Crate expectations: Realistic strategies for postoperative confinement
When your veterinary patient requires crate rest to heal from surgery or injury, make sure to educate owners about the challengesand be ready with strategies to make the process manageable for both pet and people.
Parilov/stock.adobe.comMandatory crate rest is a critical component of recovery for patients with orthopedic conditions such as intervertebral disc disease or who have undergone surgery. However, several weeks to months of strict confinement can quickly become frustrating for pets and daunting for their owners.
Melissa Bain, DVM, DACVB, MS, DACAW, recently described a variety of strategies to assist patients through the stress of strict confinement. Dr. Bain serves as professor of clinical animal behavior at the University of California, Davis, School of Veterinary Medicine, where she regularly encounters behavioral issues that arise during mandatory rest.
While Dr. Bain focuses here primarily on canine surgical patients, many of her concepts apply to other species and long-term medical conditions, such as arthritis and neurologic dysfunction, she says.
Confining the ‘out-of-control' patient
Patients are exposed to a variety of potential stressors during hospitalization, including pain, illness, separation from their owner, and the unpredictable clinic environment. Many patients return home with great relief, only to quickly become bored due to their strict confinement.
Dr. Bain describes the case of a 2-year-old Labrador retriever mix that has undergone surgical repair of a ruptured cranial cruciate ligament. The otherwise healthy dog primarily lives outdoors-her owners admit that she is destructive in the house. While friendly, the dog has never undergone leash, crate or general obedience training and receives no exercise other than free roam of the yard.
After a six-week period of mandated crate rest, the dog returns to the clinic for a follow-up examination. At this point the owners are frustrated and angry that the dog is not healed despite the financial burden of surgery. Furthermore, they say the crate training has been a failure because their dog “can't be confined.”
Dr. Bain uses this example to highlight several common mistakes. “Whose fault is it that this the dog is not better?” she asks. In fact, the owner and veterinarian share responsibility for treatment failure, Dr. Bain says; the veterinarian has a duty to discuss the reality of difficult treatments with the owner and to gauge whether the owner is willing to comply with recommendations.
Begin preventive training early
Dr. Bain urges veterinarians to utilize a combination of prevention, behavior management and medication to address potential complications associated with confinement. She explains that the best candidates for crate rest are preventively trained for handling and restraint before treatment is even needed. Although not always realistic, she urges all her clients to incorporate positive reinforcement training into the pet's regular routine.
Training should begin when pets are first acquired and should include crate training, medication administration and quiet leash walking, as well as the acceptance of handling and restraint. She discusses with clients any underlying behavioral issues that can potentially cause injury, such as aggression and foreign body ingestion, so that behavior modification can be used to minimize risk.
Effective client education
What should you do when a poor candidate for confinement needs surgery? Dr. Bain says recovery procedures should be clearly discussed with the client before surgery occurs, as some clients are reluctant to comply with confinement and may prefer alternative treatment. At this time, determine whether the pet is crate-trained and has any underlying issues that may complicate crate rest, such as separation anxiety.
Then, work closely with the client to devise an individualized recovery plan. “Focusing on the overall goals [of confinement] will be less stressful for owners,” Dr. Bain says, adding that clients tend to be more optimistic when the veterinarian emphasizes permitted activities rather than restrictions. Provide several forms of communication, including handouts (find one here) and follow-up conversations, and ensure that all members of the veterinary team-including doctors, technicians and receptionists-deliver the same information.
Physical activity and environmental stimulation are invariably limited during crate confinement; therefore, mental enrichment should be increased to fend off boredom and destructive activities. Dr. Bain advocates providing all meals and treats in enrichment devices and adding stationary or tethered toys to the crate.
All time spent outside the crate should be closely supervised. If allowable, she recommends that owners attach a 1-foot lead from their wrist or waist to the dog's collar and limiting interaction to the floor rather than sitting on furniture. Many dogs thrive by learning new behaviors during this time, such as hand targeting or handshakes, while others enjoy going for “walks” in a stroller or bicycle carrier. For patients averse to wearing a hard Elizabethan collar, commercial and homemade alternatives, such as a cloth cone or duct-taped towel around the neck, may be more comfortable if appropriate to the case.
Once recovery is adequate to resume mild activity, it's crucial to keep the pet calm to prevent reinjury. Dr. Bain recommends that clients add barriers (such as baby gates) and use rugs or rubber toenail covers to increase traction on slippery floors. She urges use of either a front-attach harness or head collar on walks and keeping pets tethered to the owner or a piece of furniture under supervision. Mental enrichment is still important during this period; this can include stationary behaviors-such as down stay, tracking and hand targeting-as well as tethered food toys.
Dr. Bain recommends discussing litter box management with cat owners, as elimination can be difficult and painful for confined or geriatric cats. Address the availability of litter boxes, pee pads and other opportunities for elimination, as well as the importance of keeping food and elimination areas separate. If conventional clay litter cannot be used, clumping or pelleted paper litter (such as PaPurr) tends to be accepted more readily than shredded newspaper. Clients can also choose supervised litter box access throughout the day.
Medication is likely necessary for dogs that cannot be crated safely due to anxiety or pain. A veterinarian for 25 years, Dr. Bain admits that her early mentors taught that a certain amount of pain was acceptable to keep recovering patients quiet, but she warns that this mentality is outdated and that pets deserve effective pain management throughout the postoperative period.
Dr. Bain advises hiding even regularly administered medications, such as heartworm preventives, in tasty treats to get pets excited about receiving them. Her clients have had success hiding pills in bits of chicken, cheese or butter; marshmallows are usually a safe option for allergic pets. She also advises owners to switch up medication routines often, as some pets pick up on owner habits and locations of stored medications.
“Know why you're medicating the patient,” Dr. Bain states. “Is it for the benefit of the pet, the owner or both?” She explains that some owners are more compliant with crate rest if the pet is quieter and less anxious.
Short-term medications. Quick-acting anxiolytic medications are best for animals that need to be crated on short-term notice. Although many options are available, effectiveness varies among medications and finding the right one may require trial and error, Dr. Bain says. Short-term options include gabapentin, trazodone, clonidine, benzodiazepines, nutraceuticals and synthetic pheromones.
Trazodone, a serotonin antagonist/reuptake inhibitor, is an antidepressant commonly used to reduce anxiety and phobias. One study evaluating postoperative use of this drug in dogs after orthopedic surgery found it was well-tolerated and had anxiolytic effects, although it did cause some sedation.1 Other common drugs for short-term use include clonidine, a central alpha-2 agonist, and gabapentin, which is effective in dogs and cats for pain management as well as anxiety. While benzodiazepine drugs offer potent anti-anxiety effects, they also often cause increased appetite and sedation, which may be desirable for certain patients. However, benzodiazepines can cause paradoxical excitation and should be used with caution in cats due to potential hepatotoxic effects.
Dr. Bain says there's limited evidence that nutraceuticals and synthetic pheromones offer potent anti-anxiety effects on their own, but they may be useful when added to other therapies. Examples used for their calming effects in pets include Solliquin (Nutramax), Anxitane (Virbac), Adaptil (Ceva Animal Health) and Feliway (Ceva Animal Health).
Long-term medications. Long-onset drugs are not appropriate for immediate postoperative use, as they take four to six weeks for full effect; however, they are effective for other behavioral issues. Dr. Bain advises against the use of acepromazine, as it causes sedation rather than reduced anxiety and has several side effects associated with long-term use. She also mentions that tramadol, which is commonly used for postoperative pain, should be used with extreme caution as it adversely reacts with several drugs (including SAMe, tricyclic antidepressants and selective serotonin reuptake inhibitors) and can cause serotonin toxicity.
Crate rest is an overwhelming prospect for many owners, particularly those with high-energy or anxious pets. However, patients needing strict confinement can be successfully managed with a combination of preventive training, behavior management and anti-anxiety medication.
1. Gruen ME, Roe SC, Griffith E, et al. The use of trazodone to facilitate post-surgical confinement in dogs. J Am Vet Med Assoc 2014;245(3):296-301.
Dr. Natalie Stilwell provides freelance medical writing services through Seastar Communications and Consulting. This article was created from a lecture given by Dr. Melissa Bain at the 2018 New York State Spring Veterinary Conference.