CCL – Sam Sherrington

Prehabilitation and Rehabilitation

Prehabilitation is a Proactive/preventive approach to manual therapy, exercise, diet and lifestyle, designed to maximise health and wellness, and minimise individual risks for injury and disease. Well-studied in human medicine, prehabilitation is found to be valuable in ‘high risk’, aged, frail or obese patients, as well as younger patients who wish to maximise their athletic performance or if injured and facing surgery, to return to their chosen sports as soon as possible. It is especially valuable when an animal is requiring surgery, and as a pre-operative approach integrates biomechanical assessment and appropriate manual therapy treatment, individualised home exercises plus diet and lifestyle advice in advance of surgery. Prehabilitation has been shown to promote lower complication rates and earlier restoration of functional activities and status during the recovery from surgery. Good quality systematic reviews show a positive impact of pre-operative exercise therapy on physical function, quality of life, postoperative complications and length of hospital stay.

border collie with toy in mouth waiting for a command

Most animals have been developing compensations for minor slips, trips and falls for many months or years prior to pain or lameness becoming evident. Individualised prehabilitation helps to make sure the animal is moving well and has the best possible strength prior to undergoing surgery. This is believed to help improve the outcomes of surgery by promoting healthy circulation, minimising inflammation, reducing pain related behaviour and movement limitations, reducing strain on the healing tissues and as a bonus will often reduce the animals reliance upon medication to control inflammation and pain both before and after the surgery.

Rehabilitation takes a similar approach around the inclusion of biomechanical assessment and appropriate manual therapy treatment, individualised home exercise, diet and lifestyle advice in respect to promoting the most efficient and successful recovery after orthopaedic surgery or acute injury. Rehabilitation typically follows a pattern guided by the natural healing mechanisms within the associated tissues.

Inflammation is the main factor to manage for the first 2 – 4 weeks depending on the individual situation. This typically includes medication and rest, however these can also be complimented by gentle therapeutic options such as lymphatic drainage, laser and kinesiology taping to help the tissues clear the active inflammation and bring fresh blood supply into the healing tissues. Treatment is always considered on a case by case basis in conjunction with veterinary advice, as individual factors play a large role in the suitability of therapies during the acute stage. Gentle modalities such as laser, kinesiotaping and lymphatic drainage often appropriate immediately post surgery, and specific home exercises may be able to help maintain the nervous and muscular system function in relation to the injury.

Weeks 5-8, are crucial in ensuring the affected tissues are building their passive and active function in a symmetrical and biomechanically correct manner in order to ensure that the repairing tissue is as healthy and functional as possible. Again, passive and active techniques, more advanced exercises and modalities may be applied as appropriate to promote healthy tissue repair.

Remodelling, during weeks 9-12 is when the fun really begins. This is where, if previous stages have been completed with success, we can really start to challenge the body while still being aware there is much change still happening within the healing tissues. Monitoring the dog during this period is particularly important as they often begin to feel ‘like new’ and can easily overdo it. Rehab exercises can increase in complexity as we challenge both the musculoskeletal tissues as well as the nervous system which controls healthy movement.

Months 3 – 6 are the cherry on top as far as rehabilitation goes. While it may seem as though the dog is back to normal, it is very important to continue monitoring them for any signs that their tissues aren’t strengthening symmetrically or fully. Owners are coached on how to monitor their animals for small asymmetries or movement patterns in their own animals specific case, to help pick up early signs of trouble. This helps to reduce the likelihood of long term development of osteoarthritic changes that are common when surgical procedures have occurred. Typically at this stage home exercises should be part of normal daily life, with lifestyle changes well integrated to help the animal continue well into their older years. I always aim to make these lifestyle factors and exercises as easy to integrate into daily life as possible, which makes it significantly more likely that they will be maintained through the animals lifetime.

Please don’t hesitate to get in touch to discuss how Osteopathy and ABM can help your individual animal, with their own specific requirements be their very best.

If you are already struggling with an adult dog who has uneven movement patterns there is plenty you can do to improve their comfort by introducing a routine of safe stretches and exercises. I have compiled a comprehensive range of these within my eBook – The Canine Athlete Warm-Up and Cool-down Manual, which is a safe way for you to start exploring better musculoskeletal health for almost any dog. Check it out HERE or get in touch if you’re uncertain how to get started for your specific dog’s problems.

Osteopathy and the Older Dog

When our dogs get older we often seek extra ways to help them. Osteopathy can be invaluable in adding quality to their lives, read on to find out how.

Life can be tough on the body, even for the best loved and pampered pooch, and by the time they reach their ‘Golden Years’ they can be starting to show their age in many different ways. Their metabolism slows down, often increasing weight and lowering their ability to regulate their body heat. This extra weight in itself, adds strain to already worn joints, which in turn make it harder to get your dog out for some gentle exercise to help manage the weight gain. Older dogs often also experience changes in their temperament, becoming grumpy or aggressive towards family members, especially other pets and children. This is frequently due to undiagnosed or under-treated pain, and goes hand in hand with depression, a reduced social capacity and loss of function in their normal daily activities. Pain management often becomes a big problem when the elderly dog shows the commonly seen increasing signs of side-effects and reactions to medication, and an increased reliance on them to manage simple daily tasks. I frequently hear owners feeling powerless to break this cycle – a feeling having very few satisfactory answers to helping their dog manage as their age creeps up.

Osteopathic care is a gentle approach to helping any animal function the best they can taking into account the conditions they are experiencing. Osteopaths are university trained professionals who are able to recognise where the body can function more efficiently, helping the animal move closer to ‘homeostasis’ – the body’s sense of optimal balance, ease and functioning. Osteopaths use primarily manual therapy techniques, as well as adjunctive techniques such as laser, kinesiology taping and exercise prescription.

Human studies focusing on Osteopathic Treatment in the elderly have shown improvements in respiratory function, functional ability, balance and wellbeing. There has also been noted reduction in pain levels, medication reliance and assistance with some side effects of medications such as constipation commonly seen with some pain medications. These studies, while conducted on humans, have great relevance for guiding the kind of allied care we can offer for elderly dogs, in conjunction with care provided by your Veterinarian.

Osteopathy helps to restore an animals range of motion of all joints and soft tissues of the body, creating an ability to move more comfortably through activities of daily living. In conjunction with Hydrotherapy, we can then add numerous general and specifically tailored exercises and activities for the dog and owner to complete at home to help build added strength and function. In the elderly, it always amazes me how many of the co-morbidities (additional conditions such as failing organs, sight, hearing etc) can become less bothersome when the dog is up and moving more efficiently. Movement really is the most amazing medicine for all bodies.

If you are already struggling with an adult dog who has stiffness or uneven movement patterns there is plenty you can do to improve their comfort by introducing a routine of safe stretches and exercises. I have compiled a comprehensive range of these within my eBook – The Canine Athlete Warm-Up and Cool-down Manual, which is a safe way for you to start exploring better musculoskeletal health for almost any dog. Check it out HERE or get in touch if you’re uncertain how to get started for your specific dog’s problems.

For more information or to discuss how I can help your Golden Oldie live their very best life, please give me a shout on 0452 472 959 or shoot me a message @centaurusosteo on facebook.

Canine Cranial Cruciate Ligament Injuries – Surgery or what??

How Cranial Cruciate Ligament Injuries can be managed when surgery isn’t the first choice.

Ruptures and partial tears to one or both Cranial Cruciate Ligaments (CCL) is a remarkably common injury in our doggy friends. While certain breeds seem to have significantly more frequency of injury, I see it in a wide variety of breeds, ages and sizes of dogs.

(image: petmd.com)

Traditionally, it has been believed that typically only small dogs, under about 15kg, fare just as well with conservative management as they do with surgical repair options. This belief is based on a study which showed very positive outcomes for the small dogs and not so much resolution of lameness in the bigger dogs. Some practitioners, however, have been questioning the assumptions since.

Dr Narda Robinson DVM is one practitioner who has been quite vocal about the lack of options many pet owners are given when faced with a CCL injury. She has compiled some good evidence here to endeavour to debunk many commonly held beliefs around why surgery should always be the primary option for sorting out our dogs dodgy knees.

So, when an owner makes the decision to give the surgical option a miss, even on a trial basis, what actually are the conservative options?

Weight management – The first step is to ensure the dog is at a healthy weight or slightly underweight. Evidence is mixed but several well designed studies suggest that advancing age and increased body weight are two of the big factors influencing the likelihood of degenerative lesions in CCLs and also risk of of full ruptures. Obviously there isn’t much we can do to stop the clock, but body weight is absolutely one of the most manageable risk factors. This makes a lot of sense from a physiologic perspective as fat cells are inherently inflammatory, and become more so as fat accumulates. As such, it’s not only the mechanical effects of extra weight itself, but even more significantly the systemic inflammation that is created when a dog is carrying excess weight that aggravates the situation.
Rest and control exercise – This one is huge, and plays an enormous role in the outcome whether managing CCR conservatively or with surgery. Complete crate rest was once advised however studies have shown it to be not necessary in most cases. Restriction to a space that minimises excitement, but has room for gentle movement is ideal. Provide good surfaces which eliminate the risk of slipping. Eliminate opportunities for jumping up or down from vehicles, bedding or step/verandas. Incorporating frequent short controlled leash walks which are more aimed at providing mental stimulation – a good sniff is amazing at calming the stir-crazy pent up energy that can build when dogs are relatively confined, is the ideal for 6-8 weeks.
Reduce inflammation and pain – Finally, the use of anti-inflammatory or analgesic medication as required. In the early weeks veterinary prescribed medications might be required, however there is a fine line to walk as far as the potential for reducing pain to such a degree that the dog becomes far too active for the stage of healing. We certainly don’t want our animals sitting through strong pain, however a small amount of awareness that they aren’t quite 100% can sometimes help during the crucial rest period. This is a topic to discuss on an individual basis with your veterinary professionals, as each dog will be very different and many factors play into this balancing act!

From an osteopathic and allied perspective it is possible to boost the effects of this conservative management firstly by recognising that it is, in most cases, strongly likely that biomechanical restrictions and asymmetrical movement in the dog’s body have contributed to uneven weight bearing through the hind legs and the stifle joint. This asymmetry and dysfunction can be addressed using Osteopathic techniques which are gentle and generally largely pain free. By allowing the dog’s musculoskeletal system to function to the best of it’s ability, it is possible to greatly reduce the overloading of individual joints and enhance the circulatory, lymphatic and nervous system function around the joints and tissues and hence allow the body to achieve optimal healing.

One of the big risks with CCL rupture is that around 50% of dogs will present with rupture to the other CCL within 6 months of surgery to repair injury to the first. This suggests two possibilities. Firstly, the obvious one that during recovery, the ‘good’ knee will be taking more than its fair share of workload. Secondly, the likelihood that there are underlying biomechanical and physiological factors that haven’t been addressed in the first instance which are continuing to compromise the healthy functioning of the joint. Whether post-surgery, or opting for the conservative option, it is therefore crucial to ensure the dog’s body is actually able to work symmetrically, as well as to then formulate a thorough rehabilitation plan to help ensure the dog begins to use themselves evenly. This rehab can begin within the first few weeks post-surgery or during the rest period if managing conservatively.

Allied therapies including dietary changes (examples here and here) and nutritional supplementation and herbs, hydrotherapy, acupuncture, laser, orthoses, stem cell therapy and cryotherapy (cold) are some of the many that may be useful within the management plan for CCL rehabilitation.

(Image: Web-dvm.net)

Prevention is better than cure! From a preventative point of view, again it is crucial to ensure dogs are able to use themselves as symmetrically as possible and carry as low an inflammatory load in their body as possible. This can be achieved by taking a few routine steps to ensure your dog is as healthy and strong as possible whatever the stage of life.

Osteopathic preventative/maintenance visits from a young age, to thoroughly examine and uncover any dysfunctional regions of the body and remove these restrictions before they begin to significantly alter the way the dog is moving.
Regularly assessing dietary needs, both for weight management as well as for minimising systemic inflammation that can develop due to unbalanced or overly processed diets.
Ensure that dogs are given consistent, relatively controlled activity that builds progressive strength and condition for their daily activities and specific sporting activities minimises the risks of injury significantly – avoid the weekend warrior approach of relatively little or no exercise during the week followed by manic ball chasing or frisbee catching at the weekend. Make intentional exercise a big part of your daily routine so your dog has a good baseline level of fitness and strength to help cope with the inevitable extra fun at the weekends or on holidays.
Specific range of motion/position exercises are particularly worthwhile for building great proprioceptive and core control in all dogs and can be built from simple routines to very complex movements depending on training levels and the needs of the individual. Chat to your Osteopath or canine conditioning expert for ideas!
Make sure nails are kept trimmed regularly, both to avoid slipping risk and also to help avoid changes in limb posture which may occur if the dog is feeling discomfort during activity from overly long nails.

If you are noticing your dog has uneven movement patterns or is occasionally showing signs of stiffness or soreness there is plenty you can do at home to improve their comfort by introducing a routine of safe stretches and exercises. I have compiled a comprehensive range of these within my eBook – The Canine Athlete Warm-Up and Cool-down Manual, which is a safe way for you to start exploring better musculoskeletal health for almost any dog. Check it out HERE or get in touch if you’re uncertain how to get started for your specific dog’s problems.

Working with excellent vets in my own local area, I am by no means anti-surgery – a well stabilised knee followed by dedicated and thorough rehabilitation is often the ideal option, however if you would like to discuss options, please don’t hesitate to contact me to discuss whether conservative management might be appropriate for your dog in the task of preventing, managing or rehabilitating a CCL injury.