The benefits of physical rehabilitation have been well documented in canine practice (Levine et al, 2005). It is far less applied and documented in feline practice and as such the benefits found in treating feline patients are often missed and under utilised. In many cases of feline referral, the referral is made as a last attempt to find support for a patient and owner, when other more conventional treatments have been tried; in these cases many of the benefits from physiotherapy or other complementary treatments, which can be dependent on application in the early stages, are lost. According to studies carried out by PetPlan in 2006, approximately 630 cats per day in the UK are hit by a car (unpublished data). In research by Rochlitz (2004) it was found that on average a cat recovering from a road traffic accident (RTA) took 47 days to recover, and that the severity of the injury directly correlated with cost and length of treatment and to the number of days to recovery. None of the cases followed received any form of physical rehabilitation which may have improved recovery time.
Rehabilitation in cats should also be considered for chronic conditions. Studies show that physiotherapy, as part of a rehabilitation programme, was a successful modality in the treatment of canine cases of osteoarthritis (OA) (Bockstahler et al, 2004); and in studies carried out by Slingerland et al (2011) it was observed that 61% of felines suffer from OA in the appendicular skeleton with the presentation including behaviours such as hiding, choosing not to jump onto furniture and going outside less. In any case, the physical rehabilitation programme is designed to meet individual patient needs and evidence highlights the advantages of a multidisciplinary team (MDT) working together to provide high-quality patient care (Ndoro, 2014).
The use of physiotherapy in cats can be more challenging for the practitioner than the application in dogs. Techniques for applying treatment must be considered in terms of patient comfort, compliance, adaptability, deliverance and success. It is often harder to predict or read feline behaviour and handling skills can be more complex and demanding than in the canine patient. Repeatability of prescriptive home exercises can be challenging for owners. However, successfully applied physiotherapy can be just as beneficial for any feline patient as it is for their canine counterparts. Primarily it is important to understand feline behaviour (Overall, 1997). Interpreting body postures and facial changes in order to understand how cats deal with stress and conflict (Rodan et al, 2011) helps with the delivery of successful physiotherapy, which depends very much on patient co-operation and relaxation.
Physiotherapy
Physiotherapy is a form of complementary therapy best used alongside or under the referral of conventional veterinary medicine. It can be used after various diagnoses, both acute and chronic, and in some cases can be used prior to surgeries to improve muscle quality and shorten healing times. Physiotherapy focuses on the application of a range of techniques to restore or improve movement, maximise and improve tissue quality and function, aid repair and decrease pain. In some cases the application of physiotherapy can be seen as a preventative tool but in most cases it works to resolve and support.
In the UK, the practice of physiotherapy on animals is governed by the Veterinary Surgery (Exemptions) Order 1962, which allows the treatment of an animal using physiotherapy, providing that treatment is given under the direction of a veterinary surgeon who has examined the animal and prescribed the physiotherapy as a form of treatment for the case. This means that animal physiotherapists will require a referral for patients under their care from the veterinary surgeon involved. It is therefore important that any veterinary surgeon uses fully qualified practitioners who are registered with governing bodies that regulate their profession and who require that the Veterinary Surgery (Exemptions) Order is adhered to.
Veterinary physiotherapists should hold an accredited level 6/7 qualification in Veterinary Physiotherapy. In the UK the current groups under which correctly trained and qualified practitioners can belong include IRVAP, NAVP, ACPAT, IAAT for Physiotherapy, the CHA or NARCH for Hydrotherapy, the MA or MCA for McTimoney Chiropractic Manipulation and the RVC and ABVA for Veterinary Acupuncturists. With all these professions, it is essential that members are used for their specialist understanding in these fields. The majority of pet insurance companies in the UK now include cover for physiotherapy and complementary treatment and will require treatment to come from individuals registered to the relevant bodies.
There are many conditions which can benefit from the application of physiotherapy. While the benefits to patients recovering from orthopaedic and neurological surgeries are well documented (Johnson et al, 1997; Olby et al, 2005), it is also of benefit to chronic conditions such as OA (Riviere, 2007). More routinely physiotherapy is applied post operatively, but has also been shown to be beneficial in preparing a patient for surgery such as cruciate ligament repaire or patella fixation pre-operatively (Sharp, 2010), where it can be applied to improve tissue quality and strength and prepare a patient and owner for post-operative requirements and home management plans. In some cases the response to pre-operative physiotherapy is so good that surgery can be avoided or limited. It is important, however, to be realistic when setting expectations. If tissue is likely to degrade again over time following cessation of physiotherapy, there can in some cases be the risk that the symptoms pointing towards surgery may reappear. It is important therefore, for three way dialogues to be established between the owner, veterinary surgeon and physiotherapist so that the various outcomes can be discussed.
Modalities used
The type of physiotherapy technique or tool used to treat a condition is called the modality and will be chosen depending on a number of factors. These include:
Manual therapy
There are several types of manual therapy which can be used on cats, but they are largely dependent on the patient being relaxed and compliant. Some of the more basic techniques such as hot and cold therapy, massage, stretching and passive movement can be applied by veterinary surgeons or nurses who have attended relevant training programmes, but many further techniques rely on specialist physiotherapy training (Sharp, 2012).
Hot and cold therapy
These are relatively easy treatments to apply. In some cases they can also be applied with minimal contact from the handler.
Heat therapy is used to help relax tissues, sometimes prior to other forms of treatment and to decrease pain and improve blood flow, which aids healing. It can be used to improve muscle and soft tissue movement and to help with joint range. It should not be applied during the acute phase of inflammation or where there is infection. Heat can be applied superficially to a depth of 1–2 cm using heat packs, spas or gentle hosing which can also have a massaging effect. If a heat pack is used it should only be heated to a comfortable temperature and should be applied through a towel to prevent scalding. Generally heat therapy is not used for longer than 10–20 minutes. For deeper heat treatment >4 cm therapeutic ultrasound can be used.
Cold therapy can sometimes be applied in the first few days following trauma and is most effective in the first 72 hours. It can be used longer term after exercise where inflammation may occur. Cold packs provide pain relief, reduce inflammation and swelling and help control bleeding. In the acute phase treatment times are short and repeatable through the day. Generally cold packs can be applied for 4–10 minutes and can be repeated every 2–4 hours depending on the severity of the injury. Cold packs should also be wrapped in a wet towel to prevent ‘ice burn’. The towel must be wet to aid dissipation of heat away from the tissue.
Passive movement
Passive movement is used to restore or maintain joint function and muscle length and to reinforce patterns of movement, which is particularly useful after neurological damage or mobility issues following trauma. The movements are made in a rhythmical manner, through the full pain-free range and involve no input from the patient. They can therefore be applied to patients on crate rest or with paralysis.
Stretch techniques
Most commonly these are passive movements, quite well tolerated by feline patients. These should be performed after heat treatments, massage or passive movements so that the tissue is warm and pliable. Stretches help to restore joint range or improve muscle length so are applicable during many different types of convalescence or indeed in cases of chronic changes to the joints and associated tissue from conditions such as OA. They are long, gentle movements. Generally static stretches are held for at least 30 seconds with little force. They are repeated several times to help realign collagen fibres and Starring et al (1988) suggest 20–30 minutes daily to be the optimum to achieve improvement. In cats, this is better subdivided into two or three sessions to prevent boredom and loss of co-operation. Stretches create plastic (permanent) deformation and increase length of tissue or range of joints. They can also help to improve muscle mass as normal function is restored. Active stretches are achieved during exercises and are shorter more energetic movements of the tissue.
Massage
Massage may be one of the better tolerated techniques in feline patients. It involves the gentle manipulation of soft tissue and muscle using a variety of techniques detailed in Table 1 achieving a variety of benefits. The massage technique chosen would be determined by the tissue type, size of area treated and outcome required. One of the benefits of massage is that it can be successfully taught to an owner so that they can continue with the benefits at home and become more involved in their pet's rehabilitation (Table 1).
| Technique | How to perform | Purpose | |
|---|---|---|---|
| Stroking | The hands are gently glided over the body in any direction (usually head to tail), minimal pressure is applied | Relaxes the patient and accustoms them to handling | |
| Effleurage | With gentle to medium pressure the hands are glided over the body in the direction of the heart/from distal to proximal | Relaxation |
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| Petrissage | Kneading | Inward and upward pressure is applied intermittently to tissue | Creates a pumping action to increase blood flow to the area and removal of waste |
| Skin rolling | The skin and subcutaneous tissues are lifted up using the thumb and fingers. Skin is then rolled between the thumb and fingers | Helps mobilise tissues | |
| Wringing | The tissue is grasped and raised up with both hands. The hands are then moved back and forth in opposite directions before the tissue is gently released | Improves circulation |
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Other manual therapies involve the movement of specific structures using targeted and very specific techniques. Joint movement occurs routinely during locomotor function and in general physiological movement. This movement is assessed in respect of range of motion (ROM), laxity or pain, but there are smaller movements within joints including slide and glide which physiotherapists will also assess and treat, where dysfunction occurs. The pain free movement of a joint rarely relies on one aspect of movement. It often also relies on the supporting soft tissues proximal or distal to the joint. The application of different techniques to these joints or their supporting tissues can be divided into three further sub groups: mobilisation; neural mobilisation and manipulations (Table 2).
| Mobilisation |
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| Neural mobilisation |
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| Manipulations |
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Therapeutic exercise
Therapeutic exercises commonly fall into the following categories:
Exercises suitable for these functions in cats are detailed in Table 3.
| Requirement | How to achieve |
|---|---|
| Strenthening | Running (controlled lead running or treadmill), uphill and downhill slopes, leg weights, standing on hind legs and dancing, wheelbarrowing, hydrotherapy |
| Flexibility | Crawling under, over or through objects, cones and poles, weaving on a lead to follow a treat, stick and feather to encourage reach and stretch |
| Balance and proprioception | Wobble cushions, rocker boards, following feathers on a stick, walking through scattered hula hoops, walking in circles and weaving through cones, walking over obstacles and using proprioceptive tracks of concurrent surfaces which vary in texture |
| Endurance | Less relevant to felines as they have rapid responses and short burst movements, but aerobic exercises such as hydrotherapy or treadmill or active exercises used for more than 15 minutes several times a week would assist |
Electro therapy
The use of medical devices in feline rehabilitation are shown to be very useful. Most of them are non-painful forms of treatment which cats tolerate well (Drum et al, 2015). However medical devices could be potentially dangerous and should only be used by operators who have received specialised training.
According to Johnson et al (1997), neuromuscular electrical stimulation (NMES) can be used to reduce atrophy in denervated muscle by stimulating the motor nerves. It is particularly useful in cats that cannot control voluntary movement or that cannot tolerate active exercise. It also helps maintain and improve muscular strength in immobilised tissue following surgery. Transcutaneous electrical nerve stimulation (TENS) helps to relieve symptomatic pain by stimulating the pain gate mechanism. Activation of sensory fibres results in the consequent reduction of noxious stimuli transmission from the ‘pain fibres’ and endogenous opioid release (Johnson, 2008). It is useful post operatively and in cases where trauma has resulted in pain during the recovery phase.
Busse et al (2002) observed in a review that there is evidence that low intensity pulsed therapeutic ultrasound treatment may significantly accelerate fracture healing. Therapeutic ultrasound is a form of mechanical energy absorbed by muscles and other tissues, speeding the rate of healing and enhancing the quality of the repairing tissue (Tis et al, 2002). Ultrasound can be used in the treatment of soft tissue injury and in some cases around the joint. It is advisable to avoid treatment over metal plates, implants or shallow bony areas as the ultrasound waves can cause discomfort in these instances or indeed if the ultrasound head is not sufficiently moved and the tissues over heat.
Low level laser uses light at different wavelengths which is absorbed in the superficial tissues. Scattering and absorption affects the distribution of photons in the targeted tissue and accelerates the tissue repair process, lymphatic activity and the production of nerve cells and B-endorphins working on pain relief (Hashmi et al, 2010). It is a well tolerated treatment with little to no sensation. It is used for a variety of conditions from wound healing to soft tissue and joint treatment. It is not used over the site of tumours or near the eye or over the uterus of pregnant females. Commonly the visible blue light laser is used where infection has occurred to help reduce bacteria and visible red only where infection is not present, to accelerate tissue repair and growth. The invisible infra-red spectrum is used for soft tissue and joints (Figure 1).
Pulsed electromagnetic field therapy can be used for acute and chronic injuries to improve cellular repair by increasing the local perfusion to the capillary blood flow. Again this treatment has no sensation and so is well tolerated by feline patients. Delivery is usually via a pad and so it can often be used on recumbent, resting or crate bound cases. It is essential to ensure no patient or handler is wearing an electronic medical device such as a pacemaker as these can be disrupted by the strong electro-magnetic fields (Figure 2).
Home management
The discussion of home management for the patient is an area often overlooked as part of the physiotherapy process. Practices such as restricting access to parts of the house, e.g. staircases or furniture, in order to limit certain movements, placing feeding stations at different heights and being cautious about access to slippery floor surfaces can all play a role in minimising detrimental effects on a physiotherapy programme or in some cases be used to support its applications, e.g. use of stairs at certain points in a recovery programme.
Referral
As previously mentioned, all patients requiring physiotherapy will be required to have a referral to the practitioner working as part of the MDT. It is worth noting in this article that the process and quality of the referral is of significant importance to the receiving physiotherapist. A well-documented referral containing as much patient history as possible will make the treatment process most fluid and appropriate. Many physiotherapists have their own referral forms which they provide for completion. These should be as detailed as possible regarding the current case history and current treatment the patient is receiving. In addition, any relevant scans or x-rays are useful and any existing notes regarding previous clinical history, both related and unrelated, should be attached. This is because on occasion history which seems medically unrelated to a current condition, can in fact have a bearing on the suitability of a potential physiotherapy treatment for that patient. A good referral history can also help enhance understanding between professionals and further their experience and learning.
Conclusion
The benefits of physical rehabilitation have been well documented in canine practice (Levine et al, 2005). It is far less applied and documented in feline practice and as such the benefits in treating feline patients are often missed and under utilised. There are many suitable physiotherapy techniques which can be successfully applied to the feline patient for the treatment of a variety of conditions. The key to successful rehabilitation is the early identification of suitable patients, an informative referral and the engagement of a correctly qualified physiotherapist to work as part of the MDT both in acute and chronic conditions and in some cases as a preventative treatment.