2: Neurology



Veterinary medicine is a progressive profession. Over the years more and more challenging neurological patients are being treated. It is equally important for veterinary nursing and physiotherapy to advance to support and rehabilitate these complex patients back to their highest level of function.

Undergoing spinal surgery is only part of the patient pathway. The patient will require nursing support to aid his recovery and physiotherapy to achieve optimum performance postoperatively. By adopting a patient-centred approach the veterinary team can work together to achieve the best outcome for the patient.

Key features of upper and lower motor neuron lesions

Upper motor neurons originate in the cerebral cortex, and terminate in the cranial nerve nuclei or spinal cord anterior horn. Signs and symptoms of upper motor neuron lesions are commonly seen in animals with head trauma resulting in brain injury.

Lower motor neurons originate in cranial nerve nuclei or in the spinal cord anterior horn, and terminate in skeletal muscle motor units. Signs and symptoms of lower motor neuron lesions are commonly seen with traumatic injuries such as brachial plexus evulsions.

Decreased muscle tone may be described as low tone, or hypotonicity. When the operator passively moves the affected limb(s) through range of motion (ROM) very little resistance to the movement will be appreciated.

Muscle tone may be increased, and described as high tone, or hypertonicity. When the affected limb(s) is passively moved through range of motion the operator will appreciate increased resistance to movements.

Clonus is an abnormal reflex seen in the affected animal in response to sudden passive dorsiflexion of the tarsus by the operator.

Tendon reflexes such as the patella reflex maybe increased, decreased or absent (Table 2.1).

Table 2.1 Features of upper and lower motor neuron lesions.

Feature Upper motor neuron Lower motor neuron
Muscle tone Increased Decreased
Clonus Increased Absent
Tendon reflexes Increased Decreased or absent
Distribution Thoracic limb flexion increased, extension decreased
Pelvic limb flexors decreased
Weakness of the muscle groups innervated by the affected spinal segment
Location Brain, C1-5 and T3-L3 lesions C6-T2, L4-S3 and neuromuscular lesions

Surgical presenting conditions

Intervertebral disc disease (IVDD)

IVDD Hansen type I

Hansen type I intervertebral disc disease (IVDD) tends to occur most frequently in chondrodystrophoid (dachshund, Lhasa apso) type breeds aged between 2 and 7 years with a peak incidence at 4–5 years old. The disc becomes cartilaginous, and its nucleus takes on a granular consistency resulting in a progressive loss of hydroelastic shock-absorbing qualities. The degenerative nucleus often undergoes calcification, further compromising its function. Traumatic events such as jumping and twisting may hasten the clinical signs of IVDD; however, once degeneration has progressed to a certain point, even normal activity can result in acute mechanical failure. This failure often results in complete rupture of the dorsal annulus and an explosive upward extrusion of a large volume of nuclear material into the vertebral canal (Slatter, 2003).

IVDD Hansen type II

Hansen type II intervertebral disc disease (IVDD) tends to occur in non-chondrodystrophoid breeds (Labrador retrievers, German shepherd dogs) later in life between 8 and 10 years of age, and generally causes less severe signs. The nucleus of the disc remains more gel-like and mineralisation is rare. Partial rupture of the annulus bands and bulging of the dorsal annulus results in a disc protrusion (Slatter, 2003) (Figure 2.1).


Figure 2.1 Chronic intervertebral disc disease at L1-2 with widespread cord compression.

Medical management for IVDD

Medical management may be considered for cases that present with mild to moderate spinal pain and paraparesis, and also if the owner has financial restraints. Medical management consists of:

  • Rest.
  • Pain relief.
  • Gentle physiotherapy to maintain joint ROM, and muscle length.
  • Heat packs to reduce muscle spasm (10–20 minutes, 3–4 times daily; use caution if the patient has altered temperature sensation).
  • Standing and gait practice with support for toileting purposes only in the early stages.
  • Progress the physiotherapy regime over weeks 4–6 if the pain is controlled; aim to strengthen pelvic limbs, and improve balance.

This type of management may be suited to Hansen type II disc protrusions, which tend to have a progressively chronic presentation. Hansen type I disc extrusions tend to require surgical intervention based on acute presentation and severity of symptoms.

Surgical management for IVDD

Surgical management may be indicated if the patient is not responsive to medical management, or if the clinical signs progress to non-ambulatory paraparesis or paraplegia. Decompressive surgery for IVDD includes hemilaminectomy, dorsal laminectomy, or ventral slot for lesions in the cervical spine region.

Physiotherapy and rehabilitation plan for surgical patients (Hansen type I or II intervertebral disc disease)

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.

Figure 2.2 A tetraparetic patient positioned on his right side with his left limbs supported to prevent muscle imbalance (he is weaker on his left side).

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).


Figure 2.3 Right thoracic limb passive range of motion (PROM) exercise to maintain joint range of motion. The operator’s right hand stabilises at the elbow joint to prevent rotation of the joint, the left hand flexes the carpal, elbow and shoulder joints.


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).


Figure 2.4 Left pelvic limb passive range of motion (PROM) exercise to maintain joint range of motion. The operator’s right hand stabilises over the hip joint, the left hand flexes the tarsal, stifle and hip joints together.

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.


Figure 2.5 A left hip flexor stretch. The operator’s left hand is placed on the distal femur and applies a caudal force into resistance; the right hand stabilises the distal limb to avoid any rotation of the joints.

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.


Figure 2.6 A left hamstring stretch. The operator’s left hand is positioned on the distal femur and applies a caudal force; the right hand is positioned at the caudal tarsus and applies an opposing cranial force to stretch the hamstrings.


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).


Figure 2.7 A right triceps stretch. The operator applies a cranial force to the caudal elbow into resistance to stretch the triceps muscle (see also 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.


Figure 2.8 A right biceps stretch. The operator’s left hand stabilises at the origin of the muscle, and the right hand is fixed on the insertion of the muscle and applies a caudal force into resistance to stretch the biceps.

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.

Figure 2.9 Assisted sitting in a paraparetic patient using The Soft Quick Lift™ sling. Note that the pelvic limbs are positioned in a functional sitting position, and the patient is being supported from behind to maintain his balance, and to prevent him from falling backwards.


Figure 2.10 Assisted standing in a paraparetic patient using The Soft Quick Lift™ sling. Note the patient is taking some weight through the left pelvic limbs, but is knuckling on his right pelvic limb.

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.

Physiotherapy home exercise programme following hemi-laminectomy for IVDD T13 – L1

Early phase (approx. 0–2 weeks)

Passive range of motion (PROM) exercises

Flex the joints in the hind limbs, and then extend the joints.

Repeat three sets of 10 repetitions.


Gentle controlled walking with sling support on a flat, firm, non-slip surfaces, 5 minutes, four times a day. Try to ensure the patient does not scuff his toes on hard surfaces; use foot protectors as necessary.


Stretch hamstrings, and a gentle hip flexor muscle stretch twice daily; hold each stretch for 15 seconds, and repeat three times.


Place a small pillow or folded towel between the back legs if the patient is lying on his side for long periods of time.

Sitting and standing practice

Try to encourage the patient to spend some of his day sitting and standing; give him only the support that is necessary and ensure his back feet are positioned correctly.

Mid-phase (approx. 2–4 weeks)


Start to add into the exercise plan work on gentle slopes up and down, and weaving between objects, 5 minutes, four times a day. The patient may not need the sling support at this stage; however, if he is still weak or unable to maintain his standing balance continue to use the sling.


Sit to stand exercises, two sets of 5 repetitions; assist the patient only as necessary.


To improve the patient’s standing balance, gently nudge him at the hips right to left side, then left to right.

Continue with the exercises from the early phase.

Late phase (approx. 4–6 weeks)


Continue with mobility as in mid-phase; add in stepping over small logs or rolls and increase duration of walks to 10–15 minutes, four times a day. Also begin to exercise the patient on different surfaces, for example concrete, grass, bark chippings and sand.

Continue with the exercises from the mid phase.


Do not allow the patient to jump on/off furniture or in and out of cars, or to play vigorously with other animals while he is recovering. He may be unsteady on stairs; if so do not allow him on the stairs. When he is not being supervised he should be kept in a confined area so he does not try to do too much and possibly injure himself.

Follow-up outpatient physiotherapy

Follow-up physiotherapy should be offered to clients to maximise patient recovery and function. If the patient is not local to your area referral to a facility closer to the owner’s home may be required. Patients are usually seen once a week following discharge to facilitate VMF and improve strength, balance, proprioception and stamina.

Weaving cones can be used to improve weight transfer on the affected limbs and challenge balance. Begin with the cones at least as far apart as the patient’s body as lateral spinal flexion may not be comfortable for the patient in the early stages.


Cavaletti poles can be used to encourage joint flexion and paw placement. Be aware that as the patient regains function in his limbs proximal joint movements will be greater than distal joint movements so hip flexion will be stronger than tarsal dorsiflexion and the patient may knuckle on his pelvic limbs for some time following surgery. Use slings and foot protectors as necessary to support the patient (Video 2.6).

Laser treatment over the surgical site can be used weekly to reduce inflammation and counter excessive fibrous tissue formation, and to improve nerve cell amplitude to increase muscle action. Power settings and duration of treatment will be determined by species, skin colour, weight, the area to be treated, and the stage of the condition (acute or chronic). Select chronic at this stage.

Unless the patient has stairs in the house, stair practice should not begin until 4 weeks postoperatively; stair climbing requires a high level of motor function, strength and balance. The spine will be in extension on the stairs and this may be uncomfortable for patients who have had surgery in the lumbar spine region.

Peanut balls should be used with caution in surgical spinal patients to prevent injury to the surgical area. Wobble boards are not recommended for at least 6 weeks following spinal surgery as any jerky uncontrolled movements may have an adverse affect on the recent spinal surgery.


Hydrotherapy using a UWT can be used to facilitate VMF and strengthen the weak affected limbs, to improve core stability, and increase joint ROM. The speed of the belt can be controlled to allow extra time for motor function in the weak affected limbs. As the patient progresses the speed of the belt can be increased to improve stamina, and resistance can also be added to improve strength. The temperature of the water can be adjusted for patient comfort. The height of the water can be adjusted; buoyancy may be desirable in early to mid stages of rehabilitation. However, as the patient progresses the water can be used to provide resistance and strengthen muscles. Most resistance is found at the surface level of the water, so set the level of the water to match the muscle group you wish to strengthen; for example, water at the level of mid-femur will strengthen the quadriceps and hamstrings muscle groups (Video 2.7).

Jul 18, 2021 | Posted by in NURSING & ANIMAL CARE | Comments Off on 2: Neurology

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