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.

Options for Canine Chronic Back Pain

If you have read some of my other posts, you are familiar with my multimodal approach to managing pain and mobility. For those of you new to this blog, this is where we use a combination of therapies to achieve a good outcome. In some cases, this is combining an oral medication with therapeutic exercises, or a surgical procedure with photobiomodulation (laser) therapy.

Using this approach, we can usually get better outcomes with less side effects. I also use this approach when an ideal treatment is not an option for a patient. This can be due to financial limitations, health of the pet (perhaps anesthesia is not an option), other options are not working, or any number of factors.

With this background, I would like to walk through some challenging cases I’ve had over the past few years. All of these dogs are German Shepherds, some male, some female, all between 7-15 years of age. While this disease can happen to many breeds, we do see it more in German Shepherds. Sometimes the spinal canal, through which the spinal cord and nerves pass, narrows and compresses the nerves.  The most common spot for this narrowing to occur is at the lumbosacral joint, where the spine meets the pelvis. Spinal canal narrowing at the lumbosacral joint is referred to as lumbosacral stenosis, and the condition resulting from the compression of these spinal nerve roots is called cauda equina syndrome.

The narrowing is most often caused by arthritic degeneration or intervertebral disc herniation, but traumatic injury, congenital malformation (born with it), or tumor growth can also be involved.

The most common symptom of lumbosacral stenosis is pain. In the beginning, you may also notice stiffness leading to difficulty in walking, climbing stairs, getting on furniture, wagging the tail, positioning to defecate, or getting into a car. One or both back legs may become weak. Some dogs will cry out in pain when trying to move. In severe cases, the nerve roots can become so compressed that urinary and fecal incontinence will result.

This can be diagnosed through a combination of physical exam, blood and urine tests, radiographs, but it needs a CT scan or MRI to be definitively diagnosed. This is because radiographs (x-rays) do not show the discs and spinal cord, which can be seen on CT scans and MRIs.

The initial pain usually responds well to NSAIDS or Non-Steroidal Anti-Inflammatory Drugs. I will combine this with weight loss (if indicated), muscle building (to strengthen the body), pain relievers (such as gabapentin) and other modalities (joint mobilizations, LASER, underwater treadmill workouts) to help keep the patient in good shape and moving.

Since it is most often caused by arthritis or disc herniation, setbacks, flare ups, and progression of the disease can happen even with the best of management. In those cases, we can add in other medications, or seek a consult with a boarded veterinary surgeon or neurosurgeon. Relieving the pressure through surgery can be very helpful in improving mobility and decreasing pain. After surgery, physical rehabilitation is needed to build upon what the surgeon has improved.

But what if a several thousand dollar CT scan or MRI isn’t in the cards? Or the scan shows the specialist that surgery is not a good option in this case? Are we out of options? Will your dog have to live in chronic pain?

I would hope you repeat readers know by now that this is not the case. So, let’s talk about options.

Studies have been done on both human and animal patients, and there is good evidence in the literature for epidural injection of cortisone. You may have heard of an epidural or spinal before. This is placing a needle or catheter in the space between two vertebrae and around the spinal cord itself. A more common place for this is childbirth, as a local anesthetic (lidocaine) can be injected into the space and block the body from perceiving pain. This is just like going to the dentist. They use novocaine so that you don’t feel them working in your mouth.

In veterinary medicine, we will use a local anesthetic (sometimes along with other pain relieving medications) for surgery (c-section, fracture repair) or for helping to relax an animal that is in labor and help to manually deliver the offspring.

Can we combine these two ideas? Absolutely. An epidural can be done for these lumbosacral patients with cortisone to provide anti-inflammatory action and pain relief. We need to rule out infection first, and ideally have a CT scan or MRI to rule out cancer or other causes. Where do I use this? When my oral medications are maxed out, the pet is still in pain, or for any number of reasons a pet cannot take certain oral medications.

For those of you thinking “wait, I had an epidural and I was awake for it, will my dog be awake?” The answer is no. While some dogs are excellent about holding still, it is not safe to do this procedure awake. It may require general anesthesia, but often can be done under heavy sedation. Their fur in the area will need to be clipped away, and a long needle is placed between the last lumbar vertebrae and the first sacral vertebrae. The cortisone is then injected around the spinal cord in the epidural space.

In my practice, we do this on an outpatient basis with the dog going home the same day. I use either triamcinolone or methylprednisolone, both of which are long acting steroids, as these have been shown to be most effective in the human literature. The dog goes home with specific instructions and restrictions and I see them back in one week. We then institute a combination of home exercises and outpatient rehab sessions to build muscle and strength.

90% of the dogs I have done this for improved in 7 days, and 100% are improved in 2 weeks. Some we are doing just for pain relief and others because they have trouble moving their legs.

How long will this last? This depends on the type of cortisone used. I had one dog that needed a repeat injection at 6 months. The others are doing well on one injection (approaching or exceeding one year).

Are there side effects/risks? With any procedure, there is always risk, but I do my best to minimize that. Blood and urine tests help to rule out other causes. Sedation is short and reversible, so that minimizes risk there. Infection is always a risk, but we do this under a sterile environment. The cortisone is confined to the epidural space, but some can get systemically absorbed. For those cases the dog may drink or urinate more for a few days, and will need to be off their NSAID for a period before and after their procedure.

So, what about those patients I talked about at the beginning? All but two are still alive and doing well. Fritz and Bailey were both over 13 years when I did their injections, and while they improved, their other mobility and health issues ultimately caught up with them. But during the time they had left, they were very comfortable. So, I’m pleased with that outcome. Yosh had an epidural and then months later herniated a disk in a different area that required surgery, I am pleased to report he is doing very well. The other patients are up and moving, and I hope that continues to be their story.

If you have questions, or think your pet may benefit from this or other procedures, please discuss it with your veterinarian or contact me.

Nutritional Supplements for the Canine Athlete

I often get asked, “What supplements should my dog be on?” There are a lot of options out there, so I wanted to provide my perspective on this for all of you.

By the end of this post you will have a working knowledge of some common (and not so common) supplements for joint health, muscular recovery and strengthening, gastrointestinal system health, and immune support. You will also be able to observe critically and identify what I call “evidence vs. claims”. And finally, you’ll apply it to your own canine athlete.

The first step is to define what a nutritional supplement is. The United States Food and Drug Administration (FDA) defines is as “a product intended for ingestion that contains a dietary ingredient to add further nutritional value to the diet.” Said ingredient may be any one or a combo of the following: vitamin, mineral, herb/botanical, or amino acid.

Well that is pretty broad and nonspecific. How about we look at what a nutraceutical is. That is defined by the North American Veterinary Nutraceutical Council as “a non-drug substance that is produced in a purified or extracted form and administered orally to provide compounds required for normal body structure and function with the intent of improving health and well-being.” So we are looking for something that can help the body. That narrows it down (sarcasm font) since it is not a drug it is NOT regulated by the Food and Drug Administration. This is important and will come up later in our discussion.

Since we do not have specifics, we need to think critically. It is important to know the difference between evidence and claims.

Evidence – These are established facts.

Examples are:

  • Double blind placebo controlled study
  • Third Party Research
  • A bibliography and sources referenced to back their statements
  • A prospective study
  • It appears in a peer-reviewed publication
  • It utilizes the scientific method

 

Claims – These are statements that something is the case, often without proof.

Examples are:

  • Catchy terms on the label
  • Copying one company’s research and using it as your own
  • Proprietary blend — don’t keep secrets. Tell us what’s in it
  • Self-published
  • Used for marketing
  • “Organic”
  • “Natural”
  • “Guaranteed”

I put those last 3 in quotes because we see those used freely and there are no regulatory methods for them. While those words sounds straightforward, they can be very misleading.

On the other hand, I don’t want you to be scared by big words. Dihydrogenmonoxide sounds scary right? But you need this every day. 65% of you is made of this. What is it? WATER!

So don’t worry about big words on your supplements. But work to identify them and make sure they’re valid and proven for your pet.

So why should we use a supplement? I think of it in “big picture” terms. We can potentially reduce or eliminate the need for medications with supplements. We want to use it as part of a whole body approach. This can include acupuncture, rehabilitation, surgery, exercise, diet (a well-balanced, appropriate feed with the CORRECT amount of calories), and use it with medications as well. We do need to use it SAFELY though. Over 22,000 trips to human emergency rooms occur EACH YEAR due to issues with supplements. So remember, you can have too much of a “good thing”.

Supplements for Joint Health

If we do that we need to understand what a healthy joint looks like and an arthritic joint as comparison. The picture on the left is what we want. It’s what we are born with. The one on the right is what can happen. It is what we are trying to avoid. Or at least DECREASE those changes if they have already occurred.

joint

Compounds for joint health:

  • Glucosamine hydrochloride
  • Chondroitin sulfate
  • Avocado/soybean unsaponifiables (ASU)
  • Long chain Omega-3 fatty acids
  • Methylsulfonylmethane (MSM)
  • Egg Shell Membrane
  • Hyaluronic Acid
  • Green lipped mussels
  • Boswellia serrata extract
  • Curcumin extract
  • Vitamin D3
  • Pilose Antler Peptide
  • Cetyl-myrestolate
  • Hyperimmune milk factor (HIMF)

And this is just the short list!

Glucosamine

This is an amino sugar found naturally in the body. It is a building block for the cartilage matrix. It stimulates cartilage cells positively. It is readily available and relatively cheap in the marketplace. Even though it sounds like glucose, it is NOT a factor in diabetic pets. There are studies (EVIDENCE) that show the sulfate form may be absorbed better than the hydrochloride. Perhaps because the hydrochloride is found in the joint. We do need a loading dose, which is 2x maintenance for 4-6 weeks to build up levels in the joints. What is maintenance? For a 75-pound (34kg) dog it’s 500mg/day.

Many dog foods on the market will supplement with glucosamine. This needs to be carefully looked at. If the average 34kg Labrador Retriever eats 1400kcal/day and the food is 4.0 kcal/gram, then they eat 350 grams of food per day. Well if that food has 475ppm (parts per million) of glucosamine that equals 475mg per kg of food. That same food may have 250ppm chondroitin sulfate (foreshadowing!) that equals 250 mg/kg of food.

Our Labrador Retriever is only eating 350grams (1/3 kg). So, it’s only getting 160mg of glucosamine and 85 mg of chondroitin. It SHOULD be getting 1000mg of each for 4-6 weeks and then 500mg daily. So we still need to supplement. We also don’t know if it is absorbed the same when it is built into the food. So check your inclusion rates and do some math. Do not just trust the bag. It may contain glucosamine but not nearly enough to be a benefit.

Chondroitin Sulfate

Up next is chondroitin sulfate. It is also naturally occurring in the body. It helps to form the matrix that cartilage forms to support joints. Chondroitin inhibits cartilage-destroying enzymes. It can be difficult to get a reliable source and extract into an edible form. Therefore it will cost more than glucosamine. Again, we need a loading dose. Both glucosamine and chondroitin are inherently safe. Some dogs that eat too much of it can get mild gastrointestinal (GI) reaction (vomiting, diarrhea). If this happens, you should stop the supplement and immediately consult your veterinarian.

There is good evidence that glucosamine and chondroitin work together. In fact, the two have a synergistic effect. That means that 1+1>2 in this case. They have been shown to lessen inflammation and lameness when given BEFORE a joint injury. Remember that these are chondroprotectants. That means they will PROTECT cartilage from damage. They can still help cartilage after an injury but work more effectively as a pre-emptive agent. They help to maintain healthy cartilage metabolism.

Now to talk about a claim with regards to these products. I was recently on a checkout line at a pet store (Yes, I go to pet stores—I have fish.) and saw a box of dog treats that said “contains glucosamine”. Having a minute as I waited, I flipped the box over and started to do the math. Calculating how much was in each treat and how many treats they would need to reach MAINTENANCE levels per day. Our 75 pound Labrador Retriever would have to eat TWO BOXES of treats PER DAY to get the 500mg glucosamine it would need for its joints. Not only is that not financially smart, it is BAD due to the amount of calories that dog would be eating. Obesity and joint health is a whole topic for another day. So be smart in the stores and READ.

Avocado and Soybean Unsaponifiables

Moving on to our next joint supplement: Avocado and Soybean Unsaponifiables. Let’s keep this simple and just refer to them as ASU. The ASUs are extracted out of the oils of the plants. These extracts have been shown to inhibit inflammation in the joint. They also complement the effects of glucosamine and chondroitin (1+1+1>3). Adding ASU decreases the amount of chondroitin needed which saves money in the long run for the consumer.

ASU supports cartilage matrix production and helps protect against cartilage damage. The safety has been widely demonstrated and there are even studies that show Dasuquin (made by Nutramax), which contains all 3 products, may be SIMILAR to the effect of non steroidal anti-inflammatory drugs (NSAID) in dogs for joint problems.

Omega-3 Fatty Acids

Next up, let’s look at the long chain Omega-3 fatty acids. Get ready for more big words.

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These are found in oil from wild caught COLD water fish (anchovies, sardines, salmon). The farm raised has low levels of omega-3 and high levels of omega-6.

Omega-3’s have been shown to support heart health, joint health, skin and coats, the nervous system, the kidneys, and the immune system. GREAT! What’s the catch, you ask? They work in all those different systems at DIFFERENT DOSES.

Let’s look at some evidence for them. Studies in dogs with arthritis fed a diet with high levels of EPA and DHA had improved weight bearing on a force plate. They also had subjective reports from owners with regards to being able to walk and play more. Omega-3’s can be used in the diet or as a supplement. They are safe and well tolerated. However, like anything in life, we can have too much of a good thing. When we reach 500mg/kg/day we can run the risk platelet dysfunction. And before you ask: NO. Flax oil or coconut oil will not provide the same effects. In fact coconut oil has been shown to decrease the dog’s ability to SMELL. So for you working dogs out there lay off the coconuts.

It’s been a bit so let’s do some math again. (I know. You love it as much as I do.) Let’s use some round numbers to make it easier. A 100-pound (50kg) dog has arthritis. For arthritis we know that dogs need 80-120 mg/kg/day of Omega-3’s. Let’s go with the median dosage and use 100mg/kg/day which means our 50kg dog will need 5000 mg/day. (100×50). That equals 3 pumps of Welactin twice a day. 3 cups of Hill’s J/D twice a day or up to TWENTY-FIVE omega-3 capsules TWICE a day. So, be careful with those over the counter gel caps. Are you really saving money? And as we will learn later, not all supplements have in them what they say they do.

Methylsulfonylmethane

MSM or Methylsulfonylmethane is up next. This is a sulfur-containing compound found in small quantities in the body as well as fruits, veggies, and grains. It is a byproduct of the breakdown of DMSO (dimethylsulfoxide). DMSO for those of you who haven’t had the pleasure, smells like onions and garlic. It can be used in horses and dogs for neurological conditions and people for interstitial cystitis. (And before you ask, yes that means if your urinary bladder is inflamed we can make your pee smell like onions. Isn’t medicine great?)

Thankfully, MSM doesn’t have that special trait. There’s good evidence with two studies in humans with knee arthritis that MSMs helps them. There’s no published research in dogs yet. So this means we aren’t sure on the dosage needed. But the safety in dogs has been shown. And like other supplements, we can have a bit of GI issues in some cases. But otherwise, no reported problems.

Eggshell Membrane

Moving on, we have eggshell membrane. (Anybody else getting hungry with all these supplements coming from food?) This is a new supplement. It’s been shown to be of benefit to people. I’m contributing to research on it for dogs. A water soluble, (hydrolyzed) powder of the eggshell has been shown to contain elastin, collage, desmosine, and isodesmosine. And yes, we are talking about the thin tissue paper like layer on the inside of the hard eggshell. It also contains glucosamine and chondroitin. So, if we can prove it beneficial in dogs, this could become another available supplement.

Hyaluronic Acid

Hyaluronic acid is our next joint supplement. It is naturally found in the body as a component of joint fluid. It can be given in the joint or in the vein in horses and dogs. It is given in the joint directly in people. There are some thoughts that it can be orally administered but the one case report in German Shepherds shows that it had benefit, but those dogs were also on other joint supplements. Therefore we are not sure about it for oral routes at this time. However, it is one of my preferred therapies for injecting directly into problem joints.

Green-lipped Mussels

OK, back to food. Green-lipped mussels. These are a New Zealand shellfish. They are also known as Perna canaliculus. There are studies in dogs that suggest benefits, but the results are not consistent. They may contain Vitamins C and E, minerals, Omega-3’s, and even chondroitin. So, we are not sure how they help. More research is needed.

Boswellia serrata Extract

Boswellia serrata extract. You may also know this as frankincense. The bark of a tree found in India. It is a mix of boswellia acids that have an anti-inflammatory effect. The benefits have been seen in human arthritis patients. A study in dogs showed improved clinical signs with problems such as lameness, pain, stiff gaits. Is it good enough as a stand-alone therapy? No. But it can help.

Vitamin D3

Vitamin D3 is next. We know this helps support good bone health. Strong bones helps support good joints. Vitamin D3 also modulates the oxidative stress that can occur in the body. It also helps in immune responses (another subject of supplements later in this class). Finally, Vitamin D3 contributes to cell differentiation. So it helps to assign cells to be workers in different arenas. Definitely helpful, but a well-balanced dog food should have this already. A little extract can help but we want to avoid toxicity.

Curcumin Extract

OK, back to food. (Can you tell what drives me?) Curcumin extract. This is the active part of turmeric. We know turmeric from good cooking. The extract has antioxidant and anti-inflammatory effects. One study in dogs showed improvement in clinical scores. The standard extracts are not well absorbed by dogs, but particular ones are. And before you go “wait, I can just flavor my dog food with turmeric” don’t bother, it will not work. Dogs can’t process pure turmeric.

Pilose Antler Peptide

Let’s talk about some antlers. The velvet parts of elk or deer antlers specifically. This is a Traditional Chinese Veterinary Medicine (TCVM) modality. It is from the antlers in a fast growing stage when the antler is CARTILAGE. We can use farmed deer or elk, but we have to consider the ethics of collecting this. What is the active ingredient you ask? Good question. It is pilose antler peptide which is a good source of chondroitin sulfate, minerals, amino acids, collagen, and Omega-3 and Omega-6’s.

Is there any evidence? Another good question. In dogs some gait parameters and owner assessments were good. The same dogs graded by veterinarians at the same time did not show any improvement. We have potential safety concerns with this too. Antlers can be chewed down and get stuck in the mouth, throat, or the GI tract. Use with caution and always under adult supervision.

Two more joint supplements and then we’ll move on to muscle supplements.

Cetyl-myrestolate

Cetyl-myrestolate is a fatty acid found in Swiss albino mice. The mechanism of action is decreasing inflammation and joint lubrication. However there are NO STUDIES in dogs and we do not know how or why this MIGHT work.

Hyperimmune Milk Factor

 We will end with (shocking) another food product. Hyperimmune milk factor is a natural component of milk. We can use it to manage inflammation. The cows that are immunized with intestinal bacterial agents grow the factor for us. The high molecular weight IgG and low molecular weight anti-inflammatory components aid in reducing inflammation by blocking the entry of neutrophil attachment to the endothelial wall of cells. The concentrated version of this factor is called MicroLactin and it is the active ingredient in Duralactin.

A study of 8000 people with arthritis was done and 80% reported considerable improvement in joint pain and 72% reported less stiffness in the morning. There are also studies in dogs that pet owners felt the dog moved better. These are subjective and more studies are needed but it remains a promising product.

Well, can’t I just give my dog milk? Nope. This is a milk factor from specifically stimulated cows. On top of that, dogs lose the ability to digest lactose from a very young age. So, unless you want a lot of diarrhea and other GI issues for your dog, do not give it milk. Same goes for our feline friends.

Nutritional Supplements for Muscle Recovery

Moving on to nutritional supplements for muscle recovery and strengthening. While these are very popular for people we need to be very critical of them in dogs. Many of the muscle supplements will contain creatine, whey protein isolate, or specific amino acids; they can also contain chromium, dimethylglycine, or lecithin. Let us look at these individually.

Creatine

 Creatine is an amino acid derivative in the body. It is found in skeletal muscle, heart, brain, and other organs. It is made via the anaerobic formation of ATP (Adenosine Triphosphate). Human studies show it may help performance and strength in repeated bouts of MAXIMAL exercise of short duration (<30 seconds): weight lifting, sprinting, cycling, etc. There are no studies in dogs at all. The biggest side effect is weight gain. This would not be helpful for dogs with arthritis. It would be borderline helpful in dogs trying to become pulling and working dogs to build muscle. I think there are better ways to do this (like rehab and conditioning and a proper diet plan).

Whey Protein Isolate

Whey protein isolate (Yep, curds and whey, just like in the nursery rhyme). This is made from milk. In human studies that looked at resistance training they had mixed results for muscle recovery, muscle mass, and strength. Again, we have no doses in dogs and, as I’ve mentioned earlier, we can’t just offer them milk.

Chromium

Chromium is an essential trace mineral found in many foods: meat, cheese, whole grain foods, fresh fruits, fresh veggies, and brewer’s yeast. It is needed for fat and carbohydrate metabolism. It can be helpful for people with diabetes but is not of benefit to diabetic dogs. The supplement is promoted for building muscle. There is absolutely no research that proves this claim in dogs or people.

Dimethylglycine

Dimethylglycine is an antioxidant that naturally occurs in the body, in cereal grains, and beans. It is marketed to support performance by decreasing lactic acid build up. Once again, we have absolutely NO research to back this up. There is conflicting research that it MAY support immune function.

Lecithin

Lecithin is a fat in the body that is also found in egg yolks and soybeans. It’s an emulsifying agent, which is a substance that helps an emulsion become more stable. An emulsion is usually a mixture of two products such as oil and water that do not mix together or that are also referred to as immiscible. An emulsifying agent is added to an emulsion to prevent the coalescence of the globules of the dispersed phase. Lecithin may support the gut barrier and it is marketed to support athletic performance, but yet again, there’s absolutely no data to support this.

We haven’t talked about food in a while so let’s talk about supplements for the GI system.

Nutritional Supplements for the GI and Immune Support

We’ll first take review probiotics for GI and immune support, then review a variety of options for immune support specifically. Some I’ve listed earlier and some are new. New to the list are bovine colostrum, Vitamin A and C, L-glutamine, Echinacea, Reishi mushroom, Maitake mushroom, Astragalus membranaceus, Thymus (sweetbread) Coenzyme Q10, Zinc (which can be toxic in dogs), glutathione, and sulforaphane glucosinolate (broccoli). These may act as antioxidants or support the body’s own production of them. They may reduce inflammation and they may directly affect immune cells.

Probiotics

These are beneficial bacteria used to help reestablish the normal GI microflora. They may be useful for stress diarrhea. The studies done in various brands have shown benefit in reducing the severity of diarrhea. More is BETTER in this case. We want multiple strains and high bacterial counts in our supplements. Much of the body’s immune tissue is in the GI, so it may also support the immune system.

Bovine colostrum

Moving on to immune support, we have bovine colostrum. Yep, this is the third time we’ll talk about cow’s milk today. Colostrum is the “first milk” full of antibodies, growth factors, and hormones. Some research in humans has shown it can support the immune system of people when they are stressed by high intensity or prolonged exercise. Research has also looked at effects on performance in people – these have been contradictory. In dogs: no research.

Echinacea

Echinacea is a perennial herb used for centuries. It is potentially helpful for stimulating the immune system to fight off infections. You do need to take it early in the course of the disease if you are feeling sick in order to have any effect. In veterinary medicine, it is a short-term aid and not for chronic use. It is suggested in literature that chronic use creates tolerance.

Maitake mushrooms

Maitake mushrooms can be fractioned into a polysaccharide called D-fraction. This may have immune modulating effects. One study for lymphoma, a cancer of the lymph glands, in dogs, showed that when given ALONE it had no effect. I am not a big fan of this study because we have so many proven good options to help with cancer treatment. Maitake mushrooms can be used for general immune function support. It is commonly used in TCVM, Traditional Chinese Veterinary Medicine.

Astaxanthin

Astaxanthin (pronounced as-ta-zan-thin) is a potent xanthophyll carotenoid antioxidant. Here are big words again. It is not converted to Vitamin A in the body. Astaxanthin is found in microalgae, yeast, salmon, trout, krill, shrimp, crayfish, crustaceans, and the feathers of some birds. It provides the red color of salmon meat and the red color of cooked shellfish. It is used for enhanced immune response in dogs.

Chinese Herbs

A brief side note here for Chinese Herbs: I use them in my practice, but use only one specific company, Jing Tang Herbal, because they verify their source material and their compounds afterwards. Many herbs will have different combinations of mushrooms, antler, and other compounds in them. A trained professional is needed to advise in this area for your pet.

Conclusion

Well that is a lot of options right? How do we implement a plan? We need to look at the breed, job, goals, and medical record of each individual canine athlete. From there, we can identify certain risks and where certain supplements may be of benefit. Remember, many of these take time to have an effect and are not a quick fix. In fact, they work better as preventatives and therefore they will need to be on them consistently (read: DAILY) for weeks to months to have a benefit for your pet.

Another important fact is that the manufacturers are NOT held to the same standard as pharmaceuticals. We therefore have to question the accuracy of information on the label, and the purity and source of the material used. Are they free from contaminants? Do we have any PROOF or do we have CLAIMS?

Let’s look at an example from the human literature. There was a study published in the Journal of the American Neutraceutical Association in 2000. It looked at the correlation between price and % label claim of chondroitin sulfate in 32 products.

supplement-graph

We can see that separate from the price per DAY for a maintenance dose of 1200mg that only SIX of the 32 had at least 90% of what they claimed to have as far as chondroitin sulfate. This report did not look at the source or the efficacy of the product, but merely if there was chondroitin IN THE PRODUCT.

Yikes, so what should you do?

Ask your veterinarian. They are the best source of information for pets. After that, trusted colleagues in the field of canine health, like Dr. Deb Gross, is a valuable asset. My general rules are to avoid products only backed by testimonials. I also recommend you contact the companies and ask for their research papers. You should also require that what’s on the label is actually in the product. Also, do a background search on the reputation of the manufacturer. You don’t always get what you pay for, and it’s easy to be taken advantage of. In the chondroitin study above, all the very costly supplements FAILED to reach 90% of their claim.

You may want to know what I use for my dogs?

Penny is my 2-year-old pit bull. She is my running partner (already has done a half marathon) and is working on agility and mountain climbing. She’s on Hills’ Science Diet Healthy Mobility and Dasuquin Advanced.

Adelaide is my 14-month-old Newfoundland. She has mild hip dysplasia and had surgery for OCD lesions in each shoulder. She is on Hill’s Prescription Diet J/D and Dasuquin Advanced. When she was growing (under a year of age), I fed her Hill’s Science Diet Large Breed Puppy.

I hope that you have found this helpful. There is a lot of information out there and it is important to take time and review your options. Again, remember to consult with your veterinarian about specific needs for your dog. If you have questions, please leave them as comments so that everyone can see them.

Skeeter’s Vomiting

This story refers back to a previous post “Quality over Quantity”. In that story, my own dog, Skeeter, was going through chemotherapy for stage 3 hemangiosarcoma. You can read the full post here: https://drbrunke.wordpress.com/2015/10/27/quality-over-quantity/

During the chemotherapy she developed a slight cough and began having intermittent vomiting. Prior to starting chemo, we had established (via x-rays and ultrasound) that there was no cancer in her lungs, stomach, or the rest of her GI tract.

In some cases, coughing can be associated with cancer that spreads into the lung known as a lung metastases. Metastases will be solid and not allow air to move in that part of the lung .In some cases vomiting can be associated with different types of chemotherapy. However, in Skeeter’s case this wasn’t true. We took special precautions around the one drug in her regiment that could possibly cause vomiting and she never vomited during that medication. This would be random vomiting weeks after that drug was given.

Disclosure: During this time I was not completely objective. As a veterinarian, I wanted to know what was causing the problems. As a caregiver, I didn’t. I wanted to ignore it because I didn’t want to have to face the possibility that this was a possible sign that her cancer was spreading elsewhere.

During her follow-up ultrasound exams (looking at the cancer in her liver as it shrunk from chemo) we did not see any problems with her stomach. This was an appeasement to myself, I had looked (a bit) and that sufficed for now.

One Friday, while working at the emergency room, Skeeter’s coughing got worse. At that point, I took x-rays of her chest. I stared over them and peered from different angles trying to find a reason for her cough. I didn’t see anything obviously wrong with her lungs or heart.

I’m lucky to have great friends. My classmates and I keep in touch via smart phone and social media. We all bounce cases off of each other looking for ideas and insights to problems that baffle us. I sent out photos of Skeeter’s x-rays to the group and asked for opinions.

Amy wrote back a moment later, “Yeah, lungs look ok, but what’s that in her stomach?” Then, two other classmates chimed in and said the same thing. I took another look. Just at the edge of the x-rays was part of Skeeter’s stomach. And sure enough it looked like something was in there. (She had not eaten yet that morning) I took another set of x-rays, focusing on her abdomen. And sure enough it looked like there was a foreign object in her stomach.

I sent all the radiographs to another friend for verification. Sean, a boarded veterinary radiologist, took a closer look as I needed to be as close to 100% sure that this was an actual problem in her stomach. Being on chemotherapy and therefore suppressing her immune system did not make her a fantastic candidate for surgery and anesthesia.

Sean wrote back saying that he didn’t know what it was exactly, but it definitely did not belong there. I explained to him her current condition but his thoughts didn’t change: Whatever it was, it needed to come out.

I had two options here: The first was that I could get Skeeter to a specialist to try and remove this via endoscopy. This is where they put the animal under anesthesia and pass a scope down their esophagus with a mini-grappling hook to grab the object and pull them back out. This is called minimally invasive since it doesn’t require surgery and having to heal from an incision. In some cases it is very successful. Sometimes it does not work (object too big, can’t latch on, etc.).

Since it was a Friday, I would have to drive to Cornell for this procedure, unless I wanted to wait until Monday. At the time there was no weekend option for endoscopy in our region.

The second choice was to go in surgically myself and check it out. Anesthesia is a minimal risk for both cases. The hesitation I had was being wrong and not actually having an object to remove as well as having Skeeter need to heal from two incisions: one in her stomach, the other her abdominal wall.

Second disclaimer: Skeeter had never been a chewer and never really played with toys. So, there wasn’t anything that I knew of that could cause the obstruction. This fact contributed to my hesitation. But there was definitely something there. I just didn’t know what it was.

Ultimately, with support from Sean, Amy, and others, I went forward with surgery that afternoon. Skeeter did great through anesthesia and I found a small “U” shaped piece of flexible rubber in her stomach.

She recovered very well and didn’t have any further vomiting, coughing (likely the rubber getting stuck in her esophagus) or other problems during her chemotherapy.

I have no idea where the piece of rubber came from, or why she chose to eat it.

It can be daunting to face your fears. I was scared of what I would find with Skeeter’s vomiting and coughing. Facing my fear and finding the support of good friends helped me get through a difficult time and I am lucky that it had a good outcome.

Cage’s Rehab: Strength

With Cage now somewhat comfortable and showing improvement with rehab, we could really start things moving. In doing that, I had to anticipate that Cage WOULD get better. That meant putting some things in place so that WHEN he was walking his body would be at its best.

The first thing I added to his regiment was a Chinese herbal compound called Double PII. This is a blend of herbs that promotes spinal cord healing and therefore better “messaging” from his thoughts to his actions. Herbal compounds can take 2-6 weeks to see improvement, so we started those once he was comfortable.

Two weeks into his rehab, Cage didn’t have sore muscles but his elbows were very uncomfortable. Remember that he had severe arthritis in both elbows for a few years now. And with 4 weeks of him putting most of his weight on his front legs, the elbows were causing him a lot of discomfort. We focused therapy with TENS and therapy laser to the elbows for short-term relief.

I also started him on Adequan injections. This is a substance that has anti-inflammatory properties and also helps prevent the cartilage from wearing down. With intact cartilage, we avoid bone on bone contact which is extremely painful. The injections can have both short and long term positive effects on the joints. They are injected into the muscle so they help ALL of his joints (remember he had knee surgery and has arthritis there as well).

With these two mechanisms in place, we had a steady routine with Cage. Each day he got acupuncture, heat, massage, range of motion exercises, electrical stimulation and therapy laser treatments.

Each day we helped him to stand so that he could relieve himself (sometimes we had to stimulate him but he progressively was able to go on his own if we were patient with him). Each day he was with us he got to float in the underwater treadmill. Here the buoyancy of the water allowed him to feel like he weighed 45 pounds instead of 70.

Some days he showed progress. Some days he didn’t. What was important was that he didn’t show any regression. Neurological rehab takes time. Nerves heal at about a MILLIMETER per DAY. That means an inch of nerve can take up to 254 days to heal, that’s over 8 months. This is why it is important to be patient with these patients.

While we were doing things to promote better nerve conduction (acupuncture, TENS) and increased sensory input (having him standing, using his legs, letting him urinate on his own), we also worked on him having muscle to be there once the message came from the nerve. So, each day, he got electrical stim pads applied to his hind legs and spinal muscle groups. The goal here was to minimize the atrophy that was occurring. Electrical stim won’t replace the body’s natural muscle tone or strength but it can be used to contract muscle and can minimize atrophy. If we don’t do these things, then even if the message gets from his brain to his legs to move there isn’t any muscle to do the actual work.

Even with keeping up with food and trying to minimize atrophy, Cage dropped another 6 pounds in the first 4 weeks he was with us.

Initially, any physical activity was exhausting for Cage. Even with our support and the buoyancy of the water, he still had to move against gravity. With each week, he made noticeable progress. Some weeks were tougher than others because sometimes he was mentally checked out. We built in rest days for him to recover. Mostly these were at home with family. Occasionally, we asked him to do less physically when in our facility because of the time spent being active with his family.

For the first few weeks in the underwater treadmill, I would be in there with him moving his legs for him. As he got stronger, I would be in there just to act as a bumper and keep him from sliding back on the treadmill. He eventually got wise to this and stopped putting in effort. Then, I took myself out of the treadmill and we worked with him on a harness to keep him walking. Our results were mixed some days. He was not a food motivated or praise motivated dog. In talking with his family, they mentioned one particular toy he was fond of. I asked them to bring that to his next session. It was a tennis ball “dumbbell” with a built in squeaker. Here is a picture.

dumbbell

 

This really changed everything. Now comfortable and moving, Cage WANTED that toy. We could use this to motivate him to play tug-of-war or to get him to fetch it in the treadmill. This proverbial “carrot on a stick” is what clicked for him. Sometimes it’s really the simple things that make us happiest.

When Cage first arrived, he could barely walk and needed a break in the underwater treadmill after 5 minutes. A month into rehab and he could walk for 30 minutes at a time. The water’s buoyancy helped him greatly. On dry land, he was limited but walking. What we saw was progress, motivation and strength.

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Cage’s Rehab: Part One

Being a paralyzed dog is hard. Being that dog’s parents can be just as challenging. It’s scary, there are a lot of unknowns and it can get expensive quickly. I don’t deny any of these. From a patient’s perspective they can get frustrated very quickly. Imagine if 99% of what you did today you couldn’t do tomorrow.

Think how you would feel in the pet’s position: To be dependent on others to sit you up, feed you, clean you; To not have the independence to stand up and walk, or to simply sit up. This is why we my team and I look to achieve a comfortable and stable atmosphere for the patient through empathy. We are objective and analytical throughout our treatment, this guides us as we make small, incremental steps in the right direction or re-assess when and where progress slows and stalls.

I met Cage on July 1st, 2015. On my initial physical exam, aside form his neurological deficits and elbow arthritis he had muscle soreness of his shoulders, front legs, neck and back muscles. This is common in paralyzed dogs because they are using tremendous amounts of effort to get themselves up and drag their hind end.

After discussing options and prognosis with the owners, they elected to take him home that night and return the next day to begin rehab. After initial evaluations I break rehabilitation down into three segments:

1) Pain Management – Reducing the pain load on the patient

2) Strength Building – Working muscles to regain motor control and coordination

3) Maintenance – Sustaining gains after treatment

 

It is the third part that incorporates proper nutrition and regular exercise as ways to protect the body or minimize progression of diseases. A commitment is needed to maintain the hard earned gains from treatment. I also ask for a commitment to get through the first two phases, no matter how dark and dismal they may seem. My patients (and clients) require patience.

Cage had an excellent neurosurgical team in Boston. They worked hard to do mechanical aspects and provide multimodal pain management. Cage had taken meloxicam (an NSAID) for his arthritis for years along with amantadine to provide pain relief. After surgery, they added in gabapentin and tramadol to alleviate the post-surgical pain and the pain from his compressed disc and subsequent infection.

I started acupuncture on Cage the first day. Acupuncture helps to release the body’s natural endorphins (what morphine is made from essentially). This, in conjunction with TENS (transcutaneous electric nerve stimulation), would help alleviate the pain in his muscles. He also received daily treatments with our therapy laser. This would target sore muscles and help release cytokines to promote muscle healing and an anti-inflammatory action. After a few days, Cage was more comfortable. His muscles didn’t jerk and spasm in his neck and shoulders.

Each day he was with us, Cage received hot packs applied to his sore muscles to warm them up. Then he was stretched out, massaged gently and all of his joints were put through cycles of normal range of motion. When a body is not weight bearing muscles atrophy quickly. If normal pressure isn’t applied to our joints, they can become stiff from inactivity.

After being warmed up, Cage was placed in either the underwater treadmill or our overhead hoist. This allowed him to stand in a normal position and see the world. It also gave his body feedback (the joints, nerves and muscles all need gravity input to function normally). He would then have electrical stimulation applied to his rear legs to “teach” his muscles how to contract again. After that, he would rest lying down with ice packs on his muscles and joints. A week later, I was able to discontinue tramadol, one of the pain medications he was on.

Each day, we were expressing his bladder and bowels 3-4 times a day. We needed to teach those nerves and muscles to do their job just like the rest of his body. On July 10th, I noticed that his urine had a foul odor to it. A test showed that he had developed a urinary tract infection. These can occur in paralyzed dogs because they are not always emptying their bladder fully. We cultured it hoping that we could just increase the antibiotic he was on for the spinal cord infection, or at least get both infections with one antibiotic. This wasn’t the case as his particular infection was resistant to many drugs. We added in another oral antibiotic to his regiment and carried on.

After the first two weeks, Cage showed improvement. In the underwater treadmill he could pull his rear limbs forward. When suspended on the overhead hoist he could stand and pull himself forward. When I placed acupuncture needles at different points, I saw progress in how the messages were being conducted along his nerves.

During this time, he became very attached to me. He would follow me around the room with his eyes and would take his pills or eat for me when he wouldn’t do it for others. I was a little worried about this but was also glad to have him engaging and participating. After daily updates and then a reassessment after 3 weeks, I recommended we continue with rehab. His parents agreed. They saw he was more comfortable. Our goal now would be to make him stronger.

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