Degenerative Myelopathy and Neurological Conditions

Question from the International Veterinary Academy of Pain Management, 2012:

“Does anyone have any recommendations regarding treatments for a 14 year old Husky with Degenerative Myelopathy? So far, the only thought I have is a cart. Also, my understanding is these animals are not in significant pain – is this true? Thanks for any info.”

From: A Veterinarian in the U.S.A.

RehabDeb Response:

Hi!
I apologize for taking so long to reply. I have a 30-yr. background in human sport science and nutrition, worked two years in a veterinary specialty hospital designing and building the rehab dept., and since 2007 have had a mobile practice wherein I serve a huge number of “mystery-ortho-neuro” cases, many of which are presumed to be D.M. (Degenerative Myelopathy) (or, as of 11/2014, may have been tested using protocol at Missouri).

The functional rehabilitation protocol I have developed over time, and which has been successful at improving function to varying, yet notable, degrees is derived predominately from my experience in sport science program design coupled with principles of neuroscience. A body at rest stays at rest and only changes with dynamic interference…
(original RehabDeb quote :))

I DO agree that while D.M. may not produce pain in and of itself, it is highly likely that an animal with any neuro condition has self-induced pain by nature of the fact that they are compensating, stressing tissues, and possibly pinching nerves, akin to when our sciatica or sub-scapular, etc…get impinged and cause us pain.

Pain management discussion aside, for my own patients I introduce a system of simple, vibration-based, massage with a less-than-ten-dollars Homedics unit (https://rehabdeb.com/pet-massage/), Low-Level Laser Therapy (MUCH research exists regarding nerve conduction, regeneration, re-invigoration), and a plan of return to whatever level of function is possible via primarily-human-induced and animal-activated movement exercises, retraining brain-to-limb neural pathways and encouraging focus on movement and function. I prefer to use dry land and gravity, and I work with clients on methods to help them get this work done. Strength and endurance/conditioning drills I propose, depending on each animals status, are best

I begin with laser twice a week for a month and review exercise protocol that the owner is charged with doing if they are capable and which I do if the owner prefers. I use a front harness designed for riding in the car that has fleece and the best stitching I have found and only costs $30 shipped from Petsmart (no longer available-2014). This is the Travelin’ Dog harness. I turn it around, and it is “perfect” for hind end support (legs through arm holes, tail through neck hole) while relieving owner back stress, if used properly. It is much better designed for the body than the blue neoprene sling or a belly towel, less pressure on the abdomen than a belly sling, and less problematic than a Bottoms-Up sling. No one pays me to promote these items; I have just found that they are simply the best and inexpensive, and in my years of experience I deem that they work better than a lot of what is out there. I have pics around this blog of neuro dogs wearing these harnesses.

There are many more things that may be done, however getting the owner started on helping the animal around the home in a manner that hurts neither owner nor animal, and in a manner that is most productive time-wise, is one of the major components of my mobile practice. I tend to not involve owners in activities that, again, would potentially cause more harm than good or waste more time than be productive. This list includes ROM, balance balls, and balance boards, among other not-as-productive work that should be performed.

I also utilize a brand of boots with excellent traction, usually sometime along the way but not usually right away. Depending on function-ability I will introduce the boots when I believe they will not encumber the pet and will be more help than hindrance. The right boots always seem to encourage hind limb use when there already is function and they give stability in the home on tile and wood floors. I also often have pet owners stop using boots if they have begun using them before the pet is functionally ready.

On several elderly canine patients I have also used Epsom salts baths to great benefit.  Owners HAVE to ensure they rinse off all the salt residue after the bath, otherwise if the dog licks it, which they usually will, diarrhea will likely ensue.

These are some of the basics, and I will be glad to discuss the topic further if you’d contact me.

Blessings-

Deborah Carroll

 

ONE LEG OR TWO? WOULD IT CHANGE WHAT WE DO?

Recent text convo with the referring veterinarian after I saw a new Doxie X client for ACL/CCL rupture:

Me: I’m sending *her* back to you to get joint formula and talk with you about pain meds for the “hard” work days. Client said you had already mentioned we’d probably do that, and I know you are a new vet to her and that she only recently sought you out for a 3rd opinion on what could be done for the CCR since she didn’t want surgery. Otherwise, *she* just needs a lot more restrictions 😉 her left stifle is slightly effused and she’s been running amok. Her right is actually sensitive also and she did not like my palpating it. Thanks for the referral, and I’ll get a written report to you…wanted you to know about my sending her back to you since she may come in before I get to the computer to make the report. I really appreciate working with you, and your clients really appreciate you, too.

Him: About to see *her* again this afternoon. When I palpated right side last time, it was normal, but the dog was somewhat resistant to everything I did, so I didn’t notice her being more reactive on that stifle. Will check again though, although I guess it really wouldn’t change much at this point.

Me: I’m with you and that’s what I told her when I said, “you know, Dr. X would probably say the same thing and it wouldn’t change anything we are doing” 🙂

Him: I didn’t know how targeted your rehab is, but I assumed it was more for hind limbs in general, not necessarily for left stifle specifically in a case like this. Thanks!

Me: Definitely doesn’t need to be targeted while laying the foundation, which takes about 4 weeks of consistent and progressive work. My work is designed to target while using more of a natural lifestyle intervention program. I told her to get some joint formula from you and she does toe-tap around the house some. Plus, until my visit she’s been a lunatic dog and client said that you had already told her there was a likelihood we’d use Tramadol for hard workout days. You are right…very few findings change what I’m already doing most of the time. I think I will make this into a blog post 🙂

 

Additional notes:

I have had only a handful of cases wherein diagnostics changed the game plan. Some of them that I recall are as follows:

1) I was called out to see a teenaged Lab that had FHO surgery. My recovery plan for post-FHO is currently posted elsewhere on this site and involves progressive, controlled walking protocol. The dog was being allowed to run up and down the street in the neighborhood. The dog was also not on any pain meds. I suspected that the dog also had a torn cruciate ligament in the opposing knee that hadn’t been addressed by the vet (because he didn’t yet know). My progressive walking protocol for the first 4 weeks is the same for both situations, however the clients believed since the dog was “x amount of time” out from hip surgery that the dog could “return to normal activity”, especially since the surgeon had said to do that. The dog wasn’t given enough pain meds to help with successful function of the hind end after either the injury or the surgery. Of course she was running up and down the street with the children because it was fun! I would have begun that dog, with appropriate pain meds and based on function at this point after FHO, at a longer time period of recovery walks than I would have used for her to begin recovery from the torn knee ligament.  Thus, the protocol changed to the shorter, introductory version.

2) I’m not counting the handful of cases where I’ve been called out to address function and after an hour of history-taking and function assessment I’ve discovered “hiding” masses…which have resulted in a recheck with the vet and a dire diagnosis/prognosis=euthanasia.

3) On the other hand, I’ve been called out for the same as #2, found masses that were deemed removable and subsequently cancer, and this has rarely changed the plan for functional rehab. The plan reduces if need be for recovery from surgery to remove a mass or reduces to help recovery during chemotherapy. Sometimes there has been amputation, and my goals for recovery and assisting the people and the animals changes to help everyone adjust and the animals to improve function.

More examples to come-out of time for now

Blessings-

 

WHERE DO I PUT THE ICE?

Where Do I Put The Ice?

I have read the homework and this is a dumb question, but I do not know where to put the ice on an ACL tear.

I would like to have an evalution to see what I can do to make my guy better. He has started limping more and I want to start using the ice. He does not seem to be in any pain at all and I do not have him on any meds except a chinese herb which is not helping. I will be setting up my work schedule tomorrow for the upcoming weeks. Is it possible for you to evalute my boy?

Not a dumb question at all…for now, you may just place a pack directly on his knee, on the side, while he is lying down. Leave on the pack for 20 minutes, no towels or other barriers, especially if he has fur…that is enough of a barrier.

Yes, we may set up an appt. I have some openings next week, and I will write you mail this weekend to set up a time and day. Thanks-

Oh, and if he is limping, he is likely in pain.

It is common for most people, even people with medical training, to think for a variety of reasons I won’t take time to discuss here that the animal is not in pain, however the best demonstration that he is in a little pain, at the least, is usually limping.

I suggest you speak to the vet about getting an anti-inflammatory or another pain reliever, like Tramadol (used a lot here in Austin, TX), if you are open to that idea, and if you are not, we will talk about some other options when I see him for evaluation. There are usually not any combinations of even several non-pharmaceutical helps that will do away with the type of pain that is enough to make the patient limp. This means you usually need pharmaceutical drugs to help your pet feel better, feel less pain.

Also, if you do give a pain reliever for a day or two and the limping stops, that is another good clue that the limping has been due to pain. For more information on pain, please see my pain posts by searching the word pain in the search box.

I also highly recommend fish oil capsules…they are anti-inflammatory, for one, and good for many things. Look for a capsule with 1000 mg of oil or less and definite amounts of EPA and DHA, noted separately on the label. A good place to start is about 20 mg of EPA daily for every kg of body weight.

Deb

Why Ice Delays Recovery

March 16, 2014

by Gabe Mirkin, MD

“When I wrote my best-selling Sportsmedicine Book in 1978, I coined the term RICE (Rest, Ice, Compression, Elevation) for the treatment of athletic injuries (Little Brown and Co., page 94).

Ice has been a standard treatment for injuries and sore muscles because it helps to relieve pain caused by injured tissue. Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.

In a recent study, athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness. Although cooling delayed swelling, it did not hasten recovery from this muscle damage (The American Journal of Sports Medicine, June 2013).

A summary of 22 scientific articles found almost no evidence that ice and compression hastened healing over the use of compression alone, although ice plus exercise may marginally help to heal ankle sprains (The American Journal of Sports Medicine, January, 2004;32(1):251-261).

Healing Requires Inflammation

When you damage tissue through trauma or develop muscle soreness by exercising very intensely, you heal by using your immunity, the same biological mechanisms that you use to kill germs. When germs get into your body, your immunity sends cells and proteins into the infected area to kill the germs. When muscles and other tissues are damaged, your immunity sends the same inflammatory cells to the damaged tissue to promote healing.

The response to both infection and tissue damage is the same. Inflammatory cells rush to injured tissue to start the healing process (Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999). The inflammatory cells called macrophages release a hormone called Insulin-like growth Factor (IGF-1) into the damaged tissues, which helps muscles and other injured parts to heal.However, applying ice to reduce swelling actually delays healing by preventing the body from releasing IGF-1.

The authors of one study used two groups of mice, with one group genetically altered so they could not form the normally expected inflammatory response to injury. The other group was able to respond normally. The scientists then injected barium chloride into muscles to damage them. The muscles of the mice that could not form the expected immune response to injury did not heal, while mice with normal immunities healed quickly. The mice that healed had very large amounts of IGF-1 in their damaged muscles, while the mice that could not heal had almost no IGF-1. (Federation of American Societies for Experimental Biology, November 2010).

Ice Keeps Healing Cells from Entering Injured Tissue

Applying ice to injured tissue causes blood vessels near the injury to constrict and shut off the blood flow that brings in the healing cells of inflammation (Knee Surg Sports Traumatol Arthrosc, published online Feb 23, 2014). The blood vessels do not open again for many hours after the ice was applied. This decreased blood flow can cause the tissue to die from decreased blood flow and can even cause permanent nerve damage.

Anything That Reduces Inflammation Also Delays Healing

Anything that reduces your immune response will also delay muscle healing. Thus, healing is delayed by: * cortisone-type drugs, * almost all pain-relieving medicines, such as non-steroidal anti-inflammatory drugs like ibuprofen (Pharmaceuticals, 2010;3(5)), * immune suppressants that are often used to treat arthritis, cancer or psoriasis, * applying cold packs or ice, and * anything else that blocks the immune response to injury.

Ice Also Reduces Strength, Speed, Endurance and Coordination

Ice is often used as short-term treatment to help injured athletes get back into a game. The cooling may help to decrease pain, but it interferes with the athlete’s strength, speed, endurance and coordination (Sports Med, Nov 28, 2011). In this review, a search of the medical literature found 35 studies on the effects of cooling . Most of the studies used cooling for more than 20 minutes, and most reported that immediately after cooling, there was a decrease in strength, speed, power and agility-based running. A short re-warming period returned the strength, speed and coordination. The authors recommend that if cooling is done at all to limit swelling, it should be done for less than five minutes, followed by progressive warming prior to returning to play.

My Recommendations

If you are injured, stop exercising immediately.

If the pain is severe, if you are unable to move, or if you are confused or lose even momentary consciousness, you should be checked to see if you require emergency medical attention. Open wounds should be cleaned and checked. If possible, elevate the injured part to use gravity to help minimize swelling. A person experienced in treating sports injuries should determine that no bones are broken and that movement will not increase damage.

If the injury is limited to muscles or other soft tissue, a doctor, trainer or coach may apply a compression bandage (or not-DC). Since applying ice to an injury has been shown to reduce pain, it is acceptable to cool an injured part for short periods soon after the injury occurs. You could apply the ice for up to 10 minutes, remove it for 20 minutes, and repeat the 10 minute application once or twice.

There is no reason to apply ice more than six hours after you have injured yourself.”

Dr. Mirkin, M.D.

 

 

Abby, Old Old English Sheepdog with Undiagnosed Neurological Issues and Hyper-extending Tarsal (Ankle) Joints

Homework Exercise Review for Elderly Sheepdog with Hind-End Neurological Problems

Here is the short write-up of my recommendations/reminders for Abby’s functional rehab and the process I believe will improve her neuro-muscular capabilities and strength.

Some of this will be stuff I’ve mentioned several times over the course of working with Abby, however it bears review, and most of the time, when I reevaluate a program, often we need to go back closer to a beginning point and press forward methodically in order to achieve expected gains.
I can’t emphasise enough how beneficial the vibrational massage is, even if you do it every other day instead of every day for now. For a refresher, please watch the 10 minute video here:
And do it as best possible without cutting corners. Pertinent questions are also covered in the video, as well as methodology and benefits. Make sure you change out the batteries as soon as they seem dull, because the best benefit from this massage is realised from the vibration, which stimulates circulation, lessens tension, and potentially improves nerve conduction. I recommend, for now, doing the massage at the end of the day, at bedtime or thereabouts.
For the next week, please walk Abby twice daily, super slowly and consistently, without stopping, for 15 minutes. There are very many reasons why I use this method, and they all contribute to the gains we are trying to achieve. Super slow walking encourages use of all limbs to the best of their ability. Abby has already been able to walk multiple times daily, super slowly, for five and ten minute sessions, having built up slowly. Using the same exercise protocol for a week allows more time for the body to adjust to the work load, and it should go well, because these are introductory workouts, to build a base.
For the following week, please walk her 2×20 minutes in the same manner, if the 15 minute walks are completed well. She should be able to complete these walks without dragging a hind limb and without sagging or falling down. Otherwise, she needs to return to 10 minute walks and do them multiple times daily to ensure success. I am not after complete fatigue and maxing ability at this point; I am after building successful progress, which I believe her body will adapt and accomplish.
I really would like her to wear two supportive hard braces during these walks, and I realize you have only one. She hyper-extends her tarsal joints, and in order to use her hind legs properly and to subsequently use the muscles better/properly, the supportive brace that prevents hyper-extension while she is doing her slow drills would be additionally beneficial. (Orthovet Splint) Use the one you have on her R hind, since that leg has the most deficits and is the weakest. She hyper-extends because of nerve weakness and defecits.
After the week of 2×20 min slow, relatively flat walks, please add in cavalettis, obstacles, to improve her proprioception. This may be accomplished in many ways and several locations around your environment. I have photos on my rehab FB site that depict a trained sporting dog doing cavalettis using an extension ladder. I have a video on this site of a cat with neuro problems using a lineup of remote controls across a bar top. I have a pic on my FB site of another older dog using obstacles in the back yard. When time allows, I will attach some of those pictures to this post.
Abby needs to do the cavalettis every other day and during one of the walk workout times. You should warm her up walking for 5 minutes then do obstacle repeats for 10-15 minutes. I suggest you use about 5 items in a row, spaced about half an Abby-length apart, and between 4-6 inches high for now. If we could get the old cat to do the work, I’m pretty sure we can get Abby to do it! If she is too stubborn for you, I will be glad to take a rehab session and work with you and her on this drill.
After a week of this drill, keep doing it as prescribed, and add in hill repeats every third day as one of her twice-daily workouts. I suggest walking out the front door, around to the back yard, and then up and down the hill on the far side of the house for 10-15 minutes, very slowly. I was able to get her to do this work this past summer when I came for rehab checks.
During the hill phase, it may be more beneficial for Abby to receive laser therapy on the hill work days. This should have the effect of stimulating nerves and cellular process and often improves work ability in the older and neuro-challenged animals. In her condition, I see reason to have twice-weekly laser sessions for at least a month.
I think it would be great if you were able to just start where I suggest, as if we were beginning from scratch, and let’s see the progress that comes from scripted protocol and collaborative effort. She won’t improve from this point if she keeps doing the same walks and leads the same life she has been leading…the body stagnates, and the same happens for humans as well. Our brains aim toward conservation while our bodies are able to do more. I believe, based on my experience that is also based on years of research, that we will see strength and muscle gains if you start here again. I suggest we review in one month after these exercises have been completed. I will then revise the protocol and change the challenges.
Thanks!
Blessings-
Deborah