As veterinary practice continues to develop and evolve, more challenging patients will require advanced nursing and supportive care to maximise the outcomes for these patients, and to return them to their highest level of function.

Early, basic physiotherapy assessment and treatment can improve the outcomes for these challenging cases, which can be a very rewarding experience for the veterinary nurse.

By incorporating objective outcome measures into the physiotherapy plan we can evaluate treatment, and progress patient treatment goals.

The focus of this session will be on physiotherapy techniques that can be incorporated into general practice, focusing on:

Passive Range of Motion Exercises

Passive range of motion (PROM) exercises are movements usually of the limbs performed by an individual such as a physiotherapist. The joints of the limbs are moved passively, the patient does not gain any strengthening benefits from passive movements of the limbs.

PROM exercises are performed to maintain or improve joint range of motion, and to prevent joint inflammation and stiffness. PROM exercises are especially important in recumbent animals that may already have established osteoarthritis and associated pain, stiffness and reduced ROM in the affected joints.

If the patient has undergone joint surgery, full ROM of this joint is not desirable or essential in the early stages. However, full ROM should be maintained in all the other joints of the affected limb.

PROM exercises can commence day one postoperatively. Gentle PROM exercises within the pain-free range will assist with lymphatic drainage of the limb and limit oedema when used in conjunction with positioning. If the distal limb is oedematous, compression followed by release exercises can be performed; 2x50 appears to be effective.

As the inflammatory phase passes, ROM exercise of the affected joint may be gradually increased within the pain-free range, and with the consent from the veterinary surgeon.

The patient is usually recumbent for the PROM exercises with the affected limb(s) uppermost. (However, the exercises can be performed in standing with the patient supported). If the patient has undergone joint surgery, this joint should be isolated and gently moved through its pain-free range in all anatomical planes. This joint would then be supported and the other joints in the affected limb would be moved through full ROM in all anatomical planes. 3x10 PROM exercise for each joint twice a day is considered to be effective.

If the patient has not undergone joint surgery and the PROM exercises are being performed to reduce pain, inflammation and stiffness in the joint, all the joints in the limb can passively be moved together. Please be aware that if the patient has established osteoarthritis, ROM in this joint may be reduced, and at the end of range you will feel a bony block; do not force the joint beyond this point as it will cause the patient further discomfort.

When performing PROM exercises the movements of the operator will push the joints together and then push them apart. PROM exercises should never involve pulling a limb or joints. Do not grip the limb tightly. If all joints are to be moved together into flexion, then extension, the patient should be supported at the medial elbow for the thoracic limb, and at the medial stifle for the pelvic limb to prevent any rotation of the joints which may be uncomfortable. The movements should be in line with normal anatomical planes of movement.

Stretches

Stretches are performed to maintain or increase muscle length. These are usually performed passively by an operator for recumbent patients, or in patients that have undergone surgery.

If a muscle crosses two joints such as the quadriceps, any shortening of this muscle group will affect the ROM of the hip and stifle joint. As the quadriceps muscle group shortens, the stifle and hip will be brought into flexion. If the quadriceps becomes shortened or contracted for a prolonged period of time the patient will be unable to flex the stifle and extend the hip, and so weight bearing through the limb will become problematic.

Changes in muscle length can occur quickly in recumbent animals, or in patients that have recently undergone surgery when they may not be moving limbs through their full ROM, or if a patient is non-weight bearing for a period of time the flexor muscles will become short and tight, and the opposing extensor muscle groups will become long and weak.

In recumbent patients stretches should begin on day one. Flexor, extensor, and internal rotator muscle groups should be stretched at least twice daily. Each stretch is held for 15 seconds, the patient is given a few seconds to rest, then the stretch is repeated three times in total. Following stretches, if the patient is resting in lateral recumbency, a wedge should be placed between the thoracic and pelvic limbs to prevent adductor/abductor muscle imbalance. Recumbent patients tend to become tight in the adductor muscle groups, and weak in the abductor muscle groups. Correct positioning following stretches can help to prevent muscle imbalance from occurring.

Stretches can be performed with the patient lying laterally or in standing. If the stretches are performed in standing, the patient will need to be supported at the trunk. The operator will use one hand to support at the origin of the muscle being stretched, with other hand a pushing force will be applied at the insertion of the muscle. The muscle should be stretched until resistance is felt in the muscle, then at this point the stretch should be held for 15 seconds and repeated 3 times. Stretching should not be uncomfortable for the patient. Pre-warming a muscle will improve the elasticity of the tissues, thus improving the range of the stretch. This may be useful if the patient is cold, has muscle spasm, or has developed muscle contractures.

Musculoskeletal Outcome Measures

• Measure joint ROM
• Assess muscle length
• Pain score
• Functional measures (independent positioning, able to sit, stand and mobilise with assistance)