JDaglish Physiotherapy and Rehabilitation Final 2023 PDF

PHYSIOTHERAPY & REHABILITATION OF THE MUSCULOSKELETAL SYSTEM JODIE DAGLISH BVSC MS DACVSMR MRCVS EQUINE SPORTS MEDICINE AND REHABILITATION CLINICIAN 1 PHYSIOTHERAPY & REHABILITATION Learning objectives: 1. Describe different approaches to trea...

PHYSIOTHERAPY & REHABILITATION OF THE MUSCULOSKELETAL SYSTEM JODIE DAGLISH BVSC MS DACVSMR MRCVS EQUINE SPORTS MEDICINE AND REHABILITATION CLINICIAN 1 PHYSIOTHERAPY & REHABILITATION Learning objectives: 1. Describe different approaches to treatment of common musculoskeletal disorders in of common musculoskeletal disorders in sport horses and dogs 2. Understand the role of para-professionals within the treatment team 3. Determine appropriate exercise programs for musculoskeletal injury including use of resources such as treadmills and hydrotherapy 4. Determine appropriate complementary treatments for musculoskeletal injury including use of resources such as manual therapy and physiotherapeutic equipment modalities 5. Develop management strategies which reduce risk of re-injury injury 2 DEFINITIONS  Physiotherapy  Treatment of disease or injury by physical methods and aided by education and advice.  Rehabilitation  The action of restoring health through training and therapy to its former condition.  To apply or recommend physiotherapy and rehabilitation programs there must be good understanding and application of anatomy, biomechanics, tissue structure and tissue function 3 APPLICATION OF PHYSIOTHERAPY & REHABILITATION  Who is involved?  TEAM approach – it can take a village Veterinarian(s) Chiropractor Nurses Physiotherapist Rehab facility Farrier Prosthetist Saddle fitter Acupuncturist Nutritionist  Everyone involved should have clearly defined goals in mind when working  Modalities shouldn’t be used unless consideration has been given to the pros and cons of each  Lack of knowledge can cause further injury or pain 4 APPLICATION OF PHYSIOTHERAPY & REHABILITATION  Main Providers of Qualifications:  For Veterinarians  For (Human) Physiotherapists  Masters courses:  Association of Chartered Physiotherapists in Animal  Veterinary Physiotherapy- Harper Adams Therapy (ACPAT)  MSc Veterinary Physiotherapy – Writtle University  Masters courses:  MSc Veterinary Physiotherapy- Hartpury College  Other complementary therapies/ specialisations:  MSc Veterinary Physiotherapy – Writtle University  Certified in Veterinary Acupuncture (CVA)  International Veterinary Acupuncture Society (IVAS)  Association of British Veterinary Acupuncturists (ABVA)  COMMUNICATE  British Veterinary Chiropractic Association (BVCA)  Be sure that you are confident in who  International Veterinary Chiropractic Association (IVCA) you are asking to help  Useful to know what is available in your area 5 REHABILITATION ISSUES  Acute Phase  Pain management  Control inflammation, swelling and effusion  Proliferative Phase  Improve reduced ROM  Re-establish muscle strength and flexibility  Resolve functional losses  Remodelling Phase  Conditioning for exercise goals  Sport specific demands 24 hours  Prevent re-injury 6 AIMS OF PHYSIOTHERAPY & REHABILITATION Exercise Physical Therapy Manual Therapy Modalities Patient Resolution of Restore Maximise Minimise Re- Pain Function Function Injury 7 PRACTICAL APPLICATION – HOW TO START?  WHOLE ANIMAL APPROACH  Faced with the patient in front of you, where do you begin?  Thorough and systematic examination  Record objective and subjective findings for comparison later  Make a list of findings in order of priority  Usually the injured site is number 1  Establish a plan to resolve initial pain and begin to encourage normal functional return  What is the owner willing to commit to?  What facilities / specialists do you have available to you?  Time frame – is there a target to aim for?  To achieve restoration of NORMAL form and function: ▪ Tailored, personalized and frequently reviewed rehabilitation plan ▪ Set up 4-6 weeks of plan and then review. If possible, review more often 8 PAIN IN THE REHABILITATING ANIMAL  Identifying Pain  Notoriously difficult to identify pain in some animals  Observational and interactive methods (Subjective)  Lameness grading  Functional tests  Pain scales  WOMAC, KOOS, Facial grimace scale, ridden horse ethogram, composite pain scales  Objective methods  Biomechanical analysis  Force mat/plate  Kinematic analysis  Inertial sensor systems  Goniometry  Pressure algometry 9 PAIN IN THE REHABILITATING PATIENT  Resolution of Pain  Systemic or topical medications – NSAIDs, opioids, neuromodulators, muscle relaxants  Intra-synovial medications – IRAP, PRP, MSCs, PSGAG, corticosteroids  Cryotherapy  Heat therapy (Laser, therapeutic US)  Electrophysical therapy (TENS, ECSWT)  Manual therapy (Massage, chiropractic, physical therapy, myofascial release)  Monitoring Pain  Routine rechecks – perform sooner if there are reported issues  Is the patient progressing as you would expect?  Patients in the rehab clinic, re-evaluate weekly → patients at home every 2-4 weeks 10 RESTORING FUNCTION  Now that pain is under control you can begin targeting tissue healing and restoration of function  Substantial overlap with pain resolution as exercise can increase and decrease inflammatory response  What to include in a program?  Exercise program  Physical therapy  Manual therapy  Modalities  Considerations for time  Considerations for expense  Consider cost : benefit ratio 11 RESTORING FUNCTION - EXERCISE Walking Programs  Can be done ‘in hand’ or on treadmill to improve conditioning and to increase muscular strength and endurance  Care with equine horsewalker – may not be suitable for unilateral structural injury  Aim for controlled and progressive programs  Shorter duration, higher frequency better  Reduces fatigue on injured structure  Increase difficulty over time  Changing surfaces – esp. equine soft tissue injury  Inclines / Downhill slopes  Introduce bending / lateral work  Progress gradually to higher speeds and intensities  Good for all conditions if appropriate support provided – orthotics / harness / theraband 12  From: www.vvphysiotherapy.co.uk RESTORING FUNCTION - EXERCISE Pole Work or Cavaletti  Incorporate into walking exercise ideally  Should be performed when tissues are warmed up  Useful challenges:  Provide mental stimulation during walking exercise  Increase ROM of joints  Increase protraction and retraction of the limb  Increase proprioception  Loading the foot following ‘landing’ over a raised pole increases impact forces  Progression achieved via increased:  Number in sequence  Height of poles  Number of passes over sequences  Configuration of poles 13 RESTORING FUNCTION - EXERCISE Underwater Treadmill or Swimming  Multiple benefits derived from water properties:  Temperature, viscosity, buoyancy, hydrostatic pressure, osmotic pressure, treadmill speed – all need to be considered when developing a program  Depth of water  As water depth increases the following are seen:  Increases ROM of next joint up (e.g. fetlock height increases hock ROM)  Reduces load on limbs (15% elbow, 30% shoulder & 75% tuber coxae)  Increases resistance to movement  Increases flexion-extension of back  Increases stride length  Increases stride symmetry  Increased postural stability  Indicated for management of OA, geriatric, neurological, overweight and weak patients. In the horse also used frequently for soft tissue injury of the distal limb.  Avoid when SI region pain diagnosed – exacerbates stress in the pelvis. 14 RESTORING FUNCTION – PHYSICAL THERAPY Physical therapy  Stretches to re-establish proprioception and neuromotor control  Improves balance and coordination  Stretches to target the injury  Improves flexibility of the injured structure (tendon, ligament, joint capsule)  Improves strength of the supporting musculature  Increases time to fatigue  Stretches to target the core  Improves strength of the supporting musculature  Improves coordinated movement  Improves cardiovascular endurance 15 RESTORING FUNCTION – PHYSICAL THERAPY Proprioceptive Training  Relays information about where the body is in space  Aim to increase neuromotor control by stimulating proprioceptive organs in:  Joint capsule  Muscle  Tendon  Vestibular system  Require increased input when:  Instability of a structure  Healing status – increased proprioceptive input = protective  Neurologically impaired (systemically or locally) From: www.healthcarehk.com 16 RESTORING FUNCTION - EXERCISE Proprioceptive Training – Theraband Systems  Used commonplace in human PT – increasing in veterinary  Wide elastic material, increasing resistance with increasing thickness  Some commercial systems available (Equicore Concepts™, Biko Progressive Resistance Bands)  Alternatively purchase from human physio resources and fashion a system  Can use to: http://veterinaryteam.dvm360.com/3-products-get-pets-back-peak-condition  Assist stretches  Direct gait patterning – external or internal input  Activate muscles during exercise  Can use in conjunction with other stimulators (e.g. poles) 17 RESTORING FUNCTION – PHYSICAL THERAPY Proprioceptive Training – Balance Training  Similar to wobble boards / bosu ball / gym ball used for humans  Many systems now available for canine patients  Murdoch Method Surefoot Pads or Theraband Proprioceptive Pads for equine  Variable deformity or degree of wobble  Increases proprioceptive stimulus  Should improve over time – see fewer obvious corrections  5 minute sessions 2-3 times per day  Increase difficulty by:  Increasing deformity of pad / ball  Perturbate the system – stretch while balancing 18 RESTORING FUNCTION – PHYSICAL THERAPY Injury Specific Stretches  Increasing elasticity of the connective tissues  Increasing strength of the supporting muscles  Increased normal range of motion  Re-establish neuromotor control  Stretches may be:  Concentric – tissue shortens under load (e.g. bicep curl, ROM)  Eccentric – tissue lengthens under load (e.g. heel raises, wither pull)  Isometric – tissue length remains consistent under loading (e.g. plank) 19 RESTORING FUNCTION – PHYSICAL THERAPY Injury Specific Stretches  Stretches should be performed in a controlled and gradual manner  Take care – know that another injury isn’t present  Trial your stretching program with the patient and owner  Is it reasonable for the patient  Does the owner understand the stretch  Point out ‘cheating’ and how to avoid it  Do baited stretches last  Stretches can be increased in difficulty by:  Increased repetitions / sets  Increased complexity  Combining with another stretch or balance work From: www.goldengatevet.com 20 RESTORING FUNCTION – PHYSICAL THERAPY Core Stretches  Many animals have been compensating for injury or MSK pain chronically  Supporting muscles in the neck, trunk and pelvis become:  Atrophied & weak  Hypertrophied, hyperresponsive & painful  Core stretches target the body to improve strength, flexibility and coordination  Re-establishes normal ‘even’ weight bearing and minimises overload  Resolves pain or restriction secondary to compensation  Think pilates – and suggest that your owner does too  Stretches should progress – they won’t be great to begin with  Provide different stretches where pain precludes another  Don’t underestimate treating pain associated with these regions to assist recovery 21 RESTORING FUNCTION – PHYSICAL THERAPY Core Stretches  Warm the tissues before stretching  Start with 5 repetitions x 1-2 set(s) per day, 5-6 days per week  Shown to be effective in:  Increasing epaxial muscle symmetry  Increasing flexibility through the axial skeleton  Improve postural control  Animals develop muscle soreness and fatigue too  Rest days are appropriate for muscle recovery  Make the program dynamic – it has to work for you, the patient and the owner 22 RESTORING FUNCTION – MANUAL THERAPY Types: Effects:  Passive mobilisations  Increases circulation  Soft tissue stretches and mobilisations (massage)  Reduces adhesions  Eliminates trigger points Indications:  Reduces pain  Muscle length restriction (reduced ‘flexibility’)  Reduces hypomobility  Limited arthrokinematics (joint motion)  Limited ROM Tools:  Primarily hands  May use activators, tennis balls, rollers Images courtesy of Lesley Goff 23 RESTORING FUNCTION – MANUAL THERAPY Passive Range of Motion  The rhythmical application of movement directed at a joint or soft-tissue structure which is performed at a comfortable speed and does not involve a high-velocity thrust  Both a way to assess range of motion and treat restriction  Perform following tissue heating/warming  20-30 repetitions, twice daily  Aim to take joint through normal ROM to ‘end feel’ and hold  Monitor limb response and facial / stance response  For therapeutic purposes perform multiple repetitions  Should improve comfort level as repetitions progress  Use post operatively as soon as day of surgery (keep very gentle) then increase from 7 days post op 24 From: Sasha A. Foster – The Art of Canine Physical Therapy RESTORING FUNCTION – MANUAL THERAPY Joint Mobilizations and Manipulations (Chiropractic)  Movement performed within ROM of a joint within the physiologic zone to produce plastic elongation (Grade 1 - 4)  Use glides and tractions to stimulate mechanoreceptors, decrease nociceptor stimulation and to reduce muscle spasm (Mailand 1977)  Use for osteoarthritis maintenance and general well being 25 Modified from: Haussler 2016 VCNA-Eq RESTORING FUNCTION – MANUAL THERAPY Soft Tissue Mobilization = Massage  Massage is manual therapy, although the area to which it is delivered is less specific than joint manual therapy  Can impart length changes and effect activity through the myofascial system  Tissue layers interfaces glide and separate triggering physiological effects  Massage increases circulation, moving lymphatics to the heart, tissue extensibility, scar mobility, pain, inflammation, muscle spasm, trigger points and promotes tissue metabolism and neuromuscular activity  Use for:  Muscle contracture, accumulation of fluid in sheaths, to break down adhesions and reduce fascial restriction 26 RESTORING FUNCTION - MODALITIES Laser Therapy  LASER = Light Amplification by Stimulated Emission of Radiation (Therapeutic window is 600-1000nm)  Photochemical, or “light” effect → increases:  Cellular metabolism  Oxygen production  Cellular proliferation (fibroblasts)  Collagen synthesis  Vasodilation  Effective in pain management, increasing blood flow and proposed to help heal cartilage  Laser classes:  Class I – ( 20,000Hz) by tissue to produce tissue relaxation and elasticity, increased local blood flow and metabolic rate, and scar tissue breakdown.  Anti-inflammatory and reduces pain thresholds  Considerations:  Pulsed mode = Anti-inflammatory  Continuous mode = Anti-inflammatory and tissue heating at 0.5-5cm depth  Intensity (0.25-3.0 W/cm2) = determines energy delivered (usually 1.5 W/cm2)  Frequency (1.0 or 3.3 MHz) = depth of penetration  Duration = most studies have shown 8-10 minutes achieves therapeutic effects  Can be used for phonophoresis: non-invasive way of administering drugs  Indicated for use: Joint capsule fibrosis, scar tissue, muscle tears or connective tissue contracture, tendinopathy, desmopathy, periosteal reaction  Contraindications: Malignancy, infection, bleeding, pregnancy, fractures, cardiac pacemakers, testes, eyes, sites of decreased sensory innervation, metal implants 28  From: Edge-Hughes 2007 RESTORING FUNCTION - MODALITIES Neuromuscular Electrical Stimulation (NMES)  Externally applied electrical current indirectly stimulates alpha motor neurons to initiate a muscle contraction  Increases muscle mass and strength by muscle fibre recruitment  Less effective than voluntary contraction  Opposite fibre recruitment  Electrodes at origin and insertion of muscle  Muscle should be at resting length or longer  Considerations:  Ramp – time from when current starts to peak current (s)  Rest cycle – 1:5 (on:off ratio)  Intensity (mA)  Duration (µs)  Frequency (Hz)  Indications: atrophied muscles, to prevent muscle loss post surgery  Contraindications: As for TU, plus osteoporosis, obesity & open wounds 29 RESTORING FUNCTION - MODALITIES Transcutaneous Electrical Nerve Stimulation (TENS)  Used for pain modulation  Stimulates sensory nerves → gate control theory for pain inhibition  Myelinated A-δ fibres  Unmyelinated C- fibres  The larger & more superficial a nerve the easier it is to stimulate – unfortunately pain fibers are small & deep  Acute pain settings:  High frequency (>100Hz)  Low pulse duration (50µs)  Chronic pain settings:  Low frequency (