Canine Osteoarthritis Recognition & Management Sponsored by Virbac Corporation In partnership with 01 Early Canine OA Recognition & Management Mark Epstein, DVM, DABVP (C/F), CVPP 02 5 Essential Therapeutic Exercises for Dogs with Osteoarthritis Kristin Kirkby Shaw, DVM, MS, PhD, CCRT, DACVS, DACVSMR 06 Orthopedic Examinations During the Wellness Appointment: Is It Possible to Do Both? Heather L. Troyer, DVM, DABVP, CVA, CVPP 08 Top 5 Conditions That Respond to Rehabilitation Therapy Suzanne Starr, DVM, CCRP
Transcript
Canine Osteoarthritis Recognition & ManagementSponsored by Virbac Corporation
In partnership with
01 Early Canine OA Recognition & Management Mark Epstein, DVM, DABVP (C/F), CVPP
02 5 Essential Therapeutic Exercises for Dogs with Osteoarthritis
06 Orthopedic Examinations During the Wellness Appointment: Is It Possible to Do Both?
Heather L. Troyer, DVM, DABVP, CVA, CVPP
08 Top 5 Conditions That Respond to Rehabilitation Therapy Suzanne Starr, DVM, CCRP
Chronic pain is ubiquitous; Of all chronic pain syndromes, osteoarthritis (OA) remains the most predictable cause in both dogs and cats. In dogs, the pathophysiology of OA is commonly heritable and conformational with a lifelong disease process that starts at a very young age.
MANAGEMENTIndustry guidelines4 summarize the evidence for management of canine OA. Modalities most appropriate for early (COAST Stage 1 and 2) canine OA include:
• Weight optimization: Keep the patient lean. Adipose tissue is a significant contributor to circulating proinflamma-tory cytokines. Evidence shows that the #1 preventive measure to slow the progression of OA in at-risk dogs is to maintain a lean body condition score.5-9
• Eicosapentaenoic acid (EPA)–rich diets10
• Modest course of NSAIDs when indicated
• Nutritional supplements: The evidence for glucosamine and chondroitin in OA remains mixed at best, although some other ingredients of oral nutraceuticals suggest varying degrees of immuno-modulating, chondroprotective, and pain-modifying effect. One Hydrolyzed Eggshell Membrane combination product showed statistical improvement in biomarkers and LOAD in a well-designed but unpublished study.11 A recent review of nutritional supplements for canine OA concluded that even if additional invest- igation is needed, dietary supplements should be considered in OA manage-ment.12 With their ease of use, relative safety, low cost, and easy acceptance by pet owners, these nutraceuticals may be deployed with earliest onset of OA signs, or even in at-risk patients before they show clinical signs.
• Controlled exercise: Therapeutic exercise is hypoalgesic13 and considered to play a crucial role in the management of osteoarthritis in dogs.14
DIAGNOSISSeveral validated clinical metrology instruments (CMIs) can be used to semi-quantify patient comfort, mobility, and ability (eg, Liverpool Osteoarthritis in Dogs [LOAD]1). However, these CMIs can be deployed only when clinical signs are evident, thus failing to detect OA in a large cohort of dogs that may not show clinical signs. COAST (Canine Osteoar-thritis Staging Tool), a novel CMI, can detect dogs that do not yet have clinically evident Stage 1 OA but may have 1 or more strong risk factors for OA.2 These risk factors for canine OA begin with breed predisposition and con-tinue with high body condition score,3 repetitive injury, previous history of limping, and more.
The entire veterinary team can pick up subtle signs in the history, conformation, and mobility changes of the pet with signs suggestive of early OA, such as chondro-dysplasia, higher-than-recommended weight, a diminished angle to stifle and hock, muscle atrophy, cheating on one hip (stifle) rather than sitting square, standing evenly rather than standing on thoracic limbs followed by pelvic limbs, and hip dysplasia “wiggle” gait. In addition, the skilled veterinarian can identify specific limb and joint changes even in a brief (2-minute) orthopedic examination conducted as part of a routine annual or semiannual visit with attention toward CREAPI: crepitance, range of motion (resistance), effusion, asymmetry, pain, and instability. CMI = clinical metrology instruments
COAST = Canine OsteoArthritis Staging ToolCREAPI = crepitance, range of motion (resistance), effusion, asymmetry, pain, and instability. EPA = eicosapentaenoic acidLOAD = Liverpool Osteoarthritis in DogsOA = osteoarthritis
REFERENCES1. Walton MB, Cowderoy E, Lascelles D, Innes JF.
Evaluation of construct and criterion validity for the ‘Liverpool Osteoarthritis in Dogs’ (LOAD) clinical metrology instrument and comparison to two other instruments. PLoS One. 2013;8(3):e58125.
2. Cachon T, Frykman O, Innes JF, et al. Face validity of a proposed tool for staging canine osteoarthritis: Canine OsteoArthritis Staging Tool (COAST). Vet J. 2018;235:1–8.
3. Kealy RD, Lawler DF, Ballam JM, et al. Five-year longitudinal study on limited food consumption and development of osteoarthritis in coxofemoral joints of dogs. J Am Vet Med Assoc. 1997;210(2):222–225.
4. Epstein M, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats. J Am Anim Hosp Assoc. 2015;51(2):67–84.
5. Smith GK, Paster ER, Powers MY, et al. Lifelong diet restriction and radiographic evidence of osteoarthritis of the hip joint in dogs. J Am Vet Med Assoc. 2006;229(5):690–693.
6. Kealy RD, Lawler DF, Ballam JM, et al. Effects of diet restriction on life span and age-related changes in dogs. J Am Vet Med Assoc. 2002;220(9):1315–1320.
7. Lawler DF, Evans RH, Larson BT, Spitznagel EL, Ellersieck MR, Kealy RD. Influence of lifetime food restriction on causes, time, and predictors of death in dogs. J Am Vet Med Assoc. 2005;226(2):225–231.
8. Lawler DF, Larson BT, Ballam JM, et al. Diet restriction and ageing in the dog: major observations over two decades. Br J Nutr. 2008;99(4):793–805.
9. Kirkby KA, Lewis DD. Canine hip dysplasia: reviewing the evidence for nonsurgical management. Vet Surg. 2012;41(1):2–9.
10. Vandeweerd JM, Coisnon C, Clegg P, et al. Systematic review of efficacy of nutraceuticals to alleviate clinical signs of osteoarthritis. J Vet Intern Med. 2012;26(3):448–456.
11. Muller C, Enomoto M, Meyers R, Steiner J, Lascelles BDX. Randomized pilot trial of ‘Movoflex’ supplementation on biomarkers of inflammation in dogs with degenerative joint disease. Comparative Pain Research Laboratory, NC State University, Raleigh, NC; Gastrointestinal Research Laboratory, Texas A&M University, College Station, TX.
12. Comblain F, Serisier S, Barthelemy N, Balligand M, Henrotin Y. Review of dietary supplements for the management of osteoarthritis in dogs in studies from 2004 to 2014. J Vet Pharmacol Ther. 2016;39(1):1–15.
13. Koltyn KF, Brellenthin AG, Cook DB, Sehgal N, Hillard C. Mechanisms of exercise-induced hypoalgesia. J Pain. 2014;15(12):1294–1304.
14. Harper TAM. Conservative management of hip dysplasia. Vet Clin North Am Small Anim Pract. 2017;47(4):807–821.
MARK EPSTEIN, DVM, DABVP (C/F), CVPP
Funded by an unrestricted educational grant from Virbac
Early Canine OA Recognition & Management
Veterinary physical rehabilitation encompasses a whole-body approach to patient assess-ment and treatment, and the foundation of treatment is therapeutic exercise. The types of exercises prescribed are determined based on the injuries or diseases present, surgery (if any) performed, functional abilities and disabilities, and assessment of axial muscle strength, core strength, proprioception, and joint range of motion (ROM).1-3
Dogs with osteoarthritis benefit from strengthening the muscles supporting an arthritic joint, maintaining and improving active ROM of all joints, strengthening the core muscles, and maintaining or improving pro-prioception and balance.4,5 The following are 5 basic therapeutic exercises that may be prescribed for dogs with osteoarthritis. The client may perform these exer-
5 Essential Therapeutic Exercises for Dogs with Osteoarthritis Kristin Kirkby Shaw, DVM, MS, PhD, CCRT, DACVS, DACVSMRAnimal Surgical Clinic of Seattle, Seattle, WA
TOP 5 h ORTHOPEDICS h PEER REVIEWED
d FIGURE 1
cises as part of a home-exercise plan, but the veterinary technician plays the crucial role of instructing the cli-ent on proper exercise performance.
1 Sit-to-Stand This exercise is prescribed for improving or maintaining muscular strength and active hind-limb ROM. The key to success is ensuring that
the dog flexes the stifles and tarsi of both limbs fully so that the limbs are both tucked in a normal position against the body.
A dog asked to stand should use both back legs to move to the standing position. For dogs that sit to one side, with the contralateral hind limb held away from the body, the client or assistant should stand behind the dog and use his or her feet to scoot the dog’s back legs into a tucked position. That person remains behind the dog while a second person stands in front and asks the dog to stand. Reward the dog each time (and only if) it sits square and stands with both limbs. Start with 3 to 5
repetitions several times a day and gradually work up to 3 sets of 10 to 12 every day.
2 Down-to-StandThis exercise is also prescribed for improving or maintaining muscular strength and active hind-limb ROM and is
particularly useful for strengthening the gluteal muscles. Down-to-stand can be a beginning-level core-strengthening exercise.Ask the dog to move to a down position. Ensure
that both back limbs are tucked against the body and the dog is in a sphinx position. Stand in front, facing the dog with a treat.
The key to success with this exercise is to take a step back from the dog while asking it to stand so that it moves directly from a down-to-stand posi-tion without sitting in between. To advance this exercise and engage the core muscles, the dog should move from down to stand and back down again without taking any steps forward or back-ward (the feet stay in the same position while the body moves over them). Start with 3 to 5 repeti-tions several times a day and gradually work up to 3 sets of 10 to 12 every day.
3 Three-Leg StandingThis exercise, which is prescribed for improving muscular strength in a weak limb by encouraging isometric muscle
contraction, is also is a beginning-level exercise for improving core strength and balance.
Lift the dog’s leg on the opposite side of the weak limb (ie, lift the left rear leg if the right rear leg is being targeted for strengthening; lift the right front limb if the left front is being targeted). Extend the leg slightly back if hind-limb or for-ward if front-limb so that the dog cannot bear weight through the hand. Hold the leg off the ground for 5 to 10 seconds and then allow the dog to stand on all 4 limbs to rest. Repeat 3 to 5 times a day. Work up to holding the limb off the ground for 30 seconds, 8 repetitions, 3 times a day. If mul-
tiple limbs are weak, repeat the exercise targeting each weak limb.
4 Cross-Leg StandingThis exercise, also known as 2-leg stand-ing or bird-dog, is prescribed for improv-ing core muscular strength and balance. It
is an advanced form of the 3-leg standing exercise to increase a weak limb’s muscular strength.
Lift one front leg and the contralateral hind leg, allowing the dog to stand on 2 legs. Extend the front leg forward and the rear leg back. Hold the leg off the ground for 5 to 10 seconds and then allow the dog to stand on all 4 limbs to rest. Repeat 3 to 5 times a day. Work up to holding the limbs off the ground for 30 seconds, 8 repetitions, 3 times a day. Repeat with the opposite 2 legs.
For an advanced exercise, wiggle the 2 legs that are off the ground to challenge balance and core stability. The dog should be able to stand on 2 legs for approximately 30 seconds before trying this exercise.
5 Cavaletti Rails, High-Stepping, or Obstacle CourseThis exercise is prescribed for improving cardiovascular endurance, propriocep-
tion, and active ROM and muscular strength in all limbs.
To perform this exercise, place 6 cavaletti rails, spaced as far apart as the dog’s shoulder height. The bars’ height should be based on the dog’s size and the joints targeted for improving flexion. For example, setting the bars at the height of the dog’s carpi can target stifle and tarsal flexion. The bars can be set at the level of the elbow for targeting elbow flexion. Walk the leashed dog slowly so that it steps over each rail with individual limbs rather than hopping. Walk back and forth 3 times. Work up to 6 times back and forth.
For an added challenge, change the height of the rails and add diagonal positions (one side of a rail
higher than the other). For an advanced challenge, place the cavaletti rails on a hill.
If cavaletti rails are not available, walk the dog through tall grass so that each hind limb is lifted and flexed at the hip, elbow, and carpus, or create an obstacle course with objects the dog will not step on (eg, brooms, water noodles, pillows, toys). Walk the dog over the course so that it must high step or pick up its legs fully to move over the objects. Walking up and down hills and stairs can also improve range of motion.2,3
Conclusion
Dogs with osteoarthritis benefit from strengtheningthe muscles supporting an arthritic joint.
While therapeutic exercises are an important part of the compressive treatment of osteoarthritis, it is crucial that a full orthopedic examination be per-formed by a veterinarian prior to recommending these exercises. The veterinarian should rule out other causes of lameness and pain, including bone
and nerve-root tumors and neurologic disease, and ensure that pain is well managed. Training and certification in canine rehabilitation therapy will enable interested veterinarians and techni-cians to provide addition manual and exercise therapies for dogs with osteoarthritis. n
REFERENCES1. McCauley L, Van Dyke JB. Therapeutic exercises. In: Zink MC, Van
Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: Wiley-Blackwell, 2013:132-158.
2. Carr JG, Millis DL, Weng HY. Exercises in canine physical rehabilita-tion: range of motion of the forelimb during stair and ramp ascent. J Small Anim Pract. 2013;54(8):409-413.
3. Holler PJ, Brazda V, Dal-Bianco B, et al. Kinematic motion analysis of the joints of the forelimbs and hind limbs of dogs during walking
exercise regimens. Am J Vet Res. 2010;71(7):734-740.4. Bosomworth NJ. Exercise and knee osteoarthritis: benefit or
hazard? Can Fam Physician. 2009;55(9):871-878. 5. Greene LM, Marcellin-Little DJ, Lascelles BDX. Associations among
exercise duration, lameness severity, and hip joint range of motion in Labrador Retrievers with hip dysplasia. J Anim Vet Med Assoc. 2013;242(11):1528-1533.
This article originally appeared on the Veterinary Team Brief website, October 2015.
typically is performed during an appointment that lasts 30 minutes or longer. An abbreviated version of this examination, or a “wellness orthopedic evaluation,” may be considered for any high-risk patient if clinical signs are not present, such as the expected presentation of a wellness patient.
For example, if a client presents a newly acquired 6-month-old Great Dane, evaluating the patient for gait abnormalities at a walk or trot, postural abnormalities, limb deformities, joint laxities, or carpal hyperexten-sion, would be appropriate.
Adapt the Examination to the Patient Given the reality of time constraints in a busy practice, consider adapting an orthopedic examination to each individual patient.
For example, a 6-year-old neutered male Labrador retriever presents for an annual wellness evaluation. The clients ask about the appropriate joint supplement
While few veterinarians perform thorough orthopedic evaluations during wellness visits, an orthopedic examination may benefit some patients. The key is to identify high-risk patients as soon as they enter the examination room and to incorporate the orthopedic evaluation into the general physical. Patients may be identified in advance based on breed, prior history, or other lameness risk factors (eg, obesity, old age).
Complete orthopedic examinations are well-defined in veterinary medicine1 and typically include observation of the patient at rest and in motion, followed by manip-ulation of all joints while standing and in lateral recum-bency. Examination for other indicators of discomfort, like trigger point sensitivity,2 is also now recom-mended. This examination takes considerable time and
Orthopedic Examinations During the Wellness Appointment: Is It Possible to Do Both?Heather L. Troyer, DVM, DABVP, CVA, CVPPThe Oradell Animal Hospital, Paramus, New Jersey
for their pet. In this case, it is important to deter-mine whether the patient already has an orthope-dic abnormality that is causing pain, or a simple supplement to support cartilage health is needed. An abbreviated examination would begin with a simple observation of the patient at rest, and of his gait in the examination room. Quick palpation of shoulders, elbows, hips, and stifles to check for thickness or effusion, pain, and range of motion with the patient standing may be useful as well.3 Patella placement or other congenital abnormali-ties are also important observations. Noting of a classic “head-bob” to determine weight shifting from an affected limb1 or short-stride to indicate pain can lead to your recommendation for a longer orthopedic evaluation or diagnostics. An abbrevi-ated orthopedic examination should not add more than 2 to 5 minutes to your overall physical exam-ination.
Educate ClientsFor those patients in which a full orthopedic exam-ination is indicated, including an additional fee for this valuable service is fair and reasonable. Narrat-ing the orthopedic examination and explaining its importance is key to educating clients and helping them appreciate the care provided.
Many veterinary practices today offer formal weight loss programs, physical rehabilitation, and
multimodal pain management strategies in both preventive and therapeutic programs.
Veterinary team members should feel comfortable discussing the important roles of proper nutrition, weight control, and appropriate exercise in pre-venting and managing orthopedic problems. Offer clients report cards, hand-outs, and other materi-als that can educate them on important concepts (eg, how weight loss can help manage orthopedic problems).
If the practice does not offer a full physical rehabil-itation program, educate team members on at-home exercises that clients can use to improve their pets’ orthopedic health. Keep evidence-based joint supplements and other products that can pre-serve patients’ orthopedic health in stock.
ConclusionOrthopedic problems affect quality of life, so screening for these disorders should be included during wellness examinations. Early identification and management can dramatically impact the pro-gression of some orthopedic conditions. Offer the team continuing education about common ortho-pedic conditions such as osteoarthritis. Ensuring that both clients and team members recognize the importance of managing orthopedic disease can improve the quality of life for many patients. n
REFERENCES1. Sumner-Smith G. Gait analysis and orthopedic examination. In:
Slatter D, ed. Textbook of Small Animal Surgery. 2nd ed. Philadelphia, PA: WB Saunders, 1993.
2. Wall R. Introduction to myofascial trigger points in dogs. Top Companion Anim Med. 2014;29(2):43-48.
3. Renberg WC. Evaluation of the lame patient. Vet Clin North Am Small Anim Pract. 2001;31(1):1-16.
SUGGESTED READINGAbdelhadi J, Wefstaedt P, Galindo-Zamora V, Anders A, Nolte I, Schilling
N. Load redistribution in walking and trotting Beagles with induced forelimb lameness. Am J Vet Res. 2013;74(1):34-39.
Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439-444.
Fry LM, Neary SM, Sharrock J, Rychel JK. Acupuncture for analgesia in veterinary medicine. Top Companion Anim Med. 2014;29(2):35-42.
International Veterinary Academy of Pain Management (IVAPM). IVAPM. http://www.ivapm.org. Accessed November 2019.
Robinson NJ, Dean RS, Cobb M, Brennan ML. Consultation length in first opinion small animal practice. Vet Rec. 2014;175(19):486.
This article originally appeared on the Veterinary Team Brief website, September 2015.
Suzanne Starr, DVM, CCRPPaws in Motion Veterinary Rehabilitation CenterNatick, Massachusetts
The goal of physical rehabilitation, in combination withmedical and surgical care, is to restore normal or near-normal mobility and musculoskeletal function. Manual
therapy includes massage, stretching, passive range-of-motion(ROM) exercise, and joint mobilization. Modalities include heatand cold therapy, therapeutic neuromuscular electrical stimula-tion, laser therapy, and therapeutic ultrasonography. Targetedexercise can include use of exercise balls or wobble boards, cav-aletti rails (ie, horizontal poles positioned at varying heights anddistances for dogs to step over), underwater or land treadmills,and pools.
Although dogs with assorted conditions can benefit from physical rehabilitation, the following are the top 5 canine conditions that the author believes best respond to rehabilita-tion therapy.
Postoperative cranial cruciateligament rupture surgeryCranial cruciate ligament disease is one of the mostcommon orthopedic conditions in dogs. Surgery isarguably the best approach to restore stability when
the cruciate ligament has been damaged. Regardless of the sur-gical procedure, rehabilitation initially involves pain manage-ment, massage, passive ROM, and icing. As tissues heal, patientsoften progress to weight-shifting exercises and water treadmillwalking (Figure 1). As lameness improves, therapy may includeleash walking (ideally involving hills), followed by jogging andtrotting.
Postoperative femoral head andneck ostectomyFemoral head and neck ostectomy is most often performed to treat Legg-Calvé-Perthes disease (ie,avascular femoral head necrosis), coxofemoral
luxation, and femoral head and neck fracture. In addition, thissurgery can be a salvage procedure for painful hip dysplasia or
December 2013 • clinician’s brief 31
TOP 5
TOP 5 Conditions That Respond toRehabilitation Therapy1. Postoperative cranial cruciate
osteoarthritis. Adequate pain management is important toencourage early use of an affected limb. Early therapy involvesmassage and gentle, passive ROM. After the skin incision hashealed, underwater treadmill activity can promote partialweight bearing and return to normal gait. Once the affectedlimb is used in a four-legged walk, additional weight-bearingexercises can be introduced. Tools (eg, balance board, exerciseball) can help improve weight bearing while strengthening thecore.
Spinal cord diseasesCommon spinal cord diseases include intervertebraldisk disease, fibrocartilaginous embolism, degenera-tive myelopathy, spinal trauma, and inflammatoryCNS disease. Classic signs are proprioceptive deficits
and severe paresis or paralysis of the pelvic or all limbs, depend-ing on lesion location. A thorough neurologic examination isessential. When indicated, cerebrospinal fluid tap and MRI orCT should be pursued. Once the diagnosis has been confirmed,therapy, including physical rehabilitation, can be planned. Physical rehabilitation therapy has a role in both these circumstances.
Therapeutic goals for dogs with spinal cord disease includereducing pain, maintaining joint flexibility, preventing or reduc-ing muscle atrophy, and restoring coordination and propriocep-tion. Techniques depend on the severity of signs and spinal corddisease, but massage, passive ROM, targeted exercises using anexercise ball (Figure 2), and water therapy are commonly used.In dogs with severe paresis or paralysis, the benefits of watertherapy are extensive. Buoyancy of the patient when surrounded
by water strengthens mobility, as dogs often initiate movementin the water before initiating movement on land. When the dogcan walk without support, adding exercises such as steppingover obstacles (eg, cavaletti rails) can help improve overall coordination.
OsteoarthritisPatients with osteoarthritis can benefit from a multi-modal therapeutic approach. A patient’s conditionoften deteriorates rapidly becomes a vicious cycle:because the arthritis is painful, the animal typically
becomes more sedentary, leading to muscle atrophy and weightgain, subsequently worsening the condition. Pain managementthrough analgesic medication and physical therapy can help.Gentle exercise in an underwater treadmill or a pool helps buildmuscle strength and endurance while minimizing stress onpainful joints. When the patient is able, targeted weight-bearingexercise is ideal to strengthen the joints.
ObesityIn the United States, an estimated 50% of dogsbetween 5 and 10 years of age are overweight orobese, making this one of the most common caninemedical disorders. Health problems caused or
complicated by obesity include joint and/or musculoskeletalproblems, exercise and heat intolerance, and pulmonary andcardiovascular disease. Although attention may be given todesigning the appropriate diet for weight loss, exercise is oftenoverlooked. When combined with caloric restriction, exercisecan induce a negative energy balance critical for weight loss.Scheduled sessions of physical activity can help burn calories,build muscle mass, and improve client motivation and compli-ance. Exercise sessions should be customized for each patient.
Closing thoughtsTherapists not only provide a service during rehabilitation ses-sions, but also participate in designing daily home plans. Clientsoften benefit greatly from receiving specific guidance followingtheir pet’s injury or surgery. In addition, therapists can recom-mend slings, harnesses, wheels, and other assistive devices thatcan help patients and caregivers. It is therefore important forgeneral practitioners and specialists to consider and discussrehabilitation as part of their patients’ complete care plans whenappropriate. � cb
See Aids & Resources, back page, for references & suggestedreading.
32 cliniciansbrief.com • December 2013
Targeted exercises, such as using an exerciseball, can help core conditioning, weight bearing,balance, and ROM.
