Rehabilitation is a rapidly growing and emerging field in veterinary medicine. Interest in canine physical rehabilitation began in the 1980s and continued throughout the 1990s as information on the topic became increasingly available via journals, textbooks, and seminars in the veterinary and human physical therapy fields. One of the early continuing education seminars on canine rehabilitation was the International Canine Sports Medicine Symposium (originally The International Racing Greyhound Symposium), which was first held in 1986 in conjunction with the North American Veterinary Conference.1 There has been rapid growth in the number and type of athletic events for dogs, and the demand for veterinary care of canine athletes and owners’ expectations regarding the standard of that care, especially during the recovery phase, have increased concurrently.2,3 As a result, during the last 15 years, programs have emerged to provide veterinarians with training and certification in animal rehabilitation. Currently, there are 2 certification programs in canine rehabilitation available in the United States.a,b Additionally, the AVMA and the American Physical Therapy Association have adopted position statements that endorse collaboration between veterinarians and physical therapists and established guidelines to uphold rehabilitation therapy to the same standards as traditional veterinary medicine.1 The American College of Veterinary Sports Medicine and Rehabilitation was approved by the American Board of Veterinary Specialties in 2010, and at the time of the study reported here had 62 diplomates specializing in canine rehabilitation.4,5 The AARV was formed in 2007 and had 404 members at the time of the study reported here.6 Results of several studies7–12 substantiate the benefits of canine rehabilitation during the postoperative recovery period. As the field of canine rehabilitation gained momentum, so has interest in the referral of canine patients to rehabilitation facilities by veterinarians and pet owners who seek to improve patient outcomes.
Most veterinarians currently in practice received little formal training in physical rehabilitation during their formal veterinary education. Although veterinary schools are beginning to offer rehabilitation programs and courses, a review of the curriculums posted on the websites for the 28 AVMA-accredited veterinary schools in the United States13 by the first author (LXA) of this report revealed that only 11 currently offer coursework related to small animal rehabilitation. Thus, as the field of veterinary rehabilitation continues to expand, it is necessary to inform and educate the veterinary community and public on the applications and potential benefits of those services. Accordingly, it is important to understand the perceptions and opinions of veterinarians regarding indications and contraindications of rehabilitation therapy and the conditions they believe might merit rehabilitation services. The purpose of the survey described here was to identify patterns of referral to small animal rehabilitation facilities across the continental United States, document referring veterinarians’ perceptions of rehabilitation services, and examine factors that encouraged and impeded referral of patients to rehabilitation facilities. We hypothesized that unresolved lameness would be the primary reason for referral and that distance to a rehabilitation facility would be the primary impediment to referral.
Materials and Methods
Data Collection
The study protocol was reviewed and approved by the Animal Medical Center's Institutional Review Board Committee. An initial pilot survey was developed and conducted in the New York City metropolitan area in April 2014, and the results from that survey were used to modify the questionnaire used in the survey reported here. The final questionnaire (Supplemental Appendix S1, available at http://avmajournals.avma.org/doi/suppl/10.2460/javma.249.7.807) consisted of 10 multiple-choice, ranking, and polar (yes-no) questions and was the same as the questionnaire used for the pilot survey, except cost was added as an option for reasons why patients were not referred to a rehabilitation facility and a question regarding geographic region was added in the demographic section. Demographic information collected included respondent's level of work experience (< 2, 2 to 5, > 5 to 10, > 10 to 15, or > 15 years), position in the workplace (associate or practice owner), area of practice (general practice, house-call practice, industry or pharmaceutical, per diem, referral or specialty practice, or research), and geographic region (Northeast, Southeast, Midwest, Southwest, or West). Referral pattern information collected included numbers and types of cases previously referred for rehabilitation therapy, reasons for or against referring a patient for rehabilitation therapy, and likelihood of referring patients with various conditions for rehabilitation therapy in the future (each condition listed was ranked on a 5-point Likert scale [1 = least likely and 5 = most likely]). Respondents were also asked to indicate whether they thought continuing education on veterinary rehabilitation was lacking.
The protocol used to administer the questionnaire was consistent with that outlined in previously published veterinary surveys.14–16 Briefly, participation in the current survey was advertised in the AARV monthly newsletter. Interested AARV members provided referral lists for their rehabilitation facilities to the principle investigator (LXA). Nine rehabilitation facilities in the continental United States submitted referral lists, which included veterinarians who had and had not referred patients to those facilities. All referral lists remained confidential. In October 2014, the questionnaire was emailed to 1, 978 veterinarians. One hundred forty-six of those emails bounced, or were returned as undeliverable, and were excluded from the tally of potential respondents; thus, 1, 832 questionnaires were delivered electronically. Questionnaires were mailed to an additional 916 veterinarians for whom email addresses were unavailable (this included the 47 veterinarians who participated in the pilot survey). Ten questionnaires were returned as undeliverable and were excluded from the tally of potential respondents. Thus, 906 paper questionnaires were delivered by traditional mail. Collectively, questionnaires were sent to 2, 738 veterinarians in the continental United States.
Although responses from veterinarians who participated in the pilot survey in April 2014 were evaluated with those from veterinarians who participated in the survey in October 2014, veterinarians who participated in the April survey were not eligible to participate in the October survey. Therefore, each respondent was represented only once in the present report. Potential respondents were offered a chance to win 1 of 5 gift cards (funded by The Animal Medical Center) as an incentive for participating in the survey and were given 2 weeks to respond.
Statistical analysis
Descriptive statistics were used to summarize survey results. For some categorical variables, certain categories were combined because of low response frequencies. For example, the Southwest and West categories were combined for geographic region and general practice and house-call practice categories were combined as were per diem, research, and industry-pharmaceutical categories (designated as other) for area of practice. A χ2 test was used to evaluate whether the frequency of responses varied among the categories within each categorical variable. Individual categories within each categorical variable were evaluated with 1-sample t tests to calculate the 95% confidence interval for the frequency percentage. All analyses were performed with commercially available software,c and values of P < 0.05 were considered significant.
Results
Three hundred twenty-five of 1, 832 (17.7%) electronic questionnaires and 136 of 906 (15.0%) paper questionnaires were completed and returned. Thus, the overall response rate for the survey was 16.8% (461/2, 738). Given the sample size for the survey, the margin of error was < 5% for all responses. None of the respondents were trained rehabilitation veterinarians or members of the AARV. Of the 461 respondents, most had been in practice for > 15 years (185 [40.1%]) and were associate veterinarians (298 [64.6%]) in general practice (387 [83.9%]; Table 1). Most of the respondents practiced in the Northeast (222 [48.2%]), followed by the West (97 [21%]), Midwest (66 [14.3%]), Southeast (63 [13.7%]), and Southwest (13 [2.8%]) regions of the continental United States.
Demographic characteristics for 461 US veterinarians who responded to a survey designed to identify patterns of referral to small animal rehabilitation facilities, document referring veterinarians’ perceptions of rehabilitation services, and examine factors that encouraged and impeded referral of veterinary patients to rehabilitation facilities.
Variable | No. (%) of respondents |
---|---|
No. of years in practice | |
< 2 | 19 (4.1) |
2–5 | 75 (16.3) |
> 5–10 | 93 (20.2) |
> 10–15 | 89 (19.3) |
> 15 | 185 (40.1) |
Workplace position | |
Associate | 298 (64.6) |
Practice owner | 163 (35.4) |
Area of practice | |
General practice | 387 (83.9) |
House-call practice | 11 (2.4) |
Industry-pharmaceutical | 1 (0.2) |
Per diem | 5 (1.1) |
Referral or specialty practice | 51 (11.1) |
Research | 6 (1.3) |
US geographic region | |
Northeast | 222 (48.2) |
Southeast | 63 (13.7) |
Midwest | 66 (14.3) |
Southwest | 13 (2.8) |
West | 97 (21.0) |
Nine US veterinary rehabilitation facilities provided investigators with their referral lists, which included the names and email and business addresses of veterinarians who had and had not referred patients to those facilities. A 10-question survey was successfully emailed or mailed to 1, 832 and 906 veterinarians, respectively, within the continental United States in 2014;461 responded, resulting in a response rate of 16.8%.
Results of χ2 analyses indicated that the number of patients referred for rehabilitation therapy varied significantly by a respondent's geographic region (P < 0.001) and area of practice (P < 0.001), and the numbers of patients referred for rehabilitation therapy during the 12 months prior to the survey were summarized for each of those variables (Table 2). Practitioners in the Northeast referred patients for rehabilitation therapy less frequently than expected (P < 0.001), whereas practitioners in the West and Southwest referred patients for rehabilitation therapy more frequently than expected (P < 0.001). Veterinarians in specialty or referral practices were significantly (P < 0.001) more likely to refer patients for rehabilitation therapy than were veterinarians in general or house-call practices. The number of patients referred for rehabilitation therapy did not vary significantly for any of the other demographic variables assessed.
Actual (expected) number of respondents to the survey described in Table 1 categorized by the number of patients referred for rehabilitation therapy within the 12 months prior to the survey within each geographic region and area of practice.
No. of patients referred for rehabilitation therapy during the 12 months prior to the survey | ||||||
---|---|---|---|---|---|---|
Variable | 0 | 1–2 | 3–5 | 6–8 | > 8 | Total |
Geographic region | ||||||
Northeast | 65 (47.7)* | 76 (70.8) | 52 (58.3) | 17 (21.7) | 12 (23.6)* | 222 |
Southeast | 10 (13.5) | 18 (20.1) | 23 (16.5) | 4 (6.2) | 8 (6.7) | 63 |
Midwest | 11 (14.2) | 20 (21.1) | 15 (17.3) | 10 (6.4) | 10 (7.0) | 66 |
West and Southwest | 13 (23.6)* | 33 (35.1) | 31 (28.6) | 14 (10.7) | 19 (11.7)* | 110 |
Total | 99 | 147 | 121 | 45 | 49 | 461 |
Area of practice | ||||||
General or house-call practice | 84 (85.5) | 131 (126.9) | 112 (104.5) | 37 (38.9) | 34 (42.3) | 398 |
Referral or specialty practice | 9 (11.1) | 13 (16.3) | 6 (13.4)* | 8 (5.0) | 15 (5.4)* | 51 |
Other† | 6 (2.6) | 3 (3.8) | 3 (3.2) | 0 (1.2) | 0 (1.3) | 12 |
Total | 99 | 147 | 121 | 45 | 49 | 461 |
Results of χ2 analyses indicated that number of patients referred for rehabilitation therapy varied significantly by a respondent's geographic region (P < 0.001) and area of practice (P < 0.001).
Actual value differs significantly (P < 0.05) from the expected value.
Included veterinarians who worked on a per diem basis and those who worked in industry, pharmaceutical, and research fields.
See Table 1 for remainder of key.
Three hundred sixty-two (78.5%) respondents had referred at least 1 patient for rehabilitation therapy within the 12 months prior to the survey, whereas the remaining 99 (21.5%) respondents had never referred a patient for rehabilitation therapy. Patients most commonly referred for rehabilitation therapy were those that required postoperative rehabilitation and those with osteoarthritis and neurologic disorders (Table 3). The most frequently cited reason for referring a patient for rehabilitation therapy was the veterinarian's belief that it would result in a better or faster recovery, followed by a chronic or unresolved lameness or mobility disorder. Of the 461 respondents, 116 (25.2%) reported referring a patient for rehabilitation therapy at the request of the owner. Respondents ranked neurologic disorder as the condition they would most likely consider for referral for future rehabilitation therapy (mean Likert score, 3.62) followed by osteoarthritis (3.31), pain management (3.18), routine postoperative care (3.13), soft tissue injury (3.08), and weight loss and fitness (2.67). The most frequently cited reason for not referring a patient for rehabilitation therapy was cost (251/461 [54.4%]) followed by distance to rehabilitation facility (134/461 [29.1%]). The majority (403/461 [87.4%; 95% confidence interval, 84.4% to 90.4%]) of respondents indicated that continuing education in the area of veterinary rehabilitation was lacking.
Frequency distribution of responses provided by the veterinarians who responded to the survey described in Table 1 regarding the reasons they did or did not refer patients for rehabilitation therapy.
Variable | No. (%) of respondents | 95% confidence interval for percentage |
---|---|---|
Types of conditions or reasons for which patients might be referred for rehabilitation therapy | ||
Postoperative rehabilitation | 324 (70.3) | 66.1–74.5 |
Osteoarthritis | 274 (59.4) | 54.9–63.9 |
Neurologic disorder | 240 (52.1) | 47.5–56.6 |
Underwater treadmill | 210 (45.6) | 41.0–50.1 |
Soft tissue injury | 180 (39) | 34.6–43.5 |
Unresolved lameness | 169 (36.7) | 32.2–41.1 |
Laser therapy | 128 (27.8) | 23.7–31.9 |
Weight management and fitness | 112 (24.3) | 20.4–28.2 |
Never referred patient for rehabilitation therapy | 53 (11.5) | 8.6–14.4 |
Shockwave therapy | 25 (5.4) | 3.4–7.5 |
Other | 12 (2.6) | 1.1–4.1 |
Reasons for referring patients for rehabilitation therapy during the 12 mos prior to the survey | ||
Better or faster recovery | 293 (63.6) | 59.2–68.0 |
Chronic or unresolved lameness | 200 (43.4) | 38.8–47.9 |
Heard of success for other patients | 181 (39.3) | 34.8–43.7 |
Owner requested referral | 116 (25.2) | 21.2–29.1 |
Other | 96 (20.8) | 17.1–24.5 |
Reasons for not referring patients for rehabilitation therapy | ||
Cost | 251 (54.4) | 49.9–59.0 |
Distance to rehabilitation facility | 135 (29.3) | 25.1–33.4 |
Other | 125 (27.1) | 23.0–31.2 |
Unaware of benefits of rehabilitation therapy | 53 (11.5) | 8.6–14.4 |
Fear of losing business | 42 (9.1) | 6.5–11.7 |
Unaware of rehabilitation services | 40 (8.7) | 6.1–11.3 |
Concern for losing patient | 28 (6.1) | 3.9–8.3 |
Respondents could select multiple categories within each variable.
See Table 1 for remainder of key.
Discussion
Results of the present study suggested that perceived cost was the most common reason that respondents did not recommend physical rehabilitation for their patients. The second most frequently cited reason for not referring patients for rehabilitation therapy was the distance to the rehabilitation facility, which we hypothesized would be the primary deterrent to rehabilitation therapy. The perception that the cost of rehabilitation therapy is generally high relative to the benefits observed may be inaccurate, and further research is warranted to assess the actual value placed on a pet's quality of life relative to the cost required to improve that quality of life. Compared with the costs for other veterinary specialty services, the cost associated with rehabilitation therapy might not be as high as many assume. For example, in 2014, the mean cost per visit for the rehabilitation service at a large veterinary teaching hospital was less than that for any other specialty service provided at that hospital.d Similar findings were reported by the other 9 rehabilitation facilities that provided referral lists for the present survey. Additionally, at least 10 pet insurance companies currently cover rehabilitation services to some extent, with most covering 80% to 90% of the costs (depending on plan level), which makes rehabilitation therapy more affordable for pet owners.17 Insurance coverage for rehabilitation therapy is comparable to that for orthopedic and neurosurgery procedures. Results of another study18 indicate that pet owners are likely to pursue treatments recommended by their veterinarians, and the pet owners’ perceptions of the value of those treatments for their pet's quality of life were positively associated with how well the veterinarian explained the need for the treatment under consideration. That study18 involved 2, 000 pet owners, and the authors concluded that, although many owners are price sensitive, cost did not prevent most of them from pursing treatments recommended by the veterinarian. Moreover, pet ownership is beneficial to the health and well-being of humans.19 Companion animals are no longer regarded as luxury items but rather as essential members of the family, and owners expect a higher level of care than they did 10 to 15 years ago. Clearly, more information needs to be collected regarding the safety, efficacy, and cost of rehabilitation therapy for veterinary patients. Also, continuing education programs targeted toward general practitioners could improve awareness of rehabilitation therapy among veterinarians and clients and permit them to make more informed decisions regarding rehabilitation services.
Investigators of multiple studies7–12,20,21 report beneficial effects of rehabilitation therapy on the outcome for veterinary patients with various disorders. Current American Animal Hospital Association guidelines advocate the use of physical rehabilitation as part of multimodal pain management programs.22 Physical rehabilitation can facilitate recovery from surgery, improve functional status, and result in a better quality of life. It involves a unique approach to medicine in which the therapist recognizes that a particular pathophysiologic diagnosis can manifest differently among patients, and this may affect the functional status of individual patients.23 Rehabilitation therapists assess each patient to determine their functional impairments and ability to perform daily tasks that are essential to quality of life, such as being able to rise independently or posture to defecate and urinate, and then offer treatments that can improve the patient's ability to function independently. In 1 study24 that involved dogs with hip dysplasia, increased duration of exercise was associated with a decrease in lameness score. In another study,25 dogs that underwent rehabilitation therapy after lateral fabellar suture stabilization surgery were not further benefitted by administration of NSAIDs.
Human patients commonly undergo physical therapy following neuromuscular and skeletal injuries, and results of multiple studies26–31 indicate that physical therapy is beneficial for injury prevention, facilitates recovery from surgery and overuse injuries, and improves the outcomes for musculoskeletal disorders. In veterinary medicine, most practices currently do not have rehabilitation facilities, and pet owners may not be offered referral for or education regarding rehabilitation therapy. Although continuing education programs in veterinary rehabilitation therapy are available, most practicing veterinarians were not exposed to that topic during their primary veterinary education, which might decrease the likelihood that they will seek out those programs. More lectures on the benefits of rehabilitation therapy should be offered at national and regional veterinary conferences to better educate the veterinary community, specifically general practitioners.
Results of the present study indicated that respondents in the West and Southwest referred patients for rehabilitation therapy more frequently than expected, whereas respondents in the Northeast referred patients for rehabilitation therapy less frequently than expected. Those results may be a reflection, or artifact, of the method used to distribute the survey. The geographic span of the referral lists provided by rehabilitation practices located in the Northeast was much broader than that for the referral lists provided by rehabilitation practices located in the West and Southwest. Thus, the driving distance for owners of patients referred to the practices in the Northeast tended to be greater than that for owners of patients referred to practices in the West and Southwest. Consequently, respondents in the Northeast might not truly be less likely to refer a patient for rehabilitation therapy. Interestingly, according to AARV member data, there are fewer veterinary rehabilitation facilities located in the Northeast than in the Midwest and Southeast.6 Additionally, we were not surprised that respondents who worked at referral or specialty practices were more likely than respondents in other areas of practice to refer patients for rehabilitation therapy, because they are likely to have greater familiarity with and perhaps closer access to rehabilitation facilities than other types of practitioners.
A limitation of the present survey was that it was not possible to determine whether the respondents were representative of the general population of veterinarians in the United States. The survey was sent only to veterinarians whose names appeared on referral lists provided by participating rehabilitation facilities. The veterinarians on those lists might have been more knowledgeable about or had more exposure to rehabilitation therapy than the general population of veterinarians and represented a biased population. However, the referral lists included veterinarians who never or seldom referred patients for rehabilitation therapy as evidenced by the fact that, of the 461 respondents, 53 (11%) had never referred a patient for rehabilitation therapy, and 99 (21%) stated that they had not referred a patient for rehabilitation therapy in the 12 months prior to the survey. Additionally, the proportion of respondents (51/461 [11.1%]) who were diplomates of AVMA American Board of Veterinary Specialties-recognized organizations was similar to that (11, 417/99, 720 [11.4%]) for the general population of US veterinarians as reported by the AVMA Market Statistics of 2013.32,33
In an ideal situation, we would have evaluated the responses from veterinarians who worked in house-call practices separately because those practitioners are more likely to care for patients with substantial functional impairments that might benefit from or necessitate rehabilitation therapy than are practitioners in other areas of practice. Unfortunately, the proportion of survey respondents who worked in house-call practice (11/461 [2.4%]) was too small to significantly affect the statistical analyses.
Findings of the present survey suggested there is a need for continuing education programs in small animal rehabilitation for veterinarians. Improved knowledge about the indications for and expected outcomes of rehabilitation therapy will enable veterinarians to better communicate with owners the value and benefit of that treatment modality for their pets regardless of the therapy cost or distance to a rehabilitation facility.
Acknowledgments
Supported by The Animal Medical Center.
Dr. Van Dyke is the chief executive officer of a company that provides certification courses and seminars in canine rehabilitation.
Presented in abstract form at the 2016 North American Veterinary Conference, Orlando, Fla.
ABBREVIATIONS
AARV | American Association of Rehabilitation Veterinarians |
Footnotes
Northeast Seminars, East Hampstead, NH.
Canine Rehabilitation Institute, Wellington, Fla.
IBM SPSS, version 22, IBM Corp, Armonk, NY.
Greene P, The Animal Medical Center, New York, NY: Personal communication, 2015.
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