KNOWLEDGE SUMMARY

Keywords: CANINE; DOGS; INTERVERTEBRAL DISC DISEASE; IVDD; INTERVERTEBRAL DISC EXTRUSION; IVDE; INTERVERTEBRAL DISC HERNIATION; IVDH; PASSIVE RANGE OF MOTION; PROM; RECOVERY TIME; REHABILITATION

Do passive range of motion exercises lead to quicker postsurgical recovery of canine IVDD?

Alexander Wallace, BSc (Hons) BVetMed Student ^1*

¹ The Royal Veterinary College – Camden Campus, 4 Royal College Street, London, NW1 0TU
* Corresponding author email: awallace21@rvc.ac.uk

Vol 8, Issue 4 (2023)
Submitted 09 Jan 2023; published: 15 Nov 2023; next review: 27 Aug 2025
DOI: https://doi.org/10.18849/ve.v8i4.670

PICO question

In canine patients recovering from surgery for intervertebral disc disease, do passive range of motion exercises, compared to no intervention, lead to a shorter or faster rate of recovery?

Clinical bottom line

Category of research

Treatment.

Number and type of study designs reviewed

Five studies (two randomised controlled trials, two retrospective cohort studies and one retrospective case series) were critically appraised.

Strength of evidence

Weak.

Outcomes reported

There is no evidence that passive range of motion (PROM) exercises are associated with a quicker postsurgical recovery in the canine intervertebral disc disease (IVDD) patient.

Conclusion

There is a lack of evidence about specific rehabilitation techniques for the postoperative canine IVDD patient. Based on the current data, a multimodal approach, including basic and intense rehabilitation techniques is suggested.

How to apply this evidence in practice

The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.

Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Clinical scenario

You are presented with a canine patient after they have had decompression surgery for intervertebral disc disease (IVDD) and consider which type of rehabilitation techniques to recommend. An advanced technique may be chosen based on the severity of injury, the equipment available, and owner financial constraints. However, regardless of which, if any, advanced technique is chosen, a basic technique such as passive range of motion exercises should be included in the patient’s rehabilitation plan.

The evidence

Five studies (two randomised controlled trials, two retrospective cohort studies, and one retrospective case series) were included in this Knowledge Summary. Three studies investigated the effects of basic rehabilitation, including but not limited to passive range of motion (PROM) exercises. However, none of these investigated the effects of PROM exercises alone on recovery. Instead, PROM exercises were one of many basic rehabilitation techniques included in the recovery plan. Two studies compared intense and basic rehabilitation programs and highlighted areas of future investigation. The overall strength of evidence is weak.

Summary of the evidence

Bennaim et al. (2017)

 

Ruddle et al. (2006)

 

Jeong et al. (2019)

 

Zidan et al. (2018)

 

Hodgson et al. (2017)

 

Appraisal, application and reflection

Introduction

The goal of this Knowledge Summary was to investigate if in canine patients recovering from surgery for intervertebral disc disease (IVDD), does the implementation of passive range of motion (PROM) exercises, compared to not implementing PROM exercises, lead to a quicker recovery?

Five studies (two randomised controlled trials, two retrospective cohort studies, and one retrospective case series) were critically appraised to investigate this PICO question. No study was found that directly investigated this PICO question. Two studies (Bennaim et al., 2017; and Ruddle et al., 2006) indirectly investigated this PICO question. One study (Jeong et al., 2019) investigated a similar PICO question but included additional variables. The final two studies (Zidan et al., 2018; and Hodgson et al., 2017) investigated a similar PICO question about the effects of intense rehabilitation therapies. While the lack of directly relevant studies weakens the level of evidence of this Knowledge Summary, it can serve to attract future research.

Basic rehabilitation is defined as PROM exercises, cold pack application, assisted, leash, or ground treadmill walking. Intense rehabilitation types included photobiomodulation, under water treadmill training, and neuromuscular electrostimulation. Additionally, this report defined recovery as when patients were able to walk independently, also known as ambulation. Exclusion criteria included review papers, lack of prior spinal decompression surgery, and inclusion of patients with comorbidities such as diabetes and myelomalacia.

A level of evidence system (Elsevier Author Services) was used to value each critically appraised paper. Level 1 consisted only of randomised controlled trials. Level 2 consisted of non-randomised controlled trials. Level 3 consisted of retrospective cohort studies. Level 4 consisted of case series.

Effect of basic rehabilitation alone on the postoperative canine IVDD patient

One study (Bennaim et al., 2017) investigated the effect of basic rehabilitation alone on the postoperative canine IVDD patient. They found there was no significant difference in time to ambulation or recovery rate between groups that received basic rehabilitation and groups that did not. They had a level 1 evidentiary value. These findings were consistent with another study that investigated the effects of basic rehabilitation on the non-surgical canine IVDE patient (Jadeson et al.,1961). Bennaim et al. (2017) additionally reported no adverse effects likely due to rehabilitation.

Caveats were identified. No research study was found that investigated PROM exercises alone on the postoperative canine IVDD patient. Rather the study above compared the effects basic rehabilitation programs including but not limited to PROM, cold pack application, balancing and standing exercises. A common caveat of retrospective studies, including three of the five appraised (Ruddle et al., 2006; Jeong et al., 2019; and Hodgson et al., 2017), was that the patients with more severe injuries were more likely to receive intense rehabilitation.

Additional information on the effect of intense rehabilitation

Two studies (Jeong et al., 2019; and Ruddle et al., 2006) investigated the effect of both basic and intense rehabilitation compared to no rehabilitation on the postoperative canine IVDD patient. Jeong et al. (2019) found a significant difference in recovery rate but not time to recovery. They had a level 3 evidentiary value. Ruddle et al. (2017) found no significant difference in recovery rate or time. They had a level 4 evidentiary value.

Caveats were identified. One was that Jeong et al. (2019) did not isolate PROM exercises. Additionally, this study incorporated passive standing exercise instead of traditional PROM exercises, such as simple flexion and extension by a physiotherapist, which some may not consider PROM exercises.

The inclusion of an additional variable, intense rehabilitation, does not allow us to isolate whether it was the intense or basic rehabilitation that is associated with improved recovery rate. Additionally, this study highlights the effects of intense rehabilitation, such as aquatic treadmill training, on the postoperative canine IVDD patients should be further investigated.

Table 1: Time to reach ambulation in no rehabilitation group and intense and a basic rehabilitation group (Jeong et al., 2019)

Two studies (Zidan et al., 2018; and Hodgson et al., 2017) compared the effect of both intense and basic rehabilitation to basic rehabilitation alone on the postoperative canine IVDD patient. Zidan et al. (2018) found no significance in recovery time or rate. This study had a level 2 evidentiary value and was not consistent with other studies. Hodgson et al. (2017) found a significant improvement in recovery rate but a decrease in time to recovery in those receiving intense and basic rehabilitation compared to basic rehabilitation alone. This study had a level 3 evidentiary value and was consistent with another study of intense rehabilitation (Bruno et al., 2020).

Caveats were identified. First, neither study isolated PROM exercises. Second, in Hodgson et al. (2017) patients with more severe clinical signs were more likely to receive intense rehabilitation.

Table 2: Summary of critically appraised papers

Conclusion

Of the five papers critically appraised, only two (Bennaim et al., 2017; and Ruddle et al., 2006) investigated the effects of basic rehabilitation, including but not limited to passive range of motion (PROM), exercises, on recovery time and rate. Both papers concluded that there was no significant difference in recovery time or rate between patients that completed PROM exercises and those that did not. The findings of Bennaim et al. (2017) were consistent with another study that investigated the effects of basic rehabilitation on the non-surgical canine intervertebral disc disease, IVDD, patient (Jadeson et al.,1961).

Of the five papers, only Jeong et al. (2019) concluded that PROM exercises in combination with other basic and intense rehabilitation techniques was effective in improving recovery rate. None of the five papers concluded that rehabilitation, intense or basic, improved recovery time.

Unfortunately, there is a lack of research on specific basic rehabilitation techniques for the postoperative canine IVDD patient. Of the papers available, two suggested that basic rehabilitation helps the non-surgical IVDD patient (Jadeson, 1961; and Sikes, 1989). Another paper suggested that only time from onset of clinical signs to surgery and severity of injury affects recovery time. Additionally, this paper suggested that more severely injured patients had a greater chance of recovery through basic rehabilitation (Immekeppel et al., 2021).

Rehabilitation has long been incorporated into human medicine, but only recently has it become common in veterinary medicine. Prior to this, the research on basic rehabilitation had been done primarily on humans and laboratory animals. By the time basic rehabilitation was incorporated into veterinary medicine, researchers were ready to investigate more intense techniques such as photobiomodulation and underwater treadmill training. One study found that electroacupuncture use in the postoperative IVDD patient was associated with a faster recovery time (Hayashi at el., 2007). Other studies have found conflicting results on the effect of photobiomodultion on rate of recovery (Bennaim et al., 2017; and Bruno et al., 2020).

None of the appraised papers reported increased rates of adverse effects. Additionally, Hodgson et al. (2017) reported a significantly (P = 0.03) lower complication rate, 16% (14/87) compared to 29% (47/161), in dogs that received a post-hospitalisation rehabilitation program. Common adverse effects of spinal injury are myelomalacia, a fatal softening of the spinal cord, gastrointestinal distress, and euthanasia due to lack of improvement.

There is contradictory evidence on the effectiveness of PROM exercises, basic rehabilitation, and intense rehabilitation on recovery time for the postoperative canine IVDD. In a 2015 survey, 64% (103/181) of surgeons and 46% (46/105) neurologists routinely recommend some form of rehabilitation. Additionally, neurological status, financial restrictions, and patient body condition were identified as common factors (Moore et al., 2016). Possibly due to a lack of supported rehabilitation techniques, a multimodal approach is commonly chosen. This combination is safe and potentially improves the chance of recovery.

A cross-sectional investigation concluded that in humans with spinal cord injuries, more physical exercise was associated with a higher quality of life (Stevens et al., 2008). If we apply these findings to canine IVDD patients, then providing physical exercise is a necessity for veterinarians.

To summarise, current evidence does not suggest that in patients recovering from surgery for IVDD, PROM exercises lead to a quicker recovery. The strength of evidence is weak as many studies did not isolate and investigate PROM exercises. Instead, they investigated PROM exercises in a combination of other basic or intensive therapies. Additionally, many studies were retrospective. No basic rehabilitation technique has been isolated to affect recovery time. Instead, a multimodal approach to rehabilitation may be important to treating the postoperative canine IVDD patient.

Methodology

Search strategy

 

Exclusion / inclusion criteria

 

Search outcome

 

ORCiD

Alexander Wallace: https://orcid.org/0000-0002-2894-1262

Conflict of interest

The author declares no conflicts of interest.

References

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2. Bruno, E., Canal, S., Antonucci, M., Bernardini, M., Balducci, F., Musella, V., Mussoni, M. & Spinella, G. (2020). Perilesional photobiomodulation therapy and physical rehabilitation in post-operative recovery of dogs surgically treated for thoracolumbar disk extrusion. BMC Veterinary Research. 16(120). DOI: https://doi.org/10.1186/s12917-020-02333-3
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