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Regenerative Medicine For Arthritis:
Part Three – Case Examples

Matt Brunke, DVM, CCRP, CVPP, CVA
Diplomate, American College of Veterinary Sports Medicine and Rehabilitation

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Multimodal approach

arthritis. Today, veterinarians have a range of treatment options, called a multimodal approach, that can be used together to improve the quality of life for their patients.

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After Joint Injections - Regen
PRP
- No Class 4 for 2 weeks (3b ok)
- No NSAID for 2 weeks?
- Galliprant ok
- No ice for 2 weeks
- No MSM for 2 weeks?
- YES REHAB

Stem Cells/PRP
- No Class 4 for 8 weeks (3b ok)
- No NSAID for 8 weeks
- Galliprant not ok?
- No ice for 8 weeks
- No MSM for 8 weeks
- REHAB

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Case Example: Jameson
- Labrador Retriever
- DOB: 8/2/13
- Obedience competitor
- On Dasuquin and Omega-3 for 2 years
- CC: Elbows

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Front Leg Bunny Hop

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Initial PE – December 2016
- 86 pounds (BCS 6/9)
- Sore, chronically thickened elbows
- Stance: LF/RF/LH/RH: 33/27/20/20
- Girth (cm) LF/RF: 37/37
- CBC/Chem/UA/Thyroid Panel: NSF
- Ddx: Elbow dysplasia and secondary OA.

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Initial Diagnostics 12-15-16
- Elbow Flexion/Extension: LF 65/165, RF 70/165 (Normal 45/165)
- Sedated ortho exam: Negative Ortolani
- Radiographs: 2 view each elbow

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Diagnostics and Treatment
- Elbow osteoarthritis
– SECONDARY to Dysplasia
- Arthroscopy of both elbows: Synovitis, erosive lesions, no in-site fragments or floating
- Collected blood for PRP, Bone marrow for Stem Cells
- Injected: Both elbows
– (2.5cc per joint, 50/50 mix)

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Recheck 2 weeks later
- Stance Analyzer: LF/RF/LH/RH: 30/30/20/20
- Flexion/Extension: L Elbow: 50/165, R Elbow 50/165
- Continue joint supplements, diet, walking
- Start formal rehab (no laser to elbows) but laser other areas, core strength, massage, ROM, UWT

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Stance Analyzer

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Underwater Treadmill Time

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Complete 6 weeks of rehab
- Stance: Still 30/30/20/20
- Weight: 80 pounds!
- Elbow Flex/Ext: Left: 60/165, Right 60/165
- Girth: 40cm each front leg (up from 37)
- Continue walking, weight loss, recheck 4 weeks

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March Recheck
- Weight: 78lbs!
- Still on supplements
- Girth – 39 cm each
- Elbow Flex/Ext: Left 60/165, Right 55/165
- Recheck in 3-4 months, sooner if needed

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Case Example: Mia
- DOB 10/13/2009
- German Shepherd
- Initial Exam: October 2015
- 107 pounds *(BCS 7/9)
- CC: Chronic LF lameness

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Initial PE
- Pain on left biceps stretch
- Pain on RIGHT biceps stretch
- NO hip extension, poor muscle mass in thighs, crunching sounds
- CBC/Chem/UA/Thyroid - WNL

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What did we do?
- Injected triamcinolone (10mg) and HA(20mg) into both shoulders
- Started on Dasuquin Advanced, Welactin, meloxicam, Adequan and eventually gabapentin
- Worked on her weight
- Got her in rehab

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What happened next?
- She did well in rehab
- Lost 10 pounds
- Became more active......
- March 2016 – strained right CCL, injected HA/triam – (hips as well)
- May 2016 – Left hip painful – had FHO and injected HA into right stifle again

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After Left FHO
- Right into rehab!
- Got her weight bearing and improved
- Continue Chiropractic visits
- Mom stopped rehab in September 2016

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January 2017
- Mia painful in both her shoulders and her right hip.
- Had gained 5 pounds
- Was back taking meloxicam every day
- My PE: Painful right hip (stifles ok), pain on biceps stretch

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What could we do?
- Triamcinolone and HA again?
- With shoulders painful, not great candidate for right FHO
- Owner financially strapped
- My thanks to Companion Animal Health and specifically Heather Weir

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Rehab Plan
- Rest for 2 weeks
- Gabapentin, joint supplements
- Chiropractic care – just not the injected joints
- Start back in rehab (again) – core strength, UWT, Laser (not the injected joints)
- No NSAIDS – (but could use Galliprant if needed)

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When are you finding patients?
- Every exam you do!
- Especially geriatrics – age is NOT a disease
- Know your normal – flex/extend every patient
- History ?’s – trouble with stairs? Less active?
- Who’s on NSAID constantly?
- Those that can’t take NSAID?
- Clients that want biologic option?

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Pricing
- Consult, minimum database (CBC/Chem/UA)
- Sedation/Tech Monitoring
- Radiographs – ORTHOGONAL VIEWS
- PRP – can’t save it for later
– Cost for the kit
– Centrifuge pay off
– # of joints injected
– ~$650-700 for PRP and first two joints
- Home on codeine
- GET INTO REHAB

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Summary
- New and evolving field
- Keep up on research
- Currently more research on PRP than “stem cells”

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You can be anything you want to be when you grow up.
STEM CELL PARENTAL ADVICE

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Questions?
- Matt Brunke, DVM, CCRP, CVPP, CVA
Diplomate, American College of Veterinary Sports Medicine and Rehabilitation
DrMattBrunke@gmail.com
DrBrunke.Wordpress.com