Our canine patients are living longer thanks to more sensitive diagnostics, improved medications and treatments, and our clients’ commitments to providing their furry family members with the best care. Especially in our larger canine patients, most of them will deal with arthritis pain as they age. Luckily, this is an area that continues to see additional options in management and treatment for our patients.
We know that a multi-modal approach in management of osteoarthritis will give the best results, but really, we want to intervene before boney changes are seen on radiographs. If you identify patients at risk for development of osteoarthritis—due to size or conformational disorders—we need to help those clients intervene early, before pain limits their pet’s activity.
We’ve heard it many times before: a lean body weight is one of the best ways to minimize inflammation from arthritis. Excess fat is both a mechanical force on the joints and also induces more inflammation. In addition, this can be one of the most frustrating parts of treatment if your patient is already overweight or obese. It is best to discuss a healthy, lean body weight with your clients, even starting as a puppy, and incorporate your discussion of lean body weight into every interaction. Getting your staff on board is key as well. You can start by helping them learn what a lean dog should look like and identifying ideal body types within your patients.
Here are some specific recommendations you can incorporate into practice every day:
1. Have charts or pictures showing a variety of dogs that are underweight, ideal, overweight and obese. Beyond manufacturers’ available charts, there are many new artwork options that are attractive for your hospitals, and can be displayed in your lobby and exam rooms.
2. Incorporate similar resources into your new puppy and annual exam report cards for clients. Always make sure to include the pet’s weight and body condition score in your report card, as well as the pet’s projected ideal body weight.
3. Make specific recommendations to help your patients lose weight, including diet, exercise and nutritional supplements.
All dogs need exercise—even those lap dogs! Weight-bearing exercise and movement are needed to maintain range of motion in joints. Again, early intervention is key; these recommendations should be made to clients starting in puppyhood. Exercise recommendations will vary based on age, breed and any disease processes for that patient. Exercise plans should ask the pet for full range of motion of their joints and work to maintain strength by doing a variety of activities. Through research in rehabilitation, we know that strengthening muscles around joints will improve the stability of those joints, resulting in reduced pain. This is another area where we want to get staff on board in client communication, and it can be a great focus for your social media accounts as well.
Here are some recommendations specific to exercise that you can incorporate into your practice:
1. Encourage clients to do some form of activity with their dog every day; consider walks or hiking, chasing toys inside or outside if appropriate, or training exercises.
2. For pets with mobility-related issues, consider consulting with a rehabilitation therapist to develop a home exercise program for the pet.
3. Make sure that muscle mass scoring and strength scoring is part of your annual exam process and document it in the medical record and on the client report card.
There are some additions to diet to consider for patients with osteoarthritis. Your diet recommendations will change based on life stage and weight, as referenced above, but consider the following when making diet recommendations:
1. High levels of Omega-3 fatty acids can be added, specifically EPA and DHA, which are very anti-inflammatory. These need to be fed far in excess of Omega-6 fatty acids to be effective (a 7:1 ratio is recommended.) Generally, cold-water-sourced fish is the most plentiful source. These can be fed through a joint-specific prescription diet or supplemented through a high-quality, dog-specific bioavailable supplement.
2. Sufficient protein is needed to both build and maintain muscular mass. Especially if calories are being restricted for weight loss, make sure to maintain enough grams of protein. If the pet has muscular atrophy, consider supplementing with Fortetropin to stop sarcopenia and help build muscular mass more quickly.
3. Owners like to treat their dogs, and if they are working on a home exercise program, treats are needed. Make sure to reserve 10% of the projected calorie intake for treats, and it’s important to give specific treat recommendations to clients. Many highly-marketed dog treats are very calorie dense and can sabotage your weight loss and fitness goals.
Our options for pain management—especially for osteoarthritis—are more numerous than ever. It is important to localize the pain to help make more specific pain management plans. Some of our options are most effective at joint pain, some are anti-inflammatory and others are modalities that treat only a portion of the body.
If these options are not available in your practice, consider referral to a rehabilitation specialist for more options:
1. Traditional, non-steroidal anti-inflammatory drugs like carprofen, meloxicam and firocoxib are great for the short term. For longer-term use, consider a novel anti-inflammatory like grapiprant, or incorporating an anti-inflammatory modality to reduce reliance on these medications that can cause gastrointestinal upset or ulcers, and may be contraindicated if your patient has renal or hepatic disease.
2. Disease-modifying osteoarthritic agents like Adequan help to specifically decrease inflammatory mediators in joints and maintain cartilage depth to slow the progression of osteoarthritis. These work best when started earlier in arthritis development and may be of less use in end-stage osteoarthritis when little cartilage is left.
3. Modalities like LASER (light amplification by the stimulated emission of radiation) and PEMF (pulsed electromagnetic field therapy) help to improve blood flow and reduce inflammation and pain, and are widely available. Some of these are available for prescription to clients to use at home (PEMF devices including beds and lower-powered LASER), while some require trips to the practice (Class IV LASER).
4. Advanced modalities like ESWT (extracorporeal shockwave therapy) or targeted joint injections like Synovetin OA may require sedation, but often have long-lasting effects of one year or more before therapy needs to be repeated.
5. Complementary therapies like acupuncture, canine massage and spinal manipulation therapy help to decrease muscular pain and spasm, decrease inappropriate neurologic pain signals and help restore mobility.
6. Additional pain-blocking medications like gabapentin, amitriptyline or amantadine can accompany your anti-inflammatory pain for osteoarthritis, especially in the later stages of this disease process.
While osteoarthritis treatment is not curative, a multi-modal management plan can help your patients maintain an active lifestyle with a great quality of life. Specific owner questionnaires, like the Canine Brief Pain Inventory (CBPI), Canine Orthopedic Index (COI) and Liverpool Osteoarthritis in Dogs (LOAD) can help you detect pain or disability in your patients. They have been validated and are responsive, so they can also be used to measure response to treatment.
Also consider use of Client-Specific Outcome Measures to help your clients identify functional limitations specific to their pet, and monitor how these improve in response to treatment. Consider incorporating these into your annual exams for senior patients to identify signs of pain in your patients earlier and monitor their response to treatment. +