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Alvarez et al: Systematic review of postoperative rehabilitation interventions after cranial cruciate ligament surgery in dogs
Veterinary Surgery 2, 2022

🔍 Key Findings

  • Exercise-based rehabilitation showed benefits in 6 of 7 studies, including increased peak vertical force (PVF) and reduced lameness, though most had high risk of bias (RoB).
  • Cold compression therapy (CCT) had 2 high-quality (Level II, low RoB) studies showing improvements in pain scores, range of motion, and swelling, supporting its clinical use.
  • Extracorporeal shockwave therapy (ESWT) was supported by 2 Level II studies; only one had low RoB, showing short-term benefits in patellar ligament thickness and PVF, but no long-term benefit on bone healing.
  • Photobiomodulation (PBM) had mixed results across 3 Level II studies (all low RoB); only 1 showed positive impact on PVF, limiting its recommendation.
  • Low-intensity pulsed ultrasound (LIPUS) showed no significant impact on gait analysis or bone healing in a Level II, low RoB study.
  • Electrical muscle stimulation (EMS) improved lameness and thigh circumference in one Level III study, but had high-moderate RoB and involved experimentally-induced CCL rupture, limiting clinical relevance.
  • No modality beyond exercise and CCT had consistent or strong evidence for efficacy in post-TPLO or extracapsular repair rehabilitation.
  • The absence of standardized protocols, small sample sizes, and inconsistent outcome measures limited the generalizability of findings.

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← Articles

Alvarez et al: Systematic review of postoperative rehabilitation interventions after cranial cruciate ligament surgery in dogs
Veterinary Surgery 2, 2022

🔍 Key Findings

  • Exercise-based rehabilitation showed benefits in 6 of 7 studies, including increased peak vertical force (PVF) and reduced lameness, though most had high risk of bias (RoB).
  • Cold compression therapy (CCT) had 2 high-quality (Level II, low RoB) studies showing improvements in pain scores, range of motion, and swelling, supporting its clinical use.
  • Extracorporeal shockwave therapy (ESWT) was supported by 2 Level II studies; only one had low RoB, showing short-term benefits in patellar ligament thickness and PVF, but no long-term benefit on bone healing.
  • Photobiomodulation (PBM) had mixed results across 3 Level II studies (all low RoB); only 1 showed positive impact on PVF, limiting its recommendation.
  • Low-intensity pulsed ultrasound (LIPUS) showed no significant impact on gait analysis or bone healing in a Level II, low RoB study.
  • Electrical muscle stimulation (EMS) improved lameness and thigh circumference in one Level III study, but had high-moderate RoB and involved experimentally-induced CCL rupture, limiting clinical relevance.
  • No modality beyond exercise and CCT had consistent or strong evidence for efficacy in post-TPLO or extracapsular repair rehabilitation.
  • The absence of standardized protocols, small sample sizes, and inconsistent outcome measures limited the generalizability of findings.

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Multiple Choice Questions on this study

In Alvarez 2022 et al., on rehabilitation modalities, which statement best reflects the findings on photobiomodulation (PBM)?

A. PBM was consistently superior to cold therapy for all outcomes
B. PBM improved lameness in most studies regardless of device class
C. Only one PBM study showed improved objective outcomes
D. All PBM studies were uncontrolled trials
E. All PBM studies were deemed high risk of bias

Answer: Only one PBM study showed improved objective outcomes

Explanation: Only one of three PBM studies (Rogatko et al.) showed improved PVF; others showed no significant benefit despite low RoB.
In Alvarez 2022 et al., on rehabilitation modalities, what was the outcome of the single study on low-intensity pulsed ultrasound (LIPUS)?

A. It significantly improved bone healing after TPLO
B. It showed reduced lameness by week 2
C. It improved ground reaction forces at 8 weeks
D. It had no significant effect on healing or function
E. It was excluded due to low evidence level

Answer: It had no significant effect on healing or function

Explanation: The LIPUS study (Kieves 2018) showed no significant improvement in radiographic healing or TPI outcomes after TPLO.
In Alvarez 2022 et al., on rehabilitation modalities, which modality had the most studies showing positive postoperative effects in dogs but also had high risk of bias?

A. Therapeutic ultrasound
B. Extracorporeal shockwave therapy
C. Photobiomodulation
D. Electrical stimulation
E. Exercise

Answer: Exercise

Explanation: Exercise had the most studies showing positive effects, but most were Level III or IV evidence with high RoB.
In Alvarez 2022 et al., on rehabilitation modalities, what was a major limitation noted across many studies included in the systematic review?

A. Lack of ethical approval
B. Lack of control groups
C. Use of non-canine models
D. Small sample sizes and high RoB
E. Inadequate surgical techniques

Answer: Small sample sizes and high RoB

Explanation: Many studies suffered from small cohorts, high RoB, lack of blinding, and poorly standardized rehab protocols.
In Alvarez 2022 et al., on rehabilitation modalities, which therapy showed consistent positive outcomes in two Level II studies with low risk of bias?

A. Cold compression therapy
B. Electrical muscle stimulation
C. Photobiomodulation
D. Low-intensity pulsed ultrasound
E. Laser acupuncture

Answer: Cold compression therapy

Explanation: CCT was the only modality supported by two Level II, low RoB studies showing pain relief, improved ROM, and reduced swelling.

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