In the human medical world, post-operative rehabilitation is imperative to the successful outcome of the orthopaedic surgery patient. Rehabilitation of the canine patient is now also becoming recognized as an important facet of veterinary medicine. Rehabilitation may be provided either in the veterinary clinic or in purpose-built rehabilitation centres by a variety of animal health professionals including animal physiotherapists, veterinarians and veterinary nurses. Many countries have qualified animal physiotherapists, who are able to provide appropriately designed treatment programmes, transerring their expertise and knowledge to rehabilitation of small animals. While having a qualified animal physiotherapist on site to oversee the rehabilitation of all patients is desirable, it is not always possible and treatment is often administered by veterinary nurses.
Nurses administering rehabilitation programmes for animals should have completed animal rehabilitation courses and work under the guidance of a veterinarian. When devising rehabilitation programmes for animals it is important to follow evidence-based guidelines to ensure that treatments administered are safe and effective, avoiding complications caused by inappropriate exercise regimens or treatments. This article outlines the aims of rehabilitation following orthopaedic surgery, when to commence therapy, appropriate selection, administration and monitoring of treatment techniques performed by the veterinary nurse. It looks at contraindications to treatment and when to refer on to a qualified animal physiotherapist or back to the referring veterinarian.
Aims of treatment
The aims of rehabilitation following orthopaedic surgery are to accelerate recovery and return to function by reducing pain, swelling and inflammation, improving joint range of motion (ROM) and muscle strength, while protecting painful and/or healing structures. This is accomplished through a combination of carefully selected and administered treatment techniques, in conjunction with a structured and individualized home exercise programme for the animal, to be completed by the owner or carer. An integral part of this rehabilitation programme is the education of the owner with regards to the orthopaedic condition and surgery, the exercise restrictions for the animal after surgery and exact instructions for home care and therapy, to reduce the incidence of post-operative complications and to accelerate recovery.
Reducing pain, swelling and inflammation
Pain, swelling and inflammation are common clinical signs following orthopaedic surgery and are known to cause arthrogenic muscle inhibition (Palmieri-Smith et al, 2007), where muscles become reflexively inhibited or difficult to ‘switch on’. If muscles are not contracting well, atrophy occurs and decreased muscle strength. Physiotherapy modalities, such as ice, compression and gentle movement, are now commonly used in the orthopaedic post-operative animal patient to help reduce these signs (Shumway, 2007) and assist the animal's recovery.
Improving joint ROM
Following orthopaedic surgery joint ROM is often reduced because of pain, swelling, joint stiffness or protective muscle guarding. For a successful return to full function and muscle strength, joint ROM needs to be restored.
When assessing joint ROM it is important to recognize factors limiting movement and only work within the animal's pain free motion, gradually regaining joint range as pain and swelling decreases.
Improving muscle strength
Once initial pain, swelling, inflammation and muscle inhibition are addressed, muscle strengthening can commence. Specific strengthening exercises are needed to grow muscle. In the absence of pain, reflex muscle inhibition will continue without specific exercise to the affected muscles (Young, 1993). Patients receiving an early intensive physiotherapy programme following orthopaedic surgery achieve not only more rapid strengthening, but larger overall increases in muscle strength (Moffet et al, 1994). Exercises should initially be very gentle and controlled, progressing to those that overload the muscle, allowing increased adaptation and strength.
Assessment and monitoring
A thorough initial assessment of the patient is required in order to devise a patient-specific rehabilitation programme. Before observing or palpating the patient, the veterinary nurse should obtain as much background information as possible. This may involve obtaining veterinary surgery and treatment reports, imaging results, expected prognosis, and current medical management. An understanding of the animal's home environment and level of exercise, both current and prior to injury, will help to guide the treatment programme and home exercise advice.
Once these subjective data have been obtained, objective assessment can commence. Objective measures that can be repeated to determine effectiveness of treatment are vital. The animal's posture, willingness to weight bear, lameness and muscle atrophy should be observed before handling the patient. Lameness assessment is a useful tool; however it is very subjective with many different lameness assessment tools identified in the literature. More objective measures of the animal's lameness can be made by videoing their gait pattern at the start, and end of the rehabilitation programme as well as at several points throughout the programme.
Measures of limb circumference and joint ROM using goniometry can also be used as objective markers to monitor outcomes (Figure 1). These measures have been proven to be most reliable when repeated with the one observer (Jakobsen et al, 2009).
In conjunction with the objective measures, the owner should be questioned on response to treatment at home, completion of the home exercise programme and any other concerns or queries they may have. Each time the animal returns for treatment, ideally twice a week, a reassessment should be performed to determine response to the programme. The outcome of this assessment will help guide progression of treatment and ensure the programme stays specific for each individual patient.
When to start treatment
Treatment should be started on the day of surgery. Early commencement of treatment following orthopaedic surgery reduces pain, swelling, inflammation, lameness, use of non steroidal anti-inflammatory medication (Shumway, 2007), and reflex muscle inhibition, which leads to accelerated muscle strengthening (Moffet et al, 1994). Icing, gentle passive motion and massage away from the wound, along with early controlled weight bearing can all start in the early post-operative period. Hydrotherapy can start once the wound has fully healed — typically at 10–14 days post operatively.
Treatment techniques
There are a multitude of treatment techniques that can be administered by the veterinary nurse following orthopaedic surgery. Selection of these techniques must be individualized and based on the assessment findings. Additional factors to consider that may require modification of the treatment technique include, the animal's age, the presence of concurrent pathologies, aggression or fear and response to pain.
Animal physiotherapists are highly skilled in the use of manual therapy techniques, electrotherapy, hydrotherapy, exercise prescription, the use of gait aids and various forms of bracing and splinting.
Veterinary nurses who have received appropriate training in animal rehabilitation are able to administer several treatment techniques including icing, heat treatment, soft tissue massage, joint ROM exercises, gentle strengthening exercises, as well as assisting with hydrotherapy and the animal's home exercise programmes.
Cryotherapy/ice treatment
Ice treatment in the early post-operative period has been shown to reduce pain (Lessard et al, 1997; Raynor et al, 2005), swelling and inflammation (Shumway, 2007), improve weight bearing and reduce use of pain medication (Lessard et al, 1997). Ice treatment can commence on the day of surgery once the patient's body temperature has returned to normal. The cold reduces blood flow to the area, reducing swelling and release of inflammatory mediators.
Various flexible commercial ice packs are available; to avoid ice burns they should be wrapped in a layer of wet material, such as a towel, before being placed over the affected area. Using repeated, rather than continuous, ice applications of 10 minutes, helps sustain reduced muscle temperature without compromising the skin and allows the superficial skin temperature to return to normal while deeper muscle temperature remains low.
Ice treatment can be used in this repeated way for the first 48 hours, then reduced to 10 minute treatments, three times per day for the first post-operative week, or longer if required.
All animals should be supervised while they are receiving ice treatment and their skin checked regularly at 5 minute intervals for excessive redness or irritation, to ensure they do not sustain an ice burn.
Passive ROM exercises
Passive movements of the peripheral (limb) joints can be used to reduce pain, regain normal movement and prevent joint contracture. Passive movements are performed by the therapist, with the animal in a comfortable and well supported position with their muscles at rest. Movements should only be performed within pain free range and tolerance of the animal (Figure 2, 3 and 4).
The aim of these exercises is to take each affected joint repetitively through its available range of motion. These movements should not be forced or painful. Suggested starting dosage: 10–20 repetitions (depending on pain) of affected joints, three times per day.
Soft tissue massage techniques
Following orthopaedic surgery, soft tissue massage techniques are aimed at reducing muscle tension and associated pain, to allow normal movement of a joint or limb. They can also be used to induce relaxation in an animal in preparation for other stronger treatments.
There are many different massage techniques available, from gentle superficial techniques to very deep tissue techniques. In orthopaedic post-operative cases, gentle massage of major muscle groups in affected limbs is recommended, ensuring the animal is not caused pain. Massaging towards the heart can help removal of swelling and waste products from an immobilized area. For safety, deeper techniques should be reserved for use by an animal physiotherapist or qualified animal remedial masseur. No massage should be performed near the surgical site for at least the first 48 hours. After this time, gentle techniques can be performed closer to the surgical site, avoiding the actual wound. Once the wound is well healed, usually at 2 weeks post surgery, scar massage to the incision site can be performed if the scar is adhered to the underlying tissues.
Thermotherapy/heat treatment
Once acute swelling and inflammation has subsided, usually at 48 hours post surgery, heat can be used to reduce pain and muscle guarding as well as improve circulation to the affected area to assist with healing.
Heat wheat packs are ideal as they are light weight and conform well to the body. Ensure that they are only ever applied warm. Do not secure a heat pack to an animal or leave an animal sitting on a heat pack as this can lead to thermal burns. Application of heat for 10 minutes three times per day prior to passive ROM exercises is recommended.
After the first 48 hours, or when acute swelling has ceased, alternating cold and heat therapy can be used to assist in the removal of swelling. Placing an ice pack on the area reduces blood flow and swelling, then heating the area increases blood flow, helping to ‘pump’ out swelling from the affected area. Use heat and ice alternatively for 10 minutes each, over a 60 minute period, three times per day.
Hydrotherapy
Water is an excellent medium to assist in the rehabilitation of the post-operative orthopaedic patient. For the animal patient, exercising in water allows unloading of painful joints, as well as earlier weight bearing on otherwise very weak or painful limbs (Steiss, 2003). Hydrostatic pressure is the pressure of water on the body surfaces. This pressure increases with depth of immersion (Edlich et al, 1987) and can be useful to assist in the reduction of oedema in limbs following surgery. Friction between water molecules causes the water to be viscous. The viscosity of the water adds resistance that can be used to accelerate strengthening when the animal swims or walks against the water.
While exercising in water is beneficial, exercises performed on land cannot be simply repeated in the water. Movements are generally slower; animals may have different awareness of their body and limbs and may also be initially fearful of the environment. Hydrotherapy programmes are best devised by an animal physiotherapist or veterinary nurse with special training in hydrotherapy for animals.
Swimming is a great form of hydrotherapy and can be used to increase joint ROM, muscular endurance, encourage limb use and general fitness providing a medium for exercise when land-based exercise is too painful. Animals need to be introduced to swimming slowly and closely monitored for signs of distress or poor limb use. Always start with small sessions and increase as the patient improves.
Underwater treadmill therapy (Figure 5) provides buoyancy to reduce weight bearing on healing structures, but also allows gentle loading that assists muscle strengthening. When used as part of a structured physiotherapy programme, underwater treadmill therapy can accelerate return to function following orthopaedic surgery (Monk et al, 2006).
Hydrotherapy can commence once the wound has healed, typically at 2 weeks post surgery.
Hydrotherapy contraindications
A thorough assessment should be performed by the referring veterinarian to ensure suitability of hydrotherapy for each patient. Contraindications to hydrotherapy following orthopaedic surgery include:
- Open wounds or unhealed surgical incisions
- Vomiting/diarrhoea
- Elevated body temperature/infection
- Respiratory compromise
- Severe systemic conditions: cardiac, liver, kidney disease
- Uncontrolled epilepsy
- External fixation of fractures (due to open wounds)
- Severe skin irritations
- Ear infection (if ears could become immersed).
Gentle strengthening
Controlled exercise including weight bearing or increased mechanical load has been shown to increase muscle strength and stimulate bone and soft tissue healing (Thomopoulos et al, 2008). Early controlled weight bearing following orthopaedic surgery can assist in the prevention of disuse muscle atrophy, increase healing and aid the animal's return to full function (Oldmeadow et al, 2006). Controlled weight bearing exercise, such as three point standing (Figure 6) or baited exercises (Figure 7, and 8) along with a slow pace on lead walking programme, can be used to encourage weight bearing on the affected limbs.
When prescribing exercises it is important for the therapist to observe the animal performing each exercise, correcting any compensatory strategies they use to unload the affected limb or to activate incorrect musculature, to ensure each exercise is performed correctly.
A slow pace walking programme can commence following bandage removal, initially consisting of a 5 minute walk for toileting two to four times a day, gradually increasing over the next 6 to 8 weeks depending on the animal's condition, and lameness.
Education of the owner/home exercise programme
It is extremely important to educate the owner in all aspects of their pet's condition, giving them clear and concise post-operative notes, including the importance of rest and confinement to prevent post-operative complications due to over activity.
Home exercises should be clearly demonstrated and documented. The owner should practice them under the supervision of the treating therapist to check that they are able to do them correctly. At each visit all exercises should be reviewed and updated.
Additional equipment
There are many different mobility aids ranging from doggie wheelchairs to harnesses, protective boots, ramps and slings. When assessing an animal for aids it is important to determine the exact needs of the animal, its home environment, its activity levels, and the owner's expectations and ability to use the aids correctly. Once purchased the correct fit and use of the aid should be assessed and reviewed regularly.
Contraindications to treatment
When attending for rehabilitation, animals should be regularly reassessed for lameness, swelling, and available joint range. Owners should be questioned about how they feel the animal is progressing both physically and behaviourally. If they have any concerns or if the animal's progress has plateaued, a further veterinary review should be sought.
When to refer on
If at any time during the rehabilitation programme a patient stops improving, is not achieving the expected outcomes or clinically deteriorates, they should be referred back to their veterinarian for reassessment.
Conclusions
The addition of rehabilitation programmes to the management of the post-operative orthopaedic patient can accelerate return to function and greatly improve quality of life. All patients should be assessed prior to commencement of treatment, have a tailor made programme and be continually monitored for their response to treatment, with their programme adjusted accordingly. Animal health professionals interested in providing this service should complete continuing education in the small animal rehabilitation field to ensure safe and effective practice.
- To answer the CPD questions for this article, visit www.theveterinarynurse.com
Key Points
- Post-operative orthopaedic rehabilitation accelerates recovery.
- Early controlled rehabilitation is essential.
- Early commencement helps to reduce pain, swelling and inflammation.
- Rehabilitation helps to prevent muscle atrophy and increase muscle strength.
- Post-operative orthopaedic rehabilitation increases range of motion.