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The successful use of veterinary physiotherapy in the management of intervertebral disc disease in an ataxic Cocker Spaniel
Barbara Houlding MScVetPhys MCSP FIRVAP
Summary
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A 2 year old male Cocker Spaniel with pelvic limb ataxia was referred for veterinary physiotherapy and hydrotherapy following multiple intervertebral disc degenerations in the thoraco-lumbar region. Following a full veterinary physiotherapy assessment, a prioritized problem list led to treatment goal planning and agreement with the dog’s owners to commence a course of treatment including a range of land and water based treatment strategies. Functional outcome measures demonstrated a significant improvement in the dog’s core stability, pelvic limb strength and gait patterning in walk, trot and gallop.
Keywords: veterinary physiotherapy, aqua and hydrotherapy, intervertebral disc disease, pelvic limb ataxia, thoraco-lumbar IVDD
Introduction
Intervertebral disc disease (IVDD) is where herniated material that lies beneath or adjacent to the spinal cord extrudes or protrudes, resulting in compression of the spinal cord, leading to variable clinical signs that are dependent on lesion severity and location. Intervertebral disc protrusion (Hansen’s Type II IVDD) in the thoraco-lumbar region is a common neurological spinal disorder with clinical signs that include a slowly progressive pelvic limb weakness, reluctance to rise or jump and problems with climbing stairs. Hyperaesthesia of the paraspinals may be present. Conservative management is indicated in dogs with early onset of Hansens Type II and mild neurological deficits. Physiotherapy has a recognized key role in the effective management of neurological diseases in humans, as well as being central to minimizing and effectively addressing the problems of disuse, immobilisation and poor movement patterning of the musculo-skeletal system. This aims to maximize the functional recovery of the biped or quadruped. However, the organization of canine motor patterning is very different to human motion, with the dog using quadruped biomechanics linked to form and function. Small animal veterinary physiotherapists are specialists able to effectively employ a range of assessment and treatment tools to deliver an individual programme, meeting the needs of their canine client and owner.
Case History
A 2 year old male (entire) blue roan Cocker Spaniel presented to Dick White’s Referral Clinic from Wangford Veterinary Surgery for further investigation of acute pelvic limb ataxia with reluctance to walk, jump or climb stairs.
On presentation to the referral clinic, a full physical and neurological assessment was performed. This revealed mild pelvic limb ataxia with mild thoraco-lumbar hyperaesethesia. Neuro-anatomical localization was consistent with a T3L3 myelopathy. Further investigations included hematology, biochemistry and electrolytes, with results being unremarkable. An MRI scan revealed multiple intervertebral disc degenerations with mild protrusion in the thoraco-lumbar area.
Conservative management was recommended with a view to surgical decompression if there was a poor response to treatment. Management consisted of Gabapentin (Neurontin, Pfizer) 100mg – every eight hours (the dog weighed 13.2kg). Hydrotherapy at least once weekly was recommended along with instructions for rest initially consisting of 5 to 10 minutes lead walks for the first two weeks (then slowly increasing over the following two weeks) to four or five times a daily for toileting purposes. Following this, lead exercise only was directed for four to eight weeks. Reexamination was arranged for four weeks or earlier in the case of any deterioration.
Wangford Veterinary Surgery then sent a referral to K9 Hydro Services. A full veterinary physiotherapy assessment was performed. The history highlighted that the Spaniel slept curled up in a rigid plastic bed, was reluctant to climb stairs in the owners second home, could no longer jump into their 4 x 4 car and was exercised on an extendable lead, constantly leaning and pulling ahead of the owner at all times. His owners reported that his mentation had altered and he was withdrawn, quiet and depressed.
Observation at rest, functional transfers and gait identified that only a walk gait pattern in a straight line was achievable as the dog collapsed if attempted to trot, turn or circle. In walk the nose was in contact with the ground at all times and the dorsum of the left pelvic limb scuffed consistently. Transfers showed poor core stability and dynamic control as the dog collapsed, using thoracic limbs to attain stance from sit, and sit from lying. In sitting posture the left pelvic limb was held cranial and abducted at all times.
On palpation it was noted that the caudal epaxials had poor muscle tone with significant muscle atrophy of both Gluteal masses and Biceps Femoris, greater loss being noticed on the left pelvic limb. Increased muscle tone was identified in the caudal cervical muscle mass and right forequarter. He was reactive and uncomfortable on palpation of Trapezius and Rhomboids and had extreme tenderness at all levels of his lumbar spine.
Proprioceptive integrity tests including the knuckling over test, sliding paper test and pelvic limb static and dynamic balance tests to challenge the stability of the pelvichip complex, along with segmental core stability tests were used. This showed a significant loss in core stability and both pelvic limbs, left much greater than right.
The prioritized problem list identified the need to address the paraspinal hyperaesthesia, poor core and pelvic limb stability, muscle atrophy of the power muscle system, poor functional transfers and posture and limited movement and gait patterning. This led to goal planning and clinical reasoning to select a range of treatment strategies.
Initial land based approaches included a course of Biomag pulsed electromagnetic therapy to the paraspinals, Trapezius and Rhomboids applying two triple concentric pads set on 200HzC for 15 minutes. Two point control using a harness, collar and training lead was introduced to enable controlled and balanced movement over a proprioceptive track and achieve the graduated motor patterning land based programme. Two point control was demonstrated and directed as part of a home programme along with husbandry advice on a larger rectangular bed with sufficient bedding for the dog to lay out more comfortably and supported, reducing unnecessary spinal forces.
Water based treatment used included Aqua Pre Stim techniques prior to pool work (vibration, compression, touch, heat) to the Gluteals, Biceps
Barbara Houlding swimming a dog
Femoris, Trapezius and Rhomboids and caudal paraspinals). Pool work commenced with the dog fitted with a land harness and flat collar, no buoyancy aids were used. Access into the pool was by a gentle ramp and the veterinary physiotherapist in the pool provided an extensive range of aqua manual and graduated movement techniques and measured buoyancy. The dog’s key motivation was identified and assisted delivery of exercises in the warm water on submerged pods and ramps along with a variety of free reflexive swimming techniques. Centre of buoyancy and manually administered turbulence/ drag were the key hydrotherapy principles manipulated to progress the aqua work and enhance the dogs function, balance, co-ordination and motor patterning. Pool exit work to optimize the eccentric loading of the power muscle system and spinal reflexive towel work post hydro further enhanced the programme.
Post treatment the outcome measures used included repeated functional sit to stand, re-palpation of paraspinals and observation of top line and gait assessment. A marked improvement was recorded after the first hydrotherapy session.
After the second session a week later the dog was reported and observed to use a trot gait pattern with increased propulsion, static and dynamic balance and was alert and interactive. The Spaniel no longer moved with nose to ground and the left pelvic limb did not drag or scuff. The dog had ceased pulling on the lead and engaged his rear power muscle system more appropriately. He continued a weekly session for 5 weeks and achieved the initial treatment goals. The dog was then transferred onto a maintenance strengthening programme of modified hydrotherapy techniques, attending once every 4 to 6 weeks, with the dog returning to full function and activities after 5 more sessions.
This single case study demonstrates that a physiotherapeutic package of specific water and land based assessment and treatment strategies is an important and significant part of the overall conservative management of thoraco-lumbar IVDD.
References
Brown, N.O., Helphrey N.L. and Prata R.G. (1977) Thoracolumbar disk disease in the dog: a retrospective analysis of 187 cases. Journal of the American Hospital Association 13, 665-672
S.R.Platt and N.J.Olby (2004) BSAVA Manual of Canine and Feline Neurology 3rd Ed, Blackwell Publishing
