chloelogoa

Rehabilitation Protocol for 

Tibial Plateau Leveling Osteotomy (TPLO)

Adapted from Canine Rehabilitation Physical Therapy by Millis, Levine, Taylor 2004
www.careanimal.com
 talalogoa

There are many different post op rehab programes so check with your veterinary surgeon for the correct procedure for your dog

Because the biomechanics of the knee are altered by this procedure there is additional stress on the patellar ligament.  Overuse of the limb before appropriate healing occurs can result in inflammation of this ligament or avulsion (tearing) of its insertion point on the tibia.  Careful attention to restriction of activity is imperative.  Activity should be restricted as outlined below.

Expected outcomes of rehabilitation:

Knee that is free of inflammation
Full range of motion of the knee
Equal muscle development between the two hind limbs
Complete healing of the bone (osteotomy site)
Slowed progression of osteoarthrits
Better limb function than before surgery
General Concepts of Pain Control During Rehabilitation

1.  NSAID (Rimadyl, Deramaxx, Metacam, Tylenol)
a.  Use medication as directed by your veterinarian
b.  Give the dose about 2 hours before performing rehab exercises

2.  Cryotherapy (icing) (see explanation)
a.  Ice pack ideas include bag of frozen peas, commercial therapeutic ice packs, or make your
     own with 1 part isopropyl alcohol to 2 parts water in heavy duty ziplock bag.
b.  Place a towel between ice pack and the skin to prevent irritation
c.  Ice for 15-20 minutes as indicated

3.  Heat (see explanation)
a.  Place a towel between pack and skin to prevent irritation
b.  Moist heat is best.  Some ideas include:  towels immersed in warm water and wrung out or
     rice in a tube sock and microwaved (be very careful of burns with this technique)
c.  Do not apply in the first 72 hours post op as this can increase inflammation and swelling
d.  Begin on day 4 or 5 before ROM (Range Of Motion) exercises to warm up the tissues and
     relax the muscles

4.  Massage (see explanation)
a.  At home gently massage the limb prior to ROM exercises to mobilize the soft tissues and
     warm up the muscles.  Include massage of the scar once it is healed
b.  Professional massage therapy is advised.  Licensed and certified massage therapists are
     recommended.  Typical schedule is once per week in the first 4-8 weeks post op and then
     as directed.

Suggested Rehabilitation Schedule:
Day 1-4 Post Op
Goals: Control swelling, improve ROM, and pain control
Daily Routine:
Gentle massage of muscle of the upper limb and knee to mobilize fluid, warm muscles, relax muscles
Passive ROM for the hip, knee, and hock (10 reps each joint 2-3 times per day)
Walks:  If toe touching, walk very slow 2-3 times per day for 5 minutes
            If not toe touching, use a towel sling to support but no walks
Finish each exercise session (massage + ROM + walk) with cryotherapy 15-30 minutes
** ROM should be increasing daily but do not exceed the comfort of the patient.  If ROM is not improving, increase the number of exercises to 3-5 times per day.
 ** On day 4 or 5 heat can be combined with massage to warm the muscles prior to ROM exercises
** Toe touching is expected on day 1-3 post op
Day 5-3 Weeks Post Op
Goals:  Reduce swelling, increase weight bearing at a walk, ROM returning to normal, pain control
Daily Routine:
Moist heat and massage before and after ROM exercises (10-15 reps hip, knee, hock)
Short leash walks immediately after ROM exercises 3 times per day
a.  Week 1: 5-10 minute walk
b.  Weeks 2 and 3 slowly increase to 10-20 minute walks
Cryotherapy for 15 minutes immediately after exercise
** By week 2, ROM can be discontinued if knee extension and flexion are near normal (compare to opposite limb)
** Increases in walk length are limited by patient comfort.  If there is increased fatigue or discomfort, decrease time until signs resolve.
** Schedule recheck appointment at end of week 3 
Weeks 3-5 Post Op
Goals:  Maximum ROM, increased endurance and strength, improved weight bearing
Daily Routine:
Continue ROM if full ROM has not yet been achieved (along with heat and massage)
Slow leash walks progressing to 20-30 minutes 3 times per day
Functional training with:
a.  Sit to stand exercises (10 reps 3 times per day) (see explanation)
     i.  Encourage patient to sit squarely with the affected limb in normal
         position then rise to stand
    ii.  This encourages pushing off with affected limb and strengthens
         muscles
b.  Figure 8 walking and circle walking both directions
c.  Slow walking on uneven ground, inflatable mattress, or couch cushions  
Weeks 6-8 Post Op
 Goals:  Improved limb use at the trot, improved muscle mass and strength, improved stamina and endurance
Daily Routine:
Before progressing to these exercises, x-rays are needed to confirm the bone has fully healed.  If it is not healed at this time, continue Week 3-5 routine.
Slow leash walks on longer leash 30-40 minutes 3 times per day
a.  Weave through cones or other obstacles
b.  Trotting but only in straight line, no sharp turns
c.  Trotting in large circles and figure 8's.
Strengthening
a.  Walking along a slope with the affected let on the downhill side.
b.  Stair walking - slow ascents and descents of up to 5-10 stairs 2-3
     times per day
c.  Hind limb dancing - holding front legs gently rock the patient's weight
     from right to left hind limbs
d.  Swimming
     i.  Do not allow jumping into the water
    ii.  Restrict to 2-3 times per week for 15-20 minutes depending on
         fitness and comfort
** Some mild lameness may appear as activity increases.  If this worsens or persists, decrease or stop activity for 1-2 days then return to activity at 50-75% intensity and gradually increase again.
** Occasional "easy" days of reduced activity are helpful
Weeks 9-12 Post Op
Goals:  Improving speed, improving muscle mass and strength, improving stamina and endurance, return to presurgery activity level by 12 weeks
Daily Routine:
Final x-rays at 9-12 weeks
Continue exercises of weeks 6-8 - swimming can increase to 15-20 minutes several times per week
New exercises
a.  Zig-zag at a trot
b.  Run in a straight line (no sharp turns at this speed)
c.  Leg weights 0.5-1 lb can be strapped onto affected limb
** Level of activity should be fairly consistent from day to day.  Do not engage in vigorous activity followed by days of little activity.

Final Notes:
This protocol is designed as a guide for rehabilitation.  As such all exercises are geared toward the individual patient's progression and comfort.  Adjustments may be necessary on an individual basis.
Pain should be controlled at all stages.  If the patient is uncomfortable, medications and rehabilitation must be adjusted.  Please contact your vet for assistance.

Follow recheck schedule as indicated.

Weight control is critical in order to manage and minimize osteoarthritis.

Throughout rehabilitation, monitor the limb and incision for swelling, redness, and drainage.  Do not allow the patient to lick or chew at the affected limb or incision.  Call you vet if any of these situations occur.
Use of a glucosamine/chondroitin sulfate supplement (Cosequin) is advised indefinately.  Other osteoarthritis management and treatment plans may be recommended on a case-by-case basis.

reprinted with kind permission from Dr. Paige Garnett
www.careanimal.com

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A Typical TPLO Post Surgery Protocol


Check the incision twice daily for swelling, redness or discharge

Do not allow chewing or licking. Keep e-collar on when you cannot directly supervise

Apply ice pack 10-15 min for 3 times a day for 1st 24 hours

After 24 hours apply a warm compress. 3-4 times for 5 minutes. (a warm compress is a washcloth soaked in warm not hot water and placed in a zip lock bag) do this until the swelling is resolved usually 3-6 days

Expect some swelling to move to the hock (ankle) . warm compress and massage will allow the body to reabsorb the swelling.
 
MEDS:
 Fentanyl patch for 3 days

Tramadol (pain) up to 3  a day (she 60 pounds)

Metacam for 5 days (anti-inflammatory)

Glucosamine formula for life
 
ACTIVITY:
Restrict exercise for at least 8 weeks

Please keep pet indoors and confined to a small room, pen or crate and with good footing.

No running, jumping stairs or playing.
 
 
Weeks 1 & 2
Begin passive range of motion exercises - 10 slow reps 3 times a day

Massage quadriceps muscles before and after PROM exercises

As soon as your dog begins to place weight on the operated limb, begin slow leash walks, for 5 minutes, 3 times a day
 

Weeks 3 & 4
Stop passive range of motion exercises once patient is using the limb well

Increase the slow leash walks, to 10-20 minutes, 3 times a day as long as the lameness is improving

Continue with massage
 
Weeks 5 & 6
Leash walks for 20-30 minutes 2-3 times a day

10 reps of sit/stand exercises 3 times a day. Have your dog sit against a wall for 10-15 reps, 2-3 times a day. keeping affected knee against the wall.
 
Weeks 7 & 8
10-15 reps of figure 8 walks 2-3 times a day, circle to the left and then to the right

Leash walks for 30-40 minutes 2-3 times a day

Recheck exam and radiographs 8 weeks after surgery to assess healing
 
Weeks 8 and on
After the bone has healed radio graphically, continue to increase the exercise periods in time and duration include running short distances on leash.

Include running short distances on leash.

Short, controlled off leash running may be started .

One month after radiographic union of the bone the dog may return to normal activity.

This protocol was kindly donated by
Denise Rolen Holistic Health Practitioner
and
A Veterinary Practice in South Carolina

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 chloebutton   talabutton
The above information is simply informational. It's intent is not to replace the advice of a veterinarian nor to assist you in making a diagnosis of your pet. Please consult with your own veterinarian for confirmation of any diagnosis. Your pets life may depend on it.