Arthritis (Canine)
Cruciate Ligament Rupture (Canine)
Pain Management in Our Companion Animals
TPLO Surgery - Rehabilitation Protocol
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Ways to Increase Your Arthritic Dog's Comfort
Is your dog stiff? Does he/she have trouble laying down or getting up? Is stair climbing more difficult? Does he/she lag behind on walks? If so, your pet probably has arthritis. If you are seeing these changes in your dog, we strongly recommend a physical exam with one of our veterinarians. Once more serious medical conditions have been ruled out and a diagnosis of arthritis is made, we can offer a variety of different treatments that can improve your pet's quality of life! Remember - many dogs don't complain about their discomfort. If your pet is stiff, she/he probably has some degree of discomfort and we can help.
Weight Loss
One of the most important factors affecting an arthritic dog's comfort is excess weight. Obesity or even a weight excess of 5-10 pounds can significantly increase the load on arthritic joints. An increased weight-bearing load adds pressure to joints, increasing both inflammation and pain. If your animal is overweight, we can recommend diet changes and a weight loss program that will help.
Bedding
Comfortable bedding can help your pet. Many dogs tend to lie for hours on a hard floor or on an uneven dog bed. This can increase stiffness and discomfort. A variety of dog beds designed for aging animals are available in stores and pet catalogs. Look for evenly cushioned beds that provide adequate padding and support. There are "orthopedic" beds available that have an eggshell design. These are particularly beneficial for the arthritic pet.
Exercise
It is important to exercise your older dog regularly to decrease joint stiffness, preserve muscle mass and strength, and to increase your pet's quality of life. Joint movement stimulates joint fluid production, thereby increasing lubrication and range of motion. It is important to gauge the amount and type of exercise to your pet's capabilities. Shorter, more frequent walks are much better than occasional long walks. Get into the habit of exercising your pet regularly for short periods. REMEMBER never to push your pet's limits. If your dog is stiffer or more uncomfortable the day after the exercise then you did too much. Shorten the distance, the duration, or change the type of exercise the next time.
Physical Therapy
Just as in people, physical therapy can help dogs with arthritis increase their strength and mobility, and decrease stiffness or pain. Physical therapy uses heat, cold, massage, and passive range of motion exercises, among other modalities. Many of the techniques are easy to do at home and may significantly help. Gently massaging sore muscles can be a wonderful treat for your pet! Gently moving the limb through its normal range of motion can help increase circulation and decrease stiffness. Ask us to demonstrate some simple things that you can do or we can contact a veterinary physical therapist to provide more advanced therapy techniques.
Acupuncture
Acupuncture is the insertion of very thin needles at specific points in the body to create a cascade of physiologic reactions. By activating the central nervous system, acupuncture causes the release of the body's natural painkillers, the endorphins. Numerous scientific studies have verified that acupuncture not only relieves pain, but also stimulates circulation and the immune system, decreases inflammation, relieves muscle spasms, and can induce a feeling of well being. This is an excellent tool for the arthritic pet! It is a natural drug-free way to increase your animal's comfort. It also can be effectively combined with the other arthritis treatments available for added benefit. Ask us for the name of a certified veterinary acupuncturist in your area!
Glucosamine/Chondroitin Sulfate
The combination of glucosamine and chondroitin sulfate (Cosequin®) is a natural nutrient supplement available for arthritic animals. These molecules are part of the normal make-up of cartilage and other joint tissues. Glucosamine stimulates the production of the cartilage matrix; chondroitin inhibits enzymes that degrade cartilage. Together they promote joint health and can significantly reduce the pain and inflammation of arthritis as well as slow the progression of further joint degeneration. This supplement is well tolerated and can be combined with the other arthritis treatments. We recommend it for the majority of animals with arthritic changes. It should be started early in the course of arthritis and can be continued for the life of the dog. Ask us for the proper dosage for your pet.
Antioxidants
As as animal develops arthritis, the joint cells become inflamed causing the release of substances called "free radicals." These free radicals contribute to further inflammation and damage to joint cells. Antioxidants such as Comfort®, Vitamins E and C, among others help neutralize free radical cell damage and inflammation. Ask us for specific antioxidants and doses that may help your pet.
Nonsteroidal Antiinflammatories (NSAIDS)
NSAIDS such as Rimadyl® and Etogesic® are highly effective drugs used to reduce the pain and inflammation of arthritis. Used either short or long term, these drugs can improve the quality of life of an arthritic pet significantly. NSAIDS are well tolerated by most dogs, but as with any medication, a small number of dogs may be intolerant. When used long term, we recommend biannual blood testing to ensure your pet's health. Unfortunately, these drugs are not tolerated well by cats.
**Why not simply use aspirin for your pet? Studies have shown that unlike the newer NSAIDS that are "chondro-protective," daily aspirin can actually further the cartilage damage seen in arthritic dogs when used long term.
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What and where are the cruciate ligaments?
There are two bands of fibrous tissue called the cruciate ligaments in each knee joint. They join the femur and tibia (bones above and below the knee) together so that the knee works as a hinged joint.
They are called cruciate ligaments because they “cross over” inside the knee joint. One ligament connects from inside to outside the knee joint and the other outside to inside, crossing each other in the middle.
Humans have the same anatomical structure of the knee. Cruciate ligament rupture is a common knee injury of athletes.
How does the injury occur?
· The knee joint is a hinged joint and only moves in one plane, backwards and forwards. Traumatic cruciate damage is caused by a twisting injury to the joint. This is most often seen in dogs and athletes when running and suddenly changing direction so that the majority of the weight is taken on this single joint. This injury usually affects the anterior (front) ligament. The joint is then unstable and causes extreme pain, often resulting in lameness.
· The injury also occurs commonly in obese dogs, just by stumbling over a pebble while walking.
- · A more chronic form of cruciate damage can occur due to weakening of the ligaments as a result of disease. The ligament may become stretched or partially torn and lameness may be only slight and intermittent. With continued use of the joint, the condition gradually gets worse until rupture occurs.
How is it diagnosed?
· With traumatic cruciate rupture, the usual history is that the dog was running and suddenly stopped or cried out and was then unable to bear weight on the affected leg.
- · Many pets will “toe touch” and place only a small amount of weight on the injured leg.
- · During the examination, the veterinarian will try to demonstrate a particular movement, called a drawer sign. This indicates laxity in the knee joint. Many dogs will require mild sedation or pain medications to perform this test. Other diagnostic tests such as radiographs (x-rays) may also be necessary.
- · Other tests such as arthroscopy may be needed to rule out other damage to the joint.
Is other joint damage common?
Inside the knee joint are pieces of cartilage called menisci. Many times these cartilages are also damaged when the cruciate ligaments rupture. They are usually repaired at the same time as the ligament surgery.
Is an operation always necessary?
Dogs under 10 kgs (22 lbs.) may heal without surgery. These patients are often restricted to cage rest for two to six weeks. Dogs over 10 kg. (22 lbs.) require surgery to heal. Unfortunately, most dogs will eventually require surgery to correct this painful injury.
What does surgery involve?
There are various techniques available to replace the action of the cruciate ligaments. These surgeries most often involve the placement of artificial ligaments along the outside of the knee joint. There is a newer surgical technique available called tibial plateau leveling osteotomy (TPLO) that is especially beneficial for larger, more athletic dogs. Your veterinarian will discuss with you the best treatment option for your pet.
Is post-operative care difficult?
It is important that your dog have limited activity for six to eight weeks after surgery. Provided you are able to carry out our instructions, good function should return to the limb within three months (See our protocol for post-op rehabilitation). Unfortunately, regardless of the technique used to stabilize the joint, arthritis is likely to develop. As your dog ages, stiffness is likely to develop in the joint. Weight control and nutritional supplements such as glucosamine / chondroitin may help reduce the risk of arthritis in your pet.
Is obesity such a problem?
Obesity can result in cruciate ligament rupture and knee arthritis. If your dog is overweight, the recovery time will be much longer. Obesity also increases the risk of injury to the other knee. We will be happy to prescribe a weight reduction diet. Weight loss is as important as surgery in ensuring rapid return to normal function.
This client information sheet is based on material written by Ernest E. Ward Jr., DVM.
© Copyright 2002 Lifelearn Inc. Used with permission under license. March 5, 2003 .
Patsy Mich, DVM
As veterinarians we are entrusted with the care of precious family members, animal companions who light our clients lives with unconditional companionship and love. What a tremendous privilege this is; our highest goal and responsibility is to honor the bond between clients and patients with compassionate care. This is the mission of Care Animal Hospital and the very meaning behind our hospital name.
A critical aspect of compassionate care is pain management. All of our doctors are committed to patient comfort and pain control. We persistently follow research and state of the art information on this issue. Pain control has been a special interest of Dr. Mich.
For many years in both human and veterinary medicine control of pain has been entirely secondary to control of disease. In recent years there has been a shift in philosophy to include patient COMFORT among primary goals in treatment. Countless studies have been done to evaluate pain perception and the effectiveness of various pain control measures. Certainly anyone who lives with and loves animals KNOWS they feel pain. Of course they do, but amazingly studies are done to prove this. These studies are most helpful in interpreting signs of pain in our patients. Remember animals are programmed for survival so displaying signs of pain in the wild is not a normal or safe behavior. Our companion animals can retain this tendency to hide their pain especially here at the hospital. This makes interpretation difficult: How painful is he? Does she need more pain medication?
At Care Animal Hospital our philosophy of pain management involves using common sense and giving our patients the benefit of the doubt. We assume there is pain and then tailor the type and amount of medication to each patient. Just like humans, animals have different levels of pain tolerance. We must be sensitive to the INDIVIDUAL animal’s comfort.
We have used pain medication for major surgery (e.g. back, knee, abdominal surgery) AS WELL AS for elective surgery (e.g. spay, neuter, declaw). Additionally, many medical conditions like pancreatitis are painful and require pain management as a part of the overall treatment plan.
In surgical patients we use a multilayer pain control plan in which we begin pain medication BEFORE surgery. This is called PREEMPTIVE pain control because it keeps pain receptors in the body from "winding up." This means the final level of pain after surgery won’t reach as high as it would if pain control was started after surgery. It is much harder to control pain after the surgery because of the wind up effect. After surgery we continue with oral and injectable medication; we send our patients home on pain medication so you can keep your wonderful companion comfortable during recovery at home.
Chronic pain such as arthritis (hips, knees, elbows) and back pain are very common in animals just as in humans. Management of chronic pain is so important because it impacts the quality of life of our patients. The entire staff at Care Animal Hospital is committed to treating this chronic pain. The trick is to recognize the pain in our athlete animals and our older patients. Often this kind of pain is subtle and develops over many years. Please talk to one of our doctors about chronic pain if your animal is over 7 years or is very athletic (hunting dogs, frisbee dogs, agility dogs, fly-ball dogs).
Some of the methods used for controlling chronic and surgical pain include:
1. NSAID’s (nonsteroidal antinflammatory drugs)
2. Cartilage protectants and joint lubricants
3. Opioids (very powerful medications for severe pain)
4. Acupuncture
5. Massage therapy
6. Safe, skilled, careful, and fast surgical technique.
Pain management is a balancing act that requires planning ahead and tailoring for the individual as well as a team effort between the hospital staff and you. Please contact us regarding any questions about the control of pain in your animal companion.
The International Veterinary Academy of Pain Management has a video on their website called "Is Your Pet In Pain?" It is about 15-20 minutes in length and can be viewed by clicking here.
Rehabilitation Protocol for Tibial Plateau Leveling Osteotomy (TPLO)
Adapted from Canine Rehabilitation Physical Therapy by Millis, Levine, Taylor 2004
Because the biomechanics of the knee are altered by this procedure there is additional stress on the patellar ligament. Overuse of the limb before appropriate healing occurs can result in inflammation of this ligament or avulsion (tearing) of its insertion point on the tibia. Careful attention to restriction of activity is imperative. Activity should be restricted as outlined below.
Expected outcomes of rehabilitation:
- Knee that is free of inflammation
- Full range of motion of the knee
- Equal muscle development between the two hind limbs
- Complete healing of the bone (osteotomy site)
- Slowed progression of osteoarthrits
- Better limb function than before surgery
General Concepts of Pain Control During Rehabilitation
- NSAID (Rimadyl, Deramaxx, Metacam, Tylenol)
a. Use medication as directed by your veterinarian
b. Give the dose about 2 hours before performing rehab exercises - Cryotherapy (icing) (see explanation)
a. Ice pack ideas include bag of frozen peas, commercial therapeutic ice packs, or make your
own with 1 part isopropyl alcohol to 2 parts water in heavy duty ziplock bag.
b. Place a towel between ice pack and the skin to prevent irritation
c. Ice for 15-20 minutes as indicated - Heat (see explanation)
a. Place a towel between pack and skin to prevent irritation
b. Moist heat is best. Some ideas include: towels immersed in warm water and wrung out or
rice in a tube sock and microwaved (be very careful of burns with this technique)
c. Do not apply in the first 72 hours post op as this can increase inflammation and swelling
d. Begin on day 4 or 5 before ROM (Range Of Motion) exercises to warm up the tissues and
relax the muscles - Massage (see explanation)
a. At home gently massage the limb prior to ROM exercises to mobilize the soft tissues and
warm up the muscles. Include massage of the scar once it is healed
b. Professional massage therapy is advised. Licensed and certified massage therapists are
recommended. Typical schedule is once per week in the first 4-8 weeks post op and then
as directed.
Suggested Rehabilitation Schedule:
| Day 1-4 Post Op | Goals: Control swelling, improve ROM, and pain control
Daily Routine:
** ROM should be increasing daily but do not exceed the comfort of the patient. If ROM is not improving, increase the number of exercises to 3-5 times per day. ** On day 4 or 5 heat can be combined with massage to warm the muscles prior to ROM exercises ** Toe touching is expected on day 1-3 post op |
| Day 5-3 Weeks Post Op | Goals: Reduce swelling, increase weight bearing at a walk, ROM returning to normal, pain control
Daily Routine:
** By week 2, ROM can be discontinued if knee extension and flexion are near normal (compare to opposite limb) ** Increases in walk length are limited by patient comfort. If there is increased fatigue or discomfort, decrease time until signs resolve. ** Schedule recheck appointment at end of week 3 |
| Weeks 3-5 Post Op | Goals: Maximum ROM, increased endurance and strength, improved weight bearing
Daily Routine:
|
| Weeks 6-8 Post Op | Goals: Improved limb use at the trot, improved muscle mass and strength, improved stamina and endurance
Daily Routine:
** Some mild lameness may appear as activity increases. If this worsens or persists, decrease or stop activity for 1-2 days then return to activity at 50-75% intensity and gradually increase again. ** Occasional "easy" days of reduced activity are helpful |
| Weeks 9-12 Post Op | Goals: Improving speed, improving muscle mass and strength, improving stamina and endurance, return to presurgery activity level by 12 weeks
Daily Routine:
** Level of activity should be fairly consistent from day to day. Do not engage in vigorous activity followed by days of little activity. |
Final Notes:
- This protocol is designed as a guide for rehabilitation. As such all exercises are geared toward the individual patient's progression and comfort. Adjustments may be necessary on an individual basis.
- Pain should be controlled at all stages. If the patient is uncomfortable, medications and rehabilitation must be adjusted. Please contact us for assistance.
- Follow recheck schedule as indicated.
- Weight control is critical in order to manage and minimize osteoarthritis.
- Throughout rehabilitation, monitor the limb and incision for swelling, redness, and drainage. Do not allow the patient to lick or chew at the affected limb or incision. Call us if any of these situations occur.
- Use of a glucosamine/chondroitin sulfate supplement (Cosequin) is advised indefinately. Other osteoarthritis management and treatment plans may be recommended on a case-by-case basis.
