Guest article by
Mary Ellen Goldberg, LVT, CVT, SRA, CCRVN, CVPP, VTS – lab animal medicine (research anesthesia), VTS – physical rehabilitation, VTS – H (anesthesia/analgesia)
NAVTA Vet Tech of the Year, 2017
How vet techs/nurses can help with client adherence to OA treatment
How many patients are seen at your practice daily, monthly, yearly? Whether these patients are young or old, how many are diagnosed with osteoarthritis (OA)? Who is going to be the person responsible for explaining the diagnosis that has been established and for treatment that has been prescribed? Who will be most instrumental in compliance with the program provided?
The answer to these last 2 questions is most often: The vet tech/nurse.
This article will help establish information the vet tech/nurse should know and be able to discuss with their client in laymen’s terms. Veterinary tech/nurses can play an invaluable role in supporting owners and monitoring a dog’s response to treatment.
What vet techs/nurses need to know
Osteoarthritis is a form of chronic pain that is statistically the most common chronic pain condition in dogs. OA is a disease of the entire joint, including synovitis, fibrosis, and atrophy, and it results in pain and progressive disability1. Therefore, it is not curable, however, there are many options to help our pets live comfortable lives with this disease.
What vet tech/nurses should know is that chronic pain almost always involves a degree of sensitization, both centrally in the dorsal horn of the spinal cord and peripherally at the pain generating site. This sensitization, also termed wind-up, amplifies perceived pain beyond what the underlying pathology would otherwise produce.
- How would you explain this to a client? You could give them an example that their pet may have more severe reactions to moving or touching depending upon whether they have been sleeping and just getting up or whether they have been very active such as a long walk or run on a trail.
There are 2 types of OA: primary and secondary. Primary OA implies that there are no inciting causes involved in the disease. However, canine OA is usually secondary to previous joint damage such as trauma or developmental disorders.
- For example, cranial cruciate ligament rupture, articular fracture or osteochondrosis can each initiate the biochemical cascade that leads to arthritis. The susceptibility of any individual to OA is related to factors such as genetics, age, and systemic factors such as obesity.
Helping clients understand chronic pain vs “old age”
Behavioral signs that owners may put down to ‘old age’ rather than chronic pain associated with this disease could include
- restlessness
- changes in sleep pattern
- increased irritability or aggression
- reduced social behavior
- depression, and anxiety
Patients with OA may experience
- joint pain and tenderness
- reduced mobility
- stiffness
- reduced range of motion
- reluctance to exercise
- crepitus
- muscle atrophy
- joint effusion and inflammation.
The pain is associated with direct stimulation of the joint capsule and bone receptors by cytokines and the degradative process. Inflammation occurs through mediators such as prostaglandin E2 within the joint, leading to the release of degradative enzymes, such as aggrecanase and matrix metalloproteinases (MMP) from chondrocytes, which then cause breakdown of the cartilage matrix6. This leads to distorted cartilage mechanics and further injury to the joint. These degenerative processes become a vicious cycle, resulting in cartilage erosion, subchondral bone sclerosis, joint capsule thickening, periarticular new bone formation, and associated pain and loss of function.
The vet tech/nurse is not expected to explain the biochemistry behind the disease of OA; however, they should know this in case the client asks about it.
The diagnosis of OA is based on a combination of history and signalment, physical/orthopedic exam findings, and radiographs; occasionally joint fluid analysis is needed to rule out other joint diseases. Remember that some owners may not have funds for all the testing that can be done for OA. The veterinarian may elect to treat empirically, which means trying certain medications to see if there is an improved outcome for the patient, without a definitive.
Helping clients understand appropriate therapies
As we have stated, there is no cure for OA, but a dog’s quality of life can be greatly improved by appropriate therapies. This is an important point to communicate to the owners and it is vital that they understand this from the very beginning. This is a key role for the veterinary tech/nurse.
Treatment aims to reduce inflammation, provide pain relief, maintain joint mobility, prevent further progression of the disease and improve quality of life. Owners may have been diagnosed with OA themselves. They might ask you about over-the-counter products they use on themselves.
TIP: It is best to have a product list approved by your veterinarians that you can share with clients. This would be an easy task for the vet tech/nurse to compile.
- So, what’s an example of this? There are many cannabis products on the market today. I will not recommend any company unless they are conducting independent research and have labeled ingredients for their product. An example of a company that I’ll share is Ellevet Sciences. You can read this guest article by Stephen Cital to better educate yourself and clients about cannabis usage in dogs.
Treatments for OA can be surgical to non-surgical. Non-surgical utilizes a combination of strategies to provide relief, including analgesia, weight management, exercise control, physical rehabilitation, and the use of nutraceuticals7. Cellular therapies are also now being developed
Helping clients understand healthy weight for their dogs
What is the No. 1 risk factor for OA development? Obesity! That means that every fat pet that walks in the front door of your practice either has OA or will have OA soon. Because so many of our companion animals are fat (59 percent of cats and 54 percent of dogs are overweight or obese, according to the Association for Pet Obesity Prevention), the average person has a hard time knowing what a healthy weight looks like.
TIP: Be sure to share the Body Condition Score from WSAVA (World Small Animal Veterinary Association) with clients.
Caloric restriction and physical rehabilitation have been shown to improve mobility and cause weight loss in a prospective randomized clinical trial of overweight dogs. Are your clients still not convinced? Tell them about Purina’s Life Span Study.
In the study, dogs that maintained a lean body weight lived longer (lean Labrador retrievers in the study lived nearly two years longer) and needed NSAIDs much later in life than their fatter counterparts. The above are 2 great resources to have in the exam room or to take with you when you are asked to talk to the client while your veterinarian is busy.
Talking to clients about rehabilitation
Physical methods of rehabilitation (non-pharmacologic therapy) for the OA patient include heat, cold, water, sound, electricity, massage, and exercise therapy. Overall, benefits are related to
- increased blood flow to the affected areas
- reduction or resolution of inflammation
- preventing or minimizing muscle atrophy
- preventing periarticular contraction
- the provision of positive psychologic effects for both patient and owner.
For in-depth information about physical rehabilitation and it’s benefits, look at Physical Rehabilitation for Veterinary Technicians and Nurses.
Care should be taken when telling owners to avoid excessive exercise in their dogs as it is difficult to assess what is too much. Most dogs get so excited at the prospect of going for a walk that any signs of discomfort are hidden.
It might be added that many physical rehabilitation therapies should be prescribed and taught to owners by certified veterinarians, physical therapists, and vet tech/nurses. These are not just techniques that you read about in a book and suddenly are an expert. Entire courses are devoted to the teaching and certification of physical rehabilitation. If the owner is serious about pursuing this therapy, make sure a licensed, certified therapist and vet tech/nurse are recommended.
Helping clients understand pain medications
Analgesic therapy will be a multimodal combination of medications. Non-steroidal anti-inflammatory drugs (NSAIDs) with their analgesic, anti-inflammatory, and anti-pyretic effects are the most frequently prescribed medications to treat OA.
Sometimes the veterinarian may decide to switch from one NSAID to another. Generally, a washout period is recommended, in order to avoid the possibility of adverse effects. Conservative washout periods for NSAIDs (except for aspirin and mavacoxib) are 5–7 days. Owners should be made fully aware of the potential side effects associated with NSAIDs and cease administration if any occur. Instruct clients to call the office immediately if any issues arise. These include renal and hepatic dysfunction, gastric irritation, and ulceration. Owners should monitor their dogs for vomiting, diarrhea, inappetence, polyuria, and polydipsia. It is suggested that bloodwork should be run pre-treatment and at regular intervals during treatment.
Gabapentin is a drug used as an adjunct anticonvulsant and analgesic for treating chronic, neuropathic pain (pain from an injury to the nervous system) in dogs. Gabapentin may be used together with opioids during an acute pain phase especially if the patient is unable to take NSAIDs. The mechanism of analgesia for gabapentin is still not fully understood but it appears to be mediated through blockade of calcium channels in neurons decreasing the release of excitatory neurotransmitters such as substance P, glutamine and norepinephrine, reducing the depolarization of nerves in the spinal cord involved in the conduction of pain perception.
Amantadine is an antiviral drug with analgesic properties and may be used as an adjunct drug with NSAIDs and opioids, in the clinical management of canine osteoarthritis pain. Amantadine is a NMDA receptor antagonist preventing and/or attenuating central sensitization at the dorsal horn of the spinal cord.
Structure-modifying drugs – the main example includes pentosan polysulfate (Cartrophen; Biopharm Australia), which may be used for OA. This medication is available in Canada, but not the USA.
Injectable polysulfated glycosaminogylcan – In the USA, this is marketed as Adequan® and is an FDA-approved chondroprotective, disease-modifying osteoarthritis drug. It is typically prescribed in doses of 2–5 mg/kg IM every 3–5 days for 3 weeks, and then twice weekly for 4 weeks. Following initial induction of 2 injections per week for 4 weeks, booster dosing every 2–4 weeks is based on patient need. Clients are instructed on administration of subcutaneous injections at home and Adequan® is dispensed.
Diet and nutrition
Omega 3 fatty acid diets – (Hill’s j/d®) Science supports that the eicosapentaenoic acid (EPA) fraction of Omega 3 fatty acids have both anti-inflammatory and anti-cartilage degradation effects. Diets are the only way to assure the delivery of adequate levels (EPA: 50–100 mg/kg).
Other important components of specialized diets are nutraceuticals, which are nutrients thought to elicit pharmacological effects. These include green-lipped mussel, glucosamine, and chondroitin sulfate. Glucosamine is a glycosaminoglycan (GAG), which is a component of the extracellular matrix of joint cartilage.
Other aspects of comprehensive OA care for vet techs/nurses to keep in mind
Environmental enrichment can be undertaken to increase the comfort of OA dogs, such as providing soft thick bedding, non-slip flooring, easy access to water and food (raised food and water bowls), and assistive devices or harnesses, such as Help ‘Em Up.
Acupuncture, when used with a scientific and methodical approach, can provide an excellent addition to the pain management pyramid. Needle placement is usually nonpainful, and most animals enjoy their acupuncture treatments so much they will relax or sleep through their treatment. Pet owners will often notice an immediate difference in their pet’s mobility, attitude, and level of pain.
Newer treatments include autologous platelet therapy, mesenchymal stem cells, Grapiprant (a new analgesic and anti-inflammatory drug that is a highly potent and selective antagonist of the PGE2 EP4 receptor) and anti-nerve growth factor antibody. If the owner wishes to pursue any of these therapies, an in-depth discussion with the veterinarian should be undertaken.
The goals of surgical treatment of OA are pain relief, amelioration or removal of pathologic changes associated with OA and maintenance of maximal joint function. While salvage surgeries to treat OA may be performed, prevention is better than cure, and correction of those conditions known to cause OA is important to reduce or slow the development of the disease. Many times, it is a younger dog that has a developmental orthopedic disease (such as OCD, elbow dysplasia or hip dysplasia) that has led to the development of OA7.
Conclusion
Veterinary tech/nurses play an integral role in the care of patients with OA and can be a huge source of support and guidance for the patient and owner. A good outcome and improved quality of life for these patients requires a multidisciplinary team approach that involves the entire pathway of care. Veterinary tech/nurses can facilitate this care with careful assessment, planning, implementation and evaluation of the patient, and continued support for the owner.
References
Epstein M. Managing Chronic Pain in Dogs & Cats Part 1: The Two Most Important Tools in the Treatment of Osteoarthritis, Today’s Veterinary Practice, November/December 2013, 20-23.
Brundell K. Canine osteoarthritis: improving quality of life, The Veterinary Nurse, 2011, 2(8): 460-467.
Pettitt RA and German AJ. Investigation and management of canine osteoarthritis, In Practice, 2015 37: 1-8 doi: 10.1136/inp.h5763
Grant D. Chronic pain management and quality of life. Pain management in small animals. Butterworth Heinemann Elsevier, London: 2006, 293–310.
Waring N. Canine osteoarthritis: pathophysiology and management, The Veterinary Nurse, 2014, 5(8): 462-467.
Kirkby Shaw K and Epstein M. OSTEOARTHRITIS IN DOGS AND CATS: NOVEL THERAPEUTIC ADVANCES, North American Veterinary Conference 2016, Orlando, FL January 16-20, 2016, 931-934
Woods S. Osteoarthritis in brief. Part 2: management, Companion animal, 2016, 21(9): 508-515.
Mlacnik E, Bockstahler BA, Muller M, Tetrick MA, Nap RC, Zentek J. Effects of caloric restriction and a moderate or intense physiotherapy program for treatment of lameness in overweight dogs with osteoarthritis. J Am Vet Med Assoc, 2006 229:1756–60
Johnston SA, McLaughlin RM, Budsberg SC. Nonsurgical management of osteoarthritis in dogs. Vet Clin North Am Small Anim Pract 2008, 38: 1449–70
Lascelles BD, Blikslager AT, Fox SM, Reece D. Gastrointestinal tract perforation in dogs treated with a selective cyclooxygenase-2 inhibitor: 29 cases (2002-2003). J Am Vet Med Assoc, 2005, 227: 1112–17
Goldberg ME. A look at chronic pain in dogs, Veterinary Nursing Journal, 2017, 32:2, 37-44
Rychel JK. Diagnosis and Treatment of Osteoarthritis, Top Companion Anim Med. 2010 Feb;25(1):20-5