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PHYSICAL REHABILITATION OF STIFLE AND ELBOW JOINTS
Denis J. Marcellin-Little DEDV, Diplomate ACVS, Diplomate ECVS College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
This presentation will focus on the rehabilitation of the most common clinical problems affecting the stifle and elbow joints of dogs: cranial cruciate ligament injuries, fractures of the humeral condyle, and elbow dysplasia.
REHABILITATION AFTER CRANIAL CRUCIATE LIGAMENT STABILIZATION
Many research projects have documented the benefits of physical therapy for people undergoing surgery after anterior cruciate ligament injuries. Similarly, several clinical studies have documented the benefits of postoperative physical rehabilitation programs on the recovery of dogs after surgical exploration and stabilization of CCL-deficient stifle joints. From a clinical standpoint, the design of a rehabilitation program after CCL surgery is challenging because many factors influence limb use and return to function after surgery. Well-designed rehabilitation plans consider all these factors.
FACTORS INFLUENCING THE REHABILITATION PLAN
Patient Profile: The patient profile is a key factor in designing a rehabilitation plan. A young dog may be less socialized, less patient, and more enthusiastic than an adult dog. The duration of each intervention is generally decreased in young dogs and interventions that represent outlets for their exuberant energy may be preferred. Also, the healing response and physiological changes secondary to their pathology and surgery is exaggerated in young dogs compared to older dogs. The rehabilitation program in puppies is therefore generally more aggressive and should be implemented without delay, immediately after surgery. Older dogs may have less muscle mass and overall fitness than middle-aged dogs and therefore decreased mobility. The rehabilitation program of older patients may need to focus on that potential lack of fitness and muscle weakness. Patient size is an important factor during rehabilitation: dogs of large breeds may prefer interventions that involve more active motion (exercise-based) but dogs of small breeds may prefer interventions that involve less active motion (passive range of motion, superficial heat, stretching). The body condition of patient greatly influences their rehabilitation program. Overweight dogs, for example, may have decreased mobility and will function better during aquatic exercises than land-based exercises. Exercises that may lead to an increase in body temperature should be avoided in overweight dogs. Joint pathology: The rehabilitation plan is influenced by the conformation and specific pathology of the patient. The chronicity of the CCL injury also influences the degree of disease and the rehabilitation plan after surgical treatment. When CCL injuries are chronic, synovitis and thigh muscle atrophy may be more severe. The overall limb alignment is taken into account. For example if a patient has genu valgum (cowhocked appearance) or varum (bow-legged appearance) specific exercises that may increase the stress placed on the medial or lateral collateral ligaments should be avoided. The amount of osteoarthritis (OA) present in the stifle joint influences the rehabilitation plan. A dog with moderate or severe OA may benefit from a slower, more progressive rehabilitation plan compared to a dog without OA. The amount of preoperative periarticular fibrosis will likely influence limb function in the postoperative period because of potential limitation in joint extension. A dog with such fibrosis will likely need repeated superficial (hot pack) or deep heating (therapeutic ultrasound) of the stifle joint prior to stretching of the caudal aspect of the joint capsule. Surgical method: The most common surgical method used for the management of CCL injuries is an open stifle joint arthrotomy and extracapsular stabilization. These methods lead to moderate tissue trauma with relatively long skin, fascial, and articular incisions. Tissue trauma is decreased when the arthrotomy is distal to the lateral or medial parapatellar fibrocartilage and the patella is not luxated during surgery, or when arthroscopy is used. In some instances, CCL injuries are treated with a tibial plateau leveling osteotomy (TPLO). TPLO is more invasive than extracapsular stabilization because in addition to the arthrotomy (and a potential partial medial meniscectomy), a medial approach to the proximal part of the tibial shaft and a corrective osteotomy are performed.
Weight bearing: Painful sensations originate from the CCL-deficient stifle joint. These sensations result from synovitis, from the pivot shift (cranial thrust) present during weight-bearing activities, or from the presence of a meniscal tear or fold. The primary rehabilitation goal will be to restore weight bearing of the affected limb. Increasing weight-bearing activity is generally achieved in the short term through a decrease in joint inflammation (rest, ice, passive range of motion) and in the longer term through a restoration of the muscle mass of the affected limb (therapeutic exercises). In order to decrease the amount of weight placed on CCLdeficient joints, dogs will shift weight away from affected joints. With unilateral CCL injuries, dogs shift weight towards their opposite pelvic limbs. With bilateral injuries, dogs will shift weight forward (Figure 1). The severity of the weight shift appears to increase with time. Posture (stifle joint extension, gait): The extension or flexion present in CCL-deficient joints may be decreased. These changes in joint motion may have profound consequences on the posture and limb function. Extension is particularly important to stifle joint function because a loss of extension will limit dogs' ability to stand, walk, trot, and gallop normally. The same rules apply to people with anterior cruciate ligament tears. Normal dogs have 160 to 164° of maximal extension in their stifle joint. When standing, they may hold their stifle joints at 130 to 140°, and when walking and trotting they may place their stifle joint at up to 155 to 160°. Dogs with CCL-deficient stifle joints may lack extension. The cause of that lack of extension is not known, but may result from the presence of an abnormally steep tibial plateau slope, from thickening or fibrosis of the joint capsule, or from other causes. The lack of extension will interfere with stance and stride. Regaining extension may sometimes require a corrective procedure (TPLO or other procedure). Extension may also be increased through superficial (heat pack) or deep (therapeutic ultrasound) heating and stretching in the short term and through therapeutic exercises (Cavaletti rail, underwater treadmill, walking uphill) in the mid-term. Stifle joint flexion may also be limited in CCL-deficient stifle joints, especially after a TPLO procedure. While limited flexion has little impact on walking and trotting, it negatively impacts sitting, squatting, and other activities. Like extension, flexion may be regained though heat, stretching, and therapeutic exercises. Beyond the gait anomalies that result directly from abnormal joint flexion and extension, several gait anomalies are often present in dogs in the weeks that follow surgical treatment of CCL injuries. These anomalies include external rotation of the limb (particularly after extracapsular stabilization), limb abduction, and reluctance to sit straight. These anomalies are treated using therapeutic exercises, including sit-to-stand exercises, step and stair climbing, underwater treadmill exercises. Muscle mass: Approximately one third of the mass of all pelvic limb muscles is lost within a few months after injury or within a few weeks after surgery. The recovery of that muscle mass requires weight-bearing activities (land-based and aquatic therapeutic exercises).
The rehabilitation interventions used in the recovery after CCL include cold therapy, passive range of motion, massage, weight-shifting exercises, superficial and deep heat therapy, stretching, and therapeutic exercises.
Cold therapy: Cold is used in the immediate postoperative period to decrease local inflammation and pain. A cold pack is placed on the medial, cranial, and lateral aspects of the stifle joint or is wrapped around the operated limb. In people, cold packs have been shown to decrease the temperature of arthritic stifle joints for more than 3 hours. Heat therapy may be used to relieve muscle spasm and to enhance the benefits of stretching. Heat may be superficially delivered using hot packs. Deep heating, below a depth of 3 cm (1 1/4") is achieved using therapeutic ultrasound.
Massage: Massage may be used in the early postoperative period to help eliminate the edema present around the stifle joint and the crus. Gentle strokes are generally used in a distal to proximal direction. Ice massage may be considered. Passive range of motion, stretching, and Grade I-II joint mobilization may be used in the early postoperative period to relieve pain, to improve joint lubrication, and to address limitations in joint motion.
Therapeutic exercises: These exercises are used to help eliminate pathologic weight shifts and other compensatory postural positions (abduction, external rotation) and to stretch joints, and to rebuild muscle mass. Therapeutic exercises may include leash walk, Cavaletti rails, uphill walking, stair climbing, sit-to-stand exercises, and aquatic therapy in an underwater treadmill or swim tank. Weight-shifting exercises may be used to decrease pathological weight shifts and to enhance proprioception of the affected limb. These exercises include standing on soft surfaces, balance boards, or exercise balls.
SMALL ANIMAL SUMMARY - The postoperative rehabilitation after stabilization of CCL-deficient stifle joints is complex and is aimed at decreasing local inflammation, restoring normal joint motion, eliminating weight shifts and other compensatory postures, and rebuilding muscle mass. This is achieved in the early postoperative period by using cold therapy, passive range of motion, stretching, and weight shifting exercises. Later, therapeutic exercises are used to continue restoring proper posture and stride length and to rebuild muscle mass
REHABILITATION AFTER STABILIZATION OF A DISTAL HUMERAL FRACTURE
Approximately 40% of all humeral fractures involve the humeral condyle. The majority of these fractures (55% in our hospital) involve of the lateral portion of the condyle (lateral condylar fracture), 30% involve the medial and lateral aspects of the condyle, and 15% involve the medial aspect of the condyle. These fractures are most often stabilized using internal fixation with screws, Kirschner wires, and, potentially, with bone plates placed on the caudo-medial and caudo-lateral aspect of the humeral condyle. Many humeral condylar fractures are Salter 4 fractures in skeletally immature dogs.
The postoperative rehabilitation of distal humeral fractures is very important because dogs tend to loose extension of the elbow joint after these injuries and their repair because of a potential joint subluxation resulting from suboptimal reduction of fracture fragments, because of swelling of the capsule and peri-articular tissues, or because of their reluctance to bear weight in the post-operative period. A loss of extension of the elbow joint may threaten limb use because extension is critical to limb use (Figure 2). Extension is regained in the immediate postoperative period through passive range of motion exercises (Figure 3). Later on, active assisted range of motion exercises may be performed using a Physioroll and active range of motion exercises may be performed through low impact therapeutic exercise, including walking in an underwater treadmill.
REHABILITATION OF DOGS WITH ELBOW DYSPLASIA
Elbow dysplasia is the more common cause of osteoarthritis in the forelimbs of dogs and may lead to a debilitating forelimb lameness and chronic pain in affected dogs. No cure is available to treat the osteoarthritis (OA) that result from elbow dysplasia. The problem may be managed conservatively with weight loss and maintenance, medical therapy using oral non-steroidal anti-inflammatory drugs and injectable polysulfated glycosaminoglycans, nutritional supplementation using chondroitin, glucosamine, and poly-unsaturated fatty acids. Physical therapy has a role in improving joint function and decreasing pain in human patients with OA and it is logical to extrapolate these benefits to dogs with elbow OA. The physical therapy of dogs with elbow dysplasia should rely on low-impact concentric and eccentric therapeutic exercises performed at low or high intensity. These exercises may include leash walks on shockabsorbing surfaces with varied slopes, underwater treadmills, and swim tanks (or other swimming area). Other options may be used to improve range of motion and comfort of elbow joints in dogs with elbow dysplasia, including stretching, heat, and cold. Therapeutic massage and acupuncture appear to offer short-term pain relief in humans with OA and could be of benefit in dogs with elbow dysplasia. Extra-corporeal shockwave therapy is being investigated as a potential source of pain relief in dogs with elbow dysplasia.
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