further veterinary intervention
TOD SAYS...
Your vet is the only person who is legally allowed to diagnose and medically or surgically manage your dog.
Arthritis is a complex disease initially localised to the joint but over time impacts the rest of the body and mind. There are a vast array of ways that this disease will present itself as arthritis of the elbow will progress differently to arthritis of the hip. Add in individual variation due to age, breed, sex, weight, lifestyle, co-morbidities and you have a disease that can create countless presentations. A one-size-fits-all approach is impossible. Some dogs may cope with their arthritis very well with weight control and lifestyle adaptations, whereas others will have had surgery and be on 3-4 medications, weight control, hydrotherapy, laser therapy, lifestyle adaptations, controlled exercise and still the pain of arthritis is difficult to control.
Whilst starting with holistic and often simple lifestyle changes is always preferred, there are inevitably times where some degree of further veterinary intervention is required, be that non-steroidal anti-inflammatory medications or a poly-pharmacy and rehabilitative approach, particularly in severe cases or later in the progression of the disease.
additional approaches to your management plan
Listed below are a few additions that are commonly added to a management plan (if not already on board from the diagnosis). This list is by no means exhaustive, but offers the reader an understanding of additional approaches as well as a guide to start further discussion with their veterinarian.
Is an opioid available alongside paracetamol in a veterinary licenced product called Pardale-V. It is often added in the short term to an NSAID to offer additional pain relief. Its bioavailability at the recommended dose is now in question, but anecdotally some owners feel it offers their dog improved pain control.
These are very powerful government controlled pain relieving drugs and are generally not used on an outpatient basis, but may be used in a practice to control acute pain of an arthritic flare up.
Tramadol is a synthetic opioid (as well as other things) with a wide safety margin that has been prescribed to outpatients extensively in the past, but recent evidence suggests that dogs do not efficiently metabolise it into its active form thus offering minimal benefit. However, there are anecdotal reports from owners who feel it is of great benefit to their dog.
Amantadine is a different class of medication called an NMDA receptor antagonist, which works synergistically with non-steroidal anti-inflammatories (NSAIDs) through a different region of the pain pathway.
It tends to be prescribed when pain is not controlled through NSAIDs alone and has varying dosing guidelines.
Memantine is a “relative” of amantadine with similar action.
Originally an anti-epilepsy drug, gabapentin has gained great popularity recently for managing chronic pain, and neuropathic pain. However, it has not proven itself in strict clinical trials. It is commonly used in addition to a NSAID.
The dose range is wide and must be tailored to effect with each dog. The initial dose should be low and the frequency and dose increased until a desired effect is noted. Finding the appropriate dose can be lengthy. With no clinical trial to refer to, advice is commonly based on specialist experience and opinion, as well as extrapolation from other species.
It is advised it is trialled for 4 weeks before discounting it as ineffective, but anecdotally there are some dogs that do well on it and others that do not.
Side-effects regularly mentioned are sleepiness, muscle weakness and weight gain. Anecdotally a common cause of the side effects are starting at too high a dose. Staring low and allowing the body to grow accustomed is always wise.
Gabapentin should not be stopped suddenly, but weaned off over a couple of weeks.
Pregablin is a relative of gabapentin with similar action.
Laser therapy has recently become very popular, with many veterinary practices using it as an adjunct or alternative chronic pain management modality.
Laser, “light amplification by stimulated emission of radiation”, technically known as photobiomodulation, aims to stimulate the body’s own healing mechanisms. It is considered to offer a reduction in pain sensitivity, reduce inflammation and promote healing.
Hydrotherapy is well established in arthritis management. Through its hydrostatic pressure, buoyancy, warmth, and resistance it can support and accelerate recovery post orthopaedic surgery, and aid in management of musculoskeletal diseases such as osteoarthritis. It can easily be argued introducing it early is better than adding it late with the hope it will improve pain management. However, it is often added later in the disease and can have a role in controlling pain as well as aiding in rebuilding function.
A significant number of practices are incorporating either a hydrotherapy pool or treadmill into their facilities or forming strong relationships with local centres.
Physiotherapy and a rehabilitative approach is best added early into a management plan, however it is not uncommon for them to be later added when pain management has become more complicated.
A rehabilitative mindset is to control pain, promote tissue healing and return the patient to full or near full independent mobility/ function. Many different modalities can be used to support this journey, such as laser, therapeutic ultrasound, manual therapies, electro-therapies and targeted exercises. These modalities can be added into a management plan alongside medications with the intention of improving pain control.
Some practices now employ a physiotherapist to run an in-house rehabilitation centre so as to ensure case continuity whilst offering a wider range of services.
Integrating physical rehabilitation techniques into a management plan may over time decrease the need for medical intervention.
A surgical approach to management can be simplified into 3 main categories:
- Preventative - a surgery that aims to mitigate the onset of arthritis due to developing joint incongruity (poorly fitting joints), or a damaged joint.
- Stabilising - a surgery that aims to slow the progression or control the pain of arthritis. A good example is surgery to re-establish the stability lost when the cranial cruciate ligament ruptures.
- Salvage - a surgery that aims to improve clinical signs and not to preserve the joint. An example is a total hip replacement, or a femoral head excision for hip arthritis.
It is a huge complex field with some surgical approaches now considered a reliable approach to management, for example a tibial plateau levelling osteotomy for cruciate disease, or total hip replacement for hip arthritis. However, there are still many questions and unknowns, so frank conversations and good communication with your vet is required to ensure you have the necessary information to make the right decision for your dog. The suitability of the patient, the post op recovery requirements, realistic expectations and costs must be discussed prior to committing to any approach.
Find out more about surgery on our Non Surgical versus Surgical page.
Managing the disease through locally treating the joint is common practice in equine medicine, and has relatively recently been introduced to managing canine arthritis.
There are many different intra articular medications/products, some with more evidence of benefit than others. Steroids, hyaluronic acid, platelet rich plasma, stem cells and hydrogels are well recognised intra articular interventions that are being incorporated into small animal practice. Data is still incomplete with clinical trials often small and not well constructed, thus choice of product, timing of intervention, number of repeats and intervals between them, expected efficacy, potential side effects and comparison to other established interventions is often derived from the veterinarian’s experience.
Dr Cameron Black, CAM’s specialist education adviser, has extensive experience in this field and offers much more advice and information in the Member Zone.
