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Physical Rehabilitation & Multimodal Treatment

Clinician's Brief (Capsule)

Orthopedics

|May 2015

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This report describes a 3.5-year-old, 25.5-kg dog that developed severe progressive weakness and bilateral plantigrade stance of the pelvic limbs following ovariohysterectomy. Clinical signs indicated a distal sciatic nerve injury, likely from compressive neuropathy and nerve stretch from surgical positioning. There were also ulcerations on the dorsa of the rear paws and enlarged popliteal lymph nodes. Positioning may have caused ischemia and mechanical deformation of the nerve at and proximal and distal to the compression site. Weekly to bimonthly physical rehabilitation was initiated along with home rehabilitation using support boots, carts, and orthotics.

Low-level laser therapy (cold laser) was used to accelerate wound collagen synthesis and promote granulation, and on the distal sciatic nerve and the distal left pelvic limb to enhance nerve regeneration, preserve muscle tissue, and reduce inflammation. Neuromuscular electrostimulation was applied to the caudal thigh muscles and tibial muscles to stimulate sensory nerves, exert trophic effects on the denervated muscle, and promote motor axonal regeneration. Ultrasound was applied to the cranial tibialis and gastrocnemius muscles to increase regenerating nerve fibers and myelination. The dog was aggressively treated and evaluated over 15 months, by which time it could support its hocks 2–3 cm above the ground without orthotics. Postural deficits were still noted, but superficial pain perception was present and the ulcerations healed. Although it was not clear which modality afforded the most improvement, this case demonstrated the potential utility of physical rehabilitation and custom orthotics for return to function and improved quality of life.

Commentary

Multimodal drug and non-pharmaceutical therapeutic strategies have long been known to work synergistically to improve outcomes, reduce drug doses and subsequent side effects, and provide a more comprehensive plan for convalescence. However, it is difficult to design a controlled study to determine which treatment works best because a multimodal approach involves many variables. The greatest challenge for a pain practitioner or physical rehabilitator is to artfully combine the components of a treatment plan to individualize the treatment. In this case, physical rehabilitation, drug therapy, orthotics, and at-home manipulation all had individual benefits, including lymphatic and microcardiovascular support at the cellular level of the trauma, support of nerve and motor regeneration, development of strength, and reduction of pain and inflammation. As more reports like this are generated, differences in treatment strategies can be compared so that we can further understand what constitutes the best therapeutic approach.—Heather Troyer, DVM, DABVP, CVA

References

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