Comparative Animal Physiotherapy Modalities

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Introduction

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 a large basket of tools available to the therapist, it becomes important to know which modality is the most effective for the condition been treated.

1. Electrotherapy modalities:

1.1 Therapeutic ultrasound

The thermal effects of therapeutic ultrasound 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

Increase of (degree celcius	Causes	Result
1 - 2	Increase in metabolic rate	rate by 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 temp by 2 – 4 deg. C
• A dosage of 1.0 W/cm2, 3.3MHz, for 5-10 min, is recommended to cause sufficient heating in tendons in both canine and equine literature.
• A window period for stretching does exist = 5 min post treatment
• Heating effect is better obtained with continuous US
• Collagen dense tissue absorbs more energy than adipose tissue.
• Heating effect on epaxial muscles was poor, less than 2 deg. C (2-4 deg. C needed to reduce pain & inflammation), thus was not effective.
• A species variability exists. Human tissue warms quicker than canine.

Non-thermal effects:

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

Use in veterinary medicine:

• Warm 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

Contraindications:

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

Precautions:

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

Challenges:

• Hair
  • The therapist may need to clip or shave, always get owners 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
  • The animal verbalise discomfort. Always make sure you are aware of their 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 muscle 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

Indications

• Post-op 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 time of treatment.
• Acute = 30 – 150 Hz, 50 – 100 us, amplitude – just below sensation, time – 2x/day for 15 min
• Chronic = time – 15 – 60 min / day
• Electrodes may be placed on relative dermatomes, along main nerves proximal to 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 spinal column).

Precautions

• Rarely side effects but may develop tolerance if used often – change parameters.
• 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. Use in veterinary medicine

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

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 been treated
• Electrodes must have low resistance, be flexible, be highly conductive & reusable
• Wipe electrodes after use with water and paper towel

Contraindications

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

Precautions

• Impaired sensation
• Areas of skin irritation or damage

1.2.3 Faradism (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 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

Effects:

• Neovascularization by causeing capillary micro ruptures and increasing growth factors release
• Mast cell activity increased which improves immune tolerance/pathogen defense 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 edema
• Release of trigger points by unblocking the calcium pump

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

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
• Area prep is important. Always clip the hair and apply coupling gel
• Restraint of the patient for 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

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 ( wounds and ulcers,   strains and sprains, contusions)

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
• Postoperative - 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 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
• Over growth 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 rolls/ glides/ slides – accessory movements.

Considerations

• Quadruped biomechanics
• Reciprocal apparatus
• Large extensive fascial system in the equine patient
• Concept of moving segments as opposed to individuals structures.
• NB ++ assess, assess, assess – before, during and after the technique
• Non-verbal feedback
• Safety of the therapist during execution of the technique
• Techniques have demonstrated clinical efficacy although not much research has been done in animal use yet.
• Feed back form owner or handler is necessary to help assess modification of technique, 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 – Wobblers
• New/ unstable fracture
• Osteoporosis
• History of aneurysm
• Local CA
• Increase of pain or inflammation

Precautions

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

Assess before, during and after the technique.

Note

• Unexpected weakness
• Lethargy
• Increased pain / stiffness
• Reduced weight bearing
• Ataxia
• End feel ( keep in mind when assessing)
• Spasm ( in encountered during mobs, perform more slowly)

2.2.  Soft tissue mobilisation

Types of Manual Therapy

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.
• Evidence exist for benefit in dogs with distal femoral physeal fractures ( to avoid tie down of quads)
• used for elbow ROM after distal humeral fracture
• Beneficial following cranial cruciate ligament rupture repair

2.1.2 Soft Tissue Techniques

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

Enhances joint and spinal mobility and soft tissue extensibility by reducing adhesions and improving mobility of tissue layers.

• Manual lymphatic drainage:

- post operative to reduce swelling

2.1.3 Neural mobilization

Indications

• Mobilization of neural tissue to allow for dispersion of intra neural 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 is the animal’s coping mechanisms the 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

• A working tool on patients between sessions
• Can be placed on for 30 min – 2  days
• Assists in rehab in any phase
• 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 – however, limited with 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 immobilization are on tissue and thus determine the dose and amplitude of the exercise. Prior to starting a rehabilitation program 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 chance of musculoskeletal injuries
• To provide mental stimulation

Side effect with aqua therapy

• Dry hair
• Dry skin
• Abrasive wounds in 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 a natural born swimmer
• Swimming increases the heart rate to 200 bpm
• Should not be  swum if they only use their hind/fore limbs
• 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 and use a horse walker

3.2.3 Therapeutic exercises

In horses:

• Core training using baited movements.
• In hand work 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/ ADL
• Enhance performance
• Address areas of weakness/ stiffness/ hyper/hypomobility
• Provide an effective controlled home exercise program for owner to follow.

Considerations

• Have knowledge of the pathology and the prognosis – work with vet
• Gradually load tendons
• Proprioceptive input – simple at first
• With soft tissue injuries – work on a firmer surface first and progress to soft
• With bone/ joint injuries – work on a softer surface and progress to harder
• 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 – 16deg 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 min 20 min was found to be effective

Heating Effects

• In horses only superficial tissues where heated with external heat
• In dogs heat compress did heat tissue at all levels if applied for 10 min