Rehabilitation and Conditioning for Animals is Moving!

The site content will be the same and improved/improving, however if you are subscribed to follow this blog, you will need to visit www.rehabdeb.com to subscribe again to the feed. This current page/blog address will be deleted Monday, April 13, 2015.

THANKS!!

Deborah

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Arthritis

Physical Therapy as Effective as Surgery for Torn Meniscus and Arthritis of the Knee, (Human) Study Suggests

“Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.” Mar. 21, 2013 — A New England Journal of Medicine (NEJM) study showing that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee should encourage many health care providers to reconsider their practices in the management of this common injury, according to the American Physical Therapy Association (APTA).

The study, published March 19, showed no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone.

“This study demonstrates what physical therapists have long known,” explained APTA President Paul A. Rockar Jr, PT, DPT, MS. “Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.” According to lead physical therapist for the trial and American Physical Therapy Association (APTA) member Clare Safran-Norton, PT, PhD, OCS, “our findings suggest that a course of physical therapy in this patient population may be a good first choice since there were no group differences at 6 months and 12 months in this trial. These findings should help surgeons, physicians, physical therapists, and patients in decision-making regarding their treatment options.” Researchers at 7 major universities and orthopedic surgery centers around the country studied 351 patients aged 45 years or older who had a meniscal tear and mild-to-moderate osteoarthritis of the knee. Patients were randomly assigned to groups who received either surgery and postoperative physical therapy or standardized physical therapy. Within 6-12 months, patients who had physical therapy alone showed similar improvement in functional status and pain as those who had undergone arthroscopic partial meniscectomy surgery. Patients who were given standardized physical therapy — individualized treatment and a progressive home exercise program — had the option of “crossing over” to surgery if substantial improvements were not achieved. Thirty percent of patients crossed over to surgery during the first 6 months. At 12 months these patients reported similar outcomes as those who initially had surgery. Seventy percent of patients remained with standardized physical therapy. According to an accompanying editorial in NEJM,”millions of people are being exposed to potential risks associated with a treatment [surgery] that may or may not offer specific benefit, and the costs are substantial.” Physical therapist and APTA member Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT, chief of physical therapy at Harvard University, said, “Physical therapists are experts in improving mobility and restoring motion. The individualized treatment approach is very important in the early phases of rehabilitation in order to achieve desired functional outcomes and avoid setbacks or complications.”

Story Source: The above story is reprinted from materials provided by American Physical Therapy Association. Note: Materials may be edited for content and length. For further information, please contact the source cited above.

Journal Reference:
Jeffrey N. Katz, Robert H. Brophy, Christine E. Chaisson, Leigh de Chaves, Brian J. Cole, Diane L. Dahm, Laurel A. Donnell-Fink, Ali Guermazi, Amanda K. Haas, Morgan H. Jones, Bruce A. Levy, Lisa A. Mandl, Scott D. Martin, Robert G. Marx, Anthony Miniaci, Matthew J. Matava, Joseph Palmisano, Emily K. Reinke, Brian E. Richardson, Benjamin N. Rome, Clare E. Safran-Norton, Debra J. Skoniecki, Daniel H. Solomon, Matthew V. Smith, Kurt P. Spindler, Michael J. Stuart, John Wright, Rick W. Wright, Elena Losina. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. New England Journal of Medicine, 2013; : 130318220107009 DOI:10.1056/NEJMoa1301408
Note: If no author is given, the source is cited instead.

Here is a second report of the same issue:

Medscape Medical News from the:

American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting
This coverage is not sanctioned by, nor a part of, the American Academy of Orthopaedic Surgeons.

Medscape Medical News > Conference News
Physical Therapy as Effective as Surgery for Meniscal Tear

Medscape Medical News from the: American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting Physical Therapy as Effective as Surgery for Meniscal Tear Kathleen Louden Mar 20, 2013 CHICAGO, Illinois — Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new clinical trial shows. In the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of patients improved substantially in function and pain. This finding, presented here at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting and published online simultaneously in the New England Journal of Medicine, provides “considerable reassurance regarding an initial nonoperative strategy,” the investigators report. Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms,” principal investigator Jeffrey Katz, MD, from Brigham and Women’s Hospital in Boston, Massachusetts, told Medscape Medical News. “These data suggest that there are 2 reasonable pathways for patients with knee arthritis and meniscal tear,” Dr. Katz explained. “We hope physicians will use these data to help patients understand their choices.” In an accompanying editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from the Monash University School of Public Health and Preventive Medicine in Victoria, Australia, said that “these results should change practice. Currently, millions of people are being exposed to potential risks associated with a [surgical] treatment that may or may not offer specific benefit, and the costs are substantial.” These results should change practice. The METEOR trial enrolled 351 patients from 7 medical centers in the United States. Eligible patients were older than 45 years, had osteoarthritic cartilage change documented with magnetic resonance imaging, and had at least 1 symptom of meniscal tear, such as knee clicking or giving way, that lasted at least 1 month despite drug treatment, physical therapy, or limited activity. In this intent-to-treat analysis, investigators randomly assigned 174 patients to arthroscopic partial meniscectomy plus postoperative physical therapy and 177 to physical therapy alone. The physical therapy in both regimens was a standardized 3-stage program that allowed patients to advance to the next intensity level at their own pace, Dr. Katz explained. The program involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the nonsurgery group. Investigators evaluated patients 6 and 12 months after randomization. The primary outcome was the between-group difference in change in physical function score from baseline to 6 months, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and WOMAC physical function scores were similar in the 2 groups. At 6 months, improvement in the WOMAC function score was comparable in the 2 groups. The mean between-group difference of 2.4 points was not statistically significant after analysis of covariance. There was also no significant difference between groups in pain improvement or frequency of adverse events. METEOR: Mean Improvement in Osteoarthritis Index at 6 Months Treatment Group Mean Improvement (Points) 95% Confidence Interval Surgery plus physical therapy 20.9 17.9–23.9 Physical therapy 18.5 15.6–21.5 There was 1 death in each group, and 8 patients in the nonsurgery group and 13 in the surgery group withdrew in the first 6 months of the study. Patients in the nonsurgery group were allowed to cross over to the surgical group at any time. Within 6 months, 30% of patients did so. “They were not doing very well,” Dr. Katz said. His team is still analyzing the reasons these patients did not benefit from intensive physical therapy. The 12-month results were similar to the 6-month results. In addition, by 12 months, outcomes for the crossover patients and for those in the original surgery group were similar. Meeting delegate John Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was asked by Medscape Medical News to comment on the findings, said most patients don’t choose physical therapy. “In the real world, most people want a quick fix” and choose surgery, he noted. Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises. He added that “most insurance plans have limits on the number of physical therapy sessions they allow.” This study is funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Katz, Dr. Buchbinder, and Dr. Mays have disclosed no relevant financial relationships. N Engl J Med. Published online March 19, 2013. Abstract, Editorial American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting: Abstract SE67. Presented March 19, 2013.

More Than Half of All ACL Reconstructions Could Be Avoided, Five-Year Follow-Up Study Shows

(From RehabDeb: This report is from human medical research, however animal studies are currently being conducted at Colorado State University. When I began animal rehab in 2005, I developed some protocol for people to use to benefit their animals if they did not want surgery for their pet, even though I was working at the time in a surgery specialty hospital. When I began independent practice in 2007, I took years of accumulated research, experience, and knowledge and created some simple functional exercise and drill protocol that has benefited hundreds of my canine patients whose people opted to not pursue surgery. That protocol and some other papers citing surgery text recommendations may be found elsewhere on this site-see the index to the right. In every case where my protocol has been followed (and there are no extenuating circumstances), the pets have stabilized the joint with muscle and scar tissue, and they have functioned very well. This work is all done in the home environment with no dependence on specialized equipment…no need when we are drawing from centuries of known exercise physiology and dynamic principles of body function. Blessings-)

Jan. 30, 2013 — In the summer of 2010, researchers from Lund University in Sweden reported that 60 per cent of all anterior cruciate ligament (ACL) reconstructions could be avoided in favour of rehabilitation. The results made waves around the world, and were met with concerns that the results would not hold up in the long term. Now the researchers have published a follow-up study that confirms the results from 2010 and also show that the risk of osteoarthritis and meniscal surgery is no higher for those treated with physiotherapy alone.

“We have continued with our study and for the first time are able to present a five-year follow-up on the need for and results of ACL surgery as compared with physiotherapy. The findings have been published in the British Medical Journal and are basically unchanged from 2010. This will no doubt surprise many people, as we have not seen any difference in the incidence of osteoarthritis,” says Richard Frobell, one of the researchers behind the study, who is an associate professor at Lund University and a clinician at the orthopaedic department, Helsingborg Hospital.

Richard Frobell explains that the research group’s results from 2010, which were published in the New England Journal of Medicine, caused a stir and questions were raised as to whether it was possible to say that an operation would not be needed in the long term.

Half of the patients who were randomly assigned not to undergo reconstructive surgery have had an operation in the five years since, after experiencing symptoms of instability.

“In this study, there was no increased risk of osteoarthritis or meniscal surgery if the ACL injury was treated with physiotherapy alone compared with if it was treated with surgery. Neither was there any difference in patients’ experiences of function, activity level, quality of life, pain, symptoms or general health,” says Richard Frobell.

“The new report shows that there was no difference in any outcome between those who were operated on straight away, those who were operated on later and those who did not have an operation at all. The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering rehabilitation rather than operating straight away.”

In Sweden, over 5 000 people every year suffer an anterior cruciate ligament injury — mainly young people involved in sport. There are different schools of treatment and Sweden stands out with treatment that is in line with the results of the study.

“On an international front, almost all of those with ACL injuries are operated on. In Sweden, just over half are operated on, but in southern Sweden we have been working for many years to use advanced rehabilitation training as the first method of treatment. Our research so far has confirmed that we are right in not choosing to operate on these injuries immediately. Longer-term follow-up is important, however, if we are to look more closely at the development of osteoarthritis in particular,” says Richard Frobell.

The research group, whose study is called KANON, Knee ACL NON-operative versus operative treatment, is now moving on to the next stage. This year, the third part of the study will begin, following up the patients ten years after anterior cruciate ligament injury.

Richard Frobell has also entered into a collaboration with researchers at the School of Economics and Management at Lund University to evaluate the health economics aspects of different treatment methods for ACL injury.

Journal References:

  1. R. B. Frobell, H. P. Roos, E. M. Roos, F. W. Roemer, J. Ranstam, L. S. Lohmander. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trialBMJ, 2013; 346 (jan24 1): f232 DOI:10.1136/bmj.f232
  2. Richard B. Frobell, Ewa M. Roos, Harald P. Roos, Jonas Ranstam, L. Stefan Lohmander. A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears.New England Journal of Medicine, 2010; 363 (4): 331 DOI:10.1056/NEJMoa0907797

From ScienceDaily

Fat is Pro-Inflammatory! Weight Loss Helps Relieve Pain From Arthritis (among other things!)

Copied from a recent post on the IVAPM*:

“…I would be looking for some of the non-pharmacologic strategies. You have already mentioned an important one, getting the weight off. Adipose tissue is the body’s largest endocrine organ, and it secretes, especially when in excess, a slew of nasty cytokines that essentially bathes the body – including the synovia and joints – in a soup of pro-inflammatory mediators. We have increasingly strong evidence in dogs that nothing more than weight loss will improve comfort and mobility in this species, including excellent one this year where the authors conclude “results indicate that body weight reduction causes a significant decrease in lameness from a weight loss of 6.10% onwards. Kinetic gait analysis supported the results from a body weight reduction of 8.85% onwards. These results confirm that weight loss should be presented as an important treatment modality to owners of obese dogs with OA and that noticeable improvement may be seen after modest weight loss in the region of 6.10 – 8.85% body weight”.”

Weight loss. There is no substitute. • Lago R, Gomez R, et al A new player in cartilage homeostasis: adiponectin induces nitric oxide synthase type II and pro-inflammatory cytokines in chondrocytes. Osteoarthritis Cartilage. 2008 Sep;16(9):1101-9. • Impellizeri JA, Tetrick MA, Muir P. Effect of weight reduction on clinical signs of lameness in dogs with hip osteoarthritis. JAVMA 2000 Apr 1;216(7):1089-91 • Burkholder, 2001 • Mlacnik E, Bockstahler BA, Muller M, et al. Effects of caloric restriction and a moderate or intense physiotherapy program for treatment of lameness in overweight dogs with osteoarthritis. J Am Vet Med Assoc. 2006 Dec 1;229(11):1756-60. • Marshall WG, Hazewinkel, HA, Mullen D, et al. Vet Res Commun. The effect of weight loss on lameness in obese dogs with osteoarthritis. 2010 Mar;34(3):241-53

*International Veterinary Association of Pain Management

Intestinal Bacteria Linked to Rheumatoid Arthritis

From ScienceDaily. com Nov. 5, 2013 — Researchers have linked a species of intestinal bacteria known as Prevotella copri to the onset of rheumatoid arthritis, the first demonstration in humans that the chronic inflammatory joint disease may be mediated in part by specific intestinal bacteria. The new findings by laboratory scientists and clinical researchers in rheumatology at NYU School of Medicine add to the growing evidence that the trillions of microbes in our body play an important role in regulating our health.

Using sophisticated DNA analysis to compare gut bacteria from fecal samples of patients with rheumatoid arthritis and healthy individuals, the researchers found that P. copri was more abundant in patients newly diagnosed with rheumatoid arthritis than in healthy individuals or patients with chronic, treated rheumatoid arthritis. Moreover, the overgrowth of P. copri was associated with fewer beneficial gut bacteria belonging to the genera Bacteroides.

“Studies in rodent models have clearly shown that the intestinal microbiota contribute significantly to the causation of systemic autoimmune diseases,” says Dan R. Littman, MD, PhD, the Helen L. and Martin S. Kimmel Professor of Pathology and Microbiology and a Howard Hughes Medical Institute investigator.
“Our own results in mouse studies encouraged us to take a closer look at patients with rheumatoid arthritis, and we found this remarkable and surprising association,” says Dr. Littman, whose basic science laboratory at NYU School of Medicine’s Skirball Institute of Biomolecular Medicine collaborated with clinical investigators led by Steven Abramson, MD, senior vice president and vice dean for education, faculty, and academic affairs; the Frederick H. King Professor of Internal Medicine; chair of the Department of Medicine; and professor of medicine and pathology at NYU School of Medicine.

“At this stage, however, we cannot conclude that there is a causal link between the abundance of P. copri and the onset of rheumatoid arthritis,” Dr. Littman says. “We are developing new tools that will hopefully allow us to ask if this is indeed the case.”

The new findings, reported today in the open-access journal eLife, were inspired by previous research in Dr. Littman’s laboratory, collaborating with Harvard Medical School investigators, using mice genetically predisposed to rheumatoid arthritis, which resist the disease if kept in sterile environments, but show signs of joint inflammation when exposed to otherwise benign gut bacteria known as segmented filamentous bacteria.

Rheumatoid arthritis, an autoimmune disease that attacks joint tissue and causes painful, often debilitating stiffness and swelling, affects 1.3 million Americans. It strikes twice as many women as men and its cause remains unknown although genetic and environmental factors are thought to play a role.

The human gut is home to hundreds of species of beneficial bacteria, including P. copri, which ferment undigested carbohydrates to fuel the body and keep harmful bacteria in check. The immune system, primed to attack foreign microbes, possesses the extraordinary ability to distinguish benign or beneficial bacteria from pathogenic bacteria. This ability may be compromised, however, when the gut’s microbial ecosystem is thrown off balance.

“Expansion of P. copri in the intestinal microbiota exacerbates colonic inflammation in mouse models and may offer insight into the systemic autoimmune response seen in rheumatoid arthritis,” says Randy S. Longman, MD, PhD, a post-doctoral fellow in Dr. Littman’s laboratory and a gastroenterologist at Weill-Cornell, and an author on the new study. Exactly how this expansion relates to disease remains unclear even in animal models, he says.

Why P. copri growth seems to take off in newly diagnosed patients with rheumatoid arthritis is also unclear, the researchers say. Both environmental influences, such as diet and genetic factors can shift bacterial populations within the gut, which may set off a systemic autoimmune attack. Adding to the mystery, P. copri extracted from stool samples of newly diagnosed patients appears genetically distinct from P. copri found in healthy individuals, the researchers found.

To determine if particular bacterial species correlate with rheumatoid arthritis, the researchers sequenced the so-called 16S gene on 44 fecal DNA samples from newly diagnosed patients with rheumatoid arthritis prior to immune-suppressive treatment; 26 samples from patients with chronic, treated rheumatoid arthritis; 16 samples from patients with psoriatic arthritis (characterized by red, flaky skin in conjunction with joint inflammation); and 28 samples from healthy individuals.

Seventy-five percent of stool samples from patients newly diagnosed with rheumatoid arthritis carried P. copri compared to 21.4% of samples from healthy individuals; 11.5% from chronic, treated patients; and 37.5% from patients with psoriatic arthritis.

Rheumatoid arthritis is treated with an assortment of medications, including antibiotics, anti-inflammatory drugs like steroids, and immunosuppressive therapies that tame immune reactions. Little is understood about how these medications affect gut bacteria. This latest research offers an important clue, showing that treated patients with chronic rheumatoid arthritis carry smaller populations of P. copri. “It could be that certain treatments help stabilize the balance of bacteria in the gut,” says Jose U. Scher, MD, director of the Microbiome Center for Rheumatology and Autoimmunity at NYU Langone Medical Center’s Hospital for Joint Diseases, and an author on the new study. “Or it could be that certain gut bacteria favor inflammation.”

The researchers plan to validate their results in regions beyond New York, since gut flora can vary across geographical regions, and investigate whether the gut flora can be used as a biological marker to guide treatment. “We want to know if people with certain populations of gut bacteria respond better to certain treatment than others,” says Dr. Scher. Finally, they hope to study people before they develop rheumatoid arthritis to see whether overgrowth of P. copri is a cause or result of autoimmune attacks.

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WHAT TO EXPECT FROM REHAB-

When discussing the importance of maintaining workouts and scheduled appointments to see recovery and progression in the first few months of my rehab work, I end up doing a lot of encouraging toward owners to continue the work and not put too much time between our rechecks if one that I/we have scheduled has to be postponed.

Humans are similar yet very different. People contact me with the same intent of finding solutions for their pets discomfort. How they respond to my information, to their pet, and to their perceptions of the world all differ. I have made it a point to observe and work with the nuances of their interpretations in order to address a greater number of people and broader issues.

Life happens, of course, during the intent to proceed with rehab work, and some of the events that cause more disruption to rehab visit and program review/upgrading are holidays, summer break from school, and return to school in the Fall. Pretty much everyone in the U.S.A. is affected by these events, in my estimation, regardless of vocation and family style, so long as they are a part of the general population.

As I was encouraging one young lady to not postpone our two-week recheck, I mentioned the following (her dog was rescued, is young, and had one FHO to repair the pelvic area after an unknown accident prior to her rescuing him. The other hip seems fine.):

About your text and the schedule…
> We can meet when you want, however I recommend sticking with two weeks for
> now, based on my experience.
> Part of the benefit of meeting in 2 weeks is to help encourage your staying
> on track.
> Part of the benefit of meeting is that in 2 weeks, potentially he’s had 3 or
> 4 or more workouts of at least 2 of the 3 drills.
> I will need to change the drills in 2 weeks to advance him to the next
> point. It actually ends up being somewhat of a waste of time if you do the
> same drills for 4 weeks at this point, because he will not advance. BUT, if you cannot >meet before the time you propose, by all means, continue the same plan. Also,
> often, people get tired of the same drills, and they begin to eliminate them
> and/or allow too much day-space in-between them.
>
> Interestingly, several people we’ve contacted to interview for the
> documentary have been out of touch with me for a year or more. Many of them
> left off over the holidays last year or during the summer a year and a half
> ago. They also left off doing the work consistently, even if intermittently,
> and they say the dog has gone back to how he/she was.

>Several of them, in contrast, have reported having had the same situation yet they >returned to a point in the work and began again and moved forward again and were able >to come out of the situation and improve again.
> Just a side note, sort of…
>
> So, if you are doing a drill every other day, and you really only get to
> work on two out of the three drills, then you will definitely need an
> upgrade for him in 2 weeks.
>
> This is based on my having decades of experience in sport training and
> program adaptation, so I hope I explained it basically yet well enough!

 

In reply, she wrote regarding the work they had done recently, and added:

>Its not very promising to hear that people who stopped the
>activities saw their animal go back to the way they were…is this
>because they stopped the program early? How long will we be doing
>these activities, for the rest of his life? If so, ok, but I need to
>know. I thought the idea was to get the animal to the point of being
>pretty much completely healed so they could live a relatively normal
>canine life.

>I am committed to healing him, but I also want to be realistic on what
>the outcome will look like. In our first meeting, you told me about 5
>sessions would most likely be good, we’ve already had four, and from
>what its looking like, one more session is not going to suffice. Have
>you seen animals go through this program and come out the other side
>completely healed? Were they are able to run on the leg and stand on
>the leg like a normal dog stance at the end of the program?  I’m sure
>you have, what did those cases look like and how long did it take for
>them to get to that point? And at what point do you consider an animal
>to have “graduated” from PT?

These are all great questions, and while I have covered the answers in our meetings and other communication, I have learned to not expect people to remember everything I have in my head and relay to them about their pet’s condition or situation. This is one reason I went ahead and began writing my basic protocol in the booklets I’ve published; so I may refer clients back to the booklet to refresh their memories and encourage their thought process regarding taking action for their pets recovery.

Par My brief response to her, as I didn’t have much time when writing, was thus:

Hi!

All good questions, and we’ll cover them again at the next meeting. For now,

There is no formula, and I can only guess at how many visits it will take when I send my first email and even at the first visit…I don’t usually have any idea at that point how the pet will respond and what the client will be able to get done 🙂

There are lots of Q&A on my website and some of them cover the process and progress features, so you might check it out.

You are correct on the “point” of rehab, and that is what happens a vast majority of the time. Life also happens. People don’t follow through, yet I also said they often pick back up and begin again, if they encountered an issue, and the pet improved again.
I implied that instead of finishing, they “left off” and mentioned that it was during the summer and holidays, when peeps usually have cluttered schedules.

Reality is that regardless of what happens to any body, mine or yours or your pet’s, there isn’t a “going back” to a set point, yet there is a “new normal”.

You have already seen great progress with him, and that’s from your doing the work.

In humans or any other animals, disuse leads to dysfunction, and it doesn’t matter how many thousands of dollars a person may have spent on rehab; if people don’t go back to doing their exercises when their back pain returns or they can’t lift their arms any more, then dysfunction continues, of course.

In pets, the problems returning are made obvious by the lameness and limping returning.
My programs work to build muscle to support the body, support the joints, and improve function. Pets will use a functional body part and will ignore another (or just make it come along for the ride). So long as they are comfortable with drugs (or adjunctive therapies or both), they will use the injured limb more, and I count on that for them to build muscle and better support the joints (in short). And, therefore, have less need for specific intervention. When they are comfortable on their own, they will use *all* their parts as normally as possible. Without interventions, they will not be induced to use a lagging body part, and it will continue to lag.

In the future, after we work more and he progresses more, I will give you guidelines regarding returning to certain drills and regarding utilizing other drills maybe once or twice a week over the next year just to maintain better function; each case is different.

Hope this makes more sense again, and we can talk about it at the next visit if you have further questions. Check out my Q&A on the website if you want to investigate more

Thanks!
Deborah

Now, when making this post, I added a few points of clarification, because the majority of people reading this post will not have had the history of conversation with me that this client and I have. The majority might not infer some things that have perhaps been implied between the client and myself based on our pre-existing relationship. I can’t foresee and clarify every snag, so feel free to ask questions below. I also have other posts on this site regarding what to expect overall from functional rehab, and one of them is here: http://wp.me/p1wSDA-pE

Keep calm and carry on-

Posted in Q&A, QUALITY OF LIFE | Tagged , , , , | Leave a comment

BOOTS AND SHOES

(boots and pants and boots and pants and…boots and shoes!)

Due to limited time in my schedule and my having wanted to post about boots for over five years and NOT having made a time slot for that post…

I’ll put a few bullet points on here:

I have had one brand of boots that I have recommended overwhelmingly for about 6 years, and they now have two styles, both of which are slightly difficult to put onto the paw and both of which have substantial traction to help a pet with nerve and strength issues. Numerous attempts to contact the company for their support with rehab went unanswered. I have many photos on this site with the boots pictured, so for now, check out the neurological helps pages.

I have been using the boot mentioned above for about 6 years or more. There is another brand with great customer service and also with great traction, out of Canada. Those boots are more expensive and are “high tops”. They work better for some pets than the low-top version.

The low-top version tends to slide around on the foot because one has to very firmly tighten the velcro tarsal strap. If you follow my use recommendations, below, this shouldn’t pose a long-term problem.

I have noticed some other boots on the market that will work to assist with traction on slippery floors, and I have seen, as have most of you, probably, MANY boots and shoes that are NOT helpful with traction and function.

Don’t waste your money on the slippery sole shoes and boots unless the leg to be protected is dragging all the time or unless you are using them to protect the toes and tops of paws while a dog drags around in a cart. Better yet, suspend those dragging hind legs in stirrups behind the dog in the cart 🙂

I do not like to use the balloon shoes, the paste-on-the-pads grips, or the toenail grippers. I am after ease of use and functional benefits. Those products are either too hard to put on, compromise overall function, and/or don’t tackle the deeper issues of function. Already noted that the boots are often hard to put on; the others in this paragraph are harder or less functional or both.

I use the boots on the two most affected limbs, usually the hind, inside if the floor is slippery, only on during the day, only on when the pet caretaker is home. Take them off at night. Take them off when going outside for drill walking or pee/poop. Take them off when you leave the house. Taking off the boots allows for the feet to breathe and taken off using these parameters usually thwarts sores from forming.

You don’t need boots on most carpet, but some carpet is as slippery as a tile floor, so use them on that carpet.

I prefer for my client animals to feel the ground outside, generally speaking, and nerve conduction can benefit from this action as well. If the ground is not too hot nor too cold, is not dangerous and the pet has traction, they may walk on the ground without boots. There are many exceptions to this rule of mine, but I will have to discuss them at a later date.

I think I can guarantee if you leave on the boots for extended periods, not following the least protocol I mention above, you will create sores and stinky feet. I’ve had plenty of veterinarian clients use loose interpretations of my recommendations and end up with stinky-feet-sore-and-ulcer dog toes and legs, so don’t think it couldn’t/wouldn’t happen to you and your pet 🙂 If it does happen, then you cannot use the boots at all, usually for about 2 weeks, while the sores and/or fungus/bacteria issues resolve.

Just say “no” to boot overuse.

Other boot points:

There is no need to use traction boots on a dog that does not have enough strength or nerve conduction to walk once assisted upright.

There are “easier” and “better” ways to assist a dog that is knuckling or dragging one or both hind, yet is able to advance both hind legs. Boots only encumber efforts in these cases and the pets need to build strength and nerve conduction using dynamic action first…then we will concern ourselves with working on correcting knuckling. Build strength using land and gravity. See my homework(s).

If you do create a sore by leaving on boots too long, or by other means, do NOT put topical antibiotic cream on it for the pet to lick off. I have yet to see a pet that doesn’t lick its sores doubly when topical treatments are applied. The way to stop licking is by using an e-collar. Yes, I know we all “hate” the e-collar, the cone of shame, so let’s start by considering it a party lampshade, the one your drunk cousin puts on their head just before the shirt comes off and table dancing begins…

See? Now it’s more fun to use the e-collar and get the healing over with and hopefully avoid infection. Licking will cause infection…I have yet to see more that .05% of cases where it didn’t. Yes, I’m guessing at the number. It’s taken me years to just put up this post; I’m not going to read through hundreds of case files to find out how correct that number is. Try to trust me on this one 🙂

If you are running your pet on rocks or walking on hot pavement or doing search and rescue, then buying four boots, as they are commonly sold, will suit you. Do know, though, that the front paws are almost always slightly larger than the hind paws. You may purchase boots two at a time from some sources.

The measurements for the boots that are given and the instructions about measuring are not really complementary to the actual size of the paws when the boots are in hand and fitting them ensues. That means that very often the size you thought you measured doesn’t fit. Do your best to get a standing, weight-bearing, measurement and/or find a local source for boots with good traction that you may fit and return. I’ve gotten some clinics in my area to carry them, and peeps may purchase one at a time or 100. I doubt they have 100 in stock, but, you know…

I don’t advocate using the socks that are often sold separately from the boots. They cause additional friction.

Wash the boots and make sure they dry very well before using them again. You will cause stinky funk if you don’t wash and if you don’t completely dry. If you have a dog that frequently pees on or otherwise soils the boots, then you are better off buying four at a time.

There is more to say, but I’m out of time, and this suffices for the basics!

Blessings-

Nov. 8, 2014

 

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CAVALETTI (OBSTACLE) VIDEOS

Kacey Cat Does Cavaletti Work

Kacey has neurological problems in her hind end. I have been performing laser therapy on her and working on finding exercises that will benefit her quality of life. The owner and I discovered during one visit that she would walk one direction across a particular section of bar top to get to some place her kitty brain holds special…so special that she will repeat this action many times.

I placed 5-6 remotes across the bar top, and Kacey is to make 5-6 passes over all of them, every other day, doing it all at one time.

She has improved much around the home, and we made some other exercises work for her too.

She is working on losing some of her “extra”.

 

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ELDERLY SHEEPDOG WITH NEUROLOGICAL PROBLEMS – HOMEWORK REVIEW

Here is the short write-up of my recommendations/reminders for Abby’s functional rehab and the process I believe will improve her neuro-muscular capabilities and strength.

To Abby’s Caretakers:

Some of this will be stuff I’ve mentioned several times over the course of working with Abby, however it bears review, and most of the time, when I re-evaluate a program, often we need to go back closer to a beginning point and press forward methodically in order to achieve expected gains. As always, I am available to do this work and especially if you need assistance because it is hard on your own body or even just to make sure it gets done so that Abby may recover well! 🙂

I can’t emphasize enough how beneficial the vibrational massage is, even if you do it every other day instead of every day for now. For a refresher, please watch the 10 minute video here:

http://wp.me/p1wSDA-kp

And do it as best possible without cutting corners. You will get the best outcome if you follow the video instructions, and I’d really like it done daily to better encourage healing on several levels. Pertinent questions are also covered in the video, as well as methodology and benefits. Make sure you change out the batteries as soon as they seem dull, because the best benefit from this massage is realized from the vibration, which stimulates circulation, lessens tension, and potentially improves nerve conduction. I recommend, for now, doing the massage at the end of the day, at bedtime or thereabouts.

For the next week, please walk Abby twice daily, super slowly and consistently, without stopping, for 15 minutes. I chose 15 minutes because you said she has already accomplished doing 10 min walks for a week, 3-4 times per day. Before that, she laid a foundation with 3-4 five minute walks daily for a week. There are very many reasons why I use this method, and they all contribute to the gains we are trying to achieve. Super slow walking encourages use of all limbs to the best of their ability. Abby has already been able to walk multiple times daily, super slowly, for five and ten minute sessions, having built up slowly. Using the same exercise protocol for a week allows more time for the body to adjust to the work load, and it should go well, because these are introductory workouts, to build a base.

For the week following the twice daily 15 min walks, please walk her 2×20 minutes in the same manner, and only if the 15 minute walks are completed well for a week. She should be able to complete these walks without dragging a hind limb and without sagging or falling down. That’s because we spent time building the base. Otherwise, she needs to return to 10 minute walks and do them multiple times daily to ensure success. I am not wanting complete fatigue and maxing ability at this point; I am after building successful progress, which I believe her body will adapt to and accomplish.

I really would like her to wear two supportive hard braces during these walks, and I realize you have only one. She hyper-extends both her tarsal joints, and in order to use her hind legs properly and to subsequently use the muscles better/properly, the supportive brace that prevents hyper-extension while she is doing her slow drills would be additionally beneficial. Use the one you have on her R hind, since that leg has the most deficits and is the weakest. She hyper-extends because of nerve weakness and deficits in this case, and that has been a problem since I began giving you instruction for her over a year ago.

After the week of 2×20 min slow, relatively flat walks, please add in cavalettis, obstacles, to improve her proprioception. This may be accomplished in many ways and several locations around your environment. I have photos on my Facebook rehab page that depict several home-based cavaletti designs. Please be sure to read the descriptions below the pictures, because not every type of cavaletti is for every pet 🙂

Abby needs to do the cavalettis every other day and during one of the walk workout times. You should warm her up walking for 5 minutes then do obstacle repeats for 10-15 minutes. I suggest you use about 5 items in a row, spaced about half an Abby-length apart, and between 4-6 inches high for now. If we could get the old cat to do the work, I’m pretty sure we can get Abby to do it! If she is too stubborn for you, I will be glad to take a rehab session and work with you and her on this drill.

After a week of this drill, keep doing it as prescribed, and add in hill repeats every third day as one of her twice-daily workouts. I suggest walking out the front door, around to the back yard, and then up and down the hill on the far side of the house for 10-15 minutes, very slowly. I was able to get her to do this work this past summer when I came for rehab checks.

During the hill phase, it may be more beneficial for Abby to receive laser therapy on the hill work days. This should have the effect of stimulating nerves and cellular process and often improves work ability in the older and neuro-challenged animals. In her condition, I see reason to have twice-weekly laser sessions for at least a month-I’ve had good outcomes from doing this with similar cases.

I think it would be great if you were able to just start where I suggest, as if we were beginning from scratch, and let’s see the progress that comes from scripted protocol and collaborative effort. She won’t improve from this point if she keeps doing the same walks and leads the same life she has been leading for the past many months…the body stagnates, and the same happens for humans as well. Our brains aim toward conservation while our bodies are able to do more. I believe, based on my experience that is also based on years of research, that we will see strength and muscle gains if you start here again. I suggest we review in one month after these exercises have been completed. I will then revise the protocol and change the challenges.

Thanks!

Blessings-

Deborah January, 2013

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DEGENERATIVE MYELOPATHY AND NEUROLOGICAL CONDITIONS

Question from the International Veterinary Academy of Pain Management, 2012:

“Does anyone have any recommendations regarding treatments for a 14 year old Husky with Degenerative Myelopathy? So far, the only thought I have is a cart. Also, my understanding is these animals are not in significant pain – is this true? Thanks for any info.”

From: A Veterinarian in the U.S.A.

RehabDeb Response:

Hi!
I apologize for taking so long to reply. I have a 30-yr. background in human sport science and nutrition, worked two years in a veterinary specialty hospital designing and building the rehab dept., and since 2007 have had a mobile practice wherein I serve a huge number of “mystery-ortho-neuro” cases, many of which are presumed to be D.M. (Degenerative Myelopathy) (or, as of 11/2014, may have been tested using protocol at Missouri).

The functional rehabilitation protocol I have developed over time, and which has been successful at improving function to varying, yet notable, degrees is derived predominately from my experience in sport science program design coupled with principles of neuroscience. A body at rest stays at rest and only changes with dynamic interference…
(original RehabDeb quote :))

I DO agree that while D.M. may not produce pain in and of itself, it is highly likely that an animal with any neuro condition has self-induced pain by nature of the fact that they are compensating, stressing tissues, and possibly pinching nerves, akin to when our sciatica or sub-scapular, etc…get impinged and cause us pain.

Pain management discussion aside, for my own patients I introduce a system of simple, vibration-based, massage with a less-than-ten-dollars Homedics unit (see the video elsewhere in this blog), Low-Level Laser Therapy (MUCH research exists regarding nerve conduction, regeneration, re-invigoration), and a plan of return to whatever level of function is possible via primarily-human-induced and animal-activated movement exercises, retraining brain-to-limb neural pathways and encouraging focus on movement and function. I prefer to use dry land and gravity, and I work with clients on methods to help them get this work done. Strength and endurance/conditioning drills I concoct depending on each animals status are implemented.

I begin with laser twice a week for a month and review exercise protocol that the owner is charged with doing if they are capable and which I do if the owner prefers. I use a front harness designed for riding in the car that has fleece and the best stitching I have found and only costs $30 shipped from Petsmart (no longer available-2014). This is the Travelin’ Dog harness. I turn it around, and it is “perfect” for hind end support (legs through arm holes, tail through neck hole) while relieving owner back stress, if used properly. It is much better designed for the body than the blue neoprene sling, less pressure on the abdomen than a belly sling, and less problematic than a Bottoms-Up sling. No one pays me to promote these items; I have just found that they are simply the best and cheap, and in my years of experience I deem that they work better than a lot of what is out there. I have pics around this blog of neuro dogs wearing these harnesses.

There are many more things that may be done, however getting the owner started on helping the animal around the home in a manner that hurts neither owner nor animal, and in a manner that is most productive time-wise, is one of the major components of my mobile practice. I tend to not involve owners in activities that, again, would potentially cause more harm than good or waste more time than be productive.

I also utilize a brand of boots with excellent traction, usually sometime along the way but not usually right away. Depending on function-ability I will introduce the boots when I believe they will not encumber the pet and will be more help than hindrance. The right boots always seem to encourage hind limb use when there already is function and they give stability in the home on tile and wood floors. I also often have pet owners stop using boots if they have begun using them before the pet is functionally ready.

On several elderly canine patients I have also used Epsom salts baths to great benefit.  Owners HAVE to ensure they rinse off all the salt residue after the bath, otherwise if the dog licks it, which they usually will, diarrhea will likely ensue.

These are some of the basics, and I will be glad to discuss the topic further if you’d contact me.

Blessings-

Deborah Carroll

 

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SHOULD MY DOG STILL BE LIMPING AFTER KNEE SURGERY?

This info could apply to almost any orthopedic surgery…

This is a common question, and the most common answers I give are as follows, based on what I find in my practice:

If your pet is limping your pet has over a 90% chance of being pain. People say, “I don’t think she’s in any pain; she’s wagging her tail…”, and I say, “She could be on fire and she’d be wagging her tail.” Eating, drinking, running, tail-wagging; if your pet is doing all of these things or some of them, that doesn’t mean they are not in pain. In contrast, if your pet is NOT doing these things, it could indicate pain. Lesson is: your pet can be in a lot of pain and could still be wagging their tail, eating well, and chasing perceived prey!

The most recent version of this topic may be found in my book for Kindle on Amazon. I have edited the topic for the books to be concise and easier to read than what is contained here on the website, however I have left some of the following info on this page for now because this topic receives thousands of hits on this site. Evidently it’s a big problem around the world! The link to my book using Amazon.com is:

http://www.amazon.com/Deborah-Carroll-CCRP-CSCS/e/B00EZYWLT0/ref=dp_byline_cont_book_1

and the book is not expensive 🙂

Also, the book contains, for $7.99 USD, instructions regarding how to protect your dog at home and how to get them walking well again without pushing them into a pain state. Check it out for more info than is on this site! Thanks-

Your dog is not limping solely “because he/she had surgery”; the dog is limping because he/she is painful after surgery.

ALSO, a common misconception I hear from veterinary professionals and clients alike (who probably heard it from a veterinary professional) is that a dog needs surgery because it is in pain after tearing a knee ligament, assuming the surgery will alleviate the pain. This is not true. Decades of chitty-chat with athletes with injuries, some in pain and some not and of observation of work in my own practice with pets (and injured humans) as well as study of research dispels the myth that surgery corrects knee pain; it’s not that simple.

This leg disuse is also not really an issue of having to retrain the dog to use the leg; again, they are very most likely not using the leg because it is painful, and there are usually very good helps available for your pet, both pharmaceutical and non-pharmaceutical to get them back on the right track.

You can accomplish leg use at home and you do not need a clinic or water treadmill to achieve leg use after surgery 🙂

This point is one I spend a lot of time going over with people, even on many occasions when their veterinarian hasn’t been quite convinced that there is pain. The vet not recognizing that the pet is in pain could be due to many reasons. Pretty much all I do daily is determine the level of pain in my clients based on multiple factors, including the animals response to daily activity and exercise programs I have outlined. I then determine whether more veterinary intervention is needed and also the next best course of functional rehab. I have to do this in order to see progression in rehab.

After working with athletes and other animals for over 30 years, as well as dealing with quite a bit of pain personally, I am well-versed in dealing with determining pain and working to eradicate it. Dogs usually aren’t quite acting themselves in the clinic when they see the vet, and most veterinarians I know, with whom I’ve had lengthy conversations, will admit to having been trained to look at the quality of the surgery and not necessarily add pain in as a factor.

Often your pets regular veterinarian will give up any post-surgical medication intervention to the surgeon, and when the meds that the surgeon scripted run out, the limping begins. My experience is that most surgeons only give a week of pain medications at this point. MUCH longer dosing is indicated as well as kind.

My experience is that vets with whom I often work are finding the benefit of dosing adequate medications so that the pet will use their leg in my rehab programs, and the pets do, every time we get the combo of pain relief correct (and when there’s nothing additional going on, as I cover below).

Veterinary medicine, on the whole, wasn’t teaching that animals felt pain, in so many words, until the late 1980’s. Another point is that in human medicine, we don’t have pain management down to an exact science, by far, and that is for people who are able to speak or convey in language and signs we are accustomed to understanding better.

1) The pain could be due to the dog being too active.

2) The pain could be due to the dog not having enough pain meds that they are actually taking, even if activity restrictions are being followed.

3) The pain could be due to the knee having an infection.

Those are the three most common situations I encounter after the surgery site has been checked by the veterinarian and has been deemed stable to the best of their knowledge. Follow your vet’s discharge instructions regarding restricting and controlling the activity of your pet, and I also have beneficial instructions regarding this on my homework pages on this site.

Depending on the type of surgery performed, many things can go wrong with the items used to stabilize the knee, but that situation is not the most frequent culprit I find in my practice and experience.

I cite infection as another culprit, and that can come from outside, i.e. licking the incision site, or that can come from suture or implants, etc…on some occasions.

You will often be able to narrow down the issue to infection if moderate to high amounts of at least two analgesics, pain relievers, are used and the dog is still limping until you try antibiotics. If your pet stops limping 1-3 days after the introduction of antibiotics, then it is likely that you have some form of infection. The “usual” pain medications don’t “usually” get rid of infection pain.

The fourth issue that I occasionally find is a torn meniscus. In older dogs that I’ve worked with for non-surgical help after a torn cruciate ligament, it has been beneficial for pets in my area when vets combine Tramadol, Gabapentin, and an anti-inflammatory (if they can tolerate it) to get them through the additional pain of torn meniscus and on to better weight-bearing and therefore better muscle improvement. Other drugs may be used more prevalently in other countries.

These drugs are great to help with the scientifically-proven exercise choice of gravity-based, weight-bearing drills, which is the most productive way to build muscle, bone, bone strength, and supportive tissue strength, including muscle strength. The increased thigh muscle will help support the joint and in most of my cases has served to stabilize the joint very well.

This work will often also help your pet get past the acute phase of torn meniscus. I have had many of these meniscal tear cases work out with sufficient pain relief over time, however, if you have access to surgery procedure to have the meniscus scoped out (two small slit incisions will be made), then that can be a moderate remedy, too. I say moderate remedy because scoping is less invasive than opening the whole knee for full cruciate repair surgery, if you are wanting to avoid surgery.

I have had cases that resolved and were strong after the non-surgical work for torn ligament and that have gone on to have the meniscus scoped out without fully opening the knee as would be done in the ligament repair surgery. Most cases are able to achieve good recovery without any surgery, in my experience and based on feedback from treating veterinarians.

Elsewhere on this site, under “Research”, I have posted data from human sports medicine research citing that both torn meniscus and torn ACL can do very well without surgical intervention. These good outcomes involve exercise and physical therapy. Surgery for a torn or ruptured ACL/CCL and/or torn meniscus is optional and making the decision for this surgery is not a “life or death” decision. Those papers are here if you would like to know more about the studies for non-surgical remedy :):

https://rehabilitationandconditioningforanimals.wordpress.com/2013/03/28/physical-therapy-as-effective-as-surgery-for-torn-meniscus-and-arthritis-of-the-knee-human-study-suggests/

https://rehabilitationandconditioningforanimals.wordpress.com/2013/03/09/more-than-half-of-all-acl-reconstructions-could-be-avoided/

If limping and pain are your pets issues, stop them from doing too much activity & read my recommendations on my homework page, which may be found here:

https://rehabilitationandconditioningforanimals.wordpress.com/2011/04/28/post-cruciate-aclcclrepair-homework/

If your dog does not have an anti-inflammatory and an additional analgesic, like Tramadol and/or Gabapentin, for the first few weeks after surgery, then I recommend you ask your vet to consider supplying those. Use rest, restriction, and even ice during the time your pet does not have other pain relievers. Fish oil, fish containing Omega 3’s (or other animal dietary sources), joint supplements (Like Xymogen DJD, Glycoflex III, Cosequin DS) are beneficial, as are natural anti-inflammatories, like turmeric/curcumin, ginger, rosemary, etc…I like a product called Xyflamend by New Chapter for this. (No, I don’t receive any compensation for mentioning any of these online or in verbal discussion ;))

If your dog is on moderate-to-high amounts of those analgesics and is being restricted as recommended yet remains lame after a couple of days of renewed restriction and medications, then it is highly possible that your dog has an infection. An infection can be present and will cause pain, even if there is no known swelling or seepage. Anti-inflammatories and the other pain relievers will not relieve infection pain. In my area the vets will often prescribe Cephalexin for a two week course, and the limping usually ceases within the first 24 hrs. of taking the antibiotics.

Infections can occur for many reasons, and an infection is not necessarily someone’s “fault”. I see many patients that are licking at their incision, even if ever so slightly or infrequently (according to owners), and I am telling you that even a small amount of licking can cause a raging infection. Most often, though, I see infections that aren’t seeping or causing additional signs of there being an issue. We are confirmed in our suspicions when the antibiotics have great effect and the limping/lameness/pain is relieved. My own dog incurred infection in a very clean surgery hospital, however she had a weak immune system, and also due to other circumstances was open much longer on the table as she would otherwise have been. Lots of things can cause infection.

I do recommend remaining on additional pain relievers in order to begin my exercise protocol, primarily because your pet has been dealing with a lot of pain and has not been using the leg very well, if at all. Even when the infection is dealt with, your pet will likely need additional pain relief to help them use their leg as best possible while following the restrictions and the recommended exercises.

Those are the basics.

Limping does NOT mean that the dog needs to be taken to a water treadmill to induce usage of the affected leg. Limping means that there is a problem that needs be rooted out and dealt with. See my suggestions at the beginning of this post for the most likely culprits 🙂

I have taken over the rehab of many dogs that were previously forced to walk in the water treadmill, didn’t have sufficient pain control, and often have had infection or breaks, which was easily rooted out after process of elimination. Some of these dogs have ended up having additional injury that was also discovered after appropriate pain meds were given yet expected relief was not achieved. Some of them incurred injury by being forced to work in the water treadmill, with the practitioner suspecting they were ‘just not using the leg’ as if it were psychological.

In my experience, if we deal with the root problem, which is pain, and we find the source of the pain, which can be as simple as “I just had surgery”, and we deal with it appropriately, then the walking will happen, leg use will occur. Animals aren’t sitting around plotting disuse of their leg and overthinking the issue. They also aren’t holding out so you will give them more drugs. It’s rarely, if ever, “just psychological” with limb disuse. It wasn’t psychological when they were first injured, before surgery…

I use massage with the small Homedics unit featured in my massage video:       https://rehabilitationandconditioningforanimals.wordpress.com/2011/11/27/simple-massage-video-uploaded-to-youtube/

I sometimes use ice, and sometimes laser therapy on the knees with infections or lots of effusion (joint swelling). I also recommend that my clients do not work the animals until the pain is relieved substantially. “Relieved substantially” means that they are only slightly favoring the leg. My exercise programs are designed to work in conjunction with adequate pharmaceutical pain relievers, where those are needed.

I have utilized many non-pharmaceutical methods of pain relief, however after surgery it seems that pharmaceutical pain relief (pills) gives the most benefit. Those pain relievers may be reduced over time as the muscles are built, the joint heals, and appropriate, slow, progressive, reintroduction to activity is accomplished. Please know that most post-surgical and some post-injury-non-surgical pets need to be on pain meds for 4-8 weeks, with 8-12 weeks usually being more productive. During this time, it is important to gauge their activity levels and utilize appropriate return-to-function exercise programs, only increasing activity slowly while gaining good pain control and only reducing pain control meds as more activity is able to be achieved without added discomfort (lameness, etc…). Use my homework for the exercise plan.

This means, stop going from total restriction to “return to normal activity”. Humans cannot go from a two-month layoff back to winning one of the top five marathons in the world, even if they are world-class…progressive reintroduction has to occur, regardless of what level you, as an athlete, or your pet were at prior to injury/surgery.

Oh, and, yes, there is always the possibility that your animal has destroyed the surgery in some manner. But the top three reasons for lameness & limping that I already cited are really the most prevalent causes. I have had a few clients who have simply not restricted the animal (dog, cat, horse, llama…) and have allowed far too much activity and have blown up the surgery. A typical example is a dog that is allowed to run up and down stairs and bounce all over the place. They usually blow out knee surgeries and have to have re-dos. Only speaking of knee surgeries here, four more biggies come to mind, and none of these have had to do with the owner allowing too much activity, although in two of them the surgeon tried to blame the owner and/or rehab, but infection was the ultimate culprit. Often I am not called onto a case until extra damage is done, so I am accustomed to rooting out these things, and hopefully this little bit of info is helpful to you.

Just speaking of knees, and just off the top of my head, one of those additional blowup cases was a tiny dog that had both cruciate ligaments and both patellas (kneecaps) operated on all at once. The practice of doing all that surgery at once is more common than you might think. The owner was very compliant, doing things the “right” way, and she had me come each weekday for a month to do the exercise and therapy work at least once daily, so she would “know” it was done correctly. I suspected infection right away in one knee because of the abnormal amount of swelling just a day or so after surgery. I reported to the surgeon excessive joint swelling (effusion) and other signs that accompanied this situation and that increased my belief that we had an infection compromising the repair. I could feel the pin in the problem knee working its way out. This would be a common side effect of infection. The short story is that the pin was removed many weeks later, and there was infection that would have most likely happened within several hours of surgery, given when I noticed the swelling.

Another case is mentioned elsewhere on this blog, that of the Great Pyranees that had knee surgery and ended up blowing out his opposing hip during recovery at a veterinary surgery center. By the time I saw him, I determined he definitely did not have adequate pain meds on board, for either the knee alone and much less for the addition of the FHO hip surgery as well. It is my guess that he was far, far too painful during recovery after the knee surgery and could not support himself well on the operated, atrophied leg. He had a series of very great complications, and the biggest battle, after we saved his life from gastro & infection-related near-death, was getting adequate pain relief for this very heavy and slightly lazy dog. Eventually so much time went by that his dysfunction (physical and psychological, in this case) complicated his recovery.

A third incident involved a dog that had a bone-modifying knee stabilization surgery (CBLO) and was damaged while in recovery at the specialty hospital where he had surgery, best we are able to determine from pre-and-post surgery xrays. The client was familiar with my work, and she called me to evaluate her dog when he was still exceedingly lame a little over a week out of surgery. He had been to work in a water treadmill already at a facility. When I first saw him, he was lame beyond what I would expect, based on my experience and based on the lack of swelling of any sort, however he also did not have enough pain control on board, based on established protocol and based on his lameness. He was set to go for another water treadmill session within the next week, and I drove home to the owner that she really, really needed to alleviate his pain and have the surgeon take another look at him. He was only being given an nsaid (non-steroidal anti-inflammatory)(Rimadyl, Vetprofen, Metacam, etc…). I pushed her to get Tramadol from either her regular vet or the surgeon. Weekend coming up, regular vet deferred to the surgeon, surgeon not responsive, associate vet finally gave script over the weekend. Yay! The pet went to his second, pre-scheduled, water treadmill session, and I saw him the following day. I told the owner to make an appointment with the surgeon and not do any more activity until they got an x-ray. The dog was far too lame for having the nsaid plus the new moderate doses of Tramadol on board. He had been on antibiotics for the surgery, if I recall correctly, so we didn’t think it was infection, plus, there wasn’t a large amount of effusion (knee joint swelling). It turned out that she got the x-ray and his fibula was broken and the screws and plates were pulled out from where the bone was cut. Eventually we were able to go back and compare post-op rx-rays and find that it seems the fibula was broken in recovery just after the surgery or ? We don’t know. What mattered was moving on and doing the best for the pup. It has been a little over a year and he is doing great! He had some re-dos and a long period of multiple pain reliever drugs being juggled. He was not on any meds at about a year out from the incidents. He did, however, need to take the pain relief drugs for many months. The point to these short stories is to give some brief recounting of post-surgical abnormal knee incidents so you may be informed and move forward with your pet. I am not going into full case studies here.

The fourth incident that comes to mind actually involves two small dogs with the same issue: both had suture repair of torn CCL/ACL and one was encouraged to run up and down the flight of stairs in the home soon after surgery because the owner thought it would help strengthen the dog. The pet had adequate pain meds, so the owner thought he was healed and encouraged this running. He blew out the surgery. The owner did receive instruction from the vet telling him of restrictions, etc…but restriction is not what happened, and often people are confused even if they receive adequate instructions. The restrictions are very important. The other case was also a small dog, and the owners felt sorry for her and allowed bouncing and running all over the house. She blew out two surgeries in one knee and about a year later had the same surgery on the other knee, this time with many restrictions heeded. 🙂

The first incident I told several paragraphs ago could happen to any pet, however in the many cases I’ve treated, even it is unique. The second and third are ones I see in large dogs once in a while because of complications in recovery. I’m convinced they should be recovered in the hospitals like a horse would be, in a supported sling, instead of on the floor! So, cover your bases regarding the first three reasons your dog may be limping/lame and pursue vet care based on this information.

In my area, we also have many vets that practice acupuncture and a few that do chiropractic work, so I often direct my patients to their services for the additional pain relief benefits. I know, based on how many I know of in this area that have had complications, as well as from feedback I receive from around the world, that very many of you out there have dealt with complications. Realize, though, that most issues I see before *major* complications set in are resolved by following the three guidelines at the beginning of this blog.

My own dog, Grace, had OCD (osteochondritis dissecans) in her knee(s), and before I knew more, before I got into this vocation and began putting together what I already knew from sports medicine and exercise physiology, I chose a TPLO surgery for her when she tore her first knee ligament, in the genetically malformed knee. She had about a half softball calcification at the medial aspect of the operated stifle, and a previous surgery performed to hopefully stimulate correct bone growth was unsuccessful. The TPLO cut was a non-union, meaning the bone did not grow back together after surgery. It wouldn’t have grown back, presumably, given that the bone was damaged inherently as it was, but I guess it was thought at the time to be worth a try, or that being able to move the position of the head of the tibia and have the plate in place to stabilize it was a positive step, given the other issues. I wouldn’t do it for that same dog and that same set of circumstances again today, but I know a lot more than I did those many years ago. That genetically bad knee turned out to be her better one over time, as the other knee eventually became destroyed. She tore the second CCL in about a years time, and I chose a TPLO for that knee as well. She seemed to have a compromised immune system, so we had a habit of starting her on Cephalexin some days prior to any surgery. Due to some circumstances, she ended up with a resistant pseudomonas infection seemingly immediately after surgery, complete with need for drains for the green slime over several weeks while I administered powerful, injectable antibiotics for weeks. It was clear within about two years that the infection had really eaten up her knee. She had two more scopes (arthroscopic surgeries) to clean out debris. She eventually became bone-on-bone in both knees, the infection knee being the worst, and she eventually tore all three ligaments (diagnosed via signs, x-rays, palpation, and common sense, collaborated by vets) in the worst, infection knee, and signs of more ligament tears existed in the original “bad” one. She was amazing nonetheless, and a pioneer for me regarding non-surgical helps for knee damage, since nothing more could be done given her dynamics and dramatic damage. With her immune system and other medical history, she probably would not have been a candidate for the knee replacement studies that were going on at the time.

And Grace’s situation is likely not the complication your dog/animal will encounter. I welcome stories of problem and resolution. I am only relaying these few stories to allow for the fact that other things do happen outside of the first three most common incidents I outlined, however the reason for lameness/limping after surgery is usually one (hopefully one) of the more simple-to-resolve first three situations I cited. ! 🙂

The most updated version of this post is now available from Amazon.com, under

Rehabilitation and Conditioning for Animals

Guidelines for Home Rehabilitation of Your Dog

After Surgery for Torn Knee Ligament,

First Four Weeks, Basic Edition

Blessings-

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Homework After Surgery or Instead of Surgery for Luxating Patellas (Loose Kneecaps)

First and foremost:  pay attention to the discharge instructions your veterinarian has given you if your pet just had surgery or has received instruction regarding an injury.  Please pay special attention to the part about no running, jumping, or playing. 

If your veterinarian did not say so, please note there should not be any flying over couches, galloping stairs, jumping into or out of cars and trucks,  jumping onto couches or your bed, jumping off of couches or beds, twisting very fast in tight circles, sliding on ice, or freedom in and out of doggie doors.  No owner jumping out from behind things to scare the dog into running crazy funny around the house like you sometimes like to do.   No running really means no running to the door when the doorbell rings, no running away from Halloween costumes, no running from one end of the house to the kitchen every time the fridge or a plastic bag is opened, no running to you when you yell to ask the dog if it wants to go outside, and no running inside after the ball, which is very similar to no running outside after the ball.  No, no swimming until at least 8 weeks after surgery and no lameness is present.

For further instructions, please see the additional links on this page:

http://wp.me/P1wSDA-bt

and please see my related book (on Amazon.com. If this link doesn’t work for you, please search the title, because I’ve made it available in all the countries Amazon has available…it just may be a different link for you than the one I posted here) The first four weeks of information are the same for non-surgical and surgical treatment of luxating patellas as they are for my rehab homework for torn knee ligament. Soon I will have a specific title available that deals with more specifics of luxating patellas:

http://www.amazon.com/Deborah-Carroll-CCRP-CSCS/e/B00EZYWLT0/ref=dp_byline_cont_book_1

Keep calm, carry on-

Deborah

Many cases of luxating patellas do not actually require surgery for correction; your veterinarian and I are able to work together in most cases to devise a plan that immediately reduces pain using medical pain control and gradually reduces pain while increasing thigh muscle & strength with rehabilitation protocol. There are many adjunctive therapies that are also helpful at this time, and they are discussed further in the book noted above. Also, please follow this link http://wp.me/P1wSDA-bt for some info on massage.

In some cases the patella ceases to luxate (flip off groove) when greater thigh muscle is created through strengthening exercises.  In some cases the increased exercise and specific exercise protocol for individual animals does not completely eliminate luxation, however in those rehab cases, luxation is often reduced and pain is either eliminated or greatly reduced.  These exercises are designed on a case-by-case basis and may include general walking, hill walking, sand walking, sand pile climbing, stairs, and a variety of other exercise physiology-based activities.

For animals with grades 1 and 2 luxation, rehabilitation protocol has worked successfully to reduce pain and/or luxation as well.  Grade 3 luxations are often similarly aided, however depending on the size and lifestyle of the animal or the severity of lameness, your vet may yet recommend surgery.  Grade 4 luxations almost always require surgery to hopefully improve quality of life, especially as your pet ages, and post-op rehab protocol should be advised (a notation of which follows this outline).

Rehabilitation should continue for at least six to eight weeks. Often owners relax around week 4, especially if things seem to be going very well.  If a rehab consult is not possible for an owner at week 5, then restrictions and exercises as per week 4 should be continued until an evaluation is made and new exercises are given or for the duration of the post-op restriction period suggested by your veterinarian.

copyright 2007, Deborah Carroll

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How to Use The Homework Guides for Rehab After Dog Knee Injury or Surgery

(taken from the booklet, found here: http://www.amazon.com/Deborah-Carroll-CCRP-CSCS/e/B00EZYWLT0/ref=dp_byline_cont_book_1)

Read the Preface.

Read the Prologue.

Read the whole booklet before beginning the work.

Thank you! Now continue to read this chapter. The above three bullet point sentences were for people who really want bullet points. Both the Preface and the Prologue contain beneficial information, and I think the following contents will answer several questions you might not even know you have!

This homework covers guidelines that may be used after any invasive procedure performed for surgical repair of your pet’s knee after a torn ligament, whether any of the bones were cut or not. Right now it does not matter so much that you know exactly which surgery was performed; the restrictions and care are equally beneficial.

These guidelines are also very beneficial for recovery after surgery for torn meniscus and after surgical intervention for osteochondritis dissecans (OCD) (yes, really, but different from psych OCD) of the stifle (knee) joint. Whichever method of surgery was used, this homework is an excellent place to continue the healing journey!

As I stated earlier, written programs like this were not readily available, if at all, when I first began working officially in small animal veterinary medicine rehab in 2004. I knew from working with athletes and others, as well as from reading related research for several decades, that very slowly progressing, return-to-function programs were needed for our pets, as well.

In light of what I knew, I began using simple post-surgical protocol I developed. The larger discussion, continually, is among varieties of veterinarians who have come to believe in a particular method or methods of surgery to be used to stabilize the knee after ruptured cranial cruciate ligament. Regardless of method used, this intro protocol should be very beneficial toward accustoming the joint to greater amounts of use again, toward improving bone healing, and toward improving bone and muscle strength.

I don’t have the money to fund a large study or the time to ask for it at this point or in recent years. I do, however, have the validation of many veterinarians who have seen the progress of the pets whose caretakers have fastidiously followed my instruction for at least 8 weeks.

Often people see such notable improvement after only 4 weeks that they don’t understand the need to continue to follow through with progressive rehab. In well-established human rehabilitation protocol for ACL surgery, patients are progressed through criteria-based functional activities and evaluations for discharge from rehab are targeted between 4 and 6 months after surgery.*

Is this happening with your pet?

My preference is that people follow at least 12 weeks of rehab protocol for their pets in almost every case. The feedback from situations of which I am aware where this has occurred has been entirely positive.  This homework is an excellent place to continue the healing journey, so take a deep breath and move forward confidently!

Also, as noted, my practice and protocol are based on using the home or a standard vet clinic environment to accomplish functional rehabilitation. I prefer land-based exercise because I find it very practical for most pets and their caretakers after this surgery. You may put your internet researching skills to good use by looking for research data which encourages the use of weight-bearing exercise, where possible, to bring about greatest changes toward healing, including bone strengthening and the strengthening of soft tissue, as well as muscle hypertrophy. The latter is often the reason animals are referred to me; people want to see the muscle rebuilt where it has diminished over time due to injury and subsequent lameness (muscle atrophy).

Some people will want to utilize a clinic and a water treadmill in addition to the instructions in this booklet, possibly because the clinic option is available and their veterinarian has recommended it. Most people do not have the option of a rehabilitation facility for their pet, and that’s okay, because it’s not necessary to have that in order for your pet to recover…so don’t fret!

Regardless, I find that people are really in need of instructions that outline steps they may take to assist the healing and improved return to function of their pet in the home environment. Caretakers usually just don’t know what to do that is proactive and practical at home after pet surgery (or injury!).

I also emphasize over and over that pain control is important to my rehab protocol. If you are not going to use enough pain control to help your pet bear weight on the injured leg, then you should consider using the water treadmill..

It is extremely important for pet caretakers to learn how to control and care for their companions at home after this surgery whether or not they also entrust this aftercare to a clinic for a few hours a week as well. Do collaborate with your vet clinic, yet also learn how to do your part, hopefully aided by the ideas in this booklet.

*You may find out more about the topic of clinic-based human rehabilitation from books like Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician, Hospital for Special Surgery, Department of Rehabilitation, Copyright 2006, Elsevier, Inc.

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