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Rehabilitation

Just like in people, dogs can benefit from participating in rehabilitation after surgery or injury. Rehabilitation can help decrease pain, improve fitness, and restore function.

The importance of rehabilitation following surgery

Partial or complete rupture of the cranial cruciate ligament (CCL) is one of the most common causes of hind limb lameness in dogs (Taylor-Brown et al. 2015). It can result in pain commonly associated with lameness, muscle atrophy (loss of muscle) and poor limb function (use of the limb) as a result of dynamic joint instability, even after surgical intervention designed to stabilise the joint (Monk et al. 2006).

Following injury or surgery, joint biomechanics or joint structure, motion and function and proprioception or the sense in which we perceive joint position and balance are affected. Even successful surgery may not result in a return to full function or neuromuscular control (the unconscious trained response of muscles to activate and stabilise the joint during dynamic activities) and can lead to the development of osteoarthritis. This has been confirmed in human medicine (Risberg et al. 2001).

The goals for the surgical management of CCL disease are not only to stabilise the joint but also to minimise pain in the short and long term, minimise complications from arising, and restore normal gait and function, allowing the patient to return to normal activities. Restoring range of motion, muscle strength, neuromuscular control and proprioception is essential to this and will minimise the progression of stifle joint osteoarthritis in the future for patients.

Problems commonly arise following CCL surgery including pain associated with lameness, reduced range of motion into flexion and extension, muscle atrophy and reduced muscle strength, modified gait pattern, reduced weight-bearing, reduced function, and a risk of reduced function a late meniscal tear. An early referral to physiotherapy will assist in identifying these problems. Addressing them early will likely achieve a better outcome.

What is physiotherapy?
Physiotherapy helps restore and maintain movement and function for individuals affected by injury, illness or disability through movement and exercise, manual therapy, electrotherapy, education and advice. It is a science-based profession and takes a ‘whole-person’ approach to health and well-being, including the patient’s general lifestyle (Chartered Society of Physiotherapy, 2018).

Physiotherapy begins immediately following anterior cruciate ligament repair in human medicine. Evidence shows that this minimises muscle atrophy, restores joint range of motion, strength and function and minimises the progression of osteoarthritis (Shelbourne and Nitz, 1990, Tyler et al. 1998, Shaw et al. 2005). There is no evidence suggesting a risk to the surgical repair or increased pain during early physiotherapy intervention.

Evidence is growing to show that the same applies following CCL surgery (Millis et al. 1997, Marsolais et al. 2002, Weigel et al. 2005, Monk et al. 2006, Berte et al. 2012, Millis and Ciuperca, 2015, Baltzer et al. 2018, Kirkby Shaw et al. 2020). A few years ago, patients who had undergone surgery for CCL disease were often not referred for physiotherapy and rehabilitation. The timing and quality for patients referred varied greatly, with some being referred at 6-8 weeks post-surgery following re-examination and repeat radiographs or when patients were not progressing as expected and some being given formal (in-person) versus informal (advice sheet) treatment. Many patients were referred straight for hydrotherapy after their veterinary re-examination at 6-8 weeks.

There is growing awareness of the benefits of physiotherapy and rehabilitation, and patients are now being referred immediately. Eiermann et al. 2020 reported recommendations for rehabilitation after surgical treatment of CCL disease in dogs by veterinary surgeons performing extracapsular stabilisation and tibial osteotomy procedures, with 71% of respondents recommended post-surgical rehabilitation. Patients undergoing extracapsular repair were twice as likely to be recommended rehabilitation. Post-surgical rehabilitation programmes are patient-centred and tailored according to the stage of tissue repair and individual progress, hence the requirement for re-examination and appropriate treatment progression during this period.

Joint range of motion (movement) following CCL surgery may be affected by pain, post-surgical swelling or soft tissue tightness and maintaining or restoring it should begin immediately post-surgery. Full range of motion is required for dogs to engage in normal functional activities such as the need for flexion (bend) in sitting and the need for extension (straightness) at end stance (weight-bearing) phase in the gait for push-off. There is also an association between loss of flexion or extension of more than 10 degrees and worse clinical lameness scores after tibial plateau levelling osteotomy (TPLO) surgery therefore, treatment should be implemented early to prevent ongoing lameness (Jandi and Schulman, 2007). Range of motion should be regained within the first two weeks post-surgery before the physiological changes within the healing tissue limits this.

Reduced muscle activity caused by pain and excess joint fluid results in muscle atrophy, commonly identified following CCL rupture and will continue to worsen for up to five weeks post-injury, regardless of whether surgery has been performed (Millis et al. 1999, Francis et al. 2006). Physiotherapy and rehabilitation aim to minimise muscle atrophy, and improvement of this is only seen at ten weeks following CCL rupture. Therefore, most protocols recommend off-lead exercises beginning any time between 10-14 weeks post-surgical repair when the stifle remains weak and lacks neuromotor control. This is a time when the stifle is particularly vulnerable to a late meniscal tear.

One of the earliest studies looking at the effect of rehabilitation on limb function following TPLO surgery looked at home exercise versus intensive physiotherapy (Monk et al.2006). The home exercise group was provided with routine post-surgical advice, including controlled lead exercise increased incrementally over the first six weeks. The intensive physiotherapy group started immediately post-surgery and included ice therapy, passive range of motion exercises, functional weight-bearing exercises including underwater treadmill therapy and controlled lead walking over the first six weeks. Intensive physiotherapy restored thigh circumference and stifle flexion and extension at six weeks post-surgery with a significant improvement over the home exercise group. There was no significant difference in lameness scores and the ability to weight bear in the affected limb.

It is not possible to measure muscle strength in dogs, but in human medicine, the degree of quadriceps muscle atrophy is proportional to strength (Järvelä at al 2002); therefore, improvements in thigh circumference are likely to improve strength. The soft tissues act as the biological scaffold to a joint. Therefore, maintaining muscle mass and restoring strength will help restore function, prevent reinjury and offset excess loading forces on a joint, minimising the progression of osteoarthritis.

Early weight-bearing is essential to help restore normal proprioception and neuromuscular control, therefore, minimising the risk of meniscal tears. They are factored into the physiotherapy treatment plan and home exercise recommendations in most if not all rehabilitation programmes from day one post-surgery. Many breeds are vulnerable to rupture of the contralateral (opposite) CCL. Early rehabilitation to restore full weight-bearing, strength and dynamic joint stability in the affected limb may reduce the likelihood of this occurring (Monk et al, 2006). Rehabilitation will also enhance strength and dynamic joint stability of the contralateral limb, reducing the risk of injury.

A veterinary physiotherapist is a multi-disciplinary team member, and working closely as a team will optimise the treatment outcomes for patients post CCL surgery. Regular physiotherapy input increases caregiver compliance for post-surgical recommendations. Procedures to improve stifle stability in the case of CCL disease have limitations on what the patient can do immediately post-surgery to prevent surgical failure, allowing the bone and soft tissues to repair. Owners are provided with lots of information when their dog is discharged from hospital and may not understand the importance of this information. Reiterating post-surgical advice and explaining tissue healing and treatment progression will prevent secondary complications from arising.

Minimising the onset and progression of osteoarthritis is one of the primary objectives for CCL surgery. Osteoarthritis results in pain, reduced function and quality of life, and therefore restoring range of motion, muscle strength and neuromuscular control, and pharmacological and weight management are key components in the management of osteoarthritis (NICE Guidelines, 2014). We do, however, need more high quality, large-scale randomised controlled trials with long term follow-up that assess the effects of different post-surgical rehabilitation programmes.

References
Baltzer, W.I., Smith-Ostrin, S., Warnock, J.J. and Ruaux, C.G., 2018. Evaluation of the clinical effects of diet and physical rehabilitation in dogs following tibial plateau leveling osteotomy. Journal of the American Veterinary Medical Association, 252(6), pp.686-700.

Berté, L., Mazzanti, A., Salbego, F.Z., Beckmann, D.V., Santos, R.P., Polidoro, D. and Baumhardt, R., 2012. Immediate physical therapy in dogs with rupture of the cranial cruciate ligament submitted to extracapsular surgical stabilization. Arquivo Brasileiro de Medicina Veterinária e Zootecnia, 64, pp.01-08.

Eiermann, J., Kirkby‐Shaw, K., Evans, R.B., Knell, S.C., Kowaleski, M.P., Schmierer, P.A., Bergh, M.S., Bleedorn, J., Cuddy, L.C., Kieves, N.R. and Lotsikas, P., 2020. Recommendations for rehabilitation after surgical treatment of cranial cruciate ligament disease in dogs: A 2017 survey of veterinary practitioners. Veterinary Surgery, 49(1), pp.80-87.

Francis, D.A., Millis, D.L. and Head, L.L., 2006. Bone and lean tissue changes following cranial cruciate ligament transection and stifle stabilization. Journal of the American Animal Hospital Association, 42(2), pp.127-135.

Jandi, A.S. and Schulman, A.J., 2007. Incidence of motion loss of the stifle joint in dogs with naturally occurring cranial cruciate ligament rupture surgically treated with tibial plateau leveling osteotomy: longitudinal clinical study of 412 cases. Veterinary Surgery, 36(2), pp.114-121.

Järvelä, T., Kannus, P., Latvala, K. and Järvinen, M., 2002. Simple measurements in assessing muscle performance after an ACL reconstruction. International journal of sports medicine, 23(03), pp.196-201.

Kirkby Shaw, K., Alvarez, L., Foster, S.A., Tomlinson, J.E., Shaw, A.J. and Pozzi, A., 2020. Fundamental principles of rehabilitation and musculoskeletal tissue healing. Veterinary Surgery, 49(1), pp.22-32.

Marsolais, G.S., Dvorak, G. and Conzemius, M.G., 2002. Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs. Journal of the American Veterinary Medical Association, 220(9), pp.1325-1330.

Millis, D.L., Levine, D., Brumlow, M. and Weigel, J.P., 1997. A preliminary study of early physical therapy following surgery for cranial cruciate ligament rupture in dogs. Vet surg, 26(2), p.434.

Millis, D.L., Levine, D., Mynatt, T. and Weigel, J.P., 1999, August. Changes in muscle mass following transection of the cranial cruciate ligament and immediate stifle stabilization. In Proceedings of the First International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine (p. 155).

Millis, D.L. and Ciuperca, I.A., 2015. Evidence for canine rehabilitation and physical therapy. Veterinary Clinics: Small Animal Practice, 45(1), pp.1-27.

Monk, M., Preston, C. and McGowan, C., 2006. Effects of early intensive postoperative physiotherapy on limb function after TPLO in dogs with deficiency of the cranial cruciate ligament. Am J Vet Res, 67, pp.529-536.

Risberg, M.A., Mørk, M., Jenssen, H.K. and Holm, I., 2001. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. Journal of Orthopaedic & Sports Physical Therapy, 31(11), pp.620-631.

Shelbourne, K.D. and Nitz, P., 1990. Accelerated rehabilitation after anterior cruciate ligament reconstruction. The American journal of sports medicine, 18(3), pp.292-299.

Taylor‐Brown, F.E., Meeson, R.L., Brodbelt, D.C., Church, D.B., McGreevy, P.D., Thomson, P.C. and O’Neill, D.G., 2015. Epidemiology of cranial cruciate ligament disease diagnosis in dogs attending primary‐care veterinary practices in England. Veterinary Surgery, 44(6), pp.777-783.

Tyler, T.F., McHugh, M.P., Gleim, G.W. and Nicholas, S.J., 1998. The effect of immediate weightbearing after anterior cruciate ligament reconstruction. Clinical orthopaedics and related research, (357), pp.141-148.

Weigel, J.P., Arnold, G., Hicks, D.A. and Millis, D.L., 2005. Biomechanics of rehabilitation. Veterinary Clinics: Small Animal Practice, 35(6), pp.1255-1285.

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