Managing canine osteoarthritis: ts ? ﬁ - Nc State Universityclubs.ncsu.edu/scivapm/Marcellin...

Managing canine osteoarthritis:What has proven benefits ?

B. Duncan X. Lascelles and Denis J. Marcellin-LittleNorth Carolina State University

Student Chapter of the IVAPM, Durham, NC10.10.2006

Osteoarthritis: What works?

Losing weight and being lightweight

NSAIDs

Nutritional supplementation

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NSAID Therapy

Weight Management

Why not just use nutraceuticals forearly OA pain?

• If the patient is assessed as requiring painrelief, this is most predictably delivered byNSAIDs

• Nutraceuticals rarely enough on their own,but can be effective adjunct

Diet modification

Physical Therapy

Treatment of physical disabilitiesPhysical agents

Heat, light, water, electricity

Manual therapyMassage, mobilization

Exercise

Ergonomics

Passive OA Treatment OptionsPhysical

Cold

Heat

E. Stimulation

Shockwave

Electro-acupuncture

Manual

Stretching

JointMobilization

Massage

MyofascialRelease

Acupressure

Misc.

Acupuncture

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IcePassive range of motion

Static weightbearing exercises

Massage

Weight Management

NSAID Therapy

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Massage

HeatStretching

Weight Management

NSAID Therapy

Benefits of Exercise

113 patients with knee OAIsometric, isotonic, and stepping exercisesPain 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

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ExerciseAquatic Exercise



HeatStretching

Weight Management

NSAID Therapy

Massage

Joint protection

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Ambulation assistance



HeatStretching

Weight Management

NSAID Therapy

Massage

Joint protection

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Weight Management




HeatStretching

NSAID Therapy

• When is each option most appropriate?

• How do we combine options?

• What has most proven benefit?

Multimodal approach to osteoarthritis

Monitor

• NSAIDs should form the basis of drug therapy• NSAIDs allow the physical therapy program to occur• Approved NSAIDs are significantly safer than non-

approved

Drug therapy in the early OA case

Risks

Benefits

Screen

Adjust dose

Use early

Correct

dose

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 forNSAIDs within the ‘program’)

Prevent the ‘putting out fires’ syndrome

Maximizes benefit from exercise

Which NSAID is most effective?

• Care with dosingLascelles et al 2005: GI perforations

• Inform owners of side effects to watch forVomitingGeneral malaise

Risks

Benefits

Screen Monitor

Adjust dose

Use early

Correct

dose

Screening & Monitoring

• Physical examination and history

• Determine and assess concurrent drug use

• Hematological and clinical chemistry evaluationBaseline

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 factorsGastric 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 insufficiencyReduced hepatic functionCushingoid animals

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Exercise

Weight Management

Passive range of motionMassage

Stretching

NSAID Therapy

Change diet; add supplements

Treatment Options - Passive

Physical modalities Cold

• Decreases blood flow,inflammation, musclespasm, and pain

• Inhibits cartilage degradingenzymes (below 30°C)

• Decreases intermittentinflammation

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

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Exercise

Weight Management

Passive range of motionMassage

Stretching

NSAID Therapy


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

Drug therapy in the severe OA case

Risks

Benefits

Screen Monitor

Adjust dose

Use early

Correct

dose

Multimodal drug therapy for canineosteoarthritis

Use of multiple drugs, with different analgesicactions, concurrently

NSAID plus: Tramadol (opioid & serotinergic) Amantadine (NMDA) Gabapentin (Ca2+ channels [ 2 subunit])

Can use such combinations for months

Adjunctive drugs: what is theevidence 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 andsignificant lumbosacral pain due to lumbosacraldegenerative 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?


Massage

Decreases myofascial pain andmuscle tension

No clear benefits in OA patients

Danneskiold-Samsoe B et al. Scand J Rheumatol, 2002

Treatment Options

Stretching

May be beneficial in OAjoints with limitedrange of motion

Stretch for 20 - 40 sec,10 to15 reps., daily

Elbow dysplasia

Range

28°

81°

149°

165°

Hip dysplasia

25°

51°171°

127°

Range


Physical modalities Heat

• Increases blood flow, enzymaticactivity, collagen extensibility,and muscle relaxation

• Decreases pain temporarily

• Decreases joint stiffness


Physical modalities Electrical stimulation

• Transcutaneous electrical nervestimulation (TENS)• Stimulation of large cutaneousnerve fibers that transmitsensory impulse faster than painfibers• Provides pain relief

Osiri M. Cochrane Data Syst Rev, 2000


Physical modalities Electrical stimulation

• Neuromuscular electrical stimulation(NMES)

• Stimulation of muscle fibers forstrengthening

• Muscle atrophy is present in OApatients, no direct help but NMES mayhelp the secondary changes present inOA patients


Acupuncture

May be effective as adjunctive therapy

Comprehensive reviews by NIH Consensus group

(1998) And British Medical association (2000):

- No clear proven benefits

Joint protection

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Static weight-bearing exercises

Massage

NSAID TherapyAmantadine

Tramadol

Env. Mod.

Weight Management


Managing canine osteoarthritis: ts ? ﬁ - Nc State Universityclubs.ncsu.edu/scivapm/Marcellin...

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Transcript of Managing canine osteoarthritis: ts ? ﬁ - Nc State Universityclubs.ncsu.edu/scivapm/Marcellin...