By Robin Downing, DVM, MS, DBe, DAAPM, DACVSMR

It is well known that physical rehabilitation is a critical component of optimal recovery from several commonly performed surgeries in veterinary medicine. These procedures include:

• Fracture repair
• Tibial Plateau Leveling Osteotomy (TPLO), tibial tuberosity advancement (TTA), or extracapsular repair (torn CCL)
• Tibial Tuberosity Transposition (TTT) for medial luxating patella
• Fractured medial coronoid process (or other elbow surgery)
• Intervertebral disc disease (IVDD) surgery
• Amputation (altered biomechanics)

It is also well known that, in IVDD, there is a population of patients who, with physical medicine interventions (including physical rehabilitation) may be able to avoid surgery altogether. Likewise, obese patients can achieve more effective weight normalization with the controlled exercise and strength work of physical rehabilitation. Finally, patients with chronic osteoarthritis (OA) can achieve improved function and mobility with—you guessed it!—physical rehabilitation.

Every physical rehabilitation specialist has a rich and deep toolbox from which to choose, for the benefit of patients, to improve functional outcomes, no matter the wide variety of patient presentations. The practitioner can create a very rich palette of both in-clinic and home-based work, tailored to the individual patient and pet owner. In fact, the need to personalize the rehabilitation plan cannot be overstated, as homework taking place between in-clinic sessions is critical to success.

If the client and pet cannot accomplish what is assigned, frustration and failure are inevitable. That said, the obligation of the rehabilitator is to optimize outcomes, which means prioritizing comfort as well as function. Prioritizing comfort is enhanced by considering the bioethical implications of treatment beyond the physiology of pain. We must remember most dogs will do whatever we ask of them, no matter if they are compromised by pain. As such, we need to be mindful of what we ask them to do. Many dogs will work their physical rehabilitation, despite their pain, and this is ethically unacceptable, as well as physically counter-productive.

So, what are we to do?

Clinical bioethics, pain, and physical rehab

Before any rehabilitation plan is created, the practitioner must identify pain, break the maladaptive pain cycle, and create a balanced multi-modal pain management strategy (which may actually overlap with the formal rehabilitation program).

In exploring a menu of options with which to build a comprehensive multi-modal pain management plan, it is important to consider why we must look beyond the mere physiology of the pain experience to appreciate the ethical implications of treating these patients.

Clinical bioethics offers four foundational principles that provide context and guidance to support a comprehensive approach to pre-rehabilitation pain management. These are (in no particular order of priority):

• Respect for autonomy
• Non-maleficence
• Beneficence
• Fairness (derived from the principle of justice)

Respect for autonomy means respecting patient preferences as much as is practical. It is reasonable to presume our patients prefer not to hurt, which reinforces our need to tackle pain management first and physical rehabilitation second. Respecting patient preferences also underlies our need to engage them in their own care, understanding how best to approach and handle them. This is at the heart of Fear Free practice. Finally, respecting patient autonomy means teaching them how to participate in their rehabilitation, both in-clinic and at home.

Non-maleficence means to avoid harm. Initiating physical rehabilitation in the face of pain exacerbates that pain, causing unnecessary harm/suffering to the patient by amplifying their pain experience, potentially making their pain more difficult to control.

Beneficence focuses on “doing good” on behalf of the patient. This principle undergirds our imperative actively to get pain under control before we start formal physical rehabilitation in order to achieve the very best outcomes.

Lastly, the bioethical principle of fairness means approaching each patient with equal concern—as in, treating like patients alike. It is reasonable to presume any patient presenting for physical rehabilitation is dealing with pain. Applying a fairness principle means starting with a careful pain assessment for every one of these patients, and following up with a multi-modal pain management plan. When we look for pain in these patients, we find it.

Pain management choices

Parallel to considering the bioethics of identifying pain in our physical rehabilitation patients, how do we leverage our understanding of the complex pathophysiology of pain?

Best practices mandate creating a multi-modal approach. This means addressing inflammation (e.g. non-steroidal anti-inflammatory drugs [NSAIDs]), addressing the nerve component of their pain (e.g. gabapentin), providing pharmacologic support of cartilage (e.g. polysulfated glycosaminoglycan [PSGAG])/Adequan), and providing nutraceuticals that can assist with decreasing inflammation, as well as offering joint structural support (follow the evidence).

Additionally, physical medicine pain management techniques like photobiomodulation (PBM) therapy, targeted Pulsed Electro Magnetic Field (tPEMF) therapy, medical acupuncture, and extracorporeal shockwave therapy (ESWT) can contribute to the pain management protocol.

These patients need to be evaluated frequently in order to modify medication doses and to identify when physical rehabilitation can begin in earnest. Once the pet’s pain is well managed, it is time to shift the focus to building strength and improving function. All patients benefit from both in-clinic and in-home rehabilitation activities. Here is where the overlap between rehabilitation and physical medicine pain management techniques happens. It is critical to create appropriate client expectations to help pet owners understand there is no quick fix here.

Once the patient has achieved their optimal outcome and is ready to “graduate” from physical rehabilitation, the pain management protocol can often be modified to the lowest effective doses, or even potentially discontinued. We must understand a fair number of pets for whom physical rehabilitation is appropriate have underlying structural issues that can benefit from long-term management. These are patients who may do best with periodic rehabilitation “tune-ups,” ongoing nutritional/nutraceutical support, and (possibly) pharmaceuticals.

Final thoughts

Both physiology and bioethics provide context for approaching our patients who can benefit from physical rehabilitation, guiding us to focus on pain relief first, laying the foundation for more effective physical rehabilitation, and even better outcomes. All parties benefit from this approach. The veterinary healthcare team enjoys higher job satisfaction. Pet owners benefit from a strengthened human-animal bond. Most importantly, pets enjoy the restoration of both comfort and function. When these pets are viewed through a wider lens that marries physiology with bioethics, they receive the very best veterinary medicine has to offer.

Robin Downing, DVM, MS (Bioethics), DBe, DAAPM DACVSMR, CVPP, CCRP, is hospital director of The Downing Center for Animal Pain Management. She has received many regional, national, and international awards, including the American Veterinary Medical Association’s (AVMA’s) Leo K. Bustad Companion Veterinarian of the Year in 2020 and the Excellence in Veterinary Medicine Award in 2001 from the World Small Animal Veterinary Association (WSAVA). Dr. Downing is an internationally sought-after speaker on topics such as pain management, physical rehabilitation, physical medicine, hospice/end-of-life care, and overcoming compliance obstacles/issues in veterinary medicine. After completing her Master of Science in clinical bioethics in 2016, Downing graduated with her Doctorate in bioethics in 2022.