Publishing Author : Jay Gray
Date Published : 29/10/18
The Benefits of Physiotherapy
Physiotherapy is useful in the treatment of injuries and issues in animals across the board, but it is often limited by any disease or illness that may directly interfere with its work. When working with dogs, it I also important to consider the behaviour of the dog, and on top of that, the level of understanding and ability from the owner. A nervous owner can unsettle the dog causing tension and stress which can have an adverse effect on any examination and subsequent treatment within that session. The final objective is always for the animal and owner to be part of any treatment so understanding can continue in the home and stress is minimised as much as possible.
The overall objectives of any rehabilitation programme are to reduce pain, restore movement, increase muscle strength or increase function. This is taken on a case by case basis where some cases can be all of the above and others can be a single target result. After taking these broad objectives into consideration an accurate rehabilitation programme can be created to suit the individual situation. To successfully complete the rehabilitation programme, all involved must also understand the healing process. The healing process can help maximise the strength of the healing tissues following injuries and prevent further injuries or issues arising in this time. Here lies the importance of the appropriate physiotherapeutic interventions at the appropriate times.
Examination of animals helps to identify both the injury itself and any compensations that may have occurred as a result of said injury. The physiotherapist will assess the animal’s conformation and posture at this time with this being one of the most important cornerstones for good movement. Poor confirmation (essentially posture in the human world) will tighten and shorten muscles which in turn, can actually pull bones out of alignment in severe cases. Although Holistic rehabilitation has been misconstrued in recent years, it is important to remember that it is merely the academic spelling of the word wholistic. Holistic healing is the understanding that the animal’s individual joint or muscle is just part of a greater whole. For example, issues in the lower leg, can occur from tightness or misalignment in the back, causing issues further down the chain.
Within physiotherapy there are multiple contradictions among unique professionals, so it is imperative for one to do their own research and understand the grand scale at a more fundamental level, so they can make their own judgement on which side of the contradicting argument they sit.
The Stages of Healing
When the body sustains any kind of injury, there are two mechanisms that can heal the wound: repair and regeneration. Following an injury, the body goes through a consistent, organised process of healing involving a series of events. It is the general consensus that the healing process has four stages, although some writings may list five, having the injury itself as one of the five events. Even though they are often listed as four separate stages, they overlap heavily and should be thought of as a breakdown of one continuous stage, rather than segregated points in time. The progression through the stages depends on the chemical and cellular processes that occur and the tissue’s ability to respond to specific stresses placed upon it.
Within this paper, the primary objective of the discussion of healing is based upon the time post injury but the same process can also be initiated by several other events such as repetitive microtrauma, mechanical irritation, excessive heating, infection or autoimmune deficiencies.
Inflammation is the body’s natural response to an injury and its occurrence is imperative to begin the complex process of healing. In the inflammatory stage, the body reacts to the injury by stimulating the clearance of the area of any debris, infection or dead cells in preparation for the repair. During this phase, the cells that clear the damaged area (which also form scar tissue) are brought to the area in the tissue fluid. This response begins within an hour of the injury but will escalate to full effect 24-48 hours after the injury. This time depends on the vascularity of the tissue. More vascular tissues will reach their peak more quickly.
The severity of the trauma is a direct correlation to the amount of inflammation one would observe. A major injury will pass through acute, subacute and chronic phases of inflammation where a minor injury may just experience acute inflammatory. The inflammatory stage has vascular and cellular events that occur simultaneously and are extremely closely interlinked.
When a tissue is injured, there are four cardinal signs to observe. Pain, swelling, redness and heat. Initially, the tissue haemorrhages as blood vessel walls are damaged and transient vasoconstriction initiated by the release of noradrenaline is followed by vasodilation. Blood loss stimulates platelet activity which will initiate coagulation by releasing phospholipids and thus the formation of the clot, which we will often see as a scab above the surface of the skin. At this time, the lymphatic system is also plugged to limit the amount of tissue fluid leaking into the damaged area.
Pain in the inflammatory stage can be caused by both mechanical and chemical influences. Mechanical pain is that which arises from the actual tissue damage, neurological reflex inhibition and protective muscle spasm whereas chemical pain is caused when the nociceptors (nerve receptors) in the injured area are activated and sensitised by chemicals in the body. If pain is prolonged for longer than expected there is a chance that the nociceptors can be over stimulated or irritated by the chemicals, causing excessive pain for a prolonged period of time even though there is no actual damage occurring to the nerve endings. This can lead to a condition known as hyperalgesia, an enhanced pain response which can be worsened from the use of opioid painkillers.
This stage begins when the scar is formed, and the repair process begins. At the peak of inflammatory, proliferation begins and peaks within 2-3 weeks. The fibroblasts attracted to the wound site will begin to produce collagen, which is the fundamental building block of scar tissue, and thus recovery. Without this important substance, healing would not be able to take place. Producing collagen requires oxygen but within the injury, the damage to blood vessels often inhibits the blood supply, leaving a hypoxic environment unideal for collagen production. In these early stages of proliferation, the primary concern is to produce new vascular vessels, creating a new bed of vessels to help the production of collagen. This process is known as angiogenesis.
Angiogenesis is one of the many overlaps in this complete process of healing. It overlaps the inflammation and proliferation stages with the early capillaries starting to develop just twelve hours after the initial injury and continuing over the following 2-3 days.
Remodelling or Repair
This stage is where the scar formed in the previous stage is turned into a functional repair. It begins roughly one week after the inflammatory stage begins fading out, but most agree that it begins in earnest from around 21 days post injury and can continue for up to two years until a fully avascular scar replaces the immature gel-like tissue formed in the earlier phases. The new scar tissue formed will become more like the tissue it is replacing and the collagen in the scar tissues responds to the physical stresses put on it and lines itself with these stress lines. The new scar tissue will not have the tensile strength or properties of the original tissue but with time it will begin to closely resemble the tissue and enable complete or partial restoration of the initial functions.
In the beginning, the orientation of the collagen fibres is random, and without tension, but overtime they become aligned correctly, found more tension and become strong. The scar in the beginning will appear red or pink (this is known as immature scar tissue) whereas over time the extensive vascular system will decrease, and the tissue becomes white (mature scar tissue).
Understanding the clinical examination is paramount to move forward with rehabilitation and successful outcomes. The clinical examination identifies both the primary and secondary problems that a patient may have so that a suitable treatment plan can be drawn up. The common acronym used in this process is SOAP. Subjective, Objective, Analysis and Plan. Included should be outcome measures to enable the monitoring of the success of the treatment protocol. It is important to remain fluid during this process to ensure that suitable changes can be made throughout the journey depending on the findings as time progresses.
The initial examination should always begin with the thorough history taking of the dog. A multitude of indicators and snippets of useful information can be gained from a solid questioning around the history of the individual animal.
Baseline information, such as age, breed, sex and neutered state can all give continued vital clues moving forwards. Other questions such as how long the problem has been going on, if the issue is recent or old, is the issue chronic or recurring. This is a general discussion between practitioner and owner around the entirety of the issue from the perspective of the owner. When asking around the medication taken by the animal NSAID’s should be particularly paid attention to.
Exercise is the second point of conversation that should be addressed at length. What distance does the dog walk in a normal day? Is this a single walk or a multitude of shorter walks? Is the dog on a lead or free running? Does the dog play with a ball? What is the terrain? Are there other dogs in the household to engage in play with? Does the introduction of new animals fit in with the lameness? Etc.
Understanding the diet and supplements of the dog can also have a further impact on issues. Is the plain of nutrition appropriate for the animal in question? Is it sufficient to support recovery? Is the animal being overfed in meals or through treats? Is the patient receiving sufficient supplements that can encourage healing?
The environment of the dog is the fourth part of the subjective discussion. Is the animal a family pet or a working dog? Such information can be important, and it can be useful to see footage of the dog working in its discipline if this is suitable. Canine athletes are often subject to injuries that pets will tend not to have. Have the owners had the dog from pup or is he rescued? Were there any issues in the growing phases of its life?
Assessing the dog’s demeanour can give a strong initial idea of how severe the issue is. Is the dog dull or depressed? Does the dog seek attention or is it withdrawn? Have there been any changes in the dog’s behaviour in recent days, weeks etc?
Any ancillary information that can be received will also help to paint a further accurate picture. The X ray report, blood tests and any surgical reports from the vet of the animal will all give further information that can be used to aid in the drawing of a treatment plan.
The objective phase of the evaluation is made up of several further subsections. Firstly, the animal should be observed in a standing position for joint alignment. Is the carpus dropped? Is the leg outwardly rotated? Weight and body condition score should be recorded at this point and at every other subsequent visit throughout the treatment programme. The skeletal structure should then be observed at the sit. Sometimes the affected leg can be held out of position (known as triangulation).
The dog should then be observed throughout its first two gaits, the walk and the trot. In the walk, there should always be three feet on the ground at any given time. The normal footfall is LH, LH, RH, RF and the centre of gravity should stay central through the central axis of the animal. If the dog is pacing (the two lateral legs moving in sync with one another and feet falling at the same time) this can be an indication of lameness or injuries relating to gait. It is an incorrect and inefficient gait although many dogs do pace. In the trot, two diagonal legs move forward together with the footfall pattern LF + RH, RF + LH. The front and hind feet on one side of the axis should land almost in the same position. Crabbing occurs when the back foot basses beyond the front foot on the same side, passing on either the medial or lateral plain to the front. This can occur due to the angulation of the hips but can also be an indicator for injury or ailment.
Walking away from the observer and walking toward the observer are both important in this phase and should be observed from front or rear on, both sides and in both the walk and the trot. After this, the dog should be observed in clockwise and anti-clockwise circles in both the walk and the trot. For front leg issues, nodding of the head can be a good indicator. The head tends to nod when the sound leg hits the ground. For rear leg issues lifting of the affected leg is common. There may also be a swaggering or swaying gait often known as a Marilyn Monroe walk.
Range of motion of a joint is defined as ‘The degree of motion that occurs when the bones comprising a joint move about the joint axis.’ The range of motion can be passive or active. Passive range of motion (PROM) means that the dog plays no part in the movement. Movement of the joint about its axis is carried out completely by the observer (or now operator) and there is no muscle contraction on the part of the dog. Active range of motion (AROM) is the polar opposite where the movement is only carried out by the dog. A goniometer is a protractor with a fixed arm, a fulcrum and a moving arm. This can be used to accurately determine PROM especially.
When measuring PROM, it is important to consider the flexibility of the muscles that flex and extend the joint itself. Flexibility is a term that refers to the length of a given muscle. Reduced flexibility is a consequence of a tight, shortened muscle. Other affecting issues of a joint can be pain, joint capsule fibrosis, fascial tissue, and swelling.
Muscle mass can be measured using a Gulick. This is a tape measure with a spring-loaded tension device on the end. The operator measures the circumference of the muscle at a set place and tensions the tape using the spring. When one red ball shows in the viewing chamber, there is 50g of pressure. When there are two red balls showing there is 100g of pressure. It is fair to assume that muscle wastage of a given limb is a good indicator of injury of the given limb.
Even if the lameness or injury is obvious, it is still important to carry out a full hands-on examination of the entire musculoskeletal system. If a dog is on three legs, it does not mean the non-weight bearing leg is the issue and it is important not to jump to conclusions. There will almost certainly be secondary problems associated with the compensation of walking on three legs. Before laying hands on the dog, it is important to relax the dog with food, affection or just time. There are eight common parts of the physical examination. They are not listed in this paper but can be found in the book ‘Practical Physiotherapy for Small Animal Practice’ (p.58-p.64) Prydie, David and Hewitt, Isobel.
Analysis and Plan
With this information, a list of problems should now be drawn up including the findings from the subjective history, any ancillary tests and lifestyle information, as well as the gait observations, objective markers and hands-on examinations.
From the analysis and list of issues found in the previous steps a treatment plan can be drawn up that will last until the next assessment. The entire examination will then be repeated, a new set of issues identified (if applicable) and an ongoing plan devised. This will be repeated until the final examination. It is important to use SMART (Specific, Measurable, Achievable, Relevant, Time Based) goals, giving a clear outline of how the treatment can progress and in what timeframe, allowing realistic goals to be set which is useful if the patient may not be able to return to full ability.
There are a multitude of ways to treat injury and ailment including superficial hot and cold treatment, light treatment, UWTM, hydrotherapy etc. In this paper we will cover manual therapies only. Manual therapy is an umbrella term used for all techniques involving the therapeutic handling of the patient. All manual therapy techniques affect joint movement either directly or indirectly by movement of the soft tissues and thus the joints. The term massage is the movement of the soft tissue and covers a number of light, to deep touch methods. These include kneading, effleurage, myofascial release, trigger point release, and transverse friction massage.
When performing manual techniques, it is important that the therapist is aware of how they perform them in their own manner. Manual techniques should never be rushed as this can make the dog tense and in turn becomes counterproductive.
Massage is usually considered as part of physiotherapy and the treatment of injuries in animals and can be used as a way of preparing the soft tissues for further treatments. The release of tight musculature will prepare the body for passive joint stretching and can increase the range of motion that can be achieved. Massage acts on the muscle and fascial systems and can also act on the nervous and circulatory systems. Function cannot be restored through massage alone in most cases, but it is an important step. The same is true of joint mobilisation; abnormal muscle tone and tension will occur following abnormal movement patterns. Massage is always a useful tool in physiotherapy for therapists to improve their palpation skills, distinguishing between normal and abnormal tones, atrophy and hypertrophy, fibrous thickenings and tissue swelling.
The activation of sensory nerves during massage therapy can produce soothing effect for the dog. If slow rhythmical massage is used, relaxation and well being are induced which in turn are well accepted to aid in recovery. Following acute injury tissue fluid can leak out of the blood vessels and accumulate in the tissue spaces. If the circulatory system is compromised and unable to remove the fluid, then massage can be effective in aiding the removal of said fluid. The mechanical pressure placed on the tissue spaces by massage will aid the movement of the tissue fluid or lymph back into the circulatory system. It also affects vasomotor nerves and stimulates vasodilation. This can be seen on the skin as pinkness (erythema) where the skin is visible to the observer. The mechanical movement can move blood in the veins and increase arterial flow which will aid recovery due to the increased nutrients and oxygen. Massage also stimulates A Delta fibres in the skin which give pain relief through the pain gate mechanism. These A Delta fibre are faster acting than the C Fibres therefore can close the gate to pain a lot quicker. Alongside the stimulation of the A Delta Fibres, there is also movement and stretch of the collagen fibres within the connective tissues which can loosed adherent structures like scars.
Types of Massage
Stroking in the Direction of the Hair – This is often used as an introductory technique as it gives the therapist a chance to assess the tension of the tissue enabling him to select the most appropriate technique moving forward for the main treatment. It can be useful to calm an anxious animal and will help relax any excessive muscle spasm. The stroke can be deep or superficial and would be performed by using the hands or finger pads. Slow strokes will produce a soothing effect whilst quick strokes will produce stimulation of the fibres. It directly affects the sensory nerve fibres and produces a sedative or stimulated feeling. Stroking will also result in the release of a histamine-like-chemical that can cause dilation of capillaries preparing for an increase in blood flow.
Effleurage – This is a method in which the hands are moulded around the animal’s body part to be massaged. The strokes are applied in the direction of the venous and lymphatic flow. When effleurage is applied to a leg, the direction of the strokes will be distal to proximal. The desired effect is to move the fluid towards the lymph nodes at the proximal end of the leg. The pressure should be even throughout the leg, but the therapist should be careful of any bony protrusions. Deep effleurage will stimulate the axon reflex which cases arteriole dilation and the release of a histamine-like substance also causes capillary dilation.
Petrissage – Petrissage is a term for a group of collective techniques that can be referred to as ‘pressure manipulation’ which is used on muscles and soft tissue. They can be transverse or longitudinal mobilisations that are particularly useful for softening muscles that have become chronically tight.
Kneading – This method can be done using the palm, finger, or thumb pads depending on the size of the area that is treated. If the technique is to be used in an oedematous area, then squeeze kneading can be used. If a large animal is being treated, then re enforced kneading is far more common where the therapist places one hand on top of the other and uses the pressure from both hands. The important factor of the technique is that the muscles are pressed inwards and upwards, squeezed and compressed and then released in a circular movement. The direction of this motion should always be towards the heart. When treating the leg, the hands are usually placed on opposite sides of the leg and the same is true for the spine.
Picking-Up – This method is where the hands are placed flat onto the body and the tissues are lifted, squeezed and released. The heel of the palm should stay in contact with the tissues and the fingers should be kept straight throughout the technique.
Tapotement – This is another blanket term for techniques that stimulate via striking rather than pressure like kneading methods. They are designed to invigorate the body. All tapotement treatments need to be performed carefully with a flexible wrist because if they wrists are locked, they can produce discomfort which can upset owner and animal. Using these techniques, it is important to explain them and possibly even demonstrate them on the owner before performing them on the animal.
Coupage – This is a technique where the hands are cupped, and they strike the body alternately. The wrists are flexed and extended with forearms pronated. The movement at the wrists should be soft and rhythmical. The clap will produce a deep, hollow sound, not a slapping sound, if performed correctly.
Hacking – This is where the ulnar borders of the hands and fingers strike the body alternately. The wrists are slightly extended, and the strike is produced by pronation and supination of the forearms. This technique is particularly useful to aid in the removal of lung secretions and the patient should be lying in a postural drainage position.
Trigger Point Release – Trigger points occur within the skeletal muscle and are always associated with a dysfunction, but this does not mean they are always painful. The definition of a trigger point is ‘a hyper irritable focus within a taut band of skeletal muscle and located in muscular tissue and/or its fascia’. Trigger points develop within a muscle tissue following sustained depolarisation of the endplate within the muscle fibre itself. This causes a prolonged shortening of the sarcomeres. The contraction of the sarcomeres will increase their energy consumption and causes compression on the local capillaries resulting in local hypoxia. This increased energy demands, and reduced circulation will cause ongoing tissue distress, which in turn causes the release of bradykinins and prostaglandins.
Active Trigger Points – These points will be observably painful under palpation and are often associated with existing pain or dysfunction in the animal. The amount of pain experienced with active trigger points is variable and depending on their severity, they can cause a great deal of referred pain, or very little. The size of the trigger point bears no relevance to the intensity of the pain experienced. It is the irritability of the trigger point that influences the amount of pain felt.
Passive Trigger Points – These are more strongly associated with a restriction of movement and can be found in clinically normal patients. They can often be described as ‘knots’ in muscle tissue. They will be considerably less painful on palpation and can be formed where there are weak muscles or when tissues are overused or overstretched.
It is important to remember that the rehabilitation of any injury or ailment is a complex matter and that this paper merely skims the surface of some of the main points. There are far more in depth proceedings needed to fully understand the rehabilitation process.