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Top Tips for a Fear Free Approach to Managing Canine OA

Kristin Shaw, DVM
Are you diagnosing and managing canine osteoarthritis the same way you were taught in vet school? Depending on when you graduated, chances are the techniques and treatments you learned may be due for a refresh. This article will offer tips for ensuring you are practicing the best medicine you can for your canine patients while following the principles of Fear Free practice.

Diagnosing OA: You don’t have to cause pain to find pain

If you were ever taught that you had to “push harder” to find the pain—forget that! Instead, there is a very good chance you can diagnose OA pain without even putting your hands on a dog (though that is still important!). Dogs show chronic, OA pain through changes in their mobility, posture, function, mood and behavior.1 Additionally, joint pain leads to compensatory pain in other parts of the body, including muscles. There are a number of ways we can identify OA pain without trying to make the dog cry out with our palpation.

  • Use a screening checklist: A recent study found that using an owner checklist that asks questions about a dog’s mobility at home can increase the rate of identifying dogs with OA.2 See here for the checklist that was used in this study and is available for you to implement in practice.
  • Observation is key: Dogs with OA may hide an obvious lameness during a traditional gait evaluation. While it is still recommended to watch how dogs walk on a leash, more rewarding information is often gleaned observing a dog’s posture and from watching how a dog moves through transitions (rising from a down position, moving into a seated or down position).3 When standing, if the spine is not neutral, and/or if limbs are held in abnormal or asymmetric positions, and/ or if weight is shifted off of a limb or body segment, these are all indications of likely joint pain. If any slowness or asymmetry to movement through transitions is seen, there is a good chance the dog has musculoskeletal pain.
  • Sedate for radiographs! Imagine being pinned to a cold table in a dark room and having your painful limbs manipulated. You would at the very least squirm too! Sedation and analgesia are musts for obtaining high quality, diagnostic radiographs while minimizing stress and discomfort. Also remember to take orthogonal views, centered on the joint of interest, and take both sides for comparison.

Treating OA: Unmanaged OA pain is a life-threatening condition

We care about OA because it causes pain. And not just pain in the arthritic joint, but over time, whole-body pain develops. Additionally, chronic/maladaptive pain is progressive and usually worsens, often drastically, without treatment.4 Multimodal, proactive, and continuous pain management is essential to reduce the devastating consequences of unmanaged OA.3

  • Multimodal is built on effective analgesia: According to the 2022 AAHA guidelines, the first line of analgesia for canine OA should be either NSAIDs or the anti-NGF monoclonal antibodies (mAbs).3 Both of these classes of drugs have proven efficacy and safety in dogs with OA. There are additional benefits of anti-NGF mAbs that may make it a better option for many dogs. Anti-NGF mAbs are administered by a veterinary professional, in the clinic, so take away the caregiver burden of an oral medication, improving owner compliance. Additionally, anti-NGF mAbs directly target a key player of chronic pain, sensitization, and neurogenic inflammation and have an encouraging safety profile. Maintenance of a lean body condition and regular exercise are also required as part of an effective OA plan. Other supplemental therapies may be considered as needed.
  • Proactive pain relief is standard of care: Canine OA is predictable- it typically develops secondary to developmental orthopedic disease (dysplasia, OCD) or joint trauma. Therefore, as soon as a dog is diagnosed with a joint disorder, which in the case of developmental disease generally occurs in the first few years of life, a proactive OA plan should be put in place. Clients should be educated on OA, the consequences of unmanaged pain, and how to monitor for pain at home. Analgesics should be started when pain is mild rather than waiting until it becomes severe.
  • Don’t let the pain break through: It is tempting to suggest to pet owners that they give analgesics on an as-needed basis. However, this can become problematic if they don’t recognize the early signs of pain. Chronic pain signaling leads to physical changes in the spinal cord that ultimately result in severe, neuropathic pain.4 A study that evaluated maintaining dogs at the NSAID label dosage vs. gradually reducing the dosage of the NSAID overtime, found that the dogs maintained at the label dosage, had the best outcome.5  Furthermore, continuous pain management through daily NSAIDs has been shown to improve signs of OA in dogs.6 Once a month anti-NGF mAb is given as a monthly SQ injection and controls pain for up to 4 weeks, which may be an optimal alternative to asking pet owners to give a daily medication. Remember to ensure a pleasant and enjoyable visit utilizing Fear Free techniques whenever dogs are coming in for any type of appointment, including monthly injections.

References

  1. Roberts C, Armson B, Bartram D, et al. Construction of a conceptual framework for assessment of health-related quality of life in dogs with osteoarthritis. Frontiers in Vet Sci. 2021.
  2. Wright A, Amodie DM, Cernicchiaro N, et al. Identification of canine osteoarthritis using an owner-reported questionnaire and treatment monitoring using functional mobility tests. JSAP 1-10, 2022.
  3. Gruen ME, Lascelles BDX, Colleran E, et al. 2022 AAHA Pain management guidelines for dogs and cats. JAAHA 58:55-76, 2022.
  4. Malfait AM, Miller RE, Miller RJ. Basic Mechanisms of Pain in OA: Experimental observations and new perspectives. Rheum Dis Clin N Am 47:165-180 (2021).
  5. Wernham BGJ, Trumpatori B, Hash J, et al. Dose Reduction of Meloxicam in Dogs with Osteoarthritis-Associated Pain and Impaired Mobility. ,J Vet Intern Med 25:1298–1305, 2011.
  6. Innes JF, Clayton J, Lascelles BDX. Review of the safety and efficacy of long-term NSAID use in the treatment of canine osteoarthritis. Vet Record 166:226-230, 2010.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

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Brought to you by our friends at Zoetis. ©2022 Zoetis Services LLC. All rights reserved. NA-03139

The Importance of Managing Pain in the Fear Free Practice

Michael Petty, DVM, CVPP, CVMA, CCRTIf you have ever hit your finger with a hammer, the immediate response is often one of surprise or even frustration. The next day, as you are having trouble using that finger, a common emotion is disappointment at the discomfort you are experiencing and wishing that you had been more careful. What causes that reaction?

The “fear center” and the “pain center” occupy adjacent areas of the brain. The thalamus is the area of the brain that registers pain, and on either side of the thalamus is the limbic system, which is responsible for emotions including fear, anxiety, and the sequelae of stress (FAS).

These two areas of the brain “talk” to each other and send signals back and forth. The thalamus sending signals to the limbic system is what causes your reaction to hitting your finger with a hammer. When this thalamic-limbic crosstalk happens in an animal in acute pain, the animal may lash out at the owner or veterinary staff.

So now consider an animal who is in pain and has been presented to you. If experiencing acute pain, the animal may lash out due to a combination of pain and FAS. If experiencing chronic pain, many of these pets act dull and disinterested. The owner may even comment that the pet just doesn’t socialize and lacks the energy and mobility that she used to demonstrate. Even worse is the animal who has chronic pain, say from osteoarthritis, and now has an acute injury on top of it. The distress in some of these animals is almost too much to bear.

It is easy for us to recognize and treat acute pain, but the diagnosis of chronic pain states can be difficult for a variety of reasons. It takes time to take a thorough history and perform a complete pain exam on dogs and cats. However, there are many resources available to make that task easier, including pet owner-friendly screening checklists for osteoarthritis (Cat, Dog) and expert tips for the OA exam (feline OA exam).

Even with successful diagnosis, the treatment of chronic pain can sometimes be difficult especially if your treatment is narrow in focus. But it is essential to make a timely diagnosis of chronic pain and provide effective analgesia to be successful in therapy. And it is also important that the owner understands your diagnosis, whether through education alone or with the help of radiographs and teaching tools (feline and canine chronic pain). The owner is an essential member of the pain treatment team, both in the evaluation of treatments over time but also in enlisting them in the day to day therapies that might be required.

My approach to the treatment of chronic pain in dogs, for example, is to build a pyramid of treatments, and on the base layer I start with an NSAID. The NSAID I use most commonly is Rimadyl® (carprofen), which I really like for its effects on both pain and inflammation. For many chronic OA cases, there are other factors that can influence the ability to manage both pain and disease progression, and they should all be looked at.

For example, consider the animal next. Is he overweight? One study showed that in an obese dog, losing only about 10 percent of body weight can significantly improve lameness1. In other words, weight loss for an overweight dog can amplify the pain relief achieved with an NSAID alone

What about exercise? Again, one human study showed that one-half hour of exercise 5 days a week for people with knee OA was the equivalent of – you guessed it: an NSAID! So now you have tripled your pain-relieving efforts by building a solid foundation of multi-modal therapies, upon which you can add other therapies as needed.

It is beyond the scope of this writing to discuss all possible treatments: medications, physical therapy, acupuncture, and so forth, but I encourage everyone to read or re-read the 2015 AAHA Pain Management Guidelines for a thorough review of all of the pain management options we have for both acute and chronic pain.

What does the future hold for us? The most exciting thing I have seen on the horizon is the introduction of anti-NGF monoclonal antibodies. NGF, or Nerve Growth Factor, is one of several major “players” in the transmission of pain via the nociceptors. The use of these monoclonal antibodies holds great promise to reduce the sensation of pain in our patients with osteoarthritis. More information about the action of anti-NGF monoclonal antibodies can be found at the New Science of OA Pain website.

IMPORTANT SAFETY INFORMATION FOR RIMADYL: As a class, NSAIDs may be associated with gastrointestinal, kidney and liver side effects. These are usually mild but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur. Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including Rimadyl. Use with other NSAIDs or corticosteroids should be avoided.

See full Prescribing Information at:
https://www2.zoetisus.com/content/_assets/docs/Petcare/rimadyl-prescribing-information.pdf

Reference:

  1. Marshall WG, Hazewinkel HA, Mullen D, et al. The effect of weight loss on lameness in obese dogs with osteoarthritis. Vet Res Commun 2010;34(3):241–53.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.Sponsored by our friends at Zoetis Petcare. ©2021 Zoetis Services LLC. All rights reserved RIM-00324

That Hurts, But I Won’t Tell You About It: How to Find and Help Your Feline OA Patients

Jason Doolittle, DVMFelis catus – the domestic cat – is an amazing animal who delights and surprises even those of us who have spent years working with them. Among their many unique personality traits is their ability, highly evolved and adapted over thousands of years, to mask their pain when frightened, surprised, or otherwise stressed. It should be no surprise, then, that when your feline patients are in an unfamiliar environment, surrounded by sights, sounds, and smells they don’t recognize (such as a veterinary exam room), they will be inclined to mask their pain.

Cats in these situations also commonly experience fear, anxiety, and stress (FAS). FAS can cause a cat to mask their pain but could also result in behaviors easily mistaken for signs of pain. Partnering with your client, the cat owner, is essential to make an accurate diagnosis of pain in your feline patients.

Helping our feline patients with osteoarthritis (OA) starts at home, with our clients. As you are aware, cat owners are highly attuned to even small changes in their cat’s habits, personality, and idiosyncrasies that make them unique. Partner with your clients and teach them to screen for OA pain at home with a validated Cat OA Checklist produced by Zoetis. On this website, there are three simple screening steps that should only take your clients a few minutes to complete:

  1. The first step utilizes animations to show healthy cat movement in performing several activities (e.g., climbing upstairs) compared to how cats move with joint disease. Your clients will be asked to check on the animations that are consistent with how their cat moves and that are suggestive of OA-related pain.
  2. The next step evaluates, on a scale, the cat owner’s perception of their favorite feline’s emotional and physical well-being. Because OA is a chronic disease that can affect cats emotionally, this is an important step in connecting to the disease state.
  3. The third, and final, step briefly summarizes, with yes/no questions, general behavior changes.

Once complete, clients can enter their email address to receive a copy of the checklist results. In some cases, clients will see the need to bring their cat into you for evaluation; others will need some encouragement to make an appointment. Consider recommending that your clients email the checklist results so you can identify those who might need to be seen.

To help prepare you for these kitties who will be coming to your office, Zoetis has created a website that provides you with resources such as helping to build cat owner awareness of feline pain, talk through the OA checklist they have completed, and feline orthopedic exam resources, including demonstration videos. This website contains a link to a printable version of the Cat OA Checklist that could be used, for example, with a client who has come into your office with their dog but has a cat at home that you haven’t seen in several years to encourage them to seek veterinary care for their feline companion.

It is important to remember that using Fear Free and Cat Friendly principles may mean that some cats who are coming to you to be evaluated for OA may require pharmaceutical help to remain calm. Keep in mind that some anxiolytic regimens may also produce analgesia and alter your exam findings. Objective diagnostic tools, such as orthopedic radiographs, are also an important part of the complete clinical evaluation.

Orthopedic exams and diagnosing OA in cats are yet more reminders that cats are not small dogs! As you partner with your cat-owning clients by asking them to screen their cats in the environment where they are most likely to show signs of OA, you will be better able to diagnose your arthritic feline patients. This partnership will greatly enhance your reputation amongst your clients who will see you as a trusted advisor to their beloved and treasured cat companion.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.Sponsored by our friends at Zoetis Petcare. © 2021 Zoetis Services LLC. All rights reserved. NA-02588

A sick dog is lying on the carpet. Treatment of dogs at home

Talking About OA with Your Clients Doesn’t Have to be Painful

Mary Ann Vande Linde, DVM, Vande Linde & Associates, Brunswick, GeorgiaOsteoarthritis is the most common joint disease diagnosed in humans and pets. What does this mean to a veterinary team? It means that a high percentage of pets and their owners have some familiarity with the discomfort and pain of joint disease. I’m sure we have all had clients tell us they have noticed a change in their pet’s activity, but they usually pass it off as normal for his/her age or suggest their pet is just “slowing down.” This belief does not mean that they don’t care; they just do not understand that what they are seeing may be due to pain. There are some simple communication tools your team can utilize to add value and increase a client’s understanding and acceptance that osteoarthritis (OA) is not normal, and their pet has options.

One of my mentors once told me “never tell a client what you can show them.” A client may see their pet hiding or not playing, and they will need assistance determining if their pet is painful or fearful. Using the Fear Free Strategies of Considerate Approach (CA) and Gentle Control (GC) allows the pet to be comfortable enough to exhibit OA signs in the client’s presence. With CA, a relaxing atmosphere can be created where the pet can have room to move and be observed. Adding pheromones to help keep them calm and non-slip surfaces both on and off the exam room table enables them to safely explore. In addition, with GC, veterinarians can examine the pet where he or she prefers and is most comfortable. Make sure to plan ahead by having materials easily accessible, and have assistance available in the room so the veterinarian can keep a gentle reassuring hand on the pet. Later during the physical exam, the doctor can communicate how their assessment relates to what the client sees their pet experiencing.

To be efficient and consistent communicators, teams need tools that open clients’ minds to possibilities.  The Zoetis Canine and Feline OA Screening Checklists can be a discussion starting point. These checklists have “cartoons” of cats and dogs doing common activities around the home that have been identified through research as top behaviors that can indicate OA pain.1,2

This visual checklist allows the client to see their pet’s behavior changes through the animations.  They can see how a healthy cat moves compared to a cat who has unhealthy changes from OA pain. With a checklist a client can tell the veterinarian what they see in comparison to the pictures, or they can review a video of what their pet is doing compared to the cartoon. By reviewing the checklist with a trained technician or veterinarian, the client can offer insight into how they view their pet’s mobility, behavior, and daily comfort. This checklist can be used prior to any exam with an email electric copy, or completed in the room by computer, phone, or as a printed hard copy. This could be a valuable addition to any biannual or annual checkup.

Age is not a disease. And we have tools, strategies and skills that make client discussion interactive, efficient and fun. Clients love to learn about their pets, they want a plan, and they want to feel confident they have made good decisions. Combining the tools of an interactive team checklist, Fear Free strategies of CA and GC and using open questions with active listening create productive discussions, save time, and produce healthier teams and pets. Go ahead talk about OA with these tools: it’s painless.

References

  1. Enomoto, M. (2020). Development of a checklist for the detection of degenerative joint disease-associated pain in cats. Journal of Feline Medicine And Surgery
  2. Wright, A. (2019). PVM1 Diagnosis and treatment rates of OA in dogs using a Health Risk Assessment (HRA) or Health Questionnaire for OA in general veterinary practice Value In Health, 22, S387
  3. Adams, C., & Kurtz, S. (2017). Skills for communicating in veterinary medicine. Oxford: Otmoor Publishing.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Sponsored by our friends at Zoetis Petcare. NA-02335

Communicating the Value of Fear Free to Your Clients

Dr. Julie Reck, Owner, Veterinary Medical Center of Fort Mill, Fort Mill, South CarolinaMore than ever, pet owners have a strong bond with their pets. That means they are expecting their pet’s experience at the clinic to be enjoyable. Fear Free provides that excellent “customer” experience for both the pet and the pet owner. However, a client’s first Fear Free experience will likely be different from previous veterinary visits and could seem strange. It is important to ensure that each client fully understands that Fear Free considers both the medical and emotional well-being of their pet and realizes the significance of taking both aspects of the pet’s care into consideration.

Three Key Messages for Our Practice

  1. We believe in the power of positive reinforcement. Patients will be treated kindly and receive lots of treats and verbal encouragement.
  2. Fear Free is reinventing the definition of a successful veterinary visit. It is no longer acceptable to “just get it done.” We take into consideration where the patient is emotionally and proceed appropriately, which may mean that some things will not get done during a visit. For example, toenail clipping may have to be done another day if the patient elevates to moderate signs of fear, anxiety, and stress (Level 3 FAS).
  3. Our hospital has a consistent approach to handling and treating our patients: Everyone is practicing Fear Free techniques with every patient.

Below are tips for successfully communicating the benefits of Fear Free to your clients.

Maximize Your Social Media Presence

Currently I have owners seeking out my clinic specifically for the Fear Free experience, but in the beginning this was not the case. It became obvious to me that the benefits of the Fear Free visit needed to be stated clearly in all my communications.

For the pet owner, the Fear Free journey begins before they get to the clinic. I want my clients to be educated consumers, so they “know before they go,” or, in other words, they know what to expect when they arrive at my clinic. My website and my clinic’s Facebook page fully communicate this to pet owners. We take a proactive approach to prepare the client for a positive experience. This includes stating our philosophy on what a good veterinary experience looks like for the pet and the pet owner using videos, testimonials, news feeds, or stories to keep pet owners informed and prepared for that great Fear Free experience.

The Customer Service Representative (CSR) Prepares the Client and Pet for the Visit

Our CSRs are the next line of communication. They are trained to answer any questions about Fear Free and are critical in making sure that the pet arrives safely and prepared for the visit.

Safety includes recommending that the pet is either in a carrier or harnessed/seat belted while in the car, and that they have a collar and leash if walked into the clinic or stay in the carrier until in the exam room. The carrier can provide the pet a sense of comfort.

Being “prepared” for the visit means making sure the pet arrives hungry and that we have their favorite treat ready for them when they arrive. A day or two before the visit, we send the owner a reminder email and/or text with these same instructions.

Continuing to Communicate During the Examination

The examination provides an opportunity to have a conversation with the pet owner, allowing them to feel more involved with the entire process. I will explain what I am doing, such as standing behind the patient instead of examining their head and face first. I will also describe the patient’s emotional status based on the patient’s body language and my physical findings. This prepares the owner for any diagnostic and/or treatment recommendations that I make, and they are more likely to be compliant with my plan.

Additionally, if the patient’s level of FAS does not allow the completion of the exam or planned procedures, such as nail clipping, the client will be more likely to understand because of the ongoing conversation about the patient’s behavior and emotional status.

It is also important that the pet owner understands their pet’s level of fear, anxiety, and stress will change, based on the situation. A dog who typically loves coming to the clinic may behave differently when coming in for examination and treatment of a painful ear infection. Where we may have never needed to sedate in the past, it is necessary now to ensure that the patient had the best possible experience because the dog’s pain has exacerbated his level of fear.

For patients with a history of severe veterinary visit FAS who we are seeing for the first time, we will inform the pet owner that the first visit will be a consultation. We take the patient’s history, perform a visual examination, but forgo the physical examination to keep the FAS level as low as possible. We may prescribe PVPs and/or schedule a series of “Happy Visits” where the patient arrives, receives treats, then leaves before we ever get to the hands-on physical exam.

What About the Client Who Fails to See the Benefits of Fear Free?

For clients who are more interested in “just getting it done,” I will inform them that the goal is to consider the long-term emotional wellbeing of their pet rather than the short-term approach of “just getting it done.” Some clients will understand and comply. For those who do not, we will agree to disagree and part ways.

It is important that the clinic owner and staff back this decision and uphold the values the Fear Free team has agreed upon. This is especially true if the pet owner is loud and unpleasant. Professional affirmation for the decision and support from colleagues can reinforce that one negative encounter with a client cannot undermine all the positive feedback and improved patient outcomes that comes with being Fear Free.

I have found that it is the small consistent changes that accumulate over time that get you to Fear Free. You might start with pheromones and see a subtle difference, then add in Considerate Approach and Gentle Restraint with liberal use of treats and see more of a change. As you continue to master the techniques and communicate the benefits of Fear Free, you will find that you and your staff are emotionally enriched, your clients have a renewed feeling of trust and bonding to you, and your clinic and your patients are actually happy to see you!

Sponsored by our friends at Zoetis Petcare. NA-02292