Get on top of rehab in your veterinary clinic

January 14, 2019
Carla Johnson, DVM
Carla Johnson, DVM

Carla Johnson, DVM, practices emergency medicine at Berkeley Dog and Cat Hospital in Berkeley, California, and general practice at Cameron Veterinary Hospital in Sunnyvale, California. Her nonveterinary loves are writing, Dressage with her Iberian warmblood mare, Synergy; watercolor painting on yupo; vinyasa yoga; and running with her dog Tyson. Try as she might, her curly-coated Scottish Fold, Hootie, refuses to go jogging with her.

Why your practice can and should offer physical therapy and rehabilitation services.

"No more joking about rehab, and I mean it!" ... "Anybody want a peanut?" (Martin Schlecht / stock.adobe.stock.com)

The belief that we general-practice veterinarians need to refer away our orthopedically challenged patients to another facility for physical rehabilitation is an error of mindset. As we follow our patients faithfully from puppyhood (or even kittenhood) to old age, they almost all face injury, arthritis, surgery or even neurological problems at some point.

A shifting balance in your clients

Our clients are phasing into a new generation of convenience-focused, one-stop shoppers who appreciate and expect results. They will follow your recommendations if they can understand why they should do them and, even more so, if they can actually see or measure the results. These clients would also rather not have to make a special trip to yet another facility to give their pets the best care. But make no mistake-they do want the best quality care.

Sure, we know they would each benefit from a comprehensive pain and mobility management program. Most of us are very comfortable handling the pain management aspect of this, maybe even recommending the use of supplements and nutritional support. But when it comes to physical rehabilitation, we send our patients away.

Well, we don't have to. It's actually relatively easy to set up this service in our own practices and stop farming these patients out.

At the 2018 Fetch dvm360 conference in San Diego, Jennifer Johnson, VMD, CVPP, discussed how to set your practice up to provide this type of care for your clients-without too much hassle-and how to expand it into a more high-tech program if you like how it works out. “There are two primary areas where a general practice can employ basic rehabilitation services,” she says. “Postsurgical care and chronic, nonsurgical arthritis.”

In addition to proactive pain management consisting of medications, nutraceuticals, supplements, therapeutic diets and weight management counseling, you'll need to provide a program to improve mobility and coordination and to build or preserve muscle mass. One of the big mistakes we make with our painful or postsurgical animals is to let them rest and not get their muscles moving.1 Dr. Johnson says the muscles atrophy rapidly, as quickly as 12% per week in people, causing more weakness and, thus, more pain. After many common orthopedic surgeries, including tibial plateau leveling osteotomy (TPLO), physical rehabilitation for mobility and preserving muscle mass should start two weeks after surgery, or even earlier.2

To treat the postsurgical and chronic arthritic patients in your general practice, Dr. Johnson suggests starting with a dedicated technician or two. Invest in a bit of extra training for them (either outsourced or at your direction) and a few tools for therapy (see “Where to find out more”). You'll need a goniometer (and maybe a stance analyzer), some slings and a peanut ball, a soft measuring tape to assess muscle mass, some exercise plans, and a way to video record your patients for gait improvements during serial orthopedic exams. Don't forget to charge by the hour for the technician time, she adds.

Maneuvers for the postops

For postoperative care, Dr. Johnson says to start with conservative icing or cooling and then progress to passive range of motion (PROM) exercises, light massage and simple weight-bearing and postural exercises. In-hospital PROM exercises and massage should be performed and demonstrated by your technicians so that clients can continue this at home. In a few weeks you can move into the mobility exercises for chronic arthritic patients (see below). Consult with the orthopedic surgeon regarding any exceptional circumstances. Set up a basic plan for each patient and condition and modify it, if needed, to the patient and as you improve your rehabilitation program.

Measures for the arthritically challenged

For your chronic arthritic or neurologically challenged dogs and cats, Dr. Johnson says to start with client education and develop an exercise and lifestyle plan, then modify the plan based on patient progress and client feedback. Dogs with mobility issues of any kind should have regular low-impact exercise and not the typical “weekend warrior” approach involving infrequent, longer high-impact sessions that do more harm than good. With cats, Dr. Johnson recommends starting with lifestyle changes that increase activity but decrease or prevent high-impact jumping and landing.

Primarily for dogs, have your technicians teach owners how to do PROM and then low-impact exercises and postural tasks such as making them stand equally on all fours, shifting weight from leg to leg, stepping up and down a curb, figure-eight walking, walking in circles, and walking hills. “Combining exercise, balance, massage, stretching, PROM and client education will provide significant improvement in outcome, with only a little effort,” says Dr. Johnson.

‘Is it working?'

Use factual data to temper client feedback and to decide whether rehab is working and how well, Dr. Johnson advises. Clients love proof of results, so don't forget this part! Goniometry is the simple measurement of the angle of a joint, and there's even an app for this. Have your technician measure and record flexion and extension of affected joints each visit with a goniometer to document improvement. Measuring the larger muscles (such as thigh girth) with a soft measuring tape at each visit will track your progress. Recording a gait video at each visit of the walk and trot will further document improvement in mobility.

Your designated rehab technicians should consult with you about progress and plan changes, but as they get more practiced and involved, they'll often be more capable of making recommendations than you are. This is fun, especially when you see progress. It will also be lucrative, if you charge for your staff time and training, because you're keeping your clients happy, informed, involved and coming back.

One step further …

If you are highly motivated, or your rehabilitation services are working out well, you can research and invest in pulsed electromagnetic field therapy (PEMF) devices and laser therapy for your general practice. You might even consider taking it one step further and having your technicians and your hospital certified for canine rehabilitation.

Where to find out more …

More specifics on various rehab modalities:

Photobiomodulation facts and functions in veterinary rehab

The 4 phases of orthopedic rehabilitation

Rehabilitating canine veterinary patients after neurosurgery

Getting dogs back on their paws

Therapeutic exercise in veterinary rehabilitation

Exploring physical therapy modalities in veterinary rehabilitation

Where to get training:

http://www.rehabvets.org/training.lasso

https://caninearthritis.co.uk/

http://www.caninerehabinstitute.com/

References

1. Jortikka M, Inkinen R, Tammi M. Immobilisation causes longlasting matrix changes both in the immobilised and contralateral joint cartilage. Ann Rheum Dis 1997;65:255-261.

2. Salter RB, Simmonds DF, Malcom BW, et al. The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit. J Bone Joint Surg Am 1980;62:1232-1251.

Carla Johnson, DVM, practices emergency medicine at Berkeley Dog and Cat Hospital in Berkeley, California, and general practice at Cameron Veterinary Hospital in Sunnyvale, California. Her nonveterinary loves are writing, Dressage with her Iberian warmblood mare, Synergy; watercolor painting on yupo; vinyasa yoga; and running with her dog Tyson. Try as she might, her curly-coated Scottish Fold, Hootie, refuses to go jogging with her.