Ronald B. Koh and Janice Huntingford* * Corresponding author Therapeutic exercises are the cornerstone of veterinary rehabilitation. Therapeutic exercises, whether land or aquatic, are a crucial component of any patient’s rehabilitation program regardless of problem or diagnosis. The purpose of this chapter is to introduce the integrative practitioner to both land and water exercises that may be applied to post-surgical, post injury, geriatric or athletic patients. Rehabilitation is a holistic specialty as it encompasses pain management, improvement of functional impairments, nutrition and supplements, and improvement in overall health. Unless the therapist understands how exercise impacts the body, it is impossible to design an appropriate exercise program [1]. Exercise physiology is a complex topic and the reader should be referred to further textbooks of exercise physiology, however a brief outline is included here. Skeletal muscle performance is dependent on muscle fiber type. Traditionally, muscles are classified as type I (oxidative or slow twitch) or type II (glycolytic or fast twitch) with subclassifications of these two types [2]. However, all muscles consist of a mix of different fiber types, in different ratios depending on the individual muscle and on training. Postural muscles (stabilizer muscles) such as the quadriceps femoris are capable of slow and sustained contraction and contain about 50 % more type I fibers [3] than muscles like the gracilis, which contain more type II and are speed and power (mobilizing) muscles [4]. Type I muscle fibers have been thought of as the endurance muscle fibers and type II as the sprinting muscle fibers. However, when compared to humans, all dogs have a high oxidative capacity in all their muscles and are adapted for endurance activities [5]. Certain breeds, for example Greyhounds, do have more fast twitch muscle fibers than others [6]. When muscles are immobilized, such as in casts or splints, muscle strength decreases rapidly, with as much as 50% of strength lost within the first week [7]. With disuse, postural muscles that contain a predominance of type I fibers, atrophy more than the mobilizing muscles containing type II fibers. In dogs with geriatric sarcopenia, the epaxial muscles atrophy early in the process. One study compared epaxial, quadriceps, and temporalis muscle size in aged dogs to young dogs that were matched in size and body condition. The results showed that epaxial muscles were smaller in aged dogs but quadriceps and temporal muscles did not differ significantly [8]. Fiber type lost, however, appears preferential for the large type II fibers [9, 10]. This is an important consideration in designing an exercise program for an athlete with muscle loss due to injury, versus a geriatric patient with age-related sarcopenia [11]. Muscle contractions can be described as having two variables: force and length. The force is either tension or load. Load is the force exerted on the muscle by an object and muscle tension is the force the muscle exerts on an object. Isometric contractions occur when muscle tension changes with no change in muscle length. This is a static exercise, for example lifting a front leg so that more weight/load is on the muscles of the contralateral front limb and the rear limbs; these limb muscles are undergoing isometric contractions to support more body weight. Tension bands applied to the standing patient rely on the instinct to lean into pressure. As a patient maintains the same body position under an increased load (whether push or pull), the muscle work has increased without a change in muscle length [12]. Isotonic contractions occur when the muscle tension remains the same, but the muscle length changes. Isotonic contractions occur as either concentric or eccentric contraction. Concentric contraction occurs when tensions in the muscle increase along with shortening. An example of this would be a human weightlifter performing a biceps curl. Eccentric contraction occurs when the muscle contracts but lengthens because the tension generated in the muscle is insufficient to overcome the load pulling down on the muscle. An example of this would be a slowly released biceps curl and with the weightlifter extending the elbow to put down the weight [12]. The eccentric contraction controls the movement – it is the natural braking force that occurs during motion [13]. Eccentric contractions can predispose to injury in untrained individuals [14]. Resistive exercise of all forms leads to the preferential hypertrophy of type II fibers and eccentric contractions render type II fibers more susceptible to damage when compared to type I fibers in humans, rabbits, and rodents [15]. In an exercise program, generally, concentric exercises are performed first to help accustom the muscle to movement. Eccentric exercises are added later as these have the potential to cause damage to the muscle and delayed-onset muscle soreness, but they help develop greater strength. A balanced program between concentric and eccentric muscle contractions is desired. Before designing an exercise program, the practitioner must consider any underlying pathology or pre-existing conditions that may affect muscular performance. As an example, a dog with geriatric onset laryngeal paralysis/polyneuropathy will have some respiratory compromise that should be considered when exercising. The experience of the client or handler and the willingness of the patient to perform exercises must also be considered. An agility dog with an experience handler will have a very different exercise program from that of a geriatric companion dog with an inexperienced owner [12]. Exercise improves physical function and reduces pain [16]. Balance and proprioception exercises are indicated for patients with neurological disease. Post-operative and geriatric patients benefit from strengthening exercises and exercises to increase ROM of affected joints. According to Fry et al. obese patients who combined a restricted calorie diet with an exercise program, lost more weight and had improved fitness [17]. All dogs can benefit from regular controlled exercise. After evaluating the patient and assessing tissue integrity, it is important to set long- and short-term goals. For success, the client and the therapist should have the same goals for the patient. Regular reassessment throughout therapy can insure that goals are met and changed as the patient progresses through therapy. Goals should be SMART – Specific, Measurable, Achievable, Relevant, and Time-Bound. Care plans can be based on functional progression [16]. According to McCauley and Van Dyke (2018), there are five variable parameters for each therapeutic exercise [18]: The frequency, intensity, and duration of each exercise is increased as the patient heals and progresses through rehabilitation, however this is based on improvement in functional abilities and tissue healing [19]. Patients should be assessed based on passive and active assessments as outlined in Chapter 13. Exercise balls come in many shapes and sizes and have many different uses. Peanut balls look exactly like a peanut shell, with an indent in the middle providing two separate points of ground contact for added stability over an oval ball. A physio roll is like a peanut ball but lacks the middle indent. Egg-shaped balls have less stability, which makes exercises on these more challenging. Round balls are the most challenging as they allow movement in all directions. A BOSU® ball is flat on one side and has a half ball attached, allowing the patient to balance on the half ball side or when flipped over to balance on the flat side. The patient may stand on the ball or stand with front feet on the ball and roll the ball forward or backward depending on which muscle groups are being strengthened. Most ball work will start with an underinflated peanut for the most stability. As the patient progresses, more air is added for an additional challenge; later, more challenging ball shapes, along with more challenging postures, are used [12, 16]. See Figure 15.1 for another use of a physioball. Figure 15.1 A dog receiving acupuncture while strengthening on a physioball. Although these ground poles have been used for exercising horses for many years, in the small animal patient they are used to train gait, improve proprioception, and strengthen front and hind limb flexor muscles. They are also used to improve active ROM – specifically they increase flexion and extension of stifle and flexion of the carpus and elbow along with flexion of the tarsus [16, 20]. Figure 15.2 shows a cat walking over cavaletti poles. Cavalettis are placed in a series and are adjustable in height. They are placed low or on the ground when the patient begins the exercise or has significant muscle weakness. The height can be adjusted as the patient progresses through rehabilitation. Spacing is patient-dependent; it depends roughly on height and body length, but most importantly on stride length. Cavalettis are easily made from pylons with holes and PVC pipe. The cones can then be used for weaving exercises [16]. Figure 15.2 A cat walking over cavaletti poles. These poles and cones are used for circling, walking in a figure eight, and weaving (in a serpentine). Weaving in and out of cones creates lateral flexion of the spine, aims to strengthen the adductor and abductor muscles and to improve balance and proprioception. Six to eight cones can be used to make up an obstacle course for the patient to weave in and out of. Alternatively, multiple objects such as bowling pins, water bottles, or a line of trees, for large dogs, can be used if they are evenly spaced so the dog can weave in and out of the objects. Vertical weave pole agility sets, or safety cones can be used. The distance between the poles needs to be adjusted so that sufficient lateral bending occurs. Weaves are used to help build core strength and improve proprioception [16]. Figure 15.3 shows a dog weaving through cones. Figure 15.3 A dog weaving through cones during an assessment. All of these exercises improve balance and proprioception and build core strength [12].Planks are 2.5–3.0 m (8–10 feet) long pieces of wood that are either 5 × 20 cm or 5 × 25 cm (2 × 8–10 inches) in length. The dog walks along the planks which are initially placed on the floor. As the dog progresses, he is further challenged by elevating the planks or placing obstacles on the plank. Blocks are smaller and thicker pieces of wood generally 10 × 15 cm with a grip tape added to create a non-skid surface. The blocks can be made in heights of 5, 10, and 15 cm (2, 4, and 6 inches). The dog stands with one foot on each block or any combination of diagonals or front or back paws. Strengthening of the stabilizer muscles of the trunk is emphasized by this exercise [16].
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Modalities Used in Rehabilitation—Land and Aquatic Exercises
Introduction
Exercise Physiology
Designing an Exercise Program
Canine Rehabilitation Exercise Equipment
Physioballs/Peanuts/BOSU® Balls
Cavaletti Poles
Weave Cones
Planks/Blocks/Stairs
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