IMPORTANT

• Rehabilitation Guidelines – These are ONLY guidelines for rehabilitation protocols when using amnion-based technology, based on anecdotal case data and the current veterinary literature.
• It is critical that the veterinarian monitors the progress of healing through regular recheck exams and close communication with the owner. If uncertainty arises, consult a board-certified veterinarian in sports medicine & rehabilitation (DACVSMR) familiar with amnion regenerative products.
• Speed of rehabilitation is individually based, and programs should be designed as such with veterinarian input and based on clinical (lameness exams) imaging findings (ultrasound and/or MRI). Diagnostics such as ultrasound/radiographs can be a lagging indicator and evaluation should be more holistic or use more advanced diagnostics such as MRI.
• Echogenicity, size of lesion & cross-sectional area of the tendon, fiber pattern, the shape of the tendon (adhesions), the position of the tendon (adhesions), margination of tendon (adhesions), vascularity should be evaluated with US for healing and used in the decision of whether to proceed to the next level.
• The protocol below may have to be adjusted depending on the severity (mild, moderate, severe) of the injury and size of the lesion, involvement of additional structures, complications, and/or the rate and quality with which healing is occurring (good, fair, poor),
• If ANY heat or lameness appears, STOP, re-evaluate, return to the prior level, and advance more slowly.
• In general, for ligament injuries, add 2-4 weeks to the tendon schedule; the average timeline for return to competition for tendons 4-6 mos.; ligaments 6-8 mos.
• Please see AniMotion™ and AniMatrX™ Treatment Instructions for details on managing these types of injuries. 

Options 24-48 Hours Post-Implantation

• Passive Range of Motion (ROM) Exercises:
  • Flex and extend affected individual joints without exceeding normal ROM.
  • Follow with bicycling motion while on the side which incorporates all joints of the limb.
  • 2-3 times per day.
• Weight Shifting:
  • Gentle pushing and quick release of applied pressure stance techniques
  • 2-3 times per day.
• Active Therapeutic Exercises:
  • Slow walking (short leash and 1-3 short sessions, 5-10 minutes each); utilize veterinary orthotics as appropriate for protection of injury site.
  • Walking on a variety of surfaces (smooth/non-slip, coarse/dirt roads, short/tall grass, wooded paths with exposed roots, soft ground with slight sinking (mats, foam, dog bed cushion), soft ground with sink (sand/snow), walking on trampoline.
  • Slowly walking backwards.
  • Walking over ground poles/cavaletti rails/over extension ladder on the ground.

***NOTE: A leash walk to the potty is recommended during the rehabilitation process. Due to the anti-inflammatory properties, the product has been shown to have a “euphoria effect” and pain reduction effects that can last up to 48 hours and beyond following treatment causing the dog to feel overly happy and comfortable, risking further injury.  Avoid running, jumping, playing, stairs, jumping on/off furniture. 

Week 1-3

• Leash walking at a regular pace of 15-20 minutes twice a day.
• Continue weight-shifting physical therapy (PT) & add 3-legged stance, 2-legged stance, and diagonal limb stance techniques (be sure the dog is transitioning out of a square sit).
• Floating in a pool with a life jacket and owner support and passive ROM exercises/no swimming or underwater treadmill passive ROM exercises, proprioception/balance exercises, and 2–3-minute slow steady walk with 1 minute rest time in between; total 6 minutes; start 1-2 x/week; increase 10-15% weekly).
• Gentle massage (stroking, kneading, shaking) of support structures near the affected area before walking or in the morning and evening.
• Add backing Laser Therapy, therapeutic ultrasound, electrical stimulation, and kinesiology taping during the first 2 weeks to treat the limb with appropriate time-frame settings. 

Week 4-6

• 30-40 minutes of leash walking.
• Begin swimming in the pool with a life jacket.
• Continue with laser, therapeutic ultrasound, electrical stimulation, and add extracorporeal shockwave therapy.
• Continue PT 2 times daily as able. 

Week 7-13

• 45-60 minutes of leash walking (including light jogging) with short supervised off-leash.
• Continue PT.
• Add Sport Specific Exercises. 

Week 14-16

• Return to full mobility based on healing and veterinarian discretion of individual cases.

 ***NOTE:

• Recommendations should be individualized, especially for acute injuries and post-surgical cases. These are only guidelines and consulting Board-Certified Rehabilitation Practitioner is recommended.
• Imaging and examination rechecks at appropriate intervals to determine appropriate healing are essential.
• This is an accelerated rehabilitation protocol based on published evidence of reduced healing time with amnion and active healing for functional recovery.
  • 4-5 mos. back to work vs 4-12 mos. with BMSC vs 6-8 mos. minimum with no regenerative therapy and inferior (not collagen type I/scar tissue quality with a high probability of not returning to previous level of performance and/or high incidence of reinjury vs 4% with amnion and 23% with BMSC; 2 years post-treatment avg incidence reinjury 15%.
  • Cellular and soluble/paracrine factor impact – immunomodulation/anti-inflammatory, no NSAIDs decreased swelling and soreness with palpation/walk soon after implantation (much earlier).
  • More active (endogenous proliferative healing, i.e. chondrocytes) sonographic evolution in shorter period vs BMSC, consistently spawning efficient and better tissue quality, more consistent results.
  • Counteract inflammation at the site of injury, reduce apoptosis of chondrocytes, and neovascularization early and last longer vs ultrasonic healing and considered a key point in allowing early return to training at the previous level of activity, improved functional recovery.
  • Improved ultrasonic lesion echogenicity within 1 mos. vs other therapies; reduce lesion size/severity and prevent progression, absence of fibrotic, metaplastic, mineralized islands – safe; positive tissue healing indications only.
• These are only guidelines. Always progress at a tolerable level for the animal without inducing increased stiffness, pain, or lameness during or after exercise.
• If pain, inflammation, or lameness are detected, return to the level below until resolved and work up more slowly.

Special considerations:

CCLR

Inflammatory and Repair Phases

• Massage thigh and back muscles 2-3 times per day.
• Passive ROM exercises 2-3 times per day.
• Slow, controlled leash walking several times per day.
• Avoid exercises that require intense extension, flexion, and possible internal rotation for the first month.
• Controlled exercise/leash walking is very important.
• Avoid stretching exercises.
• Stabilization/protection of stifle crucial.
• Cautiously proceed with stabilization exercises: bouncing, and weight shifting.
• Avoid exercises where the risk of falling exists.
• Aqua therapy is extremely beneficial, time frame appropriate exercise.
• During the remodeling phase control and avoidance of jumping and playing should be avoided.
• Slowly increase the weight-bearing load.
• Exercises to strengthen hamstring muscles are important; agonistic to CCL and can help stabilize the joint.
• Exercises to strengthen the quadriceps are important.
• Organizational Phase – continue to increase weight bearing and strengthening exercises gradually (especially quadriceps and hamstrings).

IVDD

• Massage the legs and the muscles around the affected area 2-3 times per day.
• Passive ROM exercises 2-3 times per day.
• Bicycling while lying on the side and standing 2-3 times per day.
• Weight shifting and assisted standing exercises.

Fractures

• Massage back and affected limbs once daily up to 2-3 times per week.
• With stabilized fractures: Passive ROM exercises 2-3 times per day and low, controlled leash walking multiple times per day.

Osteoarthritis and Spondylosis

• Same as CCLR.

Degenerative Myelopathy

• Massage back 1-2 times per day.
• Bicycle on side and/or while standing several times per day.
• Weight shifting several times per day.
• NMES for muscle strengthening 1-2 times per day.
• Cavalettis daily.

References

1. Bockstahler B, Wittek K, Levine D, Maieri J, and Millis D. (2019). Chapters 7-28.  In B Bockstahler (Ed.).  Essential Facts of Physical Medicine, Rehabilitation and Sports Medicine in Companion Animals – First Ed. Babenhausen (ppgs109-592), Germany.  VBS GmbH.  720 ppgs.  https://vbsgroup.eu
2. Lange-Consiglio A, Tassan S, Corradetti B, Meucci A, Perego R, Bizzaro D, and Cremonesi F. (2013).  Investigating the efficacy of amnion-derived compared with bone marrow-derived mesenchymal stromal cells in equine tendon and ligament injuries.  Cytotherapy.  2013:1-10.  http://dx.doi.org/10.1016/j.jcyt.2013.03.002
3. Lange-Consiglio A, Rossi D, Tassan S, Perego R, Cremonesi f, and Parolini O. (2013).  Conditioned medium from horse amnionic membrane-derived multipotent progenitor cells:  Immunomodulatory activity in vitro and first clinical application in tendon and ligament injuries in vivo.  Stem Cells and Development.  22:3015-3024.  DOI:  1089/scd.2013.0214