Rehabilitation and Conditioning for Animals

Information Regarding Ligament Ruptures and Conservative Treatment

Ligaments are dense connective tissue structures consisting of fibroblasts, water, collagen, proteoglycans, fibronectin, and elastin that connect two or more bones. (1, 2)

Currently, a great deal of information remains unanswered regarding timing of ligamentous healing, especially with respect to postoperative mobilization techniques (graft, suture, TPLO, etc…).  This is because ligaments heal differently depending on the location.  For example, the healing potential of the medial collateral ligament of the stifle is very good, but the cranial cruciate ligament, which has received the most investigation, demonstrates virtually no healing response following injury. (2)

Within hours of injury, the defect is filled with an organized hematoma and the surrounding tissue becomes edematous from perivascular leakage of fluid.  Monocytes and macrophages are found in the wound by 24 hours and respond by cleaning up the site and transitioning to the next phase.  This acute injury phase lasts approximately 48-72 hours. (2)  It is during this acute phase that the use of ice is strongly recommended 1-6 times per day for 20 minutes each application on average, depending on fur density and type of ice used.  The use of heat on an acute injury is not recommended and will likely be destructive to the natural healing process.  During this time and throughout the healing process the use of low-level laser therapy is also warranted.

The reparative phase begins 2 to 3 days after injury and persists approximately 6 weeks. (2)  The final stage of remodeling and maturation progresses as with normal wound healing and may take more than 12 months to complete.  At that point, ligament strength is only 50% to 70% of the original tensile strength. (2)

In many cases, loss of ligamentous support invariably leads to progressive osteoarthritis, such as in cranial cruciate ligament (ACL) ruptures.  Slatter’s Textbook of Small Animal Surgery, 2^nd Edition states that small dogs often do well without surgical intervention, and that based on particular studies, “it is prudent to wait for at least 6 to 8 weeks before recommending surgery for small dogs.  These dogs are older at diagnosis and are often obese with concurrent medical problems.  Small dogs that are lame for 6 weeks after diagnosis and show no improvement often have meniscal tears and are operated on for meniscectomy and joint stabilization.” (pg.1832) 

However, studies have increasingly shown that while conservative therapy may suffice, surgical treatment is preferred to reduce the atrophic and degenerative changes that invariably occur with conservative treatment and that in larger dogs, some form of stifle (knee) stabilization is nearly always advocated to prevent or minimize the progression of OA. (3)  Slatter also notes (pg. 1832) that large dogs, greater than 15 kg, clearly benefit from surgical therapy and cites a study wherein 46 of 57 large dogs with CCL rupture treated conservatively had persistent or even worsened lameness during a follow-up period of 10.2 months.  In a latter study, only 6 of 20 large dogs that had clinical CCL rupture and were treated conservatively became sound.

Additionally, excessive exercise during periods of acute joint inflammation may be detrimental to articular cartilage, and immobilization may be protective during acute bouts of inflammatory joint disease. (4)  Joint inflammation will occur with greater stresses that are placed on the joint in the presence of ligament damage.  If surgery is not opted, then for a period of time, depending on the severity of the injury, short, controlled leash walks and restricted activity along with mandatory rest are indicated during the first phase of acute injury. 

Given that we have discussed loss of support and inflammation of ligament and joint, then it would follow that muscle atrophy would be another complication to address.  Muscle atrophy will occur whether or not surgery is performed and rehab interventions are proven to aid in gaining strength and muscle tone in the affected limb.  The degree of quadriceps muscle atrophy present before surgery for CCL rupture seems to correlate significantly with the degree of cartilage fibrillation, indicating a relationship with the severity of the condition.  In studies, muscle mass improved 7 and 13 months after surgery, but significant residual muscle atrophy remained in many dogs even after 1 year.

Outside the scope of this paper is the argument as to whether a natural course of events follows evolution or deterioration without intervention; either way it is the primary purpose of rehabilitation interventions to improve upon what natural abilities would theoretically otherwise be realized.  Whether or not an animal will do well on its own without intervention is inconsequential when the overwhelming benefits of rehabilitation intervention are considered. In light of this, rehabilitation treatment is indicated whether or not ligament repair surgery is performed. 

For non-surgical patients, rehab treatment may consist of conservative exercise that increases in difficulty as healing progresses and of  therapies such as massage, low-level laser, ice, ultrasound, nutraceuticals, weight control plans and range of motion exercises.  For patients who receive surgical repair, the same rehab treatment holds and depending on the outcome from surgery, exercises will be more complex over time and therapeutic interventions less necessary (ice, laser, and ultrasound).  For non-surgical patients, building muscle and supporting tissue will be important as well as maintaining protective interventions for affected joints, i.e., the use of therapies mentioned and maintaining dosing supplements proven to aid.  Nutrition supplement support, or nutraceuticals, proven to aid include glucosamine sulfate with chondroitin sulfate with MSM (all work better together) and fish oil Omega 3’s.  Some propose that additional vitamin C is warranted, although canines do manufacture their own, whereas humans do not.  It is also outside the scope of this paper to argue or discuss the benefits of the nutraceuticals mentioned. 

As a qualified functional rehabilitation practitioner I am able to design an appropriate plan of action to meet your and your pet’s needs.  It is within the scope of this paper to briefly and generally give information regarding ligament damage and specifically cruciate ligament damage.  The conclusion is that if this information generates more questions, then answers should be sought from a me or another physiology and functional rehab based specialist.

References:

1.  Fowler D:  Principles of wound healing.  In Harari J, editor:   Surgical complications and wound healing in the small animal practice, Philadelphia, 1993, WB Saunders.

2.  Frank C et al:  Normal ligament:  structure, function, and composition.  In Woo S, Buckwalter J, editors: Injury and repair of the musculoskeletal soft tissues, Park Ridge, Illinois, 1991, American Academy of Orthopedic Surgeons Symposium.

3.  Moore KW, Read RA:  Rupture of the cranial cruciate ligament in dogs.  II. Diagnosis and management, Compendium of Continuing Education Pract Vet 18:381391, 405, 1996

POST-CRUCIATE LIGAMENT REPAIR HOMEWORK

First and foremost:  pay attention to the discharge instructions your veterinarian has given you.  Please pay special attention to the part about no running, jumping, or playing.  If your veterinarian did not say so, please note there should not be any flying off couches, flying over couches, galloping stairs, jumping into cars and trucks, jumping out of cars and trucks, jumping onto couches and your bed, jumping off of couches or beds, twisting very fast in tight circles, sliding on ice , or freedom in and out of doggie doors.  No jumping out from behind things to scare the dog into running crazy funny around the house like you sometimes like to do.   No running really means no running to the door when the doorbell rings, no running away from Halloween costumes, no running from one end of the house to the kitchen every time the fridge or a plastic bag is opened, no running to you when you yell to ask the dog if it wants to go outside, and no running inside after the ball, which is very similar to no running outside after the ball.  No, no swimming until your vet or rehab practitioner says so. 

Week 1 of active homework may usually be safely begun at suture/staple removal when your vet sees the dog and examines the surgical repair.  Week 1 consists of 2-4 five minute walks per day only.  These should be done very slowly so as to encourage more weight bearing.  When the dog goes too fast, he/she can “cheat” and not use the repaired leg much or well.  Too fast could also prolong the inflammation and pain as well as damage the repair.  There should be at least two-hours’ rest in-between each walk session.  These walks are to be purposeful exercise and are separate from potty walks.  Potty walks during this time should be in and out with business getting done separately from the five-min. walks.  Outside sniffing for four minutes and walking for one minute does not constitute the weight-bearing, purposeful exercise we hope to accomplish.  Please stop exercises for the day if you go to do the next set and your dog will no longer use the leg, is more swollen or is more lame in another manner.  Use the time to apply ice to the surgery site according to icing instructions provided.  If your dog continues this way into the next day, do not hesitate to call your vet or me regarding the issue.  Do call especially if you happen to know of an incident like the ones listed above that could have caused an injury to the repair site.

Week 2 is just like week 1 but the walks are for ten minutes instead of five.  Ten minute walks should only be begun if 3-4 five min. walks are able to be accomplished without producing greater lameness.

Week 3 consists of only two walks per day for a duration of fifteen minutes.  All the other rules and restrictions still apply.  Do not begin unless your dog is able to do at least three ten min. walks per day without greater lameness.

Week 4 is the same as above and the walks are to be twenty minutes in length.  2x20. Still no running, jumping, playing or swimming.

All of the above-listed scenarios have happened in real life and have complicated the outcome from surgeries, sometimes resulting in a re-do of the surgery because the dog is too active and destroys the first surgery.  Please forgive me if these all seem like obvious no-no’s; they have happened to otherwise sensible people in the recent past.  People have told me they took the dog on a leash out front to potty but thought it was ok to be off the leash in the back yard (because it has a fence).  Keep in mind the purpose of the leash is for control and I have even seen clients need to use the leash in the house, which is not a bad idea for some dogs.  Protect the surgery, and the dog and everyone will be happier.

LUXATING PATELLAS and REHABILITATION

First and foremost:  pay attention to the discharge instructions your veterinarian has given you if your pet has had surgery for correction of luxating patellas/shifting kneecaps.  Please pay special attention to the part about no running, jumping, or playing.  If your veterinarian did not say so, please note there should not be any flying over couches, galloping up/down stairs, jumping into or out of cars and trucks,  jumping onto couches or your bed, jumping off of couches or beds, twisting very fast in tight circles, sliding on ice, or freedom in and out of doggie doors.  No owner jumping out from behind things to scare the dog into running crazy funny around the house like you sometimes like to do.   No running really means no running to the door when the doorbell rings, no running away from Halloween costumes, no running from one end of the house to the kitchen every time the fridge or a plastic bag is opened, no running to you when you yell to ask the dog if it wants to go outside, and no running inside after the ball, which is very similar to no running outside after the ball.  No, no swimming until your vet or rehab practitioner says so. 

Many cases of luxating patellas do not actually require surgery for correction; your veterinarian and I are able to work together in most cases to devise a plan that immediately reduces pain with medical pain control and gradually reduces pain while increasing thigh muscle & strength with rehabilitation protocol. 

In some cases the patella ceases to luxate when greater thigh muscle is created through strengthening exercises.  In some cases the increased exercise and specific exercise protocol for individual animals does not completely eliminate luxation, however luxation is often reduced and pain is either eliminated or greatly reduced.  These exercises are designed on a case-by-case basis and may include general walking, hill walking, sand walking, sand pile climbing, stairs, and a variety of other exercise physiology-based activities.

For animals with grades 1 and 2 luxation, rehabilitation protocol has worked successfully to reduce pain and/or luxation as well.  Grade 3 luxations are often similarly aided, however depending on the size and lifestyle of the animal or the severity of lameness, your vet may yet recommend surgery.  Grade 4 luxations almost always require surgery to hopefully improve quality of life, especially as your pet ages, and post-op rehab protocol should be advised (a notation of which follows this outline).

Week 1 of active homework may usually be safely begun at suture/staple removal when your vet sees the dog and examines the surgical repair.  Week 1 consists of 2-4 five minute walks per day only.  These should be done very slowly so as to encourage more weight bearing.  When the dog goes too fast, he/she can “cheat” and not use the repaired leg much or well.  Too fast could also prolong the inflammation and pain as well as damage the repair.  There should be at least two-hours’ rest in-between each walk session.  These walks are to be purposeful exercise and are separate from potty walks.  Potty walks during this time should be in and out with business getting done separately from the five-min. walks.  Outside sniffing for four minutes and walking for one minute does not constitute the weight-bearing, purposeful exercise we hope to accomplish.  Please stop exercises for the day if you go to do the next set and your dog will no longer use the leg, is more swollen or is more lame in another manner.  Use the time to apply ice to the surgery site according to icing instructions provided.  If your dog continues this way into the next day, do not hesitate to call your vet or me regarding the issue.  Do call especially if you happen to know of an incident like the ones listed above that could have caused an injury to the repair site.

Week 2 is just like week 1 but the walks are for ten minutes instead of five.  Ten minute walks should only be begun if 3-4 five min. walks are able to be accomplished without producing greater lameness.

Week 3 consists of only two walks per day for a duration of fifteen minutes.  All the other rules and restrictions still apply.  Do not begin week three unless your dog is able to do at least three ten min. walks per day without greater lameness.

Week 4 is the same as above and the walks are to be twenty minutes in length.  2x20. Still no running, jumping, playing or swimming.

Rehabilitation should continue for six to eight weeks.  Exercises beyond week 4 are not listed in this paper because these exercises should be designed on a case-by-case basis, more definitively than weeks 1-4.  Often owners relax around week 4, especially if things seem to be going very well.  If a rehab consult is not possible for an owner at week 5, then restrictions and exercises as per week 4 should be continued until an evaluation is made and new exercises are given or for the duration of the post-op restriction period suggested by your veterinarian.