Intervertebral disk disease is a common cause of neurologic dysfunction in dogs. Hansen type I or extrusive IVDDs are mainly observed in chondrodystrophic breeds1 and typically are associated with acute onset of clinical signs. Affected animals can have various clinical signs, including signs of pain referable to the vertebral column, ambulatory or nonambulatory paraparesis, paraplegia, urinary dysfunction, and loss of nociception.2,3 Medical management can be considered for dogs with signs of mild pain or mild neurologic deficits,4 but in more severe cases, surgical decompression is needed.5 The most common surgical treatment for Hansen type I thoracolumbar IVDD is hemilaminectomy.
The goals of postoperative physical rehabilitation in patients with acute spinal cord disease are maintaining a normal range of motion of the joints, reducing the degree of muscle atrophy, and improving the degree and speed of neurologic recovery, compared with results for patients that do not receive postoperative physical rehabilitation.6 Investigators of 2 studies7,8 on cranial cruciate ligament rupture found that postoperative physical rehabilitation was associated with improved function of the affected limb after surgery, compared with that for dogs that underwent exercise restriction or a home-exercise (walking) program. In another study,9 dogs with degenerative myelopathy remained ambulatory longer when a rehabilitation program was used, with dogs undergoing intensive rehabilitation having longer survival time than dogs that had moderate or no rehabilitation treatment. However, no association was found between physical rehabilitation and outcome in 1 retrospective study10 of dogs with ischemic myelopathy. Although reduced pain has been mentioned as a goal of physical rehabilitation in patients with spinal cord diseases,6 exercise during the early postoperative period has the potential to exacerbate pain. To the authors' knowledge, no study has evaluated the effects of physical rehabilitation on recovery or pain management variables in dogs following surgery for treatment of intervertebral disk herniation.
Photobiomodulation therapy, also described as low-level laser therapy,11 has been the focus of many clinical studies in human medicine. In experimental wound healing studies, photobiomodulation has been reported to improve rates of healing (less time for wound closure), collagen formation, wound tensile strength, and flap survival.12 It was also shown to resolve inflammation,13 reduce the pain associated with chronic neuropathic lesions and chronic joint disorders,12,14–17 and reduce acute soft tissue injury edema after second-degree ankle sprain,18 compared with standard care (rest, ice compress application, and elevation). Positive outcomes (ie, reduction of pain, improved function, faster recovery, and circulating concentrations of markers for inflammation and muscle damage) have been associated with photobiomodulation therapy for diseases such as osteoarthritis, tendinopathies, wounds, muscle fatigue, and various neurologic dysfunctions19,20 in human clinical trials. Results of a systematic review with meta-analysis of randomized controlled trials showed that photobiomodulation reduces pain immediately after treatment in human patients with acute neck pain and up to 22 weeks after completion of treatment in those with chronic neck pain.16
The mechanism of action of photobiomodulation therapy is not fully understood. It has been established that red and near-infrared wavelengths penetrate tissue easily and induce dissociation of nitric oxide from the oxygen-binding site of cytochrome c oxidase in the mitochondria.19,21,22 This photodissociation would allow oxygen fixation and thereby enhance cellular respiration and metabolism. This type of treatment has been shown to reduce production of factors associated with oxidative stress in various cell types in vitro as well as in affected tissues of laboratory animals with experimentally induced ischemia-reperfusion injury or age-related retinal changes21,23–26 and to protect against oxidative stress by activating scavenging superoxide anions.27 In rats with blunt-impact muscle trauma, photobiomodulation therapy blocked reactive oxygen species release and activation of nuclear factor-κB, inhibited overexpression of inducible nitric oxide synthase, reduced the inflammatory response, and decreased collagen production in the traumatized muscle, compared with traumatized muscles from rats that did not undergo photobiomodulation therapy.28
Results of in vitro studies have shown that exposure to light enhances proliferation of Schwann cells,29 affects nerve cell metabolism, and increases neuronal sprouting and migration.30–32 Moreover, in vivo and in vitro studies have shown that exposure to light causes changes in inflammatory cell migration into the injured spinal cord33–36 and modulates microglia polarization from a proinflammatory to anti-inflammatory phenotype.37 After peripheral (sciatic) nerve injury, the transcutaneous application of laser light over the corresponding segment of the spinal cord improved measures of nerve function and neurologic recovery in rats, compared with values for (non–laser-light-treated) controls.38,39
To the author's knowledge, only 2 clinical trials on photobiomodulation therapy in dogs with naturally occurring SCI have been conducted. In one of those studies,a 17 dogs with acute onset of paraplegia secondary to IVDD were assigned to receive 1 laser application (635-nm wavelength, 4 × 5 mW, in pulsed mode) once daily for 4 days following hemilaminectomy or to receive no laser treatment. There was no association between recovery of ambulation 2 weeks after surgery and photobiomodulation therapy. In the other study,40 postoperative photobiomodulation therapy (once daily for 5 days; 810-nm wavelength, 5 × 200 mW, in pulsed mode) was associated with a shorter time to regain ambulation in dogs following surgery for IVDD. The effect of postoperative photobiomodulation therapy on signs of pain or the need for analgesic treatment was not evaluated in these trials.
The purpose of the study reported here was to assess and compare the effects of immediate postoperative photobiomodulation therapy and physical rehabilitation in dogs undergoing hemilaminectomy for treatment of thoracolumbar IVDD. We hypothesized that dogs receiving either treatment would have a more rapid recovery, as assessed by a predetermined grading system over a 10-day postoperative period, compared with that of dogs receiving sham photobiomodulation treatment alone. We also hypothesized that dogs undergoing physical rehabilitation would require postoperative IV opioid analgesic administration for a longer duration than dogs receiving photobiomodulation therapy or sham treatments.
Supported in part by the Fondation Camille Hela, University of Liège.
James D. Carroll is the founder and chief executive officer of THOR Photomedicine Ltd, manufacturer of the laser probe and control unit used in this study.
The authors thank Dr. Stephanie Noel, Nicolas Barthelemy, Juan Ramirez, Olivier Broux, Michael Lefebvre, Dominique Leverd, and Valerie Borguet for technical assistance.
Intervertebral disk disease
Modified Frankel score
Spinal cord injury
Williams CC, Barone G. Is low level laser therapy an effective adjunctive treatment to hemilaminectomy in dogs with acute onset paraplegia secondary to intervertebral disc disease? (abstr) J Vet Intern Med 2011;25:730–731.
DDv control unit and laser cluster probe, THOR Photomedicine Ltd, London, England.
Cefar Rehab X2, DJO Inc, Guildford, Surrey, England.
R, version 2.15.3, R Statistical Software, Foundation for Statistical Computing, Vienna, Austria.
Schubert T, University of Florida, Gainesville, Fla: Personal communication, 2015.
1. Hansen HJ. A pathologic-anatomical study on disc degeneration in the dog, with special reference to the so-called enchondrosis intervertebralis. Acta Orthop Scand Suppl 1952; 11: 1–117.
2. Scott HW. Hemilaminectomy for the treatment of thoracolumbar disc disease in the dog: a follow-up study of 40 cases. J Small Anim Pract 1997; 38: 488–494.
3. Scott HW, McKee WM. Laminectomy for 34 dogs with thoracolumbar intervertebral disc disease and loss of deep pain perception. J Small Anim Pract 1999; 40: 417–422.
4. Mann FA, Wagner-Mann CC, Dunphy ED, et al. Recurrence rate of presumed thoracolumbar intervertebral disc disease in ambulatory dogs with spinal hyperpathia treated with anti-inflammatory drugs: 78 cases (1997–2000). J Vet Emerg Crit Care 2007;17: 53–60.
6. Olby N, Halling KB, Glick TR. Rehabilitation for the neurologic patient. Vet Clin North Am Small Anim Pract 2005; 35: 1389–1409.
7. Marsolais GS, Dvorak G, Conzemius MG. Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs. J Am Vet Med Assoc 2002; 220: 1325–1330.
8. Monk ML, Preston CA, McGowan CM. Effects of early intensive postoperative physiotherapy on limb function after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament. Am J Vet Res 2006; 67: 529–536.
9. Kathmann I, Cizinauskas S, Doherr MG, et al. Daily controlled physiotherapy increases survival time in dogs with suspected degenerative myelopathy. J Vet Intern Med 2006; 20: 927–932.
10. De Risio L, Adams V, Dennis R, et al. Association of clinical and magnetic resonance imaging findings with outcome in dogs suspected to have ischemic myelopathy: 50 cases (2000–2006). J Am Vet Med Assoc 2008;233: 129–135.
11. Anders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy versus photobiomodulation therapy. Photomed Laser Surg 2015; 33: 183–184.
12. Enwemeka CS, Parker JC, Dowdy DS, et al. The efficacy of low-power lasers in tissue repair and pain control: a meta-analysis study. Photomed Laser Surg 2004; 22: 323–329.
13. Bjordal JM, Lopes-Martins RAB, Joensen J, et al. The anti-inflammatory mechanism of low level laser therapy and its relevance for clinical use in physiotherapy. Phys Ther Rev 2010; 15: 286–293.
14. Kleinkort JA. Low-level laser therapy: new possibilities in pain management and rehab. Orthop Phys Ther Pract 2005; 17: 48–51.
15. Chow RT, Johnson MI, Lopes-Martins RAB, et al. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet 2009; 374: 1897–1908.
16. Bjordal JM, Couppe C, Chow R, et al. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother 2003; 49: 107–116.
17. Desiderá AC, Nascimento GC, Gerlach RF, et al. Laser therapy reduces gelatinolytic activity in the rat trigeminal ganglion during temporomandibular joint inflammation. Oral Dis 2015; 21: 652–658.
18. Stergioulas A. Low-level laser treatment can reduce edema in second degree ankle sprains. J Clin Laser Med Surg 2004; 22: 125–128.
20. Hashmi JT, Huang YY, Osmani BZ, et al. Role of low-level laser therapy in neurorehabilitation. PM R 2010; 2(12 suppl 2): S292–S305.
21. Lindgård A, Hultén LM, Svensson L, et al. Irradiation at 634 nm releases nitric oxide from human monocytes. Lasers Med Sci 2007; 22: 30–36.
23. Lim WB, Kim JS, Kwon H, et al. Effects of 635 nm light-emitting diode irradiation on angiogenesis in CoCl(2)—exposed HUVECs. Lasers Surg Med 2011; 43: 344–352.
24. Huang YY, Nagata K, Tedford CE, et al. Low-level laser therapy (LLLT) reduces oxidative stress in primary cortical neurons in vitro. J Biophotonics 2013; 6: 829–838.
25. de Lima FM, Albertini R, Dantas Y, et al. Low-level laser therapy restores the oxidative stress balance in acute lung injury induced by gut ischemia and reperfusion. Photochem Photobiol 2013; 89: 179–188.
26. Gkotsi D, Begum R, Salt T, et al. Recharging mitochondrial batteries in old eyes. Near infra-red increases ATP. Exp Eye Res 2014; 122: 50–53.
27. Lim W, Kim J, Lim C, et al. Effect of 635 nm light-emitting diode irradiation on intracellular superoxide anion scavenging independent of the cellular enzymatic antioxidant system. Photomed Laser Surg 2012; 30: 451–459.
28. Rizzi CF, Mauriz JL, Freitas Correa DS, et al. Effects of low-level laser therapy (LLLT) on the nuclear factor (NF)-kappaB signaling pathway in traumatized muscle. Lasers Surg Med 2006; 38: 704–713.
29. Van Breugel HHFI, Bär PR. He-Ne laser irradiation affects proliferation of cultured rat Schwann cells in a dose-dependent manner. J Neurocytol 1993; 22: 185–190.
30. Wollman Y, Rochkind S, Simantov R. Low power laser irradiation enhances migration and neurite sprouting of cultured rat embryonal brain cells. Neurol Res 1996; 18: 467–470.
31. Wollman Y, Rochkind S. In vitro cellular processes sprouting in cortex microexplants of adult rat brains induced by low power laser irradiation. Neurol Res 1998; 20: 470–472.
32. Rochkind S, El-Ani D, Nevo Z, et al. Increase of neuronal sprouting and migration using 780 nm laser phototherapy as procedure for cell therapy. Lasers Surg Med 2009; 41: 277–281.
33. Fitch MT, Silver J. Activated macrophages and the blood-brain barrier: inflammation after CNS injury leads to increases in putative inhibitory molecules. Exp Neurol 1997; 148: 587–603.
34. Fitch MT, Doller C, Combs CK, et al. Cellular and molecular mechanisms of glial scarring and progressive cavitation: in vivo and in vitro analysis of inflammation-induced secondary injury after CNS trauma. J Neurosci 1999; 19: 8182–8198.
35. Popovich PG, Guan Z, McGaughy V, et al. The neuropathological and behavioral consequences of intraspinal microglial/macrophage activation. J Neuropathol Exp Neurol 2002; 61: 623–633.
36. Byrnes KR, Waynant RW, Ilev IK, et al. Light promotes regeneration and functional recovery and alters the immune response after spinal cord injury. Lasers Surg Med 2005; 36: 171–185.
37. von Leden RE, Cooney SJ, Ferrara TM, et al. 808 nm wavelength light induces a dose-dependent alteration in microglial polarization and resultant microglial induced neurite growth. Lasers Surg Med 2013; 45: 253–263.
38. Rochkind S, Nissan M, Alon M, et al. Effects of laser irradiation on the spinal cord for the regeneration of crushed peripheral nerve in rats. Lasers Surg Med 2001; 28: 216–219.
39. Shamir MH, Rochkind S, Sandbank J, et al. Double-blind randomized study evaluating regeneration of the rat transected sciatic nerve after suturing and postoperative low-power laser treatment. J Reconstr Microsurg 2001; 17: 133–137.
40. 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: 465–469.
41. Laitinen OM, Puerto DA. Surgical decompression in dogs with thoracolumbar intervertebral disc disease and loss of deep pain perception: a retrospective study of 46 cases. Acta Vet Scand 2005; 46: 79–85.
42. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMC Med 2010; 8: 18.
44. Davis GJ, Brown DC. Prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with acute thoracolumbar disk extrusions: 112 cases. Vet Surg 2002; 31: 513–518.
45. Ruddle TL, Allen DA, Schertel ER, et al. Outcome and prognostic factors in nonambulatory Hansen type I intervertebral disc extrusions: 308 cases. Vet Comp Orthop Traumatol 2006; 19: 29–34.
46. Millis DL, Levine D, Taylor RA, et al. Sample protocols. In: Canine rehabilitation and physical therapy. St Louis: Elsevier-Saunders, 2004;472–486.
48. Wall R. Physical rehabilitation for the paralyzed patient. In: Fingeroth JM, Thomas BT, eds. Advances in intervertebral disc disease in dogs and cats. Ames, Iowa: Wiley-Blackwell, 2014;279–285.
49. Thota A, Carlson S, Jung R. Recovery of locomotor function after treadmill training of incomplete spinal cord injured rats. Biomed Sci Instrum 2001; 37: 63–67.
50. Multon S, Franzen R, Poirrier AL, et al. The effect of treadmill training on motor recovery after a partial spinal cord compression-injury in the adult rat. J Neurotrauma 2003; 20: 699–706.
51. Engesser-Cesar C, Anderson AJ, Basso DM, et al. Voluntary wheel running improves recovery from a moderate spinal cord injury. J Neurotrauma 2005; 22: 157–171.
52. Fouad K, Metz GA, Merkler D, et al. Treadmill training in incomplete spinal cord injured rats. Behav Brain Res 2000;115: 107–113.
53. Lovely RG, Gregor RJ, Roy RR, et al. Effects of training on the recovery of full-weight-bearing stepping in the adult spinal cat. Exp Neurol 1986; 92: 421–435.
55. de Leon RD, Hodgson JA, Roy RR, et al. Locomotor capacity attributable to step training versus spontaneous recovery after spinalization in adult cats. J Neurophysiol 1998; 79: 1329–1340.
56. Levine JM, Levine GJ, Porter BF, et al. Naturally occurring disk herniation in dogs: an opportunity for pre-clinical spinal cord injury research. J Neurotrauma 2011; 28: 675–688.
57. Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Arch Phys Med Rehabil 2013; 94: 2297–2308.
58. Shin JC, Kim JY, Park HK, et al. Effect of robotic-assisted gait training in patients with incomplete spinal cord injury. Ann Rehabil Med 2014; 38: 719–725.
59. Hady LL, Schwarz PD. Recovery times for dogs undergoing thoracolumbar hemilaminectomy with fenestration and physical rehabilitation: a review of 113 cases. J Vet Med Anim Health 2015; 7: 278–289.
60. Stevens SL, Caputo JL, Fuller DK, et al. Physical activity and quality of life in adults with spinal cord injury. J Spinal Cord Med 2008; 31: 373–378.
61. Aikawa T, Fujita H, Kanazono S, et al. Long-term neurologic outcome of hemilaminectomy and disk fenestration for treatment of dogs with thoracolumbar intervertebral disk herniation: 831 cases (2000–2007). J Am Vet Med Assoc 2012; 241: 1617–1626.
62. Dowdle SM, Joubert KE, Lambrechts NE, et al. The prevalence of subclinical gastroduodenal ulceration in Dachshunds with intervertebral disc prolapse. J S Afr Vet Assoc 2003; 74: 77–81.
Summary of a 3-phase postoperative rehabilitation protocol used for treatment of a subset of dogs (rehabilitation group) in a study to evaluate the effects of postoperative rehabilitation and photobiomodulation therapy in dogs following hemilaminectomy for IVDD.
|A||Cold pack application|
|B||Range-of-motion exercises Toe-pinch exercises* Assisted standing|
|Assisted standing and weight shifting|
The physical rehabilitation protocol was based on procedures described in other sources.6,46,47 Phase A was started 2 days after surgery, except that cold pack application was performed only during the first 48 hours after surgery. Phase B was implemented once the animal was able to support its own weight in a standing position (without pelvic limb movements), and phase C was started when deliberate movement of the pelvic limbs was observed.
Performed for patients with upper motor neuron injury only.
When phase B or C was implemented ≤ 3 days after surgery, hydrotherapy was postponed until the third day after surgery to allow for adherence to surgical wound care requirements.
Duration was determined on the basis of the attendant's subjective assessment of the dog's degree of fatigue.
(Adapted from Olby N, Halling KB, Glick TR. Rehabilitation for the neurologic patient. Vet Clin North Am Small Anim Pract 2005;35:1389–1409. Reprinted with permission.)