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Managing Osteoarthritis Beyond the NSAID: Part Two

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

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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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Management
- 1) Those that have a primary problem and have or will develop OA or those with “incidental” OA
- Ex: A ruptured CrCL -
- Ex: Acute gastroenteritis with hip OA and no C/S
- 2) Those that had a primary problem and now suffer from OA
- Ex: The typical “OA Consult”

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NSAID is the cornerstone of therapy
- Quick action
- Anti- “itis”
- But what happens when:
- Owner declines it?
- Patient can’t take it?
- It’s not working?
- We have lost the pharmacy?

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Management
- 1) That have a primary problem & have or will develop OA or those with “incidental” OA
- Give owners clear expectation of the future
- Warn of Flare-ups!!

- Establishing a Baseline
- Dasuquin Advanced and Welactin
- Promote daily activity
- Manage weight
- Diet
- Daily exercise

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Personal Thoughts!
- Joint Supplements:
- Deep dark world to recommend “joint supplements”
- No FDA regulations on “nutraceuticals”
- Don’t have to meet label claim!!!!!
- Same for CBDs
- Source, purity, ethical, safety, GMP, etc., etc....
- Best current research on
- Omega-3’s FA (cold water, wild caught)
- ASU’s (avocado soybean unsaponafiables
- UC-2 (un-denatured type 2 collagen)
- EggShell Membrane

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Controlling inflammation with n-3 fatty acids

Chondrocyte damage
Cell membrane phospholipid
Arachadonic Acid (n-6 FA) Omega 3-FA Replace

Lipoxygenase Cyclooxygenase
Omega-3 FA Inhibit
Leukotrienes Prostaglandins (PGE2) Thromboxanes
Inflammation

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Omega-3 diets in dogs

Effect of a diet enriched with green-lipped mussel on pain behaviour and functioning in dogs with clinical osteoarthritis

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And cats!
Evaluation of a therapeutic diet for feline degenerative joint disease

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Management
- Omega-3 FA
- Dose???
- Much higher for joint health vs. skin/kidney/etc.
- Dogs: 175 mg/kg of DHA/EPA

Bauer JE. Therapeutic use of fish oils in companion animals. JAVMA, 2011.

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Management
- Weight Control/Daily Exercise
- Obese dogs1:
- More OA
- Require more analgesia/shorter lives
- Reduces load/stress on joints
- Reduced calorie diets
- Regular exercise
- Running around the back yard is not exercise!!!
- Daily walks - build up to 20 min/flat ground 2x daily
- 10% BW at 1-2% weekly
- Evaluate for metabolic abnormalities
Hypothyroidism

1. Kealy RD. JAVMA, 2002

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Obesity

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Life-shortening disease

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Obesity Effects - Two-fold
- Biomechanical stress contributes to clinical signs and progression of disease
- Adipokines secreted by white fat cells contribute to the progressive inflammation of osteoarthritis
- Leptin levels are elevated in obese dogs
- In humans with osteoarthritis, increase leptin levels correlate with elevated MMPs and NO in synovial fluid
- Adiponectin is anti-inflammatory, but levels are low in obese dogs
- In human patients with knee osteoarthritis there is a significant correlation with adiponectin:leptin ratios

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Effects of weight loss on OA
- Humans with increased body mass index (BMI) experience OA in non-weight bearing joints, which resolves with weight loss
- Decrease in BMI, is associated with symptomatic relief from knee OA in man
- Systematic review of canine studies found:
Preventing Obesity Decreases Incidence of OA
Weight Loss Reduces Signs of OA

1. Cicuttini FM, et al. J Rheumatol. 1996; 23: 1221-1226.
2. Toda Y, et al. Rheumatol. 1998; 25: 2181-2186.
3. Marshall et al. Vet Comp Ortho Traumatol 2009; 5: 339-345.

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Rehabilitation (Physical Therapy)
- Physical Modalities
- Therapeutic laser, ultrasound, TENS, etc.
- Manual Therapies
- Joint mobilization
- Massage
- ROM, stretching
- Therapeutic Exercise - Core of PT
- Core strengthening
- Weight bearing
- Proprioception
- Underwater treadmill

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Goal of Rehabilitation with OA

Maintain/Improve Muscle Mass
Build Muscle Support Around Joint
Reduce Pain
Weight Loss when indicated

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Reaching Goals with Rehab
Determining Goal
- Begin with patient assessment
- Determine mobility status, limb girth, range of motion
- Assess body condition score

Program Can Then Be Tailored to Individual Patient
- At home therapies
- In-clinic rechecks and therapy
- Concurrent pain management should be considered as part of the rehabilitation program
Walking

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Walking
- A great exercise
- On leash, continuous movement - flat non-slip surfaces
- At a pace appropriate for the patient, not the owner
- Start with 10-12 minutes twice a day, increase each week by 3-5 minutes
- Add in hills, varying traction (sand, snow, high grass)

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