General veterinary practices: Don't be daunted by the down dog

Don't immediately assume a down dog is out of your scope because you're a general practice. (Shutterstock.com)What goes through your mind when a down dog presents to your general veterinary practice?

If your instinct is to hightail it out of the situation, Fetch dvm360 speaker Matt Brunke, DVM, CCRP, CVPP, CVA, understands. Down dogs can be expensive, time-consuming, heartbreaking and scary, he admits. But odds are that if you haven't seen one yet, you will, and when you do see one, you may not be able to refer it to a specialist right away.

If you feel ill-equipped to handle a down dog, Dr. Brunke says you might be overthinking it. You don't need a building full of high-dollar equipment and string of credentials after your name to manage rehabilitation. You do, however, need a plan.

Down dog diagnosis

According to Dr. Brunke, the down dog can “arise” (pun intended) from several causes, including trauma (such as being hit by a car), congenital malformations, neoplasia, tick paralysis, tetanus, lumbosacral disease, degenerative myelopathy, intervertebral disk disease and fibrocartilaginous embolism, to name but a few. So your first task with a down dog is to determine the cause.

For Dr. Brunke, this typically doesn't require anything that's overly complex or expensive. He starts with a thorough physical exam and history, along with a minimum database (complete blood count, serum chemistry profile and urinalysis, as well as a thyroid or urine culture, if indicated). Dr. Brunke also notes that rectal exams and survey radiographs can be helpful in determining the big picture.

You may have noticed something missing from this list-magnetic resonance imaging (MRI).

“MRI is often the last test we need,” says Dr. Brunke. “It's not something every client can afford, and it doesn't do a lot of good if the client can afford the MRI but not the treatment.”

Commitment issues

Once you know why the dog is down, the treatment will of course be tailored to the diagnosis, but the care for these dogs is relatively universal, says Dr. Brunke.

His next step is to open up an honest dialogue with the dog's owners to determine expectations and capabilities.

“I always tell clients that it may take a full three months for the dog to start walking on its own, but I only ask them to commit to two-week blocks of treatment at a time,” says Dr. Brunke. “I reassess constantly and meet with my team about a patient to reset goals every one to two weeks. The team approach is critical, as my team spends the most time with the patient and the clients.”

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Whether or not the down dog will need to be inpatient or outpatient depends the severity of the case, the size of the dog, the client's capabilities and your facilities, says Dr. Brunke. For example, the 85-year-old owner of a 150-lb dog that can't use any of its legs should be inpatient. But if the young, healthy owner of a dachshund wants to watch over her pet overnight and save a little money in the process, that's a bit more practical. However, Dr. Brunke does prefer hospitalizing down dog patients as it's more efficient and the outcomes tend to be better (assuming you have a 24-hour facility).

“For outpatients with neurologic causes, it's easier to have them come in for a whole day during the first four to six weeks,” says Dr. Brunke. “Neuro patients are exhausted after as little as five minutes of work, so if you try to squeeze all of their rehab activities into an hour, your patients won't want to do anything for days. But if they can stay for the whole day, you can slowly build strength and stamina by working with them for 15 minutes in the morning, afternoon and evening.”

Down dogs enjoy being part of the action. Take a bench, flip it over and help prop the patient up in your office so they can check out what's going on. (Image courtesy of Dr. Brunke)Nursing down dogs back to health

“Fundamental nursing care is essential for these patients,” says Dr. Brunke, “and it doesn't involve anything you haven't already learned in veterinary school.”

> Dr. Brunke stresses the importance of letting these dogs rest. He sets aside one day of the week (usually Sunday) as a rest day during which the dogs still get nursing care but don't do any rehab. Dr. Brunke also prefers to keep down dog patients back in wards where they can get some sleep.

> “Changing recumbency every four to six hours (and attempting to keep the dog sternal during the daytime) is vital for both physical and mental well-being. Clean soft bedding, with appropriate padding (to minimize risk for pressure sores) is also needed,” says Dr. Brunke.

> Bladder expression may be necessary, but Dr. Brunke recommends avoiding urinary catheters (indwelling or temporary) after the first 72 to 96 hours for two reasons: 1) Urinary function can help you determine patient progress, and 2) Catheters provide an infection access point. “Urinary medications (e.g. phenoxybenzamine, bethanecol) should be used carefully and only after ruling out any infection,” says Dr. Brunke.

> “Bowel expression may be needed as well,” says Dr. Brunke. “This can be done in a variety of ways, but the important thing to remember is to give the patient time.” Dr. Brunke has found that many clients (and clinicians) aren't patient enough to give these dogs the time they need to void on their own (in a harness, hoist, etc.). “What used to take them three minutes may now take 30 minutes,” he says. “Enemas, oral lactulose and movement (walking) can help facilitate proper bowel movements.”

What about depressed clients?

For owners of outpatient down dogs who live far away, Dr. Brunke sets up times for them to visually check in on their beloved pets via FaceTime.

> Dr. Brunke says that about a third of his inpatient down dogs end up clinically depressed. “These dogs are stuck in a hospital, unable to do the things they love,” he says. “I'd be depressed too.” So if he notices that a dog isn't making progress, Dr. Brunke will sometimes add an antidepressant.

Bust a (passive) move

Once you get these patients through the acute period and get their pain under control, then you can introduce some passive range of motion (10 to 15 reps per exercise, three to five times a day), says Dr. Brunke. This can be a great job for technicians, who can also teach the owners of outpatient dogs how to do the exercises at home.

“Once the patient is ready to progress to standing exercises, start with maximum assistance (in which you provide 75 to 100 percent of the work) a couple of times a day after range of motion exercises,” says Dr. Brunke. “Items such as carts, harnesses or hoists can be quite useful to save the staff members' backs.”

Be a proprioception pro

“Every time these dogs stand up, you need to put their feet in the appropriate places, as conscious proprioception is a treatment modality,” says Dr. Brunke. “However that dog learns to walk again is how it will walk for the rest of its life.”

When the patient is strong enough to stand without as much assistance, you can start involving other items like a clinic quad cart or an overhead hoist system, says Dr. Brunke. (Note: Don't panic if you don't have these. They're only a good investment if you see a lot of down dog patients.) These standing exercises should occur every two to four hours, between 8 a.m. and 8 p.m. (This last part is especially important to explain to clients, as they sometimes think they need to get up at 2 a.m. to exercise their pups, resulting in tired patients and owners.) Dr. Brunke also adds some proprioceptive training at this point, such as gently rocking the dog back and forth and side to side.

According to Dr. Brunke you need to give the patient time to rest between these exercises, and he often uses additional modalities during these resting periods (e.g. laser therapy, massage, thermotherapy, cryotherapy and electrical stimulation).

If you'd rather refer, that's OK

There's no shame in referring, and sometimes you won't have a choice due to the dog's size or treatment needs (e.g. it can take a team of three or four people to move a dog that weighs 100 lb). But don't immediately assume a down dog is out of your scope because you're a general practice.

“Often, progress can be made with these patients by working with owners to set and work toward reasonable goals,” says Dr. Brunke. “I recommend starting with small and medium dogs first until you get more comfortable with the process.” In other words, start with a Maltese before you attempt a Mastiff.