Canine Rehabilitation and Physiotherapy Quiz

Physiotherapy & Rehabilitation of the Musculoskeletal System

• This presentation covers physiotherapy and rehabilitation for musculoskeletal disorders in sport horses and dogs.
• Learning objectives include describing different treatment approaches, understanding the role of para-professionals (e.g., chiropractors, farriers), determining appropriate exercise programs and complementary treatments, and developing management strategies to reduce re-injury risk.
• Definitions of physiotherapy and rehabilitation are provided. Physiotherapy is the treatment of injury or disease by physical methods. Rehabilitation is restoring health through training and therapy back to its previous condition.
• To apply these programs, a good understanding of anatomy, biomechanics, and tissue function is essential.
• A team approach for treatment, involving veterinarians, nurses, rehabilitation facilities, farriers, prosthetists, saddle fitters, and nutritionists, is vital.
• All team members should have clearly defined goals to avoid potential issues from lack of knowledge. Modality use should consider the pros and cons of each.
• Veterinarian qualifications include masters courses (e.g. veterinary physiotherapy from Harper Adams and Writtle University), and other specializations (e.g., certified in veterinary acupuncture).
• Human physiotherapists may qualify via the Association of Chartered Physiotherapists in Animal Therapy (ACPAT).
• Communication is important to ensure everyone is on the same page in the healthcare of the patient.

Rehabilitation Issues

• Rehabilitation is phased, starting with the acute phase that involves pain management, controlling inflammation and swelling, and improving reduced range of motion (ROM).
• The proliferative phase focuses on re-establishing muscle strength, flexibility, and resolving functional losses.
• The remodelling phase involves conditioning for exercise goals, considering sport-specific demands, and preventing re-injury.

Aims of Physiotherapy & Rehabilitation

• Exercise, physical therapy, manual therapy, and modalities aim to resolve pain, restore and maximize function, and minimize re-injury.

Practical Application - How to Start

• The whole animal approach should be utilized. Start with a thorough examination, recording objective and subjective findings and prioritising the injured area.
• Develop a plan to resolve the initial pain and encourage normal function. Establish the owner's commitment, available resources, and the time frame for treatment.
• These plans should aim for restoration of normal form and function, and should be tailored, personalised, and frequently reviewed every 4-6 weeks or as often as possible.

Pain in the Rehabilitating Animal

• Identifying pain in animals can be difficult, requiring observational and interactive methods. These include lameness grading, functional tests, and pain scales (WOMAC, KOOS, Facial grimace scale, ridden horse ethogram, composite pain scales).
• Objective pain methods include biomechanical analysis, force mat/plate, kinematic analysis, inertial sensor systems, goniometry, and pressure algometry

Pain in the Rehabilitating Patient

• Resolution of pain incorporates systemic or topical medications, intra-synovial medications, cryotherapy, heat therapy, electrophysical therapy (TENS, ECSWT), manual therapy (massage, chiropractic, and physical therapy), myofascial release, and routine rechecks.
• Monitoring includes re-evaluating the patient based on progression or problems reported.

Restoring Function

• Once pain is controlled, focus shifts to targeting tissue healing and function restoration.
• Essential components of a rehabilitation program can include exercise programs, physical therapy, manual therapy, and various modalities.
• Important factors to consider as treatments are implemented are time, cost, and balancing them against the benefits of treatment received.

Restoring Function - Exercise

• Walking programs, both in hand and on treadmills, can improve conditioning. Care should be taken with horsewalkers. Aim for controlled and progressive programmes, while adjusting frequency and duration. Shortening duration with higher frequency is beneficial. Consider changing surfaces and introducing inclines/downhill slopes and lateral work. Progressive increase in speeds/intensities is beneficial for all conditions if appropriate support is available (e.g. orthotics/harness/theraband).
• Pole work or cavaletti exercise incorporation is ideal as this stimulates the tissues safely and increases engagement and proprioception. Progression can be via increasing number in sequence, height of poles, and number of passes/configuration.
• Underwater treadmills and swimming are recommended due to the benefits of temperature, viscosity, buoyancy, and water pressure. These are helpful to recover from arthritis or joint pain, etc.

Restoring Function - Physical Therapy

• Stretching is important for re-establishing proprioception (sense of body position and movement) and neuromotor control, improving balance and coordination, flexibility of the injured structure and strength of the supporting musculature.
• Maintaining recovery time to fatigue and stretching of core musculature are also crucial for improving cardiovascular health, coordination, strength, and overall well-being.
• Proprioceptive training plays a crucial role. This relays body positioning. Joint capsule, muscle and tendons require proper stimulus. Conditions like instability of a structure, healing status, neurologic impairments need extra care.

Restoring Function - Physical Therapy: Exercise

• Methods like wobble boards, balance balls, and proprioceptive pads offer variety. Sessions should start shorter and gradually increase intensity, frequency, and difficulty to help identify and improve shortcomings over time.

Restoring Function - Physical Therapy: Injury Specific Stretches

• Injury-specific stretches aim to improve connective tissue elasticity, increase the strength of supporting muscles, and restore normal ranges of motion.
• Stretches can be categorized as concentric, eccentric, or isometric – dependent on the loading direction to increase or reduce muscle/tissue length.

Restoring Function - Physical Therapy: Injury Specific Stretches

• Stretches should be performed gradually in a controlled and gradual manner in a safe and beneficial way. Consider additional work such as balance work to continue improving the patient. Additional difficulty can be attained by increasing repetitions, sets, and complexity.

Restoring Function - Physical Therapy: Core Stretches

• Core stretches focus on injury or MSK pain that can be chronically present in some animals. This includes proper strength, flexibility, and coordination.
• Re-establishing normal weight bearing and reducing overload of the back (as indicated from stretching) are essential for improving posture and functionality.
• Additional considerations should be given to conditions of pain, inflammation, and compensating structures.

Restoring Function - Manual Therapy

• Manual therapy techniques include passive mobilization (e.g., massage), manual stretching and mobilization, and joint mobilizations and manipulation (chiropractic).
• Indications for manual therapy include muscle length restriction (reduced flexibility), limited arthrokinematics (joint motion), and limited range of motion (ROM). Passive range of motion (ROM) assessed rhythmically in joints to allow for comfortable assessment and treat any restriction. Passive ROM should be performed at a comfortable speed for both the patient's comfort and efficient treatment.
• Manual therapy tools include hands, activators, tennis balls, and rollers.

Restoring Function - Manual Therapy: Soft Tissue Mobilization

• Massage (soft tissue mobilization) is another manual therapy. Techniques can be used to address the myofascial system, increase tissue extensibility, reduce pain, inflammation and fascial restrictions.

Restoring Function - Modalities

• Numerous modalities are used for pain relief and tissue healing. They include laser therapy, therapeutic ultrasound, neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), extracorporeal shockwave therapy, and cryotherapy.

Restoring Function - Modalities: Laser Therapy

• Laser therapy utilizes light to increase cellular metabolism, oxygen production, collagen synthesis, and vasodilation.
• Different classes of lasers exist, with varying powers and uses for conditions like wound healing, inflammation, and pain.

Restoring Function - Modalities: Therapeutic Ultrasound

• Therapeutic ultrasound uses high frequency sound waves to increase blood flow, reduce pain, and promote tissue healing. Various modes (pulsed and continuous) and intensities to achieve specific effects. Therapeutic ultrasound is helpful for scar tissue, muscle tears, and joint capsule fibrosis.

Restoring Function - Modalities: Neuromuscular Electrical Stimulation (NMES)

• NMES utilizes electrical currents to stimulate muscles, increase muscle mass and strength, and target specific muscle fibres.
• Important factors when using NMES are the resting muscle length, and duration and intensity to achieve the desired results.

Restoring Function - Modalities: Transcutaneous Electrical Nerve Stimulation (TENS)

• TENS utilizes electrical currents to stimulate nerve tissues. It's employed to manage pain through nerve modulation, using high frequency and low frequency signals and durations depending on the client needs.

Restoring Function - Modalities: Extracorporeal Shockwave Therapy

• Extracorporeal shockwave therapy uses high-pressure, short-duration sound waves to reduce inflammation, promote tissue healing, and increase blood flow. This is useful for conditions requiring reduction of inflammation and increased blood flow.

Restoring Function - Modalities: Cryotherapy

• Cryotherapy involves cooling the tissues with ice packs to reduce pain, inflammation, swelling. This helps reduce tissue damage, nerve conduction and improve recovery times post-operatively.

Restoring Function - Modalities: Kinesiotape Application

• Kinesiotape is an elastic therapeutic tape used to provide an elevation action to support the patient. It is used in conjunction with the myofascial tissues, to move and increase flexibility, improve blood vessels, and improve lymph flow and increase support and proprioception to relieve pain and/or discomfort.

Restoring Function - Modalities: Acupuncture

• Acupuncture, a traditional Chinese medicine method, is used to normalize homeostasis and promote self-healing through promoting relaxation, activating immune and anti-inflammatory responses, pain relief via endorphin release, and promoting accelerated tissue healing.
• It's often used as a supplementary treatment for various conditions.

Rehabilitation Monitoring: Procedure

• Frequent monitoring (including telephone calls, video conferences, in-person rechecks) and dynamic interaction between veterinarians, and rehabilitation providers are essential.
• Rehabilitation protocols are tailored, simple and provide success to both the patient and owner, and are easily adaptable in case setbacks or deviations occur.

Summary

• Physiotherapy and rehabilitation are personalized, requiring frequent re-evaluation to monitor an animal's recovery rate.
• Commitment, attention to detail, and thorough diagnoses are paramount in a successful recovery.

References

• A list of relevant resources and research papers are listed for further reading.