Using a phased progression approach
by Alan Gardner PgD A. Phys, MDip, DipMgmt, IAAT
Physiotherapy is often referred to as ‘treatment by physical methods such as electro / thermal modalities, massage, manual manipulation and exercise’. It can be employed for post-surgical rehabilitation, as a conservative treatment or to aid the canine patient to return to performance based activities.
This article focuses on non-aquatic  exercise programs which are typically employed in
1. The later stages of rehabilitation following recovery from surgical intervention. For post-operative cases, the protocols laid out by Bockstahler et al (2004)  indicate that the time to start initial therapeutic foundation exercises in the canine patient may begin some 3 weeks post-operation
2. As part of the strengthening following a soft tissue injury where active exercises can be introduced during the final stages of tissue healing. 
3. As a conservative treatment.
A feature of exercise programs is that they can be continued daily by the patient’s owner at home, therefore optimising the treatment program. Physiopedia  reports that Home Exercise Programs (HEP) are one of the most fundamental and important aspects of physiotherapy and patients who adhere to their exercises are significantly better at achieving their goals” and demonstrate a greater increase in physical function.
To facilitate this, each client that I work with receives access to Canine Exercise Solutions  online exercise portal. This allows us to tailor and update a specific program following each consultation and review. Of course, like any physiotherapy program, there is no ‘cookie cutter’ approach and each case will be unique and the advice of the animals’ veterinarian must be followed before commencing any active exercise program.
Goals and phasing of therapeutic exercises
Basic rules of exercise include: 
- Use it or lose it
- Individualise the program
- Vary routine – avoid adaptation
- The overload principle
- Patient guides program intensity increases
Gross Saunders (2007) describes the goals of therapeutic exercises to include the improvement of:
Which ultimately helps with daily life, preventing re-injury and if an athletic dog, enhance performance. Table 1 compares how we might implement and interpret outcomes to each of these improvements.
These improvements can be broken into phases. Although each phase will overlap, it helps to work out exercise progression. Initially the practitioner can propose gait and floor based exercises to encourage use of all limbs. They can then move to working on the core and stabilising muscles , active ROM  before focusing on strengthening the main extensor muscles using methods based on increasing resistance . Having a phased plan to an exercise program also helps the practitioner meet the basic rules outlined above:
- It targets the muscles that need improving
- Exercises will be tailored for the patient
- The phases add variety
- Each stage builds on the last
- The practitioner can decide if the patient is ready to move on
- The program is guided by the longterm goal
Common conditions in canine rehabilitation 
There are certain conditions that appear regularly in a canine physiotherapists workload. These are outlined in table 2. The phased based approach to designing an exercise program can be applied to each condition and examples are discussed below. Whenever starting a new exercise program, the practitioner should always consider that each individual case is unique. Therefore, this approach is proposed as an open template, facilitating the design and implementation a program of based on:
- Case specifics
- Therapists knowledge of canine exercises
- Equipment availability
- Owner compliance
To demonstrate an exercise based rehabilitation program using a phased progression approach I will use case studies based on THR, FCE and an iliopsoas strain which represent different approaches from the beginning namely:
- THR case was initially unable to walk unassisted
- FCE case could stand for a limited time unassisted
- Iliopsoas case had weight bearing lameness and over-abduction of corresponding rear limb
The primary aim during the exercise process is to continue the increase in muscle strength and joint flexibility with quality over quantity being a crucial factor  . In each case they had received or were receiving the appropriate treatment with electrophysical agents, massage, ROM and stretching, as applicable. Exercise being a complementary treatment to restore movement and tissue strength.
Greater strength may be required to perform active ROM compared to normal ambulation
The use of physiotherapy is becoming more widespread for the treatment of soft tissue injuries, as a possible conservative treatment for orthopaedic conditions and for post-surgery rehabilitation. An important modality in physiotherapy programs is tailored exercise programs of which Home Exercise Programs (HEP) are used between face to face consultations.
A phased program helps the practitioner design and the owner carry out a targeted HEP, stimulating both progression and variety to aid completion of the program and successful outcome. To demonstrate this, we introduced and described 3 cases based on Total hip replacement (THR), Fibrocartilaginous Embolism (FCE) and an Iliopsoas strain. These represented very different starting points and exercise needs. For each case examples were given of a phased program starting with improving limb use, recuperation of proprioception / balance, progressing joint ROM and building muscle strength.
Case 1 - THR
The owners of the THR case that I had in mind when preparing this article didn’t think of the sling stage as physiotherapy or rehabilitation, but a physical necessity. The dog in question weighed more than 50 kgs and some 5 times a day, 2 people had to physically walk help him get up and out to ‘do his business’. I explained that this was a critical stage in him ‘re-learning’ to walk and that once we could see independent rear limb movement, we could progress this to phase 2, stimulating his proprioceptive reactions.
The size, as well as the condition of our patient dictated what exercises we might chose in phase 2. Any potential fall could potentially damage the hip and result in a complete new operation. So, we chose to use a ‘football ladder’ which is essentially very small dimeter poles held together by fabric to prevent movement of the rails. This meant:
- The owners could assist
- We could do the exercise in the home on soft carpet
- Our patient could work out for himself deliberate picking up and placing down of all limbs.
As the dog gained the ability to walk without assistance, we raised the height of the poles to hock height in preparation for increasing hip extension. With the weight of the dog a major factor, we decided to have his front legs resting on a peanut ball. Making small forward and backward movements we could achieve some of the advantages of dancing, namely encouraging active hip extension.
Finally, we could introduce some strengthening work including ‘round and round’ exercise. This involves raising the front limbs onto a balance disc and then encouraging the dog to step side wards using just rear limbs and therefore engaging adductor and abductor muscles.
Case 2 - FCE
Case 2 was a medium sized terrier breed weighing around 12 kgs. Although there was some pain / reflex sensation in the rear limb, the ability to stand and walk was very limited.
In addition to sling walking, with an appropriately sized canine specific inflatable to support body weight. This allowed us to position the dog’s limbs in their natural position and therefore provide assisted weight bearing. The exercised was progressed by gradually;
- Increasing time of standing to 30 seconds with no noticeable fatigue
- Decreasing the pressure in the inflatable, therefore reducing level of support
When the dog could support its own body weight we could further progress this by slowly applying pressure to the dog’s flank inducing a muscular contraction to remain upright. At first this exercise is performed on hard ground and then gradually increasing to uneven surface (i.e. gym mat) and then to a low inflatable. Concurrently we could move to phase 3 as the dog gained core muscle strength and encourage. This involved weaving in and out of cones to further develop use of the spinal muscles.
Our final phase involved controlled stair climbing. At first, about a month after first seeing the patient, we just climbed 2 stairs. Then progressed it each day for a step at a time until the dog could manage the whole flight using each limb in turn.
Case 3 - Iliopsoas
Case 3 differed from the previous 2 in that the dog showed no visible signs of lameness in a normal walk, but over abduction of the rear limb when walking at 2.5 kph on a treadmill. This would also correspond to a weight shift to the opposite side during limb retraction. So, phase 1 involved using the treadmill encourage even limb use by loosely tying a theraband around the waist of the dog which has the effect of correcting the tracking. This is continued until there is noticeably less ‘leaning’ into the band.
Phase 2 was targeted at improving balance on all fours and is an ideal home exercise. . The dog is encouraged to hold a 4-legged stance on a balance discs or FITbone for up to 30 seconds without shifting weight off the affected limb. Weight shifting and head movements are added to increase the level of difficulty.
With the dog used to standing on inflatable equipment, we can then introduce the next stage of active improvement of ROM. This involves having (alternatively) the front limbs and then the rear limbs raised and using a treat to encourage the dog to extend shoulder / hip joint respectively. The aim is for the dog to engage the stretch for 30 secs, with a full session of 3 repetitions per set.
Finally, we can introduce some power work to strengthen the rear limb and hip flexor muscles. By having the dog place front limbs on a peanut ball, we can use a treat to move him from sit to stand to sit (1 repetition). This can be equated to human ‘squats’. The exercise can be varied between slow (2 – 4 seconds per repetition) to fast with a repetition per second.
 Aquatic therapies such as swimming and water based treadmill are complementary therapies to most physiotherapy and I often work alongside hydrotherapy with my cases. However, for this article it is to demonstrate the use of ‘land’ exercises with a focus on home based treatments to supplement in practice consultations.
 Bockstahler, B., Levine, D., Millis, D. (2004) Essential facts of physiotherapy. Babenhausen, Germany.
 Cameron, M. (2003) Physical agents in rehabilitation. Elsevier science. Missouri, USA.
 https://www.physio-pedia.com/Adherence_to_Home_Exercise_ Programs [accessed 5th April 2018]
 *https://www.verywellfit.com/the-6-scientific-rules-you-must-followtoget-fit-3120111 [accessed 5th April 2018]
 Gross Saunders, D. (2007) Therapeutic Exercise, Topics in companion animal medicine, Volume 22, Issue 4, Pages 155–159, DOI: https://doi. org/10.1053/j.ctsap.2007.09.003 http://www.companimalmed.com/ article/S1096-2867(07)00074-6/fulltext [Accessed 2nd April 2018]
 https://www.health.harvard.edu/healthbeat/the-real-world-benefitsofstrengthening-your-core [Accessed 2nd April 2018]
 Millis, D.L, Levine, D. & Taylor, R. (2004) Canine Rehabilitation and Physical Therapy, Saunders, Missouri USA
 Kristensen, J. Franklyn-Miller, A. Resistance training in musculoskeletal rehabilitation: a systematic review. Br J Sports Med 2012;46:719–726. doi:10.1136/bjsports79376
 The remainder of this article focuses on therapeutic exercises and assumes that the examples given have already received or are receiving appropriate electro-physical, massage or manual therapies.
 Gardner, A. Lyons, B (2016) Canine Groin Muscles Rehabilitation http:// www.animaltherapymedia.co.uk/winter2016/#/46
 There is a temptation to push them too fast and miss the type 1/slow twitch muscle action, so attention is given to correct form
Canine Exercise Solutions provides an essential clinical tool for physio and other therapists. The online program is used to create home exercises programs and informative advice for their clients. Advantages include HD videos of each exercise which are accessible on any kind of device. New exercises can be created on demand.