Don t drown the dog: practical and safe approaches to rehabilitation

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1 Vet Times The website for the veterinary profession Don t drown the dog: practical and safe approaches to rehabilitation Author : Kate Rew, Lowri Davies, Rebecca Sharples Categories : Vets Date : February 2, 2009 Kate Rew, Lowri Davies, Rebecca Sharples discuss physiotherapy, hydrotherapy and therapeutic exercise for dogs post-injury and surgery, and the role of the vet, physiotherapist and veterinary nurse in the animal s recovery The benefits associated with physiotherapy and rehabilitation after surgery or injury are becoming increasingly apparent within the veterinary profession. However, it is essential, when looking to refer or to develop an expertise, that the best possible standards of practice are achieved. A successful outcome, as defined by the restoration of optimal form and function, requires a multidisciplinary approach by skilled veterinary professionals often working in conjunction with trained chartered physiotherapists and veterinary nurses. A well-constructed management plan may involve physiotherapy, hydrotherapy and therapeutic exercises, used in conjunction with an appropriate pain management regime. Safe and effective application of these techniques requires a thorough understanding of musculoskeletal injury and tissue response to injury. While the number of skilled professionals in the field is growing steadily, there are also a number of animal physiotherapists whose training, usually in hydrotherapy or canine massage, limits the range of cases they are able to help. It is clearly essential that both the referring veterinarian and owner are aware of the level of training and understanding that an individual has prior to 1 / 22

2 commencing treatment. Multidisciplinary team approach A well-run rehabilitation centre should be staffed by a veterinary surgeon, a chartered physiotherapist and qualified nursing staff. Good communication within the team is essential from the start, as with the referring veterinary surgeon(s) and owner. This coordinated and structured approach aids progress and improvement through to the animal s return to function. Poor communication, however, can lead to an unsatisfactory outcome. Since, in essence, rehabilitation involves the application of controlled challenges, how do we know what constitutes an appropriate challenge? Accurate assessment and setting an appropriate level of challenges are key in rehabilitation. Over-challenge may lead to tissue damage but, equally, under-challenging may never achieve restoration of function and performance. Veterinary surgeon s role The cornerstone of any rehabilitation team is a veterinary surgeon with the appropriate skill sets. He or she is responsible for evaluating the patient with respect to orthopaedic and neurological function, and must fully understand associated surgical procedures. Detailed knowledge of anatomy and physiology needs to be overlain with an understanding of tissue response to injury, disuse and remobilisation. An understanding of limb biomechanics and the principles of movement, over and above traditional lameness examination, is fundamental to a successful outcome. Such a functional approach is often better achieved when working in conjunction with experienced physiotherapists, as they are adept at understanding the principles of movement and assessing gait, as well as performing a detailed musculoskeletal examination. Identification and accurate assessment of pain in all its forms (both acute and chronic) is a key element, as is appropriate treatment. This may involve the use of drug therapy, such as NSAIDs, opiates and centrally acting drugs, or acupuncture (Figure 1). Inappropriate management can result in the animal continuing to compensate and resisting the application of specific challenges, resulting in reduced progress or failure of the rehabilitation plan. It may be necessary to look beyond the original injury to establish the ongoing cause of dysfunction. Physiotherapist s role Trained physiotherapists are experts in rehabilitation. However, it should be noted that the title veterinary physiotherapist is not a protected one, and there are individuals practising who are not fully trained or adequately insured. Veterinary-run rehabilitation clinics should work with members of the Chartered Society of Physiotherapists (CSP) and the Association of Chartered 2 / 22

3 Physiotherapists in Animal Therapy (ACPAT). These practitioners have a degree in physiotherapy, which includes three to five years of theoretical and practical training in rehabilitation in the human, NHS field. They also have training in the veterinary field (Figure 2). Hydrotherapy is a large part of the clinical training syllabus. Many of these physiotherapists have continued their work in either the NHS or in the private human sector. Some CSP members have also completed a masters in veterinary physiotherapy at the RVC to further their knowledge and specialise in the treatment and rehabilitation of animals. Their experience with animals may vary, but to be allowed to treat animals CSP members are also required to be members of ACPAT and to work under veterinary supervision/referral. As with veterinary surgeons, members of both ACPAT and the CSP are regulated within their profession, and all must have professional indemnity insurance to practise. They also have a CPD requirement to keep their qualifications and help ensure professional standards are maintained. Veterinary nurse s role Veterinary nurses play a vital role in the rehabilitation team, not only to provide nursing care for spinal and complex orthopaedic cases, but also to implement rehabilitation programmes under the guidance of vets and physiotherapists. They should have a thorough understanding of anatomy and physiology, as well as the type of conditions being treated and common orthopaedic procedures. Nurses should be skilled in lameness evaluation and gait analysis, as well as in the recognition of pain or poor health in an animal. A veterinary nurse should always, as in practice, work under the direct supervision and support of a veterinary surgeon, as only the vet can make decisions with regards to animal health, pain relief and prescription of medicines. Ideally, nurses should also work closely with the physiotherapist, as he or she will usually devise an appropriate tailored rehabilitation programme for the individual animal, while the nurse is involved in implementing it under the physiotherapist s supervision (Figure 3). Hydrotherapy by laypersons Centres throughout the UK offer hydrotherapy, and many are members of the Canine Hydrotherapy Association (CHA), which has developed a quality standards document to, as it claims, raise and regulate the quality, standard and consistency of canine hydrotherapy in the UK. This ensures adequate water quality and management, and correct equipment specification, and insists on veterinary liaison and referral and emergency back up by a local veterinary practice. Training in canine first aid and a minimum of two days experience in a CHA member centre is required. These centres must provide employer liability and public liability insurance, but do not usually provide professional indemnity insurance, unless they are run by a veterinary practice (under the 3 / 22

4 direct supervision of a veterinary surgeon) or chartered physiotherapist. Although often skilled at swimming fit dogs, staff will have limitations in pain assessment, and are unlikely to be trained to safely treat individuals with significant neurological or orthopaedic conditions. Ideally, therefore, laypersons performing hydrotherapy should work under the direct supervision of a veterinary surgeon and/or an ACPAT member. If a veterinary surgeon refers an animal to a non-veterinaryrun hydrotherapy centre, he or she, in effect, will be accepting the level of insurance cover that the centre does or does not provide, and care and control of the animal remains with the referring practice. Specialist equipment Rehabilitation is a broad term that encompasses many areas, including manual physiotherapeutic techniques, use of thermal and electrical modalities and hydrotherapy. Much confusion and controversy exists regarding the most appropriate techniques and equipment to use. Re-education of the neurological and musculoskeletal system is extremely specific. For example, in the rehabilitation of post-surgical thoracolumbar disc patients, the protocol has to address both the ability to stand and the ability to walk. A regime that focuses on standing alone will have very little influence on the animal s ability to walk and vice versa. Non-functional training can result in inappropriate development of muscle groups, which can not only hamper training, but can lead to abnormal stresses on the skeletal system. In these cases it is necessary to alter an animal s exercise regime, or even limit exercise completely for a period prior to embarking on a more appropriate regime. Hydrotherapy Hydrotherapy allows for early intervention, and exercising in water allows the unloading of painful joints and earlier weightbearing on weak or painful limbs. Weight-bearing forces are reduced in water, which may reduce damage and inflammation to soft tissues, and also aid in pain reduction while maximising functional training. In orthopaedic and neurological conditions, hydrotherapy is commonly used within a rehabilitation programme to enhance recovery and restore function. Human studies have confirmed that hydrotherapy minimises pain and improves strength and balance, muscular endurance, cardiorespiratory function, joint range of motion, agility and psychological well-being. The physiological effects of exercising in heated water at approximately 27 C are believed to increase joint flexibility and decrease pain. It is, therefore, essential that any equipment used is appropriate for the task and provides the correct challenge. 4 / 22

5 Underwater treadmill In most cases underwater treadmill work is preferable to swimming in a hydrotherapy pool for rehabilitation purposes, as it is a much safer and more controlled environment. It allows for targeted activity of individual muscle groups (to strengthen and re-educate) and joints (such as range of motion, reducing effusion), improved mobility and earlier progression of treatment. Being able to vary the treadmill speed and water depth may provide an environment where an animal s gait can be altered and trained. It challenges the neuromuscular system in a functional manner and, when used as part of a comprehensive regime, plays a key role in rehabilitation (Figures 4 and 5 ). Hydrotherapy pool The hydrotherapy pool is excellent for fi tness and cardiovascular work in healthy animals and working and agility dogs. It may be useful in the progression of exercise programmes, or in laterstage rehabilitation for example, to improve lateral spinal and abdominal muscle strength. It may also be useful for certain sporting injuries, neurological cases and following orthopaedic surgery (Figure 6). Each animal must be carefully assessed and swum under the close supervision of a trained professional, as the hydrotherapy pool is not as safe and controlled as the hydrotherapy treadmill. Adequate support and proper use of buoyancy aids and jets is essential and, for many animals, it will not be appropriate. Physiotherapy equipment and therapeutic exercises Equally important are apparatuses or devices designed to improve postural work. These can range from simple air beds and gym balls to more sophisticated balance trainers. They are generally inexpensive and often supplied for the owners to use at home. Again, they must be used correctly and at the appropriate time within a rehabilitation programme (Figures 7 and 8). Other equipment, such as ultrasound, laser, neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS) and thermal modalities (ice and heat packs) are useful to help with pain relief, reduction of effusion or inflammation, improving neuromuscular function, re-education and increasing joint range of motion. Many of these therapies, along with passive therapeutic exercises, are particularly useful as early interventions immediately postinjury or postsurgery (Figure 9). Therapeutic exercises may also be very important early in an animal s rehabilitation programme, and in these cases, owner compliance and cooperation is essential. Intensive rehabilitation at home may be difficult in complicated cases, so hospitalisation at a specialist rehabilitation facility, with nurses who have the time and training to perform these exercises, may be more appropriate. 5 / 22

6 Going home, owner compliance and longterm treatments Owner compliance is essential to effectively implement an animal s rehabilitation programme. Treatments performed at a rehabilitation centre must be coordinated along with a home exercise programme that is acceptable and achievable by the owner. The owner(s) must be able to correctly and safely perform home exercises, and a detailed written plan should be provided. Length and speed of lead exercise is important, as are instructions on the type of activity that should be avoided for example, ball throwing and use of stairs. Concurrent health issues If an animal has concurrent health issues, such as hypothyroidism, cardiac disease, diabetes or obesity, these must be taken into account or treated before a programme commences and requires direct veterinary input. Longer-term pain relief Many dogs with mobility disorders have pre-existing or chronic osteoarthritis. This is usually associated with poor muscle development and a compensatory gait pattern. If animals receive appropriate rehabilitation postinjury or post-surgery, the chance of developing degenerative joint disease or muscle wastage may be signifi cantly reduced. Adequate relief of both acute and chronic pain is essential in these cases and may require a multifactorial approach. The traditional NSAIDs are especially effective where there may be an acute flare-up of a chronic condition and in treatment of musculo-skeletal pain. Chronic pain may be addressed by using analgesic drugs in combination with other therapies, such as acupuncture and TENS. Many drugs may have adverse side effects. Lethargy and depression, for example as seen in some dogs on particular medications may have a significant effect on their willingness to exercise and must be addressed. Some of the newergeneration NSAIDs are more COX-2 selective and appear not to cause the lethargy or depression that can be seen with other medications. Intensive, long-term hospitalisation In severe or complicated orthopaedic and neurological cases, intensive hospitalisation may be required to achieve the best outcome. This will usually require considerable veterinary input and nursing care. Abnormalities of bladder and bowel function, analgesic medication and other concurrent or complicated health issues will require management. This will be ideally offered in a specialist, dedicated rehabilitation facility, where manual handling equipment, such as hoists and winches, 6 / 22

7 body slings, harnesses and standing and walking frames, are available. This type of facility will also provide care when an owner is unable to carry out rehabilitation and necessary exercises at home, for reasons such as owner disability or lack of time. Mental stimulation is very important, especially in longerterm hospitalised cases or when dogs may be suffering from chronic pain. A constantly innovative approach is required with frequent reassessment, and varying the working environment also helps with these cases (Figure 10). Owners may also require and benefit from ongoing support once their animal has been discharged from treatment or continues to attend as a day patient. Harnesses and other supportive treatment, either on loan or purchased, may be necessary for the owners (Figure 11). Responsible referral Vets need to refer responsibly and must be aware that inappropriate rehabilitation by unskilled persons will be, at best, ineffective and, at worst, detrimental to the animal. If the veterinary surgeon does not refer to another qualified veterinary surgeon then he or she will remain ultimately responsible for that animal s welfare. Referral to a lay hydrotherapy centre that is, without any veterinary or physiotherapeutic input may adversely affect an animal s recovery, following both orthopaedic and neurological surgery. With respect to neurological cases in particular, the damage can be permanent and irreversible. Referral to a veterinary-run centre ensures the animal is under the care of a veterinary surgeon and that he or she is responsible for the health and welfare of the animal. It is important, however, that the veterinary surgeon is trained and skilled in rehabilitation. All veterinary surgeons will have their own practice and professional indemnity insurance and will be regulated by the RCVS. If accepting referrals, under RCVS guidelines he or she, ideally, should be adequately trained in this area of expertise. Many insurance companies now cover rehabilitation and hydrotherapy only if it is performed in a veterinary practice and under direct veterinary supervision or by veterinary referral. New organisation to improve standards In the interest of promoting appropriate veterinary rehabilitation and encouraging responsible referral to trained veterinary surgeons and chartered physiotherapists, a veterinary rehabilitation special interest group called Physiovet has been formed. Membership is open to veterinary surgeons and CSP or ACPAT members. Veterinary nurses and veterinary students will be offered associate membership at a reduced rate. All members will have up-to-date professional indemnity insurance and be regulated by either the CSP, ACPAT or RCVS. The aim of the group is to improve the teaching and understanding of rehabilitation within the 7 / 22

8 profession and subsequently improve the standard of practice within the discipline. The eventual aim is to form the British Veterinary Rehabilitation Association, which will also help to provide regulation within this discipline. Another idea is to develop a star rating system where veterinary surgeons, insurance companies and the general public will be able to make an informed choice as to the level of service and care they receive when choosing a centre for hydrotherapy or rehabilitation. A Physiovet CPD meeting is planned to take place in May in Cardiff. Further details will follow on the group s website at Anyone interested in becoming a member of Physiovet, or who would like a directory of members in their area, can contact Kathrin Porter at Linhay Veterinary Rehabilitation Centre on or via (kathrin@linhayvet.co.uk) References are available by request to the editor. 8 / 22

9 Figure 1. A dog undergoing acupuncture treatment. 9 / 22

10 Figure 10. Varying the environment helps in chronic cases. 10 / 22

11 Figure 11. Loaned or purchased harnesses may be necessary. 11 / 22

12 Figure 2 (above). Trained animal physiotherapists are experts in rehabilitation. 12 / 22

13 13 / 22

14 Figure 3. Manual therapy performed on a dog. 14 / 22

15 Figures 4 and 5. Therapy using the underwater treadmill challenges the neuromuscular system in a functional manner and plays a key role in rehabilitation. 15 / 22

16 Figures 4 and 5. Therapy using the underwater treadmill challenges the neuromuscular system in a functional manner and plays a key role in rehabilitation. 16 / 22

17 Figure 6. The hydrotherapy pool is excellent for fi tness and cardiovascular work. 17 / 22

18 18 / 22

19 19 / 22

20 Figures 7 and 8. Apparatuses or devices designed to improve the patient s posture are generally inexpensive, so treatment can be continued at home by the animal s owner. 20 / 22

21 Figures 7 and 8. Apparatuses or devices designed to improve the patient s posture are generally inexpensive, so treatment can be continued at home by the animal s owner. 21 / 22

22 Figure 9. Therapies, such as ultrasound, along with passive therapeutic exercises, are particularly useful as early interventions immediately post-injury or post-surgery. 22 / 22 Powered by TCPDF (

Ratified by: Care and Clinical Policies Date: 17 th February 2016

Ratified by: Care and Clinical Policies Date: 17 th February 2016 Clinical Guideline Reference Number: 0803 Version 5 Title: Physiotherapy guidelines for the Management of People with Multiple Sclerosis Document Author: Henrieke Dimmendaal / Laura Shenton Date February