Osteoarthritis Treatment Options: Platelet Rich Plasma

Osteoarthritis affects at least 1 in 5 dogs in the United States. We have known this since 1997 (Johnston et al, Vet Clinics North America). Let that sink in for a moment. 1 out of every 5 dogs you see in a day has some form of osteoarthritis.

This could be the Labrador with cruciate disease that had a TPLO, but still has trouble going up the stairs. The German Shepherd that has elbow dysplasia. The agility dog that has arthritic carpi and tarsi. The Newfoundland that had OCD lesions surgically removed from both shoulders and has hip dysplasia (personal experience right there).

Once the surgeon’s job is done, is the patient cured? No. It is, by far, better off than before, but the pet will have arthritis for the rest of its life. That arthritis will have to be managed. The management of that may be with a boarded sports medicine specialist, a rehab doctor, or the general practitioner.

Some patients may not have had surgery, or have been diagnosed with “arthritis.” Please remember that, unless you were born on Krypton, we have to confirm our arthritis diagnosis by taking radiographs. Just because the 9 year-old Boxer can’t climb the stairs doesn’t mean it has arthritis. It could have osteosarcoma, IVDD, or degenerative myelopathy. Being the advocate for our patients, we have to be good diagnosticians as well.

Management of arthritis requires a multi-modal approach. Weight-wise, it’s best if the pet is lean, as an obese pet puts more pressure on its arthritic joints.  Joint supplementation with appropriate chondroprotectants is extremely helpful.

Regular, low-impact exercise is critical.  For arthritic patients, this is not being out in the yard to play. This means going for a walk 15-20 minutes, 1-2 times a day, 5-7 days a week. And that walk means WALKING, not stopping every 10 feet to smell something.

But none of us likes to exercise when we hurt. So, after confirming the diagnosis, starting on analgesics is important. This may be short term or long term, depending on the patient.

Once the patient is diagnosed pain free and treated, we’re done, right? Not even close. Remember, we’re managing this disease for the rest of their lives. Arthritis will flare, the owners will get lazy about walking the dog, the kids will feed it tons of treats, and it will gain weight. And even if this backsliding doesn’t happen, arthritis is a progressive disease and will have flares. There will be periods of time that the joints are more uncomfortable, and the pet’s quality of life will temporarily dip.

When those flares occur, (either at initial diagnosis or later) the patient will need our intervention. In years past this was often a pharmaceutical intervention. Non-steroidal anti-inflammatory drugs, polysulfated glycosaminoglycans (PSGAGs), or even direct analgesics (codeine, tramadol, amantadine) have been utilized. These pharmaceutical options can be very helpful (ok, not tramadol, but that is a topic for another day), the patient feels better, the owner feels better. It is our job to then try and minimize the flares (weight loss, exercise, and joint protectants).

But what about a biologic option? Instead of suppressing the inflammation, can we do something to minimize the production of inflammatory cytokines directly in the joint? Photobiomodulation (laser therapy) is a developing field and providing some good options for our patients. It works from a cumulative effect, which means committing to regular treatments, then tapering off. What if that doesn’t work for the owner? Or what about the pet already undergoing laser therapy but their joints are still painful? Or what if it’s the mild arthritis patient who is just mean and you can’t treat them in your clinic awake? Or the owner that wants a natural, holistic approach to their pet? What other biological options do we have? What does the body do when left to its own defenses?

It heals itself. It sends out platelets to clog a wound and trigger the inflammatory cascade. Neutrophils and macrophages come in to clean up the site. Fibroblasts are alerted and sent in to lay down tissue to heal the area. This is good inflammation, as opposed to the bad inflammation that is at the heart of arthritis.

Platelet rich plasma (PRP) allows veterinarians a targeted, biologic approach to helping our patients. The platelets contain the helpful cytokines and inflammatory factors to reduce the synovitis.

Blood is collected from the patient and then processed in about 10 minutes into PRP. We want to eliminate the erythrocytes and neutrophils, and reduce the amount of plasma. The PRP Pure kits from Companion take 50cc of blood (and 10cc of ACD-A {Anticoagulant Citrate Dextrose Solution}) to yield 4cc of PRP. A smaller kit, (25cc of blood/5cc of ACD-A) yields 2cc of PRP for those smaller patients in your practice.

In my practice, we confirm the patient is healthy and we confirm our disease before we inject. That’s a history, physical exam, gait/stance analysis, CBC/Chem, and radiographs. Then we inject our problematic joints with PRP. I recommend doing this with your patients sedated. While some joints (stifles, shoulders, and elbows) might be injected awake (in cases where sedation is too risky), many cannot (hips, hocks, carpi) and there is a learning curve to this, and your patient will thank you if they are unconscious and receiving analgesia for it.

And for those of you thinking “injections are easy for him, he’s a specialist”, well, I did these injections well before taking boards. I learned joint injections in vet school, worked on them in practice (working up septic arthritis or immune-mediated disease), and practiced on cadavers. I actually find doing intra-articular injections easier than drawing blood. The patient is sedated (via that catheter that my tech puts in), and with some brief review of anatomy, putting the needle in is very straightforward.

If you’re worried about doing damage to the joint, don’t. These joints are inflamed and arthritic, so the cartilage damage is already done, your job is to help the patient feel better.

Depending on the size of the patient, we can allocate the appropriate amount of PRP for each joint. Labrador stifle is about 1.5–2cc, so that lab with two bum knees – 4cc is perfect.

For mild arthritis (based on physical exam and radiographs) a one-time injection can get 6-9 months of relief. For moderate or severe arthritis, a series of injections (3 injections total, 3-4 weeks apart) will be needed. This will still get about 9-12 months of relief.

For all patients, I start with a sterile clip and scrub. Then, with sterile gloves on, I do an aseptic approach to the joint. Once the needle is in, I aspirate all the joint fluid I can out of it. I do this is for two reasons. First, to confirm we are in the joint, and second, to alleviate the pain from the mechanical distention of a swollen joint. (On some large breed dogs, I will get 3-5cc of inflamed joint fluid from an elbow or stifle!) This fluid can be analyzed if further confirmation of the disease is needed.  Then, I inject the PRP in the joint, followed by 10-15 reps of range of motion to distribute the PRP in the joint. And since this is an outpatient procedure, usually on dexmedetomidine and butorphanol, the patient is then reversed and sent home accordingly.

But we are not curing the disease. We have made it better, but we can improve it even more. With a comfortable joint, we can now build muscle. Taking the patient from the diagnostics and injections to a rehab program is critical. PRP is not magic pixie dust, and so we return to that multimodal approach. Light leash walks, home exercise programs, and then improving strength and balance through underwater treadmill workouts and other activities are all part of the treatment.

In the immediate post-injection period the patient cannot take NSAIDs. This is because we have triggered GOOD inflammation, and the NSAID would block that cascade. The same is for ice packs, as we want healthy inflammation to improve the joint.

To be honest, once we’ve injected the joints, the patient will feel better and usually only take NSAIDs on a very limited, as needed basis. The goal is a targeted approach, not a systemic one. We have addressed the patient as a whole, and improved outcomes for all involved: pet, owner, and veterinary team.

In specialty practice, many clients come for a consult because they have had PRP injections themselves or heard about it from a friend who had it for their dog. Or they may have read about it on a blog or social media group. Those same clients may come to you looking for options. If they are not, how do you build PRP into your practice?

I start by have an honest discussion with a client. Those senior dogs that are coming in for rechecks and follow up blood tests for NSAIDs, I chat with them. I ask the owners if they think their medication is helping. Or when was the last time Fluffy went upstairs.  I explain to them what I do for my own dog with arthritis.

If I want more objective info, I measure muscle mass and compare it to their last visit. If the dog has progressive atrophy, the pain medications they are on are not helping. I talk with owners about doing some investigation (CBC/Chem/UA and radiographs) and discussing platelet rich plasma or other treatment options in the multimodal approach to arthritis.

So think about the 20% of the dogs you see each day. Identify which ones are on long term pain meds, which ones could use more help. Exercise your brain and have fun being a good diagnostician. Get a refresher on an old skill and learn a new application. Expand your practice, and give your clients and patients a new option.

 

If you are interested in setting up a consult for your pet, you can visit

https://www.vscvets.com/

or

https://www.queenstownvet.com/

and set up a consult with me.

For veterinarians looking for more information can also contact me through those hospitals.

 

 

Updates

I hope that everyone is staying safe in these challenging times. Social distancing, wearing masks, supporting our fellow human beings can seem like a lot for anyone to handle. It will all be worth it when we are a safer community.

My community has changed a bit recently. I have accepted a full-time position as medical director at Veterinary Surgical Centers Rehabilitation in Northern Virginia. I am honored to join this amazing team of doctors, technicians, assistants and support staff in helping dogs and cats in our area.

As medical director, I look forward to adding sports medicine to the rehab department.  We will be adding new aspects to the department in the near future, including a pressure sensitive walkway, new treatment options and new imaging capabilities. Our entire team in VSCR is Fear-Free Certified, with the goal of a positive environment for your pets. Check us out online at https://www.vscvets.com/rehabilitation and on Facebook and Instagram as well.

I will still be working with the team at Queenstown Veterinary Hospital in Maryland on a regular basis as well. Their website is https://www.queenstownvet.com/services/rehabilitation/

While Covid-19 has postponed many conferences, I have enjoyed working with different groups to provide online learning in the field of rehab and sports medicine. VetScope.Vet (https://vetscope.vet/videos?search_word=brunke), CSAVS (http://en.csavsapp.com/), OnlinePetHealth (https://onlinepethealth-info.com/), CARE (https://caninearthritis.org/), VSMRI (https://www.vsmri.com/), and PetLifeER (https://www.petliferadio.com/ervet.html)

Keep an eye out for more coming later this year.

There will be some new posts on cases later this year, and I am also very excited to be working on two NEW courses and will be announcing those here soon.

Stay safe.

International Rehab Meeting – COVID-19 Update

***Updated 19 March 2020***

In response to the Covid-19 outbreak, the IAVRPT has postponed the symposium until August 2021. I do hope to see you all there. Please stay safe.

 

For those that are veterinary professionals, I’d like to invite you to the 2021 International Association of Veterinary Rehabilitation Meeting.

The meeting NEXT year will be in Cambridge, England during August. There will be lecture topics on canine, equine and feline rehabilitation. Research updates will also be presented, along with hands on learning.

Come and network with your colleagues from around the globe! Previous meetings have had representatives from six continents (sorry Antartica), and over 80 countries!

To see the conference schedule and register – please go to https://www.iavrpt2020.org/

To follow the meeting updates on Facebook, “like” us here – https://www.facebook.com/symposiumIAVRPT/

I will be there as an attendee, as well as a member of the executive board and planning committee.

Hope to see you all there!

Now in Virginia!

Recently I have joined the team at Veterinary Surgical Centers Rehabilitation in Virginia. Here I work with an amazing team of boarded surgeons, rehab doctors and rehab technicians. At this group I can provide consultations, radiographs (including PennHIP), CT and MRI as well as diagnostic musculoskeletal ultrasound. For treatment options we have shockwave, platelet rich plasma, adipose derived progenitor cells as well as other therapies.

The surgery department can evaluate and treat joints arthroscopically and total hip replacements are done regularly with Dr. Anke Langenbach who is the co-owner. The surgery department also provides soft tissue, oncologic and neurologic surgical services.

Our rehab team includes me, Dr. Cameron Weber (certified in rehab and acupuncture) as well as Kirsten Oliver (VTS Physical Rehabilitation) and Jessie Pulley (certified in rehab and pain management). We also work with a fantastic team of licensed veterinary technicians to provide anesthesia monitoring during procedures and veterinary assistants to facilitate our consults and rehab sessions.

I look forward to working with this team, getting to know primary care veterinarians and clients in the area and helping all patients with their mobility issues.

Check out http://www.vscvets.com/ for more information.

Canine Manual Therapy

For veterinary rehab professionals –

If you’re interested in adding manual therapy (massage, joint mobilizations) to your knowledge base and aiding your patients, check out the UT CCRP Manual Therapy Course.

https://www.utvetce.com/canine-manual-therapy

This combo online and live course is for those already certified in rehab therapy. Once you’ve completed the online portion you can attend the 3 day hands on course. I will be teaching this in Connecticut later this year and we are aiming to bring it to the west coast in 2020!

Thank you,

Dr. Matt

For Rehab Professionals

Already certified in rehab but trying to keep up with all the learning? Wanting to do it from home and at your pace? Want an on-line discussion forum for all things veterinary rehab? Then check out VSMRI – The Veterinary Sports Medicine and Rehabilitation Institute. https://www.vsmri.com/

I am honored to be part of a great team that brings this new platform to the veterinary rehab community. Looking forward to seeing you there!

Thanks

Dr. Matt

Epidurals for Canine Chronic Back Pain

For some dogs with chronic lumbosacral disease an epidural injection of cortisone can be used to help relieve pain. I have done many of these procedures with good outcomes. If you are interested to see if this is an option for your dog, please set up a consult with me at Queenstown Veterinary Hospital. http://www.queenstownvet.com/

To read more about this condition please check out my previous post on it here:

https://drbrunke.wordpress.com/2017/01/24/options-for-canine-chronic-back-pain/