Wiley the wonder dog

Wiley is a nine year old intact male Golden Retriever who was hit by a car while chasing a ball. He remained at his rDVM/emergency hospital for six days and was then transferred to a neurology specialist where he spent a few days. Deep pain sensation and withdrawal were absent from the right rear limb. The right front limb had weak and incomplete withdrawal on the medial surface. Motor was present on the left front and hind limbs. The neurologic evaluation and diagnostics revealed C4-5 luxation and a possible fracture of C4. Nerve root avulsion was suspected for the right hind limb deficits.

After a few days, Wiley was showing signs of improvement. He was able to move his left side while in sternal recumbency but would not move while supported in a standing position. Conscious proprioception deficits were present in all four limbs. The right front limb had increased tone, reflexes, withdrawal and deep pain sensation. The right rear limb had improved tone and reflexes but deep pain was still absent. Nine days post trauma, Wiley was transferred to the Regional Veterinary Referral Center for in-patient rehab. He had a cervical collar (a no-bite collar) in place to provide stability as well as a urinary catheter. While in the hospital he would receive intense physical therapy daily.

Physical Therapy Evaluation: Day of Admission

Functionally Wiley was dependent on our assistance for everything (even eating and drinking) but would attempt to transition from lateral recumbency into a sternal position (right side down only). He required assistance to maintain this position. When facilitated to stand he could bear weight on his left front and hind limbs. Motor function was present in all four limbs however the right front and rear limbs were extremely weak and he was not able to bear weight on these limbs. It took two people and maximal effort to “walk” him. His right lateral trunk and neck muscles were also extremely weak. Wiley had difficulty looking to the right and his entire body remained curved with a convexity to the right. He resisted being placed on his left side due to the weak right trunk muscles.

Therapy consisted of short, frequent sessions throughout the day. Emphasis was on giving Wiley assistance with all functional positions, transitions and activities such as maintaining a sternal position, moving from lateral recumbency to a sternal position, standing, eating, drinking and walking. The early phase of therapy not only concentrated on functional activities but also pulmonary hygiene and prevention of bed sores. The owners visited frequently and they were incorporated into therapy and educated on how best to handle Wiley. One of the most important devices in getting Wiley up and walking was his seat belt harness. Without the support between his front limbs and around his thorax, he could not be facilitated to walk safely. Wiley’s movement was hindered by the cervical collar as he was not able to engage his neck muscles which are important for recruitment of other musculature. Another important factor was Wiley’s motivation and fatigue. At times he could do significantly more if motivated by food or his owners. In two days, Wiley had made progress however it was very slow and he remained dependent for all activities.

Day 2: Neurology recheck

The neurologist was encouraged by the gains made. There was some concern over the fact that radial nerve deficits remained in the right front limb. The neurologist requested that the urinary catheter be removed and that he continue in-patient therapy. The cervical collar could be discontinued except when being transported.

Day 4

The urinary catheter was removed. Part of Wiley’s therapy consisted of assisted walks outside to eliminate. This proved difficult at first partly due to the amount of assistance he required and awkwardness of his gait. A seat belt harness was used to assist the front limbs and a hind limb harness (placed in front of his hips) assisted the rear limbs. Due to significant curvature of his spine with a convexity to the right, Wiley also needed to lean the right side of his body on the therapist. At this time his right front limb paddled but did not bear weight and his right rear limb did not move during the walks.

Week 2

Wiley continued to improve. Wiley’s owners visited frequently and were involved in therapy sessions in order to learn how to manage and to help motivate Wiley. Therapy consisted of techniques to facilitate and encourage active movement. The amount of assistance was varied in order to improve strength and balance. He began to bear weight on his right front limb and could support his weight on his front limbs without assistance for a few seconds. The right front limb became more functional on walks and only knuckled if Wiley was tired or unmotivated. The right rear limb began to exhibit motor on walks (when Wiley was very motivated) but did not bear weight. Wiley’s motivation (or lack thereof) continued to greatly impact his functional status.

Week 3

The owners took Wiley home for a night however it proved too difficult and they requested he return to RVRC to resume intense in-patient therapy. Wiley continued to make amazing gains. His front limbs required very little support in standing and walking. His right hind limb moved when he was walked and even bore weight when passively abducted. As is common in hind limb paresis, the adductor muscle was the strongest, making the right hind limb scissor and become stuck on the left hind limb. Various techniques and slings were attempted to abduct his right hind limb when walking. When positioned properly, Wiley could stand for five seconds without support, bearing weight on all limbs.

The significant weakness of his right trunk muscles continued to hinder many functional positions and abilities. An important theory to understand is: proximal stability leads to distal mobility.

Wiley is a classic case where without proximal control (trunk, hip and scapular muscles), limb movement was difficult and uncoordinated.

We began to concentrate on strengthening the right trunk muscles. Wiley could not lie in sternal/lateral recumbency with his left side down due to right sided weakness. As indicated before, this was exacerbated by weak right lateral neck muscles. Strengthening of the neck muscles was not performed in therapy due to the cervical injuries present. Pressure sores were a concern as Wiley would flip onto his right side if placed with his left side down.

The underwater treadmill was initiated which required great effort and assistance. Wiley was able to propel all limbs in a reciprocal fashion. He was forced to engage his right trunk muscles more in the water.

Week 4

Wiley could now push himself into a standing position with minimal assistance. When motivated, he stood unassisted for as long as 15 seconds. Therapy continued to focus on strengthening, functional activities and improved endurance and balance. His right trunk muscles were improving however the inability to turn his head to the right significantly limited his functional abilities including positioning and balance.

One month post injury: Neurology recheck

The neurologist was extremely pleased with Wiley’s progress and predicted that he would regain normal mobility over time. Continued therapy was recommended.

Week5:

Wiley was becoming more manageable at home. He required less assistance to descend stairs and walk around the neighborhood to eliminate. The right hind limb was slowly gaining strength in the abductor muscles (outer hip muscles) which made walking easier and less awkward.

Week 6:

Wiley could now ambulate without assistance in his front limbs and minimal assistance at his hind limbs. He was able to stand independently and even take a couple of steps unassisted. Right lateral neck flexion was improving slowly which improved his balance. Wiley tolerated lateral

recumbency with his left side down for a few hours at a time, showing objective gains in the right lateral trunk muscles. He no longer required assistance in the underwater treadmill but did need very high water levels to support his weight. He was now ambulating in the treadmill for 20 minutes two times a day in addition to other therapeutic techniques (including balance activities, ambulation with varied assistance and manual facilitation to improve active movement)

Week7:

Improvements continued steadily. Sling assistance was varied to increase effort required by Wiley. The seat belt harness was still used for front limb support however the hind limb sling was moved forward under the rib cage. This forced Wiley to engage his proximal pelvic musculature (hip muscles). This change also challenged his balance and coordination. Wiley returned home on Thursday for the weekend. His mom called Friday to announce that Thursday evening he had gotten up and walked four steps across the room to see her!

Week8:

Passive range of motion for right lateral neck flexion was allowed by the neurologist. Active strengthening of the neck muscles was also progressed. Wiley still showed significant weakness of his right lateral neck muscles. Functionally he was able to ambulate long distances with little assistance from one handler, stand for long periods of time and transition from lateral recumbency to sternal and get up from the floor; all without assistance. He could maintain his balance in standing while looking around and could walk for 4-5 steps without assistance if on a non-slip floor. Proprioception of his right hind limb was improving greatly and he could catch himself when falling to the right. Wiley also began sitting although this required time and great effort for eccentric control of his hind limb musculature.

Week 10:

Wiley is now able to walk slowly on his own for longer distances (approximately 25-30 yards). He requires constant reminders to go slowly. If he is walking too quickly or becomes distracted, he will fall down. The owner reports that Wiley will now get up and stagger across a room to retrieve a toy. He is also able to circle and bring the toy back to his owner.

The owners continue to bring Wiley for in-patient therapy a few days a week. Most of his days are spent at home and he is making amazing progress. Although he still has a long way to go and the ultimate outcome is unknown, he will most likely continue to improve and be a functional family dog ambulating without assistance.

Barriers continue to be right front limb knuckling and continued weakness of his right lateral

neck and trunk muscles. Wiley also must regain higher level balance and coordination so that he may perform functional activities with distractions or while turning. It is critical to challenge him appropriately to facilitate success rather than failure. This requires constant re-assessments and exercise modification so the proper deficits are targeted.

This case is an example of the type of care and therapy that we provide to patients with severe injuries and disabilities. Thanks to Wiley’s owners’ patience and dedication, he was given the chance to return to the highest functional level possible and will continue to live a happy life.

Morgan Francis, PT, DPT, CCRP