Integrative rehab in a veterinary teaching hospital

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Integrative rehab in a veterinary teaching hospital

When it comes to integrative rehab, a teaching hospital offers many benefits, including a collaboration between services, access to specialized equipment, research opportunities, and a sharing of information between teachers and students.

Due to the wide variety of therapeutic options, rehabilitation in integrative veterinary medicine varies tremendously among practices. It can include, but is not limited to, exercise therapy, laser therapy, regenerative medicine, acupuncture, herbal therapy, assistive device fitting, and nutraceutical guidance. This multitude of integrative rehab treatment options naturally lends itself to an element of creativity that colors day-to-day veterinary practice. Working in a teaching hospital offers unique features, such as collaboration between specialty services, accessibility of specialized equipment, and the opportunity to contribute to the veterinary community through research and education.

Nutraceutical guidance

Nutraceutical guidance plays a significant role in daily integrative rehab. It’s not uncommon for owners to arrive toting hefty shopping bags of various supplements purchased online. Veterinarians often struggle with critically evaluating the endless array of over-the-counter supplements and herbs marketed for pets. The reality is that these products are not regulated by the Food and Drug Administration and therefore their safety and contents cannot be confirmed unless the nutraceutical company voluntarily uses third party laboratory testing. A study performed by the University of Maryland on glucosamine and chondroitin supplements found that product contents varied significantly from their label claims — as low as 0% to 115% (Adebowale 2000)! Verification of such testing is demonstrated by the presence of Good Manufacturing Practices (GMP), United States Pharmacopeia (USP) or National Animal Supplement Council (NASC) seals. Bear in mind that these labels only verify the contents and quality control of the product, not its bioavailability and efficacy.

Research opportunities

Practicing specialty medicine offers us the unique opportunity to make contributions to veterinary science through research. Admittedly, this can be challenging to implement in day-to-day practice and would be difficult without the support of an academic environment. Many integrative medicine therapies lack robust clinical trials (low subject numbers, conflicting results, poor study designs), which provides limitless opportunities for innovation. Conducting research has changed the way I practice in that it has made me more critical and methodical in my evaluation of new technologies and therapies. This is imperative for integrative medicine to gain a wider acceptance in veterinary specialty medicine.

(Left) Many patients require creative adaptations of equipment in order to accommodate their varied levels of mobility. (Middle) This patient was treated with pulsed electromagnetic field therapy, acupuncture and therapeutic laser for his chronic rhinitis. (Right) A quad cart enabled this patient to maintain independent mobility well into the later stages of his degenerative myelopathy.

Assistive devices

The use of assistive devices for animals with impaired mobility is an area of rehabilitation that is rapidly growing and expanding as technology improves. Examples include carts, orthoses and prosthetics. For many patients with nonsurgical or degenerative conditions, the availability of these devices often plays a vital role in their long term quality of life. Product selection is particularly important, as different products possess different strengths and weaknesses. In particularly challenging cases, customized devices often require extensive measurement and fitting visits with repeated follow-ups. In such cases, it is especially crucial to work with a company offering high quality customer service and follow-up care. Rehabilitation plays a complementary role in employing the new device in gait retraining. While some of these devices are intended for permanent use, we also employ these tools for patients experiencing a temporary decline in mobility, in order to facilitate recovery. A typical example would be using a cart to provide a post-op hemilaminectomy patient with controlled independent mobility.

Regenerative medicine

Customized rigid orthoses can offer patients with joint instability an alternative to surgery.

Regenerative medicine, including platelet rich plasma (PRP) and stem cell therapy, is a rapidly growing area of interest and often a source of referral for nonsurgical orthopedic conditions. The most common conditions treated with regenerative medicine are osteoarthritis and tendinopathies. The primary mechanism of action of these therapies is through the growth factors and anti-inflammatory cytokines in PRP and released by stem cells (Pelletier 2013, Caplan 2006). In a recent study, stifles that received PRP injections demonstrated evidence of repair and less synovitis as compared to saline control (Cook 2015). Stem cell therapy in dogs currently requires harvesting from adipose tissue (falciform or subcutaneous) or bone marrow. Platelet rich plasma is extracted from the patient’s whole blood using an onsite concentration system. Both these therapies require only mild sedation and can be performed on an outpatient basis. Many owners who are adverse to the chronic use of pharmaceuticals are attracted to the concept of regenerative medicine, as it employs the patient’s natural biological materials to self heal.

Care for acute illnesses

Although often overlooked, rehabilitation and integrative medicine can play an important role in critical care. While the majority of our cases involve treatment of chronic conditions, rehabilitation can sometimes be key in the recovery of acutely ill hospitalized patients. While the patient may have recovered from their primary systemic, underlying weakness, orthopedic, or neurological conditions can result in mobility changes that prevent discharge from the hospital. We often say “movement is life,” and the effects of prolonged recumbency can have a dramatic negative effect on a patient’s circulation, respiratory system, musculoskeletal system, and mental well-being.  These changes can result in life and death decisions depending on the level of care owners are equipped to provide at home. In these cases, intensive rehab and often acupuncture therapy and owner discussion of at-home care play a vital role in the patient’s recovery.

Educational opportunities

Working in a teaching hospital provides unique mutual benefits resulting from the exchange of information between students and teachers. Many students and interns rotating through our service have had limited previous exposure to both rehabilitation and integrative medicine. We try as much as possible to open their eyes to the variety of treatment options available for cases they will likely often encounter. Our hope is that their experience during rotation will help spread knowledge about alternative approaches among this new generation of doctors. Teaching also provides the teacher with new learning opportunities and challenges one’s own knowledge. The continuous circulation of new graduates provides us with the benefit of new perspectives from other practices and teaching institutions, and that furthers our own growth as well.

Conventional versus integrative medicine

Cavalettis are a common tool in rehabilitation used to improve proprioception, retrain gait, and improve joint range of motion.
Cavalettis are a common tool in rehabilitation used to improve proprioception, retrain gait, and improve joint range of motion.

We always make a point to clearly state that we practice integrative medicine. Integrative medicine does not necessarily have better tools than conventional medicine does; but it offers a larger variety. We emphasize the importance of choosing the “best tool from the box”, and often marry the best elements of both Eastern and Western approaches to achieve effective results. For example, many of our patients with osteoarthritis are managed with a multi-modal combination of non-steroidal anti-inflammatories, acupuncture, herbs and rehabilitation. Excluding prescription medications such as NSAIDs from our practice would be a disservice to our patients, and would limit their ability to engage in therapeutic exercise. By always offering the best treatment options with a truly integrative approach, our patients receive the maximum benefits possible.

Evidence-based medicine

One of the most important features of performing integrative rehabilitative medicine in a specialty practice is the focus on evidence-based medicine. According to the AVMA Guidelines for Complementary and Alternative Veterinary Medicine, it’s the veterinarian’s responsibility to critically evaluate existing literature demonstrating the efficacy of offered therapies. This is especially critical in a teaching hospital. Internal referrals from other specialty departments are particularly dependent on the availability and knowledge of supporting evidence demonstrating both the safety and efficacy of various therapies. For this reason, it is crucial to remain current on the literature for a variety of relevant topics, including physical therapy, acupuncture, nutraceuticals and other modalities. This is both challenging and fun, since methods of practice are constantly evolving. For example, there have been several studies pertaining to the use of laser therapy with variable results (Draper 2012, Bennaim 2017). Part of this variation may be attributed to differences in the power delivered, and the laser type. Results from future studies such as these will continue to shape the way we practice so we can more effectively treat our patients.

References

Adebowale, Abimbola O., et al. “Analysis of glucosamine and chondroitin sulfate content in marketed products and the Caco-2 permeability of chondroitin sulfate raw materials.” J Am Nutraceutical Assoc 3.1 (2000): 37-44.

AVMA guidelines for Complementary and Alternative Veterinary Medicine.

www.avma.org.

Bennaim, Michael, et al. “Preliminary evaluation of the effects of photobiomodulation therapy and physical rehabilitation on early postoperative recovery of dogs undergoing hemilaminectomy for treatment of thoracolumbar intervertebral disk disease.” American journal of veterinary research 78.2 (2017): 195-206.

Caplan, Arnold I, and James E. Dennis. “Mesenchymal stem cells as trophic mediators.” Journal of cellular biochemistry 98.5 (2006): 1076-1084.

Cook, James L., et al. “Multiple injections of leukoreduced platelet rich plasma reduce pain and functional impairment in a canine model of ACL and meniscal deficiency.” Journal of Orthopaedic Research 34.4 (2015): 607-615.

Draper, WE, et al. “Low‐level laser therapy reduces time to ambulation in dogs after hemilaminectomy: a preliminary study.” Journal of Small Animal Practice 53.8 (2012): 465-469.

Pelletier MH, Malhotra A, Brighton T, Walsh WR, Underman R. Platelet function and constituents of platelet rich plasma. Int J Sports Med (2013) 34:74–80.

Hope Science Horizontal May 2019