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Physiotherapy for cats and dogs applied to locomotor disorders of arthritic origin
Physiotherapy has positive effects on the entire locomotor system
The morphology, physiology and metabolism of the structures involved in locomotion are mainly determined by mechanical factors related to movement: cycles of loading/unloading, the direction and orientation of force. Connective tissue (ligaments, tendons, muscles, fascias, conjunctive tissue), joint cartilages and bone adapt to mechanical demands, not only during juvenile growth but also in adults (1).

Sarah Rivire, DVM, MSc


Scientific Communication, Royal Canin Research Center, Aimargues, France Sarah Rivire graduated from the National Veterinary School of Lyon in 2000. The same year she went to work for the Breeding and Sports Medicine Unit (Unit de Mdecine de lElevage et du Sport) at the Alfort Veterinary School in Paris. Sarah has worked for five years in canine sports medicine, developing the use of functional rehabilitation and physiotherapy for domestic carnivores. Her doctoral thesis, defended in 2002, dealt with this subject. Sarah Rivire joined the research team at Royal Canin in September 2005 and is responsible for scientific studies and communication.

Physiological movement is essential to the good condition of the locomotor system


There are three types of constraints that harm the locomotor system: - constraints related to performing supra-physiological movements or repetitive movements during sporting activities - non-physiological constraints generated by postural disorders (congenital malformation, trauma etc.) - prolonged immobilization for therapeutic reason, or caused by the animals refusal to move a part of the locomotor system (pain, mechanical discomfort etc.) All locomotor organs are subject to change during non-physiological loading or immobilization (1,2): - the elasticity and mechanical resistance of joint cartilage and subchondral bone decreases. Shock absorption is less effective and the degenerative mechanisms of arthritis evolve - bone metabolism is modified: osteoporosis may develop after a few weeks of immobilization or poor osteosynthesis - joint capsules, ligaments and tendons contract and may become sclerotic, adhesions develop with loss in joint mobility and proprioceptive deficiency (Figure 1)

Introduction
Over recent years, veterinary medicine has made real progress in the diagnosis and treatment, both medical and surgical, of locomotor disorders. However, the benefits of physiological attention in the pre- and post-operative periods is a more recent finding. The positive effects of functional rehabilitation on man have been accepted worldwide since the 1970s, suggesting that it could also benefit domestic carnivores. Since the 1990s, new techniques that improve recovery have been used extensively in veterinary medicine.

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PHYSIOTHERAPY FOR CATS AND DOGS APPLIED TO LOCOMOTOR DISORDERS OF ARTHRITIC ORIGIN

- the fleshy body of the muscles undergoes degenerative retraction, even fibrosis and adhesions form between ligaments and muscle fatigability increases - cicatrisation processes are disturbed and adhesion formation favored, since local vascularization is modified, decreasing the elimination of metabolic waste - blood and lymph circulation is impaired, which may affect major body functions The harmful effects of non-physiological mobilization and immobilization explain why orthopedists agree on the need to bear weight and carry out physiological movement as early as possible during the treatment of a locomotor disorder.

Early stimulation of joints and muscle, together with careful application of controlled weight during physiotherapy sessions, improves quality of life and helps the animal become autonomous, speeding up functional recovery.

Indications
The principal indication for physiotherapy is postoperative management of animals having undergone orthopedic or neurological surgery (4). However it is also useful before surgery to help fight pain, reduce inflammation and prepare the animal physically for surgery (for example: increase muscle mass in some cases of hip dysplasia). Physiotherapy also offers the possibility of treating acute and chronic disorders not requiring surgery (tendonitis, sprain, muscle pain, arthritis etc.). It can also be implemented to prevent recurrence or to prepare sporting dogs (5,6).

The benefits of physiotherapy in the treatment of locomotor disorders


Definition
Physiotherapy is defined as a therapy using physical means such as: movement (mobilization, stretching, exercise, massage), thermal agents (cold, heat), electric current, sound waves (therapeutic ultrasound), light (laser), magnetic fields, extra-corporeal shock waves etc.

Physiotherapy as an integral part of a general functional rehabilitation program


Functional rehabilitation is, above all, an overall and sensible approach aimed at treating the impaired function and limiting any repercussions on the body. When an animal suffers from a locomotor disorder, it redistributes the forces required for posture and locomotion onto its valid limbs, which are subject to supplementary, non-physiological, constraints. Thus, a locomotor problem is often accompanied by a cascade of negative effects: voluntary restriction of physical activity, weight gain, modification in rest areas, joint stiffness, amyotrophy, increased pain etc. The vicious circle needs to be broken. The aim of a functional rehabilitation program is to ensure and preserve optimal functional recovery as early as possible. It is based on a careful combination of physiotherapy techniques, often associated with other modalities (acupuncture, osteopathy etc.),
Figure 1. a. Prolonged immobilization of a limb may result in irreversible ankylosis of one or several joints. b. Maximum extension and flexion of the knee of a Poodle after three months of immobilization.

Expected effects
These non-invasive techniques, used on cats and dogs, present multiple therapeutic benefits (1,3). They: - combat pain - combat acute and chronic inflammatory processes - improve blood perfusion and consequently tissue growth - prevent adhesions, fibrosis and tissue retraction - reduce muscle contractions and tension - strengthen muscles and improve resistance to fatigue - stimulate the nervous system, prevent neuropraxia and stunned muscle - encourage proprioceptive functional rehabilitation and re-learning of motor patterns - improve cardio-respiratory capacity

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together with good daily care. It supplements the effects of medical and surgical treatment. Improved functional rehabilitation is always observed as soon as physiotherapy is started (7-11). To obtain the best results, pet owners are encouraged to participate in the functional rehabilitation of their animals by carrying out simple movements regularly.

by S. Sawaya, page 37). All the joints of the impaired limb are successively manipulated. Several times a day, the limb is gently flexed then extended by the therapist ten or twenty times successively, without causing pain. If the joint is stiff and there is decreased movement amplitude, some degree of stretching must be incorporated: the final extension or flexion position is maintained for about ten seconds, then repeated about ten times. One study demonstrated that twice daily passive mobilization combined with stretching for 21 days effectively increased the amplitude of arthritic joint movement in dogs (15). Here it is clear that the pet owner should be able to carry out these simple manipulations for the animal to receive therapy as often as necessary. These exercises can be completed by mobilizing the entire limb by a "bicycle" movement which provides a final, overall action that stimulates the entire nervous system (3).

Physiotherapy in the management of arthritic patients


The quality of life of arthritic animals is much impaired. As the clinical signs (pain, joint stiffness) progress, animals move less and inactivity results in decreased joint flexibility and muscular atrophy. The greater the decrease in movement amplitude, the higher the risk of capsular adherences and ligament retractions. Pain generates muscle tension, spontaneous activity decreases and a vicious circle results. Therapeutic management should slow down the arthritic process and limit the animals discomfort. A functional rehabilitation program can be combined with drugs for arthritis, or possibly with surgery (if necessary) (12). The aims are to: - relieve pain - preserve or improve joint function - increase muscle strength - stimulate voluntary physical activity (13) Many physiotherapy techniques are beneficial to arthritic patients. In this article, we shall limit ourselves to "manual" techniques, which unlike "instrumental" techniques require no specific equipment. Manual techniques are always the basis of any physiotherapy program, and they can be adapted to the severity of the animals clinical signs by evaluating pain and functional capacity. There is however one exception to this rule: in the event of an attack of acute arthritis, complete restriction of activity is required and only certain instrumental techniques can be used (see article by S. Sawaya, page 37).

Active therapeutic exercises


Active therapeutic exercises are voluntary movements that are selected and oriented by the therapist (or owner). They encourage recovery of physiological weight bearing, stimulate the complete locomotor system (increased strength and endurance) and improve cardio-respiratory capacity. They also help relieve pain and improve activity, as seen for man in a meta-analysis of publications from 2002 to 2005 concerning the use of active therapeutic exercises during functional rehabilitation (16). Active therapeutic exercises should be started as early as possible, bearing in mind the cicatrisation phases of impaired tissue. The type, duration, frequency and intensity of the exercises are determined from the arthritic animals clinical signs. Short sessions (five to ten minutes) several times a day are recommended, and difficulties should be increased gradually. Assisted therapeutic exercises are also very useful for animals that cannot move alone correctly. The principle is to support the cat or dog (using a harness, a towel etc.) to help and guide it during simple movements such as walking. Progressively, throughout sessions, the exercises will be carried out on different types of ground (grass, sand etc.) to stimulate the proprioceptive function.

Passive joint mobilization and stretching


These manipulations preserve or increase flexibility and amplitude of joint movements and stimulate muscles and the nervous system. The animal is laid on its side and should not resist the movements. Joints and muscles may be previously heated to obtain better relaxation (14) (see article

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PHYSIOTHERAPY FOR CATS AND DOGS APPLIED TO LOCOMOTOR DISORDERS OF ARTHRITIC ORIGIN

Figure 2. Wheelbarrow walking strengthens forelimbs.

Immersion in water induces constant exteroceptive stimulation that forces the animal to mobilize its entire locomotor system to maintain its position. Heat relaxes tissue and relieves pain, whilst the viscosity of the medium offers a resistance that stimulates muscle work. Some movements that are impossible to make on the ground can be made in water (18). Hydrotherapy promotes joint work, muscle development and cardio-respiratory capacity. Two to three sessions per week of five to twenty minutes are recommended preferably in an immersed treadmill in a rehabilitation swimming pool (Figure 5) or in a natural environment, if the water temperature is suitable.

Figure 3. Mounting stairs strengthens hind limbs and stimulates the voluntary extension of knees and hips.

Massage
Walking is the simplest and most essential exercise (3). A slow walk on a lead controls both posture and weight distribution. A treadmill helps stimulate certain weight-bearing points refused by the animal, since the floor moves under its paws it has to use all four limbs. This apparatus is also beneficial as speed can be regularly increased to reach a trot. Galloping is not recommended since weight-bearing points are not controlled and shocks to the joints are increased. Other active therapeutic exercises have a more specific action: - removal of support from healthy limbs, either by "wheelbarrow walking" or "dancing" to stimulate targeted members (Figure 2) - mounting stairs to induce hip and knee extension (Figure 3) - obstacle circuit to obtain limb flexion - load pulling to strengthen muscles - "sitting-standing" exercises to strengthen hind limbs - voluntary flexion/extension of the neck by offering a ball or food from left to right or up and down - walking in a circle or an 8 to stimulate the proprioceptive function etc. (3,12). There are many different types of massage which help the animal to relax, reduce muscle tension and pain, improve venous and lymphatic circulation, facilitate metabolic waste elimination, reduce adherences and stimulate the nervous system. Massage is used to reduce muscle tension in arthritic animals as a complement to other techniques. A massage session must be performed prior to any other physiotherapy exercises. Heat application at the start and end of the session will improve relaxation. For arthritic patients, only superficial techniques are used and massage is not recommended on places of acute arthritis. - the session starts by gentle massage or effleurage where the therapist makes contact with the patient by gently stroking the skin.

38%

Greater trochanter of the femur

85%

Lateral condyle of the femur


(Jean-Michel Labat)

Hydrotherapy
Walking in water and swimming are very useful active therapeutic exercises for arthritic animals. They are particularly recommended where the animal is overweight or has difficulty in moving. Buoyancy puts the animal in a state of relative weightlessness which relieves the locomotor system (17) (Figure 4).
91% Lateral malleolus of the tibia

Figure 4. The weight borne by the animal (as a % of bodyweight measured out of the water) as a function of the depth of immersion in water, as per Levine, et al. (17).

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PHYSIOTHERAPY FOR CATS AND DOGS APPLIED TO LOCOMOTOR DISORDERS OF ARTHRITIC ORIGIN

Figure 5. Hydrotherapy in a rehabilitation swimming pool in the Breeding and Sports Medicine Unit* School of Veterinary Medicine, Alfort, France.

Weight management
Any excessive load placed on joints may accelerate the development of arthritis and pain (13). When assessing an animal before functional rehabilitation, always assess its ideal weight. If necessary, caloric restriction is prescribed simultaneously with exercises to maintain healthy musculature. In veterinary medicine, as in human medicine, a program of functional rehabilitation combining weight loss with physiotherapy was seen to decrease the symptoms and improve clinical signs (19).

- it continues with superficial petrissage: the therapist takes a skin fold and rolls it. He/she starts at the tail and works towards the head along the back and from the distal area towards the proximal area of limbs. - percussion can also be used: for example, the skin is tapped gently with the palm or the side of the hand. Large areas of muscle are treated in this way. - the session ends by vibrations, either by holding a group of muscles that are slowly mobilized in a to and fro movement, or by holding the tip of the paw to stimulate the whole limb. It is an ideal technique for the end of a massage session since it fully relaxes muscles. Eff leurage can also be performed at the end of a session.

Conclusion
In the framework of integrated multimodal therapy, a careful combination of various physiotherapy techniques (manual and instrumental), drugs and other non-pharmacological therapies such as acupuncture, osteopathy or homeopathy provide excellent results.
* The Breeding and Sports Medicine Unit (UMES) was created in 1996 by Professor Dominique Grandjean within the National Veterinary School of Alfort. Its mission is to make the canine and feline professionals and the veterinarians work together. The UMES has developed the first French clinic specialized in functional re-education for dogs and cats.

REFERENCES
1. Rivire S, Sawaya S. Rducation fonctionnelle du chien et du chat: intrt de la physiothrapie. Le point Vtrinaire 2006; S63: 52-55. 2. Millis DL. Reponses of musculoskeletal tissues to disuse and remobilization. In: Millis DL, Levine D, Taylor RA. Canine rehabilitation and physical therapy. Saint Louis: WB Saunders 2004, pp. 113-159. 3. Bockstahler B, Levine D, Millis D. Essential facts of physiotherapy in dogs and cats, rehabilitation and pain management. Babenhausen: BE Verlag 2004. 4. Olby N, Halling KB, Glick TR. Rehabilitation for the neurologic patient. Vet Clin Small Anim 2005; 35: 1389-1409. 5. Marcellin-Little DJ, Levine D, Taylor R. Rehabilitation and conditioning of sporting dogs. Vet Clin Small Anim 2005; 35: 1427-1439. 6. Levine D, Millis DL, Marcellin-Little DJ. Introduction to veterinary physical rehabilitation. Vet Clin Small Anim 2005; 35: 1247-1254. 7. Downer AH, Spear VL. Physical therapy in the management of long bone fractures in small animals. Vet Clin North Am 1975; 5: 157-164. 8. Johnsonn JM, Johnson AL, Pijanowski GJ, et al. Rehabilitation of dogs with surgically treated cranial cruciate ligament-deficient stifles by use of electrical stimulation of muscles. Am J Vet Res 1997; 58: 1473-1478. 9. Johnston KD, Levine D, Price MN, et al. The effect of TENS on osteoarthritic pain in the stifle of dogs. In: Proceedings of the Second International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine. Knoxville: American Physical Therapy Association 2002, pp. 199. 10. Marsolais GS, Dvorak G, Conzemius MG. Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs. J Am Vet Med Assoc 2002; 43: 433-439. 11. Millis DL, Levine D. The role of exercise and physical modalities in the treatment of osteoarthritis. Vet Clin North Am Small Anim 1997; 27: 913-930. 12. Lascelles BDX, Marcellin-Little DJ. Practical approach to pain management and rehabilitation in canine osteoarthritis. In: http://www.rehabsymposium.com 2007. 13. Davidson JR, Kerwin SC, Millis DL. Rehabilitation for the orthopaedic patient. Vet Clin Small Anim 2005; 35: 1357-1388. 14. Steiss JE, Levine D. Physical agent modalities. Vet Clin Small Anim 2005; 35: 1317-1333. 15. Crook T, McGowan C, Pead M. Effect of passive stretching on the range of motion of osteoarthritic joints in 10 labrador retrievers. Veterinary record 2007, 160: 545-547. 16. Taylor NF, Dodd KJ, Shields N, Bruder A. Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002-2005. Australian Journal of Physiotherapy 2007; 53: 7-16. 17. Levine D, Tragauer V, Millis DL. Percentage of normal weight bearing during partial immersion at various depths in dogs. In: Proceedings of the Second International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine. Knoxville: American Physical Therapy Association 2002, pp. 189-190. 18. Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee osteoarthritis: result of a single-blind randomized controlled trial. Phys Ther 2007; 87: 32-43. 19. Mlacnik E, Bockstahler BA, Mller M, et al. Effects of caloric restriction and a moderate or intense physiotherapy program for treatment of lameness in overweight dogs with osteoarthritis. JAVMA 2006; 11(229): 1756-1760.

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