Signs of inflammation

• Pain – from swollen or damaged nerve endings.
  
• Redness – from damage of local tissues.
  
• Heat – from dilation of local blood vessels.
  
• Swelling – from the associated capillaries becoming more permeable resulting in oedema of the local area.

Cold can be applied to the affected area in several ways. Broken ice chippings wrapped in a plastic zip-lock bag covered by a damp cloth, applied to the affected area for 10–20 minutes can be effective. This treatment can be repeated every 4–6 hours as required.

Usually begin the treatment early to minimise the inflammatory response. If an animal is recovering from surgery and is hypothermic, treatment may be postponed until the patient’s body temperate returns to normal.

Cold therapy works by causing vasoconstriction of the local damaged blood vessels, thereby reducing swelling, damage to local tissues, and oedema.

Contraindications

• Cold hypersensitivity.
  
• Altered skin sensation.

Cautions

• Cardiac conditions.
  
• High blood pressure.
  
• Open healing wounds.
  
• Areas over superficial nerves.

Contraindications

• Sensory changes.
  
• Burns/scalds.
  
• Thrombus/embolism.
  
• Hyper- or hypo-sensitivity to heat.
  
• Infections.
  
• Malignant tumours.

Slings

Slings are used to assist the animal when he is mobilising. A variety of slings are available for veterinary use, most commonly used with orthopaedic patients is The Soft Quick Lift™ (Four Flags Over Aspen, Inc.) abdominal sling. This type of sling is useful following pelvic limb surgery, is easy to use, and is usually well tolerated by the patient. If you are using a sling to assist the patient to mobilise, position yourself on the same side as the unaffected limb in line with the pelvic limb. In this position you can tilt the patient slightly onto his unaffected limb and assist with balance if necessary and prevent him from falling.

In the early stages following orthopaedic surgery it is not desirable for a patient to weight-bear on the affected limb. This is because the soft tissues and bones are still healing, stabilising and remodelling. Early weight-bearing is not a sign of successful surgery. The sling is used in much the same way that a human would use crutches following surgery to a pelvic limb. The crutches are used to protect the limb whist healing takes place until a bony callus forms; the implant used to stabilise the joint is not strong enough to allow the individual to bear full weight through the affected limb.

A Helping Hand pelvic support sling (Mikki, Dorking, Surrey, UK) is sometimes used to support orthopaedic patients postoperatively when they are mobilising. A Helping Hand can be more difficult to place on the patient, it may be easier to assist the patient to stand, then whilst supporting him, position his feet in the limb holes of the Helping Hand and then pull them up, secure with Velcro and fasten the clips.

A Helping Hand sling is preferred to The Soft Quick Lift™ sling for animals undergoing pelvic or hip surgery as it gives added support to the pelvis and does not block hip flexion movements. A Helping Hand sling would also be the support aid of choice for thoracic limb post-surgical support. Given that the dog bears 60% of his bodyweight through the thoracic limbs support of the thoracic limbs to allow healing to take place is even more crucial.

For animals with multiple trauma to several limbs a fully body sling and mobile hoist may be necessary to assist mobilisation. The body sling supports the animal’s trunk, whereas the hoist supports the animal’s bodyweight; the hoist is slowly moved forwards and the animal can move his limbs without taking very much of his body weight.

Passive range of motion exercises

Passive range of motion (PROM) exercises are movements usually of the limbs performed by an individual such as a physiotherapist. The joints of the limbs are moved passively, and the patient does not gain any strengthening benefits from passive movements of the limbs.

PROM exercises are performed to maintain or improve joint ROM, and to prevent joint inflammation and stiffness. PROM exercises are especially important in recumbent animals that may already have established osteoarthritis and associated pain, stiffness and reduced ROM in the affected joints.

If the patient has undergone joint surgery full ROM of the joint is neither desirable nor essential in the early stages. However, full ROM should be maintained in all the other joints of the affected limb.

PROM exercises can commence from day 1 postoperatively. Gentle PROM exercises within the pain-free range will assist with lymphatic drainage of the limb and limit oedema when used in conjunction with positioning. If the distal limb is oedematous, compression followed by release exercises can be performed: two sets of 50 repetitions appear to be effective.

As the inflammatory phase passes PROM exercise of the affected joint may be gradually increased within the pain-free range, and with consent from the veterinary surgeon.

The animal is usually recumbent for the PROM exercises with the affected limb(s) uppermost. (However, the exercises can be performed in standing with the patient supported.) If the animal has undergone joint surgery this joint should be isolated and gently moved through its pain-free range in all anatomical planes. This joint would then be supported and the other joints in the affected limb would be moved through full ROM in all anatomical planes. PROM exercise three sets of 10 repetitions for each joint twice a day is considered to be effective.

If the patient has not undergone joint surgery and the PROM exercises are being performed to reduce pain, inflammation and stiffness in the joint, all the joints in the limb can passively be moved together. Be aware that if the patient has established osteoarthritis, ROM in the joint may be reduced and at the end of range you will feel a bony block; do not force the joint beyond this point as it will cause the patient further discomfort.

When performing PROM exercises the movements of the operator will push the joints together and then push them apart. PROM exercises should never involve pulling a limb or joints. Do not grip the limb tightly. If all joints are to be moved together into flexion then extension the patient should be supported at the medial elbow for the thoracic limb, and at the medial stifle for the pelvic limb to prevent any rotation of the joints, which may be uncomfortable. The movements should be in line with normal anatomical planes of movement (Table 1.2).

Stretches

Stretches are performed to maintain or increase muscle length. These are usually performed passively by an operator for recumbent patients, or in patients that have undergone surgery.

If a muscle crosses two joints, such as the quadriceps, any shortening of this muscle group will affect the ROM of the hip and stifle joint. As the quadriceps muscle group shortens, the stifle and hip will be brought into flexion. If the quadriceps becomes shortened or contracted for a prolonged period of time the patient will be unable to extend the stifle and hip, and so weight-bearing through the limb will become problematic.

Changes in muscle length can occur quickly in: (i) recumbent animals; (ii) patients that have recently undergone surgery when they may not be moving limbs through their full ROM; or (iii) an animal that is non-weight-bearing for a period of time, when the flexor muscles will become short and tight, and the opposing extensor muscle groups will become weak.

In recumbent animals stretches should begin on day 1. Flexor, extensor and internal rotator muscle groups should be stretched at least twice daily. Each stretch is held for 15 seconds, the animal is given a few seconds to rest, then the stretch is repeated three times in total. Following stretches, if the patient is resting in lateral recumbency, a wedge should be placed between the thoracic and pelvic limbs to prevent adductor/abductor muscle imbalance. Recumbent animals tend to become tight in the adductor muscle groups, and weak in the abductor muscle groups. Correct positioning following stretches can help to prevent muscle imbalance from occurring.

Stretches can be performed with the patient lying laterally or in standing. If the stretches are performed in standing, the animal will need to be supported at the trunk. The operator will use one hand to support at the origin of the muscle being stretched; with other hand a pushing force will be applied at the insertion of the muscle. The muscle should be stretched until resistance is felt in the muscle, then at this point the stretch should be held for 15 seconds and repeated three times. Stretching should not be uncomfortable for the patient. As described earlier pre-warming a muscle will improve the elasticity of the tissues, thus improving the range of the stretch. This may be useful if the animal is cold, has muscle spasm or has developed muscle contractures.

Mobilisations

Mobilisations are graded movements or manipulations of joints that are passive and usually performed by a physiotherapist.

The grade of movement delivered depends on the desired effect of the mobilisation or manipulation. For example, a grade II mobilisation would be a repetitive movement of a joint within its pain-free range with the aim of relieving pain within the joint. However, a grade III mobilisation would also be a repetitive movement of a joint but greater force would be applied with the aim of increasing ROM within that joint.

Mobilisations are treatments used to maintain ROM in painful joints; once the pain within the joint is manageable the grade of mobilisation can be increased to increase ROM within stiff joints.

The operator will be positioned close to the patient. If, for example, the joint mobilisation is to be applied to the spinal processes of the lumbar spine to increase extension the patient will preferably be lying in sternal recumbency. The operator will position her or his hands so that one thumb overlaps the other and using a pulsing motion pressure will be applied directly to the spinal process. The physiotherapist is aligned over the patient and the pressure transmits from the shoulders down the arms to the thumbs; if the pressure was generated from the thumbs alone the physiotherapist would fatigue quickly.

In conjunction with passive exercises to improve ROM and passive stretches to increase muscle length, progressive exercise programmes focused around the assessment findings can be useful adjuncts to achieve short- and long-term goals.

Progressive exercise programmes

1. Begin with gentle passive and progressive PROM exercises; aim to work within the pain-free range. Repeat the PROM flexion/extension exercises for three sets of 10 repetitions.
   

   Consider the use of electrotherapy such as a class IV K-Laser™, if available, to reduce pain and inflammation within the joint and control scar tissue, which may reduce ROM.

   
   

   If available hydrotherapy using an underwater treadmill (UWT) would be an ideal active exercise for the patient to increase ROM of the joint. Use the buoyancy effect of the water and fill to the level of the patient’s mid-trunk. Start with slow speeds and short duration with plenty of rest breaks, then increase speed and time as the patient progresses.

   
   
2. Stretch short/tight muscles into early resistance, and hold each stretch for 15 seconds, then allow the patient to relax and repeat the stretch, for a total of three stretches. As the patient progresses with his exercise programme he will be functionally stretching muscles as he ambulates and increases weight-bearing through the limb. Controlled stair climbing with support or ascending gentle slopes will all functionally stretch muscles.
   
3. Gently start to gradually increase weight-bearing on the affected limb by using weaving exercises to encourage weight transfer onto the affected limb. Start with the cones wide apart; to progress the exercise over the 6-week period reduce the distance between the cones, increase the speed of the exercise (tempting the patient with a treat may help), and gradually towards the end of the 6-week period reduce the support given by the sling.
   

   Hydrotherapy using a UWT can also be used to strengthen the extensor muscles as the patient places his limb in the stance phase and pushes through the limb and enters the swing phase. As the patient progresses a faster belt speed will encourage longer strides and greater activity in the extensor muscle groups.

   
   
4. Inflammation within the joint may affect conscious proprioception (CP). Stepping over cavaletti poles will challenge and improve CP as the patient will need to think about where he is placing his limb once he clears the pole. Start with the poles low and wide apart, progress by increasing the height and number of poles. Progress him further by altering the arrangement of poles (high, low, high, low).
   

   Exercising him on different surfaces will improve his CP, as on a slightly uneven surface he will receive increased afferent feedback from his foot to his brain signalling how he should place his foot. Start by exercising him on flat, firm, non-slip surfaces and progress him to grass, bark chippings and sand, which will be the most challenging surface.

   
   

   Practising functional activities in a controlled environment will boost the animal’s confidence to carry out these activities in the home environment. If the animal has stairs to negotiate in the home or other places he visits this activity should be practiced under supervision.

   
   

   Stair climbing is a functional activity that requires strength to ascend the stairs, and balance to descend the stairs (Figure 1.2).

   
   

   Another common functional activity that the animal may need to perform is getting in and out of the car. A ramp is recommended for medium to large dogs. If the animal has not used the ramp before he may be reluctant to use it. Always make sure the ramp is firmly secured to the car. Start by practising getting into the car first so he can gain confidence. Practice this several times before attempting using the ramp to exit the car. Like with stair practice he will feel most vulnerable on the descent. It may be useful to have an assistant at the opposite side of the ramp to yourself to give extra reassurance and to assist the patient should he lose his balance.

   
   

   Early gait re-education is vital to prevent any secondary complications or compensatory postures from developing. If the animal is holding the limb in extreme hip flexion most of the time he is at risk of developing muscle imbalance (tight in flexors vs weak in extensors). He is also at risk of developing severe muscle atrophy in the extensor muscle groups, and reduced joint ROM.

   
   

   Another point to note is the extra pressure placed on the other limbs, mainly the other pelvic limb and the contralateral thoracic limb. The joints and muscles in these limbs will be placed under greater stress so function in these limbs should also be assessed and treated as necessary. Also the lumbar spine should be assessed in pelvic limb chronically lame animals for any signs of stiffness, and for pain in the associated muscles, which may develop muscle tension or trigger points.

   
   

   Laser therapy can be useful in treating lumbar spine pain and inflammation associated with chronic pelvic limb lameness. Alternatively, or as an adjunct to laser therapy treatment, direct ischaemic pressure treatment can be used at the site of the trigger point. A gradual pressure equating to approximately 4 kg is applied until the trigger point or muscle spasm diminishes.

   
   

   Lumbar spine pain and stiffness can be treated with mobilisations. Start gently with grade II for pain relief, then progress to grade III to improve mobility and reduce stiffness.

   
   

   Active-assisted (using a sling) exercises in a controlled environment are an excellent way to reduce gait abnormalities. As the patient is challenged by the exercises (weaving cones/cavaletti poles) he will not be able to compensate by mobilising on three limbs and therefore will commence with gentle weight-bearing, which is desirable at this stage of the rehabilitation programme.

   
   
5. Hydrotherapy using a UWT is another excellent exercise to improve gait abnormalities as the buoyancy of the water means the patient will have less weight and concussive forces passing through his joints so he will be more likely to use the limb. The warmth of the water will also assist in relaxing any muscle tension. The speed, duration (time), and level of the water (buoyancy effect) can all be controlled to suit the needs of the patient and the rehabilitation programme. Start with slow speeds and short duration; it is important that the patient gains confidence to begin with.

The aim of the late-stage rehabilitation programme is to fine tune any minor discrepancies regarding joint ROM or muscle imbalances. The late-stage programme aims to improve strength of the affected limb, improve muscle bulk, improve CP and balance, and finally to improve stamina.

1. Balance: simply start by testing the patient’s ability to resist perpetrations or ‘nudges’, forcing the patient to take weight through the affected limb(s). This exercise can be progressed to incorporate limb lifting. Start by lifting the affected limb, then progress to lifting the non-affected pelvic limb (support the patient as necessary with an arm under his abdomen at the start). Progress the exercise by lifting the contralateral thoracic limb (diagonal lifting). Hold each limb lift for 5 seconds and repeat five times.
   

   A wobble cushion can be placed under the patient’s limb. Perpetrations or nudges at the contralateral hip will force the patient’s limb onto the wobble cushion, which is an unstable surface so he will need to use stabilising muscles in the limb to maintain his balance. If this exercise is well tolerated, it can be progressed by incorporating limb lifting of the contralateral pelvic limb whilst the affected limb is balancing on the cushion. This will increase the stabilising muscle strength in the limb and also further challenge his ability to balance. Hold each limb lift for 5 seconds and repeat five times.

   
   

   Wobble boards can also be used to challenge balance and improve strength. The patient walks onto the board and faces forwards. Start by gently wobbling the board in an anterior/posterior motion. If the patient tolerates this progress to challenge the patient’s balance in the medial/lateral motion. Progress this exercise further to target a limb by incorporating limb lifting into the exercise; start by lifting a pelvic limb. This will force the patient to take more weight through the standing limb, thus increasing strength, and challenging balance. Because a dog takes 60% of his bodyweight through his thoracic limbs this exercise can be further progressed again by lifting the contralateral thoracic limb (diagonal limb lifting), forcing the patient to shift his weight back onto the pelvic limb to increase strength and balance. Hold each limb lift for 5 seconds and repeat five times.

   
   

   The owner can be taught how to carry out the limb-lifting exercises at home. The owner could also have the patient walk in figures-of-eight or in circles to challenge balance. Start with wide figures-of-eight and circles, and then progress by making them smaller.

   
   
2. Stamina and cardiovascular (CV) fitness: will start to improve as the patient is allowed more lead exercise at this stage. Hydrotherapy can be useful in the late stages of rehabilitation as the speed of the belt can be increased to a fast walking pace or gentle trot; this will also improve joint ROM as the patient will take longer strides and improve extensor muscle strength as he propels himself forwards. The level of the water can also be adjusted to give a strengthening effect. The greatest resistance of the water is at the surface level so this level should correspond with the level of the muscle groups you are aiming to strengthen. Resistance can be added by using the UWT water jets; this will further increase strengthening. The work time can also be increased, and the rest time decreased to increase stamina and CV fitness.

Hip dysplasia (HD)

Hip dysplasia is described as an abnormal development of the coxofemoral joint characterised by subluxation or complete luxation of the femoral head from the acetabulum in young animals (<1 year old) leading to degenerative joint disease in later life.

HD is thought to be a multifactorial disease process. The primary cause is thought to be hereditary, and the incidence of HD is highest in large breeds of dogs including Labradors and German shepherd dogs. Environmental factors cited include rapid weight gain, rapid growth and over-exercise.

Hip dysplasia is also seen in humans. However, this is not considered a hereditary condition and is not screened for. The primary cause in humans relates to the size (large) and presentation of the foetus. The incidence is highest in large female babies who develop in a confined space with the hip joint flexed and rotated. All babies are assessed for excessive hip laxity shortly after birth. If hip dysplasia is confirmed the baby is fitted with a special hip brace, which is worn for most of the day for a period of months to correct the hip deformity.

However, the disease process of HD in animals is described as:

• Slackening of coxofemoral joint ligaments.
  
• Subluxation of the femoral head from the acetabulum.
  
• Destruction of cartilage surfaces.
  
• A change in shape of joint surface, the femoral head becomes flattened, and the acetabulum becomes shallow.

Secondary osteoarthritis develops resulting in new bone growth at the destroyed cartilage sites, and the formation of fibrous tissue within the joint space as an attempt to provide joint stability.

History

1. Joint instability/wobbly pelvic limb gait pattern.
   
2. Pain, especially on end-of-range hip extension, and later abduction.
   
3. Muscle atrophy, especially in gluteals.
   
4. Difficulty rising, especially after lying for a long period of time, which is common in the morning, or following exercise.
   
5. Exercise intolerance or reduced levels of exercise.

Physical examination

1. Increased hip laxity caused by weakened ligaments and sub/luxation of the hip joint.
   
2. Reduced ROM in the hip joint, caused by remodelling of the joint surfaces and associated joint fibrosis.
   
3. Poor musculature; the animal will be reluctant to weight-bear through the affected limb and will attempt to shift weight onto other limbs, often most evident in stance.

Hip dysplasia – general management

Dietary management: control weight gain especially in immature animals that are still growing. Immature joints have a higher degree of mobility; increased weight gain will place further stress on these developing joints.

Exercise management: again in immature animals that are still growing excessive uncontrolled exercise can place the developing hip joint under increased stress, which may lead to an abnormally developing joint.

Pain control: short-term use of 1–3 weeks’ analgesia and strict rest may be prescribed by a veterinary surgeon if indicated.

Nutraceuticals: these may be considered as an adjunct to therapy. The aim of these natural products is to protect the cartilage surfaces and prevent the formation of new bone forming at these sites. Since the changes in cartilage occur early in the disease process the use of nutraceuticals should commence at an early stage also.

Chondroprotectants and nutraceuticals are compounds that are proposed to have a positive effect on the health and metabolism of chondrocytes and synoviocytes (Beal, 2004).

Chondroprotective agents have three main effects:

1. To support or enhance metabolism of chondrocytes and synoviocytes (anabolic).
   
2. To inhibit degradative enzymes in the synovial fluid and cartilage matrix (catabolic).
   
3. To inhibit formation of thrombi in the small blood vessels supplying the joint (antithrombotic) (Beal, 2004).

A combination of glucosamine hydrochloride, chondroitin sulphate, manganese and ascorbate is a commonly used nutraceutical in osteoarthritic small animals (Hulse, 1998). The use of these nutritional supplements is supported by clinical studies investigating the treatment of osteoarthritis (Leeb et al., 2000).

Cosequin^® has also been found to suppress the anti-inflammatory effects of acute synovitis and immune-mediated arthritis (Beren et al., 2001; Canapp et al., 1999).

Hip dysplasia – conservative versus invasive surgery

The surgical options for hip dysplasia include total hip replacement (THR) or femoral head and neck excision (FHNE) (Figure 1.3). However, when choosing between conservative therapy and surgery, one should take into account the animal’s age and current level of activity. The aim of the rehabilitation programme should be to return the animal to its highest level of function. A case study of a conservative rehabilitation programme illustrates a typical approach taken with a 12-month-old dog.

Anatomy

Cruciate ligament injury

Cruciate injury is a relatively common condition in small animals. It is typically seen in young active dogs. Presentation maybe seen as an acute, chronic or a partial tear.

Aetiology

Canine cruciate ligament (CCL) rupture may be acute and related to trauma, and seen in any breed. Chronic injury occurs over a period of time and may be multifactorial in nature. Obesity and muscle imbalances may contribute to chronic cruciate injury. Partial tears can cause pain and inflammation; if the tear is minor it may settle with rest and conservative treatment. However, major partial tears may require a more invasive approach (surgery) (Figure 1.5).

It may be worth noting that not all humans or indeed animals undergo surgical procedures to stabilise a ruptured cruciate ligament. Over time capsular fibrosis occurs and this scar tissue stabilises the joint to some degree. However, a trade-off may be some loss of ROM in the stifle, but the limb will be functional. If the patient goes on to develop a meniscal injury this will require surgical intervention as pain will be present when the animal flexes and loads the joint, resulting in chronic lameness. Secondary osteoarthritis of the stifle joint will occur as a consequence of CCL injury.