Getting Your Patients Back on All Fours

By Robert Sullivan, VMD

Understanding Rehabilitation Medicine

As veterinarians, we took an oath that included, “The prevention and relief of animal suffering… .” Since becoming a veterinarian, the meaning of those words has evolved many times for me. They now include physical rehabilitation and integrated pain management.

Very quickly after learning how to repair ACLs and plate broken bones, I learned that knowing how to repair these maladies was only part of the healing process for our patients. We have to get our patients moving using physical rehabilitation along with appropriate pain medication. I enrolled in the Certified Canine Rehabilitation Program at the University of Tennessee (Knoxville) to learn more.

According to the American Association of Rehabilitation Veterinarians, “Physical rehabilitation is the diagnosis and management of patients with painful or functionally limiting conditions, particularly those with injury or illness related to the neurologic and musculoskeletal systems. The goal of rehabilitation is to achieve the highest level of function, independence, and quality of life possible for the patient.”

During the rehabilitation program at UT, we were introduced to methods to evaluate and measure our patient’s condition at the beginning of therapy and to track their progress during therapy. Knowing these measurements and comparing them to norms not only help us to create a treatment plan, it gives us data to show owners to demonstrate their pet’s improvement. Some of the measurements and tools we use include:

• Goniometry measures the angles of flexion and extension of the joints. • Tape measures measure the circumference of the limbs to show loss or gain of muscle mass. • Video, especially slow motion, aids in determining which limb or joint is in need of attention. • Force plates, either static or a runway, will digitally show which limb the patient is using less and on which limb the pet is placing more weight. • Thermography can pinpoint an area of inflammation in a joint, muscle, or tendon.

As important as the objective measurements are, subjective, hands-on exams are essential to determine the source of lameness or pain. Observing the pet’s response, or lack of response, to flexion, extension, rotation, palpation, and pressure will help determine where you need to focus your attention. Palpating each joint to feel for crepitus, effusion, or warmth will also aid in locating injury or illness.

Once the patient’s needs have been determined, a plan must be created to return the pet to normal function. Owners must understand that this is not a short process. Explaining to the owner that a single session is not enough has proven to be our biggest hurdle.

The first, and sometimes hardest, step in rehab is to get the patient moving. For each day of immobility, there can be up to one week of rehab. Owners can play an important role in this stage of treatment. Simple range-of-motion exercises can be done by the owner and are part of each rehab session in the office. Cross-legged extension, which involves lifting the leg opposite the injured limb to stimulate the pet to extend the affected limb, can be taught to the owner as well. Other exercises, such as wheel-barrowing, walking on hind legs, and sit-to-standto-sit-to-lie-to-sit will also be part of the treatment plan. If capable, the patient can be asked to walk an obstacle course, the easiest being cavaletti rails for the pet to step over.

Core strengthening exercises work on the whole patient, building up abdominal; epaxial; and the small, but vitally important, adductor muscles of the groin and thorax. Leaning, gently pushing the pet forward, backward, or side to side so the pet pushes back at you, are easy to learn and teach. Using exercise balls and balance boards can be added to increase the difficulty and will also allow you to pinpoint specific muscle groups.

Typically, when rehabilitation is mentioned, the image is of the underwater treadmill (UWT). The UWT is a wonderful tool for getting a patient to

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For More Information

Veterinary Rehabilitation Associations

• American Association of Rehabilitation

Veterinarians - rehabvets.org • American College of Veterinary Sports

Medicine and Rehabilitation - vsmr.org • International Association of Veterinary

Rehabilitation and Physical Therapy -

iavrpt.org

Veterinary Rehabilitation Training

• Academy of Animal Sport Science -

academyofanimalsportscience.com

» Animal Sports Therapy and Rehabilitation Certification • Canine Rehabilitation Institute -

caninerehabinstitute.com

» Certified Canine Rehabilitation Therapist » Certified Canine Rehabilitation Veterinary Nurse » Certified Veterinary Acupuncture Therapist • Northeast Seminars/University of

Tennessee - utvetce.com » Certified Canine Rehabilitation Practitioner

Simple At-Home Care for Osteoarthritis

• Weight control » Weight loss, weight loss, weight loss • Joint supplements » Chondroitin sulfate, glucosamine » Omega-3 fatty acids • Multimodal pain management » NSAIDs » +/- Gabapentin or pregabalin » +/- NMDA antagonists » +/- Antidepressants » +/- CBD (?) • Keep those joints moving » Exercise promotes inflammation. Inflammation is both beneficial for healing as well as detrimental. Antiinflammatories block the negative aspects. move, but it is not required for rehab. The UWT uses the patient’s buoyancy so the pet is walking while carrying less of its mass. A 100-pound dog in a treadmill filled up to the dog’s shoulder will only be walking on 35% of its usual weight, giving even a limb weak from prolonged disuse a better chance of supporting the pet. And the pet is moving in warm water. An alternative to UWT is to use a folding treadmill to help keep a pet moving. A swimming pool can also provide weightless movement with a little resistance from the water.

In addition to getting patients moving, treatments that improve blood flow to the affected area are important for success and help to relieve pain. This can be done through warming the affected area with moist heat for 10 minutes prior to any exercise. Other warming modalities include therapeutic ultrasound to warm deeper into tissue and photobiostimulation (laser) therapy. The skin needs to be shaved for these last two processes to be effective. Appropriate use of massage will also loosen muscles and improve circulation. Myofascial trigger point therapy is another technique that is used to “release” or relax muscles in spasm.

Sometimes, either through extensive disuse or nerve damage, additional stimulation is required to get the patient to move a limb. Electrostimulation (stim) uses numerous wave-forms, frequencies, and milliamperes to stimulate the muscles to contract and relax or twitch to recruit muscle fibers and rebuild some muscle and nerve functions.

Through hands-on patient assessment and measurements, exercise, handson therapy and manipulation, and the use of various modalities, your orthopedic, neurologic, or otherwise motion-deprived pets can get moving again.

About the Author: Robert Sullivan, VMD, graduated from the University of Pennsylvania School of Veterinary Medicine in 1996, then moved to and started working in Montrose, PA. In 2005, he started Southtown Veterinary Hospital, and eight years later, built the current facility, which includes rehab. In 2014, Dr. Bob completed certification in Canine Rehabilitation at the University of Tennessee. He also has special interests in internal medicine, general and orthopedic surgery, and lately, pain management. Dr. Bob is married to Rebecca and they have two wonderful children, Alannah and Lee John. Over the years, his pets have included ferrets, fish, horses, and rodents. Currently, the Sullivans have a 12-yearold rescue dog, Hank, a Chesapeake Bay Retriever who spends most days with Dr. Bob at the office. They also have four cats: two pairs of orange siblings, Pumpkin and Blizzard, and Trick and Treat that were orphaned at 5 days old, bottle fed, and cared for by the family. When not in the office, Dr. Bob is tending to his flock of chickens, his beehives, or his garden.