Veterinary Vertex
Veterinary Vertex is an SSP EPIC Award–winning weekly podcast that takes you behind the scenes of the latest clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Each episode explores cutting-edge advancements in veterinary medicine, offering expert insight you won’t find anywhere else. Tune in to gain practical knowledge you can apply in your own practice—along with fresh inspiration to reconnect with what you love about veterinary medicine.
Veterinary Vertex
From Diagnosis to Recovery: Equine and Canine Rehabilitation
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Rehabilitation isn’t a luxury line item at the end of a case anymore. It’s becoming the difference between “we fixed the lesion” and “this patient truly returns to function.” We’re joined by Drs. Heidi Reesink, Denise Marcellin-Little, and David Levine to unpack a first-of-its-kind JAVMA rehabilitation Technical Tutorial Video supplemental issue and what it signals about where veterinary rehabilitation and physical therapy are headed.
We talk honestly about what makes rehabilitation challenging and exciting in real clinical practice: plans that look totally different for dogs, cats, and horses; chronic cases like osteoarthritis that demand long-term strategy; and the reality that owner goals, time, and cost shape what care can actually happen. You’ll hear why a multidisciplinary rehab team matters, how technicians and assistants help deliver consistent protocols, and why listening to the patient over time can be just as important as any single test.
From there we get practical and tech-forward. We dig into objective gait analysis using wearable sensors and motion capture, the stubborn underuse of goniometry despite validation, and how ultrasound-guided injections and arthroscopy support both diagnosis and treatment while enabling longitudinal monitoring. We also explore major modalities clinicians ask about every day, including shockwave therapy and underwater treadmill aquatic therapy, plus what we still need to learn to tighten protocols. Finally, we tackle orthobiologics and regenerative medicine evidence, why big studies are so hard in veterinary patients, and how video tutorials can bridge the gap between research and day-to-day rehabilitation outcomes.
If you care about better mobility, clearer measurements, and more predictable recoveries, listen now, share it with a colleague, and subscribe so you don’t miss what’s next. After you listen, leave us a rating and review and tell us: which rehabilitation tool has changed your practice most?
JAVMA editorial: https://doi.org/10.2460/javma.264.s1.s3
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Welcome And Video Issue Overview
Welcome to Epic Award-winning Veterinary Vertex Podcast, where we delve into behind-the-scene looks with manuscript authors. I'm editor-in-chief Lisa Fortier, joined by Associate Editor Sarah Wright. Today we're so excited to welcome guests, colleagues, and friends Heidi Resink, Denise Marcel Little, and David Levine to discuss the first of its kind JABMA rehabilitation technical tutorial video supplemental issue. Wow, that's a mouthful. Thank you for joining us, Heidi, Denise, and David. We're so excited to have you here today. Thank you. Thank you. Thank you very much. All right, let's jump on in.
What Rehab Looks Like Today
Veterinary rehab is described sometimes by some people as rapidly evolving yet a still maturing field. What does that actually look like in day-to-day clinical practice today? It means that we're still learning and have a lot to learn about the topic of veterinary rehabilitation, which was one of the motivating factors for this special issue. In day-to-day clinical practice, rehab is offered to dogs, cats, horses, not just in academic settings, but also in the private sector from specialty to general practice. Fundamentally, rehab is an essential part of recovery and return to function after a musculoskeletal injury or surgical procedure. And what that can look like in the complexity of rehab programs can vary based on the location, the personnel, and the underlying condition. So a rehab plan in a cat might look very different than a rehab plan in a horse. And even within equine patients, that might vary between breed discipline and injury type. Yeah, that response reminds me of Lisa's favorite phrase. Every day is a school day. So we're always learning too.
How Rehab Became A Specialty
So why has rehabilitation only recently emerged as a recognized specialty? And what gap was it filling in veterinary care? Well, I think uh, you know, when we look at rehabilitation or or as we commonly look at rehab and physical therapy on the human side, it's actually not as old a profession as people think. It really emerged more after the world wars and the need for rehabilitation of the injured. And within veterinary medicine, it has been around uh for probably 50 years in a more informal way, but it has grown significantly over that time as we've learned more. And in terms of uh a specialty, you know, it's only been recognized for about 15 years now, both for veterinary and veterinary technicians. Um I think some of the gaps it's filling are certainly in our chronic patients, patients with chronic conditions uh that are non-surgical, conditions that negatively impact limb use and locomotion or athletic performance. And then also on the surgical patients, maybe speeding recovery, optimizing function after a surgical procedure. I really like how you said that, David, as a that it's sometimes for the chronic cases too. As a surgeon, I get a bit monocular, right, that it's rehab for surgical patients. Uh some describe some of the more chronic cases that you might uh have a rehab approach to helping.
Chronic Cases And Owner Goals
Sure. I think, well, you know, our our most common chronic case would be our our osteoarthritis. We see, you know, cases of osteoarthritis, uh, whether it's elbow or hip or stifle every single day. And and I think the interesting thing about rehab is that every patient is a little different. There's not a one, you know, size fits all. We we really have to look at what does that animal need to do? Or in in designing a program with an owner, what are the real goals that they have? It might be returning to sport, or it might be just being comfortable enough to be pain-free going on a short walk. So, you know, it's um it's a very uh owner-involved type of specialty where we spend a lot of time with people to really uh come up with the optimal solution for that pet.
Building A Multidisciplinary Rehab Team
I love that. Uh the other thing I really appreciate is the articles that you three have curated for the supplemental issue really emphasize a multidisciplinary approach. Who's typically involved in a in a rehab team and why is that collaboration so critical to an optimal outcome? Well, in rehab, as Dave just mentioned, we deal with chronic and complex problems, and then we try to apply a range of solutions to these problems. So you really want somebody who has experience or expertise in understanding complex problems, in orthopedics, for example, or neurology, and you want somebody who has experience and expertise in managing these problems, and they're gonna have to draw from you know having a precise assessment. That's not always the exact same assessment from the clinical part and the therapeutic part. They want a disability-oriented assessment, that's the PT assessment. They want to leverage energy beams, electrophysical modalities, manual therapy, therapeutic exercise, uh, kind of ergonomic assistance, uh, all you know in kind of as simple and streamlined way as possible. So you're gonna often need to have two heads working together, the person understanding the problem and the person proposing a solution. It's often kind of an interaction. If you have the luxury of having expertise in both areas in one person, that's great. But often it's gonna take a mini-team to do that. Beyond that, you have a fairly time-consuming and labor-intensive approach because you are kind of balancing options, manual therapy, the energy, the exercise. And so, as you know, we're all very busy and we try to streamline care. So we're gonna try to engage with technicians and assistants, leverage the owner to a point as much as they can do. We're gonna have a technician assistant owner team that's gonna help delivering that care in the best possible way. So you that that complexity warrants having a team working together. Yeah, I like that team approach.
Making Decisions With Limited Evidence
So, in some areas, there may be some limited high-quality evidence. How do clinicians make confident decisions when the data isn't fully there? This is a great question. I think that many clinicians are not 100% confident making decisions in the absence of evidence-based recommendations, and that's okay. I think we do our best with the information that's available at the time, and that's part of the art of medicine, including veterinary medicine. We may try to weigh evidence from other species, often human patients, uh, because of some of the principles of tissue healing, condition, and training are largely universal across species, though there are some differences. And when evidence in humans or other species is not available, we may employ weaker levels of evidence, whether that's expert opinion, anecdotal information, or even some data from limited case series or case reports. But I think most importantly, um, as my colleagues have alluded to, it's really important to observe and listen to the individual patient and the feedback that you're getting from that animal, particularly longitudinal or serial information over time and incorporating that into your decision-making process. Heidi, I like how you just alluded to that, you know, sometimes we try to learn from human medicine, but that might not always work. And it might not work for the dog or the cat or the horse, and vice versa. And oftentimes veterinary medicine is leading in the area of, you know, biologics, for example, and others uh leading the human field. What are some of the risks or benefits with that approach of like trying to learn from human medicine? Yeah, I think it's important to be aware of both. So as you mentioned, Lisa, I think the veterinary field has certainly led the way with some of the orthobiologics and regenerative medicine approaches, but there are also some areas where we are really lacking a lot of data. Um, and so I think um the advantage of human medicine is that there are um in some fields more high-quality studies that have more patient numbers due simply to the resources available and the patient um the volume of the caseload. Um, so that includes things like more kind of double-blinded, placebo-controlled, randomized multi-center trials, which are kind of like the gold standard of the pyramid, um, as well as systematic reviews and guidelines. And so for some conditions, we see more of that in in humans. What I would say is on the positive side, I think that there are many parallels between certain types of injuries. A few examples of that are human Achilles tendonopathy and equine flexor tendon injuries in terms of that pathophysiology or even cruciate ligament disease in humans and dogs. Um, but as you mentioned, despite uh the conservation of a lot of these biomolecular, cellular, and tissue physiologic processes across mammals, there are some important differences. And I think we could highlight that with metabolism or bioavailability of certain therapeutics, for example. Um, but there could be potential um, you know, dangers in extrapolating from one species to another. Um, I think kind of lastly, one thing to consider in veterinary patients is how care is delivered. And it's quite different from the human model where costs are often covered by owners without third-party payers, and that can restrict access to certain um options and modalities for some clients and their patients. Oh, for sure. I actually just took my cat to her internist this morning. And every time I go, I'm like, how much is the bill gonna be this time? I love you so much. I'm like, you're what? So one of the topics that is covered, this supplemental issue, is wearable sensors.
Wearables And Motion Capture For Gait
So let's talk wearable sensors and motion capture for gate analysis. How are these changing diagnostics in real time? I think this is an extremely exciting and emerging area. Um, I'll comment on with respect to equine practice, where I think we've seen wearable sensors and video-based motion capture really have a significant impact in the last decade with likely significant future impact to come. So, whether that's from wearables that can detect changes in gait or stride to try to preempt injuries in race horses or the use of AI-based phone apps such as Slate, where these metrics are being used for pre-race or pre-competition screening, to even things like pre-purchase exams. Specifically in the cases of injury management and rehabilitation, I think these modalities can increase the accuracy and repeatability of gait asymmetry measurements. That can help improve our diagnosis following diagnostic nerve blocks and can remove some of the potential bias, conscious or unconscious, that we as veterinarians may have uh when uh coming to a diagnosis or even when evaluating the efficacy of some of our surgical and pharmaceutical interventions. Yep, that's real. Especially when we're trying to block a nasty horse. Yeah, that it worked. I'm sure it's better. And then objective, nope. Uh I'm totally guilty
Why Goniometry Still Gets Skipped
about this one. So goniometry uh is validated and there's some good information on it in your supplemental issue, uh, but it's still underused. Why isn't it more widely adopted by people like me in practice? Well, my first thought is that there is great inertia in clinical practice. I we still do a lot of things very much the same. You know, in some way, I think we have a moldable period in our training. I remember reading on the human side about human orthopedic surgeons how they mostly did procedures that they learned during their formative years, and they didn't like to shift from a type of repair, you know, a type of joint replacement this way versus that way, because they were trained one way. So people tend to change very slowly. Maybe there is a bit of a what's in it for me thoughts in the background that says I'm I'm pretty good at my orthopedic examination, and uh why would I make it more complicated? What am I gonna gain? And maybe the case has not been made very well about saying why is it critical to know what joint motion is? You know, what does that tell you about the severity of injury or treatment uh planning, for example, so we can do a better job justifying the use of goniometry. It's pretty obvious that things have to move well to function, but there is a gray zone with where joint motion is impaired, but not horribly impaired, where goniometry can be very helpful. For me, it's it's it's a critical piece of information, but that doesn't mean everybody is gonna think the same way. Also, I think the opportunities to really learn it, to feel comfortable with it are generally lacking. And that's why I'm super excited to see some of it included in this video tutorial issue, because that's a perfect medium to be showing something and letting people be exposed to it without being forced to use it, and to kind of have time to reflect and incorporate that into their practice. Yeah, we're really excited about these video manuscripts. They're, like you said, the perfect medium for techniques like that. So yep.
Ultrasound And Arthroscopy For Precision Care
So ultrasound guided injections and arthroscopy are becoming more common in companion animals. What makes these techniques valuable for both diagnosis and treatment? Ultrasonography and arthroscopy are both considered standard of care, if not gold standard, techniques for the diagnosis of soft tissue injuries and joint injuries, respectively. Uh, while MRI and volumetric imaging can offer some advantages. This often requires general anesthesia and is not as practical for longitudinal monitoring. I would say ultrasound is it's readily available as an excellent modality for charting most soft tissue injuries. Um, it can allow the longitudinal assessment following the progression of healing, and that enables the veterinary care and rehab team to make informed decisions about rehabilitation, return to exercise, and therapeutic interventions. Critically, the ultrasound guidance allows more accurate and efficacious uh targeting of injuries while also minimizing collateral or iatrogenic damage. And likewise, arthroscopy has a lot of those same benefits for intra-articular pathology. So it allows direct visualization of cartilage and certain other structures that are pretty difficult to assess with non-invasive imaging approaches. Uh, and then an added um advantage of arthroscopic approaches is that um in some cases it can be very possible to treat the injury uh at the same time as diagnosis. Thanks, Heidi. You teed me up perfectly for transition to treatment.
Shockwave Therapy Promises And Gaps
Uh so let's start with shockwave, which appears uh and is commonly used in both equine and canine cases in academia and private practice. What's the mechanism behind it and where in neck or shoulder or elbow, soft tissue, joint, where does it show the most promise? Thank you for an easy question there, Lisa. Uh no, it's uh, you know, I think if we're honest, we have to admit we don't know everything about shockwave. And and what we also fall short on sometimes is our evaluation pre- and post-treatment. Um, you know, having had the benefit of using it on humans as well, 500 plus humans, we might look at three or four objective validated measures pre and post-shockwave, follow that for the next week till the next treatment. And I think that's where we need to do a little bit better job on the veterinary side. Um, you know, shockwave is the primary mechanism is through mechaniconduction, which is really, you know, we're we're using it as a signaling for different uh cellular events to assist in healing or decreasing pain. But I I think making sure that uh we are trying to constantly uh you know push that envelope on getting better and better protocols, looking at the dosage in terms of you know millijoules per millimeter squared, being as objective as we can and looking at pain responses through validated measures, things like that pre and post. I mean, we use it on a lot of elbows, and I'm excited about the tutorial we did uh that I did with um Margaret from uh Cornell because it's uh you know it's one of those that I think you can apply to a lot of parts of the body, how we specifically look at uh at one condition, and and I think uh hopefully that will help a lot of people. So I think Shockwave has a lot of promise for a lot of different conditions. Um, I was a skeptic in the beginning and have been kind of won over. So I've been doing a bit more research into what it's really doing and long-term effects.
Underwater Treadmill Protocol Unknowns
So now we get to move on to the treatment modality that's featured on the cover of your supplemental issue, water treadmill. So, water treadmill therapy sounds intuitive, but protocols vary widely. What are the biggest unknowns clinicians are still trying to solve? Um, I'll get started with that. Maybe um, you know, water is super magical, obviously. Um, and often owners realize its power when they see how much better. If you are really impaired with your locomotion, aquatic therapy does amazing things. And it doesn't take a lot of research to you know see the transformation of a dog that can barely stand, um, which I've seen, I've seen clients burst into tears seeing their pet, uh, how well they move in an underwater treadmill. So I guess sometimes you don't really need a huge amount of research to see how transformative that is. But it's also extremely versatile, you know, like how much time do you spend in it, how much water do you need, uh, how often you're gonna do it, and what you're actually doing in the water probably needs to be worked out. So there is room for kind of tailoring aquatic therapy to specific problems, a bit like a theme we hear about. You know, we know something is really transformative, but we gotta see how it, how, and how much it is by doing some research. So, for example, uh, you know, look at the neuropatient. We can facilitate early locomotion in patients with, you know, compromised mobility. The intervertebral discarniation dog is the first that comes to mind. So, how beneficial is it to be in water early on when you are you have very impaired locomotion? What is it gonna do to your recovery? Does it change the timing of your recovery and maybe the essence of your recovery? Are you gonna do better if you recover more promptly? In athletes, how can we leverage water? You know, it's a big effort. Well, maybe that's part of training. There is a lot we can do in understanding how we can use aquatic therapy in athletic performance. Again, maybe to make the recovery safer or to boost uh fitness conditioning in athletes. Uh, maybe we can accelerate recovery. The clock is ticking for some athletes, and we want to re-accelerate the recovery. How can water do that? And so, does it maybe the softer side of aquatic therapy is that it's really energizing, it's facilitating uh care, it's maybe decreasing the burden of care. Dog can have a good session of exercise without having a ton of people involved. And so maybe that has a strong psychological impact on recovery, might be saving life to have access to water. We can also continue to understand that better and document the benefits of aquatic therapy. Dini, you just shared a pretty emotional experience watching a client break into tears. Do you have a funny story to tell too? Well, I have dogs that psychologically are puzzling me because they seem to play kind of an arm wrestling contest to see who is gonna give up first. They're refusing to walk in the underwater treadmill and they pretend to drown. And so I'm like, this is very exciting. I'm playing poker with a dog uh in the underwater treadmill. So it goes both ways. Some of them quite readily, you know, they take it with a kind of a gentle approach and they say, Oh, well, I'm walking now in water, but some others are a little bit more uh challenging, and that also is something we can learn to manage well, to say how do we incentivize or decrease the stress or facilitate it. But sometimes, sometimes it's a joyful experience, and sometimes it's like a high-stake poker game. Can you predict who the poker players are going to be? Is there a breed or an attitude? Yeah, Doberman. I hate to say it, but uh for me that's the Doberman coming. They are the best at uh with the poker face trying to grow. Well, thanks for the levity.
Orthobiologics Evidence And Study Challenges
Uh one of my passions, of course, is orthobiologics. Uh, we've been using them in humans and and veterinary medicine and much more increasing. So for OA and small animals, and they're increasingly use in tendon ligament injury. Where's the evidence to support that efficacy? Yeah, I could ask you that question as well, Lisa. I'm happy to take a stab. I have thought about this certainly recently with some of the uh tutorial videos that we were working on. And I think when you look at the entire body of evidence across all species, veterinary and humans combined, generally the take-home for a lot of these systematic reviews are really attempts to kind of synthesize all the literature is that the there is evidence. It's probably weak to moderate at best for a potential benefit of orthobiologics, particularly for soft tissue injuries. There's maybe a little more historical support. But as you mentioned, increasing scientific studies and evaluations looking at applications in OA. I think it's just another opportunity to highlight, you know, there are, these are not easy studies to perform. There are several limitations. And some of those with veterinary studies can involve the selection bias of whether an owner or particular client wants to pursue a therapy, and that could involve cost. There's recruiting sufficient patient numbers, investigator blinding. We often are lacking truly a true control or comparison population or placebo. And so I think all of these challenges are intrinsic to any study, whether that's a human or veterinary patient. But I think it's why it can be helpful to take an approach and broadly look at all of the evidence across all species. Just one thing that I took away fairly recently from a recent publication from Roger Smith and Michael Schramm's group, uh, looking at power calculations of how many horses do we have to enroll per treatment group. So picking equine flexor tendon injury as a common example where a lot of horses recover, but reinjury is the common limitation. And I think it's just important for us to be aware they they calculated a sample size of about 88 horses per treatment group in order to detect a cleaning, clinically meaningful benefit of a 50% reduction in reinjury rate. And so I think it's just important for us to be aware that that is a somewhat daunting task. Um, and that maybe one of the best ways to get there is through the combination of standardized protocols, standardizing products as much as possible, multi-center trials. And I think we're really headed in that right direction, but we we still have a ways
How Video Manuscripts Change Practice
to go. Yeah, that's a really good point. And how much, how might these uh video manuscripts bridge the gap between the research that you all are doing and everyday clinical practice? I think that's a great point. I'm happy to start off and then I can pass that on to some of my colleagues. But I think um, as mentioned previously, like whether that's with goniometry or the water treadmill videos, there are some practical aspects of rehabilitation. It's a very hands-on um modality, and sometimes that's not as easily translated from several pages of text. I think many of us, especially um in you know, modern um ages, we're spatial or spatial or visual learners, um audio learners. I think condensing that where we can visually see how other groups are doing that, that could actually be a really important first step in standardization of protocols and perhaps even facilitating some of these um higher powered, better designed multi-centered trials. Um I'm gonna build up on that by saying that these videos, they are really an opportunity to kind of show the best of a procedure. So I think that the the mindfulness of whoever is putting them together is very important. You could say, oh, I'm I'm, you know, I think goniometry is a piece of cake, but you don't really think about the details until you really are filmed. And then and somebody says, Why did you do this part, or why did you do this part? So there is a certain uh kind of a higher level of precision that's required to really share it. And also there is a self-selection of whoever is doing it generally tends to be pretty good at what they do because you don't really want to show something that you barely know, I'm thinking. So you have you know self-selected people with knowledge that are paying attention to what they are doing. And now, as it's being offered, you remove kind of the pressure to be learning on the spot if you want. You know, like people always regret that information shared with them is fleeting. They want to be um able to review it at their own pace, once again, as many times as they need. And that video is allowing them to go back to it, to think about it, to see a little piece at a time, to practice it. So it's a great format. It's well done by people who probably have some experience with the process, uh, and ends up being very
The Big Takeaway And Rehab Future
useful. So, now for our big take-home. So, this is going to be the one thing our listeners really need to know about this really special video manuscript issue. So, if you had to summarize it, how is veterinary rehabilitation reshaping outcomes for patients compared to traditional approaches alone? And maybe I can get that started. I'm thinking it's uh rehabilitation is a critical aspect of managing complex problems. I think the assessments that are performed are more precise, more comprehensive. It's not just naming a problem, it's looking at the impact of that problem. I think it accelerates the detection of complications. Uh, they get diagnosed more quickly, they can be managed more effectively. It improves communication. If you think about it, if you're more fact-based, talking about a problem more comprehensively, you're gonna have a better exchange of information with whoever is involved. People can make more better decisions, colleagues and clients, uh the same. It also, I think, decreased the burden of care because care is more structured. There is a comprehensive look of care, and you can make decisions about maybe doing a little bit more of exercise-based rehab or manual therapy-based rehab. It's adaptable to the situation and the owner and the pet. Some pets are hands-on, some pets are hands-off. So it can tailor care, but it also has a look at how much care is going to be needed rather than just sending a pet home and the owner wondering what the next steps are. And finally, I think it makes the recovery more predictable or predictably successful because there is that sustained communication, getting to know the owner, as we heard from Heidi. You know, we we we build stronger ties, we communicate more readily, we know where things are going, we assess progressions more off more often, and so we are we have a more predictable success. I think we have a really exciting future from high-level sports medicine and working dogs and horses to chronic conditions to even hospice. I mean, I think rehabilitation really affects patients at all parts of their lives. It helps the owners. Uh, I and I think the future is really going to be strong. The the college is growing quickly. And uh, you know, having just been at ACVSMR, it it's one of the more fun meetings you can go to where there's just a lot of energy. And you were just inducted as a diplomate, weren't you, David? Yes, yes. Uh thank you. Uh yeah, this past year uh as an honorary diplomate as a non-DVM, uh very big honor. But, you know, I I think, you know, in in my thank you, we still have a lot of work to do, and and the work is exciting and fun. And it's it's a great college to be a part of. And, you know, I with people like Heidi and Denny kind of leading the charge and, you know, the great research we have going on, uh, you know, there's no limit to the future. And so, you know, I'd also have to give my plug to uh the podcasts. I've watched a lot of these and they are wonderful. Uh, you know, things you might not think you want to know about, like watching a neuro exam on a guinea pig, or um, you know, AI or One Health, and some really cool stuff that that is kept kind of light and fun uh while you're on the treadmill or the elliptical or the bike or eating
Where To Watch And Final Requests
lunch. Thank you. Well, thank you, David. So, Heidi, Denise, and David, thank you so much for joining us and pioneering this video manuscript supplemental issue. Thank you. Thank you. Back to real clothes now. Almost almost there. So, for our listeners and viewers, you can watch the video supplemental issue on YouTube and our website. I'm Sarah Wright here with Lisa Fortier. Be sure to tune in next week for another episode of Veterinary Vertex. And don't forget to leave us a rating and review on Apple Podcasts wherever you listen.
