The Passive Range of Motion exercise or the PROM is a mainstay of the home exercise program. The idea behind this exercise is quite simple: one is to move a joint through a normal or limited range of motion to keep the joint itself and its associated structures healthy. This exercise can be used to keep tissue healthy while one is waiting for healing. These exercises can also be used to increase the joint's mobility towards normal. It is also useful to use these exercises to maintain joint health, including circulation and mobility in the face of degenerative conditions. Although it would be impossible to review range of motion exercises for every joint in the canine body or for every condition where this would be useful. The value of the embedded videos demonstrate the slow methodical motion that seems to work best. We will frequently include these types of exercises in our home animal rehabilitation programs.
Saturday, September 25, 2010
Monday, September 20, 2010
Veterinary Specialty Services, LLC
VSS, LLC is an extension of one of the oldest and most respected specialty animal hospitals in the world. Dr. Steve Steinberg started a referral only hospital in 1977. He has been involved in specialty veterinary medicine since that time and has consulted with some of the largest veterinary corporations and most progressive veterinary universities in the world.
VSS, LLC practices veterinary neurology and animal rehabilitation medicine at VCA/VRA one of the largest referral-only hospitals in the country. We merge our extensive experience, with our state-of the-art equipment, never losing sight of the fact that the patient that you are bringing is one of your best friends. Our tens of thousands of neurology cases over the years never cause us to lose sight of this commitment.
Dr. Steve Steinberg has lectured extensively all over the world including having produced numerous publications. He is considered a pioneer in neurosurgery especially those cases involving brain tumors. Our interest in conservative management of the geriatric neurologic and orthopedic patient is gaining national interest.
Dr. Steinberg lectures on various topics for the Canine Rehabilitation Institute out of Wellington, Florida.
You can find us at 500 Perry Parkway, Gaithersburg, MD 20877
Our phone number is 301-926-3300 and our fax number is 301-977-1308
Please make appointments for neurologic evaluations with our director of Neurologic Services Ms. Yona Severe
Please make appointments for rehabilitation services with our director of Rehabilitation Services Ms. Renee Mills
We see emergencies 24/7 if Dr. Steinberg is in town.
The vast majority of dogs with mild to moderate spinal disease--especially when intervertebral disc prolapses are suspected--do amazingly well with STRICT cage confinement. This is in most cases this is more important than any medications we can put a dog on. Actually, in many cases, medication actually increases movement and increases the recovery time.
So how do you cope with cage confinement? Typically, it’s harder on the owner than it is the dog. But remember—it’s for the best!
How To Cope With Cage Confinement
Below are some tips to get you and your dog through cage confinement:
- The best cages are the fiberglass airline carriers. The floor space should be just large enough for your dog to turn around, but no larger. Extra space can be taken up with a cardboard box or pillow if the cage is too large. Here are two different examples of cages to use. We don't endorse any specific kennel brand. The wire cages are not perfect--animals with paresis in particular can get their feet caught in them—so be cautious.
- Food and water in the cage is best but some animals are too messy and may require these activities occurring outside of the cage.
- The first 48 hours usually set the tone for this confinement. If every time your dog whines you go to them, they will want you sitting there all of the time. Putting them somewhere where there isn’t a lot of activity and foot traffic is usually best.
- Your pet should be restricted to going out-of-doors--no more than three times per day. and that is just to use the bathroom--no exercise!
- A re-examination after the two weeks is strongly suggested. We are very active in canine rehabilitation training and we believe that rehabilitation activities can prevent recurrences.
- Evaluations at each out-of-doors trip to be sure your pet is continuing to improve are very important.
- If your pet isn’t making steady progress and improvement, we should be contacted immediately. Continued improvement should be expected and any loss of progress may be very important. Large changes from walking to paralysis should be considered emergencies. Call us immediately.
For more information, contact VCA-VRA today.
Does Your Dog Have Degenerative Myelopathy?
Degenerative Myelopathy is a diagnosis that no pet owner wants to hear. But with a simple at-home test, you can point to an answer. Of course, it is important to always consult a professional at VCA-VRA if you have any questions.
Signs of Degenerative Myelopathy in Dogs
Being on the lookout is important with this disease—it does not cause pain in your dog, so they won’t actively whimper or cry. Also some of the serious signs—loss of bowl control and the loss of functionality in limbs—do not come until late in the disease. If you notice that your dog is moving slowly, or suspect a spinal problem, here are some things to look out for:
- The condition is slowly progressive and unrelenting
- Your dog begins to drag one a hind limb, followed by a spreading of this asymmetry through a side of their body
- It is unresponsive to the medications that are commonly used for spinal conditions, such as corticosteroids and non-steroidal anti-inflammatory medications
Keeping your dog active is a great method of prevention.
About Degenerative Myelopathy
In 1973 the disease was first described by Dr. Skip Averill, who thought it was a degenerative condition of the mid-thoracic spinal cord. He thought it primarily affected German Shepherds, Collies, and mixes of those two breeds. While clinical signs had been noted years before, it was thought previously to be the result of compression of the spinal cord from ossifications within the dura—described as ossifying pachymengitis. However, in the mid-70’s, it was learned that several other breeds of dogs having similar symptoms.
Although a great deal of anecdotal information was presented on the internet, very little hard data was available to add to the science of this disease. Within the last few years, it became a serious problem in Corgis. Dr. Joan Coates and Dr. Gary Johnson and their co-workers have found a genetic association in this disease that has been found to be statistically relevant.
Unfortunately, the test will only determine if a dog can get the disease. But fortunately, false negatives are virtually unheard of. This means that if one's dog is negative for this disease with this test, our science today tells us they don't have DM.
In addition, a genetic link has been found between the dog disease and Amyotrophic Lateral Sclerosis (ALS)—commonly called Lou Gehrig's disease.
VCA-VRA supports this test. Not because it is perfect--but because this diagnosis is frequently used when a dog has an undiagnosed spinal cord condition. There are other diseases that are progressive and some of them are not fatal. Degenerative Myelopathy, to the best of our knowledge, is always fatal. We encourage owners to perform this simple, at-home test and see if their dog is negative. If so, they should consider further testing to find out whether their dog has a similar-looking neurologic condition.
Resources
For some more information bout degenerative myelopathy, check out these links:
http://www.pnas.org/content/early/2009/02/02/0812297106.full.pdf+html
http://www.caninegeneticdiseases.net/DM/ancmntDM.htm
http://secure.offa.org/cart.html
Friday, September 10, 2010
MENINGIOMA: A DIAGNOSIS WITHOUT CLEAR DIRECTION
Kayla, a 6-year-old spayed female German Shepherd owned by a local veterinarian, presents with a history of recent onset seizures. Although Kayla shows no other signs and her neurologic examination is otherwise normal, a prefrontal meningioma is certainly a consideration. MRI confirms this diagnosis within a few days, and Kayla heads to the surgery table. The tumor is approached through her frontal sinus and a large portion of her right olfactory tract is removed so that there are clean margins. Kayla’s recovery is uneventful and she goes on to run, play and be the wonderful family member she was before this ordeal first started. She never has another seizure and she lived for three years eventually succumbing to suspected tumor regrowth at the age of nine.
Of course, we best remember our successes, but the decision making process surrounding this most common of brain tumors is not so straightforward.
At least 85% of the older dogs that we see with recent onset seizures have a brain tumor. The vast majority of those are meningiomas and those patients that present without other neurologic signs, are most likely to have a prefrontal neoplasm that must be irritative but not affecting critical neural pathways. Most of these dogs present with seizures. These seizures can most often be terminated in the short-run with corticosteroids.
We know that the Golden Retriever is over represented with this particular neoplasm and more often than not, their meningiomas are in this prefrontal location. Although brachycephalic breeds have a higher incidence of brain tumors, they do not often have meningiomas. Boxers often present with brain tumors at a younger age (five to eight years) and typically present with additional signs of intracranial dysfunction such as “head-pressing”, circling, compulsive pacing and behavioral changes as well as seizures.
Although all meningiomas arise from arachnoid cells, there are several types of meningiomas. It is difficult to distinguish between them based upon MRI findings. In cats, meningiomas tend to compress the brain as they grow and their growth is assumed to be quite slow because the severely compressed cortex looks rather healthy once the neoplasm is removed. In dogs, it is far more likely that the meningioma will actually invade the brain tissue itself and for that reason, the tumor is often much more difficult to remove. Although we often state that canine meningiomas are slow growing, the evidence that this is true is anecdotal at best.
As in all things oncologic, there are several treatment options available. Radiation, as the sole therapy, has limited use with this particular tumor type in my opinion. In the few that I have followed, radiation shrinks the tumor somewhat (about 10%) and then it begins to grow again within a very short period of time.
We have placed dozens of dogs on CCNU using a modification of the protocol first described by Dr. Lisa Fulton and me in 1982. Whether this is a good primary protocol is unknown. We do not have any cases where there is a biopsy diagnosis and a follow-up autopsy that shows there is complete tumor remission. Nor, do we have any cases where the follow-up MRI shows complete regression of the tumor. We do, however, have numerous cases that have survived for the entire treatment course of twelve months and beyond. We have a handful of cases where the owner reports modest to complete recovery but, when the MRI’s were repeated, the tumor is unchanged or mildly smaller in size.
Surgical excision of this neoplasm is quite popular among those neurologists that perform surgery. Wide excision, with tumor-free margins, should theoretically be curative. This has not turned out to be the case and in several patients tumor re-growth has been discovered at some distance from the original surgical site. Whether this represents seeding from the original surgical removal, or is the result of the meningeal tissue being specifically prone to forming tumors at this time in the animal’s life, is totally unknown. An even more bothersome aspect of these meningeal re-growths is that the tumor can re-grow at a truly impressive rate. We have removed neoplasms that are only 1 cm3 in volume and tumor re-growth twelve weeks later reveals a neoplasm at the surgical site that is ten times larger. Does this reflect an enhanced growth rate related to some factor involved in the original surgery or was this a fast-growing neoplasm from the onset? These questions remain unanswered.
Over the years and after hundreds of meningioma surgeries, I, in conjunction with the neuropathology department at The University of Pennsylvania, have gone back over dozens of meningiomas to see if there is some association between the behavior of the neoplasm and the histopathologic type of meningioma removed. To date, no hint of an association has been discovered. It is quite remarkable that a meningioma in the same location, presenting with the same clinical signs and the exact same MRI findings, is likely to be one of several different types of meningiomas recognized by the WHO (World Health Organization). The WHO recognizes nine different types of meningioma.
1) Meningotheliomatous
2) Fibrous
3) Transitional
4) Psammomatous
5) Angiomatous
6) Papillary
7) Granular Cell
8) Myxoid
9) Anaplastic
We have also seen no correlation between tumor size and the success rate of any of the treatments. This surprisingly includes cases involving the surgical removal of very large tumors sometimes yielding the best patient response and longest survival times.
We currently are following an 11 year old, German Shepherd that presented with a single generalized seizure. An MRI revealed a pea-sized prefrontal meningioma-like lesion. We discussed surgical removal, but the owner elected to wait and see what happens without treatment of any kind. We repeated the MRI on this dog six months later and the tumor was unchanged in every way. We hope to follow this dog with additional MRI studies and are hopeful that, ultimately, the diagnosis will be confirmed on autopsy.
We have a handful of dogs whose tumor was removed a second time, after confirming they have regrown. We have had a small number of owners ask that radiation or chemotherapy be performed on animals that have had a surgical excision. It is hard to know the impact of these follow-up treatments, when we include a substantial population whose tumor never returns once it is removed. A corollary to this includes the fact that on presentation, the average age of these dogs is ten and they therefore may succumb to other age-related diseases before we actually know how the tumor or the surgical site might behave.
With all of this experience and with so few really dependable facts, the discussion with the pet owner about their best choices is both challenging and extensive. As with any treatment plan, the veterinarian wants to know the percentages when discussing complications and successful outcomes with the client. Although our experience in treating prefrontal meningiomas at VRA extends over three decades and includes hundreds of cases, dependable facts that apply to this very common brain neoplasm have neither surfaced in our collective literature nor our collective experience.
Friday, September 3, 2010
This exercise has this strange name because of the device we used
to use to reinforce this exercise. Bear bells are Velcro straps with a free
hanging bell attached that one can obtain from any camping store. They are to
be placed on one's backpack when one is in the Bear Country so the Bear can
hear you coming. This encourages the Bear to leave before you reach them or if
the Bear is hungry get out the condiments before you reach them. In the same
way, we can use this contraption as a therapy device!
A strap-like device that is placed above the hock or
"ankle" in the dog will generally get their attention and they will
start lifting the limb higher in the leg with the strap. In dogs that drag
their toes this encourages them to lift their limbs higher and we often can
retrain them to have a better less traumatic gait. In our experience, the bell
sound which was supposed to reinforce the change in gait doesn't seem to have
much effect on most dogs and the bell itself seems unnecessary.
We
commonly use Velcro straps that are readily available and also find that
pony-tail scrunchies are excellent for this exercise. There are a large number
of variations on how to use these straps and scrunchies, and we recommend that
our rehab specialists try variations on your dog till we find the most
effective method. Bear Bells is an extremely common home exercise that we
recommend.
As some dogs age they have a tendency to have entrapment of their nerve roots at the caudal spinal canal above their tails. Dogs who are afflicted with this problem may be predisposed to this condition because their spinal canals are particularly narrow at that level. Although this condition represents quite a number of various degenerative changes, these dogs are commonly lumped into the category of Cauda Equina Syndrome. Cauda Equina literally means horses' tail and the end of the spinal canal with its many nerve roots looks very much like a horse's tail. The presentation for this condition is quite variable. Hindlimb lameness or gait abnormalities as well as a weak tail and sometimes a loss of control over urine and stool are most common.
The surgical treatment for this condition has been well described and has a high rate of success, but since many of these dogs are older, a more conservative approach is desirable. Several years ago it was noted in cadavers that when the hind limbs of dogs were pulled forward that the entire lower spinal cord and roots moves as much as three-quarters of an inch. This should come as no surprise to any one who has tried sitting in a chair with their head tucked down against their chest knows that with a straight leg lift one can feel the tug on the spinal cord from one end to the other.
Several years ago in response to this information we initiated conservative treatment for Cauda Equina Syndrome with aggressive tail manipulation. To our surprise we determined that we were experiencing about a 75% improvement rate in cases.
Although the success of this therapy seems to require aggressive manipulation that really should be performed by our rehab therapists on a regular basis, our home program includes straight tail pulls performed by the owner (see the attached movie).
Sit behind the dog and place a hand on the caudal "points" of your dog's pelvis (the ischia) on each side of the anus and pull for five to 10 seconds straight back with quite a bit of force. This should not be painful and should be repeated 4-5 times per session and 3-4 sessions per day is recommended.
The surgical treatment for this condition has been well described and has a high rate of success, but since many of these dogs are older, a more conservative approach is desirable. Several years ago it was noted in cadavers that when the hind limbs of dogs were pulled forward that the entire lower spinal cord and roots moves as much as three-quarters of an inch. This should come as no surprise to any one who has tried sitting in a chair with their head tucked down against their chest knows that with a straight leg lift one can feel the tug on the spinal cord from one end to the other.
Several years ago in response to this information we initiated conservative treatment for Cauda Equina Syndrome with aggressive tail manipulation. To our surprise we determined that we were experiencing about a 75% improvement rate in cases.
Although the success of this therapy seems to require aggressive manipulation that really should be performed by our rehab therapists on a regular basis, our home program includes straight tail pulls performed by the owner (see the attached movie).
Sit behind the dog and place a hand on the caudal "points" of your dog's pelvis (the ischia) on each side of the anus and pull for five to 10 seconds straight back with quite a bit of force. This should not be painful and should be repeated 4-5 times per session and 3-4 sessions per day is recommended.
Thursday, September 2, 2010
Cookie Stretches are one of the best exercises for dogs with spinal problems who are not experiencing acute pain or clinical signs. It has been well documented in man that these kinds of stretching exercises decrease the incidence of back and neck problems and the hope is that those results will carry over to our canine friends.
To start Cookie Stretches one stands behind the patient and stabilizes their pelvis. The idea is to prevent the dog from actually turning and rather stretch the back and neck tissues themselves. Once the pelvis is stable then the dog is encouraged to take a treat from one side then the other in a slow alternating manner. Dogs with back and neck problems will have very little mobility and will not be able to reach all the way back to their hips or tail but with time most dog's flexibility increases quite dramatically.
This is an excellent exercise to perform first thing in the morning before your dog goes out into the yard or for his first walk. As with most rehab exercises, it is best to perform this activity for a short period of time, i.e. a couple of minutes, rather than setting aside a long period of time considering the nature of the dog's attention span. Likewise these exercises are best performed multiple times per day rather than attempting a long single session per day.
Once a significant amount of flexibility is attained, more advanced stretching can be attempted including activities like "sit-ups" and stretching by moving the head through various planes not just side to side.
To start Cookie Stretches one stands behind the patient and stabilizes their pelvis. The idea is to prevent the dog from actually turning and rather stretch the back and neck tissues themselves. Once the pelvis is stable then the dog is encouraged to take a treat from one side then the other in a slow alternating manner. Dogs with back and neck problems will have very little mobility and will not be able to reach all the way back to their hips or tail but with time most dog's flexibility increases quite dramatically.
This is an excellent exercise to perform first thing in the morning before your dog goes out into the yard or for his first walk. As with most rehab exercises, it is best to perform this activity for a short period of time, i.e. a couple of minutes, rather than setting aside a long period of time considering the nature of the dog's attention span. Likewise these exercises are best performed multiple times per day rather than attempting a long single session per day.
Once a significant amount of flexibility is attained, more advanced stretching can be attempted including activities like "sit-ups" and stretching by moving the head through various planes not just side to side.
Wednesday, September 1, 2010
The "Sit To Stand" exercise is one of the most common exercises that we give to our dog owning clients. In so many cases we are working with dogs that have hindlimb weakness. This exercise can be compared to weight-lifting exercises to buiold strength.
The dog is positioned head away from the owners body with the owner kneeling or crouching over the dog. The hind limbs are squared up so that the paw's position on the ground is directly under the dog's hip joints. In small dogs the thumbs are placed over the tops of the pelvis and the pinkie fingers are placed behind the knees. Pressure is placed downward over the pelvis at the same time that the pinkies are pressing on the backs of the knees. This forces the dog to squat and the resistance the dog places against this movement tires the muscles used in standing. Three or four sqats is the correct number to start with and one quickly gets a feel for the number that is takes to tire these muscles. Like most rehab exercises, this one should be performed 3-4 times per day and shouldn't take more than a few minutes each time. Working on this exercise for a longer period of time is counterproductive.
In smaller dogs it often helps to put your "Pinkie" behind the knee to get the stifle (knee) to flex while pushing on the pelvis (hip bones).
In larger dogs it is not possible to position ones Pinkie properly and some pressure can be exerted behind the hamstring muscles. In very large dogs it is often necessary to place one's shoulder over the pelvis to produce enough downward force to cause a squat.
The dog is positioned head away from the owners body with the owner kneeling or crouching over the dog. The hind limbs are squared up so that the paw's position on the ground is directly under the dog's hip joints. In small dogs the thumbs are placed over the tops of the pelvis and the pinkie fingers are placed behind the knees. Pressure is placed downward over the pelvis at the same time that the pinkies are pressing on the backs of the knees. This forces the dog to squat and the resistance the dog places against this movement tires the muscles used in standing. Three or four sqats is the correct number to start with and one quickly gets a feel for the number that is takes to tire these muscles. Like most rehab exercises, this one should be performed 3-4 times per day and shouldn't take more than a few minutes each time. Working on this exercise for a longer period of time is counterproductive.
In smaller dogs it often helps to put your "Pinkie" behind the knee to get the stifle (knee) to flex while pushing on the pelvis (hip bones).
In larger dogs it is not possible to position ones Pinkie properly and some pressure can be exerted behind the hamstring muscles. In very large dogs it is often necessary to place one's shoulder over the pelvis to produce enough downward force to cause a squat.
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