Managing canine osteoarthritis: What has proven benefits? B. Duncan X. Lascelles and Denis J. Marcellin-Little North Carolina State University Student Chapter of the IVAPM, Durham, NC 10.10.2006
Osteoarthritis: What works? Losing weight and being lightweight NSAIDs Nutritional supplementation
NSAID Therapy Weight Management 0 1 2 3 4 5 6 7 8 9 Time
Why not just use nutraceuticals for early OA pain? If the patient is assessed as requiring pain relief, this is most predictably delivered by NSAIDs Nutraceuticals rarely enough on their own, but can be effective adjunct
Diet modification
Physical Therapy Treatment of physical disabilities Physical agents Heat, light, water, electricity Manual therapy Massage, mobilization Exercise Ergonomics
Passive OA Treatment Options Physical Manual Misc. Cold Heat E. Stimulation Shockwave Electroacupuncture Stretching Joint Mobilization Massage Myofascial Release Acupressure Acupuncture
NSAID Therapy Massage Passive range of motion Ice Static weightbearing exercises Weight Management 0 1 2 3 4 5 6 7 8 9 Time
Massage Passive range of motion Ice Static weightbearing exercises Weight Management NSAID Therapy Stretching Heat 0 1 2 3 4 5 6 7 8 9 Time
Benefits of Exercise 113 patients with knee OA Isometric, isotonic, and stepping exercises Pain scores decreased by 23% (vs. 6% without exercise) Functional scores increased by 17% Treated patients were less anxious, less depressed, lost weight, and used less analgesic drugs O Reilly SC et al. Ann Rheum Dis, 1999
Benefits of Exercise 14 trials, 1633 patients Immediate moderate benefits for joint pain Immediate small benefits for limb function Long-term adherence to program is important Fransen M et al. J Rheum, 2002
Massage Passive range of motion Ice Static weightbearing exercises Stretching Heat Weight Management NSAID Therapy Aquatic Exercise 0 1 2 3 4 5 6 7 8 9 Exercise Time
Massage Passive range of motion Ice Static weightbearing exercises Stretching Heat Weight Management NSAID Therapy Ambulation assistance Joint protection Aquatic Exercise 0 1 2 3 4 5 6 7 8 9 Exercise Time
Massage Passive range of motion Ice Static weightbearing exercises Stretching Heat Weight Management NSAID Therapy Ambulation assistance Joint protection Aquatic Exercise 0 1 2 3 4 5 6 7 8 9 Exercise Time
Multimodal approach to osteoarthritis When is each option most appropriate? How do we combine options? What has most proven benefit?
Drug therapy in the early OA case NSAIDs should form the basis of drug therapy NSAIDs allow the physical therapy program to occur Approved NSAIDs are significantly safer than nonapproved Use early Adjust dose Risks Benefits Screen Correct dose Monitor
Maximize benefit Use early Before pain becomes progressively more difficult to treat Prevents central sensitization May decrease progression of the disease Pelletier et al 2000; 2004 Use continuously (but keep re-evaluating the need for NSAIDs within the program ) Prevent the putting out fires syndrome Maximizes benefit from exercise
Which NSAID is most effective?
Use early Adjust dose Risks Benefits Screen Correct dose Monitor Care with dosing Lascelles et al 2005: GI perforations Inform owners of side effects to watch for Vomiting General malaise
Screening & Monitoring Physical examination and history Determine and assess concurrent drug use Hematological and clinical chemistry evaluation Baseline 2 weeks after initiating treatment Every 6-12 months (young dog) Every 2-3 months, or as appropriate (older dog)
Screening & Monitoring Identify preexisting risk factors Gastric ulceration Risk factors: History of GI ulceration Concurrent aspirin Inadequate washout» Lascelles et al 2005 vs. Dowers et al 2006 Liver disease Renal disease MCT Renal insufficiency Reduced hepatic function Cushingoid animals
NSAID Therapy Change diet; add supplements Weight Management Massage Passive range of motion Stretching Exercise 0 1 2 3 4 5 6 7 8 9 Time
Treatment Options - Passive Physical modalities Cold Decreases blood flow, inflammation, muscle spasm, and pain Inhibits cartilage degrading enzymes (below 30 C) Decreases intermittent inflammation Lehmann JF et al. Clin Orthop, 1974
Home Exercise Program (HEP) Variety of exercises adapted to the patient profile, limitations and to the owner Start with moderation Self-guided increase in duration, frequency, and intensity Should always include outcome assessment (Leash) walks, trotting, slopes, stand to sit, swimming, Cavaletti rails, balance board
NSAID Therapy Change diet; add supplements Weight Management Massage Passive range of motion Stretching Exercise 0 1 2 3 4 5 6 7 8 9 Time
Drug therapy in the severe OA case NSAIDs will form the basis of drug therapy NSAIDs often do not provide complete pain relief well supported by, but not recognized in, the literature NSAIDs sometimes appear ineffective Use early Adjust dose Risks Benefits Screen Monitor Correct dose
Multimodal drug therapy for canine osteoarthritis Use of multiple drugs, with different analgesic actions, concurrently NSAID plus: Tramadol (opioid & serotinergic) Amantadine (NMDA) Gabapentin (Ca 2+ channels [ 2 subunit]) Can use such combinations for months
Adjunctive drugs: what is the evidence for pain relief in OA? Tramadol: One unpublished study (Lembert et al, Montreal, Canada) (Used and recommended in human OA pain: American Pain Society 2002) Amantadine: NCSU Comparative Pain Research Laboratory; randomized, controlled, blinded, parallel, owner assessment (Lascelles, Marcellin-Little, Roe) Gabapentin: (One study in rats: Fernihough et al 2005)
Bonnie 7 year history of osteoarthritis of hips and significant lumbosacral pain due to lumbosacral degenerative disease Currently 18 years old Intolerant to all NSAIDs Epidural steroids: no effect
Bonnie Treatment: Diet: Hill s j/d Nutritional supplements Regular physical therapy (Acupuncture: no effect) Adjunctive drugs (continuous) In hospital analgesic therapy (intermittent)
Bonnie Continuous adjunctive drugs: Continuous gabapentin (10mg.kg BID) Continuous amantadine (3mg.kg SID) When pain gets worse, 48 hrs in hospital for desensitization therapy: iv lidocaine (30mcg.kg.min after 1mg.kg bolus) iv ketamine (2mcg.kg.min after 0.5mg.kg bolus) iv medetomidine (2mcg.kg.hr after 2mcg.kg bolus) What evidence is there for this therapy?
Treatment Options - Passive Massage Decreases myofascial pain and muscle tension No clear benefits in OA patients Danneskiold-Samsoe B et al. Scand J Rheumatol, 2002
Treatment Options Stretching May be beneficial in OA joints with limited range of motion Stretch for 20-40 sec, 10 to15 reps., daily
Elbow dysplasia Range 28 149 81 165
Hip dysplasia 25 Range 51 171 127
Treatment Options - Passive Physical modalities Heat Increases blood flow, enzymatic activity, collagen extensibility, and muscle relaxation Decreases pain temporarily Decreases joint stiffness
Treatment Options - Passive Physical modalities Electrical stimulation Transcutaneous electrical nerve stimulation (TENS) Stimulation of large cutaneous nerve fibers that transmit sensory impulse faster than pain fibers Provides pain relief Osiri M. Cochrane Data Syst Rev, 2000
Treatment Options - Passive Physical modalities Electrical stimulation Neuromuscular electrical stimulation (NMES) Stimulation of muscle fibers for strengthening Muscle atrophy is present in OA patients, no direct help but NMES may help the secondary changes present in OA patients
Treatment Options - Passive Acupuncture May be effective as adjunctive therapy Comprehensive reviews by NIH Consensus group (1998) And British Medical association (2000): - No clear proven benefits
Amantadine Tramadol Change diet; add supplements Weight Management NSAID Therapy Massage Passive range of motion Ice Static weight-bearing exercises Aquatic Exercise Exercise Ambulation assistance Joint protection Env. Mod. 0 1 2 3 4 5 6 7 8 9 Time