Patient care report for the stabilisation of a cat with a ... Dip VN... · cat with a traumatic diaphragmatic rupture Abstract Diaphragmatic ruptures in cats are often seen following

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498 October 2015 • Vol 6 No 8 • The Veterinary Nurse

This patient care report highlights the initial veterinary nursing interventions provided to an emergency feline patient. The patient pre-

sented to the practice with shock and dyspnoea fol-lowing a suspected traumatic incident.

SignalmentSpecies: FelineBreed: Domestic short hairAge: 2 years 3 monthsSex: Neutered maleWeight: 3.18 kg

Presenting problemThe patient presented with a history of acute dysp-noea and lethargy progressing to collapse. He was re-ported to be inappetant and it was unknown whether he had passed urine or faeces within the last 24 hours. The owner reported that he had not vomited over-night and that preceding this event he was a healthy cat. He had never been seen by a veterinarian and so had no known previous history.

Initial patient assessmentRespiratory Visual assessment of the patient revealed tachyp-noea (respiration rate (RR) of 44 breaths per minute

Patient care report for the stabilisation of a

cat with a traumatic diaphragmatic rupture

AbstractDiaphragmatic ruptures in cats are often seen following trauma and can cause severe respiratory distress. This article reflects on the author’s experience of pro-viding emergency nursing care to a 2-year-old, domestic short hair cat, with a traumatic diaphragmatic rupture. In order to provide effective nursing care it is essential for the veterinary nurse to understand the effects of shock in the feline patient. Creating a protocol for the management of the dyspnoeic trauma cat could facilitate a more efficient treatment plan, allowing for available monitoring equipment to be fully utilised. If advanced monitoring techniques are not avail-able, a successful patient outcome is still achievable with basic nursing skills and a good underpinning knowledge of the emergency and critical patient.

Key words: diaphragmatic hernia, respiratory distress, shock, oxygen therapy, fluid therapy, cat

Debbie Nelson Grad Dip RVN A1 Assessor, Head Nurse, Yourvets, Stechford, Birmingham, UK

(bpm)) and paradoxic respiration (when breathing movements are in reverse to normal, i.e. chest wall moves in on inspiration and out on expiration). He lay in sternal recumbency with abducted elbows and neck stretched outwards (orthopnoea). Auscultation revealed dull lung sounds and muffled heart sounds; his airways appeared clear from obstruction.

CardiovascularHeart rate (HR) was bradycardic at 120 beats per minute (btpm) with no notable arrhythmias. He had absent peripheral pulses and pale pink mucous mem-branes (MMs). The capillary refill time (CRT) was de-layed at 2–3 seconds. He was severely hypothermic with a core temperature of 34.1oC. An initial systolic blood pressure (BP) reading was attempted using the Doppler technique (the only available method in that practice), but was unsuccessful, as the carpal pulse could not be determined.

NeurologicalThere were no signs of extracranial injuries, but he was obtunded and quiet. The patient’s pupils were symmetrical and pupillary responses were normal.

Veterinary investigationsAn intramuscular injection of a partial μ receptor agonist, buprenorphine (Vetergesic, Ceva Animal Health Ltd, Buckinghamshire, UK), 20 μg/kg was giv-en. Alternatively a full μ opioid agonist such as mor-phine or methadone may have been used. These act at a number of different receptor systems and com-pared with partial μ receptor agonists provide more effective analgesia (Murrell, 2011). A study by Steagall et al (2006) found that administration of methadone and morphine provided a longer reduced sensitivity to pain compared with buprenorphine. The use of full μ opioid agonists are indicated in the management of moderate to severe pain and as methadone is the only full μ opioid agonist with veterinary marketing authorisation, this should be used over morphine (Murrell, 2011).

An initial blood sample was obtained to provide a survey of the patient’s clinical status to tailor the treatment plan accordingly (Chapman, 2013; Tomp-kins, 2013). Biochemistry results revealed mildly el-evated urea 14.9 mmol/litre (normal range 5.7–12.9

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mmol/litre), high alanine transaminase 740 U/li-tre (normal range 12–130 U/litre) and high gamma-glutamyl transferase 4 U/litre (normal range 0–1 U/litre). Complete blood count revealed increases in haemoglobin 16.5 g/dl (normal range 9.0–15.1 g/dl) and neutrophilia 13.66 x 109/litre (normal range 2.50–12.50 x 109/litre); total protein and haematocrit were both normal.

A radiograph revealed a diaphragmatic rupture. No signs of a dilated stomach were detected (which would indicate the need for immediate surgical inter-vention (Gibson et al, 2005)), so it was decided that the patient should be stabilised for 24 hours prior to surgical repair.

Discussion Diaphragmatic ruptures are a common cause of respi-ratory distress in cats (Cariou et al, 2009) and require rapid intervention (Rozanski and Chan, 2005; Jordan, 2011; Sharp and Rozanski, 2013; Sumner and Rozan-ski, 2013) such as oxygen therapy, shock interventions and pain management. Trauma is a common cause of diaphragmatic rupture and there are often concurrent problems such as shock (Schmiedt et al, 2003) that need to be addressed in order to ensure the most immediate threats to the patient’s life are treated as priorities.

Nursing considerations and interventionsThe patient displayed signs of pain on his hind quar-ters and his ability to mobilise, urinate and defecate was monitored. Also consideration was given to pain management, nutritional requirements, stress re-duction and self care, which were analysed using the Orpet and Jeffery Ability Model (2007) (Orpet and Welsh, 2011). To discuss all of these nursing re-quirements is beyond the scope of this care report. Therefore, the author has focused this discussion on the nursing interventions required to address his im-mediate and life-threatening disorders.

Oxygen therapyIt is widely agreed that oxygen therapy should be pro-vided immediately to the dyspnoeic patient (Mackay, 2001; Rozanski and Chan, 2005; Jordan, 2011; Sharp and Rozanski, 2013). In this incident a clinical exami-nation took place before initiating oxygen therapy. Although this could have prolonged the patient’s discomfort Sumner and Rozanski (2013) advise that a brief assessment before placement into an oxygen cage can exclude other causes of distress such as stress, cardiac and/or pulmonary disease. It could have been possible to achieve both the initial clini-cal examination and oxygen support for this patient if methods such as flow-by oxygen (achieving a mean

fraction of inspired oxygen (FiO2) of 24–45% (Sum-ner and Rozanski, 2013)) had been provided. To fur-ther improve FiO2 from 24–45% to 35–55% a face mask could have been used (Sumner and Rozanski, 2013). This is not always tolerated well and can in-crease stress and therefore respiratory effort (Sharp and Rozanski, 2013). For this reason, providing flow-by oxygen may have been the better approach for this patient in order to minimise stress while oxygen therapy was provided. However, it should be noted that using flow-by oxygen is labour intensive as vet-erinary personnel need to be available to hold both the oxygen circuit and patient (Sharp and Rozanski, 2013). In addition, using flow-by oxygen is labour in-tensive as veterinary personnel need to be available to hold both the oxygen circuit and patient (Sharp and Rozanski, 2013).

A useful way to provide oxygen therapy is with an oxygen cage (Mackay, 2001; Mazzaferro, 2009). In the dyspnoeic cat this can be particularly useful as it does not require patient restraint (Mackay, 2001) and the cage can reach reasonably high concentrations of ox-ygen (up to 60% FiO2 (Sumner and Rozanski, 2013)) depending on the size of the cage, patient and flow rate (Richmond, 2010). This patient was placed into an oxygen cage after his initial assessment; on admis-sion his RR was 48 bpm and after 30 minutes this had reduced to 38 bpm.

The oxygen cage (Buster® ICU cage, Kruuse, Marslev. DK) was a basic model and could not con-trol all aspects of the environment inside the cage. Some complex models are able to control humidity, temperature and oxygen levels which can be modified from the outside of the cage. With the Buster® ICU cage the door had to be opened at regular intervals to gauge the temperature inside. This was to ensure the patient did not become hyperthermic as there was no temperature monitoring equipment in this particular Buster® ICU cage. This results in a rapid fall in the FiO2 (Sharp and Rozanski, 2013) which could have been detrimental to the patient. To compensate for this, the author suggests the use of a wall thermom-eter, attached to the inside of the cage. This could al-low for the environmental temperature of the oxygen cage to be monitored visually, reducing the need to open the door unnecessarily.

Although the oxygen therapy improved the pa-tient’s RR, it did not resolve the dyspnoea. The low-est recorded RR for this patient was 36 bpm (nor-mal ranges 10 to 20 bpm (Jordan, 2011)) and he still displayed some respiratory effort. This could be ex-plained by the fact that a diaphragmatic hernia can be classified as a pleural space disease (Pachtinger, 2013), which may only benefit from therapeutic in-

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(Pachtinger, 2013). However, pulse oximetery only provides a ratio of the percentage of haemoglobin sat-urated with oxygen (SpO2) using infared light (Moens and Coppens, 2007). The PaO2 measured in ABG dis-plays the oxygen molecules dissolved in plasma, i.e. not bound to haemoglobin. Therefore, to determine how much oxygen is in the blood, combined meas-urements of PaO2, oxygen saturated arterial blood (SaO2) and haemoglobin content (CaO2) need to be assessed (Martin, 1999). Oxygen therapy was discon-tinued when the patient was considered stable (re-duced RR, improved respiratory effort and improved pallor) and only auscultation and visual checks con-tinued. A pulse oximeter could have been used for continued monitoring, giving a measurement of the patient’s oxygenation. However, as patients with dia-phragmatic ruptures are most likely to have issues with ventilation, measuring the PCO2 or partial pres-sure of carbon dioxide in the blood (PaCO2) may have been more beneficial (Barton, 2009).

Fluid therapyThe impairment to cellular oxygen delivery due to the failure of global tissue perfusion is described as hypoperfusion and is commonly referred to as shock (Boag and Hughes, 2005; Jordan, 2012). One of the most common forms of shock in the emergency pa-tient is hypovolaemia (Boag and Hughes, 2005) and is characterised in most species by hypotension (de-compensated hypovolaemia), tachycardia, pale MMs with a prolonged CRT, mild to absent peripheral puls-es and altered mentation (Boag and Hughes, 2005; Goggs et al, 2008; Mazzaferro and Powell, 2013).

In comparison to dogs, cats have unique physiologi-cal responses to shock and display clinical effects asso-ciated with bradycardia, hypotension, and hypother-mia, known as the ‘shock triad’ (Kirby, 2004). These findings are supported by Brady et al (2000) who found that in cats with distributive shock, over half present-ed with these three clinical abnormalities. The shock triad were present in this patient so bolus compound sodium lactate (Aquapharm 11 Hartmann’s solution, Animalcare Ltd, York, Uk) 40 ml/kg (127.2 mls), over 30 minutes, was prescribed. This was to be continued until a minimum BP of 80 mmHg was recorded. Dur-ing this time the RVN monitored for improvements in pulse strength, HR and mentation and systolic BP monitoring was repeated using the Doppler technique. The veterinary surgeon requested that the fluids were to be continued at 40 ml/kg, to achieve a minimum systolic BP of 80 mmHg, with the view to reassessing fluid administration rates in order to ensure a normal BP was reached. Waddel and Brown (2009) advise that in cats a normal systolic BP is between 120–170

tervention (Sumner and Rozanski, 2013) or surgical intervention (Gibson et al, 2005).

To assess general patient improvement the regis-tered veterinary nurse (RVN) observed for changes to MM colour, a reduction in RR and improved demean-our. Blood gas analysis is the ‘gold standard’ method for assessing oxygenation and ventilation. Blood gas analysis or arterial blood gas (ABG) analysis provides a direct assessment of gas exchange, giving an overall view of pulmonary function (Miller, 2007). To assess the lung’s ability to oxygenate blood the value of par-tial pressure of oxygen in arterial blood (PaO2) can be measured. However, this is meaningless without knowing the exact FiO2 (Moens and Coppens, 2007) (see Table 1 for normal ranges). In order to assess ven-tilation, ABG remains the gold standard however, ven-tilation can be assessed by capnography, which may be advantageous as it is not invasive and allows for con-tinuous monitoring (Pypendop, 2009). Capnography measures the arterial partial pressure of carbon diox-ide (PCO2) although it is more accurate in intubated patients (Pypendop, 2009). Unfortunately capnogra-phy was not available in the author’s practice. There-fore ventilation could not be accurately assessed.

As well as the lack of capnography, the author’s practice does not currently have an ABG analyser. If these had been available they could have been used to determine how adequate the patient’s pulmonary function was, facilitating the evaluation of his nursing care needs. When deciding on ABG analysis it should be considered that interpretation is complex. Fur-thermore, obtaining a sample may be distressing for the patient and therefore detrimental to their condi-tion. The approach that patients should not be taken off oxygen therapy to obtain an assessment of oxygen levels (Sumner and Rozanski, 2013) should be applied.

Instead of ABG analysis the use of a pulse oximeter could have been considered, as this is non-invasive method of measuring the patient’s oxygen saturation

Table 1. Normal values of blood gas analysisParameter Normal value Decrease Increase

PaCO2 35–45 mmHg Respiratory component: alkalosis

Respiratory component: acidosis

PaCO2 If oxygen levels in inspired gas (FiO2) = 21%: 80–100 mmHg (10.7–13.3kPa

Hypoxaemia: <60 mmHg (8kPa)

Due to increase FiO2 or increased atmospheric pressure

SaO2 95–100% Hypoxaemia: <90%

Moen and Coppens (2007)

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mmHg, with hypotension being defined as less than 80 mmHg. This supports the veterinary surgeon’s goal of providing shock rate fluids to achieve a minimum systolic BP of 80 mmHg.

Venous access had to be achieved to provide fluid therapy, which is often the responsibility of the RVN (Goddard, 2010). The fur at the patient’s right ce-phalic vein was clipped, and oxygen supplementation provided via flow-by during this time. There were no visual signs of the vein and it could not be palpated, so, the area at the right lateral saphenous vein was clipped instead. With successful visualisation of the saphenous vein, lignocaine 25 mg/g and prilocaine 25 mg/g cream (Emla, AstraZeneca UK Limited, Bedfor-shire, UK) was applied and left for 15 minutes. A 22 g intravenous (IV) catheter was inserted by the RVN, using an aseptic technique and secured and dressed accordingly. The RVN calculated that 21.2 mls of Aq-uapharm 11 could be given every 6 minutes, in an at-tempt to provide the prescribed dose of 40 mls/kg/30 minutes. Although this only allowed the administra-tion of 21.2 mls of fluid every 6 minutes and not the prescribed dose of 40 ml/kg over 30 minutes. Using an infusion pump or syringe driver may have been a more appropriate way to administer the recommend-ed bolus of fluids (Aldridge, 2009).

Although the choice and rate of the fluids pre-scribed is the responsibility of the veterinary surgeon the RVN must understand the reasons for selected rates of infusion and the physiological effects of ad-ministration (Sheridan, 2009) to avoid associated complications such as over infusion or inadequate fluid resuscitation. It is generally the RVN’s role to administer fluid therapy, and close observation of the patient while doing so is important. It should be appreciated that cats are at risk of volume overload; careful administration along with thoracic auscul-tation should be performed to monitor for signs of pulmonary and pleural fluid accumulation (Kirby, 2004), which would indicate signs of over infusion. Should these become apparent fluid therapy should be stopped, oxygen therapy initiated and the vet-erinary surgeon informed immediately, so that the patient can be assessed and administration of drugs (i.e. diuretics) can be initiated if indicated (Davis et al, 2013).

After the first 127.2 mls of Aquapharm 11 was ad-ministered, a systolic BP of 60 mmHg was recorded. After a further 18 minutes of fluid administration a systolic BP of 80 mmHg was achieved. At this stage the patient’s other vital signs had also shown im-provement. The RVN noted that peripheral pulses were stronger, the HR had increased to 168 btpm and MMs were pinker with a CRT of <2 seconds. The pa-

tient’s temperature had also increased from 34.1oC to 37.9oC and he appeared more alert and responsive.

The method in which this patient was reperfused is supported by many (Kirby, 2004; Boag and Hughes, 2005; Goggs et al, 2008; Mensack, 2008; Pachtinger, 2013), but it could be argued that perfusion in this pa-tient could have been monitored more accurately by measuring serum lactate concentrations (Karagian-nis et al, 2006) or systemic oxygen parameters (Boag and Hughes, 2005). It is important to highlight that (as with this patient) these monitoring tools are not always available, regardless, the RVN’s role of moni-toring critical patients is crucial. They can detect physiological changes in the patient and facilitate the development of the care plan to avoid patient dete-rioration (Polton and Branscombe, 2008).

HypothermiaIn order to avoid peripheral vasodilation, caused by warming the patient while hypovolaemic, hypother-mia was the last abnormality to be addressed. Severe hypothermia causes the hypothalamus to become less responsive and if the core temperature drops below 31°C, thermoregulation is unattainable (Kirby, 2004). To avoid the risk of diminished thermoregula-tion, patient warming was initiated using the Buster® ICU cage. This acted like a heated incubator by in-creasing the air temperature around the patient. It was decided against the use of blankets so that the patient could be observed easily. This approach was also adopted by Tompkins (2013) who opted out of the use of a forced air warming blanket so that patient ob-servations could be continued without restrictions.

This method did help increase the patient’s rectal temperature to 36°C. The patient was removed from the Buster® ICU cage when the environment inside was deemed to be too hot for the patient to reside in comfortably. This was judged by observing the patient’s behaviour for signs of discomfort, e.g. rest-lessness, panting (Boag and Nichols, 2011) and by how warm the inside of the cage felt to the RVN. As previously stated, using a thermometer or thermostat mounted on the inside of the cage would have been a more reliable way to assess the temperature and could have reduced the risk of removing the patient from an oxygen enriched environment too early.When the patient was removed from the Buster® ICU cage, pas-sive surface re-warming (with the use of bubble wrap and blankets) continued until a core temperature of 37.9°C was achieved. The use of heat pads was avoided to eliminate the risk of skin burns and to prevent pe-ripheral vasodilation. As sensory nerve fibres in the skin are particularly sensitive to changes in local tem-perature (Sjaastad et al, 2003), peripheral vasodilation

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could cause a reduced response to neuronal feedback, thus decreasing the body’s ability to maintain core in-ternal temperature (Kirby, 2004).

Armstrong et al (2005) and Byers (2014) suggest that for moderate to severe hypothermic patients the use of active surface re-warming, such as forced air warming blankets, should be considered. These minimise heat loss by raising the temperature of the microenvironment of the skin, reducing the tempera-ture gradient between the body and the environment (Armstrong et al, 2005). The author’s practice does not currently have a forced air warming blanket, but this could have been useful instead of passive surface re-warming. With the use of bubble wrap and blan-kets it took approximately 4 hours for the patient to reach an optimal core body temperature, which may have been reduced with a forced air warming blanket.

Additional recommendationsIn addition to the recommendations made in the previous section the author would suggest that a pro-tocol for the management of dyspnoeic trauma pa-tients is created. Although it is important to consider the individual needs of a patient, the availability of a guiding protocol could facilitate the development of a more efficient treatment plan. A study by Hancill (2013) found that introducing a ‘care bundle’ (a set of evidence-based interventions performed simultane-

ously) improved some individual quality indicators, i.e. patient checks, and although compliance in their use was low, the potential for these ‘care bundles’ to improve patient care was recognised. Once guiding protocols are established, they can be adopted by the RVNs to ensure that basic therapy, such as immediate oxygen supplementation or the use of available moni-toring systems, is not overlooked.

Patient outcomeThe care administered to this patient did have a posi-tive outcome. The patient stabilised overnight and had surgery to repair the diaphragmatic rupture the following day. The patient made a full recovery and was discharged after a total of 3 days’ hospitalisation.

ConclusionInitial assessment of the dyspnoeic patient identifies relevant clinical issues and facilitates the creation of appropriate nursing interventions. In turn, this al-lows for the RVN to evaluate the care given and high-light any problems that have progressed or improved. Even when advanced monitoring techniques are not available, a successful patient outcome is still achiev-able with basic monitoring skills and a good under-pinning knowledge of the pathophysiology of disease processes in the emergency and critical patient. VN

AcknowledgementsThis article was produced as part of the author’s stud-ies at the Royal Veterinary College, Graduate Diploma in Professional and Clinical Veterinary Nursing. The author would like to thank the Course leader Perdi Welsh BSc (Hons)DipAVN (Surg) Cert Ed RVN, mod-ule contributors Karen Humm MA VetMB CertVA Di-pACVECC FHEA MRCVS and Belinda Andrew-Jones VTS (ECC) DipAVN (Surg) PG Dip Vet Ed RVN FHEA. With thanks also to Louise O’Dwyer MBA BSc(Hons) VTS(Anaesthesia & ECC) DipAVN(Medical & Surgi-cal) RVN and Yourvets.

Key PointsllDiaphragmatic ruptures are a common cause of respiratory distress in cats and require rapid intervention.ll In comparison to dogs, cats have uniquely different physiological responses to shock and display a triad of clinical effects identified as bradycardia, hypoten-sion and hypothermia.llWhen advanced monitoring techniques are not available, a successful patient outcome is still achievable with basic monitoring skills and good underpinning knowledge.

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Armstrong SR, Roberts BK, Aronsohn M (2005) Periop-erative hypothermia. J Vet Emerg Crit Care 15(1): 32–7

Barton L (2009) Daily Assess-ment of the critically ill patient. In: Silverstein DC, Hopper K, eds. Small Ani-mal Critical Care Medicine. Saunders Elsevier, Missouri:

C201Boag AK, Hughes D (2005) As-

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NEWS ANALYSIS • LETTERS • BOOK REVIEWS • JOBS

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CLINICALSmall animal post-operative orthopaedic rehabilitationPain assessment and pain scoring models: a reviewEar mites: tackling a persistent problem Plant toxicosis in birds: educating owners

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Clinical

to unload the affected limb or to activate incorrect musculature, to ensure each exercise is performed correctly.

A slow pace walking programme can commence following bandage removal, initially consisting of a 5 minute walk for toileting two to four times a day, gradually increasing over the next 6 to 8 weeks de-pending on the animal’s condition, and lameness.

Education of the owner/homeexercise programmeIt is extremely important to educate the owner in all aspects of their pet’s condition, giving them clear and concise post-operative notes, including the impor-tance of rest and confinement to prevent post-oper-ative complications due to over activity.

Home exercises should be clearly demonstrated and documented. The owner should practice them under the supervision of the treating therapist to check that they are able to do them correctly. At each visit all exercises should be reviewed and updated.

Additional equipmentThere are many different mobility aids ranging from doggie wheelchairs to harnesses, protective boots, ramps and slings. When assessing an ani-mal for aids it is important to determine the ex-act needs of the animal, its home environment, its activity levels, and the owner’s expectations and ability to use the aids correctly. Once purchased the correct fit and use of the aid should be assessed and reviewed regularly.

Contraindications to treatmentWhen attending for rehabilitation, animals should be regularly reassessed for lameness, swelling, and avail-able joint range. Owners should be questioned about how they feel the animal is progressing both physi-

cally and behaviourally. If they have any concerns or if the animal’s progress has plateaued, a further veterinary review should be sought.

When to refer onIf at any time during the rehabilitation programme a patient stops improving, is not achieving the expect-ed outcomes or clinically deteriorates, they should be referred back to their veterinarian for reassessment.

ConclusionsThe addition of rehabilitation programmes to the management of the post-operative orthopaedic pa-tient can accelerate return to function and greatly improve quality of life. All patients should be as-sessed prior to commencement of treatment, have a tailor made programme and be continually moni-tored for their response to treatment, with their programme adjusted accordingly. Animal health professionals interested in providing this serv-ice should complete continuing education in the small animal rehabilitation field to ensure safe and effective practice. VN

Conflict of interest: none

Acknowledgements:Dogs in Motion and Animal Physiotherapy Solutions for the use of the photographs included in this article.

Edlich FR, Towler MA, Goitz RJ et al (1987) Bioengineering principles of hydrotherapy. J Burn Care Rehab 8(6): 580–4

Jakobsen TL , Christensen M, Christensen SS, Olsen M, Bandholm T (2009) Reliabil-ity of knee joint range of mo-tion and circumference meas-urements after total knee arthroplasty: does tester ex-perience matter? Physiother Res Int: http://lib.bioinfo.pl/pmid/journal/Physiother%20Res%20Int (accessed May 20 2010)

Lessard LA, Scudds RA, Amen-

dola A, Vaz MD (1997) The efficacy of cryotherapy fol-lowing arthroscopic knee surgery. J Orthop Sports Phys Ther 26(1): 14–22

Moffet H, Richards CL, Malouin F, Bravo G, Paradis G (1994). Early and intensive physi-otherapy accelerates recovery postarthroscopic meniscec-tomy: results of a randomized controlled study. Arch Physi-cal Med Rehab 75(4):415–26

Monk M, Preston C, McGowan C (2006) Effects of early in-tensive postoperative physi-otherapy on limb function

after tibial plateau leveling osteotomy in dogs with defi-ciency of the cranial cruciate ligament. Am J Vet Res 67(3): 529–36

Oldmeadow LB, Edwards ER, Kimmel LA, Kipen E, Robert-son VJ, Bailey MJ (2006) No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg 76(7): 607–11

Palmieri-Smith RM, Kreinbrink J, Ashton-Miller JA, Wojtys EM (2007) Quadriceps Inhi-bition Induced by an Experi-mental Knee Joint Effusion

Affects Knee Joint Mechanics During a Single-Legged Drop Landing. Am J Sports Med 35(8): 1269–75

Raynor MC, Pietroban R, Guller U, Higgins LD (2005) Cryo-therapy ofter ACL reconstruc-tion. J Knee Surg 18(2):123–9

Shumway R (2007) Rehabilita-tion in the first 48 hours after surgery. Clin Tech Small Anim Pract 22(4): 166–70

Steiss JE (2003) Canine Rehabili-tation. Clinical Neurology in Small Animals - Localization, Diagnosis and Treatment.

Braund KG ed. International Veterinary Information Serv-ice, New York

Thomopoulos S, Zampiakis E, Das R, Silva MJ, Gelberman RH (2008) The effect of mus-cle loading on flexor tendon-to-bone healing in a canine model. J Orthop Res 26(12): 1611–7

Young A (1993) Current issues in arthrogenous inhibition. Ann Rheum Dis 52(11): 829–34

References

Key Points z Post-operative orthopaedic rehabilitation accelerates recovery. z Early controlled rehabilitation is essential. z Early commencement helps to reduce pain, swelling and inflammation. zRehabilitation helps to prevent muscle atrophy and increase muscle strength. z Post-operative orthopaedic rehabilitation increases range of motion.

Manuka honey: an effective wound healing environment

Clinical


Animal physiotherapists are highly skilled in the use of manual therapy techniques, electrotherapy, hydrotherapy, exercise prescription, the use of gait aids and various forms of bracing and splinting.

Veterinary nurses who have received appropriate training in animal rehabilitation are able to adminis-ter several treatment techniques including icing, heat treatment, soft tissue massage, joint ROM exercises, gentle strengthening exercises, as well as assisting with hydrotherapy and the animal’s home exercise programmes.

Cryotherapy/ice treatmentIce treatment in the early post-operative period has been shown to reduce pain (Lessard et al, 1997; Raynor et al, 2005), swelling and inflammation (Shumway, 2007), improve weight bearing and reduce use of pain medication (Lessard et al, 1997). Ice treatment can commence on the day of surgery once the patient’s body temperature has returned to normal. The cold reduces blood flow to the area, reducing swelling and release of inflammatory mediators.

Various flexible commercial ice packs are avail-able; to avoid ice burns they should be wrapped in a layer of wet material, such as a towel, before being placed over the affected area. Using repeated, rather than continuous, ice applications of 10 minutes, helps sustain reduced muscle temperature without com-promising the skin and allows the superficial skin temperature to return to normal while deeper muscle temperature remains low.

Ice treatment can be used in this repeated way for the first 48 hours, then reduced to 10 minute treat-ments, three times per day for the first post-operative week, or longer if required.

All animals should be supervised while they are re-ceiving ice treatment and their skin checked regularly at 5 minute intervals for excessive redness or irrita-tion, to ensure they do not sustain an ice burn.

Passive ROM exercisesPassive movements of the peripheral (limb) joints can be used to reduce pain, regain normal movement and prevent joint contracture. Passive movements are performed by the therapist, with the animal in a com-fortable and well supported position with their mus-cles at rest. Movements should only be performed within pain free range and tolerance of the animal (Figure 2, 3 and 4).

The aim of these exercises is to take each affected joint repetitively through its available range of motion. These movements should not be forced or painful. Suggested starting dosage: 10–20 repetitions (depend-ing on pain) of affected joints, three times per day.

Soft tissue massage techniques Following orthopaedic surgery, soft tissue massage techniques are aimed at reducing muscle tension and associated pain, to allow normal movement of a joint or limb. They can also be used to induce relaxation in an animal in preparation for other stronger treatments.

Figure 2. Passive hip flexion.

Figure 3. Passive hip extension.


Clinical

protective muscle guarding. For a successful return to full function and muscle strength, joint ROM needs to be restored.

When assessing joint ROM it is important to recog-nize factors limiting movement and only work within the animal’s pain free motion, gradually regaining joint range as pain and swelling decreases.

Improving muscle strengthOnce initial pain, swelling, inflammation and mus-cle inhibition are addressed, muscle strengthening can commence. Specific strengthening exercises are needed to grow muscle. In the absence of pain, reflex muscle inhibition will continue without spe-cific exercise to the affected muscles (Young, 1993). Patients receiving an early intensive physiotherapy programme following orthopaedic surgery achieve not only more rapid strengthening, but larger over-all increases in muscle strength (Moffet et al, 1994). Exercises should initially be very gentle and control-led, progressing to those that overload the muscle, al-lowing increased adaptation and strength.

Assessment and monitoringA thorough initial assessment of the patient is re-quired in order to devise a patient-specific reha-bilitation programme. Before observing or palpat-ing the patient, the veterinary nurse should obtain as much background information as possible. This may involve obtaining veterinary surgery and treat-ment reports, imaging results, expected prognosis, and current medical management. An understand-ing of the animal’s home environment and level of exercise, both current and prior to injury, will help to guide the treatment programme and home exercise advice.

Once these subjective data have been obtained, ob-jective assessment can commence. Objective meas-ures that can be repeated to determine effectiveness of treatment are vital. The animal’s posture, willing-ness to weight bear, lameness and muscle atrophy should be observed before handling the patient. Lameness assessment is a useful tool; however it is very subjective with many different lameness assess-ment tools identified in the literature. More objective measures of the animal’s lameness can be made by videoing their gait pattern at the start, and end of the rehabilitation programme as well as at several points throughout the programme.

Measures of limb circumference and joint ROM us-ing goniometry can also be used as objective markers to monitor outcomes (Figure 1). These measures have been proven to be most reliable when repeated with the one observer (Jakobsen et al, 2009).

In conjunction with the objective measures, the owner should be questioned on response to treat-ment at home, completion of the home exercise pro-gramme and any other concerns or queries they may have. Each time the animal returns for treatment, ide-ally twice a week, a reassessment should be performed to determine response to the programme. The outcome of this assessment will help guide progression of treat-ment and ensure the programme stays specific for each individual patient.

When to start treatment Treatment should be started on the day of surgery. Early commencement of treatment following ortho-paedic surgery reduces pain, swelling, inflammation, lameness, use of non steroidal anti-inflammatory medication (Shumway, 2007), and reflex muscle inhi-bition, which leads to accelerated muscle strengthen-ing (Moffet et al, 1994). Icing, gentle passive motion and massage away from the wound, along with early controlled weight bearing can all start in the early post-operative period. Hydrotherapy can start once the wound has fully healed — typically at 10–14 days post operatively.

Treatment techniques There are a multitude of treatment techniques that can be administered by the veterinary nurse follow-ing orthopaedic surgery. Selection of these tech-niques must be individualized and based on the as-sessment findings. Additional factors to consider that may require modification of the treatment technique include, the animal’s age, the presence of concurrent pathologies, aggression or fear and response to pain.

Figure 1. Goniometry measuring hip range of motion.

PRODUCT FOCUSManuka honey: an effective wound healing

to unload the affected limb or to activate incorrect musculature, to ensure each exercise is performed

A slow pace walking programme can commence following bandage removal, initially consisting of a 5 minute walk for toileting two to four times a day, gradually increasing over the next 6 to 8 weeks depending on the animal’s condition, and lameness.

Education of the owner/homeexercise programmeIt is extremely important to educate the owner in all aspects of their pet’s condition, giving them clear and concise post-operative notes, including the importance of rest and confinement to prevent post-operative complications due to over activity.

Home exercises should be clearly demonstrated and documented. The owner should practice them under the supervision of the treating therapist to check that they are able to do them correctly. At each visit all exercises should be reviewed and updated.

Additional equipmentThere are many different mobility aids ranging from doggie wheelchairs to harnesses, protective boots, ramps and slings. When assessing an animal for aids it is important to determine the exact needs of the animal, its home environment, its activity levels, and the owner’s expectations and ability to use the aids correctly. Once purchased the correct fit and use of the aid should be assessed

Manuka honey: an effective wound healing

Soft tissue massage techniques Following orthopaedic surgery, soft tissue massage techniques are aimed at reducing muscle tension and associated pain, to allow normal movement of a joint or limb. They can also be used to induce relaxation in an animal in preparation for other stronger treatments.

Clinical


Hydrotherapy programmes are best devised by an an-imal physiotherapist or veterinary nurse with special training in hydrotherapy for animals.

Swimming is a great form of hydrotherapy and can be used to increase joint ROM, muscular endurance, encourage limb use and general fitness providing a medium for exercise when land-based exercise is too painful. Animals need to be introduced to swimming slowly and closely monitored for signs of distress or poor limb use. Always start with small sessions and increase as the patient improves.

Underwater treadmill therapy (Figure 5) provides buoyancy to reduce weight bearing on healing struc-tures, but also allows gentle loading that assists mus-cle strengthening. When used as part of a structured physiotherapy programme, underwater treadmill therapy can accelerate return to function following orthopaedic surgery (Monk et al, 2006).

Hydrotherapy can commence once the wound has healed, typically at 2 weeks post surgery.

Hydrotherapy contraindications A thorough assessment should be performed by the referring veterinarian to ensure suitability of hydro-therapy for each patient. Contraindications to hydro-therapy following orthopaedic surgery include:

zOpen wounds or unhealed surgical incisions zVomiting/diarrhoea z Elevated body temperature/infection z Respiratory compromise z Severe systemic conditions: cardiac, liver, kidney disease zUncontrolled epilepsy z External fixation of fractures (due to open wounds) z Severe skin irritations z Ear infection (if ears could become immersed).

Gentle strengtheningControlled exercise including weight bearing or in-creased mechanical load has been shown to increase muscle strength and stimulate bone and soft tissue healing (Thomopoulos et al, 2008). Early control-led weight bearing following orthopaedic surgery can assist in the prevention of disuse muscle atro-phy, increase healing and aid the animal’s return to full function (Oldmeadow et al, 2006). Controlled weight bearing exercise, such as three point stand-ing (Figure 6) or baited exercises (Figures 7 and 8) along with a slow pace on lead walking programme, can be used to encourage weight bearing on the af-fected limbs.

When prescribing exercises it is important for the therapist to observe the animal performing each exer-cise, correcting any compensatory strategies they use

Figure 6. Three point standing balance exercise.

Figure 7. Baited stretches encouraging cervical and thoracic flexion.

Figure 8. Baited stretches encouraging cervical and thoracic side flexion.


Clinical

There are many different massage techniques avail-able, from gentle superficial techniques to very deep tissue techniques. In orthopaedic post-operative cas-es, gentle massage of major muscle groups in affected limbs is recommended, ensuring the animal is not caused pain. Massaging towards the heart can help removal of swelling and waste products from an im-mobilized area. For safety, deeper techniques should be reserved for use by an animal physiotherapist or qualified animal remedial masseur. No massage should be performed near the surgical site for at least the first 48 hours. After this time, gentle techniques can be performed closer to the surgical site, avoiding the actual wound. Once the wound is well healed, usually at 2 weeks post surgery, scar massage to the incision site can be performed if the scar is adhered to the underlying tissues.

Thermotherapy/heat treatment Once acute swelling and inflammation has subsided, usually at 48 hours post surgery, heat can be used to reduce pain and muscle guarding as well as improve circulation to the affected area to assist with healing.

Heat wheat packs are ideal as they are light weight and conform well to the body. Ensure that they are only ever applied warm. Do not secure a heat pack to an animal or leave an animal sitting on a heat pack as this can lead to thermal burns. Application of heat for 10 minutes three times per day prior to passive ROM exercises is recommended.

After the first 48 hours, or when acute swelling has ceased, alternating cold and heat therapy can be used to assist in the removal of swelling. Placing an ice pack on the area reduces blood flow and swelling, then heating the area increases blood flow, helping to ‘pump’ out swelling from the affected area. Use heat and ice alternatively for 10 minutes each, over a 60 minute period, three times per day.

HydrotherapyWater is an excellent medium to assist in the rehabili-tation of the post-operative orthopaedic patient. For the animal patient, exercising in water allows unload-ing of painful joints, as well as earlier weight bear-ing on otherwise very weak or painful limbs (Steiss, 2003). Hydrostatic pressure is the pressure of water on the body surfaces. This pressure increases with depth of immersion (Edlich et al, 1987) and can be useful to assist in the reduction of oedema in limbs following surgery. Friction between water molecules causes the water to be viscous. The viscosity of the water adds resistance that can be used to acceler-ate strengthening when the animal swims or walks against the water.

While exercising in water is beneficial, exercises performed on land cannot be simply repeated in the water. Movements are generally slower; animals may have different awareness of their body and limbs and may also be initially fearful of the environment.

Figure 4. Whole limb flexion (hip, stifle and tarsal flexion).

Figure 5 Underwater treadmill.

Contraindications to treatmentWhen attending for rehabilitation, animals should be regularly reassessed for lameness, swelling, and avail-able joint range. Owners should be questioned about how they feel the animal is progressing both physi-

Conflict of interest: none

Acknowledgements:Dogs in Motion and Animal Physiotherapy Solutions for the use of the photographs included in this article.

dola A, Vaz MD (1997) The efficacy of cryotherapy fol-lowing arthroscopic knee

J Orthop Sports Phys (1): 14–22

Moffet H, Richards CL, Malouin F, Bravo G, Paradis G (1994). Early and intensive physi-otherapy accelerates recovery postarthroscopic meniscec-tomy: results of a randomized controlled study. Arch Physi-cal Med Rehab 75(4):415–26

Monk M, Preston C, McGowan C (2006) Effects of early in-tensive postoperative physi-otherapy on limb function

after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament. 529–36

Oldmeadow LB, Edwards ER, Kimmel LA, Kipen E, Robertson VJ, Bailey MJ (2006) No rest for the wounded: early ambulation after hip surgery accelerates recovery. Surg

Palmieri-Smith RM, Kreinbrink J, Ashton-Miller JA, Wojtys EM (2007) Quadriceps Inhibition Induced by an Experimental Knee Joint Effusion

October 2010 • Vol 1 No 1


protective muscle guarding. For a successful return to full function and muscle strength, joint ROM needs to be restored.

When assessing joint ROM it is important to recog-nize factors limiting movement and only work within the animal’s pain free motion, gradually regaining joint range as pain and swelling decreases.

Improving muscle strengthOnce initial pain, swelling, inflammation and mus-cle inhibition are addressed, muscle strengthening can commence. Specific strengthening exercises are needed to grow muscle. In the absence of pain, reflex muscle inhibition will continue without spe-cific exercise to the affected muscles (Young, 1993). Patients receiving an early intensive physiotherapy programme following orthopaedic surgery achieve not only more rapid strengthening, but larger over-all increases in muscle strength (Moffet et al, 1994). Exercises should initially be very gentle and control-led, progressing to those that overload the muscle, al-lowing increased adaptation and strength.

Assessment and monitoringA thorough initial assessment of the patient is re-quired in order to devise a patient-specific reha-bilitation programme. Before observing or palpat-ing the patient, the veterinary nurse should obtain as much background information as possible. This may involve obtaining veterinary surgery and treat-

In conjunction with the objective measures, the owner should be questioned on response to treatment at home, completion of the home exercise programme and any other concerns or queries they may have. Each time the animal returns for treatment, ideally twice a week, a reassessment should be performed to determine response to the programme. The outcome of this assessment will help guide progression of treatment and ensure the programme stays specific for each individual patient.

Figure 1. Goniometry measuring hip range of motion.

The Veterinary Nurse • Vol 1 No 1 • October 2010

Contraindications to treatmentWhen attending for rehabilitation, animals should be regularly reassessed for lameness, swelling, and available joint range. Owners should be questioned about how they feel the animal is progressing both physi

Edlich FR, Towler MA, Goitz RJ et al (1987) Bioengineering principles of hydrotherapy. J

(6): 580–4Jakobsen TL , Christensen M,

Christensen SS, Olsen M, Bandholm T (2009) Reliabil-ity of knee joint range of mo-tion and circumference meas-urements after total knee arthroplasty: does tester ex-perience matter? Physiother Res Int: http://lib.bioinfo.pl/pmid/journal/Physiother%20Res%20Int (accessed May 20 2010)

Lessard LA, Scudds RA, Amen-

dola A, Vaz MD (1997) The efficacy of cryotherapy following arthroscopic knee surgery. J Orthop Sports Phys Ther 26(1): 14–22

Moffet H, Richards CLF, Bravo G, Paradis G (1994). Early and intensive physiotherapy accelerates recovery postarthroscopic meniscectomy: results of a randomized controlled study. cal Med Rehab

Monk M, Preston C, McGowan C (2006) Effects of early intensive postoperative physiotherapy on limb function

Vol 1 No 1 • The Veterinary Nurse



Gentle strengtheningControlled exercise including weight bearing or in-creased mechanical load has been shown to increase muscle strength and stimulate bone and soft tissue healing (Thomopoulos et al, 2008). Early control-led weight bearing following orthopaedic surgery can assist in the prevention of disuse muscle atro-phy, increase healing and aid the animal’s return to full function (Oldmeadow et al, 2006). Controlled weight bearing exercise, such as three point stand-ing (Figure 6) or baited exercises (Figures 7 and 8) along with a slow pace on lead walking programme, can be used to encourage weight bearing on the af-can be used to encourage weight bearing on the af-can be used to encourage weight bearing on the affected limbs.

When prescribing exercises it is important for the therapist to observe the animal performing each exer-cise, correcting any compensatory strategies they use

Figure 8. Baited stretches encouraging cervical and thoracic side flexion.

Clinical

While exercising in water is beneficial, exercises performed on land cannot be simply repeated in the water. Movements are generally slower; animals may have different awareness of their body and limbs and may also be initially fearful of the environment.

Figure 4. Whole limb flexion (hip, stifle and

Clinical


In the human medical world, post-operative reha-bilitation is imperative to the successful outcome of the orthopaedic surgery patient. Rehabilitation

of the canine patient is now also becoming recognized as an important facet of veterinary medicine. Rehabili-tation may be provided either in the veterinary clinic or in purpose-built rehabilitation centres by a variety of animal health professionals including animal physi-otherapists, veterinarians and veterinary nurses. Many countries have qualified animal physiotherapists, who are able to provide appropriately designed treatment programmes, transerring their expertise and knowl-edge to rehabilitation of small animals. While having a qualified animal physiotherapist on site to oversee the rehabilitation of all patients is desirable, it is not al-ways possible and treatment is often administered by veterinary nurses.

Nurses administering rehabilitation programmes for animals should have completed animal rehabili-tation courses and work under the guidance of a vet-erinarian. When devising rehabilitation programmes

for animals it is important to follow evidence-based guidelines to ensure that treatments administered are safe and effective, avoiding complications caused by inappropriate exercise regimens or treatments. This article outlines the aims of rehabilitation following orthopaedic surgery, when to commence therapy, ap-propriate selection, administration and monitoring of treatment techniques performed by the veterinary nurse. It looks at contraindications to treatment and when to refer on to a qualified animal physiotherapist or back to the referring veterinarian.

Aims of treatmentThe aims of rehabilitation following orthopaedic surgery are to accelerate recovery and return to func-tion by reducing pain, swelling and inflammation, improving joint range of motion (ROM) and mus-cle strength, while protecting painful and/or healing structures. This is accomplished through a combi-nation of carefully selected and administered treat-ment techniques, in conjunction with a structured and individualized home exercise programme for the animal, to be completed by the owner or carer. An integral part of this rehabilitation programme is the education of the owner with regards to the orthopae-dic condition and surgery, the exercise restrictions for the animal after surgery and exact instructions for home care and therapy, to reduce the incidence of post-operative complications and to accelerate recovery.

Reducing pain, swelling and inflammationPain, swelling and inflammation are common clinical signs following orthopaedic surgery and are known to cause arthrogenic muscle inhibition (Palmieri-Smith et al, 2007), where muscles become reflexively inhibited or difficult to ‘switch on’. If muscles are not contracting well, atrophy occurs and decreased mus-cle strength. Physiotherapy modalities, such as ice, compression and gentle movement, are now com-monly used in the orthopaedic post-operative animal patient to help reduce these signs (Shumway, 2007) and assist the animal’s recovery.

Improving joint ROMFollowing orthopaedic surgery joint ROM is often reduced because of pain, swelling, joint stiffness or

Small animal post-operative orthopaedic rehabilitationAbstractIn the human medical world, post-operative rehabilitation is imperative to the successful outcome of the orthopaedic surgery patient. Rehabilitation of the ca-nine patient is now also becoming recognized as an important facet of veterinary medicine. Rehabilitation may be provided by a variety of animal health profession-als including animal physiotherapists, veterinarians and veterinary nurses. While having a qualified animal physiotherapist on site to oversee the rehabilitation of all patients is desirable, it is not always possible and treatment is often administered by veterinary nurses. This article outlines the aims of rehabilitation following or-thopaedic surgery, when to commence therapy, appropriate selection, administra-tion and monitoring of treatment techniques, contraindications and when to refer on to a qualified animal physiotherapist or back to the referring veterinarian.

Key words: physiotherapy, rehabilitation, hydrotherapy, exercise

Lindsey Connell MAnSt (Animal Physiotherapy) is Director of Animal Physiotherapy Solutions, Veterinary Specialist Services, Shop 14 ‘Hometown’, Corner of Lexington and Logan Roads, Underwood, Q 4119, Australia. Michelle Monk MAnSt (Animal Physiotherapy) is Director of Dogs in Motion Canine Rehabilitation, Doveton, Australia. Correspondence to: Lindsey Connell

CPD

VETN_2015_6_8_498_503.indd 503 21/10/2015 14:19


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