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Here's another e-mail from a random person / dog owner. Again, putting this up for discussion... AND to highlight research I found in regards to e-stim for peripheral nerve damage.

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Dear Laurie,

I was referred to you by Dan Beatty. He said you might be able to help me. I have a puppy (13 weeks old Lab) that sustained a brachial plexus injury when I accidentally rolled my truck over her leg. I didnt see her there (well I saw her across the yard with our other dog before I started to move. Any how we took her to the vet and she was declared in good health with no fractures or internal injuries. She does however have what looks like a brachial plexus and radial nerve injury of the front left extremity.

I am a physical therapist in Pennsylvania with a neuro and ortho background. I have an NMES unit, access to cold laser, and lots of knowlege about rehab and humans. I read a blog entry by Dr. Beatty about e-stim ( it seemed like NMES he was describing) and a full regiment of treatment at this url http://evetclinic.com/?s=Cassidy. Kona has reflexive withdrawal that is stronger on the ulnar side of the paw. When ranging her in sidelying she seems to push me away with the paw every few reps. It seems as though there is some neural connection. I am hopeful that this is only a neuropraxia as opposed to full nerve root avulsion of C6-T1.

The reason for my email is to see if you would be willing to share any protocols for dogs that you might have. I have started putting Kona in a 90 degree pool and and asking her to paddle and she does. she reaches out with the injured limb well but not with the power of the uninjured limb, I have attempted nmes with her using the human protocols but am not sure I had good electrode contact through her fur. Do I need to shave the electrode sites on the wrist/carpal extensors and triceps regions. Dr. Dan outlines using nmes once a week. Would more frequency be helpful like it is in humans? Our vet has a cold laser and she will receive that tomorrow.

Anyhow, I have a bunch of questions and wonder if you might be willing to help me by getting on the phone with me to review the canine protocol for this problem to make sure I am doing this right for her. I am happy to pay you for your time in consultation and would so appreciate any help you could offer.

Dave

Here's my reply:

Hi David,

My apologies for the tardy reply. I’m actually better to catch by e-mail than to try to pin me down by phone. So, I’ll do my best to answer you here.

Okay - so as you know, as evidenced by what you’ve written, it’s a crap shoot as to whether your case if an avulsion or neuronotmesis of the nerve / nerve roots, or a neuropraxia or axonotmesis. I use e-stim only to test the muscles to see if anything is coming back. If you get a contraction… it’s coming back. Otherwise, you can’t get the muscles to contact with a standard e-stim. To get surface contact, you need to super goop a patch of skin to put the electrode on. To just gel the electrode, you won’t get enough skin contact. So I do two goop spots (not touching each other) for the electrodes to go on. I believe it can help a neuropraxia and by research could help an axonotmesis, but if it’s a neuronotmesis (without surgical reconnection) or an avulsion, it won’t do much.
Here’s what I found:
https://www.ncbi.nlm.nih.gov/pubmed/25181499 (20Hz x 1 hour, daily)
https://www.ncbi.nlm.nih.gov/pubmed/20873447 (20Hz x 30 mins per day)
https://www.ncbi.nlm.nih.gov/pubmed/19079975 (20Hz x 1 hour - 2 weeks!!! - that must have been a typo)
All low amplitude.


Usually it’s the radial nerve that’s affected.
So flexor withdrawal is possible with intact ulnar and median nerves (carpal / digit flexors) and musculocutaneous nerve (biceps).
It’s that darn radial nerve that we cross our fingers for!!

Laser I would do daily if you can - axilla, and C6 - T2. Higher doses b/c you are trying to reach very deep target tissues.
If you can rent one, that would be great!

Otherwise, your main concern becomes preventing contracture - so you might need to create some sort of a splint with a foot hold. But if there is no elbow control, that becomes tricky. I’d at least try to keep the carpus from contracting by making something from thermoplastics.


And as you know nerve grow about a mm a day. So, I say you want to see some sort of ‘flicker’ of hope within a month to 2 months. If you’re not, then the injury was likely more like an avulsion… and you end up changing the conversations.
The other concern is if it’s an axonotmesis / neuropraxia and sensation starts to come back… some dogs with literally chew their foot off. If you think your dog is starting to get sensation back and/or you see her chewing on that foot, you may need to put a cone on her to keep the foot from being mutilated. Traditional vet practice has not recognized that it’s likely return of sensation that is causing the dog to self mutilate - to that’s when they suggest amputating. But I’ve wondered if you could get a dog through that if you could get them the rest of the way. I only had one dog that fit this category, and despite my warning to the owner to keep her in a cone if unsupervised for ANY period of time… they felt bad for her and woke one morning to find that she had chewed off enough of her foot that they had no choice but to amputate. So, just a gross story, to get you to understand the severity of the warning!


Best of luck,

Laurie

Happy Update from this person!

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Thanks Laurie. We have a fabulous story. Kona is walking , bearing weight, has full sensation from what we can tell, good reflexes, but still 2/5 to 3/5 or so strength in triceps and muscles innervated by the radial nerve.

We found that our vet has a rehab department and the PT is dual credentialed as VMD and PT. I was able to take Kona to her and spend an hour or two learning from a local expert there. What a great experience. Additionally I was able to get the Handbook of Veterinary Neurology as an Ebook and that has been very helpful too.

Everyone here now seems to think we have intact roots, and not nerve avulsion. The most striking thing to me is the similarities between human and canine protocols for facilitation and stabilization and use of nmes to assist in the maintenance of contractibility and strength during neural regeneration and healing. Seems like the only real difference is the use of the front/uppers in gait.

In the three weeks since the injury, Kona is weight bearing in gait and running, she goes up and down steps pretty well and is using the injured from paw with the left to manipulate bones while she chews.

In slow gait she is walking close to what I see my other lab doing, extending the injured extremity the weight bearing over it to swing the other side. There is mild triceps collapse on the affected side.

In running she looks decent w a mild lateral carpal collapse/roll at mid-stance. The bugger for her is intermediate speeds. It looks like a matter of patience and allowing return of the carpal extensors and pronators to have better return.

In sit she will sometimes posture the two front limbs in normal weight bearing and at times sit w it forward and just touching ground.

In terms of rehab work we have a peanut ball and put her on that with stim on an alternate cycle between the triceps and carpal extensors. When the stim comes on, we offer a treat in front of her requiring her to lean forward and weight bear on the extremity. This repeats for the entire stim time. I use kineseotape on the carpal extensor, hooking the toes with holes in the tap then use in a facilitation manner, anchoring with pre-spray and coban. I do this for her triceps as well. Her gait pattern is nearly normal with the tape in place. We only use this method when around her to ensure she does not eat it. She is very tolerant. We have advanced to front paws up on the ball with perturbation and rear paws on the ball.

Seems to me all the facilitation and motor planning work I can do with her will help...and it is. We spend about an hour a day on different activities as above or swimming in warm water pool, etc.

The PT at our vets office gave me license to be as creative as possible with my neuro and ortho background... It appears to be working. Kona is playing with her big brother Jack (our other lab) running, jumping, doing stairs, and just about everything else puppies do.

I appreciate your help and will read the articles you sent, and implement as necessary.

Best Regards

Dave

PS if you want video on anything i am doing with her so you can see and maybe use on your end, I am happy to do that as a thank you for your direction, information and help.

She has a triceps hematoma

I am doing nmes w her daily