Approaches to the physical rehabilitation of dogs and cats with chronic neurologic and musculoskeletal disorders (Proceedings) - Veterinary Healthcare
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Approaches to the physical rehabilitation of dogs and cats with chronic neurologic and musculoskeletal disorders (Proceedings)


CVC IN BALTIMORE PROCEEDINGS


Rehabilitaiton of Tendon and Ligament Injuries

Complete rupture of a tendon or ligament, depending on the location, usually requires surgical intervention and do not commonly present as chronic injuries. Sprains and strains of tendons, ligaments and muscles can present as chronic lamenesses or recurrent episodes of lameness in small animals. With these injuries, permanent laxity or weakness due to inferior healing with fibrotic scar tissue can occur. In addition, muscle injuries chronically develop a fibrotic myopathy in which decreased extension of the muscle develops and a resultant short-strided gait.

Chronic tendon and ligament injuries can be treated with physical therapy but the progress of the treatment must be slow, often requiring months of progressive increase in exercises and treatments before maximal benefits can be seen. Many of these injuries can also recur if the animal does not participate in a maintenance program of rehabilitation so having a dedicated owner is a must. These chronic injuries can be addressed in three ways: 1) strengthening of the remaining normal fibers of the injured tendon, ligament, muscle, 2) strengthening of the muscles of the affected limb to provide greater support and less strain on the remaining normal fibers of the injured tendon, ligament or muscle, and 3) development of general proprioception. General proprioception allows the animal's brain and spinal cord to determine the position of the body and limbs in space and in relation to each other and provides feedback to these systems for coordinated movement and prevention of injury to supporting structures of the limb. Enhancing the body's ability to determine where it is spatially allows the brain and spinal cord to use its musculoskeletal system most effectively when walking or running. Because the brain and spinal cord learn to more effectively predict movements of the limbs in space, injury can be prevented and the safest, yet most effective, use of tendons, ligaments, and muscles occurs.3

Treatment of chronic tendon and ligament injuries begins with very slow passive range of motion exercises, first flexing the proximal and distal joints to the affected structure then extending these joints. Each flexion and extension to the point of mild discomfort should take 2 to 5 minutes. While performing these PROM, a therapeutic ultrasound or laser unit may be employed by individuals trained to use these units. The therapist may only get 2 to 3 repetitions of motion in the first week or so but the best results occur by performing these slow PROM exercises every day. It may take several months to a year to regain adequate strength and flexion depending on the severity and chronicity of the injury.1 As range of motion increases, strengthening of the muscles of the affected limb can begin. Strengthening through swimming, underwater treadmill work, or elastic bands placed across both hind limbs or both forelimbs will increase muscle mass to support and protect the injured tendon, ligament or muscle. Again, muscle strengthening should proceed very slowly, often with work only 5 minutes long per day, then slowing increasing the time, in order to prevent further injury. Finally, development of general proprioception is performed (but can begin as soon as the first week rehabilitation is instituted), by placing the patient on a balance ball (if they cannot stand on their own) or a balance board and gently rocking the animal. In addition, cavalettis can be used, first with the bars on the ground, then raising them as the patient's abilities increase, to increase range of motion and muscle strength while increasing general proprioception. Its important to remember to work slowly but progressively and not to miss many sessions or lack of recovery (and even re-injury) may occur.

An example of a tendon injury in the dog is the biceps brachii tendon. This injury is often so chronic that calcification of the tendon with repeated injury occurs and can be seen on radiographs. Early rehabilitation before most of the tendon has torn can prevent further rupture and the need for surgery. Development of the brachialis muscle to protect the tendon can prevent reinjury. Passive range of motion exercises can strengthen the biceps tendon itself and should be performed for the rest of the dog's working life. Strengthen the brachialis muscle is performed by active range of motion exercises such as walking over cavalettis (the higher the bar the more work the brachialis muscle does), swimming, underwater treadmill work, and down to sit exercises. In cases with severely atrophied brachialis muscle, electrical stimulation (e-stim) of the muscle may need to be employed.

An example of severe muscle injury is quadriceps contracture or tie down. The muscle has fibrosed to the femur and cannot flex or extend the stifle joint. Animals with this chronic condition are best hospitalized for the first two weeks of physical therapy so that they may be anesthetized three times a week and PROM exercises performed along with deep myofascial palpation. After the first two weeks when some range of motion has returned the owner may perform the exercises at home or bring the animal in to the hospital 3 times a week for treatment. Function can be returned to the limb with this method but may require 3 months or more of treatment.4


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Source: CVC IN BALTIMORE PROCEEDINGS,
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