Multi-modal Management of Arthritis
Written by Kristin Kirkby, DVM, MS, CCRT, Diplomate ACVS
Non-steroidal anti-inflammatories (NSAIDs) are the first line of pain relieving medication used in small animals. These medications decrease inflammation and relieve pain associated with acute trauma and/or chronic arthritis. Examples of veterinary NSAIDs include: Deramaxx, Rimadyl, Metacam, Previcox, and Zubrin.
***It is essential that you follow the recommended dosing for the individual medication prescribed. Side effects can occur with these drugs that can potentially be severe. If your pet starts vomiting, stops eating or develops other signs of GI upset, please discontinue the medication and call us or your regular veterinarian right away.
***It is essential that these medications not be combined with steroids, aspirin, or other NSAIDs. Do not give a new or different NSAID within 7 days of stopping the previous medication. Similarly, do not give an NSAID within 7 days of aspirin, prednisone or any other steroid.
If your pet is intolerant or does not respond to NSAIDs, other pain relievers can be prescribed, including Tramadol, gabapentin and amantidine.
Weight loss/ management
It has been shown that the most effective way of decreasing the pain and progression of arthritis in both people and pets is by maintaining a lean body weight. In dogs and cats, this often means that they are “on the skinny side of normal”. In other words, you should be able to see a waistline from the top and from the side, and should be able to feel but not see the ribs.
Weight loss is best achieved through a combination of diet and exercise. Just like in people, it is all about calories in vs. calories out. If your pet needs to lose weight, it is essential that the proper amount of calories be given throughout the day: this often means decreasing the quantity of food being fed and most importantly, decreasing the amount of high calorie treats.
Arthritis is a vicious cycle of cartilage breakdown, leading to increased production of inflammatory products, which then lead to further degeneration of cartilage. There are several ways that we can decrease the breakdown of cartilage and slow the progression of arthritis.
Adequan: This is a polysulfated glycosaminoglycan, which is a large molecule that is very similar to a normal part of cartilage. The medication has been shown to decrease joint inflammation and protect cartilage, delaying the progression of arthritis and decreasing pain. This medication is given under the skin or into the muscle twice a week for 4 weeks and then once a month.
Glucosamine and chondroitin sulfate: These are also components of normal articular cartilage. Supplementing these molecules has been shown to decrease the degeneration of cartilage and decrease pain. These are available as supplements that are given orally or are available already combined in certain diets. There are no federal regulations with regard to the products available commercially. Therefore, some products may not contain the amount of glucosamine or chondroitin that the label claims. We recommend the veterinary specific brand Dasuquin, which has been shown to contain the appropriate amount of glucosamine and chondroitin and additionally contains ASU and MSM, which have additional beneficial effects.
High levels of omega 3 fatty acids are capable of decreasing inflammation associated with arthritis. Diets that are high in omega 3 fatty acids have been found to improve lameness, decrease pain, increase activity, and reduce the need for NSAIDs in dogs with arthritis. In order to supplement the same amount of omega 3 fatty acids that are found in the therapeutic diets, a 60 pound dog would require about 40 capsules of fish oil every day, which is not practical or cost effective. We recommend the therapeutic food Hills j/d, as this is the diet that has proven results in dogs with arthritis.
Physical rehabilitation/ therapeutic exercise
Regular controlled physical activity is an important aspect of managing arthritis. Low impact exercises such as walking and swimming are the corner stone of physical rehabilitation. Other exercises should be incorporated that strengthen the muscles supporting effected joints, increase core strength, improve joint range of motion, increase endurance, and improve body coordination. Home exercises are very effective if 30 minutes can be dedicated to exercising your dog every day. Additionally or alternatively, therapy appointments can be scheduled with a rehabilitation therapist. These sessions typically last 30 minutes and will incorporate exercise therapy along with manual therapy such as massage and therapeutic modalities (see below). The most important thing to remember is that regular, controlled exercise is needed rather than “weekend warrior” or infrequent/ high intensity activities.
A therapeutic modality is a device or tool that transfers energy to the patient for a therapeutic purpose. Common therapeutic modalities include: ice packs, heat packs, laser (“cold laser”), and extracorporeal shockwave therapy.
- Ice packs: Ice is recommended to decrease inflammation following an acute injury or “flair up”. The application of ice decreases the blood flow to the area and decreases the transmission of pain from the site of injury to the brain (numbs the joint). Animals with arthritis can benefit from the application of an ice pack to the effected joint for 15-20 minutes after exercise.
- Heat packs: Heat is recommend to reduce muscle spasms and provide a soothing sensation. The application of heat increase the blood flow to an area. Animals with arthritis can benefit from the application of a warm pack to the low back or muscles surrounding the effected joint. **Heat should be applied at least 2 hours after exercise.
- Laser: Laser therapy, otherwise known as photobiostimulation, is the administration of light energy to the tissue in order to stimulate a biologic response. It has been scientifically proven that cells respond to laser light by increasing the production of ATP (increasing their metabolism). This enables cells to function more efficiently and effectively. The end results of photobiostimulation include: improved wound healing, decreased swelling, decreased pain, and decreased muscle spasms. Laser treatments are painless. A sensation of heat can be felt, but sedation is not required. Treatments take between 5-20 minutes, depending on the size of the area being treatment. Laser energy has a cumulative effect, so several treatments are recommended over the first few weeks, and later “top off” treatments can be administered. Laser therapy is FDA approved for the treatment of carpal tunnel syndrome in humans.
- Extra-corporeal shockwave therapy (ESWT): This modality is a high-powered ultrasound. Sound waves are transmitted to the tissue, which stimulate cells to express growth factors and other molecules that improve healing and decrease pain. ESWT has been used in horses and people for the past 2 decades to treat a variety of musculoskeletal conditions, particularly ligament and tendon injuries. Other conditions that have been shown to respond to ESWT include arthritis, delayed bone healing and chronic, non-healing wounds. This treatment requires heavy sedation. Typically, treatments are administered every 3 weeks for a total of 3.
Additional therapies that are beneficial for the treatment of arthritis include acupuncture, hydrotherapy and regenerative stem cell therapy. We can provide you with a list of facilities that provide acupuncture and hydrotherapy.
Stem Cell Therapy
Stem cell therapy has sparked much controversy over the last several years. It is essential to note that these debates concern embryonic stem cells that are derived from an embryo or fetus and are pluripotent, or capable of differentiating into any cell line. Stem cell therapy that is currently used in veterinary medicine utilizes adult, or mesenchymal stem cells. These cells are derived from an animal’s own bone marrow or fat, and are capable of limited differentiation.
Mesenchymal stem cells have the capacity to differentiate into cartilage, ligament, tendon, bone, muscle, nerve, liver, and cardiac tissue. When stem cells are implanted into a region, they secrete growth factors and other molecules that can stimulate repair and regeneration of tissue, similar to using a bone graft to stimulate fracture healing. It is also believed that inflammation is decreased and pain relieved through this process.
Current clinical indications for stem cell therapy in small animals include:
- Immune-mediated poly-arthritis
- Osteochondrosis/ OCD
- Ligament and tendon injuries
The treatment process:
Patients are evaluated through the surgery department. If current radiographs are not available, they will be obtained. Surgery to collect fat from either the falciform ligament or caudal to the scapula is performed on Tuesdays. Animals are discharged the evening of surgery or the following morning. The collected fat is shipped overnight to Vet Stem, in California, where the stem cells are isolated and then shipped back to SVS, so that we receive the cells 48 hours after collection. The animal must return on Thursday for stem cell injection. Heavy sedation, or sometimes, brief anesthesia is required for stem cell injection into the joints and/ or tendons being treated. Fluoroscopy and/or ultrasound is commonly used to aid injection into severely arthritic joints or directly into tendons. The animals are discharged again Thursday afternoon.
All patients should return for follow up examinations every thirty days, for the first three months. Note: When the initial fat is processed, additional cells will be saved (or banked) for future use, if needed.
We believe that stem cell therapy is most effective when combined with rehabilitation. Therefore, we recommend that patients enroll in a physical rehabilitation program.
Contraindications for stem cell therapy include: cancer (any), and any condition that precludes general anesthesia.
Published on February 3, 2011.