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Managing Osteoarthritis Beyond the NSAID: Part One

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

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American College of Veterinary Sports Medicine and Rehabilitation

ROSS UNIVERSITY
SCHOOL OF VETERINARY MEDICINE

CHI INSTITUTE
TRADITIONAL CHINESE VETERINARY MEDICINE

IVAPM

IRONMAN
Lake Placid

A little about me... I like to keep busy.

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Introduction/Goals
- Osteoarthritis
- Pathophysiology - quickly
- Diagnosis - quickly
- Treatments
- Joint Supplements
- Weight Control
- Rehabilitation
- Pharmaceuticals
- Others

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Osteoarthritis
- Most common form of arthritis in dogs and cats
- 20% of adult dogs and 60% of adult cats have radiographic evidence1,2
- 31% of owners said bone and joint problems were an issue with their pet

1. Johnston SA: Osteoarthritis: joint anatomy, physiology, and pathobiology. Vet Clin North Am Small Anim Pract 27:699, 1997.
2. Hardie EM, Roe SC, Martin FR: Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases (1994-1997). J Am Vet Med
Assoc 220:628, 2002.

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Osteoarthritis is the #1 Cause of Chronic Pain in Dogs
Impact
- Chronic pain
- Decreased activity
- An overall negative impact on the patient
- Interferes with human- animal bond
- Decreased food intake
- Euthanasia for dogs that become non-responsive to treatment

Affects 25% of Dogs in U.S.
20 MILLION DOGS

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Elbow disease in dogs A big problem for big dogs

This study evaluated the frequency, predispositions and clinical management of elbow joint disease in dogs in the UK.

CONCLUSION
- Elbow joint disease severely impacts welfare of dogs.
- Larger breeds are most at risk.
- Owners should be alert to the early signs of elbow joint disease as their dogs age and seek veterinary advice if signs develop.

This study included 804 elbow disease cases from 455,069 dogs under : primary veterinary care in the UK during 2013

Epidemiology and clinical management of elbow joint disease in dogs under primary veterinary care in the UK

Canine Genetics and Epidemiology (Freely available)

- Elbow joint disease affects 0.6% of dogs under primary veterinary care.
- Elbow disease contributed to the decision to euthanase in 41% of dogs that died during the study.
- Both elbows are affected in 61% of cases.

Most commonly reported signs by owners
- 76% LAMENESS
- 20% DIFFICULTY EXERCISING
- 14% PAIN

LAMENESS
14% DIFFICULTY
PAIN Both elbows EXERCISING were affected in 61% of cases.

20%
8 Breeds with highest risk 7 of elbow joint disease 5.9x Risk level compared
to Crossbreeds)

ONeill, D.G. et al. (2020)
OTHER RISK FACTORS
- Advancing age
- Being neutered
- Larger bodyweight
- Being male
- Being insured

Breeds with higher risk of elbow joint disease
- Rottweiler
- Labrador Retriever
- English Springer Spaniel
- Golden Retriever
- German Shepherd Dog

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So what does this mean?
- OA should be thought of as a global disease process rather than an isolated disease entity
- Its the final pathway of a failing joint
- Articular cartilage is part of an organ with cross-talk amongst tissues
- Dogs: Almost exclusively always a secondary phenomenon
- Cats: Typically primary in nature, esp. the elbow

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Pro-inflammatory Mediators Cause Progressive Joint Damage

Progression to severe Osteoarthritis
Thickening of subchondral bone
Osteophyte

1. Pelletier JP et al. A Textbook of Rheumatology, Koopman W (ed). 14th Ed: 2195-2245. Lippincott, Williams and Wilkins; Baltimore, 2000.
2. Clegg PD et al. Equine Vet J. 29:335-342; 1997.
3. Martel-Pelletier et al. Frontiers in Bioscience 4: D694-D703; 1990. 8

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Pro-inflammatory mediators initiate pain and hyper-sensitize the CNS

1. Camu F, Shi l, Vanlersberghe C. Drugs. 63 Suppl 1:1-7; 2003.
2. Johnston S. Vet Clinics of NA: Small Animal Practice, 31:39- 53; 2001.

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Vicious Cycle
Joint Pain
Motor Dysfunction
- Decreased mobility
- Decreased muscle tissue
Structural Modulation
- Increased Mechanical stress on joint capsule, cartilage, and ligaments
- Deterioration of articular cartilage
Sensitization
- Increased pain sensation
- Release of inflammatory mediators

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Pathophysiology of OA/DJD involves the entire joint
Normal
- Synovium
- Synovial fluid
- Cartilage
- Capsule
- Subchondral bone

Osteoarthritis
- Inflamed synovium
- Reduced viscosity of synovial fluid
- Narrowed joint space
- Osteophyte
- Fibrillated/destroyed cartilage
- Thickened subchondral bone
- Thickened capsule
- Cruciate ligament destruction

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Pathophysiology...
- SYNOVIAL disease
- Osteophytes are the end stage
- Do we see synovium on radiographs?

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Diagnosis
- Remember its usually always secondary (so treat the primary dz)
- Obesity, dysplasia, hypothyroid, CCL tear, etc.
- Primary OA usually involves the smaller joints (manus and pes)
- Any problem that involves or disrupts the joint will lead to OA
- Make owners aware
- Be proactive in treating/minimizing and slowing progression

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Diagnosis
- Owners will complain of reluctance to exercise, stiffness, lameness, inability to jump, and some behavioral changes
- Cats (not small dogs): have very few signs but can show
- Reduction in activity
- Reluctance to jump (decrease in max height)
- Unkempt appearance
- Aggression

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Diagnosis
- Orthopedic exam:
- Dogs: muscle atrophy, joint swelling, capsular/extracapsular fibrosis, joint effusion, reduced ROM, crepitus, pain, etc
- Cats: Hard to examine, performance tests (allowing free movement in room, encouraging to jump).
- Most are willing to jump off an exam table so reluctance to do so may provide information
- Radiographs:
- Only provide bony information (osteophytosis and sclerosis)
- Osteophytosis is useful to diagnose OA but it is not pathognomonic.
- Value of osteophytosis for staging is controversial
- Does not correlate with clinical signs
- Non-wt bearing

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Diagnosis- Objective

Red arrow: Joint effusion with compression of the fat pad
Orange arrow: Osteophytosis of the distal pole of the patella
Green arrow: Osteophytosis of the proximal border of the trochlear groove
Blue arrow: Osteophytosis of the caudal tibial margin

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Diagnosis
- So how does this help you???
- And.... Radiographs help dx but don’t really help stage for monitoring or progression????
- Gait analysis, muscle measurements, goniometry
- Is there some type of subjective assessment based on DVM and/or owners????

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Diagnosis- Subjective
- Canine Orthopedic Index (COI)
- Brown, DC. Vet Surg 2014
- Designed and validated to provide reliable assessment of dogs with OA in terms of staging as well as response to treatment
- Questions address stiffness, gait, and specific functions
- Downloaded at www.CanineOrthopedicIndex.com

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Treatment - Management
NSAID
Weight control and exercise
Chondroprotective
EPA-rich Diet
Adjunct
Physical Rehabilitation
Multimodal Osteoarthritis Management

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Thank You
- Matt Brunke, DVM, CCRP, CVPP, CVA Diplomate, ACVSMR
DrMattBrunke@gmail.com
DrBrunke.wordpress.com