Day 0

Day 0 is the day of surgery. Laser therapy, if available, may commence as the patient is recovering from surgery. Select the acute incision setting. NB do not use the laser over the thyroid area for ventral slot surgery, as lasering over the thyroid gland is contra-indicated.

The aim of laser therapy in this case is to promote healing of the incision site post-surgery. Eye protection must be worn by the operator, and anyone else in close proximity to the laser beam. Laser therapy of the surgical area should be repeated daily.

Day 1

Day 1 postoperative is considered a rest day. The patient is likely to be on opioid-based medication and non-steroidal anti-inflammatory drugs (NSAIDs). Nursing considerations are important and a waterproof mattress with absorbent bedding, such as vetbed^® (Petlife International Ltd, Bury St Edmunds, Suffolk, UK) or a similar type, should be used to ensure the patient is comfortable and dry. The patient should be turned every 4 hours; if tolerated the patient may prefer to be in sternal recumbency, then just turn the hips. Ensure the patient is adequately supported when turning and avoid any rotation of the spinal column. Two people will be required to turn large dogs. Aim to maintain good spinal alignment when turning a spinal patient and avoid twisting or rotating the spine during the manoeuvre.

If the surgical site is in the cervical spine region ensure the patient’s head is supported when turning. If the patient is in the sternal position a small pad should be available for him to rest his head on to maintain a neural spinal position; do not elevate the head into extension.

The bladder should be palpated every 4 hours, and size and tension of the bladder noted. If the bladder is becoming large and tense, manual expression of the bladder may be necessary. If the veterinary surgeon is concerned about bladder function preoperatively he or she may place an indwelling urinary catheter at the end of surgery. This should be cleaned twice daily with a chlorhexidine solution, and the volume of urine should be measured every 4 hours to ensure urine production remains in the range 1–2 mL/kg/hour. Nursing of the patient will also include optimal nutrition for the recovering patient.

Laser therapy – repeat as for day 0; repeat daily until suture or staple removal.

If therapeutic laser is not available the veterinary surgeon may request:

• Ice packing of the site every 4–6 hours; the aim is to reduce postoperative inflammation. An ice pack wrapped in a damp towel can be gently applied to the area for 10 minutes if tolerated by the patient. Also check with the veterinary surgeon beforehand as he or she may not wish for the surgical site to be interfered with. Ice packing is usually applied to the area every 4–6 hours for the first 72 hours post-surgery.
  
• Positioning – if the patient is in lateral recumbency ensure a pad is placed between the thoracic limbs, and a second pad between the pelvic limbs to ensure the limbs remain in a neutral position and to prevent muscle imbalance. The internal rotator muscle groups tend to become short and tight and the external rotator muscle groups tend to become long and weak, in non-ambulatory patients. Ensuring correct muscle length by supporting the patient with positioning aids aims to minimise this (Figure 2.2).
  

  If the animal is in sternal recumbency, only his pelvic limbs will require turning and supporting in neutral with a pelvic wedge.

  
  
• Standing – supported standing may be performed once on day 1. This is usually with the veterinary surgeon present as he or she will assess the patient’s neurological status post-surgery. From a physiotherapy point of view you will be observing how much weight the patient is taking through his limbs and also noting his muscle tone, which may be normal, hypertonic or hypotonic.

Day 2

Continue with all the nursing care and physiotherapy from day 1, plus begin the following.

Passive range of motion exercises (PROM exercises) – are performed to maintain joint ROM. N.B. Because the exercise is passive the patient does not receive any strengthening benefits from the PROM exercises. If the patient has had cervical spinal surgery all four limbs may be affected; if surgery was in the thoracolumbar or lumbosacral region only his pelvic limbs will be affected.

When performing these exercises on the thoracic limbs the patient should be in lateral recumbency. Support the patient under the medial elbow with one hand to prevent any rotation of the joint and with the other hand bring all the joints together into full flexion. Then using the hand supporting the elbow to guide the movement, extend the joints in the thoracic limb; again avoid rotation by supporting the limb at the carpal joint. No hold is necessary at full flexion or extension. No pulling on the limb or tight gripping of the limb should occur. Three sets of 10 repetitions performed twice daily should be sufficient to maintain joint ROM (Figure 2.3; Video 2.1).

PROM exercises on the pelvic limbs follow the same formula as for the thoracic limbs, supporting at the medial stifle joint to prevent rotation(Figure 2.4; Video 2.2).

Stretches are important to maintain muscle length. If the patient is recumbent for a period of time muscle changes will occur resulting in muscle imbalance. If the flexors and internal rotator muscles become short and tight the patient will find it very difficult to ambulate even with support as the limbs will be flexed and internally rotated, meaning he will not be able to place or position his feet and the limbs will be crossed over. It is easier to prevent muscle changes with stretching and positioning than it is to correct them.

Hip flexor stretch: The patient is placed in lateral recumbency with the limb to be stretched uppermost. One hand is placed at the level of the mid-femur, the other hand supports at the tarsal joint, and to avoid any rotation of the joints. The limb is passively extended until mild resistance is felt in the hip flexor muscle group (Figure 2.5). Stretches are held for 15 seconds, repeated three times, twice a day to maintain correct muscle length. Stretching should not be uncomfortable for the patient. N.B. If the patient has undergone surgery in the lumbar spine region and has marked spinal flexion in this area, be gentle with this stretch as he may find it uncomfortable as extension of the hip will also extend the lumbar spine resulting in discomfort at the level of decompression.

Hamstring stretch: Straighten the pelvic limb and place one hand at the level of the cranial mid-femur applying a caudally directed force, and place a second hand on the caudal aspect of the tarsal joint, applying an opposing cranially directed force (Figure 2.6). Stretches are held for 15 seconds, repeated three times, twice a day to maintain correct muscle length. Stretching should not be uncomfortable for the patient.

Adductor stretch: With the patient positioned in lateral recumbency flex the stifle to 90° support with one hand at the medial stifle then abduct the limb, position the other hand over the greater trochanter and apply a counter pressure to prevent any lax movement occurring at the hip joint. It may be useful to support the patient’s lumbar sacral spine with your knee to prevent spinal rotation. Stretches are held for 15 seconds, repeated three times, twice a day to maintain correct muscle length. Stretching should not be uncomfortable for the patient (Video 2.3).

If the patient has undergone cervical spine surgery and the thoracic limbs are affected the triceps and internal rotators of the thoracic limbs should be stretched.

Triceps stretch: With the patient positioned in lateral recumbency place a hand on the caudal aspect of the elbow joint and advance the limb in a cranial direction until mild resistance is noted in the triceps. Use your other hand to support the limb at the carpal joint to avoid any rotation of the limb. Stretches are held for 15 seconds, repeated three times, twice a day to maintain correct muscle length. Stretching should not be uncomfortable for the patient (Figure 2.7; Video 2.4).

Internal rotator stretch: With the patient positioned in lateral recumbency use one hand to support the shoulder joint (humeral head), place your second hand on the medial aspect of the elbow joint and rotate the limb externally to stretch the internal rotator muscle group. Stretches are held for 15 seconds, repeated three times, twice a day to maintain correct muscle length. Stretching should not be uncomfortable for the patient.

Biceps stretch: Caution is required when stretching the biceps if the patient has undergone ventral slot cervical spine surgery as this stretch may also stretch the surgical incision site.

N.B. If you or the surgeon have any concerns regarding this stretch then it may be better to omit this stretch.

With the patient positioned in lateral recumbency place one hand in the region of the mid-humerus, and apply a caudal force until mild resistance is noted in the biceps muscle; use a second hand to stabilise over the proximal humerus (Figure 2.8; Video 2.5) Stretches are held for 15 seconds, repeated three times, twice a day to maintain correct muscle length. Stretching should not be uncomfortable for the patient; avoid any rotation of the joints.

Following the passive exercises and with the veterinary surgeon’s permission progress the supported standing exercises to supported gait practice. A minimum of two people will be required for this and ideally manual handling aids will be available to support the patient.

• Use a chest harness rather than a neck collar and lead, unless the lesion was very caudal.
  
• It may be easier to assist the patient from the kennel, then to step the patient into The Soft Quick Lift™ sling from a stable surface.
  
• Use The Soft Quick Lift™ sling to assist the patient to ambulate (Figures 2.9 and 2.10); if the patient is mildly affected a Helping Hand sling maybe used.
  
• Use foot protectors as necessary.
  
• Ideally working as a team, each person should take one of The Soft Quick Lift™ handles. If the patient is very small one person can position themselves behind the patient and hold one of the handles in each hand.
  
• Aim to give the patient adequate support to facilitate tip-toe walking.
  
• Walk slowly and give the patient time to use the affected limbs.

The patient may be taken out two to three times daily for 2–5 minutes each time for toileting purposes. When the patient is returned to his kennel ensure he is correctly positioned and supported to avoid muscle imbalances.

Days 3 and 4

Continue with the exercises from day 2.

Day 5

Hydrotherapy may commence on day 5 with the veterinary surgeon’s permission. It is worth knowing beforehand if the patient is happy in water. If the patient is not happy in water and panics, the risks of the hydrotherapy may outweigh the benefits. Surgical sites can be protected with waterproof dressings.

Aims: Hydrotherapy can be used to increase the patient’s buoyancy by reducing bodyweight passing through the limbs to facilitate voluntary motor function (VMF) in the limbs. It is essential that a trained member of staff is in the water with the patient to reassure him, should he panic, to support him in the water and to facilitate VMF in the affected limbs. Keep the first session short to allow the patient to become used to the exercise; 3 × 1 minutes of exercise with rests in between can be used as a starting guide. Begin with a slow speed to allow time for VMF in the affected limbs. The water should be comfortably warm at approximately 30°C.

Technique: An underwater treadmill (UWT) allows the patient to exercise in a functional way. Walking in the treadmill is a transferable activity to walking on dry land. Ensure at least two people are available, one in the water and one on dry land to control the settings and provide extra support to the patient. Buoyancy jackets should be available in a range of sizes; use the straps and clips to ensure a snug fit to utilise the buoyancy effect of the water. An overhead tracking hoist can be used to support large patients. A range of body slings, The Soft Quick Lift™ and Helping Hand slings should be available to support the patient in the hoist. This allows the person in the water to assist the patient to use his limbs in a functional way.

The buoyancy effect is relative to the amount of water supporting the patient. If the aim is to support the patient’s weight and facilitate VMF a high level of buoyancy is required. However, care must be taken not to have the water too close to the patient’s face as he may feel vulnerable, and the patient’s feet should remain in contact with the treadmill belt and not float. A water level at the height of the patient’s mid-trunk may be used as a starting guide. A slow speed should be selected, much slower than the patient’s normal walking speed. This is to allow time for the patient to engage VMF in the affected limbs, which will be much slower than the motor function in the unaffected limbs. If the speed is too fast the patient will pull himself forwards with his unaffected limbs, and not allow time for weak early stage rehabilitation VMF in the affected limbs.

Patients may be discharged between days 5 and 10 postoperatively. This will depend on many factors such as how the patient has progressed with his mobility following surgery, if the patient has independent bladder function, the owner’s home situation, and their ability to assist the patient to maximum recovery and function.

No two patients are the same – even if they have undergone the same procedure their recovery rates will vary. Some patients may have concurrent joint disease, which will affect their rehabilitation. It is important that patients who are on medication for joint disease continue this medication while hospitalised.

Bladder function may be altered in neurological patients with spinal cord compression. Following spinal decompression bladder control may still be compromised and the patient’s bladder should be palpated every 4–6 hours to assess size and to monitor how firm the bladder is. If in any doubt bladder size can be confirmed with a quick ultrasound scan. If the bladder becomes large and firm and the patient does not empty the bladder himself it may need to be manually expressed, or catheterised. When the patient begins to regain bladder control the flow may be weaker so it is important to provide him with time and support to empty his bladder.

If access to the owner’s house has steps, and the patient is too heavy for the owner to carry, the rehabilitation programme in the hospital may need to include stair practice. This will require two people, one to lead the patient and a second to support the patient with The Soft Quick Lift™ sling or a Helping Hand sling on the stairs. The patient will need support ascending the stairs as he will have reduced strength to push off on the pelvic limbs, and his balance will be affected on the descent so he will require close support to maintain his balance.

At the time of discharge the owner is provided with a progressive rehabilitation programme to assist the patient back to his highest level of function. Spend time demonstrating the exercises to the owner and allow the owner time to practise the exercises under supervision. Show the owner how to use any slings and foot protectors the patient may be discharged with. Ensure the owner gives the patient adequate support when using slings to ensure the patient does not damage his feet on rough surfaces, but ensure that the owner does not carry the pelvic limbs for the patient. Ask the owner to aim for tip toe walking support and ensure the patient walks slowly to allow VMF in the affected limbs. Finally, show the owner how to lift the patient in and out of the car. Under no circumstances should the patient be allowed to jump in or out of the car. Small dogs can be lifted by one person supporting the animal with one hand under the abdomen and a second hand in front of the chest. Larger dogs should be lifted by two people, with one supporting the animal under the chest and a second person supporting him under the abdomen; when lowering the patient place his unaffected limbs onto the stable surface just ahead of his affected limbs so he can take his weight in a controlled manner.