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Canine rehabilitation: Getting orthopedic patients back on their feet
Cranial cruciate ligament tears and ruptures are common conditions that can lead to debilitating osteoarthritis. Consider a veterinary team approach to canine rehabilitation to improve every patient's quality of life.
Orthopedic surgery and physical rehabilitation are fast growing fields in veterinary medicine, with more specialty practices popping up in every city. As a technician, you play an important role in owner education when it comes to discussing orthopedic diseases, postoperative care, medical management, and necessary physical rehabilitation.
One of the most common orthopedic diseases is a cranial cruciate ligament (CCL) tear or rupture. This condition can cause patients extreme pain. If left untreated, it can cause meniscal tears and, in some cases, severe and sometimes debilitating osteoarthritis. Treatment options include medical management, physical rehabilitation, surgery, or a combination of all three options.
Even if your clients are going to specialty practices for surgical intervention or physical rehabilitation, knowing the basics of what they're going through will help build owner confidence in you and your practice. Registered technicians or properly trained assistants can also perform many aspects of physical rehabilitation to increase their skills and grow the practice.
CCL ruptures and tears
Being familiar with the anatomy of the stifle joint will make it easier to understand what happens to the body after a CCL tear, so let's briefly review the ligaments. The joint is stabilized by the medial and lateral collateral ligaments and the cranial and caudal cruciate ligaments. The collateral ligaments limit the varus and valgus (side-to-side) movement of the stifle. The cruciate ligaments prevent cranial and caudal drawer motion, hyperextension, and internal rotation, and they also help limit varus and valgus motion. Although it's possible to injure any of these ligaments, CCL injury is most common.
Additional important structures within the stifle joint are the menisci, which are two C-shaped fibrocartilaginous structures in the joint that act as a cushion between the femoral condyles and the tibial plateau. This cushion helps protect the cartilage during weight-loading activity and helps absorb some of the shock from high-impact or concussive activity. The menisci also help stabilize the femoral condyles on the tibial plateau.
An easier way to understand the role of the CCL is to learn how it stabilizes the knee during weight-loading activity. It keeps the round femoral condyles from slipping caudally on the tibial plateau—think of a bowling ball on a hill—which would then push the tibia cranially, otherwise known as tibial thrust. So a positive tibial thrust and cranial drawer sign are good indications of a cruciate tear or rupture. That, in combination with palpation for a medial buttress (fibrous tissue accumulated on the medial aspect of the proximal tibia in most chronic cases), gait analysis, and confirmation of joint effusion via radiographs will help confirm the diagnosis.
In some cases, the patient may also have a meniscal tear. Although this cannot be confirmed until the surgeon looks into the joint, an audible popping sound or click within the stifle during manipulation can occur. These patients tend to be more painful than patients with a cruciate tear without a torn meniscus.
In human anatomy, the CCL is called the anterior cruciate ligament (ACL). People often traumatically injure the ACL playing sports, but in dogs the CCL injury occurs from a slow, degenerative breakdown of the ligament. Dogs stand at a much steeper tibial plateau angle, placing more responsibility and workload on the cruciate ligament. So surgical repair for canine patients is drastically different from surgery in humans.
Although some primary care veterinarians perform surgical correction, orthopedic surgery is complex, so many patients are referred to a veterinary surgeon at a specialty clinic. Surgical options for stabilizing a stifle with a CCL tear include tibial plateau leveling osteotomy (TPLO), extracapsular imbrication (ECI), tibial tuberosity advancement (TTA), or a tight rope (TR).
Not every dog will be a candidate for every surgery, and depending on the surgeon's preference, he or she may recommend one surgery over the other. No current studies show that one surgical technique is better than another for all patients. However, the surgeon will be able to recommend the best option for the patient based on size, activity level, and owner lifestyle.
Some pet owners may opt for nonsurgical management of their dogs' CCL tears. Although this is not the most ideal recommendation for canine patients, it's still an option. However, it's important to discuss realistic goals at length with the owner. These patients may never recover to the same capacity as those that have had surgery, and osteoarthritis within the joint is more likely to progress at an increased rate than it would in patients that have surgery. There is also about a 36 percent chance of a meniscal tear without surgery.1
Nonsurgical management of a CCL tear typically consists of exercise restriction, physical rehabilitation, nonsteroidal anti-inflammatory drugs (NSAIDs), and chondroprotectives. Nonsurgical options may be chosen because a patient is an anesthetic risk or suffers from an infection or other metabolic illness that could delay or prevent healing. Owners may also have financial concerns.
Whether the client opts for surgical intervention or not, the patient's stifle will never be normal. The goal with surgery is to get patients as close to 100 percent function as possible, but, with or without surgery, osteoarthritis is inevitable.
Osteoarthritis, otherwise called degenerative joint disease (DJD) in dogs, is typically secondary to a primary condition. Radiographic signs of osteoarthritis indicate the joint has reacted to an acute or chronic event, such as a ligament tear or strain, infection, or other disease process. Osteoarthritis in dogs typically begins more rapidly than in humans. Some dogs may begin to show signs of osteoarthritis as early as just days after injury, depending on the injury.
Managing osteoarthritis in dogs is similar to nonsurgical management of a CCL injury. Physical rehabilitation, NSAIDs, chondroprotectives, weight loss, and lifestyle changes all help when managing an arthritic patient, no matter its age. It's important to know that every patient will respond differently to treatment and that there is not always a correlation between clinical function and severity of radiographic signs.
Radiographs give us insight into the progression of the disease and allow us to more easily explain to clients why their dogs may be lame in the morning or after rough play. But, just as in humans, there is no cure for osteoarthritis in dogs, and the goal of treatment is to slow the process down and alleviate the patient's pain.
It's also important to recognize that too little activity is just as bad for osteoarthritis as too much. Put this in perspective for clients with simple framing, such as, "Do you know how you feel when you lie in the same position for too long and feel stiff? The same thing is happening to your pet." Most people have experienced a twist, a sprain, or a break, and explaining that similar processes are happening to their dogs—only at a much quicker rate—will help them understand the importance of keeping their dogs lean and paying attention to their pets' exercise routines.
Physical rehabilitation is a specialty with both veterinary professionals and human physical therapists working toward the overall improved care of pets, working or sporting dogs, and our feline and equine patients.
Some of the different modalities for treatment include therapeutic ultrasound, cold or low-level laser therapy, electrical stimulation, therapeutic exercises such as wobble boards, massage, and the underwater and land treadmills (Figures 1-5). Not every rehabilitation facility or veterinary hospital is going to offer all of the different modalities and equipment on the market. The most important piece of equipment is a pair of experienced hands. Then you let your ingenuity take over. (See "Physical rehabilitation at your hospital".)
Figure 1. Cody, a patient with femoral head and neck excision, undergoes low-level laser therapy. This modality can be used on nearly every condition, from wound healing to osteoarthritis.
Since you cannot talk to your canine patients and politely ask them to put their legs on the ground or to stand with one leg in the air, you have to learn how to do it for them and engage their muscles and even their minds. Dogs want to do what's easy. And sometimes what's easy is running on three legs, hopping up the stairs, or keeping their head down low when walking. All of these issues can have some simple corrections that will make a huge difference in their recovery and overall daily living. It can be challenging to change the way a patient walks after they've been doing it for 10 years—or even just eight weeks after recovering from surgery—but the difference can benefit them for the remainder of their lives.
Figure 2. A gel pack can be used for heating and icing. To demonstrate the therapy in the photo above, there is no barrier used between the skin and pack.
And remember, you are not just changing how the patient moves, you are also asking owners to change their day-to-day routines. You must keep that in mind when discussing any changes back at the pet's home. For example, some owners may have never had their dogs on a leash, let alone taken them for walks. So asking them to spend time two to three times a day walking them may be difficult in the beginning.
Figure 3. A wobble board helps strengthen core muscles by working on balance and helps improve the ability to shift weight to different limbs.
The rehabilitation practitioner will perform a complete orthopedic evaluation, gait analysis, and neurologic examination as the first step in assessing a patient. Then, with that information and a history and lifestyle discussion with the owner, the practitioner can determine the best plan for that patient. A Certified Canine Rehabilitation Practitioner (CCRP) will also offer home exercise plans and nutritional counseling.
Figure 4. Bear undergoes passive range-of-motion therapy.
How you can get involved in rehabilitation
Physical rehabilitation is a fast-growing field that within the past 20 years has really made a breakthrough into the specialty world. This has been great news for technicians. It's a new role where you can grow your skills, improve your career, and help your patients.
Figure 5. Bear undergoes passive range-of-motion therapy.
Two certification programs are now available for registered veterinary technicians. The University of Tennessee offers a CCRP program that is open to veterinarians, technicians, physical therapists, and physical therapist assistants. Many patients will benefit from seeing a CCRP. This certification requires extensive training and knowledge on all the various conditions, injuries, and diseases that would require physical rehabilitation.
The Canine Rehabilitation Institute (CRI) in Wellington, Fla., offers a CCRT for veterinarians and physical therapists and CCRA program for technicians and physical therapist assistants. For technicians to participate in the CRI program, they must have a veterinarian at their practice who has been certified through the program or is going through the program at the same time.
How much rehabilitation is necessary? There is no cookie-cutter protocol for any condition. Although there may be similarities in how a patient with an acute CCL tear is rehabilitated compared with a patient with chronic osteoarthritis, each patient and owner needs an individualized plan. Many variables, including the owner's schedule and financial means and the patient's degree of lameness, come into play when deciding on a pet's home exercise program, in-house or at-home therapy, and which modalities would be the best fit for the condition.
Cruciate disease is one of the most common orthopedic conditions we see in veterinary medicine. There are multiple treatment options for a dog with this injury, both surgical and nonsurgical.
Osteoarthritis is inevitable, and there is no cure, but with the guidance of a veterinary professional and the proper use of physical rehabilitation, clients should be able to help their pets live high-quality lives.
Physical rehabilitation should be part of every postsurgical patient's home care. It should be a staple in your day-to-day veterinary operations, even if you don't have a rehabilitation facility in your clinic.
Just remember that there are certified rehabilitation practitioners located in nearly every state who are ready and willing to help. A multi-team-member approach is not only great for your patients—it helps build a strong veterinary community.
Jodi Beetem, RVT, CCRP, helped launch the small animal rehabilitation program at University of Missouri Veterinary Teaching Hospital. In 2010, she joined Atlanta Animal Rehabilitation and Fitness and Veterinary Referral Surgical Practice.