Adelaide

This is a story about my own pup. I met Adelaide in January 2016 when she was 8 months old. I had known her breeder from my previous job and we have a good working relationship. Addie is a Landseer Newfoundland, and was from lines that are used for showing, working, and breeding. It is great to see these big dogs do their job, and they are wonderful pets to boot.

The concern was Adelaide wasn’t developing well, and seemed to walk funny.  I found some discomfort in her shoulder and hip joints, and suggested sedated radiographs. Those showed some mild hip dysplasia and osteochondrosis dessicans (OCD) lesions in both shoulders. OCD is a developmental orthopedic disease where the cartilage and bone don’t form correctly in a joint. This can lead to pain, arthritis, and the inability to work. It can happen in any dog, and there is some link genetically and environmentally. The key is to identify it early, remove that animal from breeding, and deal with the problem.

I sent Addie home that day with her breeder knowing that she could not be a show or breeding dog. However, she could make an excellent pet. About two weeks later, I called to check up on her and asked if she had been placed in a home yet. She hadn’t, and I took her in in February as a trial. If she would fit in with my pets, I would keep her as my own.

Addie fit right in with Penny and Milo, and soon I had a happy pup in the house. Great, now what do I do? Surgery was needed to minimize the arthritic damage in her shoulder joints. Then keeping her in good physical condition, protecting her joints and getting her moving would be my job. And since this is what I do for my patients, this is an easy fit for me.

Through some colleagues at the University of Pennsylvania, Addie had her shoulder joints cleaned out in April. The goal was doing them arthroscopically to minimize her healing time. The left shoulder went well, but the cartilage flap in her right shoulder was too large to remove. We successfully opened the joint and removed the flap. Then, we placed hyaluronic acid in both shoulders. This is essentially a synthetic joint fluid to help lubricate her joints and minimize further cartilage damage.

Addie recovered very well, and a month later, I spayed her and prophylactically did a gastropexy on her. This is tacking the stomach wall to the body cavity to prevent rotation or volvulus of the stomach during a bloat or GDV (Gastric Dilatation Volvulus) episode. Giant breed dogs are prone to bloat, and by doing this surgery I minimized her risk of gastric torsion. At the same time, I injected her shoulder and hip joints with hyaluronic acid and objectively measured her hips by taking radiographs in the PennHip method.

PennHip allows us to measure the distraction index between the hip joint of dogs, and correlates to how loose the joint is. Since hip dysplasia is based on laxity, the laxer a joint is, the higher the risk of arthritic change. Addie was dysplastic, but her score was mild. This allowed me to not consider a total hip replacement for her. If her scores had been worse, further surgery would be indicated.

After her recovery, I got Addie moving. She had continued to grow as well, and was now a lean 125 pounds. We began to work on walking and hiking. Last summer we hiked every weekend, and walked 2-4 miles each day during the week.

Penny, Addie, and I hiked to the top of Buck Mountain to overlook Lake George in July. By the fall, Addie could hike 10 miles a day nonstop.

Last fall, I had her groomed to a buzz cut. I weighed her the morning before, 125 pounds. Her weight right after the haircut was 113 pounds. 12 pounds of hair, and a reduction in 10% of her body weight. Not only is it easier to keep her clean in this cut, but reducing her body weight minimizes stress on her arthritic joints.

How do I keep her going? It is a multimodal approach. She eats Hill’s Science Diet J/D which is specifically formulated for dogs with arthritis. She also takes Dasuquin Advanced every day. This spring, I will inject her hips and shoulders with platelet rich plasma and bone marrow stem cells to further protect her cartilage.

I also keep her active, we walk 3-5 miles every day, and she plays regularly with Penny and her friend Dexter the Golden Retriever. We work on core strength through exercises on TotoFit equipment, and she gets out and swims when the weather cooperates.

At some point, she may need other medications, but currently she doesn’t have to take them. She is a wonderful girl and I am very thankful to have her as part of my family.

If you have questions about managing arthritis in your pet, please contact me.

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Mia’s Journey

Mia is a 7-year-old German Shepherd that I met in October of 2015. She was referred for a left front leg lameness that had been going on for a few months. Mom had Mia since she was a pup, and no major issues were in her history. She was on some supplements, but no medications when I met her.

Mia is a large framed dog, and weighed in at 107 pounds when I first met her. She was about 10 pounds overweight. On physical exam, she had a definite left front lameness, with pain on the palpation of her biceps tendon. I also found bilateral hip joint pain, and lower back pain which had not been found before.

After checking her complete blood count, blood chemistry, thyroid function, and urine for any underlying diseases (there were none), I sedated Mia to further evaluate the painful areas. Radiographs showed severe arthritis in both hip joints. Mia also had spondylosis (bridging arthritis of her vertebrae) and mineralization of the biceps tendon in both shoulders.

Biceps tendonitis can occur for many reasons, but my suspicion in her case was years of chronic overload on her front legs. Because of her painful hips, she would transfer her weight to her front legs and overwork them. This shows us how animals can be sneaky about their problems and hide them from their owners for years.

While sedated, I injected Mia’s biceps tendons with long acting cortisone. The goal here was to provide targeted relief and anti-inflammatory action in the painful leg. Mia’s sedation was reversed and I sent her home to rest for 2 weeks. I discussed with her owner all the findings, and suggested that Mia may need surgery for her hips.

When I saw her again, the left front lameness was nearly resolved. It was no longer tender to the touch, and she walked evenly on her legs. With the pain reduced, we could now work on building strength and addressing her other issues. Mia was seeing our veterinary chiropractor to help with her posture, and I wanted to work more with Mia’s arthritic hips.

I didn’t inject her hips earlier for two reasons. One, it wasn’t why she was currently painful and limping. Two, since they had never been diagnosed before, mom needed some time to process her options on it. At her two week recheck, we started an Adequan injection series. This goes under the skin and penetrates the synovial joints to help improve joint fluid. By doing this we could help her and allow Mia to tell us what she needed. Adequan is a great option for dysplastic/arthritic hips, and I use it as one of my first options.

Another key step in managing arthritis is managing obesity. Mia was 10 pounds overweight, so we worked on a weight loss plan for her. In two months she dropped 8 pounds and was moving much easier! (Mom inadvertently was feeding her 3-4x her daily calorie requirements. Some quick math on my part made for her rapid weight loss.)

After the injections and adjusting her diet, our rehab team worked with Mia through underwater treadmill workouts, photobiomodulation (therapy laser treatments), core strengthening, and muscle building. By December 2015, Mia was 98 pounds and moving very well. She went from walking 10 minutes per walk to 45-50 minutes per walk, 5-7 times a week!

We maintained Mia in a rehab program all winter long and she was doing well. In March 2016, she came in favoring her right hind leg. Mom was concerned it was her hip, but I found pain and swelling in the right knee. My physical exam findings were consistent with a strain or partial tear of her cranial cruciate ligament. This is essentially the ACL in dogs, and is a common cause of injury.

After reviewing options with the owner, I again sedated Mia and injected the right knee with a combination of short acting cortisone and hyaluronic acid. This allowed for targeted anti-inflammatory action (like her shoulders a few months ago) and the hyaluronic acid helps to improve the viscosity in the joint, protecting the cartilage and giving time for the ligament to heal. While I was there, I injected this same combination into both hip joints to relieve discomfort there as well.

Mia resumed her rehab program a week later, and her right knee pain resolved. The swelling I had found before was gone, and she was bearing weight fully on the leg.

In May 2016, Mia’s left hip became very painful. She was having trouble standing up, putting weight on it, and lying down. We tried a course of oral medications, but only had mild improvement. That month our surgeon did an FHO procedure on Mia’s left hip to remove the bone on bone contact that was causing Mia so much pain.

Side note: There are two main surgical options for hip arthritis. One is a total hip replacement, where an artificial ball and socket are placed to create a new joint. This is commonly done in people and is done regularly in dogs also. It is the gold standard and has excellent outcomes. It can be expensive, and there is a restricted period on the patient because the bone must heal and hold the implants in place.

 An FHO (or FHNE) is the other option. The femoral head and neck is removed and a false joint is created. This removes the worn-out cartilage and exposes bone/nerve endings that cause a lot of pain. No implants are needed, and the healing time is about 2 weeks. The key is to be aggressive in rehabilitation with these patients, to encourage them to use the leg. It is not as expensive as a hip replacement and has very good outcomes. It was done in people before hip replacement became the go-to option.

Mia did great through surgery and anesthesia, and excelled in her rehab program. Within a month, she was fully weight bearing, and improved her muscle mass in all her legs. She got back to her 45-50 minute walks within 2 months and we stopped seeing her for rehab in October 2016.

The plan was to keep her active and happy, and then see when/if she would need further rehab or surgery. She would continue to have regular veterinary chiropractic appointments and remain active. This also allowed her owner to catch up on finances. She had pet insurance but it doesn’t cover everything.

I saw Mia at the end of January 2017. She weighed 94 pounds, but was having trouble walking and moving. She was already on gabapentin and meloxicam and her joint supplements. About 2 weeks ago, she had started acting sore and was less inclined to walk, but the last 3 days before I saw her, she was painful when going outside and was favoring her right hind leg, holding it up and not wanting to stand on it.

My physical exam showed that her knee was fine, but the pain was coming from her hip. No neurological problems were noted, but the pain was back in both of her bicep tendons as well. After reviewing options with the owner, I checked some basic organ function (blood tests) and presented treatment options.

We could do the injections we had done before, or we could try a different approach. This new approach would be to collect Mia’s blood and bone marrow and inject platelet rich plasma (PRP) and her own stem cells into the painful areas. This is called regenerative medicine.

Side note #2: Platelet rich plasma contains numerous growth factors that facilitate tissue healing and repair. Growth factors are small proteins that are contained within a compartment inside the platelet. When a platelet is exposed to an area of damage or to fibrinogen, it becomes activated and releases its growth factors. These growth factors play an important role in tissue repair by promoting new vessel formation, enhancing cellular proliferation and promoting extracellular matrix formation.

When stem cells are injected in a concentrated form, they perform various functions to repair and regenerate tissue. They can differentiate into the surrounding tissue types which can include bone, cartilage, tendon, ligament, muscle, and nervous tissue. Other primary functions of stem cells in regenerative therapy includes: activating surrounding resident stem cells, stimulating new blood supply, recruiting additional cell types to aid in tissue repair, stimulating healing and tissue growth with the release of cytokines and growth factors, decreasing inflammation by moderating inflammatory pathways, reducing and/ or eliminating scar tissue, and creating a scaffold for healing tissues.

I did this in mid-February for Mia, and saw her this week for her recheck. Her right hind lameness has resolved, and both shoulder tendons are normal to the touch. This will be a slow road with her, I equate regenerative medicine to re-seeding your lawn. It may not look like you did much the first few weeks, but once the seeds sprout and the grass grows, it can be wonderful. In Mia’s case, it was also covered by her pet insurance.

Mia is back on a regular rehab program with our team and is improving weekly. Mom realizes that she may ultimately need surgery for her right hip, but for now she can work on strengthening Mia again and having her be in the best comfort and shape possible.

Stay tuned for regular updates on Mia. Here are a few pictures of her throughout the process, including her bone marrow collection and joint injections a few weeks ago.

Making a Case for Acupuncture

Shortly after my acupuncture final exam, I was asked to consult on a case at a local veterinary hospital. Molly was a 5-year-old Bassett Hound mix who had no function in her hind legs. She was brought to her primary care veterinarian a week before Christmas for back pain, but could walk normally. She was started on pain relievers and was placed on restricted activity.

Two days after Christmas, she could not use her back legs at all. There was no trauma or incident that they could identify as a cause. She was re-examined and baseline blood tests were overall unremarkable. Radiographs of her spine showed a narrow space between two vertebrae. At this point, a consult with a veterinary neurologist for potential surgery was recommended. This was not an option for the owner since the consult and surgical estimate was $5,000-$7,000 and this was beyond their capabilities. She was started on cortisone and antibiotics to prevent infections, tumors or anything that could be placing pressure on her spinal cord.

When there is inappropriate pressure on the spinal cord function can be impaired. The most common cause of pressure is a bulging or herniated intervertebral disc. Other causes can be infections, tumors, fractures or fibrocartilaginous emboli (FCE). Without a CT scan or MRI exam these can be very challenging to tell apart, but survey radiographs can be helpful.

As the pressure builds on the spinal cord, the patient will usually start with back pain and it may stop there. It can also progress slowly or rapidly to impair the spinal cord. The job of the spinal cord is to relay the message from the legs to the brain for interpretation like a cell phone signal. When the cord is impaired it’s like trying to talk on the phone with less than 5 bars of service, the message can be choppy or incomplete.

As the “signal” gets weaker the back pain can lead to a wobbly or ataxic gait because the patient doesn’t know where their feet are. This can progress to losing the ability to walk entirely and even the ability to perceive pain. The loss of pain for an extended period of time is a very poor prognosis.

If the pressure can be relieved the spinal cord regains its function in the reverse order that it lost it. Pain comes back first and then, hopefully, the ability to walk followed by the fine motor skills. Urination and defecation can be anywhere in between pain and fine motor as it depends on where the cord is damaged.

When I met Molly on January 2nd, she had lost the ability to feel pain 6 days prior. Ideally, she would have had surgery to relieve the pressure within 24-48 hours of losing that ability, but that was not an option for her family.

Although an MRI exam and spinal surgery were not an option, Molly’s family did not want to give up. I was asked to consult and see if anything else could be done. After examining Molly and discussing my thoughts and prognosis with them, I treated Molly with acupuncture and adjusted some of her medications. I placed her on low doses of cortisone, along with muscle relaxants and continued her on gabapentin to reduce any neuropathic pain.

Given her age, breed and progression of her signs, I was suspecting that a herniated disc was the cause of her problems. I recommended treating Molly three times to see if we could regain pain perception. If we could, then we could continue to treat her. If not, we would talk about the ability for the owners to provide long term care for a paralyzed, incontinent Molly.

When I saw her 3 days later, she had regained pain perception. This was excellent but we were still not out of the woods. I didn’t know if Molly would regain the ability to walk. I treated her again with acupuncture, including electro acupuncture and aqua acupuncture with Vitamin B12. This combination approach would provide different levels of stimulation to her body for varying lengths of time.

On her third treatment three days later, I repeated those acupuncture points and had a frank discussion with her owners. Molly weighed 50 pounds and can be challenging to move around. Her front legs were working perfectly and they had a harness to support her chest and back legs so that she did not scrape her body on the ground. At 50 pounds, she is not a dog they could pick up and carry around. We discussed using a cart (from Eddie’s Wheels) as a potential to assist in her mobility and also as part of her rehab. The cart could also support her long term if she did not make a full recovery. The owners would think about it and let me know.

At this time, I had given her family detailed instructions on doing range of motion exercises and other therapeutic exercises to help with Molly’s rehab. They were doing these every day along with providing her nursing care. In other cases, I have hospitalized patients to do this but given all the circumstances for this case this option was most feasible for Molly’s owners.

I saw Molly a week after her third treatment and now she could consistently wag her tail. She also had very weak but present motor function in her back legs. The owners were trying to figure out finances of a cart. With her improvement I recommended starting her on a Chinese herbal compound to assist her spinal cord healing. This would reinforce the acupuncture treatments she was receiving.

The following week, I measured Molly her for her cart and started the herbal treatment with her. Again, I repeated her acupuncture treatment and also started to taper off some of her other medications.

Due to some outside factors, I did not see Molly again for almost three weeks. I was surprised to see her WALKING into the treatment room! Molly had regained 80% of her motor function in 6 weeks. The average time for this type of recovery is usually 2-3 months. I was very pleased and we agreed to hold on having her cart shipped since she had done so well so quickly. I continued to treat her with acupuncture and scheduled to see her again three weeks later.

At this time, she had 95% of her function back and was in excellent spirits. We had weaned her off most of her pain meds but continued her herbal treatment. I will see Molly in another 3 weeks and then only as needed. I expect her to make a full recovery.

Each individual case is just that, an individual. I am always hopeful when I work with challenging cases, but, I have to admit, Molly’s recovery exceeded my expectations. I hope to be able to repeat this outcome with other patients through a combined approach of Western and Eastern treatment.

If you have any questions about spinal injuries and your pet that are NOT urgent, please contact me.

For more information on herniated discs please check out this website. http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2373

For information on FCE check out this site. http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1663

Victory Over Cancer

I received an update on Victory the other day and wanted to share it with you.

Victory is a shepherd/husky cross and was diagnosed at 11 years of age with osteosarcoma, an aggressive cancer of the bone, in his left hind leg. He is the dog in the post “Proof That Dogs Don’t Read”.

Victory continues to do well four years after his amputation. He will turn 15 years old this December and is comfortable and active at home with two younger dogs, Hershey and Zeke.

Victory is a great example that there is always an exception to the rule. He and his family are very lucky to have had all this time together.

He never underwent chemotherapy after his amputation. Chemotherapy has been shown to help patients after a surgery like Victory’s.

Pets handle chemo remarkably better than we do because our goals are different. For people, oncologists are aiming for 15-30 years of life and have to wipe out every last cancer cell to do that. Veterinary oncologists are aiming to comfortably extend our pets time by perhaps 12 months.  Therefore pets get lower doses of chemotherapy and generally don’t lose their hair or get sick from the treatments.

I believe it is also important to look at the big picture. Each family has to take into account their pet, the diagnosis, the prognosis with or without chemotherapy, the follow up visits and expenses and also the chances of what the chemo will do versus the natural life expectancy of their pet.

In Victory’s case, his family made an informed decision that was best for them and their beloved pet. I am very glad that they did. This was a family decision I supported.

If you have questions about osteosarcoma, pain or quality of life you can message me through this blog or discuss it with your veterinarian.

Here is a recent picture of Victory enjoying the outdoors.

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The Winds of Change

I am very happy to announce that I am relocating. Starting September 13, I will be practicing at New Baltimore Animal Hospital. (http://www.newbaltimoreanimalhosp.com/) While I greatly enjoyed my time working in NYC and Long Island  this year, I was drawn back to upstate NY for many reasons. My interests in orthopedics and sports medicine requires a caseload found among outdoor and active dogs.
This move will also allow me to enjoy and pursue my personal interests in triathlons and the necessary training for those.
I look forward to meeting a new group of clients and patients at my new practice and continuing to see you all here on the web.
-Matt Brunke, DVM, CCRP