Rehabilitation therapy for orthopedic conditions (Proceedings)

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Rehabilitation therapy for orthopedic conditions (Proceedings)

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Nov 01, 2010

Annapolis Junction, MD



There are numerous studies indicating the positive benefits of rehabilitation therapy following CCL surgery. In summary, rehabilitation therapy has been shown to improve muscle mass and attenuate muscle atrophy that occurs in the post-operative period, increase stifle joint ROM, especially extension, improve weight-bearing as measured by force plate analysis, and reduce the progression of osteoarthritis.

Rehabilitation guidelines following stifle surgery are structured to direct the clinician in returning dogs to pre-injury activity levels as quickly and safely as possible. Criterion-based protocols eliminate subjective progression through rehabilitation by dictating the milestones that must be reached in order to progress to the next phase. The rate of progression can differ between dogs and is dependent on the individual rate of healing and the demands of the dog's activity level. Also, clinicians should prescribe therapeutic interventions within each phase that are tailored to the patient's needs. Prescribing therapeutic interventions in a 'cookbook' fashion for each particular diagnosis is committing a disservice to the patient.

Three phases of rehabilitation are included for recovery in dogs: the acute phase, advanced phase, and return-to-play phase (Table 1).

Acute Phase



In the acute phase of rehabilitation, strategies are focused on controlling the effects of inflammation (pain, effusion, loss of motion, and muscle atrophy). The goal of the acute phase is to revise full range of motion, reduce effusion, retard muscle atrophy, and ambulate without assistance (Table 2). Cryotherapy, Laser therapy, NMES, TENS, passive range of motion, and compression of the affected limb can assist in counteracting the effects of inflammation and edema. A combination of low-load sustained stretching, joint mobilizations of the patella and tibiofemoral joints, and modalities to control pain and resultant muscle spasm are commonly performed following CCL surgery.

Cryotherapy

Cryotherapy (Ice compresses) following CCL surgery provides an excellent method to help control pain and inflammation in the immediate postoperative period. Not only is cryotherapy beneficial in the acute phase of tissue injury and inflammation, it is also advantageous after exercise and throughout rehabilitation when inflammation occurs. The effects of cryotherapy include vasoconstriction, decreased blood flow, reduced cellular metabolism and permeability, attention of traumatic or exercise-induced edema, and decreased muscle spasm. Another primary effect of cryotherapy is analgesia, which is thought to be a result of decreased sensory and motor nerve conduction velocity that occurs when nerve fibers are cooled.

Cryotherapy following CCL surgery can be accomplished with a variety of methods. The simplest way is by placing crushed ice in a sealed plastic bag and than wrapping the bag in a thin towel. Alternatively, you can prepare a mixture consisting of two parts water and one part alcohol in a double-sealed plastic bag and place it in a freezer. The resulting pack should be frozen slush that conforms to any surface. Apply the cold pack to the stifle for 15 to 20 minutes immediately after surgery while the patient is still recovering from anesthesia. Be careful when applying cold packs to patients that are already hypothermic postoperatively. Following CCL surgery cryotherapy is used for the first three or four days to help minimize inflammation, swelling, and pain from surgery. Apply the cold compress for 15 to 30 minutes three or four times a day. Monitor the patient for discomfort, and assess the tissues periodically for signs of adverse effects such as white or pale areas. Do not use cryotherapy in patients with poor or absent pain sensation. Cryotherapy will be a valuable part of the home rehabilitation program once the patient is discharged (Tables 1-3).

Laser Therapy

L.A.S.E.R. (Light Amplification by Stimulated Emission of Radiation) therapy is a modality that is commonly used in our practice during the postoperative period. Laser therapy, also known as phototherapy and low level laser therapy, involves the application of low power coherent light to injuries and lesions to stimulate healing and reduce pain. It is used to increase the speed, quality and strength of tissue repair, resolve inflammation and give pain relief.

Using photochemical processes, laser light inserts bio-photons into damaged cells. The cells begin to produce energy (ATP), which improves their function and assists their division. Laser therapy promotes healing in the postoperative period because it penetrates the skin, increases the ATP and activates enzymes in the targeted cells. Laser therapy has been shown to stimulate growth factor response within the cells and tissue as a result of increased ATP and protein synthesis. It has also been shown to improved cell proliferation. The effects of pain relief is due to a result of increased endorphin release. Laser therapy has also demonstrated the ability to strengthening the immune system response via increasing levels of lymphocyte activity.

The main advantages of the use of Laser therapy following CCL surgery is due to its benefits of enhanced wound care and tissue repair, anti-inflammatory properties, and ability to assist with pain control. Following CCL surgery, laser therapy is typically performed daily for the first 24-72 hours followed by weekly treatments and is targeted to the incision as well as the stifle joint. The specific use and details of laser therapy can be found elsewhere within this text.