Options for Canine Chronic Back Pain

If you have read some of my other posts, you are familiar with my multimodal approach to managing pain and mobility. For those of you new to this blog, this is where we use a combination of therapies to achieve a good outcome. In some cases, this is combining an oral medication with therapeutic exercises, or a surgical procedure with photobiomodulation (laser) therapy.

Using this approach, we can usually get better outcomes with less side effects. I also use this approach when an ideal treatment is not an option for a patient. This can be due to financial limitations, health of the pet (perhaps anesthesia is not an option), other options are not working, or any number of factors.

With this background, I would like to walk through some challenging cases I’ve had over the past few years. All of these dogs are German Shepherds, some male, some female, all between 7-15 years of age. While this disease can happen to many breeds, we do see it more in German Shepherds. Sometimes the spinal canal, through which the spinal cord and nerves pass, narrows and compresses the nerves.  The most common spot for this narrowing to occur is at the lumbosacral joint, where the spine meets the pelvis. Spinal canal narrowing at the lumbosacral joint is referred to as lumbosacral stenosis, and the condition resulting from the compression of these spinal nerve roots is called cauda equina syndrome.

The narrowing is most often caused by arthritic degeneration or intervertebral disc herniation, but traumatic injury, congenital malformation (born with it), or tumor growth can also be involved.

The most common symptom of lumbosacral stenosis is pain. In the beginning, you may also notice stiffness leading to difficulty in walking, climbing stairs, getting on furniture, wagging the tail, positioning to defecate, or getting into a car. One or both back legs may become weak. Some dogs will cry out in pain when trying to move. In severe cases, the nerve roots can become so compressed that urinary and fecal incontinence will result.

This can be diagnosed through a combination of physical exam, blood and urine tests, radiographs, but it needs a CT scan or MRI to be definitively diagnosed. This is because radiographs (x-rays) do not show the discs and spinal cord, which can be seen on CT scans and MRIs.

The initial pain usually responds well to NSAIDS or Non-Steroidal Anti-Inflammatory Drugs. I will combine this with weight loss (if indicated), muscle building (to strengthen the body), pain relievers (such as gabapentin) and other modalities (joint mobilizations, LASER, underwater treadmill workouts) to help keep the patient in good shape and moving.

Since it is most often caused by arthritis or disc herniation, setbacks, flare ups, and progression of the disease can happen even with the best of management. In those cases, we can add in other medications, or seek a consult with a boarded veterinary surgeon or neurosurgeon. Relieving the pressure through surgery can be very helpful in improving mobility and decreasing pain. After surgery, physical rehabilitation is needed to build upon what the surgeon has improved.

But what if a several thousand dollar CT scan or MRI isn’t in the cards? Or the scan shows the specialist that surgery is not a good option in this case? Are we out of options? Will your dog have to live in chronic pain?

I would hope you repeat readers know by now that this is not the case. So, let’s talk about options.

Studies have been done on both human and animal patients, and there is good evidence in the literature for epidural injection of cortisone. You may have heard of an epidural or spinal before. This is placing a needle or catheter in the space between two vertebrae and around the spinal cord itself. A more common place for this is childbirth, as a local anesthetic (lidocaine) can be injected into the space and block the body from perceiving pain. This is just like going to the dentist. They use novocaine so that you don’t feel them working in your mouth.

In veterinary medicine, we will use a local anesthetic (sometimes along with other pain relieving medications) for surgery (c-section, fracture repair) or for helping to relax an animal that is in labor and help to manually deliver the offspring.

Can we combine these two ideas? Absolutely. An epidural can be done for these lumbosacral patients with cortisone to provide anti-inflammatory action and pain relief. We need to rule out infection first, and ideally have a CT scan or MRI to rule out cancer or other causes. Where do I use this? When my oral medications are maxed out, the pet is still in pain, or for any number of reasons a pet cannot take certain oral medications.

For those of you thinking “wait, I had an epidural and I was awake for it, will my dog be awake?” The answer is no. While some dogs are excellent about holding still, it is not safe to do this procedure awake. It may require general anesthesia, but often can be done under heavy sedation. Their fur in the area will need to be clipped away, and a long needle is placed between the last lumbar vertebrae and the first sacral vertebrae. The cortisone is then injected around the spinal cord in the epidural space.

In my practice, we do this on an outpatient basis with the dog going home the same day. I use either triamcinolone or methylprednisolone, both of which are long acting steroids, as these have been shown to be most effective in the human literature. The dog goes home with specific instructions and restrictions and I see them back in one week. We then institute a combination of home exercises and outpatient rehab sessions to build muscle and strength.

90% of the dogs I have done this for improved in 7 days, and 100% are improved in 2 weeks. Some we are doing just for pain relief and others because they have trouble moving their legs.

How long will this last? This depends on the type of cortisone used. I had one dog that needed a repeat injection at 6 months. The others are doing well on one injection (approaching or exceeding one year).

Are there side effects/risks? With any procedure, there is always risk, but I do my best to minimize that. Blood and urine tests help to rule out other causes. Sedation is short and reversible, so that minimizes risk there. Infection is always a risk, but we do this under a sterile environment. The cortisone is confined to the epidural space, but some can get systemically absorbed. For those cases the dog may drink or urinate more for a few days, and will need to be off their NSAID for a period before and after their procedure.

So, what about those patients I talked about at the beginning? All but two are still alive and doing well. Fritz and Bailey were both over 13 years when I did their injections, and while they improved, their other mobility and health issues ultimately caught up with them. But during the time they had left, they were very comfortable. So, I’m pleased with that outcome. Yosh had an epidural and then months later herniated a disk in a different area that required surgery, I am pleased to report he is doing very well. The other patients are up and moving, and I hope that continues to be their story.

If you have questions, or think your pet may benefit from this or other procedures, please discuss it with your veterinarian or contact me.

Skeeter’s Vomiting

This story refers back to a previous post “Quality over Quantity”. In that story, my own dog, Skeeter, was going through chemotherapy for stage 3 hemangiosarcoma. You can read the full post here: https://drbrunke.wordpress.com/2015/10/27/quality-over-quantity/

During the chemotherapy she developed a slight cough and began having intermittent vomiting. Prior to starting chemo, we had established (via x-rays and ultrasound) that there was no cancer in her lungs, stomach, or the rest of her GI tract.

In some cases, coughing can be associated with cancer that spreads into the lung known as a lung metastases. Metastases will be solid and not allow air to move in that part of the lung .In some cases vomiting can be associated with different types of chemotherapy. However, in Skeeter’s case this wasn’t true. We took special precautions around the one drug in her regiment that could possibly cause vomiting and she never vomited during that medication. This would be random vomiting weeks after that drug was given.

Disclosure: During this time I was not completely objective. As a veterinarian, I wanted to know what was causing the problems. As a caregiver, I didn’t. I wanted to ignore it because I didn’t want to have to face the possibility that this was a possible sign that her cancer was spreading elsewhere.

During her follow-up ultrasound exams (looking at the cancer in her liver as it shrunk from chemo) we did not see any problems with her stomach. This was an appeasement to myself, I had looked (a bit) and that sufficed for now.

One Friday, while working at the emergency room, Skeeter’s coughing got worse. At that point, I took x-rays of her chest. I stared over them and peered from different angles trying to find a reason for her cough. I didn’t see anything obviously wrong with her lungs or heart.

I’m lucky to have great friends. My classmates and I keep in touch via smart phone and social media. We all bounce cases off of each other looking for ideas and insights to problems that baffle us. I sent out photos of Skeeter’s x-rays to the group and asked for opinions.

Amy wrote back a moment later, “Yeah, lungs look ok, but what’s that in her stomach?” Then, two other classmates chimed in and said the same thing. I took another look. Just at the edge of the x-rays was part of Skeeter’s stomach. And sure enough it looked like something was in there. (She had not eaten yet that morning) I took another set of x-rays, focusing on her abdomen. And sure enough it looked like there was a foreign object in her stomach.

I sent all the radiographs to another friend for verification. Sean, a boarded veterinary radiologist, took a closer look as I needed to be as close to 100% sure that this was an actual problem in her stomach. Being on chemotherapy and therefore suppressing her immune system did not make her a fantastic candidate for surgery and anesthesia.

Sean wrote back saying that he didn’t know what it was exactly, but it definitely did not belong there. I explained to him her current condition but his thoughts didn’t change: Whatever it was, it needed to come out.

I had two options here: The first was that I could get Skeeter to a specialist to try and remove this via endoscopy. This is where they put the animal under anesthesia and pass a scope down their esophagus with a mini-grappling hook to grab the object and pull them back out. This is called minimally invasive since it doesn’t require surgery and having to heal from an incision. In some cases it is very successful. Sometimes it does not work (object too big, can’t latch on, etc.).

Since it was a Friday, I would have to drive to Cornell for this procedure, unless I wanted to wait until Monday. At the time there was no weekend option for endoscopy in our region.

The second choice was to go in surgically myself and check it out. Anesthesia is a minimal risk for both cases. The hesitation I had was being wrong and not actually having an object to remove as well as having Skeeter need to heal from two incisions: one in her stomach, the other her abdominal wall.

Second disclaimer: Skeeter had never been a chewer and never really played with toys. So, there wasn’t anything that I knew of that could cause the obstruction. This fact contributed to my hesitation. But there was definitely something there. I just didn’t know what it was.

Ultimately, with support from Sean, Amy, and others, I went forward with surgery that afternoon. Skeeter did great through anesthesia and I found a small “U” shaped piece of flexible rubber in her stomach.

She recovered very well and didn’t have any further vomiting, coughing (likely the rubber getting stuck in her esophagus) or other problems during her chemotherapy.

I have no idea where the piece of rubber came from, or why she chose to eat it.

It can be daunting to face your fears. I was scared of what I would find with Skeeter’s vomiting and coughing. Facing my fear and finding the support of good friends helped me get through a difficult time and I am lucky that it had a good outcome.

Hunting for a reason.

Hunter is a neutered, five-year old male Pembroke Welsh Corgi. He lives with two adults and two other Corgis. I met him after discussing his case with his mother on the phone. She had called looking for an evaluation to see if he was painful. Hunter had become grumpy over the past few months and he had nipped at a few people. His eating habits had also changed.

He had recently been examined by his primary care vet and no problems had been found. A full set of blood tests were also normal. The owner was concerned about his behavioral changes and wanted to be sure she wasn’t missing a painful condition.

Pain comes in many forms. There is bone pain, joint pain, nerve associated pain. Pain from surgery, pain from arthritis. Detecting pain in pets can be very challenging. Hunter had nipped at the staff of his primary care when they were drawing blood. While drawing blood isn’t painful, it can be stressful. It can also be uncomfortable for a pet to have blood drawn if they have a painful elbow or hip joint and have to be in certain positions. I try to keep my mind open to these when I do my evaluations.

Hunter came in and was immediately anxious. Panting, pacing and looking all around the room. He also stuck close to his mom. New hospitals can be stressful for any pet and taking the time to make a good first impression is key. I let Hunter wander around the exam room for about 15 minutes while I went through his history and asked mom questions about him.

For many appointments, I do not wear a white doctors coat. It can be intimidating to some patients, and there is a study that showed it can elevate the pressure within the eyes of patients with glaucoma. In human medicine, some people have elevated heart rates, blood pressure and stress levels from just seeing the doctors white coat. For Hunter, I wanted to minimize his stress. I also sat down and kept my voice soft. Being over six feet tall, male and deep voiced has its drawbacks to some patients.

After letting Hunter check me out and feeding him some treats, I was able to examine him. He let me check out every body part, move his neck, legs, and check all of his organ systems. Never once did he growl or snap. I did my exam on the floor so that he could step away if he got too stressed. I found no obvious sources of pain, atrophy or other complications.

Without a source of physical pain evident, I chatted with mom about other options. A consult with a veterinary behaviorist would be tremendously helpful. They have special training in animal behavior and treating it. Often times we can use Xanax or Prozac to help pets work through their problems.

While the owner agreed with the behavior consult she was not a huge fan of using anti-anxiety meds with him. Changing gears, I started to ask her my common background questions for Traditional Chinese Veterinary Medicine (TCVM). I found that Hunter had once been a confident, friendly and outgoing dog, but parts of his environment had changed lately.

The owners work schedule had changed, two new dogs had come into the house and the owners had been arguing at home. Hunter had been with his mom before the other two dogs and her husband had come into the picture. That is a lot of change.

In TCVM your mind is your Shen. Anxiety is a Shen disturbance. This emotional pain Hunter was carrying around was my suspicion for his behavioral changes. I discussed trying acupuncture and herbal therapy to help with this. I could not guarantee results nor would it be the whole solution, but I felt it would allow Hunter to minimize some of his stress or at least manage it better. I did three acupoints that day as his first treatment and waited to hear back from the owner.

Hunter had a consult with a veterinary behaviorist who diagnosed conflict aggression. She discussed pharmaceutical therapy as well as modifying how the owners introduced Hunter to certain situations and how to react when he was aggressive. The owner took a combination approach and did the exercises and re-training the behaviorist recommended along with acupuncture and herbal therapy.

After one acupuncture treatment, the owner said she had seen a change in him. This often doesn’t happen, but can in some cases.

I saw Hunter once a week over the next six weeks, each time making it a low stress, positive experience. He was my last appointment of the day on Saturdays so there were not many patients around for him to be stressed about. Each week he became easier and easier to treat. Initially he was timid about his needles but we worked slowly with that.

Acupuncture works on a cumulative effect and, over the course of the month, Hunter’s personality changed. He would now come in wagging his tail and jumping up to greet me. He enjoys his treatments and we are trying to see him less often.

The owners have made great strides at home minimizing the stress triggers for him. Taking the time to set the right environment at home and at the hospital helped this case succeed.

As I said before, pain can be very hard to identify in pets. The dog that holds its leg off the ground with a torn ACL is obvious. The subtle changes that arise from stress and emotional pain can be easily overlooked. But with a calm eye and heart, these troubles can be seen and alleviated.

Acupuncture Certification Official

As many of you may know, last year I attended the Chi Institute in Florida (www.tcvm.com) to study veterinary acupuncture. It was an eye opening and intense training that now allows me to offer complimentary services to my patients.

In December, I took the final exam and passed both the written and practical parts. I then had to complete an externship and submit a case report to complete my certification. Those steps were recently approved and I am now a Certified Veterinary Acupuncturist (CVA).

Acupuncture can be used in many conditions both acute and chronic. Many patients that have orthopedic or neurologic diseases will benefit from acupuncture. Pets with other ailments such as kidney disease, inflammatory bowel problems and chronic skin and ear infections can also improve with acupuncture.

Studies show that 85% of patients will benefit from acupuncture. Often 3 treatments are needed to see if a patient is responding. The most common undesired effect from acupuncture is that a patient does not respond.

If you are interested in learning more about acupuncture for your pet, please contact me at drmattbrunke@gmail.com

Making a Case for Acupuncture

Shortly after my acupuncture final exam, I was asked to consult on a case at a local veterinary hospital. Molly was a 5-year-old Bassett Hound mix who had no function in her hind legs. She was brought to her primary care veterinarian a week before Christmas for back pain, but could walk normally. She was started on pain relievers and was placed on restricted activity.

Two days after Christmas, she could not use her back legs at all. There was no trauma or incident that they could identify as a cause. She was re-examined and baseline blood tests were overall unremarkable. Radiographs of her spine showed a narrow space between two vertebrae. At this point, a consult with a veterinary neurologist for potential surgery was recommended. This was not an option for the owner since the consult and surgical estimate was $5,000-$7,000 and this was beyond their capabilities. She was started on cortisone and antibiotics to prevent infections, tumors or anything that could be placing pressure on her spinal cord.

When there is inappropriate pressure on the spinal cord function can be impaired. The most common cause of pressure is a bulging or herniated intervertebral disc. Other causes can be infections, tumors, fractures or fibrocartilaginous emboli (FCE). Without a CT scan or MRI exam these can be very challenging to tell apart, but survey radiographs can be helpful.

As the pressure builds on the spinal cord, the patient will usually start with back pain and it may stop there. It can also progress slowly or rapidly to impair the spinal cord. The job of the spinal cord is to relay the message from the legs to the brain for interpretation like a cell phone signal. When the cord is impaired it’s like trying to talk on the phone with less than 5 bars of service, the message can be choppy or incomplete.

As the “signal” gets weaker the back pain can lead to a wobbly or ataxic gait because the patient doesn’t know where their feet are. This can progress to losing the ability to walk entirely and even the ability to perceive pain. The loss of pain for an extended period of time is a very poor prognosis.

If the pressure can be relieved the spinal cord regains its function in the reverse order that it lost it. Pain comes back first and then, hopefully, the ability to walk followed by the fine motor skills. Urination and defecation can be anywhere in between pain and fine motor as it depends on where the cord is damaged.

When I met Molly on January 2nd, she had lost the ability to feel pain 6 days prior. Ideally, she would have had surgery to relieve the pressure within 24-48 hours of losing that ability, but that was not an option for her family.

Although an MRI exam and spinal surgery were not an option, Molly’s family did not want to give up. I was asked to consult and see if anything else could be done. After examining Molly and discussing my thoughts and prognosis with them, I treated Molly with acupuncture and adjusted some of her medications. I placed her on low doses of cortisone, along with muscle relaxants and continued her on gabapentin to reduce any neuropathic pain.

Given her age, breed and progression of her signs, I was suspecting that a herniated disc was the cause of her problems. I recommended treating Molly three times to see if we could regain pain perception. If we could, then we could continue to treat her. If not, we would talk about the ability for the owners to provide long term care for a paralyzed, incontinent Molly.

When I saw her 3 days later, she had regained pain perception. This was excellent but we were still not out of the woods. I didn’t know if Molly would regain the ability to walk. I treated her again with acupuncture, including electro acupuncture and aqua acupuncture with Vitamin B12. This combination approach would provide different levels of stimulation to her body for varying lengths of time.

On her third treatment three days later, I repeated those acupuncture points and had a frank discussion with her owners. Molly weighed 50 pounds and can be challenging to move around. Her front legs were working perfectly and they had a harness to support her chest and back legs so that she did not scrape her body on the ground. At 50 pounds, she is not a dog they could pick up and carry around. We discussed using a cart (from Eddie’s Wheels) as a potential to assist in her mobility and also as part of her rehab. The cart could also support her long term if she did not make a full recovery. The owners would think about it and let me know.

At this time, I had given her family detailed instructions on doing range of motion exercises and other therapeutic exercises to help with Molly’s rehab. They were doing these every day along with providing her nursing care. In other cases, I have hospitalized patients to do this but given all the circumstances for this case this option was most feasible for Molly’s owners.

I saw Molly a week after her third treatment and now she could consistently wag her tail. She also had very weak but present motor function in her back legs. The owners were trying to figure out finances of a cart. With her improvement I recommended starting her on a Chinese herbal compound to assist her spinal cord healing. This would reinforce the acupuncture treatments she was receiving.

The following week, I measured Molly her for her cart and started the herbal treatment with her. Again, I repeated her acupuncture treatment and also started to taper off some of her other medications.

Due to some outside factors, I did not see Molly again for almost three weeks. I was surprised to see her WALKING into the treatment room! Molly had regained 80% of her motor function in 6 weeks. The average time for this type of recovery is usually 2-3 months. I was very pleased and we agreed to hold on having her cart shipped since she had done so well so quickly. I continued to treat her with acupuncture and scheduled to see her again three weeks later.

At this time, she had 95% of her function back and was in excellent spirits. We had weaned her off most of her pain meds but continued her herbal treatment. I will see Molly in another 3 weeks and then only as needed. I expect her to make a full recovery.

Each individual case is just that, an individual. I am always hopeful when I work with challenging cases, but, I have to admit, Molly’s recovery exceeded my expectations. I hope to be able to repeat this outcome with other patients through a combined approach of Western and Eastern treatment.

If you have any questions about spinal injuries and your pet that are NOT urgent, please contact me.

For more information on herniated discs please check out this website. http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2373

For information on FCE check out this site. http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1663

Dixie the Miracle Dog

Dixie is a fifty-five pound Flat Coat Retriever Mix. When I met her, she was 4 years old. She had been brought to NY through a rescue group from the south that summer. She had been spayed and adopted to a wonderful family from the Lake George area.

A few weeks before I met her, Dixie had been shot in the neck with a rifle. The round had fractured two of the vertebrae in her neck. She had been found by her owner and rushed to a veterinarian for emergency stabilization. Once stabilized it was determined that her spinal cord was damaged and she had no function in any of her legs.

She was referred to a veterinary neurosurgeon in Latham, NY, but due to the metal fragments from the bullet they could not do an MRI.  (Magnetic Resonance Imaging uses magnets, it would have pulled the bullet out of her body). She was then referred to Cornell University’s Veterinary Teaching Hospital. There she had a CT scan (no magnets) and a nine hour surgical procedure to stabilize her fractured vertebrae and spinal cord. Numerous screws and wires were used to support her spinal cord. After surgery was complete, she had another CT scan to verify the alignment of her spine.

Dixie remained hospitalized at Cornell during her immediate post-operative period and received rehabilitation through the vet school. In trying to get her closer to home (Mom was driving seven hours each way to visit her) she was transferred to my care approximately two weeks after surgery.

Upon her arrival, Dixie could wag her tail and had feeling in her legs but could not move them. After reviewing her CT scans and her case file, we admitted Dixie to start comprehensive rehabilitation. Dixie would be hospitalized 24/7 for two weeks and we would see what progress could be made. I discussed with the family that she may not regain any function or that she may only make a partial recovery. We would aim for a complete recovery and see how she responded. If, after two weeks, she showed improvement we would continue to work with her. I wasn’t sure how long Dixie would need to be hospitalized.

The first thing I set out to do with Dixie was to make friends. We would be working together constantly and needed a good relationship. That took all of ten seconds. Her tail wagged and she smiled as I petted her. We then set up a plan for Dixie. Her full time job would be to learn how to walk again. Like us, no patient can work constantly.

My plan for Dixie would include continuing the oral pain relieving medications she was already on. These were designed to minimize pain originating from the spinal cord. I also added in low doses of muscle relaxants and anti-inflammatory medication since we would be working with her legs and needed to keep them comfortable. Her rehabilitation sessions would be broken up into three 30-45 minute sessions three times a day. This would be done Monday through Friday and on Saturdays she would have a lighter workout day. Sunday would be her day of rest. Dixie would also receive acupuncture treatments twice a week for pain relief and to stimulate her nervous system.

My phases with any patient for neurological rehabilitation are this: First, we establish good pain control. There is no point in trying to do anything constructive if the patient is not comfortable. This can be established with a combination of medications, massage, laser therapy, electrical stimulation and acupuncture. Finding the right combination for each individual can take some trial and error.

The second phase is the actual rehabilitation. In early steps this is teaching individual muscle groups what to do. This can be done with electrical stimulation and therapeutic exercises. Some of those exercises include the very basic one of being upright. Dixie could not use her legs and she was dependent on us to keep her sternal or change which side she laid on. This was rotated frequently to avoid pressure sores. For small periods throughout the day, Dixie was placed in a sling and lift to stimulate her standing. This is not only good for her frame of mind (who wants to see the world lying down all the time?) but also for her spinal cord and nerves. The stimulation of her body standing helps to re-educate the nervous system.

Neurological rehabilitation goes through many smaller phases from working on individual muscle groups, simulating leg movement, teaching balance and eventually harmonizing those movements to teach the patient how to walk again. Along the way, there can be setbacks from pain as muscles can be sore from disuse. Setbacks can also occur from pressure sores, urinary tract infections or aspiration pneumonia, which can all potentially occur if proper nursing care is not practiced. Some patients will plateau at a certain point and may not make a full recovery. These can be difficult to identify because there is not necessarily a hard and fast rulebook on when each step of the rehab will occur in each individual patient.

The first two weeks went very well with Dixie. She adjusted to our hospital staff and settled in to a good routine with her rehab. Of course, she also had her say in it as well. When we were not working with her, I had planned to have her in the intensive care unit (ICU) so that she could rest and be observed. Remember, she had orthopedic screws and wires holding together her fractured vertebrae. After a few days of her whining and rubbing her nose on cage door demanding attention, we moved her into the rehab room full time. We had tried to avoid having her with us in order to allow her down time to rest and also as a safety precaution with her neck. Dixie would have nothing to do with that. She would have a rehab session and then relax and nap off to the side of the rehab room while we were all talking and working on other patients. She is a very social dog and wanted to be part of our day.

Each day, Dixie would be hand fed, stimulated to urinate and defecate, cleaned up, have her pain relievers and joint support medications and then start into her rehab sessions. We worked on changing the order of the sessions and treatments to provide variety for her. Each day she would have range of motion exercises in all four limbs, a full body massage, low level laser treatments, electrical stimulation of different muscles groups and time “standing”. We varied the standing from me supporting her to time in the sling and Hoyer lift. (See below).

Her family came to visit after the first week and she was very happy to see them. When they came the second week, we all agreed she was comfortable and doing well and agreed to continue treatment. We would re-evaluate her every two weeks to determine what progress had been made. Either the rehab technicians or I talked with her owner every day or every other day during the course of her stay.

After three weeks of treatment, we had seen some improvement in Dixie. Her tail wag was consistent and she needed less stimulation to urinate and defecate. She would often give us clues that she needed to go.

At five weeks, she had a consistent routine for going to the bathroom with very few mistakes. At this time, she also had become quite fed up with the sling and lift. In the last two weeks, we would have her in the sling for longer and longer periods of time to allow her body to be in a more natural position. The sensation of standing gave her nervous system positive feedback and she could look around to observe her environment. Unfortunately, she was not as enthusiastic about being in the sling and would slump and not cooperate as well with her rehab sessions when they involved it.

This is when we got a quad cart from Eddie’s Wheels. This cart is adjustable and designed for in hospital use for different sized patients with neurological injuries. The lift had wheels but was very bulky and not designed for mobility. In the quad cart, Dixie could go places. So each day, we worked on standing and walking. Dixie loved the sunshine and the attention she got and her enthusiasm returned.  (See below for pictures and video in quad cart).

At this point, Dixie could not support her own weight but was starting to have small consistent movements in her legs when we pushed her in the cart. This is when we added in underwater treadmill sessions to her rehab. We phased out some of the electrical stimulation and I got in the treadmill with her and we worked on limb movement. The life jacket and buoyancy of the water made Dixie feel like she only weighed about 60% of her weight and her muscles were strong enough to support that.

Initially, she was very unsure about being in water and it took some time for us to adjust her to it. It eventually became a fun part of her therapy and we would alternate aquatic therapy and cart sessions depending on the weather.

At this time, Dixie and her family went back to Cornell for a follow up CT scan. This showed that her fractured vertebrae had healed and we would not have to worry about her injuring her neck or moving a screw and causing her pain or paralyzing her.

The CT scan required anesthesia and a long car ride each way, so we kept Dixie’s rehab light for a few days after. Once that had passed, we took to having her upright as much as possible and Dixie wanted to help. She was now making consistent efforts to right herself to a sternal position or she would roll over on her back to flip like a pancake.

I’m not sure when but I was very hopeful that Dixie would be walking on her own soon. That “soon” took a while.

Over the next four weeks, Dixie would make small improvements but was often not participating in her rehab. We changed her routine, her activity and had her family visit more often. Nothing seemed to make a difference. I discussed with her family the potential that she had plateaued in her recovery. We talked about getting her a cart for home and stopping for a while. Her mom suggested taking her home for a few days and I agreed. Maybe we all needed a break. So, Dixie went home for a three-day weekend to have some fun.

Sometimes a break is needed. Dixie came back with a renewed energy. She was making efforts to stand and started to bark if she wasn’t getting herself to the position she wanted.

That week, after an underwater treadmill session Dixie had her breakthrough. She was very wet and we got the hair dryer out to help. She was never a big fan of this (what dog is?) but always tolerated it. This time she stood up and walked away! It was only about four feet — but she did it! I was paged to rehab to see it and she did it again. I called her mom with the great news and she started crying on the phone.

Just as each patient’s neurological rehab progresses at its own pace, they also have their own motivation. For Dixie, that was getting away from the hair dryer. We would continue to use that consistently in her rehab and eventually just the sight of it was enough to get her to stand.

Over the next two months, we worked with Dixie four or five days a week and she spent weekends at home with her family. Seemingly each day she made progress and became stronger and stronger. She seemed to wear a smile on her face each day.

After nearly six months from the date of her injury, Dixie walked out of the rehab department on her own to go home. I saw her regularly for follow up visits and slowly weaned her off her medications.

Due to the nature of her injury, Dixie walked with her head down and her legs moving a bit like a crab. It was the prettiest walk I had ever seen. Over the next year, she went to the beach, the mountains and all over with her family. She got stronger and stronger. Occasionally, she would have problems due to her posture. We would work on those as needed with medication or with massage sessions by her family.

This is the last phase of rehabilitation: maintenance. Her recovery was a culmination of the emergency treatment, surgical correction and rehabilitation efforts of her owners, the rehab staff and most importantly Dixie herself. This team approach will be needed to maintain her mobility and comfort due to the severity of the initial injury. The importance of preventing obesity, keeping her mobile and active and anticipating the additional wear and tear her body will go through as a consequence of her injury and posture, all play a role in the quality of life Dixie will have going forward. And that is the phase of rehab that doesn’t end.

For a few years, I lost track of Dixie but was lucky enough to reconnect with her and her family last summer. She is doing very well and still having fun. Below is a recent picture.

For more information on Dixie, including her owner’s legal battle, check out this site. http://www.dixiethemiracledog.com/5001.html

Pictures of Dixie (double click to view larger image)

In her quad cart

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First steps on her own. Note her crab-like posture.

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Summer 2013

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Professional News: Pain Management Certification

I am proud to announce that I have been awarded the title of Certified Veterinary Pain Practitioner (CVPP) from the International Veterinary Academy of Pain Management (www.ivapm.org). This completes 2 years of work in the form of skill verification for a multi-modal approach to pain management, a written examination covering the fundamentals of the different aspects of pain management, 90 hours of pain management specific continuing education courses and acceptance of my two pain management case reports.

 

If you have questions about pain and your pet from arthritis to cancer and all points in between please contact me at drmattbrunke@gmail.com