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Why the Standards of Care for Spinal Cord Injuries Are Changing

A look at the latest evidence.


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Evidence against cage rest is building.

Atiger/shutterstock

Veterinary medicine is experiencing a culture shift in the treatment of spinal cord injury and disk disease. With more veterinarians incorporating integrative physical medicine treatments (i.e., acupuncture, laser therapy and rehabilitation) into their practices, the standards of care for spinal cord injury could well be changing. Research is illustrating that the standard approaches of surgery, cage rest or steroids no longer have a rock-solid grasp as the best or only options.

Cage rest, for example, has no evidence in favor but is accruing evidence against. This includes the physical (not to mention, mental and emotional) deterioration brought about by living in a small box with little movement or freedom day after day.1 

As stated by the authors of a recent paper on immobilization in paraplegics, “Mechanical loading and movement are essential for the maintenance of the integrity of skeletal tissues including articular structures and cartilage. Prolonged immobilization after spinal cord injury (SCI) has been suggested to be a cause of contractures, periarticular osteoporosis, heterotopic ossification, osteoarthritis and periarticular connective tissue alterations. Lower extremity articular cartilage needs some regimen of joint loading and motion to maintain its native physical and biochemical properties.”

As more becomes known about the drawbacks of forced stillness, why do we continue to keep dogs from benefiting from assisted stands and slow, careful walking? Surely, we should be able to monitor and modulate their exercise with sufficient supervision and instruction to keep them moving and strong while they heal.

Invasive Approach 

And then there’s surgery. Is it really that crucial to rush a “down dog” into surgery, especially when she or he has lost pain sensation? A recently published multicenter, prospective cohort study examined the most seriously affected individuals (i.e., those who had lost pain perception) and found that “immediacy of surgical treatment had no apparent association with outcome.”

This statement stands in stark contradistinction to the dogma frequently taught and repeated to clients today—that pursuing surgery with little delay will yield the best results.

The authors continued: “Most importantly, we found no evidence to support the notion that the two factors over which veterinarians presumably have the most control (delays between onset of paraplegia and spinal decompression surgery or corticosteroid drug administration) had an effect on prognosis within the three-month period. Most surprisingly, no evidence was obtained to suggest a poorer prognosis for [more than] 48 hours after onset of paraplegia than the prognosis for dogs in which it had been absent for [less than] 48 hours.”

These findings should help alleviate some of the second- guessing of practitioners who offer integrative physical medicine and appropriate medical support as a first-line approach.3 

While surgery might remove compression in the short-term, it induces its own trauma, pain and risk of not working. What about the neuroprotectants methylprednisolone sodium succinate and polyethylene glycol? A recent placebo-controlled, prospective, randomized clinical trial “did not show a benefit [for either] in the treatment of acute, severe thoracolumbar intervertebral disk herniation when used as adjunctive medical treatment administered to dogs presenting within 24 hours of onset of paralysis.”4 

Another Consideration 

Perhaps these approaches are missing something. Maybe they are overlooking the innate capacity of the body to recover, especially when assisted by acupuncture and laser therapy.

We know that one of the most lethal aspects of nerve compression involves the lack of oxygen from reduced blood flow. Furthermore, the neurologic prognosis for recovery after SCI likely is “strongly influenced by the precise nature of the initiating injury.”5 As such, carefully improving circulatory supply could conceivably treat one of the main vectors of neuronal death directly and specifically. 

Which physical medicine measures improve blood flow to the central nervous system? Acupuncture6,7 and photo (light) therapy.Furthermore, in that one of the initiating factors for disk disease involves circulatory insufficiency to the vertebral endplate,9 maintaining healthful blood flow to the back with proactive treatments that catch problems early conceptually could reduce the risk of inter-vertebral disk disease (IVDD). 

But acupuncture and laser therapy offer much more than circulatory improvement, and their value for patients with disk disease and spinal cord injury has been reviewed in earlier columns.10-12 Briefly, the physiologic effects of both treatments overlap and include modulation of endogenous biological mediators such as growth factors, neurotransmitters, neurotrophins and cytokines.13,14

Look Inside 

Finally, we see much enthusiasm among both scientists and the public about using stem cells to fix broken body parts.15 While much hope is riding on implanted stem cells and patches after traumatic spinal cord injury, we might be overlooking a key natural resource: the central nervous system’s own stem cells—no harvesting, no cultivating and no implanting necessary. 

What acupuncture can do is mobilize these endogenous agents and propel them to differentiate, enhancing spontaneous regeneration after neurologic injury.16 Electroacupuncture inhibits pro-inflammatory cytokine expression, induces neuronal stem cell proliferation and differentiation, and inhibits the contrast of neuronal stem cells into astrocytes.17 

Laser therapy, too, has the potential to photoactivate endogenous molecules in order to stimulate host stem cells to promote tissue regeneration.18 Surgery, steroids and sitting in a cage for weeks on end do none of this. 

References

  1. Panisset MG, Galea MP, and El-Ansary D.  Does early exercise attenuate muscle atrophy or bone loss after spinal cord injury?  Spinal Cord.  2016;54:84-92.
  2. Yilmaz B, Demir Y, Ozyoruk E, et al. The effect of knee joint loading and immobilization on the femoral cartilage thickness in paraplegics.  Spinal Cord.  2015, 1-4. 
  3. Personal communication with a neurologist and former neurosurgeon.
  4. Olby NJ, Muguet-Chanoit AC, Lim J-H, et al.  A placebo-controlled, prospective, randomized clinical trial of polyethylene glycol and methylprednisolone sodium succinate in dogs with intervertebral disk herniation.  J Vet Intern Med.  2016;30:206-214.
  5. Jeffery ND, Barker AK, Hu HZ, et al.  Factors associated with recovery from paraplegia in dogs with loss of pain perception in the pelvic limbs following intervertebral disk herniation.  J Am Vet Med Assoc.  2016;248:386-394. 
  6. Byeon HS, Moon SK, Park SU, et al.  Effects of GV20 acupuncture on cerebral blood flow velocity of middle cerebral artery and anterior cerebral artery territories, and CO2 reactivity during hypocapnia in normal subjects.  J Altern Complement Med.  2011;17(3):219-224.
  7. Naeser MA.  Acupuncture in the treatment of paralysis due to central nervous system damage.  J Alt Complement Med.  1996;2(1):211-248.
  8. Salgado AS, Zangaro RA, Parreira RB, et al.  The effects of transcranial LED therapy (TCLT) on cerebral blood flow in the elderly women.  Lasers Med Sci.  2015;30(1):339-346.
  9. Jeffery ND, Levine JM, Olby NJ, et al.  Intervertebral disk degeneration in dogs:  consequences, diagnosis, treatment, and future directions.  J Vet Intern Med.  2013;27:1318-1333.
  10. Robinson NG.  Evidence points to acupuncture for disk disease.  Veterinary Practice News. 2009.  Accessed at http://www.veterinarypracticenews.com/June-2009/Evidence-Points-To-Acupuncture-For-Disk-Disease-0/ on 03-30-31.
  11. Robinson NG.  Laser therapy may work on TL IVDD.  2010.  Accessed at http://www.veterinarypracticenews.com/March-2010/Laser-Therapy-May-Work-On-TL-IVDD-0/ on 03-30-16.
  12. Robinson N.  Non-surgical options for IVDD?  Keeping hope, and dogs, alive.  Accessed at http://www.veterinarypracticenews.com/May-2011/Non-Surgical-Options-For-IVDD-Keeping-Hope-And-Dogs-Alive/ on 03-30-16.
  13. Hashmi JT, Huang Y-Y, Osmani BZ, et al.  Role of low-level laser therapy in neurorehabilitation.  PM R. 2010; Dec; 2(12 Suppl 2): S292-S305.
  14. Ando T, Sato S, Kobayashi H, et al.  Low-level laser therapy for spinal cord injury in rats:  effects of polarization.  J Biomed Opt.  2013;18(9):098002.
  15. Mole B.  Scientists regenerate spinal cord in injured rats with stem cells.  Ars Technica.  March 29, 2016.  Accessed at http://arstechnica.com/science/2016/03/scientists-regenerate-spinal-cord-in-injured-rats-with-stem-cells/ on 03-31-16.
  16. Wu H, Hu M, Yuan D, et al.  Electroacupuncture promotes the proliferation of endogenous neural stem cells and oligodendrocytes in the injured spinal cord of adult rats.  Neural Regen Res. 2012;7(15):1138-1144.
  17. Geng X, Sun T, Li J-H, et al.  Electroacupuncture in the repair of spinal cord injury:  inhibiting the Notch signaling pathway and promoting neural stem cell proliferation.  Neural Regen Res.  2015;10(3):394-403.
  18. Arany PR, Cho A, Hunt TD, et al.  Photoactivation of endogenous latent transforming growth factor – beta 1 directs dental stem cell differentiation for regeneration.  Science Translational Medicine.  2014;6(238):238ra69.  DOI:  10.1126/scitranslmed.3008234.

Dr. Robinson, Dipl. ABMA, FAAMA, oversees complementary veterinary education at Colorado State University and is president and CEO of One-Health SIM Studio, a continuing education company in Fort Collins, Colo. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News. 

Originally published in the May 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today! 

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