Clinician's Forum: Advancing Joint Health Strategies in General Practice

Sponsored by Nutramax Laboratories Veterinary Sciences, Inc

PARTICIPANTS

Caroline Adrian, PT, PhD, tCPT, Canine Physical Therapist, Independent Research Consultant Owner & Founder, Canine IQ, LLC

Tanya Battiston, DVM, Certified Animal Reiki Practitioner, Chief of Staff, Star Meadow Animal Clinic, Farmington, Connecticut

Dayle Dillon, DVM, CVSMT, CCRP, CoAC, Sports Vet Animal Medical Center, Savoy, Illinois

Michael H. Jaffe, DVM, MS, CCRP, DACVS, Mississippi State University

MODERATOR

Beth Molleson, DVM

Joint health is a critical component of overall well-being in dogs, influencing mobility, comfort, and long-term quality of life. Early identification of joint issues, proactive intervention, and multimodal management strategies can help improve the lives of patients dealing with joint disorders. Clinical decisions—ranging from pharmaceutical pain control and nutraceutical supplementation to weight management and adjunctive modalities—play a key role in maintaining joint function. This panel of experts convened to discuss the practical approaches to supporting joint health in both at-risk and affected patients.

KEY TAKEAWAYS

• Client education and early intervention are essential to supporting joint health and helping owners recognize early signs of joint issues.

• Pet owners often struggle to identify joint issues, but tools like targeted questionnaires, videos, photos, and functional examinations can aid in detection.

• Maintaining movement and muscle health is essential to joint function, with proper alignment, adequate range of motion, and targeted stretching helping to ensure safe and effective exercise and rehabilitation.

• Multimodal management is key in joint disorders and may include pharmaceuticals, supplements, weight control, exercise, physical therapy, and adjunctive therapies like laser or acupuncture.

• Supplements can help support joint health in at-risk patients and those with existing joint issues; selecting a trusted, transparent brand can help ensure consistent quality.

Dr. Molleson: At what point do you begin to consider joint health in patients? How do you approach early intervention, especially in younger dogs or predisposed breeds?

Dr. Battiston: Being in general clinical practice, I consider joint health at every age, including new puppies. They all receive a full orthopedic, neurologic, and physical examination. For chondrodystrophic or large-breed dogs, the conversation starts with their predisposition. I see plenty of small-breed dogs that already have patellar luxation or laxity. For those patients, I start joint health supplementation young, and I start educating owners about joint health even before that. If you start talking about joint health early on, pet owners will be able to identify joint health issues earlier and may be more open to conversations about joint disease as time goes on.

Dr. Adrian: With there being >200 dog breeds, it’s important to consider the different structures and conformations of our patients. Do we really have a good grasp on what leads to pathomechanics and, ultimately, pathology? Being able to identify warning signs early on is extremely important. Unfortunately, a lot of the time, I will see a patient for the first time when they come in for physical therapy, after their joint health has deteriorated. Ideally, we should start discussing joint health within that first year of life. We need to start talking to clients about appropriate exercise for neuromuscular dynamic control and how to strengthen those passive stabilizers as early as we can to potentially prevent disease. It can be a difficult subject to tackle with clients, though. There are no guarantees with treatment, and we can’t just say, “If we do X, Y, and Z, we’re going to prevent pathology.” It is very important to get the ball rolling early with educating clients on joint health and what steps they can take at home to support joint health.

Dr. Jaffe: I approach it the same way: by ideally starting these conversations early. I also emphasize weight management. We know that weight loss benefits dogs, even later in life, but it’s so much more valuable to start that conversation as early in life as possible. In the “Life Span” study, we saw the many benefits of weight management.¹ I tell my clients about that study all the time and emphasize the fact that there are so many other health issues, in addition to their pet’s OA, that we can hopefully diminish or even prevent with good weight management. It’s an integral part of the multimodal management of joint health.

Dr. Battiston: Regarding starting weight discussions early, discussing a patient’s body condition score with clients is key. It’s also important to explain why their pet received the score they did so they can really understand how and why we use this tool. Most clients also do not have a lot of guidance or tools to determine appropriate caloric intake per day for their particular pet, which is very important for lifelong weight management. For every patient that I want to make a dietary adjustment or nutritional recommendation for, I will calculate the number of calories the pet should eat per day to get to their ideal body weight so the owner has a game plan.

Dr. Adrian: The other thing that perhaps does not get enough attention is taking the animal’s lifestyle into consideration. For example, if somebody says they are planning for their corgi to do flyball or agility, then that should be taken into consideration when having discussions around joint health. Structure and function play a role in joint deterioration over time, so it’s important to have those conversations early in an animal’s life.

Dr. Dillon: When talking about vaccines and the whole health of the pet, it’s easy to ask the owner what their lifestyle is and what their plans are with their dog. That is a perfect opportunity to educate owners about the things we can be doing prophylactically from an early patient age to try and make sure their pet will be able to have the quality of life they want for as long as they possibly can. It goes hand in hand with lifestyle vaccines, diet, and all of the things we need to be talking to new puppy owners about anyway.

Dr. Molleson: Many pet owners miss the subtle early signs of joint issues, resulting in these problems being underdiagnosed. What advice do you have or tools do you recommend to help veterinarians identify these issues sooner?

Dr. Dillon: One of the tools I use a lot, particularly with my aging patients, is the Osteoarthritis Pain Checklist (see Suggested Reading), which has cartoon depictions of what a dog or cat looks like when it has arthritis and goes up the stairs, jumps off a table, et cetera. We so frequently run into people just assuming their pet is getting older and slowing down; they just think it’s normal to see a decline in their pet, and they don’t stop to consider what is actually happening from a physical perspective to make them slow down. Is it because they’re painful? Is it because they have muscle atrophy that occurs naturally with the aging process? We have monitors in our examination rooms and we play these animated videos for clients while they wait. Having clients see actual physical representations of what pets in pain look like is really helpful.

Dr. Battiston: The most important thing is raising client awareness and providing education, because many clients’ perception of pain is often altered; many of them expect their pet to cry out or show some outward sign of pain. I use the COAST staging tool (see Suggested Reading), which provides some of those observational questions, like are they taking longer to rise from a seated position, are they hesitating before they jump up on the couch or use the stairs, are they needing a lot of rest after activity? Sometimes, they’ll say, “Oh, yeah. I have noticed that,” so it’s important to bring awareness to the fact that an animal’s way of communicating pain isn’t what we might expect. Animals are not going to vocalize unless the pain is pretty severe, so it’s important to shift their perspective and have them look for these subtle signs and understand that animals are hardwired to hide signs of weakness, pain, and illness.

Dr. Adrian: I would call that a “functional assessment,” where you’re evaluating the patient’s ability to go from a lateral recumbent position to a sternal position, or from sitting to standing, helping to identify areas of pain. For example, are they pulling with their thoracic limbs instead of pushing with the pelvic limbs? A functional assessment, along with an observational gait analysis, is important in getting the full picture of patient mobility. It’s helpful to identify where some of that pathoanatomical/pathomechanical dysfunction is coming from. When conducting a pain assessment or assessing functional mobility, stiffness, and joint range, my best tool is my hands and being able to palpate, touch, and feel the patient from nose to tail and identify primary versus secondary dysfunction.

Dr. Jaffe: For me, it’s a little bit different, since I’m at a university and most of the cases are referred to me, but as everybody else has mentioned, education is key to ensuring pet owners seek evaluation when they notice changes in their pet. We need to help them understand that even subtle changes in their pet warrant evaluation and, again, that we don’t have to accept these changes as normal, even in older patients. We often start with a comprehensive physical, orthopedic, and neurologic examination to get a complete picture of everything going on with a patient that could be contributing to their clinical signs, then we certainly offer radiography to try to quantify the changes we’re seeing. I use a gait analyzer to try to assess weight distribution on different limbs in these pets as well. We also utilize our rehab tools such as goniometry and muscle circumference, and like everybody has said, when it comes to joint disease, the more client awareness, the better. We need to help them understand that these are not necessarily acceptable or age-related changes; there’s pathology behind the changes we’re seeing. Identifying these changes can be challenging because they occur so slowly over the years that owners don’t always notice. Cats are the classic example of that, where the changes can be gradual and subtle, and often veterinarians don’t recognize the changes either. We have to actively look for those things and ask detailed questions of cli-ents; otherwise, we are going to easily miss signs of pain at home.

Dr. Molleson: When you think about a multimodal approach to joint health, where do you focus your efforts?

Dr. Jaffe: My focus is on cartilage. It all comes down to cartilage damage and the secondary changes that occur in the synovial membrane and within the joint capsule itself. I’m always thinking about what is going on with the cartilage in these cases of joint disease.

Dr. Dillon: I also emphasize cartilage health, and I also talk with owners about synovial fluid, but it’s important to translate these concepts to pet owners in a way they can grasp. At the end of the day, we can all know how to maintain good joint health, but if an owner doesn’t understand or buy in, then it’s hard to get them to do the things that can help their pet. For cartilage health and synovial fluid, I like to relate these to 2 components of a car. I talk about how cartilage is like your brake pads, and if you don’t keep those brake pads healthy, then all of a sudden you’re out $600 or $800 to replace your brakes. Cartilage is the same; eventually, you’re going to start to wear through the cartilage and end up with bone-on-bone grinding. I relate synovial fluid to a car’s engine oil; if we’re not keeping that healthy and we have all of this inflammation, it’s like running your car and never taking it for an oil change, so you lose that lubrication and things start to get clunky, so to speak. Being able to stress the importance of those components in a way that the owner can understand allows me to get a little bit more of that buy-in.

Dr. Adrian: That’s a good point. From my perspective as a physical therapist, I’m also thinking a lot about cartilage. Physical therapists play a primary role in applying therapeutic interventions and sometimes supplements. I also focus on helping pet owners see the functional mobility changes in their pets. For example, in a dog with hip dysplasia, pointing out altered posture such as reduced hip extension during gait, joint stiffness, tight adductors, or weakness in the abductors and gluteal muscles helps illustrate how these biomechanical issues affect movement. By highlighting these changes, a physical therapist can show what can be addressed through targeted therapy while collaborating with the veterinarian to guide decisions around supplementation and medical management.

Dr. Molleson: How should veterinarians think about supporting muscle strength, especially in aging patients? What role do physical therapy and exercise play?

Dr. Adrian: Being in this field for 25 years, I’ve noticed people tend to move to strengthening right off the bat, and although it’s important, proper alignment and functional mobility have to come first before we focus on strengthening. Without restoring those foundations, you’ll reinforce abnormal movement patterns and drive more compensation.

Dr. Jaffe: I try to emphasize the periarticular changes that we see, specifically the contracture and the fibrosis that occur in the muscle and tendons and the tightness of the joint capsule. I really emphasize the value in addressing those issues through passive range of motion, deep muscle massage, warm compresses, and, following exercise, cold compresses to help reduce inflammation. These are interventions that owners can do at home that don’t cost a thing. I agree that the last thing we want to focus on is muscle strengthening. We want to improve stamina, range of motion, and stability of the joints, so before exercise, we want to do things like light passive range of motion and deep muscle massage, which can improve muscle contractility, stretch the joint capsules that have become contracted, and break down any tissue that has started to form between muscle fibers. We see so many dogs that are painful on hip extension, and we can diminish or reduce a great deal of that hip extension pain just by stretching these guys, which breaks down some of the fibrosis that occurs.

Dr. Dillon: I think, to some degree, we as general practitioners tend to primarily think about muscle loss and focus solely on how to gain back muscle. We also tend to think about muscle only in terms of movement, and I think we forget that it also provides protection to the joints. When we think about the functional movement of a dog—whether they’re doing some sort of high-impact activity or simply jumping up and down because they’re excited for a treat—good muscle health can really help protect some of the stress that’s applied on those joints. That muscular support leads to healthier joints, even though the muscles aren’t integrated within the joint capsule itself.

Dr. Adrian: Muscle provides significant force and stability across a joint. Because of that, cocontraction (ie, muscles around the joint firing simultaneously) is extremely important; this is where neuromuscular control (ie, the nervous system’s ability to coordinate those muscles properly) comes in. Joint stability relies on the nervous system’s ability to coordinate those muscles, and that control can break down with pain, weakness, fatigue, altered biomechanics, et cetera, whether that’s caused by repetitive strain in an agility dog, for example, or from swelling and effusion within that region, so it’s very important for us to identify how healthy the joint is, where the pathology lies, and how to address it. Then we need to focus on restoring that neuromuscular control to again provide stability to protect that joint.

Dr. Dillon: That also goes back to what we were saying regarding aging pets that are slowing down; they’re just not as active anymore, and people take that at face value, thinking their dog surely won’t be as quick at 10 years of age as they were at 5. I think we forget that, if you don’t use it, you lose it; these mobility issues can take on a snowball effect. Like Dr. Adrian said earlier, you get these patients that are 10, 11, or 12 years of age, and they’re doing the splits in the exam room because they don’t have that adductor or abductor control, and all of a sudden the owner’s wanting you to fix them. At that point, sometimes the mobility is so far gone that it’s hard for the patient to make a comeback. You’re starting to talk about traction devices and things like that, because trying to build that muscle back is really difficult at that stage, so addressing those changes in the muscle at the very first instance is going to pay dividends down the road versus waiting to try to fix it only once the problem is glaringly obvious to the owner.

Dr. Adrian: The fact of the matter is that sarcopenia happens in these geriatric patients, and once it has occurred, how can we help maintain that patient’s mobility for as long as possible? Strengthening and muscle rebuilding are not the primary goals. That’s when the choice of assisted devices comes in and providing added stability to help a pet stay mobile for as long as possible becomes a key part of client education. We need to keep these patients moving.

Dr. Battiston: In general practice, we have a responsibility to impress upon owners the importance of regular, low-impact exercise in animals with joint disease. Many clients, if they have a fenced-in yard, will open the back door and let their dog out, and they think their dog is aerobically getting all the activity it needs. And people are very busy, so they may rely on just allowing the animal to go outside on its own, but it is really important to put the responsibility back on the owner and remind them that it’s good for their pet’s emotional, social, and physical health as well as to be out there with them and be going on walks and just stimulating the animal in all aspects.

Dr. Adrian: Exercise is needed; it’s great, but if we can’t identify how that animal is compensating, then we’re just feeding right into all those postural adaptations and potentially making the issues worse. So the priority for me is performing an examination and identifying where that joint stiffness is and where the capsular restrictions and et cetera are that we need to focus on first before we consider activity, the level of exercise, and what’s appropriate, controlled exercise at that point.

Dr. Molleson: How are you incorporating joint supplements into your multimodal approach? Which patients do you find benefit most from them?

Dr. Battiston: In general practice, I recommend supplements a lot, because they’re a proactive tool. Fortunately, nowadays, people have a higher level of awareness of the benefits of nutraceuticals, and many are using them in their own lives and seeking out more natural interventions. There has been a lot more discussion about natural, scientifically backed supplements, and people are far more open to prevention-focused care than they were even a decade ago. I no longer see the hesitation I did 20 years ago when I first started recommending joint supplements for breeds predisposed to OA. For large-breed dogs, I recommend starting them on joint supplementation early.

Dr. Dillon: I concur with that. Just within the last 10 years of practice, I’ve noticed a big switch in how clients want to approach managing their pet, particularly moving from a pharmaceutical to a nutraceutical or supplemental approach. When an owner is hesitant about medications like carprofen, antibiotics, or other traditional therapies, it opens the door to conversations about an approach that includes nutraceuticals.

Dr. Jaffe: I recommend joint supplements for all patients with OA but also for those that I suspect may either have subclinical OA or are susceptible to developing OA. These often are pets with conformational attributes that may add stress to joints such as hip laxity or those with a lifestyle that may predispose them to developing joint-related injuries such as working dogs or extremely active dogs, to name a few. My students don’t understand why we sometimes recommend supplements on top of a joint diet. One of the things that I look at carefully when pets come in is whether they’re getting the recommended dose of glucosamine, chondroitin sulfate, and omega fatty acids, even if they’re on a therapeutic diet. I have my students calculate what the therapeutic dose range should be for some of the ingredients we recommend and then calculate what our patients are getting through those diets. That’s when they get the little “aha” moment and understand that, although these foods do contain some ingredients we want patients to get, they’re not necessarily getting them in therapeutic doses. These are oftentimes great diets, but we may need to supplement on top of them, and we need to explain that to owners.

Dr. Dillon: Some of these joint health diets are calorically dense, too. I’ve seen situations where a patient would start a mobility or joint health diet and then the dog would gain weight, which ultimately works against the goal of improving joint health. Personally, I often recommend a well-backed, well-formulated standard diet and then supplement on top of that rather than try to fix everything just with one single diet change alone.

Dr. Molleson: When recommending supplements, how do you talk to owners about expectations?

Dr. Dillon: I’m big on using videos to track a patient’s progress, regardless of the intervention I’m initiating. Having owners take videos of their pets can be very helpful. Not only can they bring these videos into their visit so we can see what’s going on at home, but then we have that video as a baseline and point of reference for the future. We can have them take videos every 2, 4, or 6 weeks, for example, and then we’re able to go back and compare any changes in mobility. I do the same thing with pictures. If we’re dealing with muscle atrophy or body condition, then having a good baseline and a tangible way to track the patient over time can be very helpful in determining which therapies are or aren’t helping the pet.

Dr. Adrian: It goes back to function. For me, that’s what mobility revolves around. Being able to identify even slight changes in functional mobility is huge. I have a similar process of utilizing videos, functional questionnaires, and pictures of postural changes. With skilled palpation, my hands can determine where soft-tissue limitations are impacting functional movement. All of that is a good, objective way to identify improvement with any new therapeutic plan of care.

Dr. Jaffe: Clients are very results-driven. If I sell them a $40 bottle of carprofen and they give that carprofen and see that their dog is more comfortable a day or 2 later, they think, “That was a good use of my $40,” but if I sell them a $40 bag of glucosamine supplements and they give it for a few days and don’t see an immediate difference, they wonder, “What did I spend $40 on?” But that’s not how supplements work. I take a vitamin supplement every morning, and after I take that vitamin and I walk into the kitchen, my wife doesn’t look at me and say, “You’re walking better since you took that vitamin 10 minutes ago,” because it’s a supplement. So why do we take it? Because we know it’s giving our body something that it needs to promote good overall health. When I started explaining the use of supplements to clients in that manner, I started seeing considerably better long-term compliance with them. We have to set the expectation that they are not going to see an immediate difference.

Dr. Battiston: I think that really highlights how much of our work should focus on prevention. From a general practitioner standpoint, we really want to focus on prevention and slowing the disease advancement process. When people come in with younger dogs before they’re symptomatic, that’s the time to discuss joint health. There are so many dogs for which we know OA is inevitable—in those large- and giant-breed dogs, overweight dogs, and chondrodystrophic breeds—so why not take advantage of early intervention to improve their quality of life and, in some cases, even their longevity? And, as we discussed, people these days are much more into the prevention mindset and the nonpharmaceutical ways to maintain overall health. Before they get to a specialist with their problems, I’m trying to do my job in primary care.

Dr. Molleson: How important are omega-3 fatty acids for joint health? How do you supplement them for your patients?

Dr. Battiston: In general practice, they’re probably my first line of defense for a lot of things, including joint and skin health. I see so many allergic skin disease cases, and there are so many benefits to omega-3s. Because of their high concentration of eicosapentaenoic acid, docosahexaenoic acid, and eicosatetraenoic acid and low-volume formulation, Welactin 3TA is my favorite product. You can administer very little of it as compared with a lot of the other available fish oils or omega-3 supplements. The bottle lists dosing guidelines for both general health and for greater joint-health support, which is helpful, because the omega-3 levels needed for joint benefits are significantly higher than what you might use in other scenarios. We use Welactin 3TA for multiple reasons, not just joint health.

Dr. Jaffe: I’m on board with Welactin 3TA as well. I’m generally using it at higher administration levels because I’m typically dealing with joint disease. I start dogs on it young, particularly dogs that are prone to developing OA. This is something that I view not necessarily as prevention but something that we can do to prolong cartilage and synovial membrane health. For me, it’s a no-brainer.

Dr. Dillon: I like the Welactin products. I go back and forth between whether I want to use liquids or capsules to supplement omega-3s. I think there are pros and cons to both. With the liquids, you have to be careful about oxidation, but you can start them at a really nice, low dose and get them used to the product, then slowly titrate the dose so as not to cause any GI upset if you have a dog that’s prone to that, whereas you maybe can’t do that with some gel capsule forms. My choice ultimately depends on the individual patient.

Dr. Battiston: With the limited regulation of supplements, it’s important to choose a trusted brand. I like the quality and standard of care that’s provided by select companies, including Nutramax, especially for fish oils. We want to ensure we’re not using a fish oil product contaminated with heavy metals, bacteria, or other impurities, and some of these salmon-based products are higher in omega-6s instead of the omega- 3s, which is another thing we need to watch out for.

Dr. Molleson: What clinical experience do you have with glucosamine and chondroitin?

Dr. Dillon: We hear so much about glucosamine and chondroitin on the human health side, so I think it’s something a lot of pet owners are looking for when they choose a supplement for their pet. Because glucosamine and chondroitin naturally occur in the body and decline with age, it can be helpful to explain to owners that supplementation is simply supporting a substance the body already produces, rather than introducing something foreign.

Dr. Battiston: When I was going to veterinary school in 1998 at Kansas State University, Cosequin had just come out, and the clinicians in the teaching hospital were running a study that induced synovitis in dogs. They used scintigraphic analysis to determine what the cartilage looked like in the placebo group versus those that had received Cosequin only prior to the induction of synovitis. I remember seeing those scintigraphic images and seeing the difference, and it really left an indelible mark on me, so I’ve been quite a proponent ever since. I continue to see a clinical benefit time and time again in my patients, which, for me, is hard to ignore.

Dr. Jaffe: I’ve been using Cosequin since the day it hit the market, and I’ve seen a lot of glucosamine and chondroitin sulfate products come and go. Nutramax has stood the test of time, which, to me, speaks for itself.

Dr. Molleson: What other ingredients have the most data to support their use in joint health?

Dr. Jaffe: Eggshell membrane (ESM) definitely does. A while back, I pulled some papers looking at the effects of ESM in dogs² and people, because I really wanted to learn what ESM was. That led me down a rabbit hole of reading about what avocado soybean unsaponifiables (ASUs)^3,4 and Boswellia do as well. All of these ingredients, to some degree—even turmeric and curcumin—have some sort of mechanism of action that has an anti-inflammatory effect. Albeit, each of them is fairly weak and by themselves may not reduce inflammation, but when combined with other ingredients as part of Dasuquin Advanced with ESM, they have a net effect in terms of reducing inflammation, so again, I tell people that these ingredients by themselves may not be enough but combined, from what I understand, strengthen the value of these ingredients.

Dr. Battiston: Since its introduction, I’ve used Dasuquin Advanced, and now I use Dasuquin Advanced with ESM. I have done some reading on ESM as a supplement as well, and based on both the available information and what I’ve observed in practice, it seems to contribute to improved functionality and comfort in many of the dogs I’ve treated.

Dr. Dillon: I agree. We almost exclusively use Dasuquin Advanced with ESM. It contains many ingredients—Boswellia, ASUs, ESM, and more—that work so nicely and synergistically together. I’ve found the greatest success with products that contain multiple, all-natural anti-inflammatories.

Dr. Battiston: I like that Dasuquin Advanced has green tea extract with polyphenols in it. Polyphenols are great for oxidative stress and have other benefits as well. I also like that this formulation contains Boswellia, which is widely used in both human and veterinary holistic circles. Turmeric and its anti-inflammatory and antioxidant effects are well-known. I think using a product that contains all these things together in a palatable form is a no-brainer.

Dr. Molleson: Considering the limited regulation of animal supplements, what should general practitioners know when selecting products?

Dr. Dillon: Several years ago, I came across a mnemonic: ACCLAIM. If you break down each of those letters, you can use that as a guide for what you should be looking for in supplements or nutraceuticals.

• A: A name that you recognize. Is the company producing this supplement one you know and trust? Have they produced other products you are familiar with and are comfortable using?

• C: What is the clinical experience? Have you had good experience with this company? Do you know of colleagues who have had good experience?

• Your second C is going to come from the contents within that product. What are the actual ingredients listed? Are they appropriate and at effective levels?

• L: Label claims, because we have to be careful with that on our supplements and nutraceuticals. Are the claims on the label accurate and well-supported?

• A: Administration recommendations. Are the dosing instructions clear and practical?

• I: Identification of the lot. Is there lot information available? That can be helpful to have, particularly if there are recalls or if you want to go digging for additional information on a particular product that’s been purchased.

• M: Manufacturer information. What is known about the company itself, including transparency, quality control, and reputation?

Dr. Jaffe: For me, it’s finding a company I trust. I’ve been a fan of Nutramax products ever since I started practicing. For me, the benefit in Nutramax’s products lies in the transparency the company provides. I look at a lot of different products and company websites, and when somebody references a study, I like to pull that paper, read the study, see how the research was done, and judge for myself whether it was a valid study or not. I see these companies that don’t provide open access to their studies. That tells me that the company is not transparent; we’re just supposed to take their word that their product performed better in some way without any demonstration of how the study was done. When I look at Nutramax’s products, there is complete transparency. They’re not trying to hide behind proprietary information that they’re not willing to share, and that speaks volumes about the product, the company, and the motivation behind promoting joint and animal health.

Dr. Molleson: How do you approach pain management as part of a multimodal plan for patients with joint disease?

Dr. Jaffe: I rely heavily on NSAIDs to reduce inflammation in these patients. I also often use amantadine to prevent wind-up pain, and for oral medication, I sometimes use acetaminophen/codeine combinations for dogs but of course never in cats. We also have acupuncturists here at the university who help with chronic pain management. For very severe acute pain, we will use injectable analgesics such as morphine derivatives. Obviously, our joint supplements are an integral part of our multimodal approach, but from the pain management standpoint, I look to other drugs. Regarding anti-nerve growth factor monoclonal antibodies, I use them very sparingly. I think they’re good products when used correctly, and I believe there is a significant role for that form of therapy in chronic pain management, but I’m really selective and careful about how and when I use them.

Dr. Battiston: I use gabapentin adjunctively in addition to many of the other options Dr. Jaffe mentioned. I also utilize laser therapy and have had very good compliance and success rates with it.

Dr. Dillon: Most of us are well-versed on the use of NSAIDs, and gabapentin or pregabalin is gaining traction as well. Amantadine is a drug I’ve been using more, especially for chronic pain cases. I’ll often use these drugs as a tool to get a good start on pain control to see how much improvement we get before diving into other modalities such as physical therapy, spinal manipulation, acupuncture, and cold laser treatment. Sometimes we need to use things like injectables or more aggressive pain control options to get through the initial hump in acute-on-chronic pain situations, and then we might be able to dial back some of those drugs by implementing these other interventions. So I certainly think these drugs for pain control are important to have in our repertoire, but they don’t have to be the only solution.

Dr. Adrian: It’s a delineation between acute and chronic pain, and that’s something that’s very important from the physical therapist’s perspective. I’m not going to treat an animal that’s in acute pain. It’s difficult to do exercise and specific, controlled activities when an animal is in pain and exhibiting avoidance behaviors. It’s extremely important to manage that pain first. Of course, in addition to pharmaceutical treatments prescribed by the referring veterinarian and adjunctive therapies such as laser and acupuncture, I consider exercise to be medicine as well. Keeping joints moving and well-lubricated is extremely important in OA. Motion is medicine. Before even beginning structured exercise or hydrotherapy, it’s critical to identify all the postural limitations, joint capsule restrictions, and reduced mobility and to address these issues using hands-on techniques. Manual therapy and joint mobilizations help restore proper alignment and function, and in some cases, I follow up with laser therapy if my interventions trigger a temporary flare. Establishing proper alignment and joint mechanics lays the foundation for effective pain management and ensures that subsequent therapies, including exercise, are safe and beneficial.

Dr. Battiston: It’s also important to discuss polysulfated glycosaminoglycan (PSGAG) injections. I use those very early on in the course of disease, and I have found them to make a tremendous difference in joint health and patient comfort. I don’t use it end-stage. I use it early, because that’s when it’s most effective.

Dr. Dillon: Yes. If I go back to my car analogy, PSGAG injections are like the oil change. We use PSGAG injections as well to try and keep things nice and lubricated within those joints.