Rehabilitation
Just like in people, dogs can benefit from participating in rehabilitation after surgery or injury. Rehabilitation can help decrease pain, improve fitness, and restore function.
The importance of rehabilitation following surgery
Partial or complete rupture of the cranial cruciate ligament (CCL) is one of the most common causes of hind limb lameness in dogs. It can result in pain commonly associated with lameness, muscle atrophy (loss of muscle) and poor limb function (use of the limb) as a result of dynamic joint instability, even after surgical intervention designed to stabilise the joint.
Following injury or surgery, joint biomechanics or joint structure, motion and function and proprioception or the sense in which we perceive joint position and balance are affected. Even successful surgery may not result in a return to full function or neuromuscular control (the unconscious trained response of muscles to activate and stabilise the joint during dynamic activities) and can lead to the development of osteoarthritis. This has been confirmed in human medicine.
The goals for the surgical management of CCL disease are not only to stabilise the joint but also to minimise pain in the short and long term, minimise complications from arising, and restore normal gait and function, allowing the patient to return to normal activities. Restoring range of motion, muscle strength, neuromuscular control and proprioception is essential to this and will minimise the progression of stifle joint osteoarthritis in the future for patients.
Problems commonly arise following CCL surgery including pain associated with lameness, reduced range of motion into flexion and extension, muscle atrophy and reduced muscle strength, modified gait pattern, reduced weight-bearing, reduced function, and a risk of reduced function a late meniscal tear. An early referral to physiotherapy will assist in identifying these problems. Addressing them early will likely achieve a better outcome.
What is physiotherapy?
Physiotherapy helps restore and maintain movement and function when someone is affected by injury, illness or disability through movement and exercise, manual therapy, electrotherapy, education and advice. It is a science-based profession and takes a ‘whole person’ approach to health and wellbeing, which includes the patient’s general lifestyle.
Physiotherapy and cruciate ligament repair
Physiotherapy begins immediately following anterior cruciate ligament repair in human medicine. Evidence shows that this minimises muscle atrophy, restores joint range of motion, strength and function and minimises the progression of osteoarthritis. There is no evidence suggesting a risk to the surgical repair or increased pain during early physiotherapy intervention.
Evidence is growing to show that the same applies following CCL surgery. A few years ago, patients who had undergone surgery for CCL disease were often not referred for physiotherapy and rehabilitation. The timing and quality for patients referred varied greatly, with some being referred at 6-8 weeks post-surgery following re-examination and repeat radiographs or when patients were not progressing as expected and some being given formal (in-person) versus informal (advice sheet) treatment. Many patients were referred straight for hydrotherapy after their veterinary re-examination at 6-8 weeks.
There is growing awareness of the benefits of physiotherapy and rehabilitation, and patients are now being referred immediately. Eiermann et al. 2020 reported recommendations for rehabilitation after surgical treatment of CCL disease in dogs by veterinary surgeons performing extracapsular stabilisation and tibial osteotomy procedures, with 71% of respondents recommending post-surgical rehabilitation. Patients undergoing extracapsular repair were twice as likely to be recommended rehabilitation. Post-surgical rehabilitation programmes are patient-centred and tailored according to the stage of tissue repair and individual progress, hence the requirement for re-examination and appropriate treatment progression during this period.
Limb function
Joint range of motion (movement) following CCL surgery may be affected by pain, post-surgical swelling or soft tissue tightness and maintaining or restoring it should begin immediately post-surgery. Full range of motion is required for dogs to engage in normal functional activities such as the need for flexion (bend) in sitting and the need for extension (straightness) at end stance (weight-bearing) phase in the gait for push-off. There is also an association between loss of flexion or extension of more than 10 degrees and worse clinical lameness scores after tibial plateau levelling osteotomy (TPLO) surgery therefore, treatment should be implemented early to prevent ongoing lameness. Range of motion should be regained within the first two weeks post-surgery before the physiological changes within the healing tissue limits this.
Reduced muscle activity caused by pain and excess joint fluid results in muscle atrophy, commonly identified following CCL rupture and will continue to worsen for up to five weeks post-injury, regardless of whether surgery has been performed. Physiotherapy and rehabilitation aim to minimise muscle atrophy, and improvement of this is only seen at ten weeks following CCL rupture. Therefore, most protocols recommend off-lead exercises beginning any time between 10-14 weeks post-surgical repair when the stifle remains weak and lacks neuromotor control. This is a time when the stifle is particularly vulnerable to a late meniscal tear.
One of the earliest studies looking at the effect of rehabilitation on limb function following TPLO surgery looked at home exercise versus intensive physiotherapy. The home exercise group was provided with routine post-surgical advice, including controlled lead exercise increased incrementally over the first six weeks. The intensive physiotherapy group started immediately post-surgery and included ice therapy, passive range of motion exercises, functional weight-bearing exercises including underwater treadmill therapy and controlled lead walking over the first six weeks. Intensive physiotherapy restored thigh circumference and stifle flexion and extension at six weeks post-surgery with a significant improvement over the home exercise group. There was no significant difference in lameness scores and the ability to weight bear in the affected limb.
It is not possible to measure muscle strength in dogs, but in human medicine, the degree of quadriceps muscle atrophy is proportional to strength; therefore, improvements in thigh circumference are likely to improve strength. The soft tissues act as the biological scaffold to a joint. Therefore, maintaining muscle mass and restoring strength will help restore function, prevent reinjury and offset excess loading forces on a joint, minimising the progression of osteoarthritis.
Early weight-bearing is essential to help restore normal proprioception and neuromuscular control, therefore, minimising the risk of meniscal tears. They are factored into the physiotherapy treatment plan and home exercise recommendations in most if not all rehabilitation programmes from day one post-surgery. Many breeds are vulnerable to rupture of the contralateral (opposite) CCL. Early rehabilitation to restore full weight-bearing, strength and dynamic joint stability in the affected limb may reduce the likelihood of this occurring. Rehabilitation will also enhance strength and dynamic joint stability of the contralateral limb, reducing the risk of injury.
A team approach
A veterinary physiotherapist is a multi-disciplinary team member, and working closely as a team will optimise the treatment outcomes for patients post CCL surgery. Regular physiotherapy input increases caregiver compliance for post-surgical recommendations. Procedures to improve stifle stability in the case of CCL disease have limitations on what the patient can do immediately post-surgery to prevent surgical failure, allowing the bone and soft tissues to repair. Owners are provided with lots of information when their dog is discharged from hospital and may not understand the importance of this information. Reiterating post-surgical advice and explaining tissue healing and treatment progression will prevent secondary complications from arising.
Minimising the onset and progression of osteoarthritis is one of the primary objectives for CCL surgery. Osteoarthritis results in pain, reduced function and quality of life, and therefore restoring range of motion, muscle strength and neuromuscular control, and pharmacological and weight management are key components in the management of osteoarthritis. We do, however, need more high quality, large-scale randomised controlled trials with long term follow-up that assess the effects of different post-surgical rehabilitation programmes.
Contributors
Author: Diane Messum MCSP, HCPC, BSc(Hons), MSc VetPhysio, ACPAT Cat A, RAMP
Diane has been a Chartered Physiotherapist since 2002, qualifying from the University of Birmingham. She went on to specialise in musculoskeletal outpatients and hand therapy where she developed knowledge and skills that were key to her current practice within the small animal field. Diane completed her Master’s Degree in Veterinary Physiotherapy in 2007, awarded by the Royal Veterinary College, London, when she started her owner private practice for equine and small animals. After dividing her time between both human and animal species, she went on to specialise in small animals, joining Davies Veterinary Specialists to head up and develop the Therapy Services in 2011. This came with the fantastic opportunity to work alongside the Orthopaedic and Neurology services, just two of the many specialists’ services at Davies Veterinary Specialists, one of the largest and most diverse small animal referrals hospitals in Europe. Growth of the service led to the launch of the Davies Therapy and Fitness Centre in January 2017 where services now include Physiotherapy, Hydrotherapy, Splinting and Orthotics and a Pain Management Clinic including Acupuncture. Diane has a special interest in the use of orthotics for the conservative management of musculoskeletal injuries. Diane continues to share her own passion for the work she does by lecturing and being an active clinical educator for the Masters Veterinary Physiotherapy Programmes in the UK.
Editor: RCVS Knowledge Communications Team
Reviewer: Dr Catrina Pennington BVM&S MRCVS and Mark Morton BVSc DSAS(Orth) MRCVS
References
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