Rehabilitation of neurological patients

Rehabilitation of neurological patients

Dr Megan Kelly, Holisticvet

editor cpd article dr megan kelly

The most common neurological cases referred for physical rehabilitation are animals requiring post operative treatment after decompressive spinal cord surgery. Some may be suffering from inoperative conditions, such as degenerative myelopathy or fibrocartilagenous embolism. The goals however are the same and the therapies used will depend on the severity of the clinical signs and any compensatory problems that may have arisen since the initial diagnosis. Clinicians have recognized the role of physical rehabilitation for people with spinal cord injuries for a long time. There is a new movement in the veterinary field to offering these services to pet owners. Gone are the days of just sending the dog home post surgery, locking it in a crate and hoping for the best. We have tools to accelerate their recovery and these tools can be passed onto the conscientious owner if need be.

Motor function is severely disrupted following spinal cord injury or damage. The spinal cord however has an ability to regenerate and evidence suggests that biochemical changes at cellular level triggered by specific activities can result in sensorimotor recovery. This is termed neural plasticity.1, 2, 3

Neurological rehabilitation focuses less on repairing lost connections and more on influencing the spinal neural plasticity for regaining function by activity dependant means. We focus on exercises that promote activation of load receptors and that trigger plantar cutaneous stimulation as well as stepping or gait training. 17

Gait or locomotor training refers to helping a patient to relearn to walk safely and efficiently. It works to “awaken” dormant neural pathways by repetitively stimulating the muscles and nerves in the lower body.

Afferent feedback during walking contributes to extensor muscle activity during the stance phase of locomotion. The sensory input comes from the actual stepping, from the contact of the paw on the ground and from the muscle receptors. 15, 19

It is believed that there are special neural circuits called central pattern generators (CPG) which allow the body to make rhythmic movements without conscious effort. 7 They cause alternating stimulation of the extensor and flexor muscles. Neurological rehabilitation aims to stimulate these CPG’s to assist with returning the patients to independent function.

Our main goals are in neurological cases are:

1. Minimize pain
2. Improve coordination and movement
3. Prevent muscle atrophy
4. Re-establish normal neural pathways
5. Re-establish urinary continence
6. Ideally return the patient to a state where they are able to function independently.

Analgesics and anti-inflammatories are very important in managing pain in neurological cases. But there are also rehabilitation modalities that can assist in decreasing the requirements of medications.

Cold packs

Ideal the first 1-3 days after surgery 3 times daily for 3-5 mins. . Do not apply directly onto the sutures. Cold counteracts inflammation and has an analgesic effect.

TENS

(transcutaneous electrical nerve stimulation) low frequency impulses provide analgesia and can be used at home by the owner as well as in hospital. One can start using tens after 3 days post-op.

Acupuncture

Blocks pain pathways back to the brain and releases endorphins and serotonins to assist with pain management and healing.

Patients may show varying degrees of co-ordination problems. Exercises to improve co-ordination and neural feedback include.

Bicycling

You can do this with the patient in standing or in recumbency. Hold the paw in your hand and using circular motions to flex and then extend the entire joint in a fluid like motion. If you are doing this exercise in standing make sure the paws touch the ground to ensure we get that cutaneous feedback necessary to stimulate neural feedback.

Weight shifting

Make sure the patient is standing square with hind feet hip width apart. Standing behind the patient with ones hands on either side of the pelvis. Gently rock the patient from left to right and front and backwards. This exercise assists with muscle strengthening as well as coordination.

Poles on the floor

Lay a few poles stride length apart on the floor and walk the patient over them. This also assists with improving proprioception.

Exercises should begin immediately post surgery to minimize muscle wastage. Disuse muscle atrophy begins after 7- 10 days. It’s better to maintain the muscle you have than loose it and try and regain it.

In cases where muscle atrophy is severe the prognosis is more guarded. This may indicate decreased nerve input to the muscle, rather than just disuse atrophy. In order to prevent muscle wastage, active motion is required.

Exercises used will depend on the neurological status of the pet.

Possible exercises may include:

Assisted standing

This should be done a few times daily with a harness. For smaller breeds with only hindlimb paresis or paralysis a hind harness with extra long handles can be used.  (Fig 1)

The dogs’ centre of gravity is just behind the shoulders. For this reason I recommend a harness that supports the body under the sternum and through the pelvis in large breed dogs. (Fig 2) Slings under the abdomen are not recommended as they place pressure on the abdominal organs and can cause stress in the lumbar vertebrae and then lumbosacral joint. (Fig 3)

Picture of a holisticpet dachshund walker. Doing exercises in standing
Picture of a holisticpet dachshund walker. Doing exercises in standing
Picture of an Holisticpet full body harness offering the correct support through the sternum and pelvis.
Picture of an Holisticpet full body harness offering the correct support through the sternum and pelvis.
Picture showing the incorrect way of supporting a paralysed or weak dog. Note the abdominal compression and how the pelvis falls into a flexed position stressing the lumbosacral area. A towel is something commonly used by owners and practioners resulting in the same compression and stress.
Picture showing the incorrect way of supporting a paralysed or weak dog. Note the abdominal compression and how the pelvis falls into a flexed position stressing the lumbosacral area. A towel is something commonly used by owners and practioners resulting in the same compression and stress.

Lower the harness to allow the pet to try and actively take wait on the limbs. If the pet drops on its hind legs use the harness to lift them back into the standing position. If the patient has proprioceptive deficits and is knuckling over make sure you continually correct the paw so the paw pads are touching the ground. If the pet is walking on the dorsum of the it’s paw there is no neural feedback occurring. If you remember one thing to tell owners post operatively remember to tell them to continually correct the paws.

Flexor relex

This exercise can be done as soon after surgery as possible and several times a day. By pinching the skin between the toes we expect to elicit a withdrawal reflex. If the patient reacts, then try and maintain the muscle tension in the leg for a short period of time before releasing.

Exercises with a ball (Fig 4)

The ball is a great tool to support patients that can stand for short periods of time. The patient should be placed with its abdomen over patient ball, allowing the pet just to be able to reach the floor with its paws, then move the ball gently back and forward and sideways.

Picture of dog on a therapy ball.
Picture of dog on a therapy ball.

Underwater treadmill

Once the incision has sealed (7-10 days) these machines are very useful in building muscle as well as gait or locomotor training. The water helps to support the body weight and give the patient stability. One finds that some animals which are not able to walk on land, are able to walk in the underwater treadmill, supported by the bouyancy of the water.

Incontinence can be a reason for owners deciding not to continue with rehabilitation. The location of the lesion or spinal injury will determine the type or urinary incontinence. Patients with spinal lesions localised in the T3-L3 region develop an upper motor neuron (UMN) bladder, wheras those with lesions from L4 caudally, will develop a lower motor neuron (LMN) bladder. UMN bladders are usually difficult to express because of increased urethral sphincter tone. LMN bladder are easily expressed and patients dribble urine due to overflow. Both upper and lower motor neuron bladders are prediposed to urinary tract infections due to incomplete emptying. It is very important to ensure that the bladder is expressed regularly and kept as small as possible to avoid this complication.

Owners can be taught to express bladders, or the dogs can wear diapers, but other complications may arise such as continuous bladder infections and urine scald. Make sure that patients are taken out to urinate or expressed at least 4 times a day. Try not to stand over them as this can sometime be inhibitive for them. If they are unable urinate unassisted, it is sometimes helpful to initiate urination by placing moderate presure on the bladder and allowing them to continue emptying the bladder unassisted. one can express the bladder in lateral recumbency or standing position. Place your hands on either side of the abdoment and gently palpate the animals caudoventral abdomen for the presence of the bladder.   Once you locate the bladder, which is often quite hard and tense and not necessarily that distended in UMN disease, gently and gradually place constant pressure by pushing your hands together and towards the pelvic outlet until the bladder is emptied. Ensure that the bladder is completely empty. Both valium (straited muscle relaxant) and prazoscin (alpha-antagonist) can assist to reduce sphincter tone. If you have a patient that is struggling with incontinence I have found acupuncture to be most beneficial.

The exercises in this article can be given to owners to do or can be done by veterinary nurses or hospital staff. Remember to be consistent and to persevere. Rehabilitation of the neurogical patients can be back breaking hard work at times but the reward when you see them walk their first few steps is one of the best feeling you will ever have.

References

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