and neurological conditions

PROCEEDINGS OF THE NEW ZEALAND VETERINARY NURSING ASSOCIATION ANNUAL CONFERENCE 2017 29

Rehabilitation is the process of helping an individual achieve the highest possible level of function, independence and quality of life following injury or illness.

The veterinary nurse plays a pivotal role in the success or failure of an orthopaedic or neurological surgery.

Oftentimes, surgery is the easy bit. The aftercare is the challenge.

Aftercare of orthopaedic patients can be broken down into:

1. Immediately post-operativea. Pain management:

• Multimodal analgesia.• Local anaesthesia.• Epidural.• Continuous rate infusion (CRI).• Opioids.• Nonsteriodal antiinflammatory drugs (NSAIDS). • Dermal patches.• Monitoring Pain Scores.• Glasgow Pain Scale.

b. Wound care:• Infection control.• Limit swelling.• Limb immobilisation (sometimes).• Cryotherapy.

c. Patient position:• Dermatitis.• Pressure sores.• Respiratory care.

d. Ambulatory assistance:• Sling walking.• Frame walking.

e. Urination and defecation:• Urinary catheterisation.• Bladder expression.

f. Nutrition:• Voluntary intake.• Assisted feeding.• Tube feeding.

2. Short term rehabilitation:• Encourage early weight bearing.• Encourage healing.

3. Long term rehabilitation:• Full return to function.

Post-operative management of orthopaedic and neurological conditions

Damian Chase BVSc MANZCVS DipECVSSpecialist in Small Animal Surgery

Immediate post operative managementPain managementAppropriate analgesia is best achieved via multimodal analgesia.

The following recommendations are based on what I use commonly at Veterinary Specialist Group (VSG) and are not an exhaustive list. The dose rates given are for dogs.

Local anaesthesia: • RUMM block (Radial, ulna, median, musculocutaneous

nerves), sciatic block, dental blocks, intra-articular blocks, wound block, splash block, epidural, lignocaine patch, lignocaine cutaneous gel.

• Lignocaine (1-2%) or bupivacaine (0.5%) 2mg/kg (maximum dose).

Epidural:• Opiod or opiod/bupivacaine combination.• E.g. Morphine 10mg/ml (preservative free) 0.1mg/kg

(0.1ml/10kg). Make up to 2ml/10kg with saline or with local anaesthetic.

• Bupivicaine or lidocaine 0.5-1ml/10kg (max 6ml).

CRI:• Fentanyl: 2-6mcg/kg/hr (60mcg/kg max).• Lignocaine: 1-2mg/kg/hr.• Ketamine: 0.1-0.5mg/kg/hr.• Combination of the above.

Opiods:• Pure agonist vs partial agonist.• Methadone: 0.1-0.3mg/kg intravenous (IV), intramuscular

(IM), subcutaneous (SQ).• Morphine: 0.1-0.5mg/ kg IV, IM, SQ. Can cause nausea.• Buprenorphine: 0.01-0.02mg/kg IM, SQ partial agonist/

antagonist.• Fentanyl CRI.

NSAIDs:• Many available.• Mainstay of treatment.• Care with renal disease or hypotension.

Dermal patches:• Fentanyl (variable efficacy due to differences in absorption

between dogs).• Spot on (Recuvyra®) may be available soon.

Other drugs:• Many other adjunctive drugs. Some examples include:• Paracetamol: 10mg/kg BID.

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PROCEEDINGS OF THE NEW ZEALAND VETERINARY NURSING ASSOCIATION ANNUAL CONFERENCE 201730

– Useful and very safe in dogs. FATAL IN CATS.– Can be used in combination with NSAIDs.

• Gabapentin: 10-60mg/kg q8-12hr PO.– Useful for Neuropathic and chronic pain.

• Tramadol: 2-5mg/kg TID PO.– Uncertain efficacy in dogs.

• Amantadine: 3-5mg/kg SID PO.– Useful for chronic pain.

• Codeine: PO.– Only 4% gastrointestinal (GI) absorption. Almost

certainly not effective in dogs.

Monitoring painMonitoring of pain is vital, especially in large clinics with multiple personnel to ensure adequate analgesia and to avoid over dosage and dysphoria. Monitoring pain in animals is also problematic. There are a number of pain scales available to try and make observations more objective. The pain scale in most common use is the Glasgow Pain Scale (see page 35).

Wound CareInfection controlIn addition to hospital infection control measures specific care should be taken with surgical wounds;• Covering all wounds prior to leaving theatre, with an

adhesive dressing such as primapore.• Wearing examination gloves when changing bandages and

sterile gloves if touching wounds.• Appropriate hand hygiene.• Appropriate use of antibiotics.• Appropriate kennelling. Don’t kennel the orthopaedic

patient next to the patient with diarrhoea.• Preventing self-trauma. Use Elizabethan collars where

appropriate.• Keep surgical wounds covered with an adhesive dressing

for the first three days if possible. After three days the wound should have a fibrin seal and be more resistant to infection.

• Reducing hospitalisation times. The risk of a post-operative nosocomial infection nearly doubles with every extra day spent in hospital.

Limit swellingCryotherapy. This is usually used for three to four days post-operatively. Wrap an ice pack (e.g. a freezer gel pack, bag filled with crushed ice or frozen peas) in a tea towel. Apply to the surgical area for five to ten minutes. Repeat three to four times a day. This will help with any swelling and provide some pain relief too. Frostbite could occur if the ice pack is not wrapped or left on too long.

Cyrotherapy can be more effective than bandaging for reducing post op swelling after certain surgeries such as tibial-plateau-leveling osteotomy (TPLO).

BandagingCasts, splints and bandages are used support, protection, pressure and immobilization. Bandages, casts and splints are most useful in the distal limb. They are rarely indicated for use proximal to the stifle or elbow.

Complications can be serious if not identified and dealt with early. Pressure sores can cause high morbidity and be very costly to treat. For this reason, Bandage application technique is very important and bandages are rarely left in place for more than five to seven days without changing them.

Unfortunately, our patients cannot tell us if there is abnormal pressure or pain from a splint so we must be very aware of behavioural patterns that can indicate a problem.

Owners must be made aware of proper bandage care. It is useful to give them explicit written instructions:

Owner bandage care instructions:• Bandages, splints and casts can cause significant

complications.• Check the bandage at least twice daily.• Check for signs of loosening or slippage of the bandage.• Ensure there is no wound discharge through the bandage.• Check for any swelling, sores, redness at the top of the

bandage.• Ensure that the toes are not swollen or causing discomfort.• Get the bandage checked or changed by your vet or vet

nurse every three to five days.• Use the Elizabethan collar if one has been provided.• If being lead walked outside a plastic bag should be placed

over the bandage to keep it clean and dry. This should be removed when inside.

Contact the clinic immediately if:• The dressing becomes soiled or wet.• You notice a foul smell or discharge from the bandage.• Your pet starts to show undue interest (chewing, etc) in the

bandage.• The bandage slips down the leg.

Patient positionFor recumbent animals, it is important to manage their position appropriately.

If an animal remains in one position for an extended period, a number of problems can arise.

DermatitisDermatitis can occur due to faecal and urine scalding. This can be managed by grooming, clipping hair and bathing around perineal region, appropriate bladder management, prompt removal of soiled bedding and use of incontinence sheets. Cleaning of dermatitis should be done with a dilute chlorhexidine solution followed by drying and application of a barrier cream.

Pressure soresPressure sores (decubital ulcers) can occur surprisingly quickly in recumbent animals, or under dressings. These can be very serious and may require surgery to repair. Avoidance of pressure sores is vital and involves appropriate use of soft bedding and orthopaedic mattresses. Appropriate padding around pressure points (inflatable rings or padded doughnuts) and turning the patient every four hours.

Respiratory careRecumbency can cause atelectasis and aspiration pneumonia,


especially in neurological patients. Respiration rate and pattern should be monitored every four to six hours and temperature taken more than once daily. In addition to regular turning of the patient, eating and drinking should only be performed in sternal recumbency and the animal kept in sternal for 30 minutes after feeding. If there is any suspicion of pneumonia this should be treated promptly with appropriate antibiotics, nebulisation and coupage.

Ambulatory assistanceIn most cases, animals should be encouraged to ambulate. This is a vital part of rehabilitation.

For small to medium sized dogs sling and harness walking can be performed with two people.

A help-em-up harness is very useful for this. In larger dogs a walking frame is necessary to enable safe and comfortable manipulation of the patient.

Urination and defecationAs a general rule, a recumbent patient will be unable to effectively urinate. This is especially true for neurological patients.

Bladder assessment should be performed three to four times daily. Palpation for bladder size before and after urination. The amount and quality of urination should be accurately recorded.

Spinal injuries may have urinary incontinence due to an upper motor neuron or a lower motor neuron bladder.

Upper motor neuron bladder• Difficult to express.• Risk of bladder overdistension & damage to bladder wall.• Urine leaks out once the pressure within the bladder

exceeds that of the urethral sphincter, this is not the same as voluntary urination.

Lower motor neuron bladder• Reduced tone of bladder and urethral sphincters (both).• Easy to express.• Difficult to assess if bladder is empty.• Constantly ‘dribbles’ urine, this is not the same as voluntary

urination.• High risk of developing urinary scalds.

If an animal is able to urinate voluntarily it should be encouraged to do so. With appropriate ambulation and posturing.

Manual expression can be used for lower motor neuron bladders, or for animals that can urinate but have difficulty posturing. Manual expression may be difficult and dangerous for animals with an upper motor neuron bladder. It can be very uncomfortable for a patient.

Urinary catheterisation is commonly used in these cases. This can be performed by intermittent catheterisation or by an indwelling urinary catheter.

Intermittent catheterisation is easy to perform in male dogs but difficult in female dogs.

Indwelling urinary catheters are well tolerated. Foley catheters can be easily placed in male dogs but placement in a female dog usually require sedation or general anaesthetic (unless paralysed) and requires a great deal more skill.

Catheters should be placed and handled in a sterile fashion, the risk of a urinary tract infection is high with an indwelling urinary catheter. Urinalysis (dipstick and sediment exam) should be performed every two to four days, whilst the catheter is in place and culture of the urine or catheter tip performed after removal of the catheter. Antibiotics are routinely avoided when an indwelling urinary catheter is in place to reduce the risk of a resistant bacterial infection.

NutritionIt is well recognised that nutrient deficiency in critically ill animals has serious deleterious effects. These include a poorer recovery from surgery, decreased healing, decreased immune function and prolonged hospitalisation when compared to adequately nourished patients. Continued malnutrition will also have serious deleterious effects on the renal, pulmonary, cardiovascular and musculoskeletal system, which can ultimately lead to death.

Unfortunately it is common for malnutrition to develop in the recumbent patient. These animals often have an altered pattern and efficiency of nutrient use, due to physiological stress and the disease process. There is also often marked decrease in voluntary food intake due to concurrent factors such as pain, fear, side effects of medication and gastrointestinal dysfunction. It is important not to overlook the nutritional needs of the patient whilst focusing on other life-threatening medical or surgical problems.

Normal dogs and cats require around 50-100 ml/kg/day of water to maintain hydration. This requirement will vary depending on the type of food consumed, the level of activity and the environmental conditions. This requirement may be primarily supplied parenterally (intravenously) with enteral support in the early stages of the nutritional plan.

The exact energy requirements of small animals during illnesses are variable and poorly defined. For most orthopaedic or neurological patients the Resting Energy Requirement (RER) is used.

RER = 70 x (Body weight kg)0.75 kcal/day for dogs

40 x (Body weight kg)0.75 kcal/day for cats

From a practical perspective, most major animal food manufacturers produce diets designed for critically ill patients, for example the Hill’s™ Urgent Care a/d diet and Royal Canin® Convalescence Support diet. Feeding charts supplied with these foods allow rapid estimation of the appropriate level of feeding required with appropriate adjustments to the individual patient. These foods have the advantage of being highly palatable, balanced (in fat, protein, carbohydrate, vitamins and minerals), moist and easy adaptable to most feeding techniques. They are also nutrient dense which allows feeding smaller volumes compared to standard foods.


Voluntary food intakeNormal voluntary feeding is the least stressful method of feeding and to encourage this, a high quality palatable diet is offered. The diet is warmed to body temperature and must be fresh. It is best to offer small amounts on regular occasions and it is important to record daily intake/refusal. Hand feeding will often increase food intake. Offering diets to inappetent patients can be labour intensive, as it often requires patience and persistence. Changing the diet according to the individual requirement/taste of the patient may be required (e.g. offering oily fish to cats). Awareness of the environment of the animal so that stressors are minimised is important in small animals. This is essential in cats where stress with cause anorexia. Using syringe feeding to initially force-feed a patient may jumpstart the appetite (but beware aspiration pneumonia if decreased consciousness), but should not be relied upon as a sole technique to feed.

Often early treatment and stabilisation of a patient will re-establish normal appetite and if this rapidly occurs, no further nutritional support may be necessary.

Appetite stimulationThis may improve food intake in the short term. Use of diazepam in cats (0.05-0.4mg.kg per dose intravenously) usually will rapidly stimulate appetite, although the effects are short-lived. This seems to work best in those cats with anxiety-related anorexia. Cyproheptadine (Periactin) is

another option as it acts as an anti-nausea agent and appetite stimulant. It is administered 30 minutes before feeding two to three times a day (2mg/cat). A safer newer alternative in cats and dogs is mirtazapine (Zirpin). This is a tricyclic antidepressant and may help with anxiety related anorexia. Cats 3.75mg/cat PO q72hrs. Dogs 0.6mg/kg PO SID.

Beware over-reliance on appetite stimulants. Continue to monitor food intake per day and ensure this is satisfactory. Early use of the tube feeding is much better than delay while waiting for response to drug.

Assisted enteral feedingThe optimal site for delivery of nutrients into the gastrointestinal tract (GIT) is one that uses the simplest method with the least contraindications and utilises as much of the GIT as possible. It also depends on the length of time support is required, the patient’s neurological/behavioural state, the safety of using sedation or general anaesthesia and the clinician’s expertise and equipment available.

Most feeding tubes are available commercially and are made of polyurethane or silicone. Older PVC tubes are best avoided as they are more irritant to patients and tend to stiffen when exposed to gastric juices. Silicone is probably best tolerated as it is softest and more flexible, but can sometimes be more difficult to manipulate (chilling the tube before placement may increase stiffness). Both silicone and polyurethane are

Tube type Advantages Disadvantages Contraindications ComplicationsNasoesophageal Easy to place.

No sedation required.Low cost.

Narrow tube.Short-term feed (<10days).Patient discomfort (may lead to inappetence).Easily dislodged (require Elizabethan collar).Can be dislodged by vomiting.

Require normal nasal cavity, pharynx, oesophagus.Vomiting.Coma.Lack of gag reflex.

Epistaxis during placement.Development of sinusitis/rhinitis.Tube-clogging.Inadvertent placement in airway.Dislodgement.

Oesophagostomy Excellent for long-term nutrition (several weeks).Easy to place in cats and small dogs.Minimal discomfort.Allows eating.Owners find easy to use.Can remove immediately.

Require short general anesthetic.Placement slightly more difficult in large dogs.Can be dislodged by vomiting.

Vomiting.Oesophageal problems.

Inadvertent placement in perioesophageal tissue/airway.Ostomy infection.Dislodgement.

Gastrostomy Excellent for long-term (several months if properly maintained).Used if oesophageal problem.Minimal discomfort.Allow eating.Owners find easy to use.

Require general anaesthetic and specialized equipment or laparotomy.Needs to stay in place for 10-14 days (to form adhesion).

Gastric problems.Upper intestinal/ pancreatic problems.

Ostomy infection.Dislodgement – risk peritonitis if earlyleakage of gastric contents into peritoneum or stoma site.

Enterostomy(Jejunal feeding tube)

Used if major problem of upper GIT (stomach, duodenum).Severe pancreatitis.

Require general anesthesia and laparotomy (difficult placement).Narrow tube.Continuous rate infusion.Special pre-digested diet.Intensive care.Expensive.

Intestinal dysfunction. Peritonitis.Ostomy infection.Dislodgement.Obstruction.Discomfort.


long lasting in-situ. Tubes are generally measured in the ‘French’ unit (1Fr = 0.33mm).

The following table lists the various options for tube feeding and the advantages and disadvantages of each option:

Short and long term rehabilitationShort and long term rehabilitation, including injury specific exercises, are best achieved by structured physiotherapy with a registered veterinary physiotherapist. At VSG we try to have a physiotherapy assessment immediately post-surgery.

PhysiotherapySome basic home physiotherapy may include:

Cold TherapyThis is usually used for three to four days post-operatively. Wrap an ice pack (e.g. a freezer gel pack, bag filled with crushed ice or frozen peas) in a tea towel. Apply to the surgical area for five to ten minutes. Repeat three to four times a day. This will help with any swelling and provide some pain relief too. Frostbite could occur if the ice pack is not wrapped or left on too long.

Heat TherapyFrom four to five days post-operatively. Apply a wheat bag, warm water bottle or similar, to regional muscles (but avoid the surgical site itself) for five to ten minutes prior to beginning massage. Repeat three to four times a day. This will increase muscle blood flow to help with the following massage therapy. Heat should not be applied to any swollen or red areas as this may cause increased pain. Ensure that the heat pack is not too hot.

MassageThis should follow heat therapy. Begin by gently stroking the affected area using gentle pressure and gently kneading the muscles surrounding (but not including) the surgical site. For limbs, massage should be performed in an upward direction (beginning at the toes and working your way up the leg). Gently increase the intensity and duration of pressure placed on the limb as the animal’s tolerance increases. Massage can be repeated two to three times daily and should precede passive exercises. Massage should never be painful; stop if there is any concern.

Passive ExerciseThis should be performed three to four times daily following heat and massage therapy. This should only be performed to the comfort level of the animal and no further. Place hands above and below the affected joint and gently flex and extend the joint while supporting the limb. Hold the stretch for 15-30 seconds and then relax. This can be repeated 10-20 times per joint, per session. With time, the range of movement and the animal’s compliance should gradually increase.

HydrotherapyThis may be a fantastic way for the animal to exercise actively without worrying about the strain or stress put on the affected limb, once sutures are removed.

Post-operative exercisePost op confinement is vital for most orthopaedic and

neurological conditions. However early weight-bearing is important and encouraged. There is however a fine balance between too much and not enough early weight-bearing.

The following exercise program can be modified to suit most animals in conjunction with physiotherapy.

For example, an animal with a routine tibial plateau leveling osteotomy might stay at exercise level six for six weeks’ post-surgery. If they are doing well at six weeks post-surgery, and radiography demonstrates satisfactory healing then they can gradually increase exercise by one stage every one to two weeks until they are back to a normal exercise pattern.

Above: hydrotherapy pool.

Above: exercise with swiss ball.


Post operative exercise programme

Grade Objective Instruction

0 Normal exercise Free exercise pattern.Regular; on and off lead, all terrains.Contact with other dogs ok.

1 Supervised free exercise Free exercise off lead with owner keeping visible contact.Limit jumping opportunities.Contact with other dogs handled carefully.

2 Supervised/controlled free exercise Controlled off lead with owner close to dog.Sessions 30-60 mins max, Flat terrain best, limit jumping..No contact with other dogs off lead.

3 Extended lead exercise (hill) All exercise on extended lead.Sessions 30-60mins, steep slopes on short lead.Contact with other dogs on lead.Limit jumping.

4 Extended lead exercise (flat) All exercise on extended lead.Sessions 20-40mins.Short (20 metres) often (three – four times daily), avoid sloping terrain.Contact with other dogs on lead.Limit jumping.

5 Controlled lead exerciseHigh level

Dog on normal lead at all times outdoors.Sessions 15-30 mins, frequent two to four times daily.Contact with other dogs ok if control.Can manage stars if on lead.Limit jumping.Off lead in house.

6 Controlled lead exerciseMedium level

Dog on normal lead at all times outdoors.Sessions 10-15 mins, Frequent three to four times daily.Contact with other dogs ok if control.Avoid stairs if convenient.No jumping.Off lead in house.

7 Controlled lead exerciseLow level

Dog on short lead at all times outdoors.Sessions 5-10 mins, Frequent three to four times daily.Avoid contact with other dogs.Avoid stairs.No jumping.Off lead in house with care.

8 Assisted mobility Confined to small space.Limited walking with sling in place and short lead.No stairs or jumping.No contact with other dogs.

9 Assisted mobility (low impact) Confined to kennel / small space.Allowed to walk for toilet requirements only with sling in place and full support .

10 No activity Confined to kennel or similar small space.Carried or moved with full support for toilet requirements.Passive manipulation of joints.

SHORT FORM OF THE GLASGOW COMPOSITE PAIN SCALE

Dog’s name _______________________________ Hospital Number __________ Date / / Time Surgery Yes/No (delete as appropriate) Procedure or Condition_____________________________________________ ______________________________________________________________

In the sections below please circle the appropriate score in each list and sum these to give the total score.

A. Look at dog in Kennel Is the dog?

D. Overall Is the dog? (v)

Happy and content or happy and bouncy 0

Quiet 1

Indifferent or non-responsive to surroundings 2

Nervous or anxious or fearful 3

Depressed or non-responsive to stimulation 4

(ii)

Ignoring any wound or painful area 0

Looking at wound or painful area 1

ing wound or painful area 2

Rubbing wound or painful area 3

Chewing wound or painful area 4

LickGroaning 2

(i)

Quiet 0

Crying or whimpering 1

Screaming 3

In the case of spinal, pelvic or multiple limb fractures, or where assistance is required to aid locomotion do not carry out section B and proceed to C Please tick if this is the case then proceed to C.

C. If it has a wound or painful area including abdomen, apply gentle pressure 2 inches round the site.

Does it? (iv)

Do nothing 0

Look round 1

Flinch 2

Growl or guard area 3

Snap 4

Cry 5

B. Put lead on dog and lead out of the kennel.

When the dog rises/walks is it? (iii)

Normal 0

Lame 1

Slow or reluctant 2

Stiff 3

It refuses to move 4

Is the dog?

(vi)

Comfortable 0

Unsettled 1

Restless 2

Hunched or tense 3

Rigid 4

Univerrsity of Glasgow University of Glasgow Total Score (i+ii+iii+iv+v+vi) = ______


SHORT FORM OF THE GLASGOW COMPOSITE PAIN SCALE

Dog’s name _______________________________ Hospital Number __________ Date / / Time Surgery Yes/No (delete as appropriate) Procedure or Condition_____________________________________________ ______________________________________________________________

In the sections below please circle the appropriate score in each list and sum these to give the total score.

A. Look at dog in Kennel Is the dog?

D. Overall Is the dog? (v)

Happy and content or happy and bouncy 0

Quiet 1

Indifferent or non-responsive to surroundings 2

Nervous or anxious or fearful 3

Depressed or non-responsive to stimulation 4

(ii)

Ignoring any wound or painful area 0

Looking at wound or painful area 1

ing wound or painful area 2

Rubbing wound or painful area 3

Chewing wound or painful area 4

LickGroaning 2

(i)

Quiet 0

Crying or whimpering 1

Screaming 3

In the case of spinal, pelvic or multiple limb fractures, or where assistance is required to aid locomotion do not carry out section B and proceed to C Please tick if this is the case then proceed to C.

C. If it has a wound or painful area including abdomen, apply gentle pressure 2 inches round the site.

Does it? (iv)

Do nothing 0

Look round 1

Flinch 2

Growl or guard area 3

Snap 4

Cry 5

B. Put lead on dog and lead out of the kennel.

When the dog rises/walks is it? (iii)

Normal 0

Lame 1

Slow or reluctant 2

Stiff 3

It refuses to move 4

Is the dog?

(vi)

Comfortable 0

Unsettled 1

Restless 2

Hunched or tense 3

Rigid 4

Univerrsity of Glasgow University of Glasgow Total Score (i+ii+iii+iv+v+vi) = ______

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and neurological conditions