Therapeutic Exercise

Exercise can bring great benefit to the rehabilitation patient. It can assist to increase range of motion, stability, endurance, and strength. Exercise can also improve balance, motor control, proprioception, and flexibility. Rehabilitation therapists apply exercises to help to normalize muscle tone, reduce pain, promote functional independence, and to improve weight-bearing tolerance.

Patient Evaluation

All therapeutic exercise programs require critical thinking and problem solving. "Cookbook" protocols will not succeed. A thorough examination is important to reveal any areas of weakness. The patient's emotional and intellectual abilities and his job must be assessed as well, as these will be important in designing an exercise program that will work for this patient. Evaluating the canine athlete is an even more challenging process, as this group can present with very subtle impairments that lead to diminished performance. This requires tests that are specific and sensitive enough to find weakness in otherwise very fit patients. Here, the therapist must search for signs of overtraining, residual impairments from previous injuries, fatigue or poor conditioning of the paraspinal muscles, and poor balance.

Therapeutic Exercise Program Design

Short- and long-term goals are created for each patient, based upon their age, life stage, and progress since injury, and the owner/handler's commitment to the program.

Each exercise can have 5 variables: Frequency (multiple times per day, daily, or weekly), speed/intensity (rate of completing a repetition while maintaining proper form), duration of work (time or distance traveled), environment (terrain, footing, substrate), and impact (non-impact, low impact or high impact). The owner/handler and the patient are coached simultaneously on new exercises. First the patient is trained how to perform the exercise. Next, the therapist demonstrates the exercise with the patient. Finally, the owner/handler is asked to attempt the exercise with the patient.

Tools of the Trade

There are many types of therapeutic exercise equipment. Physioballs come in many sizes and shapes. Peanuts are the most stable, so are used for new patients. Physiorolls can roll in just one direction. Egg-shaped balls have some side-to-side movement, so add more challenge than the peanuts and rolls. Round balls are the most challenging.

Cavaletti poles are used to enhance proprioception, strengthen flexors, and elongate stride length. Blocks are easily made from wood with a nonslip surface affixed to the top. These blocks are 4" by 6", and created in multiple heights (2", 4", and 6"). Blocks are used to work on strengthening stabilizer muscles.

Land treadmills are used for endurance work. Belt length is the key component to consider when purchasing a treadmill. Human treadmills are 4 to 5 feet long. Dogs larger than Border Collies need at least a 6-foot tread, which is available on canine-specific treadmills only.

Balance discs are inflatable discs that are used as low, unstable surfaces. The patient is asked to stand with one or more paw(s) on the disc(s). This works to improve balance and to strengthen stabilizer muscles.

Rocker boards offer unidirectional movement over a rail or dowel affixed to the underside of the board. Wobble boards create multidirectional movement over a hemisphere affixed to the underside.

Specific Exercises

Exercise programs focus upon walking, proprioception, balance and weight shifting, speed work, endurance work, and unilateral or focal strengthening.

For Proprioception

Afferent information from proprioceptors (mechanoreceptors) contributes to conscious sensations, total posture, and segmental posture. Improving proprioception enhances patient neuromuscular control and functional joint stability, and decreases the risk for further injury. Proprioception training exercises include work over cavaletti poles in designs, zigzag walking on a hill, rocker and wobble board work, and weave pole exercises. These exercises are progressed when the patient can accomplish each activity by creating a circuit of exercises and performing multiple reps of the circuit.

The goal of work with cavaletti poles is to navigate an obstacle course without touching the poles. Once the patient understands the 'game,' new designs are created. This is progressed by moving the poles closer together, creating patterns on non-level surfaces, such as hills, and by elevating the poles.

When working on a rocker or wobble board, the patient must maintain proper balance while the therapist applies nonrhythmic perturbations to the board. Starting with both of the patient's forelimbs or pelvic limbs on the ground and the other two feet on the board, the therapist applies nonrhythmic motion to the board from the start to prevent the patient from simply riding the board. Wobble board work is best for early work with neurological patients, placing the weakest legs on the board. Here, the patient is controlled with a harness if needed. Progression for rocker/wobble board work involves faster motion changes, placing the patient's stable paws on a surface above that of the board, and placing both fore and rear paws on unstable surfaces.

Weave pole work involves the patient walking through a pattern in a coordinated manner, including accomplishing a rapid pivot at each end of the pattern. A minimum of 6 traffic cones are set 18" to 48" apart. The patient completes gentle weaves while the therapist stays outside of the pattern. The patient is monitored for maintaining balance throughout the exercise, including the sharp turns. Weave work is progressed by moving the cones closer together and doing faster reps.

For Balance and Weight Shifting

The goal of balance and weight-shifting exercises is to work on balance with perturbations as well as isometric contractions. The tools used for this work include balance beams (2" x 8" x 10'), balance blocks, and trampolines or air mattresses. Beam work involves asking the patient to walk the length of the plank. This is progressed by narrowing the plank and placing obstacles on the plank. Blocks are introduced with the patient standing with paws on four level blocks. The patient is asked to maintain proper posture for progressively longer time periods. This is progressed by adding perturbations and moving the blocks to narrower positions.

For Speed

Speed work is designed to improve stride length, efficiency and burst speed. Cavaletti poles are used for stride length and efficiency work while interval work is introduced to create burst exercises. With cavaletti poles set at 2" height and separated by a distance equal to the height of the patient's greater tubercle, the patient is asked to trot through 6 to 8 poles. This is progressed by slowly increasing the distance between the poles. Burst exercises are introduced after a warm up appropriate to the patient's level of fitness. Sprint exercises are added, progressing by increasing the duration of the sprints and the number of sprint intervals.

For Endurance

The goal of endurance work is to increase the duration and intensity of training as the patient's fitness improves. It is important to emphasize cross-training skills to prevent overtraining injury and/or boredom. Endurance generally involves walking, running and swimming. For example, a fit police dog may run on a treadmill with maximum incline for up to 60 minutes. Retrievers may practice 5 to 6 water retrieves of up to 150 years or complete 30 to 50 sprint ball retrieves.

For Unilateral or Focal Strengthening

Unilateral or focal strengthening work is done to increase weight bearing on the affected limb or body part to cause a relative increase in strength on that side. This work is for those patients who are fully and appropriately using this body part but who need help to achieve symmetry. Leg lifts are employed for unilateral strengthening. With the patient standing squarely, the therapist tickles the toes of the affected limb to cause abduction, adduction, full flexion, or proximal joint extension with distal limb flexion.

Core strength is important for all patients. This work will improve abdominal strength to protect the spine, prevent limb injuries and improve balance. A wonderful exercise for this is the sit > beg > stand > beg > sit exercise. The patient must first be capable of maintaining a square sit. They are next trained to beg. Once the patient is secure in the beg posture, they are trained to stand on just the pelvic limbs. From this position, they are trained to return to the beg position without allowing the front paws to touch the ground.

Conclusion

There are no cookbook programs for therapeutic exercise. Patients are unique, and different every time you see them. The therapist should focus upon patient motivation, skills and impairment(s), and must remember that owner/handler motivation, commitment and strength must match the home exercise program. The keys to success with therapeutic exercise are as follows: Keep it fun! Be prepared to stay ahead of your patient, and find new ways to use old 'tools'. For our canine patients, life is a series of games. Our job is to make them meaningful, safe, and effective.