So thank you to everybody for attending this webinar. I hope you find it useful. So what I tend to do with my webinars is prefer to provide practical information rather than making them too science heavy.
So there is some science in there, there has to be, but what I would like people to do is to be able to take away some of the information and implement it in their own clinic. Tomorrow. So the reason that I'm so interested in osteoarthritis management is because it can be very rewarding.
It is a very, very common condition. . And it goes without saying that whenever you have a painful debilitating chronic condition, it is incumbent upon the veterinary team and all the professionals involved to make sure that we minimise the suffering of the patients under our care.
So, it is in fact the case that canine osteoarthritis is one of the greatest animal welfare issues in today's small animal practise. And the vet Compass Group identified osteoarthritis and obesity in the top three health-related conditions for pet animal welfare. So, before we consider how to go about setting up a clinic, it's essential to do a few things like get the owner engaged, because if the owner's not engaged in the process, if we don't build enough rapport, then we won't get anywhere.
So it's absolutely crucial that we can build some trust and get the owner on board. So, The way that I've found that this works best is by educating and informing the clients so that they are. You know, as informed as they can be, and they can really get on board with what we're doing.
Unfortunately, there is so much competing and often contradictory information out there that clarity can be hard to come by. So cutting through this noise of all of those opinions can be quite difficult, but It is the case that the owner is obviously essential, clearly it's the pet that that we're we're there to help, and the pet has to be at the centre. But unless we get the owner on board, then we're not going to make much progress in the management of osteoarthritis.
And where would the vet fit in now? Consider the situation where a dog is lame or limping and the owner notices the problem. Who do you think they're going to contact and and which expert might they go to first?
Well, it may not be the vet, unfortunately, and we've all had cases where everybody's given an opinion, it might be from the breeder, it might be from the dog walker, it might be from the dog trainer. Friends, family, social media blogs, chat rooms. Everybody and his brother might have an opinion, and they, those opinions might, in the owner's eyes, carry more weight or get in there first, long before the vet has a chance.
So, there are reasons why as a profession, we may be missing a trick and in failing to be proactive around osteoarthritis. And if we leave the education part of the osteoarthritis discussion to internet sources, then we're unlikely to be doing the best for our owners and their pets. So what might be the reasons around why the vet is not the first port of call?
Well, a lot of owners cite that they don't want to bother the busy vet. And that is a problem. Now, unfortunately, what can happen with veterinary surgeons and all veterinary professionals is, we become very busy as kind of victims of our own success, and the more successful we are, the the busier we are, and we get into this trap where we're not only busy, but we seem and appear busy, and the busier that we look to the client, the less likely they may want to be consulting us.
So, not wanting to bother the busy bet with something that may be possibly trivial in the client's eyes, might be a reason why they don't. A lot of the time, they don't think that we can help. Obviously, a lot of people, including clients, will have outdated information about what is available and what can be done for animals with mobility problems.
How often do you hear owners saying, oh well, you know, my dog went off his legs and then we put him to sleep. And that kind of sums up their understanding of, of, you know, what happens with dogs' immobility. A lot of clients don't want to use what they in their eyes might think is harmful chemicals or medications.
They don't, you know, they prefer to have something that they consider natural, because there is a general mistrust. Of science and chemicals. So there's a lot of hurdles to overcome there and a lot of misconceptions to try to dispel.
They might think that we're expensive and proper veterinary care is not cheap, but you can tailor your service, to give the best possible value to clients and their pets, and so it doesn't have to be preclusively expensive. What a lot of clients will do is they will have a friend or or have a previous dog where there was a lameness and something apparently worked for that. So they may say to themselves, well, my, my friend's dog was lame, X, Y or Z worked.
I'll do that for my dog. Not realising that the diagnosis may be completely different and the cause, the aetiology of the problem might be something completely different. So, getting over the concept that a diagnosis precedes treatment might also be quite difficult.
So, where should we position ourselves within this OA management scheme? Well, fortunately for the patients, the vets do hold a unique position morally, ethically and legally. OK?
So it's worth explaining to owners that during the discussions around osteoarthritis, that it may be impossible to recommend a course of action or a new supplement, simply because there's insufficient scientific evidence for its, for its use. . So it's only the vet who can actually make the diagnosis, only the vet who can order imaging and other tests, and only the vet who can make a prescription of proper veterinary medicines.
We might also use the high ground that we occupy to advocate for only evidence-based medicine, and this is in the interest of the patient first and foremost. A lot of clients may not realise that as veterinary surgeons, we are bound by oath to prevent and alleviate animals from suffering, and we are obliged to use effective evidence-based safe medicine. They may not realise that we're legally liable for our actions, and they may also not realise that we could be held to account by our professional body.
So, you know, our opinion is the one that should carry weight, because obviously, as professionals that we are, we have something to lose by not giving appropriate advice. So, why as vets, do we not promote ourselves as the genuine experts in osteoarthritis? Reasons might be that we perceive that we don't have the time.
Some vets, although probably no vets on this call, may think that osteoarthritis is not an exciting field. It may be our knowledge that's lacking or incomplete. And the fact that the osteoarthritis field is progressing fast, it may be difficult to keep up.
It may be the controversy around certain things like supplements that we just don't want to get involved in. And we may just not feel confident in discussing osteoarthritis or educating the clients. So, where should we position ourselves?
We are busy people. Osteoarthritis is maybe not particularly as exciting as other fields, but perhaps, I obviously disagree. Maybe we're just overwhelmed by all the inflammation, all the information and all the controversy.
So, Let's address not having time. We do have time for other cases with chronic diseases. We have time for cases with heart failure, with renal disease, with Cushing's, .
Hyperthyroidism, A to B, and we obviously allocate time for them. So why don't we allocate time for osteoarthritis care? And if we did that, the benefits will be manyfold.
The vet is in a central position to be the professional who can build a team, OK? But the vet is not the whole team. So, we, as vets, we tend to be control freaks.
So we need to maybe overcome that control freakery, . And then build a team around us of trusted professionals from other disciplines. So, a lack of action on osteoarthritis can no longer really be justified.
In my opinion, each practise should create a service within it to address the problem of osteoarthritis. It can be coalesced around a new or existing function of the practise. For example, there may already be a therapeutic class 4 laser on which the OA service could be centred.
It is possible also, perhaps that in a practise, there may be a vet who's trained in acupuncture, and this could be the anchor for the service. So you may already have a lot of what you need in your practise that you can build on. So the importance of osteoarthritis is that it affects so many animals worldwide.
It can be unrecognised, it definitely underdiagnosed and very, very often undertreated. Every practise has animals in it that have osteoarthritis. Osteoarthritis is a painful and distressing disease that causes suffering, OK?
And although it's canine osteoarthritis is a joint disease, it rapidly progresses to become a disease of the whole dog by modifications that occur within the nervous system and the, the windup that occurs and the central sensitization of, of the nervous system. So, osteoarthritis is important, and everybody within the veterinary practise should be aware of this. If there is no buy-in, then the results will be disappointing.
So, If we vets try to do it all, we will fail. We just don't have the time. So how much more likely are we to succeed if we recruit, educate and encourage our colleagues from all departments.
So we need a multidisciplinary team, and if we can do that, then we can get somewhere in building a really efficacious service for our patients and for the clients. So we include in this, the front of house team. The veterinary nurses, animal care assistants, physios, and other therapists, and obviously the veterinary surgeons.
So, Education is a crucial piece because . Without the knowledge, then we're not going to be able to build a service. And colleagues of my vintage will probably not remember being taught so much about osteoarthritis in veterinary school.
But fortunately, times have changed, and knowledge has increased on osteoarthritis, such that there is now a wealth of readily accessible information, and this is bound to increase and improve with time. So my advice would be to educate. All the involved personnel, each department will need different education content appropriate for their role.
For example, there's no point trying to give the same information that you give to your vets, to your receptionists. They need a different set of skills, they need a different delivery of, of the knowledge. So it needs to be tailored to each.
Department where you're trying to educate them. It needs to be fun and engaging, so there's nothing worse than than boring presentations, . And death by PowerPoint, what you really need to do is get people involved and get people co-creating your own materials.
There are lots of materials available from the Cane and arthritis Management website and from VOA, but if you can take what's there and tailor it to your practise, because all practises are different, and what works in one practise won't work in every practise. So, a clear idea of why we're setting up the service is essential, but the next main resource is time, OK? And using a related service that's already in place as a foundation may be helpful.
So as we've already said, you may have a laser service, you may have an acupuncture service, and you can build around that, a much more comprehensive osteoarthritis care package. Maximising the effectiveness of veterinary time spent needs careful planning. Many of the tasks needed can be outsourced to willing team members.
So receptionists and many RVNs can be excellent at spending time talking to owners and reassuring them, and this may be the glue that holds together the VA service from the client communication point of view. But veterary time is expensive and needs to be charged for. So correct pricing makes the OA service self-funding, and if you don't get this right from the outset, then you're not going to succeed, .
Your bosses are not going to be happy and it's just not gonna work. So you need to, by getting the team collaborating, maximise the value of all the veterinary time that's spent, but if you can take a lot of the hands-on work away from the vet to other parts of the team, then that can be much more cost effective. So One way that we've found of of doing this is to delegate the human resources in a certain way that frees up veterinary time.
So we looked at the front of house and we thought, well, what can the reception do to lighten the load of everybody else? And that They've got their own certain skills, and they're very good at doing things like meeting and greeting, weighing dogs, supervising questionnaires, coordinating all the paperwork and all the information, arranging the letters, arranging referrals, all that kind of thing. Veterinary nurses are excellent at doing technical tasks, so assessing animals physique, drawing blood, taking videos, taking photographs, and running laboratory tests, doing laser treatment, and doing radiography, that would all come under the remit of the veterinary nurses in our practise.
And by doing that, that gives the vet time. To do the clinical part, the clinical examination, the ordering of the diagnostic tests, the making of the diagnosis, the prescribing of the medications, and coordinating the whole service. So, it is mandatory that the vet takes control of the situation.
The vet is analogous to a team captain, and he or she is able to select appropriate individuals as required to fulfil the other needs. So the vet is the head of the team, but the vet is not the entire team. And by cooperating with other professionals, a synergistic effect may be gained, whereby the patient benefits from that pooled skill set.
Follow up is absolutely crucial and the first and last responsibility of the vet is to make sure that things are followed up correctly. So, in our multidisciplinary, cooperative team, the receptionists have certain duties, as we've already alluded to, weighing pets, supervising questionnaires, coordinating the, the team, gathering materials, making referrals, all of these kinds of things. So, It's very important to remember how crucial the front of house team is.
They have a lot of contact with the owners and with the pets, and if they're properly trained, they can be a very important integral part of the team. Now, veterinary nurses, as we all know, are in most practises, the backbone of the practise. Their skills can be deployed in many parts of the osteoarthritis service, but be aware that not all nurses are alike.
While some of them are in their element in the consulting room, others prefer a more behind the scenes type of environment. So, putting the right person in the right place is very important for team harmony, and the more extrovert types, they are going to feel much happier in a client facing role, perhaps, the more introvert people, they may prefer to be doing the radiography or the laboratory tests or whatever. I have a great deal of respect for physiotherapists and worked with them for many years, and a lot of what I've learned has actually come from my contact with veterinary physiotherapists, .
Now, they may be in-house, most of us don't have in-house physios, so we need to be a bit proactive in finding our local physiotherapists, befriending them, and, making professional contacts, OK? The referral street is two ways. We receive as many recommendations from the physios as they do from us.
So, getting to know some good local professionals will benefit everybody in the end. So the veterinary surgeon has hit her or his own responsibilities and as part of the OA team, they're responsible for the clinical examination. They're responsible for not just making a diagnosis, but also considering the differential diagnosis.
Now, this is something that owners very often don't understand, that there is a differential diagnosis, to consider, and it might well be that there's more than one diagnosis going on. In other words, there may be comorbidities. And unless we take account of these comorbidities, then we're not doing a proper job.
And the two most common comorbidities, comorbidities that we see would be osteoarthritis with obesity. The veterinary surgeon is responsible for using evidence-based medicine, OK, for prescribing appropriate medicines and combinations of those, and bringing in other disciplines and making referrals for maybe physiotherapists, perhaps hydrotherapy and other disciplines. .
The veterinary surgeon may decide that regenerative medicine is appropriate, or surgery, or acupuncture, or any combination of all of those things. And the vet is also central in the owner education piece as well. And above all other things, as I already mentioned, follow-up is a non-negotiable thing, and if we're gonna do proper osteoarthritis care, then we're gonna do follow up.
So, how do we become an expert in osteoarthritis management? Well, compared to everybody else, vets are already experts in pet health. However, we may feel that there are gaps in our knowledge of osteoarthritis, and there are new developments constantly appearing.
So how do we sharpen our skills and keep on top of, of, of the most current knowledge? Well, we can study textbooks, . There is a very good book by Stephen Fox on multimodal osteoarthritis management, which is kind of the the cornerstone of, of, of the knowledge of what we do.
And there are loads of online resources, . There are more and more webinars, and there are even organisations now that you can join, to get educated and get upskilled in the field of osteoarthritis, and I mentioned two of them there. Canine arthritis management provides very good information and especially materials and handouts that you can give to owners.
And the veterinary osteoarthritis Alliance is excellent from the point of view of being a source of of information and knowledge, but also, if you follow their programme, you and your practise can get accreditation, which gives you a certificate, which kind of proves your credentials that you are not just An amateur, you're actually doing a professional job of your osteoarthritis care. So how do we get an osteoarthritis team together? Well, what we did was we looked around our practise and we found that we were Quite well blessed with a wealth of skilled and knowledgeable people already.
So, we decided, well, we could coalesce these people around an objective if we have a clear objective of what we're trying to do and why. Undoubtedly some extra education was going to be needed. And that's was put in place.
But we also needed to have a means of measuring success. So, every practise is different, and what you consider success and what I consider success might be a different thing, but having some sort of metric for measuring. How we're doing and how successful we're being and what needs to change, is crucial.
And to that end, I would recommend embedding within the service, perhaps a quarterly review, just to take stock of where we are, what's going well, what's not, and how we can improve matters. So a system of continual improvement is a good idea. So how might a patient pass through the service?
Well, the possible process might be as follows. So, a vet might be doing an ordinary appointment, not an osteoarthritis appointment, but just an ordinary appointment, and they may suspect osteoarthritis. At that stage, if that case, if that patient can be channelled into a scheduled osteoarthritis appointment in an osteoarthritis clinic, then that would be ideal.
And then, if that is the case, then between the reception and the veterinary nurses, appropriate tests can be run, X-rays might be ordered, prescriptions might be made, and then, a multimodal suite of treatments can be implemented, which might involve, nutrition, occupational therapy, laser, physiotherapy, and crucially, vet follow-up. So, In the general appointment, if the vet suspects osteoarthritis, this can be a a very crucial time, because only a short space of minutes is available, . And what I like to do if I can, is to try to get the client on board as quickly as possible.
So, to this end, having some printed high quality materials that you could hand out would be a good way of trying to convey to the client that this is not going to be a quick fix. We suspect there might be osteoarthritis. We need to confirm or refute whether or not that's the case, and then, if that is the case, then there's a lot that we can do, so we have to be optimistic about what we can do, .
But We're not going to be able to do it in 10 or 15 minutes. So getting that client on boarded in that way, and that's a crucial time. And not all clients will go for it.
Obviously, not all clients will want it, but those that do, if they could be channelled appropriately into an OA clinic, then that would be great. Once you get them into the OA clinic, then you can allocate yourself more time. So having a long enough appointment is essential, because if you don't have enough time, then you're not going to do your job in a detail enough and the patient's not going to get the best service.
So what we tend to do is observe the, the, the pet the dog moving. I like to video them because by having a video, I find that that provides a great resource for referring back to, you can look at it in slow motion, you can pick up subtle things that you didn't see, you know, live. So I like to video them and just observe them hands off, and, and from the hands-off examination, you can get a lot of information.
Then we do the hands-on examination, and we try to consider is there likely to be osteoarthritis or not, OK? And if so, which joints are affected? At that point, it is important to consider any concurrent conditions, such as cruciate ligament dysfunction.
So it might well be that there is osteoarthritis in the stifle, but the cause might be a cruciate. So, it's no good just going down a multimodal treatment for osteoarthritis in that knee without considering surgical treatment for the CCL. And we also consider the differentials and comorbidities, and at that stage we can order some diagnostic tests.
So, as you will agree, this is not a 10 minute appointment. OK. Some sort of clinical metrology is useful, and from the client point of view, I like to use the load questionnaire, because that gives us a number and a baseline, and if we do that on day one, and then do that at intervals, then we can see what's working and what's not working, and we can make those tweaks from there.
So that works well in our hands, and fortunately, most of that paperwork can be outsourced to the front of house. So then we come to what the nurses do in our clinic. So we might order blood tests, in which case the nurses can take the blood, they can run the blood samples.
We might need some radiographs, so we can ask them, . To do the radiographic views that we need, and we might get them to do things like laser therapy. But obviously, it's the vet who will interpret the findings.
So the nurses will do the, the technical side of the radiography, but the radiology will obviously come back to the vet. OK, so you may find in your practise, there are, there are certain nurses who love radiography and certain ones who hate it. Obviously, you're going to get a happier team and a better quality of images if you hone the skills of the ones who like it, and, and try to get the ones who don't like doing it, doing something that they do like.
So that will make the diagnosis and formulate the treatment plan, . They will make prescriptions, and they will order any further investigations. And it's at that stage they might recruit other professionals such as physiotherapists, and so on.
And the vet will then provide the continuity of care, and it's the continuity of care that is key in making a success of any clinic. The vet might prescribe pharmaceuticals such as non-steroidals and adjunctive analgesics and things like supplements and in our clinic, we use a white labelled omega 3 from VBS. One thing that we find particularly good for once again, you could anchor your service around this, if you did regenerative medicine, such as platelet rich plasma or mesenchymal stromal cells, or both, then you can Use that as as a foundation for your service.
And if you don't already do regenerative medicine, then getting involved by starting to do some platelet rich plasma injections into joints is a very recommended way of starting. So, other things that we might have facilities wise in our practise are . Laser.
Now, when we started our OA service, lasers weren't very common, and we were an early adopter of a laser, and we found that that was a wonderful way of anchoring the service, and we could coalesce everything else around that. One of the good things about having a laser service is that you might be seeing a pet twice a week for 3 weeks or so. In which case there's a lot of contact time between, say, the veterinary nurse or whoever's doing the laser therapy, and the owner and the pet, which is wonderful for building rapport and for education.
Not only that, but you get a lot of feedback from the client and a lot of information that you wouldn't have had, had you not had that additional contact time. So if you . Want to have a successful osteoarthritis clinic, then you have to have a successful obesity clinic.
And the two can go together, or one can be a subset of the other, but if you want to succeed in a way, you have to be good at managing weight. So, in our clinic, the nurses will do the weighing and measuring. They will assess the physique by the body condition score and the body fat index.
They will weigh the pets, they will recommend the food and the amount, and they will do follow up. So the importance of obesity in OA pathogenesis is difficult to overstate. Both of the lifelong chronic conditions, and, you know, you might even build your OA clinic around your existing obesity, clinic.
So the interaction between adiposity and osteoarthritis is both physical, chemical and biological. The biological basis can be summed up in one word, which is adibokines. So these adibokines are the combined output of the biochemical messaging molecules from adipose cells.
The proflammatory characteristics of the adibokines aggregate increases in obesity. So, the, the more adiposity that you have, the worse the inflammatory signalling from the adipokines and the worst the osteoarthritic pain. So it's not just a question of the physical weight that's acting on the joints.
It is that, but more importantly, probably, it's the biochemical aspect of these adibokines in It's inflammation within the joints. So that is a very important sort of message to get across to owners that it's the inflammation from the fat that we're trying to affect rather than anything else. So, occupational therapy, well, there's a lot of information on this aspect from the can and arthritis Management website, and basically occupational therapy refers to all those other things that might be forgotten about, like modifications to the pet's environment, which will help with osteoarthritis.
So, just having softer mats on the floor, just having carpet instead of wood. Just having slings, having ramps, all of these kinds of adaptations, which don't have to be expensive, but can really make a big difference to animals with osteoarthritis. All of that would come under the heading of occupational therapy, and that's another thing that can be delegated to a veterinary nurse or veterinary nurses with an interest in that subject.
Physiotherapists are highly qualified people, . I, I'm lucky that I have quite a lot of contact with physiotherapists, and I would encourage all vets to establish good professional relationships with their local physios. They can be in-house or outside, and their skills can dovetail well into your osteoarthritis clinic.
But communication is crucial, so you need to get, get on well with them, and you need to, help them to help you, really. What I tend to do is, I don't, . I know all that much about physiotherapy, but I'm trying to upskill myself.
But what I would tend to do is give my diagnosis and my instructions to the physios, but how they achieve my objectives, which might be increasing joint range of motion or helping with proprioception or offsetting muscle atrophy, . Those kinds of things, the details of how they get there is up to them. I will obviously cooperate and see the animal back and between us, we will, hopefully, get to where we want to be.
So, I believe that I've established that vets are the experts in OA care, OK? That a team response, team approach is essential, OK, and it needs to be multi-disciplinary, and different skills and expertise can be combined synergistically, and I've shown that it's possible, using our own practise of how a framework. But for an OA team can be created.
Now, that's not the only way of doing it, it's the way that we've done it, and I'm sure there are lots of other ways, but at least it shows that if we can succeed in that way, then anybody can. Thank you for your attention.