References

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Johnston SA, McLaughlin RM, Budsberg SC Nonsurgical management of osteoarthritis in dogs. Vet Clin North Am Small Anim Pract. 2008; 38:1449-70

Marsolais GS, Dvorak G, Conzemius MG Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs. J Am Vet Med Assoc. 2002; 220:(9)1325-30

Millis DL Responses of musculoskeletal tissues to disuse and remobilization. In: Millis DL, Levine D, Taylor RA St. Louis, Mo: Saunders; 2004

Millis DL, Levine D, Brumlow M, Weigel JP A preliminary study of early physical therapy following surgery for the cranial cruciate ligament rupture in dogs. Vet Surg. 1997; 26:(2)

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How to perform effleurage and passive range of motion exercises

22 September 2014
Clinical
5 mins read
02 September 2014
Volume 5 · Issue 7

Abstract

There are a number of basic physiotherapy techniques that can be performed by veterinary nurses, under the direction of a veterinary surgeon, which could be extremely beneficial to the patients in their care. For example, effleurage is a massage technique which helps relax the patient, reduces oedema, improves blood flow and reduces pain. Additionally, passive range of motion (PROM) exercises are essential to maintain the range of motion (ROM) of joints when patients have reduced mobility. Without the use of PROM exercises a permanent reduced ROM could result. These physiotherapy techniques are best used as part of a rehabilitation programme designed to support the patient to make a full functional recovery.

Recent years have seen an increase in the use of physiotherapy techniques in the treatment of animals and numerous conditions have been seen to benefit. In the UK (other countries may differ), The Veterinary Surgery (Exemptions) Order 1962 allows non veterinary surgeons (VS), such as veterinary nurses (VN), to perform physiotherapy on animals if done under the direction of a VS who has examined the animal and prescribed the treatment. Although this theoretically allows VNs to perform any form of physiotherapy as prescribed by the VS, there are some physiotherapy techniques that should be reserved for qualified veterinary physiotherapists or those who have received additional training. However, there are a number of basic physiotherapy techniques that can be applied by VNs that can have a beneficial impact on the speed of recovery and quality of life of the patients in their care. This article will cover two such techniques: effleurage and passive range of motion (PROM) exercises.

Purpose of treatment

Effleurage

Effleurage is a massage technique where gentle pressure is applied to the skin while moving the hands proximally in the direction of the heart and towards the nearest lymph node. Massage has psychological benefits for the patient by helping them to relax, along with multiple physiological benefits including:

  • Directional pressure applied during effleurage encourages venous and lymphatic drainage and thus reduces oedema (Johnston et al, 2008).
  • Arterial blood flow is increased which is beneficial to healing tissues (Johnston et al, 2008).
  • Increased blood flow into and out of the tissues helps remove metabolites that may be contributing to pain (Downing, 2011).
  • Physical movement of tissues during massage helps to break down adhesions that may have formed between tissues which could be contributing to reduced movement and pain.

    • Additionally, the use of massage prior to the application of other techniques, such as PROM exercises, is beneficial as it has been reported to warm the tissues making them more flexible (Downing, 2011).

    PROM exercises

    Many conditions suffered by animals result in a period of reduced mobility. Disuse of a limb or limbs, even over a short period of time, can result in significant changes to the musculoskeletal tissues as is summarised in Table 1. PROM exercises involve the passive movement of joints within their available range of motion (ROM) with the intention of maintaining the current available ROM. Along with helping maintain the ROM of the joint, the use of PROM exercises helps to maintain the flexibility of the musculoskeletal tissues of the limb and distribute synovial fluid to maintain the health of the joint. They are seen as an important component of most physiotherapy programmes because if they are not utilised a permanent reduced ROM can occur (Shumway, 2007). It is recommended they should be performed 2–3 times daily until the animal is more mobile and able to perform exercises that encourage active movement of the joints. Controlled active exercise should be introduced as early as possible in the rehabilitation of patients as passive exercises, requiring no muscular contraction, are not sufficient to prevent/reverse the changes (Table 1) that occur due to disuse (Millis, 2004).


    Musculoskeletal tissue Effects of disuse
    Cartilage Reduced synovial fluid production and distribution
    Reduced cartilage thickness
    Changes in cartilage matrix
    Joint capsule Reduced range of motion
    Increased intra-articular pressure
    Muscle Reduced muscle strength
    Reduced mitochondrial function
    Increased stiffness of connective tissues
    Ligaments/tendons Reduction in the cross-sectional area and disorganisation of fibrils
    Reduction in collagen
    Reduced strength
    Bone Reduced bone mass, density and stiffness

    Step-by-step guide to performing effleurage and passive range of motion (PROM) exercises on the right hind limb:

    Figure 1. Patient positioned in lateral recumbency with right hindlimb uppermost.
    Figure 2. Performing effleurage.
    Figure 3. Positioning of the hands either side of the joint.
    Figure 4. Flexion of the stifle.
    Figure 5. Extension of the stifle.
    Figure 6. Flexion of the digits.
    Figure 7. Flexion of the hock.
    Figure 8. Extension of the hip.

    Step by step guide to performing effleurage and passive range of motion (PROM) exercises on the right hind limb:

  • Position the patient in lateral recumbency with the limb to be treated uppermost (Figure 1).
  • Prior to commencing effleurage spend some time stroking the patient to accustom them to your touch.
  • Effleurage: with hands moulded to the contours of the limb, start from the distal part of the limb and apply gentle to medium pressure while moving your hands proximally up the limb (Figure 2). Repeat a number of times, always working from distal to proximal to encourage venous and lymphatic return.
  • PROM: isolate the joint to be treated (e.g. the stifle) and place hands either side of the joint (Figure 3).
  • Holding the hand above the joint steady and moving the hand below the joint, gently flex the joint to the point of resistance or the first signs of patient discomfort (Figure 4). Return the joint to the neutral position.
  • In the same manner, gently extend the joint to the point of resistance or first signs of patient discomfort (Figure 5).
  • Allow the joint to return to the neutral position, and then repeat steps shown in Figures 4 and 5. Typically 15–20 repetitions are performed during a treatment session.
  • Every joint within the affected limb should be treated as all will suffer from the effects of disuse. In the case of the hind limb, PROM exercises should be performed on the digits (Figure 6), hock (Figure 7), stifle and hip (Figure 8).

    • Suitable cases and contra-indications

    Any patient that has limited use of one or more limbs will have the potential to suffer the detrimental effects of disuse, and would be suitable candidates for the application of effleurage and PROM exercises. Suggested cases include recumbent patients, arthritic patients, patients recovering from spinal injury/surgery and patients recovering from orthopaedic surgery. Research has been conducted to show the benefits of physiotherapy programmes, which incorporated massage and PROM exercises, in patients recovering from cruciate ligament surgery (Millis et al, 1997; Marsolais et al, 2002; Monk et al, 2006).

    There are however circumstances where the application of these techniques could be detrimental and so discussion should always take place with the treating VS prior to implementing these techniques. The use of massage should be limited in the inflammatory phase post surgery, as the increase in blood flow can exacerbate swelling. Care should also be taken when implementing PROM exercises in the presence of unstable fractures, joint luxations, recent skin grafts and certain ligamentous and tendonous injuries where treatment could result in further injury (Shumway, 2007).

    Conclusion

    Physiotherapy techniques are beneficial to a patient's wellbeing and to help minimise the detrimental effects of disuse and accelerate a patient's recovery. This article has described two basic techniques that can be employed by VNs under the direction of the prescribing VS. Other techniques that VNs may wish to consider exploring are cryotherapy, heat therapy, other massage techniques and therapeutic exercises. Although each physiotherapy technique has its individual benefit they are best used in combination as part of an ongoing rehabilitation programme.

    Key Points

  • Veterinary nurses can perform basic physiotherapy techniques under the direction of a veterinary surgeon.
  • Passive range of motion exercises and effleurage are simple techniques that can benefit patients who have reduced use of one or more limbs.
  • Passive range of motion exercises are essential to prevent a permanent reduced range of motion occurring.
  • Effleurage can help relax a patient as well as helping reduce pain and oedema.
    • physiotherapy
    passive range of motion exercises
    effleurage