SIGNALMENT: “George” Meyer
Domestic long hair
Life style: House cat
HISTORY: George was adopted at 4-6 weeks of age. He needed to be hand fed kitten milk replacer. He has been generally healthy until three years ago when he was diagnosed by a kidney specialist with chronic renal failure. He is on a prescription low protein diet. He is currently taking Buprenorphine as needed for his back pain and daily lactulose for constipation.
The owner noticed about 1 year ago that George was not jumping up on the furniture as much. Approximately six months prior to the diagnosis, the owner noticed that George was hesitating before jumping. And approximately 2 months prior, the owner noticed constipation and occasional slipping on the hind end. Lactulose improved the constipation but the slipping in the rear progressed to left rear limb paresis with decreased range of motion and muscle atrophy. He also lost one pound. At home he was slightly ataxic in the rear and falling down on smooth surfaces but was still jumping on the couch. George would fall onto the hardwood floors while playing but would slowly get up on his own. Recently, George had a dental with his primary care veterinarian. Shortly thereafter, he started dragging his left rear leg and limping. The veterinarian took x-rays and then referred him to a neurologist. The neurologist diagnosed George with L7-S1 disc protrusion and sacral nerve root compression with rear limb neuropathy. They found gluteal atrophy, plantigrade stance of the left hind limb, decreased hemihopping and hemistanding on the pelvic limbs, decreased cranial tibial reflex on the left and right hind limb, decreased patellar reflex on the left rear. MRI scan of thoracolumbar and lumbosacral spine revealed Type II disk protrusion at L7-S1 disk space with moderate midline sacral nerve root compression. Their diagnosis was chronic lumbosacral disk disease. Nerve conduction testing was done and there were some changes which were most likely secondary to chronic renal disease and age. The options given to treat George were surgery with post op rehab versus long term prescription pain management. The kidney specialist was consulted and concluded that George was an anesthetic risk due to the renal pathology; so medical management was pursued with Buprenorphine on a regular basis. The owner was instructed to discourage jumping at home, carry him up/down the stairs, and 3 weeks of semi-confinement .
EVALUATION: Observation: Lying on the exam table, George was alert and nervous but he did not appear to be distraught. He had visible bilateral muscle atrophy of the pelvic limbs. His Body Condition Score was 4/9. Girth measurements: right thigh 19.5 cm and left thigh 19 cm taken while cat was standing with minimal support and somewhat crouched. Gait Assessment: hard to assess gait because pet is timid and unwilling to move around the exam room. He had a crouched gait in the rear. No obvious knuckling/dragging. The tail was in a neutral position and not limp. Passive Range Of Motion: George had normal range of motion of the pectoral limbs. He was guarding extension of his right coxofemoral joint and seemed uncomfortable with manipulation of this limb. He seemed uncomfortable and moved away at end extension of the left coxofemoral joint. His hocks and stifles had normal range of motion. His lower lumbar vertebrae were less mobile. The lumbosacral region was sensitive to dorsoventral digital pressure and the cat would try to sink/collapse underneath the pressure. Neurological Testing: postural reflexes were hard to assess since the cat was uncooperative. He had normal pain withdraw in the pelvic limbs. The cranial tibial and patellar reflex were a little decreased on the right rear compared to the left. He was reactive to palpation of the proximal aspect of the left sciatic nerve cranial to the ischiatic tuberosity. Bilaterally he had slow CPs of the pelvic limbs with the left worse than the right. Pain Assessment: Overall I rated George at a 6 out of 10 using the pain assessment scale from Mathews, K.A., Pain assessment and general approach to management, Management of Pain, The Veterinary Clinics of North America, Small Animal Practice, July 2000, p. 729-755. The left rear sciatic nerve and sacrum were reactive to palpation and I rated these areas 8 out of 10 on the same pain scale.
GOALS : The client goals were to manage pain and improve the quality of life. The rehab goals were to decrease pain and inflammation, increase muscle mass/strength of the pelvic limbs (taking into consideration his debilitating kidneys disease), increase range of motion, tonify the nervous system, improve and restore functional daily activities, and resolve any compensatory issues.
TREATMENT PLAN: A 6 week rehab treatment plan was designed which consisted of Low Level Laser therapy (icing the areas pre and post treatment to his lumbar vertebrae, lumbosacral joint, coxofemoral joints and proximal sciatic nerve routes along with acupuncture twice a week for 3 weeks, then once a week during week 4,5, and 6. Veterinary Chiropractic once during week 3 and 6. Underwater Treadmill twice a week starting on the third week. Home Therapeutic Exercises during week 3. The exercises chosen would focus on balance and coordination such as Cavalettis, figure 8s, balance board or disk, weight shifts and diagonal leg lifts, standing and walking on foam blocks or cushions/mattress, and peanut physioball therapies. A combination of the above exercises for 5 minutes 1-2 times a day 4-5 times per week and then slowly work up to 10 minute sessions. The owner was instructed to finish with ice on lower back for 10-15 minutes. The pet’s cooperation dictates the techniques chosen. Treatment Plan Progress Exam with the prescriber during week 3 and 6 to re-assess and re-evaluate.
OUTCOME: George tolerated the first three weeks of his therapies and was more tolerant with digital pressure at the lumbosacral region. He allowed gentle palpation, manipulation, and some range of motion of both rear limbs. According to the owner, he became more mobile around the house. He was more willing to walk around the exam room but still had a slightly crouched stance. His CPs in the rear were still slow but equal timing. He was defecating more regularly. On the fourth week of therapies we added hydrotherapy and home therapeutic exercises while tapering off the laser and acupuncture treatments. George went into the underwater treadmill with a veterinary technician certified in rehabilitation. The technician sat on a bench in the tank while guiding the cat donned with a life vest to walk through the six inch water. George was very nervous at first in the UWTM but once he was surrounded by water and the treadmill was turned on he started walking immediately. No dragging of the rear limbs at all. In general his gait was stilted on the right rear and he placed his left rear lighter and leaned off the left rear more. The client was instructed to start some home therapeutic exercises with leg lifts, weight shifts, and walking on foam, pillows, couch cushions, along with post exercise icing on the days that he did not have hydrotherapy.
George continued to slowly improve. The owner reported that he would be somewhat tired after longer hydrotherapy sessions but was much more active once he recovered. Less and less pain medication was required. The more advanced home therapeutic exercises like cavalettis and the physioball were not all that successful because George was a cat and not very motivated to be told what to do. The owner would compromise and play with him by chasing string and a laser light. Also, with our advice she assisted him to go slow up and down the stairs once a day. He was defecating regularly without difficulties so the lactulose was discontinued.
At the 6 week recheck George looked and felt a lot better. He was walking around the exam room tall and proud with the tail up. He still had a stilted gait in the rear but he was definitely less ataxic and more coordinated. His thigh measurements were 20cm on the left and 20cm on the right. No more pain at the L-S junction. He had better overall range of motion of his coxofemoral joints but was still tight on end extension of his left hip. His CPs in the rear were not as slow and more even. The sciatic nerves on both sides were calm when palpated. His pain score was 2 out of 10. He had gained two pounds since the initial visit.
At the end the client, my staff, George, and I were very happy. Unfortunately, George’s kidney values continue to increase and he will eventually succumb to the chronic disease. But, at present his quality of life is great for an old man!