Arthritis

Introduction

One of the most insidious diseases we encounter in animals is arthritis. It was not long ago that we all-too-often euthanized animals that seemed “old” based on their symptoms of poor appetite, decreased activity, and lethargy. In reality they were not “old”, they had arthritis, and acted like they were old because they were painful. Today we can treat their arthritis and give them a new lease on life and lead a great quality of life for many more years.

Many of our pets are stoic, and can have a disease process brewing on the inside yet show no external symptoms. As the disease progresses eventually the symptoms appear and we are presented with a pet that is very ill that seemingly became sick overnight. The reality is that the problem was present for a period of time and it went unnoticed until now, when the bodies mechanisms for compensating and coping with the disease have become overwhelmed and the pet is in critical condition. At this point the disease process is so well entrenched that the prognosis for recovery is poor. This concept applies to arthritis in dogs and cats.

With our new digital radiography that gives us much more detail, along with substantially improved treatments, we can successfully treat these animals and give them a vastly improved quality of life for many more years. What’s even better is the fact that some of these new treatments do not involve the use of drugs.

We have a multi-system approach to arthritis due to its chronic and debilitating nature and the fact we strive for treatment modalities that involve minimal use of long term drugs.

1. If your pet is overweight, a common problem, modifying diet and feeding habits to bring it back to its fighting weight can minimize the symptoms of arthritis. This common sense and inexpensive and drug free option seems to escape many people.

2. Arthritis tends to be a disease of the aging. Older pets have different nutritional needs that need to be addressed. These needs cannot be addressed by going to a pet store and listening to the advice of some amateur nutritionist behind the counter trying to sell you the latest gimmick in dog food marketing. It comes after you discuss your pets individual lifestyle needs with your veterinarian, and your pet is given a thorough physical exam, and your veterinarian has blood panel and radiographic tests on your pet. Only then will the full picture of your pets needs be understood and a custom treatment protocol established.

3. Chondroprotective agents called neutraceuticals can help in some cases.  These are the chondroitin sulfate- glucosamine products available everywhere, including Trader Joe’s at the checkout stand. They are not a panacea, and its important to take a critical look to see if they are working in your pet's case. Sometimes the placebo effect seems to be transmitted in our minds and we do not have an objective standard to determine if these medications truly help. Fortunately they do not hurt, so we can achieve or first goal of “do no harm” as veterinarians.

4. NSAID's  (non-steroidal anti-inflammatory drugs) are a tremendous advancement in the treatment of arthritis. Non-steroidal means they do not contain cortisone, which was one of the primary drugs used to treat arthritis in the recent past. The NSAID’s are better at treating arthritis when used judiciously to maximize their good effects while minimizing their potential for side effects. Every pet reacts differently, so if one NSAID does not seem to work we will try another.

5. Veterinary Neuronal Adjustment (VNA or VOM) is a tremendous treatment modality that uses the bodies natural healing processes without the use of any drugs. It involves stimulating the autonomic nervous system (specifically the sympathetic branches) and provides substantial pain relief. We have been using VNA at the Long Beach Animal Hospital for almost a decade.

6. Therapy Laser brings an additional and highly effective treatment modality that again does not involve the use of drugs. This laser penetrates the hair and skin and goes right to the problem area to decrease inflammatory mediators. We recently updated our equipment to include a new therapy laser called MLS that treats using two different wavelengths.

7. Acupuncture can also be used to augment all of the above therapies.

8. Exercising your pet in the cooler part of the day, without excess trauma like jumping for long periods of time, will keep your pet flexible, the joins warm and lubricated, and keep its weight under control. If your pet is not afraid of water letting it swim in a shallow area is a great way to enhance mobility.

We will use the words arthritis and osteoarthritis (OA) interchangeable because they are the same thing in regards to the pain your pet is feeling and how it is treated.

You can go right to the detailed explanation of these treatments by clicking here, or you can read some background first and see how we diagnose this malady by scrolling down to the next topic.

What is Arthritis?

Dogs are prone to many different types of bone problems. This page will focus on the arthritis that tends to occur in dogs, especially as they age. Arthritis literally means inflammation of the joint, but the term is used more generally to describe several different processes. These include degenerative joint disease (DJD), infectious joint disease, immune mediated joint disease, and crystal-induced joint diseases. Many people use the term arthritis synonymously with osteoarthritis (OA), a complex, slowly progressive, and degenerative arthritis that is characterized by the gradual development of joint pain, stiffness, and a decreased range of motion.This is the type of arthritis common in older pets, and is increasing as pets live longer.

As we learn more about the subtleties of feline medicine we realize that many cats get significant arthritis especially in their lower back. This problem, also know as feline hypersethesia syndrome, causes tremendous discomfort and decreases the quality of life for many cats.

Anatomy

A normal joint is lined with hyaline cartilage, which is the covering over the end of the bone. It provides an almost frictionless surface for the bones to articulate, and also acts as a shock absorber. Hyaline cartilage is comprised of chondrocytes, proteoglycans, and collagen.

A normal joint is encased in a fibrous structure called the joint capsule. The joint capsule helps stabilize the joint and keeps the cartilage bathed in synovial fluid. Ligaments, which attach bone to bone, also provide joint stability.

This is what cartilage looks like in the knee joint. It is glistening because it is very smooth and has a lubricating layer over it called synovial fluid.

This picture is from an actual surgery on the knee of a dog with a ruptured cranial cruciate ligament. The ridge of bone running vertically at the left is arthritis. Compare its roughened surface to the picture above.

Cause

The cause of this complex and multi factorial disease can be primary or secondary. Primary OA results from normal stresses acting on abnormal cartilage. Secondary OA is more common, and results from abnormal stresses acting on normal cartilage, such as an unstable joint caused by canine hip dysplasia, fragmented coronoid process, ununited anconeal process, patellar luxation, or a ruptured cruciate ligament. Some of the factors that can cause OA include excessive exercise, obesity, poor nutrition, trauma, immune reactions, and genetic predispositions.

The radiograph on the left is from a normal shoulder joint. The one on the right has an abnormal flap of cartilage at the arrow. This is know as osteochondritis dissecans, and is a primary OA. Without this radiograph we never would have know this limping pet had this problem.

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Damage to cartilage might occur as one event, or be the culmination of many small events over years. As swelling occurs and the joint capsule becomes stretched pain occurs. Your pet will use the joint less because of this pain, leading to muscle atrophy and the inability of the surrounding tendons and muscles to support the joint. As the muscular support of the joint weakens the joint capsule, ligaments, and cartilage become further stressed and stretched, leading to even further pain.

At this point the body releases chemicals called inflammatory mediators, (the therapy laser works on these mediators) which further damage the cartilage and add to even more swelling. It is obvious that this rapidly becomes a vicious cycle leading to debilitating pain. When OA progresses to the point that you notice your pet in discomfort or pain the damage to the joint might be irreversible.

Symptoms

Symptoms are related to joint pain and stiffness. Most owners notice a pet losing its ability to perform normally, such as a reluctance to jump or climb stairs, or even limping. Stiffness after rest that diminishes rapidly is a hallmark sign of OA. Other symptoms of arthritis include lethargy and poor appetite, which are the result of pain.

Dogs that will not go on extended walks, or dogs that pant excessively during a walk could also indicate OA. Symptoms can be worsened by obesity, too much exercise, and by cold or damp conditions.

It is important to understand the initial symptoms might be subtle. Your pet will be experiencing pain or discomfort, yet it might not show any external signs. 

Diagnosis

Signalment

OA is commonly diagnosed in older dogs and cats. Some breeds are prone to getting it because of the conformation of their joints.

Dogs like Dachshunds have abnormally shaped long bones that might predispose them to OA.This is the wrist, forearm, and elbow of a Doxie.

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History

Most dogs show a reluctance to run or move about. Some will be reluctant to go up or down stairs, or might even be limping. As the disease progresses these dogs might be in overt pain and lose their appetite. Some of these symptoms occur in other diseases, notably hip dysplasia and intervertebral disk disease. The are treated in similar ways in most cases, in  different  ways in other cases, so a proper diagnosis is imperative.

Physical Exam

In some pets there are no abnormalities detected during a physical exam. Pain or discomfort might be found by palpating a joint or pushing on the mid or lower back. We might feel grinding of joints (crepitus), a swollen joint, abnormal bone formation and roughened bones, or inflammation at the joint. Dogs with longer standing OA might show atrophy of muscles. There might also be subtle signs during the neurologic part of the exam. 

Some pets are so distracted during an exam (this happens to us people commonly) that they do not exhibit signs of pain when touched in painful places. This is why we need some basic diagnostic tests.

Diagnostic Tests

Radiography is an important diagnostic test to perform on a dog or cat suspected of having OA. Even though a radiograph can be normal in a pet that has OA, it is a substantial help in verifying the diagnosis and determining the degree of involvement. There are many diseases that can mimic the symptoms of OA, so a radiograph should be taken on every suspected OA  to eliminate these other causes.

This one has arthritis. The arrows point to all of the rough edges that are indicative of OA. Compare these rough edges to the smooth edges on the radiograph above. Also, the bone has a stronger whitish appearance, another indication of OA.

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This dog was originally suspected of having arthritis based on a history of soreness in the hip area. Radiographs revealed a different story, as can be seen at the arrow at the far left of the radiograph. The white circular area in the bone has the potential to be many things, some of them serious, so a biopsy is need to know for sure.

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A close-up view gives you a better idea of this dog's problem.

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This form of OA is called spondylosis, which is arthritis of the vertebrae in the spine.
It is very common as pets age and causes substantial discomfort and even
urinary and bowel incontinence.

You can learn more about the bones of the spine by going to our intervertebral disk page.

This dog was sore around its rear quarters when petted by the owner. This could easily be arthritis, but as you probably already figured out, something else was amiss.

Did you figure out what is going on? Those circular white objects towards the top right of the radiograph are 3 pennies in the rectum! At least its a safe place to store your money.

A very important differential when diagnosing OA on a radiograph is a bone tumor. This one is on the femur (thigh bone). This dog had symptoms of muscle atrophy and limping on this leg. If a radiograph had not been taken these symptoms could have easily been mistaken for arthritis. 

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The other important differential on radiograph is a bone infection,called osteomyelitis. The fuzzy or roughened edges at the arrows is the infection.

The incorporation of digital radiography into our practice gives us substantiallly
more detail on a radiograph. This is easily seen in the Ferret spine radiograph below.

Treatment

Treatment of OA initially includes correction of any underlying primary diseases such as surgical correction of a torn ligament or arthroscopy to remove a cartilage flap. Once any primary disease has been addressed, the goal of treatment is to slow the progression of OA and to keep your pet comfortable. It's important to realize that there is no cure for OA.

Nutrition

Most pets with OA will require some adjustment in their lifestyle. Weight management is most important, since obese pets put unnecessary strain on joints, leading to a more rapid progression of the disease. Depending on the degree of obesity your veterinarian might put your overweight pet on Hill's W/D (weight diet) or Hill's R/D (reducing diet).  Generally we first put overweight pets on R/D to get to the optimum weight, then we switch to W/D to maintain a proper weight.

If your pet is not overweught  we will utilize a food called Hill's J/D (joint diet). It has added chondroitin sulfate and glucosamine in addition to essential fatty acids and carnitine. These foods are complete and balanced nutrition and can be fed for the rest of your pets life. There is a version for dogs and one for cats. We highly recommend them in almost every case of arthritis unless your pet has some other disease that precludes their use.

Excessive exercise that leads to pain or discomfort should be avoided, but moderate exercise is recommended. Swimming is an excellent exercise for pets that have OA and aren't fearful of water. Most pets do best with several short, exercise periods per day rather than fewer extended periods. Each patient will have their own unique program of weight management and exercise, and we can help you individualize one for you and your pet.

Chondroprotective Agents

These products typically contain precursors of cartilage and joint fluid synthesis. We like to use these medications first since there are negligible side effects and they might be an aid in preventing further deterioration of the cartilage.

These products have a positive effect on cartilage matrix synthesis and  an inhibitory effect on the enzymes that break cartilage down. They might require up to 6 weeks of use before OA symptoms are diminished.

Adequan

Adequan (polysulfated glycosaminoglycan) is an injectable chondroprotective agent. Adequan incorporates into joint cartilage and inhibits several enzymes that break down cartilage. No studies have been done in animals other than horses and dogs, but it appears to be safe and effective in other species including cats, rabbits, ferrets, and birds. We use it first because of its ability to rapidly help a painful pet.

The intramuscular injections are initially given twice weekly (every 3-4 days) for a month, then given monthly as needed. adequan seems to be most effective when given in the early stages of OA, but is beneficial in all stages of the disease. Side effects of adequan are much less common than with NSAID's.

Dasuquin

Unlike the injectable adequan, Dasuquin and other oral joint supplements are considered nutraceuticals, or nutritional supplements, and do not require FDA approval. Cosequin contains glucosamine and chondroitin sulfate, agents proven to be effective at supporting and protecting joint cartilage.

In addition, Dasuquin contains ASU (avocado/soybean unsaponifiables) that makes the glucosamine and chondroitin sulfate more effective.

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There is a Dasuquin made for cats also

The non-steroidal anti-inflammatories (NSAID'S) are the most commonly used drugs in treating OA in dogs. NSAID'S work by inhibiting an enzyme in the inflammatory pathway, thereby providing analgesia (pain relief), antipyrexia (decreased fever) and reduced tissue swelling. The enzyme that is inhibited is  cyclooxygenase (abbreviated COX). This enzyme causes an inflammatory reaction in the joint fluid that surrounds the joint.

The primary NSAIDS we use our Rimadyl, Metacam, and Piroxicam.

Before we start your pet on NSAID'S we perform an examination and run a baseline blood sample. Every 6 months we will examine your pet and recheck the blood to look for any potential side effects. This will make sure kidney and liver function is adequate.

Using NSAID'S alone is not recommended since the signs of arthritis are masked, leading to a more active dog and a quicker progression of arthritis. NSAID'S, in combination with chondroprotective agents, provide cartilage building blocks in addition to pain relief, and may slow the progression of OA.

All NSAID'S carry a small risk of side effects, so careful observation of your pet while on one of these medications is important. If they occur, the most common side effects are vomiting and diarrhea. There might also be kidney and liver problems, and even bleeding. These side effects can be minimized by using the lowest dosage and frequency possible for your pet and giving Pepcid AC at the same time.  The best way to minimize the potential for side effects, yet still get the most out of NSAID's, is to use the lowest effective dose of the NSAID of choice, and combine it with  VNA and Therapy laser as additional treatments. 

Labradors are reported to be more sensitive to Rimadyl than other breeds, so the use of this NSAID in this breed should be carefully monitored and used at the lowest dose possible or another NSAID should be utilized.

We do not use NSAID's in cats due to their high potential to cause kidney damage. These cats do best with weight loss if they are overweight, Dasuquin, VNA, and Therapy Laser. 

VNA or VOM

An additional treatment modality that has yielded great success is called VOM. It is a non-invasive and non-painful way to stimulate the nervous system to help correct the problem. Through the use of VOM we can decrease the use of the above medication in almost all cases. By decreasing the use of these medications we help your pet live a longer and healthier life, while decreasing you medication costs over the life of your pet. Click here to learn more about VNA.

This dog is getting VNA therapy for its arthritic spine