Physical rehabilitation for geriatric patients

Introduction

In the evolving field of veterinary medicine, physical rehabilitation has become a pivotal component of comprehensive care, enhancing the quality of life for geriatric patients by addressing the unique challenges associated with aging. As pets get older, they often experience a decline in mobility, strength, and overall function, leading to decreased activity levels and an increased risk of injury and chronic conditions such as osteoarthritis (OA). This paper offers a short overview of the options available for the geriatric patient, but does not aim to describe the methods in any detail; rather, it will discuss the factors to be considered when establishing a rehabilitation program, with a focus on managing osteoarthritic patients.

What strategies are available?

Rehabilitation strategies (including tailored exercise programs, manual therapy, ergonomic adjustments, and therapeutic modalities like photobiomodulation therapy (PBMT) and hydrotherapy) help maintain and improve joint flexibility, muscle strength, endurance and overall well-being. These interventions not only alleviate pain and discomfort, but also enhance mobility and independence. Additionally, rehabilitation can prevent further deterioration of physical abilities and support weight management, which is vital for reducing stress on aging joints. By incorporating a holistic approach that includes nutrition and environmental modifications, rehabilitation ensures that geriatric patients enjoy a higher quality of life, remaining active and engaged in their daily activities.

Applications and indications of rehabilitation

The clinical applications of rehabilitation are extensive and significantly affect a spectrum of conditions, specifically customized to meet the individual needs of each patient. This includes facilitating recovery from injuries and surgeries, managing OA or other chronic ailments in aging pets, and assisting overweight pets in achieving a healthier weight [1],[2], with the most common benefits of rehabilitation listed in Box 1. Proactively, early rehabilitation can also slow the progression of degenerative ailments such OA by addressing musculoskeletal imbalances and pain, thus preventing the onset of further degenerative issues, and embedding itself as a key preventative measure in patient care [3]. Box 2 details the top ten conditions that often benefit from rehabilitative care [2],[3].

Box 1. Top 10 benefits of rehabilitation (from [2],[6]).

Box 2. Top 10 common conditions requiring rehabilitation (from [2],[3]).

Multimodal therapy

Typically, a multimodal approach with both pharmaceutical and non-pharmaceutical interventions is utilized by rehabilitation therapists to manage patients with OA or during their recovery from surgery or trauma [4],[5]. Techniques such as manual therapy (Figure 1) effectively enhance blood circulation and promote healing, while therapeutic methods like heat therapy, cryotherapy, PBMT, acupuncture, pulsed electromagnetic field therapy (PEMF), extracorporeal shockwave therapy (ESWT) target pain and inflammation with notable efficacy [4],[6],[7]. Therapeutic exercises and hydrotherapy (Figure 2) are particularly beneficial post-injury, aiding dogs in regaining strength and mobility – for instance, after procedures such as cranial cruciate ligament repair [4],[8]. Weight management is another key benefit which can help in preventing joint stress and other obesity-related health issues in geriatric patients [5]. Prior to incorporating rehabilitation into practice settings, veterinary professionals or physical therapists must undergo rigorous training to ensure the highest standards of care, with certifications and residency programs available worldwide to specialize in this transformative field (Box 3).

Box 3. Resources for animal physical rehabilitation.

Selection of appropriate rehabilitation

Selecting appropriate rehabilitation for OA involves a multifaceted approach tailored to each disease stage (Table 1) [7],[8]. For at-risk dogs (Stage 1), proactive preventive measures focus on maintaining strength, flexibility, and Range of Motion (ROM) (Figure 3). In mild OA (Stage 2), strategies include reducing joint strain and incorporating strengthening exercises to slow progression and maintain mobility and strength (Figure 4). For moderate OA (Stage 3), the primary goals are pain management and mobility improvement, achieved through comprehensive ergonomic adjustments, low-impact targeted exercises, and regular therapeutic modalities. In severe OA (Stage 4), which often causes chronic pain with central and peripheral sensitization, the primary focus is on comfort and quality of life through extensive multimodal pain management, combining intensive pharmacologic and non-pharmacologic approaches. Nutrition rich in high-quality proteins, antioxidants, and omega-3 fatty acids, along with joint supplements, supports joint health and helps maintain an ideal body weight throughout all stages [5],[7].

Table 1. The four stages of OA and its proposed rehabilitation intervention ([5],[7],[8],[14]).

Additionally, rehabilitation programs, whether conservative or surgical, are also guided by the stages of tissue healing: inflammatory (acute), reparative (subacute), and remodeling (chronic) [9]. Table 2 shows the healing stages of tissue corresponding the phases of rehabilitation [2],[9]. These stages, although overlapping, follow a specific sequence unique to each tissue type. Healing times vary significantly due to differences in blood supply and cellular makeup [10]. Bones typically heal within 6-8 weeks due to their rich blood supply, while cartilage and ligaments, lacking direct blood supply, may take months to years, or may not fully recover without intervention [9],[10]. Muscle and tendon injuries generally heal in a few weeks to several months, depending on severity and blood supply [9],[10]. Customized rehabilitation plans are essential, considering the healing stages, tissue type, clinical signs and patient needs to ensure safe and effective recovery. Generally, rehabilitation strategies focus on protecting tissues, controlling pain, and reducing edema in the acute phase, progressing to weight-bearing, balancing, and Active Range of Motion (AROM) exercises in the subacute phase, and eventually strengthening, proprioception, and endurance activities in the chronic phase [2],[9].

Table 2. The three stages of tissue healing corresponding to the three phases of rehabilitation and its proposed rehabilitation intervention (Adapted from [2],[9]).

The selection of rehabilitation therapies is comprehensive, involving ergonomics, manual therapy, therapeutic exercises, therapeutic modalities, and nutrition, each tailored to align with the patient’s specific healing phase and individual needs. An example of a rehabilitation protocol for intervertebral disc disease based on healing stages is shown in Table 3. Ergonomics enhances treatment outcomes and reduces injury risk by modifying the environment and utilizing assistive devices [3]. There are many commercial devices now available, although simple home-made options are often quite satisfactory (Figure 5). Manual therapy involves skilled, hands-on techniques (Figure 1) to manipulate muscles and joints, decreasing pain and improving function [11]. Therapeutic exercises correct impairments, restore function, and maintain mobility (Figure 6) [12]. Therapeutic modalities, such as electrotherapy, photobiomodulation therapy, and extracorporeal shockwave, aid in pain relief, healing, and function restoration (Figure 7) [4],[13]. Finally, it is again emphasized that nutrition is crucial for tissue recovery, providing essential nutrients, supporting immune function, and maintaining muscle mass [5].

Table 3. Rehabilitation phases and protocol for thoracolumbar intervertebral disc disease ([14],[15],[16],[17],[18]). 

Conclusion

The integration of rehabilitation into veterinary practice is not merely an adjunct but a cornerstone of patient-centered care that profoundly impacts recovery outcomes. Rehabilitation should employ a multi-modal approach that can accelerate recovery, enhance pain management, maximize function, and significantly improve the quality of life for companion animals. This approach is especially critical for geriatric patients, particularly those suffering from osteoarthritis (OA). Drawing on the foundational principles of OA stages, tissue healing, and the latest research in veterinary rehabilitation, it is clear that patient outcomes are markedly improved when rehabilitation is tailored to the individual needs of each animal.