facing forwardThe standards for standard of care are changing.  As veterinary medicine falls in step with its human “big sib”, the bar for prudent practice will begin to rest on “what ought to be done” in place of “what is being done” by professional peers.[1] [2]  Clinical guidelines that consider evidence over opinion are increasingly defining standard of care and could one day replace expert testimony.[3]  Holding that “a doctor does not breach the legal standard of care, and is therefore not negligent, if the practice is supported by a responsible body of similar professionals”[4], would need to change.

Consider this in regard to the treatment of dogs with thoracolumbar intervertebral disk disease (TL IVDD).  As science evolves and evidence accrues; certain approaches now considered “the norm” by some may fall by the wayside. The old mindset that nothing can cure a dog but surgery and strict cage confinement (with minimal to no analgesia) remains widely held in some circles, even academia.  This “ignorance is bliss” attitude persists despite growing support for integrative medicine.[5] [6] [7] [8]

Acupuncture, for example, confers neuroprotection by reversing inflammation and inhibiting the activation of microglia, i.e., immune cells that foster neurodegenerative changes after spinal cord injury (SCI).  Acupuncture reduces the extent of damage by helping keep neurons and oligodendrocytes alive.  In comparison, what does cage confinement without physical medicine do to a dog with disk disease and back pain?   It risks further degrading the disks, increasing muscle tension, and inducing long-term maladaptive gait patterns[9], not to mention the psychological toll it takes on the patient and the parent.  Human physicians now advise patients with low back pain to stay active instead of in bed.[10]  Might a change be coming for dogs with disk disease?  Surely, we need to keep them from re-injuring themselves, but is being imprisoned in a box for weeks on end with no activity the best we can do?

Not only do some veterinarians “omit” discussion of physical medicine for dogs with disk disease, but they also may actively intercede and advise clients against doing so.  Surgeons may dismiss laser therapy and acupuncture as “unnecessary”, “ineffective”, or “risky”.   Clearly, these individuals have not kept up with the literature.[11] [12] [13]  Or, they may insist that clients wait for weeks before seeking these appropriate and needed treatments. This causes the animal to miss valuable and urgent opportunities for healing.  How can such suggestions be considered standard of care?

On the brighter side, changes are taking place and more surgeons acknowledge the benefits of adjunctive care.  At the University of Florida, neurologists have instituted low-level laser therapy for all dogs admitted with SCI from disk disease. “Patients walk sooner, they avoid additional medical complications, their owners save money and the animals are less stressed due to less hospitalization time.”[14]  At Texas A&M University, a pamphlet on “Cage Rest for Spinal Cord Injury” includes the statement, “Rest, however, needs to be combined with a physical rehabilitation plan…Our clinicians have helped innovate techniques to facilitate recovery, including water treadmill therapy and electrical muscle stimulation.”[15]

When will surgeons’ recommendations change across the board and what will help the process move forward?

Parents of dogs with disk disease need to know the facts about TL IVDD and their options.  They need to discuss with their veterinarian evidence-based outcomes with and without surgery.  They should realize that those same nerves and muscles that a dog needs to maintain postural and spinal integrity often suffer severe damage during disk surgery.  Surgery can cause clinically significant spinal instability, especially when impacting multiple intervertebral segments.[16]  This makes post-operative recovery measures such as acupuncture, laser, and neuromuscular re-education particularly important.

Surgery does not guarantee a successful outcome; nothing does.  However, clients should realize that serious complications can occur following both imaging (myelography) and surgery.  Dogs with inadequately controlled pain post-hemilaminectomy may reinjure their back, at times necessitating another surgery within days of the first.

Even after surgery, the rate of recurrence of neurologic signs and consequent euthanasia in dogs nears 50%.[17]  According to one paper, “Dogs were euthanatized for financial reasons or because the owners did not wish their pet to undergo a second surgery or have the potential for further recurrences in the future.”   Several questions come to mind – were clients offered nonsurgical approaches as an option? Were clients themselves traumatized when they watched their dog languish for weeks in a kennel without adjunctive care or told that there was “nothing more they can do” to treat the unending pain?  Did they themselves find help for their own back pain through physical medicine measures and wonder why these options were not considered or were pooh-poohed?

Have clients received input from a science-based integrative medicine practitioner?[18]  Not only do physical medicine and rehabilitation providers treat patients over the long-term, but they also identify and treat many problems that complicate spinal cord injury, including urinary tract infections, voiding dysfunction, acute and chronic abdominal complications, cardiopulmonary compromise, and skin breakdown.[19]  Dry needling[20] treats weak spinal muscles affected by myofascial discomfort.  Acupuncture reduces acute postoperative pain in human patients following spinal surgery and allows for reduction in demand for opiates and opiate dose.  This helps patients avoid the negative effects of opioids (constipation, dysphoria, etc.) and itself supports proper motility and voiding functions.  Acupuncture not only confers analgesia without the negative side effects of medication, but it also improves general well-being and sleep quality.[21]  Massage, laser therapy, cryotherapy, and cautious rehabilitation by a veterinarian or physical therapist[22] all play important roles in supporting a “back dog” with or without surgery.

Dogs with back pain and disk disease require proactive analgesia – pre-, peri-, and post-operatively as well as for nonsurgical cases.  Animals should not remain in pain while awaiting a neurologic evaluation.  There is no reason to not treat them for their suffering before the neurologist arrives; the neurologic deficits with TL IVDD are plainly apparent even with multimodal analgesia on board.  Pain after surgery should be anticipated and controlled in a multimodal fashion.  Animals should not be dismissed from the hospital without a thorough and competent pain evaluation and treatment regimen; the majority of patients who have had thoracic, cranial abdominal, or orthopedic surgery experience pain and of these, 80% to 85% report moderate-to-severe pain.[23]

Research needs to compare nonsurgical and surgical approaches with up-to-date methods of each to further build evidential insight.[24]   An impressive recovery rate has been reported with presumptive exercise-associated peracute thoracolumbar disc extrusion.  As the authors indicate, “Because spinal cord injury is primarily contusive rather than compressive and vertebral instability is not a feature, neither decompressive nor stabilisation surgery is generally warranted.”[25]

The need for a new standard of care could not be clearer. How many “failed backs” [26] and euthanized dogs might have been helped by early institution of physical medicine and/or avoidance of surgery entirely?”

References

[1] Favre DS.  Veterinarian malpractice.  Michigan State University College of Law.  Animal Legal and Historical Center, 2002.  Accessed at http://www.animallaw.info/articles/arusfavrevetmalpractice.htm#19 on 03-02-13.

[2] Samanta A and Samanta J.  Legal standard of care:  a shift from the traditional Bolam test.  Clin Med. 2003;3(5):443-446.

[3] Davies J.  Clinical guidelines as a tool for legal liability.  An international perspective.  Med Law.  2009;28(4):603-613.

[4] Samanta A and Samanta J.  Legal standard of care:  a shift from the traditional Bolam test.  Clin Med. 2003;3(5):443-446.

[5] Robinson NG.    Nonsurgical options for IVDD?  Keeping hope, and dogs, alive.  Veterinary Practice News.  May 23, 2011.  Accessed at http://www.veterinarypracticenews.com/vet-practice-news-columns/complementary-medicine/non-surgical-options-for-ivdd-keeping-hope-and-dogs-alive.aspx on 03-07-13.

[6] Robinson NG.  Laser therapy may work on TL IVDD.  Veterinary Practice News.  Accessed at http://www.veterinarypracticenews.com/vet-practice-news-columns/complementary-medicine/laser-therapy-may-work-on-tl-ivdd.aspx on 03-07-13.

[7] Robinson NG.  Acupuncture for neurologic recovery.  Veterinary Practice News.  Accessed at http://www.veterinarypracticenews.com/vet-practice-news-columns/complementary-medicine/acupuncture-for-neurologic-recovery.aspx on 03-07-13.

[8] Choi DC, Lee JY, Moon YJ, et al.  Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury.  Neurobiology of Disease.  2010;39:272-282.

[9] Belavy DL, Bansmann PM, Bohme G, et al.  Changes in intervertebral disc morphology persist 5 mo after 21-day bed rest.  J Appl Physiol.  2011;111(5):1304-1314.

[10] Stern C.  Summaries of nursing care-related systematic reviews from the Cochrane Library:  Bed rest for acute low-back pain and sciatica.  Int J Evid Based Healthc.  2010;8(3):153-154.

[11] Draper WE, Schubert TA, Clemmons RM, et al.   Low-level laser therapy reduces time to ambulation in dogs after hemilaminectomy:  a preliminary study.  J Small Anim Pract. 2012;53(8):465-469.

[12] Hayashi AM, Matera JM, Fonseca Pinto AC.  Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs.  J Am Vet Med Assoc.  2007;231(6):913-918.

[13] Joaquim JG, Luna SP, Brondani JT, et al.  Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits.  J Am Vet Med Assoc.  2010;236(11):1225-1229.

[14] Carey S.  Study:  Laser treatment helps dogs with spinal cord injury.  The Veterinary Page, UF College of Veterinary Medicine.  Accessed at http://veterinarypage.vetmed.ufl.edu/2011/09/19/laser-treatment-helps-dogs-with-spinal-cord-injury/ on 03-07-13.

[15] Texas A&M University.  College of Veterinary Medicine & Biomedical Sciences.  Cage rest for spinal cord injury.  Accessed at http://vetmed.tamu.edu/common/docs/public/services/CRSCI%20Levine%20Brochure.pdf on 03-07-13.

[16] Arthurs G.  Spinal instability resulting from bilateral mini-hemilaminectomy and pediculectomy.  Vet Comp Orthop Traumatol.  2009;22:422-426.

[17]  Brisson BA, Moffatt SL, Swayne SL, et al.  Recurrence of thoracolumbar intervertebral disk extrusion in chondrodystrophic dogs after surgical decompression with or without prophylactic fenestration:  265 cases (1995-1999).  J Am Vet Med Assoc.  2004;224:1808-1814.

[18] Fox J, Haig AJ, Todey B, et al.  The effect of required physiatrist consultation on surgery rates for back pain.  Spine.  2013; 38(3):E178-184.

[19] Bergman SB, Yarkony GM, and Stiens ST.  Spinal cord injury rehabilitation.  2. Medical complications.  Arch Phy Med Rehabil.  1997;78:S53-S58.

[20] Gunn CG, Milbrandt WE, Little AS, et al.  Dry needling of muscle motor points for chronic low-back pain.  A randomized clinical trial with long-term follow-up.  Spine.  1980;5(3):279-291.

[21] Nayak S, Shiflett SC, Schoenberger NE, et al.  Is acupuncture effective in treating chronic pain after spinal cord injury?  Arch Phys Med Rehabil.  2001;82:1578-1586.

[22] Hides JA, Lambrecht G, Richardson CA, et al.  The effects of rehabilitation on the muscles of the trunk following prolonged bed rest.  Eur Spine J.  2011;20(5);808-818.

[23] Warfield CA and Kahn CH.  Acute pain management.  Programs in US hospitals and experiences and attitudes among US adults.  Anesthesiology.  1995;83:1090-1094.  Cited in: Yeh M-L, Chung Y-C, Chen K-M, et al.  Acupoint electrical stimulation reduces acute postoperative pain in surgical patients with patient-controlled analgesia:  a randomized controlled study.  Altern Ther Health Med.  2010;16(6):10-18.

[24] Atlas SJ, Keller RB, Su YA, et al.  Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation:  10 year results from the Maine Lumbar Spine Study.  Spine.  2005;30(8):927-935.

[25] McKee WM, Downes CJ, Pink JJ, et al. Presumptive exercise-associated peracute thoracolumbar disc extrusion in 48 dogs.  Veterinary Record.  2010;166(17):523-528.

[26] Dankaerts W, O’Sullivan PB, Burnett AF, et al.  The use of a mechanism-based classification system to evaluate and direct management of a patient with non-specific chronic low back pain and motor control impairment – a case report.  Manual Therapy.  2007;12(2):181-191.

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