Feline Physiotherapy and Rehabilitation: 1. Principles and potential

Practical relevance: Physiotherapy is highly valued within human medicine and relatively well established for canine patients. Despite a popular misconception that feline patients will not cooperate with such treatment, physiotherapy is now increasingly being performed with cats. With cat ownership increasing in many countries, and an emergence of specialist physiotherapy practitioners, there is demand for effective postoperative and post-injury rehabilitation for any cat with compromised physical function due to injury, surgery or disease. Clinical challenges: While physiotherapy and rehabilitation are potentially beneficial for cats, due to their independent nature feline patients certainly present a greater challenge in the pursuit of effective therapy than their canine counterparts. Audience: This two-part review article is directed at the primary care veterinary team. The benefits of physiotherapy and the various treatment modalities available to the qualified veterinary physiotherapist, as well as the non-specialist veterinarian and veterinary nurse or technician, are examined in this first part. Evidence base: The benefits of human physiotherapeutic intervention are well documented, and there is good evidence for the effectiveness of most treatment modalities. Animal studies are still in their infancy, although some preliminary studies in dogs have shown good results.     

Advanced imaging: use and misuse

SUMMARY: The primary purpose of diagnostic imaging is to enable clinicians to make correct decisions about a patient's diagnosis and severity of its condition and, thereby, to contribute to effective and efficient treatment. Advanced imaging modalities are inherently better detectors of morphological lesions than radiography; hence, they offer the possibility of more accurate diagnosis and staging, with correspondingly better patient outcomes. However, there is a lack of evidence that better outcomes are being realised for veterinary patients. Furthermore, increased use of advanced imaging carries the possibility of increased misuse, primarily through unnecessary studies that contribute little to patient management other than increased costs. SCOPE: This article is intended to be relevant to all veterinary species. Advanced imaging of cats is not sufficiently developed as a specific discipline that a balanced review could be based purely on feline examples or references.     

Neurological lameness in the cat: common causes and clinical approach

PRACTICAL RELEVANCE: Neurological causes of lameness are infrequently seen in cats but they are an important consideration when an obvious orthopaedic cause cannot be identified. Monoparetic cats are also frequently presented for veterinary investigation with the main complaint being lameness. CLINICAL CHALLENGES: Neurological causes of lameness may be difficult to determine without access to advanced imaging modalities, electrodiagnostics or cerebrospinal fluid analysis. AUDIENCE: This review, aimed at all veterinarians who treat cats, sets out to describe the specific approach to cats with lameness that cannot be attributed to an orthopaedic cause. It describes the diagnosis and management of the most common neurological conditions responsible for lameness or monoparesis in cats.     

Nonsteroidal anti-inflammatory drugs in cats: a review

OBJECTIVE: To review the evidence regarding the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in cats. DATABASES USED: PubMed, CAB abstracts. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs should be used with caution in cats because of their low capacity for hepatic glucuronidation, which is the major mechanism of metabolism and excretion for this category of drugs. However, the evidence presented supports the short-term use of carprofen, flunixin, ketoprofen, meloxicam and tolfenamic acid as analgesics in cats. There were no data to support the safe chronic use of NSAIDs in cats.     

Diagnosis of pancreatitis.

In summary, pancreatitis is common in dogs and cats, but it seems that most cases remain undiagnosed. Serum amylase and lipase activities are useful as a quick screening test for pancreatitis in the dog only. Serum amylase or lipase activity must be at least three to five times the upper limit of the reference range to suggest a diagnosis of pancreatitis. Furthermore, the diagnosis must be confirmed by other diagnostic modalities, and normal test results do not eliminate the possibility of pancreatitis. Abdominal ultrasound is highly specific for pancreatitis in dogs and cats but is not particularly sensitive, especially in cats. Serum cPLI concentration is highly specific for exocrine pancreatic function and is also highly sensitive for pancreatitis. Similarly, initial data would suggest that serum fPLI is the most sensitive and specific diagnostic test for feline pancreatitis. Until further data are available, however, serum fPLI should be used in conjunction with other diagnostic tests to arrive at a diagnosis of feline pancreatitis. Histopathologic evidence of pancreatitis is conclusive for a diagnosis of pancreatitis. In most cases, however, lesions are localized, and the lack of histopathologic evidence of pancreatitis does not eliminate a diagnosis of pancreatitis.     

Idiopathic sclerosing orbital pseudotumor in seven cats

OBJECTIVE: To review the clinical presentation and histopathologic findings on a series of cats with orbital fibrotic disease and compare the data to that of humans with sclerosing orbital pseudotumor. ANIMALS: A retrospective study was undertaken, which identified tissue samples from seven cats between 1997 and 2002 with a history of orbital mass effect and pathology characterized by fibrous tissue proliferation. PROCEDURE: Information was obtained from medical records for affected cats, including age, sex, clinical signs, management, and outcome, with histopathology re-examined. RESULTS: Six of seven cats presented with unilateral orbital involvement that progressed to bilateral orbital disease despite treatment. Onset was insidious, evolving over weeks to months and was associated with fixation of orbital structures. Owners of six of the cats opted for euthanasia because of disease progression and pain. Histopathology of affected orbital tissue included extensive fibrosis with encapsulation of normal tissues without characteristics of neoplasia. CONCLUSIONS: Clinical findings and histopathology of globes and orbital tissues in cats bore many similarities to idiopathic sclerosing orbital pseudotumor in humans. In cats, the prognosis for the globe appears to be poor but an elucidation of the pathogenesis and earlier diagnosis coupled with more aggressive treatment modalities as indicated in humans may be beneficial.     

Feline ureteral strictures: 10 cases (2007-2009)

Background: Feline ureteral obstructions have emerged as a common problem. Ureteral strictures rarely are reported as a cause and the predisposing factors and clinical course of this condition have not been described. Objectives: Evaluate cases of feline ureteral strictures and characterize historical features, clinical signs, diagnostic imaging, surgical and endoscopic findings, histopathology, treatment modalities, and short‐ and long‐term outcomes. Animals: Ten cats diagnosed with ureteral strictures based on compatible findings from at least 2 of the following: ultrasonography, ureteropyelography, surgical exploration, or histopathology. Methods: Retrospective study. Results: Median age, serum creatinine concentration, and size of the renal pelvis were 12 years, 3.7 mg/dL, and 11.75 mm, respectively. Six of 10 cats had hyperechoic periureteral tissue on ultrasound examination at the stricture site. Four cats had evidence of a circumcaval ureter at surgery. Eight cats had an intervention including ureteral stent placement (n = 6) and traditional surgery (n = 2). Seven of 8 cats had decreases in serum creatinine concentration and renal pelvic parameters preceding discharge and 6 had persistently improved results at their last examination. All patients survived to discharge. Median survival time was >294 days (range, 14 to >858 days) with 6/10 cats still alive. Conclusions and Clinical Importance: Ureteral strictures may occur in cats secondary to ureteral surgery, inflammation, a circumcaval ureter, impacted ureterolithiasis, or for unknown causes. With appropriate and timely intervention, the prognosis for long‐term survival is good. In addition to ureteral reimplantation or ureteronephrectomy, ureteral stenting or SC ureteral bypass may be considered as future therapeutic options.     

Veterinary Neurologic Rehabilitation: The Rationale for a Comprehensive Approach

The increase in client willingness to pursue surgical procedures, the heightened perceived value of veterinary patients, and the desire to provide comprehensive medical care have driven the recent demand of using an integrative treatment approach in veterinary rehabilitation. Physical therapy following neurologic injury has been the standard of care in human medicine for decades, whereas similar rehabilitation techniques have only recently been adapted and utilized in veterinary medicine. Spinal cord injury is the most common neurologic disease currently addressed by veterinary rehabilitation specialists and will be the primary focus of this review; however, research in other neurologic conditions will also be discussed. Of particular interest, to clients and veterinarians are techniques and modalities used to promote functional recovery after neurologic injury, which can mean the difference between life and death for many veterinary patients.The trend in human neurologic rehabilitation, often regardless of etiology, is a multimodal approach to therapy. Evidence supports faster and improved recoveries in people after neurologic injury using a combination of rehabilitation techniques. Although the primary neurological disorders researched tend to be spinal cord injury, peripheral neuropathies, allodynia, multiple sclerosis, and strokes—many correlations can be made to common veterinary neurological disorders. Such comprehensive protocols entail gait training activities in combination with neuromuscular electrical stimulation and directed exercises. Additionally, pain-relieving and functional benefits are bolstered when acupuncture is used in addition to rehabilitation. Studies, both laboratory and clinical, support the use of acupuncture in the management of neurologic conditions in small animals, specifically in cases of intervertebral disc disease, other myelopathies, and neuropathic pain conditions. Acupuncture’s ability to promote analgesia, stimulate trophic factors, and decrease inflammation, including neuroinflammation, make it an alluring adjunct therapy after neurologic injury.Although there is limited research in veterinary medicine on physical techniques that expedite recovery after neurologic injury, there are sparse publications on clinical veterinary research suggesting the benefits of acupuncture, rehabilitation, and LASER in dogs with intervertebral disk disease. Accordingly, due to the relative lack of evidence-based studies in veterinary neurologic rehabilitation, much of the data available is human or laboratory-animal based, however, evidence supports the utilization of an early, comprehensive treatment protocol for optimal neurologic recovery. The rationale for why an integrative approach is critical will be detailed in this review; in addition, literature on specific physical rehabilitation techniques that have evidence of improved recoveries after neurologic injury, will be addressed.     

Image-guided interventional procedures in the dog and cat

Medical imaging is essential for the diagnostic workup of many soft tissue and bone lesions in dogs and cats, but imaging modalities do not always allow the clinician to differentiate inflammatory or infectious conditions from neoplastic disorders. This review describes interventional procedures in dogs and cats for collection of samples for cytological or histopathological examinations under imaging guidance. It describes the indications and procedures for imaging-guided sampling, including ultrasound (US), computed tomography (CT), magnetic resonance imaging and fluoroscopy. US and CT are currently the modalities of choice in interventional imaging.     

Head trauma in the cat: 2. assessment and management of traumatic brain injury

PRACTICAL RELEVANCE: Feline trauma patients are commonly seen in general practice and frequently have sustained some degree of brain injury. CLINICAL CHALLENGES: Cats with traumatic brain injuries may have a variety of clinical signs, ranging from minor neurological deficits to life-threatening neurological impairment. Appropriate management depends on prompt and accurate patient assessment, and an understanding of the pathophysiology of brain injury. The most important consideration in managing these patients is maintenance of cerebral perfusion and oxygenation. For cats with severe head injury requiring decompressive surgery, early intervention is critical. EVIDENCE BASE: There is a limited clinical evidence base to support the treatment of traumatic brain injury in cats, despite its relative frequency in general practice. Appropriate therapy is, therefore, controversial in veterinary medicine and mostly based on experimental studies or human head trauma studies. This review, which sets out to describe the specific approach to diagnosis and management of traumatic brain injury in cats, draws on the current evidence, as far as it exists, as well as the authors' clinical experience.     

Feline alimentary lymphoma: 2. Further diagnostics, therapy and prognosis

PRACTICAL RELEVANCE: Accurate diagnosis of the distinct subtypes of alimentary lymphoma (AL) that occur in cats is important as there are major differences between them in clinical presentation, treatment and prognosis. Unlike intermediate- and high-grade alimentary lymphoma (I/HGAL) and large granular lymphocyte lymphoma (LGLL), which can often be diagnosed by aspiration cytology, full-thickness intestinal biopsies are usually required for the diagnosis of low-grade alimentary lymphoma (LGAL). CLINICAL CHALLENGES: LGAL is an increasingly recognised clinical problem and it can be challenging to differentiate from inflammatory disease. Where there is ambiguity on histology, further diagnostics (immunophenotyping and clonality analysis) may be required. The diagnosis of LGLL requires an index of suspicion as it may be missed with routine diagnostics. While cats with LGAL typically achieve durable remissions with oral prednisolone and chlorambucil, I/HGAL runs a more aggressive clinical course and requires multi-agent chemotherapeutic protocols. Information on the treatment of LGLL is limited and this form of AL has the poorest prognosis. Preliminary studies suggest that abdominal irradiation may potentially be of benefit in cats with AL and further investigations are warranted. EVIDENCE BASE: The evidence supporting this review is derived from grade II, III and IV prospective studies, retrospective case series, reviews, extrapolation from other species, pathophysiological justification and the combined clinical experience of those working in the field.     

The cardiopulmonary effects and quality of anesthesia after induction with alfaxalone in 2‐hydroxypropyl‐β‐cyclodextrin in dogs and cats: a systematic review

To systematically review the quality of evidence comparing the cardiopulmonary effects and quality of anesthesia after induction with alfaxalone vs. other anesthetic agents in dogs and cats. Studies published from 2001 until 20th May 2013 were identified with the terms ‘alfaxan’ OR ‘alfaxalone’ OR ‘alphaxalone’ in electronic databases: Discovery, PubMed, ScienceDirect, and Wiley Interscience. The study design and risk of bias of all included studies were assessed. Twenty‐two studies from 408 (22 of 408, 5.39%) satisfied the inclusion criteria. Fourteen studies (14 of 22, 64%) focused on dogs and nine (9 of 22, 40%) on cats. One study had both dogs and cats as subjects. (Hunt et al., 2013) Twelve studies were rated an LOE1, and six of these as ROB1. One, seven, and two studies were rated as LOE2, LOE3, and LOE5, respectively. In dogs, strong evidence shows that induction quality with either alfaxalone‐HPCD or propofol is smooth. Moderate evidence supports this finding in cats. In dogs, moderate evidence shows that there is no significant change in heart rate after induction with either alfaxalone‐HPCD or propofol. In cats, moderate evidence shows no significant difference in postinduction respiratory rate and heart rate between alfaxalone‐HPCD and propofol induction. Strong evidence shows dogs and cats have smooth recoveries after induction using either alfaxalone‐HPCD or propofol, before reaching sternal recumbency.     

The Use of Treadmills Within the Rehabilitation of Horses

Treadmills and water treadmills are found in research centers, therapy centers, and are becoming increasingly common in private competition yards, yet little evidence exists which informs their use for rehabilitation of injury. The control that they afford in terms of speed, intensity, and duration of exercise is attractive, but guidance regarding any possible benefits and/or contraindications for treadmill exercise in any given scenario is limited. In this review, the evidence pertaining to the physiology and biomechanics of treadmill exercise in horses is examined and combined with our experiences of using treadmills for rehabilitation over 15 years to offer some basic guidelines as to their use. Evidence is presented to support the use of a land treadmill in the rehabilitation of horses following various distal limb conditions and back pain. The effects of water treadmill exercise on limb and back kinematics are considered and suggestions made as to how to select the most appropriate water depth for various conditions. Successful rehabilitation depends as much on avoidance of unsuitable exercise as selection of beneficial exercise. In time, more evidence regarding the use of treadmills for specific conditions will accrue; but as horses commonly suffer from multiple conditions (e.g., hindlimb lameness and back pain), it is likely that a rationale devised on a case by case basis will always be necessary, with regular monitoring of the gait pattern throughout rehabilitation.     

Exogenous Insulin Treatment after Hypofractionated Radiotherapy in Cats with Diabetes Mellitus and Acromegaly

Background: The optimal treatment for feline acromegaly has yet to be established. Surgical and medical therapies are minimally effective although radiotherapy might have greater efficacy. The purpose of this study was to review the response and outcome of cats with acromegaly and insulin-resistant diabetes mellitus (DM) to radiotherapy.
Hypotheses: That radiotherapy improves glycemic control in cats with acromegaly and that improved glycemic control is due to remission of clinical acromegaly; demonstrated by a fall in serum insulin-like growth factor-1 (IGF-1) concentrations.
Animals: Fourteen cats with naturally occurring acromegaly.
Methods: Retrospective case review; records of all cats treated for acromegaly with radiotherapy were reviewed from 1997 to 2008. Cats were selected on the basis of compatible clinical signs, laboratory features, and diagnostic imaging findings. Fourteen cats received radiotherapy, delivered in 10 fractions, 3 times a week to a total dose of 3,700 cGy.
Results: Thirteen of 14 cats had improved diabetic control after radiotherapy. These improvements were sustained for up to 60 months. DM progressed in 2 cats and 1 did not respond. Seven cats responded before the final treatment. Ten cats were euthanized, 1 as a consequence of radiotherapy. In 8 cats in which IGF-1 was measured after treatment, changes in its concentration did not reflect the clinical improvement in glycemic control.
Conclusions and Clinical Importance: Radiotherapy represents an effective treatment for cats with insulin-resistant DM resulting from acromegaly. IGF-1 concentration after treatment does not provide a suitable method by which remission from either acromegaly or insulin-resistant DM may be assessed.     

CT angiography and MRI imaging features do not predict the tumor type and grade of feline injection site sarcoma

Computed tomographic angiography (CTA) and magnetic resonance imaging (MRI) have been described as methods for preoperative surgical planning in cats with feline injection site sarcomas (FISS), however, few published studies have compared these modalities. The objective of this retrospective, secondary analysis study was to determine if imaging features of FISS on CTA and MRI are predictive of neoplastic peritumoral projections. Archived data from a previous prospective study were retrieved for 10 cats with FISS. All cats had been evaluated in a single anesthetic episode with MRI and dual phase CT (CTA) imaging followed by surgical removal. Histopathological grading and targeted histopathology of imaging‐identified peritumoral projections were performed. Two observers evaluated the CTA and MRI studies for FISS shape, margination, size, enhancement pattern, postcontrast uniformity, pre‐ and postcontrast margination, the number of muscles involved, mass mineralization, and bone lysis. Metal was present in the imaging field of three of 10 cats, resulting in one nondiagnostic MRI. Peritumoral projections were detected in all cats with both imaging modalities, and most were benign. At least one neoplastic peritumoral projection was detected in six cats using MRI, five cats using CTA, and three cats with both modalities. Higher grade FISS were larger than low grade using MRI, and FISS were larger using MRI. Other FISS imaging features using MRI and CTA were similar. Findings supported use of either MRI or CTA for detecting neoplastic peritumoral projections in cats with FISS. Authors recommend CTA for cats with known metallic objects in the scan field.     

Current understanding of feline diabetes: part 2, treatment.

When treating diabetic cats, the primary aim is to control clinical signs without causing clinical hypoglycaemia. Secondary goals are to maximise the chances of attaining diabetic remission and to minimise the risk of complications due to chronic hyperglycaemia. A treatment plan that is convenient for the owner is important for compliance. Underweight or overweight diabetic cats should be fed with the aim of normalising bodyweight. Current evidence suggests that non-obese diabetic cats can be fed ad libitum. The oral hypoglycaemic drug glipizide is well established as a treatment for about a third of diabetic cats, which have residual beta cell function. Preliminary studies on other oral agents such as vanadium salts, metformin, and troglitazone indicate a potential use in some diabetic cats. Insulin treatment remains the treatment of choice for the majority of diabetic cats. Choice of insulin, dose rates and monitoring of treatment are discussed.     

What's in a Name? Classification of Diabetes Mellitus in Veterinary Medicine and Why It Matters

Diabetes Mellitus (DM) is a syndrome caused by various etiologies. The clinical manifestations of DM are not indicative of the cause of the disease, but might be indicative of the stage and severity of the disease process. Accurately diagnosing and classifying diabetic dogs and cats by the underlying disease process is essential for current and future studies on early detection, prevention, and treatment of underlying disease. Here, we review the current etiology‐based classification of DM and definitions of DM types in human medicine and discuss key points on the pathogenesis of each DM type and prediabetes. We then review current evidence for application of this etiology‐based classification scheme in dogs and cats. In dogs, we emphasize the lack of consistent evidence for autoimmune DM (Type 1) and the possible importance of other DM types such as DM associated with exocrine pancreatic disease. While most dogs are first examined because of DM in an insulin‐dependent state, early and accurate diagnosis of the underlying disease process could change the long‐term outcome and allow some degree of insulin independence. In cats, we review the appropriateness of using the umbrella term of Type 2 DM and differentiating it from DM secondary to other endocrine disease like hypersomatotropism. This differentiation could have crucial implications on treatment and prognosis. We also discuss the challenges in defining and diagnosing prediabetes in cats.     

Feline alimentary lymphoma: 1. Classification, risk factors, clinical signs and non-invasive diagnostics

PRACTICAL RELEVANCE: Alimentary lymphoma (AL) occurs commonly in cats and exists as distinct subtypes that differ in their clinical course, response to treatment and prognosis. Accurate diagnosis is important to guide appropriate treatment. CLINICAL CHALLENGES: Differentiation of low-grade alimentary lymphoma from lymphoplasmacytic enteritis can be challenging, especially where endoscopic intestinal biopsies, which sample only the mucosa and submucosa, are used. The major differentials for intermediate- and high-grade alimentary lymphoma are other neoplastic and non-neoplastic intestinal mass lesions. The diagnosis of large granular lymphocyte lymphoma requires vigilance as it may be missed with routine diagnostics. PATIENT GROUP: AL affects predominantly middle- to old-aged domestic crossbred cats (median age 10-13 years). EVIDENCE BASE: The evidence supporting this review is grade II, III and IV, derived from prospective studies, retrospective case series, reviews, extrapolation from other species, pathophysiological justification and the combined clinical experience of those working in the field.     

A review of phosphorus homeostasis and the impact of different types and amounts of dietary phosphate on metabolism and renal health in cats

Elevated concentrations of serum phosphate are linked with progression and increased case fatality rate in animals and humans with chronic kidney disease. Elevated concentrations of serum phosphate can be a risk factor for development of renal and cardiovascular diseases or osteoporosis in previously healthy people. In rodents, an excess intake of dietary phosphorus combined with an inverse dietary calcium : phosphorus ratio (<1 : 1) contributes to renal calcification. Renal injury also has occured in cats fed experimental diets supplemented with highly soluble phosphate salts, especially in diets with inverse calcium : phosphorus ratios. However, not all phosphorus sources contribute similarly to this effect. This review, which focuses on cats, summarizes the published evidence regarding phosphorus metabolism and homeostasis, including the relative impact of different dietary phosphorus sources, and their impact on the kidneys. No data currently shows that commercial cat foods induce renal injury. However, some diets contain high amounts of phosphorus relative to recommendations and some have inverse Ca : P ratios and so could increase the risk for development of kidney disease. While limiting the use of highly soluble phosphates appears to be important, there are insufficient data to support a specific upper limit for phosphate intake. This review also proposes areas where additional research is needed in order to strengthen conclusions and recommendations regarding dietary phosphorus for cats.     

Echocardiographic Findings in 11 Cats with Acromegaly

Background

Information regarding cardiac changes in domestic cats with acromegaly is limited.

Hypothesis/Objectives

The objective of this study was to describe the echocardiographic findings in cats with acromegaly.

Animals

Eighteen cats diagnosed with acromegaly at Colorado State University between 2008 and 2012. Of these 18 cats, 11 had echocardiography performed.

Methods

A retrospective review of medical records was made to identify cats with acromegaly that also had echocardiography performed.

Results

Of the 11 cats identified, 7 had left ventricular concentric hypertrophy, 6 had left atrial enlargement, and 7 had evidence of abnormal diastolic function. All 11 cats had evidence of structural or functional cardiac disease.

Conclusions and Clinical Importance

Cardiovascular abnormalities frequently are present in cats with acromegaly, and a complete cardiac evaluation should be considered in these patients.