Welcome everybody. We're going to talk about canine rehabilitation and what it means for your patients, your clients, and what it can mean for your business. Let's first talk a little bit about the history of rehabilitation.

Human physiotherapy probably started with Hippocrates and Galen in way before Christ, and already we're talking about physiotherapy, whereas the title of the presentation is about rehabilitation, and we'll come back to that in a moment. Modern physiotherapy has been practised for a very long time and in the World War One, there were plenty of patients who had issues, which would then helped with physiotherapy. And then in the 1960s, which is not that long ago, physiotherapy started to become a commonplace for horses, and in horse medicine and veterinary medicine, people started a little bit sooner than we did with dogs, where we only started in the 1980s, which really isn't that long ago at all.

So the whole area of canine physiotherapy and rehabilitation is really still a relatively new field. Now, since then, there's been an increasing demand for physiotherapy services, mainly client-driven, and up to today, I find that sometimes clients seek out my services or any general physiotherapy and rehabilitation services rather than necessarily the veterinary profession, which is quite an interesting fact. There's also been an increase in demand due to the increasing popularity of canine sports, and the fastest growing and most popular canine sport is agility, but I guess fly ball, field trials, other working dogs, obedience, and sledge dogs, and so on.

So due to the increasing popularity of those sports as well as the increase in public awareness, Kenya physiotherapy has definitely been more and more popular. And nowadays there are European and world veterinary physiotherapy and rehabilitation congresses, and there are various organisations both in real terms as well as online and lots and lots of publications. So it is an ever increasing and speedily increasing field of veterinary medicine.

Physiotherapy in the UK is a protected term in the human medicine field, which means no one can practise physiotherapy on people unless they are a registered and chartered and properly qualified and educated physiotherapist. In veterinary world that is not the case. Anyone can call themselves a veterinary physiotherapist, which obviously leaves things open for abuse.

I personally find that the term rehabilitation is a wider term than physiotherapy, and in my mind that includes the diagnostics, the treatments, the follow-up, prevention, advice, and physiotherapy in my mind is part of rehabilitation. The rehabilitation, I think, is a, is a bigger, wider thing. And generally it involves a full orthopaedic and a neurological examination as well as a proper specialised rehabilitation examination.

And also some special tests. And the treatments can consist of many different things. For instance, soft tissue techniques such as stretches, manual therapies such as joint mobilizations and massage or myotherapy.

We have modalities under which we find laser, ultrasound, TES, neuromuscular, electrical stimulation, and so on. Hydrotherapy is part of treatment and rehabilitation as well, which in itself comes in various forms. And very importantly, therapeutic exercises.

And in my own daily life as a rehabilitation therapist, therapeutic exercises and a home exercise plan is a very important part of my treatment protocol. Rehabilitation is a team effort and it does need the full cooperation and communication between all the members of the team and that team consists of, first of all, the primary care vet or clinician, which is the principal person who is responsible for the case and will remain responsible for that case. Then there's the rehabilitation therapist or the physiotherapist, if you like, who does the examination, designs the treatment protocol, and does the treatments and so on, and then communicates back to the primary care vet as well as the client.

That can be the involvement of a vet nurse or a rehabilitation assistant who can assist with the examination and the hands-on care and treatment. And very often also the hydrotherapist centre. I, for instance, have a relationship with various hydrotherapy centres where I regularly refer my patients to because I personally don't have my own hydrotherapy set up.

And it's very important that all the members of the team know what the others are doing, have mutual trust and respect, and communicate fully. I am a CCRT, which is a certified Kine Rehabilitation therapist, and the training is handled by the CRI or the Kine Rehabilitation Institute, which is based in Florida, and they're associated to the University of Colorado, and they run the course both overseas as well as in Europe. The course is only open to people who are already qualified vets and physiotherapists, as in human physiotherapists.

And the course is made up of lots of different modules, and it takes several years to get the qualification. So the modules that I did were introduction to canine rehabilitation, specific canine sports medicine, neurological rehabilitation, sort of my favourite. The rehabilitation therapist and then after a big, big exam, there is the need for a practical time and a dedicated practise.

And for that, for instance, I went to Belgium for 2 weeks to join a rehabilitation practise there to get the necessary practical experience. Now when you've done all those parts, you can call yourself a CCRT. There are of course other ways of getting a rehabilitation qualification as well.

And the other big one is a CCRP which is a certified KI rehabilitation, practitioner. Excuse me. That is a course that is organised by the University of Tennessee, also in the US and it's very, very similar.

However, there are other ways to become a physiotherapist, and there are various training routes in the UK itself, and they either come from the human first or the animal first area. In other words, people can be a human physiotherapist and then say, you know what, I actually want to work in canine physiotherapy, or people can be vets or nurses and then trained to be a therapist. And it should definitely be a level 6 training with a minimum of 2 years study.

Unfortunately, in the past, there definitely have been courses that are much, much, much shorter and go into the subject matter in a much more superficial way, and people afterwards can still call themselves a veterinary physiotherapist. At the moment I got 2 voluntary registers in the UK, the REM and the AHPR, and veterinary physio therapists are going to be assessed prior to be accepted, and it's quite a stringent register. You don't have to be on these registers.

I, for instance, I'm not, but it does show that you're doing gold standard. They have very strict, rules for how to work and, and so on. There are also trade association, IEP NAVP and IAAT.

And a lot of therapists are on these registers. EFF and NAVP have very strict entry requirements. Therapists must be a member of these associations to practise to get insurance for working as a physiotherapist.

Personally, I am not a member of these organisations because I'm already a veterinary surgeon and have all my insurance through being a vet already. Physiotherapists have to work within the Veterinary Surgeons Act of 1966, which means they can only ever do a treatment if they are. In possession of a referral and a consent from the primary care veterinary surgeon.

Again, in my personal case, that's not so much the case because I'm a vet myself, but Generally, if a dog is seen by a physiotherapist, and that goes for other people as well, like chiropractors and osteopaths, they have to have a consent from the primary care veterinary surgeon. This is very important. The assessment by the rehab practitioner contains a number of elements, and we first review the signal and the history.

For instance, I will always ask for a full clinical history from a primary care vet before I see a case. We do a long question and answer session with the owner. We look at the vet report if there is any specialist referral reports like CT scans or MRI scans or surgery reports.

And then after that we do a full assessment of the patient ourselves again. And that can be an assessment in stances, and walk and trot. We can do gait analysis either with gait analysis equipment or simply letting the dog walk and trot outside or inside if you have the space and do things like photographs and video.

Personally, I take photos and I do a lot of video quite often nowadays, slow mo video, which is very, very revealing. And of course with the advent of mobile phones who can do this very easily. There is no excuse to not do this.

Then we repeat if necessary a full examination, and I think that should include both an orthopaedic and a neurological examination, at least for most of the patients we see. And then there are special things we do from a rehabilitation point of view. Which aren't necessarily part of a veterinary orthopaedic or neurological examination.

We do a full assessment of the bony and the soft tissue structures foreleg, hind leg, and trunk, head and neck, and so on. And the easiest way to do this is to do the same thing again and again and again. So you get used to the order in which you examine the patient, which makes it much easier and more reliable.

I just would like to emphasise the soft tissue structures on my first sentence because we are so used, especially as veterinary surgeons, to look at bones and joints, especially when we do an orthopaedic examination. When I trained as a rehabilitation therapist, I found that examining the soft tissues can very often give you much more information than just feeling the bones and the joints and so on. Soft tissues react to all sorts of injuries and conditions and very often will give you a really good clue as to where the problem may lay.

We do an assessment of the joints and we do PROM, which stands for passive range of movement, and we check all the joints of both the fore and the hind leg. This also includes an assessment of the end view. What that means is when, for instance, you do an extension of the elbow, you should in that case, in a normal elbow, have a firm end view when you get a bone on bone limitation of extension.

But in other joints that might not be the case. For instance, if you think about flexion of the stifle joint, the end feel is a soft end feel because the flexion of the stifle is restricted by the coming together of the gastrocnemic and the hamstring muscles, which is a very different endfield to the passive range of movement assessment. We also very often do goniometry, and goniometry means the measuring of the angles of the joint, and we know, for instance, from studies what is the normal angle of a fully flexed and a fully extended joint in various joints in the body, at least in certain types of dogs, and there are schedules available online of what the normal angles are.

We do an assessment of the muscle mass and the flexibility of the muscles, and just a quick word here flexibility is to do with soft tissue. That of range of movement is to do with joints, so therefore bones and joints and harder tissue. And girthometry is a sort of made up term which means measuring of the girth or the thickness or width or the circumference of the muscle mass.

We also check joint play, and joint play is the amount of normal movements that is in any kind of joint. For instance, glides and traction, glides, we do particular manipulations of the joints to work out if a joint is functioning correctly and if it has the normal passive and active range of movement of that joint. And for instance, the shoulder joint has a natural glide which is much bigger than you would find in an elbow joint.

We also do special tests on shoulder carpus, hips, stifle, and hook, and the spine, and these tests are a whole variety, and most people are familiar, for instance, with the anterior drawer sign of the stifle in cases of cranial cruciate ligament issues. However, there are other tests, and some of the tests we see here are MSI test. MSI stands for medial shoulder instability.

There's a biceps tendon test. Of course we can test for valgus and the virus. Most people are familiar with Ortolani test for hip dysplasia or hip laxity, I should say.

There's a tibial compression test and so on and so forth. This is a short video of an examination I did on a patient I had in practise, and I will just explain as the video runs what I'm doing here. So this is a trico a border collie who has a problem on the left foreleg, and I'm examining the right foreleg first.

So what I'm doing here is I'm checking the shoulder and the elbow, and I am doing full extension of the shoulder joints and then abduction, Abduction. Inflexion you can have duct, but an extension, there shouldn't be more than about 2025 degrees of abduction. I'm also at the same time doing a test for the biceps in full flexion of the shoulder.

There shouldn't be extension of the elbow beyond 90 degrees. So full flexion of the shoulder, no more than 90 degrees extension of that elbow, and a full extension of the shoulder, no more than about 25, maybe 30 degrees abduction of the forelimb. So this is the normal side.

And then on the affected side, we'll now examine the affected side of the dog, and this particular patient has two issues and you will find out as you see the examination that there is a problem with both aspects. So this is the affected shoulder in full extension of the shoulder. There is much more abduction, a reduction of that forelimb.

In this case, about 40, 45 degrees abduction, which is more than normal in full flexion of the shoulder. I can also extend the elbow far beyond the 90 degrees that is normal and was present on the other side. That indicates an issue with the biceps tendon, a partial or a total erosion of the biceps tendon, and this dog also has a medial shoulder instability due to the abduction of about 45 degrees.

So after we've done an examination that it may include some of the special tests as well as all the standard tests we talked about earlier, we come to a rehabilitation diagnosis and based on that, we then decide on a treatment plan. So we, we make a problem list of the findings of our examination together what the patient already came with, and we decide on a treatment plan and we quite often make a different plan for the acute phase, the subacute phase, and the chronic phase because treatments may change throughout the treatment of the patients. And we plan them and we talk about the frequency of treatments or for instance home exercises, the intensity, how long they will go in for, and we will also, if necessary, get input from the primary care vet.

All the treatments are recorded. And most importantly, we try to set outcome measures and of course it is better to do objective measurements such as for instance the goniometry or the girthometry where you can have actual numbers to work with or stance analyse or pressure met measurements that you can see change over time. Progress is also monitored by our subjective assessment of the patient as well as the owner's opinion, but objective measurements are of course better.

As we mentioned before, there are lots of different options for rehabilitation treatment manual therapies, modalities, hydrotherapies, the home exercise plan, and we also can sometimes work with orthotics, prosthetics, and other assistive devices. And for instance, when I do a report after an examination that I send out to the client, it is very often 7 or 8 pages long. And there'll be lots of information there about the history and the examination and the findings and then ideas about treatment plan, home exercises, but also lots and lots of advice, for instance, about alterations to the home environment, about nutrition, about supplements, and so on and so forth.

Let's talk about manual therapies. The most important thing we do in manual therapies is soft tissue techniques, and part of that is therapeutic massage, which can also be called myotherapy, and there are lots of different types of that, and they all have nice names like petrisage and tapportment. It doesn't really matter what they're called.

If you're trained in massage, you will automatically use some or most of these techniques every single time. For me, the most important ones that I use in my work are myofascial release and trigger point therapy. And trigger point therapy can actually happen in various ways.

A massage can definitely be part of that, but also we will treat trigger. Points, for instance, with acupuncture, acupuncture doesn't feature much in this rehabilitation presentation per se, but it's something that I am trained in and do as well and actually starting to form a bigger and bigger part of my multi-modal approach to, for instance, pain therapy. Manual therapies can also involve stretches, and there is a difference between active stretches and passive stretches.

And as you can see in this picture here, I'm actually doing a stretch here of the biceps tendon by doing flexion of the shoulder and extension of the elbow. However, you have to remember that a passive stretch can cause some discomfort to the patient, and they may not be able to give you all the feedback necessarily. An active stretch is something that the patient does themselves, and in general we prefer active stretches over passive stretches, but both definitely have a place.

Many of therapies can also include joint mobilizations. We talked earlier a little bit about glides and traction, and rolls and glides and traction are all types of manipulations we do on joints to release, for instance, pain and inflammation and swelling around joints and so on. There are different types and grades possible, and depending on the the goal of what you're trying to achieve and the function of a joint, we do different things for different joints at different times of the therapy.

Modalities is basically a word that explains all the different types of treatments we can do using, I would say, fancy machines, and they include laser treatment, therapeutic ultrasound, E-STEM, which contains both TE and and MES. I'll talk about it a bit later, cold and heat therapy, extracorporeal shock wave therapy, and some more advanced treatments. Let's talk a little bit about laser.

I can probably talk about laser for an hour in itself, but you get one slide. Laser stands for light amplification by stimulated emission of radiation, and it is a light therapy that stimulates tissue directly, and the correct term is called philtre biomodulation. And laser works by the light directly interacting with the cells and the tissue, rather than causing heat.

People should be specially trained to know laser exactly the safety aspects, the indications, and most importantly, contraindications. Effects of the laser are multiple. It decreases pain, inflammation, and edoema, which is particularly useful in the direct postoperative phase.

It increases blood supply and metabolism. It stimulates wound healing, angiogenesis, and even nerve regeneration, very important. It can stimulate bone healing and fibroblast proliferation, leading to better scar formation, for instance.

But the effect is dependent on the wavelength, and this is important because not all lasers are equal. Some lasers have different wavelength in nanometers. For instance, the 660 nanometers is particularly good for wound healing.

This is the visible red light that some other red light pens have, very good for very superficial things. The 800, the 905, and the 970 wavelength have different effects on different things. And depending on the wavelength used in the laser and the power of the laser and the different settings, you can achieve very, very different things.

Personally, I use the laser mainly for two classes of conditions. There's the orthopaedic issues and skin issues. And when I talk about orthopaedic issues, this can be tendon and ligament injuries, but also muscular injuries, but mostly we use it for osteoarthritis.

I will use a laser routinely for stifle or elbow arthritis, for instance. But there there's lots more you can do with it, and there are lots of internal and medical conditions that also can benefit from laser treatment. For skin cases, we can use it for enhanced wound healing of surgical wounds, but mostly it is extremely useful for chronic and non-healing wounds and burns and liquidanalomas and so on.

But do be aware, there are lots and lots of different machines out there. Not all lasers are equal. You have to look into it.

There are different classes of laser and certainly different power settings and wavelength, and that can have a big influence on the cost of the laser. Ultrasounds in this case, of course, we're talking about therapeutic ultrasounds rather than diagnostic ultrasound, and it's about acoustic energy influences the tissue, and the effects are both thermal and nonthermal. The thermal effect, the heating effect of the tissue, will increase circulation and metabolic rates and can be useful, especially in chronic conditions.

The nonthermal effects of therapeutic ultrasounds are of a mechanical nature. The ultrasound waves cause micro massage and cause various cellular effects that can be beneficial. And we mainly use this for causing an increased circulation and tissue extensibility.

It decreases inflammation and muscle spasms, and it facilitates tissue healing, and I personally use it mainly for tendon and ligaments and some muscular issues. For instance, the biceps tendinitis, we use it for ileosoar strains and so on. And the machine has got different settings and it only works with 3 and 1 megahertz settings, which are very different, of course, from it's like a diagnostic ultrasound where you can work with 10 or 12 or 15 megahertz settings.

There are settings for continuous waves or post waves, the duration of the treatment, the intensity, and so on. Excuse me. They're not very expensive, especially compared to laser machines, so well worth investing in a therapeutic ultrasound if you're into physiotherapy and rehabilitation.

E-stem or electrical stimulation has two main parts, tenses, which is transcutaneous electrical nerve stimulation, which is mainly used for pain relief. You can buy a TENS machine that boots for like 50 quid that has good settings for pain relief, and a lot of people use it in their own home on themselves. TENS works on sensory nerves.

The other setting is for NMES, which stands for neuromuscular electrical stimulation. And that stimulates motor nerves and it's intended to elicit a muscle contraction. It's very good for preserving or recovering muscle mass in cases of severe muscle atrophy, either due to disuse or more so in cases of neurological damage.

Nerve damage leads to a much quicker and more extensive muscle atrophy than disuse, and even though the use of NMES is more fatiguing for the muscle than volatile muscle contractions, it is definitely a sensible therapy to regain some muscle mass in those situations. Lots of different settings. So again, you need to know what you're dealing with.

They have different pulse rates, pulse width, cycle, duration, intensity, different modes. Many machines have both functions. I have a machine which only costs about 70 pounds and has both functions.

Don't use it an awful lot, but it's a very, very usual, useful part of the therapeutic modalities. Cold therapy is simple and cheap and can be very effective. Officially, of course, it's called cryotherapy.

And we can use ice, cold packs, or circulating cold fluids. There is a machine called Game Ready, which is an American machine, which is used a lot to fill up centres, but especially on a mobile situation or when you have your little clinic, ice packs and hot and cold packs that can be purchased quite cheaply from places like Amazon, etc. Are absolutely fine.

The effect is caused by decrease in inflammation and a reduction of pain, and cold packs really are easy to use, easy to carry around with you as well. This is an example of a cold pack that I quite often use post cushion surgery. This is a patient who's had a TPLO surgery, and whilst having the postoperative X-rays and waiting to come around from general anaesthesia, we iced the knee for about 20 minutes in a specially designed canine ice pack that has some ice packs inside.

To do a 20 minute icing directly post-operatively and it can have a major benefit to the postoperative phase causing a lack of inflammation or or a decrease in inflammation and swelling. The opposite of cold therapy, of course, is heat therapy. And you can use ultrasound, as we mentioned earlier, ultrasound has a thermal effect, or we can use hot packs.

It has an effect by promoting blood flow, reducing muscle spasms, relaxing stiff joints, and thereby also causing pain relief. And heat packs again are cheap and easy to carry and use. And the picture you can see there is a hot and cold pack which is exactly the same one pack that you can buy quite cheaply on Amazon, and you can either use it as a frozen pack for a cold pack or put it in a microwave for a hot pack, and they're reusable, hygienic, easy to clean, and very easy to use.

Shockwave therapy or ESWT works with high energy sound waves, and it's mainly used for musculoskeletal injuries, mostly those to do with tendons and bones, for instance, delayed and non-unions and other tendon injuries as well. It is very, very noisy, so most patients will require sedation or general anaesthetic, but some animals can be accustomed to it and don't require that. The effects are that there is a production of new blood vessels, which of course, especially in chronic conditions and and malunions and non-union delayed unions is very, very important.

It stimulates collagen inflammation and reduces inflammation and by all these things also causes pain relief. Even if you don't have a shockwave therapy machine, patients can also be referred to specialist centres for this. There's also hyperbolic oxygen treatment, quite specialised, very, very few and far between.

This is a machine that uses a high level of oxygen, 100% oxygen at up to 2 atmosphere, which causes 10 times the amount of oxygen surrounding a patient and normally would be the case, and patients can be inside this tank for up to 1 hour at a time, once or twice a day for several treatments, quite often on a daily basis. It is usually used for head and spinal cord trauma, things like FCEs, invertible disc disease, but also some wound healing and burns, and it induces swelling and edoema, it induces new blood vessel growth. It actually causes really good control of infection, and most of all, it is thought to reduce the pressure in the spinal canal.

So in certain places, this will be used especially for neurological conditions in the acute stage. It is good as far as safety is concerned, but it's very expensive and has to be used by people who are specially trained in using this machine. As there are so few in this country, you would need to be further patient for this.

There's still a lot of research going on, so watch this space. Hydrotherapy, not an awful lot I can add to that, but it's been around for quite a few years. There are lots of hydrotherapies around and it is probably the most well known form of physiotherapy for a long time already.

It's about therapeutic exercise and aquatic environment and it works mainly by being able to exercise with partial or even non-weight bearing. And the effects of hydrotherapy are positive due to a combination of the buoyancy which causes the reduction in weight bearing, the viscosity of the water, which causes a stabilising effect but also leads to muscle strengthening, the hydrostatic pressure of the water, which causes a reduction in edoema and swelling, the resistance of the water, which can help with both sensory awareness in neurological cases or muscle strengthening for fitness training. And a thermodynamic effect which relaxes muscles, the water in highery is generally about 28 to 30 degrees.

There are different types of hydrotherapy. For instance, we can talk about open water. The reason I put a couple of question marks on this slide is that It's sort of debatable whether open water swimming is actually hydrotherapy.

In my mind, it is swimming, it is fun. It is nice, and dogs enjoy it. It's not really hydrotherapy in my mind.

Most hydrotherapy places have either a pool or an underwater treadmill. They both have their pros and cons. They both have their specific indications, and we'll talk about it a little bit more in detail.

And some centres also have a spa tank, which is usually a slightly higher temperature and it's mainly for relaxation and. Good feeling. Indications for hydrotherapy can be of course a lot of ortho and nervo patients that we have.

Post-operative, especially very useful in a post-operative phase, and we can also use it in a pre-operative phase. Right now I'm treating a golden retriever who has a cruciate ligament injury and he's going to have surgery, but due to the delay in the surgery, we're doing already some exercises and hydrotherapy before the surgery. We call that rehab rather than rehab.

Of course, hydrotherapy can also just be for relaxation and fun. We can use it for conditioning, especially in sporting dogs for pure fitness training. We can also use it as part of a weight loss programme.

And certain precautions we have to take. For instance, we have to be a little bit careful with patients who have cardiorespiratory diseases, skin issues. Very young and very old patients or those who have open wounds or are still in the direct postoperative phase where they still have stitches, and of course those patients with diarrhoea, vomiting, and other kinds of discharge.

I put two organisations out there, NO and CHA. Most hydrotherapy places are associated to either one of these two organisations. Again, to safeguard the patients and make sure that the people doing the hydrotherapy are well trained in the safety aspects of hydrotherapy, the indications, the different modalities, and also first aid training and so on.

The main goals of higher therapy would be muscle strengthening of fitness, cardiopulmonary conditioning, increased range of movement in the joints, and increase increased flexibility. And if you remember, that is to do with the soft tissues, mainly muscles but also tendons and ligaments. For balance and coordination, generally for pain relief and endurance, for instance, again in the sporting dogs, and it can increase the metabolism.

That cat is clearly just having fun. Different types of exercises are possible with higher therapy. We can make the patient walk, and I'm talking mainly about treadmill here.

They can run in the treadmill if they're very fit. Of course we're talking about swimming either in the pool or in the treadmill. If you have a small enough dog, they can swim in the treadmill.

We can do some surfing in the treadmill or in the pool, and I'll show you an example of that later. We can do specific movements in the treadmill and in the water as well, and generally we would always advise that a therapist is in the treadmill or in the pool with the patient to guide them, to help them, to increase the safety aspects, and also to do targeted movements and exercises. And we can work with special aids like existance bands, floats, and weights, and I'll show you an example of that a bit later as well.

If you are a rehabilitation therapist or a physiotherapist, I would suggest that you refer to a small number of selected and expected 100% that you have checked yourself. You are still responsible for the treatment of that pet, and as a veterinary surgeon, you will still be responsible for the full treatment of that pet, even if they go to another hydrotherapy centre, so it's wise to choose them carefully. Let's talk a little bit about therapeutic exercises, one of my favourite parts of rehabilitation.

The exercises that we set have different goals, and there are certain exercises we do specifically for balance and coordination and pro reception. Certain exercises are more to do with strength or flexibility or endurance. We do core strength exercises as well.

And the exercises will differ during the therapeutic programme, and it is based on their weight bearing and their strength and, and the ease of doing those exercises over time. And it also depends very much on the owner's goals. One of the important questions that I have in the original assessment is what is your aim?

What is your goal? What would you like to get out of this treatment? Some people might say, you know what, I want a happy dog.

That I can take to the woods and he's not in pain. Perfect. Other people might say my dog is is going to rots and is in the agility finals in 3 months' time, and he needs to be ready for that.

So it's very important to know right from the outset what the individual goals are and to work with that. There are different phases of the therapeutic exercises, the acute, subacute and chronic phase, and weight bearing can be non-weight bearing, partial or full weight bearing, and based on all these things, we can assess what would be the sensible exercise to do in those particular cases. When I do a report, there will be probably between 10 and 15 different types of exercises in the different categories for each individual patient, and every report I do is different.

It's very important to have an individually tailored programme for each patient rather than a cookbook approach. So for instance, people will phone sometimes and say, I've got a dog, he's had a TPO. What do I do?

And my answer is it depends on the dog because every patient is different, the goals are different, the surgery is different, the personal reaction of that patient. To the injury and the surgery may be different, so you need to do an individually tailored programme in each and every case. We can use lots of different devices as well for therapeutic exercises, to be fair, most of them don't need anything at all.

For instance, giving a pole, a three-legged stances, and certain stretches, you don't need anything at all. But we do make use. Of things like wobble boards and wobble cushions, physio balls and peanuts, some poles, cones, mattresses, and so on.

And most of these things can be readily available online, can be purchased for for really quite little money. And instead of buying cavaletti poles or agility jumps, people can use, broom handles and so on. You have to be sometimes a little bit inventive about how you use certain things in the house or the garden to help people do exercises with their pets.

Some simple exercises which don't need anything at all will be three-legged stands, rocking, perturbations, which is little pushes onto the front or the back end of the dog to incite a reactive muscle contraction. We can walk patients up and down inclines, do sidestepping, sit to stands, walking backwards, and so on. You can see in some of the pictures there that I'm doing some very simple exercises in the bottom right corner.

I'm doing some hobo cushion work on the Labrador. In the top pictures I'm working with my own little dog Spike doing a foot and a two-legged stance, which is actually a diagonal stance, which is something that can be quite hard and requires a very good balance and coordination as well as a good core strength. Let's talk about post-operative handling.

I think it's really, really important to handle patients very gently and carefully and appropriately in the post-operative phase, depending on the individual, their condition, and any kind of surgery performed. I have worked in places where sometimes patients get seen by the very best surgeons, have the most amazing surgery done, but if the postoperative handling of that patient is not perfect, it can be detrimental to the effect of the surgery and the treatment. Even as simple as taking patients in and out of kennels or walking them to the exercise area is very important and can actually be part of the exercise itself.

We can adjust the stance or the gait of the patients while they're walking to the exercise area. The kennels itself and what sort of bedding you use and so on can be important as well. I think it's important that the patients are handled by people who are knowledgeable about the surgery, the condition, and that particular patient.

It can make a big difference. So things like non-slip matting, boots on certain dogs, support with harnesses or slings or using multiple people or even as simple as a towel on the back ends of the dog and very sympathetic handling and taking care of yourself because patients of course can be in discomfort, so you have to be careful for yourself, for your own back, but also not to be bitten, so use muscles if necessary and so on. As far as evidence is concerned, there are lots and lots and lots of studies already out there proving the efficacy of mobile rehabilitation and the evidence is ever increasing.

There are some examples on this slide of meta-analysis articles and so on and systematic reviews of rehabilitation. Of course there are many more studies proving physiotherapy and rehabilitation in the human field, but even in the veterinary field it is massively increasing currently. There is also a huge amount of anecdotal evidence from efficacy of rehabilitation and physiotherapy, which of course is of a lower standard than proper double blind placebo controlled studies and systematic reviews and meta-analysis, but these are definitely already.

Available and we're still a long way to go for some types of treatment like the shock wave therapy and especially the hyperbaric oxygen treatment. There is not a lot of evidence for them at this moment in time, but it is increasing all the time. I would just like to show you some examples of hydrotherapy and so you can see for yourself what happens in certain circumstances.

This is one of my previous own dogs, Little Sky, a Jackla or Yorkie cross, doing some swimming in a treadmill. Now it looks like we're having a very, very good action of all four limbs here, but if we slow this down to Sorry, to a slow motion video, you will see that there's a big difference between the movement of the front legs and the hind legs. Excuse me.

At the front we have a beautiful circular action of the front legs in a nice plane, but at the back we just get these little kicks of the hind legs. They do not have a motion that is anywhere near as nice and proper as we see on the front legs. And I think this goes for a lot of patience, which means that for me, swimming is a great exercise.

For instance, for general fun and conditioning and fitness, as well as for a lot of conditions involving the front legs. However, I'll show the video again. However, for hind leg issues, I often prefer treadmill over pool, mainly because a lot of dogs have an inefficient action with the hind legs, and in fact in some cases it can be detrimental to their recovery.

This is the same dog and the same treadmill doing treadmill work in low water. And as you can see, Both front legs and rear legs are used in a next to normal way. The gait patterns of dogs in the treadmill is not exactly the same as on dry land, but very, very similar.

And when we slow this down. You can see that the dog is now using both the front legs and the rear legs in a much more natural way. And especially the hind legs.

This is one of the reasons that especially for hind leg problems, I very much prefer the treadmill over the pool in the direct postoperative phase. For instance, a post TPLO case for me would not go in the pool, maybe to a very, very advanced stage of the rehabilitation where they already have regained muscle mass and normal gait patterns and so on. I mentioned surfing before.

It's not something that is often done, but this is my little previous dog, Sky inside a treadmill onto a surfing board with a therapist in the tank as well, and we're just doing some cracked square placement of all the limbs. And then the therapist is able to move the surfboard side to side. This is sort of the aquatic equivalent of a wobble board or a wobble cushion exercise, but here we're doing a three-legged stance as well as walking onto a surfboard onto the water which engages a lot more muscles and requires a very strong sense of balance and coordination as well as core strength.

Here we will show you an example of a dog in a water treadmill with the use of an assistive device, in this case, a peer band. Tied to the right hind leg, this particular patient had had a TPO surgery done, is now in an advanced stage of rehabilitation, and we're working on increasing the muscle strength, especially of the qualiceps muscle by using the lagaban coal to the patient. This means that the protection of the right hind leg is slightly made more difficult by using the stagger band, so it requires the dogs to engage specifically the hip flexors of the right hind leg in a stronger way.

And so with the tagger bands you can work on not only specific limbs, but sometimes specific muscle groups within specific limbs for a specific purpose. This is an example of a dog walking in an underwater treadmill with floats on the hind legs, and what you will see when we look at the movement in a moment is that during the gait there is a much higher flexion of stifle and hook and even the hip because of the floats, the rear legs will lift higher and higher and therefore it increases the flexion of the joints. Have a look at this.

The rear legs are lifted much, much higher, and of course this is in a in a passive way, but it helps the dog to engage those muscles every time it takes a step. Floats and agga bands are not used by everyone, not used very often, but in specific cases, they can make a big difference to the rehabilitation in these patients. This is an example of the little dog that you've seen earlier in the treadmill.

Doing a balance and coordination exercise on a wobble cushion. In this case, it's quite an advanced exercise because we're making a dog not just sit on the wobble cushion but then get into a sit. And they sit pretty or a bag and then back to stand.

So the dog's going to sit on the wobble cushion, then get into a bag, then get into a stand onto the wobble cushion which takes enormous balancing coordination and again very good core strength. Have a look at this. Up we go, still on the bubble cushion.

This little dog was 11 years old at the time of doing this video, and it just proves that age is just a number. If dogs are fit and strong and kept strong, all these things are possible. I'll show this once more.

And this is a slow motion video. And the next video shows the same dog doing a similar exercise on top of her physio peanut bowl, which is being stabilised by a veterinary nurse. You can see by a constant readjustment of the position of the dog that is using all sorts of muscles to do this.

This is not something that can be done with patients with serious conditions or disease. This is a healthy fit dog in this particular case. It's just really to show what is possible and how things can be used in a relatively simple way.

I talked earlier for a short time about orthotic prosthetics and other assistive devices. They definitely have a place. It goes beyond the scope of this presentation to talk about this in detail, but there are some examples here of a dog wearing boots.

A dog wearing a corrective assistive device on one of its paws and one dog wearing two tarsal braces on both hind legs. This was a little sheltie that had had multiple surgeries on both tarsal joints without success, and the owner chose to have the orthotics specially made for this. They are made in America.

And these are very useful in selected cases. Assistive devices also include things like wheelchairs, harnesses, and so on. There are lots and lots available and in a special presentation we can talk about that more in detail at some point in the future perhaps.

Just a short slide about Pennyha, which is the rehabilitation business that that I run, together with my partner. We're an independent family run vet led mobile rehabilitation service, and we decided when we set this up in 2021 to do this on a mobile basis so we can actually do treatment in the, in the comfort of people's homes without having to travel to a practise. Our consultations are usually 1.5 to 2 hours long at people's home.

We do the full examination. We discuss all the findings. We do all the treatments there and then.

We carry everything with us that we might need, and we do big, big reports to both the clients as well as to referring vets. And we also work closely with certain practises and hytherapy centres in our, in our area. And this is the start of the show at the moment, which is our current dog Spiky.

Spiky is 3 years old. He's a Barson Russell terrier, and we had to do some photo shoots with our physio balls and peanuts, and as you can see, Spiky was demonstrating one particular potential use of these pieces of equipment in this photograph. This particular stance alone can take quite a bit of balance and coordination and again a good core stability as well.

We can also work with sporting and working dogs. For instance, dogs form agility, obedience, fly ball, and so on, or police dogs and border force dogs, and I've worked with all of those. The consults that you can do with dogs as a rehabilitation practitioner are very much the same as any kind of rehabilitation consults, but for instance for agility dogs that can be pre, mid and end of season checks as well.

And a lot of people in agility are very knowledgeable, very proactive in. Incredibly committed owners and they know when their dogs aren't quite right and even if they are right, they will quite often go for pre or postseason checks, and it's surprising how often we find tiny little things, little niggles, sometimes in the spine or in the in the joints that require treatment and that can be found before they become a clinical problem, before the dog goes lame or has a performance issue. So minor injuries and performance issues can often be the case in these working dogs.

I myself have worked in agility for a long time, including instructing and judging and being the team vet for the agility World Championships, and I've treated lots and lots of agility dogs, and it's very, very interesting to work with these dogs, and it's also really, really nice to treat really super fit athletic dogs. Rather than necessarily the patients we see in in day to day clinical practise in the vet world. Just to show you a little bit of what these dogs go through in agility, for instance, particularly if you just have a look at these dogs and then imagine the forces going through their joints and the activity of the muscles, tendons, ligaments, and the entire body necessary to perform these actions, it is not surprising that sometimes you can work with injuries in these dogs.

These dogs take jumps from many, many, many metres away, and sometimes things go wrong. And if you just look at the body position of this dog and you imagine the forces going through the joints when this dog lands while it has rotation as well, you can just imagine things could go wrong. And sometimes do go wrong.

This is a very old picture. These types of tyres are no longer used in agility, as you can see, this is a picture of 2006. At the time, these fixed tyres caused a lot of injuries in dogs.

This dog is just going through the weaves doing the the stepping through the weaves, and there is increasingly high levels of flexion, rotation, and, and spinal, you know, movement in this dog whilst going through the weaves. A super strong fit athletic dog has no issues with this, but that's not always the case. You also need to know when you're working with sporting dogs what's normal, and if you look at the top left picture, you think, oh my God, this dog has serious hyperextension of both carpus joints.

This is actually a normal dog on the landing after a jump, and you can see similar hyperextension of the carpus in the dogs on the dog walk and the A frame in the other pictures. This is actually normal for a dog during high level of activity. These dogs have not got any problems at all.

You will not be able to cause this level of hyperextension of the carpus during a clinical examination, but during active work with the dogs, this is normal. Conclusion, there is a huge amount that I feel that rehabilitation can do for your patients after surgery, after injury, for general and sports conditioning, and so on. There's also a huge potential case load like all the routine surgeries like the TPOs, the TTAs, the medial patellar laxation, fracture repairs, and most neurological patients, disc cases, and so on, and it can be post-surgical or it can be instead of surgery, conservative treatment of cruciate injury cases and disc cases is very, very important.

There is a large and ever increasing amount of evidence for the efficacy of rehabilitation, but the results depends, of course, on the injury itself, the goals of the owner, the cooperation of the patient and the owner, and most importantly, the knowledge base and the experience of the therapist. And good rehabilitation always takes really good cooperation between the primary care vets. The nurse or assistant, the rehabilitation practitioner, and the owner.

And for me, early intervention is key. Classically Surgeons have been perhaps a little bit conservative in their approach to rehabilitation, but that is rapidly changing. A lot more people are aware of these treatments, aware of the safe, safety and the efficacy of these treatments, and will be quite willing to have their cases seen by rehabilitation therapists.

And the earlier we intervene after surgery, for instance, or after injuries, the better the results can be. I would like to thank you all for your time and attention and hopefully it will have increased your understanding a little bit of what canine rehabilitation can mean and that hopefully you'll soon be refilling more patience for rehabilitation, whether that's in-house or outside of your practise. And finally, just another little picture of my current dog Spike moving quite fast over a field and our motorists moved to improve a big part of rehabilitation.

Thank you.