Importance of rehabilitation in your practice: how to get started (Proceedings)

Surgical intervention for clinical problems arising from a traumatic episode (fracture, ligament sprain) or congenital abnormality (elbow dysplasia, hip dysplasia) is a common procedure in veterinary practice. As Veterinarians, each of us tends to rely on surgical intervention to resolve clinical dysfunction arising from one of the aforementioned conditions. There is no question that appropriate surgical procedure and surgeon expertise are important factors determining optimal outcome. However, perioperative pain control and rehabilitation are as important, if not more important, than the surgical procedure itself. Unfortunately, most Veterinarians place little emphasis on this part of the equation for optimal outcome. The benefits of post operative rehabilitation are described at length in the Human and Veterinary literature. As example, a study examining the kinematic analysis of the hind limb during swimming and walking in healthy dogs and dogs with surgically corrected cranial cruciate ligament rupture concluded that swimming resulted in greater ROM of the stifle and tarsal joints than did walking. In that ROM is a factor in the rate or extent of return to function, aquatic rehabilitation would likely result in a better overall outcome than walking alone (Marsolais, G. S.; McLean, S.; Derrick, T.; Conzemius, M. G: Journal of the American Veterinary Medical Association. American Veterinary Medical Association, Schaumburg, USA: 2003. 222: 6, 739-743. 40). A separate study examined the Rehabilitation of dogs with surgically treated cranial cruciate ligament-deficient stifles by use of electrical stimulation of muscles. This investigation concluded that improved lameness scores, larger thigh circumference, and decreased radiographically apparent bony changes were observed for the treated group of dogs. This finding supports the hypothesis that dogs treated by EMS after surgical stabilization of the CrCL-deficient stifle had improved limb function, with less DJD, than did dogs treated with the currently accepted clinical protocol of cage rest and slow return to normal activity. (Johnson JM, Johnson AL, Pijanowski GJ, Kneller SK, Schaeffer DJ, Eurell JA, Smith CW, Swan KS. Am J Vet Res. 1997 Dec; 58(12):1473-8. In addition to the investigational studies are journal articles and textbooks addressing Physical Therapy in dogs (and cats). In the NAVC Clinician's Brief (2005. 3: 6, supplement, 8 pp), Dunning et. al. reported that rehabilitation elevates the overall quality of medicine practiced, promotes patient recovery and function, and enhances client relationships. Clinical Techniques in Small Animal Practice (W.B. Saunders, Philadelphia, 2004. 19: 3, 180-191.), reported that rehabilitation is now becoming more common in small animals recovering from fractures. The detrimental effects of immobilization, including the potential for development of fracture disease, must be considered when formulating a Rehabilitation plan of care. Many Rehabilitation interventions are readily amenable to application by both Veterinary professionals and owners of patients. Superficial thermal modalities, passive range of motion and stretching, soft tissue massage, therapeutic ultrasound, electrical stimulation, and therapeutic exercise can ensure a more complete patient recovery. Providing owners with education regarding appropriate patient handling and home modifications allows a safer return to the home environment. Detailed written rehabilitation instructions for home care promote owner compliance and accurate completion of the surgical experience. The benefits of rehabilitation modalities are not limited to postoperative care. Conditioning of the canine athlete or senior dog (cat) with osteoarthritis is readily accomplished with appropriate exercises to promote strength, endurance, and greater range of joint motion. Printed in 2004 is a textbook by Millis et. al. entitled Canine Rehabilitation and Physical Therapy. This text is a comprehensive review of current scientific literature and a detailed description of Rehabilitation modalities. Everyone interested in canine rehabilitation should be an owner of this textbook.

As one becomes involved in prescribing rehabilitation for post operative care or treatment of osteoarthritis (conditioning), additional benefits associated with the rehabilitation process become apparent. As the owner returns for rehabilitation sessions, contact with the hospital and the staff provide a means for emotional contact between the owner and the hospital. At each session their pet is evaluated to determine progress of recovery. The owner is provided the opportunity to ask questions and express concerns. They see the care and compassion given their pet by the hospital staff and often have an opportunity to have conversation with the attending Veterinarian. The owner observes the in hospital rehabilitation modalities and is first hand witness to the progress being made by their pet.

At each session, the owner is given exercises to administer at home. More accurate and complete home care is provided and the owner becomes intimately involved with the treatment (post surgery, conditioning, or osteoarthritis) process. All these factors reinforce the emotional contact with the hospital and offer the owner a rewarding experience for owner and their pet.

The opportunity to observe the progress of dogs (cats) following surgery or during the treatment of osteoarthritis (conditioning) is particularly beneficial to the attending Veterinarian. The attending is able to document common occurrences (complications, owners concerns) that may occur during the recovery process. For example, following an extra-articular procedure to correct a cranial cruciate ligament injury, the attending surgeon is able to observe and/or receive reports of progress on a weekly basis for 8 – 10 weeks. Exact knowledge of the course of recovery is helpful in knowing if a problem or owner concern needs intervention or is one which will resolve on its own and not adversely effect outcome. Likewise, knowledge of the time needed to observe the benefits of osteoarthritis treatment (weight loss, decrease joint pain) will help owners maintain commitment to a rehabilitation program. For the owner to have their concerns addressed in a knowledgeable and accurate manner lends credibility and invokes owner confidence in the attending Veterinarian and hospital staff.

There are different methods by which the attending veterinarian can encourage owners to participate post operative rehabilitation or conditioning rehabilitation. For post operative rehabilitation, some hospitals prefer to have the Rehabilitation Practitioner meet with the client at the time of initial consultation and diagnosis. The attending Veterinarian discusses diagnosis, pain management, and outcome with the owner. The attending Veterinarian stresses the importance of appropriate post operative care and then to introduces the Rehabilitation Practitioner. The Rehabilitation Practitioner will address modalities used for optimal outcome and discuss fees with the owner. Another effective method (and the one used by our hospital) is to include post operative rehabilitation sessions (generally 2 – 4 sessions) within the treatment process. As with pre-operative blood work, hospitalization, radiology, etc., post operative rehabilitation is part of the treatment provided for the care of their pet. Included in the fee estimate would be items such as the surgery, anesthesia, hospitalization, radiology, pain management, and rehabilitation. Our experience is that less than 1% of owners request not to engage in a post operative rehabilitation program (of those that decline, the reason given is generally extended travel time to the hospital). Indeed most owners desire and expect post operative care the same as they expect diagnostics (radiogrphs, blood work) and appropriate peri-operative pain management. (Remember to discuss peri-operative pain management with the owner. They are grateful and relieved to know their pet is not going to experience serious discomfort). In addition to arresting peri-operative pain, appropriate pain control also serves to enough provide patient comfort to effectively begin early rehabilitation. In addition to the sessions included with the surgery, owners often request additional rehabilitation sessions. A study of cases at our hospital showed that the average number of additional rehabilitation sessions requested by owners whose pet had undergone ACL surgery was four whereas with hip surgery the average additional sessions was six. Owners are provided with exercises to administer at home in between in-hospital rehabilitation sessions. Home exercises enhance the recovery process and intimately involve the owner in the post operative care. Owners monitor their pets' progress more closely and identify problems before they become serious issues. Having a venue where owners may express their observations and/or concerns to the hospital staff further consolidates the bond between the owner and hospital. In the end, owners frequently express that the rehabilitation process was a beneficial and rewarding experience.

Conditioning (weight loss, strength, endurance) is a major factor in preventing or treating osteoarthritis. As such maintaining body condition is a major component of rehabilitation. Research (in man) shows that exercise is one of the best treatments for osteoarthritis. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general physical fitness. There is reason to believe that the same benefits are true in dogs and cats. Exercise is also inexpensive and, if done correctly, has few negative side effects. Normal joints in individuals of all ages appear to tolerate prolonged and vigorous exercise without adverse consequences or accelerated development of osteoarthritis. Exercise may actually help prevent the development of osteoarthritis and a regular exercise program is known to be helpful in individuals that have developed osteoarthritis. An exercise program for your pet must begin with a healthy outlook by you and all the family members. Optimal results are reached when the family unit works together to accomplish the goals set forth by the family, veterinarian and rehabilitation therapist. Research shows that people with osteoarthritis who take part in their own care report less pain and make fewer doctor visits. As important, each family member should take part in the care of the pet. They should be well informed about the process of osteoarthritis and how each interventional strategy prescribed will be of benefit. Family members ought to plan and develop daily routines to implement approved activities. Changing assignments every so often helps prevent boredom and maintains enthusiasm. One osteoarthritis study in man showed that people with the lowest levels of disability at the end of the study period were those who had adhered most stringently to their exercise regimen. Adopting lifestyles in which exercise is accumulated throughout the day appears to be a good approach to sustaining physical activity. Lifestyle exercise may enhance exercise adherence by increasing options to be active and reducing time barriers. Finally, scheduled examinations and discussions with the attending veterinarian and rehabilitation practitioner are needed to make sure the prescribed treatment is working well. Regular physical activity and rest play a key role in wellness. Episodic physical activity may also be preferable to continuous exercise by avoiding injury due to overuse. Episodic activity refers to those activities that occur for a reasonable time period multiple times throughout the day. Of considerable harm to the process of osteoarthritis is your pet having a sedentary life throughout the week only to exercise strenuously on the weekend. This lifestyle exacerbates the osteoarthritis and is very likely to result in serious injury. Treatment regimes should include regularly scheduled rest. Exercise effectively squeezes the water out of the cartilage making it less compliant and more susceptible to injury. Rest allows fluids to seep back into the cartilage restoring its mechanical efficiency and lessening the incidence of injury due to overuse. Family members must learn to recognize their pet's body signals and know when to stop or slow down. Doing so prevents pain and injury caused by overexertion. Two types of exercise are important in osteoarthritis management. The first type, therapeutic exercises, keeps joints working as well as possible. Therapeutic exercises are low impact and designed to maintain or increase joint range of motion, proprioceptive feedback, muscle tendon unit and periarticular tissue elasticity. Examples of therapeutic exercises are passive range of motion activity, massage, aquatic therapy, and stretching. The other type of exercise, aerobic conditioning exercises, improves strength and fitness, and controls weight. Examples are brisk walking, brisk, walking or trotting through high grass, cavaletti training, and aquatic therapy. The attending veterinarian and/or a rehabilitation practitioner can evaluate the pet and develop a safe, personalized exercise program to increase strength and flexibility.

Weight and body condition are important in preventing Osteoarthritis as well as an important factor in the treatment of osteoarthritis. Heavy dogs are at increased risk of developing arthritis because their joints may be strained by excess weight. This is especially evident in weight-bearing joints such as the knees and hips, which often show the first signs of weight-related strain and injury. An investigation into the cause of cranial cruciate ligament injury and the development of secondary osteoarthritis showed a significant risk factor to be obesity. One study in man showed that an average of 10 pounds of weight loss over a 10-year period decreased the risk of osteoarthritis of the knee by 50%. Similarly, obesity accounts for up to 30% of knee OA in man, exacerbates symptoms, and is associated with more rapid progression of the disease. A weight loss program will dramatically decrease the risk of a pet injuring its knee joint and developing osteoarthritis. In fact studies of dogs with hip osteoarthritis show that reaching target reduction weight increases a dogs' ability to move in a more normal fashion as assessed by gait analysis and owner observations. An important facet of a Rehabilitation center is diet and weight management. A well informed rehabilitation practitioner is able to prescribe an effective weight reduction program tailored to the needs of the pet and owner.