Physical Rehabilitation and the Neurologic Patient

Stephanie Thomovsky, DVM, MS, DACVIM (Neurology), CCRP

Physical Rehabilitation (PR) is a critical part of successful healing from neurologic disease.  This is true in human medicine and also in veterinary medicine.  It is important, when developing a PR program for a patient with neurologic disease, to understand the diagnosis and neurolocalization.  Having a basic knowledge of the function of the nervous system and how it heals is important.  As a general rule, the nervous system is slow to heal.  Similarly, when comparing the peripheral and central nervous system, the peripheral nervous system is faster to heal than the central nervous system.  It is because the nervous system is slow to heal that appropriate PR is essential to improvement.  If you do not make sure the muscles and joints are fluid and ready to function once re-innervation has occurred, the patient will never function normally even if their nervous system is completely healed.  The focus of this talk today will be post-operative neurologic recovery and PR.

There are various neurologic conditions that require PR post operatively.  The most common neurologic surgeries performed in veterinary medicine are spinal surgeries followed by intracranial surgeries.  The goal of the PR in these patients is to make them functional again.  The term ‘functional’ for most house pets means voiding consciously and also walking without assistance.  But for some higher functioning animals, such as agility dogs, or working dogs, cardiovascular fitness and physical fitness is also a major part of this healing and of a successful PR program. 

As stated earlier the bulk of neurosurgery patients needing PR will be those who have had neurosurgical procedures on the cervical and also the thoracic/lumbar/sacral spinal cord. It is more common with patient’s with cervical spinal cord disease to retain some degree of motor function in all four limbs.  The vast majority of patients are neurologically one grade worse in the pelvic limbs than in the thoracic limbs.  That being said there is a condition called, central cord disease, wherein anatomically the gray matter of the spinal cord is more affected than the white matter.  Subsequently, the thoracic limbs are functionally worse than the pelvic limbs.  Animals with central cord signs, no matter what the cause, are more challenging cases from a PR standpoint.  Confidence seems to be at the crux of why these patients are more challenging PR patients.  Animals carry a larger percentage of their weight on their thoracic limbs as compared to the pelvic limbs.  When the front limbs are neurologically weaker, the patient’s confidence has to be repaired before they will try to utilize their front limbs to catch themselves and propel themselves forward. 

The most common types of surgeries performed on the cervical spine are the ventral slot and also the dorsal laminectomy.  The ventral slot carries with it less morbidity than an approach dorsally.  Patients are considerably less painful peri-operatively when the approach is performed ventrally mainly because tissue dissection is less.  The ventral approach is made with spinal fractures, spinal stabilizations, some forms of wobbler’s disease and also with intervertebral disc disease.  A dorsal approach requires substantial muscle dissection and trauma; as a result, peri-operatively patients are much more painful.  They have difficulty raising their heads following this surgery and are generally more painful in their peri-spinal muscles following this surgery.  This approach is taken for some forms of wobbler’s disease and spinal tumor removal. 

The most common spinal surgery performed on the thoracic and lumbar spinal cord is the hemilaminectomy.  Surgery on the sacral spine is most commonly performed via a dorsal laminectomy.  Both the hemilaminectomy and the dorsal laminectomy carry similar peri-operative discomfort. There is a considerable amount of muscle dissection required to access the spinal cord via either a dorsal or hemilaminectomy.  Another difference when considering PR in patients suffering from thoracic and lumbar spinal cord disease vs. cervical spinal cord disease is the degree of limb weakness.  As stated earlier, it is much more common to see true plegia with thoracic and lumbar disease as compared to cervical disease.  The latter more commonly causes just paresis.

Having the appropriate supportive equipment on hand to assist in lifting and supporting neurologic patients during PR is essential for the supporting the patient and also protecting your staff.  It is critical to have supportive harnesses, slings and lifts to aid in getting these patients up on their limbs and also providing appropriate spinal support.  Cushioned bedding is also critical for these patients when they are sitting and laying in their kennels.  Kennel rest is an essential post-operative recommendation to allow for vertebral fibrosis and also annular ligament healing.  The most common cause of worsening neurologic signs in the first month post hemilaminectomy for type one intervertebral disc disease is further herniation from the disc that was just operated.  This herniation occurs because the annulus still has a hole in it; this hole, until healed over, can continue to act as an exit point through which remaining insitu nucleus can herniate.  Reducing this further herniation is why strict cage rest is a part of post-operative neurologic treatment recommendations.  That being said controlled PR is also an essential portion of treatment. Appropriate bladder management is also vital as it can prevent detrusor atony and also limit urine scald.  Scald can lead to sores and open wounds in recumbent patients.  It is especially important in patients with dense undercoats, such as German shepherd dogs, and also dogs who are being put in water frequently, to monitor for sores.  Liquid can become trapped in this undercoat and serve as a constant skin irritant. 

Therapeutic exercises utilized in veterinary neurosurgical patients are easy to perform and of great importance.  Massage is helpful in all neurologically affected patients.  The purpose of massage is to increase blood flow and also allow muscles to remain limber and stretched.  It can also reduce stress and alleviate pain.  While performing massage it also allows for quiet time when a bond can be built and trust gained between the neurologic patient and the therapist

Passive Range of Motion (PROM) is a critical part of an effective PR program in the neurosurgical patient.  It is most helpful in patients who have significant paresis and certainly plegia.  Many times patients who regain motor function start to resent PROM.  Remember that anything a patient can actively do is better than a passive motion.  If your patient can now stand and ambulate on his own, as long as a near normal range of motion is attained, PROM is probably no longer required.  PROM increases blood flow and also synovial flow.  It also prevents contracture and reduces fibrosis formation in addition to cartilage atrophy.  It improves sensory input and limb and joint proprioception.

Weight-shifting Exercises can be performed on patients with upper motor neuron (UMN) tone.  These exercises are much more difficult in patients with lower motor neuron (LMN) neurolocalizations.  These LMN patients have decreased limb tone and a great deal of difficulty supporting weight against gravity.  They will need more assistance when attempting to stand.  Weight shifting allows animals to build postural muscle strength.  Postural musculature are anti-gravity muscles.  These muscles can quickly atrophy in recumbent animals.  As patients stand their weight is shifted back and forth on their limbs to allow for muscle memory and strengthening.  In patients with high thoracic spinal cord lesions or cervical lesions sitting in the sternal position and maintaining a sternal position may be difficult.  Encouraging these patients to stay in sternal recumbency and try to get into this recumbency without assistance.  Once in sternal recumbency, weight-shifting can also be performed.  These recumbent patients have to utilize their core muscles and also thoracic limbs to maintain the sternal position during shifting.  To increase difficulty patients should be asked to stand on uneven surfaces.  Remember it is always more difficult to stand and walk on an uneven surface such as on sand than on a flat, paved road.  This same rule applies to PR for spinal cord disease.  Patients who have mastered standing on flat surfaces should be asked to stand on a soft mat, in a sand box or on a wobbly surface (dino-disc or wobble board).  Texture is also important. Standing on a textured surface increases sensory input from the ventral surface of the paw and helps to build the mind/body connection.

Physioball Standing and weight shifting is a great exercise for neurologic patients.  The physioball can be used to allow patients to stand on all four limbs.  It can also be used when there are less people to help with large dog PR.  The more a patient is allowed to be up on all four limbs the more quickly they regain confidence.  It also allows for targeted core exercises and muscle activation. 

Aquatherapy is extremely helpful when performing post-operative neurologic physical therapy.  The buoyancy of the water reduces joint load and reduces the weight a patient has to carry with each step.  Water resistance also helps to build muscle mass. The warmth of the water increases blood flow.  Swimming is a great exercise for core strengthening and thoracic limb injuries.  Underwater treadmills are ideal for post-operative patients as it allows for a controlled environment wherein patients can be appropriately supported, build muscle memory, core strength and also confidence.  Speed can also be adjusted to allow for patients with varying degrees of paresis to place their limbs with each step.  Each time they successfully place their limbs muscle memory and sensory input is increased.

Electrical Equipment is also helpful when performing PR on a post-operative neurologic patients.  Low-level laser therapy, electrical stimulation, therapeutic ultrasound are all useful tools to have in your neurologic PR tool kit.  Low-level laser can be used to improve blood flow to the paraspinal musculature post-operatively.  It can also be utilized to speed incisional healing and the healing of pressure sores or ulcerations. 

Electrical stimulation includes TENS (transcutaneous electrical nerve stimulation) and NMES (neuromuscular electrical nerve stimulation).  TENS is most commonly used to reduce pain associated with the surgical incision and also muscle dissection.  It can also be utilized as an ancillary treatment for wind-up pain and anticipatory pain.  These types of pain are most commonly seen in dogs with cervical spinal cord disease.  TENS may also reduce edema, increase perfusion and speed tissue healing.  NMES allows for muscle recruitment and contraction.  It is less effective than voluntary muscle contraction but it can be utilized to reduce muscle atrophy.

Therapeutic ultrasound is used for deep tissue heating and also to improve collagen elasticity.  It can be used to heat tissue deeper than the traditional warm pack.  It is can effectively be used to warm and loosen tight, contracted muscle bellies. 

Appropriate controlled PR is a critical component to treatment recommendations for post-operative veterinary neurosurgery patients.  A Dachshund being allowed to jump off the couch is not controlled PR.  A Dachshund being allowed to heal in a kennel for 6 weeks and taken out for 3-4 daily controlled PR sessions is necessary for effective healing.

 

References

Dhupa S, Glickman N and Waters DJReoperative neurosurgery in dogs with thoracolumbar disc disease. Vet Surg 1999; 28: 421428.

Sherman J and Olby NJ.  Nursing and rehabilitation of the neurological patient.  In:  Platt SR, Olby NJ (eds). BSAVA Manual of canine and feline neurology, 3rd ed. Gloucester (England); Replika Press, 2004. 394-407.

Sims C, Waldron R, Marcellin-Little DJ.  Rehabilitation and physical therapy for the neurologic veterinary patient.  Vet Clin North Amer 2015; 45: 123-143.

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