Veterinary rehabilitation optimizes clinical outcomes

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Rehabilitation therapy for canine patients improves functional outcomes post-operatively, and helps with neurological conditions, intervertebral disc disease and soft tissue injuries.

The goal of veterinary rehabilitation is to provide pain management, promote mobility, and return a patient to the most functional outcome possible. Rehabilitation has become an important part of the treatment plan for animals recovering from orthopedic or neurological surgery and soft tissue injury, as well as for chronic osteoarthritis management, neurological conditions, and obesity management. The purpose of this article is to highlight several conditions in which rehabilitation would play an important part in optimizing a patient’s condition.

Orthopedic surgery

Femoral head ostectomy (FHO) is a surgery for which rehabilitation should be discussed and recommended to the client, preferably prior to the operation, as part of the overall treatment plan. Early postoperative rehabilitation is imperative to optimize range of motion and achieve the most functional outcome for the affected leg. This is especially important in small dogs with an FHO, since it is not uncommon for them to resist using their legs after any orthopedic surgery. In the early postoperative period (before sutures are removed), the focus is on pain management. Traditional pharmaceutical pain therapies are augmented with cryotherapy, gentle passive range of motion, and cold laser therapy.

After the initial recovery period, acupuncture and musculoskeletal manipulation can help manage compensatory issues such as back pain and local hip pain. A qualified rehabilitation therapist can assist with incorporating appropriate modalities and progressing therapeutic exercises for optimal outcome. Underwater treadmill therapy is very useful in facilitating use of the limb due to the buoyancy and resistance effect of the water. The underwater treadmill is superior to swimming in recovery, because the patient is more likely to actively stretch the hip when he is walking on the treadmill; many dogs while swimming may “dangle” or not properly extend and use the hip.

TPLO and MPL surgeries benefit from rehabilitation to help manage pain and encourage weight-bearing as soon as possible after surgery. Not as beneficial is the approach many clinicians take, which is to recommend rehabilitation for patients experiencing less than optimal outcomes after surgery, including not using the leg after significant time has passed, and encountering significant atrophy and loss of function. This is unfortunate as it is harder to reverse atrophy and preserve range of motion after chronic disuse.

In my experience, the best benefit of rehabilitation after stifle surgery is that dogs are less likely to tear the ligament on the nonsurgical leg, which is placed under greater stress during the recovery period. Since recovery is dynamic, it is important that pain is managed thoughout the entire rehabilitation process. A supervised rehabilitation program with controlled return to function optimizes clinical outcomes.

Neurological conditions

Degenerative myelopathy is the disease that prompted me to search for options outside traditional Western medicine, to help patients cope with the devastating decline they endure without intervention. Unfortunately, many patients present after months of being administered a laundry list of medications, dietary recommendations and supplements.  Many of these supplements and dietary interventions should, in theory, prevent progression.

In the integrative medicine paradigm, there is no standalone therapy for a degenerative myelopathy patient. This is a disease that truly requires an integrative approach, and early intervention with rehabilitation is critical. A study done in the Journal of Internal Medicine showed that physical rehabilitation kept patients ambulatory on an average of 255 days longer.2

A genetic test offered through the Orthopedic Federation of Animals3 looks for the genetic markers of degenerative myelopathy. If a patient is homozygous recessive, and is exhibiting signs of neurological decline and hind end weakness, it is highly likely he has the disease. If this is the case, it is critical to develop a program to manage other concomitant painful diseases that may cause pain as weak animals compensate for the degenerative myelopathy by placing stress on the spine and front end, which are overworked trying to stay ambulatory.

Spinal manipulation is helpful, as is acupuncture, in managing pain for these animals. Dogs with degenerative myelopathy are often deficient from a Chinese Medical perspective, and need a conservative physical therapy program that consists of a shorter and more frequent exercise and treatment regimen. Prolonged exercise and aggressive treatment often depletes these dogs. Therapeutic exercises for proprioception and strength, along with underwater treadmill use, are key in keeping patients with degenerative myelopathy ambulatory.

Consider having assistive devices at your clinic for patients with hind end weakness. These can include harnesses that support both the front and rear end (Help ‘Em Up), toe up boots (available through handicappedpets.com), and toe grips (Dr Buzby’s). Clients often struggle with fitting harnesses, and a poorly-fitted sling or harness can rub and cause sores and irritation. Helping clients choose and fit a harness is an important service we can provide.  Also, trimming nails to an appropriate length and applying toe grips is very helpful; clients appreciate assistance with this.

Walking clients through recumbent dog care, including how to prevent decubital ulcers and helping with bladder expression and assisting with bowel movements, is not often thought of, but it’s an important part of helping clients cope with the degenerative myelopathy towards the end.

Most importantly, despite the plethora of supplements with antioxidant and neuro-protectant qualities that have been recommended for patients with presumptive degenerative myelopathy, the one modality that stands out for making a significant difference is physical rehabilitation.

Intervertebral disc disease

Dogs with intervertebral disc disease come in a diverse variety of presentations:

  1. For the acutely painful dog without proprioceptive deficits, consideration should be given to nonsteroidal anti-inflammatories and gabapentin. Cold laser is helpful in managing both acutely painful dogs and those with chronic pain. Care must be given when one is considering musculoskeletal manipulation at acutely affected sites. Acupuncture and electroacupuncture are helpful in managing the acutely painful patient.
  2. Owners of painful dogs with rapid proprioceptive decline must be aware that surgery is a consideration. Dogs that had surgery and received electroacupuncture and Western medicine recovered faster than those that received electroacupuncture alone.4 Cold laser in the postoperative period is helpful for healing the incision, and for pain management.
  3. It is possible to help a patient with no deep pain to achieve spinal walking, but the majority will not walk again without surgical intervention. These dogs are good candidates for carts. Assisting clients with making measurements and fitting carts is a useful service to offer. As mentioned above, a poorly-fitted cart leads to skin chafing and improper biomechanics that may cause discomfort.

It is also important to address diet in patients with intervertebral disc disease as they are often on restricted activity and more likely to gain weight during this time. Switching from a higher-carbohydrate processed kibble diet to a raw or home-cooked balanced diet is helpful. Consideration should be given to cutting daily calories fed by 25% to 30%.

Omega 3 fatty acids should be considered. Along with traditional pain management (gabapentin and nonsteroidal anti-inflammatories), numerous anti-inflammatory herbal formulas contain herbs such as boswellia and curcumin. Traditional Chinese medical formulas include Acute and Chronic Back formulas from Evergreen, and Jingtang Herbs Double P formula. Pulse Magnetic Therapy is being used more and more for patients with intervertebral disc disease.

Soft tissue injuries

Veterinarians and physical therapists trained in animal rehabilitation focus heavily on pinpointing the specific soft tissues involved in an injury, so that a targeted program can be implemented. This contrasts to the old school approach of “cage rest” for a generic diagnosis of soft tissue injury. While cage rest is an important part of rehabilitation, what’s more important is incorporating controlled activity designed to help with healing, pain management and preservation of range of motion. There is a fine balance between encouraging a gradual return to function and offsetting the development of scar tissue, disuse atrophy and compensatory changes as a result of the injury. Often there are subluxations present in the spine as the animal compensates for soft tissue injury.  Weakness or injury to an extremity creates a high likelihood that the animal will sustain an injury to his core trying to compensate for the injury.

Common soft tissue injuries seen in active dogs and canine athletes

Following are some of many soft tissue injuries, along with their most common presentations:

Carpal laxity:  Hyperextension at the carpus can present with varying degrees of pain, and dogs that perform in flyball and agility are predisposed. Carpal support wraps help dogs with instability.

Bicipital tenosynovitis, supraspinatus tendinopathy and medial shoulder instability: These injuries result from repetitive activities and overuse of the limb. Modalities such as ultrasound, shock wave, cold laser, platelet rich plasma and stem cell therapy are utilized to facilitate healing. Home exercises are designed to challenge the tissues after the acute phase when ice, rest and gentle massage and stretching may be the only things indicated.  Manual therapy encompasses cross friction massage and stretching, home exercises to strengthen the limb, underwater treadmill, progressing to trotting and walking downhill, and wheelbarrowing on the front legs.

Iliopsoas strain: Pain occurs on extension of the hip with slight abduction and internal rotation. When one of these strains is suspected, look for other issues such as anterior cruciate ligament disease, meniscal tears, hip issues and lumbosacral disease. After the diagnosis is confirmed and the dog is comfortable with appropriate pain management, a rehabilitation program can begin. Modalities include cold laser and massage. Gentle stretching focusing on hip extension can involve an active hip stretch by having the dogs’ paws up on a surface and luring him forward to open the hip. Core strengthening exercises may also be prescribed.

Anterior cruciate ligament tear: Rehabilitation should be considered for dogs with partial tears if surgery is not an option. The best outcome is likely in dogs that weight than 45 pounds. Dogs that are poor surgical candidates may benefit from a custom brace.

Trauma to toes: Don’t forget to look at toes as a source of lameness, especially in athletes that turn tight; longer nails can catch on equipment and surfaces when dogs dig in to turn.  Also look at the pads closely for corns.

Learning more about veterinary rehab

As with many areas of integrative medicine, there is no single cookbook protocol to rehabilitating a patient. Veterinarians, veterinary technicians and physical therapists pursue advanced training in rehabilitation to better understand what is appropriate for each individual dog’s situation.

For those interested, advanced training may be pursued through the Healing Oasis Wellness Center, the University of Tennessee Northwest Seminars, and the Canine Rehabilitation Institute.

In conclusion, rehabilitation therapy has proven to be safe and effective for improving functional outcomes post-operatively, for neurological rehabilitation, and soft tissue injuries. Physical therapy has long been the standard of care for these conditions in human medicine versus the veterinary medicine approach of forced rest. While there is always a place for crate rest, incorporating rehabilitation as a part of our treatment plan speeds healing and provides improved chances for long-term mobility.

References

“Safety and functional outcomes associated with short-term rehabilitation therapy in the post-operative management of tibial plateau leveling osteotomy”. Canadian Veterinary Journal. 2015 Volume 56:942-946.

ofa.org/diseases/dna-tested-diseases/dm

I Kathmann, S. Cizinauskas, MG Doherr, et.al. “Daily controlled physiotherapy increases survival time in dogs with suspected degenerative myelopathy”. J Vet In Medicine. 2006 July-August;20(4): 927-32. 

Jean GF Joaquin, Stelio PL Luna, Juliana T Brondani, et al. “Comparison of decompressive surgery, electroacupuncture and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral dis disease with long-standing severe neurologic deficits”. J Am Vet Med Assoc. June 2010;236:1225-1229.