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An Introduction to Veterinary Sports Medicine and Rehabilitation
Matt Brunke, DVM, CCRP, CVPP, CVA Diplomate, American College of Veterinary Sports Medicine and Rehabilitation

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A little about me..... I like to keep busy

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Acknowledgments
- Ms. Rebecca Chase
- Dr. Darryl Millis
- Dr. Deb Gross
- Dr. Joe Wakshlag
- Dr. David Levine
VETERINARY MEDICINE IS A TEAM SPORT
TEAMWORK IS NOT OPTIONAL.

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Origins of Veterinary Rehab
- Human Physical Therapy
- Treating the soldiers of World War I (1914-1918)
- Equine Rehab
- 1960’s
- Equine and Canine Rehab
- Mainstream in Europe and UK by 1980’s
- University of Tennessee - 1998
- Canine Rehabilitation Institute -2003
- American College of Veterinary Sports Medicine and Rehabilitation - 2010

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Objectives
- 5 questions about rehab
- Apply in your practice
- When/where to refer
- Quick case examples

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Who, what, when, where, why and how?
- Guidelines not rules - Adapt for the individual

Briefcase with important lab results.

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Who?
Who can do it?
- Veterinarians and Vet Techs
- Physical Therapists/Physio
- Depends on state/province
- Check your practice acts
Who can train me?
- CCRP : UTVetCE.com
- CCRT : CanineRehabInstitute.com
- CVMRT - HealingOasis.edu
- ACVSMR Residencies - VSMR.org

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More importantly.... Who needs rehab?
- EVERYBODY!
- Old – mobility issues
- Young – start with good habits. Congenital defects
- Arthritic
- Overweight
- Post-op (CCL, FHO)
- Pre-op - Non-operative
- Athletes – agility, law enforcement, military
- Alternatives to meds?
- IVDD
- Lumbosacral Dz
- Degenerative Myelopathy
- FCE
- Amputees
- Trauma cases
- Brain surgery (ok, that one you may want to refer)

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Just remember
- They don’t read books
- See the big picture
- More than one issue
- DJD and CRF
- CHF and IVDD

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A moment for our feline friends
- They need our help too!
- They are NOT small dogs
- Have special requirements (carnivore)
- Do great in rehab (acupuncture)
- Yes they can swim!

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What is involved in rehab?
- More learning!
- Being practical
- A good knowledge base (anatomy, diseases, meds, tissue healing)
- Communication (owner’s goals, specialist’s input, doctors and techs)

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What else?
Things you already have
- NSAIDs
- Chondroprotectants
- Gabapentin, amantadine
- Prescription food
- Ice packs
- Microwave
- Towels
- Bedding
- LASER?
- Space?
Or you may have to buy
- Hydrocollator
- Goniometers
- Girth tape
- Cavaletti rails
- Physioballs
- Agility equipment
- Electrical stim units
- Land treadmill
- Underwater treadmill
- Pool

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Basic Equipment

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What about the environment?
- Hot?
- Cold?
- Indoor?
- Outdoor?
- Footing?
- Diseases? Heat stroke, ticks, snakes
- Are we feeding?

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What am I looking for?
- Full PE (ortho/neuro)
- Symmetry/girth
- Range of motion
- Shifting weight/lameness
- At a walk/trot (treadmill)
- Secondary effects
- RADIOGRAPHS
- What goals are you aiming for?

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Stance Analyzer
- Scale
- Measures weight on each leg
- Normal – 30% on each front leg, 20% on each hind leg

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Results

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Gait Analysis – Pressure Walkway

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Treadmills
- Diagnostic tool also
- Safe and contained
- Feet always touching ground
- Buoyancy
- Takes a few seconds/minute to get them used to it

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SOAP BOX
- ALWAYS, ALWAYS TAKE RADIOGRAPHS
- 2 views, and the other leg
- Radiology Consult
- VIN Post
- VSMRI Post
- Phone a friend

Why Radiologists want 2 views - Lateral view vs AP view

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But collimate and be safe!

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Other diagnostics
- X-rays
- Ultrasound (diagnostic)
- CT Scan - MRI
- Arthroscopy
- Gait analysis software
- Force plate

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Goals of rehab
- 4 phases
1) What’s the problem?
2) Control pain
3) Improve strength
4) Maintain/return to function

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Be Active
- Leash walking, jogging
- Treadmill????
- Agility activities
- Hiking
- Be inventive

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Thermotherapy
Be creative.
DON’T USE ELECTRIC HEATING PADS.

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Running hot and cold
Heat
- Vasodilation
- Increase blood flow
- Warm up before stretching
- Pain relieving
- Reduce muscle spasm
- NOT: on cancer, open wounds, impaired circulation
- Test on yourself first
Cold
- Vasoconstriction
- Decrease blood flow
- Anti-inflammatory
- Pain relieving
- NOT: advanced CV dz, open wounds, cancer, never directly to skin use a thin towel ).Careful around implants

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Other modalities
Therapeutic Ultrasound
Electrical Stimulation

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In further detail...
Therapeutic Ultrasound
- Deep heating of tissues.
- Quadriceps, biceps tendonitis, fibrotic myopathy
- Heat and stretch contractures
- Not on cancer or pregnancy (E- stim too)
Electrical Stim
- Two types
- NMES (Neuro Muscular Electrical Stim)
- Mimic muscle movement
- LMN Disease
- TENS (Transcutaneous Electrical Nerve Stimulator)
- Pain relieving

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Light Amplification by Stimulated Emission of Radiation
- Photobiomodulation
- Amplification or Oscillation? (better acronym)
- Activate cytokines and other tissue factors
- Decrease pain and inflammation - Increase wound healing
- Always use goggles
- Can use in acupuncture
- Not on cancer or pregnancy

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Therapeutic Exercises

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Other examples

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Core Strengthening

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Advanced Core Strength

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Underwater treadmills

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Carts

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Carts
- Can be set as wheelchairs or walkers
- Adaptive - Make pet twice as wide
- Always supervised
- Front wheel, rear wheel, 4 wheel
- Ferrets, cats, dogs, goats, sheep, llamas

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Orthoses and Prostheses
- Variable applications
- Numerous Companies
- K9 Orthotics/Prosthetics
- Support braces
- Therapaw

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Image of Prosthetic leg made for not fully developed leg

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Stifle brace

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Other therapies
- Pain medications (NSAIDs, gabapentin, amantadine)
- Neutraceuticals (Glu/Chond/MSM, Omega- 3)
- Disease Modifying Agents - Hyaluronic Acid
- Stem Cells, Platelet Rich Plasma (PRP)
- Surgery (minimally invasive)
- Shockwave
- Massage
- Joint Mobilizations
- Acupuncture
- Herbal/food therapy
- Chiropractic

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What about food?
- HUGE importance
- Obesity – diet and exercise
- Prescription diets
- Hill’s/Purina/Royal Canin programs
- Nutritional Advocate
- Technicians
- Nutrition consults
- Boarded nutritionists – web/phone
- Some patients have other "special" needs
- IBD, allergies, renal dz

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Life-shortening disease

Average reduction in lifespan for overweight dogs across popular breeds
Figures show average reduction in years of life for overweight dogs, compared with those at ideal weight.

- Chihuahua Male: -2.1 years, Female: -2.1 years
- Pomeranian Male: -1.8 years, Female: -1.9 years
- Yorkshire Terrier Male: -2.5 years, Female: -2.0 years
- American Cocker Spaniel Male: -1.5 years, Female: -1.5 years
- Dachshund Male: -2.3 years, Female: -2.3 years
- Beagle Male: -2.0 years, Female: -2.0 years
- German Shepherd: Male: -0.4 years, Female: -0.6 years
- Golden Retriever Male: -0.8 years , Female: -0.8 years
- Labrador Retriever Male: -0.6 years, Female: -0.6 years

German A Association between life span and body condition in neutered client-owned dogs. Journal of Veterinary Internal Medicine December 2018 Available here: https://onlinelibrary.wiley.com/doi/full/10.1111/jvim.15367

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What techniques do I use?
- All of the ones we just mentioned!
- I adjust to my patient's needs, client's needs/wants
- I offer what I would do if it was my pet!

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When are you finding rehab patients?
- Every exam you do!
- Especially geriatrics. – Age is NOT a disease
- Know your normal – flex/extend every patient
- History ?’s – Trouble with stairs? Less active?
- Feel for: joint thickening, muscle wasting, decreased elbow flexion, decreased hip extension
- Look for: scuff marks on nails, poor posture,swayback, uneven pad wear

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When do we do rehab?
- Set aside parts of your schedule
- Initial consult – 60-90mins
- Rechecks - 30 minutes
- Rehab sessions (tech) - 60- 90 minutes.
- Owners drop off or stay - Start with two days a week (Mon/Thurs?)

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When do pets need rehab?
- Post CCL repair – 2x week for 6 weeks
- FHO – twice a week for 2-3 months
- IVDD – 2-3 times a week for 1-4 months
- "Fat Camp" – 1-2x week (treadmill) until skinny
- Geriatrics – Every 1-2 weeks – "spa days"

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Inpatient vs. outpatient
- Getting started – outpatient
- Down patient – might be better with daily nursing care.
- Back and forth morning and night

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Where do we do rehab?

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Before and after

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Where on the pet do we rehab?
- See the big picture
- "TPLO" vs. obese lab with arthritic left hip and TPLO on right leg
- Balance the body
- Focus on the obvious, but apply to whole pet.

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Why?
- Safe
- Fun
- Return to work
- Bonding time
- Keep/get in shape
- Conditioning
- To do it again

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Why do rehab?
- It helps!
- Get back to function faster
- Higher expectations by owners
- You have to like it
- You can blend different areas (physiotherapy, LASER, shockwave, acupuncture, etc..

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How do we get rehab done?
- Has to be a team approach
- Different departments working together
- Veterinarians and LVT/CVT (both can be certified, vets can be VSMR’d, VTS coming for technicians)

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Take home message
- Rehab is fun!
- You can make it easy or challenging
- It is NEEDED and we need to work as a team

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Contact info
- VOSM - Veterinary Orthopedic & Sports Medicine Group
- drmattbrunke@gmail.com

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Resources/References
- UTVetCE.com
- VSMR.org
- IVAPM.org
- IAVRPT.org
- Canine Rehabilitation & Physical Therapy 2nd edition – Millis, Levine, Taylor
- BSAVA Manual of Canine and Feline Rehabilitation, Supportive and Palliative Care – Lindley and Watson