Therapeutic Exercises: Joint Motion, Strengthening, Endurance, and Speed Exercises



Therapeutic Exercises


Joint Motion, Strengthening, Endurance, and Speed Exercises



Darryl L. Millis, Marti Drum and David Levine


image

Therapeutic exercises to improve active joint motion through a more complete range, and to build power, strength, and speed are the final phases of rehabilitation to return the patient to as normal a function as possible. The therapist must keep in mind the degree of injury or disability in determining the likelihood for the patient to reach higher levels of function and adjust the rehabilitation program and expectations accordingly. For example, it is not expected that a 7-year-old dog with severe bilateral elbow arthritis would be able to achieve near-normal function, but there are exercises that can be performed to help achieve greater function and ability. Some of the common goals of therapeutic exercise are to improve active pain-free range of motion (ROM), muscle mass and muscle strength, performance, and conditioning. Common activities include stair climbing, sit-to-stand exercises, treadmill activity with resistance, pulling or carrying weights, “wheelbarrowing” (for forelimb activity), “dancing” (for rear limb activity), walking and trotting across cavaletti rails, jogging, running, underwater treadmill activities, swimming, playing ball, and activities using balance balls or rolls. These higher levels of therapeutic exercise are important in assisting an animal’s return to the best function possible following early limb use and proprioceptive exercises. Many of the exercises that target certain aspects of performance, such as joint motion, conditioning, and strength, have some overlap (Box 30-1). In addition, the equipment needed for most exercises is relatively inexpensive, and similar principles apply to a variety of individuals and conditions. Therapeutic exercise programs designed for the home environment also provide an opportunity for owners to become actively involved in their pets’ rehabilitation. In any case, it is very important to have good footing to avoid slipping and to have adequate space to perform exercises with as little distraction as possible.



Box 30-1   Exercises to Improve Joint Motion, Conditioning, and Strength






It is also important to remember to use patience when working with the dog to learn new exercises. Most of the exercises in this chapter have been purposefully selected so that most dogs that are trained to leash can perform them with some basic training. However, some dogs are highly trained and the therapist should work with the owner to select exercises based on the patient’s needs, as well things the dog is already trained to perform. The therapist is cautioned to use training techniques that are based on positive reinforcement. Negative reinforcement techniques may temporarily work in some instances, but because rehabilitation is an ongoing treatment, dogs will become less willing to perform an activity or to learn new ones. Many dogs will be somewhat nervous or frightened when first undergoing rehabilitation, especially if pain is involved from their injury or surgery. It is important to go slowly and gently at the beginning. Treats, favorite toys, or other rewards should be kept handy to encourage dogs when learning new exercises. The reader is referred to Chapter 4 for further tips on applying behavior techniques in the rehabilitation environment.


When designing a high-level therapeutic exercise program, several factors must be considered. A problem list is developed based on an initial evaluation of the rehabilitation patient, and a treatment plan is formulated to address the identified problems. Realistic outcome goals are then established. Appropriate exercises are those that can be performed safely and effectively and accomplish the therapeutic goals. The exercise plan should target the affected muscles, joints, and other structures. When prescribing therapeutic exercise, the therapist should understand the diagnosis, identify the structure or structures involved, and recognize the stage of tissue recovery with the resultant functional limitations. Without a good understanding of these principles, it is easy to over stress the involved tissues and potentially cause harm. The type of injury or repair must be considered when formulating a treatment plan. For example, a patient with a tibial plateau leveling osteotomy (TPLO) will require several weeks for tissue remodeling and healing of the osteotomy before engaging in high-speed activities. Similarly, a patient with a partial brachial plexus injury may initially have a difficult time performing a shaking hands exercise. But over time, the dog may recover and perform shaking hands exercise with a limb weight to achieve greater strengthening. With this knowledge and understanding, appropriate decisions can be made regarding therapeutic exercise choices.


Treatment considerations and choice of exercises vary with each stage of tissue repair and endurance. As the animal improves clinically and tissue healing progresses, the exercise plan should be altered to match the animal’s progress and appropriately challenge the involved tissues. The intensity of an exercise may be increased or reduced by changing the duration of time that an animal performs an exercise, the rate of speed at which a particular exercise is performed, or the frequency (how many times per day) that it is performed.


These factors may be altered to fine-tune an exercise prescription to achieve the expected outcome goals. For example, a realistic initial goal for a morbidly obese, deconditioned patient with degenerative joint disease may be to increase the amount of time the dog is able to comfortably tolerate walking, thus improving endurance and promoting weight reduction. Increasing the speed at which the dog walks may not be a realistic initial goal for this animal. A contrasting example may be an athletic animal recovering from injury that must be challenged to improve speed and frequency to meet the goal to return to a high level of performance. It is important for the therapist to have an understanding of exercise intensity and what is appropriate for each patient during rehabilitation treatment. Routine reevaluation of the patient is recommended to assess the adaptations that are occurring with the rehabilitation treatment plan and to determine the appropriate rate of progression.


Therapeutic exercise routines should be monitored at regular intervals by a trained individual familiar with the patient and the exercise techniques. Inappropriate exercise or improper technique may result in inappropriate stresses, further injury, or exacerbation of an existing condition. Certain exercises may not be safe for the strength, flexibility, or endurance level of the animal performing the exercise, or an exercise may not be the correct one to accomplish the intended goal. The exercises described in this chapter are listed with the desired outcomes of joint motion, conditioning, or speed and strength, but there is significant overlap with some exercises, and the differences are indicated for the various outcomes. The reader is also referred to Chapter 24 on biomechanics of rehabilitation for further details on therapeutic exercises, especially as they relate to joint motion and forces.



Joint Motion Exercises


Incline Walking


Walking the dog up an inclined surface alters joint motion and aids in strengthening of the hip and stifle muscles, especially the extensors, while ascending (Figure 30-1).


image

Figure 30-1 Leash walking up ramps or hills encourages muscle strengthening and cardiovascular endurance.


Joint Motion Considerations


Climbing up an inclined surface promotes increased flexion, extension, and ROM of the hip. Stifle flexion is decreased, however.1 When the limb is in the stance phase of gait and the body is traveling forward, the knee and hip must extend to propel the animal forward. If extension is painful, the dog’s stance time on the limb may be reduced and an altered gait may result. In addition, dogs may shorten the stride length to help control joint motion if a particular joint position causes pain. For example, a dog with hip dysplasia may shorten its stride while walking up an incline so that excessive hip extension and pain are avoided. If this occurs and a particular joint motion that is desired does not occur, it may be better to use another exercise, such as stair climbing, in which the limb must travel a discrete distance to negotiate the step rather than adjust the stride length while walking up a ramp.


Walking up an inclined ramp also results in greater ROM of the forelimb joints.2 Shoulder extension and ROM, elbow flexion and extension, and carpal flexion are greater when walking up a ramp as compared with ascending stairs or trotting over level ground.



Exercise Considerations


Initially, walking should be done slowly and on leash; otherwise the dog may only toe-touch with the limb or hop in a non–weight-bearing fashion. Inclines should be introduced slowly, beginning with gradual slopes. As the dog’s ROM, strength, and limb use improve, the dog may be challenged by walking up longer, steeper slopes and by increasing the duration, speed, and frequency of the climbing exercise. Further challenges are provided by doing inclines while wearing a weighted vest, leg weights (Figure 30-2), or pulling a small amount of weight with a harness. Ascending or descending a slope at an angle may also alter joint motion of an affected limb. If the affected limb is on the downhill side while ascending diagonally, the joints and muscles perform with the limb in a more extended position. Conversely, if the affected limb is on the uphill side while ascending diagonally, the joints and muscles perform with the limb in a more flexed position. It is particularly important to monitor gait patterns when walking downhill as many dogs with neurologic conditions may exhibit more ataxia, causing the hind end to sway to one side or the other. Also, if descending too fast, the patient may stumble and fall even if its gait appears to be normal on level ground. Varying speeds up and down inclines is another method to increase the challenge of this exercise.


image

Figure 30-2 Walking up a ramp or hill while wearing a leg weight provides greater challenges.


Stair Climbing


Climbing stairs is useful to improve ROM, power in the rear limb extensors, coordination, and proprioception, and in many instances, is an activity of daily living that must be performed in the home environment (Figure 30-3). Quadriceps and gluteal muscle groups are strengthened as the animal pushes off, extending the stifles and hips while propelling the body up the steps.


image

Figure 30-3 Stair climbing should begin on stairs with a gradual rise (A) and progress to steeper stairs (B). Care should be taken to be certain that the dog pushes symmetrically off of both rear limbs.


Joint Motion Considerations


ROM of the pelvic limb joints is significantly increased during stair climbing compared with trotting on level ground.3,4 Extension of the hip and hock joints is moderately increased with stair climbing, whereas stifle extension may be mildly increased or decreased, depending on the size of the dog relative to the size of the step. Flexion of the stifle and hock is also increased. Although hip flexion contributes little to stair ascent, the stifle and hock joints seem to contribute significantly to ascending stairs by flexing these joints to raise the limb up to the height of the step.


Regarding the forelimb joints, there is less ROM with stair ascent as compared with walking up a ramp with similar slope.2 These differences are primarily due to changes in extension, with no significant differences in flexion of forelimb joints. Shoulder extension is less with stair climbing as compared with trotting over ground, whereas flexion is greater with stair climbing. Elbow and carpal flexion, extension, and ROM are greater with stair ascent as compared with trotting over ground.


Stair descent results in significantly greater stifle flexion and hock flexion and extension compared with walking down a declined surface.5 Significantly greater ROM also occurs in the coxofemoral, femorotibial, and tibiotarsal joints during stair descent.



Exercise Considerations


The dog must begin slowly climbing stairs to encourage proper use of the rear limbs, as opposed to simply carrying the limb, hopping with both rear limbs, or skipping up stairs. Encourage the dog to go slowly and deliberately, climbing the stairs in a reciprocal stepping gait. Stairs should be introduced slowly because this is a challenging exercise for both the musculoskeletal and cardiovascular systems and the animal may fatigue quickly. Initially, some dogs may require assistance from the handler. Begin with five to seven steps, and gradually increase to two to four flights of stairs once or twice daily. In severely affected dogs or smaller dogs, it is advisable to begin stair climbing on stairs with a gradual ascent and progress to steeper stairs. Another strategy for smaller dogs is to attach blocks to existing stairs to make “half stairs.” As the patient improves, dogs may jog up stairs. In the motivated patient, walking backward up or down stairs can be an additional significant challenge. To introduce this exercise, use a treat or toy to encourage stepping backward up one step while the patient keeps the forelimb on the ground and then have patient come back down to level ground. The reverse is true for backing down a step. Repeat this several times until the patient is comfortable with this movement before having the patient walk backward up or down two to three steps, and advance to a full flight after the patient is comfortable and understands what is being asked. This advanced exercise is often easier to teach using a few steps versus a full flight of stairs. A three- or four-stair block can be built for this purpose.



Dancing and Wheelbarrowing


Raising the forelimbs off the ground and walking the dog forward or backward, also called dancing, alters motion of rear limb joints and challenges proprioception, coordination, and strength. The amount of peak force placed on the limbs is slightly greater than what would occur at a trot.6 Therefore if the stage of recovery is not adequate to withstand trotting, then dancing should not be undertaken. On the other hand, additional strengthening of postural muscles may be obtained with dancing when it is safe to perform the exercise.


Wheelbarrowing is an exercise similar to dancing, except that the forelimbs are targeted by raising the rear limbs off the ground and walking the dog forward. This exercise encourages increased use of the forelimbs and challenges proprioception, coordination, and strength. The dog’s orthopedic condition must be adequately stable to handle the stresses of these exercises. Wheelbarrowing results in peak force placed on the limb that is between walking and trotting.6




Exercise Considerations


It is important for the therapist or veterinarian to evaluate available ROM in the rear limb joints before attempting dancing to identify any potential limitations that may prevent the animal from safely performing the exercise. For example, in the early phases of a therapeutic exercise program for a dog that is painful with hip extension as a result of hip dysplasia, gluteal muscle strengthening may be more comfortable by dancing the dog forward rather than backward.


When a dog is using its affected limb consistently at a walk with minimal lameness, dancing may begin. Muzzling may be necessary for some dogs before this exercise, particularly in dogs that do not like to have their feet touched or feel threatened by the therapist’s posture. The forelimbs are lifted off the ground, allowing the patient to bear weight only on the rear limbs (Figure 30-4). Dogs with normal proprioception will naturally move the rear limbs as the handler moves and the animal “dances” backward and forward. Some dogs may resist dancing forward if the handler stands in front of the dog; dogs may plant their rear limbs and stretch out as the handler moves until the forelimbs reach the ground. In this situation, the handler should stand behind the dog, placing the arms under the axillary region to support the dog, and walk forward. How far the dog is elevated off the ground depends on the amount of stress the animal is able to comfortably handle on the rear limbs. Dogs may be elevated as high as possible and also dance up and down inclines or hills to place additional stress on the rear limbs. Dancing activities may also be accomplished with the assistance of a physioroll or ball. The front limbs of the patient are placed on the roll or ball and the therapist slowly rolls the ball toward the patient, forcing the dog to move the hindlimbs backward (Figure 30-5). Most dogs will reposition their forelimbs, especially if they are standing on the ball, rather than resting their antebrachium on the ball. Once comfortable with walking backward in this fashion, the ball can be slowly rolled away from the patient, stimulating forward walking of the rear limbs. A harness to provide support for the patient is very helpful for this activity. Alternatively, a wagon or other flat surface on wheels can be used for this activity, particularly for forward dancing.


image

Figure 30-4 Dancing encourages weight bearing on the rear limbs. Muzzling may be necessary for some dogs before this exercise, particularly in dogs that do not like to have their feet touched or feel threatened by the therapist’s posture. The forelimbs are lifted off the ground, allowing the patient to bear weight only on the rear limbs.

image

Figure 30-5 Dancing activities may also be accomplished with assistance of a physioroll or egg ball. The patient places their front limbs on the roll or ball and the therapist slowly rolls the ball toward or away from the patient forcing them to move their hindlimbs backward or forward.

To perform the wheelbarrow exercise, the handler places the hands under the caudal abdomen and lifts the rear limbs of the dog off the ground, and the dog is moved forward (Figure 30-6). The handler may wish to place a muzzle on the dog. Dogs with normal proprioception will move the forelimbs so they do not fall. Some dogs may require sling support if they are weak. Dogs may be wheelbarrowed up and down inclines for greater muscle strengthening (Figure 30-7). Theoretically, the higher the animal is lifted, the greater the forces placed on the forelimbs. However, the increase in weight bearing may not be as great as anticipated because the stride length is much shorter when the animal wheelbarrows from a greater height. The shortened stride results in less force placed on the limbs while wheelbarrowing as compared with walking or trotting at a faster speed. A hindlimb sling, particularly one that lifts at the pubis rather than the abdomen, may be used to assist the dog while wheelbarrowing.


image

Figure 30-6 Wheelbarrowing encourages use of the forelimbs. The therapist supports the abdomen and lifts the rear limbs of the dog off the ground, and the dog is moved forward. The handler may wish to place a muzzle on the dog.

image

Figure 30-7 Dogs may be wheelbarrowed up and down inclines for greater muscle strengthening.


Sit-to-Stand Exercises


Sit-to-stand exercises help strengthen hip and stifle extensor muscles and improve active ROM. The act of sitting, then standing up, requires muscle strength of the gluteal, quadriceps, hamstring, and gastrocnemius muscle groups.




Exercise Considerations


Some training may be necessary, and low-calorie treats may be offered as a training aid to provide motivation to perform the movement. It is important to perform these exercises correctly. Attention should be paid to sitting and standing straight, with no leaning to one side, and the joints of both rear limbs should be symmetrically flexed so that the dog sits squarely on its haunches (Figure 30-8). While on the leash, after a sufficient warm-up period of walking, the handler asks the dog to sit squarely for a few seconds and then asks the dog to stand, take a few steps forward, and then again sit. The sit-to-stands may be repeated a number of times before the dog is allowed to rest. It may be easier in some cases to back the dog into a corner, with the affected limb next to a wall so that the dog cannot slide the limb out while rising or sitting. Start with 5 to 10 repetitions once or twice daily, and work up to 15 repetitions three to four times daily.


image

Figure 30-8 Sit-to-stand exercises. A, Note the symmetrical position of the dog in the sitting position. Placing the affected limb toward a wall will help the dog to sit in a square, symmetrical position. B, As the dog rises, it should push off equally with both rear limbs. Attention should be paid to sitting and standing straight, with no leaning to one side, and the joints of both rear limbs should be symmetrically flexed so that the dog sits squarely on its haunches.

This exercise may be particularly beneficial for dogs with osteoarthritis of the hips. These patients generally feel pain when the hip joints are extended. Going from a sitting position to a standing position results in movement of the hip joint from a greatly flexed position to a hip angle similar to normal standing. In addition, there may be atrophy of the gluteal muscles. The sit-to-stand exercise allows active contraction of the gluteal muscles, but the hip joint is not generally extended to the point that results in pain. Therefore strengthening of the gluteal muscles can occur without the excessive pain encountered with hip extension.


Of course, each patient must be assessed to be certain that sit-to-stands are not too stressful or painful for that individual. If normal sit-to-stands are too painful, or the patient is too weak to rise from a sitting position, several modifications may be tried. Doing sit-to-stands with the pelvis in an elevated position may be helpful in patients that are too weak to rise from a complete sitting position. Dogs may sit with their pelvis on a stool, step, stack of books, curb, firm cushion, or the therapist’s leg or knee, and rise from this elevated position. Many dogs will need guidance from the therapist’s hands to learn to sit on an object because it may feel strange for some patients. Alternatively, dogs may be assisted with a sling from a sitting to a standing position. Dogs may also do sit-to-stands on an incline, with the body facing downhill to make it easier to stand. Alternatively, dogs may do sit-to-stands on an incline with the body facing uphill or sideways to each direction to provide an additional challenge and greater strengthening. For this challenge, dogs may perform five repetitions in each direction, twice daily. Finally, dogs may find it easier to do sit-to-stands in the water, using the buoyancy of the water to help assist them to a standing position.



Down-to-Stand Exercises


A variant of the sit-to-stand exercise is the down-to-stand. With this exercise, the dog is allowed to rise from a ventrally recumbent position to a standing position. In addition to strengthening the muscles of the pelvic limb, muscles of the forelimb are also engaged.

You may also need

Tags:
Jul 8, 2016 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on Therapeutic Exercises: Joint Motion, Strengthening, Endurance, and Speed Exercises
Premium Wordpress Themes by UFO Themes