Case Study: 9 Year Old Female Neutered Staffordshire Bull Terrier

Ciara Glaisher ACPAT RAMP CSP HCPC

O sought physio from advice on a local social media page describing her symptoms.

HPC: 8 week history of urinary incontinence, generally seeming old and sad, plus noticed intermittent shakiness of hindlimbs for the last 6-8 weeks. Occasionally hindlimbs buckle under her. Right forelimb also intermittently points her toes outwards. Last few weeks has been slow to walk up hills. Last 3 weeks has occasionally been sleeping with eyes open, and last few days has occasionally ‘winked’ at owner, with left eye closing. Seen vet three times since symptoms began, initially treated for UTI, then a ‘dropped bladder’. On day of initial physio appt, was also diagnosed with reduced kidney function, given new medications to start that evening.

Observations on initial appt: BCS 2.5/5, happy demeanour around owner’s garden. Posture was standing with increased extension of L>R stifles and tarsi. Mildmoderately flexed lumbosacral spine, with tail tucked. Sitting tended to sit on one side, always done.

Gait Ax: In walk, R carpus ‘dishing’, slight increased carpal extension on weightbearing, slightly wide forelimb stance. Intermittently wide hindlimb stance. Slightly laterally flexed lumbar spine to R. In trot, laterally flexed lumbosacral spine to right, on 3 tracks. Running, tended to bound around. Able to do walk in tight circles and back-up 1-2 strides, but difficulty assessing due to anxiety.

Postural sets no deficit noted.

Reflexes: Knuckling immediate replacement. Paw placement good. Cutaneous trunci absent entire spine. Myotatic reflexes unable to assess due to fear of reflex hammer. Clonus unable to assess as not relaxed enough (never layed down during appt.s).

Palpation: Muscle atrophy R side middle gluteal, quadriceps, mildly hamstrings. L side quadriceps + mildly hamstrings.

PAIVMs in all directions on thoracic and lumbar spine all NAD; normal mobility, no pain reactions. Dorsoventral on S1-3 likely painful as she stopped moving + concentrated on physio (Subtle body language signal only).

ROM R carpus mild hyperextension + 10degree MCL laxity.

Impression: I worked on a theory that this dog potentially had lumbosacral stenosis, affecting R>L S1/2, potentially with Lower Motor Neuron bladder deficit (from re-reading university notes, explaining neural control of bladder; S1+2 nerve roots). Complicated by reduced kidney function diagnosed, which she had new medication for, so discussion with owner to explain we don’t know how much of her symptoms could be caused by each pathology. Explained that kidney function would be highly unlikely to cause the concurrent muscle atrophy and altered gait pattern, so worth treating what we find from a musculoskeletal perspective. Owner was very keen to do everything possible to maintain quality of life.

Treatment: Applied NMES to S1/2 nerve roots x5minutes bilaterally. NMES to gluteals, required intensity of 23 to activate muscle contraction. Manual therapy PAIVMs dorsoventral glides to S1/2, grade 3; to relieve pain and stimulate neural firing. Advised strengthening exercises including sit-to-stands, controlled uphill walking, playing tug of war.

Review 2 weeks later: Owner reported urinary incontinence had resolved immediately following initial appointment. They started new kidney medication the same evening, but highly unlikely to have had effect immediately as needed to build up levels in her system. Observations showed much improved gait pattern, no longer wide base of support. Standing posture less flexed lumbosacral spine, tail still tucked. Palpation revealed increase muscle bulk in gluteals + quadriceps.

Treated with repeat NMES to S1/2 nerve roots x10mins, NMES to gluteals + quadriceps x5mins. Progressed exercises to rhythmic stabilisations on 3 legs, plus wobble cushion standing. Planned to monitor R carpus + splint/support if any signs of lameness or increased laxity.

Case was left open for owner to contact me when urinary incontinence returned, or deterioration of functional abilities. No contact for months, however I did see a post from the owner on the original social media page, 4 months later. When I asked how she was doing, the owner replied happily that urinary incontinence has never returned since the first physio treatment, she was functioning well and happy with strengthening exercises/ advice. Sadly, a few months later I saw another post, to say she was PTS, for other unrelated reasons.

Discussion/learning point: Unfortunately the veterinarian involved is a local GP vet known to never refer cases (to any specialty), and does not see the need for Physiotherapy. He did agree to me seeing this case, so consent officially gained, although he did say the problem was not ‘anything to do with physio’ and did not understand the potential benefits. It was difficult to converse with him, regarding the potential cross-over effects of kidney medication and physio treatment, so we can only conclude our interpretation of signs/symptoms.

In my opinion, although the clinical signs of this patient could have been at least partly, or fully, due to kidney function, I would be very surprised if medication would have such an immediate effect on incontinence. Of all the signs/symptoms, the owner was most concerned about the incontinence, as it seemed to be causing a lot of stress in the dog by soaking her bed multiple times a night (O washed 3 blankets every night). From reading about neural control of the bladder, it made sense that the nerve roots involved (S1/2) are also susceptible to stenotic changes. The localisation of muscle weakness and behavioural changes fit with lumbosacral stenosis, a common ailment in older dogs, so I treated on this theory. Having spoken to a human physio colleague specialising in Pelvic Health, it is not common practice to stimulate nerve roots for incontinence as a physio, however this is available as a surgical option when appropriate. There may be a difference in anatomy, where canine nerve roots are closer to the surface than human, so may be more accessible.

As NMES is used for stimulating nerve following injury, as well as muscle stimulation, I felt it was an appropriate modality to try. At no point did I expect immediate improvement, and the owner expected to require multiple sessions with follow-up maintenance sessions, if it was to work at all. However, with this one experience, I will now consider NMES to nerve roots for urinary incontinence in the future, as long as correct veterinary management is also pursued, and there are signs of a LMN bladder.