Monday, June 14, 2010

The Veterinary Rehab Business

You wake up. Your not sure of where you are. The nurse asks if you would like some juice. Expecting the worst, your just-operated-upon knee doesn't feel bad at all. Of course, once the local anesthetic wears off things will be different. What's in the immediate future, one word, Physical Therapy! Woops; that's two words but in veterinary medicine we have to use just one word. The word Rehabilitation or Rehab for short.

Some wonderful Physical Therapists and forward-thinking Veterinarians, have been exploring these reparative techniques for treating our companion animals for quite a few years. While this form of treatment has become routine in human medicine, this aspect of veterinary medicine has really only come into its own over the last decade or so.

I have been fortunate enough to take numerous classes at The Canine Rehabilitation Institute(CRI) of Wellington, Florida.

While rubbing elbows with extremely knowledgeable and dedicated Physical Therapists who have decided to treat companion animals, my eyes were opened to an entirely new way of examining and healing. The basis of any approach to an animal patient is having the correct diagnosis. The diagnostic skills of the veterinary rehab specialist extend the scope of tentative diagnoses well beyond what was available to me in veterinary school. Likewise, the approach to treating even the most common companion animal diseases evolves from a completely different direction and incorporates many techniques, unheard of in the world of traditional veterinary medicine.

Many times the disease states we are trying to improve with rehab are the result of neurologic dysfunction. Therefore, a merger of skill sets led me to the faculty of CRI. I teach veterinary neurology, incorporating my new found knowledge of animal rehabilitation. After more than 35 years practicing veterinary neurology and lecturing on various topics in veterinary neurology all over the world, this wonderful collaboration was new, exciting and more than anything, rewarding.

We started applying our new found knowledge to my neurology patients that were recovering from surgery. This naturally extended to encompass a much larger group of patients....Those that are older, who have lost neurologic function that aren't good surgical candidates no matter what the diagnosis. We have also focused on those young patients where surgery for one reason or another isn't an option. All of these animals are beloved family members and just need a little help to get through the day in the most pain-free and efficient manner. The goals may be small, getting up stairs unaided, getting in or out of the family car, going for hours without urinary or fecal accidents. Of course, the approach to the athlete or working dog are quite different and require different standards. Once everyone agrees on the goals and they are there in front of us, our dedicated team of Rehabilitation Specialists, under my guidance, directs our efforts to get these patients to these desired endpoints. Weeks of slow progress, so often ends in the most rewarding of success stories.

After building a brand-new veterinary facility with an outdoor work area, a dry rehab area, and a wet rehab space, it was only natural to explore similar areas of recovery in the orthopedic realm. The idea is that by increasing strength, improving range of motion, controlling pain and inflammation with individualized plans for each patient, we can improve their response to traditional treatment by decreasing the recovery time and by improving the recovery outcome. As with the neurologic patients, we are exploring the many options for those patients where surgery might be the best choice but is not a consideration. Our approach is all about balance and quality of life issues.

Can there be a more rewarding sentence, " For the first time in years, my best friend wagged his tail and effortlessly climbed up on the sofa next to me to help me read a book"?

Thursday, June 10, 2010

CCNU and Treating Canine Brain Tumors

On December 23, 1971, President Richard Nixon signed the National Cancer Act. This was soon designated as our national "War on Cancer". This act opened the door and financed a massive review of drugs synthetic and natural that might produce a positive result in the treatment of cancer. In response to this effort a massive amount of review material was generated that was available to the public at the NIH library in Bethesda, Maryland.

As we solidified our meager knowledge about brain tumors in dogs, Dr. Lisa Fulton, our gifted oncologist, and I realized that if we were going to attack these tumors, we would have to better establish the same multi-modal techniques available in human medicine. We had been performing CT scans since 1977 and MRI's since 1984. Being very selective with our cases, we were able to define intracranial masses with a new degree of certainty. We approached tumor removal and biopsy with trepidation but early post-operative surgical results were quite encouraging. Realizing that man and dog were quite different when surgical planning was on the table was quite a fascinating lesson. Radiation therapy was not readily available but was developing in the private veterinary sector quickly. It was available enough for us to call upon it if we thought this was the best choice. What we were missing was that chemotherapeutic agent that penetrated the blood brain barrier with manageable toxic side effects. All of the currently available agents did not penetrate this biological impasse that so carefully guarded the brain's home.

Fortunately President Reagan's act to remove cancer from the face of the earth put a huge amount of readily available knowledge in one place. Whenever I could get away from my growing Specialty Hospital (Veterinary Referral Associates, Inc., in Gaithersburg, Maryland), I went down to the hallowed halls of the NIH library in Bethesda and read article upon article about medicinals of all types, many of which would be explored and abandoned and never be heard of again. During one of these sojourns, I came across a drug called BCNU or Carmustine. Bis-chloronitrosurea is a nitrosurea that is actually related to "Mustard Gas" an agent used by the Germans against the British and French during World War One. Mustard Gas' nephews and nieces would in a peculiar turn of events become key players in the "War on Cancer"? There in Bethesda, I found that some of the original research on BCNU was performed on the dog and there was substantial information that it crossed the blood brain barrier. Not only were these effects exactly what we were looking for but it also had an oral analog, CCNU or Lomustine that could be administered in pill form. To develop treatment protocols from the available research was kind of like trying to guess how much weight a bridge can hold by jumping up and down upon it. The fact is that most of the dogs we wanted to treat were going to die in a few months without treatment and the owners were always made aware of our ignorance. Starting in about 1983, Dr.Fulton and I determined a dosage protocol that was well tolerated and at least by anecdote seemed to extend our patient's lives. The real breakthroughs were to come when we had biopsy material and long-term followup, with autopsies, once our patients died. In the world of veterinary medicine these numbers are always small. Our ability to pull multiple centers together to get real statistically relevant numbers has been stymied by our culture.

In 1990, Lisa and I published the first paper on the use of CCNU in the dog. It continues to be one of numerous primary chemotherapuetics used in dog cancer treatment today. It has a significant place in the treatment of canine brain tumors.

We have yet to erase the frustration of treating canine brain tumors but we certainly have one more bullet in our arsenal.

Tuesday, June 8, 2010

Securos Veterinary Tools

In 1976 I was trained to perform spinal surgery in dogs and cats by the flamboyant and very skilled Dr. Eric Trotter of the veterinary teaching hospital at Cornell University in Ithaca, NY. I was ending my neurology residency at the University of Pennsylvania and Cornell was one of the premier institutions for veterinary neurosurgery. Little did I realize that in just another year I would be opening one of the first private practice veterinary specialty hospitals in the country and the lessons I learned in Ithaca would be indispensable.

One of the procedures I learned was how to perform a cervical ventral decompression. In this procedure, once the trachea and esophagus are moved out of the way, one is looking right at the bottom or ventral aspect of the cervical spine. Once the muscles are removed a high speed drill is used to carve a slot through the intervertebral disc and adjoining vertebrae and then comes the fun part. An opening is made into the spinal canal and through this tiny opening the protruded disc material is removed. The surgical approach can be quite deep, as much as seven inches sometimes. The hole carved into the bone gives one a 1/2 inch to a 3/4 inch slot to maneuver this offensive, abnormal disc material, out of the hole so it will cease to irritate the spinal cord and the associated nerve roots. This abnormally positioned material which originally was part of a once healthy intervertebral disc, produces one of the most painful conditions in the world of the dog.

I can't remember what instrument Dr. Trotter used for this procedure, but after I performed several hundred of these surgeries I found a dental instrument that was just perfect for teasing the abnormal disc material safely out of these tight, deep quarters. Having hundreds of these procedures in my future (by now I have performed several thousand cervical decompressions) I purchased about a half dozen of these perfect dental pics.

The pics had two ends and over the years the instruments were either misplaced or an end broke off because they weren't of the finest steel. Twenty some years later, I found myself with just one single pic with only one working end and the manufacturers of this instrument out of business. In earnest, I bought instruments that looked similar from catalogs and off the exhibit tables of our national shows. Only trying these supposed replacement instruments, did I realize that the predicament I was in was more serious than originally thought.

Along comes a gregarious and passionate tool maker/artist Harry Wooton. Harry and I met at a surgery conference and ended up at dinner together arranged by a mutual friend. Harry was the President of a veterinary company, Securos,, that designs instruments for the veterinary orthopedic market. Harry shared his passion for design at dinner and when I described the instrument that I could not find, he assured me he could make it to my exact standards. With giddiness, I started imagining slight changes I might make to the "perfect instrument" that just moments before was irreplaceable.

When I expressed my concern about allowing this one-of-a-kind instrument out of my sight, Harry assured me if I overnighted it to him he would copy it and I'd have it back in just two days. This became the only hitch in our relationship. The instrument wasn't back in three days and now I was worried. When I called Harry with trepidation, he told me he didn't think he could do the instrument justice copying it in the office so he had sent it to Germany for a better reproduction, my heart sank. I envisioned every nightmare that ended with the irreplaceable becoming the irretrievable.

Not all nightmares come true. Harry's team of engineers went into high gear and reproduced this instrument with my exact recommendations, making this beloved instrument even more perfect. A few prototypes later, I now have six of the most perfect instruments for this delicate procedure. They fit my hand and my need perfectly. Harry's the best.

Monday, June 7, 2010

Brain Tumors in Dogs

After holding my breath and removing my first brain tumor from a dog in 1982, it is worth taking pause and reflecting on what we have learned during these 28 years and several hundred brain tumors later. One really big issue is that dogs aren't people. They probably don't have right brains and left brains as is common to man. This difference is critical as information in the dog is most likely stored in both hemispheres. The ability, well recognized in young children, for one area of the brain to take over for another may stay with dogs their entire lives as both brain hemispheres aren't restricted as they are in adults. In man, the need to fit language skills somewhere has often been incriminated for this hemispheric commitment. This and the fact that dogs are called upon to perform in a more limited way, for example no opposable thumbs, can't read a book; make our surgical decisions in dealing with the dog brain much more flexible. Because dogs can perform adequately, often with just minimal deficits, with large portions of their brains missing, the approach to a more radical surgery in the dog is often acceptable where this wouldn't be the case in man. The vast majority of dog brain tumors are primary and have not arisen elsewhere. The large majority of dog brain tumors do not metastasize elsewhere. Therefore with all of these attributes that distinguish our considerations in dealing with the dog brain, a wide surgical excision even in the most extensive hemispheric lesions has yielded in many cases very acceptable results. The MRI's attached and the short videos are all from the same 10 year old, castrated male boxer. The tumor seen on the attached MRI's was removed with wide margins. The tumor was an Oligodendroglioma, a highly malignant tumor in the dog but if removed totally, can yield some excellent results in selected cases.

Here is this dog 8 weeks after surgery.

Immediately post operatively these dogs are quite incapacitated but with time other areas of the brain take over and within weeks they frequently make a very acceptable recovery.

Eight months after surgery this same 10 year old Boxer is doing great. We will continue on his chemotherapy protocol for approximately 12 months. The video below is at his eight month checkup.