Physiotherapy Case Report: Rehabilitation for the trauma patient
Written by: Jessica Grainger BSc (Hons) Physiotherapy, MCSP, MSc Veterinary Physiotherapy, (ACPAT – Cat A). Animal Physiotherapist
2 year old entire male Labrador was involved in an unwitnessed road traffic accident on the 1st March 2017. He was seen by his first opinion practice and given supportive care and imaging, radiography of the spine and forelimbs found no injury, however he presented with monoplegia of the left forelimb. Initially amputation was advised however the owner was keen to follow conservative management. He was referred to SCVS for neurological examination and physiotherapy, on assessment at SCVS on the 10th March; he was unable to bear weight on the left forelimb and lacked response to nociceptive stimulation of the dorsal paw suggestive of a radial nerve injury, alongside musculocutaneous nerve involvement as he had an inability to flex the elbow, and absent nociception of the medial antebrachium. With ulna nerve nociceptive feedback unremarkable it was suggestive of injury to C6-C7 spinal cord segments. Further diagnostic testing was not undertaken as it was not deemed to change the treatment protocol that the owner was willing to undertake at that time, and he was referred to physiotherapy.
Physiotherapy assessment highlighted poor pain management with intermittent vocalisation on movement; however no specific movement triggered this response. He was non weight-bearing (NWB), with low tone and absent withdrawals and holding the limb in a flexed and adducted posture. He presented with cervical spine paraspinal muscular spasm, and significant supraspinatus atrophy, however the whole limb was mildly atrophied.
Physiotherapy Treatment Plan:
- Pain Management – discussion with the neurological team and started on gabapentin.
- Neuromuscular electrical stimulation (NMES) – used to activate the left scapula, inparticular supraspinatus and infraspinatus (Bajd, 2004; Glanz et al, 1996). The owner was loaned a unit and taught to perform at home daily.
- Massage, soft tissue release and passive stretches – to reduce overload on contralateral and hindlimbs (Coates, 2013).
- Passive range of movement – to all joints on the left forelimb, these techniques are used to reduce pain and increase function (Childs et al, 2004).
- Sensory Stimulation to the left forelimb.
- Environmental control – home adaptations to limit further trauma, such as managing steps and stairs. Instructing the owner as to correct ergonomics with appropriate harness use and adaptive exercise.
- Underwater Treadmill – gait re-education supported with hydrotherapists to re-educate normal movement patterns whilst supported by buoyancy of the water (Monk, 2016).
- Rehabilitation programme – focussing on maintaining range of movement and encouraging functional movement (Hyytiainen, 2016; Vallani et al, 2004).
Improvements to scapula and elbow voluntary movements were seen and the treatment programme was adapted in view of progress:
- Exercise progression – the rehabilitation programme was altered to incorporate weight bearing exercises, and introduce low level strengthening exercises to encourage scapula stability.
- Hydrotherapy – changed from underwater treadmill to swimming to encourage active scapula and elbow range of movement. A splint to wear whilst swimming was designed to maintain a neutral carpal position whilst in the water.
- Splinting – fitted for a carpal support brace to maintain carpal extension to encourage weight bearing. This was combined with a ‘Toe-Up’ sling to assist correct paw placement when walking.
Steady improvements have been seen and he is now weight bearing at low speed and a focussed exercise programme has been reviewed to encourage elbow stability to improve confidence and comfort when weight bearing. Further orthopaedic assessment has been considered to assist long-term management of carpal instability but the owner is engaged with conservative management and wants to avoid invasive procedures at this time. This case has highlighted the importance of inter-disciplinary working available at SCVS and by the physiotherapy team, who work closely alongside veterinarians at both SCVS and primary care vets to ensure a holistic approach to treatments.
At SCVS, our team of Physiotherapists are happy to discuss and assist management of conservative and post – operative cases, and use a wealth of experience to offer an extensive assessment and treatment protocols, including manual therapy, exercise therapy, TENS, NMES, Laser and hydrotherapy.
To find out more about our physiotherapy department, please click here.
References
Bajd, T. (2004) ‘Neurorehabilitation of standing and walking after spinal cord injury’ IN: Rosch, P., Markov, M. (eds) Bioelectromagnetic Medicine. New York: Marcel Dekker: 439-459.
Childs, J., Piva, S., Erhard, R. (2004) ‘Immediate improvement in side-to-side weight bearing and iliac crest symmetry after manipulation in patients with low back pain’ J Manipulative Physiol. Ther. 27 (5): 306-313.
Coates, J. (2013) ‘Manual therapy’ IN: Canine Sports medicine and rehabilitation. Zink, C., Van Dyke, J. (eds) West Sussex: Wiley: 100-115.
Glanz, M., Klawansky, S., Stanson, W. et al (1996) ‘Functional electrostimulation in poststroke rehabilitation: a meta-analysis of the randomised control trials’ Arch Phys Med Rehab 77: 549-553.
Hyytiainen, H. (2016) ‘Small animal treatment and rehabilitation for neurological conditions’ IN: Animal Physiotherapy – Assessment, treatment and rehabilitation of animals. McGowan, C., Goff, L. (eds) West Sussex: Wiley: 260- 271.
Monk, M. (2016) ‘Aquatic Therapy’ IN: Animal Physiotherapy – Assessment, treatment and rehabilitation of animals. McGowan, C., Goff, L. (eds) West Sussex: Wiley: 225 – 238.
Vallani, C., Carcano, C., Piccolo, G. et al (2004) ‘Postural pattern alterations in orthopaedics and neurological canine patients: postural evaluation and postural rehabilitation techniques’ Vet. Res. Commun. 28 (suppl 1): 389-391.