Comparative Animal Physiotherapy Modalities

Original Editor - Cheryl Danks Top Contributors - Carin Hunter, Kim Jackson, Tarina van der Stockt, Robin Tacchetti, Jess Bell and Olajumoke Ogunleye

Introduction

Animal physiotherapy is a specialist field that has been gaining more acceptance and has been successfully used with companion and farm animals. Interventions can be similar to human physiotherapy with the use of modalities. When using modalities for animal physiotherapy the goals are:

1. Promote healing process
2. Decrease pain
3. Restore normal movement patterns
4. Increase cardiovascular fitness level
5. Increase and maintain muscle strength

There are various physiotherapy modalities that can be used in the treatment of animal patients. These modalities include manual techniques, electrotherapy, exercise and proprioceptive rehabilitation and hot or cold treatment. All these modalities are used based on the applied science of human physiotherapy. With such a large basket of tools available to the therapist, it is important to know which modality is the most effective for the condition being treated.

1. Electrotherapy modalities:

1.1 Therapeutic ultrasound

The thermal effects of therapeutic ultrasound (US) cause tissue heating, due to the molecular oscillation within the tissue as they absorb the sound wave energy. An increase in tissue temperature has different effects in the tissue (see Table 1).

Increase of (degrees celsius)	Causes	Result
1 - 2	Increase in metabolic rate	By approximately 13%
3 - 4	Reduction in pain and spasm	Reduces inflammation and increases blood flow
4	Increased extensibility of tissue	Mainly collagen

Table 1. Effects of increased tissue temperature

• Recommended raise in temperature by 2 – 4 degrees Celsius (deg. C)
• A dosage of 1.0 W/cm2, 3.3MHz, for 5-10 minutes, is recommended to cause sufficient heating in tendons in both canine and equine literature
• A window period for stretching does exist = 5 minutes post-treatment
• Heating effect is better obtained with continuous US
• Collagen dense tissue absorbs more energy than adipose tissue
• The heating effect on epaxial muscles was poor, less than 2 deg. C (2-4 deg. C is needed to reduce pain and inflammation), thus it was not effective
• A species variability exists. Human tissue warms more quickly than canine.

US Non-thermal effects:

• Increase in inflammatory phase in healing tissue
• Promotes ion transport across cells
• Increases cell permeability
• Increases fibroblast protein synthesis
• Promotes shifts in extracellular ion concentration gradients

US use in veterinary medicine:

• Warms connective and peri-articular tissue prior to stretching
• Used in conditions that cause tightening or contractures of the structures – post-surgery, post prolonged immobilization
• Care must be taken to avoid breakdown or laxity of tendons during the healing phase
• Pain relief
• Care must be taken not to exacerbate bleeding in the initial inflammatory phase
• Soft tissue healing
• Low doses ( 0.1/0,2 w/cm2 ) may promote healing in delayed union or complicated fractures

US contraindications:

• Cancerous tumor / carcinoma
• Active hearmorrahage
• Active infection / genital / eyes
• Pregnant uterus
• DVT

US precautions:

• Ischemic areas
• Areas of decreased sensation
• Implants
• Skin conditions
  

US challenges:

• Hair
  • The therapist may need to clip or shave - always get the owner's permission
• Awkward surfaces
  • The therapist may require a large amount of coupling gel
• Personal safety in treating certain limb parts e.g. hind leg of a horse
• Non-verbal communication
  • Always make sure you are aware of the animal's body language

1.2 Electrical Muscle Stimulation

Definitions

• TENS (Transcutaneous Electrical Nerve Stimulation) is associated with pain control
• NMES (Neuro Muscular Electrical Stimulation) is used to treat muscles that are innervated by a motor neuron
• EMS (Electrical Muscle Stimulation) is associated with muscle strengthening and re-education. It can be used to treat muscles that are denervated and require muscle firing through electrical stimulation

1.2.1 TENS

TENS indications

• Post-operative pain relief
• Arthritic pain relief
• Injury recovery
• Neuropathy
• Assists in relaxation and better functioning
• Can be used before / during / after exercise and in different phases of healing
• Assess acute / chronic pain as this will determine the time of treatment
• Acute = 30 – 150 Hz, 50 – 100 us, amplitude – just below sensation, time – 2x/day for 15 minutes
• Chronic = time – 15 – 60 minutes / day
• Electrodes may be placed on relative dermatomes, along the main nerves proximal to the origin of pain, paravertebrally or to contralateral ‘mirror’ sites

Two types of TENS:

1. Conventional TENS uses high frequency (HF), >50 Hz, short pulse width and low intensity. This should be a comfortable sensation with no muscle activation. This is most commonly used and uses the Pain Gate Theory of pain relief
2. Acupuncture TENS uses low frequency (LF), 2 – 5 Hz, longer pulse width and high intensity. This activates muscle twitch (endogenous release of opioids into the spinal column)

TENS precautions

• There are rarely side effects, but animals may develop tolerance if it is used often – change parameters
• Animals may develop skin irritation and contact dermatitis beneath the electrodes

1.2.2 Micro current

This closely approximates the natural occurring bioelectrical currents in the body and augments the body’s natural healing process and repair.

Micro current uses

Dogs:

• Soft tissue injuries
• Paw issues
• Wound healing
• Decreases scar tissue
• Body soreness
• Speeds up healing

Equine:

• Joint inflammation
• Bowed tendons
• Arthritic conditions
• Colic
• Pulled muscles
• Suspensory ligament
• Cartilage damage
• Bucked shins
• Muscle spasms
• Pinched nerves
• Trauma
• Sore back
• Laminitis
• Splints
• Ring bone
• Post performance
• Pre performance
• Wound healing

Micro current considerations

• The patient cannot verbalise what they are feeling, so always make sure you are watching their body language
• Clip the area of excess hair
• Clean with alcohol or water to remove debris under electrode placements
• Use a contact medium
• Electrode must be sized for the area being treated
• Electrodes must have low resistance, be flexible, be highly conductive and reusable
• Wipe electrodes after use with water and paper towel

Micro current contraindications

• Over heart
• Pacemakers
• Seizure disorder
• Over areas of thrombosis or thrombophlebitis
• Infections / neoplasms
• Carotid sinus
• If active motion is contraindicated
• Pregnant trunk

Micro current precautions

• Impaired sensation
• Areas of skin irritation or damage

1.2.3 Faradism (NMES/EMS)

NMES/EMS uses

• Improve muscle strength following injury
• Reduce disuse atrophy
• Increase joint ROM
• Decrease contracture
• Decrease oedema
• Enhance circulation
  
• Retard loss of volitional control
• Decrease spasticity
• Improve sensory awareness
• Correct gait abnormalities

1.3 Extracorporeal Shockwave therapy

Extracorporeal shockwave therapy(EST) is an acoustic wave. It uses kinetic energy from a projectile created by compressed air, transferred to a transmitter and into tissue. It is widely used in veterinary medicine. There are two types:

1. Focussed
2. Radial

EST effects:

• Neovascularization by causing capillary micro-ruptures and increasing growth factors release
• Mast cell activity is increased which improves immune tolerance / pathogen defence leading to vascular permeability
• Production of pro-inflammatory compounds which restores healing
• Stimulation of collagen production which repairs damaged tissue
• Dissolution of calcified fibroblasts
• Pain reduction by dispersion of substance ‘P’
• Reduces inflammatory oedema
• Release of trigger points by unblocking the calcium pump

EST indications

• Bone fracture
• Cartilage
• Arthritis
• Tendons
• Suspensory ligaments

Clinical Evidence in Equine Medicine

• Proximal suspensory desmitis: A larger number of horses returned to full work compared to injections
• SDFT tendinosis: Significant improvement in lameness and return to work
• Navicular disease: Improvement in lameness when treated over the frog and heel bulb
• Stress  fractures: 90% returned to full racing
• Angular limb deformities in foals: Treating the convex side
• Kissing spine

Clinical Use in Dogs

• Hip and elbow dysplasia
• Shoulder lameness
• DJD
• OA
• Tendons/ ligament injuries
• Non or delayed bone union
• Back pain
• Chronic non healing wounds

EST considerations

• Adverse effects are rare
• In equine use:
  • SWT causes reduced sensory nerve conductivity, thus minimal exercise for 2 days after treatment
  • FEI prohibits the use of shockwave therapy within 5 days of a competition
• Prepping the area is important - always clip the hair and apply coupling gel
• Restraint of the patient for the safety of the practitioner and equipment
• The treatment area must be defined by x-rays / palpation / scans
• The number of shocks is determined by the surface and cross-sectional area been treated and the vascularization of the tissue
• Chronic injuries may have a less favourable outcome

EST contraindications

• Avoid large blood vessels, nerves, air-filled structures, brain

1.4 Light/ laser therapy

Photomodulation is used in tissue healing. Light stimulation increases cellular activity during healing, has a primary effect on cell proliferation. Mitochondria are receptive to near infra-red spectrum 600 – 1000 Nm.

Effects

• Reduces pain
• Decreases inflammation
• Accelerates healing

Uses

• Skin conditions - wounds, bruising, saddle sores, otitis externa, pyoderma, and pododermatitis
• Musculoskeletal - arthritis, tendonitis, myositis, sprains, strains, back and neck pain, splints, synovitis, muscle spasms
• Post-operative - on wounds, skin grafts
• Other - swellings, haematoma, seroma, ulcers, cellulitis, phlebitis

Considerations

• Clip the hair
• Protect the eyes if using laser
• No contact with the probe on open wounds
• Hold perpendicular to the skin
• Caution in animals with black fur / black skin / tattoo – increased tissue heating through light absorption

Contraindications

• Carcinoma
• Thyroid gland
• Active haemorrhage
• Over autonomic nerve centres
• Pregnant uterus
• Overgrowth plates in immature animals – may cause closure of epiphysis
• Caution in long bones of animals < 1 year

2. Manual therapy

2.1.  OMT

Osteokinematics = physiological movements of the joint that changes its angle.

Arthrokinematics = movement of the joint surfaces as they roll/ glide/ slide – accessory movements.

Considerations

• Quadruped biomechanics
• Reciprocal apparatus
• Large extensive fascial system in the equine patient
• Concept of moving segments as opposed to individuals structures
• Non-verbal feedback
• Safety of the therapist during the execution of the technique
• Feedback from the owner or handler is necessary to help assess modification of technique, the intensity of treatment, safe and effective dosage and progression for optimal functional goals and outcomes
• Improvement in status must be noted between sessions

Assessment prior to choosing technique

• Functional abilities
• Posture
• Gait
• Passive ROM
• Soft tissue palpation
• Joint lines
• Bony prominences
• Special tests, neurological tests ( reflexes, reactions, proprioception)
• Strength, balance, co-ordination

Then consider

• Potential origin of symptoms
• Treatment precautions
• Prognosis
• Neuro-muscular pathology
• Medical history

Goals

• Reduce pain
• Lubrication / nutrition of joints
• Facilitation of muscular contractures
• Improve ROM
• Soft tissue flexibility
• Influence motor control
• Influence muscle tone
• Effect joint/ spinal biomechanics
• Improve function

Contraindications

• Joint/ spinal instability
• C1/C2 laxation
• New/ unstable fracture
• Osteoporosis
• History of aneurysm
• Local cancer
• Increase of pain or inflammation

Precautions

• Older patients
• Long term immobilisation
• Young patient with open growth plates

Note

• Unexpected weakness
• Lethargy
• Increased pain / stiffness
• Reduced weight bearing
• Ataxia
• End feel
• Spasm

2.2.  Soft tissue mobilisation

2.1.1 Range of Motion and Stretching

• To improve ROM
• Increase flexibility
• Prevent adhesions
• Remodelling and realignment or peri-articular fibrosis
• Improved muscle and soft tissue extensibility
• PROM immediately after surgery helps reduce pain

2.1.2 Soft Tissue Techniques

• Myofascial release – reduces adhesions between muscle and fascial tissue
• Scar tissue mobilization
• Trigger point therapy
• Massage

• Manual lymphatic drainage - post operative to reduce swelling
• Enhances joint and spinal mobility and soft tissue extensibility by reducing adhesions and improving mobility of tissue layers.

2.1.3 Neural mobilization

Indications

• Mobilization of neural tissue to allow for dispersion of intraneural oedema
• Lengthening of neural tissue
• Improved blood flow
• Potential improvements in axonal transport

General contraindications

• Severe muscle spasm/ guarding
• Know fractures
• Acute muscle tear
• Ligament strain
• Contusion/ hematoma
• Neurological condition

General precautions

• Releasing secondary spasm may make the animal more lame
• If the spams/ stiffness are the animal’s coping mechanisms then don’t remove it – e.g. arthritic joint
• Be aware of treatment soreness- watch the body language
• Be aware of a certain amount of muscle tone/ fascial tightness that is necessary for proprioception and stability. Especially in racing horses or completion dogs.

3. Rehabilitation

3.1. Functional taping

• Can be placed on for 30 min – 2  days
• Assists in rehabilitation in all phases
• Use in muscular conditions, postural imbalances, fascial restrictions
• Goal is to assist the body’s self-healing potential to bring tissue back into homeostasis
• Can be combined with other modalities

Effect of taping

• Lifts skin to create space, this can be limited by hair
• Fascia – unwinding, redirection of movement
• Muscle – optimization of function
• Lymphatic – decongestion of fluid redirection
• Joint – realignment through direct proprioceptive action in ligaments or indirect through muscle control

3.2 Exercise prescription

The restoration of optimal function and lifestyle following a disease or injury. Important to know what the effects of immobilisation are on tissue and thus determine the dose and amplitude of the exercise. Prior to starting a rehabilitation programme and the testing thereof during and after is important.

Can incorporate

• Aquatic exercise
• Land treadmill
• Therapeutic exercises

The Setting of Baseline Test

• Gait analysis
• Activities of daily living
• Return to function
• Sport performance

3.2.1 Aquatic exercises:

Uses in Dogs

• Cranial and cruciate ligament ruptures
• Dysplasia
• Osteoarthritis

Uses in Horses

• To increase cardiovascular output
• To facilitate rehabilitation following injury
• To enhance insulin-glucose metabolism
• To alter skeletal muscle fibre composition thus improving fitness
• To reduce the chance of musculoskeletal injuries
• To provide mental stimulation

Side Effects with Aqua Therapy

• Dry hair
• Dry skin
• Abrasive wounds in the armpit of dogs
• Red eye
• Otitis
• Swimming induced colic in horses

Considerations

• Heart and respiratory rate increase, specific to different size dogs
• More strenuous to swim an overweight dog

Aqua Therapy in Horses

• Not natural-born swimmers
• Swimming increases the heart rate to 200 bpm
• Should not be swum if they only use either their hind or forelimbs
• Should not be swum if they tend to kick out to the side
• Evidence shows better use for maintaining condition and fitness

3.2.2 Land Treadmill

This is a good way of looking at joint mobility.

3.2.3 Therapeutic Exercises

In horses:

• Core training using baited movements
• In handwork on ground for proprioception, different surfaces
• Work under saddle – straight lines / pole work / gymnastics / hill work / grids
• Stretching
• Lunging / long reining
• Training aids such as the neuromuscular facilitation effect of the abdominal and hind Theraband system

In Dogs:

• Slow walking
• Wheel-barrowing
• Ball balancing
• Incline / decline walking – ascending / descending stairs
• Cavaletti walking
• Sit-stand

Reasons for rehab:

• Strengthening
• Gradual loading of tendon / bone/ ligament / joint
• Restore proprioception
• Sports specific re-education
• Reduce the chance of re-injury
• Ensure that the patient is fully recovered and ready to return to sport / ADLs
• Enhance performance
• Address areas of weakness / stiffness / hyper or hypomobility
• Provide an effective controlled home exercise program for owner to follow

Considerations

• Have knowledge of the pathology and the prognosis – it is important to work with the veterinarian
• Gradually load tendons
• Proprioceptive input – simple at first
• With soft tissue injuries – work on a firmer surface first and progress to soft surfaces
• With bone / joint injuries – work on a softer surface first and progress to harder surfaces
• The longer the patient is out of work the longer it may take to fully recover

4. Hot and Cold Therapy

Cooling Effects

• Cold water ( 6 – 16 deg. C) was shown to be more effective than cool packs / crushed ice or cooling splints,  in cooling of tissue in horses
• In dogs, cold compression for 20 minutes was found to be effective

Heating Effects

• In horses, only superficial tissues were heated when external heat was applied
• In dogs, a heat compress did heat tissue at all levels if was applied for 10 minutes