Janet B. Van Dyke, DVM, DACVSMR
Canine rehabilitation is the application of physiotherapeutic techniques to evaluate and treat musculoskeletal impairments in our canine patients. It incorporates the use of objective outcome measures (goniometers, girthometers, etc.), manual assessments (including palpation, joint glides, and neurological assessment), gait analysis, and special tests brought from the field of human physiotherapy. This allows the therapist to tease out the specific structure and tissue type causing the impairments. The therapist evaluates the presenting complaint, subjective information from the owner, and objective assessment carried out during the examination to create a problem list. Each item on the problem list is addressed in the plan of care.
Therapeutic plans generally involve a combination of manual therapies (joint mobilizations and soft tissue mobilizations), physical modalities (laser, therapeutic ultrasound, e-stim, shockwave), and therapeutic exercises. The modalities are generally used to prepare the tissues for the manual therapies and therapeutic exercises. Physical modalities should never be the sole therapeutic method applied to any patient. Therapeutic exercise plans are based upon the weight-bearing status of the patient, with early interventions focusing upon functional weight-bearing exercises, later progressing to functional strengthening exercises. All exercise plans incorporate proprioception, balance, strength, flexibility, and endurance. Exercise equipment includes physioballs (shaped as rolls, peanuts, eggs, donuts and balls), cavaletti poles, therapy band, rocker/wobble boards, and treadmills. Physical modality parameters are chosen based upon the acuity of the injury. They are used to prepare the tissues for additional therapy and can generally be applied by trained veterinary nurses. The most commonly used physical modalities include neuromuscular electrical stimulation, laser, therapeutic ultrasound, extracorporeal shock wave therapy, and ice/compression units.
When the postoperative FHO patient presents to rehabilitation in our practice, the patient is still recovering from anesthesia. We assess the patient thoroughly, and using the objective data, create a problem list.
For the typical FHO patient this list will appear as follows: Pain, Muscle Atrophy, Skin Incision, Ostectomy, Decreased hip ROM, Hip Flexor Shortening.
From this problem list, we create a narrative or assessment: 9-month-old miniature poodle with 2-week history of RPL lameness presents immediately post-op with pain, atrophy of the muscles of the thigh and crus (mild), skin incision (staples), radiographic evidence of ostectomy, decreased ROM hip (loss of approximately 30 degrees of flexion and 20 degrees of abduction compared to L side), loss of flexibility in hip flexors (moderate compared to L side).
This assessment provides the framework from which the therapist creates the treatment plan, based upon the functional goals for this patient. We may wish for ‘normal’ ROM for all joints in our patients, but for many, this is not a functional or achievable goal.
For the 9-month-old miniature poodle in this example, we know that the FHO will preclude his obtaining ‘normal’ hip ROM. The therapist’s goal for this patient is to reach ROMs that are functional and realistic. In our example here, the functional goals would be:
Pain control, symmetrical muscling, healed skin incision, functional hip ROM, and functional flexibility at the coxofemoral joint.
The treatment plan to achieve these goals will address each goal separately.
Pain control will be addressed through use of TENS and cold compression. These will be applied immediately postoperatively.
Once pain is controlled, muscle atrophy can be addressed using NMES to create co-contractions of the quadriceps group and the hamstrings simultaneously, so no joint motion occurs during this acute phase.
The skin incision is treated with laser daily to speed healing, and cold compression is applied to prevent swelling and pain. NMES and laser are used to decrease any swelling as well.
Returning FHO patients to full weight-bearing can be quite challenging due to the ability of the miniature and toy breeds to ambulate on 3 legs. We address this issue by starting with the patient standing next to a stack of wooden blocks. The blocks are stacked to the approximate height at which the patient prefers to hold the paw and are then slid under the paw. Gentle perturbations are applied to encourage the patient to bear weight through the paw on the affected limb. Treats and encouragement are given whenever the paw is placed upon the blocks. As the patient becomes more comfortable with weight-bearing, the blocks are gradually lowered, encouraging the patient to slowly extend the limb toward a normal standing position. This process may be done over 7 to 10 days. TENS is used to provide pain control during this exercise. The next exercise for these patients involves working on a rocker board or wobble board. There are many options available and each patient responds differently, so the therapist must be ready to adapt to the situation. We generally start with the patient’s front feet on a rocker board that is set up to rock side to side. If moving the board does not result in the affected limb being extended to the ground, the board can be switched to rocking forward and back. If this does not work, the patient can be moved to a wobble board. Finally, if all else has failed, the patient’s rear feet are placed on the board and all positions are tried until success is found. Cavaletti poles are used to encourage longer weight bearing on the affected limb. This is accomplished by setting up the poles higher on the non-affected side.
For this patient, with a right FHO, the poles would be set up with the left side of each pole slightly higher than the right side. As the patient steps over the pole, he must spend more time bearing weight on the right limb as he lifts the left limb over the higher end of the pole. Gradually, the height of the poles, number of poles, and complexity of the pattern are increased as the patient regains strength and range of motion. Range of motion issues are treated using manual therapies. The hip is treated with Grade 1–2 joint mobilizations until the swelling and discomfort are resolved. Grade 2–3 mobilizations are then applied as needed. Therapeutic exercises to increase ROM include work over cavaletti poles as above. Hip flexor shortening is treated via stretches and soft tissue mobilization techniques to the iliopsoas, tensor fascia latae, and rectus femoris.
In conclusion, treating postoperative FHO patients requires a thorough evaluation of their orthopedic as well as soft-tissue impairments, creating a problem list, generating a list of functional goals for each of the impairments, and carrying out a treatment plan that addresses each of the goals. The temptation is to look for ‘protocols’ to treat these commonly seen patients; however, each patient recovers at their own rate, and they do not ‘read the book’ on how fast they are ‘supposed’ to reach each level of recovery. Creative problem solving, attention to detail, and focusing upon creating and meeting goals that are functional for each patient will result in superior results.