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Physical Rehabilitation as Part of Multimodal Pain Management Mary Ellen Goldberg BS, LVT, CVT, SRA, CCRVN, CVPP, VTS-lab animal medicine (research anesthesia, VTS-physical rehabilitation Vetscope 2019
Cervical Disc Pain
Excess Load on Pelvic Limbs
Multimodal pain management of the physical rehabilitation patient, whether postoperative, post injury, because of a disease state or because of the aging process is necessary to ensure a comfortable and cooperative patient.

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Veterinary Specialty Groups have Pain Management as a Primary Focus
-International Veterinary Academy of Pain Management
-American College of Veterinary Anesthesia and Analgesia
-American College of Veterinary Sports Medicine and Rehabilitation
-American Association of Rehabilitation Veterinarians
-Academy of Veterinary Technician Anesthesia and Analgesia
-Academy of Physical Rehabilitation Veterinary Technicians (1st Exam Aug 9, 2018)

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IVAPM
ACVAA FOUNDED IN 1975
AMERICAN COLLEGE OF VETERINARY ANESTHESIA AND ANALGESIA
AARV
AVTAA
ACADEMY OF VETERINARY TECHNICIANS IN ANESTHESIA AND ANALGESIA
American college of Veterinary Sports Medicine and Rehabilitation
APRVT
Academy of Physical Rehabilitation Veterinary Technicians

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What are the benefits of physical rehabilitation?
-Reduce pain
-Increase and maintain muscle strength and flexibility
-Joint mobility
-Promote and restore normal movement patterns
-Increase cardiovascular fitness
-Combat acute and chronic inflammatory processes
-Improve blood perfusion and consequently tissue growth
-Prevent adhesions, fibrosis and tissue retraction
-Stimulate the nervous system and prevent neurapraxia
-Promote the healing process

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Evidence-based medicine for pain reduction and (human) physical (rehabilitation) therapy
1. Reduced knee pain and improved physical function for people with knee Osteoarthritis
2. Exercises in water have been shown to reduce edema, inflammation, and peripheral neuropathic pain
3. PFPS (Patellofemoral pain syndrome) most effective physiotherapy program: strength training of the quadriceps and hip abductors and stretching of the quadriceps muscle group

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Millis DL and Ciuperca IA. Evidence for Canine Rehabilitation and Physical Therapy. Vet Clin Small Anim 45 (2015) 1–27
-Brown DC, Boston RC, Coyne JC, et al. Development and psychometric testing of an instrument designed to measure chronic pain in dogs with osteoarthritis. Am J Vet Res 2007;68:631–7.
-Brown DC, Boston RC, Coyne JC, et al. Ability of the Canine Brief Pain Inventory to detect response to treatment in dogs with osteoarthritis. J Amer Vet Med Assoc 2008;233:1278–83.
-Brown DC. Power of treatment success definitions when the Canine Brief Pain Inventory is used to evaluate carprofen treatment for the control of pain and inflammation in dogs with osteoarthritis. Amer J Vet Res 2013;75:1467–73.
-Brown DC, Boston R, Coyne JC, et al. A Novel Approach to the Use of Animals in Studies of Pain: Validation of the Canine Brief Pain Inventory in Canine Bone Cancer. Pain Med 2009;10:133–42.
-Hielm-Bjorkman AK, Rita H, Tulamo R-M. Psychometric testing of the Helsinki chronic pain index by completion of a questionnaire in Finnish by owners of dogs with chronic signs of pain caused by osteoarthritis. Am J Vet Res 2009; 70:727–34.
mewhitester@gmail.com

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The World Health Organization’s (1992) definitions
-Impairment is defined as "Any loss or abnormality of psychological, physiological, or anatomic structure or function."
-Disability is defined as "Any restriction (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for the species."

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Dr. Robin Downing personal communication
-Generally, patients that present for rehabilitation therapy are reluctant to move.
-One of the major factors contributing to this reluctance is pain.
-"It is absolutely necessary that pain be controlled prior to initiation of physical rehabilitation."

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Acute Pain post orthopedic surgery

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Chronic maladaptive pain associated with long-standing osteoarthritis

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OA in Cat

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OA in Dog

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Neurophysiology of Pain

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Human video but the same for our veterinary patients
Where Drugs Work in the Pain Pathway Why is this important? Because by targeting what works where in the Pain Pathway then multimodal analgesia can be used effectively.

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Will these dogs want to participate in rehabilitation without pain medication?

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Will these cats want to participate in rehabilitation without pain medication?

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Will these horses want to participate in rehabilitation without pain medication?

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Part of the Rehabilitation Team!
If changes in a patient’s pain level are noted, the supervising veterinarian should be notified immediately. It is very important for the rehabilitation veterinary technician to remain in open communication with their supervisor about anything abnormal or any changes in progress.

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Are their limitations to Pain Scales?
The most common approach to pain assessment is the use of charts and scales.
1. Pain scales should be used in conjunction with a thorough
physical exam and history to assess every patient
2. Recognize that all pain scales have limitations
3. Individual patient behavior may dictate prompt pain relief,
regardless of the pain score
4. Caregivers should strive for low pain scores in a comfortable appearing patient

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Using Pain Scoring Effectively
-Have same person evaluate the patient
-Request VAS readings as treatments
-Assess behavior
-Assess body posture, activity and position in cage
-Evaluate response to approach
-Interact with patient
-Palpation of Surgical Site
-Ask patient to ambulate, if appropriate
-Ask patient to eat, if appropriate

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Teach the Owner how to Pain Score

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When should your patient be assessed for pain?
-Ability to ascend and descend stairs
-Ability to enter and exit vehicles
-Ability to cope with difficult surfaces such as wooden or tiled floors
-Ability to remain standing while eating
-Willingness to exercise and exercise tolerance
-Ability to remain squatting while defecating
-Ability to posture for urination
-Inappropriate elimination
-Willingness to play
-Change in demeanor
-Response to grooming
-Response or lack thereof to medication
-Effect of exercise on the lameness/pain
-Effect of rest on the lameness/pain
-Duration and intensity of the lameness/pain
-Changes in sleep patterns
New patients should have a detailed history to correctly identify the animal’s degree of pain and disability. Identifying how the patient copes with daily living activities creates a realistic picture of the patient’s disability. Information regarding the following should be gathered

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Questions for Clients
-‘has your pet appeared painful?’
-what medications these are and the dosages?
-any changes to medications or stoppage of a specific type of medication?

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During the certified rehabilitation therapist or practitioner’s clinical evaluation, several items will be assessed
-Static Assessment
-Dynamic Assessment
-Gait Assessment
-Neurological Examination
-Palpation and Range of Motion
-Range of Motion and End Stop Assessment of Joints

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Static Assessment
Assessment of muscle hypertrophy or atrophy, head and tail position, abdominal muscle tone, scarring or swelling, symmetry of the axial and appendicular skeleton, deviation in the sagittal plane of the thoracic and lumbar spine or lordosis or kyphosis, distribution of body weight among all four limbs, and any adduction or abduction of the limbs in the animal at rest.

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Dynamic Assessment
Dynamic assessment involves moving the limbs and noting reactions and resistance in the muscles as joints are flexed and extended or limbs are advanced and retracted, observing the patient as it moves from standing to sitting and vice versa, and assessing quality and control of movement. Symmetry of the animal when sitting, and any tendency to lean or to brace with the forelimbs, is assessed.

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Gait Analysis
Gait Assessment - This portion of the assessment allows grading of the severity of the lameness.

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Gait Analysis

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A neurological examination should be part of the assessment to help differentiate poor balance due to stiffness and pain from ataxia due to a neurological lesion, as each has different rehabilitation requirements and prognosis.
Neurological Examination

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Palpation and Range of Motion - Palpation and manipulation should occur with the patient during standing and in lateral recumbency. It is best to develop a systematic approach: palpate muscles for their overall symmetry, texture, and tone, presence of edema, trigger point formation, and the presence of lactic acid, which confers a feeling of crackling tissue paper within the muscle

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Palpation and Range of Motion

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Range of Motion and End Stop Assessment of Joints
Range of motion within a joint is the degree of motion that joint is capable of undergoing from full flexion to full extension in the sagittal plane.
End Feel refers to any barrier that may prevent full range of motion. Tight muscle tissue, soft tissue approximation, or contact of different joint surfaces.

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Commonly used rehabilitation techniques that aid with pain management are:
-Cryotherapy
-Thermotherapy
-Therapeutic exercises
-Transcutaneous electrical nerve stimulation (TENS) or Neuromuscular electrical stimulation (NMES)
-Low level laser therapy (LLLT)
-Pulsed electromagnetic field therapy (PEMF)
-Extracorporeal shock wave treatment (ESWT)
-Acupuncture
-Manual therapies – massage, mobilizations, manipulations

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Cryotherapy

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Thermotherapy

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Therapeutic Exercises

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NEMS and TENS

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Low Level Laser Therapy

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Pulsed electromagnetic field therapy (PEMF)

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Extracorporeal Shockwave Therapy

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Acupuncture

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Manual Therapies

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Environmental Modifications
Yoga Mats

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Environmental Modifications

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Environmental Modifications
Flooring Pet
Gate
Ramps

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Environmental Modifications
Raised Water and Food Bowls

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Environmental Modifications
More Ramps

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Harnesses

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Carts, Orthotics and Prosthetics

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Painful Mobility Issues in Geriatrics
Two types of geriatric pets with painful mobility issues:
-The aging, often overweight pet with little systemic disease and varying amounts of physical disability.
-Extremely frail, geriatric pet with reduced appetite, weight loss, concurrent diseases, and more extreme loss of strength and mobility

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Shearer T.S. Managing Mobility Challenges in Palliative and Hospice Care Patients. In VCNA Small Animal Practice: May 2011 41(3) pg 609-617
Mobility questionnaire Owners should assign a grade to each question based on the rating scale. Rating System: 0 = none; 1 = mild; 2 = moderate; 3 = severe Difficulty with walking: 0, 1, 2, 3 Difficulty to move from lying down to stand: 0, 1, 2, 3 Difficulty to move from stand to lying down: 0, 1, 2, 3 Difficulty to move from sit to stand: 0, 1, 2, 3 Difficulty to move from stand to sit: 0, 1, 2, 3 Difficulty to hold posture to defecate: 0, 1, 2, 3 Difficulty to hold posture to urinate: 0, 1, 2, 3 Difficulty ascending stairs: 0, 1, 2, 3 Difficulty descending stairs: 0, 1, 2, 3 Difficulty with jumping: 0, 1, 2, 3 Difficulty with running: 0, 1, 2, 3 Difficulty with climbing inclines: 0, 1, 2, 3 Difficulty with losing weight: 0, 1, 2, 3 Difficulty with gaining weight: 0, 1, 2, 3 Difficulty with endurance: 0, 1, 2, 3

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Shearer T.S. Managing Mobility Challenges in Palliative and Hospice Care Patients. In VCNA Small Animal Practice: May 2011 41(3) pg 609-617.
Questionnaire on activities of daily living
-Is the pet an indoor or outdoor pet?
-What type of terrain is outside? Rugged, inclines, flat?
-What type of flooring is in the house?
-Does the pet have steps to climb? How many and where?
-Does the pet sleep in the pet owner’s bed?
-Does the pet travel in the car?
-What activities does the pet participate in?

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Shearer T.S. Managing Mobility Challenges in Palliative and Hospice Care Patients. In VCNA Small Animal Practice: May 2011 41(3) pg 609-617
-Can stand to support self with minimal lameness, paraparesis (partial paralysis of lower limbs) , or ataxia
-Can stand to support self but frequently stumbles and falls with mild lameness, mild paraparesis, or ataxia
-Unable to stand to support self, but when assisted moves limbs yet stumbles and falls frequently with moderate lameness, paraparesis, or ataxia
-Unable to support self, has slight movement when supported, with severe lameness or paraparesis
-Absence of purposeful movement secondary to disease or near death

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Feline Physical Rehabilitation

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Keep it Simple!

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Think About
1. Physiotherapy and rehabilitation with cats
requires a calm, confident approach.
2. Treatment time should be kept to a minimum
to prevent boredom and minimize handling.
3. Competent and confident manual skills are
essential to ensure effective treatment.
4. Use a hands-off approach whenever possible.

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Cats are Special!
Treatment is best carried out in a quiet, calm environment with no distractions. Owner assistance can aid effectiveness of treatment and can ensure continuation of therapy between formal treatment sessions.

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Images

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Cats Remember!
Ensure that pain is not a restriction to the performance of a treatment or exercise. Adequate pain relief is essential for effective therapy. Repetitive attempts to perform a treatment on a cat that is in pain are doomed to failure, and may create resistance to any further attempts at the same treatment.

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My Cat’s Program
Tailored to the patient, based on the individual cat’s identified problems and needs

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Cats in pain may:
-Have decreased grooming
-Be reluctant to jump
-Have an inability to jump as high as before
-Urinate or soil outside the litter box
-Have increased or decreased sleep time
-Avoid human interaction
-Hide
-Dislike being stroked or brushed
-Inappropriate activity level
-Sitting in the back of the kennel
-Mental attitude/demeanor (stupor or anxiety)
-Changes in attitude/personality
-Lack of comfort when palpated
-Facial expression
-Staring, fixed gaze
-Dilated pupils
-Lack of appetite and thirst
-Self-mutilation – like FOP
-Vocalizations
-Posture
-Tachycardia
-Tachypnea

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Obese Cat in Underwater Treadmill

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Equine Rehabilitation

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Evaluation for the Horse
-Equitation involves close contact between horse and rider.
-Most presenting horses are athletes of some form, thus the rider expects a full return of function.
-Evaluate the horse
-Farrier
-Saddle fit
-Role of the rider in causing or magnifying the lameness
-The rider may need to undergo their own rehabilitation program if problems are caused by the rider’s posture and balance.

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Pain Assessment for Horses
Behavioral
-Kicking or biting when the tender area is touched
-Generalized restlessness
-Sweating
-Frequent movement of the painful limb
-Continuous shifting of weight from one limb to another
Pain Assessment in Horses

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Pain Assessment in Horses
Back Pain
-Poor performance
-Poor appetite
-Slight changes in demeanor may be very subtle initially
- Tail swishing or holding the tail to one side - Bruxism head shaking - Resistance to saddling and grooming - Loss of flexibility - Stumbling - Bucking - Rearing - The horse may be withdrawn and the abdomen may have tight abdominal muscles or appear to be “tucked-up”.

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Objective measurements of pain in the horse
-Heart rate (not consistently increased in pain)
-Respiratory rate
-Pressure algometry
-Thermography
-Kinematic gait analysis
-Response to analgesia (e.g. nerve blocks).

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Ways to Treat the Pain in Horses
1. Analgesics
2. Acupuncture
3. Physical rehabilitation therapy
4. Local heat
5. Osteopathy
6. Veterinary Spinal Manipulation or “Veterinary Chiropractic”
7. Massage

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Conclusion
TEAM
-Certified rehabilitation veterinarian, certified rehabilitation veterinary technician, physical therapist and owner must work as a team to have successful management of pain and restore the patient (no matter what species) to a functional life.
-Each animal should have its own tailored plan. Nothing should be “cook-book” in this process.
-The ultimate aim should be to restore the patient to an active and pain free lifestyle, whether this is in the context of a slow leisurely walk or full athletic activity.

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Thank you