Laurie's Blogs.

How do you progress your patient?

How hard do you push?

Is some soreness acceptable after an exercise session?

This conversation came up at my work this week and it reminded me of conversations I’ve had with other physiotherapists about new grad physios (in human practice).

A colleague once told me that when she had a physio student in her practice, that the caseload of the clinic would drop.  Why?  She noted that the physio students didn’t know how often to bring the patient’s back into clinic for treatment.  This would result in patients not getting better in a timely manner, or dropping off because they weren’t seeing results.

I’ve also noted from questions that have come in to me over the years and those on Facebook groups or chat groups, that those who are new the profession, face the same issues that any of us who are new to our own respective professions make, that the answers to the questions above come from clinical experience.

Experienced (human) physios have an advantage – we learned how hard to push, how to progress, and what sort of discomfort after treatment is acceptable and expected on patients that could talk.  So, to accommodate for learning how to progress on a non-verbal patient, we need to spend more time talking to the owner.  How was your dog after last appointment?  When did the lameness subside?  How long did the soreness last?  How was he/she after that initial soreness?  OR… Was there no change at all?  Did you change anything else?  And so on.

We know that an assessment can flare up a sore joint or soft tissue, simply because of the test / retest phenomenon.  This typically subsides quickly.  If your assessment also contains therapy, often a short bout of soreness is mitigated right then and there.  We also know that building muscle require micro-tearing of the muscle fibres in order to initiate muscle growth.  The day after doing leg weights at the gym, or starting a running program, or going for a long hilly hike on the weekend, our leg muscles are stiff and sore.  However, we understand that THIS is the stimulus for muscle growth.  So, we need to translate that knowledge to our canine patients.

I have found that one way to problem solving a question that doesn’t have a definitive answer (i.e. an answer that is patient-specific) is to ask additional questions.  So, as an example, if the question is, “How do you know if a dog is exercising too much?”  Let’s ask the following questions for which there are more definitive answers:

• Is the patient an athlete, a weekend-warrior dog, a regularly walked dog, or a potato?
• What would you see in an athlete that was exercising too much?  Recurring injuries.  Regular injuries.  Being more prone to sickness.  
• What would you see in a weekend-warrior dog or regularly walked dog that is exercising too much?  Hmmm… this question then gets reframed to ‘too much in one bout of exercise’.  Here I say that the dog should be better within 24 hours post-exercise.  If it takes longer than that, then the dog was pushed beyond its current physical capabilities.
• How do you know if you’ve pushed your potato-dog too much?  Well, the answer above also holds true.  24-hours of soreness is permissible, more than that, and you may have pushed too hard during that exercise session.

Now, let’s put this into a canine rehab clinical context.  Let’s say the dog is in the Underwater Treadmill, and you are unsure of how fast to start the dog, how fast to get the dog going when you build up to top speed, and you’re unsure of whether or not to implement interval training.  Let’s think about these.  Questions to ask yourself beforehand; How fit is the dog going in to rehab?  How old is the dog?  How badly affected is the dog currently (i.e. neurologic from IVDD, post-op CCL, FHO, or is it a weight loss case)? Is this a joint issue or a soft tissue issue?  Can you assess the difference between a joint flare up, a soft tissue flare up, or exercise induced muscle soreness?  What is the worst that can happen if you ‘push too hard’?  How well do you know the owner and the dog?  What stage of healing / rehab are you at?

To prioritize, stage of healing and type of injury are likely my first questions.  If this is an acute post-op or neuro case, then you start slower.  What does slower look like?  Normal walking speed on land should be the speed you start them in the water.  If it’s acute, then you can also add more water to increase buoyancy.  With a normal walking speed and increase of water height (i.e. to hip level), this is NOT more difficult, it is an easier way to walk.  So, don’t think of the water as ‘resistance’ at this stage, think of it as an aid to early weight bearing.  As time progresses and healing progresses, then water levels can decrease and speeds can increase.  Your first session, it’s likely forgivable to take it easy or go too slow, AS YOU ARE LEARNING… but take it as just that, LEARNING.  Within any session, you should have a warm up, a work out, and a cool down. I say just about any dog can do 15 minutes.  10 for very compromised dogs… but those are few and far between.

As the dog moves into the subacute phase or late stage of healing, then you need to be building up in time, and likely more importantly speed with EVERY session.  If you are doing land-based strengthening exercises, you actually want to exercise to the point of muscle fatigue.  THAT is where muscle building occurs!  Here, I actually want the dog to be a bit stiff / sore when leaving the session or later in the day.  (i.e. Leg-day at the gym.  It’s been a good workout when walking down the stairs is difficult!)  What does fatigue look like during a session?  It’s when movement gets sloppy or performance wanes.  It’s a shaking of the muscles.  It’s when the dog is telling you he/she has had enough of that exercise.

The second priority questions to think about are, fitness levels of the dogs going IN to rehab.  A fit dog can likely start out at a faster speed in the UWT or progress through the acute stage of rehab a bit quicker.  These could be your agility dogs, flyball dogs, field trialing dogs, and so on.  I think they are mentally tougher and physically tougher.  They are used to pushing their bodies.  Plus, they likely have something sporting-wise to get back to as well.  So, capitalize on this.  An agility athlete could likely do low cavaletti poles in week 2, whereas a potato-dog might not tolerate them until week 3.

Now, is this a joint or a soft tissue injury?  What do you worry about with each?  A joint issue can flare, causing swelling in a joint.  This is NOT advantageous to healing.  So you and the owner need to monitor if the joint becomes hot or swollen after exercise, or if there is an increase in pain with joint tests such as an increase in pain at end ranges of motion.  If yes, then you pushed too hard.  Is this a soft tissue injury (biceps, supraspinatus, iliopsoas, etc.)?  In these instances, you heal a tendon with STRENGTHENING exercise, not continuous slow repetitive movement.  In other words, get your soft tissue cases OUT of the UWT and do land-based strengthening.  Tendons need to be loaded.  So load the tendons (i.e. start with isometrics, push up exercises for shoulder tendons, eccentric exercises, controlled movement exercise, progress to plyometrics, and so on.)  Human research tells us that in order to heal a tendinopathy, some degree of discomfort is necessary during an exercise session.  So, these dogs SHOULD walk out of treatment looking like they’ve had a ‘work out’.

Lastly, I’ll throw in, “How well do you know the owner?”  If you know the owner well and have established a rapport and relationship, then you are often ‘forgiven’ when you make their dog sore.  They’ve likely seen it before with this dog or another one of their dogs.  They understand the process.  However, if this is a ‘new to you’ client, then you’ll need to spend much more time COMMUNICATING.  Absolutely critical that the owner understands the process of healing and muscle building.  They need to know when to expect their dog to be sore and for how long.  You need to empower them to help you figure out how much you can push their dog, and why it’s important to find the ‘sweet spot’ of pushing just enough.  A lot of misunderstandings, disgruntled owners, and/or patients failing to return to therapy can be avoided with strong communication.   “Here’s what I want to try today.  Here’s what I expect to happen.  Here’s what I want you to monitor.  Are you okay with this?”  Inform, educate, and get consent.

That’s a lot for one blog.  I didn’t even get in to HOW to progress.  So, let’s make that the topic for next week.

On that note, have a great week ahead, and really put some thought into your THINKING in regards to exercise progression.

Cheers,  Laurie