Osteoarthritis. at a Glance STEP 2

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1 STEP 1: Comprehensive Overview Osteoarthritis at a Glance Julia Tomlinson, BVSc, MS, PhD, DACVS, CCRP, CVSMT, DACVSMR Twin Cities Animal Rehabilitation Clinic Burnsville, Minnesota Through education about osteoarthritis prevention, management, and pain control, the veterinary team and clients join forces to help ensure pets good joint health. PREVENTION IS TOP DOG Understand the importance of arthritis prevention by taking these steps at every wellness examination: Evaluate motion, joint mobility, and pain on palpation. Interpret radiographic changes in light of pain score and mobility changes. Provide client education handouts and prominently display posters about understanding mobility issues and recognizing pain in pets. Emphasize to clients the importance of weight control in managing arthritis in pets. NUTRITIONAL SUPPORT FOR AGING JOINTS Mature patients (ie, any large-breed dog 5 years) should receive a high-quality glucosamine chondroitin supplement daily. If a patient has a history of a physical injury, educate the client about the possibility of arthritis and place the patient on a joint mobility supplement (eg, glucosamine chondroitin, glucosamine hydrochloride, chondroitin sulfate). TEAM TIP Train team members to look for historical and physical markers that can signal arthritis and alert the veterinarian regardless of the reason for the appointment. Allot adequate time for diagnosis and client education about treatments and supportive care. CHEW IT OVER Overweight dogs are more likely to develop osteoarthritis than those of normal weight. There is great potential for targeting these patients nutritionally and with physical rehabilitation. STEP 2 Team Education Primer h 26

2 STEP 2: Team Education Primer Boning Up on Osteoarthritis Julia Tomlinson, BVSc, MS, PhD, DACVS, CCRP, CVSMT, DACVSMR Twin Cities Animal Rehabilitation Clinic Burnsville, Minnesota Understanding the anatomy of joints and how osteoarthritis develops is key to successful diagnosis and management. ANATOMY Joints are composed of cartilagecovered long bone epiphyses (rounded ends) articulating with one another; the joint space is encased in a synovial membrane and fibrous joint capsule and contains synovial fluid. Soft tissues around the joint contribute to the integrity and movement of the joint. Muscles around the joint provide concussive cushioning and help to limit joint movement within certain anatomic boundaries. DISEASE PROCESS Both the synovial lining and articular cartilage are instrumental in the arthritic disease process. The synovial lining is composed of 2 cell types; one produces synovial (joint) fluid, the other supports immune function within the joint. The synovial lining contains many nerve endings, some of which carry pain signals. The cartilage surface of the joint consists of chondrocytes (ie, cartilage cells) and the extracellular matrix produced by those cells. This matrix is comprised of collagen and large molecules known as aggrecan. The tensile strength of the matrix derives from the collagen network; the compressive stiffness and elasticity is caused by aggrecan, which binds hyaluronan within the cartilage matrix. Healthy cartilage matrix is continuously manufactured by cartilage cells, replacing the old matrix. In arthritic cartilage, there is an imbalance between removal of old matrix and synthesis of new matrix, with an overabundance of breakdown enzymes being produced. Loss of cartilage matrix causes joint pain on everyday weight-bearing loads. As the cartilage surface roughens, underlying bone is exposed, resulting in increased pain. Because of joint pain, activity is limited; subsequently, tissues tighten, and the range of joint motion is reduced. inflammation, but additional pain control may be needed. Support of cartilage matrix production is provided through diseasemodifying osteoarthritic agents (eg, polysulfated glycosaminoglycan, omega-3 fatty acids, glucosamine chondroitin sulfate). Physical therapeutic modalities target pain and inflammation, and therapeutic exercises aim at improving mobility and increasing muscle support. Mobility aids also can play a role in management of the arthritic patient. Physical therapeutic modalities target pain and inflammation, and therapeutic exercises aim at improving mobility and muscle support. TREATMENT Therapies should target the inflammatory signals from the synovial immune cells and the cartilage; NSAIDs are the firstline therapy to reduce joint STEP 3 Communication Keys h May 2014 Veterinary Team Brief 27

3 STEP 3: Communication Keys Client Discussions on Arthritis Pain Jessica Goodman Lee, CVPM Brakke Consulting Dallas, Texas The entire team has many opportunities to discuss arthritis and the pain associated with the disease. Some human drugs are not for pets, and the doses can vary greatly. SCENARIO 1 Barney, a 13-year-old Labrador retriever, has difficulty standing and walking on hardwood floors. He sleeps more and no longer wants to go for his walks. One of the veterinarian s recommendations is an NSAID trial to reduce pain and inflammation. Ms. Barron, Barney s owner, tells the veterinarian, I won t give Barney pain medication! My neighbor did that and her dog had horrible side effects and ended up dying 6 months later! THE VETERINARIAN S REPLY: Ms. Barron, I understand your concerns. There can be adverse effects with any medication, but we will monitor Barney closely and can stop or change the medication at any time. The first thing we ll do is run a blood test to make sure there are no contraindications for a pain reliever. If things go well, we can keep Barney on the medication long-term, as long as we continue to test his blood regularly. You will be amazed at how Barney s quality of life can improve once his pain is under control. I can give you some information on canine pain management that also includes other options, such as supplements and alternative therapies like acupuncture and laser therapy. Let s test Barney s blood and then I will call you in a day or so and see how you would like to proceed. SCENARIO 2 Jamie, a technician, is checking in Ms. Lilles and her 9-year-old cocker spaniel, Sophie. Ms. Lilles tells Jamie that Sophie has started to limp after long walks and that she has been giving her acetaminophen and aspirin on an as-needed basis. THE TECHNICIAN S REPLY: Poor Sophie. I know how much she loves her walks. I ll tell Dr. Margaret, and I m sure she will have more questions for you. After she examines Sophie, we ll put together a treatment plan that will probably include x-rays. In the meantime, I ll bring you some material about treating Sophie s pain and why it s not a good idea to give her any medications without calling us. Some human drugs are not for pets, and the doses can vary greatly. I completely understand that you just want to make her feel better. Once we know what s going on, Dr. Margaret will talk to you about the different 28

4 pain medications specifically formulated for dogs. Does that sound like a plan? SCENARIO 3 Mr. Frederick is beside himself his 15-year-old cat, Spicy, has been defecating outside the litter box and has stopped grooming herself. Mr. Frederick calls to make an appointment and tells the receptionist, Spicy has always been so particular about grooming and since we ve been together, I don t think she s ever had an accident! She won t even jump up on the bed. What do you think is wrong with her? THE RECEPTIONIST S REPLY: I m not the veterinarian, but we recently had a team education meeting on this topic, and all the changes you are describing are some of the common ways that cats behave when they are in pain. At 15, Spicy still looks like a kitten, but there s a good chance she may have some arthritis or something else making her physically uncomfortable. Cats are masters at hiding pain and illness, so it s completely understandable that you wouldn t have recognized the signs. I am so glad you are going to bring her in. Dr. Margaret has an opening at 3:00; does that work with your schedule? HOT-BUTTON ISSUE What if a patient is in pain and is overweight? If a patient is overweight and has arthritis, it is not enough to prescribe medication diet and exercise must be discussed with the client. Although common sense tells us that excess weight worsens arthritis, many clients are unaware that their pet is carrying extra pounds (see Obesity in Dogs & Cats, November/December 2013 issue, page 36). Sometimes clients may feed their pets more because they want to do something to make them feel better. These can be uncomfortable discussions, but it is imperative that clients fully understand the impact that being overweight can have on pain, and discussing weight management should be a part of any practice s pain management protocols. Remaining positive and highlighting the benefits of a normal body condition score (eg, increased mobility, energy, potential for a lower dose of medication [if any]) will show clients just how much you care. Discussing weight management should be a part of any practice's pain management protocols. STEP 4 Team Workflow h May 2014 Veterinary Team Brief 29

5 STEP 4: Team Workflow Team Workflow Jessica Goodman Lee, CVPM Brakke Consulting Dallas, Texas RECEPTIONIST 4 Schedule the initial appointment. If pain or arthritis is a possibility, ask the client to complete a mobility questionnaire (via or the practice website) to bring to the visit (see the mobility questionnaire on page 33) TECHNICIAN/ASSISTANT 4 Greet the client, weigh the patient, and bring both into the examination room 4 Obtain a history, including any change in behavior or daily activities 4 If the client completed a pain assessment, review briefly but give to the veterinarian for full review before the examination 4 Explain the numeric pain assessment scale and ask the client to subjectively rate the patient s current level of pain; document in the patient record 4 Collect radiographs and diagnostics as directed by the veterinarian 4 Fill medications and provide education about potential adverse effects 4 Recommend that the owner keep a daily pain log to assess treatment 4 Schedule follow-up visits or transfer directly to the receptionist to schedule VETERINARIAN 4 Review the mobility assessment before entering the examination room 4 Use the touch-and-talk method to examine the patient for joint mobility, pain, range of motion, and body condition score 4 Educate the client about findings, pain signs, and responses 4 Discuss options for a therapeutic plan and set realistic expectations KENNEL ATTENDANT/GROOMER 4 Notify the veterinarian if the patient exhibits behavior that could potentially be associated with pain (but leave the responsibility of the discussion with the client to the veterinarian) PRACTICE MANAGER STEP 5 Team Roles h 4 Motivate veterinarians to develop a numeric pain scale, standards of care (including time for NSAID refills and required laboratory work), and an assessment questionnaire 4 Manage pain medication inventory and keep veterinarians abreast of any new medications 4 Ensure the team is adequately educated on signs and treatment options for pain 4 Prepare educational material for clients based on veterinarians preferences 4 Produce articles in newsletters or on social media to increase client awareness 4 Research modalities such as laser therapy, acupuncture, or rehabilitation 30

6 STEP 5: Team Roles Team Roles By working together to educate clients about osteoarthritis prevention, disease management, and pain control, the team helps ensure patients good joint health and quality of life. Veterinarian: Medical expert, diagnostician, client educator, patient advocate Receptionist: Empathetic client communicator and educator Kennel Attendant/ Groomer: Patient advocate Veterinary Technician: Patient advocate, client educator, liaison between client and veterinarian Practice Manager: Overseer of team training, protocol creator, materials creator Ensure the team is adequately educated on signs and treatment options for pain. GUIDELINES FOR PAIN MANAGEMENT Download the American Animal Hospital Association/American Association of Feline Practitioners Pain Management Guidelines for Dogs & Cats at aahanet.org/publicdocuments/painmanagementguidelines.pdf. STEP 6 Team Training Plan h May 2014 Veterinary Team Brief 31

7 STEP 6: Team Training Plan Team Training Plan Jessica Goodman Lee, CVPM Brakke Consulting Dallas, Texas Before scheduling team meetings dedicated to pain management, consider a team member survey to build enthusiasm while determining the overall level of knowledge. Having one or more credentialed CVPPs in the practice is beneficial for educating clients and team members. The next step is to build a task force to assist with this program, preferably made up of at least one veterinarian and one technician. Team education should focus on: Recognizing behaviors that may indicate pain in cats and dogs Common causes of pain Understanding the subjective pain scale that clients will be asked about at every visit Treatment options, including pain medications, supplements, and any additional modalities the practice offers to manage pain Potential adverse effects of medications and the practice s policy on refills, laboratory work, and rechecks A review of all client education materials and social media campaigns or newsletters. CVPPs ELEVATE PAIN MANAGEMENT PROTOCOLS & EDUCATION The International Veterinary Academy of Pain Management (ivapm.org) offers an intensive program for veterinarians or licensed technicians to become a credentialed certified veterinary pain practitioner (CVPP). Having one or more CVPPs in the practice is beneficial for educating clients and team members and assuring clients that the practice is doing all it can to understand and manage pain in patients. STEP 7 Client Handout h 32

8 STEP 7: Client Handout Mobility Questionnaire: Does Your Pet Show Signs of Pain? Julia Tomlinson, BVSc, MS, PhD, DACVS, CCRP, CVSMT, DACVSMR Twin Cities Animal Rehabilitation Clinic Burnsville, Minnesota Pet name: Owner name: Breed: Age: In general, how do you rate your pet s health? 3 Excellent 3 Very Good 3 Good 3 Fair 3 Poor Has your pet ever seen a veterinarian because of joint pain, stiffness, or limping? 3 No 3 Yes Details: Living in pain can lead to changes in behavior, which can be hard to read in a pet. On average, would you say your pet [Choose 1] 3 Is completely uninterested in its surroundings; sleeps all the time? 3 Will show interest, but no longer comes to greet you? 3 Is mostly interested in life and food, but reluctant to play? 3 Plays only when encouraged, and not for long? 3 Has had no change in personality? Has your pet s activity level changed? If so, select all that apply: 3 Seeks more affection than usual 3 Has difficulty getting up from a lying position 3 Lies very still 3 Reluctant to move 3 Shows trembling 3 Becomes restless 3 Repetitively gets up and lies down 3 Shows circling 3 Other Has your pet s appetite or thirst changed? 3 Yes 3 No Does your pet have trouble in areas where it never used to need assistance? 3 Cannot manage any steps without assistance 3 Cannot manage a full flight of steps (only 2 to 4 steps alone) 3 Manages a full flight of steps, but has difficulty 3 Can only go upstairs without assistance 3 Can only go downstairs without assistance 3 No problems on stairs Has your pet become protective of itself? If so, select all that apply: 3 Protects hurt body part 3 Hides 3 Doesn t put weight on a limb 3 Limps 3 Doesn t want to be held or picked up 3 Other 3 Cannot jump onto the furniture without assistance 3 Cannot get into the vehicle without assistance 3 Has no problem jumping Does your pet have pain, swelling, or stiffness? 3 Yes, in many joints 3 Yes, in a few joints 3 Yes, in 1 joint 3 Very rarely 3 Never Continued on page 34 h May 2014 Veterinary Team Brief 33

9 STEP 7: Client Handout How long can your pet walk without getting tired, limping, or stopping? 3 Less than 5 minutes 3 10 to 20 minutes 3 More than 30 minutes/my pet doesn t get tired or sore 3 Does not show signs until finished walking and rests for a while (ie, will stiffen up) Does your pet favor one side of its body more than the other? 3 No 3 Yes (details: ) Did your pet s signs begin slowly or suddenly? 3 Slowly, over the course of a few months 3 Suddenly, within days or a few weeks Has the joint pain suddenly gotten worse? 3 Within the past few days 3 Within the past few weeks 3 Not applicable In the morning, are the affected areas stiff for more than half an hour? 3 Yes 3 No 3 There is no morning stiffness Has your pet had a joint/bone injury or surgery? 3 Yes (details: ) 3 No 3 Unsure Which of the following methods do you use to manage your pet s pain, swelling, or stiffness? [Check all that apply.] 3 Physical activity/exercise 3 Nutritional supplements 3 Weight management 3 Physical rehabilitation/chiropractic/massage 3 Cold or heat treatment 3 Medication 3 Other: 3 None of the above Which medication and/or joint supplements do you currently give your pet? [Check all that apply.] 3 Prescription medication from veterinarian: 3 Over-the-counter medication: 3 Aspirin: 3 Glucosamine human medication (brand): 3 Veterinary joint supplement (brand): 3 Herbal supplement (brand): 3 Other: 3 None Does your pet have any of the following conditions? [Check all that apply.] 3 Kidney disease 3 Skin disease 3 Liver disease 3 Active infection 3 Lung disease 3 Bladder problems 3 Cardiovascular disease 3 Other Is there anything else we should know about your pet? 34