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In this week’s Knowledge Nibble we discuss Principles of Rehabilitation.
Kirkby Shaw, K., Alvarez, L., Foster, S. A., Tomlinson, J. E., Shaw, A. J., & Pozzi, A. (2020). Fundamental principles of rehabilitation and musculoskeletal tissue healing. Veterinary Surgery, 49(1), 22-32.
If you would like to read the transcript for this post then please click on the reference below.
Welcome! Here we will be discussing the principles of rehabilitation as set out by Kristen Kirkby, Shaw and others. We are going to focus on the fundamental principles of rehabilitation and musculoskeletal tissue healing as set out in a review paper of which I will pop the link in the email for you. It is an open access paper so you can just click the link and you can access it. It was quite an interesting paper. It is only a couple of years old and it was a group of experts discussing the principles of rehabilitation, but with canine cruciate patients in mind. It is all very relevant information. So whether you work with or you are interested in horses or dogs, the paper and the authors state that while this review specifically addresses post CCL surgery rehabilitation, these fundamental principles should be applied broadly to animals enrolled in rehabilitation programs.
I just thought it was quite an interesting view with these four principles of rehabilitation. For those of you that are canine therapists or vet nurses working with patients with cruciate post cruciate surgery, then you might want to dig a little bit deeper into the paper to get some more ideas. Even if you are interested in horses, I would still recommend reading the paper and using the sections that interest you. There are a couple of good graphs there and it is good for a bit of review and a bit of lateral thinking.
We will discuss the four principles and the scientific background/ related information. Have a little think about how this applies to us in our practice.
The first principle is that tissues follow a predictable pattern of healing. I have just added a paragraph here that I have stolen from Tim Watson. It is obviously basic, but it is quite useful.
It is about the different stages of healing and I’m sure you will know the stages of healing and tissue repair.
I’ve been teaching this subject for years and it’s always one of the subjects that is really difficult to grasp, no matter whether you are a university student or whether you are doing CPD. It is a very complex subject. You do not need to understand every single thing about it, but it is very important that you understand the different stages of tissue repair. It is very relevant to working in rehabilitation which is why the authors have set this out as being one of the main principles that we need to think about or adhere to.
I am not going to go into too much depth in terms of the content of the paper. It does discuss these briefly, but I would advise you to have a little think about the tissue healing time frames and carry out some revision of those. Carry out some reading and just refresh your memory if you have learnt them before and just make sure you understand the different phases.
First of all, there is the inflammatory proliferation or remodelling phases. It starts with bleeding which stops within a few hours. During the first 72 hours or so, there will be inflammation (or it peaks at that), and then it tails off over the next couple of weeks.
Proliferation will then peak at about two to three weeks. This is the stage of healing where all of the building blocks are laid down ready to remodel. That is a time where they start to get a bit more strength, but the building blocks have not been remodelled yet and not strengthened and remodelled. Proliferation can take place for months (four to six months or beyond).
For remodelling, we always state that it starts after 21 days, or that is a traditional understanding. You may come across that when you carry out your own research. In fact, it starts much earlier, probably within the first week or so and in some cases, it will go on for a long time.
Remodelling will take place for a long time and this is where we want to try and encourage the tissue to become more like the parent tissue. Once you have had an injury, it is always scar tissue and it never goes back to being tendon, ligament or muscle. It will be scar tissue but we want to try and make that scar to look as much like muscle, tendon or ligament as we can. That remodelling can go on for a year. So even when the animal looks and sounds happy and comfortable, we could still be in that phase. We need to bear in mind that if you are working with an animal eight months after it has had a particular injury, even if it looks fine at the time, there is probably some remodelling still taking place.
In the paper, there is a good graph that shows the different stages of tissue healing. I have just covered a little bit of information and adjusted it very slightly to what I tend to use.
If we are looking at the time for strength to return in these tissues, we want to think about why this is important first. For example, say I have a horse that is six months into a tendon injury. I want to know when it happened and how severe it was at the time. That will give me some indication at six months where we should be. It is a best guess because you are just guessing. You do not know how quickly because there are lots of factors that affect the healing process such as age, other injury, etc. So I cannot categorically say at six months, if you had only a minor or grade one injury that you will be healed. We cannot say that, but it is just to get an idea at what stage I am working at and what I am working with. For example, if I had a dog with a fracture repair and it was three months down the line, then I should know that I am healed and I am ready to start doing a little bit more on that.
Obviously the problem with this is, how often do you actually have a fracture that is only a fracture where there are no ligaments involved and there is no joint capsule involved? There are no other structures involved. It is quite rare that you have only injured one piece of the network. You always need to bear this in mind. So how do you know where you are? It is the best guess and we discuss that in more depth.
Before I move on, just reflect and think about a client and an animal that you are working with at the moment, whether you are a therapist or nurse. As a therapist, choose an animal and then state what stage of healing is taking place at the moment. Where exactly are they in terms of the healing process? Can you quickly pull that out of your mind? Think about it before we move on.
I would say that if you couldn’t do that and you couldn’t quite quickly think of the patient and think about where you are in the healing process, then I would probably suggest that you need to add a little bit more thought to where you are in the healing process when you are working with animals. It is very important to make sure that you keep thinking and checking back and to state where we are in the healing process and you are not just following a protocol that says ‘at this state we should be doing this’. We really need to know our individual animals and where they are at the moment. That is just a little something that you could possibly tweak a little bit with your practice.
We will now be moving onto individualised treatment plans. These should be developed by the rehabilitation therapist and adjusted as frequently as required. The patient’s progress through rehabilitation should be based on assessment of tissue, healing, strength and functional abilities limitations. So let’s cover what that actually means. We need to be producing and carrying out individualised treatment plans.It is fine to have blueprints and protocols, but we just need to individualise them. Every time we get a new patient, we need to tweak them and individualise them for that specific patient. We also must adjust that frequently. So even if you set out a plan and you think you know exactly what you are going to do when you see them on a weekly basis, you need to see what is happening at the time and see where you are and then you need to adjust it each time. Are we on track or do we need to change it? Nine times out of ten, you will need to adjust it and change it.
It says the patient’s progress should be based on assessment of these three things. We have just discussed tissue healing, but how do we really know where we are with tissue healing? And actually, there is only one way to know and that is through imaging. We can palpate and we can look at how much pain there is. We can look at lameness and see how much pain we think there is. Those of you that listened to the knowledge nibbles last week, you would have had a think about pain and we know that is not necessarily a reliable indicator. So really the only way to know if a fracture has been repaired or if a tendon or ligament has healed is to image it. I would encourage you to try and persuade your clients and your vets that you are working with to carry it out on a regular basis.
The other two of these are strength and functional abilities limitations. We will now have a quick look at those in the paper.
The authors have discussed these passive and active assessments of muscle mass and range of movement. We can measure muscle mass and we can measure range of movement. Both of those are more difficult with horses than they are with dogs, but it is quite a good thing to be able to measure.You can measure whether the range of movement is improving and whether the muscle mass is improving. Don’t get disheartened if it doesn’t happen for about a good six weeks or so. It takes time for muscle to actually start to gain mass, but it is a good indicator that you can have a look at. We can then move to the active assessment, one of which is the gait. This is just looking at how they are moving. With static and weight bearing, this is much easier with dogs than it is with horses. You can feel the weight bear and you can put your hands underneath them and it’s a lot safer. You are not going to put your hands on the horses feet to feel their weight. So with horses, I tend to do that more by sort of rocking them from side to side and seeing whether they are actually getting back into a comfortable position and whether they are shifting their weight.
For small animals, you can have a look at the paper because they have suggested some functional tests which are really sort of sit to stand and sit, sit to standing up with horses (I tend to use poles quite a lot for this). You can put them over a set of poles. You can assess their proprioception, you can assess their range of movement and you can assess their posture. You can measure quite a lot just by getting them to go over a set of poles but basically a functional test is what would be an exercise. It is like asking them can you do this? Can you sit down squarely and can you navigate a series of poles? If you can’t, then obviously that is an exercise, but it is also a test.
I’m going to go through principle three which is about specific measurable, attainable and relevant goals that should be set for each rehabilitation patient. There is a table in the paper that sets out the goals for cruciate patients and they are all very relevant. We will discuss where they are relevant for all of our patients. You can go and have a look at that table and it does actually indicate what therapies you can use to try to achieve the goal. They said that these are specific, measurable, attainable, relevant goals for each patient, but these goals are actually very general. Therefore, I would take these as general goals or aims if you like, but for each patient you need to make them specific for that patient.
For decrease in pain, inflammation, effusion and swelling, I don’t agree that you want to decrease inflammation. You want to help the animal move through that phase and it’s an important phase. We don’t just want to knock it on the head. We want to get through it and through the other side to proliferation. You won’t always see effusion (for a cruciate you probably will) and you won’t always see that swelling there. Even if you can’t see it, understand that there will be oedema and inflammatory fluid around the issue itself even if we can’t visually see that.
For facilitate tissue healing, I think we can quite happily say that we want to do that with all of our patients. For balance tissue protection versus load, we can go back to those healing time frames/ tissue timeframes, where are we at? What stage are we at? And can we now start loading that or do we still need to protect it? We will move through that as you move into remodelling. You want to add more and more load, and that is the same for every patient. For restore muscle flexibility, you need to be doing that alongside strength training. I think people get a bit obsessed with flexibility but it needs to be alongside it. You want to get strong and flexible and not just flexible because being flexible could sometimes be unstable. We want that along with strength. For restore joint function and kinematics, obviously we want to do that and that will be impaired in most patients that are injured. Not even if it’s not the joint itself that is the issue. You want to try and correct the biomechanics and that is the same for every patient.
For promote bearing and dynamic stabilisation, these are two really different points, but then they are not in the paper. So you need to promote weight bearing and that is going to be through the reduction of pain and neuromuscular facilitation to train the animal to start using that limb again. Dynamic stabilisation is very important. It is very important and definitely in cruciate patients and for any patient really. If we have lost the muscle strength around the joint and the correct neuromuscular patterning, then that means we are going to have joints that are unstable. Getting those muscles strong around the joints and the firing correct is going to help with that dynamic stabilisation.
For normalised proprioception, any animal that has been injured will have a proprioception issue to work on afterwards. That is definitely relevant for every patient. For restore normal neuromuscular patterning, it is very important and it is the key thing that will make the difference between a basic rehabilitation plan and one that is going to prevent further injury. For normalise muscle strength, endurance and mass, I believe that is quite an obvious one and we would want to do that with every patient. Even if we are looking at a horse with a ligament injury or a distal limb injury, there will be muscle strength further up that is a problem and we need to address that as well. For weight loss if indicated, yes this is true and nutrition in general is important. You need to question if they are getting enough protein and are they getting enough nutrients for what we are asking them to do and to strengthen.
For address compensatory issues in other limbs/ spine – those of you that are new to rehabilitation, we are not just rehabilitating the one individual limb that we are working on. We are rehabilitating the whole body. We need to take a step back and look at the compensatory problems and address all of those in our rehabilitation plan. For hatestened and guided return to activity, it is really more about trying to get the owners to understand and to follow our advice.
Principle four is “ The foundation of veterinary physical rehabilitation includes pain management, therapeutic exercise, manual therapy, and guided return to activity. Therapeutic modalities may play a beneficial yet supplementary role in therapeutic plans. Client education is an important role of the rehabilitation therapist”.
I have just used those specific points so that we can see what they are trying to say with this principle 4 because I believe pain management, therapeutic exercise and manual therapy has already been covered and we understand that. I think what they are trying to say with these final 3 points (guided return to activity, therapeutic modalities and client education) is that you can’t just use a therapeutic modality in isolation. For those of you that might have a laser in your practice and you are just using that for injuries, it is not good enough unless you are also thinking about the whole animal and you are rehabilitating them through exercise as well. Client education is obviously very key here and we need to aim to get those owners on board with what we are doing.