Emerging Therapies

Emerging Therapies

Short Answer

Compared to the human or equine field, dogs and cats fall far behind when it comes to the availability of non-surgical options for lameness management.

There are a number of conditions Dr Lane has identified that respond well to the non-surgical techniques, but because there is no published data on success rates, many people aren’t even aware that these treatment options exist.

In an effort to bring awareness to this situation, Dr. Lane has begun collecting data about the success rate for treating certain conditions. It is his goal to eventually publish this information and hopefully widen the scope of available treatments.

Long Answer

Below are three potential treatments that Dr. Lane is documenting his success with – treating urinary incontinence from a musculoskeletal perspective, treating tail self mutilation in cats, and joint injections for refractory arthritis.

Dr Lane is simply treating patients as he normally does – the only difference is that your pet’s response to treatment will become part of a database that will hopefully be published one day. As part of that process, you will be asked to fill out a history form before the appointment, and again after treatment in order to assess how well the therapy worked.

Patients are not required to participate in the data collection process if they do not wish to be – simply inform us at the time of your appointment and we will forgo the additional questionnaires.

Musculoskeletal Treatment of Urinary Incontinence
Background

Urinary incontinence in dogs has several causes, including congenital defects, infection with or without crystals in the urine, and trauma. Perhaps most commonly though is a form that mostly affects spayed female dogs – hormone responsive incontinence or more properly, urethethral sphincter mechanism incompetence (USMI).

Weak bladder sphincter and urethral muscle tone causes varying degrees of urine leakage when the patient is sleeping. Severe cases leak large amounts regularly, and more mildly affected dogs just leak intermittently, perhaps only after heavy exercise gives rise to deep sleep.

Some cases respond well to hormone (DES) supplementation and/or phenylpropanalanine (PPA) prescriptions, but some do not. These refractory cases can be quite frustrating.

Transient or permanent urinary incontinence following traumatic luxation of the sacro-iliac (SI) joint is well documented. Presumably, soft tissue swelling places abnormal pressure on the pudendal nerve, causing dysfunction.

Muscle spasm affecting the lower back, sacrum, and SI joints is common in dogs. In treating this spasm, Dr. Lane has noticed that many of his patients who had concurrent USMI, leaked less once the SI issue was resolved. He estimates that a least half his patients showed some degree of improvement ranging from a complete resolution, to a reduction in that amount of medication needed to control leakage.

Hypothesis

Dr. Lane is hypothesizing that some cases of USMI are musculoskeletal in origin, that in much the same way traumatic SI luxation can cause complete urinary incontinence in an awake animal, muscle spasms in the same area can cause less severe form of urinary leakage while asleep. This may be a reason why some patients are refractory to medication.

Eligibility

Any patient with frequent urine leakage while sleeping (at least once per month) is eligible, especially those with evidence of lower back pain. Patients must have had a recent urine chemical and sediment analysis (routine urinalysis) with no urinary abnormalities detected. A concurrent negative urine culture is ideal.

Patients receiving treatment must have not undergone any other change in treatment protocol within 3 weeks of their initial consultation (e.g.: adjustments in medication dosage, initiating antibiotics, diet change etc.).

Treatment Protocol

Treatment consists of a combination of chiropractic, acupuncture, and rehabilitation therapy techniques that are safe and non-invasive. The treatment is formatted primarily to eliminate pelvic pain and abnormal muscle tension, as well as traditional acupuncture points intended to specifically address urinary incontinence. For those patients not experiencing back pain, he will treat them using traditional Chinese medicine acupuncture techniques.

Patients will be asked to participate in two sessions, an initial consult (approx 1 hour) and a follow up appointment (approx ½ hour), and will receive treatment both times.

Owners will be asked to record the frequency and severity of urinary leakage before and after treatment. Other observations about hind end strength, co-ordination and comfort (e.g.: ability to walk, run, jump into car, etc.) should also be made.

Tail Self Mutilation in Cats
Background

Tail mutilation is an uncommon but distressing condition in which cats will attack their own tail or hind end, sometimes to the point of inflicting such severe wounds that subsequent amputation of the tail is required.
The cause of this condition is largely speculative. Some appear to do it secondary to itchy skin disease, and some as a form of redirected aggression secondary to stress or anxiety. Steroidal anti-inflammatories and/or anti-anxiety medication is often used to treat these cases.

For many, the reason appears to reflect underlying pain. Many cats have a history of tail or hind end trauma that pre-dates the self mutilation. They may or may not respond to gabapentin or other pain control medication. Gabapentin is a drug that is particularly effective for nerve root pain.

Hypothesis

Pain induced tail mutilation may stem from primary pelvic muscle spasm and secondary tension on or entrapment of nerve roots in that region. From the cat’s perception, this pain appears to originate from further down the tail and causes such distress and frustration that they respond by attacking it. If pressure can be removed from the nerves, then the pain should abate.

It is also possible that some of these cats who respond to anti-anxiety medicine may also be feeling pain, and although the medication may be doing little to alleviate the pain itself, it may be addressing the secondary distress.

Eligibility

Any patient with a history of ongoing tail mutilation, or mutilation of some other body region is eligible. Patients will be examined for presence of dermatologic disease or other non-pain related causes for the condition before beginning treatment.

Patients must have not undergone any other change in treatment protocol within 3 weeks of their initial consultation (e.g.: adjustments in pain control or anti-anxiety medication).

Treatment Protocol

Treatment consists of a combination of chiropractic (pointseastwest/chiropractic), acupuncture (pointseastwest/acupuncture), and rehabilitation therapy techniques (pointseastwest/rehabilitation) that are safe, and non-invasive. The treatment is intended to diagnose and eliminate pelvic pain and abnormal muscle or fascial tension.

Patients will be asked to participate in two sessions, an initial consult (approx 1 hour) and a follow up appointment (approx ½ hour), and will receive treatment both times.

Owners will be asked to record the frequency and severity of tail mutilation episodes before and after treatment. Other observations about hind end strength, co-ordination and comfort (e.g.: ability to jump onto objects) should also be made.

Since developing his referral practise, Dr Lane has seen multiple cats with this condition. Some were cured, some showed no response at all, and others showed signs of improved hind end comfort but persisted with the tail mutilation. By gathering a large sample size and more meticulous documentation of treatment results, he hopes to better document the effectiveness of this treatment protocol.

Intra-articular injections for refractory arthritis in dogs
Background

Intra-articular (IA) injections of hyaluronic acid (HA) or corticosteroids is frequently done to treat arthritis in both human and equine medicine, but is rarely used as a treatment in canine medicine.

HA is a key component of healthy joint fluid and cartilage and is injected into arthritic joints to improve their health and comfort. HA is of benefit on its own, but it is also thought that perhaps a combination of the anti-inflammatory properties of corticosteroids with the cartilage building properties of HA would have a symbiotic benefit.

Some steroids, particularly depo-medrol which is a commonly used corticosteroid in dogs, have been shown to have deleterious affects to joint cartilage. This is a commonly cited reason why practitioners discourage the use of any IA corticosteroids in dogs. However some steroids, e.g. traminisolone, have been shown to have an overall protective benefit to the cartilage of horses1, although no long term safety studies have been done in dogs.

Little to no documentation exists regarding the injection of HA with or without steroids in dogs. Dr Canapp, a sports medicine, surgery, and rehabilitation medicine specialist believes approximately 70% of his arthritic patients respond to IA injections2. A recent study also reported a benefit in comfort score of patients receiving HA given with steroids3

Hypothesis

Intra-articular HA injections, with or without triamcinolone may be a viable treatment option for arthritic joints.

Early reports are encouraging, but more data about the degree and duration of response needs to be gathered in order to assess this hypothesis. Cross referencing this information against the location and severity of arthritis in the joints being treated may help determine which patients are most likely to respond.

Eligibility

Patients who have ongoing arthritic issues that have been refractory to standard treatments are eligible. Diagnosis will be made by physical examination combined with radiographic evidence of arthritis and/or joint fluid cytology.

Owners will be asked to sign a waiver indicating that they understand that the use of IA HA with or without steroids is not a widespread treatment, and that no long term studies have been done on the effect of repeat injections of either HA or triamcinolone on cartilage health in dogs.

Treatment Protocol

Eligible patients will be sedated, and the injection site will be clipped and surgically prepped before intra-articular injection. Bloodwork is often required before sedation.

Observations about the severity of lameness will be made both before and after treatment. The effectiveness and duration of response will be recorded, both at home and by follow-up appointment.

Side Effects and Safety

Patients might experience transient discomfort for a day or two following injection.

Because HA is a nutrient normally found in joints, and because it has properties that benefit joint mechanics, there is little reason to suspect it will cause adverse side effects within the joint. Research in other species has shown positive benefits which is why it is commonly done in both humans and horses. Having said that, there is no research about the long term effects of HA injections in dogs.

Research suggests that triamcinolone has protective benefits for the cartilage1 of horses but there is no research on its long term affects in dogs.

With any joint injection, there is the potential for secondary infection. Every precaution is taken to prevent this, and the likelihood of secondary infection is low but not impossible. Infections typically respond to antibiotics.

References

1 Carlson KL, Steward AA, Steward MC, Pondenis HA, Effects of Hylartin V in combination with triamcinolone acetate on interleukin-1 induced inflammatory mediator production. Proceedings of the Veterinary Orthopaedic Society Annual Conference. Crested Butte, CO, 2012

2 Canapp S, Surgery STAT: Intra-articular therapies for the elbows in dogs, DVM newsmagazine, Sept 2010

3 Franklin SP, Cook JL, Prospective clinical trial of autogenous conditioned plasma versus hyaluronan plus steroid for treatment of chronic elbow osteoarthritis in dogs, Proceedings of the Veterinary Orthopaedic Society Annual Conference. Crested Butte, CO, 2012