Neurological Canine Rehabilitation
L.L. McCauleyContinence is an issue only in its absence. Some people will decide not to pursue treatment if this issue cannot be resolved relatively quickly. Owners can be taught to express bladders, and dogs can wear diapers (although this is not very successful for stool), but other complications may arise, such as urine or stool scald and bladder infections. There are methods to help this process along. First, make sure the patient goes outside at least four times daily on a consistent schedule, in some cases every 2 hours is beneficial. If they have some control this will become evident. They need to be outside for at least few minutes to work on expressing themselves. If you leave them out for too long each time they will not know why they are outside and may urinate or defecate as soon as you bring them back in. On a beautiful day, it is beneficial to leave them outside for several hours, but after they urinate or defecate move them to a different location. Another trick is to not stand over them. Many dogs will not urinate or defecate with someone standing right next to them. Put them on grass, unless they are trained to go on concrete or wood chips, in which case that substrate should be provided, and place a paper towel under the penis or vulva to monitor the release of urine. If defecation is not controlled, using a Q-tip to stimulate the internal anal sphincter muscle will often stimulate a response. Lubrication should not be used as it decreases the urge to defecate. This and bladder expression should only be done after the patient has been given time outside to go on their own. Bethanachol, often used in association with Phenoxybenzamine HCl, may also be indicated in some cases. If urinary incontinence lasts for more than 2 - 3 weeks, the urine should be monitored, by cystocentesis, at regular intervals for urinary tract infections.
Monitoring muscle atrophy can be diagnostic. In cases of spinal cord injuries, if muscle atrophy is severe within two to three weeks, prognosis is more guarded then if the atrophy is slower. This is due to decreased nerve input to the muscle versus disuse atrophy. To prevent or restore muscle mass, active motion is required. Neuromuscular stimulation may be used on the Quadriceps, Gastrocnemius, Cranial Tibial, and Triceps muscles as well as the Hamstring group, Paraspinal group, Forelimb flexor group, and Forelimb extensor muscle groups. Reflexive motion is also beneficial. Tickling the toes or gently pulling or pushing the limb can trigger a reflex that is active motion. Make sure your clients understand that passive range of motion (PROM), although important for circulation and joint health, also prevents muscle loss.
Joint care is also necessary. Degenerative joint disease (DJD) can form relatively quickly in immobilized joints. This may be due to the fact that there is low blood circulation in the cartilage itself. Cartilage nutrition is usually supplemented by the capillary rich synovial capsule, which allows nutrients and waste products to be transported to and from the chondrocytes through movement of the synovial fluid. PROM and joint mobilization can decrease the rate of DJD by circulating this synovial fluid. The other benefits include preventing loss of range of motion, stimulating the golgi tendon organs (a mechanoreceptor) and increasing blood and lymph circulation in the muscles. This should be done a minimum of three times daily until active motion is frequent or ambulation exercises have begun, in which case it can be done on a daily basis for stretching purposes. Nerves are like muscles in that if you "don't use them, you lose them". Not that the nerve fibers themselves disappear, but several studies have shown that the number of mitochondria inside the nucleus are increased in athletes and decreased in inactive people. Remember the mitochondria are the "power house" of the cell and if diminished may decrease the nerves ability to transmit messages correctly or quickly.
Neuromuscular re-education consists of progressive exercises that will re-teach the patient to walk as it strengthens the muscles needed to do this activity. The patient should be stood up at least 3 - 5 times a day and "bounced," even if they are unable to support weight on the affected limbs. This aids in maintaining a positive attitude for the patient, stimulates the muscles, nerves, and joint tissues, and helps assess when some of the weight can be supported by the patient. Individual braces can be made to hold the dog in a standing position. These are made like casts, but then cut on each side and Velcro is used to hold it in position on the dog. By using these braces we get active contractions in the quadriceps and hamstring muscles before we would normally see this with out the braces. Stationary or mobile carts, and therapy balls can be used to assist in supporting weight and allowing some weight bearing and initiating steps to be accomplished. Walk-about slings are also very useful. As soon as the patient is continent, the hydro-treadmill is utilized. Often dogs have motion up to two weeks in the water before they have voluntary motion on land. Tickling or pinching the toes, stimulating the tail and verbal encouragement are important aspects of re-training. If the limbs do not move voluntarily, manual motion for 15 - 20 steps is done and then one limb is released at a time to see if the motion continues. There will often be diminishing motion over several steps. Once the motion stops, the foot is moved manually again. One to three minutes is all that is done the first time and this time is slowly increased.
The hydro-treadmill is utilized every other day and neuromuscular stimulation may be done on the skipped day, or directly before the hydro-treadmill, as this is beneficial in many dogs. Once they are able to support their weight, even if they need assistance with balance, ambulation and isometric exercises begin. Gentle pressure over the scapulas and pelvis can be done. It is better to do several repetitions several times a day, then to work them until they are tired once daily. Making them stand to eat is a good exercise as it distracts the mind and lets the body run on autopilot. The position of the bowl and height are extremely important so as not to make the patient lean or twist the body. Each meal is divided in to three portions with 3 - 5 minute rests in between standing sessions. Once standing to eat is accomplished a few times, the patient is asked to step forward in normal foot progression before eating. This is done by tickling the toes, pinching the toes, or manually placing the foot after shifting weight off the limb you are moving. After eating, there is a progressively longer wait before they can sit down and rest (count down out loud). Each day the number of steps and the time before they are allowed to sit down are increased. They can also be fed with the forelimbs elevated on a box or step to increase load to the rear limbs. Once they can walk 20 feet, even if balance support is needed, sit to stand exercises are added. This aids in muscle strengthening and re-education of normal daily activities. Mild turns, zigzags on hills, ball and board exercises, and gentle pushes are next. As they progress, figure 8's, cavaletti poles, walking backwards, weave poles, and stairs are added. If the patient has begun walking after rear limb paralysis, but still shifts weight to the forelimbs, the incline land treadmill can be used, even if balance support is needed, to re-educate front to back balance. When to add or modify exercises is individual to each patient. Some patients also need assistance to learn to walk on smooth surfaces, and some on different color surfaces. Watching the patient and constant reevaluation of the situation is needed to make the progression to ambulation as speedy as possible.
Previous injuries are an important consideration in the patient's rehabilitation. Often the patient has been able to compensate for DJD in the affected limbs, but now due to muscle atrophy they cannot and there is a pain issue and possibly instability at the affected joints. Often, if DJD is present, we will see problems shortly after we start ambulation exercises. Nutraceuticals, pulsed signal therapy, and acupuncture can be beneficial. It is important to make sure exercises are done correctly to make sure undue strain is not put on these or any joints.
The spirit of the dog is extremely important in the outcome of the case. When a patient gives up or decides it is easier to drag them self around than try to get up, your job has just gotten five times harder. The spirit of the owner often affects the spirit of the patient. This translates that you and your staff, the authority figures, need to be as supportive of the emotional state of the owner as well as that of the patient. Having owners be able to see other patients and talk to other owners that have experienced the same feelings can be beneficial. The patient may board or come in for appointments. I prefer to have them come and go for the mental health of the dog and financial cost to the owner, but this may not always be an option due to lifting restrictions, work schedules, or distance traveled by the owner. If the dog is boarding, several things can be done to prevent depression. These include: being outside or in the treatment room where there is constant visual and auditory stimulation, having family visitors or paid play timers (high school kids who love to come in and give them TLC), toys from home (especially ones that make annoying noises), a TV with children's shows or animal shows (animal planet is a bonus) for the high voices and music, and breaking up their treatments so they come out of their rooms several times daily rather than for one long session.
Rehabilitating a paralyzed dog can be hard on your back, tiresome, and time consuming work. But, to see a dog that has been given little to no hope of returning to normal function be able to walk, run, and jump again is the most rewarding feeling you will ever have.
