25/01/2020 by Danielle Anderson, BSc, DVM, CCRP, cVMA 0 Comments
Cookie Cutter Medicine in Rehabilitation
Over the last few years I have seen an increase in the standardization of veterinary medicine. By this I don't mean standard protocols to make clinics run more efficiently, but instead to provide vets with how they should approach cases. I personally find it disheartening and it seems to remove the "art" of veterinary medicine; reliance on communication and connection with clients, and your physical examination to then proceed with the best possible plan for the patient and the client. This 'cookie cutter' approach, although not common, is seeping into the rehabilitation field and I wanted to take a minute to address it from my perspective.
Lets use an example. We frequently receive phone calls asking what owners can do after a cruciate repair. They may live far away from rehabilitation, or they can not financially move forward with any structured rehab plan at this time. It is too easy to give a menu for them to follow: 1-2 weeks post-op do range of motion, and ice. The next two weeks add 5 minute walks and some cavallettis. Add some sit to stands and then some figure of eights and keep adding 5 minutes to your controlled walks at 4-6 weeks. Increase your sit to stands and time of walks, and voila at 12 weeks add stairs and return to full function. They are easy exercises for owners to do and then all we need to do is some water treadmill and laser therapy right??? NO! Each one of these patients heals differently from surgery and may or may not have other conditions affecting their recovery process. Every cruciate repair surgery does not have the same recovery. A TPLO recovers differently from a TTA which recovers differently from an extracapsular repair. Each has different potential complications. Do we still have an intact meniscus because that will also change the long term prognosis and expectation for arthritis and recovery. Cookie cutter prescriptions just don't fit and potentially lead to problems. Just because they SHOULD be able to walk 30 minutes at 8 weeks, does not mean they CAN. In July of last year an amazing article came out titled "Fundamental principles of rehabilitation and musculoskeletal tissue healing" by Kristin Kirkby Shaw DVM, MS, PhD, CCRT, DACVS, DACVSMR Leilani Alvarez DVM, CVA, CCRT, ACVSMR, and Sasha A. Foster MSPT, CCRT, etal. It reinforces the different stages of healing and how that applies to the modalities we use for rehabilitation. It also discussed the differences in technique and healing among the different cruciate repair techniques.
What are the compensatory changes we may see in a dog recovering from a cruciate repair surgery? How do we address those? Another example would be having a patient with Degenerative Myelopathy who only receives water treadmill and laser therapy. The research shows that this is the best way to maintain them for as long as possible. So clearly this is all they need right? How many of these patients have concurrent osteoarthritis? How many have marked compensatory changes in their front limbs from their hind end weakness? Not addressing these means potentially a less than desirable outcome long term.
There is definitely a reason to have standard protocols for many things including cleaning protocols, training protocols, etc. Veterinary medicine is definately not one of those areas. It should never be categorized in a box.....lets do better and think OUTSIDE the box. Our patients deserve it.