Management and treatment options for Osteoarthritis are changing, due to a new philosophy emerging from latest information looking into the process of the disease and its impact. Much of the veterinary effort to date has been focused on the pathology and degeneration of cartilage, coupled with short term improvement of the most obvious clinical signs (usually pain causing lameness). It is now suggested that the best practice is using multimodal or integrated management.
The 5 key shifts in improving management of OA are listed below:
– The role of pain
– Considering the joint as an ‘organ’ before deciding treatment options
– Pain and joint pathology; multiple targets for treatment
– Early, established or late disease
– Identifying successful management
Considering the joint as an ‘organ’. What does this mean?
Quite simply is it considering other tissues which are influenced by the pathology brewing in the affected joint. This disease originates in the joint, but it soon affects neighbouring structures and systems – joint capsules, ligaments, muscles, tendons and the nervous system. Any successful management plan must establish potential involvement of each of these structures and identify which areas are the key to the clinical issue presented by each individual animal.
Not applying this ‘organ’ approach to Osteoarthritis makes us focus only on the health of the cartilage. However, if the cartilage is one of many components of the disease, addressing cartilage will not miraculously resolve problems in other affected structures resulting in a poor outcome for the patient.
The ‘silver bullet’ (one form of treatment to solve all issues) approach to OA once hoped to solve the issue using ‘arthritic drugs’, but this is no longer considered the case. The evaluation required for each patient presents a diagnostic and therapeutic challenge which is likely the reason why Osteoarthritis is so poorly managed in many practices. This type of assessment takes not only skill but also time, and that does not fit well into the current model of so many busy veterinary practices who simply cannot find the time required.
Pain and joint pathology; multiple targets for treatment
We’re likely looking at multiple targets for treatment of OA. Cartilage pathology is often thought of as the source of the disease. The standard approach of achieving optimal health by removing the cause of the disease (usually bacteria or virus) does not work well in the case of OA. First of all, cartilage pathology is difficult to alter and in spite of some encouraging signs in the research field, we’re still far from regenerating or replacing damaged cartilage. Secondly, just resolving the issues with the cartilage will not resolve OA due to the involvement and influence of other structures.
Interesting research in human medicine shows a very high incidence of persistent pain after total knee replacement surgery. It is suspected that the surgery has been done on patients with a pain sensitised brain, which I briefly mentioned in the previous blog. (Grosu et al 2015).
It still makes sense to address the cartilage pathology which will be progressing. However, for the best results, this must be combined with simultaneous treatment of other structures. This is where the new science into OA and a multimodal treatment strategy sits. The new approach to the treatment of OA is all about treating every clinical component of the disease separately, for example, surgery or other treatment will be combined with painkillers, physical therapy techniques as well as dietary, environmental and lifestyle management. So much for the silver bullet approach!
Does it matter then whether your dog/horse has early or late stage OA?
Yes, it definitely does! However it’s important to remember that there is a tendency to treat all OA joints using the same strategy. We have various treatments available and some will have a greater impact in early stage disease, whereas others will be much more effective in late stage OA. Similarly, the needs of animals with multiple joints affected by OA will be different. These patients are much more likely to have pain sensitised brains and this should be considered when building a management plan.
Identifying successful management
Identifying successful management is the last hurdle in the fight against OA. Given all the veterinary effort required to diagnose and identify all the structures involved in the disease process, devising a treatment plan which takes into consideration all clinical, dietary and environmental factors, combined with the owners efforts to manage a treatment on daily basis, how do we assess how successful we are? How do we know we’ve got it right or whether there is another new or previously missed component of the disease which is now affecting the current picture?
There are various tests using Clinical Metrology Instruments such as LOAD; GUV-Quest; HCPI and CBPI. There are also various wearable devices on the market tracking the activity of your dog which could be used to assess management if the data they provide is accurate. There is also AIM OA Sys for the veterinary practices which combines structured assessments and digital algorithms to assist treatment. New online resources aimed at educating the wider public such as Canine Arthritis Management are available too.
Dog with early stage Osteoarthritis
This is also where Vet-IR imaging services are being utilised by many veterinary practices and hospitals. Thermography detects the inflammatory processes which are produced during physiological changes in the joint. X-Ray can be helpful in monitoring the progression of lesions within the joint but incremental changes or successful landmarks in treatment can only be obtained by arthroscopy which requires sedation and is relatively expensive, deeming it too costly to use as a means of regularly monitoring treatment. Our technology is highly sensitive, non-invasive, sedation free and offers affordable physiological testing which can aid the long term treatment plan for your animal. Regular scans provide the treating vets with an invaluable insight into the physiology of the joint and how it reacts to stress, which is another key component in the successful management of OA.
One of the reasons I love being involved with this technology is the welfare implications of the work we do. There is finally hope for a “cure” for OA. The new drive to tackle this huge welfare issue for our animals is very much gaining momentum and we’re part of this effort. I will quote the words of Professor Stuart Carmichael “… more attempts must be made to ‘measure’ the success of management strategies so that we truly understand how we can slow, halt or reverse this attritional disease as we move into the future.”
This is where I believe we can contribute the most; by measuring and sharing the data gained during treatment and research in the hope of improving the quality of life of animals suffering with OA in the future.
This and my previous blog on primitive brain and pain have been inspired by the presentation of Professor Stuart Carmichael, Director of Joint Adventures Ltd and Visiting Professor of Veterinary Science in the University of Surrey, during Vet Festival 2017. I would like to thank Professor Stuart Carmichael for a fascinating presentation and for his permission to share some of his work.
Kat is one of Vet-IR partners. To read more about her and the team follow the link or contact Kat directly on firstname.lastname@example.org
References and further reading:
1. Belshaw Z et al (2016) The attitudes of owners and veterinary professionals in the United Kingdom to the risks of adverse events associated with using nonsteroidal anti-inflammatory drugs (NSAIDs) to treat dogs with osteoarthritis. Preventative Veterinary Medicine 131; 121-126
2. Grosu I et al (2014) Pain after knee arthroplasty: an unresolved issue. Knee Surg Sports Traumatol Arthrosc 22: 1744-58
3. Walton MB, Cowderoy E, Lascelles D, Innes JF (2013) Evaluation of Construct and Criterion Validity for the ‘Liverpool Osteoarthritis in Dogs’ (LOAD) Clinical Metrology Instrument and Comparison to Two Other Instruments. PLoS ONE 8(3): e58125. doi:10.1371/journal.pone.0058125
4. Wiseman-Orr ML, Scott EM, Reid J, et al. Validation of a structured questionnaire as an instrument to measure chronic pain in dogs on the basis of effects on health-related quality of life. Am J Vet Res 2006;67:1826–1836.
5. Hielm-Bjorkman AK, Kuusela E, Liman A, Markkola A, Saarto E, et al. (2003) Evaluation of methods for assessment of pain associated with chronic osteoarthritis in dogs. Journal of the American Veterinary Medical Association 222: 1552–1558.
6. Brown DC et al (2008) ability of the Canine Brief Pain Inventory to detect response to treatment in dogs with osteoarthritis J Am Vet Med Assoc 233:1278-1283
7. Aim-OA.Sys – www.aim-oa.com
8. Canine Arthritis Management – www.caninearthritis.co.uk