Hello,
I am currently working with a 6 year old MN Boston Terrier named Mason who was recently diagnosed with spinal cord ischemia and inflammation of C-spine. The neurologist believes that this lesion is most likely secondary to an autoimmune process. They also report mild disc lesions at C2-C4 and degenerative disc disease at C6-C7. Mason presented to the neurologist with hemiparesis on the right side. He is currently on a weaning dose of prednisone and is now taking the pred EOD. I thought it was interesting that I could not appreciate pain with side glide of the C-spine, though I did notice a decreased joint space of AO on the left. I also noticed that Mason was reactive with palpation (lateral pressure on the spinous process and flinches with DV pressure on the ribs, bilaterally, at T8-T10. As well, I feel that Mason has hyperextension of both shoulders though I did not get a pop or pain with extension. I am just wondering if you think I should investigate the shoulder hyperextension more? For a pup with cervical lesions, I expected him to be tight and tense and to have decreased extension but Mason seemed relaxed.....I would think if Mason had medial shoulder instability, I would see signs of pain and a lameness ....though he is on Prednisone....
I am just curious what you think about this history and exam findings! Thank you so much!
Juli
6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperextension
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JuliPotter
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Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Hey Juli,
First off, I think you've done a very impressive evaluation as per your report! Nicely done!
Okay, so I'm going to start with the tenderness at T8 - 10. That could be 'normal'. Since 10 is the transition vertebra (T9/10 facets are horizontal and T10/11 are vertical), it is not uncommon for most dogs to have some degree of tenderness in and around T10. However, you can do some mobilizations there... but just be sure to add some flexion into the body as you do them, to perhaps make them more effective / less painful as you do them. (From my Advanced Manual Therapy for the Canine Spine course, I'd do Dorsal Glides as well...)
Alternately, some T/S tenderness (but usually it's mid to cranial T/S) can be associated with being neurologic and the need to 'pull' themselves up and around in order to move forwards.
Now, in regards to the shoulders. Interesting finding! I had a little border collie in the class I was teaching in Sweden. She had had some neck issues and as a result her shoulders seemed to be positioned quite far forwards... but the shoulders themselves had no pain, and were very mobile (almost like what you described). Given the dog's history, I thought I would find stiff / tight shoulders, but not so! Could it be that in order to avoid certain neck postures, the shoulders allow more mobility over time? I would think this not to be true in every case... but we're all individuals after all!
I also think there are plenty of dogs with Medial Shoulder hypermobility without lameness! Okay, not 'think', I should say 'know'! In that I've found TONS! I'm now more surprised when an agility dog ISN'T hypermobile.
Okay... so in that regard, I think you leave the shoulders be.
Thus taking you back to neck therapies, T/S therapies, and functional movement therapies.
And yes, recheck when he's off the Pred.
Cheers!
Laurie
First off, I think you've done a very impressive evaluation as per your report! Nicely done!
Okay, so I'm going to start with the tenderness at T8 - 10. That could be 'normal'. Since 10 is the transition vertebra (T9/10 facets are horizontal and T10/11 are vertical), it is not uncommon for most dogs to have some degree of tenderness in and around T10. However, you can do some mobilizations there... but just be sure to add some flexion into the body as you do them, to perhaps make them more effective / less painful as you do them. (From my Advanced Manual Therapy for the Canine Spine course, I'd do Dorsal Glides as well...)
Alternately, some T/S tenderness (but usually it's mid to cranial T/S) can be associated with being neurologic and the need to 'pull' themselves up and around in order to move forwards.
Now, in regards to the shoulders. Interesting finding! I had a little border collie in the class I was teaching in Sweden. She had had some neck issues and as a result her shoulders seemed to be positioned quite far forwards... but the shoulders themselves had no pain, and were very mobile (almost like what you described). Given the dog's history, I thought I would find stiff / tight shoulders, but not so! Could it be that in order to avoid certain neck postures, the shoulders allow more mobility over time? I would think this not to be true in every case... but we're all individuals after all!
I also think there are plenty of dogs with Medial Shoulder hypermobility without lameness! Okay, not 'think', I should say 'know'! In that I've found TONS! I'm now more surprised when an agility dog ISN'T hypermobile.
Okay... so in that regard, I think you leave the shoulders be.
Thus taking you back to neck therapies, T/S therapies, and functional movement therapies.
And yes, recheck when he's off the Pred.
Cheers!
Laurie
LAURIE EDGE-HUGHES
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JuliPotter
- Posts: 75
- Joined: Sat May 28, 2016 5:35 am
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Dear Laurie,
thank you so much! I always look forward to reading your response!
First I want to say that I am very much looking forward to taking your Basic manual therapy for the Canine spine workshop at the STAAR conference; hopefully, I will one day be able to take the Advanced course! Maybe next year you might consider teaching the advanced course at the STAAR conference?!!
As for Mason, I was wondering if the increased shoulder extension could in any way be related to the spinal cord injury? could there possibly be a decrease in motor innervation from the spinal cord injury? I continue to treat the neurologic deficits by working on sensory stimulation - massage, rubbing, tapping, proprioception and coordination. He has quite a bit of muscle atrophy in both the thoracic and pelvic limbs on the right and since he does not seem to be painful, though that may change once he has been off the prednisone, I plan to progress to more strengthening exercises at our next appointment, after an evaluation to check for pain, of course.
I am also wondering what you think about laser therapy for Mason at this point; his symptoms were initially reported on January 31? I want to try to be proactive with the health of his C-spine, based on the findings of disc disease on the MRI, even though the neurologist does not feel that these lesions are the main cause of his current symptoms. There has been some concern about using laser tx due to the fact that Mason most likely has an immune mediated disease of the spinal cord but there have been several sources recommending laser therapy suggesting that it may help in the healing process.
Thank you,
Juli
thank you so much! I always look forward to reading your response!
First I want to say that I am very much looking forward to taking your Basic manual therapy for the Canine spine workshop at the STAAR conference; hopefully, I will one day be able to take the Advanced course! Maybe next year you might consider teaching the advanced course at the STAAR conference?!!
As for Mason, I was wondering if the increased shoulder extension could in any way be related to the spinal cord injury? could there possibly be a decrease in motor innervation from the spinal cord injury? I continue to treat the neurologic deficits by working on sensory stimulation - massage, rubbing, tapping, proprioception and coordination. He has quite a bit of muscle atrophy in both the thoracic and pelvic limbs on the right and since he does not seem to be painful, though that may change once he has been off the prednisone, I plan to progress to more strengthening exercises at our next appointment, after an evaluation to check for pain, of course.
I am also wondering what you think about laser therapy for Mason at this point; his symptoms were initially reported on January 31? I want to try to be proactive with the health of his C-spine, based on the findings of disc disease on the MRI, even though the neurologist does not feel that these lesions are the main cause of his current symptoms. There has been some concern about using laser tx due to the fact that Mason most likely has an immune mediated disease of the spinal cord but there have been several sources recommending laser therapy suggesting that it may help in the healing process.
Thank you,
Juli
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Hey Juli,
So I'll be doing the Advanced course in California in October, and likely again in NJ next year - or the year after, or in Canada next January.
Okay... I like and accept your theory on the low tone shoulder hyperextension. That's not a crazy thought!!!
Now, in regards to laser for this condition. Well, you can try! I've seen auto-immune skin flare ups with laser... so, I suppose there is a chance. I'd likely chat about it with the owner and if he/she is okay with trying laser to see how it goes, then give it a shot.
Otherwise, you are looking at lots of neuro rehab, functional retraining, strengthening in functional patterns. in a case like this - it really is a crapy shoot as to whether you can overcome an autoimmune issue. (I very much dislike autoimmune issues!)
See you at STAAR!
Cheers!
Laurie
So I'll be doing the Advanced course in California in October, and likely again in NJ next year - or the year after, or in Canada next January.
Okay... I like and accept your theory on the low tone shoulder hyperextension. That's not a crazy thought!!!
Now, in regards to laser for this condition. Well, you can try! I've seen auto-immune skin flare ups with laser... so, I suppose there is a chance. I'd likely chat about it with the owner and if he/she is okay with trying laser to see how it goes, then give it a shot.
Otherwise, you are looking at lots of neuro rehab, functional retraining, strengthening in functional patterns. in a case like this - it really is a crapy shoot as to whether you can overcome an autoimmune issue. (I very much dislike autoimmune issues!)
See you at STAAR!
Cheers!
Laurie
LAURIE EDGE-HUGHES
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JuliPotter
- Posts: 75
- Joined: Sat May 28, 2016 5:35 am
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Thank you, Laurie!!
See you next month!
Juli
See you next month!
Juli
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JuliPotter
- Posts: 75
- Joined: Sat May 28, 2016 5:35 am
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Laurie,
I am wondering, is there anything in particular that I can do long term for Mason as a way to prevent further problems in his
C-spine? Even though the spinal cord inflammation was believed to be due to an immune mediated process, several mild disc lesions were seen on MRI at C2-C3 and C3-C4 and degenerative changes at C6-C7. If we continue to do traction of the C-spine, cranial chest lifts and cookie stretches, will these exercises be helpful for the overall health of the C-spine? and as for therapeutic exercises....I know this is a very basic question, but as the patient progresses, how do you decide what you do at the clinic vs what you teach the owner to do at home? I feel that I have added on way too many exercises for the owner to do at home....Thank you!
I am wondering, is there anything in particular that I can do long term for Mason as a way to prevent further problems in his
C-spine? Even though the spinal cord inflammation was believed to be due to an immune mediated process, several mild disc lesions were seen on MRI at C2-C3 and C3-C4 and degenerative changes at C6-C7. If we continue to do traction of the C-spine, cranial chest lifts and cookie stretches, will these exercises be helpful for the overall health of the C-spine? and as for therapeutic exercises....I know this is a very basic question, but as the patient progresses, how do you decide what you do at the clinic vs what you teach the owner to do at home? I feel that I have added on way too many exercises for the owner to do at home....Thank you!
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Good questions Juli!
Yes, the manual therapies, chest lifts, & cookies exercises could have a beneficial effect on the spine.
I would caution against giving too much credence to the MRI findings. In human medicine we are very much finding that there are many 'findings' on MRI, X-ray, etc that are incidental and have no clinical relevance nor any predictive value for future issues. So, don't stress too much about the other findings.
In regards to exercises. Think about it as this is a permanent issue / condition that they will deal with, walks are favoured as a general exercise with perhaps no more than 15 minutes (every day or every second day). So pick only the best exercises and/or one per location. Of the list you gave these 3 are acceptable for sure and easy for the owner.
In regards to 'in clinic' versus 'home'. I always say that what is done at home every day is more important that the dog being able to come to me once or twice a week. Where we come in, is to progress the exercises, do manual therapies, or use modalities that the owner doesn't have access to, and to use our brains & hands to assess the situation. If the exercises are easy for the owner to do at home, then why pay someone else to do them. If you are doing something different or a 'boot camp' kind of scenario (i.e. perhaps you have a treadmill and do other unique land based exercises, or some circuit training / drills once a week), then sure - coming IN Clinic for exercise makes sense. Otherwise, set the owners up with a good home program (that doesn't overwhelm them) and maintain a roll of professional rehab coach / advisor / 'progresser' of the home program.
I hope that helps!
See you soon!
Cheers,
Laurie
Yes, the manual therapies, chest lifts, & cookies exercises could have a beneficial effect on the spine.
I would caution against giving too much credence to the MRI findings. In human medicine we are very much finding that there are many 'findings' on MRI, X-ray, etc that are incidental and have no clinical relevance nor any predictive value for future issues. So, don't stress too much about the other findings.
In regards to exercises. Think about it as this is a permanent issue / condition that they will deal with, walks are favoured as a general exercise with perhaps no more than 15 minutes (every day or every second day). So pick only the best exercises and/or one per location. Of the list you gave these 3 are acceptable for sure and easy for the owner.
In regards to 'in clinic' versus 'home'. I always say that what is done at home every day is more important that the dog being able to come to me once or twice a week. Where we come in, is to progress the exercises, do manual therapies, or use modalities that the owner doesn't have access to, and to use our brains & hands to assess the situation. If the exercises are easy for the owner to do at home, then why pay someone else to do them. If you are doing something different or a 'boot camp' kind of scenario (i.e. perhaps you have a treadmill and do other unique land based exercises, or some circuit training / drills once a week), then sure - coming IN Clinic for exercise makes sense. Otherwise, set the owners up with a good home program (that doesn't overwhelm them) and maintain a roll of professional rehab coach / advisor / 'progresser' of the home program.
I hope that helps!
See you soon!
Cheers,
Laurie
LAURIE EDGE-HUGHES
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JuliPotter
- Posts: 75
- Joined: Sat May 28, 2016 5:35 am
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Laurie,
Yes, thank you, this does help!!
I don't have much equipment and right now, I am doing house calls....so each time I see Mason, I feel that I am basically checking his progress and maybe doing a few manual therapies if needed! Since, upon examination, he does not seem to be painful and his flexibility seems pretty good, I wanted to start on muscle building/ strengthening exercises, he has quite a bit of muscle loss in both the right TL (triceps) and PL (glutes, quads and hamstrings). Though he does have pretty good muscle tone. He continues to have neuro deficits on both the right TL and PL, which we expect, but I wanted to continue to work on proprioception and coordination.....so based on your recommendation, and after evaluating Mason's progress again, I think I will reevaluate the HEP and pick one exercise to address each of the issues I am trying to address.
Thanks so much!!
Juli
Yes, thank you, this does help!!
I don't have much equipment and right now, I am doing house calls....so each time I see Mason, I feel that I am basically checking his progress and maybe doing a few manual therapies if needed! Since, upon examination, he does not seem to be painful and his flexibility seems pretty good, I wanted to start on muscle building/ strengthening exercises, he has quite a bit of muscle loss in both the right TL (triceps) and PL (glutes, quads and hamstrings). Though he does have pretty good muscle tone. He continues to have neuro deficits on both the right TL and PL, which we expect, but I wanted to continue to work on proprioception and coordination.....so based on your recommendation, and after evaluating Mason's progress again, I think I will reevaluate the HEP and pick one exercise to address each of the issues I am trying to address.
Thanks so much!!
Juli
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Good plan!
So use your time to evaluate how he's doing with his existing exercises, see if you can progress any exercises, test them out, do them a few time, write them into a home program. Then manual therapies and/or modalities.
Perfect appt!
Laurie
So use your time to evaluate how he's doing with his existing exercises, see if you can progress any exercises, test them out, do them a few time, write them into a home program. Then manual therapies and/or modalities.
Perfect appt!
Laurie
LAURIE EDGE-HUGHES
-
JuliPotter
- Posts: 75
- Joined: Sat May 28, 2016 5:35 am
Re: 6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperexten
Update on Mason -
Dear Laurie, I would love your thoughts on this.....Please! So Mason seems to be doing very well overall. He does still have neurologic deficits on both the right thoracic limb and the right pelvic limb- he knuckles occasionally on the thoracic limb and he has fallen a couple of times. As well, he weight shifts to the left in the pelvic limbs while standing, CP is decreased on the right Pelvic limb and he does appear to be weaker on this side but in general, he has increased muscle mass and good muscle tone in both the the right thoracic and pelvic limbs; most obvious atrophy is still in the right gluteal muscles.
I also noticed that he resists flexion of the neck while assessing the AO joint and he sneezed repeatedly when I attempted this; he seemed quite anxious as well! His muscle tone has returned in the neck and I would describe it as tense.
I just found this sneezing a little odd. But Mason is also a character and would prefer that I play with him then do an exam, of course. I am also curious about the presence of the CP deficits (and weakness) but yet his muscle mass and tone has definitely improved.... and another odd finding -over the past month or so, Mason seems to not have total control over defecation. Though he does not have fecal incontinence; he will sometimes act like he is taken by surprise and didn't expect to have a BM....does that make sense? he will still posture but he will stop what he is doing and defecate... and he has had several house soiling incidents as well. I hope I don't sound crazy, or like a complete idiot.... I am just curious to know what your thoughts are on these changes!
Thanks so much,
Juli
Dear Laurie, I would love your thoughts on this.....Please! So Mason seems to be doing very well overall. He does still have neurologic deficits on both the right thoracic limb and the right pelvic limb- he knuckles occasionally on the thoracic limb and he has fallen a couple of times. As well, he weight shifts to the left in the pelvic limbs while standing, CP is decreased on the right Pelvic limb and he does appear to be weaker on this side but in general, he has increased muscle mass and good muscle tone in both the the right thoracic and pelvic limbs; most obvious atrophy is still in the right gluteal muscles.
I also noticed that he resists flexion of the neck while assessing the AO joint and he sneezed repeatedly when I attempted this; he seemed quite anxious as well! His muscle tone has returned in the neck and I would describe it as tense.
I just found this sneezing a little odd. But Mason is also a character and would prefer that I play with him then do an exam, of course. I am also curious about the presence of the CP deficits (and weakness) but yet his muscle mass and tone has definitely improved.... and another odd finding -over the past month or so, Mason seems to not have total control over defecation. Though he does not have fecal incontinence; he will sometimes act like he is taken by surprise and didn't expect to have a BM....does that make sense? he will still posture but he will stop what he is doing and defecate... and he has had several house soiling incidents as well. I hope I don't sound crazy, or like a complete idiot.... I am just curious to know what your thoughts are on these changes!
Thanks so much,
Juli