Deborah Carroll's Blog

Hips – 7 Posts

POST-FHO HOMEWORK SUGGESTIONS FOR CATS

(Femoral Head Ostectomy/Removing the Ball off the Femur at the Hip Joint)

First and foremost: pay attention to the discharge instructions your veterinarian has given you and really try to follow them. These instructions usually include keeping your cat as subdued as possible for at least two weeks, preferably subdued with only controlled activity for 8-12 weeks. I highly recommend you not allow playing, no cat rugby, no no toys, no “I’m still the bossiest kitty” smack-downs from the surgery kitty to the other kitties, etc…and definitely no jumping onto things for 8-12 weeks. Given the opportunity, it is highly likely your cat will escape from you upon arriving home from the hospital and will promptly and speedily dash to some hiding place. It is better to keep your cat in their crate and upon arriving home from the clinic, keep them in a place of your choosing to govern them during this time of healing. I’m pretty sure controlled restriction will work out better than if you end up pulling your cat by the armpits out from under the bed.

During this surgery, there was cutting of muscle and other tissue that will require care and time to heal. Please follow the icing instructions noted on a separate sheet and which are also available on my websites if your cat will allow it.

In physical rehabilitation after FHO we should aim at keeping the “false” joint comfortable after surgery by promoting hip flexion and extension through therapeutic exercises that stimulate leg use, leading to muscle strengthening and avoiding chronic disuse of the operated limb.

The muscle that was cut into during the FHO requires a little over 6 weeks to achieve a normal collagen ratio and will take longer to heal more fully. This should be considered when you think your cat is ready to jump onto high places at 2 weeks after surgery. Don’t let them if you hope for the best outcome from the surgery. On the other hand, the bone that was cut does not require the same care that a fracture repair would; there is no need to be concerned that you will cause further damage to the bone by allowing exercise.

In light of this information I recommend working on some of the rehab activities noted below:

Some cats are accustomed to going on walks, even leash walks, with owners, and if your cat is one of them, then the standard walking homework I write for canines may be followed for cats as well. You may want to try to implement that homework even if you have not previously “walked” your cat. Please use a harness to introduce this walking activity.

During the first two weeks especially, we want your cat to walk and stretch and use their operated leg in a natural, yet controlled manner and with moderate to slow movements. Any walking is fine, i.e., to the litter box, to food and water, but pouncing, jumping and dashing are to be avoided altogether or as much as possible.

If your cat is using the leg fairly well a day or two after surgery, then I encourage you to slowly increase the time of consistent leg use and otherwise start some structured walking at five days after surgery. If your cat will not go for structured walks with you, then another possibility is to use a favorite treat to coax them to walk slowly across the floor. You could hold up the treat at head height and crawl along with your cat to get them to walk along in a continual gait pattern as best possible.

Two to five minutes of this walking a couple of times a day for the first week will be beneficial for the cat and possibly hard on you. This same treat method may be used in conjunction with another person holding a leash on a harness on the cat to introduce the concept of leash walking, which would be easier on you. Some cats will follow a string or feather, etc…pulled slowly across the floor, and this method may be used if your cat will walk sluggishly. However, many cats will wait for distance and then pounce on the string or feather, so use your knowledge of your cat to act as wisely as possible.

The goal is to encourage enough continual, weight-bearing leg use so as to create a callous of scar tissue within the compartment where the top of the femur now rides. Too much activity and/or abrupt, jumping movements could tear up the scar tissue we want and instead create more scarring from the new damage. Eventually, with too much activity, there could be a bulk of scar tissue and increased pain. This doesn’t happen as often in cats as it does in dogs, primarily because they do not weigh as much, and therefore do not put as much pressure on the surgery leg. That extra, harsh, impact pressure is what can cause the top of the femur to tear into the healing area where we’d like to have a callous of scar tissue form. Slow, steady, easy exercise brings the best healing in most cases.

After about five days, and especially if your cat is not using the leg much, then I recommend you speak to your veterinarian about finding some additional pain control medications that will suit your cat. Recovery will improve if your pet feels less pain and is able to use their leg more “normally”, yet gently. Pain medicine helps achieve this, and it seems the medications are needed for an average of 4 weeks for cats after this surgery.

There are a variety of ways to get your cat to stretch out that operated hind leg and any may be utilized as long as the end result is not further injury. I find that with careful restrictions and exercise, along with proper pain medication, cats will usually come around to using their leg as fully as ever without anyone stretching it or forcing movement.

If I see a cat more than 6 weeks out from surgery, and they have plenty of pain medication yet aren’t using the leg in good extension, I will work on exercises and drills that encourage the cat to stretch on their own. Sometimes I get a cat to extend from the floor to a couch for a treat or toy and then I draw them back to the floor again. During the first four weeks this works best if the cat does not end up jumping onto the couch. A stretching drill like this should be done 2-4 times per day with 10 repetitions each time. Please allow your cat to rest and recovery at least 2 hours between exercise sessions.

After three weeks, then more structured play to encourage stretching, leg use and muscle strengthening may be implemented. One example of this is to use a feather or string in the air that your cat will rise onto their hind legs and reach to bat. Two to three minutes of this type of play or twenty repetitions at this time, twice per day is beneficial.

At four weeks, if your cat will walk with you up and down stairs without bounding, it is good to start this exercise. Some cats will follow the owner for continual repetitions. Some cats will need a leash and harness. Where and when possible, a set of five times eight to ten stairs once every other day could be a good workout. Any slow climbing is better than none, and more repetitions in a row serve the muscles better than only one or two stairs here and there.

By three to four weeks, your cat will be wanting to run around more and will function as if they are ready for all the “usual” household activities. I still prefer to avoid very harsh movements at this time so that cats don’t disrupt the good scar tissue that has formed. I tell people that the tissue we want is very much like what you get when you ride a bike a lot. If you have not ridden in a while and you go out for a longer ride, the bones at your seat will likely feel like they hurt the next day when you sit in a hard chair. People who frequently ride have scar tissue that operates as padding between bone and tissue. After a couple of riding sessions, the appropriate scar tissue forms and it is no longer painful to sit. This is very similar to the type of tissue I want to see your cat form after an FHO; they need a slow build-up of scar tissue to cushion between the femur and the muscle, and while it is forming due to friction from consistent leg use, I don’t want to tear it or otherwise disrupt it with harsh movements. That could lead to formation of more bulky scar tissue which makes it harder for the leg to move and sometimes causes nerve pain. Similarly, we don’t want to allow the animal to not use the leg, because scar tissue will form that will bind the leg into a place of diminished function and it will always then hurt to do some favorite activities in the future. Not too much, not too little.

If your pet is not using the operated leg after week 1, then I recommend calling your vet or me for rehab intervention and to get them started on beneficial exercise and pain medications. If you follow the exercise prescription well and after week 4 would like advanced exercises, then a rehab consult is necessary. I have some separate recommendations for canine FHO’s, so feel free to contact your vet for a copy of that if you need it.

And if your cat does end up hiding under the bed when you get home because you felt sorry for them and let them out of their crate, don’t pull them out from under the bed by the armpits J I do recommend that you shut the doors to the bedroom, closet, and bathroom, though, so that when they do come out from under the bed, you will have a better chance of collecting them and getting them back into a crate.

Deborah Carroll CCRP, CSCS

Homework After FHO for Canines (Hip Surgery)

Femoral Head Ostectomy/Removing the Ball off the Femur at the Hip Joint

First and foremost: pay attention to the discharge instructions your veterinarian has given you. During this surgery, there was disruption of muscle and other tissue that will require care and time to heal. Please follow the icing instructions noted on a separate sheet and which are also available on my websites. While other tissues are disrupted during an FHO, muscle requires a little over 6 wks. to achieve a normal collagen ratio and will take longer to heal more fully. This should be considered when you think your dog is ready to chase squirrels @ 2 wks. after surgery. Don’t let them if you hope for the best outcome from the surgery. On the other hand, the bone that was cut does not require the same care that a fracture repair or a TPLO would; there is no need to be concerned that you will cause further damage to the bone with exercise.

In light of this information, I believe the best outcome from surgery will be realized with a rehab consult from me to give instruction and homework specific to your pet. In-person consultation will always be better than the generic homework that follows. Otherwise, I recommend starting by following the rehab program below:

Week 1 of active homework may begin the day after your pet returns home from surgery. Week 1 consists of 2-4 five minute walks per day only. These should be done very slowly so as to encourage more weight bearing. When the dog goes too fast, he/she can “cheat” and not use the repaired leg much or well. Too fast could also prolong the inflammation and pain as well as create damage to the area of the muscle at the end of the femur. There should be at least two-hours’ rest in-between each walk session. These walks are to be purposeful exercise and are separate from potty walks. Potty walks during this time should be in and out with business getting done separately from the five-min. walks. Outside sniffing for four minutes and walking for one minute does not constitute the weight-bearing, purposeful exercise we hope to accomplish. We hope to create a slightly and increasingly calloused area at the end of the modified femur. This will make the tissue feel the end of the bone less and less and will create a cushion of sorts. You can do this with moderate & slowly increased exercise. Running & rambunctious play during this time will upset the scar tissue we want to create. On the other hand, not enough exercise, which is usually the problem, results in too much scar tissue all around the hip and your pet will experience decreased mobility and more continuous pain, especially when he is technically at a point that he may play and be wild.

Week 2 is just like week 1 but the walks are for ten minutes instead of five. Continue with ice.

Week 3 consists of only two walks per day for a duration of fifteen minutes each. Still no crazy running & jumping. Do not begin unless your dog is able to do at least three ten min. walks per day without greater lameness.

Week 4 the walks are to be twenty minutes in length, two per day. Still no running, jumping, or playing.

Weeks 5 & 6 should continue with 2×20 min walks and at this time hills may be introduced for at least half of each walk. If no hills are available, then slow stair climbing may be used. The idea with the stairs is to work in 3 sets of 5, for instance, on a typical set of outside stairs, or 2 sets of 8-10 on an indoor set. Make your pet go slowly so that hind leg usage is optimal and beneficial. Swimming is ok if your vet or rehab practitioner okays it.

If your pet is not using the operated leg after week 1, then I recommend calling your vet or me for rehab intervention and to get them started on beneficial exercise. At this time it is possible that passive range of motion and other exercises may be demonstrated. If you follow the exercise prescription well and after week 6 would like advanced exercises, then a rehab consult is necessary. I have some separate recommendations for feline FHO’s, so feel free to contact me for a copy of that if you need it.

My Dog is Just Old…

Quite frequently I hear this comment from clients and even from people active in the practice of animal health and science. I provide a mobile rehabilitation and conditioning service to encourage better recovery after surgery or otherwise improve quality of life through functional rehabilitation. Roughly 80% of my client base is elderly dogs, usually with orthopedic and/or neuro issues. Following are some short comments on beneficial treatments for aging pets:….Any fitness/rehabilitation/conditioning/bodywork program should be collaborated with your pets regular veterinarian, i.e., they should be in the loop. This may be accomplished by having your veterinarian refer you to me or by my contacting the vet after you have contacted me should you desire to work hands-on with me as a rehabilitation and conditioning specialist. Dachshunds flying off couches is not the same as plyometrics training, and many owners may not know the risks or benefits to either activity! So make sure to include your primary care veterinarian in your plans to have additional therapies practiced on your pets…..

In addition to #1, pain control, and #2, functional (possibly assisted) exercise protocol:

Massage is a common therapy that almost anyone can use beneficially to encourage circulation and subsequently possibly encourage healing. Many owners may take a stab at performing massage, but instruction from me is always best to start. Different massage techniques accomplish different results, and hands-on massage is not even recommended in some cases! Otherwise, I have found great benefit in using the little AAA battery-operated massagers produced by the Homedics company. My favorite ones cost $5.99, have four balled feet, and the spread of the feet is usually just right to straddle the spine of different animals. These little massagers have a great vibration frequency and anecdotal evidence proves that their use is extremely beneficial. I ran across them in a store about 5 yrs. ago, and based on reading years of research regarding vibrations and circulation, etc…I decided to give it a try. At the least, this massager will increase circulation and the animal will hopefully enjoy it. Cat owners are using it too!

I recommend beginning by slowly using the massager from neck to tail without it turned on, travelling the spine one direction, again, slowly. After a couple of passes, turn on the massager and do the same movement as when it was off. I like to divide the body into 5 minute sections, beginning with the department giving the most discomfort, i.e. mid-spine to tail base, then neck to mid-spine, right thigh, right shoulder, left thigh, left shoulder. If your pet has hip problems, start with the thighs then do the spine then the shoulders, etc…The idea is that doing this form of massage on the whole dog could take 30 min. in one sitting, but if you only have time for 10 minutes’ worth, then do the most important parts first. It is all complimentary and helpful; an animal with hip problems is taking more stress on his front end, and one with elbow problems is straining the neck, spine, and other parts of the body in compensation, so hopefully you get the idea.

Passive range of motion (PROM) should usually be performed and instructed to owners by an experienced practitioner. Some owners I have counseled have come away from surgery discharge having been told to perform massage or PROM, yet the owner actually does not know what this means or how to perform it so that the animal is not injured. A referral to a rehab practitioner to judge protocol and beneficial movements would be great for owners in these cases. Joint mobilization should only be performed by an experienced practitioner. PROM is not usually necessary if the pet is moving on their own, and other physical activities will be a better use of owners time. If your dog is moving and flexing & extending his knee after surgery, very likely his joints are staying mobile and you need not bug him by making him endure your “bicycling” his knee. Other drills and exercises will bring about improved use and recovery of the knee, and you subsequently have less opportunity to hurt him (or you) if you are not trying to manipulate him. Animals do not have the same hesitancy to use their offended joints as humans do, and the PROM is largely unnecessary unless the animal has nerve damage and cannot move the limbs, THEN PROM is indicated.

Controlled, specific swimming in warm water can be beneficial for the improvement of muscle tone, fitness and strength, especially if an animal is too sore in their joints to walk well for just basic fitness. Swimming for conditioning or therapy should be done in a controlled manner with the use of a dog life jacket and in short, steady bouts while better fitness is achieved. Just because a 15-year-old dog “likes to swim” does not mean he/she should go at it for 15 minutes straight the first or even the fifth time. I carry a full set of life jackets in my mobile practice should an owner possess facilities for swimming at home. In some environments, a regular harness may be used instead of a life jacket. Small dogs with short legs, like Dachshunds, may be swum in many home tubs. ….I find that outside the home environment, elderly animals (and many of other ages as well) are usually not happy to be in a swim tank in a foreign environment. I worked with a water tank/treadmill during the first years of my practice and determined that I would not miss it one bit in mobile practice. Elderly animals are often slightly confused and seem to want to do things in the comfort of their accustomed environment. In addition to incalculable fear levels when trying to use a facility-based water tank for therapy, this fear often induces nervous diarrhea in the water and the fear is potential cause for new injury. Travel to and from a facility can produce unnecessary stresses on both owner and animal. Therefore, I have come up with a variety of exercises and slings to assist elderly animals while they learn to return to better function on land…..

Epsom salt baths have been very beneficial for my elderly patients whose owners have tried them. Your pet may have health conditions making these baths prohibitive, so check with me or your veterinarian. Make sure to rinse off all the residue after the bath, otherwise when your pet licks off the residue, diarrhea will likely ensue…(magnesium).

Many machine modalities may be used in the practice of rehabilitation. I consider low-level laser therapy to be the most complementary and productive machine modality I utilize in my practice. Laser therapy has immense benefits which I will not attempt to cover here. A wonderful website to peruse is Thorlaser.com, and much information regarding laser therapy may be found there.

Ultrasound therapy on arthritic or sore joints and muscles has been proven to be beneficial. I also utilize this therapy in my practice and have had very positive owner feedback with regard to improved function in their animals. Much research information, including evidence-based research, is available on the web regarding these modalities…..People often ask me about using heating pads on their dogs; the use of heat depends on the nature of the injury or disease process. A combination of ice/heat/ice is often more therapeutic or the use of moist heat or brown rice in a sock heated in the microwave are usually preferential heat application options, but moist is good for some things while dry heat is for others. When in doubt, use ice. Instructions for the use of ice and heat may be found on my websites.

Chiropractic interventions are the choice of some and in my opinion should be combined with other therapies, especially massage, and should be administered by vets who have studied chiropractic or by chiropractors who have studied animal chiropractic—especially with regard to spinal issues—and are working in conjunction with the vet.

Acupuncture intervention has been proved to be beneficial as well and especially for pain control. There are several vets in the Austin area who practice acupuncture.

Diet: There are commonly-recommended neutraceuticals for elderly and injured dogs as well as for young dogs that have genetic or early-onset of disease process in their joints. Younger sporting dogs should benefit from these as well. Animals, like people, are not always being fed an optimal diet, so the receipt of quality nutrition from feeding varies, and the supplementation of neutraceuticals is often warranted. It is my preference, based on 30+ years’ experience, well-performed and founded research, and successful nutritional healing protocol, to encourage my patients toward a grain-free diet. The research is out there, and I will not attempt to summarize is here. Among commonly-used and readily-available supplements in this catagory are Glucosamine Hydrochloride with Chondroitin Sulfate (synergistic benefit), MSM (additional synergistic benefit), SAMe (joint, liver, tissue, brain, pain), and Omega 3 fatty acids, preferably in the form of fish oil. Oil-based supplements included in animal food are chemically altered during the production process to the point of diminishing their efficacy and/or they soon become rancid when the bag is opened. Omega 3 fatty acid chains are very fragile and research shows use of the capsule form is best. Additional options are digestive enzymes, probiotics, vitamin C, B vitamins & L-Glutamine, to name a few.

Bed: Bedding DOES make a difference. If your old dog/cat is still trying to jump onto your bed, I recommend you either stop them and provide an eggcrate bed nearby or get them started using stairs or a ramp up to the bed (and into the car, too…). Infrared bedding is nice (expensive), and solid research proves benefits. I have a Great Dane, and she has the chaise end of a couch, a Papasan Chair cushion, and two egg crate foam beds (in different rooms).

Elevate Food and Water: this reduces strain on elbows and neck. I put my Great Dane’s kibble in a Rubbermaid container that stands about 18″ high. Many varieties of elevated stands are available from stores and many homemade ideas about on the net. Definitely makes a beneficial difference.

There are definitely more ideas to be shared, and you are welcome to make note of some in the comments section. Pain control and exercise are key to keep your pet moving and healthy. I have a 10.5 year old Great Dane, Grace, as of this writing (Aug. 4, 2011), and she has had many severe orthopedic and some neurological issues, as well as several systemic internal issues. She appears as though she is 3 years old to most people. She does okay…:)

Simple Massage Video Uploaded to YouTube

Water Treadmill is Not Necessary for Rehabilitation

Compared to the number of dogs in the world, then compared to the number of ruptured cruciate ligaments on aforementioned dogs, then compared to the number of said dogs with ruptured ligaments who are treated by a veterinarian, then compared to the number of those dogs who are taken to surgery for structural remedy, there are relatively very few rehab clinics in the world and fewer still water treadmills.

Dogs of the world do relatively “ok” on all areas of the treatment spectrum and definitely do not need to be “put down” due to ruptured cruciate ligament (torn ACL, CCL). I have encountered clients in my practice who were told unless they had surgery, the dog would have to go. Just wanted to clear up that situation.

That being said, and along with explaining the title of this blog, of foremost importance I will note that I came into veterinary functional rehabilitation with approximately 25 years experience in human sport science and nutrition. I decided to call my practice “functional rehab”, not having seen that designation applied much but having presumably heard the term somewhere. I decided to use it when I began an independent, mobile rehab practice in 2007, two years after starting and running a rehab clinic for a veterinary specialty hospital.

I became aware of the water treadmill via my work at the hospital, and I found that the use of it was/is widely promoted within veterinary medicine and the canine rehab model, which draws heavily from structured, academic-oriented, human physical therapy concepts. I think the overall concept is decent, yet the wtm is one very, very small tool in the vast array of protocol and modalities that exist in order to better the health of your pet.

Unfortunately, I found that what is not taught within this same model is a good basis and understanding of program design, writing training programs, and the development of dynamic activities/protocol designed to encourage healing and increase muscle and bone mass. These are principles I began learning over 30 years ago as an athlete, as a self-coached athlete, and then as a coach and trainer to others, even world-class athletes.

What does this mean to you and your pet (primarily dogs…)?

The chief complaint I hear from people who contact me is that they were referred to this clinic or that one for post-surgical rehab, and after many weeks of walking in the treadmill, moving around on balls, and doing a variety of other things, the dog is not much better or is not to a place where the owner feels comfortable with letting them be loose and rambunctious. They aren’t where the owner thought they would be after surgery. When I was in a clinic setting and working on utilising the wtm we had, I did structure the workouts to be progressively difficult, using a 3x workout adjustment protocol, meaning that if three workouts went well, then I changed the protocol, making the workout more dynamic. This could be done by increasing time or lowering water in the tank. Since I do not believe that much benefit is realised by walking in a wtm more than 20 min., and some data is published to recommend that animals not be worked beyond that time anyway, I find more benefit realised by lowering the water height, thus increasing the force on the joint/leg/muscle/bone.

HOWEVER, I also find that after very many years of reading many, many reports in sport science and regarding functional return to activity, the best benefit is realised via gravity-based, slow, structured exercise protocol, and I began developing that for small animal rehab since I did not find any published when I arrived on the scene.

Your dog will use their leg to some extent and increasingly after surgery if he/she is not in pain. That has been my finding after working with hundreds of cases. With that in mind, a structured workout program is entirely necessary and may vary from any standardized protocol depending on the nature of the dog and the owner.

If your dog is not using the leg within 2-3 days after surgery, then my findings are always that they are in pain, and that they are in pain due to 1) not enough post-op analgesic, which I believe should be a combo of at least two analgesics for potentially several weeks while we pursue the best activity and homework for healing (in this area we commonly use an nsaid and Tramadol); 2) infection, the pain of which will only be finally remedied by antibiotics (and subsequently the infection remedied as well); or 3) structural abnormality, i.e. some sort of failure related to the surgery, yet not necessarily the surgeons/your/your dogs *fault*.

The homework protocol I generically recommend is contained elsewhere in this blog. If you are within range of my services, I recommend you contact me for an evaluation appointment and we establish a base for your dog and then you perform the exercises which will bring solid healing while helping to also protect the opposing limb.

Thank you!

ICE (CRYO) THERAPY

Ice therapy is used to decrease pain and inflammation and to increase healing. Ice may be effectively applied 2-4 times per day, with 4 being optimal within the first week after injury/surgery. Ice may be used in several forms, some of which are as follows:

*Frozen vegetables make a tidy ice pack, although not as cold as other options. These should be left on the treatment area for approximately 20-30 minutes without a towel and on bare skin. Frozen veggies are not cold enough, nor do they retain cold well long enough, so that is why extended application times are recommended.

*Slush ice in two zip lock-type baggies. This turns out to be very cold and is made with one part water to two parts rubbing alcohol. If the mixture is too watery, add more water to make it icier. If the mixture is too hard, add more alcohol to make it slushier. This ice pack should only be left in place for ten minutes at a time without a towel or twenty minutes on a medium-to-large dog with full fur. Fur is no more a barrier to icing than a towel on a human would be, especially if “colder” icing options are used (pupsicle, slush packs, etc…) and ice is applied for adequate time, i.e., 20 min. Smaller animals with less dense hair coats will still only need a 10 min. ice application, so try to use good judgment. Dish soap in double sliding zip-locked baggies and frozen works like the slush pack mentioned above.

*Pupsicle ice is a cup, either paper or Styrofoam, that has been filled ¾ with water

and then frozen. This ice is especially effective and may also accomplish some surface

tissue massage at the same time as the cryotherapy. The ice melts into puddles, so grab a towel. You should rub this ice over the affected area for approximately ten minutes at a time using circular or stroking motions, as in massage.

Ice, not heat, should be used for at least the first 72 hours post-surgery or injury, and there is generally no need for heat at all. This phase is often referred to as phase one inflammation-breakdown or phase one post-trauma. Pupsicle and slush ice may be left on 10 min, taken off 10 min, and then reapplied 10 min. during phase one inflammation.

I am often asked if ice may be used any time, and the answer is yes. If back muscle spasm episodes occur, if there seems to be pain or inflammation, or even if a new incident of disc rupture occurs, ice may be used even while on the way to the vet. In these instances, always use ice and not heat.

Ice increases blood flow by cooling and slowing blood while constricting the blood vessels, after which the body reacts by sending more blood to the cold area to warm it and thus increase the flow of body fluids through the area. This is actually beneficial in reducing swelling. Heat increases blood flow by opening up blood vessels. The opening of the blood vessels by heat early in post-injury phases could cause unwanted swelling and inflammation, so even though heat may seem to feel good, it is not what should be done to help healing at this time.

Rehabilitation and Conditioning for Animals

Deborah Carroll, CCRP, CSCS