Postoperative Physical Rehabilitation

Chapter 95 Postoperative Physical Rehabilitation



Darryl L. Millis


The appropriate postoperative management of small animals undergoing orthopedic or neurologic surgery is critical for a successful outcome. Inadequate surgical and postoperative treatment may result in fracture disease. The appropriate use of physical rehabilitation techniques in combination with pharmaceutical agents is necessary to achieve an optimal outcome.



GOALS OF POSTOPERATIVE PHYSICAL REHABILITATION



• Prevent loss of joint range of motion and stiffness

• Reduce the deleterious effects of disuse of musculoskeletal tissues

• Improve the rate of recovery

• Improve the quality and quantity of movement

• Enhance the ultimate outcome

• Enhance performance, conditioning, and endurance


PREOPERATIVE CONSIDERATIONS IN THE REHABILITATION PLAN



• Patient’s age and physical condition. Obese patients and those with poor cardiovascular condition will require a less aggressive rehabilitation plan.

• Surgical condition and the repair technique. The stability of the surgical repair helps determine how aggressive the rehabilitation plan may be.

• Presence of concurrent injuries. Animals with multiple injuries generally undergo a less aggressive rehabilitation plan.

• Owner compliance. The therapist must consider the ability and willingness of the owner to participate in the rehabilitation plan.

• Expertise of the rehabilitation team.


PERIOPERATIVE PAIN MANAGEMENT


Institute preemptive pain management to allow post-operative therapy to be as comfortable and pain free as possible (see Chapter 6). Effective control of pain and postoperative inflammation allow rehabilitation to begin earlier with more rapid progress to functional activities.



Medications and Techniques



• Preoperative butorphanol or morphine.

• Epidural opioid analgesia.

• Intra-articular administration of local anesthetic agents such as bupivacaine.

• Morphine or buprenorphine are commonly used for immediate postoperative analgesia.

• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as deracoxib or carprofen may be administered prior to or immediately after surgery and continued in the postoperative period in healthy patients free of renal and gastrointestinal disease or bleeding tendencies. Knowledge of NSAID pharmacokinetics is important so that dosing strategies take advantage of peak drug effects. Medication is continued for 7 to 14 days after surgery.

• See Chapter 6 for further discussion of postoperative pain management.


REHABILITATION IN THE IMMEDIATE POSTOPERATIVE PERIOD




Key Point


The main objectives in the first 24 to 72 hours after surgery are to provide pain control, reduce joint effusion and tissue edema using cryotherapy, and reestablish normal joint range of motion (ROM) as soon as possible.


If normal motion is not established by 2 weeks, dogs may permanently lose some ROM. Prevention of muscle atrophy is also critical. Early use of the limb with functional weight bearing is the key to returning the patient to function as soon as possible.



Cryotherapy (Cold Packs)



• Cryotherapy is the therapeutic use of cold.

• The effects of cryotherapy include the following:
• Vasoconstriction

• Decreased blood flow

• Reduced cellular metabolism and permeability

• Attenuation of traumatic or exercise-induced edema

• Decreased muscle spasm

• Analgesia as a result of decreased sensory and motor nerve conduction velocity


Cryotherapy Devices



• Place crushed ice in a sealed plastic bag and wrap the bag in a thin cloth, such as a pillowcase or towel.

• Prepare a mixture consisting of two parts water and one part alcohol in a double-sealed plastic bag and place it in a freezer. The resulting pack is a frozen slush that conforms to any surface.

• Use commercially available cold packs.

• Use circulating cold water cryotherapy units.


Cryotherapy Technique



1. Apply to the affected area immediately after surgery during recovery from anesthesia.

2. Apply the cold pack for 15 to 20 minutes.

3. Use caution when applying cold packs to hypothermic or small patients.

4. Apply for 15 to 30 minutes every 6 to 8 hours for the first 3 or 4 days after surgery.

5. Monitor the patient for discomfort.

6. Do not use cryotherapy in patients with poor or absent pain sensation.

7. A compression bandage, such as a modified Robert Jones bandage, may be applied after cryotherapy to help prevent swelling and edema.


Range of Motion and Stretching Exercises


Perform ROM and stretching exercises to help maintain or improve flexion and extension of joints; improve flexibility of muscles, tendons, and ligaments; and help enhance awareness of neuromuscular structure and function. ROM exercises are important in dogs undergoing any joint surgery, especially cranial cruciate ligament rupture stabilization, elbow fractures, and fracture of the distal femoral physis in skeletally immature dogs.



Range of Motion Exercise Technique



1. Place the patient on soft padding in lateral recumbency.

2. Stabilize the limb proximal to the joint.

3. Gently grasp the limb below the affected joint. The closer the hands are placed to the joint, the lower the forces will be that are applied to the joint.

4. Slowly flex the joint over several seconds until there is the first indication of discomfort, such as tensing the limb, turning the head in recognition, or trying to gently push away. Under no circumstances should the animal vocalize in pain or attempt to bite. In general, joint flexion is more comfortable than joint extension.

5. Slowly extend the joint over several seconds until there is the first indication of discomfort.

6. Other motions may be appropriate, such as abduction and adduction or rotary motions, especially of the shoulder and hip.

7. Repeat for 10 to 30 repetitions depending on the animal’s reaction to the motion, 3 to 6 times daily.

8. Do all joints in the affected limb, including the digits.



Key Point


Over-aggressive ROM exercises will result in pain, reflex inhibition, delayed use of the limb, and ultimately more fibrosis of the tissues around the joint.


The primary objective is to gently flex and extend individual joints through their comfortable ROM.


As the animal nears full ROM, more natural gait movement may be instituted by putting all of the joints of a limb through a ROM simultaneously, similar to the motion of riding a bicycle.



Stretching Technique



1. Stretching is often combined with ROM exercises in stiff joints with decreased ROM.

2. Stabilize the limb proximal to the joint, and grasp the limb below the affected joint and gently move it.

3. At the end range of flexion, hold the position for 15 to 30 seconds. Gradually attempt to increase flexion as long as the patient remains comfortable.

4. Extend the joint, and at the end range of extension, hold the position for 15 to 30 seconds. Gradually attempt to increase extension as long as the patient remains comfortable.

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Aug 27, 2016 | Posted by in SMALL ANIMAL | Comments Off on Postoperative Physical Rehabilitation

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