By Jennifer Palmer, DVM, CCRT
Veterinary Physical Rehabilitation encompasses a large variety of treatments and modalities which vary dramatically in their degrees of difficulty and requirement for advanced equipment. Ranging from in-hospital treatments to options available upon referral, we can help you integrate Physical Rehabilitation into your veterinary practice!
The Physical Rehabilitation Evaluation
The Physical Rehabilitation Evaluation involves both observation from a distance as well as a hands-on examination. The evaluation should begin with posture and gait analysis to identify abnormal weight-bearing, lameness, or abnormal function. Evaluating how a patient positions his/her limbs while seated or lying down is important, as well as his/her ability to engage all four limbs during the transitions to standing from sitting or lying down.
The hands-on portion of the evaluation often includes a physical exam (if the practitioner is a veterinarian) and a physical rehabilitation exam focusing on orthopedic, soft tissue, and neurologic health. Goniometer measurements can be taken to document in degrees any changes in joint range of motion. Use of a Gulick tape measure can document precise muscle mass measurements.
One aspect of Physical Rehabilitation treatment that requires training and practice but can be performed without advanced equipment is manual therapies. This category encompasses soft tissue mobilization (STM), stretching, passive range of motion (PROM), and joint mobilizations. Stretching and PROM are often the most straight-forward, and they can sometimes be incorporated into a Home Exercise Program for owners. Soft tissue mobilization, i.e. massage, is also a great manual therapy to utilize and sometimes recommend for owners to perform. Joint mobilizations are a more advanced technique that should not be performed without more formal training.
Soft tissue mobilization is a very useful tool with the ability to address primary areas of concern as well as regions of possible compensatory injury. Some benefits of STM include analgesia, improved mobility, generalized relaxation, and circulatory effects. Three of the more basic but highly applicable STM techniques include effleurage, petrissage, and trigger point pressure release. Effleurage involves light-moderate pressure with long, slow strokes applied parallel to muscle fibers. Petrissage is moderate-deep pressure with short, brisk strokes applied multi-directionally to muscle fibers. Both of these techniques increase circulation, muscle extensibility, and range of motion, while decreasing swelling, pain, and muscle spasm. Trigger point pressure release is a slightly more focused technique involving gentle digital pressure applied to trigger points to alleviate localized pain and referred sensations. Trigger point pressure release will also increase muscle extensibility and range of motion while decreasing pain.
Passive range of motion and stretching use the same techniques for both assessment and treatment, with the differences being the duration and frequency of application. For example, during assessment a limb may be taken through its available PROM once or twice to document abnormalities, but for treatment the limb would be held in flexion or extension for a more prolonged period of time with multiple repetitions. Stretching involves taking a muscle through the opposite of its motion of action to a point of tension and holding that position for 15-30 seconds. For example, the motion of action for the hamstring muscle group is extension of the hip and flexion of the stifle. Therefore, the stretch for this muscle group involves flexion of the hip and extension of the stifle. The origin of the muscle should be held stable while the insertion of the muscle should be mobilized. It is important to focus on the difference between PROM and stretching, meaning PROM is focused on joint mobility and stretching is focused on muscle flexibility. While assessing or performing PROM, you must ensure the joint is not restricted by muscle tension. Using the above hamstring example, if you are trying to assess hip flexion, it is important to ensure the stifle is flexed and therefore not concurrently applying tension to the hamstring muscle group. Passive range of motion is performed by stabilizing the proximal segment and mobilizing the distal segment to a point of mild tension while maintaining comfort, holding this position for 10-20 seconds, and repeating.
Joint mobilizations are a great tool for assessing and treating arthrokinematic abnormalities within a joint. Arthrokinematics is the study of motion between articular surfaces during movement. The use of joint mobilizations as a treatment method requires more specialized training. An example of a joint mobilization commonly used for assessment is cranial drawer within the stifle. Treatment goals of joint mobilizations include analgesia, alleviating range of motion restrictions associated with joint capsule changes, and stimulating intraarticular mechanoreceptors and proprioceptive fibers.
Therapeutic exercise is another versatile tool that can be used in a wide range of locations with varying pieces of equipment. Therapeutic exercises can be tailored to fulfil both physical and mental goals for specific patients, including strength-building, proprioceptive work, gait retraining, preventative conditioning, mental stimulation, and a safe, productive energy outlet for activity-restricted patients. Common equipment that can be used in-hospital or at home include physioballs, rocker or wobble boards, Cavaletti poles, steps, ramps, land treadmills, etc. Therapeutic exercise is so versatile because you can also perform many exercises without specific equipment. For example, hills can be used in lieu of ramps, partially inflated air-mattresses can be used for rocker/wobble boards, etc. Therapeutic exercise prescriptions are tailored to each patient and included in a Home Exercise Program. These should be varied in their exercise type and goal, and can typically be made more or less challenging with specific modifications based on patient and client needs.
There are many Physical Rehabilitation modalities that can be used ranging from thermal therapy to hydrotherapy. The appropriate use of heat and cold can be very effective for analgesic and range of motion purposes, and are easily incorporated into a Home Exercise Program. Heat or warm compresses are best used for chronic or restrictive conditions, and/or prior to rehabilitation work. A warm compress should be kept at a comfortable temperature and held for 15-30 minutes, or as tolerated by the patient. Cold compresses are best used with acute conditions and can be utilized throughout a rehabilitation session, though they can sometimes increase stiffness. These are usually held in place for 5-10 minutes, or as tolerated.
Laser therapy has become increasingly more available for in-hospital, and sometimes at-home, use. We typically use class 3b or class 4 lasers. Be sure to follow recommended safety guidelines for your laser therapy unit including protective eyewear and/or motion at the probe depending on its safety class. The wavelength of the laser therapy unit is what determines depth penetration, and a typical therapeutic unit will be 800-900 nm. As long as you are using a therapeutic wavelength, similar treatment can be achieved with either class 3b or 4 lasers, though higher class lasers can work more quickly. The mechanism of action of laser therapy is not fully understood, but benefits are thought to include increased joint health, expedited tissue repair and wound healing, and analgesia. Common indications include wounds, orthopedic injuries, inflammatory conditions, osteoarthritis, and neurologic conditions. Contraindications include neoplasia, active hemorrhage, pregnancy, epilepsy, periorbital, over endocrine glands, over photosensitive topical treatments, and over epiphyseal plates.
Electrical stimulation, or e-stim, is a modality with different treatment goals depending on the parameters set on the unit. Neuromuscular electrical stimulation (NMES) is used with the goal of muscle contraction and strengthening. This is best used with immobile patients to treat and/or prevent muscle atrophy. Active stimulation of the muscle group always provides stronger and more effective contractions. Transcutaneous electrical nerve stimulation (TENS) can provide analgesic effects, and this too can be used in-clinic or at home. The analgesic effects only last during active stimulation. Transcutaneous electrical nerve stimulation units can be purchased over the counter. Precautions for e-stim include decreased mentation or sensation, obesity, wounds/skin irritation, or over topical treatments that can alter skin permeability. Contraindications of e-stim include implanted electronic devices, pregnancy, seizure disorders, infection, neoplasia, or use over the carotid sinus, eyes, heart, or areas of thrombosis.
Therapeutic ultrasound provides benefits via both thermal and mechanical effects. Therapeutic ultrasound is effective at heating deep tissues, 3-5 cm below the skin’s surface. This stimulates blood flow, tissue extensibility, cellular metabolism, and increases pain thresholds. The mechanical effects work in two ways: microstreaming, which involves small-grade pressure waves extra- and intracellularly, and cavitation, which is the compression and expansion of small gas bubbles in body fluids. Microstreaming increases flow of body fluids around cells, while cavitation increases cellular activity and cell membrane diffusion. The thermal effects of therapeutic ultrasound are useful for scar tissue, periarticular restrictions, muscle spasms, and non-acute injuries. The mechanical effects are indicated for edema and acute injuries. Contraindications and precautions for therapeutic ultrasound are decreased circulation or sensation, bone fracture, pacemakers, neoplasia, infection, hemorrhage, or use over the eyes, testes, or epiphyseal plates.
Extracorporeal shockwave therapy (ESWT) is also becoming more widely available with portable units. It can be used to expedite healing, fight infection, or relieve pain. A “shock wave” is a rapid increase in pressure, like thunder generated from lightning. As a shock wave encounters an impedance (i.e. tissues) energy is released. The mechanism of action of ESWT is not fully understood, but it is thought to inhibit pain, stimulate osteoblast activity and revascularization, recruit stem cells, and release inflammatory mediators. It is often used with wounds and/or chronic, painful musculoskeletal conditions such as osteoarthritis and tendinopathies.
Hydrotherapy, though not required to perform effective physical rehabilitation, provides many benefits for animals with limited weight bearing, abnormal gaits, or activity restrictions. The five key principles of hydrotherapy allowing for its therapeutic benefits are buoyancy, hydrostatic pressure, viscosity, resistance, and thermodynamics. Adjusting water depth allows us to control buoyancy and weight bearing, viscosity contributes to weight bearing support while it also works with resistance for strengthening, and circulatory effects arise from hydrostatic pressure and keeping the water at a therapeutic temperature. Veterinary physical rehabilitation tends to use underwater treadmills and pools as our major sources of hydrotherapy. Underwater treadmills provide some weight-bearing with a more controlled active range of motion. Adjustments in water depth affect buoyancy, range of motion, and weight bearing depending on goals for a particular patient. Swimming allows for non-weight bearing exercise with a slightly less controlled active range of motion and the possibility of more vigorous exercise if desired. Contraindications and precautions for hydrotherapy in either modality include cardiac disease, respiratory disease, skin sutures/staples, dermal lesions, chronic otitis externa, thermoregulatory issues, and/or behavioral issues.
Creating a home plan for the veterinary physical rehabilitation patient and client is of equal or greater importance than in-hospital work! This includes the Home Exercise Program with PROM, stretching, massage, and exercises, but also addresses environmental and lifestyle changes. Leash walks are a critical component of the Home Exercise Program. Other commonly prescribed exercises include sit-to-stands, hills, or just encouraging the patient to stand. It is critical to understand the patient’s home environment and offer appropriate suggestions like changing the height of food and water bowls, providing additional traction for floors, addressing stairs or entering/exiting the car, etc. This often includes discussing assistive devices, like the Help ’Em Up Harness, carts, or Dr. Buzby’s ToeGrips. Another key aspect of the home plan is reiterating activity restrictions and trying to suggest alternative options for stimulation during this difficult time.
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- Sasha Foster. The Canine Rehabilitation Therapist Course: Therapeutic Modalities Lecture. Animal Innovation Lab, 2013.
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- Ellen Martens. The Canine Rehabilitation Therapist Course: Aquatics Lecture. Canine Rehabilitation Institute, 2014.
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