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.

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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.

Cage’s Rehab: Strength

With Cage now somewhat comfortable and showing improvement with rehab, we could really start things moving. In doing that, I had to anticipate that Cage WOULD get better. That meant putting some things in place so that WHEN he was walking his body would be at its best.

The first thing I added to his regiment was a Chinese herbal compound called Double PII. This is a blend of herbs that promotes spinal cord healing and therefore better “messaging” from his thoughts to his actions. Herbal compounds can take 2-6 weeks to see improvement, so we started those once he was comfortable.

Two weeks into his rehab, Cage didn’t have sore muscles but his elbows were very uncomfortable. Remember that he had severe arthritis in both elbows for a few years now. And with 4 weeks of him putting most of his weight on his front legs, the elbows were causing him a lot of discomfort. We focused therapy with TENS and therapy laser to the elbows for short-term relief.

I also started him on Adequan injections. This is a substance that has anti-inflammatory properties and also helps prevent the cartilage from wearing down. With intact cartilage, we avoid bone on bone contact which is extremely painful. The injections can have both short and long term positive effects on the joints. They are injected into the muscle so they help ALL of his joints (remember he had knee surgery and has arthritis there as well).

With these two mechanisms in place, we had a steady routine with Cage. Each day he got acupuncture, heat, massage, range of motion exercises, electrical stimulation and therapy laser treatments.

Each day we helped him to stand so that he could relieve himself (sometimes we had to stimulate him but he progressively was able to go on his own if we were patient with him). Each day he was with us he got to float in the underwater treadmill. Here the buoyancy of the water allowed him to feel like he weighed 45 pounds instead of 70.

Some days he showed progress. Some days he didn’t. What was important was that he didn’t show any regression. Neurological rehab takes time. Nerves heal at about a MILLIMETER per DAY. That means an inch of nerve can take up to 254 days to heal, that’s over 8 months. This is why it is important to be patient with these patients.

While we were doing things to promote better nerve conduction (acupuncture, TENS) and increased sensory input (having him standing, using his legs, letting him urinate on his own), we also worked on him having muscle to be there once the message came from the nerve. So, each day, he got electrical stim pads applied to his hind legs and spinal muscle groups. The goal here was to minimize the atrophy that was occurring. Electrical stim won’t replace the body’s natural muscle tone or strength but it can be used to contract muscle and can minimize atrophy. If we don’t do these things, then even if the message gets from his brain to his legs to move there isn’t any muscle to do the actual work.

Even with keeping up with food and trying to minimize atrophy, Cage dropped another 6 pounds in the first 4 weeks he was with us.

Initially, any physical activity was exhausting for Cage. Even with our support and the buoyancy of the water, he still had to move against gravity. With each week, he made noticeable progress. Some weeks were tougher than others because sometimes he was mentally checked out. We built in rest days for him to recover. Mostly these were at home with family. Occasionally, we asked him to do less physically when in our facility because of the time spent being active with his family.

For the first few weeks in the underwater treadmill, I would be in there with him moving his legs for him. As he got stronger, I would be in there just to act as a bumper and keep him from sliding back on the treadmill. He eventually got wise to this and stopped putting in effort. Then, I took myself out of the treadmill and we worked with him on a harness to keep him walking. Our results were mixed some days. He was not a food motivated or praise motivated dog. In talking with his family, they mentioned one particular toy he was fond of. I asked them to bring that to his next session. It was a tennis ball “dumbbell” with a built in squeaker. Here is a picture.

dumbbell

 

This really changed everything. Now comfortable and moving, Cage WANTED that toy. We could use this to motivate him to play tug-of-war or to get him to fetch it in the treadmill. This proverbial “carrot on a stick” is what clicked for him. Sometimes it’s really the simple things that make us happiest.

When Cage first arrived, he could barely walk and needed a break in the underwater treadmill after 5 minutes. A month into rehab and he could walk for 30 minutes at a time. The water’s buoyancy helped him greatly. On dry land, he was limited but walking. What we saw was progress, motivation and strength.

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Cage’s Rehab: Part One

Being a paralyzed dog is hard. Being that dog’s parents can be just as challenging. It’s scary, there are a lot of unknowns and it can get expensive quickly. I don’t deny any of these. From a patient’s perspective they can get frustrated very quickly. Imagine if 99% of what you did today you couldn’t do tomorrow.

Think how you would feel in the pet’s position: To be dependent on others to sit you up, feed you, clean you; To not have the independence to stand up and walk, or to simply sit up. This is why we my team and I look to achieve a comfortable and stable atmosphere for the patient through empathy. We are objective and analytical throughout our treatment, this guides us as we make small, incremental steps in the right direction or re-assess when and where progress slows and stalls.

I met Cage on July 1st, 2015. On my initial physical exam, aside form his neurological deficits and elbow arthritis he had muscle soreness of his shoulders, front legs, neck and back muscles. This is common in paralyzed dogs because they are using tremendous amounts of effort to get themselves up and drag their hind end.

After discussing options and prognosis with the owners, they elected to take him home that night and return the next day to begin rehab. After initial evaluations I break rehabilitation down into three segments:

1) Pain Management – Reducing the pain load on the patient

2) Strength Building – Working muscles to regain motor control and coordination

3) Maintenance – Sustaining gains after treatment

 

It is the third part that incorporates proper nutrition and regular exercise as ways to protect the body or minimize progression of diseases. A commitment is needed to maintain the hard earned gains from treatment. I also ask for a commitment to get through the first two phases, no matter how dark and dismal they may seem. My patients (and clients) require patience.

Cage had an excellent neurosurgical team in Boston. They worked hard to do mechanical aspects and provide multimodal pain management. Cage had taken meloxicam (an NSAID) for his arthritis for years along with amantadine to provide pain relief. After surgery, they added in gabapentin and tramadol to alleviate the post-surgical pain and the pain from his compressed disc and subsequent infection.

I started acupuncture on Cage the first day. Acupuncture helps to release the body’s natural endorphins (what morphine is made from essentially). This, in conjunction with TENS (transcutaneous electric nerve stimulation), would help alleviate the pain in his muscles. He also received daily treatments with our therapy laser. This would target sore muscles and help release cytokines to promote muscle healing and an anti-inflammatory action. After a few days, Cage was more comfortable. His muscles didn’t jerk and spasm in his neck and shoulders.

Each day he was with us, Cage received hot packs applied to his sore muscles to warm them up. Then he was stretched out, massaged gently and all of his joints were put through cycles of normal range of motion. When a body is not weight bearing muscles atrophy quickly. If normal pressure isn’t applied to our joints, they can become stiff from inactivity.

After being warmed up, Cage was placed in either the underwater treadmill or our overhead hoist. This allowed him to stand in a normal position and see the world. It also gave his body feedback (the joints, nerves and muscles all need gravity input to function normally). He would then have electrical stimulation applied to his rear legs to “teach” his muscles how to contract again. After that, he would rest lying down with ice packs on his muscles and joints. A week later, I was able to discontinue tramadol, one of the pain medications he was on.

Each day, we were expressing his bladder and bowels 3-4 times a day. We needed to teach those nerves and muscles to do their job just like the rest of his body. On July 10th, I noticed that his urine had a foul odor to it. A test showed that he had developed a urinary tract infection. These can occur in paralyzed dogs because they are not always emptying their bladder fully. We cultured it hoping that we could just increase the antibiotic he was on for the spinal cord infection, or at least get both infections with one antibiotic. This wasn’t the case as his particular infection was resistant to many drugs. We added in another oral antibiotic to his regiment and carried on.

After the first two weeks, Cage showed improvement. In the underwater treadmill he could pull his rear limbs forward. When suspended on the overhead hoist he could stand and pull himself forward. When I placed acupuncture needles at different points, I saw progress in how the messages were being conducted along his nerves.

During this time, he became very attached to me. He would follow me around the room with his eyes and would take his pills or eat for me when he wouldn’t do it for others. I was a little worried about this but was also glad to have him engaging and participating. After daily updates and then a reassessment after 3 weeks, I recommended we continue with rehab. His parents agreed. They saw he was more comfortable. Our goal now would be to make him stronger.

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Dealing with the cards we are dealt

This case is from a few years ago but I have been re-telling the story again lately and wanted to share it with you.

When I met Gus, he was a two-year old male French Mastiff who couldn’t use his hind legs and had no control of his bladder or bowels. The first time I examined him he urinated all over me. It wasn’t his fault but I knew we had a long road ahead of us.

Gus lived in Albany with his owners and their three small children. His dad was called back to active duty in the Army and left overseas. While Gus loved his mom and the kids, dad was the center of his universe. The day after his dad deployed, Gus kept looking for him at the front door; pacing and whining he kept searching for him. His mom would call him back to the living room to be with the family but as soon as he was there, he would head back to the front door to look for his dad.

After the third day, Gus started jumping at the door. One time he hit the handle just right and the door opened. Gus took off into the street. His mom yelled and ran after him, only to see Gus run over by a truck in the road. He was rushed to the local animal emergency room and was treated for shock and pain.

The truck had fractured a vertebrae in his lower back and caused a disc to herniate against his spinal cord. It also broke many of the bones in his tail. The damage was severe. He had no function in his back legs or tail.

The only two options were to pursue a neurosurgery specialist or euthanize him. Surgery would stabilize his fracture and take the pressure off his spinal cord. At the time, his mom could not reach her husband to let him know what had happened. Knowing how much he loved Gus, she made the decision to go forward with surgery.

The closest specialist was in Boston. So, mom, the kids and Gus drove out there. Dr. Stephanie Kube operated on Gus, amputating his tail, stabilizing the fracture and removing the herniated disc. After surgery, Gus could feel his legs but did not gain much function back. This can happen in spinal cord surgery. Sometimes function comes back quickly, other times very slowly, and, in rare cases, not at all.

Gus stayed in Boston for about 2 weeks after his surgery and began fundamental rehab there. But due to the distance away from home and the need for a formal rehab center he was transferred to my care.

After changing into dry pants, I admitted Gus for a week of rehab. I had advised caution with his mom and could not make guarantees that he would recover. We agreed to take it one week at a time and look for steady improvements. Gus had weighed 90 pounds before his accident and was down to 75 pounds. This was caused by muscle atrophy in his hindquarters.

Unfortunately, Gus was still too big to manage at home and was incontinent. He was being catheterized 3-4 times a day if he wasn’t urinating on his own. I did not keep a permanent catheter in him for three reasons. First, with a catheter in, I wouldn’t know if he had the ability to urinate on his own. Second, a catheter can put the patient at risk for infections and third, his bodyweight would compress it and occlude the line.

His front legs worked perfectly and he would lift himself up in the run to move around. He would also get fed up with his rehab and try to walk away. While most of the time he laid still for his rehab he would get frustrated some days.

Gus’s rehab was an all day affair. He was living at the hospital, so we worked with him for 15-20 minutes at a time 3-4 times a day instead of the typical 90 minutes straight. This gave him time to rest and also added variety to his day. Some days we had to change our plan if he had urinated or defecated on himself.

Gus had electrical stimulation to work the muscle groups in his back legs. He also had range of motion exercises, standing exercises and therapeutic laser treatments for his hind legs. His front legs were working hard supporting all of his weight, so we worked on those and his back muscles to keep him comfortable.

His mom and the kids came to visit him after a few days and we agreed to continue on for two more weeks. Gus became attached to my rehab technician, Rebecca, and I as much as we became attached to him. He enjoyed the interactions and always wanted to see what we were doing. After a few weeks, he started living in the rehab room permanently instead of the ICU. This allowed him more mental stimulation and actually made our lives easier. By having him there, we could do short exercises with him without taking the 20 minutes to get him up from the cage, over to rehab and back to his cage.

Each week Gus would make progress. We had to catheterize him less often as he gained sensation and the ability to urinate on his own. It was far from perfect but he made steps. I had him on medications to help stimulate bladder contraction and antibiotics since he had developed a urinary tract infection.

After a month or so, he could move his legs but wasn’t strong enough to stand to walk. The owner wasn’t sure she could continue on with rehab and was considering euthanizing him. We worked it out that he would stay with us for another few weeks but if he didn’t make more progress we would stop.

I completely understood and respected her concerns. Managing Gus was a full time job for Rebecca and I and we had the help of other staff at the hospital. Trying to do that and raise three kids would be impossible. There were still days Gus would either urinate or defecate on himself and require a bath. There was also the financial aspect to consider.

We had a cart from a previous patient that we started to use for Gus. Carts are great tools as part of rehab. They allow the pet to be upright and can be set either as a “walker” or a wheelchair depending on the ability the pet has. With his front legs working well, Gus could pull himself around the room in the cart. This minimized his chances of injuries and getting pressure sores on his back legs.

Gus also used a harness to keep his back legs up. Doing this on a land treadmill we could exercise his front half and two of us could move his back legs for him. One of us would hold the harness and the other would place his feet in time with his front legs. This was done to mimic walking and get input up his spinal cord that his legs could do this.

While he had made progress, the owner decided she could not keep going. Instead of euthanasia he would be placed in a foster home through a French Mastiff Rescue group. I had spoken with the owner about this and the group leader. Unfortunately they could not take Gus for a few more weeks. The owner could not afford to keep paying us, so we agreed that Gus could stay with us at no charge until the rescue group could take him.

During his time with us, we became very attached to Gus. He was a happy two year old who just wanted to play and didn’t understand why his legs didn’t work. He would get “jealous” of us working with other dogs and bark or whine. If we weren’t working with patients, he would bark at the door to have someone play with him.

His favorite toy was a soccer ball. He would nudge it back to you if you rolled it to him. He even learned to bump it back to you using his head. I would lob the ball at him and he could head butt it back. This game could last hours if you let him have his way.

We kept working with Gus each day. Although he had shown some motor function, he hadn’t walked using his back legs on his own. While it was still early, this troubled me because he would be very hard to place in a home with all of his conditions. And while he enjoyed his time in the cart, it made him twice as wide due to the wheels. This would make using it inside a normal house difficult.

About a week before the rescue group was coming to pick him up, I was working at the desk in the rehab room. My back was to Gus as I finished some paperwork. I was also racking my brain trying to figure out why he wasn’t walking. There were no other patients there and I was reviewing my notes again on him to see what I had missed.

Being in the room meant I was there to play with Gus. Well, that’s what he thought at least. He was laying at the opposite end of the room and would roll the ball to my feet. I could work and gently kick it backwards to him at the same time. This was the only way to get any work done, otherwise he would whine or bark for attention.

As the ball came rolling back to me it slid under the desk. I couldn’t find it with my foot and stopped reading his chart. As I bent down to find the ball, I felt Gus lick my hand. As I turned to nudge him away, I saw him STANDING on all four feet. I stepped back and he WALKED to me. Not his half-walk, half-drag but a choppy walk using all four feet.

I shouted in joy and got down to hug him. Gus of course walked right past me and got the ball. I had taken too long in his opinion.

Sometimes you just have to wait for the right time. Gus had waited and walked when he was good and ready.

I let his mom know that he was walking and she started crying over the phone. She was happy he had recovered but it didn’t change her situation. Gus faced a lifetime of medical problems ahead and she couldn’t provide the care he needed.

A week later, Gus left with the French Mastiff Rescue foster family. I made sure they had plenty of soccer balls to keep him motivated. I received updates from the rescue group the first year that Gus was doing well. After that we lost touch.

Patience, time and dedication can improve outcomes. Sometimes the changes in lifestyle or financial concerns change the outcome as well. Gus and his family may not have gotten what they wanted, but they got what they needed.

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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