SPINAL CORD TRAUMA PHYSICAL THERAPY and

2nd VEPRA CONFERENCE
INTERNATIONAL CONFERENCE ON PHYSICAL THERAPY
AND REHABILITATION OF ANIMALS
SPINAL CORD TRAUMA
PHYSICAL THERAPY
and REHABILITATION
17-18 September 2011
Warsaw, Poland
Wydawca:
Przychodnia Weterynaryjna KANVET
Anna Kaniewska
ul. Liliowa 37
11-041 Olsztyn
ISBN 978-83-933750-0-4
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committees
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Honorary Committee:
Prof. dr hab. Andrzej Koncicki
- Dean of the Faculty of Veterinary Medicine
UWM Olsztyn (POL)
Dr Ludovica Dragone( ITA)
Dr Zoran Vrbanac (CRO)
Dr hab. Zdzislaw Kielbowicz (POL)
Dr hab. Jacek Sterna (POL)
Cajsa Ericson (SWE)
Dr Karin Holler (AUT)
Dr Barbara Assis (POR)
Scientific Committee:
Dr Barbara Bockstahler (AUT)
Prof. dr hab. Zbigniew Adamiak (POL)
Dr hab. Andrzej Pomianowski (POL)
Organizing Committee:
Anna Kaniewska, DVM (POL)
Dr Izabella Babinska, DVM (POL)
Solicitor Magdalena Karwecka (POL)
Miloslawa Kwiatkowska, DVM (POL)
Anna Barecka-Malik, DVM (POL)
Aneta Bochenska, DVM (POL)
Dr Marcin Nowicki, DVM (POL)
Secretary:
Agnieszka Zdunek (POL)
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welcome message
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Dear Colleagues
Colleagues,
It is our honor to introduce you to the 2nd VEPRA Conference
which will be held on 17-18 September 2011 in Warsaw - Jachranka,
Poland. The success of the 1st Conference encouraged us to further
work and development. Physiotherapy is a dynamically growing area
in veterinary medicine. Our goal is to spread knowledge about
rehabilitation and showing its impor-tance in the process of recovery.
In this year we will focus on rehabilitation after spinal cord injury,
the conference topic is: ”SPINAL CORD TRAUMA - PHYSICAL
THERAPY and REHABILITATION”
Also this time we were able to invite lecturers from around the world
who are willing to share their knowledge and experience. We hope
that thanks to distinguished lecturers our meeting is a great
opportunity to broaden Your knowledge of neurology and
physiotherapy of spinal cord.
Friday's meeting at the barbecue or a gala dinner which will
take place on Saturday night will be excellent occasions to meet the
new friendships.
Participating in the 2nd VEPRA Conference is opportunity to
visit Polish capital - Warsaw and acquaint with the history of this city.
We would like to thank the sponsors for their help and support .
We would like also thank all participants for coming, we hope
that the newly acquired knowledge will be useful in practice and will
bring a lot of success at work with patients.
We wish successful time during 2nd VEPRA Conference.
Best regards.
Organizing Committee
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program
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general information
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Venue:
Warszawianka Congress Center
Hotel Wellness & SPA
address: Jachranka 77, 05 - 140 Serock
Phone: +48 22 768 90 00
Fax: +48 22 768 92 58
web site: www.vepra2011.pl
e -mail: [email protected]
Opening hours of the registration office:
16th September (Friday) 16.00 - 19.00
17th September (Saturday) 07.30 - 09.00
The registration fee includes Conference bag, Book of Proceedings,
coffee breaks, lunch.
Official language:
English
Simultaneous translation into polish
Social events:
Welcome reception
16th September at 20.00
Barbecue organized by VEPRA
Chata Góralska Restaurant in Warszawianka Congress Center
Warsaw City tour
17th September at 17.00
Departure from the Conference venue at 17.00
Gala Dinner
17th September at 21.00
Restaurant Yacht Club, Congress Center
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invited lectures
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VETERINARY REHABILITATION OF SPINAL CORD TRAUMA
CONSERVATIVE AND SURGICAL THERAPIES
Darryl L. Millis, MS, DVM, DACVS, CCRP, DACVSMR
University of Tennessee College of Veterinary Medicine
Knoxville, Tennessee, USA
Spinal cord trauma in dogs and cats may be a result of vascular,
concussive, or compressive injuries. Although vascular lesions, such
as infarcts associated with fibrocartilagenous embolic myelopathy
occur with some frequency, this discussion will primarily address
intervertebral disk disease and spinal fractures and luxations. The
initial management and treatments of common conditions will be
discussed. Rehabilitation of spinal cord trauma will be introduced
and will be more thoroughly explored in the following discussion.
Diagnosis
A history is often definitive in differentiating trauma as a result
of automobile trauma or other forms of trauma. In some instances,
however, the owner did not witness an episode and found their pet
recumbent and unable to walk. In cases of potential trauma, it is very
important to manage the patient properly to avoid the potential for
further injury. If the owner has called prior to moving the animal,
instructions may be relayed regarding proper handling of the patient.
First, people that are helping should avoid injury to themselves
because spinal cord trauma patients may be painful, anxious and
frightened. A muzzle should be placed if the animal is not in
respiratory distress. If possible, a solid flat item, such as a board,
should be gently slid under the animal with the animal restrained in
lateral recumbency. Caution should be exercised to prevent
struggling and excessive motion that may cause further displacement
an unstable spinal column. The animal may be restrained with a
blanket, rope, or tape to help immobilize them as well as possible for
transport.
Attention should be directed to initial life-threatening injury,
paying particular attention to perfusion and oxygenation of tissues. A
quick examination, including evaluation of the spinal column, may
reveal information about gross displacement. Following palpation to
assess the integrity of the spinal column, a neurologic evaluation can
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be performed. In particular, the presence or absence of deep pain is
important. After localizing the lesion, further diagnostics may be
performed to evaluate the type and extent of injury. In the case of
trauma, it is important to be cautious when moving the animal for
radiographs. It may be better to obtain all radiographs with the
animal in lateral recumbency and to move the x-ray tube and cassette
to obtain a ventral dorsal view with the animal remaining in lateral
recumbency to obtain a horizontal beam view. If the animal has pain
sensation, attempts are made to manipulate the animal with as little
sedation as possible so that if the spinal column is inadvertently
moved, the animal's reaction will indicate this and steps may be taken
to prevent further displacement of the spinal canal. Similarly, if
surgical stabilization is to be performed, the animal is positioned for
surgery and then induction of anesthesia is performed on the surgical
table to avoid unnecessary movement of the patient and
manipulation of the spinal column. The lack of deep pain sensation in
an animal with a traumatic spinal column injury carries a poor
prognosis in most cases.
If intervertebral disc disease is suspected, it is also important
to establish whether or not the pain is present. Also, a thorough
neurologic examination will help to localize the lesion for further
diagnostic imaging. Myelography, magnetic resonance imaging, and
computerized tomography may all be useful to further assess
compression of the spinal cord. MRI can be especially valuable to help
determine damage to the spinal cord. Over 90% of dogs within a
vertebral disc disease treated with decompressive hemilaminectomy
have return to ambulatory function. In contrast, the loss of deep pain
sensation carries a more guarded prognosis with only about 50% of
patients becoming ambulatory.
Ruling out spinal cord compression as a result of trauma or
intervertebral disc disease often results in a diagnosis of
fibrocartilaginous embolism. MRI is particularly valuable in
diagnosing FCE because the infarct may be seen on the image.
Pathophysiology of Spinal Cord Trauma
A number of events occur with spinal cord injury. With
compression of the spinal cord, the spinal cord and vasculature are
compromised by compression, contusion, stretching, or tearing. The
initial compression results in a cascade of inflammatory events.
Calcium and sodium are sequestered intracellularly, matrix
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metalloproteinases are released, reactive oxygen species are formed,
and a variety of cytokines and other inflammatory mediators are
produced. In addition, continued compression of the spinal cord
results in further hypoxia to the spinal cord with areas of infarcts. With
trauma, hypovolemia and hypotension may result in decreased spinal
cord blood flow and hypoxic changes may occur in the spinal cord. It is
important to expand the vascular space and reestablish normal blood
pressure. In addition, attempts have been made to administer
corticosteroids, however the effectiveness of these treatments is
questionable.
Treatment with dexamethasone has been recommended as
an initial treatment for acute spinal cord injury. The concept is to
reduce inflammation and swelling to help limit damage to the spinal
cord. However, most studies have failed to demonstrate the efficacy
of this treatment. In contrast, methylprednisolone sodium succinate
helps to improve blood flow and scavenge reactive oxygen species, in
addition to being anti-inflammatory. While benefit has been
demonstrated in experimental models, clinical use has resulted in
questionable benefit. In fact, treatment with any corticosteroid has
been associated with adverse events. High-dose corticosteroid
treatment may result in diarrhea, vomiting, gastrointestinal
hemorrhage or ulceration, and in advanced cases, death. In one study,
9 of 10 patients treated with high dose methylprednisolone sodium
succinate had severe gastric hemorrhage. The use of corticosteroids
may also inhibit wound healing, including recovery of the spinal cord.
Other experimental treatments for acute spinal cord injury
include thyrotropin releasing hormone, stem cell therapy, olfactory
mucosa, minocycline, erythropoietin, melatonin, polyethylene glycol,
hypothermia, oscillating electrical fields, and therapeutic laser. A
treatment that shows promise for restoring function to demyelinated
axons is a potassium channel blocker, 4-Aminopyridine, which
restores conduction to demyelinated axons and improves synaptic
transmission. In addition, cells such as olfactory ensheathing cells
and cultured Schwann cells have also shown promise.
Schiff-Sherrington Posture
Dogs with severe T3-L3 spinal cord trauma may have a SchiffSherrington posture, which is manifested by increased thoracic limb
extensor tone with normal thoracic limb postural reactions. This
condition is thought to result from a release of inhibitory input to the
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ascending tracts to the thoracic limbs with severe spinal cord injury.
Spinal Shock
Dogs that sustain trauma may (uncommonly) develop a
condition known as spinal shock, which is temporary hypotonia and
hyporeflexia caudal to severe spinal cord injury. The loss of reflexes is
generally temporary and typically lasts for several hours. The
condition may be a result of an acute disruption of upper motor
neuron facilitatory input to lower motor neurons. The clinician should
be aware of this condition to avoid giving an overly grave prognosis
to the owner initially.
Myelomalacia
Dogs with severe spinal cord disease (loss of deep pain
sensation) may develop a condition called ascending-descending
myelomalacia, which is softening and degeneration of the spinal cord
as a result of hemorrhagic necrosis. As the process spreads, clinical
signs will also progress from the initial clinical picture. This condition
is important for therapists to recognize because it may not be
apparent at the time of surgery and it must be recognized. Dogs may
develop decreased reflexes, anal and urethral sphincter
incompetence, loss of additional cutaneous trunci reflex, and possibly
flaccid paralysis of forelimbs and respiratory arrest. There is no
known treatment, and the prognosis is poor.
Surgical Decompression
Early surgical decompression is probably the most effective
form of therapy for spinal cord injury. In the case of trauma to the
spinal column, reduction and stabilization of the lesion as early as
possible is recommended. In most cases, realignment of the spinal
column is generally adequate to provide decompression. It is usually
not necessary to do a hemilaminectomy or dorsal laminectomy, which
may result in further destabilization of the spinal column.
Postoperatively, the area is supported with a splint or body brace.
This is especially important if the surgical stabilization is questionable.
In some cases with minor displacement and mild clinical signs, a splint
or brace may be the only stabilization required. Surgical stabilization
techniques include ventral or lateral vertebral body plating, dorsal
spinal plates, pins and bone cement, spinal stapling, and external
skeletal fixation.
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In cases of intervertebral disk disease, decompression of the
area with a hemilaminectomy is recommended in dogs with severe
ataxia, poor or no motor function, and early loss of deep pain
sensation. Removal of the disc material from the spinal canal is
performed, followed by fenestration of the affected disk space.
Studies have indicated decreased chance of recurrence if other disk
spaces are also fenestrated. The association of recurrence of disk
herniation with radiographic signs of disk calcification of adjacent
discs suggests that it is especially important to fenestrate diseased
discs.
Conservative Management
In cases of mild intervertebral disk disease, cases where the
owner cannot afford surgery or surgery would pose a life-threatening
risk to the patient, or there is loss of deep pain for several days,
conservative management may be instituted. Dogs must be
restricted to strict cage rest for 4 weeks. Compliance is absolutely
essential because of the risk for further disk herniation if the patient is
too active. This is especially important if analgesics are administered.
Rehabilitation efforts should be restricted to passive range of motion
exercises to the limbs, neuromuscular electrical stimulation, and
standing outside to urinate of defecate.
Pain Management
Pain should be managed in patients with spinal cord injury.
NSAIDs are often used, but caution should be exercised to be certain
that the patient has not already received corticosteroids. Many
veterinarians continue to treat spinal cord injury with corti-costeroids
and the combination of NSAIDs with corticosteroids can result in a
much higher risk of adverse gastrointestinal events. In addition, other
analgesics such as opioids, may also be administered. It is important
to maintain vascular perfusion and blood pressure if opioids are
administered. Other treatments may include gabapentin,
cryotherapy, and TENS application.
Nursing Care
Nursing care is very important to maintain the health of
patients with spinal cord injury. Owners must be committed to
perform homecare to help prevent complications and encourage
recovery as soon as possible. A soft padded bed is essential to help
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prevent decubital ulcers. The patient should be rotated from side to
side several times per day to help improve circulation and to reduce
the effects of pulmonary congestion of the dependent lung. Special
care should also be taken to encourage standing several times a day if
the spinal column is stable.
Many dogs have urinary incontinence as a result of spinal cord
injury. Lower motor neuron bladders are generally more problematic
because of the continued leakage of urine and the potential for urine
scalds. Adequate absorbent pads should be placed under the patient
and the integrity of the skin should be assessed several times daily.
Various creams and powders may be applied to help reduce the
effects of urine scalding and skin ulceration. In addition, with an upper
motor neuron bladder, it may be necessary to catheterize or express
the bladder several times per day. Various drugs may be administered
to help relax the urethral sphincter and stimulate contraction of the
detrusor muscles.
For upper motor nerve bladders,
phenoxybezamine (0.25-5 mg/kg q 12-24 h) or prazosin (1 mg/15 kg q
8-24 h) may be given to decrease urethral sphincer tone. Bethanocol
(2.5-25 mg (total dose) q 8 h) may be given to enhance detrusor
muscle contraction in dogs with upper or lower motor neuron
bladders. Detection and treatment of urinary tract infections is also
important.
Dogs should be monitored for any signs of dyspnea. Dogs
with poor motor function have a higher incidence of pneumonia.
Infection of the surgical site is also a concern and the incision is
assessed daily for any swelling, excessive redness, pain, or discharge
from the incision. Nutritional support is also important for healing.
Adequate protein and calorie intake as well as water are necessary for
optimal healing. Most dogs will be non-ambulatory for a period of
time and it will be necessary to be certain that water and nutritional
intake are adequate.
References
Kube SA, Olby NA. Managing acute spinal cord injuries.
Compendium on continuing education for the practicing veterinarian Sept 2008, pp 496-506
Olby NA. The pathogenesis and treatment of acute spinal cord
injuries in dogs. Vet Clin N Amer Small Anim Prac 40:791807, 2010.
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Griffin JF, Levine JM, Kerwin SC. Canine thoracolumbar
intervertebral disk disease: Pathophysiology, neurologic examination, and emergency medical therapy. CompendiumVet.com, March
2009.
Griffin JF, Levine JM, Kerwin SC, Cole RC. Canine
thoracolumbar intervertebral disk disease: Diagnosis, prognosis, and
treatment. CompendiumVet.com, March 2009.
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VETERINARY REHABILITATION OF SPINAL CORD TRAUMA
Darryl L. Millis, MS, DVM, DACVS, CCRP, DACVSMR
University of Tennessee College of Veterinary Medicine
Knoxville, Tennessee, USA
A properly designed rehabilitation program is an important
part of the overall treatment for patients with spinal cord trauma. It
should be designed to address the underlying problem, its severity,
and any other special considerations for the individual patient. The
location of the spinal cord trauma is one of the most important
considerations. Patients with typical T3-L3 thoracolumbar disc
herniation have normal forelimbs and upper motor neuron signs to
the rear limbs. These cases are generally easier to rehabilitate
because the upper motor neuron tone in the rear limbs facilitates
standing. In contrast, patients with a lesion from L4-S3 have a lower
motor neuron component, which is typically more difficult to
rehabilitate because of the lack of strength and flaccid limbs. Patients
with cervical spinal cord disease also present a challenge because all
four limbs are involved. Patients with lesions from C6-T2 are
especially challenging because of the presence of lower motor
neuron signs in the forelimbs and upper motor neuron signs in the
hind limbs.
When evaluating the patient with acute spinal cord injury for a
rehabilitation program, the first consideration is the type of injury.
Dogs with traumatic spinal column injuries are unique because of the
wide variety of trauma, the severity of neurologic signs, and the form
of fixation. Those with very stable spinal column/implant constructs
may progress through a rehabilitation program more rapidly. Dogs
with some spinal column displacement managed with external cooptation must be handled cautiously to avoid any further
displacement of the spinal column and additional trauma to the spinal
cord. In reality, most dogs have some neurologic deficits, adequate
reduction of the spinal column, and reasonably stable repairs.
However, it is up to the therapist, in conjunction with the surgeon, to
evaluate the stability of the repair to determine if specific exercises
are contraindicated. Dogs with intervertebral disc disease have more
consistent surgical procedures, but consideration should still be given
to the degree of instability as a result of hemi-laminectomy or
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complete dorsal laminectomy. Dogs with fibrocartilaginous emboli
have completely stable spinal columns but may have multifocal
lesions.
The next consideration in evaluating the patient with spinal
cord trauma is the degree of neurologic impairment. Dogs with no
deep pain sensation are relatively difficult to rehabilitate until they
regain some pain sensation. Keep in mind that not all dogs will
recover deep pain sensation, however. One study evaluated 34 dogs
with loss of deep pain perception at the time of surgery and found
that the 21 of 34 cases that recovered function had deep pain
perception at 2 weeks following surgery. Another study indicated
that a relatively high percentage of dogs with T-L disk disease that
recover from paraplegia with loss of deep pain perception have
persistent mild problems with urinary (32%) and fecal (41%)
continence. The same study looked at the long term recovery of dogs
with disc herniations that did not regain deep pain perception. Just
under 40% of these dogs recovered apparent voluntary motor
function and tail wag, although they did not recover deep pain
perception or continence. The mean time to recovery of motor
function was just over nine months. The recovery of a voluntary tail
wag preceded the recovery of pelvic limb function and in most cases
was present within a month of injury, potentially serving as a useful
prognostic indicator. Until the patient recovers pain sensation,
rehabilitation is restricted to passive range of motion exercises to
maintain joint motion and stretch of muscles and other soft tissues,
reflex-type exercises, massage, neuromuscular electrical stimulation,
and standing exercises if upper motor neuron disease is present.
Standing exercises are usually not rewarding in patients with lower
motor neuron disease, but neuromuscular electrical stimulation may
help to maintain muscle mass.
The return of motor function allows the introduction of a variety
of other therapeutic exercises, including assisted standing and
assisted walking, supported treadmill walking, and aquatic therapy.
As motor function improves and the patient can support the entire
body weight during ambulation, attention can be directed to
recovery of proprioceptive function. A variety of proprioceptive
exercises, including weight shifting, balance board activity, rocker
board exercise, and physioroll activity all help to enhance the
development of proprioceptive function. In the later phases of
recovery, other activities such as walking over obstacles, walking on
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different surfaces, and dynamic perturbation exercises may be
instituted. Finally, in the later phases of rehabilitation, speed and
strengthening activities may be instituted to help return the patient
to complete function.
In addition to the neurological status of the patient,
consideration must also be made to other confounding conditions,
the home environment, and the willingness and ability of the owner to
provide home therapy. Confounding conditions include other
neurologic or orthopedic issues. Dogs with severe hip dysplasia or
rupture of the cranial crucial ligament may have more difficulty doing
exercises such as sit to stand. Understanding the home environment
is also important. Dogs should have good footing while recovering
from neurologic conditions. Also, the patient should be in an area that
requires minimal stairs, and when possible, ramps should be built to
help the dog get in and out of the house. The ability of the owner to
provide home exercise care is important in helping the patient
recover as quickly as possible. Owners must be physically able to
perform the exercises and should receive adequate training,
including written instructions and demonstrations, followed by
having the owner perform the activities under the supervision of the
therapist. This minimizes miscommunication and confusion on the
part of the owner.
Assistive Devices
Assistive devices can play an important role in the overall wellbeing and functional abilities of the animal with neurological
impairments. In addition to providing increased independence for
the pet, these devices can provide additional autonomy for the owner
as well. They give support to a weak or non-functioning body part and
may assist with rehabilitation. They can also help to prevent decubital
ulcers from forming, increase an animal's mobility, and prevent future
complications in recumbent patients. These devices are available in a
variety of forms, including boots, slings, and two-wheeled and fourwheeled carts.
Boots
Boots are an excellent way to protect the feet when an animal
with neurological deficits is knuckling or turning its feet over and
walking on the dorsum of the foot when ambulating. Animals that
have poor proprioception are not aware of the placement of their
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paws and tend to walk on the dorsum of their paws or drag the nails
when walking. Boots act as sock-like coverings that are securely
fastened by Velcro straps at the top. Most have a rubber sole to
prevent slipping and are machine washable.
It is important to remove the boots periodically (several
times/daily) to assess skin condition, especially in neurologically
impaired patients, and if possible, when performing therapeutic
exercise to increase weight-bearing and proprioception through the
bottom of the pads. If not fitted properly, boots can interrupt
circulation, become cumbersome and impede gait patterns or
strides, and potentially cause more problems if the animal stumbles
and falls. Proper fit is essential and appropriate client education
instructions for skin care and rehabilitative exercises must be
communicated to the owner.
Boots can be ordered through a variety of veterinary or
specialty rehabilitation companies with products designed
specifically for dogs. Outdoor adventure stores, pet stores, and
online businesses may also sell supplies for dogs. When choosing the
proper boot, make sure they are machine washable, waterproof or
water resistant, made of a durable material so they do not wear down
quickly, and have a non-skid bottom to prevent slipping. Old socks
may also be used to help provide padding; however, be cautious if the
top is secured with tape to avoid cutting off circulation.
Slings
Slings come in a variety of shapes and sizes. Some products
may be strapped around the belly or fitted for the forelimbs or
hindlimbs, or both. They should have long hand-held straps attached
to allow proper body mechanics to avoid personal injury to the
handler when supporting the pet. They aid in transitioning a
recumbent animal to a standing position, especially larger dogs. They
can also assist with ambulation and prevent falls on slippery floors,
especially after surgery, to avoid further injury to the animal. Support
slings are also available for forelimb assistance and patients with
amputations.
Slings are available in a variety of sizes to provide the best fit. It
is important to select a properly sized sling for safety and comfort of
the patient. The sling used for the forelimbs should not obstruct
respiration, and urine flow should not be compromised with hindlimb
slings in male dogs. They should have a soft lining against the animals
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skin to avoid irritation and sores, and they should be washable. Be
cautious that the sling is not too thin, especially around the groin and
belly region, to avoid excessive pressure and sores. They can be
conveniently designed for both male and female patients.
Slings are also useful during the rehabilitation phase and can be
used for supported standing during therapeutic exercises, such as
repeated sit to stands. With a sling supporting the caudal abdomen
or hindlimbs, the hind end is assisted to a standing position, with the
therapist making sure the feet are in a standing position. As the dog
is allowed to sit back down, the patient is assisted to a standing
position again, repeating the exercise. When documenting patient
progress, the amount of assistance given through sling support can
be rated as minimum, moderate or maximal assistance.
In dogs with spinal cord trauma, crossing the hind limbs under
the abdomen while walking is common. In an effort to assist
ambulation and keep the legs properly positioned, a rolled towel may
be taped to the middle of a sling to maintain the hindlimbs in a normal
position or in slight abduction, improving independent ambulation. If
the towel is too large over-abduction of the hindlimbs may occur and
adversely affect gait.
Carts
Carts, or canine wheel chairs, are beneficial to provide support,
allow independence for both the owner and animal, and prevent the
deleterious effects of recumbency. Carts can be designed with two
or four-wheels for a variety of companions that are permanently
disabled. It is relatively easy for one person to place an animal into
the lightweight frame, and the wheels are designed to traverse most
terrains.
Carts should not be used in place of a rehabilitation program. If
ordered early in the rehabilitation phase, owners may become too
dependent on the cart's support and use it as a replacement for
exercise and rehabilitation. They are also not to be used in place of
therapeutic exercises that may help to improve function. It is
important that the owner is encouraged to carry out the rehabilitation
program before ordering a cart to encourage the patient to ambulate
and achieve as complete a recovery as possible, including neurologic
function and muscle strength.
As with introducing any new device, the transition into the cart
should be a positive experience. To reduce unnecessary stress on the
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animal, familiarize yourself with the cart and its parts prior to placing
an animal in the device. Animals should be supervised at all times
when in a cart so that they do not fall out, tumble down a flight of
stairs, tip over, or become stuck on an object. Animals should be able
to eat and drink while in their carts, although bowls may need to be
elevated. A rest period out of the cart is necessary on frequent
occasions, especially for larger dogs, because it is difficult for animals
to rest comfortably while in a cart. Frequent skin assessment is
important to ensure no areas of skin breakdown occur. Patients
standing in a cart may also be unable to tolerate for more than a short
time period the cardiac, pulmonary, or neuromusculoskeletal stress of
being in a cart. For those animals, such as those with Wobbler's
disease, that are in a cart with all four limbs supported or are
completely non-weightbearing, 30 minutes at one time is sufficient.
After this time, there is the potential that ischemic damage may occur
as a result of vascular compression and compromised circulation.
Rehabilitation
The goals for rehabilitation of the acute spinal cord patient
include reducing pain, addressing inflammation, maintaining joint
range of motion, reducing muscle atrophy, and restoring ambulatory
function.
Massage therapy should include gentle manipulation of soft
tissues superficially and, over time, more deeply to minimize
adhesions, promote muscle relaxation, and to reduce joint stiffness.
The massage is performed in the direction of tissues or in circular
strokes, moving skin and underlying tissue together to loosen tissue.
If the purpose of the massage is to relax the patient and prepare for
range of motion or therapeutic exercises, a 5 to 10 minute superficial
massage is likely adequate immediately preceding these activities.
Muscle relaxation may be further encouraged by using petrissage, a
technique of rolling and kneading muscles.
Passive range of motion exercises are useful to help maintain
joint motion and the flexibility of soft tissue such as muscle and
tendons. The patient should be placed in lateral recumbency with
each joint place through 15 to 20 cycles of flexion and extension. In
addition, the entire limb may be placed through a range of motion in a
bicycling fashion. Because many patients have upper motor neuron
disease, avoid placing their hands on the bottom of the foot well
doing range of motion activities because this may stimulate and
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extensor reflex. Sometimes gently flexing the digits will help to
disrupt the extensor tone.
Flexor reflexes may be used to help the less active muscle
contraction and flexion of joints. The activity is performed as it would
during a neurologic evaluation. Particular care must be taken to avoid
drama to the digits and eliciting too much pain or discomfort. Other
reflexes may also be incorporated, such as the patellar reflex or
triceps reflex.
Standing exercises help to strengthen postural muscles and
begin the process of muscle reeducation for balance and
proprioception. Assistive devices such as slayings, fizzy or roles or lifts
may be used in large animals to maintain them in a standing position.
Smaller patients may be manually supported. The patient is placed in
a standing position with the feet squarely placed under the body. The
animal is supported until it begins to fatigue, and is then picked up
and placed in a standing position again. This exercise is performed for
15 to 20 repetitions, 3 to 4 times a day, with the goal of having the
animal remain in a standing position with full weight bearing for five
minutes. As the patient improves, assisted sit to stand activities may
be incorporated. Initially, 5 to 10 repetitions are performed, gradually
working up to 20 repetitions three times per day.
Aquatic exercises may be incorporated as early as 3 to 5 days
after surgery, as long as the incision is not submerged. Supported
swimming may be especially useful in the patient with some motor
function, but severe proprioceptive deficits. In many cases, patients
with severe spinal cord injury will begin to reflexively move the legs in
the water, generating some neuromuscular reeducation and muscle
strengthening. As the motions become more coordinated, the
patient may be exercised on a land or underwater treadmill. Research
regarding human stroke patients has indicated that patients walking
on a treadmill with support recover function sooner and more
completely as compared to simply walking over ground. It is
important that the therapist help assist limb motion and correct foot
placement for all strides while the dog is exercising on a treadmill.
Short periods of activity with adequate rest while walking are
important to prevent fatigue. Gradually, the length of the walks is
increased. Sling assisted walking over ground may be instituted.
During this phase, foot protection is important to prevent ulcerations
on the dorsum of the feet.
As the patient develops strength and better motor control,
31
attention is directed toward improving proprioceptive function.
Perturbation exercises with the patient in a standing position are
initially used. Other activities include balancing on a balance or
wobble board, a quadruped balance board, physiorolls, or therapy
balls. Ambulatory activities include walking in a figure of eight
pattern or through a series of vertical weave poles. As strength and
coordination improve, other activities such as walking over Cavaletti
rails will help to facilitate proprioceptive functioning. Walking over a
variety of ground surfaces, a trampoline, or air mattress help to
further improve proprioception.
The later phases of rehabilitation concentrate on muscle
strengthening and adding speed to the activities to help return the
dog to normal function. Walking on a treadmill with theraband
resistance is one way to improve strengthening. Limb weights may
also be used. Swimming is also useful. Incorporating jogging, and
jogging up hills and inclines will help with speed and strength
development. Stair climbing not only helps with muscle
development, but also proprioceptive awareness.
Sample Protocol for Intervertebral Disk Disease
A step-wise program to rehabilitation is recommended for
patients recovering from intervertebral disk disease surgery. The
increases in activities are based on the patient reaching certain
milestones in their recovery.
Step 1: Immediately Postoperatively to Supporting Weight
The surgical approach to the spinal cord is quite extensive, and
multiple muscles are elevated from the articular facets of the
vertebrae. Cryotherapy of the incision site and underlying tissues
may be beneficial to reduce inflammation and swelling in this area.
Depending on the surgeon and the severity of injury to the spinal
cord, corticosteroids or NSAIDs may be administered to help reduce
the effects of swelling and inflammation on the spinal cord. Because
the patient may not be ambulatory for a period of time, ROM
exercises should be performed to all of the joints of the rear limbs.
Massage of the rear limb muscles may help to relax the muscles in
cases with upper motor neuron lesions, while tapotment of the
muscles may be beneficial to help maintain muscle tone in cases with
lower motor neuron lesions.
Neuromuscular electrical stimulation to the rear limb muscles is
32
helpful to attenuate muscle atrophy if lower motor neuron signs are
present. Standing exercises are instituted the day after surgery to
encourage neuromuscular re-education of the muscles responsible
for maintaining normal standing posture and to strengthen these
muscles to allow weight- bearing, and ultimately, ambulation.
It is also extremely important to provide excellent nursing care
to dogs that are recumbent and unable to shift body positions
without assistance. Care of the recumbent dog includes being certain
that the patient is on a soft bed, is turned every 4 hours to help
prevent decubital ulcers, is kept clean to avoid urine scalds, can easily
reach food and water (offering these every few hours is important),
and providing bladder care to be certain that the bladder does not
become overdistended, especially if an upper motor neuron lesion is
present. Because patients will knuckle over on the dorsum of the feet,
these areas must be evaluated on a daily basis to be certain that there
are no excoriations or abrasions. Protective boots may be placed on
the feet, which helps to protect them from injury and helps to position
the foot in a more correct standing position.
Step 2: Supporting Weight to Initial Motor Function
Passive ROM exercises are continued, as are standing
exercises. The patient should be placed in a standing position with all
four limbs placed squarely under the dog to provide stability. The
therapist then helps to balance the patient to prevent it from falling to
the side. If the patient begins to weaken and collapse, the therapist
pulls the dog into a standing position again. This will help to
strengthen the back and limb muscles in preparation for ambulation.
Standing in water is very beneficial because the buoyancy of the
water helps the patient to maintain a standing position, even if
weakness is present. The buoyancy of the water also gives the animal
more time to maintain a standing position if the patient loses its
balance, allowing a split second of time to readjust the limbs before
falling. Standing in water is especially useful if the patient is a large or
giant breed of dog. When a dog is able to stand without assistance,
even for a few seconds, gentle force may be applied to the wings of
the iliums to increase muscle strengthening and to provide neuromuscular reeducation.
Swimming is excellent to encourage early motor function.
Many patients will make minimal attempts to move their limbs when
on dry ground, even if supported by an attendant. Many of these
33
patients will make some crude motor movements while floating in the
water, even if those motions are weak and uncoordinated. This form
of initial motor activity is important for neuromuscular reeducation
and to help maintain muscle mass.
Walking while supported in a sling is the next step to encourage
gait patterning and strengthening. The back is a critical component to
help the dog support its weight, and to initially help the patient to
shift a large amount of the body weight to the forelimbs while the rear
limbs are recovering coordination and strength. Because a
hemilaminectomy is the typical surgical procedure to remove
herniated disk material, and the muscles on one side undergo
extensive dissection, neuromuscular electrical stimulation to the
weak side of the back may be beneficial.
Step 3:Initial Motor Function to Good Motor Function With Proprioceptive Deficits
Swimming is continued to help with muscle strengthening and
gait retraining. In addition, walking on a ground treadmill with the
therapist positioned to assist gait and correct placement of the foot
when it is advanced helps with gait training and is a vital functional
activity.
Balancing activities, to help enhance proprioceptive training
may be instituted when motor function is recovered to the point that
some gait patterning has returned. Proprioceptive exercises are
those that facilitate rapid muscle contractions, focusing on closed
kinetic chain exercises and improving dynamic stability. Such
exercises include use of a balance board, weight shifts, standing on a
therapy roll while it is rocked back and forth, varying the speed of
ambulation, incorporation of zig-zags when walking or trotting, figure
8s patterns, circles to the right and left, and walking on trampolines or
other unstable surfaces.
Step 4: Good Motor Function with Proprioceptive Deficits to Near
Normal Gait
Swimming and treadmill walking are continued to enhance gait
training and muscle strengthening. Increasing the speed and length
of treadmill walking will help challenge patients to achieve a higher
level of functioning. Stair climbing may be added as another
functional activity that should be mastered. In addition, negotiating
stairs helps with proprioceptive training, as well as strength training
34
of the rear limb muscles.
Balancing activities are continued as in step 3. To further help with
proprioceptive training, patients may be walked over rails placed on
the ground, or raised Cavaletti rails. Rear limb muscle strengthening
may be further enhanced with sit-to-stand exercises. Jogging may be
added as the patient regains proprioceptive functioning to allow
work at higher speeds.
Step 5: Near Normal Gait to Normal Gait
The other activities in previous steps may be continued. The
length of time spent swimming is increased to improve endurance
and muscle strengthening. In addition, jogging on the treadmill and
jogging up and down small stairs may be added to encourage
proprioceptive challenges at higher speeds. Walking over raised
Cavaletti rails is continued, and if the patient is able, they may
negotiate the rails while jogging. Playing ball is added as an activity as
the patient nears return to a normal gait.
References
Drum MG. Physical rehabilitation of the canine neurologic patient. Vet
Clin Small Anim 40:181193, 2010.
Millis DL, Levine D, Taylor R. Canine rehabilitation and physical
therapy. Philadelphia: WB Saunders; 2004.
Olby N, Halling KB, Glick TR. Rehabilitation for the neurologic patient.
Vet Clin North Am Small Anim Pract. 35:1389-409, 2005.
35
36
THE PARETIC PATIENT: WHERE AND WHAT IS THE PROBLEM?
Dr. Cristian Falzone, DVM, DECVNS, MRCVS
European Specialist in veterinary neurology
Dogs with gait disorders are commonly presented to the
attention of veterinary neurologists but also, to general practitioners
with an increasing frequency.
The first and most important step is to define those patients
with gait disorders that are affected by a neurological problem. In
fact, orthopedic diseases can sometimes mimic neurologic ones or
can be concurrent with the latter. The evaluation of gait and
proprioceptive positioning is fundamental to differentiate between
an orthopedic and a neurologic disease. The two most common gait
changes noticed with neurological disorders are ataxia and paresis.
Ataxia is a sensory deficit and it can be more simply described as
incoordination: it is mainly encountered with vestibular, cerebellar
and spinal diseases. Paresis is a motor deficit instead, severe
weakness in other words; paresis can progress to paralysis or plegia in
case of complete absence of movements. Both ataxia and/or paresis
can involve 2 or all 4 legs, depending onto the location of the lesion,
as it will be discussed later. So far, it is possible to state animals with
ataxia/paresis on their gait evaluation should be suspected as
suffering from a neurologic disease, until proven otherwise. This
suspicion should be then confirmed by evaluating the proprioceptive
positioning: this is performed by knuckling the paws while supporting
the animal's weight and then assessing their replacement (Fig. 1). If
proprioceptive deficits are noticed, then a neurological disease is very
likely to be the cause of the gait disorder.
The second step would be to localize the neurological problem.
Generally and simplistically speaking, a paretic patient might be
affected by a spinal or a neuromuscular disorder; a brainstem
problem can also give paresis amongst other, sometimes more
severe, clinical signs.
With spinal diseases it is not uncommon to have ataxia and paresis
together; all the 4 legs will be affected with a cervical spinal cord
disorder and only the back legs will be abnormal with a thoracolumbar
cord problem.
With diffuse neuromuscular diseases all 4 legs will be affected
37
and weakness/paresis alongside a variable degree of exercise
intolerance will be the major clinical signs. In such a case
proprioceptive deficits will be noticed in all 4 legs and moreover,
spinal reflexes (mainly patellar and withdrawal) will be generally
decreased. In these patients it is also quite common to identify
concurrent larynx/pharynx and esophageal involvement with
dysphagia, abnormal gag, hypophonia and megaesophagus (+/aspiration pneumonia) as the result.
With brainstem disorders, beside ataxia/paresis on all 4 legs,
there are usually signs of intracranial involvement like altered mental
status, menace response deficits, and involvement of multiple cranial
nerves.
How to confirm the diagnosis and treat the most common
neurological causes of paresis: part 1
When a patient has been suspected and localized with a
neurological problem, it is fundamental to establish the correct
diagnosis and then the treatment.
Magnetic Resonance Imaging (MRI) is generally accepted as the
gold standard in diagnosis of central nervous system disorders, either
intracranial or spinal, thanks to its high resolution for soft tissues.
Moreover, it allows acquisition of images onto the three spatial
planes, which is very useful when relationships between normal and
abnormal areas should be assessed and/or a surgical excision should
be planned.
However, especially in case of a suspected spinal lesion, other
imaging modalities, sometimes more easily accessible, may provide
the diagnosis and this is one of the reasons why it is important to list
the most likely differentials, before performing any advanced
investigation. The acronym VITAMIN D is generally useful to go
trough the possible etiologies and to guide the imaging modality
decision: Vascular, Inflammatory/infectious, Traumatic, Anomaly,
Metabolic, Idiopathic, Neoplastic and Degenerative.
The most common vascular disease affecting the spine is the
ischaemic myelopathy, also known as fibrocartilaginous embolic
myelopathy. This is characterized by peracute/acute onset of
lateralized ataxia/paresis, quite commonly while running. MRI is the
only imaging modality that can potentially show the ischemic cord
changes. Provided the deep pain perception is present and there are
38
no major underling predisposing diseases, the prognosis is good with
physiotherapy, though some permanent residual deficits are likely,
especially in severely affected patients.
The group of the inflammatory/infectious diseases is mainly
made by meningitis/meningomyelitis and discospondylitis.
Meningitis and meningomyelitis are inflammation of the meninges
and meninges plus spinal cord, respectively. Spinal pain is commonly
the only clinical/neurological sign, alongside low head carriage and
stiff gate. Systemic signs may be present (eg., fever, leucocytosis) but
the most important test to confirm a presumptive diagnosis of
m e n i n g i t i s i s t h e c e re b ro s p i n a l f l u i d ( C S F ) a n a l y s i s .
Meningitis/meningomyelitis are sterile in the vast majority of cases,
likely immune-mediated in origin. The most famous form of
meningitis is probably the Steroid responsive meningo-arteritis
(SRMA) which mainly affects dogs younger than 1 year of age: the
recommended treatment is steroids (Prednisolone) at a decreasing
dose over an average period of 6 months and the prognosis is
generally good, though a minority of patients can relapse.
Discospondylitis consists of an infection of the vertebral end
plates and disc: they are commonly held by bacteria that can reach the
disc space by hematogenous spread or by a migrating foreign body.
Treatment is generally conservative (antibiotics and rest), and
prognosis good; the prognosis is poor in case of fungal origin instead.
If major involvement of the spinal canal/compression of spinal cord
(eg., epidural empyema) or severe spinal instability were present,
surgery cold be required.
With traumatic spinal diseases x-rays are very useful to establish
vertebral subluxation/fracture; surgical stabilization is mandatory
anytime spinal instability is suspected. In the absence of major
radiographic findings, CT or even MRI might be required: thanks to
the latter traumatic disc disease and/or spinal cord contusion can be
visualized.
The spinal anomalies can involve the vertebrae or the neural
structures: amongst the former, hemivertebra and atlanto-axial
subluxation are probably the most common. They can lead to
different degree of spinal cord damage as a consequence of vertebral
instability and/or vertebral canal stenosis and subsequent cord
compression. X-rays, CT and MRI can all be useful diagnostic tools.
Surgery is usually necessary as the definitive treatment with variable
prognosis, though it is usually fair/good when no severe neurological
39
signs are present at the time of surgery.
Common anomalies of the neural structures are represented by
spinal cysts. Myelography and myelo-CT generally show the cyst
itself and the spinal cord compression; MRI can also be used but on
some occasion the imaging interpretation may be challenging. An
early surgical treatment, before severe clinical signs (e.g., faecal
and/or urinary incontinence) develop, usually end up in a fair-good
prognosis, though some deficits may remain and some patients may
show a relapse.
Metabolic diseases do not generally cause spinal disorder; the
concept of “idiopathic myelopathies” is relatively vague and they
tend to be excluded as a cause of spinal ataxia/paresis.
Neoplasia can affect primarily the spinal cord or arise from adjacent
structures (vertebras, nerve roots) and then compress/infiltrate the
spinal cord itself. X-rays sometimes can already be of some diagnostic
benefit, even if CT or MRI scan may be further necessary. The
prognosis is generally guarded, though some of the most common
spinal tumors (e.g., lymphoma, meningioma) can be treated with
chemotherapy, radiotherapy and/or excisional surgery, with a
relatively fair/good survival time.
Degenerative diseases mostly comprehend degenerative
myelopathy and degenerative disc diseases (disc hernitations).
Degenerative myelopathy affects middle/old aged and large
breed dogs: it is characterized by chronic onset and progressive
paraparesis. It is not a painful condition and the diagnosis, despite
being possible only as a post-mortem exam, can be suspected by
excluding other possible causes of thoracolumbar disorders with
advanced imaging modalities. Unfortunately at present, there exists
no curative treatments and the prognosis is inevitably poor.
Degenerative disc diseases are classically divided into Hansen
type I and Hansen type II or, more generally, in disc extrusion and
protrusion respectively (Fig. 2). With disc extrusions the onset of the
clinical signs is acute and the spinal cord compression is due to fresh
extruded nucleus pulposus: the diagnosis can be done via
myelograpgy, CT and MRI. They commonly required a surgical
treatment (decompressive surgery) and, in case of positive deep pain
perception, the success rate is close to 90% or even higher. If deep
pain was lost, the prognosis seems more guarded, even if recent data
suggest good outcome up to about 60% of the cases.
Disc protrusions usually have a more chronic/insidious onset of
40
the clinical signs: the latter, if not severe, can be treated
conservatively (pain relievers and restricted exercise) with relatively
good short-term outcome, though they usually tend to deteriorate
over a long run. In case of moderate/severe clinical signs and obvious
cord compression, an early surgical treatment is advisable in order to
guarantee a better long-term outcome.
How to confirm the diagnosis and treat the most common
neurological causes of paresis: part 2
Generalized neuromuscular disorders can be due to a diffuse
involvement of the peripheral nerves, muscles or the neuromuscular
junction.
Relatively common causes of generalized peripheral nerves and
muscles disorders are inflammatory/infectious diseases, metabolic
diseases, “tumors” (see later for further details) and even more
commonly, they are idiopathic in origin.
The most common form amongst the polyneuropathy is the
acute polyradiculoneuritis: histologically it is an inflammatory disease
but in reality, it is an idiopathic form as generally no etiologies are
identified.
The inflammation seems immune-mediated and it can
be triggered by any event able to stimulate the immune system:
vaccines, trauma, infections, etc.. This form has been previously
known also as “Coonhound Paralysis”, since it was commonly
encountered in dogs after being in contact with raccoon saliva.
All dogs (and cats) can be affected with no gender or age
predisposition: the signs (compatible with a lower motor neuron
involvement) usually start from the back legs and progress to the
front over 3-7 days. As in many neuromuscular diseases, the
electromyography (EMG) is abnormal but non-specific. Common
EMG changes are fibrillation potentials and positive sharp waves:
lumbar CSF analysis may reveal increase of protein. Histological exam
of peripheral nerves might show, besides axonal degeneration and
segmental demyelination, inflammatory cells infiltration, even though
those changes tend to be less severe or absent in the more distal part
of the nerve (the part which is usually sampled) and more prominent in
the nerve roots and as such, they can be missed on a routine nerve
biopsy evaluation.
There is no proven effective treatment for acute
polyradiculoneuritis and the use of corticosteroids is controversial;
41
supportive care and intensive physiotherapy are the key. Most dogs
recover fully, though some of them may be left with residual
neurologic deficits and some others can even die, usually because of
severe respiratory compromise that can occur especially during the
first days of disease.
Neospora caninum can cause polyneuropathy and/or polymyopathy:
dogs affected are very young, usually weeks, and show diffuse muscle
atrophy/contracture mainly on the back legs (Fig. 3). The infection
usually occurs in utero and an early diagnosis (via serology, EMG and
nerve-muscle biopsy) and treatment (Clindamycin 10-15 mg/kg twice
daily) are crucial for a good prognosis, which otherwise it is guardedpoor.
Amongst the metabolic disorders, diabetes mellitus and
hypothyroidism are usually a cause of polyneuropathy and
polymyopathy, respectively. Commonly other clinical signs are
present besides the neurological problem and the diagnosis is
achieved via laboratory tests. The prognosis is fair to good and it
mostly depends on the severity and chronicity of the clinical signs at
the time of the beginning of the treatment.
A relatively common cause of polyneuropathy is tumor: in fact,
neoplasia (eg, Lymphoma, Insulinoma, carcinoma) can end up in what
is called paraneoplastic neuropathy which is secondary to a possible
immune-mediated involvement of the peripheral nervous system
though the underlying mechanism is not fully understood yet.
Occasionally, anti-neoplastic drugs (eg, Vincristine, Cisplatin) can also
lead to diffuse neuromuscular symptoms.
Inflammatory myopathies are generally immunemediated in
origin and they might be focal or generalized: among the former
Masticatory Muscle Myositis is the most common form. All the muscle
of mastication can be monolaterally or, more frequently, bilaterally
involved. Dogs are usually presented for severe pain, reluctance to
open the mouth and, at an early stage, swollen masticatory muscle or
exophthalmos can be noticed. The diagnosis can be achieved by
performing blood tests (antibodies against type IIM myofibers) and
muscle biopsy; head MRI scan can show muscle changes compatible
with muscle inflammation, fibrosis/atrophy. Immunosuppressive
dosage of steroid is the treatment of choice: the prognosis is
generally very good if identified and treated during the acute phase
of the disease. However, persistent muscle atrophy is a common
residual sign. Less responding patients may never regain the ability to
42
adequately open the jaw and eat normally (trismus).
In case of a more diffuse polymyositis, exercise intolerance,
weakness, stiff gait and low head carriage and generalized pain over
muscle palpation are common findings; blood test can reveal increase
of muscle enzymes (mainly CK). The diagnosis is confirmed by EMG
and muscle biopsy; treatment is based on immunosuppression and
the prognosis is generally good in the absence of megaesophagus.
In the case of episodic neuromuscular signs, especially if
exercise-induced, myasthenia gravis should be suspected. It may be
congenital (eg, Jack Russell, Springer Spaniel) or, more commonly,
acquired, focal (43%) or generalized (57%). The diagnosis is achieved
by demonstration of circulating antibodies against Acetylcholine
receptors. Treatment is a quite controversial, though supportive
therapy seems the key. Prognosis is guarded-good, mainly depending on the presence/absence of secondary major complication such
as megaesophagus and aspiration pneumonia.
Fig.1: absence of proprioception on the right back leg
Fig.2: schematic representation of disc extrusion and protrusion
(left to right)
43
Fig.3: note the hyperextension of the left hind limb in this
Labrador puppy affected by Neosporosis
44
NEUROLOGICAL EXAMINATION
Refresh your diagnostic knowledge
Prof. Andrzej Pomianowski, DVM,PhD
Department of Internal Diseases Veterinary Medicine Faculty
Olsztyn, Poland
The neurological examination is composed of six parts: the
evaluation of the mental status, gait and posture, cranial nerves
reflexes, posturaI reactions, spinal reflexes and pain perception. Of
these, it is the evaluation of the mental status and gait and posture
that are the most important to localize the lesion. The mental status
dictates if the lesion is intra or extra-cranial. The evaluation of the gait
and posture is crucial in determining if the nature of the gait
abnormalities is related to the nervous system or to a musculoskeletal problem.
Mental status
The mental status is the most important clue in differentiating intrafrom extracranial disease in the animaI with cranial nerve
abnormalities. The abnormalities of the mental status relate to the
brainstem or to the thalamocortex.
The mental status cannot be evaluated in the examination room, even
if the animal has had time to relax. In most cases, the evaluation is
obtained from the history, not from observation of the animal. Dogs
and cats are excited and/or fearful in the hospital environment. This
adrenaline surge hides the mental changes, especially if subtle.
The history is crucial and must be thoroughly performed.
Brainstem: State of consciousness
The bulk of the brainstem parenchyma is made of the reticular
formation or the so-called Ascending Reticular Activating System
(ARAS). This formation is responsible for the arousal of the cerebrum.
When this system is affected, the animal becomes somnolent,
lethargic, stuporous or comatose. However, he is aware of his
surrounding because his intelligence (cerebrum and thalamus) is not
affected. The owner must be asked specific questions regarding the
45
mental status of the animal: Is the animal as playful? Does he sleep
more than before? Is he quieter, lethargic? If the animal is historically
somnolent and this is accompanied by cranial nerve deficits, the
disease is intracranial and involves the brainstem.
When the animal is acting strangely, the key question here is
whether the forebrain is functioning normally at this particular time.
The best tests here are to observe the animal and then to test the
menace response (which requires much of the brain to function
normally) and test the response to lightly touching the nasal mucosa.
Although the trigeminal nerve is responsible for providing sensation
to the mucosa, the sensory cortex is required to interpret light touch
in this area as being irritating. Therefore the loss of this response
whilst the cranial nerve tests of trigeminal function (blink reflex and
jaw tone) are intact would suggest a lesion of the contralateral
sensory cortex.
Cranial nerves
Many tests are very quick to do : an examination of most of the cranial
nerves can be completed within a minute and simply looking for
asymmetry in an animal's face can quite often detect deficits in cranial
function. If the all cranial nerves reflexes are intact, the pathological
problem is localizing in spinal cord.
Gait and posture
The evaluation of the gait is important in lesion localization. For the
small cat or dog, the examiner lets the animal walk freely on the floor
of the examination room while taking the history. Most hospital
rooms do not allow a good examination of the gait because of their
small size. It is preferable that the medium to large size dog be leashwalked by the owner in the parking lot, back yard or sidewalk. Use a
non-slippery floor such as concrete, grass, asphalt, etc. The dog is
evaluated at different paces, towards and away from the examiner.
The clinician observes the front limb gait as the animal is coming
toward him/her and the hind limb gait as the animal is going away
from him/her.
Particular attention is given to the foot placement when the animal
turns or changes speed. A series of questions are then answered. The
46
questions should not be left unanswered. If unsure, look at the gait
again and again.
1. Is the animal able to walk?
2. If the animal is walking, is the gait normal?
3. Which limb(s) is/are affected: one limb, both hind limbs,
the hind and front limbs, or the ipsilateral limbs only?
4. Is there ataxia?
5. If there is ataxia, of which type: vestibular, cerebellar
or proprioceptive?
Proprioceptive positioning
Performed appropriately, proprioceptive positioning (knuckling) is an
invaluable tool to evaluate proprioception. To evaluate
proprioceptive positioning of the hind limbs, the clinician is
positioned behind the animal. The animal's weight must be
supported with a hand (and forearm in the large dog) between and
behind the hind limbs. For the evaluation of the front limbs, the
exarniner's hand is placed between the limbs and behind or in front of
the limbs. The paw is then slowly knuckled over. The flexion of the
toes stimulates hundreds of proprioceptors located in the tendons
and joints of the toes. The test must be done with care to enhance
subtleties. A pet that knuckles does not necessarily have
proprioceptive deficits. Orthopaedic problems, generalized weakness and patient's personality may all have an effect on the test. The
test results must be taken in the light of the entire examination.
Patellar reflexes
The patellar reflex (tendinous or monosynaptic reflex) is elicited by
tapping the patellar tendon. There are two components to the reflex:
the ascending sensory pathway and the descending pathway or lower
motor neuron.
Both must be intact for the reflex to be present. To elicit the reflex. the
limb is positioned in a relaxed flexion to tighten the patellar tendon.
This reflex is the most often erroneously found to be absent. It is
important to pay attention to details when eliciting it to ensure its
absence is real and not the result of poor technique. If the reflex is
absent yet the animal can walk and/or stand, the lesion likely involves
47
the sensory pathway and not the lower motor neuron.
Withdrawal or flexor reflexes
The withdrawal (flexor) reflexes are difficult to examine objectively
because in most of our patients, purposeful movements are still
present (so pain perception is as well) and the animal inhibits the
response, leading to a falsely decreased reflex. A normal animal
should be able to bring his body to the examiner's hand while flexing
the limb. The front limb reflexes can be used as a comparison for the
hind limbs and vice versa. Musculo-skeletal disorders may affect the
nature of the flexor and patellar reflexes. The patellar reflex may be
absent or decreased in a dog with a cruciate rupture because the
tension in the tendon cannot be raised. Hip dysplasia, polyarthritis
and muscle diseases may lead to decreased flexor reflexes because
the animal is too weak to withdraw his limb with force.
The neurological examination should be done in a methodical and
stringent manner every single time paying attention to details. A
neurological form should always be filled. Although the examination
when performed on a regular basis becomes a routine, the form
serves as a "check list" ensuring that all parameters have been
evaluated. More importantly, it is an invaluable document in the
follow up and monitoring of progressive and protracted nervous
system diseases.
Table 1. Neurologic Examination
I.Observation"
Mental status
Posture
Movement
II. Palpation"
Integument
Muscles
Skeleton
III. Postural Reactions
Proprioceptive positioning"
Wheelbarrowing
48
Hopping"
Extensor posturaI thrust
Hemistanding and hemiwalking
Placing (tactile)
Placing (visual)
Sway test
Tonic neck
IV. Spinal Reflexes
Myotatic
Pelvic limb
Quadriceps
femoris
rnuscle"
Cranial tibial
muscle
Gastrocnernius
muscle
Thoracic limb
Extensor carpi
radialis
muscle
Triceps
brachii
muscle
Biceps brachii muscle
Flexor"
Extensor thrust
Perineal"
Crossed extensor
Extensor toe
V. Cranial Nerves
Olfactory
Optic"
Oculomotor"
Trochlear
49
Trigeminal"
Abducent"
Facial”
Vestibulocochlear"
Glossopharyngeal"
Vagus"
Accessory
Hypoglossal"
VI. Sensation
Touch
H yperesthesia”
Superficial pain"
Deep pain*
“lncluded in a screening examination.
* if superficial pain is absent.
The animal cannot walk on its hind limbs
There are two key questions that need to be answered here: 1) is the
lesion in the ,,lower motor neuron”section of the spinal cord (L4-S3) or
is it more cranial ?; 2) is there any sign of a problem with the thoracic
limbs ?
In such a case it is not necessary to test the postural reactions in the
pelvic limbs since they must be deficient if the animal cannot use them
to walk; instead the focus should be on postural reaction testing in the
thoracic limbs (could the lesion extend beyond T3) and reflex testing
in the pelvic limbs (is the lesion caudal or cranial to L4). The best reflex
test is the flexor reflex because this is always reliable and may also
suggests where within the L4-S3 segment is affected if the lesion is
caudal to L4. The best postural reaction test is hopping since it is rare
for animals to be deficit in that test but normal in the proprioceptive
knuckling test but not vice versa.
The most likely site of lesion would be around the thoracolumbar
junction (because it is commonly affected by many pathological
processes) and use of the panniculus reflex will aid in localizing within
the T3-L3 segment. The next issue if the lesion suggests T3-L3
location is to test the ,,deep pain'' response because it is important
50
for determining prognosis.
Deep pain is tested by applying firm pressure to the bones of the
digit of a thoracic or pelvic limb with the fingers or a hemostat to elicit
behavioral response. A positive behavioral response to deep pain is
consistent turning of the head an looking, vocalizing, trying to bite of
examiner, or trying to escape when the toe is pinched. Withdrawal of
the limb is only the flexor reflex and does not mean the animal
consciously perceives the painful stimulus. If response to deep pain
appears absent from one digit, all remaining digits and the tail should
be tested to determine if there is a complete loss of deep pain
perception. Deep pain is a small-fiber, nonlocalizing pain, which is
carried in a multifocal network within the spinal cord and is usually the
last sensation that remains in spinal cord lesions. Complete loss of the
ability to feel deep pain signifies a severe spinal cord lesion. If the
deep sensation is absent for a month or longer in animals with spinal
cord lesions, recovery function is unlikely.
Table 2. Summary Table for Lesion Localization
Lesion
Flexor Reflex:
Thoracic Limbs
Flexor Reflex:
Pelvic Limbs
Hopping:
Thoracic Limbs
Hopping:
Pelvic Limbs
C1-C5
C6-T2
T3-L3
L4-S3
present
reduced
present
present
present
present
present
reduced
reduced
reduced
present
present
reduced
reduced
reduced
reduced
The animal cannot walk on any of its limbs
The key question here is whether it is a generalized lower motor
neuron lesion (commonly multiple peripheral nerve disease) or
whether it could be a cervical spinal cord or brainstem lesion. The best
test here would be reflex testing in thoracic and pelvic limbs, since
that will quickly discriminate between those two possibilities again,
the flexor reflexes are the most useful.
When the neurologic examination is complete, an attempt should be
made to explain all abnormal findings by a lesion at one anatomic site.
If this cannot be done, the animal may have a multifocal or diffuse
process and the differential diagnosis should reflect this. Two
51
separate and distinct lesion sites from two different diseases is an
unlikely scenario in clinical neurology unless one can be explained by
a history of longstanding problem unrelated to the current primary
complaint. Each anatomical region has specific signs, which localize
lesions to that region.
52
NEUROLOGIC ADDITIONAL SPECIAL EXAMINATION
Miloslawa Kwiatkowska, DVM
Aneta Bochenska, DVM
University Warmia and Mazury Olsztyn, Poland
Survey radiography
Survey radiographs need to be performed with the animal deeply
sedated or under general anaesthesia, properly positioned and
preferably with an empty colon. Radiographs must be always
perfomed to rule out the fractures, luxations, osseous neoplasia,
intradiscal osteomyelitis associated with discospondylitis, or
congenital backbone deformities. While looking at radiograph each
veterinarian should find “its own way of investigation”, he may start
from the head looking towards tail, or the opposite way, afterwards
adjacent soft tissues should be investigated. Stress radiography, such
as dynamic flexion/extension studies, may accentuate some the
lesions, like the lumbosacral instability or atlantoaxial subluxation.
Contrast-Enhanced radiography
Myelography is indicated when focal spinal cord lesion is suspected
and no inflammatory response is seen on CSF analysis. The contrast
may be injected in subocciptial injection, or in the lumbosacral
injection. The contrast media mixes with CSF that surrounds the
spinal cord and demonstrates focal spinal cord compression or
expansion. Myelography is performed when neurological examination indicates a particular spinal lesion, but is not visible on plain
radiography. It may be helpful when multiple lesions are identified on
plain radiographs and in determining the presence of persistent cord
compression. If a veterinarian does not have an MRI modality and
considers performing surgery myelography is helpful to asses
indications. Among disadvantages of myelography according to
Penderis, et al. (1999), sub dural injection is most common
complication observed during cisternal injection of contrast medium,
post-procedural seizures, and slight risk of needle puncture into
medulla oblongata or cervical spinal cord.
Discography is performed by the injection of contrast into the disc. In
53
healthy dogs, less than 0.2ml of contrast can be injected under
pressure into disc, whereas 1-3ml can easily be injected into a
degenerated disc. The procedure is helpful to diagnose lateral disc
herniations. Foraminal stenosis causing nerve root compression and
dorsal stenotic lesions may not be seen. The accuracy of discography
in the diagnosis of LS disc disease has been documented to be
between 87-93%. Although a normal discogram certainly rules out
disc herniation, false positives are possible.
Epidurography may be performed
following discography by
injecting contrast medium after repositioning the tip of the needle
into the ventral epidural space at the level of the LS junction. It has
been reported to be diagnostic in 78%-93% of dogs confirmed
surgically to have lumbosacral stenosis. The examination is easier to
perform than myelography and is characterised by smaller morbidity
rate. Injection of upto 6ml of contrast is performed between the 3rd
sacral and the 1st caudal vertebrae. Complicated anatomy of epidural
space, presence of fat and multiple lateral openings, in general make
interpretation of epidurograms difficult in many cases. Flexed and
extended views of the LS joint during epidurography may accentuate
a compressive lesion. If myelogram is not diagnostic, discography,
and epidurography are performed in combination. Such combined
survey radiography and discography-epidurography are diagnostic in
up-to 90% of dogs.
Computed Tomography (CT)
Computed tomography is a non-invasive imaging technique primarily
providing accurate cross-sectional (transverse) studies of osseous
and soft tissue structures, which cannot be completely visualised on
conventional radiography. Vertebral structures like lateral recesses,
intervertebral foramina and articular processes are either well
visualised. The scan are received in dorsal, sagittal and transverse
planes. CT provides bone detail superior to that seen with MRI and
soft tissue contrast superior to that of conventional radiography. It
allows visualisation of individual nerve roots because of the contrast
provided by the epidural fat. It may be extremely valuable in lateral
disc herniation, which are difficult to diagnose by more conventional
imaging techniques. Disadvantages of CT include the identification of
54
clinically insignificant lesions in older dogs, the use of ionising
radiation and the cost and limited availability of this procedure.
Magnetic Resonance Imaging (MRI)
An MRI (magnetic resonance imaging) provides more detail than CT
examination or X-ray examination. Its advantage in comparison to CT
is that lack of radiation. While an X-ray or an ultrasound scan will show
the size and shape of an internal organ or tissue, an MRI scan will show
its structure either. Therefore MRI is the most advanced imaging
technique available to investigate the spinal cord region, brain and
its adjacent soft tissues in dogs. Additionally, MRI is multiplanar
maintaining a better image quality accessible in transverse, saggittal,
dorsal planes. MRI can clearly reveal soft tissue, such as ligaments,
epidural fat, and the intervertebral disc without use of contrast
medium, and has better soft tissue resolution than CT.
To perform an MRI examination the dog must be placed under
general anaesthesia. It needs to stay perfectly still for up to two hours.
The dog is allowed to be given only water on the day of the
examination, and should not be fed at least 12 hours before.
MRI examination is extremely helpful in cervical spinal cord diseases
like, syringomyelia, DAWS (disc associated wobbler syndrome),
atlantoaxial subluxation, lumbosacral region diseases like cauda
equine syndrome, degenerative myelopathy, and generally ivdd
(intervertebral disc diseases).
In humans MRI imaging sometimes leads to the 'over-diagnosis'. It is
reported that many people with disc bulges or protrusions visible on
MR imaging does not have any pain symptoms. Prospective studies,
which have been performed, revealed that it was not predictive of the
subsequent development of spinal pain. It should be considered in
dogs either, to prevent a false positive diagnosis. The diagnosis
should always be based upon clinical acumen in addition to the
imaging.
Although great advantages of the MRI diagnostic technique, the
biggest minus is the cost of owning, operating and maintaining MRI. It
is the reason, why they are not commonly available. The veterinary
55
machines can cost up to 1 million euros. It is also very expensive to
operate and maintain, so the average veterinary clinic will not have
one. Usually, only large, well-funded or academic veterinary
institutions will provide MRI scans for dogs or other animals.
Electrophysiology
Electrophysiologic examinations must be performed in anastehesia,
which is induced with medethomidine in a dose of 40-80 µg/kg of
metabolic bodyweight and a single intravenous dose of propofol in a
dose 1-2 mg/kg of b. w. A dog should be intubated and anaesthesia
was maintained with 4 mg of propofol/ kg/h. Electromyographic
(EMG) examination is helpful in detection of muscles denervation,
especially in paraspinal, pelvic and front limb, coccygenal, anal
sphincter muscles. This procedure can help to confirm neurological
disease. Assessment of denervation map is helpful in finding the
damaged spinal nerve roots. It is extremely helpful in diagnosis of
cauda equine syndrome, degenerative myelopathy under condition
that the axonal damage is at least of 8 days duration. One study found
that EMG was accurate in predicting the presence or absence of
cauda equina compression in all cases.
SSEP (somatosensory evoked potentials) %). An author during
examination uses a stimulus of square-wave pulses of 0.2 ms duration,
applied at a intensity of 8 V, which is generated by a stimulator and
started by computer signal. The stimulus intensity is set to cause a
clear, visually detectable digital extension, and tarsal flexion. First
channel electrodes (Cz) are placed in the frontal lobe region and Fpz
(positive) placed between eyes The second channel are positive
needle electrode placed again between eyes, whereas negative one
in the C5 region. The third channel is placed in the TH13- L1. The
fourth channel electrodes is placed in L7-S1 region, whereas a ground
electrode is placed subcutaneously in the fossa subpoplitea. A tibial,
sciatic, ulnar nerves are easily accessible to perform SSEP
examination. Authors experience proves that SSEP testing in
syringomyelia and spinal cord tumours can be helpful to delineate the
neurophysiologic boundaries of the lesions. It is important to
remember that SSEP are not disease specific but can indicate afferent
conduction impairments associated with certain disorders. In
56
syringomyelia and IVDD patients SSEP are helpful in evaluating the
grade of compression on dorsal spinal column . This examination is a
tool that can confirm or reject when suspicion of diagnosis is uncertain
by indicating whether a disease concerns somatosensory pathways.
SSEP are often helpful in localising the anatomic site of the lesion. This
aspect is extremely helpful before performing surgery in IVDD
patients, because it indicates the site of surgical approach. If the
procedure is performed segmentally, it is useful in assessing the width
of lesion. SSEP may be widely used in clinical medicine to diagnose
abnormal sensory function. An author finds it helpful to monitor
neurologic status of animals treated conservatively or surgically. It has
been also shown to have a great prognostic value in assessment of
functional outcome of acute spinal cord injury.
Summary
The oldest diagnostic imaging procedure is radiography. When it
comes to spine, it mainly allows seeing hard tissues like bones,
therefore it is useful in diagnosis of backbone trauma or calcified
intervertebral discs. . Magnetic resonance imaging (MRI) is a
technique of choice when it comes to nervous system imaging. MRI
scanners are valuable at looking at the non-bony parts or "soft
tissues" of the body. In particular, the brain, spinal cord, nerves; also
muscles, ligaments, tendons are seen much more clearly with MRI
than with regular X-rays and computed tomography (CT) scans. A
disadvantage of MRI is its higher cost compared to a regular X-ray or
CT scanning. CT combines special X-ray equipment with
sophisticated computers to produce multiple images or pictures of
the inside of the body. CT scans of internal organs, bones, soft tissue,
and blood vessels provide greater clarity and reveal more details than
regular X-ray exams, therefore it is useful in soft tissue and bone
imaging. Electrodiagnostic procedures like somatosensory evoked
potentials (SSEP) and brain auditory evoked potentials (BAER), EMG
(electromyography) are techniques commonly used in human
medicine and are being introduced into veterinary medicine.
Advantage of electrodiagnostic procedure is its checking the
integrity of neural pathways and nervous conduction.
57
58
REHABILITATION IN CONGENITIVE SPINE
AND CORD DEFORMITY
Prof. Ireneusz M. Kowalski MD, PhD
Kierownik Katedry i Kliniki Rehabilitacji, Wydział Nauk Medycznych,
Uniwersytet Warmińsko - Mazurski w Olsztynie
e-mail; [email protected]
key words: congenital deformities, backbone, spine, rehabilitation
Introduction:
Treatment of congenital backbone deformities is a very current issue
therefore it is necessary to search for new ways of treatment. When it
comes to rehabilitation the prevention of spine deformities is most
important way of treatment. The accurate diagnosis of disease and
knowledge about its etiology is necessary to introduce a proper
treatment.
Aim:
The aim of this study is to present how important is performing very
peculiar preoperative examinations.
In atypical cases of congenital spine cord deformities, it is essential to
understand the etiology and character of disease. Moreover it must
be remembered that it is a interdisciplinary disease concerning
genetics, internal medicine, orthopedics, neurosurgery. In this cases
apart from radiologic examination, MRI,CT should be performed. MRI
and CT are helpful in assessing the degree of spinal cord
compression, deformity , localization of pathological changes in
spinal canal, intervertebral foramina, and pathologies of
intervertebral disc. Electromyography is an additional exercise
helpful in monitoring neuro-muscular diseases. Mentioned above
examination are necessary in hospitalized patients.
Results:
The results of patient clinical observation indicates the greater
importance of neuro- skeletal diseases in comparison to skeletal
diseases, they also lead to greater backbone static disorders.
Observations are compatible with conclusions of rehabilitation
59
specialists and orthopedists. It has been observed that pathologies in
thoracic backbone are the most difficult to be treated. The greater
risk of progression is due to danger of lesion adhesion to ribs head.
The most common complication are systemic diseases.
Conclusions:
1. Researches leading to diagnosis and determination
of rehabilitation preoperative plan should be completed
with additional examinations like MRI, CT,
electromyography.
2. Progression of backbone static disorders is dependent on
coexisting pathologies of central nervous system.
60
ASSISTED EQUIPMENT IN HUMAN REHABILITATION
Prof. Ireneusz M. Kowalski MD, PhD
Kierownik Katedry i Kliniki Rehabilitacji, Wydział Nauk Medycznych,
Uniwersytet Warmińsko- Mazurski w Olsztynie
e-mail; [email protected]
key words: modern equipment, rehabilitation, Progress
Introduction:
The progress in rehabilitation is based on actual state of medical
knowledge concerning diagnosis and treatment of various diseases.
Apart from progress in basic techniques of clinical examination,
additional diagnostic methods, which would help to objectify,
broaden the specialist diagnosis, treatment are still searched for. It is
difficult to imagine work without the examination which link
achievement of physics, computer science, cybernetics, molecular
biology, and neurobiology. Progress in technical science allows to
make use of new diagnostic, therapeutic, treatment devices.
Rehabilitation is a branch of medicine where technological progress
leads to treatment progress. Although it must be remembered that
only when a physiotherapist knows how the equipment, he is using
works, it may be fully exploited.
Aim:
The aim of work is to show usefulness of advanced diagnostic,
therapeutic, measurement devices in objective evaluation of modern
rehabilitation.
The basic issues in current problems of rehabilitation is use of actual
knowledge in fields of neuro- rehabilitation, pediatric and orthopedic
rehabilitation. A legible progress in rehabilitation is clearly visible
within several years, mostly it concerns the new, introduced
technologies, machines. The newest machines are atbilometric
platform, balance platform, balance trainer, BIODEX, CPM rail,
computer system of tonsometry, device for posture defect treatment
Biofeedback, pool ARIO, neuropysychologic computer diagnostic
device.
61
Results:
The lack of universal rehabilitation standards leads to discrepancy
among doctors and physiotherapists concerning diagnosis and
treatment. Objective diagnostic methods allow to unify the most
helpful rehabilitation methods. Therefore setting up protocols should
be concerned as one of the most important goals.
Conclusions:
1. The necessity of examination results verification is obvious.
Worldwide, the EBM (Evidence based medicine)
is considered to be a court of appeal.
2. A quick and objective diagnosis of pathology allows to
introduce quick and modern rehabilitation plan.
62
abstracts
63
64
ACUPUNCTURE IN A DOG WITH FIBROCARTLAGINOUS
EMBOLISM C6-T2
Ann Essner, RPT, State-authorized Animal Physical therapist,
Sweden.
Lulea University of Technology, Department of Health/Science
and Rehabilitation, S 971 87 Lulea.
E-mail: [email protected]
Phone: +46 70 692 75 62, Fax: +46 26 10 63 18
Introduction:
Fibrocartilaginous embolism (FCE) is a condition that affects dogs
and occurs as an acute onset of non-progressive paralysis in a single
limb or as para- or tetra paresis. FCE is a diagnosis of exclusion,
determined by orthopedic and neurological examination and
possibly MRI. Early mobilization and active rehabilitation and physical
therapy are crucial for the prognosis of FCE.
Aim:
The aim of this single case study was to describe a dog with FCE C6T2 that was treated with early physiotherapy.
Case description:
A 7 year old Cavalier King Charles Spaniel with FCE in spinal cord
segments C6-T2. The treatments were evaluated by using Texas
Spinal Cord Injury Score (TSCIS). Acupuncture points stimulated were
GV-14, SI-11, SI-12, LI-11, LI-14, LI-4, TE-13, BL-14 BL-15 BL-16. The
dog in also received therapeutic exercises and hydrotherapy
(swimming).
Result:
Before physiotherapeutic treatment began the dog could not stand,
was not ambulatory and had no voluntary movements in the left front
leg. One month after onset and treatments, the dog was ambulatory,
with consistent ground clearance and moderate residual paresis in
the left front leg.
65
Conclusion:
This case report supports early physiotherapy interventions such as
therapeutic exercise and acupuncture for dogs with tetra paresis due
to FCE. Acupuncture treatment and home exercise for the dog seems
to be a cost-effective treatment and probably reduces the risk of
secondary complications due to tetra paresis. Further studies
focusing on physiotherapy interventions and veterinary rehabilitation
is needed in dogs with FCE.
66
ASSESSMENT OF LOW-FREQUENCY TENS IN HORSES
BY MEAN OF PRESSURE ALGOMETRY
AND MUSCULAR RESPONSE THRESHOLD (RHEOBASE)
MEASUREMENT
Guerin Caroline DVM, SAWAYA Serge G. DVM, PhD
UPSP 2007-03-135 RTI2b
Unité Physiothérapie- Rééducation - Ostéopathie
Département Hippique - GREMERES
VETAGRO-SUP- Campus vétérinaire de Lyon, 1 avenue Bourgelat;
69280 Marcy-l'étoile France
Tél : 33 (0) 4 78 87 25 44, 33 (0) 6 74 22 55 02
Email : [email protected]
(Corresponding author : Sawaya SG)
Introduction:
There is a lack of experimental evaluation of TENS in veterinary
physiotherapy. The objective of this study is to assess the
effectiveness of low-frequency TENS treatment on horse back.
Materials and method:
21 riding club horses underwent this study in three successive stages.
1) All of the horses underwent a sham tens test. 2) Eleven horses
received a 30 minutes single treatment with a 2 Hz low-frequency
TENS current. 3) Three months later, 6 horses from the same group
underwent a five sessions TENS treatment (every two days). The
pressure pain threshold (PPT) of 60 points located between the
withers and the tail was measured with an algometer, and the
muscular response threshold (rheobase) to the same tens current was
determined, before and just after treatment, than at 3 hours, and 1, 2,
7 and 15 days. Mean values evolution were compared with the
Student and Fisher tests. Significance was set at p < 0,5.
Results:
Mean PPT is significantly increased and sustained all over the 15 days
follow-up for the both treated groups compared to the control group,
with a peak at 1 day after each session (p < 0,0001 in all cases) and
a cumulative effect with the five sessions treatment. Mean rheobase
was significantly increased in both treated groups (p = 0,0358 and
p < 0,0001).
67
Conclusion:
Increases of the pressure pain and muscular response thresholds may
be related respectively to tenderness reduction and spasm relieve.
These results support the use of low-frequency TENS in treating
chronic back pain in horses.
68
THE EFFECT OF MODERATE TREADMILL EXERCISE ON
AEROBIC CAPACITY IN LABRADOR RETRIEVERS
a preliminary study
Zoran VRBANAC1, Maja BELIĆ1, Branimir ŠKRLIN1,
Nika BRKLJAČA BOTTEGARO1, Dinko KOLARIĆ2, Hrvoje CAPAK1,
Blaženka PUGELNIK3, Marijo BAKOVIĆ4,
Damir STANIN1
1
Faculty of Veterinary Medicine, University of Zagreb, Zagreb, Croatia
2
Special Rehabilitation Hospital “Daruvar Spa”, Daruvar, Croatia
3
Center for Rehabiltation “Silver”, Zagreb, Croatia
4
Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
e-mail: [email protected]
Introduction:
Aerobic capacity is defined as maximum amount of oxygen that body
can use during specific period, and it can be improved by exercise.
The aim of this preliminary study was to research the effects of
moderate intensity level treadmill exercise on aerobic capacity in
Labrador Retrievers.
Material and methods:
Five Labrador Retrievers from the same litter, aged 14 months, mean
weight 29.2 kg were submitted to moderate treadmill exercise
training (25 min) two times per week for one month. Moderate
exercise intensity was determined by the heart rate frequency that
should remain below 80 percent of maximum heart rate. Heart
frequency was monitored by POLAR heart rate device. The initial
testing was performed by increasing the speed of treadmill until the
heart rate reached the frequency of 130-140 beats per minute (bpm).
The mean treadmill speed at initial testing was 4.7 km/hour. After one
month of treadmill exercise the dogs were put on the same speed as
at the initial testing and their heart rate was monitored.
Differences between inital and final heart rate values were tested by
Student's t-test. Statistically significant difference was set at p<0.05.
Results:
The mean (±SE) heart frequency at the initial testing was 136.8 (±
69
0.58) bpm, while at the final testing the mean heart frequency was
126.6 (± 3.35) bpm. A heart frequency measured at the final testing
was significantly lower (p=0.001) than the one in the initial.
Conclusions:
The study demonstrated a positive transformation of aerobic
capacity in Labrador Retriever sibilings after one month of moderate
treadmill exercise.
70
RECOVERY OF A TETRAPLEGIC ROTTWEILER
WITH A HOME BASED PHYSIOTHERAPY PROGRAM
Béatrice Bach-Lijour
Oniris-Nantes, BP 40 706, 44 307 Nantes Cedex 3, France
Phone: 33 (0)2 40 68 76 68 Fax : 33 (0)2 40 68 77 73
[email protected]
A 9 year-old, 35 kg, female Rottweiler, with a one month
tetraparesia and a one week tetraplegia, deep pain sensation
preservation was referred to the veterinary school. She had a C5-C6
disc herniation diagnosed with MRI. A corpectomy was performed.
The dog received a medical treatment for pain and physiotherapy
program was introduced. The main aims were to avoid pressure sores,
to regain the muscle volume and strength, to regulate muscle tone, to
coordinate movements. The dog received massage, passive and
assisted movements, electrostimulation. A fortnight after surgery,
the bitch was able to stand for a few seconds and was discharged.
The owner, a nurse, bought a four wheel cart. It was very helpful
because of the weight of the dog for assisted movements, no pool
was available. An electrotherapy device was bought too and twice
daily stimulations were performed to front and hind legs. The dog had
massages every day.
Follow up and treatment were discussed on the web. No
pressure sore appeared. A period of muscle spasm was treated with
many massages and electrotherapy. Painkillers had to be used for 4
months. Three months after surgery the bitch was able to stand and 5
weeks later she walked a few steps without any help. Gait isn't normal
but complete autonomy is regained.
Physiotherapy is or paramount importance to recover from
tetraplegia. An informed and clever owner, with few devices and
physiotherapist instructions, can play a crucial role.
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