Janet B. Van Dyke, DVM, DACVSMR
What Is Veterinary Rehabilitation?
Many people believe that veterinary rehabilitation consists of a series of therapeutic exercises, especially involving the underwater treadmill and laser therapy, which can be applied to our animal patients. The notion that this field would be easy to grasp, with intuitive reasoning and little training, has led many to attempt to add rehabilitation to their veterinary practices.
In reality, veterinary rehabilitation is the application of an all-new diagnostic algorithm to our patients. It focuses upon soft tissues rather than bone and joint. It involves special tests that allow for determination of specific tendinopathies and soft tissue abnormalities. The use of objective outcome measures, evaluated with goniometers and Gulick girthometers, provides clear evidence of the progress of the patient during and after rehabilitation therapies have been applied. The emphasis in rehabilitation therapy is on meeting goals that are functional for the patient. Physiotherapists bring these new skills to the veterinary market. A licensed physiotherapist completes a 4- to 5-year postgraduate program at an accredited college of physiotherapy. They graduate with a DPT (Doctor of Physiotherapy) and can pursue board certification in several areas of specialization.
The goals of rehabilitation include the restoration, maintenance, and promotion of optimal function and quality of life as they relate to movement disorders. The majority of rehabilitation therapeutics involves manual therapies and problem solving rather than the use of toys. Examples of manual therapies include joint mobilizations, focusing on arthrokinematics rather than osteokinematics stretches, flexibility and hypomobility, and therapeutic exercises, progressing from concentric to eccentric contractions.
Exercise equipment utilized on a regular basis in veterinary rehabilitation includes physioballs, therapy bands, rocker/wobble boards, cavaletti poles, and land treadmills. Hydrotherapy equipment can include pools, resistance pools, and underwater treadmills. Physical modalities include laser, therapeutic ultrasound, electrical stimulation, cold compression units, and extracorporeal shock wave therapy.
History of Veterinary Rehabilitation
The field of human physiotherapy began during World War I, when tens of thousands of injured soldiers returned home in need of extensive care in order to return to productive lives. Equine rehabilitation began in the 1960s with the advent of increased interest in equine sporting events. In Europe and the UK, canine rehabilitation became mainstream in the 1980s. In North America, canine rehabilitation began to grow in the early 1990s with the start of the certification programs in 1997.
Future Trends in the Industry
Veterinary rehabilitation is widely regarded as the 'fastest growing area in veterinary medicine.' In 2010, the AVMA approved the formation of the newest specialty college in veterinary medicine. The American College of Veterinary Sports Medicine and Rehabilitation currently has 85 diplomates with 7 active residencies, and more in the planning stages.
What is driving this new field? Public awareness is bringing dog owners to veterinary hospitals, expecting state-of-the-art care for their pets. This is not unlike acupuncture's rise in the 1980s - client-driven demand for new veterinary services. The current drivers include the huge interest in agility and flyball. In addition, several governments are now seeking rehabilitation care for service dogs injured in the line of duty.
Osteokinematics is the study of the movement of bones around an axis. An example is joint flexion and extension. There are two kinds of osteokinematic movement: Passive range of motion (PROM) and active range of motion (AROM). Assessment of both movements is essential in the rehabilitation evaluation. AROM is the movement that is initiated by the patient, requiring muscular effort. PROM is the movement created by the therapist, requiring no muscular effort by the patient. This is the movement that is assessed with a goniometer, using specific landmarks. For instance, when measuring elbow flexion, the goniometer is placed with its fulcrum over the lateral humeral epicondyle, the proximal end on the greater tubercle, and the distal end on the lateral styloid process.
The rehabilitation therapist uses the measurements of AROM and PROM to help localize the source of lameness. Looking at a simple example: a patient presents with a single forelimb lameness characterized by limited glenohumeral extension and evidence of pain on forelimb protraction. On assessment by the therapist, shoulder extension PROM is normal and nonpainful. What can cause this pair of findings? AROM limitation with no pain on PROM suggests that the source of active movement (muscle/tendon) is the source of pain. This allows the therapist to narrow the search to muscles that contribute to glenohumeral extension: the biceps and supraspinatus would be the likely rule-outs.
What can limit range of motion? We have seen a muscle/tendon example. In addition, intra-articular lesions (meniscus, bone, etc.), joint capsule shortening, ligamentous hypertrophy, joint pain, and regional swelling can all limit range of motion.
How does a physiotherapist (or a rehabilitation trained veterinarian) determine which of these structures is the source of limitation? The answer is end-feels, which by definition are the sensations (in the therapist's hands) when the joint is at the end of its available PROM. There are many types of end-feels described. The most commonly used in veterinary rehabilitation are bony, soft-tissue approximation, firm, springy block, and empty. Each has a sensation and a blocking substance. For example, the bony end-feel has a hard/abrupt sensation caused by bone-on-bone contact. It is generally painless. A normal example is elbow extension. Abnormal bony end-feel occurs when an osteophyte limits coxofemoral extension prior to the normal end range in the hip OA patient. Why do we care about end-feels? They assist the therapist to identify the structure or tissue limiting PROM, thus allowing for a more focused treatment.
To review: ROM is assessed, noting both active and passive ranges. Abnormalities are noted, including the direction of abnormal measurement (extension, flexion, abduction, etc.) and the quantity of the measurement. End-feel is noted, and flexibility is assessed, especially in all 2-joint muscles. With this information, the therapist must next assess the arthrokinematics, accessory joint motions, ligamentous stability, and muscle strength.
Arthrokinematics describe the movements that occur between two joint surfaces. The two most common movements are roll and glide. Both must be normal in order to have normal osteokinematic movement. Pure glide without roll results in impingement of soft tissues and/or joint cartilage. For example, stifle drawer without the normal roll results in meniscal impingement. Pure roll without glide results in subluxation of the joint. Arthrokinematics are passive and involuntary. They are also called 'accessory joint motions.'
In Conclusion: Why Should You Add Rehabilitation to Your Practice?
The increased public and professional awareness of the availability of rehabilitation for our animal patients is key. Our clients are expecting (and demanding) state-of-the-art pain management (which includes rehabilitation practice). They want their companion athlete to return to sport, and their working dog to return to its job. Rehabilitation medicine is a key component in offering best practices for geriatric patients and for assisting patients with weight management. What would it take to add rehabilitation to your practice? Training your team is the first and most important step. Rehabilitation practice requires a minimal equipment list and minimal space. Most can be done in an exam room or cage-side.
Training the Rehabilitation Team
Training in rehabilitation medicine is available in four programs in the United States. Two offer canine rehabilitation, and two offer equine rehabilitation training. There is no oversight board for these programs. How can you choose which program to attend? We suggest that you look at the experience of the faculty, the success of their graduates, and the amount of hands-on experience offered.
All programs offer the training in multiple modules. The basic certification requires approximately 14 classroom days to complete. Exams and internships round out the programs. You can get more information at the Veterinary Rehabilitation List Serve: VetRehab@yahoo.com.
Managing the Rehabilitation Team
Before opening your rehabilitation practice, we advise that you read your state practice acts. Be sure to use the terms 'physical rehabilitation' or 'animal rehabilitation' rather than physiotherapy or veterinary physiotherapy to describe your practice's new offering. Create a cohesive team that will create a profitable center for your practice. This team, all trained in veterinary rehabilitation, should have a veterinarian as team leader who maintains responsibility for the case; a physiotherapist who develops the therapeutic program and performs treatment techniques and modalities; a veterinary technician who assists in the hands-on care, freeing up the vet and the physio to see the next case.
Is veterinary rehabilitation a viable business? Done correctly, yes! The business models that have worked the best include referral centers that have surgery and oncology, freestanding rehabilitation-only/referral-only facilities, and specialty centers with an emphasis on integrative medicine and pain management.
There is great interest in this field, and great opportunity. Excellent training and careful business management are both required to make this new art and science a viable business.