INTRODUCTION 11/26/12. Why is Rehabilita-on Important to My Pa-ents?

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1 Why is Rehabilita1on Important to My Pa1ents and My Prac1ce? Darryl Millis, MS, DVM, DACVS, CCRP, DACVSMR Director, CARES Center for Veterinary Sports Medicine INTRODUCTION Con1nued growth area of veterinary medicine One of top 5 areas veterinarians were adding to their prac1ce Physical therapy in humans is common Techniques and procedures adapted for small animals Many changes in the musculoskeletal system with orthopedic or neurologic condi1ons Many situa1ons where physical rehabilita1on may be used, including orthopedic and neurologic condi1ons, chronic disease such as osteoarthri1s, geriatric pa1ents, and obesity management Why is Rehabilita-on Important to My Pa-ents? Pa1ents that undergo surgery for orthopedic or neurologic condi1ons undergo a variety of changes, resul1ng in muscle atrophy, reduced range of mo1on, weakness, loss of propriocep1on, and compromised respiratory and cardiovascular condi1on Pa1ents with surgery for IVDD stand, walk, and recover in approximately half the 1me as compared with pa1ents that do not receive rehabilita1on Dogs with degenera1ve myelopathy have longer survival 1mes when undergoing intense rehabilita1on 1

2 Dogs that receive rehabilita1on for CCLR are less lame than dogs that do not undergo rehabilita1on ROM, especially extension, is improved with rehabilita1on S1fle ROM is associated with lameness Dogs with ar1cular fractures, especially the elbow, benefit from rehabilita1on to improve joint ROM Obese dogs lose weight more rapidly and have beuer clinical func1on if rehabilita1on is part of the weight loss plan Arthri1c dogs benefit from a rehabilita1on program that incorporates low impact and aqua1c exercises, and other modali1es to provide analgesia Condi1ons in Dogs Poten1ally Benefi1ng from PT Elbow Young Dogs Fragmented Coronoid Process Ununited Anconeal Process Osteochondrosis Dissecans Mature Dogs Osteoarthri1s Fractures 2

3 Hip Hip Dysplasia Young vs. Old Conserva1ve treatment Change exercise Diet An1- inflammatory drugs Total Hip Replacement Femoral Head & Neck Excision S1fle (Knee) Cranial Cruciate Ligament Rupture Generally due to ligament degenera1on Luxa1ng Patella Neurologic Disorders Intervertebral disk extrusion Common in chondrodystrophic dogs Paresis and paralysis common Lumbosacral instability Peripheral nerve disorders Radial & scia1c nerves Generally trauma- related 3

4 Trauma- Related Disorders Fractures of long bones Ar1cular fractures Y fractures of the humerus Tarsal/Carpal fractures Physeal fractures Distal femoral physeal fractures S1fle ligaments Collaterals, cruciates, menisci Quadriceps Tie- Down Rehab and Osteoarthri1s Rehab is very important in pa1ents with osteoarthri1s Es1mated that 20% of dogs have arthri1s Medica1on helps most pa1ents, but can be significantly enhanced by incorpora1ng physical rehabilita1on and therapeu1c exercises Regular, low- impact exercises help build muscle mass, enhance cardiovascular condi1oning, and improve flexibility and joint range of mo1on Aqua1c exercises, such as walking in an underwater treadmill or swimming are especially beneficial 4

5 Maggie - Lef S1fle Aqua1c Therapy Why is Rehabilita1on Important to My Prac1ce? Many factors that have contributed to the recent interest and popularity of veterinary rehabilita1on Awareness of the merits of physical rehabilita1on by the pet- owning public and their demand for more of these services has largely driven the development of this field The public realizes the value of op1mal medical services for humans, and expects similar if not beuer care for their pets Small animal physical rehabilita1on is an exci1ng new developing field of veterinary medicine 5

6 Humans have served as models for animal rehabilita1on The value and efficacy of physical therapy is well documented in the medical literature for humans Veterinary research has documented the benefits of small animal physical rehabilita1on Historical post- opera1ve and conserva1ve management protocols are an1quated Incorpora1ng physical rehabilita1on into veterinary prac1ce results from the pursuit of op1mal animal care The differences in clinical outcomes are recognized by owners and veterinarians Rehabilita1on is important in conveying concern for the overall health of an owner s pet Can dis1nguish your prac1ce from others Value to the Prac1ce Let s look at one example of how managing OA pa1ents can add value Assume a 50 pound dog is diagnosed with arthri1s and is on an NSAID, nutri1onal supplement, PSGAG injec1ons, and prescrip1on dog food The owner may spend approximately $2300 per year Assuming a 100% mark- up on these items, a profit of $1150 per year could be appreciated Assume that the pa1ent is diagnosed at 5 years of age and lives un1l age 12, a total profit of $9200 may be realized over the life1me of the pa1ent 6

7 Suppor1ng Data Study by Dr. Paul BartleU, MPH, PhD, Michigan State and Dr. James Van Buren, MBA, Vector Scien1fic Resources to evaluate treatment costs at the university s veterinary teaching hospital Cost do not include examina1on fees, overnight hospital charges, or clinical pathology charges Median cost $2447 (25 th percen1le $1124, 75 th percen1le $6502) Furthermore, assume a veterinarian sees approximately pa1ents per day, with (conserva1vely) two of those being arthri1c If a veterinarian sees pa1ents 250 days per year, there is the poten1al for $575,000 of profit per year from just the chronic management of arthri1c pa1ents (250 days)(2 OA/day)($1150/pa1ent) = $575,000 This is exclusive of any office calls, blood work, or other diagnos1cs and treatments found as a result of regular follow- ups Also excludes surgical procedures, such as surgery for CCLR, hip dysplasia or elbow dysplasia The Economics of OA Treatment A prac1ce may further dis1nguish itself from other prac1ces by adding rehabilitaion modali1es Aqua1c and rehabilita1on services $50/wk x 50 wks = $2500/year x 7 years = $17,500 Therapeu1c Laser $75/treatment x 25 trts/year = $1875 x 7 years = $13,125 Extracorporeal shock wave therapy $200/treatment x 4 trts/year = $800 x 7 years = $5600 Transcutaneous electrical nerve s1mula1on (TENS), and Acupuncture Ini1al outlay for some modali1es may be substan1al, but it provides owners with addi1onal treatment op1ons and can be a prac1ce builder 7

8 Why is Rehabilita1on Important? Pa1ents that undergo surgery, such as fractures, rupture of a cruciate ligament, or neurologic condi1ons have changes to car1lage, bone, muscle, and tendons and ligaments For example, dogs may lose one- third of their muscle mass in the rear limb following surgery for a cranial cruciate ligament rupture and it may take over one year to regain the lost muscle 1ssue In some cases, complete recovery may not occur Benefits of Physical Therapy Increased speed of recovery Posi1ve psychological effects for the pet and owner Improved performance and quality of movement Increased strength and endurance Benefits of Physical Therapy Improved biomechanics and flexibility Reduced pain Non- invasive approach Minimized complica1ons Preven1on of future injury through owner/ trainer educa1on 8

9 Considera1ons in Star1ng Rehab Beginning a new rehab service must follow a sound business plan Pa1ent survey to establish a need for this service Determine the projected numbers of in- house and referred cases Musculoskeletal condi1ons, neurosurgical cases and other condi1ons, such as arthri1c and obese pa1ents 20% of mature dogs have OA, and up to 40% of dogs are overweight or obese Facility should have three to five pa1ents per day to jus1fy a full- 1me effort Costs of Facili1es and Equipment Purchase, set- up, marke1ng and adver1sing costs considered Space is usually a limi1ng factor in veterinary facili1es Exis1ng space or addi1onal space through renova1on or separate facility construc1on? Professional appearance is a must Facili1es Planning Recep1on and wai1ng area, pa1ent assessment area, treatment area including room for aqua1c equipment, pa1ent housing (par1cularly for in- house cases), an exercise area for outside therapeu1c modali1es and care, office space, storage, and client parking must be considered 9

10 Equipment Rehabilita1on efforts may begin with very liule equipment PROM, massage, icing, hea1ng, gait training, and many other therapeu1c ac1vi1es have minimal expense Ice packs, frozen packaged peas, hot packs or a wet towel warmed in a microwave, and a therapeu1c mat are basic equipment to get started Tape measure and goniometer for evalua1on Safety equipment muzzles, slings, harnesses Therapeu1c US, NMES, therapeu1c lasers, ground treadmill, aqua1c therapy, stairs, and an exercise area Exam and Client Educa1on Exercise Room 10

11 Modali1es/ Quiet Room Aqua1c Room Pa1ent Housing 11

12 The Rehab Team DVMs and veterinary technicians receive no training in physical rehabilita1on PTs receive no training in veterinary medicine Important to develop collabora1ve working rela1onships to advance the care of pa1ents Some prac1ces have an area for rehab, some have a PT on staff, while others have consultants Educa1on and training are key What Happens if I Don t Do Rehab for My Pa1ents? Musculoskeletal 1ssues, including car1lage, muscle, bone, ligaments and tendons, undergo tremendous change as a result of injury or following surgery Tissues auempt to revert back to their preinjured state Knowledge of the character and 1ming of these events is important to develop rehabilita1on protocols Effect of Physical Therapy on S1fle Extension Stifle Extension (degrees) * * * * Time (days) * * PT No PT * p <.05 Millis DL, Levine D, Brumlow M, Weigel JP: A Preliminary Study of Early Physical Therapy Following Surgery for Cranial Cruciate Ligament Rupture in Dogs. Proceedings of the 24 th Annual Conference of the Veterinary Orthopedic Society, pg. 39,

13 S1fle Extension vs. Peak Ver1cal Force in Dogs 10 weeks afer CCLR Transec1on and S1fle Stabiliza1on Peak Vertical Force (ratio of affected/unaffected limb) Stifle Extension (Degrees) Summary Poten1al to improve the outcome of surgical (and nonsurgical) condi1ons with physical rehabilita1on Some rehabilita1on is beuer than none Knowledge of medical condi1ons, treatments, and the response of 1ssues to disuse and remobiliza1on is cri1cal to success Enhances quality of life, owner sa1sfac1on, and owner s enjoyment of their pet 13

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