was limited. Physiotherapy was performed three times daily by the owner. As the rigidity in her hindlimbs reduced, she also attended monthly chiropractic sessions, with increasing intervals between sessions as her mobility improved. The owner chose to attend chiropractic sessions as the practitioner was local, had been recommended and was registered with the Veterinary Chiropractic Association. Physiotherapy is often the preferred option to reduce muscle stiffness, as chiropractic adjustments can be too forceful for patients recovering from tetanus [ 11 ]. However, in this case, the chiropractor was able to adjust her treatments accordingly to aid the owner with effective massage and range-of-motion techniques to benefit Sybil ' s recovery.
By week 10, Sybil was beginning to flex the stifle and hock on her right hindlimb. On a repeat examination in week 13, a secondary grade 3 medial luxation of the right patella was noted, but by 18 months this had self-corrected. A case of luxation of the coxofemoral joint in a cat with hindlimb localised tetanus has been reported [ 12 ], but no other cases of joint luxation have been reported in the sparse literature on tetanus in cats. Due to the severe muscle rigidity and spasms associated with tetanus, patients should be monitored for luxation throughout recovery. By the beginning of week 15, Sybil was no longer on medication.
At month 18, during a repeat examination to confirm recovery of the patellar luxation, mildly reduced flexion of the patient ' s right hock was noted, but this did not affect her normal activities. Sybil has otherwise returned to normal function with no long-term side effects( Figure 3). However, early onset of arthritis is a possibility as a result of the severity of rigid extension of the hindlimbs, so she is receiving long-term medication with joint supplements.
Nursing considerations
Nursing a patient with tetanus often requires supportive and intensive care in a 24-hour veterinary hospital. The paralysis of the hindlimbs and subsequent muscle spasms cause a lot of discomfort, so regular pain score assessments and multimodal analgesia are crucial to ensure the patient ' s pain is well managed. Although sometimes criticised for being subjective, pain scoring is still very helpful when assessing whether pain is being well managed, as it allows veterinary nurses( VNs) to monitor trends and changes in behaviour that may indicate whether a patient ' s pain is becoming more or less severe [ 8 ]. In this case, it was very evident that Sybil was in significant pain, as she was vocalising and demonstrating aggressive behaviours on palpation of her hindlimbs, whereas she is normally a friendly and affectionate cat. This highlights the importance of knowing the normal behaviour and character of a patient, which should be acquired by questioning the owner on admission.
Sybil was unable to ambulate for several weeks and was on potent analgesia. To prevent pressure sores, she was provided with thick bedding and an incontinence pad for toileting, as a standard litter tray would have been too challenging for her to access due to the high rim. For patients that are unable to mobilise at all, regular rotation from lateral to sternal recumbency will help prevent decubitus ulcers and respiratory complications [ 13 ]. Regular grooming of Sybil ' s coat using a waterless shampoo and flannel was undertaken, as she was unable to adequately self-groom following urination. Without this intervention, there was a significant risk of urine scalding. As cats typically maintain a clean coat themselves, an inability to do so may adversely affect both their health and demeanour. It is therefore essential that VNs provide appropriate grooming care while also fostering a positive bond with the patient during the process. In addition, any wounds on the patient that are likely to have been the source of infection will need thorough cleaning and debriding, with the aim of decontaminating the area [ 14 ].
Patients with tetanus are often hypersensitive to stimuli such as light, touch and noise [ 14, 15 ]. Nursing these patients in a room where the light can be dimmed and noise is minimal is preferable, but if a separate room is not possible then techniques such as placing cotton wool in the patient ' s ears to reduce noise levels and putting a towel over the front of the kennel to dim the lighting can reduce spasms and improve patient comfort.
Figure 2. The patient, 18 months after the onset of clinical signs.
While many cats will continue to eat and drink normally throughout their recovery, those that do not will require IV fluids to maintain hydration. The IV catheter should be placed in an unaffected limb to avoid triggering pain and muscle spasms [ 14 ]. If the patient were to stop eating, they would also require placement of a feeding tube, although this is rarer in cats than in dogs as cats
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