Hey Gang... I'm posting this question / conversation thread that was sent to me by e-mail. I'd love more eyes and thoughts! Thanks in advance! Laurie
Lola is a 86lb 6 year old SF Labrador who presented...
10/21/18: acute nonambulatory paraplegia deep pain negative
10/29/18 present to UVHsmart, nonambulatory paraplegia with superficial pain present bilaterally
11/19/18: improved to severe paraparesis in hindlimbs.
Due to finances we were unable to pursue diagnostic testing at that time and opted to perform rehab for 3 weeks to assess if she could regain motor to hindlimbs and when she did her family opted to continue therapy but had still declined diagnostics. Performed laser therapy of TL spine, NMES of bilateral hindlimbs (until she had normal motor back), acupuncture, neurodevelopmental sequencing, hydrotherapy twice weekly.
Patient continued to improve and in Feb 2019 CPs to RHL returned but decreased and March 2019 CPs to LHL returned but decreased. Normal CPs to bilateral hindlimbs June 2019 but patient continues to be nonambulatory paraparetic.
Pelvic radiographs in June revealed mild Bilateral coxofemoral joints osteoarthrosis, worse on the left. We performed PRP of bilateral hips. Ordered cart and have been using for therapeutic exercises in addition to continuing laser therapy of her hips and hydrotherapy.
7/14/19: CT scan: "Decreased caliber of the spinal cord over T 12 – 13 with no current signs of extradural compression. Consider spinal cord atrophy associated with previous fibrocartilaginous embolus or disk extrusion with no persistent compression at this site. Otherwise unremarkable cervical, thoracic, and lumbar spine. Bilateral hip dysplasia with secondary degenerative joint disease"
So I have a a dog who is neurologically normal and has been since June but can't physically get from a down to a square sit. Instead she sloppy sits on her L hip and even then can not stand up unassisted. If she is placed in a square sit she can get to a stand and stand unassisted for 30-60sec before falling over to her left side. Her hip dysplasia is mild and isn't causing any restricted range of motion or flexibility. My gut is telling me that she doesn't have enough core or hindlimb strength from the fact she has been laying around the majority of the day from last Nov to June and that in light of the CT results that says nothing is compressing her spine that she should be able to get up and walk unassisted. Her family and I are running out of options. I have her cart walking 30 minutes 4 times daily, hydrotherapy 20minutes at a faster speed twice weekly. I need to restart her neurodevelopmental exercises again (we stopped for 3 weeks post PRP to ensure we didn't overwork her hip joints).
What is your experience, strength, and hope for a case like this?
- My other grade 3 disk (acute nucleus pulposus extrusion) and FCE patients have all made full recoveries within 4 months. One little terrier mix post hemilamin did take me 10months to get her proprioception back to normal and walking normally but this is, to date, my most difficult case.
- Do I go to daily water therapy for 20 minutes daily? in addition to 30 minutes cart walking (involves hills and circling), if they can afford it
- When do I say, "this is as good as it gets"?
Thank you in advance for your time and effort. I feel lost and these people sold their car to afford for her rehab so I also feel the pressure to get her walking again.
JM
Chronic 'stumper' neuro case
Re: Chronic 'stumper' neuro case
Hey J.,
Thanks for the notes.
As usual, I have more questions than answers to begin with:
Have you ever appreciated any discomfort or stiffness in the neck / thoracic / lumbar spine?
How are the rest of her reflexes? Tendon reflexes? Flexor withdrawal?
Does she have decent bowel and bladder?
How does the tone of her muscles compare forelimbs to rear?
Any tonal changes when you palpate down the epaxials? An area of dramatic decrease in tone?
Can she walk in the UWT and/or move her legs in the cart?
Some comments:
Don’t worry about her hips. Neuro trumps Ortho every time.
And just an aside, I wouldn’t stop therapy after PRP - normal use and loading would be therapeutic. Additionally, modalities such as laser can also actually enhance activation of PRP.
But that’s neither here nor there in this case… just thought I’d bring it up for future cases.
Ideas:
Yes, continue with neurodevelopmental rehab, however, I think more time may need to be spent on the cord. With a ‘short in the cord’, no amount of changing the lightbulb or flicking the switch will allow the light to turn on!
Timing is now not our friend however, given that she is so far out from initial injury.
I’d do waaaay high dosing of laser of the T12-13 region - is there a laser they could rent? If the clinic doesn’t have one, maybe contact Spectravet and ask about their Zeus Model, or Respond and their 2400XL with the Wide Head multiprobe. If they can get a rental laser, do it twice a day with HIGH HIGH doses. Whatever dose of laser you were doing / thinking of doing, up that by 500% or more!
Show the owners tail pull traction and perhaps the rotation mobilizations (no blocking, just rotations).
Perhaps they could purchase an Assisi Loop or Heal Fast Loop (Assisi is apparently stronger, but much more expensive - we retail the Heal Fast’s at my clinic and owners and therapists like it.)
Show them skin lifts for over the spine and T12-13 in particular.
(Basically anything to stimulate the nervous system… AND give them things to do at home.)
Acupuncture might be useful… but maybe show them points to stimulate at home manually (fingers, pen cap, etc…)
So, this would be my last ‘kick at the cat’ (such a terrible phrase) before saying, ‘This is as good as it gets,’ and getting them to purchase a permanent cart.
Okay, back to you!
Laurie
Thanks for the notes.
As usual, I have more questions than answers to begin with:
Have you ever appreciated any discomfort or stiffness in the neck / thoracic / lumbar spine?
How are the rest of her reflexes? Tendon reflexes? Flexor withdrawal?
Does she have decent bowel and bladder?
How does the tone of her muscles compare forelimbs to rear?
Any tonal changes when you palpate down the epaxials? An area of dramatic decrease in tone?
Can she walk in the UWT and/or move her legs in the cart?
Some comments:
Don’t worry about her hips. Neuro trumps Ortho every time.
And just an aside, I wouldn’t stop therapy after PRP - normal use and loading would be therapeutic. Additionally, modalities such as laser can also actually enhance activation of PRP.
But that’s neither here nor there in this case… just thought I’d bring it up for future cases.
Ideas:
Yes, continue with neurodevelopmental rehab, however, I think more time may need to be spent on the cord. With a ‘short in the cord’, no amount of changing the lightbulb or flicking the switch will allow the light to turn on!
Timing is now not our friend however, given that she is so far out from initial injury.
I’d do waaaay high dosing of laser of the T12-13 region - is there a laser they could rent? If the clinic doesn’t have one, maybe contact Spectravet and ask about their Zeus Model, or Respond and their 2400XL with the Wide Head multiprobe. If they can get a rental laser, do it twice a day with HIGH HIGH doses. Whatever dose of laser you were doing / thinking of doing, up that by 500% or more!
Show the owners tail pull traction and perhaps the rotation mobilizations (no blocking, just rotations).
Perhaps they could purchase an Assisi Loop or Heal Fast Loop (Assisi is apparently stronger, but much more expensive - we retail the Heal Fast’s at my clinic and owners and therapists like it.)
Show them skin lifts for over the spine and T12-13 in particular.
(Basically anything to stimulate the nervous system… AND give them things to do at home.)
Acupuncture might be useful… but maybe show them points to stimulate at home manually (fingers, pen cap, etc…)
So, this would be my last ‘kick at the cat’ (such a terrible phrase) before saying, ‘This is as good as it gets,’ and getting them to purchase a permanent cart.
Okay, back to you!
Laurie
LAURIE EDGE-HUGHES
Re: Chronic 'stumper' neuro case
Good morning,
Thank you so much for your time and effort regarding this case.
Have you ever appreciated any discomfort or stiffness in the neck / thoracic / lumbar spine? NO NEVER EVEN SINCE THE BEGINNING
How are the rest of her reflexes? Tendon reflexes? Flexor withdrawal? ALL REFLEXES WITHIN NORMAL LIMITS, STRONG WITHDRAWALS ON BILATERAL HINDLIMBS
Does she have decent bowel and bladder? YES, VERY GOOD BLADDER AND BOWEL CONTROL, only urinates when you are picking her up to get into cart if any pressure put on bladder, if she defecates in her room she is able to move herself away from it
How does the tone of her muscles compare forelimbs to rear? LOW TONE TO CORE AND HINDLIMB MUSCLES
Any tonal changes when you palpate down the epaxials? An area of dramatic decrease in tone?MODERATE DECREASE IN TONE AT MID-THORACIC AND CONTINUES DOWN TO HINDLIMB MUSCULATURE
Can she walk in the UWT and/or move her legs in the cart?YES, STRONGLY AMBULATORY BUT NEEDS MAXIMUM ASSISTANCE TO WALK WITHOUT LEFT HINDLIMB CROSSING UNDER HER AND TRIPPING HER RIGHT HINDLIMB
Attached is a short hydrotherapy video. This email only lets me send <13 sec videos. I will email the cart walking video next.
We do have a companion class 4 laser and will proceed with targeting the focal T12-T13 area with 5x as much treatment as before and increasing the frequency to twice daily.
I will restart tail pulls and remind the owners as well.
Regarding myofascial release and tissue work - all of her skin is very loose and there are no restricted areas that I have found thus far but I will reassess each week.
Will teach owners how to stimulate the acupuncture points.
Please let me know any other recommendations/advice you have after receiving these answers and the videos. Thank you again for your help!
Kind Regards,
J
Thank you so much for your time and effort regarding this case.
Have you ever appreciated any discomfort or stiffness in the neck / thoracic / lumbar spine? NO NEVER EVEN SINCE THE BEGINNING
How are the rest of her reflexes? Tendon reflexes? Flexor withdrawal? ALL REFLEXES WITHIN NORMAL LIMITS, STRONG WITHDRAWALS ON BILATERAL HINDLIMBS
Does she have decent bowel and bladder? YES, VERY GOOD BLADDER AND BOWEL CONTROL, only urinates when you are picking her up to get into cart if any pressure put on bladder, if she defecates in her room she is able to move herself away from it
How does the tone of her muscles compare forelimbs to rear? LOW TONE TO CORE AND HINDLIMB MUSCLES
Any tonal changes when you palpate down the epaxials? An area of dramatic decrease in tone?MODERATE DECREASE IN TONE AT MID-THORACIC AND CONTINUES DOWN TO HINDLIMB MUSCULATURE
Can she walk in the UWT and/or move her legs in the cart?YES, STRONGLY AMBULATORY BUT NEEDS MAXIMUM ASSISTANCE TO WALK WITHOUT LEFT HINDLIMB CROSSING UNDER HER AND TRIPPING HER RIGHT HINDLIMB
Attached is a short hydrotherapy video. This email only lets me send <13 sec videos. I will email the cart walking video next.
We do have a companion class 4 laser and will proceed with targeting the focal T12-T13 area with 5x as much treatment as before and increasing the frequency to twice daily.
I will restart tail pulls and remind the owners as well.
Regarding myofascial release and tissue work - all of her skin is very loose and there are no restricted areas that I have found thus far but I will reassess each week.
Will teach owners how to stimulate the acupuncture points.
Please let me know any other recommendations/advice you have after receiving these answers and the videos. Thank you again for your help!
Kind Regards,
J
Re: Chronic 'stumper' neuro case
VIDEOS
https://youtu.be/TB6hEHUCaZs
https://youtu.be/sBRkVUnzyZc
Please watch... The videos add to why this is such a stumper case!
https://youtu.be/TB6hEHUCaZs
https://youtu.be/sBRkVUnzyZc
Please watch... The videos add to why this is such a stumper case!
Re: Chronic 'stumper' neuro case
Okay… thank you for the answers, and both videos have come in.
Wow, I’m somewhat stumped as well in regards to seeing something that might be missing.
So, 1) I think our plan is sound, to at least try to stimulate the T12-13 area to see if we can facilitate / stimulate more healing.
2) Walking practice is good - whether it be in the UWT or with use of a cart. I would say that I prefer a flexible saddle cart (i.e. Doggon Wheels) because it allowed more normal movement at the hips. It’s a good cart for full paralysis, but in an incomplete case, it takes away any hip function and creates a weird gait. So, if they are looking into buying one… I’d look into Doggon Wheels - if that’s what ends up being the case.
3) Can you try to create something that will keep her legs separated as she walks (i.e. a pool noodle between her legs - make a home-made sling out of a reusable grocery bag; side panels cut out, and leg holes cut in, with the noodle between.) (Or try using theraband tied around each thigh and tied together over the back - might need to affix it to a harness to keep it from slipping off her rear end.)
In regards to the myofascial / skin lifts, I’m not thinking of it being beneficial for tight fascia, but rather for stimulation of cutaneous nerves which feed / communicate with the spinal cord. So, really, just any kind of external stimulus that will get the spinal cord working, processing, etc.
Just throwing this out there. I have a fellow who has been e-mailing me about his older Boston Terrier with IVDD. He is doing all sorts of things to keep her going despite having severe IVDD. Anyhoo, the point of this is that he has had some improvement with stem cells injected paraspinally. As well, he’s contemplating flying out to New York to see someone that does prolotherapy paraspinally… (a dextrose-lidocaine solution). Heck, it’s worth a try…!
I’m going to throw this up on my FourLeg Forum to see if anyone else had ideas. I’ll let you know. But in the mean time, you have a bit of a plan.
Cheers,
Laurie
Wow, I’m somewhat stumped as well in regards to seeing something that might be missing.
So, 1) I think our plan is sound, to at least try to stimulate the T12-13 area to see if we can facilitate / stimulate more healing.
2) Walking practice is good - whether it be in the UWT or with use of a cart. I would say that I prefer a flexible saddle cart (i.e. Doggon Wheels) because it allowed more normal movement at the hips. It’s a good cart for full paralysis, but in an incomplete case, it takes away any hip function and creates a weird gait. So, if they are looking into buying one… I’d look into Doggon Wheels - if that’s what ends up being the case.
3) Can you try to create something that will keep her legs separated as she walks (i.e. a pool noodle between her legs - make a home-made sling out of a reusable grocery bag; side panels cut out, and leg holes cut in, with the noodle between.) (Or try using theraband tied around each thigh and tied together over the back - might need to affix it to a harness to keep it from slipping off her rear end.)
In regards to the myofascial / skin lifts, I’m not thinking of it being beneficial for tight fascia, but rather for stimulation of cutaneous nerves which feed / communicate with the spinal cord. So, really, just any kind of external stimulus that will get the spinal cord working, processing, etc.
Just throwing this out there. I have a fellow who has been e-mailing me about his older Boston Terrier with IVDD. He is doing all sorts of things to keep her going despite having severe IVDD. Anyhoo, the point of this is that he has had some improvement with stem cells injected paraspinally. As well, he’s contemplating flying out to New York to see someone that does prolotherapy paraspinally… (a dextrose-lidocaine solution). Heck, it’s worth a try…!
I’m going to throw this up on my FourLeg Forum to see if anyone else had ideas. I’ll let you know. But in the mean time, you have a bit of a plan.
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: Chronic 'stumper' neuro case
Check out this NEW Rear End Harness that might work for this case!
Hey J,
Thought of you and your case when I scrolled down this advert and saw their Walkin’ Hip-EEZ Cross Assist.
It might help with your case that we were discussing.
Cheers,
Laurie
https://www.handicappedpets.com/walkin- ... c75ec8a673
Hey J,
Thought of you and your case when I scrolled down this advert and saw their Walkin’ Hip-EEZ Cross Assist.
It might help with your case that we were discussing.
Cheers,
Laurie
https://www.handicappedpets.com/walkin- ... c75ec8a673
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LAURIE EDGE-HUGHES
Re: Chronic 'stumper' neuro case
Thank you for thinking of me Laurie!
We actually came up with that idea ourselves but our execution was less than to be desired. That device certainly looks like we might have more success with it. The great news is that following your advice we are lasering her 500% more twice daily and we've actually noticed an increase in her motor to her tail, ability to hold her urine/stool when excited when previously she would urinate on us getting her up and in the cart. She even stood up on her own in her carpeted room here at the hospital. I'm cautiously optimistic but am very excited to see something changing. I'm not certified in acupuncture so I've been lasering her acupuncture sites recommended from the STAAR conference lecture I attended in addition to her laser therapy, neurodevelopmental exercises and increasing the speed to 1mph in hydrotherapy for 20 minutes. We stroke, rub the acupuncture point (not pull) her tail during it to get strong steps during hydrotherapy. Thank you again for taking the time to share that information with me because I've never seen a device like that and it might be exactly what we need for this case. Will let you know how it works out.
Kind Regards,
J
We actually came up with that idea ourselves but our execution was less than to be desired. That device certainly looks like we might have more success with it. The great news is that following your advice we are lasering her 500% more twice daily and we've actually noticed an increase in her motor to her tail, ability to hold her urine/stool when excited when previously she would urinate on us getting her up and in the cart. She even stood up on her own in her carpeted room here at the hospital. I'm cautiously optimistic but am very excited to see something changing. I'm not certified in acupuncture so I've been lasering her acupuncture sites recommended from the STAAR conference lecture I attended in addition to her laser therapy, neurodevelopmental exercises and increasing the speed to 1mph in hydrotherapy for 20 minutes. We stroke, rub the acupuncture point (not pull) her tail during it to get strong steps during hydrotherapy. Thank you again for taking the time to share that information with me because I've never seen a device like that and it might be exactly what we need for this case. Will let you know how it works out.
Kind Regards,
J