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Proceeding of the SEVC Southern European Veterinary Conference

Oct. 2-4, 2009, Barcelona, Spain

http://www.sevc.info

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October 1-3, 2010 - Barcelona, Spain

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COMPLEMENTARY AND EMERGINGPAIN MANAGEMENT TECHNIQUES

Sheilah A Robertson, BVMS (Hons), PhD, DACVA, DECVAA, MRCVSCollege of Veterinary Medicine University of Florida Gainesville, FL

Complementary therapies

In recent years, the popularity of more “holistic” or “natural” approaches to medicine for both humans andpets has increased. Complementary, alternative or integrative veterinary medicine is somewhat challengingto define but the American Veterinary Medical Association (AVMA) has coined the phrase Complementaryand Alternative Veterinary Medicine (CAVM)A and state that this approach to medicine includes, but is notlimited to, aromatherapy; Bach flower remedy therapy; energy therapy; low-energy photon therapy;magnetic field therapy; orthomolecular therapy; veterinary acupuncture, acutherapy, and acupressure;veterinary homeopathy; veterinary manual or manipulative therapy (similar to osteopathy, chiropractic, orphysical medicine and therapy); veterinary nutraceutical therapy; and veterinary phytotherapy. Some ofthese modalities were reviewed during the AVMA Welfare Symposium in 2001[1].

The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards andthat claims for safety and effectiveness ultimately should be proven by the scientific method. Some of thesetherapies have a strong scientific basis but the problem in veterinary medicine is the lack of well controlledlarge scale clinical trails. It is important that the veterinary community strive to add good scientific evidencebased medicine to the body of literature.

Acupuncture

This is the most ancient of the disciplines that we will discuss. Historically the legitimacy of acupuncture hasbeen questioned, due to a lack of well controlled scientific and clinical trials, but the tide has turned, and in1997 the office of alternative medicine based at the National Institutes of Health in the USA issued astatement declaring that there was sufficient evidence of the value of acupuncture to expand its use intoconventional medicine and encourage further studies. In December of 2004 the NIH published the followingstatement “acupuncture provides pain relief and improves function for people with arthritis and serves as aneffective complement to standard care”. There are many veterinarians pursuing formal training in thisdiscipline; the International Veterinary Acupuncture Society (IVAS)B has certified almost two thousandveterinarians and the Chi Institute of Traditional Chinese Veterinary MedicineC holds several comprehensivetraining sessions every year with certification through the China National Society of Traditional ChineseVeterinary Medicine.

Acupuncture is an ancient Chinese discipline that can be used for many ailments including pain relief. Itinvolves placing needles at specific points on the body and the cause of the resultant analgesia is complexbut involves the release of endogenous opioids, norepinephrine, oxytocin, ACTH and serotonin. It is welldocumented that opioid antagonists such as naloxone block acupuncture analgesia. A detailed discussion ofacupuncture is outside the scope of this paper but there are several excellent reviews [2, 3].

Most dogs and cats tolerate needle placement surprisingly well and acupuncture should be considered aviable choice for analgesic therapy especially for chronic conditions. Each patient is unique and is usuallytreated differently even if the underlying cause (for example osteoarthritis of the elbows) is the same.Methods of treatment in acupuncture involve assigning the animal to one of the five phases or elements(wood, fire, water, earth, and metal); this is rather like deciding on the animal’s personality, feeling theirpulses carefully and close examination of the tongue. Different types of acupuncture include dry needles,electro-acupuncture, aqua-acupuncture, moxibustion and low intensity laser therapy.

In a review of the animal specific acupuncture literature Habacher [4 ] stated that more well controlledstudies were required in this field but that there were enough promising results to support pursuingacupuncture as a viable treatment in veterinary patients.. Xie and Ortiz-Umpierre [5] have written a goodreview on what conditions acupuncture can and cannot be used for. Acupuncture was successful in reducingintraocular pressure in normal dogs [6] and may be a treatment option in dogs with glaucoma. In a smallstudy of dogs with elbow osteoarthritis [7] electroacupuncture was not shown to significantly improve theirperformance (compared to sham treatment) as measured by force plate testing, however eight out of nineowners correctly guessed when their dog had received acupuncture treatment. When acupuncture wascombined with “traditional” (steroids and tramadol) treatment of intervertebral disc disease in dogs the time

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required to walk was reduced and overall success improved [8], compared to “western” treatment alone.

Some animal that are painful will not eat and in my experience acupuncture has been effective for appetitestimulation. The classical or traditional point that is often used is called Shan-gen which is similar to GV-25(GV = Governing Vessel) which is on the midline of the boundary between the hair and non-haired part ofthe nose.

Rehabilitation medicine

Physical therapy is now commonly incorporated into many veterinary practices for acute post-surgicalpatients and those with chronic pain syndromes most commonly osteoarthritis. This is a rapidly expandingarea of veterinary medicine and several training opportunities exist. Most small animal rehabilitation coursesfocus on dogs but many of the principals can be applied to cats and despite what one may think, cats canactually do very well and will even tolerate underwater treadmill sessions. Outcome measures have beendescribed so that the efficacy of different therapies can be scientifically studied [9 ]. The application ofphysical therapy techniques have shown positive results following stifle surgery in dogs [10, 11]. The use oflasers and shock wave therapy is also increasing but much of this information remains anecdotal.

Stem cell therapies

Autologous adipose-derived stem cell therapy has been commercially available to veterinarians in the UnitedStates since 2003. Fat is harvested from the patient, stem and regenerative cells are isolated andadministering back to the patient either in specific locations [e.g. into a joint] or intravenously. There aretwo reports of stem cell therapy in dogs with severe osteoarthritis [12, 13] and both reported a favorableoutcome.

Nutritional approaches

Chondroprotectives and NutraceuticalsThe AVMA statement on CAVM reminds veterinarians that animal nutritional supplements and botanicalstypically are not subject to pre-marketing evaluation by the FDA for purity, safety, or efficacy and maycontain active pharmacologic agents or unknown substances. The mechanism of action of many of theproposed compounds is not known. No well controlled prospective clinical trial using this approach toalleviation of pain related to OA in animals has been published, however surveys show that nutraceuticalsare recommended by a lot of practitioners[14]. Chondroprotectants are available as oral nutraceuticals andas injectable (IM, IV or intra-articular) pharmaceuticals. Oral nutritional supplements have been advocatedfor treatment of chronic pain from osteoarthritis in companion animals although the benefits are stillsomewhat controversial. Hardie[15] suggests that Cosequin (Nutramax Laboratories) may have somebenefits in the treatment of osteoarthritic pain in cats. Some practitioners consider that nutraceuticals maybe the first choice of treatment in some dogs and cats with osteoarthritis but their safety and efficacy havenot yet been the subject of large scale controlled clinical trials.Combinations of chondroitin sulphate, glucosamine hydrochloride, and manganese ascorbate are being usedin animals with osteoarthritis and cancer as part of a multi-modal approach to pain relief, but again thereare no well documented studies. Polysulfated glycosaminoglycans can be given by intramuscular injection indogs and cats but are only licensed by the FDA for use in dogs (Adequan®, Novartis Animal Health). For anexcellent review of nutraceuticals and chondroprotective agents for OA in cats and dogs the reader isreferred to the article by Dr Brian Beale [16].

In this brief discussion we can conclude that there are effective alternative methods for treating pain inanimals and that they can be safe if used correctly. However a great deal of research needs to be done sothat these therapies can be compared with “Western” methods which are widely published in scientificjournals and have proven efficacy.

References1.Pascoe, P.J., Alternative methods for the control of pain. J Am Vet Med Assoc, 2002. 221(2): p. 222-9.2.Mittleman, E. and J.S. Gaynor, A brief overview of the analgesic and immunologic effects of acupuncture in domestic animals. JAm Vet Med Assoc, 2000. 217(8): p. 1201-5.3.Lee, A. and M.L. Done, The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis.Anesth Analg, 1999. 88(6): p. 1362-9.4.Habacher, G., M.H. Pittler, and E. Ernst, Effectiveness of acupuncture in veterinary medicine: systematic review. J Vet Intern Med,2006. 20(3): p. 480-8.5.Xie, H. and C. Ortiz-Umpierre, What acupuncture can and cannot treat. J Am Anim Hosp Assoc, 2006. 42(4): p. 244-8.6.Kim, M.S., K.M. Seo, and T.C. Nam, Effect of acupuncture on intraocular pressure in normal dogs. J Vet Med Sci, 2005. 67(12): p.1281-2.7.Kapatkin, A.S., et al., Effects of electrostimulated acupuncture on ground reaction forces and pain scores in dogs with chronicelbow joint arthritis. J Am Vet Med Assoc, 2006. 228(9): p. 1350-4.8.Hayashi, A.M., J.M. Matera, and A.C. Fonseca Pinto, Evaluation of electroacupuncture treatment for thoracolumbar intervertebral

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disk disease in dogs. J Am Vet Med Assoc, 2007. 231(6): p. 913-8.9.Hesbach, A.L., Techniques for objective outcome assessment. Clin Tech Small Anim Pract, 2007. 22(4): p. 146-54.10.Marsolais, G.S., G. Dvorak, and M.G. Conzemius, Effects of postoperative rehabilitation on limb function after cranial cruciateligament repair in dogs. J Am Vet Med Assoc, 2002. 220(9): p. 1325-30.11.Monk, M.L., C.A. Preston, and C.M. McGowan, Effects of early intensive postoperative physiotherapy on limb function after tibialplateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament. Am J Vet Res, 2006. 67(3): p. 529-36.12.Black, L.L., et al., Effect of intraarticular injection of autologous adipose-derived mesenchymal stem and regenerative cells onclinical signs of chronic osteoarthritis of the elbow joint in dogs. Vet Ther, 2008. 9(3): p. 192-200.13.Black, L.L., et al., Effect of adipose-derived mesenchymal stem and regenerative cells on lameness in dogs with chronicosteoarthritis of the coxofemoral joints: a randomized, double-blinded, multicenter, controlled trial. Vet Ther, 2007. 8(4): p.272-84.14.Anderson, M.A., M.R. Slater, and T.A. Hammad, Results of a survey of small-animal practitioners on the perceived clinical efficacyand safety of an oral nutraceutical. Prev Vet Med, 1999. 38(1): p. 65-73.15.Hardie, E.M., Management of osteoarthritis in cats. Vet Clin North Am Small Anim Pract, 1997. 27(4): p. 945-53.16.Beale, B.S., Use of nutraceuticals and chondroprotectants in osteoarthritic dogs and cats. Vet Clin North Am Small Anim Pract,2004. 34(1): p. 271-89, viii.A. http://www.avma.org/issues/policy/comp_alt_medicine.aspB. http://www.ivas.orgC. http://www.tcvm.com

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