ORTHOPEDICS ORTHOPtDIE

Postoperative physical therapy in orthopedic patientsGreg Harasen

The concept of postoperative rehabilitative therapy isnot new in human orthopedics; however, the experi-

ence seems to be quite different with small animalpatients. After cranial cruciate ligament surgical repair,for example, many surgeons attempt to immobilize thejoint for several days in a padded bandage and pre-scribe strict exercise restriction for 6 wk or longer.There is ample evidence to suggest that restricting jointmovement leads to decreased range of motion, deterio-ration in articular cartilage, and atrophy of the periar-ticular musculature.The benefits of a physiotherapy program for patients

following cruciate ligament surgery have recently beendocumented. Increased weight bearing, as demonstratedby force plate analysis, was 42% better 4 wk postoper-atively in a group receiving physiotherapy versus acontrol group (1), while in another study, thigh cir-cumference and stifle extension were significantlybetter in treated patients compared with controls (2).The goals of postoperative rehabilitation in the patient

with a repaired cranial cruciate ligament are to maintainrange of motion in the stifle and to minimize the thighmuscle atrophy, which begins within 2 wk of cruciaterupture and can decrease thigh circumference by up toone-third at 5 wk (3).

Postoperative rehabilitation in our practice beginsimmediately after surgery, when an ice bag is appliedto the stifle joint while the patient is recovering fromanesthesia. This decreases edema and provides mildanalgesia (4). The rehabilitation sessions are conductedby our veterinary technologists and begin when thesutures are removed 10 d postoperatively. The clientleaves the dog at the clinic for the day, during which time2 rehabilitation sessions are conducted. On postopera-tive days 10 through 14, these sessions consist of slowflexion and extension of the joint, repeated 25 times; mas-sage of the periarticular musculature; and leash walking,increasing in duration from 5 to 10 min as the week pro-gresses. These walks must be at a slow enough pace thatthe patient bears weight on the affected leg. Duringthe first week, the sessions are followed by icing the joint.On postoperative days 15 and 16, the owner rests the dogat home.On postoperative days 17 through 21, the owner pro-

vides twice daily leash walks of 10 min duration.Days 22 and 23 are rest days.The dog returns to the clinic for postoperative days 24

through 28, when the range of motion exercises, massage,and leash walks are repeated. In addition, 25 repeti-tions of an exercise, where the dog is made to sit and thenasked to stand again, and stair climbing, increasing

through the week, are included. Postoperative days 29and 30 are rest days, while days 31 through 35 includetwice daily walks of increased duration at home; days 36and 37 are rest days.The final sessions in the clinic are on postoperative days

38 through 42. They include the continuation of theexercises begun previously, plus an additional strength-ening exercise. In small dogs, this may consist of walkingdown a hallway on their hindlegs. In large dogs, thefront legs may be supported on a medicine ball or largeinflatable ball. Alternatively, or in addition, controlled ballplaying in a restricted area, such as an exercise run, or stairclimbing with leg weights attached may be added.

This program is adaptable to most practices withlittle or no specialized equipment or expense. Its dura-tion corresponds to the time in which most muscle atro-phy is seen in the patient following cruciate ligamentsurgery (3). Several veterinary schools have utilizedother modalities, including neuromuscular electricalstimulation, therapeutic ultrasound, and swimming(4,5). Some of these modalities may be available toprivate practitioners through local physiotherapists.The intensity and rate of progression of each reha-

bilitation program must be tailored to the individualpatient. Some patients may require analgesics or anti-inflammatory medications, while some exercises mayneed to be modified or eliminated, based on the patient'ssize, behavior, or pain tolerance. Communication betweenthe surgeon, veterinary technologist, and the owner isessential in assessing progress and modifying the pro-gram, if necessary. The same principles may be appliedto many other orthopedic conditions where muscle toneand range of motion are critical factors.

Subjectively, postoperative rehabilitation has been ahit in our practice! Our patients seem to be returning tonormal function very quickly, our veterinary technolo-gists are enthusiastic about their involvement in this facetof patient care, our clients are sold on the importance ofrehabilitation (thank-you cards and chocolates areincreased at a statistically significant level!), and the dogstruly seem to enjoy the attention!

References1. Conzemius MG, Marsolias G, Dvorak G. The role of postoperative

physical therapy in the management of cranial cruciate diseasein the dog [abstract]. Proc Annu Meet Vet Orthop Soc 2000:8.

2. Millis DL, Levine D, Brumlow M, Weigel JP. A preliminary studyof early physical therapy following surgery for cranial cruciate lig-ament rupture in dogs [abstract]. Proc Annu Meet Vet Orthop Soc1997:39.

3. Millis DL, Levine D, Mynatt T, Weigel JP. Changes in muscle massfollowing transection of the cranial cruciate ligament and imme-diate stifle stabilization [abstract]. Proc Annu Meet Vet Orthop Soc2000:3.

4. Clark B, McLaughlin RM. Physical rehabilitation in small-animalorthopedic patients. Vet Med 2001:234-246.

Can Vet J Volume 42, August 2001

Animal Clinic of Regina, 1800 Garnet Street, Regina,Saskatchewan S4T 2Z2.

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