13 Introduction to Rehabilitation
Ronald B. Koh and Janice Huntingford*
* Corresponding author
Introduction
Physical rehabilitation is a rapidly expanding field within veterinary medicine. Initially it was considered an alternative therapy but is quickly emerging as an essential service for small animal practice as more clients treat their pets as family members, and pets are living longer and developing more chronic conditions that would benefit from rehabilitation [1]. The American Association of Rehabilitation Veterinarians (AARV) defines physical rehabilitation as “the diagnosis and management of patients with painful or functionally limiting conditions, particularly those with injury or illness related to the neurologic and musculoskeletal systems” [2]. Rehabilitation focuses on improving the function and quality of life in animals with arthritis or neurologic disorders as well as those recovering from surgical procedures [2]. The overall goal of rehabilitation is to decrease pain, reduce edema, promote tissue healing, restore gait and mobility to its prior activity level, regain strength, prevent further injury, and promote optimal quality of life [3]. Typically, a multimodal approach Integrating pharmacological and non-pharmacological intervention is utilized by rehabilitation therapists to manage patients during their recovery. Formal education in rehabilitation is required before incorporating these techniques into practice settings. In addition to certificate programs, Veterinary Sports Medicine and Rehabilitation is now a recognized specialty with over 200 diplomates in many countries. (See Table 13.1 for list of formal education for rehabilitation).
Table 13.1 Resources on animal physical rehabilitation.
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Anatomy
Knowledge of canine and feline anatomy is critical to develop rehabilitation plans safely and effectively. A working knowledge of boney landmarks, the origin, insertion and function of muscles and neurology is critical for this discipline. A discussion of anatomy is beyond the scope of this book, however many books, and websites thoroughly review anatomy for the practitioner. Formal rehabilitation courses teach working anatomy for rehabilitation veterinarians.
Assessments
Accurate orthopedic, neurological, and physical examinations are required for successful rehabilitation. Box 13.1 summarizes an Integrated Patient Evaluation. In some cases, further diagnostics may be required. These may include radiographs, musculoskeletal ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), arthrocentesis and laboratory tests. All therapists should be able to perform a thorough physical examination and understand underlying diseases and appropriate treatment. Failing to properly diagnose the patient can result in aggravation of pre-existing conditions or prescribing inappropriate treatments.
Medical History
The medical history should consist of general information and history of presenting problem. Signalment, species, diet, vaccination status, allergies, pre-existing problems, pre-existing surgeries or injuries and activity level of the patient should be noted. The history of the presenting problem should be thoroughly documented. An important part of the history is the patient’s diet. Animals in rehabilitation have an increased need for protein to strengthen and build muscle and heal from injury [4]. The therapist should be able to evaluate the suitability of the patient’s diet with consideration for rehabilitation, weight loss if appropriate, and determine the optimum number of calories required for health and healing.
Physical Examination
A complete physical examination should be performed on all rehabilitation patients. This would include current body weight and Body Condition Score (BCS) as well as vitals and pain score. The ability to assess pain in an individual patient is essential before beginning any form of rehabilitation. Patients with significant pain cannot perform therapeutic exercise as effectively, and rehabilitation becomes unpleasant for the patient, client, and therapist if the exercises make the patient uncomfortable [5]. To avoid this, each patient should be pain scored appropriately. Several validated pain scales exist for scoring both acute and chronic pain (See Chapter 18). The rehabilitation team should select one acute and one chronic pain scale and use these appropriately with each patient. Both pharmacologic and non-pharmacologic therapies may be instituted for pain control throughout rehabilitation [6]. For more information on animal pain consult www.ivapm.org.
TCVM Examination
Many integrative practitioners are trained in Traditional Chinese Veterinary Medicine (TCVM). TCVM emphasizes individualized treatment by using a unique theory and terminology to diagnose and treat a wide range of health problems in animals. Two concepts that are unique and fundamental to TCVM are Qi (usually translated as “vital energy”) and Yin and Yang [7]. Qi flows through the body to maintain proper functioning of body systems towards health and wellbeing. Yin and Yang are the harmony of all the opposite and complementary forces that make up all aspects and phenomena of life, and when they are in balance, the body is in harmonious and healthy state. Disharmony or imbalance of Qi and/or Yin and Yang cause disease and illness. Additionally, the Wu Xing or Five Elements is another unique theory that is central to the practice of TCVM. It describes stages of the constantly moving cycle between Yin and Yang in nature and is used to explain the body’s physiology [7]. The Five Elements include Wood, Fire, Earth, Metal and Water. Each Element is associated with a number of characteristics, such as certain body organs, a color, a taste, an emotion, a constitution, and a season of the year (Table 13.2) [7]. Prior to treatment, a TCVM practitioner will complete a detailed assessment based on the four diagnostic methods to evaluate the patient’s condition, including observing (tongue, mental attitude, appearance and color of feces and urine), hearing/smelling (vocal, odor of body, feces, and urine), asking (history, diet, and environmental interaction), and touching/palpating (pulse, integument, nails, muscle, meridians, and acupoints) [7]. The practitioner will then determine a TCVM pattern diagnosis based on examination findings, followed by formulation of an individualized treatment plan that may include acupuncture, herbal therapy, food therapy, and Tui-na (Chinese Medical Massage).
Table 13.2 Characteristics of the Five Elements ([7]. Xie, H and Preast V 2013 / Jing Tang).
| Wood | Fire | Earth | Metal | Water | |
|---|---|---|---|---|---|
| Season | Spring | Summer | Late Summer | Fall | Winter |
| Organs | Liver (LIV) | Heart (HT) | Spleen (SP) | Lung (LU) | Kidney (KID) |
| Gallbladder (GB) | Pericardium (PC) | Stomach (ST) | Large Intestine (LI) | Bladder (BL) | |
| Small Intestine (SI) | |||||
| Triple Heater (TH) | |||||
| Constitution | Competitive, confident, dominant, aggressive | Lively, playful, affectionate, sensitive | Friendly, relaxed, laid back, slow response to a stimulus | Aloof, quiet, independent, obey the rules | Careful, timid, fearful, self-contained |
Posture Examination
Abnormalities in posture may give you clues to both neurological and orthopedic problems.
Table 13.3 lists common postural abnormalities and possible diagnoses.
Table 13.3 Common postural abnormalities (Adapted from [8]. Duerr, Felix, 2013).
| Clinical Abnormality | Orthopedic Condition | Neurological Condition |
|---|---|---|
| Dropped hock | Calcaneal Tendon (Achilles) Injury | Diabetic Neuropathy in cats |
| Gastrocnemius muscle injury | Peripheral nerve issues | |
| Lumbosacral Disease | ||
| Fixed Extension of Limb | Myopathies, LMN disease or UMN spasticity | |
| Flexion of limb | Joint or Muscles Disease causing pain eg arthritis, ruptured CCL | Nerve root signature pain |
| Head tilt | Vestibular disease | |
| Kyphosis | Back/ muscle pain, arthritis | IVDD |
| Lordosis | Muscle weakness | Spinal disease |
| Ventral Neck flexion | Muscle weakness | Pain, Hypokalemia in cats, Myasthenia gravis, hyperthyroidism |
Gait/Movement /Lameness Examination
All rehabilitation patients should have an assessment of gait and movement and a lameness evaluation to determine which limb or limbs are affected. This gait examination should be performed prior to manipulation. Remember that patients may have orthopedic or neurological lameness [9, 10] Before watching a patient ambulate, assessment of symmetry is critical. Static stance analyzers, pressure walkways or force plates can objectively measure the amount of weight placed on each limb. Slow motion video may also be helpful [9]. Figure 13.1 demonstrates an abnormal posture.
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