Multimodal Analgesia for Dogs: Beyond the Pharmacy

Sponsored by Companion Animal Health

The merit of combining non-pharmacologic therapy with physical rehabilitation, cold compression, acupuncture, and other adjunctive methods has been well-documented.^1,2 In fact, emphasis on a multi-modal approach in veterinary medicine was evidenced by the founding of the International Veterinary Academy of Pain Management in 2003.³ The field of palliative care and pain medicine has become interdisciplinary between veterinary surgeons, anesthesiologists, neurologists, pain practitioners, physical rehabilitators, and integrative practitioners; however, with the expansion of these educational organizations and resources, multimodal techniques and pharmaceuticals are more accessible to the general practitioner and are no longer limited to referral facilities. 

The following lists several ways that general practitioners can enhance their pain and palliative practice:

• Laser therapy for osteoarthritis and post-surgical trauma.
• Regenerative medicine for osteoarthritis and soft-tissue injuries.
• Cryotherapy and intermittent compression for post-surgical trauma.
• Myofascial therapy (dry needling, massage) for orthopedic and soft tissue trauma.
• Hydrotherapy for weight loss, neurologic disease, or degenerative disease.
• Stance analysis for initial evaluation and outcome measurement.

Low level light therapy (LLLT) is the emission of light radiation at specific wavelengths and power over an area of inflammation with the intent of photobiomodulation.⁴ LLLT promotes angiogenesis, inhibits fibrosis, stimulates mitochondrial respiration, affects genetic transcription, and causes a myriad of complex biochemical changes within inflamed tissue.^4,5 Although evidence in companion animals is still growing, ample research in humans and laboratory animals establishes a solid foundation for use. Therapy lasers are portable, are easy to maneuver by either a veterinarian or veterinary nurse, and may come with pre-set protocols for various disorders, depending on the manufacturer. Treatment time depends on a number of important factors, including: condition treated, weight, body type, coat length, coat color, skin color, power of the device, and the area and depth of treatment. Therapy laser treatments using a class IV laser can be as effective as they are fast (as short as 5 minutes per location).⁶

Platelet-rich plasma (PRP) is an autologous product made from the patient’s own blood and contains a platelet- and growth-factor–rich precipitate. Recent retrospective evidence suggests that a combination of PRP and mesenchymal stem cells (MSCs) may be more effective than PRP alone,^7-9 but prospective, controlled, and randomized studies are needed. Regenerative medicine employs the use of MSCs or blood products to regenerate, heal, or replace tissue.⁷ Mesenchymal stem cells from stromal vascular fraction of adipose tissue (SVF) or bone marrow (BM-MSCs) are injected into the joint to promote angiogenesis, tissue remodeling, differentiation, anti-apoptotic events, and decrease pro-inflammatory mediators.⁷ There are several commercial systems on the market today for both PRP and stem cell harvesting, each with benefits and disadvantages associated with ease of harvesting, cost of the system, and production of a PRP product that has the least amount of pro-inflammatory red blood cells and/or white blood cells in the precipitate.¹⁰

Cryotherapy, or cold compression therapy, is a documented technique for providing acute post-surgical analgesia within the first 24 hours of healing.^2,11 Compressive techniques for providing cold include pneumatic devices that can be easily applied to the canine stifle.⁶ Cryotherapy can improve post-surgical outcome with less post-operative pain and a quicker return to function of the leg.¹¹

Myofascial trigger points cause a well-established pain syndrome and are associated with a variety of disease states relating to trauma, surgery, and chronic degenerative disease.^12,13 Techniques to treat myofascial pain include massage, acupressure, or dry needling techniques.^12-14 Although acupuncture involves a complex system of point identification based on an ancient and modern understanding of meridians, the dry needling of myofascial trigger points employs a relatively simple technique of needling and/or the electrostimulation of the painful point. Additional manipulation of trigger points can include massage or acupressure, as 80% of acupoints also translate into trigger points and can be easily located by palpation.¹⁵

Hydrotherapy refers to the use of water to provide increased resistance and decreased vertical impact during exercise, and can be useful as adjunctive treatment of pain-related states, neurologic dysfunction, and obesity.^16-18 The most common way to provide hydrotherapy in private practice is through the use of an underwater treadmill (UWT). The UWT can facilitate weight loss with as little as one treatment per week.¹⁷

Measurements of gait and posture can be translated into therapeutic success or failure via a visual analogue scale, kinematic gait analysis, or a Stance Analyzer.²⁰ The Stance Analyzer is convenient and easy to use in the private practice setting in order to obtain a standing weight-bearing analysis. A Stance Analyzer can be used to provide the owner and practitioner with data that supports treatment on an affected limb in addition to showing improvement in the treated limb. The Stance Analyzer can be used at the time of consultation and at various time points during the patient’s treatment. 

Case 1

A 12-year-old female spayed 35-kg yellow Labrador retriever was presented for pelvic intermittent non-weight bearing lameness of 2 days’ duration. Physical examination and production of cranial tibial drawer and tibial thrust confirmed diagnosis of a full tear of the cranial cruciate ligament (CCL). A tibial tuberosity trans-position (TTA) surgery was performed, and the patient had significant degenerative joint disease in the right front elbow and contralateral pelvic limb. 

Treatment Protocol

• Dogs distribute 60% of their body weight on the thoracic limbs and 40% of their body weight on their pelvic limbs.¹⁹ A Stance Analyzer would be useful in determining the predominant weight bearing leg in this patient before and after surgery.
• LLLT, cold-compression therapy, and myofascial trigger point therapy would be useful during the immediate post-operative period. Therapeutic goals: to preserve joint health, encourage mobility, and decrease pain and inflammation.
• Hydrotherapy would help this patient after her sutures are removed by encouraging strength training, endurance, and range of motion in the affected leg. 
• PRP or stem cells would be useful adjuncts to surgery to prevent chronic degenerative joint disease, as well as a treatment for possible partial CCL rupture in the contralateral pelvic limb. 

Case 2

A 5-year-old male neutered Bernese mountain dog was presented for thoracic limb lameness of 4 months’ duration. Radiography confirmed degenerative joint disease of the elbow, likely secondary to ununited anconeal joint disease (elbow dysplasia). 

Treatment Protocol

• LLLT therapy on the affected joint. Myofascial trigger point therapy may be useful in the caudal cervical and trapezius muscles of the ipsilateral shoulder, as well as possible tendinopathies in the contralateral shoulder.
• PRP or stem cell therapy is indicated in the affected elbow joint, as well as tendinopathies in the ipsilateral shoulder and trigger points in the contralateral shoulder.
• Hydrotherapy would improve the range of motion of the elbow, as well as discourage muscle atrophy and disuse of the affected limb.
• Stance analysis could be used to measure outcomes and demonstrate to the client how their investment was well spent.

The purchase of equipment and CE to support the use and outcome measurements of adjunctive pain techniques is worth the investment. A practitioner can easily turn a general practice into a state-of-the-art facility that focuses on well-being and quality of life of its patients.