Canis ISSN: 2398-2942

Physical rehabilitation (after fracture stabilization)

Contributor(s): Courtney J Arnoldy, Jacqueline Davidson

Rehabilitation principles/healing time frames

  • A thorough examination and evaluation is essential to determine the most appropriate therapeutic plan of care.
  • Collaboration between the veterinary and physical therapy professions is an ideal team approach to ensure safe and effective rehabilitation.
  • The rehabilitation team must have a working knowledge of anticipated outcomes based on the injury and surgical precedure (as applicable). A complete understanding of tissue healing and repair is necessary. The following patient-specific factors are esential when establishing your plan of care:
    • Patient's age.
    • Tissues involved (location and severity of tissue damage).
    • Fracture configuration.
    • Surgical procedure.
    • Pre-existing medical conditions and disabilities.
    • Body condition.
    • Owner compliance.
    • Personality of the patient.
  • Healing time frames can be divided into three phases:
    • The inflammatory phase of tissue healing (phase 1). The inflammatory phase predominates until about day 5. It is characterized by inflammation and pain.
    • The repair phase (phase 2) starts around day 3-5 and predominates until 17-20 days after injury. Inflammation and pain are decreasing, while collagen and capillaries are formed in the wound. Pain may be noted at the end of available ROM (range of motion). Soft tissue contratures and muscle weakness may develop during this time.
    • The maturation or remodeling phase (phase 3). This phase begins around 3 weeks and continues for months or years. Alignment of collagen occurs and the scar contracts and remodels. There are no clinical signs of inflammation but there may be pain apparent after tissue resistance is encountered at the limits of ROM.
  • The inflammatory phase (phase 1) of wound healing is the protection phase of physical rehabilitation treatment. The primary problems are inflammation, pain, edema, soft tissue tension and muscle spasms and impaired movement. The goals are to control inflammation and edema, promote early healing, and prevent the deleterious effect of rest by use of PROM and massage.
  • The repair phase (phase 2) of wound healing corresponds with the controlled-motion phase of rehabilitation. Goals are to promote healing and develop mobile scar. Joint mobility may be progresively restored with passive or active ROM. Muscle strengthening and endurance exercises may begin, with careful progression in intensity.
  • In phase 3, maturation or remodeling begins as inflammation is resolving. This phase focuses on healing of tissues and continues approximately 3-4 weeks post-operative until full recovery. Goals in this phase of therapy include re-establishing range of motion (active and passive), mobilizing scar tissue, improving strength and proprioception and addressing dysfunctional movement patterns. The maturation and remodeling phase is the return-to-function phase for rehabilitation intervention. Goals are to increase the strength and alignment of the scar and improve function. Methods used include progressive stretching, strengthening, endurance training, and functional exercises.
  • During each phase, appropriate stresses are applied to the healing tissue. It is important to stress healing tissues, although not to a point of failure. In phase two, strengthening and proprioceptive exercises can be initiated with a goal of re-establishing function. Wolffs law can be summarized:tissues respond to the physical demands placed upon them. Understanding this principle is important when determining the progression of your rehabilitation plan. For example, rehabilitation techniques in the immediate post-operative period following a rigid stabilization will be different and may be started earlier compared to the techniques chosen for a tenuous repair. Equipment availability will also determine interventions and initiation of rehabilitation. Rehabilitation techniques in an underwater treadmill may be safer to initiate in the first 3-4 weeks as compared to a pool or land-based exercise.
  • During the rehabilitative process, it is important to integrate all phases of healing as the phases are not really distinct. The therapist should be cognizant of which phase is likely to be predominating and focus on the inherent problems for that phase of healing. A comprehensive rehabilitation program is essential throughout the healing process. An understanding of the intent and rationale as well as the contraindications is crucial prior to implementing any exercise, technique or modality.
    Print off the owner factsheet on Physical therapy and rehabilitation Physical therapy and rehabilitation to give to your client.

Post-operative phases of healing and therapeutic interventions

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Therapeutic activities and modalities

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Reassessment

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Summary

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Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Davidson J R, Kerwin S C, Millis D L (2005) Rehabilitation for the orthopedic patient. Vet Clin North Am Small Anim Pract 35 (6), 1357-1388, viii PubMed.
  • Doyle N D (2004) Rehabilitation of fractures in small animals: maximize outcomes, minimize complications. Clin Tech Small Anim Pract 19 (3), 180-191 PubMed.
  • Mann F A & Payne J T (1989) Bone healing. Sem Vet Med Surg (4), 312-321 PubMed.

Other sources of information

  • Millis, Levine & Taylor (2004) Canine Rehabilitation and Physical Therapy. Saunders.
  • Rehabilitation of Fracture Patients. Proceedings 3rd International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine 2004.


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