Thank you very much Antony and hello everyone, welcome wherever you are, and I hope over the next 50 minutes or so we can discuss some aspects of OA that you haven't maybe thought about . Too much before, osteoarthritis was a research passion of mine, still is, even though I'm no longer in academia, but, now I, more involved in delivering care at the coalface, as it were, and discussing that with lots of colleagues in primary care practise as well as specialty practise, then I think, it's an area that, is really, really important in Bentley practise because it's so common. And perhaps has been a little bit of a Cinderella subject over the years because it perhaps doesn't have the the glamour of some other conditions, but it certainly is a major welfare issue for dogs and cats.
I'm, I'm gonna speak about dogs because that's where my experience and expertise lies, but of course, we were chatting before we started this session that cats are also commonly affected with osteoarthritis. So just by way of transparency, I should just highlight any competing interests for this session, in particular, I suppose, I should mention that I was the developer, of the Liverpool osteoarthritis in dogs, questionnaire, and while I was at the University of Liverpool, and, that questionnaire is now licenced to. Ilanco on a global basis, and we'll mention it during this talk, that's why I'm particularly highlighting that particular interest.
And that's, that was a research interest of mine over over 1520 years or so, in terms of developing tools for vets to use in the clinic to, to make their assessment of osteoarthritis in dogs, more, repeatable and more useful. And we'll, we'll focus a fair bit on that particular area during this session. So just to outline what we're, I'm gonna talk about, I'm gonna talk briefly about osteoarthritis and what it is, just so we're all on the same page, very briefly about the diagnosis because, er, just we don't have too much time today.
And I think that's something that most people are pretty comfortable with. Then I'm gonna focus the majority on, on staging the disorder and, and how, how we decide how bad the problem is, because that ultimately drives how we manage the problem at the different stages of the, disorder. And, and it is a chronic progressive disorder.
It does tend to get worse over time. And therefore, it's right that we match our management to the severity, . And it's also the case that sometimes that our interventions may have risks, and that's another reason why we should, carefully consider the risk benefit ratio of our interventions.
So I will, in the latter part of this, session, talk a little bit about some selected areas of management, just to highlight those and maybe some, some, horizon scanning to a little degree, to talk about what's coming down the, the pipeline. So, Anton and I are, well, we were, I think one year apart at vet school. Antony's just maybe a little bit older than me, but we're both reaching the age where this type of condition might, might be of more concern to us and getting the odd twinge from knees or hips is very, very common in older people.
So I think a lot of clients can relate to the word osteoarthritis. I think one of the issues that we sometimes have though is that. People associate it with old age, which in dogs it very often is not, and, it's very often a problem that starts when dogs are a few months of age, and they, it's a lifetime disease for for some dogs.
Of course it does tend to cause more problems in later life as well because it's a very slowly progressive disorder. But, certainly the most common age, for example, for a dog to have a hip replacement is between 1 and 2 years of age. Which is somewhat alien to a lot of clients.
And it is by far and away the most common form of, of arthritis. There are lots of different forms of arthritis in dogs, but, OA is the most common. So very often it's the default, type of arthritis that we might, diagnose, but, we just have to be careful that we're not missing other types of arthritis.
We'll allude briefly to that in the, diagnosis section. Because immune mediated and infective arthritis does occur and can occur on top of osteoarthritis. So we need to be aware of that.
I suppose the, the most straightforward way to to define OA would be to pretend we, we are a pathologist and look at the tissues of the joint that are affected and erosion of articular cartilage is a hallmark of OA as is inflammation of the synovium, although that's difficult for us to see and measure. What we're very familiar with in measuring or seeing is osteophytosis, so bone formation on X-rays. That gives us the, the confidence that we've got the, the, the seat of the lame in the right place, but it's important to, to remember that the degree of osteophytosis does not drive the management of the condition.
It's very easy to fall into that trap that the X-ray can drive decision making, whereas actually it's the patient. And the severity of the functional issues with the disorder that should drive decision making. So I just had, so I'd start off with a, a poll question, in terms of how common osteoarthritis is in adult dogs, and just to see what people think.
So I've, I've put 4 possible answers here. What's the best estimate of the prevalence of osteoarthritis in adult dogs? And Anthony's gonna help me out with this poll here, and we'll just see what, what people might think.
So just letting people vote away there, John, so we'll give people a, a few seconds, but it, it should hopefully be appearing for everybody, so just click on your best guess. We'll give it another. Few, moments to go and then we'll, we'll, we'll shout out the score, so still a few more people to vote, so even if you're not sure, put a guess at it, it often is, makes it a bit more fun, so if anybody else wants to vote.
I'll give that another 5 seconds and we'll close that. But basically what we've got is nobody thinking it's less than 3%, nobody thinking it's less than 6%, about 20% thinking it's about 14%, and, 25%, is, is scored by 80% of the audience. So the majority of people think it's, it's approximately, 25%, sorry, yeah, it's about 25%, about 80% of the audience.
Yeah. OK, thank you Anthony. I mean that's, that's very interesting because .
There, there aren't great data on the prevalence of OA in dogs actually. There are, there are a couple of studies and of course it does depend on how you define OA. Do you define it as a clinical diagnosis or do you define it as an X-ray diagnosis?
I think most studies are done on an X-ray basis, which doesn't necessarily mean clinical disease, but, the estimates suggest between 8 and 20. Percent of the adult dog population. So, I suppose I chose 14% being in the middle of those estimates.
So it's interesting that the majority of people think it's more common than that, with, 25% or more. But, so that's great that people realise it's an important thing. And if you put that in the context of the estimates of the canine populations in these two countries here, the USA and.
And the UK then you know 7 or 8 million dogs in the US alone, with osteoarthritis, so, you know, it's a major challenge, a major care delivery issue for for the profession. And of course, it is the final common pathway of joint failure. So, anything that goes wrong with a joint will initiate some degree of osteoarthritis.
So it's, something that, once there's a problem, it's almost inevitable to a certain degree. And of course, we, we recognise that, the hips and the, the elbows can be affected in young dogs and therefore lifetime problems for. For those particular patients, and we know that cruise ship rupture is exceedingly common.
So the, these are the big three problems. Cruise ship rupture occurring more in middle age, but we'll initiate OA in all dogs, which may start to cause problems 234 years after cruise ship surgery. And one of the things the literature doesn't really tell you because surgeons that publish on cruise ship rupture tend to only follow their cases for 6 or 12 months before they publish.
But the long-term studies that do exist suggest that 345 years down the line, a lot of those dogs are starting to, to deteriorate in a functional sense, and that's presumably because of the osteoarthritis in their knees. So I, I've, lifted this particular diagram form a paper in The Lancet, written by Paul Diet and Stefan Lomander, a number of years ago now, but I like this, this particular model of thinking about OA. There's Paul Diet there in the bottom left.
He was actually my PhD supervisor. He's, he's reaching the end of his career now. He, he was professor of rheumatology in, in Bristol when I, was, doing my PhD.
Very inspirational man and . His, his way of thinking here, is that of course OA is a localised problem, so it tends to affect one joint at a time, . But of course there are systemic factors that interact with that local disease, such as the age of the patient, whether they're overweight, what their genetics are, and those, those systemic factors interplay with the local joint biomechanics to drive the biochemical pathways in the joint and drive the site and severity of osteoarthritis.
And ultimately, this causes pain, and it's, it's pain er that is the focus for a lot of the management of OA because that's what limits function and decreases quality of life for our patients. But I think it's important to remember that chronic pain and osteoarthritis is one of the common, most common causes of chronic pain, means that there are, there can be structural changes throughout the central nervous system. Such that we can't think about OA as just a disorder of a joint, and, OK, it's a slightly, jovial thing to say, it's a disease of the brain, but clearly, any condition associated with pain involves.
The central nervous system, and it's known that, chronic pain in joints causes structural changes in the dorsal horn of the spinal cord, and it can even cause changes in higher centres in the thalamus, so, . It's a, a problem that can affect the whole patient, and we need to be aware of that. There is some evidence for this in dogs.
Here's just one example, a paper from Dylan Clements and colleagues at Edinburgh, vet school, showing that dogs with cruciate rupture do have hypersensitivity in, in their, in the ipsilateral limb. So that they, this hypersensitivity phenomenon occurs pretty rapidly, in dogs that have cruciate rupture and presumably, it may well be causing similar problems with elbows or hips, as well. I think down the pipe, down the line and and some some to some degree already people think about that hypersensitivity as an area that where we might address no susception in in in dogs with OA.
So we'll just leave that early section now and just move into how we assess patients and I hope this video will will will play OK . Is that playing OK Anthony for you? Yeah, looks fine, it's a tiny bit slow, but I get the idea of it, John.
Yeah, OK, so here we've got, hopefully people can see, we've got a dog with thoracic limb lamus, and it's quite a marked thoracic limb lamus, . And, I guess you may have your, your own system for grading lameness, but, I might gra that lane, that dog as 60s lame, or 6 out of 10. Other people use, a scale of 1 to 5, so maybe 3 out of 5.
But it's a unilateral thoracic limb lameness and therefore relatively easy to. To convey in the clinical notes, to grade, and to tell your colleagues about. I think the problem sometimes comes when we have dogs with multifocal disease.
And I've got this one slowed down for you already. Hopefully it's playing OK. But, if you look at this dog, this dog is in musculoskeletal meltdown.
His gait pattern is disrupted. There's no set pattern to his gait, cycle. He probably doesn't know which limb to put to the ground next because every limb is painful.
And you can also see that his demeanour is. He's indicative of tiredness and pain, his head carriage is low, his tongue is hanging out, his economy of motion is poor. And when your economy of motion is poor, it's tiring to move, let alone the pain.
So how, how would you grade this dog's, lameness in your clinical notes, or how would you convey the severity to it, severity to a collie? And that's a, that's a real challenge. Of course, the other, as well as watching our patients move, we also in the orthopaedic examination, manipulate the joints and try and get an assessment of the degree of pain on manipulation.
And I'll just show you this particular dog here. Reject OK OK, so that, that dog clearly has a painful hip, and I knew it was going to bite, so I thought I'll take the video and let my colleague examine the dog. But, as well as that, we will bear in mind the breed of this dog.
It's a sighthound. It's likely to be a breed that responds very rapidly to any joint pain, whereas other breeds may not. So there's another variable in how we, we grade the severity of joint pain.
So, I'm gonna come, return to some of these clinical aspects, to discuss that in a bit more detail, but of course the, once we suspect OA we might then decide to try and confirm the problem with radiographs and osteophytosis is the hallmark marker of OA on radiographs. And it can be very subtle, of course. So here's a, the second one, the lower, image there is an elbow with a very mild osteophytosis on a proximal ward of the anchor heal process, but that's enough to say that this elbow is pathologic.
But it, it looks very minor change, and so there's a tendency to say, well this is mild osteoarthritis, but of course we haven't seen the patient, this patient could be very late, . On, on the other hand, here's an elbow with extreme. Osteophytosis, really, really severe, and there's a tendency to inherently think this, this dog must be very, very lame, but we don't know that.
Clearly it's not going to be a normal joint, it's going to be mechanically affected, but we, we can't assess the degree of pain from the degree of osteophytosis. And dogs of course don't have any anxiety or anguish about how their radiographs look. They just er are worried about how much their joints hurt.
So clearly radiographs are are useful, in in a primary care setting because they, they add confidence to our, our diagnosis. They tell us the joint is pathologic, but we should use our clinical judgments to guide our management decisions. I, I'll just put this one slide in here just to remind people that, as well as radiographs and, and in some clinics, of course, maybe advanced imaging might be used.
More these days as well, but as well as imaging techniques, we should be thinking about, synovial fluid analysis if we're ever concerned that there might be something, something else going on when things don't quite add up, if the, if the degree of lameness or pain or swelling is so severe that it, we think it might be something other than OA we should reach for synovial fluid analysis very cost effective and with the right technique, it's very, very safe indeed. Because OA joints might be, can become infected with hematogenous infection, they could be an underlying immune-mediated problem, and that's the sign of a fluid is the way to get to the root of that. So if we've got a diagnosis of osteoarthritis, and I said it was the final common pathway and all roads lead to Rome, but if we decide we're now in Rome, what are we gonna do?
And that is, something of course that we could feel probably a whole virtual congress on. But I'm gonna concentrate on one aspect, which is how we stage the problem. And, one of the challenges we've got with, with many chronic conditions, and I'm sure Anthony would, would say this is also true of dermatology, when we've got pruritutis, it's also true of, many chronic medical conditions, .
In that we rely a lot on the, the owner and the, the client to tell us how the dog is doing in response to our interventions, because there simply isn't the ability within a short consultation. To assess the patient, ourselves. And of course we're, we're seeing the patient in a an unnatural setting, and particularly with, with aspects of osteoarthritis, there are elements of the disorder that are simply not seen in the consulting room, and a dog's behaviour may be very different.
There's a bit of an adrenaline rush, when dogs come to the clinic, and, that may well mask, the degree of their problem. And also certain activities we just can't see in the clinic, inactivity stiffness or stiffness in the joint after a lie down is again is something we can't assess in the clinic. So we have to piece the information from the client together with our assessment together, and we've got the dog's behaviour, I've already alluded to that and it's demeanour and how it responds to our manipulations, but all to factoring.
So, I guess one of the reasons that many years ago, I got interested in trying to pull all this information together is back when I was in, in Bristol with Paul Diep where back in the 90s, I was seeing how this was being approached in, in human medicine and rheumatology, and back then there were already questionnaires, patient questionnaires that were well validated to try and assess. The patient's osteoarthritis and the effect it has on their lives. And those questionnaires aim to try and gather information on the whole construct of osteoarthritis.
So here I've mapped out a possible construct of osteoarthritis in dogs, and it's, it's based around different dimensions of the disorder, whether that be pain. And pain may elicit as reluctance to move, or different types of pain, let's say night pain or change demeanour. But there are also mobility issues, and so there may be an inability to climb or descend, stairs or jump into the car.
There may be lameness, asymmetry, there may be reduced economy of motion, complex adaptations, there may be joint stiffness. And of course, we've also got the pathology in the joint, and we've also got inflammation. So there are lots of dimensions and what we would want to do ideally is to capture all of this information as best we could to get a a proper handle on the severity of the problem.
Now if we're measuring the severity of a problem, then there are different sources of error in the measurement. There's the situation we're in, there's this responder to the measurement, there's the measurer, she's either vet or the veterinary nurse or the vet tech, and there's the instrument. And I guess one of the areas where we could perhaps improve this or reduce the error is by getting better instruments to to make that measurement.
So, this essentially is the area of clinical metrology, which is measuring clinical status, and the development of clinical metrology instruments. These are generally a sequence of items, or questions, and these are ascribed a score based on an observation. And usually the final score is a function of the item scores.
It could be the mean or it could be the aggregate score. So why would you consider using such an instrument for patients with osteoarthritis in your clinic? Well, hopefully I've, I've given you some introduction to why we should do that, to reduce error, and to .
To get a better way of conveying the severity of the problem to our colleagues and to the client and standardising that approach. That does reduce inter-observer variance, it's time efficient. It also has softer aspects such as owner buying to what we're trying to do.
It educates owners about their pet's problem. We can measure the response to our interventions, so it can give us a a handle on the impact. And that was the title I used, for this webinar, the impact that we're having on our patients, with this challenging condition.
And of course these days, you know, communication with clients is becoming more and more important and may move to online or to devices, electronic devices, smartphones, and these sorts of instruments are very amenable to those technologies. So, I guess it's not a simple process of just, pick up a few questions and putting them in a questionnaire and off you go. It does really need to be a process of validation, and that needs to be there to give confidence to the users of these instruments that we're actually measuring something meaningful here.
And I'm aware that, you know, there is a lot of scepticism about. These instruments, and you know, some of that is absolutely valid, and we will come back to some of those issues in the discussion here. But a lot of these techniques are borrowed from the, field of psychology, where these methods are very well, developed.
That doesn't mean that there are no errors or, in, in those, methods, but it does mean that we're getting hopefully as close to a robust instrument as we can be. So validity, there are different types of validity, and I, I'm not gonna go through this in detail. Suffice to say there was a a a session at the pain and Animals meeting in Washington DC which is at the NIH back in November, organised by Duncan Laces and there were representatives from the regulators there, the FDA etc.
So there's, there's a strong interest. From the regulators in, in these instruments because they're starting to use them in clinical trials. And if they're being used in clinical trials, that will mean that our, our interventions are measured by these, and that's, that, that then means that these instruments will be very applicable in the clinic.
And certainly they are, they get regularly used in our clinics. So validity is, an, an important area, and I'll come back to to some of that reliability and responsiveness, so making sure these instruments are as reliable as possible, and also. That they can show us that there's been a change in clinical status, so that's responsiveness, and they've got to be practical.
They, they, they can't take so long to fill out that clients lose interest or it slows down our clinical day. So to put all that together in terms of how one might go about, validating an instrument, this is the process, that we followed, in our validation, and there are other groups around the world that'll mention some of the other instruments around for dogs as well. But we start with face validity and content validity.
We might run a pilot on that basis, then we might look at construct validity and factor analysis, which is, assessing. You know, whether the instrument is actually measuring what we think it's, it should be measuring and how . The, what's the consistency and reliability, in a statistical sense.
At that point, we, we might revise the instrument to refine it. We might then go into more clinical testing, testing with clients and pets with, test, retest scenarios. We might men then, measure the, instrument against other.
Accepted measures, so looking at criterion validity, and then we might look at responsiveness and how it tells us about the effect size of various interventions. So content validity right at the start is obviously designing the content, using input from client interviews and expert interviews and literature review to do that. That's relatively straightforward.
And we might use experts and clients to tell us how valid they think the, the content is what's the face validity. Construct validity is, how well the test measures what it's supposed to measure. Is it constructed in a way that it successfully tests what it claims to?
Now we might assess that by looking at other similar measures to make sure they're highly correlated. And so we've done that. This is a paper in PLO one, so it's open access, if you want to read the whole paper.
Ben Walton was the first author on this paper, and, this was a collaboration with Duncan Laces. So we took the, the Liverpool osteoarthritis in dogs, the load questionnaire, and we compared it to the. Helsinki Chronic Pain Index, which has, been published from this group in Finland, led by Heon Bjorkman, and the canine Brief Pain Inventory, which is, which is out of, Pennsylvania, Dottie Brown is the, has been the lead investigator there.
And these instruments are, you may well be aware of them. And we took 222 dogs and clients with osteoarthritis. We also ran all these dogs over a force platform, so we've got a.
Mechanical measure of their lameness, just as a an objective test of their functional status. And we've looked at construct validity and criterion validity, so criterion validity was measuring against the force platform. And we did some factor analysis during this study as well.
So the factor analysis is a is a way of looking at how the items in the questionnaire cluster around different factors which are defined statistically, rather than, being defined, in terms of what we think that the clusters might be. And these eigen plots here allow us to, to see those factors. And the strength of those, and if the if the eigenvalue is above one, we will consider that a significant factor.
So if we look at load, . We've got 3 factors above the threshold here. So load seems to be based on 3 factors, which are essentially lameness, stiffness, and the effect of the weather on the degree of lane or mobility dysfunction.
Now weather is well known to affect arthritis, so it's probably to do with atmospheric pressure. So that's why we retained those questions in the questionnaire. And it does seem that there is some usefulness to those questions.
If you look at CBPI in this study, CBPI came out as a one factor, questionnaire, and that factor seems to be pain. So I think this is interesting in that CBPI is a, you know, a very well established questionnaire too. But it may be that, you choose your questionnaire, depending on what really you're most interested in.
And if you're most interested in pain alone, then maybe CBPI is, is the one to use. If you're interested in pain, and mobility, then maybe load, is, is perhaps the one to use. And I guess they've been designed in slightly different ways, and that's why they come out with slightly different, answers in those studies.
Of course, everyone believes the force platform, because it's a machine, and we did force platform all these dogs. The one thing I would say about having done a lot of force platform analysis is that it's use, it's pretty good for unilateral lameness. It's not so good when we've got multi-site lameness, because, there are, you know, there are effects in the limbs and it's not so easy to tease out, the, the parameter to be as useful.
But it is a machine, so we think it's, it gives us confidence, and, and actually in this study we did show that, load and, an element of CBPI pain interference score, were significantly correlated with force platform measures of these dogs. Not very strong correlations, but they were statistically significant. You wouldn't necessarily expect them to be strong because the, the clinical metrology instruments measure.
And measuring different dimensions other than just, weight bearing on an index limb. But it does give us some confidence. So I guess this, to summarise this process, really what we're looking for is an instrument that is reliable, so the data are as tight as possible but also valid, in other words, it's telling us about our target interest.
Which is the severity of the OA and the effect on the patient. So Duncan Laces has led some other studies around, these instruments, looking at, reliability as well. You can see for load here, data looking quite tight, on these two visits, which were a week apart in the study which was performed in in North Carolina.
And this is looking at responsiveness, and in this particular study, this is CBPI and this is . Active treatment versus placebo. And you can see that the, you know, placebo control blinded study, these instruments can tell us about a treatment effect, but it's, it's also interesting to note that there is a bit of a placebo effect too.
And we would expect a caregiver, give a placebo effect with these instruments because they're being completed by the caregiver. And, this is a phenomenon in, in osteoarthritis in dogs, as it is in osteoarthritis in people. So that is, something one has to be aware of.
So, a good understanding of these instruments involves placebo-controlled studies. Here's another example of that, from Mike Kinzzemius and Rich Evans, looking at this caregiver placebo effect, and here they have compared the force platform measures in a, in a cohort of dogs over 42 days. Against the owner questionnaire data, over the same time period.
And you can see that force platforms don't have any placebo effect, whereas the, owner questionnaire, which was not a validated questionnaire, in this particular study, showed, that the owners thought the dog was getting better. So we do have to bear that in mind, but that doesn't invalidate the use of these, these, questionnaires. And just to, to, show you that, here's a study from Wisconsin led by Peter Muir, using CBPI, for accepted treatments, and you can see Carprafen here, and the effect size was 0.64.
Tramadol, interestingly, had had a larger effect size in this particular study, . But placebo, only 0.34.
So we are teasing out treatment effects with these instruments, and you, you can do that in the clinic too. So they are a useful measure, but we just need to bear in mind there is a caregiver placebo effect. I thought I would just, show you some data on how you can roll out this sort of instrument into your clinic.
This is, these are early data actually from a rollout of using the load questionnaire across CVS practises in the UK and Lanca have supported us in this educational process. And then we, we were able to measure the use of the, the, . Instruments through our, practise management system.
So we, we've had an educational programme, and the Laco representatives have gone into some of our practises to do that, and you can see how the use of the instrument has, has really lifted, in response to our educational programme. So this is Obviously, hopefully improving attention to OA care within clinics and it's also raising the awareness of clients around osteoarthritis and helping to deliver better care for those pets. And of course these questionnaires can be very easily used in arthritis clinics which might be run by.
Nurses or or technicians, so it doesn't have to be a veterinary surgeon administering the questionnaire. In fact, in our clinic, if we know that this is a lame miss consultation, then our receptionists, would ask the client to fill out the questionnaire in the waiting room before they even come into the consult. And essentially it takes a lot of the history taking time out of the consult because the answers are already there.
So just some, some more info just to show you how these questionnaires can give you a signal. This is a, a study again that Ben Walton and I conducted, using two non-steroidals in dogs over 12 weeks. And you can see on the left here the force platform measures at 06, at 12 weeks.
So the peak vertical force is going up in these dogs over 12 weeks. Interestingly, after 6 weeks' use. They, they're at this point here, but after 12 weeks they, they rise even further, showing you that continuous non-steroidal use has better efficacy.
And you can see that the load questionnaire data also show a similar pattern, obviously mirrored because the load score goes down with improvement, whereas peak vertical force goes up. So again, we can see that difference with the questionnaire. Even owners can perceive that through the questions on the instrument.
These data are interesting for two reasons. One is that, again, it shows that the load questionnaire here, is a study led by Duncan Laces, the load questionnaire was able to tell us about significant treatment effects in a clinical trial here, whereas, the placebo showed no. A significant change, at, at day 14 and day 28, so owners can perceive treatment effects with these instruments.
But it's, it's interesting because this is a clinical trial, it's a clinical trial with, anti nerve growth factor antibody, done by a company called Nexvet which has now been bought by Zoeys. So, we have one antibody therapy in veterinary medicine so far in dermatology, cytopoint. And this is potentially another area where we might see an antibody come to market, which is in the treatment of chronic pain.
And, this would be, really useful, I think, to have in our, our armoury against chronic pain in dogs. And may well be quite paradigm shifting in terms of adverse events, etc. So quite exciting data there, but again it's the, it's the questionnaire has been able to show us that, treatment effect.
So, you know, I do, we do use these questionnaires in our, our clinic, all the time. They help us convey severity to the client, they help us decide how to treat patients. So, and they allow us to put things in context so the load score, a particular patient has can be put on this graph, this graphic here, which, and these are the load scores from those 222 dogs.
With OA that we saw in that study earlier. So, you know, a low score above 40 is extremely, rare. Maximum score is 52, but anything, over 20 is suggesting severe disease.
And moderate, dropping down to about 10. Below 10, we're looking at, relatively mild or sometimes even normal patients because, even normal, patients with no muscular disease may may score 1 or 2 or 3 or so on the low questionnaire. So just very briefly, I know we're starting to run out of time, but, I'll just show you these videos.
So, and just show you the limitations of a force plate as well. So this particular dog here, you can see the force platform measures, for this dog, and the asymmetry index was 17.8.
So that's the difference in the ratio really of the difference in peak vertical force between. The left hind and the right hind, and it's load score was only 13, . So you can see this dog move.
It's pretty nimble, doesn't look too bad, but it, it moves quickly, it looks relatively OK. But it's asymmetry index measures 17.8.
So the force platform, is telling us that it's, it's significantly, lame. Now if you compare it to. This next dog, which I'll show you the video, .
Well, the asymmetry index for this dog is 15, so a bit better. So if you just relied on force platform data for this dog, yeah, you might think this dog was better. But the load score's 23, so it's higher.
And I think you only have to look at the video of that dog, I think to realise that this dog has more mobility issues than the first dog. So I'll just show you that as an anecdotal example as to how force platforms don't always. Deliver, the objective data that you might think because they're only measuring one limb or two limbs and comparing them, rather than looking at the whole patient.
So, just a last few slides really, just to say, my main message this evening, is that, you know, a management, we need to be staging this order, educating, intervening, monitoring, and monitoring means, using these sorts of instruments again over time, and then staging, I mean, using this circular process to, to keep on top of these patients. Now I, I said I'm not gonna say much about management, there really isn't time this evening, but, er, we know that the majority of dogs with OA either don't even see a veterinarian, or when they do, we carry out these various . Things such as weight loss programmes, exercise advice, non-steroidal anti-inflammatories, nutritional supplements, etc.
If things get worse, we might try some additional analgesia. If they get really bad, we might think about surgery, and for some dogs, arthritis is an end of life problem. So, you know, I would just encourage you to think about, this very simple model, and Stuart Carmichael's been, working hard on developing this AMOA system.
And this simple, way to remember that the aspects of what we should be thinking about for each patient, not necessarily doing for every patient, but thinking about. And, that will keep us on the straight and narrow. Weight management is particularly important.
For those dogs that are overweight or obese. And there's good evidence to show that weight loss can influence the, the progression of the disorder over time. And there's no evidence that any medicine or or nutritional supplement can effectively do that, but weight loss can.
So those studies that have been done in, in, in those colonies over their lifetime showing that dogs that are . Have a more optimal body condition score and develop less OA compared to dogs that are overweight or obese. Some evidence now emerging around physical activity, and we, we don't have too much time to talk about that, but in early life, it may be that activity can have an influence on the way that joints are developing.
And this particular Norwegian study suggested that avoiding stairs in early life in puppies is useful, but off-leash exercise on soft ground, may be beneficial for hips. Another study in dogs that have established arthritis showing that, . Showing that exercise is actually beneficial as long as it's controlled exercises.
So I guess in terms of management, generally, we know that there's evidence for for some particular modalities and less evidence for others, and that's the challenge, you know, a management. There are, I'll just point you in the direction of some systematic reviews. I'm not going to discuss them this evening, but, they these systematic reviews generally show that, .
The best evidence is is there for non-steroidals, on the other hand, they have the biggest studies and, and probably the most investment behind them. And I've shown you that before. So, take home message from that brief discussion, there is that long term non-steroidal treatment appears to be more effective than short term treatment.
So I showed you those the study, where the force platform data showed that and also the load data showed that. But I do recommend, obviously they're, monitoring those patients carefully, because safety is the other side of the coin, to efficacy. If we think about additional analgesia, that's an interesting area and we go, a lot of vets go off label at this point, so, I, I thought I was just gonna do a quick poll if that's right, Antony, and we're very close to the end here, we'll do a quick poll on what.
Here's the question, sorry, let's go back. What additional analgesic do you reach for first if you're non-steroidal is not, cutting it enough for you? We'll just see what people reach for at the moment, I, I think this has changed maybe a little bit over the last few years, .
It's a question I often ask when giving live lectures to the audience, and it's interesting to see what hands go up for which particular agent. And of course it will vary around the world depending on what's available. I can hear you just now, great, good, I think I just, it's getting late, so I've swapped the bottom, the button, the bottom, the button.
Right, we've got . Most people voted now, so we have 24% like paracetamol or acetaminophen, amantadine 5%, gabapentin, 13%, Tramadol 55%, 3% something else, so presumably not in Egypt though, because I think . She got into trouble in Egypt didn't she?
Yes, indeed, poor lady. Pacetamol probably the, the safe option in, in most occasions. But we've got about a quarter with paracetamol, 13% for gabapentin, Tramadol 55%.
So tramadol, wins. Yes. And this is, this is an interesting area because, we're working in a, an uncertain, space here because we don't have many studies, and these drugs are not, specifically licenced here.
But, yeah, interestingly, I at the chronic pain meeting back in November, Professor of, neuropathic pain from Imperial College was speaking. And he said, in, in human patients, gabapentin only works in, in 1 in 7 patients. Actually the efficacy of gabapentin and neuropathic pain in in human patients is actually low.
I think we need to bear that in mind that we're working in this uncertain space so we haven't got the answers, but hopefully we've got other things coming along. I think you've also said in webinars you've done previously for us, John, I mean, tramadol is very hit and miss and not really, we don't, again, we don't know much about tramadol either, do we? We don't accept, I guess there there there have been some more studies emerging, and there was a placebo controlled study presented in poster format at that pain meeting in November.
Using a force platform, and showing that tramadol had no effect in that group of patients with OA, so that's, that was somewhat sobering, equally, there are some studies suggesting some efficacy. So, I guess we'll get more information over time, but we just, I think we need to remain healthily sceptical, I suppose, about these unlicensed products. No, that's great, John.
So John, is, is that you, is that your last slide there? I think, yeah, other than, all I'll say is don't forget surgery. I'm a surgeon after all, and we should remember that that's an area that can help some dogs.
So, whether it's salvage, or whether it's joint replacement, don't, don't forget that option for some, for some patients, carefully selected. So I'll, I'll finish up there, Anthony and say thank you very much to everyone for listening in and to Anthony for cheering and everyone a webinar vet for putting on a great event. Well done, thank you.
Thanks John. Just while people are thinking of some questions, we've got some questions. I think we've got 5 or 10 minutes.
Are you happy to take some of those? Yeah, I guess I, I was timing for that, that's fine. Yeah, no, that's brilliant.
So first of all just people pop in where they're listening in from, it's always good to know. Where people are listening in from, so if you want to put that into the question and answer box, I can read those out. But we have already had a couple of people asking questions.
Jamon has been asking for the slide of the ABCDEF of osteoarthritis management again. Obviously, Jam and everything is recorded. I think most things have notes, so you've probably got some notes on things, but I think, John, if you want to go into .
Back into ordinary mode, you can perhaps just find the slides that way. While you're doing that, I will read out where people are listening in from. If people are going to put that down, so we've just got Claire saying from the Highlands of Scotland at the moment.
So if if people just pop that in, it's always nice to know, we're just past dinner time now as well, so . We, we had a few photographs of refreshments that were being . Try it out at lunchtime and so on, but do feel free to put those out onto Twitter #VC2018 .
Whatever else you want to to put in, put down into Facebook. Let's see if we've got a few more, a few more people putting in where they're listening in from, so, oh no, they're just questions. Oh, everybody's really keen.
OK, that's fine. Birmingham. And I think because you put that, Michelle, you can actually, I'll put your question to the top of the list.
What would John's first choice of second analgesia be? Yes, well, I guess at the moment, I would say at the moment, I, I tend to use paracetamol. And the reason for that is if you dig back way back when, you know, there, there, there are some, pharmacokinetic studies that shows it lasts for about 6 to 8 hours in dogs.
And, I, you know, I, I, I accept that in human OA there's been a bit of a shift in opinion. In NOA, but in other areas there's good evidence for paracetamol, so, . I guess that's the one I reach for first because I've just got a little bit more confidence in the in in it's .
Efficacy and it's probably relatively behaves relatively similarly in most dogs, and I use 10 milligrammes per kilogramme, as my starting dose. But, you know, tramadol for me, I think, you know, can work in some dogs. It seems to be quite variable.
Some dogs, you know, just laugh in the face of tramadol, and, some others seem to be quite sedated by it. Yeah. I guess we just have to be sure it's not the sedation that makes clients think that their dog's better and it's actually pain relief, so.
Yeah, I will, I will try to tramadol, but probably the first line, yeah. Is Claire, Claire has asked do you use paracetamol long term and daily, or just as you need it? Yes, no, I, I, I tend to use most of my medications long term and daily, and continuously because, there, you know, there's good evidence that providing analgesia continuously gives you better impact.
So that's why I stick with that really, rather than . You know, but a lot of my patients are at the point where, you know, they need that. I'm not saying that in early cases that's what you should do, but a lot of my patients are quite severely affected.
Of course. So, yeah. But obviously, you know, bear in mind the potential, with paracetamol around liver function, so, and it's off label, of course, so we've got to make sure we're informing the client and getting consent, yeah.
Great, did you say paracetamol label or? Well, yes, because they, I mean, although it's like, I mean, where I, where I'm working in the UK there is a licenced product which is called Pardale, which has codeine in it. It's only licenced for up to 5 days continuous use, and it's not licenced for to be given at the same time as a non-steroidal.
But you know, in my experience, giving it alongside a non-steroidal is absolutely fine, but it's off label, yeah, so it's worth getting informed consent, absolutely, absolutely. Great, . Oh, I, I had a question which I've just gone past.
Yeah, Hillary's just asking about the notes. I'm not sure about the notes. I know Catherine was getting those out, .
So Perhaps Richard, if we can just look into that where the notes are so that people can refer back to those if they want to, . Jamie's saying, how does one go about getting and using the load questionnaire in a practise? OK, very easy.
Just speak to your, wherever you are in the world, speak to your locallanco rep. And they should be, but, very shortly, there will be a load website, which alanco are administering, and if you register on there, you'll be able to download it. But, because it's a global, licence and a global website, there's, it's been months and months of .
Process through the Lanko legal teams. Yeah, so it's a long time, yeah. Yeah, yeah.
Hilaria says, I understand that fat releases an inflammatory cytokine, so even if no osteoarthritis, you could, they can seem a bit achy and stiff. Does this apply to dogs as well as people? Yeah, that's a really, that's a really good question.
Yes, overweight and obese people are in a hyperinflammatory state. It's not, not a single cytokine, it's a blend of cytokines that, such as TNF, alpha, I IL 6. So yeah, you're absolutely right, and we don't have much information on that in dogs yet, but there is some, and certainly, dogs have increased leptin.
Circulating and another adipokines, and, that's well recognised now and some of those adipokines are known to affect joints as well, so their effects of leptin will affect joint tissues, etc. So there is quite a compelling argument to say that overweight and obese patients are not suffering just because, there's a mechanic increased mechanical load on their joints. It's also rather hyperinflammatory state, yeah.
And, and interesting, I mean, of course, probably if we do this lecture in 5 years' time, it will be a completely different lecture and, you know, we've seen that from the monoclonal antibody that you were mentioning there. There are these new treatments coming through that will really challenge the way we do things, won't they? Yes, and there is, there is a, I didn't mention it tonight, but there is an EP4.
Inhibitor coming, which has been launched already in the States in January last year, and, he's going through the process in Europe. Of course, it, it's still targeting, the prostaglandin pathway, but in a more targeted way. So, I think it may well improve safety, but, obviously the efficacy is probably gonna be similar to, .
The traditional non-steroidals, but it's another option for us, for sure. Yeah. Fantastic.
John, that is absolutely great. Thank you so much for that.