Julie Moss BSc. Hons. AdvCertVPhys, Dip.APhys.
Non-pharmaceutical pain management
Whilst the first choice for pain management is often medication, there are many alternative non-pharmaceutical ways to manage pain. It is important to use a multimodal approach to get the best overall pain management for each individual animal patient, with the least amount of drug induced side effects (Corti, 2014), and in the case of musculoskeletal conditions this includes addressing the cause of pain by assisting healing in acute conditions or slowing down degeneration in the case of chronic conditions. This approach can also assist in the prevention of injuries if applied correctly, however, an understanding of the physiological effects is necessary to evaluate which methods of pain relief are appropriate at which stage in the treatment plan. One of the most versatile, effective and all-encompassing non-pharmaceutical methods of managing pain is the use of hydrotherapy.
The role of hydrotherapy in pain management
Hydrotherapy can assist with pain management in many ways. The physical properties of water can be utilised to support a patient in doing activities they could not manage on land. In addition to that, the inclusion of therapeutic handling and manual therapy techniques can further improve function and aid healing, which contributes greatly to pain relief. Neuromuscular techniques can further enhance improvement of function and reduce the risk of injury. Hydrotherapy can address most aspects of physical rehabilitation in one package, reducing the need for using many different methods separately. The warm temperature of the water and the pre- and post-showering can also add an extra dimension of pain relief.
A thorough assessment incorporating observations, history taking and including palpation using therapeutic handling helps to identify areas of pain and dysfunction. These issues are then prioritised and a tailored treatment plan is devised. As treatment progresses the issues are monitored for progress using suitable outcome measures and the patient is re-assessed to check ongoing progress. If pain is not reducing it is appropriate to refer back to the referring vet.
Properties of water
This is one of the unique properties of water which can be used to relieve some of the effects of gravity (Becker, 2009), allowing the animal to move with less effort put into weight-bearing as they no longer have to support all of their body weight in the water. This allows joints to work with freedom not afforded to them when working on land and allows them to explore possibilities of movement outside of their normal range of motion which improves joint health and function. It allows the use of different muscles than those that would be used to move on land. Buoyancy reduces the load on painful joints when standing or walking in a pool or underwater treadmill and varying the height of the water provides more or less buoyancy as desired. ‘A body immersed in a liquid, either wholly or partially, is buoyed up by a force equal to the weight of the liquid displaced by the body’ (Archimedes Principle) meaning in practice that the more the body is immersed the less weight bearing it has to do.
Resistance and viscosity
This occurs between the molecules of a liquid and affects how the liquid flows. Viscosity is the measure of a fluid’s resistance to flow. The viscosity of water provides twelve times more resistance than air (Becker, 2009). Resistance allows several muscle groups to be worked at the same time. It dampens jerky movements and so reduces the risk of injury. More stabiliser muscles are used in water than on land and cardiovascular fitness is increased. Improving core strength gives greater stability. During free movement the resistance of the water can be used to further build up strength as can the use of a suitable harness to slightly and momentarily restrain.
This can aid lymph drainage and reduce swelling to assist with reduction of pain (Bockstahler et al., 2004). It can be easier to accept in this environment than hands-on massage out of the water and occurs during the course of the session and in conjunction with other techniques used. Reduction of swelling and oedema relieves pain.
This is created whenever a body moves through water so is created by the patient themselves and by the therapist. It can be utilised to improve balance and strength during later stages of rehabilitation to further improve the patient’s balance and core stability (Bockstahler et al., 2004).
Inflammation is a cause of pain and although a legitimate and useful response to injury by the body, if left to go on beyond the usual timescale for healing, it can continue to cause pain as it becomes chronic and delays healing. Oedema and swelling can cause the interruption of nerves and circulation and cause pain. Muscle spasm also causes pain which can cause a reduction of use of one or more areas of the body leading to muscle atrophy and strain in other areas, causing further pain. Shortened fascia and connective tissue ischemia can also cause pain. Chronic pain from osteoarthritis can result in stiffness and muscle spasm also causing further pain and immobility.
Heat causes vasodilation and an increase in metabolic activity which creates a demand for oxygen and increases circulation to the area. This results in an increase in nutrient and oxygen delivery and waste removal (Porter, 1998). It also facilitates the arrival of antibodies to the site (McGowan, 2007) and so helps optimise the repair process.
Stimulation of thermoreceptors and blood flow causes pain relief via gate control activation and reduction of nociceptor activity (Bockstahler 2004). Increased nerve impulse conduction velocity means heat messages travel faster to the brain and block pain messages which can raise the threshold of sensory nerve endings to provide long term pain relief. (Porter, 1998).
Combined heat and exercise are more beneficial together (Porter, 1998). Warming tissues before exercise and range of motion exercises increases the extensibility of connective tissue, especially in the joint capsule (Porter, 1998) and also reduces synovial fluid viscosity within the joint (Porter, 1998). The temperature must be raised by 3 degrees C to be effective (Bockstahler, 2004).
During hydrotherapy, animals are immersed in water heated to 30 degrees which, even when just standing, surrounds the distal joints and some of the sternal area. Using the warm water from the pre-session or post-session shower in a certain way on particular areas of concern is a way of including another heat treatment. This means heat treatments can be applied to multiple areas during the treatment almost effortlessly and can increase the efficacy of other treatment techniques use during the treatment time.
Performing range of motion techniques in the water is more achievable as the animal is better able to allow limbs to be lifted and moved as they are already supported by the water and by the therapist. Along with the heat and buoyancy, work on those limbs can facilitate an extension of range to joints which then also increases joint health (Bockstahler et al., 2004). Tissues soften which also facilitates the use of myofascial release techniques which gives even greater freedom of movement. Underwater massage units can add a further aspect of treatment to mobilise soft tissues, soften fibrous tissue and bring about pain relief.
The hydrotherapy pool or treadmill is a proprioceptively enriched environment where the patient actively engages both physically and consciously with their own actions and movement. Slow, repetitive, consciously mediated movement sequences improve proprioception (McGowen et al., 2008). This enables learning to take place of new sequences rather than sudden protective actions which are reflexive and not consciously mediated. Immersion in warm water during hydrotherapy allows utilisation of the properties of water to facilitate effective movement patterning, movement shaping and sequencing. This is coupled with free movement in the water in a smooth, organised and thoughtful way to dynamically utilise all the proprioceptive information the nervous system has just received using targeted movement sequences to build on that information and incorporate new possibilities it has promoted.
Additional proprioceptive input can be added vis the showering session pre-and post-pool work. Directing the water from the shower to targeted areas to ease soreness or activate muscle groups means this is part of the treatment session. Movement shaping as the dog moves from space to space within the centre and up and down the ramps to enter and exit the pool slows the dog down and enables them to organise their movement. The exit ramp from the pool is particularly important as it allows a crossover of all the proprioceptive information gained and used to move well in the water to that of then using the limbs more effectively on land without the aid of support from the water. Organised and careful movement descending the ramp makes use of the new skills learned and puts them into practice in real-life movement.
An optimally functioning proprioceptive system can prevent injury by ensuring good balance, co-ordination and movement sequencing. It is important to allow any dog in any situation to move and function as safely, efficiently and with as low risk as possible as this reduces the risk of injury and therefore pain. This can combat the impaired joint position sense that occurs after injury or during degenerative conditions, causing a further ongoing risk of injury (McGowen et al., 2008).
Hydrotherapy can cause a release of endorphins, which then interact with the opiate receptors in the brain to reduce the perception of pain and create feelings of pleasure. TTouch bodywork can help to calm an animal, which makes the experience more enjoyable and productive. It can also give sensory awareness to specific areas of the body to interrupt poor habitual patterns and make way for new more functional patterns of movement to be learned and practiced. Therapeutic handling also helps to contain and direct the animal gently and calmly to reduce stress and risk of injury from a patient panicking or becoming overwhelmed.
Exercises in water can assist with pain relief as they improve function and reduce the risk of injury. A sit to stand exercise in water is easier to achieve than on land so it allows those muscle groups to be used fully and strengthened where they may not be otherwise.
The water is a perfect place to improve both static and dynamic balance. It is an unstable environment and so challenges the patient to retain their balance. By assisting the patient with techniques such as rhythmic stabilisation exercises it is possible to educate the patient to correct balance and also improve core strength to assist even further with balance, strength and good quality movement.
Cardiovascular fitness can be increased in the pool which enables the patient to be mobile for longer and be physically stronger and eccentric loading on exiting the pool via the ramp helps with strengthening, as does a land-based exercise plan for the owner to do at home.
Increased strength and stability all help to reduce the risk of injury and therefore prevent pain (Bockstahler et al., 2004).
A hydrotherapist can advise an owner on ways to improve and modify the home environment and daily activities to further reduce the risk of injury and preserve and improve function. These further preserve good function for longer. Advice on nutraceuticals and other therapies can give owners direction towards other therapies that may help.
Becker, B. E. MD, MS. (2009). Aquatic therapy: Scientific foundations and clinical rehabilitation applications. American Academy of Physical Medicine and Rehabilitation Vol 1: 859-872.
Bockstahler, B., Levine, D. and Millis, D. (2004). Essential Facts of Physiotherapy in Dogs and Cats. Rehabilitation and Pain Management. BE Vet Verlag, Germany.
Bromiley, M.W. (1991). Physiotherapy in Veterinary Medicine. Blackwell Publishing, Oxford.
Corti, L. DVM, DACVS, CCRP. (2014). Nonpharmaceutical Approaches to Pain Management. Topics in Companion Animal Medicine. 29: 24-2826.
McGowan, C., Goff, L. and Stubbs, N. (2007). Animal Physiotherapy. Assessment, Treatment and Rehabilitation of Animals. Blackwell Publishing, Oxford.
Porter, M. (1998). The New Equine Sports Therapy. The Blood-Horse Inc.,Lexington.
Julie Moss BSc. Hons., AdvCertVPhys, Dip.APhys.
Julie is a canine behaviourist, veterinary physiotherapist and TTouch Practitioner. She started Best Behaviour in 2005, which has since become part of her business, Canine Mind and Body Balance. She has a special interest in integrative veterinary care, where CAM therapies play an important role in truly holistic animal care. Her passion is working with older animals to give them back the best quality of life possible and she is committed to education and enabling people to recognise early signs of lameness in our dogs.
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