To form an effective rehabilitation plan you need to fully understand the condition you are working with as well as the needs of the patient. Initially we will look at some of the commonly seen neurological disorders – the cause and their common symptoms – before looking at common rehabilitation techniques and nursing considerations which may be beneficial to these conditions.
Common neurological conditions
Spinal cord issues
Intervertebral disc disease is a common neurological condition seen in patients in practice and is caused by the displacement of part of the spinal disc. Spinal discs are found between each vertebral body, except for the first and second cervical vertebrae and the fused sacrum. Disc herniation can occur as a result of direct trauma; however, it most commonly occurs due to disc degeneration. Disc herniation results in neurological deficits and can also result in a pain response; generally the more severe the disc herniation, the less the pain response. Symptoms can range from pain, vocalisation and abnormal gait and proprioceptive responses, to loss of reflexes, including panniculus and patellar reflex, and, in some cases, loss of conscious urination and defecation.
Degenerative lumbosacral stenosis
This condition sees compression of the cauda equina due to stenosis of the vertebral canal or disc protrusion, most commonly around L7 to S1. It is a common condition in middle-aged large-breed dogs such as Labradors and German Shepherds. Symptoms often manifest as pain and lameness, rather than typical neurological symptoms. Patients will struggle to jump and climb steps, and will seem weak behind. The tail is often carried in an abnormal position due to weakness and some patients will develop urinary and faecal incontinence.
Cervical spondylomyelopathy
Commonly known as wobbler syndrome, cervical spondylomyelopathy is caused by abnormal development of the cervical vertebrae, which results in the compression of the spinal cord. It is a condition common in young giant-breed dogs such as Great Danes. Symptoms can be slowly progressive or acute in presentation. The most noticeable sign is a mild ataxia on all four limbs, with an increased stride length in the hindlimbs and a shortened stride in the forelimbs. Neck pain can be variable and some dogs will hold their head low. In severe and acute cases paresis or paralysis can occur in all limbs.
Vestibular disease
Vestibular disease is a common neurological condition in elderly dogs, and while it can occur as a result of inner or middle ear infection, it is commonly idiopathic. It has a similar presentation to that of vertigo in humans, with nausea, nystagmus, head tilt and ataxia as common presenting signs. It is normally self-limiting, and improvements usually occur from around day two to three. Some dogs may have a residual head tilt, but most patients return to normal over the course of two to three weeks.
Fibrocartilaginous embolism
Fibrocartilaginous embolism is an acute infarction of the spinal cord because of a vascular embolus, normally originating from the intervertebral disc. Ataxia, paresis or paralysis are the common signs of this neurological condition. There may be some initial pain at the point of the embolus lodging, but after this it is normally a non-painful condition. Fibrocartilaginous embolism is a sudden onset condition, normally associated with running, playing or jumping. It is commonly seen in adult large- and giant-breed dogs. Nursing and physical care for these patients is crucial and plays an essential role in promoting recovery as there are no other treatments.
Nursing and physical care for patients [with a fibrocartilaginous embolism] is crucial and plays an essential role in promoting recovery as there are no other treatments
Paresis
Paresis is often the result of trauma, but can also be seen as a subsequent complication of the previously discussed neurological conditions, most commonly intervertebral disc disease. This can be in two limbs or four limbs. It is important to consider the nursing care of these patients, which may include bladder and bowel care, as well as the care of the affected limbs.
Nursing considerations
Food and water
It is essential to ensure that the nutritional needs of a patient with a neurological condition are met. This may mean making some alterations to their normal routines.
Raising bowls to a more neutral height to stop patients having to lower their heads to the floor to drink or eat can massively help. This, I feel, should be considered in all rehabilitative neurological problems, not just for patients who are suffering some form of paresis. Imagine for a minute that you are suffering a vestibular attack, or that you have a condition which affects your balance and proprioception: if you had to stand up and bend your head down and forward while you were already struggling with the proprioception of your body, it must be really disorientating and uncomfortable enough to put you off eating and drinking.
Some patients may experience nausea from their condition and require an antiemetic before feeling like eating or drinking. Intravenous fluids may be required if the patient is refusing water, but if possible do not include the foot in the cannula bandage. Though this is often done to prevent the foot swelling, if the patient is suffering from a neurological condition with altered proprioception then covering the pads of the foot can only add to the confusion.
Toileting
Managing a patient’s urination and defecation during a neurological condition is important as these conditions often result in decreased ability to perform normal bodily functions. This may include regular checking and emptying of the bladder. If the patient is able to pass urine consciously, they may not be able to move away from the urine, so care to prevent urine scalding is required. Considerations might include barrier creams, regular changing of bedding, absorbent pads and vet bedding and, if appropriate, indwelling urinary catheters. Laxatives may be required if the patient is not defecating voluntarily, as constipation can be painful and uncomfortable.
Managing a patient’s urination and defecation during a neurological condition is important as these conditions often result in decreased ability to perform normal bodily functions
Mobility
Patients with any of the mentioned neurological conditions may have impaired mobility, which may include an altered gait, resulting in the knuckling and subsequent dragging of feet. For these cases, the patient may require a boot to prevent trauma to the skin and potential injuries; however, the choice of boot is crucial. The conventional dog boots used to cover bandages and such are quite thick and heavy, meaning the proprioceptive responses for that foot may be altered; when proprioception is already impaired, this is far from ideal. I have had success with the rubber balloon-like boots which are strong enough to prevent rub injuries, but thin enough to allow some proprioception. It is important boots are only put on when the patient is having mobility sessions, as they can become quite warm and sweaty if left on for periods of time.
When periods of exercise are occurring, it is important to think about the type of restraint used – collars may not be appropriate in many conditions, including wobbler syndrome and issues with cervical intervertebral discs, as added pressure applied via a collar may exacerbate the issue. There are various harnesses available, but for neurological conditions it is worth using a whole-body harness, like a “help-me-up” type harness. These harnesses allow for even weight distribution and provide the chance to have control over more of the body, as well as minimising the trauma to the handler’s back through straining and heavy lifting!
It is crucially important for the neurological signals to get the patient into a normal standing and weight-loading position regularly during their recovery
Mobility also encompasses rehabilitative processes such as passive range of motion exercises – this is the movement of joints through their normal range of motion. For patients suffering paresis or proprioceptive deficits these motions need to be produced manually by the nursing team. Motion exercises can also include periods of assisted standing – muscle wasting and tissue weakness develop very quickly, and it is crucially important for the neurological signals to get the patient into a normal standing and weight-loading position regularly during their recovery. Now, this can be achieved with specialist inflatable peanut balls, but I have used yoga balls in practice and for small dogs I have even used rolled-up towels or quilts. You basically want something that you can place the dog over, which supports their body weight but allows all four feet to be placed into a natural position on the floor. Once they are in this position, you can then gently rock the patient backward and forward to provide proprioceptive stimulation to the feet when in a normal position. This will also help to trigger some muscle activity.
Mental stimulation
Mental stimulation, I believe, plays a huge part in the recovery and rehabilitation of patients with neurological conditions. If you have ever had a bad back and had to spend days laid flat out on the floor, imagine how much worse that would be without the TV or your phone to float around social media. Put your patients somewhere where they can watch what is going on or leave radios on talk channels on in the background. If appropriate you can use feeding puzzles or toys to provide meals in and if your patient is non-ambulatory, you can carry them outside onto the grass and sit with them several times during the day.
Bedding
The correct type of bedding is essential for patients with neurological conditions. Vet bed type bedding is great to wick away bodily fluids while providing some padding to minimise the risk of decubitus ulcers and bed sores; however, what you place under the vet bed will depend upon the patient’s condition. For patients suffering paresis and spending long periods of time in recumbency some form of kennel mattress made from a memory foam material is perfect to minimise recumbency issues. On the other hand, for patients who have proprioceptive deficits but have some mobility I have found that a firmer surface is better. This is because anything too padded or slippery provides an unfirm surface, making movement tricky.
Vet bed type bedding is great to wick away bodily fluids while providing some padding to minimise the risk of decubitus ulcers and bed sores
I have two favourite items which I use for nursing my neurological patients in their kennels; these are:
- Rubber-backed bath mats – the type you put on your bathroom floor. I have found that these are great for the bottom of kennels as they are non-slip, so I tend to place one of these down first, and then cover them with kennel pads and place a vet bed on the top. This minimises the slipping and movement of bedding on the slippery kennel floors when proprioceptively challenged patients may be scrabbling around
- Bean bags – for my recumbent patients I want them to spend time not only in flat lateral recumbency, but in sternal and raised sternal positions. This is for physical reasons, such as helping with reduction of thoracic secretion build-up and lowering the risk of decubitus ulcers, but also for mental reasons. Imaging lying flat out on your side for hours at a time… how boring that would be! Spending some time in an upright position is more mentally stimulating. Now, I’m sure we’ve all spent time trying to “prop” patients up into sternal recumbency with rolls of towels or blankets, but forget that and invest in some bean bags. We purchased a few differently sized bean bags and placed them inside heavy-duty plastic bags (I use cremation bags) to prevent contamination with bodily fluids. You can then place these inside old duvet covers to make them more comfortable. These are then perfect to position your patients in different recumbencies depending on their needs
Conclusion
As you can see, there are lots of things we can do to help patients with neurological conditions which don’t involve complex procedures or equipment but can make a huge difference to their physical and mental rehabilitation and care. Think outside the box and consider how you would feel or how you would like your pet to be treated. I regularly move dogs who are suffering paresis out of their kennels and onto a bed or bean bag next to my desk while I’m working, to give them a change of scene and some mental stimulation. Neurological patients really need veterinary nurses!
