Introduction to rehabilitation

Andrea Looney, DVM, DACVAA, CCRP, DACVSMR
Ethos Veterinary Health, Inc.
Posted on 2017-08-29 in Sports medicine & rehabilitation

Rehabilitation is the evaluation and treatment of functional problems or impairments, the latter of which occur due to aging, disease, trauma, or surgical intervention. The many benefits of physical rehabilitation in veterinary patients include: hastened post-surgical recovery and return to function, minimization of side effects from and complementing of traditional medical and surgical approaches, improved strength and endurance in the injured area, prevention of future injury and enhancement of the veterinary owner pet bond. The physiologic mechanisms behind why rehabilitation techniques and modalities actually work include: reduction in inflammatory mediators, maintenance of normal A and C fiber homeostatic input and normal joint homeostasis, increased production and strength of connective tissue, and minimization of contracted periarticular tissue and muscle atrophy.

Rehabilitation programs

The new AAHA/AAFP revised pain management guidelines state that using only pharmacologic management for pain is no longer sufficient. Although animals will heal and recover without rehabilitation, they will suffer less and heal better/faster with rehabilitation. For chronic disease, degradation of soft tissue, attitude (mental state) human animal bond will not occur with rehab; and animals will thrive healthier/ better longer. Most tools that can be used in rehabilitation are inexpensive: balance boards, balance balls, peanut balls, Cavaletti, slings, harnesses, ice packs, hot packs, stairs, ramps, and land (dry) treadmills. However, higher priced items which a rehab practice can utilize are a therapeutic laser (ideally 9–15 watts) and an underwater treadmill (UWTM).

Exercise in Home programs and in hospital programs under a well-trained technician or doctor are priceless for postoperative care, quality of recovery long term and retained happy clientele. Appropriate programs are often a combination of treatments in-house, modality use, medical (analgesic) therapy and in home exercise programs which parallel the two phases of healing. Essential to all programs are a complete and thorough physical exam, an understanding of the patient’s home environment, an explanation and conversation about realistic goals, and development of outcomes assessments via recheck appointments and phone/internet regular feedback. Home programs are often developed and supplemented by in house/hospital techniques, modalities, and programs using more expensive professional and technician driven tools.

Phases of healing

Phase I of healing post-acute disease process, trauma/injury or surgical intervention describes a period from initial insult up to 2-3 weeks post insult. During this period, the body is protective and focused on preventing re-injury. Rehab programs need to be likewise focused on pain control, protection of stability, comfort and assistance with the initial scarring/inflammation, and maintenance of life functions around that injury. The early phases of healing involve movement but the movement must be gentle and align with the fixation or lack thereof. Phase II of healing involves the post inflammatory period from 2-3 weeks onward when the injured area has regained stability but needs indeed to return to function, regain strength in that function, and maintain endurance for the long haul.

Rehabilitation program assessments, modalities, techniques and exercise agendas all have to parallel these phases, and most importantly parallel the fixation afforded and the pain control (endogenous and exogenous) provided to the patient.

Rehab modalities of use in Phase I

Cryotherapy is the application of cold to an affected area. Cold therapy not only reduces local prostanoid and cytokine production but also reduces C and A fiber transmission, edema, and limits local blood flow if performed appropriately. Cold therapy is best utilized with intermittent pressure, constant cycling and water/ice mixes vs. simple topical cold packs. Passive range of motion (PROM) is best performed preceded by massage therapy, the latter of which is best effective if performed away from the area in question, especially proximally to induce lymphatic circulation. Passive range of motion exercises then focus on the area in question ONLY when the patient is heavily sedated/under anesthesia, otherwise should focus on reciprocal apparatus and joints distal/proximal to the affected body part. Passive range of motion DOES NOT build muscle, induce proprioceptive feedback and neuromuscular input of the patient however, and for this reason, is only a treatment technique that should be utilized in Phase I of healing.

Active Assisted Range Of Motion (AAROM) exercises and proprioceptive facilitation techniques both require a) device or handler assistance but b) active participation by the patient are techniques that truly do help to rejuvenate and build muscle, reduce joint contraction, facilitate active arterial and venous circulation and most of all, improve neuromuscular feedback /healthy homeostasis. These tricks or minor exercise programs can bridge the gap between phase I and II of healing.

Rehab modalities of use in Phase II

As inflammation recedes and focus goes from injured body part to whole body reconditioning/healing, exercises also change from AAROM to AROM (active range of motion) whereby true Exercise programs focused on conditioning, strengthening the body part, establishing endurance and truly returning the Animal patient to function and beyond are developed. Triads of exercises are often suggested/explained using both in home and in house/hospital equipment, and these are re-checked/challenged every 10d-2 weeks to allow progress alongside healing stability of injured area, pain control, and progress in program. In each program frequency, speed of exercises, duration and timing in regards to daily life functions should be carefully spelled out. Hydrotherapy has beneficial effects of buoyancy (which reduces joint concussion and tendon strain), increasing cardiac output, edema reduction and warming/cooling therapy. Hydrotherapy doesn’t necessarily require an underwater treadmill; large tubs, floatation tanks, ponds, and even kiddie pools/small adult pools can suffice.

Therapeutic ultrasound is used to provide heat to deep structures in hopes of relieving pain, reducing strain and sprain inflammation, and reducing contracture potential. Electrical stimulation in the form of neuromuscular reconditioning (NMES) and TENS (transcutaneous nerve stimulation) can be helpful for reducing pain, excitation of neuromuscular coupling, and facilitation of muscular fibers (recruitment). Photobiomodulation is a modality that is rapidly gaining popularity for assistance in rehabilitation but also as a solo therapy for more chronic pain and inflammation reduction. Low level red and infrared radiation is utilized to provide increased healing through improved blood flow, reduced cytokine production and increased mitochondrial cellular metabolism.

References

1. Canine Sports Medicine and Rehabilitation. Zink MC and VanDyke JB eds. Wiley Blackwell 2013.
2. Canine rehabilitation and Physical Therapy, ed. 2 Millis DM and Levine D eds. Elsevier 2014.
3. Animal Physiotherapy: Assessment, Treatment and Rehabilitation of Animals, Edition 2. McGowan C and Goff L eds. John Wiley and sons 2016.