38 Rick Wall The discipline of physical rehabilitation is one of the recent additions to therapeutic protocol of the intervertebral disc disease patient. However, the paucity of veterinary literature combined with the absence of controlled scientific studies sometimes hampers its universal or widespread acceptance. Anecdotal observations and conclusions by experienced rehabilitation practitioners are currently the largest source of both information and therapeutic recommendations. Primary care veterinarians and specialists accept that in adult dogs intervertebral disc herniation is considered to be one of the most common causes of spinal cord injury and subsequent neurologic deficits [1]. Education of veterinary professionals regarding rehabilitation will enhance their consideration for including formal physical therapy as part of the management of conservative nonsurgical and postoperative intervertebral disc herniation patients. This chapter aims to assist veterinarians with understanding rehabilitation assessment of the intervertebral disc herniation patient, establishment of prognosis and goals, development of a patient rehabilitation program, and assessment of patient progress and outcome. This knowledge will assist the practitioner with the ability to promote rehabilitation services to their clients, with the possibility of improved patient outcomes. Initial physical evaluation and a review of the clinical history are required to accurately suggest a prognosis and develop a specific rehabilitation program. The physical evaluation should involve a neurologic assessment, including urogenital function, evaluation for concomitant orthopedic problems, examination for general medical conditions, and an evaluation of patient discomfort. In both conservatively managed and postoperative intervertebral disc herniation patients, the most important component of the clinical history used to shape prognosis is the subjective observation by the owner and/or referring veterinarian of changes in neurologic dysfunction since the onset of signs or since surgical intervention. Perceived improvements in ambulation, musculoskeletal strength, or voluntary motor activity of impaired limbs are considered very positive for the prognosis. Voluntary motor activity or gait assessment if the patient is able to walk, proprioceptive positioning, and nociception are of importance in determining neurologic status. The Texas Spinal Cord Injury Score for dogs can be used to numerically score each limb (Table 38.1) [2]. The scale reflects the typical sequence after spinal cord injury of functional loss and recovery in gait, proprioceptive positioning, and nociception [3]. Video recordings of neurologic examination and ambulation can serve as a baseline reference of initial presenting status for comparison to future evaluations. Table 38.1 Texas Spinal Cord Injury Score (TSCIS) for dogs It must be understood, regardless of the severity of the spinal cord injury, that a diagnosis of intervertebral disc herniation is tentative and the prognosis may be guarded without further diagnostic information in those patients where only conservative treatment is being utilized. Micturition disorders are common in intervertebral disc herniation patients with spinal cord injury. These disorders are discussed elsewhere in this text (see Chapters 10, 22, and 27). Discomfort in the intervertebral disc herniation patient is often a complex combination of injury to the spinal cord or nerve roots (referred to as neuropathic pain), myalgia, surgically induced trauma, and exacerbation of preexisting conditions such as osteoarthritis. Clinical history and careful examination to identify pain generators are necessary to develop a patient specific pain management protocol. This complex pain may not be controllable with any single pharmaceutical or modality. Therefore, a multimodal approach is preferred (see Chapter 24). The use of gabapentin in combination with an opioid, nonsteroidal anti-inflammatory drug, or antidepressant has shown positive responses in the treatment of neuropathic pain in people [4]. Others reported a dramatic improvement in three dogs with presumed neuropathic pain treated with gabapentin or amitriptyline [5]. Establishment of realistic goals in the impaired intervertebral disc herniation patient provides the veterinary client with both a definition of success and an awareness of a potential therapeutic endpoint. Goals should focus on the reestablishment of ambulation and a level of musculoskeletal strength sufficient to provide a minimum level quality of life. This minimum level can be defined as the restoration of the patient’s ability without assistance to secure nourishment (drink and eat) and complete eliminations (urination and defecation). When these minimum goals cannot be met, the patient will require prolonged or lifetime nursing care. A particular nursing task acceptable to some veterinary clients may, however, be impossible to maintain by others. Following patient assessment and establishment of treatment goals, a rehabilitation therapy program should be designed. Therapy is focused on addressing neurologic dysfunction due to the spinal cord injury. The primary components include (i) passive and active range of motion exercise to maintain or improve proper joint and spinal range of motion; (ii) neurologic therapeutic exercises to increase both proprioceptive and kinesthetic awareness; (iii) therapeutic exercises to improve musculoskeletal strength, limit disuse atrophy, and strengthen core muscles; (iv) exercise to maintain or improve cardiovascular fitness; and (v) gait retraining.
Physical Rehabilitationfor the Paralyzed Patient
Introduction
Patient evaluation and establishment of a prognosis
Clinical history
Neurologic examination
Gait
0 = no voluntary movement seen when supported
1 = intact limb protraction with no ground clearance
2 = intact limb protraction with inconsistent ground clearance
3 = intact limb protraction with consistent ground clearance (>75%)
4 = ambulatory, consistent ground clearance with moderate paresis–ataxia (will fall occasionally)
5 = ambulatory, consistent ground clearance with mild paresis–ataxia (does not fall, even on slick surfaces)
6 = normal gait
Proprioceptive positioning
0 = absent response
1 = delayed response
2 = normal response
Nociception
0 = no deep nociception
1 = intact deep nociception, no superficial nociception
2 = nociception present
Micturition
Pain examination
Goals of rehabilitation therapy
Development of a rehabilitation program
Range of motion and stretching exercises
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