Important considerations when treating cases include concurrent conditions such as those that occur following trauma, prevention of further injury, and repeat examination to identify problems that were not previously diagnosed.
Important considerations when treating cases include concurrent conditions such as those that occur following trauma, prevention of further injury, and repeat examination to identify problems that were not previously diagnosed. Do not try to start too many treatment modalities at once as this will overwhelm the patient as well as the client. Rehabilitation is contraindicated in cases with bleeding disorders, cardiac disease that is not well controlled or compensated for, and infection in the area to be treated, or an elevated or decreased body temperature.
Other contraindications will be discussed with each treatment modality utilized. Remember to reassess the patient's progress frequently and to ask the client about the patient's attitude and progress at home. It is vital to gain a written client consent to treatment, even for rehabilitation, before any program is instituted.
All of the following examples and protocols are merely rough guidelines and suggestions of protocols that can be used in clinical cases. Each specific case needs a protocol developed specifically for that patient and client and each case is different. In addition, we recommend that if you are going to pursue regular rehabilitation care of patients in your practice that you become certified by a reputable training facility.
Our first example will be of a post-operative patient, either dog or cat, with a femoral head and neck ostectomy. There will not be any other concurrent diseases or problems in the patients presented here as examples. In the first 3 days following surgery the patient will be faced with pain, postoperative swelling and inflammation and a decreased range of motion.
Therefore, the first 3 days, starting before the patient has recovered from anesthesia, will focus on 3 treatments: cryotherapy with cold packs, passive range of motion exercises (PROM), and pain management (drugs, Transcutaneous electrical nerve stimulation (TENS), ultrasound (US), therapeutic laser).2 Cryotherapy is usually performed every 4 to 6 hours during this time and immediately prior to PROM exercises to maintain patient comfort during the exercises. Cold packs also decrease bleeding and edema into the operated tissues.
Do not leave the cold pack directly on the patient but place a cloth between the patient and the pack and do not leave the pack on for longer than 10 minutes. This is because there is a rebound vasodilation in the area if a pack is left on longer than 15 minutes thus resulting in an increase in swelling and bleeding in the operated area (Hunter's reflex0. Do not use a cold pack if the patient is hypertensive or has no sensation in the area to be cooled. The passive range of motion exercise should be focused on the operated hip joint and only flex and extend the joint, do not abduct or adduct following femoral head and neck ostectomy.
During the first 3 days postop, try to perform the PROM exercise 4 to 5 times a day. For pain, adequate analgesia is a must and will not be addressed here. TENS units can decrease pain as well as inflammation. Laser therapy can be used to speed healing in cases where there are other conditions on the contralateral limb and early full weight bearing on the operated limb needs to occur. Laser therapy is generally used 3 times a week for the first week, twice a week for the second week, and once during the third week following surgery. Ultrasound therapy is used to warm deeper tissues, increase elasticity of fibrous tissue, reduce pain and muscle tension and thereby increase joint mobility.
Therapeutic US in acute conditions should be used once daily with low doses and pulsed waves beginning no sooner than 2 days postop. Usually the unit has preset application protocols for you to use but the time of the treatment should be no longer than 5 minutes and with a 5 cm probe, the area to be treated should be less than 10 cm. Always keep the ultrasound unit in constant motion, keep the hair clipped, and keep a uniform amount of gel on the area being treated.
During the next 4 to 30 days postoperatively, the cryotherapy can be replaced with warm compresses applied prior to PROM exercises and the cryotherapy used only after the PROM for 5 minutes. Ultrasound can continue to be utilized but will warm the tissues therefore, when it is performed, do not use a warm pack at that treatment time. PROM exercises, with warm compresses before and cold packs after, should be performed 2 to 3 times a day. PROM exercises can include the flexion and extension as during the first 3 days postop, but may also include moving the limb in a bicycling motion while standing as well as flexor reflex stimulation.
Flexor reflex stimulation involves gently holding the skin between the toes and pulling the leg away from the body to stimulate the patient to flex the entire limb. The patient may also benefit from massage of the quadriceps, hamstrings, and gluteal muscles. The patient should also be encouraged to use the limb by slow short walks twice a day.
If the patient is not placing some weight on the affected leg by two weeks postop, I will sometimes begin physio-ball or balance board exercises as well as sit to stand exercises and controlled stair climbing on a leash. In addition, if available, aquatic therapy will also be instituted after the incision has healed. If at 5 weeks postop, the patient has a continued decreased use of the limb or lameness, I will begin continuous wave ultrasound therapy (chronic conditions) or laser therapy and walking with cavaletti rails as well as dancing exercises.
The owner is encouraged to increase the lengths of walks (distance or time) and walking on an incline slowly. If after 9 weeks muscle atrophy is still present, I will add walking with weights on the affected limb, either on land or underwater treadmill and potentially electrical stimulation to atrophied muscle groups 2 to 3 times per week.
For surgery of the stifle, the protocol used varies with the method of surgery and type of injury the patient has had. I will only address extracapsular, lateral fabella to tibial suture repairs of cranial cruciate ligament ruptures here. With this surgery excessive fibrosis and subsequent loss of range of motion is a common postoperative complication. Cold packs are applied 4 to 5 times a day for the first 3 days postoperatively. In addition, PROM exercises are performed by flexing and extending the stifle, 10 repetitions, 2 to 3 times a day. Massage of the quadriceps and hamstrings can also reduced pain and inflammation. A TENS unit can be used once a day or a therapeutic laser can be used every other day for one week in addition to the above protocol.
During the 4 to 14 days postop, The PROM exercises as described above are continued and flexor stimulation exercises and bicycling movements are added to the protocol. Warm compresses for 10 minutes before the PROM exercises and cold packs for 10 minutes after the exercises are used. Pulsed signal therapeutic US can also be used once a day during this time. The patient should be encouraged to use the limb on short, slow leash walks as well. During the 2 to 4 weeks postop, in addition to the above protocol (4-14 days postop), I will ask the owners to perform on the patient weight shifting exercises and sit to stand exercises. If muscle atrophy is present, the patient can be placed in an underwater treadmill or go swimming, or electrical stimulation can be performed 2 to 3 times per week.
After the first month postoperatively, if the patient is still painful, continuous wave ultrasound can be employed before therapeutic exercises. If the patient's gait continues to be abnormal, I will begin exercises on the therapy ball, balance board, or cavaletti's 3 times a week. Incline walking, weights on the affected limb, dancing exercises can increase the strength of the limb if performed 2 times a day. If after 8 weeks of treatment, the patient continues to have atrophy, swimming or underwater treadmill work should be instituted 3 times a week in addition to the above protocols.
For any of these protocols or conditions, heat should never be applied to joints that are inflamed and warm to the touch. PROM exercises should be performed to the point of discomfort but not pain. Active exercises should only be performed after the initial postoperative inflammation has resolved, usually 4 days postoperatively.
Rehabilitation of patients following surgical repair of fractures depends upon the severity of the fracture, stability of the repair, and concurrent injuries in the patient. No single management scheme is available but some guidelines can be mentioned. The time frames of various protocols often need to be modified especially if the patient is older, has severe soft tissue trauma surrounding the fracture, or the fracture involves a joint. Therapeutic lasers have been used to help speed healing of fractures in humans and may have some benefit in small animals.
During the first 3 weeks postoperatively, the physical therapy should be aimed at reducing muscle tension and maintaining range of motion of joints on the affected limb. Massage and cold packs on the affected limb can be used 3 times a day. Do not place the cold pack directly over metallic implants.
PROM exercises should be limited to movement through a comfortable range only but incorporate all joints of the affected limb if possible. Short leash walks can be instituted but the animal should be supported with a sling at all times. Activity restriction is required until there is evidence radiographically that the fracture has healed. Therapeutic ultrasound can be used once daily in continuous wave to prevent muscle and tendon contracture, but often massage will be enough to prevent this.
During the 4 to 8 weeks following fracture stabilization, the PROM exercises can be continued and active exercises can be added such as sit to stand or down to sit exercises, balance board or physioball, cavaletti's, and slow leash walks. If muscle atrophy develops the patient can begin swimming or underwater treadmill therapy, or if stabilization is still tenuous or other injuries are present, electrical stimulation to the muscles can be instituted once daily. If a fracture involves a joint, mobilization of the limb as soon as possible is very important.
I will begin PROM exercises even before the patient is recovered from anesthesia and will continue them 3 to 4 times daily from the day after surgery to 8 weeks postoperatively. Active exercises should be started if the patient refuses to use the limb and can include swimming, sit to stand or down to sit exercises, and weights on the affected limb. Shifting weight exercises can also be used to encourage use of the limb. Do not allow the patient to jump or move faster than a walk on the limb until the joint has completely healed. Therapeutic ultrasound can be used to increase flexibility of the joint during the healing process and may be used in conjunction with the PROM exercises. For this purpose a continuous wave ultrasound should be used no more than twice a day.
For acute intervertebral disk disease (IVDD) where the patient can be conservatively managed, rehabilitation can be utilized to improve outcome. Only patients with mild pain and mild neurological deficits that can still walk are candidates for conservative therapy. Patients in which their condition deteriorates or does not improve following a month of therapy must have further diagnostics performed and likely will require surgical intervention.
It is imperative that patients with mild IVDD have strict cage confinement for one month. Any activity could cause further rupture of the disk and further neurological damage. If conservative management is successful, then the patient may slowly increase its activity over the following 2 months but must never be allowed to jump on or off furniture, steps or stairs or retrieve a ball or Frisbee again.
The patient should be maintained on nonskid surfaces that are horizontal (no ramps greater than 3 degrees of incline) for the rest of its life. Cryotherapy and TENS can be used to decrease pain in the epaxial muscles and PROM exercises limited to small movements can be performed in the first 3 days since the onset of clinical signs. In addition, laser therapy has been used to treat IVDD in dogs although no blinded placebo controlled studies have been performed to assess its advocacy. Therapeutic ultrasound in a pulsed wave can be used 4 days to 8 weeks postoperatively to painful areas of epaxial muscles. After 4 weeks of strict cage rest, slow leash walks may be begun.
These are just some examples of the types of diseases that can benefit from rehabilitation as part of the treatment plan. Again, the protocols here are some suggestions but have not been verified in clinical studies and therefore, client consent is required in written form prior to beginning any rehabilitation program. The patient must be reassessed frequently in order to ensure not only that progress is being made but also that no harm occurs during treatment. Most forms of rehabilitation require some maintenance therapy in the long term and recheck examination is encouraged even after the goals of therapy have been met.7
Some precautions must be taken to prevent reinjury or breakdown of the repair in an injured sporting dog participating in a rehabilitation program. Torson, twisting and rotation of the joint and limb that has been injured must be avoided for at least 8 weeks following injury. It is true that athletes tend to recover faster from injuries than patients that are out of shape, the rate of healing remains unchanged.
Bone healing is highly variable and affected by many factors including age, breed, location of the bone, surrounding soft tissue damage, etc. Bone healing has ranged between 5 and 15 weeks with external skeletal fixation.8 One year following injury to a tendon, it has recovered only 50-70% of its original strength. Tendons have reached 56% of their original strength by 6 weeks post-injury and 79% by one year. Before any muscle can be exercised it must have adequate healing or reinjury will occur, and this takes approximately 6 weeks in most cases.9 While these tissues are increasing their strength and healing, some exercise of light intensity can be beneficial to improve the strength of the tissue, align collagen fibers along the lines of stress, and increase muscle mass.
Too intense exercise during this time will reinjure the structure. There are many ways to provide light intensity exercise. Some examples include walking on soft surfaces such as grass slowly, swimming or underwater treadmill walking, elastic band therapy, and cavalettis. When the dog is using the injured limb, the range of motion in a cranial caudal direction should be emphasized while the dog is actively contracting the muscles to increase strength and tone. The exercise should be very controlled and in a slower motion- never fast jerky or twisting.
After the tissues have reached a significant amount of healing, the addition of exercise to recondition the dog is recommended. This period of recovery requires controlled exercise just as in the early recovery period, however, the environment and potentially, even the dog's sport may be begun.For example, a flyball dog may begin to trot to the flyball box and can even hit the box but not yet catch a ball to practice the balance and proprioception that is necessary for this sport.
In addition, sprinting can be started but without the jumps to increase muscle strength and mass as well as develop the cardiovascular stamina that is necessary. Once the dog can complete these exercises without reinjury, jumps and catching the ball can then be added to the practice routine.
There is tremendous variability in rehabilitation of the canine athlete, but a gradual increase in strength, stamina and proprioception along with healing time for recovery can return a patient to his/her former athleticism, depending on the type and severity of the injury. The patient must be regularly examined, even every 2 weeks, to ensure that strength is continuing to increase without breakdown of the repair, since early evidence of recurrence of the injury can be abated much more easily than complete reinjury.
Levine D, Millis DL, Marcellin-Little DJ. Introduction to veterinary physical rehabilitation. Vet Clin North Am Small Anim Pract 2005;35:1247-1254, vii.
Shumway R. Rehabilitation in the first 48 hours after surgery. Clin Tech Small Anim Pract 2007;22:166-170.
Millis DL, Levine D, Taylor RA. Canine Rehabilitation and Physical Therapy. First ed. St. Louis, Missouri: Saunders, 2004.
Goff L, Stubbs N. Animal Physiotherapy. First ed. Oxford: Blackwell Publishing, Ltd., 2007.
Edge-Hughes L, Nicholson H. Canine Treatment and Rehabilitation In: McGowan C, Goff L,Stubbs N, eds. Animal Physiotherapy Assessment, Treatment, and Rehabilitaiton of Animals. First ed. Oxford, UK: Blackwell Publishing, Ltd., 2007.
Bockstahler B, Levine D, Millis DL. Essential Facts of Physiotherapy in Dogs and Cats: Rehabilitation and Pain Management. 1st ed. Babenhausen, Germany: Be-vetverlag, Im Schloss, 2004.
Marcellin-Little DJ, Levine D, Taylor R. Rehabilitation and conditioning of sporting dogs. Vet Clin North Am Small Anim Pract 2005;35:1427-1439, ix.
Marcellin-Little DJ. External skeletal fixation In: Slatter DH, ed. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, PA: WB Saunders, 2003;1818-1834.
Williams N. Wound healing: tendons, ligaments, bone, muscles, and cartilage In: Taylor R, ed. Canine Rehabilitation and Physical Therapy. St. Louis, MO: WB Saunders, 2004;100-112.