The benefits of physiotherapy during

revalidation after orthopedic surgery in

small animals

Word count: 8549

Maïté Achten Student number: 01103469

Supervisor: Dr. Yves Samoy

Supervisor: Prof. dr. Bernadette Van Ryssen

A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree

of Master of Veterinary Medicine

Academic year: 2017 - 2018

Ghent University, its employees and/or students, give no warranty that the information

provided in this thesis is accurate or exhaustive, nor that the content of this thesis will not

constitute or result in any infringement of third-party rights.

Ghent University, its employees and/or students do not accept any liability or responsibility for

any use which may be made of the content or information given in the thesis, nor for any

reliance which may be placed on any advice or information provided in this thesis.

Foreword

The realization of this dissertation would not have been possible without the direct and indirect help of the following people. First of all, I would like to thank my supervisor, Dr. Yves Samoy. He was always able to come with solutions and prepositions whenever I was overwhelmed with information or data. He was able to remain calm in stressful times, which always gave me support and confidence, in order to persevere in writing this thesis. Secondly, I would like to thank my co-promotor, Prof. Dr. Bernadette Van Ryssen, who always was and still is able to lighten me up with her enthusiasm. I would also like to thank the entire department of orthopedics at the Faculty of Veterinary Medicine in Ghent, for the stimulation to be critical about the study performed in this dissertation and in others, and for the stimulation to remain innovative. I would also like to show my gratitude to all dog owners, who were so kind to participate in this study and who were willing to sacrifice their time in order to establish this study. Lastly, I would like to thank my boyfriend, friends, family, neighbours and colleagues for the support while writing this dissertation, without them this would not have been possible.

Table of contents

1. Abstract 6 2. Samenvatting 7 3. Literature 8

3.1) History 8 3.2) Definition and categories 8

3.2.1) Manual therapy 8 3.2.2) Therapeutic modalities 9 3.2.3) Therapeutic exercises 9

3.3) Obtaining a physiotherapeutical program 9 3.4) Physiotherapy and nutrition 10 3.5) Physiotherapy and its effect on tissue 10

3.5.1) Effect on muscle tissue 11 3.5.2) Effect on tendon and ligaments 11 3.5.3) Effect on cartilage tissue 11 3.5.4) Effect on bone tissue 11 3.5.5) Effect on joint capsule 12

3.6) Measuring methods 12 2.6.1) Activities of Daily Living (ADL) and Return to Function 12 2.6.2) Muscle mass and muscle strength 12 2.6.3) Stance analysis 12 2.6.4) Gait analysis 13

4. Issue and purpose 14 5. Material and methods 15 6. Results 16 7. Discussion and conclusion 19 8. References 21 9. Attachments 24

List of abbreviations

- ADL = Activities of Daily Living - ACVS = American College of Veterinary Surgeons - APTA = American Physical Therapy Association - AVMA = American Veterinary Medical Association - BCS = Body Condition Score - CBPI = Canine Brief Pain Index - CCL = Cranial Cruciate Ligament - CT = Computerized Tomography - GPS = Global Positioning System - HCPI = Helsinki Chronic Pain Index - MCS = Muscle Condition Score - MRI = Magnetic Resonance Imaging - NMES = Neuromuscular Electrical Stimulation - NRS = Numerous Continuous Scales - PVF = Peak Ventral Force - ROM = Range Of Motion - TENS = Transcutaneous Electrical Nerve Stimulation - TPLO = Tibial Plateau Levelling Osteotomy - TSCI = Texas Spinal Cord Injury Score - VAS = Visual Analogue Scales - VI = Vertical Impulse

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1. Abstract

Small animal ownership is increasing in many countries, and the demand for effective postoperative and post-injury treatment is increasing with it. The fact that animals are immobilized after surgery or injury is obsolete, considering the negative effects on muscle tissue, cartilage tissue, ligaments and bone tissue. These effects may consist of muscle atrophy, muscular stiffness, loss of function… However, it is challenging to verify the extent a treatment with physiotherapeutical aspects may achieve, since it is mostly combined with other surgical or medicinal treatments and since it is rather difficult to apply a measuring method which is objective, easy to apply, inexpensive, noninvasive and able to discriminate the effectiveness of treatments.

The objective of this study was to be able to determine a potentially faster, better and more efficient healing process in dogs treated with physiotherapy or rehabilitation. As a result, there was found that overall, dogs treated with physiotherapy had similar or slightly better results than dogs without the treatment, mostly considering muscle gain and activity level. The results considering weight support and pain management are quite similar in dogs treated with physiotherapy and dogs not treated with physiotherapy. Most owners and dogs did not experience any load while in the process of treatment. Lastly, there was found that the overall satisfaction of owners of dogs treated with physiotherapy were above average as well, although owners of dogs not treated with physiotherapy practically ended up with similar scores.

This means that there certainly are some benefits correlated to physiotherapeutical treatment during revalidation.

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2. Samenvatting

In verschillende landen neemt het houden van gezelschapshuisdieren toe, en de vraag naar een effectieve postoperatieve en posttraumatische behandeling stijgt aan een vergelijkbaar tempo. Het feit dat gezelschapsdieren na een chirurgische behandeling of na een trauma volledig geimmobiliseerd worden, is achterhaald, gezien de negatieve effecten op spierweefsel, kraakbeenweefsel, ligamenten en botweefsel. Deze effecten kunnen bestaan uit spieratrofie, spierstijfheid, verlies van functie… Het is echter een uitdaging de effecten van een fysiotherapeutische behandeling te objectiveren, aangezien deze meestal gecombineeerd wordt met andere chirugrische of medicamenteuze behandelingen en aangezien geen enkele meetmethode perfect is.

De doelstelling van de dit onderzoek was om de een mogelijks sneller, beter en meer efficiënt genezingsproces vast te stellen bij honden behandeld met fysiotherapie. Als resultaat werd bevonden dat honden behandeld met fysiotherapie over het algemeen iets betere resultaten hadden bekomen, voornamelijk op vlak van toename in spieromtrek en activiteitsniveau. De bekomen resultaten betreffende belasting van de ledematen en managment van pijn zijn vrij gelijkaardig in de groep van honden behandeld met fysiotherapie en honden die de behandeling niet hebben ondergaan. De meeste eigenaars en honden ervaarden de behandeling niet als belastend. Ook was de algemene tevredenheid van deze eigenaars beter dan gemiddeld, hoewel de eigenaars van honden die de behandeling niet ondergingen met gelijkaardige scores antwoordden op deze vraag.

Dit betekent dat er zeker voordelen verbonden zijn aan een fysiotherapeutische behandeling tijdens de revalidatie.

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3. Literature

3.1) History

Traditionally, veterinarians were educated to immobilize patients as much as possible after surgery or trauma, but it had already been proven in human medicine that this immobilization negatively affects the health of the muscles, cartilage, ligaments and bones. (Shumway R., 2007) Physiotherapy in veterinary medicine in Europe has started growing since the mid 1990s, but in the US it already became a point of interest in the late 1980s. Thanks to the American Physical Therapy Association (APTA), the American Veterinary Medical Association (AVMA) and the American College of Veterinary Surgeons (ACVS), meetings and national presentations were organized, thus physiotherapy gained more and more momentum. Increasingly more animals are used to investigate the benefits of physiotherapy, especially in dogs, instead of using them solely as animal models for developing human treatment protocols. However, scientific research in physiotherapy in veterinary medicine is only recently on the increase. These branches are now among the fastest growing ones in veterinary medicine. The growing number of research studies is due to several causes, such as the need to improve postoperative patient care and higher owner expectations, combined with improving education and increasing technical abilities of veterinary clinicians. (Millis D., 2014; Millis D., 2015)

3.2) Definition and categories

Physiotherapy is the general stimulation or the selective treatment of an affected region by natural stimuli. Indications for physiotherapy are legio and include postoperative recovery, neurological conditions, orthopedic conditions, pain control, chronic or progressive conditions and weight loss. (Canapp D.A., 2007) Increasing and maintaining a general condition, restoring and maintaining normal functionality and movement (improving the range of motion), reducing pain and minimizing discomfort, facilitating healing, increasing muscle strength and improving function and strength are only some of the goals we are trying to achieve using physiotherapy. These are general goals, independent of the species. (Samoy Y., 2016) It can be used as a curative treatment or as a form of rehabilitation, but it has preventive means as well. There are lots of individuals who can contribute to animal rehabilitation, provided that these individuals continue their education in order to gain knowledge, such as qualified veterinary physiotherapists, non-specialist vets and even nurses. (Sharp, 2008) However, diagnosis and treatment – medical and surgical – are preserved as a responsibility for the attending veterinarian. (McGowan, 2007)

It has been suggested that rehabilitation would decrease muscle spasm, promote tissue healing and repair, increase range of motion, decrease edema, increase muscle strength and endurance, improve the range of motion (ROM), provide cartilage nutrition and provide orientation and strength of collagen fibers, e.g. in the cranial cruciate ligament (CCL). (Vasseur et al., 1993) It has also been suggested that low impact exercises, including swimming and walking, avoid worsening of osteoarthritis while maintaining muscle strength, joint mobility, and function. Additionally, it has been reported that rehabilitation after joint surgery decreases adhesions, that it is valuable for maintenance of muscle mass, bone, cartilage, and ligaments, and provides the stress needed for reorganization of transplanted tissues. (Marsolais et al., 2002)

According to Prydie and Hewitt (2015) there are three therapeutic categories to accomplish these goals. All of these modalities consist of natural stimuli and are introduced as a natural energy source to the body.

3.2.1) Manual therapy

Fig. 1: Manual therapy (stretching) From: www.dogsinmotion.com.au, last consulted in May 2018

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The first modality is manual therapy. This kind of therapy consists of skilled hand movements that eventually will induce relaxation and lead towards some general goals, such as reduction in pain. It is a conservative treatment method that is mainly indicated for pain relief and improvement of mobility related with neuromusculoskeletal dysfunction. (Saunders D.G., 2005) It includes massage, stretching exercises (as seen on Fig. 1.), tractions, translations and exercises for proprioception and balance. (Millis D., 2014)

3.2.2) Therapeutic modalities

The second category is the use of external energy sources to the body, i.e. the so-called modalities, such as heat therapy and cryotherapy, therapeutic ultrasound with pulsed and continuous waves, electrical stimulation - such as transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) - and laser therapy, in order to create an effect on the tissue that will stimulate and support the healing process. (Saunders D.G., 2005; Prydie D., 2015)

3.2.3) Therapeutic exercises

The third category is the use of therapeutic exercises. According to Millis and Levine (2014), these exercises are the most valuable techniques used in canine physical rehabilitation, because natural muscle stimulation overall is the best way to exercise muscles. They consist of early limb use exercises – such as assisted and active standing exercises, standby assisted standing and aquatic standing – joint motion, strengthening, endurance and speed exercises – such as stair climbing, dancing, wheelbarrowing and cavaletti rails – and aquatic therapy. (Millis D., 2014) These exercises can be designed as a program for the owner to continue in the patient’s home environment. Clear instructions and guidelines are needed in order to proceed the treatment in a safe and effective way, and in order to eventually accomplish the therapeutic goals.

The best results will be achieved when combining these three categories, taking the individual problem list, realistic outcome goals and individual needs and opportunities of every patient into account.

3.3) Obtaining a physiotherapeutical program

It is rather difficult to balance out a physiotherapeutical program in which the application of controlled challenges, where tissue is safely remobilized or supported, and not overchallenged, is performed. If tissues are overchallenged, there may occur damage which can result in additional injury. Unfortunately, it always requires more time to remobilize any musculoskeletal tissue than it takes to cause musculoskeletal atrophy.

According to Sharp (2008), physiotherapy is best combined with a conventional veterinary treatment, such as a medicinal or surgical treatment, whereas it is often complementary to it. There are several authors who have documented the benefits of postoperative physiotherapy, and various physiotherapeutic interventions have been examined. However, in many of these studies, interventions did not commence until 3 weeks after surgery, exercises were not performed by a physiotherapist or a veterinarian who followed an additional education, or there remains a preference for a conservative management of certain conditions in certain type of dogs. (Monk et al., 2006; Comerford et al., 2013)

Table 1 Physiotherapy and its effects

Pain Edema ROM Muscle strengthening

Weight support

Tissue healing

Manual therapy

+ + +

Cryotherapy + + + +

Heath therapy

+ +

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TENS +

NMES + + +

Pulsed waves

+ + +

Continuous waves

+ +

LASER + +

Aquatic therapy

+ + ++ ++ ++

Therapeutic exercise

+ + + + +

Redrawn from: Samoy, Y., 2017. Fysiotherapie, Faculty of Veterinary Medicine, University of Ghent, Merelbeke, Belgium.

Evidently, it is often not possible to perform solely one type of physiotherapy. Every plan of care needs to be customized in order to provide the fastest and most predictable positive outcome for a specific patient. The history and future goals, the severity of the possible injury, the age of the patient… All have to be taken into account in this process. Some patients might require additional medicinal support, such as analgesia or anti-inflammatory drugs. This plan of care should also be adapted to the stage of healing the patient or the tissue is in. For example, icing bags are recommended in the early stage after an orthopedic surgery to reduce pain and edema in the inflammatory phase. A few weeks later, therapeutic exercises are required in order to gain faster and more tissue healing and to enhance the range of motion, muscle strength and weight bearing. (Harasen, 2001) These different types are all able to work synergistically in order to be able to achieve the physiotherapeutical goals.

3.4) Physiotherapy and nutrition

According to Warren et al. (2011) nearly 40% of dogs seen by veterinarians in the USA are categorized as overweight. Globally, there has been estimated that dog obesity levels are between 22 and 40% (White et al., 2011; German, 2006; Courcier et al., 2010). It is essential that the veterinarian or individual who provides the patient’s plan of care raises awareness about the role of nutrition in rehabilitation for the owners. Specifically, obesity has a large impact on the mobility and lameness of the dog. Marshall et al. (2010) state that a reduction of body weight pre-operatively will decrease clinical signs of lameness, which makes surgical intervention sometimes unnecessary. It has been reported as well that the combination of physical therapy with weight reduction has a beneficial effect on the clinical signs of osteoarthritis. (Mlacnik et al., 2006) Another study has described that either including exercise sessions with an underwater treadmill or active client motivation, or both, may improve the rate of weight loss. (Chauvet et al., 2011) A dog with a body condition score (BCS) that is close to normal, will automatically be more active and exercise more than a dog with severe obesity, which results in the fact that physiotherapeutical exercises will be performed more easily and with more pleasure. It is of great importance to not be stuck in this vicious circle.

3.5) Physiotherapy and its effect on tissue

It is obvious that a lot of changes will occur post-operatively in different kinds of tissue, specifically when the limb or the patient would be immobilized for a certain amount of time. Adequate, early physical rehabilitation and active motion can prevent these changes from occurring. (Millis, 2004) Physiotherapy has an effect on all different kinds of tissue, but according to Millis and Levine (2014) muscle tissue, tendons and ligaments, cartilage tissue, bone tissue and the joint capsule respond the

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most to immobilization and remobilization. Following is a summary of the most important, clinical effects of immobilization and remobilization on these kinds of tissue.

3.5.1) Effect on muscle tissue

Immobilization quickly leads to a disuse atrophy because of a decrease in chronic loading of the muscle tissue. According to Monk et al. (2006) muscle mass typically continues to decrease up until 5 weeks after surgery, with only a slight increase by 10 weeks after surgery. This decrease is due to the disuse atrophy, alterations in sarcoplasmatic reticulum function, a decreased protein synthesis, a decreased function of mitochondriae, a reduction in fiber size and an increase of intramuscular connective tissue. This intramuscular connective tissue, among others, is a cause of muscle stiffness during and after immobilization. Muscle strength will rapidly decrease along with muscle mass, during the first week of immobilization. The period following, this strength will continue to decrease, but a more gradual pace. (Latoree et al., 1993; Pette and Staron, 1997; Liu et al., 2005) Early and high- intensity remobilization is preferred in order to stimulate correct growth and orientation of regenerating myofibers. It is known that, when remobilization is performed correctly, the decreased muscle length will readapt rapidly. Mechanical loading is essential in this process. Exercises on the underwater treadmill appear to give excellent results in this case. After a period of 6 to 8 weeks of neural and physiological adaptation, when full function has reoccurred, further progress is due to gradual muscular hypertrophy. (Kannus et al., 1992)

3.5.2) Effect on tendon and ligaments

It is known that immobilization rapidly reduces the mechanical properties of the ligament and tendon tissue, due to stress deprivation. This reduction can result in elastic stiffness in the tendons and ligaments, due to fiber splitting and disorientation of the tensile fibers. By performing physiotherapy on a limb, collagen fiber thickening will be induced. The goal of remobilization is to increase tensile strength and to minimize elastic stiffness and adhesion formations, in order to be able to return to normal functionality of the limb. According to Millis and Levine (2014) having 25-30% of normal tensile strength has been considered adequate for withstanding normal muscle force. Unfortunately, sufficient strength return in consideration of normal weight bearing may take a lot of time. It has to be noted that ligaments heal differently depending on the location. (Kannus et al., 1997)

3.5.3) Effect on cartilage tissue

Articular cartilage is very sensitive to all sorts of immobilization. Considering the decreased joint motion and the reduced loading, it can result in atrophic or degenerative changes, reduced synovial fluid production, arthritic changes, a decrease in matrix and cellular components... depending on the age of the dog and the form of immobilization. In the end, these changes will evidently affect the biomechanical properties of the joint as well. It appears to be essential to expose the cartilage tissue to some regimen of joint motion and loading, in order to maintain the composition and structure of the cartilage. (Setton et al., 1997) When remobilization of the cartilage occurs, it is important to not expose the tissue to high stresses or repeated loading, since injury or damage of the softened matrix may occur. In contrast to remobilization of muscle tissue, mild to moderate levels of exercise are desired since they may stimulate a meaningful adaption, instead of causing detrimental articular changes. According to Millis and Levine (2014), the response of the cartilage tissue depends on the biochemical demand - defined by the duration and the degree of load bearing- that the joint is exposed to, the current condition of the cartilage and the length of the immobilization and remobilization period. Saämänen et al. (1990) suggested that a longer period of immobilization in young dogs may result in more long-standing effects as well, even with a gentle remobilization period. The collagen network needs to be intact in order for the tissue to be able to restore biomechanical properties. (Jurvelin et al., 1989)

3.5.4) Effect on bone tissue

Bone healing consists of two major types of healing, specifically primary and secondary healing. By cause of direct cellular regeneration, it is possible for bone to restore 100% of the original biomechanical properties. This is an almost unique characteristic typically for bone tissue. Physiotherapy performed in a fractured bone stimulates a micromotion between fracture fragments. Stress placed on the bone tissue caused by physiotherapy may not exceed the acceptable

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interfragmentary strain for osteoid deposition, whereas this may result in a reoccurring fracture or in inhibition of bone healing. In the inflammatory phase, it is useful to perform physiotherapy in order to decrease pain, minimize soft tissue inflammation, maintain joint health and an adequate range of motion. During the repairing phase it is useful to maintain the joint health and the range of motion, and to improve callus formation with secondary healing. Unfortunately, the process of repairing and remodeling bone tissue is a relatively slow process that may take months.

3.5.5) Effect on joint capsule

After immobilization, not only the articular cartilage, but also the joint capsule undergoes several changes, which can cause stiffness of the joint with a progressive restriction in the range of motion and an increase in articular pressure. Focal adhesions between the capsule and the subcapsular bursa can be formed and observed. (Schollmeier, 1994) Continued motion of the joint, by means of physiotherapy, can prevent this from happening.

3.6) Measuring methods

It is challenging to verify the extent a treatment with physiotherapeutical aspects may achieve, in other words, to plot the benefits it may create, because of the fact that it is rarely the only treatment used. Most of the time it is combined with a medicinal or with a surgical treatment. Nailing down this extent objectively may also be problematic, as will be discussed further on. According to Millis and Ciuperca (2015), the ideal outcome assessment instrument should be objective, easy to apply, inexpensive, noninvasive and able to discriminate the effectiveness of treatments.

3.6.1) Activities of Daily Living (ADL) and Return to Function

Activities of Daily Living (ADL) and Return to Function are very useful parameters for owners to evaluate the progress, by themselves or by a veterinarian, in their home environment. The completion of several tasks and performing certain activities, such as maintaining a standing position for a given time, climbing the stairs or going for walks without falling or stumbling, are used to check if the patient returns to their normal level of activity and functioning during daily life, as they were used to it before the developed injury and treatment. (Millis, 2004) Another more quantified possibility may be to use pedometers, accelerometers and global positioning systems (GPS) to obtain an idea about the daily activity level of the patient in their home environment. (Millis and Ciuperca, 2015)

3.6.2) Muscle mass and muscle strength

It is possible to evaluate the outcomes purely based on muscle mass and strength, since this can be an indication for improving function and limb use and regaining muscle mass and strength are among the most important goals during physiotherapeutical treatment. This procedure is relatively inexpensive and fast. One can use the muscle condition score (MCS), which is independent form the body condition score (BCS) and which evaluates the muscle mass. This includes visual examination and palpation over temporal bones, scapulae, lumbar vertebrae and pelvic bones. (Baldwin et al. 2010) In order to objectify this method, this practice should always be performed by the same person, at the exact same place on the limb, for example the middle of the thigh. Specific bony landmarks may be used in order to achieve the most accurate measurements when comparing several animals. Additionally, it is important to use the same material, for example a Gullick measuring tape or a spring-tension tape, with the dog standing perfectly straight, during every measurement as long as the study goes on. Needless to say, that this practically is unachievable because of the lack of repeatability. Objectifying an increase in muscle mass would also be possible by working with computed tomography (CT) or magnetic resonance imaging (MRI). Economically speaking, this would be a relatively expensive choice. Practically and ethically, it would mean all patients would have to be brought under anesthesia and they would have to be monitored, which takes a large amount of time and a lot of staff to fulfill this procedure, and which results in a lot of stress for the animals. (Millis and Ciuperca, 2015) Measuring muscle strength is even more challenging than measuring muscle mass and is therefore rarely performed.

3.6.3) Stance analysis

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Impaired limb function can be manifested by a wide range of clinical signs, from an unnoticeable change to complete lameness and avoidance of the limb. (Quinn et al., 2007) It may also be possible that some patients don’t show any clinical signs in movement, but that these clinical signs may appear when they have to bear weight equally on their limbs. In the case of analyzing the patient on the basis of its stance, as an indication of the willingness and ability to place complete weight on a possibly painful limb, it is important that the patient is positioned squarely in a standard position. The observer must pay attention to the placement of the feet of the patient. If physically possible, balancing the dog on both palms of the observer’s hands could be a way to estimate the weight distribution subjectively. Obviously, the repeatability, reliability and objectivity of the outcome will be better when obtaining a computerized device, for instance a force plate, since it can be very difficult and sometimes even impossible to be able to perceive subtle changes, even for the most talented specialist. (Gillette and Angle, 2008) The use of the force plate will be discussed more in depth in chapter 2.6.4.

3.6.4) Gait analysis

Another possibility is to analyze the kinetic gait of the patient as a parameter for weight bearing and functionality of the limb. Subjective scoral systems, such as accreditation of a lameness score, expressed in simple, descriptive, numerical rating scales (NRS) or continuous, visual analogue scales (VAS), are a frequently used technique in private clinics and in research evaluation, since it is a relatively inexpensive method and since it requires no specific equipment. According to Hudson et al. (2004), a VAS is more likely to detect subtle changes than a NRS, although the issue of variability among and between observers remains, and even for seasoned gait evaluators it remains a challenge to characterize certain abnormalities, especially if several limbs or joints are involved in the process. (Millis and Ciuperca, 2015) Utilization of a canine pain index, for example the Canine Brief Pain Index (CBPI), the Helsinki Chronic Pain Index (HCPI) or the Texas Spinal Cord Injury Score (TSCI) to assess pain and lameness in dogs, is a possibility as well. (Hielm-Björkman et al., 2009)

However, it is often the case that the gait of the patient shows a minimal deviation, practically undetectable for an individual to notice. Obtention of computerized kinetic gait analysis may be a solution for this issue, in order to maintain repeatable and objective results. With a force or pressure plate, as seen on Fig. 2, measures of the forces exerted by a dog’s limb on the ground during ambulation can be made (Quinn et al., 2007). Measurements of these forces happen in three planes: vertical, mediolateral and craniocaudal. However, the two values most cited by researchers are peak ventral force (PVF, the maximal force applied during the stance phase) and the vertical impulse (VI, total force applied over time), as explained by Besancon et al. (2003) and by Quinn et al. (2007). According to Voss et al. (2007), the two symmetric gaits, walk and trot, are both useful in this technique since they both create sufficient ground reaction forces. It is obvious that the trotting gait creates much larger forces than the walking gait does. It is a fact that some dogs may show different clinical signs in a clinical environment in contrast to what they show at home, especially when they have to walk or trot across the force plate, which they are not used to. In order to minimize the amount of stress the patient is exposed to, it is recommended to embed the plate into the floor, so that it is even with the surface of the floor.

Kinematic gait analysis is a sophisticated, powerful and expensive method that provides information about the stance and swing phase of the limbs of the patient. It is capable of measuring extension and flexion angles of joints during the gait. It is performed using retroflective targets on specific anatomic landmarks and a series of cameras interfaced with specific computer software. (Marsolais et al., 2003) It is mostly used in combination with kinetic gait analysis, a force plate for instance, since dynamic three-dimensional characteristics of limb motion can be correlated with ground reaction measurement, as described by McLaughlin (2001).

Fig. 2: Force plate From: http://www.nationalnewstoday.com/pets-and-animals/3-tips-diagnosing-lameness-in-dogs-evaluating-canine-force-plates-gait-analysis-and-pressure-pads.php, last consulted in May 2018

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4. Issue and purpose

According to many different articles, e.g. Sharp (2008), physiotherapy and rehabilitation in small animals has been increasingly recognized the past few years. However, physiotherapy is mostly highly valued within human medicine. The benefits of human physiotherapy are well documented and there is good evidence for the effectiveness of most treatment modalities. Nonetheless, only recently scientific research in veterinary physiotherapy is on the increase. There are not too many significant scientific articles to be found concerning awareness of the possible importance of postoperative rehabilitation and physiotherapy, nor comparisons between postoperative treatment with physiotherapy and immobilization, delayed or no postoperative treatment in any form of physiotherapy.

The purpose of this research will therefore be to determine a potentially faster, better and more efficient healing process in dogs treated with postoperative physiotherapy and rehabilitation. The null-hypothesis is that there would be no difference with or without physiotherapy. If the dogs gain muscle strength, weight support, show an increased activity level and if they experience less pain in less time than in the case when we would not perform post-operative treatment, this hypothesis will be rejected.

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5. Material and methods

Study population

In the following study, we will use client-owned dogs of any breed and both sexes, intact or neutered, who suffered from any orthopedic problem and who were treated with any kind of surgery, presented to the faculty of veterinary medicine in Merelbeke, within a period of 5 months (from November until the end of March).

Study design

We handed out a customized questionnaire, as a subjective scoral system, to every owner, who agreed to participating in this study, of a patient, presented to the department of orthopedics at the Faculty of Veterinary Medicine in Ghent, during the period of time mentioned earlier, in order to put their results and potential progress, regress or stability into place. The questionnaire was designed in order to be comprehensive for the owners of the patient. They were handed out by a veterinary assistant, who performed the physiotherapeutical exercises, or by a veterinarian working at the department of orthopaedics, who both were able to clarify any ambiguity the owners might have had. (see Attachment 1)

Data analysis

Data were collected and organized using Microsoft excel.

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6. Results

In total, there were 25 participants in the study. There were 11 patients who were receiving a treatment with physiotherapy and 14 of them did not receive any treatment with physiotherapy. The groups of patients are later on respectively referred to as group 1 and group 2, the control group. In group 1, there were 6 patients who were receiving the treatment at the moment of filling in the survey. There were 5 patients who treated with a program of hydrotherapy. In this group of dogs who received physiotherapy, 9 of them got to perform their exercises daily and 2 of them performed them weekly. These exercises went effortless for 5 dogs, 5 other dogs showed a little effort and 1 dog performed the exercises with an average amount of effort.

The owners of both groups were asked about evolutions concerning different parameters, i.e. weight support, activity level, pain management and muscle gain. The answers to these questions had a range from much better to much worse.

The results were visualised on the graphics and in table 2.

Table 2 Number and percentage of owners and their answers per parameter

Pain management Muscle gain Activity level Weight support

Group 1 Group 2 Group 1 Group 2 Group 1 Group 2 Group 1 Group 2

Much better 36% (4/11)

50% (7/14)

27% (3/11)

0 45% (5/11)

14% (2/14)

45% (5/11)

50% (7/14)

Better 64% (7/11)

50% (7/14)

27% (3/11)

36% (5/14)

27% (3/11)

64% (9/14)

55% (6/11)

43% (6/14)

Stayed the same

0% (0/11)

0% (0/14)

27% (3/11)

43% (6/14)

18% (2/11)

21% (3/14)

0% (0/11)

7% (1/14)

Worse 0% (0/11)

0% (0/14)

18% (2/11)

21% (3/14)

9% (1/11)

0% (0/14)

0% (0/11)

0% (0/14)

Much worse 0% (0/11)

0% (0/14)

0% (0/11)

0% (0/14)

0% (0/11)

0% (0/14)

0% (0/11)

0% (0/14)

Fig. 3: Patients participating in this study

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Results seem quite similar for both groups, at first sight. Most questions are answered with “much better” and with “better” in both group 1 and group 2. Keeping this in mind, we can conclude that any kind of treatment after orthopedic surgery mostly provides some kind of improvement in the parameters mentioned earlier. Besides, both owners of patients in group 1 and in group 2 never answered any question with “much worse” and the minority of owners answered with “the same” or “worse”.

It is remarkable that, in general, the best results were seen considering pain management and weight support, since these questions got mostly answered with “much better” and since there were no results regarding “worse” and “much worse”. However, the answer most frequently chosen is “better”. Questions concerning muscle gain and activity level are answered less convincingly positive than the other ones. Muscle gain is the parameter which scored the most answers with “worse”.

When focussing on group 1, the best results are seen in pain management and weight support, similar to the general distribution, as discussed before. Weight support in specific leads to a majority of owners who believed that it had positively increased. The least positive scores were given to the parameters muscle gain and activity level. Group 2 has similar positive results, but there were no owners who thought musculation had become much better in their dogs and there were relatively more owners who believed it had gotten worse.

Disregarding the parameters mentioned above, owners of group 1 were asked about the load they experienced when performing the exercises with their dog. They were able to answer this question by giving a score of 0-10, with 0 meaning they did not experience any load, and 10 meaning they experienced the treatment with a very heavy load. Most owners answered the questions with the fact that they did not experience any load at all. The answers

considering the load experienced by the dog, according to the owners, are more equally divided than the load experienced by the owner. It is remarkable that either the owners did not experience any load at all, or that they give their load a relatively high score. The highest score given was a 9 out of 10. There were no owners who gave their experience a score of 10. The scores attributed to the dogs are generally slightly better.

Fig. 4: Load experienced by owners and their dogs while in treatment

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The last question on the survey was a general question for both owners of group 1 and group 2 on their overall satisfaction about the progress their dog had made, up until the point of filling in the survey. They were able to answer this question by giving a score of 0-10, with 0 meaning they are not satisfied at all with the result of the therapy, and 10 meaning the result could not have turned out better. Most owners answered with a score of 8. The lowest score that was

given is a 6, which means that the overall satisfaction of owners of both groups is definitely better than average. There is also 1 owner of both group 1 and group 2 who gave their experience a 10 out of 10. When comparing group 1 and group 2, it seems that the results are equally divided.

Fig. 5: Overall satisfaction of owners about the treatment

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7. Discussion and conclusion

It is challenging to verify the extent a treatment with physiotherapy may achieve, not only because it is mostly combined with a medicinal or surgical treatment, but also because most measuring methods are not ideal, meaning they are inefficient, expensive, invasive… and do not represent the actual efficacy of physiotherapy. The list of factors which are influencing the physiotherapeutical recovery rate is not limited and is rather difficult to determine. For example, the preoperative musculation, activity level, the age of the dog, the willingness and ability to cooperate of the dog and the owner… are only some of the factors which play an important part in this process.

In this study, there may have been some bias in the results of the questions, referring to activity level, pain management, muscle gain and support. This may be due to the measuring method used in this study, namely the questionnaire to be filled in by the owner, which certainly does not give us objective results. There obviously are differences in opinions between owners, the way they observe their dog and the coincidence of time as wherein the survey was presented to the owner. Using another measuring method, spreading out the study over time or combining the questionnaire with additional research, such as utilization of a force plate or measuring the muscle mass, could be a solution to this problem. It is important to notice as well that there are no statistics performed nor analyzed, which implies that all conclusions should be made carefully. To obtain more conclusive results in this study, these would ideally have to be statistically processed and analyzed. An important fact which also needs to be kept in mind is that the study is limited to a small case series, which makes it hard to extrapolate the obtained data to any other dog or patient, and that there is a disproportion present of 3 participants between both groups. Results would be more representative when obtained from a larger number of patients.

No difference has been made between the applied specific physiotherapeutical modalities used in different dogs. Therefore, it is impossible to conclude which specific modalities will result in the obtained answers. Additionally, there has not been made a difference between a group of dogs who received a post-operative treatment with physiotherapy, dogs who received a post-injury treatment, dogs at a certain age who received a preventive treatment, dogs with neurological conditions who received a treatment, obese dogs in a weight loss program and, for example, cats in treatment. If this would be the case, the study results would be more complete.

A new study with a more extended number of patients and another, more objective measuring method, in which we would not rely completely on the opinion of the owners, such as a force plate, would ensue results, which would be more objective. Additionally, the control of a licensed veterinarian and the performance of statistics on the results would objectify these results as well.

In this study, the current preliminary results suggest that there seems to be no obvious difference between the group of dogs who received a treatment with physiotherapy and the group of dogs who did not, and there seems to be no reason to assume that physiotherapy is the ultimate solution for a fast and effective postoperative or post-injury rehabilitation. This may suggest several things, such as the fact that owners are satisfied with any kind of treatment to help their dog’s problem and that they see a difference no matter what treatment is performed, as a so-called placebo effect. However, this does not necessarily have to be the case, since most kinds of treatment are described, proven to have a positive effect on the specific problem. There certainly are some results which indicate a slightly more positive outcome in dogs treated with physiotherapy, mostly the results based on muscle gain and activity level. Results in weight support and pain management are more similar comparing both studied groups than the results in muscle gain and activity level. In these last two, the difference between both groups is relatively obvious, which makes it possible to conclude that physiotherapy has an evident effect on both these fields and that the effect on weight support and pain management is similar in both groups. There may be a bias in the results obtained considering activity level, since owners can presume that the physiotherapeutical exercises form an increase in activity level as well. Muscle gain is the parameter which scored the most answers with “worse”. This can be explained by the fact that the questionnaire was introduced to the owners too soon after injury or surgery, when (post-operative) muscle atrophy, due to disuse, is likely to occur and to still be present, which may have given the owners the wrong impression. The same applies for activity level. Dogs evaluated

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immediately after injury or immediately post-operative, are not likely to show an increase in activity level, but rather stay stable or even decrease.

The results on the question considering the load experienced by the owners, most answers consisted of the fact that they did not experience any load at all. This might be explained by the fact that owners are willing to put a large amount of effort in their dogs and in their rehabilitation and that these owners do not want to give the impression to the veterinarian or to the person that takes care of the treatment, that they are not taking proper care of the dog. Additionally, it is remarkable that either the owners did not experience any load at all, or that they give their load a relatively high score. The highest score given was a 9 out of 10, which, for example, could be due to lack of time, stress linked to transporting their dog to the clinic or the fact that they do not feel comfortable at the clinic for some reason. The scores attributed to the dogs are generally slightly better, from which we can conclude that most dogs do not show large amounts of stress to their owners while performing their exercises and that they do not experience coming to the clinic as a rather stressful event.

The results considering overall satisfaction of owners of both groups are definitely better than average. This definitely is consistent with the fact that owners are satisfied with any kind of treatment to help their dog’s problem, as seen before. The obtained results of owners of dogs within the group of physiotherapeutical treatment also imply that most owners are satisfied with the achieved outcome after treatment, nonetheless the fact that not all parameters might have improved spectacularly.

In the study performed by Monk et al. (2006), the effects of early intensive physiotherapy on limb function were determined after tibial plateau levelling osteotomy (TPLO). The results found considering muscle gain were similar to the results found in the study reported here. The group of dogs treated with physiotherapy had a significant larger thigh circumference than the group of dogs not treated with physiotherapy. The difference in ROM was also determined, with significant better results in the physiotherapy group. There were no differences found considering weight bearing and lameness, which also matches the results found in the study reported here. In another study, performed by Mlacnik et al. (2006), the effects of physiotherapy combined with a weight reduction program were determined on lameness in overweight dogs with osteoarthritis. The effects were analysed by means of kinetic gait analysis on a treadmill with 4 force plates, which is a much more objective measuring method than used in the study reported here. The best outcome was seen in the group of dogs treated with physiotherapy, which showed improvement of mobility and symmetry in their gait. They attained greater weight reduction as well. The combination of the classic therapy with physiotherapy ends up being a more efficient way in this study to obtain a positive outcome, which again matches the results determined in the study reported here.

The objective of this study was to be able to determine a potentially faster, better and more efficient healing process in dogs treated with physiotherapy or rehabilitation. The findings in this study show that dogs treated with physiotherapy achieve similar or slightly better results than dogs not treated with physiotherapy, especially in terms of muscle gain and activity level. This indicates that there certainly are benefits of physiotherapy during revalidation after orthopedic surgery in small animals and that treatments with physiotherapy definitely should be continued in the future and that they should be considered a part of every postoperative treatment. However, another study, including the elements mentioned in the paragraph above, may deliver results which would be more objective.

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9. Attachments

Attachment 1: questionnaire

Development of the healing process

1. What kind of treatment did your dog receive? a. Combination of medication and physiotherapy b. Combination of surgery and physiotherapy c. Only physiotherapy d. Combination of surgery and medication

2. Did your dog receive physiotherapy during revalidation/treatment?

a. Yes, for this long:……………………………………………………………. b. No, go to question 7

3. Does your dog still receive physiotherapy at this moment? If so, what kind of physiotherapy

does he/she receive? a. Yes, namely………………………………………………………………………………. b. No, stopped since………………………………………………………….............

4. Does your dog receive hydrotherapy at this moment (swimming, under water treadmill…)?

a. Yes b. No, stopped since…………………………………………………………...

5. How frequent do you perform the exercises, prescribed by your vet, with your dog?

a. Not b. Daily c. Weekly d. Monthly e. Other:………………………………………………………………………. f. This does not apply (go to question 7)

6. How much effort do you think your dog needs to put in his/her exercises?

a. No effort b. Almost no effort c. An average amount of effort d. A little bit of effort e. A lot of effort

7. How do you judge the weight support of the affected limb of your dog?

a. Much better b. Better c. The same d. Worse e. Much worse

8. How do you think the activity level of your dog has changed?

a. Much better b. Better c. The same

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d. Worse e. Much worse

9. How do you think the pain management of your dog has changed?

a. Much better b. Better c. The same d. Worse e. Much worse

10. How do you think the musculation of the affected limb of your dog has changed?

a. Much better b. Better c. The same d. Worse e. Much worse f. Difficult to answer

11. Give a score of 0-10 to your overall satisfaction about the result achieved at this point of the

treatment. 0 = not satisfied and 10 = could not be more satisfied. 0 1 2 3 4 5 6 7 8 9 10

12. What load did you experience during treatment, as an owner? 0 = no load and 10 = very heavy load.

0 1 2 3 4 5 6 7 8 9 10

13. What load do you think your dog experienced during treatment? 0 = no load and 10 = very heavy load.

0 1 2 3 4 5 6 7 8 9 10