Good evening everybody and welcome to this session on physiotherapy and rehabilitation plans. It's my privilege to be chairing the session tonight. My name is Bruce Stevenson and we have a great presentation for you tonight with Kate McSkimming.
But before I introduce Kate, just a little bit of housekeeping for those of you that don't know. If you want to ask questions to our presenter, all you need to do is hover your cursor over the screen. You'll see a black control bar comes up.
Sometimes it's at the top and sometimes it's at the bottom. And then there's a little box that says Q and A. Simply click on that and type in your message.
It'll come through to me and we'll hold all the questions to the end. Kate has very kindly agreed to take questions after the session tonight. So don't be shy.
Feel free to pop a question in there and Kate will discuss it. So as I said, we're in for a good treat tonight. Kate graduated with a first class honours in veterinary physiotherapy from Harper Adams University in 2017.
And since graduating, she has been employed at the University of Glasgow's small animal hospitals, working with a variety of small orthopaedic and neurological cases. Kate is also a member of the National Association of Veterinary Physiotherapists. Kate, welcome to the webinar vet and without further ado from me, it's over to you.
Thank you. OK, so tonight's webinar is on physiotherapy and rehab plans and how the veterinary nurse can implement them in practise. So we're gonna discuss why we use physiotherapy, the role of the vet nurse in physiotherapy, various physiotherapy techniques, and then I've got 4 case studies at the end as well.
So there's 5 aims of the webinar, so they're to know how, when and why to use physiotherapy and rehabilitation plans and patient recovery. To understand the role of the veterinary nurse in implementing the rehabilitation plan, to know how, when and why to use passive range of motion exercises in the rehabilitation plan, to know how, when and why to use manual techniques in the rehabilitation plan. And to understand the role of active prescriptive exercises and the rehabilitation plan with the aim of returning to the patient's highest possible level of function.
So what is physiotherapy and why do we use it? Veterinary physiotherapy is a science-based profession, which takes a holistic approach to each patient by providing functional assessment following a veterinary referral. So that's an important point, is that any physiotherapy carried out has to be via a veterinary referral.
So it helps to restore movement and function, and that can either be post-surgery, post-injury. Or as part of a chronic condition, it helps to enhance surgical outcomes, so that can be orthopaedic surgical outcome or neurologic surgical outcomes. We can help to improve the quality of life of patients that can be with the chronic conditions or post-surgery and optimise patient performance.
So sometimes we see performance animals as well as part of the physiotherapy. OK, so the role of the veterinary nurse in physiotherapist, so as I said before, it's part of the veterinary surgeons Act, so any. Require two people, particularly of their.
And if you're working as part of a larger practise. And then sometimes as well when you're discharging the patient, or if the owner has any questions, you might be involved in communicating certain aspects of the physiotherapy plan to owners. OK, so there's 4 sort of main physiotherapy techniques that I'm going to discuss tonight.
So we have our passive techniques, that's things like the passive range of motion, stretching, manual techniques such as massage. Those are ones that don't require input from the patient and that we as a therapist can do. There's the electrotherapy, so they're the electrical modalities used to promote healing, pain relief, anti-inflammatory.
There's the active prescriptive exercise, so there's a wide range of exercises that we can use, . To increase things like weight bearing, muscle mass, joint range of motion, gait. Patterns, so it's worth knowing about all of those exercises and what they achieve as well, and then there's a hydrotherapy which is using the water to exercise, which might be in the pool or the treadmill.
OK, so I'll start with talking about passive range of motion. So passive range of motion aims to promote joint range of motion. As I said before, it doesn't require any input from the patient, therefore, it's a passive exercise.
It can help to maintain or improve joint range of motion poster post injury or surgery, and it can also help to reduce joint stiffness. It doesn't build muscle mass because it's a passive technique, so the patient isn't moving their own limb, we're doing it for them. So therefore it's a passive technique.
OK, so the first one is the flexion of the joints in the forelimb. So if you position the patient in lateral recumbency, you have one hand. Behind the elbow, one hand in front of the carcass, and when you're carrying out the passive techniques, if you're trying not to grip round any joints, if you try and keep your hand holds nice and light and just make sure that you're not bringing the limb out at any sort of angle away from the body, so you want to keep it in a sort of natural plane.
So you want to flex the joints, so rather than doing pulling motions, try to use a pushing motion, so be nice and gentle and use your right hand that's in front of the carpet to gently flex the joints. And what you would want to do would be to flex all the way up to the shoulder and you're looking for any sort of end feeling in the joint, so if you get a bony end feel, obviously don't push it too far. And then the extension of the forelimb, so it's the same hand holes as the previous slide, whereas this time you're using your left hand to gently push behind the elbow, so you can bring the limb into an extended position.
Again, just take note of any sort of in feel, any crepitus, any inflammation, just when you've got that hold on the joints. So you want to repeat that for 10 repetitions and you want to carry it out 3 times a day. There's a hind limb flexion as well, so one hand again, just gently behind the tarsus, and one hand just above the stifle.
And again, you can use your hand behind the tarsus just to gently push and bring the joints into a flexion. If it's a smaller dog or there's quite a lot of muscle atrophy around the hip, you might just want to use your thumb or the back of your hand just to sort of gently stabilise the hip to avoid any sort of subluxation. And then when you bring in the limb into extension, so again, it's a similar hand holds as before.
Whereas this time use your right hand to put gentle pressure, and your left hand to put gentle pressure behind the tarsus and bring the joints into an extended position. And as with the forelimb, you want to carry that out for 10 repetitions 3 times a day. The next manual technique is stretching.
So again, it's a passive exercise, it's a manual technique. We use it to improve flexibility of joints and maintain or improve muscle and soft tissue extensibility and length. So we don't want to develop any contractors, particularly post-surgery or post neurological condition in the patient.
So it's really important to keep that soft tissue length. When you're doing the stretching as well, it shouldn't be painful for the patient, so you don't want to stretch to the point of pain for the patient, just the point of gentle resistance, and you should hold each stretch for between 10 and 15 seconds, ideally. As with the passive range of motion as well, try to avoid gripping hard round the joints or moving the limb into an abnormal position.
So the first stretch is the bicep stretch, so if you pop one hand on your sort of behind the elbow, distal humus and one hand in front of the carcass, and just gently. Stretch the biceps, so you might want to bring the limb into an extension first, and then move the limb into sort of caudal position to stretch the biceps, and as I said, hold that one for 10 to 15 seconds and carry it out 3 times a day. Then there's the triceps stretch.
So if you put one hand just over. The top of the scapula just to stabilise the shoulder, and one hand just behind the elbow, and you use the hand just behind the elbow to apply a sort of cranial force, and then stretch the triceps muscle and again hold that one for 10 to 15 seconds, 3 times a day. There's the quadriceps stretch or the hip flexor, so.
For the stretch if you use some hand holds to the passive range of motion, so one hand just above the stifle and one hand just below the tarsus, and if you extend the limb to start with and then use your right hand to apply. A caudal force to the limb, you'll be able to stretch the quadriceps muscles, the same as before if you hold for 10 to 15 seconds, 3 times a day, and as with the passive range of motion in the hind limb, if you're a bit worried about the hip not being too stable, you can stabilise it either with your thumb or the back of your hand. And to stretch the hamstring, some of the hand holds again, so one hand behind the tarsus, one above the stifle, extend the limb and then use your left hand that's behind the tarsus to apply a cranial force to the limb, stretch the hamstrings.
So the next technique I'm going to talk about is the massage. So massage is generally very good for increasing venous and lymphatic flow, so it's good for reduction of edoema in the limbs. If you are looking to reduce any edoema as well, it's quite important if you massage back towards the heart.
Massage is a good way to relax the patient before you start any other physiotherapy techniques, so if you've got a patient that's a bit worried, it's a very nice way of just sort of bonding with the patient and relaxing them. Always make sure you're gauging the patient comfort throughout the massage as well. Some of the techniques are very light, but some of them are a bit deeper, so we don't want to be causing the patient any discomfort there.
And then try not to massage over any sort of bony landmarks, any tumours, and also we don't want to massage anywhere where we've got areas of very acute inflammation, so if you've got any surgical wounds or anything like that, we don't want to be increasing the blood flow to there, when it's in the acute stage. So the three sort of main techniques that I'm going to talk about are efferage kneading and compression massage. So to start with Farage, that's a stroking motion, used with your hand in a sort of flat palm position and you're just using a light to medium pressure there.
So that's a good one to start off any massage, just to get the patient used to you being there, get them used to the feel of your hands. Theage is good for increasing blood flow. Improves your soft tissue mobility, and again as I said, it prepares the patient for the deeper massage techniques, so it warms up the tissues basically.
And then you've got your kneading. So it's a form of deeper massage, so you're using your fingers, to knead the soft tissues with a medium to hard pressure. So that's really for areas where you've got your larger muscle groups, you don't want to be using a medium to hard pressure over areas where there's not a lot of muscle and you could potentially cause discomfort.
So again, you want to, you're gonna be able to increase the blood flow to the tissue and ideally reduce soft tissue and muscular tension with that technique. And then the compression, so that uses flat fingers to compress the tissue for 2 to 5 seconds at a time. There's no gliding motion with the compression.
Fingers on, it's a fairly firm, technique for hold for 2 to 5 seconds and then take your hand away. And what you're doing there is you're increasing the venous return, which is going to help to flush toxins from the area and reduce your soft tissue and mus muscular tension again. So the next thing to mention is electrotherapies.
So we're seeing electrotherapy is more commonly used in practise now. Not every practise uses them and they're not an essential part of the rehabilitation plan, but they're good to include if you do have access to them. Again, the vet nurse might be required to assist with, the administration of any electrotherapies, or you might actually receive some training on administering some of the electrotherapies, .
Anyway, it's worth knowing about the benefits, just in case you are ever asked about them or you are using it in your practise. So for the purposes of this lecture, I'm going to discuss a therapeutic laser. You might come across other electrotherapies, so there's 10, there's pulsed magnetic therapy, things like that, so it's just worth knowing that they exist and and knowing a little bit about what they do.
So the low level laser therapy, so quite commonly used, it's the Class 4 lasers, stands for light amplification by simulated emission of radiation. So it utilises the process of photobiomodulation, so the very strong light is fired into the tissues and the light energy is absorbed by the cells within the tissues and healing is enhanced. So some of the benefits of the low level laser therapy, so you can have a reduction of pain.
So there's a release of endorphins when the laser is applied to the tissues, and some of the nerve fibres are also depolarized, which stops all of the pain signals returning to the brain. There's a reduction of inflammation, so when you're applying the laser therapy, it brings a lot of new blood to the area, a lot of new oxygen and nutrients, and it then in turn helps to flush out the inflammatory cells. And again with your vasodilation, it increases blood flow to the area.
And then increase collage information, so it's very good for things like wound healing, so it can be used on surgical wounds or other traumatic wounds as well. And then just things to consider and a couple of contraindications of you using the laser therapy. Just only use it or assist to use it if appropriate training has been undertaken.
You want to make sure that you are appropriately trained so that you don't cause any harm. Again, you should always wear the specific eye protection at all times with the laser, and it has to be the laser specific eye protection. You can't get away with just using sunglasses or not looking at it.
Again with the laser, because it promotes cell regeneration, we want to avoid lasering over any sort of tumours or cancerous growths, and we also want to avoid the thyroid area. And then we also want to avoid lasing over a gravid uterus. OK, so the next part I'm going to talk about some of the active prescriptive exercises and some of the benefits and considerations for each of those.
So our active prescriptive exercises are things like sit to stands, cavalleti poles, inclines, stairs, different things that we can use to increase weight bearing, build muscle mass, improve joint range of motion, improve gait pattern, challenge proprioception. Some exercises can be used for more than one purpose, so they're good for a variety of conditions. Sort of general rule with talking about our prescriptive exercises is start with the easiest version of the exercise with low repetitions and sets and build up as a rehabilitation plan progresses.
You don't want to go in with too much to begin with if the patient's not going to cope with it. And again, you want to make sure that you start off, If the patient requires support, start off with the most support and then gradually ease off on the support as well. So The first exercise we've got is the set to stand, so very, very easy exercise to do.
Most dogs have been trained how to sit, so it's a nice one to start with. So the benefits of the sit to stand is that you have an increased flexion of the stifle and hip joints compared to standing. And again, it's beneficial for strengthening your gluteal quadriceps and hamstring muscle groups.
Just one to think about when you're asking the patient to sit, it's worth walking round them and seeing what their confirmation's like when they're sitting, looking for any induction of the limb or if one stifles more flexed than the other. Things like that gives you an idea if they're compensating for anything. You can use treats to tempt them if they're not particularly impressed, and that applies to most of the exercises, usually, if you can.
Attempt them with treats that can help to do some of the exercises. And then with the sit to stand, if the patient's weak, you can do a half set to stand, so you can ask them to sit onto the therapist's knee, or you can have a sort of low stool or a step and ask them to do sort of a half set to stand, so it doesn't require quite as much. From the muscles and the hind limbs.
Our cavalletti rails, so, the ones here, we've got 3 different heights to choose from in the pictures. So that's quite important. You can use cavalletti at different heights to target different things.
So. Benefits of cavallette is that we have an increased flexion of the elbow, stifle, hock and hip joints. It challenges proprioception, balance and coordination, and it encourages weight bearing of the opposite limb.
So when the patient lifts a limb to step over the cavalletti, there's gonna be more weight through the contralateral limb. And what you can do with the cavallettipos is you can start with them quite wide, so quite often we say start them a body length or a body length and a half apart. And then you can bring them closer together, so the patient at the bottoms, obviously Cavalletti poles aren't quite as challenging as the patient at the top.
And then you can think about your height of the poles as well, so how much flexion is a patient realistically able to achieve and how much do we want to challenge them. You can also place a mattress under the cavalleti pole to challenge the stabilising muscles as well. The next exercise we've got is the weaving.
So weaving's very good for strengthening the abductor and abductor muscles. It encourages weight shifting to the opposite side, and again, it challenges proprioception, balance and coordination. It's important with the weaving, don't start with the poles too tight together because if the patient isn't able to achieve it, they can potentially make themselves uncomfortable or shift too much weight onto the affected limb.
You can use household objects at home for this as well. It's quite an easy one to ask owners to do at home. Most people have something they can lay out to encourage the dog to weave round it.
And just make sure if the patient's post surgery that you're not doing any sharp turns that could potentially dislodge implants or anything like that. And the evening as well, it's quite good for your sort of medial and lateral elbow movements. So give pause and high fives, so again it's an easy one.
A lot of patients are already trained to do this, so it's very beneficial. So you have an increased elbow flexion, obviously as you can see from the picture there, increased weight bearing on the opposite limb. So if you're hoping to achieve, increased weight bearing on the opposite limb, you can always do it, ask to give a paw and hold it for sort of 5 to 10 seconds and just get them to weight bear through that contralateral limb.
And then. Strengthen the elbow flexor muscles, so by flexing the elbow, you're using the biceps muscle. So stairs, stairs in general have an increased pelvic limb range of motion when the dog is ascending.
You also have increased elbow and carpal flexion and extension. Stairs help to challenge the proprioception, and it helps to challenge the quadriceps and gluteals muscles when they're using the stairs. The stairs as well, it's quite a functional exercise.
Most people have stairs at some part of their home layout that the dog usually has to use. So it's quite important if you're returning the patient to function, that you sort of consider these sort of things and, you know, are there stairs in the home and that's something that you can then work on. And the physiotherapy sessions.
With the stairs as well, sometimes if the patient has any sort of hind limb pain or hip problems, they can do, they can be quite tempted to bunny hop up the stairs. So sometimes if you're working on the stairs, it's worth popping them on the lead and just taking them very, very slowly to try and encourage single limb use in the hind limbs. And again with the stairs, just make sure you consider that the patient has good strength to get up the stairs, but also good balance for coming back down the stairs.
We don't want to get them to the top of the stairs and realise that they're going to struggle to come back down. And then there's inclines, so you can use inclines outside or you can use ramps, and some people have ramps for the dogs getting in and out of the car as well. So you have an increased shoulder and elbow extension and an increased hip and stifle extension.
And again with the inclines it challenges the hip extensor muscles, so. Things like the hamstrings. With the incline as well, the patient has to take more weight onto the hind limbs, so that's something to consider if you're using it as part of an exercise plan.
So some weight bearing and balance exercises, so you can use simple things such as weight bearing. With the four limbs on a single step and weight bearing onto the hind limbs, and then you have things like the wobble board as well, so the wobble board's very good for challenging core strength and the stabilising, muscles and all of the limbs. So with your weight bearing and balance exercises, you obviously have the benefit of increasing weight bearing on selected limbs, increased core strength, particularly when you're doing the sort of balance and wobble exercises and challenging balance and coordination.
So some other exercises that you can do for weight bearing and balance, you can do specific limb lifts, so you can lift things like the left floor and the right hind together to challenge the patient's balance and weight bearing on those affected limbs. You can ask the patient to give pause when they're on the wobble board. You can ask the patient to have 4 limbs on a wobbly surface and hind limbs on a stable surface, so it just depends what you want to target really, but it's just to give you an idea of some of the exercises that we can use.
Just be careful with any patients where their joint stability might be reduced, so they sort of immediately or, post-surgery, any sort of orthopaedic surgeries and things like that. And then for anything where you're doing the wobble board or anything that requires. 2 handlers, it's better to have two handlers and have a bit more stability for the patient.
So, I'm going to have a quick talk about hydrotherapy as well. So obviously there's two forms of hydrotherapy, there's pool-based hydrotherapy and treadmill-based hydrotherapy. For the purposes of this lecture, I'm gonna talk about treadmill-based hydrotherapy.
So there's several properties of hydrotherapy, so there's the buoyancy of the water, the buoyancy of the water helps to take a lot of the dog's weight, so it reduces your sort of weight bearing through the joints, the resistance of the water, so obviously there's more resistance in the water than air, so it's been very beneficial for muscle strengthening when the patient's moving through the water. And then there's a surface tension, so the surface tension. And breaking the surface tension is very hard work for the patient, so again, it's very good for your muscle strengthening.
So we'll just have a quick chat about the hydrotherapy treadmill. The patient should always have a harness fitted before they go into the hydrotherapy treadmill, and that just allows you to support them, and sometimes as well we tend to go in with some patients that require a little bit of additional support or you can use some sort of hoists and lifting aids as well. The benefits of hydrotherapy and the treadmill, is that the patient's moving in a natural gait pattern, so they're in a nice upright position, they're walking, the moving belts set at a specific speeds.
And the waters filled to specific height. It increases active joint range of motion as opposed to walking on land. It has increased muscle strengthening due to resistance to the water, as I already said, and again it reduces the stress through the joints due to the buoyancy of the water.
The fact that the belt's moving as well is good, it also provides some proprioceptive feedback to the patient. And when you're deciding where to fill with the water level 2 on the treadmill, you can fill it to an area of your choice, you can fill it to where you want to target specific muscle groups for breaking the surface tension. But if you had a very weak patient, you can also feel it's quite high, sort of to the trunk level, and the waters provide quite a lot of support for them there.
Contraindications of hydrotherapy, so we don't want to put them in hydrotherapy with any sort of open surgical wounds, any sickness, diarrhoea, any potential bacteria, sort of any pseudomonas, anything like that. And you want to sort of be careful as well. I usually check with the owners, if the dog is usually OK with water, just to give you an idea before you go in.
If the dog's absolutely terrified of water, it might not be the best idea, but it just gives you a bit of a bit of a plan of action when you're heading in there. And quite often as well, it's beneficial to use toys or treats, things to motivate the dog, and we find it's always more motivational for the patient if the owner's lead as well, so you can ask the owner to call the dog or use commands. Usually as well when you're starting off with a hydrotherapy, you want to start off maybe with sort of.
32nd to 1 minute bursts. I would normally do sort of 4 of those on the first visit. It's quite a lot for the patient, it's harder work than it looks, so it's quite important to, to think about that for them as well.
And as well, just make sure you give them plenty of support first because most dogs haven't been on a moving belt or any sort of treadmill before, so they're probably not going to know what's happening straight away. So I'm gonna have a little chat about the outcome measures and some of them that we use in physiotherapy. So outcome measures are very important.
It gives us an idea of how the patient is progressing through the physiotherapy plan. Some of the outcome measures you might want to use every time you see the patient, and some you may want to use every so often, so sort of every 4 to 6 weeks. The first one is the pain score, so you can use a simple sort of 0 to 4 pain score.
So if the risk score is 0, and for example you were manipulating the elbow joint. They would have no signs of pain during palpation or manipulation of the joint. If there is score 1, you could have signs of mild pain during manipulation and palpation.
If there are scoring 2 signs of moderate pain during manipulation and palpation. If there is score 3, severe pain, and then if there is score 4, the patient will not allow the examiner to palpate the joints of. Quite serious pain there.
If you're just using the 0 to 4 pain score, it's quite handy just to pain score the patient each time you see them. And then the lameness or the gate score. So again, I've just popped a simple one in, so it's just the 0 to 5 score that we've got.
So score 0 would be normal, score 1 would be a reduced weight bearing through the affected lemon stands. Score 2 would be a mild lame miss at trot. Score 3 would be a moderate lameness at walking trot, score 4 would be an intermittently carrying the limb and layman trot, and score 5 would be a non like weight bearing lameness.
So some other outcome measures you can use, you can measure the muscle mass on the affected limb and the opposite limb as well. So if we're gonna measure the muscle mass on the hind limb, try to measure sort of halfway down the muscle belly and try to make sure that you yourself are consistent with what you're measuring. So some people measure down the length of the femur, or some people measure over the greater jucantus, so have a landmark where you're going to measure.
And if you're going to use a measuring tape, the spring brown tape measure is quite good for having the same sort of resistance on the tape measures, it makes it a little bit less subjective. And then we've got the joint goniometry, so you can measure flexion and extension of the joint using the goniometer. And again, you might want to measure that at the first session and then maybe a few weeks later just to see how your joint range of motion's doing, make sure you're at least maintaining and if not improving that.
And then some other outcome measures. So client feedback, that one is very important. So sometimes clients will come in and say that their dog's managing to do a bit more activity at home, it's managing more on its walks, or they might come in and say that some behaviours have changed, so they might become more playful.
Again, the requirement for pain medication, so whether or not they're having to have the same amount of pain medication they were when they were first on the physiotherapy plan, and then any changes in the dog's routine, so sometimes you have to ask quite leading questions, to get the client to give things away. And then we've got the weight bearing on the pressure mat here on the right, so, not all practises will have this quite often it's the bigger practises and the referral practises that have the weight bearing pressure mats. So what it is is it's a map that the patient can step onto and it gives us an idea of what percentage of their weight they're taking through the left limb and the right limb.
It's quite nice as well, it gives us an idea of. Are there any, any areas where there's more pressure being taken than others, so the one we've got has green, yellow, red and orange, so it gives us an idea of how much pressures through each aspect of the paw as well. If you don't have access to the weight bear, pressure mat, you can use some digital bathroom scales as well, so you have two sets and get the patient to step on.
I'll give you an idea of how much weight has been taken through each side. OK. So I'm just going to talk through.
A few case studies now. So the first one is the cranial cruciate ligament rupture and following the TPLO surgery. The second one is fragmented medialchronoid process of the ulna postarthroscopy.
The third one is conservative management of hip dysplasia, and the 4th 1 is the fibrocartilaginous embolism. So the cranial cruciate ligament rupture, it's one of the most common orthopaedic injuries seen in practise. Everyone's probably seen a patient with a ruptured cruciate ligament.
Just briefly, the cranial cruciate ligament attaches the femur to the tibia and stabilises the stifle during weight bedding. Sometimes a rupture can occur due to trauma, and you're likely to see a sudden onset nonweight bearing lameness with that. And other times it can occur due to degeneration of the ligament, so you might see an acute lameness which worsens over time.
There might be some compensating muscle loss or other compensating problems. So the TPLO. Involves the creation of a cut on the top of the tibia and rotating the plateau segment until the previous slope in the bone is no longer present.
So that bone is then subsequently fixed with plates and screws, so you can see in the X-rays there. So this case is a 3 year old female neutered West Highland terrier with a traumatic cranial cruciate ligament rupture, and the TPLO surgery was performed to stabilise the stifle. So, each of the rehab plans are broken up into phases.
So the early phase following the TPLO is the sort of 1st 0 to 3 weeks. So your goals at this point are to promote early weight bearing and limb use, to maintain and improve stifle joint range of motion, and to provide pain relief and reduce inflammation. So outcome measures at this point, you might want to be pain scoring the patient, you might want to take a baseline muscle mass measurement and do some goniometry of the stifle, and then lame risk score the patient as well.
So to start with, you want to do some gentle passive range of motion of the stifle. Make sure you just keep it within comfortable range so the patient's unlikely to be able to achieve full flexion extension straight away, and you want to repeat that 5 to 10 times. And do that 13 times a day.
And then if you have the laser therapy, you can use that as well. Maybe use it on the wound settings so you're more treating the incision wound for the first week and then on the acute stifle setting following that. And then some gentle on lead walking on a flat firm non-slip surface using an abdominal sling if required.
So quite often if you have a larger dog, you might want to use an abdominal sling just to give them a bit more support in the hindquarters. And if you try to place yourself on the non-affected side as well. Just to know as well at this point that the patients should avoid stairs, high impact activities, slippery floors, playing with other dogs, playing with toys, and they're likely to be on cage rest or small room rest.
So the mid phase of the TPLO, your goals are to encourage limb use and promote active stifle flexion and extension, and to start building some muscle mass as well. So again, we can carry on with the laser therapy on the acute settings if we've got it, and gentle passive range of motion of the stifle within comfortable range. And then you can add in some gentle quadriceps and hamstrings stretches as well, so just be very gentle and just make sure that you're noting whether or not the patient's comfortable with it.
And then we can start a sort of slow lead walking, so again, avoiding any sort of high impact exercise, making sure we're staying on the lead. And you can do that 5 minutes progressing to 10 minutes 4 times a day. And it's important if you walk nice and slowly as well, just to encourage the limb use with the patient.
And then we can start to introduce some gentle set to stand exercises. So for repetitions twice a day. Some very low caletic poles, so just around the carpal height, about 4 walks over 4 poles twice a day.
And then hydrotherapy and the underwater treadmill if we've got it. So we want to fill the water quite high, sort of mid to mid femur height, following the healing of the surgical wound. And again, we might just start with that 30 seconds to 1 minute and progress by 1 minute total each week.
And then in the late phase of the TPLO our goals are to improve gait pattern, improve muscle mass and return to function. And again, that would be sort of following the satisfactory vet check and radiographs to assist the implant. So our outcome measures here, we want to still be paying scoring the patient.
We want to take the weight bearing measurements on the pressure map, and it's important to remember that most people won't be 50/50, so we can't expect all the patients to be 50/50, but we want to be sort of within 5% of that, so sort of 45 and 55, as a minimum. And then measuring our muscle mass as well, so giving us an idea from when we first took it in the early phase, how our muscle mass is doing, and then gait score as well. So at this point we can carry on with the laser therapy if it's still required in the chronic cycle settings, and sort of once a week at the session or if they were coming into the practise once a week.
Again with our quadriceps and hamstring stretches, just make sure we're still being gentle with those. Lead walking we can progress to 10 minutes, 4 times a day and then progress that exercise by 5 minutes per walk and 5 minutes per week. I sit to stand exercises, so 6 to 8 repetitions twice a day.
Cavallettipos just to sort of mid tibia fibia height. Again, we can do that once a day to twice a day and introduce some inclines and stairs after the check with the surgeon to assess the implant. And we can add in some weaving as well, again, just making sure that we're avoiding any sharp turns, keeping the weaving pools nice and wide apart and carry on with our hydrotherapy.
So the next case study is the fragmented medialcorronoid process. So the fragmented medialcorronoid process occurs as part of elbow dysplasia. It's often bilateral but you do often see it worse on one side.
It occurs when an abnormal force or loading is placed on the medialcorronoid process of the ulna and small parts of that then fracture off and become fragments in the joint. So your symptoms include pain on flexion and extension of the elbow, you might have some thickening of the joint, a fusion of the joint, and you might find some crepitus and reduced range of motion, with the patient as well. It's important to palpate as well and just check if the patient is painful in palpation.
So the fragments can't always be seen on the X-ray. You might see osteoarthritis or mild degeneration at that point, but the fragments are quite often seen on CT or if not by arthroscopy. So the case that we've got for this one is a 2 year old male entire Labrador post bilateral elbow arthroscopy to remove fragments seen on CT.
He presented with a mild weight bearing lameness, so 2 out of 5 lame. So, in the early stage here, the 1st 0 to 3 weeks post-surgery. Our main goals are to reduce pain, promote early weight bearing, and achieve mild to moderate elbow flexion.
So gentle passive range of motion within the. Comfortable range of the elbow and make sure that we're ensuring that we've got full range of motion in the shoulder and carpus, check the paws for edoema as well, and if there's any edoema build up in the paw, you can use some compression massage. Laser therapy again we can do on the incision wound, for the 1st 0 to 7 days, and then the acute elbow setting.
And then slowly walking on a flat firm surface. Again, you might want to use a chest harness here just to provide a bit more support for the patient, but just make sure it's not one that rubs on the medial aspect of the elbow. Our mid phase, so 4 to 6 weeks post-op, we want to continue to reduce pain, improve weight bearing, improve elbow range of motion and improve for the muscle mass.
So we can carry on with our laser therapy on the acute and onto chronic settings. We can continue with our gentle passive range of motion of the elbows within comfortable range. We can add in our gentle biceps and triceps stretches.
Again, that's the 10 to 15 2nd hold, and we can do that twice a day. Slow lead walking at this point we can bring from 5 to 10 minutes, so gradually increase 4 times a day. And then we might want to provide some eage and medium massage to the shoulder muscles as well, for the patient's developing some soft tissue tension there.
And you can start to ask the patient to give pause, so get them to do a bit more of an active elbow flexion, so sort of 2 to 4 repetitions twice a day, and then we can add in some wide weaving poles about 1.5 body lengths apart. Some cavalletti poles at carpal height and some hydrotherapy in the underwater treadmill.
And then in the late phase of the. Fragmented medialcorronoid process. Our main goals are to improve gait pattern, improve exercise tolerance, maintain elbow range of motion, and then return to function as well.
So we can carry on our laser therapy if still required on the chronic elbow settings, we can carry on with the stretching, and we can get them to do some more active and passive range of motion as well. So we can do passive to get a feel of how the flexion and extension is, check for any crepitus and inflammation, but then we can get the patient to do some active elbow flexion with the giving pause and the high fives. We can bring the cavalletti poles to sort of mid radiation and the height.
And carry on with the weaving, and then we can introduce stairs after the check with the surgeon from about 8 weeks onwards, and then carry on with the hydrotherapy. And just consider as well here, the patient's likely to be on cage rest for the sort of 1st 4 weeks post surgery. We want to avoid any jumping, explosive exercise, playing with other dogs, slippery floors, things like that.
OK, so the next case study we've got is the conservative management of hip dysplasia. So I'm sure everyone's seen a case of hip dysplasia in practise. So hip dysplasia develops as an abnormal development of the hip joint, and young dogs sometimes there can be lux luxation or subluxation of the hips.
Thought to be a genetic condition, but there can be some other factors, so rapid growth, rapid weight gain. Things like that, and then you're likely to also have osteoarthritis developing as well. So quite often the patient prevents with bunny hopping gait, so using both hind limbs together.
You might see joint laxity, lameness, shorter hind limb strides, crepitus of the joint on flexion and extension, and loss of muscle, particularly in the sort of the teal and hamstring groups, . So our case study for this one is a 4 year old female neutered border collie with bilateral hip dysplasia, presenting with short pelvic limb strides and pain on hip extension and abduction around half range. And she had some compensated muscle tension as well, present t thoracol lumbar paxial muscles, and she was currently exercised at 2 times 20 minutes on lead per day when she presented.
So in our early phase with the hip dysplasia. We want to reduce pain, improve hid limb muscle mass, and improve function and overall gait. So it's important to remember in the early phase of the hip dysplasia, although the patient hasn't had any surgery, we don't want to overdo things too early and potentially cause more pain or discomfort.
So when they come in, we want to take some baseline muscle measurements, muscle mass measurements, pain score, weight bearing measurements, and a gait score as well. So we can apply laser therapy to the hips on the chronic hip setting as it's a chronic condition. We can do some eag and compression massage to the thoraccal lumbar patios and gluteum and hamstring muscle groups as well to reduce some soft tissue tension.
We can do some hip extension, quadriceps stretches and some abduction stretches as well for the adapters, . Lead walks preferably on soft ground to start with to sort of prevent . Shock up through the joints, so we don't want the patient to do loads and loads of exercise on hard surfaces, cause that'll be quite uncomfortable for them.
So we want to probably limit that at the moment to between 10 and 20 minutes, 4 times a day, and we can increase some gentle inclines on those walks as well. And then at home the owner can do some weaving, some sit to stand, and we can introduce hydrotherapy at this point as well. Mid-phase of the hip dysplasia, so we want to continue to improve the hind limb muscle mass.
We want to improve active hip extension, and we want to improve our stride lengths as well. And we want to reduce pain and maintain a low pain score. So again, we can apply the laser to the hips, carry on with our quadriceps, stretching, maybe increase the incline slightly, so go for slightly steeper inclines.
Again, on the stairs, maybe try to keep the patient on the leads or in the harness just to avoid them bunny hopping, we want to really, really encourage that individual limb use. Sit to stand exercises at home as well, so they can be doing sort of 6 to 8 exercises twice a day. Cavalletti polls start them at carpal height, but some patients will be able to tolerate higher, even in the mid phase, and then when they're in for their sessions we can use the wobble board as well, just to sort of.
Challenge those stabilising muscles and then we can carry on with the hydrotherapy as well. So you probably want to have the water to around the mid femur height so that they're using those muscles around the hip to push through the surface tension. And then in our sort of maintenance phase of the hip dysplasia, so we want to maintain that improved hip extension, maintain the improved stride lengths, maintain the muscle mass that we've achieved, maintain the low pain score, and we want to review that every 4 to 8 weeks.
So again, we can retake all of those outcome measurements that we did at first, but maybe consider the functional ability of the patient as well. So how are they coping at home, are they managing with the exercise that we've given them? Is there anything we need to add in or take away?
So with this part, we can continue with the laser, the stretching, we can continue with all the exercises in the previous phase, and as I said, just alter the exercise plan if we need to, and then continue to review the outcome measures. So when we're carrying on with that exercise programme at home, you'll see in the notes that. Provided, you can just pick sort of 3 to 4 exercises a day and rotate.
We don't need to be overloading the owner with loads of exercises that are unrealistic, so it's better to give them a few to do each day and then rotate the exercises so that we're still using all of them. OK, and the final case study is the fibrocartilaginous embolism. So the FCE stands the fibro cartilaginous embolism, which occurs when vessels supplying the blood to the spinal cord become blocked.
It's thought to be caused from intervertebral discs, which have the inner nucleus proposis and the outer annulu fibrosis, so it's thought that. Part of the fibrocartilage from the Disc breaks away and becomes lodged in the spinal cord vasculature, so it causes a bit of an ischemic necrosis of the spinal cord grey matter. Quite often, patients with the FC present sort of hemitic or plegic rather than paraytic or plegic, and they're not usually painful, it can be painful in the onset, but they're not usually painful in the spine after this.
There's no specific treatment for the FC, so usually they need a lot of physio and rehabilitation. And it has about an 85% recovery rate, but it's dependent sort of on the level of damage to the spinal cord, and then the owner compliance as well. So the case study that we've got for this one.
Is the six year old male entire Labrador, which presented with non-ambulatory left-sided hemiparesis at the level of C5 to C6. And it was diagnosed on MRI. So, the early phase of the FC.
Approximately 0 to 1 weeks, so we want to maintain joint range of motion and soft tissue length, and we want to promote early weight bearing. So it's really important, we want to passive range of motion and stretching in all of the limbs. We want to apply E as in kneeing massage to the left for and left hind, and we can do some active assisted standing over a peanut ball or something similar.
And again, active assisted gate practise that can be in a full body harness, or we can use the underwater treadmill to provide a bit of support as well. The things to consider at this point, is that we want to use a sort of full body harness for support. We always want to make sure we've got enough staff and support as well, so it's the kind of thing you may well be asked to help out with, .
We want to position the patient internal or tilt to the right hand side and then support the left hand side limbs so we can place some sort of blanket wedges between the limbs. And then obviously we'll need to assist with food and water, so making sure that we're offering, and then ensure that the patient has independent bladder controls plus minus express if we need to. In the mid phase for the FCE, so approximately 1 to 6 weeks, our goals are independent standing and weight bearing, supported walking with movement in all of the limbs, maintaining the joint range of motion and muscle length of the affected limbs, and maintaining and improving the remaining muscle mass on the affected limbs.
So again, make sure that where pains grow in the patient, there shouldn't really be any pain unless there's contractors in the affected limbs. We can take our muscle mass measurements there as well. And then continue using the full body harness for support if required, and continuing to monitor and manage the bladder if required.
So if we carry on with our passive range of motion, stretching and massage, as in the early phase, we can add in some active assisted weight bearing on the hind limbs using a single step. And again, you can use some different surfaces there to stimulate sensory feedback. Start with some ground-based cavalleti poles, so making sure we've got plenty of support, plenty of handlers with the body sling.
I'm slowly walking, so just 5 minutes, 4 times a day, just encouraging limb use, making sure that we're going nice and slow to allow the patient to move the limbs. Some weave pulls very gently, just to challenge balance and coordination. And then you can ask the patient to give pause as well to encourage weight bearing through the left floor and then carry on with our hydrotherapy.
And then in the late phase. So we want to maintain the joint room and monitor the muscles soft tissue length, and monitor the weight bearing as well. We want to challenge balance and proprioception.
We want to improve the gait pattern and then eventually return to function. So at this point we might want to just consider using a chest harness or a pelvic sling, depending on which limb is weakest at this point, so we can probably come out of the full body harness, . So continue the hydrotherapy and the underwater treadmill, .
And continue active assisted weight bearing on the step. Continue the cavalleti poles, you can challenge the patient slightly more, with the weaving. You can do stair climbing, but again, just make sure you've got plenty of support for the patient and just make sure that their balance is going to be OK for coming back down.
We can introduce some inclines and declines, it's the same with that, and continues to ask the patient to give pause just to promote the weight bearing through that left side. And again, just sort of work on a variety of surfaces to balance to challenge and sensory feedback and for perception as well. OK, so just lastly, a few of our practical considerations.
The things to consider when you're talking to owners, it's quite important to think about the layout of the home environment, so making sure that the person doesn't live up three flights of stairs and won't manage with the dog, sometimes just suggesting that they might want to put mats down over slipy floors, things like that. Obviously with our patients that have had the surgeries, we don't want any jumping, so maybe using a car ramp or making sure that the person can lift the dog in and out of the car. The chest tightness as well, so that'll provide a little bit more support to the body than just the collar and lead, especially the patients shifting a lot of weight to the forelimbs, just helps you to be able to support them.
So it's another thing to maybe suggest to the owner. And then just our mental stimulation as well, we don't want patients are on the sort of reduced exercise or Kre to become frustrated. And then communicating The Sort of any parts of the rehab plan to the client, just things to consider, the clients are best with sort of clear written plans, so how many repetitions and how many sets of the exercises and sometimes a wee bit explaining exactly what the exercise is.
Again, using simplistic language, so unless the person has a medical or veterinary background. We don't want to be using really clinical terms, so just things that clients can understand. Images and visual guides were appropriate, so it's nice to be able to show the client a sort of either a picture or a video of certain exercises.
And again, it's more likely, you know, if they can take that home, then they're more likely to comply with the exercise plan. And then again, as I said, just consider the circumstances of the home environment, make sure that the owner is going to be able to cope. OK, so just to conclude, so we have our physiotherapy and rehabilitation plans are more commonly used in practise now and helps enhance recovery.
Each patient should be treated as an individual, and that's a really important point to remember. Not one size of the rehab plans fits all. We have to tailor them individually.
Each exercise can have more than one benefit, and you can always utilise what equipment you have in practise and improvise where appropriate. A lot of the exercises you can improvise and and do yourself. And then there's a bit of time for questions.
Kate, that was absolutely fabulous and gave us a huge insight into the benefits of physiotherapy and, and putting plans in place. And hopefully our attendees tonight will go back to their practises and and plant the seed that this is a really, really worthwhile thing to do for patients and, and it just benefits the patients dramatically. So thank you for that.
Thank you. Greg wants to know, do you ever use force plate measurements to assess the effectiveness of individual types of treatment? You could do, so when we use the force plate, we tend to use it as part of a full rehabilitation plan, but it's something that certainly could be used in research studies.
So, you know, if you wanted to just use laser hydrotherapy, there's some, some good scope for some further research to be done there. Excellent. Well, that was the only question that we got in from, from people tonight.
I think that's because you were so clear and concise on your explanations. Oh, Nigel's just popped in a question. He says, is there a place for cold therapy in the acute stages of FCEs and heat therapy post 2 to 3 days?
Yeah, so quite often, especially with the heat therapy, the patients become very high tone or develop some slight contractures, it can really help to relax the muscles, . So quite often what we find is I've recently had a patient where the left forelimb is held in quite a flex position, and the owners were using hot water bottles at home before they were doing their passive range of motion and stretching, and they found that the patient was much more comfortable, but also that they were getting a better stretch and better range of motion after they used the heat packs, so it definitely is a place for the heat packs. Excellent.
Well, folks, that's it for this evening's webinar. It's my pleasure to once again thank Kate McSkimming for everything that she has presented to us tonight in such a clear and concise plan. And Kate, we look forward to having you back on the webinar in the future.
Thank you very much. Right, folks, that's it to my controller Lewis in the background for making everything happen seamlessly. Thank you very much and have a wonderful evening.
We'll catch you again on the next webinar. Good night everybody.
