Physiotherapy and Rehabilitation Plans: How veterinary nurses can implement them in practice

Transcription

1 Physiotherapy and Rehabilitation Plans: How veterinary nurses can implement them in practice Below are example rehabilitation plans for the following four conditions: Cranial Cruciate Ligament Rupture (TPLO surgery) Fragmented Medial Coronoid Process (post arthroscopy) Hip Dysplasia- conservative management Fibro Cartilaginous Embolism Please note that the rehabilitation plans are examples only. Each patient should be treated as an individual and rehabilitation plans tailored accordingly. Physiotherapy techniques and rehabilitation plans should only be used under veterinary referral/ supervision. Each example case study includes goals and outcome measures. Remember to use a consistent pain and lameness score (orthopaedic cases) along with other objective measurements. Owner feedback is also beneficial to gauge any changes in behaviour or activity which may be a result of the rehabilitation plan. Condition: CrCL rupture (TPLO) History: 3y/o female neutered west highland terrier with traumatic cranial cruciate ligament rupture. TPLO surgery performed to stabilise stifle. Early Phase (0-3 wks approx.) Promote early weight bearing and limb use. Maintain/ improve stifle joint ROM Provide pain relief and reduce inflammation Pain score (0-4) Stifle goniometry Lameness score (0-5) Weight earing measurements on pressure mat Technique Repetitions Frequency per day Gentle PROM of stifle within comfortable 5-10 TID range Ensure full ROM hip& tarsus LASER therapy- incision wound for 0-7 days then acute stifle settings 1 SID or at physio sessions

2 Slow lead walking on flat, firm surface using 1x 5 mins abdominal sling for support if required. Avoid stairs, high impact activities, slippy floors, playing with other dogs / toys. Crate or small room rest. Mid Phase (4-6 wks approx.) Encourage Limb Use Promote active stifle flexion/ extension Build Muscle Mass Pain score (0-4) Weight bearing measurements on pressure mat Stifle goniometry Gait / lameness score (0-5) QID LASER therapy- acute/ chronic stifle settings 1 Weekly at sessions Gentle PROM of stifle within comfortable 5-10 TID range Gentle quadriceps/ hamstrings stretch 1 x 10-15s TID hold Slow lead walking 1x 5-10 mins QID Avoid high impact activities, slippy floors, playing with other dogs / toys Sit-to-stand exercises 4 SID Gentle inclines 1 SID on lead walks Cavaletti poles at carpal height 4 walks over SID or at physio sessions Hydrotherapy in UWT water to mid femur height. 4x 30s-1min progressing by 1 min total each week. 1x weekly at sessions Late Phase (6-12 wks approx.) Improve Gait Pattern Improve Muscle Mass Return to Function (following satisfactory vet check / rads to assess implant) Pain score Weight bearing measurements on pressure mat Stifle goniometry Gait / lameness score (0-5)

3 LASER therapy- chronic stifle settings 1 1x weekly at session Quadriceps/ Hamstrings stretch 1x 10-15s SID hold Lead Walking 10 minutes, QID progressing by 5 minutes per week Sit-to-stand exercises 6-8 BID Cavaletti mid tib/fib height 6-8 walks SID over Incline walking- steeper incline 1 SID on walks Stairs after check with surgeon- 8 weeks 3-5 steps, SID onwards increasing by 2 steps Weaving avoiding sharp turns 4 SID-BID Hydrotherapy As before- 1x weekly at session increase total time by I minute Practical considerations: Cage rest for first 4 weeks post sx No jumping/ explosive exercise/ play with other dogs Use abdominal sling for support if large dog in first couple of weeks post sx (position yourself on side of non-affected limb). Condition: FMCP (post arthroscopy) History: 2y/o male entire Labrador post bil elbow arthroscopy to remove fragments Early Phase (0-3 wks approx.) Reduce pain Promote Early Weight Bearing Achieve mild- moderate elbow flexion Pain score (0-4) Elbow Goniometry Gait / lameness score (0-5) Weight bearing measurements on pressure mat Technique Repetitions Frequency per day Gentle PROM of elbow within comfortable 5-10 TID range. Ensure full ROM of shoulder/ carpus.

4 Check paws for oedema ( compression 1x 5mins TID massage if present) LASER therapy- incision wound for 0-7 days 1 SID or at physio sessions then acute elbow settings Slow lead walking on flat, firm surface using a chest harness to provide additional support 1x 5 mins QID Mid Phase (4-6 wks approx.) Reduce pain Improve weight bearing Improve elbow ROM Improve FL muscle mass Pain score Weight bearing measurements on pressure mat Elbow goniometry Lameness Score (0-5) LASER therapy- acute/ chronic stifle settings 1 Weekly at sessions Gentle PROM of elbows within comfortable 5-10 TID range Gentle biceps/ triceps stretch 1 x 10-15s SID hold Slow lead walking 1x 5-10 mins QID Effleurage and kneading massage to 1x 15 mins SID shoulder muscles Giving paws 2-4 BID Weaving poles x3, 1.5 body lengths apart 3 SID Cavaletti poles at carpal height 4 walks over SID or at physio sessions Hydrotherapy in UWT water to shoulders 4x 30s-1min progressing by 1 min total each week. 1x weekly at sessions Late Phase (6-12 wks approx.) Improve gait pattern Improve exercise tolerance Maintain elbow ROM Return to Function Pain score (0-4) Weight bearing measurements on pressure mat

5 Elbow goniometry Lameness score (0-5) LASER therapy- chronic elbow settings 1 1x weekly at session Biceps/ triceps stretch 1x 10-15s SID hold Giving paws/ high fives 6-8 BID Cavaletti mid radius/ulna height 6-8 walks SID over Weave poles x3, 1 body length apart 4-6 SID Stairs after check with surgeon- 8 weeks 3-5 steps, SID onwards increasing by 2 steps Hydrotherapy in UWT As before- 1x weekly at session increase total time by I minute Practical considerations: Cage rest for first 4 weeks post sx No jumping/ explosive exercise/ play with other dogs Use chest harness to provide upper body support (especially on stairs) - ensure this does not rub at the elbow area. Condition: Hip Dysplasia (conservative management) History: 4 year old female neutered Border Collie with bilateral hip dysplasia presenting with short pelvic limb stride lengths and pain on hip extension and abduction around ½ range. Compensatory muscular tension present in thoracolumbar epaxial muscles. Currently exercised 2x 20 minutes on lead per day. Early Phase (0-4wks approx.) Reduce Pain Improve HL muscle mass Improve function / overall gait Pain score (0-4) Weight bearing measurements Gait / lameness score (0-5)

6 Technique Repetitions Frequency per day Effleurage and compression massage 1x 5 minutes SID applied to T-Lx epaxials LASER therapy- chronic hip settings 1 at physio sessions Hip extension and abduction stretches 1x 15s hold SID or at sessions (quadriceps/ ilipsoas) Lead walks on soft ground mins QID Gentle inclines 1 SID-BID on walks Weave poles x 3, 1 body length apart 4 BID Sit- to- stand exercises 4 BID Hydrotherapy in the UWT 4x 1 min progressing to 4x 2min At sessions Mid Phase (4-8 wks approx.) Continue to improve HL muscle mass Improve active hip extension (stride lengths) Reduce pain/ Maintain low pain score Pain score (0-4) Weight bearing measurements on pressure mat Gait / lameness score (0-5) Functional ability (e.g. how is the patient managing with stairs, exercise etc.) LASER therapy- chronic hip settings 1 Weekly at sessions Hip extension stretches 1x 15s SID or at sessions Effleurage and compression massage 1 x 5 minutes SID applied to T-Lx epaxials if tension still present Lead Walks mins QID with some off lead exercise on soft ground (gradually introduce) Steeper inclines 1 SID- BID on walks Sit-to-stand exercises 6-8 SID Stairs- slowly on lead to encourage 1 flight BID individual limb use Cavaletti poles at carpal height 4 walks over BID 4 Weave poles, 1 body length apart 6 BID Wobble board 1x 30s At sessions

7 Hydrotherapy in UWT- water to mid femur height. 4x 2.5 mins progressing to 4x 4 minutes 1x weekly at sessions Maintenance Phase Maintain improved hip / abduction extension Maintain muscle mass Maintain low pain score / reduce meds / address any weight issues Aim to review every 4-8 weeks Pain score (0-4) Weight bearing measurements on pressure mat Lameness / gait score (0-5) Functional ability e.g. how is the patient coping with stairs, exercise etc. LASER therapy- chronic hip settings 1 At sessions Quadriceps stretch 1x 15s hold SID Sit-to-stand exercises 8-10 BID Lead walks Up to 45 mins QID with some off lead exercise on soft ground (gradually introduce) Cavaletti stifle height 6-8 walks BID over Incline walking- steeper incline 1 SID on walks Stairs- off lead if no longer bunny hopping 1-2 flights BID Weaving poles x 4, 1 body length1 apart 8 BID Wobble board 1x 1 minute At sessions with hind limb lifts Hydrotherapy 4x 4 minutes At sessions with resistance Practical considerations: Pick 3-4 exercises per day and rotate- regularly review home exercise plan and alter accordingly Consider use of chest harness if body weight consistently shifted to forelimbs Consider use of ramp in and out of car as jumping may be painful Avoid repeated ball throwing, uncontrolled play with other dogs, high impact activity.

8 Condition: FCE History: 6y/o male entire Labrador presented with non-ambulatory left sided hemiparesis. C5-6 FCE diagnosed on MRI. Early Phase (0-1 wks approx.) Maintain joint ROM/ Maintain muscle/ soft tissue length Promote weight bearing and limb movement Take baseline muscle mass measurements Pain score Functional ability: independent sitting, standing, turning etc CONSIDERATIONS: Use full body harness for support Position in sternal or tilt to RHS with LHS limbs supported with blanket wedges etc. Assist with food / water Ensure independent bladder control +/- express Technique Repetitions Frequency per day PROM all limbs 10 TID Laser FCE C5-6 and 4 disc spaces caudally 1 SID on chronic setting Stretching- all limbs 1x 15s holds TID Effleurage and Kneading massage applied to left sided limbs 1x 5 mins per limb TID Active assisted walks in supportive body 1x 3-5mins QID harness Active assisted standing practice with 1x 15-30s TID peanut ball Active assisted sitting practice 1x 30s BID Active assisted hydrotherapy in the UWT using full body supported harness- water to trunk *ensure sufficient staff / support* 4x 30s-1min SID Mid Phase (1-6 wks approx.) Independent standing and weight bearing Supported walking with movement all limbs Maintain joint ROM/ muscle length of affected limbs Maintain remaining muscle mass on affected limbs Pain score (should not be painful unless inflammation / contractures present in affected limbs)

9 CONSIDERATIONS: Use full body harness for support Continue to monitor and manage bladder if required PROM, stretching and massage Active assisted weight bearing on hind limbs using single step- use different surfaces to stimulate sensory feedback As with early phase 1x 15-20s Cavaletti Poles on ground 4 walks over SID-BID Slow lead walking 1x 5 mins QID Weave poles x 3, 1.5 body lengths apart 3 SID- BID Giving paws to encourage WB through left 4x 5s holds BID forelimb Hydrotherapy in UWT- water to trunk 4 x 1-2min 2x weekly at sessions Late Phase (approx. 6wks onwards) Maintain joint ROM / monitor muscle ST length Increase muscle mass Challenge balance and proprioception Improve gait pattern Return to best possible function Pain score Weight bearing measurements on pressure mat Gait / functional lameness assessment CONSIDERATIONS: Use chest harness for support TID TID Active assisted weight bearing on hind 1x 20s TID limbs using single step Cavaletti Poles at carpal height 6-8 walks BID over Slow lead walking on a variety of surfaces 1x 10 mins QID to aid proprioception progressing by 5 minutes Weave poles x 3, 1 body length apart 4-8 BID Giving paws to encourage WB through left 4x 5-10s holds BID forelimb Stairs 1x 4-6 steps progressing BID

10 Inclines 1 BID on walks Hydrotherapy in UWT- water to trunk 4 x 1-2min 2x weekly at sessions Practical considerations: A full body supportive harness will be required in the early-mid phase Thin rubber booties (or similar) should be used when exercising outside until paw placement is achieved to prevent sores (Do not leave on for more than 20 mins). The patient should have comfortable bedding and be turned regularly. Food and water may need to be offered until the patient is ambulatory. During late phase pick 3-4 exercises per day and rotate. Cage rest during first 4-6 weeks recovery dependant on extent of condition. Provide non slip floors/ matting to prevent injury. No rough play with other dogs. Lift in / out car and avoid steps in early stages of recovery. Offer treats/ toys to stimulate patient from affected side.