Conditions that require neurologic physical rehabilitation in humans include stroke, traumatic brain injury, and spinal cord injury.1 Physical rehabilitation therapy is beneficial and effective to help return or improve function lost as a result of these conditions in some patients.2
Neurologic disease is unique in that physical therapy has a critical role in maintenance and recovery of function. Dysfunction of the nervous system can cause loss of motor and autonomic function and a range of sensory abnormalities, including loss of sensation (analgesia), abnormal sensations (paresthesia), and heightened sensitivity to stimuli (hyperesthesia).3 Articles in the veterinary literature support the usefulness of rehabilitation in recovery from neurologic injury and nonsurgical management of neurologic conditions.4 Several neurologic disorders affecting small animals are amenable to rehabilitation, including paresis, muscle atrophy, muscle contractures, pressure ulcers, and pain.4 Additional indications include postoperative rehabilitation (e.g., intervertebral decompression surgery), central or peripheral nerve injuries, wobbler syndrome, fibrocartilaginous embolism (e.g., type III disc disease), degenerative myelopathy (management of current presenting signs), and balance/vestibular problems.5
THE ROLE OF VETERINARY TECHNICIANS
As part of the veterinary rehabilitation team, credentialed veterinary technicians, under the supervision and direction of licensed credentialed rehabilitation veterinarians, are an integral part of caring for hospitalized recumbent or neurologic patients. Although technicians can work in this field without being credentialed, the American Association of Rehabilitation Veterinarians strongly discourages this practice. Rehabilitation veterinarians examine patients and determine the best treatment options for each patient. Rehabilitation technicians then carry out prescribed therapies. They also play an integral role in educating clients and communicating with clients about daily progress. Troubleshooting technique with the prescribed exercises and discussing pain management with supervising veterinarians help ensure that treatment plans are effective.
Physical rehabilitation during recovery from neurologic disorders is important not only for strengthening and increasing flexibility but also for reducing pain and improving quality of life.6Understanding the potential complications and risks—and implementing strategies to minimize them—can reduce the duration of hospitalization, improve patient comfort, and promote faster return to function. Rehabilitation practitioners or therapists perform neurologic examinations to document patients’ current neurologic status and become familiar with individual animals’ response to therapies to measure progress. Neurolocalization and determination of the severity of the lesion and pain status are the primary focus of the examination. Deep pain sensation, ability to stand and support weight, duration of disease, and presence of motor and bowel/bladder function are key factors influencing prognosis for recovery.4
ESTABLISHING RECOVERY GOALS
Short-term goals are the component skills established at each phase of rehab that are needed to attain long-term goals. Short-term goals are essentially subskills required for basic daily functional needs (e.g., sitting upright, toileting, eating or drinking with minimal or no assistance) and help identify specific areas of limitation. Establishing patient needs though goal setting helps formulate the at-home treatment plan given to clients.7
Long-term goals define the patient’s expected level of performance at the end of the rehabilitation process. Technicians note the amount of independence, assistance, supervision, and equipment or environmental adaptation necessary to ensure the safety of pets and clients. Understanding which problems can be addressed and influenced, and which cannot, is crucial in defining realistic expectations.
RISKS AFFECTING HOSPITALIZED RECUMBENT OR NEUROLOGIC PATIENTS
Rehabilitation therapy for neurologic patients places a profound emphasis on nursing and supportive care to protect the patient from complications and preserve tissue strength and function during the recovery period.8 Several adverse conditions can affect these patients (BOX 1).
- Prolonged or permanent loss of mobility and independence secondary to disuse atrophy
- Chronic pain
- Decubital ulcers
- Urine scald
- Self-inflicted trauma
- Reduced lung capacity and compliance
Credentialed rehabilitation practitioners or therapists and their credentialed rehabilitation veterinary technicians must be cognizant of the risks facing recumbent patients. Skin, vascular, and pulmonary integrity can be compromised if patients are not turned on a proper schedule. Positioning changes and skin integrity (along with other vital signs) are important and should be noted on patient charts. Patients should be positioned on either side in lateral recumbency, in sternal recumbency, and sitting and standing, if possible. Bolsters (positioning blocks or rolls of towels) can be used to help patients maintain such postures, keep an extremity in a neutral (i.e., normal) position, and improve patients’ overall visual perspective while hospitalized.10
Neurologic patients are at a higher risk for experiencing pain.11 This may be due to a healing surgical procedure, muscle spasms, or nerve pain. Manual therapy, ice, heat, electrostimulation, and therapeutic ultrasound may be used depending on the severity and phase of recovery (acute versus subacute). Precautions must be taken with each therapeutic modality for patients with altered pain sensation or lack of pain perception. Pain-free animals are relaxed and cooperative and recover more quickly and completely, and owners are much happier and more compliant with recommendations when their pets are comfortable.12 Multimodal pain management is always advisable for painful patients and is recommended by the 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.13 Therefore, pain medications should be used to allow for patient comfort.
THERAPY FOR RECUMBENT PATIENTS
Therapy for neurologic patients entails physically challenging them and pushing them to improve, but sessions should end on a positive note with ample praise and encouragement. The purposes of the exercises are to stimulate proprioceptive fibers, encourage joint fluid circulation, and enhance circulation to adjacent tissues.14,15 General guidelines for neurologic rehabilitation include frequent, low-duration exercises to avoid overexertion.
Patients should be encouraged to do as much as possible for themselves within their functional capabilities. Patients that are unable to support themselves may be encouraged to stand with the assistance of appropriate slings or harnesses while eating and drinking. This helps promote strength and is also an excellent opportunity for weightbearing or weight-shifting exercise. Encouraging patients to ambulate and stretch for treats is an easy early mobility exercise. For patients that lack proprioception (awareness of where their body is in space), placing food near their paws and limbs can increase body awareness. A few exercises are described below; more are listed in BOX 2.
- Proprioceptive neuromuscular facilitation (PNF patterns)
- Ice massage
- Muscle tapping
- Weightbearing techniques
- Postural reflexes
- Treadmill exercise
- Underwater treadmill or supported swimming
- Supported standing
- Rhythmic stabilizations
- Ball rocking
- Tensor bandaging
- Joint compressions (veterinarians only)
- Joint distraction (veterinarians only)
- Tactile sensory stimuli
- Tellington touch
- Wringing the limb
- Acupressure/laser acupuncture
- Client education in lifestyle management (accommodations in home environment for patient mobility) during recovery
- Carts or slings
- Splints or orthotics
Encouraging correct posture is a key component of all mobilization exercises. FIGURE 1demonstrates correction of hindlimb placement for manual weight-shifting to the hind end. Weight-shifting first to the right side and then to the hind end is accomplished by using a treat. The therapy ball peanut provides the required support for this patient, while the boots and mat improve foot traction.
Details about the level of assistance patients need to get up from a down position (i.e., slight assistance versus full body support) should be recorded in the medical record. Example transitions include lateral to sternal recumbency (FIGURE 2), sternal recumbency to sit (FIGURE 3), and sit to stand (FIGURE 4). Assisted sling walking is a great way to provide patients with safe ambulation and weightbearing; several slings are available (FIGURE 5).
NURSING CARE FOR RECUMBENT PATIENTS
Patients presenting with neurologic disorders with incoordination (ataxia) or weakness (paresis) have the potential to become recumbent. Because these patients are not steady on their feet, providing nonslippery surfaces is essential. Moreover, recumbent patients require soft bedding that does not “bottom out” to the floor to avoid decubital ulcers (bed sores). Frequent turning schedules help avoid such complications and also prevent hypostatic pneumonia or atelectasis.4,16 BOX 3 provides an overview of additional key therapeutic considerations for neurologic patients.
- Bladder care must be initiated for incontinent animals to prevent atony and treat infections.
- Attention to bedding and hygiene helps prevent decubital ulcers.
- Neuromuscular electrical stimulation may be used to strengthen muscle.
- Massage can reduce muscle spasms and pain.
- Passive range of motion is used to maintain joint motion and health.
- Assisted standing, balancing, and various types of exercise are incorporated, depending on the animal’s neurologic status.
As a general rule, recumbent patients cannot or will not urinate voluntarily and require frequent bladder assessment or management in the form of catheterization or manual expression. Urinary function usually returns in patients with thoracolumbar disease (only pelvic limbs affected) as soon as they are weakly ambulatory. Patients with cervical disease (all four limbs affected) regain voluntary urination earlier but may be reluctant to urinate because they are unable to adopt a posture for urination. Diseases of the lumbosacral spinal cord are an exception: these patients have urinary difficulties despite retaining the ability to walk.
It is important to teach patient caregivers how to palpate the bladder and assess bladder function. Understanding patient urinary function is critical to determine whether urination is voluntary. When pressure in the bladder exceeds that of the urethral sphincter, urine will leak out, which may be misinterpreted as voluntary urination. Therefore, other measures are needed to assess the presence of voluntary urination. With proper training, bladder size can be assessed before and after urination. All urination should be recorded in the medical record, along with a notation of whether it was voluntary, expressed manually, or expelled via a catheter. Urinalysis should preferably be performed on admission; urine should then be tested with a dipstick for the presence of white blood cells and protein every 2 to 4 days.
Appropriate bladder management in recumbent patients includes regular walks outside (at least 3 times daily) to encourage patients to urinate. For patients unable to urinate, the bladder can be manually expressed, intermittent catheterization can be implemented, or an indwelling catheter can be placed. Urine should be expressed every 4 to 6 hours depending on bladder size, or the urine bag should be checked at the same interval. The amount of urine produced should be noted in the patient record. In addition, prescription medication to aid in bladder voiding can be prescribed at the discretion of the veterinarian.
Additional nursing care includes providing bedding that either absorbs liquids or allows them to pass through and away from the patient’s skin (e.g., acrylic bedding). If incontinence pads are used, care must be taken to avoid placing the pad directly beneath the patient’s skin because the urine simply disperses across the pad, resulting in increased contact time and leading to urine scalds. Acrylic absorbent bedding should be placed directly beneath the patient, followed by the incontinence pad; this prevents multiple layers of bedding from becoming soiled and avoids having recumbent patients lie in their own urine. Finally, patients should be kept clean and dry at all times. Soiled bedding should be removed promptly. Long hair should be clipped if necessary to enable hygiene management and allow accurate assessment of the development/progression of urine scalding.
Fecal incontinence mainly affects dogs with severe lumbosacral disease, which can lead to a lack of voluntary control over defecation and severe soiling. Cats with neurologic problems have a tendency toward constipation and megacolon. Patients must be kept clean and dry at all times. Lactulose may be used, especially in cats, if constipation is suspected; unlike the situation in dogs, manual evacuation is difficult in cats. In addition, patients receiving opioid analgesia should be monitored closely for constipation due to reduced intestinal motility, and pelvic trauma patients should be monitored for tenesmus. Both patient groups may need treatment to aid in defecation.
Recumbency alone can lead to secondary complications, including atelectasis and aspiration pneumonia indepen- dent from the disease process itself. Hypoventilation can also be caused by neurologic disease processes severe enough to cause recumbency in all four limbs (e.g., a slipped disc in the neck, brain disease). Patients with generalized lower motor neuron disease affecting the laryngeal and pharyngeal muscles and the esophagus (e.g., myasthenia gravis) are particularly predisposed to aspiration pneumonia.
The respiratory pattern and rate should be recorded on a regular schedule: up to every 4 to 6 hours in severely affected patients, less often in stable patients. If aspiration pneumonia is suspected, temperature should be checked at least twice daily to monitor for pyrexia (raised body temperature or fever).
Preventive nursing care is crucial for a positive outcome in these patients. Several measures can be taken to help prevent respiratory complications. Patients should be turned every 4 to 6 hours, with the goal of maintaining a sternal position as often as possible using appropriate padding. The details of each change of position should be noted in the medical record (e.g., from sternal to left lateral to sternal to right lateral to sternal).
Water and food should be offered only when patients are in a sternal position. Someone should sit with patients while they eat. It is beneficial for patients to maintain an upright position for 30 minutes after feeding to decrease the risk of regurgitation and aspiration pneumonia.
Coupage, also known as percussion therapy, is indicated for dogs with pneumonia to dislodge mucus that can then be expelled from the body while coughing. If tolerated, coupage should be performed each time patients are turned if aspiration or hypostatic pneumonia is suspected; however, radiologic evaluation should be carried out to confirm pneumonia and repeated to monitor progress or deterioration in lung fields. Coupage is contraindicated in thoracic trauma patients. Thoracic auscultation should be performed at least once daily to identify abnormalities, which should be reported to the veterinarian immediately. Postural physiotherapy techniques can also be implemented to aid in removal of excess secretions in combination with nebulization and coupage.
Recumbent patients are at risk for developing dermatitis secondary to urine scald and fecal soiling and even more so for the development of decubital ulcers over pressure points. In addition, skin abrasions can develop if patients drag themselves or a limb over rough ground. Several steps can be implemented to prevent skin complications. In addition to the guidelines presented under BLADDER MANAGEMENT, appropriate padding should be used around pressure points, and bony prominences/pressure points should be systematically checked twice daily to monitor for skin redness or early development of decubital ulcers. Regular turning (every 4 to 6 hours, as discussed above) and massage of prominences/pressure points to increase local blood flow can help prevent skin problems.
Treatment of Skin Complications
Skin complications may develop despite good nursing care. Veterinarians must assess patients and prescribe any medications or therapy. The veterinarian may also recommend the following measures:
- Dermatitis can be cleaned with a dilute chlorhexidine solution followed by thorough drying and application of a barrier cream.
- Excessive moisture around affected areas must be avoided, as should application of thick layers of barrier cream; the latter harbors and insulates bacteria.
- Applying a dilute solution of bicarbonate of soda and cooled boiled water is very effective for urine scalds or irritation of the testes. The area should be doused and left to dry at room temperature. This can be repeated 3 to 4 times daily.
- If decubital ulcers develop, pressure over that region must be avoided. This can be accomplished by using a cushion (doughnut).
- Dead tissue can be debrided.
- Elizabethan collars should be used to prevent patients from licking or chewing the region.
Neurologic rehabilitation can be among the most challenging and rewarding work for the veterinary team. Determining time for recovery is often the most difficult task. Recovery times can be extremely variable and are intrinsically linked to the neurologic condition, underlying medical conditions, and neurologic status at time of presentation for rehabilitation.4 The time needed for treatment by both the veterinary team and owners must be considered. It is often not feasible to perform all exercises and modalities for a single patient, and some exercises may not be applicable or possible in certain patients. Each patient requires an individualized rehabilitation protocol specifically designed for the neurologic condition, owner expectations, level of participation and time commitments of caregivers, and expertise of the veterinary team.
Credentialed rehabilitation veterinary technicians are the “eyes and ears” for rehabilitation veterinarians and physical therapists. They are the ones educating clients and performing recommended treatments.
Author: Mary Ellen Goldberg