D. Dunning

College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.

INTRODUCTION

Therapeutic exercise is a key component of a rehabilitation program for a variety of impairments. Therapeutic exercise may be the basis of the intervention, such as with animals that are obese, or more commonly, may be a component of the total plan. Therapeutic exercise includes activities and techniques to improve physical function and health status resulting from the primary disease. When structuring an exercise program, it is helpful to first identify and create the problem list stemming from the primary disease. From this, the rehabilitation practitioner can identify specific performance goals that will allow an animal to function at a higher level. Success of any therapeutic program is based upon taking into consideration the owner’s expectations of the animal, the owner’s commitment to continuing the work at home, and the underlying condition being treated.

When developing an effective, efficient therapeutic exercise program, it is helpful to answer the following questions regarding your animal patient:

• Which elements of the musculoskeletal system need to be address to restore function?
• Which activities or techniques can be chosen to achieve a functional outcome?
  • Include the sequence and duration necessary within a given exercise session
• What is the purpose of each specific activity or technique chosen?
• What posture and movement must the animal be able to perform to fully achieve the activity?

It is also important to realize that, unlike people, you can not push animals into an activity or overexert a recovering animal. If you hurt a rehabilitation patient, it is likely that either the animal or the owner will become rapidly noncompliant with your program. The following proceedings outline a template protocol that you can use and modify for your outpatient rehabilitation. It is very important to reemphasize, however, that you must evaluate each animal patient individually prior to implementing any plan. There is not one plan to fit all animals or their owners. In addition, owners will need sufficient training to perform the following exercises.

FOUR PHASES OF POSTOPERATIVE JOINT REHABILITATION

The recovery of a postoperative joint patient can be generally split into four discrete phases:

Phase 1

Phase 1 is approximately two weeks in duration. The focus of this phase is on wound healing, control of swelling, and regaining musculoskeletal control of the operative limb. Therapeutic activities focus on wound management, local cold packing, proprioceptive activity and muscle strengthening exercises.

Phase 2

Phase 2 generally runs from two to four weeks postoperatively. The focus of this phase is on increasing joint range of motion (ROM) and developing a functional gait.

Phase 3

Phase 3 is generally seen at six to eight weeks postoperatively, assuming no complications and a normal recovery. Once the surgeon has evaluated the animal, the animal may begin to resume activities of daily living with continued strength training.

Phase 4

Phase 4 is the final stage of recovery (greater than 6 to 8 weeks postoperatively), when the animal begins a slow return to competitive or athletic activities.

EXAMPLE AT-HOME PROTOCOL FOR A CRANIAL CRUCIATE REPAIRED VIA AN EXTRACAPSULAR METHOD

Week 1

• Perform passive range of motion (PROM) to the entire involved leg (including the knee, hip, and ankle) for 30 repetitions to each joint 3 times a daily. Increase PROM daily to tolerance.
• Short controlled leash walks to tolerate increasing distance daily on level surfaces.
• Compressive ice packs 20 minutes 3–4 times daily especially following exercise.

Week 2

• Continue PROM, as directed above, to the involved knee joint only.
• At day 7–10, after recheck and suture removal and complete wound healing of the surgical incision is observed, whirlpool leg for 20 minutes in 100–104^oF degree water (if whirlpool tub is available) once daily.
• If no whirlpool tub is available, apply moist heat (via a warm, wet cloth) for 15 minutes prior to exercise at least once a day.
• Continue leash walks increasing time to 20 minutes at least once a day.
• Continue compressive ice packs following exercise.

Week 3

• Continue PROM to involved knee joint only.
• Continue whirlpool or moist heat application at least once daily prior to exercise.
• Progress leash walks to uneven surfaces such as grass lawns and concrete.
• Perform one leash walk per day for distance increasing to 30 minutes.
• Continue to follow exercise sessions with compressive ice pack for 12–15 minutes.

Week 4

• Continue PROM to the involved knee joint.
• Continue whirlpool or moist heat application at least once a day prior to exercise.
• Increase leash walks to 45 minute daily on even and uneven surfaces.
• Continue to follow exercise session with compressive ice pack for 12–15 minutes, only if swelling is present.

Week 5

• Continue PROM to the involved knee joint.
• Discontinue whirlpool and/or moist heat if normal range of motion is observed by comparing to other leg. If not equal, continue whirlpool.
• Continue leash walks activities from week four. Begin to add sit-stays, figure-eight walks, and walking the patient up and down hills.

Week 6

• Make an appointment to return to the primary clinician/orthopedic surgeon for rehabilitation reevaluation. With the surgeon’s permission, begin a slow return to normal function by increasing the intensity of the rehabilitation regime.
• Continue PROM to the knee joint.
• Continue leash walk for warm-up for 10 minutes
• Perform sit/stay, figure eights, up and down hills for 15 minutes a day.
• Initiate trotting for 5 minutes and add 5 minutes each day.
• If possible, initiate short (5 minutes) swimming sessions and add 5 minutes each subsequent day.
• Start stair climbing 8–10 flights of stairs three times a day.

Weeks 7–12

• Continue swimming exercises to the animal’s endurance and cardiopulmonary capacity.
• Begin brief running for the dog increasing time as tolerated.
• By week 12, pending recheck appointments normal physical activity is allowed.

SUMMARY

Outpatient programs are an important component of improving function in an animal that has a prolonged or lengthy recovery. Owners can be taught to perform rehabilitation regimes at home. To improve compliance and ensure that the activities are being performed appropriately, periodic rechecks should be scheduled. No rehabilitation program is ever static, and most will need adjustment to cope with an animal’s changing needs. Owners also should be taught to be creative in their use of the environment as a rehabilitation facility. Children's play areas and parks, bicycle racks (weaving), sand pits/sand boxes (footing changes, proprioceptive feedback), curbs/ditches (hill climbing), railroad ties (for cavaletti rails), and public stairs/ramps are all useful and easily accessible devices to implement in any program.