- Email: [email protected]
Rehabilitation in the First 48 hours after Surgery
Rehabilitation in the First 48 hours after Surgery Renee Shumway, LVT, CCRP Physical therapy is commonly used postoperatively in humans to decrease pain, inflammation and recovery time. The same goals can be achieved in our veterinary patients using similar modalities such as; cryotherapy, passive range of motion, massage, transcutaneous electrical stimulation and low-level light laser therapy. When used in the first 48 hours following surgery, the reduction in pain, increased mobility, and decreased inflammation will aid in early return to normal function. Applied appropriately these treatments have both immediate and long term benefits. Clin Tech Small Anim Pract 22:166-170 © 2007 Elsevier Inc. All rights reserved. KEYWORDS cryotherapy, massage, inflammation, range of motion, canine
P
hysical therapy is widely used in human medicine to ease pain and speed recovery. It is, in most cases, a safe, noninvasive method of treatment that is now becoming more popular and more available in veterinary medicine. Traditionally, veterinarians have been trained to use immobilization devices and techniques after surgery. Discharge instructions included limited leash walking and bicycle movement of the injured limb. However, in human medicine, periods of immobilization can result in severe muscle atrophy (especially in type I fibers), and fibrous contracture can result in the limb.1 Immobilization is also detrimental to the health of cartilage, ligaments, and bone. Although it may at times be necessary to immobilize the limb, the consequences should be anticipated. Reduced range of motion occurs after a period of joint immobilization and may take 8 to 12 weeks of remobilization for improvement to occur.2 Early intermittent passive range of motion is now considered the standard of care for postoperative human patients. The same rehabilitation principles apply to small animals. Veterinarians now initiating early range of motion postoperatively are experiencing decreased postinjury and postoperative recovery times in their patients.1,3 Surgery results in a number of physiological responses, including inflammation, pain, catabolic changes in tissues, and protection of the operated limb. The side effects of these physiological changes include increased metabolic rate and oxygen demand, inflammatory mediator and cytokine production, peripheral and central nervous system hyperalgesia, tissue catabolism, impaired immune function, ileus, tachycardia, hypertension, and tachypnea.4 Although many of the effects of inflammation are beneficial in some instances, excessive and/or prolonged inflammatory responses can be detThe Animal Medical Center, New York, New York. Address reprint requests to Renee Shumway, LVT, CCRP, The Animal Medical Center, 510 East 62nd Street, New York, NY 10021. E-mail: [email protected].
166
1096-2867/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.ctsap.2007.09.005
rimental and may even be more harmful than the inciting stimulus. Postoperative rehabilitation can aid in decreasing the length and intensity of the adverse effects. Rehabilitation techniques in our hospital are implemented as the patient is taken from the surgery table. If postoperative radiographs are required, therapy is initiated as the patient is transported and waits in radiology. As the patient recovers from anesthesia, one or a combination of the following treatments may be used: passive range of motion, massage, lowlevel light laser therapy, electrical stimulation, and cryotherapy. These therapies are continued until the animal is discharged from the hospital with the addition of appropriate therapeutic exercises the day after surgery. Recommendations for at-home therapies and the option to return for rehabilitation on an outpatient basis are given to the client at discharge. Each session is monitored according to the individual patient’s needs and changed accordingly.
Inflammation Following Surgery To properly and safely apply rehabilitation techniques immediately following a surgical procedure, an understanding of the body’s inflammatory response is needed. Injury to tissue initiates a complex series of events involving many cellular and biochemical responses that ultimately result in wound healing. The series of events depends on the severity of the injury and the tissues involved. The goal is regeneration or repair of the injured or traumatized tissue. During the inflammatory phase of tissue healing, increased permeability of the microvasculature occurs as a result of histamine and bradykinin release. In addition, these chemical mediators cause vasodilatation and increased blood flow to the area. These events, coupled with hypoxic cellular changes, are primary factors in the formation of edema. The immediate vascular component of the response is centered around hemostasis and the result is formation of a fibrin
Rehabilitation in the first 48 hours after surgery
Figure 1 Proper support of the limb during ROM therapy.
network to support the hemostatic plug and to act as a scaffold for cellular infiltration.4 The cellular aspect of the inflammatory phase involves neutrophils migrating into the area, beginning by 6 hours after injury and increasing in number over a 2- to 3-day period. Their roll is to provide initial debridement and phagocytosis of microorganisms, minimizing the potential for infection.4 Macrophages, appearing 24 to 48 hours later, are key in the transition from the inflammatory phase to the reparative phase. They play a central part in phagocytosis, wound debridement, matrix synthesis regulation, cell recruitment and activation, and angiogenesis.4
Range of Motion The full motion that a joint may be moved through is termed the range of motion.2 Postoperative patients that do not receive early range of motion exercises, such as those undergoing femoral head ostectomy, may suffer reduced stifle extension, which can be permanent. The benefits of passive range of motion following joint surgery were initially described by Salter and coworkers and included decreased pain and improved rate of recovery.5 These broad benefits are mediated by prevention of soft-tissue adaptive shortening, maintaining mobility between soft-tissue layers, reduced pain, enhanced blood and lymphatic flow, and improved synovial fluid production and diffusion.6,7 It is critical, however, that the therapist maintain a range of motion that is comfortable to the patient and not injure tissues by exceeding their anatomic or physiologic limits. Passive range of motion, when done gently, can also work to relax nervous animals. Treatment should be administered in a quiet and comfortable area, away from distractions, such as loud noises, other pets, and other people who are not helping with the treatment. This establishes an environment that promotes relaxation, allowing the patient to be more receptive to the treatment. Generally the patient is placed in lateral recumbency with the affected limb up. Beginning the session with 2 to 3 minutes of gentle stroking massage may also help with relaxation. The bones proximal and distal to the joint should be supported to avoid excessive stress on the joint (Fig. 1). The therapist should gently grasp the limb and avoid painful ar-
167 eas, such as incisions and wounds. The motion should be smooth, slow, and steady with movement at the distal aspect of the limb while the proximal limb is held steady. The other joints of the limb should be allowed to remain in a neutral position. Try not to move the other joints while working on the affected joint because some joints may be restricted by the position of the joints above or below the target joint. In these situations, the other joints should be placed in a position that will allow as complete a range of motion as possible to the target joint. For example, maximal hock flexion cannot be obtained while the stifle is maintained in an extended position. In this case, placing the stifle in a flexed position allows more complete flexion of the hock. Slowly continue to flex the joint until the patient shows initial signs of discomfort, such as tensing the limb, moving, vocalizing, turning the head toward the therapist, or trying to pull away. With the hands maintained in the same positions, slowly extend the joint. Again, try to keep the other joints in a neutral position and minimize any movement of the other joints. The patient should be continually monitored for any discomfort and the technique altered if necessary to enhance comfort.2 After completing range of motion of the affected joint, keep the limb in a neutral position and slowly move the hands distally to the digits (or if already working on the digits, move proximally). Range of motion exercises are then performed on the other joints of the limb. For example, begin with the digits; proceed to the tarsus, stifle, and last, the hip. It is important to fully flex and extend each joint. The number of range of motion repetitions and the frequency of the treatments depend on the condition treated. In general, for most routine postoperative conditions, 15 to 20 repetitions performed two to four times per day is likely to be adequate. We often end the range of motion session with a gentle massage to the injured limb for approximately 5 minutes. Massage will help to maintain a relaxed state. Passive range of motion is contraindicated when motion may result in further injury or instability, such as unstable fractures near joints and some ligamentous or tendon injuries. These exercises should also be omitted or limited in patients with joint hypermotility (luxation), osteopenic bones, or recent skin grafts.1
Massage Massage is the gentle manipulation of muscles and soft tissues. Using the hands to manipulate soft tissue can enhance circulation, reduce edema, loosen and stretch tendons, and minimize scar tissue formation. Massage also sooths anxious and uncomfortable patients and is often used before the patient undergoes other forms of rehabilitation.1,6 The mechanical effects of massage also increase nutrient delivery and waste removal from various tissues.8 Endless variations on massage exist; some of the common techniques include the following: stroking, effleurage, petrissage, shaking, vibration, friction, and tapotements. Sessions are often initiated and concluded with stroking. Stroking movements are performed in a relaxed manner using very lightly the tips of your fingers or the palm of the hand. While this technique can be performed in any direction, it usually follows the length of the muscles. When done slowly, the result is a calm patient.
R. Shumway
168
Figure 2 Compression massage.
Using effleurage every 10 to 20 seconds during massage may help promote fluid mobilization and proper tissue drainage. The direction of the strokes is toward the heart to assist venous circulation. The whole hand is used and is in full contact with the body part being massaged. The pressure is even through the entire stroke. The draining effect on the lymphatic circulation is proportional to the pressure applied and the rhythm of the movement. Petrissage utilizes movements that include kneading, compression, muscle squeezing, wringing-up, and skin rolling alone or in combination. Kneading is done in a rhythmical, circular pattern similar to kneading dough. Contact is maintained at all times and the tissues are intermittently compressed against the underlying bone. Kneading will have a pumping effect, which boosts the circulation, improves gas exchange, and helps remove toxins. Compression is performed with the palm of the hand or with a lightly clenched fist, alternating each hand rhythmically and applying pressure directly on to the muscle groups (Fig. 2). Compression complements kneading; it is used to save time and reduce fatigue when working on large muscle groups. This massage technique is not appropriate for small patients or directly over postoperative or traumatized tissues; however, it may be beneficial to other areas of the body, which can be stressed and overworked when compensating for disease or injury. Similar to compression, muscle squeezing is not recommended on postoperative tissue; however, it can be applied to other areas of the patient’s body. This technique is used to decongest and relax tense muscles. It is used mostly along the crest of the neck and is a very useful move to work on the legs and the tail. The movement is made between extended fingers and the heel of the hand using the entire palm surface in full contact with the body part. You can use one or two hands to deliver the muscle squeezing (Fig. 3). Wringing up is a great technique to increase circulation. It is also useful in decreasing inflammation over the muscles of the back. Wringing up is done with the palmar surface of the hand and the thumbs abducted at a 90-degree angle. With both hands placed flat on the animal, wring the muscles side to side much like winging a wet towel. This technique is also beneficial in warming up the muscle groups (Fig. 4). Skin rolling is beneficial in postoperative patients to pre-
Figure 3 Muscle squeezing.
vent the formation of adhesions and maintain elasticity of the skin. With the thumbs on one side and fingers on the other, grasp and lift the tissues. Using one or both hands, push the thumbs forward, rolling the skin toward the fingers. The fingers draw the skin toward the thumbs, lifting, stretching, and squeezing the tissues. This technique is performed in a slow soothing manner to avoid irritating the skin nerve endings. Care should be taken over areas of recent trauma. Vibration is a quivering type of movement done with the hands. Start the vibration movement from the elbow and translate them through your wrist to your hand. This technique is beneficial in soothing and relaxing the patient. Minimal pressure should be used. This technique may be effective in stimulating the parasympathetic nervous system. The shaking technique is performed with the fingertips or the whole palm of the hand in full contact with the body part. The skin is shaken over the muscles. This technique is also used to increase circulation. Friction massage is a useful technique to break down adhesions developing over muscular fibers, tendons, ligaments, fascia, joint capsules, and bones. Attention should be paid to the dimension and the location of the incision in relation to other structures such as bone, joint, nerve, or vein. It is important to warm the area with effleurage before proceeding.
Figure 4 Wringing-up.
Rehabilitation in the first 48 hours after surgery
169 TENS works by eliciting the release of endorphins into the bloodstream and cerebral spinal fluid as well as altering pain gating mechanism. The effects of TENS are fast-acting and may provide pain relief or increased tolerance to pain for several hours. TENS may be used, as needed; however, NMES for muscle strengthening and attenuation of muscle atrophy should only be administered once daily to prevent muscle soreness. Energy added to tissues in the form of low-level laser therapy alters cell membrane permeability, opens Ca2⫹ channels, increases cellular proliferation, and magnifies the release of growth factors from macrophages influencing wound healing, pain perception, and edema.10 The specifics of low-level laser therapy use and contraindications are also covered elsewhere in the text.
Figure 5 Friction massage.
Cryotherapy Friction can be done gently or coarsely to break down the fibrous adhesions. The tip of the thumb and first three fingers are used over smaller areas and both hands can be used over larger areas. At least 24 hours should pass before applying this technique over incisions or wounds (Fig. 5). One massage combination we commonly use starts by gently petting or stroking the affected limb using moderate pressure. When the initial tenderness seems to be relieved and the animal is relaxed, a gentle vibration movement can be used to stimulate circulation. Light stroking is then resumed. This will stimulate the circulation and begin the drainage process. A gentle kneading massage using both thumbs can then be applied at the edge of the swelling and can be moved around the area in a clockwise direction. Drain the excess fluid toward the outside of the edematous area. Very light pressure can be used over areas that are tender to the touch. After the first circumference to the edematous area is completed, apply light effleurage movements. Direction of the movement is away from the periphery of the trauma and in the direction of the heart. The kneading technique is then repeated in a spiral fashion toward the center of the affected area. Alternate the kneading with effleurage. The massage is completed with kneading in a circular direction around the swollen area. A continual awareness of the patient’s injury, tolerance, and comfort level is needed. Massage is contraindicated in patients with hypotension, fever, certain dermatologic conditions (ringworm), other infectious disorders, and over highly reactive or neoplastic tissues.
Cold is the agent of choice for managing the acute phase of tissue injury because it minimizes the inflammatory process and provides analgesia. Cryotherapy is commonly used to treat postoperative inflammation, musculoskeletal trauma, and muscle spasm and to minimize secondary inflammation following therapeutic exercise. Lowering the temperature of skin and underlying tissue causes vasoconstriction, reduces blood flow, and decreases sensory and motor nerve conduction velocity.6 The simplest method of cryotherapy immediately after surgery is to wrap a freezer bag containing crushed ice in a thin cloth (such as a towel or pillowcase) and then place it directly on the operated area. Cryotherapy is generally applied to the wound for 15 to 20 minutes immediately following surgery while the animal is recovering from anesthesia (Fig. 6). Cryotherapy is then applied two to four times daily to help combat swelling and pain after surgery or therapy. Cold compression units, which are commercially available, combine compression with cryotherapy (Fig. 7) and are highly effective during the acute phase of tissue inflammation and healing.11 The application of cold to hypothermic or very small patients is usually contraindicated. In addition care should be exercised in areas of reduced sensation, over superficial
Other Techniques While the details and use of neuromuscular electrical stimulation (NMES) and transcutaneous electrical neuromuscular stimulation (TENS) are covered in the modalities section of this text, application in the early postoperative period helps attenuate muscle atrophy, reduce join effusion, prevent muscle spasms, and reduce pain.1 NMES can also be used to facilitate muscle contraction on the impaired limb while the animal is unable to use the limb.3 When NMES is combined with early passive range of motion of the stifle joint, fibrosis of muscle can be reduced.9
Figure 6 Patient receiving cryotherapy while recovering from anesthesia.
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170
References
Figure 7 Cold compression unit (Opti-ice, Chattanooga Co., Hixson, TN).
nerves (ulnar, superficial peroneal nerves) and metal fixation devices, or in areas of vascular compromise (skin grafts). Signs of cold urticaria (wheals and swelling) as well as prolonged blanching of the skin are indications of tissue damage and a sign to avoid further cryotherapy.11,12 Early application of techniques to control inflammation and preserve range of motion can have a significant effect on patient comfort and attitude and on the speed and completeness of recovery.
1. Taylor RA: Post surgical physical therapy: the missing link. Compendium 14:1583-1593, 1992 2. Millis DL, Lewelling A, Hamilton S: Range of motion and stretching exercises in canine rehabilitation and physical therapy, in Millis DL (ed): Canine Rehabilitation and Physical Therapy. Philadelphia, PA, Saunders, 2004, pp 228-243 3. Millis DL: Getting the dog moving after surgery. J Am Animal Hosp Assoc 40:429-434, 2004 4. Ackermann MR: Acute inflammation, in Guyton AC, (eds): Textbook of Medical Physiology (ed 11). Philadelphia, PA, Saunders, pp 101-145 2006, 5. Salter RB, Simmonds DF, Malcolm BW, et al: The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit. J Bone Joint Surg Am 62:1232-1251, 1980 6. Knap K, Johnson AL, Schulz K: Fundamentals of physical rehabilitation, in Fossum TW, (ed): Small Animal Surgery (ed 3). St Louis, MO: pp 111-129 2007, 7. Millis DL, Levine D, Taylor RA: Canine Rehabilitation and Physical Therapy. St. Louis, MO, Saunders, 2004 8. Hourdebaigt JP: Canine massage: a complete reference manual. Wenatchee, WA, Dogwise Publishing, 2004 9. Johnson JM, Johnson AL, Pajanowsi GJ, et al: Rehabilitation of dogs with surgical treated cranial cruciate ligament-deficient stifles by use of electrical stimulation of muscles. Am J Vet Res 58:1473-1478, 1997 10. Edge-Hughes L: Canine Rehabilitation Certification Program. Loxahatchee, FL, 2007, pp 89-93 11. Heinrichs K: Superficial thermal modalities, in Millis DL (ed): Canine Rehabilitation and Physical Therapy. Philadelphia, PA, Saunders, 2004, pp 277-288 12. Haltrecht H: Physical therapy. Can Vet J 41:573-574, 2000
P
hysical therapy is widely used in human medicine to ease pain and speed recovery. It is, in most cases, a safe, noninvasive method of treatment that is now becoming more popular and more available in veterinary medicine. Traditionally, veterinarians have been trained to use immobilization devices and techniques after surgery. Discharge instructions included limited leash walking and bicycle movement of the injured limb. However, in human medicine, periods of immobilization can result in severe muscle atrophy (especially in type I fibers), and fibrous contracture can result in the limb.1 Immobilization is also detrimental to the health of cartilage, ligaments, and bone. Although it may at times be necessary to immobilize the limb, the consequences should be anticipated. Reduced range of motion occurs after a period of joint immobilization and may take 8 to 12 weeks of remobilization for improvement to occur.2 Early intermittent passive range of motion is now considered the standard of care for postoperative human patients. The same rehabilitation principles apply to small animals. Veterinarians now initiating early range of motion postoperatively are experiencing decreased postinjury and postoperative recovery times in their patients.1,3 Surgery results in a number of physiological responses, including inflammation, pain, catabolic changes in tissues, and protection of the operated limb. The side effects of these physiological changes include increased metabolic rate and oxygen demand, inflammatory mediator and cytokine production, peripheral and central nervous system hyperalgesia, tissue catabolism, impaired immune function, ileus, tachycardia, hypertension, and tachypnea.4 Although many of the effects of inflammation are beneficial in some instances, excessive and/or prolonged inflammatory responses can be detThe Animal Medical Center, New York, New York. Address reprint requests to Renee Shumway, LVT, CCRP, The Animal Medical Center, 510 East 62nd Street, New York, NY 10021. E-mail: [email protected].
166
1096-2867/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.ctsap.2007.09.005
rimental and may even be more harmful than the inciting stimulus. Postoperative rehabilitation can aid in decreasing the length and intensity of the adverse effects. Rehabilitation techniques in our hospital are implemented as the patient is taken from the surgery table. If postoperative radiographs are required, therapy is initiated as the patient is transported and waits in radiology. As the patient recovers from anesthesia, one or a combination of the following treatments may be used: passive range of motion, massage, lowlevel light laser therapy, electrical stimulation, and cryotherapy. These therapies are continued until the animal is discharged from the hospital with the addition of appropriate therapeutic exercises the day after surgery. Recommendations for at-home therapies and the option to return for rehabilitation on an outpatient basis are given to the client at discharge. Each session is monitored according to the individual patient’s needs and changed accordingly.
Inflammation Following Surgery To properly and safely apply rehabilitation techniques immediately following a surgical procedure, an understanding of the body’s inflammatory response is needed. Injury to tissue initiates a complex series of events involving many cellular and biochemical responses that ultimately result in wound healing. The series of events depends on the severity of the injury and the tissues involved. The goal is regeneration or repair of the injured or traumatized tissue. During the inflammatory phase of tissue healing, increased permeability of the microvasculature occurs as a result of histamine and bradykinin release. In addition, these chemical mediators cause vasodilatation and increased blood flow to the area. These events, coupled with hypoxic cellular changes, are primary factors in the formation of edema. The immediate vascular component of the response is centered around hemostasis and the result is formation of a fibrin
Rehabilitation in the first 48 hours after surgery
Figure 1 Proper support of the limb during ROM therapy.
network to support the hemostatic plug and to act as a scaffold for cellular infiltration.4 The cellular aspect of the inflammatory phase involves neutrophils migrating into the area, beginning by 6 hours after injury and increasing in number over a 2- to 3-day period. Their roll is to provide initial debridement and phagocytosis of microorganisms, minimizing the potential for infection.4 Macrophages, appearing 24 to 48 hours later, are key in the transition from the inflammatory phase to the reparative phase. They play a central part in phagocytosis, wound debridement, matrix synthesis regulation, cell recruitment and activation, and angiogenesis.4
Range of Motion The full motion that a joint may be moved through is termed the range of motion.2 Postoperative patients that do not receive early range of motion exercises, such as those undergoing femoral head ostectomy, may suffer reduced stifle extension, which can be permanent. The benefits of passive range of motion following joint surgery were initially described by Salter and coworkers and included decreased pain and improved rate of recovery.5 These broad benefits are mediated by prevention of soft-tissue adaptive shortening, maintaining mobility between soft-tissue layers, reduced pain, enhanced blood and lymphatic flow, and improved synovial fluid production and diffusion.6,7 It is critical, however, that the therapist maintain a range of motion that is comfortable to the patient and not injure tissues by exceeding their anatomic or physiologic limits. Passive range of motion, when done gently, can also work to relax nervous animals. Treatment should be administered in a quiet and comfortable area, away from distractions, such as loud noises, other pets, and other people who are not helping with the treatment. This establishes an environment that promotes relaxation, allowing the patient to be more receptive to the treatment. Generally the patient is placed in lateral recumbency with the affected limb up. Beginning the session with 2 to 3 minutes of gentle stroking massage may also help with relaxation. The bones proximal and distal to the joint should be supported to avoid excessive stress on the joint (Fig. 1). The therapist should gently grasp the limb and avoid painful ar-
167 eas, such as incisions and wounds. The motion should be smooth, slow, and steady with movement at the distal aspect of the limb while the proximal limb is held steady. The other joints of the limb should be allowed to remain in a neutral position. Try not to move the other joints while working on the affected joint because some joints may be restricted by the position of the joints above or below the target joint. In these situations, the other joints should be placed in a position that will allow as complete a range of motion as possible to the target joint. For example, maximal hock flexion cannot be obtained while the stifle is maintained in an extended position. In this case, placing the stifle in a flexed position allows more complete flexion of the hock. Slowly continue to flex the joint until the patient shows initial signs of discomfort, such as tensing the limb, moving, vocalizing, turning the head toward the therapist, or trying to pull away. With the hands maintained in the same positions, slowly extend the joint. Again, try to keep the other joints in a neutral position and minimize any movement of the other joints. The patient should be continually monitored for any discomfort and the technique altered if necessary to enhance comfort.2 After completing range of motion of the affected joint, keep the limb in a neutral position and slowly move the hands distally to the digits (or if already working on the digits, move proximally). Range of motion exercises are then performed on the other joints of the limb. For example, begin with the digits; proceed to the tarsus, stifle, and last, the hip. It is important to fully flex and extend each joint. The number of range of motion repetitions and the frequency of the treatments depend on the condition treated. In general, for most routine postoperative conditions, 15 to 20 repetitions performed two to four times per day is likely to be adequate. We often end the range of motion session with a gentle massage to the injured limb for approximately 5 minutes. Massage will help to maintain a relaxed state. Passive range of motion is contraindicated when motion may result in further injury or instability, such as unstable fractures near joints and some ligamentous or tendon injuries. These exercises should also be omitted or limited in patients with joint hypermotility (luxation), osteopenic bones, or recent skin grafts.1
Massage Massage is the gentle manipulation of muscles and soft tissues. Using the hands to manipulate soft tissue can enhance circulation, reduce edema, loosen and stretch tendons, and minimize scar tissue formation. Massage also sooths anxious and uncomfortable patients and is often used before the patient undergoes other forms of rehabilitation.1,6 The mechanical effects of massage also increase nutrient delivery and waste removal from various tissues.8 Endless variations on massage exist; some of the common techniques include the following: stroking, effleurage, petrissage, shaking, vibration, friction, and tapotements. Sessions are often initiated and concluded with stroking. Stroking movements are performed in a relaxed manner using very lightly the tips of your fingers or the palm of the hand. While this technique can be performed in any direction, it usually follows the length of the muscles. When done slowly, the result is a calm patient.
R. Shumway
168
Figure 2 Compression massage.
Using effleurage every 10 to 20 seconds during massage may help promote fluid mobilization and proper tissue drainage. The direction of the strokes is toward the heart to assist venous circulation. The whole hand is used and is in full contact with the body part being massaged. The pressure is even through the entire stroke. The draining effect on the lymphatic circulation is proportional to the pressure applied and the rhythm of the movement. Petrissage utilizes movements that include kneading, compression, muscle squeezing, wringing-up, and skin rolling alone or in combination. Kneading is done in a rhythmical, circular pattern similar to kneading dough. Contact is maintained at all times and the tissues are intermittently compressed against the underlying bone. Kneading will have a pumping effect, which boosts the circulation, improves gas exchange, and helps remove toxins. Compression is performed with the palm of the hand or with a lightly clenched fist, alternating each hand rhythmically and applying pressure directly on to the muscle groups (Fig. 2). Compression complements kneading; it is used to save time and reduce fatigue when working on large muscle groups. This massage technique is not appropriate for small patients or directly over postoperative or traumatized tissues; however, it may be beneficial to other areas of the body, which can be stressed and overworked when compensating for disease or injury. Similar to compression, muscle squeezing is not recommended on postoperative tissue; however, it can be applied to other areas of the patient’s body. This technique is used to decongest and relax tense muscles. It is used mostly along the crest of the neck and is a very useful move to work on the legs and the tail. The movement is made between extended fingers and the heel of the hand using the entire palm surface in full contact with the body part. You can use one or two hands to deliver the muscle squeezing (Fig. 3). Wringing up is a great technique to increase circulation. It is also useful in decreasing inflammation over the muscles of the back. Wringing up is done with the palmar surface of the hand and the thumbs abducted at a 90-degree angle. With both hands placed flat on the animal, wring the muscles side to side much like winging a wet towel. This technique is also beneficial in warming up the muscle groups (Fig. 4). Skin rolling is beneficial in postoperative patients to pre-
Figure 3 Muscle squeezing.
vent the formation of adhesions and maintain elasticity of the skin. With the thumbs on one side and fingers on the other, grasp and lift the tissues. Using one or both hands, push the thumbs forward, rolling the skin toward the fingers. The fingers draw the skin toward the thumbs, lifting, stretching, and squeezing the tissues. This technique is performed in a slow soothing manner to avoid irritating the skin nerve endings. Care should be taken over areas of recent trauma. Vibration is a quivering type of movement done with the hands. Start the vibration movement from the elbow and translate them through your wrist to your hand. This technique is beneficial in soothing and relaxing the patient. Minimal pressure should be used. This technique may be effective in stimulating the parasympathetic nervous system. The shaking technique is performed with the fingertips or the whole palm of the hand in full contact with the body part. The skin is shaken over the muscles. This technique is also used to increase circulation. Friction massage is a useful technique to break down adhesions developing over muscular fibers, tendons, ligaments, fascia, joint capsules, and bones. Attention should be paid to the dimension and the location of the incision in relation to other structures such as bone, joint, nerve, or vein. It is important to warm the area with effleurage before proceeding.
Figure 4 Wringing-up.
Rehabilitation in the first 48 hours after surgery
169 TENS works by eliciting the release of endorphins into the bloodstream and cerebral spinal fluid as well as altering pain gating mechanism. The effects of TENS are fast-acting and may provide pain relief or increased tolerance to pain for several hours. TENS may be used, as needed; however, NMES for muscle strengthening and attenuation of muscle atrophy should only be administered once daily to prevent muscle soreness. Energy added to tissues in the form of low-level laser therapy alters cell membrane permeability, opens Ca2⫹ channels, increases cellular proliferation, and magnifies the release of growth factors from macrophages influencing wound healing, pain perception, and edema.10 The specifics of low-level laser therapy use and contraindications are also covered elsewhere in the text.
Figure 5 Friction massage.
Cryotherapy Friction can be done gently or coarsely to break down the fibrous adhesions. The tip of the thumb and first three fingers are used over smaller areas and both hands can be used over larger areas. At least 24 hours should pass before applying this technique over incisions or wounds (Fig. 5). One massage combination we commonly use starts by gently petting or stroking the affected limb using moderate pressure. When the initial tenderness seems to be relieved and the animal is relaxed, a gentle vibration movement can be used to stimulate circulation. Light stroking is then resumed. This will stimulate the circulation and begin the drainage process. A gentle kneading massage using both thumbs can then be applied at the edge of the swelling and can be moved around the area in a clockwise direction. Drain the excess fluid toward the outside of the edematous area. Very light pressure can be used over areas that are tender to the touch. After the first circumference to the edematous area is completed, apply light effleurage movements. Direction of the movement is away from the periphery of the trauma and in the direction of the heart. The kneading technique is then repeated in a spiral fashion toward the center of the affected area. Alternate the kneading with effleurage. The massage is completed with kneading in a circular direction around the swollen area. A continual awareness of the patient’s injury, tolerance, and comfort level is needed. Massage is contraindicated in patients with hypotension, fever, certain dermatologic conditions (ringworm), other infectious disorders, and over highly reactive or neoplastic tissues.
Cold is the agent of choice for managing the acute phase of tissue injury because it minimizes the inflammatory process and provides analgesia. Cryotherapy is commonly used to treat postoperative inflammation, musculoskeletal trauma, and muscle spasm and to minimize secondary inflammation following therapeutic exercise. Lowering the temperature of skin and underlying tissue causes vasoconstriction, reduces blood flow, and decreases sensory and motor nerve conduction velocity.6 The simplest method of cryotherapy immediately after surgery is to wrap a freezer bag containing crushed ice in a thin cloth (such as a towel or pillowcase) and then place it directly on the operated area. Cryotherapy is generally applied to the wound for 15 to 20 minutes immediately following surgery while the animal is recovering from anesthesia (Fig. 6). Cryotherapy is then applied two to four times daily to help combat swelling and pain after surgery or therapy. Cold compression units, which are commercially available, combine compression with cryotherapy (Fig. 7) and are highly effective during the acute phase of tissue inflammation and healing.11 The application of cold to hypothermic or very small patients is usually contraindicated. In addition care should be exercised in areas of reduced sensation, over superficial
Other Techniques While the details and use of neuromuscular electrical stimulation (NMES) and transcutaneous electrical neuromuscular stimulation (TENS) are covered in the modalities section of this text, application in the early postoperative period helps attenuate muscle atrophy, reduce join effusion, prevent muscle spasms, and reduce pain.1 NMES can also be used to facilitate muscle contraction on the impaired limb while the animal is unable to use the limb.3 When NMES is combined with early passive range of motion of the stifle joint, fibrosis of muscle can be reduced.9
Figure 6 Patient receiving cryotherapy while recovering from anesthesia.
R. Shumway
170
References
Figure 7 Cold compression unit (Opti-ice, Chattanooga Co., Hixson, TN).
nerves (ulnar, superficial peroneal nerves) and metal fixation devices, or in areas of vascular compromise (skin grafts). Signs of cold urticaria (wheals and swelling) as well as prolonged blanching of the skin are indications of tissue damage and a sign to avoid further cryotherapy.11,12 Early application of techniques to control inflammation and preserve range of motion can have a significant effect on patient comfort and attitude and on the speed and completeness of recovery.
1. Taylor RA: Post surgical physical therapy: the missing link. Compendium 14:1583-1593, 1992 2. Millis DL, Lewelling A, Hamilton S: Range of motion and stretching exercises in canine rehabilitation and physical therapy, in Millis DL (ed): Canine Rehabilitation and Physical Therapy. Philadelphia, PA, Saunders, 2004, pp 228-243 3. Millis DL: Getting the dog moving after surgery. J Am Animal Hosp Assoc 40:429-434, 2004 4. Ackermann MR: Acute inflammation, in Guyton AC, (eds): Textbook of Medical Physiology (ed 11). Philadelphia, PA, Saunders, pp 101-145 2006, 5. Salter RB, Simmonds DF, Malcolm BW, et al: The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit. J Bone Joint Surg Am 62:1232-1251, 1980 6. Knap K, Johnson AL, Schulz K: Fundamentals of physical rehabilitation, in Fossum TW, (ed): Small Animal Surgery (ed 3). St Louis, MO: pp 111-129 2007, 7. Millis DL, Levine D, Taylor RA: Canine Rehabilitation and Physical Therapy. St. Louis, MO, Saunders, 2004 8. Hourdebaigt JP: Canine massage: a complete reference manual. Wenatchee, WA, Dogwise Publishing, 2004 9. Johnson JM, Johnson AL, Pajanowsi GJ, et al: Rehabilitation of dogs with surgical treated cranial cruciate ligament-deficient stifles by use of electrical stimulation of muscles. Am J Vet Res 58:1473-1478, 1997 10. Edge-Hughes L: Canine Rehabilitation Certification Program. Loxahatchee, FL, 2007, pp 89-93 11. Heinrichs K: Superficial thermal modalities, in Millis DL (ed): Canine Rehabilitation and Physical Therapy. Philadelphia, PA, Saunders, 2004, pp 277-288 12. Haltrecht H: Physical therapy. Can Vet J 41:573-574, 2000