WVTA 10/2013 How to utilize rehab therapy post operative/geriatric


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Given at the 10/2013 WVTA meeting. How to utilize rehabilitation therapy in post-operative and geriatric patients

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WVTA 10/2013 How to utilize rehab therapy post operative/geriatric

  1. 1. How Does One Get into Rehab? • CRI (Canine Rehabilitation Institute) • Training started 2009 • Received certification 5/2011 • House Call Service—On the Go Animal Rehabilitation Service (onthegoanimalrehab.com) • True Veterinary Clinic, Lake Mills Veterinary Clinic, West Towne Veterinary Center, Odyssey Veterinary Care
  2. 2. How to Utilize Rehabilitation Therapy in Post-operative and Geriatric Patients Rehabilitation Therapy is more than fancy modalities—you already own the two most important tools—your hands! This session will focus on massage techniques, other manual techniques and exercises you can perform and then teach clients to do for their pets. Presented by Deanna Clark DVM, CCRT at WVTA Meeting 10/12/2013
  3. 3. What is Rehabilitation? • Physical Therapy is protected term • Preservation, enhancement, restorati on of movement and function • Utilizes therapeutic exercise, modalities, devices, patient education and training • Physiotherapy
  4. 4. Who Qualifies? • Any animal • Creativity is vital • Motivation can be difficult!
  5. 5. Our Various Roles • Veterinarians—Diagnosis and monitor progression/set limitations • Technicians—carry out treatment plan, communicate between owners and veterinarian, help progress patient • Owners—willing and excited as many techniques/exercises best done more frequently
  6. 6. Certifications • Veterinarians, Physical Therapists, Veterinary Technicians • CRI • Certified Canine Rehabilitation Assistant • University of Tennessee
  7. 7. The Full Effect of Injury • • • • • • Pain is protective—allows area to heal Disuse causes atrophy Muscles overworked from compensation Develop trigger points Referred pain Vicious cycle!
  8. 8. Break the Cycle! • • • • • Provide pain relief Treat the muscles 6 weeks to build muscle Every day of rest requires 3 days to rebuild May no longer need pain medications!
  9. 9. The Healing Touch • Massage • Personal preferences • Rough massage or anxiety creates rigid muscles-less benefit • Some patients tolerate very little (laser?) • Ease into relationship and tolerance • Brings blood supply and energy
  10. 10. Massage Techniques • Rolling of skin to ease into massage • Rub with muscle fibers to relax/lengthen • Break up scar tissue with firm touch and cross fiber direction • Isolate the muscle and lift to break adhesions • Rub over muscle with fibers to bring heat— works well for dogs that don’t enjoy massage
  11. 11. Trigger Points • Painful • Muscle will jump when palpated • Treat by applying firm pressure and holding it for 10 seconds, release and repeat • Treat with massage techniques • Dogs don’t appreciate trigger point work
  12. 12. Myofascial Release • Over spine—will cause mild traction to release spastic para-spinal muscles • Extremely gentle pressure-cross hands and place one palm at dorsal shoulders and crossed hand to cranial pelvis--push hands apart • Patient relaxes into stretch and rolls onto your hands!
  13. 13. Range of Motion • If you don’t use it you lose it! • Vicious cycle affects the rest of the body and movement
  14. 14. Benefits of Range of Motion • • • • • Most important in post-operative or disuse Moves joint fluid Joint fluid bathes cartilage providing nutrition Helps healing and pain relief Reduce swelling
  15. 15. Proper Range of Motion • Within tolerance! • Rarely push beyond—only with guidance • Stress this to clients! (remember you won’t go back to the painful masseuse) • Slowly and with support (no leg dangling) • Stretching muscles at end of motion • 15-20 repetitions 2-4 times daily • Don’t prevent loss of muscle (8 hours a day!) • Have client demonstrate for you
  16. 16. Putting it Together • • • • • • • Range of Motion finds restrictions Know normals –your pets will love you for this!! Do this every visit (though generally less intense) Start with unaffected leg and work around Prefer laying down, but can do standing NEVER push a dog outside of tolerance Muzzles?
  17. 17. Abnormal Muscles • • • • Ropey Hard Calcified Painful • Crepitance • React with spontaneous twitch (tendons too)
  18. 18. Abnormal Joints • • • • • • End Feel Empty—pain stops motion Capsular--firm Bony--bone-to-bone contact Abrupt—protective muscle spasm Springy block—soft tissue approximation
  19. 19. Checking the Neck/Spine • Have the dog follow treat to shoulder, hip then floor • C6-C7 can generally palpate inflammation • Focus on paraspinal muscles along each vertebral body • Myofascial stretch
  20. 20. Elbow • Fold the front leg like an accordion • The infamous “shelbow” (Dr. Canapp) • Biceps--Learn to palpate this muscle well • Early arthritis can be difficult to detect
  21. 21. Shoulder • Supraspinatus tendon • Arthritis • Medial shoulder
  22. 22. Dorsal Scapula • Ties into thoracolumbar junction and C6-C7 • Often over-worked • Often crepitance
  23. 23. Shoulder/Neck Stretch • Subscapularis and Pectorals • Great Stretch--With leg in neutral position lift medial shoulder and rotate elbow internal • Pulls cranial scapula off the body stretching caudal neck • Caution significant shoulder/elbow arthritis
  24. 24. Forelimb Extension Restriction • Teres major strain—palpated at caudal midshoulder or in axilla
  25. 25. Rear Limb ROM • Again flexion like accordion • Commonly lose flexion in stifle • Don’t forget the tarsus!
  26. 26. Hamstrings • Hip flexion/stifle extension to stretch • Check proximal medial hamstrings (semitendinosis) • Fibrotic myopathy • “Strip” this muscle to help it stretch • Distal medial attachment to stifle (semimembranosis)
  27. 27. Quadriceps • Hip/stifle extension to stretch • Pull rear limb caudal and rub down quadriceps to encourage the patient to stretch • Also helps relieve spasms • Frequently over-worked
  28. 28. Iliopsoas • Major hip flexor and tender loin/groin • Resent rear extension of leg • Very sensitive and sometimes best treated using laser therapy • Stretching will help • Chiropractic?
  29. 29. Pectineus • • • • Most proximal medial thigh Connects femoral neck and acetabulum Spastic with hip dysplasia Stretch with butterfly position (hip abduction)
  30. 30. Stretches • • • • • • Helps restore motion Helps maintain motion Prepares muscle for ROM expected Proven for injury prevention (humans) Detect early injury Monitor for loss of function/pain
  31. 31. Stretching Concerns • • • • Active Stretches preferred Stretching cold can cause injury Warm up prior to stretching Use these to warm up/cool down athletes
  32. 32. Active Stretches--Spine • • • • • Same as test! Cookie Spinal Stretches Great for active/chronic spine patients Within tolerance Avoid cervical extension
  33. 33. Stretch Front Limb • Play bow
  34. 34. Stretch Rear Limb • Stand with front feet up on object • Can be painful for dogs with rearlimb pain, weakness or spinal cases (especially lumbo-sacral) • Work into increasing height and duration • Hold stretches for 30 seconds and increase
  35. 35. Exercise • • • • • Exercise builds muscle which provides pain relief Targeted exercises can be an art Motivation can be questionable! Clients afraid to exercise dogs with conditions Every day of rest takes 3 days to build back muscle! • Can take 4-6 weeks to see results • Prepare for realistic goals
  36. 36. Types of Muscle Contraction • Isometric • Isotonic
  37. 37. Isometric • • • • Best exercise to start with Rehabiliation Static Holding weight in hand Plank
  38. 38. Isotonic • Dynamic • Contraction results in movement • Can only prescribe when injury can support movement—walking progressed to running • Concentric and eccentric
  39. 39. Concentric • Shortening of muscle fibers • Force generated bigger than resistance • Lifting 10 lb weight
  40. 40. Eccentric • • • • Resistance is greater than force Causing lengthening of fibers Lowering 10 lb weight Proven to heal tendonitis through pain
  41. 41. Exercise Rules of Thumb • Don’t push beyond limitations • If patient becomes more sore during /after exercise it is either too high intensity or too long duration • Neurologic patients key is to exercise right up until fatigue, but not go beyond • Generally more frequent, but shorter sessions • Lowest impact until recovered and in conditioning program for work/return to function
  42. 42. Types of Exercise • • • • • Strength training Endurance training Proprioception training Stretches Skill training “Provide strength and endurance exercise in proportion to the amount required by the dog’s performance events” (Dr. Chris Zink)
  43. 43. Is He Tired or Lazy? • • • • Dogs tend to be honest Avoid task or disengage Sit down Panting • Like yoga– how long can you hold “plank”
  44. 44. How often do you have to do this?? • • • • • Short duration (about 15 minutes max) More frequent (2-4 times daily max. benefit) At least 3-4 times weekly But a little is still better than none! Balance different types of exercise
  45. 45. Core Exercises • • • • Dogs lose core with age like people Supports the spine Possibly contributes to IVDD? Possibly contributes to incontinence?
  46. 46. Easy Core—3 and 2 legged Stand • • • • • • • • Start easy and make difficult Hold up front leg if affected in rear Moving leg slightly causes counter balance Lift opposite leg from the affected Progress to two legged stand—cross stance Move both legs to further engage core Safe for most any patients May only be able to start at 5 sec!
  47. 47. Making Core Harder • • • • • Unstable surface Physio-balls if size is appropriate Wobble board Couch cushion or air mattress Do the same exercises
  48. 48. Ultimate Doggy Abs—Sit Pretty and Beg! • NOT safe with active IVDD or significant stifle/hip arthritis/active ACL • Use a treat lure and pull over nose • Stand from this position and then sit back down • Takes athlete 3 weeks to master • Just attempting 3 times daily will build muscle
  49. 49. Weakest Core • Significantly muscle wasted patients • Tummy tickles
  50. 50. Targeting Rear Legs • Dogs carry 60% of weight on front • Many easy exercises work • 3/2 legged stands will weight shift them to rear
  51. 51. Stair Stands • Front feet up 6 inches and increase time and height --graduate to standing on couch • Stretches quadriceps and iliopsoas • Favorite exercise for post-operative ACL • Remember to start low and for short periods of time (30 sec.)
  52. 52. Weight Shifting • Gently push dog onto affected leg in differing intervals and angles • Builds muscle as they “catch” themselves--we don’t want them to fall! • Can also scratch over butt and let them bounce around—happy butt rub dance!
  53. 53. Doggy Squats—Sit to Stands • Target gluteals and cause full flexion of stifles/hocks • Another favorite for ACL disease • Can be tricky • Place the leg, sit them on an elevated plank, use a treat to lure, assist using pillow or assistant • Can be very hard to push into stand—so help if needed • Generally start with 3-6 repetitions
  54. 54. Front limb Exercises • Can reverse all the ones just mentioned! • Down stairs, 3/2 legged stands, physioballs • Wave for biceps
  55. 55. Exercise Guidelines • Veterinarian/Surgeon will guide restrictions and progression based on diagnosis • A few simple daily exercises can make a big difference • Listen to the patient and you can’t do harm • Be creative and use what the environment provides!
  56. 56. Spike • Geriatric • Progressive rear limb weakness
  57. 57. Mesa • • • • • Post-operative ACL Severe multiple progressive joint DJD Partial ACL with severe patella tendonitis Prevented other knee from surgery Return to full function!
  58. 58. It’s worth the Effort!!
  59. 59. Questions?