (IQR 46.5-57); p < 0.001).

CLINICAL RELEVANCE

Needle arthroscopy-assisted removal of osteochondral fragments was performed in all dogs with satisfactory short-term clinical outcome. NA is a feasible technique for diagnosis and lesion assessment in dogs with a fissured or fragmented coronoid process. Larger clinical studies with longer follow-up are necessary to validate the NanoScope operative arthroscopy system as an alternative strategy to SA for video-assisted treatment of medial coronoid disease.

Regenerative Medicine and Rehabilitation Therapy in the Canine

Regenerative medicine is used in the canine to optimize tissue healing and treat osteoarthritis and soft tissue injuries. Rehabilitation therapy is also often implemented in the treatment and management of musculoskeletal conditions in the canine. Initial experimental studies have shown that regenerative medicine and rehabilitation therapy may work safely and synergistically to enhance tissue healing. Although additional study is required to define optional rehabilitation therapy protocols after regenerative medicine therapy in the canine, certain fundamental principles of rehabilitation therapy still apply to patients treated with regenerative medicine.

Minimal clinically-important differences for the 'Liverpool Osteoarthritis in Dogs' (LOAD) and the 'Canine Orthopedic Index' (COI) client-reported outcomes measures

Client-reported outcomes measures (CROMs) have been previously validated for the evaluation of canine osteoarthritis. A published systematic review indicated that the 'Liverpool Osteoarthritis in Dogs' (LOAD) and the 'Canine Orthopedic Index' (COI) can be recommended for use in dogs with osteoarthritis; these CROMs have also been used in the context of measuring surgical outcomes of dogs with orthopaedic conditions. However, the minimal clinically-important differences (MCIDs) for these CROMs have not been investigated. Such estimates would be useful for investigators and regulators so that these CROMs can be used in clinical trials. Data from the RCVS Knowledge Canine Cruciate Registry were extracted, and baseline and 6 week follow-up data on dogs that had received surgery for cranial cruciate ligament rupture were used to make estimates of MCIDs using distribution-based and anchor-based methods. Data from 125 dogs were categorised based on the anchor question and LOAD and COI scores analysed accordingly. The four anchor-based methods provided a range of MCIDs for each CROM (1 to 8.8 for LOAD and 3.5 to 17.6 for COI). In the two different distribution-based methods, the MCIDs for LOAD ranged from 1.5 (effect size) to 2.4 (standard error of measurement) and the effect size method yielded a result of 2.2 for COI. The results showed that the value of the MCIDs depended on the method that was applied. Receiver operator characteristic curves provided areas under the curve (AUCs) greater than 0.7, which indicated that the cut-off point was acceptable; LOAD had the greater AUC at 0.867. In summary, the authors currently recommend a MCID of '4' for LOAD and '14' for COI although further work in other clinical contexts (such as osteoarthritis associated with chronic pain) is required to add confidence to these estimates. For the first time, we have provided estimates for MCIDs for these two CROMs which will facilitate sample size estimates in future clinical studies that use these CROMs as outcomes measures.

Initial psychometric evaluation of the Portuguese version of the Liverpool Osteoarthritis in Dogs

BACKGROUND

Osteoarthritis (OA) is the most commonly diagnosed joint disease in companion animals, and proper tools are necessary to assess patients and response to treatment. We aimed to perform an initial psychometric evaluation of the Portuguese version of the Liverpool Osteoarthritis in Dogs (LOAD).Fifty Police working dogs with bilateral hip OA were assessed in a prospective, randomized, double-blinded study. Canine handlers, who were native Portuguese speakers, completed a copy of the translated version of the LOAD. Their results were compared with those of fifty sound dogs. Construct validity was evaluated by assessing differences between OA and sound animals with the Mann-Whitney test. Further evaluation was performed with the Kaiser-Meyer-Olkin measure of sampling adequacy, Eigenvalue, and scree-plot analysis. Internal consistency was tested with Cronbach's α.

RESULTS

A significant difference was observed between OA and sound dogs (p < 0.01), indicating construct validity. Two factors accounted for 81.5% of the total variance. Cronbach's α was 0.96, and a high inter-item correlation was observed, raging from 0.76 to 0.95, showing strong internal consistency. We presented criterion and construct validity of the Portuguese version of the LOAD, which is valid for use in the Portuguese language. It is an additional stage in providing a broader number of clinicians with an accessible tool to evaluate dogs with osteoarthritis. Further studies are required.

A survey on the orthopedic and functional assessment in a Portuguese population of police working dogs

BACKGROUND

Working dogs are at an increased risk of developing an orthopedic disease compared to companion dogs. This study aimed to evaluate functional and orthopedic index fitness in a Portuguese population of police working dogs. In an observational, prospective study, information on 165 dogs was collected. The age, sex, breed, specific work, and history of previous diagnosis of orthopedic disease were recorded for each patient. A copy of the Canine Orthopedic Index (COI), Hudson Visual Analogue Scale (HVAS), and Functional Assessment (FA) was collected for all dogs. COI, HVAS, and FA scores between breeds, work, age, sex, and history of a previous diagnosis of orthopedic disease were compared. Multiple regression was run to predict COI, HVAS, and FA scores from breeds, work, age, sex, and history of orthopedic disease. Correlations between items were determined with Pearson's correlation. A p < 0.05 was set.

RESULTS

The sample was composed of 92 males and 73 females, with a mean age of 5.2 ± 3.2 years. Four main dog breeds were represented, 60 Belgian Malinois Shepherd Dogs, 52 German Shepherd Dogs, 29 Labrador Retrievers, and 14 Dutch Shepherd Dog. A prevalence of diarrhea of 10.6% was determined, with 4% of dogs having liquid diarrhea. German Shepherd Dogs had significantly higher FA scores (p = 0.03). Dogs with a history of previous veterinary assistance due to orthopedic issues had significantly lower HVAS scores and higher scores with all remaining questionnaires (p < 0.01 for all). No differences were found between sexes or specific work. Age and a history of orthopedic disease contributed to the prediction of all scores. FA scores had a good correlation with COI and HVAS.

CONCLUSION

This population of police working dogs has a good to excellent level of physical fitness. There was a relationship between increasing age, history of orthopedic disease, and worse scores with all questionnaires. All considered questionnaires could differentiate between animals with a previous history of orthopedic disease and sound dogs.

Canine Geriatric Rehabilitation: Considerations and Strategies for Assessment, Functional Scoring, and Follow Up

Geriatric animals account for half of the pet population in the United States with their numbers increasing annually. Furthermore, a significant percentage of veterinary patients with movement limitations could be grossly categorized as geriatric and living within the end stage of their predicted lifespans. Because mobility is correlated to quality of life and time to death in aging dogs, a major goal in optimizing canine geriatric health is to improve functional movement. Within the geriatric population, identifying disabilities that affect daily living and quality of life may be used by the rehabilitation practitioner to provide stronger prognoses, treatment goals, and outcome measures. Examples of such means are described within this review. In human medicine, the concept of “optimal aging”, or “healthy aging”, has emerged in which inevitable detrimental age-related changes can be minimized or avoided at various levels of physical, mental, emotional, and social health. Both environment and genetics may influence aging. Identifying and improving environmental variables we can control remain a key component in optimizing aging. Furthermore, diagnosing and treating age related comorbidities common to older populations allows for improved quality of life and is often directly or indirectly affecting mobility. Obesity, sarcopenia, and a sedentary lifestyle are a trifecta of age-related morbidity common to both people and dogs. Healthy lifestyle choices including good nutrition and targeted exercise play key roles in reducing this morbidity and improving aging. Disablement models act as essential tools for creating more effective physiotherapy plans in an effort to counter dysfunction and disability. Within these models, functional testing represents a standard and validated means of scoring human geriatric function as well as monitoring response to therapy. Because of the great need in dogs, this review aims to provide a reasonable and testable standardized framework for canine functional scoring. We believe a complete assessment of canine geriatric patients should comprise of identifying environmental variables contributing to health status; diagnosing comorbidities related to disease and aging; and characterizing disability with standardized methods. Only through this process can we construct a comprehensive, reasonable, and targeted rehabilitation plan with appropriate follow up aimed at healthy aging.

Evidence-based evaluation of owner-reported outcome measures for canine orthopedic care - a COSMIN evaluation of 6 instruments

OBJECTIVE

To systematically review the currently available validated owner-reported outcome measures (OROMs) for assessing pain and function in dogs with osteoarthritis and other joint diseases.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature search of PubMed and Web of Science was performed in December, 2019, using search terms relevant to OROMs for pain and function in dogs with osteoarthritis and other joint diseases. The measurement properties of the resulting outcome instruments and validation studies were evaluated with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN).

RESULTS

Seventeen publications describing the validation of 6 OROMs were selected and evaluated with the COSMIN. The Canine Brief Pain Inventory (CBPI), Canine Orthopedic Index (COI), and Liverpool Osteoarthritis in Dogs (LOAD) provided evidence of sufficient content validity. Internal consistency, reliability, construct validity, and responsiveness were the most frequently validated other properties. Both CBPI and COI had sufficient internal consistency; LOAD, being formative in construct, need not be assessed for internal consistency. No instruments provided information on measurement errors.

CONCLUSION

The CBPI, COI, and LOAD can be recommended for use in dogs with osteoarthritis. Further evidence is necessary to increase the interpretability of these instruments or expand their application into other canine orthopedic conditions. Further evidence is also needed before the other 3 instruments can be recommended.

CLINICAL SIGNIFICANCE

This systematic evaluation of 6 OROMs provides clinicians and researchers with a tool that facilitates and improves evidence-based selection of outcome measures for evaluating canine osteoarthritis and other joint disease treatments.

Construction of a Conceptual Framework for Assessment of Health-Related Quality of Life in Dogs With Osteoarthritis

An owner's ability to detect changes in the behavior of a dog afflicted with osteoarthritis (OA) may be a barrier to presentation, clinical diagnosis and initiation of treatment. Management of OA also relies upon an owner's ability to accurately monitor improvement following a trial period of pain relief. The changes in behavior that are associated with the onset and relief of pain from OA can be assessed to determine the dog's health-related quality of life (HRQOL). HRQOL assessments are widely used in human medicine and if developed correctly can be used in the monitoring of disease and in clinical trials. This study followed established guidelines to construct a conceptual framework of indicators of HRQOL in dogs with OA. This generated items that can be used to develop a HRQOL assessment tool specific to dogs with OA. A systematic review was conducted using Web of Science, PubMed and Scopus with search terms related to indicators of HRQOL in dogs with osteoarthritis. Eligibility and quality assessment criteria were applied. Data were extracted from eligible studies using a comprehensive data charting table. Resulting domains and items were assessed at a half-day workshop attended by experts in canine osteoarthritis and quality of life. Domains and their interactions were finalized and a visual representation of the conceptual framework was produced. A total of 1,264 unique articles were generated in the database searches and assessed for inclusion. Of these, 21 progressed to data extraction. After combining synonyms, 47 unique items were categorized across six domains. Review of the six domains by the expert panel resulted in their reduction to four: physical appearance, capability, behavior, and mood. All four categories were deemed to be influenced by pain from osteoarthritis. Capability, mood, and behavior were all hypothesized to impact on each other while physical appearance was impacted by, but did not impact upon, the other domains. The framework has potential application to inform the development of valid and reliable instruments to operationalize measurement of HRQOL in canine OA for use in general veterinary practice to guide OA management decisions and in clinical studies to evaluate treatment outcomes.

Platelet-rich plasma therapy in dogs with bilateral hip osteoarthritis

Background

Osteoarthritis (OA) is the most commonly diagnosed joint disease in companion animals, and hip OA is commonly diagnosed in the canine population. The use of platelet-rich plasma has gained increasing interest for the treatment of musculoskeletal conditions in companion animals. To evaluate the effect of the intra-articular administration of platelet-rich plasma in police working dogs with bilateral hip OA compared to a control group, twenty dogs were assigned to a control group (CG, n = 10) or treatment group (PG, n = 10), using the statistical analysis software. PG received two intra-articular administrations of platelet-rich plasma, 14 days apart, while CG received an intra-articular administration of saline, in the same moments. Response to treatment was determined with the Canine Brief Pain Inventory, Liverpool Osteoarthritis in Dogs, Canine Orthopedic Index, and Hudson Visual Analogue Scale, before treatment, + 8, + 15, + 30, + 60, + 90, + 120, 150, and + 180 days after initial treatment. Kaplan-Meier estimators were conducted and compared with the log-rank test. Cox proportional hazard regression analysis was performed to determine treatment survival, p < 0.05.

Results

The sample comprised 20 animals of both sexes (male n = 12, female n = 8), with a mean age of 8.4 ± 2.4 years and a bodyweight of 31.5 ± 5.7 kg. Joints were classified as moderate (13) and severe (7) according to the Orthopedic Foundation for Animals grading scheme. No differences were found between groups at the initial evaluation. Better results with the majority of scores were observed in the PG, in some cases lasting up to the last evaluation moment. Kaplan-Meier estimators showed that PG produced longer periods with better results in all scores compared to CG. Treatment was the covariate influencing all scores in the Cox regression analysis. OFA hip score also influenced two dimensions of the Canine Orthopedic Index.

Conclusion

The intra-articular administration of platelet-rich plasma can improve pain and functional scores of police working dogs with bilateral hip OA, compared with a control group. Its effects lasted for significantly longer periods, and treatment was the main covariate affecting the improvements observed.

Evaluation of digital thermography imaging to assess and monitor treatment of police working dogs with naturally occurring hip osteoarthritis

BACKGROUND

In dogs, thermal imaging has been documented only recently, but a growing interest in this modality has led to studies using thermography to assess pathologies in the canine hip, stifle, elbow, intervertebral disc, and bone neoplasia. This study aimed to evaluate the use of digital thermography in assessing and evaluating treatment response in dogs with hip osteoarthritis (OA) and comparing its results with an objective measure and two clinical metrology instruments. In an experimental, randomized, double-blinded study, one hundred hip joints of fifty police working dogs with bilateral hip OA were evaluated. A dorsoventral and lateral thermographic image were obtained on days 0, 8, 15, 30, 90, and 180. Mean and maximal temperatures were determined. Additionally, the animal's weight-bearing distribution and radiographic examination of the hip joint (extended legs ventrodorsal view) were performed. Copies of the Canine Brief Pain Inventory (CBPI) and Canine Orthopaedic Index (COI) were obtained. Results were analyzed by ANOVA, followed by an LSD post-hoc test, and correlations were assessed with Spearman correlation coefficient, with p < 0.05.

RESULTS

Values recorded on the lateral view were higher than those on the dorsoventral view. No differences or correlations were found between Orthopedic Foundation for Animals hip grades and temperature. Digital thermographic images showed a weak significant correlation with weight-bearing evaluations (r = 0.13, p < 0.01) and different clinical metrology instruments scores (r = - 0.25, p < 0.01 for pain severity score, and r = - 0.21, p = 0.04 for gait). It also correlated with radiographic findings, specifically the circumferential femoral head osteophyte and caudolateral curvilinear osteophyte.

CONCLUSION

To our knowledge, this is the first study presenting the digital thermography assessment of Police working dogs submitted to treatment for hip OA. Digital thermography, mainly based on a lateral view evaluation, showed a weak significant correlation with stance analysis and clinical metrology instruments scores.

Clinical and diagnostic imaging findings in police working dogs referred for hip osteoarthritis

Background

Osteoarthritis (OA) is the most commonly diagnosed joint disease in veterinary medicine, with at least 80% of the cases of lameness and joint diseases in companion animals being classified as OA. Sporting and working animals are more predisposed to develop OA since they are exposed to chronic fatigue injuries, leading to bone and muscular tissue damage and failure, resulting in clinical signs. To characterize the clinical signs and diagnostic findings of Police working dogs presenting with bilateral hip OA at the time of diagnosis. Fifty animals were evaluated with a bodyweight ≥ 15 kg, be older than two years, and without any medication or nutritional supplements for ≥ 6 weeks.

Results

Weight distribution, joint range of motion at flexion and extension, thigh girth, digital thermography, and radiographic signs were collected. Data from different Clinical Metrology Instruments (CMI) were collected: Canine Brief Pain Inventory, Liverpool Osteoarthritis in Dogs, Canine Orthopedic Index, and the Hudson Visual Analogue Scale. Results were compared by breed, age, sex, and Orthopaedic Foundation for Animals hip grades with the Independent Samples T-Test, ANOVA followed by a Bonferroni post hoc test, and Pearson correlation coefficient, with p < 0.05. The sample included 30 males and 20 females, with a mean age of 6.5 ± 2.4 years and a bodyweight of 26.7 ± 5.2 kg. Animals with weight distribution below normal levels had significant variations of joint extension and function scores. This evaluation was the only not correlated with at least one breed. Animals with caudolateral curvilinear osteophyte showed a poorer clinical presentation and worse scores in all considered CMIs. Radiographic changes correlated with age and corresponded to worse CMIs scores and weight distribution. Dutch Shepherd Dogs showed better CMI scores than the other considered breeds.

Conclusions

Police working dogs presented with complaints related to hip OA at an early stage of the disease. Hip scores influenced clinical presentation, with moderate cases showing lower thigh girth and worse pain interference and severity, and function scores than mild cases. Patients with severe OA had lower thermographic evaluations than patients with moderate OA. Age was the primary variable influencing considered CMI scores.

Long-Term Prognosis of Quality of Life in Dogs Diagnosed With Mild to Moderate Elbow Dysplasia in Sweden

Objective: The objective of this study was to increase knowledge regarding long-term prognosis of mild to moderate elbow dysplasia (ED) using a canine orthopedic index.

Study Design: Cross-sectional observational study.

Sample Population: Sixty dogs randomly selected from each of five different breeds and three ED groups: ED0 (control), ED1, and ED2, based on the Kennel Club's screening results. The total number of selected dogs was 900 (60^*5^*3).

Methods: Questionnaires were administered to owners by telephone interview. Bayesian network modeling was used to assess the relation between ED grade, treatment options, dog demographics, and quality-of-life indicators.

Results: Seven hundred sixty-five questionnaires were collected (85% response rate), of which 61 concerned dogs euthanized due to osteoarthritis. There was no direct association between ED grade and owner's perceived quality of life, but ED1 and ED2 dogs were more likely to receive veterinary care and subsequent NSAID treatment compared to ED0 dogs. A significant association was found between the occurrence of euthanasia due to orthopedic disease and ED scores 1 and 2 in the sample (p < 0.001).

Conclusion: The degree of osteoarthritis was not directly associated with the canine orthopedic index, except for ED2 and lameness score. It can be speculated that owners who paid closer attention to orthopedic symptoms and perceived them as impairing their dogs' lives were also more likely to seek veterinary care and get treatment, irrespective of the ED grading.

Impact: ED1-graded dogs had a lower risk than might be expected to develop visible clinical symptoms and showed a similar quality of life as dogs with ED0. ED2-graded dogs were more likely than ED0-graded dogs to have their lives impaired by lameness, according to the owners' perception.

Measurement of chronic pain in companion animals: Discussions from the Pain in Animals Workshop (PAW) 2017

In the face of increasing recognition and interest in treating chronic pain in companion animals, we struggle with a lack of therapeutic options. A significant barrier to the development of new therapeutics, or the critical evaluation of current therapies, is our inability to accurately measure chronic pain and its impact on companion animals. Over the last 20 years, much progress has been made in developing methods to measure chronic pain via subjective and objective methods - particularly in owner assessment tools and measurements of limb use and activity. Most work has been focused on chronic joint pain conditions, but there has been relatively little work in other areas of chronic pain, such as neuropathic and cancer pain. Although progress has been made, there is a considerable interest in improving our assessment of chronic pain, as evidenced by the multiple disciplines across industry, academia, and clinical practice from the veterinary and human medical fields that participated in the Pain in Animals Workshop held at the National Institutes of Health in 2017. This review is one product of that meeting and summarizes the current state of knowledge surrounding the measurement of chronic pain (musculoskeletal, cancer, neuropathic), and its impact, in cats and dogs.

Adaptation of the Canine Orthopaedic Index to evaluate chronic elbow osteoarthritis in Swedish dogs

BACKGROUND

Owner questionnaires may be used to assess osteoarthritis (OA) in dogs. The validated American College of Veterinary Surgeons' (ACVS) Canine Orthopaedic Index Questionnaire quantifies quality of life in dogs with orthopaedic disease. This index was modified and translated into Swedish and evaluated for validity, reliability and sensitivity. One group with confirmed moderate elbow dysplasia (n = 117) and one healthy control group (n = 146) without radiographic elbow disease and without lameness were included. Telephone interviews with the dog owners were conducted throughout the study using owner-completed questionnaires.

RESULTS

A 16-item questionnaire developed from an initial data set including 22 items, were able to differentiate between the affected group and the control group with good readability. Validity was measured through factor analysis which yielded a three-factor model accounting for 66.3% of the variance. Cronbach's α was 0.89 for the total instrument, > 0.7 for stiffness, lameness and function, but < 0.7 for quality of life. Based on the process the modified questionnaire can be used in Swedish, as the ACVS COI, to make intra-patient comparisons and evaluation of disease progression.

CONCLUSIONS

A sound owner-completed questionnaire translated into Swedish and modified, able to differ healthy dogs from dogs suffering from chronic osteoarthritis is presented. Performed statistical analysis show the items of the instrument to be reasonable and have high construct validity. The questionnaire may be used in the clinical setting and for research.

Survey of Handlers of 158 Police Dogs in New Zealand: Functional Assessment and Canine Orthopedic Index

Objectives: To determine the functional assessment (FA) of fitness and Canine Orthopedic Index (COI) scores of 158 police dogs. The hypothesis was the dogs would have excellent fitness and no evidence of orthopedic disease regardless of age as reported by the handlers. Study Design:Observational, prospective study. Sample Population: Handlers of dogs >1 year of age in active duty or breeding/active duty. Methods: COI and FA questionnaires were completed via e-mail. Fisher's Exact test for count data assessed scores by age group (<2 years, 2-5 years, >5 years); Wilcoxon Signed-rank test correlated COI parameters (stiffness, function, gait, quality of life) to FA. Results: The dogs were 3.2 ± 2.4 (mean ± standard deviation) years-old, 96% were German Shepherds and 111 were male. 32% of dogs could hold the "Hup" position for no longer than 4 s and 8% frequently had difficulty with this task. Difficulty jumping into vehicles occurred in 1/3 of the dogs. Overall FA was impaired in 20% (score >8), abnormal in 15% (score = 5-7), and reduced (score = 1-4) in 36% of dogs. Only 29% had normal function (FA score = 0) and these were significantly younger (2.8 ± 1.7 years, p < 0.05) than impaired dogs (6.6 ± 2.2 years). COI stiffness score was abnormal in 37% (3.3 ± 2.2) and gait was abnormal in 41% (5.4 ± 4.0). Quality of life (QOL) was excellent in 69% of dogs. Stiffness for the <2 year-old group was 0.2 ± 0.8, for the 2-5 year-old group was 1.1 ± 2.0 and for the >5 year-old group was 3.2 ± 2.4. Gait score for the <2 year group was 0.8 ± 2.2, and for the 2-5 year group was 1.9 ± 3.2 and for the >5 year group was 6.0 ± 4.3. Quality of life was close to excellent for the <2 year-olds (0.3 ± 1.1) and 2-5 year-olds (0.8 ± 2.0) but the >5 year-olds scored higher (3.0 ± 2.5). Only the COI gait score correlated with the FA score (p = 0.30). Conclusions and Clinical Relevance: Police dogs were reported by handlers to have good to excellent QOL, however, increasing age was associated with declining FA and COI scores.

Initial psychometric testing and validation of the French version of the Canine Brief Pain Inventory

OBJECTIVE

The Canine Brief Pain Inventory (CBPI) is an owner-completed questionnaire quantifying the severity and impact of chronic pain in dogs. The English version of the CBPI was adapted into French and the objective of this study was to validate this French version of the CBPI.

STUDY DESIGN

Prospective clinical study.

ANIMALS

A group of 32 dogs with a medical history, clinical signs and radiographic evidence consistent with osteoarthritis.

METHODS

Owners of dogs with osteoarthritis who were native French speakers completed a single administration of the translated questionnaire. The psychometric properties were evaluated including construct validity (by factor analysis), reliability (internal consistency) and convergent validity.

RESULTS

Factor analysis on the responses from this cohort confirmed a two-factor questionnaire: the Pain Severity (PS) factor and the Pain Interference (PI) factor. The mean inter-item correlation for PS and PI questions was 0.74 and 0.53, respectively. These findings reveal strong internal consistency, suggesting that the questions contained within each factor measure the same concept and can be pooled to generate the PS score (PSS) and PI score (PIS). Cronbach's α was 0.91 and 0.87 for PSS and PIS, respectively. There was strong negative correlation between PSS and PIS with the overall quality of life score (r = -0.62 and r = -0.79, respectively, with p < 0.001 for both), consistent with the hypothesis that increases in PS and PS with function are highly correlated with a corresponding decrease in overall quality of life.

CONCLUSIONS AND CLINICAL RELEVANCE

Initial validation of this French version of the CBPI represents an important step in the expanded use of validated owner-completed outcome assessment instruments for use by researchers and clinicians who seek reliable methods to quantify the severity and impact of chronic pain in dogs with osteoarthritis.

Development and psychometric testing of the Canine Owner-Reported Quality of Life questionnaire, an instrument designed to measure quality of life in dogs with cancer

OBJECTIVE To describe development and initial psychometric testing of an owner-reported questionnaire designed to standardize measurement of general quality of life (QOL) in dogs with cancer. DESIGN Key-informant interviews, questionnaire development, and field trial. SAMPLE Owners of 25 dogs with cancer for item development and pretesting and owners of 90 dogs with cancer for reliability and validity testing. PROCEDURES Standard methods for development and testing of questionnaire instruments intended to measure subjective states were used. Items were generated, selected, scaled, and pretested for content, meaning, and readability. Response items were evaluated with exploratory factor analysis and by assessing internal consistency (Cronbach α) and convergence with global QOL as determined with a visual analog scale. Preliminary tests of stability and responsiveness were performed. RESULTS The final questionnaire-which was named the Canine Owner-Reported Quality of Life (CORQ) questionnaire-contained 17 items related to observable behaviors commonly used by owners to evaluate QOL in their dogs. Several items pertaining to physical symptoms performed poorly and were omitted. The 17 items were assigned to 4 factors-vitality, companionship, pain, and mobility-on the basis of the items they contained. The CORQ questionnaire and its factors had high internal consistency (Cronbach α = 0.68 to 0.90) and moderate to strong correlations (r = 0.49 to 0.71) with global QOL as measured on a visual analog scale. Preliminary testing indicated good test-retest reliability and responsiveness to improvements in overall QOL. CONCLUSIONS AND CLINICAL RELEVANCE The CORQ questionnaire was a valid, reliable owner-reported questionnaire that measured general QOL in dogs with cancer and showed promise as a clinical trial outcome measure for quantifying changes in individual dog QOL occurring in response to cancer treatment and progression.

Evidence-Based Veterinary Medicine: A Tool for Evaluating the Healing Process After Surgical Treatment for Cranial Cruciate Ligament Rupture in Dogs

This study aims to validate a tool, the Bologna healing stifle injury index (BHSII), for the evaluation of the clinical picture and the healing after surgical treatment for cranial cruciate ligament (CCL) rupture. The study included 158 client-owned dogs with CCL rupture and 20 healthy dogs. The BHSII is a questionnaire made up of 34 multiple-choice questions, divided into a part directed to the clinician and a part for the dog's owners. It was applied twice in the healthy dogs in order to test and retest the device. It was evaluated for reliability, validity, and responsiveness to clinical changes involving the dogs treated at the time of surgery, and 1, 3, and 6 months postoperatively. Statistical analyses were performed and the intraclass correlation coefficient test was ≥0.9 and the Cronbach-α was 0.84 suggesting good stability and good internal consistency of the tool. The area under the curve of the receiver operating characteristic curve was >0.9, indicative of the high accuracy of this tool. The clinician survey correlated with the owner questionnaire. In dogs with CCL rupture, the scores of the BHSII increased significantly postoperatively as compared with baseline. In conclusion, this clinical study proved the reliability, validity, and responsiveness of the BHSII. The results achieved from the BHSII provided an instantaneous, collective complete vision of the healing process of the stifle joints treated. It can be considered a valid tool for collecting data and for assessing successful surgical treatment in clinical practice.

Influence of class IV laser therapy on the outcomes of tibial plateau leveling osteotomy in dogs

OBJECTIVE

To determine the effects of low-level laser therapy (LLLT) on clinical outcomes in dogs with cranial cruciate ligament disease treated with tibial plateau leveling osteotomy (TPLO).

STUDY DESIGN

Randomized, placebo-controlled clinical trial. Owners and surgeons (care providers and assessors) were masked.

ANIMALS

Ninety-five dogs were admitted for TPLO and assigned to 1 of 2 groups, laser group (LG; n = 51) or placebo group (PG; n = 44).

METHODS

Three treatments (laser or placebo) were administered within a 4-day perioperative period. A fourth treatment was recommended and was accepted in 28.4% of cases (LG, n = 14; PG, n = 13). Dogs in the LG group received laser at wavelengths 660 nm red (100 mW) and at 800, 905 and 970 nm infrared (maximum 15 W continuous wave, 20 W peak pulsed wave), administered simultaneously. Dogs in the PG group received placebo laser (660 nm, 4 mW). Other treatments were identical. Outcomes were measured by difference in clinical metrology instruments (Liverpool Osteoarthritis in Dogs and adjusted Canine Orthopedic Index [COI]), osteotomy healing on a radiographic scale, time to cessation of nonsteroidal anti-inflammatory drug administration, and wound healing by owner questionnaire.

RESULTS

The only difference detected between groups consisted of a greater improvement in the gait section of the adjusted COI (ACOI) in the LG group (median [interquartile range; IQR] = 6 [4-7.5]) compared with the PG group (median [IQR] = 4 [2-6]; P < .05).

CONCLUSION

The laser protocol used in this study was associated with a greater improvement in ACOI gait in dogs treated with TPLO but did not improve any other clinical metrology instrument scores or bone healing.

CLINICAL SIGNIFICANCE

This study provides some evidence that LLLT may improve the gait of dogs recovering from a TPLO, as assessed by owners.

Measuring pain in dogs and cats using structured behavioural observation

The contemporary approach to pain measurement in people and animals seeks to measure the affective (emotional) component of the pain experience using structured questionnaires with formal scoring methodology. Chronic pain has wide-ranging impacts which affects the quality of life (QOL) of the individual, whether that is a person or an animal. Accordingly instruments to measure chronic pain are designed to measure its impact on QOL and are called health-related quality of life (HRQL) instruments. In veterinary science instruments to measure pain are based on behavioural observation by the veterinary surgeon/nurse in the case of acute pain and by the owner in the case of chronic pain. The development of HRQL instruments is an expanding field in veterinary science, not just for the measurement of pain, but for other chronic diseases, and it has a wide application in pharmaceutical research and clinical practice to improve patient care. This review highlights the challenges involved in creating such measures for dogs and cats, seeking to provide the reader with an understanding of their development process. It then provides an overview of the current status with regard to acute and chronic pain measurement.

Systematic Review of Outcome Measures Reported in Clinical Canine Osteoarthritis Research

Objective

To record and categorize the outcome measures used in dogs with naturally occurring osteoarthritis (OA) by systematically reviewing the peer reviewed publications on OA in dogs.

Study Design

Systematic literature review.

Study Population

Peer reviewed literature on canine OA.

Methods

A computer‐based bibliographic search was performed on PubMed and CAB Abstracts in August 2013 to find peer reviewed publications relevant to canine OA. Inclusion and exclusion criteria were applied. The outcome measures reported within each publication were recorded and categorized for comparison. Adequately described outcome measures were assessed for uniqueness and evidence of prior validation.

Results

Of 3,697 publications identified and screened, 117 were deemed eligible for inclusion. Within eligible publications, outcome measures were used 618 times (median of 4 outcome measures per publication). Outcomes measured were divided into 5 groups containing 65 categories. The most frequently assessed outcomes were lameness assessment with no stated gait/mixed gaits (66 outcomes), radiography (58), and lameness single gait/lateral motion (55). Of 618 outcome measures reported, 491 were assessed for uniqueness and 348 (71%) were unique to a single publication. Ten outcome measures were reported to have been validated.

Conclusion

Many outcome measures have been used to assess canine OA. There is no consensus on which are the most useful outcomes or by which method they should be assessed. There is a pressing need for agreement on outcomes reporting in canine OA and for validation of outcome measures used for these assessments. Until consensus is reached, we recommend at least one validated outcome measure be used in every clinical study.

A prospective, randomized, double blind, placebo-controlled evaluation of the effects of eicosapentaenoic acid and docosahexaenoic acid on the clinical signs and erythrocyte membrane polyunsaturated fatty acid concentrations in dogs with osteoarthritis

BACKGROUND

Osteoarthritis (OA) in dogs is a prevalent and serious condition. The most common treatment for the clinical signs of OA in dogs is the administration of nonsteroidal antiiflammatory pharmaceuticals. Omega-3 (n-3) fatty acids have been shown to reduce the clinical signs of osteoarthritis in dogs.

OBJECTIVE

The primary goals of this study were 1) to determine the effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) on the clinical signs of OA in dogs, 2) to evaluate the effects of supplementation on the arachadonic acid (ARA)/ (EPA+DHA) algorithm and 3) to correlate alterations in the ARA/(EPA+DHA) with changes in the clinical signs of canine OA.

METHODS

Seventy-eight client owned dogs were enrolled in a prospective, randomized, double-blind, placebo controlled clinical trial. Dogs were randomized to placebo oil or triglyceride n-3 oil (providing an average dose of 69mg EPA+DHA/kg/day). Orthopedic examinations and blood analyses were performed at baseline, day 42, and day 84. A single investigator confirmed a diagnosis of OA of the coxofemoral joints and/or stifle joints in all dogs.

RESULTS

Seventy-four dogs completed the trial. All clinical outcomes for measuring discomfort, lameness, and joint severity at day 84 and all blood metrics at day 42 and day 84 significantly (p<0.05) improved compared with placebo. No major side effects were observed.

CONCLUSION AND CLINICAL RELEVANCE

This study demonstrated that the daily supplementation of a dogs diet with EPA and DHA shifts the blood fatty acid concentrations correlating to relief of clinical signs associated with OA in dogs.

The Canine Orthopedic Index. Step 3: Responsiveness testing

OBJECTIVE

To determine whether the Canine Orthopedic Index (COI) can detect changes in dogs with osteoarthritis (OA) treated with either non-steroidal anti-inflammatory drugs (NSAID) or placebo.

STUDY DESIGN

Double blind randomized placebo controlled trial.

ANIMALS

Dogs (n = 80) with OA.

METHODS

Owners completed the COI on Day 0. Dogs were administered either carprofen or placebo on days 1 through 14. Owners completed the COI again on Day 14. The change in total instrument, stiffness, gait, function, and quality of life scores were assessed between groups.

RESULTS

Dogs administered carprofen had significant decreases in the total instrument score (P = .002) as well as 3 of the 4 factor scores compared to dogs treated with placebo (stiffness score P = .015; gait score P = .001; and function score = 0.008). The change in quality of life score was not significantly different between carprofen and placebo treated dogs (P = .124).

CONCLUSIONS

The COI delivered the decreases in total instrument, stiffness, gait, and function scores that one would expect in dogs with OA treated with an NSAID compared with placebo administration. In this cohort of dogs, the quality of life score was not sensitive to the changes associated with NSAID administration.

The Canine Orthopedic Index. Step 2: Psychometric testing

OBJECTIVE

To perform psychometric testing an owner self-administered questionnaire, the Canine Orthopedic Index (COI), designed to assess outcome in dogs with orthopedic disease.

STUDY DESIGN

Original study.

SAMPLE POPULATION

Owners (n = 20) of dogs with osteoarthritis (OA) for item (question) pretesting, and 80 owners of dogs with OA for reliability and validity testing.

METHODS

Standard methodology for the stepwise development and testing of instruments designed to assess subjective states was followed. Items generated in previous studies were pretested for readability, ambiguity, and inter-item correlations; poorly performing items were removed; and the reduced set of items subjected to factor analysis, reliability, and validity testing.

RESULTS

Four factors were identified and named on the basis of the items contained in them: "Stiffness," "Gait," "Function," and "Quality of Life." Cronbach's α ranged from 0.76 to 0.86, suggesting the items in each factor could be assessed as a group to compute factor scores (i.e., stiffness, gait, function, and quality of life scores). The test-retest analysis revealed κ values from 0.68 to 0.80. Overall, the scores amongst the 4 factors correlated moderately well (r = 0.52-0.58), with a mild correlation (r = 0.35) between gait and function scores.

CONCLUSIONS

The COI is a psychometrically sound owner completed instrument that can assess 4 domains in dogs with OA: Stiffness, Gait, Function, and Quality of Life.