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Care of the Down Dog: Part One

Matt Brunke, DVM, CCRP, CVPP, CVA
Diplomate, American College of Veterinary Sports Medicine and Rehabilitation

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American College of Veterinary Sports Medicine and Rehabilitation

ROSS UNIVERSITY
SCHOOL OF VETERINARY MEDICINE

CHI INSTITUTE
TRADITIONAL CHINESE VETERINARY MEDICINE

IVAPM

IRONMAN
Lake Placid

A little about me... I like to keep busy.

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Objectives
- Who is the down dog?
- Why do we help?
- What can we do to help?
- When does it start?
- Where do we get help?
- How about some case examples?

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Who is the down dog?
Acute
- Dachshunds! (IVDD)
- Fibrocartilagenous Emboli (FCE)
- Vertebral Fractures
- Bilateral CCL ruptures
- Infection – Tetanus?
- Tick Paralysis
- Limber Tail (cold tail)
- Metabolic (subacute)
– Insulinoma/ T4

Chronic
- Degenerative Myelopathy
- LS Disease
- Diskospondylitis
- Neoplasia (multiple myeloma)
- Congenital/Early Developmental
- End stage, multi-site DJD

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Why do rehab?
- Higher chance of complete recovery
- Less risk of complications
- Higher expectations by owners
- 3 month commitment?
- Work in 2 week increments

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Research
Influence of in-house rehabilitation on the postoperative outcome of dogs with intervertebral disk herniation.

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Research
A Review of Fibrocartilaginous Embolic Myelopathy and Different Types of Peracute Non-Compressive Intervertebral Disk Extrusions in Dogs and Cats.

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Thorough PE and expectations
- Signalment, history, chart review
- Full PE – ortho, neuro, derm focus
- Rectal exam
- Vulvar/Prepuce (ticks)
- Take photos/video
- CBC/Chem/T4/UA
- Culture Urine?
- Current Meds?
- Communicate with owner/GP/specialist
- Neuro referral?
- Are they painful?
- Underlying issues?

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Pain Scales – Pick one and use it
Acute
Date
Time

Colorado State University Veterinary Medical Center Feline Acute Pain Scale

Rescore when awake
Animal is sleeping, but can be aroused - Not evaluated for pain
Animal can’t be aroused, check vital signs, assess therapy

Pain Score Example Psychological & Behavioral Response to Palpation Body Tension
0 - Content and quiet when unattended - Not bothered by palpation of - Minimal
- Comfortable when resting wound or surgery site, or to
- Interested in or curious about
surroundings palpation elsewhere

1 - Signs are often subtle and not easily detected in - May or may not react to palpation - Mild
the hospital setting; more likely to be detected by of wound or surgery site
the owner(s) at home
- Earliest signs at home may be withdrawal from
surroundings or change in normal routine
- In the hospital, may be content or slightly unsettled
- Less interested in surroundings but will look
around to see what is going on

2 - Decreased responsiveness, seeks solitude - Responds aggressively or tries to - Mild to
- Quiet, loss of brightness in eyes escape if painful area is palpated - Moderate
- Lays curled up or sits tucked up (all four feet or approached - Reassess
under body, shoulders hunched, head held - Tolerates attention, may even perk analgesic
slightly lower than shoulders, tail curled tightly up when petted as long as painful plan
around body) with eyes partially or mostly closed area is avoided
- Hair coat appears rough or fluffed up
- May intensively groom an area that is painful or
irritating
- Decreased appetite, not interested in food

3 - Constantly yowling, growling, or hissing - Growls or hisses at non-painful - Moderate
when unattended palpation (may be experiencing - Reassess
- May bite or chew at wound, but unlikely allodynia, wind-up, or fearful that analgesic plan
to move if left alone pain could be made worse)
- Reacts aggressively to palpation,
adamantly pulls away to avoid
any contact

4 - Prostrate - May not respond to palpation - Moderate to
- Potentially unresponsive to or unaware of - May be rigid to avoid painful - May be right
surroundings, difficult to distract from pain movement to avoid
Receptive to care (even mean or wild cats painful
will be more tolerant of contact) movement
- Reassess
analgesic plan

Chronic
Tender to palpation Warm Tense
Colorado State University Veterinary Medical Center Canine Chronic Pain Scale

Many signs of chronic pain are non-specific; rule out anxiety, poor general health, and systemic disease as part of a full workup.

Pain Score Example Psychological & Behavioral Postural Response to Palpation
0 - Happy, energetic - Comfortable when resting - Minimal body tension
- Interested in or curious - Stands and walks normally - Does not mind touch
about surroundings
- Responsive; seeks attention - Normal weight bearing on all limbs - No reaction to palpation of joint

1 Subdued to slightly unsettled or Stands normally, may Mild body tension
restless occasionally shift weight
Distracted easily by surroundings Slight lameness when walking Does not mind touch except painful area
Responsive; may not initiate interaction Turns head in recognition of joint palpation

2 Anxious, uncomfortable Abnormal weight distribution Mild to moderate body tension
Not eager to interact with people Moderate lameness when Doesn’t mind touch far away
or surroundings but will look walking away from painful area
around to see what is going on May be uncomfortable at rest Pulls limb away during palpation
affected joint
Reassess analgesic plan
3 Fearful, agitated, or aggressive Abnormal posture when Moderate body tension
Avoids interaction with people standing Tolerates touch far away from
and surroundings - Does not bear weight on affected limb
- May lick or otherwise attend to affected limb when walking - Vocalizes or responds
painful area - Guards painful area by aggressively to palpation of
shifting body position affected joint
- Reassess analgesic plan

4 - Stuporous, depressed - Reluctant to rise and will not - Moderate to severe body tension
- Potentially unresponsive walk more than 5 strides - Dislikes or barely tolerates any
Surroundings - Does not bear weight on limb touch (may be experiencing
- Difficult to distract from pain - Appears uncomfortable at rest allodynia, wind-up, or fearful that
pain could be made worse)
- Will not allow palpation of joint
Reassess analgesic plan
2006/PW Hellyer, SR Uhrig, NG Robinson
Supported by an Unrestricted Educational Grant from Pfizer Animal Health
Additional Comments:

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Canine Acute Pain Scale

Rescore when awake
- Animal is sleeping, but can be aroused - Not evaluated for pain
- Animal can’t be aroused, check vital signs, assess therapy

Pain Score Example Psychological & Behavioral Response to Palpation Body Tension
0 - Comfortable when resting - Nontender to palpation of wound or - Minimal
- Happy, content surgery site, or to palpation elsewhere
- Not bothering wound or surgery site
- Interested in or curious about
surroundings

1 - Content to slightly unsettled or restless - Reacts to palpation of wound, surgery - Mild
- Distracted easily by surroundings site, or other body part by looking around,
flinching, or whimpering

2 - Looks uncomfortable when resting - Flinches, whimpers cries, or guards/pulls - Mild to
- May whimper or cry and may lick or rub away Moderate
wound or surgery site when unattended - Reassess
- Droopy ears, worried facial expression analgesic
(arched eye brows, darting eyes) plan
- Reluctant to respond when beckoned
- Not eager to interact with people or surroundings
but will look around to see what is going on

3 - Unsettled, crying, groaning, biting or - May be subtle (shifting eyes or - Moderate
chewing wound when unattended increased respiratory rate) if dog - Reassess
- Guards or protects wound or surgery site by is too painful to move or is stoic analgesic
altering weight distribution (i.e., limping, - May be dramatic, such as a sharp plan
shifting body position) cry, growl, bite or bite threat, and/or
- May be unwilling to move all or part of body pulling away

4 - Constantly groaning or screaming when - Cries at non-painful palpation - Moderate to
Unattended (may be experiencing allodynia, Severe
- May bite or chew at wound, but unlikely to wind-up, or fearful that pain - May be rigid to
move could be made worse) avoid painful
- Potentially unresponsive to surroundings - May react aggressively to palpation - Reassess
- Difficult to distract from pain analgesic plan

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Inpatient vs. Outpatient
- Down patient – might be better with daily nursing care.
- Back and forth morning and night?

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Inpatient or Outpatient?
- Outpatient – Drop off
- 3-6 times/week
- Work in 15-20 minute sessions, 3-6x a day
- Allows pet to rest, meds, pee/poop
- Gives owner a break
- As they progress – maybe able to work into true outpatient
- Inpatient
- Who is caring for overnight?
- ICU? Wards?
- Weekends?
- Schedule client visits
- 5-6 days/week – Sunday rest? (But keep up nursing care)

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What goes down must get up
- Change recumbency, sides – q 4-6 hours
- Good soft clean bedding
- Try keeping them sternal (during the day)
- Watch for IV lines, urinary catheters, incisions
- Anxiety meds?
– Trazodone? Fluoxetine?

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Thank You
- Matt Brunke, DVM, CCRP, CVPP, CVA Diplomate, ACVSMR
DrMattBrunke@gmail.com DrBrunke.wordpress.com