ORTHOPEDICS

ORTHOPtDIE

NR-..
Postoperative physical therapy in orthopedic patients
Greg Harasen
The concept of postoperative rehabilitative therapy is not new in human orthopedics; however, the experience seems to be quite different with small animal patients. After cranial cruciate ligament surgical repair, for example, many surgeons attempt to immobilize the joint for several days in a padded bandage and prescribe strict exercise restriction for 6 wk or longer. There is ample evidence to suggest that restricting joint movement leads to decreased range of motion, deterioration in articular cartilage, and atrophy of the periarticular musculature. The benefits of a physiotherapy program for patients following cruciate ligament surgery have recently been documented. Increased weight bearing, as demonstrated by force plate analysis, was 42% better 4 wk postoperatively in a group receiving physiotherapy versus a control group (1), while in another study, thigh circumference and stifle extension were significantly better in treated patients compared with controls (2). The goals of postoperative rehabilitation in the patient with a repaired cranial cruciate ligament are to maintain range of motion in the stifle and to minimize the thigh muscle atrophy, which begins within 2 wk of cruciate rupture and can decrease thigh circumference by up to one-third at 5 wk (3). Postoperative rehabilitation in our practice begins immediately after surgery, when an ice bag is applied to the stifle joint while the patient is recovering from anesthesia. This decreases edema and provides mild analgesia (4). The rehabilitation sessions are conducted by our veterinary technologists and begin when the sutures are removed 10 d postoperatively. The client leaves the dog at the clinic for the day, during which time 2 rehabilitation sessions are conducted. On postoperative days 10 through 14, these sessions consist of slow flexion and extension of the joint, repeated 25 times; massage of the periarticular musculature; and leash walking, increasing in duration from 5 to 10 min as the week progresses. These walks must be at a slow enough pace that the patient bears weight on the affected leg. During the first week, the sessions are followed by icing the joint. On postoperative days 15 and 16, the owner rests the dog at home. On postoperative days 17 through 21, the owner provides twice daily leash walks of 10 min duration. Days 22 and 23 are rest days. The dog returns to the clinic for postoperative days 24 through 28, when the range of motion exercises, massage, and leash walks are repeated. In addition, 25 repetitions of an exercise, where the dog is made to sit and then asked to stand again, and stair climbing, increasing
Animal Clinic of Regina, 1800 Garnet Street, Regina, Saskatchewan S4T 2Z2.
Can Vet J Volume 42, August 2001

through the week, are included. Postoperative days 29 and 30 are rest days, while days 31 through 35 include twice daily walks of increased duration at home; days 36 and 37 are rest days. The final sessions in the clinic are on postoperative days 38 through 42. They include the continuation of the exercises begun previously, plus an additional strengthening exercise. In small dogs, this may consist of walking down a hallway on their hindlegs. In large dogs, the front legs may be supported on a medicine ball or large inflatable ball. Alternatively, or in addition, controlled ball playing in a restricted area, such as an exercise run, or stair climbing with leg weights attached may be added. This program is adaptable to most practices with little or no specialized equipment or expense. Its duration corresponds to the time in which most muscle atrophy is seen in the patient following cruciate ligament surgery (3). Several veterinary schools have utilized other modalities, including neuromuscular electrical stimulation, therapeutic ultrasound, and swimming (4,5). Some of these modalities may be available to private practitioners through local physiotherapists. The intensity and rate of progression of each rehabilitation program must be tailored to the individual patient. Some patients may require analgesics or antiinflammatory medications, while some exercises may need to be modified or eliminated, based on the patient's size, behavior, or pain tolerance. Communication between the surgeon, veterinary technologist, and the owner is essential in assessing progress and modifying the program, if necessary. The same principles may be applied to many other orthopedic conditions where muscle tone and range of motion are critical factors. Subjectively, postoperative rehabilitation has been a hit in our practice! Our patients seem to be returning to normal function very quickly, our veterinary technologists are enthusiastic about their involvement in this facet of patient care, our clients are sold on the importance of rehabilitation (thank-you cards and chocolates are increased at a statistically significant level!), and the dogs truly seem to enjoy the attention!

References
1. Conzemius MG, Marsolias G, Dvorak G. The role of postoperative physical therapy in the management of cranial cruciate disease in the dog [abstract]. Proc Annu Meet Vet Orthop Soc 2000:8. 2. Millis DL, Levine D, Brumlow M, Weigel JP. A preliminary study of early physical therapy following surgery for cranial cruciate ligament rupture in dogs [abstract]. Proc Annu Meet Vet Orthop Soc 1997:39. 3. Millis DL, Levine D, Mynatt T, Weigel JP. Changes in muscle mass following transection of the cranial cruciate ligament and immediate stifle stabilization [abstract]. Proc Annu Meet Vet Orthop Soc 2000:3. 4. Clark B, McLaughlin RM. Physical rehabilitation in small-animal orthopedic patients. Vet Med 2001:234-246.

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