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The Essential Elements of a Holistic Approach to Physiotherapy and Rehabilitation for Animals

Equine veterinary surgeons
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In this week’s Knowledge Nibble we discuss Principles of Rehabilitation.

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We will be covering the essential elements of a holistic approach to physiotherapy and rehabilitation for animals. Think about the essential elements of a holistic approach. I think that we have all been trained in certain specialist areas (or certainly when we started out) and may have begun with something particular. Then through CPD and through experience, your knowledge grows and you develop and start to use new techniques and new theories. What I see quite often and what tends to happen (it’s happened to myself as well) is that sometimes I have to give myself a little shake up now and then and say ‘Are you covering all these elements? Are you doing enough? Are you doing too much in one area and not enough in another?’ This is to get you thinking and have a look at the treatment that you give or that you are working towards/ learning about. If you can think about these different elements, you can then think about the different techniques that you use and where they fit within these elements. You can then see where you might be perhaps using too much in one area and not enough in another.

It is really important for a holistic approach for an animal that we look outside of what we are doing and try to work with others. We can look at the animals’ lifestyle and the picture as a whole. So being a therapist is not about just coming in and giving your treatment and then off you go again, I’ll see you in six months. I think at one point it was a little bit like that and that is what owners expected, but now we have moved forward a lot since then. If any of you still have that type of approach where you come in and you give one hands-on session and you see them again in a few months, I’m going to try to explain to you how that might not be the best approach anymore. I will give you some indicators of where you can change to provide a little bit more for your patients.

These essential elements that we are going to look at now are put into buckets. Everything goes into a bucket for me when I am trying to separate things. With a subject like this, I would like to be able to check each bucket and see what is in each bucket. I need to think about what I am providing and whether I am covering all of these elements. I will talk you through the actions at the end and how you can visually carry that out.

The bucket that we are going to consider first is called ‘heal’ and it relates to tissue and pain (we will discuss this further). The second bucket is called ‘restore’ and the third bucket is called ‘support’.

What I would like you to do at the end of this is to think about the service that you give and make sure that you can give everything (as much as possible) to your patients. You also need to make sure that there is something in each of these buckets. It can then help you to balance out the treatment that you are giving and make sure you are using a holistic approach.

Looking at the ‘heal’ bucket first, this is where we need to address the tissue problem. Within this element, what we are actually doing is addressing the injury itself. I did start to think about a root cause here, but it’s not really the root cause or it’s not the root cause very often. This is because the root cause can go back a lot further than what we are actually presented with. For example, if we are presented with a ligament injury or tendon injury, it is likely that the root cause of that comes from something else previously. It may be a compensation in movement, a lameness somewhere else, or it may even be even a genetic predisposition or a breed predisposition. It is not really the root cause, but it is the problem that we have been presented with.

As mentioned previously, that can be a tendon or ligament problem as examples. The reason why I call this heal and then call it tissue and pain is because the first element (or certainly the element that we keep coming back to throughout our treatment) is the healing element.

The healing is not always only a tissue problem, like specifically a ligament injury. What we need to heal or put our hands on or do something to make it better, is actually the pain. An example of this might be that I have addressed the tissue problem or/ and the pain problem.

It might be that you have got a ligament injury and you have to address that tissue problem. Somehow we need to do something with our treatment or within the treatment of the team that is going to address that healing of that tissue. For example, a horse with a sore back is something that is very common and it may possibly have a root cause. The horse may have a change in movement and lack of strength plus all of those things. The problem that we are presented with on the day is a horse with a sore back. You have an animal in front of you that is sore to touch and doesn’t want to be ridden and it doesn’t want the saddle on, so you have got to do something to get started on that case. There may not be tissue damage there. Another knowledge nibbles session will link to this (pain and exercise), and it discussed having pain without tissue damage.

There is usually pain with tissue damage. If there is a tissue problem and tissue damage, you are likely to have pain with that, but you can have pain on its own without tissue damage. You may be presented with this horse, or it could be a dog or any other animal that has this back pain, and discomfort. What we are aiming to heal on our first visit to that animal would be the pain. Healing pain is the very primary thing that we need to do.

The first thing we need to address is that they are uncomfortable. There is no point, especially with animals, trying to say ‘what you need to do is move like this’ or ‘you need to do this’. If you haven’t in some way addressed that pain, we can’t talk to them and say ‘Just push through the pain and exercise through it’. We can’t say ‘We can get you stronger. It’s going to be okay.’ With an animal, we have to provide that comfort and help them to modulate their own pain. This will help them to decrease that pain so that you can then ask them to do something and they will be more comfortable to do it.

There are certain ways in which we can address this healing and this tissue or this pain problem.
Rest is something that might be advised. When I say rest, I don’t necessarily just mean cage rest or box rest. I mean reducing the work or the pressure that is causing that injury. It’s not necessarily rest as in complete rest. It could just be to rest that injury and don’t keep doing that movement at the moment because it’s aggravating it. Originally we initially need to remove that source, that aggravation to the tissue or the thing that keeps repetitively causing the pain. This may be the saddle not fitting or other various things like that.

We need to remove the aggravator and then rest a little bit of that tissue so that we can then just sort of take all of that provocative stuff out of it. That is what I mean by rest there. But of course they may also be prescribed box or cage rest (which is a discussion for another day). The vet may perform surgery to fix the offending injury, for example for a cruciate ligament, we would go in there and have a repair or TPLO or something like that. It may be that they go in to do some sort of provocative treatment, like the splitting of a ligament or something like that. With some sort of surgery, the idea is to heal the issue but it won’t necessarily heal it straight away.

There is healing that needs to occur after that, but the surgery might be the initial thing that starts with the healing process. If that is the case, then we need to be there to support that animal and to follow that healing through. Surgery alone is not going to be as good as surgery with physiotherapy or follow-ups from us. Medication is another way that this might be addressed. It may be some sort of pain medication to help heal that pain problem that we have. It might be corticosteroids or something like that to try and rapidly reduce inflammation within the joint. We have to work alongside the vets with this. Very often the medication might be a sticky plaster, or it might be something that they need long-term. Even if it is a sticky plaster or it’s something that we can use. We can have a window of opportunity If we can remove some pain and we can then start working to restore movement and hopefully later we don’t need to mask that pain anymore.

We have actually made a change that can maintain that comfort for the animal, so these are really the two that are most relevant to us. So what are you doing in this bucket? Have a think about your therapy, what you do in your practice, how you treat an animal, what your normal protocols are and what is in your ‘heal’ bucket. What do you do for healing?

It may be that if you are a veterinary nurse and you might not be trained in EPA’s or manual techniques. Maybe you work alongside a physiotherapist or you have a massage therapist that comes in to address this part of it. It may be through the vets and you work with medication to try and mask some of that pain to start getting the animal moving. If you are a therapist, I would recommend that you use either an electrophysical agent such as laser, radio-frequency pulsed electromagnetic field, or something similar. Or/ and you use manual techniques.

Now what we are actually then trying to do is to use the electrophysical agent on a very basic term to apply energy to the tissues to help heal those tissues. So we are actually trying to push forward the healing in those tissues. Maybe it’s that you use an EPA or various EPA’s, and then do you also use manual techniques? For years I have taught manual techniques and I have always used terms such as it increases blood flow, it can reduce the oedema and it can promote healing.

There is some debate related to how much the manual techniques contribute to the healing of tissues. There were a lot of original things that we used to think that we could do, but now there is literature to suggest that perhaps those original ideas are not exactly the mechanism of a treatment. What I can quite categorically say for manual techniques, they are most useful for us to use as part of our toolkit is that they do help to modulate the animal and to modulate their pain.

We can go in and we can use a manual technique to heal that pain element that I was talking about (think about when we were discussing the horse with a sore back) and there is no underlying tissue damage or underlying issues, but it is still painful. We can use our hands to override that pain and to make the animal more comfortable. We can get them to accept our touch and to accept pressure, and give them the confidence then to move.

That is really useful and it is certainly a massive part of what we do. If you are delivering manual treatments and manual techniques alone without any follow-up in the other buckets that we are going to talk about, the therapy that you give (although it is very effective and you see an immediate change in the animal), you need to ask yourself is how long can they maintain that? How long will that be effective without a change in movement or a removal of something that is irritating.

There are things I would like you to think about, and it’s not just manual techniques. If we are not using each of these buckets and having things in each of the buckets, then we are not really given a holistic approach. It is a very big subject and is an area of massive debate, but what we want is the best for the animal. If we can relieve that discomfort, then that is worth a lot of money as far as I’m concerned. We need to make sure we follow that through because we can’t just keep going in and relieve the discomfort. We need to make some sort of mechanical change or some sort of change moving forward through the weeks ahead to try and address that underlying issue/ reason for why we have the problem. The two things relate to each other.

The next bucket is the restore bucket and this is where we do exercise. There are a range of different things here that we can do in this bucket. First of all, do you have a restore bucket? Do you have stuff inside that bucket that you can use and that are related to exercise? If you are using a laser or you are using a different EPA radio frequency, or you are using manual techniques, and then you don’t have anything in the restore bucket, you are really only addressing the first part of the problem. You are not moving that animal forward to restore them and to reduce the likelihood of reinjury. You are not able to remove that mechanical thing that caused the problem in the first place or compensations that have happened since.

So we will move on from healing into the restore bucket. It is important to point out that there are three different buckets in reality, but there is a crossover and they do merge together (certainly the healing part and the removing the pain part carry on all of the way through). Exercise, for example, can help to reduce pain. So there are crossovers here, but I’m just trying to make sure that the treatment that you are giving is balanced.

In your restore bucket, you can have exercises that are able to improve proprioception. Proprioception is going to be affected after any sort of injury or for other reasons so it’s very important to reduce the likelihood of reinjury and we address proprioception. Motor control – we are going to have to teach these animals how to use themselves properly. That’s what motor control means. They can move from A to B, but they do not do it properly and that is putting strain on their body.

We need to re-establish the motor control pathways so that they are using the correct muscles and everything is in balance. We need to get that foundation in place before we then build on it with strength. We need to use exercises to address range of movement. It is very often impaired with injury or through compensation, the lack of motor control, or an increased pain perception.

Range of movement is very often affected by weakness. We often look at an animal and think ‘is it lacking a range of movement?’. Therefore, it must have a joint problem or it must have something else. In fact, if they have no strength or very reduced strength, then in order to lift their limbs up they don’t have the strength to do that. That means they are going to have a lack of range of movement so it is really important that we restore range of movement. We can do that through active exercise. Strength is something else that we need to have in this bucket. In our restore bucket, we need to restore the strength. If you just come along and you treat an animal and you don’t follow it through with exercise, where’s the strength? Where are you restoring any of the strength that they have lost or have a problem with? You can’t do that in one day. It has to be a program and it has to be working with the rider to make some changes.

Confidence is really important. In order to help them restore their movement effectively, you need to help them to improve their confidence. Don’t forget we can’t talk to them and we can’t explain things to them. We need to be really kind and through exercises, we can really build their confidence. We can push them a little bit to say ‘you can do this and it doesn’t hurt’. We can retrain their brain to understand that they can use all of their body without something hurting. Confidence is a really important part of the restore element. For body position, what we really want to restore is a good body position and a static body position (we are thinking about posture there). We want the body posture to be as optimal as possible. Then we want to move onto exercise. We’ll move that from static correction to dynamic body position. So that is in movement. We still want good posture. We still want everything to be used in the right order and in the right balance and that will help us to affect and restore correct loading of the limbs as well. I’ve added pain in here because pain is always going to something we need to think about throughout this. We can re-use the restore elements. Exercise will help to reduce pain as well, providing it is done at the right time for the right reasons and at the right dose. Exercise will help to continue to address the pain problem.

Finally we will move onto support. This is something that once again, I don’t know whether we always follow through with this and I have been guilty of this myself in the past. I go along, I give a treatment, I might give some exercises or an exercise program. But there is a lot to supporting an animal and there may have been times where I may not have thought about the ongoing quality of life of the animal. It is extremely important that with this final bucket, we make sure that our service is not about turning up for an hourly rate and we don’t just do something for an hourly rate. It is all encompassing help for this animal. That is what we want to do because the owner doesn’t necessarily know what has happened or what needs to be addressed. They don’t have the knowledge that we have. Somehow we need to intwine ourselves into the way that they would be looked after and try to make a few tweaks there with some advice (if we can).

So are you just going along and giving your treatment or are you just giving your treatment, following up some exercise and then you leave the animal? Or are you considering these other parts? You need to think about whether there is anything else that you could do or could include that would help the support element. This really comes down to quality of life. We go along and we treat these animals and our overriding aim is to reduce their pain and to make them move better. Often it is to make them perform better if they are performance animals as well. But how about their quality of life? I don’t really want to get an animal up and then just leave it like that if it’s not happy. There are other things that feed into making the animal happy. You can’t just make them happy by putting your hands on and fixing the problem that they have.

There are lots of other things around their healing and their rehabilitation process that feeds into that. We can either help them or hinder them as far as the success of the rehabilitation program. The obvious thing is their lifestyle. With dogs, we always make sure that we give advice such as around the home. How are they being fed from the floor, have they got a raised bowl or is the floor slippery? If you have covered any basic rehabilitation will know that there are a number of things that we can do around the home. However, we need to think about it a bit more, such as how many times are they being walked and what are they doing when they are walking them? We need to dig a little bit further just to find out what works and what their life looks like from morning until evening.

There are small pieces of advice that we could give them that might be able to help. I am an animal owner the same as all of you probably are. I want my animals to look healthy and I want them to be the correct weight. I want them to be happy and have perked ears. If I ever see any deviation from that, I don’t like it. A lot of owners won’t necessarily see that, so sometimes there are elements of just their general health that we need to talk to them about. For example, do they realise that their horse is wheezing? You need to go back to the vet to find out why there is a respiratory problem and why it is coughing every time it is ridden. The horse shouldn’t be doing that. The coat is very dull and just doesn’t look right and the horn growth is not very good.

If you are looking at a dog, the very common thing that we have to deal with is whether they are overweight. Do people understand how much of that is impairing their health and causing problems that they just don’t need to have? You need to look at their general health and to familiarise yourself with that and learn more about things like nutrition. For horses, it may be farriery and for small animals, it may be nutrition. It would be really helpful to give those owners a little bit more support because that sort of health element is so important.

We will now move onto emotional and mental wellbeing which is a big area and we will cover this in more depth at some point. This would come down to the next one and quite often, it would be husbandry and the way they are being looked after – are they happy? Do they have contact with other animals? If it is a horse, are they allowed to go out in the field like a normal horse should be able to? If it is a dog, is it isolated on its own and does it have contact with other dogs? Are they getting enrichment in their home?

If there is a dog that is in pain and it’s elderly and you have done a lot to help them and they are much better, but they may be extremely bored at home and they have no enrichment. You can teach owners about enrichment such as snuffle mats and things like that, just to give the dog something to do. It can reduce their pain and can make them feel happier just by letting them see other dogs or taking them to the park just to watch other dogs, etc. There are things related to their home life that can really help their emotional and mental wellbeing.

Pain can cause depression (hopefully we have covered all of that). It is always really important and I will sometimes look at an animal and just think they are just miserable. I think to myself I have fixed the problems that you have but it can’t all be fixed but I’ve done my best for your physical problems. However, there are mental problems and you hate being in a state where you can’t go out and you can’t see other animals. Those things we have to gently somehow try to see if we can help the owners with.

So that is husbandry and then confidence comes in so think about are you supporting those animals? Do you go back and see them regularly? Do you help them a little bit if they start to waiver and they are a bit unsure about something new? Can you help them go and back again to your manual techniques? Can you give them a bit of confidence and help them if they have a bit of new discomfort and help them with a bit of confidence doing something new? So that is part of your support and your ongoing support for animals is to help them to feel happy and confident. Finally, how much do you liaise with the multidisciplinary team? This is where we all need to pull together as a team because we can’t just do this on our own. We need to be speaking to the hydrotherapist, behaviourist, nutritionist, vet, farrier, sadler, and so on. We need to all be working together to help this one animal.

Just look at your support bucket and just think, do you just treat that animal and then leave them? Or are you trying to ask these little leading questions? Are you trying to get in contact with the team to say can we work together? Are there times where you haven’t really done that when you think you should have? I do appreciate sometimes it’s finding the time to do all of this. You might think, hang on a minute – I spend a lot of time doing X, Y and Z but is that the best I can do for that animal or is it best to spend some of the hour that I’m there asking more questions and talking to other people and doing something else? Is that going to be more of a benefit?

We need to question ourselves constantly and think, is what we are doing the right thing? Could we be doing something slightly different that would have a better outcome than just doing one thing for an hour? We need to really think about that. So that is the final element which is the support element.

Sort the elements of your service into the buckets. If you are a visual learner, you might actually want to do this – have three plates or three sticky notes or three of something else and write it on bits of paper and put it in there. Once you have done that, that’s your service from right from the start, right to the finish of when you have a new client. What you do is think about where you are and what do you do? What do you deliver? Where does it go in these buckets? Have a look at these buckets and consider which ones are full and which ones are empty.

There are some questions I would like you to ask yourself. Do the full buckets need to be so full or are you wasting precious time duplicating? For example, this might be if you are working with horses with a back injury (just going back to the same analogy), are you spending a whole hour using laser and massage and then leaving yourself no time to follow up with the saddler? Are you leaving no time to maybe talk to them about the tack and the rider? Are you leaving no time to show them some exercises that they can do? Are you balancing that out well enough? Or are you just spending all your time putting your hands on an animal and hoping that will work?

It is just worth thinking about. ‘Is that the best thing I can do for that animal?’ is certainly very valuable, but think ‘do I need to do it for the whole thing or can I pull that back a little bit and then focus on something else for 15 minutes?’. That would be more useful. Have a look whether you really need all of those things in one bucket and whether you are duplicating things that you don’t necessarily need to be doing.

If you have empty or almost empty buckets, these are the buckets you should be filling with your continued learning and changes to your practice. If some of your buckets are empty, that is a good time for you to say ‘Well, I need to start putting some things in these buckets. I need to start being more holistic in my approach to get the best outcome for my clients’. That might be where you direct your continued learning or doing some courses, more reading in those areas, or working with one of your fellow therapists that does something slightly different and then learning from each other. You should be thinking about trying to balance these buckets out a little bit.

I hope you have enjoyed that and I hope that it is useful to you. It is just giving you another way to think about your practice and how we can deliver the best service that we can to these animals.

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