Integrative Pain Management

For optimal results, both conventional and complementary therapies should be utilized along with close attention to weight management, exercise, diet and supplements.

by Rob Butler DVM, CVA, CVCH, CVFT

When dealing with chronic pain, integrative pain management takes advantage of all the tools a veterinarian may have available. These encompass both conventional and alternative/complementary therapies to keep patients comfortable while improving or maintaining mobility and health. It is unlikely that a single modality, pharmaceutical or supplement can achieve this optimal state of comfort and health on its own.

For integrative pain management to be most successful, each patient must be assessed individually based on his environment, lifestyle, level of fitness and health so that an appropriate treatment plan may be implemented. As veterinarians, I believe we do ourselves, as well as our clients and patients, a disservice if we fail to take the time to fully address each of these areas in order to formulate the best options for every individual animal. For many of us, this will be best accomplished by scheduling an appropriate time for a complete pain management assessment and consultation.

Three Key Factors

When dealing with chronic pain, most conventional as well as alternative focused practitioners will likely agree on the importance of the following:

1. The need to achieve or maintain ideal body weight and condition.

2. Appropriate activity levels to keep joints and tissues mobile and maintain suitable muscle mass.

3. A properly balanced diet that includes supplements to promote lean body weight while providing a source of high quality protein, antioxidants, a therapeutic level of Omega 3 fatty acids, and glycosaminoglycans.

Without an emphasis on the above three factors, optimal results are unlikely with additional treatment strategies. For obese pets, weight reduction may have the most significant effect on chronic pain by reducing the level of systemic inflammatory mediators and reducing the load on individual joints and associated tissues. I believe, therefore, that an integrative approach to managing chronic pain must start with weight control along with specific dietary recommendations and a plan for an appropriate level of activity.

Comfort and Mobility

An integrative pain management program should also assess the best and safest options available to maintain comfort and mobility.

I believe that non-steroidal anti-inflammatory drugs (NSAIDs) have too often been relied on as the primary means of managing chronic pain. I have personally seen several cases in which the use of NSAIDs by themselves has had either poor or sub-optimal results. I have also seen owners who have been given overly high expectations for the use of a single nutritional supplement as the primary means of keeping their pets comfortable. We need to be realistic in setting expectations for our clients, with the likely reality that most patients will require a combination of therapies for the best success long term.

10 recommendations for improving owner compliance and clinical results

1. Start with a clear explanation of what will likely be required, including the importance of diet, exercise and appropriate supplementation.

2. Provide some immediate pain relief so owners can see their pets’ ability to respond to therapy. This also allows patients to become more mobile so that appropriate activity can be maintained. Immediate pain relief may include acupuncture, laser therapy, initial short term use of NSAIDs, or any combination of these or other therapies.

3. Herbal and homeopathic therapies can be individually tailored to each patient’s needs where appropriate.

4. Pharmaceutical drugs have a valuable role to play when used appropriately. NSAIDs should be used for the shortest required duration, or when necessary, maintained at the lowest dose needed. At least twice-yearly blood screening, particularly for kidney and liver function, should be done for animals on long term NSAIDs. Narcotic and other adjunct pharmaceuticals such as Tramadol and Gabapentin can help improve overall response and reduce the required dose of NSAIDs.

6. Acupuncture can provide significant benefits and may be coupled with laser therapy for an even greater overall effect in some patients.

7. Chiropractic therapy can significantly improve mobility and help manage pain in many patients.

8. Biotherapeutic homeopathic drugs such as Traumeel® and Zeel® have good scientific evidence to support their use in veterinary patients. Some patients may respond as well to these as to conventional NSAIDs – at times even better – particularly when they’re administered by injections, IV, SQ, IM or into specific acupuncture points.

9. Injectable disease modifying drugs such as Adequan® or Cosequin® can provide additional long term benefits and reduce the need for NSAIDs or other pharmaceuticals. 10 The importance of daily activity/exercise cannot be overemphasized. For patients with more pronounced mobility issues, muscle wasting or neurologic deficits, rehabilitative therapies such as underwater treadmill, supported swimming, massage therapy or Chinese Tui-na should be recommended.

CASE STUDY: Django

Django was an 11-year-old neutered male German shepherd with persistent proprioceptive deficits following surgery three years earlier for IVDD at T12-13 and L1-L2. On presentation, Django was having difficulty walking, seemed in pain when rising, and was less interested in going for walks. On occasion, he was also defecating in the house.

On physical examination, Django had decreased muscle mass in both hind limbs and was sensitive on palpation along the thoracic and lumbar spine, with a limited range of motion in both hips. He was currently at a suitable lean body weight.

Recent blood work including CBC and biochemical profile revealed no concerns. His owners declined X-rays due to his temperament and their concerns over sedation and costs. His current diet consisted of a commercial lamb and brown rice kibble to which the owners were adding kelp and herring oil along with the occasional raw food patty.

Django’s initial treatment plan included:

• A homemade diet, properly balanced and formulated to contain therapeutic levels of EPA as well as antioxidants, and the addition of a green lipped mussel supplement as a source of glycosaminoglycans and other anti-inflammatories.

• Twice weekly sessions of acupuncture coupled with Class 4 laser therapy. Acupuncture points were chosen primarily on the distal limbs, while the laser therapy concentrated on the thoracic and lumbar spinal region.

Django’s owners noticed significant improvement after the first treatment. He continued to improve over the course of six treatments with no further fecal accidents and at least 50% improvement in overall energy and activity levels.

Django continued to have periodic treatments over the next few months before presenting with some acute pain, including left hind end lameness and arched back. Further treatment included:

• Therapeutic laser for thoracic and lumbar spinal areas.

• Aquapuncture utilizing a combined homeopathic mixture of Traumeel® and Zeel® injected into local acupuncture points around the left stifle and hip.

• Meloxicam dosed at 0.1 mg/kg once daily for two to three weeks.

Django again improved significantly and after a couple treatments went back to maintenance laser therapy on a monthly basis.

The following spring, he started having some fecal incontinence again and also show increased signs of discomfort in his back end. Treatment included:

• Meloxicam dosed at 0.1mg/kg once daily

• Gabapentin 200mg twice daily

• Underwater treadmill and other rehab therapy performed every few weeks.

• Continued maintenance with laser therapy every few weeks.

Django did very well with this therapy for several months when he suddenly presented with very acute cervical and shoulder pain. Treatment this time included:

• Continuation of Meloxicam and Gabapentin.

• Combined acupuncture and laser therapy.

• TCM herbal formula designed for cervical neck pain.

Once again, Django had an excellent response and did well for a few more months before presenting with sudden marked tetraparesis, unwilling to walk on his own and uninterested in eating. Electro-acupuncture was performed along the thoracolumbar spine and hind legs, and a single IV injection of Traumeel® was administered. Following this treatment, Django got up on his own and was able to walk out of the clinic. He seemed remarkably better next day. This treatment was repeated the following day.

Django was maintained on Metacam®, Gabapentin, Traumeel® oral tablets, Cervical Formula and a Glucosamine, MSM and Chondroitin product until he was eventually euthanized a couple months later.

This case demonstrates the success of a multimodal, integrative pain management program that likely allowed this dog to remain mobile and comfortable for well over a year beyond what was otherwise possible.

Dr. Rob Butler DVM, CVA, CVCH, CVFT, is a 1988 graduate of the Ontario Veterinary College and a co-owner of the Guelph Animal Hospital in Guelp , Ontario. He is certified in Veterinary Acupuncture, Chinese Herbal Therapy and Food Therapy.