So yeah, I'm gonna, talk about my approach to joint disease in the consultation room. So yeah, so the, the aims of the session, will be to generate a relevant capsule history. Implement a logical therapeutic strategy and assess the long-term efficacy, of our therapeutic strategy.
So as I said, osteoarthritis is probably the most common, joint disease diagnosed in UK pets. And it is defined as the apparent repair and eventual degradation of articular cartilage in association with alterations in subchondral bone metabolism, perarticular osteophytosis, and a variable degree of synovial effusion. So, in canine patients, osteoarthritis is typically, typically secondary.
So it's usually subsequent to joint instability that we may see with things like cranar crucial ligament disease like hip dysplasia, joint incongruence, which is commonly associated with elbow dysplasia, osteochondrosis, osteochondritis, desiccines, joint trauma, which you may see in some articular fractures, for instance, and obesity. So primary osteoarthritis in canine patients is actually quite uncommon, but we may see in older dogs, particularly around the metacarpal phalangeal joint region. So in UK first opinion practise, the prevalence of osteoarthritis has been estimated between 2.5 to 7%.
And it's been estimated to affect dogs for approximately 11% of their lifespan. I would probably think that that value is, probably quite underestimated. It's quite a, a difficult value to, to determine.
So I'd, I'd guess it is a lot higher than that, but that's what's out there in the literature. In the referral setting, in the UK, the prevalence of osteoarthritis is estimated to be on about 20%, and in North America, it's estimated to be 20% in dogs greater than 1 year, and, up to 80% in dogs greater than 80 years of age. So the reason these cases usually present to us, predominantly in in dogs is because they're lame.
They may be exercise intolerant, or reluctant to exercise. Owners will quite often report an activity stiffness, and they may report that the dogs can no longer jump in and out of the car, and we may see some behavioural changes such as, aggression. In cats, primary osteoarthritis, is probably more common.
Only 11% of cats that had radiographic evidence of osteoarthritis actually had a clear exciting cause. Cats also tend to present a lot later in the disease process. So 34% of cats greater than 6.5 years of age had radiographic evidence of osteoarthritis, and up to 90% of cats had radiographic evidence of osteoarthritis, that were older than 12 years of age.
But interestingly, only 33% of these cats with radiographic evidence of osteoarthritis actually had clinical signs attributed to OA. So this is probably because cats are able to cope with lower grade joint disease better than canine patients are. But I think it's probably also a fact that, as vets, we probably don't recognise osteoarthritis in cats as well as we do in dogs.
And I think dog owners are much more aware of osteoarthritis affecting their pets than maybe cat owners are. In cats, the most common location for osteoarthritis is the spine, and this is followed by the elbow, and the cox femoral joints. So hip dysplasia isn't uncommon in cats and it's probably the reason why they develop osteoarthritis in the hips.
Presenting signs for cats usually differs slightly to canine patients, so owners may report that there is a reluctance to jump or, or an inability to jump. They may also report that the cat's no longer able to jump on surfaces that they once were able to. Inactivity stiffness can be a presenting sign, or the owners may notice that the cats have a stiff gait.
Patients with oste arthritis may have difficulty grooming, so they may have, an uncant appearance. And you may find that the cats are starting to inappropriately use litter tray, which may sometimes wronger be attributed to kind of more, senile type changes, but it may be just due to the fact that the cats are unable to get into the litter tray because of the osteoarthritic disease. Lameness is probably a less common presenting sign for cats, and again, cats may also present with behavioural changes such as aggression.
So I guess in these kind of COVID times, there's questions of what can we do er before these patients get into our consultation room. So we do like to use clinical metrology instruments at Liverpool quite often. Now, these are basically questionnaires which are designed to give you an aggregate score.
And the aggregate score that they generate is able to give you an idea of how pain or osteoarthritis is affecting our patients' quality of life, although their mobility. So, unsurprisingly, the most common one I use is a load questionnaire, and this generates a score up to 52, and it allows you to be able to categorise, your lameness as mild, moderate, severe, sorry, your impact on mobility is mild, moderate, severe or extreme. The K9B pain inventory is also one, which I will use.
And this is a little bit different. It allows you to generate, a pain severity score, and it also allows you to generate a score that shows the impact that that pain is having on our patients' quality of life. So, the values generated from these questionnaires are useful in that they can give you an idea of how Much our patients are affected, but it also provides us with a value that we can then use later on down the line and assess the efficacy of our treatment plans.
There is also a questionnaire that's now been, validated for using CATS, the feline musculoskeletal pain index that was developed at North Carolina State University by Duncan, Duncan La Salle's Group. And this is a questionnaire. Compulsive 17 questions which will either generate, generate you a score out of 68 or it will generate you a percentage possible score.
The reason for the percentage possible score is on, on this particular questionnaire, owners have the option of applying non-applicable to their answers, which obviously will reduce the overall score. The good thing about these questionnaires as well is that they will ask the owners questions, which may be useful in your consultation, but you may forget or not have time to ask. So it will also give you additional information that can add to the clinical picture that you want to generate.
So it's one thing that I would strongly advise using in practise, and it's something that you can even either email to patient, clients before the patients present at the practise, or your reception team, or nursing team can give these questionnaires, to the patients before they come. Into the consultation. So, in terms of my approach to the osteoarthritic patients, so the clinical history is probably one of the is the one of the most important things, that we do.
So it's very important to be logical and methodical. The clinical history gives us our best chance of developing a picture of how our patients are coping with their disease and how this disease is affecting their general day to day life. It may also give us clues as to which particular area, is affecting our patient.
So you want to ask questions which are focused and help you generate a baseline information. The information that you generate is gonna help you facilitate, implement a bespoke management plan. But it's also again, gonna help you generate baseline data that you can then refer back to when you're assessing these patients.
And in the future. One of the things I would say with consultations is you need to make sure that you dictate the way the questions are going and don't let the owners dictate the consultation. If you let the owners dictate the consultation, you end up getting a lot of information which isn't relevant or it's not given in the right context and you don't take a ster clinical history.
So, on the right hand side of the screen, watch, I'll mess this up now on my laser. So I have, I've developed a consultation sheet which, to be honest, I've developed this really to help. The students on the orthopaedic rotation, generate a good clinical history, or good orthopaedic history, so that I don't have to keep repeating questions that they should have asked when I go into the consultation room.
But I actually find now that it's actually quite a good a memoir for me when I go into the consult either if I'm on a busy consultation day or I've had a night where the kids have been awake and you may not thinking quite as clearly as, as you should, it, it helps stimulate the the questions that you should be, should be asking. So. So one of the first things you need to establish is the onset of the lameness.
So is it acute or chronic? An acute lameness will have a very different differential list to a chronic lameness. So, acute lameness, cruciate disease may becomes more obvious.
In a chronic laness, you start looking more towards things like your elbow dysplasia or your hip dysplasia. And ideally, you want to get an idea of which limb is affected, although I wouldn't necessarily recommend trusting owners on identifying the limb that is affected either. And then it's nice to know how the lameness is affected by exercise.
So does exercise induce a lameness? Does it exacerbate a lameness? Is the lameness more apparent after rest or do our, do our patients have inactivity, stiffness?
And is our lameness affected by surface? So, again, that. That will help in terms of formulating your plan going forward.
So if your patients are coping better with walking on grass, then your management strategy going forward is gonna probably involve a lot of walking on grass. Equally, if your patients are more lame on the hard ground, you know on soft ground, it may indicate that your lameness is originating lower down the limit and higher, so that can help there. It's good to establish exercise prior to lameness.
This kind of gives you an idea of what owner owner expectations are, and it gives you a, a level of exercise that you may be looking to achieve with your management strategy. So that's a good thing to, to establish. You also want to know what the exercise is like now the lame is developed, so.
Impact this limbs is having on their ability to exercise, whether the owners have had to enforce, exercise restrictions to manage the limbs or whether the pets themselves are starting to enforce, a reduction in the amount of exercise to, to cope with ID. So they're either refusing to go out on the walks or they're not able to walk as far as they were previously. And finally, it's good to find out what medication they've been on previously, .
If they've responded well to that medication, great, you know, you can try use that medication. If you've not responded well to the medication they've had in the past, you may want to elect to use something different. So it's good to have a very logical consultation plan going forward.
The next step in, in the approach to the osteoarthritic patient is to do a dynamic assessment. Now, we can perform a dynamic assessment in, in two ways. We can either use subjective gate analysis, which is our visual analogue scales, our numerical rating systems, or we can just use simple descriptions.
Or we can use objective gate analysis. Now obviously, in practise, that, that's, not going to be something that's applicable. The advantages of objective gait analysis, it gives you definite data, that, that correlates well with patients' ability to use, their, their limbs.
But I will also add that on a day to day basis, even though I have access to, a pressure sensitive walkway each day, it's very rare that I will use it for, for my routine workups. I, I do rely on subjective data analysis as well. So with, with dynamic assessment, you're probably most likely to use a numerical rating system or a descriptive method.
The, the thing that I would say with this again, which probably something I'm gonna say is, is to be consistent. So firstly you want to use the same assessment methods, so. When I, when I ask the students to grade the lays, I don't mind if they use the 5 point scale, if you use a 10 point scale, or if they just tell me whether a layness is mild, moderate, severe.
All I want them to do is every time they assess the patient is to use the same scale, and on each subsequent visit, using the same scale. It's also good to see the same patient back. So it's no good kind of having these patients dotting around from vet to vet.
I know this isn't always, practical in, in the first opinion setting, but it's, it's good to see your patients back. The reason being that there is. With the subjective assessment techniques, there is a lot of variation between individuals.
So my 2 out of 5 isn't going to be the same as your 2 out of 5. There is more chance that every time you see this patient back, you're gonna be consistent with, with yourself. So ideally seeing your patients back is, is the best thing to do.
With cats, cats are a little bit more tricky, so cats won't walk on a lead. So trying to, I often walk on a lead, so trying to. Get analysed, a cat can be quite difficult.
So we catch you have to employ different techniques. So you either have to do things like, put the basket in the opposite corner of the room and allow them to walk to the basket. You can place them on high surfaces and watch how they jump down from the surfaces or try and encourage them to jump up on surfaces to get an idea, of how, how lame they are that way, but they're certainly not as straightforward, as assessing canine patients.
And one of the biggest tips I, I could probably give you is to use a smartphone to record lanesses. So, the smartphone is very useful in the COVID, in this COVID kind of, pandemic. We will use smartphones to record the lameness quite commonly, or we'll ask owners to record the lameness and ask them to send the videos to us so that when we're doing video consultations, rather than trying to have an owner follow a background with the phone while they're on the video, video console, we can look at the video of their pet walking on the computer and that gives us an idea of, of how lame they are.
The other advantage of smartphones is that you can, you can slow the videos down. So if you're having trouble deciding which leg the dog is laying, then you can slow the video down and you can watch it much more accurately and work out which leg is, is the problem. The only thing I would say with recorded videos, if you're gonna slow them down, is it's very difficult to assign a grade.
To a video that's in slow motion, but I would probably say that if you're using slow motion to look at a video, it's probably a very mild lameness anyway. And the last thing, the good thing with recorded lameness is they're a good visual diary of what is happening with that patient. So you can refer back to recordings of lameness and use that again to try and monitor progress of these patients.
On the physical examination, again, be methodical and consistent. And one of the things I would definitely recommend doing is examine the normal legs first. So what you want to do is, firstly, allow the patient to acclimatise to the consultation room situation and allow them to acclimatise to the examination.
But also, you want to establish how those patients are going to react to manipulation. So you get some dogs which are very stoical and don't give a lot away at all. You'll get some patients which are very hypersensitive and will react to manipulation even in the, in the absence of pain.
So it's good to try and determine how that patient's going to respond before you focus on the affected leg. And then it's really a case of being methodical. As long as you're methodical with your approach to your orthopaedic examination, you are very unlikely to miss something.
The times when you start to miss diagnosis is when you become a little bit haphazard with your examination and you're not, you're not logical in the way that you're moving through, through the examination or you assume that a certain joint is the problem and you don't assess the other joints on the patient. So the first thing I will do is I will assess, my soft tissue. So I'll work from proximal to distal, and I'll assess muscle mass and symmetry.
And I will do this subjective there are ideas that you can use, tape to measure, muscle mass, and quantify things out, but it's very variable. I think that subjective assessment of muscle mass. It's usually absolutely fine.
As you move down the limb, particularly as you get to walls, things like the stifle the elbow, carpustasis, you can start to palpate for joint fusions whether there are any problems there. And it's also good to, at this stage, palpate tenderness insertions. So the, the most common one you should probably checking is the insertion of your gastroemus on the calcaneus.
. Then I will often palpate long bones, which, to be honest, in the osteoarthritic patient, I usually fairly unrewarding. Palpation of long bones is normally more, applicable in dogs that you either suspect to have neoplasia or in young dogs which may have things like panosteitis or metasteal osteopathy. But it's something that even if I don't suspect a long bone problem, I will still do because it's part of my normal approach to, to the orthopaedic patients.
And then lastly, I will assess, I'll assess the joints. So, it's good to assess range of motion, and it's good to quantify that range of motion. So you need to say, it's no, it's no good on your notes, just say range of motion reduced.
You need to say where the range of motion is reduced, so is it reduced in extension, is it reduced inflexion? Is it mildly, moderately, severely reduced? Cause again, these are things that should go into your clinical notes that are good reference points to go back to on subsequent examinations.
You should be feeling for pericular thickening, so the most common one is in cra crucial ligament disease. You'll often have medial bus in, the stifle, and you'll quite often feel crepitation or manipulation. Again, you should try and quantify the degree of crepitation that, that's there because again it's a monitor, it's a monitoring tool.
And try and record all these findings accurately. So again, I've, I've developed my own, examination sheet to make sure that, well, it's really to make sure that the students check every joint and record everything accurate, but the clinicians will use these sheets as well. It's just a way of making sure, even if the joints are normal, that we write that those joints are normal, so that we have, we have, we have a, a comprehensive history of how this patient was on that particular visit, because this is important, when it comes to subsequent reassessments.
So in terms of my therapeutic strategy, number one is to provide analgesia. So we need to return functions to these patients, and the best way to do that is to, in the short term is to provide pain relief. We're going to modify our exercise.
And weight management is, as we've touched on already, is incredibly important. And physical therapy in osteoarthritic patients, again, it is invaluable and it's, although I won't touch too much on this in this presentation, if you have a chronic osteoarthritic patient, I would definitely encourage you to, recruit the, the help from a, a chartered physio. So the main aims of our therapeutic strategy firstly is to decrease lameness and increase exercise tolerance.
Ideally I want to increase the range of motion in those joints. I want to increase muscle mass, and I ideally want to decrease the analgesic requirement of these patients. So in terms of my standard analgesic therapy, I will always use an NSAID where indicated, providing there are no, concurrent illnesses that mean I can't use them.
I have no particular preference towards, any non-steroidals. Each have their advantages and disadvantages. Non-steroidals will work well in some dogs, but not in others.
So it's a case of finding the right non-steroidal for, for the right patient. . I do typically tend to, to reach for Robena Coxy was my first non-steroidal, that's probably cos it's the one that's on, on the shelf really.
. I'll tend to add in paracetamol, at least for the 1st 2 to 4 weeks. Again, just to help me get control of the patient's pain levels. And if with the combination of a non-steroid and paracetamol isn't working, I'll usually add an additional analgesic and, and the one I'll normally reach for first is Amantidine, Omantine and followed by gabapentin.
The reason I I'm man to do more than anything as well is, it's once their administration compared to G Penton, which is 3 days. So again it's more convenient for, for the owners. You also have to consider at this stage whether surgery might facilitate a better control of the disease.
So, for instance, in, in osteoarthritis associated with cranial cruciate ligament disease, if the stifle is unstable, it's probably better for that patient to have a procedure which will stabilise. The stifle first before you start with your, your therapeutic plan. That's gonna give you a lot better chance of getting on top of the pain associated with that disease.
Patients that are presented with hyperextension, again, it may be that surgery is your first line control to control pain in these patients rather than the medication. The excise modification. So the, the aim of an excise plan is to establish a baseline level of exercise that the patient can tolerate without exacerbation the clinical signs.
So it is a little bit of trial and error, but what you're trying to find out is, is what your patient firstly is able to tolerate either with or without medication, and whether that level of exercise that you can achieve is compatible with a good quality of life. So quite often what we'll see on histories when we get to send them in is rest Benji for a few weeks and see how he goes. Or the, the climb will say, oh the vet just told me to, to rest, rest him for a few weeks.
Rest is a very non-specific term and rest means a lot of things to a lot of different people. So somebody who is walking the late strip for two hours on a Saturday and a Sunday, rest for them might be an hour long walk, which in terms of osteoarthritis isn't rest at all. Whereas rest for, Somebody that only walks their dogs for 15 minutes round the block might be that the dog is just going out into the garden.
So just using rest as a, as a way of applying exercise modification isn't really a good way forward. So what it's probably best to do is to say, here's a structured 8 week plan for Benji in in this case. So, my structure plan, again, the, this is just the way I do things, this isn't necessarily the right or the wrong way, or it might not be the way that you choose to do it, but this is, this is my approach to exercise modification.
So firstly, I will, Use lead restricted exercise. So I'll reduce exercise by around about 25% of the typical walk, and I will exercise those cases 2 or 3 times a day. So for most dogs, this will probably be a reduction down to around about 10 minutes, 2 to 3 times a day.
Providing they're coping well, I will increase the length of each walk by 5 minutes every 7 to 14 days, depending on, on how well the patient is coping with that level of exercise. And I'm normally aiming for a maximum duration of around about 40 minutes. So I think for most medium, large breed dogs, Monday to Friday, if they're walking for 40 minutes a day.
That's probably enough exercise for those patients. Once we get to that stage, then I'll start to think about introducing off lead work. And I usually recommend introducing off lead work at the end of every walk.
So you don't want them going crazy straight away at the start of the walk off the lead. It's probably better to tie them out first with the lead restricted component and then introduce the off-lead stuff a little bit later on. The same rules apply for the garden.
So if you're implementing an exercise plan, then don't just let the dogs, run around in the garden, cause you, you go through the whole frustration of restricting exercise for 10 minutes, 3 times a day. The dog goes out in the garden, runs around for 15 minutes, and they've just done undone all the hard work. So if you, if you, if you're enforcing that degree of restriction, then you should enforce that degree of restriction when these patients are out in the garden as well.
And you should continuously reassess and modify the plan. So the way, the way the case moves forward depends on how the patient is responding to the plan there. So it's good to keep in touch with your owners and find out how well the cases are doing.
So obesity and osteoarthritis, so this has already been touched on, but obesity is a growing problem in UK pets. So in the last paper that I read, or the last communication on this, around about 65% of adult dogs were considered overweight or obese. And more worrying is that 40% of juvenile dogs, that's dogs that were less than 24 months of age, were either overweight or obese.
And as was touched on previously, obese cats are almost 3 times more likely to present with lameness than non-obese cats. So obesity has kind of two problems, it causes two problems. One is biomechanical, one is metabolic.
So the biomechanical kind of makes sense. If a patient's overweight, they put an increased load through the joint, increased load through the joint is gonna cause increased wear and tear. It's gonna predispose to osteoarthritis.
It's also gonna put abnormal forces through joints, which may be already incongruent or unstable, so cases that have hip dysplasia, elbow dysplasia, cran crucial ligament disease. But obesity itself also causes postural changes, which redistributes loads to areas of joints which are not necessarily used to bearing weight, and that can predispose to osteoarthritic change. The other side of the things is that fat cells are an organ, and they will secrete adipokines.
So the most commonly studied adipokines, leptin and adiponectin, and they will stimulate the release of proflammatory cytokines. They will cause the production of matrix metalproteinases, and they will cause the release of nitric oxide. Basically, the end result of that is they cause a catabolic effect within the joint and they, they cause the destruction of hyaline cartilage rather than aiding the repair of hyaline cartilage.
So, the effects of diet restriction was studied in a cohort of 48 Labrador retrievers. So they were case maps. So you had one sibling was in the control group, one sibling was in the diet restricted group, the control dog was allowed to eat what they wanted, and the diet restricted, case was fed 25% less than that.
And by the end of the study, the control group had a mean weight of 37 kg, and then 34 kgs, which equated to a body condition score of between 6 and 7. So these patients were considered overweight. Whereas in the diet restricted group, they had a mean weight of 24 kg and a body condition score between 4 and 5.
So these cases were in ideal condition. No. They looked at the effect that this had radiographically on the joints, and the most profound effect was in the hip joints.
So you can see that by the time these patients were 2 years of age, already, the control group had a, a prevalence of 25% osteoarthritis versus only 4% in the diet restricted group. As we move through getting towards the 8-year mark, 64% of dogs in the control group have osteoarthritis versus only 14% in the diary restricted group. And by the end of life study, 83%, of dogs in the control group have osteoarthritis versus 50%.
So, obesity, being overweight is having a massive effect on the development of osteoarthritis in the hip joint. A similar trend is seen in the elbow joint, although significance was only seen at the 6 year mark. By the time we got to 8 years, there was no significant difference, in the prevalence of osteoarthritis or numerically, it's still a lot higher in the control group.
And the shoulder joint, again, it's a similar, it's a similar idea in that there is significantly more osteoarthritis in the control group than that in the diet restricted group through the duration of this study. So, there's, there's massive evidence there to suggest that allowing patients to become overweight early on in their life is gonna predispose them to developing osteoarthritis a lot earlier on in life. So by the end of this study, only 10% of the control dogs had radiographic normal joints versus 25% of the dogs that were in the diet restricted group, .
Osteoarthritis in 2 or more joints, was seen in 45% of the control dogs versus only 5% of the diet restricted group, and in three joints, 32% of the controlled dogs versus 5% of the diet restricted group. So again, osteoarthritis is more common in multiple joints and dogs that are overweight than dogs that are, that are in a good body condition. 55% of dogs in this study were euthanas because of the musculoskeletal disease, and this occurred at a mean age of 11 years for the, control group versus 13 years for the diet restricted group.
The control group needed treatment for osteoarthritis a lot earlier on in life, so around about 10 years of age versus 13 years, in the in the direrited group. And the survival time was significantly longer in dogs which were in the diary restricted group versus the dogs that were in the control group. So again, there's massive evidence there to suggest that these patients should be kept in an ideal body condition as possible throughout their life.
And then just quickly, the, the opposite argument that caloric restriction on weight loss has also been demonstrated to reduce lameness scores. So we can see in these three studies, a weight loss of around about 10% is achievable in a 10 to 20 week period, and this is associated with a significant reduction in subjective, Subjective gait scores. And the last study done by William Marshall actually at 16 weeks, and at around about 10% weight loss showed a significant improvement with objective gait analysis as well.
So there's also strong evidence to show that if your patients are diagnosed with osteoarthritis, we should be putting things in place to make sure these patients are losing weight, because this will have a massive impact on our ability to control, the pain associated with osteoarthritis. Dietary supplements, is I guess a little bit of a controversial topic. The overall evidence for the use of dietary supplements is actually quite low, but this could be either due to a genuine lack of efficacy of these products, or it's because the study designs haven't been designed in a way that allows us to convincingly show that these products are having a beneficial effect.
So the most common dietary supplements that we see are fish omega 3 fatty acids, green lit mussel extract, glucosamine chondroitin, and chimeric extracts. I would say out of those, the fish omega 3 fatty acids probably have the strongest evidence for not only being. Symptom relieving, but they also will potentially reduce the dose of non-steroidals that are used.
There is some evidence to suggest that green muscle extract is beneficial in the management of these cases. Glucosamine chondroitin is a little bit on the fence, and. Some of the evidence with the turmeric extracts may have been promising, but some of the recent studies looking at the addition of turmeric extract into, into the diet doesn't necessarily have a big beneficial effect, certainly in objective data anyway.
So the benefits of them are that they do have they do have potential non-steroidal dose sparing effects. They have very few side effects. So if you've got particular older patients which have concurrent disease, you're very unlikely to exacerbate any of those ongoing disease processes.
And they may have disease modifying effects. So, while it's difficult to, based on the literature, recommend. Using these, what I would say that is if you are going to use dietary supplements, your best chance of them having a beneficial effect is to introduce them early on in the disease process and use them for a longer period of time.
I don't think they, they have particular benefit in very chronic end stage cases, but I think if you pick cases early enough and introduce them early enough, then they can have a beneficial effect. The big negative to these supplements as always is cost. They do tend to be quite expensive, so you have to balance that up in your management strategy as well.
For me, if cost is in, I will always go for my non-steroidal paracetamol. Side before I will introduce joint supplements. And then, lastly, you've got to continue to assess your therapeutic success, so you've introduced your analgesics, you've you've modified the exercise, you've introduced your weight management, and you've, you've worked with your local physio, but you need to assess how well you're doing.
So I will, I'll tend to see these patients back every 6 to 8 weeks initially until I've got good control. And then after that, I will review them every 6 months. Every 6 months ties in quite nicely with prescription checks for represcribed medication, but also allows you to, perform routine haematology biochemistry analysis in your older patients that you're prescribing chronic non-steroidals to.
So one of the best ways we can assess therapeutic test is to ask our owners. So we ask them to fill out our, our questionnaires again, and hopefully, we should see that our overall scores are starting to reduce. They may also note that their, their pet is exercising better, he's less stiff, after rest.
We, we're gonna rega analyse our, our patients, so we're gonna subjectively assess their gait. Hopefully, their lameness scores are reducing. We're gonna put them on the scales and hopefully they are losing weight or at least we'll have a reduction in body condition score.
They should hopefully have an increased range of motion in those joints that may have had a decreased range of motion. Hopefully our physios helped us out there. And hopefully we should have improved muscle mass, so we should be starting to regain a bit more symmetry in, in our muscles.
And then finally, it's knowing when, when medical management isn't going to work. So at some point, we will reach a stage where we are not able to maintain a good quality of life with, our excise modification with our, our painkillers. So that's when we need to start thinking about using salvage procedures.
So I'll use salvage procedures, when my patients are failing to respond to conservative management. They are highly dependent on analgesics to maintain a good quality of life, or they have end-stage joint disease. So the, the ones we're quite commonly perform are to joint replacements, to hip replacements, which is where I was literally just before we came and did this talk, or in the small joints, we may consider arthrodesis, of those joints, and that is a good way of providing analgesia to those joints that are chronically affected.
So in conclusion, I'll use your time taking the clinical history to generate a database of useful and clinically relevant information. Provide the owners with specific and realistic therapeutic plans. Don't underestimate the importance of good weight management and continue to review and modify your management strategy.
And that's me. Lovely. Thanks, Andy.
That was brilliant. I can see there's a question in the chat box here, so I shall. Open it up.
Can, can you get access to the chat box or would you like me to ask you the question? Would it be right to say you see more benefits to young dogs arthritic issues. I'll read it out properly, sorry.
Would it be right nutraceuticals are more beneficial in younger dogs with osteoarthritic issues rather than older dogs. I've always felt younger dogs are more likely to be able to repair damaged cars. So I guess, I guess, firstly, I would say yes.
If, if you're gonna get a beneficial effect from nutraceuticals, I would say the earlier you introduce them. The better. As far as disease modifying effects go, that's where things start to get a little bit controversial.
I don't think that's been truly demonstrated that that happens, in clinical cases. But I would say that, yes, if it's going to happen, it's probably more likely to happen in less severely affected cases than those with, more severe cases. To answer the question?
It did from where I'm sitting, but I didn't ask it, but yeah, yeah. And there was, I've got a list of a few questions here actually that have come in sort of internally, that I thought I might ask. How can we encourage more owners to recognise mobility disorders in their cats, e.g., arthritis, so many dismiss a reduction in activity or reluctance to jump as normal and non-painful consequence of ageing and are reluctant to do anything.
Yeah, it's a good question. I think that A lot, a lot of this may be, I guess he's discussed at your annual checks will be the first thing. So these kind of questions, particularly in your ageing cats should form maybe part of your, of your normal consultation during those routine vaccinations.
And I guess I would always come back to asking, asking patients, or asking clients, sorry, to fill out questionnaires isn't a, a massive inconvenience, and they can do that while awaiting the consultation room, and you may actually find that the answers generated from those questionnaires. Highlight something to, to the vet that they should then go on, to discuss with the client, or it may be that the actual questionnaire itself actually highlights a problem that the owner didn't necessarily consider was a, was an issue before. Great, thank you.
Yeah, I, I, I think unless anybody else has got more questions, I can see some have come in the chat box. How long would you feel happy to give long term analgesia if this controlled OA before moving on to salvage procedures? Again, that's another good question, and there's not really a right or wrong answer to that.
So, in terms of long-term allergy, part of it will depend on the condition that I'm treating and part of it will depend on the age of the patient, so. If I have a young dog with, with hip dysplasia, for instance, that isn't responding to analgesics. By the time they're kind of approaching 18 months of age, then those cases I will potentially opt to go for a salvage procedure, or I will.
Offer the, the, the option of a salvage procedure as that patient is, is likely to be on non-steroidals for a long period of time. But I guess a lot of it will also come down to what the owner wants to do as well, because you can't make every owner go for a hip replacement or every owner can afford a hip replacement. Sometimes a salvage procedure is actually not a better option than managing the primary disease itself.
So, I think that if an owner can't afford. A salvage procedure, then you use, you use analgesics long term as you need to to maintain quality of life. I think a lot of it comes back down to, it's better to have a, a short, good quality of life than have a long quality of life which has been, a longer life which has been suboptimally managed because of the fear of using things like non-steroidals.
So I think it is very. It's very case, very patient, very client orientated really as to when we do that, but I have no problems with using painkillers long term if that's what the patient needs to, to give it the quality of life that it needs. It just means we have to be a little bit more careful with the way we monitor those patients, monitoring for signs of side effects, routine blood work just to make sure we're not causing any, any mishaps.
Wonderful, thank you. I think that's it for the question. So yeah, again, thank you very much.
I think what we're gonna do now is we've got a little bit of time back. So we will continue as planned. We'll have a break now.
